McDonald Procedure Research Articles

The efficacy of therapeutic cervical cerclage in singleton pregnancies: a retrospective study

Objectives We compared the pregnancy prolongation effect attributable to cervical cerclage to that achieved by conservative management, and determined the cervical length for which cervical cerclage is effective. Methods We retrospectively examined medical records of 281 women admitted to our hospital between January 2013 and December 2017 for management of threatened preterm birth at 22−28 weeks of gestation. Obstetricians determined suitability for cervical cerclage, which was performed using the McDonald procedure in all cases. Of the 281 subjects, 71 underwent cervical cerclage (cerclage group); the other 210 received conservative therapy (non-cerclage group). We recorded maternal and neonatal characteristics of all patients. The two groups were compared in terms of length of extension of pregnancy and weeks of gestation at delivery. Multivariate analysis was performed to identify factors associated with extension of time to delivery. Results Our analyses revealed that the cerclage group was hospitalized earlier in pregnancy than the non-cerclage group (23.7 ± 1.5 weeks vs. 26.4 ± 1.9 weeks, p < .001) and had shorter cervixes (6.0 ± 9.4 mm vs. 16.9 ± 13.0 mm, p < .001). The two groups did not differ significantly in terms of gestational weeks at delivery. Multivariate analysis regarding extension of pregnancy revealed significant differences in extension of pregnancy related with cervical cerclage (26.65 days, 95% CI 17.0 − 36.3, p < .001) and cervical length <10 mm (−27.4 days, 95% CI −36.0–−18.8, p < .001). While the time to delivery was extended by cervical cerclage in women with short cervixes (<25 mm), the two groups did not differ when cervical length was ≥15 mm. Conclusions Cervical cerclage was a significant positive factor and short cervix was a significant negative factor for elongating pregnancy. In primigravida and multigravida women with no history of preterm birth, when the cervix is short (<10 mm), cervical cerclage should be recommended.

Comparison of cerclage and pessary in prevention of preterm birth in twin pregnancies.

Background: The preterm labor has increased in multiple pregnancies over the past 2 decades. Preterm labor has led to increase in neonatal mortality rates, long-term morbidity, respiratory distress, and neonatal infections. Thus, this study aimed at investigating the effect of cerclage versus pessary on the prevention of preterm birth in twin pregnancies. Methods: This prospective randomized clinical trial was performed on 50 women pregnant with twins who visited Taleghani hospital in 2016-2018. Their cervical length, which was measured by transvaginal ultrasonography (TVS), was less than 30 millimeters at week 14 of pregnancy. The participants were randomly divided into 2 groups (n=25). They separately underwent cervical pessary and cerclage. McDonald's procedure was performed in cerclage group from 14 to 27 weeks. The suture material was Mersilene Ethicon 5-0 double-armed s14 needle. Ring hodge pessary was also inserted in the vagina of the participants in the pessary group. All the patients were injected 250 mg intramuscular 17 alpha-hydroxyprogesterone caproate weekly from week 16 to week 36. All statistical analyses were performed using SPSS 18 software. Results: The results of this study showed that the mean ± standard deviation (SD) for pregnancy length of the cerclage and pessary groups were 238.6±32.4 and 223.6±16.6, respectively. Also, significant differences were found between the 2 groups (p=0.048). No significant difference was found in pregnancy (p=0.565), length of pessary/cerclage use (p=0.491), and BMI before and after delivery between the cerclage and pessary groups (p>0.05). Conclusion: The use of cerclage in twin pregnancies is recommended to increase the length of pregnancy.

Factors associated with delivery at or after 28 weeks gestation in women with bulging fetal membranes before 26 weeks gestation

Objective: To elucidate the factors that contribute to prolonged pregnancy and promote neonate survival in women with bulging fetal membranes. Methods: A database was reviewed to identify women with singleton pregnancies who underwent amniocentesis on admission to determine amniotic fluid neutrophil elastase levels before 26 + 0 weeks gestation between July 2001 and January 2015. Following delivery, the placentas of these patients were examined for histologic chorioamnionitis. Results: Ninety-seven women delivered before 28 weeks gestation, and 117 women delivered at or after 28 weeks gestation. Rescue cerclage performed via the McDonald procedure (adjusted odds ratio [aOR]: 3.78; 95% confidence interval [CI]: 1.35–11.80) was associated with a higher likelihood of reaching at least 28 weeks gestation before delivery, whereas protruding membranes (aOR: 0.38; 95% CI: 0.18–0.78), elevated amniotic neutrophil elastase levels (≥0.15 μg/ml) (aOR, 0.41; 95% CI: 0.20–0.82) and elevated peripheral C-reactive protein levels (≥0.4 mg/dl) (aOR: 0.34; 95% CI: 0.180.65) were associated with a significantly reduced likelihood of reaching this gestational age before delivery. Among women who underwent rescue cerclage, amniorrhexis was associated with a negative prognosis (aOR: 0.18; 95% CI: 0.05–0.51). Conclusions: Intra-amniotic inflammation, protrusion of fetal membranes and amniorrhexis are factors that may prevent pregnancy prolongation. Rescue cerclage improves pregnancy outcomes.

Cases of difficult suture removal following the McDonald procedure

We examined the clinical significance of difficult suture removal following the McDonald procedure. We examined 117 patients following the McDonald procedure with a singleton pregnancy who delivered at ≥34 weeks of gestation. Difficult suture removal was defined as when spinal anesthesia was required for suture removal. Seven patients (6.0%) were defined as involving difficult suture removal. The cervical length in the difficult-removal-group was significantly shorter than that in the easy-removal-group at suture removal (p = 0.04). If the cervical length was shorter than 20 mm, the odds ratio for difficult suture removal was 9.0 (95% CI 1.6–49, p = 0.01). The progression of cervical ripening following the McDonald suture may be associated with an increased risk of difficult suture removal.

The role of prophylactic cerclage in preventing preterm delivery after electrosurgical conization

To evaluate pregnancy outcomes after electrosurgical conization. We retrospectively analyzed the outcomes of 56 singleton pregnancies after electrosurgical conization of the uterine cervix. Of the 56 cases, 25 women underwent prophylactic cerclage with McDonald procedure (cerclage group), and 31 were managed expectantly (expectant group). Pregnancy outcomes including rate of preterm delivery were compared, and the effect of potential risk factors such as depth of cone, interval between conization and pregnancy, and cervical length on the risk of preterm delivery was assessed. The rate of preterm delivery was significantly higher in women with a history of electrosurgical conization than those without (32.1% vs. 15.2%, p<0.001). However, preterm delivery rate was not different between the two groups (expectant group vs. cerclage group; <28 week, 6.5% vs. 8.0%, p=1.000; <34 week, 19.4% vs. 20.0%, p=1.000; <37 week, 29.0% vs. 36.0%, p=0.579). All obstetric and neonatal outcomes were similar in the two groups. Even when we confined the study subjects to 19 women (19/56, 33.9%) with cervical length less than 25 mm, the preterm delivery rate also was not significantly different between the expectant (n=7) and cerclage group (n=12). Finally, the potential risk factors for preterm delivery were not associated with risk of preterm delivery in patients with a history of electrosurgical conization. The rate of preterm delivery was significantly higher in women with a history of electrosurgical conization before pregnancy. However, prophylactic cervical cerclage did not prevent preterm delivery in these patients.

Endoloop ligation of the umbilical cord of an aborted fetus in a twin gestation

A 28-year-old primigravida who had conceived bichorionic twins after undergoing assisted reproductive treatment presented to the emergency department in the 18th week of pregnancy. She was experiencing contractions and mild vaginal bleeding, and the cervix was found to be dilated to 5 cm. The contractions stopped after the spontaneous expulsion of one of the fetuses, approximately 3 hours following admission. The vaginal bleeding stopped, there were no clinical or laboratory signs of chorioamnionitis, and the results of the clotting tests were normal. On ultrasound the other fetus was of appropriate size for gestational age, was surrounded by a normal amount of amniotic fluid, and seemed viable. The prolapsed umbilical cord of the aborted fetus wasexposedusing an aseptic speculum and ligated high in the cervical canal using the Endoloop automated device fitted with a size-0 Endoloop ligature (Endoloop Ligature Type-0 Coated Vicryl; Ethicon, Summerville, NJ, USA). The cervix was then sutured according to the McDonald procedure. Prophylactic antibiotics were administered perioperatively. The patient had no clinical signs of infection or impending placental abruption and was soon discharged.

Shirodkar versus McDonald Cerclage for the Prevention of Preterm Birth in Women with Short Cervical Length

The efficacy of Shirodkar cerclage was compared with that of the McDonald procedure for the prevention of preterm birth (PTB) in women with a short cervix. Secondary analysis using data from all published randomized trials including women with a short cervical length (CL) was performed comparing the use of Shirodkar versus McDonald sutures. Analysis was limited to singletons with short CL on transvaginal ultrasound. The primary outcome measure was PTB < 33 weeks. Statistical analysis was performed using bivariate and multivariable techniques. From 607 women randomly assigned in the study, 277 met our inclusion criteria; 127 received Shirodkar and 150 women received McDonald sutures. The mean ( +/- standard deviation) gestational age at delivery was 35.0 +/- 5.3 versus 36.3 +/- 4.7 for the Shirodkar versus McDonald groups, respectively ( p< 0.02). PTB < 33 weeks was seen in 61 (22%) of 277 women; 26 (20%) of 127 in the Shirodkar and 35 (23%) of 150 in the McDonald groups, respectively (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.5 to 1.6). On adjusting for confounders using logistic regression modeling, no significant difference in PTB < 33 weeks was found between the two groups (OR, 0.55; 95% CI, 0.2 to 1.3). In women with short cervical length randomly assigned to receiving cerclage, no significant difference in prevention of PTB was observed using Shirodkar or McDonald's procedures.

Modifications to the modified Shirodkar operation.

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

Outcome of Shirodkar Cervical Cerclage Following a Failed McDonald Cerclage in a Previous Pregnancy

ABSTRACT Our objective was to determine the pregnancy outcome in women who underwent a Shirodkar cerclage following a failed McDonald procedure in previous pregnancy. The study included 62 women who underwent an elective Shirodkar procedure between week 9 and week 15 of their singleton pregnancies. They had all failed to complete 34 weeks of gestation in their previous pregnancy despite the use of a McDonald cerclage. Complications observed included premature contractions in 18 patients (29.0%), preterm premature rupture of the membranes (PROM) in 7 (11.3%), vaginal bleeding in 6 (9.7%), chorioamnionitis in 2 (3.2%), cervical laceration in 1 (1.6%), and a single case (1.6%) of rupture of the uterus. Spontaneous abortion ( 37 weeks gestation) in 41 (66.1%) of the women. The fetal survival rate was 88.7% (55 viable newborns). I...

Cervical Internal OS Cerclage: Description of a New Technique and Comparison with Shirodkar Operation

Internal os cerclage for cervical incompetence was performed in 90 patients who had previous McDonald procedure failure (70 patients) or had unfavorable cervical anatomy (short or lacerated cervix) for primary McDonald type cerclage (20 patients). Two different techniques were used: the Shirodkar operation (n = 44) with Mersilene band, and a simpler new technique (n = 46). The new technique is characterized by anterior colpotomy for exposure of the internal os, and a 0.6 mm nylon suture encircling the cervix to be tied high in the posterior fornix. The pregnancy outcome for both groups was similar. Late abortions of 8.7 and 11% and premature deliveries of 13 and 18% occurred in the new technique and the Shirodkar groups, respectively. The removal of the suture was generally difficult in the Shirodkar group and in eight patients analgesia and sedation were required. In the new technique group, the removal was easier and in only one patient was sedation required (p less than 0.0001). Severe vaginal discharge was found in 52% of the Shirodkar patients and none in the other group. Apparently the monofilament nylon suture prevented this side effect. It seems that the new technique is simpler to perform, involves fewer side effects, the removal of the suture is easier, and it is as effective as the Shirodkar procedure.

The technique of fibrin adhesion for premature rupture of the membranes during pregnancy

The description of a new technique for fibrin adhesion (in 28 patients) for premature rupture of the membranes in pregnancy is reported. Unless cerclage has been carried out earlier, it is necessary to suture the cervical canal immediately after rupture of the membranes in order to be able to insert a fibrin clot. The author's modified cerclage technique (reverse McDonald procedure) is described. The advantages are minimal trauma to the lower uterine segment and a somewhat physiologic fixation of the synthetic suture material. For application of the fibrin sealant, the Duploject syringe clip is used, as it allows exact dosage and blending of the two sealant components in the course of their application to the site of sealing. The problem of evaluation of the results of the procedure is discussed. The technique carries no risk to mother or child. No cases of amniotic infection syndrome have been observed. Through prolongation of the pregnancy, time is gained for maturation of the fetal lungs. Accordingly, the authors recommend the technique for treating premature rupture of the membranes, although there is as yet no definite answer as to the optimal timing of this adhesion treatment during pregnancy.

Suture reinforcement of the incompetent cervix: Experience at the Lutheran Hospital of Milwaukee

A modified McDonald procedure, used to correct cervical incompetence, was performed on 44 patients after all other conservative methods for the prevention of late abortion had failed. Diagnosis was established by the history of previous reproductive failure in the early second trimester of pregnancy. Before suture reinforcement, these 44 patients had had 174 conceptions with successful outcome of pregnancy in 37. If the first trimester abortions are deleted, successful outcome had occurred in only 25 per cent of this series. Following suture reinforcement, the same 44 patients reported 72 conceptions with 45 successful pregnancies; a success rate of 63 per cent. Suture reinforcement of the incompetent cervix is a useful procedure but should, however, be performed only as a last resort. Emphasis should be placed on the importance of accurate diagnosis, with other causes of abortion and prematurity first being eliminated.

The incompetent cervix: An analysis of cases at Lewis Memorial Maternity Hospital

1. A plea is made for consideration of measures for both obstetric and surgical success in evaluating the efficacy of a procedure to remedy the incompetent internal cervical os.2. Vaginal delivery is an important advantage which seems to have been overlooked in many instances. Hence, we strongly urge the consideration of the McDonald procedure with severance of the suture near term and subsequent vaginal delivery.