Management of cervical cerclage after preterm premature rupture of membranes: an argument for removal

Cervical cerclage is a widely used intervention to prevent preterm birth in high-risk pregnancies. However, cerclage is associate with risks, including preterm premature rupture of membranes and subsequent complications, such as chorioamnionitis. Our review evaluates the evidence for immediate removal (ie, removal at the time of diagnosis) vs retention of cervical cerclage (ie, removal when clinically indicated) after preterm premature rupture of membranes, 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 rates of pregnancy prolongation >48 hours and >7 days were significantly lower in the group who underwent immediate removal of cerclage than in the group who had delayed removal of cerclage (pregnancy prolongation >48 hours: 47% vs 85%, respectively; odds ratio, 0.15; pregnancy prolongation >7 days: 33% vs 57%, respectively; odds ratio, 0.30). In addition, pregnancy latency was significantly lower, despite the absolute mean difference being only 2.84 days. However, the rates of chorioamnionitis and Apgar score <7 at 5 minutes were significantly lower in the immediate removal group than in the retention group (chorioamnionitis: 29% vs 41%, respectively; odds ratio, 0.57; Apgar score <7 at 5 minutes: 16% vs 43%, respectively; odds ratio, 0.22). A proposed balanced approach involves retaining the cerclage for approximately 24 hours after premature rupture of membranes (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.