Meta-Analysis Review

Authors: Cecile C Hulshoff, Remko P Bosgraaf, Marc E A Spaanderman...

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

Review

Authors: Magdalena Wierzchowska-Opoka, Żaneta Kimber-Trojnar, Bożena Leszczyńska-Gorzelak...

Despite the progress of medicine in the last decades, recurrent pregnancy loss, premature birth, and related complications are still a vast problem. The reasons for recurrent pregnancy loss and preterm delivery are diverse and multifactorial. One of the main reasons for these complications is cervical insufficiency, which means that the cervix is weak and unable to remain closed until the date of delivery. It manifests as painless softening and shortening of the cervix without contractions. The aim of the study was to review the available literature on rescue sutures, which are an emergency treatment in pregnancies with premature cervical dilatation and protrusion of the fetal membranes in the second trimester of pregnancy. This review confirms that emergency cerclage reduces the rate of preterm birth in patients with advanced cervical insufficiency. This procedure prolongs gestational age and improves the chances of survival of the newborn without increasing the risk of chorioamnionitis and preterm premature rupture of membranes.

PubMed: 33803886
DOI: 10.3390/jcm10061270

Authors: Zaneta Kimber-Trojnar

PubMed: 32411749
DOI: 10.21037/atm.2020.03.137

Clinical Trial

Authors: Giuliano Testa, Greg J McKenna, Anji Wall...

IMPORTANCE

Uterus transplant in women with absolute uterine-factor infertility offers the possibility of carrying their own pregnancy.

OBJECTIVE

To determine whether uterus transplant is feasible and safe and results in births of healthy infants.

DESIGN, SETTING, AND PARTICIPANTS

A case series including 20 participants with uterine-factor infertility and at least 1 functioning ovary who underwent uterus transplant in a large US tertiary care center between September 14, 2016, and August 23, 2019.

INTERVENTION

The uterus transplant (from 18 living donors and 2 deceased donors) was surgically placed in an orthotopic position with vascular anastomoses to the external iliac vessels. Participants received immunosuppression until the transplanted uterus was removed following 1 or 2 live births or after graft failure.

MAIN OUTCOMES AND MEASURES

Uterus graft survival and subsequent live births.

RESULTS

Of 20 participants (median age, 30 years [range, 20-36]; 2 Asian, 1 Black, and 16 White), 14 (70%) had a successful uterus allograft; all 14 recipients gave birth to at least 1 live-born infant. Eleven of 20 recipients had at least 1 complication. Maternal and/or obstetrical complications occurred in 50% of the successful pregnancies, with the most common being gestational hypertension (2 [14%]), cervical insufficiency (2 [14%]), and preterm labor (2 [14%]). Among the 16 live-born infants, there were no congenital malformations. Four of 18 living donors had grade 3 complications.

CONCLUSIONS AND RELEVANCE

Uterus transplant was technically feasible and was associated with a high live birth rate following successful graft survival. Adverse events were common, with medical and surgical risks affecting recipients as well as donors. Congenital abnormalities and developmental delays have not occurred to date in the live-born children.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02656550.

Topics: Adult; Female; Humans; Pregnancy; Young Adult; Feasibility Studies; Graft Survival; Infertility, Female; Live Birth; Living Donors; Uterus; Prospective Studies

PubMed: 39145955
DOI: 10.1001/jama.2024.11679

Authors: Eeva-Marja Rutanen

Topics: Bed Rest; Cerclage, Cervical; Female; Humans; Obstetric Labor, Premature; Pregnancy; Pregnancy Outcome; Risk Assessment; Uterine Cervical Incompetence

PubMed: 17486456
DOI: 10.1080/00016340701239651

Evidence that antibiotic administration is effective in the treatment of a subset of patients with intra-amniotic infection/inflammation presenting with cervical insufficiency.

Authors: Kyung Joon Oh, Roberto Romero, Jee Yoon Park...

BACKGROUND

Cervical insufficiency is a risk factor for spontaneous midtrimester abortion or early preterm birth. Intra-amniotic infection has been reported in 8-52% of such patients and intra-amniotic inflammation in 81%. Some professional organizations have recommended perioperative antibiotic treatment when emergency cervical cerclage is performed. The use of prophylactic antibiotics is predicated largely on the basis that they reduce the rate of complications during the course of vaginal surgery. However, it is possible that antibiotic administration can also eradicate intra-amniotic infection/inflammation and improve pregnancy outcome.

OBJECTIVE

To describe the outcome of antibiotic treatment in patients with cervical insufficiency and intra-amniotic infection/inflammation.

STUDY DESIGN

The study population consisted of 22 women who met the following criteria: (1) singleton pregnancy; (2) painless cervical dilatation of >1 cm between 16.0 and 27.9 weeks of gestation; (3) intact membranes and absence of uterine contractions; (4) transabdominal amniocentesis performed for the evaluation of the microbiologic and inflammatory status of the amniotic cavity; (5) presence of intra-amniotic infection/inflammation; and (6) antibiotic treatment (regimen consisted of ceftriaxone, clarithromycin, and metronidazole). Amniotic fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas, and polymerase chain reaction for Ureaplasma spp. was performed. Intra-amniotic infection was defined as a positive amniotic fluid culture for microorganisms or a positive polymerase chain reaction for Ureaplasma spp., and intra-amniotic inflammation was suspected when there was an elevated amniotic fluid white blood cell count (≥19 cells/mm) or a positive rapid test for metalloproteinase-8 (sensitivity 10 ng/mL). For the purpose of this study, the "gold standard" for diagnosis of intra-amniotic inflammation was an elevated interleukin-6 concentration (>2.6 ng/mL) using an enzyme-linked immunosorbent assay. The results of amniotic fluid interleukin-6 were not available to managing clinicians. Follow-up amniocentesis was routinely offered to monitor the microbiologic and inflammatory status of the amniotic cavity and fetal lung maturity. Treatment success was defined as resolution of intra-amniotic infection/inflammation or delivery ≥34 weeks of gestation.

RESULTS

Of 22 patients with cervical insufficiency and intra-amniotic infection/inflammation, 3 (14%) had microorganisms in the amniotic fluid. Of the 22 patients, 6 (27%) delivered within 1 week of amniocentesis and the remaining 16 (73%) delivered more than 1 week after the diagnostic procedure. Among these, 12 had a repeat amniocentesis to assess the microbial and inflammatory status of the amniotic cavity; in 75% (9/12), there was objective evidence of resolution of intra-amniotic inflammation or intra-amniotic infection demonstrated by analysis of amniotic fluid at the time of the repeat amniocentesis. Of the 4 patients who did not have a follow-up amniocentesis, all delivered ≥34 weeks, 2 of them at term; thus, treatment success occurred in 59% (13/22) of cases.

CONCLUSION

In patients with cervical insufficiency and intra-amniotic infection/inflammation, administration of antibiotics (ceftriaxone, clarithromycin, and metronidazole) was followed by resolution of the intra-amniotic inflammatory process or intra-amniotic infection in 75% of patients and was associated with treatment success in about 60% of cases.

Topics: Adult; Amniocentesis; Amniotic Fluid; Anti-Bacterial Agents; Biomarkers; Candida albicans; Ceftriaxone; Cerclage, Cervical; Chorioamnionitis; Clarithromycin; Delivery, Obstetric; Female; Humans; Interleukin-6; Leukocytes; Matrix Metalloproteinase 8; Metronidazole; Pregnancy; Retrospective Studies; Streptococcus anginosus; Ureaplasma; Uterine Cervical Incompetence

PubMed: 30928565
DOI: 10.1016/j.ajog.2019.03.017

Review

Authors: B Shortle, R Jewelewicz

In the early 1950s, when treatment of cervical incompetence was first described, diagnosis seemed relatively simple and management favorable, but after more than 35 years of trying multiple variations of procedures and treatment regimens, no advances have been made. In 1959, Neser questioned the very existence of cervical incompetence as an entity, and concluded that, in the final analysis, the problem is a diagnostic one. Liberal use of cerclage in situations of moderate risk of preterm delivery or as a prophylactic measure for multiple gestation does not appear to improve outcome, as judged by prematurity or survival. Because of advances in neonatal care in the last decade, fetal survival has improved tremendously. It is hoped that, in the future, more objective and accurate criteria for the diagnosis of cervical incompetence will emerge, and that outcome of treatment will be measured not by fetal survival, but by prolongation of pregnancy and by birth weight. At present, making an unequivocal diagnosis of cervical incompetence remains an elusive, challenging, and unsolved problem.

Topics: Anti-Bacterial Agents; Cervix Uteri; Female; Humans; Pregnancy; Progesterone; Progestins; Surgical Wound Infection; Tocolytic Agents; Uterine Cervical Incompetence

PubMed: 2666173
DOI: 10.1016/s0015-0282(16)60839-7

Authors: Yi Huang, Qi Li, Weishe Zhang...

To evaluate the predictive effect of transvaginal ultrasound measurement of cervical length and cervical elasticity examination on cervical insufficiency in twin pregnancies. Data from twin pregnant women in our hospital were collected retrospectively, including relevant vaginal ultrasound parameters (e.g., cervical length, cervical elasticity score, and the strain value of each part of the cervix). We assessed the risk factors using receiver operating characteristic curve analysis to evaluate the predictive effect of each factor on the occurrence of cervical insufficiency. A total of 284 pregnant women with twin pregnancies, including 142 with cervical insufficiency and 142 without cervical insufficiency, were included. Significant differences between the two groups were observed in the use of assisted reproductive technology, age, history of second-trimester miscarriage, etc. The cervical length of pregnant women with cervical insufficiency was significantly shorter at 22-24 weeks of gestation. Cervical length had the largest area under the receiver operating characteristic curve for predicting cervical insufficiency at that time. The area under the curve of cervical insufficiency predicted by the cervical elasticity score at 12-14 weeks of pregnancy was greater than that predicted by the cervical length at the same time, and the area under the curve of cervical insufficiency predicted by the elasticity score and pre-pregnancy body mass index during the same period was the largest. The cervical elasticity score at 12-14 weeks of gestation effectively predicted the occurrence of cervical insufficiency. The combination of the cervical elasticity score and pre-pregnancy body mass index predicted cervical insufficiency in women with twin pregnancies.

Topics: Humans; Female; Pregnancy; Adult; Elasticity Imaging Techniques; Pregnancy, Twin; Cervix Uteri; Retrospective Studies; ROC Curve; Uterine Cervical Incompetence; Cervical Length Measurement; Risk Factors; Ultrasonography, Prenatal

PubMed: 39628693
DOI: 10.7150/ijms.99444