#142 Cerclage for the Management of Cervical Insufficiency

Question 1

What is the definition of cervical insufficiency?

Answer 1

Inability of the uterine cervix to retain a pregnancy in the second trimester (typically <24wks) in the absence of the signs and symptoms of clinical contractions, or labor, or both

Question 2

What factors may increase the risk of cerivcal insufficiency?

Answer 2

Surgical trauma to cervix from conization, LEEP, mechanical dilation during pregnancy termination, or obstetrical lacerations, although data confirming these associations are inconsistent. Other proposed etiologies: congenital mullerian anomalies, deficiencies in cervical collagen and elastin, in utero exposure to DES

Question 3

Is activity restriction effective for the treatment of cervical insufficiency?

Answer 3

No

Question 4

Is bed rest effective for the treatment of cervical insufficiency?

Answer 4

No

Question 5

Is pelvic rest effective for the treatment of cervical insufficiency?

Answer 5

No

Question 6

Is vaginally pessary effective for the treatment of cervical insufficiency?

Answer 6

Evidence is limited for potential benefit

Question 7

What are the names of the transvaginal cerclage methods?

Answer 7

Modifications of the McDonald and Shirodkar techniques

Question 8

What does the McDonald cerclage procedure involve?

Answer 8

Simple purse-string suture of nonresorbable material inserted at the cervicovaginal junction

Question 9

What does the Shirodkar cerclage procedure involve?

Answer 9

Dissection of the vesicocervical mucosa in an attempt to place the suture as close to the cervical internal os as might otherwise be possible. Bladder and rectum are dissected from the cervix in a cephalad manner, suture placed and tied, mucosa replaced over the knot. Nonresorbable suture.

Question 10

What are indications for transabdominal cerclage?

Answer 10

Failed transvaginal cerclage. Anatomy restriction to transvaginal, such as after a trachelectomy.

Question 11

When can you place a transabdominal cerclage?

Answer 11

10-14wks gestation or in nonpregnant state

Question 12

Do you need to remove transabdominal cerclage?

Answer 12

Can be left in place between pregnancies with subsequent cesarean delivery

Question 13

What is a history-indicated cerclage?

Answer 13

Cerclage placed after history of one or more 2nd trimester pregnancy losses related to painless cervical dilation and in the absence of labor or placental abruption. Prior cerclage due to painless cervical dilation in 2nd trimester

Question 14

What is a physical exam indicated cerclage?

Answer 14

Stitch placed due to identified painless cervical dilation in second trimester

Question 15

What is an ultrasound-indicated cerclage with history of prior preterm birth?

Answer 15

Current singleton pregnancy, prior spontaneous preterm birth at <34wks, short cervical length (<25mm) before 24wks

Question 16

When is history-indicated cerclage typically placed?

Answer 16

Between 13-14 weeks

Question 17

What needs to be assessed prior to physical exam indicated cerclage?

Answer 17

Rule out uterine activity, intraamniotic infection

Question 18

What is a safe way to monitor patients at risk of cervical insufficiency?

Answer 18

Transvaginal ultrasound in second trimester

Question 19

How has the use of transvaginal ultrasound affected the practice of history-indicated cerclages?

Answer 19

Unnecessary history-indicated cerclages can be avoided in more than half of the patients

Question 20

When should transvaginal cervical length surveillance occur (during which weeks of gestation?)

Answer 20

16 to 24 weeks

Question 21

At what cervical length would you place a cerlage for a woman without a history of prior preterm birth?

Answer 21

You wouldn’t. No significant reduction in preterm birth. (physical exam indicated is only one without need for prior preterm birth)

Question 22

What is the recommendation for asymptomatic woman with singleton gestation without prior preterm birth with incidentally identified short cervix (< 20mm) before 24 weeks

Answer 22

Vaginal progesterone

Question 23

What is the definition of short cervix?

Answer 23

<25mm with prior preterm birth
<20mm with no prior preterm birth
[before 24 wks]

Question 24

What is the role of cerclage in twin pregnancies?

Answer 24

May increase the risk of preterm delivery

Question 25

What are possible complications of cerclage placement?

Answer 25

Rupture of membranes, chorioamnionitis, cervical lacerations, and suture displacement. Life-threatening complications of uterine rupture and maternal septicemia are extremely rare, but reported

Question 26

Do transvaginal or transabdominal cerclages carry a higher risk of hemorrhage?

Answer 26

Transabdominal

Question 27

Should patients going for cerclage placement receive pre op and/or post op antibiotics?

Answer 27

No. Does not improve efficacy, regardless of timing or indication

Question 28

Should patients going to cerclage placement receive pre op and/or post op tocolytics?

Answer 28

No. Does not improve efficacy, regardless of timing or indication

Question 29

What is the role of ultrasonographic surveillance of cervical length after cerclage placement?

Answer 29

Unnecessary

Question 30

When should the transvaginal McDonald cerclage be removed in uncomplicated patients?

Answer 30

Removal at 36-37 weeks in the office for anticipated vaginal delivery. If planned cesarean section, can delay until time of delivery, but not necessary

Question 31

If a patient with a cerclage PPROMs, should you remove the cerclage or keep in it?

Answer 31

A firm recommendation cannot be made, either is reasonable. Either way, prolonged antibiotic ppx beyond 7d is not recommended

Question 32

If a patient with a cerclage PPROMs, how long do you continue latency antibiotics for?

Answer 32

Same 7 days