The efficacy of emergency cervical cerclage in singleton and twin pregnancies: a systematic review with meta-analysis

OBJECTIVE

An emergency (rescue) cervical cerclage can be offered to pregnant women presenting with dilatation and prolapsed membranes in the second trimester of pregnancy because of cervical insufficiency. This study aimed to investigate the effectiveness of an emergency cerclage in both singleton and twin pregnancies in the prevention of extreme premature birth.

DATA SOURCES

We performed a systematic literature search in PubMed and Embase from inception to June 2022 for transvaginal cervical emergency cerclages.

STUDY ELIGIBILITY CRITERIA

All studies on transvaginal cervical emergency cerclages with at least 5 patients and reporting survival were included.

METHODS

Included studies were assessed for quality and risk of bias with an adjusted Quality In Prognosis Studies tool. Random-effects meta-analyses and meta-regressions were performed for the primary outcome: survival.

RESULTS

Our search yielded 96 studies, incorporating 3239 women, including 14 studies with an expectant management control group, incorporating 746 women. Overall survival after cervical emergency cerclage was 74%, with a fetal survival of 88% and neonatal survival of 90%. Singleton and twin pregnancies showed similar survival, with a pregnancy prolongation of 52 and 37 days and a gestational age at delivery of 30 and 28 weeks, respectively. Meta-regression analyses indicated a significant inverse association between mean gestational age at diagnosis and pregnancy prolongation and no association between dilatation or gestational age at diagnosis and gestational age at delivery. Compared with expectant management, emergency cerclage significantly increased overall survival by 43%, fetal survival by 17% and neonatal survival by 22%, along with a significant pregnancy prolongation of 37 days and reduction in delivery at <28 weeks of gestation of 55%. These effects were more profound in singleton pregnancies than in twin pregnancies.

CONCLUSION

This systematic review indicates that, in pregnancies threatened by extreme premature birth because of cervical insufficiency, emergency cerclage leads to significantly higher survival, accompanied by significant pregnancy prolongation and reduction in delivery at <28 weeks of gestation, compared with expectant management. The mean gestational age at delivery was 30 weeks, independent of dilatation or gestational age at diagnosis. Survival was similar for singleton and twin pregnancies, implying that emergency cerclage should be considered in both.

Comparison of emergency cervical cerclage and expectant treatment in cervical insufficiency in singleton pregnancy: A meta-analysis

OBJECTIVE

To compare the therapeutic effects of emergency cervical cerclage and expectant treatment in preterm birth due to cervical insufficiency in singleton pregnancy.

METHODS

A combination of subject words and free words was used to search major domestic and foreign databases. According to inclusion and exclusion criteria, 23 studies were included that met the criteria and quality evaluation and data extraction was carried out. The data were analyzed using STATA 15 and the reporting was done in reference to the list of Preferred Reporting Items for Systematic and Meta-Analyses.

RESULTS

Emergency cervical cerclage was superior to expectant treatment for the primary outcome of pregnancy prolongation (WMD = 5.752, 95% CI 5.194-6.311, 22 studies, N = 1435, I2 = 97.1%, P = 0.000). Cervical cerclage was also superior to expectant treatment for the secondary outcomes of neonatal birth weight (WMD = 1051.542, 95% CI 594.107-1508.977, 9 studies, N = 609, I2 = 96.4%, P = 0.000), neonatal Apgar 1' (WMD = 2.8720, 95% CI: 2.105-3.639, 11 studies, N = 716, I2 = 99.0%, P = 0.000), number of live births (OR = 6.018, 95% CI 2.882-12.568, 10 studies, N = 724, I2 = 55.3%, P = 0.000), deliveries after 32 weeks (OR = 8.030, 95% CI 1.38-46.892, 8 studies, N = 381, I2 = 85.9%, P = 0.021). deliveries after 34 weeks (OR = 15.91, 95% CI 5.92-42.77, 9 studies, N = 560, I2 = 59.6%, P = 0.000), number of vaginal deliveries (OR = 3.24, 95% CI 1.32-7.90, 8 studies, N = 502, I2 = 69.4%, P = 0.018), and number of neonatal survivals (OR = 9.300, 95% CI 3.472-24.910, 10 studies, N = 654, I2 = 80.5%, P = 0.000). No difference between emergency cervical cerclage and expectant treatment was found in patients with chorioamnionitis (OR = 1.85, 95% CI 0.602-4.583, 4 studies, N = 296, I2 = 16.3%, P = 0.273).

CONCLUSION

Before the 28th week of pregnancy, emergency cervical cerclage can significantly prolong the gestational week and improve the neonatal survival rate, compared to expectant treatment, in women with singleton pregnancies who have a dilated uterine orifice caused by cervical insufficiency.

A Three-Step Procedure for Emergency Cerclage: Gestational and Neonatal Outcomes

(1) Background: The objective of our prospective observational study was to evaluate a new technique for emergency cerclage, which was performed on a cohort of patients with cervical incompetence in the second trimester. (2) Methods: 26 pregnant women presented at 15 to 24 weeks of gestation with cervical dilatation and bursa prolapse. A new emergency cerclage was performed using a technique consisting of the first cerclage in a tobacco bag and a second occlusive cerclage located inferiorly to the first. The technique is concluded with the performance of a cervical cleisis when vaginal bag prolapse is present, and this overall procedure is called the three-step procedure for emergency cerclage (TSEC). (3) Results: To assess its effectiveness, we measured the latency from procedure to delivery, pregnancy duration, infant birth weight, and rate of premature amniorrhexis. The mean latency from procedure to delivery was 14 weeks + 6 days, the mean weight of newborns was 2550 g and the mean gestational age at delivery was 35 weeks. The neonatal survival rate was 95.8%. The rate of premature amniorrhexis (<34 weeks gestational age) was 8.3% (two cases) with successful perinatal outcomes. There were significant differences (p < 0.05) between groups. A multivariate regression model showed that the best variables for predicting the latency to delivery were the cervical dilatation at diagnosis, use of the three-step cerclage, cervical length after the procedure, and gestational age at diagnosis. (4) Conclusions: The excellent results obtained with the TSEC procedure in terms of the latency from the procedure to delivery, gestational age at delivery, birth weight, and having few reported complications highlight the importance of collecting new data on this promising novel procedure.

A new quantification system for assessing the degree of acute cervical insufficiency based on physical and sonographic examination

OBJECTIVES

Acute cervical insufficiency accounts for 10-25 % of all mid-trimester pregnancy losses. However, the definition and description for the degree of acute cervical insufficiency were obscure and different among the many studies. The aim of this study was to suggest a new 4-digit quantification system and to evaluate the outcome according to the new system in women with acute cervical insufficiency.

STUDY DESIGN

A retrospective cohort study was conducted in patients with acute cervical insufficiency who underwent physical examination indicated cervical cerclage. Acute cervical insufficiency was defined as painless external os dilation with prolapsed and/or visible membranes on speculum examination. The status of fetal membranes was described using two values: 1) size of the prolapsed membrane (P, measured using ultrasound); and 2) size of visible fetal membranes (M, evaluated by speculum examination). The status of cervix was described using two values: 1) dilatation of the narrowest os (O, measured by ultrasound); and 2) functional cervical length (C, measured by ultrasound). The patients were divided into 3 groups as follows: Stage I, patients with visible fetal membranes (M > 0) but with a remaining functional cervix (C > 0) (N = 7); stage II, those with visible fetal membranes (M > 0) and a functional cervical length of 0 but without prolapsed membranes (P = 0) (N = 33); and stage III, those with prolapsed membranes (P > 0) (N = 40).

RESULTS

1) Patients who delivered before 34 weeks of gestation had a significantly lower median gestational age at cerclage operation and a significantly higher median P, M, C values than those who delivered at or beyond 34 weeks of gestation(P < 0.01 for gestational age at operation, P and M values; P < 0.05 for C value); 2) The higher the stage based on PMOC quantification system, the greater the risk of preterm delivery before <24, <32, <34, and <37 weeks of gestation (P < 0.001 for all); 3) The neonatal survival rate was 100 % (7/7) for stage I, 93.9 % (31/33) for stage II, and 60 % (24/40) for stage III.

CONCLUSION

The PMOC system was a simple method to describe the individualized conditions and to predict the risk of preterm births in all spectrums of acute cervical insufficiency.

Emergency cerclage in singleton pregnancies with painless cervical dilatation: A meta-analysis

INTRODUCTION

Emergency cerclage is the most common active intervention in pregnant women with cervical insufficiency. This meta-analysis aimed to compare the effectiveness of emergency cerclage vs expectant management on maternal and perinatal outcomes, and to assess the current status of evidence.

MATERIAL AND METHODS

A search was conducted from 1 June 2019 until 1 September 2019 and eligible studies were identified in the MEDLINE, Scopus, Cochrane and US clinical trials registry without limitations concerning the publication dates and languages. Randomized controlled trials (RCTs), non-RCTs and observational studies comparing emergency cerclage with no cerclage/expectant management, in women presenting with painless cervical dilatation were included.

RESULTS

The electronic search yielded 3607 potential studies, of which 38 were fully reviewed and 12 observational studies (1021 participants) were included. Cerclage was superior to expectant management for the primary outcomes of preterm birth before 28 and 32 gestational weeks, OR 0.25 (95% CI 0.16-0.39, five studies, N = 392, I² = 41%, low quality) and 0.08 (95% CI 0.02-0.29, four studies, N = 176, I² = 51%, low quality), respectively. Cerclage was also superior to expectant management for the secondary outcomes of fetal loss OR 0.26 (95% CI 0.12-0.56, 8 studies, N = 455, I² = 46%, very low-quality), pregnancy prolongation in days mean difference 47.45 (95% CI 39.89-55.0, 12 studies, N = 1027 I² = 86%, very low quality), gestational age at birth in weeks mean difference 5.68 (95% CI 4.69-6.67, 9 studies, N = 892, I² = 73%, very low quality), admission to neonatal intensive care OR 0.21 (95% CI 0.07-0.70, two studies, N = 79, I² = 36%, very low quality) and neonatal death OR 0.12 (95% CI 0.04-0.34, five studies, N = 130, I² = 0%, very low quality). There were no differences between cerclage and expectant management concerning premature rupture of membranes during or after the procedure OR 0.68 (95% CI 0.31-1.48, two studies, N = 155, I² = 85%, very low quality) and chorioamnionitis OR 1.14 (95% CI 0.31-4.25, three studies, N = 88, I² = 33%, very low quality).

CONCLUSIONS

Emergency cerclage in pregnant women with painless cervical dilatation seems to decrease preterm births, prolong the pregnancy, and decrease the neonatal deaths and fetal losses, but does not increase the risk of chorioamnionitis and premature rupture of membranes. Despite the extremely favorable estimates for cerclage, the results should be viewed with caution because, as a result of the lack of randomized control trials, the quality of evidence is low to very low.

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.

Emergency cerclage: gestational and neonatal outcomes

BACKGROUND

The gestational and neonatal outcomes of women with early cervical dilatation undergoing emergency cerclage were evaluated and compared with women treated with expectant management and bed rest.

METHODS

Retrospective analysis of pregnant women admitted between 2001 and 2017 with a diagnosis of early cervical dilatation and/or bulging membranes. Patients with a singleton pregnancy of a fetus without malformations, between 16 and 25 weeks and 6 days, with cervical dilatation of 1 to 3 cm were included; patients who delivered or miscarried within 2 days after admission were excluded.

RESULTS

The study enrolled 30 patients: 19 in the cerclage group and 11 in the rest group. There was a significant difference, with the cerclage group showing better results concerning gestational age at delivery (28.7 vs. 23.3 weeks; p=0.031) and latency between hospital admission and delivery (48.6 vs. 16 days; p=0.016). The fetal death rate was lower in the cerclage group (5.3% vs. 54.5%, p=0.004). Considering gestational age at delivery of live newborns, no difference was observed between the cerclage and rest groups (29.13 vs. 27.4 weeks; p=0.857).

CONCLUSIONS

Emergency cerclage was associated with longer latency, a significant impact on gestational age at delivery and reduction in the fetal death rate.

Is Uterocervical Angle Associated with Gestational Latency after Physical Exam Indicated Cerclage?

OBJECTIVE

Prediction of gestational latency after placement of physical exam indicated cerclage (PEIC) is limited. Uterocervical angle (UCA) has been associated with spontaneous preterm delivery in the general population. Our objective was to examine whether UCA is associated with gestational latency in women with PEIC.

STUDY DESIGN

This retrospective cohort included women with a singleton gestation who had PEIC placed at a single tertiary care center between January 2010 and September 2015. Ultrasound images of the cervix obtained prior to placement of PEIC were reviewed. Spearman's correlation coefficient for the relationship between UCA and gestational latency was estimated. UCA was dichotomized at 95° and 105°. Survival analyses were performed and Cox proportional hazard ratios were calculated.

RESULTS

Sixty women met the inclusion criteria. Median gestational latency was 93 days (IQR 39-121 d). There was no significant correlation between UCA and gestational latency (Spearman's rho 0.08, p = 0.54). Survival analyses demonstrated no significant difference in gestational latency stratified by UCA ≥ 95° (HR 1.19, 95% CI 0.70-2.04) or UCA ≥ 105° (HR 0.95, 95% CI 0.56-1.63). Findings persisted after adjusting for potential confounders (aHR 1.29, 95% CI 0.74-2.23 for UCA ≥ 95° and aHR 1.04, 95% CI 0.60-1.82).

CONCLUSION

UCA is not associated with gestational latency in women with PEIC.

Physical Examination-Indicated Cerclage: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate the effectiveness of physical examination-indicated cerclage in the setting of second-trimester cervical dilatation by systematic review and meta-analysis of published studies.

DATA SOURCES

We searched MEDLINE, EMBASE, Scopus, ClinicalTrials.gov, Web of Science, and the Cochrane Library for studies published between 1966 and 2014 that evaluated cervical cerclage for the treatment of cervical insufficiency.

METHODS OF STUDY SELECTION

The search yielded 6,314 citations. We included cohort studies and randomized controlled trials comparing cerclage placement with expectant management of women with cervical dilatation between 14 and 27 weeks of gestation. Two investigators independently reviewed each citation for inclusion or exclusion and discordant decisions were arbitrated by a third reviewer. Summary estimates were reported as the mean difference and 95% confidence interval (CI) for continuous variables or relative risk and with 95% CI for dichotomous outcomes. Fixed- and random-effects meta-analysis was used, depending on heterogeneity.

TABULATION, INTEGRATION, AND RESULTS

Ten studies met inclusion criteria and were included in the final analysis. One was a randomized controlled trial, two were prospective cohort studies, and the remaining seven were retrospective cohort studies. Of the 757 women, 485 (64%) underwent physical examination-indicated cerclage placement and 272 (36%) were expectantly managed. Cerclage was associated with increased neonatal survival (71% compared with 43%; relative risk 1.65, 95% CI 1.19-2.28) and prolongation of pregnancy (mean difference 33.98 days, 95% CI 17.88-50.08).

CONCLUSION

Physical examination-indicated cerclage is associated with a significant increase in neonatal survival and prolongation of pregnancy of approximately 1 month when compared with no such cerclage. The strength of this conclusion is limited by the potential for bias in the included studies.