This document summarizes research on cervical cerclage and other interventions for preventing preterm birth. It discusses when cerclage is recommended based on gestational age, prior preterm birth history, and cervical length measurements on ultrasound. Cerclage is generally effective for reducing preterm birth in high-risk singleton pregnancies but not for multiple gestations. Complications of cerclage are also summarized. The document concludes by stating that while cerclage provides clear benefits, it is not absolutely indicated and should be considered based on individual risk factors and cervical status.

1. Erken Doğumda
Serklaj ve Peser Uygulamaları
Doç Dr Zeki Şahinoğlu
F E T U S
Prenatal

2. 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
%
Ölüm oranı
Gestation (wks)
Perinatal mortalite
■ prematürite komplik
■ Konjenital malform
■ SIDS
■ injury
■ premat. dışı enf
■ diğer
< 30 hf
CDC National Center for Health Statistics, 2012
PRETERM FETUS

3. 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
• Myokard infarktusü 1 milyon
• Kanser – yeni olgu 1.4 milyon
• Down sendromu tanısı 6000 yenidoğan (1 / 733 YD)
• Preterm bebek 500.000 (26 milyar $)
0
10
20
30
40
50
23 24 25 26 27 28 29 30 31 32 33
Gestasyon (hf)
handikap%

4. Model performance
• Multimarker positivity rate:
• 35% (31-39%)
• Benefit from pessary in multimarker-positives
• 15% (7- 23%)
• Benefit from no pessary in multimarker-negatives
• 8% (3-13%)
• Risk reduction by multimarker-based strategy
• 10% (6-15%)
-30 -20 -10 0 10 20 30 40
-30-20-10010203040
Expected Treatment Effect
ObservedTreatmentEffect
Illustration of the evaluation
of risk prediction models in
randomized trials
Examples from women’s health studies

5. Membran değişiklikleri
• Fibronektin
• BV enfeksiyonu
• Membran rüptürü
Myometrial kontraksyion
• KTG
PRETERM DOĞUM - ÖNGÖRÜ
Serviks değişiklikleri
• kısalma
• dilatasyon
• hunileşme
• yetmezlik prevalans % 1

6. TVUS – serviks ölçümü
• Boş mesane
• Anterior forniks
• Büyük resim: % 75
• Sagittal plan
• Ön = arka serviks
• İnternal - eksternal os
• 15 sn transfundal basınç
• Düz hat ölçümü - ♯ 3
• En iyi ve en kısa ölçüm
17 mm27 mm
14 mm 11 mm

7. SERVİKS
Berghella, Roman, et al, OG 2007
0
1020304050607080
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Gestational Age (week)
Iams JD et al. N Engl J Med. 1996

8. TANIM
– Servikal uzunluk ölçümü
• universal tarama
– Metodoloji
– Kısa serviks
• sınırı
• anlamı
– Preterm öykü (+)
KISA SERVİKS
0
20
40
60
80
0 10 20 30 40 50 60
Cervical Length (mm)
IncidenceofPretermBirth<35w(%)
Week 16
Week 20
Week 24
Week 28
Pretermdoğuminsidansı<35hafta(%)
16. haf
20. haf
24. haf
28. haf
Servikal uzunluk (mm)

9. 0
5
10
15
20
25
30
1st 5th 10th 25th 50th 75th >75thps
Serviks 13 22 26 30 35 40 (mm)
Relative Risk of at or below percentile compared to >75th Percentile
24. hafta - TVUS
servikal uzunluk – Preterm Doğum RR
Iams JD, NICHD, N Engl J Med 1996

10. Serklaj - endikasyon
• Öykü esas alınarak serklaj uygulama
– Profilaktik / elektif
• Fizik muayene bulgularına göre serklaj
(acil serklaj)
Berghella V, Cont Ob Gyn 2005
• Ultrason – serviks bulguları
– Ekspektan
İnvazif
• Serklaj
Non invazif
• Progesteron
• Pesser

11. 10 – 13 + 6 hafta
14 – 23 + 6 hafta

12. 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 <25 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 <25 mm occur
between 16 and 22 weeks.

14. Berghella V, 2010
PTD öyküsü yok
v
serklaj
izlem
PTD öyküsü var
v
serklaj
izlem
PTD öyküsü (+) gebelerde SU ölçümü
• 16. haftada TV / USG
• 23. haftaya kadar 2 hafta aralarla ölçüm tekrarları

15. To et al
2004
470 kısa serviks
( <15 mm )
1%
253 randomizasyon
% 54
47.123 gebe
22 – 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 <34 hf:
15% azalma (NS)
GA kontrol serklaj RR (%%CI)
<35w %20.6 %31.2 0.84 (0.60–1.17)
To MS, Lancet 2004
USG - Kısa serviks + PTD öyküsü yok RCT: Serklaj

16. 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.

17. TV / USG serviks ölçümü
12 – 22 haftalar
SU <15 mm Serklaj
Progesteron 200 mg / gece
18-34 hafta
PTD öyküsü YOKVAR
12, 16, 18, 20, 22, 24 haftalar
25 mm

18. Althuisius SM, 2000.
To MS, 2002.
Higgins SP, 2004
 Preterm doğum öyküsü (+) gebelerin
• 2 /3 den fazlasında
 serviks > 25 mm
 serklajsız izlem: tekrarlayan PTD
Copyright © 2013 Elsevier Inc.
• 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 – 8)
çoğul gebeliklerde RR, 2.15
Berghella V, 2005
Roman AS, 2005.

19.  Serklaj açık ve net fayda sağlar
 Serklaj mutlak endikasyon yoktur
• PTD öyküsü + olan ve servikal yetmezlik tanımlı olguda
• Obstetrik öyküde
 3-4 geç abortus veya
 1 - 2 preterm doğum veya
 objektif servikal kısalma gelişen olguda
• Uterin anomali
• Geçirilmiş konizasyon
• İkiz gebelik
 paradoksal komplikasyon (preterm doğum oranı )
• Servikal silinme – açılma - kontraksiyon (+)
 acil serklaj: yararı ??
Berghella V, 2004 Mancuso MS, 2009Jay D. Iams CREASY & RESNIK’S 2013

20.  Serklaj / klinik
• Shirodkar & MacDonald arasında klinik etkinlik farkı yok
• Serklaj – internal os arası 10 mm: etkili serklaj
 Serklaj / uygulanmayan koşullar
• Aktif preterm eylem, PPROM
• Koryoamnionitis kliniği
• Plasenta previa – uterin kanama
• Servikal / vaginal enfeksiyon (IL - 8)
• Fetal anomali – poli / oligohidramnios
• Fetal distres
• Maternal kontrendikasyon
Berghella V, 2004 Mancuso MS, 2009Jay D. Iams CREASY & RESNIK’S 2013

21. • We included 12 trials (involving 3328 women).
• When cerclage was compared with no treatment, there was
significant reduction in preterm births (average RR 0.80; 95% CI 0.69
to 0.95; nine trials, 2898 women).
Authors’ 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

22. Canada No 301, December 2013
 12 – 14. haftada elektif serklaj (I-A)
• II. trimester gebelik kaybı (≥ 3) veya erken preterm doğum
• Etyolojide potansiyel servikal yetmelik dışında başka faktör yok
 Serklaj (I-A)
• Spontan preterm doğum öyküsü var
• Servikal yetmezlik olasılığı yüksek
• Gebelik haftası < 24 ve servikal uzunluk < 25 mm
 Abdominal serklaj (II-3C)
• Klasik servikal yetmezlik + etkisiz vaginal serklaj öyküsü
• Trakelektomi operasyonu
 Acil serklaj (II-3C)
• < 24. gebelik haftasında sancısız servikal dilatasyon < 4 cm
 USG - servikal uzunluk izlemi (II-2B)
• Serklaj düşünülmeyen gebe
• Öyküsünde:
• 1 veya 2 erken midtrimester doğum
• Ekstrem preterm doğum
 Serklaj önerilmez: (II-1D)
• Rastlantısal kısa serviks + preterm doğum için risk faktörü yok
• Çoğul gebelik
• Kısa serviks (II-1D)

23. Serklaj / teknik
Sutur materyeli
• Mersilene 5 mm tape (Ethicon)
• Geniş non-absorbabl monofilament ( Prolen)
Teknik
• Mc Donald
• Shirodkar
• Wurm
• Lash
• Trans-abdominal
Operasyon
• Genel anestezi
• Steril şartlar
• Antibiyotik
• Tokoliz
• Progesteron

24.  McDonald tekniği
 Modifiye Shirodkar tekniği  Wurm (Hefner)tekniği

25. • Vaginal serklajın başarısız olduğu 2.trimester gebelik kaybı
• Konjenital anomaliye bağlı kısa serviks
• Trakelektomi gibi cerrahi sonrası kısa serviks
• Gebelik öncesi
• ilk trimester sonunda
• Erken 2. trimester (10-14 hafta)
 Transabdominal serklaj
Laparotomi
Laparoskopi

26. Serklaj / komplikasyon
• % 0.6
• Perop.
anestezi komplik.
• Postop.
 erken dönem
- kontraksiyon
- kanama
- sütürün doku
kesmesi (%6-19)
- fetal kayıp
 geç dönem
- Koryoamnionitis % 6.2
 Maternal olumsuzluklar
- vaginal akıntı artışı
- kanama
- inflamasyon
- sezaryen oranı (RR 1.19)
Wanyonyi S, 2013
- PPROM % 11
- Preterm eylem % 20
- < 32 hafta doğum % 8
- Üriner fistül
- Trigon nekrozu
- Servikste yırtılma %1-3
− servikal dilatasyon ile risk
 < 2 cm % 6.2
 > 2 cm % 41.7
 elektif % 5.2
 acil serklaj % 14.4
Jay D. Iams CREASY & RESNIK’S 2013

27. 21 çalışma – 2757 olgu
sensitivite / spesifisite
35 mm % 78 / % 66
30 mm % 41 / % 87
25 mm % 36 / % 94
20 mm % 30 / % 94
Çoğul gebeliklerde serviks

28. Authors’ 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.

30. Multiple Gestations
… elective cerclage placement in multiple pregnancies
without additional risk factors has not been shown to benefit
pregnancy outcomes.
… in contrast to singleton gestations, data have shown no
benefit in the placement of cerclage in multiple gestations
with ultrasound-identified cervical shortening.
… a meta-analysis has shown a relative risk increase of 2.15
for preterm delivery (< 35 weeks) in such pregnancies with
an ultrasound-indicated (cervical length < 25 mm) cerclage.
Düşük riskli çoğul gebelikte elektif serklaj faydasız
Tekil gebeliklerden farklı olarak
USG tanımlanmış kısa servikste serklaj faydasız
USG tanımlanmış kısa servikste serklaj sonrası
< 35 hafta PTD riski artar (2.15)
Am J Obstet Gynecol. 2014 Jul;211(1):5-6
Cerclage in twins: we can do better!
Berghella V, Roman A.

31. Pesser ‘to do nothing is not any longer an option

32. Pesser takılmasının kuralları
 Klinik uygunluk
1. Spontan preterm doğum öyküsü olan + TV / USG: serviks < 25 mm
gebeler
2. Aktif preterm eylem olmamalı
3. Servikal – vaginal enfeksiyon olmamalı
4. Pesser – tedavi etkinliği bilgilendirilmeli
5. Spekulum: serviks boyutları – pesser kalınlık ve genişlik uygunluğu
6. Çapı daha dar olan kısım servikse kanalı tamamen sarmalı,
membran fıtıklaşmasını öneleyecek kadar eksternal os kapalı olmalı
Kişisel
1. Pesser takılmasından sonra gebede rahatsızlık, sancı, kanama
olmadığı gözlemlenmeli
2. İdrar çıkışı rahatlığı sorgulanmalı
3. Pesserin çıkarılma koşulları açıklanmalı:
− kanama
− PPROM
− kontraksiyonların başlaması
4. Normal koşullarda, kişinin şikayeti olmadığı takdirde gebeliğin 37.
haftasına kadar pesserin kalacağı belirtilmeli

34. Pesser etkisi
• Uteroservikal açıyı daraltır
• Kaldığı sürece etkinliğinde azalma olmaz
• Membranların internal osa olan basınç etkisini uterus alt
segment ön duvara yansıtır

36. 10568 gebe 726 olguda 18 – 22 hafta Cx ≤ 25 mm
380 gebe dahil olmuş
Pesser grubu
190
İzlem grubu
190
< 28 hafta doğum % 2 % 8
< 34 hafta doğum % 6 % 27
< 37 hafta doğum % 22 % 59

37. − En az 1 kez < 34. hafta PTD
− Kısa serviks < 25 mm
• 142 gebe SERKLAJ
• 59 gebe VAGİNAL PROGESTERON (200 mg)
• 42 gebe PESSER
< 34. hafta DOĞUM

38. Randomized Study of Pessary Versus Standard
Management in Women With Increased
Chance of Premature Birth
King's College Hospital NHS Trust. (ClinicalTrials.gov Identifier: NCT00735137)
Vaginal pessary (CE0482, MED/CERT ISO 9003 / EN 46003) Phase 3
Katılan gebe sayısı
1,600
Expectant
sPTB 6%
Pessary
sPTB 4%
FMF Randomized study: Cx <26mm Pessary at 22 wks Vs
expectant
vaginal silicone pessary
Randomized trials
Prematurity in singletons - Vaginal silicone pessary
… 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.
…
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.

39. 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 < 38 mm
(%25 ps)
Normal serviks
uzunluğu

40. Authors’ 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.

41. Öykü endikasyonlu serklaj ne zaman yapılmalı?
Am J Perinatol. 2010 Jun;27(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

42. Önceki gebelikte serklaj tekrar serklaj endikasyonu ?
Am J Perinatol. 2008 Aug;25(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.

43. Yüksek riskli grupta serklaj uygulamasında öykü vs USG ?
Am J Obstet Gynecol. 2009 Jun;200(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.

44. Düşük riskli grupta serviks ≤ 25 mm serklaj vs istirahat ?
Am J Obstet Gynecol. 2007 Sep;197(3):315
Cervical length < 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 < or = 25 mm
in the early second trimester.

45. Rescue Shirodkar serklaj – gebelik prognozu ?
J Perinatol. 2009 Apr;29(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.

46. Am J Perinatol. 2009 Jan;26(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 öncesi
amniosentez ?
… the performance of an amniocentesis was not an independent
contributor to PTB < 28 weeks ( P = 0.90). The performance of
an amniocentesis prior to cerclage did not independently
contribute to PTB less than 28 weeks.

47. Ultrason – endikasyonlu serklaja 17 OH progesteron ilavesi
?
Am J Perinatol. 2011 May;28(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 < 35 weeks (odds
ratio 1.72, 95% confidence interval 0.50 to 5.89), nor did it have a significant
effect on the secondary outcomes. Among women with a prior
spontaneous PTB and current UIC for CL < 25 mm, 17P did not
reduce the rate of PTB < 35 weeks.

48. Ultrason – endikasyonlu serklaja indometasin ilavesi ?
Am J Obstet Gynecol. 2008 Jun;198(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.

49. Am J Obstet Gynecol. 2009 May;200(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 – endikasyonlu serklaj hattı eksternal os
mesafesi – PTD ilişkisi ?

50. Önceki gebelikteki başarısız serklaj sonrası yeni serklaj
TA vs TV ?
Am J Obstet Gynecol. 2000 Oct;183(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.

51. Serklaj: tek vs çift 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 Mar;208(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.

52. Serklaj sonrası hunileşme
Ultrasound Obstet Gynecol. 2002 Sep;20(3):252-5.
Funneling to the stitch: an informative ultrasonographic finding after
cervical cerclage.
O'Brien 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.

53. Ultrason endikasyonlu serklaj ve sutur materyeli seçimi
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 (Mersilene™ or
Ethibond™) and polyester braided Mersilene tape™ seem to
have similar efficacy.
J Matern Fetal Neonatal Med. 2012 Nov;25(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.

54. USG endikasyonlu kısa serviks - serklaj olgularında
fibronektin – uygun olgu seçimi?
Am J Obstet Gynecol. 2009 Feb;200(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.

55. Servikal serklaj ve PPROM
Clin Obstet Gynecol. 2011 Jun;54(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.

56. Preterm doğum dağılımı