D
12
SA
ovember 1975
MEDIESE
TYD
2013
KRIF
(Byvoegsel-Suid-Afrikcul/lse Tydskrif vir Obsterrie en Ginekologie)
Cerclage
•
III
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& 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)
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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.
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