Cervical cerclage: when a relatively uncommon procedure deserves careful follow-up
Few situations in obstetrics generate more anxiety than the prospect of losing an otherwise wanted and potentially healthy pregnancy.
Prof. Andreas Obermair
3
min read
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News
Insights
Few situations in obstetrics generate more anxiety than the prospect of losing an otherwise wanted and potentially healthy pregnancy. When the cervix shortens or begins to dilate, doing something can feel inherently preferable to watching and waiting. Cerclage offers a tangible intervention and, understandably, the fear of pregnancy loss can sometimes drown out the more difficult question: in whom does cerclage actually improve the outcome? The evidence is very clear that a cerclage is not always successful in preventing pregnancy loss.
Good level evidence tells us that patient selection matters. One identical procedure can be beneficial in one clinical setting, offer little or no benefit in another and potentially cause harm in a third.
Should we operate? When? For whom? And once we have placed a cerclage, how do we know whether our own outcomes are what we would expect?
Most obstetricians will perform cervical cerclage only occasionally. That makes cerclage an even more interesting procedure for surgical outcome monitoring.
The indication matters
Perhaps the clearest evidence for benefit is in singleton pregnancies where there is both a previous spontaneous preterm birth and a short cervix.
An individual patient data meta-analysis reported that, among women with a singleton pregnancy, previous spontaneous preterm birth and cervical length below 25 mm before 24 weeks, preterm birth before 35 weeks fell from 41.3% without cerclage to 28.4% with cerclage. Composite perinatal mortality and morbidity also fell from 24.8% to 15.6%.
Change one part of that clinical picture, however, and the evidence changes.
For a singleton pregnancy with a short cervix but without previous preterm birth, the evidence summarised in the review does not demonstrate the same benefit from cerclage.
Twins are more complicated again. Routine prophylactic or ultrasound-indicated cerclage may be neutral or potentially harmful in some twin populations, whereas physical examination-indicated cerclage in women with cervical dilation appears considerably more promising.
And for rescue cerclage, the degree of cervical dilation matters. A systematic review found an association with improved neonatal survival and approximately one month of pregnancy prolongation, although much of the evidence was observational. Outcomes deteriorated substantially with increasing cervical dilation at the time of placement.
In other words, simply recording that a cerclage was performed tells us remarkably little.
Why we have updated Cervical Cerclage in SurgicalPerformance
As the evidence around cervical cerclage has evolved, we have recognised that our own approach to measuring the procedure needed to evolve with it.
Cervical cerclage has been available in SurgicalPerformance for some time. But the original procedure captured relatively limited information. It recorded that a cerclage had been performed, but not the indication, clinical circumstances surrounding the decision or pregnancy outcomes that followed.
And, as the evidence above makes clear, those details matter.
A history-indicated cerclage is very different from an ultrasound-indicated cerclage or a rescue procedure in a woman with an already dilated cervix. Cervical length, cervical dilatation, membrane status and gestational age all provide important context when interpreting what happens afterwards.
Most importantly, the outcome that ultimately matters is not simply whether the procedure was completed without a surgical complication. It is what happened to the pregnancy and the baby.
Connecting patient selection with outcomes
The updated procedure allows users to prospectively capture the indication for cerclage, including history-indicated, ultrasound-indicated and physical examination or rescue cerclage.
It also records the clinical findings that informed the decision to intervene, including cervical length, cervical dilatation and other relevant features.
These can then be linked with pregnancy outcomes, including gestational age at delivery and pregnancy prolongation, as well as neonatal outcomes.
This creates something we did not have before: the ability to connect who we select for cerclage, the circumstances in which we intervene and what happens afterwards.
That seems particularly important for a procedure where patient selection can change the expected benefit so substantially. And for uncommon procedures where most obstetricians perform relatively few cervical cerclages each year. That makes measurement harder, but arguably more valuable.
We tend to remember the exceptional cases: the pregnancy that reached term despite terrible odds or the heartbreaking loss that remains with us years later. What is much harder is remembering what happened across every consecutive patient.
Over time, we can ask: What were my indications in my practice and how supported are my indications by the available evidence? How has my indication and decision making changed over time? How advanced were my rescue cases? How long were pregnancies prolonged? At what gestation did my patients deliver? What complications occurred? And, ultimately, what happened to the babies?
Why measuring outcomes from uncommon procedures matter
This update is not intended to create another registry. It is about retaining clinically meaningful information from care we are already providing and making it available for our own reflection and quality improvement.
Cerclage is a hugely impactful procedure for expecting mums but also for obstetricians and gynaecologists to save a life. The evidence tells us that its value depends heavily on selecting the right patient in the right clinical circumstances. Our outcome measurement should reflect that complexity.
If cervical cerclage is part of your practice, we encourage you to use the updated Cervical Cerclage procedure in SurgicalPerformance with your next case.
Within our community of SurgicalPerformance users, one case becomes several. Several cases become a picture of your practice.
And that is when measurement starts becoming useful.
Few situations in obstetrics generate more anxiety than the prospect of losing an otherwise wanted and potentially healthy pregnancy. When the cervix shortens or begins to dilate, doing something can feel inherently preferable to watching and waiting. Cerclage offers a tangible intervention and, understandably, the fear of pregnancy loss can sometimes drown out the more difficult question: in whom does cerclage actually improve the outcome? The evidence is very clear that a cerclage is not always successful in preventing pregnancy loss.
Good level evidence tells us that patient selection matters. One identical procedure can be beneficial in one clinical setting, offer little or no benefit in another and potentially cause harm in a third.
Should we operate? When? For whom? And once we have placed a cerclage, how do we know whether our own outcomes are what we would expect?
Most obstetricians will perform cervical cerclage only occasionally. That makes cerclage an even more interesting procedure for surgical outcome monitoring.
The indication matters
Perhaps the clearest evidence for benefit is in singleton pregnancies where there is both a previous spontaneous preterm birth and a short cervix.
An individual patient data meta-analysis reported that, among women with a singleton pregnancy, previous spontaneous preterm birth and cervical length below 25 mm before 24 weeks, preterm birth before 35 weeks fell from 41.3% without cerclage to 28.4% with cerclage. Composite perinatal mortality and morbidity also fell from 24.8% to 15.6%.
Change one part of that clinical picture, however, and the evidence changes.
For a singleton pregnancy with a short cervix but without previous preterm birth, the evidence summarised in the review does not demonstrate the same benefit from cerclage.
Twins are more complicated again. Routine prophylactic or ultrasound-indicated cerclage may be neutral or potentially harmful in some twin populations, whereas physical examination-indicated cerclage in women with cervical dilation appears considerably more promising.
And for rescue cerclage, the degree of cervical dilation matters. A systematic review found an association with improved neonatal survival and approximately one month of pregnancy prolongation, although much of the evidence was observational. Outcomes deteriorated substantially with increasing cervical dilation at the time of placement.
In other words, simply recording that a cerclage was performed tells us remarkably little.
Why we have updated Cervical Cerclage in SurgicalPerformance
As the evidence around cervical cerclage has evolved, we have recognised that our own approach to measuring the procedure needed to evolve with it.
Cervical cerclage has been available in SurgicalPerformance for some time. But the original procedure captured relatively limited information. It recorded that a cerclage had been performed, but not the indication, clinical circumstances surrounding the decision or pregnancy outcomes that followed.
And, as the evidence above makes clear, those details matter.
A history-indicated cerclage is very different from an ultrasound-indicated cerclage or a rescue procedure in a woman with an already dilated cervix. Cervical length, cervical dilatation, membrane status and gestational age all provide important context when interpreting what happens afterwards.
Most importantly, the outcome that ultimately matters is not simply whether the procedure was completed without a surgical complication. It is what happened to the pregnancy and the baby.
Connecting patient selection with outcomes
The updated procedure allows users to prospectively capture the indication for cerclage, including history-indicated, ultrasound-indicated and physical examination or rescue cerclage.
It also records the clinical findings that informed the decision to intervene, including cervical length, cervical dilatation and other relevant features.
These can then be linked with pregnancy outcomes, including gestational age at delivery and pregnancy prolongation, as well as neonatal outcomes.
This creates something we did not have before: the ability to connect who we select for cerclage, the circumstances in which we intervene and what happens afterwards.
That seems particularly important for a procedure where patient selection can change the expected benefit so substantially. And for uncommon procedures where most obstetricians perform relatively few cervical cerclages each year. That makes measurement harder, but arguably more valuable.
We tend to remember the exceptional cases: the pregnancy that reached term despite terrible odds or the heartbreaking loss that remains with us years later. What is much harder is remembering what happened across every consecutive patient.
Over time, we can ask: What were my indications in my practice and how supported are my indications by the available evidence? How has my indication and decision making changed over time? How advanced were my rescue cases? How long were pregnancies prolonged? At what gestation did my patients deliver? What complications occurred? And, ultimately, what happened to the babies?
Why measuring outcomes from uncommon procedures matter
This update is not intended to create another registry. It is about retaining clinically meaningful information from care we are already providing and making it available for our own reflection and quality improvement.
Cerclage is a hugely impactful procedure for expecting mums but also for obstetricians and gynaecologists to save a life. The evidence tells us that its value depends heavily on selecting the right patient in the right clinical circumstances. Our outcome measurement should reflect that complexity.
If cervical cerclage is part of your practice, we encourage you to use the updated Cervical Cerclage procedure in SurgicalPerformance with your next case.
Within our community of SurgicalPerformance users, one case becomes several. Several cases become a picture of your practice.
And that is when measurement starts becoming useful.
SurgicalPerformance is a confidential online platform, built for surgeons by surgeons, to help you ‘know better’.
SurgicalPerformance is a confidential online platform, built for surgeons by surgeons, to help you ‘know better’.