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Cervical Cerclage: A Stitch in Time

Guideline Watch |
February 20, 2014

Cervical Cerclage: A Stitch in Time

  1. Allison Bryant, MD, MPH

ACOG provides guidelines regarding cerclage for suspected cervical insufficiency.

  1. Allison Bryant, MD, MPH

Sponsoring Organization: American College of Obstetricians and Gynecologists (ACOG)

Target Population: Obstetric care providers

Background and Objective

Accurately diagnosing cervical insufficiency is often difficult, and the condition is identified often only after second-trimester pregnancy loss following painless cervical dilatation. Attempts to diagnose cervical insufficiency prior to expulsion of pregnancy have been thwarted by lack of specific diagnostic tools. ACOG has provided guidance to help determine which women are most likely to benefit from the classic treatment, cervical cerclage (placement of a suture to keep the cervix closed).

Key Recommendations

Indications for Cerclage

  • One or more previous second-trimester pregnancy losses characterized by painless cervical dilation without preterm labor or placental abruption

  • Painless second-trimester cervical dilation noted at physical examination

  • Prior spontaneous preterm birth before 34 weeks' gestation; current cervical length ultrasonographically measured at <25mm before 24 weeks

Other Considerations for Managing Cervical Insufficiency

  • In many women with histories consistent with cervical insufficiency, serial ultrasound monitoring and cerclage placement for cervical shortening can be safely pursued instead of prophylactic cerclage.

  • Cerclage is not appropriate for women with ultrasound-detected asymptomatic cervical shortening without histories of preterm birth; such women are more likely to benefit from vaginal progesterone.

  • Cerclage is not beneficial (and may be harmful) in women with multiple gestations.

  • Candidates for cerclage should be counseled about possible associated complications (e.g., ruptured membranes).

  • Regarding the two standard transvaginal cerclage techniques (McDonald and Shirodkar), superiority of one over the other has not been determined.

  • Transabdominal cerclage should only be considered if transvaginal cerclage has failed in a previous pregnancy or if significant anatomic abnormalities are present.

Comment

As we await better tools for diagnosing true cervical insufficiency, these recommendations provide clinicians with a reasonable means to select those women at risk for preterm delivery who would most benefit from cervical cerclage. Women with prior second-trimester loss are often eager to do everything possible to maximize their likelihood of a good outcome; however, they should be counseled that cerclage placement can probably be delayed until cervical shortening occurs — and often the procedure can be avoided altogether.

  • Disclosures for Allison Bryant, MD, MPH at time of publication Nothing to disclose

Citation(s):

Reader Comments (2)

RAJ SARIN Physician, Obstetrics/Gynecology, Aastha Medical Center Patiala India

very clear guidelines to avoid undue inteventions &do cerclage when absolutly indicated.

KAMAL ANWAR Medical Student, Obstetrics/Gynecology, mansoura university hospital -egypt

very important information

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