Comparison of Success and Morbidity
in Cervical Cerclage Procedures
Dr Nasim Akhtar
Department of Obstets and Gynae,Mardan Medical Complex
Abstract
Objective:
cerclage.
to compare the success rate and morbidity of elective e cervical cerclage with emergency cervical
Method:
A prospective descriptive observational study with seven distinct indication for cervical cerclage
under taken over a five year period from (First July 2006 to 30 June 2011) at District Headquarter Hospital Mardan.
Result:
55 women were studied of these 42 had elective cerclage while 13 had emergency cerclage
procedure. Complete medical record of these patients was retrieved. They ranged from 20-38 years of age with
median at 27 years. 90 % of patients presented at 12 to 26 week of gestation. The fetal survival rate in elective
cerclages was 83%, while 69% was fetal survival rate in emergency cerclage group.
Conclusion:
This study adds to the existing knowledge on the controversial diagnosis of cervical insufficiency
and the use of cerclage in our population. The prematurity and complications rate is higher in patient with
emergency cerclage. More comprehensive studies are needed to compare the complication in cerclage and control
groups.
Key words:
Cervical insufficiency, cerclage, fetal survival rate, complications.
Introduction:
Cervical
cerclage
is
a
common
prophylactic
intervention for the management of 2nd trimester
pregnancy
losses,
although
its
application is not standard all over the world (1). The
diagnosis of cervical insufficiency is notoriously
difficult to make, and is largely retrospective based
on history
1
(2). Cervical surveillance by use of transvaginal
This was a descriptive prospective study based on
ultrasonography has been recommended. The
record files of 55 patients at DHQ hospital Mardan
efficacy of cervical cerclage and its need has been
from first July 2006 to 30 June 2011. Historical data
discounted,
an
about previous pregnancies, the course of the
unnecessary intervention in 50% of the cases.
pregnancies, operation and delivery records, post
However there is some evidence of positive role of
operative care record and subsequent pregnancy
cerclage in women at high risk with more than one
record were all maintained. Approval was granted by
second trimester losses (28-protocol). Strong risk
the hospital ethics committee. Clinical indication for
factor for preterm birth is a prior history of cervical
cervical cerclage were divided into seven categories
insufficiency, based on a history of repeated,
in an effort to determine which historical feature
painless midtrimester losses or preterm delivery.
would predict the success rate of the procedure.
Previous studies has indicated that ascending
Patients with contraction and vaginal bleeding were
infection from the vagina leads to preterm delivery
considered to have premature labour rather than
as well as cerebral palsy (4,5). In recent years the
cervical insufficiency. These different indication
importance of the cervical mucus plug as gatekeeper
were;
protecting the feto placental unit against ascending
1.
History of single second trimester loss.
infection from vagina has been demonstrated
2.
History of >2 second trimester losses.
(6,7,8). There is convincing data showing that
3.
History of single second trimester loss with
with
Althusis
(1)
calling
it
increased intrauterine cytokine production in the
prior cervical trauma.
amniotic fluid contributes to the mechanism of
4.
History of premature labour.
cervical incompetence (9). Premature dilatation can
5.
History of previous successful cerclage.
be followed by infection but it can also be visa-versa.
6.
Second trimester cervical dilatation without
Measuring cervical length by ultrasound has been
contractions.
directly correlated with the duration of pregnancy
7.
(10). The trans abdominal cerclage in cases of failed
Second trimester cervical dilatation with
contractions.
previous transvaginal cerclages (11), and cervical
Category 6 and 07 were called emergency cerclages
occlusion in combination with cervical cerclage in
while 1-5 were called elective cerclage. Differences
order to retain the mucus plug has been proposed to
in the fetal survival rate and complications were
improve the take- home baby rate. The incidence of
analysed. In all the patients McDonald procedure
cervical
between
was performed with purse-string suture of No.2 silk.
departments and countries. Part of this variation in
General anaesthesia was used in all the patients.
incidence rates is due to difficulties in diagnosis.
Post operative bed rest for 24 to 72 hours was given
insufficiency
varies
widely
in emergency procedures while elective cerclage was
Material and Method:
done on day care basis with patients staying upto
12-18 hours at Hospital. Parentral antibiotics were
2
given in all the patients for first 24 hours. 06 patients
i.e. 83% than it had been in the pregnancies prior to
had history of previous cervical cerclages. In one
cerclage in those women (25%). Fetal survival rate
patient both the cerclage procedure failed due to
after 13 emergency cerclages was not significantly
badly damaged cervix in previous term pregnancy.
greater than it had been in the pregnancies prior to
13 procedures were emergency cerclages.
cerclage i.e,60%. The results and their significance
remained un-changed when the first cerclage
Results: The 55 patients had 222 pregnancies before
treated pregnancy was analysed in each women.
the cerclage was performed and the fetal survival
When the cerclage procedures are categorized
rate was 25%. In patient having elective cerclage the
according to indications the improvement in
fetal survival rate in 192 prior pregnancies was 20%
pregnancy outcome is not significant in any category
where as the previous fetal survival rate in 30 prior
that includes cervical dilatation as the reason for the
pregnancies of women with emergency cerclage was
cerclage. The greatest increase in pregnancy
57%. The difference between these rates is
outcome i.e. more than 6-fold increase occurs in the
significant (p<.001) suggesting that two population
operation performed for 2 or more second trimester
were not similar. The population having emergency
pregnancy losses.
cerclage had better previous record of reproductive
success but the fetal survival rate after 13
Post-op Morbidity
emergency cerclage procedures was only 69%
Estimated blood loss averaged 20ml in
compared to 83% after 42 elective cerclages. The
elective McDonald procedure. No Major post
cerclage does not reduce the number of first
operative complication occurred within two weeks
trimester losses. These were omitted from the two
of the 42 elective procedures. The risk of pregnancy
population for the purpose of comparison with
loss apparently cause by elective procedures was
survival rate after cerclages. In patients having
1%. One of the elective cerclage suture was found
elective cerclage the fetal survival rate in 150 prior
displaced from
pregnancies beyond twelve weeks was 27% where as
procedure which was reapplied and pregnancy
it was 60% in the 25 prior pregnancies beyond
reached to term. One patient delivered one week
twelve weeks in women with emergency cerclage.
after the procedure. Among the 13 emergency
When elective cerclage procedures were sub divided
cerclages
by gestational age at the time of operation, no
charioamnionitis within one week postoperatively.
significant differences in the fetal survival rate,
The fetus didn’t survive. Among the entire series of
premature delivery and small for gestational age
55 cases there were two cases of post op
infants were found. There were no significant
charioamnionitis forcing immediate suture removal
differences in these parameters among the 13-
and delivery (3.6%). In two cases membranes were
women with emergency McDonald procedure. The
bulging with cervical dilatation upto 2cm, in non of
fetal survival rate was higher after elective cerclages
these sac ruptured during surgery but both
3
there
the cervix, two weeks after the
was
one
case
of
acute
developed PROM after surgery and delivered within
section after cerclage. During the study time there
3 weeks of application of suture. At parturition one
were 597 Cesarean-sections among the six thousand
women had irregular cervical tear which needed
deliveries. An overall rate of 9.95%. The McDonald
repair. She had elective cervical cerclage. No cervical
procedure might increase the cesarean section rate
lacerations were reported in 13 of the emergency
for obstetric indications only. Since maternal
cervical cerclages. In the 6000 deliveries performed
morbidity is five time greater after cesarean section
at DHQ Mardan, 120 cervical lacerations at
than after vaginal delivery, the cerclage procedures
parturition required surgical repair or about 1 in
thereby increase maternal morbidity and potential
every 50 deliveries (2 %). After cerclage cervical
mortality. Among 55 patients, in this study, only 6
laceration occurred 1 in 55 cases which is the same.
patients (10.9%) needed cesarean section and that
There was no case of bladder damage or Laparotomy
too for obstetric reasons only.
for repair or control of bleeding.
Progestin’s:
Cesarean Section:
Additional
No greater fetal cervical rate in 35
morbidity
patients treated with progestin’s post operatively
occurs in women with cerclage procedure because
)80%) compared to 20 patients receiving no post op
some physicians prefer to electively deliver by C-
progestin (78%).
Progestin’s:
Tocolysis:
No greater fetal cervical rate in 35
There was no significant difference
patients treated with progestin’s post operatively
in preterm birth rate before 35 weeks in 25 patients
)80%) compared to 20 patients receiving no post op
using tocolysis i.e.
progestin (78%).
(B-Mimetics) and 30 patients not using tocolysis,
18% vs 16%.
Indication for cerclage
No
Term
Preterm &
SGA
Total
History of single second
trimester loss
History of >2 second trimester
losses
History of singe second
trimester loss and prior
cervical trauma
History of premature labour
History of prior successful
11
7 (64%)
1 (9%)
8 (73%)
8 /32 (25%)
12
8 (67%)
2 (17%)
10 (84%)
12/80 (15%)
6
2 (33%)
2 (33%)
4 (66%)
4/27 (15%)
7
6
5 (71%)
4 (67%)
1 (14%)
1 (16%)
6 (86%)
5 (83%)
10/29 (34%)
4/24 (17%)
4
Prior pregnancy
fetal survival
cerclage
Second trimester cervical
dilatation without
contractions
Second trimester dilatation
with contractions
Discussion:
Establishing
5 (56%)
2 (22%)
7 (78%)
11/20 (55%)
4
1 (25%)
1 (25%)
2 (50%)
6/10(60%)
of
infection. Elective Transvaginal cerclages can be
midtrimester loss actually caused by cervical
safely performed as day case procedures (12). Most
insufficiency
accepted
studies in the literature indicate a low major
indications for cervical cerclage vary widely. There is
complications rate (18) i.e,in less than 10% of
no satisfactory objective test that can identify
procedures (19) charioamnionitis is 2-3 times higher
women with cervical weakness in the non pregnant
in elective cerclages (20). The complication rate
state (12). Most physician offer history indicated
increase with increasing gestational age and cervical
cerclage to women with three or more previous
dilatation. PROM after elective cerclage occurs in 2%
preterm births or second trimester losses. (13)
and up to 58% in non elective procedures. Cervical
Elective cerclage is either history indicated or
dystocia and cervical trauma in labour have been
ultrasound indicated while rescue cerclage is an
reported in fewer than 5% of patients. Excessive
emergency
bleeding, maternal sepsis and fistula formation are
is
very
procedure
the
9
difficult.
for
diagnosis
The
premature
cervical
dilatation with exposed fetal membranes. 2-3 cm
rare.
cervical dilatation without effacement does not
In a comprehensive review on cervical cerclage
dictate imminent vaginal delivery (14,15). The
Drakely (21) has noted an increase in cesarean
substantial variation in fetal survival rate depends on
delivery in cervical suture group, thought not
the type of indication used for the operation, and
statistically significant. This increased risk of
the difference in population. Overall fetal survival
cesarean section has probably due to Scar tissue
rates before and after cerclage in this study are
preventing cervical dilatation (22). Recent report
comparable to those of the other large series.
indicate that fetal rather than maternal indications
(16,17,18). On analyzing the fetal survival rates,
influence the rate of cesarean delivery (23,24).
which vary considerably, the prognosis is worse in
Some report in are in discordance with the general
cases of emergency cerclage when cervical dilatation
trend that cesarean section rate increase with
has begun compared to elective procedure same is
cerclage (25,26).
in this study(69%vs83%). Patients undergoing rescue
pregnancies are medicalised once a stitch is inserted,
cerclage do benefit from at least 24-hours post
hence increased anxiety to expedite delivery so
operative period observation in hospital owing to
many women may be treated unnecessarily due to
the
PP
poor prediction and indications(21) .In this study
ROM, early preterm delivery, miscarriage and
cesarean section rate in the cerclage group was
higher
risk
of
5
One of the postulates is than
similar
to
the
rest
of
the
population
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Hein M. The immunology of the cervical
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Hein M, Helmig RB, Schonheyder HC, Ganz
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Am
J
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Lee KY, Jun HA, Kum HB, Kang SW.
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