Cerclage In Pregnancies Research Articles

Removal Versus Retention of Cervical Cerclage With Preterm Prelabor Rupture of Membranes: Systematic Review and Meta-analysis

ABSTRACT One predictor of preterm birth (PTB) is a short cervical length before 24 weeks of gestation. For pregnant women with short cervical length and a history of PTB, cervical cerclage plus progesterone is offered. This procedure has been shown to reduce the risk of PTB, pregnancy loss, and perinatal morbidity and mortality. However, it also increases the risk of preterm, premature rupture of membrane (pPROM). When pPROM occurs, the decision must be made to either remove or retain the cerclage. This decision is a challenge due to a lack of evidence to support retaining cerclage, which could prolong the duration of pregnancy, or removing it, which may decrease the risk chorioamnionitis. In addition, guidelines from international societies are conflicting: a practice bulletin from the American College of Obstetricians and Gynecologists regards both removal and retention of cerclage in pregnancies complicated with pPROM as reasonable options, whereas a practice guideline from the Royal College of Obstetricians and Gynecologists supports the removal of cerclage. The aim of this study was to compare the removal of cervical cerclage with its retention on maternal and perinatal outcomes. This was a systematic review and meta-analysis using an electronic search of Medline, Embase, and Cochrane electronic databases in February 2023. Included were prospective and retrospective publications, reported in English, which evaluated perinatal outcomes of removing or retaining cervical cerclage complicated by pPROM. Excluded were case reports, case series, review articles, letters to the editors, or editorials. The primary outcomes were pregnancy latency from pPROM >48 hours and >7 days. Quality assessment of the included studies used the Newcastle-Ottawa Scale. A total of 6 studies, representing 377 women (169 in the removal group and 208 in the retention group), were included in this systematic review. The removal group had significantly lower rates of pregnancy latency than the retention group at >48 hours (47% vs 85%; odds ratio [OR], 0.15; 95% confidence interval [CI], 0.07–0.31; P < 0.0001) and >7 days (33% vs 57%; OR, 0.30; 95% CI, 0.11–0.83; P = 0.02). However, the removal group also had lower rates than the retention groups of chorioamnionitis (29% vs 41%; OR, 0.57; 95% CI, 0.34–0.96; P = 0.03) and Apgar score <7 at 5 minutes (16% vs 43%; OR, 0.22; 95% CI, 0.08–0.56; P = 0.002). No significant differences were observed in the rates of postpartum endometritis, cesarean delivery, respiratory distress syndrome, neonatal sepsis, intraventricular hemorrhage, necrotizing enterocolitis, birthweight, fetal death, and neonatal mortality. In conclusion, the group that had cervical cerclage removal had a lower risk of experiencing pregnancy latency at >48 hours and >7 days than the group with cerclage retention. However, the retention group had a higher risk of chorioamnionitis and Apgar <7 at 5 minutes.

Prophylactic Cervical Cerclage in Cases Following Cervical Conization at a Japanese Perinatal Center.

The objective of this study was to re-examine the effect of cerclage on the possible factors associated with preterm delivery in women who had cervical conization. This was a retrospective cohort study comparing the obstetric outcomes of women with or without prophylactic cervical cerclage in pregnancy following a prior conization and managed at our institute between 2004 and 2023. In this study, there were 75% of pregnant women with a history of cervical conization. In 13 women of these (17%), prophylactic cervical cerclage was performed at 12-17 weeks' gestation. The incidence of preterm delivery was 15 (9/62) and 31% (4/13, p = 0.38) in cases with and without cervical cerclage, respectively. The prevalence of histological chorioamnionitis (CAM) in cases of preterm delivery following cervical cerclage was 100%. Prophylactic cervical cerclage in the cases following conization did not contribute to the prevention of preterm delivery associated with the development of CAM.

Laparoscopic Cerclage during Pregnancy

<h3>Study Objective</h3> The objective of this study is to demonstrate techniques for successful placement of laparoscopic cerclage in pregnancy, highlighting ways to mitigate the challenges of operating on the gravid uterus, and differences from the procedure performed outside of pregnancy. <h3>Design</h3> Video case presentation illustrative of techniques for laparoscopic cerclage in pregnancy. <h3>Setting</h3> Quaternary care academic hospital <h3>Patients or Participants</h3> 34-year-old with two prior preterm deliveries in the setting of cervical insufficiency, a prior failed vaginal cerclage, and currently 13 weeks gestation. <h3>Interventions</h3> Laparoscopic abdominal cerclage placement. <h3>Measurements and Main Results</h3> The patient had an uncomplicated pregnancy following her laparoscopic cerclage, delivering at 37 weeks by cesarean following spontaneous rupture of membranes. <h3>Conclusion</h3> There are important differences between laparoscopic placement of a cerclage outside of pregnancy and during pregnancy. For the latter, the uterus is more difficult to manipulate, the vessels are larger and more fragile, and the risk of pregnancy loss exists. Creating windows in the broad ligaments helps identify the correct location for cerclage placement and avoid injury to the uterine vessels. An anterior-to-posterior on the left, followed by posterior-to-anterior approach on the right allows for ergonomic needle handling using two 5-mm right-sided ipsilateral ports.

The comparative analysis of laparoscopic or transvaginal cerclage in pregnancies with cervical insufficiency: a retrospective cohort study.

To evaluate the efficacy and safety of prophylactic cervical cerclage by laparoscopy in pregnant women versus transvaginal way. Retrospective, monocentric cohort study was performed. The First Affiliated Hospital of Sun Yat-sen University. Cases with cervical insufficiency (defined by previous history of painless second or early third trimester pregnancy loss/losses) were selected. Laparoscopic or transvaginal cerclage were conducted. The maternal information and the neonatal data were collected and compared. The pregnancy outcomes including the incidence of full-term labor and gestational weeks at delivery were defined as the primary outcomes. Neonatal survival and birth weight, neonatal complications were evaluated as the secondary outcomes. Totally 36 twin pregnant cases and 82 singleton pregnant cases were managed with cerclage, either trans-laparoscopy (totally 78 cases) or transvaginal (totally 40 cases). Demographic characteristics showed no significant differences. Cases in laparoscopic group had a prolonged gestational age at delivery (36.43 ± 0.93weeks and 33.60 ± 2.78weeks, respectively, P < 0.001), a higher incidence of full-term labor (60.26% vs 42.50%, P = 0.05) with no significant difference of perinatal mortality (P = 0.661). Meanwhile, higher incidence of normal birth weight infants (88.46% vs 67.50%, P = 0.007) was shown in laparoscopic group with no more complications such as the cases of neonatal with Apgar < 7 (P = 0.296), and the incidence of NICU admission (P = 0.237). Besides, LTC showed good efficiency on VTC in the incidence of full-term labor: HR 0.24 (95% CI 0.070-0.85), P < 0.001. While LSC showed the similar efficiency on VSC: HR 0.734 (95% CI 0.36-1.49), P = 0.857, showing that cases with twin pregnancy may benefit more from laparoscopic cerclage. The comparative effect between laparoscopic and transvaginal cerclage in pregnant women showed that laparoscopic cerclage may be a relatively effective and safety prophylactic way for cervical insufficiency. This would be an acceptable and safe replace for traditional transvaginal cervical cerclage.

Severe maternal morbidity associated with cerclage use in pregnancy

Objective To quantify the frequency of serious maternal complications associated with cerclage use during pregnancy. Study design We performed a retrospective population-based cohort study of all live births in Ohio from 2006 to 2015. Maternal sociodemographic, medical, and obstetric characteristics were compared for births in which cerclage was utilized during the pregnancy versus those without cerclage. The primary outcome for the study was a composite of adverse outcome including maternal intensive care unit (ICU) admission, blood product transfusion, uterine rupture and unplanned hysterectomy in all births. Secondary outcomes included each of the individual adverse outcomes as well as maternal hospital transfer to a tertiary facility, unplanned operation after delivery and chorioamnionitis. Each outcome was also analyzed separately in singleton and twin births. Generalized linear modeling was used to estimate the relative risk of adverse maternal outcomes associated with cerclage placement after adjustment for coexisting risk factors. Results Of the 1,428,655 singleton and twin live births in Ohio from 2006 to 2015, 4595 [0.3%] were recorded on the birth certificate as having cerclage during pregnancy. Of those, 11.7% experienced a serious adverse maternal outcome, compared to 3.7% without cerclage, adjRR 2.7 [95% CI 2.5, 3.0]. The rate of the composite maternal adverse outcome was significantly increased for pregnancies with cerclage versus those without overall, and in singleton and twin pregnancies when measured individually [all p ≤ .001]. Even after adjustment for coexisting risk factors, cerclage remained significantly associated with composite adverse outcome in each of these groups. Conclusions Over 1 in 10 women with cerclage experience an adverse maternal outcome. Even after adjusting for gestational age at delivery and other risk factors, maternal risk for serious adverse event remains over twofold increased for pregnancies with cerclage. This information may be helpful in counseling women regarding potential maternal risk when considering neonatal benefit of cerclage in pregnancies at high risk of preterm birth.

VP35.06: Anatomical and functional changes of the uterine arteries after modified laparoscopic transabdominal cerclage in pregnancy: a case report

VP35.06: Anatomical and functional changes of the uterine arteries after modified laparoscopic transabdominal cerclage in pregnancy: a case report

Removal vs. retention of cervical cerclage in pregnancies complicated by preterm premature rupture of membranes: a retrospective study.

To compare pregnancy outcomes in women with pPROM and a cervical cerclage in whom the cerclage was removed within 24h and those in whom the cerclage was retained in situ. A two-center retrospective cohort study of women with a singleton gestation with pPROM at < 340/7weeks of gestation in the presence of cervical cerclage (January 1, 2012-July 30, 2016). Maternal and perinatal outcomes were compared between women in whom cerclage was removed within 24h from pPROM and those in whom cerclage was retained until the onset of delivery. The primary outcome was time from pPROM to delivery. Seventy women met inclusion criteria. Cerclage was left in situ in 47 (67.1%) and removed in 23 (32.9%) women. Women in the cerclage retention group had a higher pPROM-to-delivery interval (7.0 ± 7.2 vs. 6.0 ± 10.9days, p = 0.03), and were more likely to have a latency period > 48h (87.2% vs. 65.2%, p = 0.03; aOR 3.9, 95% CI 3.1-4.9) or > 7days (29.8% vs. 8.7%, p = 0.04; aOR 7.0, 95% CI 2.5-19.6) compared with women in whom cerclage was removed. Furthermore, chorioamnionitis rate was lower in the cerclage retention group compared to cerclage removal group (aOR 0.7, 95% CI 0.5-1.0). There were no differences between the groups in early neonatal sepsis, severe brain injury, or composite neonatal outcome. In women with pPROM and cervical cerclage, retention of cerclage may be associated with a longer latency period, and a lower chorioamnionitis rate, without an associated increase in the risk of neonatal infectious morbidity. Presentation information: The abstract of this study was presented as a poster at the 38th SMFM (Society of Maternal and Fetal Medicine) annual meeting, February 2018, Dallas, Texas, USA.

Anatomical and functional changes in arteries of uterine circulation after modified laparoscopic transabdominal cerclage in pregnancy: A case report and review of the literature.

Modified laparoscopic transabdominal cerclage (LTAC) was developed as a safer approach for the treatment of cervical insufficiency in pregnancy, with the cerclage tape placed lateral to the uterine vessels. We describe and review the evolution of a woman who successfully underwent an LTAC at 12 weeks of gestation, whose fetus developed growth retardation after 32 weeks. Three-dimensional power Doppler reconstruction viewed both uterine arteries (UtAs) inside of the cerclage until the second trimester. Thereafter, the visualization of UtAs showed the development of a rich array of collateral vascularization, adaptation supported by the findings of low velocity and pulsatility of blood flow in the UtAs. The appearance of the UtAs varies throughout the gestation. There is a moderate variation of the shape and curvature that could result due to their elongation. Furthermore, the cervical length increased during gestation, from 20 to 30 mm. We speculate that this is a mechanical modeling during the late gestation. More studies are needed to understand the hemodynamic and mechanical effects as well as the impact on fetal growth and development of modified LTAC in women with a short cervix or cervical incompetence.

Cerclaje transabdominal con abordaje laparoscópico en el primer trimestre con nacimiento a término

El parto pretérmino es una de las principales causas de muerte neonatal y de hospitalización antenatal. La insuficiencia cervical constituye un factor de riesgo para dicha patología, el objetivo del artículo es describir un caso de insuficiencia cervical manejado con cerclaje transabdominal por vía laparoscópica. Presentación del caso Paciente de 37 años con antecedente de tabique uterino corregido por histeroscopia a quien en su primera gestación se le realizó cerclaje vaginal fallido por parto pretérmino a las 24 semanas de gestación con producto fallecido por prematurez extrema. En el siguiente embarazo se le realizó un cerclaje transabdominal por vía laparoscópica, consiguiendo embarazo a término con recién nacido sano de 38 semanas de gestación y peso de 2840 gramos. Conclusiones: el cerclaje transabdominal por vía laparoscópica presenta tasas elevadas de éxito durante el embarazo, asociado a bajas complicaciones, menor perdida sanguínea intraoperatoria y menor estancia hospitalaria constituyéndose como una técnica factible y segura en pacientes con diagnóstico de insuficiencia cervical con algunas indicaciones tales como cerclaje vaginal previo fallido.

1091: Outcome of cerclage in pregnancies without a prior preterm birth

1091: Outcome of cerclage in pregnancies without a prior preterm birth

The therapeutic effect of cervical cerclage in pregnancy with cervical incompetence

Abstract The shortening of the cervix, cervical incompetence or insufficiency that causes late miscarriage or preterm birth syndrome gives importance and clinical significance for the cervical cerclage or cervical stitch as treatment. Nowadays closure of the cervix with cerclage surgery is an effective way of preventing premature opening of the cervix, helping the pregnancy near due date, thus significantly reducing the risk of miscarriage and premature delivery. The retrospective longitudinal cohort study is based on an examination of 164 pregnant woman who underwent cervical cerclage surgery at Obstetrics and Gynecology Clinic nr. I Târgu-Mureș, between 2000-2017. The McDonald’s method was used in every case that we have studied. Cerclage surgery was performed in most cases in the second trimester. The results in the study reflect that in the majority of the cases, intervention is effective in preventing premature opening of the cervix. Most women are multipara and had multiple gestational pregnancy, which can also contribute to the weakening and early opening of the cervical closure system. In 66.5% of the cases, at least one abortion or miscarriage is present in the history of the disease, which may also lead to a weakening of the cervical closing function. Following cerclage surgery, 11.6% abortion and 88.4% in childbirth occurred, and in most cases, intervention can effectively prevent second trimester abortion while reducing the risk of premature birth (65, 8% had no premature birth in our study).

Laparoscopic transabdominal cerclage in pregnancy: A single centre experience.

Transabdominal cerclage can reduce the risk of preterm birth in women with cervical insufficiency. This study evaluated outcomes following insertion of a laparoscopic transabdominal cerclage in pregnant women. A retrospective observational study. pregnant women who underwent laparoscopic transabdominal cerclage from 2011 to 2017. Eligible women had cervical insufficiency and were not suitable for a transvaginal cerclage. the insertion of a laparoscopic transabdominal cerclage in the pregnancy. neonatal survival, delivery of an infant at ≥34weeks gestation and surgical morbidity were evaluated. Of 19 women who underwent laparoscopic transabdominal cerclage in pregnancy, at 6-11weeks gestation, the perinatal survival rate was 100%. There were no complications. The average gestational age at delivery was 37.1weeks. Sixteen women delivered after 34weeks. Laparoscopic transabdominal cerclage is a safe and effective procedure in women with poor obstetric histories. It requires the correct skill, expertise and patient selection.

Robotic-Assisted Laparoscopic Abdominal Cerclage Placement During Pregnancy

Study ObjectiveThe objective of this study is to report our center's series of robotic-assisted laparoscopic abdominal cerclage (RALAC) placement during pregnancy. DesignDescriptive study (Canadian Task Force classification III). SettingSingle academic institution. PatientsPatients undergoing RALAC placement during pregnancy. InterventionsEleven patients underwent RALAC. Measurements and Main ResultsNine out of 11 (81.8%) primary RALAC procedures resulted in a viable live-born neonate; 8 (72.7%) were born at >34 weeks of gestation. Three patients (27.3%) had preterm premature rupture of membranes on postoperative day one, 2 of whom subsequently underwent a dilation and curettage, and 1 patient carried the pregnancy to 29 weeks and delivered a live-born neonate. Four patients had subsequent pregnancies after placement of a RALAC in the antepartum period, all of whom carried successfully beyond 36 weeks, for a total of 16 pregnancies. Fourteen pregnancies (87.5%) resulted in a live birth, and 13 pregnancies (81.3%) were delivered beyond 34 weeks. ConclusionRALAC is a minimally invasive procedure with an acceptable risk profile and comparable efficacy to traditional open abdominal cerclage. RALAC may be considered an acceptable alternative to open abdominal cerclage in pregnancy, and may be a particularly favorable option in certain settings.

Increasing Incidence Rate of Cervical Cerclage in Pregnancy in Australia: A Population-Based Study.

Objective: Data published from the United States have demonstrated that the use of cervical cerclage has fallen in the period 1998–2013. This is in contrast to recommendations in Australia. We examined this trend using data from the Australian Institute of Health and Welfare (AIHW). Study design: Retrospective population-based study. Methods: Data from the Australian Institute of Health and Welfare procedural database were used to determine the total number of cervical cerclage sutures inserted during the period 2004 to 2013. Population datasets were used to calculate age-stratified incidence rates of cerclage. Findings: There was a significant increase in the rate of cervical cerclage in women aged 25 to 34 years and in the 35 years and older age group. The incidence of preterm birth was stable for gestations of 32 to 36 weeks, but slightly increased in the 20 to 27 week and 28 to 31 week gestational age groups. Further research into cervical cerclage and the use of vaginal progesterone for the prevention of preterm birth would be valuable.

Outcome of pregnancy with history-indicated cervical cerclage insertion in a low-resource setting

Objective: History-indicated cervical cerclage insertion is required when factors in a woman's history could predispose to spontaneous miscarriage or preterm birth. This retrospective study determined the pregnancy outcome after insertion of history-indicated cervical cerclage for at least one previous mid-trimester spontaneous abortion over a 10-year period in a low-resource setting.Methods: This was a retrospective analysis of hospital data. Data was retrieved on biosocial and obstetrics parameters and analysed. The outcome measures were recurrence of spontaneous miscarriage, preterm delivery rate and fetal salvage rate. Descriptive frequencies were used to present results. The test of statistical significance was with Yates' coefficient correlation at 95% confidence interval.Results: Cervical cerclage rate was 7 per 1000 births. Diagnosis was clinical and cerclage was inserted at a mean gestational age of 15 ± 3.6 weeks. Hospital admission greater than five days after cerclage insertion had no statistically significant difference on preterm delivery (CI 95%; p value = 0.98). Repeat spontaneous miscarriage occurred less (5.6%) after cerclage insertion, fetal salvage rate was 75% and the preterm birth rate was 30%.Conclusion: The limitations of the study notwithstanding, use of history-indicated cervical cerclage in pregnancy resulted in better fetal salvage rate and reduced recurrence of spontaneous miscarriage.

Cervical cerclage in a Nigerian tertiary hospital: A review

Aim: The aim of the following study is to document the outcome of cervical cerclage in pregnancy. Materials and Methods: A retrospective analysis was undertaken of patients who had cervical cerclage for cervical incompetence at the Obstetrics and Gynecology Department of the University of Benin Teaching Hospital, Benin-City, Nigeria from January 2007 to December 2012. The cerclage was termed successful if the pregnancy was carried to term. Multiple demographic and clinical characteristics and their relationship to cerclage outcome were analyzed. Results: The records of 123 patients who underwent cerclage over the 6 years period reviewed were analyzed. The mean age was 33.3 ± 3.9 and majority (68.3%) were multiparous, with most of them (90.2%) having had a previous miscarriage. Majority (90.2%) had elective cerclage and 4 (3.3%) had emergency cerclage. Overall majority of patients delivered at 37 and 38 weeks gestation 23.6% and 19.5% respectively. Outcome of cerclage was adjudged successful in 92 (74.8%) of cases and failed in 31 (25.2%) cases. The most frequent complication was pre-viable or preterm rupture of membranes (14.6%). Cerclage outcome was not influenced by age, parity, gestational age at cerclage or experience of the surgeon. The mean duration for which pregnancy was prolonged after an emergency cerclage was 2.6 ± 2.4 weeks and emergency procedure was significantly associated with a failed cerclage. Of the 111 patients with previous miscarriages who had cerclage procedure, 68 (61.3%) had term deliveries and 23 (20.7%) preterm births. Fetal salvage rate of 98 (79.7%) was observed. Conclusion: Use of cerclage for suspected cases of cervical incompetence can have an important beneficial effect in carefully selected cases of cervical incompetence even amongst pregnant black African women.

Risk of intrapartum cervical lacerations in women with cerclage

Objective: The aim of our study was to estimate whether the placement of cerclage in pregnancy to prevent preterm birth (PTB) is associated with higher incidence of intrapartum cervical lacerations. Methods: A retrospective cohort study was conducted on singleton pregnancies with risk factors for PTB. The study group consisted of women with either a history- or ultrasound-indicated cerclage placed between 12 and 24 weeks of gestation, while the control group consisted of women with similar risk factors for PTB but who did not receive a cerclage. Primary outcome was the incidence of intrapartum cervical lacerations. A sample size calculation was performed on the basis of the results of previous studies on cervical lacerations. Results: We identified 134 women who had a cerclage placed in pregnancy. They were compared with 236 controls with no cerclage. Cases and controls had similar risk factors for cervical lacerations. Cervical lacerations occurred with similar frequencies in the cerclage and no-cerclage group (2.2 vs 1.3%, p = 0.78). There was no significant difference between the two groups for the risk of cervical lacerations (RR 1.76, 95% CI: 0.36–8.60). Conclusions: Cerclage placement during pregnancy is not associated with an increased risk of intrapartum cervical lacerations.

Contemporary Use of Cerclage in Pregnancy

Second trimester pregnancy loss and preterm delivery may be considered an obstetrical syndrome. A multifactorial approach to the diagnosis of true cervical insufficiency is paramount. Surgical modification of the cervix benefits those with at least 3 second trimester losses or preterm deliveries, those with 2 early second trimester losses when no other cause for loss is identified, and those with a previous second trimester loss or preterm birth with ultrasound findings of a short cervix defined as less than 25 mm. Multifetal pregnancies do not benefit from cerclage and causes harm in those with ultrasound or physical examination identified cervical changes.

Robotic-Assisted Laparoscopic Placement of Transabdominal Cerclage During Pregnancy

Cervical incompetence treated with transabdominal cerclage can carry significant morbidity with the need for sequential laparotomies and necessitating prolonged postoperative recovery. Laparoscopic transabdominal cerclage placement has been described but has significant limitations with only two-dimensional depth perception and limited dexterity. Robotic-assisted laparoscopic surgery (RALS) is rapidly gaining acceptance in gynecologic surgery. RALS has reportedly been used for placement of an interval transabdominal cerclage. We report the first two cases where the da Vinci robot was used during pregnancy for placement of abdominal cerclage. Two women were successfully treated with robotic-assisted laparoscopic placement of transabdominal cerclage in pregnancy. Robotic-assisted laparoscopic transabdominal cerclage placement is less invasive and is effective not only as an interval procedure but also during pregnancy, offering the patient an alternative to the traditional laparotomy with quicker recovery time.

Transabdominal cerclage in pregnancy after history of two or more failed vaginal cerclages

Transabdominal cerclage in pregnancy after history of two or more failed vaginal cerclages