INTRODUCTION

Cervical cerclage refers to a variety of surgical procedures in which sutures, wires, or synthetic tape are used to reinforce
the cervix. These procedures are intended to mechanically increase the tensile strength of the cervix, thereby reducing the
occurrence of adverse perinatal events associated with cervical insufficiency (ie, relatively painless cervical changes that
occur in the second trimester and result in recurrent pregnancy loss). Adverse perinatal events associated with cervical
insufficiency include:

• Prolapse of the fetal membranes into the vagina

• Intraamniotic infection
• Preterm premature rupture of the fetal membranes (PPROM)
• Preterm labor and delivery (PTD)
• Fetal loss

However, the efficacy of cerclage for prevention of these adverse events compared to no intervention or other
interventions is uncertain. (See "Cervical insufficiency", section on 'Treatment'.)

INDICATIONS AND CONTRAINDICATIONS

Indications

• Poor obstetrical history — An elective (prophylactic or history-indicated) cerclage is typically placed at the end of
the first trimester (12 to 14 weeks of gestation) to prevent recurrence of early preterm delivery [1]. The procedure is also
performed in some women with risk factors for early preterm delivery, such as a history of in-utero diethylstilbestrol (DES)
exposure, congenital cervical anomalies, or history of significant trauma to the cervix (eg, large conization); however,
there is no proven benefit to elective cerclage placement in the absence of one or more prior early preterm deliveries.
(See "Cervical insufficiency".)
• Cervical changes on ultrasound — An urgent (ultrasound-indicated) cerclage is performed when cervical
shortening is visualized on ultrasound evaluation of the cervix. (See "Cervical insufficiency", section on 'Clinical assessment
of the pregnant patient with suspected cervical insufficiency' and "Prediction of prematurity by transvaginal ultrasound
assessment of the cervix".)
• An emergent (rescue, physical examination indicated) cerclage is placed when advanced cervical changes are
noted on digital and visual examination.

Contraindications — Not all women are good candidates for cervical cerclage; the major contraindications are fetal
anomaly incompatible with life, intrauterine infection, active bleeding, active preterm labor, premature rupture of
membranes, and fetal demise. The presence of fetal membranes prolapsing through the external cervical os is a relative
contraindication to the procedure because the risk of iatrogenic rupture of the membranes in this setting may exceed 50
percent [1,2]. Several techniques (eg, Trendelenburg position, back-filling the maternal bladder, decompression
amniocentesis) have been used to make the fetal membranes retract prior to cerclage placement, with variable results
(see 'Replacement of prolapsed membranes' below).

» To continue reading this article you need to login or subscribe.

Ready to join over 400,000 satisfied users?Subscribe to read this article and others like it.

Clinicians Learn MorePatients Learn More

Last literature review version 18.3: September 2010
This topic last updated: August 19, 2009
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the
advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed
by the UpToDate Terms of Use (click here) ©2011 UpToDate, Inc.

References
Top

1. Harger, JH. Cerclage and cervical insufficiency: an evidence-based analysis. Obstet Gynecol 2002; 100:1313.
2. American College of Obstericians and Gynecologists. ACOG Practice Bulletin. Cervical insufficiency. Obstet
Gynecol 2003; 102:1091.
3. Althuisius, SM, Dekker, GA, van Geijn, HP, Hummel, P. The effect of therapeutic McDonald cerclage on cervical
length as assessed by transvaginal ultrasonography. Am J Obstet Gynecol 1999; 180:366.
4. Funai, EF, Paidas, MJ, Rebarber, A, et al. Change in cervical length after prophylactic cerclage. Obstet Gynecol
1999; 94:117.
5. Dijkstra, K, Funai, EF, O'Neill, L, et al. Change in cervical length after cerclage as a predictor of preterm delivery.
Obstet Gynecol 2000; 96:346.
6. O'Connell, MP, Lindow, SW. Reversal of asymptomatic cervical length shortening with cervical cerclage: a
preliminary study. Hum Reprod 2001; 16:172.
7. Hershkovitz, R, Burstein, E, Pinku, A. Tightening McDonald cerclage suture under sonographic guidance.
Ultrasound Obstet Gynecol 2008; 31:194.
8. Rust, OA, Atlas, RO, Meyn, J, et al. Does cerclage location influence perinatal outcome? Am J Obstet Gynecol
2003; 189:1688.
9. Groom, KM, Shennan, AH, Bennett, PR. Ultrasound-indicated cervical cerclage: outcome depends on preoperative
cervical length and presence of visible membranes at time of cerclage. Am J Obstet Gynecol 2002; 187:445.
10. MCDONALD, IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Emp 1957; 64:346.
11. Shirodkar, VN. A new method of operative treatment for habitual abortion in the second trimester of pregnancy.
Antiseptic 1955; 52:299.
12. Woensdregt, K, Norwitz, ER, Cackovic, M, et al. Effect of 2 stitches vs 1 stitch on the prevention of preterm birth
in women with singleton pregnancies who undergo cervical cerclage. Am J Obstet Gynecol 2008; 198:396.e1.
13. Berghella, V, Seibel-Seamon, J. Contemporary use of cervical cerclage. Clin Obstet Gynecol 2007; 50:468.
14. American College of Obstetricians and Gynecologists. ACOG practice bulletin number 47, October 2003:
Prophylactic Antibiotics in Labor and Delivery. Obstet Gynecol 2003; 102:875.
15. Rust, OA, Atlas, RO, Reed, J, et al. Revisiting the short cervix detected by transvaginal ultrasound in the second
trimester: why cerclage therapy may not help. Am J Obstet Gynecol 2001; 185:1098.
16. Treadwell, MC, Bronsteen, RA, Bottoms, SF. Prognostic factors and complication rates for cervical cerclage: a
review of 482 cases. Am J Obstet Gynecol 1991; 165:555.
17. Romero, R, Gonzalez, R, Sepulveda, W, et al. Infection and labor. VIII. Microbial invasion of the amniotic cavity in
patients with suspected cervical incompetence: prevalence and clinical significance. Am J Obstet Gynecol 1992;
167:1086.
18. Novy, MJ, Ducsay, CA, Stanczyk, FZ. Plasma concentrations of prostaglandin F2 alpha and prostaglandin E2
metabolites after transabdominal and transvaginal cervical cerclage. Am J Obstet Gynecol 1987; 156:1543.
19. Novy, MJ, Haymond, J, Nichols, M. Shirodkar cerclage in a multifactorial approach to the patient with advanced
cervical changes. Am J Obstet Gynecol 1990; 162:1412.
20. Visintine, J, Airoldi, J, Berghella, V. Indomethacin administration at the time of ultrasound-indicated cerclage: is
there an association with a reduction in spontaneous preterm birth? Am J Obstet Gynecol 2008; 198:643.e1.
21. Yoon, HJ, Hong, JY, Kim, SM. The effect of anesthetic method for prophylactic cervical cerclage on plasma
oxytocin: a randomized trial. Int J Obstet Anesth 2008; 17:26.
22. Scheerer, LJ, Lam, F, Bartolucci, L, Katz, M. A new technique for reduction of prolapsed fetal membranes for
emergency cervical cerclage. Obstet Gynecol 1989; 74:408.
23. Goodlin, RC. Cervical incompetence, hourglass membranes, and amniocentesis. Obstet Gynecol 1979; 54:748.
24. Pereira, L, Levy, C, Lewis, D, et al. Effect of suture material on the outcome of emergent cerclage. Am J Obstet
Gynecol 2005; 193:S128.
25. Ludmir, J, Jackson, GM, Samuels, P. Transvaginal cerclage under ultrasound guidance in cases of severe cervical
hypoplasia. Obstet Gynecol 1991; 78:1067.
26. Andersen, HF, Karimi, A, Sakala, EP, Kalugdan, R. Prediction of cervical cerclage outcome by endovaginal
ultrasonography. Am J Obstet Gynecol 1994; 171:1102.
27. Guzman, ER, Houlihan, C, Vintzileos, A, et al. The significance of transvaginal ultrasonographic evaluation of the
cervix in women treated with emergency cerclage. Am J Obstet Gynecol 1996; 175:471.
28. O'Brien, JM, Hill, AL, Barton, JR. Funneling to the stitch: an informative ultrasonographic finding after cervical
cerclage. Ultrasound Obstet Gynecol 2002; 20:252.
29. Hedriana, HL, Lanouette, JM, Haesslein, HC, McLean, LK. Is there value for serial ultrasonographic assessment of
cervical lengths after a cerclage? Am J Obstet Gynecol 2008; 198:705.e1.
30. Roman, AS, Rebarber, A, Sfakianaki, AK, et al. Vaginal fetal fibronectin as a predictor of spontaneous preterm
delivery in the patient with cervical cerclage. Am J Obstet Gynecol 2003; 189:1368.
31. Duhig, KE, Chandiramani, M, Seed, PT, et al. Fetal fibronectin as a predictor of spontaneous preterm labour in
asymptomatic women with a cervical cerclage. BJOG 2009; 116:799.
32. Bisulli, M, Suhag, A, Arvon, R, et al. Interval to spontaneous delivery after elective removal of cerclage. Am J
Obstet Gynecol 2009; 201:163.e1.
33. Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists multicentre
randomised trial of cervical cerclage. MRC/RCOG Working Party on Cervical Cerclage. Br J Obstet Gynaecol 1993;
100:516.
34. Aarts, JM, Brons, JT, Bruinse, HW. Emergency cerclage: a review. Obstet Gynecol Surv 1995; 50:459.
35. Wong, GP, Farquharson, DF, Dansereau, J. Emergency cervical cerclage: a retrospective review of 51 cases. Am J
Perinatol 1993; 10:341.
36. Simcox, R, Shennan, A. Cervical cerclage in the prevention of preterm birth. Best Pract Res Clin Obstet Gynaecol
2007; 21:831.
37. Barth WH, Jr. Cervical incompetence and cerclage: unresolved controversies. Clin Obstet Gynecol 1994; 37:831.
38. Baxter, JK, Airoldi, J, Berghella, V. Short cervical length after history-indicated cerclage: is a reinforcing cerclage
beneficial? Am J Obstet Gynecol 2005; 193:1204.
39. Rush, RW, Isaacs, S, McPherson, K, et al. A randomized controlled trial of cervical cerclage in women at high risk
of spontaneous preterm delivery. Br J Obstet Gynaecol 1984; 91:724.
40. Lazar, P, Gueguen, S, Dreyfus, J, et al. Multicentred controlled trial of cervical cerclage in women at moderate
risk of preterm delivery. Br J Obstet Gynaecol 1984; 91:731.
41. Harger, JH. Cervical cerclage: patient selection, morbidity, and success rates. Clin Perinatol 1983; 10:321.
42. Grant, AM. Cervical cerclage. In: Pregnancy and Childbirth Module (Enkin MW, Keirse MJNC, Renfrew MJ, Neilson
JP, eds.) Cochrane Database of Systematic Reviews, Review # 04135, 1994.
43.Yeast, JD, Garite, TR. The role of cervical cerclage in the management of preterm premature rupture of the
membranes. Am J Obstet Gynecol 1988; 158:106.
44. Blickstein, I, Katz, Z, Lancet, M, Molgilner, BM. The outcome of pregnancies complicated by preterm rupture of
the membranes with and without cerclage. Int J Gynaecol Obstet 1989; 28:237.
45. Kuhn, RPJ, Pepperell, RJ. Cervical ligation: a review of 242 pregnancies. Aust N Z J Obstet Gynecol 1977:79.
46. Ludmir, J, Bader, T, Chen, L, et al. Poor perinatal outcome associated with retained cerclage in patients with
premature rupture of membranes. Obstet Gynecol 1994; 84:823.
47. McElrath, TF, Norwitz, ER, Lieberman, ES, Heffner, LJ. Management of cervical cerclage and preterm premature
rupture of the membranes: should the stitch be removed? Am J Obstet Gynecol 2000; 183:840.
48.McElrath, TF, Norwitz, ER, Lieberman, ES, Heffner, LJ. Perinatal outcome after preterm premature rupture of
membranes with in situ cervical cerclage. Am J Obstet Gynecol 2002; 187:1147.
49.Jenkins, TM, Berghella, V, Shlossman, PA, et al. Timing of cerclage removal after preterm premature rupture of
membranes: maternal and neonatal outcomes. Am J Obstet Gynecol 2000; 183:847.
50. Kominiarek, MA, Kemp, A. Perinatal outcome in preterm premature rupture of membranes at < or = 32 weeks
with retained cerclage. J Reprod Med 2006; 51:533.
51. Arias, F. Cervical cerclage for the temporary treatment of patients with placenta previa. Obstet Gynecol 1988;
71:545.
52. Cobo, E, Conde-Agudelo, A, Delgado, J, et al. Cervical cerclage: an alternative for the management of placenta
previa? Am J Obstet Gynecol 1998; 179:122.
53. Neilson, JP. Interventions for suspected placenta praevia. Cochrane Database Syst Rev 2003; :CD001998.
54. Odibo, AO, Berghella, V, To, MS, et al. Shirodkar versus McDonald cerclage for the prevention of preterm birth in
women with short cervical length. Am J Perinatol 2007; 24:55.
55. Harger, JH. Comparison of success and morbidity in cervical cerclage procedures. Obstet Gynecol 1980; 56:543.
56. Peters WA, 3rd, Thiagarajah, S, Harbert GM, Jr. Cervical cerclage: twenty years' experience. South Med J 1979;
72:933.
57. Robboy, MS. The management of cervical incompetence. UCLA experience with cerclage procedures. Obstet
Gynecol 1973; 41:108.
58. Perrotin, F, Marret, H, Ayeva-Derman, M, et al. [Second trimester cerclage of short cervixes: which technique to
use? A retrospective study of 25 cases]. J Gynecol Obstet Biol Reprod (Paris) 2002; 31:640.
59. Berghella, V, Odibo, AO, To, MS, et al. Cerclage for short cervix on ultrasonography: meta-analysis of trials using
individual patient-level data. Obstet Gynecol 2005; 106:181.
60. Fejgin, MD, Gabai, B, Goldberger, S, et al. Once a cerclage, not always a cerclage. J Reprod Med 1994; 39:880.
61. Pelham, J, Lewis, D, Farrell, C, et al. Prior cerclage: to repeat or not to repeat, that is the question. Am J Obstet
Gynecol 2002; 187:S115.