Clinical Analysis Of 293 Cases With Cervical Insufficiency

Objective:Currently,the diagnosis of cervical:insufficiency is still lacking of unified standards.It is also controversial to perform cervical cerclage in patients with cervical insufficiency,especially for the twin pregnancies of patients.The purpose of this study is to investigate the effects of timing and mode of operation on the outcome of pregnancy in patients with cervical insufficiency in the second trimester of pregnancy,further discuss the advantages and disadvantages of cervical cerclage in twin pregnanciesMethod:A total of 465 patients performed cervical cerclage for cervical insufficiency were choose out from Qilu hospital of Shandong University from March 2014 to December 2017 and the clinical data were collected for retrospective analysis.The puerpera who did not give birth in our hospital were followed up by telephone.After inclusion and exclusion criteria,a total of 293 cases were included in this study.Data were collected including age,chief complaint,brief medical history,preoperative ultrasound,surgical method,operative time,intraoperative blood loss,postoperative hospitalization days(Due to the difference in preoperative preparation time,the total number of hospital days was not counted to exclude the difference),pregnarncy-related complications,neonatal birth weight,and transfer to NICU.We obtained 278 cases with pregnancy outcomes,including 212 cases of single pregnancy and 66 cases of twin pregnancies.In the 212 cases,there were 153 cases performed transvaginal cervical cerclage and 118 cases were successful.A total of 59 patients underwent laparoscopic cervical cerclage,56 of them were successful.There were 226 cases of neonatal coexistence and 52 cases of abortion or induced labor due to premature rupture of membranes,uncontrollable contractions,fetal death in utero or fetal malformation.Neonatal survival of maternal was divided into success group and failure group.The successful group was divided into transvaginal surgery group and laparoscopic surgery group according to different surgical approaches.Among them,the transvaginal operation group was divided into MacDonald operation(115 cases in the group without pushing up the bladder)and the improved Shirodkar operation(55 cases in the group with pushing up the bladder)according to different surgical methods.According to the different number of pregnancies we divided them into single group and twin group;According to the different time of operation,it was divided into emergency cervical cerclage group(13 cases)and elective cervical cerclage group(157 cases).According to the different gestational weeks,the patients were divided into two groups:Less than 20 weeks group(112)and more than 20 weeks group(58 cases).According to the preoperative cervical canal length,patients were divided into two groups:the shorter than 2.5cm group(50 cases)and longer than 2.5cm group(120 cases).Aims to investigate the effects of timing and mode of operation on the outcome of pregnancy in patients with cervical insufficiency in the second trimester of pregnancy,further discuss the advantages and disadvantages of cervical cerclage in twin pregnancies.The clinical data of puerpera were analyzed by GraphPad Prism 6.0 statistical software,the measurement data were compared by t test,and the count data were compared by x2 test.,with P<0.05 as the difference has statistical significance.Results:1.In comparison between various groups for extending the pregnancy period,average prolong pregnancy in success group is(17.23±6.58)W,that the weeks of delayed pregnancy in failure group is(3.79±3.43)W.Although giving the cervical cerclage to patients with CI whether improve the pregnancy outcome is in dispute.But it is helpful to effectively extend gestational age,longer gestational weeks buy precious time for premature babies to mature and increase their chances of survival.The average pregnancy extension time of 157 cases in the non-emergency ligation group was(17.83± 6.15)W,which was longer than that of 13 cases in the emergency ligation group(10.14± 7.6)W,with significant difference and statistical significance(P<0.05).The average gestational age of 55 patients in the pushing bladder group was longer(16.69±6.03)W than that of 115 patients in the non-pushing bladder group(8.68±6.83)W,and the difference was statistically significant(P<0.05).The average pregnancy duration of 118 cases in the singleton group was longer than that of 52 cases in the twin group(18.33±6.22)W and(14.74±6.74)W,respectively,and the difference was statistically sigjnificant(P<0.001).2.Success and failure group compared with preoperative cervical length,delivery gestational age,extend gestational age,previous miscarriage in the second trimester or number of very premature delivery in the third trimester,operation time,the differences were statistically significant,while in age,cerclage gestational age,intraoperative blood loss,postoperative hospitalization days,and the incidence rate of pregnancy-related complications,there was no statistically significant difference.However,it should be noted that if the weeks of pregnancy were divided into two groups,?19+6W group and?20W group.The surgical success rate(80.6%)in the 19+6W group was significantly higher than that in the 20W group(72:.5%),and the difference was statistically significant(OR:1.57,95%CI[0.8-3.0],P=0.036).This indicates that the probability of success is higher if the procedure is performed before 20 weeks of gestation.3.To the transvaginal cerclage group,we divide preoperative cervicat length into shorter than 2.5 cm group and longer than 2.5 cm group and then compare two groups,they have significant differences in the rate of surgical success rate,premature birth,.if we give surgical intervention to patients with cervical insufficiency when cervical length longer than 2.5 cm,surgical success rate and the pregnancy outcome in patients will benefit greater than the shorter than 2.5 cm.4.Emergency cerclage group compared with the emergency cerclage group,the comparnsons of two groups of cerclage in gestational age,extend gestational age,delivery gestational age,birth weight,postoperative hospitalization days,operation time,the rate of premature birth,abortion rate,admission rate of NICU and the incidence rate of premature rapture of membranes,and neonatal survival all havesignificant difference,(P<0.05),with statistical significance.There were no statistically significant differences between the two groups in terms of age,previous miscarriage in the second trimester or number of very premature delivery in the third trimester,cervical length,intraoperative blood loss and the incidence rate of pregnancy-related complications.5.Compared with the without pushing up the bladder group and pushing up the bladder group,the two groups showed statistically significant differences in prolonging gestational weeks,gestational weeks of delivery,neonatal birth weight,operative time,intraoperative blood loss and incidence of premature rupture of membranes.But the two groups in age,previous miscarriage in the second trimester or number of very premature delivery in the third trimester,preoperative cervical length,cerclage gestational age,postoperative hospitalization days,the number of premature infants,preterm birth rates,admission rate of NICU,delivery mode,neonatal survival rate,and the incidence rate of pregnancy-related complications have no statistically significant differences.6.Single group compared with twins group,the two groups showed statistically significant differences in the preoperative cervical length,previous miscarriage in the second trimester or number of very premature delivery in the third trimester,extend gestational age,delivery gestational age,birth weight,delivery methods,premature birth rate,the incidence of premature rupture of membranes,pretermquantity,and the incidence of GDM difference was statistically significant have the difference has statistical significance,but in the age,cerclage gestational age,operation time,intraoperative blood loss,postoperative hospitalization days,admission rate of NICU and the incidence rate of pregnancy-related complications have no statistically significant differences.7.Compared with the laparoscopic puncture group,the transvaginal single puncture group had significant differences in previous miscarriages in the second trimester,extremely premature delivery in the third trimester,extended gestational weeks,operation time,intraoperative blood loss,postoperative hospitalization days,operation success rate,delivery mode and admission rate of NICU,with statistical significance.There were no statistically significant differences between the two groups in age,gestational age,neonatal birth weight,preterm birth rate and the incidence rate of pregnancy-related complications.8.In the study of this paper,there were 278 patients and 226 cases were delivered successfully with neonates survived,the success rate is 81.3%,suggesting that cervical cerclage is inclined to benefit patients.The success rate of laparoscopic surgery group is about 94.92%.The success rate of transvaginal surgery for single pregnancy is about 77.12%,and for double pregnancies is about 78.79%.The possible reasons for this result may be that most of the pregnant women with twin pregnancies are conceived through assisted reproductive technology,and they are more nervous about the loss of the fetus during pregnancy,and have a higher and stronger expectation for cervical cerclage,leading to a broader indication of cervical cerclage.Conclusions:1'.Comparison of different surgical methodsIn terms of the success rate of operation and the prolongation of pregnancy,laparoscopic cervical cerclage is better than transvaginal cervical cerclage,but it increases the operation time and intraoperative blood loss.The Shirodkar method was better than MacDonald method,but it increased the operation time and incidence of premature rapture of membranes.2.Comparison of the timing of different operationsIt is suggested that surgical intervention should be carried out as far as possible when cervical tube is>2.5cm.The gestational weeks should be controlled within 20 weeks as far as possible,because the success rate of the cervical cerclage will decrease after 20 weeks.3.Comparison of different surgical indicationsEmergency cervical cerclage can extend the gestational age to a certain extent,but the rate of preterm birth,the rate of NICU transfer,the probability of low birth weight and the incidence of premature rupture of membranes are all higher than that of elective cervical cerclage4.Although cervical cerclage for pregnant women with twin pregnancies iscontroversial,its success rate in this study is higher than that of those with single pregnancy liaation,but the rate of preterm birth and the rate of low birth weight infant are also higher than the latter.The specific surgical value still needs a multi-center large sample control study.