Cerclage Placement Research Articles

Predictors of Cervical Cerclage Success in the Prevention of Spontaneous Preterm Birth [13L

INTRODUCTION: Cerclage is one of the interventions to prevent spontaneous preterm birth (sPTB). This study aimed to identify predictive factors of cerclage success in preventing sPTB. METHODS: Retrospective study of singleton pregnancy at high risk of sPTB in University of Illinois at Chicago between 2013 and 2017. Baseline characteristics, duration of pregnancy, pregnancy outcomes and other predictive factors were analyzed using χ2, student t test, and multiple logistic regression analysis. RESULTS: Of the 310 women identified, 90 (29%) had rescue cerclage, and 65 (21%) had prophylactic cerclage. Most statistically significant predictors of sPTB of rescue cerclage were insertions at 17–20 weeks, aOR 2.26 (95% CI: 1.47–3.50, P<.0001), and at 21–22 weeks, aOR 1.81 (95% CI: 1.15–2.87, P<.0001). Cerclages placed at CL <10 mm was associated with increased likelihood of sPTB, aOR 1.60 (95% CI: 1.10–2.34, P<.0001). Cervical length at 21–25 mm and cerclage at GA <16 weeks were associated with decreased rate of sPTB, aOR 0.40 (95% CI: 0.26–0.61, P<.0001), and aOR 0.26 (95% CI: 0.16–0.40, P<.0001). Except for indomethacin in prophylactic cerclage, cervical dilatation, funneling, presence of sludge, prior sPTB, vaginal infections and use of 17-OHPC, these were not statistically significant in preventing sPTB. CONCLUSION: The success of cerclage in the prevention of sPTB depends on several factors. The most predictive factors were the degree of short cervix and earlier GA at cerclage placement.

The association of different progesterone preparations with preterm birth prevention

Objective: We aimed to compare the efficacy of commonly available progesterone preparations for preterm birth prevention.Methods: A retrospective cohort study of all women treated with progesterone to prevent preterm birth and delivered in a single university-affiliated tertiary medical-center. Four progesterone preparations were compared: vaginal Endometrin 100 mg twice daily, vaginal Crinone 8% gel 90 mg daily, vaginal Utrogestan 200 mg daily, and intramuscular 17α-hydroxyprogesterone caproate (17-OHPC) 250 mg weekly. All women were considered at risk for preterm birth according to: prior preterm birth or cervical length below 25 mm measured during the second trimester. Significant maternal morbidity, pregnancy achieved by artificial reproductive technique and cerclage placement were excluded. Primary outcome was the rate of preterm birth prior to 37 weeks of gestation.Results: Overall, 422 women were allocated to four study groups according to progesterone preparation: Endometrin 175 (41.5%), Crinone 73 (17.3%), Utrogestan 154 (36.5%), and 17-OHPC 20 (4.7%). Rates of preterm birth prior to 37 gestational weeks were lowest on the Endometrin treatment group (12.6 versus 20.5, 17.5, and 35% in the rest, p = .05). Multivariate analysis revealed that the progesterone preparation was associated with preterm birth prior to 37 gestational weeks (LR = 8.3, p = .004). The need for maternal red blood cells transfusion was significantly higher in the Endometrin subgroup (4% versus 0 in all others, p = .018). This finding remained significant after adjustment to potential confounders (LR 16.44, p < .001). Neonatal outcomes did not differ between groups.Conclusions: Different progesterone preparations prescribed to women at risk, may possess different efficacy in preventing preterm delivery prior to 37 weeks of gestation.

Early fetal reduction to twin versus prophylactic cervical cerclage for triplet pregnancies conceived with assisted reproductive techniques

ObjectiveTo compare the obstetric outcomes of triplet gestations managed by early fetal reduction to twins with those managed by prophylactic cervical cerclage in women conceived with assisted reproductive techniques (ART). Materials and methodsRetrospective study of the pregnancy and neonatal outcomes of trichorionic triplet gestations achieved by ART and managed either by early transvaginal fetal reduction to twins (n = 53) or by prophylactic placement of cervical cerclage (n = 65). ResultsThe pregnancy duration was significantly longer with fetal reduction and the incidences of delivery before 34 and 32 weeks gestational age were significantly lower with fetal reduction. Both miscarriage and live birth rates were comparable in the two groups. The incidences of very low birth weight (VLBW), neonatal respiratory distress syndrome (RDS), admission to neonatal intensive care unit (NICU) and early neonatal death (END) were significantly lower with fetal reduction. ConclusionEarly transvaginal reduction of triplets to twins leads to improved obstetric outcomes as it decreases prematurity and its related neonatal morbidities and mortality without increase in the miscarriage rate. Early fetal reduction seems to be better than continuation of triplet pregnancies with prophylactic placement of cervical cerclage.

Management of twin–twin transfusion syndrome with an extremely short cervix

The objective of this study was to describe the management and perinatal outcomes of patients with twin–twin transfusion syndrome (TTTS) and an extremely short cervical length (CL). This retrospective study examined 17 patients with TTTS and a preoperative CL ≤1.0 cm who had undergone laser surgery and perioperative cervical cerclage placement successfully. In this subset of patients, the median interval between surgery and delivery was 9.6 (range 2.1–13.9) weeks and only one patient had PPROM within 3 weeks of surgery. The median gestational age at delivery was 30.9 (range 23.1–37.6) weeks, 30-day survival of at-least-one twin was 88.2% and dual survivorship was 82.4%. Overall, patients with TTTS and a preoperative CL ≤1.0 cm who were able to undergo successful laser surgery and emergent cerclage placement had favourable outcomes.Impact statementThe management of patients with twin–twin transfusion syndrome (TTTS) and extremely short cervical length (CL) varies between foetal surgery centres.This study demonstrates that laser surgery and cerclage placement in such patients are not only technically feasible, but also can result in favourable perinatal outcomes.Patients with an extremely short CL should not be uniformly excluded from laser surgery for TTTS.

533: Ultrasound-indicated cerclage: Does the actual cervical length or gestational age matter?

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. However, it is unknown if the actual CL measurement or gestational age (GA) at cerclage placement are associated with preterm birth. Our objective was to determine if CL and GA at the time of ultrasound-indicated cerclage placement are associated with preterm birth. This was a retrospective cohort study of all patients who underwent ultrasound-indicated cerclage placement at a single maternal-fetal medicine practice in New York City between 11/2005 and 5/2017. All patients underwent CL screening for an increased risk of preterm birth (prior preterm birth, prior midtrimester loss, or history of LEEP). All cerclages were of the Shirodkar type. Cervical length 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 weeks, as cerclages were typically removed between 36-37 weeks. Data were analyzed using the Student’s t-test and Chi-square test for trend. There were 123 patients identified who underwent ultrasound-indicated cerclage, 26 (21.2%) of whom delivered <36 weeks. Cervical length (16.4 vs. 17.6 mm, p=0.28) and GA (19.7 vs. 20.0 weeks, p=0.58) at the time of cerclage placement were similar in patients who delivered <36 and >36 weeks’ gestation, respectively. When stratified by CL prior to cerclage placement, there was no significant difference in rates of preterm birth <28, <32, and <36 weeks (Table). Cerclage placement <20 weeks’ vs. >20 weeks’ gestation also did not significantly impact the rate of preterm birth. Cervical length and gestational age at the time of ultrasound-indicated cerclage placement do not appear to impact the likelihood of preterm birth <36 weeks. Patients should be reassured that outcomes are similar regardless of the CL or GA prior to cerclage placement.

534: Exam-indicated cerclage: Does the dilation or gestational age at the time of placement affect outcome?

For patients with painless cervical dilation in the mid-trimester, cerclage may be offered for the prevention of preterm birth. However, it is unknown if the cervical dilation or gestational age (GA) at cerclage placement are associated with outcomes. Our objective was to determine if cervical dilation and GA at the time of exam-indicated cerclage placement are associated with preterm birth. This was a retrospective cohort study of all patients who underwent exam-indicated cerclage placement at a single MFM practice between 11/2005 and 5/2017. Cervical dilation and GA at the time of cerclage placement were collected, as were demographic and obstetric outcomes. The primary outcome was delivery <36 weeks, as cerclages were typically removed between 36-37 weeks. Data were analyzed using the Student’s t-test and Chi-square test for trend. There were 39 patients identified who underwent exam-indicated cerclage. The median GA at delivery was 33 6/7 weeks (range 16 3/7 - 41 0/7), 24 (61.5%) patients delivered <36 weeks. Cervical dilation at the time of cerclage placement was significantly higher in patients who delivered <36 weeks compared to ≥36 weeks’ gestation (2.2 vs. 1.5 cm, p=0.05). Gestational age at the time of cerclage placement was similar between the two groups (20.1 vs. 20.5 weeks, p=0.55). When stratified by cervical dilation <2 cm versus ≥2 cm prior to cerclage placement, there was no significant difference in rates of preterm birth <28 and <32 weeks, though there was a significant difference between rates of preterm birth <36 weeks (Table). There was no difference in the rate of preterm birth when an exam-indicated cerclage was placed <20 vs. >20 weeks, or <22 vs. >22 weeks. Cervical dilation ≥2 cm at the time of exam-indicated cerclage is associated with an increased rate of preterm birth <36 weeks. However, even with cervical dilation of 2 cm or more, 50% delivered at 32 weeks or later. Gestational age at cerclage placement does not appear to be associated with outcomes. While limited by small numbers, this may be used to counsel patients about reasonable expectations for delivery timing when an exam-indicated cerclage is placed.

692: Association of cerclage removal with maternal and neonatal outcomes in pregnancies complicated by preterm premature rupture of membranes

To compare pregnancy outcomes between women with pPROM in the presence of cervical cerclage in whom the cerclage was removed within <48h and those in whom the cerclage was retained in situ. We conducted a retrospective cohort study of all women with a singleton pregnancy admitted with pPROM in the presence of cerclage to one of two tertiary referral centers in Toronto, Ontario between 2012-2016. The two centers differ in their approach with regard to the management of cerclage in the context of PPROM: in one center (SB) the common practice is to retain cerclage while in the second center (MSH) the common practice is to remove cerclage. Outcomes were compared between women in whom cerclage was removed within 48 hours and those in whom cerclage was retained until the onset of delivery. 1) Of a total of 79 women who met the study inclusion criteria, cerclage was removed in 44 (55.7%) and retained in 35 (44.3%). 2) There were no differences between the removal and retention groups in baseline characteristics, gestational age at cerclage placement (19.3±3.3 vs.18.0±4.1 weeks, p=0.1), cervical dilatation at cerclage, and gestational age at pPROM (28.3±2.9 vs. 28.0±2.6 weeks, p=0.7). 3) Women in the cerclage removal group had a lower pPROM to delivery interval (2.0±6.5 vs. 7.9±7.5 days, respectively, p<0.001) and were less likely to have a latency period of >7 days (4.5% vs. 37.1%, respectively, p<0.001) compared with women in whom cerclage was retained (Figure 1). 4) After adjustment for confounding factors, retention of cerclage was associated with higher odds for latency >7 days and lower odds for composite neonatal outcome (Figure 2). There were no differences between the groups in the odds for clinical chorioamnionitis and neonatal sepsis (Figure 2). In this multi-center retrospective study of women with pPROM and cervical cerclage, retention of cerclage was associated with longer latency period and lower rate of adverse neonatal outcome without increasing the risk of infection in the mother and newborn.

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.

Outcomes after periviable ultrasound-indicated cerclage

Background: Cerclage placed for a sonographically short cervix has been shown to reduce the risk of preterm delivery in women with a history of prior preterm birth. While short cervix is traditionally placed before viability, the threshold gestational age at which viability is achieved continues to decrease, and, as a result, a larger subset of women may be ineligible to receive this potentially beneficial procedure.Objective: To evaluate the association between obstetric outcomes and perioperative complications after placement of an ultrasound-indicated cerclage at periviability compared to placement in the previable period.Methods: This retrospective cohort study of patients who underwent ultrasound-indicated cerclage evaluated obstetric outcomes and perioperative complications based on gestational age at cerclage placement. Ultrasound-indicated cerclage was considered to have been placed at periviability if placed at 22 to <24 weeks (exposed) and at previability if placed at 16 to <22 weeks gestational age (unexposed). The primary outcome was preterm delivery <36 weeks. Secondary outcomes included mean gestational age at delivery, preterm delivery <32 weeks, <28, and <24 weeks, preterm premature rupture of membranes (PPROM), chorioamnionitis, and perioperative complications. Adjusted analyses were performed to account for demographic and obstetric factors.Results: Of the 426 patients included in the analysis, 94 (22%) had cerclage placed between ≥22 weeks to <24 weeks, while 332 (78%) had cerclage placed at <22 weeks. On univariate analysis, women who had a periviable cerclage placed were less likely to have a recurrent preterm delivery <36 weeks compared to women with previable cerclage placement (26.6 versus 38.3%, respectively, p = .04). The adjusted model did not demonstrate a significant difference in risk for preterm delivery <36 weeks associated with periviable versus previable cerclage (odds ratio 0.66, 95%CI 0.37–1.17). Secondary outcomes were similar between the previable and periviable groups, including mean gestational age at delivery (35.1 versus 36.2 weeks, respectively, p = .08) and preterm delivery before 32-week gestation (20.7 versus 13.8%, respectively, p = .17). Intraoperative and postoperative complications were rare and rates were similar between groups.Conclusions: Obstetric outcomes between patients receiving periviable and previable cerclage are similar. Ultrasound-indicated cerclage placement is associated with a relatively low rate of complications. Given the evidence supporting benefit of cerclage for women with short ultrasound cervical length and prior preterm birth, our findings demonstrate that benefits of placement at ≥22 weeks to <24 weeks may outweigh risks.

299 - Laparoscopic Abdominal Cerclage: Tips and Tricks

30 year old G2P0200 with a history of recurrent 2nd trimester pregnancy loss presented for abdominal cerclage prior to attempting pregnancy for a third time. Her cerclage was placed without complication. We aimed to review advantages of abdominal cerclage placement, timing of placement and tips and tricks for successful placement of a laparoscopic abdominal cerclage, based on our institution's 10 years of experience.

162 - Minimally Invasive Abdominal Cerclage Compared to Laparotomy: a Comparison of Surgical and Obstetric Outcomes

Study Objective The objective of this study is to report surgical and obstetric outcomes of patients following abdominal cerclage placement through either minimally invasive (MIS) or open techniques. We previously published a study comparing eleven MIS and nine open abdominal cerclage recipients, and here we give an updated report on this infrequently performed procedure. Design Retrospective cohort study. Setting Referral centers specializing in high risk pregnancy and minimally invasive gynecologic surgery. Patients or Participants Women who underwent abdominal cerclage placement either during pregnancy or prior to conception via laparoscopy or laparotomy at Yale New Haven or Bridgeport Hospital between December 2011 through December 2019. Interventions One cohort of women had their abdominal cerclage placed using conventional or robotic-assisted laparoscopy. The other cohort consisted of women whose abdominal cerclage was placed through laparotomy. Electronic medical charts were reviewed to collect baseline demographic and pre-procedure obstetric information, as well as surgical and post-procedure obstetric outcomes. Measurements and Main Results Twenty-three minimally invasive and 14 open abdominal cerclages were performed during the study period. Fifteen of the MIS and three open cerclages were performed as interval procedures, when patients were not pregnant. Average operative time was longer in the minimally invasive cohort by 40 minutes. Estimated blood loss was lower in the minimally invasive group (43mL in MIS vs 167mL in open cohorts). Length of hospital stay was shorter in the MIS group (0.2 days vs 2.1 days). Post-procedure obstetric outcomes were similar between the two cohorts, and cerclages placed during pregnancy resulted in live birth or maintenance of pregnancy in 88% of MIS and 82% of open cases. Conclusion Minimally invasive abdominal cerclage is a safe alternative to laparotomy, when performed by a surgeon with appropriate training and technical skills, providing patients with improved surgical outcomes without impairing the obstetric outcomes.

OP25.10: Outcomes of emergency cerclage placement in twin pregnancy

OP25.10: Outcomes of emergency cerclage placement in twin pregnancy

Cervical Cerclage: Does the Location of the Suture Placement Make a Difference?

Introduction: The aim of cervical cerclage is to prevent or treat cervical insufficiency. The goal of the study was to investigate the correlation between the location of the cerclage suture within the cervix and its efficacy in preventing preterm birth. Materials and methods: Sixty-seven images of the cervix performed within two weeks of cerclage placement were extracted from the sonographic database and collected. The location of cerclage was divided into three categories: within the vicinity of the internal os, in the middle portion of the cervix, and in the vicinity of the external os. Gestational age at delivery was analyzed in the groups. Results: In 26 patients, the suture was identified in the vicinity of the internal os. Most of these patients delivered between 34 and 41 weeks of pregnancy. In 29 patients, the suture was located in the middle portion of the cervix. Most of these patients delivered between 33 and 40 weeks of pregnancy. The third group consisted of 12 patients, in whom cervical cerclages were detected in the lower third of the cervix in the vicinity of external os. Five of the 12 patients delivered prior to 30 weeks of pregnancy; the rest delivered between 30 and 34 weeks. Conclusion: Our experience links the sonographically detected cerclage location with pregnancy outcome.

Minimally invasive abdominal cerclage compared to laparotomy: a comparison of surgical and obstetric outcomes.

The objective of this study is to report surgical and obstetric outcomes of patients following abdominal cerclage placement through either minimally invasive or open techniques. Subjects of this retrospective cohort study were patients at two referral centers specializing in high-risk pregnancy and minimally invasive gynecologic surgery. Electronic medical records of all patients who underwent abdominal cerclage placement between December 2011 and December 2015 at Yale New Haven Hospital and Bridgeport Hospital were reviewed. The patients included were women who underwent abdominal cerclage placement either during pregnancy or prior to conception. One cohort of women had their abdominal cerclage placed using traditional laparoscopy or robotic-assisted laparoscopy. The other cohort consisted of women whose abdominal cerclage was placed through laparotomy. Electronic medical charts were reviewed to collect baseline demographic and pre-procedure obstetric information, as well as surgical and subsequent obstetric outcomes. Eleven minimally invasive and nine open abdominal cerclages were performed during the study period. Seven of the minimally invasive and two open cerclages were done outside of pregnancy. Average operative time was longer in the minimally invasive cohort. Estimated blood loss was typically lower in the minimally invasive group. Length of hospital stay was shorter in the minimally invasive group. Obstetric outcomes were similar between the two cohorts, with a total of nine live births in the minimally invasive group and seven live births in the open group. Minimally invasive abdominal cerclage is a safe alternative when performed by a surgeon with appropriate training and technical skills, and obstetric outcomes are comparable to those after open abdominal cerclage.

Outcomes following rescue cerclage in twin pregnancies

Objective: Our aim was to compare perinatal outcomes in twin pregnancies complicated by premature asymptomatic cervical dilatation treated with rescue cerclage and expectant management.Methods: A retrospective cohort study was conducted at a single tertiary referral center between 2003 and 2014 and included all women with twins found to have a dilated cervix with intact membranes before 25-week gestation. Pregnancy outcomes were compared between women with rescue cerclage and those managed expectantly. A total of 36 women were eligible for the study, 27 (75.0%) of whom had a rescue cerclage compared to 9 (25.0%) women managed expectantly. Student’s t-test was used to compare continuous variables between the groups and the chi-square and Fisher’s exact tests were used for categorical variables as appropriate. Statistical analysis was performed with the SPSS v21.0 software (IBM Corp; Armonk, NY). Differences were considered significant when the p value was less than .05.Results: Among the 27 women with a rescue cerclage, the mean gestational age at time of cerclage insertion was 21.5 ± 2.6 weeks. The intervention and control groups were similar with respect to the degree of cervical dilatation at presentation (2.6 ± 1.3 versus 3.0 ± 1.5 cm, p = .5). Women in the cerclage group gave birth at a more advanced gestation (28.9 ± 6.1 versus 24.2 ± 2.6 weeks, respectively, p = .03) and were less likely to give birth at <34 and <28 weeks (66.7 versus 100.0%, p = .046, and 59.3 versus 100.0%, p = .02, respectively). The mean latency from the placement of cerclage to delivery was 7.3 ± 5.5 weeks. Similar findings were observed when analysis was limited to women with cervical dilatation of ≤3 cm at presentation.Conclusions: In asymptomatic women with twin pregnancies and cervical dilatation before 25 weeks of gestation, rescue cerclage can prolong pregnancy and improve perinatal outcomes when compared to expectant management.

Cervical cerclage placement decreases local levels of proinflammatory cytokines in patients with cervical insufficiency

Cervical insufficiency is characterized by premature, progressive dilation and shortening of the cervix during pregnancy. If left unattended, this can lead to the prolapse and rupture of the amniotic membrane, which usually results in midtrimester pregnancy loss or preterm birth. Previous studies have shown that proinflammatory cytokines such as interleukin-1β, interleukin-6, interleukin-8, and tumor necrosis factor alpha are up-regulated in normal parturition but are also associated with preterm birth. Studies evaluating such markers in patients with cervical insufficiency have evaluated only their diagnostic potential. Even fewer studies have studied them within the context of cerclage surgery. The objective of the study was to evaluate the impact of local and systemic inflammatory markers on the pathogenesis of cervical insufficiency and the effect of cerclage surgery on the local immune microenvironment of women with cervical insufficiency. We recruited 28 pregnant women (12-20 weeks' gestation) diagnosed with insufficiency and referred for cerclage surgery and 19 gestational age-matched normal pregnant women as controls. Serum and cervicovaginal fluid samples were collected before and after cerclage surgery and during a routine checkup for normal women and analyzed using a targeted 13-plex proinflammatory cytokine assay. Before surgery, patients with cervical insufficiency had higher levels of interleukin-1β, interleukin-6, interleukin-12, monocyte chemoattractant protein-1 and tumor necrosis factor alpha in cervicovaginal fluid compared to controls, but after surgery, these differences disappeared. No differences were found in serum of insufficiency versus control women. In patients with insufficiency, the levels of interleukin-1β, interleukin-6, interleukin-8, monocyte chemoattractant protein-1, and interferon gamma in cervicovaginal fluid declined significantly after cerclage compared with before intervention, but these changes were not detected in serum. Compared with normal women, patients with cervical insufficiency have elevated levels of proinflammatory cytokines in cervicovaginal fluid but not in serum, suggesting a dysregulation of the local immune environment. Cerclage intervention led to a significant decline in these proinflammatory cytokines, suggesting that cerclage may help reduce local inflammation in cervical insufficiency.

Outcome Comparison Between Obese and Nonobese Patients With Singleton Gestations Following Cerclage Placement [38F

INTRODUCTION: Cervical cerclage is an established treatment in preventing preterm birth, however, there are little data regarding the effect of obesity on cerclage efficacy. The primary purpose of this study was to identify the effect of obesity on preterm birth prevention in patients undergoing cerclage placement. METHODS: A retrospective cohort study was performed at a single teaching institute and included all singleton pregnancies that underwent McDonald cerclage placement between 2006 and 2014. The study group consisted of patients with a body mass index (BMI) greater than or equal to 30 kg/m2 and was stratified into obesity classes based on World Health Organization (WHO) criteria. The control group consisted of patients with a BMI less than 30 kg/m2. Additional variables included maternal demographics, progesterone use, cerclage indication, and maternal co-morbidities (hypertension, smoking, history of preterm birth and diabetes). RESULTS: 326 deliveries were included. There was a statistically significant latency between non-obese and class III obesity in reaching 30 weeks gestation (70% vs 55%, P = .0477). There was no difference in delivery less than 37 weeks and no difference in neonatal outcomes (Apgar scores, intubation, ICU admission, interventricular hemorrhage). There was a significant increase of chorioamnionitis in class III obesity (47% vs 14%, P &lt; .005). A non-significant increase in the rate of preterm premature rupture of membranes (PPROM) with increasing BMI class was observed. CONCLUSION: In patient’s undergoing cerclage placement, class III obesity appears to increase the risk of earlier preterm birth as well as antenatal maternal complications (PPROM and chorioamnionitis) however this had no impact on neonatal outcomes.

Cerclage for Management of Twin Pregnancies With Short Cervical Length: A Single-Center Retrospective Cohort Study [33D

INTRODUCTION: Cerclage for prevention of preterm birth (PTB) in twin pregnancies with short cervical length (CL) remains controversial. The study purpose was to compare perinatal outcomes of twin pregnancies with short CL managed with cerclage vs no cerclage. METHODS: Single-center retrospective cohort study of twin pregnancies with transvaginal ultrasound (TVUS) CL less than or equal to 25mm between 16 and 24 weeks gestation from 2010 to 2016. Monoamniotic, anomalous, or aneuploid fetuses, and pregnancies with indicated PTB were excluded. Primary outcomes were mean gestational age (GA) at delivery, interval from diagnosis to delivery, and birth weight. Secondary outcomes were incidence of PTB less than 28, 32, 34, and 37 weeks, cesarean section, low Apgar (less than 7), and NICU admission. RESULTS: Twenty-two women were included, twelve managed with cerclage and ten without. Mean GA at delivery was significantly higher, 32.8 ± 3.59 vs 29.3 ± 5.31 weeks (P=.0122); interval from diagnosis to delivery was significantly prolonged, 96.58 ± 23.36 vs 51.1 ± 27.71 days (P=.0001); and neonatal birth weight was significantly higher, 1990.58 ± 670.06 vs 1477.35 ± 796.90 (P=.0252) in the cerclage vs no cerclage group. Incidence of PTB less than 34 weeks GA was significantly less 33.33% vs 80% (P=.0027) and low Apgar was significantly lower 4.17% vs 30% (P=0.0353) in the cerclage vs no cerclage group. CONCLUSION: Cerclage placement in twin pregnancies with short CL was associated with higher mean GA at delivery, prolongation of pregnancy by 45 days, and decreased PTB less than 34 weeks GA compared to no cerclage.

Does cervical cerclage decrease preterm birth in twin pregnancies with a short cervix?

Purpose: To determine if use of cerclage in twin gestations with mid-trimester short cervix is associated with decreased preterm birth rate. Study design: This is a retrospective cohort of twin gestations identified with cervical length of ≤2.5 cm before 24 weeks of gestation through the perinatal ultrasound database of two institutions from 2008 to 2014. Patients with and without cerclage were compared for a primary outcome of preterm birth at <35 weeks. A pre-planned sub-group analysis of patients with cervical length ≤1.5 cm was also performed. Results: Eighty-two patients were included; 43 received cerclage, 39 did not. Mean gestational age at cerclage placement was 20.8 weeks. There was no significant difference in rate of preterm birth <35 weeks between the groups (34.9% versus 48.7%, respectively). In the sub-group analysis of patients with cervical length ≤1.5 cm, there was a significant decreased risk of preterm birth <35 weeks [37% versus 71.4%; adjusted RR 0.49 (0.26–0.93)]. Conclusion: Cerclage placement for cervical length ≤2.5 cm in twin gestations did not decrease the rate of preterm birth at <35 weeks; however, cerclage placement for cervical length ≤1.5 cm was associated with a significantly decreased rate of preterm birth <35 weeks when compared to patients managed without cerclage.

What is the impact of preconception abdominal cerclage on fertility: evidence from a randomized controlled trial.

There is documented concern that cerclage may cause cervical stenosis or changes to the cervical mucus, which may reduce fertility. The aim of this study is to determine whether placement of a preconception abdominal cerclage affects fertility. This was a planned subgroup analysis of a randomized controlled trial comparing abdominal cerclage, high vaginal cerclage or low vaginal cerclage. Women with a history of previous second-trimester miscarriage or preterm birth despite having a low vaginal cerclage, presenting to specialist preterm birth services in the UK, were eligible for inclusion. Only women randomized before conception were included in this analysis. Women randomized to abdominal cerclage had the surgery performed before conception (abdominal group). Women randomized to high or low transvaginal cerclage received it in the subsequent pregnancy (control group). Abdominal cerclage was performed in 19 women and transvaginal cerclage in 48 women. Overall, there was no statistically significant difference between time to conception between the two groups (hazard ratio 1.34; 95% confidence interval 0.72-2.50, p = 0.35). Rates of conception at 6, 12, and 18 months were similar - 37% in abdominal group vs. 35% in control group at 6 months (relative risk 1.04; 95% confidence interval 0.52-2.10; p = 0.91); 58% in abdominal group vs. 42% in control group at 12 months (relative risk 1.39; 95% confidence interval 0.84-2.31, p = 0.21); 74% in abdominal group vs. 56% in control group at 18 months (relative risk 1.31; 95% confidence interval 0.91-1.89; p = 0.15). This subgroup analysis of randomized data indicates that abdominal cerclage does not affect fertility rates.