Cervical cerclage GT60 Flashcards
What % of all live births in England & Wales were under 37+0 in 2005?
7.6%
2/3 post-ROM
What is the mortality rate for infants born at 32/40?
2%
What is the mortality rate for infants born at 23/40?
90%
When is a history indicated cerclage usually placed?
12-14/40
What are the criteria for history indicated cerclage?
> =3 previous preterm births +/- T2 losses
What are the criteria for ultrasound-indicated cerclage?
If having serial scans with >= 1 previous prem birth/T2 loss and cx <25mm under 24/40 - not if funnelling alone
Who should receive ultrasound surveillance of cervical length?
hx of spontantous T2 loss or prem delivery not given cerclage - however expectant management reasonable alternative as majority will deliver >33/40
Why is cerclage contraindicated in multiple pregnancy?
May increase rate of prem delivery and pregnancy loss
What is the guidance re: cerclage at the time of trachelectomy?
Numbers too few to give evidence based guidance - individualised care
When should transabdominal cerclage be considered?
When previous transvaginal cerclage has failed
To what gestation has dilatation and evacuation for miscarriage been described with a transabdominal cerclage in situ?
What are the alternatives for management?
18/40
Cut stitch using posterior colpotomy
If not - hysterotomy/CS
By how long can rescue cerclage delay delivery compared to bed rest/expectant management alone?
5/52
By how much can rescue cerclage reduce chance of delivery before 34/40?
x2
What is associated with a high chance of rescue cerclage failure?
Cervical dilation >4cm
Membrane prolapse beyond the external os
What are the contraindications to cerclage insertion?
- Active preterm labour
- Clinical evidence of chorioamnionitis
- Continuing vaginal bleeding
- PPROM
- Evidence of fetal compromise
- Lethal fetal defect
- Fetal death
What are the complications with cerclage?
- Increase in mat pyrexia (x2) but not chorioamnionitis
- No increase in PPROM, IOL, C/S
- No increase in PTD or T2 loss
- Small risk bladder damage, cervical trauma, ROM, bleeding
- 2nd Anaesthetic risk for Shirodkar removal
- Risk cervical laceration if labours with stitch in place
What is the guidance re: amniocentesis prior to insertion of cerclage?
- Insufficient evidence to recommend
- May be considered in selected cases where there is suspicion of intra-amniotic infection
What is the guidance re: genital tract screening and insertion of cerclage?
- No evidence for routine screening
- If a swab is taken and has a positive culture - ideally complete course of abx before insertion if elective
What are the intraoperative recommendations with insertion of cerclage?
- No evidence for routine tocolysis
- Prophylactic abx/choice of anaesthesia at discretion of the operating team
- Consider IP stay for 24 hrs in us-indicated or rescue cerclage (48 hours if transabdominal)
What is the follow up advice post-cerclage?
- Do not need to abstain from sex
- Serial scans post op not recommended but may be useful in ultrasound-indicated to time steroids/IUT
When should cerclage be removed?
36+1 - 37+0 if not laboured, or if planned CS can wait until then
Can leave transabdominal in place at time of CS
What should be done with cerclage when there is a PPROM?
- If 24-34/40, no infection/labour - consider leaving 48 hrs for steroids/IUT
- Delaying until delivery not recommended - sepsis risk
- Do not delay if <23 or >34/40
