Emergency cervical cerclage after 20 weeks' gestation: A retrospective study of 6 years' practice in 34 cases

The aim of this study was to evaluate the outcome of late emergency cervical cerclage, after 20 weeks' gestational age (GA). This report describes a retrospective study from January 1, 1988 to December 31, 1993, of 34 patients with intact membranes who required emergency cervical cerclage after 20 weeks of GA, on observing significant cervical changes such as 'cervix dilated at least 2 cm and bulging membranes', in the Department of Obstetrics and Gynecology (Bichat-Claude Bernard Public Hospital, Paris, France). Eight patients were primigestae, and 3 had twin pregnancies. After 48 h resting under tocolysis infusion, emergency cervical cerclage (MacDonald technique) was performed with general anesthesia and prophylactic antibiotic administration. Out of 34 patients, 19 (73.1%) had a past history of one or more previous obstetrical events capable of causing cervical incompetence (CI). Mean duration of pregnancy at emergency cervical cerclage was 22.1 weeks of GA, and at delivery was 35.7 weeks of GA. The mean prolongation of pregnancy obtained was 13.9 weeks. There was a significant negative linear relationship between term at time of cerclage and the prolongation of pregnancy. In this series, 6 patients (17.6%) delivered before 28 weeks of GA, and 6 further patients (17.6%) delivered between 28 and 37 weeks of GA. Chorioamnionitis was observed in 5 cases (14.8%). Overall the neonatal survival rate was 86.5%, with 5 deaths among a total of 37 newborn. Two fetuses died in utero as a consequence of chorioamnionitis, 2 twins died shortly after birth at 24 weeks of GA, and 1 died after failure of emergency cervical cerclage (peroperative rupture of membrane). Out of 32 alive newborn, 7 were admitted to intensive care and were followed up at age 1 year with no signs of major handicap. On observing significant cervical changes with bulging membrane through an open cervix after 20 weeks of GA, an 'aggressive' multifactorial approach including cervical cerclage is legitimate and is associated with a satisfactory fetal survival rate with a minimum of maternal complications. However, in the absence of a controlled study and regardless of the major ethical problems this might entail, these beneficial effects described cannot be considered as proved.