Cerclage Removal After Premature Rupture of the Membranes (PROM)?
Updated Clinical Summary
Evidence comparing cerclage retention vs. immediate removal after preterm premature rupture of membranes (PPROM) shows:
- Retention for >24 hours may slightly increase the chance of remaining pregnant for ≥48 hours, but does not significantly prolong overall latency or improve neonatal outcome.
- Multiple studies demonstrate higher rates of maternal chorioamnionitis with cerclage retention.
- Immediate removal shows a trend toward less infectious morbidity without clearly worsening neonatal outcomes.
- If the goal is corticosteroid administration (24–33 6/7 weeks), some clinicians may consider 24–48 hours of short-term retention after counseling.
ACOG (Practice Bulletin 160) concludes that evidence is insufficient to mandate one approach; therefore either cerclage removal or retention is reasonable, individualized to maternal–fetal condition.
Evidence Review
A review by Giraldo-Isaza & Berghella reported that:
- Retention >24 hours prolongs pregnancy beyond 48 hours but is associated with higher maternal chorioamnionitis and increased neonatal mortality from sepsis.
- Immediate removal is generally preferred, though steroid administration before removal can be considered between 24–33 6/7 weeks.
A 2014 multicenter randomized trial (Galyean et al.) found:
- No statistically significant difference in latency, infection, or composite neonatal outcomes.
- A numerical trend favoring immediate removal for decreased infectious morbidity.
A 2015 meta-analysis (Pergialiotis et al.) found that retention:
- Increased likelihood of pregnancy beyond 48 hours.
- Did not reduce neonatal sepsis, neonatal death, or RDS.
- Significantly increased maternal chorioamnionitis.
The authors recommended retention only in clinical trials or after detailed counseling, and ideally only for the brief period required to administer corticosteroids.
References
1. Giraldo-Isaza MA, Berghella V. Cervical cerclage and preterm PROM. Clin Obstet Gynecol. 2011;54:313–20. PMID: 21508701
2. Galyean A, et al. Removal versus retention of cerclage in PPROM: RCT. Am J Obstet Gynecol. 2014;211:399.e1–7. PMID: 24726507
3. Pergialiotis V, et al. Retention of cervical cerclage after PPROM: meta-analysis. Arch Gynecol Obstet. 2015;291:745–53. PMID: 25416200
4. ACOG Practice Bulletin 160: Premature Rupture of Membranes. Obstet Gynecol 2016;127:e39–51. PMID: 26695586