What is the recommended procedure and management for a patient at risk for cervical insufficiency undergoing a cervical cerclage?

Cervical Cerclage Procedure and Management for Cervical Insufficiency

Cervical cerclage is recommended for patients with a history of three or more second-trimester pregnancy losses or extreme premature deliveries without other identifiable causes, but is not generally recommended for patients without a history of preterm birth who have a sonographic short cervix (10-25 mm). 1, 2

Patient Selection Criteria

• Cervical cerclage is indicated in the following scenarios:

  • History-indicated cerclage: Patients with three or more second-trimester pregnancy losses or extreme premature deliveries without other identifiable causes 1, 3
  • Ultrasound-indicated cerclage: Patients with prior spontaneous preterm birth AND cervical length ≤25 mm before 24 weeks gestation 3
  • Exam-indicated (emergency) cerclage: Patients with asymptomatic cervical dilation <4 cm without contractions before 24 weeks gestation 3

• Cerclage is NOT recommended for:

  • Patients without a history of preterm birth who have a sonographic short cervix (10-25 mm) 2
  • Multiple gestations, even with history of preterm birth 3
  • Incidental finding of short cervix without prior risk factors 3

Pre-Procedure Assessment

• Transvaginal ultrasound is the standard for evaluating cervical length, allowing complete visualization of the cervix including the internal os 4
• Consider cervical examination when cervical shortening of <11-15 mm is diagnosed, as 30-70% of these patients may have cervical dilation of ≥1 cm 2
• Screen for and treat any infections before cerclage placement:
  • Urinalysis for culture and sensitivity 3
  • Vaginal cultures for bacterial vaginosis 3

Cerclage Techniques

• Transvaginal cerclage:

  • McDonald technique: Most commonly used approach, involving a purse-string suture around the cervix at the level of the internal os 5
  • Shirodkar technique: Alternative approach with suture placement higher at the level of the internal os 5

• Transabdominal cerclage:

  • Consider when prior vaginal cerclage has been unsuccessful 3
  • Recommended for patients who have undergone trachelectomy 3
  • Laparoscopic approach may offer safety advantages 5

Post-Procedure Management

• Serial cervical length assessments are not routinely recommended after cerclage placement due to insufficient evidence supporting clinical benefit 1
• Vaginal progesterone after ultrasound-indicated cerclage placement may be beneficial:
  • One study showed reduced spontaneous preterm birth at <34 weeks (2.2% vs 18.4%) and <37 weeks (9.1% vs 29.7%) 1
• Do NOT recommend after cerclage:
  • Bed rest 6
  • Routine use of antibiotics 6
  • Routine tocolysis 6

Cerclage Removal

• Planned removal:

  • Typically at 36-37 weeks gestation 6
  • Earlier removal may be considered for patients with risk factors for preterm delivery 6

• Emergency removal:

  • Remove cerclage in cases of established preterm labor 6
  • Management of preterm premature rupture of membranes (PPROM) is controversial - consider either removing the cerclage or leaving it in situ after discussing risks and benefits 1

Special Considerations

• For patients with extremely short cervix (<10 mm) without prior preterm birth history:

  • A subgroup analysis showed decreased preterm birth at <35 weeks (39.5% vs 58.0%) with cerclage placement 1, 2
  • Consider cerclage based on shared decision-making in these cases 1

• For patients with progressive cervical shortening despite vaginal progesterone:

  • Limited evidence suggests benefit of adding cerclage when cervix shortens to <10 mm 2
  • One study showed increased latency to delivery (34 3/7 vs 27 2/7 weeks) 2