On at least one occasion, I have discovered that the patient scheduled for cerclage has not undergone preoperative screening for genital tract infections. In such a scenario, it is unclear whether it is best to cancel the procedure or to proceed. Berghella and colleagues concluded that evidence is insufficient to support routine, universal screening for genital tract infection prior to cerclage. In the absence of risk factors for infection, it may be appropriate to proceed with cerclage.
The issue of combined use of cerclage and 17α hydroxyprogesterone caproate also was addressed in this review. Berghella and colleagues recommended that progestin supplementation be continued if cerclage is subsequently performed. I, too, follow this approach, although the two interventions (progestin followed by cerclage) have not been studied in this sequence.
Related article: A stepwise approach to cervical cerclage (June 2012)
Data are limited, and conflicting, on the use of 17α hydroxyprogesterone caproate after cerclage. A small randomized trial suggested benefit,9 while a retrospective cohort study10 and a secondary analysis of data from a randomized trial of cerclage11 found no benefit for the addition of 17α hydroxyprogesterone caproate.
Berghella and colleagues advocated against reinforcing (second or repeat) cerclage, an intervention that may be associated with a higher incidence of preterm birth.12 Accordingly, continuing sonographic assessment of cervical length after cerclage may be futile. What this evidence means for practice
Increasing evidence suggests that cervical shortening is not limited to an innate or acquired cervical weakness but represents an early, asymptomatic phase on the pathway to preterm birth. Nevertheless, cerclage continues to be practiced widely and has been shown to be beneficial in selected populations.
We clinicians often face complex cases of presumed cervical insufficiency for which there are no simple or unequivocal recommendations. This appraisal by Berghella and colleagues will help us separate evidence-validated approaches from misconceptions in the technical aspects of cerclage.
--Alex C. Vidaeff, MD, MPH
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