Effect of different surgical routes on pregnancy outcome of history-indicated cervical cerclage

doi:10.21203/rs.3.rs-2122379/v1

Download PDF

Research Article

Effect of different surgical routes on pregnancy outcome of history-indicated cervical cerclage

https://doi.org/10.21203/rs.3.rs-2122379/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 01 Apr, 2023

Read the published version in Archives of Gynecology and Obstetrics →

You are reading this latest preprint version

Objective

To study the guiding significance of medical history on laparoscopic and vaginal cervical cerclage in the treatment of cervical incompetence and its influence on pregnancy outcome.

Methods

A total of 53 cases of cervical cerclage by laparoscopy before pregnancy (laparoscopic group) and 73 cases of preventive cervical cerclage by vagina (vaginal group) at 12–14 weeks of pregnancy were collected. Multivariate logistic regression analysis was performed on the influencing factors of delivery gestational weeks. To further compare the difference of delivery gestational weeks after cervical cerclage between laparoscopic group and vaginal group with high and low risk levels.

Results

The number of previous uterine cavity operations in laparoscopic group was more than that in vaginal group, the hospitalization days and operation time were longer than those in vaginal group, the delivery rate of cesarean section was higher than that in vaginal group, but the total hospitalization times were less than that in vaginal group(P < 0.05). The rate of delivery before 34 weeks of pregnancy and the incidence of premature rupture of membranes or premature labor in laparoscopic group were lower than those in vaginal group(P < 0.05). In the vaginal group, the increased number of prior PTB or STL and the history of cervical cerclage failure will increase the risk of premature delivery before 34 weeks of pregnancy. There was no significant difference in the influence of laparoscopic history on delivery before 34 weeks of pregnancy(P > 0.05). According to the risk level, in the high-risk group the delivery rate of laparoscopic group at gestational weeks < 37 weeks, < 34 weeks and < 28 weeks was lower than that of vaginal group.

Conclusion

Laparoscopic cervical cerclage is more effective in preventing premature delivery before 34 weeks of gestation, and its influence on delivery gestational weeks is not affected by related medical history. For high-risk patients, laparoscopic cervical cerclage is more effective than vaginal cervical cerclage in preventing extremely preterm 28 weeks ago, premature delivery 34 weeks ago and preterm delivery 37 weeks ago. Therefore, laparoscopic cervical cerclage is preferred for patients with high-risk medical history. However, laparoscopic cervical cerclage significantly increases the cesarean section rate, and the advantages and disadvantages of retaining laparoscopic cervical cerclage in situ still need further follow-up and research.

Cervical incompetence

Cervical cerclage

Laparoscopy

Vaginal

Cervical incompetence (CIC) is due to the abnormal anatomical structure or function of the cervix, which leads to the progressive and painless shortening, flattening and expansion of the cervix before the 37th week of pregnancy, with or without premature rupture of membranes and protruding amniotic sac at the cervix, which leads to the inability to maintain the pregnancy in the second and third trimesters of pregnancy. The incidence of CIC in premature delivery is 0.1%~1.0%^[1], and it accounts for 15% of recurrent spontaneous abortion in 16–28 weeks of pregnancy ^[2]. At present, the etiology of CIC is not completely clear ^[3], mainly including recurrent second-trimester pregnancy abortion or premature delivery, history of cervical trauma, infection factors, congenital cervical dysplasia or uterine malformation ^[4], etc. CIC can lead to an increase in perinatal morbidity, including premature rupture of membranes, chorioamnionitis and premature delivery ^[5]; Therefore, it is of great significance to effectively evaluate the treatment methods and related factors of CIC to prevent premature delivery and improve the reproductive quality.

At present, cervical cerclage is the main surgical method to treat CIC. According to the guidelines of Royal College of Obstetricians and Gynaecologists (RCOG) in 2022 ^[6], cervical cerclage can be divided into cervical cerclage indicated by medical history, cervical cerclage indicated by ultrasound and cervical cerclage indicated by physical examination. Among them, preventive cervical cerclage with medical history indication is an effective method to treat CIC ^[7]. Indicative preventive cervical cerclage can be performed via vagina or abdomen. McDonald's and Shirodkar's methods are two main methods of transvaginal cerclage ^[8]. Transvaginal operation is convenient and easy to operate and has been used in clinical practice for over 60 years. However, in many cases such as excessive cervical position or other anatomic abnormalities, transvaginal cerclage may be technically limited ^[9]. Transabdominal cerclage may be another effective way, while laparoscopy has the advantages of minimally invasive, avoiding foreign bodies in vagina and infection ^[10]. However, cesarean section is the main way to terminate pregnancy, which increases the rate of cesarean section and surgical complications. Analyzing the effect of different surgical routes can help to choose the optimal treatment, improve the prognosis, and reduce the perinatal morbidity. This article retrospectively analyzes the differences between laparoscopic and vaginal preventive cervical cerclage, compares the effects of the two surgical methods on the gestational age of delivery, and explores the potential influencing factors related to the two surgical methods, providing guidance for optimal preoperative planning.

Study population

This retrospective research was carried out in the department of Gynaecology and Obstetrics, Chongqing Health Center for Women and Children, Chongqing, China. We selected and collected a total of 216 patients with indications of preventive cervical cerclage due to cervical incompetence between January 2018 to December 2021, which including 98 patients with laparoscopic cervical cerclage and 118 patients with transvaginal cervical cerclage. The medical history, clinical data and pregnancy outcomes were retrospectively reviewed. Laparoscopic cervical cerclage was pre-pregnancy cervical cerclage, among which 45 patients were excluded without pregnancy outcome by the end of follow-up, including 18 cases lost to follow-up, 12 cases without pregnancy plan, 9 cases currently undergoing assisted reproduction and 6 cases in pregnancy; 26 patients with transvaginal cerclage lost follow-up, and 19 twins were excluded from this study(Fig. 1). Finally, the patients included in the study included 53 cases of cervical cerclage with pregnancy outcome by laparoscopy before pregnancy (LAC group), and 73 cases of prophylactic cervical cerclage with pregnancy outcome by vagina at 12–14 weeks of pregnancy (TVC group).

Eligibility Criteria

① One or more cases of abortion or premature delivery in the second trimester of pregnancy due to painless cervical dilatation; ② Positive uterus enlargement test in non-pregnancy period; ③ Patients and their families fully understand and sign the informed consent form; ④ The medical history is complete.

Exclusion Criteria

① Multiple pregnancy; ② Termination of pregnancy and medical premature birth for medical reasons; ③ Emergency ring ligation and emergency ring ligation; ④ Signs of abdominal pain, infection or bleeding; ⑤ Patients with coagulation dysfunction.

Surgical Techniques

Urine examination, routine examination of vaginal secretion and general bacterial culture were performed in both groups before operation, all of which indicated that there was no infection of genitourinary organs; Before operation, all the patients in the vaginal group underwent ultrasound examination to confirm the fetal survival, and combined with serum chromosome and ultrasound examination to check the malformation. Both groups were well prepared before operation, and the contraindications of operation and anesthesia were excluded. Use a unified Mersikence loop tie (polypropylene loop tie with needles at both ends, 40cm in length and 5mm in width) for cervical cerclage.

LAC

The specific operation of laparoscopic abdominal cervical cerclage(LAC) was as follows: After the patient was placed in supine position and given general anesthesia, laparoscopic perforation was performed on both sides of the umbilical region and lower abdomen. During the operation, the uterus was pushed forward by a uterine lifter, and the upper edge of the root of bilateral sacral ligaments was taken about 1cm. The inner edge of uterine artery was the puncture point, and the polypropylene loop was punctured. Four knots were tied on the front wall of cervical canal. Finally, there was no abnormality in the uterine cavity after hysteroscopy. Antibiotics were routinely used to prevent infection after operation. One month after operation, the laparoscopic group began to actively try to get pregnancy. The suture should be removed by cesarean section from normal pregnancy to the third trimester of pregnancy.

TVC

The specific operation of transvaginal cervix cerclage(TVC) was as follows: The pregnant woman was performed continuous epidural anesthesia. We took the loop strap, inserted the needle at 11 o'clock, and then took out the needle at 10 o'clock for purse-string suture. At the last 2 o'clock, the needle was inserted at 1 o'clock, avoiding the vascular plexus, and the suture depth reached 2/3 of the cervical muscularis, without penetrating the mucosa. The loop strap was gradually tightened at the anterior fornix. Antibiotics were routinely used to prevent infection and desmoprogesterone 10mg q8h was treated after operation. The suture can be removed at 36–38 weeks of pregnancy from normal pregnancy to the third trimester of pregnancy. If premature labor starts, remove the cervical cerclage line immediately.

Date Collection

Date were collection from the patients’ medical records and telephone follow-up. All the subjects We reviewed the subjects’ medical history, and collected general clinical features, surgical conditions, pregnancy outcomes, etc. We defined the risk level, less than three prior PTB or STL and no history of cervical cerclage failure were low-risk groups (35 cases in LAC group and 50 cases in TVC group), while three or more prior PTB or STL (8 cases in LAC group and 10 cases in TVC group) and/or the history of cervical cerclage failure (16 cases in LAC group and 15 cases in TVC group) were high-risk groups (18 cases in LAC group and 20 cases inTVC group).

Statistical analysis

The data that conformed to the normal distribution was expressed as mean ± SD, and the comparison among the means was made by Student’s T test. The data that did not conform to the normal distribution was expressed as the median (interquartile range), M(P25,P75). The counting data were expressed by the number of cases (n) and percentage (%), and the comparison was made by chi-square test or Fisher exact test. The factor analysis of factors related to gestational age of delivery was carried out by multivariate logistics regression model. A P values < 0.05 was consided significant. SPSS25. statistical software was used to analyze the data.

Comparison of clinical characteristics, surgical conditions, and delivery outcomes between LAC group and TVC group(Table 1). There is no significant difference between the two groups in age, BMI, pregnancy times, parity, abortion or premature delivery times in the second trimester, history of previous cervical cerclage failure, history of cervical surgery, cervical length measured by B-ultrasound before pregnancy and bleeding volume (P > 0.05). The number of uterine cavity operations between laparoscopic and vaginal groups was statistically significant (P < 0.05). The hospitalization days and operation time of LAC group were longer than those of TVC group, and the total hospitalization times from pregnancy to delivery were less than those of TVC group (P < 0.05). Compared with the mode of delivery, there were 50 cases (94.3%) of cesarean section in LAC group and 16 cases (21.9%) in TVC group. The rate of cesarean section in LAC group was higher than that in TAC group(OR0.017, 95% CI 0.005–0.061, P < 0.05). The gestational weeks were divided into three groups according to 37 weeks, 34 weeks and 28 weeks respectively. There were 5 cases (9.4%) in LAC group and 18 cases (24.7%) in TVC group with gestational weeks less than 34 weeks. The rate of delivery before 34 weeks in LAC group was lower than that in TVC group (P < 0.05). 10 cases (18.9%) of newborns weighed less than 2500g in LAC group and 26 cases (35.6%) in TVC group, which were lower than those in TAC group (OR 0.420 and 95%CI 0.182–0.972, P < 0.05). Results Compared with the TVC group, LAC group had a better improvement effect on premature delivery and low birth weight. There was no significant difference in the rate of neonatal admission to intensive care unit (NICU) between the two groups.

Table 1

Comparison of general clinical data and pregnancy outcome between the two groups
Characteristics		LAC group(n = 53)	TVC group(n = 73)	t/χ²/z	P value
Age^a(years)		30.62 ± 3.79	29.63 ± 4.54	1.296	0.197
BMI^b(kg/m²)		23.53(21.37, 25.51)	22.26(20.21, 24.92)	1.735	0.083
Gestity^b		3(2,4)	3(2,4)	0.32	0.749
Parity^b		0(0,0)	0(0,1)	1.624	0.104
Prior PTB or STL^c	≤ 1 2 ≥ 3	29(54.7%) 16(30.2%) 8(15.1%)	40(54.8%) 23(31.5%) 10(13.7%)	0.059	0.971
Prior cerclage failure ^c	No Yes	37(69.8%) 16(30.2%)	58(79.5%) 15(20.5%)	1.539	0.215
Prior cervical surgery ^c	No Yes	46(86.8%) 7(13.2%)	62(84.9%) 11(15.1%)	0.087	0.803
Intrauterine operation^c	≤ 1 2 ≥ 3	34(64.2%) 9(17%) 10(18.8%)	64(87.7%) 6(8.2%) 3(4.1%)	10.647	0.005
Cervical length before pregnancy ^b(cm)		2.7(2.5-3.0)	3.0(2.5–3.3)	1.474	0.140
Hospital stays^b(days)		7(6,8)	3(3,5)	0.397	＜0.001
Time of operation^b(min)		48(45,50)	20(19.5,34.5)	7.639	＜0.001
Amount of bleeding^b(ml)		10(10, 20)	10(5, 20)	1.868	0.062
Hospitalization times ^b		2(2, 2)	2(2, 2.5)	3.523	＜0.001
Delivery ^c	Cesarean Vaginal	50(94.3%) 3(5.7%)	16(21.9%) 57(78.1)	64.567	＜0.001
Delivery gestational age^c(weeks)	＜37 ≥ 37 ＜34 ≥ 34 ＜28 ≥ 28	13(24.5%) 40(75.5%) 5(9.4%) 48(90.6%) 5(9.4%) 48(90.6%)	29(39.7%) 44(60.3%) 18(24.7%) 55(75.3%) 14(19.2%) 59(80.8%)	3.192 4.769 2.277	0.074 0.029 0.131
Neonatal weight ^c(g)	＜2500 ≥ 2500	10(18.9%) 43(81.1%)	26(35.6%) 47(64.4%)	4.221	0.040
NICU ^b		4(7.5%)	10(13.7%)	1.176	0.278
Retained of the loop tie		7	-	-	-
PPROM/Premature		10(18.9%)	27(37%)	4.860	0.027
BMI:body mass index; PTB or STL: preterm birth or second trimester loss; NICU:neonatal intensive care unit;PPROM: Preterm premature rupture of the membranes
^a x̄ ± s; ^b M(P25,P75); ^c n(%);^b M(P25,P75); ^c n(%);

Multivariate logistic regression analysis was performed on the influencing factors of delivery gestational age (Table 2), with delivery gestational age as dependent variable, ≥ 34 weeks as 0 and < 34 weeks as 1, and age, BMI, operation mode, prior PTB or STL, prior cervical cerclage failure, prior cervical surgery and prior uterine cavity operation as independent variables. The results showed that different surgical routs had statistically significant effects on delivery gestational weeks (OR = 5.625,95% CI 1.504–21.032, P < 0.05). The history of prior PTB or STL has statistical significance on the gestational weeks of delivery (OR = 2.755,95% CI 1.406–5.398, P < 0.05). The increase of the number of prior PTB or STL would increase the risk of premature delivery before the 34th trimester. The history of cervical cerclage failure has statistical significance on the gestational age of delivery (OR = 3.682, 95% CI 1.206–11.243, P < 0.05). The history of cervical cerclage failure will increase the risk of delivery before 34 weeks of pregnancy. The history of cervical surgery, the number of uterine cavity operations,age and BMI had no statistical significance on delivery before 34 weeks of pregnancy.

Table 2

Multivariate logistic regression analysis of the factors affecting labor gestational age(34weeks) in both groups.
Variable	group	β	SE	Wald	P value	OR	95%CI
Age(years)		0.035	0.062	0.317	0.573	1.036	0.917–1.170
BMI (kg/m²)		-0.082	0.084	0.949	0.330	0.921	0.781–1.086
Surgical routes	LAC^d TVC	-1.727	0.673	6.588	0.010	5.625	1.504–21.032
Prior PTB or STL	≤ 1^d 2 ≥ 3	1.013	0.343	8.712	0.003	2.755	1.406–5.398
Prior cerclage failure	NO^d YES	1.303	0.570	5.237	0.022	3.682	1.206–11.243
Prior cervical surgery	NO^d YES	-0.461	0.732	0.396	0.529	0.631	0.150–2.649
Intrauterine operation	≤ 1^d 2 ≥ 3	0.416	0.420	0.980	0.322	1.515	0.665–3.452
^d Control group

Multivariate logistic regression analysis was performed on the gestational weeks of delivery in LAC group and TVC group respectively (Table 3), and the differences of influencing factors between the two groups were compared. The results showed that the number of prior PTB or STL and the history of prior cerclage failure in the TVC group had statistical significance on the gestational weeks. With the increaseing of the number of prior PTB or STL would increase the risk of premature delivery before 34 weeks after vaginal cerclage (OR = 3.050,95% CI 1.352–6.879, P < 0.05). The failure history of cervical cerclage would increase the risk of delivery before 34 weeks after vaginal cerclage (OR = 6.270, 95% CI 1.680-23.399, P < 0.05). In the LAC group, the number of prior PTB or STL and the history of cervical cerclage failure had no significant influence on the delivery before 34 weeks of pregnancy after laparoscopic cerclage.

Table 3

Multivariate logistic regression analysis of influencing factors of gestational age in both groups.
	Variable	group	β	SE	Wald	P value	OR	95%CI
LAC
	Prior PTB or STL	≤ 1^e 2 ≥ 3	1.047	0.625	2.811	0.094	2.850	0.838–9.695
	Prior cerclage failure	NO^e YES	-1.496	1.250	1.432	0.231	0.224	0.019–2.597
TVC
	Prior PTB or STL	≤ 1^e 2 ≥ 3	1.115	0.415	7.223	0.007	3.050	1.352–6.879
	Prior cerclage failure	NO^e YES	1.836	0.672	7.465	0.006	6.270	1.680-23.399
^e Control group

Furthermore, we included the patients with less than three prior PTB or STL and no history of cervical cerclage failure in the low-risk group (35 cases in laparoscopic group and 50 cases in vaginal group), and the patients with three or more prior PTB or STL and/or history of cervical cerclage failure were in the high-risk group (18 cases in LAC group and 23 cases in TVC group), among which the patients with more prior PTB or STL and history of cervical cerclage failure were in LAC group(Table 4). In the LAC group, The mean gestational age at delivery was lower in the high-risk group than in the low-risk group[37.3(35, 38) vs.38(37.3, 38.1), OR 0.5, 95% CI 0.0-1.20, P < 0.05]. In the low-risk group, there is no significant difference between the LAC group and the TVC group in the gestational weeks of delivery < 37 weeks, < 34 weeks and < 28 weeks respectively. In the high-risk group, the LAC group had lower gestational weeks < 37 weeks, < 34 weeks and < 28 weeks respectively than TVC group [Gestational weeks < 37 weeks 6(33.3%)vs.16(69.6%), OR 0.219, 95% CI 0.058–0.821,P < 0.05, Gestational week < 34 weeks 2(11.1%)vs.11(47.8%), OR 7.333, 95% CI 1.364–39.438, P < 0.05, Gestational week < 28 weeks 2 (11.1%) vs. 9 (39.1%), OR 5.143, 95% CI 0.947–27.921, P < 0.05].

Table 4

Analysis of delivery outcomes after cervical cerclage at different risk levels.
	Gestational weeks	LAC(n,%)	TVC(n,%)	χ²	P value
Low-risk group
	＜37w	5(14.3)	14(28.0)	2.231	0.135
	＜34w	2(5.7)	7(14.0)	1.493	0.222
	＜28w	2(5.7)	5(10.0)	0.500	0.479
High-risk group
	＜37w	6(33.3)	16(69.6)	5.331	0.021
	＜34w	2(11.1)	11(47.8)	6.286	0.012
	＜28w	2(11.1)	9(39.1)	4.038	0.044

Cervical incompetence is one of the main causes of pregnancy loss. Successful cervical cerclage will improve the outcome of pregnancy, prolong the pregnancy as much as possible, and reduce the cost of treatment and rehabilitation of premature infants ^[11]. It is safe and feasible to perform laparoscopic cervical cerclage with medical history indication in non-pregnant women with cervical incompetence, plus the inherent advantages of minimally invasive surgery, and it has better obstetric outcomes ^[12]. In this paper, we retrospectively analyzed and studied the influence of laparoscopic and transvaginal surgical routes on pregnancy outcome in view of the indication of cervical cerclage with medical history. Considering that laparoscopic cervical cerclage is better than vaginal cervical cerclage in preventing premature delivery before 34 weeks of pregnancy. laparoscopic cervical cerclage is superior to vaginal cervical cerclage in newborn weight. Similar to the recent research report, Shennan et al. ^[13] pointed out that abdominal cerclage was superior to vaginal cerclage for cervical incompetence patients with a history of abortion in the second trimester of pregnancy. Compared with transvaginal cervical cerclage, abdominal cerclage significantly reduces premature delivery before gestational week < 32 weeks. Moawad, G.N, etc.^[14] also pointed out that transabdominal cerclage can significantly reduce the premature delivery rate before 34 weeks. In the current era of minimally invasive surgery, the effect of laparoscopic surgery is equally good ^[15]. Tian, S et al. ^[7] found that compared with the transvaginal group, the number of babies delivered at ≥ 34 weeks in the laparoscopic group was significantly higher (94.6%vs.71.3%, P < 0.01).

The timing of laparoscopic cervical cerclage surgery is mostly before pregnancy, and some of them are performed at 6–8 weeks of pregnancy, because the small uterus is more suitable for laparoscopic surgery at this time. Transvaginal cerclage is usually performed in 12–14 weeks during pregnancy, when the fetus is stable, which reduces the impact of surgical stimulation on the fetus. In this paper, laparoscopic cervical cerclage before pregnancy and vaginal cerclage during pregnancy are selected. Both groups are preventive cerclage, which excludes threatened abortion such as abdominal pain and vaginal bleeding, and avoids the influence of operation timing on the research outcome. Previous studies have pointed out that preoperative cervical length ^[16], age, BMI, prior PTB or STL ^[17] are independent risk factors that affect pregnancy outcome. In this paper, there is no significant difference in age, BMI, prior PTB or STL, prior cervical cerclage failures, cervical operations and the length of cervix in non-pregnancy between the two groups. The inclusion of the two groups is reasonable. The number of uterine cavity operations in LAC group was more than that in TVC group, which was related to hysteroscopy before laparoscopic cervical cerclage, so as to ensure the good condition of uterine cavity and eliminate intrauterine adhesion. In this study, the number of uterine cavity operations was not the influencing factor of delivery gestational age, while Gokce, A et al. ^[18] proposed that the full-term delivery rate of women who underwent hysteroscopy within 6 months before pregnancy decreased significantly. The difference between this study and the literature was related to the fact that this study focuses on the number of uterine cavity operations, and did not group the specific time of uterine cavity operations.

In this study, different rout of cervical cerclage operation, the number of prior PTB or STL, and the history of cervical cerclage failure were all independent influencing factors of preterm birth before 34 weeks of gestation. The increase of prior PTB or STL and the history of cervical cerclage failure would increase the risk of premature delivery before 34 weeks after vaginal cerclage. However, both of them had no significant effect on preterm delivery before 34 weeks of pregnancy after laparoscopic cervical cerclage. Therefore, we believe that laparoscopic cervical cerclage is more effective in improving early and middle term preterm delivery, and the effect on gestational age at delivery is not easily affected by medical history related factors.It is related to the following points: 1) Laparoscopic cervical cerclage is higher than vaginal cerclage, which is closer to the cervical isthmus, and the cervical length does not change during the whole pregnancy ^[7,19]. 2) Laparoscopic cervical cerclage is pre-pregnancy cerclage, which avoids the adverse effects of stimulation of cervical surgery during pregnancy on pregnancy ^[20]. 3) The infection risk of transvaginal surgery is higher than that of abdominal surgery. 4) Cervical dysfunction caused by abortion or premature delivery in the second trimester is related to chronic endometritis ^[21]. Laparoscopic cervical cerclage before pregnancy is beneficial to improve the microecology of endometrium before pregnancy and facilitate embryo implantation and development.

At present, it is recommended that preventive cervical cerclage be feasible for patients with three or more spontaneous preterm births or miscarriages ^[6], and there is no conclusion on the treatment of patients with less than three trimester miscarriages or preterm births. Therefore, it is very important to identify the high-risk patients with cervical incompetence early and accurately, and then take active intervention measures to improve the pregnancy outcome. Huang, X et al. ^[22] proposed that laparoscopic cervical cerclage was an effective method to treat cervical incompetence that failed transvaginal cerclage. A history of three or more prior PTB or STL and cervical cerclage failure was a high-risk history of cervical insufficiency. LAC was more effective than TVC in preventing extremely preterm 28 weeks ago, premature delivery 34 weeks ago and preterm delivery 37 weeks ago. Therefore, LAC could be preferred for patients with high-risk history, but it might be possible to wait for patients with multiple spontaneous abortions. For patients with spontaneous abortion history, uterine cervical length can be monitored by ultrasound during pregnancy ^[23], and preventive cervical cerclage can be performed when necessary.

One of the disadvantages of LAC is termination of pregnancy by cesarean section, the rate of cesarean section is higher than that of TVC, and gynecologists are required to have rich experience in minimally invasive surgery. At the same time, due to the strict requirements of laparoscopic transabdominal surgery, general anesthesia and fasting, as well as abdominal incision healing and other factors, the length of hospital stay and operation time of LAC are longer than those of TVC. However, the total number of hospitalizations is reduced, which avoids the infection of vaginal operation, absolute bed rest, and fetus protection rate in hospital. Cervical girdle can be removed during cesarean section. However, with the full liberalization of the three-child policy, some women will choose to keep the girdle. In this article, 7 cases chose to keep the band, and there was no discomfort and normal menstrual flow during the follow-up. Ades, A et al. ^[24] analyzed 22 women who underwent laparoscopic cervical cerclage and retained cervical cerclage in situ. Among them, 19 women gave birth after two pregnancies, and 3 women gave birth three times. Their third pregnancy was as successful as the first and second pregnancies. Due to the small number of cases and related studies, there is no strong evidence to show the pregnancy outcome of retaining laparoscopic cervical girdle in situ, which is also the value of this study that needs to be continuously observed and followed up.

Laparoscopic cervical cerclage is more effective in preventing premature delivery before 34 weeks of gestation, and the influence of gestational weeks is not affected by the number of prior PTB or STL and the history of cervical cerclage failure. The number of prior PTB or STL and the history of cervical cerclage failure are independent factors influencing the gestational age of delivery after TVC, which will increase the risk of premature delivery before 34 weeks of pregnancy. In high-risk patients with the history of prior PTB or STL and failed cerclage, LAC is more effective than vaginal cerclage in preventing abortion before 28 weeks, premature delivery before 34 weeks and premature delivery before 37 weeks. Therefore, LAC cerclage can be preferred for patients with high-risk history. However, LAC significantly increases the cesarean section rate and requires gynecologists to have rich experience in minimally invasive surgery. The advantages and disadvantages of retaining laparoscopic cervical girdle in situ still need further follow-up and research.

Author Contributions

All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. These should be presented as follows. All authors—conceptualization; F QIN and B LIU: followed up the patient and data collection; Y YANG:data analysis; F QIN: manuscript writing/editing. W ZHOU, YG CHI and GL CHEN: project development and revised the manuscript. GL CHEN: review and editing.

Ethics Approval and Consent to Participate

The study was conducted in accordance with the guidelines of the Declaration of Helsinki. This study was approved by the Institutional Review Board (IRB) of Chongqing Health Center for Women and Children.

Acknowledgment

Thanks to all the peer reviewers for their opinions and suggestions.

Funding

This research received no external funding.

Conflict of Interest

The authors declare no conflict of interest.

This article retrospectively analyzes the differences between laparoscopic and vaginal preventive cervical cerclage, compares the effects of the two surgical methods on the gestational age of delivery, and explores the potential influencing factors related to the two surgical methods, providing guidance for choosing the optimal treatment, improve the prognosis, and reduce the perinatal morbidity.

Akladios, C.Y., et al., [Cervical cerclage]. J Gynecol Obstet Biol Reprod (Paris), 2015. 44(8): p. 771-5.
Berghella, V., et al., Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth: a meta-analysis. Obstet Gynecol, 2011. 117(3): p. 663-671.
Sundtoft, I., et al., Cervical collagen is reduced in non-pregnant women with a history of cervical incompetence and a short cervix. Acta Obstet Gynecol Scand, 2017. 96(8): p. 984-990.
Mastrolia, S.A., et al., Independent association between uterine malformations and cervical incompetence: a retrospective population-based cohort study. Arch Gynecol Obstet, 2018. 297(4): p. 919-926.
Pang, Q., X. Jia, and L. Chen, Perinatal Outcomes After Emergency Cervical Cerclage for Cervical incompetence with Prolapsed Membranes. Med Sci Monit, 2019. 25: p. 4202-4206.
Shennan, A.H., L. Story, and G. Royal College of Obstetricians, Cervical Cerclage: Green-top Guideline No. 75. BJOG, 2022. 129(7): p. 1178-1210.
Tian, S., S. Zhao, and Y. Hu, Comparison of laparoscopic abdominal cerclage and transvaginal cerclage for the treatment of cervical incompetence: a retrospective study. Arch Gynecol Obstet, 2021. 303(4): p. 1017-1023.
Figueroa, R., et al., McDonald versus Shirodkar cervical cerclage for the prevention of preterm birth: impact of body mass index. J Matern Fetal Neonatal Med, 2019. 32(20): p. 3408-3414.
Tulandi, T., et al., Pre and post-conceptional abdominal cerclage by laparoscopy or laparotomy. J Minim Invasive Gynecol, 2014. 21(6): p. 987-93.
Tusheva, O.A., et al., Laparoscopic placement of cervical cerclage. Rev Obstet Gynecol, 2012. 5(3-4): p. e158-65.
Barinov, S.V., et al., Analysis of risk factors and predictors of pregnancy loss and strategies for the management of cervical incompetence in pregnant women at a high risk of preterm birth. J Matern Fetal Neonatal Med, 2021. 34(13): p. 2071-2079.
Vigueras Smith, A., et al., Laparoscopic Transabdominal Cerclage for Cervical Incompetence: A Feasible and Effective Treatment in 10 Steps. J Minim Invasive Gynecol, 2020. 27(5): p. 1025-1026.
Shennan, A., et al., MAVRIC: a multicenter randomized controlled trial of transabdominal vs transvaginal cervical cerclage. Am J Obstet Gynecol, 2020. 222(3): p. 261 e1-261 e9.
Moawad, G.N., et al., Systematic Review of Transabdominal Cerclage Placed via Laparoscopy for the Prevention of Preterm Birth. J Minim Invasive Gynecol, 2018. 25(2): p. 277-286.
Demirel, C., et al., Fertility outcomes after preconceptional laparoscopic abdominal cerclage for second-trimester pregnancy losses. Eur J Obstet Gynecol Reprod Biol, 2021. 257: p. 59-63.
Liu, Y., et al., Pregnancy outcomes and superiorities of prophylactic cervical cerclage and therapeutic cervical cerclage in cervical incompetence pregnant women. Arch Gynecol Obstet, 2018. 297(6): p. 1503-1508.
Chen, R., X. Huang, and B. Li, Pregnancy outcomes and factors affecting the clinical effects of cervical cerclage when used for different indications: A retrospective study of 326 cases. Taiwan J Obstet Gynecol, 2020. 59(1): p. 28-33.
Gokce, A., et al., The association between operative hysteroscopy prior to assisted reproductive technology and cervical incompetence in second trimester. Arch Gynecol Obstet, 2021. 303(5): p. 1347-1352.
Bolla, D., et al., Cervical length after cerclage: comparison between laparoscopic and vaginal approach. Arch Gynecol Obstet, 2017. 295(4): p. 885-890.
Wei, M., et al., A comparison of pregnancy outcome of modified transvaginal cervicoisthmic cerclage performed prior to and during pregnancy. Archives of Gynecology and Obstetrics, 2018. 297(3): p. 645-652.
Li, J., et al., The association of chronic endometritis with mid-trimester loss due to cervical incompetence and the outcome of laparoscopic cervical cerclage. Arch Gynecol Obstet, 2021. 304(5): p. 1345-1351.
Huang, X., et al., Simplified laparoscopic cervical cerclage after failure of vaginal suture: technique and results of a consecutive series of 100 cases. Eur J Obstet Gynecol Reprod Biol, 2016. 201: p. 146-50.
Pan, M., et al., Predictors of cerclage failure in singleton pregnancies with a history of preterm birth and a sonographic short cervix. Int J Gynaecol Obstet, 2022. 156(2): p. 316-321.
Ades, A. and D.P. Hawkins, Laparoscopic Transabdominal Cerclage and Subsequent Pregnancy Outcomes When Left In Situ. Obstet Gynecol, 2019. 133(6): p. 1195-1198.

Download PDF

Journal Publication

published 01 Apr, 2023

Read the published version in Archives of Gynecology and Obstetrics →

Reviewers agreed at journal
22 Nov, 2022
Reviewers invited by journal
05 Oct, 2022
Editor invited by journal
03 Oct, 2022
Editor assigned by journal
01 Oct, 2022
First submitted to journal
30 Sep, 2022

You are reading this latest preprint version

Effect of different surgical routes on pregnancy outcome of history-indicated cervical cerclage

Status:

Journal Publication

Version 1

Abstract

Objective

Methods

Results

Conclusion

Figures

Introduction

Patients And Methods

Study population

Eligibility Criteria

Exclusion Criteria

Surgical Techniques

LAC

TVC

Date Collection

Statistical analysis

Result

Discussion

Conclusion

Declarations

References

Status:

Journal Publication

Version 1