PP-020 Comparative review of major guidelines on cervical cerclage

The aim of this study was to review and compare the most recently published major guidelines on the indications, contraindications, techniques and timing of placing and removal of cervical cerclage, which represents one of the limited effective measures currently available for the prevention of preterm labor caused by cervical insufficiency contributing in the reduction of neonatal morbidity and mortality rates, worldwide.

A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynaecologists, the Society of Obstetricians and Gynaecologists of Canada and the International Federation of Gynaecology and Obstetrics on cervical cerclage was carried out.

There is consensus among the reviewed guidelines regarding the recommended techniques, the physical examination-based indications for cervical cerclage, the contraindications as well as the optimal timing of placement and removal. All medical societies also agree that ultrasound-indicated cerclage is justified in women with history of prior spontaneous preterm labor or mid-trimester loss and a short cervical length detected on ultrasound. In addition, following cerclage, serial sonographic measurement of the cervical length, bed rest and routine use of antibiotics, tocolysis and progesterone are unanimously discouraged. In case of established preterm labor, cervical cerclage should be removed, according to the American, the English and the Canadian guidelines. Furthermore, the Royal College of Obstetricians and Gynaecologists and the Society of Obstetricians and Gynaecologists of Canada agree on the prerequisites that should be met before attempting CC. These two guidelines along with the International Federation of Gynaecology and Obstetrics recommend history-indicated cerclage for women with three or more previous preterm deliveries and/or 2nd trimester pregnancy losses, while the American College suggests the use of cerclage in singleton pregnancies with one or more previous 2nd trimester miscarriages related to painless cervical dilation or prior cerclage due to painless cervical dilation in the 2nd trimester. The role of amniocentesis in ruling out intra-amniotic infection before rescue cerclage remains a matter of debate. As for preterm premature rupture of membranes, the Royal College points out that if it occurs between 24 and 34 weeks of gestation and there are no signs of infection or preterm labor, cerclage removal should be delayed for 48 hours in order to allow in utero transfer.

Cervical cerclage is an obstetric intervention used to prevent miscarriage and preterm labor in women considered as high-risk for these common pregnancy complications. The development of uniform international practice protocols for the insertion of cervical cerclage seems of paramount importance and will hopefully improve the outcomes of such pregnancies.