What are the indications for cervical cerclage (cervical circumvallation procedure)?

From the Guidelines

Cervical cerclage is indicated for women with a history of cervical insufficiency, including those with a history of painless cervical dilation in the second trimester leading to pregnancy loss, a history of spontaneous preterm birth before 34 weeks, or a short cervical length (less than 25 mm) detected on transvaginal ultrasound before 24 weeks of gestation, particularly in women with a previous preterm birth 1, 2, 3.

Indications for Cervical Cerclage

• History of painless cervical dilation in the second trimester leading to pregnancy loss
• History of spontaneous preterm birth before 34 weeks
• Short cervical length (less than 25 mm) detected on transvaginal ultrasound before 24 weeks of gestation, particularly in women with a previous preterm birth
• Physical examination-indicated cerclage is performed when cervical dilation of 1-4 cm with visible membranes is found on examination in the second trimester
• Prophylactic cerclage may be considered for women with a history of three or more second-trimester losses or preterm births ### Procedure and Technique
• The procedure is typically performed between 12-24 weeks of gestation
• The McDonald technique (purse-string suture around the cervix) is the most common technique used ### Contraindications
• Multiple gestations
• Active vaginal bleeding
• Ruptured membranes
• Intrauterine infection
• Fetal anomalies incompatible with life
• Active labor ### Evidence-Based Recommendations
• History-indicated cerclage should be reserved for individuals with classic historical features of cervical insufficiency or an unexplained second-trimester loss in the absence of placental abruption 1
• Cerclage placement for management of subsequent pregnancies after a previous previable PPROM was associated with increased odds of preterm birth, and therefore, its use should be cautioned 1
• In individuals without a history of PTB who have a sonographic short cervix (10-25 mm), cerclage placement is not recommended in the absence of cervical dilation 2, 3

From the Research

Cervical Cerclage Indications

The indications for cervical cerclage are as follows:

• Women with a history of cervical insufficiency, defined as three or more second-trimester pregnancy losses or extreme premature deliveries, should be offered elective cerclage at 12 to 14 weeks of gestation 4
• Women with a classic history of cervical insufficiency in whom prior vaginal cervical cerclage has been unsuccessful, abdominal cerclage can be considered in the absence of additional mitigating factors 4
• Women who have undergone trachelectomy should have abdominal cerclage placement 4
• Emergency cerclage may be considered in women in whom the cervix has dilated to < 4 cm without contractions before 24 weeks of gestation 4
• Women in whom cerclage is not considered or justified, but whose history suggests a risk for cervical insufficiency (1 or 2 prior mid-trimester losses or extreme premature deliveries), should be offered serial cervical length assessment by ultrasound 4
• Cerclage should be considered in singleton pregnancies in women with a history of spontaneous preterm birth or possible cervical insufficiency if the cervical length is ≤ 25 mm before 24 weeks of gestation 4
• History-indicated cerclage for women with 3 or more previous preterm deliveries and/or second trimester pregnancy miscarriages 5
• Ultrasound-indicated cerclage is justified in women with history of prior spontaneous preterm delivery or mid-trimester miscarriage and a short cervical length detected on ultrasound 5

Specific Patient Populations

• Women with a history of one or more previous second trimester miscarriages related to painless cervical dilation or prior cerclage due to painless cervical dilation in the second trimester may be considered for cerclage in singleton pregnancies 5
• There is no benefit to cerclage in a woman with an incidental finding of a short cervix by ultrasound examination but no prior risk factors for preterm birth 4
• Present data do not support the use of elective cerclage in multiple gestations even when there is a history of preterm birth 4
• The literature does not support the insertion of cerclage in multiple gestations on the basis of cervical length 4

Alternative Techniques

• A transvaginal double cervical cerclage with mersilene tape using a modified McDonald's technique may be considered as a viable alternative to abdominal cervical cerclage in women with failed vaginally applied cervical cerclage 6