Does a cerclage (cervical cerclage) increase the risk of bladder injury during a cesarean section (C-section)?

Cerclage Does Not Increase Risk of Bladder Injury During Cesarean Section

There is no evidence that cervical cerclage specifically predisposes patients to bladder injury during cesarean section. The available evidence indicates that prior cesarean sections and resulting adhesions are the primary risk factors for bladder injury during cesarean delivery, not cerclage placement.

Risk Factors for Bladder Injury During Cesarean Section

Primary Risk Factors:

• Previous cesarean deliveries: Multiple studies show this is the most significant risk factor 1, 2
  • Incidence of 0.27% in primary cesarean vs 0.81% in repeat cesarean 1
  • OR of 2.35 (95% CI 0.759-7.319) for prior cesarean vs no prior cesarean 2
  • OR increases to 3.75 (95% CI 1.002-14.07) when comparing one prior cesarean to no prior cesarean 2

Other Significant Risk Factors:

• Adhesions: Most significant risk factor with OR of 67.5 (95% CI 11.14-408) 2
• Failed vaginal birth after cesarean (VBAC): 31.5% vs 3% in cases vs controls 2
• Type of skin incision: Pfannenstiel incision was associated with higher risk (84% vs 32%) 2
• Longer operative time: 135 vs 58 minutes in cases vs controls 2
• Greater blood loss: 744cc vs 509cc in cases vs controls 2

Cerclage and Cesarean Section

None of the guidelines or research evidence specifically identifies cerclage as a risk factor for bladder injury during cesarean section. The Society for Maternal-Fetal Medicine (SMFM) guidelines discuss cerclage management extensively but do not mention increased risk of bladder injury during cesarean 3.

When cerclage is present at the time of cesarean delivery, the guidelines state:

• "Cerclage management after previable or periviable PPROM is similar to cerclage management after PPROM at later gestational ages; it is reasonable to either remove the cerclage or leave it in situ after discussing the risks and benefits and incorporating shared decision-making" 3

Prevention Strategies for Bladder Injury

For patients with risk factors for bladder injury (primarily multiple prior cesareans with adhesions), the following technique has been shown to reduce bladder injury:

• Cystoinflation: Bladder retro-fill with 300cc saline significantly reduces bladder injury rates (2.8% vs 20.6%, P<0.0001) and blood loss (585.33cc vs 797.10cc, P<0.0001) 4
• This technique helps visualize bladder margins during adhesiolysis

Management Algorithm for Cesarean in Patients with Cerclage

1. Preoperative Assessment:

   • Identify primary risk factors for bladder injury (prior cesareans, known adhesions)
   • Note presence of cerclage but recognize this alone is not a specific risk factor

2. Surgical Approach:

   • Consider cystoinflation technique if multiple prior cesareans or suspected adhesions 4
   • Use careful surgical technique when developing the bladder flap
   • Be particularly cautious when opening the peritoneal cavity and developing the bladder flap 1

3. Cerclage Management:

   • Decision to remove cerclage before, during, or after cesarean should be based on clinical factors and timing of delivery
   • Cerclage removal itself is not specifically associated with bladder injury risk

Conclusion

The primary risk factors for bladder injury during cesarean section are previous cesarean deliveries and resulting adhesions, not cerclage placement. Careful surgical technique and consideration of preventive measures like cystoinflation in high-risk cases (multiple prior cesareans) are more important for preventing bladder injury than concerns about cerclage status.