Outpatient cervical cerclage

Predictors of Outcomes of Non-Elective Cervical Cerclages

BACKGROUND

Non-elective cervical cerclages are associated with significant perinatal complications. There is scant available information about what the predictors of these outcomes are, thus making counselling difficult.

OBJECTIVE

To identify which factors predict delivery at or beyond 28, 34, and 37 weeks' gestation in women with emergency/rescue cervical cerclage.

METHODS

We conducted a retrospective cohort study of nonelective cerclages over 10 years in our centre. We included women with singleton pregnancies, morphologically normal fetuses, and a cervix dilated to at least 1 cm. Our primary outcome was delivery at or beyond 28 weeks' gestation, and secondary outcomes consisted of delivery at or beyond 34 and 37 weeks' gestation. Descriptive statistical and logistic regression analyses were performed.

RESULTS

We identified a total of 69 cases, and 47 met the inclusion criteria; 44.6% of these women delivered at or beyond 28 weeks' gestation. Membranes seen in the vagina on ultrasound and postcerclage preterm premature rupture of membranes decreased the chance of delivery at or beyond 28 weeks by 81.7% (OR 0.183; 95% CI 0.048 to 0.703) and 95% (OR 0.050; 95% CI 0.006 to 0.429), respectively. The same factors were predictive of deliveries at or beyond 34 and 37 weeks' gestation.

CONCLUSION

Membranes seen in the vagina on ultrasound and postcerclage pre-labour premature rupture of membranes were the strongest predictors of failure to reach 28 weeks' gestation. This information is of critical importance when counselling patients about non-elective cervical cerclage.

Transvaginal cervical cerclage: evidence for perioperative management strategies

The objective was to review the evidence supporting various perioperative technical and management strategies for transvaginal cervical cerclage. We performed MEDLINE, PubMed, EMBASE, and COCHRANE searches with the terms, cerclage, cervical cerclage, cervical insufficiency, and randomized trials, plus each technical aspect (eg, suture, amniocentesis, etc) considered. The search spanned 1966 through September 2012 and was not restricted by language. Each retrieved manuscript was carefully evaluated, and any pertinent references from the reports were also obtained and reviewed. All randomized trials covering surgical and selected perioperative, nonsurgical aspects of cerclage were included in the review. The evidence was assessed separately for history-, ultrasound-, and physical examination-indicated cerclage. Evidence levels according to the new method outlined by the US Preventive Services Task Force were assigned based on the evidence. There are no grade A high-certainty recommendations regarding technical aspects of transvaginal cervical cerclage. Grade B moderate-certainty recommendations include performing a fetal ultrasound before cerclage to ensure fetal viability, confirm gestational age, and assess fetal anatomy to rule out clinically significant structural abnormalities; administering spinal, and not general, anesthesia; performing a McDonald cerclage, with 1 stitch, placed as high as possible; and outpatient setting. Unfortunately, no other recommendations can be made regarding the other technical aspects of cerclage.