Relationship between vaginal microbial dysbiosis, inflammation, and pregnancy outcomes in cervical cerclage

Abstract

Preterm birth, the leading cause of death in children under 5 years, may be caused by inflammation triggered by ascending vaginal infection. About 2 million cervical cerclages are performed annually to prevent preterm birth. The procedure is thought to provide structural support and maintain the endocervical mucus plug as a barrier to ascending infection. Two types of suture material are used for cerclage: monofilament or multifilament braided. Braided sutures are most frequently used, although no evidence exists to favor them over monofilament sutures. We assessed birth outcomes in a retrospective cohort of 678 women receiving cervical cerclage in five UK university hospitals and showed that braided cerclage was associated with increased intrauterine death (15% versus 5%; P = 0.0001) and preterm birth (28% versus 17%; P = 0.0006) compared to monofilament suture. To understand the potential underlying mechanism, we performed a prospective, longitudinal study of the vaginal microbiome in women at risk of preterm birth because of short cervical length (≤25 mm) who received braided (n = 25) or monofilament (n = 24) cerclage under comparable circumstances. Braided suture induced a persistent shift toward vaginal microbiome dysbiosis characterized by reduced Lactobacillus spp. and enrichment of pathobionts. Vaginal dysbiosis was associated with inflammatory cytokine and interstitial collagenase excretion into cervicovaginal fluid and premature cervical remodeling. Monofilament suture had comparatively minimal impact upon the vaginal microbiome and its interactions with the host. These data provide in vivo evidence that a dynamic shift of the human vaginal microbiome toward dysbiosis correlates with preterm birth.

The vaginal microbiota, human papillomavirus infection and cervical intraepithelial neoplasia: what do we know and where are we going next?

“…In their study, vaginal samples collected from 396 ethnically diverse reproductive age women were analysed using Roche 454 FLX-based sequencing of bacterial 16S rRNA genes. In total, 282 taxa were identified and, using hierarchical taxonomic clustering, the vaginal microbial profile of each woman could be classified into a total of five ‘community state types’ (CSTs), which have subsequently been used by numerous other studies [16, 19, 20]. CSTs I, II, III and V are characterised by dominance of Lactobacillus crispatus , L. gasseri , L. iners and L. jensenii respectively and tend to have low species diversity and evenness.…”

Preterm Birth Prevention Post-Conization: A Model of Cervical Length Screening with Targeted Cerclage

“…Evidence thus far indicates that this may not be the case and therefore the risk of preterm labour could plausibly be unaffected or even worsened by cervical cerclage[17–20, 32]. As these reports were exclusively in cohorts in which braided suture was used for cerclage, we hypothesized the reported lack of cerclage efficacy in pregnancy post-conization, relates to the effects of ‘foreign’ material (cerclage) on the vaginal microenvironment[23–25] and the immune system[33]. Braided suture is the current material of choice for the cervical cerclage despite a lack of evidence to support its preferential use [17, 21, 22].…”

“…The multifilament structure of braided suture favours bacterial colonisation over monofilament suture [23–25], and is associated with poorer wound healing [26–28]. This may explain the doubled risk of puerperal pyrexia associated with cerclage insertion [29], and the lack of any observed benefit of a cerclage for preterm birth prevention post-conization [17–20].…”

Lactoginal for correction of abnormal vaginal microbiocenosis in pregnant woman with cervical cerclage: clinical case and literature review

“…Для выполнения цервикального cеркляжа могут быть использованы как моноволоконные, так и мультиволоконные плетеные шовные мате-риалы, при этом мультиволоконные плетеные материалы используются примерно в 80 % слу-чаев [13]. Недавно L.M.…”

“…Недавно L.M. Kindinger et al (2016) исследовали связь между применением опре-деленного вида шовного материала и исходом беременности путем ретроспективного анализа 678 случаев применения цервикального серкля-жа у беременных женщин в 5 университетских клиниках в Великобритании [13]. Результаты показали, что цервикальный серкляж, выпол-ненный с использованием мультиволоконного плетеного шовного материала, был ассоции-рован с повышенным риском внутриутроб-ной смерти плода (в три раза) и повышенным риском преждевременных родов (в два раза) по сравнению с серкляжем, выполненным с использованием моноволоконного шовного материала.…”