J Korean Med Sci.  2024 Nov;39(42):e310. 10.3346/jkms.2024.39.e310.

Rescue Cerclage in Women With Acute Cervical Insufficiency and IntraAmniotic Inflammation: A Retrospective Cohort Study

• Park KH
• Lee KN
• Choi BY
• Lee MJ
• Jeong DE

• KMID: 2560621
• DOI: http://doi.org/10.3346/jkms.2024.39.e310

Abstract

Background
To assess the effectiveness of rescue cerclage concerning pregnancy and neonatal outcomes in women with acute cervical insufficiency (CI) complicated with intraamniotic inflammation (IAI) compared with those managed expectantly.
Methods
This retrospective cohort study included 87 consecutive singleton pregnant women (17–25 weeks) with acute CI who underwent amniocentesis to assess IAI. Amniotic fluid (AF) samples were assayed for interleukin-6 to define IAI (≥ 2.6 ng/mL). Primary and secondary outcomes were assessed in a subset of CI patients with IAI. The primary outcome measures were spontaneous preterm birth (SPTB) at < 28 and < 34 weeks, and the secondary outcomes were interval from sampling to delivery, neonatal survival, neonatal birth weight, and histologic and clinical chorioamnionitis. Macrolide antibiotics were prescribed depending on the type of microorganism isolated from the AF, clinically suspected IAI, and the discretion of the attending clinician.
Results
IAI was identified in 65.5% (57/87) of patients with CI, of whom 73.6% (42/57) were treated with macrolide antibiotics. Among the CI patients with IAI (n = 57), 40 underwent rescue cerclage and 17 were expectantly managed. The rates of SPTBs at < 28 and < 34 weeks were significantly lower and the latency period was significantly longer in the cerclage group than in the group that was managed expectantly. The median birth weight and neonatal survival rate were significantly higher in the cerclage group than in the group that was managed expectantly. However, the rates of histologic and clinical chorioamnionitis did not differ between the groups. Multivariable analyses revealed that rescue cerclage placement and administration of macrolide antibiotics were significantly associated with a decrease in SPTBs at < 28 and < 34 weeks, prolonged gestational latency, and increased likelihood of neonatal survival, after adjusting for possible confounding parameters; however, macrolide antibiotic administration did not reach statistical significance with respect to SPTB at < 34 weeks and neonatal survival (P = 0.076 and 0.063, respectively).
Conclusion
Rescue cerclage along with macrolide antibiotic treatment may positively impact pregnancy and neonatal outcomes in women with CI complicated by IAI, compared with expectant management. These findings suggest the benefit of cerclage placement even in patients with CI complicated by IAI.

Keyword

Amniotic Fluid; Cervical Insufficiency; Intra-Amniotic Inflammation; Neonatal Outcome; Rescue Cerclage; Spontaneous Preterm Birth

Figure

• 

  Fig. 1 Study flow chart showing the enrollment process of the participants.CI = cervical insufficiency, AF = amniotic fluid, IAI = intra-amniotic inflammation.

• 

  Fig. 2 Kaplan-Meier survival estimates of the sampling-to-delivery interval for (A) cerclage or no-cerclage (median, 97.00 days [95% confidence interval, 85.69–108.31] vs. 3.00 days [95% confidence interval, 1.89–4.11]; P < 0.001) and (B) macrolide or non-macrolide (median, 94.00 days [95% confidence interval, 80.14–107.86] vs. 13.00 days [95% confidence interval, 1.04–24.96]; P = 0.004) groups among 87 patients with cervical insufficiency. Kaplan-Meier survival estimates of the sampling-to-delivery interval for (C) cerclage or no-cerclage (median, 83.00 days [95% confidence interval, 34.17–131.83] vs. 3.00 days [95% confidence interval, 2.01–3.99]; P < 0.001) and (D) macrolide or non-macrolide (median, 47.00 days [95% confidence interval, 0.00–110.61] vs. 13.00 days [95% confidence interval, 0.00–28.15]; P = 0.051) groups among 57 patients with IAI complicated by cervical insufficiency.IAI = intra-amniotic inflammation.

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