CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 52, Number 4, 597610

r 2009, Lippincott Williams & Wilkins

Contemporary
Use of Cerclage
in Pregnancy
ROBERT H. DEBBS, DO, FACOOG and JANINE CHEN, MD
Department of Obstetrics and Gynecology, Pennsylvania Hospital,
Division of Maternal Fetal Medicine, University of Pennsylvania
School of Medicine, Philadelphia, Pennsylvania

Abstract: Second trimester pregnancy loss and preterm delivery may be considered an obstetrical syndrome. A multifactorial approach to the diagnosis
of true cervical insufficiency is paramount. Surgical
modification of the cervix benefits those with at least
3 second trimester losses or preterm deliveries, those
with 2 early second trimester losses when no other
cause for loss is identified, and those with a previous
second trimester loss or preterm birth with ultrasound
findings of a short cervix defined as less than 25 mm.
Multifetal pregnancies do not benefit from cerclage
and causes harm in those with ultrasound or physical
examination identified cervical changes.
Key words: cerclage, cervical insufficiency, pregnancy
loss, preterm birth, transvaginal ultrasound

Introduction
The thought of suturing the cervix closed
to prevent pregnancy loss or premature
birth seems intuitive and simplistic for
many obstetricians around the world.
However, many controversies exist regarding the pathophysiology, management and screening of those who have
Correspondence: Robert H. Debbs, DO, FACOOG.
Department of Obstetrics and Gynecology, Pennsylvania
Hospital Maternal Fetal Medicine Network, University
of Pennsylvania School of Medicine, 800 Spruce St.
Philadelphia, PA 19107. E-mail: Debbsr@pahosp.com
CLINICAL OBSTETRICS AND GYNECOLOGY

had a midtrimester pregnancy loss, recurrent preterm deliveries and those who
may be at risk for second trimester loss
or early delivery without a prior history.
Many physicians subscribed to a dichotomous theory that cervical change in
pregnancy is either premature labor or
cervical insufficiency, distinct and separate entities. Because of this, a physicians
desire to help prevent pregnancy loss has
included the placement of a cervical suture in many patients.
As evidence-based medicine takes a
firm hold of our daily interventions and
management schemes, it is increasingly
obvious that what was once thought beneficial by hypothesis is many times disprove when adequately studied. Thus, the
decision to place a cerclage during or
before pregnancy is not as simple as once
thought. Ignorance of the facts and fear of
either litigation or recurrent loss, in addition to patient pressure from internet chat
rooms and blogs, can lead to surgical
intervention which can cause harm to
both mother and baby. Thus it is incumbent upon well-trained physicians to not
only use clinical experience, but also to
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Debbs and Chen

infuse experience with the available evidence. With the volume of evidence before
us, it is evident that carefully selected
patients can benefit from surgical modification of the cervix to prevent pregnancy loss and preterm delivery. It is
equally apparent, when cerclage is used
inappropriately, it can increase the risk of
earlier delivery and thus cause harm. It is
the aim of this chapter to review the best
available evidence and provide a framework from which obstetrical care providers may choose surgical interventions to
reduce the risk of pregnancy loss or premature birth from suspected cervical insufficiency while always keeping in mind
the most important aspect of medical
intervention, primum non-nocere!

The Syndromic Phenomena

of Cervical Change
Similar to preterm labor, preeclampsia,
intrauterine growth restriction, fetal death,
preterm premature rupture of membranes

and many other disease entities in pregnancy, the clinical condition of cervical
insufficiency should be considered an obstetrical syndrome. There is no question
that many genetic, environmental, surgical, infectious, structural, hormonal, and
inflammatory mediators may be at work
to contribute to cervical change (Fig. 1).
Cervical shortening and dilatation, which
many times leads to the inability to retain
the conceptus, is the final common pathway of this obstetrical syndrome. Therefore, it does not pass scientific scrutiny to
assume the breakdown of the extracellular matrix of the cervix, which occurs
before passage of the conceptus, is prevented solely by placing a suture in all
women with a history or risk factor for
pregnancy loss or preterm delivery. The
lack of unequivocal diagnostic criteria, in
addition to the identified lack of efficacy
of the cerclage procedure in many situations, support the syndromic nature of
cervical change. In short, the hammer is
not right for every nail.

FIGURE 1. The syndromic nature of cervical change. CRH indicates corticotropin releasing
hormone; HPA, hypothalamic pituitary axis; pPROM, preterm premature rupture of membranes, TNF, tumor necrosis factor.

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Contemporary Use of Cerclage in Pregnancy

Further complicating the diagnosis of
cervical insufficiency is the typical and historical context from which the definition of
cervical insufficiency has come. Whether
or not true cervical insufficiency is primarily
just a cervical disorder or characterized by
premature breakdown of support mechanisms, which may or may not repeat in subsequent pregnancies, explains the difficulty
with which practitioners are faced in assigning this diagnosis. The failure of the cervix to
remain closed with protruding membranes
and rupture of the amniotic sac in repeated
pregnancies has historically been the criteria
with which the diagnosis is made.1
Yet a seemingly insufficient cervix may
retain the pregnancy without intervention
and a seemingly competent cervix may
not. Many patients are given the diagnosis
of cervical insufficiency with no standard
extensive evaluation of other etiologies
for prior poor obstetrical history. In a
group of patients referred for consideration of an abdominal cerclage, because
of prior failed pregnancies with a vaginal
cerclage, we identified confounding factors for previous deliveries in 23% of
patients. These included overwhelming
infections, abruption placenta, compound thrombophilia, uterine malformations, intracavitary myoma uteri, multiple
gestations, and substantial preterm labor.2 Because of the syndromic nature
of midtrimester pregnancy loss, cervical
change, and preterm birth (PTB), an
extensive evaluation is warranted. An
evaluation for uterine malformations, synechiae, intracavitary lesions such as submucous myoma should be considered
before assigning the diagnosis of cervical
insufficiency. Pathologic evaluation of
previous pregnancy losses or early deliveries many times will identify a vasculopathy, significant inflammatory response,
chronic abruptio placenta as well evidence of genetic abnormalities. In addition, placental tumors, large infarctions,
syncytial knots, and evidence of chronic
placental malperfusion are many times iden-

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tified. In the nonpregnant state, multiple

modalities have been used to confirm the
presence of cervical insufficiency. Hysterosalpingography with difficulty retaining the
balloon, cervical resistance index calculation
and noting the ease with which dilators or a
hysteroscope is passed have not proven to
have sensitivity or predictive values sufficient to be used as a screening tool.
Assuming these entities have been excluded, patients can then be placed into 4
categories. Those that have displayed classical and historical mid trimester losses,
those with ultrasound findings of a shortened cervix or funneling of the membranes
with obstetrical history suggesting a high
risk of loss, those who have incidental
ultrasound findings consistent with cervical
effacement and funneling without prior
adverse history and those who present with
clinically apparent quiet cervical dilation,
ballooning or hour glassing membranes
without obvious preterm contractions, evidence of abruption or fetal abnormality.

Historical Risks Suggesting High

Risk for Cervical Insufficiency
and History Indicated Cerclage:
Those Who Present in Pregnancy
With Prior History of Preterm
Birth or Second Trimester Loss
or Those With Other Historical
Risk Factors
Historically, selection of individuals for
whom a cerclage is considered has been
based on prior second trimester pregnancy loss or preterm delivery where
other causes have been excluded. However, those who have acquired surgical or
congenital defects of the cervix, mullerian
anomalies, multiple gestations, and those
with a congenitally hypoplastic cervix are
at risk for premature birth or mid trimester delivery. In utero exposure to diethylstilbestrol (DES) alters the structure of
the cervix in up to 69% of women.3
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Debbs and Chen

Women exposed to DES are 2.6 to 6.7

times more likely than unexposed women
to experience premature delivery.3 The
available data, however, suggests that
prophylactic cerclage is not indicated in
patients with a history of in utero exposure to DES unless those women have
experienced a previous pregnancy loss or
have clear evidence of cervical shortening,
in which case an ultrasound indicated
procedure may be performed. (Level III
evidence).4 In a recent retrospective analysis of 115 pregnancies in 48 women with
duplication anomalies (septate, didephic
or bicornuous), most delivered at term or
near term with the most common complication that of malpresentation, suggesting
no indication in this group for history
indicated cerclage without prior history
of loss.5
A history indicated cerclage, previously termed prophylactic cerclage, is that
which is based solely on either a prior
poor obstetrical history or risk factors
that are thought to be sufficient to perform this intervention. A history indicated cerclage substantially improves the
outcome of pregnancies in women with 3
or more prior second trimester losses or
preterm deliveries and approaches statistical significance after 2 such losses.6 In
a large randomized controlled trial by
McNaughton et al,6 a subgroup analysis
was necessary to reveal a benefit for
a reduction in preterm deliveries<33
weeks (15% vs. 32%) in those with prior
preterm delivery. It is of note, none of the
other randomized controlled trials of prophylactic placement proved benefit but
were substantially limited by inclusion
cirteria, small numbers, and selection
bias.68 None of the other historical indications such as prior loop excision of the
endocervical canal, conization of the
cervix, multifetal pregnancy, mullerian
+ anomalies, DES exposure or genetic
predisposition to collagen deficiency, that
is, Ehrlers-Danlos syndrome, have proven to benefit from a history indicated
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procedure.9 In the Preterm Prediction

study, Mercer et al10 sought to evaluate
the effect of prior PTB between 13 and 22
weeks, 23 and 27 weeks, and after 28
weeks on subsequent obstetrical outcome.
Although prior PTB between 23 and 27
weeks carried a 27% risk of recurrent
PTB, in those that had a very early PTB
between 13 and 22 weeks, the association
was not nearly as strong. This explains, to
some degree, why history indicated cerclage has not yet proven to be effective
except in women with possibly 2 and
definitively 3 or more prior PTBs or second-trimester losses. This begs the question; do you perform the procedure for
the 15% to 30% of women who may have
recurrent PTB or second trimester delivery after one loss when the procedure
does have risk? As a policy, transvaginal
ultrasound in high-risk populations is
equivalent to prophylactic cerclage. History indicated cerclage, therefore, should
be relegated to the population with known
benefit.

Risks of History
Indicated Vaginal
Cerclage
Elective cervical cerclage, by whichever
technique used, carries some risks for the
pregnancy and subsequent pregnancies.
Surgical manipulation of the cervix can
cause uterine contractions, bleeding or infection, which may lead to miscarriage or
preterm labor and occurs in up to 9% of
prophylactic cerclage procedures. In addition, cervical laceration, cervical dystocia,
cervical stenosis, vesico-vaginal fistula,
uterine rupture, and anesthetic complications have all been reported. These risks
have to be carefully balanced against the
benefit from mechanical support to the
cervix. Maternal pyrexia, hospital admission, cesarean section, tocolytic therapy,
and possible displacement of the cerclage
are all reported with varying frequency.11

Contemporary Use of Cerclage in Pregnancy

Ultrasound Indicated Vaginal

Cerclage: Those Who Present
With Ultrasound Shortening of
the Cervix, With or Without
Prior History of Midtrimester
Loss or Preterm Birth
Over the last 20 years, there have been
multiple well designed studies to assess
the normal and pathologic cervical ultrasound findings in pregnancy both in those
with term and preterm deliveries.12,13
However, not all women with a shortened cervix on ultrasound will benefit
from a cerclage. There have been several
trials to try and answer the question of
whether a cerclage placed based on ultrasound findings improves the outcome of
the pregnancy. In 1998, Heath et al14
performed transvaginal sonography at
23 weeks of gestation in 2702 women with
singleton pregnancies. There was a statistically significant reduction in the rate of
delivery before 32 weeks in the cerclage
group (5% vs. 50%, P = 0.001). In this
study, however, the choice to place or not
place the cerclage was left up to the obstetrician thereby infusing such selection
bias as to render the results suspect. One
could understand this. Since no randomization was done, patients with seemingly
similar ultrasound findings may have
vastly different digital examinations,
which would influence the decision of the
individual practitioner. Hassan et al,15
compared pregnancy outcomes in 70
patients whose cervical length was 15 mm
between 14 and 24 weeks gestation.
Cerclage placement was also at the discretion of the attending physician. The rate of
spontaneous PTB was similar in both
groups with a higher risk of preterm premature rupture of the membranes in the
cerclage group (P<0.05). Althusius et al in
2001,16 Rust et al in 200117, Berghella et al
in 200418 and To et al19 in 2004 performed
randomized controlled trials of cerclage
based on ultrasound criteria with mixed
results. When analyzing subgroups of pa-

601

tients, however, it becomes more clear

who may benefit from an ultrasound indicated procedure. In those patients with
a prior PTB or midtrimester loss with a
cervical length less 25 mm, up to a 40%
reduction in PTB is realized. The results of
a recently completed randomized controlled trial by the National Institute of
Child Health and Human Development
of cerclage versus no intervention for
patients with a sonographic short cervix
and history of preterm delivery are pending. In women without a prior loss or
preterm delivery, no benefit form cerclage
could be identified. In women without
prior loss or PTB with a previously performed conization or multiple cervical
dilatations, no benefit from the procedure
could be identified with the placement of a
cerclage when ultrasound findings suggested a short cervix. Most importantly,
in patients who had multiple gestations
and a sonographic short cervix, placement of a cerclage increased the risk of
PTB with a relative risk of 2.15, suggesting harm from the procedure in this population.9 It is of note, the trial by
Althusius et al, although showed improvement in the cerclage group, included
only 35 women in the randomization, 19
of which underwent cerclage. These small
numbers do not seem to be generalizable
as To et al19 randomized 470 women, with
no benefit identified to ultrasound indicated cerclage. This underscores the importance of meta-analysis when most
studies are too small for adequate power.
Because an ultrasound indicated cerclage appears to be beneficial only in those
who have previously had a poor pregnancy outcome and a sonographically
short cervix, some have assessed whether
other objective data could identify those
who would benefit from the cerclage procedure when ultrasound finds a short
cervix. Romero et al,20 in 2006, suggested that an objective measure of
endocervical inflammation may select out
those destined to have cerclage failure and
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Debbs and Chen

identify those with asymptomatic microbial invasion of the amniotic cavity who
would not benefit from cerclage. Sakai et
al21 found that among women with an
interleukin-8 concentration <360 ng/mL
who underwent cerclage, the rate of preterm delivery was significantly lower than
those with an elevated interleukin-8 level.
Thus an objective measure of inflammatory cytokines in endocervical mucous may
select those who may benefit from this
procedure.
Thus, despite the continued failure of
population studies to elicit a benefit of
prophylactic or rescue cerclage, except in
those with prior PTB or second trimester
loss, the procedure continues to be used
routinely. These interventions underline
the dichotomy between evidence-based
medicine and the personal experience of
many obstetricians. On the basis of the
above literature and a body of evidence to
voluminous to include here, in addition to
the usual selection criteria for cervical cerclage such as obstetric history and cervical
length, patient selection based on other
factors such as markers of inflammation
may improve pregnancy outcomes.

Physical ExaminationIndicated Cerclage: Those

Who Present With Clinically
Apparent Funneling,
Ballooning or Hour Glassing
of Membranes and Dilatation
Over 50% of women with dilatation
greater than 2 cm have microbial invasion
of the amniotic sac underscoring the difficulty in proving success with surgical
intervention. Digital examination has certainly proven to be insensitive compared
with ultrasound diagnosis as many women have been shown to have dilatation
of 1 to 2 cm with most delivering at term.
Although there have been multiple non
randomized evaluations of cerclage based
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on clinically apparent cervical change,

membrane protrusion or complete prolapse of membranes into the vagina,22
these trials were all problematic with selection bias, small numbers, and nonrandomized design. Without randomization,
the cerclage group can become selected
for success when counseling, and thus
patient choice or physician perception of
risk, is predicated on the likelihood of
success and apparent safety of the procedure. This is immediately apparent when
one evaluates 2 patients, both 3 cm dilated, 1 of which has a thick cervix with
membranes at the external os and the
other paper-thin with membranes at the
external os. Many physicians would offer
the cerclage in the patient with a thick
cervix but not the thin one, thereby selecting the cerclage group for success. Thus,
the true efficacy of the procedure can only
be clearly delineated with randomization.
Unfortunately, there has only been one
such small trial without sufficient power
or exclusion criteria to generalize the
results.23 This trial by Althusius et al
randomized women with membranes at
or beyond the external os between 20 to
24 weeks gestation to cerclage, bed rest and
indomethacin versus bed rest alone. This
randomized controlled trial randomized
only 23 patients and included twin gestations making the results hardly conclusive.
Thus, although there are many other
retrospective evaluations, none of the
available data provides a mandate for
previously described urgent or emergent
cerclage and individual patient counseling
and treatment is appropriate.

Recurrent Premature Birth or

Second Trimester Loss Despite
Cerclage: Transabdominal
Cervicoisthmic Cerclage (TAC)
Cervical insufficiency is often diagnosed
on the basis of an obstetric history of
repeated painless mid-trimester losses or

Contemporary Use of Cerclage in Pregnancy

preterm deliveries. Although transvaginal
cerclage (TVC) has been an accepted
management for cervical insufficiency
for decades, as already elucidated, its
efficacy remains in question under many
circumstances. TAC has been used in
women with congenitally short or extensively amputated cervices, markedly
scarred or lacerated cervices, cervicovaginal fistulas, sub acute cervicitis, or failed
TVC. Potential advantages of TAC include placement of the stitch at the level of
the internal os, decreased slippage of the
suture, lack of a foreign body within the
vagina that could act as a source of infection, and the ability to leave the suture in
place for future pregnancies. One known
disadvantage of TAC is the need for at
least 2 laparotomies during pregnancy.
TAC has been associated with less recurrent PTB and improved neonatal survival
compared with controls receiving a repeat
TVC in those who previously failed TVC
in previous pregnancies. Unfortunately,
no randomized controlled trials exist to
compare outcomes of patients with a
prior failed TVC or in those with classic
history of cervical insufficiency. Despite
the lack of randomization and the potential for selection bias, carefully selected
patients enjoy a high likelihood of success
with minimal morbidity in experienced
hands.2 Some have used a lack of the
vaginal portion of the cervix as an indication for TAC. Given the likelihood of a
successful pregnancy with careful vaginal
dissection in those with prior loss or with
ultrasound findings without prior loss,
TAC in this circumstance appears aggressive and unnecessary for most patients.
However, in those who meet the criteria
for a history indicated cerclage and who
also have minimal cervical tissue in the
vagina, either a transvaginal dissection
or abdominal approach seem to afford a
high degree of success with low morbidity.
Given the avoidance of the vaginal flora,
abdominal placement may be preferred,
although comparative studies are cer-

603

tainly lacking. Laparoscopic, and now

robotic TAC has been performed and
reported in case series both as interval
and during pregnancy procedures.24,25
Given the long operative times and limited
tactile maneuvering that is needed for uterine vessel dissection and knot tying, the
robotic interval laparoscopic approach
may have several advantages. The Robot
offers many of the advantages of open
surgery allowing articulating wrist movement to facilitate vessel retraction and to
enable relative ease in intracorporeal knot
tying. Given the small numbers, however,
a minimally invasive approach should not
yet be presumed to offer the same published success rates that open surgery has
accomplished with live birth rates in the
third trimester in up 96% of patients.2

Surgical Technique:
Transvaginal Approach
A history indicated cerclage based on typical history is placed between 11 and 15
weeks gestation. With first trimester
screening techniques, chorionic villus sampling and ultrasound, the concern over
early loss from abnormal conceptus is substantially mitigated. Given the frequent use
of regional anesthetic techniques, there is
little concern over medication exposure.
There are few studies comparing anesthetic
techniques for this procedure. When cerclage is placed after 12 weeks, concern over
teratogenic exposures is unfounded and
both regional and general techniques can
be used with safety with little difference in
uterine activity.
Preoperative evaluation should include
an ultrasound evaluation of viability,
early anatomic abnormalities, first trimester screening if desired, a Papanicolaou
smear and cervical cultures for gonorrhea, chlamydia with evaluation and
treatment of symptomatic and pathologic
vaginitis. Many investigators have used
prophylactic antibiotics and tocolytic
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Debbs and Chen

agents before and after the placement of

cerclage. There are no adequately powered studies for guidance in this area. As
infection is the most common complication after TVC placement, randomized
trials are needed. Similarly, no randomized evaluation of tocolytic agents has
been performed for history indicated cerclage although there is 1 randomized trial
in a group of patients with ultrasound
shortening of the cervix. One trial showed
a decreased incidence of PTB when
randomized to both cerclage and indomethacin compared with those who received neither therapy.16 It is the authors
preference to use a nonsteroidal antinflammatory agent for 24 hours after
placement for patient pain and discomfort associated with extensive vaginal dissection during the procedure. In addition,
it has been previously shown that prostaglandin metabolites are dramatically
elevated after transabdominal or TVC
procedures. Amniocentesis should be considered for those with digital cervical dilatation as the risk of infection can approach
50%. In those who are having a history
indicated procedure or ultrasound indicated procedure, the risk of infection is
sufficiently low as to perform amniocentesis only in those with suspected infection
or suspicious symptoms.17 A short course
of antibiotic therapy can be considered
before cerclage placement as empiric therapy. Suture selection has also not been
subjected to randomized controlled trials
to suggest efficacy of one suture over another. A 5 mm Mersilene tape (Ethicon RS21 or D-8113; Ethicon Inc, Somerville, NJ)
is used by the majority of surgeons.
Alternatively, and according to physician
preference, a large nonabsorbable monofilament sutures (eg, No. 1 Ethilon or
Prolene; Ethicon Inc) can also be used
and may be beneficial in those with more
effaced cervixes to avoid laceration.
In the dorsal lithotomy position, the
bladder is emptied and a weighted vaginal
speculum or Sims retractor is placed in the
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vagina. A Sims, right angle or Dever

retractor is used to retract the vaginal
mucosa cephalad and the anterior lip of
the cervix can be grasped with ring forceps, a curved allis tenaculum or tissue
forceps. It is the authors preference to
soak the mersilene in betadine solution
before placement. In the McDonald technique, a purse string or clover leaf configuration is used (Figs. 2, 3). The posterior
portion of the cervix is where most slippage occurs and thus close attention
should be made to adequate posterior
retraction by replacing the forceps on
the posterior lip of the cervix and displacing cephalad. At the same time, care
should be taken to retract the posterior
vaginal mucosa and fornix deeply so that
the suture does not encompass significant
amounts of mucosa and does not involve
the rectovaginal septum. Entry into the
endocervical canal is avoided. Each bite
should be placed at the exit point of the
bite prior so as to attempt submucosal

FIGURE 2. The McDonald Technique.

Adapted with permission from Clin Obstet
Gynecol. 2007;50:468477.

Contemporary Use of Cerclage in Pregnancy

FIGURE 3. The McDonald Technique.

Adapted with permission from Clin Obstet
Gynecol. 2007;50:468477.

placement. In 1955, Shirodkar described

a cerclage using an aneurism needle. The
anterior and posterior incisions are made
at the level of the cervicovaginal junction
and the vesicovaginal and rectovaginal
fascia is reflected as high as possible using
a combination of blunt and sharp dissection. The suture is then tunneled in the sub
mucosa and tied anteriorly. The cut ends
can be left uncovered, but the mucosa is
then closed with an absorbable suture.
Many modifications have been developed
with many using a modified Shirodkar for
shortened or partially amputated cervices
in those with prior losses thought to be
from insufficiency. This technique is akin
to a McDonald with mucosal incisions to
attempt placement as high as possible.
Although many proclaim the superiority
of one over the other, Odibo et al26
evaluated the efficacy of Shirodkar
cerclage compared with that of the
McDonald procedure for the prevention of PTB in women with a short cervix.
This secondary analysis of published
randomized trials revealed 127 women
who received a Shirodkar and 150
women who received a McDonald suture.
After adjusting for confounders using

605

logistic regression modeling, no significant difference in PTB <33 weeks was

found between the 2 groups (Odds ratio,
0.55; 95% CI, 0.2 to 1.3). The choice of
procedure is a matter of individual preference.
In patients deemed candidates for digitally indicated or urgent/emergent cerclage, extreme caution must be exercised as
up to 50% of these patients have already
colonized the amniotic cavity and substantial morbidity may be encountered.27
Careful assessment for infection including
maternal temperature, WBC with differential should be performed. A detailed
ultrasound should be performed to assess
fetal anatomy. Acute prolapsed of membranes may be encountered in a variety of
fetal abnormalities, especially those with
onset of polyhydramnios of structural
origin. Amniocentesis for gram stain,
culture and glucose should be performed. Once fetal abnormalities, abruption
placenta, progressive labor with uterine
activity and infection have been excluded,
appropriate candidates should be placed
in trendelenberg and provided appropriate broad spectrum antibiotics. Nonsteroidal anti-inflammatory medication
can be used and continued for 24 to 48
hours perioperatively.28
Several techniques have been described
to reduce prolapsed membranes, always
keeping in mind intra-operative rupture
occurs in up to 50% of cases. Amnio
reduction can be used to reduce the volume of amniotic fluid to a degree as to
eliminate tense membranes. Hyperinflation of the bladder usually allows regression of the membranes cephalad although
the vaginal bulge of the bladder makes
placement more challenging. It is the
authors preference to use either a moist
sponge on a stick covered with a condom
or surgical glove, or most often a 16
french foley balloon. The tip of the foley
is cut so that it is inside the balloon
when inflated. Ultrasound can be used
to ascertain the level of the membranes.
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Debbs and Chen

The balloon is inflated to displace the

membranes inside the internal os. The
suture of choice is then placed and tied
down as the balloon is deflated and removed. Continuation of antibiotics for 48
hours to 1 week is common and hospitalization for 24 to 72 hours to observe for
signs of labor, infection, and abruption
are not unwarranted. To temper the success rates encountered by some, Olatunbosum et al27 compared the outcome of 22
women treated with cerclage in this fashion compared to 15 at bed rest alone. All
patients were at least 4 cm with no difference in perinatal mortality.

Surgical Technique: The TAC

When repeated pregnancy loss or premature birth occurs with clinically suspected cervical insufficiency in the face of
previously failed cerclage, absence of
the vaginal cervix or substantial vaginal
pathogens, a transabdominal approach
can be used with minimal risk in experienced hands.6 The procedure can be
performed safely either as an interval
procedure or during the pregnancy. The
authors preference is to place the suture
between 11 and 14 weeks when first trimester genetic screening or diagnosis is
completed and there is sufficient laxity to
the parametrium for uterine vessel displacement. Alternatively, in morbidly obese
women, those with myomas that may
preclude uterine exteriorization, in those
who may undergo laparscopic or robotic
assisted procedures and in those with
previous abdominal surgery, adhesions
or tracheolectomy, an interval procedure
seems to have similar outcomes. Cefazolin
(1 g) can be given intravenously before
an abdominal incision. A Foley catheter
is placed. A Pfannenstiel or vertical incision can be used depending on gestational
age. The bowel is packed out of harms
way and the vesicouterine peritoneum is
incised and developed to allow exposure
to the isthmic region. Careful attention
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should be made not to injure the large

perivesicular vessels. The uterus is exteriorized whenever possible. Adhesiolysis is
performed when necessary. The surgeon
grasps the uterine vessels at the cervicoisthmic junction with his hand and
fingers, and a window is made with a
right-angle clamp at the level of the junction of the ascending and descending
branches of the uterine artery. The clamp
can enter from anterior to posterior if tied
anteriorly and opposite if tied posteriorly.
Alternatively, the mersilene band may be
kept on its needle and placed in a similar
fashion. Some have advocated posterior
knot tying to avoid bladder irritation and
to allow colpotomy for removal if needed.
Given the availability of laparoscopy, this
is unnecessary. The author prefers to tie
the knot anteriorly as complete control of
bleeding is accomplished simply by pulling up on the sutures. The window is made
1 cm medial and 1 cm superior to the
uterosacral ligaments on both sides. An
assistant then passes a 5 mm Mersilene
suture on a long Kelly clamp to the open
right-angle clamp. The suture is brought
from posterior to anterior or vice versa
and a sponge is then placed both posteriorly and anteriorly to tamponade the
puncture sites, after which the contralateral side is addressed. The same procedure is performed on the opposite side.
The suture is then pulled taut and tied.
The puncture sites are inspected and can
be sutured with a figure 8 of 2-0 vicryl for
hemostasis. After hemostasis is confirmed, the uterus was placed back into
the abdominal/pelvic cavity. The sites are
inspected for bleeding and the abdomen
closed in the usual fashion.

Should a Cerclage That Has

Slipped Be Replaced?
In women with either history indicated
cerclage in place who are found to have
suture slippage or significant shortening
do not appear to benefit from placement

Contemporary Use of Cerclage in Pregnancy

of a second suture. Although there are no
randomized trials for this procedure, a
case controlled study found a higher incidence of preterm delivery in those in
which a second suture was attempted.29

Should a Cerclage Be Removed

in the Face of Ruptured
Membranes?
Certainly, the major concern with ruptured membranes and a cerclage in place
is that of infection. As up to 38% of
patients with a cerclage may experience preterm premature rupture of membranes (pPROM), this is a common event.
Ludmir et al30 suggested substantial morbidity with a retained cerclage under
these circumstances with reduced neonatal survival and increased neonatal sepsis
although also suggested prolonged latency. This study, however, was published
before the use of routine antibiotics to
prolong latency, which emerged in 1997.
McElrath et al31 compared patients with
ruptured membranes at 24 to 33.9 weeks
gestation retrospectively in those without
and with cerclage. This analysis suggested
no difference in any parameter analyzed.
This data, however, did not specifically
answer the question as to whether or not
to remove a cerclage but merely compared
populations of patients with and without
cerclage at the time of pPROM. Whether
or not the cerclage was removed was at the
discretion of the provider and was not the
basis for the study. The overall similarity
in pregnancy outcomes in both groups
suggests that there is no meaningful difference in clinical course and outcome
between pregnancies complicated by
pPROM with and without cerclage although based on this study, it appears
that the pathophysiology in those with
pPROM with and without cerclage is
similar. Jenkins et al32 retrospectively
evaluated women with preterm premature
rupture of the membranes at less than 34

607

weeks who presented with a cerclage in

place. This analysis identified 25 women
in the delayed removal group and 37 in the
immediate removal group. Both groups
received antibiotics and betamethasone
although more in the delayed group received short-term tocolytics. This study
showed fewer deliveries in the delayed
removal group within 48 hours and no
difference in infection rates. However,
there was no difference in the rate
of neonatal morbidities, mortality, birth
weights or duration of stay in the intensive
care nursery suggesting no meaningful
differences in outcome. The retrospective
nature of both the above studies introduces the possibility of significant bias.
Thus it appears an individualized approach is warranted until a properly designed randomized trial is performed. On
the basis of Level IIb and III data, the
cerclage should be removed at 32 weeks or
after, as there is no meaningful benefit to
prolongation or steroid administration in
the face of ruptured membranes. In the
face of active labor, bleeding or evidence
of infection, prompt removal is warranted. At gestational ages less than 22
weeks, individualized care is warranted
although because of the high degree of
morbidity, with and without the cerclage,
maternal safety takes precedent and strong
consideration of cerclage removal is warranted. At a gestational age of 22 to 31.9
weeks gestation, it is reasonable to maintain
the cerclage until steroids are completed
although care should be individualized.
Level II-b and III data.

Does a Cerclage Need to Be

Carried Out in Subsequent
Pregnancy After Previously
Successful Pregnancy
It is common in both general obstetrical
and maternal fetal medicine practices to
encounter patients who underwent a prior
cerclage for indications not adhering to
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608

Debbs and Chen

evidence-based data. It is understandable

that such patients would be reluctant
to not undergo a repeat procedure or
even may be considering an abdominal
procedure when in fact the original failed
cerclage was placed for questionable indications. However, many of these same
patients may have had complications
from the procedure that were thought to
be a symptom of cervical insufficiency
and may have infection or premature
labor incited by the cerclage itself. Some
of these patients may have also suffered
from pPROM with the cerclage suggesting to them and their caregivers true
cervical insufficiency when in fact, many
may have delivered prematurely because
of the cerclage. In a series of patients
presenting for consideration of abdominal cerclage after a failed vaginal cerclage, a subgroup analysis was performed
in those who were counseled concerning
the likely unnecessary nature of the previously placed failed cerclage. Out of 39
women with prior cerclage who were
counseled concerning nonevidence-based
placement of a previous cerclage, 24
agreed to expectant management. Only 7
patients (29%) went on to have an ultrasound indicated procedure with all attaining a gestational age of at least 32 weeks.
Out of the other 24 patients, all went to
term without intervention.2 The same
experience has been elucidated in at least
another publication.33 Thus caregivers
should not be fearful of providing a detailed discussion with the patient concerning the performance of unnecessary
surgery which may cause harm or even
contribute to prematurity in some patients. As previously described, a policy
of ultrasound monitoring reveals similar
outcomes in those with history or ultrasound indicated procedures.11

Summary and Conclusions

Our understanding of the pathophysiology of cervical change and subsequent
www.clinicalobgyn.com

preterm delivery or second trimester loss

has rendered the treatment with cerclage
for all those with a prior loss obsolete
and naive. There remains a population
of patients who appear to substantially
benefit from surgical modification of the
cervix and when carefully chosen, a gratifyingly high degree of success is encountered. However, when unclear, one must
always remember the harm that may be
done should an unnecessary procedure
lead to premature birth because of the
procedure. It is easy when dealing with
prior pregnancy loss to act out of fear
because of our desire to do something.
Ones expertise in most evident, however,
when appropriately chosen candidates
have a successful pregnancy with surgical
intervention. With this in mind, the following recommendations are made.
1. A history indicated cerclage benefits those
with at least 3 prior preterm deliveries or
second trimester losses or after 2 second
trimester losses without other obvious
etiologyLevel B, II-1, and II-2.
2. Acceptable exceptions to this rule are those
who do not have the ability to be followed
with ultrasound and have a classic history of
recurrent painless dilatation and delivery in
addition to those with an obvious anatomic
defect such as a deeply lacerated cervix.
3. Ultrasound monitoring starting at 16
weeks gestation is appropriate for those
with prior PTB or second trimester loss
with an Ultrasound indicated cerclage
placed when the cervical length is less than
25 mm Level A and I.
4. Women with a conization or leep, mullerian anomaly, multiple dilatations and
evacuations of the uterus and short cervix
without a prior loss or preterm delivery do
not benefit from cerclage Level B II-1
and II-2.
5. A TAC should be considered in women
with a prior history indicated cerclage
and preterm delivery less than 32 weeks
or second trimester loss Level B, II-2
II-3, and III.
6. Women with multifetal gestations do not
benefit from elective cerclage Level A
and I.

Contemporary Use of Cerclage in Pregnancy

7. Women with multifetal gestations and
either digital or ultrasound findings of a
shortened or dilated cervix do not benefit
from cerclage and the procedure seems to
be harmful in this population and thus
should be offered only under the auspices
of a well designed randomized trial
Level B II-2.
8. Women with prolapsing membranes or
digitally dilated cervices should undergo
evaluation for intramniotic infection
before consideration of cerclage placement Level B II-2. Inconsistent data is
available concerning this population and
individualized care is warranted until
larger randomized trials are available
Level B II-1 and Level C III.
9. The evaluation of a patient with premature cervical dilation, ultrasound identified funneling or shortening should
undergo extensive evaluation for signs of
labor, infection, abruption, fetal abnormalities, and intrauterine/myometrial
causes for cervical change Level C.
10. Interval pregnancy evaluation of those
with a prior second trimester loss or
PTB should include an assessment of the
uterine cavity, review of prior placental
pathology for genetic, thrombophilic or
infectious causes, autopsy data if available and comprehensive physical examination to identify obvious defects from
obstetrical trauma Level B II-2.

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