Preterm labour and birth

This guideline covers the care of women at increased risk of, or with symptoms and signs of, preterm labour (before 37 weeks), and women having a planned preterm birth. It aims to reduce the risks of preterm birth for the baby and describes treatments to prevent or delay early labour and birth. In this guideline we use the terms 'woman' or 'mother' throughout. These should be taken to include people who do not identify as women but are pregnant or have given birth. In June 2022, we made new recommendations on the use of repeat courses of maternal corticosteroids. For further details see update information.

Association of adherence to guidelines for cervical cerclage with perinatal outcomes and placental inflammation in women with cervical length ≥2.0 cm.

OBJECTIVES: Cerclage operation is one of the most common obstetric controversies. The aim of this study was to compare the perinatal outcomes and placental inflammation of cerclage performed adherent and non-adherent to international guidelines. MATERIAL AND METHODS: This study included all consecutive women with singleton deliveries who underwent cerclage. According to the current American College of Obstetricians and Gynecologists (ACOG) guideline, we designated our study population into two groups: the adherent-to-guideline and non-adherent groups. Each group was categorized into two groups according to cervical length (CL) at the time of cerclage (<2.0 cm vs. ≥2.0 cm). We evaluated the reasons for cerclage, maternal characteristics, perioperative variables, pregnancy and neonatal outcomes, and placental inflammatory pathology according to the criteria proposed by the Society of Pediatric Pathology. RESULTS: Among 310 women with cerclage, we excluded patients (n = 21) with indicated preterm delivery (PTD), major fetal anomaly, fetal death in-utero, and missing information for reason of cerclage. We also excluded patients who underwent physical examination-indicated cerclage (n = 53) and with missing information of CL at the time of cerclage (n = 52). A total of 184 women were eventually analyzed. In women with CL < 2.0 cm, the non-adherent group showed similar PTD (<28 weeks, <34 weeks) and neonatal composite morbidity rates compared to the adherent-to-guideline group. However, in women with CL ≥ 2.0 cm, the non-adherent group manifested significantly higher PTD (<28 weeks; 16.7% vs. 4.4%, p = 0.04, <34 weeks; 23.8% vs. 5.8%, p = 0.006) and neonatal composite morbidity (20.5% vs. 5.9%, p = 0.028) rates than the adherent-to-guideline group despite similar perioperative variables and lower PTD history rates. The non-adherent group with CL ≥ 2 cm at the time of cerclage was also associated with severe histologic chorioamnionitis (p = 0.033). CONCLUSION: Cerclage performed beyond the current guidelines in pregnant women with CL ≥ 2.0 cm may confer an additional risk of perinatal complications in association with severe placental inflammation.

Cerclage Use: A Review of 3 National Guidelines.

IMPORTANCE: Preterm birth is a major contributor to perinatal morbidity and mortality. The most common intervention performed to improve perinatal outcomes for a woman experiencing cervical dilation in the second trimester without signs or symptoms of preterm labor is the cerclage. OBJECTIVE: We sought to review and compare available national guidelines on cerclage use. EVIDENCE ACQUISITION: We performed a descriptive review of 3 national guidelines on cerclage: The American Congress of Obstetricians and Gynecologists Practice Bulletin on "Cerclage for the Management of Cervical Insufficiency," Green-top Guideline from the Royal College of Obstetricians and Gynaecologists entitled "Cervical Cerclage," and the Society of Obstetricians and Gynaecologists of Canada Clinical Practice Bulletin entitled "Cervical Insufficiency and Cervical Cerclage." Guidelines were compared, and the following aspects of cerclage use for prevention of preterm delivery were summarized: indications and contraindications, risk factors for cervical insufficiency, perioperative considerations, and timing of removal. Recommendations and strength of evidence were reviewed based on each guideline's method of reporting. The references were compared with regard to the total number of randomized control trials, Cochrane Reviews, and systematic reviews/meta-analyses cited. RESULTS: The variations highlighted in the guidelines reflect the heterogeneity of the literature contributing to guidelines and the challenges of diagnosing and managing cervical insufficiency. CONCLUSIONS: A cohesive international guideline may improve safety and quality and optimize patient outcomes. TARGET AUDIENCE: Obstetricians and gynecologists, family physicians. LEARNING OBJECTIVES: After completing this activity, the learner should be better able to outline variations in indications and contraindications for cervical cerclage use by international guideline, identify variation in perioperative considerations for cervical cerclage use by international guideline, and recognize variation in timing of removal by international guideline.

Emergency Cerclage: Improvement of Outcomes by Standardization of Management.

INTRODUCTION: Cervical dilatation followed by prolapse and ballooning of membranes into the vagina at mid-gestation is a critical situation. The aim of this study was to describe the outcome of emergency cerclage in a tertiary referral center during a 10-year period (2001-2010) in which a defined selection of women and standard protocol were introduced. SUBJECTS AND METHODS: Thirty-nine cases of emergency cervical cerclage performed before 24 completed weeks were retrospectively reviewed. Data related to maternal history, diagnosis, procedure details, postoperative management and perinatal outcome were recorded. Maternal characteristics and perinatal outcomes are described. RESULTS: Gestational age at cerclage (mean ± SD) was 22.1 ± 2.0 weeks with 61% (24/39) of women presenting bulging membranes. Gestational age at delivery and cerclage-to-delivery time (mean ± SD) were 28.6 ± 6.2 weeks and 49.1 ± 36.5 days, respectively. Only 38.5% (15/39) of the whole group and 44.1% (15/34) of those who reached 24.0 weeks delivered beyond 28 weeks of gestational age. Neonatal survival before discharge was 82.4% (28/34). DISCUSSION: Perinatal outcomes after emergency cerclage are still poor with more than half of the cases delivering before 28 weeks. A standard protocol may help in the management of these rare cases.

[Cervical cerclage]. / Le cerclage cervical.

Cervical cerclage aims to strengthen not only the mechanical properties of the cervix, but also its immunological and anti-infectious functions. The demonstration of a strong interrelation between cervical insufficiency as well as decreased cervical length at endo-vaginal ultrasonography and infection has changed the indications cerclage. Actually we can distinguish three indications for cerclage: prophylactic, for obstetrical history; therapeutic, for shortened cervical length at ultrasonography in patients at risk and; emergency cerclage in case of threatening cervix at physical examination. The McDonald's technique is the most recommended. In case of failure, it is proposed to realize cerclage at a higher level on the cervix either by vaginal or abdominal route.

Cerclaje cervical de emergencia: nuestra experiencia / Emergency cervical cerclage: our experience

Objetivo: Analizar la efectividad del procedimiento a través de los resultados perinatales obtenidos, mediante un estudio descriptivo y retrospectivo. Material y métodos: Se han revisado los casos de cerclaje cervical de emergencia aplicados en nuestro servicio entre los años 2000 y 2007, ambos incluidos, estableciendo criterios de selección que determinan a las pacientes susceptibles beneficiarse de este método. Resultados: Hemos obtenido una supervivencia neonatal libre de secuelas en el 87,5 % de los casos. Las complicaciones asociadas fueron menores, entre las que destacan la amenaza de parto prematuro y la rotura prematura pretérmino de membranas. Conclusión: Pese a la escasa bibliografía acerca de este tipo de cerclaje y sus resultados, a veces contradictorios, en nuestro centro optamos por éste como una alternativa eficaz a la actitud expectante en los casos de incompetencia cervical tardía como los descritos (AU)

Objective: To analyze the effectiveness of emergency cervical cerclage through a descriptive and retrospective analysis of our perinatal results.
Material and method: We reviewed cases in which emergency cervical cerclage was applied in our department between 2000 and 2007, both inclusive. During this review we established the necessary criteria to select the female patients likely to benefit from this method. Results: In the patients studied, we achieved a sequel-free neonatal survival rate of 87.5%. The associated complications were minor, mainly threatened preterm labor and preterm premature rupture of membranes. Conclusion: Despite the scarce literature about emergency cervical cerclage and its results (which are sometimes contradictory), we have chosen this technique as an effective alternative to expectant management in cases of late cervical incompetence, such as those described above (AU)