Term Labor Outcomes after Cerclage Placement in a Multi-institutional Cohort

Abstract

Objective The placement of a cervical cerclage in early pregnancy could influence subsequent labor outcomes at term. Prior studies have yielded conflicting results regarding the potential association with adverse labor outcomes such as cesarean delivery (CD), cervical laceration, and prolonged labor. Our objective was to evaluate rate of CD and adverse maternal outcomes in women who labored at term with and without a cerclage within the Consortium on Safe Labor (CSL) cohort. We hypothesize that women with a cerclage in the incident pregnancy will have an increased frequency of CD and other adverse term labor outcomes.

Study Design A retrospective cohort study was performed using data from the CSL. Women with live nonanomalous singleton gestations≥ 37 weeks with induced or spontaneous labor were identified. The risk of CD and other maternal and neonatal outcomes were compared between women with and without cerclage placement during pregnancy. Univariable and multivariable analyses were performed with adjustment for confounding factors. Planned subgroup analysis by history of CD was performed.

Results A total of 374 of the 147,463 patients who met study inclusion criteria in the CSL (0.25%) had a cerclage. In univariable analysis, cerclage placement was associated with a significant increase in the frequency of CD (17.1 vs. 12.8%, p = 0.016, odds ratio: 1.4, 95% CI: 1.07–1.84), cervical lacerations, infectious morbidity, and blood loss. The association with CD persisted in multivariable regression. Cerclage placement was not associated with an increased risk of neonatal morbidity.

Conclusion Cerclage placement in pregnancy is associated with an increased risk of CD, cervical laceration, and infectious morbidity among women delivering at term. These findings suggest that cerclage placement may impact labor progression and outcomes. However, the magnitude of the association may not alter clinical decisions regarding cerclage placement in appropriate candidates.

Keywords

cerclage - cervical laceration - cesarean delivery - chorioamnionitis - endometritis - labor - term

• References

• 1 Committee on Practice Bulletins—Obstetrics, The American College of Obstetricians and Gynecologists. Practice bulletin no. 130: prediction and prevention of preterm birth. Obstet Gynecol 2012; 120 (04) 964-973
• 2 Boelig RC, Berghella V. Current options for mechanical prevention of preterm birth. Semin Perinatol 2017; 41 (08) 452-460
• 3 Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Obstet Gynecol 2005; 106 (01) 181-189
• 4 MRC/RCOG Working Party on Cervical Cerclage. Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists multicentre randomised trial of cervical cerclage. Br J Obstet Gynaecol 1993; 100 (06) 516-523
• 5 Knight KM, Hackney DN. Re-evaluation of the subgroup analysis from the Royal College of Obstetricians and Gynaecologists randomized controlled trial of cervical cerclage. J Matern Fetal Neonatal Med 2012; 25 (06) 864-865
• 6 American College of Obstetricians and Gynecologists. ACOG practice bulletin no.142: cerclage for the management of cervical insufficiency. Obstet Gynecol 2014; 123 (2 Pt 1): 372-379
• 7 Vink J, Myers K. Cervical alterations in pregnancy. Best Pract Res Clin Obstet Gynaecol 2018; 52: 88-102
• 8 Iwahashi M, Muragaki Y, Ooshima A, Umesaki N. Decreased type I collagen expression in human uterine cervix during pregnancy. J Clin Endocrinol Metab 2003; 88 (05) 2231-2235
• 9 Leppert PC, Yu SY, Keller S, Cerreta J, Mandl I. Decreased elastic fibers and desmosine content in incompetent cervix. Am J Obstet Gynecol 1987; 157 (05) 1134-1139
• 10 Golan A, Barnan R, Wexler S, Langer R, Bukovsky I, David MP. Incompetence of the uterine cervix. Obstet Gynecol Surv 1989; 44 (02) 96-107
• 11 Parisi VM. Cervical incompetence and preterm labor. Clin Obstet Gynecol 1988; 31 (03) 585-598
• 12 Shin JE, Shin JC, Kim SJ, Lee Y. Effect of cerclage on labor course and obstetric outcome: a case-control study. J Matern Fetal Neonatal Med 2012; 25 (09) 1779-1782
• 13 Koduri P, Bisulli M, Bogana G, Berghella V. Effect of cerclage on cesarean delivery. Am J Perinatol 2011; 28 (05) 395-398
• 14 Fox NS, Rebarber A, Bender S, Saltzman DH. Labor outcomes after Shirodkar cerclage. J Reprod Med 2009; 54 (06) 361-365
• 15 Weissman A, Jakobi P, Zahi S, Zimmer EZ. The effect of cervical cerclage on the course of labor. Obstet Gynecol 1990; 76 (02) 168-171
• 16 Boyle A, Reddy UM, Landy HJ, Huang CC, Driggers RW, Laughon SK. Primary cesarean delivery in the United States. Obstet Gynecol 2013; 122 (01) 33-40
• 17 Laughon SK, Zhang J, Grewal J, Sundaram R, Beaver J, Reddy UM. Induction of labor in a contemporary obstetric cohort. Am J Obstet Gynecol 2012; 206 (06) 486.e1-486.e9
• 18 EB Research: Consortium on Safe Labor (CSL). https://www.nichd.nih.gov/about/org/diphr/officebranch/eb/safe-labor . Accessed March 8, 2019
• 19 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. ; STROBE Initiative. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007; 370 (9596): 1453-1457
• 20 Caughey AB, Cahill AG, Guise JM, Rouse DJ. ; American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210 (03) 179-193