PB#142: Cerclage for the Management of Cervical Insufficiency

Question 1

Definition of cervical insufficiency

Answer 1

Inability of uterine cervix to retain pregnancy in absence of signs/sxs of clinical ctxs and/or labor in 2nd tri

Question 2

US finding associated w/ increased risk of PTD

Answer 2

Short CL in 2nd tri (though this is not sufficient for dx of cervical insufficiency)

Question 3

Factors that may increase risk of cervical insufficiency (6)

Answer 3

Surgical trauma to cervix (ie LEEP, CKC, excision), mechanical dilation of cervix during pregnancy termination, OB lacs, congenital müllerian anomalies, deficiencies in cervical collagen and elastin, in utero DES exposure

Question 4

Dx of cervical insufficiency

Answer 4

Hx of painless cervical dilation after 1st tri w/ subsequent expulsion of pregnancy in 2nd trimester, typically <24wga, w/o ctxs/labor and in absence of other clear pathology (ie bleeding, infection, ROM)

Question 5

Surgical approaches for management of CI (2)

Answer 5

TV, TA cervical cerclage

Question 6

Standard TV cerclage methods (2)

Answer 6

McDonald, Shirodkar

Question 7

Situations in which TA cervicoisthmic cerclage is indicated (2)

Answer 7

Pts who have anatomical limitations (ie s/p trachelectomy), in cases of failed TV cervical cerclage procedures

Question 8

Route of placement of TA cerclage (2)

Answer 8

Laparotomy, minimally invasively

Question 9

When are TA cerclage procedures typically performed?

Answer 9

Late-1st tri or early-2nd tri, or in nonpregnant state

Question 10

Can TA cerclage stitch be left in place between pregnancies?

Answer 10

Yes, w/ subsequent C/S deliveries

Question 11

Indications for cerclage (3)

Answer 11

Hx of CI, PE findings, hx of PTD + US findings

Question 12

Criteria for hx-indicated cerclage (2)

Answer 12

Hx of 1+ 2nd tri pregnancy losses related to painless cervical dilation and in absence of labor/abruption, prior cerclage 2/2 painless cervical dilation in 2nd tri

Question 13

Criteria for physical exam-indicated cerclage

Answer 13

Painless cervical dilation in 2nd tri

Question 14

Criteria for US-indicated cerclage

Answer 14

Current singleton pregnancy, prior spontaneous PTD at <34wga, and short CL (<25mm) at <24wga

Question 15

When should cerclage be placed?

Answer 15

2nd tri pregnancies before fetal viability is achieved

Question 16

When are hx-indicated cerclages typically placed?

Answer 16

~13-14wga

Question 17

Common name for exam-indicated cerclage

Answer 17

Emergency/Rescue cerclage

Question 18

Routine monitoring of pts at risk of CI

Answer 18

Serial TVUS exams in 2nd tri

Question 19

When should US surveillance be conducted for pts at risk of CI?

Answer 19

16-24wga

Question 20

Does presence/absence of funneling determine if cerclage is indicated?

Answer 20

No, short CL w/wo presence of funneling are US findings indicative of cerclage placement in high-risk pts

Question 21

Does cerclage placement improve outcomes in pts w/ CL <25mm on US at 16-24wga who do not have a hx of prior spontaneous PTD?

Answer 21

No

Question 22

What intervention is recommended to reduce risk of PTD in asymptomatic pts w/ singleton gestation w/o prior PTD w/ incidentally identified very short CL (<20mm) at <24wga

Answer 22

Vaginal progesterone

Question 23

Is cerclage recommended for pts w/ twin gestation and US-detected CL <25mm?

Answer 23

No, as it may increase risk of PTD

Question 24

Overall complication risk w/ cerclage placement

Answer 24

Low

Question 25

Route of cerclage placement that carries higher risk of hemorrhage

Answer 25

Transabdominal

Question 26

When is delivery indicated w/ transabdominal cerclage in place (in o/w uncomplicated pregnancy)?

Answer 26

39+wga

Question 27

Have abx been shown to improve efficacy of cerclage; have ppx tocolytics been shown to improve efficacy of cerclage?

Answer 27

No; no

Question 28

What additional US assessment of CL s/p cerclage placement is needed?

Answer 28

None

Question 29

When is transvaginal McDonald cerclage removal indicated in pts w/o complication who intend to undergo VTOL?

Answer 29

36-37wga

Question 30

When is intentional deferral of cerclage removal until time of labor recommended?

Answer 30

Never

Question 31

Is cerclage removal indication for delivery?

Answer 31

No

Question 32

When is cerclage removal indicated for pts who opt for C/S at 39+wga?

Answer 32

At time of C/S (though possibility of spontaneous labor at 37-39wga must be considered)

Question 33

What is most appropriate setting for transvaginal cerclage removal?

Answer 33

In office

Question 34

Should cerclage be removed following PPROM?

Answer 34

No firm recommendation re removal or retention

Question 35

Are prolonged abx (beyond 7 days) recommended in PPROM pts w/ cerclage that remains in place?

Answer 35

No

Question 36

When is cerclage removal indicated in pts presenting w/ sxs of PTL?

Answer 36

Per clinical judgment

Question 37

Management of symptomatic PTL in pts w/ cerclage

Answer 37

As per routine

Question 38

Indications for cerclage removal in pts w/ PTL (3)

Answer 38

Cervical change, painful ctxs, VB