EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008 Hamdi
EFFECTS OF CERVICAL CERCLAGE ON PERINATAL OUTCOME IN
WOMEN AT HIGH RISK FOR PRETERM DELIVERY
Mamdouh T. Hamdi MD
Department of Obstetrics and Gynecology
EL-Minia Faculty of Medicine
ABSTRACT:
Objectives: The purpose of this study was to determine whether cervical cerclage will be of benefit or not for women at high risk for preterm delivery.
Study design: This randomized controlled study included ninety-five women with asymptomatic singleton pregnancy with clinical and sonographic risk factors for preterm delivery.
All women were between 16 and 24 weeks of gestation. All women were recruited from the attendants of Obstetrics Department, El-Minia University
Hospital between May 2006 and December 2007. The study sample was randomized into 2 groups. The 1 st group (cerclage group) included 44 women who had McDonald cerclage. The 2 nd
group (no cerclage group) included 51 women who received no cerclage. After randomization, both groups were treated with an identical protocol with the exception of cerclage placement. All women were followed up as an outpatient with bed rest and weekly sonographic evaluation. Women in the cerclage group who demonstrated continued dilatation of the internal os with prolapse of the membranes beyond the level of the cerclage were offered a revision cerclage. Women in the no cerclage group had a rescue cerclage if internal os continued to dilate with increasing funneling up to 24 weeks’ gestation. There were 2 revision cerclage in the cerclage group and one rescue cerclage in the no cerclage group. One women in the cerclage group and 4 women in the no cerclage group were lost to follow-up and excluded from final analysis. Cerclages were removed electively at 37 weeks’ gestation or before, if any of the followings occurred: documented rupture of membranes, preterm labor refractory to therapy, or other medical or obstetric indications for delivery. Otherwise, the route and timing of delivery was according to standard Obstetric indications. Effects of cerclage treatment on perinatal outcome for both groups were assessed and statistically compared.
Of the 95 women who met the inclusion criteria, 90 women (43 in the cerclage group and 47 in the no cerclage group) completed the study and included in the final analysis. Both groups were comparable with respect to maternal demographics, risk factors for preterm birth, and sonographic cervical characteristics.
There were no statistical significant differences between both groups regarding frequency of preterm delivery at < 34 weeks’ gestation (15/43 versus 17/47 for cerclage and no cerclage groups respectively) and neonatal survival (41/43 versus
44/47 for cerclage and no cerclage groups respectively). Other perinatal outcome measures were not significantly different in both groups.
Conclusion: Cervical cerclage for women at high risk for preterm delivery does not affect perinatal outcome measures.
KEYWORDS:
Cervical cerclage
Dilation of the internal os
Perinatal outcome.
Cervical length
Preterm delivery
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EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008 Hamdi
INTRODUCTION:
The prevention of preterm delivery is a major desiderate in contemporary obstetrics and a societal necessity. The means to achieve this goal remain elusive, and the research efforts have been punctuated by several ineffective intervention proposals. More recently, new areas of proposed preventive strategy have arisen, focusing on cervical competence, subclinical infection, and hormonal effects.
1
Cervical incompetence is traditionally defined as a history of recurrent second trimester miscarriages, or very preterm delivery whereby the cervix is unable to retain the pregnancy until term.
2 The diagnosis of cervical insufficiency is notoriously difficult to make, and is usually a retrospective one based on a history of recurrent second trimester loss (or early preterm delivery) following painless cervical dilatation in the absence of contractions, bleeding, or other causes of recurrent pregnancy loss.
3 Recently, transvaginal ultrasonographic evaluation of the cervix has been shown to be a better predictor of preterm delivery than traditional manual examination of the cervix, 4 and to be correlated with the risk of preterm delivery in both low-risk and high-risk patients.
5
Transvaginal ultrasound of the cervix is commonly used to diagnose cervical incompetence and has been the basis of recommendation for many cerclage procedures.
6 The sonographic criteria for the diagnosis of cervical incompetence included dilation of the internal os, prolapse of the membranes into the endocervical canal, shortening of the distal cervical segment, and exacerbation of these findings that are associated with transfundal pressure.
6-7
Cerclage therapy for these sonographic findings has been recom-
73 mended because of several studies have demonstrated serial transvaginal sonography in the 2 nd trimester is superior to the traditional diagnosis of cervical incompetence by historic criteria.
4,8 In addition, there were several studies that claimed improved perinatal outcome that was associated with cerclage in patients with these sonographic findings 8-10 .
On the other hand, many studies reported that cervical cerclage has no beneficial effects on perinatal outcome in women at risk of preterm delivery. In 1999, Berghella et al., 11 in their cohort to assess the benefit of cerclage therapy, implied that there may be no benefit of cerclage therapy in these patients. Likewise, Rust et al., 12 showed no benefit of cerclage in patients with sonographically detected dilation of the internal os and shortening of the distal cervix. The absence of benefit might have been a result to the inconsistent cerclage placement in proximity to the internal os.
13
For date, cervical cerclage in the prevention of preterm birth has been the subject of many observational and randomized controlled trials.
Although, it has been used in the management of cervical insufficiency for several decades, yet the indications are uncertain and benefits marginal. It remains a controversial intervention.
2
Therefore, the purpose of this study was to determine whether cervical cerclage will be of benefit or not for women at high risk for preterm delivery.
PATIENTS AND METHODS:
Patient enrolment:
This randomized controlled study included ninety-five women with asymptomatic singleton pregnancy with clinical and sonographic risk factors for preterm delivery. All

EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008 Hamdi women were between 16 and 24 weeks of gestation. All women were recruited from the attendants of Obstetrics
Department, El-Minia University
Hospital between May 2006 and
December 2007.
Inclusion criteria:
The study included any women with asymptomatic singleton pregnancy between the gestational ages of
16 and 24 weeks with clinical and sonographic risk factors for preterm delivery.
Clinical risk factors for preterm delivery included history of preterm delivery, 2 nd
-trimester pregnancy loss, documented uterine anomalies (e.g. mullerian anomaly), previous cervical surgery and multiple cervical dilation procedures.
The sonographic criteria included dilation of the internal os, prolapse of the membranes into the endocervical canal (at least 25% of the total cervical length), shortening of the distal cervical segment (< 2.5cm), and exacerbation of these findings that are associated with transfundal pressure.
6-7
Exclusion criteria:
Exclusion criteria included membrane prolapse beyond the external cervical os, any fetal lethal congenital or chromosomal anomaly, clinical evidence of abruptio placentae, unexplained vaginal bleeding, chorioamnionitis, persistent uterine activity accompanied by cervical change
(consistent with the diagnosis of preterm labor), or any other contraindication to a cerclage procedure.
Ethical issues:
The study was carried out with the approval of the local ethics committee. A detailed written
74 informed consent was taken from all patients prior to the study.
Study Protocol:
Eligible women were randomly assigned treatment with cerclage
(cerclage group) or no cerclage (no cerclage group). The cerclage group included 44 women who had
McDonald cerclage. The no cerclage group included 51 women who received no cerclage. After randomization, both groups were treated with an identical protocol with the exception of cerclage placement.
Any women who did not meet the inclusion criteria or refused randomization was treated according to standard Obstetrics protocols.
Multiple urogenital cultures were obtained from all eligible and they were placed at inpatient bed rest for 48 to 72 hours. During this period, all women received empiric antibiotic therapy with (1.2 gm amoxacillin and clavulanic acid combination i.v. every
8 hours and 500 mg metronidazole i.v. every 8 hours) and indomethacin therapy (100 mg loading dose per rectum followed by 50 mg orally every
6 hours). Any women with a positive urogenital culture (gonorrhea, chlamydia, bacterial vaginitis or urine) was treated according to standard guidelines before randomization.
All patients were the sonographically reevaluated after the empiric treatment period. If the patients continued to meet the inclusion criteria, they were randomly assigned to receive a McDonald cerclage or no cerclage. All cerclage procedures were done using a single stitch of permanent multifilament (silk).
The procedure was done under regional anesthesia by staff obstetriccians. Membranes were reduced above the internal os by placing the patient in steep Trendelenberg position.

EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008 Hamdi
Indomethacin and antibiotic therapy were withdrawn beginning approximately 24 hours after randomization for both groups. Women were discharged from hospital after 48 hours.
At home, women encouraged to continue the conservative policy until
32 weeks’ gestation. They instructed for modified bed rest (8 hours of rest during the day, allowed to mobilize 3 times for a quarter of an hour each time and allowed to leave the bed to go to the bathroom), avoidance of intercourse and educated about the signs and symptoms of preterm delivery.
Transvaginal ultrasonographic reevaluation of the lower uterine segment was done weekly. This was conducted by A Toshiba SSA-340A
(Toshiba Corporation, 1385, SHI-
MOSHIGAMI, OTAWARE-SHI,
TOGHIGI-KEN, 324 JAPAN) ultrasonographic machine with a 7.5 MHz transvaginal transducer. Patients were instructed to empty the bladder before the ultrasonographic examination and were examined in the dorsal lithotomy position. The vaginal transducer was placed in the anterior fornix of the vagina. The appropriate sagittal plane to measure cervical length includes a triangular area of echodensity representing the external cervical os, an almost Y-sahped notch that represents the external cervical os, and a faint line of echodensity or echolucency between both cervical openings that represent the endocervical canal.
14 After an ultrasonographic image of the cervix that contain all three representations has been obtained, the transducer was withdrawn slightly to avoid an artificial increase of cervical length as a result of pressure on the transducer against the uterine cervix. Cervical measurements (in centimeters) that were analyzed included: width of internal os dilation, depth of membrane
75 prolapse into the endocervical canal.
These measurements were repeated with the application of transfundal pressure as described by Guzman et al., 6 . All patients had cervical measurements obtained with and without transfundal pressure. Dynamic imaging of the cervix in this fashion was used to localize the internal os.
All ceclages were removed electively at 37 weeks’ gestation or before on an emergency basis, if any of the followings occurred: documented rupture of membranes, preterm labor refractory to tocolytic therapy, preterm labor with contraindications to tocolysis and clinical documentation for chorioam-nionitis or abruptio placentae or other medical and obstetric indications for delivery.
Otherwise, the route and timing of delivery was according to standard
Obstetric indications.
Women in the cerclage group who demonstrated continued dilatation of the internal os with prolapse of the membranes beyond the level of the cerclage were offered a revision cerclage. Women in the no cerclage group had a rescue cerclage if internal os continued to dilate with increasing funneling up to 24 weeks’ gestation.
13
Maternal complications that were analyzed included read mission for preterm labor, chorioamnionitis, placental abruption, cervical laceration, and rescue or revision procedures.
The main outcome measures in this study were gestational age at delivery and neonatal survival.
Gestational age was measured in weeks, and neonatal morbidity was stratified according to outcome. No neonatal morbidity was defined as a newborn nursery admission with no prolonged length of stay for neonatal indications. Minimal morbidity was defined as an intensive care unit admission without life-threatening complications. Severe morbidity was

EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008 Hamdi defined as life-threatening illness (such as respiratory distress syndrome, sepsis or other serious morbidity). The outcome of perinatal death was defined as any stillborn fetus or death during the neonatal period.
STATISTICAL METHODS: group (cerclage group) included 44 women who had McDonald cerclage.
The 2 nd group (no cerclage group) included 51 women who received no cerclage. One women in the cerclage group and 4 women in the no cerclage group were lost to follow-up and excluded from final analysis. Of the 95
The data were fed and analyzed with the SPSS statistical package version 11.0 (SPSS Inc, Chicago, Ill) for windows. Data were expressed as mean ± standard deviation (SD) or as numbers and percents. Comparisons between study groups were done using unpaired student’s t-test (for continuous variables) or chi-square or
Fisher’s exact tests (for categorical variables). In the cerclage group, the comparison of cervical measurements women who met the inclusion criteria,
90 women (43 in the cerclage group and 47 in the no cerclage group) completed the study and included in the final analysis. There were 2 revision cerclage in the cerclage group and one rescue cerclage in the no cerclage group.
The 43 patients in the cerclage group delivered 51 infants, and the 47 patients in the no cerclage group delivered 56 infants. There were no before and after cerclage placement was done by paired student’s t-test.
The test was considered statistically significant when p<0.05. significant statistical differences between both groups with respect to maternal demographic characteristics or risk factors for preterm birth. These
RESULTS:
The study sample was randomized into 2 groups. The 1 st results are summarized in table (1).
Table (1): Demographic characteristics and risk factors for preterm labor in the
cerclage and no cerclage groups.
Demographic characteristics and risk factors for preterm labor
Maternal age (years)*
Cerclage group
(n=43)
26.3±1.8
No cerclage group
(n=47)
24.1±1.2
P value
NS
Gestational age at diagnosis (wk)*
22±2.3 22.8±2.2
NS
Previous preterm birth*
Previous second trimester loss**
23(53.48%)
5(11.62%)
17(36.17%)
13(27.66%)
NS
NS
NS = non-significant (>0.05).
* = values are mean ± standard deviation (SD).
** = values are numbers and (percent).
The ultrasonographic cervical measurements at time of initial examination were also matched for both cerclage and no cerclage groups.
There were no significant statistical differences between both groups as regards to dilation of internal os, depth of membrane prolapse, distal cervical length and total cervical length. Of the
90 women included in the final
76

EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008 Hamdi analysis in both study groups, 18 (20%) women had funneling > 25% of the total cervical length, 11 (12.2%)
61 (67.8%) women showed both cervical changes at time of inclusion in this study, table (2). women with a distal length <2.5cm and
Table (2): The ultrasonographic cervical measurements at time of initial examination
in the cerclage and no cerclage groups.
Ultrasonographic cervical measurements
Dilation of internal os (cm)
Cerclage group
(n=43)
1.7±0.6
No cerclage group
(n=47)
1.8±0.9
P value
NS
Depth of prolapse (cm) funneling
Distal cervical length (cm)
Total cervical length (cm)
1.7±1.1
2±1.1
3.6±1.2
1.7±1
2±0.8
3.5±1
NS
NS
NS
NS = non-significant (>0.05). All values are mean ± standard deviation (SD).
In the cerclage group, the comparison of cervical measurements before and after cerclage placement is of membrane prolapse. It also significantly increased the distal cervical length. However, there was no summarized in table (3). Cerclage placement significantly reduced the width of internal Os dilation and depth significant change in total cervical length.
Table (3): Cervical measurement (in centimeters) comparison in cerclage group
before and after cerclage.
Ultrasonographic cervical measurements
Dilation of internal Os (cm)
Before cerclage
1.7±0.6
After cerclage
0.7±0.5 *
P value*
<0.001
Depth of prolapse (cm)
1.7±1.1 0.6±0.3 *
<0.001
Distal cervical length (cm)
Total cervical length (cm)
2±1.1
3.6±1.2
3.1±0.9 *
3.6±1
<0.001
NS
NS = non-significant (>0.05).
All values are mean ± standard deviation (SD).
 = paired student’s t-test
Maternal complications are summarized in table (4). There were 2 uterine activity with cervical changes) that needed tocolytic therapy. The
(4.7%) revision cerclage in the cerclage group and one (2.13%) rescue cerclage in the no cerclage group.
However, this difference was not statistically significant. About 50% of women in each group had at least one episode of preterm labor (increased cerclage group seems to have maternal complications (puerperal pyrexia, placental abruption and chorioamnionitis) more often than the no cerclage group but these differences were not statistically significant.
77

EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008 Hamdi
Table (4): Maternal complications in the cerclage and no cerclage groups.
Maternal complications Cerclage group
(n=43)
No cerclage group
(n=47)
Rescue procedure 2(4.7%) 1(2.13%)
Preterm labor
Puerperal pyrexia
Placental abruption
22(51.1%)
6(13.9%)
6(13.95%)
25(53.1%)
4(8.5%)
4(8.5%)
P value
NS
NS
NS
NS
Chorioamnionitis 8(18.6%) 5(10.6%) NS
NS = non-significant (>0.05).
All values are numbers and (percent).
The main perinatal outcome measures are summarized in table (5).
There were no statistically significant differences between the cerclage and
Perinatal outcome
Mean gestational age at delivery (wk)* gestational age at delivery, percent of preterm deliveries at less than 34 weeks’ gestation and the perinatal deaths or admission rate to neonatal intensive care unit (NICU). no cerclage groups as regards to mean
Table (5): Perinatal outcome in the cerclage and no cerclage groups.
Cerclage group
(n=43)
33.7±7
No cerclage group
(n=47)
33.8±6
P value
NS
Preterm delivery at less than 34 wks**
Perinatal death**
15(34.8%)
6(13.9%)
17(36.1%)
6(12.7%)
NS
NS
Admission to NICU:**
No
Yes, for observation
Yes, for intensive care
29(67.5%)
9(20.9%)
5(11.6%)
32(68.1%)
10(21.3%)
5(10.6%)
NS = non-significant (>0.05). NICU = Neonatal Intensive Care Unit.
* = values are mean ± standard deviation (SD).
** = values are numbers and (percent).
DISCUSSION:
Several recent studies have demonstrated a continuum of risk between shorter cervix on ultrasound and higher rate of preterm delivery, leading to the hypothetical argument that women with short cervix on relative paucity of data and the conflicting nature of the available evidence dictate caution whenever decisions for cervical monitoring or intervention are made.
1 ultrasound might benefit from cervical cerclage. Observational and randomized clinical trials of cerclage as a modality of pregnancy prolongation have provided conflicting results. The
The Sonographic findings of dilation of the internal os, prolapse of the membranes into endocervical canal, shortening of the distal cervix, and exacerbation that was associated with transfundal pressure have been
NS
78

EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008 Hamdi presumed to indicate cervical incompetence.
15 This theory suggested that these ultrasound findings indicate a defect in the cervical stroma that antedated the pregnancy and if, left untreated would result in spontaneous preterm birth or second trimester loss.
Iams et al., 16 have suggested that cervical incompetence is not an “all or none” phenomenon but rather a continuum. They postulate a multifactorial model of spontaneous preterm birth that suggests that one or more pathophysiologic processes may act on an otherwise competent cervix to convert it into a distendable conduit through which preterm birth can take place. Therefore, the sonographic findings of internal os dilation, prolapse of the membranes, and shortening of the cervix are anatomic manifestations of altered cervical physiologic factors and represent a final common pathway for multiple pathologic processes.
In the present study, funneling through the level of the cerclage was found in 4.7% of women in the cerclage group who were subjected to revision cerclage. This demonstrates that serial transvaginal ultrasonography after cervical cerclage, identifies early evidence of cerclage failure and provides an opportunity for earlier intervention (repeated or revision cerclage).
These results are similar to that reported by many authors.
17,18
The reported prevalence of different complications and perinatal outcome for cerclage vary widely in the literature. Drakeley et al., 19 reviewed systematically in a metaanalysis study 7 trials done to assess the effectiveness and safety of prophylactic cerclage. They found that cervical cerclage was associated with maternal complications in the form of mild pyrexia, increased use of tocolytic
79 therapy and hospital admission but without serious morbidity. Sheiner et al., 20 assessed the impact of obestetric risk factors for preterm delivery among women with McDonald cerclage performed due to cervical incomepetence. They found that secondtrimester bleeding, chorioamnionitis, placental abruption, premature rupture of membranes and severe preeclampsia were ominous among women having
McDonald cervical cerclage.
In the present study, similarly, maternal complications in the cerclage group were found to be more frequent than in the no cerclage group. About
50% of women in each group had at least one episode of preterm labor
(increased uterine activity with cervical changes) that needed tocolytic therapy.
The cerclage group seems to have maternal complications (puerperal pyrexia, placental abruption and chorioamnionitis) more often than the no cerclage group. These results were in agreement with that reported by the aforementioned studies.
19,20 However these differences were not statistically significant. Progression of subclinical pathophysiologic factors can explain the high rate of maternal morbidity and significant increases in the neonatal morbidity and death that are associated with failed cerclage therapy or the necessity of rescue procedures. Also,
Rust et al., 21 identified 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. Those authors concluded that the sonographic findings of second trimester internal os dilation, membrane prolapse, and distal cervical shortening likely represent a common pathway of several pathophysiologic processes.

EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008 Hamdi
The present study showed that treatment with cervical cerclage for women at high risk of preterm delivery in comparison with no cerclage did not significantly improve the clinical outcome of pregnancy. There were no statistically significant differences between the cerclage and no cerclage groups as regards to mean gestational age at delivery, percent of preterm deliveries at less than 34 weeks’ gestation and the perinatal deaths or admission rate to neonatal intensive care unit (NICU). These results were in agreement with those reported by many recent studies.
12,21,22
On the other hand, a randomized trial by Althuisius et al., 14 used therapeutic McDonald cerclage with bed rest at 15 weeks’ gestation in
19 women with a previous preterm delivery (< 34 weeks) and with a cervical length < 25mm prior to the
27 th
week of pregnancy. This group was compared with bed rest alone in
16 pregnant women. The results showed less frequent preterm births in the cerclage group than in the bed rest group. In addition, the neonatal morbidity was significantly higher in the bed rest group. These contradictory results of the effects of cerclage on pregnancy outcome may be caused by different study populations. It appears that the study population of Althuisius et al., 14 may have been at greater risk than the patients in the other results.
12,21,22
In the present study, cerclage placement significantly reduced the width of internal Os dilation and depth of membrane prolapse. It also significantly increased the distal cervical length. However, there was no significant change in total cervical length.
Several studies demonstrated that both urgent cerclage and
80 prophylactic cerclage procedures increase cervical length. Funai et al., 23 reported data from 31 women treated with prophylactic cerclage and noted that cervical length was considerably improved. Dijkstra et al., 24 reported data collected from 80 women treated with cerclage, 50 who received a prophylactic cerclage and 30 whose sutures were placed urgently in response to cervical dilation and/or effacement. Cervical length was longer after cerclage in both groups, but the increase in cervical length after cerclage therapy was not predictive of term delivery. Women who were delivered preterm had considerable shortening of cervix before preterm birth.
Our data were in agreement with these studies.
23,24 However these results did not analyze perinatal outcome with respect to postcerclage distal cervical length.
The study by O’Brien et al., 25 analyzed data from 53 women treated with cerclage (9 emergency and 25 urgent and 19 prophylactic) and found an increase in cervical length after cerclage. Cervical length was measured before and after cerclage and the cervical length beyond the cerclage was recorded. In the same instance, the study by To et al.
(22) demonstrated that the insertion of a Shirodkar suture in women with a short cervix does not substantially reduce the risk of early preterm delivery. However, routine sonographic measurement of cervical length at 22-24 weeks identifies a group at high risk of early preterm birth.
A recent study by Berghella et al., 26 showed that cerclage does not prevent preterm birth in all women with short cervical length on transvaginal ultrasonography. In the

EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008 Hamdi subgroup analysis of singleton gestations with short cervical length, especially those with a prior preterm birth, cerclage may reduce preterm birth, and a well-powered trial should be carried out in this group of patients.
Rust et al., 13 postulated that the anatomic changes of internal os dilation, prolapse of the amniotic membranes into the endocervical canal, shortening of the distal cervical length, and dynamic change associated with transfundal pressure demonstrated by second trimester transvaginal ultrasound are a final common pathway of the pathophysiologic events. The surgical technique of cerclage is an attempt to restore or at least improve the anatomic appearance of the cervix, regardless of the mechanism that caused the changes.
Restoration of the anatomy does not necessarily address the pathophysiology related to a short or funneled cervix, thus explaining the failure of cerclage therapy in a population selected on the basis of ultrasound findings. Therefore, another randomized clinical trial is therefore advocated to evaluate effectiveness of cerclage in these cases with short cervix.
In conclusion, cervical cerclage for women at high risk for preterm delivery does not affect perinatal outcome measures.
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اتلا ااعواووملا نام – رراكتملا ااهجلإا عنم لئاسو نم ةليسوك
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ااساردلا نم ريثك اهلوانت
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اادياسلل وءارجإ دنع محرلا قنع طبر ةعفنم ىدم ديدحتل ةساردلا وذه ايرجأ قلطنملا اذه نمو
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ااددراتملا اادياسلا نم كلذو ةينويزفيلتلا ةعشلأا زاهج ةطساوبو ايكينيلكإ نهصحف دعب ةركبملا
نهماسقت مات داقو م 2007 ربماسيد لإ 2006 ويام نيبام ةرتفلا ف عماجلا اينملا فشتسم لع
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ةافرعمل ةاينويزفيلتلا ةعاشلأا زااهج ةطاساوب نيتعوامجملا اف اادياسلا عايمج ةاعباتم مات دقو اذه
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