Abdominal Cerclage



Abdominal Cerclage


Kelly Benabou

Soorin Kim

Isil Ayhan

Masoud Azodi

Mert Ozan Bahtiyar



GENERAL PRINCIPLES



Physical Examination



  • Pelvic examination is usually performed in the dorsal lithotomy position, using a speculum to visualize the cervix and vagina. Digital examination may be performed; however, careful consideration should be given to patients with cervical dilation and amniotic sac protrusion. Cervical insufficiency can be completely asymptomatic and may be diagnosed in the absence of any contractions or other signs (e.g., bleeding, infection, and/or ruptured membranes).


Differential Diagnosis



  • Other causes of preterm delivery include the following:



    • Maternal infection


    • Intra-amniotic infection or inflammation


    • Uterine anomalies


    • Trauma


    • Placental abruption


Nonoperative Management



  • Daily vaginal progesterone is recommended in asymptomatic women with a singleton pregnancy, who have no history of PTB, and who have a short cervix measuring ≤20 mm before or at 24 weeks of gestation (1). The definition of short cervix is however not well established, and some clinicians use different cut-off values (15-25 mm).


  • A vaginal pessary may be considered in patients who have a short cervix and who are at risk of cervical insufficiency (1).


  • Activity restriction, bed rest, and pelvic rest have not been shown to be effective for the treatment of cervical insufficiency (1).


IMAGING AND OTHER DIAGNOSTICS



  • Serial transvaginal cervical length ultrasound, performed weekly or biweekly from 16 to 24 weeks of gestation, is recommended for women with a history of PTB at <34 weeks of gestation.


  • In our institution, cervical shortening is diagnosed when cervical length measured (from internal to external os) is ≤25 mm on transvaginal ultrasound before 24 weeks of gestation.


  • Patient evaluation for cervical insufficiency may also include tocodynamometry to rule out preterm labor after 20 weeks of gestation.


  • Additional workup may be indicated to rule out differential diagnoses including amniocentesis to rule out intrauterine infection or cervical cultures.



PREOPERATIVE PLANNING



  • In this chapter, we will focus on preoperative planning, surgical management, and postoperative care of patients undergoing abdominal cerclage. Placement of abdominal cervical cerclage may occur pre- or postconceptionally.


  • We recommend performing abdominal cerclage (via laparotomy or laparoscopic/robotic) before 14 weeks of gestation. This procedure may be performed later in pregnancy; however, at that time, it may be technically more difficult and associated with a higher risk for complications.


  • When considering postconceptional placement of abdominal cerclage, it is essential to ensure fetal viability (ultrasound examination between 10 and 13 weeks of gestation) and to rule out genetic abnormalities if possible with noninvasive (NIPT) or invasive (chorionic villus sampling [CVS]) prenatal testing.


  • Contraindications to abdominal cerclage placement include the following:



    • Ruptured amniotic membranes


    • Uterine contractions


    • Any suspicion of intrauterine infection


    • Fetal anomalies incompatible with life


    • Suspected fetal chromosomal abnormality



      • Further discussion with the patient is needed to determine eligibility.


    • Vaginal bleeding


    • Technical considerations


  • In cases of trachelectomy performed for early-stage cervical cancer in ongoing first and early second-trimester gestation, we recommend consideration of simultaneous abdominal cerclage.


SURGICAL MANAGEMENT



  • Indications for placement of cervical cerclage (Figure 2.4.1) in singleton pregnancy are reviewed in Table 2.4.1.


  • The choice of suture material for cervical cerclage is still debated, and no single suture has been shown to be superior to any other (1).


  • Different suture types used for cerclage include the following:



    • Polypropylene suture is formed by propylene polymerization. The main distinguishing feature of this suture is the low coefficient of friction, making it ideal for cerclage (5) as it passes easily through tissue. This same feature, however, can make knots less secure.


    • Polyester suture is made from synthetic, braided, multifilament, polymerized, permanent material and is manufactured in coated and uncoated forms. Mersilene is the most common uncoated form used in obstetric practice. Polyester is nonabsorbable and retains its tensile strength indefinitely being second only to metal sutures in terms of tensile strength (6).


  • Despite the theoretical increased risk of infection with braided suture material, studies have failed to demonstrate any causal relationship between the type of suture material and adverse pregnancy outcomes (7). We favor 5-mm Mersilene tape for abdominal cervical cerclage, regardless of the approach.







Positioning



  • Abdominal cerclage via Pfannenstiel incision is performed with the patient in the dorsal supine position.


  • Laparoscopic/robotic abdominal cerclage is performed with the patient in the dorsal lithotomy position with Trendelenburg tilt.

Sep 8, 2022 | Posted by in OBSTETRICS | Comments Off on Abdominal Cerclage
Premium Wordpress Themes by UFO Themes