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Contribution of Cervical Plasty in the Management of Cervico-Isthmic Incompetency at the General Hospital of Lamentin in Martinique
Abstract
Objectives: To evaluate the influence of pre-conception cervical plastic surgery on the prognosis of pregnancy in women with a history of abortive disease through cervical incompetence.
Method: Retrospective study over a period of 20 years, from January 1990 to June 2010. We carried out an exhaustive census of the patients with a cervico isthmic gap, who benefited of a pre-pregnancy cervical plasty associated with a systematic cervical cerclage carried out in the first trimester of pregnancy.
Results: We identified 10 files that met the inclusion and non-inclusion criteria. The mean age of the patients was 33.8 years. They were multigravida (extremes 2 and 10) and pauciparous (mean parity was low of 1.29). The history of recurrent spontaneous miscarriage was found in all women. The diagnosis of cervico isthmic gap was evoked on the basis of clinical and paraclinical arguments. Seven women got pregnant for a total of nine pregnancies. All pregnancies have reached the age of viability which was 24SA. The prematurity rate was 4/9 pregnancies and the average gestational age for preterm delivery was 31 SA. Five pregnancies evolved to term and the average term for childbirth was 38 SA+6 days.
Conclusion: Pre-pregnancy cervical plasty associated with cervical cerclage in the first trimester of pregnancy has yielded interesting results in the prevention of preterm delivery in patients with cervico-isthmic gap. A study on a larger sample is necessary to draw conclusions.
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To assess the efficacy of performing transvaginal cervicoisthmic cerclage (CIC) using synthetic tape in prevention of preterm labor in high-risk women.
A retro and prospective analysis of 23 transvaginal cerclages using polypropylene tape performed in women presenting with high risk of preterm delivery: prior histories of two or more losses in the second trimester and/or prior failure of Hervet or Mac Donald's cerclage. Cerclage was at 14 weeks of gestation. A polypropylene tape was placed at the cervicoisthmic junction by vaginal route.
The median age of the patients in this series was 33.2 years (range 25-41 years). No intra-operative complication occurred. The median operating time was 36.9 minutes (±4.1) (range 30-45 min). Cesarean delivery was systematically performed in all patients since the cerclage was considered to be definitive. Term birth rate was 57.5% (3% before CIC; p<0.0001). Pregnancy loss in the second trimester was 7.8% (66% before CIC; p<0.0001). Preterm birth rate was 23.1% (31% before CIC). Birth at less than 28 weeks occurred in only 1patients (3.7%) (10.7% before CIC). In one case, the tape has been removed later because of secondary displacement. Amniotic fluid infection occurred in 4 cases (5%). Living birth rate was 80.7% (21% before CIC) and no neonatal death occurred (13% before CIC).
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.
A total of 506 women at moderate risk of preterm delivery were randomly allocated to either cervical cerclage or a control group. Significantly more women in the group allocated to cerclage were admitted to hospital for reasons other than the operation and more received oral toco-lytic drugs. There were also more caesarean sections and more preterm deliveries in the women allocated to cerclage although the differences between the two groups were small and not statistically significant.
The transabdominal cervico-isthmic cerclage could to be proposed in case of failure of vaginal cerclage, 2nd trimester fetal losses and cervical defects. The efficiency of the laparoscopic approach, more recently described, has to be demonstrated for the prevention of obstetrical accident.
This study is a retrospective monocentric evaluation of 14 laparoscopic cervico-isthmic cerclages performed with Benson modified technique before pregnancy between 2005 and 2007. Previous obstetrical accidents, etiology of cervical incompetence and patient outcome after cerclage were compared.
Median age of the patients was 33.5 years; 93% had previous fetal losses or preterm delivery and 42.9% had failure of Mac Donald cerclages. The indication of laparoscopic cervico-isthmic cerclage was Mac Donald cerclage failure (six cases), and eight cases of anatomic incompatibility of Mac Donald cerclage. Mean duration of laparoscopic cervico-isthmic cerclage was 45 minutes. All patients were hospitalized on an outpatient basis. No operative complication was reported. Six women were pregnant after cerclage: five deliveries by caesarean section at term, and one first trimester foetal loss.
The cervico-isthmic cerclage can be easily performed by laparoscopy. The indications are strictly the same as cervico-isthmic cerclages by laparotomy. Increasing the number of term deliveries and the obstetrical outcome of these patients, the efficiency of the cervico-isthmic cerclage by laparoscopy is demonstrated.
The effect of cervical suture on pregnancy outcome was studied in 194 women with a high risk (approximately 30%) of having a late abortion or a preterm delivery. The women were randomly allocated either to have a cervical suture inserted (n = 96) or to be managed without a suture (n = 98). There was no evidence that cervical cerclage either prolonged gestation or improved survival. Patients allocated to receive cerclage spent significantly longer in hospital, even when the period of admission for insertion was excluded. The patients in the cerclage group were more likely to receive tocolytic drugs, and more of them experienced puerperal pyrexia, although these differences between the groups were not statistically significant.
The indications for a transabdominal approach for cervicoisthmic cerclage (TCIC) included traumatic laceration, congenital or surgical shortening of the cervix, previously failed transvaginal cerclage, and advanced cervical effacement with intact membranes. The frequency of all cerclage procedures was 1 in 260 deliveries; one TCIC was performed for each six vaginal procedures in the period from 1966 to 1980. A 0.5-cm Mersilene band was applied at the level of the anatomical internal os in an avascular space between branches of the uterine artery. Prior to this operation, the 16 patients had had 55 pregnancies (excluding first-trimester abortions) and had experienced 42 fetal losses (24% salvage rate). After TCIC, 22 pregnancies in 16 patients resulted in 19 term births, two premature births with favorable outcomes, and one fetal loss (95% salvage rate; chi 2 = 46.5, P less than 0.001). All infants were delivered by cesarean section. Postoperative morbidity and the incidence of premature labor or rupture of the membranes were low. Transabdominal cerclage is effective in selected patients with poor obstetric histories that show anatomically defective cervices, or when marked effacement has precluded high vaginal placement of the cerclage.
This study was undertaken to review pregnancy course and outcome in 56 pregnancies after the placement of a cervicoisthmic cerclage transvaginally.
Fifty-three pregnant patients with unique indications such as previous failure of conventional cerclages or compromised cervical anatomy, underwent transvaginal placement of a cervicoisthmic cerclage during pregnancy.
There was 100% fetal survival. Preterm birth rate was 32% and births at less than 30 weeks occurred in 21% of our patients. In 6 patients, the suture was not removed and 3 patients had an additional gestation with the same suture. Serious complications included 1 instance of intraoperative bladder laceration and 1 of intrapartum cervical tear. Minor complications included a postoperative hematoma and transient urinary retention with pelvic pain in 2 patients.
The placement of transvaginal cervicoisthmic cerclage was associated with favorable pregnancy outcome and may be considered as a suitable safe alternative to the transabdominal cerclage.
To assess the efficacy of performing transvaginal cervico-isthmic cerclage using synthetic tape in prevention of preterm labor in high-risk women.
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.
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.
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.