Combined vaginal progesterone and cervical cerclage in the prevention of preterm birth: a systematic review and meta-analysis

Adjunctive pessary therapy after emergency cervical cerclage in patients with protruding fetal membranes - a multicenter cohort study

OBJECTIVE

We aimed to compare the perinatal outcomes in women with cervical dilatation with fetal membranes visible before 26 weeks of gestation managed with an adjunctive pessary after emergency cervical cerclage or emergency cerclage alone.

METHODS

We performed a retrospective analysis of women with singleton gestation, diagnosed with cervical dilatation accompanied by fetal membranes visible at or beyond the external os, who underwent emergency cervical cerclage. The participants were recruited at 3 tertiary perinatal centers. Adjunctive pessary treatment depended on the choice of the attending physician. The primary outcomes included preterm delivery before 34 weeks of gestation and a live infant discharged home.

RESULTS

Emergency cerclage alone was performed in 35 women, and 39 underwent emergency cerclage and adjunctive pessary therapy. Women in the adjunctive pessary group delivered significantly later (median 36, IQR 32-38 weeks vs 34, IQR 24-37 weeks of gestation; p = 0.03). No statistically significant differences were observed in rates of deliveries <34 weeks and rates of live infants discharged home. A significant prolongation of pregnancy (median 107, interquartile range 52-134 vs median 69, interquartile range 27-99 days; p = 0.02) and reduction in the rates of preterm deliveries <28 (7.7% vs 28.6%; p = 0.03) and <30 weeks of gestation (12.8% vs 34.3%; p = 0.05) were observed in adjunctive pessary group, despite more advanced cervical insufficiency. Adjunctive pessary significantly reduced the risk of delivery <30 weeks (aOR 0.2, 95% CI 0.06-0.7) and <34 weeks of gestation (aOR 0.2, 95% CI 0.05-0.81).

CONCLUSION

The use of a pessary as an adjunctive therapy after emergency cervical cerclage may be effective in lowering the risk of delivery <30 weeks and may offer a new option for managing women with advanced cervical insufficiency.

Concerns about data integrity across 263 papers by one author

OBJECTIVE

Comprehensive investigation of published work by authors suspected of academic misconduct can reveal further concerns. We aimed to test for data integrity concerns in papers published by an author with eight retracted articles.

STUDY DESIGN

We investigated the integrity of all papers reporting on prospective clinical studies by this author. We assessed the feasibility of study methods, baseline characteristics, and outcomes. We plotted the author's clinical research activity over time. We conducted pairwise comparisons of text, tables, and figures to identify duplicate publications, and checked for consistency between conference abstracts, interim analyses, trial registrations, and final papers. Where indicated, we recalculated p-values from the reported summary statistics.

RESULTS

We identified 263 papers claiming to have enrolled 74,667 participants between January 2009 and July 2022, 190 (72 %) of which reported on studies that recruited from the Assiut Women's Health Hospital in Assiut, Egypt. The number of active studies per month was greatest between 2016 and 2019, with 88 ongoing studies in May 2017. We found evidence of data integrity concerns in 130 (49 %) papers, 43 (33 %) of which contained concerns sufficient to suggest that they could not be based on data reliably collected from human participants.

CONCLUSION

Our investigation finds evidence of widespread integrity concerns in the collected work of one author. We recommend that the involved journals collaborate in a formal investigation.

Cerclage in singleton pregnancies with no prior spontaneous preterm birth and short cervix: a randomized controlled trial

BACKGROUND

Preterm birth remains a leading cause of neonatal morbidity and mortality. Cerclage for short cervical length ≤25 mm in patients with singleton pregnancies with a history of spontaneous preterm birth is associated with decreased neonatal morbidity/mortality. Both vaginal progesterone and cerclage individually have level 1 evidence supporting benefit in the prevention of preterm birth in pregnancies complicated by short cervical length. However, there is a paucity of level 1 evidence regarding the potential benefit of cerclage with progesterone relative to progesterone alone for short cervical length ≤25 mm in patients with singleton pregnancies without a history of spontaneous preterm birth.

OBJECTIVE

This study aimed to conduct a pragmatic randomized controlled trial to evaluate the additional benefit of cerclage with vaginal progesterone relative to vaginal progesterone alone in patients with singleton pregnancies without prior spontaneous preterm birth and with a current midtrimester transvaginal ultrasound cervical length ≤25 mm.

STUDY DESIGN

This was a multicenter international randomized controlled trial conducted from September 2017 to September 2023, involving 4 sites in the United States and Italy. Patients with singleton pregnancies without prior spontaneous preterm birth received transvaginal ultrasound cervical length (universal) screening during the midtrimester anatomy ultrasound examination as part of routine care. Inclusion criteria included transvaginal ultrasound cervical length ≤25 mm at 18 0/7 to 23 6/7 weeks. Exclusion criteria included current or planned cerclage, cervical dilation, symptoms of labor, infection, bleeding, and rupture of membranes at screening. Participants were randomized in a 1:1 ratio to cerclage with vaginal progesterone (200-mg vaginal progesterone daily) or vaginal progesterone alone. Randomization was stratified by study site and transvaginal ultrasound cervical length ≤15 mm. The primary outcome was preterm birth <35 weeks, assessed using intention-to-treat analysis. Secondary outcomes included preterm birth <37, 32, 28, and 24 weeks, gestational age at delivery, latency to delivery, and neonatal outcomes. Categorical variables were compared using the Pearson chi-square test and relative risk estimates with 95% confidence intervals. Continuous variables were compared using the Mann-Whitney U test. Latency to delivery and gestational age at delivery were also compared using Kaplan-Meier survival curves. Planned enrollment was set at N=206 on the basis of an estimated 0.54 relative risk with cerclage and a 34% incidence of preterm birth with standard care. The trial was registered on ClinicalTrials.gov (NCT03251729) on June 22, 2017.

RESULTS

Enrollment ran from September 22, 2017 to October 31, 2023, and was halted early because of lagging enrollment. A total of 93 participants were randomized; 3 were excluded because of withdrawal (n=1) and loss to follow-up (n=2). Of the 90 participants included in the intention-to-treat analysis, 43 were assigned to cerclage and progesterone and 47 to progesterone alone. Overall, 40 participants (40.4%) had a transvaginal ultrasound cervical length ≤15 mm. There was no significant difference in the primary outcome of preterm birth <35 weeks between those randomized to cerclage with progesterone vs progesterone alone (16.3% vs 23.4%; relative risk, 0.70 [0.30-1.63]). Those randomized to cerclage with progesterone had significantly increased latency from randomization to delivery (median difference, 13 [5-20] days; P=.01) and a significantly later gestational age at delivery (median difference, 1.0 [0.2-1.7] weeks; P=.035). A Kaplan-Meier survival curve also demonstrated increased latency to delivery and gestational age at delivery for cerclage with progesterone compared with progesterone alone (Mantel-Cox log-rank P<.001 and P=.003, respectively). These findings persisted within both subgroups of cervical length ≤15 mm and 16 to 25 mm.

CONCLUSION

In singleton gestations without a prior spontaneous preterm birth and a transvaginal ultrasound cervical length ≤25 mm before 24 weeks, cerclage with progesterone was not found to significantly reduce the preterm birth rate compared with progesterone alone. However, cerclage and progesterone did result in a significantly longer latency from randomization to delivery and a significantly later gestational age at delivery, compared to progesterone alone. These results suggest the potential benefit of cerclage and progesterone relative to progesterone alone in patients with singleton pregnancies without a prior spontaneous preterm birth and a short cervical length ≤25 mm before 24 weeks. This trial was halted early, and these findings should be confirmed in a larger trial or meta-analysis. El resumen está disponible en Español al final del artículo.

Efficacy of transabdominal cerclage by open laparotomy relative to existing risk factors

INTRODUCTION

To prevent extreme preterm birth, women with cervical insufficiency are eligible for transabdominal cerclage in case of prior failure or technical impossibility for transvaginal cerclage. This study aimed to identify patient characteristics that affect the success rate of transabdominal cerclage to prevent extreme preterm birth in women with cervical insufficiency.

MATERIAL AND METHODS

Single-center retrospective cohort study in 87 women who underwent transabdominal cerclage by open laparotomy during first and early second trimester of pregnancy over a 20-year period. Participants were divided into subgroups according to indication for the intervention. Linear regression and meta-regression-analyses were performed to assess the effect of mean cervical length (before and after transabdominal cerclage placement) and gestational age of previous preterm birth, on gestational age at delivery. Kaplan-Meier analysis was performed to evaluate treatment effects on gestational age at delivery.

RESULTS

Of 87 women, 62 women underwent a history-indicated and 25 an ultrasound-indicated transabdominal cerclage. Fetal survival was 92%: 91% in the history-indicated and 96% in the ultrasound-indicated group. Median gestational age at delivery was 37.3 weeks, with a median pregnancy prolongation of 163.0 days and with 92% of deliveries ≥34 weeks. Between groups, irrespective of singleton and twin pregnancies, outcomes were comparable. Gestational age at delivery was neither affected by cervical length before transabdominal cerclage, distance between transabdominal cerclage and external os, gestational age of previous preterm birth nor additional progesterone treatment.

CONCLUSIONS

The efficacy of transvaginal cerclage placement via open laparotomy during high-risk pregnancy is favorable and relates to fetal survival of 92%. Regardless of indication, pregnancy outcomes after transabdominal cerclage are similar, and independent of gestational age at previous preterm birth, cervical length before transabdominal cerclage placement, distance between transabdominal cerclage and external os, and additional progesterone administration.

Transvaginal Ultrasound Findings Predicting Prolonged Pregnancy in Cases of Prolapsed Fetal Membrane: A Retrospective Study

Background/Objectives: Fetal membrane prolapse can occur due to advanced cervical insufficiency. We investigated the yet unclear predictors of prolonged pregnancy in women with prolapsed fetal membranes. Methods: This retrospective observational study included 100 pregnant women with prolapsed fetal membranes between November 2017 and March 2023. We examined the correlation between transvaginal ultrasound findings at the time of admission and the duration of prolonged pregnancy, which was defined as the period from admission to delivery. We defined five transvaginal ultrasound indices: (1) width of the external os, (2) maximum width of the prolapsed fetal membrane, (3) distance from the external os to the presenting part of the fetus, (4) thickness of the posterior uterine lip, and (5) morphology of the prolapsed fetal membrane. Results: Women who underwent cervical cerclage comprised the cerclage group (n = 17), while those who underwent conservative management comprised the non-cerclage group (n = 83). The pregnancy period was significantly longer in the cerclage group than in the non-cerclage group (81.4 days vs. 9.1 days, p < 0.001). Multiple regression analysis revealed that type A morphology was a significant factor for prolonged pregnancy in the non-cerclage group (p < 0.05), which was significantly associated with a prolonged pregnancy period of over 7 days (p = 0.037). Conclusions: In cases of prolapsed fetal membranes, cerclage is challenging because of the high risk of iatrogenic preterm rupture of the membrane; however, if successful, a significant prolongation of the pregnancy period can be obtained. Morphological evaluation using ultrasonography is simple and easy to understand and correlates well with pregnancy outcomes, making it very useful.

Rescue Cervical Cerclage for Previable Birth Prevention: A Comprehensive Review of Indications, Techniques, and Outcomes

Cervical cerclage is a surgical intervention aimed at preventing previable birth by providing mechanical support to the cervix through the placement of a suture. This procedure is primarily indicated for cases of cervical incompetence, where the cervix is prone to premature dilation and can lead to early miscarriage or preterm birth. This review seeks to comprehensively analyze rescue cervical cerclage (RCC), focusing on its indications, techniques, and outcomes. The goal is to offer an in-depth understanding of its effectiveness in preventing previable birth and to guide clinical decision-making in managing pregnancies at risk of premature delivery. A thorough literature review examined recent studies and clinical data on RCC. Key aspects evaluated include the criteria for intervention, various surgical techniques employed, and the associated maternal and fetal outcomes. Comparative analysis was also performed with other preventive measures, such as progesterone therapy and bed rest. RCC has demonstrated efficacy in reducing the incidence of previable births, particularly when performed in cases of identified cervical incompetence or shortening. The review highlights variations in the technique, such as McDonald and Shirodkar cerclage, and discusses their relative success rates and potential complications. The procedure is associated with improved pregnancy outcomes and reduced risk of previable birth, though it carries some risks, including infection and cervical laceration. RCC remains a valuable intervention for preventing previable births in selected patients. This review underscores its importance in managing pregnancies at risk due to cervical incompetence and provides a detailed evaluation of its indications, techniques, and outcomes. Future research should optimize criteria for cerclage placement and explore novel strategies to enhance its effectiveness and safety.

Patient perspectives and preferences on cerclage and preterm birth: a focus group study

AIM

This qualitative focus group study aims to asses cerclage-related symptoms, the impact of a cerclage on daily functioning and patient perspectives of their healthcare experience. This study extends beyond the current focus on surgical and obstetric outcomes of a cerclage, thereby contributing to a more comprehensive understanding of the challenges faced by individuals in the context of extreme preterm birth and fetal loss and the impact of a cerclage on multiple facets in life.

METHODS

Participants were recruited from the Amsterdam University Medical Center, Amsterdam, the Netherlands or via the website of a Dutch patient organization for (extreme) preterm birth. Eligible participants were ≥ 18 years old with a previous vaginal and/or abdominal cerclage with a subsequent delivery at ≥ 34 weeks of gestation with neonatal survival. Two focus group discussions (FGD) were performed. A predefined format was used, which was identical for both the vaginal and abdominal cerclage group. The International Classification of Functioning, Disability and Health (ICF-DH) was used to provide structure. Outcomes were a broad range of participants reported perspectives on physical, emotional, and social-related quality of life.

RESULTS

In the Vaginal Cerclage Group (VCG) and Abdominal Cerclage Group (ACG), respectively, 11 and 8 participants were included. Fear for a subsequent pregnancy loss was the most limiting factor to perform daily activities during pregnancy in all participants with a cerclage. Fear to conceive again because of prior second-trimester fetal loss was experienced by 27% in the VCG and 13% in the ACG. The majority of participants experienced a reduction in anxiety after placement of their cerclage (VCG = 64%, ACG = 75%). Decreased mobility/bedrest (VCG = 100%, ACG = 75%) and blood loss (VCG = 55%, ACG = 13%) were frequently mentioned complaints during pregnancy with cerclage. Other aspects mentioned in both groups were social isolation, the lack of societal participation, and the perceived need to quit work and sports. All participants in the abdominal cerclage group reported a lack of comprehensible and unambiguous information about obstetric management and expectations during pregnancy in secondary care hospitals. Clear communication between secondary and tertiary care hospitals about obstetric management following an abdominal cerclage, for example, about the need for cervical length measurements by ultrasound, the need for bedrest or advice concerning sexual activity was missing (63%). Psychologic support was desired in half of all participants, but was not offered to them.

CONCLUSIONS

The fear of a subsequent pregnancy loss was reported as the most limiting factor in daily life by all participants. Cerclage placement resulted in the reduction of anxiety. Participants mentioned a significant impact of bedrest and activity restriction during pregnancy with cerclage on social participation and daily activities. Unfortunately, no high level evidence is available on this matter. Patients might even benefit from appropriate levels of physical activity throughout their pregnancy to promote their overall well-being. More evidence is needed to determine the optimal level of physical activity. There is a need for clear and unambiguous patient information about obstetric management.

Assessment of current biomarkers and interventions to identify and treat women at risk of preterm birth

Preterm birth remains an important global problem, and an important contributor to under-5 mortality. Reducing spontaneous preterm birth rates at the global level will require the early identification of patients at risk of preterm delivery in order to allow the initiation of appropriate prophylactic management strategies. Ideally these strategies target the underlying pathophysiologic causes of preterm labor. Prevention, however, becomes problematic as the causes of preterm birth are multifactorial and vary by gestational age, ethnicity, and social context. Unfortunately, current screening and diagnostic tests are non-specific, with only moderate clinical risk prediction, relying on the detection of downstream markers of the common end-stage pathway rather than identifying upstream pathway-specific pathophysiology that would help the provider initiate targeted interventions. As a result, the available management options (including cervical cerclage and vaginal progesterone) are used empirically with, at best, ambiguous results in clinical trials. Furthermore, the available screening tests have only modest clinical risk prediction, and fail to identify most patients who will have a preterm birth. Clearly defining preterm birth phenotypes and the biologic pathways leading to preterm birth is key to providing targeted, biomolecular pathway-specific interventions, ideally initiated in early pregnancy Pathway specific biomarker discovery, together with management strategies based on early, mid-, and-late trimester specific markers is integral to this process, which must be addressed in a systematic way through rigorously planned biomarker trials.

The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth

BACKGROUND

An increased risk for preterm birth has been observed among individuals with a previous second stage cesarean delivery when compared with those with a previous vaginal delivery. One mechanism that may contribute to the increased risk for preterm birth following a second stage cesarean delivery is the increased risk for cervical injury because of extension of the uterine incision (hysterotomy) into the cervix. The contribution of hysterotomy extension to the rate of preterm birth in a subsequent pregnancy has not been investigated and may shed light on the mechanism underlying the observed relationship between the mode of delivery and subsequent preterm birth.

OBJECTIVE

We aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery.

STUDY DESIGN

We performed a retrospective cohort study using electronic perinatal data collected from 2 university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks' gestation; secondary outcomes included subsequent preterm birth at <34, <32, and <28 weeks' gestation. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios and 95% confidence intervals. Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labor, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity.

RESULTS

A total 4797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labor, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses that controlled for several confounders showed that a history of hysterotomy extension was not associated with a higher risk for preterm birth <37 weeks' gestation (adjusted rate ratio, 1.55; 95% confidence interval, 0.98-2.47), but it was associated with preterm birth <34 weeks' gestation (adjusted rate ratio, 2.49; 95% confidence interval, 1.06-5.42).

CONCLUSION

Patients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks' gestation when compared with patients who did not have this injury. This association was not observed for preterm birth <37 weeks' gestation. Future research should aim to replicate our analyses with incorporation of additional data to minimize the potential for residual confounding.

Persistence Pays Off: Live Birth after Uterus Transplant, Overcoming Recurrent Pregnancy Loss with Cerclage Placement

Recipients of uterus transplantation have unique factors that may increase their risk of cervical insufficiency. This report describes a uterus transplant recipient with cervical insufficiency resulting in two second-trimester miscarriages. After McDonald cerclages (one that failed), she underwent an interval transabdominal cerclage and delivered a healthy term child in her third pregnancy. The longitudinal information of this case provides observations from which we can propose testable hypotheses that address venous outflow and inflammation. This case also suggests that there could be a role for prophylactic cerclage placement at the time of transplantation.