Development and validation of a model for individualized prediction of cervical insufficiency risks in patients undergoing IVF/ICSI treatment

Early Magnetic Resonance Imaging Measurements and Prediction of Second Trimester Pregnancy Loss: a Nomogram Model Analysis

Objective

To investigate the magnetic resonance imaging (MRI) features of women with prior second-trimester pregnancy loss, and to establish a nomogram prediction model for subsequent miscarriage.

Methods

A retrospective cohort study of women with prior second-trimester pregnancy loss from January 2018 to December 2021 in Second Affiliated Hospital of Soochow University was performed. A total of 245 patients were included. Data from January 2018 to December 2019 were used to construct the model, and data from January 2020 to December 2021 were used to evaluate the model. Data on maternal demographic characteristics, MRI cervical measurements were extracted. The prediction model was constructed with independent variables determined by multivariate logistic regression analyses. Through receiver-operating characteristic (ROC) curve analysis, the predictive ability of the model for subsequent second trimester pregnancy loss in women was evaluated, and internal validation was performed through validation data.

Results

Thin cervix was observed in 77 (31.42%) women with prior second-trimester pregnancy loss, the mean longitudinal diameter of cervical canal on MRI was 11.76±2.75mm. The model reached a sensitivity of 80%, specificity of 75.90%, positive predictive value (PPV) of 55.80% and negative predictive value of 90.90%; ROC characteristics proved that the model was superior to any single parameter with an AUC of 0.826.

Conclusion

Our observations showed that thin cervix and longitudinal diameter of cervical canal reliably predicted second trimester pregnancy loss. We developed and validated a nomogram model to predict the individual probability of second trimester pregnancy loss in the next pregnancy and hopefully improve the prediction and indication of interventions.

A nomogram for predicting prognosis of patients with cervical cerclage

Introduction

Cervical insufficiency is an increased risk of midterm miscarriage and early preterm birth which increase the risk of fetal loss. This study aimed to construct a nomogram for patients with cervical insufficiency after cervical cerclage, which may assist clinicians to have individualized treatment for patients with cervical insufficiency.

Methods

A study was done retrospectively from January 2013 through July 2022 in our hospital. The primary outcomes were delivered at more than 28, 30, 32, or 34 gestational weeks. Kaplan-Meier curves were applied to analyze 17 variables. All patients were randomly split (147:64) into development and validation cohorts. Based on the multivariate Cox regression analysis, a nomogram was constructed through the 'rms' package in R.

Results

A total of 211 patients with cervical insufficiency were enrolled: 121 had history-indicated cerclage; 58 had ultrasound-indicated cerclage and 32 had emergency cerclage. Times of gestations, times of miscarriages, IVF, abdominal pain, diagnostic classification, preoperative and postoperative management were demonstrated to impact overall extended days when delivering at more than 28 gestational weeks was set as the primary outcome. Except for preoperative and postoperative management, the above other five variables impacted the primary outcomes of delivering at more than 30, 32, or 34 gestational weeks. Postoperative tocolytics had an impact on the prognosis of patients who delivered at more than 30 gestational weeks. In development cohort data, a nomogram was established to predict overall extended days of patients with cervical cerclage. In present study, C-index was 0.662 in the development cohort and 0.687 in the validation cohort respectively, suggesting that the model presented some satisfied prediction. Moreover, the clinical decision curves for patients with delivering at more than 28, 30, 32 or 34 weeks set as primary outcomes also displayed that this nomogram demonstrated good clinical predictive usefulness.

Conclusions

The nomogram developed in this study may be a valuable tool assisting clinicians to evaluate outcomes of patients with cervical insufficiency after cervical cerclage, which helps them develop individualized management for the patients.

The Association of Inflammatory Markers with Maternal-Neonatal Outcome After Cervical Cerclage

Objective

Cervical cerclage is effective in prolonging the number of weeks gestation in patients with cervical insufficiency(CI). However, valuable predictors with successful cervical cerclage remain limited. It aimed to evaluate the value of the systemic immune-inflammation index (SII), and systemic inflammation response index (SIRI) to predict the outcomes of cervical cerclage.

Methods

This study analyzed 374 participants. Inflammatory markers were calculated using maternal peripheral blood. The association of inflammatory markers and the outcome of cervical cerclage were analyzed. And the optimal cut-off values of inflammatory markers were calculated. Also, the Chi-square test and logistic and linear regression analyses were performed to evaluate inflammatory markers with the maternal outcome and neonatal outcomes.

Results

374 pregnancies were included in this study. Finally, 268 (71.7%) participants suffered successful cervical cerclage. This study demonstrated that the baseline BMI (cm²/kg), the bulging membrane, cervical dilation (≥2cm), the amniotic sac herniation, the neutrophils counts, the systemic immune-inflammation index (SII), and systemic inflammation response index (SIRI) were significant difference between the successful and unsuccessful groups (all P<0.05). Additionally, maternal blood inflammatory markers, such as WBC, lymphocyte, neutrophils, monocyte, platelet counts, SII, and SIRI, were significantly associated with maternal-neonatal outcomes. Furthermore, the results demonstrated that the SII level had the highest OR (OR=4.626; 95% CI (2.500-8.560)), as well as the following: SIRI level (OR = 3.795; 95% CI (1.989-7.242)), cervical dilation (≥2cm) (OR =3.477; 95% CI (1.458-10.844)), and amniotic sac herniation (OR = 1.796; 95% (0.473-4.975)).

Conclusion

This study demonstrated that the baseline SII level and SIRI level are important biochemical markers for predicting the outcome of cervical cerclage and maternal-neonatal outcomes with non-invasive procedures. They can help to provide personalized treatment before surgery and enhance postoperative surveillance.

Dynamic Change of Novel Systemic Inflammation Markers to Predict Maternal-Neonatal Prognosis After Cervical Cerclage

Objective

Cervical cerclage is an effective method to prevent preterm birth. However, the clinical indicators that can predict cervical cerclage remain limited. This study aimed to explore whether dynamically inflammatory markers are valuable biomarkers for the prognosis of cervical cerclage.

Methods

This study included 328 participants. Inflammatory markers were calculated using maternal peripheral blood before and after the cervical cerclage procedure. The Chi-square test, linear regression, and logistic regression were performed to evaluate the dynamic change of inflammatory markers with the prognosis of cervical cerclage. And the optimal cut-off values of inflammatory markers were calculated.

Results

Totally 328 pregnant women were analyzed in the study. 223 (67.99%) participants obtained successful cervical cerclage. This study revealed that the maternal age, the baseline BMI (cm²/kg), the times of gravida, the rate of recurrent abortion, the PPROM, cervical length shorter (<1.5cm), cervical dilation (≥2cm), the bulging membrane, the Pre-SII, the Pre-SIRI, the Post-SII, the Post-SIRI, and the ΔSII were significantly associated with outcomes after cervical cerclage (all P<0.05). Pre-SII, Pre-SIRI, Post-SII, Post-SIRI, and ΔSII levels were mainly related to maternal-neonatal outcomes. Furthermore, the results demonstrated that the ΔSII level had the highest OR (OR=14.560; 95% CI (4.461-47.518)). In addition, we revealed that Post-SII and ΔSII levels had the highest AUC (0.845/0.840) and relatively higher sensitivity/specificity (68.57/92.83% and 71.43/90.58%) and PPV/ NPV (81.82/86.25% and 78.13/87.07%) compared with other indicators.

Conclusion

This study suggested that the dynamic change of SII level and SIRI level are important biochemical markers to predict the prognosis of cervical cerclage and maternal-neonatal prognosis, especially the Post-SII and ΔSII levels. They can help to determine candidates for cervical cerclage before surgical procedure and enhance postoperative surveillance.

Identification of risk factors for incident cervical insufficiency in nulliparous and parous women: a population-based case-control study

BACKGROUND

Cervical insufficiency is one of the underlying causes of late miscarriage and preterm birth. Although many risk factors have been identified, the relative magnitude of their association with risk in nulliparous versus parous women has not been well demonstrated, especially for incident cervical insufficiency (ICI). The aim of this study was to investigate and compare the magnitude of the association of ICI with predictive factors in nulliparous and parous women, and to further investigate various aspects of obstetric history for parous women.

METHODS

Pregnant women with a first diagnosis of cervical insufficiency were compared to a random sample of control pregnancies from women with no diagnosis by using Swedish national health registers. Demographic, reproductive, and pregnancy-specific factors were compared in case and control pregnancies, and relative risks presented as odds ratios (OR), stratified by nulliparous/parous. Independent associations with ICI were estimated from multivariable logistic regression. Associations with obstetric history were further estimated for multiparous women.

RESULTS

A total of 759 nulliparous ICI cases and 1498 parous cases were identified during the study period. Multifetal gestation had a strong positive association with ICI in both groups, but of much larger magnitude for nulliparous women. The number of previous miscarriages was also a much stronger predictor of risk in nulliparous women, especially for multifetal pregnancies. History of preterm delivery (<37 weeks' gestation) was an independent predictor for parous women, and for those whose most recent delivery was preterm, the association with ICI increased with each additional week of prematurity. A previous delivery with prolonged second stage of labor or delivery of a very large infant were both inversely associated with risk of ICI in the current pregnancy.

CONCLUSIONS

The differences in importance of predictive risk factors for incident cervical insufficiency in nulliparous and parous women can help resolve some of the inconsistencies in the literature to date regarding factors that are useful for risk prediction. Stratifying on parity can inform more targeted surveillance of at-risk pregnancies, enable the two groups of women to be better informed of their risks, and eventually inform screening and intervention efforts.

A nomogram to predict extremely preterm birth in women with singleton pregnancies undergoing cervical cerclage

Objective

To develop a nomogram to predict preterm birth before 28 weeks in pregnant women undergoing cervical cerclage.

Study design

We retrospectively studied the medical records on pregnant women who underwent cervical cerclage in January 2016 to September 2020. We developed the model from a development cohort in Women's Hospital, Zhejiang university, School of medicine, which randomly divided by 7:3 into training cohort for nomogram development, and internal validation cohort to confirm the model's performance. We then tested the nomogram in an external validation cohort over a similar period. The Harrell's C-index, calibration curve, decision curve analyses (DCA) were performed to assess the model.

Results

528 patients formed the development cohort, and 97 patients formed the external validation cohort. The model initially incorporated 10 baseline variables, while 5 variables were estimated in the nomogram at last: history of prior second-trimester loss, use of in-vitro fertilization (IVF), cervical dilation at cerclage, C-reactive protein (CRP) and platelet-lymphocyte ratio (PLR). The nomogram achieved good concordance indexes of 0.82(95%CI 0.77–0.88), 0.80(95%CI 0.72–0.88) and 0.79 (95%CI 0.68–0.90) in the training, internal and external validation cohort, respectively. And the nomogram had well-fitted calibration curves. Decision curve analysis demonstrated that the nomogram was clinically useful.

Conclusions

The well-performed nomogram graphically represents the risk factors and a pre-operative predicted model in predicting the risk of preterm birth at <28 weeks in singleton pregnant women undergoing cervical cerclage. The model can provide a useful guide for clinicians and patients in making appropriate clinical decisions.

A Validated Model for Individualized Prediction of Live Birth in Patients With Adenomyosis Undergoing Frozen-Thawed Embryo Transfer

PURPOSE

This study aimed to develop a predictive tool for live birth in women with adenomyosis undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment.

METHODS

A total of 424 patients with adenomyosis who underwent frozen-thawed embryo transfer (FET) from January 2013 to December 2019 at a public university hospital were included. The patients were randomly divided into training (n = 265) and validation (n = 159) samples for the building and testing of the nomogram, respectively. Multivariate logistic regression (MLR) was developed on the basis of clinical covariates assessed for their association with live birth.

RESULTS

In total, 183 (43.16%) patients became pregnant, and 114 (26.88%) had a live birth. The MLR showed that the probability of live birth was significantly correlated with age [odds ratio (OR), 3.465; 95% confidence interval (CI), 1.215-9.885, P = 0.020], uterine volume (OR, 8.141; 95% CI, 2.170-10.542; P = 0.002), blastocyst transfer (OR, 3.231; 95% CI, 1.065-8.819, P = 0.023), twin pregnancy (OR, 0.328; 95% CI, 0.104-0.344, P = 0.005), and protocol in FET (P < 0.001). The statistical nomogram was built based on age, uterine volume, twin pregnancy, stage of the transferred embryo, and protocol of FET, with an area under the curve (AUC) of 0.837 (95% CI: 0.741-0.910) for the training cohort. The AUC for the validation cohort was 0.737 (95% CI: 0.661-0.813), presenting a well-pleasing goodness-of-fit and stability in this model.

CONCLUSIONS

This visual and easily applied nomogram built on the risk factors of live birth in patients with adenomyosis provides useful and precise information for physicians on individualized decision-making during the IVF/ICSI procedure.