PB 142: Cerclage of the Management of Cervical Insufficiency

Question 1

The pathophysiology of cervical insufficiency is poorly understood.

What are 4 factors that may increase the risk of cervical insufficiency?

Answer 1

1. LEEP
2. CKC
3. Cervical dilation in setting of D&E
4. Obstetric laceration

Question 2

What are the standard transvaginal cerclage methods?

Answer 2

1. McDonald Cerclage
2. Shrid

Question 3

McDonald Cerclage

Answer 3

Simple purse-string suture of nonresorbable material inserted at the cervicovaginal junction

Question 4

Shirodkar Cerclage

Answer 4

Dissection of the vesicocervical mucosa in an attempt to place the nonresorbable suture as close to the cervical internal os as possible > the rectal and bladder mucosa are then replaced over the knot

Question 5

When would a transabdominal cervicoisthmic cerclage be indicated?

Answer 5

Based on the diagnosis of cervical insufficiency but cannot be placed because of anatomical limitations (e.g., after a trachelectomy), or in the case of a failed transvaginal cerclage that resulted in a second trimester loss

Abdominal cerclage procedures usually are performed in the late first trimester or early second trimester (10–14 weeks of gestation) or in the nonpregnant state. The stitch can be left in place between pregnancies with subsequent cesarean delivery.

Question 6

Clinical Considerations and Recommendations:

In which patients is cerclage indicated based on obstetric history or physical examination findings?

Answer 6

Question 7

Is there a role for additional perioperative interventions and postoperative ultrasono- graphic assessment with cerclage placement?

Answer 7

1. Neither antibiotics nor prophylactic tocolytics has been shown to improve the efficacy of cerclage, regardless of timing or indication
2. Further ultrasonographic surveillance of cervical length after cerclage placement is not necessary

Question 8

When is removal of transvaginal McDonald cerclage indicated in patients with no compli- cations, and what is the appropriate setting for removal?

Answer 8

36-37 weeks

For patients who elect cesarean delivery at or beyond 39 weeks, can remove at time of delivery

Question 9

How should women with cerclage and pre-term premature rupture of membranes be managed?

Answer 9

A firm recommendation on whether a cerclage should be removed after premature PROM cannot be made, and either removal or retention is reasonable.

Regardless, if a cerclage remains in place with preterm PROM, prolonged antibiotic prophylaxis beyond 7 days is not recommended.