Green-top Guideline No. 75
June 2022
Key recommendations
Background and scope
The procedure, a stitch inserted into the cervix, was first performed
in 1902 in women with a history of second trimester loss or spontaneous preterm birth suggestive of cervical insufficiency, with the aim of preventing recurrent loss
Definitions
History-indicated cerclage
Insertion of a cerclage as a result of factors in a woman’s obstetric or gynaecological history, which increase the risk of spontaneous second trimester loss or preterm birth.
usually inserted as a planned procedure at 11–14 weeks of gestation.
Preterm Birth
Birth before to 37+0 weeks’ gestation.
Ultrasound-indicated cerclage
Insertion of a cerclage as a therapeutic measure in cases of cervical length shortening seen on transvaginal ultrasound.
usually performed between 14 and 24 weeks of gestation by transvaginal scan and with an empty maternal bladder.
Emergency cerclage (also known as physical exam-indicated or emergency cerclage)
Insertion of cerclage as a salvage measure in the case of premature cervical dilatation with exposed fetal membranes in the vagina.
It can be considered up to 27+6 weeks gestation.
Transvaginal cerclage (McDonald)
A transvaginal purse-string suture placed at the cervical isthmus junction, without bladder mobilization.
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 ligaments.
Transabdominal cerclage
A suture performed via a laparotomy or laparoscopy, placing the suture at the cervicoisthmic junction.
Occlusion cerclage
Occlusion of the external os by placement of a continuous non-absorbable suture. The theory behind the potential benefit of occlusion cerclage is retention of the mucus plug.
Ultrasound surveillance of cervical length is advocated in women at high and intermediate risk in Element 5 of the Saving Babies Lives Care Bundle
Women at high risk include
those with a previous preterm birth or second trimester loss (16–34 weeks’ gestation)
previous preterm prelabour rupture of membranes (PPROM) less than 34 weeks
previous use of cerclage
known uterine variant
intrauterine adhesions
history of trachelectomy.
These women are recommended to be reviewed by a preterm prevention specialist by 12 weeks where possible, or with the dating scan whichever is sooner, and offered transvaginal cervix scanning as a secondary screening test every 2–4 weeks between 16 and 24 weeks.
Women at intermediate risk include:
women including those who have a history of a previous full dilatation C-section
significant cervical excisional surgery i.e. large loop excision of the transformation zone (LLETZ)
with an excision depth greater than 1 cm, more than one procedure or a cone biopsy.
These women should undergo a single transvaginal cervix scan no later than 18–22 weeks as a minimum.
Can cervical cerclage be recommended in any other groups of women considered at increased
risk of preterm birth?
Transabdominal Cerclage
How should women who experience delayed miscarriage or fetal death be cared for?
When should a rescue cerclage be discussed and considered?
What are the contraindications to cerclage insertion?
What information should be given to women before cerclage insertion?
What investigations should be performed before insertion of cervical cerclage?
Should amniocentesis to detect infection be performed before rescue or ultrasoundindicated cerclage?
Is amnioreduction before emergency cerclage recommended?
About the Author
