What is the recommended management for emergency cerclage?

Emergency Cerclage Management

Emergency cerclage can be considered in patients with fetal membranes visible at or past the external cervical os in the absence of uterine contractions, preterm premature rupture of membranes (PPROM), or intra-amniotic infection at less than 24 weeks of gestation. 1

Patient Selection Criteria

• Emergency cerclage is indicated when there is cervical dilation with visible fetal membranes in the second trimester (typically before 24 weeks) without signs of infection, labor, or PPROM 1
• Contraindications include:
  • Active labor or uterine contractions 1, 2
  • Maternal pyrexia or signs of intra-amniotic infection 2, 3
  • Preterm premature rupture of membranes 1
  • Gestational age beyond 24 weeks 1

Pre-Procedure Assessment

• Evaluate for signs of infection (maternal fever, uterine tenderness, foul-smelling discharge, elevated white blood cell count, elevated C-reactive protein) 2, 3
• Confirm absence of uterine contractions through clinical assessment and monitoring 1, 4
• Verify intact membranes 1
• Consider ultrasound assessment to confirm fetal viability and rule out fetal anomalies 4, 3

Procedural Considerations

• Antibiotic prophylaxis is recommended both locally and systemically to reduce infection risk 2, 4
• The McDonald cerclage technique is commonly used, though multiple techniques exist 5, 4
• For cases with significant membrane prolapse, specialized approaches may be required:
  • Some centers use a three-step procedure involving a tobacco bag cerclage, followed by an occlusive cerclage, and cervical cleisis when vaginal bag prolapse is present 6
• Tocolytics may be considered to prevent uterine contractions during and immediately after the procedure 1

Post-Procedure Management

• Observational and randomized controlled studies show that emergency cerclage is associated with:
  • Pregnancy prolongation 1, 4
  • Increased live births 1
  • Improved neonatal survival compared to expectant management 1
• Consider continuation of vaginal progesterone after cerclage placement, as limited evidence suggests reduced spontaneous preterm birth rates (2.2% vs 18.4% at <34 weeks) 1
• Patients should be monitored for signs of infection or preterm labor 4, 3
• Activity restriction is often recommended, though evidence for its efficacy is limited 4

Outcomes and Prognosis

• Success rates vary significantly based on:
  • Degree of cervical dilation at diagnosis 4, 3
  • Presence of bulging membranes 4, 3
  • Gestational age at diagnosis 4
  • Cervical length after procedure 6, 4
• Reported outcomes from studies include:
  • Mean latency from procedure to delivery: 14 weeks + 6 days in one study 6
  • Mean gestational age at delivery: 35 weeks in one study 6
  • Neonatal survival rates of up to 95.8% have been reported in selected series 6
  • However, older studies reported higher complication rates with abortion rates of 59% and significant perinatal mortality 2

Complications and Pitfalls

• Potential complications include:
  • Membrane rupture during procedure 4, 3
  • Chorioamnionitis (found in 79.2% of poor outcomes in one study) 3
  • Preterm labor triggered by manipulation 4
• Poor prognostic factors include:
  • Advanced cervical dilation (>5 cm) 4, 3
  • Prolapsed membranes 3
  • Maternal symptoms 3
  • Equivocal markers of infection 3

Special Considerations

• For twin pregnancies, emergency cerclage may still be beneficial despite traditionally being considered higher risk 4, 3
• A multidisciplinary approach involving obstetricians, maternal-fetal medicine specialists, and neonatologists is recommended for counseling and decision-making 1
• Patients should be informed that even with advanced dilation and membrane prolapse, successful outcomes are possible, though risks remain significant 3