This document provides guidelines on cervical cerclage for the management of cervical insufficiency, including indications for history-indicated, ultrasound-indicated, and emergency cerclage based on prior preterm birth history and cervical length on ultrasound; it describes the McDonald and Shirodkar surgical techniques as well as considerations for removal and complications; and notes that cerclage is not recommended for twin pregnancies or short cervical length without prior preterm birth.
This document provides guidelines on cervical cerclage for the management of cervical insufficiency, including indications for history-indicated, ultrasound-indicated, and emergency cerclage based on prior preterm birth history and cervical length on ultrasound; it describes the McDonald and Shirodkar surgical techniques as well as considerations for removal and complications; and notes that cerclage is not recommended for twin pregnancies or short cervical length without prior preterm birth.
This document provides guidelines on cervical cerclage for the management of cervical insufficiency, including indications for history-indicated, ultrasound-indicated, and emergency cerclage based on prior preterm birth history and cervical length on ultrasound; it describes the McDonald and Shirodkar surgical techniques as well as considerations for removal and complications; and notes that cerclage is not recommended for twin pregnancies or short cervical length without prior preterm birth.
This document provides guidelines on cervical cerclage for the management of cervical insufficiency, including indications for history-indicated, ultrasound-indicated, and emergency cerclage based on prior preterm birth history and cervical length on ultrasound; it describes the McDonald and Shirodkar surgical techniques as well as considerations for removal and complications; and notes that cerclage is not recommended for twin pregnancies or short cervical length without prior preterm birth.
Management of Cervical Insufficiency Practice Bulletin # 142 Karlene Vega Figueroa, PGY-1 Definition • Inability of uterine cervix to retain a pregnancy in the absence of clinical contractions, labor, or both in the second trimester Pathophysiology • Poorly understood
• Factors that increase risk :
• Surgical trauma (conization, LEEP, mechanical dilation of cervix during termination, obstetric lacerations) • Congenital Mullerian anomalies, Cervical collagen deficiency, in-utero DES exposure
• Not indications for cervical cerclage
Diagnosis • History of painless cervical dilation after first trimester • Subsequent expulsion of pregnancy in the second trimester • Typically occurs before 24 WGA • In absence of other clear pathology
• Cervical length has been shown to be a marker for preterm
birth, rather tan specific marker for cervical insufficiency Indications Cerclage should be limited to pregnancy in second trimester, before viability is achieved History Indicated/Prophylactic
• History of unexplained second trimester delivery in absence of labor
or abruptio placentae.
• Typically placed at 13-14 WGA
• 1/3 trials found fewer deliveries before 33 WGA in patient with
history indicated cerclage Physical Exam-Indicated/ Emergency or Rescue • Advanced cervical dilation (internal os) in the absence of labor and abruptio placenta in singleton pregnancy
• Rule out uterine activity and/or intraamniotic infection
• Due to lack of larger trials that show clear benefit, counsel patient about potential morbidity Ultrasonography Indicated
• History of prior spontaneous PTD <34 WGA.
• Most patients can be safely monitored with serial transvaginal
ultrasounds q2 wks in second trimester (16 WGA – 24 WGA)
• Unnecessary history indicated cerclage procedures can be avoided in
more than one half of the patients. Ultrasonography Indicated • Recommended for those who have changes on TVUS consistent with a short cervical length (<25mm) with or without funneling.
• Although patient with current singleton pregnancy with prior
spontaneous PTD <34WGA and short cervical length is not diagnostic criteria for cervical insufficiency, evidence suggest cerclage may be effective.
• Cerclage has not shown significant reduction in preterm birth, if no
history of PTD and CL <25mm between 16-24WGA Treatment Options
• Non-surgical approaches have not shown to be effective or
have limited evidence • Bed rest, activity restriction, pelvic rest, etc. – DISCOURAGED • Pessary – HIGH RISK PATIENTS • Surgical approaches • Transvaginal - McDonald & Shirodkar • Transabdominal cervicoisthmic • None superior to other • Hemorrage risk: Transabdominal>>>Transvaginal McDonald Shirodkar
https://www.youtube.com/watch?v=lkYK6vux6D8 Suture: 1 or 2 Nylon, Propylene monofilament or Mersilene tape Two cerclage sutures are not more effective than one. Cerclage Removal (McDonald)
• Recommended between 36-37 WGA
• In office setting
• Not an indication for delivery
• If cesarean section, at >= 39WGA, cerclage removal at time of surgery
may be performed Transabdominal Cervicoisthmic
Reserved for: 1. Anatomical limitations (trachelectomy) 2. Failed transvaginal cerclage that resulted in 2nd trimester pregnancy loss
Performed late trimester or early second
trimester (10-14 WGA)
Can be left in place between pregnancies
until childbearing is complete. • Incidentally detected short cervical length in second trimester in the absence of prior singleton preterm birth is not diagnostic of cervical insufficiency Which patients should NOT be • Vaginal progesterone for incidental short cervical length (<=20mm) before 24 WGA considered candidate for • Twin pregnancy. May increase risk of PTD. Not recommended cerclage? • Lacking evidence for prior LEEP, cone bx, or Mullerian anomaly Rupture of Chorioamnionitis Membranes Morbidity Cervical Suture Laceration Displacement
Uterine Rupture Maternal Septicemia Perioperative interventions No antibiotics and US Assessment No tocolytics
US surveillance after placement is not necessary Cerclage in PPROM and PTL Management
PPROM PTL • Retention for >24hrs after • Clinical judgement advised PPROM is associated with • If cervical change, painful pregnancy prolongation contractions or vaginal • Retention has been associated bleed>>remove with neonatal sepsis and mortality, RDS, chorioamnionitis • Firm recommendation cannot be made to remove or retain • Williams Obstetrics, Chapter 18, Section 6
• Cerclage for the management of
cervical insufficiency. Practice Bulletin No. 142. American College of Obstetricians and Gynecologists. References Obstet Gynecol 2014;123:372–9.
