1
|
Norooznezhad AH, Zargarzadeh N, Javinani A, Nabavian SM, Qaderi S, Mostafaei S, Berghella V, Oyelese Y, Shamshirsaz AA. The effect of cervical pessary on increasing gestational age at delivery in twin pregnancies with asymptomatic short cervix: a systematic review and meta-analysis of randomized controlled trials. AJOG Glob Rep 2024; 4:100347. [PMID: 38655568 PMCID: PMC11036094 DOI: 10.1016/j.xagr.2024.100347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Objective The incidence of preterm delivery is much higher in twin pregnancies than in singletons and even higher if a short cervical length is detected in the second trimester. Studies are contradictory regarding the efficacy of a cervical pessary to decrease preterm birth in twin pregnancies and short cervical length. To conduct a systematic review and meta-analysis investigating the efficacy of cervical pessary in prolonging gestation, preventing preterm birth, and reducing adverse neonatal outcomes in twin pregnancies with an asymptomatic short cervix. Data sources PubMed, Scopus, Web of Science, and ClinicalTrials.org were searched for randomized controlled trials from inception to June 2023. Study eligibility criteria In this study, randomized controlled trials comparing the cervical pessary to expectant management in the pregnant population with twin gestations and asymptomatic short cervix were included. Methods The Cochrane risk-of-bias-2 tool for randomized controlled trials was used for the evaluation of the risk of bias in included studies. A meta-analysis was performed by calculating risk ratio and mean difference with their 95% confidence interval using the random effects model or fixed effect model on the basis of heterogeneity and accounting for potential covariates among the included randomized controlled trials. Results A total of 6 randomized controlled trials were included in the analysis. Cervical pessary did not significantly increase the gestational age at delivery in twin pregnancies with asymptomatic patients (mean difference, 0.36 weeks [-0.27 to 0.99]; P=.270; I2=72.0%). Moreover, the cervical pessary use did not result in a reduction of spontaneous or all-preterm birth before 37 weeks of gestation (risk ratio, 0.88 [0.77-1.00]; P=.061; I2=0.0%). There was no statistically significant difference in the composite neonatal adverse outcomes (risk ratio, 1.001 [0.86-1.16]; P=.981; I2=20.9%), including early respiratory morbidity, intraventricular hemorrhage, necrotizing enterocolitis, and confirmed sepsis. Conclusion The use of cervical pessary in twin pregnancies with asymptomatic short cervix does not seem to be effective in increasing the gestational age at delivery, preventing preterm birth, or reducing adverse neonatal outcomes. This indicates that alternative interventions should be sought for the management of this patient population.
Collapse
Affiliation(s)
- Amir Hossein Norooznezhad
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran (Dr. Norooznezhad and Dr. Nabavian)
| | - Nikan Zargarzadeh
- Maternal Fetal Care Center, Division of Maternal Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Zargarzadeh, Dr. Javinani, Dr. Qaderi, Dr. Oyelese, and Dr Shamshirsaz)
| | - Ali Javinani
- Maternal Fetal Care Center, Division of Maternal Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Zargarzadeh, Dr. Javinani, Dr. Qaderi, Dr. Oyelese, and Dr Shamshirsaz)
| | - Seyedeh Maedeh Nabavian
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran (Dr. Norooznezhad and Dr. Nabavian)
| | - Shohra Qaderi
- Maternal Fetal Care Center, Division of Maternal Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Zargarzadeh, Dr. Javinani, Dr. Qaderi, Dr. Oyelese, and Dr Shamshirsaz)
| | - Shayan Mostafaei
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (Dr. Mostafaei)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (Dr. Berghella)
| | - Yinka Oyelese
- Maternal Fetal Care Center, Division of Maternal Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Zargarzadeh, Dr. Javinani, Dr. Qaderi, Dr. Oyelese, and Dr Shamshirsaz)
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Oyelese)
| | - Alireza A. Shamshirsaz
- Maternal Fetal Care Center, Division of Maternal Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Zargarzadeh, Dr. Javinani, Dr. Qaderi, Dr. Oyelese, and Dr Shamshirsaz)
| |
Collapse
|
2
|
Ferro J, Diago V, Diago DM, Pellicer N, Olmo I, Vázquez S, Lara C, Perales A, Serra V. The effectiveness of cervical cerclage in twin pregnancies with a mid-trimester short cervix: A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2024; 294:33-38. [PMID: 38184898 DOI: 10.1016/j.ejogrb.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE To analyze the effectiveness of cerclage in twin pregnancies with a short cervix. STUDY DESIGN Retrospective cohort study performed in two University Institutions in Valencia (Spain) with two different protocols for the management of asymptomatic dichorionic diamniotic twin pregnancies with mid-trimester cervical length ≤ 25 mm: treatment with indomethacin, antibiotics and cerclage (cerclage group) (N = 43) versus expectant management (control group) (N = 37). RESULTS The initial cervical length was similar in both groups but detection of a short cervix was performed earlier in the cerclage group (21.6 vs 24.1 weeks, p < 0.001). Women with cerclage had a greater pregnancy latency (12.5 vs. 7.7 weeks, p < 0.001); higher gestational age at delivery (34.1 vs. 31.8 weeks, p < 0.04); less spontaneous preterm birth (SPB) < 28 weeks (11.6 % vs 37.8 %, p < 0.009); higher birthweight (2145 vs 1733 g, p < 0.001); lower birthweight < 1500 g (12.5 % vs 40.0 %, p < 0.001); less admissions to the neonatal intensive care unit (NICU) (24.1 % vs 43.3 %, p < 0.03); shorter stay at NICU (25.6 vs 49.4 days, p < 0.02); lower respiratory distress requiring mechanical ventilation (14.9 % vs 36.5 %, p < 0.02); fewer patent ductus arteriosus (8.9 % vs 26.9 %, p < 0.008); and lower composite adverse neonatal outcome (26.6 % vs. 44.8 %, p < 0.03). Cerclage and gestational age at diagnosis were the only independent predictors of SPB < 32 and < 28 weeks by multivariate analysis. The cumulative data in the literature show promising beneficial effects of cerclage. CONCLUSION Our data suggest that cerclage in asymptomatic twin pregnancies with a short cervix may reduce the earliest SPB and may improve neonatal outcome.
Collapse
Affiliation(s)
- Jaime Ferro
- Unidad de Medicina Materno-Fetal, Instituto Universitario IVI Valencia, IVIRMA Global, Valencia, Spain
| | - Vicente Diago
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Departamento de Pediatría, Obstetricia y Ginecología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
| | - Diana M Diago
- Servicio de Obstetricia, Hospital General Universitario Santa Lucía, Cartagena, Murcia, Spain
| | - Nuria Pellicer
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Inés Olmo
- Unidad de Medicina Materno-Fetal, Instituto Universitario IVI Valencia, IVIRMA Global, Valencia, Spain; Departamento de Pediatría, Obstetricia y Ginecología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
| | - Sheila Vázquez
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Coral Lara
- Unidad de Medicina Materno-Fetal, Instituto Universitario IVI Valencia, IVIRMA Global, Valencia, Spain
| | - Alfredo Perales
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Departamento de Pediatría, Obstetricia y Ginecología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
| | - Vicente Serra
- Unidad de Medicina Materno-Fetal, Instituto Universitario IVI Valencia, IVIRMA Global, Valencia, Spain; Departamento de Pediatría, Obstetricia y Ginecología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain.
| |
Collapse
|
3
|
Song JE, Park S, Ryu J. Physical Examination-Indicated Cerclage in Singleton and Twin Pregnancies and Risk Factors for Predicting Preterm Birth < 28 Weeks. J Pers Med 2023; 14:38. [PMID: 38248739 PMCID: PMC10820401 DOI: 10.3390/jpm14010038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
We compare the outcomes of physical examination-indicated cerclage (PEIC) between singleton and twin pregnancies and analyze predictive factors for preterm birth < 28 weeks of gestation. Patients who underwent PEIC at our center were reviewed. We compared perinatal outcomes between singleton and twin pregnancies. The primary outcome was delivery before 28 weeks of gestation. Also, we analyzed perioperative clinical, laboratory, and sonographic findings to determine the risk factors for predicting preterm birth < 28 weeks. The rate of preterm birth < 28 weeks was not significantly different. Also, neonatal outcomes were not different. Also, we compared the outcomes according to GA (gestational age) at delivery before (Group A) or after (Group B) 28 weeks, which is the primary outcome. In perioperative findings, group A was likely to have more advanced cervical dilatation, bulging membranes into the vagina, positive fFN or IGFBP-1, and shorter postoperative CL (cervical length) than group B. Also, positive fFN or IGFBP-1 and postoperative CL < 21.6 mm were independently associated with a higher risk of preterm birth < 28 weeks. These findings provide the effectiveness of PEIC with twin pregnancy as well as singleton pregnancy and helpful predictive methods that might effectively identify women at high risk of preterm birth < 28 weeks following PEIC.
Collapse
Affiliation(s)
- Ji-Eun Song
- Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea;
| | - Suyeon Park
- Department of Obstetrics and Gynecology, Inha University College of Medicine, Inha University Hospital, Incheon 22332, Republic of Korea;
| | - Jiwon Ryu
- Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea;
| |
Collapse
|
4
|
Kumari P, Kumar M, Joseph T, Kumari M, Yadav B, Beck MM. Comparing Obstetric and Perinatal Outcomes Following Elective and Emergency Cervical Cerclage in Singleton and Multiple Pregnancies in a Tertiary Care Perinatal Centre. J Obstet Gynaecol India 2023; 73:213-221. [PMID: 38143986 PMCID: PMC10746619 DOI: 10.1007/s13224-023-01845-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 08/19/2023] [Indexed: 12/26/2023] Open
Abstract
Objective To compare the success, failure rates and perinatal outcomes following emergency and elective cervical cerclage in singleton and twin pregnancies at a tertiary care perinatal centre over half a decade. Methods All pregnant women, both with singleton and twin pregnancies, who had cervical cerclage between June 2014 and May 2019 were included in the retrospective study. Success rates, failure rates, maternal complications and perinatal outcomes were compared in both groups. Results There were 129 women enrolled in the study, 48 in the emergency and 81 in the elective group. A significantly greater number of multiparous women were in the elective group (97.5% versus 68.7%; p-value < 0.001). Twins were nearly four times more in the emergency group as compared to the elective group. The mean cervical length at time of cerclage was 2.05 cm and 1.5 cm; (p-value < 0.001) respectively in the elective and emergency groups. Almost half of the women in the emergency group had bulging membranes. (52.2%). Following cerclage, mean gestational age at delivery was similar in both groups. However, more women in the elective group delivered at or beyond 34 weeks in comparison to the emergency groups (71% versus 53.3%. P-value 0.05). Preterm labour leading to preterm births was almost twice in the emergency group than elective group (49% versus 22%, P-value 0.002). Rates of maternal chorioamnionitis were similar in both groups. The overall live birth rates were comparable (81.3% versus 84.4% P-value 0.85) in both the groups. These results were also seen on doing subgroup analysis of elective versus emergency cerclage in singleton pregnancies only. Failure rates were also similar in both groups (18.7% versus 15.6%, P-value 0.85) Composite neonatal morbidity was more in the emergency group than in the elective group (35.5 versus 14%, P-value 0.01). Conclusion Live birth rates and failure rates were comparable following elective and emergency cerclage both overall and in singleton pregnancies. Maternal chorioamnionitis and neonatal sepsis rates were similar in both the groups. However, composite neonatal morbidity was higher in the emergency cerclage group.
Collapse
Affiliation(s)
- Pushplata Kumari
- Obstetrics and Gynecology, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Manish Kumar
- Department of Neonatology, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Treasa Joseph
- Department of Reproductive Medicine and Surgery Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Minakshi Kumari
- Obstetrics and Gynecology, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical and Hospital, Vellore, Tamil Nadu 632004 India
| | - Manisha Madhai Beck
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India
| |
Collapse
|
5
|
Diago-Muñoz DM, Martínez-Varea A, Alonso-Díaz R, Perales-Marín A, Diago-Almela VJ. Physical examination-indicated cerclage in twin pregnancies compared with singleton pregnancies. J Matern Fetal Neonatal Med 2023; 36:2228963. [PMID: 37369372 DOI: 10.1080/14767058.2023.2228963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 05/01/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE The aim of this study was to compare pregnancy outcomes of physical examination-indicated cerclage in twin and singleton pregnancies with bulging membranes. METHODS All women with bulging membranes in the second trimester of pregnancy who were admitted to La Fe University and Polytechnic Hospital from January 2009 to January 2022 were included. A total of 128 participants were enrolled, 102 singleton pregnancies and 26 twin pregnancies. All patients underwent an amniocentesis to rule out intra-amniotic inflammation (IL-6 < 2.6 ng/mL). Cerclage was placed in the absence of intra-amniotic inflammation. RESULTS Compared with singleton gestations, twin pregnancies displayed a significantly higher prevalence of nulliparity and assisted reproductive techniques. The incidence of intra-amniotic inflammation/infection was similar in both groups (68.62% in singleton vs. 65.38% in twin pregnancies). The average gestational age of delivery without cerclage in singleton gestations was 23.83 weeks (95% CI 22.82-24.84) and in twin pregnancies, it was 23.69 weeks (95% CI 21.8-25.57). The average gestational age at delivery among patients with cerclage was 37.27 weeks (95% CI 35.35-39.19) in singleton gestations and 36 weeks (95% CI 33.51-38.63) in twin pregnancies, with no significant differences. Time from diagnosis to delivery in patients with IL-6 < 2.6 ng/mL was 79.88 days, and in those with IL > 2.6 ng/mL was 10.87 days. Gestational age at delivery was significantly higher in both singleton and twin pregnancies with cerclage, compared with those without cerclage (log-rank p < .001). CONCLUSIONS Singleton and twin pregnancies with bulging membranes behave similarly when cerclage is placed in the absence of intraamniotic inflammation/infection.
Collapse
Affiliation(s)
- D M Diago-Muñoz
- Department of Obstetrics and Gynecology, University Hospital Santa Lucía, Cartagena, Spain
| | - A Martínez-Varea
- Department of Obstetrics and Gynecology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - R Alonso-Díaz
- Department of Clinical Laboratory, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - A Perales-Marín
- Department of Obstetrics and Gynecology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - V J Diago-Almela
- Department of Obstetrics and Gynecology, La Fe University and Polytechnic Hospital, Valencia, Spain
| |
Collapse
|
6
|
Olisova K, Sao CH, Lussier EC, Sung CY, Wang PH, Yeh CC, Chang TY. Ultrasonographic cervical length screening at 20-24 weeks of gestation in twin pregnancies for prediction of spontaneous preterm birth: A 10-year Taiwanese cohort. PLoS One 2023; 18:e0292533. [PMID: 37797073 PMCID: PMC10553282 DOI: 10.1371/journal.pone.0292533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 09/21/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Shortened cervical length is one of the primary predictors for spontaneous preterm deliveries in twin pregnancies. However, there is lack of consensus regarding cut-off values. Recent evidence highlights that established cut-offs for cervical length screening might not always apply across different populations. This study aims to present the distribution of cervical length in Taiwanese twin pregnancies and to assess its predictive value for spontaneous preterm birth during mid-trimester screening. MATERIALS AND METHODS This retrospective analysis of cervical length screening in Taiwan evaluated 469 twin pregnancies between 20-24 weeks of gestation. Outcome data were obtained directly from the medical records of the delivery hospital. The study explored the predictive value of cervical length screening for spontaneous preterm birth and the characteristics of cervical length distribution in Taiwanese twin pregnancies. RESULTS The average gestational age at screening was 22.7 weeks. Cervical length values displayed a non-normal distribution (p-value <0.001). The median, 5th and 95th centiles were 37.5 mm 25.1 mm, and 47.9 mm, respectively. Various cut-off values were assessed using different methods, yielding positive [negative] likelihood ratios for spontaneous preterm births between 32-37 weeks of gestational age (GA) (1.3-30.1 and [0.51-0.92]) and for very preterm births between 28-32 weeks GA (5.6-51.1 and [0.45-0.64]). CONCLUSIONS The findings from our analysis of Taiwanese twin pregnancies uphold the moderate predictive potential of cervical length screening, consistent with prior investigations. The presented likelihood ratios for predicting preterm birth at different gestational ages equip clinicians with valuable tools to enhance their diagnostic rationale and resource utilization. By fine-tuning screening parameters according to the spontaneous preterm birth prevalence and clinical priorities of the particular population, healthcare providers can enhance patient care. Our data implies that a cervical length below 20 mm might provide an optimal balance between minimizing false negatives and managing false positives when predicting spontaneous preterm birth.
Collapse
Affiliation(s)
- Ksenia Olisova
- Department of Medical Research, Taiji Clinic, Taipei, Taiwan
| | - Chih-Hsuan Sao
- Department of Obstetrics and Gynecology, Taipei Tzu Chi Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Eric C. Lussier
- Department of Medical Research, Taiji Clinic, Taipei, Taiwan
| | - Chan-Yu Sung
- Department of Medical Research, Taiji Clinic, Taipei, Taiwan
| | - Peng-Hui Wang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Obstetrics and Gynecology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Female Cancer Foundation, Taipei, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Chang-Ching Yeh
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Obstetrics and Gynecology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tung-Yao Chang
- Department of Medical Research, Taiji Clinic, Taipei, Taiwan
- Department of Fetal Medicine, Taiji Clinic, Taipei, Taiwan
| |
Collapse
|
7
|
Tan H. The use of cervical cerclage in asymptomatic twin pregnancies with cervical shortening or dilation: a twelve-year retrospective cohort study. BMC Pregnancy Childbirth 2023; 23:700. [PMID: 37773110 PMCID: PMC10540472 DOI: 10.1186/s12884-023-06013-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/20/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND To identify the effect and optimal time of cervical cerclage in asymptomatic twin pregnancies with cervical shortening or dilation. METHODS This observational retrospective study enrolled all women with asymptomatic twin pregnancies who were diagnosed with asymptomatic cervical shortening or dilation at the Second Affiliated Hospital of Wenzhou Medical University between 2010 and 2022. Women included were allocated into the cerclage group (n = 36) and the no cerclage group (n = 22). The cerclage group was further divided into the cerclage group (< 24 weeks group) and the cerclage group (24-28 weeks group) according to the time of cerclage. The no cerclage group was further divided into no cerclage group (< 24 weeks group) and no cerclage group (24-28 weeks group) according to the time of ultrasound-indicated or physical exam indicated cerclage. The rates of PTB < 24, 28, 32 and 34 weeks of gestation, maternal and neonatal outcomes were compared among the groups. RESULTS The gestational age (GA) at delivery was higher (P = 0.005) and the interval time between the presentation of the indicated cerclage and delivery was longer in the cerclage group (P < 0.001). The rates of PTB before 28, 32, and 34 weeks of gestation, caesarean section and stillbirth were lower in the cerclage group (P < 0.05). The birthweight of the twins was higher in the cerclage group (P = 0.012). Admissions to the NICU were more frequent in pregnancies with no cerclage (P = 0.008). Subgroup analysis showed that the interval time between the presentation and delivery was longer in the cerclage group (< 24 weeks) (P < 0.001). The GA at delivery and the birthweight of the twins were significantly higher in the cerclage group (< 24 weeks) (P < 0.001). No differences were found in the GA at presentation, the GA at delivery, the interval time between the presentation to delivery and birthweight between the cerclage group (24-28 weeks group) and the control group (24-28 weeks group) (P > 0.05). CONCLUSIONS Cerclage appears to prolong the GA at delivery and the interval time between the presentation to delivery, and may reduce the incidence of PTB before 28, 32 and 34 weeks of gestation and adverse perinatal outcomes in asymptomatic twin pregnancies with cervical shortening or dilation. Cerclage before 24 weeks of gestation showed longer GA at delivery, longer interval time between the presentation to delivery and higher birthweight of the twins. The GA at presentation, the GA at delivery, the interval time between the presentation to delivery and birthweight in women with cerclage at 24-28 weeks were similar to those in women without cerclage at 24-28 weeks.
Collapse
Affiliation(s)
- Hongying Tan
- Zhejiang College of Security Technology, 325027, Wenzhou, China.
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
| |
Collapse
|
8
|
Ekici H, Okmen F, Saritas DG, Khaligli G, Ergenoglu AM. Cervical cerclage in twin pregnancies: obstetric and neonatal outcomes. Ir J Med Sci 2023; 192:1751-1755. [PMID: 36121601 DOI: 10.1007/s11845-022-03164-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although there have been significant improvements in prenatal and neonatal care in recent years, twin pregnancies account for 17-20% of all preterm births and are associated with an increased risk of perinatal mortality and morbidity. AIMS To evaluate the contribution of cerclage to the continuation of pregnancy in twin pregnancy cases required cervical cerclage. METHODS Cases of twin pregnancies who performed cervical cerclage with follow-up and deliveries between January 2010 and January 2022 in the Department of Obstetrics and Gynecology, Ege University Faculty of Medicine Hospital, were retrospectively analyzed. Obstetric and neonatal outcomes were evaluated. RESULTS A total of 23 women who performed cervical cerclage due to cervical insufficiency in twin pregnancies were evaluated retrospectively. The mean time between cerclage placement and delivery was 12.1 ± 7 weeks, maximum prolongation was in the obstetric history-indicated cerclage group. The gestational age at delivery was 20-38 (median 30) weeks. The rate of spontaneous preterm birth at < 34, < 32, < 28, and < 24 weeks was higher in the physical examination-indicated cerclage group. Overall neonatal survival was 82.5% (n = 33/40). CONCLUSION The time between cerclage placement and birth were considered as an important gain for twin pregnancies at the limit of viability. Further studies are needed to better understand the role of cervical cerclage in preventing premature birth and to determine the indications for cerclage.
Collapse
Affiliation(s)
- Huseyin Ekici
- Department of Obstetrics and Gynecology, Ege University School of Medicine, 35100, Bornova, Izmir, Turkey.
| | - Firat Okmen
- Department of Obstetrics and Gynecology, Ege University School of Medicine, 35100, Bornova, Izmir, Turkey
| | - Didem Gul Saritas
- Department of Obstetrics and Gynecology, Ege University School of Medicine, 35100, Bornova, Izmir, Turkey
| | - Gultap Khaligli
- Department of Obstetrics and Gynecology, Ege University School of Medicine, 35100, Bornova, Izmir, Turkey
| | - Ahmet Mete Ergenoglu
- Department of Obstetrics and Gynecology, Ege University School of Medicine, 35100, Bornova, Izmir, Turkey
| |
Collapse
|
9
|
Qiu L, Lv M, Chen C, Li J, Zhao B, Luo Q. Efficacy of ultrasound-indicated cerclage in twin pregnancies: a retrospective case-control study matched by cervical length. Am J Obstet Gynecol MFM 2023; 5:100847. [PMID: 36638868 DOI: 10.1016/j.ajogmf.2022.100847] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/27/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Twin pregnancies with a progressively shortening cervix in the midterm pregnancy have an increasing risk for spontaneous preterm birth. Currently, there is no known effective method to prevent preterm birth among those women, and the use of an ultrasound-indicated cerclage in twin pregnancies is still controversial. OBJECTIVE This study aimed to estimate whether a combination of ultrasound-indicated cerclage, indomethacin, and antibiotics in twin pregnancies between 18 and 26 weeks' gestation could extend the pregnancy, reduce the risk for spontaneous preterm birth, and improve perinatal and neonatal outcomes. STUDY DESIGN A retrospective cohort study was conducted. The ultrasound-indicated cerclage group included twin pregnancies with a transvaginal cervical length <25 mm that underwent cerclage at 18 to 26 weeks of gestation in the Women's Hospital, Zhejiang University School of Medicine, from December 2015 through August 2021. Twin pregnancies in our study that underwent cerclage also received antibiotics and indomethacin. A control group of twin pregnancies that were managed expectantly were matched with the treatment group in terms of transvaginal cervical length at diagnosis (±3 mm), gestational age at presentation of diagnosis (±3 weeks), and maternal age (±5 years). An additional subanalysis was performed in which the patients were divided into 2 subgroups based on transvaginal cervical length of either <15 mm or between 15 and 24 mm. The primary outcome was gestational age at delivery. The secondary outcomes were pregnancy latency, the rate of spontaneous preterm birth at <28, <32, <34, <36 weeks' gestation, and neonatal outcomes. RESULTS A total of 90 twin pregnancies with a transvaginal cervical length <25 mm were managed with either a cerclage (ultrasound-indicated cerclage group, n=45) or expectantly (control group, n=45). Demographic characteristics were not significantly different between the groups. When compared with the control group, the gestational age at delivery was significantly higher (33.11±3.16 vs 30.22±4.12 weeks; P=.001) and the pregnancy latency was significantly longer (72.40±22.51 vs 45.56±28.82 days; P<.001) in the ultrasound-indicated cerclage group. The rates of spontaneous preterm birth at <28, <32, <34, and <36 weeks' gestation were significantly lower in the ultrasound-indicated cerclage group than in the control group. In terms of neonatal outcomes, there were significant reductions in the overall perinatal mortality (4.4% vs 20.0%; P<.001), neonatal intensive care unit admissions (69.0% vs 92.6%; P<.001), and composite adverse neonatal outcomes (43.7% vs 64.7%; P=.010) for the ultrasound-indicated cerclage group when compared with the control group. In the subgroup of women with a transvaginal cervical length of between 15 and 24 mm (with 21 in the ultrasound-indicated cerclage group vs 21 controls), the data were adjusted for maternal age, pregestational body mass index, in vitro fertilization, operative hysteroscopy, previous cervical surgery, previous spontaneous preterm birth, white blood cell counts, C-reactive protein level, neutrophil to lymphocyte ratio, and the shortest transvaginal cervical length measured at diagnosis. In ultrasound-indicated cerclage group, gestational age at delivery was significantly higher (32.95±3.81 vs 30.24±4.01 weeks; beta, 3.34; 95% confidence interval, 0.14-6.55; P=.042), pregnancy latency was significantly prolonged (77.19±24.81 vs 48.52±29.67 days; beta, 33.81; 95% confidence interval, 12.29-55.34; P=.003), and the rates of spontaneous preterm birth <36 weeks' gestation (57.1% vs 95.2%; adjusted odds ratio, 0.03; 95% confidence interval, 0.01-0.69; P=.029) was significantly decreased, and for neonatal outcomes, there were significant reductions in neonatal intensive care unit admissions (53.7% vs 96.7%; adjusted odds ratio, 0.04; 95% confidence interval, 0.01-0.32; P=.003) and the composite adverse neonatal outcomes (39.0% vs 73.3%; adjusted odds ratio, 0.24; 95% confidence interval, 0.08-0.68; P=.008) in the ultrasound-indicated cerclage group when compared with the control group. In the subgroup of women with a transvaginal cervical length <15 mm, gestational age at delivery was higher (33.25±2.52 vs 30.00±4.33 weeks; beta, 3.96; 95% confidence interval, 1.51-6.42; P=.002), pregnancy latency was significantly prolonged (68.21±19.85 vs 42.96±28.43 days; beta, 30.11; 95% confidence interval, 12.42-47.81; P=.001), rates of spontaneous preterm birth at <32 weeks (16.7% vs 54.2%; adjusted odds ratio, 0.10; 95% confidence interval, 0.01-0.61; P=.020) and <34 weeks (54.2% vs 83.3%, adjusted odds ratio, 0.08; 95% confidence interval, 0.01-0.66; P=.019) of gestation was significantly decreased, and neonatal birthweight was significantly increased (2023.96±510.35 vs 1421.77±611.40 g; beta, 702.40; 95% confidence interval, 297.02-1107.78; P=.001) in the ultrasound-indicated cerclage group when compared with the control group. CONCLUSION Cerclage among women with twin pregnancies with a transvaginal cervical length <25 mm may reduce the rate of spontaneous preterm birth and improve perinatal and neonatal outcomes when compared with expectant management. It is worth noting that even with a short transvaginal cervical length of 15 to 24 mm, cerclage will significantly decrease the risk of delivery at <36 weeks' gestation and prolong pregnancy latency. Among women with a short transvaginal cervical length <15 mm, cerclage will significantly decrease the risk of delivery at <32 and <34 weeks' gestation and prolong pregnancy latency.
Collapse
Affiliation(s)
- Liping Qiu
- Department of Obstetrics, Huzhou Maternity & Child Health Care Hospital, Huzhou, Zhejiang, China (Dr Qiu)
| | - Min Lv
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China (Drs Lv, Chen, Li, Zhao, and Luo)
| | - Cheng Chen
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China (Drs Lv, Chen, Li, Zhao, and Luo)
| | - Juan Li
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China (Drs Lv, Chen, Li, Zhao, and Luo)
| | - Baihui Zhao
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China (Drs Lv, Chen, Li, Zhao, and Luo).
| | - Qiong Luo
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China (Drs Lv, Chen, Li, Zhao, and Luo).
| |
Collapse
|
10
|
Huang G, Deng C, Liao H, Hu Q, Yu H, Wang X. Comparison of transvaginal cervical cerclage versus laparoscopic abdominal cervical cerclage in cervical insufficiency: a retrospective study from a single centre. BMC Pregnancy Childbirth 2022; 22:773. [PMID: 36253759 PMCID: PMC9575299 DOI: 10.1186/s12884-022-05108-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 10/07/2022] [Indexed: 12/05/2022] Open
Abstract
Background Cervical cerclage has been proposed as an effective treatment for cervical insufficiency, but there has been controversy regarding the surgical options of cervical cerclage in singleton and twin pregnancies. This study aimed to compare the pregnancy outcomes between transvaginal cervical cerclage (TVC) and laparoscopic abdominal cervical cerclage (LAC) in patients with cervical insufficiency. We also aimed to evaluate the efficacy and safety, and provide more evidence to support the application of cervical cerclage in twin pregnancies. Methods A retrospective study was carried out from January 2015 to December 2021. The primary outcomes were the incidence of spontaneous preterm birth (sPTB) < 24 weeks, < 28, < 32, < 34 weeks, and < 37weeks, gestational age at delivery, and the incidence of admission for threatened abortion or preterm birth after cervical cerclage. The secondary outcomes included admission to the Neonatal Intensive Care Unit, adverse neonatal outcomes and neonatal death. We also analysed the pregnancy outcomes of twin pregnancies after cervical cerclage. Results A total of 289 patients were identified as eligible for inclusion. The LAC group (n = 56) had a very low incidence of sPTB ˂ 34 weeks, and it was associated with a significant decrease in sPTB < 28 weeks, ˂32 weeks, ˂34 and < 37 weeks, and admission to the hospital during pregnancy for threatened abortion or preterm birth after cervical cerclage (0 vs.27%; 1.8% vs. 40.3%; 7.1% vs. 46.8%; 14% vs. 63.5%, 8.9% vs. 62.2%, respectively; P < 0.001), and high in gestational age at delivery compared with the TVC group (n = 233) (38.3 weeks vs.34.4 weeks,P < 0.001). Neonatal outcomes in the LAC group were significantly better than those in the TVC group. The mean gestational age at delivery was 34.3 ± 1.8 weeks, with a total foetal survival rate of 100% without serious neonatal complications in twin pregnancies with LAC. Conclusion In patients with cervical insufficiency, LAC appears to have better pregnancy outcomes than TVC. For some patients, LAC is a recommended option and may be selected as the first choice. Even in twin pregnancies, cervical cerclage can improve pregnancy outcomes with a longer latency period, especially in the LAC group. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-05108-w.
Collapse
Affiliation(s)
- Guiqiong Huang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, 610041, Sichuan, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Chunyan Deng
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, 610041, Sichuan, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Hua Liao
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, 610041, Sichuan, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Qing Hu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, 610041, Sichuan, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Haiyan Yu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, 610041, Sichuan, Chengdu, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China.
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, 610041, Sichuan, Chengdu, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China.
| |
Collapse
|
11
|
Khalil A. Reply. Ultrasound Obstet Gynecol 2022; 60:145-146. [PMID: 35776009 DOI: 10.1002/uog.24934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- A Khalil
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
| |
Collapse
|
12
|
Munim S, Islam Z, Zohra N, Yasmin H, Korejo R. Guidelines on prevention of preterm birth. J Matern Fetal Neonatal Med 2022; 35:9527-9531. [PMID: 35240915 DOI: 10.1080/14767058.2022.2045582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This guideline has been prepared by the National Maternal Fetal Medicine guidelines committee and approved by the Society of Obstetricians and Gynecologists Pakistan. These recommendations will enable the practicing clinicians to optimally manage pregnancies at risk of preterm birth.
Collapse
Affiliation(s)
- Shama Munim
- Department of Obstetrics and Gynecology & Fetal Medicine, Jinnah Medical and Dental University, Karachi, Pakistan
| | - Zaheena Islam
- Department of Obstetrics and Gynecology, Aga Khan University Hospital, Karachi, Pakistan
| | - Nishat Zohra
- Department of Obstetrics and Gynecology, Isra University Hyderabad, Hyderabad, Sindh, Pakistan
| | - Haleema Yasmin
- Department of Obstetrics and Gynecology, Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Razia Korejo
- Department of Obstetrics and Gynecology, Baharia University, Karachi, Pakistan
| |
Collapse
|
13
|
Abstract
An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes an assessment of safety of birth centers in the United States and commentaries on reviews focused on aspirin prophylaxis in pregnancy and the new gestational weight gain evidence summary from the United States Preventive Services Task Force.
Collapse
|