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Cerclage Reinforcement Following Primary Cerclage Procedure for Prevention of Preterm Birth: A Systematic Review and
Neel S Iyer1, Virali Patel2, Amanda Roman3
1Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Olive View-UCLA Medical Center, Sylmar, California, USA.
Background:
Transvaginal cerclage is an important intervention used to decrease the risk of preterm delivery.
Objective:
We performed a systematic review and meta-analysis to evaluate the efficacy of a reinforcing cerclage (RC) should the initial cerclage fail.
Search Strategy:
Scopus, PubMed, Cochrane Central Register of Controlled Trials, Ovid Medline, CINAHL and clinicaltrials.gov were searched from database inception through December 2023.
Selection Criteria:
All studies compare the use of RC to expectant management after initial cerclage placement to prevent preterm birth.
Data Collection And Analysis:
Two authors extracted data following PRISMA guidelines. Primary outcomes were gestational age at delivery and preterm delivery rate before 37 weeks. Subgroup analyses examined outcomes by initial cerclage indication (history-indicated, ultrasound-indicated, and physical exam-indicated). Results were summarised as weighted mean difference (MD) or risk ratio (RR) with associated 95% confidence intervals. Heterogeneity was measured using Higgins I2.
Main Results:
Eight studies (n = 440), comparing RC to no RC after initial cerclage failure, met inclusion criteria. Primary analysis showed delivery occurred 3.98 weeks earlier with RC (95% CI [-5.29, -2.67], p < 0.0001). The RC group had a higher preterm delivery rate before 37 weeks (RR 1.46, 95% CI [1.03, 2.06], p = 0.03). High heterogeneity (I2 > 80%) was noted, and all included studies were observational, increasing the risk of selection bias.
Conclusion:
Placement of a RC following failure of an initial cerclage was associated with a reduced pregnancy latency and an increased risk for preterm delivery. Given the non-randomised nature of the available evidence and significant heterogeneity, these findings should be interpreted with caution. Reinforcing cerclage should only be considered within research settings.
