Adjunct Therapy at Time of Examination-Indicated Cervical Cerclage in Singleton Pregnancies: A Systematic Review and Meta-analysis

Abstract

Objective: Physical exam-indicated cerclage for cervical insufficiency prolongs gestation, but evidence on the addition of adjuncts to further prolong latency is limited. The aim of this systematic review and meta-analysis was to compare gestational latency between those who did and did not receive adjunct antibiotic or tocolytic therapy at the time of exam-indicated cerclage. Study Design: Electronic databases (1966 to 2020) were searched for randomized controlled trials (RCT) and cohort studies comparing adjunct antibiotic or tocolytic use versus non-use at time of exam-indicated cerclage, defined as placement for cervical dilation ≥ 1 cm, in a current singleton pregnancy. Studies including individuals with intra-amniotic infection, cerclage in place, non-viable gestation, or ruptured membranes were excluded. The primary outcome was latency from cerclage placement to delivery. Secondary outcomes included preterm birth, preterm premature rupture of membranes, birth weight and neonatal survival. Risk of bias was assessed using standardized tools. Heterogeneity was assessed using X2 and I2 tests. Results were pooled and analyzed using a random-effects model. PROSPERO registration (CRD42021216370). Results: Of 923 unique records, 163 were reviewed in full. Three met inclusion criteria: one RCT and two retrospective cohorts. The RCT was nested within one of the cohorts, and therefore only one of these two studies was utilized for any given outcome to eliminate counting individuals twice. Risk of bias was “critical” for one cohort, “moderate” for one cohort, and “some concerns” for the RCT. Gestational latency could not be pooled and meta-analyzed. Adjunct tocolytic-antibiotic therapy was not associated with a decrease in risk of preterm delivery <28 weeks (RR 0.90, 95% CI 0.65-1.26; X2=0.0, I2=0.0%) or neonatal survival to discharge (RR 1.11, 95% CI 0.91-1.35; X2=0.05, I2=0.0%). Conclusion: There is not enough evidence to robustly evaluate the use of adjunct tocolytics or antibiotics at time of exam-indicated cerclage to prolong la

Desafios na prevenção do parto pré-termo associado à insuficiência cervical

“…Revisões sistemáticas e metanálise com objetivo de avaliar o impacto da associação de terapias adjuvantes à cerclagem, indicada pela história e/ou achado de colo curto ao US e/ou exame físico, concluíram não haver evidências suficientes para indicar o uso de tocolíticos ou antibióticos no momento da cerclagem para melhoria dos resultados obtidos 31,32 .…”