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ABSTRACT: Cervical cerclage is a well-known surgical procedure carried out during pregnancy. It involves positioning of a suture (stitch) around the neck of the womb (cervix), aiming to give a mechanical support to the cervix and thereby reducing the risk of preterm birth. The effectiveness and safety of this procedure remains controversial.
To assess whether the use of cervical stitch in singleton pregnancy at high risk of pregnancy loss based on a woman's history and/or ultrasound finding of 'short cervix' and/or physical exam improves subsequent obstetric care and fetal outcome.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2011) and reference lists of identified studies.
We included all randomised trials of cervical suturing in singleton pregnancies carried out when pregnancy was considered to be at sufficiently high risk of pregnancy loss for cerclage to be potentially indicated. We included any study that compared cerclage with either no treatment or any alternative intervention.
Three review authors independently assessed trials for inclusion. Two review authors independently assessed risk of bias and extracted data. Data were checked for accuracy.
We included 12 trials (involving 3328 women). When cerclage was compared with no treatment, there was no statistically significant difference in perinatal deaths (8.4% versus 10.7%) (risk ratio (RR) 0.78; 95% confidence interval (CI) 0.61 to 1.00; eight trials, 2391 women) and neonatal morbidity (9.6% versus 10.2%) (RR 0.95; 95% CI 0.63 to 1.43; four trials, 818 women), despite significant reduction in preterm births (average RR 0.80; 95% CI 0.69 to 0.95; nine trials, 2898 women). Cervical cerclage was associated with the higher rate of maternal side effects (vaginal discharge and bleeding, pyrexia) (average RR 2.25; 95% CI 0.89 to 5.69; three trials, 953 women). Caesarean section rates were significantly higher after cervical cerclage (RR 1.19; 95% CI 1.01 to 1.40; 8 trials, 2817 women).There was no evidence of any important differences across all prespecified clinical subgroups (history-indicated, ultrasound-indicated)One study that compared cerclage with weekly intramuscular injections of 17 α-hydroxyprogesterone caproate in women with a short cervix detected by transvaginal ultrasound, failed to reveal any obvious differences in obstetric and neonatal outcomes between the two management strategies.Two studies compared the benefits of performing cerclage based on previous history with cerclage, only if the cervix was found to be short on transvaginal ultrasound. There was no significant difference in any of the primary and secondary outcomes.
Compared with no treatment, cervical cerclage reduces the incidence of preterm birth in women at risk of recurrent preterm birth without statistically significant reduction in perinatal mortality or neonatal morbidity and uncertain long-term impact on the baby. Ceasarean section is more likely in women who had cervical suture inserted during pregnancy.The decision on how best to minimise the risk of recurrent preterm birth in women at risk, either because of poor history of a short or dilated cervix, should be 'personalised', based on the clinical circumstances, the skill and expertise of the clinical team and, most importantly, woman's informed choice.
Cochrane database of systematic reviews (Online) 01/2012; 4:CD008991. · 5.72 Impact Factor
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Devender Roberts
BMJ (Clinical research ed.). 01/2011; 342:d1614.
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Clinical dysmorphology 03/2010; 19(3):146-9. · 0.47 Impact Factor
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American Journal of Medical Genetics Part A 07/2007; 143A(11):1249-52. · 2.39 Impact Factor
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ABSTRACT: The cerebellar and pontocerebellar hypoplasias present a unique challenge when detected in the developing fetus. A diverse aetiology and prognosis make counselling of these families difficult. Advances in fetal imaging allow for more accurate diagnosis and counselling, but postnatal MRI is still required. A case is presented in which cerebellar hypoplasia was detected at 20 weeks gestation. Later fetal imaging provided further information, but a diagnosis of pontomedullary disconnection was not made until the postnatal MRI scan. The clinical findings and possible causes of such pontocerebellar abnormalities are discussed.
Pediatric Radiology 09/2005; 35(8):812-4. · 1.67 Impact Factor
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ABSTRACT: Antenatal diagnosis of congenital heart disease is most commonly made at the routine 20-week anomaly scan. Not all abnormalities can be detected by prenatal ultrasound but detection can be improved by obtaining outlet views and by the use of colour Doppler. This article provides an overview of the uses and limitations of fetal echocardiography.
Hospital medicine (London, England: 1998) 08/2004; 65(7):396-9. · 0.33 Impact Factor
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ABSTRACT: To estimate the effectiveness of prophylactic and therapeutic cerclage by meta-analysis of randomized clinical trials.
We searched the Cochrane Pregnancy and Childbirth Group specialized register of clinical trials (May 2002). Congress proceedings of international society meetings of fetal-maternal and reproductive medicine were searched by hand.
Meta-analysis of randomized clinical trials comparing cervical cerclage with expectant management during pregnancy was performed. Further clarification was sought from trial authors when required.
Six trials describing a total of 2175 women were analyzed. Prophylactic cerclage was compared with no cerclage in four trials. Pooled results failed to show a statistically significant reduction in pregnancy loss and preterm delivery rates, although a small reduction in births less than 33 weeks' gestation was seen in the largest trial (relative risk [RR] 0.75; 95% confidence interval [CI] 0.58 to 0.98). Cervical cerclage was associated with mild pyrexia, increased use of tocolytic therapy, and hospital admission but no serious morbidity. Two trials examined the role of therapeutic cerclage when ultrasound examination revealed a short cervix. Pooled results failed to show a reduction in total pregnancy loss, early pregnancy loss, or preterm delivery before 28 and 34 weeks in women assigned to cervical cerclage.
The effectiveness of prophylactic cerclage in preventing preterm delivery in women at low or medium risk for second-trimester pregnancy loss has not been proven. The role of cerclage in women whose ultrasound reveals short cervix remains uncertain.
Obstetrics and Gynecology 10/2003; 102(3):621-7. · 4.73 Impact Factor
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ABSTRACT: To determine whether inherited and acquired thrombophilias are associated with adverse obstetric complications.
A systematic review; studies where women with adverse obstetric complications were tested for one or more acquired and inherited thrombophilias were included.
Prevalence of thrombophilia in women with severe pre-eclampsia/eclampsia, severe placental abruption, intrauterine growth restriction or unexplained stillbirth.
Compared with controls, placental abruption was more often associated with homozygous and heterozygous factor V Leiden mutation, heterozygous G20210A prothrombin gene mutation, homocysteinaemia, activated protein C resistance or anticardiolipin IgG antibodies. Women with pre-eclampsia/eclampsia were more likely to have heterozygous factor V Leiden mutation, heterozygous G20210A prothrombin gene mutation, homozygous MTHFR C677T mutation, protein C deficiency, protein S deficiency or activated protein C resistance compared with controls. Unexplained stillbirth, when compared with controls, was more often associated with heterozygous factor V Leiden mutation, protein S deficiency, activated protein C resistance, anticardiolipin IgG antibodies or lupus anticoagulant. Women with intrauterine growth restriction had a higher prevalence of heterozygous G20210A prothrombin gene mutation, homozygous MTHFR C677T gene mutation, protein S deficiency or anticardiolipin IgG antibodies than controls. There was wide heterogeneity in the prevalence of thrombophilia between the studies.
Women with adverse pregnancy outcome are more likely to have a positive thrombophilia screen but studies published so far are too small to adequately assess the true size of this association. Screening for thrombophilia should not become standard practice until clear evidence emerges that thromboprophylaxis during pregnancy improves perinatal outcome. Further research into the link between the observed association, causality and heterogeneity is required.
European Journal of Obstetrics & Gynecology and Reproductive Biology 03/2002; 101(1):6-14. · 1.97 Impact Factor
