Outcome of emergency cerclage for advanced cervical dilatation: a retrospective analysis
Keywords:Late second trimester, Bulging membranes, Emergency cerclage, Pregnancy outcomes
Background: The objective was to evaluate the outcome of late second trimester emergency cerclage in patients with advanced cervical dilatation with bulging membranes.
Methods: Setting: department of obstetrics and gynaecology, PSG Institute of medical sciences & research, Coimbatore, Tamil Nadu, India. This is a retrospective study of case files of patients who underwent emergency late second trimester cerclage for advanced cervical dilatation with bulging membranes between January 2009 to January 2014. McDonald’s technique was used in all the cases.
Results:Altogether, 7 patients (100%) underwent late second trimester emergency cerclage between 20-28 weeks of gestational age, out of which three patients (42.86%) had term deliveries (>37w), and 3 patients (42.86 %) carried on their pregnancies to more than 32 weeks resulting in healthy live born babies. Two of them delivered by normal vaginal delivery, 4 underwent LSCS, and one patient had severe abdominal pain with bleeding and draining per vaginum after 3 days of cerclage, in view of which the stitch was removed. Subsequently, the patient expelled a live foetus weighing 620gms, which died in the Neonatal Intensive Care Unit (NICU) after 3 hours. This procedure prolonged the duration of pregnancy in all patients with a mean duration of 70.4 days. The mean gestational age at the time of delivery was 34.33 weeks. The mean birth weight was 2.18 kg and ranged between 1.97 to 2.64 kg. The mean APGAR at one minute was 8/10 and the mean duration of stay in NICU was 1.66 days. All the new-born babies were healthy at the time of discharge. The live birth rate following emergency late second trimester cerclage in this series was 85.75%.
Conclusion:Favourable neonatal outcome can be accomplished in patients with cervical incompetence in the second trimester of pregnancy following emergency cervical suturing, even if performed when the membranes are bulging through the cervix.
Norwitz ER, Greene MF, Repke JT. Cervical cerclage - elective and emergent. ACOG Update. 1999;24:1-11.
Novy J, 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 Gynaecol. 2001;184(7):1447-56.
Stromme WB, Haywa EW. Intrauterine foetal death in second trimester. Am J Obstet Gynaecol. 1963;85:223-33.
Jewelewicz R. Incompetent cervix. Pathogenesis, diagnosis and treatment. Semin Perinatol. 1991;15:156-61.
Iams JD, Jhonson FF, Sonek J, Sacks L, Gebaur C, Samuels P. Cervical incompetence as a continuum: a study ultrasonographic cervical length and obstetric performance. Am J Obstet Gynaecol. 1995;172:1097-106.
Althuisius SM, Dekker GA, van Geijn HP, Bekedam DJ, Hummel P. Cervical incompetence prevention randomized cerclage trial (CIPRACT): study design and preliminary results. Am J Obstet Gynaecol. 2000;183:823-9.
MacNaughton MC, Chalmers JG, Dubowitz V, Dunn PM, Grant AM, McPherson K, et al. Final report of the Medical Research Council/Royal College of Obstetrics and Gynaecology multicentre randomized trial of cervical cerclage. Br J Obstet Gynaecol. 1993;100:516-23.
Berghella V, Odibo AO, Tolosa JE. Cerclage for prevention of preterm birth in women with a short cervix found on transvaginal ultrasound examination: a randomized trial. Am J Obstet Gynaecol. 2004;191:1311-7.
Owen J1, Hankins G, Iams JD, Berghella V, Sheffield JS, Perez-Delboy A, et al. Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length. Am J Obstet Gynaecol. 2009;201(375):e1-8.
American College of Obstetricians and Gynecologists. Cervical cerclage. In: ACOG, eds. ACOG Criteria Set Number 18. Washington, D.C.: ACOG, 1996.
MacDougall J, Siddle N. Emergency cervical cerclage. Br J Obstet Gynaecol 1991;98:1234-8.
Holman MR. An aid for cervical cerclage. Obstet Gynaecol. 1973;42(3):468-9.
Sher G. Congenital incompetence of the cervical os: reduction of bulging membranes with a modified Foley catheter. J Reprod Med. 1979;22(3):165-7.
Rust OA, Atlas RO, Reed J, van Gaalen J, Balducci J. Revisiting the short cervix detected by transvaginal ultrasound in the second trimester: why cerclage therapy may not help? Am J Obstet Gynaecol. 2001;185(5):1098-105.
Groom KM, Bennett PR, Maxwell DJ, Shennan AH. Successful cerclage at advanced cervical dilatation in the second trimester. Int J Obstet Gynaecol. 2001;108:1005-7.
Ventolini G, Neiger R. Management of painless mid-trimester cervical dilatation: prophylactic vs. emergency placement of cervical cerclage. J Maternal-Fetal Neonat Med. 2009;22:510-6.
Kanai M, Ashida T, Ohira S, Osada R, Konishi I. A new technique using a rubber balloon in emergency second trimester cerclage for fetal membrane prolapse. J Obstet Gynaecol Res. 2008;34:935-40.
Cockwell HA, Smith GN. Cervical incompetence and the role of emergency cerclage. J Obstet Gynaecol Can. 2005;27:123-9.
Thomas Obinchemti Egbe, Theophile Nana Njamen, Gregory Halle Ekane, Jacques Kamgaing Tsingaing, Charlotte Nguefack Tchente, Gerard Beyiha, et al. Outcome of late second trimester emergency cerclage in patients with advanced cervical dilatation with bulging amniotic membranes: a report of six cases managed at the Douala general hospital, Cameroon. ISRN Obstet Gynaecol. 2013;2013:843158.
Matijevic R, Olujic B, Tumbri J, Kuriac A. Cervical incompetence: the use of selective and emergency cerclage. J Perinat Med. 2001;29(1):31-5.
Purnima Deb, Nighat Aftab, Shabana Muzaffar. Prediction of outcomes for emergency cervical cerclage in the presence of protruding membranes. ISRN Obstet Gynaecol. 2012;2012:842841.
Romero R, Hillier SL, Eschenbach DA, Sweet RL. A review of premature birth and subclinical infection. Am J Obstet Gynaecol. 1992;166(5):1515-28.