J. Perinat. Med. 2015; 43(4): 493–494
Letter to the Editor Monika Dräger*
A cerclage is not a modified total cervical occlusion! Keywords: Cerclage; cervical occlusion; early total cervix occlusion (ETCO); terminology. DOI 10.1515/jpm-2014-0099 Received March 24, 2014. Accepted April 3, 2014. Previously published online May 15, 2014.
Dear Sir, We have read with interest the article about the modified Shirodkar cerclage by Skupski et al. [12] in which the authors wrote that their procedure “… was a modification of the ‘early total cervical occlusion’ (ETCO) procedure originally proposed by Saling [5, 6]”. Although we appreciate that the authors apparently have been inspired by the work of Prof. Saling, we would like to point out that for a total occlusion, the upper surface of the portio has to be dissected, that is to say, the epithelium has to be completely removed. Otherwise, the tissue cannot grow together and the cervix is not completely occluded (which is the prerequisite for the safest possible prevention of the ascension of microorganisms). For more details, please see our links below. At least the authors did not call in the title of their article their procedure an “occlusion”, as others have unfortunately done. For example, the study group around Secher performed a so-called “cervical occlusion trial”. However, their so-called occlusion was just a tight cerclage and the results have been so poor that they stopped the trial before completion [1, 10, 11]. We have not been too surprised about this because – as the name “micro-organism” indicates – microorganism can still pass through a cervical canal, which is not completely occluded. It is scientifically unacceptable, if a procedure, which is not a total occlusion, is said to be so. Therefore, we have to ask doctors Skupski et al. [12] (as well as any other authors of scientific articles)
*Corresponding author: Dr. med. Monika Dräger, MD, Erich Saling Institute of Perinatal Medicine, Vivantes Clinics Berlin Neukölln, Rudower Str. 48, D-12351 Berlin (Neukoelln), Germany, Tel.: +49-30-13014-8334, Fax: +49-30-6254087, E-mail: [email protected], URL: http://www.saling-institut.de
to keep the terminology straight: a cerclage – may it be very tight, very high, or whatsoever – is not a “modified total cervical occlusion”. With their modified Shirodkar cerclage, Skupski et al.[12] achieved good results, and they are proposing a randomized trial. We are convinced that the results with the “proper” ETCO might be even better. Why not be inspired again by Prof. Saling’s work and include in the trial a third arm (with a “proper” occlusion) into the study? The ETCO is performed in German-speaking countries widely and with good success [2–4, 7–9, 13]. Even with a “late” occlusion (later in pregnancy or with already shortened cervix) or as an emergency measure (for example in cases with amniotic sac prolapse), good results have been achieved with the total cervical occlusion [4].
More information –– Information about the (early) total cervix occlusion (including a video): http://www.saling-institut.de/ eng/04infoph/04tmv.html. –– List of units in which the total cervix occlusion is performed: http://www.saling-institut.de/ german/06contact/04clin.html).
References [1] Brix N, Secher NJ, McCormack CD, Helmig RB, Hein M, Weber T, et al. Randomised trial of cervical cerclage, with and without occlusion, for the prevention of preterm birth in women suspected for cervical insufficiency. Br J Obstet Gynaecol. 2013;120:613–20. [2] Garnier Y, Gantert M, Schneider J, Valter M, Mallmann P. Kölner Interventionsstudie zur Frühgeburtenprävention bei anamnestisch hohem Risiko für Früh- und Fehlgeburten. Kongressbeitrag. Geburtsh Frauenheilk. 2007;68:FV1_2. [3] Hormel K, Künzel W. Der totale Muttermundverschluß. Prävention von Spätaborten und Frühgeburten. [Total occlusion of the uterine cervix. Prevention of late abortion and premature labor]. Gynäkologe. 1995;28:181–6. Ger. [4] Ramsauer B. Spätabort und extreme Frühgeburt, mechanische Eingriffe zur Prävention. Der Gynäkologe. 2012;45:527–32.
Unauthenticated Download Date | 6/27/16 7:57 AM
494 Dräger, A cerclage is not a modified total cervical occlusion! [5] Saling E. Der frühe totale Muttermundverschluß zur Vermeidung habitueller Aborte und Frühgeburten. [Early total occlusion of os uteri to prevent habitual abortion and premature deliveries]. Z Geburtsh Perinat. 1981;185:259–61. Ger. [6] Saling E. Prevention of habitual abortion and prematurity by early total occlusion of the external os uteri. Eur J Obstet Gynecol Reprod Biol. 1984;17:165–70. [7] Saling E, Dräger M. Infection related recurrent late abortions and preterm birth: early total cervix occlusion (ETCO) versus cerclage. In: Canfield RN, editor. Infectious pregnancy complications. New York: Nova Science Publishers; 2009. p. 83–109. ISBN: 978-1-60471-038-6. [8] Saling E, Schumacher E. Der operative totale Muttermundverschluß (TMV). Erhebung von Daten einiger Kliniken, die den TMV einsetzen. [Total surgical cervical occlusion. Conclusions from data of several clinica, which use total surgical cervical occlusion]. Z Geburtsh Neonatol. 1996;200:82–7. Ger. [9] Schulze G. Ergebnisse des frühen totalen Muttermundverschlusses nach Saling (FTMV) bei Mehrlingsschwangerschaften – eine
[10]
[11]
[12]
[13]
retrospektive Studie der Jahre 1995–2005. [Results of early total cervix occlusion (ETCO) according to Saling in multiple pregnancies – a retrospective study of the period 1995 to 2005]. Z Geburtsh Neonatol. 2008;212:13–7. Ger. Secher NJ, McCormack CD. The cervical occlusion trial, a randomized controlled trial, 2011. (Accessed February 20, 2012, at http://www.cervicalocclusion.com/index.html.). Secher NJ, McCormack CD, Weber T, Hein M, Helmig RB. Cervical occlusion in women with cervical insufficiency: protocol for a randomised, controlled trial with cerclage, with and without cervical occlusion. Br J Obstet Gynaecol. 2007;114:649, e1–6. Eng. Skupski DW, Lin SN, Reiss J, Eglinton GS. Extremely short cervix in the second trimester: bed rest or modified Shirodkar cerclage? J Perinat Med. 2014;42:55–9. Vetter K, Kilavuz Ö. Zervixinsuffizienz: operative Möglichkeiten. Gynäkologe. 2001;34:726–31. Ger.
The authors stated that there are no conflicts of interest regarding the publication of this article.
Unauthenticated Download Date | 6/27/16 7:57 AM
Letter to the Editor Monika Dräger*
A cerclage is not a modified total cervical occlusion! Keywords: Cerclage; cervical occlusion; early total cervix occlusion (ETCO); terminology. DOI 10.1515/jpm-2014-0099 Received March 24, 2014. Accepted April 3, 2014. Previously published online May 15, 2014.
Dear Sir, We have read with interest the article about the modified Shirodkar cerclage by Skupski et al. [12] in which the authors wrote that their procedure “… was a modification of the ‘early total cervical occlusion’ (ETCO) procedure originally proposed by Saling [5, 6]”. Although we appreciate that the authors apparently have been inspired by the work of Prof. Saling, we would like to point out that for a total occlusion, the upper surface of the portio has to be dissected, that is to say, the epithelium has to be completely removed. Otherwise, the tissue cannot grow together and the cervix is not completely occluded (which is the prerequisite for the safest possible prevention of the ascension of microorganisms). For more details, please see our links below. At least the authors did not call in the title of their article their procedure an “occlusion”, as others have unfortunately done. For example, the study group around Secher performed a so-called “cervical occlusion trial”. However, their so-called occlusion was just a tight cerclage and the results have been so poor that they stopped the trial before completion [1, 10, 11]. We have not been too surprised about this because – as the name “micro-organism” indicates – microorganism can still pass through a cervical canal, which is not completely occluded. It is scientifically unacceptable, if a procedure, which is not a total occlusion, is said to be so. Therefore, we have to ask doctors Skupski et al. [12] (as well as any other authors of scientific articles)
*Corresponding author: Dr. med. Monika Dräger, MD, Erich Saling Institute of Perinatal Medicine, Vivantes Clinics Berlin Neukölln, Rudower Str. 48, D-12351 Berlin (Neukoelln), Germany, Tel.: +49-30-13014-8334, Fax: +49-30-6254087, E-mail: [email protected], URL: http://www.saling-institut.de
to keep the terminology straight: a cerclage – may it be very tight, very high, or whatsoever – is not a “modified total cervical occlusion”. With their modified Shirodkar cerclage, Skupski et al.[12] achieved good results, and they are proposing a randomized trial. We are convinced that the results with the “proper” ETCO might be even better. Why not be inspired again by Prof. Saling’s work and include in the trial a third arm (with a “proper” occlusion) into the study? The ETCO is performed in German-speaking countries widely and with good success [2–4, 7–9, 13]. Even with a “late” occlusion (later in pregnancy or with already shortened cervix) or as an emergency measure (for example in cases with amniotic sac prolapse), good results have been achieved with the total cervical occlusion [4].
More information –– Information about the (early) total cervix occlusion (including a video): http://www.saling-institut.de/ eng/04infoph/04tmv.html. –– List of units in which the total cervix occlusion is performed: http://www.saling-institut.de/ german/06contact/04clin.html).
References [1] Brix N, Secher NJ, McCormack CD, Helmig RB, Hein M, Weber T, et al. Randomised trial of cervical cerclage, with and without occlusion, for the prevention of preterm birth in women suspected for cervical insufficiency. Br J Obstet Gynaecol. 2013;120:613–20. [2] Garnier Y, Gantert M, Schneider J, Valter M, Mallmann P. Kölner Interventionsstudie zur Frühgeburtenprävention bei anamnestisch hohem Risiko für Früh- und Fehlgeburten. Kongressbeitrag. Geburtsh Frauenheilk. 2007;68:FV1_2. [3] Hormel K, Künzel W. Der totale Muttermundverschluß. Prävention von Spätaborten und Frühgeburten. [Total occlusion of the uterine cervix. Prevention of late abortion and premature labor]. Gynäkologe. 1995;28:181–6. Ger. [4] Ramsauer B. Spätabort und extreme Frühgeburt, mechanische Eingriffe zur Prävention. Der Gynäkologe. 2012;45:527–32.
Unauthenticated Download Date | 6/27/16 7:57 AM
494 Dräger, A cerclage is not a modified total cervical occlusion! [5] Saling E. Der frühe totale Muttermundverschluß zur Vermeidung habitueller Aborte und Frühgeburten. [Early total occlusion of os uteri to prevent habitual abortion and premature deliveries]. Z Geburtsh Perinat. 1981;185:259–61. Ger. [6] Saling E. Prevention of habitual abortion and prematurity by early total occlusion of the external os uteri. Eur J Obstet Gynecol Reprod Biol. 1984;17:165–70. [7] Saling E, Dräger M. Infection related recurrent late abortions and preterm birth: early total cervix occlusion (ETCO) versus cerclage. In: Canfield RN, editor. Infectious pregnancy complications. New York: Nova Science Publishers; 2009. p. 83–109. ISBN: 978-1-60471-038-6. [8] Saling E, Schumacher E. Der operative totale Muttermundverschluß (TMV). Erhebung von Daten einiger Kliniken, die den TMV einsetzen. [Total surgical cervical occlusion. Conclusions from data of several clinica, which use total surgical cervical occlusion]. Z Geburtsh Neonatol. 1996;200:82–7. Ger. [9] Schulze G. Ergebnisse des frühen totalen Muttermundverschlusses nach Saling (FTMV) bei Mehrlingsschwangerschaften – eine
[10]
[11]
[12]
[13]
retrospektive Studie der Jahre 1995–2005. [Results of early total cervix occlusion (ETCO) according to Saling in multiple pregnancies – a retrospective study of the period 1995 to 2005]. Z Geburtsh Neonatol. 2008;212:13–7. Ger. Secher NJ, McCormack CD. The cervical occlusion trial, a randomized controlled trial, 2011. (Accessed February 20, 2012, at http://www.cervicalocclusion.com/index.html.). Secher NJ, McCormack CD, Weber T, Hein M, Helmig RB. Cervical occlusion in women with cervical insufficiency: protocol for a randomised, controlled trial with cerclage, with and without cervical occlusion. Br J Obstet Gynaecol. 2007;114:649, e1–6. Eng. Skupski DW, Lin SN, Reiss J, Eglinton GS. Extremely short cervix in the second trimester: bed rest or modified Shirodkar cerclage? J Perinat Med. 2014;42:55–9. Vetter K, Kilavuz Ö. Zervixinsuffizienz: operative Möglichkeiten. Gynäkologe. 2001;34:726–31. Ger.
The authors stated that there are no conflicts of interest regarding the publication of this article.
Unauthenticated Download Date | 6/27/16 7:57 AM
