What is the recommended post‑cerclage management regimen, including activity restriction, progesterone supplementation, prophylactic antibiotics, tocolysis, serial monitoring, and timing of cerclage removal?

Post-Cerclage Management

After cervical cerclage placement, add vaginal progesterone 200 mg daily, permit routine daily activities while avoiding moderate-to-vigorous exercise, do NOT prescribe bed rest, do NOT use prophylactic antibiotics or tocolysis routinely, do NOT perform serial ultrasound monitoring, and remove the cerclage at 36-37 weeks of gestation. 1, 2

Progesterone Supplementation

Vaginal progesterone 200 mg daily should be added after cerclage placement, as retrospective evidence demonstrates substantial reductions in spontaneous preterm birth at <34 weeks (2.2% vs 18.4%) and <37 weeks (9.1% vs 29.7%) compared to cerclage alone. 1, 2 This recommendation is supported by the American College of Obstetricians and Gynecologists. 1

• Do NOT use 17-alpha hydroxyprogesterone caproate (17-OHPC) for post-cerclage management, as ACOG specifically recommends against this formulation. 1

Activity Restriction

Routine daily activities and light upper-body resistance exercise are permitted after cerclage placement. 1

• Moderate-to-vigorous physical activity should be avoided both before and after cerclage. 1
• Bed rest is explicitly NOT recommended and should be avoided, as it offers no benefit and may be harmful. 1

Prophylactic Antibiotics and Tocolysis

Routine prophylactic antibiotics are NOT indicated after cerclage placement. The evidence does not support their use in uncomplicated post-cerclage management. 3

• Antibiotics should be reserved for specific clinical indications such as signs of infection (fever, uterine tenderness, purulent discharge). 1
• Routine tocolysis is NOT recommended after cerclage placement in the absence of contractions. 4

Serial Monitoring

Routine serial ultrasound monitoring after cerclage is NOT recommended, as the American College of Radiology states that insufficient evidence supports clinical benefit from this practice. 1

• While shorter cervical length below the cerclage and funneling are associated with higher preterm birth rates, monitoring these parameters does not change management or improve outcomes. 1
• If ultrasound is performed for clinical indications, measure the total length of closed cervix regardless of sutures, and when funneling is present, measure from the level of funneling to the cerclage sutures. 1

Patient Education and Symptom Monitoring

Patients must be instructed to promptly report signs of preterm labor or infection. 1

• Preterm labor warning signs include: uterine contractions, pelvic pressure, vaginal bleeding, or fluid leakage. 1
• Infection indicators include: fever, uterine tenderness, or purulent vaginal discharge requiring immediate evaluation. 1

Timing of Cerclage Removal

Remove the cerclage at 36-37 weeks of gestation in women anticipating vaginal delivery. 5

• This timing balances the risk of preterm birth against the need for cerclage removal before spontaneous labor. 5

Management of Complications

Preterm Premature Rupture of Membranes (PPROM)

If PPROM occurs with a cerclage in place, either removal or retention is reasonable through shared decision-making. 1, 6

• Evidence shows no significant difference in pregnancy prolongation between removal and retention (45.8% vs 56.2% had 1-week prolongation, p=0.58). 6
• Discuss the risks of infection with retention versus the potential for pregnancy prolongation. 1, 6