Cervical Cerclage
DESCRIPTION
Cervical cerclage is used for the treatment of an incompetent cervix that has been associated with previous spontaneous abortion or miscarriage. It is used to conserve an already existing pregnancy and is considered a surgical procedure. It is also referred to as tracheloplasty, Shirodkar, Lash type or McDonald's purse string procedures.
Cervical incompetence can occur from a variety of circumstances. It may be anatomic, but usually results from surgical or obstetric trauma to the cervix. A diagnosis of cervical incompetence is usually made when a mid-trimester (18-22 weeks) pregnancy loss occurs, and there is a sudden unexpected rupture of membranes followed by a painless expulsion of the products of conception. A functional incompetence can be defined as a cervix that is anatomically indistinguishable from a normal cervix and is associated with a pregnancy loss as described above. Cervical incompetence may be associated with previous cervical trauma (surgical or prior birth related) or with congenital abnormality of the uterine fundus. There is controversy regarding the true definition of this disorder and whether the clinical presentation of the individual with this condition may represent an element of premature contractions. Other symptoms might include presentation in the second trimester with uterine cramps, leaking amniotic fluid, chorioamnionitis, or bleeding with cervical dilation and effacement that seems out of proportion to the duration and/or severity of the presenting complaints.
POLICY
Cervical cerclage for the treatment of an incompetent cervix is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Cervical cerclage for the treatment of preterm delivery without indications of an incompetent cervix is considered investigational.
MEDICAL APPROPRIATENESS
Any device utilized for this procedure must have FDA approval specific to the indication.
An emergent cervical cerclage is considered medically appropriate for any of the following conditions:
Premature effacement or dilation of the cervix in the absence of labor prior to 28 weeks gestation; or
Sonographic evidence of cervical shortening (2 cm or less) and/or funneling in an individual with prior history of mid-trimester delivery, or
Sonographic evidence of significant cervical shortening (less than 2 cm) in a symptomatic individual (pressure, cramps, etc.) without a prior history of mid-trimester loss.
A prophylactic cervical cerclage is considered medically appropriate for any of the following conditions:
History of prior pregnancy consistent with incompetent cervix; or
Prepregnancy physical findings suggesting possible cervical incompetence in an individual with a history of prior spontaneous midtrimester abortion and documentation of any of the following:
Ability to introduce a number 8 Hegar dilator or equivalent through the internal os when individual is not pregnant; or
Hysterosalpingogram demonstrating cervical funneling; or
Prior to the procedure, completion of the following must be documented:
An ultrasound examination to confirm fetal age, viability, and absence of major fetal anomaly, and
The release of the cervical cerclage as part of the delivery is considered medically appropriate.
ADDITIONAL INFORMATION
Literature to support the use of cervical cerclage for indications other than those previously listed are not available.
Cervical cerclage for the treatment of preterm delivery without indications of an incompetent cervix does not meet the following technology evaluation criteria:
The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
The technology must improve the net health outcomes.
The technology must be as beneficial as any established alternatives.
The improvement must be attainable outside the investigational settings.
Contraindications for cervical cerclage include the following:
Labor
Active uterine bleeding
Chorioamnionitis
Premature rupture of membranes
Fetal anomaly incompatible with life
Fetal demise
SOURCES
American College of Obstetricians and Gynecologists. (1996, October). Cervical cerclage. ACOG criteria sets 17-18.
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2004). Cervical cerclage (4.01.03). Retrieved February 13, 2007 from BlueWeb.
Cardwell, M. S. (1988). Cervical cerclage: a ten-year review in a large hospital. Southern Medical Journal, 8 (1), 15-19.
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc., p.608-613 & 799-804.
Hacker: Essentials of Obstetrics & Gynecology - 3rd ed., Saunders, 1998, p.480 & 482-483.
Jongen, V. H., & van Roosmalen, J. (1997). Complications of cervical cerclage in rural areas. International Journal of Gynaecology and Obstetrics, 57 (1), 23-6.
Mishell: Comprehensive Gynecology-3rd Edition. Mosby, 1997, p.410-411.
Saling, E., & Schumacher, E. (1997). Results of follow-up of mothers with previous surgical, total cervical cerclage, also with reference to neonatal data. Zeitschrift Fur Geburtshilfe Und Neonatologie, 201 (4), 122-127.
ORIGINAL EFFECTIVE DATE: 4/1981
MOST RECENT REVIEW DATE: 4/12/2007
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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