Cervical Incompetence and Cerclage - 9 - My Approach to Prophylactic Cerclage
Monday, September 22, 2008
Kenneth F. Trofatter, Jr., MD, PhD
“Deeply enough” and “tightly enough” were technical components of good cerclage placement that I learned on my own early in my career and were actually contrary, especially the latter, to the classical approach to cerclage placement that I had been taught. I found that by placing the cerclage deeply into the cervical stroma, it is much more secure, less likely to dislodge, and goes beneath the major blood supply to the cervix so that when you tie the knot “tightly enough”, you do not run the risk of strangulating the cervix. Indeed, when I was originally taught to perform a cerclage I was specifically instructed never to tie the knot too tightly and to place either a finger or a small diameter dilator into the cervical canal and to tie the knot down against that. “Don’t close up an abscess” was the mantra that was drilled into my head. But, as I soon learned, patients with true cervical insufficiency would use the opportunity of the slight opening this left in the cervical canal to eventually ‘balloon’ their membranes past the point of the cerclage.
With these points in mind, my step-by-step approach to cerclage placement in the patient who is having this done prophylactically at 13-14 weeks is the following:
1) Perform an ultrasound and offer combined first trimester screening for aneuploidy at 11-12 weeks
2) Evaluate the cervix by speculum examination to determine the amount of cervix present in the vagina (portio vaginalis)
3) During the latter, send diagnostic studies for Chlamydia and gonorrhea if appropriate and evaluate the vaginal fluid for evidence of bacterial vaginosis
4) Evaluate the urine for evidence of a urinary tract infection
5) Treat any cervical, vaginal, or urinary tract infections before cerclage placement
6) Prophylactic antibiotics and tocolytic agents are usually not used for prophylactic early cerclages
7) The procedure itself is usually performed under regional (epidural or spinal) anesthesia
8) The patient is placed in the dorsal lithotomy position and the perineum and vagina prepped with a betadine solution
9) The bladder is emptied or a foley catheter is placed after the patient is prepped
10) A weighted speculum is placed in the vagina and the cervix is visualized with retractors – good assistance and visualization is very important to adequate cerclage placement
11) The cervix is grasped at the 12:00 o’clock position with a sponge stick and downward traction applied to ascertain the junction between the vaginal mucosa and the cervix – in and out movement of the sponge stick while holding the cervix can help to readily identify this anatomical landmark
12) A double-strand of #5 Ethibond is loaded on a free CT-1 needle and the tails are together held with a hemostat
13) Using the edge of the needle to push up on the junction between the cervix and vaginal mucosa (this will often give an additional cm or more of cervical length) the cerclage is begun at the 12:00 o’clock position by deeply seating (about two-thirds of the depth of the cervical stroma) the suture, angling the needle somewhat cephalad with each ‘bite’ of the cervix, and exiting between 9:00 and 10:00 o’clock.
14) The sponge stick is then moved to 9:00 o’clock, the retractors are repositioned, the next ‘bite’ of the cervix is begun right where the needle last exited (being careful not to place the needle between the double-strand of suture), and then exited between 7:00 and 8:00 o’clock.
15) The next stitch is VERY important (and also very risky once there has been cervical change later in the pregnancy). The cervix is grasped at 6:00 o’clock and the cervix pulled upward, retractors repositioned, and the next bite is placed as high as possible posteriorally on the cervix exiting between the 4:00 and 5:00 o’clock positions.
16) Movement of the sponge stick to 3:00 o’clock is done, the next stitch exited at 2:00 to 3:00 o’clock and then one more time brings the suture back to the 12:00 o’clock position (As you can see, I typically use a “five point” approach to cerclage placement with significant support brought to the posterior aspect of the cervix)
17) The next step is also VERY important. Before tying the knot, I cinch the suture material up snugly by grasping both ends of the suture and moving it through the tissue 3-4 times, seating the suture material even more deeply
18) I then tie the knot TIGHTLY with 6-7 knots – enough to cause slight cyanosis of the cervix before I leave the operating room
19) Irrigate the vagina with warm (not hot) saline (not squirting this into the cervical canal) and then DRY the vagina completely with sponges
20) The cervix should be slightly cyanotic at this point and ‘pouting’ at you; if the cerclage is well-placed, this pouting should be very symmetrical
21) The patient is not discharged until she can void on her own (and I will often leave the catheter in place until her full sensation to void has returned to avoid overdistention of the bladder and a call from the operating room nurse informing me that the patient has “ruptured membranes,” usually leaking urine from an overly full bladder)
22) The patient is given a prescription for ibuprofen 600 mg q 6 hour, instructed to use this for the expected cramping sensation she will experience, and told to call if she needs to use the medication for more than 72 hours.
23) She is scheduled for a tranvaginal ultrasound 2-3 weeks following the procedure to assess cervical length, integrity at the internal os, and the level of the cerclage placement
I fully realize that some components of my approach to cerclage placement may be controversial, but I can assure all of you who read this that this approach has worked well and has been accompanied by virtually no complications in the prophylactic cerclages I have performed for more than 20 years. In the next post, I will go through my approach to ‘rescue cerclage’ placement….
Labels: cerclage, cervical incompetence, cervical insufficiency; premature labor
10 Comments:
At Wed Sep 24, 01:41:00 PM 2008,
Stephanie said…
Hello Dr.T,
Thank you for this post. My name is Stephanie and you have been very helpful to me on your early pregnancy loss thread. I am 25 weeks pregnant with twins and have 1.5 cm cervical length with a McDonald cerclage. This post is great because there is a support group on MSN.com for Incompetent Cervix, and all of the women on there seem to feel the Shirodker is best and have very negative things to say about the McDonald. Since I have the McDonald, it is very encouraging to see this post.
Thanks again,
Stephanie
At Wed Sep 24, 07:01:00 PM 2008,
Mikki said…
Dear Dr. T.
I have a question about my rescue cerclage done last Wednesday at 22 weeks gestation. I work long hours on my feet. (12 hrs a day). At 29 weeks I started having contractions after I had my level 2 ultrasound a few days earlier. After the dr requested another ultrasound, my cervix went down to 1.6 cm with funneling. The dr performed the cerclage the next day. My OBGYN is very experienced with fantastic reviews. Yesterday (1 week later) I went for my follow up appt and the dr said that the surgery went well, placement was excellent and all the possible complications that they worry about when placing cerclages, none happened with me. So he said in another week from now I can resume normal activity and my stitches will come out at 37 weeks. What I wanna know from you though is what do you think the likelihood of me getting to 37 weeks is from what I told you? And do you agree that I can do normal activity? What do you assume the dr meant by it's in a good place? And is 1.6 cm THAT BAD?? I appreciate any advice. And thanks for the blog. Amazing read.
Yours sincerely,
Mikki
At Tue Oct 07, 11:46:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Stephanie: In most cases (but not all) it is not the type of cerclage, but the way it is placed that makes the difference. You should now be about 27 weeks, so best wishes and hang in there as long as possible! Let us know how things turn out. Nice to hear from you again. Dr T
At Tue Oct 07, 12:02:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Mikki: Sorry, but I do not have my crystal ball working today. Ask the doctor to show you an ultrasound picture of your cervix with the cerclage in place and explain exactly what you want to know. If your cervix was only 16mm at 22 weeks, that would have put you in a high risk category for premature delivery, especially if this is your first baby. I don't know if going back to a "12 hour" day at work is such a good idea at this point though. I usually recommend cutting back on strenuous activity, prolonged time on your feet, and intercourse until you get to a point of reasonable viability - beyond 28 weeks in my book. That's just my own opinion, but I don't like to 'challenge' even a well-placed cerclage in women who may well have cervical incompetence. Good luck and let us know how things turn out. Dr T
At Sat Oct 18, 08:29:00 AM 2008,
Sujita said…
Hello Dr. T,
Thank you very much for this information. I would like to ask your opinion on the effectiveness of progesterone pessaries vs. the stitch for cervical incompetence.
I have had 2 terminations (at 5 and 6 weeks resp.). Around 2 yrs after my 2nd second termination I had a planned pregnancy which at 19 weeks saw dilation of the cervix and bulging membranes. The membranes were bulging for six days without pain when I went to seek a second opinion. This doctor showed me the scan showing the umbilical cord prolapsed and said it was better not to place the emergency stitch. So after 2 more days this doctor said there was no point in prolonging it and induced me. One year later I got pregnant again and this time had a stitch placed at 11 weeks. My cervix did funnel around 18 weeks, to 1.5cm above the stitch when I was placed on strict bedrest at hospital and had progesterone pessaries. at 20 weeks the cervix had closed up. (I was on bedrest anyway from 12 to 36 weeks at home). My stitch was removed at 37 weeks and I was induced at 39weeks. Now I am pregnant again. However, it's a different doctor treating me (national health service, so we don't get to choose!) and he believes that progesterone pessaries alone are sufficient, and that a stitch is not necessary. He has offered me close monitoring of the cervix (every week) with the pessaries, or the stitch and scans every 2-3 weeks. I am afraid that a scan once in 3 weeks during the crucial period of 16-20 weeks won't be enough to detect the funelling in my case (which has been at 18 weeks unfailing!).
I would like to know your opinion, do you think the progesterone alone is sufficient?
At Tue Oct 21, 06:58:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Sujita: With your history, personally, I do NOT think the progesterone pessary alone is sufficient. You probably need a consultation with a specialist in Maternal-Fetal Medicine for a second opinion. Good luck and thanks for writing. Dr T
At Mon Nov 17, 10:43:00 AM 2008,
Anonymous said…
I have a question about my McDonald Cerclage (which is still in place). I was high risk due to PROM in a prior delivery so I had to go to a specialist to have a cerclage. The doctor released me and advised me that my gyno could remove the cerclage when it was time. I went into my gyno at 38 weeks to have it removed and he clipped on side and was not able to clip the other. I had by baby at 38 1/2 weeks gestation by c-section with no complications she weighed 8.4. I went back for my 6 week follow up and when I went to have my pap they advised not to worry about the removal of the cerclage I did have my tubes tied and do not plan to have any other children. Is this okay to leave inplace. I have had brown/pink discharge everyday and and irregular periods since then inaddition to bright red bleeding with intercourse. Is this an okay thing to do? Is it safe? Thanks for your help
At Fri Nov 21, 07:11:00 PM 2008,
Anonymous said…
Dear Dr. T.,
I have been pregnant 4 times and do not have any children. My husband and I started trying in April 2007. I got pregnant right away and had a miscarriage in June at 6 weeks followed by a DNC. I got pregnant again in August and carried the baby for 21 1/2 weeks and then went into pre-term labor and was told I had an infection. I had to have another DNC and a blood transfusion at North Shore Hospital on Long Island because I could not make it to my doctor at Columbia Pres.. I did a lot of research and got third and fourth opinions from top doctors at Yale Maternal Fetal Medicine, Columbia Pres. Maternal Fetal Medicine, Lenox Hill in NYC and North Shore. All of the doctors came to the conclusion that it was a freak virus. I had my uterus, fallopean tubes and cervix examined by x-ray in Feb., chromosomal tests on myself and spouse all which came out normal. I then got pregnant in March and miscarried (blighted ovum) at 5 weeks. I did not have a DNC this time. I got pregnant again July 3rd and at 18 1/2 weeks my doctor saw that my cervix opened 1 cm. She was checking me weekly and giving me progesterone shots. I went straight to the hospital via ambulance and had a cerclage the following day but my membranes were bulging out and I was dialated almost 2 cm. The procedure seemed to go well and I was in the hospital for almost 2 weeks on bed rest and was scheduled to be sent home the following day. My doctor checked my cervix and the membranes were again bulging out. I ended up losing the baby that evening. She also said the placenta smelled so I might have had a low grade infection. I am devastated and want to try again but am scared and want to know how well cerclages work, how to avoid infection and what your thoughts are on my situation? Thank you in advance for your time.
Sincerely,
Heartbroken
At Fri Nov 28, 10:34:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Nov 17: Usually you just need to clip one side of the cerclage and then pull it out. If both sides were clipped, the knot might have been removed, but the cerclage material itself may have retracted into the cervical tissue where it cannot be easily taken out. My only suggestion would be that if you continue to have problems and think that might be related to retained cerclage suture, go back to the doctor who put it in to begin with if your own doctor does not want to handle it. Best wishes. Dr T
At Fri Nov 28, 10:40:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To heartbroken: Based on what you have told me, I believe you have an incompetent cervix. I think your "infections" were not the primary cause of your losses, but the result of premature cervical change associated with the incompetent cervix. Before you get pregnant again, I recommend that you have a sonohysterogram done by a specialist in Reproductive Endocrinology and Infertility to evaluate your uterine cavity to rule out the possibility of a congenital uterine abnormality. If all that checks out okay, after you get pregnant again, you need a good cerclage placed by a very experienced person at about 13 weeks gestation. You should then be followed by serial cervical evaluation by ultrasound. I will have some other suggestions for you at that point if you would like to get back in touch. Best wishes and I am so sorry for what you have been through. Dr T
Post a Comment
<< Home