Factors Associated With Success of Emergent Second-Trimester Cerclage Mary Faith C. Terkildsen, MD, Barbara V. Parilla, MD, Praveen Kumar, MD, and William A. Grobman, MD, MBA OBJECTIVE: To assess the factors associated with delivery greater than or equal to 28 weeks’ gestation after placement of an emergent cerclage in women with singleton gesta- tions. METHODS: All women who underwent emergent cerclage, defined as any cerclage placed between 16 and 24 6 /7 weeks’ gestation in response to documented cervical change on physical examination, at Northwestern Memorial Hospital from 1980 to 2000 were identified. Univariable and multi- variable analyses were used to determine the factors most associated with achieving at least 28 weeks’ gestation. RESULTS: One hundred sixteen women were eligible for analysis. Maternal age, race, and operative variables such as suture type and use of antibiotics were not associated with differences in the frequency of delivery at or after 28 weeks. Cerclage placement at or after 22 weeks’ gestation increased the likelihood of reaching 28 weeks, whereas several cervical examination findings (dilatation greater than 3 cm, cervical length less than 0.5 cm, and membranes prolapsing beyond the external cervical os) as well as need for placement in a nullipara significantly reduced the like- lihood of reaching 28 weeks. In multivariable analysis, nulliparity (odds ratio 0.31, 95% confidence interval 0.1, 0.8) and membranes prolapsing beyond the external cervi- cal os (odds ratio 0.24, 95% confidence interval 0.1, 0.4) continued to be associated with delivery before 28 weeks, whereas cerclage placement at or after 22 weeks (odds ratio 3.2, 95% confidence interval 1.2, 8.6) increased the chance of achieving at least 28 weeks’ gestation. CONCLUSION: Nulliparity, the presence of membranes pro- lapsing beyond the external cervical os, and gestational age less than 22 weeks at cerclage placement are associated with decreased chance of delivery at or after 28 weeks after emergent cerclage; these factors may be used to help coun- sel patients considering the procedure. (Obstet Gynecol 2003;101:565–9. © 2003 by The American College of Ob- stetricians and Gynecologists.) Painless cervical dilatation (also known as “cervical in- competence”) leading to premature rupture of mem- branes (PROM) and preterm delivery is implicated in 10 –25% of second-trimester pregnancy losses. 1,2 Pro- phylactic cerclage placed early in the second trimester is an accepted treatment in patients with a history of incom- petent cervix in a prior pregnancy, with fetal salvage rates reported as high as 75–90%. 3 The management of cervical incompetence in the emergent setting, when cervical change documented on physical examination has already occurred, is more controversial. No random- ized study has prospectively documented the benefits that emergent cerclage placement imparts. Although one prospective nonrandomized study has suggested that increased gestational time can be gained by placement of emergent cerclage, the benefits of this increased latency remain unclear, as many children continue to be deliv- ered at the threshold of viability, and thus suffer from the resultant sequelae of extreme prematurity. 4,5 Indeed, little published evidence exists to assist in counseling patients who present with cervical change documented by physical examination in the second tri- mester regarding the probability of a desirable outcome after emergent cerclage placement. The present litera- ture is predominantly limited to series with small num- bers of patients and with a wide variation in entry criteria. For example, some series have included diagno- sis of cervical shortening or funneling by ultrasound as an indication for emergent cerclage placement, rather than strictly defining entry criteria by physical examina- tion findings alone. 6 Along these lines, two randomized trials have been performed to assess the benefits of cerclage in response to cervical change, but only cervical change diagnosed by routine ultrasonographic assess- ment. 7,8 In fact, in these trials, women with significant cervical change on physical examination, as evidenced by membranes prolapsing beyond the external os, were explicitly excluded. In the retrospective trials that have included only women with cervical change diagnosed by physical examination, a variety of surgical techniques From the Sections of Maternal–Fetal Medicine and Pediatrics, Northwestern University Medical School, Northwestern University, Chicago, Illinois. 565 VOL. 101, NO. 3, MARCH 2003 0029-7844/03/$30.00 © 2003 by The American College of Obstetricians and Gynecologists. Published by Elsevier. doi:10.1016/S0029-7844(02)03117-4