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1.
Z Geburtshilfe Neonatol ; 223(6): 373-394, 2019 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-31801169

RESUMO

AIMS: This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. METHODS: The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). RECOMMENDATIONS: Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.


Assuntos
Ruptura Prematura de Membranas Fetais , Trabalho de Parto Prematuro/prevenção & controle , Guias de Prática Clínica como Assunto , Nascimento Prematuro , Sociedades Médicas , Prevenção Terciária , Incompetência do Colo do Útero , Áustria , Feminino , Ruptura Prematura de Membranas Fetais/prevenção & controle , Ruptura Prematura de Membranas Fetais/terapia , Humanos , Recém-Nascido , Obstetrícia , Gravidez , Nascimento Prematuro/prevenção & controle , Nascimento Prematuro/terapia , Sistema de Registros
2.
Int J Gynaecol Obstet ; 147(3): 382-388, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31529463

RESUMO

OBJECTIVE: To evaluate risk factors associated with neonatal morbidity and mortality in pregnant women with preterm prelabor rupture of membranes (PPROM) after cervical cerclage. METHODS: A retrospective cohort study of singleton pregnancies with cervical insufficiency was conducted at a tertiary referral center in Taiwan from May 1, 2000 to July 31, 2017. Patients with PPROM after cerclage and delivered between 20 0/7 days and 36 6/7 days were recruited. Logistic and linear regression analyses were performed to evaluate various risk factors. RESULTS: Overall, 109 women were included. Mothers with a higher white blood cell count, a higher C-reactive protein (CRP) level, a lower amniotic fluid index, and chorioamnionitis were significantly associated with neonatal morbidity. Neonatal mortality was related to oligohydramnios (adjusted odds ratio [aOR] 2.98, 95% confidence interval [CI] 1.11-8.01) and chorioamnionitis (aOR 3.17, 95% CI 1.03-9.69). An elevated CRP level was associated with a shorter PPROM to delivery latency (adjusted B -16.64, 95% CI -29.88 to -3.41), but cerclage retention more than 12 hours after PPROM was associated with a prolonged latency (adjusted B 17.21, 95% CI 3.25-31.18). CONCLUSION: Oligohydramnios and chorioamnionitis are associated with neonatal mortality.


Assuntos
Ruptura Prematura de Membranas Fetais/epidemiologia , Nascimento Prematuro/prevenção & controle , Incompetência do Colo do Útero/cirurgia , Adulto , Cerclagem Cervical/estatística & dados numéricos , Corioamnionite/mortalidade , Feminino , Ruptura Prematura de Membranas Fetais/mortalidade , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Oligo-Hidrâmnio/mortalidade , Gravidez , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/etiologia , Nascimento Prematuro/metabolismo , Estudos Retrospectivos , Fatores de Risco , Taiwan
3.
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
4.
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
5.
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
6.
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
7.
Int J Gynaecol Obstet ; 146(2): 223-230, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31004354

RESUMO

OBJECTIVE: To determine whether term fetal membranes from transabdominal cerclage (TAC) patients have favorable characteristics compared with membranes from patients without TAC. METHODS: A prospective study of consecutive pregnant women who had undergone TAC and were delivered by elective cesarean after 37 weeks before the onset of labor at Cliniques universitaires Saint-Luc, Brussels, between January 2015 and June 2016. Membranes were collected from two areas: overlying the cervix and located far from the cervix. Membrane thickness, 15-hydroxyprostaglandin dehydrogenase (PGDH), toll-like receptor-2 (TLR2) expression, and senescence were measured and compared between the TAC group and a control group without TAC enrolled using the same study criteria. RESULTS: In the cervical area of the TAC group, the chorion was significantly thicker (P=0.003). PGDH and TLR2 expression were also significantly increased in the cervical area of the TAC group (P=0.021 and P=0.043, respectively). Senescence was significantly decreased in the TAC group (P=0.001). CONCLUSION: A significant relationship between chorion thickening and increase in PGDH and TLR2 expression and decrease in senescence was reported in the cervical area of membranes in the TAC group. These membrane changes could prevent triggering of parturition and may account for favorable outcomes and clinical success in pregnancies with TAC.


Assuntos
Cerclagem Cervical , Córion/patologia , Membranas Extraembrionárias/patologia , Incompetência do Colo do Útero/terapia , Adulto , Estudos de Casos e Controles , Cesárea , Feminino , Humanos , Hidroxiprostaglandina Desidrogenases/metabolismo , Gravidez , Estudos Prospectivos
8.
Am J Obstet Gynecol ; 221(2): 140.e1-140.e18, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30928565

RESUMO

BACKGROUND: Cervical insufficiency is a risk factor for spontaneous midtrimester abortion or early preterm birth. Intra-amniotic infection has been reported in 8-52% of such patients and intra-amniotic inflammation in 81%. Some professional organizations have recommended perioperative antibiotic treatment when emergency cervical cerclage is performed. The use of prophylactic antibiotics is predicated largely on the basis that they reduce the rate of complications during the course of vaginal surgery. However, it is possible that antibiotic administration can also eradicate intra-amniotic infection/inflammation and improve pregnancy outcome. OBJECTIVE: To describe the outcome of antibiotic treatment in patients with cervical insufficiency and intra-amniotic infection/inflammation. STUDY DESIGN: The study population consisted of 22 women who met the following criteria: (1) singleton pregnancy; (2) painless cervical dilatation of >1 cm between 16.0 and 27.9 weeks of gestation; (3) intact membranes and absence of uterine contractions; (4) transabdominal amniocentesis performed for the evaluation of the microbiologic and inflammatory status of the amniotic cavity; (5) presence of intra-amniotic infection/inflammation; and (6) antibiotic treatment (regimen consisted of ceftriaxone, clarithromycin, and metronidazole). Amniotic fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas, and polymerase chain reaction for Ureaplasma spp. was performed. Intra-amniotic infection was defined as a positive amniotic fluid culture for microorganisms or a positive polymerase chain reaction for Ureaplasma spp., and intra-amniotic inflammation was suspected when there was an elevated amniotic fluid white blood cell count (≥19 cells/mm3) or a positive rapid test for metalloproteinase-8 (sensitivity 10 ng/mL). For the purpose of this study, the "gold standard" for diagnosis of intra-amniotic inflammation was an elevated interleukin-6 concentration (>2.6 ng/mL) using an enzyme-linked immunosorbent assay. The results of amniotic fluid interleukin-6 were not available to managing clinicians. Follow-up amniocentesis was routinely offered to monitor the microbiologic and inflammatory status of the amniotic cavity and fetal lung maturity. Treatment success was defined as resolution of intra-amniotic infection/inflammation or delivery ≥34 weeks of gestation. RESULTS: Of 22 patients with cervical insufficiency and intra-amniotic infection/inflammation, 3 (14%) had microorganisms in the amniotic fluid. Of the 22 patients, 6 (27%) delivered within 1 week of amniocentesis and the remaining 16 (73%) delivered more than 1 week after the diagnostic procedure. Among these, 12 had a repeat amniocentesis to assess the microbial and inflammatory status of the amniotic cavity; in 75% (9/12), there was objective evidence of resolution of intra-amniotic inflammation or intra-amniotic infection demonstrated by analysis of amniotic fluid at the time of the repeat amniocentesis. Of the 4 patients who did not have a follow-up amniocentesis, all delivered ≥34 weeks, 2 of them at term; thus, treatment success occurred in 59% (13/22) of cases. CONCLUSION: In patients with cervical insufficiency and intra-amniotic infection/inflammation, administration of antibiotics (ceftriaxone, clarithromycin, and metronidazole) was followed by resolution of the intra-amniotic inflammatory process or intra-amniotic infection in 75% of patients and was associated with treatment success in about 60% of cases.


Assuntos
Antibacterianos/uso terapêutico , Corioamnionite/tratamento farmacológico , Incompetência do Colo do Útero/microbiologia , Adulto , Amniocentese , Líquido Amniótico/metabolismo , Líquido Amniótico/microbiologia , Biomarcadores/metabolismo , Candida albicans/isolamento & purificação , Ceftriaxona/uso terapêutico , Cerclagem Cervical , Corioamnionite/microbiologia , Claritromicina/uso terapêutico , Parto Obstétrico , Feminino , Humanos , Interleucina-6/metabolismo , Leucócitos/metabolismo , Metaloproteinase 8 da Matriz/metabolismo , Metronidazol/uso terapêutico , Gravidez , Estudos Retrospectivos , Streptococcus anginosus/isolamento & purificação , Ureaplasma/isolamento & purificação
9.
J Perinat Med ; 47(5): 500-509, 2019 Jul 26.
Artigo em Inglês | MEDLINE | ID: mdl-30849048

RESUMO

Background The frequency of intra-amniotic infection/inflammation (IAI/I) in patients with midtrimester cervical insufficiency is up to 50%. Our purpose was to determine the perinatal outcomes of cervical cerclage in patients with acute cervical insufficiency with bulging membranes, and to compare the admission-to-delivery interval and pregnancy outcomes according to the results of amniotic fluid (AF) analysis and cerclage placement. Methods This was a retrospective cohort study including singleton pregnancies with cervical insufficiency between 15 and 26.9 weeks in two tertiary health centers. IAI/I was defined when at least one of the following criteria was present in AF: (a) a white blood cell (WBC) count >50 cells/mm3; (b) glucose concentration <14 mg/dL; and/or (c) a Gram stain positive for bacteria. Three different groups were compared: (1) absence of IAI/I with placement of a cerclage; (2) amniocentesis not performed with placement of a cerclage; and (3) IAI/I with or without a cerclage. Results Seventy patients underwent an amniocentesis to rule out IAI/I. The prevalence of IAI/I was 19%. Forty-seven patients underwent a cerclage. Patients with a cerclage had a longer median admission-to-delivery interval (33 vs. 2 days; P < 0.001) and delivered at a higher median gestational age (27.4 vs. 22.6 weeks; P = 0.001) than those without a cerclage. The neonatal survival rate in the cerclage group was 62% vs. 23% in those without a cerclage (P = 0.01). Patients without IAI/I who underwent a cerclage had a longer median admission-to-delivery interval (43 vs. 1 day; P < 0.001), delivered at a higher median gestational age (28 vs. 22.1 weeks; P = 0.001) and had a higher neonatal survival rate (67% vs. 8%; P < 0.001) than those with IAI/I. Conclusion The pregnancy outcomes of patients with midtrimester cervical insufficiency and bulging membranes are poor as they have a high prevalence of IAI/I. Therefore, a pre-operative amniocentesis is key to identify the best candidates for the subsequent placement of a cerclage.


Assuntos
Cerclagem Cervical/estatística & dados numéricos , Incompetência do Colo do Útero/terapia , Adulto , Feminino , Humanos , Gravidez , Resultado da Gravidez , Estudos Retrospectivos , Adulto Jovem
11.
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
12.
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
13.
Gynecol Obstet Fertil Senol ; 47(3): 273-280, 2019 03.
Artigo em Francês | MEDLINE | ID: mdl-30745158

RESUMO

OBJECTIF: Balloon catheters for labor induction at term after previous cesarean section is an alternative option to iterative cesarean section. The aim of this study was to analyze the maternal and neonatal outcomes of the trial of labor after cesarean (TOLAC) in women with unfavorable cervix and balloon catheter induction, 2 years after introduction of this process. METHODS: Unicentric observational study of women with term cephalic singleton, unfavorable cervix (simplified Bishop score<5) after TOLAC using double-balloon catheter. Were analyzed the mode of delivery and severe maternal (uterine rupture, post-partum hemorrhage, severe perineal tears) and neonatal (neonatal unit admission, APGAR<7 at 5minutes, pH<7.1) outcomes. Predictive factors for failed TOLAC were analyzed by using multivariate logistic regression. RESULTS: Between 2016-2017, 455 (75.4%) women had TOLAC, whose 59 (13%) women with balloon catheter. The overall vaginal delivery (VD) was 73.9%. After Balloon catheter, the VD rate was 50.8%, versus 79.1% after spontaneous labor, and 68.2% after alone oxytocin/artificial membrane rupture induction (P<0.05). Previous VD (aOR 0.176 CI-95% [0.048-0.651]) and prior sweeping membrane (aOR 0.161 CI-95% [0.034-0.761]) was protective for cesarean section after TOLAC. Severe maternal and neonatal morbidities were observed in 10 (17%) and 8 (13.6%) cases, respectively. CONCLUSION: Double-Balloon catheter is an option for unfavorable cervix and term induction after previous cesarean section. However, the TOLAC in women whose unfavorable cervix is not without maternal and neonatal risk, especially due to its failure.


Assuntos
Cateterismo/métodos , Trabalho de Parto Induzido/métodos , Resultado da Gravidez , Prova de Trabalho de Parto , Nascimento Vaginal Após Cesárea/estatística & dados numéricos , Adulto , Cateterismo/instrumentação , Cesárea , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Trabalho de Parto Induzido/efeitos adversos , Gravidez , Estudos Retrospectivos , Fatores de Risco , Falha de Tratamento , Incompetência do Colo do Útero/terapia
14.
J Matern Fetal Neonatal Med ; 32(22): 3757-3763, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29764255

RESUMO

Objective: To study the effect of McDonald cerclage knot position on the different maternal and neonatal outcomes. Methods: This historical cohort study included women with singleton pregnancy who had a prophylactic McDonald cervical cerclage between 1 May 2010 and 31 September 2017. Maternal and neonatal outcome parameters were compared between the anterior and posterior knot cerclage procedures. The primary outcome measure was the rate of term birth. Results: 550 Women had a prophylactic McDonald cervical cerclage, 306 with anterior knot (Group A) and 244 with posterior knot (Group B). There were no statistically significant differences regarding gestational age (GA) at delivery (36.3 ± 4.2 versus 35.8 ± 5.3 for groups A and B respectively), term birth rate, post-cerclage cervical length, symptomatic vaginitis, urinary tract infection, difficult cerclage removal and cervical lacerations. Similarly, there were no statistically significant differences as regards the studied neonatal outcomes including take home babies, neonatal intensive care admission, respiratory distress syndrome and neonatal sepsis. Survival analysis on GA at delivery demonstrated no statistically significant difference as regards the proportion of term deliveries in the anterior and posterior knot cerclage groups (log-rank test p-value = .478). Conclusions: Knot positioning during McDonald cervical cerclage, anteriorly or posteriorly, didn't significantly impact the studied maternal and neonatal outcomes.


Assuntos
Cerclagem Cervical/métodos , Trabalho de Parto Prematuro/prevenção & controle , Técnicas de Sutura , Incompetência do Colo do Útero/cirurgia , Adulto , Cerclagem Cervical/efeitos adversos , Cerclagem Cervical/mortalidade , Estudos de Coortes , Feminino , Idade Gestacional , Humanos , Lactente , Mortalidade Infantil , Masculino , Trabalho de Parto Prematuro/mortalidade , Gravidez , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/mortalidade , Nascimento Prematuro/prevenção & controle , Análise de Sobrevida , Técnicas de Sutura/efeitos adversos , Técnicas de Sutura/mortalidade , Incompetência do Colo do Útero/mortalidade , Adulto Jovem
15.
J Matern Fetal Neonatal Med ; 32(20): 3408-3414, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29712493

RESUMO

Objective: To compare obstetrical outcomes on women undergoing a McDonald or Shirodkar cerclage and to estimate the impact of maternal body mass index (BMI) on these outcomes. Methods: We conducted a retrospective review of the medical records of all women with singleton pregnancies who underwent placement of a McDonald or Shirodkar cerclage at St. Francis Hospital from January 2008 to October 2013. The subjects were categorized based on BMI groups (normal: less than 25 kg/m2, overweight: 25-29 kg/m2, obese: 30 kg/m2 or more). The primary outcome was gestational age at delivery. Statistical analyses included chi-square, Student's t-test, and multivariable regression analysis. Results: Of 95 women, 47 (49.5%) received a Shirodkar, and 48 (50.5%) a McDonald cerclage. 16 women (16.8%) were categorized as normal weight, 35 (36.8%) as overweight, and 44 (46.3%) as obese. Gestational age at delivery differed significantly by group, decreasing with each categorical increase in BMI (normal: 39.0 ± 0.3 weeks; overweight: 36.6 ± 0.7 weeks; obese: 33.0 ± 1.1 weeks; p < .01). Overall, women receiving a Shirodkar cerclage had significantly longer pregnancies than women with a McDonald cerclage (36.7 ± 0.6 weeks versus 33.9 ± 1.0 weeks; p = .02). However, analysis showed a significant interaction between weight status and gestational age at delivery. Obese women had significantly longer pregnancies when they received a Shirodkar cerclage versus a McDonald cerclage (32.6 ± 1.0 weeks versus 28.8 ± 0.9 weeks; p < .01). However, there was no significant difference in gestational age at delivery between women categorized as normal/overweight (Shirodkar: 33.5 ± 0.9 weeks; McDonald: 32.9 ± 0.9 weeks; p = .63). Conclusions: Compared to obese women receiving a McDonald cerclage, obese women receiving a Shirodkar cerclage had significantly longer pregnancies. No significant differences in pregnancy duration were found in normal/overweight women regardless of cerclage technique. Pregnancy duration in obese women receiving a Shirodkar cerclage was similar to the pregnancy duration of normal/overweight women.


Assuntos
Índice de Massa Corporal , Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle , Incompetência do Colo do Útero/cirurgia , Adulto , Cerclagem Cervical/mortalidade , Cerclagem Cervical/estatística & dados numéricos , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Mortalidade Materna , Trabalho de Parto Prematuro/epidemiologia , Trabalho de Parto Prematuro/prevenção & controle , Gravidez , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos , Incompetência do Colo do Útero/epidemiologia
16.
J Matern Fetal Neonatal Med ; 32(14): 2287-2294, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29357727

RESUMO

OBJECTIVE: Hypoxia inducible factor 1α (HIF1α) has been reported to activate inflammatory cascade. Recently, exosomes have been known to have pivotal roles in intercellular communication. The aim of this study was to compare the concentration of amniotic fluid (AF) HIF1α, exosomal HIF1α, and inflammatory cytokines such as interleukin 1α (IL1α), interleukin 1ß (IL1ß), interleukin 6 (IL6), and tumor necrosis factor α (TNFα) between physical examination-indicated cerclage (PEIC) and control group. We also investigated the associations between biomarkers and amniocentesis-to-delivery interval and the correlations of inflammatory cytokines, HIF1α, and exosomal HIF1α. METHODS: Case-control study was performed. Cases are defined as 16 patients who underwent PEIC and controls are 19 women who underwent amniocentesis for confirming chromosomal abnormalities. The concentration of IL1α, IL1ß, IL6, TNFα, HIF1α, and exosomal HIF1α were measured using enzyme-linked immunosorbent assay (ELISA). Exosomes were confirmed by tumor susceptibility Gene 101 (TSG 101) and transmission electron microscopy (TEM). RESULTS: The mean HIF1α in PEIC group was higher than control group (PEIC, 15.03 ± 9.60-pg/mL versus control, 2.96 ± 1.99 pg/mL; p < .01). There were significant differences in inflammatory cytokines between two groups. A significant difference in exosomal HIF1α was shown between two groups (PEIC, 27.97 ± 28.61-µg/mL versus control, 12.42 ± 8.20 µg/mL; p < .01). HIF1α, IL1α, IL6, TNFα, and exosomal HIF1α showed significantly negative association with cerclage-to-delivery interval. However, IL1ß was not associated with cerclage-to-delivery interval. HIF1α was positively correlated with exosomal HIF1α (rho = 0.93, p < .01). Both HIF1α and exosomal HIF1α were significantly associated with TNFα (rho = 0.94, p < .01; rho = 0.97, p < .01). Both HIF-1α and exosomal HIF1α had positive correlation with IL1α (rho = 0.96, p < .01; rho = 0.91, p < .01). However, IL1ß showed no correlations with HIF1α and exosomal HIF1α. A positive correlation between HIF-1α and IL6 was observed (rho = 0.58, p = .01.) Exosomal HIF1α also had correlation with IL6 (rho = 0.52, p = .03). CONCLUSIONS: This study demonstrated that amniotic fluid (AF) HIF1α and AF exosomal HIF1α were higher in physical examination-indicated cerclage (PEIC) group than control group. AF HIF1α and AF exosomal HIF1α were associated with shorter amniocentesis-to-delivery interval. More importantly, they had positive correlations with AF inflammatory cytokines such as IL1α, IL6, and TNFα. Our results may indicate that AF HIF1α and AF exosomes interact with AF inflammatory cytokines and contribute inflammatory cascade in complicated pregnancies.


Assuntos
Líquido Amniótico/metabolismo , Subunidade alfa do Fator 1 Induzível por Hipóxia/análise , Incompetência do Colo do Útero/metabolismo , Adulto , Amniocentese/estatística & dados numéricos , Estudos de Casos e Controles , Cerclagem Cervical , Ensaio de Imunoadsorção Enzimática , Exossomos/metabolismo , Feminino , Humanos , Recém-Nascido , Interleucina-1beta/análise , Interleucina-6/análise , Gravidez , Nascimento Prematuro , Estudos Retrospectivos , Fator de Necrose Tumoral alfa/análise , Incompetência do Colo do Útero/cirurgia
17.
J Matern Fetal Neonatal Med ; 32(18): 3007-3011, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29631471

RESUMO

Objectives: To evaluate the safety and effectiveness of late cervical cerclage performed beyond 17 weeks of gestation. The outcomes of interest were effectiveness of late cerclage in prolongation of pregnancy and evaluation of pregnancy outcome including maternal and fetal complications. Study design: A total of 30 patients underwent late cervical cerclage during the study period. Of them, two were twin pregnancies. A late cerclage was performed after the diagnosis of cervical shortening or dilatation in 20 patients. We performed a retrospective case series review. One case was lost to follow up (delivery in another medical center). Medical information was retrieved from all cases of patients who underwent a late cervical cerclage between the years 2010 and 2016 at the Soroka University Medical Center, a tertiary medical center. Continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as proportions. Results: The average gestational age at birth was 35 ± 5.1 weeks of gestation. The mean interval between cerclage and delivery in the study population was 17 ± 5.62 weeks. Nine cases (32.1%) resulted in preterm deliveries, three of them below 34 weeks of gestation (one twin pregnancy and two pregnancies diagnosed with cervical dilation prior to cerclage). Among all the preterm deliveries, there were four cases of preterm prelabor rupture of membranes (13.3%). Of the 28 deliveries, 24 women (85.7%) had a vaginal delivery, while four women (14.3%) underwent a cesarean section. No cases of cervical tear were described. The cerclage was sent to bacteriology after removal, showing positive cultures for Candida species in nine cases (31%). Conclusions: In our study population, late cervical cerclage was found to be a safe procedure resulting in almost 90% of successful vaginal deliveries without maternal or fetal complications. This procedure might be effective in the prolongation of pregnancy in women with cervical dynamics in the late second trimester.


Assuntos
Cerclagem Cervical/efeitos adversos , Nascimento Prematuro/prevenção & controle , Incompetência do Colo do Útero/cirurgia , Adulto , Cerclagem Cervical/estatística & dados numéricos , Parto Obstétrico/estatística & dados numéricos , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Nascimento Vivo/epidemiologia , Masculino , Gravidez , Segundo Trimestre da Gravidez , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
18.
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
19.
Eur J Obstet Gynecol Reprod Biol ; 232: 70-74, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30476879

RESUMO

OBJECTIVE: High-risk pregnancy stratification and the use of Progesterone and prophylactic cerclage based on prior obstetrical outcomes and cervical length screening have been successful in curbing the impact of preterm birth. However, a large number of women will still suffer from preterm delivery even with optimal management. Experts agree that a transabdominal cerclage is the next best option for women who fail a transvaginal cerclage in a prior pregnancy. Our primary objective with this study is to assess the obstetric benefits and feasibility of robotic-assisted transabdominal cerclage in high-risk women projected to have poor obstetric outcomes. STUDY DESIGN: A multicenter retrospective cohort analysis of consecutive patients undergoing a robotic-assisted transabdominal cerclage (RA-TAC) for obstetric indications at two urban teaching university hospital and one academically affiliated community hospital. High-volume gynecologic surgeons performed all transabdominal cerclage procedures (N = 68). To assess whether the transabdominal cerclage had any effect on subsequent pregnancies, we categorized gestational age into ordinal variables and used a two-proportion z-test to compare pregnancy outcomes and neonatal survival pre (n = 200) and post (n = 59) abdominal cerclage placement. RESULTS: A total of 68 consecutive patients undergoing a RA-TAC for obstetric indications were selected. We compared 200 pregnancies pre-robot-assisted cerclage to 59 pregnancies post-robot-assisted cerclage. The odds of delivering after 34 and 37 weeks gestational age was 4.0 and 3.6 times greater post-robot-assisted cerclage, respectively (P < 0.001). The RA-TAC also had a significant effect on neonatal survival. The odds of neonatal survival was 12.6 times greater after RA-TAC placement when compared to prior pregnancy outcomes. Surgical outcomes were also favorable with no conversions to laparotomy or perioperative pregnancy loss. CONCLUSION: The RA-TAC influences an increase in gestational age and improves neonatal survival in women projected to have poor pregnancy outcomes. The robot-assisted transabdominal cerclages provide excellent obstetric outcomes without the morbidity of a laparotomy or the technical challenges associated with a conventional straight-stick laparoscopy. This procedure is not intended to replace any other minimally invasive modality for cerclage placement but rather increase awareness of a less technically challenging option for transabdominal cerclage placement to help propagate the procedure to more patients.


Assuntos
Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle , Procedimentos Cirúrgicos Robóticos/métodos , Incompetência do Colo do Útero/cirurgia , Adulto , Feminino , Idade Gestacional , Humanos , Gravidez , Resultado da Gravidez , Estudos Retrospectivos , Resultado do Tratamento
20.
Int J Med Robot ; 15(1): e1966, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30315678

RESUMO

INTRODUCTION: The gold standard in the management of cervical incompetence is cerclage via vaginal approach. Minimally invasive techniques, such as robotic, have been also described. MATERIALS AND METHODS: A systematic search was performed in PubMed and Scopus, searching evidence on robotic assisted laparoscopic cerclage in both pregnant and non pregnant women. RESULTS: Sixty-four patients were included in this study. Cervical insufficiency, failure of transvaginal cerclage, and short cervix were the most frequent indications for robotic assisted cerclage. Mean operative time was 107.3 minutes. Mean estimated blood loss was 62.8 mL. Four patients converted to laparotomy. No postoperative complications were reported. Pregnancy after robotic cerclage was reported in 59 patients with mean gestational age at delivery of 36.4 weeks. The majority of pregnant women who underwent robotic assisted cerclage gave birth to live neonates. CONCLUSION: Till now, evidence does not show a clear advantage of robotic over laparoscopic approach, under the evaluation of the current literature. However, further comparative studies might be essential to clarify the possible role of da Vinci robot in this field; this might be quite difficult even in the near future based on the fact that only five cases per year are described in the current literature.


Assuntos
Laparoscopia/métodos , Procedimentos Cirúrgicos Robóticos , Incompetência do Colo do Útero/cirurgia , Adulto , Colo do Útero/cirurgia , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Duração da Cirurgia , Complicações Pós-Operatórias , Gravidez
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