SPOTLIGHT

Does a stitch in time save structural differences, or iatrogenic due to previous cervical
surgery or full dilatation caesarean section.

lives? An update on the For preterm birth and mid-trimester pregnancy loss mediated
by cervical insufficiency, defined as shortening of the cervix prior

evidence for cervical to 24 weeks, or cervical incompetence, historically defined as

repeated mid-trimester delivery in the absence of significant

cerclage in 2024 haemorrhage, cerclage remains a key treatment. A Cochrane

review in 2017 found cerclage probably reduces the risk of
perinatal death compared with no cerclage although the result
Nicole Pilarski was not statistically significant. Additional or alternative thera-
R Katie Morris peutic options to cerclage include progesterone, and treatment of
bacterial vaginosis and urinary tract infection.
Victoria Hodgetts-Morton The aim of this review is to highlight the latest guidance
and summarise new published research in relation to cervical
cerclage and it’s role in preventing pregnancy loss and preterm
Abstract birth.
The potential therapeutic benefit of cervical cerclage for preventing
pregnancy loss has been recognised for over 120 years; however,
there remain many unanswered questions. There is considerable A summary of current guidance
uncertainty regarding who is most suitable or will benefit most from
cerclage, what type of suture should be used, such as low vaginal,
Royal College of Obstetrics and Gynaecology (RCOG)
high vaginal or transabdominal sutures, and indeed the suture
guidance
technique, as well as when alternative or adjunctive therapies may
The latest RCOG Green Top Guideline for cervical cerclage was
be employed. This review presents a summary of recent guidance, published in 2022. The key recommendations are summarised in
new evidence and expectations for ongoing research to inform Table 1. The only Grade A recommendation is that after a failed
understanding of the role of cervical cerclage in 2024 and beyond. transvaginal suture a transabdominal suture should be consid-
ered and discussed. This is based on the evidence from the
Keywords Cervical cerclage; cervical suture; emergency cerclage;
MAVRIC trial, a randomised controlled trial (RCT) of women
pregnancy loss; preterm birth
who had previously experienced a failed cerclage. 111 women
were randomised to either low vaginal suture, high vaginal
suture, or transabdominal suture (TAC). The trial found TAC
Introduction after failed vaginal cerclage to be associated with a significant
reduction in the risk of preterm birth <32 weeks gestation and
Preterm birth remains the leading cause of neonatal morbidity fetal loss compared to either high- or low-vaginal suture.
and mortality in the UK as well as globally and therefore these The authors explicitly mention terminology and some of the
answers cannot come soon enough. Spontaneous preterm birth, confusion that differing or vague terms can create for patients but
distinct form iatrogenic preterm birth, is a clinical syndrome with also healthcare professionals. The guidance makes recommen-
many underlying aetiologies and therefore there will not be one dations for appropriate nomenclature which are laid out in
“silver bullet”, a cure-all intervention for all prematurity. Spon- Table 2.
taneous preterm birth may occur due to placental factors such as
early onset growth restriction and placental abruption, infectious
factors such as ascending urogenital tract infection, bacterial NICE preterm labour and birth [NG25]
vaginosis and urinary infections, and mechanical factors such as The NICE preterm labour and birth guideline [NG25] was
cervical insufficiency which may be related to congenital published in 2015. However the following updates have been
since issued relevant to the discussion of cervical cerclage:
(1) in 2019, following the OPPTIMUM study of vaginal proges-
terone, it was recommended to offer a choice of vaginal
Nicole Pilarski MBBS MSc Clinical Research Fellow for C-STICH2 and progesterone or vaginal cerclage for women with a history of
Obstetrics and Gynaecology Trainee (ST3), Institute of Applied Health
previous PTB or mid-trimester loss and a short cervix of
Research, University of Birmingham and Birmingham Women’s and
Children’s NHS Foundation Trust, UK. Conflicts of interest: none <25 mm. In addition, women with no risk factors and an
declared. incidental finding of a short cervix (<25 mm) between 16
and 34 þ 0 weeks gestation should be offered prophylactic
R Katie Morris MBBS MRCOG PhD Professor of Maternal Fetal
vaginal progesterone
Medicine and Consultant Obstetrician, Institute of Applied Health
Research, University of Birmingham and Birmingham Women’s and (2) In 2019 the NICE guidance was updated to recommend using
Children’s NHS Foundation Trust, UK. Conflicts of interest: none a cervical length of <25 mm as the threshold for high-risk of
declared. preterm birth.
(3) In 2022 the guidance was changed to expand upon the advice
Victoria Hodgetts-Morton MBBS MRCOG PhD Associate Professor and
Consultant Obstetrician, Institute of Applied Health Research, surrounding repeated courses of antenatal steroids, recom-
University of Birmingham and Birmingham Women’s and Children’s mending that not more than two courses should be given for
NHS Foundation Trust, UK. Conflicts of interest: none declared. the risk of preterm birth.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 34:6 167 Ó 2024 Elsevier Ltd. All rights reserved.
 SPOTLIGHT

Key recommendations of the RCOG Green Top Guideline

Women with singleton pregnancies and three or more previous preterm births should be offered a Grade B
history-indicated cervical cerclage.
Women with a singleton pregnancy and a history of spontaneous second trimester loss or preterm Grade B
birth who have not undergone a history-indicated cerclage may be offered serial sonographic surveillance,
as those who experience cervical shortening may benefit from ultrasound-indicated cerclage while those
whose cervix remains long (greater than 25 mm) have a low risk of second-trimester loss/preterm birth.
For women with a singleton pregnancy and no other risk factors for preterm birth, insertion of cervical cerclage Grade B
is not recommended in women who have an incidentally identified short cervix.
In women with a previous unsuccessful transvaginal cerclage, insertion of a transabdominal cerclage may be Grade A
discussed and considered.
In women with a singleton pregnancy insertion of an emergency cerclage may delay birth by an average of Grade B
34 days, compared with expectant management/bed rest alone in suitable cases. It may also be associated
with a two-fold reduction in the chance of birth before 34 weeks of gestation. However, there are only limited data
to support an associated improvement in neonatal mortality or morbidity.
The choice of transvaginal cerclage technique (high cervical insertion with bladder mobilization or low cervical Grade C
insertion) should be at the discretion of the surgeon, but the cerclage should be placed as high as is practically possible.

Table 1

Saving Babies Lives Care Bundle (version 3) A summary of new evidence for history- and ultrasound-
Saving Babies Lives Care Bundle (SBLCB) version 2 element 5 indicated cerclage
focusses on reducing preterm birth. Version 2 standardised the
C-STICH is a UK-based RCT published in 2022 which recruited
risk factors for which preterm birth surveillance is indicated
2049 women over 6 years and randomised to either mono-
(Table 3). Version 3 of the care bundle was released in 2023 and
filament or braided suture. The trial found no difference in the
Element 5 was renamed as reducing preterm birth and optimising
primary outcome of pregnancy loss, or a composite outcome
perinatal care. The new recommendations for perinatal optimi-
including miscarriage, stillbirth, termination of pregnancy and
sation focus on antenatal actions, including place of birth, cor-
early neonatal death (adjusted risk ratio 1$05 [95% CI 0$79 to
ticosteroids, and magnesium sulphate, intrapartum antibiotics
1$40]). There was no significant difference in almost any of the
and cord management, and early post-partum interventions.
outcomes studied with the exception of maternal sepsis and

Recommended terminology and definitions from the RCOG Green Top Guideline
History-indicated cerclage Insertion of a cerclage as a result of factors in a woman’s obstetric or gynaecological history,
which increase the risk of spontaneous second trimester loss or preterm birth. A history-indicated
suture is performed as a prophylactic measure in asymptomatic women and usually inserted as
a planned procedure at 11e14 weeks of gestation.
Ultrasound-indicated cerclage Insertion of a cerclage as a therapeutic measure in cases of cervical length shortening seen on
transvaginal ultrasound. Ultrasound-indicated cerclage is performed on asymptomatic women
who do not have exposed fetal membranes in the vagina.
Emergency cerclage (also known as physical Insertion of cerclage as a salvage measure in the case of premature cervical dilatation with
exam-indicated or rescue cerclage) exposed fetal membranes in the vagina. This may be discovered by ultrasound examination
of the cervix or as a result of a speculum/physical examination performed for symptoms such
as vaginal discharge, bleeding or ‘sensation of pressure’. It can be considered up to 27þ6 weeks
gestation.
Transvaginal cerclage (McDonald) A transvaginal purse-string suture placed at the cervical isthmus junction, without bladder
mobilization.
High transvaginal cerclage requiring bladder A transvaginal purse-string suture placed following bladder mobilization, to allow insertion
mobilization (including Shirodkar) above the level of the cardinal ligaments.
Transabdominal cerclage A suture placed laparoscopically, or at laparotomy, at the cervicoisthmic junction.
Occlusion cerclage Occlusion of the external os by placement of a continuous non-absorbable suture, the intention
being to help with retention of the mucus plug.

Table 2

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 34:6 168 Ó 2024 Elsevier Ltd. All rights reserved.
 SPOTLIGHT

Saving Babies Lives: Risk assessment and management tool for pregnant women at risk of preterm birth
Surveillance and management

High risk
Previous preterm birth or mid-trimester loss 1 Referral to local or tertiary Preterm Prevention (PP) clinic by 12 weeks.
(16e34 weeks gestation).Previous preterm 2 Further risk assessment based on history  examination as appropriate in secondary
prelabour rupture of membranes <34/40. care with identification of pregnant women needing referral to tertiary services.
Previous use of cervical cerclage. 3 All pregnant women to be offered transvaginal cervix scanning every 2e4 weeks
Known uterine variant (i.e., unicornuate, between 16 and 24 weeks as a secondary test to more accurately quantify the risk
bicornuate uterus or uterine septum). of preterm birth.
Intrauterine adhesions (Ashermann’s syndrome). 4 Additional use of quantitative fetal fibronectin in asymptomatic pregnant women may
History of trachelectomy (for cervical cancer). be considered where centres have this expertise.
5 Interventions should be offered to pregnant women as appropriate, based on either
history or additional risk assessment tests by clinicians able to discuss the relevant
risks and benefits according to up to date evidence and relevant guidance, for example,
UK Preterm Clinical Network guidance (www.tommys.org/our-organisation/our-research/
premature-birth-research/reducing-preterm-birth-rates) and NICE guidance. These
interventions should include cervical cerclage, pessary and progesterone as appropriate.
Intermediate risk
Previous birth by caesarean section at 1 Refer to preterm birth prevention clinic by 12 weeks.
full dilatation. 2 Further risk assessment based on history  examination as appropriate in
History of significant cervical excisional event secondary care with discussion of option of additional risk assessment tests, including:
i.e., LLETZ where >15 mm depth removed, a A single transvaginal cervix scan between 18 and 22 weeks as a minimum.
or >1 LLETZ procedure carried out or cone biopsy b Additional use of quantitative fetal fibronectin in asymptomatic pregnant women
(knife or laser, typically carried out under can be considered where centres have this expertise.
general anaesthetic). 3 Interventions should be discussed with pregnant women as appropriate based on
either history or additional risk assessment tests by clinicians able to discuss the
relevant risks and benefits according to up-to-date evidence and relevant guidance.
These interventions should include cervical cerclage, pessary and progesterone as
appropriate.
4 Pregnant women at intermediate risk should be reassessed at 24 weeks for
consideration of transfer back to a low-risk pathway.

Table 3

chorioamnionitis, both unblinded and subjective clinical di- Summary of new evidence for emergency cerclage
agnoses. This evidence is consistent with previous guidance
The role of emergency cerclage (ECC), when the cervix has already
which advised the choice of suture material should be at the
dilated and the membranes are exposed, remains controversial.
discretion of the surgeon, although previously there was little
The Green Top guideline recommendations regarding emergency
evidence to support this assertion (grade 4, good practice point).
cerclage state that the decision for emergency cerclage should be
C-STICH offers a level of clinical certainty not often seen in ob-
carefully balanced, taking into account the parent’s views (grade
stetrics. Further work is awaited for secondary analyses to
2þ, strength D), and that ECC may prolong pregnancy by up to
explore the role of progesterone and suture technique particu-
34 days compared to expectant management but the impact on
larly related to the height of placement of the suture (low vs high-
neonatal morbidity and mortality is uncertain (grade 2-, strength
vaginal sutures) in preventing pregnancy loss. A recent system-
D). This is based on systematic review data, however the majority
atic review and meta-analysis of combined progesterone and
of studies are small observational studies at high risk of bias. A
cerclage found combination treatment to reduce the risk of PTB
more recent systematic review presents detailed analysis of the
before 37 and neonatal mortality compared to either cerclage or
evidence for ECC in singleton and twin pregnancies, including
progesterone alone.
analysis of demographic data of participants and frequency of use
A network meta-analysis of interventions to prevent preterm
of adjunctive treatments, however this data could not be analysed
birth in high-risk women with singleton pregnancies found that
with regards to clinical outcomes.
vaginal progesterone and Shirodkar suture (low certainty) were
C-STICH2 is a RCT of ECC compared to expectant manage-
associated with fewer preterm births at <34 weeks gestation.
ment currently recruiting in the UK. The study also includes an
Vaginal progesterone was the only intervention significantly
observational cohort for those participants that are not willing to
associated with reduction in perinatal death. McDonald suture
accept randomisation or where the responsible clinician was not
and cervical suture (unspecified) appeared to reduce the risk of
in equipoise and gave a recommendation of either emergency
perinatal death but the 95% credible interval included 1.0.
cerclage or conservative management.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 34:6 169 Ó 2024 Elsevier Ltd. All rights reserved.
 SPOTLIGHT

Cerclage in multiple pregnancies Hodgetts Morton V, Toozs-Hobson P, Moakes CA, et al. Monofilament
suture versus braided suture thread to improve pregnancy out-
The Cochrane review of 5 trials of cervical cerclage use in mul-
comes after vaginal cervical cerclage (C-STICH): a pragmatic
tiple pregnancies found no difference in perinatal deaths or
randomised, controlled, phase 3, superiority trial. Lancet 2022; 400:
neonatal morbidity. At that time there was insufficient evidence
1426e36.
to examine the role of emergency cerclage in multi-fetal preg-
Hulshoff CC, Bosgraaf RP, Spaanderman MEA, et al. The efficacy of
nancies. The RCOG guideline recommends that cervical cerclage
emergency cervical cerclage in singleton and twin pregnancies: a
is not performed in multiple pregnancies (grade 1þþ strength B)
systematic review with meta-analysis. American J Obstetrics Gy-
based on the meta-analysis results from the Cochrane systematic
necology MFM 2023; 5: 100971.
review. A recent systematic review and meta-analysis including
Medley N, Vogel JP, Care A, et al. Interventions during pregnancy to
26 studies again found no benefit of vaginal progesterone pessary
prevent preterm birth: an overview of Cochrane systematic reviews.
or cervical cerclage in the prevention of PTB <34 weeks in an
Cochrane Database Syst Rev 2018; 11: CD012505.
unselected population of twin pregnancies, nor in those with a
NICE. Preterm labour and birth NICE Guideline 25. National Institute
short (<25 mm) cervical length.
for Health and Care Excellence (NICE), 2015.
Only recently in 2020 was the first RCT of emergency cerclage
Norman JE, Marlow N, Messow CM, et al. Vaginal progesterone pro-
in twins published. The trial reported a significant reduction in
phylaxis for preterm birth (the OPPTIMUM study): a multicentre,
PTB <34 weeks and perinatal morbidity. Of note the trial was
randomised, double-blind trial. Lancet 2016; 387: 2106e16.
closed prematurely by the data monitoring committee after
Rafael TJ, Berghella V, Alfirevic Z. Cervical stitch (cerclage) for pre-
recruiting only 34 participants. The Twin-Cerclage trial of
venting preterm birth in multiple pregnancy. Cochrane Database
emergency cerclage for exposed membranes or ultrasound-
Syst Rev 2014; 2014: CD009166.
indicated cerclage for a very short cervix (<15 mm) in twin
Shennan AH, Story L. Cervical cerclage: green-top guideline No. 75.
pregnancies is currently recruiting. A Bjog 2022; 129: 1178e210.
Shennan A, Chandiramani M, Bennett P, et al. MAVRIC: a multicenter
FURTHER READING randomized controlled trial of transabdominal vs transvaginal cer-
Alfirevic Z, Stampalija T, Medley N. Cervical stitch (cerclage) for pre- vical cerclage. Am J Obstet Gynecol 2020; 222: 261.e1e9.
venting preterm birth in singleton pregnancy. Cochrane Database
Syst Rev 2017; 6: CD008991.
Aubin AM, Mcauliffe L, Williams K, et al. Combined vaginal proges- Practice points
terone and cervical cerclage in the prevention of preterm birth: a C Cervical cerclage is an important intervention for preventing
systematic review and meta-analysis. Am J Obstet Gynecol MFM
pregnancy loss in certain populations, such as women who have
2023; 5: 101024.
experienced multiple mid-trimester losses or early preterm births
Care A, Nevitt SJ, Medley N, et al. Interventions to prevent sponta-
and high-risk women with a short cervix identified by transvaginal
neous preterm birth in women with singleton pregnancy who are at
ultrasound scan
high risk: systematic review and network meta-analysis. Bmj 2022; C The potential benefit in other populations, such as those with an
376: e064547.
incidental finding of a short cervix or twin pregnancy, is uncertain
Ehsanipoor RM, Seligman NS, Saccone G, et al. Physical examination- C Suture thread and suture technique do not appear to make a
indicated cerclage: a systematic review and meta-analysis. Obstet
difference, although a transabdominal approach may be of benefit
Gynecol 2015; 126: 125e35.
if previous stitches have failed
Hezelgrave NL, Watson HA, Ridout A, et al. Rationale and design of C Further research is needed to understand the role of adjunctive
SuPPoRT: a multi-centre randomised controlled trial to compare
treatments such as progesterone alongside cerclage, surgical
three treatments: cervical cerclage, cervical pessary and vaginal
technique and whether emergency cerclage is a safe and effective
progesterone, for the prevention of preterm birth in women who
intervention when the membranes are exposed
develop a short cervix. BMC Pregnancy Childbirth 2016; 16: 358.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 34:6 170 Ó 2024 Elsevier Ltd. All rights reserved.