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Objective The aim of this systematic review and meta-analysis was to quantify the efficacy of cervical cerclage in preventing preterm birth (PTB) in asymptomatic singleton pregnancies with a short mid-trimester cervical length (CL) on transvaginal sonography (TVS) and without prior spontaneous PTB. Methods Electronic databases were searched from inception of each database until February 2017. No language restrictions were applied. All randomized controlled trials (RCTs) of asymptomatic singleton pregnancies without prior spontaneous PTB, found to have short CL

A finding of a short cervical length (CL) during the second trimester on transvaginal ultrasound predicts preterm birth. Previous data from a meta-analysis and a large trial have shown that cerclage prevents preterm birth in singleton women with a previous preterm birth, once a short cervix has been detected on ultrasound imaging. Because the CL at which cerclage was performed varied between ≤15 mm and

Objective To evaluate the efficacy of cerclage for preventing preterm birth in twin pregnancies with a short cervical length. Design We performed an individual patient data meta-analysis. Searches were performed in electronic databases. Setting Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA. Population Twin pregnancies in mothers with short cervical length. Methods We performed an individual patient data meta-analysis of randomized trials of twin pregnancies screened by transvaginal ultrasound in second trimester and where mothers had a short cervical length

Purpose of review The diagnosis of cervical incompetence remains extremely difficult because there is no diagnostic test available prior to, during or after pregnancy. This review will summarize the latest publications on the use of transvaginal ultrasonography to identify women at high risk of preterm delivery and the use of cervical cerclage in these women. Recent findings Cervical length is not only inversely related to the risk of preterm delivery but also inversely related to the risk of intrauterine infection in women with preterm labor. Furthermore, previous history of preterm delivery is related to the risk of preterm delivery. Cerclage trials on women with short cervical length present conflicting results both in low and high-risk populations. Assessment of risk factors and obstetric history remain important in the diagnosis of cervical incompetence. Women at high risk of preterm delivery due to cervical incompetence should be followed-up with transvaginal measurements of cervical length. Only a minority of these women will develop a short cervical length and will consequently be at high risk of preterm delivery. Summary A combination of assessment of risk factors, obstetric history and follow-up of cervical length enables us to identify women who benefit from a cervical cerclage.

Objective The purpose of this study was to compare preterm delivery rates and neonatal morbidity/mortality rates for women with cervical incompetence with membranes at or beyond a dilated external cervical os that was treated with emergency cerclage, bed rest plus indomethacin, versus just bed rest. Study design Women with cervical incompetence with membranes at or beyond a dilated external cervical os, before 27 weeks of gestation, were treated with antibiotics and bed rest and randomly assigned for emergency cerclage and indomethacin or bed rest only. Results Twenty-three women were included; 13 women were allocated randomly to the emergency cerclage and indomethacin group, and 10 women were allocated randomly to the bed rest–only group. Gestational age at time of randomization was 22.2 weeks in the emergency cerclage and indomethacin group and 23.0 weeks in the bed rest–only group. Mean interval from randomization until delivery was 54 days in the emergency cerclage and indomethacin group and 20 days in the bed rest–only group (P = .046). Mean gestational age at delivery was 29.9 weeks in the emergency cerclage and indomethacin group and 25.9 weeks in the bed rest–only group. Preterm delivery before 34 weeks of gestation was significantly lower in the emergency cerclage and indomethacin group, with 7 of 13 deliveries versus all 10 deliveries in the bed rest–only group (P = .02). Conclusions Emergency cerclage, indomethacin, antibiotics, and bed rest reduce preterm delivery before 34 weeks compared with bed rest and antibiotics alone.

Objective To compare the effects of therapeutic cerclage and bed rest vs. just bed rest on cervical length and to relate these effects to the risk of preterm delivery. Design Cervical length was measured in patients at high risk of cervical incompetence. When a cervical length < 25 mm was measured before 27 weeks' gestation, randomization for therapeutic cerclage and bed rest vs. just bed rest was performed. After randomization, cervical length was measured weekly. For statistical analysis, t-test and Fisher's exact tests were used and P < 0.05 was considered statistically significant. Results Nineteen women were randomly allocated to receive a therapeutic cerclage and bed rest and 16 were allocated to receive bed rest only. Mean cervical lengths and mean gestational ages before randomization were comparable between both groups, overall 19.8 mm and 20.7 weeks. Cervical length was measured again at a mean gestation of 22.1 weeks. Mean cervical length (31 mm) was significantly (P < 0.0001) longer after cerclage than after bed rest only (19 mm). A cervical length ≥ 25 mm was measured in 22 of the 35 included women, 16 in the cerclage group and six in the bed-rest group (P = 0.006). Of these 22 women, only one delivered before 34 weeks' gestation, which was significantly less frequent than six out of 13 women with a cervical length < 25 mm (P = 0.006). Conclusions Therapeutic cerclage with bed rest increases cervical length more often than bed rest alone. A postintervention cervical length ≥ 25 mm reduces the risk of preterm delivery in women at high risk of cervical incompetence and a preintervention cervical length < 25 mm.

Objective: To compare preterm delivery rates (before 34 weeks of gestation) and neonatal morbidity and mortality in patients with risk factors or symptoms of cervical incompetence managed with therapeutic McDonald cerclage and bed rest versus bed rest alone. Study Design: Cervical length was measured in patients with risk factors or symptoms of cervical incompetence. Risk factors for cervical incompetence included previous preterm delivery before 34 weeks of gestation that met clinical criteria for the diagnosis of cervical incompetence, previous preterm premature rupture of membranes before 32 weeks of gestation, history of cold knife conization, diethylstilbestrol exposure, and uterine anomaly. When a cervical length of

The efficacy of Shirodkar cerclage was compared with that of the McDonald procedure for the prevention of preterm birth (PTB) in women with a short cervix. Secondary analysis using data from all published randomized trials including women with a short cervical length (CL) was performed comparing the use of Shirodkar versus McDonald sutures. Analysis was limited to singletons with short CL on transvaginal ultrasound. The primary outcome measure was PTB < 33 weeks. Statistical analysis was performed using bivariate and multivariable techniques. From 607 women randomly assigned in the study, 277 met our inclusion criteria; 127 received Shirodkar and 150 women received McDonald sutures. The mean ( +/- standard deviation) gestational age at delivery was 35.0 +/- 5.3 versus 36.3 +/- 4.7 for the Shirodkar versus McDonald groups, respectively ( p< 0.02). PTB < 33 weeks was seen in 61 (22%) of 277 women; 26 (20%) of 127 in the Shirodkar and 35 (23%) of 150 in the McDonald groups, respectively (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.5 to 1.6). On adjusting for confounders using logistic regression modeling, no significant difference in PTB < 33 weeks was found between the two groups (OR, 0.55; 95% CI, 0.2 to 1.3). In women with short cervical length randomly assigned to receiving cerclage, no significant difference in prevention of PTB was observed using Shirodkar or McDonald's procedures.

Our aim was to estimate if indomethacin therapy prevents preterm birth (PTB) in women with a short cervical length (CL) on transvaginal ultrasound (TVU).Individual-level data from all randomized trials including asymptomatic women with a short CL on TVU were analyzed for use of indomethacin at the time of the short CL. The trials eligible would be ones that randomized women with a short CL25 mm, identified between 14 and 27 weeks. The eligible trials randomized such women to receive either cerclage or no cerclage. Only women who did NOT receive cerclage were analyzed. Exclusion criteria were major fetal anomaly and cerclage. We compared demographics, risk factors, and outcomes in women who, at the time of the short CL, received indomethacin or not. Primary outcome was PTB35 weeks.Three of the 4 randomized trials identified had databases which recorded indomethacin use at the time of the short CL. A total of 139 women with a short CL25 mm identified at 14 to 27 weeks were identified. Of these women, 99 (71.2%) received indomethacin, and 40 (28.8%) did not. Demographics and risk factors, including previous PTB (45.5% vs 62.5%; P = .11), were similar in the 2 groups. The primary outcome of PTB35 weeks occurred in 29.3% (29/99) of women who received indomethacin, and 42.5% (17/40) of women who did not receive indomethacin (RR 0.69, 95% CI 0.44-1.13). PTB24 weeks occurred in 1.0% (1/99) versus 7.5% (3/40), respectively (RR 0.14; 95% CI 0.02-0.92). Incidence of perinatal death was similar in the 2 groups (6% vs 10%; RR 0.61, 95% CI 0.19-1.95).Indomethacin therapy for asymptomatic women who have a short CL25 mm on TVU at 14 to 27 weeks and do not receive a cerclage did not prevent spontaneous PTB35 weeks, but did prevent PTB24 weeks. Further research including larger numbers and a randomized trial design is necessary to further clarify the effectiveness as well as the risks of this therapy.

Preterm birth is the main cause of perinatal morbidity and mortality. A short cervical length on transvaginal ultrasonography predicts preterm birth. Our aim was to estimate by meta-analysis of randomized trials whether cerclage prevents preterm birth in women with a short cervical length.MEDLINE, PubMed, EMBASE, and the Cochrane Library were searched with the terms "cerclage," "cervical cerclage," "short cervix," "ultrasound," and "randomized trial." We included randomized trials involving the use of cerclage in women with short cervical length on transvaginal ultrasonography using patient-level data.Four properly conducted trials were identified. In the total population, preterm birth at less than 35 weeks of gestation occurred in 29.2% (89/305) of the cerclage group, compared with 34.8% (105/302) of the no-cerclage groups (relative risk [RR] 0.84, 95% confidence interval [CI] 0.67-1.06). There was no significant heterogeneity in the overall analysis (P = .29). There was a significant reduction in preterm birth at less than 35 weeks in the cerclage group compared with the no-cerclage groups in singleton gestations (RR 0.74, 95% CI 0.57-0.96), singleton gestations with prior preterm birth (RR 0.61, 95% CI 0.40-0.92), and singleton gestations with prior second-trimester loss (RR 0.57, 95% CI 0.33-0.99). There was a significant increase in preterm birth at less than 35 weeks in twin gestations (RR 2.15, 95% CI 1.15-4.01).Cerclage does not prevent preterm birth in all women with short cervical length on transvaginal ultrasonography. In the subgroup analysis of singleton gestations with short cervical length, especially those with a prior preterm birth, cerclage may reduce preterm birth, and a well-powered trial should be carried out in this group of patients. In contrast, in twins, cerclage was associated with a significantly higher incidence of preterm birth.

Transvaginal cervical cerclage was introduced as a treatment for cervical incompetence in 1951. Over the years, our understanding of this clinical entity has changed tremendously, which has implications for obstetric management. This review focuses on the obstetric management of women considered to be at high risk of preterm delivery due to cervical incompetence at different stages of pregnancy.

UNLABELLED Cervical incompetence is not a categoric but rather a continuous variable, meaning that there are various degrees in the competency of the cervix. Furthermore, a certain degree of competency of the cervix can be expressed differently in subsequent pregnancies. Women with risk factors for cervical incompetence in their gynecological/obstetric history should be followed by transvaginal ultrasonography. History alone is not an indication for a prophylactic cerclage. Although transvaginal ultrasonography identifies women at high risk of preterm delivery, it does not discriminate between different underlying pathologies. Short cervical length alone is not an indication for a therapeutic cerclage. Serial transvaginal ultrasonographic measurements of cervical length in women with risk factors can identify those women truly at high risk of preterm delivery. A transvaginal cervical cerclage with bed rest reduces preterm delivery and improves perinatal outcome in women with a short cervical length and risk factors for cervical incompetence. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader will be able to define cervical incompetence, explain the role of transvaginal ultrasonography in the prediction of preterm delivery, and summarize the data on the use of transvaginal cervical cerclage.

Cervical cerclage and bed rest, by themselves or in combination, are common approaches to pregnant women having an incompetent cervix. Transvaginal cerclage is known to increase cervical length, but it is possible that bed rest alone has the same effect. This study of 35 women was an attempt to compare combined cerclage and bed rest with management by bed rest alone, using as the primary outcomes delivery before 34 weeks' gestation and neonatal morbidity. Women whose cervical length was less than 25 mm before 27 weeks' gestation, as estimated by transvaginal sonography, were randomly assigned to one of the two treatment conditions. Cervical length was subsequently measured at weekly intervals. Cervical incompetence was diagnosed from painless, progressive cervical dilation when, without intervention, preterm delivery seemed inevitable. Cerclage was performed using a single purse-string suture of braided polyester Nineteen women were assigned to cerclage and bed rest, and 16 were assigned to bed rest only. Mean initial cervical length and gestational age were comparable in these groups (averaging 19.8 mm and 20.7 weeks, respectively). At a mean gestational age of 22 weeks, cervical length was significantly greater in the cerclage group (31 vs. 19 mm). In 22 of 35 women, cervical length was 25 mm or greater; 16 had undergone cervical cerclage. Only 1 of these 22 women delivered before 34 weeks, significantly fewer than the 6 women among 13 whose cervical length did not reach 25 mm. In addition to rest in bed, cerclage ensuring a cervical length of at least 5 mm significantly lowers the likelihood of preterm delivery in women diagnosed as having cervical incompetence.