ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Transvaginal cervical cerclage

Transvaginal cervical cerclage
Literature review current through: Jan 2024.
This topic last updated: Sep 15, 2023.

INTRODUCTION — Cerclage refers to a variety of surgical procedures in which synthetic suture or tape is used to mechanically increase the tensile strength of the cervix of patients with cervical insufficiency and thereby reduce the occurrence of adverse perinatal events such as:

Pregnancy loss

Prolapse of the fetal membranes into the vagina

Preterm prelabor rupture of the fetal membranes (PPROM)

Intraamniotic infection

Preterm labor and birth

However, the efficacy of cerclage for preventing these adverse events compared with no intervention or other interventions is controversial, given the absence of data from large randomized trials.

Most cerclages are placed via a transvaginal approach, and result in a position slightly distal to the internal os. Placement at the cervicoisthmic portion of the uterus is possible with a transabdominal approach, but it is a more invasive procedure generally reserved for patients unable to undergo a transvaginal procedure or who failed to give birth to a healthy newborn after at least one previous prophylactic transvaginal cerclage.

This topic will discuss the procedure for transvaginal cervical cerclage. General issues related to cervical insufficiency and procedures for transabdominal cervicoisthmic cerclage are reviewed separately. (See "Cervical insufficiency" and "Transabdominal and laparoscopic cervicoisthmic cerclage".)

GOAL — Cerclage is performed to reduce pregnancy loss/preterm birth in patients with cervical insufficiency, which may be based on their past obstetric history, premature cervical shortening on transvaginal ultrasound examination, or a prematurely dilated and/or effaced cervix on a digital or speculum examination. (See "Cervical insufficiency" and "Short cervix before 24 weeks: Screening and management in singleton pregnancies", section on 'Clinical approach'.)

CONTRAINDICATIONS — The major absolute contraindications to cerclage are clinical scenarios where the procedure is unlikely to reduce the risk of preterm birth or improve fetal outcome:

Fetal anomaly incompatible with life

Intrauterine infection

Active preterm labor

Preterm prelabor rupture of membranes (PPROM)

Fetal demise

Active uterine bleeding (eg, placental abruption); however, placenta previa is not an absolute contraindication to cerclage placement (see "Placenta previa: Management", section on 'Cerclage')

Relative contraindications — The chance of an adverse outcome is increased in patients with widely dilated cervixes and/or prolapsed membranes; therefore, shared decision-making is particularly important in these cases. There is no dilation at which cerclage should not be attempted; however, the prognosis worsens when cervical dilation exceeds 4 cm [1]. Fetal membranes prolapsing through the external cervical os is a relative contraindication to the procedure because up to 65 percent of patients will experience iatrogenic rupture of the membranes in this setting [2-5]. Exposure of the membranes to the vaginal flora also likely increases the risk of infection. Nevertheless, cerclage has been placed with successful newborn outcome in patients with widely dilated cervixes, 0 mm ultrasound-measured cervical length, and/or prolapsed membranes [6]. (See 'Replace prolapsed membranes, if present' below.)

UPPER AND LOWER GESTATIONAL AGE THRESHOLDS FOR CERCLAGE PLACEMENT

Pregnancies between 12 and 24 weeks – Most cerclages are placed between 12 and 24 weeks of gestation. There is no consensus about the precise lower and upper gestational age limits for performing the procedure.

It should be appreciated that there is a risk that an emergency procedure performed because of advanced cervical change and/or prolapsed membranes at the upper end of this gestational age range may prevent the birth of a neonate with no possibility of survival but result in the birth of a very preterm, very low birth weight neonate who survives with serious long-term neurodevelopmental disability. Thus, outcomes at the limit of viability and potential options need to be discussed with the patient before the procedure; neonatology service involvement can be helpful. (See "Periviable birth (limit of viability)".)

Pregnancies less than 12 weeks – The procedure generally is not performed before 12 weeks of gestation because results of aneuploidy screening may not be available. If aneuploidy screening is not performed, waiting until the end of the first trimester allows most miscarriages related to aneuploidy to occur. Even if it is known that the fetus is euploid, waiting until the end of the first trimester permits sonographic evaluation for major fetal anomalies that may affect decision-making regarding continuation of pregnancy [7].

Pregnancies at 24 to 28 weeks – Cerclage placement at 24 to 28 weeks of gestation, a period characterized by high neonatal morbidity and mortality if delivery occurs, is controversial. We avoid placing a cerclage after extrauterine survival is likely (generally regarded as approximately 24 weeks of gestation) since the procedure may cause accidental rupture of the fetal membranes or preterm labor leading to an extremely preterm birth, with its attendant high risk of neonatal morbidity and mortality. If others consider cerclage after 24 weeks in selected patients, the risks and benefits in the individual patient should be thoroughly discussed and documented before placement.

In a meta-analysis of individual patient-level data from four randomized trials of cerclage versus no cerclage in 131 singleton pregnancies at 24+0 to 26+6 weeks of gestation, cerclage placement did not significantly reduce preterm birth <37, <34, <32, or <28 weeks' gestation or improve any neonatal outcome (eg, gestational age at birth, preterm prelabor rupture of membranes [PPROM], low and very low birth weight, perinatal death) [8]. Planned subgroup analyses revealed no statistically significant differences in the rate of preterm birth <37 weeks' gestation between the two groups based on cervical length measurement (≤15 mm or ≤10 mm), gestational age at randomization (24+0 to 24+6 weeks or 25+0 to 26+6 weeks), or history of preterm birth. However, the wide confidence intervals around the relative risks for each outcome suggest that modest benefits or harms cannot be excluded definitively.

The American College of Obstetricians and Gynecologists' guidance on cerclage states that its safety and efficacy after fetal viability have not been adequately assessed and its use should be limited to pregnancies in the second trimester before fetal viability has been achieved [9].

Pregnancies greater than 28 weeks – A cerclage is not placed after 28 weeks because no data on efficacy at this gestational age are available and the procedure may increase rather than decrease the risk of preterm birth.

PROCEDURE — The cerclage procedure is largely based on data from case series, observational studies, and expert opinion; there are a few small but no large randomized trials evaluating any aspect of the procedure.

Preoperative assessment

Fetal assessment — Before scheduling the cerclage, the clinician should:

Confirm fetal number, cardiac activity, and gestational age

Obtain a fetal anatomic survey to identify structural anomalies that could affect the patient's decision to continue the pregnancy

Offer aneuploidy screening, if not already performed

Evaluation for infection

Cervicovaginal infection – We do not routinely screen for cervicovaginal infections. Preprocedure screening for sexually transmitted infection has not been proven to improve cerclage outcome, and available data are limited. If the patient is symptomatic or at high risk of acquiring a sexually transmitted infection and has no documentation of recent negative test results, the author tests for gonorrhea and chlamydia. If antibiotic therapy is indicated for positive test results, treatment is completed prior to cerclage placement, if possible. Evaluation and treatment of sexually transmitted infection according to standard guidelines is good obstetric practice. (See "Screening for sexually transmitted infections", section on 'Chlamydia and gonorrhea' and "Prenatal care: Initial assessment", section on 'Laboratory tests'.)

Subclinical intraamniotic infection – Intraamniotic infection is a contraindication to the procedure since the cerclage is not likely to be effective [10-12] and prolonging the pregnancy places the patient and fetus at risk of sepsis [11,13]. However, the prevalence of infection is not consistent across patient populations, definitive diagnosis of intraamniotic infection requires amniocentesis, and randomized trials to determine the utility of amniocentesis before cerclage have not been performed; therefore, amniocentesis for diagnosis of subclinical infection is performed selectively, not routinely.

History-indicated cerclage – Amniocentesis is not performed before history-indicated cerclage given the very low prevalence of subclinical intraamniotic infection in early pregnancy and the risks for procedure-related pregnancy loss and fetal harm after early amniocentesis [14].

Ultrasound-indicated cerclage – Most clinicians do not perform amniocentesis before ultrasound-indicated cerclage because the prevalence of subclinical infection is relatively low (1 to 2 percent) in asymptomatic patients with a closed cervix and the clinical significance of Ureaplasma and Mycoplasma species, which are the most common organisms detected, is unclear [14,15].

Physical examination-indicated cerclage – The best approach before physical examination-indicated cerclage (also called rescue or emergency cerclage) is more controversial. The author of this topic performs amniocentesis when he suspects intraamniotic infection even though the patient is afebrile. If the Gram stain and biomarkers of intraamniotic infection (eg, glucose, leukocyte count, lactate dehydrogenase, interleukin-6) are not indicative of infection, then he proceeds with cerclage. He is generally unwilling to wait 48 hours to obtain microbiologic culture results on amniotic fluid before performing a physical examination-indicated procedure.

The incidence of intraamniotic infection ranges from 10 to 50 percent when the cervix is dilated ≥2 cm on physical examination and/or membranes are prolapsed into the vagina [14]. The incidence is increased, but lower (<5 to 10 percent), in patients with ultrasound findings suggestive of inflammation (membrane edema, separation of membranes from the decidua (image 1), or debris [sludge] in the amniotic fluid) or membranes visible and exposed at the external os, but cervical dilation <2 cm and no prolapse into the vagina.

Cerclage is not performed when there is laboratory evidence of intraamniotic infection. Although treatment of intraamniotic infection without delivery has been reported, it is investigational. Diagnosis and treatment of intraamniotic infection are reviewed in more detail separately. (See "Clinical chorioamnionitis".)

Urinary tract infection – There is no consensus regarding preprocedure screening for asymptomatic bacteriuria and lack of data showing that preprocedure screening improves pregnancy outcome. Although one study reported urine and vaginal-cervical cultures obtained on admission were not predictive of good versus poor pregnancy outcome, there were too few patients to detect meaningful differences [16].

Observation period before unplanned procedures — The author of this topic observes candidates for ultrasound- or physical examination-indicated cerclage for up to 24 hours before proceeding with surgery to help exclude preterm prelabor rupture of membranes (PPROM), preterm labor, occult abruption, and intraamniotic infection. Cerclage is unlikely to be effective in these settings and may increase maternal morbidity.

PPROM is excluded using standard methods. (See "Preterm prelabor rupture of membranes: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation and diagnosis'.)

When the cervix is widely dilated, a small to moderate amount of fluid that contains both a mucous and a watery component may collect in the posterior vaginal fornix and likely represents transudation across intact membranes. It is important to distinguish this fluid from amniotic fluid using standard methods. (See "Preterm prelabor rupture of membranes: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation and diagnosis'.)

Mild, irregular contractions noted on a uterine contraction monitor can be a normal finding and usually resolve over time, but regular contractions, especially those of increasing frequency and intensity, may indicate idiopathic preterm labor, subclinical intrauterine infection, or occult abruption. Placement of a cerclage in the setting of contractions can lead to tearing of the cervical tissue, which may compromise future pregnancies.

Prophylactic pharmacotherapy

Prophylactic antibiotics and tocolytics — Prophylactic antibiotics have been considered to reduce the risk for intraamniotic infection. Use of prophylactic indomethacin, a prostaglandin synthetase inhibitor, has also been considered because cerclage placement has been associated with transient elevation in prostaglandin levels and prostaglandins induce uterine contractions [17]. Use of these medications is common before physical-examination indicated cerclage, less common before ultrasound-indicated procedures, and unusual before a history-indicated procedure. The American College of Obstetricians and Gynecologists and others have not made a strong recommendation for or against use of prophylactic antibiotics or tocolytics to improve the efficacy of cerclage, regardless of timing or indication, because of very limited available evidence [9,18-21].

Our approach is as follows:

History-indicated cerclage – Antibiotic prophylaxis is not administered as there appears to be minimal risk that a history-indicated procedure will promote intraamniotic infection [22,23]. Similarly, tocolytics are not administered as these patients do not have clinically measurable uterine irritability and virtually no data are available on the use of tocolytics in the first trimester.

Ultrasound-indicated cerclage – The author does not administer antibiotic or indomethacin preprocedure prophylaxis, but will administer postprocedure indomethacin for 48 hours to patients who have contractions/uterine irritability after cerclage placement.

A retrospective cohort study in patients undergoing ultrasound-indicated cerclage reported similar preterm birth rates whether or not prophylactic indomethacin was administered (spontaneous preterm birth <35 weeks: 20 out of 51 [39 percent] with indomethacin versus 17 out of 50 [34 percent] without indomethacin; risk ratio [RR] 1.15, 95% CI 0.69-1.93) [24]. However, given limited data regarding antibiotic and/or indomethacin prophylaxis, practice patterns vary and may include use of one or both of these medications.

Physical examination-indicated cerclage – Antibiotic prophylaxis and indomethacin are routinely administered perioperatively to prolong latency. Preoperative indomethacin may also provide uterine relaxation and reduce membrane prolapse, thus facilitating cerclage placement [25]. In a randomized trial of 53 patients undergoing physical examination-indicated cerclage, use of both prophylactic antibiotics and indomethacin resulted in nonstatistically significant reductions in preterm birth <24, <28, and <36 weeks compared with no treatment, and significantly increased the proportion of patients with latency greater than 28 days (92 versus 63 percent) [26].

We use the following regimen because it is the only one that has been evaluated in a randomized trial [26]:

Cefazolin 1 g (2 g for patients ≥100 kg) intravenously preoperatively and at 8 and 16 hours postoperatively

Indomethacin 50 mg orally preoperatively and at 8 and 16 hours postoperatively

However, other regimens may be as or more effective (eg, cefazolin 2 g [3 g for patients ≥100 kg] or use of another broad-spectrum antibiotic, indomethacin 50 or 100 mg loading dose followed by 25 or 50 mg every six hours for 48 hours).

Potentially toxic fetal effects (eg, oligohydramnios, premature closure of the ductus arteriosus) from in utero exposure to indomethacin typically occur with exposures >48 hours and with increasing gestational age after 20 weeks, with the greatest risk after 30 weeks. These risks are discussed separately. (See "Inhibition of acute preterm labor", section on 'Fetal side effects'.)

Other pharmacotherapy

Group B Streptococcus – In patients colonized with group B Streptococcus, antibiotic prophylaxis for obstetric procedures such as cerclage is not recommended, although this has not been studied directly. (See "Prevention of early-onset group B streptococcal disease in neonates", section on 'Patients undergoing obstetric procedures'.)

Progesterone – The author does not begin daily vaginal progesterone supplementation pre- or postoperatively, but continues it postoperatively in patients who are already taking the drug. These data are reviewed separately. (See "Cervical insufficiency", section on 'Cerclage placement and use of progesterone supplementation'.)

Anesthesia — Neuraxial anesthesia is preferred over general anesthesia for its overall safety, but either method is acceptable. (See "Anesthesia for nondelivery obstetric procedures", section on 'Choice of anesthetic technique'.)

If additional uterine relaxation is needed during the procedure, such as when the membranes are prolapsed, it can be achieved with intravenous nitroglycerin.

Preparation

Ensure that the bladder is empty before beginning the procedure to enhance exposure; however, placement of a catheter for urinary drainage during the procedure is unnecessary.

Prepare the vagina and cervix with an antiseptic or saline solution, avoiding contact with the fetal membranes if exposed.

The availability of an assistant to help expose the operative field is useful and generally essential for physical examination-indicated procedures.

Replace prolapsed membranes, if present — Prolapsed fetal membranes substantially increase the risk for iatrogenic PPROM, which occurs in up to 65 percent of cases [2-5]. If cerclage placement is attempted in this setting, the prolapsed membranes must be replaced in the uterine cavity before applying the cerclage. The optimum technique has not been established by randomized trials. Our approach follows:

Place the patient in steep Trendelenburg position to allow gravity to retract the membranes.

If unsuccessful, less invasive options include:

Administer a uterine relaxant (eg, nitroglycerin).

Backfill the bladder in 250 mL increments through a bladder catheter [27], although a full bladder tends to reduce exposure of the operative field and pull the cervix deeper into the pelvis.

Place ring forceps or stay sutures of 00 silk around the circumference of the external os and then gently pull and shake the cervix to help ease the membranes back into the uterus (figure 1).

Push the membranes back with a smooth surfaced device, such as a gloved finger, sponge-filled condom, or bladder catheter balloon (a specialized balloon device may be available for this purpose [28]). A 30 mL bladder catheter can be used to hold the membranes in the uterus while the cerclage is placed; it is deflated and removed just before the knot is secured. However, such techniques may be associated with an increased risk of membrane rupture.

If these less invasive options are unsuccessful, transabdominal amniocentesis with amnioreduction under ultrasound guidance reduces amniotic fluid volume and pressure in the prolapsed sac, allowing it to retract back into the uterine cavity [29,30]. Approximately 150 to 250 mL is typically removed.

Technical goals — The primary technical goal of cerclage placement is to reinforce the cervix at the level of the internal os; lengthening the cervix is a secondary benefit [31-35]. In one study, after cerclage placement, longer upper cervical length (the length of closed cervix between the cerclage and internal os), but not total cervical length, correlated with birth after 28 and after 32 weeks of gestation [36]. Although another study reported that cervical height (ie, the length of cervix between the cerclage and external os) was not an important factor in determining subsequent pregnancy outcome [37], an expert review concluded that achieving a cerclage height >20 mm reduced preterm birth compared with shorter cervical height [38].

Choosing a McDonald versus Shirodkar procedure — The two most common transvaginal techniques for cerclage were described by Shirodkar [39] and McDonald [40]; modifications of both procedures have also been described. The Shirodkar cerclage is placed as close as possible to the level of the internal os after surgically reflecting the bladder anteriorly and the rectum posteriorly, whereas the McDonald cerclage is a purse-string suture that does not involve any dissection (thus, theoretically, it cannot be placed as close to the internal cervical os as the Shirodkar). In contrast to the McDonald cerclage, the Shirodkar suture does not pass through the cervical stroma.

The author's preference is to perform the Shirodkar procedure because it can be placed closer to the internal os, does not pass through the cervical stroma, and he finds it technically easier to place in patients with advanced cervical effacement. Others prefer the McDonald procedure because they find it easier to perform and remove.

A meta-analysis of mostly retrospective studies found that the Shirodkar technique was associated with a small reduction in preterm birth before 37 weeks compared with the McDonald technique (RR 0.91, 95% CI 0.85-0.98), but this finding was not statistically significant when sensitivity analysis removed studies with a serious risk of bias [41]. The only randomized trial comparing the McDonald and Shirodkar cerclages included 34 participants in each group and found no significant differences in preterm birth (RR 0.85, 95% CI 0.64-1.14) or perinatal outcome between groups, or compared with outcomes in a group of 34 participants who were managed with bedrest alone (no cerclage) [42]. One study observed McDonald and Shirodkar procedures had similar obstetric outcomes in patients undergoing their first cerclage, but higher birth weight when Shirodkar rather than McDonald cerclage was performed for the second procedure (3020 and 2470 grams, respectively) [10].

Technique — Techniques for the Shirodkar and the McDonald cerclage are described below. (See 'Shirodkar cerclage' below and 'McDonald cerclage' below.)

Needle type – The optimum type of needle has not been evaluated in randomized trials. The choice should be based on general surgical principles and the operator's experience and preference.

Choice of suture – In a multicenter randomized trial comparing monofilament versus braided sutures for performing history- or ultrasound- indicated transvaginal cerclage, the frequency of pregnancy loss was similar in both groups (80 in 1003 [8.0 percent] versus 75 in 999 [7.6 percent]; adjusted RR 1.05, 95% CI 0.79-1.40) [43]. The type of cerclage was at the discretion of the surgeon; 17 percent of patients in each group underwent bladder dissection, suggesting a Shirodkar procedure was performed. Pregnancy loss was defined as miscarriage and perinatal mortality, including any stillbirth or neonatal death in the first week of life.

Use of a monofilament suture resulted in lower rates of clinical chorioamnionitis (2.7 versus 6 percent; adjusted RR 0.45, 95% CI 0.29-0.71) and maternal sepsis (3.9 versus 6.8 percent; adjusted RR 0.58, 95% CI 0.40-0.82), but no statistically significant differences in the rate of suspected or confirmed neonatal sepsis, mean gestational age at delivery, or rate of preterm birth <28, 32, or 37 weeks. It is unclear why the increased risk for chorioamnionitis in the braided suture group did not translate into an increased risk for pregnancy loss and preterm birth in that group, as these complications are consequences of chorioamnionitis. The authors hypothesized that the finding might have been related to bias among the outcome assessors.

Knot position – The optimum knot position (anterior versus posterior) has not been evaluated in randomized trials. The choice should be based on general surgical principles and the operator's experience and preference.

Shirodkar cerclage — This procedure is more complicated than the McDonald cerclage because it requires incisions and dissection of the paracervical area. The author's approach is described below.

The cervix is pulled toward the surgeon with one or two ring forceps while an assistant retracts the vaginal sidewalls.

1 to 2 mL of sterile saline is injected into the submucosa to raise a wheal before the incision is made to facilitate dissecting tissue planes.

A scalpel with a number 10 blade or an electrocautery needle is used to make a 1 to 3 cm vertical or transverse incision on the posterior cervix at the junction of the rugated vaginal epithelium and the smooth cervix (figure 2). The author prefers a 2 to 3 cm transverse incision. Making the first incision posteriorly prevents the operative field from becoming obscured by bleeding from the anterior incision, which can occur even with use of electrocautery.

After the posterior incision is made, a transverse incision is made anteriorly.

The rectum is bluntly dissected off the posterior cervix and the bladder is bluntly dissected off of the anterior cervix using a finger, sponge on a stick, or peanut sponge on a long clamp. The dissection should be carried back far enough to allow the surgeon to palpate the insertion of the uterosacral and cardinal ligaments onto the cervix at the level of the internal os. Electrocautery can be used to control small bleeders.

Long curved Allis clamps, or similar tissue forceps clamps (eg, Teale Vulsellum), are used to grasp and approximate the lateral edges of the anterior and posterior aspects of the transverse incisions and some paracervical tissue.

Two atraumatic (blunted) needles premounted with a single 5 mm polyester braided tape (Mersilene tape) are used for the cerclage, but polyester braided or polypropylene nonbraided monofilament suture can be used instead [43,44]. Bending the needle to reduce the curvature is sometimes helpful for guiding the needle to the desired position. The tip of one needle is introduced anteriorly at the lateral edge of the incision at the level of the internal os (or as close as possible) and threaded submucosally adjacent to the cervical stroma (and medial to the cervical branches of the uterine vessels) to emerge at the lateral edge of the posterior incision at the level of the internal os. If not at the internal os, the cerclage should be at least 2 cm cephalad to the external os, as feasible [45]. Intraoperative ultrasound can be helpful for judging the site of the suture relative to the internal os, maternal bladder, and rectum [46]. (See 'Number of cerclages' below.)

The procedure is then repeated on the opposite side and the two ends are tied tightly using four to seven square knots. It is the surgeon's preference as to whether the stitch is placed so that the knot is tied anteriorly or posteriorly. The author usually finds it easier to perform the cerclage with anterior placement of the knot, although there are rare instances of an anterior knot causing bladder discomfort, and even eroding into the bladder. It is also easier to remove the cerclage in the office if the knot is anterior to the cervix.

The Mersilene tape is cut 2 to 3 cm in length and then tagged with 2-0 silk that is left long. If a suture is used, the ends are left longer.

The epithelium may be reapproximated with a fine chromic catgut suture, although this is not necessary if good hemostasis is achieved. It is not necessary to bury the ends of the knot under the epithelium or anchor the tape to the cervix. Avoiding burying and anchoring the cerclage facilitates removal prior to birth. Alternatively, if cesarean birth is planned, the Shirodkar cerclage can be left in-situ indefinitely postpartum for use in a future pregnancy. It is advantageous to completely bury the knot under the vaginal epithelium in these cases to minimize vaginal discharge.

McDonald cerclage — The procedure is begun by grasping the anterior and posterior lips of the cervix with one or two ring forceps. We insert a curved needle loaded with large caliber nonabsorbable synthetic suture (at least number 1 or 2 braided or monofilament) at 12 o'clock, at the junction of the rugated vaginal epithelium and the smooth cervix just distal to the vesicocervical reflection and at least 2 cm above the external os, as feasible [45]. Alternatively, the needle can be inserted posteriorly at the cervicovaginal reflection at approximately 6 o'clock. As with the Shirodkar cerclage, there is no evidence that knot position (anterior versus posterior) [47] or choice of suture (monofilament versus braided) [43] affects pregnancy loss rate.

Four to six deep bites of a purse-string suture are taken circumferentially around the entire cervix as high (close to the internal os) as safely possible, avoiding the bladder, rectum, and uterine vessels (at 3 and 9 o'clock). Approximately 1 cm of space is left between the exit of one deep bite and the entry of the next deep bite. Each deep bite should extend at least midway into the cervical stroma to reduce the risk that the suture will pull out over time, but should not enter the endocervical canal (figure 3). The pass at 6 o'clock is particularly important because this is the most common site for pull-through [40]. The two ends of the suture are then tied securely and cut, leaving the ends long enough to grasp with a clamp when it is time to remove it. Intraoperative ultrasound can be helpful for judging the site of the suture relative to the internal os, maternal bladder, and rectum [46].

Number of cerclages — A single cerclage is usually adequate, if well placed. In some cases, an inadequate initial cerclage is used for traction, and then a second cerclage is placed in a more optimal position closer to the internal os. A second cerclage may be needed to achieve adequate closure of the cervix when the procedure is performed on a widely dilated cervix with prolapsed membranes. If two cerclages are placed, they are generally removed at the same time.

Although some clinicians routinely place a second cerclage, this practice did not improve outcome in three retrospective studies [48-50]. In addition, a randomized trial found that placing a second stitch at the external os to keep the mucus plug in place (termed cervical occlusion) did not increase gestational age at delivery or decrease neonatal intensive care unit days or neonatal mortality [51].

POSTOPERATIVE CARE AND FOLLOW-UP

Counseling and care

Hospital discharge – Cerclage is typically an outpatient surgery procedure. Most patients can be discharged after recovery from the anesthetic and when able to ambulate and void; however, a longer period of in-hospital observation may be indicated for some patients who undergo physical examination-indicated cerclage because of their increased risk for complications. (See 'Complications' below.)

Documentation – The fetal heart rate and normal amniotic fluid volume should be documented prior to discharge.

AnalgesiaAcetaminophen alone provides adequate analgesia for most patients.

What to expect – Patients are told to expect some spotting, cramps, and dysuria (due to minor muscle injury from the vaginal wall retractors) which will abate within a few days. Those who have undergone a Shirodkar procedure may note passage of the fine chromic catgut in two to three weeks as the mucosal stitches dissolve; they should be forewarned that this does not represent loss of the cerclage itself.

Patients who have undergone cerclage placement have an increased frequency of uterine contractions [52], but the presence of uterine irritability is not predictive of an increased risk for preterm birth.

When to call the clinician – Patients should report any leakage of fluid from the vagina so that they can be evaluated for membrane rupture and any vaginal bleeding other than spotting.

Activity – Although there is no evidence that coitus adversely affects perinatal outcome, the author asks patients to maintain pelvic rest for at least one week after a history-indicated procedure and to use condoms thereafter (semen contains prostaglandins). Patients who have had an ultrasound- or physical examination-indicated cerclage are managed more conservatively; the author typically asks them to limit physical activity and limit/avoid coitus until a favorable gestational age is reached, usually 32 to 34 weeks of gestation, although there is no high-quality evidence that reducing these activities improves outcome.

Follow-up — Patients followed as outpatients are seen on regularly with frequent (weekly or biweekly) visits for cervical examination.

Ultrasound assessment of cervical length is useful for identifying those patients at highest risk for preterm birth [53-60]. Proximal cervical shortening after 23 weeks may affect subsequent management, including advising a reduction in physical activity, increased frequency of prenatal visits, and increased concern about the potential for preterm birth, which might involve prompt administration of antenatal corticosteroids for fetal lung maturation and, if birth is imminent, magnesium sulfate for cerebral palsy prophylaxis. (See "Antenatal corticosteroid therapy for reduction of neonatal respiratory morbidity and mortality from preterm delivery" and "Neuroprotective effects of in utero exposure to magnesium sulfate".)

The author does not routinely follow patients with serial fetal fibronectin assays, as the value of testing asymptomatic patients is unproven. If performed, the test should not be done until at least four weeks postoperatively and a positive result may be less reliable in this setting [61,62].

CERCLAGE REMOVAL

Timing – The cerclage is removed electively at 36+0 to 37+0 weeks of gestation in anticipation of labor. In patients with preterm labor before 36 weeks, we would remove the cerclage immediately at the onset of regular uterine contractions if the pregnancy is ≥34 weeks or upon determination of lack of response to tocolysis in pregnancies <34 weeks. The absolute risk of laceration in early labor is unclear given the small number of reports [63]. Whether to remove the cerclage in the setting of preterm prelabor rupture of membranes (PPROM) is controversial. (See 'Removal of cerclage after PPROM' below.)

A Shirodkar cerclage does not have to be removed if cesarean birth is anticipated and future pregnancies are planned. However, there is a theoretical risk of reduced fertility from inflammation/infection of the cervix due to the foreign body and a risk of erosion into adjacent tissue. McDonald cerclages are routinely removed. We are not aware of any reports of leaving them in place for use in a future pregnancy so the consequences of not removing a McDonald cerclage are unknown.

Site of removal – A McDonald cerclage usually can be cut and removed in the office without analgesia. A Shirodkar cerclage more often requires a return to the operating room for removal, either because the knot is buried under the vaginal epithelium or the Mersilene tape has been infiltrated by cervical granulation tissue.

Follow-up – Patients are generally sent home after cerclage removal to await the onset of labor, which generally occurs within two weeks; only approximately 10 percent labor spontaneously within 48 hours of planned cerclage removal [64].

Removal of cerclage after PPROM — Whether to remove the cerclage if PPROM occurs is a matter of debate. One concern is that removal will lead to earlier birth; however, retention of the foreign body may increase the risk of infection, leading to preterm birth and maternal and newborn morbidity. Gestational age at PPROM appears to be the most important determinant of neonatal outcome [65].

Based on the available limited data and personal clinical experience, the author removes the cerclage in patients with PPROM in either of the following settings:

Chorioamnionitis

Gestational age ≥32 weeks

Vaginal bleeding

Before 32 weeks, in the absence of clinically apparent infection, bleeding, or preterm labor, the cerclage is left in place as there is greater concern about the possible increased risk of neonatal morbidity and mortality from preterm birth with cerclage removal than the possible increased risk of ascending infection with the cerclage left in place.

In a meta-analysis of six studies (377 participants with PPROM and cerclage), cerclage removal was associated with less chance of pregnancy prolongation >48 hours (OR 0.15, 95% CI 0.07-0.31) or >7 days (OR 0.30 95% CI 0.11-0.83) compared with retention, shorter pregnancy latency (mean difference -2.84 days, 95% CI -5.40 to -0.29), but also less risk of chorioamnionitis (OR 0.57, 95% CI 0.34-0.96) [66]. The only randomized trial included in the analysis found no statistically significant differences between groups in any pregnancy outcome, but the trial was terminated early after only 56 of the proposed 142 patients had been recruited, and was underpowered for all of the outcome measures [67].

COMPLICATIONS — The frequency of complications is higher with increasing gestational age and cervical dilation, but not higher with McDonald versus Shirodkar cerclage. A meta-analysis of three randomized trials, three prospective cohort studies, and 38 retrospective cohort studies with a total of over 4500 singleton pregnancies that underwent transvaginal cerclage noted the following [68]:

Most perioperative complications occurred in physical examination-indicated cerclage, particularly hemorrhage (2.3 percent, 95% CI 0.0-7.6) and preterm prelabor rupture of membranes (PPROM: 2.5 percent, 95% CI 0.91-4.5).

The fewest complications occurred in history-indicated cerclage (PPROM: 0.0 percent, 95% CI 0.0-1.7; hemorrhage: 0.9 percent, 95% CI 0.0-7.9).

The most common complications in ultrasound-indicated cerclage were hemorrhage (1.4 percent, 95% CI 0.0-4.1), lacerations (0.6 percent, 95% CI 0.0-3.1) and PPROM (0.3 percent, 95% CI 0.0-0.8).

However, the timing of the complications (ie, perioperative or later in pregnancy) was not well documented and many studies were excluded from the analysis because of poor documentation of complications.

Membrane rupture – Rupture of membranes intraoperatively or in the immediate postoperative period is rare with history-indicated cerclage, but a concern with ultrasound-indicated cerclage and a major concern with physical examination-indicated cerclage, especially with advanced cervical dilation and/or prolapsed fetal membranes [68]. In the absence of perioperative rupture, the risk for PPROM at <34 weeks of gestation may not differ by cerclage indication.

Intraamniotic infection – The median frequencies of intraamniotic infection after history-indicated and nonhistory-indicated cerclage were 2 and 25 percent, respectively, in one review [2]. Maternal sepsis has been reported after history-indicated, ultrasound-indicated, and physical examination-indicated cerclage [69].

Suture migration – Suture migration has been reported in 3 to 13 percent of cases [70]. This often occurs late in gestation and thus is of little clinical consequence. When migration occurs early in pregnancy (before 24 weeks), the clinician must decide whether to repeat the procedure. It is likely that the same factors that led to failure of the first cerclage will affect a second procedure. In fact, placement of a second (reinforcing) cerclage may worsen the outcome when cervical shortening has occurred in the presence of a history-indicated cerclage [71], and is not generally recommended [22]. Hospitalization and/or a course of antenatal glucocorticoids are options if a preterm potentially viable birth appears likely. (See "Antenatal corticosteroid therapy for reduction of neonatal respiratory morbidity and mortality from preterm delivery".)

Other – Cervical dystocia and cervical trauma in labor have been reported in fewer than 5 percent of patients; however, uterine rupture as a consequence is rare [10,72]. Excessive bleeding and fistula formation are also rare.

PREGNANCY OUTCOME — Cervical cerclage is the conventional treatment for cervical insufficiency, despite the paucity of data from randomized trials proving its efficacy. Most case series report a live birth rate of 70 to 90 percent after history-indicated cerclage, as compared with 10 to 30 percent prior to the procedure [73]. However, using patients as their own controls (ie, comparing pregnancy success rates in the same patient before and after cerclage) is subject to bias since changes in the patient and their management other than cerclage may have accounted for the higher rate of success in the subsequent pregnancy. In fact, trials in which patients were randomly assigned to undergo cerclage or no cerclage report much higher live birth rates in the untreated group than observed in historic controls [74,75].

In a 2017 meta-analysis of randomized trials of cerclage versus no cerclage in singleton pregnancies at high risk of pregnancy loss based on history and/or ultrasound finding of short cervix and/or physical examination, placement of a cerclage [76]:

Reduced preterm birth <34 weeks (18 versus 24 percent; risk ratio [RR] 0.77, 95% CI 0.66-0.89; nine trials, 2415 pregnancies; high-quality evidence)

Probably reduced perinatal loss (7.5 versus 9.2 percent; RR 0.82, 95% CI 0.65-1.04; 10 trials, 2927 pregnancies, moderate-quality evidence)

There were too few trials for each of the indications to evaluate whether there were differences in efficacy by indication.

Pregnancy outcome with each of the three types of cerclage is reviewed in more detail separately (see "Cervical insufficiency", section on 'Obstetric history-based cervical insufficiency' and "Cervical insufficiency", section on 'Ultrasound-based cervical insufficiency' and "Cervical insufficiency", section on 'Physical examination-based cervical insufficiency') Pregnancy outcome with cerclage in twin pregnancies is also reviewed separately. (See "Twin pregnancy: Management of pregnancy complications", section on 'Patient selection for cerclage'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic Patient education: Cervical insufficiency (The Basics)

SUMMARY AND RECOMMENDATIONS

Goal – Cervical cerclage refers to a variety of surgical procedures in which synthetic suture or tape is used to reinforce the cervix and thereby prevent pregnancy loss/early preterm delivery. (See 'Introduction' above and 'Goal' above.)

Timing and contraindications – Cerclages are typically placed between 12 and 24 weeks of gestation. The major contraindications are clinical scenarios where the procedure is unlikely to reduce the risk of preterm birth or improve fetal outcome, such as fetal anomaly incompatible with life, intrauterine infection, active preterm labor, preterm prelabor rupture of membranes (PPROM), fetal demise, or active uterine bleeding (eg, placental abruption). (See 'Upper and lower gestational age thresholds for cerclage placement' above and 'Contraindications' above.)

Preoperative assessment

An ultrasound examination is performed proximate to the procedure to determine if there are identifiable fetal structural anomalies that might affect the patient's decision to continue the pregnancy and to confirm gestational age and viability. Aneuploidy screening is offered, if not already performed. (See 'Fetal assessment' above.)

Before ultrasound- and physical examination-indicated cerclage, the patient is monitored for up to 24 hours before proceeding with surgery to help exclude the presence of PPROM, occult abruption, infection, and preterm labor. (See 'Observation period before unplanned procedures' above.)

Pharmacotherapy – (See 'Prophylactic antibiotics and tocolytics' above.)

History-indicated cerclage – Prophylactic antibiotics or tocolytics are not administered since infection and uterine contractions/irritability are uncommon.

Ultrasound-indicated cerclage – We do not administer prophylactic antibiotics or tocolytics since infection and uterine contractions/irritability are uncommon, but acknowledge that the risk is slightly higher than in history-indicated procedures and that practice patterns vary in this setting.

Physical examination-indicated cerclage – We suggest antibiotic and indomethacin prophylaxis to prolong latency (Grade 2C). These patients are at high risk of developing infection and postprocedure uterine contractions/irritability. We use cefazolin and indomethacin.

Procedure

The choice of procedure should be based on general surgical principles and the operator's experience and preference. The body of data shows no significant differences in outcome or complications between McDonald (figure 3) and Shirodkar (figure 2) procedures. The frequency of complications is higher with increasing gestational age and cervical dilation. (See 'Choosing a McDonald versus Shirodkar procedure' above and 'Complications' above.)

A single cerclage is usually adequate. (See 'Number of cerclages' above.)

If suture migration subsequently occurs early in pregnancy (before 24 weeks), we suggest not placing another cerclage (Grade 2C). (See 'Complications' above.)

Hemorrhage and rupture of membranes intraoperatively or in the immediate postoperative period occurs primarily in patients with advanced cervical dilation and/or prolapsed fetal membranes. (See 'Complications' above.)

Removal – The cerclage is removed electively at 36+0 to 37+0 weeks of gestation. In patients with preterm labor before 36 weeks, we remove the cerclage immediately at the onset of regular uterine contractions if the pregnancy is ≥34 weeks or upon determination of lack of response to tocolysis in pregnancies <34 weeks. (See 'Cerclage removal' above.)

Prelabor rupture of membranes – In otherwise asymptomatic patients ≥32 weeks of gestation with prelabor rupture of membranes, we suggest removing the cerclage rather than expectant management (Grade 2C). Before this gestational age, we feel the possible increased risk of preterm birth with cerclage removal is a greater concern than the possible increased risk of ascending infection if the cerclage is left in place. (See 'Removal of cerclage after PPROM' above.)

Effectiveness – In singleton pregnancies at high risk of pregnancy loss based on history and/or ultrasound finding of short cervix and/or physical examination, placement of a cerclage reduced preterm birth <34 weeks by 23 percent and reduced perinatal loss by 18 percent. However, outcomes vary by the clinical setting at the time of placement. (See 'Pregnancy outcome' above.)

  1. Uzun Cilingir I, Sayin C, Sutcu H, et al. Does emergency cerclage really works in patients with advanced cervical dilatation? J Gynecol Obstet Hum Reprod 2019; 48:387.
  2. Harger JH. Cerclage and cervical insufficiency: an evidence-based analysis. Obstet Gynecol 2002; 100:1313.
  3. Aarts JM, Brons JT, Bruinse HW. Emergency cerclage: a review. Obstet Gynecol Surv 1995; 50:459.
  4. Wong GP, Farquharson DF, Dansereau J. Emergency cervical cerclage: a retrospective review of 51 cases. Am J Perinatol 1993; 10:341.
  5. Simcox R, Shennan A. Cervical cerclage in the prevention of preterm birth. Best Pract Res Clin Obstet Gynaecol 2007; 21:831.
  6. Freegard GD, Donadono V, Impey LWM. Emergency cervical cerclage in twin and singleton pregnancies with 0-mm cervical length or prolapsed membranes. Acta Obstet Gynecol Scand 2021; 100:2003.
  7. Liao Y, Wen H, Ouyang S, et al. Routine first-trimester ultrasound screening using a standardized anatomical protocol. Am J Obstet Gynecol 2021; 224:396.e1.
  8. Gulersen M, Lenchner E, Nicolaides KH, et al. Cervical cerclage for short cervix at 24 to 26 weeks of gestation: systematic review and meta-analysis of randomized controlled trials using individual patient-level data. Am J Obstet Gynecol MFM 2023; 5:100930.
  9. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency. Obstet Gynecol 2014; 123:372. Reaffirmed 2019.
  10. Treadwell MC, Bronsteen RA, Bottoms SF. Prognostic factors and complication rates for cervical cerclage: a review of 482 cases. Am J Obstet Gynecol 1991; 165:555.
  11. Romero R, Gonzalez R, Sepulveda W, et al. Infection and labor. VIII. Microbial invasion of the amniotic cavity in patients with suspected cervical incompetence: prevalence and clinical significance. Am J Obstet Gynecol 1992; 167:1086.
  12. Mönckeberg M, Valdés R, Kusanovic JP, et al. Patients with acute cervical insufficiency without intra-amniotic infection/inflammation treated with cerclage have a good prognosis. J Perinat Med 2019; 47:500.
  13. Mays JK, Figueroa R, Shah J, et al. Amniocentesis for selection before rescue cerclage. Obstet Gynecol 2000; 95:652.
  14. Berghella V, Ludmir J, Simonazzi G, Owen J. Transvaginal cervical cerclage: evidence for perioperative management strategies. Am J Obstet Gynecol 2013; 209:181.
  15. Rust OA, Atlas RO, Reed J, et al. Revisiting the short cervix detected by transvaginal ultrasound in the second trimester: why cerclage therapy may not help. Am J Obstet Gynecol 2001; 185:1098.
  16. Caruso A, Trivellini C, De Carolis S, et al. Emergency cerclage in the presence of protruding membranes: is pregnancy outcome predictable? Acta Obstet Gynecol Scand 2000; 79:265.
  17. Novy MJ, Ducsay CA, Stanczyk FZ. Plasma concentrations of prostaglandin F2 alpha and prostaglandin E2 metabolites after transabdominal and transvaginal cervical cerclage. Am J Obstet Gynecol 1987; 156:1543.
  18. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery. Obstet Gynecol 2018; 132:e103.
  19. Smith J, DeFranco EA. Tocolytics used as adjunctive therapy at the time of cerclage placement: a systematic review. J Perinatol 2015; 35:561.
  20. Eleje GU, Eke AC, Ikechebelu JI, et al. Cervical stitch (cerclage) in combination with other treatments for preventing spontaneous preterm birth in singleton pregnancies. Cochrane Database Syst Rev 2020; 9:CD012871.
  21. Shennan A, Story L, Jacobsson B, et al. FIGO good practice recommendations on cervical cerclage for prevention of preterm birth. Int J Gynaecol Obstet 2021; 155:19.
  22. Berghella V, Seibel-Seamon J. Contemporary use of cervical cerclage. Clin Obstet Gynecol 2007; 50:468.
  23. Kessler I, Shoham Z, Lancet M, et al. Complications associated with genital colonization in pregnancies with and without cerclage. Int J Gynaecol Obstet 1988; 27:359.
  24. Visintine J, Airoldi J, Berghella V. Indomethacin administration at the time of ultrasound-indicated cerclage: is there an association with a reduction in spontaneous preterm birth? Am J Obstet Gynecol 2008; 198:643.e1.
  25. Skupski DW, Lin SN, Reiss J, Eglinton GS. Extremely short cervix in the second trimester: bed rest or modified Shirodkar cerclage? J Perinat Med 2014; 42:55.
  26. Miller ES, Grobman WA, Fonseca L, Robinson BK. Indomethacin and antibiotics in examination-indicated cerclage: a randomized controlled trial. Obstet Gynecol 2014; 123:1311.
  27. Scheerer LJ, Lam F, Bartolucci L, Katz M. A new technique for reduction of prolapsed fetal membranes for emergency cervical cerclage. Obstet Gynecol 1989; 74:408.
  28. Kanai M, Ashida T, Ohira S, et al. A new technique using a rubber balloon in emergency second trimester cerclage for fetal membrane prolapse. J Obstet Gynaecol Res 2008; 34:935.
  29. Goodlin RC. Cervical incompetence, hourglass membranes, and amniocentesis. Obstet Gynecol 1979; 54:748.
  30. Locatelli A, Vergani P, Bellini P, et al. Amnioreduction in emergency cerclage with prolapsed membranes: comparison of two methods for reducing the membranes. Am J Perinatol 1999; 16:73.
  31. Althuisius SM, Dekker GA, van Geijn HP, Hummel P. The effect of therapeutic McDonald cerclage on cervical length as assessed by transvaginal ultrasonography. Am J Obstet Gynecol 1999; 180:366.
  32. Funai EF, Paidas MJ, Rebarber A, et al. Change in cervical length after prophylactic cerclage. Obstet Gynecol 1999; 94:117.
  33. Dijkstra K, Funai EF, O'Neill L, et al. Change in cervical length after cerclage as a predictor of preterm delivery. Obstet Gynecol 2000; 96:346.
  34. O'Connell MP, Lindow SW. Reversal of asymptomatic cervical length shortening with cervical cerclage: a preliminary study. Hum Reprod 2001; 16:172.
  35. Hershkovitz R, Burstein E, Pinku A. Tightening McDonald cerclage suture under sonographic guidance. Ultrasound Obstet Gynecol 2008; 31:194.
  36. Groom KM, Shennan AH, Bennett PR. Ultrasound-indicated cervical cerclage: outcome depends on preoperative cervical length and presence of visible membranes at time of cerclage. Am J Obstet Gynecol 2002; 187:445.
  37. Rust OA, Atlas RO, Meyn J, et al. Does cerclage location influence perinatal outcome? Am J Obstet Gynecol 2003; 189:1688.
  38. Berghella V, Rafael TJ, Szychowski JM, et al. Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth: a meta-analysis. Obstet Gynecol 2011; 117:663.
  39. Shirodkar, VN. A new method of operative treatment for habitual abortion in the second trimester of pregnancy. Antiseptic 1955; 52:299.
  40. MCDONALD IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Emp 1957; 64:346.
  41. McAuliffe L, Issah A, Diacci R, et al. McDonald versus Shirodkar cerclage technique in the prevention of preterm birth: A systematic review and meta-analysis. BJOG 2023; 130:702.
  42. Otsuki K, Nakai A, Matsuda Y, et al. Randomized trial of ultrasound-indicated cerclage in singleton women without lower genital tract inflammation. J Obstet Gynaecol Res 2016; 42:148.
  43. Hodgetts Morton V, Toozs-Hobson P, Moakes CA, et al. Monofilament suture versus braided suture thread to improve pregnancy outcomes after vaginal cervical cerclage (C-STICH): a pragmatic randomised, controlled, phase 3, superiority trial. Lancet 2022; 400:1426.
  44. Berghella V, Szychowski JM, Owen J, et al. Suture type and ultrasound-indicated cerclage efficacy. J Matern Fetal Neonatal Med 2012; 25:2287.
  45. Scheib S, Visintine JF, Miroshnichenko G, et al. Is cerclage height associated with the incidence of preterm birth in women with an ultrasound-indicated cerclage? Am J Obstet Gynecol 2009; 200:e12.
  46. Ludmir J, Jackson GM, Samuels P. Transvaginal cerclage under ultrasound guidance in cases of severe cervical hypoplasia. Obstet Gynecol 1991; 78:1067.
  47. Atia H, Ellaithy M, Altraigey A, Ibrahim H. Knot positioning during McDonald cervical cerclage, does it make a difference? A cohort study. J Matern Fetal Neonatal Med 2019; 32:3757.
  48. Woensdregt K, Norwitz ER, Cackovic M, et al. Effect of 2 stitches vs 1 stitch on the prevention of preterm birth in women with singleton pregnancies who undergo cervical cerclage. Am J Obstet Gynecol 2008; 198:396.e1.
  49. Giraldo-Isaza MA, Fried GP, Hegarty SE, et al. Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage for preterm birth prevention. Am J Obstet Gynecol 2013; 208:209.e1.
  50. Park JM, Tuuli MG, Wong M, et al. Cervical cerclage: one stitch or two? Am J Perinatol 2012; 29:477.
  51. Brix N, Secher NJ, McCormack CD, et al. Randomised trial of cervical cerclage, with and without occlusion, for the prevention of preterm birth in women suspected for cervical insufficiency. BJOG 2013; 120:613.
  52. Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists multicentre randomised trial of cervical cerclage. MRC/RCOG Working Party on Cervical Cerclage. Br J Obstet Gynaecol 1993; 100:516.
  53. Andersen HF, Karimi A, Sakala EP, Kalugdan R. Prediction of cervical cerclage outcome by endovaginal ultrasonography. Am J Obstet Gynecol 1994; 171:1102.
  54. Guzman ER, Houlihan C, Vintzileos A, et al. The significance of transvaginal ultrasonographic evaluation of the cervix in women treated with emergency cerclage. Am J Obstet Gynecol 1996; 175:471.
  55. O'Brien JM, Hill AL, Barton JR. Funneling to the stitch: an informative ultrasonographic finding after cervical cerclage. Ultrasound Obstet Gynecol 2002; 20:252.
  56. Hedriana HL, Lanouette JM, Haesslein HC, McLean LK. Is there value for serial ultrasonographic assessment of cervical lengths after a cerclage? Am J Obstet Gynecol 2008; 198:705.e1.
  57. Miller ES, Gerber SE. Association between sonographic cervical appearance and preterm delivery after a history-indicated cerclage. J Ultrasound Med 2014; 33:2181.
  58. Ridout AE, Ross G, Seed PT, et al. Predicting spontaneous preterm birth in asymptomatic high-risk women with cervical cerclage. Ultrasound Obstet Gynecol 2023; 61:617.
  59. Cook JR, Chatfield S, Chandiramani M, et al. Cerclage position, cervical length and preterm delivery in women undergoing ultrasound indicated cervical cerclage: A retrospective cohort study. PLoS One 2017; 12:e0178072.
  60. Pils S, Eppel W, Promberger R, et al. The predictive value of sequential cervical length screening in singleton pregnancies after cerclage: a retrospective cohort study. BMC Pregnancy Childbirth 2016; 16:79.
  61. Roman AS, Rebarber A, Sfakianaki AK, et al. Vaginal fetal fibronectin as a predictor of spontaneous preterm delivery in the patient with cervical cerclage. Am J Obstet Gynecol 2003; 189:1368.
  62. Duhig KE, Chandiramani M, Seed PT, et al. Fetal fibronectin as a predictor of spontaneous preterm labour in asymptomatic women with a cervical cerclage. BJOG 2009; 116:799.
  63. Simonazzi G, Curti A, Bisulli M, et al. Cervical lacerations in planned versus labor cerclage removal: a systematic review. Eur J Obstet Gynecol Reprod Biol 2015; 193:19.
  64. Bisulli M, Suhag A, Arvon R, et al. Interval to spontaneous delivery after elective removal of cerclage. Am J Obstet Gynecol 2009; 201:163.e1.
  65. McElrath TF, Norwitz ER, Lieberman ES, Heffner LJ. Management of cervical cerclage and preterm premature rupture of the membranes: should the stitch be removed? Am J Obstet Gynecol 2000; 183:840.
  66. Zullo F, Di Mascio D, Chauhan SP, et al. Removal versus retention of cervical cerclage with preterm prelabor rupture of membranes: Systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2023; 288:83.
  67. Galyean A, Garite TJ, Maurel K, et al. Removal versus retention of cerclage in preterm premature rupture of membranes: a randomized controlled trial. Am J Obstet Gynecol 2014; 211:399.e1.
  68. van Dijk CE, Breuking SH, Jansen S, et al. Perioperative complications of a transvaginal cervical cerclage in singleton pregnancies: a systematic review and meta-analysis. Am J Obstet Gynecol 2023; 228:521.
  69. Bauer ME, Bateman BT, Bauer ST, et al. Maternal sepsis mortality and morbidity during hospitalization for delivery: temporal trends and independent associations for severe sepsis. Anesth Analg 2013; 117:944.
  70. Barth WH Jr. Cervical incompetence and cerclage: unresolved controversies. Clin Obstet Gynecol 1994; 37:831.
  71. Baxter JK, Airoldi J, Berghella V. Short cervical length after history-indicated cerclage: is a reinforcing cerclage beneficial? Am J Obstet Gynecol 2005; 193:1204.
  72. Bauer AM, Lappen JR, Hackney DN. Term Labor Outcomes after Cerclage Placement in a Multi-institutional Cohort. Am J Perinatol 2020; 37:119.
  73. Harger JH. Cervical cerclage: patient selection, morbidity, and success rates. Clin Perinatol 1983; 10:321.
  74. Rush RW, Isaacs S, McPherson K, et al. A randomized controlled trial of cervical cerclage in women at high risk of spontaneous preterm delivery. Br J Obstet Gynaecol 1984; 91:724.
  75. Lazar P, Gueguen S, Dreyfus J, et al. Multicentred controlled trial of cervical cerclage in women at moderate risk of preterm delivery. Br J Obstet Gynaecol 1984; 91:731.
  76. Alfirevic Z, Stampalija T, Medley N. Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Cochrane Database Syst Rev 2017; 6:CD008991.
Topic 6737 Version 57.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟