Late or emergency (salvage) cerclage of a dilated cervix after tissue support with Pelvicol implant: a case

Prevention of spontaneous preterm delivery – an update on where we are today

Spontaneous preterm birth (delivery before 37 completed weeks) is the single most important cause of perinatal morbidity and mortality. The rate is increasing world-wide with a great disparity between low, middle and high income countries. It has been estimated that the cost of neonatal care for preterm babies is more than 4 times that of a term neonate admitted into the neonatal care. Furthermore, there are high costs associated with long-term morbidity in those who survive the neonatal period. Interventions to stop delivery once preterm labor starts are largely ineffective hence the best approach to reducing the rate and consequences is prevention. This is either primary (reducing or minimizing factors associated with preterm birth prior to and during pregnancy) or secondary - identification and amelioration (if possible) of factors in pregnancy that are associated with preterm labor. In the first category are optimizing maternal weight, promoting healthy nutrition, smoking cessation, birth spacing, avoidance of adolescent pregnancies and screening for and controlling various medical disorders as well as infections prior to pregnancy. Strategies in pregnancy, include early booking for prenatal care, screening and managing medical disorders and their complications, and identifying predisposing factors to preterm labor such as shortening of the cervix and timely instituting progesterone prophylaxis or cervical cerclage where appropriate. The use of biomarkers such as oncofetal fibronectin, placental alpha-macroglobulin-1 and IGFBP-1 where cervical screening is not available or to diagnosis PPROM would identify those that require close monitoring and allow the institution of antibiotics especially where infection is considered a predisposing factor. Irrespective of the approach to prevention, timing the administration of corticosteroids and where necessary tocolysis and magnesium sulfate are associated with an improved outcome. The role of genetics, infections and probiotics and how these emerging dimensions help in the diagnosis of preterm birth and consequently prevention are exciting and hopefully may identify sub-populations for targeted strategies.

Clinical effect of emergency cervical cerclage and elective cervical cerclage on pregnancy outcome in the cervical-incompetent pregnant women

PURPOSE

To compare the clinical effect of emergency cervical cerclage and elective cervical cerclage on pregnancy outcome in the cervical-incompetent pregnant women.

METHODS

Literature was searched from the databases of Pubmed, Embase and Google scholar. The fixed or random effects model was used to calculate pooled risk ratios on the basis of heterogeneity. Meta-regression, sensitive analysis, subgroup analysis, and publication bias assessment were also conducted to confirm the results according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009.

RESULTS

The meta-analysis results showed that there were significant associations between cerclage operations and pregnancy outcomes in gestation age, birth weight, and PROM rate. Gestation age was significantly higher in women with elective cerclage than those with emergency cerclage, and birth weight was significantly higher in newborns for the elective group as compared with emergency group. The rate of PROM in elective group was lower than emergency group. However, there were no differences between the emergency cerclage group and the elective cerclage group regarding the rate of vaginal delivery.

CONCLUSIONS

This meta-analysis suggests that emergency cerclage has lower gestation age and birth weight than elective cerclage, and it increases the risk of PROM. Further well-designed studies are warranted to confirm these results.