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S M Althuisius - One of the best experts on this subject based on the ideXlab platform.
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a five century evolution of Cervical Incompetence as a clinical entity
Current Pharmaceutical Design, 2005Co-Authors: S M Althuisius, G A DekkerAbstract:Since Cervical Incompetence was introduced in the English literature in 1678, our understanding and obstetric management of this clinical entity, have changed tremendously over the years. This review shows the historical perspective of the development of Cervical Incompetence as a distinct clinical entity and an all or nothing phenomenon to Cervical Incompetence as part of a spectrum leading to preterm delivery, which can express differently in subsequent pregnancies. These changes in our understanding imply consequences for the obstetric management of Cervical Incompetence. This review focuses on the obstetric management of women considered to be at high risk of preterm delivery due to Cervical Incompetence, by transvaginal ultrasonographic follow-up of Cervical length and transvaginal Cervical cerclage.
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controversies regarding Cervical Incompetence short cervix and the need for cerclage
Clinics in Perinatology, 2004Co-Authors: S M Althuisius, Gus DekkerAbstract:Cervical Incompetence (CI) is not an all or nothing phenomenon but a continuous variable. CI and preterm labor are not distinct entities but rather part of a spectrum leading to preterm delivery. Cervical length (CL) is an independent variable in the prediction of preterm delivery, to which it is inversely related. Application of a primary transvaginal Cervical cerclage appears to be an unnecessary intervention in about 50% of women presenting with a history suggesting Cervical Incompetence. A better alternative for women with a history of or risk factors for CI is transvaginal ultrasonographic follow-up of CL. To facilitate the comparison of studies of CI, the authors suggest a nomenclature reflecting the different stages of prevention: primary, secondary, and tertiary transvaginal Cervical cerclage.
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Cervical Incompetence prevention randomized cerclage trial emergency cerclage with bed rest versus bed rest alone
American Journal of Obstetrics and Gynecology, 2003Co-Authors: S M Althuisius, G A Dekker, Pieter Hummel, Herman P Van GeijnAbstract:Abstract Objective The purpose of this study was to compare preterm delivery rates and neonatal morbidity/mortality rates for women with Cervical Incompetence with membranes at or beyond a dilated external Cervical os that was treated with emergency cerclage, bed rest plus indomethacin, versus just bed rest. Study design Women with Cervical Incompetence with membranes at or beyond a dilated external Cervical os, before 27 weeks of gestation, were treated with antibiotics and bed rest and randomly assigned for emergency cerclage and indomethacin or bed rest only. Results Twenty-three women were included; 13 women were allocated randomly to the emergency cerclage and indomethacin group, and 10 women were allocated randomly to the bed rest–only group. Gestational age at time of randomization was 22.2 weeks in the emergency cerclage and indomethacin group and 23.0 weeks in the bed rest–only group. Mean interval from randomization until delivery was 54 days in the emergency cerclage and indomethacin group and 20 days in the bed rest–only group (P = .046). Mean gestational age at delivery was 29.9 weeks in the emergency cerclage and indomethacin group and 25.9 weeks in the bed rest–only group. Preterm delivery before 34 weeks of gestation was significantly lower in the emergency cerclage and indomethacin group, with 7 of 13 deliveries versus all 10 deliveries in the bed rest–only group (P = .02). Conclusions Emergency cerclage, indomethacin, antibiotics, and bed rest reduce preterm delivery before 34 weeks compared with bed rest and antibiotics alone.
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Cervical Incompetence prevention randomized cerclage trial cipract effect of therapeutic cerclage with bed rest vs bed rest only on Cervical length
Obstetrical & Gynecological Survey, 2003Co-Authors: S M Althuisius, G A Dekker, Dick Bekedam, Pieter Hummel, D Kuik, H P Van GeijnAbstract:Cervical cerclage and bed rest, by themselves or in combination, are common approaches to pregnant women having an incompetent cervix. Transvaginal cerclage is known to increase Cervical length, but it is possible that bed rest alone has the same effect. This study of 35 women was an attempt to compare combined cerclage and bed rest with management by bed rest alone, using as the primary outcomes delivery before 34 weeks' gestation and neonatal morbidity. Women whose Cervical length was less than 25 mm before 27 weeks' gestation, as estimated by transvaginal sonography, were randomly assigned to one of the two treatment conditions. Cervical length was subsequently measured at weekly intervals. Cervical Incompetence was diagnosed from painless, progressive Cervical dilation when, without intervention, preterm delivery seemed inevitable. Cerclage was performed using a single purse-string suture of braided polyester Nineteen women were assigned to cerclage and bed rest, and 16 were assigned to bed rest only. Mean initial Cervical length and gestational age were comparable in these groups (averaging 19.8 mm and 20.7 weeks, respectively). At a mean gestational age of 22 weeks, Cervical length was significantly greater in the cerclage group (31 vs. 19 mm). In 22 of 35 women, Cervical length was 25 mm or greater; 16 had undergone Cervical cerclage. Only 1 of these 22 women delivered before 34 weeks, significantly fewer than the 6 women among 13 whose Cervical length did not reach 25 mm. In addition to rest in bed, cerclage ensuring a Cervical length of at least 5 mm significantly lowers the likelihood of preterm delivery in women diagnosed as having Cervical Incompetence.
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Cervical Incompetence prevention randomized cerclage trial cipract effect of therapeutic cerclage with bed rest vs bed rest only on Cervical length
Ultrasound in Obstetrics & Gynecology, 2002Co-Authors: S M Althuisius, G A Dekker, Dick Bekedam, Pieter Hummel, D Kuik, H P Van GeijnAbstract:Objective To compare the effects of therapeutic cerclage and bed rest vs. just bed rest on Cervical length and to relate these effects to the risk of preterm delivery. Design Cervical length was measured in patients at high risk of Cervical Incompetence. When a Cervical length < 25 mm was measured before 27 weeks' gestation, randomization for therapeutic cerclage and bed rest vs. just bed rest was performed. After randomization, Cervical length was measured weekly. For statistical analysis, t-test and Fisher's exact tests were used and P < 0.05 was considered statistically significant. Results Nineteen women were randomly allocated to receive a therapeutic cerclage and bed rest and 16 were allocated to receive bed rest only. Mean Cervical lengths and mean gestational ages before randomization were comparable between both groups, overall 19.8 mm and 20.7 weeks. Cervical length was measured again at a mean gestation of 22.1 weeks. Mean Cervical length (31 mm) was significantly (P < 0.0001) longer after cerclage than after bed rest only (19 mm). A Cervical length ≥ 25 mm was measured in 22 of the 35 included women, 16 in the cerclage group and six in the bed-rest group (P = 0.006). Of these 22 women, only one delivered before 34 weeks' gestation, which was significantly less frequent than six out of 13 women with a Cervical length < 25 mm (P = 0.006). Conclusions Therapeutic cerclage with bed rest increases Cervical length more often than bed rest alone. A postintervention Cervical length ≥ 25 mm reduces the risk of preterm delivery in women at high risk of Cervical Incompetence and a preintervention Cervical length < 25 mm.
Herman P Van Geijn - One of the best experts on this subject based on the ideXlab platform.
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Cervical Incompetence prevention randomized cerclage trial emergency cerclage with bed rest versus bed rest alone
American Journal of Obstetrics and Gynecology, 2003Co-Authors: S M Althuisius, G A Dekker, Pieter Hummel, Herman P Van GeijnAbstract:Abstract Objective The purpose of this study was to compare preterm delivery rates and neonatal morbidity/mortality rates for women with Cervical Incompetence with membranes at or beyond a dilated external Cervical os that was treated with emergency cerclage, bed rest plus indomethacin, versus just bed rest. Study design Women with Cervical Incompetence with membranes at or beyond a dilated external Cervical os, before 27 weeks of gestation, were treated with antibiotics and bed rest and randomly assigned for emergency cerclage and indomethacin or bed rest only. Results Twenty-three women were included; 13 women were allocated randomly to the emergency cerclage and indomethacin group, and 10 women were allocated randomly to the bed rest–only group. Gestational age at time of randomization was 22.2 weeks in the emergency cerclage and indomethacin group and 23.0 weeks in the bed rest–only group. Mean interval from randomization until delivery was 54 days in the emergency cerclage and indomethacin group and 20 days in the bed rest–only group (P = .046). Mean gestational age at delivery was 29.9 weeks in the emergency cerclage and indomethacin group and 25.9 weeks in the bed rest–only group. Preterm delivery before 34 weeks of gestation was significantly lower in the emergency cerclage and indomethacin group, with 7 of 13 deliveries versus all 10 deliveries in the bed rest–only group (P = .02). Conclusions Emergency cerclage, indomethacin, antibiotics, and bed rest reduce preterm delivery before 34 weeks compared with bed rest and antibiotics alone.
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final results of the Cervical Incompetence prevention randomized cerclage trial cipract therapeutic cerclage with bed rest versus bed rest alone
American Journal of Obstetrics and Gynecology, 2001Co-Authors: S M Althuisius, G A Dekker, Dick Bekedam, Pieter Hummel, Herman P Van GeijnAbstract:Objective: To compare preterm delivery rates (before 34 weeks of gestation) and neonatal morbidity and mortality in patients with risk factors or symptoms of Cervical Incompetence managed with therapeutic McDonald cerclage and bed rest versus bed rest alone. Study Design: Cervical length was measured in patients with risk factors or symptoms of Cervical Incompetence. Risk factors for Cervical Incompetence included previous preterm delivery before 34 weeks of gestation that met clinical criteria for the diagnosis of Cervical Incompetence, previous preterm premature rupture of membranes before 32 weeks of gestation, history of cold knife conization, diethylstilbestrol exposure, and uterine anomaly. When a Cervical length of <25 mm was measured before a gestational age of 27 weeks, a randomization for therapeutic cerclage and bed rest (cerclage group) or bed rest alone (bed rest group) was performed. The analysis is based on intention to treat. Results: Of the 35 women who met the inclusion criteria, 19 were allocated randomly to the cerclage group and 16 to the bed rest group. Both groups were comparable for mean Cervical length and mean gestational age at time of randomization, mean overall 20 mm and 21 weeks. Preterm delivery before 34 weeks was significantly more frequent in the bed rest group than in the cerclage group (7 of 16 vs none, respectively; P =.002). There was no statistically significant difference in neonatal survival between the groups (13 neonates survived in the bed rest group vs all in the cerclage group). The compound neonatal morbidity, defined as admission to the neonatal intensive care unit or neonatal death, was significantly higher in the bed rest group than in the cerclage group (8 of 16 vs 1 of 19, respectively; P =.005; RR = 9.5, 95% CI, 1.3-68.1). Conclusions: Therapeutic cerclage with bed rest reduces preterm delivery before 34 weeks of gestation and compound neonatal morbidity in women with risk factors and/or symptoms of Cervical Incompetence and a Cervical length of <25 mm before 27 weeks of gestation. (Am J Obstet Gynecol 2001;185:1106-12.)
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Cervical Incompetence prevention randomized cerclage trial cipract study design and preliminary results
American Journal of Obstetrics and Gynecology, 2000Co-Authors: S M Althuisius, G A Dekker, Herman P Van Geijn, Dick Bekedam, Pieter HummelAbstract:Objective: The objective of this study was to compare different management strategies for women at risk for Cervical Incompetence. Study Design: In an ongoing randomized trial patients with a previous preterm delivery at <34 weeks’ gestation who met clinical criteria for the diagnosis of Cervical Incompetence are allocated to receive a prophylactic cerclage (prophylactic cerclage group) or not (observational group) in a proportion of 1:2. Transvaginal ultrasonographic follow-up examination of the cervix is performed in both groups. When a patient of the latter group has a Cervical length <25 mm at <27 weeks’ gestation, a further random assignment of therapeutic cerclage or no cerclage is performed. The analysis is by intent to treat. Results: Primary random assignment allocated 23 women to the prophylactic cerclage group and 44 to the observational group. Both groups were comparable with respect to obstetric history. No significant difference was found between the prophylactic cerclage group and the observational group in preterm delivery at <34 weeks’ gestation (3/23 vs 6/44, respectively) and neonatal survival (21/23 vs 41/44, respectively). A Cervical length <25 mm was found in 18 patients (41%) in the observational group at a mean gestational age of 19.1 ± 2.9 weeks’ gestation. Incidence of preterm delivery at <34 weeks’ gestation was significantly higher in the group with short Cervical length (6/18 vs 0/26; P = .003). Secondary random assignment of the 18 patients with short Cervical length allocated 10 to undergo therapeutic cerclage. Preterm delivery at <34 weeks’ gestation was significantly less frequent in the therapeutic cerclage group (1/10 vs 5/8). Conclusion: Transvaginal ultrasonographic serial follow-up examinations of the cervix in women at risk for Cervical Incompetence, with secondary intervention as indicated, appears to be a safe alternative to the traditional prophylactic cerclage. Transvaginal ultrasonographic follow-up examination of the cervix can save the majority of women from unnecessary intervention. Placement of a therapeutic cerclage may reduce the incidence of preterm delivery at <34 weeks’ gestation among high-risk patients. (Am J Obstet Gynecol 2000;183:823-9.)
Pieter Hummel - One of the best experts on this subject based on the ideXlab platform.
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Cervical Incompetence prevention randomized cerclage trial emergency cerclage with bed rest versus bed rest alone
American Journal of Obstetrics and Gynecology, 2003Co-Authors: S M Althuisius, G A Dekker, Pieter Hummel, Herman P Van GeijnAbstract:Abstract Objective The purpose of this study was to compare preterm delivery rates and neonatal morbidity/mortality rates for women with Cervical Incompetence with membranes at or beyond a dilated external Cervical os that was treated with emergency cerclage, bed rest plus indomethacin, versus just bed rest. Study design Women with Cervical Incompetence with membranes at or beyond a dilated external Cervical os, before 27 weeks of gestation, were treated with antibiotics and bed rest and randomly assigned for emergency cerclage and indomethacin or bed rest only. Results Twenty-three women were included; 13 women were allocated randomly to the emergency cerclage and indomethacin group, and 10 women were allocated randomly to the bed rest–only group. Gestational age at time of randomization was 22.2 weeks in the emergency cerclage and indomethacin group and 23.0 weeks in the bed rest–only group. Mean interval from randomization until delivery was 54 days in the emergency cerclage and indomethacin group and 20 days in the bed rest–only group (P = .046). Mean gestational age at delivery was 29.9 weeks in the emergency cerclage and indomethacin group and 25.9 weeks in the bed rest–only group. Preterm delivery before 34 weeks of gestation was significantly lower in the emergency cerclage and indomethacin group, with 7 of 13 deliveries versus all 10 deliveries in the bed rest–only group (P = .02). Conclusions Emergency cerclage, indomethacin, antibiotics, and bed rest reduce preterm delivery before 34 weeks compared with bed rest and antibiotics alone.
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Cervical Incompetence prevention randomized cerclage trial cipract effect of therapeutic cerclage with bed rest vs bed rest only on Cervical length
Obstetrical & Gynecological Survey, 2003Co-Authors: S M Althuisius, G A Dekker, Dick Bekedam, Pieter Hummel, D Kuik, H P Van GeijnAbstract:Cervical cerclage and bed rest, by themselves or in combination, are common approaches to pregnant women having an incompetent cervix. Transvaginal cerclage is known to increase Cervical length, but it is possible that bed rest alone has the same effect. This study of 35 women was an attempt to compare combined cerclage and bed rest with management by bed rest alone, using as the primary outcomes delivery before 34 weeks' gestation and neonatal morbidity. Women whose Cervical length was less than 25 mm before 27 weeks' gestation, as estimated by transvaginal sonography, were randomly assigned to one of the two treatment conditions. Cervical length was subsequently measured at weekly intervals. Cervical Incompetence was diagnosed from painless, progressive Cervical dilation when, without intervention, preterm delivery seemed inevitable. Cerclage was performed using a single purse-string suture of braided polyester Nineteen women were assigned to cerclage and bed rest, and 16 were assigned to bed rest only. Mean initial Cervical length and gestational age were comparable in these groups (averaging 19.8 mm and 20.7 weeks, respectively). At a mean gestational age of 22 weeks, Cervical length was significantly greater in the cerclage group (31 vs. 19 mm). In 22 of 35 women, Cervical length was 25 mm or greater; 16 had undergone Cervical cerclage. Only 1 of these 22 women delivered before 34 weeks, significantly fewer than the 6 women among 13 whose Cervical length did not reach 25 mm. In addition to rest in bed, cerclage ensuring a Cervical length of at least 5 mm significantly lowers the likelihood of preterm delivery in women diagnosed as having Cervical Incompetence.
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Cervical Incompetence prevention randomized cerclage trial cipract effect of therapeutic cerclage with bed rest vs bed rest only on Cervical length
Ultrasound in Obstetrics & Gynecology, 2002Co-Authors: S M Althuisius, G A Dekker, Dick Bekedam, Pieter Hummel, D Kuik, H P Van GeijnAbstract:Objective To compare the effects of therapeutic cerclage and bed rest vs. just bed rest on Cervical length and to relate these effects to the risk of preterm delivery. Design Cervical length was measured in patients at high risk of Cervical Incompetence. When a Cervical length < 25 mm was measured before 27 weeks' gestation, randomization for therapeutic cerclage and bed rest vs. just bed rest was performed. After randomization, Cervical length was measured weekly. For statistical analysis, t-test and Fisher's exact tests were used and P < 0.05 was considered statistically significant. Results Nineteen women were randomly allocated to receive a therapeutic cerclage and bed rest and 16 were allocated to receive bed rest only. Mean Cervical lengths and mean gestational ages before randomization were comparable between both groups, overall 19.8 mm and 20.7 weeks. Cervical length was measured again at a mean gestation of 22.1 weeks. Mean Cervical length (31 mm) was significantly (P < 0.0001) longer after cerclage than after bed rest only (19 mm). A Cervical length ≥ 25 mm was measured in 22 of the 35 included women, 16 in the cerclage group and six in the bed-rest group (P = 0.006). Of these 22 women, only one delivered before 34 weeks' gestation, which was significantly less frequent than six out of 13 women with a Cervical length < 25 mm (P = 0.006). Conclusions Therapeutic cerclage with bed rest increases Cervical length more often than bed rest alone. A postintervention Cervical length ≥ 25 mm reduces the risk of preterm delivery in women at high risk of Cervical Incompetence and a preintervention Cervical length < 25 mm.
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final results of the Cervical Incompetence prevention randomized cerclage trial cipract therapeutic cerclage with bed rest versus bed rest alone
American Journal of Obstetrics and Gynecology, 2001Co-Authors: S M Althuisius, G A Dekker, Dick Bekedam, Pieter Hummel, Herman P Van GeijnAbstract:Objective: To compare preterm delivery rates (before 34 weeks of gestation) and neonatal morbidity and mortality in patients with risk factors or symptoms of Cervical Incompetence managed with therapeutic McDonald cerclage and bed rest versus bed rest alone. Study Design: Cervical length was measured in patients with risk factors or symptoms of Cervical Incompetence. Risk factors for Cervical Incompetence included previous preterm delivery before 34 weeks of gestation that met clinical criteria for the diagnosis of Cervical Incompetence, previous preterm premature rupture of membranes before 32 weeks of gestation, history of cold knife conization, diethylstilbestrol exposure, and uterine anomaly. When a Cervical length of <25 mm was measured before a gestational age of 27 weeks, a randomization for therapeutic cerclage and bed rest (cerclage group) or bed rest alone (bed rest group) was performed. The analysis is based on intention to treat. Results: Of the 35 women who met the inclusion criteria, 19 were allocated randomly to the cerclage group and 16 to the bed rest group. Both groups were comparable for mean Cervical length and mean gestational age at time of randomization, mean overall 20 mm and 21 weeks. Preterm delivery before 34 weeks was significantly more frequent in the bed rest group than in the cerclage group (7 of 16 vs none, respectively; P =.002). There was no statistically significant difference in neonatal survival between the groups (13 neonates survived in the bed rest group vs all in the cerclage group). The compound neonatal morbidity, defined as admission to the neonatal intensive care unit or neonatal death, was significantly higher in the bed rest group than in the cerclage group (8 of 16 vs 1 of 19, respectively; P =.005; RR = 9.5, 95% CI, 1.3-68.1). Conclusions: Therapeutic cerclage with bed rest reduces preterm delivery before 34 weeks of gestation and compound neonatal morbidity in women with risk factors and/or symptoms of Cervical Incompetence and a Cervical length of <25 mm before 27 weeks of gestation. (Am J Obstet Gynecol 2001;185:1106-12.)
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Cervical Incompetence prevention randomized cerclage trial cipract study design and preliminary results
American Journal of Obstetrics and Gynecology, 2000Co-Authors: S M Althuisius, G A Dekker, Herman P Van Geijn, Dick Bekedam, Pieter HummelAbstract:Objective: The objective of this study was to compare different management strategies for women at risk for Cervical Incompetence. Study Design: In an ongoing randomized trial patients with a previous preterm delivery at <34 weeks’ gestation who met clinical criteria for the diagnosis of Cervical Incompetence are allocated to receive a prophylactic cerclage (prophylactic cerclage group) or not (observational group) in a proportion of 1:2. Transvaginal ultrasonographic follow-up examination of the cervix is performed in both groups. When a patient of the latter group has a Cervical length <25 mm at <27 weeks’ gestation, a further random assignment of therapeutic cerclage or no cerclage is performed. The analysis is by intent to treat. Results: Primary random assignment allocated 23 women to the prophylactic cerclage group and 44 to the observational group. Both groups were comparable with respect to obstetric history. No significant difference was found between the prophylactic cerclage group and the observational group in preterm delivery at <34 weeks’ gestation (3/23 vs 6/44, respectively) and neonatal survival (21/23 vs 41/44, respectively). A Cervical length <25 mm was found in 18 patients (41%) in the observational group at a mean gestational age of 19.1 ± 2.9 weeks’ gestation. Incidence of preterm delivery at <34 weeks’ gestation was significantly higher in the group with short Cervical length (6/18 vs 0/26; P = .003). Secondary random assignment of the 18 patients with short Cervical length allocated 10 to undergo therapeutic cerclage. Preterm delivery at <34 weeks’ gestation was significantly less frequent in the therapeutic cerclage group (1/10 vs 5/8). Conclusion: Transvaginal ultrasonographic serial follow-up examinations of the cervix in women at risk for Cervical Incompetence, with secondary intervention as indicated, appears to be a safe alternative to the traditional prophylactic cerclage. Transvaginal ultrasonographic follow-up examination of the cervix can save the majority of women from unnecessary intervention. Placement of a therapeutic cerclage may reduce the incidence of preterm delivery at <34 weeks’ gestation among high-risk patients. (Am J Obstet Gynecol 2000;183:823-9.)
G A Dekker - One of the best experts on this subject based on the ideXlab platform.
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a five century evolution of Cervical Incompetence as a clinical entity
Current Pharmaceutical Design, 2005Co-Authors: S M Althuisius, G A DekkerAbstract:Since Cervical Incompetence was introduced in the English literature in 1678, our understanding and obstetric management of this clinical entity, have changed tremendously over the years. This review shows the historical perspective of the development of Cervical Incompetence as a distinct clinical entity and an all or nothing phenomenon to Cervical Incompetence as part of a spectrum leading to preterm delivery, which can express differently in subsequent pregnancies. These changes in our understanding imply consequences for the obstetric management of Cervical Incompetence. This review focuses on the obstetric management of women considered to be at high risk of preterm delivery due to Cervical Incompetence, by transvaginal ultrasonographic follow-up of Cervical length and transvaginal Cervical cerclage.
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Cervical Incompetence prevention randomized cerclage trial emergency cerclage with bed rest versus bed rest alone
American Journal of Obstetrics and Gynecology, 2003Co-Authors: S M Althuisius, G A Dekker, Pieter Hummel, Herman P Van GeijnAbstract:Abstract Objective The purpose of this study was to compare preterm delivery rates and neonatal morbidity/mortality rates for women with Cervical Incompetence with membranes at or beyond a dilated external Cervical os that was treated with emergency cerclage, bed rest plus indomethacin, versus just bed rest. Study design Women with Cervical Incompetence with membranes at or beyond a dilated external Cervical os, before 27 weeks of gestation, were treated with antibiotics and bed rest and randomly assigned for emergency cerclage and indomethacin or bed rest only. Results Twenty-three women were included; 13 women were allocated randomly to the emergency cerclage and indomethacin group, and 10 women were allocated randomly to the bed rest–only group. Gestational age at time of randomization was 22.2 weeks in the emergency cerclage and indomethacin group and 23.0 weeks in the bed rest–only group. Mean interval from randomization until delivery was 54 days in the emergency cerclage and indomethacin group and 20 days in the bed rest–only group (P = .046). Mean gestational age at delivery was 29.9 weeks in the emergency cerclage and indomethacin group and 25.9 weeks in the bed rest–only group. Preterm delivery before 34 weeks of gestation was significantly lower in the emergency cerclage and indomethacin group, with 7 of 13 deliveries versus all 10 deliveries in the bed rest–only group (P = .02). Conclusions Emergency cerclage, indomethacin, antibiotics, and bed rest reduce preterm delivery before 34 weeks compared with bed rest and antibiotics alone.
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Cervical Incompetence prevention randomized cerclage trial cipract effect of therapeutic cerclage with bed rest vs bed rest only on Cervical length
Obstetrical & Gynecological Survey, 2003Co-Authors: S M Althuisius, G A Dekker, Dick Bekedam, Pieter Hummel, D Kuik, H P Van GeijnAbstract:Cervical cerclage and bed rest, by themselves or in combination, are common approaches to pregnant women having an incompetent cervix. Transvaginal cerclage is known to increase Cervical length, but it is possible that bed rest alone has the same effect. This study of 35 women was an attempt to compare combined cerclage and bed rest with management by bed rest alone, using as the primary outcomes delivery before 34 weeks' gestation and neonatal morbidity. Women whose Cervical length was less than 25 mm before 27 weeks' gestation, as estimated by transvaginal sonography, were randomly assigned to one of the two treatment conditions. Cervical length was subsequently measured at weekly intervals. Cervical Incompetence was diagnosed from painless, progressive Cervical dilation when, without intervention, preterm delivery seemed inevitable. Cerclage was performed using a single purse-string suture of braided polyester Nineteen women were assigned to cerclage and bed rest, and 16 were assigned to bed rest only. Mean initial Cervical length and gestational age were comparable in these groups (averaging 19.8 mm and 20.7 weeks, respectively). At a mean gestational age of 22 weeks, Cervical length was significantly greater in the cerclage group (31 vs. 19 mm). In 22 of 35 women, Cervical length was 25 mm or greater; 16 had undergone Cervical cerclage. Only 1 of these 22 women delivered before 34 weeks, significantly fewer than the 6 women among 13 whose Cervical length did not reach 25 mm. In addition to rest in bed, cerclage ensuring a Cervical length of at least 5 mm significantly lowers the likelihood of preterm delivery in women diagnosed as having Cervical Incompetence.
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Cervical Incompetence prevention randomized cerclage trial cipract effect of therapeutic cerclage with bed rest vs bed rest only on Cervical length
Ultrasound in Obstetrics & Gynecology, 2002Co-Authors: S M Althuisius, G A Dekker, Dick Bekedam, Pieter Hummel, D Kuik, H P Van GeijnAbstract:Objective To compare the effects of therapeutic cerclage and bed rest vs. just bed rest on Cervical length and to relate these effects to the risk of preterm delivery. Design Cervical length was measured in patients at high risk of Cervical Incompetence. When a Cervical length < 25 mm was measured before 27 weeks' gestation, randomization for therapeutic cerclage and bed rest vs. just bed rest was performed. After randomization, Cervical length was measured weekly. For statistical analysis, t-test and Fisher's exact tests were used and P < 0.05 was considered statistically significant. Results Nineteen women were randomly allocated to receive a therapeutic cerclage and bed rest and 16 were allocated to receive bed rest only. Mean Cervical lengths and mean gestational ages before randomization were comparable between both groups, overall 19.8 mm and 20.7 weeks. Cervical length was measured again at a mean gestation of 22.1 weeks. Mean Cervical length (31 mm) was significantly (P < 0.0001) longer after cerclage than after bed rest only (19 mm). A Cervical length ≥ 25 mm was measured in 22 of the 35 included women, 16 in the cerclage group and six in the bed-rest group (P = 0.006). Of these 22 women, only one delivered before 34 weeks' gestation, which was significantly less frequent than six out of 13 women with a Cervical length < 25 mm (P = 0.006). Conclusions Therapeutic cerclage with bed rest increases Cervical length more often than bed rest alone. A postintervention Cervical length ≥ 25 mm reduces the risk of preterm delivery in women at high risk of Cervical Incompetence and a preintervention Cervical length < 25 mm.
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Cervical Incompetence a reappraisal of an obstetric controversy
Obstetrical & Gynecological Survey, 2002Co-Authors: S M Althuisius, G A Dekker, Herman P Van GeijnAbstract:UNLABELLED Cervical Incompetence is not a categoric but rather a continuous variable, meaning that there are various degrees in the competency of the cervix. Furthermore, a certain degree of competency of the cervix can be expressed differently in subsequent pregnancies. Women with risk factors for Cervical Incompetence in their gynecological/obstetric history should be followed by transvaginal ultrasonography. History alone is not an indication for a prophylactic cerclage. Although transvaginal ultrasonography identifies women at high risk of preterm delivery, it does not discriminate between different underlying pathologies. Short Cervical length alone is not an indication for a therapeutic cerclage. Serial transvaginal ultrasonographic measurements of Cervical length in women with risk factors can identify those women truly at high risk of preterm delivery. A transvaginal Cervical cerclage with bed rest reduces preterm delivery and improves perinatal outcome in women with a short Cervical length and risk factors for Cervical Incompetence. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader will be able to define Cervical Incompetence, explain the role of transvaginal ultrasonography in the prediction of preterm delivery, and summarize the data on the use of transvaginal Cervical cerclage.
Dick Bekedam - One of the best experts on this subject based on the ideXlab platform.
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Cervical Incompetence prevention randomized cerclage trial cipract effect of therapeutic cerclage with bed rest vs bed rest only on Cervical length
Obstetrical & Gynecological Survey, 2003Co-Authors: S M Althuisius, G A Dekker, Dick Bekedam, Pieter Hummel, D Kuik, H P Van GeijnAbstract:Cervical cerclage and bed rest, by themselves or in combination, are common approaches to pregnant women having an incompetent cervix. Transvaginal cerclage is known to increase Cervical length, but it is possible that bed rest alone has the same effect. This study of 35 women was an attempt to compare combined cerclage and bed rest with management by bed rest alone, using as the primary outcomes delivery before 34 weeks' gestation and neonatal morbidity. Women whose Cervical length was less than 25 mm before 27 weeks' gestation, as estimated by transvaginal sonography, were randomly assigned to one of the two treatment conditions. Cervical length was subsequently measured at weekly intervals. Cervical Incompetence was diagnosed from painless, progressive Cervical dilation when, without intervention, preterm delivery seemed inevitable. Cerclage was performed using a single purse-string suture of braided polyester Nineteen women were assigned to cerclage and bed rest, and 16 were assigned to bed rest only. Mean initial Cervical length and gestational age were comparable in these groups (averaging 19.8 mm and 20.7 weeks, respectively). At a mean gestational age of 22 weeks, Cervical length was significantly greater in the cerclage group (31 vs. 19 mm). In 22 of 35 women, Cervical length was 25 mm or greater; 16 had undergone Cervical cerclage. Only 1 of these 22 women delivered before 34 weeks, significantly fewer than the 6 women among 13 whose Cervical length did not reach 25 mm. In addition to rest in bed, cerclage ensuring a Cervical length of at least 5 mm significantly lowers the likelihood of preterm delivery in women diagnosed as having Cervical Incompetence.
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Cervical Incompetence prevention randomized cerclage trial cipract effect of therapeutic cerclage with bed rest vs bed rest only on Cervical length
Ultrasound in Obstetrics & Gynecology, 2002Co-Authors: S M Althuisius, G A Dekker, Dick Bekedam, Pieter Hummel, D Kuik, H P Van GeijnAbstract:Objective To compare the effects of therapeutic cerclage and bed rest vs. just bed rest on Cervical length and to relate these effects to the risk of preterm delivery. Design Cervical length was measured in patients at high risk of Cervical Incompetence. When a Cervical length < 25 mm was measured before 27 weeks' gestation, randomization for therapeutic cerclage and bed rest vs. just bed rest was performed. After randomization, Cervical length was measured weekly. For statistical analysis, t-test and Fisher's exact tests were used and P < 0.05 was considered statistically significant. Results Nineteen women were randomly allocated to receive a therapeutic cerclage and bed rest and 16 were allocated to receive bed rest only. Mean Cervical lengths and mean gestational ages before randomization were comparable between both groups, overall 19.8 mm and 20.7 weeks. Cervical length was measured again at a mean gestation of 22.1 weeks. Mean Cervical length (31 mm) was significantly (P < 0.0001) longer after cerclage than after bed rest only (19 mm). A Cervical length ≥ 25 mm was measured in 22 of the 35 included women, 16 in the cerclage group and six in the bed-rest group (P = 0.006). Of these 22 women, only one delivered before 34 weeks' gestation, which was significantly less frequent than six out of 13 women with a Cervical length < 25 mm (P = 0.006). Conclusions Therapeutic cerclage with bed rest increases Cervical length more often than bed rest alone. A postintervention Cervical length ≥ 25 mm reduces the risk of preterm delivery in women at high risk of Cervical Incompetence and a preintervention Cervical length < 25 mm.
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final results of the Cervical Incompetence prevention randomized cerclage trial cipract therapeutic cerclage with bed rest versus bed rest alone
American Journal of Obstetrics and Gynecology, 2001Co-Authors: S M Althuisius, G A Dekker, Dick Bekedam, Pieter Hummel, Herman P Van GeijnAbstract:Objective: To compare preterm delivery rates (before 34 weeks of gestation) and neonatal morbidity and mortality in patients with risk factors or symptoms of Cervical Incompetence managed with therapeutic McDonald cerclage and bed rest versus bed rest alone. Study Design: Cervical length was measured in patients with risk factors or symptoms of Cervical Incompetence. Risk factors for Cervical Incompetence included previous preterm delivery before 34 weeks of gestation that met clinical criteria for the diagnosis of Cervical Incompetence, previous preterm premature rupture of membranes before 32 weeks of gestation, history of cold knife conization, diethylstilbestrol exposure, and uterine anomaly. When a Cervical length of <25 mm was measured before a gestational age of 27 weeks, a randomization for therapeutic cerclage and bed rest (cerclage group) or bed rest alone (bed rest group) was performed. The analysis is based on intention to treat. Results: Of the 35 women who met the inclusion criteria, 19 were allocated randomly to the cerclage group and 16 to the bed rest group. Both groups were comparable for mean Cervical length and mean gestational age at time of randomization, mean overall 20 mm and 21 weeks. Preterm delivery before 34 weeks was significantly more frequent in the bed rest group than in the cerclage group (7 of 16 vs none, respectively; P =.002). There was no statistically significant difference in neonatal survival between the groups (13 neonates survived in the bed rest group vs all in the cerclage group). The compound neonatal morbidity, defined as admission to the neonatal intensive care unit or neonatal death, was significantly higher in the bed rest group than in the cerclage group (8 of 16 vs 1 of 19, respectively; P =.005; RR = 9.5, 95% CI, 1.3-68.1). Conclusions: Therapeutic cerclage with bed rest reduces preterm delivery before 34 weeks of gestation and compound neonatal morbidity in women with risk factors and/or symptoms of Cervical Incompetence and a Cervical length of <25 mm before 27 weeks of gestation. (Am J Obstet Gynecol 2001;185:1106-12.)
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Cervical Incompetence prevention randomized cerclage trial cipract study design and preliminary results
American Journal of Obstetrics and Gynecology, 2000Co-Authors: S M Althuisius, G A Dekker, Herman P Van Geijn, Dick Bekedam, Pieter HummelAbstract:Objective: The objective of this study was to compare different management strategies for women at risk for Cervical Incompetence. Study Design: In an ongoing randomized trial patients with a previous preterm delivery at <34 weeks’ gestation who met clinical criteria for the diagnosis of Cervical Incompetence are allocated to receive a prophylactic cerclage (prophylactic cerclage group) or not (observational group) in a proportion of 1:2. Transvaginal ultrasonographic follow-up examination of the cervix is performed in both groups. When a patient of the latter group has a Cervical length <25 mm at <27 weeks’ gestation, a further random assignment of therapeutic cerclage or no cerclage is performed. The analysis is by intent to treat. Results: Primary random assignment allocated 23 women to the prophylactic cerclage group and 44 to the observational group. Both groups were comparable with respect to obstetric history. No significant difference was found between the prophylactic cerclage group and the observational group in preterm delivery at <34 weeks’ gestation (3/23 vs 6/44, respectively) and neonatal survival (21/23 vs 41/44, respectively). A Cervical length <25 mm was found in 18 patients (41%) in the observational group at a mean gestational age of 19.1 ± 2.9 weeks’ gestation. Incidence of preterm delivery at <34 weeks’ gestation was significantly higher in the group with short Cervical length (6/18 vs 0/26; P = .003). Secondary random assignment of the 18 patients with short Cervical length allocated 10 to undergo therapeutic cerclage. Preterm delivery at <34 weeks’ gestation was significantly less frequent in the therapeutic cerclage group (1/10 vs 5/8). Conclusion: Transvaginal ultrasonographic serial follow-up examinations of the cervix in women at risk for Cervical Incompetence, with secondary intervention as indicated, appears to be a safe alternative to the traditional prophylactic cerclage. Transvaginal ultrasonographic follow-up examination of the cervix can save the majority of women from unnecessary intervention. Placement of a therapeutic cerclage may reduce the incidence of preterm delivery at <34 weeks’ gestation among high-risk patients. (Am J Obstet Gynecol 2000;183:823-9.)