2022 75 Cervical Cerclage Flashcards
Who should be offered history-indicated cervical cerclage & when?
Singleton pregnancies
3+ preterm births
11-14 weeks
Who should be offered serial sonographic cervical surveillance & when?
Singleton pregnancy
Every 2-4 weeks between 16 & 24/40
1. Previous 2nd trimester loss or preterm birth
2. PPROM <34/40
3. Previous cerclage
4. Known uterine variant
5. Intrauterine adhesions
6. Had of trachelectomy
What are the conditions for ultrasound-indicated cerclage?
Cervix <25mm
With risk factors for PTB
NOT if found incidentally
NOT cervical funnelling in the absence of shortening
When can transabdominal cerclage be considered? When is it performed?
Previous unsuccessful transvaginal cerclage
Can be pre-conceptual, without causing subfertility (less risks) or in early pregnancy
What is the potential improvement following emergency cerclage?
- Delay birth by up to 34 days
- 2-fold reduction in birth before 34/40
BUT - Weigh against neonatal M&M risk
- <4cm dilation or membranes below external os more likely to fail
What are the different methods of transcervical cerclage? How are they chosen?
Surgeon’s discretion
McDonald:
TV purse-string at cervical isthmus junction
Shirodkar:
TV purse-string following bladder mobilisation, above cardinal ligaments
Who should be offered a single scan for cervical length surveillance & when?
Singleton pregnancy
No later than 18-22/40 TV
1. Previous fully dilated C/S
2. Significant cervical excision surgery: LLETZ >1cm depth, 2+ LLETZ, cone biopsy
What method should be used for transabdominal cerclage?
Laparoscopic if possible due to fewer complications
No difference in birth rates or fetal survival
What are the options for managing fetal death with a transabdominal stitch in situ?
- Complete suction evacuation through the stitch <18/40
- Dilation & evacuation <18/40
- Cut suture via posterior colpotomy
- Hysterotomy
- Caesarean section
What are the contraindications to cervical cerclage?
- Active preterm labour
- Clinical evidence of chorioamnionitis
- Continuing vaginal bleeding
- PPROM
- Evidence of fetal compromise
- Lethal fetal defect
- Fetal death
What should be consented for in all types of cerclage?
- Intraoperative injury:
Bladder damage, cervical trauma, membrane rupture, bleeding - Injury if labour with suture in place:
Cervical laceration or trauma - Anaesthetic, including for removal is bladder mobilisation method used
What additional consent should be taken for emergency cerclage?
- No increased risk of:
PPROM, chorioamnionitis, IOL, C/S - No opposite effect:
No increase in PTB or 2nd trimester loss
What investigations should be performed before cervical cerclage?
History-indicated:
1st trimester USS & aneuploidy screening to ensure viability, singleton, no lethal/major anomaly
US-indicated or emergency:
Anomaly scan ideally
Emergency:
Consider WCC & CRP to exclude chorio
In which cases should amniocentesis be used prior to cerclage?
Not routinely
If suspicion of intra-amniotic infection (due to poor prognosis)
For what interventions & investigations is there not enough evidence with cervical cerclage?
- Amnioreduction
- Defined latency interval
- Routine genital screening
- Perioperative tocolysis
- Routine antibiotic prophylaxis
- Bed rest
- Abstaining from sex
- Post-cerclage scanning
- Post-cerclage FFN
- Post-cerclage progesterone
