Cervical+Insufficiency+and+Cerclage

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** CCRMC OBGYN **** Prenatal Guideline ** Consultation available 24 hours per day from OB on-call at 925-370-5608 or via page/amion, via inbasket to OB dept member or by calling Perinatologist at 510-444-0790 during the day and 510-204-1572 after hours. Consultation appointments or transfer of care to more experienced prenatal clinician available at major clinics sites—see consultation guidelines for more information.

** Cervical Insufficiency and Cerclage ** Be sure to inquire about circumstances of second trimester losses, later SABs, pre-viable deliveries, very preterm deliveries or early PPROM to see if consistent with cervical incompetence during initial prenatal visit. Note cervical length on anatomy scan if prior LEEP.
 * __Criteria for Placement__**
 * 1) Prior pregnancy loss(s) or delivery 15-28 weeks with history of significant cervical dilation without labor. Don’t be falsely reassured by long cervix on NT or other first trimester sono
 * 2) History of indicated cerclage in prior pregnancy
 * 3) Cervical length < 1.5cm by ultrasound (rescue cerclage indicated)
 * __Criteria for weekly ultrasounds from 16-26 weeks for cervical length instead of elective cerclage__**
 * 1) Possible prior loss or early delivery due to cervical insufficiency (circumstances unclear)
 * 2) Patient prefers monitoring to elective cerclage placement
 * 3) If cervix < 1.5-2.5 cm and history of possible cervical insufficency recommend urgent cerclage
 * __Logistics of elective placement__**
 * 1) Schedule for placement ideally at 14 weeks; ideally post NT ultrasound if desired. Do at least clinic sono to verify dates and viability.
 * 2) Schedule in OB Attending prenatal or GYN clinic at least a week before cerclage needed—inbasket OB provider to let them know so they can schedule and review chart before visit
 * __Logistics of rescue placement for incidental short or dilated cervix by sono or found on exam__**
 * 1) Less than 23 weeks EGA call OB on call and plan immediate transfer to CCRMC
 * 2) 23 weeks or greater call Perinatology at ABMC or JMH and arrange immediate transfer per their instruction.
 * __Care of cerclage__**
 * 1) Patient needs to tell all relevant care providers of cerclage
 * 2) Pelvic rest suggested for 2 weeks post elective cerclage and for entire pregnancy for rescue cerclage
 * 3) Serial ultrasound cervical lengths every 2 weeks after placement until 26 weeks
 * 4) Patient to go urgently to labor and delivery for regular contractions and/or bleeding

__**Cerclage removal**__
 * 1) Removed anytime in labor or if bleeding (patients should always tell providers that they have a cerclage)
 * 2) Typically removal scheduled on Labor and Delivery by calling 370-5608 for about 37 weeks EGA
 * 3) May be removed in clinic