Ultrasound Indicated- and Physical Exam Indicated Cervical Cerclage in Twins versus Singleton Gestations

doi:10.21203/rs.3.rs-1519523/v1

PDF

Research Article

Ultrasound Indicated- and Physical Exam Indicated Cervical Cerclage in Twins versus Singleton Gestations

https://doi.org/10.21203/rs.3.rs-1519523/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background: The use of cervical cerclage in singleton gestations is a well-established method to prevent preterm birth. Although cervical cerclage is becoming more frequently used among twin pregnancies, it is still a matter of great controversy. The purpose of this study was to compare the safety and efficacy of physical examination- and ultrasound-indicated cervical cerclage in twin versus singleton gestations.

Methods: A retrospective cohort study of all ultrasound (cervical length ≤25 mm) and physical examination indicated cerclage cases performed over a 9-year period. The primary outcome was the time interval from cerclage placement to delivery.

Results: The study cohort included 100 singleton and 16 twin pregnancies. Time interval from cerclage placement to delivery was comparable in twin and singleton gestations (14.1 versus 16.3 weeks, p=0.11), as well as the rates of preterm births <28 and <32 weeks. The rate of alive newborns >24 weeks was lower in the twin group (62% versus 89%, p=0.045). Regression analysis identified that cervical dilation, but not twin gestation, was the only factor independently associated with increased risk for birth before 32 weeks.

Conclusion: Ultrasound-indicated and physical examination-indicated cerclage in twin and singleton gestations have comparable efficacy.

cervical cerclage

physical exam indicated cerclage

twin gestation

preterm birth

short cervix

bulging membranes

The prevalence of twin gestation has increased significantly over the past 30 years, mainly due to increased use of reproductive technology (1, 2). Multiple gestations are associated with an increased risk of neonatal morbidity and mortality mostly due to preterm births (PTB) with 50% of twin pregnancies delivering prior to 37 weeks of gestation and 9% delivering before 32 weeks of gestation (3). The efficiency of various measures to treat or prevent PTB in twin gestations such as bed rest, tocolytics, progesterone and cerclage is controversial (4–12). Sonographic short cervix is a well-known risk factor for PTB in both singletons and twin gestations (13). A cervical length of 20 mm or less at mid-gestation in twin pregnancies is associated with a rate of 24% for PTB < 32 weeks, increasing to 66% if the cervical length is 10 mm (14). Emergency cerclage, defined as cerclage placement following physical examination or ultrasound diagnosis of cervical insufficiency, has been shown to increase cerclage to delivery interval in singleton gestations with imminent preterm delivery during the second trimester (15–18). However, the use of cerclage in twin pregnancies is controversial and the evidence in the literature regarding its efficacy in twin gestations is both sparse and inconsistent. Previous studies showed that emergency cerclage in twin pregnancies may be harmful and could be associated with an increased risk for PTB (5, 19), while a more recent systematic review support its use, especially among women with cervical length < 15 mm or dilated cervix > 10 mm (12). However, the conclusions of this review were based exclusively on data from observational studies, whereas randomized clinical trials (RCT) showed increased risk of preterm birth and adverse perinatal outcomes (20). A recent RCT showed that physical examination-indicated cerclage significantly reduced the risk of PTB and perinatal mortality in twin gestations (11). Given the inconsistency of the current data, we aimed to evaluate the safety and efficacy of ultrasound- and physical examination- indicated cervical cerclage placement in twin versus singleton gestations.

A retrospective cohort study conducted at a single tertiary referral center of all women who underwent either ultrasound- or physical exam indicated cerclage between 2011 and 2019. Ultrasound indicated cerclage was defined as cervical length < 25 mm as indicated by previous studies (11, 13). Physical examination indicated cerclage was defined as cervical dilation > 1 cm on manual exam. A total of 116 women were included and were divided to singleton (n=100) and twin pregnancies (n=16). The latter group included 13 dichorionic and three monochorionic twin pregnancies. Exclusion criteria included women who underwent history indicated cervical cerclage, cases with incomplete medical records (N=35), patients who had positive culture on amniocentesis prior to cerclage placement (N=1) and monochorionic twin pregnancies complicated by twin-to-twin transfusion syndrome. Figure 1 describes patient flowchart. Pregnancy and neonatal outcomes were compared between the two groups.

Data collection

The medical records of all women were reviewed and data regarding patient history, cervical cerclage and delivery was extracted. Pertinent demographic data included maternal age, prepregnancy body mass index, comorbidities, gravidity, parity and mode of conception. Past obstetrical and gynecological risk factors for PTB including history of PTB, uterine anomalies, conization, hysteroscopy, chronic hypertension and smoking were also recorded. Physical examination and ultrasound characteristics before cerclage placement included cervical length measured by transvaginal ultrasound, cervical dilation by digital examination, presence of bulging membranes on speculum exam, presence of sludge and funneling on ultrasound and gestational age at time of presentation for cerclage placement. Additional information collected included progesterone treatment and amniotic fluid glucose, white blood cell count and culture, if amniocentesis was performed prior to cerclage placement to exclude intra-uterine infection. Of note, according to our department’s protocol, amniocentesis to rule out intra-uterine infection should be considered prior to emergency cerclage, especially in the presence of bulging membranes.

The technique used for cervical cerclage was performed at the discretion of the operating physician and included either Shirodkar or McDonald techniques (21, 22). As part of our departments protocol, patients received perioperative prophylactic antibiotic treatment (1 g Cefazolin intravenously). Pregnancy and delivery outcomes collected included the occurrence of preterm premature rupture of membranes (PPROM) or chorioamnionitis, intrauterine fetal demise, termination of pregnancy due to PPROM prior to 24 weeks of gestation or due to chorioamnionitis, time interval from cerclage to delivery, gestational age at delivery and mode of delivery.

Neonatal data included gender, birthweight and birthweight percentiles, one- and five- minute Apgar score, umbilical cord pH, mechanical ventilation use, neonatal intensive care unit admission, duration of hospitalization and neonatal mortality within the first 24 hours and first month of life. Birth weight percentiles were calculated using local, population-based live-born infants birth weight curves (23).

The primary outcome was defined as the time interval between cervical cerclage placement and time of delivery. Secondary outcomes were gestational age at time of delivery, the rate of PTB prior to 24^th, 28^th, 32^nd and 37^th week of gestation and a composite adverse neonatal outcome defined as one or more of the following: neonatal intensive care unit admission, mechanical ventilation, neonatal mortality. Neonatal outcomes were calculated for live births only. Cases of fetal demise, termination of pregnancy and delivery at <24 weeks of gestation were excluded from this analysis. For comparison of neonatal outcomes between singletons and twins, the twin with the worst outcomes for each outcome was chosen for the analysis. Time interval from cerclage to delivery by cerclage indication was compared between and within groups.

Statistical analysis

Categorical variables were reported as frequency and percentage. Continuous variables were evaluated for normal distribution using histogram and Q-Q plot and reported as mean and standard deviation (normally distributed variables) or median and interquartile range (skewed variables). Chi square test and Fisher’s exact test were used to compare categorical variables between the two groups. Independent samples T test and Mann–Whitney test were used to compare continuous variables between the groups. Multivariate logistic regression was applied to study the association between type of pregnancy (twins vs singleton), gestational age at the time of cerclage placement, cervical dilatation and presence of bulging membranes and delivery before 28, 32 and 37 weeks of gestation. Adjustment was conducted for maternal age, pre-gestational body mass index and parity. All statistical tests were two sided and p<0.05 was considered as statistically significant. SPSS software (IBM SPSS Statistics for Windows, version 23, IBM corp., Armonk, NY, USA, 2015) was used for all statistical analyses.

Demographic and pregnancy characteristics are depicted in Table 1. Maternal age, body mass index, history of PTB as well as medical risk factors for PTB were comparable between the two groups. The rate of nulliparity was significantly higher in women in the twins group compared with singleton gestation, and within the twins group most women conceived with ovulation induction/ intrauterine insemination whereas in the singleton group most women conceived spontaneously.

Table 1

Comparison between twins and singleton gestation
a. Patient characteristics	Twins (n = 16)	Singletons (n = 100)	p value
Age, years	31.2 ± 5.8	34.2 ± 6.1	.07
Nulliparous	13 (81.3)	56 (56.0)	.04
Pre-pregnancy BMI, kg/m²	22.03 (20.6–25.2)	22.27 (19.8–26.7)	.90
Hx of PTB	12.5 (2)	25.0 (25)	.30
Medical risk factors for PTB₁	81.3 (13)	73.0 (73)	.70
Present pregnancy
Mode of conception Spontaneous Ovulation induction/ IUI IVF/ ED	2 (3.1) 3 (33.3) 11 (25.6)	62 (96.9) 6 (66.7) 32 (74.4)	.001
GDM GDMA1 GDMA2	1 (6.3) 0	16 (16.0) 6 (6.0)	.47
Hypertensive disorders of pregnancy₂	0	2 (2.0)	1.00
Intrahepatic cholestasis of pregnancy	0	1 (1.0)	1.00
b. Cerclage Characteristics
GA at cerclage placement, weeks	20.85 (18.6–22.8)	20.85 (18.6–22.8)	.90
Presence of cervical dilation	8 (50.0)	40 (40.0)	.40
Cervical length, mm	11.5 (7.2–14)	14 (7.2–20.7)	.10
Bulging membranes	7 (43.8)	34 (34.0)	.40
Indication for cerclage Short cervical length Dilation and/ or bulging membrane	8 (50.0) 8 (50.0)	54 (54.0) 46 (46.0)	.70
Sludge	2 (12.5)	16 (16.0)	1.0
Funneling	11 (68.8)	51 (51.0)	.10
Cerclage type McDonald Shirodkar	3 (18.8) 13 (81.3)	17 (17.3) 81 (82.7)	1.00
Progesterone treatment before cerclage	7 (43.8)	50 (50.0)	.60
Progesterone treatment after cerclage	12 (75)	77 (77.0)	1.00
Amniocentesis before cerclage	1 (6.3)	19 (19.0)	.30
c. Perinatal Outcome
Alive newborn deliveries ≥ 24 weeks	11 (62)	89 (89)	.045
Time interval from cerclage to delivery, weeks	14.1 (6.2–16.2)	16.3 (10.8–18.6)	.10
GA at delivery, weeks	36.1 (25.3–37.2)	37.7 (32.5–38.9)	.02
< 24 weeks	4 (25)	11 (11)	.132
< 28 weeks	4 (25.0)	20 (20.0)	.70
< 32 weeks	6 (37.5)	24 (24.0)	.35
< 37 weeks	10 (62.5)	43 (43.0)	.10
Mode of delivery
Vaginal	5 (31.3)	68 (68.0)	0.01
Cesarean	5 (31.3)	25 (25.0)	0.56
Operative vaginal	5 (31.3)	4 (4.0)	0.002
Abortion (D&E)	1 (6.3)	3 (3.0)	0.45
PPROM	3 (18.8)	19 (19.0)	1.00
Chorioamnionitis	4 (25.0)	14 (14.0)	.27
Termination of pregnancy	2 (12.5)	8 (8.0)	.60
Fetal death	1 (6.3)	1 (1.0)	.25
d. Neonatal outcomes₄	n = 11₅	n = 89₆
Gender Male Female	6 (54.5) 5 (45.5)	44 (49.5) 45 (50.5)	.70
Birth weight, g	2615 (2100–2788)	2965 (2403–3290)	.03
Weight percentile	76.0 (52.0–82.0)	51.0 (31.0–71.0)	.10
Apgar 1	9.0 (8.0–9.0)	9.0 (9.0–9.0)	.07
Apgar 5	10.0 (9.0–10.0)	9.0 (8.0–9.0)	.10
pH Cord	7.22 ± .087	7.26 ± .059	.20
NICU₇	3 (27.2)	17 (19.1)	.525
Mechanical ventilation	1	8
Death during 1st month of life	0	1 (1.1)	1.00
Days in hospital	6 (4–25)	4 (4-7.5)	.30
Composite neonatal complications³	3 (27.2)	17 (19.1)	.525

Values are presented as median (IQR) or n (%)

BMI – body mass index, PTB – preterm birth, IUI – intrauterine insemination, IVF – in vitro fertilization, ED – egg donation, GDM – gestational diabetes mellitus, GA – gestational age, PPROM – preterm premature rupture of membranes, NICU – Neonatal intensive care unit.

¹Positive history of any of the following: D&E, cervical preparation, conization, hysteroscopy, uterine anomaly, chronic hypertension, smoking.

² Pregnancy induced hypertension, preeclampsia or HELLP syndrome.

³ Composite adverse neonatal outcome included one or more of the following: NICU admission, mechanical ventilation, neonatal mortality.

₄ Neonatal outcomes are reported for alive born deliveries from 24 weeks of gestation

₅ Excluded (n = 5):

Deliveries at < 24 weeks (n = 4)
- sPTL (n = 1)
- Chorioamnionitis (n = 3), of which 2 underwent labor induction and D&E and 1 had sPTL
Chorioamnionitis with IUFD at 37 weeks (n = 1)

₆ Excluded (n = 11):

PPROM at < 24 weeks (n = 4). All cases underwent labor induction or D&E.

Chorioamnionitis at < 24 weeks (n = 7), of which 1 case with IUFD. 2 had sPTL, the rest underwent labor induction or D&E.

Table 1 describes cerclage characteristics in the two groups. The rate of indications for cerclage (short cervix indicated by transvaginal ultrasound vs cervical dilation by physical examination) did not differ significantly between the two groups. A comparison between the time interval from cerclage to delivery by indications for cerclage between and within groups was performed (Table 2).

Table 2

Time interval from cerclage to delivery by cerclage indication
	Twins		p value	Singletons		p value
	Cervical dilation (n = 8)	Cervical shortening (n = 8)		Cervical dilation (n = 40)	Cervical shortening (n = 60)
Time interval from cerclage to delivery, weeks	8.0 ± 6.4	15.4 ± 4.6	0.025	12.1 ± 7.4	15.9 ± 5.2	0.007
	Twins (n = 8)	Singletons (n = 40)		Twins (n = 8)	Singletons (n = 60)
	Cervical dilation			Cervical shortening
Time interval from cerclage to delivery, weeks	8.0 ± 6.4	12.1 ± 7.4	0.153	15.4 ± 4.6	15.9 ± 5.2	0.803

Values are presented as mean ± standard deviation.

Results show that among singleton and twin gestations, the time interval was significantly prolonged in cases of cervical shortening versus cervical dilation, and there was no significant difference between the two groups when compared by cerclage indications. Other variants including the rate of cases in which amniocentesis was performed prior to the procedure, gestational age at cerclage placement and the mean cervical length measured by transvaginal ultrasound were similar between the two groups. Similarly, the presence of cervical dilatation, bulging membranes, sludge, and funneling were also comparable between the two groups. The majority of patients underwent Shirodkar cerclage technique. The use of intravaginal progesterone application (either Utrogestan 200 mg twice daily or Crinone 8%, 1 application daily) before and after cerclage placement did not differ between groups. Six patients in the singletons group underwent repeated cerclage, whereas no repeated cerclage was performed in the twins group. The indication for a second cerclage was either progressive cervical dilatation or bulging membranes.

Delivery and neonatal outcomes are presented in Table 1. The time interval from cerclage placement to delivery did not differ between twins and singleton gestations (14.1 weeks (IQR 6.2–16.2) vs 16.3 weeks (IQR 10.8–18.6), respectively, p = .11). As expected, women with twin gestations delivered earlier compared to women with singletons (36.1 weeks (IQR 25.3–37.2) vs 37.7 weeks (IQR 32.5–38.9), p = .02), but the rates of PTB prior to 24, 28, 32, and 37 weeks did not differ between the two groups. Similarly, there was no difference in the rate of PPROM, chorioamnionitis, termination of pregnancy and fetal demise between the groups. Eleven (62%) twin pregnancies and 89 (89%) singleton pregnancies ended with alive newborn (p = .045). Four (25%) cases of the twin group and 11 (11%) cases of the singleton group (p = .132) delivered prior to 24th weeks of gestation due to spontaneous preterm labor (one case of twins, 2 singletons), or underwent induction of labor or D&E due to chorioamnionitis (three twins and seven singletons) and PPROM (four singletons). As expected, the mean birth weight was significantly lower in the twin group compared to the singleton group (2615 g, (IQR 2100–2788) vs. 2965 g (IQR 2403–3290), p = .037). However, weight percentiles did not differ between the groups. Apgar scores, umbilical cord pH, length of hospitalization and the rate of neonatal intensive care unit admission, as well as mechanical ventilation use, neonatal mortality, and the rate of the composite adverse neonatal outcome were similar between the two groups.

Multivariate regression analysis (Table 3) revealed that cervical dilation at the time of cerclage placement was the only factor independently associated with increased risk for PTB < 32 weeks of gestation (Odds ratio [OR], 3.63; 95% confidence internal 1.02–12.85), while twin gestation was not associated with increased risk for PTB < 32 weeks (OR, 1.68; 95% confidence interval .49- 5.77).

Table 3

Multivariate analysis of factors associated with preterm birth < 32 weeks
Variable	OR (95% CI)	p value
Twin gestation	1.683 (.490- 5.779)	.40
Gestational age at time of cerclage placement	.882 (.741 − 1.050)	.10
Cervical dilation	3.630 (1.025–12.855)	.04
Bulging membranes	2.308 (.714-7.455)	.10
Adjustment was made for maternal age, pre-gestational body mass index and parity.

The present study compared the effect of emergency cerclage on obstetric and neonatal outcomes in 16 twins versus 100 singleton gestations. The primary outcome, median time interval from cerclage placement to delivery, did not differ between groups. The rate of alive newborns after 24th weeks of gestation was significantly lower in the twins group compared to the singleton group. Secondary outcomes including delivery prior to 24, 28, 32 and 37 weeks of gestation and a composite of adverse neonatal outcome were also comparable between the two groups.

We included women who underwent emergency cerclage placement following either physical examination or ultrasound indications. As current literature is inconclusive regarding the effect of emergency cerclage in twin pregnancies, the decision to place an emergency cerclage in these circumstances is often complex, based on multiple variables, as well as the practicing physician’s expert opinion. Previous studies have usually examined only one of the indications (24). As our cohort included both physical examination and ultrasound indications, with similar rates in both groups, it might represent more accurately the clinical scenario.

As expected, women with twins delivered earlier than women with singleton pregnancies. However, there was no significant difference in the time interval from cerclage placement to the delivery, or the rate of PTBs. In line with these results, most obstetric outcomes, excluding mode of delivery, as well as neonatal outcome measures were also comparable between the two groups. Based on these findings, physical examination- and ultrasound- indicated cerclage seems to prolong cerclage to delivery interval in twin gestations without increasing the risk of adverse neonatal outcomes similarly to singleton gestations. These results are supported by a RCT that reported a decrease in the rate of preterm birth among women with twin gestations who underwent cervical cerclage for asymptomatic cervical dilation (25). In addition, our results are consistent with previous studies that showed a beneficial effect of emergency cerclage by comparing twin to singleton gestations (24, 26–28). Two recent cohort studies reported favorable obstetrics outcomes for physical exam- indicated cerclage in twin gestations vs. singletons. These articles reported a shorter cerclage to delivery interval compared to our study (Miller et al: 69 vs 83 days, Rebarber et al: 92 vs 106 days, our study: 98.7 vs 114.1 days) (24, 27). This difference could be attributed to minor differences in management, cerclage technique and our study population which included both physical examination- and ultrasound- indicated cervical cerclage. Bernabeu et al. presented favorable outcomes in women with twin gestations undergoing physical examination indicated cerclage with prolongation of 10.0 weeks for singletons and 12.1 weeks for twin gestations (26).

Barbosa et al investigated the efficacy of cerclage in physical examination- indicated versus ultrasound- indicated cerclage in twin pregnancies. They supported the use of cervical cerclage in twin pregnancies for both indications and showed better obstetric outcomes in case of ultrasound- indicated cerclage (29). This is consistent with our results. Possibly, cervical dilation may be the progression of cervical shortening. Furthermore, a recent meta-analysis showed that the use of cerclage in twin pregnancies is beneficial for pregnancy prolongation and the reduction of risk of PTB in cases with a cervical length of < 15 mm or dilated cervix. According to this meta-analysis, previous RCTs showed a beneficial effect of ultrasound-indicated cerclage in twin pregnancies, while cohort studies showed contradictory effects. This discrepancy precludes a definite conclusion regarding the management of this subgroup (12). Our results are consistent with these studies, showing improvement in the cerclage to delivery interval and neonatal outcomes in cases of sonographic short cervix as well as cervical dilation and stand in contrast with earlier studies, in which cerclage placement in twin pregnancies was associated with a significant two-fold increase in the rate of PTB as compared to no cerclage (5). Of note, comparison of cases that underwent cerclage due to cervical dilatation only, revealed a 4-week difference in cerclage to delivery interval between twins and singletons (8 vs 12 weeks). This difference did not reach statistical significance that may be related to the small sample size. Lastly, our study shows that the only significant independent risk factor for PTB < 32 weeks is cervical dilation. This is supported by another analysis showing that the time interval from cerclage to delivery was shorter in dilated versus short cervix in both groups. Our results are consistent with the results of Han et al, that compared perinatal outcomes of cerclage versus no cerclage in twins and showed that cervical dilation was the only significant risk factor for PTB < 32 weeks (30).

The retrospective design of this study carries inherent biases, and the relatively modest sample size of our study may explain some of the absence of statistically significant differences between the two groups secondary to lack of statistical power. The detailed medical record permitting extraction of comprehensive data and being a single center study with uniform antenatal and neonatal management protocols are the strengths of this study.

Women with twin gestations undergoing emergency cerclage had a successful prolongation of pregnancy. The time interval from cerclage placement to delivery was similar between the two groups. However, the rate of alive newborns was lower in the twins group. Our results suggest that the use of ultrasound- and physical examination- indicated cervical cerclage may prolong pregnancy in women with twin gestations as in singleton gestations. However, the lower rate of alive newborns should be taken into consideration during patient counseling. Randomized prospective studies are urgently needed to establish the efficacy of cerclage placement in twin pregnancies with short and/or dilated cervix.

PTB- preterm births, RCT- randomized clinical trial, PPROM - preterm premature rupture of membranes.

Ethics approval and consent to participate: Approval from the Institutional Review Board of Chaim Sheba medical center was granted for this study (5587-18-SMC), waiving informed consent as data was identified. All methods were perfomed in accordance with relevant guidelines and regulations.

Consent for publication: Not applicable

Availability of data and materials: The dataset supporting the conclusions of this article are available in the Sheba institute repository, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. The datasets are however available from the corresponding author on reasonable request and with permission of the Sheba institute.

Competing interests: The authors declare that they have no competing interests.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions: DAK, R.M, YY concept and design, DAK, IY, DS Data collection, RM, IH, SM, YY Data analysis, DAK, RM, SM, YY Manuscript writing, IY, DS, IH, SM, YY Manuscript editing.

Acknowledgements: We would like to thank Dr. Tomer Ziv-Baran for his assistance with the statistical analysis.

American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Obstetrics; Society for Maternal-Fetal Medicine; ACOG Joint Editorial Committee. ACOG Practice Bulletin #56: Multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy. Obstet Gynecol. 2004 Oct;104(4):869 – 83. doi: 10.1097/00006250-200410000-00046. PMID: 15458915.
Martin JA, Hamilton BE, Sutton PD et al. Births: final data for 2007. Natl Vital Stat Rep. 2010 Aug 9;58(24):1–85. PMID: 21254725.
Schaaf JM, Mol BW, Abu-Hanna A, Ravelli AC. Trends in preterm birth: singleton and multiple pregnancies in the Netherlands, 2000–2007. BJOG. 2011 Sep;118(10):1196–204. doi: 10.1111/j.1471-0528.2011.03010.x. Epub 2011 Jun 14. PMID: 21668771.
Crowther CA, Han S. Hospitalisation and bed rest for multiple pregnancy. Cochrane Database Syst Rev. 2010 Jul 7;2010(7):CD000110. doi: 10.1002/14651858.CD000110.pub2. PMID: 20614420; PMCID: PMC7051031.
Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Obstet Gynecol. 2005 Jul;106(1):181-9. doi: 10.1097/01.AOG.0000168435.17200.53. PMID: 15994635.
Rode L, Klein K, Nicolaides KH, Krampl-Bettelheim E, Tabor A; PREDICT Group. Prevention of preterm delivery in twin gestations (PREDICT): a multicenter, randomized, placebo-controlled trial on the effect of vaginal micronized progesterone. Ultrasound Obstet Gynecol. 2011;38(3):272 – 80. doi: 10.1002/uog.9093. PMID: 21739497.
Berghella V, Ciardulli A, Rust OA et al. Cerclage for sonographic short cervix in singleton gestations without prior spontaneous preterm birth: systematic review and meta-analysis of randomized controlled trials using individual patient-level data. Ultrasound Obstet Gynecol. 2017 Nov;50(5):569–577. doi: 10.1002/uog.17457. Epub 2017 Oct 5. PMID: 28295722.
MacLennan AH, Green RC, O'Shea R, Brookes C, Morris D. Routine hospital admission in twin pregnancy between 26 and 30 weeks' gestation. Lancet. 1990 Feb 3;335(8684):267-9. doi: 10.1016/0140-6736(90)90079-k. PMID: 1967729.
Serra V, Perales A, Meseguer J et al. Increased doses of vaginal progesterone for the prevention of preterm birth in twin pregnancies: a randomised controlled double-blind multicentre trial. BJOG. 2013 Jan;120(1):50–7. doi: 10.1111/j.1471-0528.2012.03448.x. Epub 2012 Aug 13. PMID: 22882759.
Newman RB, Krombach RS, Myers MC, McGee DL. Effect of cerclage on obstetrical outcome in twin gestations with a shortened cervical length. Am J Obstet Gynecol. 2002 Apr;186(4):634 – 40. doi: 10.1067/mob.2002.122126. PMID: 11967484.
Roman A, Zork N, Haeri S et al. Physical examination-indicated cerclage in twin pregnancy: a randomized controlled trial. Am J Obstet Gynecol. 2020 Dec;223(6):902.e1-902.e11. doi: 10.1016/j.ajog.2020.06.047. Epub 2020 Jun 25. PMID: 32592693.
Li C, Shen J, Hua K. Cerclage for women with twin pregnancies: a systematic review and metaanalysis. Am J Obstet Gynecol. 2019 Jun;220(6):543–557.e1. doi: 10.1016/j.ajog.2018.11.1105. Epub 2018 Dec 7. PMID: 30527942.
Iams JD, Goldenberg RL, Meis PJ et al. The length of the cervix and the risk of spontaneous premature delivery. National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network. N Engl J Med. 1996 Feb 29;334(9):567 – 72. doi: 10.1056/NEJM199602293340904. PMID: 8569824.
To MS, Fonseca EB, Molina FS, Cacho AM, Nicolaides KH. Maternal characteristics and cervical length in the prediction of spontaneous early preterm delivery in twins. Am J Obstet Gynecol. 2006 May;194(5):1360–5. doi: 10.1016/j.ajog.2005.11.001. Epub 2006 Apr 21. PMID: 16647922.
Sperling JD, Dahlke JD, Gonzalez JM. Cerclage Use: A Review of 3 National Guidelines. Obstet Gynecol Surv. 2017 Apr;72(4):235–241. doi: 10.1097/OGX.0000000000000422. PMID: 28426125.
Roman A, Suhag A, Berghella V. Cerclage: Indications and Patient Counseling. Clin Obstet Gynecol. 2016 Jun;59(2):264-9. doi: 10.1097/GRF.0000000000000185. PMID: 27015230.
Alfirevic Z, Stampalija T, Roberts D, Jorgensen AL. Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD008991. doi: 10.1002/14651858.CD008991.pub2. Update in: Cochrane Database Syst Rev. 2017 Jun 06;6:CD008991. PMID: 22513970.
Owen J, Hankins G, Iams JD et al. Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length. Am J Obstet Gynecol. 2009 Oct;201(4):375.e1-8. doi: 10.1016/j.ajog.2009.08.015. PMID: 19788970; PMCID: PMC2768604.
Jorgensen AL, Alfirevic Z, Tudur Smith C, Williamson PR; cerclage IPD Meta-analysis Group. Cervical stitch (cerclage) for preventing pregnancy loss: individual patient data meta-analysis. BJOG. 2007 Dec;114(12):1460–76. doi: 10.1111/j.1471-0528.2007.01515.x. Epub 2007 Sep 27. PMID: 17903224.
Sanchez-Ramos L. The placement of a cerclage in patients with twin pregnancies and a short cervix is associated with increased risk of preterm birth and adverse perinatal outcome. Am J Obstet Gynecol. 2020 Feb;222(2):194–196. doi: 10.1016/j.ajog.2019.09.038. Epub 2019 Oct 3. PMID: 31586601.
Shirodkar VN. A new method of operative treatment for habitual abortions in the second trimester of pregnancy. Antiseptic. 1955;52:299.
McDonald IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Emp. 1957 Jun;64(3):346 – 50. doi: 10.1111/j.1471-0528.1957.tb02650.x. PMID: 13449654.
Dollberg S, Haklai Z, Mimouni FB, Gorfein I, Gordon ES. Birth weight standards in the live-born population in Israel. Isr Med Assoc J. 2005 May;7(5):311-4. PMID: 15909464.
Miller ES, Rajan PV, Grobman WA. Outcomes after physical examination-indicated cerclage in twin gestations. Am J Obstet Gynecol. 2014 Jul;211(1):46.e1-5. doi: 10.1016/j.ajog.2014.03.034. Epub 2014 Mar 18. PMID: 24657791.
Roman A, Zork N, Haeri S et al. Physical examination-indicated cerclage in twin pregnancy: a randomized controlled trial. Am J Obstet Gynecol. 2020 Dec;223(6):902.e1-902.e11. doi: 10.1016/j.ajog.2020.06.047. Epub 2020 Jun 25. PMID: 32592693.
Bernabeu A, Goya M, Martra M et al. Physical examination-indicated cerclage in singleton and twin pregnancies: maternal-fetal outcomes. J Matern Fetal Neonatal Med. 2016;29(13):2109–13. doi: 10.3109/14767058.2015.1076786. Epub 2015 Sep 15. PMID: 26371753.
Rebarber A, Bender S, Silverstein M, Saltzman DH, Klauser CK, Fox NS. Outcomes of emergency or physical examination-indicated cerclage in twin pregnancies compared to singleton pregnancies. Eur J Obstet Gynecol Reprod Biol. 2014 Feb;173:43–7. doi: 10.1016/j.ejogrb.2013.11.016. Epub 2013 Nov 28. PMID: 24321466.
Park JY, Cho SH, Jeon SJ et al. Outcomes of physical examination-indicated cerclage in twin pregnancies with acute cervical insufficiency compared to singleton pregnancies. J Perinat Med. 2018 Oct 25;46(8):845–852. doi: 10.1515/jpm-2017-0218. PMID: 29116935.
Barbosa M, Bek Helmig R, Hvidman L. Twin pregnancies treated with emergency or ultrasound-indicated cerclage to prevent preterm births. J Matern Fetal Neonatal Med. 2020 Oct;33(19):3227–3232. doi: 10.1080/14767058.2019.1570119. Epub 2019 Jan 27. PMID: 30688138.
Han MN, O'Donnell BE, Maykin MM, Gonzalez JM, Tabsh K, Gaw SL. The impact of cerclage in twin pregnancies on preterm birth rate before 32 weeks. J Matern Fetal Neonatal Med. 2019 Jul;32(13):2143–2151. doi: 10.1080/14767058.2018.1427719. Epub 2018 Jan 23. PMID: 29363371; PMCID: PMC6251764.

No competing interests reported.

PDF

Submission checks completed at journal
11 Apr, 2022
First submitted to journal
03 Apr, 2022

You are reading this latest preprint version

Ultrasound Indicated- and Physical Exam Indicated Cervical Cerclage in Twins versus Singleton Gestations

Status:

Version 1

Abstract

Figures

Introduction

Materials And Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Competing Interests

Status:

Version 1