Outcome of emergency cerclage for advanced cervical dilatation: a retrospective analysis.

Background: The objective was to evaluate the outcome of late second trimester emergency cerclage in patients with advanced cervical dilatation with bulging membranes. Methods: Setting: department of obstetrics and gynaecology, PSG Institute of medical sciences & research, Coimbatore, Tamil Nadu, India. This is a retrospective study of case files of patients who underwent emergency late second trimester cerclage for advanced cervical dilatation with bulging membranes between January 2009 to January 2014. McDonald’s technique was used in all the cases. Results: Altogether, 7 patients (100%) underwent late second trimester emergency cerclage between 20-28 weeks of gestational age, out of which three patients (42.86%) had term deliveries (>37w), and 3 patients (42.86 %) carried on their pregnancies to more than 32 weeks resulting in healthy live born babies. Two of them delivered by normal vaginal delivery, 4 underwent LSCS, and one patient had severe abdominal pain with bleeding and draining per vaginum after 3 days of cerclage, in view of which the stitch was removed. Subsequently, the patient expelled a live foetus weighing 620gms, which died in the Neonatal Intensive Care Unit (NICU) after 3 hours. This procedure prolonged the duration of pregnancy in all patients with a mean duration of 70.4 days. The mean gestational age at the time of delivery was 34.33 weeks. The mean birth weight was 2.18 kg and ranged between 1.97 to 2.64 kg. The mean APGAR at one minute was 8/10 and the mean duration of stay in NICU was 1.66 days. All the new-born babies were healthy at the time of discharge. The live birth rate following emergency late second trimester cerclage in this series was 85.75%. Conclusion: Favourable neonatal outcome can be accomplished in patients with cervical incompetence in the second trimester of pregnancy following emergency cervical suturing, even if performed when the membranes are bulging through the cervix.

Management of Cervical Incompetence with Bulging Fetal Membranes : Emergency Cerclage Versus Bed Rest / 대한주산의학회잡지

PURPOSE: To compare clinical outcomes after management with bed rest versus cerclage for treatment of amniotic sac bulging in the second trimester. METHODS: Women with cervical incompetence with membranes at or beyond a dilated external cervical os, before 27weeks of gestation, were treated with bed rest or emergency cerclage. We analyzed the pregnancy outcome retrospectively. 25 women underwent an emergency cerclege and 35 women underwent the bed rest. RESULTS: Gestational age at time of diagnosis was 22.40 weeks in the emergency cerclage and 22.39 weeks in the bed rest group. Mean interval from diagnosis until delivery was 8.65 weeks in the emergency cerclage group and 1.18 weeks in the bed rest group (p<0.001). Mean gestational age at delivery was 31 weeks in emergency cerclage group and 23.74 weeks in the bed rest group (p<0.001). Preterm delivery before 26 weeks and 34 weeks of gestation were significantly lower in the emergency cerclage group (p<0.001). Perinatal mortality was 17.4% in the emergency cerclage group and 48.6% in bed rest group (P=0.026). CONCLUSION: Emergency cerclage reduced preterm delivery before 26 and 34 weeks and improved perinatal outcome compared with bed rest treatment.

Delayed Interval Delivery after Emergency Cerclage of Cervical Incompetency in Twin Pregnancy by in vitro Fertilization / 대한주산의학회잡지

Twin pregnancies are at substantially higher risks for premature delivery than singleton pregnancies. This further increases their risk of perinatal and infant mortality. Recently there has been a marked increase in multiple pregnancies as a direct result of assisted reproductive technology. Cervical incompetency is a condition in which a pregnant woman's cervix begins to dilate and efface before her pregnancy has reached term. And multiple pregnancies and pregnancies by in vitro fertilization (IVF) have been increasing the risk of cervical incompetency. In twin pregnancy during preterm delivery, successful delayed-interval deliveries may improve the neonatal outcomes of the second fetus. We report a case of a delayed interval delivery in twin pregnancy of incompetent of cervix with an interval of 28 days after 3rd emergency cerclage.

Delayed Interval Delivery after Emergency Cerclage of Cervical Incompetency in Twin Pregnancy by in vitro Fertilization / 대한주산의학회잡지

Twin pregnancies are at substantially higher risks for premature delivery than singleton pregnancies. This further increases their risk of perinatal and infant mortality. Recently there has been a marked increase in multiple pregnancies as a direct result of assisted reproductive technology. Cervical incompetency is a condition in which a pregnant woman's cervix begins to dilate and efface before her pregnancy has reached term. And multiple pregnancies and pregnancies by in vitro fertilization (IVF) have been increasing the risk of cervical incompetency. In twin pregnancy during preterm delivery, successful delayed-interval deliveries may improve the neonatal outcomes of the second fetus. We report a case of a delayed interval delivery in twin pregnancy of incompetent of cervix with an interval of 28 days after 3rd emergency cerclage.

Emergency cerclage in cervical incompetence / 대한산부인과학회지

Emergency cerclage is the only way to prolong pregnancy for women with advanced cervical dilatation with or without prolapsed membrane. Without cerclage, miscarriage is almost always inevitable. Emergency cerclage should be performed after considering indications, contraindications, benefits and risks. Further researches on advanced operative skill, prognostic factors and postoperative medical treatment will improve the outcome of emergency cerclage.

Emergency cervical cerclage in advanced cervical incompetence / 대한산부인과학회지

OBJECTIVE: To investigate the clinical effectiveness of emergency cervical cerclage in pregnant women with advanced cervical incompetence in the second trimester. METHODS: This study analyzed retrospectively the pregnancy outcomes of 20 patients who were offered emergency cerclage between June 2000 and April 2004. Group I was defined as the patients cervical dilatation without membrane prolapse. Group II was the patients with membrane prolapse into vagina, who were underwent amniocentesis to decrease intraamniotic pressure. RESULTS: The mean+/-SD gestational age at cerclage was 21.6+/-2.4 weeks (Group I: 21.0+/-2.5, Group II: 22.1+/-2.3). The mean cervical dilatation was 2.5+/-0.9 cm (Group I: 1.8+/-0.5, Group II: 3.2+/-0.8) and mean effacement was 79.0+/-12.9% (Group I: 68.8+/-11.6, Group II: 87.3+/-6.4). The mean interval from cerclage to delivery was 9.4+/-5.3 weeks (Group I: 11.1+/-6.1, Group II: 7.9+/-3.7) and mean gestational age at delivery was 31.0+/-6.0 weeks (Group I: 32.2+/-7.4, Group II: 30.0+/-4.9). The birth weight was 1.9+/-1.1 kg (Group I: 2.4+/-1.4, Group II: 1.6+/-0.8) and the perinatal survival rate was 75% (Group I: 77%, Group II: 73%). Cervix dilatation and effacement were significantly more advanced in group II compared to the group I (p<0.05). However, the duration of pregnancy prolongation and birth weight, gestational age at the delivery were not significantly different between both groups. CONCLUSION: This results suggest that emergency cervical cerclage might be an effective treatment in advanced cervical incompetence, and that the concomitant amniocentesis could help the cerclage in the patients with membrane prolapse.

A Clinical Significance of Emergency Cerclage for Patients with Advanced Painless Cervical Dilatation / 대한산부인과학회지

OBJECTIVE: To assess the clinical significance of emergency cerclage in the patients with advenced painless cervical dilatation. METHODS: We performed the analysis of the pregnancy outcomes of the 14 patients who underwent emergency cerclage between January 1990 and December 2001 at Seoul National University Hospital. Only singleton pregnancies were included. We compared these results with those of the 56 patients who underwent elective cerclage in the same period. RESULTS: In the patients with emergency cerclage, mean gestational age at cerclage was 20.71 +/- 3.24 weeks and mean gestational age at delivery was 29.84 +/- 7.40 weeks. The mean cerclage-to-delivery interval was 9.14 +/- 7.53 weeks and overall perinatal survival rate was 63.4%. After cerclage, rupture of membrane occurred in 2 cases (14.3%), preterm labor developed in 8 cases (57.1%) and slipping out of cerclage suture developed in 3 cases (21.4%). In comparison with elective cerclage, mean gestational age at delivery, interval between cerclage and delivery, Apgar scores at birth, perinatal death, preterm delivery rate before 28 and 32 weeks' gestation and neonatal birth weight showed worse outcome in emergency cerclage group than elective cerclage group. CONCLUSION: Although emergency cerclage shows worse outcomes than elective cerclage, it seems to be optional treatment modality for patients with painless cervical dilatation considering pregnancy prdongation and neonatal survival.

Recent Management of Cervical incompetence / 대한산부인과학회지

Treatment of incompetent cervix has traditionally been surgical correction of presumed physical deficit in tissue strength with an encircling or cerclage suture, placed electively between 12 and 15 weeks or urgently in the second trimester. Despite the prolonged controversy about the role of cerclage, a randomized trial of cerclage versus bed rest or no therapy in women with atypical history of incompetent cervix has not been concluded. Until conclusive information is available, clinicians challenged to make the best management decision or each patient based on her history and cervical examination. Women with either a typical history of recurrent midtrimester delivery in the absence of another diagnosis or with atypical history accompanied by significant cervical effacement should be offered treatment with cerclage accompanied by an acknowledgement that it's efficacy is unproven. A cerclage operation may be considered during pregnancy in four clinical setting which is elective cerclage, urgent cerclage, emergency cerclage, transabdominal cerclage.

Emergency Cervical Cerclage: A Retrospective Study of 5 Years' Practice in 71 Cases / 대한산부인과학회잡지

OBJECTIVE: We investigated the outcome of emergency cervical cerclage in women with cervical incompetence. Cervical incompetence was diagnosed when cervical dilatation exceeded 2 cm with intact but bulging membranes. METHODS: Retrospective chart review of 71 cases of patients who underwent emergency cervical cerclage using Mcdonald suture after amnioreduction performed for cervical incompetence with cervical dilatation and membrane bulging from March 1998 through August 2003 at Kang-Nam Sacred Heart Hospital, Hallym University. Clinical variables evaluated included gestational age at cerclage, cervical dilatationa at cerclage, prolongation of pregnancy, and neonatal outcome. RESULTS: Emergency cerclage was performed successfully in 67 cases (94%). Gestational age at cerclage ranged from 16 weeks to 29 weeks, with the mean being 23.6 +/- 3.3 weeks. Cervical dilatation at cerclage was between 2 cm and 9 cm (mean 3.8 +/- 1.6 cm). Gestational age at delivery ranged from 16 to 40 weeks (mean 28.2 +/- 6.0 weeks). Prolongation of pregnancy following cerclage varied from between 1 to 134 days (mean 31.5 +/- 33.1 days). The median birth weight was 1370.29 +/- 72.6 g (range 140-3640 g). Thirty-seven babies were born live, and 30 of them survived (survival rate 49%). CONCLUSION: The possibility of a 49% survival rate is considered a good result for emergency cerclage. Emergency cervical cerclage can prolong pregnancy and influence the outcome of pregnancy favorably, and may be considered one potential method of treatment in such cases.

Emergency Cervical Cerclage Using Shirodkar Method / 대한산부인과학회잡지

Cervical incompetence is characterized by painless dilation and effacement of the cervix in the second trimester of pregnancy leading to premature rupture of membranes and preterm delivery. Various surgical and nonsurgical approaches have been advocated as treatment for incompetent cervix. The most widely used surgical methods are the Shirodkar and McDonald methods of cervical cerclage. Shirodkar method is more difficult to perform than the McDonald method, but it makes it possible for the cervix to return to more anatomically safe position. We experienced two cases of mild amniotic membrane bulging associated with incompetent cervix; one during 28(+4) weeks of pregnancy and the other during 25(+6) weeks of pregnancy. We were able to perform the emergency cervical cerclage with Shirodkar method by using the allis clamp on the edge of the incision site to traction the dilated and effaced cervix effectively, and were able to maintain the two cases of pregnancy. Both delivered healthy babies at term. So we report this case with a brief review of literature.

Emergency Cervical Cerclage Using Shirodkar Method / 대한산부인과학회잡지

Cervical incompetence is characterized by painless dilation and effacement of the cervix in the second trimester of pregnancy leading to premature rupture of membranes and preterm delivery. Various surgical and nonsurgical approaches have been advocated as treatment for incompetent cervix. The most widely used surgical methods are the Shirodkar and McDonald methods of cervical cerclage. Shirodkar method is more difficult to perform than the McDonald method, but it makes it possible for the cervix to return to more anatomically safe position. We experienced two cases of mild amniotic membrane bulging associated with incompetent cervix; one during 28(+4) weeks of pregnancy and the other during 25(+6) weeks of pregnancy. We were able to perform the emergency cervical cerclage with Shirodkar method by using the allis clamp on the edge of the incision site to traction the dilated and effaced cervix effectively, and were able to maintain the two cases of pregnancy. Both delivered healthy babies at term. So we report this case with a brief review of literature.

Experiences of Amnioreduction and Emergency Cerclage for Advanced Cervical Incompetence / 대한산부인과학회잡지

Cervical incompetence is one of the main contributors to repeated pregnancy loss and preterm delivery. Typically it results in progressive cervical dilatation, leading to a painless second or early third trimester abortion. Emergency cerclage can be used in the setting of advanced cervical incompetence, even when fetal membranes bulge through the dilated cervix. To facilitate the procedure, various techniques have been developed to replace the fetal membranes into the uterine cavity. We performed six successful cases of emergency cerclage combined with amnioreduction in advanced incompetent internal os of cervix (IIOC). Interval from emergency cerclage to delivery was 8.1 +/- 2.4 weeks (range 4-10 weeks) and we delivered viable fetuses in all but one. Hereby we report our experiences with a brief review of literature.

A Significance of Emergency Cerclage in Cervical Incompetence with Advanced Cervical Dilatation / 대한산부인과학회잡지

OBJECTIVE: To investigate the clinical significance of emergency cerclage on prologation of pregnancy and perinatal outcome in mid-trimester cervical incompetence with advanced cervical dilatation. METHODS: We analyzed the pregnancy outcome retrospectively by the medical record review for 16 patients who had emergency cervical cerclage placed from March 1995 to June 2001. And these data were compared with those of 48 patients who had elective cervical cerclage placed during the same period. RESULTS: The mean gestational age of the patients at emergency cerclage was 22.0+/-2.3 weeks. The mean cervical dilatation was 2.9+/-1.2 cm and mean effacement was 55.3+/-4.7%. The mean prolongation of pregnancy after cerclage was 63.1+/-54.7 days (median 61, range 2-152) and the mean duration of antepartum hospitalization was 10.1+/-12.6 days (2-52). After cerclage, preterm premature rupture of the membranes occurred in 5 cases (31%), clinical chorioamnionitis in 3 cases (19%), and preterm labor in 5 cases (31%). The mean gestational age at delivery was 31.1+/-7.1 weeks. Perinatal survival rate was 85% (17/20), and neonatal survival rate was 94% (17/18). CONCLUSION: It seems that emergency cerclage contribute to maintenance of pregnancy and improve perinatal outcome of fetuses in cervical incompetence with advanced cervical dilatation.

A Case of Emergency Cerclage for Advanced Cervical Incompetence / 대한산부인과학회잡지

Emergency cerclage commonly known as that performed in the setting of advanced cervical dilatation with bulging membranes and associated with significantly increased failure rates. We experienced a successful emergency cerclage for advanced incompetent internal os of cervix ( IIOC ). Pregnancy was prolonged and we delivered viable fetus. Hereby we report this case with the brief review of literature.

Clinical Efficacy of Emergency Cerclage for Advanced Cervical Incompetence / 대한산부인과학회잡지

To evaluate the clinical efficacy of emergency cervical cerclage in the treatment of advanced cervical incompetence, a prospective clinical trial was performed in 18 patients with advanced cervical incompetence at 20 to 25 weeks gestation. Modified McDonalds operation with or without transabdominal amniocentesis was used for cervical cerclage. Pregnancy was prolonged for a sufficient time to deliver viable fetuses in 56.3% of patients. The median procedure-to-delivery interval was 8.6 (range 0.1 to 20.5) weeks for the entire group, and 13.9 (range 6.5 to 20.5) weeks for 9 patients who achieved live birth. The median gestational age at delivery was 38.6 (range 28.3 to 41.0) weeks for the live infants. The median birthweight of the live infants was 3062 g (range 1050 to 3620 g). The lack of significant matemal morbidity combined with the results for the fetus-infant supports further efforts in this area.