Curious About Cervical Cerclage

Curious About Cervical Cerclage

2022-05-20 12:20:10/ Kategori : Gynecology and Obstetrics

Cervical Cerclage

Cerclage was first used in 1902 in order to prevent recurrent pregnancy loss in women who gave birth prematurely due to cervical insufficiency or had a history of second trimester pregnancy loss.

Cerclage In women who are at risk for premature birth and losses in the second period of pregnancy, due to risk factors such as shortening of the cervix, history of trauma to the cervix (operations performed with conization and widening of the cervical canal), uterine anomalies and multiple pregnancies detected in ultrasonographic examination since the 1960s. used in management. Although it is still performed as a preventive intervention by many obstetricians, its use and effect in different groups is highly controversial and there is no clear consensus on the optimal cerclage technique and suture timing.

Prematurity is a leading cause of perinatal death and is responsible for approximately 7.6% of all live births.

According to what cerclage should be planned?

Story-Based Cerclage

It is applied as a result of obstetric or gynecological factors that increase the risk of spontaneous second trimester pregnancy loss or premature birth. It is usually performed between 12-14 weeks of pregnancy.

Ultrasound Based Cerclage

It is applied between 14-24 weeks of pregnancy in patients with shortening of the cervix in transvaginal ultrasonographic examination.

Emergency Cerclage

It is applied in cases of vaginal discharge, vaginal bleeding or a feeling of pressure in the lower region, and in case of an opening in the cervix detected by speculum or physical examination.

What are Cerclage Methods?

Transvaginal Cerclage (McDonald)

It is thrown into the cervicovaginal junction without the need for bladder mobilization.

High Transvaginal Cerclage (Shirodkar)

It is expelled above the cardinal ligaments following bladder mobilization.

Transabdominal Cerclage

It is thrown into the cervicoistmic region by open or laparoscopic method.

Story-Based Cerclage

It should be offered to patients with three or more preterm births or second trimester losses. It should not be recommended for patients with two or fewer preterm births or second trimester losses.

Additional factors such as painless opening of the cervix, previous poor obstetric history such as watering before the onset of pain, or surgical interventions applied to the cervix are not helpful in the application of cerclage based on the history.

There are insufficient data on the reliability of methods such as cervical resistance index, hysterography or cervical expanders used in the diagnosis of cervical insufficiency in women with a history of second trimester pregnancy loss or preterm delivery.

Ultrasound Based Cerclage

Cerclage application is not recommended in women with a singleton pregnancy, without a history of preterm birth or a second trimester pregnancy loss, even if the cervix length is determined incidentally below 25 mm.

In women with a singleton pregnancy, a history of one or more second trimester pregnancy loss or preterm birth, if the cervical length is less than 25 mm and before the 24th gestational week, ultrasound-based cerclage is recommended.

Ultrasound-based cerclage is not recommended in cases where the cervix is ​​normal in length and there is only funneling in the inner part of the cervix.

Conditions with an Increased Risk of Premature Birth

  • Multiple Pregnancies

Ultrasound or history-based cerclage is not recommended in women with multiple pregnancies.

  • History of Uterine Anomalies and Trauma to the Cervix

Ultrasound-based or history-based cerclage is not applied in women with Müllerian anomaly, LEEP or Conization surgeries to the cervix, or women with a history of more than one curettage.

  • Infertility-Preserving Surgery in the Treatment of Cervical Cancer

In the infertility-preserving surgical method applied in cervical cancer cases called radical trachelectomy, personalized concurrent cerclage can be applied.

Transabdominal Cerclage

  • When should it be considered?

Transabdominal cerclage application may be considered in women with a history of unsuccessful transvaginal cerclage application, this application should generally be applied before pregnancy or in the first trimester of pregnancy.

  • Can it be applied by laparoscopic method?

The laparoscopic method can be used, but the data proving the superiority of the laparoscopic method over open surgery are quite scarce.

Emergency Cerclage

  • To Whom Should It Be Applied?

Depending on the gestational week, the risk of serious preterm birth, neonatal mortality and morbidity risks should be considered and should be personalized.

  • What are the positive results?

It has been shown in studies that when applied in appropriate cases, compared to expectant method or bed rest, it increases the expected delivery time by 5 weeks on average and decreases the probability of giving birth before the 34th gestational week by approximately 2 times.

When is the Chance of Success Less When Applied?

In cases where the membranes are seen in the cervix or with a gap of 4 cm or more, the chance of success is very low.

What are the situations in which cerclage should not be applied?

  • active labor
  • Clinical chorioamnionitis status
  • ongoing vaginal bleeding
  • fetal distress
  • fetal death
  • severe fetal anomaly
  • Cases with active water intrusion

What Information Should Be Made Before Cerclage is Applied

  • Cerclage application may cause maternal fever, but it does not increase the serious infection we call chorioamnionitis.
  • Cerclage application is not associated with second trimester pregnancy loss or increased risk of preterm delivery.
  • Complications such as bladder injury, cervical trauma and bleeding may occur during cerclage application.

Which Tests Should Be Done Before Cerclage Application?

  • Before the cerclage application, first trimester detailed ultrasonographic evaluation and anomaly screening must be performed.
  • If clinical chorioamnionitis is not suspected before cerclage is applied, tests such as complete blood count and c-reactive protein are not required.
  • Scientific evidence to support routine amniocentesis before emergency cerclage or ultrasound-based cerclage is insufficient.
  • Scientific data supporting or not recommending amnioreduction (water drainage) prior to emergency cerclage are insufficient.
  • There is insufficient data to support screening for genital tract infections prior to cerclage application.
  • If any genital infection is detected before cerclage application, all cultures should be taken, treatment should be planned and cerclage application should be discontinued after treatment.
  • There is no scientific evidence to support the use of tocolytic agents prior to cerclage application.
  • Scientific data supporting routine antibiotic use prior to cerclage application are insufficient.

Suggestions after Cerclage Application

Bed rest is not recommended after routine cervical cerclage, but may be recommended in some cases on a personalized basis.

Avoiding sexual intercourse is not routinely recommended after cervical cerclage.

Measurement of cervical length at regular intervals after cerclage is not routinely recommended.

Second cerclage application is not routinely recommended in cases with ultrasound-based shortening of the cervix after cerclage application, but the risk of pregnancy loss and delivery before 35th gestational week increased when compared to expectant management in cases where it was applied.

Routine fetal fibronectin testing is not recommended after cerclage application.

Routine progesterone supplementation after cerclage is not recommended.

When Should Cerclage Be Taken?

Unless there is a planned cesarean delivery, cerclage should be taken at 36-37 weeks of gestation before labor begins.

Cesarean delivery is recommended in patients undergoing transabdominal cerclage, and the cerclage suture can be removed or left at the time of cesarean section.

Cerclage may not be taken for 48 hours if there is no risk of infection or premature birth in women with cerclage and water break between 24-34 weeks of gestation. The reason for not removing the cerclage suture is to prolong the latent period and gain time for steroids that accelerate lung development.

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