Editorial
The role of cervical cerclage in obstetric practice: Can the patient who could benefit from this procedure be identified?

https://doi.org/10.1016/j.ajog.2005.12.002Get rights and content

This editorial critically examines the definition of “cervical insufficiency.” The definition, the clinical ascertainment, efforts to develop an objective method of diagnosis, as well as the nature of cervical disease leading to spontaneous mid-trimester spontaneous abortion and preterm delivery are reviewed. The value and limitations of cervical sonography as a risk assessment tool for spontaneous preterm delivery are appraised. The main focus is on the role of cervical cerclage to prevent an adverse pregnancy outcome. The value of assessing the presence or absence of endocervical inflammation in the outcome of cerclage placement is discussed.

Section snippets

When and how cervical cerclage was introduced into obstetric practice

Cervical cerclage was introduced in 1955 by V.N. Shirodkar, Professor of Midwifery and Gynecology at the Grant Medical College in Bombay, India.1 The procedure was developed in response to his observation that “some women abort repeatedly between the fourth and seventh months and no amount of rest and treatment with hormones seemed to help them in retaining the product of conception.”1 Shirodkar referred to a group of 30 women who had had at least 4 abortions (some between 9 and 11). He stated

The initial recognition of cervical incompetence as a mechanism for pregnancy loss

Cole, Culpepper, and Rowland are credited with the first description of cervical incompetence.32 In the “Practice of Physick,” published in 1658, they wrote, “the second fault in women which hindered conception is when the seed is not retained or the orifice of the womb is so slack that it cannot rightly contract itself to keep in the seed; which is chiefly caused by abortion or hard labor and childbirth, whereby the fibers of the womb are broken in pieces one from another and the inner orifice

Cervical incompetence/“cervical insufficiency”

Authors have repeated, often uncritically, definitions of cervical incompetence proposed by others. Such definitions need to be examined, particularly in light of recent observations and results of clinical trials. For example, the expectation that pregnancy loss and/or preterm delivery can be prevented with a “prophylactic cerclage” is now open to question based upon the results of randomized controlled trials7, 50, 51, 52 and some systematic reviews.18, 19, 20, 21 Moreover, the paper

Problems with the definition of “cervical insufficiency”

Harger defined “cervical insufficiency” as “the inability of the uterine cervix to retain a pregnancy in the absence of contractions or labor.”54 Yet, it is unclear how a clinician can objectively use this definition. For example, 1) How can an obstetrician identify “the inability of the cervix to retain the pregnancy?”; 2) What is the scientific evidence that the typical description of a patient with “cervical insufficiency” truly identifies a primary cervical disorder?; 3) What is the

Description of the typical patient with “cervical insufficiency”

The clinical diagnosis of “cervical insufficiency” is traditionally applied to patients with a history of recurrent mid-trimester spontaneous abortions and/or early preterm deliveries in which “the basic process is thought to be the failure of the cervix to remain closed during pregnancy.”33 The assumption is that cervical dilatation and effacement have occurred in the absence of increased uterine contractility.33 The presenting symptom is reported to be a feeling of vaginal pressure caused by

The lack of an objective test

Although the existence of “cervical insufficiency” is widely accepted among obstetricians, there is no objective diagnostic test for this condition. Several methods have been proposed for the diagnosis of “cervical insufficiency” in the nonpregnant state, including the progressive passage of Hegar number 6 to 8 mm or Pratt dilators through the internal cervical os,58, 59, 60 the use of balloon elastance test,58 or the ability of the cervix to hold an inflated Foley catheter during

Sonographic cervical length

Digital examination of the cervix is the method used to determine cervical status (effacement, dilatation, position, and consistency). Cervical sonography has become an objective and reliable method to assess cervical length, which approximates cervical effacement. The shorter the sonographic cervical length in the mid-trimester, the higher the risk of spontaneous preterm labor/delivery.63, 64, 65, 66, 67 However, there is no agreement on what is a sonographic short cervix. For example, Iams et

Cervical sufficiency/insufficiency as a continuum

The hypothesis that cervical competence or sufficiency represents a spectrum was proposed by Parikh and Mehta, who used digital examination of the cervix to assess sufficiency. The authors, however, concluded that degrees of cervical competence did not exist.78 Iams et al, using sonographic examination of the cervix, suggested that cervical sufficiency/insufficiency is a continuum.79 The authors reported a strong relationship between cervical length in pregnancy and previous obstetric history.

Cerclage to prevent mid-trimester abortion/preterm birth: A summary of the evidence

The clinical value of cervical cerclage has been subject of many observational and randomized clinical trials,4, 6, 7, 10, 12, 13, 17, 23, 27, 50, 51, 52, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103 and the studies have been subject to several systematic reviews.18, 19, 20 The evidence suggests the following conclusions:

  • 1)

    Cervical cerclage in women with a sonographic short cervix (15 mm or less) and at low risk for preterm delivery (by history) does not reduce the rate of

Is “cervical insufficiency” a discrete condition or a syndrome?

In a similar manner to preterm labor, preeclampsia, small-for-gestational age, fetal death, preterm prelabor rupture of membranes, the clinical conditions that describe “cervical insufficiency” can be considered “an obstetrical syndrome.”104 Cervical ripening in the mid-trimester may be the result of: 1) the loss of connective tissue after a cervical operation such as conization105, 106, 107; 2) a congenital disorder such as cervical hypoplasia after diethylstilbestrol (DES) exposure108, 109,

“Cervical insufficiency” as a clinical manifestation of intrauterine infection

A proportion of patients presenting with asymptomatic cervical dilatation in the mid-trimester have microbial invasion of amniotic cavity (MIAC)112, 113 that can be as high as 51.5%.112 MIAC may be caused by premature cervical dilatation with the exposure of the chorioamniotic membranes to the microbial flora of the lower genital tract. Microorganisms may gain access to the amniotic cavity by crossing intact membranes.112 Under these circumstances, infection would be a secondary phenomenon to

Cervical mucus concentrations of interleukin-8 in the mid-trimester of pregnancy: A risk factor for preterm delivery

Interleukin (IL)-8, a chemokine capable of inducing neutrophil chemotaxis,119, 120, 121 is produced by cervical tissue42, 122 and is capable of inducing cervical ripening when applied topically.123 The cervical mucus of normal pregnant women contains IL-8, and its concentration increases during the third trimester of pregnancy and labor, as do the number of granulocytes.124 IL-8 concentrations in cervical mucus can reflect physiologic changes such as cervical ripening but also pathology:

Can the combination of cervical ultrasound and markers of endocervical inflammation identify the patient who may benefit from a cerclage?

The study by Sakai et al published in this issue of the Journal included 16,508 women with singleton pregnancies in whom sonographic cervical length was determined. A short cervix (defined as 25 mm or less) was detected in 252 women and 246 were eligible for the study. A cervical cerclage was placed in women with a short cervix at the discretion of the attending physicians (cerclages were placed in 165 and not placed in 81). Cervical mucus was collected at the time of ultrasound examination,

Acknowledgment

The authors wish to acknowledge the contribution of Dr Jay lams for the insightful discussion on the subject of cervical insufficiency and cervical cerclage.

References (134)

  • V. Berghella et al.

    Cerclage for prevention of preterm birth in women with a short cervix found on transvaginal ultrasound examination: a randomized trial

    Am J Obstet Gynecol

    (2004)
  • K.M. Groom et al.

    Elective cervical cerclage versus serial ultrasound surveillance of cervical length in a population at high risk for preterm delivery

    Eur J Obstet Gynecol Reprod Biol

    (2004)
  • R. Pramod et al.

    Cerclage for the short cervix demonstrated by transvaginal ultrasound: current practice and opinion

    J Obstet Gynaecol Can

    (2004)
  • M.S. To et al.

    Cervical cerclage for prevention of preterm delivery in women with short cervix: randomised controlled trial

    Lancet

    (2004)
  • J.K. Baxter et al.

    Short cervical length after history-indicated cerclage: is a reinforcing cerclage beneficial?

    Am J Obstet Gynecol

    (2005)
  • P.C. Leppert et al.

    Decreased elastic fibers and desmosine content in incompetent cervix

    Am J Obstet Gynecol

    (1987)
  • M.K. Sennstrom et al.

    Interleukin-8 is a mediator of the final cervical ripening in humans

    Eur J Obstet Gynecol Reprod Biol

    (1997)
  • P.C. Leppert

    Proliferation and apoptosis of fibroblasts and smooth muscle cells in rat uterine cervix throughout gestation and the effect of the antiprogesterone onapristone

    Am J Obstet Gynecol

    (1998)
  • M. Sakai et al.

    Evaluation of effectiveness of prophylactic cerclage of a short cervix according to interleukin-8 in cervical mucus

    Am J Obstet Gynecol

    (2006)
  • H.F. Andersen et al.

    Prediction of risk for preterm delivery by ultrasonographic measurement of cervical length

    Am J Obstet Gynecol

    (1990)
  • P. Taipale et al.

    Sonographic measurement of uterine cervix at 18-22 weeks' gestation and the risk of preterm delivery

    Obstet Gynecol

    (1998)
  • S.S. Hassan et al.

    Patients with an ultrasonographic cervical length ≤15 mm have nearly a 50% risk of early spontaneous preterm delivery

    Am J Obstet Gynecol

    (2000)
  • R.L. Goldenberg et al.

    The preterm prediction study: risk factors in twin gestations. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network

    Am J Obstet Gynecol

    (1996)
  • A.P. Souka et al.

    Cervical length at 23 weeks in twins in predicting spontaneous preterm delivery

    Obstet Gynecol

    (1999)
  • E.R. Guzman et al.

    Use of cervical ultrasonography in prediction of spontaneous preterm birth in triplet gestations

    Am J Obstet Gynecol

    (2000)
  • E.R. Guzman et al.

    Use of cervical ultrasonography in prediction of spontaneous preterm birth in twin gestations

    Am J Obstet Gynecol

    (2000)
  • C. Vayssiere et al.

    Cervical length and funneling at 22 and 27 weeks to predict spontaneous birth before 32 weeks in twin pregnancies: a French prospective multicenter study

    Am J Obstet Gynecol

    (2002)
  • O. Kushnir et al.

    Vaginal ultrasonographic assessment of cervical length changes during normal pregnancy

    Am J Obstet Gynecol

    (1990)
  • E.R. Guzman et al.

    The natural history of a positive response to transfundal pressure in women at risk for cervical incompetence

    Am J Obstet Gynecol

    (1997)
  • E.R. Guzman et al.

    A comparison of ultrasonographically detected cervical changes in response to transfundal pressure, coughing, and standing in predicting cervical incompetence

    Am J Obstet Gynecol

    (1997)
  • E.R. Guzman et al.

    Longitudinal assessment of endocervical canal length between 15 and 24 weeks' gestation in women at risk for pregnancy loss or preterm birth

    Obstet Gynecol

    (1998)
  • W.R. Crombleholme et al.

    Cervical cerclage: an aggressive approach to threatened or recurrent pregnancy wastage

    Am J Obstet Gynecol

    (1983)
  • A. Ayhan et al.

    Postconceptional cervical cerclage

    Int J Gynaecol Obstet

    (1993)
  • E.R. Guzman et al.

    The significance of transvaginal ultrasonographic evaluation of the cervix in women treated with emergency cerclage

    Am J Obstet Gynecol

    (1996)
  • M. Kurup et al.

    Cervical incompetence: elective, emergent, or urgent cerclage

    Am J Obstet Gynecol

    (1999)
  • S.M. Althuisius et al.

    Final results of the Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): therapeutic cerclage with bed rest versus bed rest alone

    Am J Obstet Gynecol

    (2001)
  • V.N. Shirodkar

    A new method of operative treatment for habitual abortions in the second trimester of pregnancy

    Antiseptic

    (1955)
  • I.A. McDonald

    Suture of the cervix for inevitable miscarriage

    J Obstet Gynaecol Br Emp

    (1957)
  • M.J. Quinn

    Vaginal ultrasound and cervical cerclage: a prospective study

    Ultrasound Obstet Gynecol

    (1992)
  • E.R. Guzman et al.

    Pregnancy outcomes in women treated with elective versus ultrasound-indicated cervical cerclage

    Ultrasound Obstet Gynecol

    (1998)
  • V.C. Heath et al.

    Cervical length at 23 weeks of gestation: the value of Shirodkar suture for the short cervix

    Ultrasound Obstet Gynecol

    (1998)
  • J.U. Hibbard et al.

    Short cervical length by ultrasound and cerclage

    J Perinatol

    (2000)
  • S.S. Hassan et al.

    Does cervical cerclage prevent preterm delivery in patients with a short cervix?

    Am J Obstet Gynecol

    (2001)
  • S. Althuisius et al.

    Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): effect of therapeutic cerclage with bed rest vs. bed rest only on cervical length

    Ultrasound Obstet Gynecol

    (2002)
  • O. Blair et al.

    A randomised controlled trial of outpatient versus inpatient cervical cerclage

    J Obstet Gynaecol

    (2002)
  • M.S. To et al.

    Elective cerclage vs. ultrasound-indicated cerclage in high-risk pregnancies

    Ultrasound Obstet Gynecol

    (2002)
  • A.J. Drakeley et al.

    Cervical stitch (cerclage) for preventing pregnancy loss in women

    Cochrane Database Syst Rev

    (2003)
  • A.O. Odibo et al.

    Prevention of preterm birth by cervical cerclage compared with expectant management: a systematic review

    Obstet Gynecol Surv

    (2003)
  • S.P. Higgins et al.

    Cervical surveillance as an alternative to elective cervical cerclage for pregnancy management of suspected cervical incompetence

    Aust NZ J Obstet Gynaecol

    (2004)
  • M. Williams et al.

    Cervical length measurement and cervical cerclage to prevent preterm birth

    Clin Obstet Gynecol

    (2004)
  • Cited by (141)

    • Perinatal outcomes of emergency and elective cervical cerclages

      2024, European Journal of Obstetrics and Gynecology and Reproductive Biology: X
    • Complications of Laparoscopic and Transabdominal Cerclage in Patients with Cervical Insufficiency: A Systematic Review and Meta-analysis

      2021, Journal of Minimally Invasive Gynecology
      Citation Excerpt :

      Some studies reported that continuous vaginal bleeding after 8 weeks of gestation may be associated with membrane rupture and pregnancy loss [58]. Some studies assert that transcervical cerclage is associated with postoperative complications and a high risk of pregnancy loss [59]. Complications associated with cervical cerclage include chorioamnionitis, bleeding, and cerclage failure, leading to fetal loss [13].

    View all citing articles on Scopus

    Funded by the Perinatology Research Branch, Division of Intramural Research of the National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health.

    Dr Sonia Hassan is a Women's Reproductive Health Research Scholar funded by NICHD.

    No reprints available from the authors. Address correspondence to Roberto Romero, Perinatology Research Branch, NICHD, NIH, DHHS, Wayne State University/Hutzel Women's Hospital, 3990 John R, Box 4, Detroit, MI, 48201.

    View full text