Indications for Cerclage Removal in Patients with PPROM
In patients with preterm premature rupture of membranes (PPROM), it is reasonable to either remove the cerclage or leave it in situ after discussing the risks and benefits with the patient through shared decision-making. 1
Key Considerations for Cerclage Management in PPROM
There is a lack of consensus surrounding cerclage management after PPROM at any gestational age, with limited high-quality evidence to guide decision-making 1
The only randomized clinical trial evaluating cerclage removal after PPROM (22-32 weeks) was stopped early due to futility, showing no significant pregnancy prolongation with cerclage retention compared to removal (45.8% vs 56.2% had 1-week prolongation) 1, 2
Cerclage retention did not significantly increase rates of chorioamnionitis (41.6% vs 25.0%), postpartum endometritis (12.5% vs 3.1%), composite neonatal morbidity (56% vs 50%), or perinatal mortality (16% vs 12%) compared to cerclage removal 1
Specific Indications for Cerclage Removal in PPROM
Signs of infection: Immediate cerclage removal is indicated if there are signs of chorioamnionitis or intraamniotic infection (maternal fever, uterine tenderness, purulent vaginal discharge, fetal tachycardia) 3, 4
Labor: Active labor is an indication for cerclage removal 5
Significant vaginal bleeding: Heavy vaginal bleeding warrants cerclage removal 3
Fetal distress: Evidence of non-reassuring fetal status requires cerclage removal 5
Considerations for Cerclage Retention
Some clinicians advocate for a balanced approach - retaining cerclage for approximately 24 hours after PPROM to permit steroid administration before removal, especially between 24-33 6/7 weeks gestation 6, 7
This strategy aims to maximize steroid benefits while minimizing risks of prolonged cerclage retention 6
Risks of Different Management Approaches
Cerclage retention risks: Some studies suggest higher rates of chorioamnionitis (up to 90%) and increased perinatal mortality primarily from sepsis (70% vs 10-18%) with cerclage retention 4
Cerclage removal risks: Immediate removal may lead to more rapid delivery, potentially before completing a course of antenatal corticosteroids 6, 7
A meta-analysis showed that immediate cerclage removal was associated with lower rates of pregnancy prolongation >48 hours (47% vs 85%) and >7 days (33% vs 57%) compared to retention, but also lower rates of chorioamnionitis (29% vs 41%) and poor Apgar scores (16% vs 43%) 6
Clinical Approach to Decision-Making
Assess for signs of infection, labor, bleeding, or fetal distress - these are clear indications for immediate removal 3, 4
Consider gestational age - at extremely preterm gestations, the risks of immediate delivery may outweigh infection risks 1, 3
If no contraindications to expectant management exist, discuss with the patient the balanced approach of short-term retention (24 hours) to allow for steroid administration when appropriate 6, 7
Monitor closely for development of infection if cerclage is retained, with low threshold for removal if clinical deterioration occurs 3, 4