Eradication of cervical canal colonization associated with prophylactic cervical cerclage: the look further study

OBJECTIVES

The perioperative management of the cervical cerclage procedure is not unified. In general population controlling microbiome cervical status does not affect obstetric outcomes, but it might be beneficial in patients with cervical insufficiency. The aim of our study was to present the obstetric, neonatal and pediatric outcomes of patients undergoing the cervical cerclage placement procedure in our obstetric department using a regimen of care that includes control of the microbiological status of the cervix and elimination of the pathogens detected.

MATERIAL AND METHODS

Thirty-five patients undergoing cervical cerclage in the 2nd Department of Obstetrics and Gynecology, Medical University of Warsaw, were included in the study. The procedure was performed only after receiving a negative culture from the cervical canal.

RESULTS

Thirty-one (88.6%) patients delivered after the 34th and twenty-eight (80.0%) after the 37th week of gestation. The colonization of the genital tract was present in 31% of patients prior to the procedure, in 42% of patients - during the subsequent pregnancy course and in 48% of patients - before delivery. A total of 85% of patients who had miscarriage or delivered prematurely had abnormal cervical cultures. In patients with normal cervical cultures, and 91.7% of women delivered at term. No abnormalities in children's development were found.

CONCLUSIONS

Controlling microbiological status of the cervical canal results in better or similar outcomes to those reported by other authors in terms of obstetric and neonatal outcomes. Active eradication of the reproductive tract colonization potentially increases the effectiveness of the cervical cerclage placement.

The effectiveness of transabdominal cerclage placement via laparoscopy or laparotomy: a systematic review and meta-analysis

OBJECTIVE

Failure or technical impossibility to place a prophylactic transvaginal cerclage in women with cervical insufficiency justifies the need for an abdominal cerclage. In this systematic review and meta-analysis, we studied the obstetrical and surgical outcomes of laparoscopic and open laparotomy abdominal cerclage approaches performed before (interval) or during pregnancy.

DATA SOURCES

We performed a systematic literature search in PubMed, Embase, and the Cochrane Library for studies on laparoscopic and open laparotomy abdominal cerclage placement in February 2022.

STUDY ELIGIBILITY CRITERIA

All studies on laparoscopic or open laparotomy placement of an abdominal cerclage with at least 2 patients that reported on our primary outcomes were included.

METHODS

All included studies were assessed for quality and risk of bias with an adjusted Quality in Prognosis Study tool. Random effects meta-analyses were performed for the primary outcomes, namely fetal survival and gestational age at delivery.

RESULTS

Our search yielded 83 studies with a total of 3398 patients; 1869 of those underwent laparoscopic cerclage placement and 1529 underwent open laparotomy placements. No studies directly compared the 2 cerclage approaches. The survival (overall, 91.2%) and gestational age at delivery (overall, 36.6 weeks) were not statistically different between the approaches. For the procedure during pregnancy, the laparoscopic group showed significantly less blood loss >400 mL (0% vs 3%), a slightly lower procedure-related fetal loss (0% vs 1%), a shorter hospital stay but a longer operation duration than the open laparotomy group. For the interval cerclages, the laparoscopic group showed significantly fewer wound infections (0% vs 3%) and a shorter hospital stay than the open laparotomy group, but showed comparable offspring preterm birth and survival rates.

CONCLUSION

Based on indirect comparisons, the laparoscopic and open laparotomy abdominal cerclage placements at interval or during pregnancy produced similar outcomes in terms of survival and gestational age at delivery. There are some small differences in perioperative care, surgical complications, interventions, and complications during pregnancy. This implies that both methods of abdominal cerclage placement have high success rates and thus we cannot conclude that one of the methods is superior for the placement of an abdominal cerclage.

Antibody microarray analysis of amniotic fluid proteomes in women with cervical insufficiency and short cervix, and their association with pregnancy latency length

Introduction

This study aimed to investigate amniotic fluid (AF) proteins that were differentially expressed between patients with cervical insufficiency (CI) and asymptomatic short cervix (SCX, ≤ 25 mm), and whether these proteins could be predictive of spontaneous preterm birth (SPTB) in these patients.

Method

This was a retrospective cohort study of 129 singleton pregnant women with CI (n = 80) or SCX (n = 49) at 17 to 26 weeks who underwent amniocentesis. An antibody microarray was used to perform comparative proteomic profiling of AF from matched CI (n = 20) and SCX (n = 20) pregnancies. In the total cohort, an ELISA validation study was performed for 15 candidate proteins of interest. Subgroup analyses of patients with CI and SCX were conducted to evaluate the association between the 15 proteins and SPTB at < 32 weeks of gestation.

Results

Eighty-six proteins showed intergroup differences. ELISA validation confirmed significantly higher levels of AF EN-RAGE, IL-8, lipocalin-2, MMP-9, S100A8/A9, thrombospondin-2, and TNFR2 in patients with CI than in those with SCX. Multivariable analysis showed that increased AF levels of EN-RAGE, S100A8/A9, and uPA were independently associated with SPTB at < 32 weeks in patients with CI; whereas in patients with SCX, high AF levels of APRIL, EN-RAGE, LBP, and TNFR2 were independently associated with SPTB at < 32 weeks.

Conclusions

Multiple AF proteins show altered expression in patients with CI compared with SCX controls. Moreover, several novel mediators involved in inflammation were identified as potential biomarkers for predicting SPTB after the diagnosis of CI and SCX. These results provide new insights into target-specific molecules for targeted therapies to prevent SPTB in patients with CI/SCX.

[Premature birth in patient with cervix incompetence and history of myasthenia gravis]

Cervical incompetence it's a dilatation of the cervix during the third trimester of pregnancy that ends with the interruption of it. The incidence in Chile is about 0.1-2% of the total pregnancies and it's one of the causes of preterm birth. A 34 years old pregnant patient. Timectomized at age 18 to treat her miastenia gravis, previously trated with medication, had 4 previous preterm labours all of them under 25 weeks and vaginal births. All fetuses died postpartum. A cerclage was made during the third, fourth and fifth pregnancies. She didn't present hypertension during the gestation and no cervical diameter under 15mm. Since the fourth gestation the following tests are taken: Antifosfolipidic antibodies, APTT,PT. All the results are either normal or negative. Microbial cultures were negative. No amniocentesis was made. A McDonald cervical cerclage was made during pregnancies number 3, 4 and 5 on the 16th week to delay the labor. Also oral micronized progesterone, on a 400mg/24 hours dosis, was administered to avoid preterm birth. On the 24th week the pharmacological treatment started including Intramuscular Betamethasone, 12 mg/24 hours (2 doses), to induce lung maturity on the fetus. It is thought that the administration of progesterone could have improved the situation of the patient, because it acts as a labour repressants. The use of cerclage could have helped, but the factors that may influence the effectiveness of this method are unknown. Perhaps there is some immunologic factor associated with the miastenia gravis that alters the normal course of pregnancy.

Effective treatment of cervical incompetence in a monochorionic monoamniotic twin pregnancy with a rescue cervical cerclage and pessary--a case report and review of literature

A monochorionic monoamniotic (MCMA) twin pregnancy is the rarest form of twin gestation, accounting for around 1:10000 to 1:20000 of all deliveries regardless of the region of the world. All multiple gestations have a higher risk of preterm delivery due to either preterm uterine contractions or asymptomatic cervical shortening (cervical incompetence). A case of a 28-year-old primigravida in MCMA twin pregnancy with cervical incompetence diagnosed at 22 weeks of gestation is presented. After obtaining cervical swabs, negative laboratory infection parameters and confirming concordant gestational age on ultrasound scan with no structural abnormalities of both fetuses, the patient was qualified for an emergency cervical cerclage according to Wurm-Hefner method. Five days after the procedure, a cervical pessary was additionally inserted. She was administered antibiotics and steroids. The wellbeing of both fetuses was strictly monitored by means of cardiotocography tracing and ultrasound examinations, on which they were both eutrophic, with no abnormalities in Doppler blood flow patterns. Spontaneous premature rupture of membranes took place at 32 weeks of gestation, a cesarean section was performed and two female fetuses of 1740 g and 1760 g were delivered. They both required antibiotics because of congenital pneumonia, but no respiratory support was necessary The twins were discharged from the hospital 22 days after birth in good general condition. This case of a rescue cervical cerclage and pessary used simultaneously can be an example of an effective method of cervical incompetence treatment in twin pregnancies.

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.

Routine cervical length in twins and perinatal outcomes

A retrospective review of twin gestations was undertaken to evaluate whether routine cervical lengths (CLs) in such instances change pregnancy outcome. Data were collected from the ultrasound database and chart review. Exclusion criteria included twins reduced to singletons, twins not delivering at our institution, and incomplete information. Twin gestations with a CL were compared with those without a CL. Outcomes of interest included gestational age (GA) at delivery, preterm delivery (PTD), antepartum admissions, antepartum length of stay (LOS), cerclage placement, birthweight, neonatal intensive care unit admissions, and neonatal LOS. Two hundred sixty-two patients met inclusion criteria. Of those, 184 had CLs and 78 did not. Comparing the CL to the no-CL group, there were no differences with respect to GA at delivery (34.8 versus 35.3 weeks; p=0.35), antepartum admissions (32.1 versus 23.1%; p=0.16), cerclage placement (7.1 versus 1.3%; p=0.06), or tocolysis use (28.6 versus 21.8%; p=0.26). There was no difference between the two groups with respect to preterm labor (26 versus 19%; p=0.25), PTD < 28 weeks (8.2 versus 3.9%; p=0.21), PTD < 34 weeks (26.1 versus 25.6%; p=0.94), or PTD < 37 weeks (76.1 versus 70.5%; p=0.34). The only significant difference was antepartum LOS (34.5 versus 31.3 days; p< 0.001). There were no differences in neonatal outcomes. Routine CL did not improve perinatal outcome but increased maternal antepartum LOS.

When is a cerclage indicated for cervical insufficiency? A literature review

Cervical insufficiency is a very difficult diagnosis to confirm. An evidenced based assessment of the randomized clinical trials, meta-analysis, cohort studies and, the American College of Obstetrics and Gynecologist (ACOG) practice bulletin demonstrated there is no difference between women treated with cerclage, and those who received bed rest in patients with an appropriate history for cervical insufficiency. Based on the existing literature, cerclage is rarely, if ever mandated, but rather can be offered if the following criteria are met: (1). signs and symptoms of first trimester abnormalities in the current pregnancy are absent; (2). the patient has three or more second trimester losses (usually 18-22 weeks) with a classic history of cervical incompetence. We also recommend serial ultrasounds be performed beginning at 16 weeks to demonstrate cervical insufficiency.

Laparoscopic metroplasty for bicornuate uterus

This is a case study of a 29-year-old nulliparous woman with a bicornuate uterus who had a poor obstetric history in whom we performed a laparoscopic metroplasty. She was advised to use barrier contraception for 3 months. A repeat hystero-laparoscopy performed 3 months later revealed a single large uniform uterine cavity without any adhesions. The patient had an incompetent cervical os after surgery and was advised to undergo cervical cerclage on conception.

Clinical outcomes following interval laparoscopic transabdominal cervico-isthmic cerclage placement: case series

The purpose of this report is to describe outcomes following laparoscopic transabdominal cervico-isthmic cerclage placement in cases of cervical incompetence not amenable to a conventional transvaginal procedure. We reviewed records of the first 11 patients at an academic teaching hospital who underwent laparoscopic transabdominal cerclage placement as an interval procedure, using a technique we previously first described. For all patients, the clinical course, including surgical complications and outcome of all subsequent pregnancies, is briefly described. One case was complicated by a small bowel injury secondary to concomitant extensive enterolysis. Otherwise there were no complications. Mean estimated blood loss was <40 ml. To date, 10 patients have conceived a total of 12 pregnancies following the procedure. Two pregnancies resulted in spontaneous losses at 8 weeks gestation, two in deliveries by Caesarean section at 34.5 weeks, and eight in deliveries by elective Caesarean section at 38 weeks or more. Each delivery resulted in the birth of a healthy infant. In conclusion, patients who require a transabdominal cerclage may undergo a laparoscopic interval procedure and achieve outcomes similar to those following placement via laparotomy during pregnancy.

Final results of the Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): therapeutic cerclage with bed rest versus bed rest alone

OBJECTIVE

To compare preterm delivery rates (before 34 weeks of gestation) and neonatal morbidity and mortality in patients with risk factors or symptoms of cervical incompetence managed with therapeutic McDonald cerclage and bed rest versus bed rest alone.

STUDY DESIGN

Cervical length was measured in patients with risk factors or symptoms of cervical incompetence. Risk factors for cervical incompetence included previous preterm delivery before 34 weeks of gestation that met clinical criteria for the diagnosis of cervical incompetence, previous preterm premature rupture of membranes before 32 weeks of gestation, history of cold knife conization, diethylstilbestrol exposure, and uterine anomaly. When a cervical length of <25 mm was measured before a gestational age of 27 weeks, a randomization for therapeutic cerclage and bed rest (cerclage group) or bed rest alone (bed rest group) was performed. The analysis is based on intention to treat.

RESULTS

Of the 35 women who met the inclusion criteria, 19 were allocated randomly to the cerclage group and 16 to the bed rest group. Both groups were comparable for mean cervical length and mean gestational age at time of randomization, mean overall 20 mm and 21 weeks. Preterm delivery before 34 weeks was significantly more frequent in the bed rest group than in the cerclage group (7 of 16 vs none, respectively; P =.002). There was no statistically significant difference in neonatal survival between the groups (13 neonates survived in the bed rest group vs all in the cerclage group). The compound neonatal morbidity, defined as admission to the neonatal intensive care unit or neonatal death, was significantly higher in the bed rest group than in the cerclage group (8 of 16 vs 1 of 19, respectively; P =.005; RR = 9.5, 95% CI, 1.3-68.1).

CONCLUSIONS

Therapeutic cerclage with bed rest reduces preterm delivery before 34 weeks of gestation and compound neonatal morbidity in women with risk factors and/or symptoms of cervical incompetence and a cervical length of <25 mm before 27 weeks of gestation.

Preterm premature rupture of membranes in a patient with the hypermobility type of the Ehlers-Danlos syndrome. A case report

OBJECTIVES

This report wants to focus on the risk of severe prematurity in patients with the hypermobility type of the Ehlers-Danlos syndrome (EDS), a heritable disorder of connective tissue. Although various obstetrical complications have been reported in patients with EDS, most reports specifically comment on the severe complications in patients with the vascular type of EDS, including uterine and arterial rupture. Pregnancy outcome in patients presenting the hypermobility type of EDS is poorly documented.

CASE

A 33-year-old nullipara was referred for preconceptual genetic counseling with a history of easy bruising, generalized joint hypermobility and chronic arthralgia and myalgia. The diagnosis of the hypermobility type of EDS was confirmed on clinical examination. During her first pregnancy, she underwent a prophylactic McDonald cerclage at 14 weeks' gestation. Premature rupture of membranes occurred at 23 weeks' gestation. A female infant was delivered at 26 weeks and died 3 h after birth. Electron-microscopic examination showed collagen fibre abnormalities in the fetus' skin, which were compatible with the diagnosis of EDS.

CONCLUSIONS

Patients with the hypermobility type of EDS can have an increased risk for pregnancy complications, including prematurity due to cervical incompetence and to premature rupture of membranes. We therefore demand the clinician's alertness for possible signs of this underdiagnosed type of EDS and recommend the collaboration between the obstetrician and the medical geneticist in the obstetrical management of these patients.

Obstetric complications in Marfan's syndrome pregnancy

Marfan syndrome is usually inherited as an autosomal dominant trait with high degree of penetrance. It is caused by an abnormal fibrillin gene located on chromosome 15q. Cardiovascular involvement in Marfan syndrome has been overstressed, although very little attention has been given to obstetric complications. Marfan syndrome may be responsible of cervical incompetence, abnormal placental site and post partum haemorrhagic complications. A 22-year-old woman with Marfan syndrome had mitral regurgitation since childhood. In addition aortic root dilatation was documented over six years by means of echocardiography and had been followed up regularly in a district hospital. Echocardiography six months before pregnancy had shown minimal mitral and aortic regurgitation and aortic root dilatation of 4.1 cm; left ventricular function was normal. Repeat echocardiography evaluations during pregnancy confirmed an aortic root dilatation. Routine booking and screening investigations were all within normal limits. At the 25th week, admission was necessary following a vaginal bleeding, without pain contraction. Echography showed a placenta praevia and cervical dilatation 2.8 cm of diameter. Bed rest and intravenous thocolitic therapy were immediately enhanced. A cervical cerclage, as described by McDonald, was placed. At the 37th week the patient was admitted and cerclage removed before the caesarean section. A healthy female of 2900 g was born. The postoperative period was favourable and patient was discharge after 7 days. In the present case, it is suggested that cervical incompetence and placenta praevia may be caused by an alteration of microfibrillar fibers.

Detection of pregnant women at risk of cervical incompetence by transvaginal sonography during straining

OBJECTIVE

To evaluate the ability of transvaginal sonography (TVS) undertaken, during straining to detect incompetent cervix in pregnant women at risk.

METHOD

Forty-seven pregnant women with risk factor(s) for cervical incompetence and 22 pregnant women (control) were evaluated for cervical changes detected by TVS during rest, transfundal pressure and during the stress induced by straining.

RESULTS

The control group demonstrated no cervical changes. The changes were more significant during straining than with transfundal pressure. In the group with risk factor(s), 48.9% showed negative response and 51.1% demonstrated positive response. The pregnancy outcome was more favourable in the group with negative response (full term pregnancy 82.6% vs 70.8%, preterm delivery 13% vs 16.7% and pregnancy loss 4.4% vs 12.5%).

CONCLUSION

TVS during straining can be applied as a stress test in women at risk for cervical incompetence.

[Results of follow-up of mothers with previous surgical "total cervical cerclage" also with reference to neonatal data]

From August 16, 1993 until March 6, 1995 a study was conducted at the Department of Obstetrics at the Berlin-Neukoelln Womens Hospital to evaluate the status of patients who had previously undergone total cervical occlusion (TCO) for the prevention of late abortion and premature birth. Special consideration was given to the possible effects of TCO on the patients' gynecologic status, the psychological circumstances associated with TCO and the developmental status of the infants. Fifty-four women participated in the study, their ages ranging between 26 and 53 years. The mean time-span between the TCO procedure and the present study was five years and five months. In the 54 women undergoing TCO, a total of 73 such procedures were performed. An extensive early TCO was performed in 63% and an extensive late TCO in 20.5%. The gestational age at the time of delivery was > or = 37 + 0 weeks in 67.1% of the women. More than half of the patients (54.9%) experienced a normal spontaneous vaginal delivery. In total, 84.5% of the infants were delivered vaginally; thus the cesarean section rate was only 15.5%. Regarding the patients' medical histories, the majority of the patients had no pathological findings on routine pap smears and pelvic examinations and, similarly, they had no complaints of menstrual irregularities. Only 10 patients (18.5%) underwent gynecological surgery in the interim; in these patients, the most common reason for surgery (in four cases) was sterilisation. The findings during speculum examination were tabulated. The majority of the patients (96%) exhibited a normal multiparous cervical portio. In 55% of the patients there was no evidence of scarring of the cervical portio. In 25% of the patients there was minor cervical scarring, in 13.5% it was moderate and in 5.8% it was severe. Except for a single case, the patients showed no evidence of vaginitis. During bimanual palpation on pelvic examination, in 82.7% of the patients the cervix was found to be at least 2 cm in length, a closed external cervical os was palpated in 65.4%, and an anteflexed/anteverted uterus that was normal in size and form was noted in 46.2%. In 95.4% of the patients, original squamous epithelium was seen colposcopically. The psychosocial status of each patient was evaluated on an individual basis. After taking all of the psychosocial circumstances associated with such a high-risk pregnancy into consideration, all the patients giving birth to a living infant described that event as a positive experience. However, this was not the case in the two patients whose premature infants did not survive. In 74.1% of the patients, the relationship with their domestic partners was described as "unchanged" when compared to the status of their relationship during the preceding pregnancy without TCO. The patients undergoing TCO described their own psychological status as "frequently strained" (61.1%) and "disturbed" (9.3%) antepartum. Postpartum, 90.7% of the patients described their psychological status as "good". In total, there were 74 births in the 54 patients included in this follow-up study. Of these 51 (68.9%) were living term infants, one stillborn (1.4%) and 22 (29.7%) premature infants. One infant weighed less than 1.000 grams while 4 (5.3%) weighed between 1.000 and 1.499 grams. Postpartum, 45.5% of the premature infants and 19.6% of the term infants were hospitalized. The primary indications for the transfer of the premature neonates were intensive care, hyperbilirubinemia and adaptation problems. The physical, emotional and mental development was unimpaired in 91.4% of the children. A capability for good social integration was displayed in 95.7% of the children. Based on the current investigation, it may be concluded that the total cervical occlusion procedure has no significant long-term negative effects.

[Cervix incompetence]

The incontinence cervix is one of the most controversial topics in obstetrics and gynecology. The cause of cervical incontinence is due to trauma to the cervix resulting from injury during childbirth, mechanical dilation, or surgery. Dilatation of the internal cervical os is difficult to detect by digital examination in patients with a closed external cervical os. Transvaginal ultrasonographic assessment of the cervix should be adopted as the "gold standard".

Screening for bacterial vaginosis and cervicitis aimed at preventing premature delivery

OBJECTIVE

We performed screening and treatment of bacterial vaginosis and cervicitis during pregnancy for prevention of premature delivery. The incidence and the etiology of lower genital tract infections and premature delivery were examined to elucidate the effectiveness and problems of this trial.

METHODS

Three hundred sixty-five pregnant women who attended the obstetrical outpatient clinic in our hospital were included as subjects. The screening was done at prenatal-care visits around the 10th, 20th, and 30th gestational weeks.

RESULTS

Fifty-eight women were diagnosed as bacterial vaginosis and 54 women were successfully treated. Thirty-five women were diagnosed as cervicitis and all were cured. Nine women (2.5%) delivered before the 37th gestational week and 1 women delivered before the 35th gestational week because of cervical incompetence.

CONCLUSIONS

The treatment of bacterial vaginosis and cervicitis may prevent microbes in the lower genital tract from penetrating the intrauterine cavity and thereby reduce the incidence of premature delivery.

Emergent and elective cervical cerclage for cervical incompetence

OBJECTIVE

The clinical outcomes of emergent and elective McDonald cerclage including cases of prolapsed amniotic sac were compared.

METHOD

Forty-eight patients undergoing elective cervical cerclage suture and 21 patients receiving emergent cervical cerclage including eight cases of prolapsed fetal membranes in the vagina were retrospectively analyzed.

RESULTS

Prolongation of pregnancy (145 +/- 27 vs. 58 +/- 56 days, P < 0.001), delay of delivery (37.0 +/- 3.1 vs. 28.3 +/- 7.8 gestational weeks, P < 0.001), higher birth weight (3033 +/- 751 vs. 1410 +/- 1139 g, P = 0.001), better fetal salvage rate (98 vs. 52%, P < 0.05), and fewer lower Apgar scores (score < 7: 4/48 vs. 13/21 at 1 min, P = 0.000; 2/48 vs. 10/21 at 5 min, P = 0.000) were attained in the elective group compared with those in the emergent group. The clinical outcomes were not significantly different between those with and those without prolapsed fetal membranes, but this may have been due to the small sample size.

CONCLUSION

In addition to elective cervical cerclage, we recommended this procedure in emergency cases even in those with a prolapsed amniotic sac.

[The diagnosis and complications of pregnancy in uterine malformation]

During the period from January 1985 until May 1990, 56 pregnant women with malformed uterus were observed for the clinical curse of pregnancy: 22 women in the first, 26 in the second and 8 in the third trimester. The diagnosis was made by complex investigations: vaginal examination--in 48 cases, ultrasound examination-in 51 cases, previous hysterosalpingography--in 14 cases. In 17 women the performance of a cerclage was needed. In 17 women a hormonal treatment with gravibinon was applied. The results prove the reliability and validity of ultrasound examination, especially through the second trimester of pregnancy and the need of adequate hormonal (gravibinon) and operative treatment (cerclage).

Emergency cerclage: a review

The treatment of patients with cervical incompetence presenting with advanced cervical changes in the second trimester remains a challenge to every obstetrician. Cerclage operation may be the only hope for prolonging gestation until fetal viability is reached. A retrospective study on so-called emergency cervical cerclage in 20 patients with supposed cervical incompetence in the late second trimester is presented, together with a review of comparable studies published between 1980 and 1992. It is concluded that emergency cerclage can be of benefit, and that the pregnancy is saved in the majority of cases, although the incidence of complications, often due to infection, is high. Many patients require prolonged hospitalization or bed rest and few pregnancies reach full term. There is a particularly high rate of infectious complications and attention must be focused on preventing chorioamnionitis to improve the outcome of the procedure in the future.

Successful treatment with the Smith-Hodge pessary of cervical incompetence due to defective connective tissue in Ehlers-Danlos syndrome

Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders with at least ten distinct types. We report a case of EDS complicated by cervical incompetence. Treatment was undertaken after confirmation that the patient's EDS was not type IV, hence not associated with potentially serious vascular complications. Because of concern about stretching or tearing of the hyperextensible connective tissue associated with EDS, cerclage was not performed. The cervical incompetence due to defective connective tissue was treated with a Smith-Hodge pessary.

Cervical incompetence occurring after caesarean section: a case report

A case of cervical incompetence as a result of caesarean section is presented. The role of caesarean section as an aetiological factor in cervical incompetence is discussed.

Incompetent cervix: pathogenesis, diagnosis and treatment

The incompetent cervix is a diagnostic dilemma. There are no well-defined or strict criteria to diagnose cervical incompetence, and therefore the indications for treatment are not always clear. Forty years ago, when the basic methods of treatment were first described, the diagnosis seemed relatively simple and the treatment acceptable. There have been very few large, prospective, randomized, well-controlled studies to determine the efficacy of the various surgical methods. Liberal use of cerclage procedures in situations of moderate risk for premature delivery or as prophylactic measures in multiple pregnancy does not appear to improve outcome as judged by prematurity or fetal survival. At the present, fetal survival cannot be a measure of the success of a surgical procedure because so many other factors play a role in outcome, such as the quality of obstetrical and neonatal care. Therefore, outcome of surgical procedures should be judged by more objective criteria, such as prolongation of pregnancy (in weeks) and birth weight. The methods that would allow making an unequivocal and objective diagnosis of incompetent cervix are not yet available. Until we reach this goal, the subject of cervical incompetence and effectiveness of its treatment will remain challenging and elusive.

[Clinical trends in 520 twin pregnancies in 22 years]

In the last 22 years 520 twin pregnancies were seen at the Department of Obstetrics and Gynecology, University of Ulm. The material was analyzed retrospectively according to the 4 time periods 1965-1974, 1975-1980, 1981-1983, and 1984-1987. An equal-size group of singleton pregnancies was used as control. 1. By the 20th week the diagnosis had been established in 67% between 1984 and 1987 and 29% between 1975 and 1980. 2. A cervical cerclage was most commonly done between 1981 and 1983 (75%). The frequency decreased afterwards and a cerclage was only done in 18% in 1987. 3. Tocolytic agents were used in 7% between 1965 and 1974 and in two thirds of cases in the last years. 4. Hospital admission before delivery was most common between 1975 and 1980 (33%). In the last 7 years it was only half as common (15%). 5. There was no difference in the frequency of preeclampsia and eclampsia between singleton and twin pregnancies in the last years. 6. Maternal hemoglobin levels below 10% were more common in twin pregnancies than in the control group: Before delivery 11%, after delivery 22% in the twin pregnancies, compared with 6% and 4% in the singleton pregnancies. 7. There was no increase in the duration of pregnancy in the last 22 years. The difference between actual birth date and estimated date of delivery remained about the same in the 4 examined time periods: 21 days, 20 days, 21 days, 27 days. There was a slight increase in the frequency of delivery before the 37th week in twin pregnancies: 38%, 41%, 43%, 47%.

Cervical incompetence in a pregnancy following a cervical ectopic pregnancy

A case of cervical incompetence is reported which occurred in a pregnancy which followed soon after treatment of a cervical ectopic pregnancy using a Foley catheter. Very few pregnancies following cervical pregnancy have been reported. Although this isolated case is clouded by other risk factors, cervical incompetence should be considered as a potential complication of such pregnancies.

Transabdominal cervicoisthmic cerclage: a review

A successful case of transabdominal cervicoisthmic cerclage is presented. The indications and surgical technique for this rarely reported treatment of incompetent cervix are described, and the pathophysiology of the condition is reviewed. The currently accepted treatment alternatives for incompetent cervix are presented and compared with the transabdominal approach. The existing reports on transabdominal cervicoisthmic cerclage are reviewed, and the morbidity of all reported cases is discussed. A scheme to assist in patient selection is suggested.

Cervical incompetence and preterm labor

The ability of the cervix to function as a competent sphincter to retain the fetoplacental unit in utero until term is dependent on a complex set of biochemical, biophysical, and environmental events. The understanding of these interactions is limited at present and requires that cervical incompetence be a diagnosis of exclusion. Currently, differentiation of cervical incompetence from preterm labor is a major problem. Advances in ultrasonography, ambulatory uterine activity monitoring, cervical histomorphology, and biochemistry should improve the understanding of both normal and abnormal cervical and uterine function and may provide new techniques to distinguish between true cervical incompetence and preterm labor. Well-designed and strictly executed randomized clinical trials of cervical cerclage should answer the question of therapeutic efficacy for this popular technique when the diagnosis of cervical incompetence is made.

Pregnancy and delivery after cone biopsy of the cervix

Seventy-seven women had 98 pregnancies after a cone biopsy of the cervix. There were 62 deliveries, 26 legal abortions, 9 spontaneous abortions and 1 ectopic pregnancy. Cervical cerclage was done for 22 out of 62 conized parturients (35.4%) and for none in the matched control group. There were 4 (6.4%) preterm deliveries in the cone biopsy group and 1 in the control group. The perinatal mortalities were 3.2% and 0% respectively. The mean duration of labour was 2.4 h shorter in the conized parturients than in the controls (P less than 0.05) but there were no difference in the mode of delivery in the two groups.

Cervicovaginal fistulas: management of subsequent pregnancy

Cervicovaginal fistulas that develop after midtrimester abortion represent a significant risk to subsequent pregnancies. Since patients with this condition appear to be at increased risk for preterm labor and cervical incompetence, I recommend a cerclage procedure. The probability of complications during labor in such cases makes elective cesarean delivery the method of choice.

The incompetent cervix

All methods for the management of CI have been described as producing a significant improvement in fetal salvage. The Lash procedure and the pessary have been deemed the most effective. However, the methods of patient selection in many of the older studies are not described, and their statistical validity is suspect. CI is thus a disease of uncertain etiology. Its pathophysiology is poorly understood, and methods of treatment vary greatly both as to technique and efficacy.

Can a low-lying placenta be the risk factor of cervical incompetence? A preliminary study on the relationship between placenta insertion and anatomical status of uterine cervix

An attempt was made to verify the hypothesis that a low-lying placenta may be a factor leading to the dynamic form of cervical incompetence. A vaginal evaluation of the cervix was made in 143 pregnant women who by means of ultrasonographic method were found to have low-lying placentas. In as many as 68 out of the 143 studied cases (47.5%), the low-lying placenta coincided with a shortening of the cervix about half its normal length or in both shortening and patency of the uterocervical canal, measuring up to 2 cm in diameter (39 cases). The statistical calculations indicate that a low-lying placenta can influence cervical behaviour and that it appears to be a risk factor of cervical incompetence.

Outcome of third trimester pregnancies after cryotherapy of the uterine cervix

A retrospective study was undertaken to assess the effect of cryotherapy of the uterine cervix on the outcome of third trimester pregnancies. It was concluded that cryosurgery of the cervix had no effect on the onset or progress of labour, or on the infant, an important advantage compared with cold-knife conization as a therapy for young women with cervical intraepithelial neoplasia.

Does cervix conization increase the risk of complications in subsequent pregnancies?

In a series of 414 patients who underwent cervix conization because of cancer in situ, the risk of complications in subsequent pregnancies was analyzed by studying the outcome of their 923 pregnancies before and after cone biopsy. After conization the incidence of late spontaneous abortion was seven times higher than before. Moreover, 20.5% of pregnancies following cone biopsy required cervix cerclage because of suspected cervical insufficiency, or cesarean section because of a scarred cervix stenosis.