Cervical Incompetence Research Articles

Істміко-цервікальна недостатність після вчасних пологів - що пішло не так?

Premature birth is a serious global medical problem. About 15 million premature babies are born annually in the world, of which 1 million dies. Spontaneous premature birth is a cause of 40-45% of all premature births. Cervical insufficiency (CI) is a significant risk factor for spontaneous premature birth. Purpose - to identify the risk factors for the development of CI in patients with a history of full-term pregnancies to draw attention to the problem of underdiagnosis of hidden obstetric injuries. Materials and methods. During 2021 – June 2023, a retrospective cohort study was conducted in the municipal non-profit enterprise “Kyiv Perinatal Center”, within which 140 patients were analyzed. The study group includes 70 patients who have a history of at least one full-term pregnancy, and who had a diagnosis of CI during the last pregnancy. The control group consisted of patients who had 2 or more pregnancies, during which they were not diagnosed with CI. Results. The odds of developing CI during the next pregnancy increased compared with the control group in the presence of the following: rapid delivery - up to ≈4:1; prolonged second stage of labour - up to ≈6.5:1; cervical surgery with cervical dilatation - up to ≈4.7:1; cervical surgery without cervical dilatation - up to ≈4.1:1. Previous spontaneous preterm delivery was not found to be a predictor of CI development at subsequent pregnancies. Conclusions. The results show that patients with precipitous delivery and surgical manipulations on the cervix in history have at least 4 times higher the risk of CI development after timely childbirth, and with a prolonged second period of childbirth - have 6.5 times higher risk. It should be noted that statistically significant differences were not found in patients who had spontaneous preterm delivery. We also postulate that such data indicate two possible phenotypes of the CI: one is of traumatic genesis, and the second is of congenital tendency of the cervix to weakness, which can first manifest in the form of precipitous childbirth, and subsequently manifest in the form of CI. The research was carried out in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Local Ethics Committee of the institution mentioned in the work. Informed consent of the women was obtained for the research. No conflict of interests was declared by the authors.

Evaluation of the Impact of Second Trimester Cervical Cerclage on Perinatal Outcomes: The Experience of a Single Tertiary Centre

Objectives: The aim of this study is to evaluate the results of patients who underwent cervical cerclage and the contribution of this procedure to the continuation of pregnancy.
 Materials and Methods: The records of patients who underwent cervical cerclage with McDonald method in the perinatology clinic of Başakşehir Çam ve Sakura City Hospital between October 2021 and September 2022 were evaluated retrospectively. The study included 58 cases diagnosed with cervical insufficiency in which cerclage was performed between the 14th and 25th weeks of pregnancy. According to the cerclage indication, patients were divided in two groups as elective cerclage (with history indication) and emergency cerclage (with physical examination and ultrasonography indication). Demographic characteristics, pregnancy and neonatal outcomes of the cases were recorded.
 Results: Out of the 58 cases included in the study, 57 of them were singleton pregnancies, and one was a twin pregnancy. The patients' mean age was 29.7±5.3 years. The elective cerclage group consisted of 23 cases and the emergency cerclage group consisted of 35 cases. Among the patients applied cerclage, 8 (15.1%) delivered before 24 weeks, 5 (9.4%) delivered between 25-28 weeks, 3 (5.7%) delivered between 29-32 weeks, 10 (18.9%) delivered between 33-36 weeks, and 27 (50.9%) delivered at 37 weeks or later. Elective cerclage patients had a lower mean gestational age (15.6±2.5 weeks) compared to emergency cerclage patients (20.9±2.7 weeks), and the interval for elective cerclage (17.1±7.5 weeks) was statistically longer than that for emergency cerclage (12.6±6.9 weeks) (p: 0.031).
 Conclusion: In our study, it has been observed that both elective and emergency cerclage in patients with cervical insufficiency extend the duration of pregnancy, and reduce the incidence of second-trimester loss and preterm birth.

Transvaginal Cervical Cerclage in Cervical Insufficiency: Outcomes of 77 Pregnancies: Single Institution Retrospective Study

Background: Cervical insufficiency is a major cause of second-trimester pregnancy loss and spontaneous preterm delivery. Cervical cerclage is a surgical procedure that can be performed in an attempt to maintain the structural integrity of the cervix in order to prolong gestation and improve obstetrical outcomes. Objective: The aim of the study was to investigate the effectiveness of the transvaginal cervical cerclage (TVCs). Materials and methods: A single-institution retrospective study included 106 pregnant women (93 singleton pregnancies and 13 twin pregnancies) who underwent transvaginal cerclage between 2015 and February 2022. Data extracted included patient demographics, gestation of suture insertion, gestation at delivery, mode of delivery, pregnancy outcomes and details about the suture insertion. The main outcomes of pregnancy which were evaluated were live birth rate and gestation at delivery. Results: During the study period, 106 women underwent transvaginal cerclage between 14 and 30 weeks of gestation. Cervical cerclages were done by the McDonald (n=105) or the Shirodkar technique (n=1). Regarding the mode of the delivery, cesarean section was performed in 59 cases (77%), in 18 cases it was vaginal delivery (23%). The outcomes of 77 pregnancies (88 babies) were analyzed. The live birth rate was 97,7%, a mean gestational age at delivery of 36 weeks; the preterm birth rate at <32 weeks was 19,5%, only 1,3% women delivered before 24 weeks. Conclusion: Placement of transvaginal cerclage appears to reduce preterm delivery before 32 weeks and improve neonatal survival. It appears to be a safe and effective procedure.

Clinical Efficacy of Laparoscopic Uterine Isthmus Cerclage in the Treatment of Cervical Insufficiency and Its Impact on Perinatal Outcomes

Objective: To investigate the efficacy of laparoscopic cervical isthmus cerclage and its impact on perinatal outcomes in patients with cervical insufficiency (CIC). Methods: A total of 120 patients with CIC admitted from July 2016 to July 2023 were randomly assigned to two groups. Group A underwent laparoscopic cervical isthmus cerclage, while Group B received vaginal cervical isthmus cerclage. Perinatal outcomes were compared. Results: Group A demonstrated shorter operation and hospitalization times compared to Group B (P < 0.05). Intraoperative blood loss was also significantly less in Group A (P < 0.05). The treatment success rate in Group A was higher than that in Group B (P < 0.05). During pregnancy, the cervical length in Group A was greater, and the perinatal body weight was higher compared to Group B (P < 0.05). Additionally, the postoperative complication rate was lower in Group A (P < 0.05), and the SF-36 score of CIC patients in Group A was higher than that in Group B (P < 0.05). Conclusion: Laparoscopic cervical isthmus cerclage demonstrates the potential to reduce the duration of the disease, increase perinatal body weight, improve treatment success rates, and enhance the quality of life for patients with CIC.

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.

Clinical study of modified Shirodkar transvaginal cervical cerclage during pregnancy in the treatment of cervical insufficiency

Objective: To investigate the clinical efficacy of modified Shirodkar transvaginal cervical cerclage (TVCC) in the treatment of cervical insufficiency (CI) and its impact on maternal and fetal outcomes. Methods: The clinical data of 218 pregnant women with CI admitted to Fu Xing Hospital, Capital Medical University from January 1, 2015 to August 31, 2021 was retrospectively analyzed. According to different surgical approaches, they were divided into modified Shirodkar TVCC treatment during pregnancy (TVCC group, 108 cases) and non-pregnant women underwent laparoscopic cervical cerclage (LACC) treatment (LACC group, 110 cases). The clinical data and pregnancy outcomes of the two groups were compared. Furthermore, the two groups of pregnant women were stratified according to cervical length (CL) to explore the effects of the two surgical methods on the pregnancy outcomes of CI women with different CL. Results: (1) Related indicators before and during cerclage: there were no complications such as massive hemorrhage, bladder injury and anesthesia accident in the two groups of pregnant women during cerclage. Compared with the LACC group, TVCC group had longer preoperative CL [(2.3±0.6) vs (2.7±0.6) cm], more intraoperative blood loss [(7.5±0.5) vs (14.4±1.4) ml] and longer hospital stay [(6.0±0.1) vs (7.3±0.4) day]. However, the operation time was shorter [(42.9±1.6) vs (25.9±1.4) minute] and the hospitalization cost was less [(9 912±120) vs (5 598±140) yuan], and the differences were statistically significant (all P<0.05). (2) Pregnancy outcomes: live birth rates were 95.4% (103/108) in the TVCC group and 96.4% (106/110) in the LACC group, showing no significant difference between the two groups (χ2=2.211, P=0.232). The preterm birth rate (12.0%, 13/108) in the TVCC group was higher than that in the LACC group (7.3%, 8/110), the neonatal birth weight was lower than that in the LACC group [(3 006±96) vs (3 225±42) g], and the proportion of low birth weight infants was higher than that in the LACC group [15.5% (16/103) vs 1.9% (2/106)], and the differences were statistically significant (all P<0.05). (3) Stratified analysis of CL: for pregnant women with CL<2.0 cm, the miscarriage rate of the TVCC group was higher than that of the LACC group (2/9 vs 3.0%), and the live birth rate was lower than that of the LACC group (7/9 vs 97.0%), and the differences were statistically significant (all P<0.05). For CL 2.0-<2.5 cm, 2.5-<3.0 cm, CL≥3.0 cm, there were no statistically significant differences in preterm birth rate and live birth rate between the two groups (all P>0.05). Conclusions: Modified Shirodkar TVCC is simple and easy to operate, which significantly reduces the cesarean section rate and medical cost compared with LACC, and there is no significant difference in the live birth rate. When there is inevitable late abortion, laparoscopic cerclage removal does not need to be performed again, which could reduce the second operation and is worthy of clinical application.

Pregnancy with uterine didelphys and history of recurrent pregnancy loss: Case report

Link of Video Abstract: https://youtu.be/H7Y7XoPOUAw Background: Uterine didelphys is an embryologic disorder that arises from the failure of Mullerian duct fusion. It is characterized by the presence of two distinct cervices, two vaginas, and two uterine horns. Obstetric complications may arise during pregnancy when uterine didelphys is present; these may include spontaneous abortion, premature labour, and fetal malpresentation. Case Presentation: A 25-year-old woman has been married for three years and had history of six gravid, zero parity, and five abortion. The patient had uterine didelphys. A fully septated uterus with double cervices and vaginas was found on pelvic magnetic resonance imaging. The patient arrived at the hospital at 27/28 weeks. Periodic sonograms demonstrated breech presentation and no (Intrauterine Growth Restriction) IUGR evidence. At 38/39 weeks, the patient was scheduled for cesarean surgery. Uterine didelphys morphology, pregnancy on the left side of the uterus, and the septum separating the left and right uterine cavities were all observed during the caesarean section. The newborn had three umbilical cords wrapped around his neck. The infant was female, 2800 grams, 48 cm, Apgar score 7-8, Ballard score (BS) 38 weeks, Lubchenco score (LS) p25-50. Conclusion: Antenatal care is required for investigating risks of uterine didelphys, including cervical incompetence, spontaneous abortion, and preterm birth, using serial sonograms to assess fetal well-being and cervical length.

Favorable surgical and obstetrical outcomes in pre- and postconceptional laparoscopic abdominal cerclage: a large multicenter cohort study

BackgroundCervical incompetence is an important cause of extreme preterm delivery. Without specialized treatment, cervical incompetence has a 30% chance of recurrence in a subsequent pregnancy. Recently the first randomized controlled trial showed significant superiority of the abdominal cerclage compared to both a high and low vaginal cerclage in preventing preterm delivery <32 weeks of gestational age and fetal loss in patients with a prior failed vaginal cerclage. Objective(s)To assess surgical and obstetric outcomes in patients with pre- and postconceptional laparoscopic abdominal cerclage placement. Furthermore, to perform subgroup analysis based on the indication for cerclage placement in order to identify patients that benefit the most from an abdominal cerclage. Study designA retrospective multicenter cohort study with consecutive inclusion of all eligible patients from 1997 onwards in the Dutch cohort (104 patients) and from 2007 onwards in the Boston cohort (169 patients) was conducted. Eligible patients suffered from at least one second- or third-trimester fetal loss because of cervical incompetence and/or a short or absent cervix after cervical surgery. This includes loop electrosurgical excision procedure (LEEP), conization or trachelectomy. Patients were divided into subgroups based on the indication for cerclage placement: 1) prior failed vaginal cerclage 2) prior cervical surgery 3) other indications. This third group consisted of patients with a history of multiple second- or early third-trimester fetal losses based on cervical incompetence (without a failed vaginal cerclage) and/or multiple dilation and curettage procedures. The primary outcome measure was delivery at ≥34 weeks of gestation with neonatal survival at hospital discharge. Secondary outcome measures included surgical and obstetric outcomes, such as pregnancy rates after preconceptional surgery, obstetric complications and fetal survival rates. ResultsA total of 273 patients were included; 250 patients in the preconceptional cohort and 23 patients in the postconceptional cohort. Surgical outcomes of 273 patients were favorable with six minor complications (2.2%). In the postconceptional cohort we had one patient (0.4%) with hemorrhage of 650 ml, resulting in conversion to laparotomy. After preconceptional laparoscopic abdominal cerclage (n=250) the pregnancy rate was 74.1% (n=137) with a minimal follow-up of 12 months. Delivery at ≥ 34 weeks of gestation occurred in 90.5% of all ongoing pregnancies. Four patients (3.3%) suffered from a second-trimester fetal loss. The indication for the cerclage in all four patients was a prior failed vaginal cerclage. The other subgroups showed fetal survival rates of 100% in ongoing pregnancies with a total fetal survival rate of 96%. After postconceptional placement, 94.1% of all patients with an ongoing pregnancy delivered at ≥ 34 weeks of gestation with a total fetal survival rate of 100%. Thus second-trimester fetal losses did not occur in this group. Conclusion(s)Pre- and postconceptional laparoscopic abdominal cerclage is a safe procedure with favorable obstetric outcomes in patients with an increased risk of cervical incompetence. All subgroups show high fetal survival rates. Second-trimester fetal loss only occurred in the group of patients with a cerclage placed for the indication prior failed vaginal cerclage, but also in this group the chance was low.

Delivery Outcomes and Postpartum Readmissions Associated with Ehlers-Danlos Syndrome.

Given that updated estimates of Ehlers-Danlos syndrome and risks for obstetric complications including postpartum readmission may be of public health significance, we sought to analyze associated obstetric trends and outcomes in a nationally representative population. The 2016 to 2020 Nationwide Readmissions Database was used for this retrospective cohort study. Delivery hospitalizations to women aged 15 to 54 with and without Ehlers-Danlos syndrome were identified. Temporal trends in Ehlers-Danlos syndrome diagnoses during delivery hospitalizations were analyzed using joinpoint regression to estimate the average annual percent change with 95% confidence intervals (CIs). To determine whether adverse obstetric outcomes during the delivery were associated with Ehlers-Danlos syndrome, unadjusted and adjusted logistic regression models were fit with unadjusted (odds ratio [OR]) and adjusted ORs with 95% CIs as measures of association. In addition to analyzing adverse delivery outcomes, risk for 60-day postpartum readmission was analyzed. An estimated 18,214,542 delivery hospitalizations were included of which 7,378 (4.1 per 10,000) had an associated diagnosis of Ehlers-Danlos syndrome. Ehlers-Danlos syndrome diagnosis increased from 2.7 to 5.2 per 10,000 delivery hospitalization from 2016 to 2020 (average annual percent change increase of 16.1%, 95% CI: 9.4%, 23.1%). Ehlers-Danlos syndrome was associated with increased odds of nontransfusion severe maternal morbidity (OR: 1.84, 95% CI: 1.38, 2.45), cervical insufficiency (OR: 2.14, 95% CI: 1.46, 3.13), postpartum hemorrhage (OR: 1.41, 95% CI: 1.17, 1.68), cesarean delivery (OR: 1.26, 95% CI: 1.17, 1.36), and preterm delivery (OR: 1.35, 95% CI: 1.16, 1.56). Estimates for transfusion, placental abruption, and placenta previa did not differ significantly. Risk for 60-day postpartum readmission was 3.0% among deliveries with Ehlers-Danlos (OR: 1.76, 95% CI: 1.37, 2.25). Ehlers-Danlos syndrome diagnoses approximately doubled over the 5-year study period and was associated with a range of adverse obstetric outcomes and complications during delivery hospitalizations as well as risk for postpartum readmission. · Ehlers-Danlos syndrome diagnoses approximately doubled over the 5-year study period.. · Ehlers-Danlos was associated with a range of adverse obstetric outcomes.. · Ehlers-Danlos was associated with increased readmission risk..

A Retrospective Study Comparing Laparoscopic Transabdominal Cerclage: Pre-Pregnancy Versus in Pregnancy With Their Reproductive Outcomes and Safety

ObjectivesTo compare the efficacy of laparoscopic transabdominal cerclage (TAC) pre-pregnancy and laparoscopic TAC in pregnancy in treating cervical insufficiency. MethodA retrospective analytical study comparing outcomes of laparoscopic TAC pre-pregnancy with laparoscopic TAC in pregnancy. A total of 178 patients who underwent laparoscopic TAC at our hospital were enrolled in the study. In total, 122 patients underwent interval cerclage, and 56 patients underwent cerclage during pregnancy. ResultsA total of 178 patients who met the inclusion criteria were included in the analysis. Second-trimester abortions decreased by 50%, with an overall increase in full-term live births (32.53%) in patients undergoing laparoscopic TAC pre-pregnancy. The fetal survival rate was around 90% and 85% with laparoscopic TAC pre-pregnancy and laparoscopic TAC in pregnancy, respectively. Although the obstetric outcomes of laparoscopic TAC pre-pregnancy and in pregnancy were comparable, laparoscopic TAC pre-pregnancy was safer than laparoscopic TAC in pregnancy due to the complications associated with the procedure during pregnancy. ConclusionsLaparoscopic TAC pre-pregnancy yielded better reproductive outcomes than laparoscopic TAC in pregnancy and was associated with fewer perioperative complications.

Validating staging criteria for sonographic and physical examination for cervical changes at

BackgroundPreterm birth represents a significant clinical challenge, and the ability to predict it effectively is a priority in obstetrics. The cervix undergoes specific changes during pregnancy, and staging these changes may offer a valuable predictive model for preterm birth, particularly in women with a mid-trimester short cervical length. ObjectiveThe study aims to validate a proposed staging model for asymptomatic women with mid-trimester short cervical length and evaluate its potential in predicting preterm birth. The integration of cervical examination and inspection with cervical length measurement was a novel approach to be assessed. Study DesignA multi-center retrospective cohort study included 925 pregnant women with a singleton fetus and a mid-trimester cervical length measurement of 25 mm or less. Cervical conditions were assessed using ultrasound, speculum, and physical examination, and classified according to five cervical staging to correlate with the likelihood of preterm birth. Statistical analyses included Kaplan-Meier Survival Analysis to illustrate the time-to-event characteristics across the five stages, and density plot evaluation to visualize the distribution of gestational ages within the stages. ResultsThe staging model included five stages based on cervical length, appearance, and dilatation. Among the 925 participants, 649 were classified as Stage 1, 245 as Stage 2, 18 as Stage 3, 10 as Stage 4, and 3 as Stage 5. The observed rates of preterm birth before 37 weeks for individuals classified in Stages 1, 2, 3, 4, and 5 were 22.3%, 26.5%, 44.4%, 60%, and 66.7%, respectively (p = 0.005). The overall observed rates of preterm birth before 28, 32, 34, and 37 weeks’ gestation were 5.5%, 9.9%, 12.2%, and 24.1%, respectively (p = 0.005). ConclusionsThis study validates the proposed staging criteria as an effective predictor of preterm birth due to cervical insufficiency. The results demonstrate a significant increase in the preterm birth rate with advancing stage classifications, indicating that the staging effectively stratifies women based on their risk of preterm birth, and highlighting the potential utility for targeted interventions. Implementing these staging criteria can potentially improve the counseling and management of pregnant women at risk for preterm birth.

Risk factors predicting pathological degradation after cervical excision in cervical intraepithelial neoplasia grade II P16-positive patients over 25 years old: a cross-sectional study.

Cervical intraepithelial neoplasia (CIN) is a collective term for pre-cancerous lesions associated with cervical invasive carcinoma. Treatment options depend on the development and progression of the disease. Especially for patients with CINII grade who are aged 25 years and older and have fertility requirements, it is a clinical challenge to determine whether to proceed with conservative or excisional treatment. Excisional treatment increases the risk of overtreatment outcomes, such as cervical insufficiency, preterm labor, miscarriage, and premature rupture of membranes, in young women with childbearing potential. P16 immunohistochemical staining has greatly improved the consistency of CINII patient's diagnosis. The aim of this study was to analyze the risk factors predicting pathological degradation after cervical excision in cervical intraepithelial neoplasia grade II P16-positive patients over 25 years old, and to provide information to help optimize clinical treatments patients with CINII disease. Single-factor and logistic regression models were used to analyze the risk factors for pathological downgrading in the CINII/P16-positive (+) group. The predicted probability of pathological downgrading in the CINII/P16(+) group of patients was calculated according to the logistic regression model to generate a new variable multi-indicator association for receiver operating characteristic (ROC) curve plotting to determine the predictive ability. A total of 248 women who met the inclusion and exclusion criteria were included. Statistical analysis showed that the CINII/P16(+) group had a higher pathological downgrading rate compared with the CINIII group after cold knife conization (CKC) (χ2=6.26, P=0.012). Univariate factors showed that the differences were statistically significant when comparing age, number of biopsy-involved quadrants, menopausal status, and involvement of glands, respectively (P<0.05). In contrast, the differences were not statistically significant when comparing cytological findings, type of transformation zone, high-risk human papilloma virus (HR-HPV) testing, abortion status, pregnancy frequency, time from diagnosis to CKC and Ki67 percentage between the two groups. Multifactorial logistic regression showed that the extent of biopsy CINII involvement [odds ratio (OR), 1.589], menopausal status (OR, 4.031), and glandular involvement (OR, 5.549) were all independent risk factors for pathological downgrading in the CINII/P16(+) patient group (P<0.05). The order of significance of the areas under the ROC curve (AUCs) was as follows: combined multiple indicators (AUC 0.716) > gland involvement (AUC 0.625) > biopsy CINII involvement extent (AUC 0.614) > menopausal status (AUC 0.565). A higher rate of pathological downgrading after CKC was found in CINII/P16-positive patients who were aged over 25 years. Overtreatment exists in patients with CINII/P16-positive diagnosis. Independent factors for pathological downgrading were identified by the factors including if the lesion involved the gland, the extent of CINII involvement on biopsy, and menopausal status.

Inflammatory status of the birth canal of pregnant women with cervical insufficiency treated with progesterone therapy, cervical cerclage and obstetric pessary

Preterm birth is a major global health problem. Every year about 15 million babies are born prematurely in the world, of which 1 million newborns die. Spontaneous preterm birth (SPB) accounts for 40–45% of all preterm births. Cervical insufficiency (CI) is a significant risk factor for SPB. The studies have established the influence of the vaginal microbiome on cervical length during pregnancy and the importance of the bacterial composition of the vagina as a factor determining the risk of preterm birth.The objective: to study the vaginal microbiome of pregnant women with CI and various treatment methods (progesterone therapy, cervical suture or obstetric pessary).Materials and methods. During 2020–2023, an observational longitudinal study was conducted in the municipal non-profit enterprise “Perinatal Center of Kyiv”, in which 94 pregnant women participated. Among them 64 women were diagnosed CI (progesterone therapy group – n=22, cervical suture group – n=23 and obstetric pessary group – n=19). The control group included 30 pregnant women without CI.Results. Vaginal progesterone therapy and the use of a cervical suture have less effect on the microbiome than the use of a pessary. Conditionally pathogenic and pathogenic microflora was detected in 27.27% of patients in the progesterone group, 47.82% of patients in the cervical suture group, and 57.89% – in the pessary group.Inflammatory smear grade 3–4 was found in 31.81% of patients in the progesterone group, 47.82% – the cervical suture group, and 57.89% – the pessary group; complaints of discomfort and discharge – in 22.72%, 39.13% and 57.89% of patients, respectively. Compared with the control group, the use of a pessary is associated with an increase in the frequency of identification of opportunistic pathogenic microflora (16.67% vs. 52.63%; p&lt;0.05), unsatisfactory results of bacterioscopic examination (20.00% vs. 57.89%; p&lt;0.05), as well as an increase in complaints of discomfort and significant vaginal discharge (16.67% vs. 57.89%; p&lt;0.05).Conclusions. It has been established that regardless of the type of therapy, inflammatory changes (presence of opportunistic pathogenic and pathogenic microflora, inflammatory type of smear, complaints of discharge and discomfort) of the birth canal are observed in pregnant women with CI.There is a connection between different methods of treatment and unsatisfactory results: bacteriological analysis – the presence of opportunistic pathogenic and pathogenic microflora (p&lt;0.05), bacterioscopic analysis – inflammatory type of smear of the 3-4 grade of purity (p&lt;0.05) and anamnestic analysis – the presence of complaints in female patients (p&lt;0.05).

Uterine Collagen Cross-Linking: Biology, Role in Disorders, and Therapeutic Implications.

Collagen is an essential constituent of the uterine extracellular matrix that provides biomechanical strength, resilience, structural integrity, and the tensile properties necessary for the normal functioning of the uterus. Cross-linking is a fundamental step in collagen biosynthesis and is critical for its normal biophysical properties. This step occurs enzymatically via lysyl oxidase (LOX) or non-enzymatically with the production of advanced glycation end-products (AGEs). Cross-links found in uterine tissue include the reducible dehydro-dihydroxylysinonorleucine (deH-DHLNL), dehydro-hydroxylysinonorleucine (deH-HLNL), and histidinohydroxymerodesmosine (HHMD); and the non-reducible pyridinoline (PYD), deoxy-pyridinoline (DPD); and a trace of pentosidine (PEN). Collagen cross-links are instrumental for uterine tissue integrity and the continuation of a healthy pregnancy. Decreased cervical cross-link density is observed in preterm birth, whereas increased tissue stiffness caused by increased cross-link density is a pathogenic feature of uterine fibroids. AGEs disrupt embryo development, decidualization, implantation, and trophoblast invasion. Uterine collagen cross-linking regulators include steroid hormones, such as progesterone and estrogen, prostaglandins, proteoglycans, metalloproteinases, lysyl oxidases, nitric oxide, nicotine, and vitamin D. Thus, uterine collagen cross-linking presents an opportunity to design therapeutic targets and warrants further investigation in common uterine disorders, such as uterine fibroids, cervical insufficiency, preterm birth, dystocia, endometriosis, and adenomyosis.

A prospective study of antepartum anxiety screening in patients with and without a history of spontaneous preterm birth

Maternal stress has been identified as one of the most common clinical phenotypes associated with preterm birth. The American College of Obstetricians and Gynecologists recommends anxiety screening at least once in the perinatal period. The prevalence of perinatal anxiety is challenged by the absence of formalized screening protocols and underreporting in high-risk populations, such as those with a history of adverse pregnancy outcomes. This study administered a validated anxiety screening tool in a cohort of patients with and without a previous spontaneous preterm birth and compared differences in score and rate of a positive screen between groups. Moreover, this study evaluated perinatal outcomes associated with a positive screen and described a referral protocol involving evaluation by a perinatal mental health counselor and clinical diagnoses. A hypothesis was made that patients with a previous history of spontaneous preterm birth would have higher self-reported anxiety symptoms than controls and that those with recurrent preterm delivery at <35 weeks of gestation would have the highest anxiety screening scores. This was a prospective observational cohort study administering the Generalized Anxiety Disorder 7-item screen to patients enrolled in 2 prenatal care clinics at our institution. The preterm birth cohort consisted of patients with a history of spontaneous preterm labor, premature rupture of membranes, or cervical insufficiency compared with the control cohort without this history. Screening was initiated at entry to prenatal care or referral to our high-risk obstetrical clinic. The inclusion criteria included English- or Spanish-speaking patients and singleton pregnancy, and the exclusion criteria included pregnancies complicated by a major congenital anomaly, enrollment after 34 weeks of gestation, delivery at <20 weeks of gestation, and incomplete delivery data. Referral to a mental health counselor was offered to those with a Generalized Anxiety Disorder 7-item screen score of ≥10. Perinatal outcomes as a comparison between the Generalized Anxiety Disorder 7-item screen-positive group and Generalized Anxiety Disorder 7-item screen-negative group were performed with statistical methods, including the Student t test, chi-square test, and Wilcoxon rank-sum test, with a P value of <.05 to determine significance. Between September 2020 and December 2021, 1349 participants were analyzed, with 143 patients (11%) in the previous preterm birth cohort and 1206 (89%) patients in the control cohort. Patients with a history of preterm birth and subsequent delivery at ≤35 weeks of gestation in the study pregnancy had significantly higher Generalized Anxiety Disorder 7-item screen scores than controls with delivery after 35 weeks of gestation (median score: 4 [interquartile range, 1-9] vs 2 [interquartile range, 0-6], respectively; P=.006). Overall, 187 participants (14%) screened positive with significantly higher rates in the previous preterm birth group than in the control group (20% vs 13%; P=.036). Of note, 117 patients (63%) accepted a referral, and 32 patients (17%) with a positive screen were diagnosed with a perinatal mood disorder. Patients with recurrent preterm birth have higher self-reported anxiety using the Generalized Anxiety Disorder 7-item screen than controls. Of those with a positive screen, 17% were diagnosed with a perinatal mood disorder.

Changes in cervical elastography, cervical length and endocervical canal width after cerclage for cervical insufficiency: an observational ultrasound study

BackgroundWe previously demonstrated that pregnant women with a history of cervical insufficiency had a softer anterior cervical lip, shorter cervical length and wider endocervical canal in the first trimester. The aim of this study was to investigate changes in cervical elastography, cervical length, and endocervical canal width in the second trimester after cerclage, and further discuss whether these ultrasound parameters are predictive of preterm delivery.MethodsThis was a secondary analysis of cervical changes in singleton pregnancies after cerclage from January 2016 to June 2018. Cervical elastography, cervical length, and endocervical canal width were measured during the second trimester in the cervical insufficiency group and control group without cervical insufficiency. Strain elastography under transvaginal ultrasound was used to assess cervical stiffness and presented as percentage (strain rate).ResultsAmong the 339 pregnant women enrolled, 24 had a history of cervical insufficiency and underwent cerclage. Both anterior and posterior cervical lips were significantly softer in the cervical insufficiency group even though they received cerclage (anterior strain rate: 0.18 ± 0.06% vs. 0.13 ± 0.04%; P = 0.001; posterior strain rate: 0.11 ± 0.03% vs. 0.09 ± 0.04%; P = 0.017). Cervical length was also shorter in the cervical insufficiency group (36.3 ± 3.6 mm vs. 38.3 ± 4.6 mm; P = 0.047). However, there was no significant difference in endocervical canal width between the two groups (5.4 ± 0.7 mm vs. 5.6 ± 0.7 mm; P = 0.159). Multivariate logistic regression analysis also revealed significant differences in anterior cervical lip strain rate (adjusted odds ratio [OR], 7.32, 95% confidence interval [CI], 1.70-31.41; P = 0.007), posterior cervical lip strain rate (adjusted OR, 5.22, 95% CI, 1.42–19.18; P = 0.013), and cervical length (adjusted OR, 3.17, 95% CI,1.08–9.29; P = 0.035). Among the four ultrasound parameters, softer anterior cervical lip (P = 0.024) and shorter cervical length (P < 0.001) were significantly related to preterm delivery.ConclusionsCervical cerclage can prevent widening of the endocervical canal, but not improve cervical elasticity or cervical length. Measuring anterior cervical elastography and cervical length may be valuable to predict preterm delivery.

Preconception laparoscopic cervical cerclage for prevention of mid-trimester pregnancy loss and preterm birth: A 6-year study

ObjectiveTo evaluate surgical results and pregnancy outcomes of preconception laparoscopic cervical cerclage (LCC) in women with cervical insufficiency. Study designWe conducted an observational study in consecutive women who had preconception LCC. Data was prospectively collected from 55 women at high risk of second trimester miscarriage and extreme preterm delivery due to cervical insufficiency who underwent pre-conception LCC between January 2017 – December 2021. This included patient demographics and relevant obstetric & gynaecological history, previous cervical cerclage, operative complications and subsequent pregnancy outcomes. All women included in study had at least one previous unsuccessful transvaginal cervical cerclage. The surgeries were conducted in private tertiary hospital in Hyderabad, India. The follow-up was until December 2022. The primary outcome was neonatal survival. Surgical morbidity and complications were also recorded. ResultsThere were 49 pregnancies of which 46 progressed beyond first trimester. 4.34 % (2/46) were delivered between 28 and 33 weeks due to preterm premature rupture of membranes (PPROM). 13.04 % (6/46) including 5 women with pregnancy complications and one with unicornuate uterus needed delivery between 34 and 36 weeks. 82.60 % (38/46) women were delivered at or beyond 37 weeks of pregnancy. In those who carried pregnancy beyond first trimester, live-birth rate and neonatal survival rate were 100 %. All neonates had favourable outcome with no long-term morbidity. There were no intraoperative or immediate postoperative complications. Two women had long-term complication in the form of tape erosion needing further surgery. ConclusionsThis study provides evidence that LCC improves pregnancy outcomes significantly in those with cervical weakness, without increasing the safety risk.

A nomogram for predicting prognosis of patients with cervical cerclage

IntroductionCervical insufficiency is an increased risk of midterm miscarriage and early preterm birth which increase the risk of fetal loss. This study aimed to construct a nomogram for patients with cervical insufficiency after cervical cerclage, which may assist clinicians to have individualized treatment for patients with cervical insufficiency. MethodsA study was done retrospectively from January 2013 through July 2022 in our hospital. The primary outcomes were delivered at more than 28, 30, 32, or 34 gestational weeks. Kaplan-Meier curves were applied to analyze 17 variables. All patients were randomly split (147:64) into development and validation cohorts. Based on the multivariate Cox regression analysis, a nomogram was constructed through the 'rms' package in R. ResultsA total of 211 patients with cervical insufficiency were enrolled: 121 had history-indicated cerclage; 58 had ultrasound-indicated cerclage and 32 had emergency cerclage. Times of gestations, times of miscarriages, IVF, abdominal pain, diagnostic classification, preoperative and postoperative management were demonstrated to impact overall extended days when delivering at more than 28 gestational weeks was set as the primary outcome. Except for preoperative and postoperative management, the above other five variables impacted the primary outcomes of delivering at more than 30, 32, or 34 gestational weeks. Postoperative tocolytics had an impact on the prognosis of patients who delivered at more than 30 gestational weeks. In development cohort data, a nomogram was established to predict overall extended days of patients with cervical cerclage. In present study, C-index was 0.662 in the development cohort and 0.687 in the validation cohort respectively, suggesting that the model presented some satisfied prediction. Moreover, the clinical decision curves for patients with delivering at more than 28, 30, 32 or 34 weeks set as primary outcomes also displayed that this nomogram demonstrated good clinical predictive usefulness. ConclusionsThe nomogram developed in this study may be a valuable tool assisting clinicians to evaluate outcomes of patients with cervical insufficiency after cervical cerclage, which helps them develop individualized management for the patients.

Neonatal outcomes of early preterm births according to the delivery indications

ObjectiveTo compare the neonatal outcomes of early preterm births according to delivery indications and determine the obstetric risk factors associated with adverse outcomes. MethodsWe retrospectively studied pregnancies delivered between 22 + 0 and 26 + 6 weeks at the tertiary center between April 2013 and April 2022. Stillbirths, elective termination of pregnancy, and multifetal pregnancies were excluded. Patients were classified into two groups according to delivery indications: spontaneous preterm birth (sPTB) due to premature rupture of membranes (PROM), preterm labor, or acute cervical insufficiency; and indicated preterm birth (iPTB). Obstetric and neonatal outcomes were compared between the groups. ResultsOf the 121 neonates, 73 % (88/121) underwent sPTB. The overall survival rates were 73 % and 49 % in the sPTB and iPTB groups, respectively (p = 0.017). Multivariate logistic regression analysis was performed with adjustment for gestational age at delivery, fetal growth restriction, cesarean section, histological chorioamnionitis, and funisitis. Moreover, in the 1-year follow-up, the proportion of body mass below the third percentile was significantly higher in the iPTB-group than in the sPTB-group (53 % vs. 20 %, p = 0.019). Furthermore, diagnoses of developmental delay and cerebral palsy were slightly higher in the iPTB-group (33 % and 20 %, respectively) than in the sPTB-group (27 % and 9 %, respectively); however, this difference was not statistically significant. ConclusionsIn early preterm births, iPTB was associated with a higher neonatal mortality than sPTB.

Transabdominal cerclage: The journey of turning bad into good

Recurrent pregnancy loss is a challenging obstetric condition that requires thorough evaluation and vigilant antenatal care. Cervical insufficiency is a well-recognized cause of late miscarriage. Here, we are reporting a case of multiple pregnancy failures including both 1st- and 2nd-trimester losses with cervical insufficiency after ruling out all other probable causes. The patient had a history of 3 failed transvaginal cervical cerclage procedures, and hence, in her 7th pregnancy, transabdominal cervical cerclage was attempted that resulted in salvaging the pregnancy beyond viability and the patient delivered a healthy baby through an emergency cesarean section near term. The patient was reconceived with the transabdominal cerclage in situ and delivered with a successful fetal and maternal outcome despite having multiple high-risk factors. This highlights the effectiveness of transabdominal cervical cerclage to prevent spontaneous mid-trimester loss and preterm delivery when previous transvaginal cerclage has failed.