Arabin-pessary or McDonald Cerclage in Cervical Shortening? / Pessário de Arabin ou cerclagem McDonald no encurtamento cervical?

Abstract Objective The aim of the present study is to compare the effectiveness of Arabin pessary and McDonald cervical cerclage on preterm delivery. Methods We conducted a retrospective analysis of data from patients who underwent either Arabin pessary or McDonald cerclage between January 1, 2019, and January 1, 2023. A total of 174 patients were included in the study, with 31 undergoing Arabin pessary and 143 receiving cervical cerclage using the McDonald technique in singleton pregnant women with cervical insufficiency, which applied between 14 and 22 gestational weeks. We included singleton pregnant women with normal morphology, and with normal combined test. The primary outcome was the impact of each method on preterm delivery (< 34 gestational weeks). Results The weeks of cervical cerclage or pessary application were compatible with each other (p< 0.680). The pessary group had a statistically significant longer time to delivery compared with the Cerclage group (cerclage group mean 30.8 c 7.1 standard deviation [SD] versus pessary group mean 35.1 ± 4.4 SD; p< 0.002). A statistically significant difference was found between the pessary and cerclage groups in terms of delivery at < 34 weeks (p= 0.002). In patients with cervical length between 25 and 15mm and < 15mm, no significant difference was found between the pessary and cerclage groups in terms of delivery week (p< 0.212; p< 0.149). Regardless of the technique applied, no statistically significant difference was observed between cervical length and birth < 34 weeks. Conclusion Our study found that pessary use for cervical insufficiency is statistically more effective than cervical cerclage surgery in preventing preterm births < 34 weeks in singleton pregnancy.

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)

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

Uso de pesario cervical y prevención de parto pretérmino / Cervical pessary use and preterm labor prevention

Introducción: El parto pretérmino constituye una causa importante de morbimortalidad perinatal con repercusiones sociales y económicas a nivel mundial. La intervención oportuna ante la identificación de factores de riesgo y un adecuado manejo consiguen reducir su incidencia y evitar las consecuencias de la prematurez. Objetivo: El presente trabajo se realiza con el objetivo de destacar al pesario cervical como una herramienta mecánica en la prevención del parto pretérmino, y una opción de tratamiento en embarazos mayores de 25 semanas con insuficiencia cervical. Presentación del caso: Se trata de una paciente de 38 años de edad con antecedente de parto pretérmino espontaneo (de 33 semanas), que ingresa a las 21 semanas de embarazo con dilatación cervical de 3cm y acortamiento de la longitud cervical de 14mm, signos ecográficos: sludge y funneling. Se optó por manejo expectante con medidas complementarias: administración de antibiótico, progesterona y uso de pesario cervical. Tras el control clínico de la infección y mayor acortamiento cervical a 7mm a pesar del uso de progesterona, se colocó un pesario cervical a las 25,5 semanas, a las 27,5 semanas fue dada de alta, a las 36,6 semanas se retiró el pesario tras inicio de actividad uterina. Discusión: La progesterona y el cerclaje son medidas de elección en casos de insuficiencia cervical, sin embargo, ante las dificultades técnicas de colocación; el pesario representó una alternativa. El uso de pesario permitió que el embarazo progrese al término con resultados beneficiosos y sin evidencia de efectos adversos.

Introduction: Preterm delivery is an important cause of perinatal morbidity and mortality with global social and economic repercussions. Timely intervention in the identification of risk factors and proper management reduce their incidence and avoid the consequences of prematurity. Objective:This work is carried out with the aim of highlight the cervical pessary as a mechanical tool in the prevention of preterm birth and a treatment option in pregnancies over 25 weeks with cervical insufficiency. Case presentation: This is a 38-year-old patient with a history of spontaneous preterm delivery (33 weeks), who was admitted at 21 weeks of pregnancy with cervical dilation of 3cm and shortening of the cervical length of 14mm, ultrasound signs: sludge and funneling. Expectant management was opted, with complementary measures: administration of antibiotics, progesterone and use of a cervical pessary. After clinical control of the infection and greater cervical shortening to 7mm despite the use of progesterone, a cervical pessary was placed at 25.5 weeks, at 27.5 weeks she was discharged, at 36.6 weeks she was discharged. The pessary was removed after the start of uterine activity. Discussion: Progesterone and cerclage are the measures of choice in cases of cervical insufficiency, however, given the technical difficulties of placement; the pessary represented an alternative. Conclusion: The use of the pessary allowed the pregnancy to progress to term with beneficial results and without evidence of adverse effects.

Cerclaje laparoscópico transabdominal en el primer trimestre con nacimiento a término / Succesful pregnancy outcome after first trimester laparoscopic transabdominal cerclage

El parto pretérmino es una de las principales causas de muerte neonatal y de hospitalización antenatal. La insuficiencia cervical constituye un factor de riesgo para dicha patología, el objetivo del artículo es describir un caso de insuficiencia cervical manejado con cerclaje transabdominal por vía laparoscópica. Presentación del caso: Paciente de 37 años con antecedente de tabique uterino corregido por histeroscopia a quien en su primera gestación se le realizó cerclaje vaginal fallido por parto pretérmino a las 24 semanas de gestación con producto fallecido por prematurez extrema. En el siguiente embarazo se le realizó un cerclaje transabdominal por vía laparoscópica, consiguiendo embarazo a término con recién nacido sano de 38 semanas de gestación y peso de 2840 gramos. Conclusiones: el cerclaje transabdominal por vía laparoscópica presenta tasas elevadas de éxito durante el embarazo, asociado a bajas complicaciones, menor perdida sanguínea intraoperatoria y menor estancia hospitalaria constituyéndose como una técnica factible y segura en pacientes con diagnóstico de insuficiencia cervical con algunas indicaciones tales como cerclaje vaginal previo fallido.

Preterm birth is a major cause of neonatal mortality and antenatal hospitalization. Cervical insufficiency constitutes a risk factor for premature birth. This article aims to describe a case of cervical insufficiency managed with laparoscopic transabdominal cerclage. A case is presented in a 37-year-old patient with septate uterus corrected by hysteroscopic surgery and a failed transvaginal cerclage with a preterm stillbirth as a result of severe prematurity in her first pregnancy. A laparoscopic transabdominal cerclage was done during her next pregnancy resulting in a healthy, full-term (38 weeks) newborn who weighed 2840 grams. Conclusions: laparoscopic cerclage in pregnancy has a high success rate with minimum complications and reduced blood loss and hospital stay. It is a feasible and safe technique for patients with cervical insufficiency and is effective in specific circumstances such as previous failed vaginal cerclage.

Insuficiencia cervical y prolapso de bolsa amniótica "en reloj de arena"en gestante pretérmino / Cervical Insufficiency and Prolapse of an "Hourglass" Amniotic Sac in Preterm Pregnant Women

RESUMEN Introducción: La insuficiencia cervical se concibe hoy día como un proceso biológico continuo con grados progresivos de insuficiencia. La expresión más extrema de la insuficiencia cervical se conoce como "bolsa en reloj de arena". La mayoría de los autores están de acuerdo en recomendar el reposo en cama y realizar cerclaje cervical de emergencia. Objetivo: Presentar el caso de una gestante en la que se logró la reversión del prolapso de las membranas amnióticas en "reloj de arena" con buenos resultados perinatales. Presentación de caso: Paciente de 31 años con antecedentes de parto anterior a las 36,5 semanas, que en los momentos actuales cursa una gestación de 20,6 semanas. Acude a la consulta por dolor en hipogastrio y al examen físico se comprueba que la bolsa amniótica protruye por el orificio cervical externo y presenta una dilatación cervical de 2 cm. Se aplica tratamiento medicamentoso y se reduce el prolapso de la bolsa. Conclusiones: Con el tratamiento conservador se logró una buena evolución de la gestación, con parto eutócico y buenos resultados perinatales(AU)

ABSTRACT Introduction: Cervical insufficiency is conceived today as a continuous biological process with progressive degrees of insufficiency. The most extreme expression of cervical insufficiency is known as "hourglass bag". Most authors agree to recommend bed rest and perform emergency cervical cerclage. Objective: To report the case of a pregnant woman in whom the prolapse reversal of the amniotic membranes in hourglass was achieved with good perinatal results. Case report: A 31-year-old patient who is currently pregnant at 20.6 weeks and has history of childbirth prior to 36.5 weeks. She comes to the consultation complaining of pain in hypogastrium. The physical examination shows that the amniotic sac protrudes through the external cervical orifice and there is 2cm cervical dilation. Drug treatment is applied and the prolapse of the sac is reduced. Conclusions: The conservative treatment achieved good evolution of the gestation, with eutócico childbirth and good perinatal results(AU)

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.

Rachianesthésie pour le cerclage du col utérin

Introduction :Notre étude avait pour but d'évaluer la rachianesthésie à faible dose de bupivacaïne et de fentanyl pour le cerclage du col de l'utérus chez des patientes en surpoids ou obèses. Le cerclage du col utérin est indiqué dans le traitement de l'incompétence cervicale, généralement réalisé sous anesthésie générale et en chirurgie ambulatoire. Méthodes : Il s'agissait d'une étude prospective observationnelle et multicentrique réalisée sur une période de 18 mois portant sur la rachianesthésie pour cerclage du col utérin. Etaient inclues les patientes de classes ASA 1 et 2, ayant un indice de masse corporelle supérieur ou égal à 25 Kg/m2. La rachianesthésie était réalisée avec une association de 5 mg de bupivacaïne et de 25 µg de fentanyl. Les principales variables étudiées étaient la qualité du bloc sensitif et moteur, les paramètres hémodynamiques, le délai de sortie de l'hôpital. L'analyse statistique a été faite à l'aide du logiciel SPSS 21.0. Résultats : Cinquante-neuf patientes d'un âge moyen de 27 ± 7 ans avec un âge de grossesse de 16 ± 4 semaines d'aménorrhée (SA) ont été inclues. Le délai d'installation du bloc sensitif était de 3,86±1,06 minutes, pour un niveau d'anesthésie à T11 chez 86,44% des patientes, et un score de Bromage à 1 à la mise en position gynécologique. Aucune plainte douloureuse n'a été exprimée à la préhension du col. La durée moyenne du cerclage était de 22,83 ± 5,04 min. Aucun cas d'hypotension artérielle ou de bradycardie n'a été observé. La récupération postopératoire était complète (score de Bromage 0) à la 2ème heure. La sortie était faite à la fin de la 3ème heure post-opératoire chez toutes les patientes. Conclusion : La rachianesthésie à faible dose de bupivacaïne et de fentanyl est suffisante et efficace pour le cerclage du col, chez des patientes à terrain particulier, permettant ainsi une récupération post interventionnelle précoce

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.

The role of three-dimensional ultrasound in pregnancies submitted to cerclage

SUMMARY OBJECTIVE: Cervical cerclage is the standard treatment for cervical incompetence (CI); however, there is still a high risk of preterm birth for women who undergo this treatment. The aim of this study was to longitudinally evaluate findings on two-dimensional transvaginal ultrasonography (2DTVUS) and three-dimensional transvaginal ultrasonography (3DTVUS) that could be related to gestational age at birth. METHODS: A total of 68 pregnant women who were treated with cerclage were evaluated by 2DTVUS and 3DTVUS in the second and third trimesters of pregnancy. Log-rank tests and Cox regression analyses were used to identify significant findings related to gestational age at delivery. RESULTS: A cervical length lower than 281 mm (p= 0.0083), a proximal cervical length lower than 10 mm (p= 0.0151), a cervical volume lower than 18.17 cm3 (p= 0.0152), a vascularization index (VI) under 2.153 (p= 0.0044), and a vascularization-flow index (VFI) under 0.961 (p= 0.0059) in the second trimester were all related to earlier delivery. In the third trimester, a cervical length lower than 20.4 mm (p= 0.0009), a VI over 0.54 (p= 0.0327) and a VFI over 2.275 (p= 0.0479) were all related to earlier delivery. Cervical funnelling in the second and third trimesters and proximal cervical length in the third trimester were not related to gestational age at birth. The COX regression analyses showed that cervical volume in the second trimester; FI and VFI in the third trimester were significantly associated with gestational age at birth. CONCLUSION: In women treated with history-indicated cerclage or ultrasound-indicated cerclage, 2nd trimester cervical volume and 3rd trimester FI and VFI are independent significant sonographic findings associated with time to delivery.

RESUMO OBJETIVOS: Determinar quais características ultrassonográficas obtidas por meio da ultrassonografia transvaginal bidimensional (USG TV 2D) e tridimensional (USG TV 3D) associam-se ao parto prematuro em gestantes submetidas à cerclagem profilática e terapêutica. MÉTODOS: Sessenta e seis gestantes com feto único submetidas à cerclagem profilática ou terapêutica e acompanhadas no ambulatório de Aborto Habitual da Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina da USP, entre 10 de juho de 2012 e 30 de outubro de 2015, foram avaliadas longitudinalmente, por meio das US TV 2D e US TV 3D associadas ao power Doppler para avaliação do VI, FI e VFI, nos três trimestres da gestação. Os resultados foram avaliados em relação ao parto em idade gestacional (IG) menor que 34 semanas e maior ou igual a 34 semanas, assim como em relação à idade do parto como variável contínua. RESULTADOS: O comprimento do colo uterino (CC) e a distância do ponto de cerclagem ao orifício interno do colo uterino (POI) diminuíram de forma significativa entre o segundo e terceiro trimestres da gestação. O CC, o POI e o afunilamento cervical no terceiro trimestre da gestação tiveram relação com a ocorrência de parto em IG<34 semanas. Na análise de regressão de COX, em que a variável de interesse foi o tempo até o parto, o volume do colo uterino no segundo trimestre e o FI e VFI no terceiro trimestre foram significativos. CONCLUSÃO: Foi possível identificar parâmetros ultrassonográficos do colo uterino bi e tridimensionais que se correlacionam com a idade gestacional do parto.

Prevención de parto pretérmino / Prevention of preterm delivery

Resumen Tradicionalmente, el parto pretérmino se considera aquel que ocurre después de las 20 semanas y antes de completar las 37 semanas de gestación; sin embargo, esta definición está siendo reevaluada. Actualmente, el parto pretérmino constituye la primera causa de mortalidad infantil en países desarrollados y aumenta significativamente su morbilidad. Debido a ello, es de suma importancia determinar sus factores predisponentes, con el objetivo de detectar a las madres en riesgo y consecuentemente, evitar este desenlace. Existen muchos factores de riesgo conocidos para parto pretérmino y algunos de estos son: parto pretérmino previo, longitud cervical corta, características demográficas, antecedente de cirugía cervical, sangrado vaginal durante primer trimestre, obesidad, infecciones, tabaquismo, bajo peso preconcepcional, abuso de sustancias y periodo intergenésico corto. Algunas medidas de prevención de parto pretérmino efectivas pueden ser: mejor control prenatal, tratamiento antibiótico de ciertas infecciones genitales y en las pacientes con ruptura prematura de membranas, tratamiento de bacteriuria asintomática, la suplementación con progesterona en pacientes con parto pretérmino previo o sin antecedente pero con longitud cervical muy corta antes de la semana 24 de gestación, el cerclaje en mujeres con antecedente de parto pretérmino previo menor a 34 semanas y longitud cervical menor a 25 mm antes de las 24 semanas de gestación, el uso de pesario en pacientes asintomáticas sin antecedentes de parto pretérmino con diagnóstico incidental de cérvix corto a las 18-22 semanas, la suplementación con zinc en mujeres de bajos ingresos y mala nutrición, y finalmente, el aumento de intervalo intergenésico a más de 12 meses.

Abstract Preterm delivery is traditionally known as birth that occurs after 20 weeks and before completing 37 weeks of gestation; however, this definition is being reevaluated. In developed countries, preterm delivery is the primary cause of children mortality and it significantly increases their morbidity. It is fundamental to determine its predisposing factors, in order to detect mothers at risk and consequently, avoid this adverse outcome. Some of the known risk factors for preterm delivery are: short cervical length, demographic characteristics, history of cervical surgery, previous preterm delivery, vaginal bleeding during the first trimester, obesity, infections, smoking, low preconceptional weight, substance abuse, and short interpregnancy interval. On the other hand, some effective prevention measures may include: better prenatal control, antibiotic treatment for certain genital infections, in patients with premature rupture of membranes, and asymptomatic bacteriuria; supplementation of progesterone in patients with or without history of previous preterm delivery, but with very short cervical length before the 24th week of gestation, use of cervical cerclaje in women with history of preterm delivery before 34 weeks and cervical length less than 25 mm at 24 weeks of gestation, use of pessary in asymptomatic women without history of preterm delivery with incidental diagnosis of short cervix at 18-22 weeks of gestation, zinc supplementation in women with low income and malnutrition, and finally, interpregnancy interval longer than 12 months.

History-indicated cerclage: the association between previous preterm history and cerclage outcome

OBJECTIVE: Our hospital's policy is to perform history-indicated cerclage (HIC) for pregnant patients with 1 or more second-trimester pregnancy losses. Recently, the American College of Obstetricians and Gynecologists (ACOG) guideline regarding indications for HIC was changed from 3 or more previous second-trimester fetal losses to one or more. In this study, we aimed to evaluate the efficacy of the revised guideline and to investigate the association between previous preterm history and cerclage outcome. METHODS: We conducted a retrospective observational study of cases of HIC in singleton pregnancies performed at our hospital between January 2007 and June 2016. We compared the perioperative complications and incidences of preterm delivery in patients with one previous second-trimester pregnancy loss against those in patients with ≥2 losses. RESULTS: The incidence of preterm delivery (< 32 weeks) was significantly lower in patients with one previous second-trimester pregnancy loss than in those with ≥2 losses (15/194 [8%] vs. 28/205 [14%]). In the 1 loss and ≥2 losses groups, the rates of preterm premature rupture of membranes (PPROM) were 7% and 8%, the rates of PPROM at < 32 weeks 2.1% and 3.4%, and the ratios of neonatal intensive care unit admission 10% and 17%, respectively. CONCLUSION: Comparison of HIC in one previous second-trimester pregnancy loss group with HIC in the 2 or more previous second-trimester pregnancy loss group found no difference in pregnancy outcome. This finding supports the amended ACOG guideline for HIC indications. Based on our results, we also propose development of a new protocol for HIC-related complications.

Successful delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a twin pregnancy / 영남의대학술지

There has been a significant increase in the number of multiple pregnancies that are associated with a high risk of preterm delivery among Korean women. However, to date, delayed-interval delivery in women with multiple pregnancy is rare. We report a case of delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a dichorionic diamniotic twin pregnancy. The patient presented with vaginal leakage of amniotic fluid at 16 weeks of gestation and was diagnosed with a preterm premature rupture of membranes. Three days later, the first twin was delivered, but the neonate died soon after. The second twin remained in utero, and we decided to retain the fetus in utero to reduce the morbidity and mortality associated with a preterm birth. The patient was managed with antibiotics and tocolytics. Cervical cerclage was not performed. The second twin was delivered vaginally at 34 weeks and 5 days of gestation, 128 days after the delivery of the first-born fetus. This neonate was healthy and showed normal development during the 1-year follow-up period. Based on our experience with this case, we propose that delayed-interval delivery may improve perinatal survival and decrease morbidity in the second neonate in highly selected cases.

Caso clínico: embarazo ectópico cervical, presentación de un caso clínico / Clinical case: cervical ectopic pregnancy, presentation of a clinical case

RESUMEN Antecedentes: El embarazo cervical es una forma rara del embarazo ectópico y representa < 1% de todos los embarazos ectópicos. Objetivo: Se presenta el caso de un embarazo ectópico cervical. Se realiza una revisión literaria sobre las diferentes opciones de manejo y tratamiento. Caso clínico: Mujer de 32 años en la semana 7+4 de embarazo en la que se objetiva un saco gestacional ístmico vascularizado, que ofrece dudas diagnósticas. Se establece el diagnóstico de embarazo ectópico cervical y se realiza un cerclaje por metrorragia. Conclusión: El embarazo ectópico cervical sigue siendo un reto importante en el campo del embarazo. El éxito del tratamiento conservador depende principalmente del diagnóstico precoz, lo que puede reducir las posibilidades de hemorragia grave y de histerectomía.

ABSTRACT Background: Cervical pregnancy is a rare type of ectopic pregnancy and it represents <1% of all ectopic pregnancies. Objetive: The case of a cervical ectopic pregnancy is presented. A literary review is carried out on the different management and treatment options. Case report: A 32-year-old woman in week 7 + 4 of pregnancy in which is objetived a vascularized isthmic gestational sac, which ofeers diagnostic doubt. The diagnosis of ectopic cervical pregnancy is established and cercaclage is performed by metrorrhagia. Conclusion: Cervical ectopic pregnancy remains a major challenge in the field of early pregnancy. The success of conservative treatment depends primarily on early diagnosis, which may reduce the chances of severe bleeding and require a hysterectomy.

El parto pretérmino: herramientas predictivas y preventivas en la práctica clinica / Preterm birth: predictive and preventive tools in clinical practice

Despite advances in both neonatal care and our understanding of the pathophysiology of the condition as a whole, preterm birth is a phenomenon that continues to have significant impact globally. It remains the leading cause of perinatal morbidity and mortality worldwide, and the prevalence is increasing. Not only does it carry significant social cost, preterm birth places huge economic burden on the healthcare system. It is increasingly recognised that preterm birth is a multifactorial syndrome, rather than a single condition and we have seen a number of exciting advances in predictive and preventative tools for clinical practice. The ability of quantitative fetal fibronectin to predict spontaneous preterm birth in both high and low risk women has been one of these recent promising developments. Exploration continues into the potential for quantitative fetal fibronectin to be used in synergy with transvaginal ultrasound measurement of cervical length to improve predictive accuracy. Developments focus on enabling clinicians to predict risk at the point of care. Research continues to explore cervical cerclage, progesterone and the Arabin pessary as prophylactic interventions for women at risk of preterm birth, with increasing evidence for their potential role. Latest exploration of reactive management for imminent preterm birth is altering our clinical approach and is likely to improve outcomes. This review article will discuss some of the recent developments we have seen in this exciting area

A pesar de los avances en la atención prenatal y en la comprensión de la fisiopatología del cuadro como un todo, el parto pretérmino es un fenómeno que continúa provocando un impacto significativo global. Continúa como la causa principal de morbilidad y mortalidad perinatal en todo el mundo y su prevalencia está en aumento. No solamente conlleva un costo social significativo, sino que el parto pretérmino produce una carga económica importante para el sistema de salud. Cada vez más, hay datos que indican que el parto pretérmino es un síndrome multifactorial, más que un cuadro único y nosotros documentamos un gran número de avances en las herramientas predictivas y preventivas en la práctica clínica. Uno de estos avances más recientes es la capacidad de la fibronectina fetal cuantitativa para predecir un parto pretérmino espontáneo, tanto en mujeres de alto riesgo como de bajo riesgo. La investigación continúa hacia el uso potencial de la fibronectina fetal cuantitativa en sinergia con la medición de la longitud cervical por ecografía transvaginal para mejorar la precisión predictiva. Los avances están dirigidos a que los clínicos puedan predecir el riesgo en el lugar de atención. Las investigaciones continúan con la evaluación del cerclaje cervical, la progesterona y el pesario de Arabin como intervenciones profilácticas para las mujeres en riesgo de parto pretérmino, con pruebas crecientes para su papel potencial. Las exploraciones ulteriores con terapia reactiva para el parto pretérmino inminente alteran nuestro enfoque clínico y probablemente mejoren los desenlaces clínicos. Esta revisión analizará algunos de los avances recientes observados en esta área apasionante

Prevención de parto prematuro en gemelar: ¿qué hay de nuevo? / Premature birth prevention in twin: what's new?

La incidencia del embarazo gemelar ha aumentado en todo el mundo de manera significativa en los últimos años. Uno de los principales problemas asociados es la prematurez, la cual afecta prácticamente al 50% de los embarazos gemelares, y es la causa única más importante de morbilidad y mortalidad perinatal. En este contexto cobran cada vez mas importancia las medidas de prevención del parto prematuro. En el embarazo único, existe evidencia sólida para recomendar el uso de múltiples estrategias de prevención, con resultados alentadores. En gestaciones múltiples en cambio, la información es menor y los resultados menos prometedores. Este articulo tiene como objetivo revisar la evidencia disponible sobre diferentes técnicas de prevención del parto prematuro en embarazos gemelares.

The incidence of twin pregnancy has increased significantly worldwide in recent years. One of the main associated problems is prematurity, which affects almost 50% of twin pregnancies, and is the single most important cause of perinatal morbidity and mortality. In this context, measures of prevention of preterm delivery are becoming increasingly important. In single pregnancy, there is strong evidence to recommend the use of multiple prevention strategies, with encouraging results. In multiple gestations, the information is smaller and the results less promising. This article aims to review available evidence on different techniques for preventing preterm birth in twin pregnancies.

Prediction of preterm birth in women with short cervix

Background: Second trimester short cervical length identifies women at increased risk for an early spontaneous Preterm birth [sPTB], hence raising a compelling needed for Cervical Assessment for prediction and possible Preventing Preterm Delivery

Objective of the study: to assess the implications associated with a short cervical length as well as the use of ultrasonographic-derived cervical length measurement in predicting preterm birth. Methods: the present review includes relevant randomized controlled trials [RCTs] that investigated the in Medline [via PubMed], Cochrane Library and Embase. Retrospective and Prospective Cohort studies, Case-control and Randomised controlled trials. There were no restrictions by outcomes examined, language or publication status

Results: The critical search results yielded 6 articles [randomized trials=2, cohort studies=3, case-control study=l] representing 653 patients . Five of the 6 presented similar pregnancy outcomes [spontaneous preterm birth or pregnancy Joss < 24 weeks' gestation] between the ultrasound-indicated and the history-indicated cerclage groups. 45-69% of the patients followed with cervical ultrasound were able to avoid cerclage

Conclusion: Evidence from randomized trials supports that transvaginal ultrasound is predictive of preterm birth in women with prior preterm birth and a short cervix. The thresholds proposed vary from 15 mm to 28 mm and cerclage is thus recommended

Cerclaje, tratamiento quirúrgico conservador en embarazo ectópico cervical, tres casos. Instituto Salvadoreño del Seguro Social, Hospital Materno Infantil 1 de Mayo / Cerclage, conservative surgical treatment in cervical ectopic pregnancy, three cases. Instituto Salvadoreño del Seguro Social, Hospital Materno Infantil 1 de Mayo

Menos del 1% de los embarazos ectópicos se implantan en el canal cervical por abajo del orificio cervical interno, la etiología de esta implantación es desconocida aunque se asocia a curetaje previo, síndrome de Asherman, leiomiomas, presencia de DIU entre otras. Timor-Tritsch define el diagnóstico ecográfico como el saco coriónico implantado debajo de OCI, canal cervical dilatado, embrión con latido cardiaco o presencia de infiltración cervical confirmada por Doppler. No existe un consenso en relación al tratamiento de esta condición, se ha tratado con Metrotexate sistémico o intracervical, embolización arterial selectiva, aspiración guiada por ecografía, aunque la histerectomía fue el tratamiento en los casos de sangrado incontrolable...

Tratamiento exitoso de un embarazo heterotópico cervical luego de un procedimiento de fecundación in vitro / Successful treatment of a cervical heterotopic pregnancy following an in vitro fertilization procedure

Mujer nulípara infértil de 37 años presentó un embarazo heterotópico cervical luego de tratamiento por fecundación in vitro. Una intervención temprana durante la 6ta semana de gestación logró remover el saco cervical mediante un aspirador manual. Para prevenir una posible hemorragia, se realizó la ligadura de las ramas cérvico-uterinas y se colocó un cerclaje cervical, antes de la aspiración. Se logró extraer el embarazo cervical con mínima hemorragia. El embarazo intrauterino progresó sin complicaciones, resultando en el parto de un varón de 2740 g, a las 35.4 semanas.

A 37-year-old nulligravida infertile female had a cervical heterotopic pregnancy following an in vitro fertilization procedure. Early intervention on the 6th week of gestation with a manual vacuum aspirator reached to remove the cervical pregnancy. Ligation of the descending cervical branches of the uterine arteries and a cervical cerclage, were placed before the aspiration, for prevention of possible hemorrhage. Successful removal of the cervical pregnancy was achieved with only mild bleeding. An intrauterine pregnancy progressed to viability without complications, resulting in a vaginal delivery of a preterm live-birth at 35.4 weeks, of a male that weighted 2740 g.