Favorable surgical and obstetrical outcomes in pre- and postconceptional laparoscopic abdominal cerclage: a large multicenter cohort study.

BACKGROUND: Cervical incompetence is an important cause of extremely preterm delivery. Without specialized treatment, cervical incompetence has a 30% chance of recurrence in a subsequent pregnancy. Recently, the first randomized controlled trial showed significant superiority of abdominal cerclage compared with both high and low vaginal cerclage in preventing preterm delivery at <32 weeks of gestation and fetal loss in patients with a previous failed vaginal cerclage. OBJECTIVE: This study aimed to assess surgical and obstetrical outcomes in patients with pre- and postconceptional laparoscopic abdominal cerclage placement. Furthermore, it also aimed to perform subgroup analysis based on the indication for cerclage placement in order to identify patients who benefit the most from an abdominal cerclage. STUDY DESIGN: A retrospective multicenter cohort study with consecutive inclusion of all eligible patients from 1997 onward in the Dutch cohort (104 patients) and from 2007 onward in the Boston cohort (169 patients) was conducted. Eligible patients had at least 1 second- or third-trimester fetal loss due to cervical incompetence and/or a short or absent cervix after cervical surgery. This includes loop electrosurgical excision procedure, conization, or trachelectomy. Patients were divided into the following subgroups based on the indication for cerclage placement: (1) previous failed vaginal cerclage, (2) previous cervical surgery, and (3) other indications. The third group consisted of patients with a history of multiple second- or early third-trimester fetal losses due to cervical incompetence (without a failed vaginal cerclage) and/or multiple dilation and curettage procedures. The primary outcome measure was delivery at ≥34 weeks of gestation with neonatal survival at hospital discharge. Secondary outcome measures included surgical and obstetrical outcomes, such as pregnancy rates after preconceptional surgery, obstetrical complications, and fetal survival rates. RESULTS: A total of 273 patients were included (250 in the preconceptional and 23 in the postconceptional cohort). Surgical outcomes of 273 patients were favorable, with 6 minor complications (2.2%). In the postconceptional cohort, 1 patient (0.4%) had hemorrhage of 650 mL, resulting in conversion to laparotomy. After preconceptional laparoscopic abdominal cerclage (n=250), the pregnancy rate was 74.1% (n=137) with a minimal follow-up of 12 months. Delivery at ³34 weeks of gestation occurred in 90.5% of all ongoing pregnancies. Four patients (3.3%) had a second-trimester fetal loss. The indication for cerclage in all 4 patients was a previous failed vaginal cerclage. The other subgroups showed fetal survival rates of 100% in ongoing pregnancies, with a total fetal survival rate of 96%. After postconceptional placement, 94.1% of all patients with an ongoing pregnancy delivered at ³34 weeks of gestation, with a total fetal survival rate of 100%. Thus, second-trimester fetal losses did not occur in this group. CONCLUSION: Pre- and postconceptional laparoscopic abdominal cerclage is a safe procedure with favorable obstetrical outcomes in patients with increased risk of cervical incompetence. All subgroups showed high fetal survival rates. Second-trimester fetal loss only occurred in the group of patients with a cerclage placed for the indication of previous failed vaginal cerclage, but was nevertheless rare even in this group.

Physical examination-indicated cerclage in twin pregnancies compared with singleton pregnancies.

OBJECTIVE: The aim of this study was to compare pregnancy outcomes of physical examination-indicated cerclage in twin and singleton pregnancies with bulging membranes. METHODS: All women with bulging membranes in the second trimester of pregnancy who were admitted to La Fe University and Polytechnic Hospital from January 2009 to January 2022 were included. A total of 128 participants were enrolled, 102 singleton pregnancies and 26 twin pregnancies. All patients underwent an amniocentesis to rule out intra-amniotic inflammation (IL-6 < 2.6 ng/mL). Cerclage was placed in the absence of intra-amniotic inflammation. RESULTS: Compared with singleton gestations, twin pregnancies displayed a significantly higher prevalence of nulliparity and assisted reproductive techniques. The incidence of intra-amniotic inflammation/infection was similar in both groups (68.62% in singleton vs. 65.38% in twin pregnancies). The average gestational age of delivery without cerclage in singleton gestations was 23.83 weeks (95% CI 22.82-24.84) and in twin pregnancies, it was 23.69 weeks (95% CI 21.8-25.57). The average gestational age at delivery among patients with cerclage was 37.27 weeks (95% CI 35.35-39.19) in singleton gestations and 36 weeks (95% CI 33.51-38.63) in twin pregnancies, with no significant differences. Time from diagnosis to delivery in patients with IL-6 < 2.6 ng/mL was 79.88 days, and in those with IL > 2.6 ng/mL was 10.87 days. Gestational age at delivery was significantly higher in both singleton and twin pregnancies with cerclage, compared with those without cerclage (log-rank p < .001). CONCLUSIONS: Singleton and twin pregnancies with bulging membranes behave similarly when cerclage is placed in the absence of intraamniotic inflammation/infection.

Antibody microarray analysis of amniotic fluid proteomes in women with cervical insufficiency and short cervix, and their association with pregnancy latency length.

INTRODUCTION: This study aimed to investigate amniotic fluid (AF) proteins that were differentially expressed between patients with cervical insufficiency (CI) and asymptomatic short cervix (SCX, ≤ 25 mm), and whether these proteins could be predictive of spontaneous preterm birth (SPTB) in these patients. METHOD: This was a retrospective cohort study of 129 singleton pregnant women with CI (n = 80) or SCX (n = 49) at 17 to 26 weeks who underwent amniocentesis. An antibody microarray was used to perform comparative proteomic profiling of AF from matched CI (n = 20) and SCX (n = 20) pregnancies. In the total cohort, an ELISA validation study was performed for 15 candidate proteins of interest. Subgroup analyses of patients with CI and SCX were conducted to evaluate the association between the 15 proteins and SPTB at < 32 weeks of gestation. RESULTS: Eighty-six proteins showed intergroup differences. ELISA validation confirmed significantly higher levels of AF EN-RAGE, IL-8, lipocalin-2, MMP-9, S100A8/A9, thrombospondin-2, and TNFR2 in patients with CI than in those with SCX. Multivariable analysis showed that increased AF levels of EN-RAGE, S100A8/A9, and uPA were independently associated with SPTB at < 32 weeks in patients with CI; whereas in patients with SCX, high AF levels of APRIL, EN-RAGE, LBP, and TNFR2 were independently associated with SPTB at < 32 weeks. CONCLUSIONS: Multiple AF proteins show altered expression in patients with CI compared with SCX controls. Moreover, several novel mediators involved in inflammation were identified as potential biomarkers for predicting SPTB after the diagnosis of CI and SCX. These results provide new insights into target-specific molecules for targeted therapies to prevent SPTB in patients with CI/SCX.

Mid-trimester miscarriage and subsequent pregnancy outcomes: the role of cervical insufficiency in a cohort of 175 cases.

OBJECTIVE: To evaluate the causes of MTM and their impact on subsequent pregnancies. MATERIAL AND METHODS: A retrospective single-center cohort study of all pregnancies with a second-trimester pregnancy loss between 14 weeks and 21 weeks + 6 days gestation, excluding terminations of pregnancy (TOP) and in utero fetal deaths. Predefined criteria were used to allocate cases to one of 6 primary etiologic diagnoses: cervical insufficiency, chorioamnionitis, placental anomalies, fetal anomalies, iatrogenic causes, or abdominal trauma. RESULTS: Among 578 mid-trimester fetal losses, 175 were MTM, a prevalence of 5.7 per 1000 live births in the center. The suspected primary cause was cervical insufficiency in 76 cases (43.4%), chorioamnionitis in 59 (33.7%), placental anomalies or preterm premature rupture of membranes in 26 (14.8%), iatrogenic in 8 (4.6%), trauma in 3 (1.7%), and undetermined in 3 cases (1.7%). A subsequent pregnancy beyond 14 WG was recorded for 78 patients. Recurrent MTM occurred in 21.8% and preterm deliveries in 14.1% ; 13% of patients without evidence of cervical insufficiency in the index pregnancy required emergency cerclage. CONCLUSION: Cervical insufficiency was the leading cause of MTM, with a high risk of recurrent MTM or preterm birth, thus prophylactic cerclage or cervical length measurements should be considered for subsequent pregnancies.

Cervical polyps in early pregnancy are a risk factor for late abortion and spontaneous preterm birth: A retrospective cohort study.

OBJECTIVE: To determine the association between cervical polyps in early pregnancy and late abortion and spontaneous preterm birth (SPTB). We also aimed to explore the relationship between cervical polyps and cervical insufficiency in the second trimester. METHODS: We conducted a retrospective cohort study of 2941 singleton pregnant women between January 2010 and December 2015. The frequency of late abortion and SPTB (before 28, 34, or 37 weeks of pregnancy) was compared between the two groups of 142 (4.8%) patients who had cervical polyps early in the pregnancy (P group) and 2799 who did not (non-P group). Multivariate analysis was performed to identify risk factors for late abortion and SPTB. RESULTS: The incidence of late abortion and SPTB was significantly higher in the P group than in the non-P group. Cervical polyps in early pregnancy were selected as independent risk factors for late abortion and SPTB before 28, 34, or 37 weeks of pregnancy. The P group had a significantly higher rate of cases requiring therapeutic cervical cerclage than the non-P group. CONCLUSION: Cervical polyps in early pregnancy are risk factors for late abortion and SPTB. They are also associated with the occurrence of cervical insufficiency.

The association of chronic endometritis with mid-trimester loss due to cervical incompetence and the outcome of laparoscopic cervical cerclage.

PURPOSE: To examine the association of chronic endometritis (CE) with cervical incompetence (CI) in Chinese women with mid-trimester loss, and the impact of the presence of CE on the outcome of laparoscopic cervical cerclage (LCC). METHODS: This retrospective cohort study included a study group of 293 women with mid-trimester loss due to CI (group I) and a comparison group of 332 women with recurrent first-trimester miscarriage (group II). Immunohistochemical study using CD138 epitope for the diagnosis of CE was completed in all subjects. Pre-conception LCC was undertaken in 247 women in the study group (group I). The study was approved by Institutional Review Board (IRB) (number 2015FXHEC-KY005). RESULTS: The prevalence of CE in group I was 42%, significantly (P < 0.001) higher than that of 23.5% in group II. Among 247 women in group I, there were no significant difference in mid-trimester loss rate, preterm delivery rate and term delivery rate in women with and without CE (2.2, 12.0, 85.8% vs. 1.8, 10.1, 88.1% respectively) and between women with CE treated and not treated with antibiotics prior to conception (2.3, 9.3, 88.4% vs. 2.0, 14.3, 83.7% respectively). CONCLUSIONS: Mid-trimester loss due to cervical incompetence is associated with chronic endometritis; However, the presence or not of CE and whether it was treated with antibiotics prior to conception did not appear to significantly influence the obstetric outcomes of women with CI after LCC.

COL1A1, COL4A3, TIMP2 and TGFB1 polymorphisms in cervical insufficiency.

OBJECTIVES: To investigate the association between selected single nucleotide polymorphisms (SNPs) with cervical insufficiency and its relationship with obstetric history. METHODS: Twenty-eight women with cervical insufficiency (case group) and 29 non-pregnant women (control group) were included. The SNPs sequenced included rs2586490 in collagen type I alpha 1 chain (COL1A1), rs1882435 in collagen type IV alpha 3 chain (COL4A3), rs2277698 in metallopeptidase inhibitor 2 (TIMP2), and rs1800468 in transforming growth factor beta 1 (TGFB1). RESULTS: We found a higher frequency of the normal allele in the control group (65.5%) and the homozygous mutated genotype in the case group (64.3%) for rs2586490 in COL1A1 (p=0.023). An unplanned finding in the cervical insufficiency group was a higher gestational age of delivery (median≥38 weeks) in the mutated allele than in the wild-type genotype (median of 28.2 weeks) for rs2857396, which is also in the COL1A1 gene (p=0.011). CONCLUSIONS: The findings of the present study corroborate the hypothesis that cervical insufficiency has a genetic component and probably involves genes encoding proteins in the extracellular matrix, in addition to inflammatory processes.

Analysis of risk factors and predictors of pregnancy loss and strategies for the management of cervical insufficiency in pregnant women at a high risk of preterm birth.

AIM: To identify risk factors and predictors of pregnancy loss and to compare the efficacy of Arabin's pessary with cervical cerclage in women at a high risk of pregnancy loss. MATERIALS AND METHODS: This was a two-center retrospective case-control study that included 240 women at a high risk of preterm delivery. Group I (n = 161) included women who underwent insertion of the Arabin's pessary between 14 and 24 weeks of pregnancy. Group II (n = 79) included women who had undergone circular cervical cerclage during the current pregnancy. All women included in the study received micronized vaginal progesterone at the dose of 200 mg/day until and including 34 weeks of gestation. RESULTS: Threatened pregnancy loss defined as spotting or vaginal bleeding in the first trimester was diagnosed in 29.8% (48/161) of patients in Group I versus 37.9% in Group II (p = .448). Postpartum bleeding occurred in 8.1% (13/161) in women in Group I versus 22.8% in Group II (χ2 = 6.500; p = .011). Our study showed that cervical cerclage was most suitable for patients with history of obstetric complications, cervical length <15 mm, and large isthmic uterine fibroids. The use of the Arabin's pessary reduced the rate of preterm births by 1.7-fold. A cluster analysis demonstrated that predictors of preterm birth in women with a high risk of pregnancy loss included: threatened pregnancy loss associated with chorionic/placental abruption, cervical incompetence, uterine fibroid growth to a large size, history of multiple spontaneous pregnancy losses, cervical tears during past labor, and gestational diabetes diagnosed for the first time during the current pregnancy. CONCLUSIONS: Women with a high risk of pregnancy loss treated with Arabin's pessary or cerclage plus vaginal progesterone had a term delivery rate of 70.4% (169/240). The combined strategy of pregnancy management allowed to markedly reduce the number of preterm births.

The prevalence of cervical insufficiency in Chinese women with polycystic ovary syndrome undergone ART treatment accompanied with negative prognosis: a retrospective study.

The objective of this study was to explore the correlation between cervical insufficiency (CI) and polycystic ovary syndrome (PCOS) in Chinese women undergoing assisted reproductive technology (ART) treatment. The retrospective study enrolled 2978 women including 1489 with PCOS and 1489 without PCOS, among which 34 women were diagnosed with CI (1.14%). The prevalence of CI in PCOS women was statistically higher than that in women without PCOS. Among those women with CI, 23 cases exhibited PCOS, and those cases had an average gestational age of 26.09 ± 5.91 weeks at the end of pregnancy, which was earlier than that of women without PCOS, and the pregnancy outcomes were worse than in the non-PCOS group though not statistically significant. Multivariable logistic regression showed that PCOS status (odds ratio: 2.050, 95% confidence interval: 1.009-4.206) were associated with increased risk of CI. Our study revealed that among those Chinese women who conceived by ART treatment, the prevalence of CI in women with PCOS was higher than that in women without PCOS. Co-morbidity of CI with polycystic ovarian syndrome negatively impacts prognosis.Impact statementWhat is already known on this subject? Women with PCOS have a higher rate of adverse obstetrical outcomes than women without PCOS.What the results of this study add? Women with PCOS were more likely to have pregnancies complicated with CI. Co-morbidity of cervical incompetence with PCOS negatively impacts prognosis.What the implications are of these findings for clinical practice and/or further research? Given these results, close surveillance of cervical changes during the second trimester in women with PCOS is necessary for reducing the risk of miscarriage related to CI.

Robotic Transabdominal Cerclage vs Laparotomy: A Comparison of Obstetric and Surgical Outcomes.

STUDY OBJECTIVE: To compare obstetric and surgical outcomes of transabdominal cerclage (TAC) via laparotomy (TAC-LAP) versus robotic-assisted (TAC-RA) approaches. DESIGN: Retrospective cohort study. SETTING: An academic medical center. PATIENTS: Sixty-nine women with acquired or congenital cervical insufficiency. INTERVENTIONS: All women underwent TAC either by laparotomy or robotic-assisted approaches by 2 primary surgeons between January 2003 and July 2018. Women with a preconceptional TAC without a subsequent pregnancy were excluded. MEASUREMENTS AND MAIN RESULTS: A total of 69 women met inclusion criteria in the 15-year study period with 40 in the historical TAC-LAP group and 29 in the TAC-RA group. Gestational age at delivery was similar in the 2 groups (36 weeks 3 days vs 37 weeks; median difference -1 day, 95% confidence interval [CI] -6 to 2, p = .36). There were no differences in birth weight, Apgar scores, neonatal intensive care unit admission, or neonatal survival. Estimated blood loss and length of stay were significantly greater in the TAC-LAP group (50 mL vs 20 mL; median difference 25, 95% CI 5-40, p = .007 and 76 hours vs 3 hours; median difference 71, 95% CI 65-75, p <.001, respectively). Operative time was significantly shorter in the TAC-LAP group (65 minutes vs 132 minutes; median difference -64.7, 95% CI -79 to -49, p <.001). There was one intra-operative complication and 4 minor postoperative complications in the TAC-LAP group and none observed in the TAC-RA group. All outcomes were similar when comparing postconceptional TAC alone, except there was no longer a difference in blood loss. When comparing pre- versus postconceptional robotic TAC, there were no differences in surgical outcomes. CONCLUSION: Robotic TAC has similar favorable obstetric outcomes to traditional laparotomy and is associated with reduced blood loss and shorter hospital stays. Despite longer operative times, the robotic group did not experience any intra-operative or postoperative complications, which speaks to the benefits of this minimally invasive approach to TAC.

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.

McDonald versus Shirodkar cervical cerclage for the prevention of preterm birth: impact of body mass index.

Objective: To compare obstetrical outcomes on women undergoing a McDonald or Shirodkar cerclage and to estimate the impact of maternal body mass index (BMI) on these outcomes. Methods: We conducted a retrospective review of the medical records of all women with singleton pregnancies who underwent placement of a McDonald or Shirodkar cerclage at St. Francis Hospital from January 2008 to October 2013. The subjects were categorized based on BMI groups (normal: less than 25 kg/m2, overweight: 25-29 kg/m2, obese: 30 kg/m2 or more). The primary outcome was gestational age at delivery. Statistical analyses included chi-square, Student's t-test, and multivariable regression analysis. Results: Of 95 women, 47 (49.5%) received a Shirodkar, and 48 (50.5%) a McDonald cerclage. 16 women (16.8%) were categorized as normal weight, 35 (36.8%) as overweight, and 44 (46.3%) as obese. Gestational age at delivery differed significantly by group, decreasing with each categorical increase in BMI (normal: 39.0 ± 0.3 weeks; overweight: 36.6 ± 0.7 weeks; obese: 33.0 ± 1.1 weeks; p < .01). Overall, women receiving a Shirodkar cerclage had significantly longer pregnancies than women with a McDonald cerclage (36.7 ± 0.6 weeks versus 33.9 ± 1.0 weeks; p = .02). However, analysis showed a significant interaction between weight status and gestational age at delivery. Obese women had significantly longer pregnancies when they received a Shirodkar cerclage versus a McDonald cerclage (32.6 ± 1.0 weeks versus 28.8 ± 0.9 weeks; p < .01). However, there was no significant difference in gestational age at delivery between women categorized as normal/overweight (Shirodkar: 33.5 ± 0.9 weeks; McDonald: 32.9 ± 0.9 weeks; p = .63). Conclusions: Compared to obese women receiving a McDonald cerclage, obese women receiving a Shirodkar cerclage had significantly longer pregnancies. No significant differences in pregnancy duration were found in normal/overweight women regardless of cerclage technique. Pregnancy duration in obese women receiving a Shirodkar cerclage was similar to the pregnancy duration of normal/overweight women.

History-indicated cervical cerclage in management of twin pregnancy.

OBJECTIVE: Cervical cerclage, when performed in twin gestation, has been reported to be associated with poor outcome. However, the role of first-trimester history-indicated cerclage among women with a twin pregnancy and a history of preterm birth has not been evaluated. The aim of this study was to assess pregnancy outcomes among women with a twin pregnancy who underwent first-trimester history-indicated cervical cerclage compared with outcomes in those managed expectantly. METHODS: This was a retrospective matched case-control study. The study group comprised all women with a twin pregnancy who had undergone first-trimester history-indicated cerclage during the period 2006 to 2017 at Hadassah-Hebrew University Medical Center. A control group of women with a twin pregnancy who were managed expectantly was established by matching age, history of spontaneous preterm birth (20-36 weeks' gestation) and year of delivery. Pregnancy and delivery characteristics and neonatal outcomes were compared between the two groups. RESULTS: Data from 82 women with a twin gestation were analyzed, of whom 41 underwent first-trimester history-indicated cerclage and 41 were matched controls who were managed expectantly. Gestational age at delivery was higher in the cerclage group than in those managed expectantly (median 35 vs 30 weeks; P < 0.0001). Rates of spontaneous preterm birth before 24 weeks (2.4% vs 19.5%; odds ratio (OR), 0.10 (95% CI, 0.01-0.87); P = 0.03), before 28 weeks (12.2% vs 34.1%; OR, 0.27 (95% CI, 0.09-0.84); P = 0.03), before 32 weeks (22.0% vs 56.1%; OR, 0.22 (95% CI, 0.08-0.58); P = 0.003) and before 34 weeks (34.1% vs 82.9%; OR, 0.11 (95% CI, 0.04-0.30); P < 0.0001) were significantly lower in the cerclage group than in the control group. Median birth weight was higher in the cerclage group (2072 g vs 1750 g; P = 0.003), with lower rates of low birth weight (< 2500 g) (65.0% vs 89.4%; P = 0.001) and very low birth weight (< 1500 g) (21.3% vs 37.9%; P = 0.03) than in the group managed expectantly. Rates were also lower in the cerclage group for stillbirth, admission to the neonatal intensive care unit, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, neonatal mortality and composite adverse neonatal outcome. CONCLUSIONS: History-indicated cerclage performed in the first trimester, as compared with expectant management, in women with a twin pregnancy had an overall positive effect on pregnancy and neonatal outcomes. These findings suggest the need for adequate randomized trials on cerclage placement in this subset of women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

A multidisciplinary approach to pregnancy loss: the pregnancy loss prevention center.

Background Pregnancy loss is probably the most common problem faced by women worldwide. There are differences in the rates of early and late pregnancy loss based on geography among the developing compared with the developed nations of the world. Most physicians worldwide have different criteria for treating pregnancy loss. Although pregnancy loss is not a disease, it might be best approached with a medical evaluation in order to define the cause and offer specific treatment. Methods This report describes the results obtained by a multi-disciplinary pregnancy loss prevention center in the initial 104 patients. Results The most common diagnoses were Asherman syndrome (intrauterine adhesions), cervical insufficiency and uterine fibroids, accounting for 47% of the patients. When the diagnosis was not obtained, which occurred in 19% of the patients, in vitro fertilization (IVF) was the treatment provided. Specifically diagnosed and treated patients achieved a 91% success rate. The 19 patients without a specific diagnosis who were treated with IVF had a 60% success rate. Thus patients for whom it was possible to specifically diagnose and treat had better results (P<0.01 t-test). There was an overall success rate of 87% including patients lost to follow-up with this multidisciplinary medical approach. Conclusion A pregnancy loss prevention center using the described multidisciplinary model can accomplish success rates of 85-90%. Preventing recurrent pregnancy loss we suggest can best be achieved by a dedicated center with a multidisciplinary medical approach.

Emergency department use during pregnancy: a prospective observational study in a single center institution.

PURPOSE: Gynecologists working in emergency department services in hospitals lately have the impression that the number of pregnant women who present themselves because of anxiety or uncertainty is increasing. Hence, the aim of this study was to assess reasons of pregnant women for presenting themselves to an emergency department. Of special interest was how far a diagnosis could be confirmed for the symptoms pregnant women complained about. METHODS: This is a prospective questionnaire-based study conducted between April 2015 and April 2016 in the Department of Gynecology and Obstetrics of the University Hospital of Cologne. The questionnaire was placed in the waiting area of the emergency department service for pregnant women. Pregnant patients were included with a gestational age of above 20 weeks of gestation. RESULTS: 331 patients were enrolled in this study. The most frequent reason for emergency department use was "pain" in 28.3% and cervical insufficiency in 19.7% of all cases. 45.6% (n = 151) of the patients had a recommendation of an outpatient practice for presentation to emergency department service. 36.3% (n = 120) of all patients were admitted to hospital for further treatment, 58.6% (n = 194) could be released from hospital. 3.3% (n = 11) of all patients rejected recommended further treatment in hospital. A trend was demonstrated concerning former abortion and hospital admission (p = 0.062). CONCLUSIONS: The high amount of patients making nonurgent use of emergency department services indicates potential uncertainty in interpretation of symptoms. Patients with former abortion history were admitted more often to hospital, and therefore need special attention during pregnancy.

Independent association between uterine malformations and cervical insufficiency: a retrospective population-based cohort study.

OBJECTIVE: The purpose of our study was to explore maternal and fetal outcomes in the second and third trimester in women with uterine malformations. STUDY DESIGN: This was a retrospective population-based cohort study including women with a diagnosis of uterine malformation arised from workup for infertility or recurrent pregnancy loss, was accidental during pregnancy, or was noticed at the time of cesarean delivery. RESULTS: A total of 280,721 pregnancies met the inclusion criteria and were divided into two study groups: (1) pregnancies in women with uterine malformations (n = 1099); and (2) controls (n = 279,662). The rate of women presenting uterine malformations was 0.39%. The prevalence of cervical os insufficiency was significantly higher in women with a uterine malformation than in the control group (3.6 vs. 0.4%, p < 0.001). A multivariate analysis, performed to evaluate risk factors for cervical insufficiency in women with uterine malformations. Mullerian anomalies (OR 6.19, 95% CI 4.41-8.70, p < 0.001), maternal age (OR 1.05, 95% CI 1.04-1.06, p < 0.001), recurrent abortions (OR 12.93, 95% CI 11.43-14.62, p < 0.001), and ethnicity (OR 2.86, 95% CI 2.454-3.34, p < 0.001) were found to be independently associated with the development of cervical insufficiency. CONCLUSION: Uterine anomalies have a strong association with cervical insufficiency. Women with uterine anomalies have an increased risk to develop pregnancy complications that arise from a loss in cervical function during the midtrimester or early third trimester.

[Clinical outcome of therapeutic cervical cerclage in short cervix syndrome].

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.

History of cervical insufficiency increases the risk of pelvic organ prolapse and stress urinary incontinence in parous women.

OBJECTIVE: A likely contributor to pelvic floor disorders is injury and degradation of connective tissue components such as collagen and elastin, leading to weakening of the pelvic floor. Prior studies have found similar connective tissue component changes in women with cervical insufficiency (CI). However, the connection between pelvic floor disorders and cervical insufficiency has not previously been evaluated. Our objective was to determine whether a history of cervical insufficiency is associated with an increased risk of pelvic organ prolapse and stress urinary incontinence after controlling for confounders. STUDY DESIGN: The study used de-identified clinical data from a large multi-institution electronic health records HIPAA-compliant data web application, Explorys Inc. (Cleveland, Ohio, USA). Women with a history of at least one prior delivery after at least 20 weeks' gestation between the years 1999 and 2016 were identified. Logistic regression models were used to identify risk factors and adjust for confounders. MAIN OUTCOME MEASURES: The primary outcome was subsequent development of either stress incontinence or pelvic organ prolapse. RESULTS: A total of 1,182,650 women were identified, of whom 30,890 (2.6%) had a history of cervical cerclage or insufficiency. A history of cervical insufficiency was associated with an increased risk of either pelvic organ prolapse or stress urinary incontinence (aOR=1.93, 95%CI: 1.84-2.02). A history of cervical insufficiency was more strongly associated with an increased risk of pelvic organ prolapse (aOR=2.06, 95%CI: 1.91-2.21) than with stress urinary incontinence (aOR=1.91, 95%CI: 1.80-2.02). CONCLUSION: A history of cervical insufficiency is associated with an increased risk of development of pelvic organ prolapse and stress urinary incontinence.

A single-center retrospective study of pregnancy outcomes after emergency cerclage for cervical insufficiency.

OBJECTIVE: To compare maternal and perinatal outcomes after emergency cerclage with those after elective cerclage. METHODS: In a retrospective review, data were assessed from women with a viable singleton pregnancy who underwent elective or emergency cerclage for cervical insufficiency at the Tongji Hospital, Wuhan, China, between January 2010 and July 2015. Subgroup analyses based on cervical length (CL; ≤15, 15-25, and 25-30 mm) were also conducted among women undergoing emergency cerclage. RESULTS: In total, 68 women underwent elective cerclage and 53 underwent emergency cerclage. The suture-to-delivery interval was significantly longer in the elective group (19.17 ± 5.86 weeks) than in the emergency group (11.29 ± 7.27 weeks; P<0.001). There was no difference between the elective and emergency groups in mean pregnancy length at delivery, frequency of Apgar score below 7 at 5 minutes (live births only), or birth weight (live births only). An inverse trend in the degree of CL shortening with pregnancy outcomes was observed; women with a CL of 25-30 mm had the best outcomes. CONCLUSION: Pregnancy outcomes were similar after emergency and elective cerclage. There was an inverse trend in the degree of CL shortening with pregnancy outcomes in the emergency cerclage group, with better outcomes observed for women with longer CL.

Is the Relationship between Short Interpregnancy Interval and Preterm Birth Related to a Short Cervix?

Objective Our objective was to determine if the relationship between interpregnancy interval (IPI) and preterm delivery was related to cervical shortening. Methods This is a secondary analysis of a prospective cohort study designed to assess the relationship between cervical length (CL) and preterm delivery. Multiparous patients, who had transvaginal CLs obtained at 22 to 24 weeks and complete pregnancy outcome data available were included. The women were divided into two groups: Group 1 with an IPI of ≤ 1 year and Group 2 with an IPI of > 1 year. The primary outcome was short cervix (CL < 2.5 cm) at 24 weeks. The secondary outcome was the incidence of preterm delivery < 37 weeks. Interaction between short cervix and IPI was examined in a regression model. Results There were 155 women in Group 1 and 328 women in Group 2. There was no difference in the incidence of short cervix between groups (10.0% in Group 1 and 12.9% in Group 2, p = 0.35). In a logistic regression model, short IPI and short cervix were independently associated with preterm birth. Conclusion The relationship between short IPI and preterm birth is not explained by a short cervix. They remain independent risk factors for preterm birth.