Cerclage for the Management of Cervical Insufficiency

Publication Date: February 1, 2014

Recommendations and Conclusions 

The following recommendations are based on good or consistent scientific evidence.

  • Although women with a current singleton pregnancy, prior spontaneous preterm birth at less than 34 weeks of gestation, and short cervical length (less than 25 mm) before 24 weeks of gestation do not meet the diagnostic criteria for cervical insufficiency, available evidence suggests that cerclage placement may be effective in this setting. Cerclage is associated with significant decreases in preterm birth outcomes, as well as improvements in composite neonatal morbidity and mortality, and may be considered in women with this combination of his- tory and ultrasonographic findings .
  • Cerclage placement in women without a prior spontaneous preterm birth and a cervical length less than 25 mm detected between 16 weeks and 24 weeks of gestation has not been associated with a significant reduction in preterm birth.
(A)
574

The following recommendations are based on limited or inconsistent scientific evidence.

  • Certain nonsurgical approaches, including activity restriction, bed rest, and pelvic rest have not been proved to be effective for the treatment of cervical insufficiency and their use is discouraged.
  • The standard transvaginal cerclage methods currently used include modifications of the McDonald and Shirodkar techniques. The superiority of one suture type or surgical technique over another has not been established.
  • Cerclage may increase the risk of preterm birth in women with a twin pregnancy and an ultrasonographically detected cervical length less than 25 mm and is not recommended.
  • Neither antibiotics nor prophylactic tocolytics have been shown to improve the efficacy of cerclage, regardless of timing or indication.
  • A history-indicated cerclage can be considered in a patient with a history of unexplained second-trimester delivery in the absence of labor or abruptio placentae.
(B)
574

The following recommendations are based primarily on consensus and expert opinion. 

  • Cerclage should be limited to pregnancies in the second trimester before fetal viability has been achieved.
  • Transabdominal cervicoisthmic cerclage generally is reserved for patients in whom a cerclage is indicated based on the diagnosis of cervical insufficiency but cannot be placed because of anatomical limitations (eg, after a trachelectomy), or in the case of failed transvaginal cervical cerclage procedures that resulted in second-trimester pregnancy loss.
  • After clinical examination to rule out uterine activity, or intraamniotic infection, or both, physical examination-indicated cerclage placement (if technically feasible) in patients with singleton gestations who have cervical change of the internal os may be beneficial.
  • In patients with no complications, transvaginal McDonald cerclage removal is recommended at 36–37 weeks of gestation.
  • For patients who elect cesarean delivery at or beyond 39 weeks of gestation, cerclage removal at the time of delivery may be performed. However, the possibility of spontaneous labor between 37 weeks and 39 weeks of gestation must be considered.
  • In most cases, removal of a McDonald cerclage in the office setting is appropriate.
(C)
574

Recommendation Grading

Disclaimer

Overview

Title

Cerclage for the Management of Cervical Insufficiency

Authoring Organization

Publication Month/Year

February 1, 2014

Document Type

Consensus

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Adolescent, Adult

Health Care Settings

Ambulatory

Intended Users

Physician, nurse midwife, nurse, nurse practitioner, physician assistant

Scope

Assessment and screening, Diagnosis, Management

Diseases/Conditions (MeSH)

D023802 - Cerclage, Cervical, D011262 - Pregnancy Trimester, Second

Keywords

cervical insufficiency, cerclage