Guidelines on cerclage placement: a comparative systematic review.

Abstract

Objective: This study aimed to systematically identify, summarize, and compare professional medical-society guidelines on cervical and abdominal cerclage.

Data sources: A systematic literature search was conducted in PubMed and Scopus on May 15, 2024 following PRISMA guidelines. The search included English-language clinical practice guidelines published between 2011 and 2024 addressing cervical cerclage.

Study appraisal and synthesis methods: Guidelines were independently screened and selected by two reviewers. Quality was assessed using the AGREE II instrument. Data were extracted into a standardized form and synthesized narratively, focusing on comparing recommendations regarding indications, contraindications, timing, technique, and perioperative management of cerclage placement.

Results: Twenty guidelines from ten professional societies were included. Consensus existed on several key indications, including history-indicated cerclage for ≥3 second-trimester losses, ultrasound-indicated cerclage for cervical lengths under 10 mm, and abdominal cerclage in cases of prior transvaginal cerclage failure or insufficient cervical tissue. However, disagreements remain. For instance, ACOG (American College of Obstetricians and Gynecologists) recommends considering cerclage after one loss, whereas most guidelines require three. There is also variation regarding the timing of physical examination cerclage beyond 24 weeks, with NICE (National Institute for Health and Care Excellence) extending the window to 28 weeks. Additionally, recommendations diverge on cerclage for prolapsed membranes, with some guidelines advising against the procedure due to a high risk of failure, while others support considering it.

Conclusions: Guidelines agree on history-indicated cerclage for ≥3 second-trimester losses, ultrasound-indicated cerclage for cervical lengths under 10 mm, and abdominal cerclage in cases of prior transvaginal cerclage failure or insufficient cervical tissue. While agreement exists on key indications and contraindications, notable divergences remain in certain recommendations. This review emphasizes the need for congruent recommendations to enhance consistency.