Cervical Incompetence Research Articles

Comparison of maternal-fetal outcomes between laparoscopic cervicoisthmic cerclage and McDonald cerclage in women with cervical insufficiency

Objective: To compare the maternal and fetal outcomes of women with cervical insufficiency (CI) undergoing McDonald cerclage (MC) and laparoscopic cervicoisthmic cerclage (LCC), so as to provide evidence for the selection of cerclage methods. Methods: A retrospective trial was carried out in the First Affiliated Hospital of Sun Yat-sen University from January 2010 to December 2020. A total of 221 women who underwent the prophylactic cerclage were divided into MC group (n=54), LCC with MC history group (n=28) and LCC without MC history group (n=129) by the mode of operation and whether the pregnant women who underwent LCC had MC history. General clinical data, pregnancy complications and pregnancy outcomes were compared between the three groups. Results: (1) General clinical data: the proportion of women accepted cervical cerclage during pregnancy in MC group, LCC with MC history group and LCC without MC history group were 100.0% (54/54), 7.1% (2/28) and 27.1% (35/129), respectively (P<0.001). The indications of the three groups showed statistical significance (P=0.003), and the main indication was the history of abortion in the second and third trimester [75.9% (41/54) vs 89.3% (25/28) vs 84.5% (109/129)]. (2) Pregnancy complications: the incidence of abnormal fetal position [7.8% (4/51) vs 17.4% (4/23) vs 19.8% (24/121)], placenta accrete [5.9% (3/51) vs 13.0% (3/23) vs 11.6% (14/121)], uterine rupture [0 vs 4.3% (1/23) vs 5.8% (7/121)] in the MC group were all lower than those in LCC with MC history and LCC without MC history groups. However, there were no statistical significances (all P>0.05). Intrauterine inflammation or chorioamnionitis [15.7% (8/51) vs 0 vs 0.8% (1/121)] and premature rupture of membrane [23.5% (12/51) vs 4.3% (1/23) vs 0] were both significantly higher in MC group than those in LCC with MC history and LCC without MC history groups (all P<0.001). (3) Pregnancy outcomes: the cesarean section rate was significantly lower in MC group (41.2%, 21/51) than that in LCC with MC history group (100.0%, 23/23) and LCC without MC history group (100.0%, 121/121; P<0.001). MC group was associated with lower expenditure than LCC with MC history and LCC without MC history groups (12 169 vs 26 438 vs 27 783 yuan, P<0.001). The success rates of live birth cerclage did not differ significantly in MC (94.4%, 51/54), LCC with MC history (82.1%, 23/28) and LCC without MC history (93.8%, 121/129) groups (χ2=5.649, P=0.059). There was no significant difference in neonatal intensive care unit occupancy, neonatal birth weight and neonatal asphyxia between the three groups (all P>0.05). Conclusions: Both LCC and MC are the treatment choice for women with CI, which may get similar liver birth. However, MC has the advantages of low cesarean section rate, economical and easy operation. Therefore, MC is recommended as the first choice for CI patients, and LCC is for women with failed MC.

Comparison of emergency cervical cerclage and expectant treatment in cervical insufficiency in singleton pregnancy: A meta-analysis.

To compare the therapeutic effects of emergency cervical cerclage and expectant treatment in preterm birth due to cervical insufficiency in singleton pregnancy. A combination of subject words and free words was used to search major domestic and foreign databases. According to inclusion and exclusion criteria, 23 studies were included that met the criteria and quality evaluation and data extraction was carried out. The data were analyzed using STATA 15 and the reporting was done in reference to the list of Preferred Reporting Items for Systematic and Meta-Analyses. Emergency cervical cerclage was superior to expectant treatment for the primary outcome of pregnancy prolongation (WMD = 5.752, 95% CI 5.194-6.311, 22 studies, N = 1435, I2 = 97.1%, P = 0.000). Cervical cerclage was also superior to expectant treatment for the secondary outcomes of neonatal birth weight (WMD = 1051.542, 95% CI 594.107-1508.977, 9 studies, N = 609, I2 = 96.4%, P = 0.000), neonatal Apgar 1' (WMD = 2.8720, 95% CI: 2.105-3.639, 11 studies, N = 716, I2 = 99.0%, P = 0.000), number of live births (OR = 6.018, 95% CI 2.882-12.568, 10 studies, N = 724, I2 = 55.3%, P = 0.000), deliveries after 32 weeks (OR = 8.030, 95% CI 1.38-46.892, 8 studies, N = 381, I2 = 85.9%, P = 0.021). deliveries after 34 weeks (OR = 15.91, 95% CI 5.92-42.77, 9 studies, N = 560, I2 = 59.6%, P = 0.000), number of vaginal deliveries (OR = 3.24, 95% CI 1.32-7.90, 8 studies, N = 502, I2 = 69.4%, P = 0.018), and number of neonatal survivals (OR = 9.300, 95% CI 3.472-24.910, 10 studies, N = 654, I2 = 80.5%, P = 0.000). No difference between emergency cervical cerclage and expectant treatment was found in patients with chorioamnionitis (OR = 1.85, 95% CI 0.602-4.583, 4 studies, N = 296, I2 = 16.3%, P = 0.273). Before the 28th week of pregnancy, emergency cervical cerclage can significantly prolong the gestational week and improve the neonatal survival rate, compared to expectant treatment, in women with singleton pregnancies who have a dilated uterine orifice caused by cervical insufficiency.

Value of cervical strain in ultrasound elastography as a predictor of spontaneous preterm delivery

BackgroundCervical incompetence is a failure of the cervix to retain the products of conception throughout pregnancy, which results into cervical dilatation and preterm delivery. Many methods are conducted for early detection of cervical shortening, ripening and eventually dilatation to lessen the incidence of the preterm delivery, which is responsible for about 75% of neonatal comorbidities. Ultrasound plays an important role in the diagnosis and early detection of cervical incompetence. Elastography is a relatively new technique, which investigates into another important factor for cervical insufficiency which is “tissue stiffness”. The process of early cervical ripening, which is an important and main step in spontaneous preterm delivery, precedes cervical shortening and renders the human cervix soft which can be diagnosed through the color-coding method of the sonoelastography technique. The aim of this study is to determine the value of cervical elastography as a predictor of spontaneous preterm labor and validate the role of strain ratio in such technique.ResultsIn our study, we examined the pregnant females by transvaginal conventional B-mode ultrasound and complementary elastography technique and recorded the elastography index of their cervix, internal os and external os together with measuring the amount of strain and strain ratio at internal and external os.ConclusionsWe concluded that women who had preterm delivery did have higher strain and elastography index as their cervices were softer than those who had full-term deliveries. Elastography therefore can be a reliable method for the prediction of preterm delivery.

Chronic glomerulonephritis and pregnancy: predictors of preterm birth

Background: Chronic kidney disease (CKD) in pregnant women, with one of its most important causes being chronic glomerulonephritis (CGN), increases the incidence of adverse perinatal outcomes and gestational complications, including preterm birth (PB). Being the main cause of infant morbidity and mortality, PB has serious medical and social significance.&#x0D; Aim: To identify clinical predictors and develop a predictive model of PB in pregnant women with CGN.&#x0D; Materials and methods: A retrospective/prospective study included 122 CGN patients, whose 128 pregnancies resulted in childbirth from January 2009 to November 2022. Eighty-eight pregnancies were in the patients with CKD stage 1, 15 in stage 2, 21 in stage 3a, 3 in stage 3b, and one in stage 4. One hundred and nine (109) patients (115 pregnancies) delivered on term (at least 37 weeks of gestation) and were included into the group of term deliveries, whereas 13 women with 13 pregnancies had PB within the range of 22 weeks to 36 weeks 6 days. In the patients of both groups, we assessed nephrological and obstetric history, proteinuria and arterial hypertension at baseline and during pregnancy, complications of the index pregnancy, such as preeclampsia (PE) and severe PE, anemia, urinary tract infections, acute kidney injury, placental insufficiency, and cervical insufficiency. Binary logistic regression was used for prediction modeling of PB in women with CGN.&#x0D; Results: The proportion of PB in total cohort of the CGN patients was 10.2%. PB was spontaneous only in 2/13 (15.4%) cases, while in the rest of 11 pregnancies (84.6%) the delivery was induced due to maternal and fetal indications. Six independent predictors of PB were identified: body mass index, CKD stage, history of non-developing pregnancies, proteinuria during pregnancy 1 g/day, PE and placental insufficiency. The predictive model had sensitivity of 76.9%, specificity 99.1%, diagnostic efficiency 96.9%, positive predictive value 90.9%, and negative predictive value 97.4%.&#x0D; Conclusion: Predicting PB and targeting modifiable factors associated with PB may improve pregnancy outcomes in patients with CGN.

The role of isthmic-cervical insufficiency in miscarriage

Cervical insufficiency (CI) is one of the main pathological conditions that leads to pregnancy loss, in particular, recurrence miscarriages and premature births, which account for up to 5 % of all obstetric cases. Recurrence pregnancy losses caused by CI lead to serious psychological trauma for both the woman and her family members, as well as significant economic losses for the society. However, many women in some regions of the world still do not know about this pathology, and clinicians do not always diagnose this condition in time.At the same time, etiology of CI remains uncertain, and there are still ambiguous points regarding the diagnosis of this pathology and its treatment. The diagnosis of CI should be established by analyzing the medical history, clinical manifestations and results of ultrasound examination. Treatment of CI mainly includes surgical and conservative methods. Surgical treatment is performed with cervical cerclage, while conservative techniques mainly include the use of vaginal progesterone and insertion of various types cervical pessaries. This article summarizes the potential risk factors associated with cervical insufficiency that are of great attention and may be useful for future researches. Also, the review of the literature considers modern methods of diagnosis and treatment of CI to understand this pathology of the cervix better. From a modern standpoint, a consensus and problematic issues are presented in accordance with the recently updated recommendations, which are of practical importance, and are also important for further deeper research on this topical issue of modern obstetrics.

A Retrospective Analysis of Cervical Cerclage Outcomes in a Low-Income Country

Background: Cervical incompetence (CI) is a common cause of mid-trimester pregnancy loss. Clinical evidence has demonstrated the role of cervical cerclage in reducing preterm births alongside engendering successful maternal and foetal outcomes in carefully selected women with cervical incompetence. This study aimed at determining foetal and maternal outcomes in women with cervical incompetence after elective cervical cerclage. Methods: A retrospective analysis of 88 patients who had elective cervical cerclage at the University College Hospital, Ibadan (UCH), Ibadan, Nigeria between January 2015 to December 2017. Data from the case records of these patients were analysed using the Statistical Package for Social Sciences version 22. Descriptive analysis was generated and summarized with the aid of pie chart, bar chart and frequency tables. Chi-square statistic was used in testing for associations between categorical variables. Results: The mean age was 32.5 ± 4.2 years. Most of the women (78%) had cervical cerclage performed between 14 -16 weeks’ gestation. The most observed complication was pre-term contractions (76.2%). Eighteen women (20.5%) had a miscarriage and 50 women (56.8%) had term deliveries. The mean gestational age (GA) at delivery was 34.1 ± 5.8 weeks. Maternal complications, use of tocolytics and duration of hospital stay had a significant influence on the gestational age at delivery (p&lt;0.005). Conclusion: Cervical cerclage is an effective surgical procedure for preventing and delaying preterm births in women with cervical incompetence evidenced by a successful outcome in 56.8% of cases depicted in this study. Its use in a low-income country with high rates of preventable pregnancy wastages cannot be over-emphasized.

Laparoscopic cerclage – an effective method of treating cervical insufficiency

Laparoscopic transabdominal cerclage is becoming the preferred method of treating patients with repeated cases of preterm birth due to cervical insufficiency. This technique reduces the frequency of miscarriages in the second trimester and is an effective prevention of premature birth. This work analyzes modern techniques of applying serclage through transabdominal access: laparotomic, laparoscopic and robot-assisted using the da Vinci® device. Taking into account the advantages and disadvantages of each of these approaches, in clinical practice, preference should be given to the laparoscopic approach, since it is the safest (in terms of blood loss, risk of miscarriage, thrombosis of the veins of the lower extremities, as well as the cosmetic effect and hospital stay) and effective method of treating cervical insufficiency in repeated miscarriages (the frequency of childbirth in the full-term period after this operation is from 82% to 86%). Transabdominal serclage can be applied prophylactically in patients with repeated miscarriages and cervical insufficiency, transabdominal serclage does not have a negative effect on fertility. A promising operation using the da Vinci® device is inferior to the traditional laparoscopic approach, since it greatly exceeds it both in terms of the duration of the operation and in terms of cost, while having comparable efficiency. The option of highly effective treatment using minimally invasive methods suggests that laparoscopic transabdominal cerclage will become the standard of treatment for refractory isthmic-cervical insufficiency. This review examines the literature regarding the indications and results of laparoscopic cerclage.

Predictors of late spontaneous miscarriage: new aspects of an old problem: A review

The main objective of this paper was to review the current studies that consider changes in concentrations of various biologically active substances at the local and systemic levels (cervical mucus/amniotic fluid and serum) as predictors of late spontaneous miscarriage. Many biological markers, such as proinflammatory cytokines (interleukins [IL-2, IL-6, IL-10, IL-1] and tumor necrosis factor ), are considered prognostic markers. Changes in their concentrations in various biological media (serum, cervical mucus, amniotic fluid) may indicate a cellular immunological imbalance in the "motherplacentafetus" system, which is often the main pathogenesis link of late spontaneous miscarriage. Changes in concentrations of fetoplacental complex hormones such as progesterone, estradiol, and human chorionic gonadotropin have also been described. The concentrations of hypoxia-induced factor HIF1a in amniotic fluid and exosomal HIF1a in patients with cervical incompetence as one of the most common causes of late spontaneous miscarriage are presented as markers. Thus, the review shows the role of changes in concentrations of various biologically active substances at local and systemic levels (cervical mucus/amniotic fluid and serum) as predictors of late spontaneous miscarriage. The following methodology was used during work on the article: selection of publications using modern information databases, analysis of the obtained information, systematization of materials, and presentation of conclusions. An electronic search was conducted using publications identified in the following databases: eLIBRARY.RU, Google Scholar, and PubMed.

The Association between Some Demographic Characteristics and the Types of Miscarriage among Women in Rania City

Background: Miscarriage or spontaneous abortion is one of the prevalent adverse reproductive outcomes, which seriously threatens maternal health around the world. Some demographic features might associate with an elevate risk of spontaneous miscarriage which include cervical incompetence, infection, previous history of miscarriage, maternal passive smoking, age, and body weight. Objectives: The current study was carried out in order to investigate the association between socio-demographic characteristics of women undergoing miscarriage and their risk for spontaneous miscarriage in Rania city. Methodology: Quantitative design, a descriptive cross-sectional study was performed to assess the types of miscarriage and associated factors among women in Rania City. Samples of the study are Non probability purposive of (158) sample who attend Rania maternity and pediatric teaching Hospital. Besides two participants induced miscarriage were excluded. The data were collected from 1st June to 15th August 2022 through the utilization of construct questionnaire, data were collected by interview technique face to face approach of the study samples. Results: The study illustrate socio-demographic characters of miscarried women, the average age was 34.6 years and majority of them have diploma qualification (27.8%), and (61.4%) were house wife, also (48.7%) were in sufficient level of income, furthermore most of the study sample were in normal weight include (50.6%) while only (2.5%) were under weight,( 38.6%) of samples were in passive cigarette of smoking, moreover the samples’ weight and smoking cigarette associated to miscarriage (P= 0.022),(P= 0.003) respectively. Conclusion: The present study concluded that most common factor where associated with miscarriage was related to sociodemographic features. Excessive focusing on cigarette smoking exposure and maternal weight. Regarding the results of this study, mother’s demographic had relationship to miscarriage.

Cervical Insufficiency May Be Aggravated by Glucose Intolerance: A Case Report

Background: Cervical insufficiency occurs in the second trimester. Herein, we report a successful term pregnancy in a woman with glucose intolerance and a history of cervical insufficiency after two consecutive preterm deliveries in the second trimester. Case Presentation: We present a 35-year-old woman, G3P2L0, with a history of two preterm deliveries in the second trimester. In the second pregnancy, vaginal cerclage at the 18th gestational week did not prevent premature delivery. Following two pregnancies with borderline fasting blood sugar (FBS) results, we decided to further evaluate the gestational diabetes mellitus (GDM) state with a two-hour postprandial (2 hpp) glucose test and glucose tolerance test (GTT). By impaired 2 hpp and GTT results, an insulin regimen was started with subsequent vaginal cerclage in the third pregnancy. She delivered a healthy 2,750-g girl at 38 weeks of gestation by tight blood sugar control. Conclusions: More attention should be paid to evaluating glucose intolerance in pregnancy, especially in patients with cervical insufficiency. Blood glucose control in these patients can probably improve pregnancy outcomes.

The Association of Inflammatory Markers with Maternal-Neonatal Outcome After Cervical Cerclage

Cervical cerclage is effective in prolonging the number of weeks gestation in patients with cervical insufficiency(CI). However, valuable predictors with successful cervical cerclage remain limited. It aimed to evaluate the value of the systemic immune-inflammation index (SII), and systemic inflammation response index (SIRI) to predict the outcomes of cervical cerclage. This study analyzed 374 participants. Inflammatory markers were calculated using maternal peripheral blood. The association of inflammatory markers and the outcome of cervical cerclage were analyzed. And the optimal cut-off values of inflammatory markers were calculated. Also, the Chi-square test and logistic and linear regression analyses were performed to evaluate inflammatory markers with the maternal outcome and neonatal outcomes. 374 pregnancies were included in this study. Finally, 268 (71.7%) participants suffered successful cervical cerclage. This study demonstrated that the baseline BMI (cm2/kg), the bulging membrane, cervical dilation (≥2cm), the amniotic sac herniation, the neutrophils counts, the systemic immune-inflammation index (SII), and systemic inflammation response index (SIRI) were significant difference between the successful and unsuccessful groups (all P<0.05). Additionally, maternal blood inflammatory markers, such as WBC, lymphocyte, neutrophils, monocyte, platelet counts, SII, and SIRI, were significantly associated with maternal-neonatal outcomes. Furthermore, the results demonstrated that the SII level had the highest OR (OR=4.626; 95% CI (2.500-8.560)), as well as the following: SIRI level (OR = 3.795; 95% CI (1.989-7.242)), cervical dilation (≥2cm) (OR =3.477; 95% CI (1.458-10.844)), and amniotic sac herniation (OR = 1.796; 95% (0.473-4.975)). This study demonstrated that the baseline SII level and SIRI level are important biochemical markers for predicting the outcome of cervical cerclage and maternal-neonatal outcomes with non-invasive procedures. They can help to provide personalized treatment before surgery and enhance postoperative surveillance.

Maternal and neonatal outcomes following previable PROM or cervical insufficiency < 22 weeks in texas

Current Texas law prohibits immediate delivery in previable pregnancy complications, unless there is a medical emergency and threat to maternal health, which has in turn caused changes to the standard of care. We report maternal and neonatal outcomes of patients who presented < 22 wks with previable premature rupture of membranes (PPROM) or cervical insufficiency.

Incompetencia cervical: presentación de un caso

Cervical incompetence (CI) is characterized by progressive dilation of the cervix in the absence of uterine contractions. This pathology is one of the main reasons for early gestational losses and preterm births. It is the dilation of the cervix, which is the portion of the uterus that is responsible for maintaining the pregnancy until term, with a normal average measurement of 35 to 40 millimeters, although this dilation is not associated with painful contractions and perceived by the pregnant. Clinically it can be manifested by different signs such as dilation of the cervix, cervical shortening and preterm onset of labor. In addition, it is related to premature rupture of membranes and chorioamnionitis. To treat this pathology, avoid second-trimester losses and trigger premature labor, different techniques can be used, such as the placement of a pessary, the administration of progesterone and the performance of a cervical cerclage. The latter is the technique of choice for the treatment of incompetent cervix, being indicated due to poor obstetric history, as a therapeutic method in case cervical changes suggestive of the onset of labor are detected by ultrasound, or emergency when the pregnant woman shows cervical dilatation and/or exposure of the membranes.

Outcomes of history indicated cerclage compared with cervical length screening in patients with cervical insufficiency

To evaluate pregnancy outcomes of history-indicated cerclage compared with ultrasound cervical length screening in patients with a history of cervical insufficiency defined as prior spontaneous preterm delivery from 14 0/7 to 23 6/7 weeks’ of gestation. This was a retrospective cohort study of patients with singleton gestations with a history of cervical insufficiency. We excluded patients who started prenatal care after 24 weeks, who delivered before 24 weeks, and who declined both a history-indicated cerclage or cervical length screening. The primary outcome was preterm delivery < 37 weeks’ gestation. Secondary outcomes included gestational age at delivery, spontaneous preterm birth < 37 weeks, spontaneous preterm birth < 34 weeks, preterm premature rupture of membranes, cesarean delivery, birthweight, and neonatal intensive care (NICU) admissions. Adjusted odds ratios (aOR) with 95th confidence intervals (95%CI) were calculated, controlling for confounders. Of 376 singleton gestations included, 177 (47.1%) underwent history-indicated cerclage and 199 (52.9%) underwent cervical length screening. Of 199 who underwent cervical length screening, 92 (46%) underwent ultrasound-indicated or physical exam-indicated cerclage. Compared to cervical length screening, history-indicated cerclage was not associated with increased odds of preterm delivery less than 37 weeks (37.7% vs. 29.4%; aOR 0.75 [95%CI 0.48-1.18]). However, compared to cervical length screening, history-indicated cerclage was associated with decreased odds of spontaneous preterm delivery less than 34 weeks (18.1% vs. 9.0%; aOR 0.47 [95%CI 0.23-0.97]). History-indicated cerclage compared with cervical length screening was associated with decreased odds of spontaneous preterm delivery less than 34 weeks. Given that approximately half of the patients undergoing cervical length screening required cerclage, history-indicated cerclage should be considered for patients with a history of cervical insufficiency.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Residency Experience With Physical Examination- and Ultrasound-Indicated Cerclage: A Single Center Retrospective Study.

Background: Cervical insufficiency, the dilation of the cervix in the absence of contractions or labor, can cause second-trimester pregnancy loss or preterm birth. Cervical cerclage is a common treatment for cervical insufficiency and has 3 indications for placement: history, physical examination, and ultrasound. The purpose of this study was to compare pregnancy and birth outcomes for physical examination- and ultrasound-indicated cerclage. Methods: We conducted a retrospective observational descriptive review of second-trimester obstetric patients with transcervical cerclage performed by residents at a single tertiary care medical center from January 1, 2006, to January 1, 2020. We present data on all patients and compare outcomes between the 2 study groups: patients who received physical examination-indicated cerclage vs those who received ultrasound-indicated cerclage. Results: Cervical cerclage was placed on 43 patients at a mean gestational age of 20.4 ± 2.4 weeks (range, 14 to 25 weeks) and with a mean cervical length of 1.53 ± 0.5 cm (range, 0.4 to 2.5 cm). With a latency period of 11.8 ± 5.7 weeks, mean gestational age at delivery was 32.1 ± 6.2 weeks. Fetal/neonatal survival rates were comparable: 80% (16/20) for the physical examination group compared to 82.6% (19/23) for the ultrasound group. No differences were found between groups for gestational age at delivery-31.5 ± 6.8 in the physical examination group vs 32.6 ± 5.8 in the ultrasound group (P=0.581)-or for preterm birth <37 weeks-65.0% (13/20) in the physical examination group vs 65.2% (15/23) in the ultrasound group (P=1.000). Rates of maternal morbidity and neonatal intensive care unit morbidity were similar between the groups. No cases of immediate operative complications or maternal deaths occurred. Conclusion: Pregnancy outcomes for physical examination- and ultrasound-indicated cerclage placed by residents at a tertiary academic medical center were similar. Fetal/neonatal survival and preterm birth rates were favorable for physical examination-indicated cerclage when compared to other published studies.

Comparison of Pregnancy Outcomes of History-Indicated and Ultrasound-Indicated Cervical Cerclage: A Retrospective Cohort Study.

Cervical cerclage is the procedure of choice for preventing preterm delivery due to cervical insufficiency. The indication for its application may be based on the woman's reproductive history, findings at ultrasound, or clinical findings on vaginal examination. Pregnancy outcomes from these indications are variable according to the available literature. To compare the effectiveness and reproductive outcomes (miscarriage, preterm birth rates, and birth weights) of McDonald's cervical cerclage after history-indicated and ultrasound-indicated cervical cerclage in pregnant women. The retrospective cohort study was conducted at Life International Hospital Awka, Nigeria and Life Specialist Hospital Nnewi, Nigeria. Pregnant women, who had a McDonald's cervical cerclage performed due to either history or ultrasound indication between January 1, 2011, and December 31, 2020, were included in the study. Women with multiple pregnancies and those with physical examination-indicated or emergency cerclages were excluded. The main outcome measures included the prevalence of cervical cerclage, miscarriage, and preterm delivery rates. Outcomes were compared between groups with the chi-square test, Fisher's exact test, or Student's t test. p value of < 0.5 was set as significant value. Overall, during the study period, 5392 deliveries occurred in the study sites, of which 103 women had a history-indicated or ultrasound-indicated cervical cerclage. This resulted in a 1.91% prevalence rate for history-indicated and ultrasound-indicated cervical cerclage. Of these, 68 (66%) had history indicated, while 35 (34%) had ultrasound-indicated cerclage. There was no difference in the sociodemographic characteristics of both groups. Both groups had similar miscarriage rates: 1.18 in 1000 and 1.04 in 1000 deliveries, respectively (RR 1.160, 95% CI: 0.3824 to 3.5186, p = 0.793). There was more preterm delivery in history-indicated cerclage than ultrasound-indicated cervical cerclage (26.50% vs. 17.10%; p = 0.292), though the difference was not statistically significant. The ultrasound group had a higher average birthweight than the history group (2.67 ± 0.99 vs. 2.53 ± 0.74). However, this difference was not statistically significant. The effectiveness and reproductive outcomes (miscarriage, preterm birth rates, and birth weights) of pregnant women with cervical cerclage due to history-indicated and ultrasound-indicated cervical cerclage appear similar. When needed, cervical cerclage should be freely applied for cervical insufficiency, irrespective of the type of indication.

Cost-effectiveness of history indicated cerclage compared to cervical length screening in patients with cervical insufficiency

Cost-effectiveness of history indicated cerclage compared to cervical length screening in patients with cervical insufficiency

Periviable Births: Association of maternal morbidity with indications for delivery

To potentially improve management of periviable pregnancies, additional data is needed regarding natural history and clinical outcomes. We described the relationship between the indications for periviable preterm birth (PTB; delivery between 22w0d and 25w6d) and adverse maternal outcomes. Our retrospective study consisted of all singleton, periviable PTB (22.0 to 25.6 weeks) at a Level-IV care, academic medical center that delivered from 01/2017 to 03/2022. People with fetal demise upon admission or who underwent perinatal hospice care were excluded. Individuals were divided into groups based on the diagnosis at admission: spontaneous (preterm labor, premature rupture of membranes or cervical insufficiency) versus medical (hypertensive disorder of pregnancy, fetal growth restriction, non-reassuring fetal status or abruption). A composite maternal outcome included endometritis, need for transfusion, postpartum dilation and curettage, any wound complication, intensive care unit admission, venous thromboembolism/pulmonary embolism or maternal death were compared between groups. Among the 204 periviable deliveries that met the inclusion criteria, 138 (68%) were identified as spontaneous labor and 66 (32%) as medically indicated. Table 1 compares the clinical characteristics between groups; people with spontaneous PTB were more likely to have transfer to our facility. Medically indicated PTB had higher rates of hypertensive disorders of pregnancy (p< 0.001), fetal growth restriction (p< 0.001) and cesarean delivery (p=0.004). There were no differences in the rates of maternal morbidity between groups (Table 2). We found no difference in latency period between spontaneous and medically indicated deliveries in the periviable period. Additionally, there was no difference in composite maternal adverse outcomes between the two groups.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The Ethics of Transabdominal Cerclage Placement

Cervical insufficiency is present in up to 1 percent of pregnancies and is involved in a significant portion of pregnancy losses in the second trimester. The first line of treatment for most women with this condition is transvaginal cerclage. However, for some this is not sufficient, and a transabdominal cerclage must be performed. In a subset of women who receive transabdominal cerclage, there has been documented concern about subfertility. To the lay person, this may raise concerns that this approaches a contraceptive effect which would have implications on the liceity of the treatment; however, consideration of the current research on the procedure indicates that the subfertility is not a result of cerclage on its own, and ethical analysis through the principle of double effect further affirms the morality of this treatment.

The risk factors and causes of spontaneous preterm birth in women with previous term delivery

Previous spontaneous preterm delivery is the most important risk factor of preterm birth, whereas term delivery without obstetric complication is a reassuring evidence for the subsequent pregnancy. However, we sometimes experience spontaneous preterm birth after uncomplicated term delivery. This study was performed to evaluate the risk factors and causes of spontaneous preterm birth after previous term delivery(sPAT). Retrospective cohort study was performed. Singleton pregnant women with spontaneous preterm birth whose previous pregnancy outcomes had been uncomplicated term deliveries were enrolled. We analyzed their causes of preterm birth and compared clinical characteristics and perinatal outcomes to controls with two consecutive term deliveries during the same period. The optimal interpregnancy interval(OPI) was defined between 18-59 months. Preterm birth with maternal-fetal indication, stillbirth, or congenital anomaly were excluded. A total 196 pregnant women met the inclusion criteria and 463 women were selected as controls. The mean gestational age at delivery was 33+3 weeks of gestation in sPAT group. Preterm premature rupture of membrane(PPROM) was the most common cause of spontaneous preterm birth, followed by preterm labor with intact membrane, and cervical insufficiency. The cervical lengths at midtrimester in the sPAT group were above 2.5cm in most cases. Women with sPAT had less total weight gain and average weight gain per week during pregnancy compared to controls. The proportion of women with OPI was significantly lower in women with sPAT than in controls. The cesarean delivery(CD) rate of the index term pregnancy was similar between the two groups, but the CD rate of the subsequent pregnancy was significantly higher in sPAT group than controls. Unlike the general spontaneous preterm birth, PPROM is the cause of preterm birth in more than half of the women with sPAT. Lower weight gain during pregnancy and inadequate interpregnancy interval were associated with preterm birth even in women with a previous term delivery.