Cerclage utilization in the new millennium: Comparison of a community and university hospital

Abstract

NITY AND UNIVERSITY HOSPITAL DANIEL STEWART, MILDRED RAMIREZ, MARK TURRENTINE, University of Texas Health Science Center at Houston, Department of Obstetrics, Gynecology and Reproductive Sciences, Houston, Texas, Kelsey-Seybold Clinic, Department of Obstetrics & Gynecology, Houston, Texas OBJECTIVE: Despite frequent utilization of cerclage, randomized prospective trials have shown no overall significant reduction in the risk of pregnancy loss. No data is available regarding current clinical practices of obstetrician’s indications for cerclage placement. The purpose of this study was to compare the indications of cerclage between a community and university hospital. STUDY DESIGN: A retrospective review of cerclage utilization from 1/1/ 2000 through 12/31/ 2001 was performed at two obstetrical centers. One a community hospital (CH) with no obstetrical residents and private physicians. The other is associated with a university-based obstetrics and gynecology residency program. Both have level III nurseries and maternal-fetal-medicine physicians on staff. Data was analyzed using two-by-two tables, significance was considered if p ! .05. RESULTS: 387 cerclages (2.4% of deliveries) were placed at the CH compared to the 19 (0.3% of deliveries) at the university hospital (UH), p !. 05. No significant (NS) difference was noted in the number of cerclages placed by a MFM physician at the CH (40.6%) versus (vs) the UH (68.4%). The CH patients were older (31 vs 27 years), more likely to be Caucasian (53.7% vs 21.1%), and have private insurance (95.9% vs 42.1%), p!0.5. NS difference was seen in the median gravidity (3 vs 4) or the number of nulligravid receiving a cercalge (13.4% vs 0%). A significant difference for cerclage indication was noted in women with R two 2nd trimester losses of which 57.9% (n=11) were performed at UH compared to 24.8% (n=96) at the CH, p ! .05.) NS difference was seen between the CH vs. UH for previous cerclage 23.5% (n=91) vs. 26.3% (n=5); short cervix 13.7% (n=53) vs. 0%; history of LEEP or cone 17.6% (n=68) vs 5.3% (n=1); or multiple gestations 11.4% (n=44) vs 10.5% (n=2). CONCLUSION: Cerclage is commonly performed (1/40 deliveries) in a community hospital as compared to a univeristy hospital. Randomized controlled trials are needed to optimize utilization of cerclage and minimize potential over-utilization of this procedure. 445 OBSTETRICAL OUTCOMES ASSOCIATED WITH LAPAROSCOPIC-ASSISTED ABDOMINAL CERCLAGE: AN OBSERVATIONAL STUDY W WHITTLE (F), L GLAUDE, J THOMAS, L ALLEN, S KEATING, R WINDRIM, Mount Sinai Hospital, Obstetrics and Gynecology; Division of Maternal Fetal Medicine, Toronto, Ontario, Canada, Mount Sinai Hospital, Obstetrics and Gynecology, Toronto, Ontario, Canada, Mount Siani Hospital, Pathology and Laboratory Medicine, Toronto, Ontario, Canada OBJECTIVE: Abdominal cerclage is utilized as a management strategy for the true incompetent cervix with previous failed vaginal cerclage; recently the laparoscopic approach to abdominal cerclage placement has been introduced. STUDY DESIGN: The objective of this observational study was to determine the obstetrical outcome associated with laparoscopic-assisted abdominal cerclage. RESULTS: 10 cerclages were placed pre-pregnancy and the remaining 17 cerclages were placed in the first trimester of the index pregnancy. 3 cases were converted from laparoscopy to laparotomy due to technical difficulties; no other surgical complications were reported. 30 pregnancies have occurred with 27 extending beyond the first trimester. 1 pregnancy is currently ongoing. 67% (18/27) of pregnancies were delivered at O32w gestation (mean 36.5w; range 32-39w) due to either idiopathic preterm labor or elective term delivery; no perinatal deaths or longterm neonatal complications were reported. 8 pregnancies (30%) were delivered at !32w with a mean gestational age of 24w (range 17-29w); 4 pregnancies were delivered previablilty (!24w) and 1 neonatal death occurred following delivery at 25w. 6 pregnancies were delivered secondary to clinical chorioamnionitis; placental pathology revealed severe chorioamnionitis in each case with no evidence of other pathologies including ischemic-thrombotic damage. 5 of these cases presented as a cerclage failure with a short/dilated cervix and underwent rescue vaginal cerclage; all 6 cases were delivered within 2w of presentation regardless of management. 2 pregnancies were delivered secondary to idiopathic preterm labor; placental pathology revealed acute abruption in 1 case. The timing of the cerclage placement did not influence obstetrical outcome. CONCLUSION: The laparoscopic assisted abdominal cerclage is associated with w70% successful pregnancy outcome. However, the incompetent cervix appears to encompass a spectrum of disease for which, in the extreme circumstance, an abdominal cerclage may not prevent the cervical failure that leads to preterm birth.