Cervical Cerclage: Types, Procedures, Precautions, and Risks

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Introduction

The medical procedure that is known as cervical cerclage aims to stop the occurrence of preterm births or miscarriages in women with a condition termed as cervical insufficiency. Such a condition occurs when the cervix can no longer hold a pregnancy, and it may be weak and allow opening too early, before the pregnancy is symptomatically or clinically ready. Cervical cerclage is defined as a procedure to sew the cervix closed to offer added support to the woman and maintain the pregnancy until term.

This article explains different types of cervical cerclage procedures, introduces the step-by-step method involved, entails the necessary precautions to ensure a successful outcome, and further discusses the potential risks involved in the process. These aspects are important for future mothers who may have had or may likely need cervical cerclage in their passage toward a safe pregnancy step.

What is Cervical Cerclage?

Cervical cerclage is a surgical intervention that necessitates the stitching of a cervix by strong sutures to provide mechanical support, keeping it from premature dilation during pregnancy. This procedure is commonly recommended for women suffering from cervical incompetence, where cervical shortening or opening occurs too early due to weakened cervical tissues. The procedure reinforces the cervix to effectively minimize the chance of preterm birth or miscarriage by keeping the uterus stable.

Who Needs Cervical Cerclage?

The use of cervical cerclage is indicated in women at risk for premature dilation of the cervix during pregnancy. Some of the indications for this procedure are:

History of Second-Trimester Miscarriages: History of one or more spontaneous abortions due to cervical insufficiency in the past.
Previous Preterm Labor: Particularly if this occurred before 34 weeks because of cervical issues.
Short Cervix Diagnosis: Diagnosed by ultrasound, generally less than 25mm by the second trimester.
Cervical Insufficiency Diagnosis: Weakening of the cervix, which may open early with no contractions.
Multiple Pregnancies: Increased risk for cervical weakening in women carrying two or more fetuses.
History of Surgical Procedures on the Cervix: Procedures such as cone biopsy or LEEP may lead to cervical weakness.

Types of Cervical Cerclage

There are three main types of cervical cerclage procedures, each of which is dependent on the history of the patient and the current condition of the pregnancy:
McDonald Cerclage: The most common type, which involves putting a purse-string stitch around the cervix to hold and support it, is often done proximally between twelve and fourteen weeks of pregnancy.
Shirodkar Cerclage: In the same way performed as what has been discussed in the McDonald technique, but in this case, the placement of the stitch is much closer to the internal cervical opening to provide much more support. A more complicated surgical procedure may be required.
Transabdominal Cerclage (TAC): It is performed through an abdominal incision; this form of surgery is the most needed option for women with very scanty or absolutely no cervix. This is normally done pre-pregnancy or at the beginning of the gestation period and would require delivery through cesarean section.

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Cervical Cerclage Procedure: Step-by-Step

Here is a more elaborate description of the cervical cerclage procedure in the usual sense:

Pre-Procedure Evaluation:
- An ultrasound examination is performed for assessment of the cervical length and any evidence of possible infections and other complications.
- Blood tests and other routine assessments of the patient are performed to assess her fitness for the procedure.
Preparation:
- The patient receives anesthesia, either spinal, epidural, or general, for comfort.
- The bladder is emptied, and the vaginal area is cleaned for hygiene purposes.
Positioning:
- The positioning of the patient is lithotomy (with the legs laid out, raised, and separated in stirrups) to allow access to the cervix.
Stitching:
- The surgeon uses heavy sutures to place around the cervix and tighten it, depending on which procedure has been carried out (McDonald, Shirodkar, or TAC).
- In some instances, additional reinforcement by tucking in the cervical tissue may also be done.
Knotting:
- The suture is tied tightly to prevent the cervix from opening. The knot’s location may vary depending on the procedure.
Post-Operative Monitor:
- The patient is observed for several hours to monitor for uterine contractions, bleeding, or signs of infection.
Recovery and Discharge:
- Most patients are released on the same day or after very brief hospitalizations. Advice on rest and restricted activities was given in the days that followed.
Stitch Removal (if needed):
- Normally, the stitch is going to be taken out at about 36-37 weeks of pregnancy or earlier, depending on the onset of natural labor.

When is Cervical Cerclage Removed?

Cerclage is often pulled out from about thirty-six to thirty-seven weeks of gestation to facilitate spontaneous physiological delivery. However, cerclage can be taken out earlier in some circumstances, such as:

Preterm Labor Signs End: Removal may occur if contractions or signs of early labor develop to avoid complications.
Rupture of Membranes: Usually, it’s left to nature; unfortunately, when the bag of waters ruptures earlier, then removal becomes necessary.
Infection Manifestations: With conditions like chorioamnionitis, immediate removal of stitches may be warranted.
Term of Pregnancy: In uncomplicated cases, it is removed even before delivery to allow normal physiologic opening of the cervix during labor.

Potential Risks & Benefits of Cervical Cerclage

Benefits:
- Prevention of Preterm Birth: Helps in preventing premature opening, thus helping in the prevention of premature delivery.
- Ensures High-Risk Pregnancy Safety: Effective for women with a history of loss in the second trimester or a diagnosed short cervix.
- Boosts Fetal Survival Rates: The procedure enhances the possibility of carrying the pregnancy to term through the maintenance of cervical strength.
Risks:
- Infection: The procedure can increase the risk for infection in both the uterus and cervix.
- Bleeding: Some minor bleeding or spotting might occur after surgery.
- PROM: Sometimes, it can cause the membranes to weaken and break the water.
- Cervix Injury: Rarely, the cervix may tear during your procedure or delivery.
- Preterm Contractions: Some women experience uterine contractions in the post-procedure stage.
- Risk of Miscarriage: Threats to the pregnancy for rare complications of such a type of procedure can cause loss.

Precautions After Cervical Cerclage

Some precautions are to be adhered to after having a cervical cerclage put in place for the surgery to guarantee a smooth recovery and protect the pregnancy:

Rest and limited activity: Put less pressure on the cervix by avoiding heavy lifting, strenuous activities, or standing in one position for prolonged periods.
Pelvic rest: Engage in no sexual intercourse, douching, or tampon use as per your physician’s orders.
Watch for Warning Signals: Any abdominal pain, contractions, vaginal bleeding, or leakage of fluid should be reported immediately.
Regular Prenatal Visits: Attend all scheduled visits for cervical monitoring and overall health of pregnancy.
Exercise fluids and nutrition: Drink lots of water, eat balanced meals, and give your body the good stuff to support fetal development and well-being.
No long travels: Avoid exhausting travels to avoid stress on the cervix and for medical support in case of emergencies.
Do-as-Are-Directed Medications: Take the prescribed medication (antibiotics or progesterone) as directed to protect against infection and to stabilize the cervix.

When should you call a doctor after cervical cerclage?

Contact your doctor as soon as possible after cervical cerclage if any of the following symptoms occur:

Severe Abdominal Pain or Cramping: Constantly debilitating pain may be a harbinger of further complications.
Vaginal Bleeding: Heavy or big clots would necessitate emergency medical attention.
Fluid Leakage: Signs of dripping amniotic fluid may mean ruptured membranes.
Fever or Chills: A body temperature above 100.4°F (38°C) may indicate an infection.
Unusual Vaginal Discharge: Discharge smelling bad, green, or yellow may indicate an infection.
Painful Contractions: Frequent and painful contractions may suggest that you are going into early labor.
Decreased Fetal Movements: Any noticeable decrease in your baby’s movements should be reported.

Conclusion

Cervical cerclage is imperative for cases of cervical incompetent premature dilatation of a woman and has been noted to appreciably decrease the rate of preterm birth as well as strengthen the chances of maintaining a healthy pregnancy.

Though not without its disadvantages, taking care and swift medical attention, along with follow-up visits, will ensure success: The procedure is under the aegis of the Obstetrics & Gynecology department, where such specialized care is critical. Patients seeking the most care and guidance on cervical cerclage procedures will find Rungta Hospital equipped with state-of-the-art facilities and well-renowned personnel to offer excellent treatment and support for mothers-to-be.

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