Cervical cerclage GT60

Question 1

What % of all live births in England & Wales were under 37+0 in 2005?

Answer 1

7.6%

2/3 post-ROM

Question 2

What is the mortality rate for infants born at 32/40?

Answer 2

2%

Question 3

What is the mortality rate for infants born at 23/40?

Answer 3

90%

Question 4

When is a history indicated cerclage usually placed?

Answer 4

12-14/40

Question 5

What are the criteria for history indicated cerclage?

Answer 5

> =3 previous preterm births +/- T2 losses

Question 6

What are the criteria for ultrasound-indicated cerclage?

Answer 6

If having serial scans with >= 1 previous prem birth/T2 loss and cx <25mm under 24/40 - not if funnelling alone

Question 7

Who should receive ultrasound surveillance of cervical length?

Answer 7

hx of spontantous T2 loss or prem delivery not given cerclage - however expectant management reasonable alternative as majority will deliver >33/40

Question 8

Why is cerclage contraindicated in multiple pregnancy?

Answer 8

May increase rate of prem delivery and pregnancy loss

Question 9

What is the guidance re: cerclage at the time of trachelectomy?

Answer 9

Numbers too few to give evidence based guidance - individualised care

Question 10

When should transabdominal cerclage be considered?

Answer 10

When previous transvaginal cerclage has failed

Question 11

To what gestation has dilatation and evacuation for miscarriage been described with a transabdominal cerclage in situ?
What are the alternatives for management?

Answer 11

18/40

Cut stitch using posterior colpotomy

If not - hysterotomy/CS

Question 12

By how long can rescue cerclage delay delivery compared to bed rest/expectant management alone?

Answer 12

5/52

Question 13

By how much can rescue cerclage reduce chance of delivery before 34/40?

Answer 13

x2

Question 14

What is associated with a high chance of rescue cerclage failure?

Answer 14

Cervical dilation >4cm

Membrane prolapse beyond the external os

Question 15

What are the contraindications to cerclage insertion?

Answer 15

• Active preterm labour
• Clinical evidence of chorioamnionitis
• Continuing vaginal bleeding
• PPROM
• Evidence of fetal compromise
• Lethal fetal defect
• Fetal death

Question 16

What are the complications with cerclage?

Answer 16

• 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

Question 17

What is the guidance re: amniocentesis prior to insertion of cerclage?

Answer 17

• Insufficient evidence to recommend

- May be considered in selected cases where there is suspicion of intra-amniotic infection

Question 18

What is the guidance re: genital tract screening and insertion of cerclage?

Answer 18

• No evidence for routine screening

- If a swab is taken and has a positive culture - ideally complete course of abx before insertion if elective

Question 19

What are the intraoperative recommendations with insertion of cerclage?

Answer 19

• 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)

Question 20

What is the follow up advice post-cerclage?

Answer 20

• Do not need to abstain from sex

- Serial scans post op not recommended but may be useful in ultrasound-indicated to time steroids/IUT

Question 21

When should cerclage be removed?

Answer 21

36+1 - 37+0 if not laboured, or if planned CS can wait until then

Can leave transabdominal in place at time of CS

Question 22

What should be done with cerclage when there is a PPROM?

Answer 22

• 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