Removal Versus Retention of Cerclage in Preterm Premature Rupture of Membranes (PPROM) (PROMCerclage)

• Chorioamnionitis as defined by temperature > 38 plus fetal tachycardia or uterine tenderness [ Time Frame: conception to birth ] [ Designated as safety issue: Yes ]
  
• Composite neonatal outcome - any one of the following (for twins, either infant): Fetal or neonatal death [ Time Frame: Birth to 28days of life ] [ Designated as safety issue: Yes ]
  
• Respiratory distress syndrome [ Time Frame: birth to 28days of life ] [ Designated as safety issue: Yes ]
  
• Documented sepsis within 72 hours of delivery [ Time Frame: birth to 72 hours after delivery ] [ Designated as safety issue: Yes ]
  
• Grade 3 or 4 intraventricular hemorrhage [ Time Frame: birth to 28days of life ] [ Designated as safety issue: Yes ]
  
• Stage 2 or 3 necrotizing enterocolitis [ Time Frame: birth to 28days of life ] [ Designated as safety issue: Yes ]
  
• Neonatal intensive care unit (NICU) stay [ Time Frame: birth to 28days of life ] [ Designated as safety issue: Yes ]
  
• Birth weight [ Time Frame: at birth ] [ Designated as safety issue: Yes ]
  
• Estimated gestational age (EGA) at delivery [ Time Frame: at delivery ] [ Designated as safety issue: Yes ]
  
• Postpartum endometritis [ Time Frame: birth to 28days of life ] [ Designated as safety issue: Yes ]
  
• Maternal sepsis [ Time Frame: birth to 28days following delivery ] [ Designated as safety issue: Yes ]
  
• Latency [ Time Frame: labor to delivery ] [ Designated as safety issue: Yes ]
  

The placement of cervical cerclage is standard of care for women who experience incompetent cervix. Treadwell et al, published the largest retrospective review of 482 patients receiving cerclage (364 elective and 118 emergent). They found premature rupture of membranes (PROM) in 38% of the subjects with 9% delivering <27 weeks. Preterm birth is the cause of at least 75% of neonatal deaths that are not due to congenital malformations. The question of whether to remove cerclage after preterm premature rupture of membranes (PPROM) is one of the unresolved controversies in obstetrics because the few available studies are retrospective, all have small numbers of patients, and the studies have given conflicting results regarding the safety of retaining a cerclage after preterm premature rupture of the membranes. It is unclear from the retrospective studies whether latency (the interval from membrane rupture to the onset of labor) is prolonged with retention of the suture. Furthermore, some, but not all studies suggest an increase in major infectious maternal morbidity and possibly neonatal morbidity. For this reason, clinicians vary greatly in deciding on whether to remove a cerclage in a patient with PPROM and either practice is currently an acceptable standard. This is a fairly rare complication, the combination of PPROM in a patient with cerclage in place only occurs in about 1-3/1000 pregnant women. Thus it has been impossible to study this problem prospectively in any single institution. The establishment of the Obstetrix Collaborative Research Group affords the unique opportunity to study this rare complication. Obstetrix manages 19 practices of Perinatologists around the U.S. and Mexico and is comprised of nearly 100 such subspecialists. This problem is most often referred to a Perinatologist when it occurs, so it is not unusual for these practices to see 5 - 10 such patients per year. Obstetrix fully funds the infrastructure of this research group and inclusion in this study will not alter the cost of patient care in either group as there is virtually no cost in removing the cerclage and all these patients are kept in hospital until delivery when membranes rupture as standard of care.

This is a multicenter trial. The purpose is to determine whether retention of cerclage after preterm premature rupture of the membranes improves latency (without a significant increase in chorioamnionitis) and lessens neonatal morbidity.