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Grand Rounds

Cervical Cerclage for a Progressively Shortening Cervix or Very Short Cervix

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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

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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?

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