Záchranné cerkláže v léčbě cervikální insuficience

Rescue Cerclage in the Treatment of Cervical Insufficiency

Objective:
To evaluate the effectiveness of the cervical cerclage in the five year period on pregnancy outcome. The primary outcomes of interest was effectiveness of rescue cerclage in prolongation of pregnancy.

Study design:
Retrospective study.

Setting:
Gynaecological and Obstetric Clinic Medical Faculty Palacky University and Faculty Hospital Olomouc.

Methods:
In the retrospective analysis of maternal and newborn records in the five year period from 1. 1. 2000 to 31. 12. 2004 we identified three groups of indications for operative cervical closure: elective – on the basis of history without objective evidence of cervical change, emergency cerclage – with objective manifestation of cervical insufficiency and rescue cerclage of a widely dilated cervix with prolapsed unruptured membranes.

Results:
A total of 50 patients underwent cerclage during the period from 1. 1. 2000 to 31. 12. 2004 between 12 and 30 weeks of gestation. The prevalence of operative intervention was 0.6% of all mothers. All patients had similar management (hospitalization, bed rest, antibiotics and tocolysis treatment). Cervical cerclage was done by the McDonald technique with single or double stich or Mersilene tape. Fourteen patients (28%) had rescue operations, 28 (56%) emergency and 8 (16 %) elective cerclage. In all groups there was no significant difference in the sociodemographic characteristics (age, BMI, education, number of previous pregnancies and parity). Also no significant difference we found in pregnancy complications. Only smoking in the pregnancy was a significant risk factor associated with rescue cerclage, relative risk = 3.30 (95%CI 1.57–6.96, P= 0.0272183). Critical gestational age 32nd week achieved 6 rescue cerclage subjects (42.9%), significantly less as for emergency cerclage subjects (85.7 %), (P= 0.0089396) and elective ones (87.5%). Mean length of interval from cerclage to delivery was significantly shorter after rescue cerclage, 42.7 ± 35.8 days, median 24, range (3–126) compared to emergency cerclage patients, 72.0 ± 28.4 median 72, range (14–130), (P=0.006247). Interval from cerclage to delivery in elective operation was 118 ± 59.1, median 109, range (32–188), (P=0.049818). Survival analysis also confirmed significantly shorter interval from cerclage to delivery in the rescue cerclage compared to other acute intervention. Log Rank test = 23.6205 (P=0.000000), Wilcoxon = 20.299 (P=0.000000). Newborn dates corresponds with earlies termination of pregnancy in rescue cerclage subjects, with mean gestational age at time of delivery 29.5 ± 6.0 weeks, median 28, range (20–41), after emergency cerclage 35.4±3.4, median 37, range (26–41), (P = 0.000592). The mean gestational age at delivery after elective cerclage was 34.8 ± 5.0, median 35, range, (25–41). There was no significant difference in hospitalization time between groups. Three fetal losses of extremly low birth weight babies were in rescue subjects, one abortion at 20 weeks gestation, fetal weight 260 grams with marked acute chorioamnionitis. Interval from cerclage to abortion was 24 days. Two female fetuses (twins) 530 anad 550 grams died early in life after caesarean section for placental abruption 34 days after the cerclage.

Conclusion:
Rescue cerclage occurs in 28% of all cervical closure. In comparison with other indications they have significantly worse outcomes in prolongation of pregnancy. Obviously, because they are extreme events of cervical insufficiency. Fetal losses were nevertheless minimal and connected with intrauterine infection and placental abruption. In combination with antibiotics and tocolysis rescue cerclage gives hopes that they can help in pregnancy prolongation.

Key words:
cervical cerclage, emergency, rescue, elective, retrospective analysis