Membrane Prolapse Research Articles

Second-trimester cervical sonography: features other than cervical length to predict spontaneous preterm birth.

To estimate whether cervical and lower uterine segment characteristics other than cervical length and funneling predict recurrent preterm birth. We conducted a secondary analysis of a multicenter, blinded observational study of 181 women with singletons and prior spontaneous preterm births. Endovaginal ultrasonic examinations were performed at 2-week intervals between 16 0/7 weeks and 23 6/7 weeks of gestation. Cervical canal contour (straight/curved), cervical position (horizontal/vertical), posterior cervical width, lower uterine segment thickness, vascularity, endocervical canal dilation, with or without associated membrane prolapse and chorioamnion visible at the internal os, were systematically assessed. At the initial sonogram (16 0/7-18 6/7 weeks), membranes visible overlying the internal os (relative risk 1.9, confidence interval [CI] 1.2, 3.1) and canal dilation of 2-4 mm (relative risk 2.6, CI 1.4, 4.7) were significant predictors of spontaneous preterm birth of less than 35 weeks in univariate analyses. Only canal dilation remained statistically significant after controlling for cervical length (odds ratio 5.5, CI 1.1, 28.6). Endocervical canal dilation of 2-4 mm during second-trimester endovaginal sonography was associated with an increased risk of recurrent preterm delivery independent of cervical length. II-2

Does cerclage location influence perinatal outcome?

Objective The study was undetaken to measure cerclage location within the cervix and to determine whether placement closer to the internal os is related to perinatal outcome. Study design We analyzed data collected during a randomized trial of cervical cerclage versus no cerclage that was conducted at Lehigh Valley Hospital between May 1998 and June 2001 in women with ultrasound findings of short cervix less than 25 mm or funneling between 16 and 24 weeks' gestation. Women who were randomly assigned to the cerclage arm had cervical measurements performed before cerclage, including dilation of the internal os, depth of membrane prolapse into the endocervical canal, cervical length below any funnel (distal length), and total cervical length (including any funnel). Measurements obtained after cerclage placement included the distance from external os to cerclage (A), and a repeat of the same four measurements. The distance from the external os to the cerclage (A) was divided by the total cervical length (B) and a cerclage to cervical length ratio (A/B) was calculated. The relationship between these measurements and gestational age at birth was assessed by linear regression analysis. Results Of 150 patients enrolled, 74 received a McDonald cerclage suture. Mean distal cervical length was1.9±0.9 cm before and 2.9±1.0 cm after cerclage ( P = .001). The mean distance between the cerclage and external os (A) was 1.8±0.6 cm; the total cervical length after cerclage (B) was 3.6±0.9 cm. The mean cerclage to cervical length ratio (A/B) was 0.5±0.1. Linear regression analysis did not demonstrate a correlation between either the cerclage to external os measurement (A) or the cervical length ratio (A/B) and gestational age at birth ( R 2 = 0.0006 and 0.008, P = .8 and .6, respectively). Conclusion The length of the cervix below the level of cerclage is not related to duration of pregnancy in women treated with cerclage because of ultrasound evidence of cervical effacement.

P369: Ultrasound cervical length to predict spontaneous preterm delivery in twin pregnancies

Objective: To analyse the predictive value of different cervical length cut-offs for spontaneous preterm delivery <32 and <34 weeks in twin pregnancies. Methods: Transvaginal cervical ultrasound examinations were performed in 106 twin pregnancies between 20 and 26.6 weeks (January 2001 to January 2003). Sensitivity, specificity and predictive values of cervical length (20, 25 mm) at 20–24 and 24.1–26.6 weeks for the prediction of spontaneous preterm birth <32 and <34 weeks were calculated. Twin gestations electively delivered preterm because of maternal or fetal indications were excluded from this analysis. Results: The median gestational age at delivery was 35 weeks (range 23.2–39.3). Cerclage was performed in 12 patients with cervical length 25 mm or prolapse of membranes at a median gestational age of 23 weeks (range 20.5–26.2). The rate of spontaneous delivery <32 and <34 weeks was 8.4% (9/106) and 13.2% (14/106) respectively. In the group of patients evaluated at 20–24 weeks, 7/85 (8.2%) women delivered spontaneously <32 weeks and 9/85 (10.6%) <34 weeks; in the group of patients evaluated at 24.2–26.6 weeks, 2/66 (3%) delivered spontaneously <32 weeks and 7/66 (10.6%) <34 weeks. Cervical length at 20–24 weeks with a cut-off value 20 mm had specificities of 99% and 99%, sensitivities of 43% and 33%, negative predictive values of 95% and 92%, positive predictive values of 75% and 75% for delivery <32 and <34 weeks, respectively. Cervical length at 20–24 weeks with a cut-off value 25 mm had specificities of 95% and 94%, sensitivities of 43% and 33%, negative predictive values of 95% and 91%, positive predictive values of 43% and 43% for delivery <32 and <34 weeks, respectively. Conclusions: In twin gestations a cervical length 20 mm measured at 20–24 weeks is the best cut-off to predict spontaneous preterm delivery.

Revisiting the short cervix detected by transvaginal ultrasound in the second trimester: Why cerclage therapy may not help

Objective: The purpose of this study was to identify the risk factors that are associated with increased neonatal morbidity in patients who were treated for sonographic evidence of internal os dilation and distal cervical shortening during the second trimester. Study Design: From May 1998 to June 2000 patients between 16 and 24 weeks of gestation with the following sonographic criteria were randomly assigned to McDonald cerclage or no cerclage: internal osdilation and either membrane prolapse into the endocervical canal at least 25% of the total cervical length but not beyond the external os or a shortened distal cervix <2.5 cm. Before randomization, all patients were treated identically with an amniocentesis, multiple urogenital cultures, and therapy with indomethacin and clindamycin for 48 to 72 hours. Except for the cerclage, all patients were treated identically after randomization. Multiple variables of perinatal outcome were analyzed. A regression model with gestational age at delivery as the dependent variable was constructed and repeated with neonatal morbidity as the dependent variable. This model was applied to 3 populations: the cerclage group, the no cerclage group, and both groups combined. Results: Of the 135 patients, 20 patients declined randomization, and 2 patients were diagnosed with acute chorioamnionitis. Of the 113 patients remaining, 55 patients were randomly assigned to the cerclage group, and 58 patients were randomly assigned to the no cerclage group. There were 8 rescue cerclage procedures (4 in each group). Regression analysis showed that readmission for preterm labor, chorioamnionitis, and abruption were consistently associated with early gestational age at delivery and increased morbidity. Cerclage did not affect perinatal outcome. Conclusion: The sonographic findings of second trimester internal os dilation, membrane prolapse, and distal cervical shortening likely represent a common pathway of several pathophysiologic processes. Use of cerclage does not alter any perinatal outcome variables. Increased neonatal morbidity in these patients appears to be associated with subclinical infection, preterm labor, and abruption. (Am J Obstet Gynecol 2001;185:1098-1105.)

The laparoscopic approach of the transabdominal cerclage of the uterine cervix in case of cervical incompetence

Cervical incompetence is characterized by painless cervical dilation in the second or early in the third trimester, with prolapse or ballooning of membranes in the vagina and expulsion of an immature fetus. Unless effectively treated, this sequence tends to recur at each pregnancy. Usually a ‘purse-string’ cerclage as described by McDonald, using a vaginal approach, is effective. If the cervix is too short for this or even absent, a transabdominal cervicoisthmic cerclage (TCC) is indicated. After TCC an eventual pregnancy always culminates in a Caesarean section, as the cerclage cannot be removed vaginally. This is, in fact, the main drawback of this technique. Objective To present the laparoscopic approach to TCC. Case history The patient was a 34-year-old woman with a history of cervical intraepithelial neoplasia and electrosurgical excision of the transformation zone. The pregnancy following this operation ended with an immature delivery, which was attributed to cervical incompetence. Before the next pregnancy, TCC using a laparoscopic approach was carried out. Using one 12-mm port and two 5-mm ports, the cervix was laparoscopically freed from the bladder. The avascular space between the ascending and descending branch of the uterine artery was penetrated and a Mersilene band was guided through, just above the level of the sacrouterine ligaments and tied. The operation lasted 40 minutes and the patient was discharged from the hospital, in a good state of health, the next day. Some months later she had an uneventful pregnancy, and a healthy but growth-retarded son, weighing 1890 g, was delivered by Caesarean section at 37 weeks of gestational age. Conclusion The laparoscopic approach to TCC was successful. The growth retardation in the subsequent pregnancy seemed coincidental. The laparoscopic approach is to be preferred for a planned TCC.

Emergency Cervical Cerclage: A Review of 15 Cases

This report describes our experience with 15 consecutive emergency cervical cerclages performed at Al Yamamah Hospital. Between February 1994 and February 1997, 15 women with singleton pregnancies between 18 and 26 weeksâ gestation, with a cervical dilatation between 3 and 10 cm and with membrane prolapse, underwent emergency cerclage after excluding labor, placental abruption and intrauterine infection. The membranes were replaced using the technique of overfilling the urinary bladder and then performing McDonaldâs cerclage. All the patients received prophylactic antibiotics and tocolytics. Of the 15 pregnancies, two aborted and 13 ended in live births. Nine of the live births survived, giving a survival rate of 60%. The mean extension of pregnancy in the survivors was 11.5 weeks (range 7.6-15.2 weeks), and the gestational age at delivery ranged from 30-38+ weeks. In six of the patients, suture failed to prolong the pregnancy long enough to produce a âtake-home baby.â All the failures were due to subclinical intrauterine infection. There was no maternal morbidity. Emergency cerclage should be considered as a management option in women with painless cervical dilatation and membrane prolapse in the midtrimester.

Emergent cervical cerclage: predictors of success or failure.

Emergent cervical cerclage is a procedure not commonly performed in general clinical practice. The outcome of pregnancies requiring emergent cerclage is based on limited information. The factors that predict success are not well known. Previous studies have suggested that advanced cervical dilation, significant cervical effacement, and the presence of prolapsed membranes are correlated with cerclage failure. We present a retrospective review of maternal characteristics predictive of perinatal survival. Analysis showed the presence of membrane prolapse to be the strongest predictor of poor outcome. Analysis also reveals a significant association between initial white blood cell count and perinatal outcome. This information may be helpful in decision making regarding adjunctive procedures such as amniocentesis and counseling patients regarding the likely outcome.

Ultrasonography in the detection of cervical incompetency.

In 80 pregnancies with clinical and ultrasonic signs of cervical incompetency, the length of the cervix and the thickness of the anterior wall of a lower uterine segment have been evaluated ultrasonically. We have also measured the width of the endocervical canal and studied the prolapse of fetal membranes (with fetal parts) into the endocervical canal. We evaluated these same parameters in 80 healthy pregnancies. The length of the cervix, the thickness of the anterior wall of a lower uterine segment, and the width of the endocervical canal were followed longitudinally in the patients from the 10th to the 36th gestation week. No statistically significant differences between age groups were found. In four age groups at risk for cervical incompetency, cervical lengths and wall thickness were significantly different (p less than 0.001) from those in comparable controls. Forty-five percent of the patients in the at-risk group, with cervical cerclage, delivered at 37.3 (range: 32 to 41) weeks and 6.25% of pregnancies ended in abortion when the amniotic membrane herniated into the cervical canal, with or without some part of the fetus.

Plasma concentrations of prostaglandin F2α and prostaglandin E2 metabolites after transabdominal and transvaginal cervical cerclage

Circulating prostaglandin metabolites 13,14-dihydro-15-keto-prostaglandin F2α and the bicyclo derivative of prostaglandin E2 were measured in maternal plasma by radioimmunoassay after transabdominal cervicoisthmic cerclage and after transvaginal cerclage (Shirodkar and McDonald procedures) performed in the first and second trimesters. Statistically significant elevations in prostaglandin E2 metabolite or 13,14-dihydro-15-keto-prostaglandin F2α occurred after transabdominal cervicolsthmic and transvaginal cerclage; they returned to control levels within 6 to 24 hours after surgery and were associated with good fetal outcome. Increases in 13,14-dihydro-15-keto-prostaglandin F2α were proportionately greater than in prostaglandin E2 metabolite. Mean basal levels and the rise in prostaglandin metabolites were not related to cerclage type, trimester of pregnancy, or cervical status (dilatation ⩽ 3 cm; effacement ⩽ 60%). Highest basal and postcerclage 13,14-dihydro-15-keto-prostaglandin F2α and prostaglandin E2 metabolite levels were associated with advanced cervical changes, uterine irritability, membrane prolapse or rupture, and premature delivery. Routine administration of prostaglandin synthetase inhibitors is not indicated for transvaginal cerclage or transabdominal cervicoisthmic cerclage; plasma prostaglandin metabolite levels may identify patients not suitable for cerclage.

LOCAL INJECTION THERAPY FOR HEMORRHOIDS WITH SUBLIMATE SOLUTION. A NEW METHOD OF LOCAL INJECTION THERAPY FOR ANGIOMA. II. REPORT

For the trearment of hemorrhoids including some anal diseases, 0.001 % sublimate solution was injected into the local tissues 0.3-0.5 ml. once a week, and we have obtained the following result:1) Almost all of the internal hemorrhoids became gradually firm and small and showed remarkable improvement.2) In cases of the fissure in ano and in cases of the intermediate hemorrhoids and the hemorrhoidal prolapses also, a good result was obtained. On the contrary, in cases of the external hemorrhoids, this treatment produced no appreciable effects.3) In one case of the mucous membrane prolapse after the hemorrhoidectomy, a considerable effective result was obtained.4) This treatment was free from harmful after-effects.In view of above therapeutic results, we would like to conclude that the injection therapy should be tried against some anal diseases except external hemorrhoid prior to the radical operation.

Functional recovery following vagosympathetic anastomosis in the cat.

Vagosympathetic anastomosis was performed in cats to direct regenerating vagal fibers to the superior cervical sympathetic ganglion. Two weeks postoperatively myosis, nictitating membrane prolapse and loss of ear temperature regulatory function were observed. By the 8th postoperative week ear temperature function had returned to normal although ocular signs of sympathetic paralysis remained. Pupillary dilatation and nictitating membrane retraction did occur at times ordinarily associated with vagal activity (accompanying feeding). Transection of the regenerated vagus nerve abolished both ocular feeding reflex and the recovered ear temperature regulatory function.