Cervical Pessary for Preventing Preterm Birth in Singleton Pregnancies With Short Cervical Length: A Systematic Review and Meta‐analysis

Abstract

Objectives-To evaluate the effectiveness of cervical pessary for preventing spontaneous preterm birth (SPTB) in singleton gestations with a second trimester short cervix.Methods-Electronic databases were searched from their inception until February 2016. We included randomized clinical trials (RCTs) comparing the use of the cervical pessary with expectant management in singletons pregnancies with transvaginal ultrasound cervical length (TVU CL) 25 mm. The primary outcome was incidence of SPTB <34 weeks. The summary measures were reported as relative risk (RR) with 95% confidence interval (CI).Results-Three RCTs (n 5 1,420) were included. The mean gestational age (GA) at randomization was approximately 22 weeks. The Arabin pessary was used as intervention in all three trials, and was removed by vaginal examination at approximately 37 weeks. Cervical pessary was not associated with prevention of SPTB <37 (20.2% vs 50.2%; RR 0.50, 95% CI 0.23 to 1.09), <34, <32, and <28 weeks, compared to no pessary. No differences were found in the mean of GA at, interval from randomization to delivery, incidence of preterm premature rupture of membranes and of cesarean delivery, and in neonatal outcomes. The Arabin pessary was associated with a significantly higher risk of vaginal discharge.Conclusions-In singleton pregnancies with a TVU CL 25mm at 20 0 -24 6 weeks, the Arabin pessary does not reduce the rate of spontaneous preterm delivery or improve perinatal outcome. Individual patient data meta-analysis may clarify whether cervical pessary may be beneficial in subgroups, such as only singleton gestations without prior SPTB or by different CL cutoffs.

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

“…Different strategies have been adopted for preventing PTB, including use of progesterone, cerclage and cervical pessary, as well as lifestyle modification, such as smoking cessation, diet, aerobic exercise and nutritional supplements. The evidence supports the use of vaginal progesterone in singleton pregnancies with short cervix, while cervical cerclage seems to be beneficial only in the subgroup of singleton gestations with both prior spontaneous PTB and CL ≤ 25 mm 10 , but not in singletons without prior PTB or in multiple gestations.…”

“…Cervical pessary is relatively non‐invasive and easy to use, as it does not require anesthesia, it can be inserted in an outpatient clinic setting and it can be easily removed if necessary. However, published data on the use of cervical pessary are contradictory, and meta‐analyses have shown that it has no efficacy in the prevention of PTB in both singleton and multiple pregnancies.…”

Prevention of preterm birth with pessary in singletons (PoPPS): randomized controlled trial

“…Hui et al 9 (n = 108) and Nicolaides et al 10 (n = 924) reported no significant differences in PTB or neonatal outcome 9,10 . A meta-analysis of these three RCTs showed no significant effect on sPTB or neonatal outcome of pessary use in singleton pregnancies with short mid-trimester TVS-CL compared with no pessary 13 . The results of the current RCT are consistent with those of Hui et al 9 , Nicolaides et al 10 and the meta-analysis of all three RCTs 13 .…”

“…A meta-analysis of these three RCTs showed no significant effect on sPTB or neonatal outcome of pessary use in singleton pregnancies with short mid-trimester TVS-CL compared with no pessary 13 . The results of the current RCT are consistent with those of Hui et al 9 , Nicolaides et al 10 and the meta-analysis of all three RCTs 13 . A potential reason for the lack of demonstrable effect of treatment with a pessary in our trial is that any reduction in PTB may have been due to treatment with progesterone and that there is no added benefit of pessary.…”

Pessary cervical and prevention preterm birth based on literature review

“…The latest 3 meta-analyses published in 2017, pessary versus expectant management in the prevention of preterm labour are those of Saccone et al, 21 in single gestations with short cervix, in twin gestations, 22 and the one published by Jim et al 23.…”