cervical incompetence [keywords]
- Comparative assessment of Arabin pessary, cervical cerclage and medical management for preterm birth prevention in high-risk pregnancies. [JOURNAL ARTICLE]
- J Matern Fetal Neonatal Med 2016 Aug 23.:1-16.
This study aimed to compare the efficacy of combined use of Arabin pessary, cervical cerclage and progesterone with progesterone-only management of pregnant women at high risk of preterm birth.The study included 203 pregnant women at high risk of preterm birth who were randomised to receive Arabin pessary (Group 1, n = 82) and progesterone, circular cervical cerclage and progesterone (Group 2 = 121), or progesterone treatment only (Group3, controls, n = 50). Patients in the pessary and cerclage group also received progesterone.The use of Arabin pessary combined with progesterone resulted in a 2.5-fold decrease in the rate of vaginal dysbiosis in pregnancy (p = 0.015) and almost 3-fold reduction in in the postpartum period (p = 0.037), combined with circular cervical cerclage and progesterone. Suture eruption was observed in 4.3% of women. In patients with abnormal placental location, placental migration was observed in 62.1% of patients in Group I, 52.1% in Group II and a significantly lower proportion of patients (14.0%) in Group III (p = 0.001). Bleeding during pregnancy was observed significantly more often in both comparison groups (p = 0.005). Incidence of intrapartum bleeding was 17.4% (p = 0.011) in Group II and 24.5% in Group III (p = 0.002). Intrapartum chorioamnionitis was observed in 4.3% of patients in Group II and 2.04% of patients in Group III.The use of Arabin pessary compbined with progesterone reduces the rate of infectious complications and bleeding during pregnancy and the postpartum period.
- Successful term delivery cases of trans-abdominal cervicoisthmic cerclage performed at more than 18 weeks of gestation. [Journal Article]
- Obstet Gynecol Sci 2016 Jul; 59(4):319-22.
A 38-year-old nulliparous woman was referred to our clinic because of cervical incompetence at 19 weeks of gestation. Trans-abdominal cervicoisthmic cerclage was performed after failure of modified Shirodkar cerclage operation in the patient at 21 weeks of gestation via a laparotomic approach. Another 38-year-old patient, who underwent loop electrosurgical excision procedure conization for treatment of cervical dysplasia 4 years ago, presented for cervical incompetence. At 18 weeks of gestation, we performed trans-abdominal laparotomic cervicoisthmic cerclage without any post-operative complications. During antenatal follow-up, there were no obstetrical co-morbidities and finally she gave birth to a healthy infant at full term by cesarean section. We report two cases of women who underwent trans-abdominal cervicoisthmic cerclage surgery because of cervical incompetence as they were not suitable for transvaginal cervical cerclage. Both patients successfully maintained their pregnancy until full term after undergoing transabdominal cervicoisthmic cerclage at more than 18 weeks of gestation.
- Severe Hemoperitoneum During Pregnancy with Obstructed Hemivagina and Ipsilateral Renal Anomaly Syndrome: A Case Report. [Case Reports, Journal Article]
- J Reprod Med 2016 May-Jun; 61(5-6):290-4.
Müllerian tract anomalies have been reported in 2-3% of females. Uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis (OHVIRA) syndrome is a rare condition, with only a few cases of the syndrome occurring during pregnancy having been reported.A 35-year-old, nulli-gravid woman at 18 weeks of gestation was referred due to cervical incompetence. Her first symptom was genital bleeding. Ultrasonography and MRI led to the diagnosis of OHVIRA syndrome, and pregnancy was confirmed on the affected side with the amniotic sac found to be protruding from the cervix into the vaginal cavity. She was subsequently hospitalized and received a tocolytic agent to treat frequent uterine contractions. At 30 weeks of gestation she experienced abrupt and acute abdominal pain. We therefore performed emergent cesarean section, at which time severe hemoperitoneum due to the rupture of an anomalous venous plexus on the surface of the uterus was noted.Pregnancies with Müllerian tract anomalies are rare, and severe hemoperitoneum during pregnancy can be life-threatening for both the mother and fetus. Therefore, clinicians should keep a diagnosis of acute hemoperitoneum in mind in the management of pregnancies complicated by OHVIRA syndrome.
- 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.