Because the data do not clearly support the use of cervical cerclage in higher-order multiple gestations, it is not recommended at this time. However, it appears that prophylactic cerclage may reduce extremely premature births in triplet pregnancies.23
Complications such as infection and erosion of the cerclage into adjacent organs suggest that the cerclage should be removed once its function has been fulfilled.
Controversy 9
Should a cerclage be placed prior to pregnancy?
Cerclage placement prior to pregnancy is predicated on the assumption that avoiding manipulation of the cervix during pregnancy is desirable. This is particularly true in circumstances when the more elaborate cerclage procedures are necessary, such as abdominal or Shirodkar techniques. With these modalities, blood loss may be greater during pregnancy, and cervical manipulation may be more extensive.
Data to support or condemn this approach are insufficient, but certain practical considerations are worth mentioning. The most frequently cited risk of cerclage placement during pregnancy is loss of the pregnancy. Anatomic injury to surrounding structures may occur in either the pregnant or nonpregnant state. Placement prior to pregnancy also can be problematic if subsequent pregnancy loss occurs or a fetal anomaly is diagnosed—especially in the case of abdominal cerclage. In extreme circumstances, the need for uterine evacuation via hysterotomy could arise. There is also the theoretical risk of reduced fertility due to increased inflammation of the cervix if the cerclage is placed prior to conception.
For these reasons, coupled with improved techniques of ultrasound diagnosis and obstetric anesthesia, I opt for placement of cerclage in the late first trimester of pregnancy.
CONTROVERSY 10
Is there a role for permanent cerclage placement?
By and large, permanent cerclage placement is not recommended. Complications, including infection and erosion of the cerclage into adjacent organs, suggest that the cerclage should be removed once its function has been fulfilled. The issue of permanent cerclage placement arises almost exclusively in regard to abdominal cerclage—less often to the “true” (as opposed to modified) Shirodkar cerclage. Since cesarean delivery is necessary in cases of abdominal cerclage, the cerclage may be removed when the patient experiences what she has determined will be her final delivery.
Dr. Repke reports no affiliations or financial arrangements with any of the manufacturers of products mentioned in this article or their competitors.