Management of Pregnancy with Cervical Shortening: Real-Life Clinical Challenges

Abstract

Background and Objectives: Preterm birth is the leading cause of neonatal mortality worldwide and may be responsible for lifelong morbidities in the survivors. Cervical shortening is one of the common pathways to preterm birth associated with its own diagnostic and management challenges. The preventive modalities that have been tested include progesterone supplementation and cervical cerclage and pessaries. The study aimed to assess the management strategies and outcomes in a group of patients with a short cervix during pregnancy or cervical insufficiency. Materials and Methods: Seventy patients from the Riga Maternity Hospital in Riga, Latvia, were included in the prospective longitudinal cohort study between 2017 and 2021. Patients were treated with progesterone, cerclage, and/or pessaries. The signs of intra-amniotic infection/inflammation were assessed, and antibacterial therapy was given when the signs were positive. Results: The rates of PTB were 43.6% (n = 17), 45.5% (n = 5), 61.1% (n = 11), and 50.0% (n = 1) in progesterone only, cerclage, pessary, and cerclage plus pesssary groups, respectively. The progesterone therapy was associated with a reduced preterm birth risk (x2(1) = 6.937, p = 0.008)), whereas positive signs of intra-amniotic infection/inflammation significantly predicted the risk of preterm birth (p = 0.005, OR = 3.82, 95% [CI 1.31–11.11]). Conclusions: A short cervix and bulging membranes, both indicators of intra-amniotic infection/inflammation, are the key risk factors in preterm birth risk predictions. Progesterone supplementation should remain at the forefront of preterm birth prevention. Among patients with a short cervix and especially complex anamnesis, the preterm rates remain high. The successful management of patients with cervical shortening lies between the consensus-based approach for screening, follow-up, and treatment on the one side and personalising medical therapy on the other.

Comparison of Perinatal Outcomes Following Elective and Emergency Cerclage Insertion: A Ten-Year Retrospective Cohort Study

“…The management options for women with a short cervix or CI include vaginal progesterone, cervical pessaries, and cervical cerclages [ 11 ]. Vaginal progesterone has been proven to reduce the rate of PTB and neonatal morbidity and is recommended for women with no prior spontaneous PTB with a cervical length below 25 mm until 36 weeks of gestation [ 17 , 18 ].…”

“…The management options for women with a short cervix or CI include vaginal progesterone, cervical pessaries, and cervical cerclages. Cervical cerclages are a significant management option in pregnancies complicated with CI [ 11 ].…”

Comparison of Perinatal Outcomes Following Elective and Emergency Cerclage Insertion: A Ten-Year Retrospective Cohort Study

“…The management options for women with a short cervix or CI include vaginal progesterone, cervical pessaries, and cervical cerclages [ 11 ]. Vaginal progesterone has been proven to reduce the rate of PTB and neonatal morbidity and is recommended for women with no prior spontaneous PTB with a cervical length below 25 mm until 36 weeks of gestation [ 17 , 18 ].…”

“…The management options for women with a short cervix or CI include vaginal progesterone, cervical pessaries, and cervical cerclages. Cervical cerclages are a significant management option in pregnancies complicated with CI [ 11 ].…”

Preterm birth in Latvia: Two‐decade national trends, structure, and risk factors

“…Next, our PTB subgroups (extremely: <28 weeks, very to moderate: 28–<34 weeks, late: 34–<37 weeks) deviate from WHO definitions (<28, 28–<32, and 32–<37 weeks), 34 hindering some comparisons. Data gaps also exist; previous PTB and cervical insufficiency—key risk factors, with the latter linked to a 48.6% PTB rate in Latvia 35 —as well as family history of PTB, cervical surgery or trauma, and low socioeconomic status, could not be analyzed as they are not recorded in the national registry. Obesity data, recorded only later, may underrepresent its role.…”

Evaluation of Cervical Cerclage Timing and Perinatal Outcomes in Women with Cervical Insufficiency: A 10-Year Retrospective Study

“…Currently, CI is defined as a measurement of <25 mm before 24 weeks of gestational age in singleton pregnancies with a history of pregnancy loss, preterm birth, or the presence of cervical changes detected by physical exam before 24 weeks on the transvaginal ultrasound examination or the presence of cervical changes detected before 24 weeks of gestation. The management of CI includes cervical cerclages, vaginal progesterone, and cervical pessaries [10]. Cervical cerclages strengthen the cervix, allowing it to maintain its length and preserve the mucus plug at the cervical opening, which protects against ascending infections [11].…”

Comparison of Perinatal Outcomes Following Elective and Emergency Cerclage Insertion: A Ten-Year Retrospective Cohort Study

“…The management options for women with a short cervix or CI include vaginal progesterone, cervical pessaries, and cervical cerclages [ 11 ]. Vaginal progesterone has been proven to reduce the rate of PTB and neonatal morbidity and is recommended for women with no prior spontaneous PTB with a cervical length below 25 mm until 36 weeks of gestation [ 17 , 18 ].…”

“…The management options for women with a short cervix or CI include vaginal progesterone, cervical pessaries, and cervical cerclages. Cervical cerclages are a significant management option in pregnancies complicated with CI [ 11 ].…”

Preterm birth in Latvia: Two‐decade national trends, structure, and risk factors

“…Next, our PTB subgroups (extremely: <28 weeks, very to moderate: 28–<34 weeks, late: 34–<37 weeks) deviate from WHO definitions (<28, 28–<32, and 32–<37 weeks), 34 hindering some comparisons. Data gaps also exist; previous PTB and cervical insufficiency—key risk factors, with the latter linked to a 48.6% PTB rate in Latvia 35 —as well as family history of PTB, cervical surgery or trauma, and low socioeconomic status, could not be analyzed as they are not recorded in the national registry. Obesity data, recorded only later, may underrepresent its role.…”

Evaluation of Cervical Cerclage Timing and Perinatal Outcomes in Women with Cervical Insufficiency: A 10-Year Retrospective Study

“…Currently, CI is defined as a measurement of <25 mm before 24 weeks of gestational age in singleton pregnancies with a history of pregnancy loss, preterm birth, or the presence of cervical changes detected by physical exam before 24 weeks on the transvaginal ultrasound examination or the presence of cervical changes detected before 24 weeks of gestation. The management of CI includes cervical cerclages, vaginal progesterone, and cervical pessaries [10]. Cervical cerclages strengthen the cervix, allowing it to maintain its length and preserve the mucus plug at the cervical opening, which protects against ascending infections [11].…”

Comparison of Perinatal Outcomes Following Elective and Emergency Cerclage Insertion: A Ten-Year Retrospective Cohort Study

“…The management options for women with a short cervix or CI include vaginal progesterone, cervical pessaries, and cervical cerclages [ 11 ]. Vaginal progesterone has been proven to reduce the rate of PTB and neonatal morbidity and is recommended for women with no prior spontaneous PTB with a cervical length below 25 mm until 36 weeks of gestation [ 17 , 18 ].…”

“…The management options for women with a short cervix or CI include vaginal progesterone, cervical pessaries, and cervical cerclages. Cervical cerclages are a significant management option in pregnancies complicated with CI [ 11 ].…”

Preterm birth in Latvia: Two‐decade national trends, structure, and risk factors

“…Next, our PTB subgroups (extremely: <28 weeks, very to moderate: 28–<34 weeks, late: 34–<37 weeks) deviate from WHO definitions (<28, 28–<32, and 32–<37 weeks), 34 hindering some comparisons. Data gaps also exist; previous PTB and cervical insufficiency—key risk factors, with the latter linked to a 48.6% PTB rate in Latvia 35 —as well as family history of PTB, cervical surgery or trauma, and low socioeconomic status, could not be analyzed as they are not recorded in the national registry. Obesity data, recorded only later, may underrepresent its role.…”

Evaluation of Cervical Cerclage Timing and Perinatal Outcomes in Women with Cervical Insufficiency: A 10-Year Retrospective Study

“…Currently, CI is defined as a measurement of <25 mm before 24 weeks of gestational age in singleton pregnancies with a history of pregnancy loss, preterm birth, or the presence of cervical changes detected by physical exam before 24 weeks on the transvaginal ultrasound examination or the presence of cervical changes detected before 24 weeks of gestation. The management of CI includes cervical cerclages, vaginal progesterone, and cervical pessaries [10]. Cervical cerclages strengthen the cervix, allowing it to maintain its length and preserve the mucus plug at the cervical opening, which protects against ascending infections [11].…”