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Cervical insufficiency

Background

Overview

Definition
Cervical insufficiency is defined by transvaginal ultrasound cervical length < 25 mm before 24 weeks in women with prior pregnancy losses or preterm births at 14-36 weeks, or by cervical changes detected on physical examination before 24 weeks of gestation.
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Pathophysiology
Potential causes of cervical insufficiency include occult uterine activity, uterine overdistension, congenital or acquired cervical insufficiency, decidual hemorrhage, infection/inflammation (amniotic fluid or fetal membranes), and biological or genetic variation.
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Disease course
Cervical insufficiency is associated with recurrent second- or early third-trimester fetal loss, following painless cervical dilation, prolapse or rupture of the membranes, and expulsion of a live fetus despite minimal uterine activity.
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Prognosis and risk of recurrence
Preterm birth due to cervical insufficiency is associated with an infant mortality of 17.2%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of cervical insufficiency are prepared by our editorial team based on guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG 2022), the International Federation of Gynecology and Obstetrics (FIGO 2021), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2019,2017), and the American College of Obstetricians and Gynecologists (ACOG 2018,2014). ...
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Screening and diagnosis

Screening for risk factors
As per SOGC 2019 guidelines:
Evaluate for risk factors for cervical insufficiency in pregnant females or females planning pregnancy. Elicit a thorough medical history at initial evaluation as it may alert about risk factors in a first or index pregnancy.
B
Obtain detailed evaluation of risk factors in patients after a mid-trimester pregnancy loss or early premature delivery or with such complications occurred in a preceding pregnancy.
B
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Diagnostic investigations

Urine and vaginal cultures: as per RCOG 2022 guidelines, do not obtain routine genital tract screening for infection before cerclage insertion.
D

Medical management

Antibiotic therapy: as per RCOG 2022 guidelines, decide on initiating antimicrobial therapy in patients with a positive culture from a genital swab on an individual basis after discussion with the microbiology team.
E

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Nonpharmacologic interventions

Activity restriction: as per RCOG 2022 guidelines, do not advise routine bed rest in patients undergone cerclage and individualize the decision, taking into account the clinical circumstances and potential adverse effects that bed rest could have on patients and their families, in addition to increased costs for the healthcare system.
D

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Therapeutic procedures

Indications for transvaginal cervical cerclage, elective: as per RCOG 2022 guidelines, perform history-indicated cervical cerclage in patients with singleton pregnancies and ≥ 3 previous preterm births.
B
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  • Indications for transvaginal cervical cerclage (emergency)

  • Indications for transabdominal cervical cerclage

  • Indications for additional cervical cerclage

  • Technical considerations for cervical cerclage

  • Indications for cervical cerclage removal

Perioperative care

Periprocedural antibiotic prophylaxis: as per RCOG 2022 guidelines, decide on administering antibiotic prophylaxis at the time of cerclage placement at the discretion of the operating team.
B

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Specific circumstances

Patients with delayed miscarriage or fetal death
As per RCOG 2022 guidelines:
Involve a senior obstetrician to aid decision making on care and treatment of delayed miscarriage or fetal death in patients with an abdominal cerclage.
E
Consider performing complete evacuation through the stitch by suction curettage or by dilatation and evacuation (up to 18 weeks of gestation). Consider cutting the suture, usually via a posterior colpotomy, as an alternative. Consider performing hysterotomy or C-section if the former strategy fails.
C

Patient education

General counseling: as per RCOG 2022 guidelines, provide verbal and written information about potential complications before history- or ultrasound-indicated cerclage. Inform patients of the following before any type of cerclage:
there is a small risk of intraoperative bladder damage, cervical trauma, membrane rupture and bleeding during insertion of cervical cerclage
B
cervical cerclage May be associated with a risk of cervical laceration/trauma if there is spontaneous labor with the suture in place
B
high vaginal cerclage, inserted with bladder mobilization, usually requires anesthetic for removal and therefore carries the risk of an additional anesthetic.
E
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Follow-up and surveillance

Serial cervical length assessment
As per RCOG 2022 guidelines:
Consider obtaining serial ultrasound measurement of the cervix individually after ultrasound-indicated cerclage to offer timely administration of corticosteroids or in utero transfer.
C
Consider obtaining serial ultrasound surveillance in patients with a history of spontaneous second trimester loss or preterm birth who have not undergone a history-indicated cerclage placement.
C

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