Prematurity is leading cause of perinatal death & disability. Around 60,000 babies are born prematurely in the UK each year putting them at a higher risk of developing health problems. This is one of the highest rates in the Europe and it’s still rising. Cervical insufficiency remains a significant risk factor for preterm labour.

Has been suggested that cervical insufficiency complicates about 1% of an obstetric population (McDonald 1980) and 8% of a recurrent miscarriage population who have suffered mid-trimester pregnancy losses (Drakeley 1998).

The diagnosis of cervical insufficiency cannot be made or excluded in nonpregnant women by any test.

The indication must be documented in the woman’s notes.

Consider prophylactic vaginal / rectal progesterone for women who have either:

• a history of spontaneous preterm birth (up to 34+0 weeks of pregnancy) or loss (from 16+0 weeks of pregnancy onwards), or

• results from a transvaginal ultrasound scan carried out between 16+0 and 24+0 weeks of pregnancy that show a cervical length of 25 mm or less.

In August 2019, this was an off-label use of vaginal progesterone. See NICE's information on prescribing medicines. [2019, amended 2022]⁵

• Active preterm labour

• Clinical evidence of chorioamnionitis

• Active vaginal bleeding

• Evidence of fetal compromise

• Pre labour preterm rupture of membrane PPROM

• Lethal fetal condition

• Fetal death

Fetal anomaly: depends on the anomaly, to discuss with fetal medicine team

• Ultrasound & Screen for aneuploidy to ensure viability & absence of lethal/ major fetal abnormality

• Before ultrasound-indicated or emergency cerclage, it is preferable to ensure an anomaly scan has been performed⁴

• Maternal white cell count and C-reactive protein to detect chorioamnionitis before insertion of a emergency cerclage can be used to aid management. The decision to perform these tests should be based on the overall clinical picture, but in the absence of clinical signs of chorioamnionitis, the decision for emergency cerclage need not be delayed²

• Routine genital tract screening should not be undertaken before cerclage insertion⁴

• In the presence of a positive culture from a genital swab, antimicrobial therapy should be decided on an individual basis after discussion with the microbiology team⁴

• The decision for antibiotic prophylaxis at the time of cerclage placement should be at the discretion of the operating team¹

The choice of cerclage is up to obstetrician and the clinical circumstances.

Transvaginal Route:

• Transvaginal cerclage (McDonald): A transvaginal purse-string suture placed at the cervical isthmus junction, without bladder mobilization McDonald technique

• High transvaginal cerclage requiring bladder mobilization (including Shirodkar): A transvaginal purse-string suture placed following bladder mobilization, to allow insertion above the level of the cardinal ligamentsShirodkar technique

Total cervical occlusion

In addition to the standard cerclage, the external cervical os is closed with non-absorbable suture. The rationale for this technique is based on the observation that mucous plug has a double role in preventing the preterm labour; it is a mechanical barrier between the vagina and uterus and its intrinsic richness in immune components makes it a very important element in defending the fetal compartment from ascending infections, thereby increasing the innate defence of cervical canal.

Transabdominal Route:

A suture performed via a laparotomy or laparoscopy, placing the suture at the cervicoisthmic junction. This approach is used for women when vaginal stitches have failed, or when a woman has short, scarred cervix making vaginal stitch insertion technically difficult (Anthony 1997; Gibb 1995).

• In women with a previous unsuccessful transvaginal cerclage, insertion of a transabdominal cerclage may be discussed and considered¹

• Transabdominal cerclage can be performed pre-conceptually or in early pregnancy. Pre-conceptual procedures may be more effective and are not associated with sub-fertility⁴

• Laparoscopic and open abdominal cerclage have similar efficacy. The laparoscopic approach is associated with fewer complications, and can be considered where suitable surgical expertise is available²

How should women who experience delayed miscarriage or fetal death be cared for?

• Decisions on care and treatment in cases of delayed miscarriage or fetal death in women with an abdominal cerclage can be difficult and women’s decision making should be aided by a senior obstetrician⁴

• Complete evacuation through the stitch by suction curettage or by dilatation and evacuation (up to 18 weeks of gestation) may be performed; alternatively, the suture may be cut, usually via a posterior colpotomy. Failing this, a hysterotomy maybe required or caesarean section may be necessary; the woman’s decision should be aided by a senior obstetrician.⁴

Frimley Health NHS at present can not offer service of transabdominal cerclage so referral to the tertiary centre should be considered if transabdominal cerclage is indicated.

These risks have to be carefully balanced against the benefit from mechanical support to the cervix. Overall risks < 1%.

• Bladder damage

• Cervical Trauma

• Bleeding

• Membrane rupture

• Shirodkar suture may require anaesthesia for removal

• Cervical laceration/ trauma if spontaneous labour start & suture insitu have been reported < 5%

• Vaginal cerclage insertion is not associated with an increased risk of PPROM, chorioamnionitis, induction of labour, or caesarean section(1+)

• The insertion of a cervical suture is not associated with an increased risk of preterm birth or second trimester loss (1+)

• Prior to cerclage insertion, women should be given appropriate verbal and written information; patient information can be found on the RCOG website

• There is no evidence to support the use of perioperative tocolysis in women undergoing insertion of cerclage. This should be considered on an individual basis⁴

• There is no evidence to use antibiotic prophylaxis at the time of cerclage placement. The decision for antibiotic prophylaxis at the time of cerclage placement should be at the discretion of the operating team¹

• Routine use of progesterone supplementation following cerclage is not recommended.

• The choice of suture material should be at the discretion of the surgeon, this should be considered on an individual basis⁴

• The choice of transvaginal cerclage technique (high vs low cervical insertion) (Shirodkar Vs McDonald) should be at the discretion of the surgeon, but the cerclage should be placed as high as is practically possible²

• There is no difference between using two purse-string sutures and one single suture and should be at the discretion of the surgeon¹

• The insertion of cervical occlusion suture in addition to the primary cerclage is not routinely recommended¹

• The choice of anaesthesia should be made by the operating team in conjunction with the woman²

• Elective cerclage can safely be performed as a day-case procedure

• Most patients can be discharged after recovery from the anaesthetic and when able to ambulate and void

• Recommended check fetal heart with USS or sonic aid prior to discharge home.

• Bed rest should not be routinely recommended, but the decision should be individualised.

• Abstinence from sexual intercourse following cerclage insertion should not be routinely recommended

• While routine serial sonographic measurement of the cervix is not recommended it may be useful in individual cases following ultrasound-indicated cerclage to offer timely administration of steroids or in utero transfer³

• In the presence of history-indicated cerclage additional ultrasound-indicated cerclage is not routinely recommended as, compared with expectant management, it may be associated with an increase in both pregnancy loss and birth before 35 weeks of gestation³

• The decision to place an emergency cerclage following an elective or ultrasound-indicated cerclage should be made on an individual basis taking into account the clinical circumstances⁴

• Routine fetal fibronectin testing is not recommended post-cerclage, However, the high negative predictive value of fetal fibronectin testing for subsequent birth at less than 30 weeks of gestation in asymptomatic high-risk women with a cerclage in place may provide reassurance to women and clinicians in individual cases²

• Patients are told to report any leakage of fluid from the vagina so that they can be evaluated for membrane rupture.

• They should also be 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.

• A transvaginal cervical cerclage should be removed between 36⁺¹ – 37⁺⁰ weeks of gestation

• If delivery is by elective caesarean section in which case suture removal could be delayed until this time.

• In women presenting in established preterm labour, the cerclage should be removed to minimise potential trauma to the cervix.

• Recommends that delayed removal of the cerclage for 48 hours can be considered in women with PPROM between 24⁺⁰ - 34⁺⁰ weeks of gestation and without evidence of infection or preterm labour. During this time a course of prophylactic steroids for fetal lung maturation can be completed and/or in utero transfer arranged.

• Given the risk of neonatal and/or maternal sepsis and the minimal benefit of 48 hours of latency in pregnancy with PPROM before 23 and after 34 weeks of gestation, delayed suture removal is unlikely to be advantageous in this situation.¹

• Delayed suture removal until labour ensues, or birth is indicated, is associated with an increased risk of maternal/fetal sepsis and is not recommended.¹

• Prior successful history-indicated cerclage – recommend repeat history-indicated cerclage for these patients.

• Prior successful ultrasound-indicated cerclage (delivery after 34 weeks) – recommend transvaginal ultrasound cervical length screening in future pregnancies.

• Prior unsuccessful ultrasound-indicated cerclage – For women with a prior ultrasound-indicated cerclage who went on to have an early spontaneous delivery (e.g., <34 weeks), recommend a history-indicated cerclage at 12 - 14 weeks of gestation in the next pregnancy.

• Current data do not support the use of cerclage in multiple pregnancies even when there is a history of preterm labour. The literature does not support the insertion of cerclage in multiple gestations on the basis of cervical length.

• The insertion of a history- or ultrasound-indicated cerclage in women with multiple pregnancies is not recommended.

Maternity Unit:

• Number of women who referred to consultant obstetrician before 12 weeks of gestation as a proportion of those eligible for elective cerclage

• Review of the indications for cerclage in women having undergone a procedure in line with local protocol.

• Proportion of women receiving aneuploidy screening before history- indicated cerclage insertion.

• Pregnancy loss rate at < 24 weeks of gestation and preterm delivery at 24 – 34 weeks of gestation following cervical cerclage insertion.

• Proportion of women who are given information about risks and potential outcome after rescue cerclage.

• Accuracy of documentation

1. Alfirevic Z, Stampalija T, Roberts D, Jorgensen AL. Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy (Protocol). Coherence Database of Systemic Reviews 2011, Issue 2. Art. No.: CD008991. DOL: 10.1002/ 14651858. CD008991

2. Berghella V, Raael TJ, Szychowski JM, Rust OA, Owen J. Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth: meta-analysis. Obstetrics and gynaecology. 2011;117(3):633-671

3. Fafael TJ, Berghella V, Alfirevic Z. Cervical stitch (cerclage) for preventing preterm birth in multiple pregnancies (Protocol). Cochrane Database of Systemic Reviews 2011, Issue6. Art. No.:CD009166. DOI:10.1002/14651858.D009166.

4. RCOG. Cervical cerclage. Green-top Guideline No. 75June 2022. Shennan AH, Story L; the Royal College of Obstetricians, Gynaecologists. Cervical Cerclage.BJOG 2022;129:1178–1210.

5. NICE. Preterm Labour and Birth guideline 25. NICE 2015

6. Alexander S, Boulvain M, Ceysens G, Haelterman E, Zhang WH. Repeat digital cervical assessment in pregnancy for identifying women at risk of preterm labour. Cochrane Database Syst Rev 2010; (6): CD005940.

7. V Berghella. Novel developments on cervical length screening and progesterone for preventing preterm birth. BJOG 2009; 116:182-7

8. Heath VCF, Southall TR, Souka AP, Elisseou A, Nicholaides KH. Cervical length at 23 weeks of gestation: prediction of spontaneous preterm delivery. Ultrasound Obstet Gynaecol 1998;92:902-7

9. Romero R, Nicolaides K, Conde-Agudelo A, Tabor A, O’Brien JM, Cetingoz E et al. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and Meta analysis of individual patient data. Am J Obstet Gynecol

10. Berghella V, Baxter JK, Hendrix NW, Cervical assessment by ultrasound for preventing preterm delivery. Cochrane Database Syst Rev 2013; (1) CD007235.

11. Crane JMG, Hutchens D, Transvaginal sonographic measurement of cervical length to predict preterm birth in asymptomatic women at increased risk: a systematic review. Ultrasound Obstet Gynecol 2008; 31:579-87.

12. Gibb D, Saridogan E. The role of transabdominal cervical cerclage techniques in maternity care

13. Berghella V, Seibel-Seamon J. Contemporary Use of Cervical Cerclage. Clin Obstet Gynecol 2007;50-468-77

14. Jones B, Shennan A. Cervical cerclage. In: Preterm Birth (Proceeding of the 36 RCOG study Group). Critchley H, Bennett P, Thornton S, editors. London: RCOG Press; 2004

15. Drakeley AJ, Roberts D, Alfirevic Z. Cervical stitch (cerclage) for preventing pregnancy loss in women. Cochrane Database Syst Rev 2003 ;( 1):CD003253.

16. Macnaughton MC, Chalmers IG, Dubowitz V, Dunn PM, Grant Am, Mcpherson Ket.al. Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists Multicentre Randomised Trial of Cervical Cerclage. Br J Obstet Gynaecol 1993;100:516-23

17. Galyean A, Garite TJ, Maurel K, Abril D, Adair CD et al. Removal versus retention of cerclage in preterm premature rupture of membranes: a randomized controlled trial. Am J Obstet Gynecol 2014;211:399.e1-399.e7.

18. Conde-Agudelo A, Romero R, Nicolaides K, Chaiworapongsa T, O’Brien JM, Cetingoz E et al. Vaginal progesterone vs cervical cerclage for the prevention of preterm birth in women with a sonographic short cervix, previous preterm birth, and singleton gestation: a systematic review and indirect comparison meta analysis. Am J Obstet Gynecol 2013; 208:42. E1-42.e18.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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