Cervical cerclage application algorithm in continued cervical shortening cases despite vaginal progesterone.

OBJECTIVE: The aim of this study is evaluation of pregnancy outcomes of the asymptomatic cases with vaginal progesterone treatment for the 20-30 mm cervical length detected in the transvaginal ultrasonography for fetal abnormality screening and cervical cerclage after cervical length detected <20 mm in weekly cervical length measures; and present the treatment algorithm of progesterone treatment combined with cervical cerclage application. METHODS: Patients who have the inclusion criteria and cervical length more than 30 mm were categorized as group 1(n = 1948). Group 2 were included patients with cervical length shorter than 30 mm (n = 95). All patients of group 2 started to use vaginal natural progesterone 400 mg/day(n = 87). Pregnancies which progressed with cervical length above 20 mm were continued vaginal progesterone until 34. Gestational week and they were named as group 2A (n = 78). Cervical cerclage were applied to patients with cervical length below than 20 mm measured via transvaginal ultrasonography and they were categorized as group 2B (n = 9). RESULTS: Excluding 8 cases (8.42 %) which cervical cerclage were applied, 87 patients were administered vaginal progesterone and in 9 cases (10.34 %) cervical shortening were continued despite progesterone treatment. Four out of these nine cases (44.44 %) had cervical cerclage and their deliveries were delayed after 34 th gestational week. Vaginal progesterone treatment prevented cervical shortening in 89.66 % of patients who had cervical length between 20-30 mm and out of these patients. CONCLUSION: Cervical cerclage application algorithm in continued cervical shortening cases despite vaginal progesterone is beneficial to delay the delivery after 34 th gestational week and related to low complication rate.

The association between cervical inflammation and histologic evidence of HPV in PAP smears and adverse pregnancy outcome in low risk population.

OBJECTIVE: Recent studies suggest an association between Human Papilloma Virus (HPV) infection, cervical inflammation and obstetric complications (i.e. spontaneous preterm parturition and cervical insufficiency). It has been proposed that viral inflammation of the placenta causes changes in the mother's immune reaction to bacterial pathogens, which leads to enhanced inflammatory reaction and preterm delivery. Therefore, the aim of this population-based study was to determine the association between abnormal cervical cytology prior to pregnancy and obstetric outcomes. STUDY DESIGN: A Retrospective population-based cohort study was designed, including all women who had a Pap smear up to two years prior to delivery or during first trimester of pregnancy (n = 15,357). Women were divided into the following groups, according to Pap smear results: group 1 - Normal PAP smear (n = 11,261); group 2 - Pap smear with evidence of an inflammatory process (n = 3895); and group 3 - Pap smear with evidence of HPV infection (n = 201). Obstetrical outcomes, gestational age at delivery, and pregnancy complications were compared among the groups. RESULTS: The rate of HPV infection in our study population was 1.3%. The rate of preterm delivery (group 1 - 8.5%, group 2 - 8.5%, group 3 - 7%, p = 0.7), preterm PROM (group 1 - 1.7%, group 2-1.6%, group 3 - 2%, p = 0.66) and cervical insufficiency (group 1 - 0.5%, group 2 - 0.7%, group 3 - 1.5%, p = 0.11) did not differ significantly among the study groups. There was no statistical difference in the rate of premature rapture of membranes, newborn small-for-gestational-age, preeclampsia or placental abruption. Women with abnormal cervical cytology, either due to inflammation or HPV infection, had similar obstetric outcome in comparison to those with a normal cervical cytology. CONCLUSION: This population-based retrospective cohort study indicates no association between positive HPV testing with Pap smear and obstetric complications such as preterm delivery, cervical insufficiency, placental abruption, PROM, Preterm PROM, neonatal SGA and preeclampsia, in a population with low prevalence HPV infection.

Cervical length after cerclage: comparison between laparoscopic and vaginal approach.

PURPOSE: The aim of our study was to investigate the sonographic changes of the cervical length during pregnancy after the placement of a transvaginal cervical cerclage (TVC) or a laparoscopic abdominal cerclage (LAC) in patients with cervical insufficiency (CI). METHODS: Between January 2008 and March 2015, a retrospective analysis of all women undergoing a prophylactic laparoscopic (LAC group) or transvaginal (TVC group) cerclage due to cervical insufficiency was conducted. Nonparametric variables were analysed with the Mann-Whitney (U) test, and categorical-type outcomes were analysed with the Fisher's exact test. A p value <0.05 was considered as significant. Data analysis was performed using Prism 5 for Mac OS X. RESULTS: Thirty-eight patients were included. Of these, 18 and 20 underwent an LAC and a TVC, respectively. Mean gestational age at surgery in the LAC and TVC groups was 11.4 ± 1.6 and 17 ± 3 weeks, respectively (p < 0.05). The cervical length prior to surgery was similar among the two groups. After cerclage placement, the distance between the tape and the external cervical os differed significantly between the two groups (LAC: 31.5 ± 8.8 mm vs TVC: 13.5 ± 4.9 mm; p < 0.0001) (Fig. 1). During pregnancy, the cervical length in the TVC group showed a significant shortening (from 26.6 ± 7 mm before surgery to 13.2 ± 7 mm at 33 weeks; p < 0.0001), while in the LAC group, the cervical length remained unchanged. CONCLUSIONS: In patients with CI, LAC is associated with a better preservation of the cervical length throughout pregnancy as compared to TVC.

Amniotic fluid sludge as a marker of intra-amniotic infection and histological chorioamnionitis in cervical insufficiency: a report of four cases and literature review.

Amniotic fluid sludge (AFS) is defined as the presence of particulate matter in the amniotic fluid in close proximity to the cervix. Although its prevalence is known to correlate with the risk of preterm delivery, initial reports describe a strong association between AFS and microbial invasion of the amniotic cavity (MIAC) and histological chorioamnionitis. However, AFS is also present in uncomplicated pregnancies, and its prevalence appears to increase with gestational age. Recent evidence debates the usefulness of AFS as a marker of early preterm delivery risk. We present four cases with AFS diagnosed by transvaginal ultrasound at admission for cervical insufficiency between 20 and 24 weeks of gestation, with confirmed lower genital tract and intra-amniotic infections by amniocentesis and histological chorioamnionitis and funisitis. Our findings reinforce the presence of AFS as a useful marker of MIAC, chorioamnionitis and funisitis that increase the likelihood of preterm delivery at an extreme gestational age.

Needleless laparoscopic abdominal cerclage placement.

STUDY OBJECTIVE: To show a technique of laparoscopic interval abdominal cerclage placement with the use of a needleless mersilene tape. DESIGN: Step-by-step explanation of the technique using a surgical video. SETTING: Cervical insufficiency affects 1% of all pregnancies and up to 8% of those with second and early third trimester losses. The abdominal method has been used in patients with an extremely short cervix in whom the transvaginal approach is not technically possible or for those who have experienced an unsuccessful transvaginal procedure. With the introduction of the transabdominal cerclage, the fetal survival rate improved from 21% to 89%. In an attempt to decrease the surgical morbidity associated with laparotomy, there have been multiple case series and cohort studies in the literature that described the laparoscopic approach for transabdominal cerclage placement. INTERVENTIONS: Laparoscopic abdominal cerclage placement was performed as an interval procedure using needleless mersilene tape after meticulous skeletonization of the uterine vessels and formation of the peritoneal window. CONCLUSION: Laparoscopic abdominal cerclage was placed without any complications, providing the patient with the benefits of minimally invasive approach. The risk of bleeding was reduced by meticulous dissection and skeletonization of uterine vessels and eliminating the use of the mersilene tape needle.

Effect of 17-alpha hydroxyprogesterone caproate on cervical length in twin pregnancies.

OBJECTIVES: Previous studies on singleton pregnancies have indicated that progestogens may reduce the rate of cervical shortening during pregnancy. The aim of this study was to investigate whether treatment with 17-alpha hydroxyprogesterone caproate (17-OHPC) has an effect on cervical shortening in twin pregnancies. METHODS: This was a secondary analysis of patients who had participated in a multicenter randomized clinical trial on the effectiveness of 17-OHPC in preventing preterm birth in multiple pregnancies (the AMPHIA-trial). We included all trial participants with a twin gestation who had undergone repeat cervical length measurements during pregnancy. We performed a separate analysis of women with repeat measurements in centers where this was standard protocol for multiple pregnancies. The rate of cervical shortening for both the 17-OHPC group and the placebo group was analyzed using a linear mixed model. RESULTS: Of the 671 patients who participated in the trial, 282 (42%) had a twin pregnancy and underwent two or more cervical length measurements. Of these women, 140 were monitored in centers where repeat measurements were standard protocol. We observed an overall reduction of cervical length from 44.3 mm at 14-18 weeks to 30.0 mm at 30-34 weeks' gestation. In the 17-OHPC group, cervical length decreased by 1.04 mm each gestational week, while this was 1.11 mm per week for the placebo group (P = 0.6). For the overall group, each 10% decrease in cervical length led to an increase in the risk of preterm birth (hazard ratio, 1.14; 95% CI, 1.08-1.21). CONCLUSION: In women with a twin pregnancy, there is progressive shortening of the cervix during pregnancy, regardless of 17-OHPC use.

Cervical funneling after cerclage in cervical incompetence as a predictor of pregnancy outcome.

OBJECTIVES: To evaluate whether cervical funneling influences pregnancy outcome in women with short cervical length (CL) after cerclage, and to identify funneling parameters associated with pregnancy outcome. METHODS: Medical records of women identified to have a short CL with or without funneling after cerclage were reviewed. Women with short CL as well as funneling were defined as cases (Funneling group), and those with short CL but no funneling were the controls (No Funneling group). We compared perinatal outcome between the two groups and analyzed the relationships between funneling parameters and pregnancy outcome. RESULTS: Seventy-two patients were included in this study; 39 women with short CL and funneling and 33 with short CL and no funneling. The mean gestational age at delivery of the Funneling group was 33.7 weeks, as compared to 36.5 weeks for the NoFunneling group (p < 0.001). We found a significant inverse association of funneling depth as well as volume with pregnancy outcome (p < 0.001, and p = 0.005, respectively). However, funneling width was not associated with pregnancy outcome (p = 0.49). CONCLUSIONS: Funneling depth and volume may be useful predictors of pregnancy outcome after cerclage.

Cervical collagen and biomechanical strength in non-pregnant women with a history of cervical insufficiency.

BACKGROUND: It has been suggested that cervical insufficiency (CI) is characterized by a "muscular cervix" with low collagen and high smooth muscle concentrations also in the non-pregnant state. Therefore, the aim of this study was to investigate the biomechanical properties, collagen concentration, smooth muscle cell density, and collagen fiber orientation in cervical biopsies from non-pregnant women with a history of CI. METHODS: Cervical punch biopsies (2 x 15 mm) were obtained from 57 normal non-pregnant women and 22 women with a history of CI. Biomechanical tensile testing was performed, and collagen content was determined by hydroxyproline quantification. Histomorphometry was used to determine the volume densities of extracellular matrix and smooth muscle cells from the distal to the proximal part of each sample. Smooth muscle cells were identified using immunohistochemistry. Finally, collagen fiber orientation was investigated. Data are given as mean +/- SD. RESULTS: Collagen concentration was lower in the CI group (58.6 +/- 8.8%) compared with the control group (62.2 +/- 6.6%) (p = 0.033). However, when data were adjusted for age and parity, no difference in collagen concentration was found between the two groups. Maximum load of the specimens did not differ between the groups (p = 0.78). The tensile strength of cervical collagen, i.e. maximum load normalized per unit collagen (mg of collagen per mm of specimen length), was increased in the CI group compared with controls (p = 0.033). No differences in the volume density of extracellular matrix or smooth muscle cells were found between the two groups. Fibers not oriented in the plane of sectioning were increased in CI patients compared with controls. CONCLUSIONS: Cervical insufficiency does not appear to be associated with a constitutionally low collagen concentration or collagen of inferior mechanical quality. Furthermore, the hypothesis that a "muscular cervix" with an abundance of smooth muscle cells contributes to the development of cervical insufficiency is not supported by the present study.

Cerclaje cervicouterino transabdominal en el embarazo: a propósito de 3 casos / Transabdominal cervicouterine cerclage in pregnancy: a report of 3 cases

Evaluar la técnica de cerclaje cervicouterino transabdominal durante la gestación. Estudio prospectivo, donde se seleccionaron 3 pacientes embarazadas, que cumplían los criterios de inclusión a las cuales se les realizó la técnica de cerclaje cervicouterino transabdominal entre las 14 y 17 semanas de gestación. Maternidad “Concepción Palacios”. En los 3 casos realizados se presentó una efectividad del método del 100 por ciento, lo cual es comparable con la experiencia internacional. El cerclaje cervicouterino transabdominal es una técnica reservada para pacientes bien seleccionadas que cumplan las indicaciones para su realización. Tiene buen resultado perinatal con baja incidencia de complicaciones durante su realización y durante el curso de la gestación

To evaluate the transabdominal cervicouterine cerclage technique during gestation. Prospective study of 3 pregnant patients that met the inclusion criteria to whom a transabdominal cervico-uterine cerclage technique was performed between 14 to 17 weeks of gestation. Maternidad “Concepcion Palacios”. In the 3 cases the method effectivity was 100 percent, comparable with the international experience. The transabdominal cervicouterine celclage is a technique reserved for selected patients that met the indications for its realization. It has a good perinatal result with low incidence of complications during the procedure and in the course of gestation

Laparoscopic transabdominal cervico-isthmic cerclage: a minimally invasive approach.

BACKGROUND: While the traditional approach to management of cervical insufficiency has been the insertion of a transvaginal cerclage during pregnancy, a transabdominal cervico-isthmic suture is indicated in certain patients. This procedure is traditionally performed via laparotomy. Laparoscopic transabdominal cervico-isthmic cerclage (LTCC) placement, however, confers the benefit of the low morbidity associated with laparoscopy. AIMS: To describe the technique and outcomes of LTCC in three cases. METHODS: LTCC was performed using Mersilene tape at the level of the internal cervical os in the prepregnancy period in three patients: one with previous cervical amputation and two with previous failed cervical cerclage. Procedures were performed at a tertiary level endoscopic unit, Sydney, Australia. RESULTS: The laparoscopic approach enabled placement of a suture with no morbidity, and rapid patient recovery in these cases. CONCLUSIONS: Laparoscopic cervical cerclage proved technically feasible and safe for a surgeon trained in laparoscopic suturing methods.

Da Vinci-assisted abdominal cerclage.

OBJECTIVE: To report the first placement of an abdominal cervicoisthmic cerclage using the da Vinci robot. DESIGN: Case report. SETTING: Tertiary-care hospital. PATIENT(S): A 39-year-old female with a history of cervical insufficiency who required a cerclage and was not a candidate for transvaginal cerclage placement. INTERVENTION(S): Abdominal cervicoisthmic cerclage placement using the da Vinci robot. MAIN OUTCOME MEASURE(S): Ability to safely and successfully place an abdominal cerclage using the da Vinci robot. RESULT(S): Abdominal cerclage was successfully placed using the da Vinci robot. The patient had minimal blood loss and was discharged to home on the same day as surgery. CONCLUSION(S): Da Vinci robot-assisted abdominal cerclage placement is an innovative application of robotic surgery and may alter the standard of care for women who require this surgery.

A novel method for laparoscopic abdominal cerclage utilizing minimally invasive hydrodissection: a case report.

BACKGROUND: Cervical incompetence can lead to the inability to sustain an intrauterine pregnancy and may account for a substantial portion of second-trimester losses. Placement of a transvaginal cerclage has been shown to decrease morbidity in a substantial number of such cases. In patients lacking sufficient cervical tissue, a cerclage may be placed by a transabdominal approach. This procedure carries risks of significant morbidity to the maternal-fetal unit if done by laparotomy. CASE: A 22-year-old gravida at 13 weeks' gestation with a past history significant for cervical incompetence and absence of cervical tissue underwent placement of an abdominal cerclage. We utilized laparoscopic operative techniques and employed hydrodissection to decrease manipulation and bleeding around the gravid uterus. CONCLUSION: A laparoscopic approach to cerclage in patients diagnosed with cervical incompetence can be performed with minimal risks to the gravid uterus.

Anatomic factors in recurrent pregnancy loss.

Anatomic uterine defects are present in 15% of women evaluated for three or more consecutive spontaneous abortions. These anatomic abnormalities can be classified as congenital or acquired. In addition to pregnancy loss, uterine malformations appear to predispose women to other reproductive difficulties including infertility, preterm labor, and abnormal presentation. These poor reproductive outcomes resulting from uterine septum, intrauterine adhesions, polyps, and fibroids are amenable to surgical correction. Therefore, it is essential to make an accurate diagnosis to offer an adequate treatment. In this article, we review the common congenital and acquired uterine anomalies associated with recurrent pregnancy losses, and discuss contemporary diagnosis and treatment options.

Can shortened midtrimester cervical length predict very early spontaneous preterm birth?

OBJECTIVE: The study was undertaken to test the hypothesis that shortened midtrimester cervical length is more predictive of early (<26 weeks) than later (26-34 weeks) spontaneous preterm birth. STUDY DESIGN: This is a secondary analysis of a blinded, multicenter observational study of 183 women with a prior preterm birth. Vaginal sonography was begun at 16 to18 weeks' gestation and scheduled every 2 weeks (maximum 4 scans per patient). Cervical length and any observed dynamic shortening were recorded at each visit to determine the shortest observed cervical length from 16 to 24 weeks' gestation. The shortest cervical length measurements were categorized as less than 25 mm, 25 to 29 mm and 30 mm or greater. The initial cervical length was also compared with the shortest cervical length to categorize patients on the basis of the timing of cervical shortening 30 mm or less. Contingency table, linear regression, and survival analysis were used to analyze the relationship between cervical length groups and spontaneous preterm birth. RESULTS: In both the less than 25 mm and 25 to 29 mm groups, the incidence of spontaneous midtrimester birth (<26 weeks) was higher than the incidence of later (26-34 weeks) preterm birth (<25 mm group: 37% vs 19%; 25-29 mm group: 16% vs 3%, respectively) as compared with women with a shortest cervical length 30 mm or greater, who had rates of 1% and 9% respectively (P <.0001). Similarly, women who had an initial cervical length 30 mm or less and those who shortened their cervix to 30 mm or less before 22 weeks were also more likely to experience a midtrimester than later preterm birth, whereas women who shortened their cervix 30 mm or less later (22-24 weeks) or who maintained a cervical length greater than 30 mm had lower rates of midtrimester than later preterm birth (P <.0001). CONCLUSION: Shortened cervical length in the midtrimester preferentially predicts early, as opposed to later, spontaneous preterm birth in high-risk women.

Cervical length evaluation by transvaginal sonography in nongravid women with a history of preterm delivery.

OBJECTIVE: To evaluate cervical length in the nongravid period in women with a past history of preterm delivery. METHODS: The study population comprised 54 women who had delivered spontaneously before 34 weeks of gestation. Etiology of preterm delivery was suspected to be related to cervical incompetence, defined as a painless and progressive dilatation of the cervix in the absence of other causes. Patients with pre-eclampsia, intrauterine growth restriction, uterine anomalies, fetal anomalies, multiple gestation and similar complications were excluded. Shortening of the cervix was recorded during pregnancy in all study patients. One hundred and four women matched for age, parity and body mass index who had given birth at term served as the control group. Cervical length was evaluated in all women at least 12 weeks after delivery by transvaginal sonography in the mid-sagittal plane. RESULTS: The mean gestational age at delivery was 30.8 +/- 1.2 weeks in the study group and 38.8 +/- 2.1 weeks in the control group (P = 0.03). The mean cervical length in the two groups was 36 +/- 6 and 38 +/- 4 mm, respectively. This difference was not statistically significant (P = 0.9). CONCLUSIONS: In nongravid women with unexplained preterm delivery there is no difference in cervical length compared to patients who deliver at term. Shortening of the cervix is most probably a reversible phenomenon that occurs during pregnancy and represents a failure of the competence mechanism to adapt to pregnancy.

Factors associated with success of emergent second-trimester cerclage.

OBJECTIVE: To assess the factors associated with delivery greater than or equal to 28 weeks' gestation after placement of an emergent cerclage in women with singleton gestations. METHODS: All women who underwent emergent cerclage, defined as any cerclage placed between 16 and 24 6/7 weeks' gestation in response to documented cervical change on physical examination, at Northwestern Memorial Hospital from 1980 to 2000 were identified. Univariable and multivariable analyses were used to determine the factors most associated with achieving at least 28 weeks' gestation. RESULTS: One hundred sixteen women were eligible for analysis. Maternal age, race, and operative variables such as suture type and use of antibiotics were not associated with differences in the frequency of delivery at or after 28 weeks. Cerclage placement at or after 22 weeks' gestation increased the likelihood of reaching 28 weeks, whereas several cervical examination findings (dilatation greater than 3 cm, cervical length less than 0.5 cm, and membranes prolapsing beyond the external cervical os) as well as need for placement in a nullipara significantly reduced the likelihood of reaching 28 weeks. In multivariable analysis, nulliparity (odds ratio 0.31, 95% confidence interval 0.1, 0.8) and membranes prolapsing beyond the external cervical os (odds ratio 0.24, 95% confidence interval 0.1, 0.4) continued to be associated with delivery before 28 weeks, whereas cerclage placement at or after 22 weeks (odds ratio 3.2, 95% confidence interval 1.2, 8.6) increased the chance of achieving at least 28 weeks' gestation. CONCLUSION: Nulliparity, the presence of membranes prolapsing beyond the external cervical os, and gestational age less than 22 weeks at cerclage placement are associated with decreased chance of delivery at or after 28 weeks after emergent cerclage; these factors may be used to help counsel patients considering the procedure.

Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): effect of therapeutic cerclage with bed rest vs. bed rest only on cervical length.

OBJECTIVE: To compare the effects of therapeutic cerclage and bed rest vs. just bed rest on cervical length and to relate these effects to the risk of preterm delivery. DESIGN: Cervical length was measured in patients at high risk of cervical incompetence. When a cervical length < 25 mm was measured before 27 weeks' gestation, randomization for therapeutic cerclage and bed rest vs. just bed rest was performed. After randomization, cervical length was measured weekly. For statistical analysis, t-test and Fisher's exact tests were used and P < 0.05 was considered statistically significant. RESULTS: Nineteen women were randomly allocated to receive a therapeutic cerclage and bed rest and 16 were allocated to receive bed rest only. Mean cervical lengths and mean gestational ages before randomization were comparable between both groups, overall 19.8 mm and 20.7 weeks. Cervical length was measured again at a mean gestation of 22.1 weeks. Mean cervical length (31 mm) was significantly (P < 0.0001) longer after cerclage than after bed rest only (19 mm). A cervical length > or = 25 mm was measured in 22 of the 35 included women, 16 in the cerclage group and six in the bed-rest group (P = 0.006). Of these 22 women, only one delivered before 34 weeks' gestation, which was significantly less frequent than six out of 13 women with a cervical length < 25 mm (P = 0.006). CONCLUSIONS: Therapeutic cerclage with bed rest increases cervical length more often than bed rest alone. A postintervention cervical length > or = 25 mm reduces the risk of preterm delivery in women at high risk of cervical incompetence and a preintervention cervical length < 25 mm.

Continuous low-dose antibiotics and cerclage for recurrent second-trimester pregnancy loss.

OBJECTIVE: To evaluate the role of continuous low-dose antibiotics in the prolongation of pregnancy in women at risk for recurrent second-trimester loss. METHODS: Only patients with a history of previous recurrent second-trimester losses associated with failed cervical cerclages were prospectively included in the study. Patients received low-dose antibiotics until delivery. Cerclage was performed at 14-24 weeks' gestation on the basis of transvaginal sonographic findings of cervical funneling. Outcome was evaluated by weeks of pregnancy gained in the current pregnancy as compared to the previous pregnancy. RESULTS: Ten patients were eligible for study after exclusions. All 10 achieved fetal viability. Pregnancy was prolonged by a mean of 13.4 +/- 4.2 weeks beyond the previous pregnancy. This was highly statistically significant (P < .001). CONCLUSION: Continuous low-dose antibiotics prolonged pregnancy in patients with recurrent second-trimester pregnancy losses and prior failed cerclage. Randomized clinical trials are needed to confirm the role of antibiotics in these high-risk pregnancies.

Emergency cerclage in the presence of protruding membranes: is pregnancy outcome predictable?

BACKGROUND: The aim of this retrospective study is to verify whether some maternal features are related to pregnancy outcome in cases of emergency mid-trimester cerclage when membranes are protruding through the dilated cervix. METHODS: Between 1988 and 1996 twenty-three pregnant patients with dilated cervix and protruding membranes were treated with emergency cerclage. At the time of cerclage, gestational age ranged from 17 to 27 weeks (median 22). RESULTS: Pregnancy was prolonged from 0 to 20 weeks (median 4). Eleven living infants were born (46%); median gestational age at delivery was 25 weeks (range 21-39) and median birth weight 700 g (range 350-3980 g). Obstetric histories, white blood cell count, and vaginal-cervical and urine cultures obtained on admission were analyzed in the two following groups: data from patients with good pregnancy outcome (live births) versus those from patients with poor outcome (stillbirths and neonatal deaths). No significant difference was found between the groups for the above mentioned maternal features. CONCLUSIONS: The possibility of 46% live births is considered a good result for mid-trimester emergency cerclage when the membranes are protruding. Success of the procedure remains unpredictable on the basis of the maternal features investigated.