Late miscarriage is defined, classically, as the outcome of pregnancy in its second trimester. According to the French National College of Gynecologists and obstetricians, This is spontaneous expulsion of uterine contents, before 22 weeks of amenorrhea [1]. If World health organization (WHO) evaluate fetal viability at 22 weeks, actual limits of late miscarriage and preterm delivery are variable across regions and medical teams according to equipment to take care of newborns [2].

In contrast to highly medical countries where therapeutic progress has improved the prognosis of these preterm evictions, in sub-Saharan Africa, the mortality and fetal morbidity of these spontaneous miscarriages remain high low-and-middle-income countries record 98% of neonatal deaths [3].

Diagnosis of late miscarriage threat is based by dilation and/or shortening of the cervix in the second trimester of Pregnancy. The risk is an expulsion of the fetus in the absence of urgent and rapid therapeutic management.

Treatment of this threat is intended to delay fetal expulsion if possible to reduce the morbidity-mortality associated with fetal immaturity. Therapeutic possibilities are well known based on symptomatic and causative medicinal means with hospitalization of sometimes long duration [4]. For the threat of miscarriage in the second trimester of pregnancy with an open cervix, we practice in our service a strapping. This technique consists in placing a strip around the cervix to provide mechanical support and thus reduce the risk of premature birth. Cervical strapping is usually done for preventive purposes at the end of the first trimester of Pregnancy. However, efficacy and safety of this procedure in the second trimester of pregnancy remains controversial [5]. Through this study, we would like to report our experience in this therapeutic approach to the threat of miscarriage with an open cervix.

Specific objectives of this study are to describe the epidemic-clinical characteristics of pregnant, appreciate the effectiveness of strapping in the outcome of these pregnancies with a circled cervix. The main objective is to contribute to improving management of these pregnancies at fetal loss risk in a low-income population where longterm hospitalization is at an additional cost at the expense of Pregnancy.

This was a descriptive cohort study conducted from February 2015 to January 2017, or a 2-year period, in the gynecology and obstetrics Department of the Yopougon University Hospital in Abidjan (Côte d’Ivoire). The study concerned the pregnant of a single or twin pregnancy in the second trimester of pregnancy (between 16 and 27 weeks) who were admitted for the threat of miscarriage. Gestational age was calculated from the last menstrual and confirmed by an early ultrasound done in the first trimester of Pregnancy. Patients selected for the study had a gaping cervix with a hernia of the amniotic membranes regardless of the length of the cervix (Figure 1). Not been included, patients with severe maternal pathology that could compromise the evolution of pregnancy such as hypertensive arterial, diabetes, HIV Infection. Cerclage was carried out considering the classical contraindications of the uterine cerclage (absence of amniotic infection, fetal malformation absence, consent of the pregnant). So we retained for the study 11 cases.

Figure 1: Opened cervix with amniotic membrane’s hernia seen in the speculum during diagnosis.

Preparing strapping

Patients were hospitalized immediately after diagnosis confirmed. An obstetric ultrasound by the same operator in order to check fetal morphology, vitality and length of the cervix have been done. An infectious balance sheet (Vaginal swab, CRP, cytobacterioligical urine exam, dipstick urine test, Blood cell count) and a pre-operative assessment (Electrocardiogram, blood crasis) were also required. The patient was kept in a Trendelenburg position. As soon as the results of the negative infectious balance were obtained, strapping was performed.

Strapping procedure

The procedure was performed by the same operator under general anesthesia in Trendelenburg position with antispasmodic infusion (Phoroglucinol) and prophylaxis by 2 g of amoxicillin-acid clavulanic administered in preoperative.

After exposure of the cervix using vaginal valves, its seized with 2 Pozzi pliers, one of which is placed on the anterior lip and the other on the posterior lip, taking care not to transfix the collar for fear of breaking the membranes (Figure 2).

Figure 2: Pozzi pliers on the lips of opened cervix.

Membranes are slowly repressed by a compress moistened with physiological serum mounted on a long clamp (Figure 3).

Figure 3: Amniotic membrane repressed using a physiological serum soaked compress.

While soft traction on the cervix using Pozzi pliers is carried out to cover the repressed membranes, intrafascial basting of the cervix is performed using mersilen strip with a length of 40 cm, 0.5 cm wide, with two needles of 48 mm, curvature 1/2, garter point (reference Ethicon Mersutures ® RS22). The technique used was that of Mac Donald. The knot was made at 12 o'clock, during the gradual removal of the tongue clamp initially introduced into the cervical channel (Figure 4). Intervention ends with the administration in intrarectal of 2 suppositories of Ketoprofen 100 mg extended 48 hours in hospitalization, associated with antispasmodics intravenously.

Figure 4: Closing cervix after removing Pozzi and compress clips, wire knotted at 12 o'clock.

Parameters studied were epidemiological characteristics (maternal age, parity, history of miscarriage or preterm delivery, abortion), Clinical aspects (gestational age at the time of diagnosis, length and cervical dilatation, associated symptomatology), the subsequent evolution of pregnancy (complications and becoming obstetric).

Data were collected from medical records and operated from Excel 2007 and Epi Info 7 software.

Epidemiological aspects

Means age of our patients was 30, 27 years (23-36 years). General data are represented in Table 1.

Table 1: Epidemiological characteristics of patients.

Clinical and therapeutic aspects

These are carried over to Table 2 3/4 of patients (72.7%) had a gestational age between 20 and 25 weeks at the time of diagnosis. Mean gestational age was 20 weeks (17-25 weeks). The average length of the cervix at ultrasound was measured at 22.18 mm (15-31 mm). The opening of the cervix to ultrasound was an average of 15.82 mm (8-24 mm). Mean duration of the intervention was 12.27 minutes (8-20 mm). We did not record any complication during the intervention. Hospitalization of pregnant after strapping lasted on average 3 days (2-7 days).

Table 2: Clinical data.

During the subsequent evolution of pregnancy, 3 pregnant (27.3%) exhibited premature rupture of membranes respectively at 31 weeks+5 days, 33 weeks+4 days and at 34 weeks, which necessitated a second hospitalization. For these 3 patients, corticotherapy for fetal pulmonary maturation with 12 mg of Betamethasone, antibiotic (Cefuroxime) have been administered. For membranes ruptures occurring between 33 and 34 weeks, fetal extraction was performed after 48 hours. The third patient with a gestational age of 31 weeks+5 days presented chorioamnionitis. Emergency cesarean section has been done. Mean gestational age at delivery was 36 weeks (31 weeks+5 days-38 weeks).

The average time between strapping and childbirth was 115 days or 15 weeks. Three children were born with a score of Apgar in the 1st minute less than 7 which improved in the 10^th minute except the great premature born in 31 weeks+5 days. He was admitted to neonatology service where stayed for 15 days for a neonatal infection. Evolution was marked by healing.

Epidemiological characteristics

There was mainly young pregnant, second pregnant and primiparous or nulliparous with a history of abortion, late miscarriage or premature delivery. According to the Royal College of Obstetricians and Gynecologists, the history of late miscarriage or preterm births is a medium or high-risk factor for the threat of miscarriage [6]. Delabaere A., [7] and Benifla JL., [8] in France reported 13 and 19% of late miscarriage in their series, respectively. 27.3% of the history of late miscarriage are higher than those of these authors. This difference may be related to the high proportion of abortion in our population, which weakens cervix. The average age of pregnancy during strapping was 20 weeks, while, respectively for Benifla JL and Daskalakis G, a mean was 22 weeks,1 day and 24 weeks, 4 days [8,9].

Strapping preparation

Recommendations of french gynecologist college in 2002 suggest waiting 48 hours after diagnosis of cervical incompetence before making cerclage to eliminate an infectious etiology and exclude premature childbirth [10]. Delabaere A. showed that in absence of uterine contraction and inflammatory syndrome, waiting 48 hours did not improve the perinatal prognosis significantly compared to a strapping immediately [7].

Therapeutic aspects

Cervical strapping can be done under loco-regional or general anesthesia according to two main techniques with or without colpotomy. The first technique described was Shirodkar, in which, after an anterior and posterior vertical colpotomy, the test strip was passed through cervix under the vaginal mucosa and colpotomy were closed [11]. MacDonald proposed another technique to pass strip in the cervix circumferentially without reaching endocervix and without colpotomy. For all our patients, general anesthesia was practiced and Mac Donald cerclage technique used.

We prefer it to Shirokar’s technique because of its simplicity and speedy. Perrattan F and his team [5] prefer the Shirodkar type without however concluding superiority of one technique compared to other.

In our series, intervention lasted on average 12.27 minutes with a minimum of 8 minutes and a maximum of 20 minutes. Perrattan F., [5] reported an average intervention time of 39 +/-13 minutes. Different operating techniques according to the teams could explain the variations of the operating times. Indeed, Perrattan uses the technique of Shirodkar longer to realize than that of Mc Donald that we have practiced.

Following pregnancy

Long-term operating suites were marked by a new hospitalization due to premature membrane rupture in 27.3% of our patients. This complication (MPR) occurred with the same proportions in the Cockwell HA study [12]. The rupture of the membranes is linked to a chorioamnionitis. MPR is often a consequence of chorioamnionitis and not its cause [13]. The occurrence of MPR and/or chorioamnionitis, cerclage more than 22 weeks with fetal membranes prolapsed had compromised pregnancy better evolution [14].

According to Yip SK., [15], there is a significant correlation between the better continuation of the pregnancy and moment of cerclage. When this is done at 22 weeks or more than, pregnancy is extended by 13.5 days while it is extended by 122 days when it had been done more early.

For Alfirevic Z., [14] in a Cochrane review more recent than YIP study [15], performing an emergency strapping whatever term in the second trimester prolongs pregnancy on average from four to five weeks so, a reduction of the preterm birth before 34 weeks. Daskalakis G., [9] Also noted an average pregnancy extension of 8.8 weeks. Althuisius SM., [16] and Cockwell HA., [12] reported a benefit of 7.7 weeks and 7 weeks of extension of pregnancy after, respectively. So emergency strapping significantly prolongs pregnancy and improves fetal outcome. In our series, we have an average extension of 115 days or 15 weeks. The risk of failure is highest for cervical dilatation more than 4 cm or if the greatest membranes a hernia in vagina [17].

Neonatal prognosis

It was generally good in our series because the age of births was most cases after 34 weeks, period of acquired pulmonary maturation. This would limit risks of prematurity by pulmonary immaturity. Bénifla JL recorded two neonatal losses [8] in her study. However, since it was carried out in 1997, neonatal resuscitation was certainly less efficient than it was now.

In a meta-analysis including 12 trials involving 3328 patients and comparing strapping to long-term hospitalization, Alfirevic Z., did not find any statistically significant difference in perinatal mortality (8.4% versus 10.7%). He, therefore, concluded that cervical strapping reduces the incidence of preterm births in women at risk of preterm delivery without statistically significant reduction of perinatal or neonatal morbidity [14]. Few studies have been done about possible long-term complications.

We can conclude that an emergency cervical cerclage is an interesting option for patients who have a threat of late miscarriage (opened cervix, fetal membranes a hernia) in the second trimester of pregnancy. This late emergency strapping prolongs pregnancy and decreases preterm births risk, which is difficult to take care of in limited-resource countries such as Côte d'Ivoire. We think that this therapeutic approach deserves to be encouraged.