Is cerclage safe and effective in preventing preterm birth in women presenting early in pregnancy with cervical dilatation?
BMJ 2021; 375 doi: https://doi.org/10.1136/bmj-2021-067470 (Published 12 November 2021) Cite this as: BMJ 2021;375:e067470
- N Pilarski, clinical research fellow for C-STICH212,
- V Hodgetts-Morton, clinical lecturer and senior research fellow for C-STICH and C-STICH2 trials12,
- R K Morris, professor of obstetrics and maternal fetal medicine, director of the Birmingham Clinical Trials Unit, and chief investigator for C-STICH212
- 1Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
- 2Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation, Trust, Birmingham B15 2TG, UK
- Correspondence to: R K Morris r.k.morris@bham.ac.uk
What you need to know
Emergency cervical cerclage is a potential treatment for women presenting with cervical dilatation and exposed unruptured fetal membranes before 28 weeks of pregnancy in the absence of bleeding, uterine activity, or infection
There is limited low quality evidence mainly from retrospective studies that emergency cervical cerclage may prolong pregnancy duration, but possible selection bias and insufficient reporting of complications restrict their clinical interpretation
There is no evidence to support the use of progesterone, NSAIDs, pessary, prophylactic antibiotics, or tocolytics as independent treatments in these women
Preterm birth and its complications account for nearly one million neonatal deaths each year globally.1 Women who present with a dilated cervix in the second trimester are at increased risk of pregnancy loss and preterm birth (fig 1). They generally have no or minimal preceding symptoms such as change in discharge or mild abdominal pain and are detected to have a dilated cervix on examination. Cervical dilatation may also be detected in the anomaly scan.
Premature cervical dilatation and exposed unruptured fetal membranes
International guidelines from the US, UK, and Canada suggest considering emergency cervical cerclage, or rescue cerclage, to prevent preterm birth in women presenting with cervical dilatation and exposed fetal membranes between 16 and 28 weeks of gestation if there are no signs of bleeding, infection, or uterine activity (see box 1).2
NICE guidelines for management of preterm labour and birth (NG25)2
Women with a closed cervix
For women with a history of spontaneous preterm birth or second trimester miscarriage, plus a cervical length of <25 mm on transvaginal ultrasound (TVUSS): offer a choice of prophylactic cervical cerclage or progesterone.
For women with a history of spontaneous preterm birth or second trimester miscarriage, or a cervical length of <25 mm on TVUSS (but not both): consider progesterone.
For women with a history of preterm premature rupture of the membranes (PPROM) or cervical trauma, plus a cervical length …
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