OBJECTIVE: Our hospital's policy is to perform history-indicated cerclage (HIC) for pregnant patients with 1 or more second-trimester pregnancy losses. Recently, the American College of Obstetricians and Gynecologists (ACOG) guideline regarding indications for HIC was changed from 3 or more previous second-trimester fetal losses to one or more. In this study, we aimed to evaluate the efficacy of the revised guideline and to investigate the association between previous preterm history and cerclage outcome. METHODS: We conducted a retrospective observational study of cases of HIC in singleton pregnancies performed at our hospital between January 2007 and June 2016. We compared the perioperative complications and incidences of preterm delivery in patients with one previous second-trimester pregnancy loss against those in patients with ≥2 losses. RESULTS: The incidence of preterm delivery (< 32 weeks) was significantly lower in patients with one previous second-trimester pregnancy loss than in those with ≥2 losses (15/194 [8%] vs. 28/205 [14%]). In the 1 loss and ≥2 losses groups, the rates of preterm premature rupture of membranes (PPROM) were 7% and 8%, the rates of PPROM at < 32 weeks 2.1% and 3.4%, and the ratios of neonatal intensive care unit admission 10% and 17%, respectively. CONCLUSION: Comparison of HIC in one previous second-trimester pregnancy loss group with HIC in the 2 or more previous second-trimester pregnancy loss group found no difference in pregnancy outcome. This finding supports the amended ACOG guideline for HIC indications. Based on our results, we also propose development of a new protocol for HIC-related complications.
Cerclage, Cervical ; Female ; Humans ; Incidence ; Infant, Newborn ; Intensive Care, Neonatal ; Membranes ; Observational Study ; Pregnancy ; Pregnancy Outcome ; Premature Birth ; Retrospective Studies ; Rupture ; Uterine Cervical Incompetence

Preterm birth defined as birth between 20-37 weeks age of gestation, poses major concerns as it causes serious health problems. Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born and the Philippines ranks 8th out of 184 countries for the number of babies born prematurely, and ranks 17th for the total number of deaths due to complications from preterm birth. Management of incompetent cervix as one of the causes of preterm birth is cerclage. However, pessary insertion is an alternative especially in cases where cerclage may not be employed. To date, there have been no local published reports on effectiveness of pessary in prevention of preterm birth. Hence this study aims to report on cases supporting the use of pessary in preterm birth. This is a case series of three patients with short functional cervical lengths (<2.5 cm) seen in ultrasound, managed with pessary insertion showing its effectiveness in prolonging pregnancy. In conclusion, pessary is an affordable and safe alternative management of preterm birth which may be employed in our setting. Future clinical trials may be helpful in strengthening this evidence.

Human ; Female ; Adult ; Pregnancy ; Uterine Cervical Incompetence ; Pessaries ; Premature Birth ; Parturition ; Pregnancy, Prolonged ; Tnfrsf11a Protein, Human ; Receptor Activator Of Nuclear Factor-kappa B

Preterm birth defined as birth between 20-37 weeks age of gestation, poses major concerns as it causes serious health problems. Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born and the Philippines ranks 8th out of 184 countries for the number of babies born prematurely, and ranks 17th for the total number of deaths due to complications from preterm birth. Management of incompetent cervix as one of the causes of preterm birth is cerclage. However, pessary insertion is an alternative especially in cases where cerclage may not be employed. To date, there have been no local published reports on effectiveness of pessary in prevention of preterm birth. Hence this study aims to report on cases supporting the use of pessary in preterm birth. This is a case series of three patients with short functional cervical lengths (<2.5 cm) seen in ultrasound, managed with pessary insertion showing its effectiveness in prolonging pregnancy. In conclusion, pessary is an affordable and safe alternative management of preterm birth which may be employed in our setting. Future clinical trials may be helpful in strengthening this evidence.

Human ; Female ; Adult ; Pregnancy ; Uterine Cervical Incompetence ; Pessaries ; Premature Birth ; Parturition ; Pregnancy, Prolonged ; Tnfrsf11a Protein, Human ; Receptor Activator Of Nuclear Factor-kappa B

BACKGROUNDPreterm birth (PTB) is the leading cause of perinatal morbidity and mortality worldwide, and its prevention is an important health-care priority. The cervical incompetence is a well-known risk factor for PTB and its incidence is about 0.1-2.0%, while there is no ideal optimum treatment recommended currently. The cervical incompetence causes about 15% of habitual abortion in 16-28 weeks. This study aimed to evaluate the effectiveness and safety of cervical cerclage and vaginal progesterone in the treatment of cervical incompetence with/without PTB history.

METHODSWe retrospectively observed the pregnancy outcome of 198 patients diagnosed with cervical incompetence from January 2010 to October 2015 in Beijing Hospital. Among the 198 women involved, women who had at least one PTB before 32 weeks (including abortion in the second trimester attributed to the cervical competence) were assigned to the PTB history cohort, and others were assigned to the non-PTB history cohort. All women underwent cerclage placement (cervical cerclage group) or administrated with vaginal progesterone (vaginal progesterone group) until delivery. The outcomes of interest were the differences in gestational age at delivery, the rate of premature delivery, neonatal outcome, complications, and route of delivery between the two treatment groups.

RESULTSAmong the 198 patients with cervical incompetence, 116 patients in PTB history cohort and 80 patients in non-PTB history cohort were included in the final analysis. In the PTB history cohort, cervical cerclage group had significantly longer cervical length at 2 weeks after the start of treatment (23.1 ± 4.6 mm vs. 12.4 ± 9.1 mm, P = 0.002), higher proportion of delivery ≥37 weeks' gestation (63.4% vs. 33.3%, P = 0.008), bigger median birth weight (2860 g vs. 2250 g, P = 0.031), and lower proportion of neonates whose 1-min Apgar score <7 (5.9% vs. 33.3%, P = 0.005), compared with vaginal progesterone group. No significant differences were found in other outcome measures between the two treatment groups. In the non-PTB history cohort, there were no significant differences in the maternal outcomes between cervical cerclage and vaginal progesterone groups, such as median gestational age at delivery (37.4 weeks vs. 37.3 weeks, P = 0.346) and proportion of delivery ≥37 weeks' gestation (55.9% vs. 60.9%, P = 0.569). There were also no significant differences in the neonatal outcomes between the cervical cerclage and vaginal progesterone groups including the median birth weight (2750 g vs. 2810 g, P = 0.145), perinatal mortality (5.9% vs. 6.5%, P = 0.908), and 1-min Apgar scores (8.8% vs. 8.7%, P = 0.984).

CONCLUSIONSCervical cerclage showed more benefits in the maternal and neonatal outcomes than vaginal progesterone therapy for women with an asymptomatic short cervix and prior PTB history, while cervical cerclage and vaginal progesterone therapies showed similar effectiveness for women with an asymptomatic short cervix but without a history of PTB.

Adult ; Cerclage, Cervical ; methods ; Female ; Gestational Age ; Humans ; Pregnancy ; Pregnancy Outcome ; Premature Birth ; prevention & control ; Progesterone ; administration & dosage ; therapeutic use ; Retrospective Studies ; Uterine Cervical Incompetence ; drug therapy ; prevention & control ; surgery ; Young Adult

A 38-year-old nulliparous woman was referred to our clinic because of cervical incompetence at 19 weeks of gestation. Trans-abdominal cervicoisthmic cerclage was performed after failure of modified Shirodkar cerclage operation in the patient at 21 weeks of gestation via a laparotomic approach. Another 38-year-old patient, who underwent loop electrosurgical excision procedure conization for treatment of cervical dysplasia 4 years ago, presented for cervical incompetence. At 18 weeks of gestation, we performed trans-abdominal laparotomic cervicoisthmic cerclage without any post-operative complications. During antenatal follow-up, there were no obstetrical co-morbidities and finally she gave birth to a healthy infant at full term by cesarean section. We report two cases of women who underwent trans-abdominal cervicoisthmic cerclage surgery because of cervical incompetence as they were not suitable for transvaginal cervical cerclage. Both patients successfully maintained their pregnancy until full term after undergoing transabdominal cervicoisthmic cerclage at more than 18 weeks of gestation.
Adult ; Cerclage, Cervical ; Cesarean Section ; Conization ; Female ; Follow-Up Studies ; Humans ; Infant ; Parturition ; Pregnancy* ; Uterine Cervical Incompetence

Cervical incompetence is characterized by painless dilatation of the incompetent cervix and results in miscarriages and preterm delivery during second trimester. We report a 25-year-old patient, gravid 2, para 1, at 11 weeks' gestation with the diagnosis of cervical incompetence, in whom transvaginal cerclage was not technically possible and laparoscopic cervical cerclage was performed successfully. There were no operative or immediate postoperative complications. A healthy infant was delivered at 35 weeks by cesarean section. Laparoscopic cervical cerclage during pregnancy can be safe and effective treatment for well-selected patients with cervical incompetence and eliminates the need for open laparotomy.
Abortion, Spontaneous ; Adult ; Cerclage, Cervical* ; Cesarean Section ; Diagnosis ; Dilatation ; Female ; Humans ; Infant ; Laparoscopy ; Laparotomy ; Postoperative Complications ; Pregnancy Trimester, Second ; Pregnancy* ; Uterine Cervical Incompetence

Emergency cerclage is the only way to prolong pregnancy for women with advanced cervical dilatation with or without prolapsed membrane. Without cerclage, miscarriage is almost always inevitable. Emergency cerclage should be performed after considering indications, contraindications, benefits and risks. Further researches on advanced operative skill, prognostic factors and postoperative medical treatment will improve the outcome of emergency cerclage.
Abortion, Spontaneous ; Emergencies* ; Female ; Humans ; Labor Stage, First ; Membranes ; Pregnancy ; Risk Assessment ; Uterine Cervical Incompetence

OBJECTIVES: The purpose of this study was to review the indications of transabdominal cervicoisthmic cerclage and clinical outcome to determine whether it is a valid alternative to transvaginal cerclage. METHODS: A retrospective review was carried out of transabdominal cerclage patients at our hospital from Jan. 1999 to Dec. 2004. Analysis of the indications for the transabdominal rather than the vaginal approach and evaluation of fetal outcomes was performed. RESULTS: 48 patients underwent transabdominal cerclage. The primary indication for transabdominal cervicoisthmic cerclage was failed transvaginal cerclage in 23 patients, the secondary indication was short cervix for transvaginal cerclage in 19 patients and cervical laceration in 6 patients. In 48 pregnancies, 8 twins were included. Therefore, total number of fetus was 56. One fetus of twin died in uterus at 27 weeks of gestation with unknown cause. 48 patients successfully delivered 55 live babies by Cesarean section. However, three babies died due to Tetralogy of Fallot, gastroschisis and preterm delivery. Complication including blood loss requiring transfusion did not occur. All patients had histories compatible with incompetent cervix requiring cerclage, and none were suitable candidates for vaginal cerclage. Live birth rate was 92% (52/56), compared with 28% salvage of pregnancies beyond the first trimester before the transabdominal cervicoisthmic cerclage procedure. CONCLUSIONS: Our results and review of literature confirm that with strict indications transabdominal cervicoisthmic cerclage offers a high rate of fetal salvage with minimum of complications in patients with extremely poor obstetric histories because of cervical incompetence.
Cervix Uteri ; Cesarean Section ; Female ; Fetus ; Gastroschisis ; Humans ; Lacerations ; Live Birth ; Pregnancy ; Pregnancy Trimester, First ; Retrospective Studies ; Tetralogy of Fallot ; Twins ; Uterine Cervical Incompetence ; Uterus

Treatment of incompetent cervix has traditionally been surgical correction of presumed physical deficit in tissue strength with an encircling or cerclage suture, placed electively between 12 and 15 weeks or urgently in the second trimester. Despite the prolonged controversy about the role of cerclage, a randomized trial of cerclage versus bed rest or no therapy in women with atypical history of incompetent cervix has not been concluded. Until conclusive information is available, clinicians challenged to make the best management decision or each patient based on her history and cervical examination. Women with either a typical history of recurrent midtrimester delivery in the absence of another diagnosis or with atypical history accompanied by significant cervical effacement should be offered treatment with cerclage accompanied by an acknowledgement that it's efficacy is unproven. A cerclage operation may be considered during pregnancy in four clinical setting which is elective cerclage, urgent cerclage, emergency cerclage, transabdominal cerclage.
Bed Rest ; Diagnosis ; Emergencies ; Female ; Humans ; Pregnancy ; Pregnancy Trimester, Second ; Sutures ; Uterine Cervical Incompetence

Backgrounds: It is estimated that 0.75-2% of parturients undergo surgical procedures unrelated to delivery. However, there are few reports on pregnant surgical patients in Korea. This study was undertaken to review the clinical information on patients who have received surgery during pregnancy. METHODS: Of the 11,772 deliveries during the 7-year period 1996-2002, 101 pregnant patients underwent nonobstetric surgery. The medical records and anesthesia records were reviwed for the following data: patient's age, trimester at operation performed, type of surgery and anesthesia, fetal monitoring, preterm labor, and for the delivery of pregnant women undergoing nonobstetrical surgery, except incompetent cervix. RESULTS: As many as 0.86% of pregnant women were found to have undergone surgery, the incidence of nonobstetric surgery, except incompetent cervix, was 0.43%. The 84.3% of patients underwent appendectomies. General anesthesia was administered to 68.6%, and regional anesthesia was administered to 31.4%. The ultrasonographies for fetal monitoring were performed in 96.1% of patients. Of the patients who received abdominal surgery during the second and third trimester, the incidence of preterm labor was 25.0%. There was no premature delivery. CONCLUSIONS: The incidence of nonobstetric surgery for reasons unrelated to pregnancy was 0.43%. Appendectomy was the most common surgical procedure. I recommend the use of uterine monitoring after abdominal surgery.
Anesthesia ; Anesthesia, Conduction ; Anesthesia, General ; Appendectomy ; Female ; Fetal Monitoring ; Humans ; Incidence ; Korea ; Medical Records ; Obstetric Labor, Premature ; Pregnancy ; Pregnancy Trimester, Third ; Pregnant Women ; Retrospective Studies* ; Uterine Cervical Incompetence ; Uterine Monitoring