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Kirstine Hansen L, Shennan AH, Louise Eisland-Schmidt Christiansen E, Tydeman G, Stirrat L, Bek Helmig R, Uldbjerg N, Glavind J. Transvaginal cervical cerclage - How well do surgeons assess their own procedures? Eur J Obstet Gynecol Reprod Biol 2024; 302:268-272. [PMID: 39340895 DOI: 10.1016/j.ejogrb.2024.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 09/20/2024] [Accepted: 09/23/2024] [Indexed: 09/30/2024]
Abstract
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.
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Affiliation(s)
- Lea Kirstine Hansen
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Andrew H Shennan
- Department of Women and Children's Health, St Thomas' Hospital, King's College London, London, United Kingdom.
| | | | - Graham Tydeman
- Department of Obstetrics and Gynecology, NHS Fife, Kirkcaldy, United Kingdom
| | - Laura Stirrat
- Department of Obstetrics and Gynecology, Royal Infirmary of Edinburgh, United Kingdom.
| | - Rikke Bek Helmig
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Julie Glavind
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
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Story L, Shennan A. Cervical cerclage: An evolving evidence base. BJOG 2024. [PMID: 38962809 DOI: 10.1111/1471-0528.17905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/05/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024]
Abstract
Cervical cerclage is an established intervention for the management of pregnancies at high risk of preterm birth. Although studies exist to support its use in certain situations, particularly in singleton pregnancies, many questions such as adjunct therapies and efficacy in specific subgroups of high-risk women have not been fully elucidated. This review will assess the current evidence as well as areas where there is currently a paucity of data and an urgent requirement for further research.
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Affiliation(s)
- Lisa Story
- Department of Women and Children's Health King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew Shennan
- Department of Women and Children's Health King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Hsieh MH, Chen CP, Sun FJ, Chen YY, Wang LK, Chen CY. Changes in cervical elastography, cervical length and endocervical canal width after cerclage for cervical insufficiency: an observational ultrasound study. BMC Pregnancy Childbirth 2023; 23:750. [PMID: 37875844 PMCID: PMC10594665 DOI: 10.1186/s12884-023-06071-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/16/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND We previously demonstrated that pregnant women with a history of cervical insufficiency had a softer anterior cervical lip, shorter cervical length and wider endocervical canal in the first trimester. The aim of this study was to investigate changes in cervical elastography, cervical length, and endocervical canal width in the second trimester after cerclage, and further discuss whether these ultrasound parameters are predictive of preterm delivery. METHODS This was a secondary analysis of cervical changes in singleton pregnancies after cerclage from January 2016 to June 2018. Cervical elastography, cervical length, and endocervical canal width were measured during the second trimester in the cervical insufficiency group and control group without cervical insufficiency. Strain elastography under transvaginal ultrasound was used to assess cervical stiffness and presented as percentage (strain rate). RESULTS Among the 339 pregnant women enrolled, 24 had a history of cervical insufficiency and underwent cerclage. Both anterior and posterior cervical lips were significantly softer in the cervical insufficiency group even though they received cerclage (anterior strain rate: 0.18 ± 0.06% vs. 0.13 ± 0.04%; P = 0.001; posterior strain rate: 0.11 ± 0.03% vs. 0.09 ± 0.04%; P = 0.017). Cervical length was also shorter in the cervical insufficiency group (36.3 ± 3.6 mm vs. 38.3 ± 4.6 mm; P = 0.047). However, there was no significant difference in endocervical canal width between the two groups (5.4 ± 0.7 mm vs. 5.6 ± 0.7 mm; P = 0.159). Multivariate logistic regression analysis also revealed significant differences in anterior cervical lip strain rate (adjusted odds ratio [OR], 7.32, 95% confidence interval [CI], 1.70-31.41; P = 0.007), posterior cervical lip strain rate (adjusted OR, 5.22, 95% CI, 1.42-19.18; P = 0.013), and cervical length (adjusted OR, 3.17, 95% CI,1.08-9.29; P = 0.035). Among the four ultrasound parameters, softer anterior cervical lip (P = 0.024) and shorter cervical length (P < 0.001) were significantly related to preterm delivery. CONCLUSIONS Cervical cerclage can prevent widening of the endocervical canal, but not improve cervical elasticity or cervical length. Measuring anterior cervical elastography and cervical length may be valuable to predict preterm delivery.
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Affiliation(s)
- Meng-Hsuen Hsieh
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, No. 92, Section 2, Zhong-Shan North Road, Taipei, 10449, Taiwan
| | - Chie-Pein Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, No. 92, Section 2, Zhong-Shan North Road, Taipei, 10449, Taiwan
| | - Fang-Ju Sun
- Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yi-Yung Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, No. 92, Section 2, Zhong-Shan North Road, Taipei, 10449, Taiwan
| | - Liang-Kai Wang
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, No. 92, Section 2, Zhong-Shan North Road, Taipei, 10449, Taiwan
| | - Chen-Yu Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, No. 92, Section 2, Zhong-Shan North Road, Taipei, 10449, Taiwan.
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.
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Giouleka S, Boureka E, Tsakiridis I, Siargkas A, Mamopoulos A, Kalogiannidis I, Athanasiadis A, Dagklis T. Cervical Cerclage: A Comprehensive Review of Major Guidelines. Obstet Gynecol Surv 2023; 78:544-553. [PMID: 37976303 DOI: 10.1097/ogx.0000000000001182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Importance Cervical cerclage (CC) represents one of the few effective measures currently available for the prevention of preterm delivery caused by cervical insufficiency, thus contributing in the reduction of neonatal morbidity and mortality rates. Objective The aim of this study was to review and compare the most recently published major guidelines on the indications, contraindications, techniques, and timing of placing and removal of CC. Evidence Acquisition A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC), and the International Federation of Gynecology and Obstetrics (FIGO) on CC was carried out. Results There is a consensus among the reviewed guidelines regarding the recommended techniques, the indications for rescue CC, the contraindications, as well as the optimal timing of CC placement and removal. All medical societies also agree that ultrasound-indicated CC is justified in women with history of prior spontaneous PTD or mid-trimester miscarriage and a short cervical length detected on ultrasound. In addition, after CC, serial sonographic measurement of the cervical length, bed rest, and routine use of antibiotics, tocolysis, and progesterone are unanimously discouraged. In case of established preterm labor, CC should be removed, according to ACOG, RCOG, and SOGC. Furthermore, RCOG and SOGC agree on the prerequisites that should be met before attempting CC. These 2 guidelines along with FIGO recommend history-indicated CC for women with 3 or more previous preterm deliveries and/or second trimester pregnancy miscarriages, whereas the ACOG suggests the use of CC in singleton pregnancies with 1 or more previous second trimester miscarriages related to painless cervical dilation or prior CC due to painless cervical dilation in the second trimester. The role of amniocentesis in ruling out intra-amniotic infection before rescue CC remains a matter of debate. Conclusions Cervical cerclage is an obstetric intervention used to prevent miscarriage and preterm delivery in women considered as high-risk for these common pregnancy complications. The development of universal international practice protocols for the placement of CC seems of paramount importance and will hopefully improve the outcomes of such pregnancies.
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Affiliation(s)
- Sonia Giouleka
- Resident, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eirini Boureka
- Resident, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Tsakiridis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Siargkas
- Resident, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Mamopoulos
- Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Kalogiannidis
- Associate Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Athanasiadis
- Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Themistoklis Dagklis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Stirrat LI, Tydeman F, Suff N, Hall M, English WJ, Shennan AH, Tydeman G. Cervical cerclage technique: what do experts actually achieve? Am J Obstet Gynecol MFM 2023; 5:100961. [PMID: 37080297 DOI: 10.1016/j.ajogmf.2023.100961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/26/2023] [Accepted: 03/30/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Cervical cerclage is a recognized intervention in the management of women at risk of preterm birth and midtrimester loss. The mechanism of action of cerclage is unclear, and the technique has been poorly researched. OBJECTIVE This study aimed to evaluate cerclage technique among experienced obstetricians, using a previously developed and evaluated cerclage simulator. STUDY DESIGN This prospective experimental simulation and observational study used identical simulators for 28 consultant obstetricians who were asked to perform their normal cerclage. Suture type, height, knot site, and free thread length were recorded. Using computed tomography, depth of bite and tension (by reduction in area of cervix) were calculated. RESULTS A total of 52 cervical cerclages were completed (Mersilene tape, n=20; monofilament suture, n=32). Mean suture height was 33 mm (standard deviation, 7.7 mm), greater with monofilament suture than with Mersilene tape, and associated with smaller needle size. Mean depth of bite and mean reduction of starting area did not differ by suture type. Seven procedures showed ≥1 suture bite that had entered the cervical canal once or more. CONCLUSION This study assessed cerclage technique of experienced obstetricians using simulators and computed tomography imaging, and demonstrated wide variation in technique; this may affect the efficacy of the procedure. Further work should establish optimal technique and consensus for training and clinical practice.
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Affiliation(s)
- Laura I Stirrat
- Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (Dr Stirrat).
| | - Florence Tydeman
- Department of Population Health Sciences, King's College London, London, United Kingdom (Dr F Tydeman)
| | - Natalie Suff
- Department of Women and Children's Health, St Thomas' Hospital, King's College London, London, United Kingdom (Drs Suff, Hall, and Shennan)
| | - Megan Hall
- Department of Women and Children's Health, St Thomas' Hospital, King's College London, London, United Kingdom (Drs Suff, Hall, and Shennan)
| | - Wendy J English
- Departments of Radiology (Ms English), Victoria Hospital, Kirkcaldy, United Kingdom
| | - Andrew H Shennan
- Department of Women and Children's Health, St Thomas' Hospital, King's College London, London, United Kingdom (Drs Suff, Hall, and Shennan)
| | - Graham Tydeman
- Departments of Obstetrics & Gynaecology (Dr G Tydeman), Victoria Hospital, Kirkcaldy, United Kingdom
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Ridout AE, Carter J, Seed PT, Chandiramani M, David AL, Tribe RM, Shennan AH. Longitudinal change in cervical length following vaginal or abdominal cervical cerclage: a randomized comparison. Am J Obstet Gynecol MFM 2023; 5:100987. [PMID: 37146686 DOI: 10.1016/j.ajogmf.2023.100987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/22/2023] [Accepted: 04/26/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Cervical cerclage has been shown to reduce the risk of recurrent spontaneous preterm birth in a high-risk patient population; however, the mechanism is not well understood. Transabdominal cerclage is superior to low and high vaginal cerclage in reducing early spontaneous preterm birth and fetal loss in women with previous failed vaginal cerclage. Cervical length measurements are commonly used to monitor high-risk women and may explain the mechanism of success. OBJECTIVE This study aimed to evaluate the rate of change in longitudinal cervical length after randomized placement of low transvaginal, high transvaginal, or transabdominal cerclage in women with a previous failed vaginal cerclage. STUDY DESIGN This was a planned analysis of longitudinal transvaginal ultrasound cervical length measurements from patients enrolled in the Vaginal Randomised Intervention of Cerclage trial, a randomized controlled trial comparing transabdominal cerclage or high transvaginal cerclage with low transvaginal cerclage. Cervical length measurements at specific gestational ages were compared over time and between groups, using generalized estimating equations fitted using the maximum-likelihood random-effects estimator. In addition, cervical length measurements were compared in women with transabdominal cerclage placed before and during pregnancy. The diagnostic accuracy of cervical length as a predictor of spontaneous preterm birth at <32 weeks of gestation was explored. RESULTS This study included 78 women who underwent longitudinal cervical length assessment (70% of the analyzed cohort) with a history of failed cerclage, of whom 25 (32%) were randomized to low transvaginal cerclage, 26 (33%) to high transvaginal cerclage, and 27 (35%) to transabdominal cerclage. Abdominal cerclage was superior to low (P=.008) and high (P=.001) vaginal cerclage at maintaining cervical length over the surveillance period (14 to 26 weeks of gestation) (+0.08 mm/week, 95% confidence interval, -0.40 to 0.22; P=.580). On average, the cervical length was 1.8 mm longer by the end of the 12-week surveillance period in women with transabdominal cerclage (+1.8 mm; 95% confidence interval, -7.89 to 4.30; P=.564). High vaginal cerclage was no better than low cervical cerclage in the prevention of cervical shortening; the cervix shortened by 13.2 mm over 12 weeks in those with low vaginal cerclage (95% confidence interval, -21.7 to -4.7; P=.002) and by 20 mm over 12 weeks in those with high vaginal cerclage (95% confidence interval, -33.1 to -7.4; P=.002). Preconception transabdominal cerclage resulted in a longer cervix than those performed during pregnancy; this difference was significant after 22 weeks of gestation (48.5 mm vs 39.6 mm; P=.039). Overall, cervical length was an excellent predictor of spontaneous preterm birth at <32 weeks of gestation (receiver operating characteristic curve, 0.92; 95% confidence interval, 0.82-1.00). CONCLUSION In women with a previous failed cervical cerclage, in the next pregnancy, the cervical length in women treated with vaginal cerclage funneled and shortened over time, whereas there was preservation of cervical length in women who receive transabdominal cerclage. Cervical length remained longer in transabdominal procedures performed before pregnancy than in transabdominal procedures performed during pregnancy. Overall, cervical length was an excellent predictor of spontaneous preterm birth in our cohort. Our findings may explain the mechanism of benefit for transabdominal cerclage, with its high placement better maintaining the structural integrity of the cervix at the level of the internal os.
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Affiliation(s)
- Alexandra E Ridout
- Faculty of Life Sciences and Medicine, Department of Women and Children's Health, School of Life Course Sciences and Population Health, King's College London, London, United Kingdom (Drs Ridout and Carter, Mr Seed, and Drs Chandiramani, Tribe, and Shennan).
| | - Jenny Carter
- Faculty of Life Sciences and Medicine, Department of Women and Children's Health, School of Life Course Sciences and Population Health, King's College London, London, United Kingdom (Drs Ridout and Carter, Mr Seed, and Drs Chandiramani, Tribe, and Shennan)
| | - Paul T Seed
- Faculty of Life Sciences and Medicine, Department of Women and Children's Health, School of Life Course Sciences and Population Health, King's College London, London, United Kingdom (Drs Ridout and Carter, Mr Seed, and Drs Chandiramani, Tribe, and Shennan)
| | - Manju Chandiramani
- Faculty of Life Sciences and Medicine, Department of Women and Children's Health, School of Life Course Sciences and Population Health, King's College London, London, United Kingdom (Drs Ridout and Carter, Mr Seed, and Drs Chandiramani, Tribe, and Shennan)
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom (Dr David)
| | - Rachel M Tribe
- Faculty of Life Sciences and Medicine, Department of Women and Children's Health, School of Life Course Sciences and Population Health, King's College London, London, United Kingdom (Drs Ridout and Carter, Mr Seed, and Drs Chandiramani, Tribe, and Shennan)
| | - Andrew H Shennan
- Faculty of Life Sciences and Medicine, Department of Women and Children's Health, School of Life Course Sciences and Population Health, King's College London, London, United Kingdom (Drs Ridout and Carter, Mr Seed, and Drs Chandiramani, Tribe, and Shennan)
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Ridout AE, Ross G, Seed PT, Hezelgrave NL, Tribe RM, Shennan AH. Predicting spontaneous preterm birth in asymptomatic high-risk women with cervical cerclage. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:617-623. [PMID: 36647576 DOI: 10.1002/uog.26161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To determine the performance of the predictive markers of spontaneous preterm birth, cervicovaginal quantitative fetal fibronectin (fFN) and cervical length, in asymptomatic high-risk women with transabdominal, history-indicated or ultrasound-indicated cervical cerclage. METHODS This was a secondary analysis of a prospective cohort of asymptomatic high-risk women with cervical cerclage and no other prophylactic intervention (including progesterone), who attended the preterm birth clinic at a central London teaching hospital between October 2010 and September 2016. Women had either transabdominal cerclage, placed prior to conception, history-indicated cerclage, placed before 14 weeks' gestation, or ultrasound-indicated cerclage for a short cervix (< 25 mm), placed before 24 weeks. All women underwent serial cervical length assessment on transvaginal ultrasound in the second trimester (16-28 weeks), and quantitative fFN testing from 18 weeks onward. Test performance was analyzed for the prediction of spontaneous preterm birth before 30 weeks (cerclage failure), 34 weeks and 37 weeks, using receiver-operating-characteristics (ROC)-curve analysis. RESULTS Overall, 181 women were included in the analysis. Cervical length and fFN were strong predictors of spontaneous preterm birth before 30 weeks in women with cerclage, with areas under the ROC curve (AUC) of 0.86 (95% CI, 0.79-0.94) and 0.84 (95% CI, 0.75-0.92), respectively. Cervical length was a better predictor of preterm birth before 30 weeks in women with history-indicated compared to those with ultrasound-indicated cerclage, although both showed clinical utility (AUC, 0.96 (95% CI, 0.91-1.00) vs 0.79 (95% CI, 0.66-0.91); P = 0.01). Quantitative fFN was a strong predictor of spontaneous preterm birth before 30 weeks in women with history-indicated cerclage (AUC, 0.91 (95% CI, 0.75-1.00)) and retained clinical utility in those with ultrasound-indicated cerclage (AUC, 0.76 (95% CI, 0.64-0.89)). There were no spontaneous deliveries before 34 weeks in women with a transabdominal cerclage, so AUC was not calculated. Delivery was delayed significantly in this group (P < 0.01). CONCLUSIONS Cervical length and quantitative fFN retain clinical utility for the prediction of spontaneous preterm birth in women with cervical cerclage, and prediction is best in women with a history-indicated stitch. These tests can be relied upon to discriminate risk and have utility when planning clinical management with regard to treatment failure. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A E Ridout
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - G Ross
- University of Newcastle, Callaghan, NSW, Australia
| | - P T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - N L Hezelgrave
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - R M Tribe
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - A H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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Ye X, Yang Y, Li J, Chang K, Xu H. Clinical factors in predicting extreme preterm birth after cerclage. Chin Med J (Engl) 2023; 136:370-372. [PMID: 35970594 PMCID: PMC10106176 DOI: 10.1097/cm9.0000000000002188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Xuping Ye
- Department of Obstetrics, Obstetrics and Gynecology Hospital affiliated to Fudan University, Shanghai 200011, China
| | - Yuezhou Yang
- ShanghaiJiai Genetics and IVF Center, Obstetrics and Gynecology Hospital affiliated to Fudan University, Shanghai 200011, China
| | - Jun Li
- Department of Obstetrics, Obstetrics and Gynecology Hospital affiliated to Fudan University, Shanghai 200011, China
| | - Kaikai Chang
- Department of Obstetrics, Obstetrics and Gynecology Hospital affiliated to Fudan University, Shanghai 200011, China
| | - Huan Xu
- Department of Obstetrics, Obstetrics and Gynecology Hospital affiliated to Fudan University, Shanghai 200011, China
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Adedipe TO, Akintunde AA, Chukwujama UO. Management of an incompetent mid-second (mid-2nd) trimester absent ecto-cervix: a case series. Cervical amplification pre-cerclage insertion. Arch Gynecol Obstet 2022; 306:969-975. [PMID: 35859041 DOI: 10.1007/s00404-022-06694-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 06/26/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Cervical cerclage is a treatment for an incompetent cervix, the latter being a contributor to spontaneous preterm birth. There is significant difficulty with a transvaginal cerclage insertion for the absent vaginal or ecto-cervix in the mid-2nd trimester period resulting in a higher risk of late miscarriages, extremely preterm labour with increased neonatal morbidity and mortality. METHODS A retrospective review of 5 consecutive cases managed by a surgical technique-modified high vaginal cerclage insertion at 18-20 weeks-and adjunct protocols which included vaginal progesterone use, serial infection screening and lifestyle advice, over a 12-month period ending in August 2021, is presented. Inclusion criteria included minimal or absent ecto-cervix, singleton pregnancies with an incompetent cervix attending for a vaginal cerclage whilst exclusion criteria were the usual contraindications to a cerclage insertion. Primary outcome was delivery after 34 weeks whilst seconday outcomes included maternal hemorrhage, bowel/bladder injury, chorioamnionitis and neonatal admission. RESULTS A increased gestational latency of 13 gestational weeks (range 12-18). Mean gestational age at delivery was 36 weeks +1 (253 days) with a range of 241-264 days. Delivery after 34 weeks gestational age was 100% with no maternal surgical complications and corresponding neonatal outcomes. CONCLUSION There is a potential therapeutic benefit of this technique and adjunct management, in managing an incompetent mid-2nd trimester absent ecto-cervix.
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Affiliation(s)
- T O Adedipe
- Women and Children's Hospital, Hull University Teaching Hospital NHS Trust, Hull, HU3 2JZ, UK.
| | - A A Akintunde
- Good Hope Hospital, Rectory road, Birmingham, B75 7RR, UK
| | - U O Chukwujama
- Women and Children's Hospital, Hull University Teaching Hospital NHS Trust, Hull, HU3 2JZ, UK
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Shennan A, Story L, Jacobsson B, Grobman WA. FIGO good practice recommendations on cervical cerclage for prevention of preterm birth. Int J Gynaecol Obstet 2021; 155:19-22. [PMID: 34520055 PMCID: PMC9291060 DOI: 10.1002/ijgo.13835] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cervical cerclage is an intervention which when given to the right women can prevent preterm birth and second‐trimester fetal losses. A history‐indicated cerclage should be offered to women who have had three or more preterm deliveries and/or mid‐trimester losses. An ultrasound‐indicated cerclage should be offered to women with a cervical length <25 mm if they have had one or more spontaneous preterm birth and/or mid‐trimester loss. In high‐risk women who have not had a previous mid‐trimester loss or preterm birth, an ultrasound‐indicated cerclage does not have a clear benefit in women with a short cervix. However, for twins, the advantage seems more likely at shorter cervical lengths (<15 mm). In women who present with exposed membranes prolapsing through the cervical os, a rescue cerclage can be considered on an individual case basis, taking into account the high risk of infective morbidity to mother and baby. An abdominal cerclage can be offered in women who have had a failed cerclage (delivery before 28 weeks after a history or ultrasound‐indicated [but not rescue] cerclage). If preterm birth has not occurred, removal is considered at 36–37 weeks in women anticipating a vaginal delivery. Cervical cerclage given to the right women can prevent preterm birth and second‐trimester fetal losses.
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Affiliation(s)
- Andrew Shennan
- Department of Women and Children's Health, King's College London, London, UK
| | - Lisa Story
- Department of Women and Children's Health, King's College London, London, UK
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Genetics and Bioinformatics, Domain of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
| | - William A Grobman
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Park H, Kwon DY, Kim SY, Park J, Kim YM, Sung JH, Choi SJ, Oh SY, Kim JS, Roh CR. Association of adherence to guidelines for cervical cerclage with perinatal outcomes and placental inflammation in women with cervical length ≥2.0 cm. Taiwan J Obstet Gynecol 2021; 60:665-673. [PMID: 34247804 DOI: 10.1016/j.tjog.2021.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Cerclage operation is one of the most common obstetric controversies. The aim of this study was to compare the perinatal outcomes and placental inflammation of cerclage performed adherent and non-adherent to international guidelines. MATERIAL AND METHODS This study included all consecutive women with singleton deliveries who underwent cerclage. According to the current American College of Obstetricians and Gynecologists (ACOG) guideline, we designated our study population into two groups: the adherent-to-guideline and non-adherent groups. Each group was categorized into two groups according to cervical length (CL) at the time of cerclage (<2.0 cm vs. ≥2.0 cm). We evaluated the reasons for cerclage, maternal characteristics, perioperative variables, pregnancy and neonatal outcomes, and placental inflammatory pathology according to the criteria proposed by the Society of Pediatric Pathology. RESULTS Among 310 women with cerclage, we excluded patients (n = 21) with indicated preterm delivery (PTD), major fetal anomaly, fetal death in-utero, and missing information for reason of cerclage. We also excluded patients who underwent physical examination-indicated cerclage (n = 53) and with missing information of CL at the time of cerclage (n = 52). A total of 184 women were eventually analyzed. In women with CL < 2.0 cm, the non-adherent group showed similar PTD (<28 weeks, <34 weeks) and neonatal composite morbidity rates compared to the adherent-to-guideline group. However, in women with CL ≥ 2.0 cm, the non-adherent group manifested significantly higher PTD (<28 weeks; 16.7% vs. 4.4%, p = 0.04, <34 weeks; 23.8% vs. 5.8%, p = 0.006) and neonatal composite morbidity (20.5% vs. 5.9%, p = 0.028) rates than the adherent-to-guideline group despite similar perioperative variables and lower PTD history rates. The non-adherent group with CL ≥ 2 cm at the time of cerclage was also associated with severe histologic chorioamnionitis (p = 0.033). CONCLUSION Cerclage performed beyond the current guidelines in pregnant women with CL ≥ 2.0 cm may confer an additional risk of perinatal complications in association with severe placental inflammation.
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Affiliation(s)
- Hyea Park
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Do Youn Kwon
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seo-Yeon Kim
- Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Juyoung Park
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yoo-Min Kim
- Department of Obstetrics and Gynecology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Ji-Hee Sung
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Suk-Joo Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo-Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Jung-Sun Kim
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Cheong-Rae Roh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Bloomfield J, Pénager C, Mandelbrot L. Shirodkar cerclage: Obstetrical and neonatal outcomes in a single-center cohort of 55 cases. J Gynecol Obstet Hum Reprod 2021; 50:102152. [PMID: 33887533 DOI: 10.1016/j.jogoh.2021.102152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/09/2021] [Accepted: 04/15/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cervical insufficiency is thought to be responsible for 10% of preterm deliveries. Shirodkar cerclage is among the available techniques ranging from McDonald's to definitive procedures, however the indications for the prevention of preterm births and mid-trimester miscarriages are still poorly delineated. OBJECTIVE To describe the characteristics, obstetrical and neonatal outcomes of pregnancies with Shirodkar cerclage procedures. METHOD We performed a descriptive retrospective single-center study, including all patients who had a Shirodkar cerclage between January 1, 2008 and December 31, 2020. The main outcomes measured were delivery at or beyond 24 and 32 weeks of gestations (WG). RESULTS 55 Shirodkar cerclages were performed over the period studied. 7.3% of patients had a uterine malformation, 9% had a history of cervical conization. 74.5% had history of one or more mid-trimester miscarriages. 63.6% had a history of a failed emergency or prophylactic cerclage. The median gestational age (GA) at cerclage placement was 14 WG. There were 4 deliveries before 24 WG, 8 before 32 WG and 16 before 37 WG. Overall neonatal survival was 48/53 (90.6%). The median GA at delivery was 38 weeks (IQR 35-39), with 70.3% of vaginal deliveries. CONCLUSION Shirodkar cerclage was successful in more than 90% of patients, despite their obstetric history. Shirodkar cerclage may be indicated in the event of prior cerclage failure using the McDonald technique or in order to allow for correct stitch placement in very short cervixes. Its advantage over definitive cerclage is to allow for vaginal delivery.
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Affiliation(s)
- Joy Bloomfield
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Louis Mourier, Colombes, France; Université de Paris, Paris, France; FHU PREMA, Paris and Colombes, France
| | - Cécile Pénager
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Louis Mourier, Colombes, France; Université de Paris, Paris, France; FHU PREMA, Paris and Colombes, France
| | - Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Louis Mourier, Colombes, France; Université de Paris, Paris, France; FHU PREMA, Paris and Colombes, France; Inserm UMR1137 IAME, Paris, France.
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Muniz Rodriguez A, Naert M, Colatosti Catanho A, Labovitis E, Rebarber A, Fox NS. The association between sonographic cervical length components and preterm birth in women with ultrasound- or exam-indicated cerclage. J Matern Fetal Neonatal Med 2021; 35:5703-5708. [PMID: 33645406 DOI: 10.1080/14767058.2021.1892061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate which parameters of a sonographic cervical length measurement are associated with preterm birth in women with ultrasound- or exam-indicated cerclage. METHODS This was a retrospective cohort study of women with singleton pregnancies who underwent ultrasound- or exam-indicated Shirodkar cerclage by a single maternal-fetal medicine practice between 2011 and 2019. All patients underwent sonographic cervical length measurement 2-3 weeks after cerclage placement, and then every 2-4 weeks up to 32 weeks. The images from the first and second post-cerclage cervical lengths were reviewed. Total cervical length, upper cervical length (from the internal cervical os to the cerclage), and lower cervical length (from the cerclage to the external os) were measured. The primary outcome for this study was gestational age at delivery. RESULTS A total of 114 women with cerclage were included (85 (74.6%) ultrasound-indicated and 29 (25.4%) exam-indicated). The first and second total cervical lengths correlated with gestational age at delivery (r = 0.26, p=.005; r = 0.33, p<.001, respectively), and the change from first to second was inversely correlated with gestational age at delivery (r = -0.20, p=.032). The first and second upper cervical lengths also correlated with gestational age at delivery (r = 0.22, p = .019; r = 0.33, p<.001, respectively), and the change from first to second upper cervical length was inversely correlated with gestational age at delivery (r= -0.20, r = 0.029). Neither the first nor the second lower cervical lengths were significantly associated with gestational age at delivery. On regression analysis, total cervical length and upper cervical length were not independently associated with gestational age at delivery (p = .108 and p=.806, respectively, for the first scan; p = .153 and p=.166, respectively, for the second scan). CONCLUSIONS Postcerclage total cervical length and upper cervical length are both associated with gestational age at delivery and risk of preterm birth, but not independently. After ultrasound- or exam-indicated cerclage, sonographic monitoring of either the total cervical length or the upper cervical length might be predictive of gestational age at delivery and the risk of preterm birth.
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Affiliation(s)
| | | | | | | | - Andrei Rebarber
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Maternal Fetal Medicine Associates, PLLC, New York, NY, USA
| | - Nathan S Fox
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Maternal Fetal Medicine Associates, PLLC, New York, NY, USA
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15
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Kunpalin Y, Burul G, Greenwold N, Tetteh A, Casagrandi D, Warner D, Fox G, Greig E, James CP, David AL. Factors associated with preterm birth in women undergoing cervical cerclage. Eur J Obstet Gynecol Reprod Biol 2020; 251:141-145. [PMID: 32505054 DOI: 10.1016/j.ejogrb.2020.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/03/2020] [Accepted: 05/13/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Cervical cerclage is used to manage women at high risk of late miscarriage (LM) and spontaneous preterm birth (PTB) due to factors such as history of cervical insufficiency (CI), uterine anomaly, cervical surgery and ultrasound (US) diagnosed cervical shortening. Urinary tract infection (UTI) and subsequent pyelonephritis, and bacterial infection are associated with PTB, but their role in PTB after cervical cerclage is unknown. We examined the relationship between UTI and bacterial vaginosis (BV), fetal fibronectin (fFN) test and PTB in women undergoing elective- or US-indicated cervical cerclage. We also investigated whether fetal fibronectin (fFN) test were useful to predict PTB. STUDY DESIGN This is a single center, retrospective study of singleton pregnant women at PTB clinic, University College London Hospital (UCLH, 2005-2015) who underwent elective or US-indicated cervical cerclage. Women were tested for UTI and BV before cerclage placement and received mid-gestation fFN testing. Patient data were extracted from the PTB clinic database and electronic records. Statistical analyses used Pearson's chi-square and Mann-Whitney U tests. P values were corrected by Bonferroni method as required. RESULTS 267 singleton pregnant women attended our clinic with completed birth outcome. Of those, 32.2% (86/267) delivered prematurely. All women with UTI or BV received antibiotic treatment. Women with a UTI before cerclage placement were more likely to deliver preterm when compared to those with negative MSU culture (OR 3.39, 95%CI 1.24-9.27, p = 0.04). Their gestational age at delivery were also lower than those with negative MSU result (36+6, IQR 31+4-38+2week vs 38+1, IQR 36+1-39+5-week, p = 0.05). However, UTI after cerclage placement or BV either before or after cerclage placement were not associated with PTB. Women who had a positive fFN result were more likely to deliver preterm (OR 3.85, 95% CI 1.81-8.41, p = 0.0007). CONCLUSIONS The presence of a UTI before cervical cerclage is associated with a higher rate of PTB in women who receive a cervical cerclage, even when treated. We did not find an association between pre or post-cerclage BV or post-cerclage UTI and PTB. Further research is needed to elucidate the link between UTI and PTB in women undergoing cervical cerclage.
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Affiliation(s)
- Yada Kunpalin
- Fetal Medicine Unit, Elizabeth Garrett Anderson Obstetric Wing, University College London Hospital NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK; Elizabeth Garrett Anderson Institute for Women's Health, University College London, 86-96 Chenies Mews, Bloomsbury, London WC1E 6AU, UK.
| | - Giorgia Burul
- Fetal Medicine Unit, Elizabeth Garrett Anderson Obstetric Wing, University College London Hospital NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - Natalie Greenwold
- Fetal Medicine Unit, Elizabeth Garrett Anderson Obstetric Wing, University College London Hospital NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - Amos Tetteh
- Fetal Medicine Unit, Elizabeth Garrett Anderson Obstetric Wing, University College London Hospital NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - Davide Casagrandi
- Fetal Medicine Unit, Elizabeth Garrett Anderson Obstetric Wing, University College London Hospital NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - Deborah Warner
- Fetal Medicine Unit, Elizabeth Garrett Anderson Obstetric Wing, University College London Hospital NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - Georgina Fox
- Fetal Medicine Unit, Elizabeth Garrett Anderson Obstetric Wing, University College London Hospital NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - Eliza Greig
- Fetal Medicine Unit, Elizabeth Garrett Anderson Obstetric Wing, University College London Hospital NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - Catherine P James
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, 86-96 Chenies Mews, Bloomsbury, London WC1E 6AU, UK
| | - Anna L David
- Fetal Medicine Unit, Elizabeth Garrett Anderson Obstetric Wing, University College London Hospital NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK; Elizabeth Garrett Anderson Institute for Women's Health, University College London, 86-96 Chenies Mews, Bloomsbury, London WC1E 6AU, UK
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16
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Shennan A, Chandiramani M, Bennett P, David AL, Girling J, Ridout A, Seed PT, Simpson N, Thornton S, Tydeman G, Quenby S, Carter J. MAVRIC: a multicenter randomized controlled trial of transabdominal vs transvaginal cervical cerclage. Am J Obstet Gynecol 2020; 222:261.e1-261.e9. [PMID: 31585096 DOI: 10.1016/j.ajog.2019.09.040] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/30/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Vaginal cerclage (a suture around the cervix) commonly is placed in women with recurrent pregnancy loss. These women may experience late miscarriage or extreme preterm delivery, despite being treated with cerclage. Transabdominal cerclage has been advocated after failed cerclage, although its efficacy is unproved by randomized controlled trial. OBJECTIVE The objective of this study was to compare transabdominal cerclage or high vaginal cerclage with low vaginal cerclage in women with a history of failed cerclage. Our primary outcome was delivery at <32 completed weeks of pregnancy. STUDY DESIGN This was a multicenter randomized controlled trial. Women were assigned randomly (1:1:1) to receive transabdominal cerclage, high vaginal cerclage, or low vaginal cerclage either before conception or at <14 weeks of gestation. RESULTS The data for 111 of 139 women who were recruited and who conceived were analyzed: 39 had transabdominal cerclage; 39 had high vaginal cerclage, and 33 had low vaginal cerclage. Rates of preterm birth at <32 weeks of gestation were significantly lower in women who received transabdominal cerclage compared with low vaginal cerclage (8% [3/39] vs 33% [11/33]; relative risk, 0.23; 95% confidence interval, 0.07-0.76; P=.0157). The number needed to treat to prevent 1 preterm birth was 3.9 (95% confidence interval, 2.32-12.1). There was no difference in preterm birth rates between high and low vaginal cerclage (38% [15/39] vs 33% [11/33]; relative risk, 1.15; 95% confidence interval, 0.62-2.16; P=.81). No neonatal deaths occurred. In an exploratory analysis, women with transabdominal cerclage had fewer fetal losses compared with low vaginal cerclage (3% [1/39] vs 21% [7/33]; relative risk, 0.12; 95% confidence interval, 0.016-0.93; P=.02). The number needed to treat to prevent 1 fetal loss was 5.3 (95% confidence interval, 2.9-26). CONCLUSION Transabdominal cerclage is the treatment of choice for women with failed vaginal cerclage. It is superior to low vaginal cerclage in the reduction of risk of early preterm birth and fetal loss in women with previous failed vaginal cerclage. High vaginal cerclage does not confer this benefit. The numbers needed to treat are sufficiently low to justify transabdominal surgery and cesarean delivery required in this select cohort.
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17
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Battarbee AN, Ellis JS, Manuck TA. Beyond Cervical Length: Association between Postcerclage Transvaginal Ultrasound Parameters and Preterm Birth. Am J Perinatol 2019; 36:1317-1324. [PMID: 31039598 PMCID: PMC7008975 DOI: 10.1055/s-0039-1688480] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the value of transvaginal ultrasound parameters after cerclage placement in estimating the risk of spontaneous preterm birth. STUDY DESIGN This is a retrospective cohort at a single tertiary care center from 2013 to 2016. Women carrying a singleton, nonanomalous fetus with cerclage in situ and at least one postcerclage transvaginal ultrasound from 160/7 to 256/7 weeks' gestation were included. In addition to abstracting maternal demographic and obstetric characteristics, two study investigators separately reviewed each of the images from the first transvaginal ultrasound after cerclage placement, masked to pregnancy outcomes. We measured the angle between the anterior uterine wall and cervical canal at the internal os and external os, closed canal length above and below the stitch, width of the anterior and posterior cervix at the level of the cerclage, and stitch distance from the cervical canal. The presence of additional ultrasound findings such as sludge and cervical funneling was also noted. The main outcomes were preterm birth < 34 weeks and preterm birth < 37 weeks. Transvaginal ultrasound parameters were compared between women with preterm birth and those without preterm birth using chi-square, Fisher's exact, and Wilcoxon's rank-sum tests, as appropriate. Log binomial regression was used to estimate the relative risk of preterm birth for all significant obstetric and ultrasound characteristics. RESULTS A total of 102 women met inclusion criteria: 58% had history-indicated, 20% ultrasound-indicated, and 23% exam-indicated cerclages. Of these, 28 (27.5%) women delivered at < 34 weeks' gestation, and 48 (47.0%) women delivered at < 37 weeks' gestation. Preterm birth did not vary by race, maternal age, insurance, smoking, or gestational age of the earliest prior preterm birth (for multiparous women), but women who had preterm birth were more likely to have exam-indicated cerclage. There were several transvaginal ultrasound parameters associated with preterm birth < 34 weeks and preterm birth < 37 weeks. Of these, cervical length below the stitch, stitch distance from the cervical canal, straight cervical canal, funneling to or past the stitch, and presence of sludge had the greatest effect sizes. CONCLUSION Rates of preterm birth are high postcerclage. In addition to measuring cervical length, utilization of postcerclage transvaginal ultrasound to evaluate the location of the cerclage within the cervix, the curvature of the cervical canal, and the presence of funneling and sludge may help identify women who are at the highest risk for preterm birth.
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Affiliation(s)
- Ashley N. Battarbee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Joshua S. Ellis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Tracy A. Manuck
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
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Saridogan E, O’Donovan OP, David AL. Preconception laparoscopic transabdominal cervical cerclage for the prevention of midtrimester pregnancy loss and preterm birth: a single centre experience. Facts Views Vis Obgyn 2019; 11:43-48. [PMID: 31695856 PMCID: PMC6822953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND A recent Cochrane review concluded that cervical cerclage reduces preterm birth before 37, 34 and 28 weeks of gestation and also probably reduces the risk of perinatal death. Transabdominal cerclage was developed for a subgroup in whom transvaginal cerclage had failed or was not possible. This approach appeared more effective in improving foetal survival rates or obstetric outcomes. Most commonly transabdominal cervical cerclage is placed at laparotomy (open transabdominal cerclage), but with the advance of minimal access techniques, laparoscopic transabdominal cervical cerclage is replacing the traditional open operation. The objective of this prospective case series is to explore the outcomes of pre-conception laparoscopic transabdominal cerclage procedures. METHOD Data was prospectively collected from 54 women at high risk of second trimester miscarriage and preterm delivery due to cervical insufficiency undergoing pre-conception laparoscopic transabdominal cerclage by a single operator. This included demographics, obstetric and gynaecological history (including previous cervical cerclage procedures), surgical complication rates, conception and subsequent pregnancy outcomes. RESULTS There were 36 pregnancies progressing beyond the first trimester with a "take home baby" rate of 89% (32/36), a live birth rate of 92% (33/36) and neonatal survival rate of 97% (32/33). The mid-trimester loss (MTL) rate was 8% (3/36) with delivery rates after 37 weeks of 75% (27/36) and between 34 -37 weeks of 8% (3/36) and 23-34 weeks of 8% (3/36). CONCLUSIONS Our prospective case series provides further evidence that laparoscopic transabdominal cerclage (TAC) is feasible, safe and effective when transvaginal cerclage fails or is not possible.
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Affiliation(s)
- E Saridogan
- Women’s Health, Elizabeth Garrett Anderson Wing, University College London Hospital, 235 Euston Road, London, NW1 2BU, United Kingdom;,Institute for Women’s Health, University College London, 86-96 Chenies Mews, London WC1E 6HX, United Kingdom
| | - OP O’Donovan
- Women’s Health, Elizabeth Garrett Anderson Wing, University College London Hospital, 235 Euston Road, London, NW1 2BU, United Kingdom;,St Michael’s Hospital, Southwell Street, Bristol BS28EG, United Kingdom
| | - AL David
- Women’s Health, Elizabeth Garrett Anderson Wing, University College London Hospital, 235 Euston Road, London, NW1 2BU, United Kingdom;,Institute for Women’s Health, University College London, 86-96 Chenies Mews, London WC1E 6HX, United Kingdom;,NIHR University College London Hospitals Biomedical Research Centre, Maple House, 149 Tottenham Court Road, London W1T 7DN, United Kingdom
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19
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Bigelow CA, Naqvi M, Namath AG, Ali M, Fox NS. Cervical length, cervical dilation, and gestational age at cerclage placement and the risk of preterm birth in women undergoing ultrasound or exam indicated Shirodkar cerclage. J Matern Fetal Neonatal Med 2019; 33:2527-2532. [PMID: 30486708 DOI: 10.1080/14767058.2018.1554050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Preterm birth is a major cause of neonatal morbidity and mortality in the USA. In many patients at risk for preterm birth, cervical length (CL) screening is used to guide decisions regarding cerclage placement. Quality evidence shows that cerclage prolongs pregnancy in high-risk women with a short CL in women with a history of preterm birth and in women with painless cervical dilation in the second trimester, though the degree of cervical shortening, dilation, or gestational age at cerclage placement are not consistently associated with the subsequent rate of preterm birth. Our objective was to determine if cervical length (CL), cervical dilation or gestational age (GA) at the time of cerclage placement are associated with preterm birth among women undergoing ultrasound-indicated or exam-indicated cerclage.Study design: This was a retrospective cohort study of all patients with a singleton pregnancy who underwent ultrasound-indicated or exam-indicated Shirodkar cerclage placement at a single maternal-fetal medicine practice in New York City between November 2005 and May 2017. All patients included in the study had previously undergone CL screening for an increased risk of preterm birth (for example, prior spontaneous preterm birth or mid-trimester loss, prior cervical excision). The cervical length or dilation and GA at the time of cerclage placement were collected, as were demographic and obstetric outcome data for the current pregnancy. The primary outcome was delivery <36 or ≥36 weeks. Planned subgroup analyses of the primary outcome were performed based on CL at the time of ultrasound-indicated cerclage (0-9 mm, 10-19 mm, ≥20 mm), cervical dilation at the time of physical exam-indicated cerclage (<2 cm vs. ≥2 cm), and gestational age at cerclage placement (<20 weeks vs. ≥20 weeks). Data were analyzed using the Student's t-test and chi-square test for trend.Results: There were 123 and 39 patients in the ultrasound- and exam-indicated cerclage groups, respectively. Twenty six (21.2%) patients in the ultrasound-indicated subgroup and 24 patients (61.5%) in the exam-indicated subgroup delivered <36 weeks. CL (16.4 versus 17.6 mm, p = .28) and GA (19.7 versus 20.0 weeks, p = .58) at the time of ultrasound-indicated cerclage placement were not significantly different in patients who delivered <36 and ≥36 weeks' gestation, respectively. Women with cervical dilation ≥2 cm prior to exam-indicated cerclage placement were significantly more likely to deliver <36 weeks when compared to women with cervical dilation <2 cm (77.8 versus 47.6%, p = .05); however, there were no significant differences in rates of preterm birth <28 and <32 weeks between these two groups (38.9 versus 23.8%, p = .31 and 50.0% versus 28.6%, p = .17, respectively).Conclusions: Cervical length and GA at the time of ultrasound-indicated Shirodkar cerclage placement do not appear to impact the likelihood of preterm birth <36 weeks, while cervical dilation ≥2 cm at the time of exam-indicated Shirodkar cerclage is associated with an increased rate of preterm birth <36 weeks, but not earlier gestational ages at delivery.
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Affiliation(s)
- Catherine A Bigelow
- Department of Obstetrics, Gynecology & Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mariam Naqvi
- Department of Obstetrics, Gynecology & Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amalia G Namath
- Department of Obstetrics, Gynecology & Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Munira Ali
- Department of Obstetrics, Gynecology & Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nathan S Fox
- Department of Obstetrics, Gynecology & Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Atia H, Ellaithy M, Altraigey A, Ibrahim H. Knot positioning during McDonald cervical cerclage, does it make a difference? A cohort study. J Matern Fetal Neonatal Med 2018; 32:3757-3763. [PMID: 29764255 DOI: 10.1080/14767058.2018.1471676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Objective: To study the effect of McDonald cerclage knot position on the different maternal and neonatal outcomes. Methods: This historical cohort study included women with singleton pregnancy who had a prophylactic McDonald cervical cerclage between 1 May 2010 and 31 September 2017. Maternal and neonatal outcome parameters were compared between the anterior and posterior knot cerclage procedures. The primary outcome measure was the rate of term birth. Results: 550 Women had a prophylactic McDonald cervical cerclage, 306 with anterior knot (Group A) and 244 with posterior knot (Group B). There were no statistically significant differences regarding gestational age (GA) at delivery (36.3 ± 4.2 versus 35.8 ± 5.3 for groups A and B respectively), term birth rate, post-cerclage cervical length, symptomatic vaginitis, urinary tract infection, difficult cerclage removal and cervical lacerations. Similarly, there were no statistically significant differences as regards the studied neonatal outcomes including take home babies, neonatal intensive care admission, respiratory distress syndrome and neonatal sepsis. Survival analysis on GA at delivery demonstrated no statistically significant difference as regards the proportion of term deliveries in the anterior and posterior knot cerclage groups (log-rank test p-value = .478). Conclusions: Knot positioning during McDonald cervical cerclage, anteriorly or posteriorly, didn't significantly impact the studied maternal and neonatal outcomes.
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Affiliation(s)
- Hytham Atia
- a Obstetrics and Gynecology Department , Armed Forces Hospital Southern Region , Khamis Mushait , Saudi Arabia.,b Obstetrics and Gynecology Department , Zagazig University , Zagazig , Egypt
| | - Mohamed Ellaithy
- a Obstetrics and Gynecology Department , Armed Forces Hospital Southern Region , Khamis Mushait , Saudi Arabia.,c Obstetrics and Gynecology Department , Ain Shams University , Cairo , Egypt
| | - Ahmed Altraigey
- a Obstetrics and Gynecology Department , Armed Forces Hospital Southern Region , Khamis Mushait , Saudi Arabia.,d Obstetrics and Gynecology Department , Benha University , Benha , Egypt
| | - Heba Ibrahim
- a Obstetrics and Gynecology Department , Armed Forces Hospital Southern Region , Khamis Mushait , Saudi Arabia
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