Cervical Cerclage

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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.

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.)

The anesthetized patient is placed in the dorsal lithotomy position, the vagina and cervix are disinfected, and the cervix is visualized using retractors. Some authors advise distending the maternal bladder to elevate the fetal presenting part, relieve pressure on the fetal membranes, and define the cervicovesical reflection. For right-handed surgeons, the needle is first placed entering the cervix at the 11 to 12-o’clock position near the inner cervical os, taking care to avoid injury to the bladder. The suture is passed below the surface of the cervix, incorporating some of the parenchyma, and exiting at about the 10-o’clock position. The suture then is passed once again into the cervical tissue, entering at about the 8-o’clock position and exiting posteriorly near the 6- to 7-o’clock position. The circumferential suture is carried up the opposite side in a similar manner, terminating at about the 1-o’clock position, where it is firmly tied to the first portion of the suture. The suture should not cause blanching of the tissue but should narrow the cervix so that it will not admit the gloved finger. The tied suture should be both tied and cut in such a manner as to facilitate eventual location and removal.

Based on the size of the cervix and needle chosen, it may be necessary to take additional bites to accomplish adequate circumferential support. Care should be taken that the portions of the suture at the 3- and 9-o’clock positions are shallow or outside the cervical epithelium to minimize the risk to the descending cervical branches of the uterine vessels.

Following conclusion of the procedure, the fetal heart is monitored to assure normal fetal status. Prophylactic antibiotics or beta-mimetic drugs have not been shown to be of any benefit in reducing the rate of complications or preterm labor.

When the suture is to be removed (generally at 38 weeks and always if labor ensues before that time), it may be carried out in the office or labor and delivery area by firmly grasping the knot or visible suture ends and applying traction to identify one side of the suture below the knot. Snipping this portion of the suture allows traction on the knot to pull the suture through the tissues and be removed. An anesthetic may be required based on exposure, patient comfort, and provider or patient preference.

COMPLICATIONS

Preterm rupture of the membranes (1% to 18%, up to 65% of emergent cases), chorioamnionitis (1% to 7%, up to 35% of emergent cases), bleeding, damage to adjacent structures (bladder or rectum). Scarring from the procedure may lead to cervical lacerations during labor (1% to 13%) or failure of the cervix to dilate (2% to 5%).

FOLLOW-UP

Fetal and maternal monitoring is generally carried out for 12 to 24 hours or longer depending on clinical factors.

When the suture is placed vaginally, it is generally removed at 38 weeks of gestation. If labor occurs before this point, the suture must be removed immediately. Because of scarring after cerclage, about 15% of patients require cesarean delivery.

CPT CODE(S)

59320 Cerclage of cervix, during pregnancy; vaginal

59325 Cerclage of cervix, during pregnancy; abdominal

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