Prematurity prevention: the role of cerclage

Complications of Laparoscopic and Transabdominal Cerclage in Patients with Cervical Insufficiency: A Systematic Review and Meta-analysis

OBJECTIVE

Cervical insufficiency is a defect of the cervix that leads to failure to preserve a full-term intrauterine pregnancy. Laparoscopic cerclage and open transabdominal cerclage (TAC) are effective ways to manage patients with cervical insufficiency. We performed this systematic review and meta-analysis to investigate the complications of laparoscopic cerclage and open TAC in the management of cervical insufficiency.

DATA SOURCES

We searched PubMed, Cochrane, Scopus, and Web of Science using our search strategy and screened the results for our criteria. We extracted the results reported and analyzed them using Open Meta-Analyst (OpenMeta[Analyst], Brown School of Public Health, Providence, RI) and Review Manager (Cochrane Collaboration, London, United Kingdom) software.

METHODS OF STUDY SELECTION

We included all randomized controlled and observational trials performed on patients with cervical insufficiency undergoing open TAC or laparoscopic cerclage that matched our search strategy. We excluded letters to the editor, reviews, meetings/conference abstracts, non-English or nonhuman studies, and instances where the full text was not available.

TABULATION, INTEGRATION, AND RESULTS

We included a total of 33 trials. Both interventions of laparoscopic cerclage and open TAC were associated with significantly less total fetal loss (laparoscopic cerclage, relative risk [RR] 0.03; 95% confidence interval [CI], 0.01-0.08; p <.001, and open TAC, RR 0.19; 95% CI, 0.07-0.51; p <.009). The overall blood loss in open TAC was 110.589 mL (95% CI, 93.737-127.44; p <.001), and in laparoscopic cerclage, it was 24.549 mL (95% CI, 9.892-39.205; p = .001). In addition, open TAC had a positive effect regarding incidence of hemorrhage >400 mL (RR 0.077; 95% CI, 0.033-0.122; p <.001). Preterm premature rupture of membranes was significant in the open TAC (RR 0.037; 95% CI, 0.019-0.055; p <.001) and laparoscopic cerclage groups (RR 0.031; 95% CI, 0.009-0.053; p = .006).

CONCLUSION

Laparoscopic cerclage may be safer than open TAC in the management of cervical insufficiency because we found a statistically significant lower incidence of fetal loss, blood loss, and rate of hemorrhage in the laparoscopic cerclage group. Clinically, this evidence may help support favoring a laparoscopic approach over an open one in appropriate patients, although it is unclear whether this benefit is limited to cerclages placed either before pregnancy or placed in the first-trimester or both.

Comparison of laparoscopic abdominal cerclage and transvaginal cerclage for the treatment of cervical insufficiency: a retrospective study

PURPOSE

To compare the pregnancy outcome of patients with cervical insufficiency (CI) underwent prophylactic laparoscopic abdominal cervical cerclage (LAC) and transvaginal cervical cerclage (TVC).

METHODS

A retrospective trial was carried out in the Department of Gynecology, Qingdao Women and Children's Hospital, Shandong Province, China. A total of 217 women with cervical insufficiency underwent the prophylactic cerclage, and the surgical approach was decided by the patients or depended on doctors' advice. The primary outcome measure was the fetal outcome. Secondary outcome measures were delivery of an infant at ≥ 34th gestational weeks, newborn birth weight, neonatal intensive care center (NICU) occupancy, and postoperative complications. Nonparametric variables were analyzed with the Mann-Whitney (U) test, and categorical type outcomes were analyzed with the Chi-square test or the Fisher's exact test. A P value < 0.05 was considered significant. Data analysis was performed using SPSS Statistics Version 19.

RESULTS

As of follow-up date, 154 eligible patients were included in this study, with 74 (48.1%) women in the LAC group and 80 (51.9%) in the TVC group. The total fetal survival rate in the two groups was 90.3% (139/154), of which the rate significantly higher in the LAC group compared to the TVC group (97.3% vs. 83.8%, P < 0.01). The delivery of an infant at ≥ 34th gestational weeks was significantly higher in the LAC group compared to the TVC group (94.6% vs. 71.3%, P < 0.01). Compared to the TVC group, the mean newborn birth weight was higher, and the NICU occupancy rate was less in the LAC group (3293.4 ± 542.8 g vs. 2953.6 ± 704.4 g, P = 0.002; 2.8% vs. 17.9%, P = 0.003).

COMPLICATIONS

No fatal surgical complications occurred in both groups.

CONCLUSION

In patients with cervical insufficiency, the history-indicated conception of prophylactic LAC appears to have a better pregnancy outcome than TVC.

Pregnancy outcomes and superiorities of prophylactic cervical cerclage and therapeutic cervical cerclage in cervical insufficiency pregnant women

PURPOSE

To compare the clinical effect of prophylactic cervical cerclage and therapeutic cervical cerclage on pregnancy outcome and operative factors in cervical insufficiency pregnant women.

METHODS

A retrospective study was conducted between June 2014 and September 2016 in a maternity ward, which included women who have had a single pregnancy and have been carried out a McDonald cerclage. All maternal medical records were reviewed. The efficacy of cerclage for preventing late foetal loss was assessed using multivariable logistic regression analysis.

RESULTS

The results showed that there were significant associations between cerclage operations and pregnancy outcomes in the duration of pregnancy prolongation in terms of live births, gestation age, live birth and cesarean section rate. In prophylactic cervical cerclage, compared with therapeutic cervical cerclage, cervical length before surgery was significantly longer (32.7 ± 5.8 vs 19.9 ± 7.3 mm, p < 0.0001). Mean operative duration and postoperative length of hospital stay in prophylactic cervical cerclage were shorter than those in therapeutic cervical cerclage (22.1 ± 10.3 vs 28.9 ± 13.0 min, p = 0.0241 and 5.6 ± 1.8 vs 7.0 ± 2.8 days, p = 0.0354), respectively. Compared with therapeutic cerclage, prophylactic cerclage had more advantages in gestational age at delivery (35.2 ± 5.5 and 31.7 ± 6.5 weeks, p = 0.0061), deliveries < 37 gestational weeks (40 vs 69.2%, p = 0.0159), live births (93.3 vs 69.2%, p = 0.0143) and the duration of pregnancy prolongation in terms of live births (19.5 ± 5.0 vs 12.0 ± 8.2 weeks, p = 0.0002). There was a higher cesarean section rate in prophylactic group than that in therapeutic group (50 vs 25.6%, p = 0.0383). The logistic analysis showed that the cervical length before surgery was the only independent prognostic factor [OR 2.860 (1.425, 5.742) p = 0.0031] for pregnancy outcome, and that is the cervical length before surgery affected late foetal loss.

CONCLUSIONS

Our study suggests that, both prophylactic cervical cerclage and therapeutic cervical cerclage reduce the incidence of recurrent abortion or preterm birth and efficiently extend the length of the pregnancy with live births. The prophylactic cervical cerclage has more advantages in operative time, length of hospital stay after surgery, gestational age at delivery, live births and preterm birth. The length of the cervical before surgery is an independent risk factor for pregnancy outcomes when pregnant women appear in the cervical shortening is less than normal. Cervical cerclage is an effective surgical technique to prevent recurrent abortion or late foetal loss.

New onset pemphigus foliaceus during pregnancy: A rare case

Pemphigus is a rare autoimmune disease during pregnancy. Among the different pemphigus types, pemphigus foliaceus (PF) is even rarer than pemphigus vulgaris. We present a case of PF in a 36-year-old female patient who presented with PF onset during pregnancy in the form of a disseminated, erythematosquamous rash. A diagnosis was made on the basis of histologic, immunofluorescence, and enzyme-linked immunosorbent assay results. A complete remission was recorded a month after steroid treatment initiation. The patient delivered a premature (33 weeks) but otherwise healthy baby girl. Only three cases of PF have been reported in two retrospective studies found in the English-language bibliography. Although pemphigus during pregnancy is a rare disease and treatment guidelines have not yet been elucidated, the management of these cases is individually evaluated. In all cases, the primary goal should be the control of the maternal disease along with the safety of the fetus.

Changes in incidence of iatrogenic and spontaneous preterm births over time: a population-based study

OBJECTIVE

To examine the proportion of iatrogenic births among all preterm births over a 26-year period.

PATIENTS AND METHODS

A registry-based survey of preterm deliveries between 1987 and 2012 analyzed by the onset of labor: spontaneous with intact membranes, preterm premature rupture of membranes (PPROM) or iatrogenic. Stratification into categories by gestation (22 weeks to 27 weeks and 6 days, 28 weeks to 31 weeks and 6 days, 32 weeks to 33 weeks and 6 days, 34 weeks to 36 weeks and 6 days) was performed. Preterm birth rates were analyzed using the Mantel-Haenszel linear-by-linear association χ2-test (P<0.05 significant). Logistic regression was used to account for potential confounders.

RESULTS

Overall preterm birth rate was 5.9% (31328 deliveries) including 2358 (0.4%) before 28 completed weeks, 3388 (0.6%) between 28 weeks and 31 weeks 6 days, 3970 (0.8%) between 32 weeks and 33 weeks and 6 days, and 21611 (4.1%) between 34 weeks and 36 weeks and 6 days There was an increase in overall preterm birth rate (P<0.001). The rate of iatrogenic preterm births and PPROM increased over time (P<0.001 and P<0.014, respectively). Rates of spontaneous preterm birth decreased (P<0.001). After accounting for potential confounders, year of birth remained an independent risk factor for iatrogenic preterm delivery in all four gestational age categories (P<0.001).

CONCLUSION

The incidence of iatrogenic preterm birth is increasing with a concomitant decrease in the incidence of spontaneous preterm birth. Attempts to analyze, interpret and decrease preterm birth rates should consider spontaneous and iatrogenic preterm births separately.

Amniotic fluid inflammation with negative culture and outcome after cervical cerclage

OBJECTIVE

To determine whether amniotic fluid (AF) inflammation, in the absence of infection, is associated with adverse pregnancy outcomes in nonelective cervical cerclage patients.

METHODS

A retrospective case-control study was carried out. The patient population included 82 singleton pregnancies with negative AF cultures. The variables used to define AF inflammation were white blood cell count (WBC) >50 cell/mm(3), glucose <14 mg/dl or interleukin-6 (IL-6) >11.3 ng/ml. The study group consisted of cases with intra-amniotic inflammation. Sub-analysis was performed for the groups in which IL-6 concentrations were measured. Adverse outcomes were evaluated with variables such as gestational age at delivery, interval from cerclage to delivery, chorioamnionitis and cumulative neonatal morbidity.

RESULTS

Elevated AF WBC was correlated with severe and extreme preterm delivery (p < 0.05). Decreased AF glucose was associated with histological chorioamnionitis and a decreased cerclage to delivery interval (p < 0.05). Elevated AF IL-6 correlated significantly with decreased gestational age at delivery (p < 0.012) and decreased cerclage to delivery interval (p < 0.001). Elevated IL-6 concentrations were associated with severe, extreme preterm delivery (p < 0.001) and neonatal death (p < 0.001).

CONCLUSION

Elevated AF IL-6, elevated WBC and low AF glucose, in the absence of a positive AF culture, are significantly associated with adverse pregnancy outcomes in patients undergoing nonelective cerclage.

Operative complications and fetal morbidity encountered in 300 prophylactic transabdominal cervical cerclage procedures by one obstetric surgeon

This retrospective cohort study identifies complications associated with transabdominal cerclage (TAC). In 300 procedures performed over a 24 year time span, 11 (3.7%) surgical complications were encountered. Fetal loss (prior to 20 weeks) occurred in 4.1% of pregnancies. The median estimated blood loss among patients was 100 ml, with blood loss sufficient to require transfusion only once. Considering patients with classical indications, the gestational age at delivery was greater (37 weeks) after TAC than in the latest pre-TAC pregnancy (24 weeks) (p < 0.001). Lower uterine dehiscence in four patients and uterine rupture in one, underscore the advisability of early term delivery after fetal lung maturity is assured. A survival rate of 98.0% was calculated among infants that were delivered at >24 weeks' gestation. Our results demonstrate that complications encountered in placing a TAC were unusual and generally manageable. This communication may assist the surgeon to balance risks in individual clinical circumstances more adequately.