The Evaluation Of Treatment Of Cervical Insufficiency During Pregnancy And The Impact On Pregnant Outcomes

Cervical insufficiency is one of the major causes that the painless cervical dilation caused recurrent late abortion and premature birth during mid trimester of pregnancy, with the incidence increasing every year, about 0.1-2%.15% of patients of 16-28 weeks of gestation habitual abortion suffered from it. Generally contraction and cervical dilation happened in the second trimester under the absence of pathological cervical shortening, then came up with abortion or premature delivery, without fetal anomalies.The cause of cervical insufficiency is not clear yet. It is divided into structural and functional insufficiency, including congenital and acquired factors. There are no clear and acknowledged diagnostic criteria at home and abroad. Diagnosis time is divided into pre-pregnancy diagnosis and pregnancy diagnosis, with pre-pregnancy diagnosis based on medical history, hysterosalpingography, hysteroscopy, etc., and pregnancy diagnosis based on medical history, clinical symptoms, vaginal examination, B-ultrasound. The treatment of cervical insufficiency includes conservative therapy and surgery. The former includes bed rest, tocolytics, antibiotics and so on. Confusion in the diagnosis of cervical insufficiency made cervical cerclage indications for surgery unclear. According to the different paths cervical cerclage operation can be divided into transvaginal and transabdominal cervical cerclage. Transvaginal cervical cerclage, including McDonald and Shirodker surgeries, usually is carried out transvaginally in the second trimester; transabdominal cervical cerclage includes traditional laparotomy surgery and laparoscopic surgery. According to the different timing of surgery, it can be divided into elective cervical cerclage, cervical cerclage of stress and emergency cervical cerclage.Surgical treatment rate of the disease significantly increased in recent years, but there are different diagnostic criteriasa and different surgical indications. Reports about correlation factors on the pregnant outcome of cervical insufficiency in our country are small samples from individual hospitals, or analysis of individual factors, lacking of large samples, multiple factor analysis of a comprehensive research, which can not fully and accurately reflect the function of the cervical insufficiency of the correlation factors on the pregnant outcome. The diagnosis, surgical indications and pregnant outcome of cervical insufficiency in recent years in our country are yet not analyzed by many hospitals in large samples.[Objective]By retrospectively analyzing the clinical data diagnosed with cervical insufficiency in patients at 9 hospistal in Guangzhou, Shenzhen, Zhongshan, Foshan, Qingyuan within 5 years, this study aims to analyze the correlation factors on the pregnant outcome, to standardize the diagnosis and treatment of cervical incompetence method provides the clinical basis.[Methods]1,Data collectionThis study retrospectively analyzed among the Nanfang Hospital, Zhujiang Hospital, the Third Affiliated Hospital of Guangzhou Medical College, the First People's Hospital of Shenzhen, Qingyuan People's Hospital, Maternal and Child Health Hospital of Shenzhen, Foshan MCH Hospital, Zhongshan Hospital, Maternal and Child Health Hospital of Bao'an District, Shenzhen City from June 2005 to May 2010 all 581 cases of cervical insufficiency diagnosed in hospital, of which 27 were lost to pregnant outcome. Within the 554 cases left at average age (29.45±4.56) years, cervical cerclage is 357 cases, conservative treatment 197 cases, among which 72 cases are twins, the rest single births. The patients who didn't give birth in the original hospital after surgery were followed up by telephone so that maternal and child outcomes are obtained.2,Diagnostic criteriaThe diagnosis of all cervical insufficiency is confirmed in pregnancy or before the pregnancy based on medical history, specialized examination, ultrasound examination. Premature delivery, premature rupture of membranes, postpartum hemorrhage, puerperal infection, cervical laceration and other diagnosis can be referred to version 7 of Obstetrics and Gynecology edited by Le Jie. According to related literature, the following circumstances should be considered to be cervical insufficiency:(1) recurrent miscarriage in pregnancy and preterm birth, no obvious uterine contraction and uterine cervix large, bulging amniotic sac and miscarriage or premature delivery; or significant history of cervical injury, such as conization history or history of severe cervical laceration; (2) non-pregnant hysterosalpingography, hysteroscopy confirmed cervical incompetence, or No.8 Hegar dilator passed inside the mouth of cervical; (3) typical characterized vaginal examination is that during mid-pregnancy the cervix opens large above 2cm, cervical shortens and softens with no significant contractions; (4) under the condition of no contractions in mid trimester of pregnancy, B-ultrasound (transvaginal B-ultrasound is more recommended) shows cervix shortened to less than 25mm or cervical enlarged in the shape of funnel with bulging amniotic sac.3,MethodBy collecting and analyzing the cases of cervical insufficiency in patients, we will understand the diagnosis of cervical insufficiency, cervical cerclage surgery gestational age, surgical indications, complications, etc.; compare different diagnostic criteria for cervical cerclage outcomes, and impact of different indications for surgery and timing on pregnant outcomes; approach the best surgical gestational age and surgical indications.4,Statistical analysisUse statistical software SPSS 13.0 for statistical analysis. Tabulation and graphics can be done by Excel 2003; and measurement data description can be expressed by mean and standard deviation; t test can be applied for statistical analysis; frequency data can be described by the percentage (%); use chi-square test (or continuous chi-square test); the relationship between observation outcome and impacts can be analyzed by using logistic regression. P<0.05 indicated significant difference. Statistical software SPSS 13.0 can be applied to draw ROC curves, seeking the best diagnostic criteria and surgical indications of cervical insufficiency.[Results]1 In general cases 554 patients:the minimum age of 19 years, maximum age 45 years, mean age (29.45±4.56) years,425 cases diagnosed group, diagnostic accuracy was 76.72%.72 cases of twin pregnancy, cervical cerclage 357 cases, including elective cervical cerclage 136 cases,197 cases with conservative treatment.2 Compared with the conservative group, the operation group of 554 cases had full-term delivery rate (40.3%vs 23.4%) and gestational days (230.88±42.77天vs 210.77±49.84 days), which was significantly better than the conservative group; the late abortion rate was significantly lower than that of conservative group (22.4% vs 40.1%); operation group had the neonatal survival rate (78.7%vs 64.1%), with cervical laceration rate (4.5% vs 0.5%)higher than that of the conservative group. 3 By revising diagnostic criteria,129 cases are acatalepsia. Term delivery rate,preterm delivery rate, late miscarriage rate, gestational period, birth weight and complications of the acatalepsia operation group were not statistically different from those of the conservative group.4 By revising diagnostic criteria,425 cases are diagnosed clearly, the rate of diagnosed clearly is 76.72%. Full-term delivery rate (44.7% vs 20.9%), gestational period (233.48±42.11 days vs 209.08±48.91 days), birth weight (2664.28±762.24 g vs 2416.88±845.00 g), neonatal survival rate (79.4% vs 60.1%) of diagnosed clearly operation group were significantly better than those of conservative group, with late abortion rate (21.4% vs 41.1%) smaller than that of conservative group.5 Acatalepsia operation group and diagnosed clearly operation group were 357 cases. Diagnosed clearly operation group's full-term delivery rate (44.7% vs 28.4%) was significantly better than that of the acatalepsia operation group, and preterm delivery rate (34.0%vs 46.3%) was lower than that of the acatalepsia operation group. The complications of both groups had no significant difference.6 Cervical cerclage in twin pregnancy:The late abortion rate, gestational period, birth weight and complications of the twin pregnancy operation group were not statistically different from those of the conservative group.7 The relationship between gestational age at surgery and pregnant outcomes on elective cervical cerclage:Surgery group in the 13-16 week group than over 16 weeks and below 18 weeks than over 18 weeks, in full-term delivery rate, preterm delivery and late miscarriage rate, number of days of pregnancy, neonatal weight and neonatal survival rates mean there are no statistical differences.8 Multinomial Logistic analysis can be carried out based on the condition of unbalanced factors and whether to operate or not as independent variables, "delivery gestational weeks divided into full-term gestational age, premature birth, abortion" as the outcome variable.8.1 In acatalepsia group, the age, the number of premature pregnancy plus spontaneous abortion, cervical length, the hospital level and whether to operate or not made no significant difference on gestational age "term"8.2 In diagnosed clearly group, the age, cervical length, width and whether to operate or not were significant variables for term delivery. The implementation of surgery and cervical length were protective factors for extending gestational weeks.9 Complications of cervical cerclage9.1 Postpartum hemorrhage:the postpartum hemorrhage of twin pregnancy and cesarean section were obviously higher than those of singleton pregnancies and the vaginal delivery group (P<0.05); birth weight, whether for cervical cerclage have no statistical meaning for postpartum hemorrhage (P> 0.05).9.2 Cervical laceration:the risk of cervical laceration in surgery group is 9.196 times than conservative group.9.3 Premature rupture of membranes:the risk of premature rupture of membranes in twin pregnancy was significantly higher than that of singleton pregnancies (P=0.044, OR=1.953); whether to make cervical cerclage or not made no statistical meaning for premature rupture of membranes (P=0.559, OR=0.854).10 Approach to the diagnostic criteria for cervical insufficiency and surgical indications for surgical casesAccording to gestational age,357 patients were divided into "greater than or equal to 28 weeks" group and "inevitable abortion" group. According to the number of premature pregnancy plus spontaneous abortion and cervical length, ROC curve analysis were carried out. The results showed that the area under the curve of spontaneous abortion is 0.537, and that of cervical length is 0.620.11 Hospital-level and pregnant outcomes:Acatalepsia operation group of in second-level hospitals there are 252 cases diagnosed clearly, diagnosed clearly rate is 73.90%; in third-level hospitals there are 173 cases, diagnosed clearly rate is 81.22%, diagnosed clearly rate in third-level hospital is higher than the second-level hospital (T=3.933, P=0.047). Full-term delivery rate, preterm delivery, late miscarriage rate, number of days of pregnancy and the newborn weight had no significant difference in two groups (P> 0.05).[Conclusion]1. The diagnosis and surgical indications of cervical insufficiency are for further specification. In accordance with the diagnostic criteria for cervical insufficiency, cervical cerclage can effectively improve the pregnancy outcomes. However, cervical cerclage can not improve the pregnancy outcomes for acatalepsia patients.2. Cervical cerclage is invalid to improve twin pregnancy outcomes; the main complication of cervical cerclage is cervical laceration.3. Doing cervical cerclage and the length of cervix are the protective factors to prolong gestational age in patients with cervical insufficiency.4 Elective cervical cerclage procedure to select a different gestational age and pregnancy outcome surgery was no significant difference.