BACKGROUND AND PURPOSE:

• Progesterone is not effective when cervical length (CL) <10 mm
• Data is limited on best management for women with
  • Progressive cervical shortening when a patient is already on progesterone or
  • Very short CL
• Cerclage may prolong pregnancy and decrease preterm births in the above clinical scenarios
• Daskalakis et al. (AJOG, 2019) studied whether cervical cerclage decreases preterm birth in women with progressively shortening CL or very short CL

METHODS:

• Prospective study
• Participants
  • singleton pregnancies
  • CL shortening (≤25mm) identified during second trimester prenatal sonogram
• Exclusion criteria
  • Major fetal anomalies | Placenta previa | Active vaginal bleeding | Cervical cerclage already present | Active labor | Adolescent pregnancy
• Exposures
  • CL ≤25 mm: Vaginal progesterone (80 mg/dL vaginal gel) at night and weekly follow-up
  • CL continues to shorten to ≤15 mm or initial CL ≤15 mm ( <26 weeks): Women offered modified McDonald procedure with using 5-mm polyester cerclage tape
• Cerclage antibiotic prophylaxis post-procedure
  • First 2 days: IV cefuroxime 750 mg and metronidazole 500 mg every 8 hours
  • Following 8 days: Oral roxithromycin 300 mg once a day
• Perinatal outcomes assessed

RESULTS:

• 101 patients were included, resulting in 3 groups
  • Remained on progesterone only: n=38
  • Initial cerclage group: n=25
  • Progesterone plus cerclage for progressive shortening: 37
• Similar between all 3 groups were
  • Baseline characteristics such as first-trimester and second-trimester pregnancy losses
  • History of preterm birth
  • Cervical conization
  • Presence of preterm contractions
• Preterm premature rupture of membranes was more frequent in the cerclage group (P = 0.014)
  • Progesterone only group: 0%
  • Cerclage group: 12%
  • Progesterone and cerclage group: 0%
• Gestational latency period was increased in the progesterone group (P = 0.028)
  • Progesterone only group: 16 weeks
  • Cerclage group: 14.4 weeks
  • Progesterone and cerclage group: 15.3 weeks
• Gestational age at delivery was similar for all three groups
  • Progesterone only group: 38.4 weeks
  • Cerclage group: 38.3 weeks
  • Progesterone and cerclage group: 38.5 weeks

CONCLUSION:

• The authors suggest that cervical cerclage to treat a progressively shortening cervix for women already on progesterone or a very short cervix may be helpful  
• Patients in this study were also treated with extended course of antibiotics which may have impacted the results

Learn More – Primary Sources:

A stepwise approach for the management of short cervix: time to evolve beyond progesterone treatment in the presence of progressive cervical shortening

Related ObG Topics:

Progesterone or Cerclage in Preterm Prevention in Women with Previous Preterm Birth and Short Cervix?

Cervical Cerclage – Professional Recommendations

Can Cervical Pessaries Prevent Preterm Birth?

Do Progestogens Prevent Preterm Birth in Symptomatic Pregnancies with a Short Cervix?