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REVIEW ARTICLE
Year : 2023 | Volume
: 12
| Issue : 1 | Page : 4-9
Complications associated with cervical cerclage: A systematic review
Sanah Alani1, Jessica Wang2, Eva Suarthana1, Togas Tulandi1
1 Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada
2 Department of Obstetrics and Gynecology, McGill University; Faculty of Medicine, University of Montreal, Montreal, QC, Canada
Correspondence Address:
Prof. Togas Tulandi
Department of Obstetrics and Gynecology, McGill University, Montreal, QC
Canada
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/gmit.gmit_61_22
Cervical cerclages are associated with improved live birth rates and have low short- and long-term risks. However, there have been reports of fistula formation or erosion of cerclage into the surrounding tissue. Those complications are uncommon and yet are serious. The risk factors associated with its development are still unclear. The purpose of our study was to evaluate the incidence of fistula formation or erosion following transvaginal cervical cerclage and the associated clinical and sociodemographic factors. We conducted a systematic search of PubMed, Medline, and Embase databases to retrieve articles related to transvaginal or transabdominal cervical cerclage. Databases were searched up to July 2021. The study protocol was registered (PROSPERO ID 243542). A total of 82 articles were identified describing cervical cerclage and erosion or fistula formation. A total of 9 full-text articles were included. There were seven case reports and series that described 11 patients who experienced late complications following cervical cerclage. Many of the cerclage procedures were done electively (66.7%). The most common type of cerclage was McDonald (80%). While all cases reported fistula formation, the main location was vesicovaginal fistulas (63.6%). One patient (9.1%) had erosion of their cerclage and another (9.1%) had bladder calculi. Of 75 patients who underwent cerclage in two retrospective case reviews, the overall incidence of fistula was 1.3% and abscess was also 1.3%. Although rare, the most common long-term complication of cervical cerclage placement is fistula formation, particularly vesicovaginal fistulas.
Keywords: Cervical cerclage, complications, erosion, fistula, vesicovaginal fistula
Preterm birth (PTB) is the delivery of a fetus between 20 and 36 + 6 weeks of gestation, and it is the main cause of neonatal morbidity and mortality.[1] While many of these births are due to preterm labor or preterm prelabor rupture of membranes, in some cases, it can be caused by cervical insufficiency. Cervical cerclage has been performed to treat cervical insufficiency, and subsequently reduces the occurrence of PTB.[2] Cervical cerclages are associated with improved live birth rates and have low short- and long-term risks. However, there have been reports of fistula formation or erosion of cerclage into the surrounding tissue. Those complications are uncommon and yet are serious. The risk factors associated with its development are still unclear.
Given the sparse publications on this topic, our objective was to evaluate the incidence of erosion or fistula formation following the placement of a cervical cerclage and to determine factors associated with this type of complication.
Materials and MethodsThe study protocol was registered with PROSPERO (ID 243542) and the analysis was reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline.[3] No amendments were required. Using EMBASE, PubMed, Ovid Medline, Google Scholar, and Cochrane Library, studies that were related to transvaginal cervical cerclages and their complications were evaluated using the following terms: “cervical cerclage” OR “cerclage” AND “erosion,” “cerclage” AND “fistula formation,” “transvaginal cerclage” AND “fistula formation,” “fistula” OR “erosion.” To assess risk of bias due to missing results, we did a quick search through Google Scholar and most articles overlapped with other electronic searches or the full-text were inaccessible.
We included articles published in the English language up to December 2021. Once duplicate articles were removed from our list, the abstracts were screened independently by two co-authors (SA and JW) to ensure relevance. In the event of disagreement, a third co-author (TT) acted as an adjudicator. This preliminary step was based on whether the title or abstract could possibly answer four questions applicable to our study. The four questions were related to the incidence of cerclage-related fistula formation, the type of suture material used for cerclage, and clinical and sociodemographic factors. Abdominal cerclage could be done by laparotomy or laparoscopy. In those performed by laparoscopy, we stated as laparoscopic abdominal cerclage.
Data extracted from each selected article included age of the patient, whether the cerclage was placed electively or emergently, gravidity and parity of the patient, whether they had a prior history of cerclage placement, the type of cerclage placed, pre- or postconceptional placement, the gestational age at the time of placement, the gestational age at time of delivery, the route of delivery (vaginal vs. cesarean), and the type of complication (erosion, fistula formation and abscess) and treatment. As all our articles were case reports, series or reviews, a quality assessment was performed using the National Heart, Lung, and Blood Institute Study Quality Assessment Tools.[4]
Statistical analysis
The pooled frequencies and percentages were presented for categorical variables. The pooled mean and standard deviations (SD) or median and interquartile range were calculated for continuous variables when appropriate. Data were analyzed using IBM SPSS Statistics version 27.0 (IBM Corp, Armonk, NY).
ResultsAfter the removal of duplicates, 82 articles were identified from the database search. We included all case series and case reports that described transvaginal cervical cerclage and erosion or fistula formation. Screening the titles and abstracts narrowed this down to 22 articles. A total of 10 full-text articles were included [Figure 1], including 8 case reports and case series,[5],[6],[7],[8],[9],[10],[11] and 2 case reviews.[2],[12] The descriptions of the included case reports and case series are shown in [Table 1], while the retrospective case reviews are shown in [Table 2]. The list of excluded studies is presented in [Supplementary Table 1].
Table 2: The clinical characteristics of patients who underwent cerclage from the case reports/seriesThe case reports described 12 patients who experienced complications following cervical cerclage. In summary, the mean age of the patients was 34.3 SD 6.5 years [Table 3]. Most of the cerclages were placed in pregnancy and electively (66.7%). The most common type of cerclage was McDonald (80.0%). Fistula formation was reported in all cases with the most location was vesicovaginal fistulas (63.6%). In most cases the interval between the placement of the cerclage and the complication was not mentioned. However, Wall et al.[7] reported 12-week interval between cerclage placement and the development of a vesicovaginal fistula. Madueke-Laveaux et al.[8] reported erosion and fistula formation 13 years after placement of the cervical cerclage. Evaluating different types of suture material used, most articles did not state the type of sutures. However, it was conventionally performed with polyethylene terephthalate tape (Mersilene, New Brunswick, NJ).[7],[8]
In the retrospective case review [Table 2], Deffieux et al.[2] described 24 cases of elective cervico-isthmic cerclages. Only 1 of 24 (4.2%) had an abscess 6 months after delivery or 47.1 weeks after cerclage placement. Wong et al.[12] reviewed 51 cases of emergency placement of Shirodkar or McDonald cerclages. One patient developed cervicovaginal fistula formation (2%). There was no report of erosion or abscess formation. The interval between cerclage placement and complication was not mentioned. Among 75 patients underwent vaginal cerclage in both case reviews, the overall incidence of fistula was 1.3% and abscess formation was also 1.3%.
Quality of the studies
Using NIH quality evaluation tool, we found that all included ten case reports and series were of good quality [Table 4]a. Overall, both case reviews also had good quality [Table 4]b.
DiscussionComplications related to cerclage placement are rare.[13] In one study, the incidence of fistula formation after cervical cerclage is <2%. Although the implications of transvaginal cervical cerclage are slightly different from that of abdominal cerclage, in a report of 16 studies of abdominal cerclage involving 678 cases, the authors did not encounter any vaginal erosion or fistulas.[7] We estimated that the actual incidence of erosion or fistula formation is 1/1000 cases of cervical cerclages.
Fistula formation was found mainly in multi-gravid women with a history of more than one cerclage placement. A McDonald's cerclage appears to be more likely to be associated with long-term complication than Shirodkar or abdominal cerclage. However, this could be due to the more frequent use of McDonald approaches. The latter is technically simpler than Shirodkar cerclage that needs bladder dissection off the cervix. Although not stated, most clinicians use polyethylene terephthalate tape (Mersilene).[13] Deffieux et al. reported having to remove the tape in a patient owing to vaginal erosion.[2]
In our study, we found that complication can occur as early as 12 weeks after transvaginal cerclage placement and could be up to 13 years. Ruan et al. reported bladder calculus around the cerclage 10 years after transvaginal cerclage suggesting the cerclage had eroded into the bladder.[14] Similarly, Tulandi et al. reported complete erosion of abdominal cerclage into the bladder with the formation of bladder calculi 5 years after laparoscopic abdominal cerclage.[15] Hawkins and Nimaroff reported vaginal erosion 7 years after laparoscopic abdominal cerclage.[16]
The main limitation of our study was the rare occurrence of long-term complications of cervical cerclage. There is no prospective cohort evaluating the occurrence of complications of cervical cerclage. However, to the best of our knowledge, this was the first systematic review evaluating long-term complications of cervical cerclage. The extraordinarily low incidence of late complications of cervical cerclage provides a reassurance to the patients requiring cervical cerclage.
ConclusionsPatients that may require multiple cerclages should be counseled that although the risk of developing a complication in the future may be rare, there is a possibility it may occur and, in that instance, surgical management is the most likely method of treatment. More data needs to be published to have a better understanding of specific risk factors that influence the development of a complication in this group of women such as the type of suture used.
Financial support and sponsorship
Nil.
Conflicts of interest
Prof. Togas Tulandi, an editorial board member at Gynecology and Minimally Invasive Therapy, had no role in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.
Supplementary Material
References
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