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Benefits of emergency cerclage unclear; tell patients of risks. (Expert Opinion).

WASHINGTON--There are no empiric data showing a clear benefit to emergency cerclage, and it should be performed only after extensive patient counseling about its inherent risks, Dr. Errol Norwitz said at the Third World Congress on Controversies in Obstetrics, Cynecology, and Infertility.

"The data are extremely limited, and as of yet there have been no randomized clinical trials on the benefit of emergency cerclage," said Dr. Norwitz of Brigham and Women's Hospital, Boston.

Yet there may never be any such studies because some researchers say it would deprive patients of standard therapy," he said. Meanwhile, "others argue that it is unethical for us to continue to pretend that emergency cerclage has ever been proved beneficial in a rigorous, scientific fashion."

Nevertheless, since cervical incompetence is responsible for up to 15% of habitual immature deliveries of between 16 and 28 weeks' gestation, emergency cerclage will continue despite its associated risks. Short-term complications include premature rupture of membranes, blood loss requiring transfusion, and anesthetic complications. Long-term complications of the procedure include a 3%-4% chance of cervical laceration, a 4% chance of chorioamnionitis, a 1% chance of cervical stenosis, and other rare complications, including intrauterine growth restriction, fetal demise, placental abruption, and uterine rupture.

Since cerclage is best performed pro-phylactically before cervical dilatation and effacement, emergency cerclage is associated with a lower success rate than prophylactic cerclage. Studies that showed this lower success rate did not pinpoint the cause, Dr. Norwitz said. The emergency cerclage may have been placed too late to be effective, or the success rate for prophylactic cerclage may have been biased by the placement of cerclage in some women who did not really need it.

Data for fetal survival in emergency cerclage vary widely; 25 studies published from 1977 to 2001 showed a fetal survival of 22%-100%.

But these data come only from retrospective descriptive studies, Dr. Norwitz cautioned. It remains unclear whether fetal survival rates are better with emergency cerclage than with bedrest and expectant management.

"In the absence of incontrovertible evidence demonstrating a benefit, emergency cerclage should be used judiciously and only after extensive and comprehensive patient counseling," he commented.
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Author:Sullivan, Michele G.
Publication:OB GYN News
Date:Nov 15, 2002
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