Effectiveness and safety of late midtrimester cervical cerclage

Impact of a previous late miscarriage on subsequent pregnancy outcomes: A retrospective cohort study over 10 years

OBJECTIVE

To explore the prognostic impact of a previous late miscarriage (LM) on the subsequent pregnancy outcomes of women with infertility.

METHOD

This retrospective cohort study included couples who had experienced LM following their first embryo transfer during an in vitro fertilization (IVF) cycle from January 2008 to December 2020. Subgroup analysis and binary logistic regression were performed to evaluate the associations between LM due to different causes and subsequent pregnancy outcomes.

RESULTS

A total of 1072 women who had experienced LM were included in this study, comprising 458, 146, 412, and 56 women with LM due to unexplained factors (unLM), fetal factors (feLM), cervical factors (ceLM; i.e. cervical incompetence), and trauma factors (trLM), respectively. Compared with the general IVF (gIVF) population, the early miscarriage rate was significantly higher in the unLM group (8.28% vs. 13.47%, adjusted odds ratio [OR] 1.60, 95% confidence interval [95% CI] 1.12-2.28; P = 0.01). Furthermore, women in the unLM and ceLM groups had a dramatically increased risk of recurrent LM (unLM: 4.24% vs. 9.43%, aOR 1.91, 95% CI 1.24-2.94; P = 0.003; ceLM: 4.24% vs.15.53%, aOR 2.68, 95% CI 1.82-3.95; P < 0.001) and consequently a reduced frequency of live birth (unLM: 49.96% vs. 43.01%, aOR 0.75, 95% CI 0.61-0.91; P = 0.004; ceLM: 49.96% vs. 38.59%, aOR 0.61, 95% CI 0.49-0.77; P < 0.001) compared with the gIVF population.

CONCLUSION

A previous LM due to an unexplained factor or cervical incompetence was significantly associated with a higher risk of miscarriage and a lower live birth rate after subsequent embryo transfer.

The impact of cerclage placement on gestational length in women with premature cervical shortening

OBJECTIVES

Cervical insufficiency (CI) is a condition consistent with painless cervical dilatation that can lead to preterm delivery. Cervical cerclage is a procedure in which cervical suture is performed for preventing preterm labor in several indications. Late emergency cerclage is technically more challenging compared to elective cerclage, performed earlier during pregnancy, prior to cervical changes. Pregnancy outcomes with emergency cerclage were found to be improved in previous reports, but there is still inconclusive data. To assess the effectiveness and safety of emergency cerclage vs. conservative management with progesterone and/or bed resting, in preventing preterm birth and improving neonatal outcomes in women with clinically evident cervical insufficiency.

METHODS

This is a retrospective cohort study conducted on all women diagnosed with cervical insufficiency between the 16th and 24th gestational week who met the inclusion criteria, from January 2012 to December 2018. Obstetric and neonatal outcomes: time from diagnosis to delivery, duration of pregnancy, birth weight and Apgar score, were compared between women who underwent cerclage and those who treated conservatively.

RESULTS

Twenty eight women underwent emergency cerclage (cerclage group) and 194 managed with a conservative therapy, progesterone and/or bed rest (control group). Time from diagnosis to delivery 13 weeks vs. 8 weeks and birth weight 2,418 g vs. 1914 g were significantly higher in the first cohort. Average pregnancy duration was three weeks longer in the cerclage group, but that was not significant. No complications occurred in the cerclage group and no difference in mode of delivery were found.

CONCLUSIONS

Emergency cerclage is an effective and safe procedure in preventing preterm birth and prolongation of pregnancy, in women with cervical insufficiency in the late second trimester.

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.

Association of Cerclage with Composite Adverse Outcomes among Women Delivered at 36 Weeks or Later

OBJECTIVE

This study aimed to compare the maternal and neonatal adverse outcomes among singletons delivered at 36 weeks or later with cerclage during index pregnancy versus those without cerclage.

STUDY DESIGN

This retrospective cohort study utilized the U.S. vital statistics datasets from 2011 to 2013. Inclusion criteria were women with nonanomalous singletons, with and without cerclage placement, without diabetes or hypertensive disorders, and delivered at 36 to 41 weeks. The coprimary outcomes were composite maternal and neonatal adverse outcomes. Composite maternal adverse outcome included admission to intensive care unit, maternal transfusion, ruptured uterus, unplanned hysterectomy, or unplanned operating room procedure. Composite neonatal adverse outcome included Apgar score less than 5 at 5 minutes, assisted ventilation for more than 6 hours, neonatal seizure, birth injury, or neonatal death. Secondary outcomes were chorioamnionitis and cesarean delivery. Multivariable Poisson's regression models with error variance were used while adjusting for confounders. Adjusted relative risk (aRR) with 95% confidence intervals (CIs) were calculated.

RESULTS

Of the 8,508,228 women who met inclusion criteria, 0.2% had a cerclage and reached 36 weeks. Composite maternal (aRR: 2.04; 95% CI: 1.76-2.36) and neonatal (aRR: 1.28; 95% CI: 1.11-1.47) adverse outcomes were significantly higher among those with cerclage than those without cerclage. Chorioamnionitis (aRR: 1.47; 95% CI: 1.30-1.67) and cesarean delivery (aRR: 1.10; 95% CI: 1.08-1.12) were also significantly higher in women with cerclage than those without cerclage.

CONCLUSION

There is an association between increased composite maternal and neonatal adverse outcomes among women with cerclage who delivered at 36 to 41 weeks as compared with those without cerclage.

KEY POINTS

· Cerclage is associated with increased composite maternal adverse outcome in women at 36-41 weeks.. · Cerclage is associated with increased composite neonatal adverse outcome in women at 36-41 weeks.. · Increased chorioamnionitis and cesarean delivery rates are associated with cerclage in women at 36-41 weeks..