Taiwanese Journal of Obstetrics & Gynecology 53 (2014) 382e384

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Taiwanese Journal of Obstetrics & Gynecology

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Short Communication

Effectiveness of delayed absorbable monofilament suture in

emergency cerclage
Takashi Yorifuji*, Shintaro Makino, Yuka Yamamoto, Toshitaka Tanaka, Atsuo Itakura,
Satoru Takeda
Department of Obstetrics and Gynecology, Juntendo University, Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To determine the sustained effects of emergency cerclage using slowly absorbable mono-
Accepted 7 April 2014 filament sutures, changes in cervical length after cerclage were evaluated in six cases.
Materials and methods: A delayed absorbable monofilament suture (1 PDS-Plus; Ethicon, Inc., Somerville,
Keywords: NJ, USA) has been used for emergency cerclage after 20 weeks of gestation at Juntendo University
absorbable monofilament suture Hospital since January 2011. A retrospective chart review was conducted including all of the patients
double cerclage
undergoing emergency cerclage between January 2011 and August 2013. The patients' characteristics,
emergency cerclage
perinatal outcome, cervical length, and obstetric data were collected.
McDonald cerclage
PDS Plus
Results: Six cases were identified from our medical records. Their characteristics and perinatal outcomes
are shown in Table 1. Of the six cases, four had an extremely short cervix, with an average cervical length
of 7.85 ± 3.38 mm, and two had prolapsed membranes. Fig. 1 shows the cervical length and the time
elapsed after cerclage. There were no cases with shortening of the cervical length below the levels at the
cerclage.
Conclusion: This absorbable monofilament suture appears useful for emergency cerclage.
Copyright © 2014, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All
rights reserved.

Introduction systematic review revealed that emergency cerclage is also asso-

ciated with a longer latency period compared with bed rest alone
Cervical cerclage is a surgical procedure that is carried out [4]. Although emergency cerclage, under ideal circumstances, can
during pregnancy to position a suture around the neck of the cer- significantly prolong pregnancy and increase the chance of a viable
vix. The cervix sometimes starts to shorten and dilate too early, pregnancy outcome [5], this rescue procedure may increase the risk
causing either late miscarriage or preterm birth. In the absence of of chorioamnionitis, with the associated risk of foetal inflammatory
uterine contractions, the cause of this pathological condition is brain injury [6]. Reduction of chorioamnionitis after emergency
considered to be cervical insufficiency. To prevent miscarriage or cerclage would contribute to reducing fetal morbidity associated
preterm birth, cervical cerclage has been used for pregnant women with fetal inflammatory response syndrome, as well as miscarriage
with a high risk for preterm labor or miscarriage [1] with emer- or preterm birth. Nonabsorbable braided sutures or woven tapes
gency cerclage performed for women with imminent risk. How- have been widely used for cerclage [7]. Monofilament macro-
ever, the efficacy of cerclage for reducing poor pregnancy outcomes porous polypropylene has been reported to be an appropriate
has long been controversial [2]. A recent meta-analysis identified material for transvaginal surgery [8]. However, the prosthetic ma-
that cerclage significantly prevented preterm birth with a prior terial may cause infection following cerclage with a nonabsorbable
preterm birth and a short cervix [3]. Subsequently, the latest polypropylene tape [9]. In addition, whether the tension of slowly
absorbable suture is maintained in this procedure until term is
uncertain. To determine the sustained effects of emergency cerc-
lage using slowly absorbable monofilament sutures for prevention
* Corresponding author. Department of Obstetrics and Gynecology, Juntendo
University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan. of preterm labor, changes in cervical length after cerclage were
E-mail address: [email protected] (T. Yorifuji). investigated in six cases.

http://dx.doi.org/10.1016/j.tjog.2014.04.023
1028-4559/Copyright © 2014, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
 T. Yorifuji et al. / Taiwanese Journal of Obstetrics & Gynecology 53 (2014) 382e384 383

Materials and methods

A delayed absorbable monofilament suture (1 PDS-Plus; Ethi-

con, Inc., Somerville, NJ, USA) has been used for emergency cerc-
lages after 20 weeks of gestation at Juntendo University Hospital
since January 2011. A retrospective chart review was conducted
including all of the patients undergoing emergency cerclage be-
tween January 2011 and August 2013. The patients' characteristics,
perinatal outcome, cervical length, and obstetric data were
collected. These cases in which cerclage was performed were all
singleton pregnancies with no past history of conisation, previous
preterm birth, exposure to diethylstilbestrol in utero, or uterine
anomaly. All cases had been followed up regularly, and no abnor-
malities were identified at prior examinations. The indications for
the emergency cerclage were sharp decline of cervical length
10 mm or prolapsed membranes after 20 weeks of gestation.
Cases of bacterial cervicitis that were elastase-positive or clinical
chorioamnionitis were excluded. All cases in this series were Fig. 1. Cervical length and time elapsed between immediately before and after
screened for Chlamydia trachomatis as part of routine obstetric care, cerclage.
and none were positive. In addition, no pathogens were found on
bacterial cultures of vaginal specimens at admission. A double
cervical cerclage procedure was performed in addition to McDo- complications, including cervical laceration, were noted. Fig. 1
nald cerclage [10]. After the first stitch was placed and tied, a sec- shows the cervical length and the time elapsed after cerclage.
ond stitch was placed in a similar fashion proximal to the first There were no cases with shortening of the cervical length below
suture, closer to the internal os. At the time of cerclage, 2 g of the levels of the cerclage.
cefazoline sodium and 50 mg/min of ritodrine hydrochloride were
given to all cases, and ritodrine hydrochloride was continued until Discussion
regular contractions ceased. Subsequently, vaginal washing with
insertion of chloramphenicol vaginal tablets was performed for 1 PDS-Plus, which is a monofilament, triclosan-coated, absorbable
week. Cervical length was measured using transvaginal ultraso- surgical suture, retains its tensile strength for a relatively long time.
nography every week after cerclage. Prior to the emergency cerc- This material retains 60% of its original strength for 6 weeks [11]. A
lage, the method of the cerclage was carefully explained, as was the PubMed search for reports published using the search terms
risk for cervical laceration, and informed consent was obtained in “McDonald cerclage” and “absorbable sutures” identified only one
every case. No ethical approval was required for this study since it report. Abdelhak et al [12] reported that McDonald cerclage using
was a retrospective chart review. delayed absorbable sutures in four cases obtained comparable
outcomes to that with non-absorbable sutures. To the best of our
Results knowledge, this is the first report describing the changes in cervical
length after cerclage using absorbable monofilament sutures. In the
Six cases were identified from our medical records. Their char- current protocol, all six cases prolonged their pregnancies more
acteristics and perinatal outcomes are shown in Table 1. Of the six than 4 weeks and obtained favorable perinatal outcomes without
cases, four had an extremely short cervix, with an average cervical any serious complications.
length of 7.85 ± 3.38 mm, and two had prolapsed membranes. The Because bacteria may be trapped in braided sutures or woven
mean gestational age at cerclage was 23.0 ± 0.9 weeks. The average tapes, monofilament sutures are assumed to be appropriate for
latency period between cerclage and delivery was 13.4 ± 2.1 weeks, transvaginal surgery. Additionally, the triclosan-coated suture de-
which allowed for no infants to be born before 30 weeks. All infants creases surgical site infection [13]. Thus, triclosan-coated sutures
were born weighing over 1.5 kg. Two cases were delivered before are assumed to be suitable for transvaginal cerclage [14]. Because
34 weeks because of preterm premature rupture of the membrane prosthetic material may increase the risk for infection and
(PROM), and four cases were delivered beyond 36 weeks. We inflammation, absorbable suture may also have the advantage of
generally avoid a digital examination of the cervix until Week 37 or prolonging pregnancies. However, wound support by this material
the onset of labor. All cervixes were able to be dilated by a physi- has been reported to be maintained for up to 6 weeks. Figure 1
cian's finger without stitch removal, and no maternal shows the cervical length and the time elapsed after cerclage.

Table 1
Clinical characteristics and outcomes in 6 cases undergoing emergency cerclage.

Case no. Prolapse of Parity Cervical length GA at GA at Mode of Interval from cerclage Indications
membranes at cerclage (mm) cerclage delivery delivery to delivery for CS

1 No 0P 6.7 22w2d 40w3d FD 18w1d

2 No 0P 10 20w5d 33w2d CS 12w4d PROM & breech
presentation
3 No 1P 8 23w1d 37w2d CS 14w1d Repeat CS
4 Yes 1P 0 27w5d 31w5d CS 4w PROM
5 No 1P 7 22w5d 36w6d CS 14w1d Repeat CS
6 Yes 1P 0 21w3d 39w2d ND 17w6d

CS = cesarean section; FD = forceps delivery; GA = gestational age; ND = normal delivery; PROM = preterm premature rupture of membranes.
384 T. Yorifuji et al. / Taiwanese Journal of Obstetrics & Gynecology 53 (2014) 382e384

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Conflicts of interest [10] Tsai YL, Lin YH, Chong KM, Huang LW, Hwang JL, Seow KM. Effectiveness of
double cervical cerclage in women with at least one previous pregnancy loss
The authors have no conflicts of interest relevant to this article. in the second trimester: a randomized controlled trial. J Obstet Gynaecol Res
2009;35:666e71.
[11] Ethicon, part of the Johnson-Johnson Family of Companies. Wound closure,
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