Antibody microarray analysis of amniotic fluid proteomes in women with cervical insufficiency and short cervix, and their association with pregnancy latency length.

INTRODUCTION: This study aimed to investigate amniotic fluid (AF) proteins that were differentially expressed between patients with cervical insufficiency (CI) and asymptomatic short cervix (SCX, ≤ 25 mm), and whether these proteins could be predictive of spontaneous preterm birth (SPTB) in these patients. METHOD: This was a retrospective cohort study of 129 singleton pregnant women with CI (n = 80) or SCX (n = 49) at 17 to 26 weeks who underwent amniocentesis. An antibody microarray was used to perform comparative proteomic profiling of AF from matched CI (n = 20) and SCX (n = 20) pregnancies. In the total cohort, an ELISA validation study was performed for 15 candidate proteins of interest. Subgroup analyses of patients with CI and SCX were conducted to evaluate the association between the 15 proteins and SPTB at < 32 weeks of gestation. RESULTS: Eighty-six proteins showed intergroup differences. ELISA validation confirmed significantly higher levels of AF EN-RAGE, IL-8, lipocalin-2, MMP-9, S100A8/A9, thrombospondin-2, and TNFR2 in patients with CI than in those with SCX. Multivariable analysis showed that increased AF levels of EN-RAGE, S100A8/A9, and uPA were independently associated with SPTB at < 32 weeks in patients with CI; whereas in patients with SCX, high AF levels of APRIL, EN-RAGE, LBP, and TNFR2 were independently associated with SPTB at < 32 weeks. CONCLUSIONS: Multiple AF proteins show altered expression in patients with CI compared with SCX controls. Moreover, several novel mediators involved in inflammation were identified as potential biomarkers for predicting SPTB after the diagnosis of CI and SCX. These results provide new insights into target-specific molecules for targeted therapies to prevent SPTB in patients with CI/SCX.

A new technique for emergency cerclage: Guard suture method.

Objective The aim of this study was to introduce a novel technique to treat midtrimester cervical insufficiency with prolapsed membranes. Material and methods This retrospective study included patients with singleton pregnancies between 16 and 28 gestational weeks that underwent emergency cervical cerclage in a tertiary center. Patients were divided into two groups as McDonald method and guard suture method group according to the procedure they underwent. The following variables were recorded and evaluated: gestational age at cerclage, cervical length between the suture and external cervical os measured by transvaginal ultrasound on postoperative 1st and 7th day, gestational age at delivery, time between the procedure and delivery, intraoperative complications, newborn intensive care unit (NICU) admission, Apgar scores of neonates, and discharged alive newborns. Results During the study period, 38 patients underwent emergency cerclage procedure. Twenty-three were included in the McDonald group and 15 were in the guard suture group. The mean gestational age at the time of cerclage was 22.1 (17 -27) weeks and the mean gestational age at delivery was 33.9 (26- 38) weeks. Prolongation time between cerclage and delivery was 80.42 (1 - 140) days. Significantly higher 1st and 5th minutes Apgar scores and significantly lower NICU admission was found in the guard suture group (p = 0.04, p = 0.01 and p = 0.02, respectively). Conclusion In cases with cervical insufficiency and prolapsed membranes, emergency cerclage may prevent premature birth by prolonging pregnancy. Guard suture method is safe, effective, and easily applicable and can help obstetricians achieve better fetal and neonatal outcomes.

Analysis of maternal and neonatal outcomes using cervical cerclage or conservative treatment in singleton gestations with a sonographic short cervix.

ABSTRACT: To investigate the effect of cervical cerclage or conservative treatment on maternal and neonatal outcomes in singleton gestations with a sonographic short cervix, and further compare the relative treatment value.A retrospective study was conducted among women with singleton gestations who had a short cervical length (<25 mm) determined by ultrasound during the period of 14 to 24 weeks' gestation in our institution. We collected clinical data and grouped the patients according to a previous spontaneous preterm birth (PTB) at <34 weeks of gestation or second trimester loss (STL) and sub-grouped according to treatment option, further comparing the maternal and neonatal outcomes between different groups.In the PTB or STL history cohort, the cerclage group had a later gestational age at delivery (35.3 ±â€Š3.9 weeks vs 31.6 ±â€Š6.7 weeks) and a lower rate of perinatal deaths (2% vs 29.3%) compared with the conservative treatment group. In the non-PTB-STL history cohort, the maternal and neonatal outcomes were not significantly different between the cerclage group and conservative treatment group. More importantly, for patients with a sonographic short cervix who received cervical cerclage, there was no significant difference in the maternal and neonatal outcomes between the non-PTB-STL group and PTB or STL group.For singleton pregnant with a history of spontaneous PTB or STL and a short cervical length (<25 mm), cervical cerclage can significantly improve maternal and neonatal outcomes; however, conservative treatment (less invasive and expensive than cervical cerclage) was more suitable for those pregnant women without a previous PTB and STL history.

Physical examination-indicated cerclage in twin pregnancy: a retrospective cohort study.

PURPOSE: This study aimed to evaluate the efficacy of physical examination-indicated cerclage in twin pregnancies and compare it with those that received conservative management. METHODS: We used a retrospective cohort study design of asymptomatic twin pregnancies identified with physical examination indications at 14-26 weeks from 2015 through 2019 at Fujian Maternity and Child Health Hospital. The primary outcomes were gestational age (GA) at delivery and the incidence of spontaneous preterm birth (SPTB) at < 34 weeks, < 32 weeks, < 28 weeks, and < 24 weeks. The main secondary outcomes were latency period from diagnosis to delivery, composite neonatal adverse outcome and neonatal survival at discharge. RESULTS: Thirty-one women with twin pregnancies were managed with physical examination-indicated cerclage, and another 31 received expectant management. The demographic characteristics of the two groups were not significantly different. GA at delivery was significantly later in the cerclage group than in the controls: 32.53 ± 4.78 vs. 27.53 ± 4.15 weeks, with a mean difference of 5.00 weeks [95% confidence interval (CI), 2.73-7.28]. There were significant decreases in the incidence of spontaneous preterm birth (SPTB) at < 34 weeks, < 32 weeks, < 28 weeks, and < 24 weeks in the cerclage group. The interval from diagnosis to delivery was increased with cerclage by a mean difference of 4.37 weeks (95% CI, 1.96-7.06). Regarding neonatal outcome, the perinatal mortality rate in the cerclage group was significantly reduced compared to that in the control group [8/62 (12.9%) vs. 26/62 (41.9%); P < 0001]. Likewise, the neonatal intensive care unit (NICU) admissions, length of stay in the NICU, and composite adverse neonatal outcome in the cerclage group were significantly reduced. CONCLUSION: Physical examination-indicated cerclage was associated with significantly later GA at delivery, longer latency period from diagnosis to delivery, decreased incidence of SPTB at any given GA, and improved perinatal outcome compared with the corresponding measures in controls treated conservatively.

Pregnancy outcomes and factors affecting the clinical effects of cervical cerclage when used for different indications: A retrospective study of 326 cases.

OBJECTIVE: To compare pregnancy outcomes resulting from the use of cervical cerclage for different indications and investigate factors that might influence the clinical effects of cervical cerclage. MATERIALS AND METHODS: This was a retrospective study of pregnant women who received cervical cerclage in The Women's Hospital, Zhejiang University School of Medicine, China. Patients were divided into three groups: a history-indicated group; an ultrasound-indicated group and a physical examination-indicated group. The pregnancy outcomes of the three groups were then compared. Univariate and multivariate logistic regression analysis were performed to assess the independent risk factors. RESULTS: Statistical differences were evident when the history-indicated group and the ultrasound-indicated group were compared with the physical examination-indicated group for gestational age at delivery [37.3(33.3-38.9), 35.4(28.9-38.4) vs. 26.1 (24.3-28.4) weeks, respectively, P < 0.05], percentage of cases delivered at < 28 weeks of gestation (13.4%, 20.3% vs. 74.3%, respectively, P < 0.05), percentage of cases delivered at < 37 weeks of gestation (42.7%, 54.2% vs. 91.4%, respectively, P < 0.05) and fetal survival rate (88.4%, 81.4% vs. 40.0%, respectively, P < 0.05). The history-indicated group and the ultrasound-indicated group were similar with regards to these outcomes. The independent risk factors affecting the clinical effects of cervical cerclage include age, body mass index (BMI), history of prior preterm birth and second-trimester loss, C-reactive protein (CRP) >5 mg/L and cervical dilation ≥3 cm (P < 0.05). CONCLUSION: Pregnancy outcomes were similar when compared between history-indicated and ultrasound-indicated cerclage. Serial cervical surveillance is beneficial for pregnant with a history of cervical insufficiency, and the placement of cervical cerclages in response to ultrasonographically detected shortening of the cervical length is a medically acceptable alternative to the use of history-indicated cerclage.

A Novel Cerclage Insertion: Modified Laparoscopic Transabdominal Cervical Cerclage with Transvaginal Removing (MLTCC-TR).

STUDY OBJECTIVE: To report on our center's experience of a novel modified approach for laparoscopic cervical cerclage and to evaluate its safety and efficacy preliminarily. DESIGN: Retrospective descriptive study. SETTING: Single academic institution. PATIENTS: Pregnant and nonpregnant women who underwent the modified laparoscopic transabdominal cervical cerclage with transvaginal removing (MLTCC-TR) from June 2016 to April 2019. Eligible participants had multiple adverse obstetric histories or the short cervix and were not suitable for a second transvaginal cerclage. INTERVENTIONS: Preconceptional or postconceptional MLTCC-TR. MEASUREMENTS AND MAIN RESULTS: A total of 24 participants (including 3 first-trimester singleton pregnant women) underwent the MLTCC-TR, giving birth to 27 infants. Among 21 women who underwent preconceptional cerclage, 26 cases of postoperational pregnancies were noted, and the incidence of term labor was 73.07%, which was significantly higher than that in the precerclage group (p <.001). Their mean gestational age at delivery was 37.21 ± 5.05 weeks. Among 3 cases of postconceptional cerclage, the mean gestational age at cerclage was 10.90 ± 2.61 weeks, and all of them had term delivery. The overall neonatal survival rate was 100% (27/27), of which 81.48% (22/27) were term infants. There were no severe perioperative complications directly related to the insertion of cerclage. CONCLUSION: Our new approach of MLTCC-TR may be a relatively effective, feasible, and safe treatment for cervical insufficiency. It may be considered as an acceptable alternative to the traditional laparoscopic cervical cerclage with its superiority of transvaginal removing.

Factors associated with neonatal outcomes in preterm prelabor rupture of membranes after cervical cerclage.

OBJECTIVE: To evaluate risk factors associated with neonatal morbidity and mortality in pregnant women with preterm prelabor rupture of membranes (PPROM) after cervical cerclage. METHODS: A retrospective cohort study of singleton pregnancies with cervical insufficiency was conducted at a tertiary referral center in Taiwan from May 1, 2000 to July 31, 2017. Patients with PPROM after cerclage and delivered between 20 0/7 days and 36 6/7 days were recruited. Logistic and linear regression analyses were performed to evaluate various risk factors. RESULTS: Overall, 109 women were included. Mothers with a higher white blood cell count, a higher C-reactive protein (CRP) level, a lower amniotic fluid index, and chorioamnionitis were significantly associated with neonatal morbidity. Neonatal mortality was related to oligohydramnios (adjusted odds ratio [aOR] 2.98, 95% confidence interval [CI] 1.11-8.01) and chorioamnionitis (aOR 3.17, 95% CI 1.03-9.69). An elevated CRP level was associated with a shorter PPROM to delivery latency (adjusted B -16.64, 95% CI -29.88 to -3.41), but cerclage retention more than 12 hours after PPROM was associated with a prolonged latency (adjusted B 17.21, 95% CI 3.25-31.18). CONCLUSION: Oligohydramnios and chorioamnionitis are associated with neonatal mortality.

Emergency cerclage: gestational and neonatal outcomes.

BACKGROUND: The gestational and neonatal outcomes of women with early cervical dilatation undergoing emergency cerclage were evaluated and compared with women treated with expectant management and bed rest. METHODS: Retrospective analysis of pregnant women admitted between 2001 and 2017 with a diagnosis of early cervical dilatation and/or bulging membranes. Patients with a singleton pregnancy of a fetus without malformations, between 16 and 25 weeks and 6 days, with cervical dilatation of 1 to 3 cm were included; patients who delivered or miscarried within 2 days after admission were excluded. RESULTS: The study enrolled 30 patients: 19 in the cerclage group and 11 in the rest group. There was a significant difference, with the cerclage group showing better results concerning gestational age at delivery (28.7 vs. 23.3 weeks; p=0.031) and latency between hospital admission and delivery (48.6 vs. 16 days; p=0.016). The fetal death rate was lower in the cerclage group (5.3% vs. 54.5%, p=0.004). Considering gestational age at delivery of live newborns, no difference was observed between the cerclage and rest groups (29.13 vs. 27.4 weeks; p=0.857). CONCLUSIONS: Emergency cerclage was associated with longer latency, a significant impact on gestational age at delivery and reduction in the fetal death rate.

Emergency cerclage: gestational and neonatal outcomes

SUMMARY BACKGROUND: The gestational and neonatal outcomes of women with early cervical dilatation undergoing emergency cerclage were evaluated and compared with women treated with expectant management and bed rest. METHODS: Retrospective analysis of pregnant women admitted between 2001 and 2017 with a diagnosis of early cervical dilatation and/or bulging membranes. Patients with a singleton pregnancy of a fetus without malformations, between 16 and 25 weeks and 6 days, with cervical dilatation of 1 to 3 cm were included; patients who delivered or miscarried within 2 days after admission were excluded. RESULTS: The study enrolled 30 patients: 19 in the cerclage group and 11 in the rest group. There was a significant difference, with the cerclage group showing better results concerning gestational age at delivery (28.7 vs. 23.3 weeks; p=0.031) and latency between hospital admission and delivery (48.6 vs. 16 days; p=0.016). The fetal death rate was lower in the cerclage group (5.3% vs. 54.5%, p=0.004). Considering gestational age at delivery of live newborns, no difference was observed between the cerclage and rest groups (29.13 vs. 27.4 weeks; p=0.857). CONCLUSIONS: Emergency cerclage was associated with longer latency, a significant impact on gestational age at delivery and reduction in the fetal death rate.

RESUMO OBJETIVO: Os resultados gestacionais e neonatais de mulheres com cervicodilatação precoce submetidas à cerclagem de emergência foram avaliados e comparados com mulheres tratadas com manejo expectante com repouso no leito. MÉTODOS: Análise retrospectiva de gestantes admitidas entre 2001 e 2017 com diagnóstico de cervicodilatação precoce e/ou membranas protrusas. Foram incluídas pacientes com gestação única de feto sem malformações, entre 16 semanas e 25 semanas e 6 dias, com dilatação cervical de 1 a 3 cm; as pacientes que tiveram parto ou aborto dentro de 2 dias após admissão foram excluídas. RESULTADOS: O estudo envolveu 30 pacientes: 19 no grupo cerclagem e 11 no grupo repouso. Houve diferença significativa, com o grupo cerclagem apresentando melhores resultados em relação à idade gestacional no parto (28,7 vs. 23,3 semanas; p=0,031) e à latência entre a admissão hospitalar e o parto (48,6 vs. 16 dias; p=0,016). A taxa de mortalidade fetal foi menor no grupo cerclagem (5,3% vs. 54,5%, p=0,004). Considerando a idade gestacional no nascimento dos recém-nascidos vivos, não houve diferença entre os grupos cerclagem e expectante (29,13 vs. 27,4 semanas; p=0,857). CONCLUSÕES: A cerclagem de emergência foi associada a maior período de latência com impacto significativo na idade gestacional do parto e à redução da taxa de mortalidade fetal.

Patients with acute cervical insufficiency without intra-amniotic infection/inflammation treated with cerclage have a good prognosis.

Background The frequency of intra-amniotic infection/inflammation (IAI/I) in patients with midtrimester cervical insufficiency is up to 50%. Our purpose was to determine the perinatal outcomes of cervical cerclage in patients with acute cervical insufficiency with bulging membranes, and to compare the admission-to-delivery interval and pregnancy outcomes according to the results of amniotic fluid (AF) analysis and cerclage placement. Methods This was a retrospective cohort study including singleton pregnancies with cervical insufficiency between 15 and 26.9 weeks in two tertiary health centers. IAI/I was defined when at least one of the following criteria was present in AF: (a) a white blood cell (WBC) count >50 cells/mm3; (b) glucose concentration <14 mg/dL; and/or (c) a Gram stain positive for bacteria. Three different groups were compared: (1) absence of IAI/I with placement of a cerclage; (2) amniocentesis not performed with placement of a cerclage; and (3) IAI/I with or without a cerclage. Results Seventy patients underwent an amniocentesis to rule out IAI/I. The prevalence of IAI/I was 19%. Forty-seven patients underwent a cerclage. Patients with a cerclage had a longer median admission-to-delivery interval (33 vs. 2 days; P < 0.001) and delivered at a higher median gestational age (27.4 vs. 22.6 weeks; P = 0.001) than those without a cerclage. The neonatal survival rate in the cerclage group was 62% vs. 23% in those without a cerclage (P = 0.01). Patients without IAI/I who underwent a cerclage had a longer median admission-to-delivery interval (43 vs. 1 day; P < 0.001), delivered at a higher median gestational age (28 vs. 22.1 weeks; P = 0.001) and had a higher neonatal survival rate (67% vs. 8%; P < 0.001) than those with IAI/I. Conclusion The pregnancy outcomes of patients with midtrimester cervical insufficiency and bulging membranes are poor as they have a high prevalence of IAI/I. Therefore, a pre-operative amniocentesis is key to identify the best candidates for the subsequent placement of a cerclage.

Outcomes after periviable ultrasound-indicated cerclage.

BACKGROUND: Cerclage placed for a sonographically short cervix has been shown to reduce the risk of preterm delivery in women with a history of prior preterm birth. While short cervix is traditionally placed before viability, the threshold gestational age at which viability is achieved continues to decrease, and, as a result, a larger subset of women may be ineligible to receive this potentially beneficial procedure. OBJECTIVE: To evaluate the association between obstetric outcomes and perioperative complications after placement of an ultrasound-indicated cerclage at periviability compared to placement in the previable period. METHODS: This retrospective cohort study of patients who underwent ultrasound-indicated cerclage evaluated obstetric outcomes and perioperative complications based on gestational age at cerclage placement. Ultrasound-indicated cerclage was considered to have been placed at periviability if placed at 22 to <24 weeks (exposed) and at previability if placed at 16 to <22 weeks gestational age (unexposed). The primary outcome was preterm delivery <36 weeks. Secondary outcomes included mean gestational age at delivery, preterm delivery <32 weeks, <28, and <24 weeks, preterm premature rupture of membranes (PPROM), chorioamnionitis, and perioperative complications. Adjusted analyses were performed to account for demographic and obstetric factors. RESULTS: Of the 426 patients included in the analysis, 94 (22%) had cerclage placed between ≥22 weeks to <24 weeks, while 332 (78%) had cerclage placed at <22 weeks. On univariate analysis, women who had a periviable cerclage placed were less likely to have a recurrent preterm delivery <36 weeks compared to women with previable cerclage placement (26.6 versus 38.3%, respectively, p = .04). The adjusted model did not demonstrate a significant difference in risk for preterm delivery <36 weeks associated with periviable versus previable cerclage (odds ratio 0.66, 95%CI 0.37-1.17). Secondary outcomes were similar between the previable and periviable groups, including mean gestational age at delivery (35.1 versus 36.2 weeks, respectively, p = .08) and preterm delivery before 32-week gestation (20.7 versus 13.8%, respectively, p = .17). Intraoperative and postoperative complications were rare and rates were similar between groups. CONCLUSIONS: Obstetric outcomes between patients receiving periviable and previable cerclage are similar. Ultrasound-indicated cerclage placement is associated with a relatively low rate of complications. Given the evidence supporting benefit of cerclage for women with short ultrasound cervical length and prior preterm birth, our findings demonstrate that benefits of placement at ≥22 weeks to <24 weeks may outweigh risks.

McDonald versus Shirodkar cervical cerclage for the prevention of preterm birth: impact of body mass index.

Objective: To compare obstetrical outcomes on women undergoing a McDonald or Shirodkar cerclage and to estimate the impact of maternal body mass index (BMI) on these outcomes. Methods: We conducted a retrospective review of the medical records of all women with singleton pregnancies who underwent placement of a McDonald or Shirodkar cerclage at St. Francis Hospital from January 2008 to October 2013. The subjects were categorized based on BMI groups (normal: less than 25 kg/m2, overweight: 25-29 kg/m2, obese: 30 kg/m2 or more). The primary outcome was gestational age at delivery. Statistical analyses included chi-square, Student's t-test, and multivariable regression analysis. Results: Of 95 women, 47 (49.5%) received a Shirodkar, and 48 (50.5%) a McDonald cerclage. 16 women (16.8%) were categorized as normal weight, 35 (36.8%) as overweight, and 44 (46.3%) as obese. Gestational age at delivery differed significantly by group, decreasing with each categorical increase in BMI (normal: 39.0 ± 0.3 weeks; overweight: 36.6 ± 0.7 weeks; obese: 33.0 ± 1.1 weeks; p < .01). Overall, women receiving a Shirodkar cerclage had significantly longer pregnancies than women with a McDonald cerclage (36.7 ± 0.6 weeks versus 33.9 ± 1.0 weeks; p = .02). However, analysis showed a significant interaction between weight status and gestational age at delivery. Obese women had significantly longer pregnancies when they received a Shirodkar cerclage versus a McDonald cerclage (32.6 ± 1.0 weeks versus 28.8 ± 0.9 weeks; p < .01). However, there was no significant difference in gestational age at delivery between women categorized as normal/overweight (Shirodkar: 33.5 ± 0.9 weeks; McDonald: 32.9 ± 0.9 weeks; p = .63). Conclusions: Compared to obese women receiving a McDonald cerclage, obese women receiving a Shirodkar cerclage had significantly longer pregnancies. No significant differences in pregnancy duration were found in normal/overweight women regardless of cerclage technique. Pregnancy duration in obese women receiving a Shirodkar cerclage was similar to the pregnancy duration of normal/overweight women.

Effectiveness and safety of late midtrimester cervical cerclage.

Objectives: To evaluate the safety and effectiveness of late cervical cerclage performed beyond 17 weeks of gestation. The outcomes of interest were effectiveness of late cerclage in prolongation of pregnancy and evaluation of pregnancy outcome including maternal and fetal complications. Study design: A total of 30 patients underwent late cervical cerclage during the study period. Of them, two were twin pregnancies. A late cerclage was performed after the diagnosis of cervical shortening or dilatation in 20 patients. We performed a retrospective case series review. One case was lost to follow up (delivery in another medical center). Medical information was retrieved from all cases of patients who underwent a late cervical cerclage between the years 2010 and 2016 at the Soroka University Medical Center, a tertiary medical center. Continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as proportions. Results: The average gestational age at birth was 35 ± 5.1 weeks of gestation. The mean interval between cerclage and delivery in the study population was 17 ± 5.62 weeks. Nine cases (32.1%) resulted in preterm deliveries, three of them below 34 weeks of gestation (one twin pregnancy and two pregnancies diagnosed with cervical dilation prior to cerclage). Among all the preterm deliveries, there were four cases of preterm prelabor rupture of membranes (13.3%). Of the 28 deliveries, 24 women (85.7%) had a vaginal delivery, while four women (14.3%) underwent a cesarean section. No cases of cervical tear were described. The cerclage was sent to bacteriology after removal, showing positive cultures for Candida species in nine cases (31%). Conclusions: In our study population, late cervical cerclage was found to be a safe procedure resulting in almost 90% of successful vaginal deliveries without maternal or fetal complications. This procedure might be effective in the prolongation of pregnancy in women with cervical dynamics in the late second trimester.

The impact of cerclage in twin pregnancies on preterm birth rate before 32 weeks.

PURPOSE: To evaluate whether cerclage in twins reduces the rate of spontaneous preterm birth <32 weeks when compared to expectant management. METHODS: This is a retrospective cohort study of twin pregnancies with the following indications for cerclage from two institutions: history of prior preterm birth, ultrasound-identified short cervix ≤2.5 cm, and cervical dilation ≥1.0 cm. The "cerclage" cohort received a cerclage from a single provider at a single institution from 2003-2016. The "no cerclage" group included all patients with similar indications that were expectantly managed from 2010-2015, at a second institution where cerclages are routinely not performed in twin pregnancies. The primary outcome was the rate of spontaneous preterm birth at <32 weeks. Secondary outcomes were the rates of spontaneous and overall (including medically indicated) preterm births at <32 weeks, < 34 weeks, and <36 weeks, chorioamnionitis, birth weight, and neonatal mortality within 30 days of life. We also performed a planned subgroup analysis stratified by cerclage indication. RESULTS: In all, 135 women were included in two cohorts: cerclage (n = 96) or no cerclage (n = 39). The rates of spontaneous preterm birth <32 weeks were 10.4% (n = 10) with cerclage versus 28.2% (n = 11) without cerclage (OR 0.23, CI 0.08-0.70, p = .017). After adjusting for cerclage indication, clinical history, age, chorionicity, insurance type, race, BMI, in-vitro fertilization, and multifetal reduction, there remained a significant reduction in the cerclage group of spontaneous preterm birth <32 weeks (adjusted odds ratio (aOR) 0.24, CI 0.06-0.90, p = .035), spontaneous preterm birth <36 weeks (aOR 0.34, CI 0.04-0.81, p = .013) as well as in overall preterm birth <32 weeks (aOR 0.31, CI 0.1-0.86, p = .018), and overall preterm birth <36 weeks (aOR 0.37, CI 0.10-0.84, p = .030). When stratified by short cervix or cervical dilation in the cerclage versus no cerclage groups, there was a significant decrease in spontaneous preterm birth <32 weeks in the cerclage group with cervical dilation (11.1 versus 41.2%, p = .01) but not in the cerclage group with short cervix only, even for cervical length <1.5 cm. Pregnancy latency was 91 days in the cerclage group versus 57 days in the no cerclage group (p = .001), with a median gestational age at delivery of 35 versus 32 weeks (p = .002). There was no increase in chorioamnionitis in the cerclage group. Furthermore, there was a significant increase in birth weight (median 2278 versus 1665 g, p < .001) and decrease in perinatal death <30 days (1.6 versus 12.9%, p = .001). CONCLUSIONS: Cerclage in twin pregnancies significantly decreased the rate of spontaneous preterm birth <32 weeks compared to expectant management. However, when stratified by cerclage indication, this decrease in primary outcome only remained significant in the group with cervical dilation.

Vaginal progesterone, oral progesterone, 17-OHPC, cerclage, and pessary for preventing preterm birth in at-risk singleton pregnancies: an updated systematic review and network meta-analysis.

BACKGROUND: Recent progesterone trials call for an update of previous syntheses of interventions to prevent preterm birth. OBJECTIVES: To compare the relative effects of different types and routes of administration of progesterone, cerclage, and pessary at preventing preterm birth in at-risk women overall and in specific populations. SEARCH STRATEGY: We searched Medline, EMBASE, CINAHL, Cochrane CENTRAL, and Web of Science up to 1 January 2018. SELECTION CRITERIA: We included randomised trials of progesterone, cerclage or pessary for preventing preterm birth in at-risk singleton pregnancies. DATA COLLECTION AND ANALYSIS: We used a piloted data extraction form and performed Bayesian random-effects network meta-analyses with 95% credibility intervals (CrI), as well as pairwise meta-analyses, rating the quality of the evidence using GRADE. MAIN RESULTS: We included 40 trials (11 311 women). In at-risk women overall, vaginal progesterone reduced preterm birth <34 (OR 0.43, 95% CrI 0.20-0.81) and <37 weeks (OR 0.51, 95% CrI 0.34-0.74), and neonatal death (OR 0.41, 95% CrI 0.20-0.83). In women with a previous preterm birth, vaginal progesterone reduced preterm birth <34 (OR 0.29, 95% CI 0.12-0.68) and <37 weeks (OR 0.43, 95% CrI 0.23-0.74), and 17α-hydroxyprogesterone caproate reduced preterm birth <37 weeks (OR 0.53, 95% CrI 0.27-0.95) and neonatal death (OR 0.39, 95% CI 0.16-0.95). In women with a short cervix (≤25 mm), vaginal progesterone reduced preterm birth <34 weeks (OR 0.45, 95% CI 0.24-0.84). CONCLUSIONS: Vaginal progesterone was the only intervention with consistent effectiveness for preventing preterm birth in singleton at-risk pregnancies overall and in those with a previous preterm birth. TWEETABLE ABSTRACT: In updated NMA, vaginal progesterone consistently reduced PTB in overall at-risk pregnancies and in women with previous PTB.

Prognostic Significance of Neutrophil-to-Lymphocyte Ratio for Repeat Cerclage in Women with Prolapsed Membranes.

OBJECTIVE: Cerclage is a surgical option for preventing preterm birth (PTB). Repeat cerclage (RC) could prevent impending PTB in women with prolapsed membrane who already had primary cerclage. PTB is associated with a state of inflammation. It has been widely known that neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) reflect systemic inflammation. We aimed to investigate whether NLR and PLR could be used as reliable markers in predicting pregnancy outcome following RC. METHODS: The study group consisted of 26 patients, who underwent RC resulting from prolapsed membrane after primary cerclage. NLR and PLR at the time of primary cerclage and RC were calculated. ROC curve analysis and multivariate analysis were performed for determining predictive factors. The study group was divided into two groups according to NLR 4.7 at RC: High NLR group was defined as NLR > 4.7, and low NLR group was defined as NLR ≤ 4.7. We compared pregnancy outcomes, such as delivery at gestational age, and rate of delivery < 28 weeks between two groups. RESULTS: The average gestational age at primary cerclage was 15.7 weeks, and the mean gestational age at RC was 21.0 weeks. NLR at RC was significantly elevated when compared with NLR at primary cerclage (NLR, 4.0 vs. 8.9, p=0.001), but there was no significant difference in terms of PLR (p=0.07). ROC curve showed that there was a significant prediction power of NLR at RC for delivery < 28 weeks (AUC, 0.91; p<0.01). Using NLR cut-off of 4.7, 8 had NLR ≤ 4.7 (low NLR group), whereas 18 had NLR > 4.7 (high NLR group). High NLR group showed worse pregnancy outcome compared to low NLR group: there were significant differences in gestational age at delivery, and neonatal survival rate between two groups (31.5 weeks vs. 25.9 weeks, p=0.02; 100% (8/8) vs. 55.6% (10/18), p=0.03, respectively). Survival analysis demonstrated a lower incidence of delivery < 28 weeks of gestation in low NLR group compared with high NLR group (p<0.01, log-rank test). CONCLUSION: NLR might be used as a reliable factor for predicting pregnancy outcome following RC.

Cerclaje Cérvico-Ístmico transabdominal: experiencia de 30 años / Cervical-Isthmic transabdominal cerclage: experience of 30 years

RESUMEN Introducción: se define incompetencia cervical como la incapacidad del cuello uterino de retener una gestación en el segundo trimestre, en ausencia de contracciones uterinas. El cerclaje cervical es la intervención que ha demostrado utilidad en el tratamiento de la incompetencia cervical. La principal vía utilizada para cerclaje es la vaginal, sin embargo existe un grupo de pacientes en el que ésta no es posible y debe realizarse un abordaje transabdominal. Este trabajo muestra los resultados y experiencia de 30 años en la instalación de cerclaje por vía abdominal abierta. Se realiza una revisión de la literatura y se discuten sus indicaciones, resultados y complicaciones. Además se analiza la técnica quirúrgica, especialmente las variantes de ella y el momento de realizar la intervención. Métodos: se revisaron datos de 20 pacientes a las que se realizó cerclaje transabdominal, desde el año 1985 hasta la fecha. En todas las cirugías participó el autor principal de este artículo. Resultados: las intervenciones se realizaron entre las 8 y 18 semanas de gestación. Las causas principales fueron la imposibilidad de realizar un cerclaje por vía vaginal, debido a ausencia de cuello por conizaciones amplias o repetidas y amputaciones cervicales o fracaso de cerclajes por vía vaginal previos. Las 20 pacientes tuvieron 23 embarazos, 20 partos (16 mayores de 37 s. y 4 mayores de 34 s.) y 3 abortos. Se obtuvo un 87% de sobrevida fetal. Conclusiones: la utilización de esta técnica es útil en pacientes con imposibilidad de cerclaje por vía vaginal o en fracasos de cerclajes vaginales previos. La literatura revisada no muestra diferencias estadísticamente significativas entre los procedimientos realizados previos o durante la gestación, ni tampoco si se realiza mediante laparoscopía o cirugía abierta.

SUMMARY Introduction: cervical incompetence is defined as the inability of the cervix to retain a pregnancy in the second trimester, in the absence of uterine contractions. Cervical cerclage is the intervention that has proven its usefulness in the treatment of cervical incompetence. The main route used for cerclage is vaginal, however there is a group of patients in which this is not possible and a transabdominal approach must be performed. This work shows the results and experience of 30 years in the installation of cerclage by abdominal open route. A review of the literature is made and its indications, results and complications are discussed. In addition, the surgical technique is analyzed, especially it's variants and the moment of performing the intervention. Methods: data from 20 patients who underwent a transabdominal cerclage from 1985 to date were reviewed. In all the surgeries, the main author of this article participated. Results: the interventions were performed between 8 and 18 weeks of gestation. The main causes were the impossibility of performing a cerclage by vaginal route due to absence of the cervix by extensive or repeated conizations and cervical amputations or failure of previous cerclage by vaginal route. The 20 patients had 23 pregnancies, 20 deliveries (16 over 37 w. and 4 over 34 w.) and 3 abortions. 87% of fetal survival was obtained. Conclusions: the use of this technique is useful in patients with inability to cerclage vaginally or in failures of previous vaginal cerclages. The literature reviewed does not show statistically significant differences between the procedures performed before or during pregnancy, nor whether it is performed by laparoscopy or open surgery.

Emergency cerclage in twins during mid gestation may have favorable outcomes: Results of a retrospective cohort.

PURPOSE: Cervical cerclage treatment for cervical changes at mid trimester is a very controversial topic in twins. The aim of the study was to present our maternal and fetal outcomes of mid-trimester cervical cerclage in twin pregnancies. BASIC PROCEDURES: This study was performed using data extracted from the medical files of the twin pregnancies whom performed emergency cervical cerclage between January 2012 and March 2018 at Trakya University, Facuty of Medicine, Department of Perinatology. MAIN FINDINGS: Mean (min.-max.) gestational age at delivery was [27.3 (21-34) weeks]. The median time between cervical cerclage and delivery was 6.4 weeks, while the maximum prolongation of the pregnancy was 11 weeks. The median prolongation period of pregnancy was 4.1 weeks in patients with bulging membranes, but 10 weeks in patients with cervical effacement and cervical shortening. Eight infants died at the neonatal period. Two patients (20%) developed late abortions at 21 and 22 weeks of gestation, and 2 women (20%) delivered extremely premature neonates at the 24th weeks. Overall neonatal mortality rate was 40% (8/20 neonates). Twelve out of twenty were born alive (60%). PRINCIPAL CONCLUSIONS: Despite the lack of randomized controlled trials, it seems reasonable to offer emergency cervical cerclage to twin pregnancies with cervical shortening (<15mm). For the twin pregnancies with advanced cervical dilatation and protruding membranes, emergency cervical cerclage should be an option only for carefully selected patients after informing about the complications and low success rate.

Cerclage is associated with the increased risk of preterm birth in women who had cervical conization.

BACKGROUND: The aim of this study was to determine the effect of cerclage in women who underwent cervical conization. METHODS: Study data were collected from the Korea National Health Insurance Claims Database of the Health Insurance Review and Assessment Service for 2009-2013. Women who had a conization in 2009 and a subsequent first delivery between 2009 and 2013 in Korea were enrolled. RESULTS: Among the women who had conization in 2009, 1075 women had their first delivery between 2009 and 2013. A cerclage was placed in 161 of the women who were treated by conization. The rate of preterm birth was higher in the women who were treated with cerclage following a conization compared with those without cerclage (10.56 vs 4.27, p < 0.01, respectively). The multivariate regression analysis revealed that the women who were treated cerclage following a conization had an increased risk of preterm delivery compared with women without cerclage (odds ratio (OR), 2.6, 95% confidence interval (CI), 1.4-4.9). CONCLUSION: Our study showed that cerclage associated with an increased risk of preterm birth and preterm premature rupture of membranes in women who underwent conization. Further studies are required to clarify the mechanism by which cerclage affects the risk of preterm birth.

Laparoscopic cervico-isthmic cerclage: About 25 cases.

INTRODUCTION: The purpose of this study is to report on our experience of laparoscopic cervico-isthmic cerclage. MATERIAL AND METHOD: A monocentric retrospective study covering a 13-year period during which 25 cases of laparoscopic cerclage outside of pregnancy were performed, using the technique described by Dubuisson, at the University Hospital of Clermont-Ferrand. Individual patient data included pregnancy outcomes before and after cerclage and the characteristics of surgery. RESULTS: The mean age of the patients was 33.9 (±4.6) years. A total of 68 pregnancies were recorded before cerclage, including 31 late miscarriages, 11 premature deliveries, with only 9 pregnancies attaining full-term. The average time of surgery was 54 (±17.5) minutes with a hospital stay of 24h. 3 minor intraoperative complications (12%) with hemorrhage <300cc were noted and managed intraoperatively. In some cases laparoscopy allowed treatment of associated pathologies (septum resection, adhesiolysis, endometriosis, ovarian drilling, tube assessment). 21 pregnancies (68% of patients) were recorded post cerclage including 5 early miscarriages and 16 cesarean deliveries with an average time taken to conceive of 11.8 months. The overall neonatal survival rate after cerclage was 76.2% versus 16.20% before surgery (p<0.0001), with a 100% neonatal survival rate beyond the 1st trimester as compared to 21.6% before cerclage (p<0.0001).