ABSTRACT
Background:
Cervical cerclage represents the most controversial surgical procedure in the obstetric field, as it is still not accepted by many obstetricians around the world as an effective maneuver, while being considered by others as a fundamental treatment of women with a history of preterm birth, shortened cervix on ultrasound, and a history of cervical incompetence.
Objectives:
To assess the success rate and investigate the impacts of cervical cerclage on pregnancy outcomes.
Subjects and Methods:
It was a retrospective cohort study through the review of medical records of singleton women who underwent cervical cerclage at Al-Hada Armed Forces Hospital, Taif, throughout 2020-2024. Successful cervical cerclage was defined as a procedure accompanied by the delivery of live infants.
Results:
This study included 125 patients. The age of more than half of them (56.8%) ranged between 30 and 39 years. The majority of women (96.7%) had elective cervical cerclage, with a success rate of 89.2%. Younger maternal age (P = 0.038), 1-3 parity (P = 0.047), and higher gestational age at delivery (P < 0.001) were significantly associated with successful cervical cerclage. Almost half (50.8%) of women who underwent cervical cerclage stayed 3 days at the hospital, while neonatal complications were observed among 23.2% of the women.
Conclusion:
High success rate of cervical cerclage has been reported, with few maternal complications. However, high neonatal complications were reported.
Keywords: Cervical cerclage, neonatal complications, pregnancy outcomes, preterm birth, success rate
Introduction
Cervical cerclage is a commonly adopted surgical maneuver that keeps the cervix closed during pregnancy by offering cervical support through the placement of a stitch. In cases of cervical insufficiency or incompetence, a status where the cervix is unable to maintain its closure and integrity throughout pregnancy, causing premature dilation and increasing the risk of miscarriage or preterm birth (PTB).[1]
Cervical insufficiency is the main cause of PTB, which is consequently considered the main reason for neonatal morbidity and mortality in developed countries and loss of pregnancy in the second trimester.[2,3] Incidence of cervical insufficiency ranges between 0.05 and 2% in the general obstetric population, but in women with a history of recurrent pregnancy loss, it may represent about 8% of cases.[4]
There are two types of cervical cerclage: prophylactic and therapeutic emergency types. Prophylactic cervical cerclage is conducted in women with a history of PTB or pregnancy loss believed to be attributed to cervical insufciency and it is usually done between 12 and 14 weeks of gestation.[4] Therapeutic emergency type is usually done after cervical dilatation in women with a short cervix visible on transvaginal ultrasound.[5] Contraindications for therapeutic emergency cervical cerclage include contractions of the uterus, rupture of fetal membranes, major fetal congenital anomaies, unexplained severe vaginal bleeding, intrauterine/vaginal infection, and gestational age (GA) of >28 weeks.[6]
Up till now, cervical cerclage is still not accepted by many obstetricians around the world as an effective maneuver,[7] despite it is considered by others as a fundamental treatment of women with a history of PTB, shortened cervix on ultrasound, and history of cervical incompetence; representing the most controversial surgical procedure in the obstetric field.[8]
Unfortunately, the advantages of the cervical cerclage as compared to expectant treatment are not fully recognized. However, a relationship between the increase in cervical dilatation before the cerclage procedure and poor pregnancy outcomes has been documented.[9]
The aim of this study was to evaluate the success and impact of cervical cerclage on pregnancy outcomes.
Subjects and Methods
It was a retrospective cohort study through the review of medical records of singleton women who underwent cervical cerclage at Al-Hada Armed Forces Hospital, Taif, throughout 2020-2024. Taif city is located in the Western Region of Saudi Arabia and has an estimated population of approximately 717 thousand, based on the 2024 estimated census.[10] Al-Hada Armed Forces Hospital is a tertiary care hospital offering medical services to military personnel and their dependents, and has a bed capacity of 350. Women who delivered outside the hospital (n = 15), those who had twins (n = 4) and those with congenital anomalies (n = 1) were excluded.
A special checklist was prepared for the study including data about participants’ age, gravidity, parity, abortions, GA (weeks) at time of cervical cerclage, GA (weeks) at delivery, cervical dilatation at time of cerclage in centimeters, delivery at ≤28 weeks (no − yes), birth weight in grams, premature rupture of membranes (no − yes), and mode of delivery (normal spontaneous vaginal-assisted vaginal-elective cesarean-emergency cesarean). In addition, data regarding neonatal complications (neonatal death, neonatal intensive care unit “NICU” admission, neonatal sepsis, neonatal jaundice, respiratory distress syndrome, retinopathy of prematurity), length of hospital stay in days, and type of cervical cerclage (elective prophylactic-emergency) were collected.
Successful cervical cerclage was defined as a procedure accompanied by the delivery of live infants.[9]
The study’s proposal approval was obtained from the Regional Research and Ethics Committee in Al-Hada Armed Forces Hospital, Taif (No. 2024-979; dated 17 December 2024).
Statistical Package for Social Sciences (SPSS) software version 28 (SPSS Inc., Chicago, IL, USA) was used for data entry and analysis. Descriptive statistics (e.g., number, percentage, mean and standard deviation) were applied. Analytic statistics using Chi-square or Fisher’s exact (in case of small frequencies) tests to investigate the association and/or the difference between two categorical variables, and Student’s t-test to compare means of two different groups were utilized. Statistical significance was considered at P ≤ 0.05 throughout the study.
Results
This study included 125 patients. Their general demographic and obstetric characteristics are presented in Table 1. The age of more than half of them (56.8%) ranged between 30 and 39 years. The gravidity ranged between 4 and 7 among 53.6% of patients while their parity ranged between 1 and 3 in 61.6% of them. Abortion was reported among majority of them (79.2%); exceeded two among 25.6% of them. Their GA at the time of cervical cerclage ranged between 10 and 22 weeks (13.3 ± 1.7) while their GA at delivery ranged between 14 and 41 weeks (35.3 ± 6.2). Delivery at ≤28 weeks was reported among 10.8% of women. The birth weight ranged between 170 and 3915 g (2524.0 ± 777.2). Premature rupture of membranes was observed in 6.7% of women. A regards the mode of delivery, normal vaginal and elective cesarean section were reported in 43.4% and 40.8% of women, respectively.
Table 1.
General demographic and obstetric characteristics of the participants (n=125)
| Variables | Frequency (%) |
|---|---|
| Age in years | |
| 20-29 | 29 (23.2) |
| 30-39 | 71 (56.8) |
| ≥40 | 25 (20.0) |
| Gravidity | |
| ≤3 | 40 (32.0) |
| 4-7 | 67 (53.6) |
| >7 | 18 (14.4) |
| Parity | |
| None | 23 (18.4) |
| 1−3 | 77 (61.6) |
| >3 | 25 (20.0) |
| Abortion | |
| None | 26 (20.8) |
| One | 43 (34.4) |
| Two | 24 (19.2) |
| >2 | 32 (25.6) |
| Gestational age (weeks) at time of cervical cerclage (n=124) | |
| Range | 10-22 |
| Mean±SD | 13.3±1.7 |
| Gestational age (weeks) at delivery (n=121) | |
| Range | 14-41 |
| Mean±SD | 35.3±6.2 |
| Delivery at ≤28 weeks (n=120) | |
| No | 107 (89.2) |
| Yes | 13 (10.8) |
| Birth weight, g (n=120) | |
| Range | 170-3915 |
| Mean±SD | 2524.0±777.2 |
| Premature rupture of membranes (n=120) | |
| No | 112 (93.3) |
| Yes | 8 (6.7) |
| Mode of delivery (n=120) | |
| Normal vaginal | 52 (43.4) |
| Elective cesarean section | 49 (40.8) |
| Emergency cesarean section | 12 (10.0) |
| Evacuation and curettage | 7 (5.8) |
SD=Standard deviation
Data on cervical cerclage type were available in 123 cases, with the majority of them (96.7%) being elective [Figure 1], while data on the outcome of cervical cerclage were available in 120 women, with a success rate of 89.2% as illustrated in Figure 2.
Figure 1.
Type of cervical cerclage among women who underwent the procedure at Al-Hada Armed Forces Hospital, Taif (Saudi Arabia), throughout 2020-2024 (n = 123)
Figure 2.
Success rate of cervical cerclage among women who underwent the procedure at Al-Hada Armed Forces Hospital, Taif (Saudi Arabia), throughout 2020-2024 (n = 120)
Maternal age was significantly associated with the success rate of cervical cerclage, as it was 96.6% in women aged 20-29 years compared to 78.3% in women aged 40 and above years, P = 0.038. In addition, parity was associated with the cervical cerclage success rate as it was 94.6% in women with 1-3 parity compared to 78.3% in nulliparous women, P = 0.047. Gestational age at delivery was significantly higher in the successful group than the failure one (36.9 ± 2.4 vs. 18.7 ± 4.1 weeks), P < 0.001. Delivery at ≤28 weeks was a strong predictor for the success of cervical cerclage, P < 0.001 [Table 2].
Table 2.
Factors associated with the success of cervical cerclage (n=120)
| Outcome of cervical cerclage, n (%) | P | ||
|---|---|---|---|
|
| |||
| Failure (n=13) | Success (n=107) | ||
| Age in years | |||
| 20-29 (n=29) | 1 (3.4) | 28 (96.6) | 0.038* |
| 30-39 (n=68) | 7 (10.3) | 61 (89.7) | |
| ≥40 (n=23) | 5 (21.7) | 5 (78.3) | |
| Gravidity | |||
| ≤3 (n=38) | 6 (15.8) | 32 (84.2) | 0.439* |
| 4-7 (n=65) | 5 (7.7) | 60 (92.3) | |
| >7 (n=17) | 2 (11.8) | 15 (88.2) | |
| Parity | |||
| None (n=23) | 5 (21.7) | 18 (78.3) | 0.047* |
| 1-3 (n=74) | 4 (5.4) | 70 (94.6) | |
| >3 (n=23) | 4 (17.4) | 19 (82.6) | |
| Gestational age (weeks) at time of cervical cerclage (n=119) | n=12 | n=107 | |
| Mean±SD | 12.7±1.6 | 13.4±1.7 | 0.154** |
| Gestational age (weeks) at delivery | |||
| Mean±SD | 18.7±4.1 | 36.9±2.4 | <0.001** |
| Delivery at ≤28 weeks (n=118) | |||
| No (n=105) | 1 (1.0) | 104 (99.0) | <0.00ⱡ |
| Yes (n=13) | 12 (92.3) | 1 (7.7) | |
| Type of cervical cerclage (n=119) | n=13 | n=106 | |
| Elective (n=116) | 12 (10.3) | 104 (89.7) | 0.295ⱡ |
| Emergency (n=3) | 1 (33.3) | 2 (66.7) | |
*Chi-square test, **Student’s t-test, ⱡFischer Exact test
Almost half (50.8%) of women who underwent cervical cerclage stayed 3 days at the hospital, whereas 15% stayed more than 3 days [Figure 3].
Figure 3.
Number of hospital stay days among women who underwent the procedure at Al-Hada Armed Forces Hospital, Taif (Saudi Arabia), throughout the period 2020-2024 (n = 120)
Neonatal complications were observed among 23.2% (n = 29) of the participating women, 10 miscarriages, 13 NICU admissions, and 6 intrauterine fetal and neonatal deaths, and 52.2% of women who underwent cervical cerclage and had data regarding neonatal complications (n = 23), as displayed in Figure 4.
Figure 4.
Neonatal complications among women who underwent the procedure at Al-Hada Armed Forces Hospital, Taif (Saudi Arabia), throughout 2020-2024 (n = 125)
Discussion
In the Kingdom of Saudi Arabia, primary healthcare centers provide comprehensive healthcare for their customers, including obstetrics and gynecology services. One of the important issues in the obstetric field is preterm birth, which is mainly produced by preterm cervical dilatation.[11] Thus, identification of cervical dilation in pregnant women and, consequently, application of emergency cervical cerclage might help in achieving term delivery. However, short- and long-term complications of post-preterm birth still represent a significant challenge for obstetricians.[12] Furthermore, one of the important reasons for carrying out this study was the fact that the subject had not previously been investigated in Saudi Arabia, to our knowledge.
In the present study, a high success rate has been reported (89.2%). A high success rate has also been observed in China (2015), where it was 82.3%.[9]
Several studies investigated the role of cervical dilatation on the success of cervical cerclage. In Qatar (2024), women with cervical dilatation of >3 cm had a significantly higher delivery rate at ≤28 weeks’ gestation and lower birth weight compared to those with cervical dilatation of ≤3 cm, and in addition, the mean latency period for pregnancy prolongation and rate of neonatal complications, as well as mortality, were higher in women with cervical dilatation of >3 cm.[13] Also, in China (2015), the degree of cervical dilatation was associated with the success of cervical cerclage.[9] In the present study, due to missing cervical dilatation data in most cases, we did not include the degree of cervical dilatation in the analysis, despite its importance.
This study showed that the rate of successful cervical cerclage was more observed in elective than emergency type, although this was not significant, which mostly attirbuted to the relatively small size of women with failure cervical cerclage. Chen et al. compared the clinical effect of emergency cervical cerclage with elective cervical cerclage on pregnancy outcomes in pregnant women with cervical-incompetent. He showed that significant associations between cerclage operations and pregnancy outcomes, and also GA and neonatal birth weight were significantly higher in women with elective cerclage than those with emergency cerclage, while the rate of premature rupture of membrane was lower in the elective group than in the emergency group. There were no differences between both groups regarding the vaginal delivery rate.[14] In Qatar (2012), failure of cervical cerclage was significantly asociated with presence of infection, symptoms, bulging membranes through the cervix and cervical dilatation >3 cm.[15]
In accordance with others,[9] the present study showed no severe maternal complications of cervical cerclage. The current study showed that neonatal complications; mainly preterm were observed among almost half (52.2%) of women who underwent cervical cerclage. In South Korea (2018), the preterm birth rate was significantly higher in women who were treated with cerclage compared with those without cerclage.[16]
This study revealed that almost half (50.8%) of women who underwent cervical cerclage stayed 3 days at the hospital, whereas 15% stayed more than 3 days. In this context, Onishi et al. concluded in their study that the performance of cervical cerclage did not impact the overall labor progress.[17] In China (2018), Liu et al. reported a significant association between cervical cerclage and pregnancy outcomes in terms of duration of pregnancy, live births, gestation age, and cesarean section rate, as well as they observed shorter postoperative length of hospital stay in prophylactic cervical cerclage than in therapeutic cervical cerclage.[18]
The present study revealed that the majority of cervical cerclages (96.7%) were elective, and the remaining 3.3% were emergency. Moreover, the type of cervical cerclage was not associated with the success rate, although it was higher in the elective type. A relatively small number of emergency types could partially explain this.
In the present study, the mean GA at the time of cervical cerclage was 13.3 ± 1.7, while at delivery, it was 35.3 ± 6.2. In China (2015),[9] the mean gestation age at delivery was 30.3 ± 4.7 weeks. In Qatar (2012),[15] the mean GA at the time of cerclage was 21 weeks, while at delivery, it was 31 weeks.
Some important limitations should be addressed. Being a single-center study is considered a limitation that could impact the generalizability of the results over other centers. The retrospective design of the study is another limitation due to the loss of important data. Finally, the degree of cervical dilatation was not included in the present study despite its importance in the success of cervical cerclage due to missing data in the majority of women. Despite those limitations, the study shed light on an important topic in clinical practice that could be of value for obstetricians.
Conclusion
High success rate of cervical cerclage has been reported, with few maternal complications. However, high neonatal complications were observed, mainly prematurity and admission to the neonatal intensive care unit. Older, nulliparous women and those with lower gestational age at delivery were more likely to have failed cervical cerclage. In order to improve the cervical cerclage success rate, appropriate selection of women, choosing an optimal time for performing the procedure, done by skilled clinicians, post-procedure monitoring and patient education are recommended. Furthermore, a larger multicenter study is warranted in this regard.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
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