EVALUATION OF PREGNANCY OUTCOME FOLLOWING ENCERCLAGE OPERATION USING USG & SCORING SYSTEM
                     EVALUATION OF PREGNANCY OUTCOME FOLLOWING 
·ENCERCLAGE OPERATION USING USG & SCORING SYSTEM 
By 
SUVARNA S. KHADILKAR, J . A. LOPEZ, C. N. PURANDARE AND K. K. DESHMUKH 
SUMMARY 
The current awareness of cervkal incompetence as a !POtential 
cause for recurrent p;egnancy losses dates to 1940's, though the 
problem was merely rediscovered and publicised in that decade. 
Diagnosis can be made only by exclusion, as there is no certain 
method to diagnose incompetent os. During pregnancy, ultra-
sonography is one of the most important investigative method for 
diagnosis of the condition. The diagnostic and prognostic system of 
Block and Rahhal is another valuable tool in the diagnosis of in-
competent os. In this study 100 cases of cervical encerclage opera4 
tions were analysed. 
Introduct-ion according to the scoring system of Block 
and Rahhal and USG diagnosis. 
The incompetent cervix as a cause of 
second trimester abortion and premature Observation 
labour has attracted much attention 
Age: Maximum number of cases was 
from obstetric fraternity over the past 
in age group of 21-30 years (83%), while 
25 years. Today, encerclage operations 
cnly 3 cases were above 30 years of age. 
offer a ray t'f hope to women previously 
denied children because of incompetent 
Obstetric History 
(ervix. 
Total number of pregnancies was 318 in 
Mate1'ial and Methods 100 patients, prior to cerclage and foetal 
survival was 150 i.e. 47;/(, foetal wastage 
A study on pregnancy outcome of 100 v1as 168 i.e. 52.9% . 
cases of cervical encerclage operations Thirty seven patients gave h/o D & C 
was carried out in Department of Obste- done in past, two patients gave h/o 1st 
trics and Gynaecology, Grant Medical trimester MTP. One patient was a diag-
College, for period of one year. nosed case of double uterus and two 
McDonald's method of encerclage was patients gave h / o Fothergill's operation. 
carried out in 85 cases, Shirodkar's in 14 
cases and Wurm's technique in one case. Score Distribution of the Patients 
The pregnancy outcome was evaluated 
Patients were scored according to 
Accepted for publication 011 9-10-87. scoring system of Block and Rahhal r 
i 
"EVALUATION OF' PREGNANCY OUTCOME 19 
(1976). They considered following Routine laboratory and cytological in-
points for diagnosis of a case of incom- vestigations were carried out in all pati-
petent os: ents, while ultrasonography for diameter 
Previous premature deliveries or mid- of internal os was carried out in 48 of 
trimester abortion wtihout obvious the 100 cases. All patients had diameter 
cause, visual evidence of previous surgi- of 14 mm or more and all except one 
cal or obstetric trauma to the cervix, went to term. As shown in Table III 
history of painless premature labour and evaluation of the cases by Block and 
short labour, progressive dilatation and Rahhal scoring system justified tighten-
dilatation greater than two ems on initial ing of the incompetent cervices as diag-
examination, previous diagnosis of cervi- nosed by USG. 
cal incompetence with previous cerclage. 
TABLE III 
Each of the above criteria is given a 
Pregnancy Outcome in 100 Cases of Cervical 
:;core of one. Usually greater the score Encerlage 
the more accurate the diagnosis of in-
competent os. As seen in Table I, 47 Outcome No. of 
patients had scores of 3 or more, 53 pati- case9 
ents had 2 or less. Abortions 4 
Preterm Normal Deliveries 18 
TABLE [ Preterm still births 2 
Score Distribution of the Patients Full term normal deliveries 58 
Full term still births 1 
Score Number of cases Full term Breech delivery 1 
Full term LSCS 13 
0 5 Full term forceps 3 
1 22 
2 26 
3 35 
Pregnancy Out-come 
4 12 
5 00 I 
As seen in Table IV, 76 patients went 
to term. Twenty patients had preterm 
Gestatio-nal Age at the Time of Cerclage deliveries while 4 patients aborted. 
Arcuate uterus was detected in one case 
As observed in Table II maximum at the time of LSCS. 
cases were operated upon around 16 Cushner (1963), Seppala and Vera 
weeks of gestation. (1971) realised the need for standardiza-
TABLE ll tion in selection of patients however, it 
was Block .md Rahhal (1976) who in-
Stage of No. of Stage of No. of troduced the diagnostic and prognostic 
gestation cases gestation cases scoring sy:::tem based on clinical findings 
in weeks in weeks 
and obstetric History. 
Abortions 00 24 14 Success Rates: Table V shows that 
14 16 '26 06 success rates rose significantly in present 
16 27 28 07 study as well as that of various authors 
18 06 30 01 after encerclage operation. Success rat~ 
20 13 32 01 in this series rose from 17.5% to 86.0% 
22 09 
and there was a decline in foetal wastage 
.. 
20 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA ' 
TABLE IV 
USG Findings in 48 Patients 
Diameter of No. of 
interval os in cases Score Outcome 
mm. 
20 4 3 4 FTND 
18 4 3 4 FTND 
17 8 2 1 FTLSCS 
3 7 FTND 
16 4 3 4 FTND 
15 16 3 1 FTLSCS 
3 1 PRND 
3 14 FTND 
14 12 3 10 FTND 
2 1 PRND (died) 
TABLE VI J 
Success Rates of the Different Series 
Success rates 
Name and Year of Series No. ~ases 
Before After 
Cerclage Cerclage 
------------------------------------------------------
Barter, 1958 110 11.0% 76.0% 
Gans, 1966 250 13 .Oo/a 82 .0 % 
Seppala, 1971 125 83.0% 
Lauersen, 1973 143 83.09' 
Kuhn, 1977 248 28 . Oo/o 81.0% 
Block, 1976 31 21.0% 80.0% 
Menjoge and Vijayker, 1979 40 8 . 1% 87.5% 
Harger 1980 251 17 .5% 81.0'}0 
Present series 100 23.0% 86.0% l 
after cerclage operations, from 82.7% to TABLE VII 
14.0% . Foetal Salvage Ratios by Various Authors 
Low birth weight played a major role 
in 7 of the 10 perinatal losses. In pre- Foetal 
sent study, the incidence of preterm Author salvage 
births was 15% in the indicated group ratio 
% 
(scores > 3) whereas it was 28.6% in 
Prophylactic group (scores < 3). 
Easterdy 1959 5.9 
Foetal salvage ration in present study Barter, 1958 6 .9 
and that of other authors is shows in Seppala et al 1971 2.7 
Table VI. Menjoge and Vijaykar report- Merk S. Robboy, 1973 2.7 
Block and Rahhal, 1976 3 . 8 
ed best salvage ratio as the majority of 
Menjoge and Vijaykar, 1979 10. 9:> 
the patients had score of 3 or more. In Present study 4 .91 
present study, foetal salvage ratio in in-
EVALUATION OF PREGNANCY OUTCOME 21 
dicated group (scores > 3) was 6.45% nancy loss. Its empirical use may obscure 
whereas in prophylactic group (scores the other important causes of recurrent 
< 3) it was 2.78%. pregnancy loss and thus it should be pre-
Ultrasound scanning is an objective ceded by comprehensive diagnostic evalu-
method of an early diagnosis of income- ation. 
petent os, and may enable the patient to 
save a wanted pregnancy. References 
Mehran (1980) stated that if measured 
1. Barter, R. H., Dusbabek, J. A., Riva, H. L. 
diameter was 15 nun during 1st trimester and Parks, J.: Am. J. Obstet. Gynec. 75: 
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our study, cerclage was beneficial to al- 1976. 
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882, 1963. 
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