Cerclage Placement
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#History *** Ultrasound *** Exam *** Indicated Cervical Cerclage ***History-indicated: ≥*** prior 2nd-tri losses/sPTB, planned ~12–14 wks ***US-indicated: prior sPTB and TVU CL <25 mm before 24 wks ***Exam-indicated: painless dilation on exam before 24 wks, no signs of labor/infection Preoperative workup: FHR *** bpm confirmed by BSUS Infectious work up: Wet prep, UA, GC/CT collected Patient consented for transvaginal cerclage placement. We discussed the risks including, but not limited to, premature rupture of membranes, fetal demise/miscarriage, intra-amniotic infection, suture migration, cervical trauma, bleeding, infection. (Date***) Confirmed patient does not have any of the following contraindications: Fetal demise or lethal anomaly, chorioamnionitis, active vaginal bleeding, preterm labor, PPROM Anticipate cerclage removal at 36–37 weeks or at onset of labor
Yellow *** markers = placeholders you fill in or delete per case.
Deep dive — rationale & evidence
Reference only — this section is not copied when you hit Copy. It explains the evidence behind the plan.
Cervical cerclage — indications & timing
| Type | Indication | Timing |
|---|---|---|
| History-indicated | ≥1 prior 2nd-trimester loss from painless cervical dilation, or prior cerclage for the same | 12–15 weeks GA |
| Ultrasound-indicated | Singleton + prior sPTB + TVU CL <25 mm before 24 wks | 16–23 6/7 weeks |
| Examination-indicated (rescue) | Painless cervical dilation on exam at 16–23 6/7 wks | At diagnosis |
History-indicated cerclage
- •Data were supportive but not statistically significant when pooled in a Cochrane meta-analysis; NNT is higher (~23).
Ultrasound-indicated cerclage
- •Singleton pregnancy with a prior sPTB receives serial TVU CL measurements q1–4 weeks from ~16 wks until cerclage is placed or 24 wks.
- •Prior sPTB + short cervix (CL <25 mm): cerclage reduces PTB <35 wks (28% vs 41%; NNT ~8).
- •Without prior PTB: cerclage benefit is uncertain unless CL <10 mm.
Examination-indicated (rescue) cerclage
- •Prolongs pregnancy by a mean of 34 days and improves neonatal survival (71% vs 43%; NNT ~4).
Vaginal progesterone is an acceptable alternative to cerclage for prior PTB + short cervix (similar efficacy).
Complications
- •Fetal demise / miscarriage
- •Intra-amniotic infection / chorioamnionitis (2.5-fold increased risk)
- •Cervical trauma / laceration (8.9–25%)
| Complication | History-indicated | Ultrasound-indicated | Exam-indicated |
|---|---|---|---|
| Perioperative PPROM | 0.0% | 0.3% | 2.5% |
| Hemorrhage | 0.9% | 1.4% | 2.3% |
| Overall PPROM during pregnancy | ~9.1% | ~7.3% | ~11.9% |
The "in-between": short cervix WITHOUT prior sPTB
- •CL 21–25 mm → vaginal progesterone can be considered
- •CL ≤20 mm → vaginal progesterone (200 mg capsule or 90 mg gel daily) reduced PTB <34 wks from 24.6% to 14.5% (~NNT 14)
- •CL <10 mm → cerclage may be considered even without prior PTB or dilation
- •CL 10–25 mm without dilation → cerclage is not recommended
Sources
- •ACOG Practice Bulletin No. 142 (2014) — Cerclage for the Management of Cervical Insufficiency: indications by type, contraindications, removal timing
- •ACOG Practice Bulletin No. 234 (2021) — Prediction and Prevention of Spontaneous Preterm Birth: US-indicated cerclage criteria, serial CL monitoring, vaginal progesterone as alternative
- •Cochrane Review — Alfirevic et al. (2017) — Cerclage for preventing PTB in singleton pregnancy: RR 0.70 for PTB <35 wks with prior sPTB + short CL
- •Cochrane Review — Eleje et al. (2020) — Cerclage in combination with other treatments for preventing sPTB
- •Giouleka et al. (Obstet Gynecol Surv 2023) — Comprehensive review of major cerclage guidelines (ACOG, RCOG, SOGC, FIGO); post-cerclage management consensus
- •SMFM Consult Series #65 — Temming et al. (Am J Obstet Gynecol 2023) — Transabdominal cerclage indications