Cerclage and Cervical Insufficiency: An Evidence-Based Analysis

A comparison of Mersilene tape versus braided suture in transvaginal cervical cerclage: A retrospective case-control study

OBJECTIVE

Previous studies have indicated that there is an association between cervical cerclage and type of suture material. However, it is still unclear which suture material can provide the greatest benefit to patients who have undergone cerclage. This study investigated the effect of two different suture materials (Mersilene tape vs braided suture) used for transvaginal cervical cerclage placement on maternal outcomes of women with cervical insufficiency.

METHODS

In this retrospective case-control study, 170 women who underwent history-, ultrasound-, or physical examination-indicated transvaginal cervical cerclage were categorized according to suture materials used for cerclage: a total of 96 received Mersilene tape and 74 received braided suture. Study participants received a transvaginal cervical cerclage before 28 weeks and were followed up until delivery to assess pregnancy and neonatal outcomes. The primary outcome was gestational age at delivery. Secondary outcomes included preterm premature rupture of membranes (PPROM), premature rupture of membranes (PROM), chorioamnionitis, neonatal survival rate, and neonatal morbidity.

RESULTS

Out of 170 eligible women, 74 (43.5%) received braided suture while 96 (56.5%) received Mersilene tape. Baseline characteristics were similar between the two groups. The group that received braided suture had a lower incidence of gestational age at delivery <37 weeks (29.2% vs 54.2%, P = 0.046), PPROM (9.5% vs 21.9%, P = 0.029) and PROM (17.6% vs 32.3%, P = 0.028) compared to the group that received Mersilene tape. However, there were no significant differences between the two groups in average gestational age at delivery, the rate of gestational age at delivery <24, <28, <32, and < 34 weeks, chorioamnionitis, and neonatal survival rate, as well as neonatal morbidity.

CONCLUSION

Compared to Mersilene tape, the utilization of braided suture has been significantly associated with a reduction in the incidence of gestational age at delivery <37 weeks, as well as a decreased risk of PPROM and PROM. However, the use of braided sutures did not result in discernible differences in the rates of chorioamnionitis or adverse neonatal outcomes.

Timing of antenatal corticosteroid administration in pregnancies with increased risk for premature birth: A retrospective cohort study

OBJECTIVE

To investigate how often antenatal corticosteroids (ACS) were administered within the optimal time frame in women at risk of preterm birth (PTB) in relation to several diagnoses and risk factors.

METHOD

The study was designed as a retrospective cohort trial, in which the data of all births taking place in 2016 in the German federal state of Rhineland-Palatinate were evaluated. Frequency analyses, subgroup analyses, and logistic regression were performed.

RESULTS

Birth occurred within the ideal time frame (≥24 h, ≤7 days) in only 15.2% of all pregnant women who were treated with ACS because of an increased risk of PTB (N = 1544). The ideal time frame after ACS administration was reached in less than 25% of all cases in each subgroup, with little difference between the different diagnoses and risk factors for PTB (range 11.3%-22.2%). Patients with multiple pregnancy had a significantly higher chance for delivery within the ideal time frame. There was an odds ratio greater than 1 for a birth event within the ideal time frame in patients with preterm prelabor rupture of membranes, pre-eclampsia, oligohydramnios, amniotic infection syndrome, and in patients with multiple diagnoses. In most diagnoses, the average time between ACS administration and birth was significantly shorter compared with patients without the diagnosis or risk factor.

CONCLUSION

In women at risk of PTB, the individual risk profile should first be identified before ACS management begins. The likelihood of achieving the ideal time frame additionally depends on the diagnosis.

Transabdominal cerclage during pregnancy: A retrospective single operator series over a quarter century

OBJECTIVE

To describe the pregnancy outcomes and complications observed in a series of cases of transabdominal cerclage (TAC), which is reserved for highly selected women with recurrent mid-trimester pregnancy loss, due to cervical insufficiency.

METHODS

A retrospective audit covering 25 years (January 1, 1997 to December 31, 2021) was performed at the Obstetric Special Care division, Tygerberg Academic Hospital in Cape Town, South Africa. All 118 pregnancies from 94 procedures, operated and managed by the principal author were included for descriptive analysis.

RESULTS

Eighty-four (91.3%) of the 92 first pregnancies after first insertion had successful outcomes. All second and third pregnancies (24/24; 100%) were successful. Eight pregnancies did not achieve viability, two women (2/8) did however achieve a successful pregnancy after a subsequent repeat TAC procedure. For the viable pregnancies (110/118), the median gestational age at delivery was 37 weeks (range 28-39 weeks). The median intraoperative blood loss during cerclage insertion was 100 ml (range 25-750 ml).

CONCLUSION

In experienced hands, TAC during pregnancy is a safe and effective operation, when other less invasive procedures have failed.

Severe maternal morbidity associated with cerclage use in pregnancy

OBJECTIVE

To quantify the frequency of serious maternal complications associated with cerclage use during pregnancy.

STUDY DESIGN

We performed a retrospective population-based cohort study of all live births in Ohio from 2006 to 2015. Maternal sociodemographic, medical, and obstetric characteristics were compared for births in which cerclage was utilized during the pregnancy versus those without cerclage. The primary outcome for the study was a composite of adverse outcome including maternal intensive care unit (ICU) admission, blood product transfusion, uterine rupture and unplanned hysterectomy in all births. Secondary outcomes included each of the individual adverse outcomes as well as maternal hospital transfer to a tertiary facility, unplanned operation after delivery and chorioamnionitis. Each outcome was also analyzed separately in singleton and twin births. Generalized linear modeling was used to estimate the relative risk of adverse maternal outcomes associated with cerclage placement after adjustment for coexisting risk factors.

RESULTS

Of the 1,428,655 singleton and twin live births in Ohio from 2006 to 2015, 4595 [0.3%] were recorded on the birth certificate as having cerclage during pregnancy. Of those, 11.7% experienced a serious adverse maternal outcome, compared to 3.7% without cerclage, adjRR 2.7 [95% CI 2.5, 3.0]. The rate of the composite maternal adverse outcome was significantly increased for pregnancies with cerclage versus those without overall, and in singleton and twin pregnancies when measured individually [all p ≤ .001]. Even after adjustment for coexisting risk factors, cerclage remained significantly associated with composite adverse outcome in each of these groups.

CONCLUSIONS

Over 1 in 10 women with cerclage experience an adverse maternal outcome. Even after adjusting for gestational age at delivery and other risk factors, maternal risk for serious adverse event remains over twofold increased for pregnancies with cerclage. This information may be helpful in counseling women regarding potential maternal risk when considering neonatal benefit of cerclage in pregnancies at high risk of preterm birth.

Patients with acute cervical insufficiency without intra-amniotic infection/inflammation treated with cerclage have a good prognosis

Background The frequency of intra-amniotic infection/inflammation (IAI/I) in patients with midtrimester cervical insufficiency is up to 50%. Our purpose was to determine the perinatal outcomes of cervical cerclage in patients with acute cervical insufficiency with bulging membranes, and to compare the admission-to-delivery interval and pregnancy outcomes according to the results of amniotic fluid (AF) analysis and cerclage placement. Methods This was a retrospective cohort study including singleton pregnancies with cervical insufficiency between 15 and 26.9 weeks in two tertiary health centers. IAI/I was defined when at least one of the following criteria was present in AF: (a) a white blood cell (WBC) count >50 cells/mm3; (b) glucose concentration <14 mg/dL; and/or (c) a Gram stain positive for bacteria. Three different groups were compared: (1) absence of IAI/I with placement of a cerclage; (2) amniocentesis not performed with placement of a cerclage; and (3) IAI/I with or without a cerclage. Results Seventy patients underwent an amniocentesis to rule out IAI/I. The prevalence of IAI/I was 19%. Forty-seven patients underwent a cerclage. Patients with a cerclage had a longer median admission-to-delivery interval (33 vs. 2 days; P < 0.001) and delivered at a higher median gestational age (27.4 vs. 22.6 weeks; P = 0.001) than those without a cerclage. The neonatal survival rate in the cerclage group was 62% vs. 23% in those without a cerclage (P = 0.01). Patients without IAI/I who underwent a cerclage had a longer median admission-to-delivery interval (43 vs. 1 day; P < 0.001), delivered at a higher median gestational age (28 vs. 22.1 weeks; P = 0.001) and had a higher neonatal survival rate (67% vs. 8%; P < 0.001) than those with IAI/I. Conclusion The pregnancy outcomes of patients with midtrimester cervical insufficiency and bulging membranes are poor as they have a high prevalence of IAI/I. Therefore, a pre-operative amniocentesis is key to identify the best candidates for the subsequent placement of a cerclage.