The cervical pessary is inserted in a lithotomy position by the obstetrician. It is vital that the curvature of the pessary shows upwards so that the larger diameter is supported by the pelvic floor. The pessary can be folded and then be placed into the vaginal fornix. Thereby the cervix should be located within the upper ring diameter. The obstetrician may control if the cervix is not surrounded too firmly. After the insertion the patient is asked to get up. Normally patients indicate “relief of prolapse complaints” immediately after placement.
The insertion of the pessary can be facilitated by spreading a gliding compound, preferably antibiotic creams not destroying the natural flora.
Before removal, the cervix should be carefully pushed back before pulling. If a pessary is “stuck” due to edema or contractions it is better to cut the whole silicone ring (e.g. with scissors used for episiotomy) instead of violently pulling and risking cervical lesions. In any case of bleeding or painful contractions a speculum examination should be performed.
Under normal conditions, the pessary should be removed at around 37 weeks in asymptomatic patients. In cases of blood loss it may be changed and cleaned in between, but in general, manipulations are better avoided. In all patients with premature rupture of membranes and signs of chorioamnionitis, vaginal blood loss and severe painful contractions the pessary should be removed to avoid cervical lesions or ascending infection.
Transvaginal sonographic examinations help to identify the cervical shape and length but the visualization of transvaginal sonography may be impaired by the pessary and the transducer better has to be directed best on the anterior or towards the posterior part of the pessary. The position of the pessary can easily be controlled manually during routine controls.
In patients with a scheduled Cesarean the pessary can be removed in the operation theatre before the skin incision.
Side Effects/Complications:The position of the pessary (with the curvature and the smaller diameter upwards and some angulation) is the key in the success of treatment. There might be some increase of abacterial discharge. However, the composition of the vaginal flora will not be substantially altered.