Cervical Cerclage GTG Flashcards
When should history indicated cerclage be offered?
Singleton pregnancy and 3 or more previous preterm births.
No benefit if previous cervical surgery or uterine abnormality
When should USS cerclage be offered?
Women with history of 1 or more spont 2nd trimester miscarriage or preterm birth who are undergoing USS surveillance if Cx <25mm at or under 24 weeks.
No recommended for funnelling without <25mm
What % of women who have had a previous 2nd trimester loss/ previous preterm birth have maintained cervical length >25mm by 24 weeks
40-70%
Of the women who maintain cervical length >25mm gave birth >34 weeks?
90%
Which women are considered high risk for preterm birth?
Previous pre-term birth/2nd trimester loss (16-34 weeks)
Previous PPROM <34week
Previous cerclage
Known uterine variant
Intrauterine adhesions
Hx trachelecotmy
For women who are high risk, what care should be offered?
Review by specialist by 12 weeks, offer USS every 2-4 weeks between 16-24 weeks.
Which women are considered intermediate risk of preterm birth?
Fully dilated EMCS
Significant cervical surgery - LLETZ >1cm, more than 1 procedure, Cone Bx)
What care should be offered to women with intermediate risk of preterm birth?
Minimum single TV cervix 19-22 weeks
Can cervical cerclage be offered to multiple pregnancy?
No
Risk of preterm birth if:
Cone Bx
14%
Risk of preterm birth if:
LLETZ <10-12mm
7%
Risk of preterm birth if:
LLETZ >12mm
10%
Risk of preterm birth if:
Repeat LLETX
13%
When should tranabdominal cerclage be considered?
Previous unsuccessful TV cerclage
Can be offered pre-conception ally or early pregnancy
When should emergency cerclage be considered?
Premature cervical dilatation with fetal membranes exposed into vagina, can be performed up to 24 weeks, consider before 20 weeks and up to 27+6
Average delay between cerclage and delivery?
34 days
Contraindications to emergency cerclage?
Active preterm labour
Evidence choir
Continued vaginal bleeding
PPROM
Fetal compromise
Lethal fetal defect
Fetal death
What is the risk of bladder damage, cervical trauma, membrane rupture or sig bleeding with History or USS indicated cerclage?
<1%
Which cerclage requires anaesthetic removal?
High vaginal cerclage - shirodkar (inserted with bladder mobilisatino)
What testing should happen before insertion of history indicated cerclage?
1st trimester USS and screening for aneuploidy
Ideally what testing should be performed before USS or emergency indicated cerclage?
Anomaly USS
For emergency → WCC and CRP
Insufficient evidence for amniocentesis
Is any specific suture or surgical equipment advised?
Non absorbable suture - e.g. polyester braided thread or mersiline tape
No difference in outcome between McDonald or Shirodkar
No difference between single or double cerclage
Following cerclage can couples have sex?
Yes
Is routine USS recommended after cerclage
No, unless history indicated and timely steroids/transfer to level 3 unit
Is routine FFN recommended after cerclage
No, however high negative predictive value for birth <30 weeks
Is routine progesterone recommended after cerclage
No
When should the cerclage be removed?
Before labour
Normally 36-37 weeks unless birth is planned by ELCS
If women have transabdominal cerclage, how should they deliver?
By CS
If PPROM 24-34 weeks + no evidence preterm labour?
Removal can be delayed for 48hrs to allow for in utero transfer
What patient leaflets can be offered?
Cervical stitch RCOG
Tommys Charity info on cervical incompetence
