Abstract
Background: The rate of prematurity in twin pregnancies is higher than 50%. Due to its multifactorial nature, different strategies are necessary to reduce the incidence of premature birth or to increase the gestational age at birth of pregnancies at risk. In this context, cervical pessary may be indicated in twin pregnancies with short cervix. Methods: In this case series, we describe six twin pregnancies that were considered as high-risk for preterm labor due to short cervix (CL < 30 mm) at second trimester and multiple risk factors for prematurity. Several strategies were associated for the goal of delaying gestational age at birth. The main strategies were: removal of labor activities, treatment of infections, vaginal micronized progesterone 400 mg/day and vaginal pessary insertion (Ingamed® Brazil). Results: The gestational age of insertion of the pessary ranged from 16 to 24 weeks. The gestational age of birth ranged from 26 to 34 weeks. Three of the pregnancies were delivered due to spontaneous onset of labor, and three were delivered due to medical reasons. The mean length of pregnancy since pessary insertion to birth was 9 weeks (range 2 to 17 weeks). All infants without severe fetal malformation were discharged from the hospital without major sequelae. Conclusion: The use of cervical pessaries associated to micronized progesterone at a dose of 400 mg/day may be an option in the management of twins at risk for preterm birth. More controlled studies are needed to evaluate the simultaneous use of cervical pessary and progesterone on twin pregnancies.
Highlights
The number of twin births has increased in recent years [1]
In this case series, we describe six twin pregnancies that were considered as high-risk for preterm labor due to short cervix (CL < 30 mm) at second trimester and multiple risk factors for prematurity
The risk of preterm delivery is inversely related to cervical length (CL) assessed at 22 - 26 weeks of gestation, and a CL ≤ 25 mm is associated with 28% risk for birth before 28 weeks [2] [3]
Summary
The number of twin births has increased in recent years [1]. About 50% of these are born before 37 weeks, which implies important fetal morbidity and mortality. One of the several factors which increase preterm birth is the presence of short cervix. Shortening of the cervical length (CL) is a predictor of preterm birth in singleton and twin pregnancies. The risk of preterm delivery is inversely related to cervical length (CL) assessed at 22 - 26 weeks of gestation, and a CL ≤ 25 mm is associated with 28% risk for birth before 28 weeks [2] [3]. The cut-off measure to classify a cervix as short in the second trimester is controversial for twin pregnancies. There are different strategies to manage twin pregnancies with short cervix (TPSC), most of them with no proven effectiveness. A randomized study associated the use of cervical pessary in twin pregnancies of mothers with a short cervix with significant reduction of prematurity [9]. In other recent meta-analysis, intravaginal progesterone 400 mg/day was more effective than in the doses of 100 or 200 mg in cases of TPSC [11]
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