Cervical Cerclage GTG

Question 1

When should history indicated cerclage be offered?

Answer 1

Singleton pregnancy and 3 or more previous preterm births.

No benefit if previous cervical surgery or uterine abnormality

Question 2

When should USS cerclage be offered?

Answer 2

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

Question 3

What % of women who have had a previous 2nd trimester loss/ previous preterm birth have maintained cervical length >25mm by 24 weeks

Answer 3

40-70%

Question 4

Of the women who maintain cervical length >25mm gave birth >34 weeks?

Answer 4

90%

Question 5

Which women are considered high risk for preterm birth?

Answer 5

Previous pre-term birth/2nd trimester loss (16-34 weeks)
Previous PPROM <34week
Previous cerclage
Known uterine variant
Intrauterine adhesions
Hx trachelecotmy

Question 6

For women who are high risk, what care should be offered?

Answer 6

Review by specialist by 12 weeks, offer USS every 2-4 weeks between 16-24 weeks.

Question 7

Which women are considered intermediate risk of preterm birth?

Answer 7

Fully dilated EMCS
Significant cervical surgery - LLETZ >1cm, more than 1 procedure, Cone Bx)

Question 8

What care should be offered to women with intermediate risk of preterm birth?

Answer 8

Minimum single TV cervix 19-22 weeks

Question 9

Can cervical cerclage be offered to multiple pregnancy?

Answer 9

No

Question 10

Risk of preterm birth if:
Cone Bx

Answer 10

14%

Question 11

Risk of preterm birth if:
LLETZ <10-12mm

Answer 11

7%

Question 12

Risk of preterm birth if:
LLETZ >12mm

Answer 12

10%

Question 13

Risk of preterm birth if:
Repeat LLETX

Answer 13

13%

Question 14

When should tranabdominal cerclage be considered?

Answer 14

Previous unsuccessful TV cerclage

Can be offered pre-conception ally or early pregnancy

Question 15

When should emergency cerclage be considered?

Answer 15

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

Question 16

Average delay between cerclage and delivery?

Answer 16

34 days

Question 17

Contraindications to emergency cerclage?

Answer 17

Active preterm labour
Evidence choir
Continued vaginal bleeding
PPROM
Fetal compromise
Lethal fetal defect
Fetal death

Question 18

What is the risk of bladder damage, cervical trauma, membrane rupture or sig bleeding with History or USS indicated cerclage?

Answer 18

<1%

Question 19

Which cerclage requires anaesthetic removal?

Answer 19

High vaginal cerclage - shirodkar (inserted with bladder mobilisatino)

Question 20

What testing should happen before insertion of history indicated cerclage?

Answer 20

1st trimester USS and screening for aneuploidy

Question 21

Ideally what testing should be performed before USS or emergency indicated cerclage?

Answer 21

Anomaly USS

For emergency → WCC and CRP

Insufficient evidence for amniocentesis

Question 22

Is any specific suture or surgical equipment advised?

Answer 22

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

Question 23

Following cerclage can couples have sex?

Answer 23

Yes

Question 24

Is routine USS recommended after cerclage

Answer 24

No, unless history indicated and timely steroids/transfer to level 3 unit

Question 25

Is routine FFN recommended after cerclage

Answer 25

No, however high negative predictive value for birth <30 weeks

Question 26

Is routine progesterone recommended after cerclage

Answer 26

No

Question 27

When should the cerclage be removed?

Answer 27

Before labour
Normally 36-37 weeks unless birth is planned by ELCS

Question 28

If women have transabdominal cerclage, how should they deliver?

Answer 28

By CS

Question 29

If PPROM 24-34 weeks + no evidence preterm labour?

Answer 29

Removal can be delayed for 48hrs to allow for in utero transfer

Question 30

What patient leaflets can be offered?

Answer 30

Cervical stitch RCOG
Tommys Charity info on cervical incompetence