DEBATE - SHORT CERVIX - OS TIGHTNING BY DR SHASHWAT JANI

1. Dr. Shashwat K. Jani
M. S. ( Obs – Gynec ) , FIAOG.
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Born Too Soon
The Global Epidemiology Of 15 Million
Preterm Births.
Hannah Blencowe et al
Why Worry About Preterm Births…???
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3. (2013) Hannah Blencowe 74, 00-00. doi:10.1038/pr.2013.204
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4. Goldenberg RL et al. The preterm prediction study. Am JPublic Health. 1998;88:233-38
The Preterm Prediction Study
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5. Etiology
TRAUMA:
Gyn Cervical Trauma
D/C & D/E
Cervical amputation
Cervical conization
Obst Cervical Trauma
Cervical lacerations and tears in precipitate labor, Breech
extraction, Forceps delivery, Large baby,
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6. Congenital defects :
Bicornuate uterus, Sub Septate uterus, Septate
uterus
Connective tissue ,fibrous tissue & smooth
muscles
Smooth muscle :7-17-27
From ext os ---endocervical canal--- int os
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7. Defining Short Cervix
The discriminatory length of cervical
shortening varies widely between
26mm ( lams et al ) to 15 mm ( Hassan et al ).
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8. Basic Parameters
Standard cervical measurements use the
“white stripe” of the internal cervical os as an
anatomic landmark for proper caliper
placement.
• Anderson found an average cervical length of
45 ± 7mm at 14 to 30 weeks.
• Lams et al found a mean cervical length of
35 ± 8 mm at 24 weeks.
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9. ULTRASOUND DIAGNOSIS
 Cervical length < 2.5 cm or progressive cervical
shortening
 Width of internal os 1.5 cms or more during 1st trimester
and > 2 cms in the second trimester (Maharan) is
diagnostic
 Funneling of cervix
 V-shaped and U-shaped lower segment
 Herniation of bag of membranes into the cervical canal
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11. Definition Cervical Cerclage
Cervical cerclage refers to a variety of
surgical procedures in which sutures or
synthetic tape are used to mechanically
increase the tensile strength of the cervix,
thereby reducing the occurrence of preterm
birth .
(Norwitz et al. 2007)
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Cervical Cerclage

13. In Whom Is A Cervical
Cerclage Indicated?
( RCOG 2011 )
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14. History- indicated Cerclage
 Insertion of a cerclage as a result of factors in a
woman’s obstetric or gynecological history
 Is performed as a prophylactic measure in
asymptomatic women and done at 12–14 weeks of
gestation.
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15. Ultrasound- indicated cerclage
 Insertion of a cerclage as a therapeutic measure
when cervical length < 25 mm in asymptomatic
women without exposed fetal membranes in the
canal .
 TVS to be done between 14 and 24 weeks of
gestation.
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16. Rescue Cerclage
(Emergent Cerclage)
Cervix dilated > 2 cm with no perceived uterine
Contractions
Premature cervical effacement > 50 %
Presence of pelvic sensation of pressure’.
Heavy mucoid vaginal discharge
Bulging membranes through the cervical os
Broad spectrum antibiotics
( RCOG Green-top Guideline 2011 No. 60 4 of 21 )
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17. Treatable Anatomical Cause For Preterm Labour &
2nd Trimester Loss
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18. How The Intervention Would Work?
Cerclage may provide a degree of
structural support to a ‘weak’ cervix.
It’s role in maintaining the cervical
length and the endocervical mucus plug
as a mechanical barrier to ascending
infection may be more important.”
http://www.rcog.org.uk/files/rcog-corp/GTG60cervicalcerclage.pdf
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20. SHORT CERVIX BEFORE 20 WEEKS
The examination should be repeated
because of the inability to adequately
distinguish the cervix from lower uterine
segment in early pregnancy.
ACOG Practice Bulletin Nov 2018
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21. SHORT CERVIX AT OR AFTER 20 WEEKS
• Should prompt assessment of the fetus
for anomalies
• Uterine activity to rule out contractions
• Maternal factors to rule out
chorioamnionitis
ACOG Practice Bulletin Nov 2018
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22. SHORT CERVIX IN THE THIRD TRIMESTER
• If labour or chorioamnionitis not present
expectant management may be considered
• Cerclage in the treatment of woman with
cervical insufficiency after determining fetal
viability has not adequately assessed
ACOG Practice Bulletin Nov 2018
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23.  McDonalds procedure 1957
 Shirodkars procedure 1951
 Wurms procedure (Hefner cerclage) 1959
 Lash and Lash procedure 1950
 Tansabdominal (Benson &Durfee 1965)
 Laparoscopic transabdominal cervico-isthmic
cerclage during pregnancy - traditional and the new
‘Soo’ procedure
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24. Advantages
 Prevents Miscarriages
 Prevents Preterm Labour
 Prevents ascending infection
 Immediate result ( No frequent f/up TVS )
 Decrease In Neonatal Morbidity & Mortality
 Very Minimum Complications
 Cost Effective
 85 – 90 % success rate
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25. ADVERSE EFFECTS
( Mainly Theoretical )
• Suture displacement
( very very rarely )
• Rupture of membranes
( Possible in Rescue cerclage )
• Chorioamnionitis
( if PPROM / PID )
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26. So,
Please don’t scare us …!!!
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27. According to….
RCOG 2011
ACOG 2018
COCHRANE 2017
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28. Can cerclage be performed as a day -
case procedure?
Transvaginal cerclage can safely be
performed as a day - case procedure.
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29. Should women receive supplemental
progesterone following cerclage?
Routine use of progesterone
supplementation following cerclage is
not recommended.
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30. Should perioperative tocolysis be used
for insertion of cerclage?
There is no evidence to support the
use of routine perioperative tocolysis
in women undergoing insertion of
cerclage.
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31. Bed rest after cerclage ?
Bed rest in women who have
undergone cerclage should not be
routinely recommended, but the
decision should be individualized
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32. Should perioperative
antibiotics be given?
The decision for antibiotic prophylaxis
at the time of cerclage placement
should be at the discretion of the
operating team
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33. Perinatal outcome of Multiple gestation does
prophylactic cerclage make a difference?
Prophylactic cerclage decreased significantly the
incidence of extremely LBW neonates in Multiple
pregnancies. The proportion of neonates delivered
at 31 weeks or more, and at 32 weeks or more was
higher in the cerclage group.
J Maternal Fetal Med. Elimian A et al 1999 May-Jun;8(3):119-22.
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44. ACOG Recommends . . .
Cerclage is indicated in the second trimester in
women with singleton pregnancies who:
• Have a history of second-trimester pregnancy loss
associated with painless cervical dilation without labor
• Have had cerclage in a previous pregnancy due to
painless dilation;
• Currently have painless cervical dilation;
• Previously had a spontaneous preterm birth before 34
weeks and, in the current pregnancy, have a cervical
length < 25 mm before 24 weeks' gestation.
ACOG Practice Bulletin No.188, Jan 2018: Cerclage for the
management of cervical insufficiency. Obst Gynacol 2014
Feb;123:372-9.
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45. SOGC CLINICAL PRACTICE GUIDELINES
• Women with a history of three or more second-
trimester pregnancy losses or extreme premature
deliveries, in whom no specific cause other than potential
cervical insufficiency is identified, should be offered
elective cerclage at 12 to 14 weeks of gestation. (I-A) 5.
• In women with a classic history of cervical
insufficiency in whom prior vaginal cervical cerclage has
been unsuccessful, abdominal cerclage can be considered
in the absence of additional mitigating factors. (II-3C)
Brown et al, Cervical Insufficiency and Cervical Cerclage; J
Obstet Gynaecol Can Dec 2013;35(12):1115–1127
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46. SOGC CLINICAL PRACTICE GUIDELINES
Cerclage should be considered in singleton
pregnancies in women with a history of
spontaneous preterm birth or possible cervical
insufficiency if the cervical length is ≤ 25 mm
before 24 weeks of gestation. (I-A)
Brown et al, Cervical Insufficiency and Cervical
Cerclage; J Obstet Gynaecol Can Dec
2013;35(12):1115–1127
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48. COCHRANE REVIEW RECOMMENDS
• Overall, cerclage probably leads to a reduced
risk of perinatal death when compared with no
cerclage.
• Pregnant women with cerclage were less
likely to have preterm births compared to
controls before 37, 34 and 28 completed weeks
of gestation.
Alfirevic Z, Stampalija T, Medley N. Cervical cerclage for preventing preterm birth in
singleton pregnancy.
Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD008991.
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50. YES!!!15-Jan-20
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