Jeffrey D Sperling1, Joshua D Dahlke2, Juan M Gonzalez3. 1. Clinical Fellow, Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA. 2. Affiliate Faculty of University of Nebraska Medical Center, Nebraska Methodist Women's Hospital and Perinatal Center, Omaha, NE. 3. Associate Professor, Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA.
Abstract
IMPORTANCE: Preterm birth is a major contributor to perinatal morbidity and mortality. The most common intervention performed to improve perinatal outcomes for a woman experiencing cervical dilation in the second trimester without signs or symptoms of preterm labor is the cerclage. OBJECTIVE: We sought to review and compare available national guidelines on cerclage use. EVIDENCE ACQUISITION: We performed a descriptive review of 3 national guidelines on cerclage: The American Congress of Obstetricians and Gynecologists Practice Bulletin on "Cerclage for the Management of Cervical Insufficiency," Green-top Guideline from the Royal College of Obstetricians and Gynaecologists entitled "Cervical Cerclage," and the Society of Obstetricians and Gynaecologists of Canada Clinical Practice Bulletin entitled "Cervical Insufficiency and Cervical Cerclage." Guidelines were compared, and the following aspects of cerclage use for prevention of preterm delivery were summarized: indications and contraindications, risk factors for cervical insufficiency, perioperative considerations, and timing of removal. Recommendations and strength of evidence were reviewed based on each guideline's method of reporting. The references were compared with regard to the total number of randomized control trials, Cochrane Reviews, and systematic reviews/meta-analyses cited. RESULTS: The variations highlighted in the guidelines reflect the heterogeneity of the literature contributing to guidelines and the challenges of diagnosing and managing cervical insufficiency. CONCLUSIONS: A cohesive international guideline may improve safety and quality and optimize patient outcomes. TARGET AUDIENCE: Obstetricians and gynecologists, family physicians. LEARNING OBJECTIVES: After completing this activity, the learner should be better able to outline variations in indications and contraindications for cervical cerclage use by international guideline, identify variation in perioperative considerations for cervical cerclage use by international guideline, and recognize variation in timing of removal by international guideline.
IMPORTANCE: Preterm birth is a major contributor to perinatal morbidity and mortality. The most common intervention performed to improve perinatal outcomes for a woman experiencing cervical dilation in the second trimester without signs or symptoms of preterm labor is the cerclage. OBJECTIVE: We sought to review and compare available national guidelines on cerclage use. EVIDENCE ACQUISITION: We performed a descriptive review of 3 national guidelines on cerclage: The American Congress of Obstetricians and Gynecologists Practice Bulletin on "Cerclage for the Management of Cervical Insufficiency," Green-top Guideline from the Royal College of Obstetricians and Gynaecologists entitled "Cervical Cerclage," and the Society of Obstetricians and Gynaecologists of Canada Clinical Practice Bulletin entitled "Cervical Insufficiency and Cervical Cerclage." Guidelines were compared, and the following aspects of cerclage use for prevention of preterm delivery were summarized: indications and contraindications, risk factors for cervical insufficiency, perioperative considerations, and timing of removal. Recommendations and strength of evidence were reviewed based on each guideline's method of reporting. The references were compared with regard to the total number of randomized control trials, Cochrane Reviews, and systematic reviews/meta-analyses cited. RESULTS: The variations highlighted in the guidelines reflect the heterogeneity of the literature contributing to guidelines and the challenges of diagnosing and managing cervical insufficiency. CONCLUSIONS: A cohesive international guideline may improve safety and quality and optimize patient outcomes. TARGET AUDIENCE: Obstetricians and gynecologists, family physicians. LEARNING OBJECTIVES: After completing this activity, the learner should be better able to outline variations in indications and contraindications for cervical cerclage use by international guideline, identify variation in perioperative considerations for cervical cerclage use by international guideline, and recognize variation in timing of removal by international guideline.