Kurdistan Regional Government-Iraq Presidency of Ministerial Council Ministry of higher education University of Sulaimani School of Medicine

Risk Scoring To Predict Preterm Birth Before 34 Weeks in Women Receiving Cervical Cerclage A Thesis Submitted to the Council of the School of Medicine at the University of Sulaimani, In partial fulfillment of the requirements for the degree of High Diploma in Obstetrics and Gynecology

BY Media Raoof Abdullah M.B.Ch.B

Supervised by Assistant professor Dr. Chro N Fattah Head of department (Obstetrics & Gynecology) Faculty of Medicine, University of Sulaimani (MBCHB, DGO, MRCPI, MRCOG, MD)

Dedication: This thesis dedicated to  My parents, brothers and sisters.  My faithful husband.  My children, Huda and Mohammed.  All my teachers especially my supervisor.  All my friends who helped me in this study.  Everyone who regards science.

Acknowledgments I would like to express special thanks to my supervisor Dr.Chro Fattah assistant professor In obstetrics and gynecology at university of Sulaimani for her careful, notes & valuable suggestion. I would like to express special thanks to my husband for his help and support. Special thanks for all women who are involved in this study and everyone who helps me in conducting this study.

LIST OF CONTENTS Dedication……………………………………………………………. i Acknowledgments…………………………………………………… ii List of contents………………………………………………………. iii List of tables…………………………………………………………. iv List of abbreviations…………………………………………………. v Abstract……………………………………………………………….1 Introduction…………………………………………………………...2 Definition and incidence of preterm birth……………………………2 Prediction of preterm labor and preterm birth……………………….2 Primary risk factors…………………………………………………..3 Secondary risk factor………………………………………………....6 Risk scoring………………………………………………………...…11 Prevention of preterm Birth………………………………………...…12 Cervical incompetence………………………………………………..12 Aim of the study……………………………………………………..18 Patient and methods………………………………………………....19 Results…………………………………………………………….…21 Discussion…………………………………………………………....29 Conclusion…………………………………………………………...32 Limitations…………………………………………………………..33 Recommendations…………………………………………………...34 References…………………………………………………………...35

List of abbreviations

APH

antepartum haemorrhage

B-hCG

beta-human chorionic gonadotrophin

BV

bacterial vaginosis

CI

coefficient interval

D&C

dilatation and curretage

LB

live birth

ND

neonatal death

SD

standard deviation

RPOC

retained product of conception

MOD

mode of delivery

GD

gestational diabetis

Ht

hypertension

OR

odds ratio

PTB

preterm birth

WHO

World Health Organization

List of tables Table 1………………………………………………….21 Table 2………………………………………………….22 Table 3………………………………………………….23 Table 4………………………………………………….24 Table 5………………………………………………….25,26 Table 6………………………………………………….27 Table 7………………………………………………….28

Abstract Cervical incompetence is primarily a clinical diagnosis, characterized by recurrent painless dilation of cervix and spontaneous second trimester loss and preterm delivery. Despite the recent advances, the indications for and efficacy of cervical cerclage still remains controversial, Analysis of clinical history and various risk factors is essential to judge the indications and timing of placement of cervical cerclage. Evaluation of the risk factors contributing to preterm delivery in women receiving cerclage is of utmost importance, as the most common cause of perinatal mortality is preterm birth. Aim: To study the risk factors associated with preterm birth before 34 weeks in women with cervical cerclage by developing a scoring system. Patient & methods: A retrospective cohort study was conducted including 95 patients who received cerclage during 2013 and 2014, From 12 to 24 weeks gestation. The total of (29) women delivered before 34 weeks were compared with control group (66) cases including those who delivered ≥ 34 weeks. Results: Our study identified 3 definite risk factors associated with preterm birth at less than 34 weeks period of gestation : cervical length <25 mm prior to cerclage placement, pathological vaginal discharge, passive smoking. The positive predictive value calculated using the prediction model was %99 with a risk score of 3, 47.6% with risk score 2 &28.2 % with risk score 1. Conclusion: The utility of the prediction model as a tool for identifying patients at a higher risk for PTD <34 weeks & to recognize whose would have benefit from Cercalge to postpone delivery after 34 weeks, Also could be a useful tool for counselling high risk patients prior to cerclage and for identifying those women with cerclage who require increased surveillance. Keywords: Risk score, predictive value, cerclage, preterm delivery

Introduction Definition and incidence of preterm birth:Preterm birth (PTB) is defined as babies born alive before 37 weeks of pregnancy are completed. (1) Classifications may vary between Countries and depend on perceptions of viability. The World Health Organization (WHO) places 22 weeks of gestational age or 380 gram birth weight as the lower limit, at least for the purpose of perinatal statistics.(1) Recent WHO data indicate that every year 15 million babies are born prematurely it is about one in 10 of all babies born around the world.(1) During the last 15 years, in- spite of remarkable improvements in neonatal care and higher survival of very premature infants, the rate of PTBs has increased.( 2 , 3)This increase in the rate of PTB has been attributed to a higher frequency of “indicated” PTBs in singleton gestations and preterm delivery in multiple gestations resulting, in part, from the use of assisted reproductive technologies. (4) However, the greatest portion of PTBs occur in pregnancies with no apparent risk factors. Spontaneous preterm delivery is indeed considered to be one of the “great obstetrical syndromes”, (5)a term which emphasizes that obstetrical disorders with a similar phenotype are caused by multiple pathologic processes, have a long subclinical phase and may result from complex gene-environment interactions.(6)

Prediction of preterm labor and preterm birth The diagnosis of preterm labour and accurate prediction of preterm delivery is notoriously difficult. Obtaining an accurate history of previous pregnancy events and underlying risk factors of PTB is the first step to identifying women at risk for PTB .(7)

Primary risk factors (A) Maternal baseline characteristics Maternal demographic characteristics associated with PTB include low socioeconomic status, (8, 9) low and high maternal ages and single marital status. The risk of PTB is three times higher in black women. These women are also three to four times more likely to have a very early PTB. (8) The nutritional status, described by indicators of body size, such as body-mass-index (BMI), might also affect PTB. Underweight women have increased risks of PTB (8,9) and low birth weight infants (10) specific working conditions (e.g. long hours, hard physical work under stressful conditions) are related to PTB. (8,11) The term "passive smoking" usually refers to the inhalation of smoke that is either exhaled by a smoker or released as sidestream smoke from a burning cigarette. Another name for passive smoking is "involuntary smoking," because the person who inhales it often has no choice in the matter. The effect of cigarettes on the pregnant woman and developing fetus are numerous with a wide range of squeal that will remain with the fetus for the rest of her life. Furthermore, cigarette smoking increases the risk of premature rupture of membranes,(12) placenta previa, (13) and preterm delivery. (14)

(B)Past medical and obstetrical history history of previous PTB or second trimester pregnancy loss are the most important risk factors of PTB, (7,8,9) with a recurrence risk ranging from 15% to more than 38% (2). This risk is inversely related to the gestational age of the previous PTB ( 11)

and increases with the number of previous events. (15) However, a previous PTB is

non-existent for the majority of all PTBs among primigravidae. (8,9) only 10-15% of women who deliver preterm have a prior PTB. (16) The risk of recurrence is increased for both spontaneous and iatrogenic PTBs. (17) There are several maternal medical complications which are often related to iatrogenic PTB. Pre-pregnancy medical risk factors can be identified in as many as 27% of PTBs, which suggests that these women might benefit from preconception interventions such as control of diabetes, seizures, correction of anemia, asthma and hypertension. (3) Other risk factors which increase risk of cervical insufficiency include history of prior cervical trauma (e.g. repeated therapeutic abortion, repetitive cervical dilatation, cone biopsy, cervical tears and lacerations, trachelectomy) should also be noted. A risk factor reducing in incidence is that of the mother herself having been exposed to diethylstilbestrol in utero.(18) A variety of other maternal risk factors include the presence of a congenital uterine anomaly or a maternal connective tissue disease or abnormalities, e.g. Ehlers-Danlos syndrome,(19) that impacts upon the integrity of normal collagen development and function.Recently, polycystic ovarian syndrome has been suggested as a risk factor for cervical insufficiency, especially in women of South Asian or Black origin. In many cases, especially when clinical features and findings lead to suspicion of the diagnosis in the first pregnancy, these risk factors may not be present and the cause may remain idiopathic. (20)

(C) Current pregnancy characteristics A short inter pregnancy interval (less than 6 months) incurs a two-fold increased risk of PTB and might be explained by a decreased opportunity to resolve the inflammatory status and to replenish nutrients associated with the previous pregnancy. This risk is even higher in women whose first birth was preterm. (21) Multiple gestations carry a substantial risk for preterm delivery: 2 to 3% multiple birth rate accounts for up to 15 to 20% of all PTBs. (9) nearly 48% of twins and all

higher multiple gestations will result in preterm delivery. Uterine over distension is believed to be the causative mechanism. Vaginal bleeding caused by placental abruption or placenta previa or bleeding in the first or second trimester is associated risk of PTB. (21)

(D) Infection: 1- Genital tract infection Early evidence for the contribution of intrauterine infection to preterm birth came from a pathologic study of over 6180 placentas.(17) Histologic evidence of chorioamnionitis (neutrophil infiltration of the fetal membranes) was found in 5% of all placenta but in 80% of the placentas of infants aborted at 21 to 24 weeks. The incidence of histologic chorioamnionitis was found to increase sequentially with decreasing gestational age. Most of these infections were subclinical because only 13.8% of women with placental histologic chorioamnionitis were febrile during labor. (17)

This histologic study clearly demonstrated the association of inflammation with

abortion but did not prove that all cases were caused by infection. The hypothesis that ascending lower genital tract infection leads to preterm labor has been supported by multiple studies. (22, 23)The entry of lower genital tract bacteria into the decidua is associated with recruitment of leukocytes followed by cytokine production. Cytokines have been found to trigger prostaglandin synthesis in the amnion, chorion, decidua, and myometrium. (24) This, in turn, leads to uterine contractions, cervical dilatation, membrane exposure, and greater entry of microbes into the uterine cavity. Bacterial vaginosis (BV) is associated with a twofold increased risk of preterm birth, with the greatest risk when BV is present before 16 weeks gestation. (25) This may indicate a critical period during early gestation when BV-related organisms can gain access to the upper genital tract and set the stage for preterm labor later in gestation. (26)

Trichomonas vaginitis infection has been associated with a small but significant increased risk of preterm birth. (27) Vaginal colonization with Candida, group B streptococci, and urealyticum has been studied and is not associated with increased risks of preterm birth. (28, 29) Treatment for asymptomatic colonization with these organisms is not warranted. Group B streptococcal bacteriuria should be treated when detected, however, to prevent both symptomatic urinary tract infection and preterm birth. (30)

2- Urinary tract infection It has long been recognized that untreated pyelonephritis is associated with preterm labor. Closer investigation has revealed that even asymptomatic bacteriuria or pyelonephritis increases the risk of preterm birth. There is strong evidence to support screening and treatment for bacteriuria in all pregnant women at the first prenatal visit. (31)

Secondary risk factors Secondary predictors are based on symptoms, signs and examination during the current pregnancy and may allow a more accurate risk assessment of PTB in an individual woman during the course of pregnancy. Screening for early signs of spontaneous preterm labour has always been an important topic in practical obstetric care. (32)

1- Biophysical predictors (A) Digital vaginal examination Cervical changes are associated with PTB. Studies have indicated poor efficacy of digital cervical evaluation and the Bishop score in predicting PTB. (33) Digital examination has some limitations: it is a subjective assessment lacking precision and reproducibility, (34,8) it tended to underestimate the cervix length compared to

transvaginal ultrasound, (34,35) the morphology of the internal os cannot be evaluated (34, 8)

and it involves potential risk of infection and membrane rupture. (34) (B) Ultrasound measurement of the cervix length The most objective and effective method for evaluating the cervix is

transvaginal sonography. (36, 37) Transvaginal sonography is more accurate than digital examination (33) and transabdominal ultrasound (36, 38, 39, 37,), because of the increased reproducibility of the complete cervix, the significantly improved visualization and the high degree of standardization. (36, 39, 35) Technical pitfalls for abdominal ultrasound include the position of the cervix, bladder distension as well as myometrium contractions, giving a falsely normal cervical appearance. (34,36) Cervical length measurement by transvaginal sonography is one of the best predictors of PTB in all populations studied so far. (16) Figure (1-4) Another method for measuring cervical length is transperineal (also known as translabial) ultrasound was originally used in France in the 1980s and proved to be superior to the transabdominal approach. This technique involves having the patient lie on an examination table with the knees and hips in a flexed position, and placing a gloved transducer on the perineum between the labia majora, ensuring to keep the transducer in a sagittal orientation. A cushion may be placed underneath the patient’s back in order to lift up the hips and enhance visualisation of the cervix.Compared with trans-abdominal approach, this technique offers significant improvements in that the image is not obstructed by fetal parts, the bladder does not have to be filled, and the transducer is closer to the cervix, thus allowing a clearer visualization of the whole cervical length in nearly 100% of cases. Other advantages offered by this technique include the fact that it does not require an additional transducer, the probe is closer to the cervix but does not enter the vagina (so no pressure can be exerted on the cervix) and is well accepted by most women. (40)

Fig. 1. Transvaginal ultrasound image of a normal-appearing cervix. Note the perpendicular ‘‘T’’ shape relationship between the fetal membranes and endocervical canal

Fig. 2. Transvaginal ultrasound demonstrating the characteristic ‘‘Y’’ shape funnel caused by dilation of the internal os, prolapse of the fetal membranes into the endocervical canal, and a shortened distal cervical segment.

Fig. 3. Transvaginal ultrasound demonstrating further membrane prolapse and a very short distal cervical length associated with the ‘‘V’’ shape.

Fig. 4. Transvaginal ultrasound demonstrating the ‘‘U’’ shape membrane prolapse with an extremely short distal cervical segment. These ultrasound findings are usually associated with changes in the external os visible on speculum examination and palpable on digital examination.

2- Biochemical predictors

(A) Fetal fibronectin Fetal fibronectin is a stable glycoprotein found in the interface between the maternal and fetal components of the choriodecidual junction. It has a relatively high concentration within the extracellular makeup of this layer. (41, 42) Cervicovaginal secretions contain fetal fibronectin early in gestation, and then again just before term labor. (43) Concentrations are normally quite low in the second and early third trimester. The preclinical onset of preterm labor seems to be associated with disruption of the choriodecidual junction, which in turn releases fetal fibronectin, which can be detected in the cervicovaginal mucous. Quantitation of fetal fibronectin can be performed and its presence or absence can then aid in the diagnosis and therapy of the patient. Initial clinical studies by Lockwood et al indicated that fetal fibronectin was a sensitive marker for risk of preterm delivery, and was also a very significant tool when it was absent, because it has a very strong negative predictive value. (42) Specimens for fetal fibronectin should be collected before digital examination, and preferably more than 24 hours since the last cervical examination or intercourse. Significant cervical dilation usually minimizes the value of the test, because treatment of preterm labor is warranted. Other factors that can affect the result of the test are premature rupture of membranes, vaginal bleeding (increased positives), the use of vaginal lubricants, and disinfectants (increased negatives). There are now significant data to support the use of fetal fibronectin in evaluating preterm patients because of high negative predictive value to give tocolytic and transfer to tertiary care. (44)

(B)

Human chorionic gonadotropin and alpha fetoprotein

Elevated levels of b-human chorionic gonadotropin (B-hCG) and alpha fetoprotein have been noted, either individually or in combination, to be associated with an increased risk for adverse pregnancy outcomes including preterm delivery. (45, 46, 47)

(C) Other biologic markers for predicting preterm labor Several other biochemical markers have been associated with an increased risk of preterm delivery including activin, inhibin, and relaxin. (48, 49) These glycoproteins are produced in the placenta and decidua and seem to facilitate the labor process through varying mechanisms.

Risk scoring Though many individual tests have failed to be predictive of PTB on their own, there have been attempts to combine risk measures into various risk models. (50)To date no combination of tests has proven useful to consistently screen women for potential PTB risk. Methodologically, the ideal study design for postulating and testing predictive methods for preterm birth are prospective cohort studies. Casecontrol studies, which are often used to investigate novel biomarkers, may indicate whether a marker is more prevalent in pregnancies that end in a PTB, but cannot give an accurate estimate of the positive and negative predictive values of a given test. This can only be done when information on an entire cohort is collected. Even if a novel biomarker or set of predictive measures is found to predict PTB in a single prospective cohort it should be validated in a new set of individuals from the same population then tested in other populations to estimate its generalizability. (51, 52)

Prevention of preterm Birth

1- Primary prevention Primary intervention is directed to all women before or during pregnancy to prevent and reduce the risk of PTB. (53) These interventions focus on the overall health of women and include screening of high risk women, weight optimization, nutritional supplementation, smoking cessation, improved access to prenatal care. (11,15)

2- Secondary prevention Secondary prevention efforts are directed to women who are already at higher risk of PTB on the basis of either obstetric history or present pregnancy risk factors (11,15) and involved interventions to attenuate, stop or reverse the progress of spontaneous preterm labour in its early stages. (53)

1- Cervical cerclage Cervical surgery to prevent recurrent pregnancy loss was introduced in 1742 by Herman, (54) when he reported on his experience of three patients treated by Emmet trachelorrhaphy. In 1803 Shirodkar and later in 1805 McDonald introduced methods of transvaginal cerclage to treat cervical incompetence. (17) Despite minor modifications, these procedures have remained the mainstay of therapy for management of cervical incompetence. (55)

Cervical incompetence: (definition and incidence) Cervical incompetence has no consistent definition, but is usually characterized by dilatation and shortening of the cervix before the 24th week of gestation in the absence of preterm labour, and is most classically associated with painless, progressive dilatation of the uterine cervix in the second or early third trimester resulting in membrane prolapse, premature rupture of the membranes, midtrimester pregnancy loss, or preterm birth. (56, 57) The incidence of true cervical

incompetence is estimated at less than 1% of the obstetric population. (58) It is estimated to occur in 8% of women with recurrent mid-trimester losses. (59)

Types of cervical cerclage:-According to timing classified to:1- Elective cerclage This type of cerclage is placed before the development of any signs or symptoms of cervical incompetence in the late first trimester or early second trimester (usually less than 16 weeks gestational age). It should be offered to women with three or more previous preterm births and/or second-trimester losses. Elective cerclage should not be routinely offered to women with two or fewer previous preterm births and/or second-trimester losses. Characteristics of the previous adverse event, such as painless dilatation of the cervix or rupture of the membranes before the onset of contractions, or additional risk factors, such as cervical surgery, are not helpful in the decision to place a history-indicated cerclage. (60) There is insufficient evidence to recommend the use of pre-pregnancy diagnostic techniques aimed at diagnosing ‘cervical weakness in women with a history of preterm birth and/or second-trimester loss in the decision to place an elective cerclage. Such techniques include assessment of cervical resistance index, hysterography or insertion of cervical dilators. (61)

2-Urgent cerclage An ultrasound indicated cerclage or urgent cerclage is usually placed between 16 and 24 weeks gestational age with most patients being asymptomatic. (62)The diagnosis is made by transvaginal ultrasound with dilation of the internal os, prolapse of the fetal membranes into the endocervical canal, and a short cervical length, or by digital examination with demonstrable cervical dilatation or significant change in effacement when compared with first-trimester examination. (61) The insertion of an urgent is not recommended in women without a history of spontaneous preterm

delivery or second-trimester loss who have an incidentally identified short cervix of 25 mm or less. (62)

3- Emergency cerclage An emergency (or salvage or rescue) cerclage is typically one placed in a woman whose cervix is already dilated. Emergency should be considered when there is clinical or sonographic identification of a cervix dilated > 10 to 20 mm with no perceived uterine contractions (with or without membranes bulging through the external os). (63, 64) It is important to note that there must be no clinical evidence of chorioamnionitis. (65) A small randomized clinical trial has shown prolongation of pregnancies by four weeks with emergency cerclage placement, (66) and other observational studies have reported pregnancy prolongation of between 6 and 9 weeks with emergency cerclage placement compared with under 4 weeks with conservative management(bed rest). (67)

According to anatomical approach classified to

1- Transvaginal cerclage It is the most common approach which is further subdivided into a McDonald type, Shirodkar type and occlusion cerclage. The McDonald type of cerclage is a purse-string stitch placed in the stroma of the ectocervix at the level of the cervical reflection of the vaginal fornices. (61) The Shirodkar transvaginal cerclage is preferred for those patients with altered or absent ectocervical anatomy. Various suture materials and anchoring techniques have been advocated for cerclage procedures. At this time, synthetic permanent monofilament suture or braided permanent tape have been utilized most often. (68)

Occlusion cerclage done by occlusion of the external os by placement of continuous non-absorbable suture. The theory behind the potential benefit of occlusion cerclage is retention of the mucus plug. (62)

2- Transabdominal cerclage A suture performed via a laparotomy or laparoscopy, placing the suture at the cervicoisthmic junction. A Transabdominal cerclage is usually inserted following a failed vaginal cerclage or extensive cervical surgery. (62)

Normal cervical length and cervical change in women who deliver preterm Cervical length is normally distributed and remains relatively constant in pregnancy until the third trimester. (69, 70, 71) If there is any statistically significant reduction in length, it is not clinically significant (< 0.5 mm /week). (69,72) Heath et al. (73)

found a mean length of 38 mm at 23 weeks. Iams et al. (74) found a mean length of

35 mm at 24 weeks and of 34 mm at 28 weeks. If funneling is present, measurement should exclude the funnel and be taken from the funnel tip to the external os. (75) In women who deliver preterm or require cerclage, the rate of cervical length change may be predictive of preterm birth. The rate of cervical shortening is faster in women who deliver preterm than in those who deliver at term; however, the difference can be quite small. (76, 72) The range of cervical length decline in those who go on to preterm delivery, preterm labour, or pregnancy intervention varies from 0.5 mm/week to 8 mm/week. (76)

Contraindication to cervical cerclage The contraindications to cerclage insertion are active preterm labour, clinical evidence of chorioamnionitis, continuing vaginal bleeding, PPROM, evidence of fetal compromise, lethal fetal defect and fetal death. (62)

Removal of cervical cerclage The cerclage is generally removed electively at 36 to 38 weeks’ gestation. Removal can usually be performed without anesthesia or with only short-acting narcotics, such as Fentanyl administered intravenously. The onset of premature labour unresponsive to tocolysis and or a strong suspicion of sepsis are indications for emergency removal of the cerclage. (77) All women with a transabdominal cerclage require delivery by caesarean section, and the abdominal suture may be left in place following delivery. (62)

Complication of cervical cerclage Three randomized clinical trials have shown that cerclage is associated with increased medical interventions and doubles the risk of puerperal pyrexia. (78, 79) The use of tocolytics increases with cerclage, as does the rate of hospital admissions, and one study found a higher rate of Caesarean sections. (80)The complications reported with cerclage include sepsis, premature rupture of membranes, premature labour, cervical dystocia, cervical laceration at delivery (11% to 14%), (81, 82) and hemorrhage. However, meta-analysis of a number of studies has not confirmed higher rates of chorioamnionitis or preterm pre-labour membrane rupture in women managed with cerclage than in those managed by other means. (83, 84, 85)

2- Progesterone Replacement The therapy with the most evidence for preventing PTB and the one most generally employed is progesterone replacement therapy. It has been tested in many different formulations (90-200 mg per day or 341 mg every 4 days) and administrations (vaginal gel, oral capsules, vaginal pessaries and intramuscular injections) but most have shown a consistent benefit. The most common indication for progesterone therapy is a past history of PTB and those with a previous PTB at an early GA may be more likely to benefit. Treatment typically begins in early to middle second trimester (16-20 weeks) and lasts through the 36th week of gestation. (86)

Aim of the study:Are to evaluate the risk factors associated with preterm birth in women before receiving cervical cerclage and to develop a scoring system for predicting preterm labour in these women. This prediction model can be used as a tool for identifying women likely to develop preterm birth and thus can be offered frequent surveillance

Patient and methods This is a retrospective cohort study in (95) patients who received cervical cerclage between 12 to 24 weeks for cervical incompetence from January 2013 to December 2015 in Sulaimani maternity teaching hospital. Of them (29) women delivered before 34 weeks compared with (66) cases who delivered at or after 34 weeks. The information were obtained from the case sheet of study population and contact with them by phone. We studied four risk factors associated with preterm birth at less than 34 weeks period of gestation, cervical length prior to cerclage placement, emergency placement of cerclage, gestational age at time of cervical cerclage placement of, history of ≥ 3 losses (include midtrimester miscarriage and preterm birth), exposure to passive and active smoking but there is no any case of active smoking so only passive smoking taken as arisk factor, history of recurrent pathological vaginal discharge which needs treatment.

Statistical analysis Data entry performed via using an excel spreadsheet then the statistical analysis was performed by SPSS program, version 21 (IBM SPSS statistics package software program for statistical analysis). The data presented in tabular form to describe the variables of the study. The patients are divided into two groups based on the delivery time (before and after 34 weeks), Comparison of these two groups were performed in respect to different study variables as well as in respect to the study outcomes. Independent t-test were used to compare the mean values of quantitative variable. Chi-square tests were used for comparing of the categorical data between the two mentioned groups of patients. Logistic regression performed to find Odds ratio of the factors found to be risky for

preterm birth. P values of 0.05 were used as a cut off point for significance of statistical tests.

Inclusion criteria Singleton pregnancies between (12 to 24) week which undergone cervical cerclage in (2013 & 2014) in Sulaimanya maternity teaching hospital

Exclusion criteria 1-

Multiple pregnancy.

2-

Cerclage which is done before 12 weeks or after 24 weeks of gestation.

3-

Pregnancies conceived by invetro fertilization (IVF).

4-

Patient with history of antiphospholipid syndrome.

Ethics Approval for this study has been obtained from clinical directorate of the Sulaimani Maternity hospital where all the data will be collected and consent were taken from all patients whom participating in this study.

Results The study carried out at a tertiary teaching hospital. (95) Cases which met inclusion criteria precipitating in the study, (29) cases delivered before 34 weeks and (66) cases delivered ≥ 34 weeks of pregnancy. Table (1) total number of live birth (LB) and neonatal death (ND) in both term and preterm infants in Sulaimani maternity teaching hospital during (2013) and (2014). In 2013 total number of live birth were (18441), neonatal mortality rate was (1.2%), (21.97%) of them were full term and (78.03%) were preterm. Among preterm deaths (18.9%) were born ≥34 weeks while (81.03%) were born before 34 weeks. In 2014 total number of live birth were (19994), neonatal mortality rate was (1.37%), (18.25%) of them were full term and (81.75%) were preterm. Among preterm deaths (17.86%) were born ≥34 weeks while (82.14%) were born before 34 weeks. Table (1) Neonatal outcome

2013

2014

Total number of live birth

18441

19994

Total number of neonatal death

223

(1.20%) of LB

274

(1.37%) of LB

Total number of term death

49

(21.97%) of ND

50

(18.25%) of ND

Total number of preterm death

174

(78.03%) of ND

224

(81.75%) of ND

≥ 34 week

33

(18.97%) of PTB

40

(17.86%) of PTB

Before 34 week

141

(81.03%) of PTB

184

(82.14%)of PTB

Table (2): shows demographic characteristic of studied group. In this study the patient were of comparable age with a mean age of patients delivered < 34 Weeks was (32.1 ± 5.0) and the mean age of patient who delivered after 34 weeks was (32.8 ± 5.6). P value=0.57 which is not significant by using Pearson chi-square test at 0.05 level of significance. In relation to employment (27.6%) of them were delivered < 34 Weeks and (72.4%) delivered ≥ 34 Weeks, while for unemployed patients (30.3%) were delivered < 34 Weeks and (69.7%) delivered ≥ 34 Weeks. P value=0.79 which is not significant by using Pearson chi-squared test at 0.05 level of significance. (40.9%) of patients who delivered < 34 Weeks and (59.1%) of patients who delivered ≥ 34 Weeks have history of passive smoking. (21.6%) of patients who delivered < 34 Weeks and (78.4%) of patients who delivered ≥ 34 Weeks history of passive smoking was negative. p value < 0.05 which is statistically significant.

Table (2):Variable

Maternal Age (Years) Mean ± SD Occupation Employed Unemployed

Passive smoking

Yes No

Weeks of pregnancy < 34 ≥ 34 Weeks Weeks 32.1 ± 5.0 32.8 ± 5.6

Total

P value

0.57

8 (27.6%) 20 (30.3%)

21 (72.4%) 46 (69.7%)

29 (100%) 66 (100%)

0.79

18 (40.9%) 11 (21.6%)

26 (59.1%) 40 (78.4%)

44 (100%) 51 (100%)

< 0.05

Table 3: Relation between parity and history of previous evacuation of retained product of conception (RPOC) with birth < 34 Weeks and ≥ 34 Weeks (38.5%) of nulliparous patients delivered < 34 Weeks and (61.5%) of them delivered ≥ 34 Weeks. While for multiparas patient (27.3%) of patients whose their parity were between (1-3) delivered < 34 Weeks and (70.4%) of them delivered ≥ 34 Weeks. (27.3%) of patients whose their parity were ≥ 4 children delivered < 34 Weeks and (72.7%) of them delivered ≥ 34 Weeks. P value=0.79 which is statistically not significant. Also (24.4%) of patients who delivered < 34 Weeks and (75.6%) of patients who delivered ≥ 34 Weeks have history of evacuation of RPOC. And the rest of patients who delivered before or after 34 weeks had no history of evacuation of retained product P value=0.22 which is statistically not significant. Table 3 Variable Parity

Nulliparous 1-3 children ≥ 4 children

Evacuation of RPOC

Weeks of pregnancy < 34 Weeks ≥ 34 Weeks 5 8 (38.5%) (61.5%) 21 50 (29.6%) (70.4%) 3 8 (27.3%) (72.7%)

Total

P value

13 (100%) 71 (100%) 11 (100%)

0.79

0.22

Yes

11 (24.4%)

34 (75.6%)

45 (100%)

No

18 (36%)

32 (64%)

50 (100%)

Table (4) Distribution of various problems specific to current pregnancy, mode of delivery (MOD), pregnancy outcome between studied groups.

This table clarifies relation of Gestational Diabetes, Hypertension disorder during pregnancy and mode of delivery in previous pregnancy, in patients who deliver < 34 weeks and those deliver ≥ 34 weeks, which is not significant (P value was > 0.05). P value for pregnancy outcome were significant.

Table 4: Variable

GD

Yes No

HT

Yes No

Mode of delivery(MOD)

NVD CS

Pregnancy outcome

Alive birth Neonatal mortality

Weeks of pregnancy < 34 ≥ 34 Weeks Weeks 1 4 (20%) (80%) 28 62 (31.1%) (68.9%) 3 2 (60%) (40%) 26 64 (28.9%) (71.1%) 18 32 (36%) (64%) 11 34 (24.4%) (75.6%) 22 65 (25.3%) (74.7%) 7 1 (87.5%) (12.5%)

Total

P value

5 (100%) 90 (100%) 5 (100%) 90 (100%) 50 (100%) 45 (100%) 87 (100%) 8 (100%)

0.6

0.14

0.22

0.001

Table 5 Analyses of various risk factors and their association with preterm birth less than 34 weeks in women with cervical cerclage

This table shows relation between timing of cerclage and type of cerclage both were non-significant. P value = 0.005 for cervical length at time of cerclage placement in predicting birth < 34 weeks, significant association present between pathological vaginal discharge and delivery before 34 weeks. Which is significant. P value= 0.51 for mean gestational age at time of cerclage placement. P value= 0.16 for predicting preterm birth in women with history of (0, 1-2 and ≥ 3) loss which includes midtrimester abortion and preterm birth.

Table 5 Variable

Elective Cerclage Type Emergency Cervical Cerclage Time/ Weeks of pregnancy

Pathological vaginal discharge Cervical length (mm)

12th-14th week 15th-17th week 18th-21st week Yes No <25 mm ≥ 25 mm

None Previous loss

1 - 2 Loss ≥ 3 loss

Weeks of pregnancy < 34 ≥ 34 Weeks Weeks 27 64 (29.67%) (70.32%) 2 2 (50%) (50%) 28 61 (31.4%) (68.5%) 0 3 (0.00%) (100%) 1 2 (33.33%) (66.6%) 15 16 (48.4%) (51.6%) 14 50 (21.9%) (78.1%) 15 9 (62.5%) (37.5%) 11 53 (17.18%) (82.8%)

2 (50%) 12 (22.6%) 15 (39.5%)

* Note:-cervical length of 88 cases were available

2 (50%) 41 (77.4%) 23 (60.5%)

Total

91 (100%) 4 (100%) 89 (100%) 3 (100%) 3 (100%) 31 (100%) 64 (100%) 24 (100%) 64 (100%) Total * 88 case 4 (100%) 53 (100%) 38 (100%)

P value

0.39

0.51

0.01

< 0.001

0.16

Table 6:- Multivariate analyses of risk factors associated with preterm birth less than 34 weeks in women with cervical cerclage

Variable

OR

95% CI

P value

Passive smoking

2.52

1.03 – 6.18

0.044

Pathological vaginal discharge Cervical length (< 25mm)

3.35

1.33 – 8.41

0.01

8.03

2.81 – 22.97

< 0.001

OR=odds ratio CI=coefficient interval

Table 7:- Predictive model for preterm birth at less than 34 weeks The positive predictive value of preterm birth before 34 weeks is 99% when there are three, 47.6% when there are two risk factors but only 28.2% when there is a single risk factor. Out of the 29 cases who delivered before 34 weeks in our study, 1 patient delivered at <26 weeks. Table (7):Risk factor score

Sensitivity %

Specificity %

PPV %

NPV %

Accuracy %

1

42.3%

54.8%

28.2

69.4%

51.1%

2

38.5%

82.3%

47.6

76.1%

69.3%

3

15.4%

99%

99%

73.8

75.0%

Discussion Being able to predict patients with cervical insufficiency at risk for preterm delivery before 34 weeks would be important for counselling prior to performing cerclage procedures and in identifying the group who require increased surveillance. Neonatal mortality and morbidity in preterm infants are directly proportional to gestational age at birth with each addition of gestational week has substantial survival advantages as well as good antenatal care, quality and availability of intensive neonatal care have a great role in surviving preterm infants. (87) Table (1) shows total number of live births and neonatal death in Sulaimani Maternity Teaching hospital since (2013 & 2014). Term neonatal deaths accounts for about 1/4 of all neonatal deaths while 3/4 of deaths occurs in preterm infants. Among preterm neonatal deaths there is significant relation between gestational ages at birth, about three quarter of preterm neonatal deaths occurs in neonates born before 34 weeks. Among studied groups there is also significant relation between gestational age and neonatal mortality (p value=0.001) which is highly significant. Teenage mothers were at increased risk of preterm delivery and this found in cohort study done by (Ali- S, Khashar et.al) in 2010,(88) we found maternal age has no significant risk in this study and all cases were above (18) years . Passive smoking have a significant risk on birth before 34 weeks of pregnancy (P value less than 0.05), This finding are correlated with similar studies done by Khader et al, at 2011 which demonstrated that exposure to passive smoking during pregnancy was significantly associated with an increased risk of preterm delivery. (89) Qiu et al, showed an association between positive history of passive smoking and preterm birth. (90) However, Andriani et al, conducted the first national prospective longitudinal cohort study of passive maternal smoking and preterm birth in Indonesia and found no significant associations. (91) Large portion of women in the general population are

exposed to passive smoking, (92) so even a small association between passive smoking and preterm birth may pose a substantial public health burden. (93) There is no significant difference regarding history of previous evacuation of RPOC between studied groups in this study and this agreed with the study done by (Madore C et. al,) does not demonstrate that cervical dilation during dilatation and curretage predisposes to cervical insufficiency as previously described. (Kalish RB, Chasen ST, Rosenzweig LB, et al,) also studied that second trimester dilation and evacuation was not a risk factor for midtrimester pregnancy loss or spontaneous preterm birth. (94, 95) Pathological vaginal discharge is present in 32.6% of studied population. (48.2%) of those deliver before 34 weeks gave history of abnormal vaginal discharge while 21.9 % of them no history of previously mentioned problem was given and this agreed with two studies done by L. F. Cram, et al, and M. F. da Silveira, et al, Found that premature labor was significantly associated with pathological vaginal discharge during pregnancy. (96, 97) There is high disparency between sample size for emergency and elective cerclage cases. (91case elective, 4 cases emergency) this is adversely affect outcome may lead to false positive or false negative cases. (29.67%) of elective cases delivered before 34 weeks and 64 (70.32%) delivered ≥ 34 weeks. For emergency cases although percentage for women delivered before 34 weeks were higher in comparison to elective cases but statistically not significant. The same result was fond in research done by (Cockwell KA, et, al. found that there were no significant difference between emergency cerclage group and elective cerclage group regarding mean gestational age of delivery, delivery beyond 34 weeks and overall pregnancy outcome.(98) Khan M. J in India evaluates Outcome associated with placement of elective, urgent and emergency cerclage and concludes that emergency cerclage does confer some benefit to patients with evidence of cervical incompetence although the outcomes are better if the cerclage is performed electively before the start of the

process of preterm labour (elective group) and in the early phase of cervical changes (urgent group), rather than when the process of incompetence has already began (Emergency group). (99) According to gestational age at time of cerclage placement studied population divided into 3 gestational age groups which are (12-14), (15-17), (18-21).There is no significant association between different gestational age groups with delivery before 34 weeks. This is agreed with Gupta et al. conducted a study in India 2013 found no difference in age groups below 21 week but there is significant relation when cervical cerclage done between (21-26 weeks). (100) Our findings confirm those of previous studies (Berghella V et al at 2005, and Rust OA et,al. in 2000) that have found an inverse relation between the length of the cervix, as measured by ultrasonography during pregnancy, and the frequency of preterm delivery. Women with cervical lengths at or below the (25) mm, had a significantly greater risk of preterm delivery than those whose cervical lengths were above (25) mm. (101,102)

Conclusion Our study identified three risk factors associated with spontaneous preterm delivery at less than 34 weeks in women receiving cervical cerclage : cervical length <25 mm prior to cerclage placement, history of pathological vaginal discharge during pregnancy and passive smoking. Those pregnant women need proper management of genital tract infection, proper advice regarding adverse effect of nicotine exposure in the form of passive smoking on preterm birth. Women with 3 risk factors were most likely to develop preterm birth. The prediction model designed in our study can be used as a tool for counselling these patients before receiving cervical cerclage for identifying those women who require frequent surveillance after cerclage placement who may deliver before 34weeks.

Limitations of study 1- Small sample size: among 120 cases which meet our inclusion criteria only (95) cases are participating in the research because I couldn’t contact them or lacking critical information especially gestational age of delivery and cervical length. 2- Lack of local guideline for cervical cerclage placement, we had some cases did not meet the criteria but still had cerclage placed. 3- In some cases cervical length were assessed by Tranabdominal ultrasound which is not ideal method for assessment of cervical length.

Recommendations 1- Cervical incompetence lacks special diagnostic test and diagnosis mostly by history and findings in current pregnancy so correct diagnosis of cervical incompetency is important in every pregnancy not depending only on previous obstetrics history. 2- Creating guideline for better selection of patients who will get benefit from cervical cerclage. 3- Transvaginal ultrasound can be used as a screening test for women at risk of preterm delivery, identifying patients whom cervical shortening higher than average and performing cerclage at cervical length of (25) mm or less whenever possible. 4- Emergency cerclage can be undertaken with clear benefit on perinatal outcome. 5- Fetal fibronectin test has high negative predictive value it is advisable to perform this test before commencing more invasive treatment for patients with risk of preterm delivery. 6- We are in need to have larger and prospective study for better selection of patients who need cervical cerclage.

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97-M. F. da Silveira, I. S. Santos, A. J. D. Barros, A. Matijasevich, F. C. Barros, and C. G. Victora, “Increase in preterm births in Brazil: review of population-based studies,” Revista de Saude Publica, vol. 42, no. 5, pp. 957–964, 2008. 98- Cockwell HA, Smith GN. Cervical incompetence and the role of emergency cerclage. J Obstet Gynaecol Can 2005; 27: 123–129. 99-Khan M. J. • Ali G. • Al Tajir G. • Sulieman H. The Journal of Obstetrics and Gynecology of India (November–December 2012) 62(6):660–664 100- Avantika Gupta, Asmita Muthal Rathore, Usha Manaktala . International Journal on biomedical research (December 2013) Journal DOI:10.7439/ijbr 101-Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Obstet Gynecol 2005 ; 106:181–9. 102-Rust OA, Atlas RO, Jones KJ, Benham BN, Balducci J. A randomized trial of cerclage versus no cerclage among patients with ultrasonographically detected second-trimester preterm dilation of the internal os. Am J Obstet Gynecol 2000;183:830–5.

‫كورتة ‪:‬‬ ‫َدان لة ثيَش هةموو شتيَك دا ناسينةوةيةكى كلينيكية كة دةبيَتة هؤى‬ ‫كارا نةبوونى ملي مندال‬ ‫َدان و لة بار ضوون لة سىَ مانطى دووةمي سكثريدا‪ .‬لة طةلَ ئةو‬ ‫كرانةوةي بيَ ئازاري ملي مندال‬ ‫َدان لة بوارى‬ ‫َبةستنةوةي ملي مندال‬ ‫ثيَشكةوتنانةى ئةم دواييةش ئاماذةكان و كاريطةري بوَ هةل‬ ‫طةنطةشةدا ماوة ‪ ,‬شيكردنةوةي ميَذوي ثزيشكي و هوَكارة جوَراوجوَرةكاني مةترسى دوو شتى‬ ‫َبةستنةوةي ملى مندالدان‬ ‫طرنطن بؤ دادوةرى كردن بةسةر ئةو ئاماذانة و كاتى دانانى هةل‬ ‫َبةستنةوةي ملي‬ ‫‪,‬نرخاندنى هوَكارةكاني مةترسى كة بوةتة هؤى زوو لةدايك بوون لةو ذنانةى كة هةل‬ ‫َبوني ثيَشوةخت سةرةكيرتين هؤكارة بوَ مردني دةوروبةري‬ ‫َدانيان بؤ كراوة طرنطة ضونكة مندال‬ ‫مندال‬ ‫لة دايك بوون‪.‬‬ ‫مةبةست ‪:‬شريؤظةكردنى هوَكارةكاني مةترسى ثةيوةست بة لةدايكبوونى ثيَشوةخت ثيَش ‪ 34‬هةفتة‬ ‫َبةنديةوة‪.‬‬ ‫َدانيان بؤ كراوة لة ريَطةى داناني سيستةمى خال‬ ‫َبةستنةوةي ملي مندال‬ ‫لةو ذنانةىكة هةل‬ ‫َينةوة‪.‬‬ ‫نةخوَش و رِيَطاكاني ليَكوَل‬ ‫َدانيان بؤ كراوة‬ ‫َبةستنةوةي ملي مندال‬ ‫َينةوةيةكى طةرِاوةية لة نيَوان ‪ 95‬نةخؤشدا كراوة كة هةل‬ ‫ليَكؤل‬ ‫َانى ‪ 2014-2013‬دا لة (‪29‬‬ ‫َدان لةنيَوان سال‬ ‫لة ‪ 12‬و ‪ 24‬هةفتةييدا بةهوَي ناكارابوني ملي مندال‬ ‫َيان بوة بةراورد كراون بة كؤمةلةى كؤنرتؤل (‪ )69‬دؤخ كة‬ ‫)نةخوَش دا كة ثيَش ‪ 34‬هةفتة مندال‬ ‫َيان بوة لة ‪ 34‬يان زياتر لة ‪ 34‬هةفتة‪.‬‬ ‫منال‬

‫ئةجنام‬ ‫َبونى ثيَشوةخت كةمرت لة ‪ 34‬هةفتة لة‬ ‫َينةوةكةمان طةيشتؤتة سىَهوَكار كة ثةيوةسنت بة مندال‬ ‫ليكؤل‬ ‫َدان و‬ ‫َبةستنةوةي ملي مندال‬ ‫َدان<‪ 25‬ملم بةر لة هةل‬ ‫سك ثرى ئةوانةش ‪,‬دريَذى ملى مندال‬ ‫دةرهاويشتة ناسروشتيةكاني زىَ و جطةرةكيَشاني نا رِاستةوخوَ ‪,‬ئةو بةها ثؤزةتيظةى كة‬ ‫َاندن كة دةكاتة‬ ‫َاندن بريتيى بوو لة رِيَذةي خةمل‬ ‫َيَنراوة لة ريَى بةكارهيَنانى كةرةسةى خةمل‬ ‫خةمل‬ ‫‪ 99%‬ئةطةر هةرسيَ مةترسيةكةي هةبيَت‪ .‬وة لة ‪ 47,6, %‬ئةطةر دووان لة مةترسيةكاني هةبيَت‬ ‫‪ %28,2‬ئةطةر يةكيَك لة مةترسيةكاني هةبيَت‬ ‫دةرئةجنام ‪:‬‬ ‫َندنة دةتوانريَت سودي ليَوةربطريدريَت بوَ دةستنيشانكردني ئةونةخوَشانةي كة‬ ‫ئةم ريَطةى خةمال‬ ‫َبوني ثيَش وةختيان لة سةرة ثيَش لة ‪ 34‬هةفتة ‪.‬دةكريَت ئةم سيستةمي‬ ‫مةترسي طةورةي مندال‬ ‫َبةندية بةكاربهيَنريَت وةك ئامرازيَكى باش بؤ رِاويَذكردن بةو ذنانةى كة مةترسي طةورةي‬ ‫خال‬ ‫َدانيان بوَبكريَت‬ ‫َبة ستنةوةي ملي مندال‬ ‫َبوني ثيَش وةختيان لة سةرة ثيَش ئةوةي كرداري هةل‬ ‫مندال‬ ‫بة مةبةسيت زياتر ضاوديَريكردنيان‪.‬‬ ‫ووشة سةرةكيةكان ‪:‬‬ ‫َدان ‪ ,‬لةدايك بووني ثيشوةخت‪.‬‬ ‫َبةستنةوةي ملى مندال‬ ‫تؤمار كردنى مةترسى ‪,‬بةهاى خةملينراو ‪,‬هةل‬

‫حكومةتي هةريَمي كوردستان ‪ -‬عيَراق‬ ‫وةزارةتي خويَندني بالَاو تويَذينةوةي زانسيت‬ ‫زانكوَي سليَماني‬ ‫لقي زانستة ثزيشكيةكان‬ ‫كوَليَذي ثزيشكي‬

‫َبة نديكردني مةترسي بوَ ثيَشبينيكردني مندالَ بونى ثيَش وةخت ثيَش ‪ 34‬هةفتة‬ ‫خال‬ ‫َدانيان بؤ ئةكريَت‬ ‫َبةستنةوةي ملي مندال‬ ‫لةو ذنانةى كة هةل‬

‫َيت زانستة‬ ‫َي ثزيشكي \ فاكةل‬ ‫َاي سكول‬ ‫َينةوةكة ثيَشكةش بة لقي خويَندني بال‬ ‫ليَكوَل‬ ‫ثزيشكيةكاني زانكوَي سليَماني كراوة وةك بةشيَك لة ثيَداويستىةكاني بةدةستهيَناني‬ ‫َبوون‬ ‫َا لة زانسيت ذنان و مندال‬ ‫برِوانامةي دبلوَمي بال‬ ‫لةاليةن‬ ‫ميديا رووف عبداللة‬ ‫سةرثةرشتيار‬ ‫ياريدةدةري ثروَفيسوَر \ دكتورة ضروَ جنم الدين فتاح‬

‫الخالصة ‪:‬‬ ‫ان عدم كفائة عنق الرحم اوال هو تشخيص سريري و تتسم بتمدد غير مؤلم و كذلك‬ ‫االجهاض في االشهر الثالث الثانی‪,‬و مع التطورات االخيرة فان مؤشرات تاثير ربط عنق‬ ‫الرحم ال يزال في طور المناقشة ‪,‬ان تحاليل سريرية و كذلك عوامل الخطر شيئان‬ ‫رئيسيان من اجل الحكم على مؤشرات و توقيت وضع عنق الرحم ‪,‬ان تقييم عوامل‬ ‫الخطر المسبب للوالدة المبكرة في النساء اللواتي اجريت لهن ربط عنق الرحم مهم‬ ‫جدا الن والدة المبكرة هو سبب رئيسى لوفيات حوالي الوالدة‪.‬‬ ‫الهدف ‪:‬تحليل عوامل الخطر ذات عالقة بالوالدة المبكرة قبل ‪ 34‬اسابيع في النساء‬ ‫اللواتي اجريت لهن ربط عنق الرحم عن طريق تطوير نظام تسجيل ‪.‬‬ ‫المريض والطرق ‪:‬‬ ‫دراسة استعادية بين ‪ 95‬مرضى الذين كانوا قد اجريت لهن ربط عنق الرحم بين ‪ 12‬الي‬ ‫‪ 24‬اسابيع من اجل عدم كفائة ربط عنق الرحم بين سنوات ‪ 29( , 2014-2013‬حالة )‬ ‫الذين ولدوا قبل ‪ 34‬اسابيع قورنن مع مجموعة السيطرة (‪ )66‬حالة من بينهم الذين‬ ‫ولدوا في او اكثر من ‪ 34‬اسابيع‬ ‫النتيجة‬ ‫ان دراستنا قد وصلت الى ثالث عوامل خطر ذات عالقة بالوالدة المبكرة اقل من ‪34‬‬ ‫اسابيع من الحمل ‪,‬و هم طول ربط عنق الرحم <‪ 25‬ملم اثناء وضع الربط ‪ ,‬اإلفرازات‬ ‫المهبلية المرضية‪,‬التدخين غير مباشر ‪,‬ان القيمة االيجابية المخمنة عن طريق استعمال‬ ‫ادوات التخمين كان ‪ 99%‬مع تسجيل مخاطر ‪ %47.6, 3‬مع تسجيل ‪ %28.2&2‬مع‬ ‫تسجيل ‪1‬‬ ‫االستنتاج ‪:‬‬ ‫ان استفادة طريقة التخمين كوسيلة من اجل التعرف على المرضى ذات مخاطر عالية‬ ‫لوالدة مبكرة قبل ‪ 34‬اسابيع و من الممكن ان يكون اداة جيدا من اجل تحديد النساء‬ ‫ذوي مخاطر عالية للوالدة المبكرة و كذالك التعريف و تحديد النساء اللواتي و تحتاجون‬ ‫الى عناية خاصة‬ ‫كلمات رئيسية ‪:‬تسجيل مخاطر ‪,‬قيمة مخمنة ‪,‬ربط عنق الرحم ‪,‬والدة مبكرة‬

‫حكومة اقليم كردستان‪/‬العراق‬ ‫وزارة التعليم العالى والبحث العلمي‬ ‫جامعة السليمانية‬ ‫كلية العلوم الطبية‬ ‫كلية الطب‬

‫تدريج المخاطر في الوالدة المبكرة قبل ‪ 34‬اسابيع في نساء اجريت لهن ربط عنق الرحم‬

‫رسالة مقدمة الى لجنة الدراسات العليا فى كلية العلوم الطبية‪/‬كلية الطب فى جامعة‬ ‫السليمانية كجزء من متطلبات الحصول على شهادة دبلوم عالى فى علم النساءية والتوليد‬

‫من قبل‬ ‫ميديا رؤوف عبدهللا‬

‫باشراف بروفيسور المساعد‬ ‫د‪.‬جرو نجم الدين فتاح‬