Cervical insufficiency

Question 1

Mx options discussion

Scenario 1 - G2P1, 17/40 twins, previous cone/CS, short cervix on scan

Scenario 2 - 32 G2P1, 28/40 with TPL w Hx of PTB - transferred to Tertiary centre - found to have short cervix + LLP

Answer 1

high risk for PTL/PTB
- short CL + cone/twin
- short CL + LLP

Expectant
- bed rest, work/exercise cessation
- pros - no intervention
- cons - worsen->PPROM/PTL/preg loss , not evidence based

PV progesterone till 36/40
- mech - daily PV, anti-inflammatory
- pros - min intervention, self-administer, no evidence of harm to mother/baby
- cons - worsen over time, need surveillance, rescue cerclage

Cerclage +/- progesterone till 36/40
- mechanism - maintain cervical length/cervical mucus <- protect against ascending infection
- pros - may prolong, no serial CL req
- cons - surgical cx - bladder/cervix/PPROM/preg loss/suture removal/scarring of cervix/cervical trauma in labour

Pre-procedure check
- no aneuploidy, normal morph
- no evidence of bleeding/infection/PPROM/PTL

Procedure of cerclage
- day procedure
- +/- steroid
- regional vs GA
- FHR before/after
- non-absorbable suture through cervix
- antibiotics + PV progesterone -> cervical surveillance OPC

In general
- tertiary center referral
- cervical surveillance clinic till 26/40
- progesterone till 36/40
- serial CL & FFN (not if cerclage) at visit
- +/- steroid loading
- cerclage removal at 36/40 - day case or OP vs cerclage removal if elLUSCS

Question 2

Pre-viable open cervix Mx (describe McDonald Cerclage)

Scenario 1 - open cervix 2-3cm at 19/40 on bkg of cervical cone bx for CIN2

Answer 2

• Admit/Bed rest
• MDI - Obs/Paeds
• All options discussed
• Risks of cerclage
• Risks of PPROM/PTL/PTB…
• +/- steroids

Procedure
- Regional vs GA
- Lithotomy
- Prep/drape
- Bladder emptied
- 2-0 PDS on large curved needle
- Gently push bulging membrane to level of internal OS
- Start purse string from superior aspect of cervix at the level of internal OS
- Knot tied superiorly to the cervix
- +/- tocolytic +/- PO Abx according to local guidelines +/- bedrest post procedure
- LMWH whilst inpatient
- Clear documentation

Post cerclage plan as above