[Cervical incompetence: diagnosis, indications and cerclage outcome]

BACKGROUND

Cervical incompetence, a major cause of late abortions and preterm delivery is a diagnosis increasingly easy to establish.Strapping is deemed effective to prevent recurrence of such accidents midwifery.

AIM

To evaluate the relevance of the diagnosis of cervical incompetence, check the main indications of banding and study the outcome of rimmed pregnancies.

METHODS

A retrospective study about 103 rimmed pregnancies collected in the service of Motherhood Hospital Mahmoud El Matri Ariana to the period of January 2001 until December 2008.

RESULTS

The diagnosis of cervical incompetence is suspected in a body of evidence linking ATCD of late abortions or premature births found in respectively 46.2% and 31.1% of our patients in our series, 16.98% are carriers of known uterine defects. 8.49% are classified as high risk front of 3-ATCD of late abortions or preterm delivery and were circled systematically. 2.83% are rimmed after confirmation the incompetent cervix by calibration of the cervix and 55.99% because of clinically short cervix. The strapping has reduced the rate of late abortion which decreased from 46.6% before strapping to 7.6% after. As for preterm delivery, it is reduced from 31.1% before strapping to 18.5% after. This difference is statistically significant. The average term of confinement in our series is 36SA six days. 68 cases were delivered at term. Among patients in whom we have accepted the vaginal delivery, 74.2% had spontaneous labor. One case of rupture of the anterior lip of the cervix was noted.

CONCLUSION

The indication of a cervical strapping needs a well established diagnosis involving data from history, clinical examination and possibly endo-vaginal ultrasound to confirm the high-risk of cervical incompetence. The strapping participates significantly to prolong the duration of pregnancy, to lower rates of early major premature and to improve the chance of viability and prognosis of fetuses without serious repercussions on the workflow.

Hysteroscopic metroplasty in women with primary infertility and septate uterus: reproductive performance after surgery

OBJECTIVE

To assess reproductive performance in women with septate uterus and otherwise unexplained infertility after hysteroscopic metroplasty.

STUDY DESIGN

A total of 72 women with septate uterus and otherwise unexplained primary infertility were included in the study. All of the women underwent hysteroscopic septal resection. Reproductive performance of these women within one year of surgery was studied and analyzed.

RESULTS

Thirty-three women (45.83%) conceived within one year of surgery. Only 4 women (12%) had spontaneous abortions, and only 5 (15%) had preterm delivery.

CONCLUSION

Hysteroscopic metroplasty in women with septate uterus significantly improves reproductive outcomes.

Chronic postpartum uterine inversion treated by abdominal replacement and cerclage

BACKGROUND

Chronic uterine inversion is a potentially dangerous condition that often requires abdominal surgical reduction of the uterine inversion. Uterine inversion can recur after successful uterine replacement.

CASE

A young primagravida presented with chronic recurrent uterine inversion 5 weeks after spontaneous vaginal delivery. The uterus was replaced abdominally and an abdominal cervical cerclage was placed to prevent recurrent inversion.

CONCLUSION

Abdominal cervical cerclage can be utilized after treatment of chronic recurrent uterine inversion to prevent future recurrence of uterine inversion.

History- or ultrasound-based cerclage placement and adverse perinatal outcomes

OBJECTIVE

To determine whether cerclage based on serial transvaginal ultrasound (STVUS) vs. cerclage based on obstetric history (prior multiple midgestation losses) is superior for treatment of cervical insufficiency.

STUDY DESIGN

This retrospective study evaluated all history-based or ultrasound-based cerclages in singleton pregnancies over a 5-year period at the University of Mississippi Medical Center. Demographic statistics, interval from cerclage placement to delivery, and gestational age at delivery were recorded, as were neonatal factors such as birthweight, morbidity, and mortality.

RESULTS

No significant difference was found in regard to gestational age at delivery between the history-based cerclage and the ultrasound-based groups. The number of patients delivered before 24 weeks or after 34 weeks was similar. Birth weights, Apgar scores, and the number with growth restriction were similar between the two groups, as were perinatal loss and significant morbidity. In the ultrasound-based cerclage group, 52.1% did not require cerclage placement despite a history consistent with cervical insufficiency.

CONCLUSION

There were no statistical differences between history-based and ultrasound-based cerclage in regard to obstetric or neonatal outcome. Using STVUS instead of cerclage procedures based on obstetric history, unnecessary procedures can be avoided in more than half the patients.

Placement of a cervical cerclage in combination with an intrauterine balloon catheter to arrest postpartum hemorrhage

Placement of a cervical cerclage postpartum allows retention of a uterine tamponade balloon in women with a dilated cervix. This novel indication for a cervical cerclage may be a useful adjunct to intrauterine balloon catheter in management of postpartum uterine hemorrhage.

Preterm birth

INTRODUCTION

Preterm birth occurs in about 5% to 10% of all births in resource-rich countries, but in recent years the incidence seems to have increased in some countries, particularly in the USA. We found little reliable evidence for incidence in resource-poor countries. The rate in northwestern Ethiopia has been reported to vary from 11% to 22%, depending on the age group of mothers studied, and is highest in teenage mothers.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of preventive interventions in women at high risk of preterm delivery? What are the effects of interventions to improve neonatal outcome after preterm rupture of membranes? What are the effects of treatments to stop contractions in preterm labour? What are the effects of elective compared with selective caesarean delivery for women in preterm labour? What are the effects of interventions to improve neonatal outcome in preterm delivery? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 58 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review, we present information relating to the effectiveness and safety of the following interventions: amnioinfusion for preterm rupture of membranes, antenatal corticosteroids, antibiotic treatment, bed rest, beta-mimetics, calcium channel blockers, elective caesarean, enhanced antenatal care programmes, magnesium sulphate, oxytocin receptor antagonists (atosiban), progesterone, prophylactic cervical cerclage, prostaglandin inhibitors (e.g., indometacin), selective caesarean, and thyrotropin-releasing hormone (TRH) (plus corticosteroids).

Association between second-trimester cervical length and spontaneous preterm birth in twin pregnancies

OBJECTIVE

The purpose of this study was to define normal second-trimester cervical length (CL) measurements and to estimate the association between second-trimester CL and spontaneous preterm birth (SPTB) in twin pregnancies.

METHODS

A retrospective cohort of 309 asymptomatic patients with twin pregnancies who had routine outpatient CL assessment in the second trimester was studied. We looked at the gestational age periods of 16 to 17 6/7, 18 to 19 6/7, 20 to 21 6/7, and 22 to 23 6/7 weeks. We estimated the association between the CL measurement during each period and SPTB. A short CL was defined both as a CL at or below the 10th percentile for gestational age and 25 mm or less. We also performed regression analyses controlling for a number of clinically important factors: maternal age, chorionicity, in vitro fertilization, multifetal reduction, prior term births, prior preterm births, prepregnancy body mass index, and cerclage.

RESULTS

The CL measurement at 16 to 17 6/7 weeks was not associated with gestational age at delivery or SPTB. At 18 to 19 6/7 and 20 to 21 6/7 weeks, the CL measurement was not significantly associated with gestational age at delivery or SPTB before 28 and 32 weeks. There was an association with SPTB before 35 weeks. At 22 to 23 6/7 weeks, the CL measurement had a significant association with gestational age at delivery and SPTB before 28, 32, and 35 weeks (P < .05). A short CL at 22 to 23 6/7 weeks was significantly associated with SPTB before 32 and 35 weeks (P < .05).

CONCLUSIONS

In second-trimester twin pregnancies, the strongest association between CL and SPTB is at 22 to 23 6/7 weeks.

Does midtrimester cervical length ≥25 mm predict preterm birth in high-risk women?

OBJECTIVE

We sought to assess pregnancy outcome along a continuum of cervical lengths (CLs) ≥25 mm.

STUDY DESIGN

We conducted planned secondary analysis of a randomized cerclage trial of women with prior spontaneous preterm birth 17(0)-34(6/7) weeks. Outcomes of women who maintained CLs ≥25 mm were analyzed. Women with CLs <25 mm randomized to no cerclage comprised an internal comparison group.

RESULTS

Of 1014 screened, 153 had CL <25 mm, and 672 had CL ≥25 mm. Birth <35 weeks occurred in 16% of the ≥25 mm cohort. The relationship between CLs ≥25 mm and birth gestational age was null (P = .15). In the <25 mm group, progressively shorter CLs predicted birth <35 weeks (P < .001); this relationship was null in the ≥25 mm group (P = .17).

CONCLUSION

The continuum of CLs ≥25 mm measured between 16(0/7)-22(6/7) weeks does not predict gestational length in women with prior spontaneous preterm birth.

Gestational age at previous preterm birth does not affect cerclage efficacy

OBJECTIVE

The purpose of this study was to evaluate the effect of earliest previous spontaneous preterm birth (SPTB) gestational age on cervical length, pregnancy duration, and ultrasound-indicated cerclage efficacy in a subsequent gestation.

STUDY DESIGN

Planned secondary analysis of the National Institute of Child Health and Human Development-trial of cerclage for cervical length of <25 mm. Women with at least 1 previous SPTB between 17-33 weeks 6 days of gestation underwent serial vaginal ultrasound screening between 16 and 23 weeks 6 days of gestation; cervical length at qualifying randomization evaluation was used.

RESULTS

We observed a significant correlation (P = .0008) between previous SPTB gestational age and qualifying cervical length. In a linear regression model that was controlled for cervical length and cerclage, neither previous SPTB gestational age nor the interaction between cerclage and previous birth gestational age was significant predictor of subsequent birth gestational age.

CONCLUSION

Although there is an association between previous SPTB gestational age and cervical length in women with a mid-trimester cervical length of <25 mm, there does not appear to be a disproportionate benefit of cerclage in women with earlier previous SPTB.

Cervical funneling: effect on gestational length and ultrasound-indicated cerclage in high-risk women

OBJECTIVE

The purpose of this study was to assess funnel type and pregnancy duration in women with previous spontaneous preterm birth and cervical length <25 mm.

STUDY DESIGN

We performed a secondary analysis of a multicenter randomized trial of cerclage. At the randomization scan that documented short cervix, the presence and type of funnel (U or V) were recorded.

RESULTS

One hundred forty-seven of 301 women (49%) had funneling: V-shaped funnel, 99 women; U-shaped funnel, 48 women. U-shaped funnel was associated significantly with preterm birth at <24, <28, <35, and <37 weeks of gestation. In multivariable models that controlled for randomization cervical length and cerclage, women with U-shaped funnel delivered earlier than women with either V-shaped funnel or no funnel. Interaction between cerclage and U-shaped funnel was observed, and analyses that were stratified by cerclage showed that women with a U-shaped funnel and cerclage delivered at a mean of 33.8 +/- 6.6 weeks of gestation, compared with women who did not receive cerclage (28.9 +/- 6.9 weeks of gestation).

CONCLUSION

U-shaped funnels in high-risk women with a short cervix are associated with earlier birth.

Antibiotic prophylaxis in obstetric procedures

OBJECTIVE

To review the evidence and provide recommendations on antibiotic prophylaxis for obstetrical procedures.

OUTCOMES

Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in obstetrical procedures.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Library on the topic of antibiotic prophylaxis in obstetrical procedures. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and articles published from January 1978 to June 2009 were incorporated in the guideline. Current guidelines published by the American College of Obstetrics and Gynecology were also incorporated. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Implementation of this guideline should reduce the cost and harm resulting from the administration of antibiotics when they are not required and the harm resulting from failure to administer antibiotics when they would be beneficial. SUMMARY STATEMENTS: 1. Available evidence does not support the use of prophylactic antibiotics to reduce infectious morbidity following operative vaginal delivery. (II-1) 2. There is insufficient evidence to argue for or against the use of prophylactic antibiotics to reduce infectious morbidity for manual removal of the placenta. (III) 3. There is insufficient evidence to argue for or against the use of prophylactic antibiotics at the time of postpartum dilatation and curettage for retained products of conception. (III) 4. Available evidence does not support the use of prophylactic antibiotics to reduce infectious morbidity following elective or emergency cerclage. (II-3) RECOMMENDATIONS: 1. All women undergoing elective or emergency Caesarean section should receive antibiotic prophylaxis. (I-A) 2. The choice of antibiotic for Caesarean section should be a single dose of a first-generation cephalosporin. If the patient has a penicillin allergy, clindamycin or erythromycin can be used. (I-A) 3. The timing of prophylactic antibiotics for Caesarean section should be 15 to 60 minutes prior to skin incision. No additional doses are recommended. (I-A) 4. If an open abdominal procedure is lengthy (>3 hours) or estimated blood loss is greater than 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-L) 5. Prophylactic antibiotics may be considered for the reduction of infectious morbidity associated with repair of third and fourth degree perineal injury. (I-B) 6. In patients with morbid obesity (BMI>35), doubling the antibiotic dose may be considered. (III-B) 7. Antibiotics should not be administered solely to prevent endocarditis for patients who undergo an obstetrical procedure of any kind. (III-E).

Preterm prelabour rupture of membranes with cervical cerclage: a review of perinatal outcomes with cerclage retention

Cervical cerclage may be indicated in specific clinical situations in an attempt to reduce the risk of preterm delivery. Preterm prelabour rupture of membranes (PPROM) occurs sometimes in the presence of a cerclage, and these pregnancies are at substantial risk of adverse maternal, fetal, and neonatal outcomes that may be attributed to complications associated with infectious morbidity and preterm birth. The benefits of retaining a cerclage in situ with ruptured membranes are unclear. This systematic review identified studies estimating maternal and perinatal morbidity and mortality associated with pregnancies with cerclage complicated by PPROM, in order to clarify the consequences of cerclage retention.

Difficulties in controlling and preventing preterm labor in multiple gestations: a clinical perspective

Prevention of preterm labor or arrest of ongoing premature labor in a twin gestation is more difficult to achieve than in singleton pregnancies. This clinical perspective is intended to review currently applied methods and to propose a more effective means to resolve this problem. A number of tocolytic methods have been employed in multifetal gestations, but none is routinely effective once true labor has commenced. Whereas a fall of serum progesterone levels precedes the onset of labor in animals, such is not the case in humans. It is proposed here that the level of serum progesterone does not define the relevance of this hormone to the maintenance of myometrial quiescence in humans. Rather, it would appear to be the progesterone supplied by the placenta directly to the myometrium that delays the onset of labor. The ratio of placental surface area to myometrial surface (P/M) as the gestation progresses more accurately reflects the capability to delay labor, especially in twin pregnancies. Hence, the application of therapeutic progesterone in closer proximity to the placenta/myometrial interface (e.g., via the vagina) should be more effective than by injection in preventing preterm labor as the P/M ratio decreases in a multifetal gestation.

Prevention of PPROM: Current and future strategies

Our understanding of the pathophysiologic processes leading to preterm premature rupture of membranes (PPROM) has grown tremendously in recent years. Evidence suggests that there may be a genetic susceptibility to PPROM and that genetic and environmental elements are important cofactors in its development. A number of risk-based protocols have been proposed in an attempt to identify those women at highest risk for PPROM. While we have made advances in the area of predicting PPROM, treatments based on current risk-based systems have failed to distinguish a specific, effective preventive therapy for PPROM. The concept that genetic factors increase susceptibility or decrease resistance to disease has stimulated new work in the field of PPROM. Several maternal and fetal gene polymorphisms have been identified that are associated with an increased risk for PPROM. Patients with 'susceptible' genotypes may also have clinical risk factors for PPROM resulting in a synergistic increase in the risk for PPROM, a so-called gene-environment interaction. The concept that these gene-environment interactions represent new targets for our efforts to prevent PPROM is explored.

Gestational age at initiation of 17-hydroxyprogesterone caproate (17P) and recurrent preterm delivery

OBJECTIVE

To compare rates of recurrent preterm birth between women starting treatment with 17alpha-hydroxyprogesterone caproate (17P) at 16-20.9 weeks of gestation versus 21-26.9 weeks.

METHODS

Women enrolled in an outpatient program of education, nursing assessment and weekly 17P injections beginning at 16-26.9 weeks were eligible. Included were patients with singleton pregnancies and a history of preterm delivery (PTD). Pregnancy outcome was compared between women starting 17P at 16-20.9 weeks (n=156) and those starting 17P at 21-26.9 weeks (n=119) using Fisher's exact and Mann-Whitney U test statistics (p<0.05 considered significant).

RESULTS

Mean gestational age at delivery (36.8 +/- 3.0 vs. 36.7 +/- 2.5) and rates of PTD at <37 weeks (40.4% vs. 48.7%), <35 weeks (16.7% vs. 16.8%) and <32 weeks (5.1% vs. 5.0%) were similar between the groups; all p > 0.05.

CONCLUSIONS

Rates of preterm delivery were similar in patients initiating 17P at 16-20.9 or 21-26.9 weeks. A larger sample size is warranted in order to confirm our findings.

Can postgraduate courses in Maternal-Fetal Medicine change clinical attitude?

OBJECTIVE

To investigate the effect of structured didactic lectures by leaders in the field of Maternal-Fetal Medicine on reported clinical decision-making.

METHODS

An interactive survey of obstetric management was performed as part of a postgraduate course at the 2004 Annual Meeting of the Society for Maternal-Fetal Medicine. Seven controversial topics were addressed, including tocolytic therapy, progesterone supplementation for the prevention of preterm birth, screening for inherited thrombophilia, cervical cerclage for a shortened cervix, the management of preterm premature rupture of membranes, magnesium sulfate seizure prophylaxis, and dexamethasone therapy for hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. The survey was carried out before and after a series of structured didactic lectures, thereby allowing for analysis of the effect of the lectures on reported clinical decision-making.

RESULTS

A total of 298 obstetric care providers attended the postgraduate course. By report, the majority of attendees were Maternal-Fetal Medicine specialists (60.7%), less than 10 years out from specialty training (56.3%), and practicing in a university-based setting (52.9%). An average of 233 practitioners (range 157-298) answered each question. Comparison of responses to the survey given before and after the lectures demonstrated significant differences, especially in the areas of tocolytic therapy and inherited thrombophilias.

CONCLUSIONS

Postgraduate lectures by leaders in the field of Maternal-Fetal Medicine have significant immediate impact on reported clinical decision-making.

Is routine prophylactic cervical cerclage associated with significant prolongation of triplet gestation?

OBJECTIVE

The purpose of this study was to determine if routine prophylactic cervical cerclage was associated with a significant prolongation of triplet pregnancy.

STUDY DESIGN

A retrospective study of all women carrying triplet pregnancies at a single institution during a four-year period was carried out. Selected maternal characteristics and obstetric outcome measures in women who received prophylactic cerclage (PC) were compared to women who did not receive PC (no cerclage placed and emergency cerclage). Statistical comparison was done using the Mann-Whitney test for continuous variables and Fisher's exact test for categorical variables.

RESULTS

Fifty-five women had PC and 40 had no PC. There was no significant difference between these two groups in mean maternal age or weight, nulliparity, history of or current sexually transmitted disease, cigarette smoking, history of cervical insufficiency, prior dilation and curettage, prior cervical surgery, prior preterm labor/prolonged preterm rupture of membranes (PTL/PPROM), medical complications in pregnancy, current PTL/PPROM, gestational age at delivery, delivery prior to 28 weeks, delivery prior to 32 weeks, or delivery of an infant weighing less than 1000 or 1500 grams. Thirteen women in the no PC group (32.5%) required emergency cerclage.

CONCLUSION

PC was not associated with significant prolongation of triplet pregnancy.

Atosiban vs ritodrine used prophylactically with cerclage in ICSI pregnancies to prevent pre-term birth in women identified as being at high risk on the basis of transvaginal ultrasound scan

Our objective was to compare the effectiveness and safety of atosiban and ritodrine, in pregnancies obtained by intracytoplasmic sperm injection (ICSI) undergoing cervical cerclage. Data from a prospective study were compared with those from a retrospective study. Sixteen ICSI pregnant women, 20-24 weeks' gestation and maternal age >18 years, received atosiban (bolus dose 6.75 mg i.v., followed by 300 microg/min i.v. for 3 h and 100 microg/min i.v. for 45 h). Cervical cerclage was performed 3 h after starting atosiban. The control group (group B) of 16 ICSI pregnant women were matched and received ritodrine hydrochloride (100-350 microg/min) for 48 h. Cervical cerclage was performed after 24 h. Pre-term rupture of membranes occurred within 48 h of cervical cerclage in one woman receiving atosiban and in four women receiving ritodrine. There was no significant difference in terms of pregnancies not delivered at 48 h (short-term tocolysis) and at 7 days (long-term tocolysis). However, there was a significantly higher incidence of maternal tachycardia with ritodrine compared with atosiban (p < 0.001). The mean gestational age at delivery was significantly higher for atosiban compared with ritodrine (36 vs 33 weeks; p < 0.001). The neonatal outcome was poorer for ritodrine than atosiban, as there were very low birth weight infants (p = 0.008), resulting in lower Apgar scores (p = 0.005) and there were more neonates requiring a long stay in the neonatal intensive care unit (p = 0.005). We conclude that atosiban is associated with a significantly lower incidence of maternal tachycardia and improved neonatal outcome compared with ritodrine.

The role of ultrasound-indicated cerclage in triplets

OBJECTIVES

Preterm delivery is the leading cause of major perinatal morbidity and mortality associated with triplet pregnancies. The objective of this study was to evaluate the efficacy of ultrasound-indicated cervical cerclage in triplet pregnancies that are diagnosed with cervical shortening on biweekly transvaginal sonography (TVS).

METHODS

A retrospective review of all triplets who were followed with biweekly TVS for measurement of cervical length was conducted. Cervical shortening was defined as cervical length <or= 2.5 cm. Outcomes of interest included cervical cerclage placement, gestational age at delivery and birth weight.

RESULTS

In our population of 24 triplet pregnancies, 13 had cervical shortening. Of these, 54% underwent cervical cerclage at a mean gestational age of 20 weeks. Overall, patients without cervical shortening delivered on average 17 days later than those with cervical shortening (32 + 2 weeks vs. 29 + 6 weeks, P = 0.034). Moreover, infants of patients without cervical shortening weighed on average 456 g more at birth than did those with cervical shortening (1751 g vs. 1295 g, P = 0.039) and had a lower percentage of very low birth weight infants (30.3% vs. 69.2%, P = 0.002). Within the subset of patients with cervical shortening, there was no statistical difference in any of the outcomes studied between patients who underwent cervical cerclage and those who did not.

CONCLUSIONS

Triplet pregnancies complicated by cervical shortening diagnosed on biweekly TVS surveillance do not appear to benefit from placement of cervical cerclage, based on assessment of gestational age at delivery, birth weight and incidence of very low birth weight infants.

Robotic-assisted laparoscopic cerclage in a pregnant patient

A robotic-assisted laparoscopic technique for transabdominal cerclage placement could offer improvements over the traditional laparoscopic approach. A gravid female with no vaginal portion of the cervix underwent a robotic-assisted laparoscopic cerclage at 12 weeks' gestation and ultimately delivered a healthy infant at term.

[Scar uterine rupture after 6 pregnancies with cerclage]

The scar uterine rupture is the most common reason for uterine rupture, because of the increased frequency of the myomectomia, cesarean sections and others. We present a case of a scar rupture in multiparous woman with seventh pregnancy, six of them with cerclage. The numerous cerclages has caused changes (lacerations) in the cervix, which made necessary each next cerclage to be placed higher and probably in the uterine isthmus. In our case the rupture started in the lower uterine segment and is combined with rupture of the bladder, which is the most common complication of the uterine rupture. We conclude that in cases with several cerclages the status of the uterus and the cervix should be evaluated very carefully and the way of delivery should be discussed.

Timing of mid-trimester cervical length shortening in high-risk women

OBJECTIVE

To examine the natural history of cervical length shortening in women who had experienced at least one prior spontaneous preterm birth at between 17+0 and 33+6 weeks' gestation.

METHODS

This was an analysis of prerandomization data from the multicenter Vaginal Ultrasound Cerclage Trial. Serial cervical length was measured by transvaginal sonography in 1014 high-risk women at 16+0 to 22+6 weeks. We performed survival analyses in which the outcome was cervical length shortening<25 mm and data were censored if this did not occur before 22+6 weeks' gestation. The incidence of cervical length shortening and the time to shortening were compared for women whose earliest prior preterm birth was in the mid-trimester, defined as <24 weeks, vs. those at weeks 24-33. Similar comparisons were performed based on each patient's most recent birth history.

RESULTS

Time to cervical length shortening by survival analysis was significantly shorter (hazard ratio (HR)=2.2, P<0.0001) and the relative risk (RR) of shortening significantly higher (RR=1.8, P<0.0001) for women whose earliest prior spontaneous preterm birth was at <24 weeks. A larger effect was observed for women whose most recent birth was at <24 weeks (HR=2.8, P<0.0001; RR=2.1, P<0.0001). The observed hazard ratios remained significant after adjusting for confounders in a multivariable Cox proportional hazards model.

CONCLUSION

Women with a prior spontaneous preterm birth at <24 weeks are at a higher risk of cervical shortening, and do so at a higher rate and at an earlier gestational age, than do women with a later preterm birth history.

Successful management of a cervical twin pregnancy: neoadjuvant systemic methotrexate and prophylactic high cervical cerclage before curettage

OBJECTIVE

To report our experience in managing a case of viable cervical twin pregnancy with systemic methotrexate and 2 weeks later with endocervical curettage after placing prophylactic high cervical cerclage.

DESIGN

Case report.

SETTING

University medical center.

PATIENT(S)

A 36-year-old woman, gravida 2, para 0, complaining of vaginal bleeding and pelvic pain, in whom cervical twin pregnancy was diagnosed at the sixth week of gestation.

INTERVENTION(S)

Systemic methotrexate was given as first-line treatment. Two weeks later because of persisting bleeding, endocervical curettage was performed after closing cervical arteries and placing but not tightening high cervical cerclage.

MAIN OUTCOME MEASURE(S)

Pregnancy termination, bleeding control, and preservation of fertility.

RESULT(S)

Notwithstanding the ligature of cervical arteries at curettage, heavy bleeding occurred, which was controlled rapidly by tightening the cerclage. Curettage then was completed successfully. Postoperative period was uneventful. Two years later the woman delivered vaginally.

CONCLUSION(S)

In case of cervical twin pregnancy methotrexate pretreatment and prophylactic placement of high cervical cerclage, but not ligature of cervical arteries, before curettage showed to be effective in terminating pregnancy ensuring effective bleeding control and preservation of fertility.

[Cervical cerclage. Results of the last ten year period (1997-2008) in Faculty Hospital Olomouc]

OBJECTIVE

To evaluate the effectiveness of the cervical cerclage in the last ten year period on pregnancy outcome.

STUDY DESIGN

Retrospective study.

SETTING

Gynaecological and Obstetric Clinic Medical Faculty Palacky University and Faculty Hospital Olomouc.

METHODS

In the retrospective analysis of maternal and newborn records in the ten year period from 1.1. 1998 to 31. 12. 2007 were identified three groups of indications for operative cervical closure: elective--on the basis of history without objective evidence of cervical change, emergency cerclage--with objective manifestation of cervical insufficiency and rescue cerclage of a widely dilated cervix with prolapsed unruptured membranes.

RESULTS

A total 102 patients underwent cerclage between 11 and 31 weeks gestation. The prevalence of operative intervention was 0.6% of all mothers. Cervical cerclage was done by the McDonald technique. 17 patients had elective operations, 57 emergency and 28 rescue cerclage. Median length of interval from cerclage to delivery was significantly shorter after rescue cerclage, 26 days, (range 2-126) compared to emergency cerclage patients, 74 days (range (7-148). (P = 0,000005). Median interval from cerclage to delivery in elective operation was 105 days (range 9-188). Newborn dates corresponds with earlies termination of pregnancy in rescue cerclage subjects, with median gestational age at time of delivery 28 weeks (range 19-41), after emergency operation median achieved 36 weeks (range 23-41). The median gestational age at delivery after elective cerclage was 36 weeks (range 22-41). Nine fetal losses were in the rescue group, sex abortions (from 260 to 560 grams) and three early neonatal deaths (530, 550, 1150 grams).

CONCLUSION

These results confirm that the use of cervical cerclage in prevention of the premature labour is rather rare as well as achievement outcomes did not fulfil our expectations. This fact could have been considered in the care of pregnant and lead to restriction of unnecessary investigations of uterine cervix especially in non risk and asymptomatic population.

Indomethacin administration at the time of ultrasound-indicated cerclage: is there an association with a reduction in spontaneous preterm birth?

OBJECTIVE

The purpose of this study was to estimate the effect of indomethacin on the prevention of preterm birth (PTB) in women with an ultrasound-indicated cerclage.

STUDY DESIGN

We performed a retrospective cohort study from 1995-2006. Asymptomatic women with a cerclage for a short cervical length (CL), which was defined as <25 mm, between 14-23 weeks 6 days of gestation were included. Women who received indomethacin therapy at the time of ultrasound-indicated cerclage for a short CL were compared with those women who did not. Our primary outcome was spontaneous PTB at <35 weeks of gestation.

RESULTS

Fifty-one women received indomethacin, and 50 women did not. There were no differences between groups regarding previous PTB, gestational age, or CL at time of cerclage. The rate of spontaneous PTB at <35 weeks of gestation was similar between those who received indomethacin (20/51 [39%]) and those who did not (17/50 [34%]; relative risk, 1.15 [95% CI 0.69-1.93]). In our post hoc power analysis, 190 patients would have been needed to detect a 50% reduction in the rate of PTB.

CONCLUSION

Administration of indomethacin around the time of ultrasound-indicated cerclage was not associated with a decrease in spontaneous PTB.

Evaluation of cervical cerclage for sonographically incompetent cervix in at high risk patients

BACKGROUND

To determine the impact of Cervical Cerclage (CC) for prolongation of pregnancy, maternal and foetal outcome.

METHODS

This Descriptive cross-sectional study was conducted over a period of 2 years patients with history of two or more recurrent midtrimester abortions/preterm deliveries were included. Those with abnormal foetus, vaginal bleeding and choreoamneonitis were excluded. All patients were subjected to transvaginal sonography. Those having sonographic evidence of cervical shortening/dilatation/cone formation were subjected to McDonald suture. Age, parity, period of gestation and aetiological factors were determined.

RESULTS

Results were evaluated on the basis of pregnancy prolongation, 14-28 weeks (7.5%), 28-36 weeks (18.7%), 35-37 weeks (73.7%),vaginal delivery in (70%), instrumental (1305%), Caesarean section (17.5%),miscarriage (7.5%), prematurity (18.7%), term delivery (73.7%), prenatal death (13.7%), foetal survival rate (85.1%). No intraoperative complication found. During pregnancy premature rupture of membrane (3.7%), abruption (2.5%), severe pre-eclampsia (3.7%). During labour cervical dystocia was found in (2.5%), foetal distress (8.7%), mal-presentations (6.2%), cervical trauma (3.7%).

CONCLUSION

We determined a high success rate of cervical cerclage on properly selected patients with sonographic evidence of cervical changes. Cervical sonography can be a valuable adjunct to clinical evaluation of these patients.

The effect of anesthetic method for prophylactic cervical cerclage on plasma oxytocin: a randomized trial

BACKGROUND

This study compared the changes in plasma oxytocin, intraoperative hemodynamics and postoperative uterine activity in patients who underwent elective Shirodkar cerclage for cervical incompetence with general or spinal anesthesia.

METHODS

Thirty-seven singleton pregnant patients were enrolled in this prospective, randomized, controlled comparison of general (n=17) and spinal anesthesia (n=20) for elective Shirodkar suture in the second trimester. Plasma oxytocin concentration was measured before, 1 h after, and 24 h after the procedure. Uterine activity was recorded by external tocography twice daily for 30 min over a three-day period.

RESULTS

Plasma oxytocin concentration did not change significantly after cerclage in either group. There were no significant differences between the two groups at any time. None of the patients reported painful contractions during study period. Two (11.8%) and four patients (20.0%) in the general and spinal groups, respectively (NS), showed increased uterine activity but these symptoms disappeared without treatment. The systolic blood pressure in the spinal group was significantly lower after anesthesia compared with the baseline and was significantly lower than in the general group during the procedure.

CONCLUSIONS

Anesthetic method used for elective Shirodkar procedure did not affect the perioperative changes in plasma oxytocin nor postoperative uterine activity.

Expectant management compared with physical examination-indicated cerclage (EM-PEC) in selected women with a dilated cervix at 14(0/7)-25(6/7) weeks: results from the EM-PEC international cohort study

OBJECTIVE

The objective of the study was to compare pregnancy outcomes in selected women with a dilated cervix who underwent expectant management or physical examination-indicated cerclage.

STUDY DESIGN

This was a historical cohort study conducted by the Global Network for Perinatal and Reproductive Health. Women between 14(0/7) and 25(6/7) weeks' gestation with a dilated cervix were identified at 10 centers by ultrasound or digital examination. Primary outcome was time from presentation until delivery (weeks). Secondary outcomes were neonatal survival, birthweight greater than 1500 g and preterm birth less than 28 weeks. Multivariate regression was used to assess the likelihood of neonatal outcomes and control for confounders.

RESULTS

Of 225 women, 152 received a physical examination-indicated cerclage, and 73 were managed expectantly without cerclage. Cervical dilation, gestational age at presentation, and antenatal steroid use differed between groups. In the adjusted analyses, cerclage was associated with longer interval from presentation until delivery, improved neonatal survival, birthweight greater than 1500 g and preterm birth less than 28 weeks, compared with expectant management. Similar results were obtained in the analyses limited to women dilated between 2 and 4 cm (n = 122).

CONCLUSION

In this study, the largest cohort reported to date, physical examination-indicated cerclage appears to prolong gestation and improve neonatal survival, compared with expectant management in selected women with cervical dilation between 14(0/7) and 25(6/7) weeks. A randomized, controlled trial should be conducted to determine whether these potential benefits outweigh the risks of cerclage placement in this population.

Collagen 1Alpha1 and transforming growth factor-beta polymorphisms in women with cervical insufficiency

OBJECTIVE

To estimate whether polymorphisms in the collagen 1Alpha1 gene (COL1Alpha1) and the transforming growth factor-beta gene (TGF-beta;1) are more common in women with cervical insufficiency than in those without the condition.

METHODS

Medical, obstetric, and family histories and blood were obtained from women with (n=121) and those without (n=165) cervical insufficiency. DNA was extracted and purified by using commercial DNA isolation kits. Samples were analyzed for variants in two genes, the COL1A1 intron 1SP1 and TGF-beta Arg-25-Pro polymorphism, by using an allele-specific polymerase chain reaction assay.

RESULTS

Thirty-four of 125 (27.2%) women with cervical insufficiency had at least one first-degree female relative affected. The frequency of the homozygous TT genotype in the COL1A1 gene was increased in women with a history of cervical insufficiency compared with controls (10.8% compared with 3.1%, P=.04). The TGF-beta polymorphisms (ArgPro and ProPro) also were increased in cases (38.3% compared with 14.6%, P<.001).

CONCLUSION

Over one fourth of women with cervical insufficiency have a family history of cervical insufficiency, and the COL1A1 intron 1SP1 and TGF-beta Arg-25-Pro polymorphisms are associated with the condition. These observations suggest that, in part, cervical insufficiency is mediated by genetic factors.

LEVEL OF EVIDENCE

II.

Management of cervical weakness based on the measurement of cervical resistance index

OBJECTIVE

To assess the value of measuring cervical resistance index (CRI) as an aid to selecting patients with a history of spontaneous mid-trimester miscarriage for cervical cerclage in subsequent pregnancies.

STUDY DESIGN

An observational study of 175 patients with a history of one or more spontaneous mid-trimester losses and 123 non-pregnant women who had CRI measurements performed while undergoing routine gynaecological surgery. Those women whose CRI indicated an incompetent cervix were recommended for cervical cerclage in future pregnancies while women with a normal CRI were recommended for conservative management without cerclage.

RESULTS

The median CRI in the 123 control women was 38.26 N while the median CRI in the study group was 17.00 N. In 62 of the 175 study women (35%) the CRI findings were at variance with the history of previous mid-trimester loss; 30 (16.6%) were deemed competent on CRI whereas the history suggested incompetence and 32 (18.4%) were incompetent on CRI while the history suggested that the cervix should be competent. The 175 study women had had 486 previous pregnancies with a successful outcome in 27.4% of the pregnancies. Ninety-four patients have now had 148 pregnancies with a successful outcome in 75.8% of the pregnancies.

CONCLUSIONS

Non-pregnant women with a history of spontaneous mid-trimester miscarriage have a significantly lower cervical resistance index than parous women who have not suffered mid-trimester loss. In 35% of patients the CRI was at variance with the history of the previous loss. CRI may be a useful technique to aid the diagnosis of cervical weakness allowing a rational selection for treatment with prophylactic cervical cerclage.

Successful continuation of pregnancy after repair of a midgestational uterine rupture with the use of a fibrin-coated collagen fleece (TachoComb) in a primigravid woman with no known risk factors

We report the first case of successful continuation of pregnancy after repair of a midgestational uterine rupture with the use of a fibrin-coated collagen fleece (TachoComb, Nycomed, Linz, Austria). For midgestational uterine rupture, adequate uterine repair and close surveillance of preterm labor could improve perinatal outcome by permitting continuation of the pregnancy.

Successful twin pregnancy after vaginal radical trachelectomy using transabdominal cervicoisthmic cerclage

The outcome of vaginal radical trachelectomy (VRT) for the management of early cervical cancer is comparable to that achieved with radical hysterectomy. Although VRT preserves the potential for pregnancy, the outcome of twin pregnancies following VRT is poor. We report a successful twin pregnancy after VRT using transabdominal cervicoisthmic cerclage.

Cervical length < or = 25 mm in low-risk women: a case control study of cerclage with rest vs rest alone

OBJECTIVE

The purpose of this study was to evaluate the clinical utility of cerclage in low risk women with cervical length (CL) < or = 25 mm at transvaginal ultrasound (TVU).

STUDY DESIGN

This was a retrospective cohort study of women with CL < or = 25 mm identified incidentally at TVU examinations between 16(0/7) to 24(6/7) weeks, with no history of previous preterm birth or midtrimester losses. The primary study outcome was rate of preterm delivery < 35 weeks' gestation.

RESULTS

Women undergoing cerclage placement (n = 31) had shorter CL (P < .001) and lower gestational age at presentation (P < .001) than those managed with rest alone (n = 36). Gestational age at delivery was 37.6 +/- 3.6 vs 38.5 +/- 2.1 weeks (P = .17), and delivery at < 35 weeks occurred in 5/31 versus 2/36 cases, respectively (P = .23). The lack of a significant association between cerclage and rate of delivery < 35 weeks persisted after controlling for gestational age at TVU and initial CL (P = .81).

CONCLUSION

Cerclage placement does not improve pregnancy outcome in low-risk women with incidental detection of CL < or = 25 mm in the early second trimester.

Prediction and Prevention of Recurrent Spontaneous Preterm Birth

Rates of preterm birth have continued to rise despite intensive research efforts over the last several decades. A woman who has a spontaneous preterm birth is at high risk for a subsequent preterm birth. Studies have identified clinical, sonographic, and biochemical markers that help to identify the women at highest risk. Determining cervical length and measuring cervicovaginal fibronectin have been proposed as useful tools for evaluating women at risk of preterm birth and may identify those who might benefit from a timely course of antenatal corticosteroids, but effective interventions to prevent preterm birth remain elusive. In the prevention of recurrent spontaneous preterm birth, recent trials have confirmed the use of progesterone beginning in the second trimester as an effective intervention. Optimal management of women with a history of spontaneous preterm birth includes a thorough review of the obstetric, medical, and social history, with attention to potentially reversible causes of preterm birth (eg, smoking cessation, acute infections, strenuous activities), accurate ultrasound dating, consideration of progesterone therapy beginning at 16-20 weeks of gestation, and close surveillance during the pregnancy for evolving findings. Results from the ongoing trials of cerclage as an interventional therapy and omega-3 fatty acid supplementation as a preventive therapy will provide additional knowledge for the optimal management of these high-risk women.

Good pregnancy outcome with emergent cerclage placed in the presence of intra-amniotic microbial invasion

Cervical insufficiency with dilation can be associated with amniotic fluid microbial invasion. Cerclage placement in the presence of infection is contraindicated because it is associated with poor fetal and maternal outcome. A 30-year-old gravida 4 para 0 with cervical insufficiency had emergent cervical suture placement at 19 weeks. The patient underwent amniocentesis to screen for infection. After the screen for infection using amniotic fluid glucose and white blood cells had indicated negative results, the patient had cerclage placed. Post cerclage placement, amniotic culture results were positive for KLEBSIELLA PNEUMONIAE, CITROBACTER FREUNDII, and STAPHYLOCOCCUS coagulase negative. The patient was counseled about the need to remove the cerclage and she declined. She was treated with azithromycin and Unasyn and a repeat amniocentesis 7 days later indicated negative results. The patient had a 14 week cerclage to delivery interval, delivery at 33 2/7 weeks. Immediate evaluations of the newborn were negative for infection. Our satisfactory outcome with treatment of very early intra-amniotic infection suggests that this option may be considered in strictly selected patients in similar clinical scenarios as an alternative to cerclage removal and evacuation of the uterus.

Cervical cerclage for prevention of preterm birth in women with twin pregnancy

OBJECTIVE

To compare the effect of elective cervical cerclage in women with twin pregnancy on gestational age at time of delivery.

METHOD

In a pragmatic fashion women in Abha Maternity Hospital, Saudi Arabia with twin gestations were allocated to receive either an elective cerclage (group I) or no cerclage (group II). Elective cerclage was performed at 12 to 14 weeks of gestation after sonographic examination of the fetus to confirm gestational age and exclude major congenital anomalies. In all cases, follow up of the pregnancy was continued until delivery.

RESULTS

Of the 176 twin pregnancies included, cerclage was performed in 76 women, and no cerclage in 100 women. In Group I: 12 pregnancies ended in spontaneous miscarriage, 37 in preterm labor, and 27 women reached full term. There were a total of 106 live births in 62 women. In Group II: 8 women aborted, 44 women ended in preterm labor and 48 women reached full term. There were a total of 160 live births in 89 women. The gestational age at delivery ranged from 20 to 41 weeks. Multiple regression analysis did not show association between cerclage and time of delivery, although a trend was observed (P=0.056).

CONCLUSION

Elective cerclage contributes little in prolongation of gestational age at the time of delivery in women with twin pregnancy, especially in women of high parity. Those with a previous history of preterm labor may be a subgroup that could benefit from elective cerclage.

Clinical aspects of cervical insufficiency

Fetal loss is a painful experience. A history of second or early third trimester fetal loss, after painless dilatation of the cervix, prolapse or rupture of the membranes, and expulsion of a live fetus despite minimal uterine activity, is characteristic for cervical insufficiency. In such cases the risk of recurrence is high, and a policy of prophylactic cerclage may be safer than one of serial cervical length measurements followed by cerclage, tocolysis and bed rest in case of cervical shortening or dilatation. In low risk cases, however, prophylactic cerclage is not useful. There is a need for more basic knowledge of cervical ripening, objective assessment of cervical visco-elastic properties, and randomized controlled trials of technical aspects of cervical cerclage (e.g. suturing technique).

Contemporary Use of Cervical Cerclage

Although it was devised over 50 years ago, only recently controlled randomized trials have evaluated the efficacy of cervical cerclage. Cerclage was originally devised for women with both prior preterm birth (PTB) and cervical changes in the current pregnancy. Evidence suggests that transvaginal cerclage probably prevents second trimester loss/PTB in women with >or=3 PTB/second trimester loss (history-indicated cerclage best placed at 12 to 14 wk); and in women with a prior PTB 16 to 36 weeks and transvaginal ultrasound cervical length<25 mm in the current pregnancy (ultrasound-indicated cerclage at 14 to 23 6/7 wk).

The effect of combined therapy with ritodrine, erythromycin and verapamil on the frequency of micronuclei in peripheral blood lymphocytes of pregnant women

The main aim of this study was to investigate the genotoxic effect of combined pharmacotherapy applied in post-operative treatment of cervical cerclage in pregnant women over six days. This study included 19 phenotypically healthy pregnant women in mid-trimester with a diagnosis of cervical insufficiency, mean age 28+/-5.33. The frequency of micronuclei (MN) was estimated in peripheral blood lymphocytes of patients before surgical intervention and after the end of applied pharmacotherapy by application of cytokinesis block micronucleus (CBMN) test. Mean value of baseline MN frequency was 6.84+/-2.91 MN/1000 binucleated cells, and after the end of the applied therapy, 10.32+/-4.27 MN/1000 binucleated cells (P<0.001) were found. The data of cell proliferation index showed that the combined therapy did not induce significant difference in cell kinetics (P>0.05). Our results showed that combined pharmacotherapy treatment over six days significantly increased the frequency of MN in peripheral blood lymphocytes of pregnant women.

Setting up a preterm prevention clinic: a practical guide

In gynaecology, specialist menopause, urogynae, colposcopy, infertility, pelvic pain and cancer, rapid access clinics exist at many teaching and busy district general hospitals in the UK. Similarly, in obstetrics many busy maternity units have fetal medicine clinics, dedicated twins clinics and maternal medicine clinics, incorporating various general medical conditions and conditions peculiarly appropriate to pregnancy such as haematological disorders, diabetes and epilepsy. In contrast, in very few hospitals is there a dedicated clinic for women at increased risk of preterm birth, yet this is the major cause of neonatal mortality and morbidity in the developed world. Such a situation may be due to the confusion created by the fact that preterm birth is a heterogeneous condition with multiple aetiologies and hence multiple therapeutic interventions. It is possible to identify a group of women at particularly high risk of preterm birth in whom screening and interventional techniques have the potential to reduce the mortality and morbidity associated with spontaneous preterm labour and preterm birth.

[Cervical cerclage and evidence-based medicine: if, how and when]

Cervical cerclage has always been the main treatment option in cases of so-called cervical insufficiency, a condition that is notoriously associated with a high risk of second trimester abortion and/or preterm delivery. We can distinguish between a prophylactic cerclage, to be performed electively, usually at 13-16 weeks gestation, only when the woman has a history extremely suggestive for cervical incompetence (3 or more mid-trimester abortions or preterm deliveries) and a therapeutic cerclage. This last cerclage is recommended either for women who have ultrasonographic changes consistent with a short cervix or the presence of funneling after the 16-20 weeks gestation (urgent cerclage) and for women who present the asymptomatic dilation of the uterine cervix of at least 2 cm and/or a prolapse of the amniochorial membranes (emergent cerclage). So far there is still a lack of controlled and randomized trials that can unquestionably demonstrate the advantages of the cervical cerclage in comparison with a ''wait and see'' aptitude. The cerclage can be performed either transvaginally, usually according to the McDonald technique, or transabdominally. This last approach is recommended when a transvaginal cerclage has to be avoided because of technical difficulties depending on the conditions of the cervix or when the pregnant woman has a history of one or more failed transvaginal cerclages. Interesting perspectives are currently offered by the laparoscopic cerclage, a method that has been effective and unexpectedly safe till now.

Conservative management of second-trimester cervical ectopic pregnancy with placenta percreta

OBJECTIVE

To report successful conservative management of advanced cervical ectopic pregnancy with placenta percreta.

DESIGN

Case report.

SETTING

University tertiary care hospital.

PATIENT(S)

A 37-year-old woman with second-trimester cervical ectopic pregnancy and placenta percreta.

INTERVENTION(S)

Ultrasound-guided injection of potassium chloride into the fetal heart followed by multiple systemic methotrexate injections, removal of fetal bones, cervical cerclage suture, and Foley catheter placement for control of hemorrhage.

MAIN OUTCOME MEASURE(S)

Low maternal morbidity and successful conservative management with preservation of fertility.

RESULT(S)

The cervical ectopic pregnancy was treated successfully without significant morbidity; the uterus was preserved, and the woman was delivered of a full-term live fetus in the next pregnancy.

CONCLUSION(S)

Advanced cervical ectopic pregnancy with placenta percreta is associated with high morbidity with surgical intervention. Conservative management with attendant low morbidity and uterus preservation is possible in advanced cervical ectopic pregnancy.