Transabdominal Cerclage

To follow along, we suggest reading SMFM Consult Series #65: Transabdominal Cerclage 

• What is the background to cerclages? 

• Preterm birth is still the leading cause of neonatal morbidity and mortality 

• Cervical insufficiency (inability of cervix to retain a pregnancy, characterized by painless cervical dilation usually in middle of second trimester) is an important cause of preterm birth 

• Diagnosis of cervical insufficiency: 

• History of one or more second-trimester losses after painless cervical dilation in absence of labor or abruption 

• Cervical cerclages are indicated for those with cervical insufficiency – most are done transvaginally 

• McDonald or Shirodkar method 

• Other indications = history of PTB <34 weeks, cervical length <25 mm before 24 weeks 

• Advanced cervical dilation before 24 weeks 

• Transabdominal cerclage (TAC) are also an option - first described by Benson and Durfee in 1965 

• Advantages: can be placed higher, in the cervicoisthmic junction, so may provide greater structural support  

• Avoids presence of foreign body in vagina, so may decrease risk of PPROM or IAI 

• Disadvantages: more morbid and more complicated surgery because need abdominal access and dissection, necessitates cesarean delivery 

• So when is a TAC indicated? 

• TACs are usually not offered as first line treatment for cervical insufficiency 

• Due to increased morbidity of placement and need for CS 

• Exception is for those where transvaginal cerclage would be very difficult to place 

• Ie. Those with history of multiple LEEPs or trachelectomy 

• More often, TAC is used for patients with unsuccessful transvaginal cerclage 

• Previous unsuccessful TV cerclage = spontaneous delivery before 28 weeks of gestation 

• TAC reduced risk of recurrent preterm birth compared with repeat transvaginal cerclage in patient with a previous delivery <33-34 weeks gestation 

• Multicentre Abdominal vs. Vaginal Randomized Intervention of Cerclage (MAVRIC) study 

• Randomized controlled trial 

• Compared use of a TAC, high vaginal cerclage, and low vaginal cerclage among patients with previous miscarriage or preterm birth between 14-28 weeks of gestation with transvaginal cerclage in situ in previous pregnancy 

• TACs were performed as an open procedure either before pregnancy or up to 14 weeks 

• Vaginal cerclages done between 10-16 weeks gestation 

• Findings: preterm birth rates <32 weeks were significantly lower with TAC compared with both low vaginal cerclage (8% vs. 33%%, RR 0.23, 95% CI 0.07-0.76), and high vaginal cerclage (8% vs. 38%, RR 0.2, 95% CI 0.06-0.64) 

• NNT to prevent 1 preterm birth when TAC was compared with low vaginal cerclage was 3.9, and compared with high vaginal cerclage was 3.2 

• How is a TAC placed?

  • We won’t go into full detail, since that’s a little beyond the scope of a podcast! 

• Open technique 

• Typically done via spinal or regional anesthesia 

• Pfannenstiel incision 

• Uterus is exteriorized and surgeon identifies and palpates the uterine vessels bilaterally 

• Uterine vessels are retracted laterally → create an avascular space between the uterus and the vessels in the broad ligament at the level of the internal os of the cervix 

• Non-absorbable thick braided 5mm suture (ie. Mersilene tape) guided through space with right-angle clamp 

• Suture is tied anteriorly or posteriorly and left in place 

• Minimally invasive technique 

• Many different techniques have been described, using both traditional laparoscopy and robotic surgery

• Most will use 3-port laparoscopic approach, some with fourth suprapubic assistant port 

• Some will use a uterine manipulator (usually done prior to pregnancy) 

• Can dissect the uterovesical and paravesical spaces and make a window in the broad ligament through which the suture is placed 

• Suture used can be same nonabsorbable thick braided 5-mm suture (Mersilene tape), and some places have described using mono-filament, non-braided polypropylene suture 

• Suture is tied anteriorly or posterior and left in-situ 

• Is laparoscopic or open better? 

• Studies show that laparoscopic TACs are associated with less risk of blood loss and shorter hospital stays 

• However, laparoscopic procedures take longer 

• Other studies show no difference in blood loss, operative time, or hospital stay between the two 

• Overall, similar rates of pregnancy and miscarriage rates after laparoscopic and open TAC placement 

• Many studies have also shown similar preterm birth rates <34 weeks with both approaches, but overall, no RCTs as of yet 

• Therefore, both laparoscopic and open TAC are acceptable 

• Should I tocolyze? 

• No evidence to suggest that tocolysis is helpful 

• Ideal time for placement 

• Can be placed before pregnancy or in the first trimester 

• However, if there is an indication for TAC after first trimester, placement up to 22 weeks can be considered 

• Management of a pregnancy after TAC? 

• Management antepartum 

• MFM consultation should be obtained before TAC placement is done 

• Can continue with MFM consultation if questions arise 

• Should we continue to measure transvaginal cervical lengths? 

• Several studies show that although cervical shortening after cerclage may increase the risk of preterm birth, cervical length does not directly correlate with outcomes 

• Rescue cerclage does not improve outcomes in the setting of a short cervix after cerclage 

• Therefore, SMFM does NOT recommend routine transvaginal cervical length screening for patients with TACs 

• Should we use progesterone? 

• In the MAVRIC trial, 27% of patients used progesterone (17% in TAC, 28% in high vaginal cerclage and 48% in low vaginal cerclage) 

• However, since this trial, the FDA has withdrawn approval of IM progesterone 

• Benefit of adding vaginal progesterone to treatment regimen of patients with cerclage is unknown

• SMFM recommend having a risk-benefit discussion of supplemental vaginal progesterone be undertaken and shared decision making take place

• What we did at Penn: If they were already on progesterone, we didn’t take it away. If they weren’t on progesterone already, we don’t recommend 

• What did they do in UW? - same

• What to do in setting of pregnancy loss 

• If needed, D&E can be done with a TAC in situ 

• Large retrospective study of 142 patients with TAC found that 14 patients underwent 19 D&E procedures, with 15 of those occurring at <12 weeks 

• Osmotic dilators and standard surgical techniques were used 

• No major complications noted 

• SMFM recommends that pregnancy loss be managed with D&C or D&E with TAC in situ or with obstetrical management after laparoscopic removal of TAC depending on gestational age 

• Timing of delivery 

• Cesarean delivery is recommended, as TACs are not removed 

• There have been case reports of uterine dehiscence or uterine rupture when patients with TAC labor 

• Therefore, recommendation is delivery timing similar to previous myomectomy (37w0d-39w0d) 

• Leave TAC in situ for future pregnancies 

Surgery: The McDonald Cerclage

What is a McDonald cerclage? 

• Definition: a suture placed around the cervix in a purse-string fashion and tied anteriorly 

• Purpose: to decrease the risk of preterm birth in patients with

• History of preterm birth and short cervix 

• Second trimester with open cervix <24 weeks 

• For more indications, please see our prevention of preterm birth episode! 

UPTODATE

Today we will focus on the surgical steps:

• For pictures, we still like Atlas of Pelvic Surgery: 

  Pre-operative 

• Surgical consent 

• Review the way the procedure is done 

• Discuss risks, benefits, and alternatives

• Risks: injury to organs around the cervix (ie. bowel, bladder, vagina), small risk of breaking the bag of water and losing the pregnancy, infection, bleeding, etc.  

• Benefits: could decrease preterm birth before 37 and 34 weeks compared to women who did not get cerclage (RR 0.77, 95% CI 0.66 to 0.89 based on a Cochrane review) 

• Alternatives: doing nothing, using vaginal progesterone, etc. 

• Preoperative work up 

• Most providers will not need a CBC or other additional work up in young, healthy patients 

• Some hospitals may require a type and screen for all patients going to the operating room, and most hospitals nowadays may also require a COVID swab 

• Patients who are Rh negative: typically do NOT give Rhogam just for cerclage, given that any bleeding caused is presumably only cervical bleeding and we are not traumatizing the pregnancy.

• Ultrasound, genetic screening 

• General practice is to perform genetic screening if a patient desires it (ie. we don’t want to put a cerclage into a pregnancy that is affected by aneuploidy in a patient who may desire termination) 

• Ultrasound - make sure there are not obvious fetal malformations early on (ie. anencephaly), make sure there is a fetal heartbeat before the procedure.

• Anesthesia 

• Most procedures are done with neuraxial anesthesia (ie. Spinal) 

• Expectations 

• Patients will go home same day 

• Some can have some cramping and spotting, but if more than cramping, should come in for evaluation 

• During the surgery 

• Patient should have adequate anesthesia in the operating room and be prepped and draped 

• Positioning: 

• Dorsal lithotomy - yellowfins vs candy canes 

• Tip: make sure patient’s bottom is slightly hanging off of the bed; put patients in slight Trendelenburg for visualization  

• Empty bladder - usually helpful to be able to visualize cervix 

• Surgical steps

• Evaluate the cervix after adequate anesthesia has been achieved even if you examined them before anesthesia

• After anesthesia and relaxation, the cervix can appear different or even more open! 

• Evaluation should be done visually first in case there are exposed membranes 

• Achieve visualization 

• Can place a weighted speculum into the posterior vagina, or can also place 3 Bryskie retractors to visualize the cervix 

• Place two ringed forceps onto the anterior and posterior lip of the cervix - this allows for maneuverability of the cervix 

• Visualize the reflection of the bladder on the anterior cervix 

• Place the suture

• Permanent suture is used 

• Types: Mersilene tape or a 0- or 1- Ti-Cron (coated braided polyester suture) - usually will use a large caliber suture

• If using Ti-Cron, will usually use a mayo needle given large size of the needle that comes with the Ti-Cron 

•  Usually the suture is placed with 4 or 5 bites 

• Start at 12 or 1 o’clock on the cervix, as far back as possible without getting into the bladder 

• The next bites should avoid 3 and 9 o’clock where the vessels are 

• Assistants should use Bryskie retractors to hold back the vaginal walls, and the surgeon should use the two ringed forceps to maneuver the cervix 

• Tying the suture 

• Tighten the suture on both sides and recheck the cervix to make sure the suture is tight and the cervix is closed 

• Tying: Fei ties 6 knots for Ti-Cron, and 4 for Mersilene tape. Then, for ease of removal later, I will tie an airknot and then tie down four more knots. You can also tag Mersilene tape with another soft non-absorbable suture (i.e., silk).

• Post-operative 

• In the hospital, the patient needs to have their spinal/epidural anesthesia wear off before they can go home 

• Should be able to walk 

• Should be able to urinate 

• Check fetal heart tones 

• Indocin and antibiotics or no? 

• Er… it depends and there is a lot of conflicting data 

• There is a randomized controlled trial of only 53 patients in 2014 looking at antibiotics and indocin for exam-indicated cerclages 

  • This showed that there was increased time to delivery for those that received Indomethacin and antibiotics, but gestational age at delivery and neonatal outcomes were the same in both groups 

  • Then a repeat study was done in 2020 that showed similar results (increase in latency):

  • So… I think many people would do Indocin and antibiotics for exam-indicated cerclages 

• A retrospective study for all cerclages showed that there was no increase in gestational age or neonatal outcomes 

  • So, maybe not use indocin in history-indicated cerclages.

• Follow-up 

• Usually 1-2 week follow up for cerclage check in office.

Updates in Preterm Birth Prevention

Check out reading for this episode: PB 234

Our last podcast on preterm birth prevention was 2 years ago in November 2019, right after the PROLONG trial was published… and there have been some major guideline changes! We’ll do prevention of preterm birth redux today, going over everything once again to provide the most up-to-date summarization of ACOG’s recommendations..

Also important: we still have podcasts on assessing/managing preterm labor where nothing has really changed! Be sure to check that out as an important CREOG topic!

Why care about preterm birth?

• Exceedingly common: 10.2% of newborns in the USA are born prematurely.

  • PTB accounts for 75% of perinatal mortality and >50% of long-term neonatal morbidity (and associated costs)

• Preterm birth rates are actually increasing in the USA:

  • Had decreased from 2007-2014, but as of 2019 had increased back to 10.2%

    • Driven primarily by increase in late preterm birth (34-36 wks)

    • Rates of early preterm birth  (less than 34wk)  largely unchanged since 2014 (2.8%)

• Preterm birth rates are disparate amongst racial/ethnic groups:

  • White women: 9.3% rate of PTB, vs Hispanic 10%, non-Hispanic Black 14.4%, AI/AN 11.5%, Hawaiian/PI 11.8%. 

    • Non-Hispanic Black women also have a disproportionately higher rate of < 34wk PTB (4.9% vs 2.7% overall rate)

• Preterm birth is not just spontaneous preterm birth:

  • 50% follow preterm labor

  • 25% follow PPROM

  • 25% are intentional, medically-indicated PTB for maternal or fetal indications

Risk factors for PTB

• Clinical

  • Prior history: prior spontaneous preterm birth <34 weeks has about a 35% recurrence risk!

    • Number of prior PTBs (more) and degree of prematurity (earlier) significantly affect this risk

    • Preterm birth followed by term birth → risk lowers

    • Twin preterm birth → still higher risk for preterm birth in subsequent singleton gestation, and as high as 40% if twins born before 30 weeks!

  • Bacterial vaginosis: 2x increased risk of spontaneous PTB, more strongly associated in early pregnancy. 

    • Treatment has not been demonstrated consistently to reduce PTB risk though.

  • UTIs in pregnancy: conflicting results based on Cochrane reviews examining risk with asymptomatic bacteriuria or symptomatic UTIs and preterm birth risk

    • However still prudent to treat - risk of pyelonephritis → sepsis, which definitely increases risk.

  • Periodontal disease: conflicting results of risk and association

  • History of prior D&C: slightly increased risk in 21-study meta-analysis of 2 million women (OR 1.29), though mechanism is uncertain. Risk slightly increased with history of multiple D&C (OR 1.74).

  • Multiple gestation: Preterm birth rate in twins of 60.3%, with 19.5% born before 34 weeks.

    • Triplets born preterm 98.3% of time, with 82.6% born before 34 weeks.

  • Short cervical length: a transvaginal short cervical length under 25mm between 16-24 weeks is associated with higher risk of PTB in a variety of screened populations.

  • History of cervical conization: inconsistent data regarding risk, though likely pronounced risk if short interval from conization-to-conception or excision greater than 15mm deep. 

• Other modifiable risks:

  • Tobacco use: likely due to vasoconstriction, hypoxic-ischemic pathways

  • Low maternal pre-pregnancy weight: BMI < 18.5

  • Interpregnancy interval < 18 months: some association in observational studies

  • Unintended pregnancy

    • Importantly for these last two, some observational data points to increased access to LARC and family planning services is associated with lower rate of preterm birth.

• What about race?

  • As we’ve discussed on the show before: race as a risk factor needs to be studied further -- a social, not a biological construct

  • Chronic stress related to exposure to racism is a potential explanation

  • Social and economic disadvantage are persistently associated with increased risk of preterm birth, with some factors including:

    • Lower educational attainment

    • Residence in ZIP code/region/states with economic disadvantage

    • Lack of access to prenatal care

  • More work is needed in evaluating and exploring these mechanisms, and more work is desperately needed in evaluating ways to correct inequity 

Screening Strategies: Identifying Patients who may Benefit from Interventions:

• Lots of things that have been tried:

  • Fetal fibronectin assay: in asymptomatic patient, has not been shown to be helpful given low PPV.

  • Home uterine contraction monitors

  • Ongoing research into biomarkers, microbiome research, cervical texture, genetic associations…

• Best and most important screening strategy we have: transvaginal cervical length screening in the 2nd trimester (16-24 weeks)

  • TVCL beyond 24 weeks is less predictive overall.

• Recommendation for universal assessment of cervix at the time of anatomy ultrasound, with TVUS then performed if suspicious:

  • TAUS under 36mm identifies 96% of patients with TVCL under 25mm, and 100% of patients with TVCL of 20mm or less.

    • This universal assessment of length outright with TVCL is debated, though the cervix should at least be visualized to assess for previa, and a TACL is a reasonable 1st screen.

• What cervical lengths are important to remember?

  • Compared to old guidelines, ACOG simplifies things in this document. There are two primary lengths to remember (both transvaginally assessed):

    • 25mm 

    • 10mm

  • Then, there are a few major interventions that can be considered:

    • Progesterone, either vaginal or intramuscular (17-OHP)

    • Cerclage

    • Pessary

  • The recommendations and intervention options vary by the history/clinical scenario of the patient (summarized in the table from the PB), so let’s review from there!

View fullsize

ACOG PB 234

Singleton Pregnancy with No Prior History of Preterm Birth:

• Shortened cervix under 25 mm:

  • Vaginal progesterone

    • Dosing: 200mg micronized, from time of dx until 34-37 weeks gestation (Varies by trial)

    • Effects:

      • Multiple trials demonstrating lowered risk of early preterm birth (less than 34 weeks) by approximately 50%.

      • OPPTIMUM meta-analysis of progesterone demonstrated vagP reduced risk of spontaneous preterm birth prior to 34 weeks by about 40%, with an NNT of 14 patients to prevent one sPTB before 34 weeks.

  • Intramuscular progesterone

    • Dosing: 500mg weekly IM

    • Effects:

      • Very few trials on this in this population (singleton, no PTB history)

      • The few direct trials of this that exist generally have not found benefit

      • Not recommended in this population.

  • Exam-indicated cerclage

    • Identified painless cervical dilation prior to 24 weeks

    • Effects:

      • Associated with pregnancy prolongation by approximately 34 days and increased neonatal survival in a meta-analysis of multiple study types → thus recommended practice if truly painless cervical dilation.

    • Technique notes:

      • Amniocentesis to assess for infection pre-procedure: 

        • limited data, no RCT described in bulletin. Retrospective data colored by amnio-performance was tied to more severe cases. 

      • Antibiotic and tocolytic use:

        • RCT of periop abx + indomethacin demonstrated improved pregnancy lengths in rescue cerclages receiving medications, but no difference in neonatal outcomes overall (good or bad) → reasonable to consider

    • Contraindications:

      • PPROM

      • Suspected infection

      • Preterm labor or active bleeding

      • Fetal demise or anomaly incompatible with life

  • Ultrasound-indicated cerclage

    • Cervical shortening without dilation prior to 24 weeks.

    • Prior ACOG recommendation: cerclage not indicated in this population (only rescue cerclage was indicated without history of PTB)

    • NEW ACOG recommendation: possibly of benefit with extreme cervical shortening < 10mm

      • Based on a subgroup analysis of 126 patients in a meta-analysis of 5 RCTs. 

        • CL < 25mm - cerclage did not reduce risk of PTB <34wk

        • CL < 10mm - cerclage reduced risk of PTB <35 weeks (39.5% vs 58%). 

      • Importantly -- none of these patients were on vaginal progesterone, nor are there trials comparing vagP to cerclage in this population, or their combined effect.

  • Pessary

    • Cervical pessaries can compress, elevate, and posteriorly rotate the cervix.

    • Trials overall have not demonstrated effectiveness of pessary in those with short cervix without prior history of PTB, alone or in combination with vaginal progesterone.

Singleton Pregnancy in Patient with Prior Spontaneous Preterm Birth

• Cervical Length Screening

  • In addition to the usual screen, in patients with prior PTB history, serial cervical length assessment has been studied:

    • A TVCL under 25mm before 24 weeks had a sensitivity of 65% for PTB under 35 weeks; PPV 33%, NPV 92%. However, sensitivity and PPV is similar for just risk factor of prior PTB.

    • Many studies have assessed utility of cervical length screening, without definitive data to guide frequency/schedule of assessment.

    • Most protocols will perform screening starting at 16 weeks and repeat q1-4 weeks through 24 weeks.

      • Because treatment is available for short cervix (US-indicated cerclage, we’ll get to that in a minute!), even with absence of superb data, serial screening is reasonable to perform.

• IM Progesterone

  • We talked about this controversy on our previous podcast with the Meis trial and the PROLONG trial. 

    • Meis trial: RCT 463 patients, IM progesterone vs placebo. Reduced risk of PTB before 35 weeks by about 33% (20.6% vs 30.7%). Overall considered to be a higher risk population than the PROLONG trial, which came later.

    • PROLONG trial: RCT 1740 patients, no difference in PTB before 35 wks (11% vs 11.5%) or neonatal outcomes.

  • SQ progesterone is also available, but there is no direct evidence to support its efficacy vs IM or other formulations. 

  • In the interim, ACOG and SMFM have released statements supporting shared decision-making and patient preference in using progesterone supplementation (IM or vaginal), given the mixed evidence.

• Vaginal Progesterone

  • Vs placebo:

    • 3 blinded RCTs demonstrate no benefit in reducing recurrent PTB.

    • 5 trial meta-analysis lookig at vagP for use in short cervix with sPTB history demonstrated a reduction of preterm birth by about 40%. 

  • Vs 17-P:

    • Meta-analysis of 3 trials comparing 17-P to vag P demonstrated patients receiving vagP had lower risk of PTB before 34 weeks, though the trials were not blinded and excluded patients with short cervix. 

    • Meta-analysis of multiple progesterone supplementation strategies suggested more robust evidence for BagP in preventing PTB prior to 34 weeks

      • Including largely heterogenous trials with a variety of risk factors present, somewhat limiting outright applicability.

• History-Indicated Cerclage

  • Indicated in those with prior spontaneous preterm birth due to painless cervical dilation in the 2nd trimester without identified etiology (i.e., abruption), or in those who have had cerclages in prior pregnancy

  • Can be placed in early 2nd trimester with good effect.

• Ultrasound-Indicated cerclage

  • Five-trial meta-analysis demonstrates that in those with prior sPTB and TVCL <25mm prior to 24 weeks, cerclage reduces the rate of PTB by about 35% (28% vs 41%). 

    • Unknown if progesterone supplementation may augment this effect at all, and there are no trials comparing cerclage to vaginal progesterone vs cerclage in this population.

    • There are ways to do indirect comparisons between trials, and when this is performed the effect size observed seemed to be similar between vagP and cerclage. 

      • Thus, ACOG states that cerclage or vagP are acceptable options in those with prior sPTB and short cervix, and states that cerclage may be offered in addition to continuation of progesterone.

• Pessary

  • Evidence has not demonstrated any efficacy of pessary alone.

Multifetal Gestations

• Cervical Length Screening

  • Multifetal pregnancies will generally have a shorter cervical length in the 2nd trimester, but the short cervix remains an effective predictor of early preterm birth:

    • TVUS < 25 mm at 20-24wks had PPV of 75.5% for delivery prior to 37 weeks, and 25.8% for delivery before 28 weeks. 

    • TVUS < 20 mm had PPV of 61.9% before 34 weeks in a separate analysis. 

  • There are not a lot of data regarding screening, and as you’ll see, less consensus regarding effectiveness of intervention in twin pregnancies; thus, serial screening is not necessarily recommended. 

  • A single screen at the anatomy scan should still be performed at minimum, as it is with singleton gestations without prior history.

• IM Progesterone

  • Trial of 661 twin pregnancies of placebo vs 17-P demonstrated no benefit; a Cochrane review of randomized trials actually found slight increase in risk of PTB before 34 weeks with 17-P (though no difference in perinatal outcomes)

  • In those with prior sPTB and subsequent twin pregnancy, 66 patient trial showed less delivery prior to 34 weeks (20.6% vs 46.9%), but mean gestational length didn’t differ, and no significant difference in neonatal outcomes.

    • Bottom line: can consider in those with prior history of sPTB, not for use in those without sPTB history (same as singletons)

• Vaginal Progesterone

  • Outright use - not recommended:

    • Cochrane review: no difference in rates of PTB before 34 weeks, perinatal death, NICU admission, or respiratory distress vs placebo.

    • Two other meta-analyses with similar conclusions, and an RCT subsequent to these meta-analyses demonstrated no difference.

  • Short cervix - could be considered, but insufficient data to make recommendation:

    • Six RCTs with different doses/compounds, but when analyzed together, demonstrates likely reduction in PTB risk prior to 33 weeks with vaginal progesterone.

    • Diffferent meta-analyses have not found a significant difference.

• Cerclage

  • Prophylactic (i.e., place in a cerclage without other risk factors than multiple gestations) -- no evidence to suggest benefit.

  • Ultrasound-indicated

    • Insufficient data to recommend at this time, though trials that exist overall are small and have not found significant benefit, though at least one meta-analysis has shown potential benefit if cervical length is <15mm. 

  • Exam-indicated/”Rescue” cerclage

    • New RCT (2020) of twin gestations with asymptomatic cervical dilation between 16’0 and 23’6 demonstrated reduced risk of PTB before a variety of cut points (24/28/32/34) in patients receiving rescue cerclage vs no cerclage

    • Small trial, but based on limited data, there may be some benefit -- so could consider! Major practice change!

• Pessary

  • Two RCTs looked at prophylactic pessary, and a third looking at pessary for short cervix, did not find benefit. 

  • Many other trials are limited by power and methodology in this space, but generally also have not found benefit.

  • Overall, pessary is not recommended in higher order gestation.

Does activity restriction reduce PTB risk?

• Super common question, and one that this update in the PB directly addresses:

  • RCT of 165 pregnant persons found no relationship between coitus and risk for recurrent PTB

  • Secondary analysis of 17-P RCT for short cervix demonstrated PTB at less than 37 weeks was more common among pts who were placed on an activity restriction, and after controlling for confounders PTB remained more common in those placed on restrictions.

    • Thus, based on available data, activity restriction is not recommended.

Summary:

• Singleton pregnancies without history of PTB:

  • CL screening: visualize at anatomy scan, TVUS if suspected to be short

  • 17-P: not indicated

  • Vag P: indicated if TVCL is <25mm

  • Cerclage: possibly indicated, more strong evidence if TVCL < 10mm; OR can be used for “rescue” with dilated cervix (painless)

• Singleton pregnancies with history of sPTB:

  • CL screening: consider serial length screening from 16-24 weeks

  • 17-P: can be considered

  • Vag P: can be considered, may be of stronger benefit if short cervix identified

  • Cerclage:

    • History-indicated: if prior cerclage, or history of painless cervical dilation leading to loss in prior pregnancy 

    • US-indicated: if TVCL < 25mm, can consider this versus vaginal P

    • Rescue: still available

• Multiples:

  • CL screening: same as singleton: at least visualize at anatomy scan

  • 17-P: Not indicated, unless prior history of sPTB

  • Vag P: not indicated, unless short cervix identified

  • Cerclage:

    • US-indicated: limited inconclusive evidence

    • Rescue: can consider → major practice change!