Cervical Cerclage

Published on 30/05/2015 by admin

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Last modified 30/05/2015

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Chapter 233 Cervical Cerclage

DESCRIPTION

Cervical cerclage is the placement of a suture or tape to support and partially occlude the uterine cervix to reduce the risk of preterm delivery in the face of cervical insufficiency. A number of procedures have been described, but the most common and simplest is the McDonald cerclage, which is described here. Cervical cerclage may also be accomplished by placing the suture by an abdominal route, although this is a much more invasive procedure and the suture is generally left in place permanently, precluding vaginal delivery.

INDICATIONS

Cervical incompetence as documented by a history of preterm pregnancy loss associated with painless cervical dilation or prolapse and ballooning of the fetal membranes into the vagina without labor. Prophylactic cervical cerclage is generally delayed until after 14 weeks so that early pregnancy losses from other factors may be resolved.

CONTRAINDICATIONS

Bleeding, uterine contractions, obvious infection, or rupture of the membranes. Beyond 24 to 26 weeks, bed rest or other treatments are often preferred because of the increased risk of surgically related labor.

REQUIRED EQUIPMENT

• Skin (vaginal) preparation materials (iodine-based antibacterial solution [e.g., Betadine] or other suitable cleansing agents)
• Sterile gloves
• Number 1 or 2 permanent synthetic suture (Prolene or similar) or 5-mm woven tape (Mersilene or similar) on a medium blunt needle (Monofilament sutures are easier to pass through the tissues, but a broader tape provides more support and less chance of suture erosion into or through the cervix.)
• Needle holder, long thumb forceps, suture scissors
• Retractors (two Deaver or right-angle retractors and/or weighted speculum)
• Sponge stick (may be useful to atraumatically grasp and manipulate the cervix)
• Foley or straight catheter (optional)
• External fetal heart rate monitor or Doppler fetal heart detector

TECHNIQUE

After appropriate informed consent has been obtained, ultrasonography should be performed to confirm a living fetus, exclude major fetal anomalies, and assess cervical length. Any obvious vaginal or cervical infections should be treated, and cultures for gonorrhea, chlamydia, and group B streptococci should be obtained prior to proceeding. (Sexual intercourse is generally proscribed for 1 week before and after the procedure.)

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