Cerclaje para tratar la insuficiencia cervical. Nuestra experiencia a lo largo de la última década

We review the cervical cerclages performed at our institution in the last decade. The outcome of elective cerclages was highly satisfactory. Several clinical, analytical and ultrasound criteria were useful to retrospectively determine a subgroup of patients with an especially poor prognosis after cerclage. However, even in this subgroup, cerclage was successful in 30%. The management of emergency cerclage should be individualized; patients with less cervical dilation, less effacement and fewer inflammatory signs are those most likely to benefit from emergency cerclage.     

Comparison of elective and empiric cerclage and the role of emergency cerclage

We describe the maternal, obstetric, and neonatal outcomes of patients undergoing elective, empiric, and emergency cervical cerclage at our institution in an attempt to determine predictive factors for adverse perinatal and maternal outcomes. A retrospective chart review was conducted on patients who underwent cervical cerclage placement over a 7-year time span. Of 55 charts, 40 contained complete peripartum data satisfactory for review; 7 elective, 15 empiric, and 18 emergency cerclages were analyzed. There was no perinatal mortality in the elective group, and 5/7 patients delivered at term. The empiric population experienced a 20% neonatal mortality; 6/15 gestations progressed to term. The perinatal mortality was 44% in the emergency group and 2/18 patients delivered at term. Relative to neonatal outcome, elective cerclage was statistically significantly better than emergent cerclage; there was no statistically significant difference between the elective and empiric groups nor between the empiric and emergent groups. This relatively small series with a large number of variables appeared to favor an elective procedure rather than an empiric one. Although emergent cerclage was associated with only a 56% neonatal survival, it did have value in some patients.     

孕期不同指征经阴道宫颈环扎术的效果评价

目的:回顾性分析孕期3种不同指征经阴道宫颈环扎术的妊娠结局和新生儿预后。方法:收集66例采用Mc Donald方法进行宫颈环扎术患者的临床资料。结果:病史指征性环扎组与超声指征性环扎组,在平均分娩孕周、活产率及新生儿平均出生体质量方面差异均无统计学意义(P0.05)。紧急性环扎组的分娩孕周(29.17±6.44)周均低于病史指征性环扎组的(34.06±6.66)周和超声指征性环扎组的(35.42±4.75)周,差异有统计学意义(P0.05)。紧急环扎组中手术失败孕妇在宫口开大程度、术后白细胞计数及C反应蛋白(CRP)最高值较手术成功孕妇高。结论:病史指征性环扎术和超声指征性环扎术均可获得良好的相似妊娠结局。术后加强抗炎可提高紧急性环扎手术的成功率。剖宫产再孕者有一定的发生宫颈机能不全的概率,孕期应B超监测宫颈的变化。     

Cervical incompetence: elective, emergent, or urgent cerclage.

OBJECTIVE: We define criteria for insertion of cervical cerclage done electively (historical), urgently (in patients without symptoms), or emergently (in patients with symptoms). We compare outcomes as determined by prolongation of pregnancy and survival in each of these groups, and we define whether urgent or emergent cerclage imparted a higher risk of spontaneous rupture of membranes or chorioamnionitis than that associated with elective cerclage. Study Design: This is a retrospective analysis of all cervical cerclages placed at Memorial Medical Center between January 1, 1993, and December 31, 1997. Outcomes oberved were as follows: (1) prolongation of pregnancy in weeks after cervical cerclage, (2) presence of spontaneous rupture of membranes or clinical chorioamnionitis necessitating delivery, and (3) neonatal outcome. RESULTS: For prolongation of pregnancy the following results were obtained: emergent cerclage, 8.3 +/- 0.9 weeks; urgent cerclage, 12.2 +/- 1.5 weeks; and elective cerclage, 20.2 +/- 0.9 weeks (elective versus emergent and urgent, P <.05). For average gestational age at delivery, the results were as follows: emergent cerclage, 30.5 +/- 0.9 weeks; urgent cerclage, 33.1 +/- 1.4 weeks; and elective cerclage, 35.5 +/- 0.9 weeks (elective versus emergent and urgent, P <.05). The total neonatal survival was 85.7%. The incidence of spontaneous rupture of membranes was as follows: emergent cerclage, 51%; urgent cerclage, 40%; elective cerclage, 18% (elective versus emergent and urgent, P <.05). The incidence of clinical chorioamnionitis showed similar results. CONCLUSIONS: It is clear that emergency cerclages confer some benefit in patients with evidence of cervical incompetence. From this study it is evident that there is a new group of patients who need cerclage on an urgent basis as shown by subtle ultrasonographic changes in the cervix. Their behavior mirrors that of those belonging to the emergent group, suggesting that if they were left untreated they would need cerclage on an emergency basis.     

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.     

Elective and emergency transabdominal cervicoisthmic cerclage for cervical incompetence

OBJECTIVE: To evaluate the success rate of transabdominal cervicoisthmic cerclage (TACIC) as an elective and emergency procedure for cervical incompetence in comparison to reported success rates for vaginal cerclage. STUDY DESIGN: Retrospective review was performed of the hospital records of patients and their neonates who underwent TACIC for cervical incompetence by the Maternal-Fetal Medicine Service, Harrisburg Hospital. Data regarding procedure indications, maternal age, gravidity/parity, gestational age at time of placement, pregnancy outcome, delivery age and fetal weight at delivery were recorded. Comparison was made to previously reported outcomes for vaginal cerclage. RESULTS: Thirteen patients underwent TACIC from July 1996 through April 2001. The overall viable delivery rate was 76.9%. Five procedures were emergency, with a viable delivery rate of 60%. Mean gestational age at delivery for this group was 34.6 weeks. The 8 elective procedures had a viable delivery rate of 87.5% and mean gestational age of 35.5 weeks. Complications from the TACIC procedure were limited to a single catheter-related urinary tract infection. CONCLUSION: In pregnancies complicated by cervical incompetence and in which Shirodkar or McDonald cerclage has previously failed or is not technically feasible, TACIC offers the possibility of a successful outcome in elective and emergency settings similar to that previously reported for vaginal cerclage.     

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.     

Cervical cerclage and evidence-based medicine: if, how and when

Cervical cerclage has always been the main treatment option in cases of so-called cervical insufficiency, a condition that is notoriously associated with a high risk of second trimester abortion and/or preterm delivery. We can distinguish between a prophylactic cerclage, to be performed electively, usually at 13-16 weeks gestation, only when the woman has a history extremely suggestive for cervical incompetence (3 or more mid-trimester abortions or preterm deliveries) and a therapeutic cerclage. This last cerclage is recommended either for women who have ultrasonographic changes consistent with a short cervix or the presence of funneling after the 16-20 weeks gestation (urgent cerclage) and for women who present the asymptomatic dilation of the uterine cervix of at least 2 cm and/or a prolapse of the amniochorial membranes (emergent cerclage). So far there is still a lack of controlled and randomized trials that can unquestionably demonstrate the advantages of the cervical cerclage in comparison with a 'wait and see' aptitude. The cerclage can be performed either transvaginally, usually according to the McDonald technique, or transabdominally. This last approach is recommended when a transvaginal cerclage has to be avoided because of technical difficulties depending on the conditions of the cervix or when the pregnant woman has a history of one or more failed transvaginal cerclages. Interesting perspectives are currently offered by the laparoscopic cerclage, a method that has been effective and unexpectedly safe till now.     

Vaginal sonography and cervical incompetence

Uterine contractions, decidual activation, and cervical competence comprise the fundamental components in contemporary models of the spontaneous preterm birth syndrome, but their relative importance and interactive pathways remain poorly defined. Moreover, the traditional concept that the cervix is either competent or incompetent has been challenged because cervical competence more likely functions along a biologic continuum. Cervical incompetence is a clinical diagnosis characterized by recurrent painless dilation and spontaneous midtrimester birth. Although the efficacy of cerclage for cervical incompetence has never been fully confirmed in randomized clinical trials, the role of cerclage has been expanded to include women with "risk factors" for spontaneous preterm birth or nonreassuring sonographic cervical findings in the mid trimester. Evidence from randomized trials suggests that cerclage has limited efficacy in women with risk factors for cervical incompetence. Results of both retrospective cohort series and randomized trials of cerclage in women with shortened cervical length are inconclusive. We believe that women with a prior early spontaneous preterm birth and shortened midtrimester cervical length represent an ideal population for the conduct of a randomized trial of cerclage, which is currently underway.     

Validity of indications for transabdominal cervicoisthmic cerclage for cervical incompetence

Objective: Our purpose was to review the indications for transabdominal cervicoisthmic cerlage to determine whether it is a valid alternative to transvaginal cerclage.Study design: A retrospective review of transabdominal cerclage patients at one institution form 1978 to 1994, analysis of the indications for the transabdominal rather than the vaginal approach, and evaluation of fetal outcomes was performed.Results: Twenty-three patients underwent 24 transabdominal cerclages. The primary indication for transabdominal cervicoisthmic cerclage was failed transvaginal cerclage in 14 patients and anatomic unsuitability for transvaginal cerclage in nine. Of the latter, five were a result of diethylstilbestrol exposure and four a result of cervical surgery. All patients were successfully delivered of one or more live babies (total 28, including two sets of twins). Two losses occurred, one after rupture of membranes at 21 weeks on the second pregnancy after cerclage placement and one intraoperative loss with herniation of the membranes. The live birth rate was 93%, compared with 18% salvage of pregnancies beyond the first trimester before the transabdominal cervicoisthmic cerclage procedure. Complications included blood loss requiring transfusion (four patients), although none of these occurred in the last 12 patients.Conclusion: We conclude that all the patients had a history compatible with incompetent cervix requiring a cerclage, and none were suitable candidates for a vaginal cerclage. We further conclude that with strict indications transabdominal cervicoisthmic cerclage offers a high rate of fetal salvage with a minimum of complications in patients with extremely poor obstetric histories because of cervical incompetence.     

Cervical cerclage in 2008

Cervical cerclage is a common surgical technique that has been used for more than 50 years to prevent preterm deliveries and in the management of a threatened second trimester loss. However, it remains one of the most controversial interventions in obstetrics and this is probably due to difficulties in diagnosing cervical insufficiency, which is based on a history of recurrent second trimester loss or early preterm delivery following painless cervical dilatation in the absence of contractions or bleeding. This article reviews in 2008 the current literature regarding the efficacy of elective cerclage, ultrasound-indicated cerclage, emergency cerclage, and cervico-isthmic cerclage for singletons and multiple pregnancies.     

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.     

Balloon replacement of fetal membranes to facilitate emergency cervical cerclage

BACKGROUND: Emergency cerclage can be used in cases of cervical incompetence, even when fetal membranes bulge through the dilated cervix. To facilitate the procedure we used a balloon device to replace the fetal membranes. TECHNIQUE: With the patient in a steep Trendelenburg position, after epidural anesthesia, the fetal membranes were replaced into the uterine cavity with an inflated balloon of the type used for endoscopic preperitoneal dissection. Cervical cerclage was done by the McDonald technique. EXPERIENCE: We have done 25 emergency cerclages with this technique. The following maternal and perinatal outcomes were assessed retrospectively: age, medical history, gestational age at inclusion and delivery, cervical dilatation at admission, preterm rupture of membranes, clinical or histologic chorioamnionitis, birth weight, admission to the neonatal intensive care unit, neonatal death, and postnatal course. CONCLUSION: Replacing prolapsed fetal membranes with an inflated balloon is a convenient technique that allows gestation to be prolonged for an average of 31 days. Cerclage was feasible when the cervix was widely dilated (more than 4 cm); it was associated with prolongation of gestation by a median of 9 days.     

紧急宫颈环扎术的指征与注意事项

紧急宫颈环扎术术后安胎成功率可高达72.72%,是宫颈机能不全者治疗不及时的一种有效补救措施。但如不能正确把握其手术时机、掌握手术指征,术后亦可带来严重并发症。因此,严格掌握紧急宫颈环扎术的手术指征,注意术中操作及术后监测,是提高紧急宫颈环扎术成功率的关键。     

Cervical cerclage for prevention of preterm delivery: meta-analysis of randomized trials

OBJECTIVE: To estimate the effectiveness of prophylactic and therapeutic cerclage by meta-analysis of randomized clinical trials. DATA SOURCES: We searched the Cochrane Pregnancy and Childbirth Group specialized register of clinical trials (May 2002). Congress proceedings of international society meetings of fetal-maternal and reproductive medicine were searched by hand. METHODS OF STUDY SELECTION: Meta-analysis of randomized clinical trials comparing cervical cerclage with expectant management during pregnancy was performed. Further clarification was sought from trial authors when required. TABULATION, INTEGRATION, AND RESULTS: Six trials describing a total of 2175 women were analyzed. Prophylactic cerclage was compared with no cerclage in four trials. Pooled results failed to show a statistically significant reduction in pregnancy loss and preterm delivery rates, although a small reduction in births less than 33 weeks' gestation was seen in the largest trial (relative risk [RR] 0.75; 95% confidence interval [CI] 0.58 to 0.98). Cervical cerclage was associated with mild pyrexia, increased use of tocolytic therapy, and hospital admission but no serious morbidity. Two trials examined the role of therapeutic cerclage when ultrasound examination revealed a short cervix. Pooled results failed to show a reduction in total pregnancy loss, early pregnancy loss, or preterm delivery before 28 and 34 weeks in women assigned to cervical cerclage. CONCLUSION: The effectiveness of prophylactic cerclage in preventing preterm delivery in women at low or medium risk for second-trimester pregnancy loss has not been proven. The role of cerclage in women whose ultrasound reveals short cervix remains uncertain.     

Clinical effect of emergency cervical cerclage and elective cervical cerclage on pregnancy outcome in the cervical-incompetent pregnant women

Purpose

To compare the clinical effect of emergency cervical cerclage and elective cervical cerclage on pregnancy outcome in the cervical-incompetent pregnant women.

Methods

Literature was searched from the databases of Pubmed, Embase and Google scholar. The fixed or random effects model was used to calculate pooled risk ratios on the basis of heterogeneity. Meta-regression, sensitive analysis, subgroup analysis, and publication bias assessment were also conducted to confirm the results according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009.

Results

The meta-analysis results showed that there were significant associations between cerclage operations and pregnancy outcomes in gestation age, birth weight, and PROM rate. Gestation age was significantly higher in women with elective cerclage than those with emergency cerclage, and birth weight was significantly higher in newborns for the elective group as compared with emergency group. The rate of PROM in elective group was lower than emergency group. However, there were no differences between the emergency cerclage group and the elective cerclage group regarding the rate of vaginal delivery.

Conclusions

This meta-analysis suggests that emergency cerclage has lower gestation age and birth weight than elective cerclage, and it increases the risk of PROM. Further well-designed studies are warranted to confirm these results.

     

Diagnosis of short cervix in a community hospital prior to placement of a therapeutic cerclage

The purpose of this study was to describe how obstetricians in the community define a short cervix prior to cerclage placement. A secondary analysis of cerclages placed for the diagnosis of short cervix, defined by either digital or ultrasound examination, were identified from a cohort of 1076 cerclages placed at a community hospital from January 1, 2000, through December 31, 2004. Two hundred twenty-six cerclages were placed for the diagnosis of short cervix. Fifty-eight women (25.7%) were nulliparous. The mean estimated gestational age at placement was 15.4 +/- 3.8 weeks. More than half of the cerclages (n = 125; 55.3%) were placed prior to 15 weeks estimated gestational age. Of those cases with documented cervical length by ultrasound (n = 171), 36 of these patients (21.1%) had a cervical length of > or = 25 mm. The most common indications for cerclage placement were short cervix only (40.3%), previous cone biopsy/loop electrocautery excision procedure (28.8%), and multiple gestation (9.7%). In a community hospital, cerclages for short cervix are often performed in nulliparous women without antecedent risk factors at a gestational age when cervical length is not a reliable tool for predicting adverse pregnancy outcome.     

Évaluation du cerclage isthmique par voie cœlioscopique

ObjectiveThe transabdominal cervico-isthmic cerclage could to be proposed in case of failure of vaginal cerclage, 2nd trimester fetal losses and cervical defects. The efficiency of the laparoscopic approach, more recently described, has to be demonstrated for the prevention of obstetrical accident.Patients and methodsThis study is a retrospective monocentric evaluation of 14 laparoscopic cervico-isthmic cerclages performed with Benson modified technique before pregnancy between 2005 and 2007. Previous obstetrical accidents, etiology of cervical incompetence and patient outcome after cerclage were compared.ResultsMedian age of the patients was 33.5 years; 93% had previous fetal losses or preterm delivery and 42.9% had failure of Mac Donald cerclages. The indication of laparoscopic cervico-isthmic cerclage was Mac Donald cerclage failure (six cases), and eight cases of anatomic incompatibility of Mac Donald cerclage. Mean duration of laparoscopic cervico-isthmic cerclage was 45 minutes. All patients were hospitalized on an outpatient basis. No operative complication was reported. Six women were pregnant after cerclage: five deliveries by caesarean section at term, and one first trimester foetal loss.Discussion and conclusionThe cervico-isthmic cerclage can be easily performed by laparoscopy. The indications are strictly the same as cervico-isthmic cerclages by laparotomy. Increasing the number of term deliveries and the obstetrical outcome of these patients, the efficiency of the cervico-isthmic cerclage by laparoscopy is demonstrated.     

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 surveillance as an alternative to elective cervical cerclage for pregnancy management of suspected cervical incompetence

OBJECTIVE: The aim of the present study was to compare the outcome of pregnancies among patients with suspected cervical incompetence treated either by elective cervical cerclage or an alternative management program involving cervical surveillance. DESIGN, SETTING AND METHODS: A prospective cohort study was performed in two groups of patients at risk of cervical incompetence with singleton gestations attending the Royal Women's Hospital, Melbourne, Australia, from 1996 to 2000. The first group was managed by their obstetric carers with an elective cerclage, while the second group was managed conservatively as part of a cervical surveillance program offered to patients attending the Department of Perinatal Medicine for pregnancy care. This program consists of weekly visits from 16 weeks' gestation and involves alternating transvaginal ultrasound assessment of cervical morphometry with cervico-vaginal bacteriology and fetal fibronectin swabs. Empiric insertion of a cerclage is undertaken when there is evidence of significant cervical shortening (cervical canal <2.5 cm in length at 相似文献