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cervical incompetence [keywords]
- PPO.52 Cervical Suture - A Single Centre Experience of Comparative Efficacy Between Elective, Semi-Elective and Rescue Sutures. [Journal Article]
- Arch Dis Child Fetal Neonatal Ed 2014 Jun.:A167.
Preterm delivery is the leading cause for infant mortality and morbidity. Cervical incompetence is a recognised cause for both extreme prematurity and second trimester loss. Use of cervical sutures may reduce these risks. We present an assessment of cervical suture use in a busy regional centre.Women who had an attempted cervical suture insertion were identified from theatre records from 2010-2013. Case notes were reviewed retrospectively and index pregnancy was identified as the first attempt to insert a cervical suture. Cervical sutures were categorised as "elective" when there was no evidence of cervical change, "semi-elective" when cervical sutures were attempted following shortening / funnelling of the cervix was identified on transvaginal ultrasound, "rescue" when cervical dilatation was said to have occurred.26 patients were identified. 25 sutures were attempted in singleton pregnancy and 1 in a DCDA twin pregnancy. 10/25 (40%) of women had a previous history of preterm birth. Elective cervical sutures were used in 11/26 (42.3%) cases, Semi-elective sutures in 7/26(26.9%) cases, Rescue sutures in 8/26 cases (30.8). 19/26 (73.1%) of pregnancies resulted in a live birth, of which 11/11 (100%) Elective sutures, 6/7 (85.7%) of Semi-elective sutures and only 2/8 (25%) Rescue sutures resulted in live birth (p 0.0005).Survival in the "rescue" cervical suture group was significantly poorer in comparison to both "elective" and "semi-elective" groups. This data supports the use of early cervical length screening in high risk cases. Further studies are required to identify optima timing of serial cervical length.
- Successful treatment of cervical incompetence using a modified laparoscopic cervical cerclage technique: a cohort study. [JOURNAL ARTICLE]
- Eur J Obstet Gynecol Reprod Biol 2014 Jun 2.:125-129.
We introduce a modified surgical method for laparoscopic cervical cerclage (LCC) and compare the operative data and obstetric outcomes to those obtained by traditional vaginal cerclage (TVC).This is a prospective cohort study in a university-affiliated hospital from August 2008 through February 2013. Nineteen patients treated by LCC were prospectively monitored and the treatment outcomes were compared to a control group consisted of 25 patients that were retrospectively studied and treated with TVC using traditional McDonald suture. Laparoscopic cervical cerclage was performed with Mersilene tape and a modified surgical technique. Perioperative complications and obstetric outcomes were compared between LCC and TVC treatment groups.No perioperative complications occurred during LCC treatment. Of the 19 LCC patients, 15 (78.9%) became pregnant during the study period. The fetal salvage rate was 92.3% (12/13) and no adverse events were encountered. The mean gestational age in LCC group was 36.4 weeks, and it was 17.4 weeks longer than their previous pregnancy age, which was significantly higher than obtained by TVC.This modified technique for laparoscopic cervical cerclage demonstrates good obstetric outcomes with low risk of adverse events, which may provide a reasonable alternative to achieve pregnancy success in patients with cervical incompetence.
- Laparoscopic transabdominal cervical cerclage: Case report of a woman without exocervix at 11 weeks gestation. [Journal Article]
- Obstet Gynecol Sci 2014 May; 57(3):232-5.
Cervical incompetence is characterized by painless dilatation of the incompetent cervix and results in miscarriages and preterm delivery during second trimester. We report a 25-year-old patient, gravid 2, para 1, at 11 weeks' gestation with the diagnosis of cervical incompetence, in whom transvaginal cerclage was not technically possible and laparoscopic cervical cerclage was performed successfully. There were no operative or immediate postoperative complications. A healthy infant was delivered at 35 weeks by cesarean section. Laparoscopic cervical cerclage during pregnancy can be safe and effective treatment for well-selected patients with cervical incompetence and eliminates the need for open laparotomy.
- Low levels of circulating T-regulatory lymphocytes and short cervical length are associated with preterm labor. [JOURNAL ARTICLE]
- J Reprod Immunol 2014 Apr 24.
Recent discoveries suggest that T-regulatory lymphocytes (Treg) might play an important role in the pathophysiology of preterm labor. The aim of this study was to assess the relationship among the levels of maternal circulating Treg cells, uterine cervical length, and the risk of preterm labor. Sixty women with regular contractions and/or cervical incompetence at 24-32 weeks' gestation were recruited into a prospective study. Each patient underwent transvaginal ultrasound examination of the cervical length, and regulatory T cells were quantified in peripheral blood samples by flow cytometry. Patients with cervical incompetence were prescribed vaginal progesterone until birth. Measurements of Treg levels and cervical length correlated with the timing of labor. The risk of preterm labor happening within 48h of testing was demonstrated to be almost 35 times higher (OR=35.21, CI 13.3; 214, p<0.001) in the group with simultaneously low Treg values (<0.031×10(9)/L) and a shortened uterine cervix (<17.5mm), compared with the situation where both of these values were normal. Similar results were found in predicting preterm delivery before 34 weeks, or between 34 and 37 weeks. A statistically nonsignificant trend toward increased cervical length and increased Treg count was noted in the women on progesterone treatment. We show for the first time that the combined assessment of Treg cell count and cervical length is a much better predictor of preterm delivery than either parameter used on its own. This combined approach may offer clinical application in patients who present with risk factors for preterm labor.
- Indomethacin and antibiotics in examination-indicated cerclage: a randomized controlled trial. [Journal Article, Randomized Controlled Trial]
- Obstet Gynecol 2014 Jun; 123(6):1311-6.
To evaluate whether perioperative indomethacin and antibiotic administration at the time of examination-indicated cerclage placement prolongs gestation.This is a randomized controlled trial performed at a single tertiary care hospital between March 2010 and November 2012. Women older than 18 years of age with a singleton pregnancy between 16 0/7 and 23 6/7 weeks of gestation undergoing an examination-indicated cerclage were eligible. Women were randomly assigned to receive either perioperative indomethacin and antibiotics or no perioperative prophylactic medications. The primary outcome was gestational latency after cerclage placement. Fifty women were required to be randomized to show, with 80% power, a 28-day improvement in latency assuming a latency without intervention of 50±35 days.Fifty-three patients were enrolled with three lost to follow-up. A greater proportion of pregnancies were prolonged by at least 28 days among women who received indomethacin and perioperative antibiotics (24 [92.3%] compared with 15 [62.5%], P=.01). However, gestational age at delivery and neonatal outcomes were statistically similar between groups.Among women receiving an examination-indicated cerclage in the second trimester, gestation was significantly more likely to be prolonged by 28 days among women who received perioperative indomethacin and antibiotics.ClinicalTrials.gov, www.clinicaltrials.gov, NCT01114516.I.
- Outcome of pregnancy with history-indicated cervical cerclage insertion in a low-resource setting. [JOURNAL ARTICLE]
- J Matern Fetal Neonatal Med 2014 Apr 16.
Abstract Objective: History-indicated cervical cerclage insertion is required when factors in a woman's history could predispose to spontaneous miscarriage or preterm birth. This retrospective study determined the pregnancy outcome after insertion of history-indicated cervical cerclage for at least one previous mid-trimester spontaneous abortion over a ten year period in a low-resource setting. Methods: This was a retrospective analysis of Hospital data. Data was retrieved on biosocial and obstetrics parameters and analysed. The outcome measures were recurrence of spontaneous miscarriage, preterm delivery rate and fetal salvage rate. Descriptive frequencies were used to present results. The test of statistical significance was with Yates coefficient correlation at 95% confidence interval. Results: Cervical cerclage rate was 7 per 1000 births. Diagnosis was clinical and cerclage was inserted at a mean gestational age of 15±3.6 weeks. Repeat spontaneous miscarriage occurred less (5.6%) after cerclage insertion, fetal salvage rate was 75% and the preterm birth rate was 30%. Hospital admission greater than 5days after cerclage insertion had no statistically significant difference on preterm delivery (CI 95%; P value = 0.98). Conclusion: The limitations of the study notwithstanding, use of history-indicated cervical cerclage in pregnancy demonstrated better fetal salvage rate and reduced recurrence of spontaneous miscarriage.
- ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency. [Journal Article, Practice Guideline]
- Obstet Gynecol 2014 Feb; 123(2 Pt 1):372-9.
The inability of the uterine cervix to retain a pregnancy in the second trimester is referred to as cervical insufficiency. Controversy exists in the medical literature pertaining to issues of pathophysiology, screening, diagnosis, and management of cervical insufficiency. The purpose of this document is to provide a review of current evidence of cervical insufficiency, including screening of asymptomatic at-risk women, and to offer guidelines on the use of cerclage for management. The diagnosis and management of other cervical issues during pregnancy, such as short cervical length, are discussed more in-depth in other publications of the American College of Obstetricians and Gynecologists.
- Cervical insufficiency and cervical cerclage. [Journal Article, Practice Guideline]
- J Obstet Gynaecol Can 2013 Dec; 35(12):1115-27.
The purpose of this guideline is to provide a framework that clinicians can use to determine which women are at greatest risk of having cervical insufficiency and in which set of circumstances a cerclage is of potential value.Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library in 2012 using appropriate controlled vocabulary (e.g., uterine cervical incompetence) and key words (e.g., cervical insufficiency, cerclage, Shirodkar, cerclage, MacDonald, cerclage, abdominal, cervical length, mid-trimester pregnancy loss). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to January 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Recommendations 1. Women who are pregnant or planning pregnancy should be evaluated for risk factors for cervical insufficiency. A thorough medical history at initial evaluation may alert clinicians to risk factors in a first or index pregnancy. (III-B) 2. Detailed evaluation of risk factors should be undertaken in women following a mid-trimester pregnancy loss or early premature delivery, or in cases where such complications have occurred in a preceding pregnancy. (III-B) 3. In women with a history of cervical insufficiency, urinalysis for culture and sensitivity and vaginal cultures for bacterial vaginosis should be taken at the first obstetric visit and any infections so found should be treated. (I-A) 4. Women with a history of three or more second-trimester pregnancy losses or extreme premature deliveries, in whom no specific cause other than potential cervical insufficiency is identified, should be offered elective cerclage at 12 to 14 weeks of gestation. (I-A) 5. In women with a classic history of cervical insufficiency in whom prior vaginal cervical cerclage has been unsuccessful, abdominal cerclage can be considered in the absence of additional mitigating factors. (II-3C) 6. Women who have undergone trachelectomy should have abdominal cerclage placement. (II-3C) 7. Emergency cerclage may be considered in women in whom the cervix has dilated to < 4 cm without contractions before 24 weeks of gestation. (II-3C) 8. Women in whom cerclage is not considered or justified, but whose history suggests a risk for cervical insufficiency (1 or 2 prior mid-trimester losses or extreme premature deliveries), should be offered serial cervical length assessment by ultrasound. (II-2B) 9. Cerclage should be considered in singleton pregnancies in women with a history of spontaneous preterm birth or possible cervical insufficiency if the cervical length is ≤ 25 mm before 24 weeks of gestation. (I-A) 10. There is no benefit to cerclage in a woman with an incidental finding of a short cervix by ultrasound examination but no prior risk factors for preterm birth. (II-1D) 11. Present data do not support the use of elective cerclage in multiple gestations even when there is a history of preterm birth; therefore, this should be avoided. (I-D) 12. The literature does not support the insertion of cerclage in multiple gestations on the basis of cervical length. (II-1D).
- Laparoscopic transabdominal cervical cerclage: A 6-year experience. [Journal Article]
- Aust N Z J Obstet Gynaecol 2014 Apr; 54(2):117-20.
Cervical cerclage has been used as a treatment for cervical insufficiency for over 60 years. Transabdominal cerclage is indicated for cervical insufficiency not amenable to a transvaginal procedure, or following previous failed vaginal cerclage. A laparoscopic approach to abdominal cerclage offers the potential to reduce the morbidity associated with laparotomy.To evaluate the obstetric outcome and surgical morbidity of laparoscopic transabdominal cerclage.An observational study of consecutive women undergoing laparoscopic transabdominal cerclage from 2007 to 2013 by a single surgeon (AA). Eligible women had a diagnosis of cervical insufficiency based on previous obstetric history and/or a short or absent cervix. The primary outcome was neonatal survival. Secondary outcomes were delivery of an infant at ≥34 weeks gestation. Surgical morbidity and complications were also evaluated.Sixty-four women underwent laparoscopic transabdominal cerclage during the study period. Three women underwent cerclage insertion during pregnancy; the remaining 61 were not pregnant at the time of surgery. Thirty-five pregnancies have been documented to date. Of those, 24 were evaluated for the study. The remaining cases were either early miscarriages, ectopic pregnancies or are still pregnant. The perinatal survival rate was 95.8% with a mean gestational age at delivery of 35.8 weeks. Eighty-three per cent of women delivered at ≥34 weeks gestation. There was one adverse intra-operative event (1.6%), with no postoperative sequelae.Laparoscopic transabdominal cerclage is a safe and effective procedure resulting in favourable obstetric outcomes in women with a poor obstetric history. Success rates compare favourably to the laparotomy approach.
- Embryo reduction in dichorionic triplets to dichorionic twins by intrafetal laser. [Journal Article, Research Support, Non-U.S. Gov't]
- Fetal Diagn Ther 2014; 35(2):83-6.
To describe a new technique for embryo reduction (ER) in dichorionic triplet (DCT) pregnancies.In 22 DCT pregnancies, ER to dichorionic twins was carried out at 11.3-13.9 weeks' gestation by ultrasound-guided laser ablation of the pelvic vessels of one of the monochorionic twins.Intrafetal laser was successfully carried out in all cases, but ultrasound examination within 2 weeks of the procedure demonstrated that the co-twin had died in 11 cases and was alive in the other 11. In the dichorionic group there was one miscarriage at 23 weeks due to cervical incompetence and in the other 10 cases there were two live births at a median gestational age of 35.0 (range 32.2-37.1) weeks. In the 11 cases where both monochorionic fetuses died the separate triplet was live born at a median gestation of 38.0 (range 32.2-40.5) weeks.In the management of DCT pregnancies, ER to dichorionic twins by intrafetal laser is an additional option to the traditional ones of expectant management, ER by intrafetal injection of potassium chloride (KCl) to monochorionic twins or ER by KCl to singleton.