Comparison of two cervical cerclages for the prevention of preterm birth and neonatal complications

Comparison of two emergency cervical cerclage techniques in twin pregnancies: A retrospective cohort study matched with cervical dilation

OBJECTIVES

This retrospective cohort study aimed to assess the efficacy of emergency cervical cerclage (ECC) performed with the combined McDonald-Shirodkar technique in twin pregnancies between 18 and 26 weeks of pregnancy with painless cervical dilation 1 to 6 cm.

METHODS

A retrospective cohort study matched with the degree of cervical dilation was conducted. The study group (case group) included women with twin pregnancies undergoing combined McDonald-Shirodkar approach with cervical dilation ≥1 cm between 18 to 26 weeks of gestation at four institutions, from December 2015 to December 2022. To minimize confounding factors, we elucidated the causality structure using a directed acyclic graph and performed 1:1 case-control matching. A control group underwent the McDonald approach. The primary outcome was gestational age (GA) at delivery. The secondary outcomes were pregnancy latency; the rates of spontaneous preterm birth at <28, <30, <32, and <34 weeks; and neonatal outcomes. Additional subanalysis was performed by dividing the patients into two subgroups of women with cervical dilation ≥3 cm and <3 cm.

RESULTS

A total of 84 twin pregnancies were managed with either the combined McDonald-Shirodkar approach (case group: n = 42) or the McDonald approach (control group: n = 42). Demographic characteristics were not significantly different in the two groups (P > 0.05). After adjusting for confounders that were represented by a directed acyclic graph, median GA at delivery was significantly higher (30.5 vs 27 weeks; Bate: 3.40 [95% confidence interval (CI), 2.13-4.67], P < 0.001) and median pregnancy latency was significantly longer (56 vs 28 days; Bate: 24.04 [95% CI, 13.31-34.78], P < 0.001) in the case group compared with the control group. Rates of spontaneous preterm birth at <28, <30, <32, and <34 weeks were significantly lower in the case group than in the control group. For neonatal outcomes, there was higher birth weight (1543.75 vs 980 g; Bate: 420.08 [95% CI, 192.18-647.98], P < 0.001) and significantly lower overall perinatal mortality (7.1% vs 31%; adjusted odds ratio, 0.16 [95% CI, 0.04-0.70], P = 0.014) in the case group compared with the control group. When cervical dilation was ≥3 cm, the combined McDonald-Shirodkar procedure can significantly reduce perinatal mortality (8.3% vs 46.7%; adjusted odds ratio, 0.09 [95% CI, 0.01-0.77], P = 0.028), significantly decrease the risk of delivery at <28 and <30 weeks, and prolong GA at delivery and pregnancy latency compared with the McDonald procedure.

CONCLUSIONS

ECC performed with the combined McDonald-Shirodkar procedure in women with twin pregnancies who have cervical dilation 1 to 6 cm in midtrimester pregnancy may reduce the rate of spontaneous preterm birth and improve perinatal and neonatal outcomes compared with the McDonald procedure, especially for twin pregnancies in women with cervical dilation of 3 to 6 cm and prolapsed membranes.

McDonald versus Shirodkar cerclage technique in the prevention of preterm birth: A systematic review and meta-analysis

BACKGROUND

Cervical cerclage has been used for decades to reduce preterm birth. The Shirodkar and McDonald cerclage are the most commonly used techniques with no current consensus on the preferred technique.

OBJECTIVE

To compare the efficacy of the Shirodkar and McDonald cerclage techniques in preventing preterm birth.

SEARCH STRATEGY

Studies were sourced from six electronic databases and reference lists.

SELECTION CRITERIA

Studies including women with a singleton pregnancy, requiring a cervical cerclage, using either the Shirodkar or McDonald technique that ran comparative analyses between the two techniques.

DATA COLLECTION AND ANALYSIS

The primary outcome was preterm birth before 37 weeks, with analyses at 28, 32, 34 and 35 weeks. Secondary data were also collected on neonatal, maternal and obstetric outcomes.

MAIN RESULTS

Seventeen papers were included: 16 were retrospective cohort studies and one was a randomised controlled trial. The Shirodkar technique was significantly less likely to result in preterm birth before 37 weeks than the McDonald technique (relative risk [RR] 0.91, 95% CI 0.85-0.98). This finding was supported by a statistically significant reduction in rates of preterm birth before 35, 34 and 32 weeks, PPROM, difference in cervical length, cerclage to delivery interval, and an increase in birthweight in the Shirodkar group. No difference was seen in preterm birth rates <28 weeks, neonatal mortality, chorioamnionitis, cervical laceration or caesarean section rates. The RR for preterm birth prior to 37 weeks was no longer significant when sensitivity analyses were performed removing studies with a serious risk of bias. However, similar analyses removing studies that utilised adjunctive progesterone strengthened the primary outcome (RR 0.83, 95% CI 0.74-0.93).

CONCLUSION

Shirodkar cerclage reduces the rate of preterm birth prior to 35, 34 and 32 weeks' gestation when compared with McDonald cerclage; however, the overall quality of the studies in this review is low. Further, large, well-designed randomised controlled trials are required to address this important question to optimise care for women who may benefit from cervical cerclage.

McDonald versus Shirodkar cervical cerclage for prevention of preterm birth: a systematic review and meta-analysis of pregnancy outcomes

OBJECTIVE

To compare pregnancy outcomes of patients undergoing either McDonald or Shirodkar cervical cerclage.

METHODS

PubMed, Web of Science, Scopus, and Google scholar were systematically searched up to June 2020. Inter-study heterogeneity was assessed using Cochrane's Q test and the I² statistic. Data were pooled using the fixed- or random-effects model and expressed as relative risk (RR) or weighted mean difference (WMD) as appropriately.

RESULTS

A total of eight observational studies, reporting data on 724 pregnancies, were included in this meta-analysis. As compared to the Shirodkar cerclage, the pooled findings showed that the gestational age at delivery (WMD = -1.95, 95% CI: -2.89 to -1.01, p < .001; I² = 57.5%) and birth weight (WMD = -355.69, 95% CI: -413.76 to -297.62, p < .001; I² = 28.8%) were significantly lower in McDonald cerclage. The risk of preterm premature rupture of the membranes (PPROM) (RR = 1.76; 95% CI: 1.14 - 2.71; I² = 0.0%) and neonatal intensive care unit (NICU) admission (RR = 1.61; 95% CI: 1.09 - 2.39; I² = 62.1%) were also higher for McDonald group. However, no significant difference was observed between both groups in terms of cesarean delivery and perinatal/neonatal death.

CONCLUSION

McDonald cerclage is associated with a shorter duration of pregnancy, lower mean birth weight and increased risk of PPROM and NICU admission compared to the Shirodkar procedure.

Shirodkar cerclage: Obstetrical and neonatal outcomes in a single-center cohort of 55 cases

BACKGROUND

Cervical insufficiency is thought to be responsible for 10% of preterm deliveries. Shirodkar cerclage is among the available techniques ranging from McDonald's to definitive procedures, however the indications for the prevention of preterm births and mid-trimester miscarriages are still poorly delineated.

OBJECTIVE

To describe the characteristics, obstetrical and neonatal outcomes of pregnancies with Shirodkar cerclage procedures.

METHOD

We performed a descriptive retrospective single-center study, including all patients who had a Shirodkar cerclage between January 1, 2008 and December 31, 2020. The main outcomes measured were delivery at or beyond 24 and 32 weeks of gestations (WG).

RESULTS

55 Shirodkar cerclages were performed over the period studied. 7.3% of patients had a uterine malformation, 9% had a history of cervical conization. 74.5% had history of one or more mid-trimester miscarriages. 63.6% had a history of a failed emergency or prophylactic cerclage. The median gestational age (GA) at cerclage placement was 14 WG. There were 4 deliveries before 24 WG, 8 before 32 WG and 16 before 37 WG. Overall neonatal survival was 48/53 (90.6%). The median GA at delivery was 38 weeks (IQR 35-39), with 70.3% of vaginal deliveries.

CONCLUSION

Shirodkar cerclage was successful in more than 90% of patients, despite their obstetric history. Shirodkar cerclage may be indicated in the event of prior cerclage failure using the McDonald technique or in order to allow for correct stitch placement in very short cervixes. Its advantage over definitive cerclage is to allow for vaginal delivery.

Comparison of laparoscopic abdominal cerclage and transvaginal cerclage for the treatment of cervical insufficiency: a retrospective study

PURPOSE

To compare the pregnancy outcome of patients with cervical insufficiency (CI) underwent prophylactic laparoscopic abdominal cervical cerclage (LAC) and transvaginal cervical cerclage (TVC).

METHODS

A retrospective trial was carried out in the Department of Gynecology, Qingdao Women and Children's Hospital, Shandong Province, China. A total of 217 women with cervical insufficiency underwent the prophylactic cerclage, and the surgical approach was decided by the patients or depended on doctors' advice. The primary outcome measure was the fetal outcome. Secondary outcome measures were delivery of an infant at ≥ 34th gestational weeks, newborn birth weight, neonatal intensive care center (NICU) occupancy, and postoperative complications. Nonparametric variables were analyzed with the Mann-Whitney (U) test, and categorical type outcomes were analyzed with the Chi-square test or the Fisher's exact test. A P value < 0.05 was considered significant. Data analysis was performed using SPSS Statistics Version 19.

RESULTS

As of follow-up date, 154 eligible patients were included in this study, with 74 (48.1%) women in the LAC group and 80 (51.9%) in the TVC group. The total fetal survival rate in the two groups was 90.3% (139/154), of which the rate significantly higher in the LAC group compared to the TVC group (97.3% vs. 83.8%, P < 0.01). The delivery of an infant at ≥ 34th gestational weeks was significantly higher in the LAC group compared to the TVC group (94.6% vs. 71.3%, P < 0.01). Compared to the TVC group, the mean newborn birth weight was higher, and the NICU occupancy rate was less in the LAC group (3293.4 ± 542.8 g vs. 2953.6 ± 704.4 g, P = 0.002; 2.8% vs. 17.9%, P = 0.003).

COMPLICATIONS

No fatal surgical complications occurred in both groups.

CONCLUSION

In patients with cervical insufficiency, the history-indicated conception of prophylactic LAC appears to have a better pregnancy outcome than TVC.

A Novel Cerclage Insertion: Modified Laparoscopic Transabdominal Cervical Cerclage with Transvaginal Removing (MLTCC-TR)

STUDY OBJECTIVE

To report on our center's experience of a novel modified approach for laparoscopic cervical cerclage and to evaluate its safety and efficacy preliminarily.

DESIGN

Retrospective descriptive study.

SETTING

Single academic institution.

PATIENTS

Pregnant and nonpregnant women who underwent the modified laparoscopic transabdominal cervical cerclage with transvaginal removing (MLTCC-TR) from June 2016 to April 2019. Eligible participants had multiple adverse obstetric histories or the short cervix and were not suitable for a second transvaginal cerclage.

INTERVENTIONS

Preconceptional or postconceptional MLTCC-TR.

MEASUREMENTS AND MAIN RESULTS

A total of 24 participants (including 3 first-trimester singleton pregnant women) underwent the MLTCC-TR, giving birth to 27 infants. Among 21 women who underwent preconceptional cerclage, 26 cases of postoperational pregnancies were noted, and the incidence of term labor was 73.07%, which was significantly higher than that in the precerclage group (p <.001). Their mean gestational age at delivery was 37.21 ± 5.05 weeks. Among 3 cases of postconceptional cerclage, the mean gestational age at cerclage was 10.90 ± 2.61 weeks, and all of them had term delivery. The overall neonatal survival rate was 100% (27/27), of which 81.48% (22/27) were term infants. There were no severe perioperative complications directly related to the insertion of cerclage.

CONCLUSION

Our new approach of MLTCC-TR may be a relatively effective, feasible, and safe treatment for cervical insufficiency. It may be considered as an acceptable alternative to the traditional laparoscopic cervical cerclage with its superiority of transvaginal removing.

A comparison of emergency and therapeutic modified Shirodkar cerclage: an analysis of 38 consecutive cases

Objective:

To compare the maternal and neonatal outcomes of patients with emergency versus therapeutic cerclage.

Materials and Methods:

The study included 38 female patients who underwent cervical cerclage using the modified Shirodkar method in the Obstetrics and Gynecology Clinics of Düzce University Medical Faculty Hospital and Düzce Atatürk State Hospital.

Results:

The operating time for the emergency cerclage group was significantly longer than that of the therapeutic group (30.40 minutes vs 19.85 minutes, p=0.001). Following the cerclage procedure, the cervical length was longer in the therapeutic cerclage group [29.90 millimeters (mm) vs. 22.45 mm, p=0.001]. The cerclage to birth interval was also longer in the therapeutic group (91 vs. 138 days).

Conclusion:

In comparison with therapeutic cerclage, the total duration of pregnancy after emergency cerclage is shorter, and newborns have a greater need for intensive care. Both methods, however, protect against advanced prematurity, which causes neonatal loss.

McDonald versus modified Shirodkar rescue cerclage in women with prolapsed fetal membranes

Purpose: We compared the efficacy of modified Shirodkar and McDonald rescue cerclage techniques in women with singleton pregnancies.Methods: The study sample included 47 women who presented at two tertiary hospitals in Turkey from 2008 to 2017 and underwent rescue cerclage due to cervical incompetence and cervical dilatation with fetal membranes prolapsed into the vagina. The outcomes were compared by cerclage technique used, Shirodkar or McDonald.Results: The McDonald cerclage was applied in 27 cases, and modified Shirodkar cerclage in 20 cases. A longer cerclage-to-birth interval (83.8 ± 37.6 vs. 63.7 ± 38.9 days) and later gestational age at delivery (33 vs. 31 weeks) were observed with the Shirodkar cerclage, although these differences were not statistically significant (p = .08 and .63, respectively). Both groups had similar delivery rates after 28, 32, and 37 weeks (p = .20, .15, and .25, respectively), whereas the modified Shirodkar technique resulted in a higher rate of live births although these differences were not statistically significant (85% vs. 63%, p = .09).Conclusion: The effects of the McDonald and modified Shirodkar cerclage procedures on prolonging pregnancy and improving the live birth rate were similar. Therefore, either technique can be applied to prevent neonatal loss due to advanced prematurity.