Cervical Cerclage In Twin Pregnancies Research Articles

The effectiveness of cervical cerclage in twin pregnancies with a mid-trimester short cervix: A retrospective cohort study

ObjectiveTo analyze the effectiveness of cerclage in twin pregnancies with a short cervix. Study designRetrospective cohort study performed in two University Institutions in Valencia (Spain) with two different protocols for the management of asymptomatic dichorionic diamniotic twin pregnancies with mid-trimester cervical length ≤ 25 mm: treatment with indomethacin, antibiotics and cerclage (cerclage group) (N = 43) versus expectant management (control group) (N = 37). ResultsThe initial cervical length was similar in both groups but detection of a short cervix was performed earlier in the cerclage group (21.6 vs 24.1 weeks, p < 0.001). Women with cerclage had a greater pregnancy latency (12.5 vs. 7.7 weeks, p < 0.001); higher gestational age at delivery (34.1 vs. 31.8 weeks, p < 0.04); less spontaneous preterm birth (SPB) < 28 weeks (11.6 % vs 37.8 %, p < 0.009); higher birthweight (2145 vs 1733 g, p < 0.001); lower birthweight < 1500 g (12.5 % vs 40.0 %, p < 0.001); less admissions to the neonatal intensive care unit (NICU) (24.1 % vs 43.3 %, p < 0.03); shorter stay at NICU (25.6 vs 49.4 days, p < 0.02); lower respiratory distress requiring mechanical ventilation (14.9 % vs 36.5 %, p < 0.02); fewer patent ductus arteriosus (8.9 % vs 26.9 %, p < 0.008); and lower composite adverse neonatal outcome (26.6 % vs. 44.8 %, p < 0.03). Cerclage and gestational age at diagnosis were the only independent predictors of SPB < 32 and < 28 weeks by multivariate analysis. The cumulative data in the literature show promising beneficial effects of cerclage. ConclusionOur data suggest that cerclage in asymptomatic twin pregnancies with a short cervix may reduce the earliest SPB and may improve neonatal outcome.

Cervical cerclage for prevention of preterm birth and adverse perinatal outcome in twin pregnancies with short cervical length or cervical dilatation: A systematic review and meta-analysis.

The optimal approach to prevent preterm birth (PTB) in twins has not been fully established yet. Recent evidence suggests that placement of cervical cerclage in twin pregnancies with short cervical length at ultrasound or cervical dilatation at physical examination might be associated with a reduced risk of PTB. However, such evidence is based mainly on small studies thus questioning the robustness of these findings. The aim of this systematic review was to determine the role of cervical cerclage in preventing PTB and adverse maternal or perinatal outcomes in twin pregnancies. Key databases searched and date of last search: MEDLINE, Embase, and CINAHL were searched electronically on 20 April 2023. Eligibility criteria: Inclusion criteria were observational studies assessing the risk of PTB among twin pregnancies undergoing cerclage versus no cerclage and randomized trials in which twin pregnancies were allocated to cerclage for the prevention of PTB or to a control group (e.g., placebo or treatment as usual). The primary outcome was PTB <34 weeks of gestation. The secondary outcomes were PTB <37, 32, 28, 24 weeks of gestation, gestational age at birth, the interval between diagnosis and birth, preterm prelabor rupture of the membranes (pPROM), chorioamnionitis, perinatal loss, and perinatal morbidity. Subgroup analyses according to the indication for cerclage (short cervical length or cervical dilatation) were also performed. Risk of bias assessment: The risk of bias of the included randomized controlled trials (RCTs) was assessed using the Revised Cochrane risk-of-bias tool for randomized trials, while that of the observational studies using the Newcastle-Ottawa scale (NOS). Statistical analysis: Summary risk ratios (RRs) of the likelihood of detecting each categorical outcome in exposed versus unexposed women, and (b) summary mean differences (MDs) between exposed and unexposed women (for each continuous outcome), with their 95% confidence intervals (CIs) were computed using head-to-head meta-analyses. Synthesis of the results: Eighteen studies (1,465 twin pregnancies) were included. Placement of cervical cerclage in women with a twin pregnancy with a short cervix at ultrasound or cervical dilatation at physical examination was associated with a reduced risk of PTB <34 weeks of gestation (RR: 0.73, 95% CI [0.59, 0.91], p = 0.005 corresponding to a 16% difference in the absolute risk, AR), <32 (RR: 0.69, 95% CI [0.57, 0.84], p < 0.001; AR: 16.92%), <28 (RR: 0.54, 95% [CI 0.43, 0.67], 0.001; AR: 18.29%), and <24 (RR: 0.48, 95% CI [0.23, 0.97], p = 0.04; AR: 15.57%) weeks of gestation and a prolonged gestational age at birth (MD: 2.32 weeks, 95% [CI 0.99, 3.66], p < 0.001). Cerclage in twin pregnancy with short cervical length or cervical dilatation was also associated with a reduced risk of perinatal loss (RR: 0.38, 95% CI [0.25, 0.60], p < 0.001; AR: 19.62%) and composite adverse outcome (RR: 0.69, 95% CI [0.53, 0.90], p = 0.007; AR: 11.75%). Cervical cerclage was associated with a reduced risk of PTB <34 weeks both in women with cervical length <15 mm (RR: 0.74, 95% CI [0.58, 0.95], p = 0.02; AR: 29.17%) and in those with cervical dilatation (RR: 0.68, 95% CI [0.57, 0.80], p < 0.001; AR: 35.02%). The association between cerclage and prevention of PTB and adverse perinatal outcomes was exclusively due to the inclusion of observational studies. The quality of retrieved evidence at GRADE assessment was low. Emergency cerclage for cervical dilation or short cervical length <15 mm may be potentially associated with a reduction in PTB and improved perinatal outcomes. However, these findings are mainly based upon observational studies and require confirmation in large and adequately powered RCTs.

Efficacy of emergency cervical cerclage in twin pregnancies and factors affecting the clinical effects of emergency cerclage

Objectives To estimate clinical effects of emergency cervical cerclage in twin pregnancies with cervical dilation ≥1.0 cm in mid-trimester of gestation and to identify risk factors after cerclage. Methods This retrospective cohort study included 99 twin pregnancies with cervical dilation ≥1cm in the mid-trimester of gestation at three institutions, from December 2015 through December 2021. The cases were treated with emergency cervical cerclage (52 cases) or expectant management (47 cases). Compare the pregnancy and neonatal outcomes of the two groups. Multiple logistic regression analysis was used to determine the independent risk factors associated with cerclage. Results Cerclage placement was associated with significantly longer gestation age and prolongation of the gestational latency (p < .05). In the cases, compared to expectant treatments, spontaneous preterm birth (sPTB) at <26, <28, <30, <32 weeks was significantly less frequent (p < .05). Pre-operation WBC > 11.55 × 109/L, CRP > 10.1 and cervical dilation >3.5 cm were found to be independent risk factors for delivery 28 weeks after cerclage. Conclusions Cervical cerclage in twin pregnancies with cervical dilation ≥1.0 cm in mid-trimester of gestation may prolong pregnancy and gestation age, and improve pregnancy and neonatal outcomes compared with expectant management. The strongest predictor of sPTB before 28 weeks after ECC were pre-operation WBC >11.55 × 109/L, CRP > 10.1 and cervical dilation >3.5 cm.

Cervical cerclage in twin pregnancies: obstetric and neonatal outcomes.

Although there have been significant improvements in prenatal and neonatal care in recent years, twin pregnancies account for 17-20% of all preterm births and are associated with an increased risk of perinatal mortality and morbidity. To evaluate the contribution of cerclage to the continuation of pregnancy in twin pregnancy cases required cervical cerclage. Cases of twin pregnancies who performed cervical cerclage with follow-up and deliveries between January 2010 and January 2022 in the Department of Obstetrics and Gynecology, Ege University Faculty of Medicine Hospital, were retrospectively analyzed. Obstetric and neonatal outcomes were evaluated. A total of 23 women who performed cervical cerclage due to cervical insufficiency in twin pregnancies were evaluated retrospectively. The mean time between cerclage placement and delivery was 12.1 ± 7weeks, maximum prolongation was in the obstetric history-indicated cerclage group. The gestational age at delivery was 20-38 (median 30) weeks. The rate of spontaneous preterm birth at < 34, < 32, < 28, and < 24weeks was higher in the physical examination-indicated cerclage group. Overall neonatal survival was 82.5% (n = 33/40). The time between cerclage placement and birth were considered as an important gain for twin pregnancies at the limit of viability. Further studies are needed to better understand the role of cervical cerclage in preventing premature birth and to determine the indications for cerclage.

361. Effectiveness of cervical cerclage in twin pregnancies

Introduction: There are robust data in the literature that cervical cerclage inserted due to maternal history does not improve neonatal outcomes in twins. However, there is insufficient data about perinatal outcomes of cerclages inserted due to physical examination or ultrasound indications in twin pregnancies. Aim of the study: Assessment of the effectiveness of the emergency cervical cerclage and for ultrasound indications cervical cerclage in a twin pregnancy. Methods: Retrospective analysis of all patients in twin pregnancies qualified for cervical cerclage due to physical examination or ultrasound indications at St.

Cervical Cerclage in Twin Pregnancies: An Updated Systematic Review and Meta-analysis

(Abstracted from Eur J Obstet Gynecol Reprod Biol 2021;260:137–149) Preventing preterm birth (PTB) in twins is important because the risk is significantly higher compared with singleton pregnancies. The effectiveness of cervical cerclage as an option to prevent PTB in twin pregnancies is unclear.

Twin pregnancies treated with emergency or ultrasound-indicated cerclage to prevent preterm births

Introduction: Multiple gestations are high-risk pregnancies associated with an increased risk of neonatal morbidity and mortality, mainly due to preterm births. Numerous interventions have been attempted in order to delay the time of delivery and subsequently, prevent preterm births in twin gestations. To date, no really effective intervention has been found. Use of cerclage in twin pregnancies has been controversial. Recently, however, small retrospective cohort studies have shown a potentially positive effect with the use of cerclage in twin pregnancies. The aim of this study was to evaluate pregnancies and neonatal outcomes in twin gestations with a short cervix treated with cervical cerclage at a single University Hospital.Methods: This retrospective cohort study included all women – with twin gestation and a short cervix – who had an ultrasound indicated or emergency cervical cerclage at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark between January 1999 and May 2017. Cervical cerclage was offered to women before 26 weeks of gestation if: (1) the cervix at ultrasound was ≤20 mm without cervical dilatation (ultrasound-indicated cerclage), or (2) the cervix at ultrasound was ≤20 mm with cervical dilatation (emergency cerclage). Women with history-indicated cerclage placement or multifetal embryo reduction were excluded. A total of 65 women participated in the study.Results: The median gestational age at cerclage placement was 22.6 weeks with a median cervical length of 10 mm (range 0–20 mm). The frequency of preterm delivery before 32 weeks of gestation was 41.5% and 27.7% before 28 weeks. Median pregnancy latency was 77 days (range 4–148) and the median gestational age at delivery was 33.0 weeks. Gestational age at delivery was significantly lower among women with cervical dilatation and visible membranes than among women with a short cervix only (27.7 versus 33.6 weeks, p < .01) and so was the median pregnancy latency (48 versus 81 days, p < .05). Overall, neonatal survival was 91.5%.Conclusion: Cervical cerclage in twin pregnancies may prolong pregnancy even when placed on a very short or dilated cervix. In our study, the procedure was safe and without any serious complications. The overall neonatal survival rate was high.

The benefit of prophylactic cervical cerclage in twin pregnancies

Background: Despite the progress in modern obstetric practice, preterm labor is second leading cause of death in the 1st month of life and the main cause of perinatal morbidity and mortality; it remains a difficult problem to prevent, delay or even stop. It occurs in 5%–13% of all pregnancies before 37 weeks' gestation but its incidence in twin pregnancies is about 25%. Objectives: This study aimed to determine the effect of prophylactic cervical cerclage (CC) in comparison to others methods: vaginal progesterone and bed rest in prolongation of gestational age in twin pregnancies to prevent preterm labor. Materials and Methods: A retrospective descriptive study was conducted between January 2012 and September 2018, in a private obstetric antenatal care clinic in Duhok/Kurdistan Region/Iraq. It involved 150 women with twin pregnancies attending this clinic for follow-up, they divided into: Group 1 (N-86): women who received prophylactic CC; Group 2 (N-44): those who got the vaginal progesterone supplementation of 100 mg from 20 to 34 weeks of gestation; and Group 3 (N-20): those who asked for advisement of bed rest and restriction of physical activity. Results: Most of the total sample 95.3% had dichorionic placenta, the majority of them 84.7% were the result of assisted reproductive techniques. There was no statistically significant difference between the three groups in relation to maternal age, gravid, and previous preterm delivery, but there was in relation to the gestational age at delivery. In Group 1, 93% who delivered >37 weeks, whereas 16% and 10% in Group 2 and Group 3 who delivered at this gestational age, respectively. The overall perinatal survival was 91.3% and 26.6% who admitted to Neonatal Intensive Care Unit. Conclusions: The current study found that the prophylactic CC was an effective method to prolong pregnancy among women with twin pregnancies.

OP07.02: Outcomes of cervical cerclage in twin pregnancies complicated by cervical shortening

OP07.02: Outcomes of cervical cerclage in twin pregnancies complicated by cervical shortening

Emergency cerclage in twins during mid gestation may have favorable outcomes: Results of a retrospective cohort

PurposeCervical cerclage treatment for cervical changes at mid trimester is a very controversial topic in twins. The aim of the study was to present our maternal and fetal outcomes of mid-trimester cervical cerclage in twin pregnancies. Basic proceduresThis study was performed using data extracted from the medical files of the twin pregnancies whom performed emergency cervical cerclage between January 2012 and March 2018 at Trakya University, Facuty of Medicine, Department of Perinatology. Main findingsMean (min.–max.) gestational age at delivery was [27.3 (21–34) weeks]. The median time between cervical cerclage and delivery was 6.4 weeks, while the maximum prolongation of the pregnancy was 11 weeks. The median prolongation period of pregnancy was 4.1 weeks in patients with bulging membranes, but 10 weeks in patients with cervical effacement and cervical shortening.Eight infants died at the neonatal period. Two patients (20%) developed late abortions at 21 and 22 weeks of gestation, and 2 women (20%) delivered extremely premature neonates at the 24th weeks. Overall neonatal mortality rate was 40% (8/20 neonates). Twelve out of twenty were born alive (60%). Principal conclusionsDespite the lack of randomized controlled trials, it seems reasonable to offer emergency cervical cerclage to twin pregnancies with cervical shortening (<15mm). For the twin pregnancies with advanced cervical dilatation and protruding membranes, emergency cervical cerclage should be an option only for carefully selected patients after informing about the complications and low success rate.

Controversies about the Secondary Prevention of Spontaneous Preterm Birth.

Preterm birth is one of the major global health problems and part of the Millennium Development goals because of the associated high number of perinatal or neonatal mortality and long-term risks of neurodevelopmental and metabolic diseases. Transvaginal sonography has meanwhile been established as a screening tool for spontaneous preterm birth despite its relatively low sensitivity when considering only the cervical length. Vaginal progesterone has been shown to reduce prematurity rates below 34 weeks in a screening population of singleton pregnancies. Up to now, no positive long-term effect could be demonstrated after 2 years. It seems to have no benefit to prolong pregnancies after a period of preterm contractions and in risk patients without cervical shortening. Meta-analyses still demonstrate conflicting results dependent on quality criteria used for selection. A cerclage is only indicated in singleton pregnancies with previous spontaneous preterm birth and a combined cervical shortening in the current pregnancy. Nevertheless, the short- and long-term outcome has never been evaluated, whereas maternal complications may be increased. There is no evidence for a prophylactic cervical cerclage in twin pregnancies even in cases with cervical shortening. Emergency cerclage remains an indication after individual counseling. The effect of a cervical pessary in singleton pregnancy seems to be more pronounced in studies where a few investigators with increasing experience have treated and followed the patients at risk for preterm birth. Mainly in twin pregnancies, pessary treatment seems to be promising compared to other treatment options of secondary prevention when the therapy is started at early stages of precocious cervical ripening. At present, several international trials with the goal to reduce global rates of prematurity are in progress which will hopefully allow to specify the indications and methods of intervention for certain subgroups. When trials are summarized, prospective meta-analyses carry a lower risk of bias than the meanwhile uncontrolled magnitude of retrospective meta-analyses with conflicting results.

423: Rescue cervical cerclage in twin pregnancies for the prevention of preterm delivery

423: Rescue cervical cerclage in twin pregnancies for the prevention of preterm delivery

Cervical cerclage in twin pregnancies

To evaluate the outcomes of cervical cerclage (CC) in twin pregnancies. Retrospective analysis of twin pregnancies undergoing CC between January 2001 and December 2009 at our Institution. CC was offered in case of a cervical length measurement ≤ 20 mm (ultrasound-indicated CC) or in case of cervical dilatation with membranes at or beyond the external cervical os (physical examination-indicated CC). Cervicovaginal and rectal swabs were obtained preoperatively. Perioperative antibiotics and tocolysis were administered. There were 28 cases of ultrasound-indicated and 14 of physical examination-indicated CC. Positive swab cultures were observed in 21 % of cases. The incidence of preterm delivery <34 weeks was 32 % [95 % confidence interval (CI) 16-52 %] and 50 % (95 % CI 23-77 %) in the ultrasound-indicated and physical examination-indicated CC group, respectively. The incidence of premature rupture of membranes <34 weeks was 21 % (95 % CI 8-41 %) and 29 % (95 % CI 8-58 %) in the ultrasound-indicated and physical examination-indicated CC group, respectively. Perinatal survival was 96 % (95 % CI 88-100 %) in the ultrasound-indicated CC group, and 86 % (95 % CI 67-96 %) in the physical examination-indicated CC group. We showed a high-risk of preterm delivery in both groups, but with a high overall perinatal survival. Our data stress the importance of re-evaluating the efficacy of CC in twin pregnancies by properly designed clinical trials, particularly if it is physical examination indicated.