cervical incompetence [keywords]
- The provocative radiographic traction test for diagnosing craniocervical dissociation: a cadaveric biomechanical study and reappraisal of the pathogenesis of instability. [JOURNAL ARTICLE]
- Spine J 2016 Jun 6.
Craniocervical dissociation is a rare but serious condition, and missed injuries have been associated with poor neurologic outcomes and deterioration. A fluoroscopic traction test is employed to interrogate the craniocervical ligaments when clinical and imaging findings are equivocal. However, no specific protocol or known parameters with respect to traction or force applied have been established.This study sought to define the parameters of the radiographic traction test with sequential sectioning of the primary ligamentous restraints under controlled distraction of the craniocervical junction in a biomechanical model.This is a cadaveric biomechanical study.A custom loading apparatus applied traction forces in six specimens (O-C3) and the following ligaments were sectioned: alar, tectorial membrane, and occiput-C1 capsules to simulate varying degrees of craniocervical dissociation. Traction was applied 0 to 20 lb with fluoroscopy. Digital image analysis quantified the relative displacements of C0-C1, average craniocervical excursion, and under what load could a 2-mm craniocervical displacement be reproducibly recorded.A weight-distance table was produced and showed a marked loss of stability with sectioning of the ligaments and across all specimens in a similar pattern. Minimal translation was noted with sectioning of two of three ligaments in any order (<1-2 mm). All specimens exhibited a firm restraint to dissociation until the last of the three stabilizers was sectioned. Thus an "all-or-none" restraint to instability is present. All specimens failed at a weight of 5-10 lb (>2 mm).The current knowledge base of craniocervical injuries is very limited. This study shows that the key restraints to craniocervical instability are the alar ligaments, tectorial membrane, and the atlantooccipital joint capsules. Dissociation requires the complete incompetence of all three. The craniocervical traction test reliably demonstrates instability and requires no more than 5-10 lb of traction to perform.
- Prolonged progesterone administration is associated with less frequent cervicovaginal colonization by Ureaplasma urealyticum during pregnancy - Results of a pilot study. [Journal Article]
- J Reprod Immunol 2016 Aug.:35-41.
Preterm birth is a leading cause of perinatal mortality and morbidity. Heavy cervicovaginal Ureaplasma colonization is thought to play a role in the pathogenesis of preterm birth. The administration of vaginal progesterone has been shown to reduce the incidence of preterm birth in women with short cervical length. Steroid hormones seem to modulate the presence of microorganisms in the vagina. The aim of this study was to assess whether the treatment with vaginal progesterone could reduce the incidence of preterm birth and cervicovaginal colonization by Ureaplasma urealyticum in a cohort of pregnant women with threatened preterm labor.A cohort of 63 females who presented with regular contractions and/or short cervical length between 24-32 weeks of gestation were recruited into a prospective study. 70% of patients had been treated with vaginal progesterone prior to recruitment and these patients continued with the treatment until birth. All patients were tested for the presence of cervicovaginal Ureaplasma urealyticum colonization at admission. The primary endpoint was preterm birth before 37 weeks.The incidence of preterm delivery was significantly increased in patients who tested positive for Ureaplasma urealyticum. Prolonged vaginal progesterone administration was associated with less frequent cervicovaginal colonization by U. urealyticum. Cervicovaginal colonization by U. urealyticum and absence of progesterone treatment were identified as two independent risk factors for preterm delivery.Our results demonstrate the beneficial effects of progesterone administration in reducing the incidence of cervicovaginal colonization by Ureaplasma urealyticum.
- Simplified laparoscopic cervical cerclage after failure of vaginal suture: technique and results of a consecutive series of 100 cases. [Journal Article]
- Eur J Obstet Gynecol Reprod Biol 2016 Jun.:146-50.
To evaluate the efficacy of simplified laparoscopic cervical cerclage (SLCC) in the prevention of miscarriage and preterm delivery in women with cervical incompetence who failed to have a live birth following a vaginal cervical cerclage in a previous pregnancy.From Dec 2010 to January 2015, a consecutive cases of 100 subjects with cervical incompetence but who failed to have a live birth following a vaginal cervical cerclage in a previous pregnancy underwent SLCC. Surgical outcome parameters (estimated total blood loss, operation time, complications) were recorded, the outcome of any subsequent pregnancy was evaluated.Among the 100 cases of SLCC, the mean±SD (range) surgical time was 26±4.7 (20-40)min. After the operation, 82 women conceived, 3 of them conceived twice. There were altogether 85 pregnancies, including 12 early miscarriages and one case of ectopic pregnancy. Among the 55 pregnancies which progressed beyond the first trimester and in whom the final outcome was confirmed, the live birth rate was 53/55 (96.4%). The mean gestational age at delivery of this group of women was 37.5±1.8 weeks.The simpliﬁed laparoscopic cervical cerclage is a simple, safe, and effective procedure for the treatment of cervical incompetence which had previously failed to benefit from vaginal cervical cerclage.
- Robotic Cerclage in Advanced-stage Endometriosis. [JOURNAL ARTICLE]
- J Minim Invasive Gynecol 2016 Apr 27.
To show a stepwise surgical technique of robotic-assisted transabdominal cerclage placement in a patient with deeply infiltrative endometriosis.A step-by-step surgical tutorial using narrated video.The George Washington University Hospital. Local institutional review board approval is not required for case reports (Canadian Task Force Classification III).A 38-year-old woman with cervical incompetence and a history of infertility with 5 pregnancies accomplished by in vitro fertilization. Pregnancies were as follows: 3 first trimester losses, 1 second trimester loss, and another second trimester loss despite McDonald cerclage placement.Indications for transabdominal cerclage placement include a congenital short or amputated cervix, cervical scarring that would prevent a transvaginal approach, and failed prior vaginal cerclage . Robotic-assisted abdominal cerclage placement was performed in a case of advanced rectovaginal endometriosis. Normal anatomy was restored; however, no excision of endometriosis was performed because the patient was asymptomatic and already undergoing in vitro fertilization for infertility. The procedure used a 12-mm camera port through the umbilicus, 2 ancillary 8-mm robotic ports, and a 5-mm assistant port; ¼-inch-width Mersilene tape (Ethicon, Somerville, NJ) was preloaded in the abdomen through the 12-mm port before docking. Survey of the pelvis revealed the presence of advanced rectovaginal endometriosis hindering visualization of the cervicouterine isthmi on the posterior side of the uterus. The preloaded needle was parked on the right parietal peritoneum. Before cerclage placement, retroperitoneal spaces dissection bilaterally was necessary to lateralize the ureters and mobilize the rectum away from the cervicovaginal junction where the cerclage would be placed. Anteriorly, the vesicouterine peritoneum was dissected transversely, and the bladder was dissected off the lower uterine segment. A window was created in the posterior leaf of the right broad ligament lateral to the cervicouterine junction and medial to the ureter. The uterine vessels were then skeletonized, and the needle was placed through the lateral cervical isthmus medial to the vascular bundle going posterior to anterior. The procedure was repeated on the contralateral side with the needle going in the anteroposterior direction. The tape was pulled tightly against the anterior cervical isthmus. The tape ends were tied together posteriorly. There was minimal blood loss with no complications.A robotic-assisted abdominal cerclage can be performed safely and effectively in patients with advanced-stage endometriosis.
- [Laparoscopic abdominal cerclage in a patient with recurrent miscarriages abortions - case report]. [English Abstract, Journal Article]
- Ceska Gynekol 2016 Jan; 81(1):58-62.
The use of laparoscopic abdominal cerclage in a patient with habitual miscarriage.Case report and literature review.Department of Obstetrics and Gynecology, University Hospital Olomouc, Faculty of Medicine, Palacký University Olomouc, Department of Neonatology, University Hospital Olomouc, Faculty of Medicine, Palacký University Olomouc, Institute of Medical Genetics, University Hospital Olomouc, Faculty of Medicine, Palacký University Olomouc.The patient is a 37 years old woman with a history of recurrent miscarriages. She had one labor at term and six pregnancies that were lost in the second trimester despite McDonald cerclages. Abdominal cerclages are necessary when the standard transvaginal cerclages fail or anatomical abnormalities preclude the vaginal placement. The disadvantage of the transabdominal approach is that it requires at least 2 laparotomies with significant morbidity and hospital stays. We discuss a case of abdominal cerclage performed laparoscopically. A 5 mm Mersilene tape was placed laparoscopically at the level of the internal os as an interval procedure. We feel it offers less morbidity and in the proper hands eliminates or significantly shortens hospital stays. Subsequent pregnancy was terminated at 28 weeks by caesarean section after premature rupture of membranes.Laparoscopic abdominal cerclage seems to be relatively effective option for the prevention of habitual abortion patients, which fail conventional surgical procedures in dealing with cervical incompetence. The success of subsequent full term pregnancy is given as 70%.
- [Analysis of clinical effect of McDonald cervical cerclage and the related risk factors]. [English Abstract, Journal Article]
- Zhonghua Fu Chan Ke Za Zhi 2016 Feb; 51(2):87-91.
To investigate the clinical effect of McDonald cervical cerclage and the affecting factors.Between January 2002 to December 2013 in Peking University First Hospital we performed McDonald cervical cerclage for 116 single pregnant women. They were defined as the successful group who deliveried the live babies after 28 weeks after the cerclage and the failure group who deliveried in the second trimester. According to the surgical indications they were divided into preventive cerclage group and therapeutic cerclage group. Then we analyzed the curative effect and the affecting factors in the groups.(1) In the 116 cases, 12 cases (10.3%) failed, and 104 cases (89.7%) succeeded. In the successful group, 37 cases (35.6%,37/104) deliveried pretermly and 67 cases (64.4%) deliveried termly. And there were 56 cases of vaginal delivery (53.8%), and 48 cases (46.2%) of cesarean section. (2) Among the 116 cases, 48 cases (41.4%) were included in prophylactic cerclage group, the gestational age was (16.3± 2.2) weeks, 68 (58.6%) cases were included in therapeutic group, the gestational age was (24.0±2.2) weeks. The operation time was (22±9) minutes in preventive group and (24±13) minutes in therapeutic group, there was no statistical difference between the two groups (P>0.05). Live-birth rate between preventive cerclage group and therapeutic cerclage group was no statistically significant difference (P>0.05). The term birth rate (72.9%, 35/48) in preventive group was higher than that in therapeutic group (47.1%, 32/68), the difference was statistically significant (P<0.01). Neonatal hospitalization rate was lower in preventive group (14.6%, 7/48) than therapeutic group (36.8%, 25/68) , the difference was statistically significant (P< 0.01). (3) In the failure group placental pathology was examed in 7 cases. The placental tissue showed a large number of neutrophils infiltrating in 6 cases (6/7). In the successful group, 27 pregnant women deliveried between 28 to 33(+6) weeks (26.0%,27/104), 10 pregnant women deliveried between 34 to 36(+6) weeks 10 cases (9.6%, 10/104), 67 cases deliveried after 37 weeks (64.4%, 67/104). A lot of factors including maternal age, the previous cervix operation history, perioperative application of progesterone, operation time and preoperative invasive procedure were compared between the successful group and the failure group. Only maternal age and preoperative invasive proedcure were statistically significant (P<0.05) and the others had no statistical significance (P>0.05). (4) There were 68 cases in the therapeutic group, 7 cases failed, and 61 cases succeeded; the preoperative cervical os in failure group [(21 ± 20) mm] was wider than that in successful group [(14±5) mm], the difference was statistically significant (P<0.05); and preoperative vaginal ultrasound measurement of cervical canal length were (18 ± 8) mm versus (19 ± 10) mm, there was no statistically significant difference (P>0.05).The McDonald cervical cerclage for cervical incompetence is a simple, safe and high successful rate of intervention measures. The term labor rate of prophylactic cervical cerclage was higher than that of the therapeutic cerclage. Older maternal age and preoperative invasive procedure may be the risk factors for cerclage. The infection may play an important factor leading to the failure of McDonald cervical cerclage.
- [Serum relaxin in cervical incompetence patients]. [English Abstract, Journal Article]
- Zhonghua Yi Xue Za Zhi 2015 Sep 15; 95(35):2817-20.
To analyze the serum relaxin and clinical character of cervical incompetence patients and normal pregnant women.A total of 33 cervical incompetence patients (research group) and 33 normal pregnancy women with the same gestational age (control group) were recruited into the study. The serum relaxin level was detected with enzyme labeled immunosorbent assay (ELSIA) in the two groups, and the cervical length of early pregnancy period (cm), body mass index (BMI, kg/m2), frequency of polycystic ovary syndrome (%), gestational diabetes mellitus/diabetes mellitus (%) and outcomes in the two groups were analyzed with independent samples t test and chi-square test.All the cervical incompetence patients were recruited between Feb. 2008 and Sept. 2012, with the average termination gestational age of 30±6 weeks. Among them, 15 (45.45%) was abortion, 12 (36.36%) was preterm birth, 6 (16.18%) was term birth. The average BMI before pregnancy was 27±4 kg/m2, and the average serum relaxin was 2,748±82 mg/L; for the 33 patients in the control group, the average termination gestational age was 38±3 weeks, and 1 (3.03%) of them was abortion, 4 (12.12%) was preterm birth, 28 (84.85%) was term birth. The average BMI before pregnancy was 23±3 kg/m2, the average serum relaxin was 2,602±126 mg/L. Compared with the control group, the research group had more patients who complicated with polycystic ovary syndrome and gestational diabetes mellitus/diabetes mellitus (P<0.01, <0.05) and worse pregnancy outcomes (P<0.01); the average BMI before pregnancy and the average serum relaxin level of the research group were significantly higher than control group (P<0.01, P<0.01). Analysis through the unconditional logistic regression showed that BMI and serum relaxin were both independent risk factors of cervical incompetence.The high level of serum relaxin is an independent risk factor of cervical incompetence; women with polycystic ovary syndrome may more likely to have cervical incompetence and serum relaxin may have the predictive value for cervical incompetence.
- Needleless Robotic-Assisted Abdominal Cerclage in Pregnant and Nonpregnant Patients. [Journal Article]
- J Minim Invasive Gynecol 2016 Mar-Apr; 23(3):298-9.
To demonstrate the step-by-step surgical technique of "needle-free" robotic-assisted transabdominal cerclage placement.Through surgical video footage, presentation of a step-by-step demonstration of robotic-assisted laparoscopic placement of abdominal cerclage (Canadian Task Force classification III).The procedure was undertaken at Banner University Medical Center in Phoenix, Arizona. The local Institutional Review Board does not consider case reports research, and thus its approval was not required.The patients had a history of cervical insufficiency. The first patient (case 1) was a nongravid 32-year-old woman with 2 late second trimester pregnancies delivered by cesarean section owing to cervical insufficiency. The second patient (case 2) was a 26-year-old woman in her sixth pregnancy with 4 previous second trimester losses due to cervical insufficiency, including a failed McDonald cerclage.Robotic-assisted abdominal cerclage placement was performed in both patients. The procedure used an 8-mm, 0° scope; an 8-mm, 30° scope; monopolar scissors; and Maryland bipolar graspers. Following a complete survey of the pelvis and abdomen, the cervicouterine isthmus was identified bilaterally. The anterior leaflet of the right broad ligament was entered sharply, and the dissection was carried out in small increments to ensure safety and hemostasis. The right uterine artery was identified and skeletonized. The left broad ligament was entered in a similar fashion. Once a bladder flap was developed, a gentle wiping technique allowed for mobilization of the bladder from the vesicouterine junction with excellent hemostasis. In case 1, a uterine manipulator was used to flex the uterus. In case 2, a laparoscopic paddle device was introduced gently to allow for mobilization of the gravid uterus. An avascular tunnel was created on both sides of the cervicouterine isthmus, thereby eliminating the need for the Mersilene tape needle. Thus, a needleless Mersilene tape was introduced into the tunnel formed previously. In our opinion, the ideal knot placement is in the posterior cul-de-sac, as shown in the nongravid uterus. However, in the gravid uterus, owing to the difficulty of access, the knot was placed anteriorly, and reperitonization was performed. Four square knots were sufficient, with the snug (but not too tight) Mersilene tape at the cervicouterine isthmus. In both cases, there was minimal blood loss with no complications. In addition to these 2 operations, robotic-assisted transabdominal cerclage was successfully performed in another 21 patients.A needle-less robotic-assisted laparoscopic technique can be performed safely and effectively in both gravid and nongravid patients.
- [Cervical cerclage in Reunion island: Evaluation of physicians' practice patterns]. [JOURNAL ARTICLE, ENGLISH ABSTRACT]
- J Gynecol Obstet Biol Reprod (Paris) 2015 Nov 24.
Cervical incompetency is one of the direct causes of neonatal morbidity and mortality; a unique and efficient treatment of which is cervical cerclage. The objective of this study was the evaluation of physicians' practice patterns concerning cerclage in Reunion Island, in order to reinforce the management and information of patients at risk. The indications and complications of cerclages effectuated in 2010 and 2011 were compared to the literature.In this retrospective study, all the medical records of cerclage realized in Reunion Island during two years were collected and analyzed, specifically data concerning patients' cerclage, the complications, and the outcome of the pregnancy.We listed 200 cerclages, which were predominantly prophylactic cerclages (75.5%) and represented 0.71% of all births. A total of 71% of the indications of cerclage in Reunion Island did not take into account the recommendations of the literature. Analysis revealed the frequent use of prophylactic cerclage and subsequently reflected the insufficient use of therapeutic cerclage. In those cases, the rate of premature delivery was indeed lower (P=0.003), as well as the rate of chorioamniotitis (P=0.003).Cerclage is an efficient treatment to extend the length of the pregnancy. Nevertheless, it is important to comply with the recommendations given by the literature, by spotting the patients at risk of premature delivery, and recommend cerclage only in case of real cervical incompetency, for the sake of improving their management and reducing the rate of complications.
- Dynamic collagen changes in cervix during the first trimester and decreased collagen content in cervical insufficiency. [Journal Article]
- J Matern Fetal Neonatal Med 2016 Sep; 29(18):2968-72.
To determine the changes in cervical collagen during the first trimester of pregnancy and to evaluate the collagen deficit in cases with a previous diagnosis of cervical insufficiency (CI).Cervical punch biopsies were obtained from 66 patients divided into three groups: patients with recurrent abortions due to CI (CI group; n = 8); first-trimester abortion group (study group; n = 37), subdivided into three groups according their gestational week (<7, 7-9 and 9-12 weeks), and patients with cervical biopsy due to gynecologic reasons (control group; n = 12). Collagen quantity was determined by a biochemical method that measured the levels of hydroxyproline (HOP) in dry cervix tissue.The HOP concentrations were significantly higher at lower gestational ages (p = 0.001). Collagen quantity was lowest in the CI group compared with other groups (p < 0.001).This study shows collagen component of cervix decreases as pregnancy advances through the first trimester. Cervical collagen concentration is lower in women with a history of CI compared to controls who has not a history of CI.