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Erken Doğumda
Serklaj ve Peser Uygulamaları
Doccedil Dr Zeki Şahinoğlu
F E T U S
Prenatal
0
10
20
30
40
50
23 24 25 26 27 28 29 30 31 32 33 Gestasyon (hf)
handikap
0
25
50
75
100
23 24 25 26 27 28 29 30 31 32 33
Oumlluumlm oranı
Gestation (wks)
Perinatal mortalite
prematuumlrite komplik
Konjenital malform
SIDS
injury
premat dışı enf
diğer
lt 30 hf
CDC National Center for Health Statistics 2012
PRETERM FETUS
Updated National Birth Prevalence estimates for selected birth
defects in the United States 2004-2006
Birth Defects Res A Clin Mol Teratol 2010
ABD YIL
bull Myokard infarktusuuml 1 milyon
bull Kanser ndash yeni olgu 14 milyon
bull Down sendromu tanısı 6000 yenidoğan (1 733 YD)
bull Preterm bebek 500000 (26 milyar $)
0
10
20
30
40
50
23 24 25 26 27 28 29 30 31 32 33 Gestasyon (hf)
handikap
Model performance
bull Multimarker positivity rate
bull 35 (31-39)
bull Benefit from pessary in multimarker-positives
bull 15 (7- 23)
bull Benefit from no pessary in multimarker-negatives
bull 8 (3-13)
bull Risk reduction by multimarker-based strategy
bull 10 (6-15)
-30 -20 -10 0 10 20 30 40
-30
-20
-10
01
02
03
04
0
Expected Treatment Effect
Ob
se
rve
d T
rea
tme
nt E
ffe
ctIllustration of the evaluation
of risk prediction models in randomized trials Examples from womenrsquos health studies
Membran değişiklikleri
bull Fibronektin
bull BV enfeksiyonu
bull Membran ruumlptuumlruuml
Myometrial kontraksyion
bull KTG
PRETERM DOĞUM - OumlNGOumlRUuml
Serviks değişiklikleri
bull kısalma
bull dilatasyon
bull hunileşme
bull yetmezlik prevalans 1
TVUS ndash serviks oumllccediluumlmuuml
bull Boş mesane
bull Anterior forniks
bull Buumlyuumlk resim 75
bull Sagittal plan
bull Oumln = arka serviks
bull İnternal - eksternal os
bull 15 sn transfundal basınccedil
bull Duumlz hat oumllccediluumlmuuml - ♯ 3
bull En iyi ve en kısa oumllccediluumlm
17 mm 27 mm
14 mm 11 mm
SERVİKS
Berghella Roman et al OG 2007
01
02
03
04
05
06
07
08
0
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Ce
rvic
al Le
ng
th (
mm
)
Gestational Age (week)
Iams JD et al N Engl J Med 1996
TANIM
ndash Servikal uzunluk oumllccediluumlmuuml
bull universal tarama
ndash Metodoloji
ndash Kısa serviks
bull sınırı
bull anlamı
ndash Preterm oumlykuuml (+)
KISA SERVİKS
0
20
40
60
80
0 10 20 30 40 50 60
Cervical Length (mm)
Inc
ide
nc
e o
f P
re
term
Bir
th lt
35
w (
)
Week 16
Week 20
Week 24
Week 28
Pre
term
do
ğum
insi
dan
sı lt
35
haf
ta (
) 16 haf
20 haf 24 haf 28 haf
Servikal uzunluk (mm)
0
5
10
15
20
25
30
1st 5th 10th 25th 50th 75th gt75thps
Serviks 13 22 26 30 35 40 (mm)
Relative Risk of at or below percentile compared to gt75th Percentile
24 hafta - TVUS
servikal uzunluk ndash Preterm Doğum RR
Iams JD NICHD N Engl J Med 1996
Serklaj - endikasyon
bull Oumlykuuml esas alınarak serklaj uygulama
ndash Profilaktik elektif
bull Fizik muayene bulgularına goumlre serklaj
(acil serklaj)
Berghella V Cont Ob Gyn 2005
bull Ultrason ndash serviks bulguları
ndash Ekspektan
İnvazif
bull Serklaj
Non invazif
bull Progesteron
bull Pesser
10 ndash 13 + 6 hafta
14 ndash 23 + 6 hafta
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
0
10
20
30
40
50
23 24 25 26 27 28 29 30 31 32 33 Gestasyon (hf)
handikap
0
25
50
75
100
23 24 25 26 27 28 29 30 31 32 33
Oumlluumlm oranı
Gestation (wks)
Perinatal mortalite
prematuumlrite komplik
Konjenital malform
SIDS
injury
premat dışı enf
diğer
lt 30 hf
CDC National Center for Health Statistics 2012
PRETERM FETUS
Updated National Birth Prevalence estimates for selected birth
defects in the United States 2004-2006
Birth Defects Res A Clin Mol Teratol 2010
ABD YIL
bull Myokard infarktusuuml 1 milyon
bull Kanser ndash yeni olgu 14 milyon
bull Down sendromu tanısı 6000 yenidoğan (1 733 YD)
bull Preterm bebek 500000 (26 milyar $)
0
10
20
30
40
50
23 24 25 26 27 28 29 30 31 32 33 Gestasyon (hf)
handikap
Model performance
bull Multimarker positivity rate
bull 35 (31-39)
bull Benefit from pessary in multimarker-positives
bull 15 (7- 23)
bull Benefit from no pessary in multimarker-negatives
bull 8 (3-13)
bull Risk reduction by multimarker-based strategy
bull 10 (6-15)
-30 -20 -10 0 10 20 30 40
-30
-20
-10
01
02
03
04
0
Expected Treatment Effect
Ob
se
rve
d T
rea
tme
nt E
ffe
ctIllustration of the evaluation
of risk prediction models in randomized trials Examples from womenrsquos health studies
Membran değişiklikleri
bull Fibronektin
bull BV enfeksiyonu
bull Membran ruumlptuumlruuml
Myometrial kontraksyion
bull KTG
PRETERM DOĞUM - OumlNGOumlRUuml
Serviks değişiklikleri
bull kısalma
bull dilatasyon
bull hunileşme
bull yetmezlik prevalans 1
TVUS ndash serviks oumllccediluumlmuuml
bull Boş mesane
bull Anterior forniks
bull Buumlyuumlk resim 75
bull Sagittal plan
bull Oumln = arka serviks
bull İnternal - eksternal os
bull 15 sn transfundal basınccedil
bull Duumlz hat oumllccediluumlmuuml - ♯ 3
bull En iyi ve en kısa oumllccediluumlm
17 mm 27 mm
14 mm 11 mm
SERVİKS
Berghella Roman et al OG 2007
01
02
03
04
05
06
07
08
0
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Ce
rvic
al Le
ng
th (
mm
)
Gestational Age (week)
Iams JD et al N Engl J Med 1996
TANIM
ndash Servikal uzunluk oumllccediluumlmuuml
bull universal tarama
ndash Metodoloji
ndash Kısa serviks
bull sınırı
bull anlamı
ndash Preterm oumlykuuml (+)
KISA SERVİKS
0
20
40
60
80
0 10 20 30 40 50 60
Cervical Length (mm)
Inc
ide
nc
e o
f P
re
term
Bir
th lt
35
w (
)
Week 16
Week 20
Week 24
Week 28
Pre
term
do
ğum
insi
dan
sı lt
35
haf
ta (
) 16 haf
20 haf 24 haf 28 haf
Servikal uzunluk (mm)
0
5
10
15
20
25
30
1st 5th 10th 25th 50th 75th gt75thps
Serviks 13 22 26 30 35 40 (mm)
Relative Risk of at or below percentile compared to gt75th Percentile
24 hafta - TVUS
servikal uzunluk ndash Preterm Doğum RR
Iams JD NICHD N Engl J Med 1996
Serklaj - endikasyon
bull Oumlykuuml esas alınarak serklaj uygulama
ndash Profilaktik elektif
bull Fizik muayene bulgularına goumlre serklaj
(acil serklaj)
Berghella V Cont Ob Gyn 2005
bull Ultrason ndash serviks bulguları
ndash Ekspektan
İnvazif
bull Serklaj
Non invazif
bull Progesteron
bull Pesser
10 ndash 13 + 6 hafta
14 ndash 23 + 6 hafta
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Updated National Birth Prevalence estimates for selected birth
defects in the United States 2004-2006
Birth Defects Res A Clin Mol Teratol 2010
ABD YIL
bull Myokard infarktusuuml 1 milyon
bull Kanser ndash yeni olgu 14 milyon
bull Down sendromu tanısı 6000 yenidoğan (1 733 YD)
bull Preterm bebek 500000 (26 milyar $)
0
10
20
30
40
50
23 24 25 26 27 28 29 30 31 32 33 Gestasyon (hf)
handikap
Model performance
bull Multimarker positivity rate
bull 35 (31-39)
bull Benefit from pessary in multimarker-positives
bull 15 (7- 23)
bull Benefit from no pessary in multimarker-negatives
bull 8 (3-13)
bull Risk reduction by multimarker-based strategy
bull 10 (6-15)
-30 -20 -10 0 10 20 30 40
-30
-20
-10
01
02
03
04
0
Expected Treatment Effect
Ob
se
rve
d T
rea
tme
nt E
ffe
ctIllustration of the evaluation
of risk prediction models in randomized trials Examples from womenrsquos health studies
Membran değişiklikleri
bull Fibronektin
bull BV enfeksiyonu
bull Membran ruumlptuumlruuml
Myometrial kontraksyion
bull KTG
PRETERM DOĞUM - OumlNGOumlRUuml
Serviks değişiklikleri
bull kısalma
bull dilatasyon
bull hunileşme
bull yetmezlik prevalans 1
TVUS ndash serviks oumllccediluumlmuuml
bull Boş mesane
bull Anterior forniks
bull Buumlyuumlk resim 75
bull Sagittal plan
bull Oumln = arka serviks
bull İnternal - eksternal os
bull 15 sn transfundal basınccedil
bull Duumlz hat oumllccediluumlmuuml - ♯ 3
bull En iyi ve en kısa oumllccediluumlm
17 mm 27 mm
14 mm 11 mm
SERVİKS
Berghella Roman et al OG 2007
01
02
03
04
05
06
07
08
0
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Ce
rvic
al Le
ng
th (
mm
)
Gestational Age (week)
Iams JD et al N Engl J Med 1996
TANIM
ndash Servikal uzunluk oumllccediluumlmuuml
bull universal tarama
ndash Metodoloji
ndash Kısa serviks
bull sınırı
bull anlamı
ndash Preterm oumlykuuml (+)
KISA SERVİKS
0
20
40
60
80
0 10 20 30 40 50 60
Cervical Length (mm)
Inc
ide
nc
e o
f P
re
term
Bir
th lt
35
w (
)
Week 16
Week 20
Week 24
Week 28
Pre
term
do
ğum
insi
dan
sı lt
35
haf
ta (
) 16 haf
20 haf 24 haf 28 haf
Servikal uzunluk (mm)
0
5
10
15
20
25
30
1st 5th 10th 25th 50th 75th gt75thps
Serviks 13 22 26 30 35 40 (mm)
Relative Risk of at or below percentile compared to gt75th Percentile
24 hafta - TVUS
servikal uzunluk ndash Preterm Doğum RR
Iams JD NICHD N Engl J Med 1996
Serklaj - endikasyon
bull Oumlykuuml esas alınarak serklaj uygulama
ndash Profilaktik elektif
bull Fizik muayene bulgularına goumlre serklaj
(acil serklaj)
Berghella V Cont Ob Gyn 2005
bull Ultrason ndash serviks bulguları
ndash Ekspektan
İnvazif
bull Serklaj
Non invazif
bull Progesteron
bull Pesser
10 ndash 13 + 6 hafta
14 ndash 23 + 6 hafta
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Model performance
bull Multimarker positivity rate
bull 35 (31-39)
bull Benefit from pessary in multimarker-positives
bull 15 (7- 23)
bull Benefit from no pessary in multimarker-negatives
bull 8 (3-13)
bull Risk reduction by multimarker-based strategy
bull 10 (6-15)
-30 -20 -10 0 10 20 30 40
-30
-20
-10
01
02
03
04
0
Expected Treatment Effect
Ob
se
rve
d T
rea
tme
nt E
ffe
ctIllustration of the evaluation
of risk prediction models in randomized trials Examples from womenrsquos health studies
Membran değişiklikleri
bull Fibronektin
bull BV enfeksiyonu
bull Membran ruumlptuumlruuml
Myometrial kontraksyion
bull KTG
PRETERM DOĞUM - OumlNGOumlRUuml
Serviks değişiklikleri
bull kısalma
bull dilatasyon
bull hunileşme
bull yetmezlik prevalans 1
TVUS ndash serviks oumllccediluumlmuuml
bull Boş mesane
bull Anterior forniks
bull Buumlyuumlk resim 75
bull Sagittal plan
bull Oumln = arka serviks
bull İnternal - eksternal os
bull 15 sn transfundal basınccedil
bull Duumlz hat oumllccediluumlmuuml - ♯ 3
bull En iyi ve en kısa oumllccediluumlm
17 mm 27 mm
14 mm 11 mm
SERVİKS
Berghella Roman et al OG 2007
01
02
03
04
05
06
07
08
0
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Ce
rvic
al Le
ng
th (
mm
)
Gestational Age (week)
Iams JD et al N Engl J Med 1996
TANIM
ndash Servikal uzunluk oumllccediluumlmuuml
bull universal tarama
ndash Metodoloji
ndash Kısa serviks
bull sınırı
bull anlamı
ndash Preterm oumlykuuml (+)
KISA SERVİKS
0
20
40
60
80
0 10 20 30 40 50 60
Cervical Length (mm)
Inc
ide
nc
e o
f P
re
term
Bir
th lt
35
w (
)
Week 16
Week 20
Week 24
Week 28
Pre
term
do
ğum
insi
dan
sı lt
35
haf
ta (
) 16 haf
20 haf 24 haf 28 haf
Servikal uzunluk (mm)
0
5
10
15
20
25
30
1st 5th 10th 25th 50th 75th gt75thps
Serviks 13 22 26 30 35 40 (mm)
Relative Risk of at or below percentile compared to gt75th Percentile
24 hafta - TVUS
servikal uzunluk ndash Preterm Doğum RR
Iams JD NICHD N Engl J Med 1996
Serklaj - endikasyon
bull Oumlykuuml esas alınarak serklaj uygulama
ndash Profilaktik elektif
bull Fizik muayene bulgularına goumlre serklaj
(acil serklaj)
Berghella V Cont Ob Gyn 2005
bull Ultrason ndash serviks bulguları
ndash Ekspektan
İnvazif
bull Serklaj
Non invazif
bull Progesteron
bull Pesser
10 ndash 13 + 6 hafta
14 ndash 23 + 6 hafta
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Membran değişiklikleri
bull Fibronektin
bull BV enfeksiyonu
bull Membran ruumlptuumlruuml
Myometrial kontraksyion
bull KTG
PRETERM DOĞUM - OumlNGOumlRUuml
Serviks değişiklikleri
bull kısalma
bull dilatasyon
bull hunileşme
bull yetmezlik prevalans 1
TVUS ndash serviks oumllccediluumlmuuml
bull Boş mesane
bull Anterior forniks
bull Buumlyuumlk resim 75
bull Sagittal plan
bull Oumln = arka serviks
bull İnternal - eksternal os
bull 15 sn transfundal basınccedil
bull Duumlz hat oumllccediluumlmuuml - ♯ 3
bull En iyi ve en kısa oumllccediluumlm
17 mm 27 mm
14 mm 11 mm
SERVİKS
Berghella Roman et al OG 2007
01
02
03
04
05
06
07
08
0
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Ce
rvic
al Le
ng
th (
mm
)
Gestational Age (week)
Iams JD et al N Engl J Med 1996
TANIM
ndash Servikal uzunluk oumllccediluumlmuuml
bull universal tarama
ndash Metodoloji
ndash Kısa serviks
bull sınırı
bull anlamı
ndash Preterm oumlykuuml (+)
KISA SERVİKS
0
20
40
60
80
0 10 20 30 40 50 60
Cervical Length (mm)
Inc
ide
nc
e o
f P
re
term
Bir
th lt
35
w (
)
Week 16
Week 20
Week 24
Week 28
Pre
term
do
ğum
insi
dan
sı lt
35
haf
ta (
) 16 haf
20 haf 24 haf 28 haf
Servikal uzunluk (mm)
0
5
10
15
20
25
30
1st 5th 10th 25th 50th 75th gt75thps
Serviks 13 22 26 30 35 40 (mm)
Relative Risk of at or below percentile compared to gt75th Percentile
24 hafta - TVUS
servikal uzunluk ndash Preterm Doğum RR
Iams JD NICHD N Engl J Med 1996
Serklaj - endikasyon
bull Oumlykuuml esas alınarak serklaj uygulama
ndash Profilaktik elektif
bull Fizik muayene bulgularına goumlre serklaj
(acil serklaj)
Berghella V Cont Ob Gyn 2005
bull Ultrason ndash serviks bulguları
ndash Ekspektan
İnvazif
bull Serklaj
Non invazif
bull Progesteron
bull Pesser
10 ndash 13 + 6 hafta
14 ndash 23 + 6 hafta
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
TVUS ndash serviks oumllccediluumlmuuml
bull Boş mesane
bull Anterior forniks
bull Buumlyuumlk resim 75
bull Sagittal plan
bull Oumln = arka serviks
bull İnternal - eksternal os
bull 15 sn transfundal basınccedil
bull Duumlz hat oumllccediluumlmuuml - ♯ 3
bull En iyi ve en kısa oumllccediluumlm
17 mm 27 mm
14 mm 11 mm
SERVİKS
Berghella Roman et al OG 2007
01
02
03
04
05
06
07
08
0
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Ce
rvic
al Le
ng
th (
mm
)
Gestational Age (week)
Iams JD et al N Engl J Med 1996
TANIM
ndash Servikal uzunluk oumllccediluumlmuuml
bull universal tarama
ndash Metodoloji
ndash Kısa serviks
bull sınırı
bull anlamı
ndash Preterm oumlykuuml (+)
KISA SERVİKS
0
20
40
60
80
0 10 20 30 40 50 60
Cervical Length (mm)
Inc
ide
nc
e o
f P
re
term
Bir
th lt
35
w (
)
Week 16
Week 20
Week 24
Week 28
Pre
term
do
ğum
insi
dan
sı lt
35
haf
ta (
) 16 haf
20 haf 24 haf 28 haf
Servikal uzunluk (mm)
0
5
10
15
20
25
30
1st 5th 10th 25th 50th 75th gt75thps
Serviks 13 22 26 30 35 40 (mm)
Relative Risk of at or below percentile compared to gt75th Percentile
24 hafta - TVUS
servikal uzunluk ndash Preterm Doğum RR
Iams JD NICHD N Engl J Med 1996
Serklaj - endikasyon
bull Oumlykuuml esas alınarak serklaj uygulama
ndash Profilaktik elektif
bull Fizik muayene bulgularına goumlre serklaj
(acil serklaj)
Berghella V Cont Ob Gyn 2005
bull Ultrason ndash serviks bulguları
ndash Ekspektan
İnvazif
bull Serklaj
Non invazif
bull Progesteron
bull Pesser
10 ndash 13 + 6 hafta
14 ndash 23 + 6 hafta
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
SERVİKS
Berghella Roman et al OG 2007
01
02
03
04
05
06
07
08
0
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Ce
rvic
al Le
ng
th (
mm
)
Gestational Age (week)
Iams JD et al N Engl J Med 1996
TANIM
ndash Servikal uzunluk oumllccediluumlmuuml
bull universal tarama
ndash Metodoloji
ndash Kısa serviks
bull sınırı
bull anlamı
ndash Preterm oumlykuuml (+)
KISA SERVİKS
0
20
40
60
80
0 10 20 30 40 50 60
Cervical Length (mm)
Inc
ide
nc
e o
f P
re
term
Bir
th lt
35
w (
)
Week 16
Week 20
Week 24
Week 28
Pre
term
do
ğum
insi
dan
sı lt
35
haf
ta (
) 16 haf
20 haf 24 haf 28 haf
Servikal uzunluk (mm)
0
5
10
15
20
25
30
1st 5th 10th 25th 50th 75th gt75thps
Serviks 13 22 26 30 35 40 (mm)
Relative Risk of at or below percentile compared to gt75th Percentile
24 hafta - TVUS
servikal uzunluk ndash Preterm Doğum RR
Iams JD NICHD N Engl J Med 1996
Serklaj - endikasyon
bull Oumlykuuml esas alınarak serklaj uygulama
ndash Profilaktik elektif
bull Fizik muayene bulgularına goumlre serklaj
(acil serklaj)
Berghella V Cont Ob Gyn 2005
bull Ultrason ndash serviks bulguları
ndash Ekspektan
İnvazif
bull Serklaj
Non invazif
bull Progesteron
bull Pesser
10 ndash 13 + 6 hafta
14 ndash 23 + 6 hafta
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
TANIM
ndash Servikal uzunluk oumllccediluumlmuuml
bull universal tarama
ndash Metodoloji
ndash Kısa serviks
bull sınırı
bull anlamı
ndash Preterm oumlykuuml (+)
KISA SERVİKS
0
20
40
60
80
0 10 20 30 40 50 60
Cervical Length (mm)
Inc
ide
nc
e o
f P
re
term
Bir
th lt
35
w (
)
Week 16
Week 20
Week 24
Week 28
Pre
term
do
ğum
insi
dan
sı lt
35
haf
ta (
) 16 haf
20 haf 24 haf 28 haf
Servikal uzunluk (mm)
0
5
10
15
20
25
30
1st 5th 10th 25th 50th 75th gt75thps
Serviks 13 22 26 30 35 40 (mm)
Relative Risk of at or below percentile compared to gt75th Percentile
24 hafta - TVUS
servikal uzunluk ndash Preterm Doğum RR
Iams JD NICHD N Engl J Med 1996
Serklaj - endikasyon
bull Oumlykuuml esas alınarak serklaj uygulama
ndash Profilaktik elektif
bull Fizik muayene bulgularına goumlre serklaj
(acil serklaj)
Berghella V Cont Ob Gyn 2005
bull Ultrason ndash serviks bulguları
ndash Ekspektan
İnvazif
bull Serklaj
Non invazif
bull Progesteron
bull Pesser
10 ndash 13 + 6 hafta
14 ndash 23 + 6 hafta
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
0
5
10
15
20
25
30
1st 5th 10th 25th 50th 75th gt75thps
Serviks 13 22 26 30 35 40 (mm)
Relative Risk of at or below percentile compared to gt75th Percentile
24 hafta - TVUS
servikal uzunluk ndash Preterm Doğum RR
Iams JD NICHD N Engl J Med 1996
Serklaj - endikasyon
bull Oumlykuuml esas alınarak serklaj uygulama
ndash Profilaktik elektif
bull Fizik muayene bulgularına goumlre serklaj
(acil serklaj)
Berghella V Cont Ob Gyn 2005
bull Ultrason ndash serviks bulguları
ndash Ekspektan
İnvazif
bull Serklaj
Non invazif
bull Progesteron
bull Pesser
10 ndash 13 + 6 hafta
14 ndash 23 + 6 hafta
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Serklaj - endikasyon
bull Oumlykuuml esas alınarak serklaj uygulama
ndash Profilaktik elektif
bull Fizik muayene bulgularına goumlre serklaj
(acil serklaj)
Berghella V Cont Ob Gyn 2005
bull Ultrason ndash serviks bulguları
ndash Ekspektan
İnvazif
bull Serklaj
Non invazif
bull Progesteron
bull Pesser
10 ndash 13 + 6 hafta
14 ndash 23 + 6 hafta
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
10 ndash 13 + 6 hafta
14 ndash 23 + 6 hafta
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
In summary even in high-risk patients transvaginal ultrasound of
the cervix is not a very sensitive predictor of preterm birth before
14 weeks since a cervical length lt25 mm rarely develops before this
gestational age except in patients with a prior second-trimester loss
or a prior cone biopsy In most high-risk patients cervical changes
predictive of preterm birth such as a cervical length lt25 mm occur
between 16 and 22 weeks
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Berghella V 2010
PTD oumlykuumlsuuml yok
v
serklaj
izlem
PTD oumlykuumlsuuml var
v
serklaj
izlem
PTD oumlykuumlsuuml (+) gebelerde SU oumllccediluumlmuuml
bull 16 haftada TV USG
bull 23 haftaya kadar 2 hafta aralarla oumllccediluumlm tekrarları
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
To et al
2004
470 kısa serviks
( lt15 mm )
1
253 randomizasyon
54
47123 gebe
22 ndash 24 hafta
Serklaj
22
izlem
26
0
20
40
60
80
100 Gebeliğin devamı
22 24 26 28 30 32 34 36 38 40 42
Gebelik haftası
PTD lt34 hf
15 azalma (NS)
GA kontrol serklaj RR (CI)
lt35w 206 312 084 (060ndash117)
To MS Lancet 2004
USG - Kısa serviks + PTD oumlykuumlsuuml yok RCT Serklaj
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
In women at increased risk of mid-trimester miscarriage or early
preterm delivery a policy of sonographic surveillance followed
by cervical cerclage in those with a short cervix may reduce the
need for surgical intervention without increasing adverse
pregnancy outcome
In the expectantly managed group about 40 did not require the
insertion of a suture because the cervix remained above 25 mm
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
TV USG serviks oumllccediluumlmuuml
12 ndash 22 haftalar
SU lt15 mm Serklaj
Progesteron 200 mg gece
18-34 hafta
PTD oumlykuumlsuuml YOK VAR
12 16 18 20 22 24 haftalar
25 mm
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Althuisius SM 2000
To MS 2002
Higgins SP 2004
Preterm doğum oumlykuumlsuuml (+) gebelerin
bull 2 3 den fazlasında
serviks gt 25 mm
serklajsız izlem tekrarlayan PTD
Copyright copy 2013 Elsevier Inc
bull 1 3 olguda
USG endik serklaj etkinliği = elektif serklaj
Cook CM 2000
Kelly S 2001
To MS 2002
bazı olgularda serklaj preterm doğum risk artışı
servikal inflamasyon (IL ndash 8)
ccediloğul gebeliklerde RR 215
Berghella V 2005
Roman AS 2005
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Serklaj accedilık ve net fayda sağlar
Serklaj mutlak endikasyon yoktur
bull PTD oumlykuumlsuuml + olan ve servikal yetmezlik tanımlı olguda
bull Obstetrik oumlykuumlde
3-4 geccedil abortus veya
1 - 2 preterm doğum veya
objektif servikal kısalma gelişen olguda
bull Uterin anomali
bull Geccedilirilmiş konizasyon
bull İkiz gebelik
paradoksal komplikasyon (preterm doğum oranı )
bull Servikal silinme ndash accedilılma - kontraksiyon (+)
acil serklaj yararı
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Serklaj klinik
bull Shirodkar amp MacDonald arasında klinik etkinlik farkı yok
bull Serklaj ndash internal os arası 10 mm etkili serklaj
Serklaj uygulanmayan koşullar
bull Aktif preterm eylem PPROM
bull Koryoamnionitis kliniği
bull Plasenta previa ndash uterin kanama
bull Servikal vaginal enfeksiyon (IL - 8)
bull Fetal anomali ndash poli oligohidramnios
bull Fetal distres
bull Maternal kontrendikasyon
Berghella V 2004 Mancuso MS 2009 Jay D Iams CREASY amp RESNIKrsquoS 2013
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
bull We included 12 trials (involving 3328 women)
bull When cerclage was compared with no treatment there was
significant reduction in preterm births (average RR 080 95 CI 069
to 095 nine trials 2898 women)
Authorsrsquo conclusions
Compared with no treatment cervical cerclage reduces the incidence
of preterm birth in women at risk of recurrent preterm birth
without statistically significant reduction in perinatal mortality or
neonatal morbidity and uncertain long-term impact on the baby
Cochrane 2012 issue 4
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Canada No 301 December 2013
12 ndash 14 haftada elektif serklaj (I-A)
bull II trimester gebelik kaybı (ge 3) veya erken preterm doğum
bull Etyolojide potansiyel servikal yetmelik dışında başka faktoumlr yok
Serklaj (I-A)
bull Spontan preterm doğum oumlykuumlsuuml var
bull Servikal yetmezlik olasılığı yuumlksek
bull Gebelik haftası lt 24 ve servikal uzunluk lt 25 mm
Abdominal serklaj (II-3C)
bull Klasik servikal yetmezlik + etkisiz vaginal serklaj oumlykuumlsuuml
bull Trakelektomi operasyonu
Acil serklaj (II-3C)
bull lt 24 gebelik haftasında sancısız servikal dilatasyon lt 4 cm
USG - servikal uzunluk izlemi (II-2B)
bull Serklaj duumlşuumlnuumllmeyen gebe
bull Oumlykuumlsuumlnde
bull 1 veya 2 erken midtrimester doğum
bull Ekstrem preterm doğum
Serklaj oumlnerilmez (II-1D)
bull Rastlantısal kısa serviks + preterm doğum iccedilin risk faktoumlruuml yok
bull Ccediloğul gebelik
bull Kısa serviks (II-1D)
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Serklaj teknik
Sutur materyeli
bull Mersilene 5 mm tape (Ethicon)
bull Geniş non-absorbabl monofilament ( Prolen)
Teknik
bull Mc Donald
bull Shirodkar
bull Wurm
bull Lash
bull Trans-abdominal
Operasyon
bull Genel anestezi
bull Steril şartlar
bull Antibiyotik
bull Tokoliz
bull Progesteron
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
McDonald tekniği
Modifiye Shirodkar tekniği Wurm (Hefner)tekniği
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
bull Vaginal serklajın başarısız olduğu 2trimester gebelik kaybı
bull Konjenital anomaliye bağlı kısa serviks
bull Trakelektomi gibi cerrahi sonrası kısa serviks
bull Gebelik oumlncesi
bull ilk trimester sonunda
bull Erken 2 trimester (10-14 hafta)
Transabdominal serklaj
Laparotomi
Laparoskopi
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Serklaj komplikasyon
bull 06
bull Perop
anestezi komplik
bull Postop
erken doumlnem
- kontraksiyon
- kanama
- suumltuumlruumln doku
kesmesi (6-19)
- fetal kayıp
geccedil doumlnem
- Koryoamnionitis 62
Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 119)
Wanyonyi S 2013
- PPROM 11 - Preterm eylem 20 - lt 32 hafta doğum 8 - Uumlriner fistuumll - Trigon nekrozu - Servikste yırtılma 1-3
minus servikal dilatasyon ile risk
lt 2 cm 62
gt 2 cm 417
elektif 52
acil serklaj 144
Jay D Iams CREASY amp RESNIKrsquoS 2013
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
21 ccedilalışma ndash 2757 olgu
sensitivite spesifisite
35 mm 78 66
30 mm 41 87
25 mm 36 94
20 mm 30 94
Ccediloğul gebeliklerde serviks
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Authorsrsquo conclusions
This review is based on limited data from five small studies of
average to above average quality
For multiple gestations there is no evidence that cerclage is an
effective intervention for preventing preterm births and reducing
perinatal deaths or neonatal morbidity
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Multiple Gestations
hellip elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes
hellip in contrast to singleton gestations data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening
hellip a meta-analysis has shown a relative risk increase of 215
for preterm delivery (lt 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length lt 25 mm) cerclage
Duumlşuumlk riskli ccediloğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
lt 35 hafta PTD riski artar (215)
Am J Obstet Gynecol 2014 Jul211(1)5-6
Cerclage in twins we can do better
Berghella V Roman A
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Pesser lsquoto do nothing is not any longer an option
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Pesser takılmasının kuralları
Klinik uygunluk
1 Spontan preterm doğum oumlykuumlsuuml olan + TV USG serviks lt 25 mm
gebeler
2 Aktif preterm eylem olmamalı
3 Servikal ndash vaginal enfeksiyon olmamalı
4 Pesser ndash tedavi etkinliği bilgilendirilmeli
5 Spekulum serviks boyutları ndash pesser kalınlık ve genişlik uygunluğu
6 Ccedilapı daha dar olan kısım servikse kanalı tamamen sarmalı
membran fıtıklaşmasını oumlneleyecek kadar eksternal os kapalı olmalı
Kişisel
1 Pesser takılmasından sonra gebede rahatsızlık sancı kanama
olmadığı goumlzlemlenmeli
2 İdrar ccedilıkışı rahatlığı sorgulanmalı
3 Pesserin ccedilıkarılma koşulları accedilıklanmalı
minus kanama
minus PPROM
minus kontraksiyonların başlaması
4 Normal koşullarda kişinin şikayeti olmadığı takdirde gebeliğin 37
haftasına kadar pesserin kalacağı belirtilmeli
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Pesser etkisi
bull Uteroservikal accedilıyı daraltır
bull Kaldığı suumlrece etkinliğinde azalma olmaz
bull Membranların internal osa olan basınccedil etkisini uterus alt
segment oumln duvara yansıtır
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
10568 gebe 726 olguda 18 ndash 22 hafta Cx le 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
lt 28 hafta doğum 2 8
lt 34 hafta doğum 6 27
lt 37 hafta doğum 22 59
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
minus En az 1 kez lt 34 hafta PTD
minus Kısa serviks lt 25 mm
bull 142 gebe SERKLAJ
bull 59 gebe VAGİNAL PROGESTERON (200 mg)
bull 42 gebe PESSER
lt 34 hafta DOĞUM
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
Kings College Hospital NHS Trust (ClinicalTrialsgov Identifier NCT00735137)
Vaginal pessary (CE0482 MEDCERT ISO 9003 EN 46003) Phase 3
Katılan gebe sayısı
1600
Expectant
sPTB 6
Pessary
sPTB 4
FMF Randomized study Cx lt26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
hellip There is some evidence that in singleton pregnancies with a
previous premature birth or a short cervix the chances of premature
birth may be reduced by them taking progesterone or cervical
cerclage Randomized studies in twin pregnancies have reported that
these treatments are not beneficial
hellip
The Fetal Medicine Foundation has conducted a multicentre study
in several countries to determine if in women with a short cervix the
insertion of a vaginal pessary reduces the chances of premature
birth
The study has now been completed and the results are being
analyzed before publication
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
A recent study done by the fetal medicine network led by Kypros
Nicolaides showed no effect of the pessary in women with a
multiple pregnancy (personal communication) Interestingly the
pessary was also not effective in the subgroup of women with a short
cervical length
This differing result might be caused by the fact that the fetal
medicine network study randomised women at a relatively late
gestational age of approximately 24 weeks In our ProTWIN trial
however results demonstrated that a large part of the treatment effect
had already occurred before 24 weeks gestation
Serviks lt 38 mm
(25 ps) Normal serviks
uzunluğu
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Authorsrsquo conclusions
The review included only one well-designed randomised
clinical trial (PECEP) that showed beneficial effect of cervical
pessary in reducing preterm birth in women with a short cervix
There is a need for more trials in different settings (developed
and developing countries) and with different risk factors
including multiple pregnancy
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Oumlykuuml endikasyonlu serklaj ne zaman yapılmalı
Am J Perinatol 2010 Jun27(6)469-74
What is the optimal gestational age for history-indicated cerclage
placement
Suhag A1 Seligman NS Bianchi I Berghella V
The optimal gestational age for placement of a history-indicated
cerclage is probably 12 to 14 weeks after screening for fetal
anomalies and aneuploidy
SIK SORULANLAR
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Oumlnceki gebelikte serklaj tekrar serklaj endikasyonu
Am J Perinatol 2008 Aug25(7)417-20
Prior cerclage to repeat or not to repeat That is the question
Pelham JJ1 Lewis D Berghella V
We concluded that in women with prior cerclage for indications
other than classic cervical insufficiency repeat history-indicated
cerclage may not improve outcome compared with management
with TVU CL follow-up
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Yuumlksek riskli grupta serklaj uygulamasında oumlykuuml vs USG
Am J Obstet Gynecol 2009 Jun200(6)623
A randomized controlled trial of cervical scanning vs history to
determine cerclage in women at high risk of preterm birth (CIRCLE
trial)
Simcox R1 Seed PT Bennett P Teoh TG Poston L Shennan AH
Screening women at high risk with cervical ultrasound to
determine cerclage placement results in more intervention but
similar outcome compared with history-indicated placement
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Duumlşuumlk riskli grupta serviks le 25 mm serklaj vs istirahat
Am J Obstet Gynecol 2007 Sep197(3)315
Cervical length lt or = 25 mm in low-risk women a case control study
of cerclage with rest vs rest alone
Incerti M1 Ghidini A Locatelli A Poggi SH Pezzullo JC
Cerclage placement does not improve pregnancy outcome in
low-risk women with incidental detection of CL lt or = 25 mm
in the early second trimester
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Rescue Shirodkar serklaj ndash gebelik prognozu
J Perinatol 2009 Apr29(4)276-9
Pregnancy outcome after placement of rescue Shirodkar cerclage
Ventolini G1 Genrich TJ Roth J Neiger R
When pregnancies are complicated by late mid-trimester cervical
dilation placement of Shirodkar cerclage in appropriately
selected patients has the potential to be a beneficial therapeutic
option
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Am J Perinatol 2009 Jan26(1)63-8
Amniocentesis prior to physical exam-indicated cerclage in women with
midtrimester cervical dilation results from the expectant management
compared to Physical Exam-indicated Cerclage international cohort study
Airoldi J1 Pereira L Cotter A Gomez R Berghella V et al
Dilate servikste uygulanacak acil serklaj oumlncesi
amniosentez
hellip the performance of an amniocentesis was not an independent
contributor to PTB lt 28 weeks ( P = 090) The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Ultrason ndash endikasyonlu serklaja 17 OH progesteron ilavesi
Am J Perinatol 2011 May28(5)389-94
The effect of 17α-hydroxyprogesterone caproate on preterm birth in
women with an ultrasound-indicated cerclage
Rafael TJ1 Mackeen AD Berghella V
17P did not have a significant effect on PTB lt 35 weeks (odds
ratio 172 95 confidence interval 050 to 589) nor did it have a significant
effect on the secondary outcomes Among women with a prior
spontaneous PTB and current UIC for CL lt 25 mm 17P did not
reduce the rate of PTB lt 35 weeks
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Ultrason ndash endikasyonlu serklaja indometasin ilavesi
Am J Obstet Gynecol 2008 Jun198(6)643
Indomethacin administration at the time of ultrasound-indicated
cerclage is there an association with a reduction in spontaneous
preterm birth
Visintine J1 Airoldi J Berghella V
Administration of indomethacin around the time of ultrasound-
indicated cerclage was not associated with a decrease in
spontaneous PTB
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Am J Obstet Gynecol 2009 May200(5)
Is cerclage height associated with the incidence of preterm birth in
women with an ultrasound-indicated cerclage
Scheib S1 Visintine JF Miroshnichenko G Harvey C Rychlak
K Berghella V
Cerclage height of 18 mm or greater is associated with a
reduction in spontaneous preterm birth for women with an
ultrasound-indicated cerclage
Ultrason ndash endikasyonlu serklaj hattı eksternal os
mesafesi ndash PTD ilişkisi
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Oumlnceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV
Am J Obstet Gynecol 2000 Oct183(4)836-9
Patients with a prior failed transvaginal cerclage a comparison of
obstetric outcomes with either transabdominal or transvaginal
cerclage
Davis G1 Berghella V Talucci M Wapner RJ
In patients with a prior failed transvaginal cerclage
transabdominal cerclage is associated with a lower incidence
of preterm delivery and preterm premature rupture of
membranes in comparison with transvaginal cerclage
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Serklaj tek vs ccedilift sutur
Two stitches at the time of cerclage do not appear to improve
pregnancy outcome either in the history- or the ultrasound-
indicated procedures compared with 1 stitch
Am J Obstet Gynecol 2013 Mar208(3)209
Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage
for preterm birth prevention Giraldo-Isaza MA1 Fried GP Hegarty SE Suescum-Diaz MA Cohen
AW Berghella V
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol 2002 Sep20(3)252-5
Funneling to the stitch an informative ultrasonographic finding after
cervical cerclage
OBrien JM1 Hill AL Barton JR
Funneling to the cerclage is significantly associated with
earlier preterm delivery in patients who have undergone
cervical cerclage Serial sonography up to 28 weeks gestation
is useful in identifying patients at higher risk for premature
rupture of the membranes and preterm delivery
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Ultrason endikasyonlu serklaj ve sutur materyeli seccedilimi
Type of suture material may not affect ultrasound-indicated
cerclage efficacy in high-risk women with short CL but further
study is needed Polyester braided thread (Mersilenetrade or
Ethibondtrade) and polyester braided Mersilene tapetrade seem to
have similar efficacy
J Matern Fetal Neonatal Med 2012 Nov25(11)2287-90
Suture type and ultrasound-indicated cerclage efficacy
Berghella V1 Szychowski JM Owen J Hankins G Iams JD Sheffield
JS Perez-Delboy A Wing DA Guzman ER Vaginal Ultrasound Trial
Consortium
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin ndash uygun olgu seccedilimi
Am J Obstet Gynecol 2009 Feb200(2)158
Fetal fibronectin testing in patients with short cervix in the
midtrimester can it identify optimal candidates for ultrasound-
indicated cerclage
Keeler SM1 Roman AS Coletta JM Kiefer DG Feuerman M Rust OA
fFN did not identify optimal candidates for cerclage
However fFN testing before an ultrasound-indicated cerclage
aids in counseling patients anticipating the outcome of
pregnancies complicated by cervical shortening
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Servikal serklaj ve PPROM
Clin Obstet Gynecol 2011 Jun54(2)313-20
Cervical cerclage and preterm PROM
Giraldo-Isaza MA1 Berghella V
Retention of cerclage for more than 24 hours after PPROM was
found to prolong pregnancy for more than 48 hours but also to
increase maternal chorioamnionitis and neonatal mortality
from sepsis making immediate cerclage removal as the
usually preferred therapeutic approach
Preterm doğum dağılımı
Preterm doğum dağılımı
