Evaluation of Outcomes Associated with Placement of Elective, Urgent, and Emergency Cerclage

Objectives

The aim of this study was to assess pregnancy outcomes after cervical cerclage.

Methods

A retrospective analysis of all cervical cerclages placed at Al Qassimi Hospital from 2004 to 2008 was performed. The primary outcome of interest was prolongation of pregnancy beyond 36 wks. Secondary outcomes were premature rupture of membranes, birth weight <1,500 g, and neonatal death.

Results

Cerclage was placed in 145 women: 112 elective, 16 urgent, and 17 emergency groups. Delivery beyond 36 weeks occurred in 79.4, 73.3, and 47.1 % in the elective, urgent, and emergency groups, respectively, p = 0.011. When comparing between elective, urgent, and emergency groups, incidences of low birth weight were 9.8, 13.3, and 33.3 %, respectively, p = 0.06, and premature ruptures of membranes occurred in 7.2, 6.3, and 17.7 %, respectively, p = 0.16. There were five neonatal deaths.

Conclusion

Therefore, although cerclage gives best results when it is performed as an elective procedure, emergency cerclage still confers some benefits.     

宫颈锥切及根治性宫颈切除术后宫颈环扎问题

宫颈部分切除术治疗宫颈上皮内瘤变,可有效降低宫颈浸润癌的发病率,根治性宫颈切除术治疗早期宫颈癌,可有效降低宫颈浸润癌的病死率。但是这两种术式均可能导致手术后宫颈机能不全。宫颈锥切术切除了部分宫颈组织,降低了宫颈承托力,引起晚期流产和早产,影响妊娠预后。宫颈环扎能够延长宫颈长度,显著降低术后因宫颈机能不全导致的早产和复发性中期妊娠流产的发生。因此,对有生育要求的患者需要进行预防性或治疗性的宫颈环扎术。为预防根治性宫颈切除术导致的宫颈机能不全,手术中常规采用不可吸收性缝合线行永久性宫颈环扎,但是术后仍有因宫颈问题发生中期妊娠流产或早产者。宫颈缝合术（trachelorraphy）是一种安全、可重复、易于掌握的操作,以预防宫颈环扎失败而再次发生的流产,有利于改善有不良产科病史者的围生期结局。     

Comparison of two cervical cerclages for the prevention of preterm birth and neonatal complications

Objective: To investigate the outcomes of singleton pregnant women with cervical insufficiency undergoing two different cervical cerclages.

Methods: This is a retrospective cohort study of women who underwent a history- or ultrasound-indicated cerclage (either Shirodkar or McDonald) at a tertiary referral center from 2002 to 2014. Outcome parameters (delivery age, postoperative cervical length, preterm premature rupture of membranes, preterm delivery rate and neonatal complications) were compared between the two cerclage procedures. Multivariate logistic regression analysis was applied to control for significant variables of preterm birth. Kaplan–Meier survival analysis was used to demonstrate delivery age to percentage of term delivery by cerclage type.

Results: Ninety-four cases were initially included. After excluding cases not meeting the study criteria, 60 pregnancies (Shirodkar 36 and McDonald 24) were recruited for analysis. The mean delivery age in the Shirodkar group was more advanced than that in the McDonald group (37.1?±?3.3 versus 34.8?±?4.9 weeks, p?=?0.039). There were significantly fewer deliveries <37 gestational weeks in the Shirodkar group than in the McDonald group (30.6% versus 58.3%, p?=?0.033) but no significant differences in deliveries <28, 32 and 34 gestational weeks. No significant differences were found in neonatal complications except for respiratory distress syndrome (5.6% in Shirodkar versus 29.2% in McDonald, p?=?0.023).

Conclusion: In the setting of history-indicated or ultrasound-indicated cerclage, Shirodkar was superior to McDonald in the prevention of late preterm birth and neonatal respiratory distress syndrome.     

Long-term sequelae of abdominal cervical cerclage and a minimally invasive approach to resolution

Cervical incompetence is diagnosed in 0.1–1% of all pregnancies and in 8% of women with repeated mid-trimester pregnancy loss. This condition may be managed by the application of a suture around the cervix, placed vaginally, abdominally, or laparoscopically. The case histories of two patients are presented, both of whom had abdominal cervical cerclage applied via laparotomy 4 and 6 years previously. Counselling and decision making processes are discussed, and the operative reports of the successful laparoscopic total removal of the cervical sutures are described. Published cases of laparoscopic cerclage removal are rare; indeed only four cases have been recorded. Three of these involved the removal of the suture after a very short period of time (5–7 weeks) with one further report of a partial removal being achieved laparoscopically. We have described successful laparoscopic total removal of two abdominally placed cervical sutures that had been in-situ for a prolonged period of time. In a unit with skilled laparoscopic surgeons and high-risk obstetricians, the potential for laparoscopic insertion and removal of abdominal cervical sutures exists.     

Laparoscopic Removal of Abdominal Cerclage at 19 Weeks' Gestation

We discuss laparoscopic removal of an abdominal cerclage in a 39-year-old woman, gravida 4, para 0, abortus 3, who presented at 19 weeks'' gestation with ruptured membranes. This patient had a failed previous vaginal cerclage. An abdominal cerclage was performed at the time of abdominal myomectomy. A subsequent pregnancy was diagnosed, with ruptured membranes at 19 weeks'' gestation, and the patient opted for pregnancy termination. After laparoscopic removal of the cerclage, cervical laminaria were placed, and the patient underwent an uncomplicated dilation and curettage procedure the following day.     

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.     

Acute Hemorrhage Related to a Residual Cervical Pregnancy: Management with Curettage,Tamponade, and Cerclage

Cervical ectopic pregnancy is uncommon, with no universally accepted protocol for conservative management of acute hemorrhage due to residual cervical ectopic pregnancy. Herein is presented the case of a 33-year-old woman with profuse vaginal bleeding 3 months after receiving treatment including intraamniotic potassium chloride injection, systemic methotrexate, and uterine artery embolization because of a cervical ectopic pregnancy. A residual cervical pregnancy was suspected. Hemorrhage was controlled using curettage, tamponade with a Bakri balloon, and cerclage. The balloon and cerclage were removed on postoperative day 2, with no recurrence of symptoms. Our experience suggests that a combination of curettage, balloon tamponade, and cerclage may be considered in the management of cervical ectopic pregnancies with acute hemorrhage, in particular in patients desiring future childbearing.     

可吸收线环扎张力带治疗髌骨骨折的生物力学研究

目的比较可吸收线环扎张力带与钢丝环扎、Magnuson钢丝、AO张力带钢丝和Weber改良张力带钢丝固定髌骨骨折的生物力学特性.方法取20具新鲜膝关节标本,随机分为5组,制成骨折模型,分别用5种方法固定,用膝关节生物力学试验机KJ一20型测定5种内固定的生物力学性能,骨折断端分离1.0mm为固定失败.结果5种内固定方法均能满足1KN股四头肌收缩力,可吸收线环扎张力带与其它内固定方法相比,无明显差异(p＞0.05).结论可吸收线环扎张力带治疗髌骨骨折具有优越的生物力学性能和良好的骨折断端稳定性,免除了二次手术之苦,扩大了手术内固定的适应范围,避免了许多不必要的髅骨切除.