ACOG's cerclage guideline puts indication, technique and alternatives in one document

ACOG has published a Clinical Practice Guideline on obstetric cerclage, developed under an a priori protocol by three maternal-fetal medicine subspecialists appointed by its Committee on Clinical Practice Guidelines-Obstetrics. Librarians searched Cochrane Library, CENTRAL, EMBASE, PubMed and MEDLINE; included studies were quality-assessed and run through a modified GRADE evidence-to-decision framework.

The scope is the whole decision, not one part of it: indications — cervical insufficiency, prior obstetric history, cervical shortening — surgical technique, management afterwards, and the alternatives to placing a stitch at all. Each recommendation carries its own strength and evidence quality, which is the part worth using. Cerclage practice varies more by unit habit than by evidence, and a graded document lets you see which of your local defaults rest on strong evidence and which rest on custom.

The practical use is not to read it once. It is to take the three or four decisions your unit makes differently from each other — whom to offer ultrasound-indicated cerclage, whether to use progesterone instead, what to do with a short cervix and no history — and check each against the grade attached to it.

• Check your unit's threshold for ultrasound-indicated cerclage against the graded recommendation, not against habit
• Look specifically at where progesterone is recommended as an alternative rather than an adjunct
• Note which recommendations are conditional — those are the ones where your local practice may legitimately differ
• Bring the technique section to the next departmental meeting; surgical approach is where unit variation is widest
• Record the indication category in the operation note, since the evidence differs sharply between them

Why it matters

Cerclage is a field where unit custom has been standing in for evidence, and this document makes the difference visible.

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