Cervical cerclage - GTG No.75 - June 2022

Question 1

women with singleton pregnancies and _____ or more preterm births should be offered history indicated cervical cerclage

Answer 1

Singleton pregnancies and 3 or more PTBs

Question 2

Those with a singleton pregnancy and hx of spontaneous 2nd trimester loss or preterm birth who have not had a cerclage may be offered…

Answer 2

Serial sonographic surveillance.
Those who experience shortening may be offered an US indicated cerclage.

Question 3

For women with a singleton pregnancy and no other risk factors for preterm birth, and an incidentally identified short cervix…

Answer 3

Cervical cerclage is not recommended

Question 4

In women with a singleton pregnancy insertion of an emergency cerclage may delay birth by an average of ___ compared with expectant management /bed rest in SUITABLE cases

Answer 4

34 days

Question 5

Emergency cerclage in suitable cases is associated with a ______ reduction in the chance of birth before 34 weeks

Answer 5

two fold.

However there is only limited data to support associated improve in neonatal mortality and morbidity.

Question 6

While cerclage may provide a degree of structural support to a “weak cervix”…

Answer 6

Its role in maintaining the cervical length and the endocervical mucus plug as a mechanical barrier to ascending infection may be more important.

Question 7

What is meant by the term “history indicated cervical cerclage”

Answer 7

Insertion based on factors in a women’s O&G history which increase risk of spontaneous 2nd tri loss or PTB.
Performed as a prophylactic measure in ASYMPTOMATIC women as a planned procedure at 11-14 weeks.

Question 8

What is meant by the term “ultrasound indicated cerclage”

Answer 8

Insertion as a therapeutic measure in cases of cervical length shortening seen on TVS.
Performed on ASYMPTOMATIC women who do not have exposed fetal membranes in the vagina.
Usually between 14-24 weeks

Question 9

What is meant by the term emergency cerclage (or physical exam indicated)

Answer 9

Insertion of cerclage as a salvage measure in the case of premature cervical dilatation with exposed fetal membranes in the vagina.
May be following US examination of the cervix or as a result of speculum examination for SYMPTOMS such as PV discharge, PVB or pressure sensation
May be considered up to 27+6 weeks gestation.

Question 10

What is a McDonald suture?

Answer 10

A transvaginal purse string suture placed at the cervical isthmus junction WITHOUT bladder mobilisation

Question 11

What is a Shirodkar suture?

Answer 11

A HIGH transvaginal purse string suture placed following bladder mobilisation, to allow insertion above the level of the cardinal ligaments.

Question 12

What is a transabdominal cerclage?

Answer 12

A suture performed via a laparotomy or laparoscopy, placing the suture at the cervicoisthmic junction.

Question 13

What is an occlusion cerclage?

Answer 13

Occlusion of the external os by placement of a continuous non-absorbable suture.
The theory behind the potential benefit of occlusion cerclage is retention of the mucus plug.

Question 14

Why is history indicated cerclage only offered to those with three or more previous PTB or 2nd trimester losses?

Answer 14

A subgroup analysis of MRC/RCOG multicentre trial found benefit was only conferred to women with a history of 3 or more PTB/2nd tri losses.

Question 15

Is US indicated cerclage recommended for funnelling of the cervix without shortening

Answer 15

Observational studies have demonstrated no association between PTB and funnelling alone in the absence of a short cervix

Question 16

What percentage of women with a history of PTB/2nd Tri loss have a cervical length >25mm at 24 weeks

Answer 16

40-70%

Question 17

What does the SBLCB consider high risk for PTB?

Answer 17

High risk factors include:
Those with prev PTB or 2nd Trim loss (16-34) weeks
Prev PPROM less than 34 weeks
Previous use of cerclage
Known uterine variant
Intrauterine adhesions
History of trachelectomy

Question 18

What does the SBLCB consider to be intermediate risk factors for PTB

Answer 18

Intermediate risk factors include:
History of previous full dilatation LSCS
Significant cervical excisional surgery with an excision depth greater than 1cm or more than one procedure or a cone biopsy.

Question 19

When does the SBLCB suggest high risk women should start US surveillance of cervical length?

Answer 19

TV US every 2-4 weeks between 16-24 weeks

Question 20

When does the SBLCB suggest women with intermediate risk should commence US surveillance of CL

Answer 20

A single TV US of the cervix no later than 18-22 weeks as a minimum.

Question 21

What do NICE recommend regarding cerclage in multiple pregnancy.

Answer 21

No evidence for history indicated or US indicated cerclage.
Meta analyses indicates no benefit in multiple pregnancies without additional risk factors.

Question 22

When should transabdominal cerclage be considered?

Answer 22

In women with previous unsuccessful transvaginal cerclage, transabdominal may be discussed./considered.

Question 23

When should transabdominal cerclage be performed?

Answer 23

Can be performed pre-conceptually or in early pregnancy.
Pre-conception may be more effective and has no effect on fertility and has lower anaesthetic or fetal risks.

Question 24

Does pre-conceptually placed transabdominal cerclage effect treatment of early miscarriage?

Answer 24

No

Question 25

Is there any difference in outcomes when abdominal cerclage is placed laparoscopically or open?

Answer 25

No difference in 2nd tri losses or birth rates after 34 weeks.
Laparoscopic approach is associated with fewer complications.

Question 26

How should women with abd. cerclage who experience delayed miscarriage or fetal death be cared for?

Answer 26

There are no studies evaluating the different methods
Senior clinicians should be involved.
Complete evacuation through the stitch by suction curettage or by D&C have been reported in case reports.
The suture may be cut via a posterior colpotomy.

Question 27

What features are associated with a high chance of emergency cerclage failure?

Answer 27

advanced dilatation >4cm or membrane prolapse beyond the external os.

Question 28

Emergency cerclage can rarely be justified beyond 24 weeks due to the potential risk of…

Answer 28

iatrogenic rupture and subsequent preterm birth.

Question 29

What are the contraindications to cerclage insertion

Answer 29

• active preterm labour
• clinical evidence of chorio
• continuing vaginal bleeding
• PPROM
• evidence of fetal compromise
• lethal fetal defect
• fetal death

Question 30

before history or US indicated cerclage women should be informed of the following:

Answer 30

• Small risk of bladder injury, cervical trauma, membrane rupture and bleeding
• Risk of cervical trauma/laceration if there is spont labour with suture insitu.
• High vaginal cerclage with bladder mobilisation usually requires anaesthetic for removal.

Question 31

What Ivx should women have before history indicated cerclage

Answer 31

1st trimester scan and aneuploidy screening.

Question 32

Before US indicated or emergency cerclage women should ideally also have…

Answer 32

Anomally scan is preferable.
Maternal WCC and CRP can be used to detect chorio but not required in the absence of clinical signs of chorio.

Question 33

Is amnio reduction before cerclage recommended?

Answer 33

There is an absence of data to either refute or support the use of amnioreduction before insertion of an emergency cerclage and this should therefore NOT be carried out.

Question 34

Should there be a latency period between presentation and insertion of a rescue or US indicated cerclage

Answer 34

There are no studies to support either immediate vs delayed.
Any delay balances the risk of inserting a suture in a cervix that is inevitably going to continue dilating against the increased risk of ascending infection.

Question 35

Should perioperative tocolysis (indomethacin) be used for insertion of cerclage

Answer 35

There is no evidence to support the use of routine tocolysis.

Question 36

What anaesthetic should be used for insertion of cerclage

Answer 36

should be on an individual basis.
Both general or regional are safe.
GA associated with quicker recovery but a higher demand for opiod and non opiod analgesia.

Question 37

Can elective cerclage be performed as a day case

Answer 37

Yes. No difference in outcomes.

Question 38

Is any method of cerclage insertion superior?

Answer 38

No difference in outcomes between the techniques of cerclage.
Therefore this is at the discretion of the surgeon.

Question 39

Should bed rest be advised after a cerclage?

Answer 39

Should not be routinely recommended but should be individualised.

Question 40

Should abstinence from sexual intercourse be advised

Answer 40

There is no evidence to recommend abstinence.
There are no studies.

Question 41

Is fFN testing useful following insertion of a cervical cerclage

Answer 41

Routine fFN testing is not recommended post cerclage, however the high negative predictive value at <30 weeks in asymptomatic high risk women may provide reassurance for women and clinicians

Question 42

Should women receive supplement progesterone following treatment

Answer 42

Not recommended by NICE

Question 43

Should women be offered progesterone or Arabin pessary instead of cerclage?

Answer 43

There is no evidence that either progesterone or Arabin pessary alone are more or less effective than cevical cerclage.

Question 44

When should cerclage be removed.

Answer 44

A transvaginal cerclage should be removed before labour between 36+1 and 37 weeks unless planning LSCS.
It should be removed in those women in established preterm labour.
Transabdominal cerclage women will have LSCS and it does not need to removed.

Question 45

When should cerclage be removed with PPROM.

Answer 45

Delayed removal can be considered to facilitate in utero transfer in those who have no signs of chorio and are <34 weeks
Do not delay if <23 weeks or >34 weeks