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1. Low risk of complications with cerclage placement. 2. Incidence of complications varies widely in relation to the timing and indications for the cerclage. 3. Life-threatening complications of uterine rupture and maternal septicemia are rare but have been reported. 4.Transabdominal cerclage carries a much greater risk of hemorrhage .
Cervical insufficiency: diagnosis
Challenging because of a lack of objective findings and clear diagnostic criteria. Diagnosis is based on history
1. Painless cervical dilation and expulsion of the
Cerclage removal is recommended at 36–37 weeks of gestation in patients with no complications. In patients planned vaginal delivery, remove cerclage before labor. In patients elected cesarean delivery, remove cerclage at the time of delivery.
Cerclage for the Management of Cervical Insufficiency
Cervical insufficiency: definition
The inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester。
One in three RCT indicated fewer deliveries before 33 weeks of gestation in the cerclage group.
Physical Examination-Indicated Cerclage
Given the lack of larger randomized trials that have demonstrated clear benefit, women should be counseled about the potential for associated maternal and perinatal morbidity.
Non-surgical treatment
1. Transvaginal cervical cerclage: McDonald procedure and Shirodkar procedure 2. Transabdominal cervical cerclage: laparotomy, laparoscopy and Robotic-assisted
Cervical insufficiency: clinical considerations and recommendations
1. Cerclage placement may be indicated based on a history of cervical insufficiency, physical examination findings, or a history of preterm birth and certain ultrasonographic findings. 2. Cerclage should be limited to pregnancies in the second trimester before fetal viability has been achieved.
Cervical insufficiency: treatment options
In which situations should Transabdominal cervical cerclage be considered? 1. Failed transvaginal cervical cerclage procedures history（这个我持保留意见） 2. Transvaginal cervical cerclage procedures can not place because of anatomical limitations
Questions 1: What is the role of ultrasonography in managing women with a history of cervical insufficiency?
Two recent summaries of the results of these multiple studies have drawn the following conclusions:
Indications for Cervical Cerclage in Women With Singleton Pregnancies
Indications for Cervical Cerclageຫໍສະໝຸດ Baiduin Women With Singleton Pregnancies
History-Indicated Cerclage
e. Cervical dilators to calculate a cervical resistance index
Cervical insufficiency: treatment options
Non-surgical treatment
1. 2. 3. 4. 5. Vaginal progesterone Vaginal pessary Activity restriction Bed rest Pelvic rest
3. Evidence is lacking for the benefit of cerclage solely for the following indications: prior LEEP, cone biopsy, or mü llerian anomaly.
Questions 3: Is cerclage placement associated with an increase in morbidity?
1. Short cervical length without history of prior singleton preterm birth. Vaginal progesterone is recommended to prevent cervical length ≤ 20mm before 24 wks. 2. Twin pregnancy with cervical length ≤ 25 mm.
Uterine cervix
Absence of the signs and symptoms
Second trimester A short cervical length in the second trimester is not sufficient for the diagnosis.
Cervical insufficiency: etiology
Short cervical length has been shown to be a marker of
preterm birth in general rather than a specific marker
of cervical insufficiency.
Cervical insufficiency: diagnosis
pregnancy in the second trimester
2. Without contractions or labor
3. In the absence of other clear pathology
Cervical insufficiency: diagnosis
Can the identification of cervical shortening by TVS be an ultrasonographic diagnostic marker of cervical insufficiency?
Diagnostic tests should not be used to diagnose cervical insufficiency.
a. Hysterosalpingography
b. Radiographic imaging of balloon traction on the cervix c. Assessment of the patulous cervix with Hegar or Pratt dilators d. Balloon elastance test
Ultrasound-indicated cerclage
Cerclage versus no cerclage in patients with short cervical length
Questions 2: Which patients should not be considered candidates for cerclage?
Cervical conization LEEP Mechanical dilation Obstetric lacerations Congenital mü llerian anomalies Deficiencies in cervical collagen and elastin Utero exposure to diethylstilbestrol And so on.
Questions 4: Is there a role for additional perioperative interventions and postoperative ultrasonographic assessment with cerclage placement?
1. Neither antibiotics nor prophylactic tocolytics has been shown to improve the efficacy of cerclage, regardless of timing or indication.
2. Further ultrasonographic surveillance of cervical length after cerclage placement is not necessary.
Questions 5: When is removal of transvaginal McDonald cerclage indicated in patients with no complications, and what is the appropriate setting for removal?
In most cases, removal of a McDonald cerclage in the office setting is appropriate.
Cervical insufficiency: diagnosis
Challenging because of a lack of objective findings and clear diagnostic criteria. Diagnosis is based on history
1. Painless cervical dilation and expulsion of the
Cerclage removal is recommended at 36–37 weeks of gestation in patients with no complications. In patients planned vaginal delivery, remove cerclage before labor. In patients elected cesarean delivery, remove cerclage at the time of delivery.
Cerclage for the Management of Cervical Insufficiency
Cervical insufficiency: definition
The inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester。
One in three RCT indicated fewer deliveries before 33 weeks of gestation in the cerclage group.
Physical Examination-Indicated Cerclage
Given the lack of larger randomized trials that have demonstrated clear benefit, women should be counseled about the potential for associated maternal and perinatal morbidity.
Non-surgical treatment
1. Transvaginal cervical cerclage: McDonald procedure and Shirodkar procedure 2. Transabdominal cervical cerclage: laparotomy, laparoscopy and Robotic-assisted
Cervical insufficiency: clinical considerations and recommendations
1. Cerclage placement may be indicated based on a history of cervical insufficiency, physical examination findings, or a history of preterm birth and certain ultrasonographic findings. 2. Cerclage should be limited to pregnancies in the second trimester before fetal viability has been achieved.
Cervical insufficiency: treatment options
In which situations should Transabdominal cervical cerclage be considered? 1. Failed transvaginal cervical cerclage procedures history（这个我持保留意见） 2. Transvaginal cervical cerclage procedures can not place because of anatomical limitations
Questions 1: What is the role of ultrasonography in managing women with a history of cervical insufficiency?
Two recent summaries of the results of these multiple studies have drawn the following conclusions:
Indications for Cervical Cerclage in Women With Singleton Pregnancies
Indications for Cervical Cerclageຫໍສະໝຸດ Baiduin Women With Singleton Pregnancies
History-Indicated Cerclage
e. Cervical dilators to calculate a cervical resistance index
Cervical insufficiency: treatment options
Non-surgical treatment
1. 2. 3. 4. 5. Vaginal progesterone Vaginal pessary Activity restriction Bed rest Pelvic rest
3. Evidence is lacking for the benefit of cerclage solely for the following indications: prior LEEP, cone biopsy, or mü llerian anomaly.
Questions 3: Is cerclage placement associated with an increase in morbidity?
1. Short cervical length without history of prior singleton preterm birth. Vaginal progesterone is recommended to prevent cervical length ≤ 20mm before 24 wks. 2. Twin pregnancy with cervical length ≤ 25 mm.
Uterine cervix
Absence of the signs and symptoms
Second trimester A short cervical length in the second trimester is not sufficient for the diagnosis.
Cervical insufficiency: etiology
Short cervical length has been shown to be a marker of
preterm birth in general rather than a specific marker
of cervical insufficiency.
Cervical insufficiency: diagnosis
pregnancy in the second trimester
2. Without contractions or labor
3. In the absence of other clear pathology
Cervical insufficiency: diagnosis
Can the identification of cervical shortening by TVS be an ultrasonographic diagnostic marker of cervical insufficiency?
Diagnostic tests should not be used to diagnose cervical insufficiency.
a. Hysterosalpingography
b. Radiographic imaging of balloon traction on the cervix c. Assessment of the patulous cervix with Hegar or Pratt dilators d. Balloon elastance test
Ultrasound-indicated cerclage
Cerclage versus no cerclage in patients with short cervical length
Questions 2: Which patients should not be considered candidates for cerclage?
Cervical conization LEEP Mechanical dilation Obstetric lacerations Congenital mü llerian anomalies Deficiencies in cervical collagen and elastin Utero exposure to diethylstilbestrol And so on.
Questions 4: Is there a role for additional perioperative interventions and postoperative ultrasonographic assessment with cerclage placement?
1. Neither antibiotics nor prophylactic tocolytics has been shown to improve the efficacy of cerclage, regardless of timing or indication.
2. Further ultrasonographic surveillance of cervical length after cerclage placement is not necessary.
Questions 5: When is removal of transvaginal McDonald cerclage indicated in patients with no complications, and what is the appropriate setting for removal?
In most cases, removal of a McDonald cerclage in the office setting is appropriate.