Cervical Cerclage- Why, Who, When, How and by Whom
Case from my practice a 20 year old pregnant patient with a history of preterm birth, followed by late pregnancy loss. Ultrasound examination revealed healthy fetus, normal uterus and very short and partially opened uterine cervix (fig. 1 and 2). To close the cervix we performed a cerclage procedure.
Q. When cerclage (suturing of the cervix) is indicated?
A. When diagnosis of cervical incompetence is made.
Q. How do we make such a diagnosis?
A. Cervical incompetence (CI) is strongly suspected in patients with history of painless opening of cervix leading to a miscarriage in the 2 nd trimester of pregnancy..
Diagnosis during current pregnancy. In such cases ultrasound examination shows short cervix (less than 2.5 cm) which may be partially opened from inside. Most cerclages are placed between 11 and 14 weeks of pregnancy; however, they may be placed at later gestational ages if indicated.
When Cerclage Should Be Avoided? Below, please, find some of the contradictions for cervical suturing
• Active preterm labor
• Rupture of fetal membranes
• Infection
• Bleeding
• Serious fetal malformations.
Surgery Itself
Most cerclages are done under spinal anesthesia and require no antibiotics or tocolytics.
Precautions After Surgery No special precautions are needed including bed rest and restricted activity. Marital relationship should be avoided for 24 hours.
What Ab out Possible Complications? Complications of cerclages are rare but may be serious: bleeding, infection, to membrane damage resulting in pregnancy loss. This procedure should be done by an experienced obstetrician.
When To Take The Sutures Out ? Most experts recommend removal of the stitches around 36 weeks of pregnancy. Certain problems may develop earlier (rupture of the membranes, premature labor, bleeding, infection, etc,) and require removal of the cerclage.
How Are the Stitches Removed? Removal of cervical stitches (cerclage removal) is usually done in the office and requires no anesthesia.
Will I Start Labor Immediately After The Stitch is Out ? Not always. You may or may not go into labor after cerclage removal. Some patients stay pregnant for weeks and even require induction of labor.
And Finally, Once A Cerclage Always a Cerclage No Doctor should assess the situation in each pregnancy and make an appropriate decision
And know back to our patient. Repeated ultrasound examinations should the cervix become shorter and shorter with cerclage. “keeping the pregnancy going.”
At around 36 weeks of pregnancy membranes touched the stitch and broke causing amniotic fluid to leak. Cerclage was out ; patient went into labor and delivered a healthy baby boy.