Cerclage for Short Cervix on Ultrasonography

Prise en charge chirurgicale des patientes présentant un utérus cloisonné total

INTRODUCTION

Septate uterus is the principal müllerian anomaly, but complete septate uterus is uncommon and often associated with frequent obstetrical complications. Surgical section of the septum is however possible.

MATERIAL AND METHOD

We report patients with a complete septum uterus operated in our department between 2002 and 2006. We performed a hysteroscopic section of the cervical, uterine and vaginal septum at discovery of the anomaly. The accuracy of imaging exams, frequency of associated malformations, past obstetrical events and reproductive outcome post surgery were analyzed.

RESULTS

The surgical technique was based on section of the cervical part with scissors and hysteroscopic section of the uterine septum; no perforation was noted. Four patients required a second procedure to achieve complete uterine section. Five patients became pregnant after surgery, 8 pregnancies are reported: 2 term delivery, 1 preterm delivery, 4 miscarriages and 1 ectopic pregnancy.

CONCLUSION

Complete surgical section of the cervical and uterine septum in case of complete septum uterus is safe. However, we cannot conclude about the obstetrical benefit of this surgical technique. A longer follow-up is needed.

The impact of multiple gestations on late preterm (near-term) births

Multiple pregnancies currently account for 3% of all births in the United States but are disproportionately responsible for larger rates of prematurity and significant neonatal morbidity. The mean birth age for most multi-fetal pregnancies occurs during the late preterm period when both spontaneous preterm labor and iatrogenic premature birth because of obstetrical or maternal complications are common. Multiples pose numerous unique challenges, emphasizing the significant impact of plurality on late preterm births.

Preterm labour: update on prediction and prevention strategies

PURPOSE OF REVIEW

The incidence of preterm birth is increasing and continues to be a significant cause of neonatal mortality and morbidity. Techniques now exist that can accurately predict early birth. Prevention can therefore be targeted, although effective measures that improve outcome are yet to be established.

RECENT FINDINGS

Obtaining an accurate history is the first step in identifying high-risk women. Clinicians then rely on other predictors such as fetal fibronectin, cervical length assessment and biochemical markers. Research should focus on the combination of noninvasive markers targeted at high-risk women as a screening tool, determining not only appropriate diagnostic levels for positive tests, but also sufficiently large studies should be performed to determine the predictive values of these tests. Interventions to prevent delivery and improve neonatal outcome remain unsatisfactory, mainly comprising tocolysis, cerclage, progesterone and, in some cases, antibiotics. Women who would most benefit from these interventions are difficult to identify and an appreciation of the pathophysiology in an individual woman, such as the relevance of the inflammatory status of the endocervix, may be important in tailoring intervention.

SUMMARY

An improved understanding of the mechanisms underlying the pathological process in preterm birth will allow screening and interventions to be appropriately targeted.

Short cervix on ultrasound: does indomethacin prevent preterm birth?

OBJECTIVE

Our aim was to estimate if indomethacin therapy prevents preterm birth (PTB) in women with a short cervical length (CL) on transvaginal ultrasound (TVU).

STUDY DESIGN

Individual-level data from all randomized trials including asymptomatic women with a short CL on TVU were analyzed for use of indomethacin at the time of the short CL. The trials eligible would be ones that randomized women with a short CL <25 mm, identified between 14 and 27 weeks. The eligible trials randomized such women to receive either cerclage or no cerclage. Only women who did NOT receive cerclage were analyzed. Exclusion criteria were major fetal anomaly and cerclage. We compared demographics, risk factors, and outcomes in women who, at the time of the short CL, received indomethacin or not. Primary outcome was PTB <35 weeks.

RESULTS

Three of the 4 randomized trials identified had databases which recorded indomethacin use at the time of the short CL. A total of 139 women with a short CL <25 mm identified at 14 to 27 weeks were identified. Of these women, 99 (71.2%) received indomethacin, and 40 (28.8%) did not. Demographics and risk factors, including previous PTB (45.5% vs 62.5%; P = .11), were similar in the 2 groups. The primary outcome of PTB <35 weeks occurred in 29.3% (29/99) of women who received indomethacin, and 42.5% (17/40) of women who did not receive indomethacin (RR 0.69, 95% CI 0.44-1.13). PTB <24 weeks occurred in 1.0% (1/99) versus 7.5% (3/40), respectively (RR 0.14; 95% CI 0.02-0.92). Incidence of perinatal death was similar in the 2 groups (6% vs 10%; RR 0.61, 95% CI 0.19-1.95).

CONCLUSION

Indomethacin therapy for asymptomatic women who have a short CL <25 mm on TVU at 14 to 27 weeks and do not receive a cerclage did not prevent spontaneous PTB <35 weeks, but did prevent PTB <24 weeks. Further research including larger numbers and a randomized trial design is necessary to further clarify the effectiveness as well as the risks of this therapy.

Technique de cerclage cervico-isthmique par voie vaginale avec bandelette de polypropylène: technique de Fernandez

OBJECTIVE

To assess the efficacy of performing transvaginal cervico-isthmic cerclage using synthetic tape in prevention of preterm labor in high-risk women.

PATIENTS AND METHODS

A retrospective analysis of 24 transvaginal cerclages using polypropylene tape performed in women presenting with high risk of preterm delivery: prior histories of pregnancy losses in the second trimester, prior failure of Mac Donald's cerclage and/or absent portio vaginalis of the cervix. Cerclage was performed between 12 and 16 weeks of gestation. A polypropylene tape was placed at the cervicoisthmic junction by vaginal route.

RESULTS

The median age of the patients in this series was 32.1 years (range 22-39 years). No intra-operative complication occurred. The median operating time was 34.9 minutes (+/-5.1) (range 30-45 min). Cesarean delivery was systematically performed in all patients since the cerclage was considered to be definitive. Mean gestational age and birth weight at delivery were respectively 37.1 weeks (+/-1.8) and 2850 g (+/-745). Preterm birth rate was 19% (4/21). Birth at less than 32 weeks occurred in only one patient (4%). In one case, the tape has been removed later because symptomatic vaginal erosion was noted. One neonatal death occurred following amniotic fluid infection at 34 weeks. At the present time, 3 women are at 22, 26 and 26 weeks of gestation with no preterm labor.

CONCLUSION

Transvaginal cerclage using polypropylene tape may be considered as an effective and minimally invasive alternative to transabdominal cervico-isthmic cerclage in women presenting with high risk of preterm delivery.

Do screening-preventative interventions in asymptomatic pregnancies reduce the risk of preterm delivery—A critical appraisal of the literature

Recent research has suggested that women who experience preterm delivery (PTD) may be identified earlier in pregnancy and before onset of symptoms. Interventions commenced at this earlier asymptomatic stage may offer an opportunity to prevent PTD or lengthen gestation sufficiently to reduce adverse perinatal outcome. Our objective was to examine the evidence that supports or refutes this approach to preventing PTD. We therefore conducted a systematic search and critical appraisal of the identified literature. We found evidence that introducing screening-preventative strategies for asymptomatic pregnancies may reduce the rate of PTD. Evidence for screening and selective treatment exists for: asymptomatic bacteriuria; bacterial vaginosis in low-risk population groups; elective cervical cerclage in high-risk pregnancies; indicated cervical cerclage in women with short cervical length on ultrasound; prophylactic progesterone supplementation in high-risk pregnancies, and smoking cessation. However, for most other strategies, such as increased antenatal attendance, or routine administration of prophylactic micronutrients, the evidence is inconsistent and conflicting. Information on neonatal outcomes apart from PTD (such as serious neonatal morbidity and mortality) was found to be lacking in most studies. It was therefore not possible to establish whether preventing PTD or prolonging gestation would correlate to improved perinatal outcome, and this lessened the potential clinical usefulness of any proposed preventative strategy. No studies were found that evaluated the effectiveness of combining screening-preventative strategies. The review concludes with a suggested an antenatal management plan designed to prevent PTD based on current practice and the evidence presented in this article.

Comparison of transvaginal sonography in recumbent and standing maternal positions to predict spontaneous preterm birth in singleton and twin pregnancies

OBJECTIVE

To evaluate whether serial transvaginal sonographic examination of the cervix with the woman in a standing position improves the prediction of spontaneous preterm birth (SPB) compared with the conventional posture.

METHODS

For both a recumbent and upright maternal position, the inter- and intraobserver agreement of cervical length (CL) measurement was calculated. In 363 pregnancies at risk for SPB, we determined prospectively CL and funnel width (FW) including differences between the positions and between longitudinal measurements from 15 weeks onwards. Multivariate logistic regression analysis, contingency tables and receiver-operating characteristics (ROC) curves were used. Data were stratified according to singleton or twin pregnancy, maternal position, gestational age at examination and different cut-off values to predict SPB < 36 weeks.

RESULTS

The interobserver variability in each position was similar, with an interclass correlation coefficient (95% CI) of 0.952 (0.811-0.984) in the recumbent and 0.942 (0.837-0.978) in the upright maternal position. After exclusion of pregnancies with iatrogenic preterm birth, 15/138 (11%) singletons and 29/153 (19%) twin pairs were born at <36 weeks. The incidence of funneling was greater in an upright compared with a recumbent maternal position by 12.3% in singleton and 13.1% in twin pregnancies before 25 weeks, and by 13.0% and 21.6% between 25 and 30 weeks, respectively. This resulted in an earlier and more accurate prediction of SPB by transvaginal ultrasound in an upright compared with a recumbent maternal position, which could be shown by all applied statistical methods. The influence of posture on the prognostic value of the CL varied depending on the cut-off value. Differences in CL or FW between 15-20 and 25-30 weeks predicted SPB better than did differences between shorter intervals.

CONCLUSIONS

Evaluation of the cervix with the woman in the upright position permits earlier detection of funneling. This may enable earlier and more appropriate intervention to avoid SPB.

Multiple gestations and late preterm (near-term) deliveries

Multiple gestations present unique challenges to the modern obstetrician. Many twin and high-order multiple pregnancies are delivered between 34 and 37 weeks' gestation either secondary to preterm labor or obstetrical complications necessitating intervention. Recognizing the increasing prevalence of multiple gestations and the impact of late preterm deliveries in modern practice, this review analyzes the impact of multiple pregnancies on perinatal outcomes, reviews the strategies to prevent preterm labor, and summarizes potential indications for late preterm delivery. In this paper, "late preterm" has been used instead of "near-term," as the former was considered more appropriate to reflect this subgroup of preterm infants in a workshop on this topic held in July 2005, organized by the National Institute of Child Health and Human Development.

Radical trachelectomy with laparoscopic lymphadenectomy: review of oncologic and obstetrical outcomes

PURPOSE OF REVIEW

Fertility preservation in early cervical cancer by radical trachelectomy is gaining in acceptance as more cases are published in the literature. Controversies regarding technique and patient management are beginning to emerge as the procedure moves from being a new surgery to a part of standard of care.

RECENT FINDINGS

As the number of cases reported in the literature increases, the effectiveness of radical trachelectomy for treating selected early-stage cancers continues to gain support. The survival of selected patients appears to be no different than that of similar patients treated with radical hysterectomy. Central recurrence in the residual cervix is a very rare event as long as the specimen has cleared the cancer. Patient selection criteria have evolved, and a more liberal use of the procedure is warranted. The effectiveness of trachelectomy in preserving fertility has now been demonstrated in series of 50 and 56 pregnancies occurring after the procedure. These larger series detail pregnancy outcomes and will be invaluable information to our patients who wish to maintain their ability to bear children. Subtle differences in technique between centers may account for different pregnancy outcomes. As more physicians begin to perform radical trachelectomy, controlled trials will be necessary to refine the procedure in order to continue to improve obstetric and oncologic outcomes.

SUMMARY

Radical trachelectomy will continue to increase in popularity as more physicians become willing to learn the technique. It should routinely be offered to young women with early cervix cancer who desire to maintain their fertility.

The role of cervical cerclage in obstetric practice: can the patient who could benefit from this procedure be identified?

This editorial critically examines the definition of "cervical insufficiency." The definition, the clinical ascertainment, efforts to develop an objective method of diagnosis, as well as the nature of cervical disease leading to spontaneous mid-trimester spontaneous abortion and preterm delivery are reviewed. The value and limitations of cervical sonography as a risk assessment tool for spontaneous preterm delivery are appraised. The main focus is on the role of cervical cerclage to prevent an adverse pregnancy outcome. The value of assessing the presence or absence of endocervical inflammation in the outcome of cerclage placement is discussed.

Noninvasive cerclage for the management of cervical incompetence: a prospective study

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of a noninvasive cerclage pessary in the management of cervical incompetence.

METHODS

This is a prospective cohort study of all pregnant women treated for cervical incompetence during a 4-year period. Women with known risk factors for preterm delivery had transvaginal ultrasonography every 2-3 weeks after 17-19 weeks of gestation. Those with progressive shortening of cervix diagnosed before 30 weeks were treated with a cerclage pessary when the cervical length was < or = 25 mm. The pessary was electively removed at 34-36 weeks. The course and outcome of pregnancy were recorded.

RESULTS

Thirty-two women were treated with a cerclage pessary. There were nine twin and two triplet pregnancies. Fifteen (47%) had two or more risk factors for preterm delivery. The mean gestational age at cerclage was 23 (17-29) weeks, cervical length 17 (5-25) mm. Two women required delivery before the onset of labor due to severe intrauterine growth restriction and one due to HELLP syndrome. These were excluded from further analysis. In the remaining 29 women, the interval between cerclage and delivery was 10.4 (2-19) weeks, mean gestational age at delivery 34 (22-42) weeks, and birth weight 2,255 (410-4,045) g. Thirteen (45%) women delivered before 34 weeks. There were a total of 35 live-born infants and four intrapartum fetal deaths (all between 22 and 25 weeks gestation). All women complained of increased vaginal discharge, but no other significant complications were observed that could be attributed to the use of pessary.

CONCLUSION

Cerclage pessary may be useful in the management of cervical incompetence. Whether it can be a noninvasive alternative to surgical cerclage merits further investigation.