Expectant management compared with physical examination-indicated cerclage (EM-PEC) in selected women with a dilated cervix at 14^0/7-25^6/7 weeks: results from the EM-PEC international cohort study

Objective: The objective of the study was to compare pregnancy outcomes in selected women with a dilated cervix who underwent expectant management or physical examination-indicated cerclage. Study Design: This was a historical cohort study conducted by the Global Network for Perinatal and Reproductive Health. Women between 14^0/7 and 25^6/7 weeks' gestation with a dilated cervix were identified at 10 centers by ultrasound or digital examination. Primary outcome was time from presentation until delivery (weeks). Secondary outcomes were neonatal survival, birthweight greater than 1500 g and preterm birth less than 28 weeks. Multivariate regression was used to assess the likelihood of neonatal outcomes and control for confounders. Results: Of 225 women, 152 received a physical examination-indicated cerclage, and 73 were managed expectantly without cerclage. Cervical dilation, gestational age at presentation, and antenatal steroid use differed between groups. In the adjusted analyses, cerclage was associated with longer interval from presentation until delivery, improved neonatal survival, birthweight greater than 1500 g and preterm birth less than 28 weeks, compared with expectant management. Similar results were obtained in the analyses limited to women dilated between 2 and 4 cm (n = 122). Conclusion: In this study, the largest cohort reported to date, physical examination-indicated cerclage appears to prolong gestation and improve neonatal survival, compared with expectant management in selected women with cervical dilation between 14^0/7 and 25^6/7 weeks. A randomized, controlled trial should be conducted to determine whether these potential benefits outweigh the risks of cerclage placement in this population.