Review Cervical cerclage in delayed interval delivery in a multifetal pregnancy: a review of seven case series Jun Zhang a,* , Courtney D. Johnson a , Matthew Hoffman b a Epidemiology Branch, National Institute of Child Health and Human Development, National Institutes of Health, NIH Building 6100, Room 7B03, Bethesda, MD 20892, USA b Department of Obstetrics and Gynecology, Christiana Care Health Systems, Newark, DE, USA Received 22 June 2002; received in revised form 16 October 2002; accepted 14 November 2002 Abstract Objective: To examine whether cervical cerclage after the first delivery prolongs the inter-delivery interval in delayed interval deliveries. Study design: We identified 66 case reports and case series of delayed interval delivery published between 1880 and 2002. We selected seven case series that identified all cases of delayed interval delivery in their institutions during a specified period. Results: Despite routine use of broad-spectrum prophylactic antibiotics, the average incidence of clinical intrauterine infection after the first delivery was 36% (95% confidence interval (CI): 26–46%). The incidence of maternal sepsis was 4.9% (95% CI: 0.2–9.6%). Studies in which cerclage was infrequently used reported a shorter inter-delivery interval compared to studies where cerclage was used in all cases (median is equal to 9 days versus 26 days, respectively, P < 0:001) despite similar gestational ages at the first delivery, types of antibiotics, tocolytics, and incidence of infection. After controlling for other factors, the use of cerclage did not significantly increase the risk of intrauterine infection (adjusted relative risk ¼ 1.1, 95% CI: 0.4–3.5). Conclusion: Cervical cerclage after the first delivery is associated with a longer inter-delivery interval without increasing the risk of intrauterine infection. Published by Elsevier Science Ireland Ltd. Keywords: Cerclage; Delayed interval delivery; Multiple; Pregnancy; Triplet; Twin 1. Introduction In many developed countries, the number of multifetal pregnancies has increased dramatically in the past 20 years. As a result, preterm labor in the second trimester, premature rupture of the membrane of one fetus, and single fetal demise are now more commonly encountered by perinatol- ogists. Despite advances in neonatal care, extremely pre- mature newborns have very high mortality and long-term morbidity. Although case reports have clearly demonstrated that delayed interval delivery can be successfully achieved in some cases, no standard protocol for the management of these patients has been tested or widely adopted. Some authors routinely perform cervical cerclage immediately after the first delivery [1–4] while others use it infrequently [5–7]. Is cervical cerclage effective in prolonging the inter- delivery interval? Does it increase risk of intrauterine infection? Since the number of patients suitable for delayed interval delivery is still very small, a prospective clinical study would be difficult, if not impossible, to conduct. Thus, despite significant limitations, a retrospective chart review remains the most feasible approach in trying to address these questions. The purpose of this study is to review the current literature on cervical cerclage in delayed interval deliveries and assess its impact on inter-delivery interval and infectious complications. 2. Materials and methods We conducted a MEDLINE search for published reports of delayed delivery from 1965 to 2002 using key words ‘‘delayed’’, ‘‘delivery’’, ‘‘interval’’, ‘‘multifetal’’, ‘‘twin’’, ‘‘triplet’’, and ‘‘pregnancy’’. We then cross-checked the references cited in the articles that we identified to ensure that no published reports of delayed delivery were missed. Using this strategy, we identified 66 original case reports or case series of delayed interval delivery published from 1880 to 2002. Since case reports are often biased towards success- ful attempts with desirable outcomes, we focused our review European Journal of Obstetrics & Gynecology and Reproductive Biology 108 (2003) 126–130 * Corresponding author. Tel.: þ1-301-435-6921; fax: þ1-301-402-2084. E-mail address: jim_zhang@nih.gov (J. Zhang). 0301-2115/02/$ – see front matter. Published by Elsevier Science Ireland Ltd. doi:10.1016/S0301-2115(02)00479-7