Overview of cervical cerclage in a Regional Referral Hospital, Oman - PowerPoint Presentation

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Overview of cervical cerclage in a Regional Referral Hospital, Oman

Dr.

Reham

Ahmed

Email :Reham_nail@yahoo.com

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No conflict of interest

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Background:

Preterm delivery, defined as delivery before 37 weeks of completed gestation.

It is a major cause of neonatal morbidity and mortality.

Despite extensive research, preterm birth still accounts for 5–10% of all deliveries in developed countries and rates are on the increase.

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Complication:

 Gestation at delivery and birthweight are the major determinant of outcome.

 Respiratory distress syndrome, necrotising enterocolitis, retinopathy of prematurity, sepsis, intraventricular haemorrhage, periventricular

leucomalacia

and long-term cognitive and sensory impairment.

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Preterm labour syndrome is multifactorial

How to prevent

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Prevention:

Treat infections.

Cervical cerclage.

Progesterone supplements.

Multivitamins and lifestyle modifications.

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Cervical Cerclage

Cervical cerclage is a treatment for cervical weakness and is placed in elective or emergency setting.

It provides a degree of structural support to a weak cervix.

1-2% of pregnant women will require cerclage.

In our practice transvaginal route is used for our patient.

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Types Of Cerclage:

History-indicated cerclage, for asymptomatic women with risk factor increasing preterm birth (including previous preterm/ 2

nd

trimestric

loss).

Ultrasound- indicated cerclage, for asymptomatic women where the scan confirmed shortening of the cervix (<25mm).

Rescue cerclage, where the cervix is dilating and fetal membranes are already exposed.

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Objective :

The objective of the study is to review risk factors, the outcome, and success and failure rates of the procedure.

Finally, to assess if indicated or not and to optimize our practice of elective cerclage.

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Method and study design:

A two-year retrospective observational study.

included all pregnant women underwent cervical cerclage, between January 2016 and December 2017, at Nizwa Hospital, Oman.

Total number of cerclages done 212, elective= 210 (99.06%) & emergency (rescue) = 2 (0.94%).

35% women had no living issue.

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Indication categories:

Multiple gestation .

IVF conception.

Prolonged subfertility.

Diagnosed Mullerian abnormality.

Previous preterm birth/2

nd

trimester loss.

Patient wishes (with previous early pregnancy

losses).

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Study findings

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Multiple gestation:

Multiple pregnancies are high-risk and associated with increased perinatal morbidity and mortality.

Pathophysiology mechanisms include intrauterine infection, cervical insufficiency and increased uterine stretch/distension.

In our institute the multiple pregnancy rate account for around 1.7%, 85% of them delivered prematurely.

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N= 6 cases (2.8%).All had normal cervical length

at 12-14wks of gestation

4 cases (66.6%) had preterm birth

at 31-33wks despite cerclage.

Result supports the evidence of increasing in prematurity in multiple gestation pregnancies and a trend towards harm when cerclage used.

 

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Recommendation

: If cerclage is considered in a twin pregnancy, observational evidence suggests that benefit is more likely with a shorter cervix(<15mm).

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Pregnancy conceived using assisted reproductive technology:

Pregnancies conceived following ART are at increased risk of PTL.

Reported incidences of very PTL (before 32 weeks of gestation) and PTL (before 37 weeks of gestation) of 2.6% and 11.2%, respectively, compared with 0.7% and 5.4% in the general population.

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In our study 19 cases (8.9%) had elective cervical cerclage in view of IVF conceptions.

11(58%) delivered term after 37wks, majority had elective caesarean delivery at 37-40 week mostly for maternal request.

4(21%) delivered prematurely <34weeks.

4 cases data are missing as they delivered in other hospital.

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This support the evidence of no additional surveillance or interventions are beneficial in reducing the rates of PTL in these conceptions.

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Recommendations: increased preterm birth and other adverse pregnancy outcomes in singleton IVF cycles warrant investigations to elucidate and mitigate. Minimizing embryo manipulation during cell culture is recommended. Increased risk of preterm birth and other pregnancy complications in ART could reflect the underlying reasons for infertility. This information should be discussed and further explored.

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Conception after prolonged subfertility:

16 cases (7.5%).

Most had normal cervical length 12-14weeks.

7(43.7%) delivered prematurely and 8(50%) had term delivery majority ended by induction of labor at 38-41weeks for postdate and gestational diabetes.

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Women with history of previous preterm birth or second trimester miscarriage:

According to NICE guideline prophylactic cerclage should be offered for women with a history of spontaneous preterm birth (up to 34+0 weeks of pregnancy) or mid-trimester loss (from 16+0 weeks of pregnancy onwards)

AND

transvaginal ultrasound scan (16+0 and 24+0 weeks) show a cervical length of 25 mm or less with discuss of the risks and benefits .

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N=150. 38(25.3%) delivered 3-4 weeks after cerclage removal; either spontaneously or got labor induced for post maturity indicating no cervical weakness.

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Short cervix (<2.5cm) was detected in 16% of cases, 68%of this group had normal cervical length at 12-14wks of gestation.

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Cerclage done for other indications:

13 cases (6.13%) had elective cerclages for diagnosed uterine anomaly.

4(30.7%) delivered 3-4 weeks after cerclage removal suggesting it is not needed, and 5(38.4%) delivered preterm.

All cases had cervical length less than 3 cm at 12-14wks.

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Women who desired for cerclage which was not medically indicated, accounted 9 cases (4.2%).7(77.7%) delivered by 37-40wks, majority by elective C. section.

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Out of 2 cases of emergency cerclage, one preterm birth and other ended as fetal demise at 16 wks.

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Limitation:

Some data are missed as patient underwent elective cerclage in our institute and delivered in other hospital for social reason or they were referred back to their parent institute for delivery. Data could not be traced from other hospital.

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Conclusion:

Management and diagnosis of a short cervix is an obstetric dilemma.

In our study 52 patients (24.5%) had preterm birth despite cerclage and 49 patients (23.1%) delivered 3-4weeks after cerclage removal suggesting that there is insufficient evidence to recommend this procedure to avoid pregnancy loss .

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Recommendation:

Proper patient counseling.

Serial cervical length assessment.

Progesterone use.

Designated preterm prevention clinics with senior involvement can save patients from unnecessary intervention.

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References:

Preterm

labour

and birth NICE guideline [NG25]Published date: 20 November 2015 Last updated: 02 August 2019.

RCOG – e-learning –

stratog

-management of

labour

and birth-preterm

labour

.

RCOG , GTG (17) ,The Investigation and Treatment

of Couples with Recurrent First trimester

and Second-trimester Miscarriage, April 2017.

International Journal of Obstetrician and Gynaecologist, volume 155, issue1 , good practice for preterm prevention.

TOG, spontaneous preterm birth prevention in multiple pregnancy, 2018;20:57–63.