Cervical Suture Research Articles

Management and outcome of 21 triplet and quadruplet pregnancies

The course of gestation and the outcome of fifteen triplet and six quadruplet pregnancies are reviewed. Twenty pregnancies followed induction of ovulation and only one was spontaneous. Bed rest, the use of β-mimetics and betamethasone, and prolonged hospitalisation were part of the management. Elective cervical suture was not used. The most frequent antenatal complications were preterm labor, preterm rupture of membranes and pregnancy-induced hypertension. The median gestational age was 33.5 weeks in the triplets and 32 weeks in the quadruplets. The overall perinatal and neonatal mortality was 4.9%. The neonatal complications resulted from prematurity and sepsis.

Is Elective Cerclage Justified in the Management of Triplet and Quadruplet Pregnancy?

The main complication in multiple gestation with more than two fetuses is prematurity, with its concomitant increase in perinatal mortality and morbidity. Clearcut indications as to management of these pregnancies are lacking, and the efficiency of elective cerclage is controversial. Twelve triplets and three quadruplets out of 27 multiple pregnancies were electively sutured and compared to 10 triplets and two quadruplets without this procedure. Otherwise, both groups were managed uniformly regarding bed-rest, beta-mimetic drugs and dexamethasone for the enhancement of fetal lung maturity. Mean duration of pregnancy in patients with cerclage was 35 weeks, significantly longer than those who did not undergo this procedure (30.7 weeks) (p < 0.01). Furthermore, in the former group, the mean neonatal weight was significantly higher (p < 0.01), mean Apgar scores were better, significantly lower rates of respiratory distress syndrome occurred (p < 0.05), perinatal mortality rate was significantly reduced (p < 0.01) and the mean hospitalization period was shorter (p < 0.025). It seems that elective cervical suture is a definite contribution to the successful management of multiple pregnancies with more than two fetuses.

Surgical management of acquired post-intubation tracheo-oesophageal fistulas: 27 patients.

From 1962 to 1987, 27 patients with tracheo-oesophageal fistulae (TOF) were treated at our institution. Mean age was 43 years. The indications for respiratory support were blunt chest trauma (11), neurological dysfunction (8), and acute pulmonary distress syndrome (8). TOF symptoms occurred 12-200 days (mean 43) after initiation of ventilatory support and was caused by tracheostomy tube cuff (17), intubation tube cuff (8), or injury at the site of tracheostomy (2). The size of the fistula ranged from 0.3 to 5 cm (mean 2 cm). Seventeen of the 27 patients were operated upon. A simple repair of the TOF was performed via a cervical approach in 10 patients; tracheal resection and reconstruction was done in 4 patients presenting with tracheal stenosis, while 2 patients with slight tracheal stenosis had a simple repair of the TOF without the need for further tracheal surgery. Three patients underwent primary oesophagostomy, followed later by colon interposition. Five patients died. Ten cases were not operated upon: the TOF closed spontaneously in 1 patient, 1 patient was lost to follow-up and 8 died. In our series, significant tracheal stenosis occurred in only 6 patients (22%), only 4 of whom had tracheal resection. Simple repair of TOF provides excellent results with a low mortality (10%) considering the poor condition of the patients, and should be considered the procedure of choice. Surgical oesophageal diversion (i.e. cervical oesophagostomy and suture of distal oesophagus) is usually unnecessary.

Streptococcus milleri and second trimester abortion.

Review of 214 fetal necropsies performed in the department of pathology, University of Aberdeen, showed 40 cases of chorioamnionitis or intrauterine pneumonia, five of which were associated with Streptococcus milleri. In two cases there was good evidence to implicate S milleri as the cause of infected abortion while in the other cases its pathogenic role was less clear.

Management of Airway Trauma II: Combined Injuries of the Trachea and Esophagus

Twenty-four consecutive patients with combined injuries of the trachea and esophagus were operated on at the Tulane University Hospital and the Charity Hospital of New Orleans between 1967 and 1983. Only 3 of the injuries resulted from blunt trauma, and 1 of these patients had a total transection of both the trachea and esophagus; the remaining injuries were due to penetrating trauma (20 gunshot wounds; 1 stab wound). The combined lesions involved the cervical region in 20 patients and the thoracic esophagus and trachea or bronchus in 4. All patients underwent bronchoscopy; in recent years all have had esophagoscopy, because our experience indicates that esophagrams, which patients also underwent, have a high rate (12.5%) of false negative results. Operative techniques included a two-layer closure of all esophageal injuries, closure of the trachea with nonabsorbable monofilament suture, and transthoracic or cervical drainage. Muscle flaps were used for suture line reinforcement. Associated operative procedures included tracheostomy (5), laparotomy (4), vascular procedures (5), neurologic procedures (2), and closed-tube thoracostomy (6). Five patients (21%) died in the perioperative period, 4 of 20 with combined cervical injuries, and 1 of the 4 with combined thoracic injuries. Deaths resulted from missed injuries to the esophagus (2 patients), a missed tracheal injury (1), associated vascular injury (1), and associated thoracoabdominal injury (1). Two patients experienced cervical esophageal suture line leaks, both of which sealed with conservative therapy. Clinical follow-up showed good results in 90% of the patients who survived. One patient had late neurologic sequela of the injury, including spinal cord trauma and recurrent nerve paralysis, and 1 had pharyngeal paralysis from extensive neurologic damage in the neck. No patient had esophageal or tracheal stenosis.

A Randomized Controlled Trial of Cervical Cerclage in Women at High Risk of Spontaneous Preterm Delivery

The effect of cervical suture on pregnancy outcome was studied in 194 women with a high risk (approximately 30%) of having a late abortion or a preterm delivery. The women were randomly allocated either to have a cervical suture inserted (n = 96) or to be managed without a suture (n = 98). There was no evidence that cervical cerclage either prolonged gestation or improved survival. Patients allocated to receive cerclage spent significantly longer in hospital, even when the period of admission for insertion was excluded. The patients in the cerclage group were more likely to receive tocolytic drugs, and more of them experienced puerperal pyrexia, although these differences between the groups were not statistically significant.

Spinal anaesthesia revisited: an evaluation of subarachnoid block in obstetrics.

A series of 442 women receiving subarachnoid block for various obstetrical procedures is described. These included caesarean section, instrumental delivery, manual removal of placenta, insertion of cervical suture and miscellaneous procedures. General anaesthesia was required in ten patients because subarachnoid block proved to be unsatisfactory. There were no serious complications. The overall headache rate, ascertained by daily direct questioning during hospital admission, was 26.2%. Clinical features of dural puncture headache (DPH) were present in 8.6% and equivocally so in a further 3.4%. A significantly higher incidence of DPH was recorded among patients receiving a cervical suture. Among the thirty-eight patients who developed DPH, a 25 or 26 SWG spinal needle had invariably been used and in most instances the procedure was described as being uneventful. There were no consistent technical features among the patients who developed DPH, although operator experience may have been a factor. DPH was graded as 'severe' in ten patients (2.3%) and an epidural blood patch was rapidly curative in each of these cases. One patient required a repeat patch. Subarachnoid block proved to be a satisfactory technique for the procedures outlined in the survey. It proved to be particularly valuable when anaesthesia was required urgently in the delivery suite and may even be regarded as the anaesthetic of choice in these circumstances.

A randomized controlled trial of cervical cerclage in women at high risk of spontaneous preterm delivery

The effect of cervical suture on pregnancy outcome was studied in 194 women with a high risk (approximately 30%) of having a late abortion or a preterm delivery. The women were randomly allocated either to have a cervical suture inserted (n = 96) or to be managed without a suture (n = 98). There was no evidence that cervical cerclage either prolonged gestation or improved survival. Patients allocated to receive cerclage spent significantly longer in hospital, even when the period of admission for insertion was excluded. The patients in the cerclage group were more likely to receive tocolytic drugs, and more of them experienced puerperal pyrexia, although these differences between the groups were not statistically significant.

Gynaecological case reports: Complications of the neglected cervical suture

SummaryCervical circlage in early pregnancy is widely practised as therapy for cervical incompetence (Shirodkar, 1960). Repair of the incompetent cervix between pregnancies has also been suggested (Lash and Lash, 1950). I report the first case to my knowledge where repair of the cervix between pregnancies with non-absorbable material was followed by a vesico-vaginal fistula, due to neglect of the suture; and a further case where long term neglect of the suture gave symptoms.

Understanding preterm labour: the use of Path Analysis.

A retrospective study was performed on 465 spontaneous preterm and 13,949 term births, in order to analyze the sequence of events that culminate in preterm labour. Twenty-one variables were investigated by the mathematical technique of Path Analysis. Nine direct and independent precursors of preterm labour were identified. These were antepartum haemorrhage, poor antenatal attendance, previous delivery of a small baby, multiple pregnancy, proteinuria, grand multiparity, cervical suture, low maternal weight, and a history of bleeding before 20 weeks.

Elective Cervical Suture of Twin Pregnancies Diagnosed Ultrasonically in the First Trimester following Induced Ovulation

Division of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel

Cervical suture in Scotland: strengths and weaknesses in the use of routine clinical summaries.

National routinely collected hospital data for 12 months from June 1976 were used to provide information on patients with cervical suture during pregnancy. The past obstetric history and outcome of the pregnancy after suture was contrasted with the experience of all pregnant women during the same year. The nature of the data did not allow adequate examination of any change in the rate of fetal wastage, before and after suture; or in the secular change in fetal wastage in the pregnant population. After cervical suture the rates of both premature delivery and of perinatal mortality were higher than in the general pregnancy population. The perinatal mortality rate in the cervical suture group showed a greater improvement after suture than was seen to occur between previous and current pregnancies in the whole population, although the excess improvement in pregnancy outcome that occurred after cervical suture could not be definitely ascribed to the suture.

Antenatal infections with Candida species.

The clinical, pathological, and microbiological features of 18 pregnancies complicated by intrauterine infection with Candida sp. are described. Chorioamnionitis with Candida sp. can be recognised macroscopically at birth. Penetration of the umbilical cord and membranes is associated with an intense fetal inflammatory response. The infection characteristically presents in infants of very low birthweight as pneumonia or a skin infection. In nearly every case the organism can be recovered from the gastric aspirate. A case control study showed that there is a striking association between chorioamnionitis caused by Candida sp. and the presence of a foreign body (an intrauterine contraceptive device or a cervical suture) in the mother's genital tract in pregnancy. This feature in the perinatal history of an infant of short gestation who exhibits a very high neutrophil count should alert the clinician to the possible presence of chorioamnionitis due to Candida sp.

Elective cervical suture of twin pregnancies diagnosed ultrasonically in the first trimester following induced ovulation.

The efficiency of elective cervical suture in preventing premature delivery thus reducing neonatal mortality was studied in a group of 50 twin pregnancies. All pregnancies occurred after induction of ovulation and twins were diagnosed early by ultrasound. 25 randomly selected patients underwent elective cervical suture. 22 sutured and 23 non-sutured patients were followed until delivery, while 5 patients aborted in the second trimester. The benefit of suturing on the duration of pregnancy and its outcome were assessed. Of the sutured patients, 10 (45.4%) delivered prematurely and the neonatal death rate was 18.2%. In the non-sutured patients, 11 (47.8%) delivered prematurely and the neonatal death rate was 15.2%. This study demonstrates that elective cervical suture was not effective in prolonging gestation or improving fetal outcome in twin pregnancies following induced ovulation.

Relative Cervical Incompetence in Twin Pregnancy. Assessment and Efficacy of Cervical Suture

A total of 88 women with a twin pregnancy who had elective cervical suture were compared with 76 women with a twin pregnancy who had cervical assessment between the 13th and the 28th weeks of gestation but received no active treatment. The incidence of spontaneous onset of labour before 36 weeks was higher in the cervical suture group, and 53.4% of them sustained cervical damage.

A survey of 59 triplet pregnancies.

The outcome of 59 triplet pregnancies from four hospitals was analyzed. The combined stillbirth and neonatal mortality rate was 232/1000. Preterm labour and birth order were the most important identifiable factors in relation to neonatal death. Birth weight within a triplet set and malpresentation were not related to neonatal death. Elective cervical suture appeared to be of no value in prolonging gestation.

The value of cervical cerclage in the treatment of cervical incompetence

The results from the treatment of cervical incompetence by cervical suturing in 100 consecutive patients are presented. A fetal salvage rate of 88% was achieved when cervical suturing was carried out between the 12th and 14th week of pregnancy.

Risk of pre-term delivery in patients with previous pre-term delivery and/or abortion.

Patients with a history of two or more pregnancies which ended spontaneously before 37 weeks gestation had an increased risk of spontaneous pre-term labour and delivery in future pregnancies. This increased risk related mainly to previous second trimester abortions and not to previous first trimester abortions. Patients with one previous spontaneous pre-term labour and delivery had a 37 per cent risk, and those with two or more pre-term deliveries a 70 per cent risk of again delivering pre-term. There appeared to be no beneficial effect of cervical suture on the incidence of pre-term delivery in these patients.

Closed Submucous Cervical Suture for Cervical Incompetence

Closed Submucous Cervical Suture for Cervical Incompetence

A simple method of removing a cervical suture.

A simple method of removing a cervical suture.