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Emergency cerclage: Does the surgical technique matter?
Letters to the Editors
ajog.org
Emergency cerclage: Does the surgical technique matter? TO THE EDITORS: We read with great interest the work of Roman et al1 that was published in your Journal. It seems that twin pregnancies that are most at risk of preterm delivery, either by presenting “cervical length” through transvaginal ultrasound <15 mm2 or by manifesting cervical dilation, can benefit from cervical cerclage. Our group performs emergency cervical cerclage in these situations, with some modifications to those published.1 The surgical technique is uniform, being a modification of the Shirodkar technique, which in some cases is associated with cervical occlusion.3 Different surgical techniques have not demonstrated superiority over one another.4 We believe that the McDonald’s intervention presents some technical limitations. The main limitation is the shortage of remaining cervix. The possibility of recovering the cervix is less in this technique than in that of Shirodkar. Our modification involves leaving the knot in the posterior vaginal fornix, not at the vesicocervical level as in the original technique. We administer a presurgical antibiotic and a rectal dose of 100 mg indomethacin preoperatively, plus 3 doses every 12 hours postoperatively and subsequently micronized progesterone 200 mg/24 hr (vaginal or oral, depending on patient’s choice) until term. Those patients with documented regular uterine dynamics are treated with intravenous atosiban with no anticipated cervical changes, because they had previously presented them. From 2000-2014, we performed 15 cerclages in twin pregnancies with exposed amniotic membranes: mean gestational age, 23.1 0.86 weeks. The mean cervical length was 11.73 2.27 mm. Patients did not undergo preoperative amniocentesis, which is not to exclude subclinical chorioamnionitis. No accidental rupture of amniotic membranes was presented. Ten of 15 pregnant women (66.67%) required additional tocolysis with atosiban and maturation with corticosteroids. Four of 15 women (26.67%) exceeded 34 weeks gestation, and 7 of 15 women (46.67%) exceeded 32 weeks gestation. Immediate neonatal outcomes were 4 second-trimester miscarriages and 3 neonatal deaths. Results are consistent with those of Roman et al.1 We believe that the cervical changes presented by these patients complicate the McDonald cerclage technique. Theoretically, it is more feasible to cross the thickness of the cervical wall with the needle and thus increase the risk of accidental rupture of the amniotic membranes. It does not allow recovery of cervical length after effacement, which leaves amniotic membranes closer to the external os. In this article, the author does not study the technique of cerclage. Did the author consider assessing the cerclage technique in his trial (protocol available at ClinicalTrials.gov ID#:NCT02490384)? -
Carlos Larrañaga-Azcárate, MD Maitane Urtasun-Murillo, MD Jesús Zabaleta-Jurío, MD Servicio Obstetricia-Ginecología Complejo Hospitalario Navarra Pamplona, Navarra, Spain [email protected] The authors report no conflict of interest.
REFERENCES 1. Roman A, Rochelson B, Martinelli P, et al. Cerclage in twin pregnancy with dilated cervix between 16 to 24 weeks of gestation: retrospective cohort study. Am J Obstet Gynecol 2016;215:98.e1-11. 2. Roman A, Rochelson B, Fox NS, et al. Efficacy of ultrasound-indicated cerclage in twin pregnancies. Am J Obstet Gynecol 2015;212: 788.e1-6. 3. Larrañaga-Azcárate C, Roche-Roche M, García-Mutiloa M, et al. Cervical occlusion associated to therapeutic cerclage: a modification of the Saling procedure. Paper presented at: 8th World Congress of Perinatal Medicine; September 9-13; 2007; Florence, Italy. 4. Berghella V, Ludmir J, Simonazzi G, Owen J. Transvaginal cervical cerclage: evidence form perioperative management strategies. Am J Obstet Gynecol 2013;209:181-92. ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog. 2016.05.026
REPLY We thank Drs Larrañaga-Azcárate et al for their interest in our publication “Cerclage in twin pregnancy with dilated cervix between 16 to 24 weeks of gestation.” The main goal of our retrospective cohort was to evaluate whether the use of physical examination-indicated cerclage (PEIC) placement in twin pregnancies with asymptomatic cervical dilation of 1 cm before 24 weeks of gestation decreased the incidence of spontaneous preterm birth (SPTB) at different gestational ages and improved the neonatal outcomes when compared with expectant management. All women received McDonald cerclage in the treatment group; other differences in the surgical technique were not evaluated. The planned randomized clinical trial (RCT) on PEIC in women with twin pregnancies (ClinicalTrials.gov ID#:NCT02490384) will evaluate whether cerclage will decrease SPTB and/or improve neonatal outcome but will not assess the PEIC technique either, because it was left up to the physician in charge of each case. Most of current information about cerclage pertains to singleton pregnancies. Currently, there is limited evidence that 1 technique is superior to the other. We do agree with Drs Larrañaga-Azcárate et al that evaluating different OCTOBER 2016 American Journal of Obstetrics & Gynecology
531
ajog.org
Emergency cerclage: Does the surgical technique matter? TO THE EDITORS: We read with great interest the work of Roman et al1 that was published in your Journal. It seems that twin pregnancies that are most at risk of preterm delivery, either by presenting “cervical length” through transvaginal ultrasound <15 mm2 or by manifesting cervical dilation, can benefit from cervical cerclage. Our group performs emergency cervical cerclage in these situations, with some modifications to those published.1 The surgical technique is uniform, being a modification of the Shirodkar technique, which in some cases is associated with cervical occlusion.3 Different surgical techniques have not demonstrated superiority over one another.4 We believe that the McDonald’s intervention presents some technical limitations. The main limitation is the shortage of remaining cervix. The possibility of recovering the cervix is less in this technique than in that of Shirodkar. Our modification involves leaving the knot in the posterior vaginal fornix, not at the vesicocervical level as in the original technique. We administer a presurgical antibiotic and a rectal dose of 100 mg indomethacin preoperatively, plus 3 doses every 12 hours postoperatively and subsequently micronized progesterone 200 mg/24 hr (vaginal or oral, depending on patient’s choice) until term. Those patients with documented regular uterine dynamics are treated with intravenous atosiban with no anticipated cervical changes, because they had previously presented them. From 2000-2014, we performed 15 cerclages in twin pregnancies with exposed amniotic membranes: mean gestational age, 23.1 0.86 weeks. The mean cervical length was 11.73 2.27 mm. Patients did not undergo preoperative amniocentesis, which is not to exclude subclinical chorioamnionitis. No accidental rupture of amniotic membranes was presented. Ten of 15 pregnant women (66.67%) required additional tocolysis with atosiban and maturation with corticosteroids. Four of 15 women (26.67%) exceeded 34 weeks gestation, and 7 of 15 women (46.67%) exceeded 32 weeks gestation. Immediate neonatal outcomes were 4 second-trimester miscarriages and 3 neonatal deaths. Results are consistent with those of Roman et al.1 We believe that the cervical changes presented by these patients complicate the McDonald cerclage technique. Theoretically, it is more feasible to cross the thickness of the cervical wall with the needle and thus increase the risk of accidental rupture of the amniotic membranes. It does not allow recovery of cervical length after effacement, which leaves amniotic membranes closer to the external os. In this article, the author does not study the technique of cerclage. Did the author consider assessing the cerclage technique in his trial (protocol available at ClinicalTrials.gov ID#:NCT02490384)? -
Carlos Larrañaga-Azcárate, MD Maitane Urtasun-Murillo, MD Jesús Zabaleta-Jurío, MD Servicio Obstetricia-Ginecología Complejo Hospitalario Navarra Pamplona, Navarra, Spain [email protected] The authors report no conflict of interest.
REFERENCES 1. Roman A, Rochelson B, Martinelli P, et al. Cerclage in twin pregnancy with dilated cervix between 16 to 24 weeks of gestation: retrospective cohort study. Am J Obstet Gynecol 2016;215:98.e1-11. 2. Roman A, Rochelson B, Fox NS, et al. Efficacy of ultrasound-indicated cerclage in twin pregnancies. Am J Obstet Gynecol 2015;212: 788.e1-6. 3. Larrañaga-Azcárate C, Roche-Roche M, García-Mutiloa M, et al. Cervical occlusion associated to therapeutic cerclage: a modification of the Saling procedure. Paper presented at: 8th World Congress of Perinatal Medicine; September 9-13; 2007; Florence, Italy. 4. Berghella V, Ludmir J, Simonazzi G, Owen J. Transvaginal cervical cerclage: evidence form perioperative management strategies. Am J Obstet Gynecol 2013;209:181-92. ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog. 2016.05.026
REPLY We thank Drs Larrañaga-Azcárate et al for their interest in our publication “Cerclage in twin pregnancy with dilated cervix between 16 to 24 weeks of gestation.” The main goal of our retrospective cohort was to evaluate whether the use of physical examination-indicated cerclage (PEIC) placement in twin pregnancies with asymptomatic cervical dilation of 1 cm before 24 weeks of gestation decreased the incidence of spontaneous preterm birth (SPTB) at different gestational ages and improved the neonatal outcomes when compared with expectant management. All women received McDonald cerclage in the treatment group; other differences in the surgical technique were not evaluated. The planned randomized clinical trial (RCT) on PEIC in women with twin pregnancies (ClinicalTrials.gov ID#:NCT02490384) will evaluate whether cerclage will decrease SPTB and/or improve neonatal outcome but will not assess the PEIC technique either, because it was left up to the physician in charge of each case. Most of current information about cerclage pertains to singleton pregnancies. Currently, there is limited evidence that 1 technique is superior to the other. We do agree with Drs Larrañaga-Azcárate et al that evaluating different OCTOBER 2016 American Journal of Obstetrics & Gynecology
531