Should it really be called a heroic cerclage? The obstetrical results of emergency late second-trimester cerclage compared with early history-indicated elective cerclage: a retrospective trial

Comparison of Perinatal Outcomes Following Elective and Emergency Cerclage Insertion: A Ten-Year Retrospective Cohort Study

Background: Cervical insufficiency (CI) is a painless cervix dilation in the second or early third trimester due to a structural or functional defect. However, CI is often diagnosed retrospectively. A cervix with CI cannot retain the fetus. This condition significantly increases the morbidity associated with extreme prematurity. Women diagnosed with cervical incompetence and dilatation in the mid-second trimester are offered interventions to prolong the duration of pregnancy, with the mainstay of therapy being emergency cerclage. A prophylactic cerclage may be offered to women with a history of extremely preterm birth due to isthmic cervical incompetence. Aim: The aim of this study was to evaluate the perinatal outcomes of elective and emergency cerclages. Materials and Methods: A 10-year retrospective analysis, from 1 January 2015 to 29 February 2024 of pregnancies with indications for cervical cerclage, was conducted. Obstetric and neonatal outcomes were assessed. Results: Prophylactic cervical cerclage was performed in 43 (57%) and emergency cerclage in 32 (43%) of all analyzed cases. The mean prolongation of gestation (measured as the period between cerclage insertion and delivery) was higher in the elective cerclage group compared with the emergency cerclage group (18.6 ± 5.4 vs. 12.2 ± 6.4 weeks; p < 0.0001). The mean gestational week at cerclage removal was also higher in the elective group (36.1 ± 2.2 vs. 31.4 ± 5.6 weeks; p < 0.001). Deliveries in the extreme prematurity period (before 28 completed weeks of gestation) were five times more often in the rescue cerclage group. A significantly higher mean birthweight was reported in the elective cerclage group, at 2920.4 ± 946.8 g vs. 2078.8 ± 1147.8 g (p = 0.0004). Emergency cerclage insertion was associated with a higher need for NICU hospitalization (28% vs. 5%, p = 0.003), continuous positive airway pressure (38% vs. 2%, p < 0.0001), and intubation (22% vs. 0%, p = 0.003). Conclusions: While elective cerclage is associated with more favorable perinatal and neonatal outcomes, this likely reflects earlier intervention in lower-risk pregnancies rather than inherent superiority of the approach. Emergency cerclage, performed under urgent and often suboptimal conditions, remains a critical and effective intervention capable of prolonging gestation and improving neonatal survival in high-risk cases.

Development and validation of a cost-effective DIY simulation model for McDonald cerclage training

PURPOSE

The prevention of preterm birth is a challenging task for obstetricians. Cervical cerclage, used as both a primary and secondary prevention method for spontaneous preterm birth, is a crucial surgical intervention. It is essential that obstetricians can learn this procedure in a simulated environment before performing the stitches on high-risk patients. This study aimed to develop a simulator based on 3D printing and evaluate its validity for clinical training.

METHODS

The objectives of this study were (1) to design and construct a cost-effective simulator for McDonald cerclage with two different cervix models-a closed cervix and a cervix with bulging membranes-using common material from a DIY store and 3D printing technology and (2) to validate its effectiveness through feedback from learners and experts in cervical cerclage. The self-made simulator was evaluated by obstetricians using a questionnaire with Likert scale.

RESULTS

Obstetricians and gynecologists assessed the simulator and found it useful for learning and practicing cervical cerclage. The simulator was deemed valuable for skill training.

CONCLUSION

Cervical cerclage is a complex procedure that should be mastered through simulation rather than initial practice on real patients. Our simulator is a cost-effective model suitable for various clinical settings. It has been validated by obstetricians for both preventive and therapeutic cerclage, demonstrating its efficacy for training in cerclage techniques. Future research should focus on less skilled obstetricians and gynecologists and investigate how repeated use of the simulator can enhance their performance in cerclage stitching.

Mechanical analysis of cerclage as a treatment for cervical insufficiency

BACKGROUND

The primary treatment for cervical insufficiency is cervical cerclage (mechanical support) with vaginal progesterone (biochemical support). Cerclage is a surgical procedure that mechanically increases the tensile capacity of the cervix. Therefore, it is necessary to analyse the effects of cerclage from a mechanical point of view.

PURPOSE

To analyse cerclage techniques based on physical principles and mechanical forces.

METHODS

We assumed that the cervix is a thin-walled pressure vessel and applied a uniform vertical distribution model, a linear vertical model, and a non-linear vertical distribution model.

RESULTS

According to our model analysis, the higher the position of the thread, the thicker the thread used, and the greater the number of threads, the more effective the confining force on the suture, when performing a cerclage.

CONCLUSION

It is necessary to provide an appropriate cerclage for each patient based on these mechanical characteristics, in addition to considering the risks and benefits and biochemical interactions of the cerclage.

Variation between countries for routine transvaginal cervical length measurement and interventions to prevent preterm birth

OBJECTIVE

To assess the variation between countries for routine transvaginal ultrasound assessment of the cervical length and interventions offered to prevent preterm birth (PTB).

STUDY DESIGN

An anonymous digital questionnaire was sent out between August and October 2023 to delegates of the European Spontaneous Preterm Birth Congress. Outcomes assessed included method, indications (i.e. singleton pregnancy in women with or without a history of PTB, or a multiple pregnancy), timing and frequency of routine cervical length measurement, interventions offered to pregnant women with a short cervix or a history of PTB, and advice on physical- and sexual activity.

RESULTS

In total, 247 visitors of the European Spontaneous Preterm Birth Congress were approached for this study and 103 (42 %) participants completed the questionnaire representing 15 countries. Most participants worked in a Public/University hospital (n = 54, 53 %) and worked as a specialist (registrar or consultant; n = 84, 82 %). In most countries, the cervix was measured via a straight-line method without the cervical isthmus, but variety existed also within countries. Routine cervical length measurement in women with no prior PTB or a multiple pregnancy is rarely performed in the first trimester. For women with a history of PTB, 39 (38 %) respondents from six countries reported to start serial cervical measurement in the first trimester and 99 (96 %) from 14 countries in the second trimester. Follow-up for women at risk for PTB mainly occurs fortnightly (n = 40, 39 %) or monthly (n = 14, 14 %). However, follow-up is often individualized according to patient's history and/or cervical length. In women with a history of PTB or a short cervix progesterone is administered vaginally (n = 99, 96 %), however dosage vary between 100 mg and 400 mg daily. The timing and gestational age at which a (primary/secondary/tertiary) vaginal cerclage is offered widely differ between countries (e.g. up to 24-28 weeks of gestation for a secondary cerclage). Advice on restrictions regarding sexual activity in pregnancy is frequently prescribed for women with a short cervix (n = 38, 37 %).

CONCLUSION

Substantial variation exist between and within countries regarding the indications and timing of cervical length measurement and interventions offered. There is a need for a more universal approach to manage patients at risk for PTB based on the existing evidence.