Green-top Guideline No. 75 Cervical Cerclage

MP3 Audio Version of Green-top Guideline No. 75, Cervical Cerclage, published February 2022 The purpose of this guideline is to review the literature and provide evidence-based guidance on the use of cerclage in women at risk of preterm birth and second trimester loss. 1. Key recommendations (0:35) 2. Background and scope (03:03) 3. Identification and assessment of evidence (05:35) 4. Definitions (07:30) 5. History-indicated cerclage (11:14) 6. Ultrasound-indicated cerclage (16:54) 6.1. When should an ultrasound-indicated cerclage be offered? (16:58) 6.1.1 Women with a singleton pregnancy and a history of spontaneous second trimester loss or preterm birth (19:45) 6.2. Who should be offered serial sonographic surveillance with a view to ultrasound-indicated cerclage? (24:19) 7. Can cervical cerclage be recommended in any other groups of women considered at increased risk of preterm birth (29:50) 7.1. Multiple pregnancy (30:00) 7.2. Cervical surgery, trauma and uterine abnormalities (35:57) 7.3. Women with raised BMI (43:43) 8. Transabdominal cerclage (45:09) 8.1. When should a transabdominal cerclage be considered? (45:14) 8.2. Should a transabdominal cerclage be performed laparoscopically? (50:06) 8.3. How should women who experience delayed miscarriage or fetal death be cared for? (53:08) 9. Emergency cerclage (55:19) 9.1. When should a rescue cerclage be discussed and considered? (55.22) 9.2. What are the contraindications to cerclage insertion? (1:00:39) 9.3. What information should be given to women before cerclage insertion? (1:01:28) 10. Pre-operative management (1:08:00) 10.1. What investigations should be performed before insertion of cervical cerclage? (1:08:04) 10.2. Should amniocentesis to detect infection be performed before rescue or ultrasound-indicated cerclage? (1:10:53) 10.2.1. Is amnioreduction before emergency cerclage recommended? (1:14:23) 10.2.2. Should a latency period be observed between presentation and insertion of a rescue or ultrasound-indicated cerclage? (1:15:20) 10.2.3. Should routine genital tract screening for infection be carried out before cerclage insertion? (1:16:17) 11. Operative issues (1:17:35) 11.1. Should perioperative tocolysis be used for insertion of cerclage? (1:17:39) 11.2. Should perioperative antibiotics be given? (1:19:11) 11.3. What method of anaesthesia should be employed for the insertion of cerclage? (1:20:31) 11.4. Can cerclage be performed as a day-case procedure? (1:21:53) 11.5. Which technique and material should be used? (1:22:58) 12. Adjuvant management (1:28:53) 12.1. Bed rest (1:28:56) 12.2. Sexual intercourse (1:30:36) 12.3. Is there a role for post-cerclage serial sonographic surveillance of cervical length? (1:31:15) 12.4. Is fetal fibronectin testing useful following insertion of a cervical cerclage? (1:35:07) 12.5. Should women receive supplement progesterone following cerclage? (1:37:38) 12.6. Should women be offered Arabin pessary or progesterone instead of cerclage? (1:40:44) 13. When should the cerclage be removed? (1:44:39) 13.1. Should the cerclage be removed following PPROM? (1:47:30) 14. Recommendations for future research (1:50:28) 15. Suggested audit topics (1:51:25) Closing statement (1:52:05)