Removal Versus Retention of Cervical Cerclage With Preterm Prelabor Rupture of Membranes: Systematic Review and Meta-analysis
Authors: Zullo Fabrizio , Di Mascio Daniele , Chauhan Suneet P. , Chrysostomou Spyridakis , Suff Natalie , Pecorini Francesco , D'Ambrosio Valentina , Sorrenti Sara , D'Alberti Elena , Galoppi Paola , Muzii Ludovico , Giancotti Antonella , Brunelli Roberto 
Published: March 2024

One predictor of preterm birth (PTB) is a short cervical length before 24 weeks of gestation. For pregnant women with short cervical length and a history of PTB, cervical cerclage plus progesterone is offered. This procedure has been shown to reduce the risk of PTB, pregnancy loss, and perinatal morbidity and mortality. However, it also increases the risk of preterm, premature rupture of membrane (pPROM). When pPROM occurs, the decision must be made to either remove or retain the cerclage. This decision is a challenge due to a lack of evidence to support retaining cerclage, which could prolong the duration of pregnancy, or removing it, which may decrease the risk chorioamnionitis. In addition, guidelines from international societies are conflicting: a practice bulletin from the American College of Obstetricians and Gynecologists regards both removal and retention of cerclage in pregnancies complicated with pPROM as reasonable options, whereas a practice guideline from the Royal College of Obstetricians and Gynecologists supports the removal of cerclage. The aim of this study was to compare the removal of cervical cerclage with its retention on maternal and perinatal outcomes.

This was a systematic review and meta-analysis using an electronic search of Medline, Embase, and Cochrane electronic databases in February 2023. Included were prospective and retrospective publications, reported in English, which evaluated perinatal outcomes of removing or retaining cervical cerclage complicated by pPROM. Excluded were case reports, case series, review articles, letters to the editors, or editorials. The primary outcomes were pregnancy latency from pPROM >48 hours and >7 days. Quality assessment of the included studies used the Newcastle-Ottawa Scale.

A total of 6 studies, representing 377 women (169 in the removal group and 208 in the retention group), were included in this systematic review. The removal group had significantly lower rates of pregnancy latency than the retention group at >48 hours (47% vs 85%; odds ratio [OR], 0.15; 95% confidence interval [CI], 0.07–0.31; P < 0.0001) and >7 days (33% vs 57%; OR, 0.30; 95% CI, 0.11–0.83; P = 0.02). However, the removal group also had lower rates than the retention groups of chorioamnionitis (29% vs 41%; OR, 0.57; 95% CI, 0.34–0.96; P = 0.03) and Apgar score <7 at 5 minutes (16% vs 43%; OR, 0.22; 95% CI, 0.08–0.56; P = 0.002). No significant differences were observed in the rates of postpartum endometritis, cesarean delivery, respiratory distress syndrome, neonatal sepsis, intraventricular hemorrhage, necrotizing enterocolitis, birthweight, fetal death, and neonatal mortality.

In conclusion, the group that had cervical cerclage removal had a lower risk of experiencing pregnancy latency at >48 hours and >7 days than the group with cerclage retention. However, the retention group had a higher risk of chorioamnionitis and Apgar <7 at 5 minutes.