Should a cerclage be removed after premature rupture of the membranes (PROM)?

     A review of the literature addressing retention versus removal of cerclage after premature rupture of the membranes (PROM) by Giraldo-Isaza MA and Berghella V reported "Retention of cerclage for more than 24 hours after PROM was found to prolong pregnancy for more than 48 hours, but also to increase maternal chorioamnionitis and neonatal mortality from sepsis, making immediate cerclage removal as the usually preferred therapeutic approach. Steroids for fetal maturity before cerclage removal can be considered between 24 and 33 6/7 weeks gestation." [1]

     In a 2014 a prospective randomized multicenter trial comparing cerclage retention versus immediate cerclage removal after preterm premature rupture of the membranes (PPROM) found " Statistically significant differences were not seen in prolongation of latency, infection, or composite neonatal outcomes. However, there was a numerical trend in the direction of less infectious morbidity, with immediate removal of cerclage." [2]

     A meta-analysis , by Pergialiotis V, et al. evaluating the outcomes of women treated with cerclage retention compared to immediate cerclage removal after (PPROM) found cerclage retention after PPROM :

•  Increased the rates of delivery after the first 48 h , but did not significantly prolong the gestational latency period (MD 2.56 days, 95 % CI - 1.06, 6.71).

• Did not significantly affect the rates of neonatal sepsis , the neonatal death rates, or rate of neonatal respiratory distress syndrome (RDS)

• Maternal chorioamnionitis was significantly more prevalent among women offered cerclage retention .

The authors of the meta-analysis concluded "... it is our belief that cerclage retention should be instituted only among cases participating in clinical trials or otherwise after the parturient receives detailed analysis of the possible adverse outcomes that seem to accompany this decision and only for a latency period of 48 h in order to administer corticosteroids." [3]

     The American College of Obstetricians and Gynecologists advises " A firm recommendation whether a cerclage should be removed after premature PROM cannot be made, and either removal or retention is reasonable." [4]

REFERENCE

1. Giraldo-Isaza MA, Berghella V. Cervical cerclage and preterm PROM.Clin Obstet Gynecol. 2011 Jun;54(2):313-20. doi: 10.1097/GRF.0b013e318217d530.
PMID:21508701
2. Galyean A, et. al., Removal versus retention of cerclage in preterm premature rupture of membranes: a randomized controlled trial. Am J Obstet Gynecol. 2014 Oct;211(4):399.e1-7. doi: 10.1016/j.ajog.2014.04.009. Epub 2014 Apr 12. PMID: PMID:24726507
3. Pergialiotis V, et al. Retention of cervical cerclage after preterm premature rupture of the membranes: a critical appraisal. Arch Gynecol Obstet. 2015 Apr;291(4):745-53. doi: 10.1007/s00404-014-3551-7. Epub 2014 Nov 22. PMID: PMID:25416200
4. Premature rupture of membranes. Practice Bulletin No. 160. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e39–51.PMID: PMID:26695586