CMECNE

Cervical Cerclage – Professional Recommendations

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

Faculty:

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 Sema4, 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 2020, 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.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

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
- Singleton pregnancy
- Prior spontaneous preterm birth (<34 weeks)
- Cervical length: <25 mm (at <24 weeks)

SMFM states that cervical insufficiency in women should be considered in the presence of

≥1 early PTB and/or second trimester losses and
Cervical length (CL) <25 mm on transvaginal ultrasound (TVUS) before 24 weeks or cervical dilatation >1cm on exam

Timing of Cerclage Placement

History-indicated cerclage
- Place between 12 and 14 weeks after confirmation of pregnancy viability
Ultrasound or exam-indicated cerclage
- May be placed prior to 23 weeks

Risk Factors

Prior PTB
Repeated cervical dilation
Cervical procedures (including cone and LEEP)
Cervical laceration
Urogenital abnormalities

SYNOPSIS:

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.

KEY POINTS:

Ultrasound Indicated Cerclage with Prior History of Preterm Birth or Second Trimester Losses (SMFM)

CL surveillance
- 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

Special Circumstances

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
- Neonatal survival
  - 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

Learn More – Primary Sources:

SMFM: Cervical cerclage for the woman with prior adverse pregnancy outcome

ACOG Practice Bulletin 142: Cerclage for the Management of Cervical Insufficiency

Physical Examination–Indicated Cerclage: A Systematic Review and Meta-analysis

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Cervical Cerclage – Professional Recommendations