Management of Cervical Cerclage after Premature Preterm Rupture of Membranes: An argument for removal: Immediate removal of cerclage after PPROM.

Cervical cerclage is a widely used intervention to prevent PTB in high-risk pregnancies. However, cerclage carries risks, including preterm prelabor rupture of membranes (PPROM) and subsequent complications such as chorioamnionitis. Our review evaluates the evidence for immediate removal (i.e. removal at time of diagnosis) versus retention of cervical cerclage (i.e. removal when clinically indicated) following PPROM, focusing on optimizing neonatal outcomes and minimizing maternal and fetal complications. A meta-analysis on the topic that included 169 patients in the "removal" group and 208 in the "retention" group showed that the rate of pregnancy prolongation > 48 hours was significantly lower in the group undergoing immediate removal of cerclage (47% vs 85%; OR 0.15), as well as the rate of pregnancy prolongation > 7 days (33% vs 57%; OR 0.30). Pregnancy latency was also significantly lower despite the absolute mean difference was only 2.84 days. However, the rate of chorioamnionitis was significantly lower in the immediate removal compared to the retention group (29% vs 41%; OR 0.57), as well as the rate of Apgar score < 7 at 5 minutes (16% vs 43%; OR 0.22). A proposed balanced approach involves retaining the cerclage for approximately 24 hours post-PROM to permit steroid administration (initial dose followed by a second dose after 24 hours) before removal. This strategy aims to maximize steroid benefits while minimizing the risks of prolonged cerclage retention, potentially achieving a correct timing that optimizes neonatal outcomes without significantly increasing complications This management approach could be beneficial in situations where immediate removal may preclude full steroid benefits. Our recommendations support a protocol balancing appropriate timing for steroid administration with the risks of extended cerclage retention, namely chorioamnionitis, unless further randomized controlled trials will show the proper evidence based management in this clinical scenario.