Primary, secondary, and tertiary preventions of preterm birth with cervical cerclage

Management of an incompetent mid-second (mid-2nd) trimester absent ecto-cervix: a case series. Cervical amplification pre-cerclage insertion

BACKGROUND

Cervical cerclage is a treatment for an incompetent cervix, the latter being a contributor to spontaneous preterm birth. There is significant difficulty with a transvaginal cerclage insertion for the absent vaginal or ecto-cervix in the mid-2nd trimester period resulting in a higher risk of late miscarriages, extremely preterm labour with increased neonatal morbidity and mortality.

METHODS

A retrospective review of 5 consecutive cases managed by a surgical technique-modified high vaginal cerclage insertion at 18-20 weeks-and adjunct protocols which included vaginal progesterone use, serial infection screening and lifestyle advice, over a 12-month period ending in August 2021, is presented. Inclusion criteria included minimal or absent ecto-cervix, singleton pregnancies with an incompetent cervix attending for a vaginal cerclage whilst exclusion criteria were the usual contraindications to a cerclage insertion. Primary outcome was delivery after 34 weeks whilst seconday outcomes included maternal hemorrhage, bowel/bladder injury, chorioamnionitis and neonatal admission.

RESULTS

A increased gestational latency of 13 gestational weeks (range 12-18). Mean gestational age at delivery was 36 weeks +1 (253 days) with a range of 241-264 days. Delivery after 34 weeks gestational age was 100% with no maternal surgical complications and corresponding neonatal outcomes.

CONCLUSION

There is a potential therapeutic benefit of this technique and adjunct management, in managing an incompetent mid-2nd trimester absent ecto-cervix.

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.

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

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 ± 3.9 weeks vs 31.6 ± 6.7 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.

Diagnosis and treatment of cervical incompetence combined with intrauterine adhesions

Background

Cervical insufficiency (CI) with concomitant intrauterine adhesions (IUAs) is a common clinical phenomenon among CI patients. But there are neither published reports regarding the difference in diagnosis and treatment of such patients compared to those with CI only, nor any report about their prognosis. This study aimed to preliminary the alteration in diagnostic and curative aspects of these patients, so as to provide a certain reference for the clinical management of such conditions.

Methods

Ten patients with CI combined with moderate to severe IUAs were diagnosed, treated and followed up at the Third Xiangya Hospital of Central South University from September 2017 to August 2019, their medical records and the pregnancy outcomes were retrospectively analyzed.

Results

All 10 patients had a previous history of typical painless cervical dilatation during the second trimester. All patients were moderate to severer IUAs, and the mean AFS score of IUAs was 9.80±1.08 (range, 8 to 12). Preoperatively, in 6 patients, the No. 7 Hegar dilator was able to pass through the internal cervical os before surgery without resistance. In the other 4 patients, the Hegar dilator could not be inserted before surgery due to the adhesions of the cervical canal and the lower uterine segment; the diagnoses of these patients were further confirmed at 3 months after hysteroscopic adhesiolysis (HA) when the No. 7 Hegar dilator was able to pass through the internal cervical os without resistance. There were 9 patients underwent pre-pregnancy laparoscopic cervical cerclage after HA. The remaining 1 patient exceptionally underwent laparoscopic cervical cerclage prior to HA, as the cervix was too loose to retain and be treated with an intrauterine device (IUD) or distended Foley's catheter balloon; which essentially prevent postoperative adhesion reformation. The patients were followed-up for 3 months to 2 years. The pregnancy rate was 60%, and the live birth rate was 100%.

Conclusions

In patients with CI and concomitant cervical or lower uterine segment IUAs, it is necessary to separate the adhesion prior to evaluating the cervical competency with the No. 7 Hegar dilator, to confirm the diagnosis. However, when the cervix is too loose, laparoscopic cervical cerclage is exceptionally carried out first and then IUAs is treated. Pre-pregnancy laparoscopic cervical cerclage has a good prognosis in patients with CI complicated by moderate to severe IUAs.

Mothering in the NICU: A qualitative exploration of maternal engagement

Research suggests maternal engagement in the neonatal intensive care unit (NICU) may positively impact maternal and infant health outcomes. However, the U.S. has lower rates of maternal engagement in the NICU compared to other developed countries. This qualitative study reflects a transdisciplinary research partnership between social work, nursing, and neonatology. Qualitative inquiry explores maternal experiences in the NICU from the perspectives of mothers of preterm infants hospitalized in 2 U.S. NICUs. Results support an ecological systems framework to understanding barriers and facilitators to maternal engagement in the NICU and the utilization of a trauma-informed health care approach in NICU settings.