Insertion Of Cerclage Research Articles

Effect Of Cerclage Suture Type On Pregnancy And Newborn Results: Mersylene Suture Versus Prolene Suture

Purpose: The aim of this study is to compare pregnancy and neonatal outcomes according to the type of the suture material used in the transvaginal cerclage operation. Materials and Methods: Patients who underwent transvaginal cervical cerclage due to cervical insufficiency in a tertiary health center between 2020 and 2024 were evaluated retrospectively. Demographic data regarding cerclage indications (ultrasound-based, prophylactic or physical examination-based), number of weeks of gestation in cerclage, cerclage suture type (prolene, mersilen), gestational week at cerclage insertion and delivery, routes of delivery were recorded. In addition, birth weight, 1st and 5th minute APGAR scores, and neonatal intensive care unit (NICU) requirements were recorded as neonatal parameters. Patients were divided into two groups according to cerclage suture type (mersilene or prolene) and maternal, newborn and pregnancy outcomes were compared between these groups. Results: Comparison of the groups in terms of age, gravidity, parity, number of miscarriages and BMI revealed significantly higher mean gravidity in group 1 compared to group 2 (P0.05). No difference was determined with regard to gestational week at cerclage application, cervical length, cervical dilatation just before cerclage insertion, gestational age at cerclage removal and delivery and birth weight (p>0.05). Groups were comparable in terms of subgroups established according to their numbr number of previous deliveries (p>0.05). Groups were comparable in terms of indications for cerclage insertion (p>0.05). Cesarean delivery rate was 40 % in group 1 while it was 43.6 % in groups 2, no statistical difference was determined in terms of rate of cesarean delivery (p>0.05). Similar number of newborns needed NICU admission between the two groups following delivery (17.5% versus 17.9 %p>0.05). Mean APGAR scores at 1st (6.8 versus 7.4) and 5 th (7.8 versus 8.3) min were comparable between the groups (p>0.05) Conclusion: Although mersilen stitch is commonly preferred, data analysis revealed similar results with prolene stitch in terms of maternal and neonatal outcomes.

6301667 Different anaesthetic techniques for cervical cerclage insertion and their influence on patient outcomes

6301667 Different anaesthetic techniques for cervical cerclage insertion and their influence on patient outcomes

Practice of Cervical Cerclage at a University Teaching Hospital in Southern Nigeria

Background: Although the aetiology of preterm deliveries is largely unknown, it is said to be multifactorial and cervical insufficiency has been implicated. Hence, cervical cerclage is a necessary and common prophylactic obstetric procedure for preventing prematurity and associated recurrent second trimester miscarriages. Objectives: To evaluate the pattern, indications, and fetal outcome of cervical cerclage. Methodology: This was a retrospective study of 50 women who had cervical cerclage insertion at the University of Port Harcourt Teaching Hospital between January 1, 2021, and December 31, 2022. Data was obtained from the ward registers, theatre records, and case notes of the women, and entered into a structured proforma. Data analysis was done with SPSS version 25, and results are presented as frequency tables and charts. Results: The mean age of the patients was 35 ± 2.07 years. The mean of number of previous miscarriages was 2.46 ± 2.07, 56.8% were multiparous and 50% had a previous manual vacuum aspiration. Majority 35 (70%) of the women had prophylactic cerclage, 10 (20%) had cerclage following in-vitro fertilization and embryo transfer pregnancy, while 5(10%) had rescue cerclage. Most 29 (58%) of the prophylactic cervical cerclage insertion were done between 11-15 weeks, with MacDonald technique being the most common technique practiced. Of these, only 18 (36%) carried the pregnancy up to 36 weeks of gestation. Conclusion: Many of cervical cerclage procedures were performed for prophylaxis and resulted in improved fetal outcomes in women who had previously experienced mid-trimester losses or preterm delivery.

Outcomes following elective cerclage versus ultrasound surveillance in women with one prior preterm event

ObjectivePreterm birth, defined as delivery before 37 weeks’ gestation, is a major obstetric challenge and is associated with serious long-term complications in those infants that survive. Preventative management includes cervical cerclage, either as an elective procedure or performed following transvaginal ultrasound surveillance and shortening of the cervix (≤25 mm). Significant questions remain regarding the optimal management, target population and technique. Therefore, this study aimed to assess differences in risk factors and pregnancy outcomes for women who received an elective cerclage versus ultrasound surveillance, following one prior premature event (spontaneous preterm birth/second trimester loss). Study designWomen were retrospectively identified from St Thomas’s Hospital Preterm Birth Clinical Network Database. Women who had one prior premature event (between 14+0 and 36+6 weeks’ gestation) were included and they were separated into those that an elective cerclage and those who underwent ultrasound surveillance to assess differences in demographics, pregnancy risk factors and preterm birth outcomes. We excluded women who received other preventative therapies. We also separately analysed those women who required an ultrasound-indicated cerclage, comparing the differences between women that delivered preterm and term. ResultsWe collected data from 1077 women who had a prior preterm event. 66 women received an elective cerclage. 11.4% of women who had ultrasound surveillance received an ultrasound indicated cerclage. Women with a prior history of mid-trimester loss, instead of preterm birth, were more likely to receive an elective cerclage. The mean gestational age of delivery was similar between those women who received an elective cerclage and those who had ultrasound surveillance with and without an ultrasound-indicated cerclage (38+1 vs 37+1), however, preterm birth rates <37 weeks’ were twice as high in this ultrasound group (OR 2.3 [1.1–4.5], p = 0.02). In those women that do require an ultrasound-indicated cerclage, 50.4% deliver preterm. ConclusionsIn conclusion, this study shows that in women with one prior preterm event, both history-indicated cerclage and ultrasound surveillance are appropriate management options. The majority of women undergoing ultrasound surveillance did not require a cerclage and so avoided the potential perioperative complications of cerclage insertion. However, those that did require an ultrasound-indicated cerclage were at high risk of preterm birth so should be followed up closely to enable adequate preterm birth preparation. Further prospective studies comparing history indicated cerclage and US surveillance in women with one prior preterm event are necessary.

Cervical cerclage training: Development and assessment of a simulator

Cervical cerclage is a mainstay intervention for the prevention of spontaneous preterm birth in high-risk women. Simulation training facilitates high-level skill transfer in a low-consequence environment, and is being integrated into obstetrics and gynecology training. This study aimed to develop a simulator for cervical cerclage, determine its validity as a simulator, and identify parameters suitable as proxy markers for performance. The 3 aims of this study were achieved, namely: (1) simulator design by obstetricians and a commercial company; (2) survey of obstetricians and gynecologists across a variety of training stages to determine need for and opinion of the simulator; and (3) comparison of novice and expert groups across a variety of proxy markers for successful cerclage insertion. Obstetricians and gynecologists found the simulator to be similar to clinical scenarios and suitable for skill training. Novice participants stated that the use of the simulator improved their confidence (P=.016). In a comparison between 6 expert and 8 novice surgeons, there seemed to be variations across multiple measurements of cerclage placement. Simulation is an increasingly prominent training modality for surgical skills. The simulator described herein was considered suitable for training by obstetricians and gynecologists. Further work should focus on the validations of proxy markers of successful insertion, longitudinal assessment of trainees, and correlation of training outcomes with clinical outcomes.

Transabdominal cerclage during pregnancy: A retrospective single operator series over a quarter century.

To describe the pregnancy outcomes and complications observed in a series of cases of transabdominal cerclage (TAC), which is reserved for highly selected women with recurrent mid-trimester pregnancy loss, due to cervical insufficiency. A retrospective audit covering 25 years (January 1, 1997 to December 31, 2021) was performed at the Obstetric Special Care division, Tygerberg Academic Hospital in Cape Town, South Africa. All 118 pregnancies from 94 procedures, operated and managed by the principal author were included for descriptive analysis. Eighty-four (91.3%) of the 92 first pregnancies after first insertion had successful outcomes. All second and third pregnancies (24/24; 100%) were successful. Eight pregnancies did not achieve viability, two women (2/8) did however achieve a successful pregnancy after a subsequent repeat TAC procedure. For the viable pregnancies (110/118), the median gestational age at delivery was 37 weeks (range 28-39 weeks). The median intraoperative blood loss during cerclage insertion was 100 ml (range 25-750 ml). In experienced hands, TAC during pregnancy is a safe and effective operation, when other less invasive procedures have failed.

Management of an incompetent mid-second (mid-2nd) trimester absent ecto-cervix: a case series. Cervical amplification pre-cerclage insertion.

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. 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. 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. There is a potential therapeutic benefit of this technique and adjunct management, in managing an incompetent mid-2nd trimester absent ecto-cervix.

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.

Cervical Cerclage For Cervical Incompetence: Indication, Complication And Pregnancy Outcome At Aminu Kano Teaching Hospital, Kano: A Five-year Review

Background: Cervical cerclage has salvaged so many pregnancies complicated by cervical incompetence. Objective: This study was carried out to determine the indications and pregnancy outcomes after cervical cerclage insertion. Methodology: This was a five-year retrospective study carried out in the department of Obstetrics and Gynecology of the Aminu Kano Teaching Hospital, Kano. The study covered the period of 1st January 2013 to 31st December 2017. The case notes of women who had cervical cerclage insertion during this period were retrieved and information such as age, gravidity, parity, indication for the cerclage and outcome of the pregnancy were extracted. This was entered into a proforma and analyzed using the SPSS Version 23 Computer software. Results:The mean age of the patients was 31.7±5.3years. Cervical cerclage was inserted between 13 and 32 weeks of gestation with a mean gestational age at insertion of 15.6 ± 3.6weeks. Mc Donald procedure accounted for 98.6% and only 1.4% had Shirodkar procedure. Cervical cerclage was history indicated in 62(87.3%), emergency cerclage was 8(11.3%) and ultrasound indicated in 1 (1.4%) of the women. Following the procedure, 64(80.28%) of the women took the pregnancy to term, however, Equal numbers of pregnancies were complicated by both preterm delivery and miscarriage, 7 (9.85%). Only seven patients had complication and out of that 4(57.1%) had pelvic pain, 2(28.6) had liquor drainage and 1(14.3%) had vaginal bleeding. Conclusion:Cervical cerclage for cervical incompetence is majorly history indicated and most of the patients carried the pregnancies to term after cerclage insertion. The complication rate is low.

Pregnancy outcomes following elective abdominal cerclage following cervical excision surgery for neoplastic disease

BackgroundLocal excisional treatment of neoplastic disease of the cervix in the form of loop excision (LLETZ) and conisation has been associated with adverse pregnancy outcomes including prelabour premature rupture of membranes (PPROM) and spontaneous preterm birth (SPTB). Insertion of a cervical cerclage is indicated for women with a short cervix <25 mm between 16 and 24 weeks gestation who also have a history of either PPROM or a history of cervical excisional treatment. The optimum timing of the cerclage and surgical technique used are both open to debate.This retrospective review of cases was performed to examine the outcomes of elective pre pregnancy placement of abdominal cervical cerclage in women who have undergone cervical excision surgery for neoplastic disease. MethodsThis was a retrospective review of case notes. Over a 10 year period 20 women who had previous cervical excision surgery had pre-pregnancy abdominal cerclage placed became pregnant with 26 pregnancies. One woman had a cone biopsy, 9 had a single LLETZ procedure, 8 had 2 LLETZ procedures and 2 women had 3 LLETZ procedures prior to the cerclage. Results21 pregnancies were achieved spontaneously, 1 by intrauterine insemination (IUI) and 4 were conceived by in-vitro fertilisation (IVF). Overall, 22 of 26 (84.6 %) pregnancies were delivered at term. There was a single 7 week miscarriage and 3 premature deliveries (12 %) including 1 preterm birth at 29 + 4 weeks gestation after an antepartum haemorrhage (APH) and 2 late preterm births at 36 + 3 (following APH) and 36 + 4 weeks gestation following preterm labour. All 25 women were delivered by Caesarean section and all 25 babies survived. ConclusionThere results of prophylactic minimally invasive insertion of a transabdominal cerclage in women with LLETZ treatments or cone biopsy prior to pregnancy demonstrated 84.6 % of pregnancies resulted in a live birth. The premature delivery rate was 12 %.

A ten year review of time interval between elective cervical cerclage removal at term and spontaneous onset of labour in Enugu, South-East Nigeria

Cervical insufficiency is a recognised cause of third trimester miscarriage and spontaneous preterm births. It is one of the leading causes of neonatal morbidity and mortality. Miscarriage and preterm deliveries due to cervical insufficiency can be prevented by cervical cerclage insertion. The study aimed to determine the time interval between elective cervical cerclage removal at term and spontaneous onset of labour in Enugu, south-east Nigeria. A ten year retrospective review of all women who had cervical cerclage inserted for suspected cervical insufficiency at the two tertiary health institutions in Enugu state was done. Their case files were retrieved and relevant data extracted. The mean time interval from cerclage removal at term to spontaneous onset of labour was 12 days. The majority of patients (45.6%) had spontaneous onset of labour at the 2nd week of cerclage removal. There was no significant difference in the mean time interval from cerclage removal to spontaneous onset of labour between ultrasound indicated group and history indicated group. These findings hopefully may assist in proper counselling and management of women who had cervical cerclage removed at term. Impact Statement What is already known on this subject? Cervical insufficiency is a known cause of mid trimester pregnancy loss and preterm delivery. Preterm babies are at risk of several complications, with high neonatal morbidity and mortality especially in developing world. Cervical cerclage insertion is a recognised surgical treatment for cervical incompetence aimed at preventing preterm births. What do the results of this study add? The study shows that removal of cervical cerclage at term does not result in immediate onset of spontaneous labour in women diagnosed to have cervical insufficiency. Notably, a majority of the women had spontaneous onset of labour at the 2nd weeks of cerclage removal. Only 5.3% of them had spontaneous onset of labour within 48 hours of cerclage removal. This is contrary to the general belief in the region that once cervical cerclage is removed, spontaneous onset of labour results. What are the implications of these findings for clinical practice and/or further research? This finding suggests that there is no compelling need for admission into hospital after removal of cerclage as very few of them will have spontaneous onset of labour within 48 hours of cervical cerclage removal.

The use of quantitative fetal fibronectin for the prediction of preterm birth in women with exposed fetal membranes undergoing emergency cervical cerclage

ObjectiveEmergency cervical cerclage is often considered a controversial salvage measure for those pregnancies at high risk of mid-trimester loss or early preterm birth. To determine the efficacy and benefit of emergency cerclage insertion, we assessed the predictive value of quantitative fetal fibronectin (fFN) concentration in cervicovaginal fluid for spontaneous preterm birth in women with exposed fetal membranes prior to cerclage insertion. Study designThis was a retrospective observational study from St Thomas’ Hospital, London of a cohort of women with singleton pregnancy and exposed fetal membranes presenting between 18 and 23+6 weeks of gestation (n = 35), in the period 2015-2018. fFN concentrations in cervicovaginal fluid were measured quantitatively at presentation in all women within 24 h prior to cerclage insertion. Results35 eligible women with exposed fetal membranes who underwent an emergency cervical cerclage were identified. The median gestational age was 20 + 0 weeks (18 + 6−21 + 2) at presentation and 29 + 3 weeks (23 + 3−38 + 2) at delivery, with a median time from emergency cerclage to delivery of 65.5 days (17–126.5). In total, 12 women (34 %) delivered within 28 days of emergency cerclage insertion. 60 % of women with an fFN level above 500 ng/mL delivered within 28 days of cerclage insertion, and they all delivered before 37 weeks gestation. No women with fFN levels below 10 ng/mL delivered within 28 days and 75 % of these women delivered at term. Concentration of quantitative fFN at presentation correlated negatively with time to delivery (Spearman's rs = −0.52, p = 0.0016). Mann–Whitney U analysis demonstrated a significant difference in the distribution of qfFN concentrations in women who delivered preterm compared to those who did not, both within 28 days from testing (p = 0.0048) and <37 weeks (p = 0.006). ConclusionQuantitative fFN has a role in predicting spontaneous preterm birth even in women with exposed fetal membranes undergoing emergency cervical cerclage. Given the serious risks associated with cervical cerclage surgery, qfFN could be used to counsel these patients at high risk of preterm delivery, as well as assisting in the decision to insert a cerclage.

Laparoscopic Uterine Cerclage: A 10 Year Experience at a Tertiary Referral Centre

Study Objective To determine the safety and efficacy of all cases of laparoscopic uterine cerclage performed in a tertiary referral center in the last 10 years. Design Retrospective Cohort Study. Setting Tertiary referral center and university teaching hospital. Patients or Participants All patients who underwent laparoscopic uterine cerclage from March 2010 to March 2019. Interventions Laparoscopic insertion of uterine cerclage. Measurements and Main Results A total of 14 cases were identified. 14/14 patients presented with a history of recurrent pregnancy loss or extreme premature labor (below 26 weeks). Indication included further mid-trimester loss or extreme premature labor despite elective cervical cerclage (8/14), failed rescue cerclage (3/14) and a short cervix on ultrasound or failure to insert cervical cerclage (3/14). No intra-operative complications were noted. Mean operating time was 98 minutes (Range 68-124). No post-operative complications or readmissions were noted. Of the 12 patients who underwent surgery greater than 12 months ago, there were 12 spontaneous conceptions (11/12 patients), 1 miscarriage and 11 livebirths after 37 weeks gestation by elective or emergency caesarean section. In the patient who suffered a miscarriage a surgical evacuation was carried out without complication. Conclusion Laparoscopic uterine cerclage remains a novel technique with a strict inclusion criteria requiring regular surveillance and audit of outcomes. This has limited the number of cases performed and there are currently no robust randomized control trials comparing management options for women with recurrent pregnancy loss after cervical cerclage. Despite the small numbers our results indicate that this technique has a good safety profile and outcomes in livebirths rates >34 weeks are good. Our results supports expansion of this service at a regional level through multi-disciplinary assessment to enable this technique can becoming established practice. To determine the safety and efficacy of all cases of laparoscopic uterine cerclage performed in a tertiary referral center in the last 10 years. Retrospective Cohort Study. Tertiary referral center and university teaching hospital. All patients who underwent laparoscopic uterine cerclage from March 2010 to March 2019. Laparoscopic insertion of uterine cerclage. A total of 14 cases were identified. 14/14 patients presented with a history of recurrent pregnancy loss or extreme premature labor (below 26 weeks). Indication included further mid-trimester loss or extreme premature labor despite elective cervical cerclage (8/14), failed rescue cerclage (3/14) and a short cervix on ultrasound or failure to insert cervical cerclage (3/14). No intra-operative complications were noted. Mean operating time was 98 minutes (Range 68-124). No post-operative complications or readmissions were noted. Of the 12 patients who underwent surgery greater than 12 months ago, there were 12 spontaneous conceptions (11/12 patients), 1 miscarriage and 11 livebirths after 37 weeks gestation by elective or emergency caesarean section. In the patient who suffered a miscarriage a surgical evacuation was carried out without complication. Laparoscopic uterine cerclage remains a novel technique with a strict inclusion criteria requiring regular surveillance and audit of outcomes. This has limited the number of cases performed and there are currently no robust randomized control trials comparing management options for women with recurrent pregnancy loss after cervical cerclage. Despite the small numbers our results indicate that this technique has a good safety profile and outcomes in livebirths rates >34 weeks are good. Our results supports expansion of this service at a regional level through multi-disciplinary assessment to enable this technique can becoming established practice.

A Novel Cerclage Insertion: Modified Laparoscopic Transabdominal Cervical Cerclage with Transvaginal Removing (MLTCC-TR)

To report on our center's experience of a novel modified approach for laparoscopic cervical cerclage and to evaluate its safety and efficacy preliminarily. Retrospective descriptive study. Single academic institution. Pregnant and nonpregnant women who underwent the modified laparoscopic transabdominal cervical cerclage with transvaginal removing (MLTCC-TR) from June 2016 to April 2019. Eligible participants had multiple adverse obstetric histories or the short cervix and were not suitable for a second transvaginal cerclage. Preconceptional or postconceptional MLTCC-TR. A total of 24 participants (including 3 first-trimester singleton pregnant women) underwent the MLTCC-TR, giving birth to 27 infants. Among 21 women who underwent preconceptional cerclage, 26 cases of postoperational pregnancies were noted, and the incidence of term labor was 73.07%, which was significantly higher than that in the precerclage group (p <.001). Their mean gestational age at delivery was 37.21 ± 5.05 weeks. Among 3 cases of postconceptional cerclage, the mean gestational age at cerclage was 10.90 ± 2.61 weeks, and all of them had term delivery. The overall neonatal survival rate was 100% (27/27), of which 81.48% (22/27) were term infants. There were no severe perioperative complications directly related to the insertion of cerclage. Our new approach of MLTCC-TR may be a relatively effective, feasible, and safe treatment for cervical insufficiency. It may be considered as an acceptable alternative to the traditional laparoscopic cervical cerclage with its superiority of transvaginal removing.

The Indication for Cervical Cerclage and Pregnancy Outcome in a Teritiary Hospital in South-South Nigeria: A Five Year Review

Background: Cervical incompetence is a major cause of second trimester miscarriage. Recurrent pregnancy loss in the second trimester is associated with significant distress. However, there should be a justifiable indication before a cerclage is inserted. There is no documentation of the indication of cervical cerclage and pregnancy outcome in Yenagoa, southsouth Nigeria. Objectives: This paper focuses on documenting the indication and obstetric outcome following cervical cerclage insertion at the Federal Medical Center Yenagoa, Bayelsa State. Methodology: A 5 year retrospective study was carried out in women who had cervical cerclage for cervical incompetence in the Federal Medical Centre, Yenagoa. The study was conducted from the 1 st of January 2014 to 31st of December 2018. All the case files of patients who had cervical cerclage were retrieved and reviewed. Results: A total of 41 patients had cervical cerclage. The commonest indication for cervical cerclage insertion was history indicated cerclage 59.4%. This was followed by ultrasound indicated cerclage 28.1% and rescue cerclage accounting for 12.5%. All patients employed McDonald’s method of cervical cerclage. The position of the knot wasin 12 0’ clock position in 53.1% of the patients and in the 6 0’clock position for 46.9% of the patients. The success rate following insertion of cerclage was 79.3%. The mode of deliveries was vaginal in 90.6% of the patients and 9.4% had caesarean section. Conclusion: There may be concern about the diagnosis of cervical incompetence. However, findings from this study clearly showed that the application of cervical cerclage is associated with good obstetric outcome.

Prospective observational study of vaginal microbiota pre- and post-rescue cervical cerclage.

ObjectiveTo investigate the relation between vaginal microbiota composition and outcome of rescue cervical cerclage.DesignProspective observational study.SettingQueen Charlotte's and Chelsea Hospital, London.PopulationTwenty singleton pregnancies undergoing a rescue cervical cerclage.MethodsVaginal microbiota composition was analysed in women presenting with a dilated cervix and exposed fetal membranes before and 10 days following rescue cervical cerclage and was correlated with clinical outcomes.Main outcome measuresComposition of vaginal bacteria was characterised by culture‐independent next generation sequencing. Successful cerclage was defined as that resulting in the birth of a neonate discharged from hospital without morbidity. Unsuccessful cerclage was defined as procedures culminating in miscarriage, intrauterine death, neonatal death or significant neonatal morbidity.ResultsReduced Lactobacillus spp. relative abundance was observed in 40% of cases prior to rescue cerclage compared with 10% of gestation age‐matched controls (8/20, 40% versus 3/30, 10%, P = 0.017). Gardnerella vaginalis was over‐represented in women presenting with symptoms (3/7, 43% versus 0/13, 0%, P = 0.03, linear discriminant analysis, LDA (log 10) and cases culminating in miscarriage (3/6, 50% versus 0/14, 0%, P = 0.017). In the majority of cases (10/14, 71%) bacterial composition was unchanged following cerclage insertion and perioperative interventions.ConclusionsReduced relative abundance of Lactobacillus spp. is associated with premature cervical dilation, whereas high levels of G. vaginalis are associated with unsuccessful rescue cerclage cases. The insertion of a rescue cerclage does not affect the underlying bacterial composition in the majority of cases.Tweetable abstractPreterm cervical dilatation associates with reduced Lactobacillus spp. Presence of Gardnerella vaginalis predicts rescue cerclage failure.

No. 373-Cervical Insufficiency and Cervical Cerclage.

The purpose of this guideline is to provide a framework that clinicians can use to determine which women are at greatest risk of having cervical insufficiency and in which set of circumstances a cerclage is of potential value. Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in 2018 using appropriate controlled vocabulary (e.g., uterine cervical incompetence) and key words (e.g., cervical insufficiency, cerclage, Shirodkar, cerclage, McDonald, cerclage, abdominal, cervical length, mid-trimester pregnancy loss). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to June 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

The Value of Late Mid-Trimester Ultrasound Cervical Assessment after Cerclage for the Prediction of Preterm Birth

Background: Spontaneous preterm birth constitutes a significant obstetric dilemma as prematurity is a major risk factor of neonatal death or a lifelong morbidity. Despite extensive efforts to reduce preterm birth, the means to identify and prevent it remains limited. Sonographic surveillance of CL can identify the increased risk of spontaneous preterm birth. Objective: To determine the predictive value of ultrasonographic assessment of the cervix after cerclage insertion for the outcome of preterm birth before 34 weeks of gestation. Patients and Methods: A prospective study included fifty women with singleton pregnancies were followed-up with monthly transvaginal ultrasonographic examinations before and after cerclage insertion. Ultrasonographic parameters of the cervix included the closed endocervical canal length and funneling depth measured from the internal cervical os. Results: The change in cervical length was predictive; as with stable cervical length an association with a later gestational age at delivery was evident. Patients with cerclage who delivered after 34 weeks had a slower rate of cervical shortening compared to those who delivered prior to that date (median = 4mm versus 7mm per 4 weeks). The overall cervical length at 28 weeks was statistically different between patients who delivered before 34 weeks and those who delivered later (24.00±2.92 versus 33.19±5.5 p<0.001). Conclusions: Transvaginal ultrasound for cervical assessment can be a helpful tool in the prediction of preterm birth after cerclage insertion. A late second-trimester cervical transvaginal ultrasound scan can guide the addition of interventions such, progesterone and antenatal corticosteroids for fetal lung maturation.

Does rescue cerclage work?

Rescue cervical cerclage (RCC), also known as emergency cerclage, has long been the subject of controversy. Its use in women who have a dilated cervix has been ambivalent. RCC is often considered as a salvage measure for pregnancies which are at a high risk of severe preterm delivery (PTD) or mid-trimester miscarriage. This study aims to examine and assess the efficacy of RCC and its ability to prolong pregnancy until neonatal viability is achieved. The current data suggest that RCC is associated with a longer latency period frequently resulting in better pregnancy outcomes (Namouz S, Porat S, Okun N, Windrim R, Farine D. Emergency cerclage: literature review. Obstet Gynecol Surv. 2013;68:379-88). This is supported by the Royal College of Obstetricians and Gynaecologists (RCOG) which states that the insertion of a rescue cerclage may delay delivery by a further 5 weeks on average as compared with expectant management or bed rest alone (Shennan AH. To MS: RCOG Green Top Guidelines: Cervical Cerclage RCOG.2011. Available from: www.rcog.org.uk). It further states that it may be associated with a two-fold reduction in the possibility of delivery before 34 weeks of gestation (Shennan AH. To MS: RCOG Green Top Guidelines: Cervical Cerclage RCOG.2011. Available from: www.rcog.org.uk). Our study reveals that the average insertion to delivery interval at our centre was 71.2 days with a live birth rate of 92.5%. A total of 89.1% of women delivered beyond 24 weeks of gestation.

A Five-Year Survey of Cervical Cerclage at a Nigerian Tertiary Hospital

Background: Cervical incompetence is an important cause of mid-trimester miscarriage. Mid- trimester pregnancy loss is a distressing event for both parents and physician contributing significantly to perinatal mortality, hence Cervical Cerclage. Proper definition of cervical incompetence and proper patient selection will improve the outcome of cervical cerclage. Objective: To document the indications, outcome and complications associated for cervical cerclage insertion Methods and Material: A 5-year retrospective analysis undertaken on patients who had cervical cerclage for cervical incompetence at the university of Abuja teaching hospital, Gwagwalada FCT within the period spanning from January 2012 to December 2017. Case folders of patients who had cervical cerclage were retrieved from the central records. Results: In this study, 96 patients had cervical cerclage. Women within the age range of 26-30 (42.7%) had the highest cerclage insertion. Most of the cerclage were done between 14-16 weeks’ gestation (45.8%) while, 38 (39.6%) were done below 14weeks and 14 (14.6%) were done above 16weeks gestation. All patients had McDonald’s stitch. The most predominant indication for cerclage insertion being “history indicated” (78.1%). The most observed complication was pre-term labour 16 (16.7%) while majority of the patients 53 (55.2%) had no complications. The hallmark of the study was, out of the 96 women who had cervical cerclage, 14 (14.6%) had miscarriage and 82 (85.4%) delivered above the age of fetal viability. Out of the 82 patients that delivered above viability, 69 (84.1%) term deliveries, 13 (15.9%) preterm deliveries. Out of the 82 deliveries above fetal viability, there were 76 (92.7%) live births and 6 (7.3%) stillbirths. Vaginal deliveries were 61 (74.4%), while 21 (25.6%) were caesarean section. Therefore 69 (71.9%) of patients within this study had a successful cerclage. Conclusion: Cervical cerclage remains one of the most practiced and deemed effective methods of preventing and prolonging preterm births. Its outcome depends on a careful patient selection and procedure.