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Preterm birth is the most common maternal complication in twin pregnancies. In recent years, cervical cerclage has been of long-standing interest in the prevention of preterm birth in twin pregnancies. However, its clinical application in the treatment of cervical insufficiency of twin pregnancies remains a controversial subject. In addition, infection or inflammation conditions are considered to be closely related to the perinatal outcomes of twin pregnancies after cervical cerclage. This paper reviews the research progress on cervical cerclage in twin pregnancies, recommending cervical cerclage for twin pregnancies with cervical length≤15 mm or cervical dilatation, while it is not suggested for those with cervical length of 15-25 mm or history-indicated cervical cerclage. The clinical significance of preoperative evaluation of intraamniotic infection or inflammation of twin pregnancies needs to be further explored, but it is necessary to avoid the effect of antibiotic use on the evaluation of surgical effects.

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Objective:To compare the maternal and fetal outcomes of women with cervical insufficiency (CI) undergoing McDonald cerclage (MC) and laparoscopic cervicoisthmic cerclage (LCC), so as to provide evidence for the selection of cerclage methods.Methods:A retrospective trial was carried out in the First Affiliated Hospital of Sun Yat-sen University from January 2010 to December 2020. A total of 221 women who underwent the prophylactic cerclage were divided into MC group ( n=54), LCC with MC history group ( n=28) and LCC without MC history group ( n=129) by the mode of operation and whether the pregnant women who underwent LCC had MC history. General clinical data, pregnancy complications and pregnancy outcomes were compared between the three groups. Results:(1) General clinical data: the proportion of women accepted cervical cerclage during pregnancy in MC group, LCC with MC history group and LCC without MC history group were 100.0% (54/54), 7.1% (2/28) and 27.1% (35/129), respectively ( P<0.001). The indications of the three groups showed statistical significance ( P=0.003), and the main indication was the history of abortion in the second and third trimester [75.9% (41/54) vs 89.3% (25/28) vs 84.5% (109/129)]. (2) Pregnancy complications: the incidence of abnormal fetal position [7.8% (4/51) vs 17.4% (4/23) vs 19.8% (24/121)], placenta accrete [5.9% (3/51) vs 13.0% (3/23) vs 11.6% (14/121)], uterine rupture [0 vs 4.3% (1/23) vs 5.8% (7/121)] in the MC group were all lower than those in LCC with MC history and LCC without MC history groups. However, there were no statistical significances (all P>0.05). Intrauterine inflammation or chorioamnionitis [15.7% (8/51) vs 0 vs 0.8% (1/121)] and premature rupture of membrane [23.5% (12/51) vs 4.3% (1/23) vs 0] were both significantly higher in MC group than those in LCC with MC history and LCC without MC history groups (all P<0.001). (3) Pregnancy outcomes: the cesarean section rate was significantly lower in MC group (41.2%, 21/51) than that in LCC with MC history group (100.0%, 23/23) and LCC without MC history group (100.0%, 121/121; P<0.001). MC group was associated with lower expenditure than LCC with MC history and LCC without MC history groups (12 169 vs 26 438 vs 27 783 yuan, P<0.001). The success rates of live birth cerclage did not differ significantly in MC (94.4%, 51/54), LCC with MC history (82.1%, 23/28) and LCC without MC history (93.8%, 121/129) groups ( χ2=5.649, P=0.059). There was no significant difference in neonatal intensive care unit occupancy, neonatal birth weight and neonatal asphyxia between the three groups (all P>0.05). Conclusions:Both LCC and MC are the treatment choice for women with CI, which may get similar liver birth. However, MC has the advantages of low cesarean section rate, economical and easy operation. Therefore, MC is recommended as the first choice for CI patients, and LCC is for women with failed MC.

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Cervical incompetence is a common cause of late abortion and premature birth, which can be effectively treated by cervical cerclage. Controversy remains on the timing and perioperative management of cervical cerclage based on different indications. This paper briefly reviews the current differences and debates and elaborates some opinions regarding cervical cerclage in order to provide a reference for clinical decision-making and research.

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Objective:To compare the effect of two vs one stitch on outcomes in women with cervical incompetence who undergo emergency transvaginal cervical cerclage.Methods:A retrospective study was conducted on 38 cases of cervical incompetence patients who underwent emergency cervical cerclage at Fujian Maternity and Child Health Hospital from January 2018 to December 2022. These subjects were divided into two groups: one stitch group (loop continuous suture and knot at cervical-vaginal junction level) and two stitches group (the first loop was closed with a single suture set, and the second loop was closed below the first loop near the cervical outlet) with 19 cases in each group. Two independent samples t or t'-test, rank-sum test, Chi-square test and Fisher's exact test were used to compare the differences in perinatal outcomes between the two groups. Kaplan-Meier survival analysis was performed to evaluate the efficacy of the prolongation of gestational age after emergency transvaginal cervical cerclage. Results:There was no statistically significant difference in the gestational age at cervical cerclage between the two stitches and the one stitch group [24.9 weeks (23.9-25.9 weeks) vs 23.6 weeks (22.6-24.9 weeks), Z=－1.61, P=0.108]. The average gestational age at delivery [(33.1±4.8) vs (28.6±4.3) weeks, t=－3.10] and the prolongation of gestational age after cerclage[(8.5±4.6) vs (5.0±2.6) weeks, t=－2.90] were significantly greater in the two stitches group compared to those in the one stitch group, while the rates of preterm birth before 32 weeks (6/19 vs 16/19, χ2=10.80), 34 weeks (8/19 vs 17/19, χ2=9.47), and 37 weeks (14/19 vs 19/19, Fisher's exact test) were lower (all P<0.05). The Kaplan-Meier survival analysis demonstrated that the two stitches group had significantly higher efficacy in prolonging gestational age compared to the one stitch group [log-rank test χ2 (1)=13.10, P<0.05]. Although there was no statistically significant difference in the neonatal mortality between the two groups (2/19 vs 4/19, Fisher's exact test, P=0.660), survival neonates in the two stitches group had significantly higher birth weight [2 370.0 g (1 775.0-2 710.0 g) vs 1 300.0 g (1 210.0-1 660.0 g), Z=－3.14], lower admission rate to the neonatal intensive care unit (9/17 vs 15/15, Fisher's exact test), lower incidence of stage Ⅲ necrotizing enterocolitis (0/17 vs 5/15, Fisher's exact test), moderate-severe respiratory distress syndrome (5/17 vs 10/15, χ2=4.44), and grade Ⅲ-Ⅳ intraventricular hemorrhage (0/17 vs 7/15, Fisher's exact test) compared to those in the one stitch group (all P<0.05). Conclusion:Compared with emergency cervical cerclage with one stitch, the procedure with two stitches can prolong the gestational age and improve the neonatal prognosis more effectively.

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Objective:To explore the clinical efficacy of ultrasound-indicated cervical cerclage in twin pregnancies.Methods:This retrospective cohort study included 96 asymptomatic twin pregnancies with cervix length (CL)≤2.5 cm at 16-27 +6 weeks indicated by transvaginal ultrasound from January 2013 to May 2022 in Fujian Maternity and Child Health Hospital. They received either cervical cerclage (cerclage group, n=45) or conservative treatment (conservative group, n=51). The subgroup analysis was further performed after stratifying the subjects into the CL≤1.0 cm subgroup, the CL>1.0-≤1.5 cm subgroup, and the CL>1.5 cm subgroup. Two independent samples t-test, Mann-Whitney U test, and Chi-square test were used to compare the differences in the pregnancy and perinatal outcomes between different groups. Multivariate logistic regression was used to analyze the impact of cervical cerclage on pregnancy outcomes of women with different CLs. Results:The average gestational age at delivery and the prolonged gestation were significantly greater in the cerclage group than those in the conservative group [35.9 (34.9-37.0) weeks vs 34.9 (29.1-36.1) weeks; 10.7 (9.6-13.1) weeks vs 8.7 (4.8-11.0) weeks, Z=－2.59 and -3.63, both P<0.05]. The incidences of preterm birth before 34 weeks and 28 weeks, chorioamnionitis, and preterm premature rupture of membrane were lower in the cerclage group than those in the conservative group [17.8% (8/45) vs 45.1% (23/51), χ2=8.16; 2.2% (1/45) vs 15.7% (8/51), Fisher' exact test; 8.9% (4/45) vs 25.5% (13/51), χ2=4.52; 15.6% (7/45) vs 33.3% (17/51), χ2=4.03; all P<0.05]. There were no statistically significant differences in the proportion of postpartum hemorrhage and live births between the two groups (both P>0.05). In the women with CL≤1.0 cm, the cerclage group had a greater gestational age at delivery [36.0 (34.8-37.3) weeks vs 34.9 (28.6-35.4) weeks, Z=－2.61, P=0.009], greater prolonged gestation [12.3 (9.7-13.9) weeks vs 7.3 (3.4-9.1) weeks, Z=－3.34, P=0.001], higher birthweight [2 430.0 (2 173.8-2 646.3) g vs 1 900.0 (1 372.5-2 435.0) g, Z=－3.06, P=0.002], lower incidence of adverse neonatal outcomes [16.7% (6/36) vs 36.7% (11/30), χ2=4.22, P=0.048] compared with the conservative group. Multivariate Logistic regression analysis showed that cerclage reduced the risks of preterm birth before 34 and 32 weeks [ aOR (95% CI)=0.083 (0.009-0.790) and 0.092 (0.009-0.939), both P<0.05]. However, cerclage did not reduce the risk of preterm birth in women with CL>1.5 cm or CL>1.0-≤1.5 cm (both P>0.05). Conclusion:Ultrasound- indicated cervical cerclage can reduce the risk of preterm birth before 34 and 32 weeks, prolong pregnancy, and improve perinatal outcomes in asymptomatic twin pregnancies with CL≤1.0 cm.

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Objective:To investigate the changes in cervical length (CL) after history- indicated cerclage through serial ultrasound measurements and the predictive value of short cervix (CL≤2.5 cm) before 24 gestational weeks after cerclage in preterm delivery before 34 weeks.Methods:In this retrospective study, clinical data of 145 singleton pregnancies with history-indicated McDonald cerclage at Peking University First Hospital from January 2010 to June 2021 were collected. CL was measured through transvaginal ultrasound and recorded during the perioperative period and at ≥20-24, ≥24-28, and ≥28-32 weeks of gestation. The participants were divided into ≥34 weeks group ( n=118) and <34 weeks group ( n=27) based on the gestational age at delivery. Chi-square or independent sample t test was applied for comparison between the two groups. The relationship between CL after cerclage and preterm birth before 34 week in the two groups was analyzed using multivariate logistic regression analysis. The risk of preterm birth in women with short cervix at 20-24 weeks of gestation after cerclage was estimated. The receiver operator characteristic curve was adopted for predicting the diagnostic value of postoperative CL on pregnancy outcomes. Results:(1) Among the 145 cases, 106 cases (73.1%) had term delivery, 27 cases (18.6%) had premature delivery before 34 weeks, among which seven cases (4.8%) had late miscarriage before 28 weeks (including two cases with survived viable infants). The overall live birth rate was 96.6% (140/145). (2) In the ≥34 weeks group, CL at ≥20-24, ≥24-28, and ≥28-32 weeks of gestation were significantly longer than those in the <34 weeks group [(3.35±0.73) vs (2.39±1.03) cm, t=5.69, P=0.008; (3.14±0.75) vs (2.14±1.10) cm, t=5.65, P=0.007; (2.91±0.85) vs (1.79±1.09) cm, t=5.84, P=0.005]. (3) Multivariate logistic regression analysis showed that CL at ≥20-24, ≥24-28, and ≥28-32 weeks after cerclage were the influencing factors of preterm birth before 34 weeks [ OR (95% CI)=0.885 (0.837-0.935), 0.886 (0.837-0.937), 0.890 (0.842-0.940), respectively, all P<0.001]. (4) The area under the curve of CL at ≥20-24, ≥24-28, and ≥28-32 weeks were 0.747, 0.734, and 0.799 for predicting delivery before 34 weeks, with the sensitivity of 60.0%, 60.0%, and 80.0%, and the specificity of 87.5%, 91.3%, and 76.9%, respectively. (5) At ≥20-24 weeks after cervical cerclage, women with a short cervix accounted for 17.2% (25/145), who were 12.7 times more likely to have premature birth before 34 weeks than those with a CL over 2.5 cm ( OR=12.7, 95% CI: 4.58-35.40, P<0.001). Conclusions:Among pregnant women with history-indicated cervical cerclage, CL after cerclage at ≥20-24, ≥24-28, and ≥28-32 weeks of gestation have predictive values for pregnancy outcomes. A short cervix at ≥20-24 weeks of pregnancy after cerclage could predict premature birth before 34 weeks.

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Objective:To investigate the incidence and risk factors associated with preterm premature rupture of membranes (PPROM) following transvaginal cervical cerclage.Methods:This retrospective cohort study involved 170 singleton pregnancies with cervical incompetence who underwent vaginal cervical cerclage at Fujian Maternity and Child Health Hospital from January 2021 to January 2022. Based on the onset of PPROM after cervical cerclage, the patients were divided into the PPROM group ( n=28) and the non-PPROM group ( n=142). Independent samples t-test, rank-sum test, Chi-square test, or Fisher's exact test were used to compare the general condition, pre- and postoperative data, pregnancy complications or comorbidities between the two groups, with a significance level at α=0.1. Multiple logistic regression analysis was conducted to identify the risk factors for PPROM after cerclage surgery. Results:The overall incidence of PPROM after vaginal cervical cerclage was 16.5% (28/170). Logistic regression analysis showed that a history of cervical conization ( OR=11.966, 95% CI:1.695-84.468), the use of Mersilene RS22 tape as the suture material ( OR=3.318, 95% CI:1.064-9.252), cervical length<2.5 cm after cerclage ( OR=3.486, 95% CI:1.116-10.888), and Mycoplasma genitalium- positive results for cervical secretion culture after surgery ( OR=4.856, 95% CI:1.487-15.861) were the independent risk factors for PPROM after cervical cerclage (all P<0.05). Conclusions:The incidence of PPROM following vaginal cervical cerclage is relatively high and can have unfavorable effects on pregnancy outcomes. Factors such as a history of cervical conization, the use of Mersilene RS22 tape for cerclage, cervical length<2.5 cm after cerclage, and Mycoplasma genitalium-positive results for cervical secretion culture after surgery may increase the risk of PPROM after cerclage.

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BACKGROUND: Abdominal cerclage is indicated for some women with cervical insufficiency. Long-term complications from cerclage are rare. CASE: Here we report the case of a patient who presented with recurrent urinary tract infection and hematuria 5 years after laparoscopic abdominal cerclage. Cystoscopy revealed bladder stones surrounding a foreign body. Another cystoscopy 3 months later showed complete erosion of the cerclage into the bladder. CONCLUSION: This case reminds us that differential diagnosis of urinary symptoms in women who have undergone cervical cerclage should include suture erosion into the bladder. Cerclage removal can be offered to women who have completed childbearing to prevent this rare complication.

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Objective:To investigate the efficacy of modified vaginal cervical cerclage in the treatment of cervical insufficiency during pregnancy.Methods:The clinical data of 18 women with cervical insufficiency during pregnancy who received treatment in Changzhi Maternal and Child Health Hospital from January 2018 to January 2020 (including nine cases receiving modified Shirodkar operation and nine cases receiving modified McDonald operation) were retrospectively analyzed.Results:The operation process was successful in all 18 women, and there were no postoperative complications. After modified Shirodkar operation, the average gestational weeks were prolonged by 14.7 weeks. Six cases had a smooth vaginal delivery [full-term delivery in five cases and preterm premature rupture of membranes (35 weeks + 1 day) in one case]. Three women had a cesarean delivery [cesarean delivery at full-term in two cases, including twin pregnancy in one case and previous cesarean delivery in one case; preterm premature rupture of membranes because of chorioamnionitis (32 weeks + 1 day) with poor prognosis in one case]. The rate of holding babies home was 88.9%. After modified McDonald operation, the average gestational weeks were prolonged by 11.5 weeks. Five cases had a smooth vaginal delivery [full-term delivery in three cases, preterm premature rupture of membranes in one case (35 weeks + 3 days) and in one case (31 weeks)]. Three women had a cesarean delivery at full-term [secondary cesarean delivery in one case, twin pregnancy in one case, and preterm premature rupture of membrane because of preeclampsia in one case]. One case had infectious abortion, and the rate of holding the baby home was 88.9%.Conclusion:Selection of different modified operations according to the length of cervical canal can prolong gestational weeks and increase the survival rate of newborns. The modified vaginal cervical cerclage is simple and easy to operate with minimal damage to pregnant women, which is suitable for clinical promotion.

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Objective:To discuss the surgical effect of modified cervical cerclage for the treatment of pregnant women with cervical insufficiency.Methods:The clinical data of 225 pregnant women who underwent modified cervical cerclage in Qilu Hospital (Qingdao) were selected for retrospective analysis from April 2014 to June 2020. Surgical success rate, full-term birth rate, preterm birth rate, prolonged pregnancy weeks and newborn birth weight were compared between singleton and twin pregnancies, preventive cerclage and emergency cerclage, surgery before and after 18 weeks, naturally and in vitro fertilization and embryo transfer (IVF-ET) conceived pregnant women respectively.Results:Among the 225 pregnant women, the gestational weeks of surgery were 14-24 +5 weeks, mean gestational weeks of delivery were 38 +2 weeks (35 +5-39 +3 weeks), the number of prolonged gestation were (20.3±5.2) weeks, and the newborn birth weight was (3 065±735) g; the overall surgical success rate was 92.9% (209/225), and the miscarriage rate was 7.1% (16/225); among the surviving newborns, the full-term birth rate was 73.7% (154/209), and the preterm birth rate was 26.3% (55/209). All cases had no intraoperative complications. Among the 225 pregnant women, 202 (89.8%, 202/225) cases were singleton pregnancies, and 23 (10.2%, 23/225) cases were twin pregnancies; 201 (89.3%, 201/225) cases underwent preventive cervical cerclage, and 24 (10.7%, 24/225) cases underwent emergency cervical cerclage; 190 (84.4%, 190/225) cases underwent the surgery before 18 weeks, and 35 (15.6%, 35/225) cases underwent the surgery after 18 weeks; 49 (21.8%, 49/225) cases were conceived by IVF-ET. There was no statistically significant difference in the overall surgical success rate of single and twin group ( P>0.05). The full-term birth rate, newborn birth weight and prolonged pregnancy weeks of single group were higher than those of twin group ( P<0.05). There were no statistical differences between preventive and emergency cerclage in overall surgical success rate, full-term birth rate, preterm birth rate, and newborn birth weight (all P>0.05). The pregnancy prolonged weeks of preventive cerclage was higher than that of emergency cerclage ( P<0.05). There were no statistically significant differences in the overall surgical success rate, full-term birth rate, preterm birth rate and birth weight of newborns at different surgical timings (all P>0.05). The pregnancy prolonged week for those who underwent surgery before 18 weeks was higher than that of surgery after 18 weeks ( P<0.05). The premature birth rate of IVF-ET was higher than that of naturally conceived pregnant women ( P<0.05). Conclusion:The modified cervical cerclage could effectively prolong the gestational weeks of delivery, reduce the rate of preterm birth, and the operation is simple and easy to promote. It could be used as a surgical option for patients with cervical insufficiency.

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OBJECTIVES: • To assess the association between sonography-derived cervical length measurement and preterm birth. • To describe the various techniques to measure cervical length using sonography. • To review the natural history of the short cervix. • To review the clinical uses, predictive ability, and utility of sonography-measured short cervix. OUTCOMES: Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions. INTENDED USERS: Clinicians involved in the obstetrical management or cervical imaging of patients at increased risk of a short cervix. TARGET POPULATION: Women at increased risk of a short cervix or at risk of preterm birth. EVIDENCE: Literature published up to June 2019 was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, cervical insufficiency, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date or language restrictions. Grey (unpublished) literature was identified through searching the websites of health technology assessment agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The evidence and this guideline were reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made and graded according to the rankings of the Canadian Task Force on Preventive Health Care (Online Appendix Table A1). BENEFITS, HARMS, COSTS: Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the sonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth. SUMMARY STATEMENTS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES): RECOMMENDATIONS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES).

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Objective: To explore the surgical opportunity of the transvaginal cervicoisthmic cerclage in the treatment of the cervical incompetence and the effect on the pregnancy outcomes. Methods: A Retrospective controlled trial was carried out between January 2014 and December 2018 in the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital in Zhejiang, China and a total of 1 027 patients with cervical incompetence underwent the transvaginal cerclage. According to the different surgical opportunity, the patients were divided into two groups: the conception cerclage (n=736) and the preconception cerclage (n=291), and the former were divided into two subgroups depending on the condition of the cervix, the history indicated conception cerclage (n=511) and the ultrasound indicated conception cerclage (n=225). Main outcome measures were the gestational age, term delivery rate, the fetal weight and the fetal survival rate. Results: After the cerclage, the gestational age was (36±4) weeks, the term delivery rate was 69.6% (710/1 020), the fetal weight was (3 038±624)g and the fetal survival rate was 94.7% (966/1 020). Compared with the ultrasound indicated conception cerclage subgroup, the gestational age, the term delivery rate, and the fetal weight were all significantly higher in the history indicated conception cerclage subgroup [(37±4) vs (36±5) weeks, t=2.691; 72.8% vs 62.7%,χ(2)=7.593; (3 091±594) vs (2 963±756) g, t=2.396; all P<0.05], but the fetal survival rate was comparable in these two groups(95.3% vs 92.9%, χ(2)=1.772, P>0.05). There were no significant differences in the gestational age, the term delivery rate, the fetal weight and fetal survival rate between the history indicated conception cerclage and the preconception cerclage (all P>0.05). Conclusion: The transvaginal cervicoisthmic cerclage is a promising and safe technique for improving obstetric outcomes in women with cervical incompetence, and the history indicated conception cerclage is better than the ultrasound indicated cerclage.

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Background: Preterm birth remains a major cause of neonatal morbidity and mortality. Several potential pathways and pathophysiologic processes can lead to preterm birth, complicating efforts to screen for the risk of preterm birth and making implementation of prevention strategies difficult. Methods: Based on a review of the literature, this article addresses screening strategies for preterm birth risk stratification and interventions for preterm birth prevention. Results: In women with a history of a prior spontaneous preterm birth, cervical cerclage placement in the setting of short cervix reduces the rate of recurrent spontaneous preterm birth. Weekly injections of 17-hydroxyprogesterone caproate (17-P) have been used as standard treatment for the prevention of recurrent preterm birth since 2011. However, results of a replication study of 17-P published in 2020 have raised questions regarding the effectiveness of this drug, and it is under review by the US Food and Drug Administration. Among women with no history of preterm birth, cervical length appears to be the best predictor of risk for preterm birth in asymptomatic women. In women with a cervical length <25 mm, vaginal progesterone has been demonstrated to reduce the risk of preterm birth. Conclusion: Strategies including cervical length screening, vaginal progesterone administration, cervical cerclage placement, and, potentially, 17-P administration may help reduce rates of preterm birth when used in the appropriate patient populations. Development of protocols for patient evaluation and risk stratification will help identify patients at highest risk for preterm birth and allow use of the best available therapeutic interventions.

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Resumen OBJETIVO: Reportar la experiencia en la práctica de cerclajes con indicación profiláctica y terapéutica en pacientes con embarazo único o múltiple, con insuficiencia cervical. Además, informar los días de gestación ganados y comparar las técnicas quirúrgicas con los cerclajes. MATERIALES Y MÉTODOS: Estudio retrospectivo, descriptivo, comparativo y transversal efectuado entre enero de 2011 y enero de 2018. Criterios de inclusión: pacientes a quienes se efectuó un cerclaje y el embarazo finalizó en nuestra unidad. Variables de estudio: edad, IMC, embarazos, abortos, días de gestación ganados, días en que se efectuó el procedimiento quirúrgico, semanas de gestación cumplidas a la finalización del embarazo, tiempo quirúrgico, medicamentos (tocolíticos y antibióticos), complicaciones a partir del cerclaje hasta la finalización del embarazo. Para el análisis descriptivo se utilizó el paquete estadístico IBM SPSS (versión 22); la distribución se obtuvo con t de Student, se aplicó la prueba de normalidad Shapiro-Wilk y las variables con distribución normal se analizaron, comparativamente, con ANOVA y las de distribución anormal con la prueba Kruskal-Wallis. RESULTADOS: Se analizaron 37 casos en los que el cerclaje prolongó 116.14 ± 47.4 días la gestación, con finalización promedio del embarazo a los 246.41 ± 26.54 días. El cerclaje Shirodkar fue superior: prolongó la gestación 134.69 días con finalización del embarazo a las 36 ± 2 semanas. CONCLUSIONES: En pacientes con insuficiencia cervical el cerclaje es una opción para prolongar el embarazo. La técnica Shirodkar tuvo márgenes de mayor seguridad hasta la finalización del embarazo (más de 34 semanas). El comportamiento en embarazos múltiples es similar, por lo que en caso de insuficiencia cervical debe aplicarse.

Abstract OBJECTIVE: To report the experience in the practice of cerclages with prophylactic and therapeutic indication in patients with single or multiple pregnancy, with cervical incompetence. In addition, report the days of pregnancy gained, compare surgical techniques and cerclages in single and multiple gestations. MATERIALS AND METHODS: Retrospective, descriptive, comparative and cross-sectional study carried out between January 2011 and January 2018. Inclusion criteria: patients who had a cerclage and the pregnancy ended in our unit. Study variables: age, BMI, pregnancies, abortions, days of gestation earned, days in which they were placed, weeks of gestation completed at the end of pregnancy, surgical time, medications (tocolytics and antibiotics), complications from the placement of the cerclage until the end of pregnancy. For the descriptive analysis the statistical package IBM SPSS (version 22) was used; the distribution was obtained with Student's t test, the Shapiro-Wilk normality test was applied and the variables with normal distribution were analyzed, comparatively, with ANOVA and those with abnormal distribution with the Kruskal-Wallis test. RESULTS: 37 cases were analyzed in which the placement of cerclage prolonged 116.14 ± 47.4 days gestation, with an average termination of pregnancy at 246.41 ± 26.54 days. The Shirodkar cerclage was superior: it extended gestation 134.69 days with the end of pregnancy at 36 ± 2 weeks. CONCLUSIONS: In patients with cervical incompetence cerclages are an option to prolong pregnancy. The Shirodkar technique had higher safety margins until the end of pregnancy (more than 34 weeks). The behavior in multiple pregnancies is similar, so in case of cervical incompetence should be applied.

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SUMMARY BACKGROUND: The gestational and neonatal outcomes of women with early cervical dilatation undergoing emergency cerclage were evaluated and compared with women treated with expectant management and bed rest. METHODS: Retrospective analysis of pregnant women admitted between 2001 and 2017 with a diagnosis of early cervical dilatation and/or bulging membranes. Patients with a singleton pregnancy of a fetus without malformations, between 16 and 25 weeks and 6 days, with cervical dilatation of 1 to 3 cm were included; patients who delivered or miscarried within 2 days after admission were excluded. RESULTS: The study enrolled 30 patients: 19 in the cerclage group and 11 in the rest group. There was a significant difference, with the cerclage group showing better results concerning gestational age at delivery (28.7 vs. 23.3 weeks; p=0.031) and latency between hospital admission and delivery (48.6 vs. 16 days; p=0.016). The fetal death rate was lower in the cerclage group (5.3% vs. 54.5%, p=0.004). Considering gestational age at delivery of live newborns, no difference was observed between the cerclage and rest groups (29.13 vs. 27.4 weeks; p=0.857). CONCLUSIONS: Emergency cerclage was associated with longer latency, a significant impact on gestational age at delivery and reduction in the fetal death rate.

RESUMO OBJETIVO: Os resultados gestacionais e neonatais de mulheres com cervicodilatação precoce submetidas à cerclagem de emergência foram avaliados e comparados com mulheres tratadas com manejo expectante com repouso no leito. MÉTODOS: Análise retrospectiva de gestantes admitidas entre 2001 e 2017 com diagnóstico de cervicodilatação precoce e/ou membranas protrusas. Foram incluídas pacientes com gestação única de feto sem malformações, entre 16 semanas e 25 semanas e 6 dias, com dilatação cervical de 1 a 3 cm; as pacientes que tiveram parto ou aborto dentro de 2 dias após admissão foram excluídas. RESULTADOS: O estudo envolveu 30 pacientes: 19 no grupo cerclagem e 11 no grupo repouso. Houve diferença significativa, com o grupo cerclagem apresentando melhores resultados em relação à idade gestacional no parto (28,7 vs. 23,3 semanas; p=0,031) e à latência entre a admissão hospitalar e o parto (48,6 vs. 16 dias; p=0,016). A taxa de mortalidade fetal foi menor no grupo cerclagem (5,3% vs. 54,5%, p=0,004). Considerando a idade gestacional no nascimento dos recém-nascidos vivos, não houve diferença entre os grupos cerclagem e expectante (29,13 vs. 27,4 semanas; p=0,857). CONCLUSÕES: A cerclagem de emergência foi associada a maior período de latência com impacto significativo na idade gestacional do parto e à redução da taxa de mortalidade fetal.

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OBJECTIF: La présente directive clinique vise à fournir aux cliniciens un cadre à utiliser pour déterminer quelles femmes présentent un risque accru d'insuffisance cervicale et dans quelles situations le cerclage aurait une valeur potentielle. DONNéES PROBANTES: Nous avons examiné des études publiées récupérées au moyen de recherches dans PubMed, Medline, CINAHL et The Cochrane Library en 2018 à l'aide d'une terminologie (p. ex., uterine cervical incompetence) et de mots-clés (p. ex., cervical insufficiency, cerclage, Shirodkar cerclage, McDonald cerclage, abdominal, cervical length, mid-trimester pregnancy loss). Nous avons tenu compte des résultats provenant de revues systématiques, d'essais cliniques randomisés, d'essais cliniques contrôlés et d'études observationnelles. Aucune restriction de date ou de langue n'a été employée. Les recherches ont été refaites régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en juin 2018. Nous avons également tenu compte de la littérature grise (non publiée) trouvée sur les sites Web d'organismes d'évaluation des technologies de la santé et d'autres organismes liés aux technologies de la santé, dans des collections de directives cliniques et des registres d'essais cliniques, et obtenue auprès d'associations nationales et internationales de médecins spécialistes. VALEURS: La qualité des données probantes a été évaluée en fonction des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. RECOMMANDATIONS.

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Objective: To investigate the relationship between the level of amniotic fluid inflammatory factor and the pregnancy outcome in patients with cervical incompetence. Methods: A retrospective case-control study was conducted. Totally 110 cases of pregnant women were diagnosed as cervical incompetence for cervical dilation at the medical examination in Sun Yat-sen Memorial Hospital of Sun Yatsen University, from January 1st, 2015 to December 31th, 2016. A total of 32 patients (29.1%, 32/110) were performed cervical cerclage. According to their neonatal outcomes, they were divided into live infant group (23 cases, 72%) and dead infant group (9 cases, 28%) . The demographic and clinical data of two groups were analyzed and compared. Results: The mean peripheral blood leucocyte counts, the median amniotic tumor necrosis factor-α (TNF-α) and the median interleukin-8 (IL-8) level of two groups were (10.5±2.8) ×10(9)/L vs (13.6±3.1) ×10(9)/L, 23.80 ng/L (14.9-85.5 ng/L) vs 379.00 ng/L (70.2-418.5 ng/L) , and 3 354 ng/L (1 020-7 500 ng/L) vs 7 500 ng/L (4 210-7 500 ng/L) respectively. The differences were statistically significant (all P<0.05) . The amniotic fluid IL-1ß, IL-2 receptor, IL-6, IL-10, C-reactive protein and procalcitonin were not significantly different (all P>0.05) between two groups. Conclusions: The peripheral blood leucocyte counts, amniotic fluid TNF-α and IL-8 level are the factors affecting the pregnancy outcome in women with cervical incompetence before cervical cerclage. When IL-8 is higher than 3 580 ng/L and TNF-α is higher than 105 ng/L, the death of perinatal infants could be predicted.

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SUMMARY OBJECTIVE: Cervical cerclage is the standard treatment for cervical incompetence (CI); however, there is still a high risk of preterm birth for women who undergo this treatment. The aim of this study was to longitudinally evaluate findings on two-dimensional transvaginal ultrasonography (2DTVUS) and three-dimensional transvaginal ultrasonography (3DTVUS) that could be related to gestational age at birth. METHODS: A total of 68 pregnant women who were treated with cerclage were evaluated by 2DTVUS and 3DTVUS in the second and third trimesters of pregnancy. Log-rank tests and Cox regression analyses were used to identify significant findings related to gestational age at delivery. RESULTS: A cervical length lower than 281 mm (p= 0.0083), a proximal cervical length lower than 10 mm (p= 0.0151), a cervical volume lower than 18.17 cm3 (p= 0.0152), a vascularization index (VI) under 2.153 (p= 0.0044), and a vascularization-flow index (VFI) under 0.961 (p= 0.0059) in the second trimester were all related to earlier delivery. In the third trimester, a cervical length lower than 20.4 mm (p= 0.0009), a VI over 0.54 (p= 0.0327) and a VFI over 2.275 (p= 0.0479) were all related to earlier delivery. Cervical funnelling in the second and third trimesters and proximal cervical length in the third trimester were not related to gestational age at birth. The COX regression analyses showed that cervical volume in the second trimester; FI and VFI in the third trimester were significantly associated with gestational age at birth. CONCLUSION: In women treated with history-indicated cerclage or ultrasound-indicated cerclage, 2nd trimester cervical volume and 3rd trimester FI and VFI are independent significant sonographic findings associated with time to delivery.

RESUMO OBJETIVOS: Determinar quais características ultrassonográficas obtidas por meio da ultrassonografia transvaginal bidimensional (USG TV 2D) e tridimensional (USG TV 3D) associam-se ao parto prematuro em gestantes submetidas à cerclagem profilática e terapêutica. MÉTODOS: Sessenta e seis gestantes com feto único submetidas à cerclagem profilática ou terapêutica e acompanhadas no ambulatório de Aborto Habitual da Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina da USP, entre 10 de juho de 2012 e 30 de outubro de 2015, foram avaliadas longitudinalmente, por meio das US TV 2D e US TV 3D associadas ao power Doppler para avaliação do VI, FI e VFI, nos três trimestres da gestação. Os resultados foram avaliados em relação ao parto em idade gestacional (IG) menor que 34 semanas e maior ou igual a 34 semanas, assim como em relação à idade do parto como variável contínua. RESULTADOS: O comprimento do colo uterino (CC) e a distância do ponto de cerclagem ao orifício interno do colo uterino (POI) diminuíram de forma significativa entre o segundo e terceiro trimestres da gestação. O CC, o POI e o afunilamento cervical no terceiro trimestre da gestação tiveram relação com a ocorrência de parto em IG<34 semanas. Na análise de regressão de COX, em que a variável de interesse foi o tempo até o parto, o volume do colo uterino no segundo trimestre e o FI e VFI no terceiro trimestre foram significativos. CONCLUSÃO: Foi possível identificar parâmetros ultrassonográficos do colo uterino bi e tridimensionais que se correlacionam com a idade gestacional do parto.

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Objective: To investigate the clinical effect of therapeutic cervical cerclage on short cervix syndrome for anti-premature birth in the second trimester. Methods: Totally 44 singleton pregnant patients were diagnosed as short cervix syndrome, which was cervical length ≤2.5 cm without cervical dilatation, and received treatment from January 2008 and July 2015 in Peking University Third Hospital were collected. Among them, 30 patients who received therapeutic cervical cerclage were defined as cerclage group and another 14 cases who received conservative treatment were defined as un-cerclage group. The days of conservative treatment, delivery rate of different gestational weeks, birth weight of newborns, neonatal survival rate within 7 days of birth were analyzed between the two groups. Results: There were no significant differences between the two groups in days of pregnancy conservative treatment [103 (84-141) vs 105 (85-114) days], delivery weeks [38.0 (35.5-39.4) vs 38.5 (37.3-39.5) weeks], birth weight of newborns [3 120 (2 750-3 400) vs 3 130 (2 760-3 545) g], and survival rate of newborns [100% (30/30) vs 13/14]. The fetuses of both groups were all delivered after 28 weeks. There was no significant difference in accumulated delivery rate between the two groups after 32 weeks, 34 weeks, and 37 weeks, respectively (all P>0.05) . Conclusions: The treatment of cervical cerclage is not superior to conservative means in single pregnancy of cervical length ≤2.5 cm without cervical dilatation. For such patients with short cervix syndrome, the treatment of cervical cerclage may not be necessary, but dynamic monitoring and search for the causing factors and prompt treatment are more important.

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Objective To investigate pregnancy outcome and feasibility of early pregnancy laparoscopic cervical cerclage surgery in patients with uterine cervical incompetence. Methods The clinical data of 24 uterine cervical incompetence patients who had underwent early pregnancy laparoscopic cervical cerclage were retrospectively analyzed, and the operation and pregnancy outcomes were observed. Results The anesthesia and operation of all patients were smooth, and no abortion occurred during and after operation. The operation time was (40.3 ± 5.8) min, and the amount of bleeding was (32.9 ± 4.3) ml. The cervical length of pregnancy was (3.5 ± 0.8) cm. All patients were cesarean delivery, and the gestational age of delivery was (34.8 ± 2.6) weeks. The term delivery rate was 50.0% (12/24); the perineonate survival rate was 95.8% (23/24), and none of the neonates had birth defects. The weight of 23 neonates was (2 735 ± 528) g, and the low birth weight infant was in 4 cases. Conclusions For those who need to progestation cervical cerclage but failed to timely surgery or whose cervical length less than 2.5 cm in patients with early pregnancy uterine cervical incompetence, early pregnancy laparoscopic cervical cerclage is safe and feasible. After the operation, the gestational age can be prolonged, the perineonate survival rate will be improved, and the pregnancy outcome will be improved.