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Laparoscopic Extracorporeal Knot-Tying for Uterine Vessel Occlusion during Hysterectomy with Cervical Cerclage in Large Uteri
Published on: September 12, 2025
Preoperative considerations for cervical cerclage (part 1)
Ilaria Paladino1, Moti Gulersen2, Amanda Roman2
1Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (Paladino, Gulersen, Roman, Boelig, and Berghella); Department of Woman, Child and Neonate, Prenatal Diagnosis and Fetal Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli studi di Milano, Milan, Italy (Paladino).
American Journal of Obstetrics & Gynecology MFM
|July 9, 2026
Summary
Transvaginal cervical cerclage is key for preventing spontaneous preterm birth. This guide clarifies preoperative management for history-indicated, ultrasound-indicated, and physical examination-indicated cerclage, optimizing patient selection and timing.
Area of Science:
- Obstetrics and Gynecology
- Maternal-Fetal Medicine
Background:
- Transvaginal cervical cerclage is a primary intervention for preventing spontaneous preterm birth (SPTB).
- Significant variability exists in the pre-, intra-, and postoperative management protocols for cerclage procedures.
- This article focuses on evidence-based preoperative decision-making for cerclage.
Purpose of the Study:
- To synthesize current evidence guiding preoperative decision-making for transvaginal cervical cerclage.
- To classify cerclage by indication: history-indicated (HIC), ultrasound-indicated (UIC), and physical examination-indicated cerclage (PEIC).
- To provide recommendations on patient selection, timing, and preoperative evaluation for each cerclage type.
Main Methods:
- Classification of cerclage based on indications: HIC, UIC, and PEIC.
- Review of evidence regarding optimal timing for cerclage placement based on indication.
- Synthesis of recommendations for preoperative evaluation, including ultrasound and genetic screening.
- Evaluation of adjunctive management options like progesterone, antibiotics, and inpatient vs. outpatient settings.
Main Results:
- HIC is recommended for specific histories of SPTB or mid-trimester losses; twin gestation alone is not an indication.
- UIC is considered/recommended based on transvaginal ultrasound cervical length (TVU CL) thresholds in singleton and twin gestations.
- PEIC is recommended for asymptomatic cervical dilation (≥1 cm) before 24 weeks.
- Timing varies: HIC (12-14 weeks), UIC (16-23 6/7 weeks, within 72 hours of diagnosis), PEIC (16-23 6/7 weeks, within 24 hours of diagnosis).
- Preoperative evaluation includes anatomic ultrasound and genetic screening; routine urogenital cultures are not indicated symptomatically.
- Amniocentesis is not recommended for HIC/UIC but considered for PEIC.
- Progesterone is recommended for short cervix; outpatient cerclage is safe.
Conclusions:
- Preoperative management for transvaginal cervical cerclage should be tailored to the specific indication (HIC, UIC, PEIC).
- Clear guidelines exist for patient selection and timing based on cervical length and obstetric history.
- Adjunctive therapies like progesterone may be beneficial, while routine inpatient management and perioperative antibiotics/indomethacin are often unnecessary.
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