Effectiveness of elective cervical cerclage according to obstetric

history
D. Korb, et al.
Division of obstetric and gynecology, Robert-Debre Hospital, Paris, France

dr. Rismawati
Departemen Obstetrik dan Ginekologi
Universitas Syiah Kuala/ RSU Dr. Zainoel Abidin Banda Aceh
2017
1 19/01/2019
 Abstract
Objective. — To assess the effectiveness of elective history-indicated cervical
cerclage according to obstetrical history.

Study design. — We analyzed pregnancy outcome of a retrospective cohort

of women who have had history-indicated McDonald’s cerclage. Principal
outcome was gestational age (GA) at delivery.

Result. —Between January 2003 and December 2013, 205 women were
included. We analyzed population in two risk groups: 1- Low-risk (≤ 2 prior
preterm birth (PTB)/second trimester loss (STL), or prior success of cerclage),
2- High risk (≥ 3 prior PTB/STL, or prior failure of cerclage). In the high-risk
group, there was a higher frequency of deliveries before 37 weeks Fifty
percent of women (n = 6/12) delivered before 37 weeks in case of three or
more prior PTB/STL, and 51% (n = 24/47) in case of prior failure of cervical
cerclage.

Conclusion. — Elective cervical cerclage may be indicated for women with ≤

2 prior PTB/STL, or prior successful cerclage. For women with ≥ 3 prior
PTB/STL, trachelorraphy or cervico-isthmic cerclage could be possible
alternatives to cervical cerclage.

2 19/01/2019
 Introduction

 Preterm birth rate is currently increasing in middle

and high income country
 The risk is higher in case:
 Prior second trimester loss (STL)
 Prior preterm birth (PTB), and
 Cervival insufficiency as one of the major cause
 Cervival insufficiency  uterine cervix inability to
maintain pregnancy when no symptoms or clinical sign
(contraction, labor, or both)

3 19/01/2019
 Introduction
 Cervical cerclage  treatment of woman with a
history of cervical insufficiency.
 If failure of cerclage  an alternative such
trachelorraphy or cervico-isthmic cerclage could be
performed
 Different countries recommendation for cerclage
 Women with ≥3 prior STL or PTB
 Women with one prior PTB or STL
 According to ultrasound monitoring
 The problem is recommendation are based on studies
with low levels of evidence

4 19/01/2019
 Objectives
 The aim of this study was to assess wheter cervical
cerclage placement, indicated by prior obstetrical
events is efective in preventing STL or PTB in women
with different level of risk according to their obstetrical
history

5 19/01/2019
 Material and Methods
 Study was conducted at tertiary unit of Robert-Debre
Hospital in Paris, France
 Design: Retrospective cohort between January 2003
and December 2013 women who have had history-
indicated McDonald’s cerclage.
 Inculded: women with a singleton who underwent a
history-indicated transvaginal cerclage before 16 weeks
gestational age (GA)
 Excluded: medical termination of pregnancy and
induced prematurity
 Principal outcome was gestational age at delivery
6 19/01/2019
 Material and Methods
 Indication for cerclage was based on
 Obstetric history: STL or PTB
 Gynecological history and risks factors for STL/PTB:
conisation, diethylstilbestrol exposure, uterine anomaly
 On cervical incompetence diagnosis
 We comparing two groups of women by their level of risk
 Low risk  one or two prior PTB or STL, or history of
success of cerclage
 High risk  three or more prior PTB or STL, or history of
failure of cerclage
 Also we divided into three group according their history
 One prior PTB or STL, or previous cerclage success
 Two prior PTB or STL
7  Three or more prior PTB or STL 19/01/2019
 Results

8 19/01/2019
 Results

9 19/01/2019
 Results

10 19/01/2019
 Results

11 19/01/2019
 Results

12 19/01/2019
 Results

13 19/01/2019
 Discussion
 This study has several strengths

 single-center study  homogenization of population characteristics

 Prophylactic cerclage indications,

 Single surgical technique (different from most cerclage studies that have ofen

analyzed a population receiving either Shirodkar or Mcdonald cerclage)

 In this study, effectiveness of elective cerclage was better than previous studies.
Indeed there was an incidence of 30% of PTB at less than 37 weeks’ in this study
population, while, in other studies, it was 45—50% in a history-indicated cerclage
group and 35—40% in an ultrasound-indicated cerclage group

 Some discrepancy of results could be in this study cerclage placement was

always made before 16 GA. Regarding cerclage procedure, this always included
monitoring a vaginal swab in order to prevent and treat any active infection

14 19/01/2019
 Discussion
 In view of study results, a new elective cervical cerclage placement in

women with successful cerclage history was effective in preventing

preterm birth.

 In case of a previously failed transvaginal cervical cerclage,

recommendations were proposing a cervico-isthmic cerclage.

Trachelorraphy is also a safe, reproducible and easy-to-learn procedure
for women with a poor obstetric history with prior vaginal cerclage failure

15 19/01/2019
 Discussion
 In this study, results for women with one or two prior PTB or STL were

similar and there was no significant difference.

 In this study, effectiveness of cerclage for women with at least three

PTB or STL decreased significantly. It was difficult to offer them a

treatment, which was successful in only 50% of cases

 For those women with a poor obstetric history, it is to be recommended

a trachelorraphy or a cervico-isthmic cerclage.

16 19/01/2019
 Discussion
 Our management proposal is in case of:

 one prior PTB/STL: elective cervical cerclage, or cervical ultrasound

monitoring until 24 weeks;

 two prior PTB/STL: elective cervical cerclage;

 three or more prior PTB/STL or one prior failure elective cerclage:

trachelorraphy outside of pregnancy, or cervico-isthmic cerclage by

Benson in case of current pregnancy;

 one prior cerclage success: elective cervical cerclage

 In this study, there were very few complications: seven (3.4%)

pregnancy losses at less than 20 weeks’ and no pregnancy losses at

less than 17 weeks’ gestation; only two (1%) intraoperative ruptures of
17 19/01/2019
membranes
 Conclusion
 Elective cerclage appears to be a simple and effective technique
when its indication is based on a suggestive history of cervival
insuficiency.
 Elective cervival cerclage sholud be recommended to women with
 One or two prior PTB or STL
 Suggestive cervical insufficiency
 Prior sucessful cerclage
 An alternative to cervical cerclage could be offered to woman with
 Three and more prior PTB or STL
 Prior cerclage failure
 Alternative to cervical cerclage are trachelorraphy or cervico
isthmic cerclage with technique of Benson

18 19/01/2019
19 19/01/2019