Cerclage for the

Management of Cervical
Insufficiency
Practice Bulletin # 142
Karlene Vega Figueroa, PGY-1
 Definition
• Inability of uterine cervix
to retain a pregnancy in
the absence of clinical
contractions, labor, or
both in the second
trimester
 Pathophysiology
• Poorly understood

• Factors that increase risk :

• Surgical trauma (conization, LEEP, mechanical dilation of cervix during
termination, obstetric lacerations)
• Congenital Mullerian anomalies, Cervical collagen deficiency, in-utero
DES exposure

• Not indications for cervical cerclage

 Diagnosis
• History of painless cervical dilation after first trimester
• Subsequent expulsion of pregnancy in the second trimester
• Typically occurs before 24 WGA
• In absence of other clear pathology

• Cervical length has been shown to be a marker for preterm

birth, rather tan specific marker for cervical insufficiency
Indications
Cerclage should be limited to
pregnancy in second trimester, before
viability is achieved
 History Indicated/Prophylactic

• History of unexplained second trimester delivery in absence of labor

or abruptio placentae.

• Typically placed at 13-14 WGA

• 1/3 trials found fewer deliveries before 33 WGA in patient with

history indicated cerclage
 Physical Exam-Indicated/
Emergency or Rescue
• Advanced cervical dilation (internal os) in the absence of labor and
abruptio placenta in singleton pregnancy

• Rule out uterine activity and/or intraamniotic infection

• Due to lack of larger trials that show clear benefit, counsel patient
about potential morbidity
 Ultrasonography Indicated

• History of prior spontaneous PTD <34 WGA.

• Most patients can be safely monitored with serial transvaginal

ultrasounds q2 wks in second trimester (16 WGA – 24 WGA)

• Unnecessary history indicated cerclage procedures can be avoided in

more than one half of the patients.
 Ultrasonography Indicated
• Recommended for those who have changes on TVUS consistent with
a short cervical length (<25mm) with or without funneling.

• Although patient with current singleton pregnancy with prior

spontaneous PTD <34WGA and short cervical length is not diagnostic
criteria for cervical insufficiency, evidence suggest cerclage may be
effective.

• Cerclage has not shown significant reduction in preterm birth, if no

history of PTD and CL <25mm between 16-24WGA
 Treatment Options

• Non-surgical approaches have not shown to be effective or

have limited evidence
• Bed rest, activity restriction, pelvic rest, etc. – DISCOURAGED
• Pessary – HIGH RISK PATIENTS
• Surgical approaches
• Transvaginal - McDonald & Shirodkar
• Transabdominal cervicoisthmic
• None superior to other
• Hemorrage risk: Transabdominal>>>Transvaginal
McDonald Shirodkar

https://www.youtube.com/watch?v=lkYK6vux6D8
Suture: 1 or 2 Nylon, Propylene monofilament or Mersilene tape
Two cerclage sutures are not more effective than one.
 Cerclage Removal (McDonald)

• Recommended between 36-37 WGA

• In office setting

• Not an indication for delivery

• If cesarean section, at >= 39WGA, cerclage removal at time of surgery

may be performed
Transabdominal Cervicoisthmic

Reserved for:
1. Anatomical limitations (trachelectomy)
2. Failed transvaginal cerclage that resulted
in 2nd trimester pregnancy loss

Performed late trimester or early second

trimester (10-14 WGA)

Can be left in place between pregnancies

until childbearing is complete.
 • Incidentally detected short cervical length in
second trimester in the absence of prior
singleton preterm birth is not diagnostic of
cervical insufficiency
Which patients
should NOT be • Vaginal progesterone for incidental short
cervical length (<=20mm) before 24 WGA
considered
candidate for • Twin pregnancy. May increase risk of PTD.
Not recommended
cerclage?
• Lacking evidence for prior LEEP, cone bx, or
Mullerian anomaly
 Rupture of
Chorioamnionitis
Membranes
Morbidity
Cervical Suture
Laceration Displacement

Uterine Rupture
Maternal
Septicemia
 Perioperative
interventions No antibiotics
and
US Assessment
No tocolytics

US surveillance after
placement is not necessary
 Cerclage in PPROM and PTL Management

PPROM PTL
• Retention for >24hrs after • Clinical judgement advised
PPROM is associated with • If cervical change, painful
pregnancy prolongation contractions or vaginal
• Retention has been associated bleed>>remove
with neonatal sepsis and
mortality, RDS, chorioamnionitis
• Firm recommendation cannot
be made to remove or retain
 • Williams Obstetrics, Chapter 18,
Section 6

• Cerclage for the management of

cervical insufficiency. Practice
Bulletin No. 142. American College
of Obstetricians and Gynecologists.
References Obstet Gynecol 2014;123:372–9.

• https://www.atlasofpelvicsurgery.c
om/4Cervix/7CorrectionofanIncom
petentCervixbytheMcDonaldOperat
ion/chap4sec7.html