Open Journal of Obstetrics and Gynecology, 2011, 1, 184-186 OJOG
doi:10.4236/ojog.2011.14035 Published Online December 2011 (
Published Online December 2011 in SciRes.
Pregnancy outcome following emergency cervical cerclage
Maheswari Srinivasan1, Raje shwa ri Navaneetha Krishanan2, S. W. Lindow3
1Specialist trainee in Obstetrics and Gynaecology, Heartlands Hospital, Birmingham, UK;
2Specialist trainee in Obstetrics and Gynaecology, Hull Royal Infirmary, Hull, UK;
3Senior Lecturer Perinatology, Hull Royal Infirmary, Hull, UK.
Received 11 October 2011; revised 15 November 2011; accepted 30 November 2011.
The pregnancy outcome following emergency cer-
vical cerclage for cervical dilatation is unclear. The
case notes of pregnant women who underwent the pro-
cedure from January 1996 until December 2005 at
Hull Royal Infirmary and Castle Hill Hospitals was
analysed. This procedure prolonged pregnancy in all
patients with the mean duration of 24 days. There
were 10 live births and two still births. Among the 10
live births there were five neonatal deaths (perinatal
mortality 583/1000). Neonatal outcome was universa-
lly poor if the initial cervical dilatation was more
than 5 cm. All patients should be informed of the su-
rvival rates befor e un dergoing this procedure.
Keywords: Pregnancy Outcome; Cervical Cerclage
Silent dilation of the cervix is a common cause of second
trimester pregnancy loss and an obstetric treatment di-
lemma. Cervical cerclage using Macdonald’s stitch is
controversial with the risk of rupturing the membranes
balanced against prolonging the pregnancy. Theoretically,
the greater the dilation the less chance of success could
be expected. However there is little data on which to
base this assumption. The aim of this study is to review
the pregnancy outcome of women who underwent cer-
vical cerclage for cervical dilatation in the second tri-
mester of pregnancy at Hull Royal Infirmary and Castle
hill Hospital.
The theatre registers of the Hull Royal Infirmary and Ca-
stle hill Hospital were reviewed from January 1995 until
December 2005 to identify cases of cervical cerclage and
the case notes were analysed. Subsequently a retrospect-
tive case note review was performed of women who
underwent cervical cerclage for cervical dilatation of
more than 3 cm.
A standard proforma was completed on all cases and
the data entered onto SPSS v 15 for statistical analysis.
All women were treated pre-operatively in the trende-
lenberg position and bed rest for approximately 48 hours.
An antibiotic (co-amoxiclav 625 mg 8 hourly) was pre-
scribed in all cases and indomethacin 100 mg per rectum
given 12 ho urly.
During the operation the patient was placed in a steep
head down, lithotomy position. The membranes were re-
placed into the uterine cavity using a Foley catheter with
a 30 ml bulb and cerclage was carried out using Mac-
Donald’s technique with merselene tape.
Post operatively the antibiotic was continued to com-
plete a 1 week course and Indomethacin was continued
for 48 hr.
48 cases of cervical cerclage were carried out in the time
period including 20 elective cervical cerclages perfor-
med between 14 weeks - 16 weeks and 28 emergency
cervical cerclages performed between 16 weeks - 28 weeks.
Of these 28 emergency cervical cerclages, 12 were per-
formed for dilation of cervix while the remaining were
performed for cervical shortening and U-shaped funnel-
ling of the uterine cervix. The outcome of these 12 wo-
men who underwent an emergency cervical cerclage was
The mean gestational age at insertion was 22.6 days.
The time interval between insertion of the cervical stitch
and delivery ranged from 1 day - 90 days (mean 24
There were 2 stillbirths, 10 live births of which 5 ba-
bies survived and 5 were neonatal deaths. The gestational
age at delivery ranged between 22 weeks + 4 days to 38
weeks. Better outcome of pregnancy was gained when
the prolongation of pregnancy was more than 2 weeks
amples of the type styles are provided throughout this
document and are identified in italic type, within
M. Srinivasan et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 184-186 185
Figure 1. Gestational age at cerclage insertion (weeks) of
the cerclage vs. suture to delivery interval (d) and preg-
nancy outcome.
parentheses, following the example. Some components,
such as multi-leveled equations, graphics, and tables are
not prescribed, although the various table text styles are
provided. The formatter will need to create these compo-
nents, incorporating the applicable criteria that follow.
(Figure 1).
6 women presented with cervical dilatation of less
than 5cm at the time of cervical cerclage and 5 women
had babies survived.
Emergency cervical cerclage for cervical dilation has
been part of obstetric practice for many decades but it
still remains a controversial decision. The responsible
Obstetricians and the patients who present with painless
dilation either have to wait for events or to undertake a
procedure that by itself carries its own risk of rupturing
the membranes and thus ending the pregnancy.
Groom et al (2001) published a successful pregnancy
outcome in a woman with advanced cervical dilation in
second trimester in which cervical cerclage was carried
out replacing the membranes in the uterine cavity.
Ventolini et al (2009) presented cohort study between
January 2003 until December 2005 of 68 women with
cervical dilatation comprising 56 women with rescue ce-
rclage and 12 women with expectant management. Me-
dian time from diagnosis to delivery was longer in the
cerclage group (9.1 weeks) than in the expectant group
(3.3 weeks P < 0.01). They concluded that cerclage is a
better option in appropriately selected cases.
Kanai et al (2008) presented 5 cases of bulging mem-
branes that were all replaced into the uterine cavity using
a balloon and the mean prolongation of pregnancy was
Cockwell et al (2005) presented 12 cases of emergen-
cy cerclage in which the mean prolongation of pregnan-
cy was 7 weeks and 1 day with a neonatal survival of o-
ver 70%. They concluded cervical cerclage is an option
if women presented with dilated cervix in the second tri-
Chasen et al (1998) published a retrospective review
of 75 patients with non-prophylactic cervical cerclage
and concluded that an advanced cervical dilation with
bulging membranes at presentation was associated with
lower cerclage-to-delivery intervals as well as a lower
chance of reaching 28 weeks of gestation than lesser de-
grees of dilation and membrane bulging.
The studies presented conclude that cervical cerclage
is indeed a therapeutic option in appropriately selected
cases. There are no studies comparing the degree of cer-
vical dilatationn to the pregnancy outcome. In our series
we found that with advanced cervical dilatation the pro-
longation of pregnancy was only a few days and there
were no neonatal survivors.
No randomised studies have been conducted regarding
prophylactic cerclage versuss expectant management in
women with dilatation of cervix. In our analysis we found
cervical cerclage is possibly a better choice if the cervi-
cal dilatation at the time of cervical cerclage is less than
5 cm. It is perhaps of limited use in performing a cer-
clage if the dilation is greater than 5 cm.
Randomised controlled trials should be conducted in
order to answer the question whether an emergency re-
scue cerclage has its benefits but in the meantime it
should be left to the individual consultant to use their
Emergency cervical cerclage is a reasonable option for
women who present with painless cervical dilatation of
less than 5 cms. Patients should be advised of the poor
outcome if the cervical dilation is more than 5 cms if
cervical cerclage is contemplated.
The authors report no declaration of interest.
[1] Chasen, S.T. and Silverman, N.S. (1998) Mid-Trimester
emergent cerclage: A ten year single institution review.
Journal of Perinatology, 18, 338-342.
[2] Cockwell, H.A. and Smith, G.N. (2005) Cervical incom-
petence and the role of emergency cerclage. Journal of
Obstetrics and Gynaecology Canada, 27, 123-129.
[3] Groom, K.M., Bennett, P.R., Maxwell, D.J. and Shennan,
A.H. (2001) Successful cerclage at advanced cervical
dilatation in the second trimester. International Journal
opyright © 2011 SciRes. OJOG
M. Srinivasan et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 184-186
Copyright © 2011 SciRes. OJOG
of Obstetrics and Gynaecology, 108, 1005-1007.
[4] Kanai, M., Ashida, T., Ohira, S., Osada, R. and Konishi, I.
(2008) A new technique using a rubber balloon in emer-
gency second trimester cerclage for fetal membrane
prolapse. Journal of Obstetrics and Gynaecology Re-
search, 34, 935-940.
[5] Ventolini, G. and Neiger, R. (2009) Management of
painless mid-trimester cervical dilatation: Prophylactic vs.
emergency placement of cervical cerclage. Journal of
Maternal-Fetal and Neonatal Medicine, 22, 510-516.