Cervical Cerclage for Cervical Insufficiency

Definition and Indications

The American College of Obstetricians and Gynecologists recommends cervical cerclage for patients with a history of cervical insufficiency, particularly those with three or more second-trimester pregnancy losses or extreme premature deliveries without other identifiable causes 1
Cervical insufficiency exists on a spectrum, with some individuals showing cervical shortening before painless dilation or clinical signs such as labor or rupture of membranes, as noted by the American Journal of Obstetrics and Gynecology 2

The American College of Obstetricians and Gynecologists states that compelling data show benefit of cerclage in patients with short cervix and previous preterm birth 2
For patients without a history of preterm birth, cerclage has not generally demonstrated reduction in preterm birth rates, according to the American College of Obstetricians and Gynecologists 3, 2
In patients with extremely short cervix (<10 mm), a subgroup analysis showed decreased preterm birth at <35 weeks (39.5% vs 58.0%; RR, 0.68), as reported by the American Journal of Obstetrics and Gynecology 2

The American College of Obstetricians and Gynecologists suggests that cerclage may be considered even without prior preterm birth history for patients with extremely short cervix (<10 mm), based on shared decision-making 4

The American College of Radiology notes that serial cervical length assessments are not routinely recommended after cerclage placement due to insufficient evidence supporting clinical benefit 5
Vaginal progesterone may be beneficial after ultrasound-indicated cerclage placement, with one study showing reduced spontaneous preterm birth at <34 weeks (2.2% vs 18.4%) and <37 weeks (9.1% vs 29.7%), as reported by the American Journal of Obstetrics and Gynecology 4

The American College of Obstetricians and Gynecologists states that management of preterm premature rupture of membranes (PPROM) is controversial - it is reasonable to either remove the cerclage or leave it in situ after discussing risks and benefits 6

The American College of Obstetricians and Gynecologists recommends that cerclage is NOT indicated for patients without a history of preterm birth who have a sonographic short cervix (10-25 mm) 7

For patients with progressive cervical shortening despite vaginal progesterone, limited evidence suggests benefit of adding cerclage when cervix shortens to <10 mm, with one study showing increased latency to delivery (34 3/7 vs 27 2/7 weeks) 7
A subgroup analysis showed decreased preterm birth at <35 weeks (39.5% vs 58.0%) with cerclage placement in patients with extremely short cervix (<10 mm) without prior preterm birth history 8

The American College of Obstetricians and Gynecologists recommends history-indicated cerclage for individuals with classic historical features of cervical insufficiency or unexplained second-trimester loss, as evidenced by prior second-trimester loss with painless cervical dilation in the absence of labor, rupture of membranes, or placental abruption 9
History-indicated cerclage should be reserved for individuals with these classic historical features or unexplained second-trimester loss, according to the American Journal of Obstetrics and Gynecology 9
After a history of previable or periviable preterm prelabor rupture of membranes (PPROM), history-indicated cerclage should be reserved for individuals with classic historical features of cervical insufficiency or unexplained second-trimester loss in the absence of placental abruption 9
One study showed cerclage placement after prior previable PPROM was associated with increased odds of preterm birth, encouraging caution 9