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Servikal Yetmezliği Olan Gebelerde Medikal Tedavi Yeterli mi? Acil Serklaj Uygulanmalı mı?

İkinci trimester gebelik kayıplarının %16-20’sinden servikal yetmezlik sorumludur. Bu çalışmanın amacı gebeliğin ikinci trimesterinde servikal yetmezlik tanısı ile acil serklaj ve medikal tedavi uyguladığımız hastalar ile yalnızca medikal tedavi yapılan kadınların maternal, perinatal sonuçlarını karşılaştırmaktır. Bu retrospektif çalışma, önceden erken doğum hikayesi olan, gebeliği tekiz ve 16-24. hafta arasında, servikal yetmezlik tanılı, amniotik membranı vajene prolabe olmuş hastalar değerlendirilerek yapıldı. Yatak istirahati tüm hastalara önerildi, serklaj tekniği olarak McDonalds yöntemi kullanıldı. Servikal yetmezlik tanısı alan hastalara tıbbi tedavi olarak antibiyotik profilaksisi, progesteron ayrıca indometasin veya nifedipin uygulandı. Bu hastalardan 24. gebelik haftasını dolduranlara akciğer olgunlaşması için betametazon verildi. Toplam 29 hastadan 19 hastaya acil serklaj + medikal tedavi, 10 hastaya yalnızca medikal tedavi uygulandı. Acil serklaj uyguladığımız hastalardan 7’sinin, medikal tedavi uyguladığımız 2 hastanın gebeliği geç abortusla sonuçlandı. Acil serklaj + medikal tedavi uygulanan hastalarda tedavi sonrası ortalama doğuma kadar geçen süre 24.83±12.44 gün; sadece medikal tedavi uygulananlarda ise 20.13±6.94 gündü. Serklaj + medikal tedavi uyguladığımız hastalarda doğum için kazanılan süre istatistiksel olarak anlamlı derecede daha fazlaydı (p=0.037). Servikal yetmezlik tanısı alan ve 24. gebelik haftasından sonra doğum yapan acil serklaj + medikal tedavi uygulanan hastaların 4'ünde, medikal tedavi alanların 3'ünde perinatal ölüm oldu. Acil serklaj + medikal tedavi uygulanan 19 hastanın 8'inde, sadece medikal tedavi uygulanan 10 hastanın 5'inde canlı doğum meydana geldi. Çalışmamızda acil serklaj uygulamalarının gebelik süresini uzattığını belirledik. Fakat acil serklaj ile kazanılan sürenin perinatal sonuçlara olumlu istatistiksel katkısı saptanmadı.

Anahtar Kelimeler:

Acil Servikal Serklaj, Perinatal Sonuçlar, Servikal Yetmezlik

Cervical insufficiency is responsible for 16-20% of second trimester losses. This study aims to compare the maternal and perinatal outcomes of the patients diagnosed with cervical insufficiency in the second trimester of pregnancy who underwent emergency cerclage and medical treatment with the patients, who were managed with only medical treatment. This retrospective study was conducted by evaluating the patients with a singleton pregnancy between the 16-24th weeks of gestation with a previous history of preterm labor, and diagnosis of cervical insufficiency, and prolapsed amniotic membrane in to the vagina. The cerclage was applied using the McDonald technique. Antibiotic prophylaxis, progesterone, indomethacin, or nifedipine were administered as medical treatment to the patients diagnosed with cervical insufficiency. It was found that among these patients, beta methasone was administered for lung maturation in those who completed the 24th gestational week. Out of a total of 29 patients, 19 patients received emergency cerclage and medical treatment, and 10 patients received only medical treatment. 7 of the patients who underwent emergency cerclage, and 2 patients that we applied medical treatment, resulted in late abortion. The mean delivery time after treatment was 24.83±12.44 days in patients who applied emergency cerclage + medical treatment; and was 20.13±6.94 days in patients who only applied medical treatment. The extra time for delivery was statistically significantly higher in the patients we applied cerclage + medical treatment (p=0.037). Perinatal death occurred in 4 of the patients diagnosed with cervical insufficiency who received emergency cerclage + medical treatment and 3 of the patients who received medical treatment after their 24th gestational week. Live births occurred in 8 of 19 patients in whom emergency cerclage + medical treatment was applied, and in 5 of 10 patients who have applied only medical treatment. In our study, we determined that emergency cerclage applications prolong the gestational period. However, no positive statistically significant contribution was found in the time gained by emergency cerclage on perinatal outcomes.

Keywords:

Emergency Cervical Cerclage, Perinatal Outcomes, Cervical Insufficiency,

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1. Osterman MJK, Martin JA. Timing and Adequacy of Prenatal Care in the United States, 2016. National vital statistics reports : from the Centers for Disease Control and Prevention, National Center for Health Statistics. Natl Vital Stat Rep. 2018;67(3):1-14.
2. Marcellin L. Prevention of preterm birth by uterine cervical cerclage. J Gynecol Obstet Biol Reprod (Paris). 2016;45(10):1299-323.
3. Kurup M, Goldkrand JWJAjoo, gynecology. Cervical incompetence: elective, emergent, or urgent cerclage. Am J Obstet Gynecol. 1999;181(2):240-6.
4. Sneider K, Christiansen OB, Sundtoft IB, Langhoff-Roos J. Recurrence of second trimester miscarriage and extreme preterm delivery at 16-27 weeks of gestation with a focus on cervical insufficiency and prophylactic cerclage. Acta Obstet Gynecol Scand. 2016;95(12):1383-90.
5. ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency. Obstet Gynecol. 2014;123(2 Pt 1):372-9.
6. Shennan A, Jones B. The cervix and prematurity: aetiology, prediction and prevention. Semin Fetal Neonatal Med. 2004;9(6):471-9.
7. Rust OA, Atlas RO, Jones KJ, Benham BN, Balducci J. A randomized trial of cerclage versus no cerclage among patients with ultrasonographically detected second-trimester preterm dilatation of the internal os. Am J Obstet Gynecol. 2000;183(4):830-5.
8. Steenhaut P, Hubinont C, Bernard P, Debiève F. Retrospective comparison of perinatal outcomes following emergency cervical cerclage with or without prolapsed membranes. Int J Gynaecol Obstet. 2017;137(3):260-4.
9. Wierzchowska-Opoka M, Kimber-Trojnar Ż, Leszczyńska-Gorzelak B. Emergency Cervical Cerclage. J Clin Med. 2021;10(6):1270.
10. Pang Q, Jia X, Chen L. Perinatal Outcomes After Emergency Cervical Cerclage for Cervical Insufficiency with Prolapsed Membranes. Med Sci Monit. 2019;25:4202-6.
11. Conde-Agudelo A, Romero R, Jung EJ, Garcia Sánchez Á J. Management of clinical chorioamnionitis: an evidence-based approach. Am J Obstet Gynecol. 2020;223(6):848-69.
12. Shitanaka S, Chigusa Y, Kawahara S, et al. Conservative management for retained products of conception after less than 22 weeks of gestation. J Obstet Gynaecol Res. 2020;46(10):1982-7.
13. Althuisius SM, Dekker GA, Hummel P, van Geijn HP. Cervical incompetence prevention randomized cerclage trial: emergency cerclage with bed rest versus bed rest alone. Am J Obst Gynecol. 2003;189(4):907-10.
14. Terkildsen MF, Parilla BV, Kumar P, Grobman WA. Factors associated with success of emergent second-trimester cerclage. Obstetrics and gynecology. 2003;101(3):565-9.
15. Fuchs F, Senat MV, Fernandez H, Gervaise A, Frydman R, Bouyer J. Predictive score for early preterm birth in decisions about emergency cervical cerclage in singleton pregnancies. Acta Obstet Gynecol Scand. 2012;91(6):744-9.
16. Namouz S, Porat S, Okun N, Windrim R, Farine D. Emergency cerclage: literature review. Obstet Gynecol Survey. 2013;68(5):379-88.
17. Aoki S, Ohnuma E, Kurasawa K, Okuda M, Takahashi T, Hirahara F. Emergency cerclage versus expectant management for prolapsed fetal membranes: a retrospective, comparative study. J Obstet Gynaecol Res. 2014;40(2):381-6.
18. Chen Q, Chen G, Li N. Clinical effect of emergency cervical cerclage and elective cervical cerclage on pregnancy outcome in the cervical-incompetent pregnant women. Arch Gynecol Obstet. 2018;297(2):401-7.
19. Debby A, Sadan O, Glezerman M, Golan A. Favorable outcome following emergency second trimester cerclage. Int J Gynaecol Obstet. 2007;96(1):16-9.
20. Çavuş Y, Uysal A, Balsak D, Acar Z, İnce Z, Uysal F. Emergency cervical cerclage: effect on pregnancy outcome and mode of delivery. J Matern Fetal Neonatal Med. 2014;27(1):80-3.
21. Stupin JH, David M, Siedentopf JP, Dudenhausen JW. Emergency cerclage versus bed rest for amniotic sac prolapse before 27 gestational weeks. A retrospective, comparative study of 161 women. Eur J Obstet Gynecol Reprod Biol. 2008;139(1):32-7.
22. Olatunbosun OA, al-Nuaim L, Turnell RW. Emergency cerclage compared with bed rest for advanced cervical dilatation in pregnancy. Int Surg. 1995;80(2):170-4.
23. Ciancimino L, Laganà AS, Imbesi G, Chiofalo B, Mancuso A, Triolo O. Evaluation of Maternal-Fetal Outcomes After Emergency Vaginal Cerclage Performed With Shirodkar-McDonald Combined Modified Technique. J Clin Med Res. 2015;7(5):319-23.
24. Costa MMF, Amorim Filho AG, et al. Emergency cerclage: gestational and neonatal outcomes. Rev Assoc Med Bras (1992). 2019;65(5):598-602.