Complications of cerclage placement in the periviable period

The objective of this study was to identify rates of intraoperative complications and delivery < 7 days in patients undergoing cerclage placement in the periviable period.

We conducted a retrospective cohort study of ultrasound-indicated and physical examination-indicated cerclages placed in the previable (< 22 weeks) or periviable (22-24 weeks) period from 2014 to 2022 at a single institution. The primary outcome was the rate of delivery within 7 days. Secondary outcomes were composite rates of intra- and postoperative complications. Categorical variables were compared with chi-square analysis and continuous variables were analyzed with the Wilcoxon rank-sum test.

A total of 321 patients underwent cerclage during the study period, with 29% (94/321) occurring in the periviable period. No difference was observed in rates of delivery < 7 days between pre- and periviable cohorts (p = 0.683). Intraoperative complications were uncommon and there was no difference between the pre- and periviable cohorts. The most common intraoperative complication was estimated blood loss > 100 cc, occurring in 3.6% of previable and 1.1% of periviable patients (p = 0.215). Postoperative complications were also infrequent with no significant difference between groups. Gestational age at delivery was earlier for previable compared to periviable placement (35.4 vs. 37.1 weeks, p = 0.011) for patients with available delivery data. When evaluating previable versus periviable cases separately by indication, ultrasound-indicated cerclages had similar complications in both cohorts with a shorter latency to delivery in the periviable group (14.5 vs. 16, p = 0.025), although this did not impact gestational age at delivery (36.6 vs. 37.1, p = 0.085). Previable physical examination-indicated cerclages had the highest complication rates with significantly more admissions in < 14 days than periviable cerclage (24.5% vs. 5.3%, p = 0.046). In addition, the gestational age at delivery for previable physical examination-indicated cerclage was significantly lower (29.3 vs. 35.5, p = 0.009).

Intra- and postoperative complications of ultrasound- and examination-indicated cerclages are infrequent regardless of gestational age at placement. There is a low risk of delivery within 7 days of periviable cerclage suggesting that interventions in anticipation of periviable delivery such as antenatal corticosteroid administration may not be necessary.

There is overlap between the evolving limits of viability and the recommended gestational age for cerclage placement. This has led to providers limiting this service and considering ancillary procedures like neonatology consultation and antenatal corticosteroid administration. Our goal was to understand the risks and outcomes of periviable cerclage.Our study indicates that complications due to periviable cerclage are infrequent and less likely to occur than in previable patients undergoing ultrasound or physical examination-indicated cerclage. Delivery within 7 days was unlikely for both groups.These data provide reassurance regarding the safety of periviable cerclage and evidence that antenatal corticosteroids and neonatology consultation may not be necessary.