Ultrasound-indicated Cervical Cerclage Research Articles

Predictors of preterm birth following emergency and ultrasound-indicated cervical cerclage: A retrospective study on 136 singleton pregnancies

ObjectiveWe aimed to retrospectively evaluate obstetric and neonatal outcomes in patients who underwent ultrasound-indicated and rescue cervical cerclage and to identify predictors for cerclage failure and consequent preterm birth (PTB). Materials and methodsWe conducted a retrospective analysis on singleton pregnancies between 16 and 27 weeks of gestation who presented with a transvaginal sonographic cervical length (TVS-CL) <25 mm and a previous PTB/second-trimester miscarriage or prolapsed amniotic membranes and/or a TVS-CL <15 mm and underwent cervical cerclage at Mangiagalli Center, Milan, between September 2011 and December 2021. Univariate and multivariate logistic regression analyses were used to identify possible predictive factors of cerclage failure. ResultsDuring the study period, a total of 136 singletons met the inclusion criteria. Overall, 3 % of pregnancies did not reach fetal viability, mostly due to post-cerclage preterm premature rupture of membranes and/or chorioamnionitis. The mean gestational age at delivery was 35.9 ± 4.5 weeks. Neonates were delivered beyond 37 weeks in 63.2 % of cases, between 28 and 37 weeks in 26.5 %, and less than 28 gestational weeks in 10.3 %. At the multivariate analysis, independent risk factors for miscarriage or PTB were cervical length <10 mm (odds ratio, OR 3.44), advanced cervical dilatation (OR 4.76), and in vitro fertilization (OR 4.66). A history of previous miscarriage, premature delivery, and uterine malformations did not increase the risk of post-cerclage delivery before 37 weeks. In the preterm delivery group, 14 % of patients experienced preterm premature rupture of membranes (pPROM) and 10 % had chorioamnionitis, while no case was registered in the term delivery group. A positive vaginal swab at the time of cervical cerclage was not significantly associated with PTB at the multivariate analysis but it emerged as a significant risk factor for both chorioamnionitis (OR 11.03) and pPROM (OR 5.28). ConclusionsUltrasound-indicated and rescue cervical cerclage were effective in prolonging pregnancy, even when placed beyond 24 weeks of gestation. Preoperative cervical length of less than 10 mm, advanced dilatation, and in vitro fertilization are associated with an increased risk of cerclage failure. A positive vaginal swab before cerclage is associated with increased rates of intrauterine infectious-inflammatory processes.

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.

Predicting spontaneous preterm birth in asymptomatic high-risk women with cervical cerclage.

To determine the performance of the predictive markers of spontaneous preterm birth, cervicovaginal quantitative fetal fibronectin (fFN) and cervical length, in asymptomatic high-risk women with transabdominal, history-indicated or ultrasound-indicated cervical cerclage. This was a secondary analysis of a prospective cohort of asymptomatic high-risk women with cervical cerclage and no other prophylactic intervention (including progesterone), who attended the preterm birth clinic at a central London teaching hospital between October 2010 and September 2016. Women had either transabdominal cerclage, placed prior to conception, history-indicated cerclage, placed before 14 weeks' gestation, or ultrasound-indicated cerclage for a short cervix (< 25 mm), placed before 24 weeks. All women underwent serial cervical length assessment on transvaginal ultrasound in the second trimester (16-28 weeks), and quantitative fFN testing from 18 weeks onward. Test performance was analyzed for the prediction of spontaneous preterm birth before 30 weeks (cerclage failure), 34 weeks and 37 weeks, using receiver-operating-characteristics (ROC)-curve analysis. Overall, 181 women were included in the analysis. Cervical length and fFN were strong predictors of spontaneous preterm birth before 30 weeks in women with cerclage, with areas under the ROC curve (AUC) of 0.86 (95% CI, 0.79-0.94) and 0.84 (95% CI, 0.75-0.92), respectively. Cervical length was a better predictor of preterm birth before 30 weeks in women with history-indicated compared to those with ultrasound-indicated cerclage, although both showed clinical utility (AUC, 0.96 (95% CI, 0.91-1.00) vs 0.79 (95% CI, 0.66-0.91); P = 0.01). Quantitative fFN was a strong predictor of spontaneous preterm birth before 30 weeks in women with history-indicated cerclage (AUC, 0.91 (95% CI, 0.75-1.00)) and retained clinical utility in those with ultrasound-indicated cerclage (AUC, 0.76 (95% CI, 0.64-0.89)). There were no spontaneous deliveries before 34 weeks in women with a transabdominal cerclage, so AUC was not calculated. Delivery was delayed significantly in this group (P < 0.01). Cervical length and quantitative fFN retain clinical utility for the prediction of spontaneous preterm birth in women with cervical cerclage, and prediction is best in women with a history-indicated stitch. These tests can be relied upon to discriminate risk and have utility when planning clinical management with regard to treatment failure. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

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.

Pre-Cerclage cervical length predicts long-term pregnancy sustenance: A case-control study

BackgroundThis study aimed to assess a predictor of long-term pregnancy sustenance post cervical cerclage in women with or without a medical history of cervical insufficiency. Materials and methodsWe included pregnant women who underwent cerclage at 12–25 weeks gestation in four perinatal medical centers between January 2009 and December 2010. We classified the cerclage modality as ultrasound-indicated cervical cerclage if the pre-cerclage CL was <25 mm because the prophylactic and therapeutic cerclage definitions varied among institutions. The procedure was deemed successful if the pregnancy continued for more than 13 weeks post cerclage. We compared the outcomes of women who underwent successful and unsuccessful cerclage and investigated whether the pre-cerclage CL could predict pregnancy outcomes in women who underwent successful cerclage using receiver-operating characteristic curves. ResultsWe screened 114 pregnant women; 91 met the inclusion criteria. Pre-cerclage CL was a moderately accurate predictor of long-term pregnancy sustenance in the successful group (optimal cut-off value: 17 mm; area under the curve: 0.76; P = 0.0016). Approximately 87% of patients with a pre-cerclage CL ≥ 17 mm sustained their pregnancies for more than 13 weeks post cerclage; however, 64% of patients with a pre-cerclage CL < 17 mm did not. ConclusionWe speculate that the use of other treatment options in addition to cerclage in women with a pre-cerclage CL < 17 mm may result in a successful pregnancy.

Ultrasound-Indicated Cervical Cerclage Efficacy Between 16 and 28 Weeks of Gestation in Twin Pregnancy: Retrospective Cohort Study.

ObjectiveThe aim of this study is to determine if cervical cerclage administration reduces the preterm birth (PTB) rate at a gestational age (GA) of 16–28 weeks in women with twin pregnancy.MethodsThis is a retrospective cohort study on asymptomatic twin pregnancy with an ultrasound-identified cervix length (CL) of ≦25 mm. The patients were divided into two groups: ultrasound-indicated cerclage (UIC) group and control (expectant management) group. The primary outcome was a PTB rate at <34 weeks. A logistic regression was also performed, and a subgroup analysis stratified by CL and GA at first short cervix diagnosis was planned.ResultsIn all 320 women, there were no differences in the overall <34-week PTB rates and neonatal outcomes between the UIC group and control group. After performing a multivariate logistic regression analysis, the subgroup analyses were planned. In patients with a CL of ≦15 mm, the <34-week PTB rate was significantly decreased in the UIC subgroup compared with the control subgroup (60.78% vs 78.26%; odds ratio (OR) = 0.43, confidence interval (CI) = 95% [0.22–0.86]; and p = 0.020). In patients with a first short cervix diagnosis GA of ≦24 weeks, the <34-week PTB rate was significantly decreased in the UIC subgroup when compared with the control subgroup (61.54% vs 84.75%; OR = 0.29; CI = 95% [0.13–0.63]; and p = 0.001). Furthermore, compared with the control groups, the UIC groups had higher mean birth weight, lower perinatal mortality, and lower NICU admission, and the differences were statistically significant.ConclusionUIC could significantly reduce the <34-week PTB rate and improve perinatal outcomes in patients with a CL of ≦15mm or first short cervix diagnosis GA of ≦24 weeks with asymptomatic twin pregnancy during the second trimester.

Rescue Adjuvant Vaginal Progesterone May Improve Outcomes in Cervical Cerclage Failure.

Introduction Aim of the study was to evaluate the effect of rescue adjuvant vaginal progesterone in women with ongoing, transvaginal ultrasound (TVUS)-confirmed cervical shortening despite cervical cerclage. Materials and Methods A retrospective case control study was performed of women undergoing cervical surveillance following either history- or ultrasound-indicated cervical cerclage. We compared women managed with cervical cerclage and vaginal progesterone to women managed with cervical cerclage alone. Women with a singleton pregnancy who underwent cervical cerclage were identified from a database. Data on the concurrent use of vaginal progesterone, cervical length measurements, interventions and birth outcomes were collected from patient notes and clinical pathology notes. Patients from each intervention group were matched, based on exact shortest cervical length measurements obtained during surveillance and age of gestation when the measurement was obtained. Results 66 women were matched and included in the study, based on exact shortest cervical length measurements. Each group had an identical mean shortest cervical length of 12.09 mm. The outcomes of 33 women who received both cervical cerclage and vaginal progesterone were compared to the outcomes of 33 women who were treated with cervical cerclage alone. The administration of vaginal progesterone to women with ongoing cervical shortening despite cervical cerclage was found to significantly prolong the pregnancy (36.36 weeks vs. 32.63 weeks; p = 0.0036) compared to women treated with cerclage alone. This use of rescue adjuvant vaginal progesterone was also associated with higher birth weights (2829 g vs. 2134 g; p = 0.0065) compared to women who had cervical cerclage alone; however, there was no difference in Apgar scores, composite neonatal morbidity or neonatal intensive care admission. Conclusion Women with cervical shortening despite the presence of cervical cerclage may benefit from further TVUS cervical length surveillance and the administration of vaginal progesterone if further cervical shortening occurs. Despite both groups having clinically significant shortened cervical lengths and cervical cerclage in situ, adjunct vaginal progesterone treatment resulted in older gestational age at birth and higher birth weight. Further investigation and confirmation of this finding in a larger prospective trial is warranted to explore this potential benefit for the management of preterm birth in future.

Neutrophil elastase in cervical fluid in women with short cervical length

ObjectiveThe aim of the study was to determine the relationships between short cervical length (CL) and levels of cervical fluid neutrophil elastase (NE), secretory leukocyte protease inhibitor (SLPI), and interleukin 8 (IL-8) in the second trimester of pregnancy of women who underwent ultrasound-indicated cervical cerclage. Materials and methodsCL of <25 mm or cervical funneling were included in the short CL group (n = 26) and the normal CL group (n = 22) included women who had CL of ≥25 mm and had no cervical funneling in women between 17 + 0 and 24 + 6 weeks of gestation. Levels of NE, SLPI, and IL-8 were measured by using enzyme-linked immunosorbent assay kits. Mann–Whitney U tests and Spearman's correlation analysis were used for statistical analyses. ResultsCompared with the normal CL group, the short CL group had significantly higher median NE levels (P < 0.001) and higher, though not significant, median IL-8 levels by approximately three times (2107.0 vs. 798.3 pg/mL, P = 0.132). The median SLPI levels in cervical fluid was similar between the two groups (107.6 vs. 103.2 ng/mL, P = 0.499). Short CL had a significant correlations with cervical fluid NE levels (r = −0.475, P = 0.001). ConclusionIncreased cervical fluid NE associated with cervical shortening in second trimester of pregnancy, whereas cervical fluid SLPI had constant levels.

Randomized trial of ultrasound-indicated cerclage in singleton women without lower genital tract inflammation.

This is the first report of a randomized trial of cerclage on pure cervical shortening without vaginosis or cervicitis. The objective of our multicenter randomized controlled trial was to assess the benefits of ultrasound-indicated cervical cerclage in the mid-trimester to prevent preterm birth in women who have no signs of infection or inflammation of the lower genital tract. Women with a short cervical length < 25 mm between 16 and 26 weeks of gestation were randomly assigned to receive a Shirodkar cerclage, McDonald cerclage, or bedrest (no cerclage). Before being randomly assigned to one of the three groups, all women were screened for infection/inflammation of the lower genital tract; those with positive results were excluded from the study. The ratio of preterm delivery as a primary end-point was evaluated in the groups. A total of 106 singleton patients with a short cervical length were assessed for study eligibility; 106 patients were randomized to the three treatment options. Ultimately, 98 patients (in the Shirodkar [n = 34], McDonald [n = 34] and bedrest [n = 30] groups) were analyzed. No differences in preterm delivery or perinatal outcomes were found between the three groups. Significantly fewer patients in the Shirodkar group required hospitalization for treatment of threatened preterm labor when compared to patients in the bedrest group. For women with a short cervical length < 25 mm between 16 and 26 weeks of gestation, Shirodkar cerclage might be considered to reduce the occurrence of threatened preterm labor.

Cervical cerclage in twin pregnancies

To evaluate the outcomes of cervical cerclage (CC) in twin pregnancies. Retrospective analysis of twin pregnancies undergoing CC between January 2001 and December 2009 at our Institution. CC was offered in case of a cervical length measurement ≤ 20 mm (ultrasound-indicated CC) or in case of cervical dilatation with membranes at or beyond the external cervical os (physical examination-indicated CC). Cervicovaginal and rectal swabs were obtained preoperatively. Perioperative antibiotics and tocolysis were administered. There were 28 cases of ultrasound-indicated and 14 of physical examination-indicated CC. Positive swab cultures were observed in 21 % of cases. The incidence of preterm delivery <34 weeks was 32 % [95 % confidence interval (CI) 16-52 %] and 50 % (95 % CI 23-77 %) in the ultrasound-indicated and physical examination-indicated CC group, respectively. The incidence of premature rupture of membranes <34 weeks was 21 % (95 % CI 8-41 %) and 29 % (95 % CI 8-58 %) in the ultrasound-indicated and physical examination-indicated CC group, respectively. Perinatal survival was 96 % (95 % CI 88-100 %) in the ultrasound-indicated CC group, and 86 % (95 % CI 67-96 %) in the physical examination-indicated CC group. We showed a high-risk of preterm delivery in both groups, but with a high overall perinatal survival. Our data stress the importance of re-evaluating the efficacy of CC in twin pregnancies by properly designed clinical trials, particularly if it is physical examination indicated.

Is cerclage height associated with preterm delivery in women undergoing ultrasound-indicated cervical cerclage?

ObjectiveTo determine whether the level of an ultrasound (USS) indicated cervical cerclage is a factor in the subsequent risk of preterm delivery.Study Design and ResultsA retrospective cohort study of women...

Perioperative complications of history-indicated and ultrasound-indicated cervical cerclage

Perioperative complications of history-indicated and ultrasound-indicated cervical cerclage

Perioperative complications of history-indicated and ultrasound-indicated cervical cerclage

To evaluate perioperative complications of history- and ultrasound-indicated cerclage. We performed a retrospective observational study of a cohort of patients who underwent history- (n = 198) or ultrasound-indicated (n = 89) cerclage procedures. We evaluated the rates of perioperative complications based on indication for cerclage. The χ(2) was used for categorical variables and Student t test for continuous data. One patient (0.35%) had an intraoperative complication (unsuccessful regional anesthesia) and 1 patient (0.35%) had a postoperative complication (contractions and bleeding 2 weeks after cerclage placement, delivered a nonviable infant). Peripartum complications included chorioamnionitis (6.2%), preterm premature rupture of membranes (11%), preterm delivery (20%), and delivery before 32 weeks' gestational age (8%), and they were similar in the history-indicated and ultrasound-indicated groups. History- and ultrasound-indicated cerclages are associated with a 0.6%; 95% confidence interval, -0.26 to 1.66 risk of perioperative complications. There was no difference in perioperative complications or outcome between the 2 groups.

127: Factors predicting gestational age at delivery following ultrasound-indicated cervical cerclage

127: Factors predicting gestational age at delivery following ultrasound-indicated cervical cerclage

A Randomized Controlled Trial of Cervical Scanning vs History to Determine Cerclage in Women at High Risk of Preterm Birth (CIRCLE Trial)

Cervical cerclage may be useful either as a preventative or therapeutic measure in women at risk for preterm delivery (PTD). The 2 common types of management currently used in pregnant women at high risk of PTD are transvaginal measurement of cervical length, or assessment of risk and need for intervention based on obstetric history. Because the RR of a preterm birth increases with shortening cervical length, ultrasound measurement of cervical length in a woman with a previous preterm birth could help target those needing cerclage. Currently, history-indicated cerclage is inserted only in women with prior multiple pregnancy losses. Suggestions have been made that identification of the ultrasono-graphically short cervix with cerclage may reduce the need for a cerclage based on a history of only 1 previous PTD. This randomized controlled trial compared use of ultrasound-indicated cervical cerclage in pregnant women with a short cervix (<20 mm in length), with elective management without ultrasound in which the decision to insert a prophylactic history-indicated suture was based solely on obstetric history. Eligible pregnant women were enrolled in the study between 2003 and 2006 from hospitals in the United Kingdom. The study subjects were asymptomatic women at high risk, who had at least 1 previous delivery between 16 and 34 weeks. Of the eligible 248 women, 123 were randomized to the ultrasound scanning group and 125 to history-indicated management group. The primary outcome measure was PTD before 34 weeks. There was no difference between the 2 groups in the incidence of preterm birth between 24 and 34 weeks of gestation (19/125 [15%] in the history-indicated management group vs 18/122 [15%] in the ultrasound scanning group); the relative risk [RR] was 0.97, with a 95% confidence interval (CI) of 0.54 to 1.76. Women in the ultrasound scanning group were significantly more likely than those in the history-indicated management group to receive a cerclage (32% vs 19%; RR, 1.66; 95% CI, 1.07-2.47) or progesterone (39% vs 25%; RR, 1.55; 95% CI, 1.06-2.25). These data suggest that the decision on placement of cervical cerclage in a women with a previous preterm birth should be made on the basis of clinical history, not on the basis of ultrasound scanning. However, the data do not support routine placement of history-indicated sutures routinely in this population. Scanning may still be beneficial in women at higher risk.

The role of ultrasound‐indicated cerclage in triplets

Preterm delivery is the leading cause of major perinatal morbidity and mortality associated with triplet pregnancies. The objective of this study was to evaluate the efficacy of ultrasound-indicated cervical cerclage in triplet pregnancies that are diagnosed with cervical shortening on biweekly transvaginal sonography (TVS). A retrospective review of all triplets who were followed with biweekly TVS for measurement of cervical length was conducted. Cervical shortening was defined as cervical length <or= 2.5 cm. Outcomes of interest included cervical cerclage placement, gestational age at delivery and birth weight. In our population of 24 triplet pregnancies, 13 had cervical shortening. Of these, 54% underwent cervical cerclage at a mean gestational age of 20 weeks. Overall, patients without cervical shortening delivered on average 17 days later than those with cervical shortening (32 + 2 weeks vs. 29 + 6 weeks, P = 0.034). Moreover, infants of patients without cervical shortening weighed on average 456 g more at birth than did those with cervical shortening (1751 g vs. 1295 g, P = 0.039) and had a lower percentage of very low birth weight infants (30.3% vs. 69.2%, P = 0.002). Within the subset of patients with cervical shortening, there was no statistical difference in any of the outcomes studied between patients who underwent cervical cerclage and those who did not. Triplet pregnancies complicated by cervical shortening diagnosed on biweekly TVS surveillance do not appear to benefit from placement of cervical cerclage, based on assessment of gestational age at delivery, birth weight and incidence of very low birth weight infants.

Ultrasound-indicated cervical cerclage: Outcome depends on preoperative cervical length and presence of visible membranes at time of cerclage

Objective: The purpose of this study was to assess cases of ultrasound-indicated cervical cerclage and to relate preoperative cervical length, operative findings, postoperative cervical length, and pregnancy outcome to establish the appropriate criteria to offer cervical cerclage. Study Design: A prospective observational study comprised 380 women at high risk of preterm labor who underwent serial transvaginal ultrasonographic assessment of cervical length. Seventy-three women had criteria for and underwent cervical cerclage. Data concerning preoperative cervical length, operative findings, postoperative cervical length, and pregnancy outcome were collected. Statistical analysis was performed with Mann-Whitney and Fisher exact tests. Results: There was a significant increase in median cervical length after cerclage, 15.0 versus 25.0 mm (P <.0001). Preoperative cervical length and postoperative upper cervical length were independently better predictors of outcome than postoperative entire cervical length. Fetal membranes were visible in 18% of cases at the time of suture insertion, which was associated with a significantly worse outcome, regardless of preoperative cervical length. Of those 41 women with a very short preoperative cervical length (≤15 mm), outcome was significantly worse in those women with visible fetal membranes at the time of cerclage compared with those women with no visible fetal membranes at the time of cerclage: median gestational age at delivery, 23 weeks versus 37 weeks 4 days (P =.002); suture insertion to delivery interval, 19 days versus 108 days (P =.0004); and fetal survival rates, 50% versus 86% (P =.03). Conclusion: In a high-risk population that undergoes serial transvaginal ultrasound surveillance of cervical length, the presence of visible fetal membranes at the time of suture insertion, regardless of preoperative cervical length, is associated with a poor outcome. Fetal membranes were not visible in any cases with a preoperative cervical length of >15 mm. These findings lend support to a practice of offering cerclage at or above a cervical length of 15 mm. (Am J Obstet Gynecol 2002;187:445-9.)

Pregnancy Outcomes in Women Treated With Elective Versus Ultrasound-Indicated Cervical Cerclage

Objective To compare pregnancy outcomes in women at risk for pregnancy loss treated with elective versus ultrasound-indicated placement of cerclage. Methods A retrospective cohort study was performed on two groups of patients with singleton gestations. The first group consisted of women at risk for pregnancy loss who were treated with an elective cerclage, while the second group was managed conservatively and followed with serial transvaginal cervical sonography and transfundal pressure. An emergency cerclage was placed in women in the second group when the endocervical canal length shortened to < 20 mm, either spontaneously or in response to transfundal pressure. The two groups were compared with respect to maternal demographics, obstetric and gynecological history, and gestational age, both at time of cerclage placement and delivery. Results A total of 138 patients were identified. Eighty-one patients were treated with an elective cerclage and 57 with an ultrasound-indicated cerclage. Patients treated with elective cerclages were older (32 versus 27 years, p = 0.0003), more commonly white (56.8% versus 38.6%, p = 0.0380), less commonly nulliparous (23.5% versus 43.9%, p = 0.0063), and more often private patients (92.6% versus 28.1%, p < 0.0001). A history of previous treatment with cerclage (45.7% versus 10.5%, odds ratio (OR) 0.2, 95% confidence interval (CI) 0.1–0.4) and one prior midtrimester loss (53.1% versus 33.3%, OR 0.4, 95% CI 0.2–0.9) were also more common in the elective versus ultrasound-indicated cerclage group. However, there was no difference in the rates of previous preterm delivery, two midtrimester losses, two terminations of pregnancy, in utero diethylstilbestrol exposure, uterine anomalies, history of cone biopsy or parity. As expected, gestational age at placement of cerclage was significantly earlier in the elective group (13.0 versus 20.0 weeks, p < 0.0001). The median (range) gestational age at delivery (37 (15–41) versus 37 (17–41) weeks, p = 0.90), the number of early (< 25 weeks) losses (9.9% versus 8.8%, OR 1.6, 95% CI 0.3–7.9), and preterm deliveries (< 37 weeks) (35.8% versus 36.8%, OR 1.1, 95% CI 0.4–3.2) were similar in the elective and ultrasound-indicated cerclage patients, respectively. Conclusion In patients at risk for pregnancy loss, placement of cervical cerclages in response to ultrasono-graphically detected shortening of the endocervical canal length is a medically acceptable alternative to the use of elective cerclage. Copyright © 1998 International Society of Ultrasound in Obstetrics and Gynecology