RCOG Guidelines on Cervical Cerclage

RCOG Guidelines on Cervical Cerclage. Green-top Guideline No. 75 February 2022.

cervical cerclage. Cervical cerclage is a way of keeping cervix closed during pregnancy to prevent premature birth due to incompetent (weakened) cervix..

nomenclature. history indicated cerclage Insertion of a cerclage as a result of factors in a woman’s obstetric or gynaecological history, which increase the risk of spontaneous second trimester loss or preterm birth and is performed as a prophylactic measure in asymptomatic women and as a planned procedure at 11–14 weeks of gestation ultrasound indicatedd cerclage I nsertion of a cerclage as a therapeutic measure in cases of cervical length shortening (less than 25 mm) seen on transvaginal ultrasound. emergency cerclage Insertion of cerclage as a salvage measure in case of premature cervical dilatation with exposed fetal membranes in the vagina. It can be considered up to 27+6 weeks gestation. transabdominal cerclage A suture performed via a laparotomy or laparoscopy, placing the suture at the cervicoisthmic junction. occlusion cerclage Occlusion of the external os by placement of a continuous non-absorbable suture. The theory behind the potential benefit of occlusion cerclage is retention of the mucus plug . transvaginal (macdonalds) suture A transvaginal purse-string suture placed at the cervical isthmus junction, without bladder mobilization. high vaginal with bladder mobilization(shirodkar) A transvaginal purse-string suture placed following bladder mobilization, to allow insertion above the level of the cardinal ligaments.

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macdonalds suture. McDonaldcerclage.

high vaginal cerclage. 1-s2.0-S0301211517303147-gr2.

recommendations for History indicated. Women with singleton pregnancies and three or more previous preterm births should be offered a history-indicated cervical cerclage History-indicated cerclage should not routinely be offered to women with less than three previous preterm births and/or second trimester losses without additional risk factors It is unknown if the specific characteristics of the previous adverse event are helpful in the decision to place a history indicated cerclage. (e.g. painless dilatation, rupture of membranes, prior cervical surgery.

recommendations for USG indicated. For women with a singleton pregnancy and no other risk factors for preterm birth, insertion of cervical cerclage is not recommended in women who have a short cervix incidentally identified on a late second trimester ultrasound scan no benefit of cerclage in women with a cervical length less than 25 mm with no other risk factors for preterm birth Women with a history of one or more spontaneous second trimester loss or preterm births who are undergoing ultrasound surveillance of cervical length should be offered cerclage if the cervix is 25mm or less at gestations less than 24 weeks An ultrasound-indicated cerclage is not recommended for funnelling of the cervix (dilatation of the internal os on ultrasound) in the absence of cervical shortening to 25 mm or less (the closed length of the cervix.

Ultrasound surveillance of cervical length is advocated in.

Women at intermediate risk include. women including those who have a history of a previous full dilatation C-section significant cervical excisional surgery i.e. large loop excision of the transformation zone (LLETZ) with an excision depth greater than 1 cm, more than one procedure or a cone biopsy These women should undergo a single transvaginal cervix scan no later than 18–22 weeks as a minimum.

recommendations for transabdominal. In women with a previous unsuccessful transvaginal cerclage, insertion of a transabdominal cerclage may be discussed and considered Transabdominal cerclage can be performed pre-conceptually or in early pregnancy. Pre-conceptual procedures may be more effective and are not associated with sub-fertility Laparoscopic and open abdominal cerclage have similar efficacy.

recommendations for emergency cerclage. The decision to place a emergency suture should be individualised, taking the parents’ views carefully into account. Insertion of a emergency cerclage may delay birth by approximately 34 days in suitable cases (CI = 18–50 days), compared with expectant management/bed rest alone. It may also be associated with a two-fold reduction in the chance of birth before 34 weeks of gestation. However, there are only limited data to support an associated improvement in neonatal mortality or morbidity Advanced dilatation of the cervix (more than 4cm) or membrane prolapse beyond the external os appears to be associated with a high chance of cerclage failure.

contraindications to cerclage insertion. active preterm labour clinical evidence of chorioamnionitis continuing vaginal bleeding PPROM evidence of fetal compromise lethal fetal defect fetal death.

consent. Before history- or ultrasound-indicated cerclage insertion women should be given verbal and written information about potential complications. women should be informed of the following: There is a small risk of intraoperative bladder damage, cervical trauma, membrane rupture and bleeding during insertion of cervical cerclage. Cervical cerclage may be associated with a risk of cervical laceration/trauma if there is spontaneous labour with the suture in place High vaginal cerclage, inserted with bladder mobilisation, usually requires anaesthetic for removal and therefore carries the risk of an additional anaesthetic..

For women undergoing non-“emergency” cerclage. Vaginal cerclage insertion is not associated with an increased risk of PPROM, chorioamnionitis, induction of labour or caesarean section. The insertion of a cervical suture is not associated with an increased risk of preterm birth or second trimester loss. Cervical cerclage may be associated with a risk of cervical laceration/trauma if there is spontaneous labour with the suture in place.

pre op management. Women should be offered a first trimester ultrasound scan and screening for aneuploidy before the insertion of a history-indicated suture to ensure both viability, singleton pregnancy, and the absence of lethal/major fetal anomaly Before ultrasound-indicated or emergency cerclage, it is preferable to ensure an anomaly scan has been performed Maternal white cell count and C-reactive protein to detect chorioamnionitis before insertion of a emergency cerclage can be used to aid management. The decision to perform these tests should be based on the overall clinical picture, but in the absence of clinical signs of chorioamnionitis, the decision for emergency cerclage need not be delayed Routine genital tract screening should not be undertaken before cerclage insertio.

perioperative measures. There is no evidence to support the use of routine perioperative tocolysis in women undergoing insertion of cerclage; this should be considered on an individual basis The decision for antibiotic prophylaxis at the time of cerclage placement should be decision of the operating team.

technique and material. The choice of suture material should be decision of the surgeon; a nonabsorbable suture should be used The choice of transvaginal cerclage technique (high cervical insertion with bladder mobilization or low cervical insertion) should be at the discretion of the surgeon, but the cerclage should be placed as high as is practically possible There is no difference between using two purse-string sutures and one single suture and should be at the discretion of the surgeon The insertion of cervical occlusion suture in addition to the primary cerclage is not routinely recommended.

adjuvant management. Bed rest Bed rest in women who have undergone cerclage should not be routinely recommended but should be individualised, taking into account theclinical circumstances and potentialadverse effects sexual intercourse Abstinence from sexual intercourse followin cerclage insertion should not be routinely recommended serial sonographic surveillance of cervical length serial sonographic measurement of the cervix is not recommended it may be useful in individual cases following ultrasound-indicated cerclage to offer timely administration of steroids or in utero transfer.

fetal fibronectin testing Routine fetal fibronectin testing is not recommended post-cerclage. progesteron supplementation Routine use of progesterone supplementation following cerclage is not recommended.

cerclage removal. A transvaginal cervical cerclage should be removed before labour, usually between 36+1 and 37+0 weeks of gestation, unless birth is by pre-labour caesarean section, in which case suture removal could be delayed until this time In women presenting in established preterm labour, the cerclage should be removed to minimize potential trauma to the cervix A high (inserted with bladder mobilization) cervical cerclage will usually require anaesthesia for removal All women with a transabdominal cerclage require birth by caesarean birth, and the abdominal suture may be left in place following birth.

crclage removal following PPROM. in women with PPROM between 24 and 34 weeks of gestation and without evidence of infection or preterm labour delayed removal of the cerclage for 48 hours can be considered to facilitate in utero transfer Delayed suture removal until labour ensues, or birth is indicated, is associated with an increased risk of maternal/fetal sepsis and is not recommended Given the risk of neonatal and/or maternal sepsis and the minimal benefit of 48 hours of latency in pregnancy with PPROM before 23 and after 34 weeks of gestation, delayed suture removal is unlikely to be advantageous in this situation.