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Clinical Obstetrics and Gynecology Sep 2014Cervical cerclage is an obstetric procedure performed for prevention of prematurity. Cerclage was first introduced by Drs Shirodkar and McDonald in the mid-1950s for... (Review)
Review
Cervical cerclage is an obstetric procedure performed for prevention of prematurity. Cerclage was first introduced by Drs Shirodkar and McDonald in the mid-1950s for women with repeated second trimester losses and cervical changes in current pregnancy. Currently, cerclage placement is based on 3 common indications in singleton gestations, including history-indicated (prior multiple early preterm births or second trimester losses), ultrasound-indicated (cervical length <25 mm before 24-wk gestational age in women with prior spontaneous preterm birth) and physical examination-indicated (cervical dilation on manual or physical examination before 24 wk).
Topics: Cerclage, Cervical; Cervical Length Measurement; Female; Humans; Medical History Taking; Perioperative Care; Physical Examination; Pregnancy; Premature Birth; Uterine Cervical Incompetence
PubMed: 24979354
DOI: 10.1097/GRF.0000000000000044 -
Obstetrics and Gynecology Feb 2014The inability of the uterine cervix to retain a pregnancy in the second trimester is referred to as cervical insufficiency. Controversy exists in the medical literature...
The inability of the uterine cervix to retain a pregnancy in the second trimester is referred to as cervical insufficiency. Controversy exists in the medical literature pertaining to issues of pathophysiology, screening, diagnosis, and management of cervical insufficiency. The purpose of this document is to provide a review of current evidence of cervical insufficiency, including screening of asymptomatic at-risk women, and to offer guidelines on the use of cerclage for management. The diagnosis and management of other cervical issues during pregnancy, such as short cervical length, are discussed more in-depth in other publications of the American College of Obstetricians and Gynecologists.
Topics: Cerclage, Cervical; Female; Fetal Membranes, Premature Rupture; Gestational Age; Humans; Labor Stage, First; Physical Examination; Pregnancy; Premature Birth; Ultrasonography; Uterine Cervical Incompetence
PubMed: 24451674
DOI: 10.1097/01.AOG.0000443276.68274.cc -
Journal of Obstetrics and Gynaecology... Feb 2019The purpose of this guideline is to provide a framework that clinicians can use to determine which women are at greatest risk of having cervical insufficiency and in...
OBJECTIVE
The purpose of this guideline is to provide a framework that clinicians can use to determine which women are at greatest risk of having cervical insufficiency and in which set of circumstances a cerclage is of potential value.
EVIDENCE
Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in 2018 using appropriate controlled vocabulary (e.g., uterine cervical incompetence) and key words (e.g., cervical insufficiency, cerclage, Shirodkar, cerclage, McDonald, cerclage, abdominal, cervical length, mid-trimester pregnancy loss). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to June 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.
VALUES
The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.
Topics: Cerclage, Cervical; Conservative Treatment; Female; Humans; Pregnancy; Uterine Cervical Incompetence
PubMed: 30638557
DOI: 10.1016/j.jogc.2018.08.009 -
Best Practice & Research. Clinical... Aug 2019Cervical cerclage in women with twin pregnancy is not routinely indicated but appears to be beneficial in subjects with a history of preterm birth or very short cervix... (Review)
Review
Cervical cerclage in women with twin pregnancy is not routinely indicated but appears to be beneficial in subjects with a history of preterm birth or very short cervix or dilated cervix. There is a paucity of literature data regarding transabdominal or laparoscopic cervical cerclage (LCC) in twin pregnancy. It is uncertain whether LCC is more effective than transvaginal cerclage. Our own experience of 24 cases of LCC in twin pregnancy showed encouraging results. Further, well-planned studies are required to answer whether, when, and how cervical cerclage should be performed in women with twin pregnancy.
Topics: Cerclage, Cervical; Cervix Uteri; Female; Humans; Infant, Newborn; Laparoscopy; Pregnancy; Pregnancy Outcome; Pregnancy, Twin; Premature Birth
PubMed: 31331744
DOI: 10.1016/j.bpobgyn.2019.06.001 -
BJOG : An International Journal of... Jun 2022
Topics: Cerclage, Cervical; Cervix Uteri; Female; Humans; Pregnancy; Pregnancy Outcome; Uterine Cervical Incompetence
PubMed: 35199905
DOI: 10.1111/1471-0528.17003 -
Obstetrical & Gynecological Survey Sep 2023Cervical cerclage (CC) represents one of the few effective measures currently available for the prevention of preterm delivery caused by cervical insufficiency, thus... (Review)
Review
IMPORTANCE
Cervical cerclage (CC) represents one of the few effective measures currently available for the prevention of preterm delivery caused by cervical insufficiency, thus contributing in the reduction of neonatal morbidity and mortality rates.
OBJECTIVE
The aim of this study was to review and compare the most recently published major guidelines on the indications, contraindications, techniques, and timing of placing and removal of CC.
EVIDENCE ACQUISITION
A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC), and the International Federation of Gynecology and Obstetrics (FIGO) on CC was carried out.
RESULTS
There is a consensus among the reviewed guidelines regarding the recommended techniques, the indications for rescue CC, the contraindications, as well as the optimal timing of CC placement and removal. All medical societies also agree that ultrasound-indicated CC is justified in women with history of prior spontaneous PTD or mid-trimester miscarriage and a short cervical length detected on ultrasound. In addition, after CC, serial sonographic measurement of the cervical length, bed rest, and routine use of antibiotics, tocolysis, and progesterone are unanimously discouraged. In case of established preterm labor, CC should be removed, according to ACOG, RCOG, and SOGC. Furthermore, RCOG and SOGC agree on the prerequisites that should be met before attempting CC. These 2 guidelines along with FIGO recommend history-indicated CC for women with 3 or more previous preterm deliveries and/or second trimester pregnancy miscarriages, whereas the ACOG suggests the use of CC in singleton pregnancies with 1 or more previous second trimester miscarriages related to painless cervical dilation or prior CC due to painless cervical dilation in the second trimester. The role of amniocentesis in ruling out intra-amniotic infection before rescue CC remains a matter of debate.
CONCLUSIONS
Cervical cerclage is an obstetric intervention used to prevent miscarriage and preterm delivery in women considered as high-risk for these common pregnancy complications. The development of universal international practice protocols for the placement of CC seems of paramount importance and will hopefully improve the outcomes of such pregnancies.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Premature Birth; Cerclage, Cervical; Abortion, Spontaneous; Obstetric Labor, Premature; Cervix Uteri
PubMed: 37976303
DOI: 10.1097/OGX.0000000000001182 -
American Journal of Obstetrics &... Jun 2023This study aimed to determine whether cervical cerclage for a transvaginal ultrasound-detected short cervical length after 24 weeks of gestation in singleton pregnancies... (Meta-Analysis)
Meta-Analysis Review
Cervical cerclage for short cervix at 24 to 26 weeks of gestation: systematic review and meta-analysis of randomized controlled trials using individual patient-level data.
OBJECTIVE
This study aimed to determine whether cervical cerclage for a transvaginal ultrasound-detected short cervical length after 24 weeks of gestation in singleton pregnancies reduces the risk for preterm birth.
DATA SOURCES
Ovid MEDLINE, Scopus, and the Cochrane Central Register of Controlled Trials were searched using the following terms: "cerclage, cervical," "uterine cervical incompetence," "obstetrical surgical procedures," "cervix uteri," "randomized controlled trial," and "controlled clinical trial."
STUDY ELIGIBILITY CRITERIA
All randomized controlled trials comparing cerclage placement with no cerclage in singleton gestations with a transvaginal ultrasound-detected short cervical length ≤25 mm between 24+0/7 and 29+6/7 weeks of gestation were eligible for inclusion.
METHODS
Individual patient-level data from each trial were collected. If an eligible trial included patients with both multiple and singleton gestations with a short cervical length detected either before or after 24+0/7 weeks of gestation, only singletons who presented at or after 24+0/7 weeks were included. The primary outcome was preterm birth <37 weeks' gestation. Secondary outcomes included preterm birth <34, <32, and <28 weeks' gestation, gestational age at delivery, latency, preterm prelabor rupture of membranes, chorioamnionitis, and adverse neonatal outcomes. Individual patient-level data from each trial were analyzed using a 2-stage approach. Pooled relative risks or mean differences with 95% confidence intervals were calculated as appropriate.
RESULTS
Data from the 4 eligible randomized controlled trials were included. A total of 131 singletons presented at 24+0/7 to 26+6/7 weeks of gestation and were further analyzed; there were no data on patients with a cerclage at 27+0/7 weeks' gestation or later. Of those included, 66 (50.4%) were in the cerclage group and 65 (49.6%) were in the no cerclage group. The rate of preterm birth <37 weeks' gestation was similar between patients who were randomized to the cerclage group and those who were randomized to the no cerclage group (27.3% vs 38.5%; relative risk, 0.78; 95% confidence interval, 0.37-1.28). Secondary outcomes including preterm birth <34, <32, and <28 weeks' gestation, gestational age at delivery, time interval from randomization to delivery, preterm prelabor rupture of membranes, and adverse neonatal outcomes such as low birthweight, very low birthweight, and perinatal death were similar between the 2 groups. Planned subgroup analyses revealed no statistically significant differences in the rate of preterm birth <37 weeks' gestation between the 2 groups when compared based on cervical length measurement (≤15 mm or ≤10 mm), gestational age at randomization (24+0/7 to 24+6/7 weeks or 25+0/7 to 26+6/7 weeks), or history of preterm birth.
CONCLUSION
Cervical cerclage did not reduce or increase the rate of preterm birth among singleton pregnancies with a short cervical length detected after 24 weeks of gestation. Because there was a 22% nonsignificant decrease in preterm birth associated with cerclage, which is a similar amount of risk reduction often associated with ultrasound-indicated cerclage before 24 weeks' gestation, further randomized controlled trials in this patient population are warranted.
Topics: Pregnancy; Female; Humans; Infant, Newborn; Cerclage, Cervical; Premature Birth; Cervix Uteri; Randomized Controlled Trials as Topic; Gestational Age
PubMed: 36924844
DOI: 10.1016/j.ajogmf.2023.100930 -
European Journal of Obstetrics,... May 2021Data on the prevention of preterm birth in twin pregnancies with cervical cerclage remain inconsistent. Thus, this study aimed to comprehensively evaluate the value of... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Data on the prevention of preterm birth in twin pregnancies with cervical cerclage remain inconsistent. Thus, this study aimed to comprehensively evaluate the value of cervical cerclage as a treatment strategy to prevent preterm birth in twin pregnancies with regard to both maternal and neonatal outcomes.
STUDY DESIGN
In this systematic review and meta-analysis, the PubMed, Cochrane Library, Medline, EMBASE, and Web of Science databases were searched for relevant studies and trials from their inception up to December 2020. Outcomes were expressed as risk ratios and standardized mean differences in a meta-analysis model using STATA 15.0 software.
RESULTS
The search included 944 studies, 15 of which were eligible for inclusion, representing 726 patients treated with cervical cerclage and 8578 non-cerclage treatment controls. When the cervical length was <15 mm, the risk ratio of preterm birth at <37 weeks (0.77, p = 0.01), <34 weeks (0.58, p = 0.002), and <32 weeks (0.61, p = 0.024) of gestation in the cerclage group was significantly lower than that in the non-cerclage group.
CONCLUSION
For twin pregnancies with a cervical length <15 mm, cervical cerclage was associated with significant reduction in preterm birth.
Topics: Cerclage, Cervical; Cervix Uteri; Female; Humans; Infant, Newborn; Pregnancy; Pregnancy, Twin; Premature Birth
PubMed: 33773260
DOI: 10.1016/j.ejogrb.2021.03.013 -
American Journal of Obstetrics &... Jul 2023An emergency (rescue) cervical cerclage can be offered to pregnant women presenting with dilatation and prolapsed membranes in the second trimester of pregnancy because... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
An emergency (rescue) cervical cerclage can be offered to pregnant women presenting with dilatation and prolapsed membranes in the second trimester of pregnancy because of cervical insufficiency. This study aimed to investigate the effectiveness of an emergency cerclage in both singleton and twin pregnancies in the prevention of extreme premature birth.
DATA SOURCES
We performed a systematic literature search in PubMed and Embase from inception to June 2022 for transvaginal cervical emergency cerclages.
STUDY ELIGIBILITY CRITERIA
All studies on transvaginal cervical emergency cerclages with at least 5 patients and reporting survival were included.
METHODS
Included studies were assessed for quality and risk of bias with an adjusted Quality In Prognosis Studies tool. Random-effects meta-analyses and meta-regressions were performed for the primary outcome: survival.
RESULTS
Our search yielded 96 studies, incorporating 3239 women, including 14 studies with an expectant management control group, incorporating 746 women. Overall survival after cervical emergency cerclage was 74%, with a fetal survival of 88% and neonatal survival of 90%. Singleton and twin pregnancies showed similar survival, with a pregnancy prolongation of 52 and 37 days and a gestational age at delivery of 30 and 28 weeks, respectively. Meta-regression analyses indicated a significant inverse association between mean gestational age at diagnosis and pregnancy prolongation and no association between dilatation or gestational age at diagnosis and gestational age at delivery. Compared with expectant management, emergency cerclage significantly increased overall survival by 43%, fetal survival by 17% and neonatal survival by 22%, along with a significant pregnancy prolongation of 37 days and reduction in delivery at <28 weeks of gestation of 55%. These effects were more profound in singleton pregnancies than in twin pregnancies.
CONCLUSION
This systematic review indicates that, in pregnancies threatened by extreme premature birth because of cervical insufficiency, emergency cerclage leads to significantly higher survival, accompanied by significant pregnancy prolongation and reduction in delivery at <28 weeks of gestation, compared with expectant management. The mean gestational age at delivery was 30 weeks, independent of dilatation or gestational age at diagnosis. Survival was similar for singleton and twin pregnancies, implying that emergency cerclage should be considered in both.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Infant; Pregnancy, Twin; Cerclage, Cervical; Premature Birth; Cervix Uteri; Pregnancy Complications
PubMed: 37084870
DOI: 10.1016/j.ajogmf.2023.100971 -
Ceska Gynekologie 2019Contemporary role of cerclage as a preterm birth treatment. (Review)
Review
OBJECTIVE
Contemporary role of cerclage as a preterm birth treatment.
DESIGN
Review article.
SETTING
Department of Obstetrics and Gynecology of the First Faculty of Medicine and General Teaching Hospital in Prague.
METHODS
Research of existing literature, predominantly foreign journal articles, but also Czech literature and personal experience with the method.
RESULTS
Cerclage is one of the well-known surgical procedures carried out during pregnancy. Its aim is to provide a mechanical support to the cervical canal and to keep the cervix closed. The cervical mucous plug serves as a mechanical barrier between the vagina and the uterine cavity, but it also contains many immune components which protect the fetal compartment from ascendent infections. Application of a cervical stitch can help to retain the mucous plug and thus increases the immunity of the cervical canal. Results of 15 randomised studies (Cochraine Database of Systematic R) suggest that in women with increased risk of preterm birth, cerclage decreases the occurrence of preterm birth relative to the expectant management.
CONCLUSIONS
Despite the decreasing numbers of cerclage surgeries, it is still a useful method of preterm birth prevention for a specific group of women. More recently, a progesterone treatment has gained popularity. Its application, however, must begin before the 16th week of pregnancy.
Topics: Cerclage, Cervical; Cervical Length Measurement; Cervix Uteri; Female; Humans; Pregnancy; Premature Birth; Prenatal Care; Randomized Controlled Trials as Topic; Uterine Cervical Incompetence; Vagina
PubMed: 31213059
DOI: No ID Found