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Cervical insufficiency
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Cervical insufficiency
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Literature review current through: Nov 2017. | This topic last updated: Dec 05, 2017.

INTRODUCTION — The American College of Obstetricians and Gynecologists defines cervical insufficiency as "the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions, labor, or both" [1]. It may occur in a single pregnancy or recur in consecutive pregnancies.

This topic will review issues related to diagnosis and management of women with cervical insufficiency. Issues related to cerclage procedures for treatment of cervical insufficiency are discussed separately. (See "Transvaginal cervical cerclage" and "Transabdominal and laparoscopic cervicoisthmic cerclage".)

PATHOGENESIS — Structural cervical weakness is the likely cause of many recurrent second-trimester losses/births, but it probably accounts for only a minor proportion of all second-trimester losses/births. The majority of these cases are probably caused by other disorders, such as decidual inflammation/infection, placental bleeding, or uterine overdistension. These other disorders can initiate biochemical changes in the cervix that lead to premature cervical shortening and often a single (ie, nonrecurrent) second-trimester loss/birth. (See "Pathogenesis of spontaneous preterm birth".)

CLINICAL FINDINGS

Past history — The classic obstetrical history of women with structural cervical weakness leading to recurrent cervical insufficiency is characterized by recurrent second-trimester pregnancy losses/deliveries that were associated with no or minimal mild symptoms (see 'Symptoms' below), often before 24 weeks of gestation, and then were found to have cervical dilation and effacement on physical examination that was unexpected based on their mild symptoms. The duration from recognition of symptoms to delivery may have been extremely short, and successive pregnancies may have been associated with progressively earlier delivery.

Cervical abnormalities, either congenital or as a result of trauma, are a risk factor for structural cervical weakness and, in turn, recurrent cervical insufficiency. Cervical trauma, which is more common than a congenital abnormality, may result from labor or delivery (spontaneous, forceps or vacuum assisted, cesarean) [2], rapid mechanical cervical dilation before a gynecologic procedure, or treatment of cervical intraepithelial neoplasia. Congenital abnormalities that have been associated with structural cervical weakness include genetic disorders affecting collagen (eg, Ehlers-Danlos syndrome) [3-5], uterine anomalies, in utero diethylstilbestrol exposure, and biologic variation.

(See "Overview of pregnancy termination", section on 'Future pregnancies'.)

(See "Cervical intraepithelial neoplasia: Reproductive effects of treatment".)

(See "Clinical manifestations and diagnosis of congenital anomalies of the uterus", section on 'Recurrent pregnancy loss'.)

(See "Outcome and follow-up of diethylstilbestrol (DES) exposed individuals", section on 'Pregnancy loss and preterm birth'.)

In contemporary obstetrics, where cervical length screening is often performed, women may describe a past pregnancy or pregnancies in which a short cervical length was detected on ultrasound and was associated with subsequent second-trimester loss/birth.

Symptoms — Women with cervical insufficiency in the current pregnancy may be asymptomatic or may present with mild symptoms, such as pelvic pressure, Braxton-Hicks-like contractions, premenstrual-like cramping, backache, and/or a change in vaginal discharge. Discharge volume may increase; the color may change from clear, white, or light yellow to pink, tan, or red spotting; and the consistency may become thinner. Symptoms, if present, typically begin between 14 and 20 weeks of gestation and may be present for several days or weeks before the diagnosis of cervical insufficiency is made.

Physical examination — Early in the course of cervical insufficiency, the cervix may be soft and closed, with minimal effacement [6]. Provocative maneuvers such as suprapubic or fundal pressure or the Valsalva maneuver may reveal fetal membranes in the endocervical canal or vagina; this is always an abnormal finding. However, in some cases, membranes may be prolapsed or ruptured. Tocodynamometry shows no or infrequent contractions at irregular intervals.

Imaging — The transvaginal ultrasound cervical length is typically short (≤25 mm), and debris (sludge [fetal squames, vernix, leukocytes, bacteria] or biofilm) may be seen in the amniotic fluid. If serial ultrasound examinations have been performed, a decrease in cervical length over time may be noted [7].

Laboratory — Uncomplicated cervical insufficiency is not associated with laboratory abnormalities.

DIAGNOSIS — We base the diagnosis of cervical insufficiency on either a classic past obstetrical history or on a combination of obstetrical history and transvaginal ultrasound measurement of cervical length. Physical examination alone is adequate in women with advanced cervical dilation and/or effacement.

The diagnosis is usually limited to singleton gestations because the pathogenesis of second-trimester pregnancy loss/extremely preterm delivery (ie, <28 weeks) in multiple gestations is usually unrelated to a weakened cervix.

Diagnostic classification and evaluation

Obstetrical history-based diagnosis — We make an obstetrical history-based diagnosis of cervical insufficiency in women with a classic history of ≥2 consecutive prior second-trimester pregnancy losses/extremely preterm births (ie, <28 weeks) associated with no or minimal mild symptoms. The presence of risk factors for structural cervical weakness supports the diagnosis. Most of these cases are pregnancy losses before 24 weeks. (See 'Past history' above.)

Challenges to making this diagnosis are that the relevant findings in the prior pregnancy are often not well-documented in medical records and the patient's recounting of events may not provide adequate information; thus, the process that led to the second trimester loss/birth is often a subjective assessment.

Ultrasound-based diagnosis — In asymptomatic women with a past history of one second trimester pregnancy loss/extremely preterm birth (ie, <28 weeks) associated with no or minimal mild symptoms (see 'Symptoms' above) and those in whom a history-based diagnosis is uncertain, we perform serial transvaginal ultrasound (TVU) examinations and make a diagnosis of cervical insufficiency when cervical length is ≤25 mm before 24 weeks. In these women, the author begins TVU measurement of cervical length at around 14 weeks, with repeat screening every two weeks until 24 weeks as long as cervical length is ≥30 mm. If cervical length is 26 to 29 mm, he repeats screening weekly as long as the length remains in this range. TVU screening is discontinued at 24 weeks of gestation, as cerclage is rarely performed after this time [8]. The presence of risk factors for structural cervical insufficiency supports the diagnosis. (See 'Past history' above.)

This approach is supported by a 2011 meta-analysis of randomized trials of women with singleton gestations and prior preterm birth managed either by (1) cervical length screening with cerclage for short cervical length or (2) obstetrical history-indicated cerclage that showed both groups had similar rates of preterm birth before 37 weeks (31 versus 32 percent, relative risk [RR] 0.97, 95% CI 0.73-1.29), preterm birth before 34 weeks (17 versus 23 percent, RR 0.76, 95% CI 0.48-1.20), and perinatal mortality (5 versus 3 percent, RR 1.77, 95% CI 0.58-5.35) [9]. In the ultrasound screening group, only 42 percent of patients developed a short cervical length and received cerclage whereas, in the history-indicated group, 100 percent of patients received a history-indicated cerclage. Thus, in patients with a history suggestive of cervical insufficiency, placement of a cerclage upon identification of a short cervix on ultrasound is effective in reducing preterm birth [10], results in pregnancy outcomes comparable with history-indicated cerclage [11], and avoids cerclage in about 60 percent of patients [11].

If a women in this population develops symptoms of cervical insufficiency (see 'Symptoms' above), an ultrasound examination for cervical length should be performed promptly because a normal physical examination cannot reliably exclude the diagnosis of cervical insufficiency. Most cervices that are 10 to 25 mm in length by second-trimester TVU feel long and closed on physical examination; effacement and dilation are usually not detected until the transvaginal cervical length is ≤10 mm. In one study, less than one-third of women with cervical length <11 mm had a cervical dilation ≥1 cm on physical examination [12]

Additional evaluation — Labor should be excluded by tocodynamometry. Infection, abruptio placenta, and bleeding placenta previa should be excluded by appropriate cultures (eg, urinalysis/urine culture), physical examination, and ultrasound examination, as these disorders could account for biochemically mediated cervical ripening leading to second-trimester pregnancy loss or preterm delivery independent of structural cervical weakness [13].

(See "Diagnosis of preterm labor".)

(See "Placental abruption: Clinical features and diagnosis".)

(See "Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and mortality".)

Subclinical intra-amniotic infection is diagnosed by laboratory examination of amniotic fluid, but is not routinely performed as most patients do not have significant cervical dilation, prolapsed membranes, or abnormal-appearing amniotic fluid. (See 'Candidates for amniocentesis' below.)

Physical examination-based diagnosis — We make a diagnosis of physical examination-based cervical insufficiency in women 14 through 27 weeks of gestation with a dilated and effaced cervix on physical examination and no contractions or weak irregular contractions that appear inadequate to explain the cervical dilation and effacement. The membranes may be prolapsed or ruptured.

As discussed above, labor, infection, abruptio placenta, and bleeding placenta previa should be excluded by appropriate cultures (eg, urinalysis/urine culture), physical examination, and ultrasound examination (see 'Additional evaluation' above). Subclinical intra-amniotic infection is diagnosed by laboratory examination of amniotic fluid, and is often indicated since many patients have significant cervical dilation, prolapsed membranes, or abnormal-appearing amniotic fluid. (See 'Candidates for amniocentesis' below.)

Candidates for amniocentesis — We perform amniocentesis to look for subclinical infection when the cervix is ≥2 cm dilated on manual or speculum examination, as the incidence of intra-amniotic infection in these women is approximately 20 to 50 percent [14]. We also perform amniocentesis on a case-by-case basis when ultrasound findings are consistent with inflammation (eg, debris in the amniotic fluid [sludge or biofilm] (image 1)) or when membranes are visible and exposed at the external os, as prolapsed membranes are associated with a poor perinatal prognosis [15].

We do not perform cerclage if we find evidence of infection on amniocentesis, as these pregnancies are at increased risk of preterm delivery and other pregnancy complications [16-19]. (See "Intra-amniotic infection (clinical chorioamnionitis or triple I)", section on 'Evaluation of amniotic fluid' and "Second-trimester evaluation of cervical length for prediction of spontaneous preterm birth in singleton gestations".)

Can cervical insufficiency be diagnosed before pregnancy? — The diagnosis of cervical insufficiency cannot be made or excluded in nonpregnant women by any test. Evaluation of cervical function with dilators, balloons, or hysteroscopy is not helpful. Ultrasound, magnetic resonance imaging, or hysterosalpingography may reveal a uterine anomaly, which is a risk factor for cervical insufficiency, but is not diagnostic.

CERCLAGE PLACEMENT AND USE OF PROGESTERONE SUPPLEMENTATION — The following approach to management applies to women with singleton pregnancies. Cerclage is not indicated in multiple gestations, given that the body of evidence shows no improvement in pregnancy outcome compared with appropriate controls without cerclage. (See "Twin pregnancy: Prenatal issues", section on 'Unproven interventions to prevent or delay preterm labor'.)

Pretreatment evaluation is reviewed above. (See 'Additional evaluation' above.)

Obstetrical history-based cervical insufficiency — We suggest cerclage placement (called history-based or history-indicated cerclage) at 12 to 14 weeks of gestation in women with this diagnosis. Structural weakness of the cervix can be treated effectively with structural support from a cerclage. Anatomical, biochemical, and clinical evidence from observational studies and randomized trials consistently support this approach [20-23].

At 16 weeks of gestation, the author also begins hydroxyprogesterone caproate weekly and continues it until 36 weeks of gestation [24]. However, the routine use of hydroxyprogesterone caproate is controversial, in part because no randomized trials have evaluated the efficacy of combination therapy (both history-indicated cerclage and hydroxyprogesterone caproate) in this patient population. One small retrospective study observed that combination therapy (cerclage and hydroxyprogesterone caproate) was more effective than cerclage alone for preventing delivery <24 weeks but not <28 or <37 weeks [25]. The small (n = 33) number of noniatrogenic deliveries <24 weeks precludes a clear conclusion about the efficacy of combined therapy. In addition, trials of use of hydroxyprogesterone caproate in women with a previous preterm birth were mostly limited to women whose delivery was at ≥20 weeks of gestation, although some hydroxyprogesterone caproate trials included women at high risk for either midtrimester pregnancy loss or preterm birth. Thus, use of hydroxyprogesterone caproate in women with a history or pregnancy losses before 20 weeks is neither well supported nor refuted by available data.

Reasonable alternative approaches are to limit use of hydroxyprogesterone caproate to women with previous preterm deliveries ≥20 weeks of gestation or to avoid progesterone supplementation unless the cervical length falls to ≤25 mm and then begin vaginal progesterone supplementation. (See "Progesterone supplementation to reduce the risk of spontaneous preterm birth", section on 'Choice of progesterone preparation'.)

Ultrasound-based cervical insufficiency — We suggest cerclage placement (called ultrasound-based or ultrasound-indicated cerclage) in women with one prior second-trimester loss/extremely preterm birth (ie, <28 weeks) and cervical length ≤25 mm before 24 weeks. A meta-analysis of randomized trials found that placement of a cerclage in this setting reduces preterm birth [10]. Women with a prior spontaneous preterm birth are prescribed hydroxyprogesterone caproate beginning at 16 to 20 weeks of gestation (which may be before or after cerclage placement) and continued through 36 weeks.

Some clinicians prescribe vaginal progesterone in addition to cerclage since the body of evidence suggests vaginal progesterone is more effective than hydroxyprogesterone caproate in women with a short cervix and no history of preterm birth. However, women with no history of preterm birth are a different population, so this evidence is not directly applicable. (See "Progesterone supplementation to reduce the risk of spontaneous preterm birth", section on 'Choice of progesterone preparation'.)

Another alternative approach is to treat these women with vaginal progesterone alone, without cerclage placement. The author does not advise this approach because a meta-analysis of randomized trials has shown that placement of a cerclage upon identification of a short cervix is effective in reducing preterm birth compared with no cerclage [10], whereas the only evidence that vaginal progesterone alone may be as effective as cerclage is an indirect meta-analysis of randomized trials [26].

Physical examination-based cervical insufficiency — For women with physical examination-based cervical insufficiency before 24 weeks of gestation, we consider cerclage placement a reasonable option (called physical examination-based cerclage, physical examination-indicated cerclage, rescue cerclage, or emergency cerclage). In a systematic review including a small randomized trial, two prospective cohort studies, and seven retrospective cohort studies, placement of a "physical examination-indicated cerclage" appeared to improve pregnancy outcome compared with no cerclage (neonatal survival 71 percent with cerclage versus 43 percent with expectant management; relative risk 1.65, 95% CI 1.19-2.28) [27]. The mean age at diagnosis in the cerclage and expectant management groups was 21.7 and 22.8 weeks of gestation, respectively; the mean time to delivery after diagnosis was 57 and 19 days, respectively; and the mean gestational age at delivery was 30.6 and 25.2 weeks, respectively. Although these largely observational data are low-quality evidence, the analysis is the best available evidence to inform decision-making in this setting.

We administer indomethacin (usually 50 mg orally every 6 hours for 48 hours total, starting before the cerclage) and antibiotics (usually one dose of cefazolin 1 to 2 g intravenously preoperatively depending on weight less than or ≥100 kg). A randomized trial reported that women who received indomethacin (immediately postoperatively and 8 and 16 hours postoperatively) and pericerclage antibiotics (preoperatively and 8 and 16 hours postoperatively) had a greater proportion of pregnancies that were prolonged by at least 28 days than women who received no perioperative prophylactic medications (24/26 [92.3 percent] compared with 15/24 [62.5 percent]) [28]. Further research including a larger number of pregnancies is necessary to further clarify the effectiveness, as well as the risks, of this therapy.

The author's practice is to continue hydroxyprogesterone caproate post-cerclage in patients who had been on the drug pr-cerclage because of a previous preterm birth. For patients with no history of previous preterm birth, the author begins vaginal progesterone postcerclage.

Most clinicians avoid placing a cerclage after about 24 weeks of gestation since the procedure may cause accidental rupture of the fetal membranes leading to early preterm delivery of a viable infant, with its attendant high risk of neonatal morbidity and mortality. However, each case must be individualized, weighing the risks of the procedure against the likely outcome with expectant management. (See "Periviable birth (Limit of viability)".)

Cerclage techniques and complications — (See "Transvaginal cervical cerclage" and "Transabdominal and laparoscopic cervicoisthmic cerclage".)

MANAGEMENT OF SPECIAL POPULATIONS

Women with no prior second-trimester pregnancy loss/extremely preterm birth, but risk factors for cervical insufficiency — Although a minority of these women develop cervical insufficiency, most do not; therefore, we believe the pregnancy course and outcome need to be evaluated before making this diagnosis. The author performs a single transvaginal cervical length measurement at 18 to 24 weeks of gestation (usually at about 20 weeks, with the anatomic survey ultrasound) in women with singleton gestations and with no prior preterm birth, and treats those with a short cervix (≤25 mm) with vaginal progesterone supplementation. A meta-analysis using individual patient data from randomized trials found that administration of vaginal progesterone to women with a short cervix reduced the rate of spontaneous preterm birth and composite neonatal morbidity and mortality [29], while another meta-analysis of randomized trials found no overall benefit from cerclage in this group [30]. The body of evidence supporting this approach is reviewed separately. (See "Progesterone supplementation to reduce the risk of spontaneous preterm birth", section on 'Choice of progesterone preparation'.)

However, in women with transvaginal ultrasound cervical length <10 mm, a cerclage may be helpful as a planned subgroup analysis in the meta-analysis discussed above showed a significantly lower rate of preterm birth <35 weeks in women with cervical length <10 mm in the cerclage group compared with no cerclage (39.5 and 58.0 percent, respectively; relative risk 0.68, 95% CI 0.47-0.98; five studies, 126 participants) [30].

Multiple gestations — The body of evidence does not support the efficacy of cerclage in multiple gestations. These data are reviewed separately. (See "Twin pregnancy: Prenatal issues", section on 'Unproven interventions to prevent or delay preterm labor' and "Triplet pregnancy", section on 'Prophylactic cerclage'.)

BEHAVIORAL COUNSELING — Lifestyle interventions (cessation of work and exercise, abstinence from coitus, bedrest/limited activity) have not been adequately evaluated by well-designed studies. Clinicians should consider the available evidence and the patient's individual circumstances when making lifestyle recommendations as there are social, psychological, financial, and medical side effects associated with these interventions.

In our practice, we advise women with an obstetrical history-based diagnosis of cervical insufficiency to continue their normal daily activities, with no restrictions other than those given to healthy pregnant women.

In women with an ultrasound-based or physical examination-based diagnosis of cervical insufficiency, we advise avoiding coitus. Although coitus is not a risk factor for onset of labor in women at term who are scheduled for induction [31], there are inadequate data on the safety of coitus in women at risk for preterm birth because of previous preterm birth or preterm cervical ripening [32]. We otherwise advise these women to continue their normal daily activities, with no restrictions other than those given to healthy pregnant women. Activity restriction in women with a short transvaginal ultrasound cervical length has been associated with an increase in preterm birth compared with no activity restriction [33].

INEFFECTIVE AND UNPROVEN INTERVENTIONS

Pessary — We do not prescribe pessaries for women with a short cervix. Vaginal pessaries may work by altering the axis of the cervical canal and displacing the weight of the uterine contents away from the cervix, as well as by other mechanisms. By changing the angle of the cervix in relation to the uterus, the pessary also obstructs the internal os and thus may provide protection against ascending infection. However, the body of evidence does not support using a pessary to prolong gestation or improve neonatal outcome.

In a 2017 meta-analysis that evaluated the effectiveness of the Arabin cervical pessary for preventing spontaneous preterm birth (SPTB) in singleton gestations with second-trimester cervical length ≤25 mm (three trials, n = 1420), use of the pessary did not prevent SPTB at <37, <34, <32, and <28 weeks of gestation compared with no pessary, and no differences were observed in the mean gestational age at delivery, incidence of preterm premature rupture of membranes, cesarean delivery rate, or neonatal outcomes [34]. A subsequent trial in singletons with short transvaginal ultrasound cervical length and no prior preterm birth also failed to show benefit from a pessary compared with no pessary [35]. Further study is warranted and may clarify whether specific subgroups may benefit.

MANAGEMENT OF FUTURE PREGNANCIES FOLLOWING CERCLAGE IN INDEX PREGNANCY

Prior successful outcome after cerclage

Prior successful obstetrical history-indicated cerclage – We usually suggest repeat history-indicated cerclage for these patients.

Prior successful ultrasound-indicated cerclage – We suggest transvaginal ultrasound cervical length screening in future pregnancies for women who received an ultrasound-indicated cerclage in a prior pregnancy and had a successful outcome (delivery after 34 weeks). The risk of preterm birth in future pregnancies does not warrant routine placement of a cerclage [36], but if ultrasound surveillance shows a short cervix in a subsequent pregnancy, then we place another cerclage. In one study, about 50 percent of women with a history of an ultrasound-indicated cerclage required another ultrasound-indicated cerclage in the subsequent pregnancy, and their outcomes were similar to those who underwent planned cerclage in the subsequent pregnancy [37].

Successful pregnancy outcome after ultrasound-indicated cerclage does not establish or exclude a diagnosis of cervical insufficiency. A substantial proportion of pregnancies with premature cervical effacement have good outcomes in the index pregnancy and future pregnancies in the absence of surgical intervention. This is particularly true in women who, after removal of the cerclage at 36 to 37 weeks, do not go into labor in the next two weeks.

Prior unsuccessful outcome after cerclage

Prior unsuccessful obstetrical-history indicated cerclage – We offer transabdominal or laparoscopic cervicoisthmic cerclage to women who fail to deliver a healthy newborn after placement of a history-indicated cerclage. (See "Transabdominal and laparoscopic cervicoisthmic cerclage".)

Prior unsuccessful ultrasound-indicated cerclage – For women with a prior ultrasound-indicated cerclage who went on to have an early spontaneous delivery (eg, <34 weeks), we generally suggest an obstetrical history-indicated vaginal cerclage at 12 to 14 weeks of gestation in the next pregnancy because these women always develop a short cervical length in subsequent pregnancies [37]. If the obstetrical history-indicated cerclage is also unsuccessful, then we offer transabdominal or laparoscopic cervicoisthmic cerclage in a subsequent pregnancy. (See "Transabdominal and laparoscopic cervicoisthmic cerclage".)

SUMMARY AND RECOMMENDATIONS

Diagnosis

We base the diagnosis of cervical insufficiency on either a classic obstetrical history or on a combination of obstetrical history and transvaginal ultrasound (TVU) measurement of cervical length. Physical examination alone is adequate for diagnosis of cervical insufficiency in women with advanced cervical dilation. The diagnosis is usually limited to singleton gestations because the pathogenesis of second-trimester pregnancy loss/extremely preterm delivery (ie, <28 weeks) in multiple gestations is usually unrelated to a weakened cervix. (See 'Diagnosis' above.)

Obstetrical history-based diagnosis of cervical insufficiency – We make an obstetrical history-based diagnosis of cervical insufficiency in women with a classic history of ≥2 consecutive prior second-trimester pregnancy losses/extremely preterm births (ie, <28 weeks) associated with no or minimal mild symptoms. The presence of risk factors for structural cervical weakness support the diagnosis. Most of these cases are pregnancy losses before 24 weeks. (See 'Obstetrical history-based diagnosis' above.)

Ultrasound-based diagnosis of cervical insufficiency – In asymptomatic women with a past history of one second trimester pregnancy loss/extremely preterm birth (ie, <28 weeks) associated with no or minimal mild symptoms (see 'Symptoms' above) and those in whom a history-based diagnosis is uncertain, we perform serial TVU examinations and make a diagnosis of cervical insufficiency when cervical length is ≤25 mm before 24 weeks. In these women, the author begins TVU measurement of cervical length at around 14 weeks, with repeat screening every two weeks until 24 weeks as long as cervical length is ≥30 mm. If cervical length is 26 to 29 mm, he repeats screening weekly as long as the length remains in this range. TVU screening is discontinued at 24 weeks of gestation, as cerclage is rarely performed after this time. The presence of risk factors for structural cervical insufficiency supports the diagnosis. (See 'Ultrasound-based diagnosis' above.)

Physical examination-based cervical insufficiency – We make a diagnosis of physical examination-based cervical insufficiency in women 14 through 27 weeks of gestation with a dilated and effaced cervix on physical examination and no contractions or weak irregular contractions that appear inadequate to explain the cervical dilation and effacement. The membranes may be prolapsed or ruptured. (See 'Physical examination-based diagnosis' above.)

Treatment

For women with history-based diagnosis of cervical insufficiency, we recommend cerclage at 12 to 14 weeks of gestation rather than ultrasound monitoring of cervical length (Grade 1B). The author also treats these women with hydroxyprogesterone caproate weekly from 16 to 36 weeks of gestation. (See 'Obstetrical history-based cervical insufficiency' above.)

For women with an ultrasound-based diagnosis of cervical insufficiency, we suggest cerclage (Grade 2B). For women with a prior spontaneous preterm birth, the author prescribes hydroxyprogesterone caproate beginning at 16 to 20 weeks of gestation (which may be before or after cerclage placement) and continued through 36 weeks. There is no high-quality evidence to guide management of progesterone in these women. One alternative approach is cerclage placement and administration of vaginal progesterone since, although not directly applicable to this population, the body of evidence suggests vaginal progesterone is more effective than hydroxyprogesterone caproate in women with a short cervix and no history of preterm birth. (See 'Ultrasound-based cervical insufficiency' above.)

For women with a physical examination-based diagnosis of cervical insufficiency, we suggest cerclage rather than expectant management (Grade 2C). (See 'Physical examination-based cervical insufficiency' above.)

We perform amniocentesis to look for subclinical infection before cerclage placement when the cervix is ≥2 cm dilated on manual or speculum examination, as the incidence of intra-amniotic infection in these women is approximately 20 to 50 percent. We also perform amniocentesis on a case-by-case basis when ultrasound findings are consistent with inflammation (eg, debris in the amniotic fluid [sludge or biofilm] (image 1)) or when membranes are visible and exposed at the external os, as prolapsed membranes are associated with a poor perinatal prognosis. We do not perform cerclage if we find evidence of infection on amniocentesis, as these pregnancies are at increased risk of preterm delivery and other pregnancy complications. (See 'Candidates for amniocentesis' above.)

For women with twin or higher-order multiple pregnancies, we suggest avoiding cerclage (Grade 2C). (See "Twin pregnancy: Prenatal issues", section on 'Unproven interventions to prevent or delay preterm labor' and "Triplet pregnancy", section on 'Prophylactic cerclage'.)

For women with a successful history-based cerclage, we repeat history-based cervical cerclage in subsequent pregnancies. For women with a successful ultrasound-indicated cerclage, we follow cervical length in subsequent pregnancies and repeat ultrasound-indicated cervical cerclage if cervical length is ≤25 mm. If the previous ultrasound-indicated cerclage was unsuccessful, we perform cerclage at 12 to 14 weeks of gestation in the subsequent pregnancy. We offer transabdominal or laparoscopic cervicoisthmic cerclage to women who have failed to have a successful pregnancy outcome after a cerclage at 12 to 14 weeks of gestation. (See 'Management of future pregnancies following cerclage in index pregnancy' above.)

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