1st order.
Surgical therapy is controversial from both prophylactic and therapeutic points of view, as the benefit has not yet been proven beyond doubt. Operative options include:
- Cerclage (cervical wrap, surgical method to keep a prematurely opening cervix still closed); indication:
- Women with singleton pregnancy after previous spontaneous preterm delivery or late abortion whose vaginal sonographic cervical length <25 mm → significant reduction in the rate of late abortion (miscarriage in the period from the 13th to the 24th week of gestation) and extreme preterm delivery evidenced in the cerclage group.
- Total cervical closure (TMMV) (according to Saling) – procedure for the primary prevention of preterm delivery or late abortion in the case of a stressed anamnesis; the current S2k guideline gives the following recommendation: “For women with singleton pregnancy after previous preterm delivery or late abortion(s), there is evidence that the installation of a TMMV can reduce the rate of preterm delivery”.
Note: The S2k guideline recommends preoperative microbial diagnosis and perioperative antibiotic administration.
Further notes
- For premature rupture of membranes at 34 to 36 weeks’ gestation (SSW) plus six days: the Preterm Prelabour Rupture Of Membranes near Term (PPROMT) trial shows advantages for waiting (versus delivery):
- Neonatal sepsis (systemic infection of the newborn, colloquially known as blood poisoning; primary study endpoint): no significant difference (3% under wait vs. 2% with delivery)
- Respiratory distress syndrome (5% vs. 8% with delivery).
- Mechanical ventilation (9% while waiting vs. 12% at delivery); infants delivered immediately were in the NICU longer on average (2 vs. 4 days)
- Antepartum or intrapartum (before and during delivery) hemorrhage (5% under wait vs. 3% during delivery)
- Maternal fever (2% under wait vs. 1% at delivery); had to stay longer in hospital (6 vs. 5 days)
Notes on the birth
- Late cord cutting may reduce brain hemorrhage and transfusion in preterm birth. However, cord-stripping should be avoided, especially before 28 weeks’ gestation, because it has been described to increase cerebral hemorrhage.
- With a fetal birth weight less than 1,500 g and cranial position, there is no benefit for a Sectio caesarea (cesarean section).
