Preterm Doğumları Önlemede Servikal Serklaj
Özet
Servikal serklaj, servikal yetmezlik durumunda uterin serviksin sütürlerle desteklenmesini sağlayarak preterm doğumu, membran prolapsusunu ve fetal ölümü azaltmayı hedefleyen cerrahi bir işlemdir. Transvajinal, transabdominal ve laparoskopik yöntemlerle uygulanabilen işlem, en çok transvajinal olarak (Shirodkar ve McDonald teknikleri) gebeliğin 12-24. haftaları arasında tercih edilir. Fizik muayeneye bağlı (acil) serklajlarda enfeksiyon riskine karşı antibiyotik ve tokoliz profilaksisi önerilirken, ultrason bağımlı işlemlerde bu rutin değildir. Transabdominal yaklaşım ise daha morbid bir işlem olup, başarısız vajinal serklaj öyküsü, ampute veya aşırı kısa serviks varlığında prekonsepsiyonel veya erken gebelik döneminde tercih edilir; düşük morbiditesi nedeniyle deneyimli ellerde laparoskopik yöntem önceliklidir. Transvajinal serklajlar genellikle 36-37. haftalarda elektif olarak çıkarılıp vajinal doğuma izin verilirken, transabdominal serklajı olan hastalara 36+0 ile 37+6. haftalar arasında planlı sezaryen doğum önerilir ve sütür sonraki gebelikler için yerinde bırakılabilir. Her iki yöntemde de koryoamniyonit, aktif kanama ve preterm erken membran rüptürü gibi durumlar kesin veya göreceli kontrendikasyon oluşturur.
Cervical cerclage is a surgical procedure aimed at reducing preterm birth, fetal membrane prolapse, and fetal loss by supporting the uterine cervix with sutures in cases of cervical insufficiency. The procedure can be performed via transvaginal, transabdominal, or laparoscopic approaches, with the transvaginal method (Shirodkar and McDonald techniques) being most commonly preferred between the 12th and 24th weeks of gestation. While antibiotic and tocolytic prophylaxis is recommended for examination-indicated (emergency) cerclage due to infection risks, it is not routinely applied in ultrasound-indicated procedures. The transabdominal approach is a more morbid procedure and is preferred either preconceptionally or during early pregnancy in patients with a history of failed vaginal cerclage, an amputated cervix, or an extremely short cervix; the laparoscopic method is favored if adequate surgical experience is available due to its lower morbidity. Transvaginal cerclages are generally removed electively at 36-37 weeks to allow vaginal delivery, whereas for patients with transabdominal cerclage, a planned cesarean delivery is recommended between 36+0 and 37+6 weeks of gestation, and the suture can be left in situ for future pregnancies. Under both methods, conditions such as chorioamnionitis, active bleeding, and preterm premature rupture of membranes constitute absolute or relative contraindications.
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