Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de los Andes, Las Condes, Santiago, Chile.
Department of Public Health and Epidemiology, Faculty of Medicine, Universidad de los Andes, Santiago, Chile.
J Perinat Med. 2019 Jul 26;47(5):500-509. doi: 10.1515/jpm-2018-0388.
Background The frequency of intra-amniotic infection/inflammation (IAI/I) in patients with midtrimester cervical insufficiency is up to 50%. Our purpose was to determine the perinatal outcomes of cervical cerclage in patients with acute cervical insufficiency with bulging membranes, and to compare the admission-to-delivery interval and pregnancy outcomes according to the results of amniotic fluid (AF) analysis and cerclage placement. Methods This was a retrospective cohort study including singleton pregnancies with cervical insufficiency between 15 and 26.9 weeks in two tertiary health centers. IAI/I was defined when at least one of the following criteria was present in AF: (a) a white blood cell (WBC) count >50 cells/mm3; (b) glucose concentration <14 mg/dL; and/or (c) a Gram stain positive for bacteria. Three different groups were compared: (1) absence of IAI/I with placement of a cerclage; (2) amniocentesis not performed with placement of a cerclage; and (3) IAI/I with or without a cerclage. Results Seventy patients underwent an amniocentesis to rule out IAI/I. The prevalence of IAI/I was 19%. Forty-seven patients underwent a cerclage. Patients with a cerclage had a longer median admission-to-delivery interval (33 vs. 2 days; P < 0.001) and delivered at a higher median gestational age (27.4 vs. 22.6 weeks; P = 0.001) than those without a cerclage. The neonatal survival rate in the cerclage group was 62% vs. 23% in those without a cerclage (P = 0.01). Patients without IAI/I who underwent a cerclage had a longer median admission-to-delivery interval (43 vs. 1 day; P < 0.001), delivered at a higher median gestational age (28 vs. 22.1 weeks; P = 0.001) and had a higher neonatal survival rate (67% vs. 8%; P < 0.001) than those with IAI/I. Conclusion The pregnancy outcomes of patients with midtrimester cervical insufficiency and bulging membranes are poor as they have a high prevalence of IAI/I. Therefore, a pre-operative amniocentesis is key to identify the best candidates for the subsequent placement of a cerclage.
在中期宫颈机能不全患者中，宫内感染/炎症（IAI/I）的发生率高达 50%。我们的目的是确定急性宫颈机能不全伴胎膜膨出患者行宫颈环扎术的围产结局，并根据羊膜液（AF）分析和环扎术的结果比较入院至分娩的间隔时间和妊娠结局。
这是一项回顾性队列研究，纳入了两家三级保健中心的 15-26.9 周的宫颈机能不全的单胎妊娠。IAI/I 的定义为 AF 中至少存在以下一项标准：（a）白细胞（WBC）计数>50 个细胞/mm3；（b）葡萄糖浓度<14mg/dL；和/或（c）革兰氏染色阳性细菌。比较了三组患者：（1）IAI/I 阴性并放置环扎术；（2）未行羊膜穿刺术但放置环扎术；（3）IAI/I 阳性并放置或不放置环扎术。
70 例患者行羊膜穿刺术以排除 IAI/I。IAI/I 的发生率为 19%。47 例患者行环扎术。与未行环扎术的患者相比，行环扎术的患者的中位入院至分娩的间隔时间更长（33 天 vs. 2 天；P<0.001），分娩时的中位孕周更高（27.4 周 vs. 22.6 周；P=0.001）。环扎组新生儿存活率为 62%，而未行环扎术的新生儿存活率为 23%（P=0.01）。未发生 IAI/I 但行环扎术的患者的中位入院至分娩的间隔时间更长（43 天 vs. 1 天；P<0.001），分娩时的中位孕周更高（28 周 vs. 22.1 周；P=0.001），新生儿存活率更高（67% vs. 8%；P<0.001）。
中期宫颈机能不全伴胎膜膨出患者的妊娠结局较差，因为 IAI/I 的发生率较高。因此，术前羊膜穿刺术是确定随后行环扎术的最佳人选的关键。
