OBJECTIVE: This study aims to investigate the predictive value of hemogram parameters in early preterm delivery (32 gestational weeks and below) among pregnant women who have undergone cervical cerclage, based on cervical changes determined before the cerclage procedure.
METHODS: Between 2010 and 2020, a total of 161 patients underwent cervical cerclage. The participants were divided into three groups. Group 1 (n=92) consisted of pregnant women who underwent prophylactic cerclage. Group 2 (n=31) included those with cervical shortening (<5 mm) and/or dilation (≤3 cm). Group 3 (n=38) comprised pregnant women with cervical dilation >3 cm. Each group was further divided based on delivery weeks, with a cutoff at 32 weeks. Demographic parameters and laboratory parameters were assessed.
RESULTS: In Group 1, all hemogram parameters showed no significant differences between deliveries below and above 32 weeks. In Group 2, the neutrophil-to-lymphocyte ratio value before cerclage was higher in the early preterm delivery group (p=0.002), with a cutoff value of 4.75 in receiver operating characteristic analysis. In Group 3, the white blood cell value before cerclage was higher in the early preterm delivery group (p=0.005), with a cutoff value of 13.05×103/μL in receiver operating characteristic analysis.
CONCLUSIONS: The use of hemogram parameters to predict early preterm delivery in pregnant women undergoing prophylactic cerclage is not appropriate. However, neutrophil-to-lymphocyte ratio value can predict early preterm delivery when cervical dilation is 3 cm or less and/or cervical shortening is 5 mm or less. When cervical dilation exceeds 3 cm, the white blood cell value is more appropriate for predicting early preterm delivery.

OBJECTIVE: To identify which non-invasive infection indicators could better predict post-cervical cerclage (CC) infections, and on which days after CC infection indicators should be closely monitored.
METHODS: The retrospective, single-center study included 619 single-pregnancy patients from January 2021 to December 2022. Patients were categorized into infected and uninfected groups based on physicians\' judgments of post-CC infections. Registered information included patient characteristics, cervical insufficiency history, gestational age at CC, surgical method (McDonald/Shirodkar), purpose of CC, mid-pregnancy miscarriage/preterm birth, infection history or risk factors, and infection indices on days 1, 3, 5, and 7 after CC. Propensity score matching (PSM) was applied to reduce patient characteristic bias. Statistical analysis of C-reactive protein (CRP), white blood cell (WBC), neutrophil count (NEU), percentage of neutrophil count (NEU_P), interleukin-6 (IL-6), and procalcitonin (PCT) in the infected group compared with the uninfected group was performed using chi-square tests and t-tests. Receiver operating characteristic (ROC) curves were used to further assess the diagnostic value of CRP, PCT, and CRP-PCT in combination.
RESULTS: Among the 619 included patients, 206 patients were matched using PSM and subsequently assessed. PCT values on day 1 and day 3 after CC exhibited significant differences between the two groups in two statistical ways (P < 0.01, P < 0.05). The CRP levels on day 1 were significantly higher in the infected group compared to the uninfected group in two statistical ways (P < 0.05). On day 3, the mean CRP value was significantly elevated in the infected group compared to the uninfected group (P < 0.05). Analyses of IL-6, WBC, NEU, and NEU_P did not yield clinically significant results. The area under the ROC curves for CRP, PCT, and CRP-PCT on day 1 and day 3 were all below 0.7. In the preventive CC group, the AUC values of CRP and CRP-PCT obtained on d1 were found to be higher than 0.7, indicating moderate diagnostic accuracy.
CONCLUSIONS: For women after CC surgery, especially of preventive aim, increased serum CRP and PCT levels from post-CC day 1 to day 3 may signal a potential postoperative infection, warranting close monitoring.

OBJECTIVE: Preterm birth (PTB) is the leading cause of neonatal morbidity and mortality worldwide, and cervical incompetence (CIC) is a significant contribution. Cervical cerclage (CC) is an effective obstetric intervention. However, many clinical factors affect the success rate of surgery. The objective was to investigate and compare the pregnancy and neonatal outcomes of patients who underwent ultrasound- and physical examination-indicated cervical cerclage and to explore the influencing factors of preterm delivery before 34 weeks.
METHODS: The sociodemographic characteristics and clinical data of patients with a diagnosis of cervical incompetence who underwent ultrasound- and physical examination-indicated transvaginal cervical cerclage at Nanjing Maternal and Child Health Hospital from January 2020 to December 2022 were retrospectively analyzed. The pregnancy and neonatal outcomes of the patients were evaluated. Continuous variables were compared using Student\'s t test (for normally distributed data) or the Mann-Whitney U test (for nonnormally distributed data). Categorical variables were analysed using the chi-square test or Fisher\'s exact test. Additionally, logistic regression analyses and receiver operating characteristic curves were used to evaluate the associations of inflammatory markers with maternal and neonatal outcomes.
RESULTS: This study included 141 participants who underwent cervical cerclage, including 71 with ultrasound-indicated cerclage and 70 with physical examination-indicated cerclage. Compared to those in the ultrasound-indicated cerclage group, the duration from cerclage to delivery, birth weight, and APGAR score in the physical examination-indicated cerclage group were significantly lower, and the rates of delivery at < 28 weeks, < 32 weeks, < 34 weeks, and < 37 weeks of gestation and neonatal mortality were significantly higher (all P < 0.05). Compared to those in the physical ultrasound-indicated cerclage group, in the physical examination-indicated cerclage group, maternal blood inflammatory markers, such as C-reactive protein (CRP), the systemic immune-inflammation index (SII) and the systemic inflammation response index (SIRI) were significantly higher (P < 0.05). Additionally, maternal blood inflammatory markers, such as the CRP, white blood cell count, platelet to lymphocyte ratio (PLR), SII, and SIRI were significantly higher in the group with delivery before 34 weeks of gestation. Furthermore, the results demonstrated that twin pregnancy had the highest OR for preterm delivery before 34 weeks of gestation (OR = 3.829; 95% CI 1.413-10.373; P = 0.008), as well as the following: the SII level (OR = 1.001; 95% CI 1.000-1.002; P = 0.003) and CRP level (OR = 1.083; 95% CI 1.038-1.131; P = 0.022). The risk factors for preterm delivery before 34 weeks of gestation were twin gestation, an increased SII level and an increased CRP level, which had good combined predictive value.
CONCLUSIONS: In patients with cervical insufficiency, ultrasound-indicated cervical cerclage appears to lead to better pregnancy outcomes than physical examination-indicated cerclage. Twin pregnancy and maternal blood inflammatory markers, such as the CRP level and the SII, are associated with preterm delivery before 34 weeks of gestation.

暂无摘要。

BACKGROUND: The leading hypothesis of the pathogenesis of cervical insufficiency suggests a role of cervical inflammation. Urogenital tract infections could play a causative role in this process. To test this hypothesis in women with a cervical cerclage, we aimed to retrospectively examine the relationship between gestational age (GA) at delivery and positive urogenital cultures.
METHODS: This single center retrospective study reviewed the records of all women with a singleton pregnancy that underwent cervical cerclage (n = 203) between 2010 and 2020 at the University Hospital of Leuven, Belgium. Transvaginal cerclages were categorized as history indicated (TVC I, n = 94), ultrasound indicated (TVC II, n = 79) and clinically indicated (TVC III, n = 20). Additionally, ten women received transabdominal cerclage (TAC). Urogenital cultures (vaginal and urine) were taken before and after cerclage with 4-week intervals. Urogenital cultures were reported \'positive\' if urine and/or vaginal cultures showed significant growth of a microorganism. Treatment decision depended on culture growth and clinical presentation. The primary aim was to evaluate the association between the urogenital culture results and the GA at delivery, for each of the cerclage groups. Secondarily, to investigate the effect of antibiotic treatment of positive cultures on GA at delivery.
RESULTS: Positive pre-cerclage urogenital cultures were associated with lower GA at delivery in TVC III (positive culture 26w4d ± 40d vs. negative 29w6d ± 54d, p = 0.036). For TVC I, GA at delivery was longer when pre-cerclage urogenital cultures were positive (positive culture 38w0d ± 26d vs. negative 35w4d ± 42d, p = 0.035). Overall post-cerclage urogenital cultures status was not associated with a different GA at delivery. Treating patients with pre- or post-cerclage positive urogenital cultures did also not change GA at delivery.
CONCLUSIONS: Positive urogenital cultures taken before clinically indicated cerclage intervention may be associated with lower GA at delivery. However, there seems to be no benefit of antibiotic treatment or routine urogenital cultures during follow-up of asymptomatic women after cerclage placement.

BACKGROUND: Cervical cerclage is the only effective treatment for cervical insufficiency, effectively preventing late miscarriage and preterm birth. The effectiveness and safety of emergency cervical cerclage (ECC) as an emergency treatment when the cervix is already dilated or when there is protrusion of the fetal membranes into the vagina remain controversial, especially in pregnancies at 24-28 weeks when the fetus is viable. There is still no consensus on whether emergency cervical cerclage should be performed in such cases.
OBJECTIVE: To investigate the effectiveness and safety of emergency cervical cerclage in singleton pregnant women at 24-28 weeks of gestation.
METHODS: This study employed a single-center prospective cohort design, enrolling singleton pregnant women at 24-28 weeks of gestation with ultrasound or physical examination indicating cervical dilation or even membrane protrusion. Emergency cervical cerclage was compared with conservative treatment. The primary endpoints included a comprehensive assessment of perinatal pregnancy loss, significant neonatal morbidity, and adverse neonatal outcomes. Secondary endpoints included prolonged gestational age, preterm birth, neonatal hospitalization rate, premature rupture of membranes, and intrauterine infection/chorioamnionitis.
RESULTS: From June 2021 to March 2023, a total of 133 pregnant women participated in this study, with 125 completing the trial, and were allocated to either the Emergency Cervical Cerclage (ECC) group (72 cases) or the conservative treatment group (53 cases) based on informed consent from the pregnant women. The rate of adverse neonatal outcomes was 8.33% in the ECC group and 26.42% in the conservative treatment (CT) group, with a statistically significant difference (P = 0.06). There were no significant differences between the two groups in terms of perinatal pregnancy loss and significant neonatal morbidity. The conservative treatment group had a mean prolonged gestational age of 63.0 (23.0, 79.5) days, while the ECC group had 84.0 (72.5, 89.0) days, with a statistically significant difference between the two groups (P < 0.001). Compared with CT group, the ECC group showed a significantly reduced incidence of preterm birth before 28 weeks, 32 weeks, and 34 weeks, with statistical significance (P = 0.046, 0.007, 0.001), as well as a significantly decreased neonatal hospitalization rate (P = 0.013, 0.031). Additionally, ECC treatment did not increase the risk of preterm premature rupture of membranes or intrauterine infection/chorioamnionitis, with no statistically significant differences (P = 0.406, 0.397).
CONCLUSIONS: In singleton pregnant women with cervical insufficiency at 24-28 weeks of gestation, emergency cervical cerclage can reduce adverse neonatal pregnancy outcomes, effectively prolong gestational age, decrease preterm births before 28 weeks, 32 weeks, and 34 weeks, lower neonatal hospitalization rates, and does not increase the risk of preterm premature rupture of membranes or intrauterine infection/chorioamnionitis.

OBJECTIVE: The aim of this study is to describe the typical microbial spectrum and the influence of distinct vaginal infections on preterm birth in pregnancies affected by cervical incompetence.
METHODS: 327 patients were admitted because of asymptomatic shortening of the cervix in the second and third trimester of pregnancy. Clinical data such as age, cervical length, gestational age at admission and at delivery and vaginal microbiologic findings were collected and analyzed.
RESULTS: The spectrum of germs in the vagina revealed seven different distinct species; the most common bacteria were Ureaplasma spp. and E. coli. In 327 included patients, 217 revealed a bacterial colonization, 110 did not. Most common bacteria in women with preterm birth before 34 weeks were Ureaplasma spp., while E. coli was most common in women undergoing preterm birth after 34 weeks. Nevertheless, the rates of occurrence of these bacterial taxa were not significantly different between who underwent preterm birth to those who did not.
CONCLUSIONS: This study gives an overview over the vaginal bacterial colonization in pregnant women with cervical incompetence. The clinical relevance of vaginal bacterial colonization remains unclear.

Studies on noninvasive factors and predicting the maintenance of pregnancy, and those comparing the usefulness of these factors with invasive amniotic fluid markers in predicting the maintenance of pregnancy following rescue cerclage, are lacking. Therefore, this study aimed to determine whether C-reactive protein (CRP) levels, White blood cell (WBC) count, absolute neutrophil count (ANC), and platelet-to-lymphocyte ratio (PLR) in maternal blood, which are noninvasive and readily available clinical markers, can predict the maintenance of pregnancy following rescue cerclage in patients with cervical insufficiency (CI). A total of 142 singleton pregnant women (15-28 wk) who underwent rescue cerclage for CI were retrospectively evaluated. The interleukin (IL)-6 concentration in the amniotic fluid; CRP levels, WBC count, ANC, and PLR in the maternal peripheral blood; and degree of cervical dilatation were evaluated before cerclage. The primary outcome was whether the pregnancy was maintained for >4 weeks after rescue cerclage. Among the 142 patients, prolonged pregnancy for >4 weeks following emergent cerclage was observed in 107 (75.35%), while 35 (24.65%) gave birth within 4 weeks. This study demonstrated that the degree of cervical dilatation at diagnosis; WBC count, ANC, and CRP levels in the maternal peripheral blood; and IL-6 concentration in the amniotic fluid significantly differed between the successful and failure groups (all P < .05). The area under the curve (AUC) of the amniotic fluid IL-6 concentration was .795 for the prediction of spontaneous preterm birth within 4 weeks after rescue cerclage. Additionally, the AUC of the CRP level, cervical dilatation, WBC count, ANC, and PLR were .795, .703, .695, .682, and .625, respectively. These findings suggest that the preoperative CRP levels can be considered a useful noninvasive marker comparable to amniotic fluid IL-6 concentration for identifying pregnant women with CI at high risk of spontaneous preterm birth following rescue cerclage.

The treatment for cervical insufficiency is cerclage surgery. Although cerclage is a common therapy for prevention of preterm birth, there is no consensus about its mechanism of efficacy. Previous investigators have hypothesized that cerclage prevents preterm birth by improving the cervical barrier to ascending infection. However, this hypothesis is difficult to study in human pregnancy.
In a mouse model of ascending infection, we hypothesized that a cerclage improves the cervical barrier leading to decreased ascending intrauterine infection and inflammation. An abdominal cerclage was studied because a vaginal cerclage is not feasible in mice.
To perform an abdominal cerclage, laparotomy was performed on timed, pregnant C57BL/6 mice on gestational day 10 (E10). A 6-0 silk suture was placed around the cervix just below the junction of the 2 uterine horns. Sham controls received the same surgery, but no cerclage was placed. To track ascending infection nonpathogenic E coli K12 was genetically modified to express bioluminescence. On E15, bioluminescent E coli K12 (20 μL of 1×109 bacteria) was inoculated into the vagina. Whole-body bioluminescence imaging was performed 0.5 hours and 24 hours after inoculation. To assess intrauterine inflammation, pathogenic E coli K1 was used. On E15, bacterial inoculums of E coli K1 (20 μL of 1×104 bacteria) were vaginally administered. Samples of uterus, placenta, and fetal membranes were collected 24 hours after inoculation. Gene expression of inflammation-related proteins was compared between 3 groups: (1) sham control surgery + inoculation of phosphate-buffered saline (PBS), (2) sham control surgery + inoculation of E coli K1, and (3) cerclage surgery + inoculation of E coli K1.
Abdominal cerclage was well tolerated. No cases of preterm birth were seen following abdominal cerclage. Whole-body bioluminescent imaging performed 0.5 hours post inoculation showed a strong luminescence signal in the vaginal region of mice in both control and experimental groups indicating successful bacteria inoculation. Twenty-four hours after inoculation, bioluminescent signal was seen ascending into the uterine horns in all control mice. However, in mice with abdominal cerclages, no bioluminescent signal was seen after 24 hours. When the reproductive tissues were imaged separately in control mice, strong bioluminescence signal was detected in the placenta, fetal membranes, and uterus. Gene expression studies showed that cerclage significantly decreased the expression of inflammatory proteins induced by E coli K1 in the uterus, placenta, and fetal membranes.
In this mouse model of ascending intrauterine infection, abdominal cerclage prevented ascending infection of E coli. In addition, abdominal cerclage prevented expression of inflammatory cytokines in the uterus, placenta, and membranes of mice. The study provides evidence for a potential mechanism of cerclage success in human pregnancy.

BACKGROUND: To identify the effect and optimal time of cervical cerclage in asymptomatic twin pregnancies with cervical shortening or dilation.
METHODS: This observational retrospective study enrolled all women with asymptomatic twin pregnancies who were diagnosed with asymptomatic cervical shortening or dilation at the Second Affiliated Hospital of Wenzhou Medical University between 2010 and 2022. Women included were allocated into the cerclage group (n = 36) and the no cerclage group (n = 22). The cerclage group was further divided into the cerclage group (< 24 weeks group) and the cerclage group (24-28 weeks group) according to the time of cerclage. The no cerclage group was further divided into no cerclage group (< 24 weeks group) and no cerclage group (24-28 weeks group) according to the time of ultrasound-indicated or physical exam indicated cerclage. The rates of PTB < 24, 28, 32 and 34 weeks of gestation, maternal and neonatal outcomes were compared among the groups.
RESULTS: The gestational age (GA) at delivery was higher (P = 0.005) and the interval time between the presentation of the indicated cerclage and delivery was longer in the cerclage group (P < 0.001). The rates of PTB before 28, 32, and 34 weeks of gestation, caesarean section and stillbirth were lower in the cerclage group (P < 0.05). The birthweight of the twins was higher in the cerclage group (P = 0.012). Admissions to the NICU were more frequent in pregnancies with no cerclage (P = 0.008). Subgroup analysis showed that the interval time between the presentation and delivery was longer in the cerclage group (< 24 weeks) (P < 0.001). The GA at delivery and the birthweight of the twins were significantly higher in the cerclage group (< 24 weeks) (P < 0.001). No differences were found in the GA at presentation, the GA at delivery, the interval time between the presentation to delivery and birthweight between the cerclage group (24-28 weeks group) and the control group (24-28 weeks group) (P > 0.05).
CONCLUSIONS: Cerclage appears to prolong the GA at delivery and the interval time between the presentation to delivery, and may reduce the incidence of PTB before 28, 32 and 34 weeks of gestation and adverse perinatal outcomes in asymptomatic twin pregnancies with cervical shortening or dilation. Cerclage before 24 weeks of gestation showed longer GA at delivery, longer interval time between the presentation to delivery and higher birthweight of the twins. The GA at presentation, the GA at delivery, the interval time between the presentation to delivery and birthweight in women with cerclage at 24-28 weeks were similar to those in women without cerclage at 24-28 weeks.