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Zou T, Wu YC, Yao Q. Vaginal delivery of triplets after emergency transvaginal cerclage: A case report and literature review. Medicine (Baltimore) 2024; 103:e37262. [PMID: 38489727 PMCID: PMC10939671 DOI: 10.1097/md.0000000000037262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/24/2024] [Indexed: 03/17/2024] Open
Abstract
RATIONALE To report a peculiar case of vaginal delivery of a triplet after emergency transvaginal cerclage and to find a way to optimize some extreme situations encountered in clinical practice after evaluating feasibility. PATIENT CONCERNS A 33-year-old gravida 6, para 0050 woman at 21 + 6 weeks of gestation was referred to the obstetric department for opening of the cervical canal. An emergency McDonald cerclage was performed at 22 weeks of gestation after a comprehensive assessment, and the pregnancy ended with vaginal delivery at 24 + 6 weeks of gestation. The postpartum period was normal, and the newborns were discharged to home care after treatment in the neonatal intensive care unit. INTERVENTIONS After discussing the risks, the patient requested emergency transvaginal McDonald cerclage at 22 weeks of gestation. OUTCOMES Emergency McDonald cerclage was performed at 22 weeks of gestation, and the pregnancy ended with vaginal delivery at 24 + 6/25 weeks of gestation, successfully prolonging gestation by 20/21 days. The postpartum period had no exceptional circumstances, and newborns were discharged to home care after treatment in the neonatal intensive care unit for 104/98/104 days. LESSONS Emergency cerclage seems to be impossible in multiple pregnancies. However, in this case, after a comprehensive assessment, it was feasible to extend the gestational age by emergency cerclage, and prompt and accurate evaluation is important to avoid complications and individualize the following management. In this case, we may find a way to optimize some extreme situations encountered in clinical practice and offer a glimmer of hope for families challenged with multiple pregnancies at risk of preterm delivery. However, more high-quality studies are needed to prove the effectiveness and safety of emergency cerclages in triplets.
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Affiliation(s)
- Tong Zou
- West China Second Hospital of Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Chengdu, China
| | - Yi-Cheng Wu
- West China Second Hospital of Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Chengdu, China
| | - Qiang Yao
- West China Second Hospital of Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Chengdu, China
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Rodo C, de la Calle M, Maroto A, Maiz N, Arévalo S, Garcia-Manau P, Mendoza M, Bartha JL, Carreras E. Gestational age-based reference ranges for cervical length and preterm birth prediction in triplet pregnancies: an observational retrospective study. BMC Pregnancy Childbirth 2022; 22:669. [PMID: 36042432 PMCID: PMC9426284 DOI: 10.1186/s12884-022-04997-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/22/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To develop gestational age-based reference ranges for cervical length in triplet pregnancies. The secondary objective was to assess the performance of cervical length measured between 18 and 20 + 6 days for the prediction of preterm delivery before 28 and 32 weeks, respectively. METHODS Observational retrospective study of triplet pregnancies in three Spanish tertiary-care hospitals between 2001 and 2019. Cervical length measurements were consecutively obtained between 15 and 34 weeks of gestation. Pregnancies undergoing multifetal reduction or fetal surgery were excluded. RESULTS Two hundred and six triplet pregnancies were included in the final analysis. There was a quadratic decrease in cervical length with gestational age. The median and fifth centiles for cervical length at 20 weeks were 35 and 13 mm. In the prediction of preterm birth < 28 weeks, for a false positive rate of 5%, and 10%, the detection rates were 40.9%, and 40.9%, respectively, and the prediction of preterm birth < 32 weeks, 22.0% and 26.0%, respectively. CONCLUSIONS In triplet pregnancies, cervical length decreases with gestational age. The performance of cervical length at 18-20 + 6 in screening for preterm birth before 28 and 32 weeks is poor.
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Affiliation(s)
- Carlota Rodo
- Maternal-Fetal Medicine Research Group, Department of Obstetrics, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
| | - María de la Calle
- Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hospital Universitario La Paz-Carlos III, Madrid, Spain
| | - Anna Maroto
- Maternal-Fetal Medicine, Department of Obstetrics, Hospital Universitari Dr Josep Trueta, Girona, Spain
| | - Nerea Maiz
- Maternal-Fetal Medicine Research Group, Department of Obstetrics, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
| | - Silvia Arévalo
- Maternal-Fetal Medicine Research Group, Department of Obstetrics, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Pablo Garcia-Manau
- Maternal-Fetal Medicine Research Group, Department of Obstetrics, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Manel Mendoza
- Maternal-Fetal Medicine Research Group, Department of Obstetrics, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - José Luis Bartha
- Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hospital Universitario La Paz-Carlos III, Madrid, Spain
| | - Elena Carreras
- Maternal-Fetal Medicine Research Group, Department of Obstetrics, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
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Vilchez G, Kumar K, Singh S, Patel N, Kao M, Lagos M, Duncan J. Risk of preterm birth and neonatal outcomes after cerclage placement in triplet pregnancies. J Matern Fetal Neonatal Med 2021; 35:5409-5415. [PMID: 33847210 DOI: 10.1080/14767058.2021.1881476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The number of triplet pregnancies in the United States has increased significantly. Perinatal morbidity and mortality are higher in these pregnancies mainly due to higher preterm birth rates. Interventions to decrease the risk of preterm delivery in this population are needed. Evidence regarding cerclage placement in triplets is limited. We performed a population-based, retrospective cohort study to study the risk of preterm birth and neonatal outcomes after cerclage placement in triplet pregnancies. METHODS All U.S. triplet deliveries from 2006 to 2013 with risk factors for cervical insufficiency were selected, excluding cases with indicated preterm delivery. Cases were categorized according to cerclage placement status. The risk of preterm birth and adverse neonatal outcomes were calculated using propensity score analysis, generalized linear, and logistic regression models. RESULTS From ∼33 million deliveries, 43,000 were triplets, and 7308 fulfilled eligibility criteria. There was no difference in the gestational age at delivery between the cerclage and noncerclage groups, aOR (95% CI) = 1.0(0.9-1.0). The difference between the risk of preterm delivery at <34 weeks and <32 weeks was not statistically significant. The risk of the composite outcome of neonatal complications was higher in the cerclage compared to the noncerclage group, aOR (95% CI) = 1.5 (1.1-2.2). CONCLUSIONS Cerclage placement in triplet pregnancies does not appear to decrease preterm birth rates and seems to increase the risk of neonatal complications.
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Affiliation(s)
- Gustavo Vilchez
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, MO, USA
| | - Komal Kumar
- Department of Medical Technology Research Institute, Universidad Nacional Federico Villareal, Lima, Peru
| | - Som Singh
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, MO, USA
| | - Neil Patel
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, MO, USA
| | - Monica Kao
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, MO, USA
| | - Moraima Lagos
- Department of Medical Technology Research Institute, Universidad Nacional Federico Villareal, Lima, Peru
| | - Jose Duncan
- Department of Obstetrics and Gynecology, University of South Florida, Tapa, FL, USA
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Abstract
A short cervix in the second trimester is a significant risk factor for spontaneous preterm birth, preterm prelabor rupture of membranes, and subsequent adverse perinatal outcome. The pathophysiology is complex and multifactorial with inflammatory and/or infectious processes often involved. Biomarkers have been developed in an effort to predict preterm birth with varying degrees of success. The treatment options of cerclage, progesterone, pessary, and combination therapy are reviewed. Evidence-based protocols are summarized for singleton and multiple gestation.
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Mhatre M, Craigo S. Triplet pregnancy: What do we tell the prospective parents. Prenat Diagn 2020; 41:1593-1601. [PMID: 33080664 DOI: 10.1002/pd.5852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/21/2020] [Accepted: 10/18/2020] [Indexed: 11/09/2022]
Abstract
Experience managing triplet pregnancies has increased over the past few decades as the incidence has changed related to assisted reproductive practices. Physicians caring for women carrying triplets cannot predict an individual outcome or pregnancy course but must educate patients about the challenges related to these high risk pregnancies. Obstetric providers can describe the wide range of risks associated with triplet gestations, and the general plan for management, but ultimately parents must make decisions with potentially lifelong consequences. Here, we present the diagnostic criteria, common complications, and management options for triplet pregnancies, to help obstetricians counsel patients on the medical and psychosocial consequences of triplet pregnancy, potential complications, and multifetal reduction.
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Affiliation(s)
- Mohak Mhatre
- Tufts Medical Center, Boston, Massachusetts, USA
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Rosen H, Hiersch L, Freeman H, Barrett J, Melamed N. The role of serial measurements of cervical length in asymptomatic women with triplet pregnancy. J Matern Fetal Neonatal Med 2017; 31:713-719. [PMID: 28277920 DOI: 10.1080/14767058.2017.1297402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess the predictive accuracy of serial measurements of cervical length (CL) for preterm birth in asymptomatic women with triplet pregnancy. METHODS A retrospective study of women with triplets who underwent serial sonographic measurements of CL until 28-32 weeks of gestation. The predictive accuracy of CL for preterm birth was determined at 4 periods along gestation: 18-20 weeks (period 1), 21-24 weeks (period 2), 25-27 weeks (period 3) and 28-32 weeks (period 4). RESULTS A total of 431 measurements of CL from were analyzed. CL decreased in a linear manner across gestation: 40.8 ± 7.1 mm, 36.5 ± 8.4 mm, 29.9 ± 11.4 mm and 25.0 ± 11.8 mm in periods 1, 2, 3 and 4, respectively. The difference in CL between women who did and did not deliver prematurely was small before 25 weeks (periods 1&2) but became more pronounced later in pregnancy (periods 3&4), mainly due to a rapid cervical shortening between periods 2 and 3 (shortening rate -29.0 ± 20.0% vs. -12.6 ± 20.5%, respectively, p = .01). The best predictors of preterm birth were either a single measurement of CL during period 3 or the degree of cervical shortening between periods 2 and 3. CONCLUSIONS Care providers should be aware of the limited predictive value of cervical length before 25 + 0 weeks in triplet pregnancies.
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Affiliation(s)
- Hadar Rosen
- a Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine , Sunnybrook Health Sciences Centre, University of Toronto , Ontario , Canada
| | - Liran Hiersch
- b Department of Obstetrics and Gynecology , Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Howie Freeman
- a Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine , Sunnybrook Health Sciences Centre, University of Toronto , Ontario , Canada
| | - Jon Barrett
- a Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine , Sunnybrook Health Sciences Centre, University of Toronto , Ontario , Canada
| | - Nir Melamed
- a Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine , Sunnybrook Health Sciences Centre, University of Toronto , Ontario , Canada
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Algergawy A, Gamal R. Prophylactic Cervical Cerclage versus Vaginal Progesterone in Triplet Pregnancy—A Randomized Prospective Comparative Study. ACTA ACUST UNITED AC 2017. [DOI: 10.4236/ojog.2017.71012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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The greater risk of preterm birth in triplets is mirrored by a more rapid cervical shortening along gestation. Am J Obstet Gynecol 2016; 215:357.e1-6. [PMID: 26996985 DOI: 10.1016/j.ajog.2016.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/16/2016] [Accepted: 03/10/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The risk of preterm birth increases with plurality. However, data are limited about the role of cervical length in triplet pregnancies and how the greater predisposition for preterm birth in triplet pregnancies, compared with twin pregnancies, is reflected by cervical length. Specifically, it is unclear whether the greater predisposition of triplet pregnancies for preterm birth is reflected by a more rapid cervical shortening during gestation compared with twin pregnancies (and therefore a shorter cervical length at any given gestational age), by a greater risk for preterm birth per given cervical length at any given gestational age, or both. OBJECTIVE The purpose of the study was to compare the rate of cervical shortening during gestation and the correlation between cervical length and gestational age at birth in asymptomatic women with triplet vs twin pregnancies. STUDY DESIGN This was a retrospective study of women with triplet or twin pregnancies who were who were observed in a tertiary center who underwent serial sonographic measurement of cervical length from 16-32 weeks gestation. Change in cervical length during gestation and relationship of cervical length with gestational age at birth were compared between the triplets and twins groups. RESULTS A total of 431 measurements of cervical length from 86 women with triplets was analyzed and compared with 2826 measurements of cervical length from 441 women with twins. The rate of cervical shortening among triplet pregnancies was higher than among twin pregnancies starting from 18 weeks of gestation (slope of regression line, -1.297 vs -0.907; P < .001). Similarly, the proportion of women with cervical length of <25 mm or 15 mm was higher among triplet pregnancies than among twin pregnancies (34.0% vs 21.0% [P < .001] and 16.7% vs 8.4% [P = .001]), respectively. For any given cervical length measured after 22 weeks of gestation, the associated gestational length at birth in triplet pregnancies was lower by 2.7 weeks on average compared with twin pregnancies (P < .001). CONCLUSION The higher rate of preterm birth in triplet pregnancies, compared with twin pregnancies, is reflected by both a more rapid cervical shortening during gestation and a lower gestational age at birth per any given cervical length.
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Young CM, Stanisic T, Wynn LB, Shrivastava VL, Haydon ML, Wing DA. Use of cerclage in triplet pregnancies with an asymptomatic short cervix. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:343-347. [PMID: 24449739 DOI: 10.7863/ultra.33.2.343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The purpose of this study was to compare the outcomes of triplet pregnancies in women with asymptomatic cervical shortening with and without a cervical cerclage. METHODS A retrospective review of all triplet pregnancies with biweekly serial cervical length surveillance was performed. Cervical shortening was defined as a cervical length of 2.5 cm or less before 24 weeks' gestation. Patients with cervical shortening managed with cerclage were compared to those managed expectantly. The primary outcome was the gestational age at delivery, with secondary outcomes including birth weight, neonatal intensive care unit length of stay, and composite neonatal outcome. Statistical significance was defined as P < .05. RESULTS Sixteen patients underwent cerclage placement versus 8 managed expectantly (control group). The median gestational ages at delivery were similar between the groups (cerclage, 31.3 weeks; interquartile range [IQR], 29.3-32.3 weeks; control, 29.8 weeks; IQR, 27.5-32.4 weeks; P = .71). The median birth weights were also similar between the groups (cerclage, 1283 g; IQR, 800-1626 g; control, 1109 g; IQR, 776-1500 g; P = .54). There was no significant difference in composite neonatal outcomes between the cerclage and control groups (P = .67). CONCLUSIONS In this limited case-control study, we found no benefit in terms of pregnancy prolongation or neonatal outcomes with cerclage placement for triplet gestations complicated by an asymptomatic short cervix.
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Affiliation(s)
- Christopher M Young
- Department of Obstetrics and Gynecology, University of California, Irvine, 101 The City Dr S, Building 56, Suite 800, Orange, CA 92869 USA.
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