McDonald versus Shirodkar cerclage technique in the prevention of preterm birth: A systematic review and meta-analysis

Efficacy of ultrasound-indicated cerclage without prior preterm birth

AIM

Our study aimed to evaluate the effectiveness of ultrasound-indicated cerclage in singleton pregnancies with cervical shortening (<25 mm), excluding those with a history of preterm birth (PTB) and infection/inflammation.

MATERIALS AND METHODS

Among the 1556 women admitted for a cervix measuring <25 mm via transvaginal ultrasound at Juntendo University Urayasu Hospital between January 2001 and December 2023, our study focused on 47 singleton patients with no prior history of PTB. After receiving information on both risks and benefits, 25 patients opted for ultrasound-indicated cerclage (cerclage group), while 22 chose expectant management (expectant management group). All participants underwent screening for infection/inflammation of the lower genital tract. The primary outcome, the rate of PTB (<37 weeks', <34 weeks', and <28 weeks' gestation), was assessed in both groups.

RESULTS

The cerclage group demonstrated a significantly lower rate of PTB before 37 and 34 weeks' gestation. Although there was no statistically significant difference, the cerclage group exhibited a delay of 3.6 weeks in the average week of gestation compared to the expectant management group. Notably, the hospitalization period in the cerclage group was significantly reduced by 42 days.

CONCLUSION

Performing an ultrasound-indicated cerclage in cases of a short cervical length <25 mm without a prior history of PTB and infection/inflammation reduces the rates of PTB (<37 and <34 weeks' gestation) and hospitalization period.

Atraumatic forceps-guided insertion of the cervical pessary: a new technique to prevent preterm birth in women with asymptomatic cervical shortening

OBJECTIVES

As previous studies on the use of a cervical pessary to prevent preterm birth (PTB) have produced conflicting results, we aimed to investigate the feasibility, acceptability and safety of a new technique for inserting a cervical pessary and compare it with the traditional technique in patients at high risk of PTB.

METHODS

Women at high risk of PTB treated with a cervical pessary between January 2018 and January 2021 were retrospectively evaluated. After applying exclusion criteria, a total of 68 eligible patients were identified and retrospectively analyzed. The primary outcome was spontaneous PTB before 34 weeks' gestation (WG).

RESULTS

Of 68 participants, 39 were treated with the traditional method (group 1) and 29 with the new insertion technique (group 2). The rate of spontaneous PTB before 34 WG was significantly lower in group 2 (p=0.020). Birthweight, APGAR scores and satisfaction with the method were significantly higher, while PTB before 37 WG was significantly lower in group 2 (p=0.043, 0.010, 0.009, 0.042 and 0.014, respectively). There were no significant differences in the rates of perinatal death (12.8 vs. 3.4 % in groups 1 and 2, respectively; p=0.229). The concomitant use of vaginal progesterone was required more frequently in group 1. According to the binary regression analysis, the new insertion technique resulted in a 5.42 and 3.97-fold protection against PTB before 34 and 37 WG.

CONCLUSIONS

Our preliminary results show that our new technique of pessary insertion is more effective than the traditional method in preventing PTB due to cervical shortening.

Development and validation of a cost-effective DIY simulation model for McDonald cerclage training

PURPOSE

The prevention of preterm birth is a challenging task for obstetricians. Cervical cerclage, used as both a primary and secondary prevention method for spontaneous preterm birth, is a crucial surgical intervention. It is essential that obstetricians can learn this procedure in a simulated environment before performing the stitches on high-risk patients. This study aimed to develop a simulator based on 3D printing and evaluate its validity for clinical training.

METHODS

The objectives of this study were (1) to design and construct a cost-effective simulator for McDonald cerclage with two different cervix models-a closed cervix and a cervix with bulging membranes-using common material from a DIY store and 3D printing technology and (2) to validate its effectiveness through feedback from learners and experts in cervical cerclage. The self-made simulator was evaluated by obstetricians using a questionnaire with Likert scale.

RESULTS

Obstetricians and gynecologists assessed the simulator and found it useful for learning and practicing cervical cerclage. The simulator was deemed valuable for skill training.

CONCLUSION

Cervical cerclage is a complex procedure that should be mastered through simulation rather than initial practice on real patients. Our simulator is a cost-effective model suitable for various clinical settings. It has been validated by obstetricians for both preventive and therapeutic cerclage, demonstrating its efficacy for training in cerclage techniques. Future research should focus on less skilled obstetricians and gynecologists and investigate how repeated use of the simulator can enhance their performance in cerclage stitching.

Transvaginal cervical cerclage - How well do surgeons assess their own procedures?

INTRODUCTION

In women with cervical incompetence, transvaginal cerclage may help prevent preterm birth. However, training for this procedure poses challenges due to the low number of cases and difficulties in visualizing the operative field. Furthermore, the objective criteria for a successful cerclage procedure are not well-described. Quality assessment relies heavily on self-assessment rather than objective criteria and feedback. To address this issue, training on a simulator may offer a solution. We aimed to objectively assess surgical performance and compare it to the self-assessed performance in transvaginal cerclage procedures.

MATERIALS AND METHODS

During the Nordic Federation of Obstetrics and Gynecology (NFOG) congress in 2023, surgeons proficient in transvaginal cerclage procedures performed a transvaginal cerclage on a simulator. To compare the observed and self-assessed outcomes we obtained measurements on the cerclage height and number of bites from the detachable cervix, and from computed tomography scans we analyzed suture bite depth, reduction of cervix surface area, and whether cerclages had perforated the cervical canal. The same outcomes were self-assessed by each participant after the cerclage procedure. We visualized the continuous paired data in a Bland-Altman plot and compared these data with a paired t-test. Paired binary data was analyzed using McNemars test.

RESULTS

29 participants from eight different nationalities performed one transvaginal cerclage each. The mean height of the cerclage was 26.8 mm (SD 9 mm) and mean depth was 6.5 mm (SD 1.9 mm) across a mean of 4.1 (SD 0.8) bites. The mean reduction of the cervix surface area was 7.6 % (SD 5.9 %). Two sutures perforated the cervical canal. The participants significantly underestimated the height of their cerclage with a mean difference of 6.0 mm (95 % CI 2.1-9.9), (p 0.002), between the observed and the self-assessed height, but otherwise revealed good self-assessment of their performed procedure.

CONCLUSIONS

Overall, the experienced cerclage surgeons showed a genuine insight into their surgical performance of a transvaginal cerclage. These results could warrant development of a procedural guidelines with objective measures, now reassured that surgeons are capable of self-assessing their procedures.

Rescue Cerclage by McDonald's Technique at 18 Weeks for Cervical Insufficiency With Intravaginal Amniotic Sac: A Case Report

Recurrent pregnancy loss, premature birth, and associated complications exhibit a multifactorial etiology and persist as substantial challenges during pregnancy, despite the notable advancements in the medical field. Among several factors, cervical insufficiency or incompetence emerges as a prominent causal factor, characterized by painless softening and shortening of the cervix associated with absent contractions. The implementation of emergency cerclage represents a pivotal intervention in mitigating preterm birth among individuals with advanced cervical insufficiency. By extending gestational age, this procedure increases the likelihood of neonatal survival without elevating the risk of chorioamnionitis or preterm rupture of the membranes. In this study, an antenatal woman presented with advanced changes in the cervix along with intravaginal bulging amniotic membranes at 18 weeks and underwent a rescue cervical cerclage, resulting in a successful pregnancy.