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.

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.

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.

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.

Modifications to the modified Shirodkar operation.

In cases of cervical incompetence, the Shirodkar procedure is occasionally necessary when the McDonald procedure cannot be used due to poor cervical anatomic conditions. We have further facilitated a modified Shirodkar procedure with some modifications. A transverse incision over the anterior lip of the cervix is made and the bladder is separated from the cervix. One end of an atraumatic forceps is introduced deeply into the space between the bladder and the cervix, and the other end is pushed against the posterior fornix to grasp paracervical tissues, so that a needle is easily passed through at the tip of the forceps. The knot is placed anteriorly and a silk thread is passed around the tape in the posterior fornix to facilitate removal of the tape. This procedure resulted in no complications and greatly facilitated removal of the tape, resulting in a cervical cerclage which was comparatively easily carried out.

Incompetencia cervical: diagnóstico y tratamiento

La incompetencia cervical es una causa relativamente poco frecuente de pérdida gestacional, que se considera se ha sobrediagnósticado, más sin embargo es una importante razón para aborto repetido en el segundo trimestre de la gestación. El diagnóstico debe sustentarse en los antecedentes obstétricos y tratar de evidenciar su existencia de forma preconcepcional para simultáneamente descartar otras causas de pérdidas repetidas. Alcanzada la gestación y de forma temprana debe realizarse cerclaje cervical, utilizando técnica de Shirodkar o McDonald, que se presentan iguales ratas de supervivencia fetal e iguales ratas de complicaciones. En nuestra experiencia hemos tenido buenos resultados con Técnica de McDonald y seda en forma de trenza, como material de sutura, pasando la rata de supervivencia fetal del 10 por ciento pre-cerclaje al 88 por ciento post-cerclaje. En aquellos pacientes en que no se pueden realizar cerclaje cervical, se recomienda cerclaje cérvico-istmico vía abdominal

Prenatal care, screening, and complications.

Articles are reviewed that give the clinician new guidelines to diagnose neural tube defects without using amniocentesis. Cervical measurement using ultrasound as a tool to objectively evaluate and follow patients at risk for premature labor and incompetent cervix are reviewed. The utility of transabdominal versus transvaginal ultrasound is discussed. Two papers are presented that look at the use of aspirin in preeclampsia. One study looks at metabolic degradation of the prostaglandins associated with pregnancy-induced hypertension and shows that there is a heterogeneity in response to aspirin therapy. However, once the patient has pregnancy-induced hypertension, aspirin does not seem to be effective. A paper is presented that looks at the safety of autologous blood donation for both the mother and the baby and confirms its usefulness in obstetrics as in the nonpregnant patient.

[Experience with 1000 cases of conization of the uterine cervix]. / 1000 portio konizáció tapasztalatai.

Authors made a follow-up study of 1000 portio conisations. They analysed the early and late postoperative complications with special regard to the further obstetrical outcome. They valued the previous cytologic and colposcopic examinations on the basis of histologic diagnosis. It has been found that complications were neither frequent nor serious and had no unfavourable influence on further pregnancies. They found a higher ratio both of false positive and negative cytologic and colposcopic results then it is given by the literature. Authors come to the conclusion, that even in cases of anatomical portio alterations it's necessary the detailed histologic examinations, that for the portio conisation is a preferable method.

Dynamic incompetent cervix uteri. Sonographic observations.

In 15 of 56 patients with incompetent cervix, rapid changes in the degree of dilatation of the cervical canal were observed during sonographic examination, with the same degree of bladder distension. In ten of those 15 patients, the canal was seen to be completely closed at some point during the examination. Because of these rapid dynamic changes in the dilatation of the cervical canal, it is necessary to observe the cervical portion of the uterus several times during the sonographic examination, especially in patients suspected to have incompetent cervix. It is possible for the cervical canal to remain closed for several minutes during the examination. Incompetent cervix can go undetected if the cervix is not observed frequently throughout the sonographic examination.

[Transvaginal echography. An application in the diagnosis of cervical incompetence]. / L'échographie transvaginale. Un apport dans le diagnostic de la béance du col utérin.

It has already been demonstrated that abdominal ultrasound is an adequate method for measuring the cervix in pregnancy. The use of the vaginal route for such measurement is new. We have been using for the vaginal approach an ultrasound transducer of 5 mHZ with an angle of sweep of 240 degrees. The study was carried out on 23 pregnant women at the 28th week of pregnancy who had been admitted because of threatened premature labour with possible cervical incompetence; and on 20 cases of normal pregnancy also at the 28th week, which is the time when we do glucose estimations normally in our antenatal clinics. The result of our work shows that this ultrasonic method through the vagina gives us much more accurate measurements of the cervix than digital vaginal examination does. A mean difference of 12.3 mm in the length of the cervix was found in normal pregnancies (46.3 mm) and in cases where there was a question of cervical incompetence (34 mm). Furthermore the phenomena of shortening, dilatation of the cervix and a funnel-shape of the internal os are ultrasound signs of value in diagnosing incompetent cervix. Further advantages of the transvaginal approach are that there is no need for the bladder to be filled previously, and that the organs are nearer which improves the ultrasound picture. All the same, it is to be emphasized that transvaginal ultrasound can only be a factor to be added to clinical examination in the diagnosis of the incompetent cervix.

Examination of the uterine cervix by ultrasound in normal and pathologic pregnancy.

New possibilities of examination of the uterine cervix are provided by sonography in normal and pathologic pregnancy. Basic data of the ultrasonographic anatomy of the non pregnant uterine cervix is presented first: the length of the cervix as well as the diameters at the levels of external and internal os. These data are compared then with those in normal, physiologic pregnancy, and contrasted with those obtained in cases of incompetent cervix. In this group shortening of the cervical length, opening of the internal os and the funnel, or hour-glass-like herniation of the fetal membranes were characteristic findings. The method seems to be suitable for the assessment of the effectivity of cerclage operations for cervical incompetence.

Can a low-lying placenta be the risk factor of cervical incompetence? A preliminary study on the relationship between placenta insertion and anatomical status of uterine cervix.

An attempt was made to verify the hypothesis that a low-lying placenta may be a factor leading to the dynamic form of cervical incompetence. A vaginal evaluation of the cervix was made in 143 pregnant women who by means of ultrasonographic method were found to have low-lying placentas. In as many as 68 out of the 143 studied cases (47.5%), the low-lying placenta coincided with a shortening of the cervix about half its normal length or in both shortening and patency of the uterocervical canal, measuring up to 2 cm in diameter (39 cases). The statistical calculations indicate that a low-lying placenta can influence cervical behaviour and that it appears to be a risk factor of cervical incompetence.