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

Background: Cervical insufficiency is one of the major causes of preterm birth among pregnant women that leads to severe mortality and morbidity issues among newborns. Prophylactic cervical cerclage is a surgical procedure performed between 11 and 14 weeks of gestation upon diagnosis of cervix insufficiency among pregnant women. Aims & Objectives: In this study, we aimed to evaluate the effectiveness of prophylactic cervical cerclage in comparison to other interventions to treat cervical insufficiency among pregnant women using a meta-analysis approach. Methods: We searched the three databases (Coachrane Library, PubMed, and MEDLINE) that were used for articles related to research aims by using MeSH keywords. The timeline of research was set from January 2015 to January 2024. The methodological quality assessment of included studies was performed by the Risk of Bias in Non-randomized Studies—of Interventions (ROBINS-I). A recent meta-analysis was conducted by using Review Manager 5.4.0 software. Results: About 441 research articles were extracted from three electronic databases and only 125 articles were assessed for eligibility criteria. Finally, 8 studies were included in the analysis for a recent meta-analysis. Six out of eight included retrospective or pilot studies were graded as having a moderate risk of bias, and two studies had low risk on the basis of owning bias. About 1008 pregnant women with cervical insufficiency were analyzed in a recent meta-analysis. By pooled analysis, it was evaluated that significant difference found in prolongation of delivery weeks (Mean difference = 1.05;Cl: 0.81 to 1.29: p > 0.00001), number of deliveries > 37 weeks (OR = 0.59;Cl: 0.19 to 1.84: p > 0.006), and preterm birth (OR = 0.73;Cl: 0.42 to 1.28: p > 0.50) among pregnant women receiving prophylactic cervical cerclage as compared to other treatment strategies. Conclusion: Recent meta-analysis suggested the prophylactic cervical cerclage reduces the rates of preterm birth, abortion rates, number of deliveries > 37 weeks, and other complications as compared to the other cervical cerclage types and conservative treatments.

Pregnancy Outcomes Following Transvaginal Cerclage for Cervical Insufficiency：Results From a Single-center Retrospective Study

To study maternal and perinatal outcomes after cervical cerclage in both singleton and twin pregnancies,we retrospectively reviewed women undergoing cervical cerclage for cervical insufficiency at Tongji Hospital,Wuhan,China from January 1,2010 to July 31,2015 to evaluate primary and secondary outcomes for subgroups with cervical length（CL） ≤15,〉15 to 〈25,and ≥25 mm.Of 166 patients who underwent cervical cerclage,after exclusion of patients with missed abortion and continuing pregnancy,141 patients（121 singleton and 20 twin pregnancies） were included in the analysis.Mean gestational age at birth was 34.22 and 28.27 weeks for singleton and twin pregnancies,respectively.There were 17（14.05%） and 13（33.33%） neonatal deaths in singleton and twin pregnancies,respectively.Mean age（31.60±4.62 vs.31.22±4.63 years,P=0.39） and gestational weeks at cerclage（18.50±4.62 vs.19.31±4.99,P=0.47） were similar for both groups.Mean gestational weeks at delivery（34.22±5.77 vs.28.27±6.17,P〈0.001） and the suture to delivery interval（15.72±7.15 vs.8.96±6.70,P〈0.001） were significantly longer in the singleton group.These variables indicate a linear negative correlation with the degree of CL shortening,with better outcomes in patients with CL ≥25 mm who underwent cerclage,both in singleton and twin pregnancies.No difference in mode of delivery existed between the singleton group and twin group.Our results indicate a high risk of preterm delivery in both groups,especially in the twin group.Patients with a history of preterm labor and CL 〉25 mm in the current pregnancy,possibly in a twin pregnancy,could benefit from elective cervical cerclage;however,cervical cerclage was inadvisable for twin pregnancies with a CL 〉15 and 〈25 mm.Our data emphasize the importance of re-evaluating the efficacy of cervical cerclage for twin pregnancies in well-designed clinical trials.

Two Successful Livebirths from Both Hemiuteruses After Laparoscopic Cervical Cerclage in a Uterus Didelphys Patient with Cervical Insufficiency

Uterus didelphys occurs in~0.4%of females and is found in~11%-20%of all uterus defects.It is a risk factor for cervical insufficiency,consequently contributing to late miscarriage or preterm birth.Thus far,only two prior cases of uterus didelphys accompanied by cervical insufficiency treated through laparoscopic cervical cerclage have been reported;however,livebirth only occurred in one hemiuterus.Herein,we report a case of uterus didelphys in a patient diagnosed with cervical insufficiency.Following the placement of a modified laparoscopic cervical cerclage,the patient had two successful livebirths through both hemiuteruses,respectively,with longer gestation age(ie,>36 weeks).The aim of this case report was to provide useful information for clinical practitioners to make better decisions on the management of cervical insufficiency in patients with uterus didelphys,and identify obstetric complications that clinicians should pay attention to during pregnancy.

Successful delivery of unicornuate uterus pregnancy after laparoscopic cervical cerclage: A case report

There are few reports of the successful delivery of unicornuate uterus pregnancy after laparoscopic cervical cerclage.Here,we report a 32-year-old woman,gravida 2 para 1,who had been admitted for unicornuate uterus pregnancy by a thawed frozen blastocyst transplantation.She accepted laparoscopic cervical cerclage for cervical insufficiency and delivered successfully via caesarean section at 35^(+3) weeks.Cervical cerclage may be used as an effective method of preventing abortion in unicornuate uterus pregnancy,while surgery by laparoscopy would be a better choice for patients with poor cervical condition.Obstetricians should pay due attention to complications such as uterine rupture for these highrisk patients.

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

Objective:This 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.Methods:A 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.Results:In 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.Conclusions:LAC 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.

Laparoscopic Transabdominal Cerclage

Cervical insufficiency is seen in 0.1% - 1% of all pregnancies and classical treatment involves vaginal cerclage. In some conditions, such as an extremely short, deformed or absent cervix, surgery needs to be done by transabdominal approach. We use a simplified technique for laparoscopic transabdominal cerclage compared to the technique described in previous studies. Furthermore, we give a review on the literature published on this subject. We have a case series of 12 patients operated in a non-pregnant state with previously failed vaginal cerclage (n = 4) or in which a vaginal approach appeared to be impossible due to a history of cervical surgery (n = 8). Minor complication of vaginal erosion of the cerclage tape was described in 2 cases. Comparable studies of transabdominal cerclage via laparotomy or laparoscopy could not show any difference in obstetric outcome. Several studies mentioned the advantages of the laparoscopic approach (short hospitalisation, fast recovery, high placement of the suture,) and no complications were described. Transabdominal cerclage performed by laparoscopy seems to be a feasible technique in cases transvaginal cerclage fails or is technically impossible.

Diagnosis and Management of Intraamniotic Infection

Intraamniotic infection(IAI)or chorioamnionitis is a common cause of preterm birth and may cause adverse neonatal outcomes,including neonatal pneumonia,respiratory distress,meningitis,sepsis,and death.Maternal morbidities from intraamniotic infection include dysfunctional labor requiring increased intervention,cesarean birth,postpartum uterine atony with hemorrhage,endometritis,peritonitis,sepsis,adult respiratory distress syndrome and,rarely,death.Chorioamnionitis can result from an ascending infection,iatrogenic causes or transplacental passage from maternal blood-borne infections.The clinical findings of chorioamnionitis include maternal fever(≥38°C),maternal(>100 beats per minute)and/or fetal tachycardia(>160 beats per minute),maternal leukocytosis on complete blood count(>15000 cells/mm 3),and uterine tenderness and/or purulent and/or foul-smelling amniotic fluid.The management of chorioamnionitis mainly includes antibiotic therapy and delivery.Women with previable preterm premature rupture of membranes should be offered realistic counseling from a multidisciplinary approach.The separation of the mother and the fetus to preserve the life of the mother should prioritize delivery methods that result in a living fetus if possible,with appropriate neonatal resuscitation available.