Although it has become the basic management tool for cervical incompetence, cervical cerclage—especially emergent cerclage—remains a procedure with well-defined risks and questionable benefits. Thus, it should be used judiciously.
This article addresses 10 particularly controversial questions about this intervention.
Indications
The only generally accepted indication for elective cerclage placement is a history suggestive of cervical incompetence. For emergent cerclage, the primary indication is premature effacement or dilatation of the cervix in the absence of labor prior to 28 weeks’ gestation. Asymptomatic women with a history of midtrimester delivery and sonographic evidence of cervical shortening or funneling also may benefit from emergent cerclage placement.
Contraindications
Absolute contraindications to cervical cerclage include uterine contractions or labor, unexplained vaginal bleeding, intrauterine or vaginal infection, rupture of fetal membranes, intrauterine fetal demise, major fetal anomaly, and a gestational age beyond 28 weeks.
Factors such as placenta previa, a mucopurulent cervical discharge with membrane opacification, fetal membranes prolapsing through the cervical os, and intrauterine fetal growth restriction may be regarded as relative contraindications to emergent cerclage.
Controversy 1
What is the role of antibiotics, tocolytics, and progestins?
Antibiotics. Disagreement remains over the advisability of administering antibiotics at the time of prophylactic cerclage placement, which is generally 10 to 15 weeks’ gestation. Unfortunately, we lack sufficient data to refute or support this strategy. Because cultures do not always identify potentially pathogenic organisms, and because some “normal” flora can become pathogenic under some circumstances, my practice is to administer a prophylactic antibiotic 30 minutes prior to the procedure. Since there is no “correct” choice of antibiotic, reasonably broad-spectrum coverage is generally desirable. Cefazolin, ampicillin, erythromycin, and clindamycin all are appropriate selections for this purpose.
Because the risk of infection is greater in emergent cerclage, given the greater exposure of the membranes to vaginal flora, my practice is to administer prophylactic antibiotics during the perioperative period. If the emergent cerclage is placed close to the limits of fetal viability, I give combined antibiotic therapy. Again, however, we lack sufficient data to definitively justify this approach. The risks and benefits must be discussed with the patient and her family, with all parties agreeing on the appropriate course.
Tocolytic therapy is a bit less controversial in regard to prophylactic cerclage. At 10 to 15 weeks’ gestation, preterm labor is unlikely. Thus, tocolytics are not called for, though sometimes they are given perioperatively to reduce cramping. As with the antibiotics controversy, data are insufficient to support or condemn this practice.
One or 2 doses of indomethacin at the time of cerclage placement has been anecdotally reported to reduce cramping and, potentially, local inflammatory response; again, evidence is lacking. The risks of such an approach are negligible. Nevertheless, they should be reviewed with the patient, along with benefits.
Prophylactic tocolytic therapy may be employed in the setting of emergent cerclage, especially if the procedure is performed at the limits of fetal viability when corticosteroid administration is being considered. Whether this approach prolongs pregnancy or improves outcomes is unclear.
CERVICAL CERCLAGE
Progestins have enjoyed episodic popularity as a means of reducing preterm birth. For this reason, clinicians have given progesterone as an adjunct to cerclage placement, either as an ongoing or perioperative regimen. The data that do exist suggest that the role of progestins—if there is one—may be to deter preterm labor rather than to reduce cervical incompetence. Therefore, progestins should not be used therapeutically as an acute intervention. For these reasons, progestins are not routinely given as an adjunct to cerclage.10 controversies
- What is the role of antibiotics, tocolytics, and progestins?
- When is transabdominal cerclage an option?
- After placement, what follow-up is necessary?
- What is the optimal time for removal?
- Should the cerclage be removed if the membranes rupture?
- Should a cerclage be placed in a woman with a short cervix?
- Should all DES-exposed women be offered prophylactic cerclage?
- What is the role of cervical cerclage in multiple gestations?
- Should a cerclage be placed prior to pregnancy?
- Is there a role for permanent cerclage placement?
In selected patients, transabdominal cervicoisthmic cerclage safely reduces the incidence of second-trimester pregnancy loss due to cervical incompetence.
Controversy 2
When is transabdominal cerclage an option?
Transabdominal cervicoisthmic cerclage (TAC) was developed for patients in whom placement of a transvaginal cerclage was technically impossible or in whom a prior cerclage had been unsuccessful. It was first described by Benson and Durfee, who published the results of their initial 10 cases in 1965.1 The perinatal salvage rate in this series was 11% (5 viable infants out of 45 pregnancies) before and 82% (11 of 13) after TAC placement.1