cervical cerclage.pptx

At the end of presentation, the participants should be able to understand the following:
Definition of Cerclage
Types of cerclage
Indications
Pre operative Preparations
Removal of Cerclage

1. CERVICAL CERCLAGE MODERATOR: Dr. Rehana Mushtaq PRESENTER: Dr. Rahul Shah PGY1 Department of Obstetrics & Gynaecology 1/9/2024

2. OBJECTIVE At the end of presentation, the participants should be able to understand the following: Definition of Cerclage and Types Types of cerclage Indications Pre operative Preparations Removal of Cerclage 1/9/2024

3. CERVIVAL CERCLAGE 1/9/2024 Principle: The procedure reinforces the weak cervix by a nonabsorbable tape, placed around the cervix at the level of internal os .

4. Cerclage remains one of the standard options for prophylactic intervention in the care of women at risk of pretermbirth and second trimester fetal loss and is used by most obstetricians, despite difficulties in identifying the population of women who would most benefit. The procedure, a stitch inserted into the cervix, was first performed n 1902 in women with a history of second trimester loss or spontaneous preterm birth suggestive of cervical insufficiency, with the aim of preventing recurrent loss. 1/9/2024

5. Types of Cerclage History Indicated cerclage Ultrasound Indicated Cerclage Cervical Cerclage in increased risk cases of preterm delivery Transabdominal cerclage Rescue Cerclage 1/9/2024

6. HISTORY INDICATED CERCLAGE Prophylactic in asymptomatic women Elective in 12-14 WOG Indications: >2 previous preterm birth and/or second trimester losses 1/9/2024 Not helpful in the decision for a history indicated cerclage. Painless dilatation of the cervix. Rupture of the membrane before the onset of contraction. Cervical surgery. Pre-pregnancy diagnostics tests: Cervical resistance Index, hysterography or insertion of cervical dilators.

7. ULTRASOUND INDICATED CERCLAGE Indication : Previous one or more spontaneous mid-trimester loss or preterm birth and cervix is 25mm or less before 24 wog Not recommended for funneling of the cervix in the absence of cervical shortening Not indicated in women who have an incidentally identified cervix of 25mm or less with no history of spontaneous mid-trimester loss or preterm birth. 1/9/2024

8. Serial surveillance? +- USG indicated cerclage Women with one or more second trimester loss or pre term delivery Those who experience cervical shortening are at an increased risk of subsequent second trimester loss/preterm birth may benefit from US indicated cerclage. Those whose cervix remain long have a low risk of 2 nd trimester loss/premature delivery Because the majority of women with a history of second trimester loss/preterm delivery will deliver after 33 WOG, no evidence to support serial sonographic surveillance over expectant management. 1/9/2024

9. Transabdominal Cerclage Indications: Previous failed Transvaginal Cerclage Associated with increased Maternal Morbidity Can be performed before or in early Pregnancy 1/9/2024

10. Rescue Cerclage Even with rescue cerclage the risk of sever preterm delivery and neonatal mortality and morbidity remain high. Delay delivery by 5 weeks on average compared with expectant management (bed rest) alone A/W 2 fold reduction in the chance of delivery before 34 weeks of gestation. 1/9/2024 Conditions associated with high failure Advanced dilatation of the cervix (>4 cm) Membrane prolapse beyond the external OS.

11. CERVICAL INSUFFICIENCY Cervix starts dilating and effacing before her pregnancy has reached term, usually between 16–28 weeks of gestation, without any associated pain or uterine contractions. 1/9/2024

12. Cervical incompetence is probably responsible for causing 20% to 25% of miscarriages in the second trimester. The woman gives history of recurrent second trimester pregnancy losses, occurring earlier in gestation in successive pregnancies and usually present with a significant cervical dilatation of 2 cm or more in the early pregnancy. However, usually there is absence of any other symptoms. In the second trimester, cervix may dilate up to 4 cm in association with active uterine contractions. This may be associated with rupture of the membranes resulting in the spontaneous expulsion of the fetus. 1/9/2024

13. On clinical examination, the cervical canal may be dilated and effaced. Fetal membranes may be visible through the cervical os . Sonographic serial evaluation (every two weeks) of the cervix for funneling and shortening in response to transfundal pressure has been found to be useful in the evaluation of incompetent cervix. 1/9/2024

14. Other findings observed on ultrasound examination include the following: Cervical length < 25mm. However finding of the short cervical length on TVS is not a confirmed diagnostic test for incompetent cervix. It could also be due to early preterm labor. Protrusion of the membranes. Presence of the fetal parts in the cervix or vagina. Cervical dilation and effacement with the changes in form of T, Y, V, U (can be remembered using the mnemonic “ T rust Y our V aginal U ltrasound”) Another important finding on TVS examination of cervical incompetence is funneling. Funneling implies herniation of fetal membranes into the upper part of endocervical canal. However this too is not diagnostic of incompetent os . 1/9/2024

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17. Non-Pregnant State The Internal OS allows the passage of No. 8 Hegar’s Dilator or foley’s catheter filled with 1 ml water without resistance. Premenstrual hysterocervicography will show the typical funneling of internal OS. 1/9/2024

18. PRESURGICAL PREPARATION Contraindications to cerclage include bleeding, contractions, or ruptured membranes, any of which substantially raise the likelihood of labor and failure . Prophylactic elective cerclage be f ore dilation is preferable, timing between 12 and 14 weeks’ gestation allows early intervention. Still, it avoids surgery in the first trimester, which is when most predestined spontaneous losses occur, and screening or aneuploidy and malformation is completed. Cervical neoplasia screening in suitable candidates and gonorrhea and chlamydial infection testing are done. 1/9/2024

19. PRESURGICAL PREPARATION Obvious cervical infection is treated. At times, the cervix instead is found to be dilated, effaced, or both, and an emergency cerclage is performed I n more-advanced pregnancy, the risk of stimulating preterm labor or of rupturing membranes with the surgery is greater. 1/9/2024

20. Regional analgesia is suitable and preferred then placed in standard lithotomy position. The vagina and perineum are cleaned For surgery and the bladder is drained. Some operators do not use potentially irritating antiseptic solution i n amnionic membranes are exposed and instead use warm saline For suturing, options include a no. 1 or 2 nylon or polypropylene monofilament suture or 5-mm Mersilene tape. During placement, the suture is placed as cephalad along the cervical length as possible, is anchored into the dense cervical stroma, yet avoids the bladder. Two tandem cerclage suture rings are not more effective than one 1/9/2024

21. Emergency cerclage placement with a thinned dilated cervix is more difficult, and tissue tearing and membrane puncture are r isks. Gentle replacement of the prolapsed amnionic sac back into the uterus can aid suturing. Options include steep terendelenburg or flling the bladder with 600 mL of saline through a Foley catheter in the bladder. However, these steps may carry the cervix cephalad and away from the operating field. Instead, membranes can be pushed inward by a wide, moist sponge stick. A Foley catheter can instead be inserted through the cervix, and infation of the 30-mL balloon can detect the amnionic sac inward. The balloon is gradually defated as the cerclage suture is tightened around the catheter tubing, which is then removed. With any of these, simultaneous gentle outward traction created by ring forceps placed on the cervical edges may be helpful. 1/9/2024

22. STEPS OF SHIRODKAR’S OPERATION 1/9/2024

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24. Shirodkar technique: A high transvaginal purse string suture placed following bladder mobilization to allow insertion above cardinal ligaments.

25. McDONALD’S OPERATION The nonabsorbable suture ( Mersilene ) material is placed as a purse-string suture as high as possible (level of internal os ) at the junction of the rugose vaginal epithelium and the smooth vaginal part of the cervix below the level of the bladder. The suture starts at the anterior wall of the cervix. Taking successive deep bites (4–5 sites), it is carried around the lateral and posterior walls back to the anterior wall again where the two ends of the suture are tied.

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27. During procedure, risk of tissue tearing and membrane rupture is more. To prevent this, steep Trendelenburg’s or filling the bladder with 600ml of normal saline through an Foley's catheter. For uncomplicated pregnancy without labor , cerclage is usually cut and removed at 37 weeks of gestation.

28. Wurm’s procedure: Also known as Hefner’s cerclage, it is done by application of U or mattress sutures and is of benefit when minimal amount of length of cervical canal is left.

29. Lash procedure This surgical procedure is usually performed in nonpregnant woman. It is usually performed for an anatomical defect in cervix resulting from cervical trauma. In this surgery, the cervical mucosa is opened anteriorly, bladder reflected and the cervical defect repaired with interrupted transverse sutures before closing the vaginal mucosa.

30. Contraindications for cerclage • Uterine contractions/bleeding. • Clinical evidence of Chorioamnionitis. • Premature rupture of membranes. • Cervical dilatation of more than 4 cm • Polyhydramnios • Fetal anomaly incompatible with life. ● Women with Mullerian anomalies. ● Previous cervical surgery. ● Multiple dilatation and evacuation. 1/9/2024

31. Risks of cerclage • Premature rupture of the membranes • Chorioamnionitis • Preterm labor • Cervical laceration or amputation resulting in the formation of scar tissue over the cervix • Bladder injury • Maternal hemorrhage • Cervical dystocia • Uterine rupture, vesicovaginal fistula 1/9/2024

32. Removal of cerclage Transvaginal cerclage should be removed before labor, usually 36 and 37 weeks of gestation. In women in establishing preterm labor, cerclage should be removed to minimize cervical trauma. A Shirodkar suture usually require anesthesia to remove. All women with transabdominal cerclage, require delivery by caesarean section.

33. REMOVAL FOLLOWING PPROM (24-34) WEEKS Without evidence of infection or preterm labour , delayed removal of the cerclage for 48 hours can be considered, for a course of prophylactic steroids and/or in utero transfer. Delayed suture removal until labour is a/w an increased risk of maternal/fetal sepsis and is not recommended. Should be removed immediately following PPROM before 23 weeks and after 34 weeks.

34. Alternative to cervical cerclage may be bed rest alone to avoid pressure on the cervix. Injection of 17 a- hydroxyprogesterone caproate 500 mg IM weekly is given as cervical incompetence is considered as a continuum of preterm birth syndrome. Use of vaginal pessary, when cervix is found short on ultrasound, is found helpful.

35. Advice on discharge (a) Usual antenatal advice. (b) To avoid intercourse. (c) To avoid rough journey. (d) To report if there is vaginal bleeding or abdominal pain. (e) Periodic ultrasonographic monitoring of the fetus and the cervix.

36. References

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