Predictive factors for emergency cervical cerclage efficacy in singleton and twin pregnancies: A retrospective cohort study.

INTRODUCTION: An emergency (rescue, exam-indicated) cervical cerclage can be offered to pregnant women presenting with cervical dilatation and prolapsed fetal membranes in the second trimester of pregnancy due to suspected cervical insufficiency. MATERIAL AND METHODS: This study aimed to evaluate the efficacy of emergency cerclage in preventing extreme preterm birth in singleton and twin pregnancies, and to identify predictors of unsuccessful outcomes. We conducted a 15-year observational cohort study at a tertiary care center in the Netherlands, including all women who underwent emergency cerclage. Analyses were conducted for the total population and stratified by pregnancy type, with direct comparisons between singleton and twin pregnancies. Outcomes included gestational age at delivery, offspring survival, and pregnancy prolongation. Kaplan-Meier analysis assessed pregnancy prolongation, with survival curves compared using the log-rank test. Multivariable logistic regression identified predictors of preterm birth <28 weeks, using backward stepwise selection. Results were reported as adjusted odds ratios with 95% confidence intervals, and model performance was evaluated using AUC. RESULTS: A total of 99 women were included: 64 singleton pregnancies and 35 twin pregnancies. We observed an overall survival of 77%, a median gestational age at delivery of 29.4 weeks, and pregnancy prolongation after cerclage placement of 53.0 days. For pregnancies that passed 24 weeks of gestation, overall survival was 92%. Outcomes were comparable between singleton and twin pregnancies. Key factors associated with reduced pregnancy prolongation were vaginal bleeding, prolapsed membranes beyond external os, cervical dilation ≥4.0 cm, elevated white blood cell count (≥13.600 mm3) and CRP levels (≥15.0 mg/L). Multivariable analysis revealed prolapsed membranes beyond external os and gestational age at cerclage placement to be the most important independent predictors for preterm birth <28 weeks. CONCLUSIONS: Emergency cerclage is associated with high offspring survival in both singletons and twins. Clinical factors, among advanced cervical dilation and elevated infectious parameters prior to placement, significantly affect its efficacy, although prolapsed membranes and GA at cerclage placement emerged to be the most critical predictors for preterm birth <28 weeks. These findings provide valuable insights that can be used in the counseling of couples about the pros and cons of an emergency cerclage.