Shirodkar versus McDonald cerclage for the prevention of preterm birth in women with short cervical length

The efficacy of Shirodkar cerclage was compared with that of the McDonald procedure for the prevention of preterm birth (PTB) in women with a short cervix. Secondary analysis using data from all published randomized trials including women with a short cervical length (CL) was performed comparing the use of Shirodkar versus McDonald sutures. Analysis was limited to singletons with short CL on transvaginal ultrasound. The primary outcome measure was PTB < 33 weeks. Statistical analysis was performed using bivariate and multivariable techniques. From 607 women randomly assigned in the study, 277 met our inclusion criteria; 127 received Shirodkar and 150 women received McDonald sutures. The mean ( +/- standard deviation) gestational age at delivery was 35.0 +/- 5.3 versus 36.3 +/- 4.7 for the Shirodkar versus McDonald groups, respectively ( p< 0.02). PTB < 33 weeks was seen in 61 (22%) of 277 women; 26 (20%) of 127 in the Shirodkar and 35 (23%) of 150 in the McDonald groups, respectively (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.5 to 1.6). On adjusting for confounders using logistic regression modeling, no significant difference in PTB < 33 weeks was found between the two groups (OR, 0.55; 95% CI, 0.2 to 1.3). In women with short cervical length randomly assigned to receiving cerclage, no significant difference in prevention of PTB was observed using Shirodkar or McDonald's procedures.     

McDonald versus Shirodkar cervical cerclage for the prevention of preterm birth: impact of body mass index

Objective: To compare obstetrical outcomes on women undergoing a McDonald or Shirodkar cerclage and to estimate the impact of maternal body mass index (BMI) on these outcomes.

Methods: We conducted a retrospective review of the medical records of all women with singleton pregnancies who underwent placement of a McDonald or Shirodkar cerclage at St. Francis Hospital from January 2008 to October 2013. The subjects were categorized based on BMI groups (normal: less than 25?kg/m², overweight: 25–29?kg/m², obese: 30?kg/m² or more). The primary outcome was gestational age at delivery. Statistical analyses included chi-square, Student’s t-test, and multivariable regression analysis.

Results: Of 95 women, 47 (49.5%) received a Shirodkar, and 48 (50.5%) a McDonald cerclage. 16 women (16.8%) were categorized as normal weight, 35 (36.8%) as overweight, and 44 (46.3%) as obese. Gestational age at delivery differed significantly by group, decreasing with each categorical increase in BMI (normal: 39.0?±?0.3 weeks; overweight: 36.6?±?0.7 weeks; obese: 33.0?±?1.1 weeks; p?p?=?.02). However, analysis showed a significant interaction between weight status and gestational age at delivery. Obese women had significantly longer pregnancies when they received a Shirodkar cerclage versus a McDonald cerclage (32.6?±?1.0 weeks versus 28.8?±?0.9 weeks; p?p?=?.63).

Conclusions: Compared to obese women receiving a McDonald cerclage, obese women receiving a Shirodkar cerclage had significantly longer pregnancies. No significant differences in pregnancy duration were found in normal/overweight women regardless of cerclage technique. Pregnancy duration in obese women receiving a Shirodkar cerclage was similar to the pregnancy duration of normal/overweight women.     

Cervical cerclage for prevention of preterm birth in women with twin pregnancy.

OBJECTIVE: To compare the effect of elective cervical cerclage in women with twin pregnancy on gestational age at time of delivery. METHOD: In a pragmatic fashion women in Abha Maternity Hospital, Saudi Arabia with twin gestations were allocated to receive either an elective cerclage (group I) or no cerclage (group II). Elective cerclage was performed at 12 to 14 weeks of gestation after sonographic examination of the fetus to confirm gestational age and exclude major congenital anomalies. In all cases, follow up of the pregnancy was continued until delivery. RESULTS: Of the 176 twin pregnancies included, cerclage was performed in 76 women, and no cerclage in 100 women. In Group I: 12 pregnancies ended in spontaneous miscarriage, 37 in preterm labor, and 27 women reached full term. There were a total of 106 live births in 62 women. In Group II: 8 women aborted, 44 women ended in preterm labor and 48 women reached full term. There were a total of 160 live births in 89 women. The gestational age at delivery ranged from 20 to 41 weeks. Multiple regression analysis did not show association between cerclage and time of delivery, although a trend was observed (P=0.056). CONCLUSION: Elective cerclage contributes little in prolongation of gestational age at the time of delivery in women with twin pregnancy, especially in women of high parity. Those with a previous history of preterm labor may be a subgroup that could benefit from elective cerclage.     

Elective cervical cerclage for prevention of preterm birth: a systematic review

BACKGROUND: Elective cervical cerclage has been purported to prevent spontaneous preterm birth. We present a systematic review to determine the effectiveness of cervical cerclage in preventing spontaneous preterm birth before 34 weeks' gestation. METHODS: Searches were conducted in MEDLINE, EMBASE, Cochrane Library, and Science Citation Index to identify randomized trials published between 1966 and 2002. All randomized trials that evaluated the effectiveness of elective cerclage compared with no cerclage in women who were at risk of preterm birth before 34 weeks' gestation were included for analysis. Quality assessment and data extraction were performed in duplicate. RESULTS: There were seven relevant trials, comprising 2354 women. Meta-analysis was inappropriate because of large differences in the quality of the studies. However, in the largest single trial of good quality, cerclage was shown to prevent birth before 34 weeks' gestation. In this single study the reported number to be treated to prevent one additional preterm birth before 34 weeks was 24 women (95% CI: 10-61). The results of other trials were consistent with the finding of the largest trial. Data on complications were sparse and inconclusive. CONCLUSION: Our systematic review shows that elective cervical cerclage has a significant effect in preventing spontaneous preterm birth before 34 weeks' gestation. Further research should focus on identification and quantification of possible complications, and of risk factors and tests that identify high-risk women who would benefit most from cerclage.     

Cervical cerclage for the prevention of preterm birth

Contemporary evidence supports the concept that cervical insufficiency is anything but a well-defined and distinct clinical entity. Instead, it is only 1 component of the larger and more complex preterm birth syndrome. Premature cervical ripening, as evidenced by shortening and effacement beginning at the internal os, provides strong evidence that parturition has begun and is the result of multiple interrelated pathways and inciting factors. Ultrasonographic screening of the cervix and treatment with cerclage for cervical shortening in the mid-trimester is reserved for women with prior spontaneous preterm birth (Fig. 1). Although cerclage benefit increases as the cervix shortens to less than 25 mm, it is appropriate to offer cerclage to women with shortened cervical length of less than 25 mm, and particularly those with a coexistent U-shaped funnel.     

Comparison of two successive policies of cervical cerclage for the prevention of pre-term birth.

The percentage of women receiving cervical cerclage increased from 5% to 18% between two periods at Haguenau maternity hospital, according to a new policy for the prevention of pre-term birth. A parallel reduction of premature deliveries by about a half was observed in the relevant group of women. This suggests that cerclage might be employed on another basis than is currently the case, and that a randomized trial is urgently needed to define its indications more precisely.     

Double versus single thrombophilias during pregnancy

Objective: The primary objective of this study was to evaluate whether women with double thrombophilias have a greater risk for obstetric complications as compared with women who have single thrombophilias.

Study design: This is a retrospective cohort study of all patients in a single practice with a clinically significant inherited thrombophilia and treated with anticoagulation between 2005 and 2013. Thrombophilias evaluated include: factor V Leiden, prothrombin G20210A gene mutation, protein S deficiency, protein C deficiency, and antithrombin III deficiency. Double thrombophilia was defined as the presence of two thrombophilias or homozygosity for factor V Leiden or prothrombin Gene Mutation. Demographic and obstetrical outcome data were collected. Data on all patients with double thrombophilias who met inclusion criteria was reported. Data was then compared between the patients with double thrombophilias and single thrombophilias with singleton gestations. The data was analyzed with Pearson’s chi-squared or Student’s t-test as appropriate with p value <.05 used for significance.

Results: Eighteen patients with clinically significant double thrombophilias who met inclusion criteria were identified. Most patients delivered full term (88.9%) and appropriate for gestational age (77.8%) infants. One hundred thirty-two patients with single thrombophilias and 14 patients with double thrombophilias with singleton gestations were then compared. Demographic characteristics were not significantly different between the two groups. There were no significant differences in obstetrical outcomes between patients.

Conclusions: There were no significant differences in obstetrical outcomes for patients with clinically significant double thrombophilias versus single thrombophilias when treated with anticoagulation.     

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.     

Cervical cerclage in the prevention of preterm birth

Cervical cerclage has been used in the management of cervical insufficiency for several decades, yet the indications are uncertain and benefits marginal. It remains a controversial intervention. The diagnosis of cervical insufficiency is traditionally based on a history of recurrent second trimester miscarriages, or very preterm delivery whereby the cervix is unable to retain the pregnancy until term. Cervical cerclage has been the subject of many observational and randomised controlled trials. This article reviews the literature regarding the effectiveness of elective or emergency transvaginal cerclage and transabdominal cerclage.     

Pessary use for the treatment of cervical incompetence and prevention of preterm labour

Objective.?To evaluate the efficacy and safety of polyvinyl chloride pessary in patients with cervical incompetence or at risk of preterm labour.

Methods.?Study was conducted on 56 pregnant women who were treated with pessary and delivered in the Department of Obstetrics and Perinatology in Lublin during a half-year period. Statistical evaluation included Spearman correlation analysis and Wilcoxon signed-rank test.

Results.?The mean gestational age at pessary insertion was 23 weeks gestation. Pessary was electively removed after 37 weeks gestation. The mean interval between pessary insertion and delivery was 13 weeks, the mean gestational age at delivery 38.3 weeks and birth weight was 3255?g. Two (3.6%) women delivered before 34 weeks. A total of 58 live infants was born. No significant complications that could be attributed to pessary use were observed.

Conclusions.?Pessary may be useful in women with cervical incompetence or at risk of preterm labour.     

Erythrocyte aggregation is increased in preterm premature rupture of the membranes

OBJECTIVE: To asses the degree of erythrocyte aggregation in the peripheral blood of women with preterm premature rupture of the membranes (PPROM). STUDY DESIGN: This was a prospective case control study. Twenty patients with preterm premature rupture of the membranes and matched controls were recruited at the Lis Maternity Hospital. A slide test and image analysis were used to quantitate the degree of erythrocyte aggregation. Hematological indices and markers of inflammation such as the erythrocyte sedimentation rate and C-reactive protein were also compared. RESULTS: The vacuum radius (VR) of the study group was significantly higher than in the control group at 14.8+/-1.6 microm versus 10.0+/-1.0 microm, respectively (P=0.03). Other hematological indices were not changed significantly between the groups. CONCLUSIONS: We found an increase in erythrocyte aggregation in the peripheral blood of patients with preterm premature rupture of the membranes. We used this sensitive marker of inflammation to further support the theory that PPROM is an inflammatory state.     

Cervical pathways for racial disparities in preterm births: the Preterm Prediction Study

Abstract

Purpose: Racial disparities in preterm birth have been long recognized, but the social and biological mechanisms for these differences are unclear. Our analysis had three goals: (1) to determine the relation between race and other social risk factors and cervical structure; (2) to determine whether social factors mediate the relation between race and cervical structure; and (3) to determine whether racial disparities in preterm birth (PTB) are mediated through changes in cervical structure observed earlier in pregnancy.

Materials and methods: Data from the Maternal Fetal Medicine Unit network Preterm Prediction Study were used to examine the relation between race and other social factors and cervical properties throughout pregnancy in 2920 black and white women. Outcomes included cervical length and dilation; cervical score (cervical length–internal dilation); and whether membranes protruded at 22–24 and 26–29 weeks. Race, education, income, insurance type, and marital status were examined as predictors of the outcomes using linear and logistic regression, adjusting for age, BMI, parity, and smoking. Mediation analysis was used to examine whether (a) any social factors explained racial differences in cervical properties, and (b) whether cervical properties mediated racial differences in risk for preterm birth.

Results: Shorter cervical length, especially at a subject’s first visit, was associated with black race (adjusted beta ?1.56?mm, p?<?.01) and lower income (adjusted beta ?1.48, p =.05). External dilation was not associated with social factors, while internal dilation was associated with black race and lower education. Black race and marital status were associated with lower cervical score. There was no evidence of mediation of the racial effect on cervical properties by any social factor. Shorter cervical length, dilation, and score were all associated with preterm birth (p?<?.01). Mediation analysis indicated that each of these mediated the effect of race, but explained a small proportion of the total effect (15–25%).

Conclusions: Race, and, to a lesser extent, other social factors are correlated with adverse cervical properties. This pathway could explain a proportion of the racial disparity in preterm birth.     

Parameters affecting latency period in PPROM cases: a 10-year experience of a single institution

Abstract

Objective: To investigate the association of epidemiological and pregnancy-related parameters with the latency period achieved in cases of preterm premature rupture of membranes (PPROM).

Method: A retrospective study was performed enrolling cases admitted in high-risk pregnancy unit (HRPU) with PPROM between 24?+?0 and 36?+?6 gestational week during 2002–2011. Cases with vaginal bleeding at admission, co-existing maternal or fetal pathology, placenta praevia, previous interventions in cervix or uterus, triplets or higher order pregnancies were excluded. Epidemiological parameters and latency period between admission due to PPROM and delivery were recorded. Obstetrical complications, mode of delivery, and neonatal morbidity parameters were also studied. A multivariate regression model was used to correlate latency period with epidemiological and pregnancy-related risk factors.

Results: Overall, there were 319 cases of PPROM admitted, of which 303 (94.9%) met inclusion criteria. Median latency period was 5.2?d. The latency interval exceeded 48?h in 65.0% of cases (197/303). Emergency cesarean was demanded in 20.2% of cases, chorioamnionitis was diagnosed in 7.5% while 76.1% of neonates were admitted in neonatal intensive care unit. Higher gestational week at admission was associated with shorter latency interval (p?<?0.001), twin pregnancy with shorter latency interval (p?=?0.02), while latency interval was significantly lower in cases complicated with chorioamnionitis (p?=?0.048).

Conclusion: Gestational week at PPROM, twin gestation and chorioamnionitis are factors significantly affecting latency interval.     

Elective cervical cerclage versus serial ultrasound surveillance of cervical length in a population at high risk for preterm delivery

OBJECTIVE: To compare pregnancy outcome for women at risk of preterm delivery undergoing elective cervical cerclage in the first trimester or serial transvaginal assessment of cervical length with cerclage only if indicated (control cases). DESIGN: A matched case control study. SETTING: Prematurity clinic at two London teaching hospitals. POPULATION: Women at high risk for preterm delivery. METHODS: Cases of elective cervical cerclage were matched for maternal age, ethnic group, previous cervical surgery, previous second trimester loss and early preterm delivery to women undergoing serial ultrasound surveillance of cervical length. Pregnancy outcome data was collected. Data was analysed using Fisher's exact, Mann-Whitney and Student's t-tests. MAIN OUTCOME MEASURES: Gestation at delivery, rate of delivery <24, 24-32 and 32-37 weeks gestation. RESULTS: Thirty-nine cases of elective cervical cerclage were matched to control cases. Both groups were similar for maternal age, ethnic group, previous cervical surgery, previous second trimester loss and early preterm delivery. Cervical cerclage was performed in 14 (36%) of the control cases due to cervical changes. There was no significant difference in median gestation at delivery (266 days versus 260 days P=0.9), number delivering <24 weeks (15% versus 13% P=0.9), at 24-32 weeks (7.5% versus 15% P=0.6) and at 32-37 weeks (15% versus 13% P=0.9). CONCLUSION: Serial transvaginal ultrasound surveillance of cervical length in women at high risk of preterm delivery appears to reduce cerclage rates without compromising pregnancy outcome. A large multicentered randomised trial is required to confirm these findings.     

宫颈环扎术在早产治疗中的应用

目的评估治疗性宫颈环扎术及预防性宫颈环扎术的效果。方法选择2003年1月至2006年3月北京大学第三医院的34周前的早产临产及宫颈机能不全患者,早产临产患者采取紧急宫颈环扎术联合宫缩抑制剂或者单纯使用宫缩抑制剂治疗。宫颈机能不全患者采取预防性宫颈环扎术、紧急环扎术以及非环扎保守治疗。对治疗结局进行统计学分析。结果在早产临产组,紧急宫颈环扎联合宫缩抑制剂（硫酸镁）来治疗早产,平均保胎天数45.00 d,较单纯用宫缩抑制剂硫酸镁抑制宫缩的34例患者保胎天数[中位数为1（0.75-16）d]明显延长,34、37周后分娩率分别为66.7%（26/39）、30.8%（12/39）,明显增加。宫颈机能不全患者预防性环扎及治疗性环扎均较非环扎组保胎天数延长,增加32、34周后的分娩率（P〈0.05）,但治疗性环扎可降低早产率（P=0.02）。结论观察资料结果显示早产临产患者硫酸镁联合宫颈环扎治疗早产效果更佳,增加34周以上的分娩率,降低早产率;预防性环扎不能降低37周前早产率,但能增加32、34周后分娩率,延长保胎天数;治疗性环扎可降低37周前早产率。     

Transabdominal cerclage in the management of cervical pregnancy: three case reports

We report three cases of cervical pregnancy, managed by transabdominal uterine cerclage and cervical curettage: each one was followed by a successful pregnangy. A review of the literature is presented. Correspondence to: G. Loverro