Adjunctive Therapies Show No Clear Benefit Over Cerclage Alone in Preventing Preterm Birth: Review
The article reports that cervical cerclage is an established intervention for certain women who face a high risk of spontaneous preterm birth or previable pregnancy loss. Because these outcomes can be severe, clinicians sometimes combine cerclage with additional therapies that have shown benefit in other contexts related to preterm labor or pregnancy prolongation.
The review examined whether adjunctive treatments used alongside cerclage provide added benefit compared with cerclage alone. The therapies considered included progesterone, reinforcing or second cerclage placement, tocolytics, antibiotics, bed rest, and pessary use.
The authors searched PubMed and Cochrane databases for English-language human studies and also reviewed bibliographies of selected articles. They identified 305 studies for review, but only 12 studies directly compared adjunctive therapy plus cerclage with cerclage alone. None of these studies were prospective randomized clinical trials.
The article explains that cerclage has evidence supporting its use in selected groups, particularly women with singleton pregnancies who have a history of preterm birth and cervical shortening in the current pregnancy. As evidence for cerclage has grown, questions have increased about whether combining it with other therapies could further reduce adverse perinatal outcomes.
Several individual therapies, such as progestins, vaginal progesterone, indomethacin, and vaginal pessary, have been reported to reduce preterm birth risk in some women who do not have cerclage. However, the review notes that other commonly used interventions, including bed rest and prolonged empiric antibiotics, lack clear evidence of benefit and may carry potential risks.
The review found no clear evidence that any adjunctive therapy provided additional benefit beyond cerclage alone. The authors identified some observational studies, but the strength of the evidence was limited by small sample sizes, mixed treatment approaches, and inconsistent reporting of how long additional therapies were used.
The article suggests that some therapies, including indomethacin and 17-alpha hydroxyprogesterone caproate, may appear promising when used with cerclage. However, the available evidence does not support firm conclusions about their added effectiveness. Other therapies, such as pessary use and vaginal progesterone, have not been adequately evaluated as adjuncts to cerclage.
The authors conclude that bed rest and prolonged empiric antibiotic use should not be routinely recommended as adjunctive treatments to cerclage, especially because they have not shown proven benefit and may be harmful. They call for future randomized clinical trials to evaluate individual adjunctive therapies with cerclage before any such approach is considered standard care.
Source: Hindawi Publishing Corporation Obstetrics and Gynecology International Volume2013, ArticleID528158 http://dx.doi.org/10.1155/2013/528158
