cervical cerculage 1

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Domiat general hospital Cervical incompetence Dr. Mohammed Abdalla

Definition : 

Definition Condition in which the cervix fails to retain the conceptus during pregnancy.

Etiology : 

Etiology Idiopathic (most) Congenital disorders (congenital mullerian duct abnormalities. DES exposure in utero. Connective tissue disorder (Ehlers-Danlos syndrome. Surgical trauma (conization, (repeated cervical dilatation associated with termination of pregnancies).

Discriminatory cervical length : 

Discriminatory cervical length No consensus about cut off length

Discriminatory cervical length : 

transvaginal U.S assessment is most accurate Discriminatory cervical length

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Discriminatory cervical length

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The discriminatory length of cervical shortening varies widely between 30mm to 15mm Discriminatory cervical length

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So we cannot rely on cervical length alone as a predictor of incompetence Discriminatory cervical length

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but, the progressive shortening , funneling ,v-shaped lower uterine segment and dynamic cervical changes with fundal or suprapubic pressure. Are the most important.

There is no place for routine ultrasound screening of the cervix in low-risk women : 

There is no place for routine ultrasound screening of the cervix in low-risk women ACOG Practice Bulletin No. 48November 2003

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but is limited to populations at greatest risk ACOG Practice Bulletin No. 48November 2003

But how to avoid undue cerclage and how not to miss a case? : 

But how to avoid undue cerclage and how not to miss a case?

Cerclage is either elective or urgent : 

Cerclage is either elective or urgent

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In whom is a cerclage indicated? When elective? when urgent?

Elective Cerclage : 

Elective Cerclage confined to patients with three or more otherwise unexplained second-trimester pregnancy losses or preterm deliveries.

Elective Cerclage : 

Elective Cerclage performed at 13 to 16 weeks of gestation after ultrasound evaluation of fetal viability

Urgent, or therapeutic, cerclage : 

Urgent, or therapeutic, cerclage for women who have serial ultrasonographic changes consistent with progressive shortening or evidence of cervical funneling.

Urgent, or therapeutic, cerclage : 

ACOG Practice Bulletin No. 48November 2003 serial TVS should not begin before 16 weeks as the upper portion of the cervix is not easily distinguished Urgent, or therapeutic, cerclage

Urgent, or therapeutic, cerclage : 

The anatomic cervical changes of dilation of the internal os, prolapse of the fetal membranes into the endocervical canal, shortening of the distal cervical segment, and exacerbation with transfundal pressure have been suggested as a final common pathway for multiple pathophysiologic processes. Urgent, or therapeutic, cerclage

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Urgent, or therapeutic cerclage : 

In patients with a history of fewer than three second-trimester pregnancy losses, urgent cerclage is not supported by evidence-based studies, and further transvaginal ultrasound surveillance may be the more judicious approach. Urgent, or therapeutic cerclage

short cervix before 20 weeks of gestation : 

the examination should be repeated because of the inability to adequately distinguish the cervix from the lower uterine segment in early pregnancy short cervix before 20 weeks of gestation ACOG Practice Bulletin No. 48November 2003

short cervix at or after 20 weeks of gestation : 

short cervix at or after 20 weeks of gestation should prompt assessment of the fetus for anomalies, uterine activity to rule out preterm labor, and maternal factors to rule out chorioamnionitis….. Regular evaluations may be performed ACOG Practice Bulletin No. 48November 2003

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Cervical change noted before fetal viability is a better indication for cerclage than if it is identified after fetal viability has been achieved. Emergency cerclage may be considered in women if clinical chorioamnionitis or signs of labor are not present.

short cervix In the third trimester : 

short cervix In the third trimester If the patient is in labor, tocolytic therapy may delay delivery long enough to promote fetal lung maturation with maternal glucocorticoid therapy.

short cervix In the third trimester : 

The presence of chorioamnionitis is grounds for immediate delivery and the use of broad-spectrum antibiotics short cervix In the third trimester

short cervix In the third trimester : 

If labor or chorioamnionitis is not present, modification of activity, pelvic rest, tobacco cessation, and expectant management may be considered. Cerclage in the treatment of women with cervical insufficiency after determining fetal viability has not been adequately assessed. short cervix In the third trimester

Role of perioperative antibiotics and tocolytics association with cerclage placement : 

Role of perioperative antibiotics and tocolytics association with cerclage placement The use of unnecessary antibiotics may lead to the development of resistant strains of bacteria and other morbidity for the patient and her fetus. No randomized studies have shown that use of tocolytic therapy after cerclage is effective. The lack of clear benefit for these adjunctive treatments suggests that these drugs should be used with caution.

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RISK ASSESMENT >=3 unexplained second-trimester losses or preterm deliveries. Elective Cerclage at 14-16 wk. No risk factor routine ultrasound screening of the cervix is not recommended <3 unexplained second-trimester losses or preterm deliveries. routine ultrasound screening of the cervix is done at 16-20 wk. serial ultrasonographic changes consistent with a short cervix or evidence of funneling. Urgent cerclage if noted before fetal viability after fetal and maternal evaluation

Transabdominal cerclage an alternative approach to the incompetent cervix : 

Transabdominal cerclage an alternative approach to the incompetent cervix

Indications of transabdominal cerclage : 

Indications of transabdominal cerclage If cervix is absent or severely shortened, if congenital or traumatic defects if the transvaginal approach is not feasible or has failed.

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It is most often placed at 10 to 14 weeks gestation Timing of placement Preconception transabdominal cerclage placement OR

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has many practical benefits: easier . smaller incision. Safer to fetus. Can be done laparoscopically. Preconception transabdominal cerclage placement

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The overall live birth rate for prophylactic transabdominal cerclage approaches 90%, in whom transvaginal cerclage has been unsuccessful. When cerclage is performed on an emergent basis-rather than prophylactically-the success rate drops to less than 60% due to the increased risk of rupturing the membranes during the procedure or trapping the membranes below the level of the cerclage.

Techniques : 

9- Ensure that the band is flattened circumferentially around the cervix before tying it snugly against the anterior aspect of the uterus at the level of the internal os with 6 single square knots 10- Secure the tails of the knots to the polyester band or adjacent tissues using a small-gauge silk suture to minimize irritation of the bladder. 11- Close the bladder flap inward to minimize adhesions to the suture. Techniques

cerclage placement Adverse effects : 

cerclage placement Adverse effects

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*Suture displacement, *rupture of membranes, *and chorioamnionitis are the most common complications associated with vaginal cerclage placement,

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*Transabdominal cerclage can be complicated by: rupture of membranes . chorioamnionitis. intraoperative hemorrhage. known risks associated with laparotomy.

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Life-threatening complications of uterine rupture and maternal septicemia are extremely rare but have been reported with all types of cerclage.

Thank you : 

Thank you