Profilaktik Serklaj ve Acil Serklaj operasyonlarının perinatal sonuçlarının karşılaştırılması: 10 yıllık deneyimComparison of perinatal outcomes of prophylactic and emergency cerclage: Ten years of experience

Yıl 2020, Cilt: 51 Sayı: 2, 96 - 100, 15.06.2020

Adile Yeşim Akdemir , Büşra Aynalı , Mustafa Çağatay Büyükuysal , Görker Sel , İnan İlker Arıkan Aykut Barut , Ülkü Özmen , Müge Harma , Mehmet Harma

https://doi.org/10.16948/zktipb.725239

Öz

Amaç: Preterm doğumu önlemek amacıyla servikal yetmezlik saptanıp proflaktik serklaj ve acil serklaj operasyonu yapılmış olan olguların perinatal sonuçlarını karşılaştırmak
Gereç ve Yöntem: Ocak 2009 - Ocak 2019 arasında Zonguldak Bülent Ecevit Üniversitesi Tıp Fakültesi Kadın Hastalıkları ve Doğum Kliniği’nde serklaj yapılmış olan hastaların medikal bilgileri retrospektif olarak incelendi. Servikal yetmezlik ile ilişkili bir veya daha fazla ikinci trimester gebelik kaybı hikayesi bulunan ya da servikal yetmezlik nedeniyle daha önce serklaj yapılmış olan hastalar proflaktik serklaj grubu olarak, ikinci trimesterde ağrısız servikal dilatasyon ve/veya membranların vajene prolabe olduğu saptanarak serklaj yapılan olgular ise acil serklaj grubu olarak ayrıldı. Gruplar arasında gebelik süresince gelişen komplikasyonlar, perinatal sonuçlar ve inflamatuar belirteçlerden lökosit (WBC), periferik kan nötrofil-lenfosit oranı (NLR) ve trombosit-lenfosit oranı (PLR) karşılaştırıldı.
Bulgular: Yirmi yedi olgudan oluşan proflaktik serklaj grubunda canlı doğum oranı %96,6 iken, 16 olgudan oluşan acil serklaj grubunda canlı doğum oranı yine oldukça yüksek bir oran olan %81,3 olarak saptandı. Proflaktik serklaj ve acil serklaj yapılan hastaların canlı doğum oranı, doğum haftası, preterm doğum oranı ve doğum kilosu her iki grupta da benzerdi (p=0,137; p=0,179; p= 0,085; p=0,602). Acil serklaj yapılan olguların servikal dilatasyonları 1-4 cm arasında değişmekteydi. Beş olguda servikal dilatasyon ≥3 cm ve membranlar prolabe idi, bu olguların sadece biri (%20) canlı term doğumla sonuçlandı. Acil serklaj grubunda lökosit (WBC) sayısı proflaktik serklaj grubundan daha yüksek bulundu (p=0,037). Buna karşılık NLR, PLR, nötrofil, lenfosit ve trombosit sayıları ise her iki grupta farksız saptandı. Tüm olgular içinde preterm doğumlar ile term doğumlar arasında yapılan karşılaştırmada ise WBC, NLR ve PLR değerleri açısından fark saptanmadı.
Sonuç: Acil serklaj operasyonunun perinatal sonuçları proflaktik serklaj operasyonu ile benzer ve her iki grupta da canlı doğum ve term doğum oranları yüksek saptanmıştır. Bununla beraber acil serklaj yapılan grupta servikal dilatasyonun ≥3 cm olduğu olgularda ise neonatal mortalite, abortus ve preterm prematür membrane rüptürü oranı yüksektir. Bu bulgular özellikle acil serklaj yapılacak hastaların seçiminde dikkatli olmak gerektiğini göstermektedir.

Objective: To compare perinatal outcomes of prophylactic cerclage and emergency cerclage operations in patients with cervical insufficiency to prevent preterm birth.
Material and Method: A retrospective study was conducted between June 2009 and June 2019 in University of xxxxxxxxxx Obstetrics and Gynecology Department. All medical records were evaluated. Patients with history of one or more second-trimester pregnancy losses related to painless cervical dilation and in the absence of labor or abruptio placentae or history of prior cerclage due to painless cervical dilation in the second trimester were included to prophylactic cerclage group and patients with painless cervical dilation and/or prolabed membranes at physical examination in the second trimester were included to emergency cerclage group. Pregnancy complications, perinatal outcomes and inflammatory markers such as WBC count, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) were assessed.
Results: Live birth rate were 96,6% in prophylactic cerclage group which was consisted of 27 patients and 81,3% in emergency cerclage group which was consisted of 16 patients. Similarity were observed in comparison of live birth rate, gestational age at birth, preterm birth rates and birthweight between both groups (p=0,137; p=0,179; p= 0,085; p=0,602). Cervical dilatation was between 1 and 4 cm in emergency cerclage group. Cervical dilatation were ≥3 cm and membranes were prolabed in 5 patients. Only one of five patient’s pregnancy was resulted with term birth. WBC count were higher in emergency cerclage group than prophylactic cerclage group (p=0,037). On the contrary, no difference was seen in comparison of NLR, PLR, neutrophil, lymphocyte, and platelet count between groups. Likewise, WBC, NLR and PLR were not different between the patients who were delivered preterm and term in all groups.
Conclusion: Our study suggests that, both prophylactic cerclage and emergency cerclage increases the live birth and term birth rates. However increased neonatal mortality, abortus and preterm premature membrane rupture rates were observed in patients with cervical dilatation ≥3 cm. Patients must be evaluated carefully before emergency cerclage operation.

Anahtar Kelimeler

preterm doğum, , servikal serklaj, , servikal yetmezlik, nötrofil-lenfosit oranı, trombosit-lenfosit oranı

Kaynakça

• 1) https://www.who.int/pmnch/media/news/2012/201204_borntoosoon_countryranking.pdf
• 2) ACOG Practice Bulletin No. 142: Cerclage for the management of cervical insufficiency. Obstet Gynecol, 2014 123 (2 pt 1): 372-9
• 3) Norman JE, Marlow N, Messow CM, et al. Vaginal progesterone prophylaxis for preterm birth (the OPPTIMUM study): a multicentre, randomised, doubleblind trial. Lancet. 2016;387(10033):2106–2116.
• 4) Althuisius SM, Dekker GA, Hummel P, et al. Final results of the cervical incompetence prevention randomized cerclage trial (CIPRACT): therapeutic cerclage with bed rest versus bed rest alone. Am J Obstet Gynecol. 2001;185(5):1106–1112.
• 5) Jarde A, Lutsiv O, Beyene J, McDonald SD. Vaginal progesterone, oral progesterone, 17-OHPC, cerclage, and pessary for preventing preterm birth in at-risk singleton pregnancies: an updated systematic review and network meta-analysis. BJOG. 2019 Apr;126(5):556-567.
• 6) Crowther CA, Ashwood P, McPhee AJ, Flenady V, Tran T, Dodd JM, et al. Vaginal progesterone pessaries for pregnant women with a previous preterm birth to prevent neonatal respiratory distress syndrome (the PROGRESS Study): a multicentre, randomised, placebo‐controlled trial. PLoS Med 2017;14:e1002390.
• 7) Sciscione AC. Maternal activity restriction and the prevention of preterm birth. Am J Obstet Gynecol. 2010 Mar;202(3):232.e1-5.
• 8) Dharan VB1, Ludmir J. Alternative treatment for a short cervix: the cervical pessary. Semin Perinatol. 2009 Oct;33(5):338-42. doi: 10.1053/j.semperi.2009.06.008.
• 9) McDonald IA. Cervical cerclage. Clin Obstet Gynaecol. 1980;7(3):461–479.
• 10) Chen R, Huang X, Li B. Pregnancy outcomes and factors affecting the clinical effects of cervical cerclage when used for different indications: A retrospective study of 326 cases. Taiwan J Obstet Gynecol. 2020 Jan;59(1):28-33.
• 11) A. Liddiard, S. Bhattacharya, L. CrichtonElective and emergency cervical cerclage and immediate pregnancy outcomes: a retrospective observational study JRSM Short Rep, 2 (2011), p. 91
• 12) Liu Y, Ke Z, Liao W, Chen H, Wei S, Lai X, Chen X. Pregnancy outcomes and superiorities of prophylactic cervical cerclage and therapeutic cervical cerclage in cervical insufficiency pregnant women. Arch Gynecol Obstet. 2018 Jun;297(6):1503-1508.
• 13) Ehsanipoor RM, Seligman NS, Saccone G, et al. Physical examination–indicated cerclage: a systematic review and meta-analysis. Obstet Gynecol. 2015;126:125–135.
• 14) Namouz S, Porat S, Okun N, et al. Emergency cerclage: literature review. Obstet Gynecol Surv. 2013;68:379–388 15) Guzman ER1, Forster JK, Vintzileos AM, Ananth CV, Walters C, Gipson K.
• Pregnancy outcomes in women treated with elective versus ultrasound-indicated cervical cerclage. Ultrasound Obstet Gynecol, 1998. 12(5): p. 323-7
• 16) Chan LL, Leung TW, Lo TK, Lau WL Leung WC. Indications for and pregnancy outcomes of cervical cerclage: 11-year comparison of patients undergoing history-indicated, ultrasound-indicated, or rescue cerclage. Hong Kong Med J. 2015 Aug;21(4):310-7.
• 17) O. Gluck, Y. Mizrachi, S. Ginath, J. Bar, R. SagivObstetrical outcomes of emergency compared with elective cervical cerclage J Matern Fetal Neonatal Med, 30 (2017), pp. 1650-1654
• 18) Kim MA, Lee BS, Park YW, Seo K. Serum markers for prediction of spontaneous pre term delivery in preterm labour. Eur J Clin Invest 2011;41(7):773–80
• 19) Jung EY, Park KH, Lee SY, Ryu A, Joo JK, Park JW. Predicting outcomes of emergency cerclage in women with cervical insufficiency using inflammatory markers in maternal blood and amniotic fluid. Int J Gynaecol Obstet. 2016 Feb;132(2):165-9.
• 20) Pereira L, Cotter A, Gom ez R, et al. Expectant management compared with physical examinationindicated cerclage (EM-PEC) in selected women with a dilated cervix at 14(0/7)–25(6/7) weeks: results from the EM-PEC international cohort study. Am J Obstet Gynecol. 2007;197(5):483.e1–483.e8.
• 21) Schneider K, Fimmers R, Jörgens M, Peter S, Pelzer V, Redlich T. J Matern Fetal Neonatal Med. 2019 Dec 18:1-7. doi: 10.1080/14767058.2019.1702960. Emergency cerclage following a standardized protocol offers an effective and safe therapeutic option for women with high risk for prematurity - a retrospective monocentric cohort study on 130 pregnancies and 155 neonates.
• 22) Debby A, Sadan O, Glezerman M, et al. Favorable outcome following emergency second trimester cerclage. Int J Gynaecol Obstet. 2007;96: 16–19.
• 23) Gupta M, Emary K, Impey L. Emergency cervical cerclage: predictors of success. J Matern Fetal Neonatal Med. 2010;23:670–674.
• 24) Cilingir IU, Sayin C, Sutcu H, İnan C, Erzincan S, Yener C, Varol F. Emergency cerclage in twins during mid gestation may have favorable outcomes: Results of a retrospective cohort. J Gynecol Obstet Hum Reprod. 2018 Nov;47(9):451-453.
• 25) Brown R, Gagnon R, Delisle MF, Maternal Fetal Medicine Committee Cervical insufficiency and cervical cerclage. J Obstet Gynaecol Can. 2013;35:1115–1127.
• 26) Lee KN, Whang EJ, Chang KH, Song JE, Son GH, Lee KY. History-indicated cerclage: the association between previous preterm history and cerclage outcome. Obstet Gynecol Sci. 2018 Jan;61(1):23-29.
• 27) Curti A, Simonazzi G, Farina A, et al. Exam indicated cerclage in patients with fetal membranes at or beyond external os: a retrospective evaluation. J Obstet Gynaecol Res. 2012;38: 1352–1357.
• 28) Buyukkaya E, Karakas MF, Karakas E, et al: Correlation of neutrophil to lymphocyte ratio with the presence and severity of metabolic syndrome. Clin Appl Thromb Hemost 2014;20: 159-63
• 29) Turkmen K, Erdur FM, Ozcicek F, et al: Platelet-to-lymphocyte ratio better predicts inflammation than neutrophil-to-lymphocyte ratio in end-stage renal disease patients. Hemodial Int 2013;17: 391-6
• 30) Yilmaz H, Celik HT, Namuslu M, Inan O, Onaran Y, Karakurt F, et al. Benefits of the neutrophil-to-lymphocyte ratio for the prediction of gestational diabetes mellitus in pregnant women. Exp Clin Endocrinol Diabetes 2014;122(1):39–43.