Sietske M. Althuisius

Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data.

Objective: 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. Data Sources: 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. Tabulation, Integration, and Results: 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). Conclusion: 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.

Effectiveness of cerclage according to severity of cervical length shortening: A meta-analysis

To estimate the effectiveness of cerclage according to degree of cervical length (CL) shortening.

Cerclage for short cervix in twin pregnancies: systematic review and meta-analysis of randomized trials using individual patient-level data

To evaluate the efficacy of cerclage for preventing preterm birth in twin pregnancies with a short cervical length.

Cervical incompetence: a reappraisal of an obstetric controversy.

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.

Loop electrosurgical excision procedure of the cervix and time of delivery in subsequent pregnancy

Objective: To study the effect of the loop electrosurgical excision procedure (LEEP) on gestational age at delivery in the subsequent pregnancy. Method: Identification of women with LEEP. Chart analysis and inquiry into gestational age at the subsequent delivery. Exclusion of first trimester abortions, multiple gestations, cold knife conizations and women over 40 years during LEEP. For comparison, 40 weeks was used as the mean date of delivery in a normal population. Wilcoxon signed rank test was used and P<0.05 was considered significant. Result: Fifty‐six women delivered after LEEP. Seven delivered preterm of whom three were induced and one had a history of preterm delivery. Deliveries prior to 32 weeks of gestation did not occur. Mean gestational age at delivery was 39 2/7 weeks (95%CI: 38 5/7–39 6/7) which is significantly earlier (P=0.03) than the hypothetical 40 weeks. Conclusion: After LEEP, deliveries prior to 32 weeks did not occur. Gestational age at delivery was only 5 days earlier than expected. LEEP cannot be considered a risk for early preterm delivery.

Cerclage for sonographic short cervix in singleton gestations without prior spontaneous preterm birth: systematic review and meta‐analysis of randomized controlled trials using individual patient‐level data

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.