Abdominal and transvaginal cervical cerclage

She is 19 weeks pregnant and the speculum shows bulging membranes at the os. She is not in labour and she is not septic — yet. In the next hour you will decide whether a stitch can save this pregnancy, and the answer turns on three things: who benefits, which technique, and what you must exclude before you operate. Cerclage is a narrow-spectrum intervention — powerful in the right phenotype, useless or harmful in the wrong one.^[1][10]

Overview and definition

Cervical cerclage places a supportive suture around the cervix to reinforce the internal os and reduce second-trimester loss and spontaneous preterm birth in women judged to have cervical insufficiency.^[1][10] The procedure comes in three indication classes and two anatomical approaches, and almost every exam answer hinges on matching the right indication to the right woman.^[1]

Three indications: ^[1][5]

• History-indicated (prophylactic) — placed electively early in the second trimester on the strength of an obstetric history strongly suggestive of cervical insufficiency, such as recurrent second-trimester losses or prior very preterm births.
• Ultrasound-indicated — placed when serial transvaginal cervical length screening shows a short cervix, in a woman already at risk.
• Examination-indicated (rescue/emergency) — placed when the cervix is already dilating painlessly and membranes are visible, after labour and infection are excluded.

Two approaches: ^[1][7]

• Transvaginal — McDonald (purse-string at the cervicovaginal junction) and Shirodkar (dissection to place a band higher, nearer the internal os). Removed in the antenatal period, delivery usually vaginal.
• Transabdominal — open or laparoscopic, the suture placed at the level of the internal os, reserved for the failed vaginal cerclage or the inaccessible cervix. Removed at caesarean.

References12ShowHide

1. [1]Shennan AH, Story L Cervical Cerclage: Green-top Guideline No. 75 BJOG, 2022.PMID 35199905
2. [2]MRC/RCOG Working Party on Cervical Cerclage 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.PMID 8334085
3. [3]To MS, Alfirevic Z, Heath VC, et al. Cervical cerclage for prevention of preterm delivery in women with short cervix: randomised controlled trial Lancet, 2004.PMID 15183621
4. [4]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.PMID 21446209
5. [5]Berghella V, Mackeen AD Cervical length screening with ultrasound-indicated cerclage compared with history-indicated cerclage for prevention of preterm birth: a meta-analysis Obstet Gynecol, 2011.PMID 21691173
6. [6]Ehsanipoor RM, Seligman NS, Saccone G, et al. Physical Examination-Indicated Cerclage: A Systematic Review and Meta-analysis Obstet Gynecol, 2015.PMID 26241265
7. [7]Shennan A, Chandiramani M, Bennett P, et al. MAVRIC: a multicenter randomized controlled trial of transabdominal vs transvaginal cervical cerclage Am J Obstet Gynecol, 2020.PMID 31585096
8. [8]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.PMID 36273481
9. [9]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.PMID 37481990
10. [10]Alfirevic Z, Stampalija T, Medley N Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy Cochrane Database Syst Rev, 2017.PMID 28586127
11. [11]Medley N, Vogel JP, Care A, Alfirevic Z Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews Cochrane Database Syst Rev, 2018.PMID 30480756
12. [12]D'Antonio F, Berghella V, Di Mascio D, et al. Role of progesterone, cerclage and pessary in preventing preterm birth in twin pregnancies: A systematic review and meta-analysis Eur J Obstet Gynecol Reprod Biol, 2021.PMID 33946019