This is a presentation on CERVICAL CERCLAGE

Presentation on cervical cerclage

1. CERVICAL CERCLAGE Dr.Haider Ali Khan PGY-2, OBGYN MEDICARE HOSPITAL MTN.

2. What is Cervical Cerclage ? Cervical Cerclage Is A Surgical Procedure Where A Stitch, Or Sutures ( Mersilene Tape), Are Placed Around The Cervix To Help Keep It Closed During Pregnancy, Especially If There's A Risk Of Premature Birth Due To A Weakened Cervix.

3. Etiology of Cervical Insufficiency Structural Abnormalities: History Of Prior Cervical Procedures:   Previous Surgeries Like LLETZ/LEEP (Loop Electrosurgical Excision Procedure) Or Cone Biopsies Can Weaken The Cervix.  Cervical Injuries From Past Abortions:  Damage To The Cervix From Previous Abortions Can Compromise Its Structural Integrity.  Congenital Abnormalities:  In Some Cases, A Structurally Weak Cervix May Be Present From Birth.  Incidence : Cervical cerclage is indicated in approximately 1% of all pregnancies. The incidence of rescue cerclage (placed after cervical dilatation) is around 0.42 per 1000 births, while for low-risk women with a short cervix, the prevalence is 0.30 per 1000 births Causes:

4. Functional Abnormalities: Cervical dilation without contractions or other signs of labor:  This can indicate that the cervix is opening prematurely, often in the absence of typical preterm labor signs. ( Preterm labor is diagnosed when regular uterine contractions, leading to cervical changes, occur between 20 and 36 weeks of gestation. The American College of Obstetricians and Gynecologists ( ACOG) defines preterm labor as regular uterine contractions and cervical dilation of at least 2 cm before 37 weeks of gestation, while the World Association of Perinatal Medicine and the Perinatal Medicine Foundation (WAPM-PMF) recommend a 3 cm dilation cutoff).  History of second-trimester miscarriages or preterm births:  Repeated losses or births at a specific gestational age can suggest a pattern of cervical insufficiency. 

5. Other Factors: Multiple gestation:  Carrying multiple fetuses can place increased pressure on the cervix, potentially increasing the risk of premature dilation.  Inflammation or infection:  Inflammatory processes or infections in the cervix or surrounding tissues may contribute to cervical weakness.  Biochemical factors:  Changes in cervical collagen or other structural proteins can affect cervical strength and elasticity. 

6. Indications Of Cx-Cerclage : History-indicated cerclage (66%): This type is offered to women with a history of three or more spontaneous preterm births or mid-trimester losses.  Ultrasound-indicated C erclage (34%): This is considered for women with a cervical length less than 25mm (2.5cm) in a singleton pregnancy and a history of spontaneous preterm birth or mid-trimester loss.  Rescue C erclage : This is considered in women who present with exposed membranes prolapsing through the cervical os , especially if they have other risk factors for preterm birth.  Emergency C erclage : May be performed when dilatation has already commenced and membranes are exposed.   Multiple Pregnancy : It's particularly recommended for twins with a cervix shorter than 15mm or dilated cervix. While not routinely indicated for all twin pregnancies, it can be beneficial in specific situations.  

7. Important Considerations: Cervical length: Ultrasound measA ] urements of cervical length are crucial in determining the need for cerclage .  Timing: Cerclage is usually placed between 12 and 24 weeks of gestation, depending on the indication.   Removal: The cerclage is typically removed at 36-37 weeks, unless labor begins before that time.

8. Types of Cx-Cerclage Transvaginal cerclage (McDonald): A transvaginal purse-string suture placed at the cervical isthmus junction, without bladder mobilization. High transvaginal cerclage requiring bladder mobilization (including Shirodkar ): A transvaginal purse-string suture placed following bladder mobilization, to allow insertion above the level of thecardinal ligaments. Transabdominal cerclage : A suture performed via a laparotomy or laparoscopy, placing the suture at the cervicoisthmic junction. Occlusion cerclage : Occlusion of the external os by placement of a continuous non-absorbable suture. The theory behind the potentialbenefit of occlusion cerclage is retention of the mucus plug. (RCOG Green-top Guideline No. 129 1181 of 1210 ª 2022 Royal College of Obstetricians and Gynaecologists )

9. Trans- Abdiminal Cerclage : Indication: Transabdominal cervical cerclage is typically indicated when a woman has a history of failed transvaginal cerclage , cervical insufficiency, or anatomical reasons why a vaginal cerclage cannot be performed. Indications: Failed Transvaginal Cerclage : The primary reason for considering transabdominal cerclage is a history of failed transvaginal cerclage , meaning a previous attempt to reinforce the cervix via the vagina did not prevent preterm birth.  Anatomic Issues: Certain anatomical features, such as a grossly disrupted or absent cervix, can make vaginal cerclage impossible, making transabdominal cerclage a necessary option.  Deeply Traumatized Cervix: A cervix that has undergone extensive trauma may also be a reason for transabdominal cerclage . 

10. How to Apply Cx-Cerclage (McDonald’s Method):

11. Simulation Of Cx Cerclage :

12. Post-Procedure Counselling: Hospital Stay : pt will be kept under observation for few hours after surgery and then discharged to go home. In some cases, if the gynecologist feels it necessary, the patient might be kept in the hospital overnight for observation. The catheter placed before surgery will be retained for some hours. If surgery has been performed under general anesthesia, solid and liquid food is withheld till the gynecologist ensures that normal intestinal movement has resumed. Before discharge, patient is examined again, the cervical sutures are checked and the catheter is removed urinary bladder. Investigations : USG is repeated after surgery to monitor fetal movements and fetal heart beat. If there has been any damage to the uterus or fetus during surgery, it can be detected during USG. Necessary treatment measures can then be implemented for rectifying the damage, if any. Physical Activity : Pt. will be advised to take as much rest as possible after the surgery. A lot of physical activity or strain over the pelvic or abdominal muscles might loosen the cervical opening again and induce uterine contractions which could lead to miscarriage or early labor. Sexual Intercourse : Pt. will be advised to abstain from sexual intercourse for at least one week after surgery. Afterwards the patient is advised to be very careful during sex, so as to prevent rupture of the cervical stitches. Follow-up : Follow up visit to the doctor once a week or once in 15 days is recommended. Physical examination is done to look for changes in the cervical opening of thinness of cervix.

13. Removal Of Cx-Cerclage : Removal of Cervical Sutures: Cervical cerclage is removed in the absence of Pre-Term labor at 36-37 weeks or If labor begins before the expected due date, the cervical stitches or tape are removed to assist easy delivery of the baby. patient may resume normal physical activity afterwards till she goes into labor. If Trans-Abdominal Cerclage is used,it is removed by performing another surgery which will require another abdominal incision. it can be retained by women who plan to have further pregnancies as well. There is not need to remove it prior to labor. However, delivery will be done by C-Section in such cases.

14. Potential Complications of Cx-Cerclage Infection:  While uncommon, infection of the cervix or vagina can occur.  Bleeding:  Most women experience some vaginal discharge(Brownish) and light bleeding after the procedure.  Premature Rupture of Membranes:  The membranes can rupture before the expected time of delivery.  Preterm Labor:   cerclage may not prevent preterm labor in all cases and itself can sometimes trigger premature contractions.  Cervical Stenosis:  cervix may become permanently narrowed after the procedure.  Cervical Laceration or Trauma:  If labor occurs before the cerclage is removed, there's a risk of tearing the cervix.  Uterine Rupture (in rare cases):  In some rare instances, a uterine rupture has been reported following cerclage .  Fistula Formation:  In rare cases, fistulas between the vagina and Urinary bladder can develop. 

15. QUESTIONS?

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