Guideline sources The following summarized guidelines for the evaluation and management of cervical insufficiency are prepared by our editorial team based on guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG 2022), the International Federation of Gynecology and Obstetrics (FIGO 2021), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2019; 2017), and the American College of Obstetricians and Gynecologists (ACOG 2018; 2014). 1 2 3 4 5 6 7 7 7 8 Definition Cervical insufficiency is defined by transvaginal ultrasound cervical length < 25 mm before 24 weeks in women with prior pregnancy losses or preterm births at 14-36 weeks, or by cervical changes detected on physical examination before 24 weeks of gestation. 7 Epidemiology https://web.pathway.md/diseases/rechVzRcFUmkJVeU2 1/7 6/29/23, 3:49 AM Cervical insufficiency Pathway Potential causes of cervical insufficiency include occult uterine activity, uterine overdistension, congenital or acquired cervical insufficiency, decidual hemorrhage, infection/inflammation (amniotic fluid or fetal membranes), and biological or genetic variation. 7 Disease course Cervical insufficiency is associated with recurrent second- or early third-trimester fetal loss, following painless cervical dilation, prolapse or rupture of the membranes, and expulsion of a live fetus despite minimal uterine activity. 8 Prognosis and risk of recurrence Preterm birth due to cervical insufficiency is associated with an infant mortality of 17.2%. 7 Guidelines 1. Screening and diagnosis Screening for risk factors: Evaluate for risk factors for cervical insufficiency in pregnant females or females planning pregnancy. Elicit a thorough medical history at initial evaluation as it may alert about risk factors in a first or index pregnancy. B Obtain detailed evaluation of risk factors in patients after a mid-trimester pregnancy loss or early premature delivery or with such complications occurred in a preceding pregnancy. B 2. Diagnostic investigations Urine and vaginal cultures: As per RCOG 2022 guidelines, do not obtain routine genital tract screening for infection before cerclage insertion. D As per SOGC 2019 guidelines, obtain urinalysis for culture and sensitivity and vaginal cultures for bacterial vaginosis at the first obstetric visit in patients with a history of cervical insufficiency, and treat any infection found. A 3. Medical management Antibiotic therapy: decide on initiating antimicrobial therapy in patients with a positive culture from a genital swab on an individual basis after discussion with the microbiology team. B Progesterone: insufficient evidence to support the use of progesterone alone over cervical cerclage. I https://web.pathway.md/diseases/rechVzRcFUmkJVeU2 2/7 6/29/23, 3:49 AM Cervical insufficiency Pathway 4. Nonpharmacologic interventions Activity restriction: as per RCOG 2022 guidelines, do not advise routine bed rest in patients undergone cerclage and individualize the decision, taking into account the clinical circumstances and potential adverse effects that bed rest could have on patients and their families, in addition to increased costs for the healthcare system. D Cerclage pessary: insufficient evidence to recommend Arabin pessary alone over cervical cerclage. I 5. Therapeutic procedures Indications for transvaginal cervical cerclage, elective: As per RCOG 2022 guidelines, perform history-indicated cervical cerclage in patients with singleton pregnancies and 3 previous preterm births. B Show 9 more As per FIGO 2021 guidelines: Perform an ultrasound-indicated cerclage in patients with a cervical length < 25 mm and a history of 1 spontaneous preterm birth and/or mid-trimester loss. B Consider performing ultrasound-indicated cerclage in high-risk patients without previous mid- trimester loss or preterm and a short cervix on an individual case basis. Recognize that the advantage for twins seems more likely at shorter cervical lengths (< 15 mm). C As per SOGC 2019 guidelines, perform elective cervical cerclage at 12-14 weeks of gestation in patients with a history of 3 second-trimester pregnancy losses or extreme premature deliveries, if no specific cause other than potential cervical insufficiency is identified. A Show 4 more Indications for transvaginal cervical cerclage, emergency: As per RCOG 2022 guidelines, decide on performing an emergency suture placement individually taking the parents' views carefully into account. Ensure a balance between a useful prolongation of pregnancy with its reduced neonatal morbidity and mortality against the possibility of prolonged severe neonatal morbidity in a baby that might otherwise die. Aid patients decisions by a senior obstetrician. B Show 3 more As per FIGO 2021 guidelines, consider performing a rescue cerclage in patients presenting with exposed membranes prolapsing through the cervical os on an individual case basis taking into account the high risk of infective morbidity to mother and baby. C As per SOGC 2019 guidelines: Consider performing emergency cerclage in patients with a cervix dilated to < 4 cm without contractions before 24 weeks of gestation. C Consider performing emergency or rescue cervical cerclage in patients with twin pregnancy with a dilated cervix (> 1 cm) before viability. C https://web.pathway.md/diseases/rechVzRcFUmkJVeU2 3/7 6/29/23, 3:49 AM Cervical insufficiency Pathway Indications for transabdominal cervical cerclage: As per RCOG 2022 guidelines, consider performing transabdominal cervical cerclage in patients with a previous unsuccessful transvaginal cervical cerclage. B Show 2 more As per FIGO 2021 guidelines, consider performing transabdominal cervical cerclage in patients failed a cerclage (delivery before 28 weeks after a history- or ultrasound-indicated, but not rescue cerclage). C As per SOGC 2019 guidelines: Consider performing transabdominal cervical cerclage in patients with a classic history of cervical insufficiency in the absence of additional mitigating factors, if a prior vaginal cervical cerclage has failed. C Perform transabdominal cervical cerclage placement in patients after trachelectomy. B Indications for additional cervical cerclage: Do not perform routine additional ultrasound-indicated cerclage in the presence of history- indicated cerclage as, compared with expectant management, it may be associated with an increase in both pregnancy loss and birth before 35 weeks of gestation. D Decide on performing an emergency cerclage after an elective or ultrasound-indicated cerclage on an individual basis taking into account the clinical circumstances. B Technical considerations for cervical cerclage: decide on anesthesia method by the operating team in conjunction with the patient. B Show 4 more Indications for cervical cerclage removal: as per RCOG 2022 guidelines, remove transvaginal cervical cerclage before labor usually between 36/1 and 37/0 weeks of gestation unless birth is by pre-labor C-section, in which case consider delaying suture removal until this time. B Show 5 more 6. Perioperative care Periprocedural antibiotic prophylaxis: As per RCOG 2022 guidelines, decide on administering antibiotic prophylaxis at the time of cerclage placement at the discretion of the operating team. B As per SOGC 2017 guidelines, do not administer prophylactic antibiotics to reduce infectious morbidity following elective or emergency cerclage. D Periprocedural tocolytics: as per RCOG 2022 guidelines, insufficient evidence to support the use of routine perioperative tocolysis in patients undergoing cerclage insertion. Consider administering tocolysis on an individual basis. I Preprocedural anomaly screening: Obtain a first trimester ultrasound and screening for aneuploidy before the insertion of a history- indicated suture to ensure both viability, singleton pregnancy and the absence of lethal/major https://web.pathway.md/diseases/rechVzRcFUmkJVeU2 4/7 6/29/23, 3:49 AM Cervical insufficiency Pathway fetal anomaly. B Ensure anomaly ultrasound has been obtained before ultrasound-indicated or emergency cerclage. B Preprocedural chorioamnionitis screening: consider obtaining maternal white cell count and CRP to detect chorioamnionitis before insertion of an emergency cerclage to aid management. Decide on obtaining these tests based on the overall clinical picture, but do not delay emergency cerclage in the absence of clinical signs of chorioamnionitis. C Preprocedural amniocentesis: insufficient evidence to recommend routine amniocentesis before rescue or ultrasound-indicated cerclage as there is no clear data demonstrating improved outcomes. I Show 2 more Preprocedural amnioreduction: do not perform amnioreduction before emergency cervical cerclage. D 7. Specific circumstances Patients with delayed miscarriage or fetal death: Involve a senior obstetrician to aid decision making on care and treatment of delayed miscarriage or fetal death in patients with an abdominal cerclage. B Consider performing complete evacuation through the stitch by suction curettage or by dilatation and evacuation (up to 18 weeks of gestation). Consider cutting the suture, usually via a posterior colpotomy, as an alternative. Consider performing hysterotomy or C-section if the former strategy fails. C 8. Patient education General counseling: Provide verbal and written information about potential complications before history- or ultrasound-indicated cerclage. Inform patients of the following before any type of cerclage: there is a small risk of intraoperative bladder damage, cervical trauma, membrane rupture and bleeding during insertion of cervical cerclage B cervical cerclage may be associated with a risk of cervical laceration/trauma if there is spontaneous labor with the suture in place B high vaginal cerclage, inserted with bladder mobilization, usually requires anesthetic for removal and therefore carries the risk of an additional anesthetic. B Show 2 more 9. Follow-up and surveillance Serial cervical length assessment: https://web.pathway.md/diseases/rechVzRcFUmkJVeU2 5/7 6/29/23, 3:49 AM Cervical insufficiency Pathway As per RCOG 2022 guidelines: Consider obtaining serial ultrasound measurement of the cervix individually after ultrasound- indicated cerclage to offer timely administration of corticosteroids or in utero transfer. C Consider obtaining serial ultrasound surveillance in patients with a history of spontaneous second trimester loss or preterm birth who have not undergone a history-indicated cerclage placement. C As per SOGC 2019 guidelines, consider obtaining serial cervical length assessment by ultrasound if cervical cerclage is not considered or justified but history suggests a risk for cervical insufficiency (1-2 prior mid-trimester losses or extreme premature deliveries). C Post-cerclage progesterone supplementation: do not initiate routine progesterone supplementation after cerclage placement. D Post-cerclage fibronectin testing: do not obtain routine fFN testing after cerclage placement, recognizing that the high negative predictive value of fFN testing for subsequent birth at < 30 weeks of gestation in asymptomatic high-risk patients with a cerclage in place may provide reassurance to patients and clinicians in individual cases. D Clinical findings Symptoms Past medical history Abdominal cramps Twin pregnancy Low back pain Past obstetric history Pelvic pressure Vaginal bleeding Injury from a previous childbirth Vaginal discharge Miscarriage Multiple pregnancy Medication history Premature labor Estrogens Premature rupture of membranes Past surgical history Recurrent miscarriages Gynecological surgery Gynecologic exam Braxton-hicks-like contractions Short cervical length References 1. Richard Brown, Robert Gagnon, Marie-France Delisle. No. 373 Cervical Insufficiency and Cervical Cerclage. J Obstet Gynaecol Can. 2019 Feb;41 2 233 247. Open 2. A H Shennan, L Story, Royal College of Obstetricians et al. Cervical Cerclage: Green-top Guideline No. 75. BJOG. 2022 Feb 24. Open https://web.pathway.md/diseases/rechVzRcFUmkJVeU2 6/7 6/29/23, 3:49 AM Cervical insufficiency Pathway 3. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No.142 Cerclage for the management of cervical insufficiency. Obstet Gynecol. 2014 Feb;123 2 Pt 1 372 379. Open 4. Julie van Schalkwyk, Nancy Van Eyk. No. 247 Antibiotic Prophylaxis in Obstetric Procedures. J Obstet Gynaecol Can. 2017 Sep;39 9):e293-e299. Open 5. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 199 Use of Prophylactic Antibiotics in Labor and Delivery. Obstet Gynecol. 2018 Sep;132 3):e103-e119. Open 6. Andrew Shennan, Lisa Story, Bo Jacobsson et al. FIGO good practice recommendations on cervical cerclage for prevention of preterm birth. Int J Gynaecol Obstet. 2021 Oct;155 1 19 22. Open 7. Amanda Roman, Anju Suhag, Vincenzo Berghella. Overview of Cervical Insufficiency: Diagnosis, Etiologies, and Risk Factors. Clin Obstet Gynecol. 2016 Jun;59 2 237 40.2016 Jun;59 2 237 40. Open 8. Frederik K Lotgering. Clinical aspects of cervical insufficiency. BMC Pregnancy Childbirth. 2007 Jun 1;7 Suppl 1 Suppl 1 S17.2007 Jun 1;7 Suppl 1 Suppl 1 S17. Open 9. Brown R, Gagnon R, Delisle MF. Cervical insufficiency and cervical cerclage. J Obstet Gynaecol Can. 2013 Dec;35 12 1115 1127. Open 10. Amanda Roman, Anju Suhag, Vincenzo Berghella. Overview of Cervical Insufficiency: Diagnosis, Etiologies, and Risk Factors. Clin Obstet Gynecol. 2016 Jun;59 2 237 40. Open 11. Frederik K Lotgering. Clinical aspects of cervical insufficiency. BMC Pregnancy Childbirth. 2007 Jun 1;7 Suppl 1 Suppl 1 S17. Open https://web.pathway.md/diseases/rechVzRcFUmkJVeU2 7/7