Removal Of Cerclage Research Articles

Case of Cardiorespiratory Arrest following Removal of Cervical Cerclage

We report a case of cardiorespiratory arrest following the removal of a cervical suture in a non-labouring woman.

Time to Delivery after Scheduled Shirodkar Cerclage Removal in Singleton Gestations based on the Original Indication for Cerclage Placement

To estimate the time to delivery after elective cerclage removal and evaluate whether there is a difference based on the indication for cerclage placement. This was a retrospective cohort of singleton pregnancies that underwent Shirodkar cerclage placement at a single maternal-fetal medicine practice between June 2005 and June 2017. We included all scheduled elective cerclage removals >36 weeks. The primary outcome was latency to delivery. We further compared time to delivery based on the original indication for cerclage. Data were analyzed using the one-way analysis of variance and chi-square test. A total of 143 patients met the inclusion criteria. Of these, 40.6% were history indicated, 51.0% ultrasound indicated, and 8.4% exam indicated. The mean time from removal to delivery was 13.3 ± 8.4 days; 12.6% (18/136) of patients delivered within 24 hours of removal. When stratified by indication for cerclage, there were no significant differences for all delivery outcomes. Delaying cerclage removal to >37 weeks resulted in a statistically significantly later gestational age at delivery compared with removal between 36 and 366/7 weeks (39.0 vs. 38.3 weeks, p = 0.001). The mean time from elective Shirodkar cerclage removal to delivery is 13 days with only 12.6% of patients delivering within 24 hours of removal.

Knot positioning during McDonald cervical cerclage, does it make a difference? A cohort study

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.

692: Association of cerclage removal with maternal and neonatal outcomes in pregnancies complicated by preterm premature rupture of membranes

To compare pregnancy outcomes between women with pPROM in the presence of cervical cerclage in whom the cerclage was removed within <48h and those in whom the cerclage was retained in situ. We conducted a retrospective cohort study of all women with a singleton pregnancy admitted with pPROM in the presence of cerclage to one of two tertiary referral centers in Toronto, Ontario between 2012-2016. The two centers differ in their approach with regard to the management of cerclage in the context of PPROM: in one center (SB) the common practice is to retain cerclage while in the second center (MSH) the common practice is to remove cerclage. Outcomes were compared between women in whom cerclage was removed within 48 hours and those in whom cerclage was retained until the onset of delivery. 1) Of a total of 79 women who met the study inclusion criteria, cerclage was removed in 44 (55.7%) and retained in 35 (44.3%). 2) There were no differences between the removal and retention groups in baseline characteristics, gestational age at cerclage placement (19.3±3.3 vs.18.0±4.1 weeks, p=0.1), cervical dilatation at cerclage, and gestational age at pPROM (28.3±2.9 vs. 28.0±2.6 weeks, p=0.7). 3) Women in the cerclage removal group had a lower pPROM to delivery interval (2.0±6.5 vs. 7.9±7.5 days, respectively, p<0.001) and were less likely to have a latency period of >7 days (4.5% vs. 37.1%, respectively, p<0.001) compared with women in whom cerclage was retained (Figure 1). 4) After adjustment for confounding factors, retention of cerclage was associated with higher odds for latency >7 days and lower odds for composite neonatal outcome (Figure 2). There were no differences between the groups in the odds for clinical chorioamnionitis and neonatal sepsis (Figure 2). In this multi-center retrospective study of women with pPROM and cervical cerclage, retention of cerclage was associated with longer latency period and lower rate of adverse neonatal outcome without increasing the risk of infection in the mother and newborn.

Selection of the method for correction of cervical incompetence

Cervical incompetence (CI) is one of the challenges of modern obstetrics. The practicing obstetrician-gynecologist faces a complex task of timely diagnosis, selection of correction method, timing of application and removal of cerclage. The problem of CI in pregnancy is known from the XIX century, but in the XI century, the outstanding scientist Abu Ali Ibn Sina (Avicenna) wrote about this pathology. According to the classical definition, CI is the softening, widening and shortening of the cervix prior to the 37th week of gestation in the absence of thretening termination of pregnancy. CI is characterized by inability to carry a pregnancy to full-term due to functional or structural abnormalities of the uterine cervix. To date, no objective diagnostic tests exists to identify patients at high risk of developing CI, not before and not during pregnancy. A high diagnostic accuracy during pregnancy can be reached with transvaginal ultrasound of the cervix. The ultrasound scale proposed by Salomon LJ allows to measure the length of the cervix depending on the gestational age and assists in making the right choice for the correction of short cervix. The selection of the method of correction of CI depends on the clinical situation, history, timing of gestation, the number of fetuses, cervicometry data, gynecological examination, the threat of abortion, and the doctor’s experience. There are two main methods of correction of CI: conservative and surgical. Surgical methods include transvaginal and transabdominal cerclage, while conservative includes adherence to bed rest, tocolytics, hormonal therapy, and the use of obstetric pessaries. Insertion of obstetric pessaries is a promising, safe, simple method of treatment and prevention of CI and for threatening termination of pregnancy in the II and III trimesters. The strategy of widespread use of pessaries in pregnant women from high-risk groups can reduce the frequency of preterm labor and improve perinatal outcomes.

Laparoscopic transabdominal cerclage: new approach

Objective: To evaluate efficiency and safety of the new approach of laparoscopic cerclage.Study design: Fifteen women were operated with our new technique. Their age ranged from 22 years to 35 years. Inclusion criteria included those with history of two or more second trimesteric abortions or early preterm labor. These women had at least two previous unsuccessful vaginal cerclage or vaginal insertion of cerclage is not possible because of congenitally short cervix, cervical conization or excessive cervical scarring.Results: Twelve of the participants delivered vaginally with the removal of cerclage, two had CS due to breech presentation and the cerclage was left in place and the last one has surgical evacuation. No intraoperative or postoperative complications were encountered namely; excessive bleeding, injury of uterine vessels or postoperative peritonitis. No technical difficulties upon doing the procedure or cerclage removal were met apart from one case where removal of the vaginal stitch was not possible [incision was done in the cervix over the tape and the Mersilene tape was cut followed by repair of the cervical tissue using (00) Vicryl stitches].Conclusion: The new approach for laparoscopic cerclage is a safe, effective and reasonable treatment after failure of vaginal cerclage.

Laparoscopic Removal of Abdominal Cerclage and Vaginal Delivery at 21 Weeks

Laparoscopic Removal of Abdominal Cerclage and Vaginal Delivery at 21 Weeks

Laparoscopic Placement and Removal of Abdominal Cerclage: A Case Report

Abdominal cerclage may be recommended in women with a shortened or absent cervix or after failure of a previous vaginal cerclage. If the abdominal cerclage has to be removed prior to delivery of a non-viable fetus, hysterotomy is not necessary. In that case a laparoscopic removal should be considered. We will discuss laparoscopic placement and removal of an abdominal cerclage placed in a 27-year old woman, gravida 10, para 2, abortus 7, who presented at 16 weeks and 6 days gestational age with abdominal cramps and protruding membranes.

PPO.47 Radical Vaginal Trachelectomy for Cervical Cancer during pregnancy and subsequent obstetric outcome

Radical Vaginal Trachelectomy (RVT) is a fertility sparing technique first described by D’Argent in 1994.1 This involves removal of the cervix and parametrial tissue, laparoscopic bilateral pelvic lymph node dissection...

Removal versus retention of cerclage in preterm premature rupture of membranes: a randomized controlled trial

The decision of whether to retain or remove a previously placed cervical cerclage in women who subsequently rupture fetal membranes in a premature gestation is controversial and all studies to date are retrospective. We performed a multicenter randomized controlled trial of removal vs retention of cerclage in these patients to determine whether leaving the cerclage in place prolonged gestation and/or increased the risk of maternal or fetal infection. A prospective randomized multicenter trial of 27 hospitals was performed. Patients included were those with cerclage placement at ≤23 weeks 6 days in singleton or twin pregnancies, with subsequent spontaneous rupture of membranes between 22 weeks 0 days and 32 weeks 6 days. Patients were randomized to retention or removal of cerclage. Patients were then expectantly managed and delivered only for evidence of labor, chorioamnionitis, fetal distress, or other medical or obstetrical indications. Management after 34 weeks was at the clinician's discretion. The initial sample size calculation determined that a total of 142 patients should be included but after a second interim analysis, futility calculations determined that the conditional power for showing statistical significance after randomizing 142 patients for the primary outcome of prolonging pregnancy was 22.8%. Thus the study was terminated after a total of 56 subjects were randomized with complete data available for analysis, 32 to removal and 24 to retention of cerclage. There was no statistical significance in primary outcome of prolonging pregnancy by 1 week comparing the 2 groups (removal 18/32, 56.3%; retention 11/24, 45.8%) P = .59; or chorioamnionitis (removal 8/32, 25.0%; retention 10/24, 41.7%) P = .25, respectively. There was no statistical difference in composite neonatal outcomes (removal 16/33, 50%; retention 17/30, 56%), fetal/neonatal death (removal 4/33, 12%; retention 5/30, 16%); or gestational age at delivery (removal mean 200 days; retention mean 198 days). Statistically significant differences were not seen in prolongation of latency, infection, or composite neonatal outcomes. However, there was a numerical trend in the direction of less infectious morbidity, with immediate removal of cerclage. These findings may not have met statistical significance if the original sample size of 142 was obtained, however they provide valuable data suggesting that there may be no advantage to retaining a cerclage after preterm premature rupture of membranes and a possibility of increased infection with cerclage retention.

Elective removal of cervical cerclage and onset of spontaneous labor

ObjectiveTo determine the time interval between elective removal of cervical cerclage and onset of spontaneous labor. MethodsA retrospective cohort study was conducted between January 2005 and December 2012 at a tertiary care hospital in Lisbon, Portugal. All singleton pregnancies with a McDonald or Shirodkar cerclage electively removed at 36–37weeks were evaluated for the time interval between cerclage removal and spontaneous labor. Delivery within 72hours after cerclage removal was compared between patients with elective cerclage and those with non-elective cerclage. In the non-elective group, a sub-analysis of the results for ultrasound- and physical examination-indicated cerclage was performed. ResultsThirty-eight women were included. The time interval between cerclage removal and spontaneous labor did not differ significantly between the elective and the non-elective group (15.6±7.6 vs 10.9±7.4days; P=0.063). A higher incidence of delivery 72hours after cerclage removal was seen in the non-elective group but this was not significant (P=0.061). There were no differences regarding the time interval from elective removal of cervical cerclage to onset of spontaneous labor between ultrasound-indicated and physical examination-indicated cerclage. ConclusionRegardless of the indication for cervical cerclage, the probability of delivery soon after elective cerclage removal is low.

Cerclage retention versus removal following preterm premature rupture of membranes and association with amniotic fluid markers

ObjectiveTo evaluate whether amniotic fluid markers can aid the decision of whether to retain or remove a cervical cerclage after preterm premature rupture of membranes (PPROM). MethodsA retrospective cohort study included pregnancies involving PPROM after diagnostic amniocentesis and cerclage placement. Cerclage was retained for more than 12hours after PPROM in the study group (n=18); the comparison group comprised women who underwent immediate cerclage removal after PPROM (n=22). Analyses were performed using concentrations of interleukin (IL)-6, glucose, and white blood cells (WBCs) in the amniotic fluid to measure relationships with adverse outcomes. ResultsThe latency period from PPROM to delivery was significantly shorter in the group that underwent immediate cerclage removal (P<0.005). Latency periods of more than 48hours (P<0.001) and more than 7days (P<0.01), and chorioamnionitis (P<0.05) were associated with cerclage retention. Neonatal outcomes were not significantly different between the study group and the comparison group. However, elevated IL-6 levels were associated with cumulative neonatal morbidity (P<0.05). Low IL-6 (P<0.001) and WBC (P<0.05) levels were significantly associated with a latency period of more than 7days. ConclusionAmniotic fluid levels of IL-6 and WBCs may be of clinical value for individualizing the management of patients with PPROM after cerclage.

Time interval from elective removal of cervical cerclage to onset of spontaneous labour

To determine the time interval between elective removal of a cervical cerclage to the onset of spontaneous labour in women who had either a history- or ultrasound-indicated cervical cerclage. A retrospective cohort study of women with a singleton pregnancy that had either a modified Shirodkar or McDonald cervical cerclage inserted were evaluated for the time interval between elective cerclage removal and onset of spontaneous labour and also spontaneous labour with 72 h of cervical cerclage removal. Two hundred and sixty-nine singleton pregnancies with either a modified Shirodkar or McDonald cervical cerclage were analysed. The mean gestational age at cerclage removal was 36.7 ± 1.10 weeks and gestational age at spontaneous labour was 39.0 ± 1.94 weeks (mean ± SD). The median interval between cerclage removal and spontaneous labour was 14 days. Only 18% of women laboured spontaneously within 72 h. Women with ultrasound-indicated cerclage were more likely to deliver within 72 h, compared with women with a history-indicated cervical cerclage (odds ratio, 3.68; 95% confidence interval, 1.31-10.85, p=0.01). Independent of the indication or technique used for cervical cerclage, the rate of early spontaneous labour following elective removal of cervical cerclage is sufficiently low to justify outpatient management.

P32.06: Cervical cerclage for prevention of preterm birth: review of 18 cases

Objectives: Preterm birth continues to be the leading cause of neonatal morbility and mortality in industrialized countries. Cervical insufficiency (CI) remains a challenging entity, especially because clear clinical criteria for the diagnosis have not been defined and because there are conflicting results in randomized controlled trials evaluating the use of cervical cerclage. To evaluate the efficacy of cervical cerclage in prolonging pregnancy and preventing preterm birth in women with cervical insufficiency. Study design: retrospective observational study. Methods: The clinical records of 18 women with singleton pregnancies and the diagnosis of CI, submitted to MacDonald’s cerclage between 2000 and 2011 were reviewed. Obstetric management decisions and perinatal results were evaluated. Results: The mean patients’ age was 33 years. 44.4% had ≥3 previous pregnancies. Had a history of abortion, curettage and previous preterm delivery, 83.3%, 38.9% and 33.3%, respectively. 77.8% had a history of late-term abortions; 44.4% early abortions and 33.3% ≥3 previous abortions. 38.9% had a history of cerclage and of these, 42.9% had ≥2. The mean gestational age at surgery was 17 weeks, removing the same, on average, at 32 weeks. 55.6% were submitted to elective cerclage. The mean gestational age at delivery was 33 weeks, with an average time between the removal of cerclage and delivery of 6.4 days. The morbidity included preterm delivery (64.7%), 27.3% of them with preterm premature rupture of membranes. There were two cases of chorioamnionitis (19/24weeks with miscarriage/perinatal death) and 29.4% of admissions in the NICU. Most (61.1%) were born by normal delivery, and the mean birth weight was 2427.6 g. Conclusions: Despite the difficulties in the diagnosis of CI and the lack of evidence demonstrating the effectiveness of cerclage, in selected cases this technique appears to be safe and to achieve good obstetric/neonatal results.

Cervical Cerclage and Preterm PROM

Preterm premature rupture of membranes (PPROM) occurs in 38% of women with cerclage in place. Controversy exists on what to do with the cerclage in this clinical scenario. The objective was to review the literature addressing retention versus removal of cerclage after PPROM and present management recommendations. Retention of cerclage for more than 24 hours after PPROM was found to prolong pregnancy for more than 48 hours, but also to increase maternal chorioamnionitis and neonatal mortality from sepsis, making immediate cerclage removal as the usually preferred therapeutic approach. Steroids for fetal maturity before cerclage removal can be considered between 24 and 33 6/7 weeks gestation.

178: Time from elective removal of ultrasound-indicated cerclage to birth

178: Time from elective removal of ultrasound-indicated cerclage to birth

Interval to spontaneous delivery after elective removal of cerclage

The purpose of this study was to estimate the time interval between elective cerclage removal and spontaneous delivery. Singleton pregnancies with McDonald cerclage were evaluated for the interval between elective cerclage removal (36-37 weeks) and spontaneous delivery. We also compared spontaneous delivery within 48 hours after cerclage removal between women with ultrasound-indicated vs history-indicated cerclage. We identified 141 women with elective cerclage removal. The mean interval between removal and delivery was 14 days. Only 11% of women delivered within 48 hours. Women with ultrasound-indicated cerclage were more likely to deliver within 48 hours, compared with women with history-indicated cerclage (odds ratio, 5.14; 95% confidence interval, 1.10-24.05). The mean interval between elective cerclage removal and spontaneous delivery is 14 days. Women with cerclage who achieved 36-37 weeks should be counseled that their chance of spontaneous delivery within 48 hours after elective cerclage removal is only 11%.

Exocervical Pregnancy in a Patient with Intrauterine Device: A Case Report

Cervical pregnancy (CP) is a rare and life-threatening ectopic pregnancy characterized by implantation of the fertilized ovum into the cervix, whereas exocervical pregnancy is an extremely rare CP with implantation of the fertilized ovum on the exocervix. Possible causative factors of CP such as tubal dysfunction, impaired sperm motility, previous uterine surgery, or the use of intrauterine device were not clearly associated with the development of CP until now. Diagnosis of CP is usually established by ultrasonography and by β-human chorionic gonadotropin serum tests, but definitive diagnosis is by histologic examination. Current treatment strategies of CP, which were described in some reports, involve: medical treatment with methotrexate, surgical removal of ectopic trophoblastic tissues, cervical cerclage and vaginal packing, ligation of descending branches of uterine arteries or hypogastric arteries, and unilateral internal iliac artery embolization. We report a case of exocervical pregnancy contemporary to intrauterine device normally inserted, diagnosed by colposcopy, β-human chorionic gonadotropin, and histology, and treated by a local excision without using methotrexate chemotherapy.

Rotura uterina por placenta percreta. Un caso clínico en útero bicorne unicollis

A woman in the 27th week of gestation, with a prior diagnosis of uterus bicornis unicollis and a cervical cerclage in situ, presented to the emergency department with severe abdominal pain. No uterine dynamics were observed. The patient rapidly deteriorated shortly after admission, warranting removal of the cervical cerclage and emergency cesarean section delivery with the working diagnoses of hypovolemic shock and abruptio placentae. Laparotomy showed free blood in the peritoneum (2 liters) as well as a placenta accreta with a 3-cm perforation in the uterine fundus. A female infant, weighing 1030 g, was delivered and progressed satisfactorily.

Long-term sequelae of abdominal cervical cerclage and a minimally invasive approach to resolution

Cervical incompetence is diagnosed in 0.1–1% of all pregnancies and in 8% of women with repeated mid-trimester pregnancy loss. This condition may be managed by the application of a suture around the cervix, placed vaginally, abdominally, or laparoscopically. The case histories of two patients are presented, both of whom had abdominal cervical cerclage applied via laparotomy 4 and 6 years previously. Counselling and decision making processes are discussed, and the operative reports of the successful laparoscopic total removal of the cervical sutures are described. Published cases of laparoscopic cerclage removal are rare; indeed only four cases have been recorded. Three of these involved the removal of the suture after a very short period of time (5–7 weeks) with one further report of a partial removal being achieved laparoscopically. We have described successful laparoscopic total removal of two abdominally placed cervical sutures that had been in-situ for a prolonged period of time. In a unit with skilled laparoscopic surgeons and high-risk obstetricians, the potential for laparoscopic insertion and removal of abdominal cervical sutures exists.