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Meta-Analysis
. 2017 Jun 6;6(6):CD008991.
doi: 10.1002/14651858.CD008991.pub3.

Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy

Zarko Alfirevic  1 , Tamara Stampalija, Nancy Medley
Affiliations
Meta-Analysis

Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy

Zarko Alfirevic et al. Cochrane Database Syst Rev. .

Abstract

Background: Cervical cerclage is a well-known surgical procedure carried out during pregnancy. It involves positioning of a suture (stitch) around the neck of the womb (cervix), aiming to give mechanical support to the cervix and thereby reduce risk of preterm birth. The effectiveness and safety of this procedure remains controversial. This is an update of a review last published in 2012.

Objectives: To assess whether the use of cervical stitch in singleton pregnancy at high risk of pregnancy loss based on woman's history and/or ultrasound finding of 'short cervix' and/or physical exam improves subsequent obstetric care and fetal outcome.

Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register (30 June 2016) and reference lists of identified studies.

Selection criteria: We included all randomised trials of cervical suturing in singleton pregnancies. Cervical stitch was carried out when the pregnancy was considered to be of sufficiently high risk due to a woman's history, a finding of short cervix on ultrasound or other indication determined by physical exam. We included any study that compared cerclage with either no treatment or any alternative intervention. We planned to include cluster-randomised studies but not cross-over trials. We excluded quasi-randomised studies. We included studies reported in abstract form only.

Data collection and analysis: Three review authors independently assessed trials for inclusion. Two review authors independently assessed risk of bias and extracted data. We resolved discrepancies by discussion. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach.

Main results: This updated review includes a total of 15 trials (3490 women); three trials were added for this update (152 women). Cerclage versus no cerclageOverall, cerclage probably leads to a reduced risk of perinatal death when compared with no cerclage, although the confidence interval (CI) crosses the line of no effect (RR 0.82, 95% CI 0.65 to 1.04; 10 studies, 2927 women; moderate quality evidence). Considering stillbirths and neonatal deaths separately reduced the numbers of events and sample size. Although the relative effect of cerclage is similar, estimates were less reliable with fewer data and assessed as of low quality (stillbirths RR 0.89, 95% CI 0.45 to 1.75; 5 studies, 1803 women; low quality evidence; neonatal deaths before discharge RR 0.85, 95% CI 0.53 to 1.39; 6 studies, 1714 women; low quality evidence). Serious neonatal morbidity was similar with and without cerclage (RR 0.80, 95% CI 0.55 to 1.18; 6 studies, 883 women; low-quality evidence). Pregnant women with and without cerclage were equally likely to have a baby discharged home healthy (RR 1.02, 95% CI 0.97 to 1.06; 4 studies, 657 women; moderate quality evidence).Pregnant women with cerclage were less likely to have preterm births compared to controls before 37, 34 (average RR 0.77, 95% CI 0.66 to 0.89; 9 studies, 2415 women; high quality evidence) and 28 completed weeks of gestation.Five subgroups based on clinical indication provided data for analysis (history-indicated; short cervix based on one-off ultrasound in high risk women; short cervix found by serial scans in high risk women; physical exam-indicated; and short cervix found on scan in low risk or mixed populations). There were too few trials in these clinical subgroups to make meaningful conclusions and no evidence of differential effects. Cerclage versus progestogens Two trials (129 women) compared cerclage to prevention with vaginal progesterone in high risk women with short cervix on ultrasound; these trials were too small to detect reliable, clinically important differences for any review outcome. One included trial compared cerclage with intramuscular 17α‐hydroxiprogestrone caproate (17 OHPC) which lacked power to detect group differences. History indicated cerclage versus ultrasound indicated cerclage Evidence from two trials (344 women) was too limited to establish differences for clinically important outcomes.

Authors' conclusions: Cervical cerclage reduces the risk of preterm birth in women at high-risk of preterm birth and probably reduces risk of perinatal deaths. There was no evidence of any differential effect of cerclage based on previous obstetric history or short cervix indications, but data were limited for all clinical groups. The question of whether cerclage is more or less effective than other preventative treatments, particularly vaginal progesterone, remains unanswered.

PubMed Disclaimer

Conflict of interest statement

Zarko Alfirevic: My employer (University of Liverpool) has received grants from UK National Institute of Health Research, Wellbeing of Women charity and Perkin Elmer to support my research group's work related to preterm birth prevention and my Cochrane editorial work.

Tamara Stampalija: none known.

Nancy Medley: Nancy Medley's work was financially supported by the University of Liverpool's Harris‐Wellbeing of Women Preterm Birth Centre research award.

Figures

1
1
Study flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
1.1
1.1. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 1: All perinatal losses
1.2
1.2. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 2: Serious neonatal morbidity
1.3
1.3. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 3: Baby discharged home healthy
1.4
1.4. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 4: Stillbirths
1.5
1.5. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 5: Neonatal deaths before discharge
1.6
1.6. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 6: Miscarriages
1.7
1.7. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 7: Preterm birth before 37 completed weeks
1.8
1.8. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 8: Preterm birth before 34 completed weeks
1.9
1.9. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 9: Preterm birth before 28 completed weeks
1.10
1.10. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 10: Serious intracranial pathology (IVH or periventricular leukomalacia)
1.11
1.11. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 11: Serious respiratory morbidity (RDS or oxygen dependency after 28 days of life)
1.12
1.12. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 12: Necrotising enterocolitis
1.13
1.13. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 13: Retinopathy of prematurity
1.14
1.14. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 14: Apgar < 7 at 5 minutes
1.15
1.15. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 15: Caesarean section (elective and emergency)
1.16
1.16. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 16: Maternal side effects (vaginal discharge, bleeding, pyrexia not requiring antibiotics)
1.17
1.17. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 17: Pyrexia
1.18
1.18. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 18: Any intravenous, oral or combined tocolysis (not prespecified)
1.19
1.19. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 19: PPROM (not prespecified)
1.20
1.20. Analysis
Comparison 1: Cerclage versus no cerclage, Outcome 20: Chorioamnionitis (not prespecified)
2.1
2.1. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 1: All perinatal losses
2.2
2.2. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 2: Serious neonatal morbidity
2.3
2.3. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 3: Baby discharged home healthy
2.4
2.4. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 4: Stillbirths
2.5
2.5. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 5: Neonatal deaths before discharge
2.6
2.6. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 6: Miscarriages
2.7
2.7. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 7: Preterm birth before 37 completed weeks
2.8
2.8. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 8: Preterm birth before 34 completed weeks
2.9
2.9. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 9: Preterm birth before 28 completed weeks
2.10
2.10. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 10: Serious intracranial pathology (IVH or periventricular leucomalacia)
2.11
2.11. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 11: Serious respiratory morbidity (RDS or oxygen dependency after 28 days of life)
2.12
2.12. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 12: Necrotising enterocolitis
2.13
2.13. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 13: Retinopathy of prematurity
2.14
2.14. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 14: Apgar < 7 at 5 minutes
2.15
2.15. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 15: Caesarean section (elective and emergency)
2.16
2.16. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 16: Maternal infection requiring intervention(antibiotics or delivery)
2.17
2.17. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 17: Maternal side effects (vaginal discharge, bleeding, pyrexia not requiring antibiotics)
2.18
2.18. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 18: Pyrexia
2.19
2.19. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 19: Any intravenous, oral or combined tocolysis (not prespecified)
2.20
2.20. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 20: PPROM (not prespecified)
2.21
2.21. Analysis
Comparison 2: Cerclage versus vaginal progesterone, Outcome 21: Chorioamnionitis (not prespecified)
3.1
3.1. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 1: All perinatal losses
3.2
3.2. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 2: Serious neonatal morbidity
3.3
3.3. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 3: Baby discharged home healthy
3.4
3.4. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 4: Stillbirths
3.5
3.5. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 5: Neonatal deaths before discharge
3.6
3.6. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 6: Miscarriages
3.7
3.7. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 7: Preterm birth before 37 completed weeks
3.8
3.8. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 8: Preterm birth before 34 completed weeks
3.9
3.9. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 9: Preterm birth before 28 completed weeks
3.10
3.10. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 10: Serious intracranial pathology (IVH or periventricular leucomalacia)
3.11
3.11. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 11: Serious respiratory morbidity (RDS or oxygen dependency after 28 days of life)
3.12
3.12. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 12: Necrotising enterocolitis
3.13
3.13. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 13: Retinopathy of prematurity
3.14
3.14. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 14: Apgar < 7 at 5 minutes
3.15
3.15. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 15: Caesarean section (elective and emergency)
3.16
3.16. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 16: Maternal infection requiring intervention(antibiotics or delivery)
3.17
3.17. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 17: Maternal side effects (vaginal discharge, bleeding, pyrexia not requiring antibiotics)
3.18
3.18. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 18: Pyrexia
3.19
3.19. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 19: PPROM (not prespecified)
3.20
3.20. Analysis
Comparison 3: Cerclage versus intramuscular progesterone, Outcome 20: Chorioamnionitis (not prespecified)
4.1
4.1. Analysis
Comparison 4: Cerclage versus pessary, Outcome 1: All perinatal losses
4.2
4.2. Analysis
Comparison 4: Cerclage versus pessary, Outcome 2: Serious neonatal morbidity
4.3
4.3. Analysis
Comparison 4: Cerclage versus pessary, Outcome 3: Baby discharged home healthy
4.4
4.4. Analysis
Comparison 4: Cerclage versus pessary, Outcome 4: Stillbirths
4.5
4.5. Analysis
Comparison 4: Cerclage versus pessary, Outcome 5: Neonatal deaths before discharge
4.6
4.6. Analysis
Comparison 4: Cerclage versus pessary, Outcome 6: Miscarriages
4.7
4.7. Analysis
Comparison 4: Cerclage versus pessary, Outcome 7: Preterm birth before 37 completed weeks
4.8
4.8. Analysis
Comparison 4: Cerclage versus pessary, Outcome 8: Preterm birth before 34 completed weeks
4.9
4.9. Analysis
Comparison 4: Cerclage versus pessary, Outcome 9: Preterm birth before 28 completed weeks
4.10
4.10. Analysis
Comparison 4: Cerclage versus pessary, Outcome 10: Serious intracranial pathology (IVH or periventricular leucomalacia)
4.11
4.11. Analysis
Comparison 4: Cerclage versus pessary, Outcome 11: Serious respiratory morbidity (RDS or oxygen dependency after 28 days of life)
4.12
4.12. Analysis
Comparison 4: Cerclage versus pessary, Outcome 12: Necrotising enterocolitis
4.13
4.13. Analysis
Comparison 4: Cerclage versus pessary, Outcome 13: Retinopathy of prematurity
4.14
4.14. Analysis
Comparison 4: Cerclage versus pessary, Outcome 14: Apgar < 7 at 5 minutes
4.15
4.15. Analysis
Comparison 4: Cerclage versus pessary, Outcome 15: Caesarean section (elective and emergency)
4.16
4.16. Analysis
Comparison 4: Cerclage versus pessary, Outcome 16: Maternal infection requiring intervention(antibiotics or delivery)
4.17
4.17. Analysis
Comparison 4: Cerclage versus pessary, Outcome 17: Maternal side effects (vaginal discharge, bleeding, pyrexia not requiring antibiotics)
4.18
4.18. Analysis
Comparison 4: Cerclage versus pessary, Outcome 18: Pyrexia
4.19
4.19. Analysis
Comparison 4: Cerclage versus pessary, Outcome 19: PPROM (not prespecified)
4.20
4.20. Analysis
Comparison 4: Cerclage versus pessary, Outcome 20: Chorioamnionitis
5.1
5.1. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 1: All perinatal losses
5.2
5.2. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 2: Serious neonatal morbidity
5.3
5.3. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 3: Baby discharged home healthy
5.4
5.4. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 4: Stillbirths
5.5
5.5. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 5: Neonatal deaths before discharge
5.6
5.6. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 6: Miscarriages
5.7
5.7. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 7: Preterm birth before 37 completed weeks
5.8
5.8. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 8: Preterm birth before 34 completed weeks
5.9
5.9. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 9: Preterm birth before 28 completed weeks
5.10
5.10. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 10: Serious intracranial pathology (IVH or periventricular leucomalacia)
5.11
5.11. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 11: Serious respiratory morbidity (RDS or oxygen dependency after 28 days of life)
5.12
5.12. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 12: Necrotising enterocolitis
5.13
5.13. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 13: Retinopathy of prematurity
5.14
5.14. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 14: Apgar < 7 at 5 minutes
5.15
5.15. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 15: Caesarean section (elective and emergency)
5.16
5.16. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 16: Maternal infection requiring intervention(antibiotics or delivery)
5.17
5.17. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 17: Maternal side effects (vaginal discharge, bleeding, pyrexia not requiring antibiotics)
5.18
5.18. Analysis
Comparison 5: Any comparison of different cerclage protocols, Outcome 18: Tocolysis (not prespecified)
6.1
6.1. Analysis
Comparison 6: Cerclage versus no cerclage (Summary of findings outcomes), Outcome 1: All perinatal losses
6.2
6.2. Analysis
Comparison 6: Cerclage versus no cerclage (Summary of findings outcomes), Outcome 2: Serious neonatal morbidity
6.3
6.3. Analysis
Comparison 6: Cerclage versus no cerclage (Summary of findings outcomes), Outcome 3: Baby discharged home healthy
6.4
6.4. Analysis
Comparison 6: Cerclage versus no cerclage (Summary of findings outcomes), Outcome 4: Stillbirths
6.5
6.5. Analysis
Comparison 6: Cerclage versus no cerclage (Summary of findings outcomes), Outcome 5: Neonatal deaths before discharge
6.6
6.6. Analysis
Comparison 6: Cerclage versus no cerclage (Summary of findings outcomes), Outcome 6: Preterm birth before 34 completed weeks
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Althuisius 2001 {published data only}
    1. Althuisius S, Dekker G, Hummel P, Bedekam D, Kuik D, Van Geijn H. Cervical incompetence prevention randomized cerclage trial (CIPRACT): effect of therapeutic cerclage with bed rest vs. bed rest only on cervical length. Ultrasound in Obstetrics and Gynecology 2002;20(2):163-7. - PubMed
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Althuisius 2003 {published data only}
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Beigi 2005 {published data only}
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    1. Shennan A, Maternal and Fetal Research Unit (MFRU). CIRCLE study: cerclage in relation to cervical length. www.mfru.org.uk/CIRCLE.htm (accessed 25 February 2004).
    1. Simcox R, Bennett F, Teoh TG, Shennan AH. A randomised controlled trial of cervical scanning vs history to determine cerclage in high risk women (circle trial). Journal of Obstetrics and Gynaecology 2007;27(Suppl 1):S18. - PubMed
    1. Simcox R, Seed PT, Bennett P, Teoh TG, Poston L, Shennan AH. A randomized controlled trial of cervical scanning vs history to determine cerclage in women at high risk of preterm birth (CIRCLE trial). American Journal of Obstetrics and Gynecology 2009;200(6):623.e1-623.e6. - PubMed
To 2004 {published data only}
    1. ISRCTN61066532. Randomised controlled trial of cervical cerclage in women with a short cervix identified by routine sonography at 23 weeks of pregnancy. www.isrctn.com/ISRCTN61066532 (accessed prior to 29 May 2017).
    1. To MS, Alfirevic Z, Heath VCF, Cicero S, Cacho AM, Williamson PR, et al. Cervical cerclage for prevention of preterm delivery in women with short cervix: randomised controlled trial. Lancet 2004;363(9424):1849-53. - PubMed

References to studies excluded from this review

Blair 2002 {published data only}
    1. Blair O, Fletcher H, Kulkarni S. A randomised controlled trial of outpatient versus inpatient cervical cerclage. Journal of Obstetrics and Gynaecology 2002;22(5):493-7. - PubMed
Broumand 2011 {published data only}
    1. Broumand F, Bahadori F, Behrouzilak T, Yekta Z, Ashrafi F. Viable extreme preterm birth and some neonatal outcomes in double cerclage versus traditional cerclage: a randomized clinical trial. ScientificWorldJournal 2011;11:1660-6. - PMC - PubMed
Caspi 1990 {published data only}
    1. Caspi E, Schneider DF, Mor Z, Langer R, Weinraub Z, Bukovsky I. Cervical internal os cerclage: description of a new technique and comparison with Shirodkar operation. American Journal of Perinatology 1990;7(4):347-9. - PubMed
Dor 1982 {published data only}
    1. Dor J, Shalev J, Mashiach S, Blankstein J, Serr DM. Elective cervical suture of twin pregnancies diagnosed ultrasonically in the first trimester following induced ovulation. Gynecologic and Obstetric Investigation 1982;13(1):55-60. - PubMed
Hui 2013 {published data only}
    1. Hui SY, Chor CM, Lau TK, Lao TT, Leung TY. Cerclage pessary for preventing preterm birth in women with a singleton pregnancy and a short cervix at 20 to 24 weeks: a randomized controlled trial. American Journal of Perinatology 2013;30(4):283-8. - PubMed
Ismail 2014 {published data only}ISRCTN15373349
    1. ISRCTN15373349. Cerclage suture type for an insufficient cervix and its effect on health outcomes (C-STICH). isrctn.com/ISRCTN15373349 Date first received: 3 December 2014.
Israfil‐Bayli 2014 {published data only}ISRCTN17866773
    1. ISRCTN17866773. Cerclage outcome by the type of suture material (COTS) study. isrctn.com/ISRCTN17866773 (first received 4 February 2013).
    1. Israfil-Bayli F, Toozs-Hobson P, Lees C, Slack M, Ismail K. Cerclage outcome by the type of suture material (COTS): study protocol for a pilot and feasibility randomised controlled trial. Trials 2014;15(1):415. - PMC - PubMed
Kassanos 2001 {published data only}
    1. Kassanos D, Salamalekis E, Vitoratos N, Panayotopoulos N, Loghis C, Creatsas C. The value of transvaginal ultrasonography in diagnosis and management of cervical incompetence. Clinical and Experimental Obstetrics & Gynecology 2001;28(4):266-8. - PubMed
Nicolaides 2001 {published data only}
    1. Nicolaides K. Randomised controlled trial of cervical cerclage in women with twin pregnancies found to have an asymptomatic short cervix. Current Controlled Trials (www.controlled-trials.com/mrct) (accessed 26 July 2001).
Rust 2001 {published data only}
    1. Rust O, Atlas R, Wells M, Rawlinson K. Cerclage in multiple gestation with midtrimester dilatation of the internal os [abstract]. American Journal of Obstetrics and Gynecology 2001;185(6 Suppl):S111.
Secher 2007 {published data only}
    1. Brix N, Secher N, McCormack C, Helmig R, Hein M, Weber T, et al. Randomised trial of cervical cerclage, with and without occlusion, for the prevention of preterm birth in women suspected for cervical insufficiency. BJOG: an international journal of obstetrics and gynaecology 2013;120(5):613-20. - PubMed
    1. Secher NJ, McCormack CD, Weber T, Hein M, Helmig RB. Cervical occlusion in women with cervical insufficiency: protocol for a randomised, controlled trial with cerclage, with and without cervical occlusion. BJOG: an international journal of obstetrics and gynaecology 2007;114(5):649-e6. - PubMed
Tsai 2009 {published data only}
    1. Tsai YL, Lin YH, Chong KM, Huang LW, Hwang JL, Seow KM. Effectiveness of double cervical cerclage in women with at least one previous pregnancy loss in the second trimester: a randomized controlled trial. Journal of Obstetrics and Gynaecology Research 2009;35(4):666-71. - PubMed
Üçyiğit 2013 {published data only}
    1. Vousden N, Carter J, Üçyiğit A, Shennan A. Risk of infertility following pre-conception abdominal cerclage: evidence from a randomised control. BJOG: an international journal of obstetrics and gynaecology 2015;122(Suppl S2):17.
    1. Üçyiğit A, Hezelgrave N, Shennan A. Risk of infertility and abdominal cerclage: Conception following placement in a randomised controlled trial. BJOG: an international journal of obstetrics and gynaecology 2013;120:189.
Varma 1986 {published data only}
    1. Varma TR [pers comm]. To assess further the value of cervical cerclage in pregnancy [personal communication]. Letter to; National Perinatal Epidemiology Unit, Oxford, UK 13 September 1989.
Von Forster 1986 {published data only}
    1. Von Forster F, During R, Schwarzlos G. Treatment of cervix incompetence - cerclage versus pessary? Zentralblatt für Gynäkologie 1986;108:230-7. - PubMed
Zakhera 2015 {published data only}
    1. Zakhera M. Cervico-isthmic cerclage for the treatment of recurrent bleeding in early pregnancy: a randomized clinical trial. International Journal of Gynecology and Obstetrics 2015;131(Suppl 5):E538.
Zolghadri 2014 {published data only}
    1. Zolghadri J, Younesi M, Asadi N, Khosravi D, Behdin S, Tavana Z, et al. Double versus single cervical cerclage for patients with recurrent pregnancy loss: a randomized clinical trial. Journal of Obstetrics and Gynaecology Research 2014;40(2):375-80. - PubMed

References to studies awaiting assessment

Ragab 2015 {published data only}
    1. Ragab A, Mesbah Y. To do or not to do emergency cervical cerclage (a rescue stitch) at 24-28 weeks gestation in addition to progesterone for patients coming early in labor? A prospective randomized trial for efficacy and safety. Archives of Gynecology and Obstetrics 2015;292(6):1255-60. [PMID: ] - PubMed

References to ongoing studies

Hezelgrave 2015 {published data only}
    1. 2015-000456-15. The prevention of pre-term birth in women who develop a short cervix. A multi-centre randomised controlled trial to compare three treatments; cervical cerclage, cervical pessary and vaginal progesterone. clinicaltrialsregister.eu/2015-000456-15 (first received 11 March 2015).
Koulalli 2014 {published data only}
    1. NTR4415. Pessary or cerclage to prevent preterm birth in women with short cervical length and a history preterm birth. trialregister.nl/trialreg/admin/rctview.asp?TC=4415 (first received 29 January 2014).

Additional references

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References to other published versions of this review

Alfirevic 2012
    1. Alfirevic Z, Stampalija T, Roberts D, Jorgensen AL. Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No: CD008991. [DOI: 10.1002/14651858.CD008991.pub2] - DOI - PubMed
Drakeley 2003
    1. Drakeley AJ, Roberts D, Alfirevic Z. Cervical stitch (cerclage) for preventing pregnancy loss in women. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No: CD003253. [DOI: 10.1002/14651858.CD003253] - DOI - PMC - PubMed

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