Transvaginal Cervical Cerclage Research Articles

Effectiveness and pregnancy outcomes of ultrasound-indicated and physical examination-indicated cervical cerclage: a retrospective study from a single centre

ObjectivePreterm birth (PTB) is the leading cause of neonatal morbidity and mortality worldwide, and cervical incompetence (CIC) is a significant contribution. Cervical cerclage (CC) is an effective obstetric intervention. However, many clinical factors affect the success rate of surgery. The objective was to investigate and compare the pregnancy and neonatal outcomes of patients who underwent ultrasound- and physical examination-indicated cervical cerclage and to explore the influencing factors of preterm delivery before 34 weeks.MethodsThe sociodemographic characteristics and clinical data of patients with a diagnosis of cervical incompetence who underwent ultrasound- and physical examination-indicated transvaginal cervical cerclage at Nanjing Maternal and Child Health Hospital from January 2020 to December 2022 were retrospectively analyzed. The pregnancy and neonatal outcomes of the patients were evaluated. Continuous variables were compared using Student’s t test (for normally distributed data) or the Mann-Whitney U test (for nonnormally distributed data). Categorical variables were analysed using the chi-square test or Fisher’s exact test. Additionally, logistic regression analyses and receiver operating characteristic curves were used to evaluate the associations of inflammatory markers with maternal and neonatal outcomes.ResultsThis study included 141 participants who underwent cervical cerclage, including 71 with ultrasound-indicated cerclage and 70 with physical examination-indicated cerclage. Compared to those in the ultrasound-indicated cerclage group, the duration from cerclage to delivery, birth weight, and APGAR score in the physical examination-indicated cerclage group were significantly lower, and the rates of delivery at < 28 weeks, < 32 weeks, < 34 weeks, and < 37 weeks of gestation and neonatal mortality were significantly higher (all P < 0.05). Compared to those in the physical ultrasound-indicated cerclage group, in the physical examination-indicated cerclage group, maternal blood inflammatory markers, such as C-reactive protein (CRP), the systemic immune-inflammation index (SII) and the systemic inflammation response index (SIRI) were significantly higher (P < 0.05). Additionally, maternal blood inflammatory markers, such as the CRP, white blood cell count, platelet to lymphocyte ratio (PLR), SII, and SIRI were significantly higher in the group with delivery before 34 weeks of gestation. Furthermore, the results demonstrated that twin pregnancy had the highest OR for preterm delivery before 34 weeks of gestation (OR = 3.829; 95% CI 1.413–10.373; P = 0.008), as well as the following: the SII level (OR = 1.001; 95% CI 1.000-1.002; P = 0.003) and CRP level (OR = 1.083; 95% CI 1.038–1.131; P = 0.022). The risk factors for preterm delivery before 34 weeks of gestation were twin gestation, an increased SII level and an increased CRP level, which had good combined predictive value.ConclusionIn patients with cervical insufficiency, ultrasound-indicated cervical cerclage appears to lead to better pregnancy outcomes than physical examination-indicated cerclage. Twin pregnancy and maternal blood inflammatory markers, such as the CRP level and the SII, are associated with preterm delivery before 34 weeks of gestation.

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.

Effectiveness of Prophylactic Transvaginal Cervical Cerclage in Improving Clinical Outcomes among Pregnant Women with Cervical Insufficiency: Meta-Analysis

Effectiveness of Prophylactic Transvaginal Cervical Cerclage in Improving Clinical Outcomes among Pregnant Women with Cervical Insufficiency: Meta-Analysis

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 &lt;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 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.

Mersilene tape versus conventional sutures in transvaginal cervical cerclage: a systematic review and meta-analysis

ObjectiveThis study aimed to assess the effectiveness of Mersilene tape versus alternative suture types in prolonging singleton pregnancies as well as other pregnancy and neonatal outcomes, in cases of history-, ultrasound-, and exam-indicated cervical cerclage.MethodsA systematic review was conducted to identify relevant studies comparing different suture types in cervical cerclage procedures. The primary outcome of interest was preterm birth (PTB) rate < 37, <35, < 28, and < 24 weeks. Statistical analyses were performed to determine the relationship between suture type and various outcomes.ResultsA total of five studies, including three randomized controlled trials (RCTs) and two retrospective studies, with a combined participation of 2325 individuals, were included. The pooled analysis indicated no significant association between suture type and PTB at less than 37 weeks of gestation (RR: 1.02, 95% CI: 0.65–1.60, p < 0.01, I2 = 74%). Women who received Mersilene tape had a higher risk of PTB at 34–37 weeks (RR: 2.62, 95% CI: 1.57–4.37, p = 0.69, I2 = 0%), but a lower risk of PTB at less than 34 weeks (RR: 0.43, 95% CI: 0.28–0.66, p = 0.66, I2 = 46%). No statistically significant differences were observed for PTB before 28 weeks (RR: 1, 95% CI: 0.65–1.53, p = 0.70, I2 = 0%), before 24 weeks (RR: 0.86, 95% CI: 0.60–1.23, p = 0.33, I2 = 0%), incidence of chorioamnionitis (RR: 0.97, 95% CI: 020-4.83, p < 0.01, I2 = 95%), neonatal intensive care unit (NICU) admission (RR: 0.79, 95% CI: 0.28–2.22, p = 0.08, I2 = 67%) and neonatal death (RR: 1.00, 95% CI: 0.42–2.35, p = 0.17, I2 = 48%).ConclusionOur findings suggest that Mersilene tape does not reduce the risk of PTB before 37, 28 or 24 weeks. We observed higher risk of preterm birth between 34 and 37 weeks with Mersilene tape but lower incidence before 34 weeks, a period with higher neonatal morbidity and mortality. Due to the limited number of studies, our results and their clinical significance should be interpreted with caution.

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.

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.

O-055 Efficacy of Laparoscopic Abdominal Cerclage in Women With Prior 2nd Trimester Losses/Preterm Birth: Perinatal Outcomes of Case Series

Abstract Study question What is the efficacy of laparoscopic abdominal cerclage (LAC) that placed during periconceptional period in singletons with prior 2nd trimester pregnancy losses/preterm deliveries (PTDs)? Summary answer LAC seems to prolong pregnancy duration and enhance perinatal outcomes in singletons prior 2nd trimester losses/PTDs. What is known already Cervical insufficiency (CI) is defined as the inability of the uterine cervix to retain a pregnancy till term without the signs and symptoms of clinical contractions ,with an incidence up to 1% (Berghella, 2011). Cervical cerclage (CC) has been proposed as an effective treatment for CI in terms of successfully prolonging the pregnancy period and improving the perinatal prognosis. The common clinical approach is transvaginal cervical cerclage (TVC), which is a feasible and relatively easy technique. However, some group of women may experience late abortions and/or PTD and LAC has been proposed to enhance pregnancy outcomes. Study design, size, duration Case series consisting of singletons with at least 2 prior PTDs and managed with LAC was reviewed between January 2019-November 2022. After placement of LAC, reproductive and perinatal outcomes of women were reviewed for 2 years. Participants/materials, setting, methods All women with at least 2 prior 2nd trimester losses and/or PTDs were offered to LAC procedure during the period. After having informed consents, total of 28 LAC procedures were performed. All surgeries were performed by a single experienced laparoscopist in the same center. Non-absorbable mersilene tape was placed during preconceptional period. Reproductive outcomes including spontaneous and assisted conception cycles and perinatal outcomes were reported. Main results and the role of chance A total of 28 LAC proceudres were performed during the period. Mean age of women was 34±2 and mean numbers of previous 2nd trimester losses/PTDs was 2.8±0.8, of which all of them were &amp;lt;24 weeks. Total of 8 women have had gynecologic surgery in their history. Less than 12 months interval, 19 out of 28 women got pregnent; 13/28 conceived spontaneously and 6/28 conceived with after IVF treatment. For the perinatal outcomes; there were no single case of 2nd trimester losses/PTDs &amp;lt;24 weeks in the entire cohort. 15 women delivered &amp;gt;34 weeks and remaining 4 delivered at term (&amp;gt;37 weeks). During the gestation, no additional medication was provided to pregnants such as progesterone treatment. The mean gestational age was 35 4/7 weeks. There were no remarkable adverse events during the pregnancy. All newborns were healthy without remarkable issues, only 2 infants required intensive care for less than 2 weeks. Limitations, reasons for caution Small sample size, lack of a control group and randomization and heterogenious patient population. Wider implications of the findings LAC appears to have favorable pregnancy outcomes in singletons with prior pregnacy losses and/or PTDs. To precisely conclude, randomized controlled trials are needed with different intervention arms in the same population. Trial registration number non applicable

P50 Improving the transvaginal cervical cerclage service: a quality improvement project at a tertiary obstetrics centre

P50 Improving the transvaginal cervical cerclage service: a quality improvement project at a tertiary obstetrics centre

Complications Associated with Cervical Cerclage: A Systematic Review.

Cervical cerclages are associated with improved live birth rates and have low short- and long-term risks. However, there have been reports of fistula formation or erosion of cerclage into the surrounding tissue. Those complications are uncommon and yet are serious. The risk factors associated with its development are still unclear. The purpose of our study was to evaluate the incidence of fistula formation or erosion following transvaginal cervical cerclage and the associated clinical and sociodemographic factors. We conducted a systematic search of PubMed, Medline, and Embase databases to retrieve articles related to transvaginal or transabdominal cervical cerclage. Databases were searched up to July 2021. The study protocol was registered (PROSPERO ID 243542). A total of 82 articles were identified describing cervical cerclage and erosion or fistula formation. A total of 9 full-text articles were included. There were seven case reports and series that described 11 patients who experienced late complications following cervical cerclage. Many of the cerclage procedures were done electively (66.7%). The most common type of cerclage was McDonald (80%). While all cases reported fistula formation, the main location was vesicovaginal fistulas (63.6%). One patient (9.1%) had erosion of their cerclage and another (9.1%) had bladder calculi. Of 75 patients who underwent cerclage in two retrospective case reviews, the overall incidence of fistula was 1.3% and abscess was also 1.3%. Although rare, the most common long-term complication of cervical cerclage placement is fistula formation, particularly vesicovaginal fistulas.

Characteristics associated with previable delivery and/or delivery

To identify socio-demographic, clinical and sonographic predictors of cerclage failure, defined as previable delivery or delivery < 21 days after transvaginal cervical cerclage placement, among women with singleton gestations.

Total Laparoscopic Cervical Encerclage in 16 Weeks Pregnant Uterine Didelphis Uterus Category: Laparoscopy

Study Objective To demonstrate Laparoscopic approach for encerclage in pregnancy in a ℅ uterine didelphys. Design A case report. Setting laparoscopy surgery with patient in lithotomy position under anaesthesia. Patients or Participants A 26-year-old female came G3 A2 with previous 2- 2nd trimester abortions with failed vaginal encerclage and uterine didelphys diagnosed on MRI with 16 weeks pregnancy. Interventions Laparoscopic cerclage was planned using Mersilene tape. Measurements and Main Results Cervical insufficiency (CI) or incompetence is a well-known condition in obstetrics with an incidence of 0.1–1% and is notoriously associated with a high risk of second trimester abortion and/or preterm delivery. The traditional surgical treatment for cervical insufficiency consists of vaginal placement of cervical stitches, known as transvaginal cervical cerclage (TVC). Advances in the field of minimally invasive surgery resulted in development of a new approach to cervical cerclage placement. Laparoscopic cerclage offers the benefit of reduced blood loss, reduced postoperative pain, and fewer adhesions, as well as decreased length of hospital stay and overall faster recovery time. Principles of surgery: 1. Dissection of loose UV fold of peritoneum. 2. Creation of window in the broad ligament on both sides. 3. Passing the needle of mersilene tape from medial to the uterine artery of left side at the level of internal os. 4. Passing the Mersilene tape all around the uterus 5. Passing the needle of mersilene tape from medial to uterine artery on right side. 6. Tightening the mersilene tape at the level of the internal os. Conclusion Similar to the transabdominal approach, laparoscopic cerclage can be placed during pregnancy or as an interval procedure. Success rates for laparoscopic cerclage were reported in the range of 76% to 100%. To demonstrate Laparoscopic approach for encerclage in pregnancy in a ℅ uterine didelphys. A case report. laparoscopy surgery with patient in lithotomy position under anaesthesia. A 26-year-old female came G3 A2 with previous 2- 2nd trimester abortions with failed vaginal encerclage and uterine didelphys diagnosed on MRI with 16 weeks pregnancy. Laparoscopic cerclage was planned using Mersilene tape. Cervical insufficiency (CI) or incompetence is a well-known condition in obstetrics with an incidence of 0.1–1% and is notoriously associated with a high risk of second trimester abortion and/or preterm delivery. The traditional surgical treatment for cervical insufficiency consists of vaginal placement of cervical stitches, known as transvaginal cervical cerclage (TVC). Advances in the field of minimally invasive surgery resulted in development of a new approach to cervical cerclage placement. Laparoscopic cerclage offers the benefit of reduced blood loss, reduced postoperative pain, and fewer adhesions, as well as decreased length of hospital stay and overall faster recovery time. Principles of surgery: 1. Dissection of loose UV fold of peritoneum. 2. Creation of window in the broad ligament on both sides. 3. Passing the needle of mersilene tape from medial to the uterine artery of left side at the level of internal os. 4. Passing the Mersilene tape all around the uterus 5. Passing the needle of mersilene tape from medial to uterine artery on right side. 6. Tightening the mersilene tape at the level of the internal os. Similar to the transabdominal approach, laparoscopic cerclage can be placed during pregnancy or as an interval procedure. Success rates for laparoscopic cerclage were reported in the range of 76% to 100%.

Comparison of transvaginal cervical cerclage versus laparoscopic abdominal cervical cerclage in cervical insufficiency: a retrospective study from a single centre

BackgroundCervical cerclage has been proposed as an effective treatment for cervical insufficiency, but there has been controversy regarding the surgical options of cervical cerclage in singleton and twin pregnancies. This study aimed to compare the pregnancy outcomes between transvaginal cervical cerclage (TVC) and laparoscopic abdominal cervical cerclage (LAC) in patients with cervical insufficiency. We also aimed to evaluate the efficacy and safety, and provide more evidence to support the application of cervical cerclage in twin pregnancies.MethodsA retrospective study was carried out from January 2015 to December 2021. The primary outcomes were the incidence of spontaneous preterm birth (sPTB) < 24 weeks, < 28, < 32, < 34 weeks, and < 37weeks, gestational age at delivery, and the incidence of admission for threatened abortion or preterm birth after cervical cerclage. The secondary outcomes included admission to the Neonatal Intensive Care Unit, adverse neonatal outcomes and neonatal death. We also analysed the pregnancy outcomes of twin pregnancies after cervical cerclage.ResultsA total of 289 patients were identified as eligible for inclusion. The LAC group (n = 56) had a very low incidence of sPTB ˂ 34 weeks, and it was associated with a significant decrease in sPTB < 28 weeks, ˂32 weeks, ˂34 and < 37 weeks, and admission to the hospital during pregnancy for threatened abortion or preterm birth after cervical cerclage (0 vs.27%; 1.8% vs. 40.3%; 7.1% vs. 46.8%; 14% vs. 63.5%, 8.9% vs. 62.2%, respectively; P < 0.001), and high in gestational age at delivery compared with the TVC group (n = 233) (38.3 weeks vs.34.4 weeks,P < 0.001). Neonatal outcomes in the LAC group were significantly better than those in the TVC group. The mean gestational age at delivery was 34.3 ± 1.8 weeks, with a total foetal survival rate of 100% without serious neonatal complications in twin pregnancies with LAC.ConclusionIn patients with cervical insufficiency, LAC appears to have better pregnancy outcomes than TVC. For some patients, LAC is a recommended option and may be selected as the first choice. Even in twin pregnancies, cervical cerclage can improve pregnancy outcomes with a longer latency period, especially in the LAC group.

Outcomes of patients who have undergone laparoscopic abdominal cerclage: A retrospective study

ObjectiveThis study aims to evaluate the surgical morbidity and obstetric outcomes following in-pregnancy or pre-pregnancy laparoscopic abdominal cerclage (LAC) for patients who were diagnosed with refractory cervical insufficiency or had a short cervix. MethodsA retrospective study was conducted on patients undergoing LAC between May 2017 and May 2019 at the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital. The patients were diagnosed with refractory cervical insufficiency based upon a previous failed transvaginal cervical cerclage (TVC), or had a short cervix who were considered unsuitable for a TVC after a previous cervical procedure. All patients were followed-up after surgery with transperineal ultrasonography until May 2020. Subsequently, surgical and obstetric data were collected and analyzed. ResultsIn total, 44 patients underwent LAC, with 8 patients in-pregnancy and 36 pre-pregnancy. For the patient with pre-pregancy LAC, the pregnancy rate was 80.6% (29/36), including 3 patients with first-trimester loss, 1 patient with an ectopic pregnancy, and 25 patients with a delivery. For the remaining 7 patients, 3 did not conceive, and another 4 had no pregnancy plans. All the patients with in-pregnancy LAC had a delivery. The “take-home baby” rate was 89.2% (33/37), with a live-birth rate of 100% and a neonatal survival rate of 100% for both patients with in-pregnancy and pre-pregnancy LAC. For patients with in-pregnancy LAC, 75.0% (6/8) patients delivered at ≥37 wk of gestation, 12.5% (1/8) delivered between 34 and 36+6 wk, and 12.5% (1/8) delivered between 28 and 33+6 wk. For patients with pre-pregnancy LAC, 80.0% (20/25) patients delivered at ≥37 wk of gestation, 16.0% (4/25) delivered between 34 and 36+6 wk, and 4.0% (1/25) delivered between 28 and 33+6 wk. No adverse-event intra-operative or post-operative sequelae were noted. ConclusionsLAC is an effective and safe procedure that results in remarkable obstetric outcomes for women with refractory cervical insufficiency, or with a short cervix who are considered unsuitable for a TVC. The success rate of in-pregnancy or pre-pregnancy LAC depends on a full evaluation of patients, a proper peri-operative management and close follow-up.

The comparative analysis of laparoscopic or transvaginal cerclage in pregnancies with cervical insufficiency: a retrospective cohort study.

To evaluate the efficacy and safety of prophylactic cervical cerclage by laparoscopy in pregnant women versus transvaginal way. Retrospective, monocentric cohort study was performed. The First Affiliated Hospital of Sun Yat-sen University. Cases with cervical insufficiency (defined by previous history of painless second or early third trimester pregnancy loss/losses) were selected. Laparoscopic or transvaginal cerclage were conducted. The maternal information and the neonatal data were collected and compared. The pregnancy outcomes including the incidence of full-term labor and gestational weeks at delivery were defined as the primary outcomes. Neonatal survival and birth weight, neonatal complications were evaluated as the secondary outcomes. Totally 36 twin pregnant cases and 82 singleton pregnant cases were managed with cerclage, either trans-laparoscopy (totally 78 cases) or transvaginal (totally 40 cases). Demographic characteristics showed no significant differences. Cases in laparoscopic group had a prolonged gestational age at delivery (36.43 ± 0.93weeks and 33.60 ± 2.78weeks, respectively, P < 0.001), a higher incidence of full-term labor (60.26% vs 42.50%, P = 0.05) with no significant difference of perinatal mortality (P = 0.661). Meanwhile, higher incidence of normal birth weight infants (88.46% vs 67.50%, P = 0.007) was shown in laparoscopic group with no more complications such as the cases of neonatal with Apgar < 7 (P = 0.296), and the incidence of NICU admission (P = 0.237). Besides, LTC showed good efficiency on VTC in the incidence of full-term labor: HR 0.24 (95% CI 0.070-0.85), P < 0.001. While LSC showed the similar efficiency on VSC: HR 0.734 (95% CI 0.36-1.49), P = 0.857, showing that cases with twin pregnancy may benefit more from laparoscopic cerclage. The comparative effect between laparoscopic and transvaginal cerclage in pregnant women showed that laparoscopic cerclage may be a relatively effective and safety prophylactic way for cervical insufficiency. This would be an acceptable and safe replace for traditional transvaginal cervical cerclage.

Suprapubic-assisted transurethral excision of eroded transvaginal cerclage suture.

The aim was to demonstrate our minimally invasive technique for excision of eroded transvaginal cervical cerclage suture through the bladder mucosa using a suprapubic-assisted transurethral approach. Transvaginal cervical cerclage is a common treatment for cervical insufficiency in pregnancy. Complications such as erosion are rare, as the duration of treatment is typically several months, with cerclage placement in the second trimester and complete removal prior to the onset of labor. Retained suture can lead to erosion through the vaginal epithelium and into other organs, as seen in our case. Our technique offers a minimally invasive approach to the excision of eroded transvaginal cervical cerclage suture through the bladder mucosa. A narrated, stepwise video demonstration for removal of eroded cervical cerclage through bladder epithelium with suprapubic-assisted transurethral technique in a single patient was carried out. Key strategies for a successful outcome include: use of a Carter-Thomason device for suprapubic assistance in lieu of suprapubic trocar or suprapubic incision, use of rigid biopsy forceps for improved traction on the eroded suture, performing a methylene blue test for evaluation of vesicovaginal fistula after excision procedure. At her 2-week postoperative evaluation, the patient reported resolution of all symptoms. The Carter-Thomason incision was well healed, and postoperative urinalysis was negative for hematuria. A suprapubic-assisted transurethral approach can be used as a minimally invasive technique for excision of eroded transvaginal cervical cerclage suture through the bladder mucosa.

Effects of vaginal microecology and immunity on the pregnancy outcome of cervical cerclage

ObjectiveTo investigate the effects of vaginal microecology and immune status on the pregnancy outcome of cervical cerclage.MethodsThe clinical data of 125 patients with cervical incompetence who underwent transvaginal cervical cerclage in our hospital from January 2018 to January 2021 were collected, based on which the associations of vaginal microecology and related immune cytokines (IL-1β, IL-6, IL-8 and TNF-α) with the cervical cerclage outcome were explored.ResultsAll of the 125 patients had singleton pregnancies, who were aged 20–43 years, with a mean of (32.34 ± 5.17) years. The surgery was successful in 104 patients (full-term delivery or survival of premature infants), while unsuccessful in 21 patients (late miscarriage or death of premature infants), revealing a success rate of 83.20%. There were 70 full-term deliveries, 34 premature deliveries (28 survived while 6 died), and 15 late miscarriages. Univariate analysis revealed statistically significant differences in the timing of surgery, gestational age of cerclage, preoperative cervical canal length, genital tract infections and preoperative invasive procedures between the successful and unsuccessful groups (P < 0.05). Insignificant differences were found in the pre-pregnancy body mass index (BMI) (P > 0.05). According to the multivariate analysis results, cerclage timing and genital tract infections were independent risk factors for postoperative pregnancy failure (P < 0.05). The pathogen detection rates in the two groups of pregnant women were analyzed, finding significantly higher incidence of bacterial vaginosis (BV) in the unsuccessful group than in the successful group (P < 0.05). Inter-group comparison revealed that the positive rates for vaginal microenvironmental factors (LE, NAG, SNA, H2O2 and pH) were all significantly higher in the unsuccessful group than in the successful group (P < 0.05). Besides, the immune cytokine levels in the cervicovaginal secretions were also all significantly higher in the unsuccessful group than in the successful group (P < 0.05).ConclusionThe pregnancy outcome of patients undergoing cervical cerclage is associated with the imbalance of vaginal microecology and the levels of IL-1β, IL-6, IL-8 and TNF-α in cervicovaginal secretions.

Laparoscopic abdominal cerclage during pregnancy: a simplified approach

Cervical insufficiency is a major cause of second-trimester pregnancy loss and spontaneous preterm delivery. Transabdominal cervicoisthmic cerclage is usually performed before pregnancy for patients of cervical insufficiency, in whom transvaginal cervical cerclage procedure cannot be placed or has failed previously. Performing a transabdominal cerclage becomes a huge challenge owing to the enlargement of the pregnant uterus in patients who were indicated for transabdominal cervicoisthmic cerclage but were missed before pregnancy. Here, we have outlined an easy and effective surgical procedure as needle-free laparoscopic trans-broad-ligament cervicoisthmic cerclage during early second-trimester. Laparoscope with 4 trocars was established, after expanding the trigonum of ureter, ovarian vascular and ascending branch of uterine artery. The needleless Mersilene tape was inserted in a posterior-to-anterior direction of bilateral trigonums, tightening the knot toward the bladder uterine reflection and simultaneously pushing the loop behind the uterus, directed to the cervix progressively. The tape was then tied anteriorly at the cervico-isthmic junction with 5 to 6 intracorporeal square knots after transvaginal ultrasound determined the presence of systolic velocity of uterine artery with first knot. The primary feature of our procedure was that the needleless Mersilene tape was inserted centrally from the broad ligaments, lateral to the uterine vessels, and finally tied above the uterosacral ligament at the level of the uterine isthmus, without dissecting the bladder off from lower uterine segment and without separating the uterine vessels from the lateral wall of the cervix. We performed this procedure on 10 patients with pregnancy outcomes and there was no pregnancy loss. This procedure proved to be an accessible and effective surgical technique for transabdominal cerclage of the uterine cervix during early-second trimester, with affirmative prognosis.

Comparison of Pregnancy Outcomes of Cervical Incompetence Treated by Transvaginal Cervical Cerclage at Different Times

Comparison of Pregnancy Outcomes of Cervical Incompetence Treated by Transvaginal Cervical Cerclage at Different Times