Effectiveness and perinatal outcomes of history-indicated, ultrasound-indicated and physical examination-indicated cerclage: a retrospective study.

OBJECTIVE: To evaluate the effectiveness and perinatal outcomes of cerclage procedure according to indication. METHODS: The pregnancy and neonatal outcomes of the patients who underwent cerclage with the diagnosis of cervical insufficiency between January 2016 and December 2020 were retrospectively analyzed. Patients were categorized into three groups: a history-indicated group, an ultrasound-indicated group and a physical examination-indicated group. RESULTS: Seventy-three patients who underwent cerclage were included in the study. Of these, 41 (56.2%) had history-indicated, 17 (23.3%) had ultrasound-indicated and 15 (20.5%) had physical examination-indicated cerclages. Compared to history- and ultrasound-indicated cerclage group, duration from cerclage to delivery (18.6 ± 6.9 weeks vs 17.8±5.9 weeks vs 11 ± 5.3 weeks, p = 0.003) was significantly lower and delivery < 28 weeks (9.8% vs 5.9% vs 33.3%, p = 0.042) and delivery < 34 weeks of gestation (26.8% vs 11.8% vs 60%, p = 0.009) were significantly higher in physical examination-indicated cerclage group. In physical examination-indicated cerclage, compared with history- and ultrasound-indicated cerclage low birth weight, low APGAR score, neonatal intensive care unit admission and neonatal mortality were higher, although not statistically significant (p > 0.05). CONCLUSION: Pregnant women who underwent physical examination-indicated cerclage had higher risks for preterm delivery < 28 weeks and < 34 weeks than history- and ultrasound-indicated cerclage.

Development and validation of a model for individualized prediction of cervical insufficiency risks in patients undergoing IVF/ICSI treatment.

BACKGROUND: Women who conceived with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) are more likely to experience adverse pregnancy outcomes than women who conceived naturally. Cervical insufficiency (CI) is one of the important causes of miscarriage and premature birth, however there is no published data available focusing on the potential risk factors predicting CI occurrence in women who received IVF/ICSI treatment. This study aimed to identify the risk factors that could be integrated into a predictive model for CI, which could provide further personalized and clinically specific information related to the incidence of CI after IVF/ICSI treatment. PATIENTS AND METHODS: This retrospective study included 4710 patients who conceived after IVF/ICSI treatment from Jan 2011 to Dec 2018 at a public university hospital. The patients were randomly divided into development (n = 3108) and validation (n = 1602) samples for the building and testing of the nomogram, respectively. Multivariate logistic regression was developed on the basis of pre-pregnancy clinical covariates assessed for their association with CI occurrence. RESULTS: A total of 109 patients (2.31%) experienced CI among all the enrolled patients. Body mass index (BMI), basal serum testosterone (T), gravidity and uterine length were associated with CI occurrence. The statistical nomogram was built based on BMI, serum T, gravidity and uterine length, with an area under the curve (AUC) of 0.84 (95% confidence interval: 0.76-0.90) for the developing cohort. The AUC for the validation cohort was 0.71 (95% confidence interval: 0.69-0.83), showing a satisfactory goodness-of-fit and discrimination ability in this nomogram. CONCLUSION: The user-friendly nomogram which graphically represents the risk factors and a pre-pregnancy predicted tool for the incidence of CI in patients undergoing IVF/ICSI treatment, provides a useful guide for medical staff on individualized decisions making, where preventive measures could be carried out during the IVF/ICSI procedure and subsequent pregnancy.

The use of PAMG-1 testing in patients with preterm labor, intact membranes and a short sonographic cervix reduces the rate of unnecessary antenatal glucocorticoid administration.

OBJECTIVES: To assess the frequency of antenatal corticosteroid (ACS) administration in cases with shortened cervical length by addition of placental alpha-microglobulin-1 (PAMG-1) testing to sonographic examination. METHODS: Single centre retrospective cohort study. Rate of ACS administration was compared between cases with cervical length between 15 and 25 mm and cases with positive PAMG-1 testing and cervical length between 15 and 25 mm. We evaluated the following outcome parameters: Rate of ACS administration, gestational age at delivery, time to delivery, delivery within seven days, delivery <34 and <37 weeks' gestation, rate of admission to neonatal intensive care unit (NICU). RESULTS: In total, 130 cases were included. "PAMG-1 group" consisted of 68 women, 62 cases built the "historical control group". ACS administration was performed less frequently in the "PAMG-1 cohort" (18 (26%) vs. 46 (74%); p<0.001). The rate of delivery within seven days did not differ (2 (3%) vs. 4 (6.5%); p=0.4239). The rates of delivery <34 weeks' gestation (7 (10%) vs. 9 (15%); p=0.4643) and <37 weeks' gestation (19 (28%) vs. 26 (42%); p=0.0939) did not differ. Time to delivery interval was longer in the PAMG-1 group (61.5 vs. 43 days, p=0.0117). NICU admission occurred more often in the "historical control group" (22 (38%) vs. 28 (60%); p=0.0272). CONCLUSIONS: Addition of biomarker testing can help to avoid unnecessary ACS administrations in women with shortened cervical length.

COL1A1, COL4A3, TIMP2 and TGFB1 polymorphisms in cervical insufficiency.

OBJECTIVES: To investigate the association between selected single nucleotide polymorphisms (SNPs) with cervical insufficiency and its relationship with obstetric history. METHODS: Twenty-eight women with cervical insufficiency (case group) and 29 non-pregnant women (control group) were included. The SNPs sequenced included rs2586490 in collagen type I alpha 1 chain (COL1A1), rs1882435 in collagen type IV alpha 3 chain (COL4A3), rs2277698 in metallopeptidase inhibitor 2 (TIMP2), and rs1800468 in transforming growth factor beta 1 (TGFB1). RESULTS: We found a higher frequency of the normal allele in the control group (65.5%) and the homozygous mutated genotype in the case group (64.3%) for rs2586490 in COL1A1 (p=0.023). An unplanned finding in the cervical insufficiency group was a higher gestational age of delivery (median≥38 weeks) in the mutated allele than in the wild-type genotype (median of 28.2 weeks) for rs2857396, which is also in the COL1A1 gene (p=0.011). CONCLUSIONS: The findings of the present study corroborate the hypothesis that cervical insufficiency has a genetic component and probably involves genes encoding proteins in the extracellular matrix, in addition to inflammatory processes.

Cervical insufficiency: a noteworthy disease with controversies.

Cervical insufficiency (CI) is a mainly disease leading to recurrent abortions and preterm birth which may present in about 1% of obstetric populations. Recurrent pregnancy losses caused by CI incur serious economic burdens on society as well as huge psychological burdens to family members. However, many patients even clinicians in some areas of the world still remain confused about this disease. At the same time, the etiology of CI is still uncertain and it is still a controversial disease in diagnosis and treatment. This article summarizes the potential risk factors associated with CI, which could be worthy of attention and helpful for future research. It also reviews the methods for diagnosis and treatment of CI to better understand this noteworthy disease, as well as presents the related consensus and controversies according to the newly updated guidelines, which has practical significance for conducting more in-depth investigations in the future.

No. 373-Cervical Insufficiency and Cervical Cerclage.

OBJECTIVE: The purpose of this guideline is to provide a framework that clinicians can use to determine which women are at greatest risk of having cervical insufficiency and in which set of circumstances a cerclage is of potential value. EVIDENCE: Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in 2018 using appropriate controlled vocabulary (e.g., uterine cervical incompetence) and key words (e.g., cervical insufficiency, cerclage, Shirodkar, cerclage, McDonald, cerclage, abdominal, cervical length, mid-trimester pregnancy loss). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to June 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

Cervical cerclage - history and contemporary use.

OBJECTIVE: Contemporary role of cerclage as a preterm birth treatment. DESIGN: Review article. SETTING: Department of Obstetrics and Gynecology of the First Faculty of Medicine and General Teaching Hospital in Prague. METHODS: Research of existing literature, predominantly foreign journal articles, but also Czech literature and personal experience with the method. RESULTS: Cerclage is one of the well-known surgical procedures carried out during pregnancy. Its aim is to provide a mechanical support to the cervical canal and to keep the cervix closed. The cervical mucous plug serves as a mechanical barrier between the vagina and the uterine cavity, but it also contains many immune components which protect the fetal compartment from ascendent infections. Application of a cervical stitch can help to retain the mucous plug and thus increases the immunity of the cervical canal. Results of 15 randomised studies (Cochraine Database of Systematic R) suggest that in women with increased risk of preterm birth, cerclage decreases the occurrence of preterm birth relative to the expectant management. CONCLUSIONS: Despite the decreasing numbers of cerclage surgeries, it is still a useful method of preterm birth prevention for a specific group of women. More recently, a progesterone treatment has gained popularity. Its application, however, must begin before the 16th week of pregnancy.

A multidisciplinary approach to pregnancy loss: the pregnancy loss prevention center.

Background Pregnancy loss is probably the most common problem faced by women worldwide. There are differences in the rates of early and late pregnancy loss based on geography among the developing compared with the developed nations of the world. Most physicians worldwide have different criteria for treating pregnancy loss. Although pregnancy loss is not a disease, it might be best approached with a medical evaluation in order to define the cause and offer specific treatment. Methods This report describes the results obtained by a multi-disciplinary pregnancy loss prevention center in the initial 104 patients. Results The most common diagnoses were Asherman syndrome (intrauterine adhesions), cervical insufficiency and uterine fibroids, accounting for 47% of the patients. When the diagnosis was not obtained, which occurred in 19% of the patients, in vitro fertilization (IVF) was the treatment provided. Specifically diagnosed and treated patients achieved a 91% success rate. The 19 patients without a specific diagnosis who were treated with IVF had a 60% success rate. Thus patients for whom it was possible to specifically diagnose and treat had better results (P<0.01 t-test). There was an overall success rate of 87% including patients lost to follow-up with this multidisciplinary medical approach. Conclusion A pregnancy loss prevention center using the described multidisciplinary model can accomplish success rates of 85-90%. Preventing recurrent pregnancy loss we suggest can best be achieved by a dedicated center with a multidisciplinary medical approach.

Independent association between uterine malformations and cervical insufficiency: a retrospective population-based cohort study.

OBJECTIVE: The purpose of our study was to explore maternal and fetal outcomes in the second and third trimester in women with uterine malformations. STUDY DESIGN: This was a retrospective population-based cohort study including women with a diagnosis of uterine malformation arised from workup for infertility or recurrent pregnancy loss, was accidental during pregnancy, or was noticed at the time of cesarean delivery. RESULTS: A total of 280,721 pregnancies met the inclusion criteria and were divided into two study groups: (1) pregnancies in women with uterine malformations (n = 1099); and (2) controls (n = 279,662). The rate of women presenting uterine malformations was 0.39%. The prevalence of cervical os insufficiency was significantly higher in women with a uterine malformation than in the control group (3.6 vs. 0.4%, p < 0.001). A multivariate analysis, performed to evaluate risk factors for cervical insufficiency in women with uterine malformations. Mullerian anomalies (OR 6.19, 95% CI 4.41-8.70, p < 0.001), maternal age (OR 1.05, 95% CI 1.04-1.06, p < 0.001), recurrent abortions (OR 12.93, 95% CI 11.43-14.62, p < 0.001), and ethnicity (OR 2.86, 95% CI 2.454-3.34, p < 0.001) were found to be independently associated with the development of cervical insufficiency. CONCLUSION: Uterine anomalies have a strong association with cervical insufficiency. Women with uterine anomalies have an increased risk to develop pregnancy complications that arise from a loss in cervical function during the midtrimester or early third trimester.

[Clinical outcome of therapeutic cervical cerclage in short cervix syndrome].

Objective: To investigate the clinical effect of therapeutic cervical cerclage on short cervix syndrome for anti-premature birth in the second trimester. Methods: Totally 44 singleton pregnant patients were diagnosed as short cervix syndrome, which was cervical length ≤2.5 cm without cervical dilatation, and received treatment from January 2008 and July 2015 in Peking University Third Hospital were collected. Among them, 30 patients who received therapeutic cervical cerclage were defined as cerclage group and another 14 cases who received conservative treatment were defined as un-cerclage group. The days of conservative treatment, delivery rate of different gestational weeks, birth weight of newborns, neonatal survival rate within 7 days of birth were analyzed between the two groups. Results: There were no significant differences between the two groups in days of pregnancy conservative treatment [103 (84-141) vs 105 (85-114) days], delivery weeks [38.0 (35.5-39.4) vs 38.5 (37.3-39.5) weeks], birth weight of newborns [3 120 (2 750-3 400) vs 3 130 (2 760-3 545) g], and survival rate of newborns [100% (30/30) vs 13/14]. The fetuses of both groups were all delivered after 28 weeks. There was no significant difference in accumulated delivery rate between the two groups after 32 weeks, 34 weeks, and 37 weeks, respectively (all P>0.05) . Conclusions: The treatment of cervical cerclage is not superior to conservative means in single pregnancy of cervical length ≤2.5 cm without cervical dilatation. For such patients with short cervix syndrome, the treatment of cervical cerclage may not be necessary, but dynamic monitoring and search for the causing factors and prompt treatment are more important.

The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention.

Preterm birth remains a major cause of neonatal death and short and long-term disability in the US and across the world. The majority of preterm births are spontaneous and cervical length screening is one tool that can be utilized to identify women at increased risk who may be candidates for preventive interventions. The purpose of this document is to review the indications and rationale for CL screening to prevent preterm birth in various clinical scenarios. The Society for Maternal-Fetal Medicine recommends (1) routine transvaginal cervical length screening for women with singleton pregnancy and history of prior spontaneous preterm birth (grade 1A); (2) routine transvaginal cervical length screening not be performed for women with cervical cerclage, multiple gestation, preterm premature rupture of membranes, or placenta previa (grade 2B); (3) practitioners who decide to implement universal cervical length screening follow strict guidelines (grade 2B); (4) sonographers and/or practitioners receive specific training in the acquisition and interpretation of cervical imaging during pregnancy (grade 2B).

Overview of Cervical Insufficiency: Diagnosis, Etiologies, and Risk Factors.

The diagnosis of cervical insufficiency can be made in women with or without prior pregnancy losses. Cervical insufficiency has been defined by transvaginal ultrasound cervical length <25 mm before 24 weeks in women with prior pregnancy losses or preterm births at 14 to 36 weeks, or by cervical changes detected on physical examination before 24 weeks of gestation.

Cerclage: Indications and Patient Counseling.

Cervical cerclage is a surgical procedure to prevent preterm birth. There are currently 3 main indications, based on either history, ultrasound, or physical exam changes.

Vaginal Cerclage: Preoperative, Intraoperative, and Postoperative Management.

The role of the cerclage procedure has expanded from its initial application as treatment or prevention of cervical insufficiency to prevention of recurrent spontaneous preterm birth. Although recent prospective studies have clarified the indications for cerclage, additional prospective studies are needed to help define optimal perioperative management. Herein, we review the current data to provide the clinician with the most evidence-based approach to managing patients who require cerclage.

Outcomes after physical examination-indicated cerclage in twin gestations.

OBJECTIVE: To compare outcomes of physical examination-indicated cerclage in women with twin gestations to those with singleton gestations and to identify whether risk factors for extremely preterm birth (before 28 weeks) differ between these 2 groups. STUDY DESIGN: This is a single institution retrospective cohort study of women who underwent a physical examination-indicated cerclage between Jan. 1, 1980, and Aug. 15, 2012. Differences in characteristics and outcomes were compared between women with twin and singleton gestations. A multivariable analysis was performed to examine whether twin gestation was independently associated with delivery before 28 weeks and whether any effect modification was present between risk factors for preterm birth and the presence of a twin gestation. RESULTS: Of the 442 women who underwent a cerclage during the period of study, 104 (23.5%) had twins. Mean gestational age and digital cervical length at placement did not differ by plurality. Although twins were more likely to deliver at a slightly earlier median gestation than singletons (31.9 weeks; interquartile range, 24.9-35.1 vs 32.7 weeks; interquartile range, 24.6-38.3; P = .015), the frequency of delivery before 28 weeks did not differ between these 2 groups (33.7% vs 35.8%, P = .69). Greater cervical dilation and prolapsing membranes were identified as risk factors for birth <28 weeks in both groups; digital cervical length <2 cm appeared to be a risk factor particularly for women with twin gestations. CONCLUSION: Women with a twin pregnancy who received a physical examination-indicated cerclage had similar risk factors for extreme preterm birth and may experience similar obstetric outcomes as women with singleton gestations.

Cervical cerclage.

Cervical cerclage is an obstetric procedure performed for prevention of prematurity. Cerclage was first introduced by Drs Shirodkar and McDonald in the mid-1950s for women with repeated second trimester losses and cervical changes in current pregnancy. Currently, cerclage placement is based on 3 common indications in singleton gestations, including history-indicated (prior multiple early preterm births or second trimester losses), ultrasound-indicated (cervical length <25 mm before 24-wk gestational age in women with prior spontaneous preterm birth) and physical examination-indicated (cervical dilation on manual or physical examination before 24 wk).

Favorable surgical and obstetrical outcomes in pre- and postconceptional laparoscopic abdominal cerclage: a large multicenter cohort study.

BACKGROUND: Cervical incompetence is an important cause of extremely preterm delivery. Without specialized treatment, cervical incompetence has a 30% chance of recurrence in a subsequent pregnancy. Recently, the first randomized controlled trial showed significant superiority of abdominal cerclage compared with both high and low vaginal cerclage in preventing preterm delivery at <32 weeks of gestation and fetal loss in patients with a previous failed vaginal cerclage. OBJECTIVE: This study aimed to assess surgical and obstetrical outcomes in patients with pre- and postconceptional laparoscopic abdominal cerclage placement. Furthermore, it also aimed to perform subgroup analysis based on the indication for cerclage placement in order to identify patients who benefit the most from an abdominal cerclage. STUDY DESIGN: A retrospective multicenter cohort study with consecutive inclusion of all eligible patients from 1997 onward in the Dutch cohort (104 patients) and from 2007 onward in the Boston cohort (169 patients) was conducted. Eligible patients had at least 1 second- or third-trimester fetal loss due to cervical incompetence and/or a short or absent cervix after cervical surgery. This includes loop electrosurgical excision procedure, conization, or trachelectomy. Patients were divided into the following subgroups based on the indication for cerclage placement: (1) previous failed vaginal cerclage, (2) previous cervical surgery, and (3) other indications. The third group consisted of patients with a history of multiple second- or early third-trimester fetal losses due to cervical incompetence (without a failed vaginal cerclage) and/or multiple dilation and curettage procedures. The primary outcome measure was delivery at ≥34 weeks of gestation with neonatal survival at hospital discharge. Secondary outcome measures included surgical and obstetrical outcomes, such as pregnancy rates after preconceptional surgery, obstetrical complications, and fetal survival rates. RESULTS: A total of 273 patients were included (250 in the preconceptional and 23 in the postconceptional cohort). Surgical outcomes of 273 patients were favorable, with 6 minor complications (2.2%). In the postconceptional cohort, 1 patient (0.4%) had hemorrhage of 650 mL, resulting in conversion to laparotomy. After preconceptional laparoscopic abdominal cerclage (n=250), the pregnancy rate was 74.1% (n=137) with a minimal follow-up of 12 months. Delivery at ³34 weeks of gestation occurred in 90.5% of all ongoing pregnancies. Four patients (3.3%) had a second-trimester fetal loss. The indication for cerclage in all 4 patients was a previous failed vaginal cerclage. The other subgroups showed fetal survival rates of 100% in ongoing pregnancies, with a total fetal survival rate of 96%. After postconceptional placement, 94.1% of all patients with an ongoing pregnancy delivered at ³34 weeks of gestation, with a total fetal survival rate of 100%. Thus, second-trimester fetal losses did not occur in this group. CONCLUSION: Pre- and postconceptional laparoscopic abdominal cerclage is a safe procedure with favorable obstetrical outcomes in patients with increased risk of cervical incompetence. All subgroups showed high fetal survival rates. Second-trimester fetal loss only occurred in the group of patients with a cerclage placed for the indication of previous failed vaginal cerclage, but was nevertheless rare even in this group.

Outpatient Foley catheter versus inpatient prostaglandin E2 gel for induction of labour: a randomised trial.

BACKGROUND: Induction of labour (IOL) is one of the commonest obstetric interventions, with significant impact on both the individual woman and health service delivery. Outpatient IOL is an attractive option to reduce these impacts. To date there is little data comparing outpatient and inpatient IOL methods, and potential safety concerns (hyperstimulation) if prostaglandins, the standard inpatient IOL medications, are used in the outpatient setting. The purpose of this study was to assess feasibility, clinical effectiveness and patient acceptability of outpatient Foley catheter (OPC) vs. inpatient vaginal PGE2 (IP) for induction of labour (IOL) at term. METHODS: Women with an unfavourable cervix requiring IOL at term (N=101) were randomised to outpatient care using Foley catheter (OPC, n=50) or inpatient care using vaginal PGE2 (IP, n=51). OPC group had Foley catheter inserted and were discharged overnight following a reassuring cardiotocograph. IP group received 2 mg/1 mg vaginal PGE2 if nulliparous or 1 mg/1 mg if multiparous. Main outcome measures were inpatient stay (prior to birth, in Birthing Unit, total), mode of birth, induction to delivery interval, adverse reactions and patient satisfaction. RESULTS: OPC group had shorter hospital stay prior to birth (21.3 vs. 32.4 hrs, p< .001), IP were more likely to achieve vaginal birth within 12 hours of presenting to Birthing Unit (53% vs. 28%, p= .01). Vaginal birth rates (66% OPC Vs. 71% IP), total induction to delivery time (33.5 hrs vs. 31.3 hrs) and total inpatient times (96 hrs OPC Vs. 105 hrs IP) were similar. OPC group felt less pain (significant discomfort 26% Vs 58%, p=.003), and had more sleep (5.8 Vs 3.4 hours, p< .001), during cervical preparation, but were more likely to require oxytocin IOL (88 Vs 59%, p=.001). CONCLUSIONS: OPC was feasible and acceptable for IOL of women with an unfavourable cervix at term compared to IP, however did not show a statistically significant reduction in total inpatient stay and was associated with increased oxytocin IOL. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN:12609000420246.

Cervical insufficiency and cervical cerclage.

OBJECTIVE: The purpose of this guideline is to provide a framework that clinicians can use to determine which women are at greatest risk of having cervical insufficiency and in which set of circumstances a cerclage is of potential value. EVIDENCE: Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library in 2012 using appropriate controlled vocabulary (e.g., uterine cervical incompetence) and key words (e.g., cervical insufficiency, cerclage, Shirodkar, cerclage, MacDonald, cerclage, abdominal, cervical length, mid-trimester pregnancy loss). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to January 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Recommendations 1. Women who are pregnant or planning pregnancy should be evaluated for risk factors for cervical insufficiency. A thorough medical history at initial evaluation may alert clinicians to risk factors in a first or index pregnancy. (III-B) 2. Detailed evaluation of risk factors should be undertaken in women following a mid-trimester pregnancy loss or early premature delivery, or in cases where such complications have occurred in a preceding pregnancy. (III-B) 3. In women with a history of cervical insufficiency, urinalysis for culture and sensitivity and vaginal cultures for bacterial vaginosis should be taken at the first obstetric visit and any infections so found should be treated. (I-A) 4. Women with a history of three or more second-trimester pregnancy losses or extreme premature deliveries, in whom no specific cause other than potential cervical insufficiency is identified, should be offered elective cerclage at 12 to 14 weeks of gestation. (I-A) 5. In women with a classic history of cervical insufficiency in whom prior vaginal cervical cerclage has been unsuccessful, abdominal cerclage can be considered in the absence of additional mitigating factors. (II-3C) 6. Women who have undergone trachelectomy should have abdominal cerclage placement. (II-3C) 7. Emergency cerclage may be considered in women in whom the cervix has dilated to < 4 cm without contractions before 24 weeks of gestation. (II-3C) 8. Women in whom cerclage is not considered or justified, but whose history suggests a risk for cervical insufficiency (1 or 2 prior mid-trimester losses or extreme premature deliveries), should be offered serial cervical length assessment by ultrasound. (II-2B) 9. Cerclage should be considered in singleton pregnancies in women with a history of spontaneous preterm birth or possible cervical insufficiency if the cervical length is ≤ 25 mm before 24 weeks of gestation. (I-A) 10. There is no benefit to cerclage in a woman with an incidental finding of a short cervix by ultrasound examination but no prior risk factors for preterm birth. (II-1D) 11. Present data do not support the use of elective cerclage in multiple gestations even when there is a history of preterm birth; therefore, this should be avoided. (I-D) 12. The literature does not support the insertion of cerclage in multiple gestations on the basis of cervical length. (II-1D).

Objectif : La présente directive clinique a pour but de fournir un cadre de référence que les cliniciens pourront utiliser pour identifier les femmes qui sont exposées aux plus grands risques de connaître une insuffisance cervicale, ainsi que pour déterminer les circonstances en présence desquelles la mise en place d'un cerclage pourrait s'avérer souhaitable. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed ou MEDLINE, CINAHL et The Cochrane Library en 2012 au moyen d'un vocabulaire contrôlé (p. ex. « uterine cervical incompetence ¼) et de mots clés appropriés (p. ex. « cervical insufficiency ¼, « cerclage ¼, « Shirodkar ¼, « cerclage ¼, « MacDonald ¼, « cerclage ¼, « abdominal ¼, « cervical length ¼, « mid-trimester pregnancy loss ¼). Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune restriction n'a été appliquée en matière de date ou de langue. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en janvier 2011. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats est évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Recommandations 1. Les femmes qui sont enceintes ou qui planifient connaître une grossesse devraient faire l'objet d'une évaluation visant les facteurs de risque de l'insuffisance cervicale. L'exécution d'une anamnèse exhaustive au moment de l'évaluation initiale pourrait attirer l'attention des cliniciens sur des facteurs de risque s'étant manifestés au cours d'une première grossesse (ou grossesse probante). (III-B) 2. Les femmes qui connaissent une fausse couche au deuxième trimestre ou un accouchement prématuré précoce devraient par la suite faire l'objet d'une évaluation détaillée des facteurs de risque; une telle évaluation devrait également être menée chez les femmes qui ont connu ces complications dans le cadre d'une grossesse précédente. (III-B) 3. Chez les femmes qui présentent des antécédents d'insuffisance cervicale, une analyse d'urine (à des fins de mise en culture et pour la tenue d'une épreuve de sensibilité) et des mises en culture vaginales visant la vaginose bactérienne devraient être effectuées dans le cadre de la première consultation obstétricale, et toute infection ainsi mise au jour devrait être traitée. (I-A) 4. Les femmes qui ont déjà connu au moins trois fausses couches au deuxième trimestre ou accouchements extrêmement prématurés et chez qui aucune cause particulière autre qu'une insuffisance cervicale potentielle n'a été identifiée devraient se voir offrir un cerclage planifié (à 12 - 14 semaines de gestation). (I-A) 5. Dans le cas des femmes présentant des antécédents classiques d'insuffisance cervicale chez qui la mise en place précédente d'un cerclage vaginal a échoué, la mise en place d'un cerclage abdominal peut être envisagée en l'absence de facteurs atténuants additionnels. (II-3C) 6. Les femmes qui ont subi une trachélectomie devraient faire l'objet d'un cerclage abdominal. (II-3C) 7. La mise en place d'un cerclage d'urgence pourrait être envisagée chez les femmes dont le col présente une dilatation < 4 cm, sans contractions, à moins de 24 semaines de gestation. (II-3C) 8. Les femmes pour lesquelles la mise en place d'un cerclage n'est pas envisagée ou justifiée, mais dont les antécédents semblent indiquer un risque d'insuffisance cervicale (1 ou 2 fausses couches au deuxième trimestre ou accouchements extrêmement prématurés), devraient se voir offrir des évaluations échographiques en série de la longueur cervicale. (II-2B) 9. La mise en place d'un cerclage devrait être envisagée, en présence d'une longueur cervicale ≤ 25 mm avant 24 semaines de gestation, chez les femmes connaissant une grossesse monofœtale qui présentent une possible insuffisance cervicale ou des antécédents d'accouchement préterme spontané. (I-A) 10. Le cerclage ne s'avère d'aucune utilité dans le cas des femmes qui ont fait l'objet d'un examen échographique ayant révélé, de façon fortuite, la présence d'un col court et qui n'ont pas déjà présenté des facteurs de risque en ce qui concerne l'accouchement préterme ou l'insuffisance cervicale. (II-1D) 11. Les données actuelles ne soutiennent pas la mise en place planifiée d'un cerclage dans le cadre d'une grossesse multiple, même en présence d'antécédents d'accouchement préterme; ainsi, cette pratique devrait être évitée. (I-D) 12. Dans le cadre d'une grossesse multiple, la mise en place d'un cerclage en fonction de la longueur cervicale n'est pas soutenue par la littérature. (II-1D).

Use of cervical cerclage as a treatment option for cervical incompetence: patient characteristics, presentation and management over a 9 year period in a Kenyan centre.

Treatment of cervical incompetence by cerclage and other methods has yet to be standardized, as its diagnosis is not uniformly accepted. Its diagnosis, particularly in the African setting, is mostly based on past obstetric history of pregnancy losses, while in developed centres; ultrasound diagnosis is increasingly being used. The mainstay of treatment in developing countries is cervical cerclage, although the indications and contraindications of this mode of treatment are not documented. Our aim was to appraise this practice in terms of patient characteristics, the diagnostic process and management at the Kenyatta National Hospital, Nairobi, Kenya. This was a descriptive retrospective study over 9 years. Predesigned questionnaires were employed to collect data on patient's socio-demographic profile, presentation, risk factors, diagnosis and management of cervical incompetence. Chi-squared test and student's t-test were used to correlate variables. A total of 199 patients were treated for cervical incompetence, with the patient mean age being 27.97. 87.4% of the patients (p = 0.02) were in the 20 to 35 years category. Most of the patients (60.1%) were of low socio-economic status. Cervical cerclage was employed in all the patients, although ultrasound investigation was not employed in 65.8% of them. Diagnosis of cervical incompetence still relies on history of previous pregnancy losses, with the standard transvaginal ultrasound relatively unemployed. There is need to intensify investigations for this condition, standardize the indications for cerclage, and diversify management to other newer modalities.