Background/Objectives: Cervical insufficiency affects 1–2% of pregnancies and represents a significant cause of second-trimester loss and spontaneous preterm birth. This review synthesizes current evidence across the clinical spectrum of cervical insufficiency, providing evidence-based management guidance and identifying areas requiring further investigation. Methods: We conducted a comprehensive review of the current literature, evidence-based clinical guidelines, and landmark randomized controlled trials examining diagnostic frameworks, therapeutic interventions, and clinical outcomes across different presentations of cervical insufficiency. Our analysis incorporated data from major obstetric databases, professional society recommendations, and recent comparative effectiveness research. Results: Cervical insufficiency diagnosis encompasses three primary categories: history-based, ultrasound-based, and physical examination-based. Vaginal progesterone achieves a 31% reduction in preterm birth before 33 weeks (RR 0.69, 95% CI 0.55–0.88; NNT= 14). Ultrasound-indicated cerclage achieves a 30% relative risk reduction for delivery <35 weeks. The landmark SuPPoRT trial (n = 386) demonstrated no statistically significant differences among cerclage, pessary, and progesterone (p = 0.4), though formal equivalence trials have not been conducted. Multiple gestations show no benefit from singleton-derived interventions (RR 0.99–1.04). Conclusions: Optimal cervical insufficiency management emphasizes individualized approaches based on comprehensive risk stratification and objective cervical assessment, with vaginal progesterone and cervical cerclage serving as cornerstone therapies supported by robust clinical evidence.

Cervical insufficiency poses risks for premature birth and neonatal outcomes. Preoperative sonography aids in the diagnosis and therapeutic considerations. Cervical cerclage is effective but carries risks. In our case series, 8 cases failed to complete emergent cerclage, leading to adverse outcomes. Analysis of preoperative images revealed thicker cervixes and cervical strictures may affect the surgical outcomes. Larger studies are needed to determine the reliable cutoff values. Preoperative assessment is crucial to inform treatment decisions.

To determine the performance of predictive markers of spontaneous preterm birth, cervicovaginal quantitative fetal fibronectin and cervical length, in asymptomatic high-risk women with transabdominal, history-indicated and ultrasound-indicated cerclage.This was a secondary analysis of a prospectively collected cohort of high-risk women (n = 181) with cervical cerclage, and no other intervention (e.g. progesterone) who attended the preterm birth clinic at a central London teaching hospital. Cerclage were categorized into 1) pre-conception transabdominal cerclage (n=18), 2) history-indicated cerclage placed before 14 weeks (n=64) and 3) ultrasound-indicated cerclage for short cervix (<25 mm) before 24 weeks (n=99). All women underwent serial transvaginal ultrasound cervical length assessment in the second trimester (16 to 28 weeks' gestation), and quantitative fetal fibronectin testing from 18 weeks. We investigated test performance and compared prediction of spontaneous preterm birth before 30 weeks (cerclage failure) We also analysed spontaneous preterm birth before 34- and 37-weeks' gestation.181 women were included in the analysis. Cervical length and fetal fibronectin were strong predictors of sPTB <30 weeks in women with cerclage [AUROC, 0.86 (95% CI, 0.79-0.94), and 0.84 (95% CI, 0.75-0.92), respectively]. Cervical length was a stronger predictor of preterm birth <30 weeks in women with history- compared to ultrasound-indicated cerclage, although both show clinical utility [AUC, 0.95 (95% CI, 0.91-1.00) vs 0.79 (95% CI, 0.66-0.91), p=0.01]. Quantitative fetal fibronectin was a strong predictor of spontaneous preterm birth in women with history-indicated cerclage [0.91 (95% CI, 0.75-1.00) and retained clinical utility in those with ultrasound-indicated cerclage [0.76 (95% CI, 0.64-0.89)]. There were no spontaneous deliveries less than 34 weeks in women with a transabdominal cerclage, so AUC was not calculated. Delivery was significantly delayed in this group (p<0.01).Cervical length and quantitative fetal fibronectin retain clinical utility for prediction of spontaneous preterm birth in women with vaginal cerclage; prediction is best in women with history-indicated stitches. Clinicians should be reassured that tests can be relied upon to discriminate risk and have utility when directing management for women with treatment failure. This article is protected by copyright. All rights reserved.This article is protected by copyright. All rights reserved.

Conventional vaginal strain ultrasound elastography, not based on shear-wave elastography imaging, can assess the biomechanical properties of the uterine cervix. This assessment may inform the risks of preterm birth and failed induction of labor. However, there is considerable variation in the approaches to strain elastography, including the placement of the region of interest (ROI). Therefore, our aim was to provide recommendations for cervical elastography.

To compare pregnancy outcomes after emergency cervical cerclage according to indication: ultrasound-indicated versus physical examination-indicated cerclage.

To compare the efficacy of bed rest, cervical cerclage (McDonald, Shirodkar, or unspecified type of cerclage), cervical pessary, fish oils or omega fatty acids, nutritional supplements (zinc), progesterone (intramuscular, oral, or vaginal), prophylactic antibiotics, prophylactic tocolytics, combinations of interventions, placebo or no treatment (control) to prevent spontaneous preterm birth in women with a singleton pregnancy and a history of spontaneous preterm birth or short cervical length.

Cervical cerclage is an established intervention for the management of pregnancies at high risk of preterm birth. Although studies exist to support its use in certain situations, particularly in singleton pregnancies, many questions such as adjunct therapies and efficacy in specific subgroups of high‐risk women have not been fully elucidated. This review will assess the current evidence as well as areas where there is currently a paucity of data and an urgent requirement for further research.

Cervical cerclage is an intervention which when given to the right women can prevent preterm birth and second-trimester fetal losses. A history-indicated cerclage should be offered to women who have had three or more preterm deliveries and/or mid-trimester losses. An ultrasound-indicated cerclage should be offered to women with a cervical length <25 mm if they have had one or more spontaneous preterm birth and/or mid-trimester loss. In high-risk women who have not had a previous mid-trimester loss or preterm birth, an ultrasound-indicated cerclage does not have a clear benefit in women with a short cervix. However, for twins, the advantage seems more likely at shorter cervical lengths (<15 mm). In women who present with exposed membranes prolapsing through the cervical os, a rescue cerclage can be considered on an individual case basis, taking into account the high risk of infective morbidity to mother and baby. An abdominal cerclage can be offered in women who have had a failed cerclage (delivery before 28 weeks after a history or ultrasound-indicated [but not rescue] cerclage). If preterm birth has not occurred, removal is considered at 36-37 weeks in women anticipating a vaginal delivery.© 2021 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.

Cervical cerclage (CC) represents one of the few effective measures currently available for the prevention of preterm delivery caused by cervical insufficiency, thus contributing in the reduction of neonatal morbidity and mortality rates.The aim of this study was to review and compare the most recently published major guidelines on the indications, contraindications, techniques, and timing of placing and removal of CC.A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC), and the International Federation of Gynecology and Obstetrics (FIGO) on CC was carried out.There is a consensus among the reviewed guidelines regarding the recommended techniques, the indications for rescue CC, the contraindications, as well as the optimal timing of CC placement and removal. All medical societies also agree that ultrasound-indicated CC is justified in women with history of prior spontaneous PTD or mid-trimester miscarriage and a short cervical length detected on ultrasound. In addition, after CC, serial sonographic measurement of the cervical length, bed rest, and routine use of antibiotics, tocolysis, and progesterone are unanimously discouraged. In case of established preterm labor, CC should be removed, according to ACOG, RCOG, and SOGC. Furthermore, RCOG and SOGC agree on the prerequisites that should be met before attempting CC. These 2 guidelines along with FIGO recommend history-indicated CC for women with 3 or more previous preterm deliveries and/or second trimester pregnancy miscarriages, whereas the ACOG suggests the use of CC in singleton pregnancies with 1 or more previous second trimester miscarriages related to painless cervical dilation or prior CC due to painless cervical dilation in the second trimester. The role of amniocentesis in ruling out intra-amniotic infection before rescue CC remains a matter of debate.Cervical cerclage is an obstetric intervention used to prevent miscarriage and preterm delivery in women considered as high-risk for these common pregnancy complications. The development of universal international practice protocols for the placement of CC seems of paramount importance and will hopefully improve the outcomes of such pregnancies.