{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,7]],"date-time":"2025-11-07T18:42:16Z","timestamp":1762540936214,"version":"build-2065373602"},"reference-count":29,"publisher":"Public Library of Science (PLoS)","issue":"11","license":[{"start":{"date-parts":[[2025,11,7]],"date-time":"2025-11-07T00:00:00Z","timestamp":1762473600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Spontaneous preterm birth (sPTB) occurs in 0.5\u20131% of pregnant women and is commonly attributed to cervical insufficiency. Cervical cerclage can reduce the rate of spontaneous preterm birth in high-risk women with a shortened cervix. Management options when primary cerclage fails are uncertain. This review aims to synthesise the evidence for repeat cervical cerclage in the same pregnancy following primary cerclage failure, to understand outcomes and aid decision making for patients and clinicians.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Materials and methods<\/jats:title>\n                    <jats:p>Databases were searched according to a prospective protocol registered with PROSPERO (CRD42025638147). Included studies reported outcomes for pregnant women with a cervical cerclage in situ that failed and compared repeat cervical cerclage with expectant management. The primary outcome was a composite outcome of pregnancy loss; to include miscarriage, stillbirth, neonatal death and termination of pregnancy. Secondary outcomes included preterm birth less than 37 and less than 34 weeks, miscarriage and previable neonatal death less than 24 weeks, birthweight and gestational age at delivery. Random effects meta-analysis was performed using Review Manager software (RevMan) and risk of bias was assessed using the Robins-I tool.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Database and citation searching retrieved 1006 titles and abstracts. There were 20 papers that underwent full text review. Six retrospective cohort studies met inclusion criteria for meta-analysis. There was no significant difference in pregnancy loss (odds ratio (OR) 1.65, 95% confidence interval (CI) 0.23\u201311.62), preterm birth less than 34 weeks (OR 1.11 95% CI 0.14\u20138.70) or preterm birth less than 37 weeks (OR 1.88 95% CI 0.74\u20134.80) for repeat cervical cerclage compared to expectant management, with a trend towards improved outcomes with expectant management.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>There was no evidence of any difference in pregnancy loss or preterm birth with or without repeat cervical cerclage. The overall quality and quantity of evidence is poor and patients should be informed of this. Further research in this area is required for informed decision making.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0329427","type":"journal-article","created":{"date-parts":[[2025,11,7]],"date-time":"2025-11-07T18:29:06Z","timestamp":1762540146000},"page":"e0329427","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Should a repeat cervical cerclage be inserted when the primary cerclage fails, to prevent pregnancy loss and preterm birth? A systematic review and meta-analysis"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1804-1882","authenticated-orcid":true,"given":"Alexandra","family":"Emms","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-6593-9623","authenticated-orcid":true,"given":"Matthew","family":"Vaughan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0983-7590","authenticated-orcid":true,"given":"Rebecca","family":"Man","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1247-429X","authenticated-orcid":true,"given":"R. Katie","family":"Morris","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9817-4313","authenticated-orcid":true,"given":"Victoria","family":"Hodgetts-Morton","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicole","family":"Pilarksi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2025,11,7]]},"reference":[{"issue":"10409","key":"pone.0329427.ref001","doi-asserted-by":"crossref","first-page":"1261","DOI":"10.1016\/S0140-6736(23)00878-4","article-title":"National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis","volume":"402","author":"EO Ohuma","year":"2023","journal-title":"Lancet"},{"issue":"10361","key":"pone.0329427.ref002","doi-asserted-by":"crossref","first-page":"1426","DOI":"10.1016\/S0140-6736(22)01808-6","article-title":"Monofilament suture versus braided suture thread to improve pregnancy outcomes after vaginal cervical cerclage (C-STICH): a pragmatic randomised, controlled, phase 3, superiority trial","volume":"400","author":"V Hodgetts Morton","year":"2022","journal-title":"Lancet"},{"issue":"4","key":"pone.0329427.ref003","doi-asserted-by":"crossref","DOI":"10.1016\/j.ajog.2009.08.015","article-title":"Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length","volume":"201","author":"J Owen","year":"2009","journal-title":"Am J Obstet Gynecol"},{"issue":"6","key":"pone.0329427.ref004","article-title":"Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy","volume":"6","author":"Z Alfirevic","year":"2017","journal-title":"Cochrane Database Syst Rev"},{"key":"pone.0329427.ref005","volume-title":"Preterm Labour and Birth","author":"Excellence NIfHaC","year":"2022"},{"issue":"7","key":"pone.0329427.ref006","doi-asserted-by":"crossref","first-page":"1178","DOI":"10.1111\/1471-0528.17003","article-title":"Cervical cerclage","volume":"129","author":"Royal College of Obstetricians G","year":"2022","journal-title":"BJOG: An International Journal of Obstetrics & Gynaecology"},{"issue":"4","key":"pone.0329427.ref007","doi-asserted-by":"crossref","first-page":"102286","DOI":"10.1016\/j.jogc.2023.102286","article-title":"Short cervix following initial cerclage-reinforcing cerclage versus expectant management","volume":"46","author":"L Clarfield","year":"2024","journal-title":"J Obstet Gynaecol Can"},{"key":"pone.0329427.ref008","article-title":"Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement","volume":"339","author":"PRISMA Group","year":"2009","journal-title":"BMJ"},{"key":"pone.0329427.ref009","article-title":"The PRISMA 2020 statement: an updated guideline for reporting systematic reviews","volume":"372","author":"MJ Page","year":"2021","journal-title":"BMJ"},{"key":"pone.0329427.ref010","unstructured":"Emms A PN, Vaughan M, Hodgetts-Morton V. Pregnancy loss rate and perinatal outcomes in women with repeat cervical cerclage, following failure of the primary cerclage, compared with expectant management: a systematic review and meta-analysis PROSPERO. 2024. https:\/\/www.crd.york.ac.uk\/PROSPERO\/view\/CRD42025638147"},{"issue":"1","key":"pone.0329427.ref011","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1097\/AOG.0000000000001195","article-title":"A Core Outcome Set for Evaluation of Interventions to Prevent Preterm Birth","volume":"127","author":"J van \u2019t Hooft","year":"2016","journal-title":"Obstet Gynecol"},{"key":"pone.0329427.ref012","article-title":"ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions","volume":"355","author":"JA Sterne","year":"2016","journal-title":"BMJ"},{"key":"pone.0329427.ref013","article-title":"Completing \u2018summary of findings\u2019 tables and grading the certainty of the evidence.","volume-title":"Cochrane Handbook for Systematic Reviews of 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Methodol"},{"key":"pone.0329427.ref017","article-title":"Analyses data and undertaking meta-analyses.","volume-title":"Cochrane Handbook for Systematic Reviews of Interventions version 65","author":"HJ Sch\u00fcnemann","year":"2024"},{"key":"pone.0329427.ref018","doi-asserted-by":"crossref","first-page":"1204","DOI":"10.1016\/j.ajog.2005.06.076","article-title":"Short cervical length after history-indicated cerclage: is a reinforcing cerclage beneficial?","volume":"193","author":"JK Baxter","year":"2005","journal-title":"Am J Obstet Gynecol"},{"issue":"15","key":"pone.0329427.ref019","doi-asserted-by":"crossref","first-page":"2423","DOI":"10.3109\/14767058.2015.1086740","article-title":"Reinforcing cerclage for a short cervix at follow-up after the primary cerclage procedure","volume":"29","author":"SA Contag","year":"2016","journal-title":"J Matern Fetal Neonatal 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Gynecol MFM"},{"issue":"1","key":"pone.0329427.ref023","doi-asserted-by":"crossref","first-page":"343","DOI":"10.1002\/ijgo.15210","article-title":"Perinatal outcomes in patients undergoing repeat cerclage: A retrospective case series study","volume":"165","author":"P Ru","year":"2024","journal-title":"Int J Gynaecol Obstet"},{"key":"pone.0329427.ref024","doi-asserted-by":"crossref","first-page":"1248321","DOI":"10.3389\/fmed.2023.1248321","article-title":"Postoperative cervical length to predict success of repeat cerclage in singleton pregnancies with prolapsed membranes after prior cerclage","volume":"10","author":"S Park","year":"2023","journal-title":"Front Med (Lausanne)"},{"issue":"3","key":"pone.0329427.ref025","doi-asserted-by":"crossref","DOI":"10.1016\/j.ajog.2016.04.027","article-title":"The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention","volume":"215","author":"J McIntosh","year":"2016","journal-title":"Am J 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