Save cerclage until ultrasound reveals short cervix: study
Last Updated: 2011-07-01 16:25:25 -0400 (Reuters Health)
By Megan Brooks
NEW YORK (Reuters Health) - Instead of routinely undergoing cerclage, women with a singleton pregnancy and a prior preterm birth can be safely followed with ultrasound to monitor cervical length, a meta-analysis of randomized trials indicates.
Cerclage, a stitch placed in the uterine cervix, can be reserved for the minority of women who develop a short cervix, said Dr. Vincenzo Berghella and Dr. A. Dhanya Mackeen of Jefferson Medical College in Philadelphia.
"The message," Dr. Berghella told Reuters Health by email, "is that women with prior preterm birth do not always have to have a cerclage at 12 to 14 weeks."
Cerclage is typically offered to women who have a history of one or more preterm births, but "the evidence for its efficacy as compared with no cerclage is limited," the authors say.
Searching the relevant literature on this topic, they identified and included in their analysis four randomized trials involving a total of 467 asymptomatic pregnant women with a history of preterm delivery.
Before 24 weeks gestation, the women were randomized to management with either second trimester transvaginal ultrasonographic cervical length screening and cerclage if the cervical length was found to be short, or to cerclage based on history alone (i.e., previous preterm birth or second-trimester loss).
The incidence of preterm birth before 37 weeks was similar in the screening group and the history-indicated cerclage group (31% and 32%, respectively), the authors report in the July issue of Obstetrics & Gynecology.
The incidence of preterm birth before 34 weeks was also similar (17% and 23%), as was the incidence of perinatal mortality (5% and 3%).
It's noteworthy, the investigators say, that 58% of women monitored with ultrasound never developed a short cervix and therefore avoided cerclage altogether.
Although the investigators did not do a formal cost-effectiveness analysis, they estimate that their policy of cervical length screening (as opposed to history-indicated cerclage) would save a considerable amount of money and yield "seemingly similar outcomes."
"A history-indicated cerclage placed for poor obstetric history," the authors conclude, "may be reserved for women with three prior preterm births or second-trimester losses, whereas most singleton gestations in women with prior preterm birth can be monitored with transvaginal ultrasound cervical length screening and cerclage reserved for the minority who developed a short cervical length."
SOURCE:http://bit.ly/kKB1c1
Obstet Gynecol 2011;118:148-155.
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