Efficacy of a simplified pre-conceptional laparoscopic cervical cerclage for cervical insufficiency: a retrospective study from a single center Running head: a simplified pre-conceptional laparoscopic cervical cerclage for women’s cervical insufficiency

Efficacy of a simplified pre-conceptional laparoscopic cervical cerclage for cervical insufficiency: a retrospective study from a single center Running head: a simplified pre-conceptional laparoscopic cervical cerclage for women’s cervical insufficiency | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy of a simplified pre-conceptional laparoscopic cervical cerclage for cervical insufficiency: a retrospective study from a single center Running head: a simplified pre-conceptional laparoscopic cervical cerclage for women’s cervical insufficiency Ledi Kuang, GuoLin Luo, Xin Tan, Hong Liao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5124095/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Nov, 2024 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Cervical insufficiency (CI) is a pathological condition in obstetrics in which the cervix fails to retain the fetus before uterine contractions or labor (painless cervical dilatation). Patients usually have fetal loss in the mid-trimester or spontaneous pre-term birth due to painless cervical dilation. For non-pregnant women with CI, prophylactic laparoscopic abdominal cerclage (LAC) has been reported to improve pregnancy outcomes, such as live birth, neonatal survival, and full-term delivery rate. Conventional LAC involves opening the vesicular space and separating the anterior broad ligament leaves. In our surgical procedure, these two steps were omitted. Methods: An observational study was conducted retrospectively on patients who underwent a simplified pre-conceptional LAC between January 2015 and December 2022 at the West China Second Hospital of West China Second University Hospital, Sichuan University. Follow-ups for all the patients ended at the delivery of the fetus. Subsequently, clinical characteristics, perioperative data, and obstetric outcomes were recorded and analyzed. Results: In total, 108 patients were included in a pre-conception LAC group. Mean operation time was 56.8 ± 22.8 min, and mean estimated blood loss was 21.4 ± 23.6 mL. Only one case of uroschesis was classified as a grade I postoperative complication, according to the Clavien–Dindo classification. No severe complications or sequelae were observed during the perioperative period. Obstetric outcomes from 98 patients were collected: three patients had miscarriages, and 95 had live births. Of the 95 live births, 4 were twins and 91 were singletons. Two patients had vaginal delivery, and 93 underwent Cesarean section; mean neonatal weight was 3310.2 ± 382.1 g. Conclusion: A simplified pre-conceptional LAC is a simple, safe, and effective method for women with CI. Thus, it is worthy of promotion to assist women with CI in achieving improved obstetric outcomes. Vaginal delivery after LAC is possible once the tape is removed before labor. Pre-conceptiona Cervical insufficiency Cervical cerclage Laparoscopy Figures Figure 1 INTRODUCTION Cervical insufficiency (CI) is a pathological condition in obstetrics in which the cervix fails to retain the fetus before uterine contractions or labor (painless cervical dilatation)[1]. Patients usually have fetal loss in the mid-trimester or spontaneous pre-term birth due to painless cervical dilation[2]. Birth defects in the genital tract and hereditary connective tissue diseases are common congenital causes of CI[3]. Cervical insufficiency can also be acquired by cervical trauma, such as conization, trachelectomy, and repetitive cervical dilatation[4]. So far, there is no consistent definition for CI; therefore, the incidence of 1% in the obstetric population could be inaccurate[5]. Clear diagnostic criteria and standard diagnostic tests for CI are lacking. It should be considered based on a history of painless cervical dilation in the second trimester or ultrasound evidence of cervical length (CL) < 25 mm before 24 weeks, or in patients with previous pre-term birth before 36 weeks of gestation[5, 6]. The diagnosis of CI in non-pregnant women is more challenging, and Hegar dilators are used to evaluate the patulous cervix, or a balloon elastance test is used to calculate the cervical resistance index[7, 8]. In China, the insertion of size 8 Hegar dilators through a non-pregnant cervix without resistance is widely accepted as an indication for CI[9]. Transvaginal and transabdominal cervical cerclage are the two main surgical approaches used to treat CI. Transvaginal cervical cerclage (TVC) involves inserting sutures around the cervical neck to prevent cervical dilation of cervix[10, 11]. However, the risks of traumatic rupture of membranes, vaginal bleeding, chorioamnionitis, and cervical lacerations increase after TVC[12]. An increase in vaginal discharge is also commonly observed. Abdominal cerclage (AC) involves placing a suture at the uterine isthmus to hold the uterine contents, and was first described in 1965[13]. With the advantage of being minimally invasive, laparoscopic AC (LAC) is widely accepted as a safe method between 12–14 weeks gestation for preventing further fetal losses[14, 15]. For non-pregnant women with CI, prophylactic LAC has been reported to improve pregnancy outcomes, such as live birth, neonatal survival, and full-term delivery rate[16–18]. The traditional LAC procedure that includes dissection of the anterior leaves of the broad ligament to create an avascular space for needle placement, which is time-consuming and possibly increases the risk of postoperative adhesions. Herein, we reported a simplified LAC in 108 non-pregnant women with previous fetal losses due to CI in this retrospective study. We described the perioperative data and followed-up the obstetric outcomes in this group. MATERIALS AND METHODS Participants This retrospective observational study was conducted between January 2015 and December 2022 at the West China Second Hospital of West China Second University Hospital, Sichuan University. A total of 108 eligible women diagnosed with CI were included in this study. This study was reviewed and approved by the ethics committee and the data inspectorate of West China Second University Hospital of Sichuan University and the methods were carried out in accordance with the relevant guidelines and regulations. Written informed consent was obtained from each participant after extensive evaluation prior to surgery. All women were informed of the possible need for elective cesarean section or transabdominal suture removal before vaginal delivery. Inclusion criteria All the participants were included by strictly following the inclusion criteria: 1) ≥ 2 mid-trimester pregnancy losses (MTL); 2) painless cervical dilation before miscarriage; 3) insertion of size 8 Hegar dilators through the cervix without resistance in non-pregnant status in a non-menstrual period; and 4) willingness to undergo prophylactic LAC after being informed of treatment options, such as TVC, LAC, and other non-surgical treatments. Endocervical swabs were sent for preoperative chlamydia and mycoplasma examinations to exclude cervical infections. Exclusion criteria Participants were excluded if they met the following criteria: 1) diagnosed diseases that were not suitable for reproduction; 2) genital malformation (uterus didelphys); 3) high suspicion of extensive pelvic adhesions by examination: 4) malignant diseases without treatment; and 5) diagnosed with diseases that were not suitable for laparoscopy. Surgical procedures Laparoscopic abdominal cerclage is usually performed during a non-menstrual period. The patients were administered general anesthesia and placed in the French position with both legs split. Instead of a traditional uterine manipulator, a uterine probe with a diameter of 5 mm was inserted into the uterine cavity to avoid cervical dilation and endometrial injury. Three trocars were used during the entire procedure: a 10 mm optical trocar was placed in the navel, and a 30° scope was used; two 5-mm trocars were placed under direct visual control laterally in each lower quadrant. A 5 mm non-absorbable polyester tape with double-armed 48 mm needles (RS-22; MERSILENE, Ethicon, Inc., 68 Somerville, NJ, USA) was used. One needle was removed, and the remaining needle was straightened before use. The uterovesicle peritoneal reflection was used as an anatomical marker to identify the uterine isthmus. It was not necessary to open the vesicocervical space for the bladder flap or separate the anterior broad ligament leaves to identify the uterine arteries. First, the uterus was maintained in its natural position. The straight needle penetrated directly into the right parametrial tissue at the isthmus level. To avoid injury to the ascending branch of the uterine artery, the penetration point should be 2–3 mm away from the isthmus. The uterus was gently manipulated in an acutely ante-verted position, and the needle was pulled out from the other side until part of the MERSILENE tape passed. The needle penetrates in opposite directions at the symmetry point of the left parametrial tissue. The natural position of the uterus was restored, and the needle was pulled out until the MERSILENE tape passed the second penetration point. The tape was flattened and tightened around the isthmus using two forceps. After removing the needle, the MERSILENE tape was tied anteriorly at the isthmic surface with five throws of intracorporeal square knots. The tape was trimmed such that each end was approximately 3 cm in length. Postoperative care The patients were encouraged to get off the bed to regain activity 2 h postoperatively, and they were discharged on the second postoperative day. The patients were followed-up for one week after discharge by telephone regarding their physical status. Data collection Patients characteristics (age, body mass index [BMI] reproductive history, previous cervical and uterine surgeries or injuries, and comorbidities) were carefully recorded. Perioperative parameters (additional procedures, operation duration, estimated total blood loss, and complications) were also recorded. Outpatient visits were arranged one month postoperatively, and conception was encouraged at one menstrual cycle later if there were no positive findings at the last visit. Obstetric outcomes (conception time, delivery mode, gestation weeks, and infant’s health status) were collected via telephone. RESULTS Study population In total, 108 patients diagnosed with CI underwent prophylactic LAC during the study period. Most of the patients (105/108) had second trimester fetal loss, and the other three had early third trimester fetal loss. The mean age of these group was 31.1 ± 3.9 years (range, 23–42 years), with a mean BMI of 23.7 ± 3.2 kg/m 2 (range, 17.9–33.3 kg/m 2 ). Twenty-three of the patients had given birth previously, but the remaining 85 were nulliparous. Of the 23 multiparous patients, 19 had a full-term delivery, and four had a pre-term delivery. There were 26 patients who underwent cervical surgery: three underwent conization; six underwent loop electrosurgical excision procedure; and 17 underwent transvaginal cerclage before the last mid-trimester fetal loss. Another 58 patients underwent uterine surgery: 18 patients underwent hysteroscopy, and 40 had an artificial abortion in the first trimester. Patient characteristics and reproductive histories are listed in Table 1 . Table 1 Patients’ characteristics and histories of reproduction and surgeries. Patient characteristics (n = 108) Values/No. of patients Mean age (y) 31.1 ± 3.9 BMI 23.7 ± 3.2 Multipara 23 Nullipara 85 Reproductive history Full-term delivery 19 Pre-term delivery 4 First-trimester loss 1 Second-trimester loss 105 Thrid-trimester loss 3 Ectopic pregnancy 7 Artificial abortion 40 History of cervical procedures Conization 3 Loop Electrosurgical Excision Procedure 6 Transvaginal cerclage 17 History of uterine procedures Hysteroscope 18 Artificial abortion 40 Perioperative outcomes Among the 108 patients, 44 underwent only LAC, and 64 underwent additional procedures at the same time. Details of the patients’ perioperative outcomes are shown in Table 2 . Regarding additional procedures, enterolysis accounted for the most (41/108), followed by hysteroscopy (24/108), which was performed in patients with irregular vaginal bleeding or suspicious endometrial polyps. Mean operative time (OT) was 45.3 ± 14.5 min, although it was increased to 56.8 ± 22.8 min for the cases with additional procedures. Mean estimated blood loss (EBL) for LAC alone was 13.9 ± 10.4 mL, and it increased to 21.4 ± 23.6 mL when patients had additional procedures. Mean intraoperative transfusion volume was 1084.3 ± 355.8 mL, and no patient received blood transfusion. Most of the patients were placed on a pelvic drainage tube for better observation of abdominal hemorrhage postoperatively, and the tubes were all removed the first day after surgery, with a mean drainage volume of 34.2 ± 5.7 mL. There was one report of uroschesis, which was classified as grade I postoperative complication according to the Clavien–Dindo classification.[19] No injuries to vessels, intestines, bladders, or ureter during surgery. The Barthel scale was used to evaluate patients’ basic activities of daily living (ADL) on the day before the surgery, the day of surgery, and the first day after surgery[20]. Mean score of ADL was 99.7 ± 2.3 before surgery, 41.5 ± 9 after surgery, and 65.5 ± 11 on the first day after surgery, suggesting patients regained their physical function on the first day after surgery. At the same time, the numerical rating scale (range, 0–10 score)was used to measure pain intensity. Patients felt mild pain on the surgery day (mean score, 2.7 ± 0.6) and first day after the surgery (mean score, 1.7 ± 0.9), and nearly no pain on the second day after the surgery (mean score, 0.5 ± 0.7). Non-steroidal substances were administered orally to alleviate pain on the surgery day. Table 2 A summary of the patients’ perioperative outcomes. Procedural outcomes (n = 108) Values/No. of patients LAC only 44 Additional procedures 64 Hysteromyomectomy 14 Oophorocystectomy 10 Electrosurgery for endometriosis 7 Enterolysis 41 Hysteroscope 24 Diagnostic curettage 6 Conization 1 Fallopian tube prosthetics 6 Ovarian drilling 1 Hydrotubation 10 Mean OT (min) All cases 56.8 ± 22.8 min No additional procedures 45.3 ± 14.5 min Mean EBL (mL) All cases 21.4 ± 23.6 mL No additional procedures 13.9 ± 10.4 mL Perioperative complications 1 (uroschesis) Transfusion volume 1084.3 ± 355.8 mL Postoperative ADL Day 0 41.5 ± 9 Day 1 65.5 ± 11 NRS of pain intensity Day 0 2.7 ± 0.5 Day 1 1.7 ± 0.8 Day 2 0.5 ± 0.7 Postoperative obstetric outcomes At the time of data collection, 98 patients became pregnant after the surgery. Among the 98 patients, 74 conceived spontaneously, and the remaining 24 underwent in vitro fertilization. The mean interval from LAC to conception was 8.9 ± 7.6 month. The postoperative obstetric outcomes are listed in Table 3 . Table 3 Obstetric outcomes of patients after pre-conceptional laparoscopic cervical cerclage. Obstetric outcomes (n = 98) Values/No. of patients Spontaneous conception 74 IVF 24 Time of pregnancy post-operation (months) 8.9 ± 7.6 Delivery mode Vaginal delivery 5 Cesarean section 93 Mersilene tape reservation 64 Mersilene tape removal 29 Termination at < 26 weeks (n = 3) First-trimester loss 0 Second-trimester loss 2 Termination due to anomaly 1 Delivered at ≥ 26 weeks (n = 95) 95 Twins 4 Singletons 91 Preterm delivery (< 37 weeks) 10 Full-term delivery 85 Premature rupture of membranes 2 Median gestational weeks at delivery 38 + 3 weeks Mean neonatal weight (g) All newborns 3310.2 ± 382.1g Without twins 3347.2 ± 338.9 g Number of low birth weight (< 2500 g) 2 Requiring NICU care 4 Neonatal death 0 There were two cases of second trimester loss and one case of termination due to fetal anomalies. The two second-trimester losses resulted in uncontrolled uterine contractions during mid-trimester. They underwent another laparoscopy to remove the cervical tape, and finally, they underwent vaginal abortion at 20 and 23 gestational weeks separately. One fetus was diagnosed with tetralogy of Fallot at 24 weeks of gestation. The women also chose to remove the cervical tape under laparoscopy, followed by vaginal abortion after fatally induced labor. There were 95 live births, of which there were 4 twins and 91 singletons. Ten cases were pre-term deliveries, with two cases of premature rupture of membranes, and 85 cases were full-term deliveries. Of the 95 live births, 94 were delivered by Cesarean section. Sixty-four (64/98) women chose to keep the Mersilene tape for future pregnancy during Cesarean section, and 29 women had the tape removed during surgery. Notably, two women underwent open surgery to remove the Mersilene tape at 37 gestational weeks, and then completed vaginal delivery at 38 + 5 and 37 + 6 gestational weeks. Mean neonatal weight was 3310.2 ± 382.1 g, and only two neonates from different twins weighted < 2500 g. Four infants who were deliveried less than 34 gestational weeks were sent to neonatal intensive care units, and no neonatal deaths were reported. DISCUSSION According to a large prospective register-based study, the incidence of miscarriage was estimated to be 21.1% before 20 weeks of gestation, whereas the incidence of stillbirth was estimated to be 17.5%[21]. Cervical insufficiency is one of the reasons for mid-trimester miscarriages. However, a history of miscarriage or pre-term delivery increases the risk of CI, which, in turn, increases the risk of miscarriage[22]. To break the vicious circle, prevention of CI could be a breakthrough to break this vicious circle. Cervical insufficiency can be congenital or acquired, and the prevention strategy should concentrate on acquired CI. Damage to the structural integrity due to trauma or surgery may be responsible for CI. Conization increases the risk of mid-trimester fetal loss due to impairment of the intact cervix, specifically when cone heights are more than 2 cm[23–25]. A history of abortion and specifically induced abortions were also associated with CI[26]. A history of a spontaneous or induced abortion increases the risk for CI by up to 2.71 times at the next pregnancy. Moreover, operative hysteroscopy may be a risk factor for CI development. In a small retrospective study, the incidence of CI was significantly higher (13.7%) in a group that underwent operative hysteroscopy, while it was 3.4% in a control group (13.7% vs. 3.4%)[27]. These procedures destroy the intact cervix or over-dilate the cervix, thereby impairing the mechanical support of cervix during pregnancy. In our study, 24.1% (26/108) of the patients underwent cervical surgery, and more than half of the patients (53.7%, 58/108) underwent uterine surgery. Recurrent dilation and extension of the cervix are non-negligible factors in cervical tissue injury. Some studies have supported the idea that CI is a subtle form of collagenopathy. From the analysis of next-generation sequencing results in 21 patients, Volozonoka et al. identified several genes ( COL1A1 , COL3A1 , FBN1 , HIF1A , LMNA , and MATR3 ) whose products participate in collagen biosynthesis and cell-extracellular matrix communication are also associated with CI[22]. In a comparison of cervical collagen between non-pregnant women with congenital CI and normal parous women, the median cervical hydroxyproline concentration was significantly lower in patients with CI[28]. Notably, pregnancy or parturition could lead to a decrease in cervical hydroxyproline concentration, which is in accordance with the finding that the number of miscarriages or deliveries increases the risk of CI[21]. Changes in cervical collagen concentration also alter the contractility of cervical smooth muscle. Decreased rigidity of the cervical extracellular matrix leads to a compromise in cervical smooth muscle cell contractile tone and a predisposition to sphincter laxity, which contributes to premature cervical failure[29]. Cervical cerclage is an option for preventing fetal loss caused by CI. Cervical cerclage is usually performed via the transvaginal route during pregnancy. It is indicated for pregnancy at high risk of pre-term births, mid-trimester fetal losses, or transvaginal ultrasound(TVU) CL of 2 cm[31]. Thus, the CL should not be short enough to allow sufficient room for suturing. Generally, TVC is regarded as a safe method, but there is still a risk of perioperative complications, such as hemorrhage, cervical lacerations, lesions or trauma of the cervix, pyrexia, severe maternal infections (amnionitis or chorioamnionitis), or direct pre-term premature rupture of membranes[32–35]. Combining data from 44 studies, Van Dijk et al. reported that most perioperative complications of TVC were hemorrhage (0.9–2.3%) and pre-term premature rupture of membranes (0.0–2.5%)[35]. Notably, the incidence of complications varied between prophylactic and emergency TVC. Complications were lowest in a prophylactic TVC group, which was performed in the first trimester for women who have had ≥ 3 pre-term deliveries and/or mid-trimester losses. Transabdominal cerclage is another option, especially for women in whom cerclage has failed (delivery before 28 weeks after a history- or ultrasound-indicated [but not rescue] cerclage)[36]. Transabdominal cerclage can be performed during laparotomy or laparoscopy, either pre-conceptually or after conception[37]. Laparoscopy has been proven to be safe for both mother and fetus, with no increase in adverse obstetric outcomes[38]. Owing to the inherent advantages of laparoscopy over laparotomy, LAC is more recommended[37]. Several retrospective studies reported that pre-gestational LAC was more effective in reducing spontaneous pre-term birth at ˂34 weeks than mid-term TVC[39, 40]. In a multicenter randomized controlled trial aimed at women with previous failed cerclage, a LAC group had significantly fewer fetal losses than a TVC group (3% [1/39] vs. 21% [7/33])[41]. Another advantage of preconceptual LAC, which could be underestimated, is the reduced anxiety caused by surgery. Anxiety and stress are common during pregnancy. However, obstetric complications and unplanned surgeries can significantly increase maternal state anxiety[42, 43]. Maternal state anxiety is associated with adverse pregnancy outcomes, such as miscarriage, pre-eclampsia, pre-term delivery, and low birth weight, with particularly strong evidence for an increased risk of pre-term birth and low birth weight[44, 45]. Thus, prophylactic pre-conceptual LAC instead of TVC during pregnancy could be a more appropriate candidate for relieving maternal state anxiety in women with CIs. In terms of prophylactic pre-conceptual LAC, conventional LAC involves opening the vesicular space and separating the anterior broad ligament leaves. These procedures help identify the uterine artery and prevent injury. However, these would also prolong surgery time, extend the surgical area, and increase tissue injury, leading to postoperative pelvic and abdominal adhesion[46]. Serious postoperative adhesions may cause small bowel obstruction and increase the risk of hemorrhage, perforation, reduced surgical exposure, and prolonged OT in repeat surgeries[47]. In our surgical procedure, these two steps were omitted, and no perioperative complications were reported. The main concern with our simplified LAC was injury to the bladder and uterine vessels. From our eight years of experience, the key point of the procedure was to recognize the uterovesicle peritoneal reflection, which could be an anatomical marker for identifying the uterine isthmus. The second key point was to keep the needle vertically penetrating the parametrial tissue in close proximity to the isthmus, which could evade the uterine vessels. From a report about the conventional LAC, mean operation time (OT) for single LAC was 51 ± 27 min, and mean EBL was 18 ± 12 mL[14]. While for our simplified LAC, the mean OT was 43.7 ± 14.4 min, and mean EBL was 14.7 ± 11.9 mL. There was another report about the experience of simplified LAC, mean OT ( 26 ± 4.7 min), and mean EBL (11.9 mL)[18]. These data support the idea that simplified LAC is safe, with less operation time and blood loss. Another advantage of our simplified LAC is that we avoided the use of a conventional uterine manipulator to position the uterus. Complications of uterine manipulation include uterine perforation, cervical laceration, and cervical bleeding[48, 49]. Additionally, the use of a vaginal cup overdraws the cervical tissue. As discussed previously, cervical injury and dilation increase the risk of CI. Thus, we chose to use a uterine probe together with a cervical tenaculum rather than a uterine manipulator or vaginal cup to minimize cervical injury. The uterine probe is much smaller than the rod of the uterine manipulator, and there are no concerns regarding the longitudinal tension of the cervix caused by lifting the vaginal cup. We also performed LAC in pregnant women (data not shown), and no probe or cervical tenaculum was used. We had another Forceps inserted through an additional 5 mm port in the left lower abdomen to manipulate the uterus. During the procedure, the tape was tied either anteriorly or posteriorly to the isthmus. In our patient, the knots were tied anteriorly to the isthmic surface. For patients undergoing vaginal delivery, the knots can be easily removed with a 5 cm long open cut superior to the pubis symphysis under local anesthesia. Each patient was informed that they still had a chance to undergo vaginal delivery once the tape had been removed before surgery. However, two patients chose to undergo vaginal delivery after tape removal at 37 gestational weeks. One baby was delivered at 38 + 5 gestational weeks, with a total labor duration of 8 h and 40 min. The other one was delivered at 37 + 6 gestational weeks with a total labor duration of 6 h and 20 min. The remaining patients underwent cesarean delivery; 64 of them chose to keep the tape for future pregnancy, and the others chose to remove the tape. In conclusion, we reported a series of patients who were diagnosed with CI and underwent pre-conceptual LAC. We demonstrated that preconceptual LAC is an effective option for preventing mid-terminal fetal loss in women with CI. Notably, the simplified LAC is a simple, safe, and effective method that is worthy of promotion. Finally, vaginal delivery after LAC is still possible once the tape is removed before labor. However, the limitations of this report mainly came from two aspects: one was the small cohort of patients, and the second was the experience drawn from a single center, which could be the cause for the deviation in the final conclusions. We hope that more centers will opt for a simplified pre-conceptual LAC to help more women with CI. Abbreviations CI Cervical insufficiency LAC Laparoscopic abdominal cerclage CL Cervical length TVC Transvaginal cervical cerclage AC Abdominal cerclage MTL Mid-trimester pregnancy losses BMI Body mass index OT Operative time EBL Estimated blood loss ADL Activities of daily living TVU Transvaginal ultrasound IVF in vitro fertilization NICU neonatal intensive care units. Declarations Ethics approval and consent to participate This study was reviewed and approved by the ethics committee and the data inspectorate of West China Second University Hospital of Sichuan University. All experimental protocols were approved by the ethics committee and the data inspectorate of West China Second University Hospital of Sichuan University. Informed consent was obtained from all subjects and/or their legal guardian(s). All methods were carried out in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no confict of all financial and non-financial competing interests in publishing the present manuscript. Funding No funding. Authors' contributions Ledi Kuang: data collection, follow-up, paper writing. Guolin Luo: medical care provision. Xin Tan: medical care provision. Hong Liao: principal medical care provision, follow-up, paper writing. Acknowledgements Not applicable References Thakur M, Mahajan K. Cervical Insufficiency. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024. Wang HL, Yang Z, Shen Y, Wang QL. [Clinical outcome of therapeutic cervical cerclage in short cervix syndrome]. Zhonghua Fu Chan Ke Za Zhi. 2018;53:43–6. Volozonoka L, Rots D, Kempa I, Kornete A, Rezeberga D, Gailite L, et al. Genetic landscape of preterm birth due to cervical insufficiency: Comprehensive gene analysis and patient next-generation sequencing data interpretation. PloS One. 2020;15:e0230771. Brown R, Gagnon R, Delisle M-F, Gagnon R, Bujold E, Basso M, et al. Cervical Insufficiency and Cervical Cerclage. J Obstet Gynaecol Can. 2013;35:1115–27. Roman A, Suhag A, Berghella V. Overview of Cervical Insufficiency: Diagnosis, Etiologies, and Risk Factors. Clin Obstet Gynecol. 2016;59:237–40. ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency. Obstet Gynecol. 2014;123 2 Pt 1. Anthony GS, Calder AA, Macnaughton MC. Cervical resistance in patients with previous spontaneous mid-trimester abortion. BJOG Int J Obstet Gynaecol. 1982;89:1046–9. Kiwi R, Neuman MR, Merkatz IR, Selim MA, Lysikiewicz A. Determination of the elastic properties of the cervix. Obstet Gynecol. 1988;71:568–74. 中国妇幼保健协会宫内疾病防治专委会. 子宫颈机能不全临床诊治中国专家共识(2023年版). 中国实用妇科与产科杂志. 2023;39:175. Vn S. A new method of operative treatment for habitual abortions in the second trimester of pregnancy. Antiseptic. 1955;52:299–300. Mcdonald IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Emp. 1957;64:346–50. Eleje GU, Eke AC, Ikechebelu JI, Ezebialu IU, Okam PC, Ilika CP. Cervical stitch (cerclage) in combination with other treatments for preventing spontaneous preterm birth in singleton pregnancies. Cochrane Database Syst Rev. 2020;9:CD012871. Harger JH. Cerclage and cervical insufficiency: an evidence-based analysis. Obstet Gynecol. 2002;100:1313–27. Clark NV, Einarsson JI. Laparoscopic abdominal cerclage: a highly effective option for refractory cervical insufficiency. Fertil Steril. 2020;113:717–22. Bolla D, Raio L, Imboden S, Mueller MD. Laparoscopic Cerclage as a Treatment Option for Cervical Insufficiency. Geburtshilfe Frauenheilkd. 2015;75:833–8. Saridogan E, O’Donovan OP, David AL. Preconception laparoscopic transabdominal cervical cerclage for the prevention of midtrimester pregnancy loss and preterm birth: a single centre experience. Facts Views Vis ObGyn. 2019;11:43–8. Huang G, Deng C, Liao H, Hu Q, Yu H, Wang X. Comparison of transvaginal cervical cerclage versus laparoscopic abdominal cervical cerclage in cervical insufficiency: a retrospective study from a single centre. BMC Pregnancy Childbirth. 2022;22:773. Huang X, Ma N, Li T-C, Guo Y, Song D, Zhao Y, 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;201:146–50. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–96. Mahoney FI, Barthel DW. FUNCTIONAL EVALUATION: THE BARTHEL INDEX. Md State Med J. 1965;14:61–5. Wilcox AJ, Morken N-H, Weinberg CR, Håberg SE, Magnus MC. Role of maternal age and pregnancy history in risk of miscarriage: prospective register based study. The BMJ. 2019;364:l869. Meng L, Öberg S, Sandström A, Wang C, Reilly M. Identification of risk factors for incident cervical insufficiency in nulliparous and parous women: a population-based case-control study. BMC Med. 2022;20:348. Pina A, Lavallée S, Ndiaye C, Mayrand M-H. Reproductive Impact of Cervical Conization. Curr Obstet Gynecol Rep. 2013;2:94–101. El-Bastawissi AY, Becker TM, Daling JR. Effect of cervical carcinoma in situ and its management on pregnancy outcome. Obstet Gynecol. 1999;93:207–12. Albrechtsen S, Rasmussen S, Thoresen S, Irgens LM, Iversen OE. Pregnancy outcome in women before and after cervical conisation: population based cohort study. BMJ. 2008;337:a1343. Brittain JJ, Wahl SE, Strauss JF, Romero R, Wolf HM, Murphy K, et al. Prior Spontaneous or Induced Abortion Is a Risk Factor for Cervical Dysfunction in Pregnant Women: a Systematic Review and Meta-analysis. Reprod Sci. 2023;30:2025–39. Gökçe A, Şükür YE, Özmen B, Sönmezer M, Berker B, Aytaç R, et al. The association between operative hysteroscopy prior to assisted reproductive technology and cervical insufficiency in second trimester. Arch Gynecol Obstet. 2021;303:1347–52. Petersen LK, Uldbjerg N. Cervical collagen in non-pregnant women with previous cervical incompetence. Eur J Obstet Gynecol Reprod Biol. 1996;67:41–5. Vink J, Yu V, Dahal S, Lohner J, Stern-Asher C, Mourad M, et al. Extracellular Matrix Rigidity Modulates Human Cervical Smooth Muscle Contractility-New Insights into Premature Cervical Failure and Spontaneous Preterm Birth. Reprod Sci Thousand Oaks Calif. 2021;28:237–51. Brown R, Gagnon R, Delisle M-F. No. 373-Cervical Insufficiency and Cervical Cerclage. J Obstet Gynaecol Can. 2019;41:233–47. Berghella V, Ludmir J, Simonazzi G, Owen J. Transvaginal cervical cerclage: evidence for perioperative management strategies. Am J Obstet Gynecol. 2013;209:181–92. Kuruma A, Hayashi S, Koh I, Yamamoto R, Mitsuda N, Ishii K. Incidences of complications associated with cervical cerclage by indication of the procedure. J Obstet Gynaecol Res. 2022;48:73–9. Schneider K, Fimmers R, Jörgens M, Peter S, Pelzer V, Redlich T. Emergency cerclage following a standardized protocol offers an effective and safe therapeutic option for women with high risk for prematurity - a retrospective monocentric cohort study on 130 pregnancies and 155 neonates. J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet. 2021;34:4053–9. Drassinower D, Coviello E, Landy HJ, Gyamfi-Bannerman C, Perez-Delboy A, Friedman AM. Outcomes after periviable ultrasound-indicated cerclage. J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet. 2019;32:932–8. Dijk CE van, Breuking SH, Jansen S, Limpens JCEJM, Kazemier BM, Pajkrt E. Perioperative complications of a transvaginal cervical cerclage in singleton pregnancies: a systematic review and meta-analysis. Am J Obstet Gynecol. 2023;228:521–534.e19. Shennan A, Story L, Jacobsson B, Grobman WA, Birth the FWG for P. FIGO good practice recommendations on cervical cerclage for prevention of preterm birth. Int J Gynecol Obstet. 2021;155:19–22. Tulandi T, Alghanaim N, Hakeem G, Tan X. Pre and post-conceptional abdominal cerclage by laparoscopy or laparotomy. J Minim Invasive Gynecol. 2014;21:987–93. Ball E, Waters N, Cooper N, Talati C, Mallick R, Rabas S, et al. Evidence-Based Guideline on Laparoscopy in Pregnancy. Facts Views Vis ObGyn. 11:5–25. Huang G, Deng C, Liao H, Hu Q, Yu H, Wang X. Comparison of transvaginal cervical cerclage versus laparoscopic abdominal cervical cerclage in cervical insufficiency: a retrospective study from a single centre. BMC Pregnancy Childbirth. 2022;22:773. Qin F, Yang Y, Zhou W, Chi Y, Liu B, Chen G. Effect of different surgical routes on pregnancy outcome of history-indicated cervical cerclage. Arch Gynecol Obstet. 2024;309:1377–86. Shennan A, Chandiramani M, Bennett P, David AL, Girling J, Ridout A, et al. MAVRIC: a multicenter randomized controlled trial of transabdominal vs transvaginal cervical cerclage. Am J Obstet Gynecol. 2020;222:261.e1-261.e9. Fischbein RL, Nicholas L, Kingsbury DM, Falletta LM, Baughman KR, VanGeest J. State anxiety in pregnancies affected by obstetric complications: A systematic review. J Affect Disord. 2019;257:214–40. Araji S, Griffin A, Dixon L, Spencer S-K, Peavie C, Wallace K. An Overview of Maternal Anxiety During Pregnancy and the Post-Partum Period. J Ment Health Clin Psychol. 2020;4. McCarthy M, Houghton C, Matvienko-Sikar K. Women’s experiences and perceptions of anxiety and stress during the perinatal period: a systematic review and qualitative evidence synthesis. BMC Pregnancy Childbirth. 2021;21:811. Bergeron J, Avraam D, Calas L, Fraser W, Harris JR, Heude B, et al. Stress and anxiety during pregnancy and length of gestation: a federated study using data from five Canadian and European birth cohorts. Eur J Epidemiol. 2024. https://doi.org/10.1007/s10654-024-01126-4. Moris D, Chakedis J, Rahnemai-Azar AA, Wilson A, Hennessy MM, Athanasiou A, et al. Postoperative Abdominal Adhesions: Clinical Significance and Advances in Prevention and Management. J Gastrointest Surg Off J Soc Surg Aliment Tract. 2017;21:1713–22. Fatehi Hassanabad A, Zarzycki AN, Jeon K, Deniset JF, Fedak PWM. Post-Operative Adhesions: A Comprehensive Review of Mechanisms. Biomedicines. 2021;9:867. Sung P-L, Chao K-C, Twu N-F, Wang P-H, Yu BK-J, Yen M-S, et al. Postconization cervical perforation during laparoscopic surgery. Taiwan J Obstet Gynecol. 2007;46:71–2. Beyan E, Kanmaz AG, Budak A, Emirdar V, Tutar SO, Inan AH. Uterine manipulator requirement in laparoscopic surgery of Ectopic Pregnancy. Pak J Med Sci. 2020;36:105–10. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Nov, 2024 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 09 Nov, 2024 Reviews received at journal 08 Nov, 2024 Reviews received at journal 31 Oct, 2024 Reviewers agreed at journal 20 Oct, 2024 Reviewers agreed at journal 19 Oct, 2024 Reviewers invited by journal 03 Oct, 2024 Editor invited by journal 24 Sep, 2024 Editor assigned by journal 23 Sep, 2024 Submission checks completed at journal 23 Sep, 2024 First submitted to journal 20 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5124095","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":376095388,"identity":"987ccb6e-78cf-4628-8e53-63e4d3f2ae37","order_by":0,"name":"Ledi Kuang","email":"","orcid":"","institution":"Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China.","correspondingAuthor":false,"prefix":"","firstName":"Ledi","middleName":"","lastName":"Kuang","suffix":""},{"id":376095389,"identity":"c5ce529c-cc7d-4f3a-8f8a-183135fbe91a","order_by":1,"name":"GuoLin Luo","email":"","orcid":"","institution":"Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China.","correspondingAuthor":false,"prefix":"","firstName":"GuoLin","middleName":"","lastName":"Luo","suffix":""},{"id":376095390,"identity":"5e084c4e-a043-47c0-9716-fb8be573383b","order_by":2,"name":"Xin Tan","email":"","orcid":"","institution":"Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China.","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Tan","suffix":""},{"id":376095391,"identity":"c012488e-456a-4ec6-a8bc-783877ba9724","order_by":3,"name":"Hong Liao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBACA2YGBmYQw769sfEBkJZhYGAjUosBz+HDBiCKsBYGmBaJtDQJ4rSwMz98XFBxx247Q45Zxce2Pzz87G0JDD8qtuFxGJux8Ywzz5J3NpwxuzmzzYBHsufYAcaeM7fx+cVMmrftcDLDwR6z27xALQY30huYGdvwaWH/BtFymMesmEgtPGBb7AyOsaUxQ7SkHSCkpdiY58zhBMke5sOSM84Zg/yScBCfX+z7j298zFNx2J5f/mHjhw9lcnLAEDN88KMCtxYYSGxA5h0gqB5kGzGKRsEoGAWjYIQCAAYPUVGLDZGlAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China.","correspondingAuthor":true,"prefix":"","firstName":"Hong","middleName":"","lastName":"Liao","suffix":""}],"badges":[],"createdAt":"2024-09-20 13:43:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5124095/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5124095/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-024-07006-9","type":"published","date":"2024-11-30T15:58:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69350770,"identity":"2d0b5ee4-c0a1-4aeb-b764-1a389821c109","added_by":"auto","created_at":"2024-11-19 13:04:44","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":304507,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5124095/v1/d0bf37370a2d6c5a5bb28320.jpg"},{"id":70389125,"identity":"a2c1111b-3e87-4eeb-8e71-4d45ed402483","added_by":"auto","created_at":"2024-12-02 17:28:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":858091,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5124095/v1/2aa8aab4-cc41-4a2d-8418-e54782dc95c7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of a simplified pre-conceptional laparoscopic cervical cerclage for cervical insufficiency: a retrospective study from a single center Running head: a simplified pre-conceptional laparoscopic cervical cerclage for women’s cervical insufficiency","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCervical insufficiency (CI) is a pathological condition in obstetrics in which the cervix fails to retain the fetus before uterine contractions or labor (painless cervical dilatation)[1]. Patients usually have fetal loss in the mid-trimester or spontaneous pre-term birth due to painless cervical dilation[2]. Birth defects in the genital tract and hereditary connective tissue diseases are common congenital causes of CI[3]. Cervical insufficiency can also be acquired by cervical trauma, such as conization, trachelectomy, and repetitive cervical dilatation[4]. So far, there is no consistent definition for CI; therefore, the incidence of 1% in the obstetric population could be inaccurate[5]. Clear diagnostic criteria and standard diagnostic tests for CI are lacking. It should be considered based on a history of painless cervical dilation in the second trimester or ultrasound evidence of cervical length (CL)\u0026thinsp;\u0026lt;\u0026thinsp;25 mm before 24 weeks, or in patients with previous pre-term birth before 36 weeks of gestation[5, 6]. The diagnosis of CI in non-pregnant women is more challenging, and Hegar dilators are used to evaluate the patulous cervix, or a balloon elastance test is used to calculate the cervical resistance index[7, 8]. In China, the insertion of size 8 Hegar dilators through a non-pregnant cervix without resistance is widely accepted as an indication for CI[9].\u003c/p\u003e \u003cp\u003eTransvaginal and transabdominal cervical cerclage are the two main surgical approaches used to treat CI. Transvaginal cervical cerclage (TVC) involves inserting sutures around the cervical neck to prevent cervical dilation of cervix[10, 11]. However, the risks of traumatic rupture of membranes, vaginal bleeding, chorioamnionitis, and cervical lacerations increase after TVC[12]. An increase in vaginal discharge is also commonly observed. Abdominal cerclage (AC) involves placing a suture at the uterine isthmus to hold the uterine contents, and was first described in 1965[13]. With the advantage of being minimally invasive, laparoscopic AC (LAC) is widely accepted as a safe method between 12\u0026ndash;14 weeks gestation for preventing further fetal losses[14, 15]. For non-pregnant women with CI, prophylactic LAC has been reported to improve pregnancy outcomes, such as live birth, neonatal survival, and full-term delivery rate[16\u0026ndash;18]. The traditional LAC procedure that includes dissection of the anterior leaves of the broad ligament to create an avascular space for needle placement, which is time-consuming and possibly increases the risk of postoperative adhesions.\u003c/p\u003e \u003cp\u003eHerein, we reported a simplified LAC in 108 non-pregnant women with previous fetal losses due to CI in this retrospective study. We described the perioperative data and followed-up the obstetric outcomes in this group.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThis retrospective observational study was conducted between January 2015 and December 2022 at the West China Second Hospital of West China Second University Hospital, Sichuan University. A total of 108 eligible women diagnosed with CI were included in this study.\u003c/p\u003e \u003cp\u003e This study was reviewed and approved by the ethics committee and the data inspectorate of West China Second University Hospital of Sichuan University and the methods were carried out in accordance with the relevant guidelines and regulations. Written informed consent was obtained from each participant after extensive evaluation prior to surgery. All women were informed of the possible need for elective cesarean section or transabdominal suture removal before vaginal delivery.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003eAll the participants were included by strictly following the inclusion criteria: 1)\u0026thinsp;\u0026ge;\u0026thinsp;2 mid-trimester pregnancy losses (MTL); 2) painless cervical dilation before miscarriage; 3) insertion of size 8 Hegar dilators through the cervix without resistance in non-pregnant status in a non-menstrual period; and 4) willingness to undergo prophylactic LAC after being informed of treatment options, such as TVC, LAC, and other non-surgical treatments. Endocervical swabs were sent for preoperative chlamydia and mycoplasma examinations to exclude cervical infections.\u003c/p\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eParticipants were excluded if they met the following criteria: 1) diagnosed diseases that were not suitable for reproduction; 2) genital malformation (uterus didelphys); 3) high suspicion of extensive pelvic adhesions by examination: 4) malignant diseases without treatment; and 5) diagnosed with diseases that were not suitable for laparoscopy.\u003c/p\u003e\n\u003ch3\u003eSurgical procedures\u003c/h3\u003e\n\u003cp\u003eLaparoscopic abdominal cerclage is usually performed during a non-menstrual period. The patients were administered general anesthesia and placed in the French position with both legs split. Instead of a traditional uterine manipulator, a uterine probe with a diameter of 5 mm was inserted into the uterine cavity to avoid cervical dilation and endometrial injury.\u003c/p\u003e \u003cp\u003eThree trocars were used during the entire procedure: a 10 mm optical trocar was placed in the navel, and a 30\u0026deg; scope was used; two 5-mm trocars were placed under direct visual control laterally in each lower quadrant. A 5 mm non-absorbable polyester tape with double-armed 48 mm needles (RS-22; MERSILENE, Ethicon, Inc., 68 Somerville, NJ, USA) was used. One needle was removed, and the remaining needle was straightened before use. The uterovesicle peritoneal reflection was used as an anatomical marker to identify the uterine isthmus. It was not necessary to open the vesicocervical space for the bladder flap or separate the anterior broad ligament leaves to identify the uterine arteries. First, the uterus was maintained in its natural position. The straight needle penetrated directly into the right parametrial tissue at the isthmus level. To avoid injury to the ascending branch of the uterine artery, the penetration point should be 2\u0026ndash;3 mm away from the isthmus. The uterus was gently manipulated in an acutely ante-verted position, and the needle was pulled out from the other side until part of the MERSILENE tape passed. The needle penetrates in opposite directions at the symmetry point of the left parametrial tissue. The natural position of the uterus was restored, and the needle was pulled out until the MERSILENE tape passed the second penetration point. The tape was flattened and tightened around the isthmus using two forceps. After removing the needle, the MERSILENE tape was tied anteriorly at the isthmic surface with five throws of intracorporeal square knots. The tape was trimmed such that each end was approximately 3 cm in length. \u003c/p\u003e\n\u003ch3\u003ePostoperative care\u003c/h3\u003e\n\u003cp\u003eThe patients were encouraged to get off the bed to regain activity 2 h postoperatively, and they were discharged on the second postoperative day. The patients were followed-up for one week after discharge by telephone regarding their physical status.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003ePatients characteristics (age, body mass index [BMI] reproductive history, previous cervical and uterine surgeries or injuries, and comorbidities) were carefully recorded. Perioperative parameters (additional procedures, operation duration, estimated total blood loss, and complications) were also recorded. Outpatient visits were arranged one month postoperatively, and conception was encouraged at one menstrual cycle later if there were no positive findings at the last visit. Obstetric outcomes (conception time, delivery mode, gestation weeks, and infant\u0026rsquo;s health status) were collected via telephone.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eIn total, 108 patients diagnosed with CI underwent prophylactic LAC during the study period. Most of the patients (105/108) had second trimester fetal loss, and the other three had early third trimester fetal loss. The mean age of these group was 31.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9 years (range, 23\u0026ndash;42 years), with a mean BMI of 23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 kg/m\u003csup\u003e2\u003c/sup\u003e (range, 17.9\u0026ndash;33.3 kg/m\u003csup\u003e2\u003c/sup\u003e). Twenty-three of the patients had given birth previously, but the remaining 85 were nulliparous. Of the 23 multiparous patients, 19 had a full-term delivery, and four had a pre-term delivery. There were 26 patients who underwent cervical surgery: three underwent conization; six underwent loop electrosurgical excision procedure; and 17 underwent transvaginal cerclage before the last mid-trimester fetal loss. Another 58 patients underwent uterine surgery: 18 patients underwent hysteroscopy, and 40 had an artificial abortion in the first trimester. Patient characteristics and reproductive histories are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients\u0026rsquo; characteristics and histories of reproduction and surgeries.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient characteristics (n\u0026thinsp;=\u0026thinsp;108)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValues/No. of patients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age (y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNullipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReproductive history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-term delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-term delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst-trimester loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecond-trimester loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrid-trimester loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEctopic pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArtificial abortion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of cervical procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoop Electrosurgical Excision Procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransvaginal cerclage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of uterine procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHysteroscope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArtificial abortion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative outcomes\u003c/h2\u003e \u003cp\u003eAmong the 108 patients, 44 underwent only LAC, and 64 underwent additional procedures at the same time. Details of the patients\u0026rsquo; perioperative outcomes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Regarding additional procedures, enterolysis accounted for the most (41/108), followed by hysteroscopy (24/108), which was performed in patients with irregular vaginal bleeding or suspicious endometrial polyps. Mean operative time (OT) was 45.3\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5 min, although it was increased to 56.8\u0026thinsp;\u0026plusmn;\u0026thinsp;22.8 min for the cases with additional procedures. Mean estimated blood loss (EBL) for LAC alone was 13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4 mL, and it increased to 21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;23.6 mL when patients had additional procedures. Mean intraoperative transfusion volume was 1084.3\u0026thinsp;\u0026plusmn;\u0026thinsp;355.8 mL, and no patient received blood transfusion. Most of the patients were placed on a pelvic drainage tube for better observation of abdominal hemorrhage postoperatively, and the tubes were all removed the first day after surgery, with a mean drainage volume of 34.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7 mL. There was one report of uroschesis, which was classified as grade I postoperative complication according to the Clavien\u0026ndash;Dindo classification.[19] No injuries to vessels, intestines, bladders, or ureter during surgery.\u003c/p\u003e \u003cp\u003eThe Barthel scale was used to evaluate patients\u0026rsquo; basic activities of daily living (ADL) on the day before the surgery, the day of surgery, and the first day after surgery[20]. Mean score of ADL was 99.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 before surgery, 41.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9 after surgery, and 65.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11 on the first day after surgery, suggesting patients regained their physical function on the first day after surgery. At the same time, the numerical rating scale (range, 0\u0026ndash;10 score)was used to measure pain intensity. Patients felt mild pain on the surgery day (mean score, 2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6) and first day after the surgery (mean score, 1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9), and nearly no pain on the second day after the surgery (mean score, 0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7). Non-steroidal substances were administered orally to alleviate pain on the surgery day.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eA summary of the patients\u0026rsquo; perioperative outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedural outcomes (n\u0026thinsp;=\u0026thinsp;108)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValues/No. of patients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAC only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdditional procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHysteromyomectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOophorocystectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElectrosurgery for endometriosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnterolysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHysteroscope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnostic curettage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFallopian tube prosthetics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian drilling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHydrotubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean OT (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.8\u0026thinsp;\u0026plusmn;\u0026thinsp;22.8 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo additional procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.3\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean EBL (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;23.6 mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo additional procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4 mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerioperative complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (uroschesis)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfusion volume\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1084.3\u0026thinsp;\u0026plusmn;\u0026thinsp;355.8 mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNRS of pain intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative obstetric outcomes\u003c/h2\u003e \u003cp\u003eAt the time of data collection, 98 patients became pregnant after the surgery. Among the 98 patients, 74 conceived spontaneously, and the remaining 24 underwent \u003cem\u003ein vitro\u003c/em\u003e fertilization. The mean interval from LAC to conception was 8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6 month. The postoperative obstetric outcomes are listed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eObstetric outcomes of patients after pre-conceptional laparoscopic cervical cerclage.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetric outcomes (n\u0026thinsp;=\u0026thinsp;98)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValues/No. of patients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpontaneous conception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIVF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime of pregnancy post-operation (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelivery mode\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMersilene tape reservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMersilene tape removal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTermination at \u0026lt;\u0026thinsp;26 weeks (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst-trimester loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecond-trimester loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTermination due to anomaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelivered at \u0026ge;\u0026thinsp;26 weeks (n\u0026thinsp;=\u0026thinsp;95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingletons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreterm delivery (\u0026lt;\u0026thinsp;37 weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-term delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePremature rupture of membranes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian gestational weeks at delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003csup\u003e+\u0026thinsp;3\u003c/sup\u003e weeks\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean neonatal weight (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll newborns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3310.2\u0026thinsp;\u0026plusmn;\u0026thinsp;382.1g\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout twins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3347.2\u0026thinsp;\u0026plusmn;\u0026thinsp;338.9 g\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of low birth weight (\u0026lt;\u0026thinsp;2500 g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRequiring NICU care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeonatal death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere were two cases of second trimester loss and one case of termination due to fetal anomalies. The two second-trimester losses resulted in uncontrolled uterine contractions during mid-trimester. They underwent another laparoscopy to remove the cervical tape, and finally, they underwent vaginal abortion at 20 and 23 gestational weeks separately. One fetus was diagnosed with tetralogy of Fallot at 24 weeks of gestation. The women also chose to remove the cervical tape under laparoscopy, followed by vaginal abortion after fatally induced labor.\u003c/p\u003e \u003cp\u003eThere were 95 live births, of which there were 4 twins and 91 singletons. Ten cases were pre-term deliveries, with two cases of premature rupture of membranes, and 85 cases were full-term deliveries. Of the 95 live births, 94 were delivered by Cesarean section. Sixty-four (64/98) women chose to keep the Mersilene tape for future pregnancy during Cesarean section, and 29 women had the tape removed during surgery. Notably, two women underwent open surgery to remove the Mersilene tape at 37 gestational weeks, and then completed vaginal delivery at 38\u003csup\u003e+\u0026thinsp;5\u003c/sup\u003e and 37\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e gestational weeks.\u003c/p\u003e \u003cp\u003eMean neonatal weight was 3310.2\u0026thinsp;\u0026plusmn;\u0026thinsp;382.1 g, and only two neonates from different twins weighted\u0026thinsp;\u0026lt;\u0026thinsp;2500 g. Four infants who were deliveried less than 34 gestational weeks were sent to neonatal intensive care units, and no neonatal deaths were reported.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAccording to a large prospective register-based study, the incidence of miscarriage was estimated to be 21.1% before 20 weeks of gestation, whereas the incidence of stillbirth was estimated to be 17.5%[21]. Cervical insufficiency is one of the reasons for mid-trimester miscarriages. However, a history of miscarriage or pre-term delivery increases the risk of CI, which, in turn, increases the risk of miscarriage[22]. To break the vicious circle, prevention of CI could be a breakthrough to break this vicious circle. Cervical insufficiency can be congenital or acquired, and the prevention strategy should concentrate on acquired CI.\u003c/p\u003e \u003cp\u003eDamage to the structural integrity due to trauma or surgery may be responsible for CI. Conization increases the risk of mid-trimester fetal loss due to impairment of the intact cervix, specifically when cone heights are more than 2 cm[23\u0026ndash;25]. A history of abortion and specifically induced abortions were also associated with CI[26]. A history of a spontaneous or induced abortion increases the risk for CI by up to 2.71 times at the next pregnancy. Moreover, operative hysteroscopy may be a risk factor for CI development. In a small retrospective study, the incidence of CI was significantly higher (13.7%) in a group that underwent operative hysteroscopy, while it was 3.4% in a control group (13.7% vs. 3.4%)[27]. These procedures destroy the intact cervix or over-dilate the cervix, thereby impairing the mechanical support of cervix during pregnancy. In our study, 24.1% (26/108) of the patients underwent cervical surgery, and more than half of the patients (53.7%, 58/108) underwent uterine surgery. Recurrent dilation and extension of the cervix are non-negligible factors in cervical tissue injury.\u003c/p\u003e \u003cp\u003eSome studies have supported the idea that CI is a subtle form of collagenopathy. From the analysis of next-generation sequencing results in 21 patients, Volozonoka et al. identified several genes (\u003cem\u003eCOL1A1\u003c/em\u003e, \u003cem\u003eCOL3A1\u003c/em\u003e, \u003cem\u003eFBN1\u003c/em\u003e, \u003cem\u003eHIF1A\u003c/em\u003e, \u003cem\u003eLMNA\u003c/em\u003e, and \u003cem\u003eMATR3\u003c/em\u003e) whose products participate in collagen biosynthesis and cell-extracellular matrix communication are also associated with CI[22]. In a comparison of cervical collagen between non-pregnant women with congenital CI and normal parous women, the median cervical hydroxyproline concentration was significantly lower in patients with CI[28]. Notably, pregnancy or parturition could lead to a decrease in cervical hydroxyproline concentration, which is in accordance with the finding that the number of miscarriages or deliveries increases the risk of CI[21]. Changes in cervical collagen concentration also alter the contractility of cervical smooth muscle. Decreased rigidity of the cervical extracellular matrix leads to a compromise in cervical smooth muscle cell contractile tone and a predisposition to sphincter laxity, which contributes to premature cervical failure[29].\u003c/p\u003e \u003cp\u003eCervical cerclage is an option for preventing fetal loss caused by CI. Cervical cerclage is usually performed via the transvaginal route during pregnancy. It is indicated for pregnancy at high risk of pre-term births, mid-trimester fetal losses, or transvaginal ultrasound(TVU) CL of \u0026lt;\u0026thinsp;25 mm before 24 weeks[9, 30]. The suture should be placed as high as possible, close to the internal os, hopefully attaining a cerclage height\u0026thinsp;\u0026gt;\u0026thinsp;2 cm[31]. Thus, the CL should not be short enough to allow sufficient room for suturing. Generally, TVC is regarded as a safe method, but there is still a risk of perioperative complications, such as hemorrhage, cervical lacerations, lesions or trauma of the cervix, pyrexia, severe maternal infections (amnionitis or chorioamnionitis), or direct pre-term premature rupture of membranes[32\u0026ndash;35]. Combining data from 44 studies, Van Dijk et al. reported that most perioperative complications of TVC were hemorrhage (0.9\u0026ndash;2.3%) and pre-term premature rupture of membranes (0.0\u0026ndash;2.5%)[35]. Notably, the incidence of complications varied between prophylactic and emergency TVC. Complications were lowest in a prophylactic TVC group, which was performed in the first trimester for women who have had\u0026thinsp;\u0026ge;\u0026thinsp;3 pre-term deliveries and/or mid-trimester losses.\u003c/p\u003e \u003cp\u003eTransabdominal cerclage is another option, especially for women in whom cerclage has failed (delivery before 28 weeks after a history- or ultrasound-indicated [but not rescue] cerclage)[36]. Transabdominal cerclage can be performed during laparotomy or laparoscopy, either pre-conceptually or after conception[37]. Laparoscopy has been proven to be safe for both mother and fetus, with no increase in adverse obstetric outcomes[38]. Owing to the inherent advantages of laparoscopy over laparotomy, LAC is more recommended[37]. Several retrospective studies reported that pre-gestational LAC was more effective in reducing spontaneous pre-term birth at ˂34 weeks than mid-term TVC[39, 40]. In a multicenter randomized controlled trial aimed at women with previous failed cerclage, a LAC group had significantly fewer fetal losses than a TVC group (3% [1/39] vs. 21% [7/33])[41].\u003c/p\u003e \u003cp\u003eAnother advantage of preconceptual LAC, which could be underestimated, is the reduced anxiety caused by surgery. Anxiety and stress are common during pregnancy. However, obstetric complications and unplanned surgeries can significantly increase maternal state anxiety[42, 43]. Maternal state anxiety is associated with adverse pregnancy outcomes, such as miscarriage, pre-eclampsia, pre-term delivery, and low birth weight, with particularly strong evidence for an increased risk of pre-term birth and low birth weight[44, 45]. Thus, prophylactic pre-conceptual LAC instead of TVC during pregnancy could be a more appropriate candidate for relieving maternal state anxiety in women with CIs.\u003c/p\u003e \u003cp\u003eIn terms of prophylactic pre-conceptual LAC, conventional LAC involves opening the vesicular space and separating the anterior broad ligament leaves. These procedures help identify the uterine artery and prevent injury. However, these would also prolong surgery time, extend the surgical area, and increase tissue injury, leading to postoperative pelvic and abdominal adhesion[46]. Serious postoperative adhesions may cause small bowel obstruction and increase the risk of hemorrhage, perforation, reduced surgical exposure, and prolonged OT in repeat surgeries[47]. In our surgical procedure, these two steps were omitted, and no perioperative complications were reported. The main concern with our simplified LAC was injury to the bladder and uterine vessels. From our eight years of experience, the key point of the procedure was to recognize the uterovesicle peritoneal reflection, which could be an anatomical marker for identifying the uterine isthmus. The second key point was to keep the needle vertically penetrating the parametrial tissue in close proximity to the isthmus, which could evade the uterine vessels. From a report about the conventional LAC, mean operation time (OT) for single LAC was 51\u0026thinsp;\u0026plusmn;\u0026thinsp;27 min, and mean EBL was 18\u0026thinsp;\u0026plusmn;\u0026thinsp;12 mL[14]. While for our simplified LAC, the mean OT was 43.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4 min, and mean EBL was 14.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9 mL. There was another report about the experience of simplified LAC, mean OT ( 26\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 min), and mean EBL (11.9 mL)[18]. These data support the idea that simplified LAC is safe, with less operation time and blood loss.\u003c/p\u003e \u003cp\u003eAnother advantage of our simplified LAC is that we avoided the use of a conventional uterine manipulator to position the uterus. Complications of uterine manipulation include uterine perforation, cervical laceration, and cervical bleeding[48, 49]. Additionally, the use of a vaginal cup overdraws the cervical tissue. As discussed previously, cervical injury and dilation increase the risk of CI. Thus, we chose to use a uterine probe together with a cervical tenaculum rather than a uterine manipulator or vaginal cup to minimize cervical injury. The uterine probe is much smaller than the rod of the uterine manipulator, and there are no concerns regarding the longitudinal tension of the cervix caused by lifting the vaginal cup. We also performed LAC in pregnant women (data not shown), and no probe or cervical tenaculum was used. We had another Forceps inserted through an additional 5 mm port in the left lower abdomen to manipulate the uterus. During the procedure, the tape was tied either anteriorly or posteriorly to the isthmus. In our patient, the knots were tied anteriorly to the isthmic surface. For patients undergoing vaginal delivery, the knots can be easily removed with a 5 cm long open cut superior to the pubis symphysis under local anesthesia. Each patient was informed that they still had a chance to undergo vaginal delivery once the tape had been removed before surgery. However, two patients chose to undergo vaginal delivery after tape removal at 37 gestational weeks. One baby was delivered at 38\u003csup\u003e+\u0026thinsp;5\u003c/sup\u003e gestational weeks, with a total labor duration of 8 h and 40 min. The other one was delivered at 37\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e gestational weeks with a total labor duration of 6 h and 20 min. The remaining patients underwent cesarean delivery; 64 of them chose to keep the tape for future pregnancy, and the others chose to remove the tape.\u003c/p\u003e \u003cp\u003eIn conclusion, we reported a series of patients who were diagnosed with CI and underwent pre-conceptual LAC. We demonstrated that preconceptual LAC is an effective option for preventing mid-terminal fetal loss in women with CI. Notably, the simplified LAC is a simple, safe, and effective method that is worthy of promotion. Finally, vaginal delivery after LAC is still possible once the tape is removed before labor. However, the limitations of this report mainly came from two aspects: one was the small cohort of patients, and the second was the experience drawn from a single center, which could be the cause for the deviation in the final conclusions. We hope that more centers will opt for a simplified pre-conceptual LAC to help more women with CI.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCervical insufficiency\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLAC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLaparoscopic abdominal cerclage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCervical length\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTVC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTransvaginal cervical cerclage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAbdominal cerclage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMTL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMid-trimester pregnancy losses\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOperative time\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEBL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEstimated blood loss\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eADL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eActivities of daily living\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTVU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTransvaginal ultrasound\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIVF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ein vitro fertilization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eneonatal intensive care units.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the ethics committee and the data inspectorate of West China Second University Hospital of Sichuan University. All experimental protocols were approved by the ethics committee and the data inspectorate of West China Second University Hospital of Sichuan University. Informed consent was obtained from all subjects and/or their legal guardian(s). All methods were carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no confict of all financial and non-financial competing interests in publishing the present manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLedi Kuang: data collection, follow-up, paper writing. Guolin Luo: medical care provision. Xin Tan: medical care provision. Hong Liao: principal medical care provision, follow-up, paper writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThakur M, Mahajan K. Cervical Insufficiency. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024.\u003c/li\u003e\n\u003cli\u003eWang HL, Yang Z, Shen Y, Wang QL. [Clinical outcome of therapeutic cervical cerclage in short cervix syndrome]. Zhonghua Fu Chan Ke Za Zhi. 2018;53:43\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eVolozonoka L, Rots D, Kempa I, Kornete A, Rezeberga D, Gailite L, et al. Genetic landscape of preterm birth due to cervical insufficiency: Comprehensive gene analysis and patient next-generation sequencing data interpretation. PloS One. 2020;15:e0230771.\u003c/li\u003e\n\u003cli\u003eBrown R, Gagnon R, Delisle M-F, Gagnon R, Bujold E, Basso M, et al. Cervical Insufficiency and Cervical Cerclage. J Obstet Gynaecol Can. 2013;35:1115\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003eRoman A, Suhag A, Berghella V. Overview of Cervical Insufficiency: Diagnosis, Etiologies, and Risk Factors. Clin Obstet Gynecol. 2016;59:237\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency. Obstet Gynecol. 2014;123 2 Pt 1.\u003c/li\u003e\n\u003cli\u003eAnthony GS, Calder AA, Macnaughton MC. Cervical resistance in patients with previous spontaneous mid-trimester abortion. BJOG Int J Obstet Gynaecol. 1982;89:1046\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eKiwi R, Neuman MR, Merkatz IR, Selim MA, Lysikiewicz A. Determination of the elastic properties of the cervix. Obstet Gynecol. 1988;71:568\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003e中国妇幼保健协会宫内疾病防治专委会. 子宫颈机能不全临床诊治中国专家共识(2023年版). 中国实用妇科与产科杂志. 2023;39:175.\u003c/li\u003e\n\u003cli\u003eVn S. A new method of operative treatment for habitual abortions in the second trimester of pregnancy. Antiseptic. 1955;52:299\u0026ndash;300.\u003c/li\u003e\n\u003cli\u003eMcdonald IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Emp. 1957;64:346\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eEleje GU, Eke AC, Ikechebelu JI, Ezebialu IU, Okam PC, Ilika CP. Cervical stitch (cerclage) in combination with other treatments for preventing spontaneous preterm birth in singleton pregnancies. Cochrane Database Syst Rev. 2020;9:CD012871.\u003c/li\u003e\n\u003cli\u003eHarger JH. Cerclage and cervical insufficiency: an evidence-based analysis. Obstet Gynecol. 2002;100:1313\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003eClark NV, Einarsson JI. Laparoscopic abdominal cerclage: a highly effective option for refractory cervical insufficiency. Fertil Steril. 2020;113:717\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eBolla D, Raio L, Imboden S, Mueller MD. Laparoscopic Cerclage as a Treatment Option for Cervical Insufficiency. Geburtshilfe Frauenheilkd. 2015;75:833\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eSaridogan E, O\u0026rsquo;Donovan OP, David AL. Preconception laparoscopic transabdominal cervical cerclage for the prevention of midtrimester pregnancy loss and preterm birth: a single centre experience. Facts Views Vis ObGyn. 2019;11:43\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eHuang G, Deng C, Liao H, Hu Q, Yu H, Wang X. Comparison of transvaginal cervical cerclage versus laparoscopic abdominal cervical cerclage in cervical insufficiency: a retrospective study from a single centre. BMC Pregnancy Childbirth. 2022;22:773.\u003c/li\u003e\n\u003cli\u003eHuang X, Ma N, Li T-C, Guo Y, Song D, Zhao Y, 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;201:146\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eClavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187\u0026ndash;96.\u003c/li\u003e\n\u003cli\u003eMahoney FI, Barthel DW. FUNCTIONAL EVALUATION: THE BARTHEL INDEX. Md State Med J. 1965;14:61\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eWilcox AJ, Morken N-H, Weinberg CR, H\u0026aring;berg SE, Magnus MC. Role of maternal age and pregnancy history in risk of miscarriage: prospective register based study. The BMJ. 2019;364:l869.\u003c/li\u003e\n\u003cli\u003eMeng L, \u0026Ouml;berg S, Sandstr\u0026ouml;m A, Wang C, Reilly M. Identification of risk factors for incident cervical insufficiency in nulliparous and parous women: a population-based case-control study. BMC Med. 2022;20:348.\u003c/li\u003e\n\u003cli\u003ePina A, Lavall\u0026eacute;e S, Ndiaye C, Mayrand M-H. Reproductive Impact of Cervical Conization. Curr Obstet Gynecol Rep. 2013;2:94\u0026ndash;101.\u003c/li\u003e\n\u003cli\u003eEl-Bastawissi AY, Becker TM, Daling JR. Effect of cervical carcinoma in situ and its management on pregnancy outcome. Obstet Gynecol. 1999;93:207\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eAlbrechtsen S, Rasmussen S, Thoresen S, Irgens LM, Iversen OE. Pregnancy outcome in women before and after cervical conisation: population based cohort study. BMJ. 2008;337:a1343.\u003c/li\u003e\n\u003cli\u003eBrittain JJ, Wahl SE, Strauss JF, Romero R, Wolf HM, Murphy K, et al. Prior Spontaneous or Induced Abortion Is a Risk Factor for Cervical Dysfunction in Pregnant Women: a Systematic Review and Meta-analysis. Reprod Sci. 2023;30:2025\u0026ndash;39.\u003c/li\u003e\n\u003cli\u003eG\u0026ouml;k\u0026ccedil;e A, Ş\u0026uuml;k\u0026uuml;r YE, \u0026Ouml;zmen B, S\u0026ouml;nmezer M, Berker B, Ayta\u0026ccedil; R, et al. The association between operative hysteroscopy prior to assisted reproductive technology and cervical insufficiency in second trimester. Arch Gynecol Obstet. 2021;303:1347\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003ePetersen LK, Uldbjerg N. Cervical collagen in non-pregnant women with previous cervical incompetence. Eur J Obstet Gynecol Reprod Biol. 1996;67:41\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eVink J, Yu V, Dahal S, Lohner J, Stern-Asher C, Mourad M, et al. Extracellular Matrix Rigidity Modulates Human Cervical Smooth Muscle Contractility-New Insights into Premature Cervical Failure and Spontaneous Preterm Birth. Reprod Sci Thousand Oaks Calif. 2021;28:237\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eBrown R, Gagnon R, Delisle M-F. No. 373-Cervical Insufficiency and Cervical Cerclage. J Obstet Gynaecol Can. 2019;41:233\u0026ndash;47.\u003c/li\u003e\n\u003cli\u003eBerghella V, Ludmir J, Simonazzi G, Owen J. Transvaginal cervical cerclage: evidence for perioperative management strategies. Am J Obstet Gynecol. 2013;209:181\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003eKuruma A, Hayashi S, Koh I, Yamamoto R, Mitsuda N, Ishii K. Incidences of complications associated with cervical cerclage by indication of the procedure. J Obstet Gynaecol Res. 2022;48:73\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSchneider K, Fimmers R, J\u0026ouml;rgens M, Peter S, Pelzer V, Redlich T. Emergency cerclage following a standardized protocol offers an effective and safe therapeutic option for women with high risk for prematurity - a retrospective monocentric cohort study on 130 pregnancies and 155 neonates. J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet. 2021;34:4053\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eDrassinower D, Coviello E, Landy HJ, Gyamfi-Bannerman C, Perez-Delboy A, Friedman AM. Outcomes after periviable ultrasound-indicated cerclage. J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet. 2019;32:932\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eDijk CE van, Breuking SH, Jansen S, Limpens JCEJM, Kazemier BM, Pajkrt E. Perioperative complications of a transvaginal cervical cerclage in singleton pregnancies: a systematic review and meta-analysis. Am J Obstet Gynecol. 2023;228:521\u0026ndash;534.e19.\u003c/li\u003e\n\u003cli\u003eShennan A, Story L, Jacobsson B, Grobman WA, Birth the FWG for P. FIGO good practice recommendations on cervical cerclage for prevention of preterm birth. Int J Gynecol Obstet. 2021;155:19\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eTulandi T, Alghanaim N, Hakeem G, Tan X. Pre and post-conceptional abdominal cerclage by laparoscopy or laparotomy. J Minim Invasive Gynecol. 2014;21:987\u0026ndash;93.\u003c/li\u003e\n\u003cli\u003eBall E, Waters N, Cooper N, Talati C, Mallick R, Rabas S, et al. Evidence-Based Guideline on Laparoscopy in Pregnancy. Facts Views Vis ObGyn. 11:5\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003eHuang G, Deng C, Liao H, Hu Q, Yu H, Wang X. Comparison of transvaginal cervical cerclage versus laparoscopic abdominal cervical cerclage in cervical insufficiency: a retrospective study from a single centre. BMC Pregnancy Childbirth. 2022;22:773.\u003c/li\u003e\n\u003cli\u003eQin F, Yang Y, Zhou W, Chi Y, Liu B, Chen G. Effect of different surgical routes on pregnancy outcome of history-indicated cervical cerclage. Arch Gynecol Obstet. 2024;309:1377\u0026ndash;86.\u003c/li\u003e\n\u003cli\u003eShennan A, Chandiramani M, Bennett P, David AL, Girling J, Ridout A, et al. MAVRIC: a multicenter randomized controlled trial of transabdominal vs transvaginal cervical cerclage. Am J Obstet Gynecol. 2020;222:261.e1-261.e9.\u003c/li\u003e\n\u003cli\u003eFischbein RL, Nicholas L, Kingsbury DM, Falletta LM, Baughman KR, VanGeest J. State anxiety in pregnancies affected by obstetric complications: A systematic review. J Affect Disord. 2019;257:214\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eAraji S, Griffin A, Dixon L, Spencer S-K, Peavie C, Wallace K. An Overview of Maternal Anxiety During Pregnancy and the Post-Partum Period. J Ment Health Clin Psychol. 2020;4.\u003c/li\u003e\n\u003cli\u003eMcCarthy M, Houghton C, Matvienko-Sikar K. Women\u0026rsquo;s experiences and perceptions of anxiety and stress during the perinatal period: a systematic review and qualitative evidence synthesis. BMC Pregnancy Childbirth. 2021;21:811.\u003c/li\u003e\n\u003cli\u003eBergeron J, Avraam D, Calas L, Fraser W, Harris JR, Heude B, et al. Stress and anxiety during pregnancy and length of gestation: a federated study using data from five Canadian and European birth cohorts. Eur J Epidemiol. 2024. https://doi.org/10.1007/s10654-024-01126-4.\u003c/li\u003e\n\u003cli\u003eMoris D, Chakedis J, Rahnemai-Azar AA, Wilson A, Hennessy MM, Athanasiou A, et al. Postoperative Abdominal Adhesions: Clinical Significance and Advances in Prevention and Management. J Gastrointest Surg Off J Soc Surg Aliment Tract. 2017;21:1713\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eFatehi Hassanabad A, Zarzycki AN, Jeon K, Deniset JF, Fedak PWM. Post-Operative Adhesions: A Comprehensive Review of Mechanisms. Biomedicines. 2021;9:867.\u003c/li\u003e\n\u003cli\u003eSung P-L, Chao K-C, Twu N-F, Wang P-H, Yu BK-J, Yen M-S, et al. Postconization cervical perforation during laparoscopic surgery. Taiwan J Obstet Gynecol. 2007;46:71\u0026ndash;2.\u003c/li\u003e\n\u003cli\u003eBeyan E, Kanmaz AG, Budak A, Emirdar V, Tutar SO, Inan AH. Uterine manipulator requirement in laparoscopic surgery of Ectopic Pregnancy. Pak J Med Sci. 2020;36:105\u0026ndash;10.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pre-conceptiona, Cervical insufficiency, Cervical cerclage, Laparoscopy","lastPublishedDoi":"10.21203/rs.3.rs-5124095/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5124095/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Cervical insufficiency (CI) is a pathological condition in obstetrics in which the cervix fails to retain the fetus before uterine contractions or labor (painless cervical dilatation). Patients usually have fetal loss in the mid-trimester or spontaneous pre-term birth due to painless cervical dilation. For non-pregnant women with CI, prophylactic laparoscopic abdominal cerclage (LAC) has been reported to improve pregnancy outcomes, such as live birth, neonatal survival, and full-term delivery rate. Conventional LAC involves opening the vesicular space and separating the anterior broad ligament leaves. In our surgical procedure, these two steps were omitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e An observational study was conducted retrospectively on patients who underwent a simplified pre-conceptional LAC between January 2015 and December 2022 at the West China Second Hospital of West China Second University Hospital, Sichuan University. Follow-ups for all the patients ended at the delivery of the fetus. Subsequently, clinical characteristics, perioperative data, and obstetric outcomes were recorded and analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e In total, 108 patients were included in a pre-conception LAC group.\u003c/p\u003e\n\u003cp\u003eMean operation time was 56.8 ± 22.8 min, and mean estimated blood loss was 21.4 ± 23.6 mL. Only one case of uroschesis was classified as a grade I postoperative complication, according to the Clavien–Dindo classification. No severe complications or sequelae were observed during the perioperative period. Obstetric outcomes from 98 patients were collected: three patients had miscarriages, and 95 had live births. Of the 95 live births, 4 were twins and 91 were singletons. Two patients had vaginal delivery, and 93 underwent Cesarean section; mean neonatal weight was 3310.2 ± 382.1 g.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eA simplified pre-conceptional LAC is a simple, safe, and effective method for women with CI. Thus, it is worthy of promotion to assist women with CI in achieving improved obstetric outcomes. Vaginal delivery after LAC is possible once the tape is removed before labor.\u003c/p\u003e","manuscriptTitle":"Efficacy of a simplified pre-conceptional laparoscopic cervical cerclage for cervical insufficiency: a retrospective study from a single center Running head: a simplified pre-conceptional laparoscopic cervical cerclage for women’s cervical insufficiency","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-19 13:04:39","doi":"10.21203/rs.3.rs-5124095/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-09T16:15:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-08T14:45:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-31T07:46:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56001593225739769673778153014164256874","date":"2024-10-20T07:39:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2024-10-19T15:29:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-03T06:09:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-09-24T17:38:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-23T06:56:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-23T06:56:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-09-20T13:41:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e374a22c-228a-47a4-9667-b0dca32f3f73","owner":[],"postedDate":"November 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T17:23:36+00:00","versionOfRecord":{"articleIdentity":"rs-5124095","link":"https://doi.org/10.1186/s12884-024-07006-9","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2024-11-30 15:58:07","publishedOnDateReadable":"November 30th, 2024"},"versionCreatedAt":"2024-11-19 13:04:39","video":"","vorDoi":"10.1186/s12884-024-07006-9","vorDoiUrl":"https://doi.org/10.1186/s12884-024-07006-9","workflowStages":[]},"version":"v1","identity":"rs-5124095","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5124095","identity":"rs-5124095","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}