Abstract
Objective
To determine whether cervical cerclage for a transvaginal ultrasound short cervical
length detected after 24 weeks of gestation in singleton pregnancies reduces the risk
of preterm birth.
Data Sources
Ovid MEDLINE, Scopus, and the Cochrane Central Register of Controlled Trials were
searched for the following terms: “cerclage, cervical”, “uterine cervical incompetence”,
“obstetrical surgical procedures”, “cervix uteri”, “randomized controlled trial”,
and “controlled clinical trial”.
Study Eligibility Criteria
All randomized controlled trials comparing cerclage placement with no cerclage in
singleton gestations with a transvaginal ultrasound short cervical length ≤ 25mm between
24 0/7 and 29 6/7 weeks of gestation were eligible for inclusion.
Study Appraisal and Synthesis Methods
Individual patient-level data from each trial were collected. If an eligible trial
included patients with both multiple and singleton gestations with a short cervical
length detected either before or after 24 0/7 weeks of gestation, only singletons
who presented at or after 24 0/7 weeks were included. The primary outcome was preterm
birth < 37 weeks. Secondary outcomes included preterm birth < 34, < 32, and < 28 weeks,
gestational age at delivery, latency, preterm prelabor rupture of membranes, chorioamnionitis,
and adverse neonatal outcomes. Individual patient-level data from each trial were
analyzed using a two-stage approach. Pooled relative risks (RR) or mean differences
with 95% confidence intervals were calculated where appropriate.
Results
Data from the four eligible randomized controlled trials were included. One hundred
and thirty one singletons presented at 24 0/7 – 26 6/7 weeks of gestation and were
further analyzed; there were no data on patients with cerclage at 27 0/7 weeks or
later. Of those included, 66 (50.4%) were in the cerclage group, and 65 (49.6%) in
the no cerclage group. The rate of preterm birth < 37 weeks was similar between patients
who were randomized to cerclage compared with those who were randomized to no cerclage
(27.3% vs. 38.5%; RR 0.78, 95% CI 0.37-1.28). Secondary outcomes including preterm
birth < 34, < 32, and < 28 weeks, gestational age at delivery, time interval from
randomization to delivery, preterm prelabor rupture of membranes, and adverse neonatal
outcomes such as low birthweight, very low birthweight, and perinatal death were similar
between the two groups. Planned subgroup analyses revealed no statistically significant
differences in rate of preterm birth < 37 weeks compared between the two groups based
on cervical length measurement (≤ 15mm or ≤ 10mm), gestational age at randomization
(24 0/7 - 24 6/7 weeks or 25 0/7 - 26 6/7 weeks), or history of preterm birth.
Conclusions
Cervical cerclage did not reduce or increase the rate of preterm birth in singletons
with a short cervical length detected after 24 weeks of gestation. As there was a
22% non-significant decrease in preterm birth associated with cerclage, which is a
similar amount of risk reduction often associated with ultrasound-indicated cerclage
before 24 weeks, further randomized controlled trials in this patient population are
warranted.
Keywords
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Article info
Publication history
Accepted:
March 9,
2023
Received in revised form:
March 6,
2023
Received:
January 11,
2023
Publication stage
In Press Accepted ManuscriptFootnotes
There was no funding for this study.
The review protocol for this study was registered with the PROSPERO International prospective register of systematic reviews (registration number CRD42022361845) prior to initiation.
Identification
Copyright
© 2023 Elsevier Inc. All rights reserved.
