The association between the degree of cervical dilatation before ultrasound and physical examination indicated cerclage and subsequent neonatal outcomes

INTRODUCTION

Preterm identification of cervical dilation in pregnant women leads to the application of emergency cervical cerclage with an expectation of achieving term delivery. However, this is not always feasible. Short- and long-term neonatal complications post-preterm birth pose a significant challenge. It is crucial to anticipate potential complications and understand the possibilities of postpartum development as they can be encountered. We aimed to evaluate the effect of the degree of cervical dilatation before ultrasound and physical examination-indicated cerclage in singleton pregnancies presenting with premature cervical dilatation with bulging fetal membranes (rescue cerclage) on subsequent neonatal outcomes.

MATERIALS AND METHODS

In this retrospective clinical study, over a 10-year period between January 2009 and January 2019, 72 singleton pregnancies undergoing rescue cerclage were included and divided into two groups according to pre-cerclage cervical dilatation: Group 1 (n = 33) and Group 2 (n = 39) with cervical dilatation ≤3 cm and >3 cm, respectively. Latency period for pregnancy prolongation, gestational age at delivery, birth weight, and neonatal morbidity and mortality were compared across the groups. Logistic regression was used to delineate the independent effect of cervical dilatation at cerclage placement on neonatal mortality.

RESULTS

Group 2 had a higher delivery rate at ≤28 weeks' gestation (p = 0.007) and lower birth weight (p = 0.002) compared to Group 1, with an increased mean latency period in Group 2 (90 ± 55 days versus 52 ± 54 days, p = 0.005). The newborn intensive care unit (NICU) requirement, respiratory distress syndrome (RDS), neonatal jaundice and sepsis, and retinopathy of prematurity (ROP) were more frequent in Group 2. Neonatal mortality rate was higher (52.6% versus 24.2%, p = 0.015) and intact survival was lower (23.1% versus 48.4%, p = 0.013) in Group 2, whereas rates of cerebral palsy (8% and 9%, respectively) were similar between the groups (p = 0.64).

CONCLUSION

Advanced cervical dilatation (>3 cm) during physical examination-indicated cerclage in singleton pregnancies is associated with earlier delivery, leading to increased neonatal morbidity and mortality when compared with pregnancies having lesser degrees of cervical dilatation at cerclage. However, short-term poor neurological outcomes seem comparable.

Perinatal outcomes of twin emergency cerclage: comparison with expectant treatment and singleton emergency cerclage

The present study aimed to evaluate the perinatal outcomes and influencing factors in twin pregnancies undergoing emergency cervical cerclage. The present retrospective cohort study included clinical data that were recorded between January 2015 and December 2021 at The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University (China). The study included data from 103 pregnancies (26 twin and 77 singleton pregnancies) that underwent emergency cerclage and 17 twin pregnancies that underwent expectant treatment. The median gestational age of twin emergency cerclage was significantly lower than that of singleton emergency cerclage, but higher than that of expectant treatment (28.5, 34.0 and 24.0 weeks, respectively). The median interval to delivery of twin emergency cerclage was significantly lower than that of singleton emergency cerclage, but significantly higher than that of expectantly treated twin pregnancies (37.0, 78.0 and 7.0 days, respectively).IMPACT STATEMENTWhat is already known on this subject? An important cause of premature birth is cervical insufficiency. Cervical cerclage extends the gestational period of women with cervical insufficiency. According to 2019 SOGC's No. 373-Cervical Insufficiency and Cervical Cerclage, both twin and single pregnancies benefit from emergency cerclage. However, there is minimal information about the pregnancy outcomes of emergency cerclage in twin pregnancies.What the results of this study add? This study shows that the outcomes of pregnancy in twin pregnancies undergoing emergency cerclage were better than that of expectant treatment but worse than that in singleton pregnancies undergoing emergency cerclage.What the implications are of these findings for clinical practice and/or further research? In this study, pregnant women with cervical insufficiency in twin pregnancies can benefit from emergency cerclage, we should treat those pregnant women as early as possible.

Abnormal vaginal flora and spontaneous preterm birth in high-risk singleton pregnancies with cervical cerclage

OBJECTIVE

To investigate abnormal vaginal and suture-based bacterial flora for associations with spontaneous preterm birth in high-risk singleton pregnancies with an ultrasound-indicated or emergency cervical cerclage.

MATERIALS AND METHODS

A retrospective study of 196 singleton pregnancies with an ultrasound-indicated or emergency cerclage at the Royal Women's Hospital, Australia, from 2004 to 2018. High vaginal swabs were collected regularly between 14 and 26 weeks' gestation, including pre- and post-cerclage insertion, and sent for microscopy and culture. Cervical suture was cultured upon removal. Primary outcomes were spontaneous preterm birth <37, <34 and <30 weeks.

RESULTS

43.4% (85/196) of women delivered preterm. The acquisition and persistence of vaginal Escherichia coli following cerclage insertion were independently associated with spontaneous preterm birth <37 weeks (p = .0225, p = .0477). Escherichia coli growth from the cervical suture upon removal was associated with spontaneous preterm birth <34 weeks (p = .0458). The acquisition of vaginal mixed anaerobes post-cerclage was independently associated with spontaneous preterm birth <34 weeks (p = .0480).

CONCLUSION

For singleton pregnancies with an ultrasound-indicated or emergency cerclage, the presence of vaginal or suture-based Escherichia coli following cerclage insertion yields increased risk of cerclage failure and spontaneous preterm birth.

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.

Amnioreduction with rescue cerclage at advanced cervical dilation or gestational age

OBJECTIVE

To determine the feasibility of rescue cerclage and amnioreduction at advanced cervical dilation or gestational age.

METHODS

We present a retrospective case series of women who underwent rescue cerclage at either an advanced gestational age (24 + 0 to 24 + 6 weeks) or cervical dilation (≥4 cm), with a subset undergoing amnioreduction prior to cerclage placement.

RESULTS

Nine women were included and amnioreduction was performed in 7 (78%). A bi-modal distribution of obstetric outcomes was observed, with 5 (56%) women delivering ≥34 weeks gestation, 3 (33%) of which delivered at term. Two (22%) women experienced intra-operative rupture of membranes and subsequent perinatal deaths. Two (22%) women delivered extremely premature, with one resulting in infant death.

DISCUSSION

Our data show that rescue cerclage with amnioreduction may be successful at advanced gestational ages or cervical dilations, suggesting that these women should be included in prospective studies to better establish the efficacy and safety of this procedure.

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.

Emergency cerclage following a standardized protocol offers an effective and safe therapeutic option for women with high risk for prematurity - a retrospective monocentric cohort study on 130 pregnancies and 155 neonates

Objective: To present emergency cerclage (EC) as a safe and effective therapeutic option for prevention of prematurity in women with advanced cervical dilation in second-trimester pregnancy. It is focused on seemingly futile situations like cervical dilation >5 cm, bulging membranes and multifetal pregnancies. The outcomes of interest are the prolongation of pregnancy, gestational age at delivery and neonatal morbidity and mortality related to distinct risk factors.Study design: Retrospective monocentric cohort study involving 130 pregnancies (105 single and 25 twin pregnancies) and 155 neonates by using a standardized protocol. Women between 18 and 28 gestational weeks with cervical shortening of <10 mm + cervical dilation >2 cm and/or bulging membranes were included. Analyses of maternal and neonatal parameters were done by chart review.Results: The medium gestational age at delivery was 35 5/7 week with a medium interval from cerclage placement to delivery of 83 days. Overall, 46.5% (72/155) neonates were born beyond 37 weeks, extreme prematurity of less than 28 gestational weeks was observed in 14.8% (23/155), no miscarriage before 22 weeks was documented. The neonatal mortality was 1.9% (3/155). Neonatal deaths and morbidity was related to severe prematurity exclusively. The association of amnion-infection syndromes and failing therapy was significantly with respect to bulging membranes and advanced cervical dilation >5 cm.Conclusions: Even in futile cases EC can be an option to save the pregnancy and prevent severe prematurity. However, a standardized protocol is imminent for successful therapy and every indication has to be a case by case decision.

Twin pregnancies treated with emergency or ultrasound-indicated cerclage to prevent preterm births

Introduction: Multiple gestations are high-risk pregnancies associated with an increased risk of neonatal morbidity and mortality, mainly due to preterm births. Numerous interventions have been attempted in order to delay the time of delivery and subsequently, prevent preterm births in twin gestations. To date, no really effective intervention has been found. Use of cerclage in twin pregnancies has been controversial. Recently, however, small retrospective cohort studies have shown a potentially positive effect with the use of cerclage in twin pregnancies. The aim of this study was to evaluate pregnancies and neonatal outcomes in twin gestations with a short cervix treated with cervical cerclage at a single University Hospital.Methods: This retrospective cohort study included all women - with twin gestation and a short cervix - who had an ultrasound indicated or emergency cervical cerclage at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark between January 1999 and May 2017. Cervical cerclage was offered to women before 26 weeks of gestation if: (1) the cervix at ultrasound was ≤20 mm without cervical dilatation (ultrasound-indicated cerclage), or (2) the cervix at ultrasound was ≤20 mm with cervical dilatation (emergency cerclage). Women with history-indicated cerclage placement or multifetal embryo reduction were excluded. A total of 65 women participated in the study.Results: The median gestational age at cerclage placement was 22.6 weeks with a median cervical length of 10 mm (range 0-20 mm). The frequency of preterm delivery before 32 weeks of gestation was 41.5% and 27.7% before 28 weeks. Median pregnancy latency was 77 days (range 4-148) and the median gestational age at delivery was 33.0 weeks. Gestational age at delivery was significantly lower among women with cervical dilatation and visible membranes than among women with a short cervix only (27.7 versus 33.6 weeks, p < .01) and so was the median pregnancy latency (48 versus 81 days, p < .05). Overall, neonatal survival was 91.5%.Conclusion: Cervical cerclage in twin pregnancies may prolong pregnancy even when placed on a very short or dilated cervix. In our study, the procedure was safe and without any serious complications. The overall neonatal survival rate was high.

Successful Rescue Cerclage in a Monochorionic Diamniotic Twin Pregnancy at 20 Weeks: Case Report and Overview of Literature

BACKGROUND

In twin pregnancies, elective cerclage placement based on obstetrical history or ultrasound findings has been shown to be ineffective and even harmful. There are currently no guidelines for the use of rescue cervical cerclage in twin pregnancies.

CASE

The current report presents the case of a 33-year-old patient with monochorionic diamniotic twins (MCDA) found to have dilated cervix at 3.5cm with exposed membranes upon physical examination at 19 weeks and 3 days. An emergency McDonald cerclage was placed at 20 weeks and the patient carried the current pregnancy until 35weeks 6 days.

CONCLUSION

Rescue cerclage represents an important option to consider in order to preserve twin pregnancies regardless of chorionicity.

Amniotic fluid total antioxidant capacity and nitric oxide in emergency cerclage

OBJECTIVE

Nitric oxide (NO) is one of the reactive oxygen species (ROS) that has been associated with inflammation. Total antioxidant capacity (TAC) neutralizes ROS. We evaluated that amniotic fluid (AF) TAC and NO correlate with the outcome of emergency cerclage.

METHODS

Thirty-six women with cervical dilatation (≥2 cm) and bulging membranes between 16 and 24 weeks underwent emergency cerclage. Sixty-seven women between 16 and 24 weeks who had amniocentesis for chromosomal test provided control samples. AF samples were tested for TAC, and NO, and then correlated with pregnancy outcome.

RESULTS

AF TAC was significantly lower in cerclage group than control group (cerclage: 92.6 mmol/L versus control: 127.2 mmol/L, p < 0.001). Higher levels of AF TAC were associated with a longer latency from cerclage to delivery (r = 0.62, p < 0.001). NO was similar between two groups (p = 0.35). The mean gestational age at delivery of control group was better than cerclage group (cerclage: 29.5 weeks versus control: 39.4 weeks, p < 0.01).

CONCLUSION

Higher levels of AF TAC are correlated with longer prolongation days after cerclage. However, AF NO and iNOS are not different between two groups.

Infant outcomes following midtrimester emergency cerclage in the presence of fully dilated cervix and prolapsing amniotic membranes into the vagina

OBJECTIVE

To investigate the morbidity of infants, whose delivery was prolonged by an emergency cervical cerclage (EC).

METHODS

Ante- and postnatal data on subsequent EC procedures performed between 14 and 28 weeks of gestation for advanced cervical dilatation with prolapsing of amniotic membranes at a single institution within a 5-year-period were retrieved.

RESULTS

We identified 21 fetuses from 18 pregnancies. Median gestational age [interquartile range, IQR] at EC and prolongation of pregnancy was 21.5 [15-26] weeks and 49.3 [24-92] days, respectively. There were 4 (19%) stillbirths, 3 (14%) neonatal deaths, and 1 (5%) infant death. Ten infants (59% of livebirths) were admitted to neonatal intensive care unit and hospitalized for a median period of 11 [6-66] d. Of the surviving fetuses (14/21, 66.7%), 9 (42.8%) were intact, whereas 3 (17.6% of livebirths) had cerebral palsy (CP), 1 was diagnosed with hypothyroidism, and another had growth failure at 12 months of follow-up.

CONCLUSION

EC seems to be beneficial only in a subset of pregnancies presenting with full cervical dilatation accompanied by prolapsing amniotic membranes into the vagina, and there is a requirement for more objective selection criteria. Neonatal morbidity, especially neurodevelopmental disability should be discussed thoroughly prior to this procedure.

Effectiveness of delayed absorbable monofilament suture in emergency cerclage

OBJECTIVE

To determine the sustained effects of emergency cerclage using slowly absorbable monofilament sutures, changes in cervical length after cerclage were evaluated in six cases.

MATERIALS AND METHODS

A delayed absorbable monofilament suture (1 PDS-Plus; Ethicon, Inc., Somerville, NJ, USA) has been used for emergency cerclage after 20 weeks of gestation at Juntendo University Hospital since January 2011. A retrospective chart review was conducted including all of the patients undergoing emergency cerclage between January 2011 and August 2013. The patients' characteristics, perinatal outcome, cervical length, and obstetric data were collected.

RESULTS

Six cases were identified from our medical records. Their characteristics and perinatal outcomes are shown in Table 1. Of the six cases, four had an extremely short cervix, with an average cervical length of 7.85 ± 3.38 mm, and two had prolapsed membranes. Fig. 1 shows the cervical length and the time elapsed after cerclage. There were no cases with shortening of the cervical length below the levels at the cerclage.

CONCLUSION

This absorbable monofilament suture appears useful for emergency cerclage.

Use of a uniconcave balloon in emergency cerclage

Pushing bulging fetal membranes back into the uterine cavity effectively without rupture of fetal membranes during emergency cerclage is a concern to obstetricians. We have developed a new uniconcave balloon device for repositioning fetal membranes into the uterus during emergency cerclage. Our technique can be accomplished easily with few complications.

Emergency cerclage placement in multifetal pregnancies with a dilated cervix and exposed membranes: case series

Pregnancies complicated by midtrimester painless cervical dilation are known to have associations with preterm birth. In situations where fetal amniotic membranes are exposed, the risk of perinatal morbidity and mortality increases dramatically in this particularly high-risk population. Multifetal gestations further increase the risk of preterm birth, yet there remains a paucity of data supporting therapeutic intervention for these patients. We report a case series of 12 multifetal gestations with painless cervical dilation and exposed fetal membranes that underwent emergency cerclage placement. Pregnancy prolongation was achieved on average 60.25 days with 76.9% neonatal survival. These findings are suggestive that emergency cerclage may be a beneficial treatment in this unique patient population.