OBJECTIVE: We aimed to determine the association between polycystic ovarian syndrome (PCOS) and cervical incompetence (CI). We hypothesise that insulin resistance induces a glucose metabolism disorder that could potentially cause cervical incompetence, resulting in an adverse outcome.
METHODS: We conducted a systematic review and meta-analysis of observational studies to summarise the evidence regarding the strength of the association of occurrence of CI in a PCOS pregnant woman compared to a non-PCOS pregnant woman. We defined PCOS as the presence of two of the three Rotterdam criteria, and a combination of clinical symptoms and ultrasound findings were used to diagnose CI.
METHODS: This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) reporting standards and the PROSPERO registration. We systematically searched PubMed, Embase and Cochrane databases to identify observational studies up to December 2022. We included studies in English which compared the PCOS and non-PCOS pregnant women who were diagnosed using Rotterdam criteria and subsequently developed CI in the same pregnancy. We excluded the studies which did not report CI as an outcome. Two reviewers independently screened studies, extracted data, and assessed the risk of bias (JBI critical appraisal tools). In the meta-analysis, effect estimates were pooled using the random effects model, and heterogeneity was measured using I2 statistics.
RESULTS: We identified 23 articles, of which 19 were screened, and three studies were included in the meta-analysis. Three observational studies reported the data of 3845 pregnant women with PCOS and 9449 pregnant women without PCOS. One hundred and forty-one (3.7 %) pregnant women with PCOS developed CI compared to 58 (0.6 %) non-PCOS pregnant women [Risk ratio: 5.3; 95 % confidence interval: 1.9-14.6; I2: 89 %]. Of the three studies included, two had a low risk of bias, and one had a moderate risk of bias.
CONCLUSIONS: The findings of the review suggested higher risk of CI in a pregnant woman with PCOS compared to pregnant women without PCOS. These findings highlight the necessity of establishing guidelines for early identification of CI in PCOS pregnant mothers to prevent adverse maternal and neonatal outcomes following preterm labour.

暂无摘要。

A history of abortion is associated with cervical dysfunction during pregnancy, but there remains uncertainty about whether risk can be stratified by the abortion type, the abortion procedure, or number of previous abortions. The objective of this study was to verify the relationship between cervical dysfunction measures in pregnancies with and without a history of termination. Embase and Medline databases were searched from 01 January 1960 to 01 March 2022 resulting in a full-text review of 28 studies. The Newcastle-Ottawa Scale (NOS) was used to assess the quality and risk of bias for non-randomized studies. The meta-analysis consisted of 6 studies that met all inclusion and exclusion criteria and included a combined total of 2,513,044 pregnancies. Cervical dysfunction was defined as either cervical insufficiency/incompetence in 4 of the studies and as short cervix in the others. Results from a random-effects model using reported adjusted odds ratios (aOR) estimated an increase in the odds of 2.71 (95% CI 1.76, 4.16) for cervical dysfunction in the current pregnancy related to a history of induced or spontaneous abortion. Subgroup analyses with only induced abortions (surgical/medical) estimated an aOR of 2.54 (95% CI 1.41, 4.57), while studies limited to surgical abortions had an aOR of 4.08 (95% CI 2.84, 5.86). The risk of cervical dysfunction in the current pregnancy was also found to be dependent on the number of previous abortions. In this meta-analysis, a prior history of abortion, and specifically induced abortions, was associated with cervical dysfunction. The protocol was registered in PROSPERO (CRD42020209723).

Failure or technical impossibility to place a prophylactic transvaginal cerclage in women with cervical insufficiency justifies the need for an abdominal cerclage. In this systematic review and meta-analysis, we studied the obstetrical and surgical outcomes of laparoscopic and open laparotomy abdominal cerclage approaches performed before (interval) or during pregnancy.
We performed a systematic literature search in PubMed, Embase, and the Cochrane Library for studies on laparoscopic and open laparotomy abdominal cerclage placement in February 2022.
All studies on laparoscopic or open laparotomy placement of an abdominal cerclage with at least 2 patients that reported on our primary outcomes were included.
All included studies were assessed for quality and risk of bias with an adjusted Quality in Prognosis Study tool. Random effects meta-analyses were performed for the primary outcomes, namely fetal survival and gestational age at delivery.
Our search yielded 83 studies with a total of 3398 patients; 1869 of those underwent laparoscopic cerclage placement and 1529 underwent open laparotomy placements. No studies directly compared the 2 cerclage approaches. The survival (overall, 91.2%) and gestational age at delivery (overall, 36.6 weeks) were not statistically different between the approaches. For the procedure during pregnancy, the laparoscopic group showed significantly less blood loss >400 mL (0% vs 3%), a slightly lower procedure-related fetal loss (0% vs 1%), a shorter hospital stay but a longer operation duration than the open laparotomy group. For the interval cerclages, the laparoscopic group showed significantly fewer wound infections (0% vs 3%) and a shorter hospital stay than the open laparotomy group, but showed comparable offspring preterm birth and survival rates.
Based on indirect comparisons, the laparoscopic and open laparotomy abdominal cerclage placements at interval or during pregnancy produced similar outcomes in terms of survival and gestational age at delivery. There are some small differences in perioperative care, surgical complications, interventions, and complications during pregnancy. This implies that both methods of abdominal cerclage placement have high success rates and thus we cannot conclude that one of the methods is superior for the placement of an abdominal cerclage.

BACKGROUND: Cervical insufficiency (CI) may result in preterm delivery. We sought out to perform this review and analysis to compare the efficacy of laparoscopic and open transabdominal cerclage (TAC) in patients suffering with CI.
METHODS: Our search included PubMed, Scopus, MEDLINE, ClinicalTrials.Gov, Cochrane and Web of Science. We analyzed the data with Open Meta-Analyst Software as well as Review Manager Software. We included observational and randomized controlled trials that included patients with CI that underwent laparoscopic cerclage or TAC.
RESULTS: We included a total of 43 studies. Laparoscopic and TAC had a positive effect by increasing gestational age (GA); for the laparoscopic group (mean deviation (MD)) = 14.86 weeks (W), 95% CI [10.67, 19.05], P < 0.001) and TAC (MD = 12.79 W, 95% CI [10.97, 14.61], P < 0.001). Furthermore, improvements in all outcomes assessed (total fetal survival rate, neonatal weight, and prevention of delivery at a gestational age of<24 weeks) were all significant with the exception of the prevention of all preterm deliveries<37 weeks; for both laparoscopic at (RR = 0.116, 95% CI [-0.006, 0.238], P = 0.063) and TAC at (MD = 1, 95% CI [0.45, 2.24], P = 1), and for prevention of deliveries<34 weeks for the laparoscopic group (RR = 0.446, 95% CI [-0.323, 1.215], P = 0.256) only.
CONCLUSIONS: Although limited data prevented pregnancy and prepregnancy subgroups as well as a head-to-head comparison, we still found that in patients suffering from CI, both TAC and laparoscopic approaches to cerclage revealed a positive effect in preserving the pregnancy.

UNASSIGNED: Cervical insufficiency (CI) is a serious complication of pregnancy, which can cause preterm birth. Identifying how to most effectively treat CI has the potential to maximize neonatal survival in this population of women.
UNASSIGNED: To determine whether transabdominal cervical cerclage should be offered as a first-line treatment option in high-risk women.
UNASSIGNED: An electronic literature search for relevant studies was conducted using keywords (CI, cervical cerclage) on the MEDLINE database.
UNASSIGNED: Although transabdominal cerclage (TAC) is reserved as a second-line treatment option over transvaginal cerclage (TVC), it has some advantages over TVC: a higher placement of the suture at the level of the cervicoisthmic junction; avoidance of placement of foreign material in the vagina, in turn, reducing risk of infection and inflammation, which can propagate preterm labor; and the option to leave the suture in place for future pregnancies. Systematic review evidence offers TAC as a more effective procedure to TVC in reducing preterm birth and maximizing neonatal survival. Although TAC is a slightly more complex procedure compared with TVC, advances in minimally invasive surgery now allow gynecologists to perform this more effective procedure laparoscopically and therefore without the added morbidity of open surgery but with the same if not better outcomes.
UNASSIGNED: Laparoscopic TAC can provide a more effective treatment option for CI without the added burdens of open abdominal surgery.
UNASSIGNED: Our article highlights future directions for study in the area of cervical cerclage and refinement of existing practices.

Cervical insufficiency is a defect of the cervix that leads to failure to preserve a full-term intrauterine pregnancy. Laparoscopic cerclage and open transabdominal cerclage (TAC) are effective ways to manage patients with cervical insufficiency. We performed this systematic review and meta-analysis to investigate the complications of laparoscopic cerclage and open TAC in the management of cervical insufficiency.
We searched PubMed, Cochrane, Scopus, and Web of Science using our search strategy and screened the results for our criteria. We extracted the results reported and analyzed them using Open Meta-Analyst (OpenMeta[Analyst], Brown School of Public Health, Providence, RI) and Review Manager (Cochrane Collaboration, London, United Kingdom) software.
We included all randomized controlled and observational trials performed on patients with cervical insufficiency undergoing open TAC or laparoscopic cerclage that matched our search strategy. We excluded letters to the editor, reviews, meetings/conference abstracts, non-English or nonhuman studies, and instances where the full text was not available.
We included a total of 33 trials. Both interventions of laparoscopic cerclage and open TAC were associated with significantly less total fetal loss (laparoscopic cerclage, relative risk [RR] 0.03; 95% confidence interval [CI], 0.01-0.08; p <.001, and open TAC, RR 0.19; 95% CI, 0.07-0.51; p <.009). The overall blood loss in open TAC was 110.589 mL (95% CI, 93.737-127.44; p <.001), and in laparoscopic cerclage, it was 24.549 mL (95% CI, 9.892-39.205; p = .001). In addition, open TAC had a positive effect regarding incidence of hemorrhage >400 mL (RR 0.077; 95% CI, 0.033-0.122; p <.001). Preterm premature rupture of membranes was significant in the open TAC (RR 0.037; 95% CI, 0.019-0.055; p <.001) and laparoscopic cerclage groups (RR 0.031; 95% CI, 0.009-0.053; p = .006).
Laparoscopic cerclage may be safer than open TAC in the management of cervical insufficiency because we found a statistically significant lower incidence of fetal loss, blood loss, and rate of hemorrhage in the laparoscopic cerclage group. Clinically, this evidence may help support favoring a laparoscopic approach over an open one in appropriate patients, although it is unclear whether this benefit is limited to cerclages placed either before pregnancy or placed in the first-trimester or both.

Cervical insufficiency is a recognised cause of third trimester miscarriage and spontaneous preterm births. It is one of the leading causes of neonatal morbidity and mortality. Miscarriage and preterm deliveries due to cervical insufficiency can be prevented by cervical cerclage insertion. The study aimed to determine the time interval between elective cervical cerclage removal at term and spontaneous onset of labour in Enugu, south-east Nigeria. A ten year retrospective review of all women who had cervical cerclage inserted for suspected cervical insufficiency at the two tertiary health institutions in Enugu state was done. Their case files were retrieved and relevant data extracted. The mean time interval from cerclage removal at term to spontaneous onset of labour was 12 days. The majority of patients (45.6%) had spontaneous onset of labour at the 2nd week of cerclage removal. There was no significant difference in the mean time interval from cerclage removal to spontaneous onset of labour between ultrasound indicated group and history indicated group. These findings hopefully may assist in proper counselling and management of women who had cervical cerclage removed at term.Impact StatementWhat is already known on this subject? Cervical insufficiency is a known cause of mid trimester pregnancy loss and preterm delivery. Preterm babies are at risk of several complications, with high neonatal morbidity and mortality especially in developing world. Cervical cerclage insertion is a recognised surgical treatment for cervical incompetence aimed at preventing preterm births.What do the results of this study add? The study shows that removal of cervical cerclage at term does not result in immediate onset of spontaneous labour in women diagnosed to have cervical insufficiency. Notably, a majority of the women had spontaneous onset of labour at the 2nd weeks of cerclage removal. Only 5.3% of them had spontaneous onset of labour within 48 hours of cerclage removal. This is contrary to the general belief in the region that once cervical cerclage is removed, spontaneous onset of labour results.What are the implications of these findings for clinical practice and/or further research? This finding suggests that there is no compelling need for admission into hospital after removal of cerclage as very few of them will have spontaneous onset of labour within 48 hours of cervical cerclage removal.

Several studies acknowledge that the presence of amniotic fluid sludge (AFS) is an independent predictive factor for preterm birth. In the present systematic review, we summarize research that focuses on the comparison of pregnancy outcomes among women with and without AFS.
Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar databases were systematically searched from inception. Both observational and randomized controlled studies were considered eligible provided that they reported data on pregnancy outcomes among women with and without AFS. Outcomes were not meta-analyzed because of the high heterogeneity in terms of selected population and outcome reporting.
Seventeen studies of 2432 women were included in this review. Six studies evaluated women at high risk for preterm birth. Pregnancies complicated by AFS had a lower gestational age at delivery and increased incidence of preterm delivery at <37 weeks. Neonatal death rates and admission to the Neonatal Intensive Care Unit were also increased. Evidence in low-risk women, those with signs of preterm labor, in those carrying twins, and in women with cervical cerclage or Arabin pessary was extremely limited.
Women with AFS seem to deliver at an earlier gestational age, and preterm birth rates are also increased. Limited data seem to point to neonatal morbidity and mortality being increased. However, the presence of a direct association should not be assumed because the evidence is not adjusted for the presence of confounders.

BACKGROUND: To compare the pregnancy outcomes of physical examination-indicated cerclage (PEIC) between twin and singleton pregnancies with acute cervical insufficiency.
METHODS: We searched Medline, Ovid, Scopus, EBSCO, ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials from their commencement until Dec 2019 for relevant studies. Patient-level data abstraction and analysis were done by two independent authors.
RESULTS: A total of five studies with 786 women were included in the final analysis. The pooled outcomes showed that PEIC was associated with a similar reduction in preterm birth (PTB) at <32 (Risk ratio [RR] 0.93, 95% CI 0.79-1.11, I2=0%, P=0.43), and 28 (RR 1.03, 95% CI 0.82-1.29, I2=0%, P=0.81) weeks of gestation; however, a much higher frequency of PTB was observed at <36 (RR 0.74, 95% CI 0.66-0.83, I2=0%, P<0.000), and 34 (RR 0.80, 95% CI 0.68-0.93, I2=0%, P=0.004) weeks of gestation in twin pregnancies than in singleton pregnancies. No significant differences in perinatal outcomes, including neonatal death (RR 1.03, 95% CI 0.64-1.67, I2=52%, P=0.900), stillbirth (RR 0.73, 95% CI 0.37-1.44, I2=0%, P=0.360), perinatal mortality (RR 0.94, 95% CI 0.65-1.38, P=0.760) and neonatal complications were found between twin and singleton pregnancies.
CONCLUSIONS: Our meta-analysis indicated that PEIC achieved good perinatal prognosis in both singleton and twin pregnancies. However, because the available evidence is insufficient to attain a strong conclusion, so further high-quality trials are needed to confirm our findings.