Cervical Pessary For Preventing Preterm Birth (Review) : Abdel-Aleem H, Shaaban OM, Abdel-Aleem MA

Cervical pessary for preventing preterm birth (Review)
Abdel-Aleem H, Shaaban OM, Abdel-Aleem MA
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2010, Issue 9
http://www.thecochranelibrary.com

Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . .
Figure 1.
. . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . .
DIFFERENCES BETWEEN PROTOCOL AND REVIEW
INDEX TERMS
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[Intervention Review]
Cervical pessary for preventing preterm birth

Hany Abdel-Aleem1 , Omar M Shaaban1 , Mahmoud A Abdel-Aleem1
1 Department
of Obstetrics and Gynecology, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt
Contact address: Hany Abdel-Aleem, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University Hospital,
Assiut, 71511, Egypt. [email protected]. [email protected].
Editorial group: Cochrane Pregnancy and Childbirth Group.
Publication status and date: New, published in Issue 9, 2010.
Review content assessed as up-to-date: 11 July 2010.
Citation: Abdel-Aleem H, Shaaban OM, Abdel-Aleem MA. Cervical pessary for preventing preterm birth. Cochrane Database of
Systematic Reviews 2010, Issue 9. Art. No.: CD007873. DOI: 10.1002/14651858.CD007873.pub2.
ABSTRACT
Background
Preterm delivery is a major health problem and contributes to more than 50% of the overall perinatal mortality. Cervical incompetence
is one of the common causes of preterm birth to which different management strategies have been tried including cervical cerclage.
Cervical cerclage is an invasive technique that needs anaesthesia and may be associated with complications. Moreover, there is still a
matter of controversy regarding the efficacy and the group of patients which could benefit from this operation. Cervical pessary has
been tried as a simple, non-invasive alternative that might replace the above invasive cervical stitch operation.
Objectives
To evaluate the efficacy of cervical pessary for prevention of preterm birth in women with cervical incompetence.
Search strategy
We searched the Cochrane Pregnancy and Childbirth Groups Trials Register (May 2010), Current Controlled Trials and the Australian
New Zealand Clinical Trials Registry (May 2010).
Selection criteria
We selected all published and unpublished randomised clinical trials comparing the use of cervical pessary with cervical cerclage or
expectant management for prevention of preterm birth. We did not include quasi-randomised trials, cluster-randomised and crossover
trials.
Data collection and analysis
Two review authors independently assessed trials for inclusion.
Main results
The search identified two trials which we excluded. Three additional trials are ongoing. This review contains no included studies.
Authors conclusions
The review did not identify any well-designed randomised clinical trial in order to confirm or refute the benefit of cervical pessary.
However, there is evidence from non-randomised trials that showed some benefit of cervical pessary in preventing preterm birth. We
are waiting for the results of three ongoing randomised controlled trials, assessing the role of cervical pessary in women with short
cervix. There is a need for further well-designed randomised controlled trials.
PLAIN LANGUAGE SUMMARY

Using cervical pessary to prevent preterm birth for women with cervical incompetence
Giving birth before term contributes to more than half of the deaths of newborn babies. Cervical weakness is a common cause, although,
its firm diagnosis is not standardised and may be based on a womans history, including two or more second-trimester pregnancy losses.
Different management techniques have been tried, and, include tightening the cervix with a stitch to prevent its premature opening.
Although it is a simple operation, it requires anaesthesia and can have bleeding complications and cause infection and pregnancy loss.
Closing the cervix with a silicone ring (cervical pessary) that is removed at around 37 weeks is a simple, non-invasive alternative that
might replace the cervical stitch operation. To date, there is no reliable evidence from well-designed randomised controlled trials to show
that a cervical pessary is beneficial. One non-randomised study showed that about half of the pessary users complained of increased
vaginal discharge after the use of the cervical pessary. Three randomised controlled trials are ongoing in pregnant women with a short
cervix.
BACKGROUND
Description of the condition

Preterm delivery is a major health problem; it complicates about
6% to 10% of pregnancies (Lumley 2003). Spontaneous preterm
delivery represents a major cause of prenatal deaths (28.7%) (Ngoc
2006). It has been also demonstrated that preterm delivery contributes to about half of the overall perinatal mortality (AIHW
2005). Premature neonates represent a large economic burden; as
each day in the standard neonatal intensive care can cost approximately 1000 US$ (Rogowski 1999). In developed countries,10%
of expenses for treating diseases in children result from preterm
delivery (Lewitt 1995).
Cervical incompetence is one of the common causes of preterm
birth; however, its firm diagnosis is far from being standardised.
Diagnosis is often based retrospectively on history and exclusion
of other causes of preterm delivery. Typical historical risk factors
include: having two or more second-trimester pregnancy losses,
especially if there is a history of losing each pregnancy at an earlier
gestational age; having preterm premature rupture of membranes
prior to 32 weeks gestation; a history of cervical trauma caused by
cone biopsy, forced dilatation, or intrapartum cervical lacerations;
or congenital uterine anomalies (Lo 2009). Clincal examination
during pregnancy revealing short cervix, dilated cervix, protruding
membranes or cervical tear(s) are suggestive of cervical incompetence. Ultrasound examination during pregnancy showing short
cervical length (less than 25 mm at 20 weeks gestation) (Owen
2004) or funnelling of the cervix during the second or early third
trimester of pregnancy (Ayers 1988) have been suggested to be
signs of cervical incompetence.
Different management strategies have been tried for management
of cervical incompetence, including trials to tighten the cervix (cervical cerclage) to prevent its premature opening (Anthony 1997;
Gibb 1995; McDonald 1957; Shirodkar 1955). However, in spite

of being a simple operation, it is an invasive technique that requires
anaesthesia, and has its complications including haemorrhage, infection and even pregnancy loss (Grant 1989). Moreover, cervical
cerclage is not always very effective in preventing preterm labour. A
systematic review done by Bachmann 2003 reported that elective
cerclage has a significant effect in preventing spontaneous preterm
birth before 34 weeks gestation. The number needed to be treated
to prevent one additional preterm birth before 34 weeks was 24
women (95% confidence interval 10 to 61). However, it has no
significant effect on preventing preterm birth between 34 and 37
weeks of pregnancy. Another systematic review concluded that the
use of a cervical stitch should not be offered to women at low or
medium risk of mid-trimester loss, regardless of cervical length
by ultrasound. Cervical cerclage was associated with mild pyrexia,
increased use of tocolytic therapy and hospital admissions, but
no serious morbidity (Drakeley 2003). A third systematic review
evaluated the role of cervical cerclage for a shortened cervix, and
concluded that the available evidence does not support cerclage
for a sonographically detected short cervix (Belej-Rak 2003). So,
cervical cerclage may not be effective in preventing preterm birth
in all groups of women at risk, and could be associated with some
morbidities.
Description of the intervention

Cervical pessary has been tried for management of cervical incompetence since the 1950s (Cross 1959). However, its use for
this purpose has passed through waves of enthusiasm and loss
of favour (Acharya 2006; Antczak-Judycka 2003; Arabin 2003;
Quaas 1990). Most of the studies have used the Arabin pessary
which is a flexible, ring-like silicone pessary available in different
sizes with the outer diameter varying between 65 mm and 70 mm,

the inner diameter between 32 mm and 35 mm, and the height

of the curvature between 21 mm and 25 mm (Figure 1). It has
been designed to be inserted with its curvature upwards so that
the larger diameter is supported by the pelvic floor. The smaller
inner diameter is supposed to encompass the cervix (Arabin 2003)
Figure 1.
Figure 1. Cervical pessary in place. Images reproduced with the kind permission of Dr. Arabin GmbH & Co.
KG
How the intervention might work

The mechanism by which pessaries can help women with an incompetent cervix was first postulated by Vitsky in 1961 (Vitsky
1961). He suggested that the incompetent cervix is aligned centrally, with no support except the nonresistant vagina. A lever
pessary, however, would change the inclination of the cervical
canal, directing it more posteriorly. In doing so, the weight of the
pregnancy would be more on the anterior lower segment (Arabin
2003).
Why it is important to do this review

Cerclage pessary is relatively noninvasive, it is operator independent, easy to use, it does not require anaesthesia, it can be used
in an outpatient clinic setting, and it is easily removed when necessary (Acharya 2006; Grzonka 2004; Newcomer 2000; Quaas
1990; Von Forster 1986). A non-randomised trial was conducted
in the USA in 1966 and it involved 35 pregnant women. They
used Hodge pessaries and reported 83% living children (Oster
1966). Dahl and Barz reported on 115 patients thought to have
an incompetent cervix (Dahl 1979). They used a Mayer-Ring pessary (glass ring and pushed around the cervix). Eighty per cent
of women treated by pessaries gave birth to neonates more than
2500 gm. More recently, Quaas et al (Quaas 1990) reported on
107 patients using an Arabin-cerclage pessary. The pessary was
used instead of surgical cerclage in 58 patients prophylactically, 44
cases therapeutically, and five patients emergently. In 92 percent
of the patients, the pregnancy was maintained until 36 weeks of

gestation, when the Arabin-cerclage pessary was removed. There

were no infectious complications reported.
Other non-randomised trials showed that treating women with
short cervix with cervical pessary succeeded in prolonging the pregnancy compared to expectant management. The mean gestational
age at delivery was 38 weeks (36+6-41) in the pessary group and 33
weeks (26+4-38) in the control group (P = 0.02) (Arabin 2003).
In another comparative non-randomised trial, cervical pessary was
as effective as cervical cerclage in delaying the onset of labour. The
primary outcome measure was prolongation of pregnancy (mean
13.4 weeks and 12.1 weeks for cerclage and pessary respectively)
(P = 0.06) (Antczak-Judycka 2003). However, the use of cervical
pessary has not been assessed in a systematic way.
8. vaginal ultrasound evidence of cervical incompetence,

including shortening (cervical length less than 25 mm at 20
weeks) and funnelling of the cervix during the second or early
third trimester of pregnancy.
Types of interventions
To avoid duplication of comparisons in various reviews of interventions for preventing preterm birth, we planned to compare the
intervention of interest (cervical pessary) with the following interventions:
cervical pessary versus placebo/no treatment;
cervical pessary versus bedrest;
cervical pessary versus cervical cerclage.
OBJECTIVES
To evaluate the efficacy of cervical pessary for the prevention of
preterm birth in women with cervical incompetence.
Types of outcome measures
Primary
1. Delivery at less than 37 weeks gestation.
METHODS
Secondary
Criteria for considering studies for this review

Types of studies
Maternal
We planned to include all randomised clinical trials comparing the

use of cervical pessary with cervical cerclage or expectant management for prevention of preterm birth. We planned not to include
any quasi-randomised trials (for example, randomisation by date
of birth or day of admission), cluster-randomised and crossover
trials.

3. Mean gestational age at time of delivery.
4. Maternal hospital admission.
5. Maternal medications (e.g. antibiotics, tocolytics).
6. Side effects of the intervention including expulsion of the
pessary.
7. Patients satisfaction.
8. Additional costs over that of routine antenatal care.
Types of participants
Pregnant women with viable fetus in the second trimester of pregnancy and with risk factors for preterm birth due to cervical incompetence. These include:
1. history of two or more second-trimester pregnancy losses
(excluding those resulting from induced preterm labour or
abruption);
2. history of losing each pregnancy at an earlier gestational age;
3. preterm premature rupture of membranes prior to 32
weeks gestation;
4. short cervical length (less than 25 mm at 20 weeks
gestation);
5. history of cervical trauma caused by cone biopsy, forced
dilatation, intrapartum cervical lacerations;
6. history of painless cervical dilatation of up to 4 to 6 cm;
7. congenital uterine anomalies;
Fetal
1. Neonatal paediatric care unit admission.
2. Perinatal death.
Search methods for identification of studies
Electronic searches
We contacted the Trials Search Co-ordinator to search the
Cochrane Pregnancy and Childbirth Groups Trials Register (May
2010).

The Cochrane Pregnancy and Childbirth Groups Trials Register

is maintained by the Trials Search Co-ordinator and contains trials
identified from:
1. quarterly searches of the Cochrane Central Register of
Controlled Trials (CENTRAL);
2. weekly searches of MEDLINE;
3. handsearches of 30 journals and the proceedings of major
conferences;
4. weekly current awareness alerts for a further 44 journals
plus monthly BioMed Central email alerts.
Details of the search strategies for CENTRAL and MEDLINE,
the list of handsearched journals and conference proceedings, and
the list of journals reviewed via the current awareness service can
be found in the Specialized Register section within the editorial information about the Cochrane Pregnancy and Childbirth
Group.
In addition, we searched Current Controlled Trials and the
Australian New Zealand Clinical Trials Registry (May 2010), using the terms pessary or pessaries.
We did not apply any language restrictions.
Results of the search
Risk of bias in included studies
The search by the Cochrane Pregnancy and Childbirth Group retrieved two trial reports (Gmoser 1991; Von Forster 1986); we
excluded both. We also identified three additional ongoing studies (Moratonas 2007; Nicolaides 2008; Nizard 2007). For more
information, see Characteristics of ongoing studies.
Included studies
There were no included studies.
Excluded studies
We excluded two studies (Gmoser 1991; Von Forster 1986). The
Von Forster 1986 study was from Germany and was excluded
because of unclear inclusion and exclusion criteria and the use of
quasi-randomisation (by the initial of the womans surname). The
Gmoser 1991 trial was from Austria and was excluded because of
inadequate reporting on the methods in relation to randomisation,
and inclusion and exclusion criteria. For more information, see
Characteristics of excluded studies.
There were no included studies.

Selection of studies
Two review authors independently assessed for inclusion the
studies resulting from the search. We resolved any disagreement
through discussion with the third author.
Effects of interventions
Data extraction and management
DISCUSSION
Because of having non-English randomised controlled trials, we

asked the Cochrane Pregnancy and Childbirth Group to provide
us with a structured English translation.
We have provided the full methods we will use for data collection
and analysis In subsequent updates of this review, as data become
available, in Appendix 1.
Preterm birth has its major health (Lumley 2003; Ngoc 2006) and
economic (Lewitt 1995; Rogowski 1999) burdens in developed
and developing countries. Cervical insufficiency is blamed for a
high percentage of preterm deliveries. Cervical cerclage has been
used for decades, as the only available option to prevent preterm
birth due to cervical insufficiency (Anthony 1997; Gibb 1995;
Grant 1989; McDonald 1957). Falilure to identify the group of
women who definitely get benefit from cervical cerclage, leads
to using this invasive procedure unnecessarily in many occasions.
Systematic reviews have failed to show a definite benefit from cervical cerclage in prevention of preterm birth or improving neonatal mortality for women with historical (Bachmann 2003) or ultrasonographically imaged short cervix as a risk factor (Belej-Rak
2003).
RESULTS
Description of studies
See: Characteristics of excluded studies; Characteristics of ongoing
studies.
There are no trials that meet the inclusion criteria for this review.
Cervical pessary, as an inexpensive and less invasive option to cervical stitch, may represent special importance to health services
in low-resource countries (Arabin 2003). Using pessary instead of

performing a cerclage operation can decrease hospital stays and

costs. If cervical pessary proves beneficial, this will definitely decrease the burden of premature delivery and care that is given
to premature and extremely premature babies. Cervical pessaries
have been used for the treatment of cervical insufficiency in several
non-randomised trials and shown to be effective in many of them.
(Arabin 2003; Oster 1966; Quaas 1990; Seyffarth 1978; Vitsky
1968).
There were two randomised trials that have been assessed for inclusion in the current review (Gmoser 1991; Von Forster 1986)
but both were excluded. The first found that cervical pessary was
as effective as cerclage in the management of cervical incompetence. Both methods succeeded in prolonging pregnancy at least
until 37 weeks in approximately 80% of cases (Von Forster 1986).
The second study found that pessary treatment was better at prolonging pregnancy and increasing the weight of the baby at birth,
compared to no intervention (Gmoser 1991).
Few complications have been reported from pessary use during

pregnancy. This is most likely due to the relatively short duration
of use and proper antenatal care given to the users. Two studies
have looked at changes in vaginal flora during pregnancy with
pessary use. One study (Havlik 1986) compared the change in
vaginal flora of 50 women wearing Mayer pessaries with 50 controls. They found that after two weeks, there were no differences
in the change of flora between users and non-users. Another study
(Jorde 1983) also reported that 5.5% of women (in a cohort of
200) using pessaries had pathogenic organisms in the vagina during pregnancy, compared with 2% of controls. About half of the
pessary users complained of increased vaginal discharge after the
use of a cervical pessary (Arabin 2003).
Summary of main results

Searching the literature retrieved two trial reports (Gmoser 1991;
Von Forster 1986) which we excluded from this review (because
of unclear criteria for selecting participants or due to inadequate
methodology relating to randomisation).
We also identified three ongoing randomised controlled trials using cervical pessary in pregnant women with short cervix to prevent preterm birth (Moratonas 2007; Nicolaides 2008; Nizard
2007). We will assess these ongoing studies for inclusion in the
next update of our review if data are available.
AUTHORS CONCLUSIONS
Implications for practice
Until more data are available, there is no reliable evidence to show
whether cervical pessary is beneficial or otherwise in the management of women at high risk of preterm birth.
Implications for research

There is a need for well-designed randomised controlled trials to
be performed with clear selection criteria.
ACKNOWLEDGEMENTS
Thanks to Emma Wood for help with translating Gmoser 1991.
As part of the pre-publication editorial process, this review has
been commented on by three peers (an editor and two referees
who are external to the editorial team) and the Groups Statistical
Adviser.
REFERENCES
References to studies excluded from this review

Gmoser 1991 {published data only}
Gmoser G, Girardi F, Mayer HO, Hermann J, Haas J. The support
pessary--a therapeutic possibility in premature opening of the
uterine cervix. Gynakologische Rundschau 1991;31 Suppl:1179.
Von Forster 1986 {published data only}
Von Forster F, During R, Schwarzlos G. Treatment of cervix
incompetence - cerclage versus pessary?. Zentralblatt fur
Gynakologie 1986;108:2307.
References to ongoing studies
Moratonas 2007 {unpublished data only}

Moratonas EC. Prevention of preterm birth using cervical pessary
in pregnant women with short cervix. http://clinicaltrials.gov/ct2/
show/record/NCT00706264 (accessed 2010).
Nicolaides 2008 {published data only}
Nicolaides K. Randomized study of pessary vs standard
management in women with increased chance of premature birth.
http://www.controlled-trials.com/mrct/trial/456767/pessary
(accessed 2010).
Nizard 2007 {published data only}
Nizard J. Evaluation of pessaries in twin pregnancies with a short
cervix (25 mm) between 20-28 WG. http://www.controlledtrials.com/mrct/trial/407673/pessary (accessed 15 May 2010).

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Jorde A, Kstli K, Hamann B, Pockrandt H. Changes in the vaginal
flora caused by supporting pessary treatment in pregnancy.
Zentralblatt fur Gynakologie 1983;105(13):8557.
Lewitt 1995
Lewitt EM, Baker LS, Corman H, Shiono PH. The direct cost of
low birthweight. The future of children. Los Altos, CA: David and
Lucile Packard Foundation, 1995:3556.
Lo 2009
Lo C. The incompetent cervix. O&G magazine 2009;11(2):302.
Lumley 2003
Lumley J. Defining the problem: the epidemiology of preterm
birth. BJOG: an international journal of obstetrics and gynaecology
2003;110 Suppl 20:37.
McDonald 1957
McDonald IA. Suture of the cervix for inevitable miscarriage.
Journal of Obstetrics and Gynaecology of the British Commonwealth
1957;64:34653.
Newcomer 2000
Newcomer J. Pessaries for the treatment of incompetent cervix and
premature delivery. Obstetrical and Gynecological Survey 2000;55
(7):4438.
Ngoc 2006
Ngoc NT, Merialdi M, Abdel-Aleem H, Carroli G, Purwar M,
Zavaleta N, et al.Causes of stillbirths and early neonatal deaths:

data from 7993 pregnancies in six developing countries. Bulletin of

the World Health Organization 2006;84:699705.
Oster 1966
Oster S, Javert CT. Treatment of the incompetent cervix with
Hodge pessary. Obstetrics & Gynecology 1966;28:2068.
Owen 2004
Owen J, Yost N, Berghella V, MacPherson C, Swain M, Dildy GA
3rd, et al.Can shortened midtrimester cervical length predict very
early spontaneous preterm birth?. American Journal of Obstetrics
and Gynecology 2004;191:298303.
Quaas 1990
Quaas L, Hillemanns HG, du Bois A, Schillinger H. The Arabin
cerclage pessary--an alternative to surgical cerclage. Geburtshilfe und
Frauenheilkunde 1990;50(6):42933.
RevMan 2008
The Nordic Cochrane Centre, The Cochrane Collaboration.
Review Manager (RevMan). 5.0. Copenhagen: The Nordic
Cochrane Centre, The Cochrane Collaboration, 2008.
Rogowski 1999
Rogowski, J. Measuring the cost of neonatal and perinatal care.
Pediatrics 1999;103 (1 Suppl E):32935.
Seyffarth 1978
Seyffarth K. Noninvasive cerclage using support pessaries for
prevention and therapy of premature birth. Zentralblatt fur
Gynakologie 1978;100:156670.
Shirodkar 1955
Shirodkar VN. A new method of operative treatment for habitual
abortions in the second trimester of pregnancy. Antiseptic 1955;52:
299300.
Vitsky 1961
Vitsky M. Simple treatment of the incompetent cervical os.
American Journal of Obstetrics and Gynecology 1961;81:11947.
Vitsky 1968
Vitsky M. Pessary treatment of the incompetent cervical os.
Obstetrics & Gynecology 1968;31:7323.
Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Gmoser 1991
Inadequate reporting about method of randomisation.

Inclusion and exclusion criteria were not defined.
This study was carried out by Gmoser and colleague, conducted in Austria and published in 1991 (Gmoser 1991)
. The investigators compared length of gestation and the weight at birth, between women treated with cervical
pessary versus those with no intervention. The study included 300 cases. They found that the length of gestation
and birth weight were higher in the pessary group compared with no intervention (39 versus 36 weeks and 2950
versus 2400 grams, respectively). They did not reach a solid conclusion from their study (Gmoser 1991).
Von Forster 1986
Using quasi randomisation in the form of initial of the womens surname.

Unclear inclusion and exclusion criteria.
Incomplete outcome data addressed, women were randomised into 3 groups and only 2 groups were
included in the analysis.
The study was carried out by Von Forster and colleagues in Germany. It was a prospective randomised trial
conducted between 1982-1983. In this study, patients were randomised into 3 groups based on the initial letter
of their surname (quasi-randomised). Patients in Group 1 were admitted as in-patients and received cerclage
(n = 112). Those in Group 2 (n = 130) were fitted with a pessary as outpatients. A third group were simply
ordered to rest in bed. The type of pessary used was not mentioned. The therapies were used in patients for
prophylactic as well as therapeutic reasons, although these terms are not defined in the article. However, at the
analysis stage the investigators only analysed the intervention groups because all patients in the rest only group
did need treatment. The results reported that the two groups were equal in the length of pregnancy (mean 37
to 38 weeks), birthweight (mean 3000 gm), Apgar scores, and fetal survival. They investigators concluded that
cerclage and pessary were equally effective in the management of cervical incompetence (Von Forster 1986).
Characteristics of ongoing studies [ordered by study ID]

Moratonas 2007
Trial name or title
Randomised controlled trial: Prevention of preterm birth using cervical pessary in pregnant women with short
cervix (PECEPO).
Methods
Prevention, randomised, single blind (outcome assessor), parallel assessment, efficacy study.
Participants
Eligibility criteria:
Inclusion criteria:
Singleton pregnancy.
Minimal age of 18 years.
Exclusion criteria:
Major fetal abnormalities (requiring surgery or leading to infant death or severe handicap).
SROM at the time of randomisation.
Cervical cerclage in situ.
Active vaginal bleeding.

Moratonas 2007
(Continued)
Previous cone biopsy or cerclage.

Major uterine structural anomalies.
Placenta previa.
Collaborators:
Maternal-Infantil Vall d Hebron Hospital
Hospital Materno-Infantil de Canarias
Hospital Son Llatzer
Institut Universitari Dexeus
Interventions
Silicon Ring (Arabin Pessary).
Outcomes
Primary outcome:
Spontaneous delivery before 34 completed weeks.
Time frame: each 6 months.
Designated as safety issue: no.
Secondary outcomes:
Birthweight, fetal or neonatal death, neonatal morbidity, maternal adverse effects, preterm birth before 37
weeks or 28 weeks, rupture of membranes before 34 weeks, hospitalisation for threatened preterm labour.
Time frame: each 6 months.
Designated as safety issue: no.
Starting date
June 2007.
Contact information
Maria M Goya, MDv Tel: +34-93-489-3185

[email protected]
Contact: Elena Carreras, PhD Tel: +34-93-489-3108
[email protected]
Notes
Contact: Elena Carreras, PhD.
Nicolaides 2008
Trial name or title
Randomised study of pessary vs standard management in women with increased chance of premature birth.
Methods
Multicentre, randomised, open label.
Participants
Women with singleton pregnancies and with a cervical length of 25 mm or less.

Women with twin pregnancies.
Interventions
Vaginal pessary (CE0482, MED/CERT ISO 9003 / EN 46003) versus standard management.
Outcomes
Primary outcome:
Spontaneous delivery from randomisation to 33 weeks and 6 days (237 days) of gestation.
Seconday outcomes:
low birth weight;
fetal or neonatal death;
major adverse outcomes (IVH, RDS, retinopathy of prematurity or necrotising enterocolitis);
need for neonatal special care (ventilation, phototherapy, treatment for sepsis, blood transfusion).

10
Nicolaides 2008
(Continued)
Starting date
August 2008
Contact information
Kypros Nicolaides, Professor

tel: +442032999000 ext.: 8256
[email protected]
Notes
ISRCTN01096902
Nizard 2007
Trial name or title
Evaluation of pessaries in twin pregnancies with a short cervix (25 mm) between 20-28 WG.
Methods
Randomised, open multicentric study.
Participants
Interventions
Device: Silicon ring positioned in the vagina, around the cervix versus control.
Outcomes
Primary outcome:
demonstrate the profit of at least 10 days in the pessary group compared to control.
Secondary outcomes:
evaluate and compare the frequency of the childbirth < 34 SA before 34 weeks;
deliveries (<34WG) 34 weeks;
evaluate the rate of side effects of pessaries during the pessaries;
neonatal outcome before 28 weeks.
Starting date
June 2007
Contact information
Jacky Nizard
Hopital POISSY-ST GERMAIN EN LAYE
Poissy
78300
Status: Recruiting
Contact: Jacky NIZARD, CCA
tel: +33(0) 1 39 27 40 50
[email protected]
Notes
NCT00502190
IVH: Intra-ventricular hemorrhage

RDS: Respiratory distress syndrome
SROM: Spontaneous rupture of membranes

11
DATA AND ANALYSES

This review has no analyses.
APPENDICES
Appendix 1. Methods to be used in future updates of this review
Selection of studies
Two review authors will independently assess studies identified by the search. We will resolve disagreements through discussion with
the third review author.
Data extraction and management
We will design a form to extract data. For eligible studies, at least two review authors will extract the data using the agreed form. We
will resolve discrepancies through discussion or, if required, we will consult the third review author. We will enter data into Review
Manager software (RevMan 2008) and check for accuracy.
When information regarding any of the above is unclear, we will attempt to contact authors of the original reports to provide further
details.
Assessment of risk of bias in included studies
At least two review authors will independently assess risk of bias for each study using the criteria outlined in the Cochrane Handbook
for Systematic Reviews of Interventions (Higgins 2009). We will resolve any disagreement by discussion or by involving the third review
author.
(1) Sequence generation (checking for possible selection bias)

We will describe for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment
of whether it should produce comparable groups.
We will assess the method as:
adequate (any truly random process, e.g. random number table; computer random number generator);
inadequate (any non-random process, e.g. odd or even date of birth; hospital or clinic record number);
unclear.
(2) Allocation concealment (checking for possible selection bias)
We will describe for each included study the method used to conceal the allocation sequence and determine whether intervention
allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.
We will assess the methods as:
adequate (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);
inadequate (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth);
unclear.
12
(3) Blinding (checking for possible performance bias)

We will describe for each included study the methods used, if any, to blind study participants and personnel from knowledge of which
intervention a participant received. We will consider that studies are at low risk of bias if they were blinded, or if we judge that the lack
of blinding could not have affected the results. We will assess blinding separately for different outcomes or classes of outcomes.
adequate, inadequate or unclear for participants;
adequate, inadequate or unclear for personnel;
adequate, inadequate or unclear for outcome assessors.
(4) Incomplete outcome data (checking for possible attrition bias through withdrawals, dropouts, protocol deviations)
We will describe for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and
exclusions from the analysis. We will state whether attrition and exclusions were reported, the numbers included in the analysis at each
stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data
were balanced across groups or were related to outcomes. Where sufficient information is reported, or can be supplied by the trial
authors, we will re-include missing data in the analyses which we undertake.
We will assess methods as:
adequate;
inadequate;
unclear.
(5) Selective reporting bias
We will describe for each included study how we investigated the possibility of selective outcome reporting bias and what we found.
adequate (where it is clear that all of the studys prespecified outcomes and all expected outcomes of interest to the review have
been reported);
inadequate (where not all the studys prespecified outcomes have been reported; one or more reported primary outcomes were
not prespecified; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome
that would have been expected to have been reported);
unclear.
(6) Other sources of bias
We will describe for each included study any important concerns we have about other possible sources of bias.
We will assess whether each study was free of other problems that could put it at risk of bias:
yes;
no;
unclear.
(7) Overall risk of bias
We will make explicit judgements about whether studies are at high risk of bias, according to the criteria given in the Handbook (Higgins
2009). With reference to (1) to (6) above, we will assess the likely magnitude and direction of the bias and whether we consider it is
likely to impact on the findings. We will explore the impact of the level of bias through undertaking sensitivity analyses - see Sensitivity
analysis.
Measures of treatment effect
Dichotomous data
For dichotomous data, we will present results as summary risk ratio with 95% confidence intervals.

13
Continuous data
For continuous data, we will use the mean difference if outcomes are measured in the same way between trials. We will use the
standardised mean difference to combine trials that measure the same outcome, but use different methods.
Dealing with missing data
For included studies, we will note levels of attrition. We will explore the impact of including studies with high levels of missing data in
the overall assessment of treatment effect by using sensitivity analysis.
For all outcomes, we will carry out analyses, as far as possible, on an intention-to-treat basis, i.e. we will attempt to include all participants
randomised to each group in the analyses, and analyse all participants in the group to which they were allocated, regardless of whether
or not they received the allocated intervention. The denominator for each outcome in each trial will be the number randomised minus
any participants whose outcomes are known to be missing.
Assessment of heterogeneity
We will assess statistical heterogeneity in each meta-analysis using the T, I and Chi statistics. We will regard heterogeneity as
substantial if T is greater than zero and either I is greater than 30% or there is a low P-value (less than 0.10) in the Chi test for
heterogeneity.
Assessment of reporting biases
If there are 10 or more studies in the meta-analysis we will investigate reporting biases (such as publication bias) using funnel plots. We
will assess funnel plot asymmetry visually, and use formal tests for funnel plot asymmetry. For continuous outcomes we will use the
test proposed by Egger 1997, and for dichotomous outcomes we will use the test proposed by Harbord 2006. If we detect asymmetry
in any of these tests or by a visual assessment, we will perform exploratory analyses to investigate it.
Data synthesis
We will carry out statistical analysis using the Review Manager software (RevMan 2008). We will use fixed-effect meta-analysis for
combining data where it is reasonable to assume that studies are estimating the same underlying treatment effect: i.e. where trials are
examining the same intervention, and the trials populations and methods are judged sufficiently similar. If there is clinical heterogeneity
sufficient to expect that the underlying treatment effects differ between trials, or if we detect substantial statistical heterogeneity, we
will use random-effects meta-analysis to produce an overall summary if an average treatment effect across trials is considered clinically
meaningful. We will treat the random-effects summary as the average range of possible treatment effects and we will discuss the clinical
implications of treatment effects differing among trials. If the average treatment effect is not clinically meaningful we will not combine
trials.
If we use random-effects analyses, we will present the results as the average treatment effect with its 95% confidence interval, and the
estimates of T and I.
Subgroup analysis and investigation of heterogeneity
If we identify substantial heterogeneity, we will investigate it using subgroup analyses and sensitivity analyses. We will consider whether
an overall summary is meaningful, and if it is, use random-effects analysis to produce it.
If cervical pessary is proved to be effective in preventing preterm birth in any update, we plan to carry out subgroup analyses to define
the group of patients who will benefit from this intervention (participants will be subgrouped according to obstetric, clinical and
ultrasound risk factors for cervical incompetence to see which group of patients will be benefited more from this intervention).
We will use the following outcomes in subgroup analysis: deliver at less than 37 weeks gestation.
For fixed-effect inverse variance meta-analyses we will assess differences between subgroups by interaction tests. For random-effects and
fixed-effect meta-analyses using methods other than inverse variance, we will assess differences between subgroups by inspection of the
subgroups confidence intervals; non-overlapping confidence intervals indicate a statistically significant difference in treatment effect
between the subgroups.

14
Sensitivity analysis
We will perform sensitivity analyses for aspects of the review that might affect the results; for example, where there is risk of bias
associated with the quality of some of the included trials or to explore the effects of fixed- or random-effects analyses for outcomes with
statistical heterogeneity.
Appendix 2. Searching trials registry websites

We searched Current controlled trials and Australian and New Zealand Clinical Trials Registry (December 2009), using the terms
pessary or pessaries.
HISTORY
Protocol first published: Issue 3, 2009
Review first published: Issue 9, 2010
CONTRIBUTIONS OF AUTHORS
Hany Abdel-Aleem is the guarantor of the review. He is responsible for conceiving the review; designing and co-ordinating the review.
Omar M Shaaban wrote the first draft of the protocol, assessed the trials retrieved from the search and sharing in writing the final
version of the review. Mahmoud Abdel-Aleem participated in reviewing the protocol, assessment of the trials retrieved from the search
and sharing in reviewing the final version of the review.
DECLARATIONS OF INTEREST
None known.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

We have updated the methods section in accordance with current guidelines. We searched the data bases for registering clinical trials,
to identify ongoing trials.
INDEX TERMS
Medical Subject Headings (MeSH)
Pessaries; Premature Birth [ prevention & control]
MeSH check words

Female; Humans; Pregnancy

15

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