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)

Cervical pessary plus progesterone for twin pregnancy with short cervix compared to unselected and non-treated twin pregnancy: a historical equivalence cohort study (EPM twin pessary study) / Pessário cervical associado a progesterona em gestações gemelares com colo curto comparado a gestações gemelares não selecionadas e não tratadas: estudo de coorte histórica de equivalência (Estudo de Pessário em Gêmeos EPM)

Abstract Objective The present study aims to determine if the use of cervical pessary plus progesterone in short-cervix (≤ 25 mm) dichorionic-diamniotic (DC-DA) twin pregnancies is equivalent to the rate of preterm births (PBs) with no intervention in unselected DC-DA twin pregnancies. Methods A historical cohort study was performed between 2010 and 2018, including a total of 57 pregnant women with DC-DA twin pregnancies. The women admitted from 2010 to 2012 (n = 32) received no treatment, and were not selected by cervical length (Non-Treated group, NTG), whereas those admitted from 2013 to 2018 (n = 25), were routinely submitted to cervical pessary plus progesterone after the diagnosis of short cervix from the 18th to the 27th weeks of gestation (Pessary-Progesterone group, PPG). The primary outcome analyzed was the rate of PBs before 34 weeks. Results There were no statistical differences between the NTG and the PPG regarding PB < 34 weeks (18.8%; versus 40.0%; respectively; p = 0.07) and the mean birthweight of the smallest twin (2,037 ± 425 g versus 2,195 ± 665 g; p = 0.327). The Kaplan-Meyer Survival analysis was performed, and there were no differences between the groups before 31.5 weeks. Logistic regression showed that a previous PB (< 37 weeks) presented an odds ratio (OR) of 15.951 (95%; confidence interval [95%;CI]: 1.294-196.557; p = 0.031*) for PB < 34 weeks in the PPG. Conclusion In DC-DA twin pregnancies with a short cervix, (which means a higher risk of PB), the treatment with cervical pessary plus progesterone could be considered equivalent in several aspects related to PB in the NTG, despite the big difference between these groups.

Resumo Objetivo Este estudo tem como objetivo determinar se o uso de pessário cervical associado a progesterona em gestações de gêmeos dicoriônicos-diamnióticos (DC-DAs) com colo do útero curto (≤ 25 mm) apresenta taxa de parto prematuro (PP) equivalente à de gestações gemelares DC-DA sem nenhuma intervenção/não selecionadas. Métodos Um estudo de coorte histórica foi realizado entre 2010 e 2018, incluindo um total de 57 mulheres grávidas com gestações gemelares DC-DA. As mulheres admitidas de 2010 a 2012 (n = 32) não receberam tratamento, e não foram selecionadas pelo comprimento cervical (grupo Não Tratado, GNT), enquanto as admitidas de 2013 a 2018 (n = 25) receberam pessário cervical rotineiramente associado a progesterona após o diagnóstico de colo curto entre a 18a e a 27ª semanas de gestação (grupo Pessário-Progesterona, GPP). O desfecho primário analisado foi a taxa de PP antes de 34 semanas. Resultados Não houve diferenças estatísticas entre o GNT e o GPP em relação ao PP < 34 semanas (respectivamente, 18,8%; versus 40,0%;; p = 0,07) e ao peso médio ao nascer do gêmeo menor (2.037 ± 425 g versus 2.195 ± 665 g; p = 0,327). A análise de Kaplan-Meyer foi realizada, e não houve diferenças entre os grupos antes de 31,5 semanas. A regressão logística demonstrou que o nascimento prematuro anterior (< 37 semanas) apresentou razão de probabilidades (odds ratio, OR) de 15,951 (intervalo de confiança de 95%; [IC95%;]: 1,294-196,557; p = 0,031*) para o nascimento prematuro < 34 semanas no GPP. Conclusão Em gêmeos DC-DA com colo uterino curto (o que significa maior risco de nascimento prematuro), o tratamento com pessário cervical associado a progesterona pode ser considerado equivalente em diversos aspectos relacionados à prematuridade no GNT, apesar da grande diferença entre os grupos.

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)

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)

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.

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.

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.

Cervical pessary in prevention of preterm birth: A case series / Philippine Journal of Obstetrics and Gynecology

Preterm birth defined as birth between 20-37 weeks age of gestation, poses major concerns as it causes serious health problems. Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born and the Philippines ranks 8th out of 184 countries for the number of babies born prematurely, and ranks 17th for the total number of deaths due to complications from preterm birth. Management of incompetent cervix as one of the causes of preterm birth is cerclage. However, pessary insertion is an alternative especially in cases where cerclage may not be employed. To date, there have been no local published reports on effectiveness of pessary in prevention of preterm birth. Hence this study aims to report on cases supporting the use of pessary in preterm birth. This is a case series of three patients with short functional cervical lengths (

Cervical pessary in prevention of preterm birth: A case series / Philippine Journal of Obstetrics and Gynecology

Preterm birth defined as birth between 20-37 weeks age of gestation, poses major concerns as it causes serious health problems. Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born and the Philippines ranks 8th out of 184 countries for the number of babies born prematurely, and ranks 17th for the total number of deaths due to complications from preterm birth. Management of incompetent cervix as one of the causes of preterm birth is cerclage. However, pessary insertion is an alternative especially in cases where cerclage may not be employed. To date, there have been no local published reports on effectiveness of pessary in prevention of preterm birth. Hence this study aims to report on cases supporting the use of pessary in preterm birth. This is a case series of three patients with short functional cervical lengths (

Successful term delivery cases of trans-abdominal cervicoisthmic cerclage performed at more than 18 weeks of gestation

A 38-year-old nulliparous woman was referred to our clinic because of cervical incompetence at 19 weeks of gestation. Trans-abdominal cervicoisthmic cerclage was performed after failure of modified Shirodkar cerclage operation in the patient at 21 weeks of gestation via a laparotomic approach. Another 38-year-old patient, who underwent loop electrosurgical excision procedure conization for treatment of cervical dysplasia 4 years ago, presented for cervical incompetence. At 18 weeks of gestation, we performed trans-abdominal laparotomic cervicoisthmic cerclage without any post-operative complications. During antenatal follow-up, there were no obstetrical co-morbidities and finally she gave birth to a healthy infant at full term by cesarean section. We report two cases of women who underwent trans-abdominal cervicoisthmic cerclage surgery because of cervical incompetence as they were not suitable for transvaginal cervical cerclage. Both patients successfully maintained their pregnancy until full term after undergoing transabdominal cervicoisthmic cerclage at more than 18 weeks of gestation.

Role of Cervical Cerclage and Vaginal Progesterone in the Treatment of Cervical Incompetence with/without Preterm Birth History / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Preterm birth (PTB) is the leading cause of perinatal morbidity and mortality worldwide, and its prevention is an important health-care priority. The cervical incompetence is a well-known risk factor for PTB and its incidence is about 0.1-2.0%, while there is no ideal optimum treatment recommended currently. The cervical incompetence causes about 15% of habitual abortion in 16-28 weeks. This study aimed to evaluate the effectiveness and safety of cervical cerclage and vaginal progesterone in the treatment of cervical incompetence with/without PTB history.</p><p><b>METHODS</b>We retrospectively observed the pregnancy outcome of 198 patients diagnosed with cervical incompetence from January 2010 to October 2015 in Beijing Hospital. Among the 198 women involved, women who had at least one PTB before 32 weeks (including abortion in the second trimester attributed to the cervical competence) were assigned to the PTB history cohort, and others were assigned to the non-PTB history cohort. All women underwent cerclage placement (cervical cerclage group) or administrated with vaginal progesterone (vaginal progesterone group) until delivery. The outcomes of interest were the differences in gestational age at delivery, the rate of premature delivery, neonatal outcome, complications, and route of delivery between the two treatment groups.</p><p><b>RESULTS</b>Among the 198 patients with cervical incompetence, 116 patients in PTB history cohort and 80 patients in non-PTB history cohort were included in the final analysis. In the PTB history cohort, cervical cerclage group had significantly longer cervical length at 2 weeks after the start of treatment (23.1 ± 4.6 mm vs. 12.4 ± 9.1 mm, P = 0.002), higher proportion of delivery ≥37 weeks' gestation (63.4% vs. 33.3%, P = 0.008), bigger median birth weight (2860 g vs. 2250 g, P = 0.031), and lower proportion of neonates whose 1-min Apgar score <7 (5.9% vs. 33.3%, P = 0.005), compared with vaginal progesterone group. No significant differences were found in other outcome measures between the two treatment groups. In the non-PTB history cohort, there were no significant differences in the maternal outcomes between cervical cerclage and vaginal progesterone groups, such as median gestational age at delivery (37.4 weeks vs. 37.3 weeks, P = 0.346) and proportion of delivery ≥37 weeks' gestation (55.9% vs. 60.9%, P = 0.569). There were also no significant differences in the neonatal outcomes between the cervical cerclage and vaginal progesterone groups including the median birth weight (2750 g vs. 2810 g, P = 0.145), perinatal mortality (5.9% vs. 6.5%, P = 0.908), and 1-min Apgar scores (8.8% vs. 8.7%, P = 0.984).</p><p><b>CONCLUSIONS</b>Cervical cerclage showed more benefits in the maternal and neonatal outcomes than vaginal progesterone therapy for women with an asymptomatic short cervix and prior PTB history, while cervical cerclage and vaginal progesterone therapies showed similar effectiveness for women with an asymptomatic short cervix but without a history of PTB.</p>

Laparoscopic transabdominal cervical cerclage: Case report of a woman without exocervix at 11 weeks gestation

Cervical incompetence is characterized by painless dilatation of the incompetent cervix and results in miscarriages and preterm delivery during second trimester. We report a 25-year-old patient, gravid 2, para 1, at 11 weeks' gestation with the diagnosis of cervical incompetence, in whom transvaginal cerclage was not technically possible and laparoscopic cervical cerclage was performed successfully. There were no operative or immediate postoperative complications. A healthy infant was delivered at 35 weeks by cesarean section. Laparoscopic cervical cerclage during pregnancy can be safe and effective treatment for well-selected patients with cervical incompetence and eliminates the need for open laparotomy.

Parto prematuro / Premature delivery

El parto prematuro es la causa única más importante de morbilidad y mortalidad perinatal. En Chile, los partos prematuros han aumentado en la última década, aunque la morbimortalidad neonatal atribuible a ella muestra una tendencia descendente, gracias a la mejoría en el cuidado neonatal de los prematuros, más que al éxito de estrategias preventivas y terapéuticas obstétricas. En este artículo se describen entidades clínicas, procesos patológicos y condiciones que constituyen factores predisponentes del parto prematuro; por otra parte se detallan procedimientos para la prevención y manejo clínico de mujeres en riesgo de parto prematuro.

Preterm delivery is the single most important cause of perinatal morbidity and mortality. In Chile, preterm births have increased in the past decade, although neonatal morbidity and mortality attributable to it shows a downward trend, thanks to improvements in neonatal care of premature babies, rather than the success of obstetric preventive and therapeutic strategies. This article describes clinical entities, disease processes and conditions that constitute predisposing factors of preterm birth, as well as an outline for the prevention and clinical management of women at risk of preterm birth.

Laparoscopic cervicoisthmic cerclage for the treatment of cervical incompetence: case reports / Cerclaje cérvico-ístmico laparoscópico en el tratamiento de la incompetencia cervical: reporte de casos

Cervical insufficiency/incompetence occurs in 0.5-1% of all pregnancies, often resulting in significant pregnancy lost. Three women with a history of second trimester miscarriages after failed transvaginal cervical cerclages were reviewed. A laparoscopic cervicoisthmic cerclage (LCC) was placed before pregnancy without any intra-operative or postoperative complications. Two patients have since delivered live babies at term by Caesarean section. This small case series supports the conclusion that LCC is a safe and cost-effective procedure in properly selected patients. Laparoscopic cervicoisthmic cerclage costs less, is less invasive, has fewer complications and should replace the traditional laparotomy technique.

La insuficiencia/incompetencia cervical ocurre en 0.5-1% de todos los embarazos, trayendo a menudo como consecuencia una pérdida significativa de embarazos. Se revisaron los casos de tres mujeres con una historia de abortos en el segundo trimestre después de cerclajes cervicales transvaginales fallidos. Un cerclaje cérvico-ístmico laparoscópico (CCL) se realizó antes del embarazo sin ninguna complicación intraoperatoria o postoperatoria. Desde entonces, dos pacientes han parido bebés vivos a término por cesárea. Esta pequeña serie de casos sustenta la conclusión de que el CCL es un procedimiento seguro y costo-efectivo en pacientes propiamente seleccionados. El cerclaje cérvico-ístmico laparoscópico cuesta menos, es menos invasivo, tiene menos complicaciones, y debe reemplazar la técnica de laparotomía tradicional.

O papel da cerclagem nas gestações múltiplas: revisão sistemática / The role of cerclage in multiple gestations: systematic review

Investigar a eficácia da cerclagem cervical na redução de partos prematuros em gestações múltiplas. Uma revisão sistemática da literatura científica foi realizada com a utilização dos Descritores em Ciências da Saúde (DECS): cerclagem cervical, gêmeos, trabalho de parto prematuro e nascimento prematuro. Utilizamos as bases de dados: Medical Literature Analysis and Retrieval System Online (Medline), The Cochrane Library e PubMed, sem restrições quanto ao ano ou idioma da busca. Foram selecionados oito artigos para análise, sendo seis originais e duas metanálises, divididos de acordo com os temas de interesse: cerclagem profilática na gestação gemelar (um artigo), cerclagem na gestação gemelar com o colo curto (cinco artigos) e cerclagem nas gestações múltiplas com mais de dois fetos (dois artigos). Os artigos selecionados foram objetos de leitura exploratória e apresentados segundo características gerais. Não há evidência científica para recomendar o uso da cerclagem cervical em qualquer modalidade de gestação múltipla sem o diagnóstico de incompetência istmo-cervical, mesmo na presença de encurtamento do colo uterino

To investigate the efficiency of cervical cerclage and reduce preterm labors in multiple gestations. A systematic review of the literature was done by using the Descritores em Ciências da Saúde (DECS): cervical cerclage, twins, preterm delivery and preterm labor. We used the electronic databases: Medical Literature Analysis and Retrieval System Online (Medline), The Cochrane Library and PubMed, without search restrictions of year or language. Eight articles were selected for analysis, six of which were original articles, and two of which were meta-analysis, classified by subject of interest: prophylactic cerclage in multiple gestation (one article), cerclage in multiple gestation with short cervix (five articles) and cerclage in high order multiple gestation (two articles). The selected articles were submitted to the exploratory reading and presented according to its general characteristics. There is no scientific evidence to recommend cervical cerclage for any form of multiple gestation without the diagnosis of cervical incompetence, even in the presence of cervical shortening

Cerclaje cervicouterino transabdominal en el embarazo: a propósito de 3 casos / Transabdominal cervicouterine cerclage in pregnancy: a report of 3 cases

Evaluar la técnica de cerclaje cervicouterino transabdominal durante la gestación. Estudio prospectivo, donde se seleccionaron 3 pacientes embarazadas, que cumplían los criterios de inclusión a las cuales se les realizó la técnica de cerclaje cervicouterino transabdominal entre las 14 y 17 semanas de gestación. Maternidad “Concepción Palacios”. En los 3 casos realizados se presentó una efectividad del método del 100 por ciento, lo cual es comparable con la experiencia internacional. El cerclaje cervicouterino transabdominal es una técnica reservada para pacientes bien seleccionadas que cumplan las indicaciones para su realización. Tiene buen resultado perinatal con baja incidencia de complicaciones durante su realización y durante el curso de la gestación

To evaluate the transabdominal cervicouterine cerclage technique during gestation. Prospective study of 3 pregnant patients that met the inclusion criteria to whom a transabdominal cervico-uterine cerclage technique was performed between 14 to 17 weeks of gestation. Maternidad “Concepcion Palacios”. In the 3 cases the method effectivity was 100 percent, comparable with the international experience. The transabdominal cervicouterine celclage is a technique reserved for selected patients that met the indications for its realization. It has a good perinatal result with low incidence of complications during the procedure and in the course of gestation

Indicações e técnicas cirúrgicas de cerclagem cervical / Therapeutic and cirurgical approaches of cervical cerclage

A insuficiência cervical acomete cerca de 2,4 em cada 1.000 gestações. A cerclagem, procedimento proposto para tratamento da insuficiência cervical, foi descrita em 1955 e rapidamente adotada na prática médica antes que fossem realizados estudos sobre sua eficácia e segurança. A literatura atual sugere três indicações para a cerclagem: profilática, baseada na história de perdas anteriores; terapêutica, baseada no achado ultrassonográfico de colo curto; de emergência, baseada no achado de colo dilatado ao exame físico. Neste artigo, o autor faz uma revisão da literatura, utilizando os princípios da medicina baseada em evidência, sobre as indicações e técnicas contemporâneas da cerclagem.

Approximately 2.4 in 1.000 pregnancies are challenged by cervical insufficiency. Cervical cerclage was first described in 1955 and soon adopted as a routine obstetric practice, before safety and efficacy trials could be conducted. The current literature cites three indications for the cerclage: prophylactic, based on the patient history of prior pregnancy loss; therapeutic, based on finding of a short cervix in the ultrasound; emergency, based on finding of a dilated cervix in the physical exam. In this paper, the author reviews the literature, using evidence based medicine principles, to describe the contemporary indications and technical aspects of cervical cerclage.

Abortamento habitual - II Fatores cromossômicos e anatômicos / Habitual abortion - II Cromossomic and anatomic factors

Embora fatores cromossômicos parentais tenham sido sugeridos como responsáveis por pequena proporção de abortamentos habituais, seu papel como causa das perdas ainda não foi convincentemente comprovado. Há evidências indiretas de que algumas mulheres teriam predisposição à não disjunção cromossômica durante a meiose, que resultaria em trissomias recorrentes nos embriões. As evidências que associam os abortamentos habituais às translocações ou inversões cromossômicas e aos mosaicismos são de baixa qualidade e controversas. Em relação ao distúrbios anatômicos, as abortadoras habituais com história típica de incompetência istmo-cervical, com mioma submucoso, sinéquias intra-uterinas ou septos não têm sido incluídas em ensaios clínicos com grupo-controle sem tratamento. Isso se deve provavelmente a um conceito empírico, fortemente estabelecido entre clínicos e pesquisadores, de que essas doenças são causas de abortamento habitual de tratamento obrigatório. Não há evidências que justifiquem a realização de metroplastias laparotômicas em pacientes com útero didelfo ou bicorno, embora algumas possam se beneficiar da cerclagem uterina

Although parental chromosomal factors have been suggested to play a role in a small proportion of habitual abortion, they have not been convincingly imputed as the cause of miscarriage. There are indirect evidences that some women are prone to chromosomal non-disjunction during meiosis yielding recurrent trisomies in embryos. The evidences associating habitual abortion to chromosomal translocations or inversions and to mosaicism are controversial and bad quality. Concerning anatomical disturbs, habitual aborters with a typical history of cervical incompetence, with submucous myomas, intra-uterine adhesions or septum have not been included in controlled trials with a no-treatment control group. This is probably due to a conception strongly established among clinicians and researchers that these are causes of habitual abortion of mandatory treatment. There is no evidence to justify laparotomic metroplasty in didelphic of bicornuate uterus, although some women could benefit from uterine cerclagem