2016
Introduction
Cervical cerclage, sometimes referred to as cervical suture or
stitch, is a procedure carried out to prevent pregnancy loss
due to cervical weakness, by placing a suture around it.
Late miscarriage and extreme
premature birth
Late miscarriage and extreme premature birth are very
traumatic for a couple, physically and particularly
psychologically.
It appears that the integrity of the cervix is partly assured by its length.
In normal pregnancy the cervix is more than 40 mm long at 18 weeks of gestation.
This is manifested by approximately 2 cm of vaginal cervix and 2 cm of
supravaginal cervix.
Logically, a cervical strengthening suture would be most effective at the internal os. Use of a Shirodkar technique is more likely to achievethis, while use of a McDonald technique5 may result in a lower suture.
Clinical assessment
Persistent placental bleeding after 8 weeks of gestation is associated with midtrimester membrane rupture and pregnancy loss.
they should have ultrasound assessment of cervicallength at 17 weeks of gestation.
Visual and digital examination of the cervix is crucial.
Case selection: transvaginal ortransabdominal suture?
indications for transabdominal suture are a grossly disrupted cervix (Figure 2) or an absent vaginal cervix (Figure 3), and previous failed elective vaginal cerclage.
The first two are the most obvious indications.
If there is a good portion of the vaginal cervix present, we believe that one option is a
well-placed Shirodkar suture with bladder reflection, an anterior knot and short trimming of the ends, which are then buried by closure of the vaginal skin incision.
Transabdominal open surgical cervical cerclage
The obvious candidate for the transabdominal technique is a
woman with a severely damaged cervix and midtrimester loss
where a vaginal suture is impossible.
In his personal experience of 98 cases, the first author found the following
practical points to be useful:
- An earlier operation (9–12 weeks of gestation) is easier, particularly when there is a multiple pregnancy.
- Obesity and abdominal scarring from previous surgery make for a more difficult operation.
- Regional anaesthesia may not be adequate, as experienced in one case requiring conversion to general anaesthesia.
We have used general anaesthesia whereas other authors
have reported satisfactory use of regional anaesthesia.
Laparoscopic technique
The first laparoscopic transabdominal cerclages were reported by Scibetta et al.24 and Lesser et al. in 1998.
Lesser et al. placed their first laparoscopic suture in a pregnant woman at 11 weeks of gestation.
The pregnancy continued and the baby was delivered by caesarean section at 35 weeks of gestation because of gestational diabetes.
Complications
Some of the complications of laparoscopic cerclage are the inherent risks of laparoscopic surgery, such as visceral or major blood vessel injury; others are specific to the cerclage
procedure.
Specific complications include bleeding fromuterine vessels and loss of pregnancy for non-interval procedures.
In the largest case series, which included 31 procedures during pregnancy and 34 interval procedures,
there were two fetal losses (2/31, 6.4%) and seven laparotomies (7/65, 10.8%)
Preterm labour, midtrimester rupture of membranes and
intrauterine fetal death are challenging complications after transabdominal cerclage.
In this situation either the suture needs to be removed or the pregnancy is terminated via
hysterotomy.
The other reported complications of transabdominal cerclage, such as suture migration,
rectouterine fistula some years later (one case we have seen after open transabdominal suture), uterine rupture and intrauterine growth restriction are rare and can be seen with
both laparoscopic and open approaches.
In cases of posterior knot, the suture may be removed via a posterior colpotomy.
Laparoscopic removal of the suture has also been reported.
Comparison of laparoscopic technique with the open approach
There are no prospective trials comparing the laparoscopic
and open approaches.
However, at least two publications have compared the outcomes of laparoscopic cerclage
procedures, either with retrospective open controls or
against the published results in the literature.
The report by Whittle et al.30 showed an 89% fetal salvage rate after
laparoscopic cerclage, while a 60–100% success rate was
found in the literature using the open technique.
The reports concluded that the laparoscopic
approach compared favorably to the abdominal approach.
The laparoscopic approach has the advantages of shorter
hospital stay, quicker recovery and better cosmesis. It may
also have a lower risk of surgical complications compared
with the open technique.
Interval versus non-interval procedures
interval procedures are easier and avoid the risk of fetal loss.
If laparoscopic skills are available, then planned open interval laparotomy has no value.
Laparoscopic planned procedures rarely require non-planned laparotomy,
while the reported conversion rates for non-interval laparoscopic procedures are approximately 10%.
The procedure requires active, and often acute, anteversion and retroversion of the uterus by an assistant with an instrument placed in the cervical canal. This is not desirable during
pregnancy.
For this reason it is preferable to carry out laparoscopic cerclage as an interval procedure before a woman becomes pregnant.
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