Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 334
Filtrar
1.
J. obstet. gynaecol. Can ; 42(11): 1394-1413, Nov. 01, 2020.
Artigo em Inglês | BIGG - guias GRADE | ID: biblio-1146596

RESUMO

To assess the association between sonography-derived cervical length measurement and preterm birth. To describe the various techniques to measure cervical length using sonography. To review the natural history of the short cervix. To review the clinical uses, predictive ability, and utility of sonography-measured short cervix. Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions. Intended Users Clinicians involved in the obstetrical management or cervical imaging of patients at increased risk of a short cervix. Women at increased risk of a short cervix or at risk of preterm birth. Literature published up to June 2019 was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, cervical insufficiency, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date or language restrictions. Grey (unpublished) literature was identified through searching the websites of health technology assessment agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The evidence and this guideline were reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made and graded according to the rankings of the Canadian Task Force on Preventive Health Care ( Online Appendix Table A1). Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the sonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth.


Assuntos
Humanos , Feminino , Gravidez , Útero/anatomia & histologia , Colo do Útero/cirurgia , Ultrassonografia Pré-Natal/métodos , Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle
2.
Cochrane Database Syst Rev ; 9: CD012871, 2020 09 24.
Artigo em Inglês | MEDLINE | ID: mdl-32970845

RESUMO

BACKGROUND: Preterm birth (PTB) remains the foremost global cause of perinatal morbidity and mortality. Thus, the prevention of spontaneous PTB still remains of critical importance. In an attempt to prevent PTB in singleton pregnancies, cervical cerclage, in combination with other treatments, has been advocated. This is because, cervical cerclage is an intervention that is commonly recommended in women with a short cervix at high risk of preterm birth but, despite this, many women still deliver prematurely, as the biological mechanism is incompletely understood. Additionally, previous Cochrane Reviews have been published on the effectiveness of cervical cerclage in singleton and multiple pregnancies, however, none has evaluated the effectiveness of using cervical cerclage in combination with other treatments. OBJECTIVES: To assess whether antibiotics administration, vaginal pessary, reinforcing or second cerclage placement, tocolytic, progesterone, or other interventions at the time of cervical cerclage placement prolong singleton gestation in women at high risk of pregnancy loss based on prior history and/or ultrasound finding of 'short cervix' and/or physical examination. History-indicated cerclage is defined as a cerclage placed usually between 12 and 15 weeks gestation based solely on poor prior obstetrical history, e.g. multiple second trimester losses due to painless dilatation. Ultrasound-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation for transvaginal ultrasound cervical length < 20 mm in a woman without cervical dilatation. Physical exam-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation because of cervical dilatation of one or more centimetres detected on physical (manual) examination. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies. SELECTION CRITERIA: We included published, unpublished or ongoing randomised controlled trial (RCTs). Studies using a cluster-RCT design were also eligible for inclusion in this review but none were identified. We excluded quasi-RCTs (e.g. those randomised by date of birth or hospital number) and studies using a cross-over design. We also excluded studies that specified addition of the combination therapy after cervical cerclage because the woman subsequently became symptomatic. We included studies comparing cervical cerclage in combination with one, two or more interventions with cervical cerclage alone in singleton pregnancies. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts of all retrieved articles, selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of the evidence for this review's main outcomes. Data were checked for accuracy. Standard Cochrane review methods were used throughout. MAIN RESULTS: We identified two studies (involving a total of 73 women) comparing cervical cerclage alone to a different comparator. We also identified three ongoing studies (one investigating vaginal progesterone after cerclage, and two investigating cerclage plus pessary). One study (20 women), conducted in the UK, comparing cervical cerclage in combination with a tocolytic (salbutamol) with cervical cerclage alone in women with singleton pregnancy did not provide any useable data for this review. The other study (involving 53 women, with data from 50 women) took place in the USA and compared cervical cerclage in combination with a tocolytic (indomethacin) and antibiotics (cefazolin or clindamycin) versus cervical cerclage alone - this study did provide useable data for this review (and the study authors also provided additional data on request) but meta-analyses were not possible. This study was generally at a low risk of bias, apart from issues relating to blinding. We downgraded the certainty of evidence for serious risk of bias and imprecision (few participants, few events and wide 95% confidence intervals). Cervical cerclage in combination with an antibiotic and tocolytic versus cervical cerclage alone (one study, 50 women/babies) We are unclear about the effect of cervical cerclage in combination with antibiotics and a tocolytic compared with cervical cerclage alone on the risk of serious neonatal morbidity (RR 0.62, 95% CI 0.31 to 1.24; very low-certainty evidence); perinatal loss (data for miscarriage and stillbirth only - data not available for neonatal death) (RR 0.46, 95% CI 0.13 to 1.64; very low-certainty evidence) or preterm birth < 34 completed weeks of pregnancy (RR 0.78, 95% CI 0.44 to 1.40; very low-certainty evidence). There were no stillbirths (intrauterine death at 24 or more weeks). The trial authors did not report on the numbers of babies discharged home healthy (without obvious pathology) or on the risk of neonatal death. AUTHORS' CONCLUSIONS: Currently, there is insufficient evidence to evaluate the effect of combining a tocolytic (indomethacin) and antibiotics (cefazolin/clindamycin) with cervical cerclage compared with cervical cerclage alone for preventing spontaneous PTB in women with singleton pregnancies. Future studies should recruit sufficient numbers of women to provide meaningful results and should measure neonatal death and numbers of babies discharged home healthy, as well as other important outcomes listed in this review. We did not identify any studies looking at other treatments in combination with cervical cerclage. Future research needs to focus on the role of other interventions such as vaginal support pessary, reinforcing or second cervical cerclage placement, 17-alpha-hydroxyprogesterone caproate or dydrogesterone or vaginal micronised progesterone, omega-3 long chain polyunsaturated fatty acid supplementation and bed rest.


Assuntos
Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle , Albuterol/uso terapêutico , Analgésicos Opioides/uso terapêutico , Antibacterianos/uso terapêutico , Viés , Cefazolina/uso terapêutico , Clindamicina/uso terapêutico , Feminino , Humanos , Indometacina/uso terapêutico , Ópio/uso terapêutico , Gravidez , Nascimento Prematuro/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Natimorto/epidemiologia , Tocolíticos/uso terapêutico
3.
PLoS One ; 15(4): e0232463, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32353024

RESUMO

Transabdominal cerclage (TAC) is reported to be effective for preventing preterm birth in women with unsuccessful transvaginal cerclage (TVC) history. However, TAC has rarely been performed in twin pregnancy given the lack of sufficient evidence and the technical difficulty of the operation. Thus, it is unclear whether TAC is an effective procedure for twin pregnancy in women with a history of unsuccessful TVC. The aim of this study is to compare the characteristics and pregnancy outcomes after TAC in twin pregnancy versus singleton pregnancy, to examine whether twin pregnancy is a risk factor for very preterm birth (before 32 weeks) after TAC, and to determine whether TAC is effective in preventing preterm birth in twin pregnancy. This single-center retrospective cohort study included women who underwent TAC because of unsuccessful TVC history between January 2007 and June 2018. Of 165 women who underwent TAC, 19 had twins and 146 had singletons. Our results showed that the neonatal survival rate improved dramatically when TAC was performed (15.4% (prior pregnancy) vs 94.0% (after TAC) in twins, p<0.01; 22.8% (prior pregnancy) vs 91.1% (after TAC) in singletons, p<0.01). Moreover, the risk of very preterm birth was significantly decreased after TAC in both groups (36/39 (92.3%) (prior pregnancy) vs 2/19 (10.5%) (after TAC) in twins, p<0.01; 290/337 (86.1%) (prior pregnancy) vs 17/146 (11.6%) (after TAC) in singletons, p<0.01). More advanced maternal age and history of prior preterm delivery between 26+0 and 36+6 weeks were independently associated with very preterm birth, whereas the presence of a twin pregnancy was not associated with very preterm birth on multivariate logistic regression analysis. These results suggest that TAC is associated with successful prevention of very preterm birth and improved neonatal survival rates in the absence of procedure-related major complications in women with twin pregnancy and previous unsuccessful TVC history.


Assuntos
Cerclagem Cervical/métodos , Resultado da Gravidez , Gravidez de Gêmeos , Nascimento Prematuro/prevenção & controle , Adulto , Cerclagem Cervical/efeitos adversos , Colo do Útero/cirurgia , Feminino , Humanos , Recém-Nascido , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Gravidez , Nascimento Prematuro/etiologia , Nascimento Prematuro/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida , Falha de Tratamento
4.
Int J Gynaecol Obstet ; 149(3): 370-376, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32246762

RESUMO

OBJECTIVE: To evaluate the effect of adjunctive use of vaginal progesterone after McDonald cerclage on the rate of second-trimester abortion in singleton pregnancy. METHODS: A randomized controlled trial at Woman's Health Hospital, Assiut University, Egypt, between April 2017 and March 2019 enrolled women eligible for McDonald cerclage. After cerclage, participants were randomly assigned to receive progesterone (400 mg pessary) once daily until 37 weeks or no progesterone. The primary outcome was rate of abortion before 28 weeks. Secondary outcomes included gestational age at delivery, preterm delivery, mean birthweight, Apgar score, and admission to the neonatal intensive care unit (NICU). RESULTS: The rate of spontaneous abortion was higher in the no-progesterone group (P=0.016). Mean gestational age and mean birthweight was higher in the progesterone group (P<0.001 and P=0.002, respectively). The frequency of preterm neonates, neonates with Apgar score less than 7, and admission to NICU was higher in the progesterone group than in the no-progesterone group (P=0.005, P=0.008, and P=0.044, respectively). CONCLUSION: Adjunctive use of vaginal progesterone after McDonald cerclage was found to decrease the frequency of second-trimester abortion and to improve perinatal outcomes in singleton pregnancy. Clinicaltrials.gov: NCT02846909.


Assuntos
Aborto Espontâneo/prevenção & controle , Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle , Progesterona/administração & dosagem , Progestinas/administração & dosagem , Aborto Espontâneo/epidemiologia , Administração Intravaginal , Adulto , Egito , Feminino , Humanos , Recém-Nascido , Gravidez , Segundo Trimestre da Gravidez , Nascimento Prematuro/epidemiologia , Adulto Jovem
5.
Arch Gynecol Obstet ; 301(4): 981-986, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32170408

RESUMO

OBJECTIVE: To assess outcomes of ultrasound and physical examination-based cerclage performed at mid to late second trimester and to assess the potential added value of progesterone treatment combined with cerclage for preventing preterm birth. STUDY DESIGN: A retrospective cohort study of women who underwent cerclage in a university-affiliated tertiary medical center (2012-2018). Inclusion criteria included only ultrasound-based cerclage and physical examination-based cerclage. Women who underwent history-based cerclage or multiple gestations were excluded. Study groups were stratified by previous PTB < 37 weeks and other risk factors for PTB. Primary outcome was the incidence of preterm birth < 35 weeks of gestation. Secondary outcomes included the potential added value of progesterone treatment and neonatal outcome. RESULTS: Sixty-nine women underwent cervical cerclage placement between 16-23 weeks of gestation. All women had short cervix (cervical length of < 25 mm) at presentation. Indications for cerclage placement included: 29% previous PTB, 32% prior cervical interventions (history of at least one D&C, hysteroscopy or cold-knife conization in the past), 22% had cervical dilatation > 1 cm at presentation, 12% due to failure of progesterone treatment defined as continued cervical shortening after 14 days of progesterone treatment, and 5% had other indications. Overall, 42 women (61%) gave birth at term. 27 women (39%) delivered prior to 37 weeks of gestation, of them, 20 women (29%) gave birth prior to 35 weeks. Overall median gestational age at delivery was 35 + 5 ± 4.7 weeks. Cervical dilatation at presentation of > 1 cm was associated with an increased risk for PTB < 35 weeks (OR 3.57, CI 1.43-30.81, p = 0.036). Previous PTB, prior cervical interventions and extent of cervical shortening at presentation did not increase the risk of PTB. Progesterone treatment in addition to cerclage did not result in a decreased risk for PTB < 35 weeks of gestation (OR 2.83, CI 0.58-13.89, p = 0.199). CONCLUSION: Late second trimester cerclage is a practical measure for preventing PTB in cases of asymptomatic cervical shortening. Our study did not find adjunctive benefit for progesterone treatment with physical or ultrasound-based cerclage in reducing the rate PTB.


Assuntos
Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle , Progesterona/uso terapêutico , Adulto , Feminino , Humanos , Gravidez , Progesterona/farmacologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Ultrassonografia
6.
Fertil Steril ; 113(4): 717-722, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32147177

RESUMO

Laparoscopic abdominal cerclage is emerging as the preferred treatment option for patients with refractory cervical insufficiency. Laparoscopic abdominal cerclage reduces second-trimester loss and preterm birth with success rates similar to open abdominal cerclage. Increasing evidence also suggests improved neonatal survival rates with abdominal cerclage compared with repeat vaginal cerclage in patients who delivered prematurely despite a vaginal cerclage. The option to perform a highly effective treatment using minimally invasive techniques suggests laparoscopic abdominal cerclage will become the standard of care for refractory cervical insufficiency. This review examines the literature with regard to the indications and outcomes of abdominal cerclage, highlighting the laparoscopic technique.


Assuntos
Cerclagem Cervical/métodos , Laparoscopia/métodos , Incompetência do Colo do Útero/diagnóstico , Incompetência do Colo do Útero/cirurgia , Feminino , Humanos , Gravidez , Nascimento Prematuro/prevenção & controle , Nascimento Prematuro/cirurgia , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Resultado do Tratamento
7.
Clín. investig. ginecol. obstet. (Ed. impr.) ; 47(1): 3-8, ene.-mar. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-187065

RESUMO

Introducción: Las guías clínicas actuales recomiendan el uso del cerclaje de emergencia (CE) como tratamiento de la insuficiencia cervical con exposición de membranas en gestaciones únicas. Sin embargo, el CE en gestación múltiple es tema de controversia dado que no existen ensayos clínicos randomizados que demuestren su eficacia. Algunos estudios retrospectivos sugieren que el CE también podría prolongar la gestación en embarazos múltiples. El objetivo de nuestro estudio es evaluar los resultados de las gestaciones múltiples que se sometieron a un CE en nuestro centro. Materiales y métodos: Se diseñó un estudio retrospectivo que incluyó los CE realizados en gestaciones gemelares en nuestro centro entre 2007-2016. No fueron tributarias de CE gestaciones con malformaciones fetales, monocoriales-monoamnióticas, triple o superior y finalizaciones activas de la gestación. Variables primarias: latencia al parto espontáneo y edad gestacional al parto. Variables secundarias: mortalidad neonatal, ingreso en UCI neonatal, rotura prematura de membranas pretérmino, corioamnionitis y fallo del cerclaje. Resultados. El estudio incluyó 17 pacientes. La edad gestacional mediana (rango intercuartil) al parto fue de 27,1 (24,5-32,3) semanas y la latencia mediana (rango intercuartil) al parto fue de 43 (21-64) días. Hubo 4/17 (23,5%) casos de parto antes de las 24 semanas de gestación y 2/26 (7,7%) de muerte neonatal. Discusión: Estos resultados muestran que la latencia al parto después del CE en gestación múltiple es remarcable, por lo que podría ser considerado como una opción terapéutica. Sin embargo, se requiere evidencia basada en estudios randomizados para hacer una recomendación firme


Introduction: Current guidelines support the use of physical-examination indicated cerclage (PEIC) as a treatment for cervical insufficiency and membrane exposure in single pregnancies. However, PEIC in twin pregnancies is a controversial issue as no data from random clinical trial are available to demonstrate its efficacy. Few studies suggest that PEIC may prolong pregnancy also in twin pregnancies. The aim of this study was to evaluate the results of twin pregnancies that underwent a PEIC in our health centre. Material and methods: A retrospective review was performed on women that underwent a PEIC from 2007-2016 in our centre. Women were not eligible if they were carrying foetuses with major foetal anomalies, more than two foetuses or monochorionic-monoamniotic pregnancies, or three or more foetuses or requesting an elective termination of pregnancy. Primary outcomes: latency to spontaneous delivery and gestational age (GA) at delivery. Secondary outcomes: neonatal mortality and Neonatal Intensive Care Unit admission, preterm premature rupture of membranes (PPROM), chorioamnionitis and cerclage displacement. Results: The study included a total of 17 women. The median (inter-quartile range) gestational age at delivery was 27.1 (24.5-32.3) weeks, and median (inter-quartile range) latency, from cervical cerclage to delivery, was 43 (21-64) days. There were 4/17 (23.5%) cases of delivery before 24 weeks of pregnancy, and 2/26 (7.7%) cases of neonatal death. Discussion: These results suggest that latency to delivery after PEIC in twins is remarkable. Therefore, it could be considered as an optional management. Nevertheless, evidence based on random clinical trial is required to make firm recommendations on its formal use


Assuntos
Humanos , Feminino , Gravidez , Adulto , Cerclagem Cervical/métodos , Gravidez de Gêmeos/fisiologia , Mortalidade Infantil , Fatores de Risco , Amniocentese/métodos , Estudos Retrospectivos , Idade Gestacional , Trabalho de Parto Prematuro/epidemiologia , Ruptura Prematura de Membranas Fetais , Gardnerella vaginalis/isolamento & purificação , Gardnerella vaginalis/efeitos dos fármacos , Klebsiella pneumoniae/efeitos dos fármacos , Klebsiella pneumoniae/isolamento & purificação , Candida albicans/efeitos dos fármacos , Candida albicans/isolamento & purificação
8.
Am J Obstet Gynecol ; 222(3): 261.e1-261.e9, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31585096

RESUMO

BACKGROUND: Vaginal cerclage (a suture around the cervix) commonly is placed in women with recurrent pregnancy loss. These women may experience late miscarriage or extreme preterm delivery, despite being treated with cerclage. Transabdominal cerclage has been advocated after failed cerclage, although its efficacy is unproved by randomized controlled trial. OBJECTIVE: The objective of this study was to compare transabdominal cerclage or high vaginal cerclage with low vaginal cerclage in women with a history of failed cerclage. Our primary outcome was delivery at <32 completed weeks of pregnancy. STUDY DESIGN: This was a multicenter randomized controlled trial. Women were assigned randomly (1:1:1) to receive transabdominal cerclage, high vaginal cerclage, or low vaginal cerclage either before conception or at <14 weeks of gestation. RESULTS: The data for 111 of 139 women who were recruited and who conceived were analyzed: 39 had transabdominal cerclage; 39 had high vaginal cerclage, and 33 had low vaginal cerclage. Rates of preterm birth at <32 weeks of gestation were significantly lower in women who received transabdominal cerclage compared with low vaginal cerclage (8% [3/39] vs 33% [11/33]; relative risk, 0.23; 95% confidence interval, 0.07-0.76; P=.0157). The number needed to treat to prevent 1 preterm birth was 3.9 (95% confidence interval, 2.32-12.1). There was no difference in preterm birth rates between high and low vaginal cerclage (38% [15/39] vs 33% [11/33]; relative risk, 1.15; 95% confidence interval, 0.62-2.16; P=.81). No neonatal deaths occurred. In an exploratory analysis, women with transabdominal cerclage had fewer fetal losses compared with low vaginal cerclage (3% [1/39] vs 21% [7/33]; relative risk, 0.12; 95% confidence interval, 0.016-0.93; P=.02). The number needed to treat to prevent 1 fetal loss was 5.3 (95% confidence interval, 2.9-26). CONCLUSION: Transabdominal cerclage is the treatment of choice for women with failed vaginal cerclage. It is superior to low vaginal cerclage in the reduction of risk of early preterm birth and fetal loss in women with previous failed vaginal cerclage. High vaginal cerclage does not confer this benefit. The numbers needed to treat are sufficiently low to justify transabdominal surgery and cesarean delivery required in this select cohort.


Assuntos
Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle , Aborto Espontâneo/epidemiologia , Aborto Espontâneo/prevenção & controle , Adulto , Feminino , Idade Gestacional , Humanos , Números Necessários para Tratar , Cuidado Pré-Concepcional , Gravidez , Nascimento Prematuro/epidemiologia
9.
Med Sci Monit ; 25: 4202-4206, 2019 Jun 06.
Artigo em Inglês | MEDLINE | ID: mdl-31168048

RESUMO

BACKGROUND To study the clinical effective of emergency cervical cerclage (ECC) in pregnant women who have cervical insufficiency with prolapsed membranes. MATERIAL AND METHODS This study was devised as a retrospective cohort in a single medical center, in which we collected clinical data from patient records. Inclusion criteria were: physical examination indicated ECC was performed at 15 to 25 gestational weeks at the Sixth Medical Center of the PLA General Hospital, and singleton pregnancy. The collected clinical data included: duration of pregnancy at delivery, interval between ECC and delivery, neonatal weight, neonatal mortality, neonatal morbidity, and Neonatal Intensive Care Unit (NICU) admission. RESULTS We included 50 women with singleton pregnancies. No surgical complications occurred in any patients. The gestational age at cerclage was 21.3±2.2 weeks. No patients had membrane damage due to surgery. No surgical complications were reported. Five (10%) patients underwent chorioamnionitis. The time interval between ECC and delivery was 11.2±7.1 weeks. The mean gestational age at delivery was 34.1 weeks. The rate of vaginal delivery was 96%. Ten patients had pregnancy lasting longer than 36 weeks. The mean neonate delivery weight was 2510.7 g. Twenty neonates were admitted to the Neonatal Intensive Care Unit (NICU), and the mean NICU stay was 21 days. CONCLUSIONS ECC has good perinatal results. Our results provide clinical evidence for the efficacy and risks of ECC.


Assuntos
Cerclagem Cervical/mortalidade , Resultado da Gravidez/epidemiologia , Cerclagem Cervical/efeitos adversos , Cerclagem Cervical/métodos , Colo do Útero/cirurgia , China , Emergências , Feminino , Ruptura Prematura de Membranas Fetais/cirurgia , Idade Gestacional , Humanos , Recém-Nascido , Morte Perinatal/etiologia , Mortalidade Perinatal/tendências , Gravidez , Nascimento Prematuro/etiologia , Estudos Retrospectivos , Suturas , Incompetência do Colo do Útero/cirurgia , Prolapso Uterino/complicações
10.
Ceska Gynekol ; 84(1): 55-60, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31213059

RESUMO

OBJECTIVE: Contemporary role of cerclage as a preterm birth treatment. DESIGN: Review article. SETTING: Department of Obstetrics and Gynecology of the First Faculty of Medicine and General Teaching Hospital in Prague. METHODS: Research of existing literature, predominantly foreign journal articles, but also Czech literature and personal experience with the method. RESULTS: Cerclage is one of the well-known surgical procedures carried out during pregnancy. Its aim is to provide a mechanical support to the cervical canal and to keep the cervix closed. The cervical mucous plug serves as a mechanical barrier between the vagina and the uterine cavity, but it also contains many immune components which protect the fetal compartment from ascendent infections. Application of a cervical stitch can help to retain the mucous plug and thus increases the immunity of the cervical canal. Results of 15 randomised studies (Cochraine Database of Systematic R) suggest that in women with increased risk of preterm birth, cerclage decreases the occurrence of preterm birth relative to the expectant management. CONCLUSIONS: Despite the decreasing numbers of cerclage surgeries, it is still a useful method of preterm birth prevention for a specific group of women. More recently, a progesterone treatment has gained popularity. Its application, however, must begin before the 16th week of pregnancy.


Assuntos
Cerclagem Cervical/métodos , Colo do Útero/cirurgia , Nascimento Prematuro/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Incompetência do Colo do Útero/cirurgia , Medida do Comprimento Cervical , Feminino , Humanos , Gravidez , Cuidado Pré-Natal , Incompetência do Colo do Útero/diagnóstico , Vagina
11.
J Obstet Gynaecol Res ; 45(8): 1597-1602, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31137082

RESUMO

Modified laparoscopic cerclage was developed as an easy laparoscopic approach during pregnancy, with sutures placed lateral to the uterine vessels. To the best of our knowledge, its successful use in the first trimester has not been reported in Japan. Additionally, there are no published data on chronological assessment of feto-placental circulation using Doppler. Here, we present the case of a 31-year-old Japanese woman (gravida 2, para 1) with refractory cervical incompetence who had a history of preterm birth at 32 weeks of gestation and cervical conization. Modified laparoscopic cervicoisthmic cerclage was performed. Doppler findings showed normal feto-placental circulation before and after the procedure. Her pregnancy progressed uneventfully with no significant feto-placental circulation or obstetric complications, and the baby showed normal growth. Elective cesarean section was performed at 37 + 0 weeks' gestation. Modified laparoscopic cervicoisthmic cerclage is suggested as one of the treatment methods for pregnant women with refractory cervical incompetence.


Assuntos
Cerclagem Cervical/métodos , Incompetência do Colo do Útero/cirurgia , Adulto , Feminino , Humanos , Japão , Laparoscopia , Gravidez , Primeiro Trimestre da Gravidez , Ultrassonografia Pré-Natal , Incompetência do Colo do Útero/diagnóstico por imagem
12.
Arch Gynecol Obstet ; 300(2): 305-312, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31056734

RESUMO

OBJECTIVE: To evaluate the efficacy of cerclage in preventing preterm birth according to indication. STUDY DESIGN: Retrospective analysis of all women who underwent cerclage to prevent preterm birth in a university-affiliated medical-center (2007-2017). Multiple gestations were excluded. Cohort was divided to three subgroups according to cerclage indication: group A-primary prevention cerclage, performed during the first trimester, based on a history of cervical insufficiency; group B-secondary prevention cerclage, performed after sonographic visualization of asymptomatic cervical length shortening and previous preterm birth; and group C-tertiary prevention cerclage, performed at mid-trimester in women presenting with asymptomatic cervical dilatation. Primary outcome was gestational age at delivery. Secondary outcomes were maternal and neonatal complications. RESULTS: During the study period 273 women underwent cervical cerclage: group A-215 (79%), group B-25 (9%), and group C-33 (12%). Patients in group C had significantly lower gravidity and parity. Gestational age at cerclage was highest in group C and lowest in group A (22 vs. 13 weeks p < 0.001). Median gestational age at delivery was 37 + 3 weeks in groups A and B and 34 + 3 in group C. This difference persisted after controlling for potential confounders (p < 0.0001). Preterm birth prior to 34 weeks of gestation were 10.7% in group A, 16% in group B, and 33.33% in group C (p = 0.0021). Neonatal complications including: respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis, were clmore prevalent in group C. CONCLUSION: Cerclage was shown to be an acceptable measure in cases of an anticipated increased risk of preterm birth with a low rate of procedure associated complications. However, the number-needed-to-treat cannot be determined from our data, because a control group was lacking.


Assuntos
Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle , Prevenção Primária/métodos , Prevenção Secundária/métodos , Prevenção Terciária/métodos , Incompetência do Colo do Útero/cirurgia , Adulto , Estudos de Coortes , Feminino , Humanos , Recém-Nascido , Pessoa de Meia-Idade , Gravidez , Estudos Retrospectivos , Adulto Jovem
13.
Obstet Gynecol ; 133(6): 1195-1198, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31135734

RESUMO

OBJECTIVE: To evaluate obstetric outcomes of subsequent pregnancies in women who had a laparoscopic transabdominal cerclage. METHODS: A prospective observational study of consecutive women who became pregnant a second or third time after a laparoscopic transabdominal cerclage. Eligible women were considered not suitable for a transvaginal cerclage or had previously failed a transvaginal cerclage. The primary outcome was neonatal survival and the secondary outcome was delivery at 34 weeks of gestation or more. RESULTS: During the study period (2007-2018), 22 women who had undergone a laparoscopic transabdominal cerclage and completed one pregnancy with the cerclage in situ became pregnant a second or third time. In the first pregnancies with the cerclage in situ, the neonatal survival rate was 100% (22/22) and 86% (19/22) of women delivered after 34 weeks of gestation. In the second pregnancies, the neonatal survival rate was 95% (21/22) and 86% (19/22) of women delivered after 34 weeks of gestation. In the third pregnancies, the neonatal survival rate was 100% (3/3) and 100% (3/3) of women delivered after 34 weeks of gestation. CONCLUSION: When left in situ for subsequent pregnancies, laparoscopic transabdominal cerclage is associated with a high rate of neonatal survival.


Assuntos
Cerclagem Cervical/métodos , Laparoscopia/métodos , Resultado da Gravidez , Nascimento Prematuro/etiologia , Incompetência do Colo do Útero/cirurgia , Adulto , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Seleção de Pacientes , Gravidez , Estudos Prospectivos , Taxa de Sobrevida
15.
J Gynecol Obstet Hum Reprod ; 48(6): 391-394, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30905851

RESUMO

OBJECTIVE: Cervical cerclage is the principal treatment for women with a cervical insufficiency, which is a predominant factor in second trimester loss and preterm birth. A cervico-isthmic cerclage is recommended in case of a previous failure of McDonald cerclage or in case of an absent portio vaginalis of the cervix. In women who have prolapsed membranes at or beyond a dilated external cervical os before 24 weeks of gestation, an emergency cerclage can sometimes be performed. The aim of this study is to report our experience with emergency transvaginal cervico-isthmic cerclage. STUDY DESIGN: This is a retrospective, single-centre study conducted between 2009 and 2017 of women who received a transvaginal cervico-isthmic emergency cerclage. Emergency cerclage was defined as cerclage performed on women who had prolapsed membranes at or beyong a dilated external cervical os before 24 weeks of gestation. The exclusion criteria were twin pregnancy, preterm rupture of membranes, and clinical or biological signs of infection. RESULTS: Three women were included. One woman had a history of failure of emergency McDonald cerclage during her previous pregnancy. The two other women had a failure of McDonald cerclage during index pregnancy. All women presented prolapsed membranes at or beyond a dilated external cervical os as defined for an emergency cerclage. The emergency cerclage was performed at a mean gestational age of 21.5 weeks of gestation. The average gestational age of delivery was 38.5 weeks of gestation by caesarean section. CONCLUSION: Despite the small number of women, this study shows that this type of cerclage was effective in pregnancy prolongation for women at high risk of preterm birth in case of McDonald cerclage failure. Nevertheless, this technique requires a trained surgical team. A randomised trial should be performed to evaluate the need for emergency vaginal cervico-isthmic cerclage.


Assuntos
Cerclagem Cervical/métodos , Vagina , Adulto , Colo do Útero/cirurgia , Cesárea , Tratamento de Emergência , Feminino , Idade Gestacional , Humanos , Primeira Fase do Trabalho de Parto , Gravidez , Nascimento Prematuro/prevenção & controle , Estudos Retrospectivos , Falha de Tratamento , Incompetência do Colo do Útero/cirurgia
16.
BJOG ; 126(7): 916-925, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30854760

RESUMO

OBJECTIVE: To investigate the relation between vaginal microbiota composition and outcome of rescue cervical cerclage. DESIGN: Prospective observational study. SETTING: Queen Charlotte's and Chelsea Hospital, London. POPULATION: Twenty singleton pregnancies undergoing a rescue cervical cerclage. METHODS: Vaginal microbiota composition was analysed in women presenting with a dilated cervix and exposed fetal membranes before and 10 days following rescue cervical cerclage and was correlated with clinical outcomes. MAIN OUTCOME MEASURES: Composition of vaginal bacteria was characterised by culture-independent next generation sequencing. Successful cerclage was defined as that resulting in the birth of a neonate discharged from hospital without morbidity. Unsuccessful cerclage was defined as procedures culminating in miscarriage, intrauterine death, neonatal death or significant neonatal morbidity. RESULTS: Reduced Lactobacillus spp. relative abundance was observed in 40% of cases prior to rescue cerclage compared with 10% of gestation age-matched controls (8/20, 40% versus 3/30, 10%, P = 0.017). Gardnerella vaginalis was over-represented in women presenting with symptoms (3/7, 43% versus 0/13, 0%, P = 0.03, linear discriminant analysis, LDA (log 10) and cases culminating in miscarriage (3/6, 50% versus 0/14, 0%, P = 0.017). In the majority of cases (10/14, 71%) bacterial composition was unchanged following cerclage insertion and perioperative interventions. CONCLUSIONS: Reduced relative abundance of Lactobacillus spp. is associated with premature cervical dilation, whereas high levels of G. vaginalis are associated with unsuccessful rescue cerclage cases. The insertion of a rescue cerclage does not affect the underlying bacterial composition in the majority of cases. TWEETABLE ABSTRACT: Preterm cervical dilatation associates with reduced Lactobacillus spp. Presence of Gardnerella vaginalis predicts rescue cerclage failure.


Assuntos
Cerclagem Cervical/métodos , Vagina/microbiologia , Aborto Espontâneo , Feminino , Morte Fetal , Gardnerella vaginalis/isolamento & purificação , Humanos , Primeira Fase do Trabalho de Parto/fisiologia , Lactobacillus/isolamento & purificação , Microbiota , Gravidez , Resultado da Gravidez , Nascimento Prematuro/microbiologia , Estudos Prospectivos , Incompetência do Colo do Útero/microbiologia , Incompetência do Colo do Útero/cirurgia
17.
Am J Obstet Gynecol ; 220(6): 543-557.e1, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30527942

RESUMO

OBJECTIVE DATA: This study was conducted to estimate whether cerclage could extend the prolongation of pregnancy, reduce the risk of preterm birth, and improve perinatal outcomes in women with twin pregnancies. STUDY ELIGIBILITY CRITERIA: We included randomized controlled trials and cohort studies comparing the efficacy of cerclage with no cerclage for women with twin pregnancies. STUDY APPRAISAL AND SYNTHESIS METHODS: The following databases were searched for all published studies that compared cerclage placement with expectant management in twin pregnancies from inception to July 2018: Medline, EMBASE, Scopus, ClinicalTrials.gov, Web of Science, and Cochrane Library. Each report was reviewed for inclusion or exclusion standard, and data extraction was performed by 2 authors independently. RESULTS: A total of 16 studies with 1211 women that met the inclusion criteria were included in the final analysis. Our outcomes indicated that cerclage placement for twin pregnancies with a cervical length of <15 mm was associated with significant prolongation of pregnancy by a mean difference of 3.89 weeks of gestation (95% confidence interval, 2.19-5.59; P=.000; I2=0%) and a reduction of preterm birth at <37 weeks of gestation (risk ratio, 0.86; 95% confidence interval, 0.74-0.99; P=.040; I2=0%), <34 weeks of gestation (risk ratio, 0.57; 95% confidence interval, 0.43-0.75; P=.000; I2=0%) and <32 weeks of gestation (risk ratio, 0.61; 95% confidence interval, 0.41-0.90; P=.010; I2=0%), compared with those pregnancies in the control group. For women with a dilated cervix of >10 mm, cerclage placement was associated with significant prolongation of pregnancy by a mean difference of 6.78 weeks of gestation (95% confidence interval, 5.32-8.24; P=.000; I2=0%); a reduction of preterm birth at <34 weeks of gestation (risk ratio, 0.56; 95% confidence interval, 0.45-0.69; P=.000; I2=28%), <32 weeks of gestation (risk ratio, 0.50; 95% confidence interval, 0.38-0.65; P=.000; I2=14%), <28 weeks of gestation (risk ratio, 0.41; 95% confidence interval, 0.20-0.85; P=.030; I2=80%), and <24 weeks of gestation (risk ratio, 0.35; 95% confidence interval, 0.18-0.67; P=.001; I2=24%), and improvement of perinatal outcomes compared with those in the control group. However, for twin pregnancies with a normal cervical length (eg, cerclage for an indication for women with a history of preterm birth or twin alone), the efficacy of cerclage placement was less certain because of the limited data. CONCLUSION: Our metaanalysis indicates that cerclage placement is beneficial for the reduction of preterm birth and the prolongation of pregnancy in twin pregnancies with a cervical length of <15 mm or dilated cervix of >10 mm. However, the benefit of history-indicated or twin alone-indicated cerclage is less certain in twin pregnancies with normal cervical length according to current literature. Further high-quality studies were needed to confirm the findings.


Assuntos
Cerclagem Cervical/métodos , Colo do Útero/diagnóstico por imagem , Gravidez de Gêmeos , Nascimento Prematuro/prevenção & controle , Medida do Comprimento Cervical , Feminino , Humanos , Gravidez
18.
Acta Obstet Gynecol Scand ; 98(2): 139-153, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30339274

RESUMO

INTRODUCTION: The purpose of this study was to evaluate whether there are additional benefits of 17-hydroxyprogesterone caproate (17-OHPC) supplementation in preventing recurrent spontaneous preterm birth in women with a prophylactic cerclage. MATERIAL AND METHODS: Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE, Scielo and the Cochrane Central Register of Controlled Trials) were searched for studies published before June 2018. Keywords included "preterm birth", "prophylactic cerclage", "history-indicated cerclage", "pregnancy" and "17-hydroxyprogesterone caproate". Studies comparing history-indicated cerclage alone with cerclage+17-OHPC were included. The primary outcome measure was preterm birth at <24 weeks of gestation. Secondary outcome measures include preterm birth at <28 weeks, <32 weeks and <37 weeks of gestation, respiratory distress syndrome, necrotizing enterocolitis, fetal birthweight, neonatal intensive care unit stay, mean gestational age at delivery, fetal/neonatal death, neurological morbidity (intraventricular hemorrhage plus periventricular leukomalacia), neonatal sepsis and a composite of severe neonatal morbidity. Severe neonatal morbidity was defined as a composite measure of periventricular leukomalacia, intraventricular hemorrhage (grades III and IV), necrotizing enterocolitis or respiratory distress syndrome. Meta-analysis was performed using the random-effects model of DerSimonian and Laird. Risk of bias and quality assessment were performed using the ROBINS-I and GRADE tools, respectively. PROSPERO Registration Number: CRD42018094559. RESULTS: Five studies met the inclusion criteria and were included in the final analysis. Of the 546 women, 357 (75%) received history-indicated cerclage alone and 189 (35%) received adjuvant 17-OHPC. The composite endpoint, severe neonatal morbidity, was present in 84 of 1515 neonates. Though there was a trend toward a reduced risk of preterm birth, the summary estimate of effect was not statistically significant when comparing cerclage alone with cerclage+17-OHPC at <24 weeks (relative risk [RR] .86, 95% confidence interval [CI] .45-1.65). Similarly, we found no differences in preterm birth at <37 weeks (RR .90, 95% CI .70-1.17) and <28 weeks (RR .85, 95% CI .54-1.32) when comparing cerclage alone with cerclage+17-OHPC. There were no differences in fetal birthweight, respiratory distress syndrome or necrotizing enterocolitis comparing cerclage alone with cerclage+17-OHPC. CONCLUSIONS: Intramuscular 17-OHPC in combination with prophylactic cerclage in women with prior preterm birth had no synergistic effect in reducing spontaneous recurrent preterm birth or improving perinatal outcomes.


Assuntos
Caproato de 17 alfa-Hidroxiprogesterona/farmacologia , Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle , Terapia Combinada , Antagonistas de Estrogênios/farmacologia , Feminino , Humanos , Gravidez , Prevenção Secundária
19.
J Matern Fetal Neonatal Med ; 32(6): 932-938, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29108444

RESUMO

BACKGROUND: Cerclage placed for a sonographically short cervix has been shown to reduce the risk of preterm delivery in women with a history of prior preterm birth. While short cervix is traditionally placed before viability, the threshold gestational age at which viability is achieved continues to decrease, and, as a result, a larger subset of women may be ineligible to receive this potentially beneficial procedure. OBJECTIVE: To evaluate the association between obstetric outcomes and perioperative complications after placement of an ultrasound-indicated cerclage at periviability compared to placement in the previable period. METHODS: This retrospective cohort study of patients who underwent ultrasound-indicated cerclage evaluated obstetric outcomes and perioperative complications based on gestational age at cerclage placement. Ultrasound-indicated cerclage was considered to have been placed at periviability if placed at 22 to <24 weeks (exposed) and at previability if placed at 16 to <22 weeks gestational age (unexposed). The primary outcome was preterm delivery <36 weeks. Secondary outcomes included mean gestational age at delivery, preterm delivery <32 weeks, <28, and <24 weeks, preterm premature rupture of membranes (PPROM), chorioamnionitis, and perioperative complications. Adjusted analyses were performed to account for demographic and obstetric factors. RESULTS: Of the 426 patients included in the analysis, 94 (22%) had cerclage placed between ≥22 weeks to <24 weeks, while 332 (78%) had cerclage placed at <22 weeks. On univariate analysis, women who had a periviable cerclage placed were less likely to have a recurrent preterm delivery <36 weeks compared to women with previable cerclage placement (26.6 versus 38.3%, respectively, p = .04). The adjusted model did not demonstrate a significant difference in risk for preterm delivery <36 weeks associated with periviable versus previable cerclage (odds ratio 0.66, 95%CI 0.37-1.17). Secondary outcomes were similar between the previable and periviable groups, including mean gestational age at delivery (35.1 versus 36.2 weeks, respectively, p = .08) and preterm delivery before 32-week gestation (20.7 versus 13.8%, respectively, p = .17). Intraoperative and postoperative complications were rare and rates were similar between groups. CONCLUSIONS: Obstetric outcomes between patients receiving periviable and previable cerclage are similar. Ultrasound-indicated cerclage placement is associated with a relatively low rate of complications. Given the evidence supporting benefit of cerclage for women with short ultrasound cervical length and prior preterm birth, our findings demonstrate that benefits of placement at ≥22 weeks to <24 weeks may outweigh risks.


Assuntos
Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle , Incompetência do Colo do Útero/cirurgia , Adulto , Cerclagem Cervical/estatística & dados numéricos , Medida do Comprimento Cervical , Feminino , Idade Gestacional , Humanos , Complicações Pós-Operatórias/epidemiologia , Gravidez , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos , Ultrassonografia Pré-Natal , Incompetência do Colo do Útero/diagnóstico por imagem
20.
J Obstet Gynaecol Res ; 45(2): 454-460, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30191633

RESUMO

Transvaginal cervicoisthmic cerclage was carried out in 12 such patients who were at high-risk of premature delivery. Patients who underwent transvaginal cervicoisthmic cerclage had undergone conization, cervical radical hysterectomy or another form of extensive cervical resection, or had a history of third-trimester miscarriage or premature delivery despite having previously undergone cervical cerclage several times for cervical incompetence. There were seven cases of pregnancy after extensive conization, and four had a history of failed cervical cerclage. Two of these cases were the same individual, who became pregnant twice after extensive conization and gave birth to a live infant each time. The mean age at surgery was 35.7 years, and cerclage was performed at 11-19 weeks' gestation. All of the infants survived to hospital discharge. Transvaginal cervicoisthmic cerclage may be considered effective for patients with the history of recurring pregnancy loss due to previous failure of prophylactic cerclage.


Assuntos
Cerclagem Cervical/métodos , Nascimento Vivo , Nascimento Prematuro/prevenção & controle , Adulto , Feminino , Humanos , Gravidez , Risco
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...