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• Transvaginal cerclage surgeons show a genuine insight into their surgical performance of a transvaginal cerclage on a simulator. • Using a simulator the surgeons placed the cerclage at a mean height of 26.8 mm. • Transvaginal cerclage surgeons will be able to assess whether they adhere to specific objective criteria as described in a procedural guideline. In women with cervical incompetence, transvaginal cerclage may help prevent preterm birth. However, training for this procedure poses challenges due to the low number of cases and difficulties in visualizing the operative field. Furthermore, the objective criteria for a successful cerclage procedure are not well-described. Quality assessment relies heavily on self-assessment rather than objective criteria and feedback. To address this issue, training on a simulator may offer a solution. We aimed to objectively assess surgical performance and compare it to the self-assessed performance in transvaginal cerclage procedures. During the Nordic Federation of Obstetrics and Gynecology (NFOG) congress in 2023, surgeons proficient in transvaginal cerclage procedures performed a transvaginal cerclage on a simulator. To compare the observed and self-assessed outcomes we obtained measurements on the cerclage height and number of bites from the detachable cervix, and from computed tomography scans we analyzed suture bite depth, reduction of cervix surface area, and whether cerclages had perforated the cervical canal. The same outcomes were self-assessed by each participant after the cerclage procedure. We visualized the continuous paired data in a Bland-Altman plot and compared these data with a paired t -test. Paired binary data was analyzed using McNemars test. 29 participants from eight different nationalities performed one transvaginal cerclage each. The mean height of the cerclage was 26.8 mm (SD 9 mm) and mean depth was 6.5 mm (SD 1.9 mm) across a mean of 4.1 (SD 0.8) bites. The mean reduction of the cervix surface area was 7.6 % (SD 5.9 %). Two sutures perforated the cervical canal. The participants significantly underestimated the height of their cerclage with a mean difference of 6.0 mm (95 % CI 2.1–9.9), (p 0.002), between the observed and the self-assessed height, but otherwise revealed good self-assessment of their performed procedure. Overall, the experienced cerclage surgeons showed a genuine insight into their surgical performance of a transvaginal cerclage. These results could warrant development of a procedural guidelines with objective measures, now reassured that surgeons are capable of self-assessing their procedures. [ABSTRACT FROM AUTHOR]

Objective: To compare the maternal and neonatal morbidity in patients with transvaginal (TVC) versus transabdominal (TAC) cerclage. Materials and methods: Retrospective analysis of patients who received cervical cerclage and terminated the pregnancy in the second trimester or third trimester in two tertiary hospitals. Data on basic clinical characteristics, predelivery maternal morbidity, intrapartum morbidity, postpartum morbidity and neonatal morbidity of TVC patients and TAC patients were analysed and compared. Results: Seventy-two TVC patients and 120 TAC patients were included. The rates of abnormal fetal presentation and placental disorders were significantly higher in TAC patients than that in TVC patients (21.67% vs 5.56% and 18.33% vs 4.17%, respectively). The rates of premature rupture of membranes and intrauterine infection were significantly higher in TVC patients than that in TAC patients (25.00% vs 2.50% and 11.23% vs 3.33%, respectively). Compared with TVC patients, the rates of estimated intrapartum hemorrhage ≥500 ml, uterine rupture and cesarean delivery in the third trimester were significantly higher in TAC patients than in TVC patients. Gestational age at delivery and neonatal morbidity were comparable between TVC patients and TAC patients. Conclusion: Compared with TVC patients, TAC patients were associated with a significantly higher incidence of maternal morbidity in placental disorders, abnormal fetal presentation, intrapartum hemorrhage ≥500 ml and uterine rupture.

Preterm delivery (PD) is a global public health problem, being the leading cause of perinatal morbidity and mortality in many countries. Despite numerous studies on the etiology of this condition, PD incidence has been increasing annually, and about 15 million infants are born prematurely (before the week 37 of gestation) worldwide. One of the main risk factors for PD is isthmic-cervical incompetence (ICI), which leads to microbial invasion of the amniotic cavity, prolapse of the fetal bladder, premature discharge of amniotic fluid and PD. Currently, several methods for ICI prevention and treatment are available: conservative (use of progesterone, obstetric pessary) and surgical (transvaginal cerclage and transabdominal cerclage).

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Objective: To investigate the efficacy of transvaginal cerclage in twin pregnancies with cervical shortening, and to narrow the threshold cervical length for transvaginal cerclage. Methods: This is a prospective cohort study and 177 twin pregnancies with asymptomatic cervical dilatation or cervical length of 15 mm or less between 16+0 and 25+6 weeks of pregnancy were included. Patients independently chose either transvaginal cerclage (n = 129) or no cerclage treatment (n = 48) after being consulted on the risk and potential benefit of transvaginal cerclage. The primary outcome measures were gestational age at delivery and neonatal survival rate. Results: Compared with the no cerclage group, the cerclage group exhibited a higher gestational age at delivery (32.1 ± 4.5 vs 28.3 ± 6.2 weeks, P < 0.001) and a higher neonatal survival rate (86.4% vs 47.9%, P < 0.001). Subgroup analysis showed that in twin pregnancies with cervical dilatation or cervical length less than 10 mm, the cerclage group had significantly higher gestational age at delivery (31.3 ± 4.6 vs 23.4 ± 4.3 weeks, P < 0.001) and a higher neonatal survival rate (123 [85.4%] vs 4 [9.1%], P < 0.001) than the no cerclage group, but in twins when cervical length was 10–15 mm, the two measures were similar between the two groups. Conclusion: Transvaginal cerclage may provide benefits for twins when cervical dilatation or cervical length is less than 10 mm, but its efficacy might not extend to twins when the cervical length is 10–15 mm. Further evidence is needed to confirm the efficacy of transvaginal cerclage for twin pregnancies with a short cervix. Synopsis: Cerclage associated with greater gestation at delivery in twin pregnancies with cervical dilatation or cervical length (CL) less than 10 mm. [ABSTRACT FROM AUTHOR]

Introduction: Cervical failure is one of the causes of early childbirth and neonatal death in the second and third trimesters of pregnancy. Most women with cervical failure can be effectively treated with cervical cerclage. Trans-abdominal cerclage is an effective and efficient method in patients with short cervix, history of preterm labor and history of unsuccessful transvaginal cerclage. In this study, a rare case of successful trans-abdominal cerclage is reported. Case presentation: The patient was a 43-year-old woman with history of cesarean section, curettage and one unsuccessful transvaginal cerclage. The patient underwent laparoscopic trans-abdominal cerclage surgery at 12th week of pregnancy due to the probability of preterm delivery, short cervical length and failure of transvaginal cerclage. The patient was subjected to cesarean section at 34th weeks of gestation due to uterine contractions and a healthy baby was born. Conclusion: Since trans-abdominal cerclage has a tremendous effect on patients with a history of preterm labor, and the patients' satisfaction with this method is very high, this surgical technique is strongly supported.

Purpose: To compare the pregnancy outcome of patients with cervical insufficiency (CI) underwent prophylactic laparoscopic abdominal cervical cerclage (LAC) and transvaginal cervical cerclage (TVC). Methods: A retrospective trial was carried out in the Department of Gynecology, Qingdao Women and Children's Hospital, Shandong Province, China. A total of 217 women with cervical insufficiency underwent the prophylactic cerclage, and the surgical approach was decided by the patients or depended on doctors' advice. The primary outcome measure was the fetal outcome. Secondary outcome measures were delivery of an infant at ≥ 34th gestational weeks, newborn birth weight, neonatal intensive care center (NICU) occupancy, and postoperative complications. Nonparametric variables were analyzed with the Mann–Whitney (U) test, and categorical type outcomes were analyzed with the Chi-square test or the Fisher's exact test. A P value < 0.05 was considered significant. Data analysis was performed using SPSS Statistics Version 19. Results: As of follow-up date, 154 eligible patients were included in this study, with 74 (48.1%) women in the LAC group and 80 (51.9%) in the TVC group. The total fetal survival rate in the two groups was 90.3% (139/154), of which the rate significantly higher in the LAC group compared to the TVC group (97.3% vs. 83.8%, P < 0.01). The delivery of an infant at ≥ 34th gestational weeks was significantly higher in the LAC group compared to the TVC group (94.6% vs. 71.3%, P < 0.01). Compared to the TVC group, the mean newborn birth weight was higher, and the NICU occupancy rate was less in the LAC group (3293.4 ± 542.8 g vs. 2953.6 ± 704.4 g, P = 0.002; 2.8% vs. 17.9%, P = 0.003). Complications: No fatal surgical complications occurred in both groups. Conclusion: In patients with cervical insufficiency, the history-indicated conception of prophylactic LAC appears to have a better pregnancy outcome than TVC. [ABSTRACT FROM AUTHOR]

Objective: The aim of this research was to investigate if an association exists between cerclage height (CH) or the ratio of CH-to-cervical length (CL) and delivery prior to 35 weeks gestational age (GA) among patients having undergone cervical cerclage. Materials and Methods: A retrospective cohort study was performed examining transvaginal imaging and obstetric medical records data from 106 women who received prenatal care, had a cerclage placed, and delivered at a tertiary referral center in Cincinnati, OH, between July 2012 and December 2014. The primary outcome was delivery prior to 35 weeks gestation. Results: No association was found between CH and the rate of preterm birth prior to or after 35 weeks (mean CH: 18.99 mm; standard deviation [SD]: SD 4.71) versus 19.03 mm; SD 6.38; p = 0.97). Additionally, no association was found between the ratio of CH-to-CL and the rate of preterm birth prior to or after 35 weeks (mean ratio: 0.588; SD: 0.174 versus 0.541; SD: 0.170; p = 0.185). The lack of association between both CH and the ratio of CH-to-CL as well as delivery prior to 35 weeks remained when the cohort was stratified by indication for cerclage. The only statistically significant difference was between the ratio of CH-to-CL length in patients who received history-indicated cerclage and delivered prior to or after 28 weeks GA (mean ratio: 0.4969; SD 0.135 versus 0.6479; SD 0.251; p = 0.0166). Otherwise, no association was found when evaluating GA cutoffs of 24, 28, 32, 35, or 37 weeks, or when patients who delivered prior to 28 weeks were compared to patients delivering at or beyond 32 weeks. There was no association between CH nor the ratio of CH-to-CL and latency between cerclage placement and delivery. Six women experienced a very short latency (≤ 3 weeks), and all 6 experienced either an intrauterine fetal demise (n = 3) or neonatal demise (n = 3). Five of these cases (83%) involved placement of a rescue cerclage where the amniotic membrane was exposed and/or prolapsing. The sixth case was performed due to the finding of a 5-mm cervical length on ultrasound imaging with a large U-shaped funnel. In comparing the 6 cases of extremely short latency to the remainder of the cohort with a latency of at least 5 weeks (n = 100), no differences were noted with regard to CH (19 ± 6 mm versus 19 ± 1 mm; p = 0.89) or the ratio of CH-to-CL (0.56 ± 0.13 versus 0.56 ± 0.17; p = 0.93). Conclusions: These findings support other reports that have shown no association between CH and GA at delivery. Surgical method (McDonald versus Shirodkar) does not appear to correlate with CH nor GA at delivery, and the factor that bears the strongest correlation with obstetric outcomes remains the indication for the procedure. (J GYNECOL SURG 34:177) [ABSTRACT FROM AUTHOR]

Purpose: To compare the pregnancy outcome of the modified transvaginal cerclage performed preconception and during pregnancy.Methods: A retrospective trial was carried out in the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital in Zhejiang, China. A total of 604 women with cervical incompetence underwent the cerclage, and the time of the operation was decided by the patients or depended on when the patient presented. Main outcome measures were the gestational age and the fetal outcome.Results: After the cerclage, the mean gestational age at delivery and the term delivery rate were significantly higher in history-indicated conception cerclage compared to preconception cerclage (36.8 ± 3.7 vs 35.8 ± 4.7, p < 0.01; 76.1 vs 66.9%, p < 0.05). The mean gestational age at delivery and the term delivery rate were significantly higher in ultrasound-indicated compared to physical examination-indicated conception cerclage (35.0 ± 5.7 vs 31.0 ± 5.5, p < 0.01; 63.2 vs 23.3%, p < 0.001). The fetal survival rate had no difference in these two comparisons, respectively.Conclusions: The modified transvaginal cervicoisthmic cerclage is a promising and safe technique to improve obstetric outcomes in women with cervical incompetence in different cerclage indications, and history-indicated conception cerclage appears to have better pregnancy outcome. [ABSTRACT FROM AUTHOR]

Background: Transabdominal placement of a cervical cerclage appears to be safe and effective procedure in reducing pregnancy loss in selected patients with cervical incompetence. It can be placed almost at the internal os, by laparoscopy or laparotomy, in non-pregnant or pregnant state and can be left in situ till the woman's obstetric career is complete. Objective: The purpose of this study was to evaluate the effectiveness of transabdominal cerclage placement, in terms of obstetric and perinatal outcomes in the study population. Material and methods: We conducted a five years retrospective study on consecutive women undergoing transabdominal cerclage from 2010 to 2015 at 'Me and Mummy' hospital, Surat (Gujarat). Data was retrieved from medical records. Eligible women had past history suggestive of cervical incompetence, previous failed transvaginal cerclage or short cervix unfavourable for transvaginal cerclage. The primary outcome of the study was to measure neonatal survival rate whereas the secondary outcomes were delivery after 34 weeks of gestation and procedure related complications. Results: Total 25 women underwent transabdominal cerclage during the study period. In 24 women the procedure was done by laparoscopy and in one woman laparotomy was done. Twenty two women underwent interval cerclage and three women underwent antenatal placement of cerclage. Total 17 pregnancies and 21 foetuses were evaluated during the study period (four pairs of twins). Neonatal survival rate was 95.65 % (20 of 21 babies). Out of 17 women, 11 women delivered after 37 weeks (64.70%), four women after 34 weeks (23.52%), one woman after 28 weeks of gestation and one woman had inevitable miscarriage within one week of procedure. There were no procedure related complications. Conclusion: Transabdominal cerclage in selective cases and in expert hands is a safe and effective procedure resulting in favourable obstetric and neonatal outcomes in women with poor obstetric history due to cervical incompetence. [ABSTRACT FROM AUTHOR]

Purpose: The aim of our study was to investigate the sonographic changes of the cervical length during pregnancy after the placement of a transvaginal cervical cerclage (TVC) or a laparoscopic abdominal cerclage (LAC) in patients with cervical insufficiency (CI).Methods: Between January 2008 and March 2015, a retrospective analysis of all women undergoing a prophylactic laparoscopic (LAC group) or transvaginal (TVC group) cerclage due to cervical insufficiency was conducted. Nonparametric variables were analysed with the Mann-Whitney (U) test, and categorical-type outcomes were analysed with the Fisher's exact test. A p value <0.05 was considered as significant. Data analysis was performed using Prism 5 for Mac OS X.Results: Thirty-eight patients were included. Of these, 18 and 20 underwent an LAC and a TVC, respectively. Mean gestational age at surgery in the LAC and TVC groups was 11.4 ± 1.6 and 17 ± 3 weeks, respectively (p < 0.05). The cervical length prior to surgery was similar among the two groups. After cerclage placement, the distance between the tape and the external cervical os differed significantly between the two groups (LAC: 31.5 ± 8.8 mm vs TVC: 13.5 ± 4.9 mm; p < 0.0001) (Fig. 1). During pregnancy, the cervical length in the TVC group showed a significant shortening (from 26.6 ± 7 mm before surgery to 13.2 ± 7 mm at 33 weeks; p < 0.0001), while in the LAC group, the cervical length remained unchanged.Conclusions: In patients with CI, LAC is associated with a better preservation of the cervical length throughout pregnancy as compared to TVC. [ABSTRACT FROM AUTHOR]

Objective: Transabdominal cerclage (TAC) is an effective intervention to prevent spontaneous mid-trimester loss and preterm delivery when a transvaginal cerclage has failed. A TAC may be inserted during the first trimester of pregnancy or preconceptually. The objective of this study was to determine whether or not preconceptual transabdominal cerclage (TAC) confers any benefit over first trimester TAC insertion in terms of associated surgical and pregnancy-related morbidity and subsequent pregnancy outcome.Study Design: This was a retrospective and prospective cohort study of 161 consecutive women who underwent preconceptual (PC) TAC versus first trimester (T1) TAC over a 22-year period from January 1993 to January 2015 at a tertiary referral miscarriage clinic. Data was obtained from case note review retrospectively from 1993 to 2006 and prospectively between 2006 and 2015. Inclusion criteria comprised a history of at least one previous spontaneous mid-trimester loss coupled with at least one failed transvaginal cerclage and screening for antiphospholipid syndrome and bacterial vaginosis. Of 144 patients who conceived, 121 had complete pregnancy outcomes; 62 in the preconceptual group and 59 in the first trimester group. Both groups had similar previous pregnancy losses and previous transvaginal cerclage history.Results: Successful pregnancies >24 weeks occurred in 97% of PC TACs compared to 93% in the T1 group. Furthermore, a successful pregnancy >34 weeks occurred in 90% (56/62) in the PC group compared to 74% (44/59) in the T1 group (OR 3.18; CI 1.14-8.8). Significantly fewer patients needed emergency caesarean section for preterm delivery in the PC group (7/62 (12%) versus 21/59 (36%); OR 4.34; CI 1.68-11.32). All 6 failures before 24 weeks gestation (T1=4, PC=2) were associated with antiphospholipid syndrome or bacterial vaginosis. In the T1 group 3/65 (5%) of patients suffered serious surgical complications and haemorrhage >500mls occurred in 32/65(50%) of cases whereas no surgical complications occurred in the PC group.Conclusions: Preconceptual TAC is more successful in preventing repeat spontaneous mid-trimester loss and preterm labour, and is associated with less surgical and pregnancy-related morbidity compared to first trimester TAC insertion. [ABSTRACT FROM AUTHOR]

There are no reports indicating the effect of prophylactic transabdominal cerclage (TAC) on the prolongation of multifetal pregnancies. We report the use of TAC in triplets, which evolved over 20 years in one practice. A retrospective cohort study of triplet pregnancies was conducted. Obstetric and neonatal outcomes were compared among women who underwent a prophylactic TAC or transvaginal cerclage and no cerclage. Of the 141 women who delivered triplets, prophylactic TAC was associated with reduced incidence of extreme prematurity and improved incidence of neonatal/postnatal survival. With the exception of mode of conception, prepregnancy weight, and the use of home monitoring uterine activity monitor, procardia and terbutaline, no major differences were found in terms of patient characteristics and pregnancy and delivery management among the three groups. It was concluded that in triplet pregnancies, prophylactic placement of a TAC appears to lower the incidence of delivery before 28 weeks. [ABSTRACT FROM AUTHOR]

To evaluate maternal and neonatal outcomes after transabdominal cerclage. Retrospective analysis of 15 patients receiving transabdominal cerclage. Using the patient’s prior pregnancy as her own control, we assessed the effect of this procedure on gestational age and neonatal survival. All patients had experienced a prior pregnancy loss. Twelve out of the 15 patients (80%) had at least one prior failed vaginal cerclage. The median gestational age at surgery was 14 (range 12–16) weeks. There was one case of surgical site infection. After cerclage, the proportion of women delivered beyond 32 weeks was significantly higher [11/15 (73.3%) vs. 1/15 (6.7%), P = 0.0016], as was neonatal survival [12/15 (80%) vs. 1/15 (6.7%), P = 0.0009]. While transabdominal cerclage is a major surgical procedure, subsequent pregnancy outcomes were improved. [ABSTRACT FROM AUTHOR]