title: Effectiveness of progesterone, cerclage and pessary for preventing preterm birth in singleton pregnancies: a systematic review and network meta-analysis.
abstract: BACKGROUND
  Preterm birth (PTB) is the leading cause of infant death, but it is unclear which intervention is best to prevent it.
  
  
  OBJECTIVE
  To compare progesterone, cerclage and pessary, determine their relative effects and rank them.
  
  
  METHODS
  We searched Medline, EMBASE, CINAHL, Cochrane CENTRAL and Web of Science (to April 2016), without restrictions, and screened references of previous reviews.
  
  
  METHODS
  We included randomised trials of progesterone, cerclage or pessary for preventing PTB in women with singleton pregnancies at risk as defined by each study.
  
  
  METHODS
  We extracted data by duplicate using a piloted form and performed Bayesian random-effects network meta-analyses and pairwise meta-analyses. We rated evidence quality using GRADE, ranked interventions using SUCRA and calculated numbers needed to treat (NNT).
  
  
  RESULTS
  We included 36 trials (9425 women; 25 low risk of bias trials). Progesterone ranked first or second for most outcomes, reducing PTB < 34 weeks [odds ratio (OR) 0.44; 95% credible interval (CrI) 0.22-0.79; NNT 9; low quality], <37 weeks (OR 0.58; 95% CrI 0.41-0.79; NNT 9; moderate quality), and neonatal death (OR 0.50; 95% CrI 0.28-0.85; NNT 35; high quality), compared with control, in women overall at risk. We found similar results in the subgroup with previous PTB, but only a reduction of PTB < 34 weeks in women with a short cervix. Pessary showed inconsistent benefit and cerclage did not reduce PTB < 37 or <34 weeks.
  
  
  CONCLUSIONS
  Progesterone was the best intervention for preventing PTB in singleton pregnancies at risk, reducing PTB < 34 weeks, <37 weeks, neonatal demise and other sequelae.
  
  
  CONCLUSIONS
  Progesterone was better than cerclage and pessary to prevent preterm birth, neonatal death and more in network meta-analysis.
authors.affiliation: Department of Obstetrics and Gynaecology, McMaster University, Hamilton, ON, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Jarde
authors.affiliation: Department of Obstetrics and Gynaecology, McMaster University, Hamilton, ON, Canada.
authors.forename: O
authors.initials: O
authors.lastname: Lutsiv
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: C K
authors.initials: CK
authors.lastname: Park
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Beyene
authors.affiliation: Department of Obstetrics and Gynaecology, University of Adelaide, Adelaide, SA, Australia.
authors.forename: J M
authors.initials: JM
authors.lastname: Dodd
authors.affiliation: Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Barrett
authors.affiliation: Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
authors.forename: P S
authors.initials: PS
authors.lastname: Shah
authors.affiliation: The Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON, Canada.|Department of Obstetrics and Gynaecology, University of Ottawa, Ottawa, ON, Canada.
authors.forename: J L
authors.initials: JL
authors.lastname: Cook
authors.affiliation: Department of Obstetrics and Gynaecology, University of Toyama, Toyama, Japan.
authors.forename: S
authors.initials: S
authors.lastname: Saito
authors.affiliation: Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: A B
authors.initials: AB
authors.lastname: Biringer
authors.affiliation: Midwifery Education Program, McMaster University, Hamilton, ON, Canada.
authors.forename: L
authors.initials: L
authors.lastname: Sabatino
authors.affiliation: Department of Paediatrics, McMaster University, Hamilton, ON, Canada.
authors.forename: L
authors.initials: L
authors.lastname: Giglia
authors.affiliation: The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China.
authors.forename: Z
authors.initials: Z
authors.lastname: Han
authors.affiliation: Canadian Premature Babies Foundation, Sherwood Park, AB, Canada.
authors.forename: K
authors.initials: K
authors.lastname: Staub
authors.affiliation: Maternal Fetal Medicine Clinic, Windsor Regional Hospital, Windsor, ON, Canada.
authors.forename: W
authors.initials: W
authors.lastname: Mundle
authors.affiliation: Save the Mothers, Uganda Christian University, Mukono, Uganda.
authors.forename: J
authors.initials: J
authors.lastname: Chamberlain
authors.affiliation: Department of Obstetrics and Gynaecology, McMaster University, Hamilton, ON, Canada.
authors.forename: S D
authors.initials: SD
authors.lastname: McDonald
mesh_terms: D000282:Administration, Intravaginal; D000328:Adult; D001499:Bayes Theorem; D023802:Cerclage, Cervical / Q000706:statistics & numerical data*; D005260:Female; D005865:Gestational Age; D006801:Humans; D007231:Infant, Newborn; D010570:Pessaries / Q000706:statistics & numerical data*; D011247:Pregnancy; D047928:Premature Birth / Q000453:epidemiology / Q000517:prevention & control*; D011374:Progesterone / Q000008:administration & dosage*; D011372:Progestins / Q000008:administration & dosage*; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D011372:Progestins; D011374:Progesterone
keywords: Cervical cerclage; cervical pessary; network meta-analysis; preterm birth; progesterone; systematic review