Cervical Cerclage 

Petrikovsky, M.D., PhD*, M. Terrani, M.D.**, F. Gonzales, M.D.**, A. Dillon, RDMS** Fetal Research Fund*, Ocean Perinanology**, Wyckoff Heights Medical Center*

The efficacy of cerclage to treat cervical incompetence had been a subject of controversy. The majority of studies fail to address the importance of the location of cerclage placement for pregnancy outcomes. The goal of the study is to report clinical outcomes of cervical cerclages in patients with various locations of the stitch placement.

Materials and methods:
Sixty-seven consecutive images of the cervix performed within two weeks of cerclage placements were extracted from sonographic database collected between January 2012 and October 2015. McDonald technique of cervical cerclage was used in all cases. The location of cerclage was divided into three categories: within the vicinity of the internal os (group I), in the middle portion of the cervix (group II), and in the vicinity of the external os or lower third of the cervix (group III). Gestational age at delivery was analyzed in all three groups. The cerclage placement site was identified by echogenic appearances of the stitch on sagittal and transverse images of the cervix. Statistical evaluation was made using SPSS for Windows V 15.0 (SPSS Inc., USA). Data were shown as frequency (percentage) or mean ± standard deviation.

In 26 patients the cerclage stitch was identified in the close vicinity of the internal os in the upper third of the cervix. These cerclages were placed between 11 and 13 weeks in 21 patients, between 14 and 16 in the remaining five.
In 29 patients, cervical cerclage was detected in the middle portion of the cervix. In 23 of those cerclages were placed between 10 and 13 weeks, and between 14 and 17 in the remaining six. One patient had preterm premature rupture of membranes followed by cerclage removal and delivery at 27 weeks of pregnancy. The third group consisted of 12 patients in whom cervical cerclages were detected in the lower third of the cervix in the vicinity of external os. Date on the timing of delivery in all studied groups is reflected in table 1.

Table 1
Timing of delivery *(mean ± SD) in patients with cerclage placed in different parts of the cervix.

 Group I 36 ± 4.2 NS
Group II 35 ± 3.8 NS
Group III 28 ± 4.8 P < 0.05

*Patients who miscarried prior to 24 weeks of gestation were excluded.

It appears that location of the cerclage placement plays an important role in prolongation of pregnancies and should be taken into consideration in future studies.

Can Weekly antepartum testing decrease still-birth rate?

Terrani, MD*, F. Gonzales, MD*, A. Dillon, RNMS* B. Petrikovsky, MD, PhD**
Garden OB/GYN*, Fetal Research Fund**, New York, NY

Stillbirth rates in the USA plateaued between 2006 and 2012 at 6.05 per 1.000 deliveries, totaling 50.045 stillbirth and 8,268.41 live births. Although there are no clearly identifiable risk factors for stillbirth, advanced maternal age puts fetuses at risk. Frequent antepartum testing was shown to decrease stillbirth rate from 5.2/1000 to 3.9/1000 in the advanced maternal age group. The purpose of the study is to assess if weekly antepartum testing after 36 weeks of pregnancy can decrease stillbirth in all age groups.

Materials and methods:
Our antepartum testing model (full biophysical profile weekly at 36 weeks on) started with a cohort of 6600 women. Patients who experienced stillbirth prior to the onset of testing were excluded. Biweekly testing was used in high-risk patients  using standard indications. A positive test served as an indication for delivery. Women with a negative test remained undelivered until the subsequent positive test or onset of labor. Control group consisted of 4420 patients in whom antepartum testing was performed using indications accepted by ACOG. All statistical computations were performed using DATA 4.0; Trec Age software, Williamstown, MA).

Without a strategy of weekly antepartum fetal surveillance between 36 and 41 weeks, women of all age groups experienced 3.04 stillbirths per 1000 pregnancies. For women undergoing weekly testing, the stillbirth rate was 1.24 per 1000. Thus, a strategy of weekly antepartum testing starting at 36 weeks of pregnancy in women of all age groups reduced the number of stillbirths by 58%.

Patients should be aware that in spite of the additional cost of testing and its effect on induction and operative delivery rates, weekly fetal assessment decreases stillbirth rate in all age groups by more than half.

Can cervical lenght monitoring and treatment affect prematurity rate?

Authors: M Terrani, F Gonzales, B Petrikovsky, A Dillon
Institutions: Ocean Perinatology, Wyckoff Heights Medical Center

Prematurity remains a major contributor to perinatal morbidity and mortality. In 2007 the Institute of Medicine reported that the annual costs associated with preterm births exceed $26 billion. In spite of enhanced efforts, the rates of prematurity didn't change much. It appears, however, that in a subset of patients with progressively decreasing cervical length surgical or medical interventions may be beneficial.

Materials and methods:
Our protocol includes cervical length measurements at 12, 16, and 20 weeks of pregnancy using transvaginal approach in all pregnant patients. A cervical length of less than 25 mm served as an indication for interventions, e.g., cerclage, progesterone therapy, or both depending on the gestational age and preference of patient and doctor. Patients of different group practice using standard management protocol served as a control group. Preterm birth was defined as a delivery between more than 24 and less than 37 weeks of pregnancy, and further subdivided into the ones delivered at less than 32 weeks of pregnancy and those delivered between 32 and 37 weeks.

A total of 1,319 patients comprised the study group and 2,518 – control group. Patients who delivered at less than 32 weeks were considered extreme prematurity, less than 37 weeks – moderate prematurity (Table 1).

Table 1

Gestational age at birth Study group (N=1319) Control group (N=2518)
Under 32 weeks 30          2.3% 78           3.1%        *
More than 32 weeks, less than 37 weeks 55          4.17% 152        6.03%      **
Total preterm:                           85          6.47%                             230        9.13%      *

*  P<0.05                     **  NS

Our policy of universal cervical length screening at 12, 16, and 20 weeks of pregnancy and indicated interventions confirms its effectiveness in reducing preterm births. It led to decreased incidence of preterm birth at less than 32 weeks and total prematurity rate.