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How can we improve the outcome of emergency cerclage?
Keun-Young Lee
Department of Obstetrics and Gynecology, Hallym University, Seoul, Korea.

Article ID: 100003G06KL2015
doi:10.5348/G06-2015-3-ED-3

Address correspondence to:
Keun-Young Lee
MD, Department of Obstetrics and Gynecology
Hallym University, Seoul
Korea

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Keun-Young L. How can we improve the outcome of emergency cerclage?. Edorium J Gynecol Obstet 2015;1:10–13.


Cervical insufficiency is a well-recognized cause of preterm birth in the second or early third trimester of pregnancy, and therefore it is very important topics related to preterm birth. Cervical insufficiency with bulging fetal membranes during the second trimester is a serious complication, often leading to still birth or preterm delivery. [1] Emergency cerclage is recognized as an essential procedure for prolonging gestation in women with advanced cervical changes and/or prolapsed membranes in the second trimester. Many studies report that women presenting with advanced cervical dilation may benefit from emergency cerclage [2] [3] [4] [5] [6] [7] [8]. Namouz et al. [9] reviewed 34 studies in literature and found that, in observational and limited randomized control trials, the cerclage groups did significantly better than the bed-rest groups in terms of mean randomization-to-delivery interval, preterm delivery before 34 weeks, and compound morbidity. Hashim et al. [10] retrieved 141 articles related to emergency cerclage and also found current evidence to show the benefits of emergency cerclage. It may prolong pregnancy by an average 4–5 weeks, with a two-fold reduction in the possibility of preterm birth before 34 weeks of pregnancy.

The rate of emergency cerclage success is relatively low, however, certainly compared with elective cerclage. Membranes are easily ruptured intraoperatively, especially when the cervix is widely dilated and the fetal membranes are prolapsed beyond the cervix [5] [6]. Pushing bulging fetal membranes back into the uterine cavity during cerclage with a sponge swab or Foley catheter is difficult. Overfilling the urinary bladder to reduce prolapsed fetal membranes without direct mechanical contact is often insufficient as a single method [11]. Other less utilized techniques include inflatable devices, such as a metreurynter or a rubber balloon, although no studies of their use have as yet appeared [12] [13]. Recently, Son et al. [14] have developed a new uniconcave balloon device for repositioning, fetal membranes into the uterus during emergency cerclage and reported its use in 103 patients who underwent emergency cerclage. This device has a shape similar to that of a red blood cell, or a donut, providing maximum surface area to allow the force exerted on the membranes to push them back into the uterus safely and effectively. Cerclage was technically successful in all cases. There were no rupture of membranes in any patients, and no operative or anesthetic complications. Son et al. [14] concluded that obstetricians could perform emergency cerclage with this uniconcave balloon easily and safely with few complications.

The recommended gestational age for emergency cerclage is less than 24 weeks, the threshold of fetal viability (that is, morethan 24 weeks' gestation), because the potential for harm likely outweighs the potential benefit [15] [16]. All contraindications to emergency cervical cerclage should be excluded-preterm labor, evidence of intraamniotic infection, unexplained vaginal bleeding (abruption), preterm premature rupture of membrane, fetal demise and major fetal anomalies [17] [18]. Amniocentesis before emergency cerclage is not obligatory, but has two important benefits. One is the decompression of amniotic fluid to place a satisfactory cerclage, especially for hourglassing bulging membranes and the other is the detection of intraamniotic infection. Data from uncontrolled retrospective studies [19][20] [21] [22] has suggested the perioperative use of tocolytics and broad spectrum antibiotics. There are no studies of emergency cerclage comparing general with regional anesthesia, but in the writer's experience general anesthesia is better for performing cerclage with marked membrane bulging [17]. A single course of corticosteroids is recommended in women with pregnancy duration of 24 weeks or more, to enhance fetal lung maturation [22]. Deb et al. [20] suggested the routine prescription of supplemental progesterone for postoperative care, but their study was not RCT.

Several predictors for emergency cerclage success have been reported, such as intra-amniotic markers of infection, systemic markers of infection, prolapsed membranes, cervical dilatation, and sonography of the cervix. [9] Among these, intra-amniotic markers show high sensitivity and specificity. Lee at al. [23] reported that elevated amniotic IL-6 predicts a cerclage short-interval latency. Linear regression analysis with latency as the independent variable revealed a significant relationship (r = -0.62: p< 0.001). The median survival analysis in patients with preoperative IL-6 levels >1700 pg/mL was two days, which was significantly shorter than in patients with preoperative IL-6 levels <1700 pg/mL whose median latency interval was 35 days (p = 0.0003). Weiner at al. [24] utilized a proteomic strategy to investigate the role of biomarkers as potential predictors. Among the patients who underwent emergency cerclage, women with high inflammatory scores had shorter cerclage-to-delivery intervals and delivered earlier; women with MR scores less than 3 and no hemoglobin had a median latency period of 40.5 days (range 1–148 days), compared with women with both MR scores of 3 to 4 and hemoglobin scores of 1 whose median latency period was three days (range 0–43 days).

Emergency cerclage in twin pregnancy with membrane bulging had not appeared useful, and has not been studied in a dictated RCT. Recently, however, Rebarber et al. [25] performed emergency cerclage on 12 women with twin gestation and cervical dilation, and showed that emergency cerclage can be associated with favorable outcomes, including a high likelihood of delivery at >32 weeks and high likelihood of survival. Levin et al. [26], and Zanardini et al. [27] also found favorable outcomes. Cases with bulging membranes following prior cerclage are also surgically challenging, as there are no relevant guidelines. Song et al. [28] evaluated 22 women with bulging membranes after primary cerclage, comparing 11 women with repeat cerclage and 11 with bed rest. After repeat cerclage, the median gestational age at delivery (p = 0.004), average birth weight (p<0.01), and median prolongation of pregnancy (<0.01) were higher, and the neonatal survival rate was also significantly higher (p < 0.009).

Emergency cerclage may be the best hope for rescuing pregnancy in women with advanced cervical changes and prolapsed membranes in the mid trimester. The operative risk is surgically challenging. However the recently reported uniconcave cerclage balloon technique may be a great help to the patient with cervical insufficiency and bulging membranes. Amniocentesis before emergency cerclage is not obligatory, but is useful in extreme cases of membrane bulging, and for detection of intraamniotic infection. We need to identify some highly sensitive biomarkers as predictors of emergency cerclage success. The role of emergency cerclage in twin pregnancy with membrane bulging should be also studied more. Repeat cerclage after prior cerclage failure should be considered [29].

Keywords: Amniocentesis, Cervical insufficiency, Emergency cerclage, Preterm birth


References
  1. Ishikawa K, Watanabe H, Tadokoro N, Oshima K, Nishikawa M, Inaba N. Outcome of prolapsed chorioamniotic membrane: relationship between the degree of herniation, infection, and pregnancy prolongation. Am J Perinatol 2003 Oct;20(7):381–9.   [Pubmed]    Back to citation no. 1
  2. Althuisius SM, Dekker GA, Hummel P, van Geijn HP. Cervical incompetence prevention randomized cerclage trial: emergency cerclage with bed rest versus bed rest alone. Am J Obstet Gynecol 2003 Oct;189(4):907–10.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Benifla JL, Goffinet F, Darai E, Proust A, De Crepy A, Madelenat P. Emergency cervical cerclage after 20 weeks' gestation: a retrospective study of 6 years' practice in 34 cases. Fetal Diagn Ther 1997 Sep-Oct;12(5):274–8.   [CrossRef]   [Pubmed]    Back to citation no. 3
  4. Daskalakis G, Papantoniou N, Mesogitis S, Antsaklis A. Management of cervical insufficiency and bulging fetal membranes. Obstet Gynecol 2006 Feb;107(2 Pt 1):221–6.   [CrossRef]   [Pubmed]    Back to citation no. 4
  5. Harger JH. Cerclage and cervical insufficiency: an evidence-based analysis. Obstet Gynecol 2002 Dec;100(6):1313–27.   [CrossRef]   [Pubmed]    Back to citation no. 5
  6. Kurup M, Goldkrand JW. Cervical incompetence: elective, emergent, or urgent cerclage. Am J Obstet Gynecol 1999 Aug;181(2):240–6.   [CrossRef]   [Pubmed]    Back to citation no. 6
  7. Pereira L, Cotter A, Gómez R, et al. Expectant management compared with physical examination-indicated cerclage (EM-PEC) in selected women with a dilated cervix at 14(0/7)-25(6/7) weeks: results from the EM-PEC international cohort study. Am J Obstet Gynecol. 2007 Nov;197(5):483.e1–8.   [Pubmed]    Back to citation no. 7
  8. Stupin JH, David M, Siedentopf JP, Dudenhausen JW. Emergency cerclage versus bed rest for amniotic sac prolapse before 27 gestational weeks. A retrospective, comparative study of 161 women. Eur J Obstet Gynecol Reprod Biol 2008 Jul;139(1):32–7.   [CrossRef]   [Pubmed]    Back to citation no. 8
  9. Namouz S, Porat S, Okun N, Windrim R, Farine D. Emergency cerclage: literature review. Obstet Gynecol Surv 2013 May;68(5):379–88.   [CrossRef]   [Pubmed]    Back to citation no. 9
  10. Abu Hashim H, Al-Inany H, Kilani Z. A review of the contemporary evidence on rescue cervical cerclage. Int J Gynaecol Obstet 2014 Mar;124(3):198–203.   [CrossRef]   [Pubmed]    Back to citation no. 10
  11. Scheerer LJ, Lam F, Bartolucci L, Katz M. A new technique for reduction of prolapsed fetal membranes for emergency cervical cerclage. Obstet Gynecol 1989 Sep;74(3 Pt 1):408–10.   [Pubmed]    Back to citation no. 11
  12. Higuchi M, Hirano H, Maki M. Emergency cervical cerclage using a metreurynter in patients with bulging membranes. Acta Obstet Gynecol Scand 1992 Jan;71(1):34–8.   [CrossRef]   [Pubmed]    Back to citation no. 12
  13. Tsatsaris V, Senat MV, Gervaise A, Fernandez H. Balloon replacement of fetal membranes to facilitate emergency cervical cerclage. Obstet Gynecol 2001 Aug;98(2):243–6.   [CrossRef]   [Pubmed]    Back to citation no. 13
  14. Son GH, Chang KH, Song JE, Lee KY. Use of a uniconcave balloon in emergency cerclage. Am J Obstet Gynecol 2015 Jan;212(1):114.e1–4.   [CrossRef]   [Pubmed]    Back to citation no. 14
  15. Norwitz ER, Greene M, Repke JT. Cervical cerclage- elective and emergent. ACOG Update 1999;24:1–11.    Back to citation no. 15
  16. Norwitz ER. Emergency cerclage: What do the data really show?. Contemporay b/Gyn 2002;104:8–66.    Back to citation no. 16
  17. Royal College of Obstetricians and Gynecologists. Cervical Cerclage: Green-top Guideline 60. Published May 2011. [Availabe at: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_60.pdf]    Back to citation no. 17
  18. Liddiard A, Bhattacharya S, Crichton L. Elective and emergency cervical cerclage and immediate pregnancy outcomes: a retrospective observational study. JRSM Short Rep 2011 Nov;2(11):91.   [CrossRef]   [Pubmed]    Back to citation no. 18
  19. Nelson L, Dola T, Tran T, Carter M, Luu H, Dola C. Pregnancy outcomes following placement of elective, urgent and emergent cerclage. J Matern Fetal Neonatal Med 2009 Mar;22(3):269–73.   [CrossRef]   [Pubmed]    Back to citation no. 19
  20. Deb P, Aftab N, Muzaffar S. Prediction of outcomes for emergency cervical cerclage in the presence of protruding membranes. ISRN Obstet Gynecol 2012;2012:842841.   [CrossRef]   [Pubmed]    Back to citation no. 20
  21. Abo-Yaqoub S, Mohammed AB, Saleh H. The effect of second trimester emergency cervical cerclage on perinatal outcome. J Matern Fetal Neonatal Med 2012 Sep;25(9):1746–9.   [CrossRef]   [Pubmed]    Back to citation no. 21
  22. Fuchs F, Senat MV, Fernandez H, Gervaise A, Frydman R, Bouyer J. Predictive score for early preterm birth in decisions about emergency cervical cerclage in singleton pregnancies. Acta Obstet Gynecol Scand 2012 Jun;91(6):744–9.   [CrossRef]   [Pubmed]    Back to citation no. 22
  23. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 475: antenatal corticosteroid therapy for fetal maturation. Obstet Gynecol 2011 Feb;117(2 Pt 1):422–4.   [CrossRef]   [Pubmed]    Back to citation no. 23
  24. Lee KY, Jun HA, Kim HB, Kang SW. Interleukin-6, but not relaxin, predicts outcome of rescue cerclage in women with cervical incompetence. Am J Obstet Gynecol 2004 Sep;191(3):784–9.   [CrossRef]   [Pubmed]    Back to citation no. 24
  25. Weiner CP, Lee KY, Buhimschi CS, Christner R, Buhimschi IA. Proteomic biomarkers that predict the clinical success of rescue cerclage. Am J Obstet Gynecol 2005 Mar;192(3):710–8.   [CrossRef]   [Pubmed]    Back to citation no. 25
  26. Rebarber A, Bender S, Silverstein M, Saltzman DH, Klauser CK, Fox NS. Outcomes of emergency or physical examination-indicated cerclage in twin pregnancies compared to singleton pregnancies. Eur J Obstet Gynecol Reprod Biol 2014 Feb;173:43–7.   [CrossRef]   [Pubmed]    Back to citation no. 26
  27. Levin I, Salzer L, Maslovitz S, et al. Outcomes of mid-trimester emergency cerclage in twin pregnancies. Fetal Diagn Ther 2012;32(4):246–50.   [CrossRef]   [Pubmed]    Back to citation no. 27
  28. Zanardini C, Pagani G, Fichera A, Prefumo F, Frusca T. Cervical cerclage in twin pregnancies. Arch Gynecol Obstet 2013 Aug;288(2):267–71.   [CrossRef]   [Pubmed]    Back to citation no. 28
  29. Song JE, Lee KY, Jun HA. Repeat cerclage prolongs pregnancy in women with prolapsed membranes. Acta Obstet Gynecol Scand 2011 Jan;90(1):111–3.   [CrossRef]   [Pubmed]    Back to citation no. 29

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Author Contributions:
Keun-Young Lee – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2015 Keun-Young Lee. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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