D 12 SA ovember 1975 MEDIESE TYD 2013 KRIF (Byvoegsel-Suid-Afrikcul/lse Tydskrif vir Obsterrie en Ginekologie) Cerclage • III o & G 97 the Treatment of Incompetent Cervix J. LIPSHITZ SUMMARY A retrospective study was undertaken of 71 patients who underwent a postconceptional cervical cerclage operation. The previous pregnancy loss in these patients was 71,4% compared with an 84,5% success rate after the operation had been performed. The possible reasons for the failures are discussed. The incidence of immediate postoperative complications was 14%. Infection, probably as a result of insertion of the suture, occurred in 30% of the patients. S. Afr. med. l., 49, 2013 (1975). Cervical incompetence exists where repeated econd-trimester pregnancy loss is due to cervical weakness of various origins. In spite of the absence of uterine activity and bleeding, the cervix dilates, becomes effaced and the membranes bulge through it. The bulging membranes rupture and the delivery of the fetus is then a rapid and near-painless procedure. 1 Since the pioneer studies,'·' cervical cerclage has been thorougWy investigated, but the complications, although usually of a minor nature, have not been adequately evaluated, neither have the possible reasons for failure. PATIENTS AND METHODS Retrospective studies were carried out on 71 patients who underwent a postconceptional cervical cerclage operation at Groote Schuur Hospital during 1971 or 1972. The indication for the cervical cerclage are given in Table I. The average age of the patients at the time of cervical cerclage was 26 years. These patients were first seen at the booking clinic at a mean gestational age of 17 weeks, and the mean gestation at the time of the cervical cerclage was 23 weeks. The operation wa carried out in 56 Coloured. 1I White and in only 4 Black patients. The technique used was similar to that described by McDonald: except that a 5-mm wide Ethicon Mer ilene band was used instead of Mersilk. Department of Obstetrics and Gynaecology, Groote Scbuur Hospital and University of Cape Town ]. LIPSHITZ, M.B. CH.B., :\1.R.C.O.G., Registrar Date received: 7 August 1975. TABLE I. INDICATIONS FOR CERVICAL CERCLAGE Cervix >2 cm dilated with or without a previous history of repeated midtrimester abortions ... Previous history alone ... Premature l<lbour with the cervix >2 cm dilated Previous cervical cerclage operations Threatened abortion Placenta praevia Total 48 8 6 4 3 2 71 Postoperative Treatment Some patients received no specific treatment except Others were given Va!ium postoperatively while a large percentage of patients received orciprenaline (Alupent) intravenously, either prophylactically or if the uterus was noted to be irritable. Some of the patients were given ampicillin prophylactically, while others used Sultrin vaginal cream for a week postoperatively. b~drest. RESULTS Table II summarises the results after cervical cerclage as compared with previous pregnancies. In the present series of 71 patients, there were 8 primiparous patients, which accounts for the fact that the past histories of only 63 patients are discussed. These 63 patients had had 220 previou pregnancies and a total of 63 live babies - a succes rate of only 28.60 0 • It i ignificant that of the 63 uccessful pregnancies, 10 were achieved by u ing a cervical suture. Therefore, if these were discounted, the success rate would have been only 24v~. Sixty successful pregnancies (84.5°,,) were achieved after cervical cerclage operations in the 71 patients. Tre term 'succes. ful pregnancie.· denotes that the babies were alive and well on leaving hospital. Th_ percentage of babies weighing less than 2500 g was still high - 33°,', after cerclage comp,Hed with 41 o~ before. However. of the 20 babies of less than 2500 g. 8 were dysmature and 12 were premature. After cervical cerclage there were 3 second-trimc. tcr abortion and 8 neonatal death These will be more fullv discu sed. The immediate postoperative complications are <ummarised in Table HT. and it can be seen that 10 of the 71 patient (41 O~) had immediate postoperative complication. Four of the 8 neonatal deaths were in this group. SA 2014 MEDICAL 12 JOURNAL ovember 1975 (Supplement-South African Journal of Obstetrics and Gynaecology) 0& G 98 TABLE 11. OUTCOME OF PREVIOUS PREGNANCIES COMPARED WITH OUTCOME AFTER CERVICAL CERCLAGE After cervical cerclage Previous pregnancies Number of patients Number of pregnancies Successful pregnancies Success rate Live babies <2500 g 1st-trimester abortions 2nd-trimester abortions 3rd-trimester deaths 63 220 63 28,6% 26 40 80 35 (41';!0) (18';!0) (36%) (16%) (19 NNDs, 16 SBs) TABLE Ill. IMMEDIATE POSTOPERATIVE COMPLICATIONS Premature labour immediately after suture Vaginal bleeding Rupture of the membranes Chest complications after regurgitation anaesthesia Pyrexia and bloody vaginal discharge ... Vaginal lacerations 4 2 1 under general 71 71 60 84,5% 20 (33%) (12 premature, 8 dysmature) o 3 8 (NNDs) TABLE VI. INDICATIONS FOR CAESAREAN SECTION Elective (2 poor obstetric histories, 1 placenta praevia, 1 previous uteroplasty) . .. Antepartum haemorrhage Poor obstetric history and cephalopelvic disproportion Cervical dystocia and fetal distress ... Triplets, with no progress after 14 hours ... Total " 3 1 1 1 10 Total 10 TABLE IV. DELAYED POSTOPERATIVE COMPLICATIONS Vaginal discharge requiring treatment Chorio-amniitis Number of patients requiring reinsertion of the suture (1 suture had to be tightened under general anaesthesia) Cervical dystocia in labour Maternal de2th 19 2 Total 31 8 1 1 TABLE V. METHOD OF DELIVERY Normal vaginal deliveries Caesarean sections Forceps deliveries Breech deliveries 50 10 5 4 2 A~~=s Total 71 Delayed postoperative complications are summarised in Table IV. The average duration of labour of the 61 patients who were delivered vaginally was 6,4 hours and there were 10 Caesarean sections (14%) (Tables V and VI). DISCUSSION The incidence of incompetence of the cervix in our series is 1 - 2 per 1 000 deliveries. In the literature it varies from 1 per 100' to 1 per 1 930' deliveries. The over-all success rate in our series is 84.5°~, compared with a pre-operative success rate of only 28,6%. McDonald' reported a success rate of 47% in 70 cases. The majority of the operations were performed at the 20th - 24th week of pregnancy. In 1963, McDonald' published an additional series of 25 cases, with a success rate of 80% when the operation was done at about the 14th week of gestation. In 1970 Seppilla and Vara' obtained an 83,2% success rate in 159 women and in 1973 Lauersen and Fuchs' • described another large series of cases (143) with a 82,5% success rate. In the original Shirodkar operation the encirclin~ ligature was obtained from the fascia lata of the patient's thigh. McDonald' described a simpler suturing method, in which the cerclage was applied as a purse-string suture of silk or Mersilene on the ectocervix at the junction of the fornix and cervical epithelium. This suture may easily be removed at the onset of labour, and the method has maintained its popularity. In our series McDonald's method was used. Navel"" reported a series where he compared this method with the more classic Shirodkar technique. Although he found the pregnancy-preserving effect to be the same with both, the Shirodkar method carried a higher rate of complications. The McDonald procedure was also preferred because it provides quicker, easier and less traumatic closure of the cervix, and permits vaginal delivery in all cases. except when contra-indicated for other obstetric reasons. When the cervix has been amputated and it is technically not possible to perform a vaginal cerclage operation, a transabdominal cervico-uterine suture has proved successful."·l1 Provided the indication for a cervical cerclage operation is correct, there will be a high success rate, and most of the failures will be caused by factors other than cervical incompetence. For this reason, I have examin.d the 8 neonatal deaths and have tried to evaluate the reasons for the failures. = 12 ovember 1975 SA MEDIESE 2015 TYDSKRIF (Byvoegsel-Suid-Ajrikaanse T)idskrij vir Obslelrie ell Gillekologie) Patients I and 2 were primiparous. A vaginal septum was removed in patient I and the possibility of a uterine abnormality cannot be ignored. Patient 3 had a threatened abortion; patient 4 had contractions: patient 5 had had 3 previous first-trimester abortions; and patient 6 had a poor obstetric record which included an intra-uterine death and a stillbirth. Patients 7 and 8 had proven cervical incompetence which was successfully treated with cervical cerclage. Patient Ts baby died from a congenital abnormality, and that of patient 8 from a concealed accidental haemorrhage. Thus it can be seen that our failures resulted from factors other than simple cervical incompetence. A rather controversial indication for cervical cerclage is the treatment of placenta praevia. Von Friesen" has reported his experience over I0 years and suggests that a suture encircling the cervix probably fixes and SIJpports the lovler uterine segment and thus prevents repeated heavy bleeding, thereby achieving greater fetal maturity before a Caesarean section is performed. Only 2 of our operations were done for this reason, and both were successful. In our series the suture was inserted at an average of 23 weeks' gestation. Although it is stated in the literature that the best time to insert the stitch is between the 14th and 18th week of pregnancy, we have achieved good results even though most of the sutures were inserted "fter 20 weeks. As can be seen from Table IV, there was a high incidence of delayed postoperative complications. These were mainly due to infection, which occurred in 30o~ of the patients. One abortion was associated with a severe profuse purulent vaginal discharge and chorioamnionitis. Infection did not play a role in the other ? bortions or neonatal deaths. The incidence of vaginal discharge would probably be lower if the stitch were completely subepithelial. instead of four or more of its portions being exposed. o & G 99 as happens with the 'multiple bite purse- tring' method. Whether the I maternal death in the series i indirectly related to the cervical suture is unknown. The patient had a suture inserted because she wa carrying triplet and the cervical os was 2 cm dilated. After 14 hours of labour with no progress, a Caesarean section was performed. She ubsequently developed gangrene of the uterus and the anterior abdominal wall, and died. Two virulent organisms were cultured. A vaginal discharge had been treated after the inse~tion of the suture. and whether this was the cause of the infection can only be speculation. Eight sutures had to b~ reinserted. This is probably to a large extent a reflection of the inexperience of the surgeon who carried out the initial operation. CONCLUSION A postconceptional cervical cerclage operation is a safe and successful procedure when performed by an experienced gynaecologist and when the indication for the operation is initially correct. We should probably modify our technique in an attempt to prevent the high incidence of infection which follows this procedure. I should like to thank Dr Robert Kiwi for his help in the collection of data for this publication. REFERENCES I. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Ben~tsson. L. P. (1968): Acta obstet. gynec. scand .. 47. suppl. I. pp. 7 - 35. Palmcr. R. and lacomme M. (1948): Gynec. et Obsret.. 47. 905. Lash A. F. and lash S. R. 09-0): Amer. J. Obstet. Gynec .. 59. 6 . Sh;Tf')c1k~r. V. I. (J955): Antisentic, 52. 299. McDonald. I. A. (1957): J. Obstet. Gynaec. Brt. Emp .. 64. 346. Duda. E. and Lighezan. I. (963): Zbl. Gynek. 85. 959. Raphael. S. 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