This post is the summary of GTG 75 Cervical Cerclage which was published in February 2022. This guideline supplements NICE 25 Preterm labour, GTG 73 PPROM and GTG 74 Antenatal corticosteroids. To prepare the topic comprehensively, it is advisable to read the other guidelines as well.
I hope this summary is helpful.
Your feedback and suggestions to improve future posts are welcome.
Thanks
To download the guidelines
- GTG 75 Cervical Cerclage
- GTG 74 Antenatal Corticosteroids
- GTG 73 PPROM Summary Click Here
- NICE 25 Preterm Labour Summary Click Here
- All GTGs Links
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Background
- Cerclage — a standard option for prophylactic intervention for those at risk of preterm birth & 2nd tri fetal loss
- Procedure to insert a stitch into cervix
- Aim is to prevent recurrent pregnancy loss
- Cervical insufficiency refers to weak cervix & unable to remain closed during pregnancy
- Cerclage provides structural support but maintaining cervical length more important
Definitions
History-indicated cerclage
- Insertion due to risk factors in patient’s history
- Prophylactic measure in asymptomatic
- Usually @ 11-14 wks
Preterm birth PTB— Birth occurring <37+0 wks
USG-indicated cerclage
- Done if cervical shortening seen on scan
- Therapeutic measure in asymptomatic without exposed fetal membranes in vagina
- USG usually TVS b/w 14-24 wks (with empty bladder)
Emergency cerclage (AKA physical exam-indicated)
- Salvage measure
- Inserted when premature cervical dilation with exposed fetal membranes in vagina
- Discovered by ultrasound or speculum/physical exam
- Considered up to 27+6 wks
Transvaginal cerclage (McDonald)
- Transvaginal purse-string suture placed at cervical isthmus junction without bladder mobilisation
High transvaginal cerclage requiring bladder mobilisation (including Shirodkar)
- Transvaginal purse-string suture after bladder mobilisation
- Inserted above cardinal ligaments
Transabdominal cerclage
- Suture via laparoscopy or laparotomy
- Placed at cervico-isthmic junction
Occlusion cerclage
- Occlusion of external os by placing continuous non-absorbable suture
- Benefits by retaining mucous plug
History-indicated cerclage
When to offer?
- Singleton pregnancy + ≥ 3 previous PTB — significant reduction in preterm birth before 37, 34 & 28 wks No change in PMR neonatal morbidity