Post-Cervical Cerclage Care
Add vaginal progesterone 200 mg daily after cerclage placement to reduce preterm birth risk, avoid routine serial ultrasound monitoring, and reserve cerclage removal for established preterm labor or PPROM (with removal vs retention being equally reasonable options). 1
Pharmacologic Management
- Initiate vaginal progesterone 200 mg daily after cerclage placement, which significantly reduces spontaneous preterm birth at <34 weeks (2.2% vs 18.4%) and <37 weeks (9.1% vs 29.7%) compared to cerclage alone 1
- The American College of Obstetricians and Gynecologists supports this progesterone supplementation based on evidence showing substantial benefit 1
Monitoring Strategy
- Do NOT perform routine serial ultrasound monitoring after history-indicated cerclage placement, as insufficient evidence supports clinical benefit from this practice 1
- This recommendation applies specifically to history-indicated cerclage where the indication was already established 1
Activity and Prophylactic Measures
- Bed rest is NOT recommended after cerclage placement, as major guidelines uniformly discourage this practice 2
- Routine prophylactic antibiotics are NOT indicated after cerclage 2
- Routine tocolysis is NOT recommended in the absence of contractions 2
Timing of Cerclage Removal
- Remove cerclage when established preterm labor occurs, according to ACOG, RCOG, and SOGC consensus 2
- Standard removal timing is typically around 36-37 weeks in uncomplicated cases 2
Management of Complications
PPROM After Cerclage
- Either cerclage removal or retention is reasonable through shared decision-making when PPROM occurs, as the Society for Maternal-Fetal Medicine notes this remains controversial with limited evidence 3
- Cerclage retention does not significantly prolong pregnancy compared to removal (45.8% vs 56.2% had 1-week prolongation, p=0.58) 4, 3
- No significant differences exist in chorioamnionitis rates (41.6% vs 25.0%), postpartum endometritis (12.5% vs 3.1%), or neonatal outcomes between retention and removal 3
Key Pitfalls to Avoid
- Do not order serial cervical length ultrasounds routinely – this wastes resources without proven benefit for history-indicated cerclage 1
- Do not prescribe bed rest – this outdated practice lacks evidence and may cause harm from immobilization 2
- Do not give prophylactic antibiotics or tocolytics unless specific indications arise 2
- Do not forget vaginal progesterone – this is the one evidence-based adjunctive therapy that substantially reduces preterm birth 1