Outcomes after cerclage and preterm prelabor rupture of membranes: data from the international collaborative for cerclage longitudinal evaluation and research (IC-CLEAR)

Background

The literature is conflicting regarding the management of cervical cerclage once patients experience preterm prelabor rupture of membranes (PPROM). While some recommend removal of the cerclage due to the risk of maternal and neonatal infectious morbidity after PPROM, others advocate retention of the cerclage due to the benefit of latency to delivery.

Objective

Our study objective is to determine the safety of cerclage retention in women who experience PPROM before 34 weeks (w) gestation.

Study Design

Retrospective cohort study of singleton pregnancies with cerclage for history, ultrasound or physical exam indications between June 2016 and June 2020 at 8 sites across United States and Colombia. The primary exposure of interest was the time from PPROM to cerclage removal (CR) categorized as early < 48 hours (h)– or delayed (≥48 h). Maternal safety outcomes collected as part of the database design included clinical chorioamnionitis, histologic chorioamnionitis, postpartum endometritis, hemorrhage, sepsis, and intensive care unit admission. Neonatal safety outcome was a composite of sepsis, prematurity complications and death. Statistical analysis included bivariate and multivariate techniques. Latency between PPROM and delivery was also compared between the early and delayed CR groups.

Results

Of 839 singleton pregnancies managed with cerclage, 135 (16.1%) experienced PPROM before 34 weeks gestation–127 with the cerclage in place. 37 underwent immediate CR for labor, bleeding, chorioamnionitis or cord prolapse and as such, were excluded from further analyses. Eighty-nine patients were included in final analysis–59 early CR (66.3%) and 30 delayed CR (33.7%). Rates of clinical chorioamnionitis and histologic chorioamnionitis were similar between groups (clinical: early CR 22.0% vs delayed CR 40.0%, P=.08; histologic: early CR 55.1% vs delayed CR 66.7%, P=.30). Postpartum endometritis rate was higher in delayed CR vs early CR (16.7% vs 1.7%, P=.008). Composite neonatal outcome and neonatal mortality were similar between groups. Latency from PPROM to delivery was longer with delayed CR by 7 days (P<.001). In adjusted analyses, clinical chorioamnionitis was not independently associated with cerclage removal timing when controlling for PPROM before 24 weeks (AOR 0.41 [95% CI 0.16, 1.07], P=.07) and endometritis was lower with early CR (AOR 0.09 [95% CI 0.01, 0.79], P=.03). We also evaluated the relationship between neonatal outcomes and cerclage removal timing controlling for corticosteroids and PPROM before 24 weeks and found that composite neonatal outcome was not independently associated with cerclage removal timing (AOR 0.36 [95% CI 0.07-1.91], P=.23). Neonatal mortality was lower with corticosteroid administration (AOR 0.15 [95% CI 0.02, 0.97], P=.046) and higher in PPROM before 24w (AOR 12.2 [95% CI 2.05, 72.7], P=.006).

Conclusion

Delaying cerclage removal in patients after a diagnosis of preterm prelabor rupture of membranes can increase the rate of postpartum endometritis and delay delivery by 1 week without significantly increasing the rate of neonatal morbidity and mortality.