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Dr.Niraj Mahajan

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Cervical Cerclage for Incompetent Cervix

By AdminPosted On 05-Oct-2016

1. Incompetent cervix


a) Is a cause for early pregnancy loss

b) Is best diagnosed by history

c) Is a cause for fetal congenital abnormalities

d) Is not encounted with uterine anomalies

e) Can be treated with tocolytics

Correct Answer: b) Is best diagnosed by history. Diagnosis of cervical incompetence can be challenging and is based on a history of painless cervical dilation usually after the first trimester without contractions and in the absence of other clear pathology. Also history of previous second trimester abortion or preterm birth provides the diagnosis (but not always). In addition to history, assessment of cervical length in second trimester to identify cervical shortening using ultrasound.


2. Bed Rest after Cerclage


Bed rest in women who have undergone cerclage should be routinely recommended.


a) True

b) False

Correct Answer: b) False. Bed rest in women who have undergone cerclage should not be routinely recommended, but the decision should be individualised, taking into account the clinical circumstances and the potential adverse effects that bed rest could have on women and their families in addition to increased costs for the healthcare system.


3. A transvaginal cervical cerclage should be removed at what gestation?


a) Between 33+1 and 34+0 weeks

b) Between 35+1 and 36+0 weeks

c) Between 36+1 and 37+0 weeks

d) During labour

Correct Answer: c) Between 36+1 and 37+0 weeks, unless delivery is by elective 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 minimise potential trauma to the cervix.


4. Should perioperative tocolysis be used for insertion of cervical cerclage?


a) Yes

b) No

Correct Answer: b) No. There is no evidence to support the use of routine perioperative tocolysis in women undergoing insertion of cerclage. (Ref: RCOG)


5. History Indicated Cerclage


History-indicated cerclage should be offered to women with ---- previous preterm births and/or second-trimester losses.


a) One

b) Two

c) Three

d) Four

Correct Answer: c) Three. History-indicated cerclage should be offered to women with three or more previous preterm births and/or second-trimester losses. Ref: RCOG. In my clinical practice, and my personal experience, I have observed that previous single preterm births or second-trimester abortion are at increased risk. So I always put a stich with single rather than three previous preterm births and/or second-trimester losses.


6. Ultrasound Indicated Cerclage


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.


a) True

b) False

Correct Answer: a) True. Studies have demonstrated that funnelling is a function of cervical shortening and does not appear to independently add to the risk of preterm birth associated with cervical length. Ref: RCOG.


7. Short Cervix


Cervical cerclage is not recommended in women without a history of spontaneous preterm delivery or second-trimester loss who have an incidentally identified short cervix of 25 mm or less.


a) True

b) False

Correct Answer: a) True. Ref: RCOG. This was based on meta-analysis of four RCTs of cerclage versus expectant management in women with a short cervix. This meta-analysis reported no overall evidence of benefit of cerclage in women with cervical length less than 25 mm who had no other risk factors for spontaneous preterm birth (Evidence Level I+++).


8. Cerclage in PPROM


When should the cervical cerclage be removed following PPROM between 24 and 34 weeks of gestation and without evidence of infection or preterm labour?


a) Immediately

b) Delayed removal of the cerclage for 48 hours

c) Delayed removal of the cerclage for 7 days

d) Delayed suture removal until labour ensues or delivery

Correct Answer: b) Delayed removal of the cerclage for 48 hours as it may result in sufficient latency that a course of prophylactic steroids for fetal lung maturation is completed and/or in utero transfer arranged.

Delayed suture removal until labour ensues or delivery 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 pregnancies with PPROM before 23 and after 34 weeks of gestation, delayed suture removal is unlikely to be advantageous in this situation.


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Dr. Niraj Mahajan

MD- Gynecologist, Laparoscopic Surgeon, Uro-gynecologist , Infertility specialist & Cosmetic Gynecologist.

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