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. 2003;2003(1):CD003253.
doi: 10.1002/14651858.CD003253.

Cervical stitch (cerclage) for preventing pregnancy loss in women

A J Drakeley  1 , D Roberts, Z Alfirevic
Affiliations

Cervical stitch (cerclage) for preventing pregnancy loss in women

A J Drakeley et al. Cochrane Database Syst Rev. 2003.

Abstract

Background: A cervical stitch has been used to prevent preterm deliveries in women with previous second trimester pregnancy losses, or other risk factors such as short cervix on digital or ultrasound examination.

Objectives: To assess effectiveness and safety of prophylactic cerclage (before the cervix has dilated), emergency cerclage (where cervices have started to shorten and dilate) and then labour halted, and to determine whether a particular technique of stitch insertion is better than others.

Search strategy: We searched the Cochrane Pregnancy and Childbirth Group specialised register (July 2002). We handsearched congress proceedings of International and European society meetings of feto-maternal medicine, recurrent miscarriage and reproductive medicine. We contacted researchers in the field.

Selection criteria: All randomised trials comparing cervical cerclage with expectant management or no cerclage during pregnancy and trials comparing one technique with another or with other interventions were included. Quasi randomised trials were excluded.

Data collection and analysis: Two reviewers independently used prepared data extraction forms. Any discrepancy was resolved by discussion or by a third reviewer. Further clarification was sought from trial authors when required. Results were reported as relative risks using fixed or random effects model.

Main results: Six trials with a total of 2175 women were analysed. Prophylactic cerclage was compared with no cerclage in four trials. There was no overall reduction in pregnancy loss and preterm delivery rates, although a small reduction in births under 33 weeks' gestation was seen in the largest trial (relative risks 0.75, 95% confidence interval 0.58 to 0.98). Cervical cerclage was associated with mild pyrexia, increased use of tocolytic therapy and hospital admissions but no serious morbidity. Two trials examined the role of therapeutic cerclage when ultrasound examination revealed short cervix. Pooled results failed to show a reduction in total pregnancy loss, early pregnancy loss or preterm delivery before 28 and 34 weeks in women assigned to cervical cerclage.

Reviewer's conclusions: The use of a cervical stitch should not be offered to women at low or medium risk of mid trimester loss, regardless of cervical length by ultrasound. The role of cervical cerclage for women who have short cervix on ultrasound remains uncertain as the numbers of randomised women are too few to draw firm conclusions. There is no information available as to the effect of cervical cerclage or its alternatives on the family unit and long term outcome.

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Conflict of interest statement

None known.

Figures

1.1
1.1. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 1 Maternal infection.
1.2
1.2. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 2 Induction of labour.
1.3
1.3. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 3 Use of tocolytics.
1.4
1.4. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 4 Episodes of 'false labour'.
1.5
1.5. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 5 Minor maternal morbidity.
1.6
1.6. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 6 Major maternal morbidity.
1.7
1.7. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 7 Miscarriage (pregnancy loss <24 weeks' gestation).
1.8
1.8. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 8 Perinatal loss.
1.9
1.9. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 9 Delivery <32 weeks' gestation.
1.10
1.10. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 10 Delivery <37 completed weeks.
1.11
1.11. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 11 Mean gestational age.
1.12
1.12. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 12 Delivery before 33 weeks' gestation (additional observation).
1.13
1.13. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 13 Caesarean section (additional outcome).
1.14
1.14. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 14 Steroids for neonatal pulmonary maturity.
1.15
1.15. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 15 Preterm prelabour ruptured membranes.
1.16
1.16. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 16 Antepartum haemorrhage.
1.17
1.17. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 17 Mean neonatal birthweight (grams).
1.18
1.18. Analysis
Comparison 1 Elective cerclage versus no cerclage or bed rest, Outcome 18 Delivery <28 weeks' gestation.
8.1
8.1. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 1 Maternal infection.
8.2
8.2. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 2 Delivery before 34 weeks' gestation.
8.3
8.3. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 3 Mean gestational age.
8.4
8.4. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 4 Perinatal loss.
8.5
8.5. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 5 Delivery <28 weeks' gestation.
8.6
8.6. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 6 Use of tocolytics.
8.7
8.7. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 7 Delivery <37 completed weeks.
8.8
8.8. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 8 Mean neonatal birthweight (grams).
8.9
8.9. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 9 Miscarriage (pregnancy loss <24 weeks' gestation).
8.10
8.10. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 10 Minor maternal morbidity.
8.11
8.11. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 11 Antepartum haemorrhage.
8.12
8.12. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 12 Steroid use for fetal pulmonary maturity.
8.13
8.13. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 13 Mode of delivery/caesarean section.
8.14
8.14. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 14 Induction of labour.
8.15
8.15. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 15 Episodes of 'false labour'.
8.16
8.16. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 16 Preterm prelabour ruptured membranes.
8.17
8.17. Analysis
Comparison 8 Cerclage versus no cerclage for short cervix by ultrasound, Outcome 17 Pregnancy prolonged (days).
See this image and copyright information in PMC

References

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References to other published versions of this review

Grant 1995a
    1. Grant AM. Cervical cerclage (all trials). [ revised 11 April 1994]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.
Grant 1995b
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Grant 1995c
    1. Grant AM. Cervical cerclage for moderate risk of early delivery. [revised 11 April 1994]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.
Grant 1995d
    1. Grant AM. Cervical cerclage in twin pregnancy. [revised 11 April 1994]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.
Grant 1995e
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