Cervical Insufficiency · Cerclage Indications

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] History/ultrasound/exam indication vs short cervix only
   Type of cerclage indication?
   • History-indicated: ≥1 painless cervical dilation causing mid-trimester loss, or prior cerclage for this → History-indicated → elective cerclage
   • Ultrasound-indicated: singleton, prior spontaneous preterm <34 weeks + current CL <25 mm (<24 weeks) → Ultrasound-indicated → cerclage + progesterone
   • Exam-indicated: mid-trimester (<24 weeks) cervical dilation/visible membranes, no labor/infection/abruption → Exam-indicated → rescue cerclage
   • Short cervix but no spontaneous preterm history (or twins) → Short cervix no preterm history → vaginal progesterone
2. [End] History-indicated → elective cerclage
   History-indicated → elective cerclage at 12–14 weeks (McDonald/Shirodkar); preoperative assessment, bed rest not required; follow the cervix postoperatively.
3. [End] Ultrasound-indicated → cerclage + progesterone
   Ultrasound-indicated (singleton + prior spontaneous preterm <34 weeks + CL <25 mm, <24 weeks) → cervical cerclage; with vaginal progesterone.
4. [End] Exam-indicated → rescue cerclage
   Exam-indicated (rescue cerclage) — mid-trimester cervical dilation, visible membranes, no labor/infection/abruption → rescue cerclage to prolong gestation; exclude infection first, full informed consent on risks.
5. [End] Short cervix no preterm history → vaginal progesterone
   Short cervix but no spontaneous preterm history → vaginal progesterone (not a cerclage indication); twins generally do not benefit from cerclage (except in a rescue situation).

Source guidelines & references

• Cervical cerclage (ACOG Practice Bulletin 142 cervical insufficiency)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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