Risk of intrapartum cervical lacerations in women with cerclage

Objective: The aim of our study was to estimate whether the placement of cerclage in pregnancy to prevent preterm birth (PTB) is associated with higher incidence of intrapartum cervical lacerations. Methods: A retrospective cohort study was conducted on singleton pregnancies with risk factors for PTB. The study group consisted of women with either a history- or ultrasound-indicated cerclage placed between 12 and 24 weeks of gestation, while the control group consisted of women with similar risk factors for PTB but who did not receive a cerclage. Primary outcome was the incidence of intrapartum cervical lacerations. A sample size calculation was performed on the basis of the results of previous studies on cervical lacerations. Results: We identified 134 women who had a cerclage placed in pregnancy. They were compared with 236 controls with no cerclage. Cases and controls had similar risk factors for cervical lacerations. Cervical lacerations occurred with similar frequencies in the cerclage and no-cerclage group (2.2 vs 1.3%, p = 0.78). There was no significant difference between the two groups for the risk of cervical lacerations (RR 1.76, 95% CI: 0.36–8.60). Conclusions: Cerclage placement during pregnancy is not associated with an increased risk of intrapartum cervical lacerations.     

Arabin cerclage pessary in the management of cervical insufficiency

Objective: To evaluate the use of Arabin cerclage pessary in the management of cervical insufficiency. Methods: The pregnancy outcome of 20 women carrying singleton pregnancy referred for suspected cervical insufficiency and chose Arabin cerclage pessary for treatment from 2009–2011 were reviewed. Pregnancy outcome were analysed according to presence of risk factors, amniotic fluid sludge, cervical length and gestation at pessary insertion. Results: At presentation, mean cervical length was 1.17?cm (range 0–2.33?cm), mean gestation at pessary insertion and delivery was 20.6 (12.9–26.1) weeks and 32.1 (14.7–40.1) weeks, respectively, and mean prolongation of pregnancy was 11.5 (0.5–25.2) weeks. Overall, 5 (25%) had fetal loss between 14.7–23.1 weeks, while 3 (15%) and 12 (60%) delivered before and after 34 weeks gestation, respectively with no perinatal mortality. Compared with women with cervical length <1.5?cm, all those with cervical length ≥1.5?cm had pregnancy prolonged for ≥49 days (100 vs. 54% p = 0.032) and 86% delivered beyond 34 weeks (86 vs. 46% p = 0.085). Conclusions: Arabin cerclage pessary appears to be optimal for treating women at high risk of cervical insufficiency with a cervical length of 1.5–2.5?cm, while it is an acceptable option for high risk women with cervical length <1.5?cm.     

Utility of volumetric assessment of cervical funneling to predict cerclage failure

Objective: To assess the utility of cervical funnel volume as a predictor of cerclage failure.

Methods: We performed a retrospective cohort study of pregnant women with a McDonald cerclage and sonographic evidence of cervical funneling between 1/2008 and 2/2014. Funnel volume (FV) was calculated and used as a correction factor for cervical length (CL) or cerclage height (CH). Receiver operating characteristic (ROC) curves were used to compare the predictive value of CL, CL:FV, CH and CH:FV for cerclage failure at?<28 or?<34 weeks. CL:FV was further stratified to the?<5th,?<10th and?>10th percentiles and analyzed for prediction of preterm delivery.

Results: Subjects with cerclage failure (n?=?30) delivered at a mean gestational age of 29.8?+/? 5.3 weeks compared to 38.1+/? 1.39 weeks in those without failure (n?=?27; p?10th percentile groups was predictive of early preterm delivery (25.1 weeks versus 34 weeks, p?=?0.01).

Conclusions: Volumetric assessment of cervical funneling may improve prediction of cerclage failure in the mid-trimester.     

Cervical insufficiency: Re-evaluating the prophylactic cervical cerclage

Historically, placement of a cervical cerclage was based almost entirely on the obstetrical history. Over the past two decades however, we have recognised that history alone may not be the only indication for cerclage but rather, complementing the obstetrical history with ultrasonographic and biochemical findings may better identify those women who may benefit most from the placement of a cervical cerclage. Review of the literature appears to suggest that the best approach towards the management of a cervical insufficiency is to first categorise women as being either high risk of low risk-based on obstetrical history. Although women with an obstetrical history of at least three 2nd trimester losses are likely to benefit from a prophylactic cerclage than those without this history may better be managed with progesterone and serial cervical length measurements. This approach can in turn be used to identify those women with early cervical shortening that may require an emergency cerclage. Although randomised controlled trials are still lacking, recent studies suggests that this approach may be more effective especially when combined with markers of intra-amniotic inflammation. As for the prophylactic cerclage itself, with the abdominal cerclage being less invasive given the possibility of a laparoscopic placement, it may prove to be a more effective alternative to the conventionally placed McDonald cerclage. This however, remains to be evaluated more carefully.     

Vaginal fetal fibronectin as a predictor of spontaneous preterm delivery in the patient with cervical cerclage

OBJECTIVE: The purpose of this study was to assess the validity of vaginal fetal fibronectin as a screening test for spontaneous preterm birth in patients with cervical cerclage. STUDY DESIGN: A historic cohort of 117 patients who underwent cervical cerclage placement between 1996 and 2002 were identified. All patients were followed up in a maternal-fetal medicine faculty practice in a university setting. Serial fetal fibronectin samples of vaginal secretions were collected every 2 to 3 weeks, starting at 22 weeks of gestation and continuing until 32 weeks or delivery, whichever came first. RESULTS: There were 81 singleton, 23 twin, 12 triplet, and 1 quadruplet pregnancies. There were 61 ultrasound-indicated, 47 prophylactic, and 9 emergency cerclages that were placed. Most cerclages were of the modified Shirodkar type (95%) with a median gestational age at cerclage placement of 16.6 weeks. Overall, 33.3% of gestations were delivered spontaneously before 37 weeks of gestation; 17.1% of gestations were delivered spontaneously before 34 weeks. For deliveries within 2 weeks and 3 weeks of a single fetal fibronectin assessment, the test had a sensitivity of 50% and 48.3%, a specificity of 90% and 91.1%, a positive predictive value of 16.3% and 28.6%, and a negative predictive value of 97.9% and 96%, respectively. Subgroup analysis by number of fetuses (singleton, twin, and higher order multiple gestations) revealed similar values. For delivery before 34 weeks of gestation, fetal fibronectin had a sensitivity of 50%, a specificity of 78.4%, a positive predictive value of 33.3%, and a negative predictive value of 88%. CONCLUSION: This study is the first to evaluate the use of vaginal fetal fibronectin assessments to screen for preterm birth in patients who had undergone cervical cerclage procedures. We conclude that this test has similar validity to predict spontaneous preterm delivery in these high-risk pregnancies, as in previously published cohorts.     

Fetal fibronectin,cervical length,and the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage

Objective: The objective of this study is to estimate the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage based on the results of fetal fibronectin (fFN) and cervical length (CL) screening.

Methods: Retrospective cohort of patients with a singleton pregnancy and an ultrasound or physical exam indicated Shirodkar cerclage placed by one maternal–fetal medicine practice from November 2005 to January 2015. Patients routinely underwent serial CL and fFN testing from 22 to 32 weeks. Based on ROC curve analysis, a short CL was defined as?≤15?mm. All fFN and CL results included are from after the cerclage placement.

Results: One hundred and four patients were included. Seventy eight (75%) patients had an ultrasound-indicated cerclage and 26 (25%) patients had a physical exam-indicated cerclage. A positive fFN was associate with preterm birth?<32 weeks (15.6% versus 4.2%, p?=?0.043), <35 weeks (37.5% versus 11.1%, p?=?0.002), <37 weeks (65.6% versus 20.8%, p?<?0.001), and earlier gestational ages at delivery (35.2?±?3.9 versus 37.4?±?2.9, p?=?0.001). A short CL was also associated with preterm birth?<35 weeks (50.0% versus 11.9%, p?<?0.01), preterm birth?<37 weeks (55.0% versus 29.8%, p?=?0.033), and earlier gestational ages at delivery (34.8?±?4.1 versus 37.2?±?3.0, p?=?0.004). The risk of preterm birth?<32, <35, and?<37 weeks increased significantly with the number of abnormal markers.

Conclusion: In patients with an ultrasound or physical exam indicated cerclage, a positive fFN and a short CL are both associated with preterm birth. The risk of preterm birth increases with the number of abnormal biomarkers.     

Effectiveness and safety of late midtrimester cervical cerclage

Objectives: To evaluate the safety and effectiveness of late cervical cerclage performed beyond 17 weeks of gestation. The outcomes of interest were effectiveness of late cerclage in prolongation of pregnancy and evaluation of pregnancy outcome including maternal and fetal complications.

Study design: A total of 30 patients underwent late cervical cerclage during the study period. Of them, two were twin pregnancies. A late cerclage was performed after the diagnosis of cervical shortening or dilatation in 20 patients. We performed a retrospective case series review. One case was lost to follow up (delivery in another medical center). Medical information was retrieved from all cases of patients who underwent a late cervical cerclage between the years 2010 and 2016 at the Soroka University Medical Center, a tertiary medical center. Continuous variables were expressed as mean?±?standard deviation. Categorical variables were expressed as proportions.

Results: The average gestational age at birth was 35?±?5.1 weeks of gestation. The mean interval between cerclage and delivery in the study population was 17?±?5.62 weeks. Nine cases (32.1%) resulted in preterm deliveries, three of them below 34 weeks of gestation (one twin pregnancy and two pregnancies diagnosed with cervical dilation prior to cerclage). Among all the preterm deliveries, there were four cases of preterm prelabor rupture of membranes (13.3%). Of the 28 deliveries, 24 women (85.7%) had a vaginal delivery, while four women (14.3%) underwent a cesarean section. No cases of cervical tear were described. The cerclage was sent to bacteriology after removal, showing positive cultures for Candida species in nine cases (31%).

Conclusions: In our study population, late cervical cerclage was found to be a safe procedure resulting in almost 90% of successful vaginal deliveries without maternal or fetal complications. This procedure might be effective in the prolongation of pregnancy in women with cervical dynamics in the late second trimester.     

Fetal fibronectin as a predictor of spontaneous preterm labour in asymptomatic women with a cervical cerclage

Objective  To assess the accuracy of fetal fibronectin (fFN) testing for prediction of preterm labour in asymptomatic high-risk women with a cervical cerclage.
Design  Retrospective observational study.
Setting  United Kingdom.
Population  Nine hundred and ten asymptomatic women at high-risk of Preterm birth referred to specialist antenatal clinics and undergoing fFN testing between November 1997 and December 2007.
Methods  Women had fFN tests taken between 23⁺⁰ and 27⁺⁶ weeks' gestation, on one or more occasions.
Main outcome measures  Sensitivity, specificity, positive predictive values and negative predictive values of fFN testing for predicting delivery <30 and <37 weeks were compared in those with and without cerclage.
Results  For delivery <30 weeks' gestation, the specificity of fFN testing was significantly lower in women with cervical cerclage (77% vs 90%; P  ≤ 0.00001). The sensitivity of the test was similar between the groups (78.6 (no-cerclage) vs 60% (cerclage); P  > 0.4). The negative predictive value of the fFN test for delivery <30 weeks was high in both groups (>98%).
Conclusions  Asymptomatic high-risk women with cerclage in situ are more likely to have a false positive fFN test. The negative predictive value is similar.     

宫颈环扎术后妊娠患者的孕期管理

宫颈环扎术作为预防宫颈机能不全导致早产的治疗手段之一,已广泛用于临床,对于其术后患者是否需使用保胎药物,围术期抗生素的使用及终止妊娠的时机和方式等问题值得临床医生关注和讨论。本文将结合国内外现有证据及笔者的临床经验就宫颈环扎术后患者管理的一些重要问题作初步探讨。     

Role of cervical cerclage and prolonged antibiotic therapy with azithromycin in patients with previous perinatal loss amnionitis

In the group of 35 patients with cerclage, intermediate fetal mortality was reduced from 37.1% to 0 (p?p?=?0.606); prematurity from 65.7% to 5.7% (p?p?=?0.671); newborns with very low weight from 34.2% to 0 (p?p p?=?402); late fetal mortality from 63.1% to 0 (p?p?p?=?0.234); newborns with very low weight from 68.4% to 15.7% (p?p?相似文献   

Suture type and ultrasound-indicated cerclage efficacy

Objective: To assess whether type of suture material affects cerclage efficacy for preterm birth (PTB) prevention. Methods: Secondary analysis of a multicenter trial of ultrasound-indicated cerclage for short cervical length (CL), in which women with prior spontaneous PTB at 16–33 6/7 weeks, a singleton gestation and CL < 25 mm between 16–22 6/7 weeks, were randomized to McDonald cerclage or no cerclage. Outcomes of women who underwent cerclage were analyzed by type of suture material, comparing polyester braided thread (Mersilene? or Ethibond?) to Mersilene tape?. Primary outcome was PTB < 35 weeks. Results: 138 women underwent McDonald cerclage: 84 (61%) received polyester braided thread and 46 (33%) Mersilene tape?. Eight (6%) received monofilament suture and were excluded from analysis. Rates of PTB < 35 weeks were similar, 35% for polyester braided thread vs 24% for Mersilene tape? (p = .24). Birth gestational age was also similar among the 2 groups (p = .18). Conclusion: Type of suture material may not affect ultrasound-indicated cerclage efficacy in high-risk women with short CL, but further study is needed. Polyester braided thread (Mersilene? or Ethibond?) and polyester braided Mersilene tape? seem to have similar efficacy.     

The effect of cervical cerclage on pregnancy outcomes in women following conization

Abstract

Objectives: To determine the effect of cervical cerclage on obstetrical complications and perinatal outcomes of patients following conization.

Design: A retrospective population based cohort study.

Setting: Tertiary academic medical center that covers all the deliveries of the region.

Population: All patients with previous cervical conization who delivered between the years 1994–2011.

Methods: A retrospective population based study.

Main outcome measures: The effect of cerclage placement on the rate of preterm birth.

Results: During the study period there were 109 deliveries of patients following a cervical conization. Cervical cerclage was placed in 22 deliveries that served as the study group and the rest (n?=?87) served as the comparison group. The rate of early preterm delivery (PTD; <34 weeks) was significantly higher in women who had a cerclage. In a logistic regression model, cerclage was found to be an independent risk factor for early PTD.

Conclusion: Cerclage is an independent risk factor for early PTD In patients who had a conization due to CIN.     

Cervical dilation as a predictor of pregnancy outcome following emergency cerclage

Objective: To determine whether cervical dilation at the time of physical examination indicated cerclage placement can predicts latency and gestational age at delivery. Methods: A retrospective cohort study of all women who underwent physical examination indicated cerclage placement from 1996 to 2011 at Duke University Hospital (DUH) was performed. Physical examination indicated cerclage was defined as cerclage placement after 16 weeks in women with a cervical length of less than 2.5?cm and/or cervical dilation greater than or equal to 1?cm at time of procedure. Subjects were divided into two groups depending on cervical dilation at time of procedure (≥2?cm, <2?cm) for comparison. A multivariate linear regression model for the outcome gestational age of delivery was constructed, controlling for confounding variables. Results: A total of 110 women with complete data were available for analysis. Median gestational age at cerclage placement was similar between the two groups (20.3 vs. 20.3 weeks, p?=?0.8). Women with cervical dilatation ≥2?cm dilation delivered at an earlier median gestational age than women with cervical dilation <2?cm (27.0 vs. 35.6 weeks, p < 0.001). Cervical dilation at the time of cerclage placement independently predicted gestational age at delivery while controlling for use of intracervical Foley balloon catheter for membrane reduction, cerclage suture type, history of prior preterm birth, race, insurance status, and tobacco use. Conclusions: Women who receive a rescue cerclage are more likely to deliver at an earlier gestational age when cervical dilation is ≥2?cm at the time of procedure.     

Pregnancy outcomes after cerclage placement in nulliparous women with a short cervix on transvaginal ultrasonography

Objective: Little is known about pregnancy outcomes associated with a short cervix and cerclage placement in nulliparous women.

Methods: An electronic query of our ultrasound database was used to identify patients whose cervical length measured <?25?mm between 16–24 weeks of gestation. Any nulliparous women, with no prior pregnancy lasting beyond 13 weeks 6 d gestational age, were included in the analysis. The primary outcome was the interval of time from the diagnosis of a short cervix (<25?mm) to the time of delivery.

Results: Our query identified 70 patients for analysis. The interval of time from diagnosis of a short cervix to delivery was observed to be 85 d (12.1 weeks) in the cerclage group and 116 d (16.6 weeks) in the expectantly managed group (p?=?0.02). In those women receiving a cerclage, there was a statistically significant risk of spontaneous preterm birth <32 weeks gestational age (R.R. 6.7 [95% CI 1.45–30.6]).

Conclusions: The impact of a short cervix is largely unknown in patients with an uncomplicated obstetrical history. Our investigation would suggest that in this subset of patients, cerclage would not be beneficial in preventing preterm delivery.     

Obstetrical outcomes of emergency compared with elective cervical cerclage

Objective: To study obstetric outcomes of emergency cerclage compared with elective cerclage.

Study design: Retrospective cohort study of pregnancy outcomes of patients who underwent cervical cerclage, performed according to ACOG guidelines, between January 2006 and December 2014. Patients who underwent emergency cerclage, due to cervical shortening or cervical dilation (emergency cerclage group) were compared with patients who underwent history-indicated cerclage (elective cerclage group). Emergency cerclage was not performed in patients with uterine contractions, vaginal bleeding, or signs of chorioamnionitis. Procedure-related complications were defined as rupture of membranes or chorioamnionitis occurring after cerclage placement and before 24 weeks of gestation.

Results: Overall, 154 patients with elective cerclage and 47 patients with emergency cerclage were included. Mean gestational age at cerclage operation was 13.1?±?1 and 20.2?±?3 weeks, respectively. There were no differences between the emergency cerclage group and the elective cerclage group regarding mean gestational age at delivery (36.1?±?3 versus 35.6?±?3, respectively, p?=?0.7), rate of deliveries beyond 34 weeks of gestation (81.81% versus 78.72%, respectively, p?=?0.67), rate of deliveries beyond 37 weeks of gestation (64.93% versus 59.57%, respectively, p?=?0.6), cesarean deliveries (33.11% versus 39.13%, p?=?0.48, respectively), or birthweight (2848 versus 2862 grams, respectively, p?=?0.9). Regarding procedure-related complications, there were no differences between the elective and the emergency cerclage groups in the rate of chorioamnionitis (1.29% versus 4.34%, respectively, p?=?0.22), or ruptured membranes (1.29% versus 4.34%, respectively, p?=?0.22).

Conclusion: Pregnancy outcomes of emergency cerclage are comparable with those of elective cerclage.