Cervical Failure, Cervical Stitches, Cervical Failure & Cerclage

What is cervical insufficiency or cervical insufficiency?

Cervical insufficiency is when, for some reason, the cervix begins to open, usually silently, from the 3rd month of pregnancy. Especially from the 4th month of pregnancy, the insufficiency gradually increases and by the 5th or even 6th month the child cannot be held in the uterus. In some special cases due to the very short cervix (cervix), we rarely have cases with follow-up starting as early as 12 weeks or even as early as 9 weeks of pregnancy.

How should the ultrasound examination and patient evaluation be?

The cervix and the lower end of the uterus should be evaluated very well by ultrasound examination. In some cases, speculum examination should also be performed.

NOTE: Some cases are very different. We do not evaluate every case in the same way. A very detailed history is essential. The patient’s past pregnancies should bemeticulously questioned. In short, our experience of more than 2,000 cases has given us many different details (see Figure 1).

Figure 1. Sterile speculum examination clearly shows the water sac coming out of the cervix.

Figure 2. When the same case as in Figure 1 is pushed, the water sac protrudes a little further and it is very clear that the outer membrane is damaged. We did not suture the cervix in this case because of the damaged outer membrane.

AT WHICH WEEKS IS CERCLAGE SUTURING PERFORMED?

It can be done after the 12th week of pregnancy. Our experience tells us that cerclage suturing is individualized. When the history of each case is carefully questioned and a detailed examination of the cervix is performed, there will be differences for each patient.

In developed countries, due to the possibility of keeping the baby alive with specialized care, the upper limit of cerclage is usually 24 weeks of gestation; rarely, cerclage can be placed up to 28 weeks.

LIFE LIMIT OF THE BABY and Cerclage Suture

According to generally accepted scientific data, except for exceptions, babies born below 24 weeks of gestation do not survive and the period between 24-26 weeks of gestation is called the gray zone. Babies born in these gray weeks (24-26 weeks of gestation) are very troubled babies.

In more general terms, babies born below 28 weeks of gestation are born as severely premature babies and may experience neurological disorders in their lives.

Note: When scientific articles and neonatology association data in our country are examined, there is an average difference of 2 weeks in terms of infant mortality (death) compared to some developed countries. In other words, infant mortality rates at 26 weeks of gestation in some developed countries are more or less equivalent to those at 28 weeks in our country. In this case, according to our experience , cerclage can be performed and we recommend it for cases of cervical insufficiency between 24-28 weeks of gestation (when the water sac comes out of the cervix).

We can say this in the light of our experience from the cases in which we have performed more than 2 thousand cervical insufficiency sutures (cerclage sutures). In other words, up to 28 weeks, in special cases, we perform cerclage sutures. These weeks not only give them a chance of survival but also a chance to live without sequelae.

IF THE BABY’S FEET HAVE PASSED THROUGH THE UTERINE CERVIX, AND THE FEET ARE IN THE VAGEN, CAN A CERCLAAGING STITCH BE DONE? It can be done. If you are very experienced, of course it can be done. In emergencies, you must undertake the follow-up of the patient 24 hours a day and night. It requires close follow-up and planning, with the responsibility being on the physician.

We have a large number of such cases and we have achieved many healthy pregnancies. We perform successful emergency cerclage sutures in pregnant women who accidentally feel the water bladder with their hand while it is in the vagina, the baby’s feet are in the vagina or the water bladder is very prolapsed. In these cases, a careful examination of the water bladder should be performed and the cases in which a cerclage suture should or should not be performed should be carefully identified. For example, in the case in Figure 2, we did not perform an emergency cerclage suture because the outer membrane of the water bladder was damaged after careful examination.

Figure 3. A case in which the baby’s feet protruded from the cervix and came to the middle of the vagina with the water sac.

Figure 4. The image of our patient after cerclage suturing, whose feet were seen in the vagina in Figure 3.

OUR CERVICAL SUTURING TECHNIQUE

The most commonly used technique is the McDonalds suture technique. We have modified this technique over the years and place our suture in a different way.

For whom is cervical cerclage suture performed?

• Previous loss due to cervical insufficiency
• Short cervix length in an existing pregnancy (short cervix)
• Pregnant women whose water sac has protruded through the cervix (emergency rescue cerclage)
• Cases of deep and wide cervical intervention (LEEP, conization, etc.)
• Pregnancy loss due to a short cervix (short cervix)

IS CERVICAL STITCHING DONE FOR MULTIPLE PREGNANCIES? Of course it is.

If there is cervical insufficiency or short cervix in multiple pregnancies such as twins, triplets or quadruplets, we suture the cervix (cerclage suture).

Contrary to the information in the international medical literature and international gynecology books, we suture multiple pregnancies and achieve very successful results. Multiple pregnancies are no different from single pregnancies and have no logic. Due to the small number of cases in international scientific publications, it is not possible for us to agree and accept these views in the literature. Our most important experience is the number of cerclage cases exceeding 2000.

WHAT IS INTERVAL CERCLAGE?

This suture is also a suturing technique unique to us. After the cerclage suture is placed, we place another suture in special cases due to very serious funneling in the following weeks or the water bladder coming back into the vagina. We will share the details of the procedure after our case series is published in the literature.

Figure 5. Interval cerclage. White hand marks indicate cerclage sutures. There is mild funneling after the interval cerclage suture, but note that we have gained sufficient length of the cervix with the sutures (history of this case: A patient with a previous history of failed cerclage and a total of 7 pregnancy losses. We placed the first suture at 14 weeks and then when severe cervical funneling occurred, we placed the second suture at 17 weeks so that we would not lose the pregnancy. Thanks to these sutures, our patient delivered her 8th pregnancy at 38.5 weeks and had a child for the first time).

NOTE: It would have been more logical to perform abdominal cerclage in the case in Picture 5. However, when she came to us, she was in her 8th pregnancy and this was her last pregnancy attempt; therefore, we wanted to take zero risk associated with abdominal cerclage surgery during pregnancy and decided to perform cerclage sutures vaginally, where our chances of success were quite high.

WHAT IS ABDOMINAL CERCLAGE?

Abdominal cerclage (intra-abdominalcerclage ), which is more guaranteed, is performed for those who have previously had pregnancy loss due to cervical insufficiency and whose pregnancy loss continues despite cerclage suturing in subsequent pregnancies.

Which methods are used for abdominal cerclage?

Abdominal cerclage can be performed laparoscopically, i.e. with a camera, or laparotomy, i.e. through a cesarean incision.

We also perform abdominal cerclage in the early weeks of pregnancy (i.e. during pregnancy).

Figure 6. We performed abdominal cerclage at 14 weeks of gestation in a patient who came to us with a history of 3 previous vaginal cerclages. The curved yellow line shows the cervical canal (length of the cervix). The abdominal cerclage in the form of a bright dot passing just below the cervix and indicated by the yellow arrows shows our sutures.

Our patient here has reached day 144 of the abdominal cerclage inFigure 6 and 34 weeks of gestation. The yellow arrows indicate the bright white suture points. You can see that the abdominal cerclage suture was placed exactly at the cervix and was a very successful suture. The baby’s head is almost in contact with the cervical opening.

Are stitches removed in pregnant women who give birth by cesarean section after an abdominal cerclage? No.

Our pregnant women for whom we perform abdominal cerclage give birth at term both in Turkey and abroad; we do not take abdominal cerclage stitches from such pregnant women. When our patients from abroad return to their home countries, if they want to become pregnant again, we recommend that they do not have the abdominal cerclage stitches removed.

Figure 8. Yellow arrows show the abdominal cerclage suture. Yellow curved line shows the length of the cervical canal; our patient is 13.5 weeks pregnant.

There are cases of re-conception with abdominal cerclage suture (see Figure 9).

Figure 9. Yellow arrows point to the abdominal cerclage sutures. We did not remove the abdominal cerclage sutures of this patient in Figure 8 after delivery in 2017 (history of this patient: This patient had unsuccessful vaginal cerclages; then she came to us and we performed abdominal cerclage sutures at 13 weeks, but she unfortunately lost her baby at 35 weeks due to detached placenta. We advised her to conceive again with the same stitches and followed her up; she finally gave birth to a healthy baby at 37 weeks. We still have the abdominal cerclage suture in case she conceives again.

HOW SHOULD ABDOMINAL CERCLAGE EXAMINATION BE PERFORMED?

A detailed history is taken, the patient is questioned very well, a very careful cervix examination and measurement is performed. The lower part of the uterus is evaluated very well.

NOTE: A meticulous examination and questioning should be performed to avoid unnecessary abdominal cerclage stitches in some pregnant women.