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Clinical Policy Bulletin:
Transabdominal Cerclage
Number: 0529


Policy

Aetna considers transabdominal cerclage medically necessary for the treatment of an incompetent cervix for any of the following conditions:

  1. Deep traumatized cervix; or
  2. Previous failed cervical (transvaginal) cerclages; or
  3. Shortened (less than 2.5 cm) or amputated cervix.

Aetna considers transabdominal cerclage experimental and investigational for all other indications because of insufficient evidence of effectiveness.

Note: A history consistent with incompetent cervix must be documented to establish the medical necessity of this procedure. This includes a history of mid-trimester pregnancy loss that is associated with painless cervical dilatation without evidence of uterine activity.



Background

Incompetent cervix is a significant cause of second-trimester pregnancy loss.  It is portrayed by gradual, painless dilation of the cervix in the second or third trimester with bulging and rupture of the membranes and subsequent expulsion of a fetus too immature to survive.

Cervical incompetence may be due to previous obstetric or gynecological trauma or a congenital weakness of the cervix (NICE, 2007). The condition is usually diagnosed after one or more late second trimester or early third trimester pregnancy losses, and after other causes have been excluded.

The role of cervical cerclage in the prevention of miscarriage due to cervical incompetence is well established yet remains controversial.  The most commonly employed techniques are performed vaginally and are designed to reinforce the cervix at the level of the internal os.  This involves placing a stitch of strong thread or tape around the cervix, via the vagina, and tightening it to keep the cervix closed. The procedure is typically performed at the end of the first trimester or the beginning of the second trimester, and the stitch is usually removed at around 37 weeks’ gestation (NICE, 2007).

If there is insufficient cervical tissue to allow placement of a cerclage vaginally, a transabdominal approach (either open or laparoscopic) is sometimes used.  With this procedure, an encircling suture is placed above the cardinal and uterosacral ligaments.  Transabdominal cerclage is not frequently performed and is only indicated for those patients with previous failed cervical cerclages, shortened or amputated cervix, and/or deep traumatized cervix.  This procedure should only be performed by physicians with special training and expertise in this procedure.

The clinical value of pre-pregnancy cerclage has not been firmly established.  In a meta-analysis, Drakeley and colleagues (2003) stated that the effectiveness of prophylactic cerclage in preventing preterm delivery in women at low or medium risk for second-trimester pregnancy loss has not been proven.  The role of cerclage in women whose ultrasound reveals short cervix remains uncertain.  Shennan and Jones (2004) stated that elective cerclage is only effective in a minority of women, and the evidence to support its use is limited.  It is currently being evaluated whether indicated cerclage, dictated by ultrasound findings, is beneficial.

The Royal College of Obstetricians and Gynaecologists' guideline on the investigation and treatment of couples with recurrent miscarriage (2003) did not mention the use of pre-pregnancy cerclage.  Furthermore, the American College of Obstetricians and Gynecologists' guideline on cervical insufficiency (2003) stated that elective cerclage can be considered in patients with a history of 3 or more unexplained mid-trimester pregnancy losses or preterm deliveries.  Moreover, cerclage should be performed at 13 to 16 weeks gestation after ultrasound evaluation has shown the presence of a live fetus with no apparent anomalies.

Guidance from the National Institute for Health and Clinical Excellence (2007) stated that the evidence on the safety and efficacy of laparoscopic cerclage for prevention of recurrent pregnancy loss due to cervical incompetence is limited, and therefore this procedure should not be used without special arrangements for consent and for audit or research. The Specialist Advisers to NICe considered this procedure to be novel and expressed uncertainty about its efficacy. They listed key efficacy outcomes of laparoscopic cerclage as live birth rate, ‘take-home baby’ rate, prolongation of pregnancy, reduction in perioperative morbidity and perinatal morbidity, operating times and blood loss. The NICE guidance noted that It was noted that there is uncertainty about the efficacy of all cervical cerclage techniques as a treatment for recurrent loss of pregnancy due to cervical incompetence. The NICE The Committee noted specific concerns about performing the procedure in women who are not pregnant. These include the difficulty in defining the internal os for correct placement of the suture, and ensuring that the suture is not tied in such a way that there is a risk of it cutting through the cervix during subsequent pregnancy.

 
CPT Codes/ HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
59325
ICD-9 codes covered if selection criteria are met:
622.5 Incompetence of cervix
654.53 Cervical incompetence complicating pregnancy
654.63 Other congenital or acquired abnormality of cervix complicating pregnancy [shortened, amputated, or deep traumatized cervix]


The above policy is based on the following references:
  1. Cunningham FG, MacDonald PC, Gant NF, et al., eds. Williams Obstetrics. 19th ed. Norwalk, CT: Appleton & Lange; 1993:673-675.
  2. Scott JR, Di Saia, Hammond CB, et al., eds. Danforth's Obstetrics and Gynecology. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999.
  3. Branch DW. Operations for cervical incompetence. Clin Obstet Gynecol. 1986;29(2):240-254.
  4. MacNaughton MC, Chalmers IG, Dubowitz V, et al. Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists multicentered randomized trial of cervical cerclage. Br J Obstet Gynaecol. 1993;100(6):516-523.
  5. Novy MJ. Transabdominal cervicoisthmic cerclage: A reappraisal 25 years after its introduction. Am J Obstet Gynecol. 1991:164(6 Pt 1):1635-1642.
  6. Herron MA, Parer JT. Transabdominal cerclage for fetal wastage due to cervical incompetence. Obstet Gynecol. 1988;71(6 Pt 1):865-868.
  7. Cammarano CL, Herron MA, Parer JT. Validity of indications for transabdominal cervicoisthmic cerclage for cervical incompetence. Am J Obstet Gynecol. 1995:172(6):1871-1875.
  8. Gibb DM, Salaria DA. Transabdominal cervicoisthmic cerclage in the management of recurrent second trimester miscarriage and preterm delivery. Br J Obstet Gynaecol. 1995;102(10):802-806.
  9. Brodman ML, Friedman F Jr, Morrow JD, et al. Wide-band transabdominal cerclage for a foreshortened, incompetent cervix. Obstet Gynecol. 1994;84(4 Pt 2):704-706.
  10. Anthony GS, Walker RG, Cameron AD, et al. Transabdominal cervico-isthmis cerclage in the management of cervical incompetence. Eur J Obstet Gynecol Reprod Biol. 1997;72(2):127-130.
  11. Zaveri V, Aghajafari F, Amankwah K, et al. Abdominal versus vaginal cerclage after a failed transvaginal cerclage: A systematic review. Am J Obstet Gynecol. 2002;187(4):868-872.
  12. Rand L, Norwitz ER. Current controversies in cervical cerclage. Semin Perinatol. 2003;27(1):73-85.
  13. Cho CH, Kim TH, Kwon SH, et al. Laparoscopic transabdominal cervicoisthmic cerclage during pregnancy. Am Assoc Gynecol Laparosc. 2003;10(3):363-366.
  14. Bachmann LM, Coomarasamy A, Honest H, Khan KS. Elective cervical cerclage for prevention of preterm birth: A systematic review. Acta Obstet Gynecol Scand. 2003;82(5):398-404.
  15. Odibo AO, Elkousy M, Ural SH, Macones GA. Prevention of preterm birth by cervical cerclage compared with expectant management: A systematic review. Obstet Gynecol Surv. 2003;58(2):130-136.
  16. Belej-Rak T, Okun N, Windrim R, et al. Effectiveness of cervical cerclage for a sonographically shortened cervix: A systematic review and meta-analysis. Am J Obstet Gynecol. 2003;189(6):1679-1687.
  17. Drakeley AJ, Roberts D, Alfirevic Z. Cervical stitch (cerclage) for preventing pregnancy loss in women. Cochrane Database Syst Rev. 2003;(1):CD003253.
  18. Groom KM, Jones BA, Edmonds DK, Bennett PR. Preconception transabdominal cervicoisthmic cerclage. Am J Obstet Gynecol. 2004;191(1):230-234.
  19. Besio M, Oyarzun E. Transabdominal cervicoisthmic cerclage. Int J Gynaecol Obstet. 2005;88(3):318-320.
  20. American College of Obstericians and Gynecologists. ACOG Practice Bulletin. Cervical insufficiency. Obstet Gynecol. 2003;102(5 Pt 1):1091-1019.
  21. Lotgering FK, Gaugler-Senden IP, Lotgering SF, Wallenburg HC. Outcome after transabdominal cervicoisthmic cerclage. Obstet Gynecol. 2006;107(4):779-784.
  22. Fick AL, Caughey AB, Parer JT. Transabdominal cerclage: Can we predict who fails? J Matern Fetal Neonatal Med. 2007;20(1):63-67.
  23. Oppenheimer L; Society of Obstetricians and Gynaecologists of Canada. Diagnosis and management of placenta previa. J Obstet Gynaecol Can. 2007;29(3):261-273.
  24. Debbs RH, DeLa Vega GA, Pearson S, et al. Transabdominal cerclage after comprehensive evaluation of women with previous unsuccessful transvaginal cerclage. Am J Obstet Gynecol. 2007;197(3):317.e1-e4.
  25. Drakeley AJ, Roberts D, Alfirevic Z. Cervical cerclage for prevention of preterm delivery: Meta-analysis of randomized trials. Obstet Gynecol. 2003;102(3):621-627.
  26. Royal College of Obstetricians and Gynaecologists (RCOG). The investigation and treatment of couples with recurrent miscarriage. London, UK: Royal College of Obstetricians and Gynaecologists (RCOG); May, 2003.
  27. American College of Obstericians and Gynecologists. ACOG Practice Bulletin. Cervical insufficiency. Obstet Gynecol. 2003;102(5 Pt 1):1091-1019.
  28. Shennan A, Jones B. The cervix and prematurity: Aetiology, prediction and prevention. Semin Fetal Neonatal Med. 2004;9(6):471-479.
  29. National Institute for Health and Clinical Excellence (NICE). Laparoscopic cerclage for prevention of recurrent pregnancy loss due to cervical incompetence. Interventional Procedure Guidance 228. London, UK: NICE; August 2007.
  30. Thuesen LL, Diness BR, Langhoff-Roos J. Pre-pregnancy transabdominal cerclage. Acta Obstet Gynecol Scand. 2009;88(4):483-486.
  31. Witt MU, Joy SD, Clark J, et al. Cervicoisthmic cerclage: Transabdominal vs transvaginal approach. Am J Obstet Gynecol. 2009;201(1):105.e1-e4.
  32. Umstad MP, Quinn MA, Ades A. Transabdominal cervical cerclage. Aust N Z J Obstet Gynaecol. 2010;50(5):460-464.
  33. Royal College of Obstetricians and Gynaecologists (RCOG). Cervical cerclage. London, UK: Royal College of Obstetricians and Gynaecologists (RCOG); May 2011.
  34. Tusheva OA, Cohen SL, McElrath TF, Einarsson JI. Laparoscopic placement of cervical cerclage. Rev Obstet Gynecol. 2012;5(3-4):e158-e165.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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