Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
Department of Obstetrics and Gynecology, Chungnam National University Hospital, Daejeon, Korea.
J Korean Med Sci. 2024 Nov 4;39(42):e310. doi: 10.3346/jkms.2024.39.e310.
To assess the effectiveness of rescue cerclage concerning pregnancy and neonatal outcomes in women with acute cervical insufficiency (CI) complicated with intra-amniotic inflammation (IAI) compared with those managed expectantly.
This retrospective cohort study included 87 consecutive singleton pregnant women (17-25 weeks) with acute CI who underwent amniocentesis to assess IAI. Amniotic fluid (AF) samples were assayed for interleukin-6 to define IAI (≥ 2.6 ng/mL). Primary and secondary outcomes were assessed in a subset of CI patients with IAI. The primary outcome measures were spontaneous preterm birth (SPTB) at < 28 and < 34 weeks, and the secondary outcomes were interval from sampling to delivery, neonatal survival, neonatal birth weight, and histologic and clinical chorioamnionitis. Macrolide antibiotics were prescribed depending on the type of microorganism isolated from the AF, clinically suspected IAI, and the discretion of the attending clinician.
IAI was identified in 65.5% (57/87) of patients with CI, of whom 73.6% (42/57) were treated with macrolide antibiotics. Among the CI patients with IAI (n = 57), 40 underwent rescue cerclage and 17 were expectantly managed. The rates of SPTBs at < 28 and < 34 weeks were significantly lower and the latency period was significantly longer in the cerclage group than in the group that was managed expectantly. The median birth weight and neonatal survival rate were significantly higher in the cerclage group than in the group that was managed expectantly. However, the rates of histologic and clinical chorioamnionitis did not differ between the groups. Multivariable analyses revealed that rescue cerclage placement and administration of macrolide antibiotics were significantly associated with a decrease in SPTBs at < 28 and < 34 weeks, prolonged gestational latency, and increased likelihood of neonatal survival, after adjusting for possible confounding parameters; however, macrolide antibiotic administration did not reach statistical significance with respect to SPTB at < 34 weeks and neonatal survival ( = 0.076 and 0.063, respectively).
Rescue cerclage along with macrolide antibiotic treatment may positively impact pregnancy and neonatal outcomes in women with CI complicated by IAI, compared with expectant management. These findings suggest the benefit of cerclage placement even in patients with CI complicated by IAI.
评估急性宫颈功能不全（CI）合并羊膜腔内炎症（IAI）孕妇行紧急宫颈环扎术（rescue cerclage）与期待治疗妊娠结局和新生儿结局的有效性。
本回顾性队列研究纳入了 87 例因急性 CI 行羊膜腔穿刺术评估 IAI 的单胎妊娠孕妇（17-25 周）。采用白细胞介素-6 检测羊膜腔液（AF）以定义 IAI（≥ 2.6ng/mL）。对部分合并 IAI 的 CI 患者进行主要和次要结局评估。主要结局测量指标为<28 周和<34 周的自发性早产（SPTB），次要结局为从采样到分娩的时间间隔、新生儿存活率、新生儿出生体重、组织学和临床绒毛膜羊膜炎。根据从 AF 中分离的微生物类型、临床疑似 IAI 和主治医生的判断，开具大环内酯类抗生素。
在 87 例 CI 患者中，65.5%（57/87）存在 IAI，其中 73.6%（42/57）接受了大环内酯类抗生素治疗。在合并 IAI 的 CI 患者（n=57）中，40 例行紧急宫颈环扎术，17 例接受期待治疗。与期待治疗组相比，紧急宫颈环扎组<28 周和<34 周的 SPTB 发生率显著降低，潜伏期显著延长。紧急宫颈环扎组的中位出生体重和新生儿存活率均显著高于期待治疗组。然而，两组的组织学和临床绒毛膜羊膜炎发生率无差异。多变量分析显示，在调整可能的混杂参数后，紧急宫颈环扎术和大环内酯类抗生素的应用与降低<28 周和<34 周的 SPTB、延长妊娠潜伏期和提高新生儿存活率显著相关；然而，大环内酯类抗生素的应用与<34 周的 SPTB 和新生儿存活率无统计学意义（=0.076 和 0.063）。
与期待治疗相比，紧急宫颈环扎术联合大环内酯类抗生素治疗可能对急性 CI 合并 IAI 孕妇的妊娠结局和新生儿结局产生积极影响。这些发现提示即使在 CI 合并 IAI 的患者中，行紧急宫颈环扎术也有益。
