Ukrainian Journal of Perinatology and Pediatrics. 2024. 3(99): 38-45. doi: 10.15574/PP.2024.3(99).3845
Bila V. V., Chernega V. O.
Kyiv City Perinatal Centre, Ukraine

For citation: Bila VV, Chernega VO. (2024). Type of suture material for cervical cerclage: the lost puzzle piece of isthmic-cervical insufficiency treatment. Ukrainian Journal of Perinatology and Pediatrics. 3(99): 38-45. doi: 10.15574/PP.2024.3(99).3845.
Article received: Jun 18, 2024. Accepted for publication: Sep 04, 2024.

Every year, preterm birth (PTB) causes more than million deaths worldwide. Cervical insufficiency (CI) is a significant risk factor for PTB. Progesterone and cervical cerclage (CC) are used to manage such patients. In this study, the authors analyzed the effect of the type of suture material used for cerclage on the inflammatory status of the birth canal and pregnancy outcomes.
The aim of our study is to evaluate the effect of using braided and monofilament sutures on the results of microscopic and microbiological examination and the level of IL-6 and IL-8 in cervical-vaginal fluid (CVF).
Materials and methods. During 2021-2024, a prospective cohort study was conducted, which analyzed 51 patients with singleton pregnancy who underwent CC. The braided suture (BS) group included 27 patients, and the monofilament suture (MS) group included 24 patients. Participants were examined twice during the study: 3 weeks after suturing and at suture removal time.
Results. The microscopy results (12 vs. 4 patients) and bacteriological examination (15 vs. 6 patients) in the BS group were significantly worse. IL-6 level in the BS group was significantly higher at the time of suture removal than at the beginning (59.67±29.95 vs. 76.6±22.29). The increase of IL-6 levels in the BS group was 2.1, and in the MS group – 1.49. The type of suture material can affect the delivery timing (34.2±2.7 weeks in BS group versus 32.9±3.1 in MS group).
Conclusions. The data indicate that CC using BS is associated with vaginal dysbiosis – increase in the frequency of 3-4 grade smear and abnormal levels of opportunistic microflora, CVF IL-6 levels, and with an increased incidence of PTB.
The research was carried out in accordance with Helsinki Declaration principles. The study protocol was approved by participating institution’s Local Ethics Committee. The informed consent of the patients was obtained for conducting the studies.
Authors declare no conflict of interest.
Keywords: cervical insufficiency, cervical suture, braided suture, monofilament suture, cytokines, interleukin, microscopy, microbiome, inflammation, pathogenic microflora.

REFERENCES

1. Aagaard K, Ma J, Antony KM, Ganu R, Petrosino J, Versalovic J. (2014). The placenta harbors a unique microbiome. Sci. Transl. Med. 6: 237ra65. https://doi.org/10.1126/scitranslmed.3008599; PMCid:PMC4929217

2. Abbott D, To M, Shennan A. (2012). Cervical cerclage: A review of current evidence. Aust. N. Z. J. Obstet. Gynaecol. 52: 220-223. https://doi.org/10.1111/j.1479-828X.2012.01412.x; PMid:22335473

3. Alfirevic Z, Stampalija T, Roberts D, Jorgensen AL. (2012). Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Cochrane Database Syst. Rev. 4: CD008991. https://doi.org/10.1002/14651858.CD008991.pub2

4. American College of Obstetricians and Gynecologists. (2014). Cerclage for the management of cervical insufficiency. Practice Bulletin No. 142. Obstet. Gynecol. 123: 372-379. https://doi.org/10.1097/01.AOG.0000443276.68274.cc; PMid:24451674

5. Berghella V, Rafael TJ, Szychowski JM, Rust OA, Owen J. (2011). Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth: A meta-analysis. Obstet. Gynecol. 117: 663-671. https://doi.org/10.1097/AOG.0b013e31820ca847; PMid:21446209

6. Berghella V, Szychowski JM, Owen J, Hankins G, Iams JD, Sheffield JS et al. (2012). Suture type and ultrasound- indicated cerclage efficacy. J. Matern. Fetal Neonatal Med. 25: 2287-2290. https://doi.org/10.3109/14767058.2012.688081; PMid:22545593 PMCid:PMC5809126

7. Dunn DL, Phillips J. (2007). Wound closure manual. Ethicon, Somerville, New Jersey.

8. Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH, Fetal Medicine Foundation Second Trimester Screening Group. (2007). Progesterone and the risk of preterm birth among women with a short cervix. N. Engl. J. Med. 357: 462-469. https://doi.org/10.1056/NEJMoa067815; PMid:17671254

9. Gajer P, Brotman RM, Bai G, Sakamoto J, Schütte UME, Zhong X et al. (2012).Temporal dynamics of the human vaginal microbiota. Sci. Transl. Med. 4: 132ra52. https://doi.org/10.1126/scitranslmed.3003605; PMid:22553250 PMCid:PMC3722878

10. Goldenberg RL, Culhane JF, Iams JD, Romero R. (2008). Epidemiology and causes of preterm birth. Lancet. 371: 75-84. https://doi.org/10.1016/S0140-6736(08)60074-4; PMid:18177778

11. Hein M, Valore EV, Helmig RB, Uldbjerg N, Ganz T. (2002). Antimicrobial factors in the cervical mucus plug. Am. J. Obstet. Gynecol. 187: 137-144. https://doi.org/10.1067/mob.2002.123034; PMid:12114901

12. Henry-Stanley MJ, Hess DJ, Barnes AMT, Dunny GM, Wells CL. (2010). Bacterial contamination of surgical suture resembles a biofilm. Surg. Infect. 11: 433-439. https://doi.org/10.1089/sur.2010.006; PMid:20673144 PMCid:PMC2967823

13. Iams JD. (2014). Clinical practice. Prevention of preterm parturition. N. Engl. J. Med. 370: 254-261. https://doi.org/10.1080/01443615.2018.1463206; PMid:29884103

14. Israfil-Bayli F, Toozs-Hobson P, Lees C, Slack M, Daniels J et al. (2014). Cervical cerclage and type of suture material: A survey of UK consultants' practice. J. Matern. Fetal Neonatal Med. 27: 1584-1588. https://doi.org/10.3109/14767058.2013.870551; PMid:24283438

15. Israfil-Bayli F, Toozs-Hobson P, Lees C, Slack M, Ismail KMK. (2013). Pregnancy outcome after elective cervical cerclage in relation to type of suture material used. Med. Hypotheses. 81: 119-121. https://doi.org/10.1016/j.mehy.2013.04.003; PMid:23628105

16. Katz S, Izhar M, Mirelman D. (1981). Bacterial adherence to surgical sutures. A possible factor in suture induced infection. Ann. Surg. 194: 35-41. https://doi.org/10.1097/00000658-198107000-00007; PMid:7018429 PMCid:PMC1345192

17. Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE et al. (2015). Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: An updated systematic analysis. Lancet. 385: 430-440. https://doi.org/10.1016/S0140-6736(14)61698-6; PMid:25280870

18. MacIntyre DA, Chandiramani M, Lee YS, Kindinger L, Smith A, Angelopoulos N et al. (2015). The vaginal microbiome during pregnancy and the postpartum period in a European popu- lation. Sci. Rep. 5: 8988. https://doi.org/10.1038/srep08988; PMid:25758319 PMCid:PMC4355684

19. Mehta P, Patel P, Olver JM. (2004). Functional results and complications of Mersilene mesh use for frontalis suspension ptosis surgery. Br. J. Ophthalmol. 88: 361-364. https://doi.org/10.1136/bjo.2002.009951; PMid:14977770 PMCid:PMC1772030

20. Nam KH, Kwon JY, Kim Y-H, Park Y-W. (2010). Pregnancy outcome after cervical conization: Risk factors for preterm delivery and the efficacy of prophylactic cerclage. J. Gynecol. Oncol. 21: 225-229. https://doi.org/10.3802/jgo.2010.21.4.225; PMid:21278883 PMCid:PMC3026300

21. Odibo O, Berghella V, To MS, Rust OA, Althuisius SM, Nicolaides KH. (2007). Shirodkar versus McDonald cerclage for the prevention of preterm birth in women with short cervical length. Am. J. Perinatol. 24: 55-60. https://doi.org/10.1055/s-2006-958165; PMid:17195146

22. Quinn M. (1993). Final report of the MRC/RCOG randomised controlled trial of cervical cerclage. Br. J. Obstet. Gynaecol. 100: 1154-1155. https://doi.org/10.1111/j.1471-0528.1993.tb15198.x; PMid:8297859

23. Rafael TJ, Berghella V, Alfirevic Z. (2014). Cervical stitch (cerclage) for preventing preterm birth in multiple pregnancy. Cochrane Database Syst. Rev. 9: CD009166. https://doi.org/10.1002/14651858.CD009166.pub2; PMid:25208049 PMCid:PMC10629495

24. Rafaeli-Yehudai T, Kessous R, Aricha-Tamir B, Sheiner E, Erez O, Meirovitz M et al. (2014). The effect of cervical cerclage on pregnancy outcomes in women following conization. J. Matern. Fetal Neonatal Med. 27: 1594-1597. https://doi.org/10.3109/14767058.2013.871254; PMid:24289749

25. Romero R, Hassan SS, Gajer P, Tarca AL, Fadrosh DW, Nikita L et al. (2014). The composition and stability of the vaginal microbiota of normal pregnant women is different from that of non-pregnant women. Microbiome. 2: 4. https://doi.org/10.1186/2049-2618-2-10; PMid:24735933 PMCid:PMC4022389

26. Shennan H, To MS. (2011). Cervical cerclage. Green-top Guideline No. 60. RCOG. 1-21.

27. Shin M-Y, Seo E-S, Choi S-J, Oh S-Y, Kim B-G, Bae D-S et al. (2010). The role of prophylactic cerclage in preventing preterm delivery after electrosurgical conization. J. Gynecol. Oncol. 21: 230-236. https://doi.org/10.3802/jgo.2010.21.4.230; PMid:21278884 PMCid:PMC3026301

28. Slack M, Sandhu JS, Staskin DR, Grant RC. (2006). In vivo comparison of suburethral sling materials. Int. Urogynecol. J. Pelvic Floor Dysfunct. 17: 106-110. https://doi.org/10.1007/s00192-005-1320-7; PMid:15995792

29. Yatsunenko T, Rey FE, Manary MJ, Trehan I, Dominguez-Bello MG, Contreras M et al. (2012). Human gut microbiome viewed across age and geography. Nature. 486: 222-227. https://doi.org/10.1038/nature11053; PMid:22699611 PMCid:PMC3376388