Comparison of maternal-fetal outcomes between laparoscopic cervicoisthmic cerclage and McDonald cerclage in women with cervical insufficiency / 中华妇产科杂志

Objective:To compare the maternal and fetal outcomes of women with cervical insufficiency (CI) undergoing McDonald cerclage (MC) and laparoscopic cervicoisthmic cerclage (LCC), so as to provide evidence for the selection of cerclage methods.Methods:A retrospective trial was carried out in the First Affiliated Hospital of Sun Yat-sen University from January 2010 to December 2020. A total of 221 women who underwent the prophylactic cerclage were divided into MC group ( n=54), LCC with MC history group ( n=28) and LCC without MC history group ( n=129) by the mode of operation and whether the pregnant women who underwent LCC had MC history. General clinical data, pregnancy complications and pregnancy outcomes were compared between the three groups. Results:(1) General clinical data: the proportion of women accepted cervical cerclage during pregnancy in MC group, LCC with MC history group and LCC without MC history group were 100.0% (54/54), 7.1% (2/28) and 27.1% (35/129), respectively ( P<0.001). The indications of the three groups showed statistical significance ( P=0.003), and the main indication was the history of abortion in the second and third trimester [75.9% (41/54) vs 89.3% (25/28) vs 84.5% (109/129)]. (2) Pregnancy complications: the incidence of abnormal fetal position [7.8% (4/51) vs 17.4% (4/23) vs 19.8% (24/121)], placenta accrete [5.9% (3/51) vs 13.0% (3/23) vs 11.6% (14/121)], uterine rupture [0 vs 4.3% (1/23) vs 5.8% (7/121)] in the MC group were all lower than those in LCC with MC history and LCC without MC history groups. However, there were no statistical significances (all P>0.05). Intrauterine inflammation or chorioamnionitis [15.7% (8/51) vs 0 vs 0.8% (1/121)] and premature rupture of membrane [23.5% (12/51) vs 4.3% (1/23) vs 0] were both significantly higher in MC group than those in LCC with MC history and LCC without MC history groups (all P<0.001). (3) Pregnancy outcomes: the cesarean section rate was significantly lower in MC group (41.2%, 21/51) than that in LCC with MC history group (100.0%, 23/23) and LCC without MC history group (100.0%, 121/121; P<0.001). MC group was associated with lower expenditure than LCC with MC history and LCC without MC history groups (12 169 vs 26 438 vs 27 783 yuan, P<0.001). The success rates of live birth cerclage did not differ significantly in MC (94.4%, 51/54), LCC with MC history (82.1%, 23/28) and LCC without MC history (93.8%, 121/129) groups ( χ2=5.649, P=0.059). There was no significant difference in neonatal intensive care unit occupancy, neonatal birth weight and neonatal asphyxia between the three groups (all P>0.05). Conclusions:Both LCC and MC are the treatment choice for women with CI, which may get similar liver birth. However, MC has the advantages of low cesarean section rate, economical and easy operation. Therefore, MC is recommended as the first choice for CI patients, and LCC is for women with failed MC.

Parto pré-termo espontâneo sem rotura de membranas: intervenções para evitar o parto pré-termo / Spontaneous preterm birth without rupture of membranes: interventions to prevent preterm birth

A prematuridade é uma síndrome com múltiplos fatores de risco e cuja causa permanece desconhecida, mas, independentemente da etiologia, a parturição converge para uma via final comum de esvaecimento, dilatação e encurtamento do colo uterino. Do ponto de vista hormonal, o responsável por esse processo é a progesterona. A prevenção de quadros de prematuridade pode basear-se em tratamentos medicamentosos como a administração diária de comprimidos de progesterona; intervenções cirúrgicas para a contenção da cérvice uterina com fios inabsorvíveis mantidos até o termo, a cerclagem cervical; e o pessário cervical, dispositivo de silicone que envolve e inclina o colo uterino, evitando sua abertura. Para propor qualquer intervenção profilática ou terapêutica, a avaliação ultrassonográfica via transvaginal no segundo trimestre gestacional desempenha papel crucial. Apresentamos neste terceiro e último artigo da série sobre parto pré-termo espontâneo as intervenções terapêuticas e o rastreamento do colo uterino.(AU)

Preterm birth is a syndrome with multiple risk factors, with unknown etiology. Parturition converges to a final path with uterine cervix effacement, dilation and shortening and progesterone is the hormone responsible for this process. Preterm birth prevention relies on daily administration of progesterone pills; cerclage as a surgical intervention; or cervical pessary, a vaginal silicone device that enfolds and deflects the cervix, avoiding its opening. To propose any of these interventions it is crucial to evaluate the cervix during the second trimester by transvaginal ultrasound. Here, in the third and last article regarding preterm birth without membrane disruption, we present therapeutic interventions and ultrasound screening.(AU)

Analysis of the effect of modified cervical cerclage in the treatment of cervical insufficiency / 中华妇产科杂志

Objective:To discuss the surgical effect of modified cervical cerclage for the treatment of pregnant women with cervical insufficiency.Methods:The clinical data of 225 pregnant women who underwent modified cervical cerclage in Qilu Hospital (Qingdao) were selected for retrospective analysis from April 2014 to June 2020. Surgical success rate, full-term birth rate, preterm birth rate, prolonged pregnancy weeks and newborn birth weight were compared between singleton and twin pregnancies, preventive cerclage and emergency cerclage, surgery before and after 18 weeks, naturally and in vitro fertilization and embryo transfer (IVF-ET) conceived pregnant women respectively.Results:Among the 225 pregnant women, the gestational weeks of surgery were 14-24 +5 weeks, mean gestational weeks of delivery were 38 +2 weeks (35 +5-39 +3 weeks), the number of prolonged gestation were (20.3±5.2) weeks, and the newborn birth weight was (3 065±735) g; the overall surgical success rate was 92.9% (209/225), and the miscarriage rate was 7.1% (16/225); among the surviving newborns, the full-term birth rate was 73.7% (154/209), and the preterm birth rate was 26.3% (55/209). All cases had no intraoperative complications. Among the 225 pregnant women, 202 (89.8%, 202/225) cases were singleton pregnancies, and 23 (10.2%, 23/225) cases were twin pregnancies; 201 (89.3%, 201/225) cases underwent preventive cervical cerclage, and 24 (10.7%, 24/225) cases underwent emergency cervical cerclage; 190 (84.4%, 190/225) cases underwent the surgery before 18 weeks, and 35 (15.6%, 35/225) cases underwent the surgery after 18 weeks; 49 (21.8%, 49/225) cases were conceived by IVF-ET. There was no statistically significant difference in the overall surgical success rate of single and twin group ( P>0.05). The full-term birth rate, newborn birth weight and prolonged pregnancy weeks of single group were higher than those of twin group ( P<0.05). There were no statistical differences between preventive and emergency cerclage in overall surgical success rate, full-term birth rate, preterm birth rate, and newborn birth weight (all P>0.05). The pregnancy prolonged weeks of preventive cerclage was higher than that of emergency cerclage ( P<0.05). There were no statistically significant differences in the overall surgical success rate, full-term birth rate, preterm birth rate and birth weight of newborns at different surgical timings (all P>0.05). The pregnancy prolonged week for those who underwent surgery before 18 weeks was higher than that of surgery after 18 weeks ( P<0.05). The premature birth rate of IVF-ET was higher than that of naturally conceived pregnant women ( P<0.05). Conclusion:The modified cervical cerclage could effectively prolong the gestational weeks of delivery, reduce the rate of preterm birth, and the operation is simple and easy to promote. It could be used as a surgical option for patients with cervical insufficiency.

Effect of modified vaginal cervical cerclage in the treatment of cervical insufficiency during pregnancy / 中国基层医药

Objective:To investigate the efficacy of modified vaginal cervical cerclage in the treatment of cervical insufficiency during pregnancy.Methods:The clinical data of 18 women with cervical insufficiency during pregnancy who received treatment in Changzhi Maternal and Child Health Hospital from January 2018 to January 2020 (including nine cases receiving modified Shirodkar operation and nine cases receiving modified McDonald operation) were retrospectively analyzed.Results:The operation process was successful in all 18 women, and there were no postoperative complications. After modified Shirodkar operation, the average gestational weeks were prolonged by 14.7 weeks. Six cases had a smooth vaginal delivery [full-term delivery in five cases and preterm premature rupture of membranes (35 weeks + 1 day) in one case]. Three women had a cesarean delivery [cesarean delivery at full-term in two cases, including twin pregnancy in one case and previous cesarean delivery in one case; preterm premature rupture of membranes because of chorioamnionitis (32 weeks + 1 day) with poor prognosis in one case]. The rate of holding babies home was 88.9%. After modified McDonald operation, the average gestational weeks were prolonged by 11.5 weeks. Five cases had a smooth vaginal delivery [full-term delivery in three cases, preterm premature rupture of membranes in one case (35 weeks + 3 days) and in one case (31 weeks)]. Three women had a cesarean delivery at full-term [secondary cesarean delivery in one case, twin pregnancy in one case, and preterm premature rupture of membrane because of preeclampsia in one case]. One case had infectious abortion, and the rate of holding the baby home was 88.9%.Conclusion:Selection of different modified operations according to the length of cervical canal can prolong gestational weeks and increase the survival rate of newborns. The modified vaginal cervical cerclage is simple and easy to operate with minimal damage to pregnant women, which is suitable for clinical promotion.

Parto pré-termo espontâneo sem rotura de membranas: prevalência, fatores de risco e o papel do colo uterino / Spontaneous preterm birth without premature rupture of membranes: prevalence, risk factors and the role of the cervix

Cerca de 15 milhões de prematuros nascem por ano globalmente. Em 2015 ocorreram mais de 4 milhões de mortes de crianças menores de 5 anos, e as complicações da prematuridade são a principal causa de óbito em neonatos. O parto pré-termo é uma síndrome em que múltiplas etiologias convergem para uma via final única, e os fatores de risco mais importantes são antecedente de prematuridade e gestação gemelar. O colo uterino tem a função de manter a gestação desde a concepção até o parto, e seu processo de amadurecimento gera esvaecimento, dilatação e encurtamento, num continuum que pode compreender desde quadros de insuficiência cervical até o parto pré-termo espontâneo sem rotura de membranas. Este primeiro artigo, da série de três, descreve a prevalência da prematuridade, seus fatores de risco e o papel do colo uterino no processo de parturição.(AU)

Around 15 million preterm births happen globally. In 2015 over 4 million deaths in children under 5 years of age died and preterm birth complications is the leading cause in neonates. Preterm birth is a multiple etiology syndrome, in which various causes converge to a single parturition path. The most important risk factors are multiple gestation and obstetrical history of preterm birth. Uterine cervix is responsible for pregnancy maintenance from conception to birth, and its remodeling process generates effacement, dilation and shortening in a continuum that comprises conditions from cervical insufficiency to preterm birth without membrane disruption. This is a first article, of a series of three, describing preterm birth prevalence, risk factors and uterine cervix role in parturition.(AU)

Cerclaje abdominal realizado durante la gestación: reporte de caso y revisión de la literatura / Abdominal Cerclage Performed during pregnancy: case report and literature review

La insuficiencia del cérvix es una alteración del tejido cervical que impide mantener el embarazo hasta su término, provocando pérdidas fetales recurrentes en el segundo trimestre de embarazo. Se presenta un caso de incompetencia cervical, causante de tres abortos previos, el último pese a cerclaje vaginal; por tanto, se realiza cerclaje por vía abdominal, logrando un embarazo viable hasta las 35,6 semanas, que termina en cesárea por amenaza de parto pretérmino y ruptura prematura de membranas. Además, se expone una revisión de la literatura sobre el tratamiento de esta patología..Au

Incompetence of the cervix is an alteration of the cervical tissue that prevents maintaining the pregnancy until its term, causing recurrent fetal losses in the second trimester of pregnancy. A case of cervical incompetence is presented, causing three consecutive abortion, the last one despite vaginal cerclage, therefore, abdominal cerclage is performed,achieving a viable pregnancy until 35,6 weeks, ending in caesarean section due to threat of preterm delivery plus premature rupture of membranes. In addition, a review of the literature on the treatment of this pathology is presented..Au

Comprimento de colo uterino ao ultrassom transvaginal como preditor de risco do parto pré-termo espontâneo / Ultrasound cervical lenght predicting risk for spontaneous preterm birth

O encurtamento do colo uterino é parte da via final comum da parturição seja a termo ou pré-termo. A identificação precoce do comprimento cervical encurtado ao ultrassom transvaginal no segundo trimestre gestacional pode atuar como preditor de risco de prematuridade. Desde a década de 1990, vários estudiosos dedicaram-se a estabelecer parâmetros de referência para as medidas de colo uterino entre 16 e 24 semanas e até hoje o limite mais consensualmente aceito é de 25 mm. Especialistas são favoráveis à triagem universal, mas diretrizes internacionais são controversas quanto à investigação em casos sem antecedente de parto pré-termo, além de diversos estudos apresentarem que há custo-efetividade no rastreamento universal. Neste artigo, discutimos criticamente os parâmetros apresentados por estudos históricos e balizadores de conduta, a custo-efetividade e os guidelines internacionais. Propomos ainda uma reflexão ao pré-natalista, sugerindo a individualização da conduta perante os dados de cada gestante específica.(AU)

Cervical shortening is the final path of parturition, regardless if it is term or preterm. Precocious identification of a shortened cervix by transvaginal ultrasound during the second gestational trimester can act as a risk predictor of prematurity. Since the 1990´s decade, numerous studies established reference ranges for cervical length measurement between 16 to 24 gestational weeks and the most accepted cutoff limit is 25 mm. Experts indicate universal screening, however international guidelines are controversial, even in cases without a history of preterm birth, furthermore, many studies demonstrated cost-effectiveness about the universal screening of cervical length in middle gestation. In this article we discuss historical reference ranges, cost- -effectiveness, and international guidelines. We propose critical thinking and suggest individualized management according to specific characteristics of each patient.(AU)

Effect of Cervical Cerclage on the Risk of Recurrent Preterm Birth after a Twin Spontaneous Preterm Birth

BACKGROUND: This study aimed to evaluate the effect of cervical cerclage on the recurrence risk for preterm birth in singleton pregnant women after a twin spontaneous preterm birth (sPTB).METHODS: This multicenter retrospective cohort study included women who had a singleton pregnancy from January 2009 to December 2018 at 10 referral hospitals and a twin sPTB before the current pregnancy. We compared the cervical lengths during pregnancy and pregnancy outcomes, according to the placement of prophylactic or emergency cerclage. We evaluated the independent risk factors for sPTB (< 37 weeks of gestation) in a subsequent singleton pregnancy.RESULTS: For the index singleton pregnancy, preterm birth occurred in seven (11.1%) of 63 women. There was no significant difference in the cervical lengths during pregnancy in women with and without cerclage. In a multivariate logistic regression analysis, the placement of emergency cerclage was an independent risk factor for subsequent singleton preterm birth (odds ratio [OR], 93.188; 95% confidence interval [CI], 1.633–5,316.628; P = 0.027); however, the placement of prophylactic cerclage (OR, 19.264; 95% CI, 0.915–405.786; P = 0.057) was not a factor. None of the women who received prophylactic cerclage delivered before 35 weeks' gestation in the index singleton pregnancy.CONCLUSION: Cerclage did not lower the risk of preterm birth in a subsequent singleton pregnancy after a twin sPTB. However, emergency cerclage was an independent risk factor for preterm birth and there was no preterm birth before 35 weeks' gestation in the prophylactic cerclage group. Therefore, close monitoring of the cervical length and prophylactic cerclage might be considered in women who have experienced a twin sPTB at extreme gestation.

Días de gestación ganados con diferentes técnicas de cerclaje en pacientes con insuficiencia cervical / Gestational days gained with different cerclage techniques in patients with cervical incompetence

Resumen OBJETIVO: Reportar la experiencia en la práctica de cerclajes con indicación profiláctica y terapéutica en pacientes con embarazo único o múltiple, con insuficiencia cervical. Además, informar los días de gestación ganados y comparar las técnicas quirúrgicas con los cerclajes. MATERIALES Y MÉTODOS: Estudio retrospectivo, descriptivo, comparativo y transversal efectuado entre enero de 2011 y enero de 2018. Criterios de inclusión: pacientes a quienes se efectuó un cerclaje y el embarazo finalizó en nuestra unidad. Variables de estudio: edad, IMC, embarazos, abortos, días de gestación ganados, días en que se efectuó el procedimiento quirúrgico, semanas de gestación cumplidas a la finalización del embarazo, tiempo quirúrgico, medicamentos (tocolíticos y antibióticos), complicaciones a partir del cerclaje hasta la finalización del embarazo. Para el análisis descriptivo se utilizó el paquete estadístico IBM SPSS (versión 22); la distribución se obtuvo con t de Student, se aplicó la prueba de normalidad Shapiro-Wilk y las variables con distribución normal se analizaron, comparativamente, con ANOVA y las de distribución anormal con la prueba Kruskal-Wallis. RESULTADOS: Se analizaron 37 casos en los que el cerclaje prolongó 116.14 ± 47.4 días la gestación, con finalización promedio del embarazo a los 246.41 ± 26.54 días. El cerclaje Shirodkar fue superior: prolongó la gestación 134.69 días con finalización del embarazo a las 36 ± 2 semanas. CONCLUSIONES: En pacientes con insuficiencia cervical el cerclaje es una opción para prolongar el embarazo. La técnica Shirodkar tuvo márgenes de mayor seguridad hasta la finalización del embarazo (más de 34 semanas). El comportamiento en embarazos múltiples es similar, por lo que en caso de insuficiencia cervical debe aplicarse.

Abstract OBJECTIVE: To report the experience in the practice of cerclages with prophylactic and therapeutic indication in patients with single or multiple pregnancy, with cervical incompetence. In addition, report the days of pregnancy gained, compare surgical techniques and cerclages in single and multiple gestations. MATERIALS AND METHODS: Retrospective, descriptive, comparative and cross-sectional study carried out between January 2011 and January 2018. Inclusion criteria: patients who had a cerclage and the pregnancy ended in our unit. Study variables: age, BMI, pregnancies, abortions, days of gestation earned, days in which they were placed, weeks of gestation completed at the end of pregnancy, surgical time, medications (tocolytics and antibiotics), complications from the placement of the cerclage until the end of pregnancy. For the descriptive analysis the statistical package IBM SPSS (version 22) was used; the distribution was obtained with Student's t test, the Shapiro-Wilk normality test was applied and the variables with normal distribution were analyzed, comparatively, with ANOVA and those with abnormal distribution with the Kruskal-Wallis test. RESULTS: 37 cases were analyzed in which the placement of cerclage prolonged 116.14 ± 47.4 days gestation, with an average termination of pregnancy at 246.41 ± 26.54 days. The Shirodkar cerclage was superior: it extended gestation 134.69 days with the end of pregnancy at 36 ± 2 weeks. CONCLUSIONS: In patients with cervical incompetence cerclages are an option to prolong pregnancy. The Shirodkar technique had higher safety margins until the end of pregnancy (more than 34 weeks). The behavior in multiple pregnancies is similar, so in case of cervical incompetence should be applied.

Successful cerclage on cervix in the mid trimester: case report

Cervical cerclage (CC) has been utilized for the cure of loss in second trimester pregnancy. The detection of cervical incompetency is problematic normally having repeated second trimester demise or early preterm delivery after cervical dilatation without pain having no bleeding, contractions, or other reasons for repeated loss in pregnancy. This study was performed at a tertiary care hospital in Dhaka, Bangladesh. These are 2 cases of patients undergoing emergency mid-trimester cerclage for advanced cervical dilatation with protruding membranes in 2016 and 2017. The 1st case patient was at 22 weeks of gestation and was admitted into hospital due to short history of lower abdominal pain and per vaginal bleeding. Vaginal inspection showed the cervix was dilated 1.5 cm. At 37 weeks of pregnancy she gave birth to a healthy female newborn by caesarean section and McDonald suture was removed. After delivery, mother and baby both were in good health. The 2nd case was of a patient of 26 years of age, second gravida, 24 weeks pregnant due to ovulation induction drug, who had a history of an abortion at 10 weeks. At her 24 weeks of pregnancy, she complained of profuse P/V whitish discharge and lower abdominal pain. It was found cervix was 2.5 cm dilated and bulging of membrane. Immediately McDonald suture was given. Patient was clinically improved, and USG showed OS is closed, length of the cervix is about 4.4 cm. At 32 weeks patient came with a complaint of rupture of membrane, then emergency caesarean section was done. A healthy premature female baby weighted 1.8 kg was delivered by vertex presentation. After operation, cerclage was removed. After delivery mother and baby both were in good health. Satisfactory neonatal result may be achieved in women having cervical deficiency in second-trimester pregnancy after emergency CC.

Emergency cerclage: gestational and neonatal outcomes

SUMMARY BACKGROUND: The gestational and neonatal outcomes of women with early cervical dilatation undergoing emergency cerclage were evaluated and compared with women treated with expectant management and bed rest. METHODS: Retrospective analysis of pregnant women admitted between 2001 and 2017 with a diagnosis of early cervical dilatation and/or bulging membranes. Patients with a singleton pregnancy of a fetus without malformations, between 16 and 25 weeks and 6 days, with cervical dilatation of 1 to 3 cm were included; patients who delivered or miscarried within 2 days after admission were excluded. RESULTS: The study enrolled 30 patients: 19 in the cerclage group and 11 in the rest group. There was a significant difference, with the cerclage group showing better results concerning gestational age at delivery (28.7 vs. 23.3 weeks; p=0.031) and latency between hospital admission and delivery (48.6 vs. 16 days; p=0.016). The fetal death rate was lower in the cerclage group (5.3% vs. 54.5%, p=0.004). Considering gestational age at delivery of live newborns, no difference was observed between the cerclage and rest groups (29.13 vs. 27.4 weeks; p=0.857). CONCLUSIONS: Emergency cerclage was associated with longer latency, a significant impact on gestational age at delivery and reduction in the fetal death rate.

RESUMO OBJETIVO: Os resultados gestacionais e neonatais de mulheres com cervicodilatação precoce submetidas à cerclagem de emergência foram avaliados e comparados com mulheres tratadas com manejo expectante com repouso no leito. MÉTODOS: Análise retrospectiva de gestantes admitidas entre 2001 e 2017 com diagnóstico de cervicodilatação precoce e/ou membranas protrusas. Foram incluídas pacientes com gestação única de feto sem malformações, entre 16 semanas e 25 semanas e 6 dias, com dilatação cervical de 1 a 3 cm; as pacientes que tiveram parto ou aborto dentro de 2 dias após admissão foram excluídas. RESULTADOS: O estudo envolveu 30 pacientes: 19 no grupo cerclagem e 11 no grupo repouso. Houve diferença significativa, com o grupo cerclagem apresentando melhores resultados em relação à idade gestacional no parto (28,7 vs. 23,3 semanas; p=0,031) e à latência entre a admissão hospitalar e o parto (48,6 vs. 16 dias; p=0,016). A taxa de mortalidade fetal foi menor no grupo cerclagem (5,3% vs. 54,5%, p=0,004). Considerando a idade gestacional no nascimento dos recém-nascidos vivos, não houve diferença entre os grupos cerclagem e expectante (29,13 vs. 27,4 semanas; p=0,857). CONCLUSÕES: A cerclagem de emergência foi associada a maior período de latência com impacto significativo na idade gestacional do parto e à redução da taxa de mortalidade fetal.

Cerclaje Cérvico-Ístmico transabdominal: experiencia de 30 años / Cervical-Isthmic transabdominal cerclage: experience of 30 years

RESUMEN Introducción: se define incompetencia cervical como la incapacidad del cuello uterino de retener una gestación en el segundo trimestre, en ausencia de contracciones uterinas. El cerclaje cervical es la intervención que ha demostrado utilidad en el tratamiento de la incompetencia cervical. La principal vía utilizada para cerclaje es la vaginal, sin embargo existe un grupo de pacientes en el que ésta no es posible y debe realizarse un abordaje transabdominal. Este trabajo muestra los resultados y experiencia de 30 años en la instalación de cerclaje por vía abdominal abierta. Se realiza una revisión de la literatura y se discuten sus indicaciones, resultados y complicaciones. Además se analiza la técnica quirúrgica, especialmente las variantes de ella y el momento de realizar la intervención. Métodos: se revisaron datos de 20 pacientes a las que se realizó cerclaje transabdominal, desde el año 1985 hasta la fecha. En todas las cirugías participó el autor principal de este artículo. Resultados: las intervenciones se realizaron entre las 8 y 18 semanas de gestación. Las causas principales fueron la imposibilidad de realizar un cerclaje por vía vaginal, debido a ausencia de cuello por conizaciones amplias o repetidas y amputaciones cervicales o fracaso de cerclajes por vía vaginal previos. Las 20 pacientes tuvieron 23 embarazos, 20 partos (16 mayores de 37 s. y 4 mayores de 34 s.) y 3 abortos. Se obtuvo un 87% de sobrevida fetal. Conclusiones: la utilización de esta técnica es útil en pacientes con imposibilidad de cerclaje por vía vaginal o en fracasos de cerclajes vaginales previos. La literatura revisada no muestra diferencias estadísticamente significativas entre los procedimientos realizados previos o durante la gestación, ni tampoco si se realiza mediante laparoscopía o cirugía abierta.

SUMMARY Introduction: cervical incompetence is defined as the inability of the cervix to retain a pregnancy in the second trimester, in the absence of uterine contractions. Cervical cerclage is the intervention that has proven its usefulness in the treatment of cervical incompetence. The main route used for cerclage is vaginal, however there is a group of patients in which this is not possible and a transabdominal approach must be performed. This work shows the results and experience of 30 years in the installation of cerclage by abdominal open route. A review of the literature is made and its indications, results and complications are discussed. In addition, the surgical technique is analyzed, especially it's variants and the moment of performing the intervention. Methods: data from 20 patients who underwent a transabdominal cerclage from 1985 to date were reviewed. In all the surgeries, the main author of this article participated. Results: the interventions were performed between 8 and 18 weeks of gestation. The main causes were the impossibility of performing a cerclage by vaginal route due to absence of the cervix by extensive or repeated conizations and cervical amputations or failure of previous cerclage by vaginal route. The 20 patients had 23 pregnancies, 20 deliveries (16 over 37 w. and 4 over 34 w.) and 3 abortions. 87% of fetal survival was obtained. Conclusions: the use of this technique is useful in patients with inability to cerclage vaginally or in failures of previous vaginal cerclages. The literature reviewed does not show statistically significant differences between the procedures performed before or during pregnancy, nor whether it is performed by laparoscopy or open surgery.

Clinical outcome of therapeutic cervical cerclage in short cervix syndrome / 中华妇产科杂志

Objective To investigate the clinical effect of therapeutic cervical cerclage on short cervix syndrome for anti-premature birth in the second trimester. Methods Totally 44 singleton pregnant patients were diagnosed as short cervix syndrome, which was cervical length ≤2.5 cm without cervical dilatation,and received treatment from January 2008 and July 2015 in Peking University Third Hospital were collected. Among them, 30 patients who received therapeutic cervical cerclage were defined as cerclage group and another 14 cases who received conservative treatment were defined as un-cerclage group. The days of conservative treatment, delivery rate of different gestational weeks, birth weight of newborns, neonatal survival rate within 7 days of birth were analyzed between the two groups. Results There were no significant differences between the two groups in days of pregnancy conservative treatment [103(84-141)vs 105(85-114)days], delivery weeks [38.0(35.5-39.4)vs 38.5(37.3-39.5)weeks], birth weight of newborns [3120(2750-3400)vs 3130(2760-3545)g], and survival rate of newborns [100％(30/30)vs 13/14]. The fetuses of both groups were all delivered after 28 weeks. There was no significant difference in accumulated delivery rate between the two groups after 32 weeks, 34 weeks, and 37 weeks, respectively(all P>0.05). Conclusions The treatment of cervical cerclage is not superior to conservative means in single pregnancy of cervical length ≤2.5 cm without cervical dilatation. For such patients with short cervix syndrome, the treatment of cervical cerclage may not be necessary, but dynamic monitoring and search for the causing factors and prompt treatment are more important.

Relationship between inflammatory indexes of amniotic fluid and pregnancy outcome of women with cervical incompetence / 中华妇产科杂志

Objective@#To investigate the relationship between the level of amniotic fluid inflammatory factor and the pregnancy outcome in patients with cervical incompetence.@*Methods@#A retrospective case-control study was conducted. Totally 110 cases of pregnant women were diagnosed as cervical incompetence for cervical dilation at the medical examination in Sun Yat-sen Memorial Hospital of Sun Yatsen University, from January 1st, 2015 to December 31th, 2016. A total of 32 patients (29.1%, 32/110) were performed cervical cerclage. According to their neonatal outcomes, they were divided into live infant group (23 cases, 72%) and dead infant group (9 cases, 28%) . The demographic and clinical data of two groups were analyzed and compared.@*Results@#The mean peripheral blood leucocyte counts, the median amniotic tumor necrosis factor-α (TNF-α) and the median interleukin-8 (IL-8) level of two groups were (10.5±2.8) ×109/L vs (13.6±3.1) ×109/L, 23.80 ng/L (14.9-85.5 ng/L) vs 379.00 ng/L (70.2-418.5 ng/L) , and 3 354 ng/L (1 020-7 500 ng/L) vs 7 500 ng/L (4 210-7 500 ng/L) respectively. The differences were statistically significant (all P<0.05) . The amniotic fluid IL-1β, IL-2 receptor, IL-6, IL-10, C-reactive protein and procalcitonin were not significantly different (all P>0.05) between two groups.@*Conclusions@#The peripheral blood leucocyte counts, amniotic fluid TNF-α and IL-8 level are the factors affecting the pregnancy outcome in women with cervical incompetence before cervical cerclage. When IL-8 is higher than 3 580 ng/L and TNF-α is higher than 105 ng/L, the death of perinatal infants could be predicted.

Analysis of efficacy and feasibility of early pregnancy laparoscopic cervical cerclage in patients with uterine cervical incompetence / 中国医师进修杂志

Objective To investigate pregnancy outcome and feasibility of early pregnancy laparoscopic cervical cerclage surgery in patients with uterine cervical incompetence. Methods The clinical data of 24 uterine cervical incompetence patients who had underwent early pregnancy laparoscopic cervical cerclage were retrospectively analyzed, and the operation and pregnancy outcomes were observed. Results The anesthesia and operation of all patients were smooth, and no abortion occurred during and after operation. The operation time was (40.3 ± 5.8) min, and the amount of bleeding was (32.9 ± 4.3) ml. The cervical length of pregnancy was (3.5 ± 0.8) cm. All patients were cesarean delivery, and the gestational age of delivery was (34.8 ± 2.6) weeks. The term delivery rate was 50.0% (12/24); the perineonate survival rate was 95.8% (23/24), and none of the neonates had birth defects. The weight of 23 neonates was (2 735 ± 528) g, and the low birth weight infant was in 4 cases. Conclusions For those who need to progestation cervical cerclage but failed to timely surgery or whose cervical length less than 2.5 cm in patients with early pregnancy uterine cervical incompetence, early pregnancy laparoscopic cervical cerclage is safe and feasible. After the operation, the gestational age can be prolonged, the perineonate survival rate will be improved, and the pregnancy outcome will be improved.

Clinical Comparative Study of Two Different Surgical Methods in Treatment of Cervical Incompetence at Non Pregnant Condition / 实用妇产科杂志

Objective:To compare the effect of laparoscopic uterine isthmus cerclage and transvaginal uterine isthmus cerclage in the treatment of cervical incompetence at non pregnant condition.Methods:A total of 63 patients with cervical incompetence from May 2013 to May 2015 in our hospital were enrolled in the retrospective analysis,all the enrolled patients had naturally conceived single birth with complete data after laparoscopic uterine isthmus cerclage or transvaginal uterine isthmus cerclage and were divided into two groups according to two different surgical methods for uterine isthmus cerclage to compare the clinical effect.30 patients treated with laparoscopic uterine isthmus cerclage were,in the research group and the other 33 patients treated with transvaginal uterine isthmus cerclage were in the control group.Results:The treatment success rate of research group (96.67％) was significantly higher than that of the control group(51.52％) (P ＜ 0.05).The research group had got a longer average pregnancy period than control group (P ＜ 0.05).Postoperative abortion rate (3.33％) and preterm birth rate(10.00％) of research group were obviously lower than the control group (48.48％,30.30％)(P＜0.05).The term infant rate of research group (86.67％) was higher than control group (21.21％) (P ＜0.05).The operation time((37.27 ± 1.93 min) and hospital stay(5.17 ±0.38 d) of the research group were less than the control group(P＜0.05).The bleeding amount in surgery of research group(13.13 ±1.57ml) was significantly lower than the control group(31.61 ± 1.87 ml) (P ＜ 0.05).The complication rate of observation group was 0,and the control group was 18.18％.The difference was significant(P ＜ 0.05).Conclusions:Laparoscopic uterine isthmus cerclage in treatment of cervical imcompetence at non pregnant condition has better clinical effect than transvaginal uterine isthmus cerclage.It has higher security and feasibility.It is worth clinically promoting.

The study on selecting pre-pregnancy cervical cerclage method in the different cervical length of uterine cervical incompetence patients / 中国医师进修杂志

Objective To study the pre- pregnancy cervical cerclage method in the different cervical length of uterine cervical incompetence patients. Methods The clinical data of 128 uterine cervical incompetence patients having underwent pre-pregnancy cervical cerclage were retrospectively analyzed. The preoperative cervical length was measured by transvaginal ultrasound. Cervical length >2.5 cm was in 60 cases, of which 34 cases underwent laparoscopic cervical cerclage, and 26 cases underwent transvaginal cervical cerclage; cervical length ≤ 2.5 cm was in 68 cases, of which 32 cases underwent laparoscopic cervical cerclage, and 36 cases underwent transvaginal cervical cerclage. Results For the patients with preoperative cervical length > 2.5 cm, there were no statistical differences in the postoperative pregnancy cervical length, gestational weeks time, perinatal birth weight, perinatal survival rate, gestational age of delivery and intrauterine infection rate between 2 methods (P>0.05). For the patients with preoperative cervical length ≤ 2.5 cm, the postoperative pregnancy cervical length, gestational weeks time, perinatal birth weight, perinatal survival rate and gestational age of delivery in laparoscopic cervical cerclage patients were significantly higher than those in transvaginal cervical cerclage patients: (3.85 ± 0.37) cm vs. (3.16 ± 0.49) cm, (101.75 ± 4.71) d vs. (80.62 ± 3.53) d, (2850 ± 323) g vs. (2330 ± 585) g, 90.6% (29/32) vs. 69.4% (25/36) and 50.0% (16/32) vs. 22.2%(8/36), but the intrauterine infection rate was significantly lower than that in transvaginal cervical cerclage patients:0 vs. 16.7%( 6/36), and there were statistical differences (P 2.5 cm patients with uterine cervical incompetence, pre- pregnancy cervical cerclage can choose transvaginal or laparoscopic. But for patients with the cervical length≤2.5 cm or previous cervical cerclage failure, laparoscopic cervical cerclage is better than transvaginal cervical cerclage.

Analysis of pregnancy outcome of laparoscopy cervical cerclage before pregnancy in treatment of uterine cervical incompetence / 中国医师进修杂志

Objective To analyze the pregnancy outcome of laparoscopy cervical cerclage before pregnancy in treatment of uterine cervical insufficiency. Methods The clinical data of 78 uterine cervical incompetence patients having underwent cervical cerclage before pregnancy were retrospectively analyzed. Among them 40 cases underwent laparoscopy cervical cerclage (laparoscopy group), and 38 cases underwent transvaginal cervical cerclage (transvaginal group). The operation time, complications, length of cervix in pregnancy, lengthen time of gestational weeks, gestational weeks, perinatal infant weight, survival rate of perinatal infants and infection rate of uterine cavity were compared between 2 groups. Results The length of cervix in pregnancy, lengthened time of gestational weeks, perinatal infant weight, term labor rate and survival rate of perinatal infants in laparoscopy group were significantly higher than those in transvaginal group: (4.35 ± 0.52) cm vs. (3.51 ± 0.66) cm, (116.7 ± 9.8) d vs. (90.2 ± 5.2) d, (3 050 ± 759) g vs. (2 500 ± 431) g, 60.0%(24/40) vs. 31.6%(12/38) and 95.0%(38/40) vs. 78.9%(30/38), and the infection rate of uterine cavity was significantly lower than that in transvaginal group: 2.5% (1/40) vs. 18.4% (7/38), and there were statistical differences (P 0.05). Conclusions Laparoscopy cervical cerclage before pregnancy in treatment of uterine cervical incompetence can effectively maintain the cervical length period of pregnancy, improve the success rate of surgery, prolong gestational weeks, and improve perinatal outcome.

Emergency Cervical Cerclage Combined Mesh Patch Suture in the Treatment Caused by Cervical Incompetence Clinical Analysis of 32 Cases / 实用妇产科杂志

Objective:To investigate the clinical value of emergency cervical cerclage combined mesh patch suture in the treatment of cervical incompetence.Methods:From January 2011 to August 2016 in our hospital 65 cases of pregnant women with inevitable abortion,32 cases of they had carried out emergency cervical cerclage combined mesh patch suture(group A),33 cases of they had carried out cervical cerclage only(group B),The prolongation of gestation time,delivery gestational age,neonatal outcome,delivery mode and postoperative complications were compared between the two groups.Results:The operation time of A group was higher than that of group B,surgical complications of cervical laceration in group A was less than B group,the difference was statistically significant(P ＜ 0.05);there was no significant difference in the incidence of chorioamnionitis between the two groups(P＞0.05);the gestational age of group A was extended to 84.45 ±35.77 days,and the gestational age of B group was extended to 51.86 ±29.93 days,there was statistically significant difference between the two groups(P＜0.05);there was more than 28 weeks delivery in 23 cases(71.88％) in group A,and 17 cases (51.52％) in group B,the difference was statistically significant(P ＜ 0.05);there were no statistically significant differences in the delivery mode between the two groups(P ＞ 0.05);neonatal birth weight,birth Apgar 1 minutes score of group B were significantly lower than those of group A,the difference was statistically significant (P ＜0.05).Conclusions:Emergency cervical cerclage combined mesh patch suture can effectively prolong the gestational age,improve neonatal outcome,no obvious complication and has certain clinical applicative value.

Role of transvaginal sonography in the objective diagnosis of incompetent cervix

The syndrome of cervical incompetence is characterized by spontaneous painless passive dilatation of cervix followed by expulsion of an immature foetus. The subject has been subjected to increasing controversy in recent years. The wide variations in the incidence of cervical incompetence arise because there are no standard criteria for the diagnosis of cervical incompetence. The certain way of diagnosing a case of cervical incompetence is by history and vaginal examination. The introduction of transvaginal ultrasonographical examination into the obstetrics diagnosis has created further possibilities in recognition of isthmico – cervical insufficiency. The present study was conducted for a period of 18 months with gestational age between 14 to 26weeks and was aimed to evaluate the efficacy of transvaginal sonography and to know the incidence of cervical incompetence in this area. 50 pregnant women at high risk of pre-term delivery were taken in to the study. 36 out of 50 cases (72%) met the criteria and they were managed surgically and had a cervix length < 2.5 cm. 14 (28%) cases had cervix length. > 2.5 cm at the initial transvaginal sonographic evaluation. 40 out of 50 (80%) delivered at around term. Though the diagnosis of cervical incompetence is based primarily on past obstetric, gynaec history and clinical findings, but transvaginal sonographic surveillance of the cervix helps us to use the cervical cerclage more selectively i.e., when the cervix length i.e, < 2.5 cm, internal os open or close with funneling of cervical canal.