Pericerclage tocolytics, antibiotics, or their combination and risk of preterm birth: a systematic review and meta-analysis

Abstract

OBJECTIVE

To evaluate whether adjunctive pericerclage therapy with tocolytics, antibiotics, or combination therapy is associated with reduced preterm birth (PTB) and improved maternal and neonatal outcomes according to therapy type and cerclage indication.

DATA SOURCES

A systematic search of PubMed, Scopus, MEDLINE, and CENTRAL was conducted from database inception through March 4, 2026.

STUDY ELIGIBILITY CRITERIA

Randomized and nonrandomized controlled studies evaluating singleton or twin pregnancies undergoing transvaginal cervical cerclage were included. Eligible studies compared perioperative adjunctive therapy, including tocolytics, antibiotics, or both, administered within 24 hours before, during, or within 48 hours after cerclage placement, with cerclage without adjunctive therapy. Studies involving transabdominal cerclage, higher-order multifetal gestations, or nonextractable cerclage-specific data were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

Risk of bias was assessed using RoB-2 and ROBINS-I tools. Random-effects meta-analyses with restricted maximum likelihood estimation were performed to calculate pooled odds ratios (OR) and mean differences with 95% confidence intervals (CIs). The primary analysis compared any adjunctive pericerclage therapy vs no adjunctive therapy. Prespecified subgroup analyses were conducted according to adjunctive therapy type (tocolytics and antibiotics alone or in combination) and cerclage indication, including ultrasound-indicated cerclage (UIC) and physical examination-indicated cerclage (PEIC). The primary outcome was PTB<37 weeks of gestation.

RESULTS

Seven studies met inclusion criteria, and 6 were included in the quantitative analysis, involving 878 patients. Adjunctive pericerclage therapy was not associated with reduced PTB<37 weeks compared with cerclage alone (OR 0.92; 95% CI 0.65–1.31). No significant differences were observed for PTB<32, <28, or <24 weeks, gestational age at delivery, gestational latency, chorioamnionitis, preterm premature rupture of membranes, birthweight, or neonatal survival. Similarly, subgroup analyses according to therapy type, including tocolytics alone, antibiotics alone, and combination therapy, similarly showed no significant effect. In the UIC subgroup, no association between adjunctive therapy and PTB<37 weeks was observed (OR, 1.14; 95% CI, 0.71–1.85). In the PEIC subgroup, adjunctive therapy was associated with a nonsignificant trend toward reduced PTB<37 weeks (OR, 0.72; 95% CI, 0.43–1.21), PTB<28 weeks (OR, 0.70; 95% CI, 0.37–1.34), and PTB<24 weeks (OR, 0.44; 95% CI, 0.18–1.08), as well a longer (by >1 week) latency.

CONCLUSION

Adjunctive pericerclage therapy with tocolysis and/or antibiotics was not associated with reduced PTB or improved maternal and neonatal outcomes. Indication-specific analyses did not demonstrate a significant benefit in either UIC or PEIC. Point estimates for several outcomes favored adjunctive therapy in the PEIC subgroup; however, these findings are exploratory and should be interpreted cautiously. Further adequately powered, indication-specific studies are needed.