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PubMed2003

Current controversies in cervical cerclage.

Cervical incompetence is defined as the inability to support a full-term pregnancy because of a functional or structural defect of the cervix. It is characterized clinically by acute, painless dilatation of the cervix usually in the mid-trimester culminating in prolapse and/or premature rupture of the membranes with resultant preterm and often previable delivery. Cervical cerclage has become the mainstay for the management of cervical incompetence, but remains one the more controversial surgical interventions in obstetrics. This article reviews the current state of the literature as regards the indications, contraindications, and techniques of cervical cerclage. This article also focuses in detail on 4 areas of controversy, namely transabdominal cerclage, cervical cerclage for a short cervix, the management of cerclage after preterm premature rupture of the membranes, and the utility of a second (salvage) cerclage.

Cerclage, Cervical↗
PubMed2003

Changing trends in the obstetric indications for cervical cerclage.

Cervical incompetence causes repeated mid-trimester miscarriage and preterm delivery with high fetal wastage. Since the introduction of cervical cerclage in 1951, it has undergone many changes with regard to the techniques, indications and postoperative care. The objective of this study is to review the changing trends in the current indications of cervical cerclage and subsequent perinatal outcome at the maternity hospital from January 1992 to December 1999. All the files of women who had had cervical cerclage were evaluated in terms of characteristics of the women, indications and obstetric outcome after cervical cerclage. Of 65539 who delivered in the hospital, 1021 women had had cervical cerclage, giving an incidence of 1.21%. There was a significant increase in the incidence of cervical cerclage, from 1.13% in 1992 to 1.40% in 1999 (P < 0.01). More women with multiple pregnancy in 1996 - 99 had cerclage than in 1992 - 94 period [22.7 vs. 8.5% (P < 0.01)]. It is clear that more cervical sutures are being performed in multiple pregnancies arising from assisted reproductive technology as well as after ultrasonographic evidence of cervical dilatation. A multicentre randomised clinical trial is therefore advocated to evaluate its effectiveness in these cases.

Adult↗
PubMedDate not supplied

Transabdominal cervical cerclage.

Cervical cerclage is a procedure carried out to increase the fetal salvage rate in women with a history of previous miscarriages. This article discusses the merits of transabdominal cerclage as opposed to the more usual procedure of transvaginal cervical cerclage.

Adult↗
PubMed2000

Laparoscopic removal of a transabdominal cervical cerclage.

Cervical incompetence has been acknowledged as a significant entity predisposing patients to second-trimester miscarriage. Various surgical techniques and approaches have been used in an attempt to prolong pregnancy and improve perinatal outcome. These include transvaginal and transabdominal cervical cerclage. Some patients require the placement of a transabdominal cervicoisthmic cerclage. Should the cerclage fail or the patient have preterm premature rupture of membranes, removal of the cerclage may be necessary. As a result the application of laparoscopy for the management of cervicoisthmic cerclage removal has been advocated in an effort to limit surgical complications. We report a case of laparoscopic removal of a transabdominally placed cervical cerclage in a 32-year-old woman at 16 weeks' gestation with preterm premature rupture of membranes and inevitable miscarriage. Laparoscopy appeared to be a safe and effective means of managing the removal of this transabdominally placed cervicoisthmic cerclage.

Abdomen↗
PubMed1990

Uterine activity in patients with cervical cerclage.

Cervical cerclage is the traditional management of cervical incompetence. Uterine activity among these patients has never been studied. This retrospective report details the contraction frequency in 96 patients with cerclage who underwent daily home uterine activity monitoring. Twenty-three percent (22) developed preterm labor and 12% (11) had preterm delivery related to failed tocolysis or rupture of the membranes. Uterine activity in the group who developed preterm labor was significantly greater than in those who labored at term. The objective contraction frequency data obtained by uterine activity monitoring are of clinical significance to physicians managing such patients.

Female↗
PubMed1996

Emergent and elective cervical cerclage for cervical incompetence.

OBJECTIVE: The clinical outcomes of emergent and elective McDonald cerclage including cases of prolapsed amniotic sac were compared. METHOD: Forty-eight patients undergoing elective cervical cerclage suture and 21 patients receiving emergent cervical cerclage including eight cases of prolapsed fetal membranes in the vagina were retrospectively analyzed. RESULTS: Prolongation of pregnancy (145 +/- 27 vs. 58 +/- 56 days, P < 0.001), delay of delivery (37.0 +/- 3.1 vs. 28.3 +/- 7.8 gestational weeks, P < 0.001), higher birth weight (3033 +/- 751 vs. 1410 +/- 1139 g, P = 0.001), better fetal salvage rate (98 vs. 52%, P < 0.05), and fewer lower Apgar scores (score < 7: 4/48 vs. 13/21 at 1 min, P = 0.000; 2/48 vs. 10/21 at 5 min, P = 0.000) were attained in the elective group compared with those in the emergent group. The clinical outcomes were not significantly different between those with and those without prolapsed fetal membranes, but this may have been due to the small sample size. CONCLUSION: In addition to elective cervical cerclage, we recommended this procedure in emergency cases even in those with a prolapsed amniotic sac.

Adult↗
PubMed1993

Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists multicentre randomised trial of cervical cerclage. MRC/RCOG Working Party on Cervical Cerclage.

OBJECTIVE: To assess whether cervical cerclage in women deemed to be at increased risk of cervical incompetence prolongs pregnancy and thereby improves fetal and neonatal outcome. DESIGN: Multicentre randomised controlled trial. SETTING: Hospitals in the United Kingdom, France, Hungary, Norway, Italy, Belgium, Zimbabwe, South Africa, Iceland, Ireland, the Netherlands and Canada. SUBJECTS: One thousand two hundred and ninety-two pregnant women whose obstetricians were uncertain whether to recommend cervical cerclage, most of whom had a history of early delivery or cervical surgery. INTERVENTIONS: Cervical cerclage was compared with a policy of withholding the operation unless it was considered to be clearly indicated. MAIN OUTCOME MEASURES: Delivery before 33 completed weeks, preterm delivery (< 37 weeks), and vital status of the baby after completion of the pregnancy. RESULTS: The overall preterm delivery rate was 28%. There were fewer deliveries before 33 weeks in the cerclage group (83 (13%) compared with 110 (17%), P = 0.03) and this difference reflected deliveries characterised by features of cervical incompetence (painless cervical dilatation and prelabour rupture of the membranes). There was a corresponding difference in very low birthweight deliveries (63 (10%) compared with 86 (13%), P = 0.05). The difference in the overall rate of miscarriage, stillbirth or neonatal death (55 (9%) compared with 68 (11%)) was less marked and was not statistically significant. The use of cervical cerclage was associated with increased medical intervention and a doubling of the risk of puerperal pyrexia. CONCLUSIONS: These results suggest that the operation had an important beneficial effect in 1 in 25 cases in the trial (95% confidence interval (CI) 1 in 12 to 1 in 300 sutures). Its use is associated with increased medical intervention and puerperal pyrexia. Nevertheless, this trial suggests that, on balance, cervical cerclage should be offered to women at high risk, such as those with a history of three or more pregnancies ending before 37 weeks gestation.

Abortion, Spontaneous↗
PubMed1988

Interim report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists multicentre randomized trial of cervical cerclage. MRC/RCOG Working Party on Cervical Cerclage.

Overall 905 pregnant women whose obstetricians were 'uncertain' whether to recommend cervical cerclage, chiefly because of a history of early delivery or cervical surgery, were randomly allocated to cerclage or no surgery; 92% were treated as allocated. The overall preterm delivery rate was 30%. The results for those allocated cerclage were marginally statistically significant, more favourable in terms of fewer deliveries before 33 weeks [59 (13%) compared with 82 (18%), P = 0.03] and correspondingly for birthweight under 1500 g [48 (11%) compared with 73 (16%), P = 0.01] and for miscarriage, stillbirth or neonatal death [37 (8%) compared with 54 (12%), P = 0.06]. There were similar numbers of deliveries between 33 and 36 weeks [65 (14%) compared with 64 (14%)]. These results suggest that the operation had an important beneficial effect in one in 20 to 25 cases in the trial. But because the observed differences are not strongly statistically significant and because no such benefit has been seen in other randomized trials, there remains uncertainty about how much (if any) of this apparent benefit is real. So, the trial still remains open for randomization of more women whose obstetricians are uncertain about the advisability of cerclage.

Birth Weight↗
PubMed2003

Subarachnoid small-dose bupivacaine versus lidocaine for cervical cerclage.

UNLABELLED: Cervical cerclage is often performed as an outpatient procedure under subarachnoid anesthesia. Lidocaine was historically the drug of choice for short procedures but has fallen out of favor because of concerns of transient neurologic symptoms (TNS). We performed this study to determine whether small-dose bupivacaine is an acceptable alternative to lidocaine for cervical cerclage. We randomized 59 women to receive either subarachnoid isobaric lidocaine 30 mg or hyperbaric bupivacaine 5.25 mg. Fentanyl 20 micro g was added to both local anesthetics, and the total volume was diluted to 3 mL with 0.9% saline. Onset and highest dermatomal level of sensory block; quality of anesthesia; hypotension; and times until T12 regression, return of lower extremity motor function, ambulation, and micturition were recorded. Symptoms of TNS were evaluated by telephone interview 24 h after surgery. We did not find any significant difference in onset or recovery times between the groups, with the exception of a longer duration until return of lower extremity motor strength in the lidocaine group. Symptoms consistent with TNS that resolved spontaneously within 48 h were reported by two women in the lidocaine group but by none in the bupivacaine group. We conclude that subarachnoid bupivacaine offers a satisfactory alternative to subarachnoid lidocaine for cervical cerclage. IMPLICATIONS: We found that small-dose subarachnoid bupivacaine (5.25 mg) with fentanyl 20 micro g provides reliable anesthesia for cervical cerclage and exhibits a pharmacodynamic profile similar to that of small-dose lidocaine.

Adult↗
PubMed2005

Strategies for prevention--cervical cerclage.

Transvaginal cervical cerclage was introduced as a treatment for cervical incompetence in 1951. Over the years, our understanding of this clinical entity has changed tremendously, which has implications for obstetric management. This review focuses on the obstetric management of women considered to be at high risk of preterm delivery due to cervical incompetence at different stages of pregnancy.

Cerclage, Cervical↗
PubMed2003

Comparison of two methods of cervical cerclage by ultrasound cervical measurement.

OBJECTIVE: To compare the effects of cerclage performed with a modified Shirodkar procedure or with McDonald's technique using transvaginal ultrasound measurement of the distance between the external os and the suture. MATERIALS AND METHODS: We performed a retrospective study of all patients who underwent a prophylactic cerclage with either the modified Shirodkar procedure or the McDonald's technique over a 3-year period. Physicians chose the cerclage technique according to their own preferences. Transvaginal ultrasound examination of the cervix was performed 2 weeks after the cerclage to measure its functional length and the distance between the external os and the cerclage. RESULTS: During the study period, 14 patients had a cerclage with the modified Shirodkar procedure and 19 patients with the McDonald's technique. Twelve of these 33 patients (36.4%) delivered before 37 weeks. The obstetric characteristics of the patients in both groups were similar. There were no significant differences between the Shirodkar and McDonald groups as to the functional cervical length before (31.3 +/- 8.7 vs. 35.6 +/- 9.7 mm, respectively) or after (37.0 +/- 7.3 vs. 36.1 +/- 7.9 mm) cerclage, the distance between the external os and cerclage (16.7 +/- 3.8 vs. 14.0 +/- 5.2 mm), or the number of deliveries before 32 (0 vs. 2) and 34 (1 vs. 3) weeks. CONCLUSION: The anterior colpotomy of the Shirodkar procedure increased the distance between the external os and the cerclage by a mean of 2.7 mm. This slight gain does not justify exposing the patient to the risks related to this procedure. When cerclage is necessary, McDonald's technique seems preferable.

Adult↗
PubMed2004

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.

Adult↗
PubMed2002

Ultrasound-indicated cervical cerclage: outcome depends on preoperative cervical length and presence of visible membranes at time of cerclage.

OBJECTIVE: The purpose of this study was to assess cases of ultrasound-indicated cervical cerclage and to relate preoperative cervical length, operative findings, postoperative cervical length, and pregnancy outcome to establish the appropriate criteria to offer cervical cerclage. STUDY DESIGN: A prospective observational study comprised 380 women at high risk of preterm labor who underwent serial transvaginal ultrasonographic assessment of cervical length. Seventy-three women had criteria for and underwent cervical cerclage. Data concerning preoperative cervical length, operative findings, postoperative cervical length, and pregnancy outcome were collected. Statistical analysis was performed with Mann-Whitney and Fisher exact tests. RESULTS: There was a significant increase in median cervical length after cerclage, 15.0 versus 25.0 mm (P <.0001). Preoperative cervical length and postoperative upper cervical length were independently better predictors of outcome than postoperative entire cervical length. Fetal membranes were visible in 18% of cases at the time of suture insertion, which was associated with a significantly worse outcome, regardless of preoperative cervical length. Of those 41 women with a very short preoperative cervical length (< or = 15 mm), outcome was significantly worse in those women with visible fetal membranes at the time of cerclage compared with those women with no visible fetal membranes at the time of cerclage: median gestational age at delivery, 23 weeks versus 37 weeks 4 days (P =.002); suture insertion to delivery interval, 19 days versus 108 days (P =.0004); and fetal survival rates, 50% versus 86% (P =.03). CONCLUSION: In a high-risk population that undergoes serial transvaginal ultrasound surveillance of cervical length, the presence of visible fetal membranes at the time of suture insertion, regardless of preoperative cervical length, is associated with a poor outcome. Fetal membranes were not visible in any cases with a preoperative cervical length of >15 mm. These findings lend support to a practice of offering cerclage at or above a cervical length of 15 mm.

Adult↗
PubMed1996

Cervical cerclage in the treatment of cervical incompetence in Zambian women.

Over a period of 5 years from January 1989 to October 1994, 207 patients with cervical incompetence were managed with Mac Donald's cervical cerclage at Nkana/Wusikili Mine Hospitals, Kitwe, Zambia. The incidence rate of cervical incompetence in our population was 1.47%. Our results confirmed a success rate of 90.8% as compared to 52.5% in previous pregnancies. This represents 159 (76.8%) full term pregnancies, 29 (14%) premature deliveries and 19 (9.2%) abortions. Post operation total survival rate was 87.4% with fetal salvage ratio of 1.68. We confirmed that optimum time to insert cerclage was 18 weeks and below. The possibility of having a mature baby in the group of low number previous abortions was significantly higher as compared to the group with a higher number of habitual abortions. Better pregnancy outcome was seen in low parity group (less than 2 previous deliveries) as compared to higher parity group. Our study confirms that cervical cerclage is a successful way in the treatment of cervical incompetence.

Abortion, Habitual↗