Cervical Cerclage May Avoid Preterm Birth, Guidelines Say

Diedtra Henderson

January 22, 2014

Women with a history of cervical insufficiency (1 or more second-trimester pregnancy losses in the absence of labor or prior cerclage because of painless cervical dilation in the second trimester) or painless cervical dilation in the second trimester on physical examination are good candidates for cervical cerclage, according to clinical management guidelines issued by the American College of Obstetricians and Gynecologists (ACOG).

The guidelines, published in the February issue of Obstetrics & Gynecology, were issued by ACOG's Committee on Practice Bulletins–Obstetrics to assist obstetrician-gynecologists in screening, diagnosing, and managing cervical insufficiency.

With cerclage, the surgeon inserts a stitch at the cervicovaginal junction, sometimes first dissecting the bladder and rectum from the cervix for closer placement of the suture to the cervical internal os to prevent the uterine cervix from opening prematurely.

Cerclage placement has a low risk for complications, which include amniotic membrane rupture, chorioamnionitis, cervical lacerations, and suture displacement. Uterine rupture and maternal septicemia, both life-threatening, are rare complications reported with all types of cerclage. Transabdominal cerclage carries a higher risk for hemorrhage than transvaginal cerclage.

Many women at risk for cervical insufficiency may be safely monitored from the 16th to the 24th week of gestation with serial transvaginal ultrasound examinations, an approach that could avoid unnecessary cerclage procedures for more than half of women, according to the guidelines.

Women whose cervical length is determined to be short in the second trimester and who have not previously had a preterm single birth are poor candidates for cerclage. For these women, the guidelines recommend prescribing vaginal progesterone to reduce the risk for preterm birth.

Although women with a current singleton pregnancy, with a prior spontaneous preterm birth at fewer than 34 weeks' gestation, and whose cervical length is less than 25 mm before 24 weeks' gestation do not meet the criteria for cervical insufficiency, cerclage placement may be effective for them. The scientific evidence supporting this recommendation is level A, according to the guidelines.

The scientific evidence does not support restricting women's activities or ordering bed rest or pelvic rest, and these nonsurgical approaches should not be used to treat cervical insufficiency. Nor is there strong evidence to support the superiority of either the McDonald or Shirodkar technique.

Cerclage is not recommended for women pregnant with twins because it may increase the risk for preterm birth. Antibiotic or prophylactic tocolytics fail to improve cerclage efficacy, according to the committee.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2014;123:372-379. Abstract

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