BACKGROUND AND PURPOSE:

• Conde-Agudelo et al. (AJOG, 2020) sought to determine the efficacy and safety of cervical pessary to prevent preterm birth and adverse perinatal outcomes in asymptomatic high-risk women

METHODS:

• Systematic review and meta-analysis
• Inclusion criteria
  • RCTs
  • Studies that compared cervical pessary with
    • Standard care (no pessary)
    • Alternative interventions (e.g., vaginal progesterone or cervical cerclage)  
• Participants
  • Asymptomatic
  • High risk for preterm birth (e.g., midtrimester sonographic short cervix, history of preterm birth, multiple gestation, and uterine anomalies or excisional cervical procedures)
• Study design and data analysis
  • Systematic review was conducted in accordance with Cochrane Handbook guidelines
  • Pooled relative risks with 95% confidence intervals were calculated
  • Quality of evidence was assessed using GRADE criteria
• Primary outcome
  • Spontaneous preterm birth <34 weeks of gestation
• Secondary outcomes
  • Adverse pregnancy, maternal, and perinatal outcomes

RESULTS:

• 12 studies | 4687 women | 7167 fetuses/infants
  • 8 evaluated pessary vs no pessary in women with short cervix
  • 2 assessed pessary vs no pessary in unselected multiple gestations
  • 2 compared pessary vs vaginal progesterone in women with short cervix
• No significant differences were observed between the pessary and no pessary groups in
  • Preterm birth <37, <32, and <28 weeks of gestation
  • Most adverse pregnancy, maternal, and perinatal outcomes
• There were no significant differences between the pessary and no pessary groups for the following
  • Spontaneous preterm birth <34 weeks among singleton gestations with cervical length ≤ 25 mm
    • Relative risk (RR) 0.80 (95% CI, 0.43 to 1.49)
    • 6 trials | 1982 women
    • Low-quality evidence
  • Unselected twin gestations
    • RR 1.05 (95% CI, 0.79 to 1.41)
    • 1 trial | 1177 women
    • Moderate-quality evidence
  • Twin gestations with cervical length <38 mm
    • RR 0.75 (95% CI, 0.41 to 1.36)
    • 1 trial | 1177 women
    • Moderate-quality evidence
  • Twin gestations with cervical length ≤25 mm
    • RR 0.72 (95% Cl, 0.25 to 2.06)
    • 2 trials | 348 women
    • Low-quality evidence
• There were also no significant differences in the risk of spontaneous preterm birth <34 weeks of gestation between pessary and vaginal progesterone
  • Singleton gestations with a cervical length ≤25 mm
    • RR 0.99 (95% CI, 0.54 to 1.83)
    • 1 trial | 246 women
    • Low-quality evidence
  • Twin gestations with a cervical length <38 mm
    • RR 0.73 (95% CI | 0.46 to 1.18)
    • 1 trial, 297 women
    • Very low-quality evidence
• Pessary was associated with an increased risk for the following
  • Vaginal discharge: RR 2.15 (95% CI, 1.67 to 2.78)
  • Pelvic discomfort: RR 3.28 (95% CI, 1.96 to 5.50
  • High quality evidence

CONCLUSION:

• Cervical pessary did not prevent preterm birth or improve perinatal outcomes in asymptomatic high-risk pregnancies
• The authors point that there are ongoing studies that may impact the results of this current meta-analysis
• The authors summarize the current available literature as follows

Current evidence does not support the use of cervical pessary to prevent preterm birth or to improve perinatal outcomes in singleton or twin gestations with a short cervix and in unselected twin gestations

Learn More – Primary Sources:

Cervical pessary to prevent preterm birth in asymptomatic high-risk women: a systematic review and meta-analysis

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