Full length article| Volume 259, P75-80, April 2021

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Optimal timing of cervical cerclage removal following preterm premature rupture of membranes; a retrospective analysis

Published:February 06, 2021DOI:


      • Largest retrospective study evaluating woman following cerclage removal or retention after PPROM.
      • Cervical cerclage retention in women following PPROM was associated with a longer latency period to delivery.
      • Cervical cerclage retention in women following PPROM was associated with a non-significant trend towards chorioamnionitis.



      Preterm prelabour rupture of membranes occurs in over one third of pregnant women with a cervical cerclage in situ. In the setting of preterm prelabour rupture of membranes, clinicians are faced with the difficult decision of the optimal timing for removing the cerclage. We compared the maternal and neonatal outcomes following immediate removal or retention of the cervical cerclage.

      Study design

      Women were retrospectively identified from St Thomas’s Hospital Preterm Surveillance clinic database. Asymptomatic women with preterm prelabour rupture of membranes were identified and separated into those that had the cerclage removed and those that had the cerclage retained within 24 h of presentation. Women who were symptomatic at presentation and who delivered within 24 h of presentation were excluded from the analysis. Maternal outcomes measured were latency between preterm prelabour rupture of membranes and delivery, gestation at delivery and maternal chorioamnionitis and infection markers. Neonatal outcomes including birthweight and Apgar scores were also measured.


      43 women with cerclage retained for over 24 h following preterm prelabour rupture of membranes were compared to 25 women in whom the cerclage was removed. The latency between preterm prelabour rupture of membranes and delivery was on average 70.4 h longer in women who had their cerclage retained compared to the removed group (p = 0.009). Rates of chorioamnionitis, maternal blood results, neonatal birthweight and Apgar scores did not differ significantly between the two groups, however a trend towards higher rates of chorioamnionitis (60 % vs 45 %) were seen in the retained group.


      Cervical cerclage retention in women following preterm prelabour rupture of membranes was associated with a longer latency period to delivery and was not significantly associated with any adverse obstetric, maternal or neonatal outcomes. Therefore, in women at risk of spontaneous preterm birth, cerclage retention may be beneficial, however these women and their babies should be monitored closely for any signs of infection. Further prospective randomised controlled studies assessing these outcomes as well as longer-term outcomes in these women and their children are needed.


      CRP (C-reactive protein), CS (caesarean section), EmCS (emergency caesarean section), PPROM (Preterm prelabour rupture of membranes), SVD (spontaneous vaginal delivery), WCC (white cell count)


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        • Simmons L.E.
        • Rubens C.E.
        • Darmstadt G.L.
        • Gravett M.G.
        Preventing preterm birth and neonatal mortality: exploring the epidemiology, causes, and interventions.
        Semin Perinatol. 2010; 34: 408-415
        • Saigal S.
        • Doyle L.W.
        An overview of mortality and sequelae of preterm birth from infancy to adulthood.
        Lancet. 2008; 371: 261-269
        • Treadwell M.C.
        • Bronsteen R.A.
        • Bottoms S.F.
        Prognostic factors and complication rates for cervical cerclage: a review of 482 cases.
        Am J Obstet Gynecol. 1991; 165: 555-558
        • Blickstein I.
        • Katz Z.
        • Lancet M.
        • Molgilner B.M.
        The outcome of pregnancies complicated by preterm rupture of the membranes with and without cerclage.
        Int J Gynaecol Obstet. 1989; 28: 237-242
        • Jenkins T.M.
        • Berghella V.
        • Shlossman P.A.
        • McIntyre C.J.
        • Maas B.D.
        • Pollock M.A.
        • et al.
        Timing of cerclage removal after preterm premature rupture of membranes: maternal and neonatal outcomes.
        Am J Obstet Gynecol. 2000; 183: 847-852
        • Galyean A.
        • Garite T.J.
        • Maurel K.
        • Abril D.
        • Adair C.D.
        • Browne P.
        • et al.
        Removal versus retention of cerclage in preterm premature rupture of membranes: a randomized controlled trial.
        Am J Obstet Gynecol. 2014; 211 (e1-7): 399
        • Aguin E.
        • Van De Ven C.
        • Cordoba M.
        • Albayrak S.
        • Bahado-Singh R.
        Cerclage retention versus removal following preterm premature rupture of membranes and association with amniotic fluid markers.
        Int J Gynecol Obstet. 2014; 125: 37-40
        • Carter J.
        • Tribe R.M.
        • Sandall J.
        • Shennan A.H.
        • Alfirevic Z.
        • Adamson C.
        • et al.
        The Preterm Clinical Network (PCN) Database: a web-based systematic method of collecting data on the care of women at risk of preterm birth.
        BMC Pregnancy Childbirth. 2018; 18
        • McElrath T.F.
        • Norwitz E.R.
        • Lieberman E.S.
        • Heffner L.J.
        Management of cervical cerclage and preterm premature rupture of the membranes: should the stitch be removed?.
        Am J Obstet Gynecol. 2000; 183: 840-846
        • Thomson A.
        • Jobot R.
        Care of women presenting with suspected preterm prelabour rupture of membranes from 24+0 weeks of gestation.
        Bjog Int J Obstet Gynaecol. 2019; 126: 52-166
        • Ludmir J.
        • Bader T.
        • Chen L.
        • Lindenbaum C.
        • Wong G.
        Poor perinatal outcome associated with retained cerclage in patients with premature rupture of membranes.
        Obstet Gynecol. 1994; 84: 823-826
        • Abbott D.
        • To M.
        • Shennan A.
        Cervical cerclage: a review of current evidence.
        Aust N Z J Obstet Gynaecol. 2012; 52: 220-223
        • M L
        • Yinon Y.
        • Whittle W.L.
        Preterm premature rupture of membranes in the presence of cerclage: is the risk for intra-uterine infection and adverse neonatal outcome increased?.
        J Matern Fetal Neonatal Med. 2012; 25: 424-428
        • Tita A.T.
        • Andrews W.W.
        Diagnosis and management of clinical chorioamnionitis.
        Clin Perinatol. 2010; 37: 339-354
        • Been J.V.
        • Rours I.G.
        • Kornelisse R.F.
        • Lima Passos V.
        • Kramer B.W.
        • Schneider T.A.
        • et al.
        Histologic chorioamnionitis, fetal involvement, and antenatal steroids: effects on neonatal outcome in preterm infants.
        Am J Obstet Gynecol. 2009; 201 (e1-8): 587