OBSTETRICS

Can a child’s speech defect be linked to insulin use in pregnancy? A patient with gestational diabetes at the antenatal clinic asked if insulin causes speech defect in children. She feels one of her child who cannot speak at age 4years was due to the insulin she used to control her blood sugar in that pregnancy. The other child has no problem with speech because she did not use insulin while pregnant. She strongly believes it and also claimed she read online that insulin use in pregnancy causes speech problem in children.

On further probing, she did not develop gestational diabetes in the pregnancy that resulted in that child with no speech problem. Also, the one with speech difficulty is actually having difficulty hearing. So, can insulin use in pregnancy cause speech problem in children? If insulin is not the culprit, what then could be responsible? Stay with me as you will have your answers right here.

GESTATIONAL DIABETES, INSULIN AND ORGANOGENESIS

The period of organogenesis also called the embryonic period is from the 3^rd to the 8^th weeks of pregnancy. This is when all the body’s organs are formed, exposure to agents that disrupt the process will result in birth defect.

The development of the sense of hearing starts in the early 4^th week of pregnancy. Babies born with deafness maybe from their genetic makeup or the presence of other maternal medical conditions such as; diabetes or infection with toxoplasmosis, rubella, cytomegalovirus, herpes or syphilis.

Hearing plays a significant role in the acquisition and development of communication skills. A child that cannot speak may not be hearing. Children born with deafness can be helped to restore their sense of hearing. They may require surgery to correct any malformation or for insertion of implant. Some may benefit from the use of hearing amplification devices and audiology rehabilitation. Significant progress has been made in research on hearing loss; in auditory hair cell and nerve regeneration.

WHAT IS INSULIN?

Insulin is a hormone produce naturally in the body by specific cells in the organ called the pancreas. The hormone is key to the uptake, utilization and storage of blood sugar in the body. It also plays a role in the production of protein and fat in the body. Intake of carbohydrate meal stimulate the release of insulin. The relative, body cells not sensitive to insulin, or absolute deficiency of this hormone insulin results in diabetes.

The discovering of insulin revolutionises the treatment of diabetes; initially, the insulin used was gotten from pig and cow, later, synthetic human insulin was produce with some limitations. The production of synthetic insulin analogue has overcome the limitation associated with human insulin. Available data from studies do not associate insulin use in pregnancy with any major birth defect or miscarriage. Side effect of insulin includes; allergic reaction, weight gain, hypoglycaemia, hypokalaemia.

WHAT IS GESTATIONAL DIABETES?

Gestational diabetes or GDM is carbohydrate intolerance that is first discovered in pregnancy and resolves within six weeks after delivery. In simple term; it means abnormal blood sugar level that is discovered for the first time in pregnancy in a woman who is not previously diabetic.

CAUSES OF GESTATIONAL DIABETES

The cause of gestational diabetes is not exactly known but there are risk factors associated with it. Although, genetic and environmental factors seem to play a major role. Pregnant women with the following risk factors as outlined below are called potential diabetes. They include;

• Family history of diabetes
• Previous history of gestational diabetes
• Obesity; weight at antenatal booking ≥90kg or a body mass index of ≥30kg/m²
• Previous delivery with one or more babies weighing ≥4kg
• Previous history of a child with birth defect
• Previous or current history of too much baby water
• Previous history of fetal demise
• Persistent glucose in urine test
• Recurrent or persistent vaginal discharge

HOW IS GESTATIONAL DIABETES DIAGNOSE?

Gestational diabetes is diagnosed using the screening test called oral glucose tolerance test (OGTT) when it is abnormal. The screening for gestational diabetes depends on the guideline for screening in your country, this differ from country to country. In my facility in Nigeria, only women with the above risk factors are screened while in other countries the recommendation is for all pregnant women to be screened.

Oral glucose tolerance test is a screening test for diabetes done between 24 to 28weeks of pregnancy. For patients who book early in pregnancy with the above risk factors, a blood sugar level is determine after a period of fasting and 2hours after eating. However, some experts advocate for an earlier OGTT which should be repeated at 24 to 28weeks of pregnancy.

WHAT TO EXPECT AT THE ORAL GLUCOSE TOLERANC TEST?

 Before the OGTT is done, there are some prerequisite to be met and they include;

• The patient should fast for at least 8hrs prior to the test
• She should be on her regular diet with no carbohydrate restriction
• She should not smoke

On the morning of the test, 75g glucose is mix in 250ml of water to be consumed within 5minutes. A blood sample is drawn to measure the fasting sugar level before starting the test. After drinking the solution, blood samples are drawn at one hour and 2hours.  Urine samples are also taken same time as the blood to check for the presence of sugar in the urine.

If any one of the result is abnormal; either the fasting, one or two hours’ blood sugar result, the patient is confirmed to have gestational diabetes.

COMPLICATIONS OF GESTATIONAL DIABETES

The complication of GDM could be to the mother or baby and they result from poor sugar control. Sometimes, these complications would have occurred in the baby before the diagnosis of GDM is made. The complication to the mother includes;

• Eye complication called retinopathy
• Kidney failure
• Risk of developing preeclampsia
• Difficulty in breathing from too much baby water
• Risk of forming blood clot in the veins
• Risk of developing type 2 diabetes later in life
• placenta previa

The complication to the baby includes;

• Big baby
• Restriction of the baby’s growth in the womb
• Birth defect that can involve any body system; including hearing loss
• Death of the baby in the womb
• Nerve injury at birth due to big size of the baby

TREATMENT OF GESTATIONAL DIABETES

The treatment of a woman with GDM in based on blood sugar level and the presence or absence of complication of GDM. This can be achieved via lifestyle modification, dietary modification and use of medication. For some patient, subscribing to the dietician feeding plan helps to control the blood sugar. However, insulin is needed when the dietary or oral medication control is not maintaining the desired blood sugar control or when there is a complication.

The fraud called ‘cryptic pregnancy’ in certain countries fuels the baby factory business. The term ‘cryptic pregnancy’ is fraudulently used in certain countries to described false pregnancy also called pseudocyesis. Women mostly infertile, who are desirous of children are deceived into subscribing to this scam. These women are often introduced by other beneficiary of the act by their testimony. They are told they will be assisted to get pregnant irrespective of their age without any modern assisted reproductive technology methods. These women are given some hormonal medications to cause some changes in their bodies.

Also, they are told the exact date of the delivery and the route of delivery which must be caesarean section. They are told not to consult with an obstetrician or get a pregnancy scan. Reason being that the pregnancy is cryptic and cannot be detected by pregnancy test nor ultrasound scan. While all these are ongoing, the fraudsters arrange for a baby from a baby factory to be delivered to their unsuspecting victim on the scheduled date of delivery. At the delivery, the woman is sedated while an incision is made on the abdomen and closed. The woman wakes up to the sight of a new born baby which she takes home as her own. 

WHAT REALLY IS CRYPTIC PREGNANCY?

Cryptic pregnancy or pregnancy denial also known as pregnancy with late detection is a covert pregnancy where the woman is not aware she is pregnant.  The usual pregnancy test will not detect pregnancy probably due to low or ineffective human chorionic gonadotropin (hCG). Also, scan cannot detect it due to its small nature; the growth of babies in cryptic pregnancies usually lags behind. Here, the symptoms of pregnancy (loss of menses, nausea, vomiting etc) are reduce and not always present.

Furthermore, the physical appearance is not usual as the tummy might be flat. Cryptic pregnancy appears to reduce the costs of pregnancy thus, favouring the mother at the expense of the baby. It is rare and occurs in 1 in 475 pregnancies at 20weeks of pregnancy according to a German study. Its might not be detected until about the 20^th week or during labour. Hence, the name pregnancy with late detection.

WHAT IS RESPONSIBLE FOR PREGNANCY SYMPTOMS AND SIGNS?

The changes to expect in pregnancy result from both hormonal and anatomical influences. The anatomical changes are under the influence of several hormones. Among these pregnancy hormones is the human gonadotropin hormone (hCG). This hormone is secreted by the placenta and it prevent the regression of the corpus luteum. The corpus luteum is responsible for the secretion of progesterone and oestrogen in the early pregnancy to prevent menstruation. While the oestrogen causes the lining of the womb to continue to grow and store nutrient for the developing baby, progesterone maintains quiescent of the womb.

The hCG hormone is secreted into the lining of the womb where it accumulates before its release into the blood stream and then urine. As early as the 20^th to 21^st day from the last menses, the β-hCG can be detected in the blood. From the 28^th day from the last menses, it can be detected in the urine by pregnancy test strips. It levels rises to a maximum at about the 10^th week of pregnancy and begins to fall from the 12^th week. The hCG is responsible for the nausea and vomiting in early pregnancy.

WHAT IS DIFFERENT IN CRYPTIC PREGNANCY?

A Rwandan proverb says, ‘pregnancy and fire cannot be kept secret’. Cryptic pregnancy however, begs to differ. It might just be evolutionary to increase maternal survival in pregnancy. Reduced hCG production and/or effectiveness is likely to be involved in the process. In cryptic pregnancy, the lining of the womb continues to shed (the woman might continue to spot blood) hindering the accumulation of hCG and it appearance in blood and urine. This is responsible for the negative pregnancy test. It could also result from failure to adjust from the interaction between the mother and baby due to some genetic reasons. It might be a coping mechanism in the relationship between the mother and baby in the stressful situation to increase her survival by decreasing her investment on the baby. Psychologically, the pregnancy might not be accepted by the woman. This can also result in late detection of the pregnancy.

WHAT SHOULD BE THE APPROPRIATE TERMINOLOGY?

In my opinion, I will prefer the term pregnancy denial or pregnancy with late detection. It is practically impossible in this modern obstetric practice that a pregnancy can go undetected till delivery. Ultrasound scan can detect a viable pregnancy as early as 6weeks from the first day of the last menses. The movement of the baby is usually felt around the 18^th to 20^th weeks of pregnancy. The question here is, why is this movement not felt by the woman with the cryptic pregnancy? Are these fetal movements confused for intestinal movement?

The possible explanation for this might be the psychological aspect of denying the pregnancy. Another explanation could be the deviation of the mind of the healthcare providers from pregnancy. The thought of pregnancy is not usually entertained in women who report regular menses. From accounts of some case reports of cryptic pregnancies, the womb was found to be gravid on abdominal examination. Therefore, it is imperative for the healthcare providers to screen for pregnancy using scan in women reporting pregnancy symptoms despite account of regular menses. A 20weeks pregnancy sitting in the womb should not be missed on scan.

RISK FACTORS OR CAUSES OF CRYPTIC PREGNANCY

It may be difficult to predict at risk women. Variant can be found in women with psychotic disorders. However, this condition occurs commonly in young, single, unmarried, non-psychotic women. Usually in situation where there is imbalance in the female hormones such as;

• Polycystic ovarian syndrome (PCOS)
• Perimenopausal women
• Women on birth control pills
• Women breastfeeding
• Women with low body mass index
• Extreme stress

COMPLICATIONS OF CRYPTIC PREGNANCY

These include;

• Psychological distress
• Birth before arrival to the delivery suite and it complications
• Preterm birth
• Babies that are small for their gestational age
• Death of the neonate.

A baby lying vertical in the womb with the buttocks, knees or feet closest to the mouth of the womb called the cervix is said to be in a breech presentation. This can be found in about 2 in 10 pregnancies <28 weeks, about 16 percent of babies at 32weeks are breech and only 3 to 4 percent of babies are breech at ≥37weeks. This cannot be prevented but its complications can, hence the need for this article.

RISK FACTOR FOR BREECH PRESENTATION

The predisposing factors for breech presentation include;

• Prematurity
• Malformation of the womb
• Uterine fibroid
• Polyhydramnios; too much baby water
• Oligohydramnios; too little baby water
• Placenta previa
• Abnormality in the baby; central nervous system malformations, neck masses.
•  Pregnancy with more than one baby
• Previous breech presentation  
• Having two or more deliveries
• Short umbilical cord; the umbilical cord connects the baby to the placenta

In general, a baby in breech presentation could be in either of these three; frank, incomplete and complete breech. Frank breech is the commonest type of breech presentation, the baby’s knees are straight with the hips and waist bent just as in the pike position. In footling or incomplete breech, one or both hips and knees are straight. The baby may look like it is standing on one foot or both feet. In complete breech, the hips and knees are bent as in the cannonball position.

DIAGNOSIS OF BREECH PRESENTATION

Breech presentation can be diagnosed via an abdominal examination where there is the presence of a soft mass (buttocks) and the absence of a hard fetal skull in the lower uterine segment. On transvaginal examination; a soft buttock, anal orifice, or feet may be felt when the cervix is open but can be difficult to feel when the cervix is closed. Ultrasound scan imaging will confirm the diagnosis.

DELIVERY WITH BREECH PRESENTATION

Your doctor will assist you with information in other to make the best decision on the route of delivery. Certain criteria as outline below will be put together to help you give an informed consent for the route of delivery. Delivery for babies coming with the buttock could be approached through either one of these four ways;

• Your doctor may attempt to turn the baby so that the baby’s head can face downward by manipulation of the baby through the mother’s abdomen; this is known as external cephalic version. If this is unsuccessful, caesarean delivery will be the next option.
•  External cephalic version then vaginal delivery for selected patients if successful.
• Caesarean delivery without external cephalic version.
• Vaginal delivery without external cephalic version.

Also, vaginal breech delivery could be spontaneous breech delivery, assisted breech delivery or total breech extraction. In spontaneous breech delivery, no traction or manipulation of the fetus is used. This is used predominantly in very preterm, often pre-viable deliveries.

In addition, assisted breech delivery is the most common type of vaginal breech delivery. The baby is allowed to spontaneously deliver up to the navel. Then manoeuvres are initiated to assist in the delivery of the remainder of the body, arms, and head.

Whereas, in total breech extraction, the fetal feet are grasped, and the entire baby is extracted. Total breech extraction is used only to deliver a second twin coming with the buttocks. It is not used for a single baby because the mouth of the womb may not be adequately open enough to allow passage of the fetal head.

To minimize risk in women who opted for vaginal breech delivery. Certain criteria need to be fulfil and they are;

• There should be no contra-indication to vaginal delivery.
• No previous caesarean delivery
• The pregnancy should be ≥36weeks
• Labour should start spontaneously
• There should be staff skilled at breech delivery and resources available for caesarean section should the need arise.
• The breech should be frank or complete as diagnosed by scan
• The estimated fetal weight should be ≥2 to ≤4kg
• There should be no fetal anomaly
• The baby’s neck should not be bent backward as if the baby is staring at the sky.

However, experts have varied opinions as regards the route of delivery of babies before 37weeks. This decision is often based on individual patient and some of the criteria above.

COMPLICATIONS OF VAGINAL BREECH DELIVERY

Breech vaginal delivery is associated with the following complications.

To the mother;

• Trauma to the genital tract
• Operative vaginal delivery such as episiotomy and forceps
• Caesarean section
• Sepsis
• Anaesthetic complication.

To the baby;

• Difficulty initiating and maintaining respiration
• Cord prolapse; the umbilical cord slight out of the vagina, this is an emergency.
• Birth trauma; fracture, dislocation, nerve injuries
• Difficulty delivering the head
• Spinal cord injuries with extended head
• Death of the baby during labour or after delivery

Premature placenta separation or bruptio placentae also known as placenta abruption is a significant cause of third-trimester vaginal bleeding. It is associated with poor health status of the mother and the unborn baby. It is defined as the premature partial or complete separation of a normally implanted placenta from the uterus after the period of viability (this varies between regions but is 28weeks in Nigeria and some African countries and is 24weeks in Europe) but before the delivery of the baby.  The overall incidence of abruption placentae is about 1 in 100 pregnancies

CAUSES OF PREMATURE PLACENTA SEPARATION

The exact cause of placenta abruption is unknown. It could probable be from abnormalities of the uterine blood vessels.  However, a number of risk factors are associated with its occurrence.  Risk factors for premature placenta separation include;

• Smoking
• Cocaine use during pregnancy
• Maternal age over 35 years
• Increasing number of birth
• Inherited or acquired thrombophilias (the blood abnormally form clots easily)
• Hypertensive disease in pregnancy (pregnancy induced hypertension, preeclampsia, eclampsia)
• Placenta abruption in a previous pregnancy
• Pregnancy with more than one baby
• High amniotic fluid level (baby water)
• Sudden uterine decompression from premature rupture of fetal membrane
• Short umbilical cord
• Trauma to the abdomen from motor vehicle accident, fall or violence resulting in a blow to the abdomen may lead to placental abruption.

CLASSIFICATION OF ABRUPTIO PLACENTAE

Abruptio placentae can be classified into four;

class 0: diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.

Class I:  manifest with no vaginal bleeding to mild vaginal bleeding, lightly tender womb, normal maternal blood pressure and heart rate, no bleeding disorder and baby not in distress.

Class 2: manifest with no vaginal bleeding to moderate vaginal bleeding, moderate to severe uterine tenderness with possible painful contractions, increase maternal heart beat with changes in blood pressure and heart rate on standing erect and the baby will be in distress.

Class 3: characteristics include the following; no vaginal bleeding to heavy vaginal bleeding, very painful contraction of the womb, maternal shock, bleeding disorder, death of the baby.

SYMPTOMS AND SIGNS OF ABRUPTIO PLACENTAE

Abruptio placentae could be the revealed type (blood is visible externally via the vagina), concealed type (blood not visible) or the mixed type where blood is concealed in the womb and also seen coming out of the vagina. The major clinical findings are vaginal bleeding which is preceded by a sudden abdominal pain, often accompanied by uterine contractions, uterine tenderness and the baby will be in distress. The mothers heart will beat too fast and her blood pressure becomes low.  

COMPLICATIONS OF ABRUPTIO PLACENTAE

The complication of placenta abruption to the pregnant woman are;

• Haemorrhage and the need for blood transfusions
• Hysterectomy (which is, removal of the womb)
• Bleeding disorder resulting from inability of the blood to form clot and stop bleeding
• kidney failure
• Sheehan syndrome (which is, damage to the pituitary gland from massive blood loss)
• Maternal death may occur.

Complication to the baby includes;

• The baby may be in distress
• The growth of the baby in the womb maybe restricted in cases of mild abruption placenta
•  Preterm birth with Low birthweight
• The baby maybe unable to initiate and sustain breathing after delivery called asphyxia
•  Death of the baby in the womb
• Death of the baby after birth

TREATMENT OF ABRUPTIO PLACENTAE

Abruptio placentae is an obstetrics emergency because it threatens the life of both mother and baby. Approach to it treatment will involve close observation by the doctor, continuous monitoring of the baby and oxygen administration. Blood loss will be replaced with drip and then blood when available; about four pints of blood maybe required. The mode of delivery whether via caesarean section or vaginal delivery depends on the hemodynamic status of the mother and whether the baby is alive or death in the womb. For a death baby, vaginal delivery is the preferred method when the maternal hemodynamic condition is stable. For a live baby the preferred option is caesarean delivery but this can be complicated by difficulty to stop bleeding.

PREVENTION OF ABRUPTIO PLACENTA

The prevention of abruption placenta is aimed at identification and elimination of known risk factors, optimization of maternal blood volume and prompt institution of therapy when it occurs to prevent complications.

Placenta previa is the leading cause of third-trimester vaginal bleeding. It is defined as the implantation of the placental tissue in the lower uterine segment, adjacent to or overlying the mouth of the womb called the internal cervical os. The incidence of placenta previa is 4 to 5 per 1000 pregnancies.

CAUSES OF PLACENTA PREVIA

The exact cause of placenta previa is not known, it is however thought to be multifactorial. One theory explains that placenta previa occur because implantation often take place in fresh site; usually away from scar areas and previous sites of implantation. The following are risk factors for placenta previa;

• Infertility treatment
• Increasing maternal age
• Having two or more deliveries
• Pregnancy with more than one baby
• Short inter-pregnancy interval; the duration from delivery to the next conception
• Previous uterine surgery like myomectomy or D & C procedure
• Previous caesarean delivery
• Previous or recurrent abortions
• Previous placenta previa 
• Smoking
• Cocaine use
• Diabetes
• Residence at higher elevation

TYPES OF PLACENTA PREVIA

There are four types or degrees of placenta previa based on its relationship with the mouth of the womb also called the cervical os namely;

• Type I /Low-lying: within 2cm margin from the mouth of the womb.
• Type II/ Marginal: the placenta reaches the margin of the internal os but does not cover it
• Type III/Incomplete or partial central: the placenta covers the internal os partially when closed but not when dilated.
• Type IV/complete: the placenta completely covers the internal os even when dilated.

SYMPTOMS AND SIGNS OF PLACENTA PREVIA

Placenta previa present as a painless, spontaneous, unprovoked bright red third-trimester vaginal bleeding. This bleeding may trigger uterine activity. There may be dizziness, weakness or fainting if the bleeding is profuse. There is usually a prior history of bleeding early in the index pregnancy. However, with ultrasound scan, most cases of placenta previa are now detected antenatally before the onset of significant bleeding. When this is discovered early in pregnancy, the scan is repeated at 32weeks as there is the possibility that a prior placenta previa will no longer be a previa. The theory of placenta migration explains this; with the formation of the lower uterine segment at 32weeks of pregnancy, the placenta will apparently move from the lower segment.

COMPLICATION OF PLACENTA PREVIA

The complication of placenta previa include;

• Preterm delivery
• Abnormal fetal presentation
• Intrauterine growth restriction
• Haemorrhage
• Higher rate of blood transfusion
• Increased incidence of postpartum endometritis
• Need for hysterectomy
• Maternal death.

TREATMENT OF PLACENTA PREVIA

The management of placenta previa most importantly depends on the clinical state of the patient; whether she is bleeding or not. Other considerations are the gestational age and resolution of bleeding. Asymptomatic patients with placenta previa or patients with a history of a small bleed that has resolved and remote from term are potential candidates for conservative management.

Conservative management consist of a hospital admission for bed rest usually in a ward with close proximity to the theatre. This is so because, there is a danger of a second bleeding which is usually heavier. When it happens, intervention will be prompt. The first bleed is consider the warning bleeding. At all-time while on admission, 4pints of blood should be readily available in the blood bank in case of emergency.

The conservative management will be discontinued when; the pregnancy gets to 37weeks, bleeding becomes torrential, when the baby’s water breaks, when labour starts, when the baby is in distress or it growth in the womb is restricted.

For asymptomatic patients with placenta previa, delivery is typically recommended by 37weeks gestation with documented fetal lung maturity or after administration of antenatal corticosteroids. The timing of delivery depends on clinical circumstances. Any patient with persistent haemorrhage mandates delivery regardless of gestational age. Caesarean delivery is indicated for all patients with sonographic evidence of placenta previa. In women with a low-lying placenta vaginal delivery may be considered.

Cervical cerclage insertion is a procedure where a non-absorbable suture material is use to reinforce the cervix (tying the mouth of the womb) to enable it retain pregnancy to maturity, which is considered to be 37weeks of pregnancy. This is mostly done in pregnant women who have been diagnosed with cervical insufficiency. It is often done as an elective procedure but can also be done as an emergency. It is usually done via the vaginal route but in selected patient it is done via the abdominal route. The transabdominal placement of a cervical cerclage could be via open surgery or laparoscopic surgery.  The abdominal cerclage when inserted is usually left for subsequent pregnancies and delivery is via caesarean section. The vaginal cerclage is remove at 37weeks of pregnancy and delivery is via the vaginal route except vaginal delivery is contraindicated. Patient for cervical cerclage insertion are usually admitted a day prior to the procedure. The procedure is done in the theatre under anaesthesia, the patient might be awake or put to sleep. The suture material used include; mersilene tape, nylon, polypropylene and silk. The duration of stay in the hospital after the procedure is not fix it depend, it might take between 3days to more than a week.

WHO QUALIFIES TO GET A CERVICAL CERCLAGE INSERTED?

The following are the possible indications for cervical cerclage insertion;

• Pregnant women with previous history of pregnancy loss in the second trimester
• Women who have been diagnosed with cervical incompetence
• Pregnant women with incidental finding of cervical funnelling, shorten cervix <2.5cm on ultrasound
• Women with recurrent preterm delivery; delivery before 37weeks
• Women with more than one baby conceived via in-vitro fertilization (IVF), most specialist offer prophylactic cervical cerclage; which is preventive in women with no indication.

CONTRA-INDICATIONS TO CERVICAL CERCLAGE INSERTION

Cervical cerclage is not inserted or it is removed when inserted in the following situation;

• When the patient is contracting
• When the patient is bleeding
• If the fetus is not alive in the womb
• If the patient is draining liquor; the fluid that is enclosed in the sac containing the baby

WHEN IS CERVICAL CERCLAGE INSERTION DONE?

Cervical cerclage is inserted early in the second trimester as an elective procedure when there are no features of cervical changes on scan between 14 to 16weeks of pregnancy. This is to ensure that the pregnancy been locked in by the cerclage is viable and not destined genetically to abort due to genetic or structural malformation. However, other specialist will prefer to insert it earlier between 12 to 14weeks of pregnancy. Also, cervical cerclage insertion can be done as an emergency procedure in a woman with suspected cervical insufficiency on follow up ultrasound scan. This is known as a rescue cerclage because it is done when there are radiologically confirmed cervical changes on ultrasound scan.

PREPARATION DONE BEFORE THE PROCEDURE

Before the patient is admitted for the procedure, some investigations are done to assess the patient’s fitness for surgery. Ultrasound scan is also done to ensure that the fetus is alive, healthy and there is no drainage of liquor. The vaginal and cervix is also inspected and sample taken for test when indicated and any infection treated before the procedure. Some prenatal test might have been done in the first trimester to ensure the fetus is not genetically or structurally malformed. The anaesthetist will also be invited to see the patient to assess her fitness for anaesthesia and offer explanation on the options of anaesthesia available.

WHAT ARE THE COMPLICATIONS OF CERVICAL CERCLAGE INSERTION?

The following are the possible complications of cervical cerclage insertion;

• Bleeding
• Membrane rupture
• Preterm labour
• Infection
• Displacement of suture
• Formation of fistula; abnormal communication between the vagina and the urinary bladder or rectum.
• Cervical dystocia; due to scarring the cervix become unyielding during labour
• Cervical stenosis; the opening of the cervix becomes narrower

WHAT YOU SHOULD KNOW AFTER CERVICAL CERCLAGE INSERTION

After the insertion of the cerclage, you will remain on admission until your doctor is sure there is no problem. This is usually about 72 to 120hour for most prophylactic cerclage inserted. While on admission, notify your doctor if you feel abdominal pain, having vaginal bleeding or leaking water via the vaginal. There might be an increase in vaginal discharge which might be notice some weeks after discharge from the hospital. This might likely be due to the presence of a foreign material (the cerclage) in the vaginal however, it is important to notify your doctor about it. There are some situations in which the cerclage might be remove even if it was just inserted. These includes; when the baby’s water breaks, when you start having vaginal bleeding, when you are having labour pains and when the pregnancy has reach 37weeks.