Cervical Cerclage, Placenta Previa and Placenta Accreta - Surgical Specialization and Experience
Modern obstetric surgery faces significant challenges when dealing with complicated conditions that threaten the lives of mother and fetus. The three main conditions requiring surgical specialization and surgical experience are cervical insufficiency requiring cerclage, placenta previa, and placenta accreta.
These pathological conditions are major causes of maternal and perinatal morbidity and mortality worldwide. Timely diagnosis and appropriate surgical treatment are of crucial importance for successful pregnancy outcome.
Cervical Cerclage
Definition and Indications
Cervical cerclage is a surgical technique aimed at strengthening the cervix so it remains closed during pregnancy. Cervical insufficiency is characterized by the cervix's inability to maintain pregnancy due to premature dilation without contractions.
Main indications:
- History of second-trimester miscarriage
- Previous preterm birth due to cervical insufficiency
- Previous surgical procedures on the cervix
Surgical Techniques
- McDonald Technique: The McDonald technique is the most commonly applied method. It involves placing a circular suture around the cervix at the level of the internal os. The procedure is usually performed between 12-14 weeks of pregnancy.
- Shirodkar Technique: The Shirodkar technique is more complex and involves creating a submucosal tunnel for suture placement at a higher level. It is preferred in cases of significant cervical shortening. The procedure is performed by a specialized urogynecologist as this technique requires bladder mobilization.
- Postoperative Monitoring: After cerclage, monitoring is required to rule out rare complications such as membrane rupture or premature contractions.
Placenta Previa
Placenta previa is characterized by implantation of the placenta in the lower part of the uterus, partially or completely covering the internal os of the cervix. This condition can cause painless bleeding, usually during the third trimester of
pregnancy. The placenta may completely cover the internal os of the cervix (complete previa) or reach close to the edge of the internal os of the cervix (marginal previa).
Diagnostic Methods
Ultrasound examination is the method of choice for diagnosis. Transvaginal ultrasound provides higher diagnostic accuracy.
Surgical Management
During pregnancy, the pregnant woman is closely monitored with frequent clinical and ultrasound monitoring, possible administration of corticosteroids to accelerate pulmonary maturation, and tocolytic drugs.
- Cesarean Section: Cesarean section is always required for delivery in cases of placenta previa.
- Special Surgical Techniques: There is always a risk of bleeding during pregnancy or delivery. In severe cases with massive hemorrhage, the following may be required:
- Surgical hemostatic techniques
- Vascular interventions (uterine artery embolization)
- Hysterectomy in cases of uncontrolled bleeding
The skill and experience of the gynecologist surgeon plays a decisive role in the smooth outcome of cesarean section without complications.
Placenta Accreta
Placenta accreta is a serious pregnancy complication where the placenta attaches excessively deeply to the uterine wall. This condition can cause severe bleeding during delivery and requires specialized medical care and surgical treatment.
- Risk Factors
- Previous cesarean section: the placenta adheres to the previous cesarean section site of the uterus
- Previous surgical procedures on the uterus: such as fibroid removal
- Symptoms and Diagnosis
Often the condition does not cause symptoms during pregnancy. Diagnosis is made with ultrasound and magnetic resonance imaging (MRI) for more detailed assessment.
- Treatment Options
- Close pregnancy monitoring by a specialized gynecologist surgeon
- Preparation for possible bleeding
- Surgical Treatment
- Cesarean section and uterine preservation while hysterectomy is necessary only in severe cases
Conclusions
Surgical management of complicated obstetric conditions is a complex clinical field requiring specialized knowledge, experience, and immediate decision-making. Cervical cerclage, placenta previa, and placenta accreta are serious conditions requiring individualized approach. Successful management of these conditions depends on team collaboration that includes the gynecologist surgeon, anesthesiologists, and neonatologists. Personalized care, use of modern diagnostic means, and application of appropriate surgical techniques are essential elements for achieving optimal outcomes for both mother and newborn.
Kostis Nikolopoulos has the experience and training for safe management of complex conditions in pregnancy and delivery.
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