[Prophylactic cerclage or cervical surveillance after a single spontaneous preterm birth: Critical review of current...

Spontaneous preterm births, particularly those occurring before 32 weeks of gestation, are a major cause of neonatal morbidity. In women with a prior spontaneous preterm birth, the risk of recurrence is estimated at around 30%. Two main preventive strategies are proposed: prophylactic cerclage, performed before 16 weeks, and cervical ultrasound surveillance with ultrasound-indicated cerclage in case of cervical shortening. In the absence of a standardized clinical definition of cervical insufficiency, comparisons between these strategies are limited by three main factors: indication bias, as women at highest risk are more likely to undergo cervical ultrasound monitoring; the lack of a standardized clinical definition of cervical insufficiency, which leads to the inclusion of lower-risk women and dilutes potential benefits; and the relative rarity of the condition, which reduces the statistical power of available studies. Meta-analyses cannot correct for these limitations. The absence of a demonstrated difference despite indication bias suggests that classical cases of cervical insufficiency may benefit more from prophylactic cerclage. Future research should also consider medico-economic and psychological aspects. In conclusion, for women with an isolated history of spontaneous preterm birth, the choice between prophylactic cerclage and ultrasound surveillance should be individualized, taking into account clinical history, patient preferences, and available resources.