From the Guidelines
Cervical cerclage is not generally recommended for individuals without a history of spontaneous preterm birth, even with a short cervix, unless there is cervical dilation or a history of cervical insufficiency. The management of cervical insufficiency and short cervix involves a range of interventions, including cervical cerclage, progesterone supplementation, and cervical pessary. However, the use of these interventions depends on the individual's history of preterm birth, cervical length, and presence of cervical dilation.
Cervical Cerclage
Cerclage is a surgical procedure where a stitch is placed around the cervix to provide mechanical support and prevent premature dilation. There are three main types of cerclage: McDonald cerclage, Shirodkar cerclage, and transabdominal cerclage. According to the Society for Maternal-Fetal Medicine (SMFM) consult series #70, cerclage placement is not recommended in individuals without a history of preterm birth who have a sonographic short cervix (10-25 mm) in the absence of cervical dilation (GRADE 1B) 1.
Progesterone Supplementation
Progesterone supplementation, such as 200mg vaginal suppository daily or 250mg intramuscular injection weekly, from 16-36 weeks may be used alone or with cerclage for women with a history of cervical insufficiency. The SMFM recommends using a mid-trimester cervical length of 25 mm to diagnose short cervix in individuals with a singleton gestation and no previous history of spontaneous preterm birth (GRADE 1C) 1.
Cervical Pessary
A cervical pessary, a silicone device that fits around the cervix, may be used in cases where cerclage is not appropriate. However, the SMFM recommends against the use of cervical pessary for the prevention of preterm birth in individuals with a singleton gestation and a short cervix (GRADE 1B) 1.
Monitoring and Prevention
Women with cervical insufficiency should receive regular transvaginal ultrasound monitoring of cervical length during pregnancy. The underlying mechanism of cervical insufficiency involves premature cervical softening and dilation without contractions, which these interventions aim to counteract by providing structural support or hormonal stabilization of the cervix.
In summary, the management of cervical insufficiency and short cervix requires a personalized approach, taking into account the individual's history of preterm birth, cervical length, and presence of cervical dilation. Cerclage placement should be reserved for individuals with a history of cervical insufficiency or cervical dilation, while progesterone supplementation and cervical pessary may be considered in specific cases 1.
From the Research
Cervical Insufficiency and Cerclage
Cervical insufficiency is a condition where the cervix is unable to support the pregnancy, leading to preterm birth or mid-trimester pregnancy loss. The treatment options for cervical insufficiency include cervical cerclage, which is a surgical procedure where a stitch is placed around the cervix to support it.
Types of Cerclage
There are different types of cerclage, including:
- Prophylactic cerclage: performed electively at 13-16 weeks gestation in women with a history of cervical insufficiency 2
- Therapeutic cerclage: performed in women with ultrasonographic changes consistent with a short cervix or the presence of funneling after 16-20 weeks gestation 2
- Emergency cerclage: performed in women who present with asymptomatic dilation of the uterine cervix of at least 2 cm and/or a prolapse of the amniochorial membranes 2
- Shirodkar cerclage: a type of cerclage that may be indicated in the event of prior cerclage failure using the McDonald technique or in order to allow for correct stitch placement in very short cervixes 3
Indications for Cerclage
The indications for cerclage include:
- History of three or more second-trimester pregnancy losses or extreme premature deliveries 4
- History of cervical insufficiency 4
- Ultrasonographic changes consistent with a short cervix or the presence of funneling after 16-20 weeks gestation 2
- Asymptomatic dilation of the uterine cervix of at least 2 cm and/or a prolapse of the amniochorial membranes 2
Benefits and Risks of Cerclage
The benefits of cerclage include:
- Reduction in the risk of preterm birth and mid-trimester pregnancy loss 4, 2, 3
- Improvement in neonatal outcomes 3 The risks of cerclage include:
- Infection 4
- Bleeding 4
- Cervical scarring 4
Conclusion is not allowed, so the response will continue with more information
Cerclage Techniques
There are different techniques for performing cerclage, including:
- McDonald technique: a transvaginal cerclage technique 2, 5
- Shirodkar technique: a transvaginal cerclage technique that may be indicated in the event of prior cerclage failure using the McDonald technique or in order to allow for correct stitch placement in very short cervixes 5, 3
- Transabdominal cerclage: a technique that is recommended when a transvaginal cerclage has to be avoided because of technical difficulties depending on the conditions of the cervix or when the pregnant woman has a history of one or more failed transvaginal cerclages 2