|
The use of cervical cerclage in threatening preterm labour - transcript
From 23rd Annual Society for Maternal-Fetal
Medicine (SMFM) Conference held in San Francisco, California - February
2003
The Use of Cervical Cerclage in Threatening
Preterm Labour
Vincenzo Berghella, MD interviewed by Gian Carlo Di Renzo, MD, PhD
Gian Carlo Di Renzo, MD, PhD:
“Good morning. We are reporting from the San Francisco Maternal Foetal Medicine Society’s annual meeting of 2003, and have as our guest, Dr. Vincenzo Berghella from Philadelphia. I am Dr. Gian Carlo Di Renzo from the University of Perugia, which is one member of this association, which I frequently attend. I have a very hot question for Dr. Berghella, reading the last paper he has produced.
In Europe, and I think also in United States, there is a lot of debate about the need and utilisation of cervical cerclage for preventing early pre-term delivery. I think that cervical cerclage has been in the last decades like a salad in any food with different recipes from different obstetricians, gynaecologists, trying to have, let’s say, idoctical results about the value of applying cervical cerclage routinely or not routinely or trying to define which are the best tools to identify the patient risk of cervical cerclage. Now we are in 2000, we have a lot of new technologies, more sophisticated, and I think more objective, to tell us which is the case; which are the patients which can benefit of a cervical cerclage, or even which are the patients which cervical cerclage may harm? What do you think, Vincenzo, about this?”
Vincenzo Berghella, MD: “Thanks, Professor Di Renzo. We’ve actually dedicated a lot of our professional life, so to speak, to study cerclage as an intervention to prevent pre-term birth because it has been studied extensively but there is only a few randomised studies and a few, only a little evidence that cerclage indeed may work and, as you say, may indeed not work in other women. I think there are three kinds of women that you may consider cerclage for. For example, there is the woman who has a bad obstetrical history, that has is cervical incompetence or prior pre-term birth for which you think you may want put a prophylactic cerclage early pregnancy at 10 to 12 to 14 weeks and the trials on that show that only the really problematic woman who has three or more prior pre-term births or second trimester losses may benefit from that and, in fact, like you say, if the history is not so severe, if she has twins, for example, or higher order multiples, to place a cerclage at the earliest stage for not a clear indication may be associated with harmful effects, like more contractions, more hospitalisation, and even more infection during or post-partum, like
endometritis.
The new hot topic has been trans-vaginal ultrasound and the detection of a short cervix and that is actually shown to be very predictable for pre-term birth and it kind of makes sense intuitively that if a cervix is opening, kind of like a funnel, you would try to fix cerclage to try to keep it closed. Similar results have been shown so that the woman, who has not really had a bad obstetrical history before, but has a short cervix, probably does not benefit from a cerclage, so we shouldn’t just buy into cerclage for these women across the board.
I’m hoping that newer studies that are on-going eventually will show that the women with a prior pre-term birth, maybe even more than one, who do open up their cervix asymptomatically during pregnancy would benefit from a so-called therapeutic cerclage between 14 and 24 weeks. I’m hoping that data will eventually support that, but so far the data is very preliminary and the only study that has shown any benefits is the one from a Dutch group led by Dr. Althuisius.”
Gian Carlo Di Renzo, MD, PhD: “I see, so, in conclusion, do you think that in any case patients should be, let’s say, identified on the basis of past history and on the basis of a careful determination by ultrasound of cervix, and then make a decision with the combination of these two, parts of the story?”
Vincenzo Berghella, MD: “Yes, I think that’s where the future is going to be because, again, the nulliparous, let’s say a 25-year-old without any risk factors who happens to have a short cervix during pregnancy, is not going to have a high chance of delivering pre-term, actually 80% of those go to term, while, like you say, someone who’s had a really poor obstetrical history in the past, she may still deliver term, so you may not want to put in a cerclage right away, follow her with ultrasound, and then if her cervix shortens, I’m hoping that in those women, cerclage would then prevent pre-term birth, give you a chance to give steroids and keep her pregnant past 32 weeks.”
Gian Carlo Di Renzo, MD, PhD: “And what is your opinion about emergency cerclage; the fact that sometimes a patient can arrive at a tertiary centre with a cervix that is effaced or almost effaced and they are in labour but you can stop labour by giving some proper drugs and then, at the time, you may decide to make an emergency cerclage. Do you think it’s worthwhile or not?”
Vincenzo Berghella, MD: “I think that there are less data on that scenario, and actually this scenario may happen less and less if we do more trans-vaginal cerclage, more fibronectin, because you cannot catch those women before their cervix actually opens up more and they have more symptoms. In that scenario, I will first make sure that contractions are not present or at least they’re stopped at some point because the women who are really contracting and their bulging membranes, if you are going to place a cerclage, you could cause again more harm than good. But if you can either make sure that contractions are not there or you give them medicine or some other kind of tocolytic to stop the contractions, in some of those women, putting in an emergency cerclage, giving the woman the benefit of steroids, in that scenario for some women it may be beneficial. But there is so far very limited information, there are no randomised control trials, which have been published on that sub-group of women.”
Gian Carlo Di Renzo, MD, PhD: “You know some obstetricians still believe that they are key point to decide if a patient should go under cerclage or not on just one visit. I mean some of them say that I can distinguish if the cervix will be prone to be effaced soon or not according to characteristics that are evaluated by just one visit. Do you think that in this respect, ultrasound can make the difference?”
Vincenzo Berghella, MD: “Yes, I think there was a first study actually we entered when we published back in 1997 comparing the same women examined prospectively by bi-manual exam versus ultrasound and trans-vaginal ultrasound, I think we’ve shown that, and a lot of people have confirmed it, is much better, much more predictive. It’s going to allow you to look internally, so actually where the first hint of any problem, of any opening of the cervix is going to happen much before weeks later, you’re going to find opening manually or by ultrasound. In fact, over three-fourths of women, who have a short cervix and at ultrasound are still asymptomatic, don’t have manual changes by bi-manual exam, which tells you that you detect them pretty much always much earlier than you would with the old traditional manual exam.”
Gian Carlo Di Renzo, MD, PhD: “So in conclusion you think that we should restrict a little bit the use of cerclage to very carefully identify the at-risk woman?”
Vincenzo Berghella, MD: “Yes.”
Gian Carlo Di Renzo, MD, PhD: “That woman and obviously to use this in the proper way and not like sometimes just because some people are used to have this as a simple subject sometime and they say that, for instance, for twins or triplets, it’s better to put a cerclage than not.”
Vincenzo Berghella, MD: “Yes.”
Gian Carlo Di Renzo, MD, PhD:
“So you think that in any case that this is the indication?”
Vincenzo Berghella, MD: “Yes, there is an American saying that says, “When you have a hammer, everything begins to look like a nail”, so that you know when you cerclage you may want to, it’s an easy operation you want to give it to everyone, and I think that they actually have to find the right patients with a specific indication and not do it to a lot of women since it may be harmful more than beneficial in many cases.”
Gian Carlo Di Renzo, MD, PhD: “Thank you very much.”
Vincenzo Berghella, MD: “Thanks,
Professor.”
|
|
