How to manage cervical shortening with a cervical cerclage (cervical stitch) in place?

From the Guidelines

To manage cervical shortening with a cervical cerclage in place, the most effective approach is to continue vaginal progesterone supplementation, typically 200 mg daily, until 36 weeks gestation, as it has been shown to reduce the risk of preterm birth and improve neonatal outcomes 1. When a cerclage is already in place, the focus should be on supporting the pregnancy and minimizing the risk of preterm labor. Key considerations include:

• Monitoring closely with regular transvaginal ultrasounds, typically every 1-2 weeks, to assess cervical length and detect any signs of further shortening or complications.
• Administering progesterone supplementation, with vaginal progesterone being the preferred option due to its efficacy in reducing preterm birth risk, as evidenced by a study showing a significant reduction in spontaneous preterm birth rates with its use 1.
• Recommending pelvic rest and reduced physical activity to minimize stress on the cervix and reduce the risk of preterm labor.
• Considering antenatal corticosteroids, such as betamethasone, if preterm birth appears imminent, to help mature fetal lungs and improve neonatal outcomes.
• Treating any concurrent infections, particularly bacterial vaginosis, to reduce the risk of preterm labor and other complications.
• Monitoring for signs of preterm labor or cerclage failure, such as vaginal bleeding, increased discharge, or contractions, and being prepared to intervene promptly if necessary.
• Planning for cerclage removal at 36-37 weeks unless earlier delivery is necessary, to minimize the risk of complications and ensure the best possible outcomes for both mother and baby.

It's essential to note that the use of 17-alpha-hydroxyprogesterone caproate (17-OHPC) is not recommended for the treatment of a short cervix, as stated in the Society for Maternal-Fetal Medicine guidelines 1. Similarly, cervical pessary placement is not recommended for the prevention of preterm birth in individuals with a singleton gestation and a short cervix, due to potential safety concerns and lack of consistent data demonstrating benefits 1. By prioritizing vaginal progesterone supplementation and close monitoring, healthcare providers can help support the pregnancy and reduce the risk of preterm birth and associated complications.

From the Research

Management of Cervical Shortening with Cervical Cerclage

• Cervical cerclage is an effective measure for preventing preterm delivery caused by cervical insufficiency, reducing neonatal morbidity and mortality rates 2.
• The American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC), and the International Federation of Gynecology and Obstetrics (FIGO) have guidelines for the indications, contraindications, techniques, and timing of placing and removing cervical cerclage 2.
• Ultrasound-indicated cervical cerclage is justified in women with a history of prior spontaneous preterm delivery or mid-trimester miscarriage and a short cervical length detected on ultrasound 2, 3.
• Serial sonographic measurement of the cervical length, bed rest, and routine use of antibiotics, tocolysis, and progesterone are not recommended after cervical cerclage placement 2.

Cervical Length and Gestational Age at Cerclage Placement

• Cervical length and gestational age at the time of ultrasound-indicated cerclage placement do not appear to impact the likelihood of preterm birth <36 weeks 4.
• Cervical dilation ≥2 cm at the time of exam-indicated cerclage is associated with an increased rate of preterm birth <36 weeks, but not earlier gestational ages at delivery 4.

Combined Treatment of Cerclage and Cervical Pessary

• The combined treatment of cerclage and cervical pessary may be a considerable alternative in the prevention of spontaneous preterm birth, especially for patients with cervical length <3rd percentile 5.
• The combined treatment may result in a shorter neonatal admission time at the neonatal intensive care unit and a trend for higher birthweight compared to cerclage alone 5.

Prevention of Preterm Birth

• Progesterone, cervical cerclage, and cervical pessary have been shown to be effective in reducing preterm delivery in pregnant women with short cervix 6.
• The successful management of pregnant women presenting a short cervix depends on the understanding that cervical shortening is the final common path for several causes of preterm delivery, and the best approach should be individualized to each patient 6.