Management strategies for the prevention of preterm birth: Part II - Update on cervical cerclage

Cerclage was devised more than 50 years ago based on the hypothesis that for some women, weakness or malfunction of the cervix has a causative role in the pathway to preterm birth (PTB). There have been many theories around the concept of cervical insufficiency but not much in the way of convincing evidence. The purpose of this review was to follow the recent developments in risk identification and prognostication of PTB in connection with appropriately targeted prophylactic interventions.

Sonographic cervical length measurement has emerged as an effective prognosticator for PTB in all populations studied so far, independently of obstetric history, consequently deriving a wider applicability than other predictors of PTB. However, the mechanisms leading to cervical shortening are poorly understood, and it cannot be assumed that all cases with a short cervix would benefit from cerclage. Specific conditions may actually reduce the efficacy and advisability of cerclage. For this reason, attempts have been made recently to further characterize the short cervix, leading to the conclusion that only women with a short cervix in the absence of infection/inflammation may be candidates for cerclage. Furthermore, two recent randomized trials of cerclage in women with short cervix on a second trimester ultrasound suggested a benefit with cerclage in PTB rate reduction only in those cases with a cervical length of less than 15 mm.

The existent literature has treated PTB prevention focusing exclusively on either progesterone use or cerclage, leaving the practitioners without any guidance on when to proceed with medical or surgical prophylaxis. Understanding that high-risk populations are not homogeneous and no single-approach modality is likely to be generally applicable, we have combined the available evidence on both progesterone and cerclage to provide guidance on how to identify subgroups of women at significantly increased risk for PTB and how to preferentially consider progesterone versus cerclage.