Is Early Treatment with a Cervical Pessary an Option in Patients with a History of Surgical Conisation and a Short Cervix?

Abstract

Objective: Patients with a history of one or more conizations have an increased risk of spontaneous preterm birth (SPTB). The aim of this study was to investigate the outcome of pregnancies in patients with a history of conization and early treatment with a cervical pessary. Methods: In this pilot observational study we included 21 patients and evaluated the obstetric history, the interval between pessary placement and delivery, gestational age at delivery, the neonatal outcome and the number of days of maternal and neonatal admission. Results: Among the study group of 21 patients, 20 patients had a singleton and one had a dichorionic/diamniotic twin pregnancy. At insertion, the mean gestational age was 17 + 2 (10 + 5–24 + 0) weeks and the mean cervical length was 19 (4–36) mm. Six patients presented with funneling at insertion with a mean funneling width of 19.7 (10–38) mm and funneling length of 19.9 (10–37) mm. Five patients had already lost at least one child due to early spontaneous preterm birth and another five had at least one previous abortion, who have now delivered beyond 34 weeks. The mean gestational age at delivery was 38 (31 + 1–41 + 0) gestational weeks and the mean interval between insertion and delivery was 145 (87–182) days. Conclusion: Our findings suggest a beneficial effect of an early pessary placement for patients at high-risk for preterm birth due to conization.

Zusammenfassung

Ziel: Schwangere Patientinnen nach Konisation haben ein erhöhtes Risiko für eine Frühgeburt. Das Ziel der vorliegenden Studie war die prospektive Beobachtung einer Kohorte von Schwangerschaften nach einer oder mehreren Konisationen und früher Behandlung mit einem zervikalen Pessar. Methoden: In dieser Pilotstudie wurden insgesamt 21 Patientinnen rekrutiert. Es wurden die geburtshilfliche Anamnese, die Zervixlänge und die Zervixstruktur (Funneling) mithilfe transvaginaler Sonografie, die Prolongation der Schwangerschaft, das Gestationsalter bei der Entbindung, sowie das neonatale Outcome und die Tage des Aufenthalts von Müttern und Kindern erfasst. Ergebnisse: Das Kollektiv umfasste 21 Patientinnen, 20 Patientinnen hatten eine Einlings- und 1 Patientin hatte eine dichoriale/diamniale Zwillingsschwangerschaft. Beim Einlegen des Pessars betrug das mittlere Gestationsalter 17 + 2 (10 + 5–24 + 0) Schwangerschaftswochen (SSW) und die mittlere Zervixlänge 19 (4–36) mm. Sechs Patientinnen zeigten eine Trichterbildung bereits beim Einlegen des Pessars mit einer mittleren Breite von 19,7 (10–38) mm und einer mittleren Länge von 19,9 (10–37) mm. Fünf Patientinnen hatten bereits ein Kind aufgrund von Frühgeburtlichkeit verloren und 5 weitere Patientinnen hatten mindestens eine Fehlgeburt in der Anamnese, welche in der aktuellen Schwangerschaft nach der 34. SSW entbunden haben. Das mittlere Gestationsalter bei Entbindung war 38 (31 + 1–41 + 0) SSW und die mittlere Zeit zwischen Einlegen des Pessars und Entbindung betrug 145 (87–182) Tage. Schlussfolgerung: Unsere Ergebnisse zeigten einen nützlichen Effekt der frühzeitigen Behandlung mit Pessar für Risikoschwangerschaften nach Konisation.

Key words

conisation - pessary - cerclage - cervical shortening - preterm birth

Schlüsselwörter

Konisation - Pessar - Cerclage - Zervixverkürzung - Frühgeburt

• References

• 1 Ortoft G, Henriksen T, Hansen E et al. After conisation of the cervix, the perinatal mortality as a result of preterm delivery increases in subsequent pregnancy. BJOG 2010; 117: 258-267
• 2 Danforth DN. The distribution and functional activity of the cervical musculature. Am J Obstet Gynecol 1954; 68: 1261-1271
• 3 Danforth DN. The fibrous nature of the human cervix, and its relation to the isthmic segment in gravid and nongravid uteri. Am J Obstet Gynecol 1947; 53: 541-560
• 4 Danforth DN, Buckingham JC, Roddick jr. JW. Connective tissue changes incident to cervical effacement. Am J Obstet Gynecol 1960; 80: 939-945
• 5 Sieroszewski P, Jasinski A, Perenc M et al. The Arabin pessary for the treatment of threatened mid-trimester miscarriage or premature labour and miscarriage: a case series. J Matern Fetal Med 2009; 22: 469-472
• 6 Kimber-Trojnar Z, Patro-Malysza J, Leszczynska-Gorzelak B et al. Pessary use for the treatment of cervical incompetence and prevention of preterm labour. J Matern Fetal Med 2010; 23: 1493-1499
• 7 Lotgering FK. Clinical aspects of cervical insufficiency. BMC Pregnancy Childbirth 2007; 7 (Suppl. 01) S17
• 8 Berghella V, Odibo AO, To MS et al. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Obstet Gynecol 2005; 106: 181-189
• 9 Lee SM, Jun JK. Prediction and prevention of preterm birth after cervical conization. J Gynecol Oncol 2010; 21: 207-208
• 10 Zeisler H, Joura EA, Bancher-Todesca D et al. Prophylactic cerclage in pregnancy. Effect in women with a history of conization. J Reprod Med 1997; 42: 390-392
• 11 Fox NS, Gelber SE, Kalish RB et al. History-indicated cerclage: practice patterns of maternal-fetal medicine specialists in the USA. J Perinat Med 2008; 36: 513-517
• 12 Kyvernitakis I, Lotgering F, Arabin B. Abdominal cerclage in twin pregnancy after radical surgical conization. Case Rep Obstet Gynecol 2014; 2014: 519826
• 13 David M, Jorde A. [Conization and pregnancy–an analysis of various therapeutic measures for the prevention of premature labor]. Zentralbl Gynakol 1991; 113: 1304-1312
• 14 Goya M, Pratcorona L, Merced C et al. Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial. Lancet 2012; 379: 1800-1806
• 15 Abdel-Aleem H, Shaaban OM, Abdel-Aleem MA. Cervical pessary for preventing preterm birth. Cochrane Database Syst Rev 2013; (5) CD007873
• 16 Arabin B, Alfirevic Z. Cervical pessaries for prevention of spontaneous preterm birth: past, present and future. Ultrasound Obstet Gynecol 2013; 42: 390-399
• 17 Iams JD, Goldenberg RL, Meis PJ et al. The length of the cervix and the risk of spontaneous premature delivery. National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network. N Engl J Med 1996; 334: 567-572
• 18 Wright D, Spencer K, Kagan KK et al. First-trimester combined screening for trisomy 21 at 7–14 weeksʼ gestation. Ultrasound Obstet Gynecol 2010; 36: 404-411
• 19 Salomon LJ, Diaz-Garcia C, Bernard JP et al. Reference range for cervical length throughout pregnancy: non-parametric LMS-based model applied to a large sample. Ultrasound Obstet Gynecol 2009; 33: 459-464
• 20 Goya M, Pratcorona L, Higueras T et al. Sonographic cervical length measurement in pregnant women with a cervical pessary. Ultrasound Obstet Gynecol 2011; 38: 205-209
• 21 Beckmann MW, Mallmann P. Uterus Commission of the Gynecological Oncology Working Group (AGO). Interdisciplinary S2k guideline on the diagnosis and treatment of cervical carcinoma. J Cancer Res Clin Oncol 2009; 135: 1197-1206
• 22 Greco E, Gupta R, Syngelaki A et al. First-trimester screening for spontaneous preterm delivery with maternal characteristics and cervical length. Fetal Diagn Ther 2012; 31: 154-161
• 23 Vayssiere C, Favre R, Audibert F et al. Cervical length and funneling at 22 and 27 weeks to predict spontaneous birth before 32 weeks in twin pregnancies: a French prospective multicenter study. Am J Obstet Gynecol 2002; 187: 1596-1604
• 24 Quaas L, Hillemanns HG, du Bois A et al. Das Arabin-Cerclage-Pessar – Eine Alternative zur operativen Cerclage. Geburtsh Frauenheilk 1990; 50: 429-433
• 25 Nam KH, Kwon JY, Kim YH et al. Pregnancy outcome after cervical conization: risk factors for preterm delivery and the efficacy of prophylactic cerclage. J Gynecol Oncol 2010; 21: 225-229
• 26 Castanon A, Brocklehurst P, Evans H et al. Risk of preterm birth after treatment for cervical intraepithelial neoplasia among women attending colposcopy in England: retrospective-prospective cohort study. BMJ 2012; 345: e5174
• 27 Poon CY, Edwards JM, Joshi S et al. Optimization of myocardial deformation imaging in term and preterm infants. Eur J Echocardiogr 2011; 12: 247-254
• 28 Schorge JO, Williams JW. Williams Gynecology. New York: McGraw-Hill Medical; 2008
• 29 Arabin B, Halbesma JR, Vork F et al. Is treatment with vaginal pessaries an option in patients with a sonographically detected short cervix?. J Perinat Med 2003; 31: 122-133
• 30 Hui SY, Chor CM, Lau TK et al. Cerclage pessary for preventing preterm birth in women with a singleton pregnancy and a short cervix at 20 to 24 weeks: a randomized controlled trial. Am J Perinatol 2013; 30: 283-288
• 31 Liem S, Schuit E, Hegeman M et al. Cervical pessaries for prevention of preterm birth in women with a multiple pregnancy (ProTWIN): a multicentre, open-label randomised controlled trial. Lancet 2013; 382: 1341-1349
• 32 Cannie MM, Dobrescu O, Gucciardo L et al. Arabin cervical pessary in women at high risk of preterm birth: a magnetic resonance imaging observational follow-up study. Ultrasound Obstet Gynecol 2013; 42: 426-433
• 33 Hildebrandt T, Kraml F, Wagner S et al. Impact of patient and procedure mix on finances of perinatal centres – theoretical models for economic strategies in perinatal centres. Geburtsh Frauenheilk 2013; 73: 783-791
• 34 Liem SM, van Baaren GJ, Delemarre FM et al. Economic analysis of use of pessary to prevent preterm birth in women with multiple pregnancy (ProTWIN trial). Ultrasound Obstet Gynecol 2014; 44: 338-345