RESUMO
OBJECTIVE: To characterize the use of cervical cerclage on a population basis. METHODS: This population-based study of U.S. natality records from 2005 to 2012 evaluated use of cerclage in singleton and multiple gestation live births. Obstetric, medical, and demographic characteristics were evaluated. A multivariable logistic regression model was developed to determine factors associated with cerclage. Sensitivity analyses were performed to evaluate cerclage placement in multiple gestations. RESULTS: A total of 21,312,920 pregnancies including 71,582 women who underwent cerclage were included in the analysis. The overall rate of cerclage ranged between 0.3% and 0.4% during the study period. Multiple gestation was a leading characteristic associated with cerclage with 0.3% of singleton pregnancies, 1.3% of twins, 7.9% of triplets, and 18.0% of higher-order pregnancies undergoing the procedure. Another leading characteristic associated with cerclage included prior preterm birth (2.4%). In multivariate regression analyses, these factors retained significance. Cerclage use based on specific risk factors did not change appreciably during the study period. CONCLUSION: Cerclage is a commonly performed obstetric procedure that was used in similar clinical scenarios over the course of the study period. Although research evidence is less supportive of cerclage use in particular high-risk groups such as multiple gestations, these findings have not been translated into clinical practice. These findings underscore the importance of society guidelines and other tools to encourage best clinical practices.
Assuntos
Cerclagem Cervical , Nascimento Prematuro , Incompetência do Colo do Útero/cirurgia , Adulto , Cerclagem Cervical/métodos , Cerclagem Cervical/estatística & dados numéricos , Cerclagem Cervical/tendências , Coleta de Dados , Demografia , Prática Clínica Baseada em Evidências/estatística & dados numéricos , Prática Clínica Baseada em Evidências/tendências , Feminino , Humanos , Paridade , Gravidez , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/etiologia , Nascimento Prematuro/prevenção & controle , História Reprodutiva , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
INTRODUCTION: The indications of placement of cerclage have recently changed, and so it is important to evaluate how many women are undergoing this procedure. With the recent completion of clinical trials, it is plausible that obstetricians and perinatologists may have become more selective in terms of the best candidates for cerclage. MATERIAL AND METHODS: We conducted a retrospective cohort study of women who underwent cerclage for prevention of preterm birth in the Division of Maternal and Fetal Medicine of Thomas Jefferson University Hospital (Philadelphia, USA) over a 16-year period, from 1998 to 2013. We included women with singleton gestations who had a history-indicated (HIC) or ultrasound-indicated cerclage (UIC). Physical examination-indicated cerclage and transabdominal cerclage were excluded. We planned to compare data before and after 2005. RESULTS: From 1998 to 2013, there were 33 353 deliveries, of which 16 871 occurred from 1998 to 2005 and 16 482 from 2006 to 2013. Of all deliveries, 328 women (1.0%) received HIC or UIC, and were therefore included in the analysis. Between 1998-2005 and 2006-2013 there were significant decreases in the overall rate of cerclage (1.4% to 0.6%; p < 0.001), as well as the rate of HIC (0.8% to 0.2%; p < 0.001) and UIC (0.6% to 0.3%; p < 0.001). CONCLUSIONS: During the last 16 years, the overall rate of HIC and UIC cerclage at Thomas Jefferson University Hospital significantly declined from 1.4% to 0.6%; significant decreases were seen for both HIC and UIC. The reason for the lower rate of cerclages may be the recently published evidence.
Assuntos
Cerclagem Cervical/tendências , Nascimento Prematuro/prevenção & controle , Adulto , Peso ao Nascer , Cerclagem Cervical/estatística & dados numéricos , Colo do Útero/diagnóstico por imagem , Estudos de Coortes , Feminino , Humanos , Recém-Nascido , Philadelphia/epidemiologia , Padrões de Prática Médica/tendências , Gravidez , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos , Ultrassonografia , Adulto JovemRESUMO
The preterm birth rate in the United States declined to 11.4% in 2013, the lowest level since 1997. Although the United States has one of the highest preterm birth rates in the developed world, we are improving this outcome and therefore improving the lives of thousands of infants. Demographic changes that may be responsible include a reduced teenage birth rate and fewer higher-order multiple births. Additionally, a public policy shift to prevent nonmedically indicated births at <39 weeks' gestation and smoking bans in several states have been associated with the reduced rate of preterm births. Last, interventions such as 17 hydroxyprogesterone caproate, vaginal progesterone, and the use of cerclage in selected populations probably are contributing to the reduction in preterm deliveries. However, a large portion of these births could still be prevented with greater access and implementation of our current interventions, the reduction of modifiable risk factors for preterm birth, and expanded reporting of outcomes and risk factors to facilitate research for both prevention and treatment.
Assuntos
Cerclagem Cervical/tendências , Gravidez na Adolescência/estatística & dados numéricos , Gravidez Múltipla/estatística & dados numéricos , Nascimento Prematuro/epidemiologia , Política Antifumo/tendências , Caproato de 17 alfa-Hidroxiprogesterona , Administração Intravaginal , Adolescente , Adulto , Medida do Comprimento Cervical , Medicina Baseada em Evidências/tendências , Feminino , Humanos , Hidroxiprogesteronas/uso terapêutico , Guias de Prática Clínica como Assunto , Gravidez , Nascimento Prematuro/prevenção & controle , Progesterona/uso terapêutico , Progestinas/uso terapêutico , Recidiva , Estados Unidos/epidemiologia , Adulto JovemRESUMO
A insuficiência cervical acomete cerca de 2,4 em cada 1.000 gestações. A cerclagem, procedimento proposto para tratamento da insuficiência cervical, foi descrita em 1955 e rapidamente adotada na prática médica antes que fossem realizados estudos sobre sua eficácia e segurança. A literatura atual sugere três indicações para a cerclagem: profilática, baseada na história de perdas anteriores; terapêutica, baseada no achado ultrassonográfico de colo curto; de emergência, baseada no achado de colo dilatado ao exame físico. Neste artigo, o autor faz uma revisão da literatura, utilizando os princípios da medicina baseada em evidência, sobre as indicações e técnicas contemporâneas da cerclagem.
Approximately 2.4 in 1.000 pregnancies are challenged by cervical insufficiency. Cervical cerclage was first described in 1955 and soon adopted as a routine obstetric practice, before safety and efficacy trials could be conducted. The current literature cites three indications for the cerclage: prophylactic, based on the patient history of prior pregnancy loss; therapeutic, based on finding of a short cervix in the ultrasound; emergency, based on finding of a dilated cervix in the physical exam. In this paper, the author reviews the literature, using evidence based medicine principles, to describe the contemporary indications and technical aspects of cervical cerclage.
Assuntos
Feminino , Gravidez , Aborto Habitual/etiologia , Cerclagem Cervical/métodos , Cerclagem Cervical/tendências , Cerclagem Cervical , Colo do Útero , Medicina Baseada em Evidências , Incompetência do Colo do Útero/diagnóstico , Incompetência do Colo do Útero , Trabalho de Parto Prematuro , Progesterona/uso terapêuticoRESUMO
Cervical incompetence causes repeated mid-trimester miscarriage and preterm delivery with high fetal wastage. Since the introduction of cervical cerclage in 1951, it has undergone many changes with regard to the techniques, indications and postoperative care. The objective of this study is to review the changing trends in the current indications of cervical cerclage and subsequent perinatal outcome at the maternity hospital from January 1992 to December 1999. All the files of women who had had cervical cerclage were evaluated in terms of characteristics of the women, indications and obstetric outcome after cervical cerclage. Of 65539 who delivered in the hospital, 1021 women had had cervical cerclage, giving an incidence of 1.21%. There was a significant increase in the incidence of cervical cerclage, from 1.13% in 1992 to 1.40% in 1999 (P < 0.01). More women with multiple pregnancy in 1996 - 99 had cerclage than in 1992 - 94 period [22.7 vs. 8.5% (P < 0.01)]. It is clear that more cervical sutures are being performed in multiple pregnancies arising from assisted reproductive technology as well as after ultrasonographic evidence of cervical dilatation. A multicentre randomised clinical trial is therefore advocated to evaluate its effectiveness in these cases.