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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 79 - Cerclage for the Management of Cervical Insufficiency

“Infinite players have rules, they just do not forget that rules are an expression of agreement and not a requirement for agreement.” ― James Carse



2018 Malbec from Altos del Plata



PB#142 - Published February 2014 (Reaffirmed 2020)


Five Pearls

  1. History-indicated cerclage (aka prophylactic): Placed at 12-14 wga. Indicated if history of unexplained 2nd trimester pregnancy loss in the absence of labor or abruptio placentae

  2. Cerclage may also be indicated if Indicated if history of one or more spontaneous losses/preterm births at <24 weeks with a CL of 25 mm or less at <24 wga in current pregnancy.

  3. If no history of preterm birth, cerclage is not recommended even if CL <20 mm. Vaginal progesterone is recommended instead.

  4. A rescue cerclage may be indicated in the rare instance in which the cervix has dilated prematurely, exposing the amniotic sack on visual inspection.

  5. If a cervical cerclage is in place at the onset of labor, it should be removed immediately (otherwise the cervix may tear)

Cervical insufficiency definition

- first off: let's start calling it "painless cervical dilation" --> every cervix is magical in its own way

- painless cervical dilation after the 1st trimester with expulsion of the pregnancy in the 2nd trimester not accompanied by signs of labor (e.g. PPROM, surges, etc.) or placental abruption (heavy bleeding w/ or w/out painful surges)

- very hard to make this diagnosis...

- short cervix alone is not diagnostic of painless cervical dilation, but certainly is indicative of higher risk for preterm labor

- risk factors: history of cervical knife conization, loop excision, mechanical dilation of the cervix for past pregnancy termination, and maybe obstetrical cervical lacerations (data confirming these associations is inconsistent)


What can be done about this?

- activity restricting, bed rest, and avoiding intercourse haven't been found to help...quit it with this silliness

- pessaries also haven't been found to be helpful

- suturing the cervix closed is the only recourse

Source: Obgyn Key

Cerclage techniques

- all techniques use a non-resorbable suture

- as with any procedure, risks and benefits should be a mainstay of counseling around the management options (compared to expectant management)


McDonald

  • Purse-string, transvaginal approach

  • Cervicovaginal junction

  • Does not require bladder mobilization


Shirodkar

  • Purse-string, transvaginal approach

  • Require bladder and rectum mobilization in cephalad direction

  • Inserted above cardinal ligaments


Transabdominal

  • Requires laparotomy or laparoscopy

  • Suture is placed at cervicoisthmic jxn

  • Indicated if transvaginal approach was unsuccessful in previous pregnancy OR if anatomical limitations are present (e.g. history of trachelectomy)

  • Patient must undergo c-section

  • Stitch can be left in place until patient has completed childbearing

Source: MD Edge



Three indications for cerclage: history, exam, and rescue


History-indicated cerclage (aka prophylactic)

  • Placed at 12-14 wga

  • Indicated if history of unexplained 2nd trimester pregnancy loss in the absence of labor or abruptio placentae OR if patient has history of cerclage for painful cervical dilation


US-indicated cerclage

  • Indicated if history of one or more spontaneous losses/preterm births at <24 weeks AND finding of a cervical length (CL) of 25 mm or less at <24 weeks in current pregnancy

  • this strategy demonstrated to decrease preterm birth rates and improve overall neonatal morbidity and mortality

  • Funneling alone doesn’t count in measuring CL

  • If a history of any spontaneous 2nd trimester loss or preterm delivery, prudent to do serial cervical surveillance

Note: If no history of preterm birth and incidental finding of short cervix (in this case CL <20 mm at <24 wga), cerclage is not recommended. Vagina progesterone is recommended instead.


Rescue cerclage

  • Placed in the event of premature cervical dilation w/ exposure of fetal membranes

  • Generally discovered incidentally on US exam or spec exam for “vaginal discharge” or “bleeding”

  • Placed before 24-28 wks

  • Don't do it if there is evidence of intraamniotic infection or uterine activity

It isn't totally black and white as to when a cerclage is indicated based on medical history alone

- history-indicated cerclages can probably be avoided in up to 50% of patients

- most patients at risk for cervical insufficiency can be safely monitored by serial ultrasound in the 2nd trimester

- surveillance should begin at 16 wga and continue through 24 wga


Any risk of complications with cerclages?

- overall low risk of morbidity with cerclage, regardless of technique

- if waters have opened or if cervix is dilated, risks of complications is greater (e.g. infection or hemorrhage)

- antibiotics are not recommended universally during placement of a cerclage, regardless of timing or indication (not helpful)

- abdominal cerclage carries much higher risk of critical hemorrhage than transvaginal approach --> if labor ensues, sutures can shear through the tissues causing lacerations to major blood vessels



When should c-section be recommended if an abdominal cerclage is in place?

- 39 wga (because you want to avoid the uterus contracting against the sutures)


After cerclage placement, do I still need to monitor CL?

- Nopers


When can a transvaginal cerclage (McDonald or Shirodkar) be removed? How?

- if labor ensues before you've removed it, then that's gotta happen ASAP!

- reasonable to remove at 36-37 wga so that you don't have to worry about uterine surges against the sutures when the surges do commence

- you remove it with a mouse, you can remove it on a house, you can remove it with a bear, you can remove a cerclage anywhere! Steps:

  1. describe the procedure

  2. get consent

  3. have her undress

  4. place her in stirrups

  5. insert a lubricate speculum

  6. snip the suture knot with scissors

- if a c-section is planned, OK to wait until the surgery to also remove the cerclage, but beware of spontaneous labor

- if a patient with cerclage in place experiences PPROM, OK to leave it in place until labor ensues or if indications for augmentation arise (e.g. suspected intraamniotic infection);

- management is otherwise no different from any other case of PPROM


What if my patient with a cerclage presents in preterm labor?

- this is where your vast experience comes in handy

- assess the whole situation and make a call

- it may help to sit in a quiet room and ask your soul for guidance

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