Cerclage Placement Research Articles

Rate of preterm delivery and latency period in asymptomatic patients undergoing cerclage for very short cervix ≤10.0 mm

AimTo estimate the rate of preterm delivery (PTD) and mean latency period to delivery in asymptomatic women with no history of preterm delivery and cervical length (CL) ≤10.0 mm undergoing or not cerclage and who were not treated with vaginal progesterone. MethodsRetrospective analysis of asymptomatic patients with singleton pregnancies and no history of preterm delivery, with an incidental finding of a CL ≤10.0 mm measured with transvaginal ultrasound during the mid-trimester scan, 56 of them (63.6%) underwent cerclage placement and 32 (36.4%) did not, none of them received vaginal progesterone. Those with evidence of advanced dilation, prolapsing, membranes, ruptured membranes, or positive signs of infection were not candidates for cerclage placement were excluded from the analysis. Differences in the prevalence of preterm birth, mean gestational age at delivery, and mean latency from very short cervix identification to delivery between the two groups were calculated. Associations between cerclage and preterm delivery adjusted for maternal characteristics and fetal weight, were estimated. ResultsMedian (range) gestational age at time of CL measurement in the cerclage group was (weeks/days) 20w6d (17w5d–23w3d) vs. 21w5d (17w6d–23w6d) in the no-cerclage group (p=0.02). No differences in CL were observed between those who had a cerclage (5.9 mm (SD 3.1 mm)) vs. those who did not (6.5 mm (SD 3.2 mm); p=0.4). The prevalence of preterm delivery (PTD) in women with cerclage vs. women without cerclage was: PTD <37 weeks 31/56 (55.3%) vs. 28/32 (87.5%); adjusted (a) OR 0.17 (95% CI; 0.05-0.62 p=0.008); PTD ≤34 weeks 27/56 (48.2%) vs. 24/32 (75.0%); aOR 0.16 (95% CI 0.05-0.55; p=0.02); PTD ≤28 weeks 19/56 (33.9%) vs. 22/32 (68.7%); aOR 0.15 (95% CI 0.05-0.51; p=0.002). The mean (range) gestational age at delivery was 32w6d (19w1d–40w1d) for the cerclage group, and 28w1d (20w1d–40w2d) for the no-cerclage group (p =0.001). The median (range) latency from the time of CL measurement to delivery in the cerclage group was 84 (8-144) vs. 43 (1-146) days in the no-cerclage group (p=0.003). ConclusionAmong low-risk asymptomatic women with a very short cervix (≤10.0 mm) in the midtrimester scan, those treated with cerclage have increased latency to delivery and lower prevalence of preterm birth as compared to expectant management.

Septic Abortion at 17 Weeks Gestation after Radical Trachelectomy and Transabdominal Cerclage: A Case Report

Septic abortion can lead to severe maternal morbidity and mortality. The management of septic abortion can be complicated by a history of radical trachelectomy and transabdominal cerclage placement. A 33-year-old G1P0 at 17 weeks and 6 days gestation presented in severe septic shock after being diagnosed 6 days prior with previable rupture of membranes at an outside hospital and managed expectantly. History was notable for cervical adenocarcinoma status post radical trachelectomy and transabdominal cerclage placement. Due to uterine occlusion from the cerclage, the patient underwent emergent uterine evacuation via an abdominal approach. The risks and benefits of expectant management of pre-viable rupture of membranes in patients with abdominal cerclage should be weighed very cautiously. Among women with abdominal cerclage for whom uterine evacuation is indicated, a transabdominal approach may be necessary.

Rescue Cervical Cerclage for Previable Birth Prevention: A Comprehensive Review of Indications, Techniques, and Outcomes.

Cervical cerclage is a surgical intervention aimed at preventing previable birth by providing mechanical support to the cervix through the placement of a suture. This procedure is primarily indicated for cases of cervical incompetence, where the cervix is prone to premature dilation and can lead to early miscarriage or preterm birth. This review seeks to comprehensively analyze rescue cervical cerclage (RCC), focusing on its indications, techniques, and outcomes. The goal is to offer an in-depth understanding of its effectiveness in preventing previable birth and to guide clinical decision-making in managing pregnancies at risk of premature delivery. A thorough literature review examined recent studies and clinical data on RCC. Key aspects evaluated include the criteria for intervention, various surgical techniques employed, and the associated maternal and fetal outcomes. Comparative analysis was also performed with other preventive measures, such as progesterone therapy and bed rest. RCC has demonstrated efficacy in reducing the incidence of previable births, particularly when performed in cases of identified cervical incompetence or shortening. The review highlights variations in the technique, such as McDonald and Shirodkar cerclage, and discusses their relative success rates and potential complications. The procedure is associated with improved pregnancy outcomes and reduced risk of previable birth, though it carries some risks, including infection and cervical laceration. RCC remains a valuable intervention for preventing previable births in selected patients. This review underscores its importance in managing pregnancies at risk due to cervical incompetence and provides a detailed evaluation of its indications, techniques, and outcomes. Future research should optimize criteria for cerclage placement and explore novel strategies to enhance its effectiveness and safety.

Surgical Tips for Robotic Assisted Laparoscopic Abdominal Cerclage: A Minimally Invasive Approach.

Preterm birth is the leading cause of perinatal and neonatal morbidity and mortality in the developed world. An important cause of preterm birth is cervical insufficiency, leading to membrane prolapse, premature rupture of membranes, and mid-trimester pregnancy loss. A cerclage can be placed vaginally or abdominally to treat cervical insufficiency. In cases of failed prior transvaginal cerclage (TVC), transabdominal cerclage (TAC) is the alternative. The procedure can be completed via laparoscopy or open approach. The suture is placed at the internal os giving greater structural support.1 In this article, we review the definition of cervical incompetence, we present the indications for TAC, we discuss the outcomes of minimally invasive TAC compared to open approach, and we review surgical tips and tricks for robotic assisted (RA) TAC placement that can be used prior to pregnancy or in early gestation. The included images delineate the surgical technique for safe placement of robotic assisted laparoscopic abdominal cerclage in the management of cervical insufficiency.

Hypoglycemia-Induced Cardiac Arrest During Cervical Cerclage Procedure Under Spinal Anesthesia.

It’s unusual for a pregnant woman to suffer sudden cardiac arrest from hypoglycemia during spinal anesthesia, but we recently encountered such a case involving a 26-year-old first-time mother-to-be at 22 weeks gestation undergoing cerclage placement. This highlights the importance of identifying individuals prone to hypoglycemia, closely monitoring their well-being, and promptly initiating treatment at any signs of cardiovascular instability.

Is There Utility in Transvaginal Cervical Length Surveillance After Cerclage Placement for the Prediction of Spontaneous Preterm Birth?

Transvaginal cervical length (TVCL) surveillance post-transvaginal cerclage placement is not universally performed, despite the correlated risk of short TVCL with spontaneous preterm birth (sPTB). This study evaluated if patients with a TVCL <2.5 cm after cerclage placement had higher odds of sPTB than those with a TVCL ≥2.5 cm after cerclage placement. This retrospective cohort study included patients with a singleton, non-anomalous gestation with a transvaginal cerclage who had TVCL surveillance post-cerclage placement. The primary outcome was the odds of sPTB among patients with TVCL <2.5 cm vs TVCL ≥2.5 cm after cerclage placement. Transvaginal cerclage placement indications included history indicated, physical exam indicated, and ultrasound indicated. Outcomes were assessed using univariate and multivariate analysis while adjusting for progesterone use, TVCL before cerclage placement, and cerclage indication. The analysis included 210 patients, and the sPTB rate was 46.7%. Those with sPTB underwent cerclage placement at later gestational ages, had higher rates of exam-indicated cerclage, and were more likely to be prescribed vaginal progesterone. Patients with a TVCL of <2.5 cm after cerclage placement did not have significantly increased odds of sPTB (OR: 2.8, 95% CI: 0.9-8.7, p=0.07); however, patients with a TVCL <2.0 cm had significantly increased odds of sPTB (OR: 6.3, 95% CI: 2.2-18.8, p<0.001). In patients with transvaginal cerclage, there does not appear to be increased odds of sPTB with TVCL <2.5 cm after cerclage placement; however, there does appear to be an increased odds of sPTB in patients with a TVCL of <2.0 cm after cerclage placement.

Racial and Ethnic Disparities in Cervical Insufficiency, Cervical Cerclage, and Preterm Birth.

Background: The frequency of cervical insufficiency differs among the major racial and ethnic groups, with limited data specific to Asian American and Native Hawaiian/Pacific Islander (AANHPI) subpopulations. We assessed cervical insufficiency diagnoses and related outcomes across 10 racial and ethnic groups, including disaggregated AANHPI subgroups, in a large population-based cohort. Study Design: We performed a retrospective cohort study of all singleton births between 20-42 weeks' gestation in California from 2007 to 2018. Logistic regression models were performed to estimate the odds of cervical insufficiency and, among people with cervical insufficiency, the odds of cerclage and preterm birth according to self-reported race and ethnicity. Results: Among 5,114,470 births, 38,605 (0.8%) had a diagnosis code for cervical insufficiency. Compared with non-Hispanic White people, non-Hispanic Black people had the highest odds of cervical insufficiency (adjusted odds ratio [aOR] 3.07; 95% confidence interval [CI], 2.97, 3.18), for cerclage placement and higher odds for preterm birth. Disaggregating AANHPI subgroups showed that Indian people had the highest odds (aOR 1.94; 95% CI, 1.82, 2.07) of cervical insufficiency and had significantly higher odds of cerclage without increased odds of preterm birth; Southeast Asian people had the highest odds of preterm birth. Conclusion: Within a large, diverse population-based cohort, non-Hispanic Black people experienced the highest rates of cervical insufficiency, and among those with cervical insufficiency, had among the highest rates of cerclage and preterm birth. Among AANHPI subgroups specifically, Indian people had the highest rates of cervical insufficiency and cerclage placement, without increased rates of preterm birth; Southeast Asian people had the highest rates of preterm birth, without increased rates of cerclage. Disaggregating AANHPI subgroups identifies important differences in obstetric risk factors and outcomes.

Impact of Prophylactic Cerclage Location on Femoral Fracture Propagation: A Biomechanical Study.

Prophylactic cerclage cables are often placed intraoperatively about a fracture to prevent propagation. However, biomechanical data supporting optimal cable placement location are lacking. The objective of this study was to evaluate the impact of prophylactic cerclage placement location on the propagation of femoral shaft fractures. The diaphysis of 14 fresh-frozen cadaveric femora were included. Volumetric bone mineral density in the femoral shaft was obtained from quantitative computed tomography scans. For each specimen, a 5-mm longitudinal fracture was created proximally to simulate a pre-existing fracture. After reaming of the femoral canal, a 3 degrees tapered wedge was advanced with an MTS machine at 0.2 mm/s until failure. The tests were conducted with a CoCr cable placed at varying distances (5 mm, 10 mm, 15 mm, 20 mm, and cableless) from the distal tip of the initial fracture. A compression loadcell was used to measure the cable tension during the tests. The axial force, displacement, and cable tension were monitored for comparison between groups. In the cableless group, the mean force needed to propagate the fracture was 1017.8 ± 450.3 N. With the addition of a cable at 5 mm below the fracture, the failure force nearly doubled to 1970.4 ± 801.1 N (P < 0.001). This also led to significant increases in stiffness (P = 0.006) and total work (P = 0.001) when compared with the control group. By contrast, in the 15 and 20 mm groups, there were no significant changes in the failure force, stiffness, and total work as compared with the control group (P > 0.05). Propagation of femoral shaft fracture was effectively resisted when a prophylactic cable was placed within 5 mm from the initial fracture, whereas cables placed more than 10 mm below the initial fracture were not effective in preventing fracture propagation.

Patient perspectives and preferences on cerclage and preterm birth: a focus group study

AimThis qualitative focus group study aims to asses cerclage-related symptoms, the impact of a cerclage on daily functioning and patient perspectives of their healthcare experience. This study extends beyond the current focus on surgical and obstetric outcomes of a cerclage, thereby contributing to a more comprehensive understanding of the challenges faced by individuals in the context of extreme preterm birth and fetal loss and the impact of a cerclage on multiple facets in life.MethodsParticipants were recruited from the Amsterdam University Medical Center, Amsterdam, the Netherlands or via the website of a Dutch patient organization for (extreme) preterm birth. Eligible participants were ≥ 18 years old with a previous vaginal and/or abdominal cerclage with a subsequent delivery at ≥ 34 weeks of gestation with neonatal survival. Two focus group discussions (FGD) were performed. A predefined format was used, which was identical for both the vaginal and abdominal cerclage group. The International Classification of Functioning, Disability and Health (ICF-DH) was used to provide structure. Outcomes were a broad range of participants reported perspectives on physical, emotional, and social-related quality of life.ResultsIn the Vaginal Cerclage Group (VCG) and Abdominal Cerclage Group (ACG), respectively, 11 and 8 participants were included. Fear for a subsequent pregnancy loss was the most limiting factor to perform daily activities during pregnancy in all participants with a cerclage. Fear to conceive again because of prior second-trimester fetal loss was experienced by 27% in the VCG and 13% in the ACG. The majority of participants experienced a reduction in anxiety after placement of their cerclage (VCG = 64%, ACG = 75%). Decreased mobility/bedrest (VCG = 100%, ACG = 75%) and blood loss (VCG = 55%, ACG = 13%) were frequently mentioned complaints during pregnancy with cerclage. Other aspects mentioned in both groups were social isolation, the lack of societal participation, and the perceived need to quit work and sports. All participants in the abdominal cerclage group reported a lack of comprehensible and unambiguous information about obstetric management and expectations during pregnancy in secondary care hospitals. Clear communication between secondary and tertiary care hospitals about obstetric management following an abdominal cerclage, for example, about the need for cervical length measurements by ultrasound, the need for bedrest or advice concerning sexual activity was missing (63%). Psychologic support was desired in half of all participants, but was not offered to them.ConclusionsThe fear of a subsequent pregnancy loss was reported as the most limiting factor in daily life by all participants. Cerclage placement resulted in the reduction of anxiety. Participants mentioned a significant impact of bedrest and activity restriction during pregnancy with cerclage on social participation and daily activities. Unfortunately, no high level evidence is available on this matter. Patients might even benefit from appropriate levels of physical activity throughout their pregnancy to promote their overall well-being. More evidence is needed to determine the optimal level of physical activity. There is a need for clear and unambiguous patient information about obstetric management.

Perinatal Outcomes Associated With the Modified Shirodkar Cervical Cerclage Technique.

The objective of this study was to describe demographic and clinical characteristics and surgical and neonatal results related to the modified Shirodkar cervical cerclage technique. This was an observational descriptive and retrospective study. Data was called from anonymized medical records of women who were pregnant and diagnosed with cervical incompetenceand who had also undergone cervical cerclage procedures using the modified Shirodkar technique. The variables recorded included demographics such as the maternal age of patients, clinical features like obstetric history, physical examination, and ultrasound findings, and surgical and neonatal outcomes. The qualitative variables were processed using frequencies and percentages, and the quantitative variables were obtained through median, interquartile range, mean, and standard deviation. Our study included 39 anonymized medical records. The main indication for cervical cerclage placement was prophylactic (56%). The median gestational age at cerclage placement was 16 weeks, with a median gestational age at birth of 38 weeks; only 13% had complications related to prematurity, and 5% were admitted to the neonatal intensive care unit. The modified Shirodkar technique is associated with favorable surgical, maternal, and neonatal outcomes.

A comparison of Mersilene tape versus braided suture in transvaginal cervical cerclage: A retrospective case-control study.

Previous studies have indicated that there is an association between cervical cerclage and type of suture material. However, it is still unclear which suture material can provide the greatest benefit to patients who have undergone cerclage. This study investigated the effect of two different suture materials (Mersilene tape vs braided suture) used for transvaginal cervical cerclage placement on maternal outcomes of women with cervical insufficiency. In this retrospective case-control study, 170 women who underwent history-, ultrasound-, or physical examination-indicated transvaginal cervical cerclage were categorized according to suture materials used for cerclage: a total of 96 received Mersilene tape and 74 received braided suture. Study participants received a transvaginal cervical cerclage before 28 weeks and were followed up until delivery to assess pregnancy and neonatal outcomes. The primary outcome was gestational age at delivery. Secondary outcomes included preterm premature rupture of membranes (PPROM), premature rupture of membranes (PROM), chorioamnionitis, neonatal survival rate, and neonatal morbidity. Out of 170 eligible women, 74 (43.5%) received braided suture while 96 (56.5%) received Mersilene tape. Baseline characteristics were similar between the two groups. The group that received braided suture had a lower incidence of gestational age at delivery <37 weeks (29.2% vs 54.2%, P = 0.046), PPROM (9.5% vs 21.9%, P = 0.029) and PROM (17.6% vs 32.3%, P = 0.028) compared to the group that received Mersilene tape. However, there were no significant differences between the two groups in average gestational age at delivery, the rate of gestational age at delivery <24, <28, <32, and < 34 weeks, chorioamnionitis, and neonatal survival rate, as well as neonatal morbidity. Compared to Mersilene tape, the utilization of braided suture has been significantly associated with a reduction in the incidence of gestational age at delivery <37 weeks, as well as a decreased risk of PPROM and PROM. However, the use of braided sutures did not result in discernible differences in the rates of chorioamnionitis or adverse neonatal outcomes.

The association between the degree of cervical dilatation before ultrasound and physical examination indicated cerclage and subsequent neonatal outcomes.

Preterm identification of cervical dilation in pregnant women leads to the application of emergency cervical cerclage with an expectation of achieving term delivery. However, this is not always feasible. Short- and long-term neonatal complications post-preterm birth pose a significant challenge. It is crucial to anticipate potential complications and understand the possibilities of postpartum development as they can be encountered. We aimed to evaluate the effect of the degree of cervical dilatation before ultrasound and physical examination-indicated cerclage in singleton pregnancies presenting with premature cervical dilatation with bulging fetal membranes (rescue cerclage) on subsequent neonatal outcomes. In this retrospective clinical study, over a 10-year period between January 2009 and January 2019, 72 singleton pregnancies undergoing rescue cerclage were included and divided into two groups according to pre-cerclage cervical dilatation: Group 1 (n = 33) and Group 2 (n= 39) with cervical dilatation ≤3 cm and >3 cm, respectively. Latency period for pregnancy prolongation, gestational age at delivery, birth weight, and neonatal morbidity and mortality were compared across the groups. Logistic regression was used to delineate the independent effect of cervical dilatation at cerclage placement on neonatal mortality. Group 2 had a higher delivery rate at ≤28 weeks' gestation (p = 0.007) and lower birth weight (p = 0.002) compared to Group 1, with an increased mean latency period in Group 2 (90 ± 55 days versus 52 ± 54 days, p = 0.005). The newborn intensive care unit (NICU) requirement, respiratory distress syndrome (RDS), neonatal jaundice and sepsis, and retinopathy of prematurity (ROP) were more frequent in Group 2. Neonatal mortality rate was higher (52.6% versus 24.2%, p = 0.015) and intact survival was lower (23.1% versus 48.4%, p = 0.013) in Group 2, whereas rates of cerebral palsy (8% and 9%, respectively) were similar between the groups (p = 0.64). Advanced cervical dilatation (>3 cm) during physical examination-indicated cerclage in singleton pregnancies is associated with earlier delivery, leading to increased neonatal morbidity and mortality when compared with pregnancies having lesser degrees of cervical dilatation at cerclage. However, short-term poor neurological outcomes seem comparable.

Cerclage Plus Adjuvant Vaginal Progesterone for Preterm Birth Prevention in Patients with a Short or Dilated Cervix without Prior Preterm Birth.

The primary objective was to determine if vaginal progesterone following cerclage for cervical length <10 mm or cervical dilation in patients without a history of spontaneous preterm birth (sPTB) decreased the risk of preterm birth at <34 weeks' gestation compared with cerclage alone. Secondary objectives were to determine if vaginal progesterone following cerclage (1) decreased the risk of preterm birth at <24, <28, and <37 weeks' gestation and (2) increased the latency period from cerclage placement to delivery compared with treatment with cerclage alone. Multicenter retrospective cohort study from 2015 to 2020 of singleton pregnancies, without prior sPTB, who had cerclage placement <24 weeks' gestation for cervical length <10 mm or cervical dilation. Exposure defined as cerclage plus vaginal progesterone postoperatively (dual therapy) and unexposed as cerclage alone (monotherapy), based on surgeon preference. We included 122 patients, 78 (64%) treated with dual therapy and 44 (36%) treated with monotherapy. In the crude analysis, dual therapy was associated with a lower risk of delivery at <28 weeks' gestation (13%) compared with monotherapy (34%; crude risk ratio: 0.38 [95% confidence interval (CI): 0.19-0.75]). When adjusted for preoperative vaginal progesterone, results were attenuated (adjusted risk ratio: 0.45 [95% CI: 0.20-1.01]). In both the crude and adjusted analyses, the risk of sPTB was not statistically different at <24, <34 or <37 weeks' gestation. Dual therapy was associated with a greater pregnancy latency from cerclage to delivery (16.3 vs. 14.4 weeks; p = 0.04), and greater gestational age at delivery (37.3 vs. 35.8 weeks' gestation; p = 0.02) compared with monotherapy. While not statistically significant, the risk of sPTB was lower at all gestational ages studied in patients treated with dual therapy compared with monotherapy. Dual therapy was associated with longer pregnancy latency and greater gestational age at delivery compared with monotherapy. · Dual therapy did not decrease preterm birth risk compared with monotherapy.. · Dual therapy prolonged pregnancy compared with monotherapy.. · Dual therapy can be considered but further studies are needed..

Urogenital cultures and preterm birth in women with cervical cerclage: a single center retrospective cohort study

BackgroundThe leading hypothesis of the pathogenesis of cervical insufficiency suggests a role of cervical inflammation. Urogenital tract infections could play a causative role in this process. To test this hypothesis in women with a cervical cerclage, we aimed to retrospectively examine the relationship between gestational age (GA) at delivery and positive urogenital cultures.MethodsThis single center retrospective study reviewed the records of all women with a singleton pregnancy that underwent cervical cerclage (n = 203) between 2010 and 2020 at the University Hospital of Leuven, Belgium. Transvaginal cerclages were categorized as history indicated (TVC I, n = 94), ultrasound indicated (TVC II, n = 79) and clinically indicated (TVC III, n = 20). Additionally, ten women received transabdominal cerclage (TAC). Urogenital cultures (vaginal and urine) were taken before and after cerclage with 4-week intervals. Urogenital cultures were reported ‘positive’ if urine and/or vaginal cultures showed significant growth of a microorganism. Treatment decision depended on culture growth and clinical presentation. The primary aim was to evaluate the association between the urogenital culture results and the GA at delivery, for each of the cerclage groups. Secondarily, to investigate the effect of antibiotic treatment of positive cultures on GA at delivery.ResultsPositive pre-cerclage urogenital cultures were associated with lower GA at delivery in TVC III (positive culture 26w4d ± 40d vs. negative 29w6d ± 54d, p = 0.036). For TVC I, GA at delivery was longer when pre-cerclage urogenital cultures were positive (positive culture 38w0d ± 26d vs. negative 35w4d ± 42d, p = 0.035). Overall post-cerclage urogenital cultures status was not associated with a different GA at delivery. Treating patients with pre- or post-cerclage positive urogenital cultures did also not change GA at delivery.ConclusionPositive urogenital cultures taken before clinically indicated cerclage intervention may be associated with lower GA at delivery. However, there seems to be no benefit of antibiotic treatment or routine urogenital cultures during follow-up of asymptomatic women after cerclage placement.

Late emergency cervical cerclage placement in a patient with early recurrent pregnancy loss and bicorporeal uterus: A case report

Introduction: Uterine Müllerian anomalies are relatively common among the population, affecting approximately 4% of women, and can lead to various pregnancy-related pathologies. Cervical cerclage, a surgical procedure involving the placement of a stitch around the cervix, has been recognized as an optional treatment to mitigate the risk factors associated with these anomalies. Case Report: A 33-year-old woman with a bicorporeal uterus and a history of early recurrent pregnancy loss, who was diagnosed with a cervical os shortening during her second anatomy screening at 22+3 weeks gestation. A cervical cerclage was performed to prevent preterm delivery, and subsequently. An elective cesarean section was conducted at 37+0 weeks of gestation, resulting in the birth of a healthy baby boy. Conclusion: Although the literature about the effectiveness of cervical cerclage in pregnant women with Müllerian anomalies is limited, this case highlights its potential as an effective treatment option.

The outcome of cervical stitch in the prevention of pre-viable and preterm deliveries in Nigerian Tertiary Hospital

Background: Cervical incompetence, defined as the inability to sustain a pregnancy to term due to functional and anatomical defects of the cervix is a distressing cause of childlessness in Nigeria. Cervical cerclage, introduced into clinical practice by Shirodkar and McDonald in the 1950s still a time-tested intervention in the prevention of pregnancy wastages from cervical incompetence. Aim: The purpose of this study was to audit the outcome of the applications of cervical cerclages in the prevention of pregnancy wastages at the Maternity Complex of the Ekiti State University Teaching Hospital and Maternal and Child Specialists’ Clinic in Ekiti State, Southwest Nigeria. Methods: In this prospective observational cohort study, we included all pregnant women who had cervical stitches applied over ten years, (2010-2019). Information on sociodemographic biodata, risk factors, indications, and outcomes were collated. Statistical analysis was performed using the SPSS package, version 22 (SPSS Inc, Chicago, IL). Statistical significance of the categorical variables was tested using the chi-square or Fisher’s exact test, confidence level of 95%and P-value of 0.05. Results: The 134 pregnant women diagnosed with cervical incompetence had cervical stitches applied over the ten years. 15,037 deliveries giving a prevalence rate of 0.89% of cervical incompetence. 75% were multigravida, while 92.5% were of low parity. Risk factors found included recurrent mid-trimester abortions (55%), and prior cervical dilatation (20%). The cervical cerclages were history and physical examination indicated in 22.5% and 75% had ultrasound scanning confirmation. In the majority (82.5%), cervical cerclage was placed at 14-16 weeks using Mersilene tape in 92.5%. Spinal anesthesia and conscious sedation were administered in equal proportion. Majority had McDonald’s procedure (96.27%) whereas only 3.73% had Shirodkar’s. Placement to removal interval ranged from 10-20 weeks in 53%, while in 12.5% it lasted 4 weeks. The indications for removal included pregnancy carried to term at 72.5%, preterm labor at 7.5%, and vagina bleeding occurred in 7.5% of cases. Vaginal deliveries were achieved in 62.5% while 25% had cesarean delivery. 7.5% expelled pre-viable fetuses. Cervical cerclage placement was successful in 75%, while 25% had failed cerclage. 10% of those who had failed cerclage had live births. We achieved 85% of babies take home. There was no significant association between the overall outcomes of cervical cerclage (inevitable abortion, preterm delivery, term delivery) and certain defined co-variables (age, gravidity, and parity). On multivariate linear regression. Conclusion: We recommend that timely application of cervical stitches will rescue women from pregnancy wastages associated with cervical incompetence in Ekiti State.

Concurrent progestogen and cerclage to reduce preterm birth: a multicenter international retrospective cohort

Objective: We aimed to evaluate whether cerclage with progestogen therapy was superior to cerclage alone in the prevention of spontaneous preterm birth (sPTB) in singleton pregnancies Methods: This is an international retrospective cohort study of singleton pregnancies, without major anomaly or aneuploidy, and with cerclage placed at 10 different institutions in the United States and Colombia from June 2016-June 2020. Exclusion criteria were: lack of documentation regarding whether progestogen was or was not prescribed, delivery outcome unavailable, and pregnancy termination (spontaneous or induced) prior to 16 weeks’ gestation. Exposure of interest was progestogen use with cerclage placement, which included those who were continued on progestogen or who started progestogen after cerclage. Comparator was those without progestogen use after cerclage placement, which included those who had no progestogen use the whole pregnancy, or who initiated progestogen and then stopped it after cerclage placement. Progestogen type, cerclage indication, maternal baseline characteristics, and maternal/neonatal outcomes were collected. Primary outcome was sPTB <37 weeks. Secondary outcomes were sPTB <34 weeks, gestational age at delivery, composite neonatal outcome including ≥1 of the following: perinatal mortality, confirmed sepsis, Grade III or IV intraventricular hemorrhage, retinopathy of prematurity, respiratory distress syndrome, bronchopulmonary dysplasia. There was planned subgroup analyses by cerclage indication, progestogen type (vaginal progesterone vs 17-hydroxyprogesterone caproate (17-OHPC)), preterm birth history, and site.Continuous variables compared in adjusted analyses with ANCOVA and categorical variables compared with multivariable logistic regression adjusting for potential confounders with adjusted odds ratio (aOR). Cox regression survival curve was generated to compare latency to spontaneous delivery, censored after 37 weeks. Results: During the study period, a total of 699 singletons met inclusion, N=561 in the progestogen with cerclage group, and N=138 with cerclage alone. Baseline characteristics were similar, except those in the progestogen group were more likely to have had a prior sPTB (61% vs 41%, p<0.001). Within the progestogen group, 52% were on 17-OHPC weekly, 44% on vaginal progesterone daily, and 3% on oral progesterone daily. Progestogen with cerclage was associated with a significantly lower frequency of sPTB<37 (31% vs 39% aOR 0.59 (0.39 - 0.89), p=0.01) and <34 weeks (19% vs 27%, aOR 0.55 (0.35 - 0.87), p=0.01), increased latency to spontaneous delivery (Hazard ratio to sPTB <37wk, 0.66 (0.49-0.90), p=0.009), and lower frequency of perinatal death (7% vs 16%, aOR 0.37 (0.20-0.67), p=0.001). In planned subgroup analyses, association with reduced odds of preterm birth <37 weeks persisted in those on vaginal progesterone, those without a prior preterm birth, those with ultrasound or exam-indicated cerclage, those that started progestogen therapy prior to cerclage, and in sites restricted to the United States. Conclusion: Use of progestogen with cerclage was associated with reduced rates of sPTB and early sPTB compared to cerclage alone. Although not powered for subgroups, the strength of evidence for benefit appeared greatest for those with ultrasound or exam-indicated cerclage, and with vaginal progesterone.

Median Effective Dose of Ropivacaine for Prophylactic Cervical Cerclage in Chinese Women: A Dose-Finding Study

(Reg Anesth Pain Med. 2023;48:168–172. doi: 10.1136/rapm-2022-104242) Complications in pregnancy leading to preterm labor or miscarriage can occur for a variety of reasons. One reason that represents a significant public health burden is cervical incompetence or insufficiency. Current treatment guidelines focus on cervical cerclage as an effective treatment to prevent or arrest the effects of cervical insufficiency. Performing this procedure requires surgery, and therefore different anesthetic methods can be used to minimize pain and adverse outcomes for the patients, namely general or neuraxial anesthesia. One local anesthetic used for spinal neuraxial blocks in obstetrics is ropivacaine, but research has not explored its effect when used for cervical cerclage. This study from China was designed to find the median effective dose of intrathecal ropivacaine for cervical cerclage placement in 50% of patients (ED50). Secondary to this, the effective dose of intrathecal ropivacaine in 95% of patients (ED95) was also calculated. Other outcome measures included the duration of the sensory and motor blocks.

Successful pregnancy outcome via in-vitro fertilization and laparoscopic resection of non-communicating rudimentary horn pregnancy containing early pregnancy: a case report

BackgroundNon-communicating rudimentary horn pregnancy (NCRHP) lead to life-threatening condition for both mother and fetus. Early diagnosis of NCRHP and laparoscopic resection is important to prevent catastrophic conditions. However, delayed diagnosis until the second or third trimester makes it difficult to accurately diagnose between NCRHP and bicornuate uterine pregnancy, as both conditions present uterine rupture and massive hemoperitoneum. Furthermore, these rare cases are challenging in pregnancy trials and associated with adverse outcomes in subsequent pregnancies.Case presentationA 31-year-old gravida 1 para 0 Korean woman visited our infertility center with a confirmed positive urine pregnancy test after timed intercourse. Before she was scheduled to have timed intercourse, a unicornuate uterus with a non-communicating right uterine horn was suspected based on an ultrasound scan and hysterosalpingography during the initial infertility workup. A gestational sac was observed in the right non-communicating rudimentary horn at 5 weeks of gestation. Serum beta-human chorionic gonadotropin (b-hCG) level was 2052.0mIU/mL. An elective laparoscopic resection of the right rudimentary horn containing a gestational sac, along with ipsilateral salpingectomy, was performed with no adverse event. After 3-month of recovery period and three cycles of conceptional trials involving timed intercourse and intrauterine insemination, in-vitro fertilization (IVF) was performed using the antagonist protocol, and successful pregnancy was confirmed. The patient had been hospitalized from 21 + 6 weeks to 35 + 6 weeks of gestation, underwent cerclage placement and tocolytics with corticosteroid treatment. She delivered an early-term male baby by cesarean section.ConclusionIn this rare case, the successful pregnancy achieved through IVF following the appropriate management of NCRHP under laparoscopy underscores the critical importance of early diagnosis and intervention in cases of NCRHP. Timely identification and management of NCRHP are vital to prevent the occurrence of catastrophic conditions and to enhance the prognosis of a successful pregnancy through assisted reproductive technology (ART). Therefore, a high index of suspicion for NCRHP is important and employs a range of diagnostic modalities.

Robotic-assisted single-site abdominal cerclage in the bicornuate uterus patient with cervical insufficiency

Robotic-assisted single-site abdominal cerclage in the bicornuate uterus patient with cervical insufficiency