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Ultrasound-indicated cervical cerclage: Outcome depends on preoperative cervical length and presence of visible membranes at time of cerclage

      Abstract

      Objective: The purpose of this study was to assess cases of ultrasound-indicated cervical cerclage and to relate preoperative cervical length, operative findings, postoperative cervical length, and pregnancy outcome to establish the appropriate criteria to offer cervical cerclage. Study Design: A prospective observational study comprised 380 women at high risk of preterm labor who underwent serial transvaginal ultrasonographic assessment of cervical length. Seventy-three women had criteria for and underwent cervical cerclage. Data concerning preoperative cervical length, operative findings, postoperative cervical length, and pregnancy outcome were collected. Statistical analysis was performed with Mann-Whitney and Fisher exact tests. Results: There was a significant increase in median cervical length after cerclage, 15.0 versus 25.0 mm (P <.0001). Preoperative cervical length and postoperative upper cervical length were independently better predictors of outcome than postoperative entire cervical length. Fetal membranes were visible in 18% of cases at the time of suture insertion, which was associated with a significantly worse outcome, regardless of preoperative cervical length. Of those 41 women with a very short preoperative cervical length (≤15 mm), outcome was significantly worse in those women with visible fetal membranes at the time of cerclage compared with those women with no visible fetal membranes at the time of cerclage: median gestational age at delivery, 23 weeks versus 37 weeks 4 days (P =.002); suture insertion to delivery interval, 19 days versus 108 days (P =.0004); and fetal survival rates, 50% versus 86% (P =.03). Conclusion: In a high-risk population that undergoes serial transvaginal ultrasound surveillance of cervical length, the presence of visible fetal membranes at the time of suture insertion, regardless of preoperative cervical length, is associated with a poor outcome. Fetal membranes were not visible in any cases with a preoperative cervical length of >15 mm. These findings lend support to a practice of offering cerclage at or above a cervical length of 15 mm. (Am J Obstet Gynecol 2002;187:445-9.)

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      References

        • Bennett PR
        • Allport V
        • Loudon J
        • Elliott C
        Prostaglandins, the fetal membranes and the cervix: the endocrinology of parturition: basic science and clinical application.
        Front Horm Res. 2001; 27: 147-164
        • Iams JD
        • Johnson FF
        • Sonek J
        • Sachs L
        • Gebauer C
        • Samuels P
        Cervical competence as a continuum: a study of ultrasonographic cervical length and obstetric performance.
        Am J Obstet Gynecol. 1995; 172: 1097-1106
        • Heath VCF
        • Southall TR
        • Souka AP
        • Elisseou A
        • Nicolaides KH
        Cervical length at 23 weeks gestation: prediction of spontaneous preterm delivery.
        Ultrasound Obstet Gynecol. 1998; 12: 312-317
        • Hassan SS
        • Romero R
        • Berry SM
        • Dang K
        • Blackwell SC
        • Treadwell MC
        • et al.
        Patients with an ultrasonographic cervical length ≤15 mm have nearly a 50% risk of early spontaneous preterm delivery.
        Am J Obstet Gynecol. 2000; 182: 1458-1467
        • Berghella V
        • Kuhlman K
        • Weiner S
        • Texeira L
        • Wapner RJ
        Cervical funnelling: sonographic criteria predictive of preterm delivery.
        Ultrasound Obstet Gynecol. 1997; 10: 161-166
        • MRCOG Working Party on Cervical Cerclage
        Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists multicentre trial of cervical cerclage.
        Br J Obstet Gynaecol. 1993; 100: 516-523
        • Rush RW
        • Isaacs S
        • McPherson K
        • Jones L
        • Chalmers I
        • Grant A
        A randomised controlled trial of cervical cerclage in women at high risk of spontaneous preterm delivery.
        Br J Obstet Gynaecol. 1984; 91: 724-730
        • Lazar P
        • Gueguen S
        • Dreyfus J
        • Pontonnier G
        • Papiernik E
        Multicentered trial of cervical cerclage in women at moderate risk of preterm delivery.
        Br J Obstet Gynaecol. 1984; 91: 731-735
        • Guzman ER
        • Forster JK
        • Vintzileos AM
        • Ananth CV
        • Walters C
        • Gipson K
        Pregnancy outcomes in women treated with elective versus ultrasound-indicated cervical cerclage.
        Ultrasound Obstet Gynecol. 1998; 12: 323-327
        • Althuisius SM
        • Dekker GA
        • Van Geijn HP
        • Bekedam DJ
        • Hummel P
        Cervical Incompetence Prevention Randomised Cerclage Trial (CIPRACT): study design and preliminary results.
        Am J Obstet Gynecol. 2000; 183: 823-829
        • Heath VCF
        • Souka AP
        • Erasmus D
        • Gibb DMF
        • Nicolaides KH
        Cervical length at 23 weeks gestation: the value of Shirodkar suture for the short cervix.
        Ultrasound Obstet Gynecol. 1998; 12: 318-322
        • Hassan SS
        • Romero R
        • Maymon E
        • Berry SM
        • Blackwell SC
        • Treadwell MC
        • et al.
        Does cervical cerclage prevent preterm delivery in patients with a short cervix?.
        Am J Obstet Gynecol. 2001; 184: 1325-1331
        • Hibbard JU
        • Snow J
        • Moawad AH
        Short cervical length by ultrasound and cerclage.
        J Perinatol. 2000; 20: 161-165
        • Novy MJ
        • Gupta A
        • Wothe DD
        • Gupta S
        • Kennedy KA
        • Gravett MG
        Cervical cerclage in the second trimester of pregnancy: a historical cohort study.
        Am J Obstet Gynecol. 2001; 184: 1447-1456
        • Berghella V
        • Daly SF
        • Tolosa JE
        • DiVito MM
        • Chalmers R
        • Garg N
        • et al.
        Prediction of preterm delivery with transvaginal ultrasonography of the cervix in patients with high-risk pregnancies: does cerclage prevent prematurity?.
        Am J Obstet Gynecol. 1999; 181: 809-815
        • Rust OA
        • Atlas RO
        • Jones KJ
        • Benham BN
        • Balducci J
        A randomized trial of cerclage versus no cerclage with ultrasonographically detected second-trimester preterm dilatation of the internal os.
        Am J Obstet Gynecol. 2000; 183: 830-835
        • Groom KM
        • Shennan AH
        • Bennett PR
        Retrospective study of non-elective cervical cerclage: outcome differs depending on indication and presence of visible membranes at time of cerclage.
        J Obstet Gynaecol. 2000; 20: S1
        • Guzman ER
        • Houlihan C
        • Vintzileos A
        • Ivan J
        • Benito C
        • Kappy K
        The significance of transvaginal ultrasonographic evaluation of the cervix in women treated with emergency cerclage.
        Am J Obstet Gynecol. 1996; 175: 471-476
        • Funai EF
        • Paidas MJ
        • Rebarber A
        • O'Neill L
        • Rosen TJ
        • Young BK
        Change in cervical length after prophylactic cerclage.
        Obstet Gynecol. 1999; 104: 117-119