EditorialThe role of cervical cerclage in obstetric practice: Can the patient who could benefit from this procedure be identified?
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)
- et al.
Prediction of preterm delivery with transvaginal ultrasonography of the cervix in patients with high-risk pregnancies: does cerclage prevent prematurity?
Am J Obstet Gynecol
(1999) - et al.
Cervical incompetence prevention randomized cerclage trial (CIPRACT): study design and preliminary results
Am J Obstet Gynecol
(2000) - et al.
A randomized trial of cerclage versus no cerclage among patients with ultrasonographically detected second-trimester preterm dilatation of the internal os
Am J Obstet Gynecol
(2000) - et al.
Revisiting the short cervix detected by transvaginal ultrasound in the second trimester: why cerclage therapy may not help
Am J Obstet Gynecol
(2001) - et al.
Patients with prior second-trimester loss: prophylactic cerclage or serial transvaginal sonograms?
Am J Obstet Gynecol
(2002) - et al.
Ultrasound-indicated cervical cerclage: outcome depends on preoperative cervical length and presence of visible membranes at time of cerclage
Am J Obstet Gynecol
(2002) Cerclage and “cervical insufficiency”: an evidence-based analysis
Obstet Gynecol
(2002)- et al.
Effectiveness of cervical cerclage for a sonographically shortened cervix: a systematic review and meta-analysis
Am J Obstet Gynecol
(2003) - et al.
Cervical cerclage for prevention of preterm delivery: meta-analysis of randomized trials
Obstet Gynecol
(2003) - et al.
Vaginal sonography and cervical incompetence
Am J Obstet Gynecol
(2003)
Cerclage for prevention of preterm birth in women with a short cervix found on transvaginal ultrasound examination: a randomized trial
Am J Obstet Gynecol
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
Cerclage for the short cervix demonstrated by transvaginal ultrasound: current practice and opinion
J Obstet Gynaecol Can
Cervical cerclage for prevention of preterm delivery in women with short cervix: randomised controlled trial
Lancet
Short cervical length after history-indicated cerclage: is a reinforcing cerclage beneficial?
Am J Obstet Gynecol
Decreased elastic fibers and desmosine content in incompetent cervix
Am J Obstet Gynecol
Interleukin-8 is a mediator of the final cervical ripening in humans
Eur J Obstet Gynecol Reprod Biol
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
Evaluation of effectiveness of prophylactic cerclage of a short cervix according to interleukin-8 in cervical mucus
Am J Obstet Gynecol
Prediction of risk for preterm delivery by ultrasonographic measurement of cervical length
Am J Obstet Gynecol
Sonographic measurement of uterine cervix at 18-22 weeks' gestation and the risk of preterm delivery
Obstet Gynecol
Patients with an ultrasonographic cervical length ≤15 mm have nearly a 50% risk of early spontaneous preterm delivery
Am J Obstet Gynecol
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
Cervical length at 23 weeks in twins in predicting spontaneous preterm delivery
Obstet Gynecol
Use of cervical ultrasonography in prediction of spontaneous preterm birth in triplet gestations
Am J Obstet Gynecol
Use of cervical ultrasonography in prediction of spontaneous preterm birth in twin gestations
Am J Obstet Gynecol
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
Vaginal ultrasonographic assessment of cervical length changes during normal pregnancy
Am J Obstet Gynecol
The natural history of a positive response to transfundal pressure in women at risk for cervical incompetence
Am J Obstet Gynecol
A comparison of ultrasonographically detected cervical changes in response to transfundal pressure, coughing, and standing in predicting cervical incompetence
Am J Obstet Gynecol
Longitudinal assessment of endocervical canal length between 15 and 24 weeks' gestation in women at risk for pregnancy loss or preterm birth
Obstet Gynecol
Cervical cerclage: an aggressive approach to threatened or recurrent pregnancy wastage
Am J Obstet Gynecol
Postconceptional cervical cerclage
Int J Gynaecol Obstet
The significance of transvaginal ultrasonographic evaluation of the cervix in women treated with emergency cerclage
Am J Obstet Gynecol
Cervical incompetence: elective, emergent, or urgent cerclage
Am J Obstet Gynecol
Final results of the Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): therapeutic cerclage with bed rest versus bed rest alone
Am J Obstet Gynecol
A new method of operative treatment for habitual abortions in the second trimester of pregnancy
Antiseptic
Suture of the cervix for inevitable miscarriage
J Obstet Gynaecol Br Emp
Vaginal ultrasound and cervical cerclage: a prospective study
Ultrasound Obstet Gynecol
Pregnancy outcomes in women treated with elective versus ultrasound-indicated cervical cerclage
Ultrasound Obstet Gynecol
Cervical length at 23 weeks of gestation: the value of Shirodkar suture for the short cervix
Ultrasound Obstet Gynecol
Short cervical length by ultrasound and cerclage
J Perinatol
Does cervical cerclage prevent preterm delivery in patients with a short cervix?
Am J Obstet Gynecol
Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): effect of therapeutic cerclage with bed rest vs. bed rest only on cervical length
Ultrasound Obstet Gynecol
A randomised controlled trial of outpatient versus inpatient cervical cerclage
J Obstet Gynaecol
Elective cerclage vs. ultrasound-indicated cerclage in high-risk pregnancies
Ultrasound Obstet Gynecol
Cervical stitch (cerclage) for preventing pregnancy loss in women
Cochrane Database Syst Rev
Prevention of preterm birth by cervical cerclage compared with expectant management: a systematic review
Obstet Gynecol Surv
Cervical surveillance as an alternative to elective cervical cerclage for pregnancy management of suspected cervical incompetence
Aust NZ J Obstet Gynaecol
Cervical length measurement and cervical cerclage to prevent preterm birth
Clin Obstet Gynecol
Cited by (141)
Perinatal outcomes of emergency and elective cervical cerclages
2024, European Journal of Obstetrics and Gynecology and Reproductive Biology: XAntibiotic treatment for intra-amniotic inflammation in threatened midtrimester miscarriage
2023, American Journal of Obstetrics and GynecologyA Retrospective Study Comparing Laparoscopic Transabdominal Cerclage: Pre-Pregnancy Versus in Pregnancy With Their Reproductive Outcomes and Safety
2023, Journal of Obstetrics and Gynaecology CanadaToward a new taxonomy of obstetrical disease: improved performance of maternal blood biomarkers for the great obstetrical syndromes when classified according to placental pathology
2022, American Journal of Obstetrics and GynecologyCerclage in singleton gestations with an extremely short cervix (≤10 mm) and no history of spontaneous preterm birth
2021, American Journal of Obstetrics and Gynecology MFMComplications of Laparoscopic and Transabdominal Cerclage in Patients with Cervical Insufficiency: A Systematic Review and Meta-analysis
2021, Journal of Minimally Invasive GynecologyCitation 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].
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.