(809) Pregnancy Outcomes of Successive Higher-Order Cerclages

There are limited data on pregnant patients who undergo successive higher-order cerclage with increasing parity.  Our objective was to review pregnancy outcomes for patients who underwent higher-order cerclages, and to estimate the association between increasing cerclage order and pregnancy outcomes.

Study Design:

Retrospective cohort study of patients who underwent cerclage placement in a single maternal fetal medicine practice from 2005-2025.  McDonald or Shirodkar cerclage were used at the surgeon’s discretion, however, over 90% of cerclages performed were Shirodkar. 5mm Mersiline suture was used in all cases.  We included women undergoing their third or higher order cerclage.  We compared baseline characteristics and pregnancy outcomes for patients undergoing their 3^rd, 4^th, and 5^th or higher order cerclage.  One way ANOVA and chi-square for trend were used for analysis.

Results:
118 patients met inclusion criteria.  Delivery data were available for 93% of patients (some are still pregnant, some delivered elsewhere).  Data are shown in Table 1.  Maternal age increased and gestational age decreased with successive cerclages, as expected. Otherwise, baseline characteristics were similar between the groups. There was a high incidence of cervical lacerations found, which increased with successive cerclages.  Complication rates were low.  There were very low rates of pregnancy loss prior to 24 weeks (2.1%, 3.4%, 2.6%, p=0.873) and did not increase across the groups.  The rates of delivery at 34+ weeks (91.3%, 89.3%, 86.8%, p=0.513) and 37+ weeks (77.8%, 77.8%, 63.2%, p=0.146) were high and did not decrease across the groups.

Conclusion:
For patients undergoing higher order cerclages, aside from a high incidence of cervical lacerations noted, there is a very low rate of complications and pregnancy loss, and high rates of delivery at or near term.  These results do not appear to change with increasing cerclage order.  Patients should not be discouraged from pregnancy solely due to multiple prior cerclages. Our data may be limited to those undergoing Shirodkar cerclage by experienced surgeons.