Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Discuss when to place a cervical cerclage based on SMFM guidelines 2. Identify ideal candidates for cervical cerclage
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from August 7 2018 through August 7 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
ACOG defines cervical insufficiency as “the inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester.” In addition, ACOG separates out indication for cerclage in to 3 categories
History: ≥1 of the following
Second trimester pregnancy losses related to painless cervical dilation and no history of labor or abruption
Previous second trimester cerclage for painless cervical dilation
Physical Examination: Also known as ‘physical examination–indicated cerclage’, ‘rescue cerclage’ and ’emergency cerclage’
Patient presents with painless second trimester cervical dilation
Ultrasound: Cervical length shortening and history of preterm birth
Prior spontaneous preterm birth (<34 weeks)
Cervical length: <25 mm (at <24 weeks)
SMFM states that cerclages are effective in woman based on the following indications:
History indicated: 3 or more PTBs or second-trimester losses.
Ultrasound indicated: ≥1 early PTB (defined as delivery between 17w to 33w6d), and cervical length (CL) <25 mm on transvaginal ultrasound (TVUS) before 24 weeks
Timing of Cerclage Placement
Place between 12 and 14 weeks after confirmation of pregnancy viability
Ultrasound or exam-indicated cerclage
May be placed prior to 23 weeks
Repeated cervical dilation
Cervical procedures (including cone and LEEP)
Clinically, cervical insufficiency is painless dilation and recurrent mid-trimester losses without signs of preterm labor (PTL), PPROM, or infection. Patient history may include superimposed symptoms (i.e. bleeding, pressure), therefore a judicious review of records is advised. Those with a history of prior preterm birth can benefit from cervical length screening to appropriate guide selected patients for cerclage.
Ultrasound Indicated Cerclage with Prior History of Preterm Birth or Second Trimester Losses (SMFM)
Begin at 16 weeks
Perform every 2 weeks
CL measurement 25-29 mm: Perform weekly
Offer cerclage when
CL <25 mm prior to 23w0d weeks and
History of spontaneous PTB at 17w0d to 33w6d
17–alpha hydroxyprogesterone caproate (17-OHPC)
Note: Cerclage placement or presence should not alter recommendations
Evidence from research studies
There is no difference in efficacy of McDonald versus Shirodkar techniques
Diagnosis of cervical insufficiency is unclear
Consider close screening starting at 16 weeks in place of history indicated cerclage placement
Very early losses
Consider beginning screening <16 weeks if there is a history of very early second trimester losses
‘Emergency’ Cerclage (Exam indicated)
There is literature, including a meta-analysis (Obstet Gynecol, 2015), to support ’emergency’ or ‘rescue’ cerclage
Cerclage: 71% survival
No cerclage: 43% survival
Relative risk 1.65 (95% CI 1.19–2.28)
Prolongation of pregnancy
Mean difference: 33.98 days (95% CI, 17.88 to 50.08)
Authors note significant limitations including quality of data and only 1 RCT included
After clinical examination to rule out uterine activity, or intraamniotic infection, or both, physical examination-indicated cerclage placement (if technically feasible) in patients with singleton gestations who have cervical change of the internal os may be beneficial
SMFM Choosing Wisely Campaign
SMFM recommends the following after cerclage placement
Do not perform serial cervical length measurements
There is no evidence that cervical length monitoring following a cerclage improves outcomes, despite cervical shortening being associated with increased risk for preterm birth
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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