Complications from cervical cerclage

Complications from cervical cerclage | Image Credit: © mi_viri - © mi_viri - stock.adobe.com.

Uniform complication reporting policy is urgently needed to determine perioperative complication risk for cervical cerclage, according to a recent study published in the American Journal of Obstetrics & Gynecology.

Cervical insufficiency, a condition where the uterine cervix fails to retain pregnancy in the second trimester, is a common cause of spontaneous preterm birth. Cervical cerclage was developed in the 1950s to treat women with cervical insufficiency, mechanically improvingthe cervix’s tensile strength for increased support.

Cerclage placement can be performed during the first or second trimester, with a reduction of preterm birth in 39% to 43% of women with a history of preterm birth. Increased neonatal survival has also been reported in women with a painless dilated cervix following cerclage.

Cervical cerclage may lead to issues such as perioperative problems during or within 24 hours after surgery, cervical lacerations, hemorrhage, lesions or trauma of the cervix, direct preterm premature rupture of membranes (PPROM), and pyrexia and severe maternal infections, along with multiple postoperative problems. Complication incidence varies based on cerclage timing and indication.

To evaluate perioperative complications of transvaginal cervical cerclage in singleton pregnancies, investigators conducted a systematic review. Studies examined included randomized controlled trials (RCTs), quasi-RCTs, and cohort studies comparing cervical cerclage with other interventions or standard care.

Studies were found using a 2-step approach. In the first step, only RCTs were collected because of the assumption these studies would address all potential complications. In the second step, the search was adjusted for complications mentioned in the RCTs. All included studies were written in English.

Inclusion criteria for studies included reporting on maternal, fetal, or neonatal outcomes and including data on adverse events. Studies also discussed transvaginal cervical cerclage in patients for preventing preterm birth or any cerclage.

Types of cerclages evaluated include history-indicated cerclage (HIC), ultrasound-indicated cerclage (UIC), and physical examination-indicated cerclage (PEIC). An HIC is a cerclage in first trimester women who are asymptomatic but have historical factors increasing their risk.

A UIC is a cerclage in second trimester women with a cervical length under 25 mm. A PEIC is a cerclage in second trimester women who are asymptomatic and have a painless, nearly resolved and partially dilated cervix.

To be included, studies had to report on hemorrhage, cervical trauma, PPROM, infection, or other related outcomes. Exclusion criteria included focusing on abdominal, cervicoisthmic, or laparoscopiccerclages or replacements of cerclages, and having a cohort of women with different indications or no numbers per indication known.

Electronic screening programs were used to select studies, which were then independently screened by 2 reviewers. Study characteristics were extracted using a predesigned data extraction form, then entered into a Microsoft Excel 2016 database and given accuracy checks by the 2 reviewers.

There were 3 RCTs and 41 cohort studies included in the review. Among all included studies, 4511 transvaginal cervical cerclages to prevent preterm birth were reported, of which 1561 were HICs, 1348 UICs, 11,549 PEICs, and 53 UICs or PEICs without further specification.

Complication rates of cerclage were reported in 33 studies, while another 11 only contained a general statement explaining complications were not observed during pregnancy. Overall, studies had a moderate level of quality.

Hemorrhage was reported in 0.9% of women with HIC, 1.4% of women with UIC, and 2.3% of women with PEIC. Cervical trauma was reported in 0.2%, 0.6% and 1.3% respectively. Women with HIC and UIC saw low rates of PPROM, but women with PEIC saw a pooled proportion of 2.5%. 

Cases of infection, maternal death, and bladder injury were not reported. Eleven studies mentioned not observing any perioperative complications.

Complications, especially hemorrhage, were primarily found in cases of PEIC, while HIC had the fewest complications. Studies showed poor documentations of complications, indicating a need for uniform complication reporting policy.

Reference

Van Dijk CE, Breuking SH, Jansen S, Limpens J, Kazemier BM, Pajkrt E.Perioperative complications of a transvaginal cervical cerclage in singleton pregnancies: a systematic review and meta-analysis. American Journal of Obstetric & Gynecology. 2023;228(5):521-534. doi:10.1016/j.ajog.2022.10.026