Cervical incompetence

Question 1

What is cervical cerclage?

Answer 1

Cervical cerclage is a procedure used to prevent preterm birth or miscarriage in women with cervical insufficiency by placing a stitch around the cervix to reinforce it and prevent premature opening during pregnancy.

Question 2

When is history-indicated cervical cerclage considered?

Answer 2

History-indicated cervical cerclage is considered for women with 3 or more consecutive midtrimester pregnancy losses that suggest cervical insufficiency. The cerclage is ideally placed at 13-14 weeks gestation.

Question 3

What is ultrasound-indicated cervical cerclage?

Answer 3

Ultrasound-indicated cervical cerclage is offered to women with a previous preterm birth after cervical length screening. It is placed before 24 weeks gestation in women with a cervix shorter than 25mm.

Question 4

What are the contraindications for cervical cerclage insertion?

Answer 4

Contraindications include active labor, vaginal bleeding, ruptured membranes, chorioamnionitis, placental abruption, lethal fetal anomalies, multiple pregnancies, and cervical dilation greater than 4 cm.

Question 5

What is physical examination-indicated cervical cerclage?

Answer 5

Physical examination-indicated cervical cerclage is performed in the second trimester in women who present with cervical dilation in the absence of labor or placental abruption.

Question 6

What are the common techniques for cervical cerclage insertion?

Answer 6

The most commonly used technique is the McDonald cerclage, which involves placing a circumferential purse-string suture around the cervix at the vesicocervical junction using non-absorbable sutures.

Question 7

What is cervical insufficiency?

Answer 7

Cervical insufficiency is a clinical diagnosis characterized by painless cervical dilatation and spontaneous mid-trimester pregnancy loss (between 14 to 24 weeks gestation), occurring in the absence of labor or other causes.

Question 8

What are the risk factors for cervical insufficiency?

Answer 8

Risk factors include a history of recurrent mid-trimester losses, previous cervical surgery (e.g., cone biopsy, large loop excision), congenital uterine abnormalities (e.g., septate or bicornuate uterus), and cervical shortening (<25mm before 28 weeks) on transvaginal ultrasound.

Question 9

At what gestational age is cervical insufficiency typically diagnosed?

Answer 9

Cervical insufficiency is typically diagnosed between 14 to 24 weeks of gestation.

Question 10

How is cervical insufficiency detected on physical examination?

Answer 10

Cervical insufficiency may be detected through physical examination by identifying cervical shortening, dilatation, or the presence of cervical tears without the presence of lab

Question 11

When should history-indicated cervical cerclage be inserted?

Answer 11

History-indicated cervical cerclage should be placed as early as possible, ideally at 13-14 weeks gestation.

Question 12

What is the general timing for cervical cerclage insertion?

Answer 12

Cervical cerclage is typically inserted between 13-24 weeks gestation, depending on the specific indications and risk factors.

Question 13

When should ultrasound-indicated cervical cerclage be performed?

Answer 13

Ultrasound-indicated cervical cerclage should be offered before 24 weeks gestation in women found to have a short cervix (<25mm) on transvaginal ultrasound.

Question 14

What are the key components of preoperative management for cervical cerclage?

Answer 14

Discuss the plan with a Consultant.
Consider antibiotic prophylaxis (e.g., Erythromycin 500 mg or Clindamycin 600 mg with Indomethacin 100 mg PO or PR q12 hours for 24 hours post-op).
Keep the patient in the hospital during treatment if antibiotics are given.

Question 15

What is the immediate postoperative management for cervical cerclage?

Answer 15

Provide analgesia.
Continue antibiotics if initiated.
Allow a normal diet unless complications arise.
Assess and discharge the patient the next day if stable.
Bed rest as clinically indicated, though not routinely for all patients

Question 16

What is the follow-up care after cervical cerclage insertion?

Answer 16

Routine antenatal care (ANC) unless otherwise indicated.
Monthly ANC visits.
For preterm labor, tocolysis is used for steroid administration if there are no contraindications and the gestation is less than 34 weeks.
Cerclage removal at 36-37 weeks gestation if no complications arise.

Question 17

What is a McDonald cerclage?

Answer 17

McDonald cerclage is a type of cervical cerclage where a circumferential purse-string suture is placed around the cervix at the vesicocervical junction to reinforce it and prevent premature dilation.

Question 18

How is the McDonald cerclage procedure performed?

Answer 18

The McDonald cerclage involves placing non-absorbable sutures (e.g., mersilene, nylon, prolene) around the cervix in 4 separate suture bites at the vesicocervical junction. The suture is tied anteriorly or posteriorly, avoiding vessels at 3 and 9 o’clock positions.

Question 19

What is the typical timing for the removal of a McDonald cerclage?

Answer 19

The McDonald cerclage is typically removed at 36-37 weeks gestation if no complications arise, such as preterm labor, PPROM, intrauterine fetal death, or antepartum hemorrhage.

Question 20

What are the potential complications during McDonald cerclage?

Answer 20

Potential complications include infection, bleeding, premature rupture of membranes (PROM), and the need for bed rest depending on clinical indications.

Question 21

What is a Shirodkar cerclage?

Answer 21

A Shirodkar cerclage is a type of cervical cerclage where a suture is placed submucosally around the cervix to reinforce it, typically in women with a very short cervix or significant cervical damage.

Question 22

How is the Shirodkar cerclage procedure performed?

Answer 22

The Shirodkar cerclage involves making a 2-3 cm anterior transverse submucosal incision at the vesicocervical junction, reflecting the bladder superiorly, and placing a suture around the cervix from anterior to posterior or vice versa. The incision is then closed, and mersilene tape is commonly used as the suture material.

Question 23

In what situations is a Shirodkar cerclage preferred over a McDonald cerclage?

Answer 23

The Shirodkar cerclage is preferred in cases where the cervix is very short or hypoplastic, or where previous cerclages have failed. It is also used when a higher level of cervical support is needed.

Question 24

What are the potential complications associated with a Shirodkar cerclage?

Answer 24

Potential complications include increased blood loss during the procedure, infection, premature rupture of membranes (PROM), and difficulty in suture removal due to its submucosal placement.

Question 25

What is an abdominal cerclage?

Answer 25

An abdominal cerclage is a type of cervical cerclage where the suture is placed around the cervix through a laparotomy, often reserved for cases where vaginal cerclage is not feasible or has previously failed.

Question 26

When is an abdominal cerclage typically indicated?

Answer 26

An abdominal cerclage is indicated in cases of severe cervical insufficiency where the cervix is too short or inaccessible for a vaginal cerclage, or in women with prior failed vaginal cerclages.

Question 27

How is the abdominal cerclage procedure performed?

Answer 27

The procedure involves a laparotomy, where the bladder is dissected inferiorly, and a mersilene tape is placed through the tissues of the lateral cervix at the level of the internal os. The cerclage is typically performed between 13-15 weeks of gestation.

Question 28

What are the delivery implications for an abdominal cerclage?

Answer 28

Women with an abdominal cerclage require a caesarean delivery because the suture cannot be removed vaginally, and the cerclage remains in place throughout the pregnancy.

Question 29

When is cervical cerclage typically removed?

Answer 29

Cervical cerclage is typically removed at 36-37 weeks gestation if no complications have occurred, such as preterm labor, PPROM, intrauterine fetal death, or antepartum hemorrhage.

Question 30

What are the indications for early removal of cervical cerclage?

Answer 30

Early removal of cervical cerclage may be indicated in cases of regular contractions (indicating preterm labor), preterm premature rupture of membranes (PPROM), intrauterine fetal death, or antepartum hemorrhage.

Question 31

What is the procedure for removing a McDonald cerclage?

Answer 31

For a McDonald cerclage, the suture is removed by simply cutting the knot (usually tied anteriorly or posteriorly) and gently pulling out the suture. This is typically done in an outpatient setting or during a hospital visit.

Question 32

What should be monitored after cervical cerclage removal?

Answer 32

After cervical cerclage removal, the patient should be monitored for signs of labor, contractions, or rupture of membranes. If removal is associated with complications like bleeding or infection, appropriate management should be initiated.