Cervical Encerclage Treatment in Bangalore

What is cervical cerclage?

Cervical cerclage, also known as a cervical stitch, is a treatment for cervical incompetence or insufficiency, when the cervix starts to shorten and open too early during a pregnancy causing either a late miscarriage or preterm birth.

When is it done?

Usually the treatment is done in the second trimester (12-14 weeks) of pregnancy, for a woman who had either one or more late miscarriages in the past. It can be planned prior to pregnancy when it is done abdominally and laparoscopically.

Who needs a cervical circlage?

A doctor might recommend a cerclage be performed if a woman has one or more of the following risk factors:

• a previous preterm delivery
• previous trauma or surgery to the cervix
• H/O early rupture of membranes ("breaking water")
• hormonal influences
• abnormalities of the uterus or cervix

In women with a prior spontaneous preterm birth and who are pregnant with one baby, and have shortening of the cervical length less than 25 mm, a cerclage prevents a preterm birth and reduces death and illness in the baby.

What are various methods of it?

Types: There are three types of cerclage

Mc Donald’s circlage is essentially a pursestring stitch used to cinch the cervix shut; the cervix stitching involves a band of suture at the upper part of the cervix while the lower part has already started to efface. This cerclage is usually placed between 16 weeks and 18 weeks of pregnancy. The stitch is generally removed around the 37th week of gestation

A Shirodkar cerclage is very similar, but the sutures pass through the walls of the cervix so they're not exposed. The Shirodkar procedure sometimes involves a permanent stitch around the cervix which will not be removed and therefore a Caesarean section will be necessary to delivera an abdominal cerclage, the least common type, is permanent and involves placing a band at the very top and outside of the cervix, inside the abdomen. This is usually only done if the cervix is too short to attempt a standard cerclage, or if a vaginal cerclage has failed or is not possible. A c-section is required for women giving birth with a TAC. A transabdominal cerclage can also be placed pre-pregnancy if a patient has been diagnosed with an incompetent cervix.

What are the preparations made before cerclage?

Before the procedure may be performed, there are a number of preparatory steps that must be taken. A complete medical history will be taken. A cervical exam will be necessary to assess the state of the cervix; usually a transvaginal (through the vagina) ultrasound will be performed. No food or drink will be allowed after midnight before the day of surgery to avoid nausea and vomiting during and after the procedure. The patient will also be instructed to avoid sexual intercourse, tampons, and douches for 24 hours before the procedure. Before the procedure is performed, an intravenous (IV) catheter will be placed in order to administrate fluids and medications.

Lap circlage- how is it done?

The procedure is performed under anesthesia through a laparoscopic ports. The peritoneum overlying the bladder and uterus is divided, and the bladder is pushed caudally. The uterine vessels are identified and displaced laterally, and a suture is then placed around the cervix at the levelof the internal os. The suture is tied posteriorly; this is to allow removal of the suture by posterior colpotomy if necessary. Some surgeons tie the suture anteriorly. The uterine vessels have to be dissected from the cervix to allow insertion of the suture medially. The technique is more demanding than that by the vaginal approach, and might lead to excessive bleeding from the uterine vessels. Transillumination of the uterine vessels and their branches with a laparoscope, and placing the suture through the avascular area of the paracervical tissue medial to the vessels, have been proposed. Most cases of abdominal cerclage have been performed during pregnancy, usually after 10 weeks of gestation. Abdominal cerclage by laparotomy and by laparoscopy have been performed in the pregnant and non-pregnant states. Compaired to open method Lap has faster recovery.

What is aftercare for circlage?

After Care INSTRUCTIONS:

Medicines:

• Take your medicine as directed: 
• Antibiotics: This medicine is given to fight or prevent an infection caused by bacteria. Always take your antibiotics exactly as ordered by your primary healthcare provider. Do not stop taking your medicine unless directed by your primary healthcare provider.
  Pain medicine: You may need medicine to decrease pain. 
• Constipation: Do not try to push the bowel movement out if it is too hard. High-fiber foods, extra liquids, and regular exercise can help you prevent constipation. Examples of high-fiber foods are fruit and bran. Regular exercise helps your digestive system work. You may also be told to take over-the-counter fiber and stool softener medicines. Take these items as directed. 
• Rest: You may need to rest in bed while lying on your left side most of the time. Avoid heavy work to prevent premature labor or delivery. 
• Vaginal or wound care: When you are allowed to bathe or shower, carefully wash without wetting abdominal cuts. Afterwards, put on clean sanitary pad. Change your bandages or pad any time it gets wet or dirty. Avoid placing anything inside your vagina, such as a douche or tampon. Ask your caregivers for more information about vaginal and wound care.

CONTACT A CAREGIVER IF:

• You have a fever.
• You have chills, a cough, or feel weak and achy.
• You have nausea (upset stomach) or vomiting (throwing up).
• Your bandage becomes soaked with blood.
• Your skin is itchy, swollen, or has a rash.
• You have questions or concerns about your surgery, condition, or care.

SEEK CARE IMMEDIATELY IF:

• You feel something is bulging out into your vagina.
• You have clear fluid coming from your vagina.
• You have lower abdominal or back pain that comes and goes like labour pains.
• You have pus or a foul-smelling odour coming from your vagina.
• You have regular contractions.
• You have trouble passing urine.
• You have vaginal bleeding.

What are the results of circlage?

The success rate for cervical cerclage is approximately 80-90% for elective cerclages, and 40-60% for emergency cerclages. A cerclage is considered successful if labor and delivery is delayed to at least 37 weeks.

What is Rescue cerclage?

In cases with advanced cervical dilatation and bulging membranes, it has been referred to as (heroic cerclage) or rescue cerclage due to its poor success rate Cervical cerclage in advanced cervical dilatation with bulging membranes in the second trimester is controversial. The outcome of these pregnancies is usually poor, but without a cerclage the loss of pregnancy is inevitable. The outcome can be improved if initially a uterine contraction suppressant is used and vaginal infection can be treated. These patients need a lot of counseling and be made aware of the risk of losing the pregnancy. Prolonging pregnancy to reach just viable gestations may also increase overall morbidity. It has been suggested that infection is likely to play a part in many cases of miscarriage in the second trimester and therefore screening for infection before insertion of the suture may predict prognosis. However, in women with bulging membranes, delay in the insertion of the suture is likely to increase the risk of infection, due to the increased exposure of the fetal membranes to vaginal bacteria Reported survival rates following emergency cerclage vary from 12.5% to 63% in women with cervical dilatation of >3cm.

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