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Park JY, Lee KN, Kim HJ, Choe K, Cho A, Kim B, Seo J, Kwon H, Kim JW, Bae JG, Sung JH, Lee SJ, Jung YM, Han YJ, Hong S, Chung JH, Won HS, Jun JK. Pregnancy outcomes of cerclage in twin gestations: a multicenter retrospective cohort study. J Matern Fetal Neonatal Med 2024; 37:2355495. [PMID: 38880661 DOI: 10.1080/14767058.2024.2355495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/10/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVES To determine the effects of cerclage on twin pregnancies. METHODS A multicenter, retrospective, cohort study was conducted at 10 tertiary centers using a web-based data collection platform. The study population included twin pregnancies delivered after 20 weeks of gestation. Patients with one or two fetal deaths before 20 weeks of gestation were excluded. Maternal characteristics, including prenatal cervical length (CL) and obstetric outcomes, were retrieved from the electronic medical records. RESULTS A total of 1,473 patients had available data regarding the CL measured before 24 weeks of gestation. Seven patients without CL data obtained prior to cerclage were excluded from the analysis. The study population was divided into two groups according to the CL measured during the mid-trimester: the CL ≤2.5 cm group (n = 127) and the CL >2.5 cm group (n = 1,339). A total of 127 patients (8.7%) were included in the CL ≤2.5 cm group, including 41.7% (53/127) who received cerclage. Patients in the CL >2.5 cm group who received cerclage had significantly lower gestational age at delivery than the control group (hazard ratio (HR): 1.8; 95% confidence interval (CI): 1.11-2.87; p = .016). Patients in the CL ≤2.5 cm group who received cerclage had a significantly higher gestational age at delivery than the control group (HR: 0.5; 95% CI: 0.30-0.82; p value = .006). CONCLUSIONS In twin pregnancies with a CL ≤2.5 cm, cerclage significantly prolongs gestation. However, unnecessary cerclage in women with a CL >2.5 cm may result in a higher risk of preterm labor and histologic chorioamnionitis although this study has a limitation originated from retrospective design.
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Affiliation(s)
- Jee Yoon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kyong-No Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Obstetrics and Gynecology, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Hyeon Ji Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kiroong Choe
- Department of Computer Science and Engineering, Seoul National University, Seoul, Republic of Korea
| | - Aeri Cho
- Department of Computer Science and Engineering, Seoul National University, Seoul, Republic of Korea
| | - Bohyoung Kim
- Division of Biomedical Engineering, Hankuk University of Foreign Studies, Yongin, Republic of Korea
| | - Jinwook Seo
- Department of Computer Science and Engineering, Seoul National University, Seoul, Republic of Korea
| | - Hayan Kwon
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Woon Kim
- Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Jin-Gon Bae
- Department of Obstetrics and Gynecology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Ji-Hee Sung
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Se Jin Lee
- Department of Obstetrics and Gynecology, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Young Mi Jung
- Department of Obstetrics and Gynecology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - You Jung Han
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, Republic of Korea
| | - Subeen Hong
- Department of Obstetrics and Gynecology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin-Hoon Chung
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong Kwan Jun
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
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Oyelese Y. Randomized controlled trials: not always the "gold standard" for evidence in obstetrics and gynecology. Am J Obstet Gynecol 2024; 230:417-425. [PMID: 37838101 DOI: 10.1016/j.ajog.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/20/2023] [Accepted: 10/07/2023] [Indexed: 10/16/2023]
Abstract
Randomized controlled trials are considered the "gold standard" for therapeutic interventions, and it is not uncommon for sweeping changes in medical practice to follow positive results from such trials. However, randomized controlled trials are not without their limitations. Physicians frequently view randomized controlled trials as infallible, whereas they tend to dismiss evidence derived from sources other than randomized controlled trials as less credible or reliable. In several situations in obstetrics and gynecology, there are no randomized controlled trials to help guide the clinician. In these circumstances, it is important to evaluate the entire body of evidence including observational studies, rather than dismiss interventions altogether simply because no randomized controlled trials exist. Randomized controlled trials and observational studies should be viewed as complementary rather than at odds with each other. Some reversals in widely adopted clinical practice have recently been implemented following subsequent studies that contradicted the outcomes of major randomized controlled trials. The most notable of these was the withdrawal from the market of 17-hydroxyprogesterone caproate for preterm birth prevention. Such reversals could potentially have been averted if the inherent limitations of randomized controlled trials were carefully considered before implementing these universal practice changes. This Clinical Opinion underscores the limitations of an exclusive reliance on randomized controlled trials while disregarding other evidence in determining how best to care for patients. Solutions are proposed that advocate that clinicians adopt a more balanced perspective that considers the entirety of the available medical evidence and the individual patient characteristics, needs, and wishes.
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Affiliation(s)
- Yinka Oyelese
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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D'Antonio F, Eltaweel N, D'Amico A, Khalil A. Role of cerclage in twin and singleton pregnancy: evidence from systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:567-569. [PMID: 37983619 DOI: 10.1002/uog.27539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Affiliation(s)
- F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - N Eltaweel
- Division of Biomedical Science, Warwick Medical School, University of Warwick, University Hospital of Coventry and Warwickshire, Coventry, UK
| | - A D'Amico
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's Hospital, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
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Lu Y, Zhu J, Yu X, Li Z, Zhou T, Chen J, Huang X, Xiang H, Bao J, Xu Z. Perinatal outcomes of twin emergency cerclage: comparison with expectant treatment and singleton emergency cerclage. J OBSTET GYNAECOL 2023; 43:2211658. [PMID: 37178123 DOI: 10.1080/01443615.2023.2211658] [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: 05/15/2023]
Abstract
The present study aimed to evaluate the perinatal outcomes and influencing factors in twin pregnancies undergoing emergency cervical cerclage. The present retrospective cohort study included clinical data that were recorded between January 2015 and December 2021 at The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University (China). The study included data from 103 pregnancies (26 twin and 77 singleton pregnancies) that underwent emergency cerclage and 17 twin pregnancies that underwent expectant treatment. The median gestational age of twin emergency cerclage was significantly lower than that of singleton emergency cerclage, but higher than that of expectant treatment (28.5, 34.0 and 24.0 weeks, respectively). The median interval to delivery of twin emergency cerclage was significantly lower than that of singleton emergency cerclage, but significantly higher than that of expectantly treated twin pregnancies (37.0, 78.0 and 7.0 days, respectively).IMPACT STATEMENTWhat is already known on this subject? An important cause of premature birth is cervical insufficiency. Cervical cerclage extends the gestational period of women with cervical insufficiency. According to 2019 SOGC's No. 373-Cervical Insufficiency and Cervical Cerclage, both twin and single pregnancies benefit from emergency cerclage. However, there is minimal information about the pregnancy outcomes of emergency cerclage in twin pregnancies.What the results of this study add? This study shows that the outcomes of pregnancy in twin pregnancies undergoing emergency cerclage were better than that of expectant treatment but worse than that in singleton pregnancies undergoing emergency cerclage.What the implications are of these findings for clinical practice and/or further research? In this study, pregnant women with cervical insufficiency in twin pregnancies can benefit from emergency cerclage, we should treat those pregnant women as early as possible.
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Affiliation(s)
- Yuanfan Lu
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, P. R. China
| | - Jing Zhu
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, P. R. China
| | - Xiaoting Yu
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, P. R. China
| | - Zhenyao Li
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, P. R. China
| | - Tong Zhou
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, P. R. China
| | - Jiajia Chen
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, P. R. China
| | - Xianping Huang
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, P. R. China
| | - Huiqiu Xiang
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, P. R. China
| | - Jiale Bao
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, P. R. China
| | - Zhangye Xu
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, P. R. China
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Hulshoff CC, Bosgraaf RP, Spaanderman MEA, Inthout J, Scholten RR, Van Drongelen J. The efficacy of emergency cervical cerclage in singleton and twin pregnancies: a systematic review with meta-analysis. Am J Obstet Gynecol MFM 2023; 5:100971. [PMID: 37084870 DOI: 10.1016/j.ajogmf.2023.100971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/31/2023] [Accepted: 04/09/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVE An emergency (rescue) cervical cerclage can be offered to pregnant women presenting with dilatation and prolapsed membranes in the second trimester of pregnancy because of cervical insufficiency. This study aimed to investigate the effectiveness of an emergency cerclage in both singleton and twin pregnancies in the prevention of extreme premature birth. DATA SOURCES We performed a systematic literature search in PubMed and Embase from inception to June 2022 for transvaginal cervical emergency cerclages. STUDY ELIGIBILITY CRITERIA All studies on transvaginal cervical emergency cerclages with at least 5 patients and reporting survival were included. METHODS Included studies were assessed for quality and risk of bias with an adjusted Quality In Prognosis Studies tool. Random-effects meta-analyses and meta-regressions were performed for the primary outcome: survival. RESULTS Our search yielded 96 studies, incorporating 3239 women, including 14 studies with an expectant management control group, incorporating 746 women. Overall survival after cervical emergency cerclage was 74%, with a fetal survival of 88% and neonatal survival of 90%. Singleton and twin pregnancies showed similar survival, with a pregnancy prolongation of 52 and 37 days and a gestational age at delivery of 30 and 28 weeks, respectively. Meta-regression analyses indicated a significant inverse association between mean gestational age at diagnosis and pregnancy prolongation and no association between dilatation or gestational age at diagnosis and gestational age at delivery. Compared with expectant management, emergency cerclage significantly increased overall survival by 43%, fetal survival by 17% and neonatal survival by 22%, along with a significant pregnancy prolongation of 37 days and reduction in delivery at <28 weeks of gestation of 55%. These effects were more profound in singleton pregnancies than in twin pregnancies. CONCLUSION This systematic review indicates that, in pregnancies threatened by extreme premature birth because of cervical insufficiency, emergency cerclage leads to significantly higher survival, accompanied by significant pregnancy prolongation and reduction in delivery at <28 weeks of gestation, compared with expectant management. The mean gestational age at delivery was 30 weeks, independent of dilatation or gestational age at diagnosis. Survival was similar for singleton and twin pregnancies, implying that emergency cerclage should be considered in both.
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Affiliation(s)
- Cecile C Hulshoff
- Departments of Obstetrics and Gynecology (Drs Hulshoff, Bosgraaf, Spaanderman, Scholten, and Drongelen).
| | - Remko P Bosgraaf
- Departments of Obstetrics and Gynecology (Drs Hulshoff, Bosgraaf, Spaanderman, Scholten, and Drongelen); Department of Obstetrics and Gynecology, Catharina Hospital, Eindhoven, The Netherlands (Dr Bosgraaf)
| | - Marc E A Spaanderman
- Departments of Obstetrics and Gynecology (Drs Hulshoff, Bosgraaf, Spaanderman, Scholten, and Drongelen); Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands (Dr Spaanderman)
| | - Joanna Inthout
- Health Evidence (Dr Inthout), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ralph R Scholten
- Departments of Obstetrics and Gynecology (Drs Hulshoff, Bosgraaf, Spaanderman, Scholten, and Drongelen)
| | - Joris Van Drongelen
- Departments of Obstetrics and Gynecology (Drs Hulshoff, Bosgraaf, Spaanderman, Scholten, and Drongelen)
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Clinical Value and Treatment Progress of Prenatal Ultrasonography in Twin Pregnancy: A Systematic Review. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:6748487. [PMID: 36051930 PMCID: PMC9424050 DOI: 10.1155/2022/6748487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/23/2022] [Accepted: 07/01/2022] [Indexed: 11/23/2022]
Abstract
Assisted reproductive technology has continued to develop in recent years, the technology has become more and more mature, and it has improved the total gestational age of the population. Assisted reproductive technology has improved twin pregnancy rates with the use of ovulation-inducing drugs. The risk factor of twins is much higher than singletons, and adverse pregnancy outcomes such as stillbirth and premature birth are more likely to occur than singletons, especially the special complications of monochorionic twins (MC), and the neonatal mortality and morbidity are also increased. Prenatal diagnosis and prognosis of twin pregnancy, as well as therapeutic interventions, are of current concern. Ultrasound can realize the understanding of intrauterine growth and development of twin pregnancy fetuses during pregnancy, can more accurately determine gestational age, organ function, and maturity, and timely detect fetal growth and development abnormalities in twin pregnancy, while the prognosis and treatment still need further improvement. The purpose of this study was to investigate the clinical value and treatment progress of prenatal ultrasound monitoring in twin pregnancy.
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Kumari P, Kumar M, David LS, Vijayaselvi R, Yadav B, Beck MM. A retrospective study analyzing indications and outcomes of mid-trimester emergency cervical cerclage in a tertiary care perinatal centre over half a decade. Trop Doct 2022; 52:391-399. [PMID: 35361021 DOI: 10.1177/00494755221080590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We studied the indications, success rate, perinatal outcomes and maternal complications following mid-trimester emergency cervical cerclage. All women undergoing mid-trimester emergency cerclage at our centre during 2014-2019 were included in this retrospective study.There were 46 women in our cohort. Mean cervical length was 1.5 cm (SD ± 0.7), and 52.1% of them had bulging membranes. The mean gestational age at cerclage was 23.35 weeks (SD ± 3.341). Three were loss to follow up.Out of 43 pregnancies (23 singletons and 20 twins) analyzed, 37/43, 86.4% had livebirths. Success rate in the singletons and twins were 91.3% and 80% respectively. Maternal complications were seen in 56.5% of patients. Composite neonatal morbidity was significantly more in the twin group (p-value 0.04).Overall live birth rate was 86.4% with similar success rates in singleton and multiple pregnancies. Although, evidence for beneficial effect of prophylactic cerclage in multiple gestation is lacking, emergency cerclage may have a role in twin gestation.
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Affiliation(s)
- Pushplata Kumari
- Department of Obstetrics and Gynaecology, 30025Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Manish Kumar
- Department of Neonatology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Liji Sarah David
- Department of Obstetrics and Gynaecology, 30025Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Reeta Vijayaselvi
- Department of Obstetrics and Gynaecology, 30025Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Manisha Madhai Beck
- Department of Obstetrics and Gynaecology, 30025Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Ponce J, Benítez L, Baños N, Goncé A, Bennasar M, Muñoz M, Cobo T, Palacio M. Latency to delivery in physical examination-indicated cerclage in twins is similar to that in singleton pregnancies. Int J Gynaecol Obstet 2021; 159:188-194. [PMID: 34890050 DOI: 10.1002/ijgo.14070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/08/2021] [Accepted: 12/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare latency to delivery and perinatal outcomes between twin and singleton pregnancies undergoing physical examination-indicated cerclage. METHODS Retrospective observational study (2007-2017) of women who underwent physical examination-indicated cerclage at the Hospital Clinic of Barcelona. Primary outcomes were latency from cerclage to delivery and gestational age at delivery. Secondary outcomes included: neonatal morbidity and mortality, preterm prelabor rupture of membranes, clinical chorioamnionitis and cerclage displacement. Wilcoxon-test and χ2 test were used to compare continuous and categorical variables. RESULTS Sixty women were included (17 twins and 43 singletons). There were no differences in gestational age at cerclage or presence of bulging membranes between groups. Median (25th;75th percentile) gestational age at delivery was 27.1 (24.5;32.3) weeks in the twin group and 27.6 (25.3;35.3) weeks in the singleton group (P = 0.594). There were no statistically significant differences in latency from cervical cerclage to delivery between the two groups (43 days [21;64] vs. 29 days [16;76], respectively; P = 0.938). There were no differences in neonatal mortality (2/26 [7.7%] vs. 1/33 [3.1%]; P = 0.578) or in composite neonatal morbidity (14 [53.9%] vs. 14 [42.4%]; P = 0.283) between groups, respectively. CONCLUSION These results suggest that physical examination-indicated cerclage placement in twins could prolong latency to delivery similarly to singleton pregnancies.
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Affiliation(s)
- Júlia Ponce
- Hospital Clínic - BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Catalonia, Spain
| | - Leticia Benítez
- Hospital Clínic - BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Catalonia, Spain
| | - Núria Baños
- Hospital Clínic - BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Catalonia, Spain
| | - Anna Goncé
- Hospital Clínic - BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Catalonia, Spain
| | - Mar Bennasar
- Hospital Clínic - BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Catalonia, Spain
| | - Míriam Muñoz
- Hospital Clínic - BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Catalonia, Spain
| | - Teresa Cobo
- Hospital Clínic - BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Catalonia, Spain.,Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Montse Palacio
- Hospital Clínic - BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Catalonia, Spain.,Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Zeng C, Fu Y, Pei C, Zhao Y, Wang W, Zhang W. Pregnancy outcomes and factors affecting the clinical effects of emergency cerclage in twin pregnancies with cervical dilation and prolapsed membranes. Int J Gynaecol Obstet 2021; 157:313-321. [PMID: 34076897 DOI: 10.1002/ijgo.13774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/18/2021] [Accepted: 06/01/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the effect of mid-trimester emergency cerclage in women with twin pregnancies with cervical dilation and prolapsed membranes, and to identify risk factors predicting spontaneous preterm birth (sPTB) before 28 weeks, after cerclage. METHODS Retrospective analysis of twin gestations with cervical dilation and prolapsed membranes treated with emergency cerclage or expectant management (2015-2020). The primary outcomes were the rate of sPTB before 28 weeks and the gestational latency. Multiple logistic regression analysis was used to determine the factors associated with sPTB before 28 weeks, after cerclage. RESULTS Ninety-seven women were included, cerclage (n = 58) or no cerclage (n = 39). Cerclage placement was associated with significantly lower incidence of sPTB before 28 weeks of pregnancy (34.5% vs 82.1%) and prolongation of the gestational latency (46.71 ± 27.52 vs 10.95 ± 11.71 days). Positive cervical culture (odds ratio [OR] 10.69, 95% confidence interval [CI] 1.82-62.95), pregnancy duration at diagnosis less than 22 weeks (OR 9.42; 95% CI 1.69-52.69) and cervical dilation at least 4 cm (OR 7.92; 95% CI 1.40-44.71) were found to be independent risk factors for sPTB before 28 weeks, after cerclage. CONCLUSION Emergency cerclage in women with twin pregnancies with cervical dilation and prolapsed membranes was associated with an overall 40% decrease in sPTB before 28 weeks and a prolongation of latency by 5 weeks. The strongest predictor of sPTB before 28 weeks after cerclage was a positive cervical culture.
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Affiliation(s)
- Chanjuan Zeng
- Department of Obstetrics and Gynecology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yimei Fu
- Department of Obstetrics and Gynecology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chenlin Pei
- Department of Obstetrics and Gynecology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yanhua Zhao
- Department of Obstetrics and Gynecology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Weinan Wang
- Department of Obstetrics and Gynecology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Weishe Zhang
- Department of Obstetrics and Gynecology, Xiangya Hospital, Central South University, Changsha, Hunan, China.,Hunan Engineering Research Center of Early Life Development and Disease Prevention, Hunan, China
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10
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Khalil A, Liu B. Controversies in the management of twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:888-902. [PMID: 32799348 DOI: 10.1002/uog.22181] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/18/2020] [Accepted: 07/30/2020] [Indexed: 06/11/2023]
Abstract
Despite many advances in antenatal care, twin pregnancies still experience more adverse outcomes, in particular perinatal morbidity and mortality. They also pose a multitude of challenges and controversies, as outlined in this Review. Moreover, they are less likely to be included in clinical trials. Many issues on classification and management remain under debate. Efforts at standardizing diagnostic criteria, monitoring protocols, management and outcome reporting are likely to reduce their perinatal risks. The top 10 most important research uncertainties related to multiple pregnancies have been identified by both clinicians and patients. More robust research in the form of randomized trials and large well-conducted prospective cohort studies is needed to address these controversies. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Khalil
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - B Liu
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
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11
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Li C, Hua K. Efficacy of physical examination-indicated cerclage in twin pregnancies compared with singleton pregnancies: a systematic review and meta-analysis. Minerva Obstet Gynecol 2021; 73:111-120. [PMID: 32315128 DOI: 10.23736/s2724-606x.20.04518-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION To compare the pregnancy outcomes of physical examination-indicated cerclage (PEIC) between twin and singleton pregnancies with acute cervical insufficiency. EVIDENCE ACQUISITION We searched Medline, Ovid, Scopus, EBSCO, ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials from their commencement until Dec 2019 for relevant studies. Patient-level data abstraction and analysis were done by two independent authors. EVIDENCE SYNTHESIS A total of five studies with 786 women were included in the final analysis. The pooled outcomes showed that PEIC was associated with a similar reduction in preterm birth (PTB) at <32 (Risk ratio [RR] 0.93, 95% CI 0.79-1.11, I2=0%, P=0.43), and 28 (RR 1.03, 95% CI 0.82-1.29, I2=0%, P=0.81) weeks of gestation; however, a much higher frequency of PTB was observed at <36 (RR 0.74, 95% CI 0.66-0.83, I2=0%, P<0.000), and 34 (RR 0.80, 95% CI 0.68-0.93, I2=0%, P=0.004) weeks of gestation in twin pregnancies than in singleton pregnancies. No significant differences in perinatal outcomes, including neonatal death (RR 1.03, 95% CI 0.64-1.67, I2=52%, P=0.900), stillbirth (RR 0.73, 95% CI 0.37-1.44, I2=0%, P=0.360), perinatal mortality (RR 0.94, 95% CI 0.65-1.38, P=0.760) and neonatal complications were found between twin and singleton pregnancies. CONCLUSIONS Our meta-analysis indicated that PEIC achieved good perinatal prognosis in both singleton and twin pregnancies. However, because the available evidence is insufficient to attain a strong conclusion, so further high-quality trials are needed to confirm our findings.
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Affiliation(s)
- Chunbo Li
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Keqin Hua
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China -
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Wei M, Yang Y, Jin X, Yang J, Huang D, Zhang S. A comparison of pregnancy outcome of emergency modified transvaginal cervicoisthmic cerclage performed in twin and singleton pregnancies. Arch Gynecol Obstet 2021; 303:1197-1205. [PMID: 33386955 DOI: 10.1007/s00404-020-05852-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 10/17/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare the pregnancy outcome of emergency cerclage performed in twin and singleton pregnancies. METHODS A retrospective trial was carried out in the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital in Zhejiang, China, from January 2013 to December 2018. A total of 89 women with acute cervical incompetence underwent the emergency cerclage. Main outcome measures were gestational age at delivery and the fetal outcome. RESULTS There were 31 twin and 58 singleton pregnancies that underwent emergency cerclage. In singleton pregnancies, gestational age at delivery (31.57 ± 6.11 vs 28.81 ± 4.34, p = 0.016), and prolongation of pregnancy (8.69 ± 6.13 vs 5.41 ± 3.72, p < 0.001) were greater, and the preterm delivery rate before 34 weeks was lower (53.4% vs 80.6%, p = 0.011) compared with twin pregnancies. Fetal weight was greater in singletons than in twins (2377.3 ± 862.1 vs 1630.3 ± 557.6, p < 0.001), but the fetal survival rate was similar. The proportion of twin gestations was significantly higher in the group with preterm delivery before 34 weeks (44.6% vs 18.2%, p = 0.011) and the proportion of previous term delivery was higher in the group with delivery at or after 34 weeks (30.3% vs 12.5%, p = 0.039). The group with preterm delivery before 34 weeks had a significantly larger size of visible membranes at cerclage than the group with delivery at or after 34 weeks (2.23 ± 0.86 vs 1.64 ± 0.80, p = 0.001). In binary logistic regression analysis, twin gestations and a larger size of visible membranes were associated with an increased risk of preterm delivery. CONCLUSION The pregnancy outcome of emergency cerclage appears to have a better prognosis in singleton pregnancies than in twin pregnancies, and twin pregnancy is a risk factor for preterm delivery.
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Affiliation(s)
- Minling Wei
- Center of Reproductive Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China
| | - Yang Yang
- Center of Reproductive Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China
| | - Xiaoying Jin
- Center of Reproductive Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China
| | - Jingyan Yang
- Center of Reproductive Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China
| | - Dong Huang
- Center of Reproductive Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China
| | - Songying Zhang
- Center of Reproductive Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China.
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, 3# Qingchun East Road, Hangzhou, 310016, People's Republic of China.
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Park JY, Oh KJ, Lee S, Kim NK, Lee YE, Park YH, Hong JS. A new quantification system for assessing the degree of acute cervical insufficiency based on physical and sonographic examination. Eur J Obstet Gynecol Reprod Biol 2020; 256:372-378. [PMID: 33278713 DOI: 10.1016/j.ejogrb.2020.11.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/06/2020] [Accepted: 11/12/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Acute cervical insufficiency accounts for 10-25 % of all mid-trimester pregnancy losses. However, the definition and description for the degree of acute cervical insufficiency were obscure and different among the many studies. The aim of this study was to suggest a new 4-digit quantification system and to evaluate the outcome according to the new system in women with acute cervical insufficiency. STUDY DESIGN A retrospective cohort study was conducted in patients with acute cervical insufficiency who underwent physical examination indicated cervical cerclage. Acute cervical insufficiency was defined as painless external os dilation with prolapsed and/or visible membranes on speculum examination. The status of fetal membranes was described using two values: 1) size of the prolapsed membrane (P, measured using ultrasound); and 2) size of visible fetal membranes (M, evaluated by speculum examination). The status of cervix was described using two values: 1) dilatation of the narrowest os (O, measured by ultrasound); and 2) functional cervical length (C, measured by ultrasound). The patients were divided into 3 groups as follows: Stage I, patients with visible fetal membranes (M > 0) but with a remaining functional cervix (C > 0) (N = 7); stage II, those with visible fetal membranes (M > 0) and a functional cervical length of 0 but without prolapsed membranes (P = 0) (N = 33); and stage III, those with prolapsed membranes (P > 0) (N = 40). RESULTS 1) Patients who delivered before 34 weeks of gestation had a significantly lower median gestational age at cerclage operation and a significantly higher median P, M, C values than those who delivered at or beyond 34 weeks of gestation(P < 0.01 for gestational age at operation, P and M values; P < 0.05 for C value); 2) The higher the stage based on PMOC quantification system, the greater the risk of preterm delivery before <24, <32, <34, and <37 weeks of gestation (P < 0.001 for all); 3) The neonatal survival rate was 100 % (7/7) for stage I, 93.9 % (31/33) for stage II, and 60 % (24/40) for stage III. CONCLUSION The PMOC system was a simple method to describe the individualized conditions and to predict the risk of preterm births in all spectrums of acute cervical insufficiency.
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Affiliation(s)
- Jee Yoon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Kyung Joon Oh
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.
| | - Sukjeong Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Nam-Kyeong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Young-Eun Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Ye Hyon Park
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Joon-Seok Hong
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
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McDonnell BP, Martin A. Delayed interval delivery of preterm multiples: experience from a large specialized twin center. J Matern Fetal Neonatal Med 2020; 35:2227-2233. [PMID: 32586161 DOI: 10.1080/14767058.2020.1782375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Preterm delivery is a recognized complication of twins and higher order multiple pregnancies. Delayed interval delivery is a rarely used management option for pre- or peri-viable preterm labor in these pregnancies. We describe the management and outcomes of 7 delayed interval deliveries over an 8-year period in a large specialized twin center.Study design: A retrospective cohort study of all delayed interval deliveries of preterm multiples from 2009 to 2016, defined as >24 h between deliveries of twins 1 and 2.Results: During the study period there were 68,845 deliveries with 1377 multiple pregnancies comprising 1331 sets of twins and 46 sets of higher-order multiples. 7 of these were identified as being delayed interval deliveries - 6 twin pregnancies and 1 triplet pregnancy. The mean gestation of delivery of the first infant was 23 + 4 weeks (range 22 + 3 to 30 + 0 weeks) with a mean interval of 10 days (range 1.5-39 days). Outcomes for the first infant delivered were poor, with 5 out of 7 (71%) dying from extreme prematurity. However, out of the remaining twins or triplets, 5/8 (62%) survived. The mean gestation of delivery of the remaining infant (or infants in the triplets) was 25 + 0 weeks (range 23 + 0 to 30 + 2 weeks). Only one mother (16%) developed clinical chorioamnionitis requiring iatrogenic delivery of the remaining infant with subsequent neonatal death due to extreme prematurity. There were no cases of severe maternal morbidity - however, there was one maternal death in the cohort due to an amniotic fluid embolism. The neonatal follow up of the surviving infants to date is mostly normal.Conclusion: Delayed interval deliveries can offer hope for survival for the remaining infant(s) with an acceptable risk profile to the mother. Close clinical and laboratory monitoring is essential to reduce the risk of severe maternal morbidity.
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Affiliation(s)
| | - Aisling Martin
- Coombe Women and Infants University Hospital, Dublin, Ireland
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Benito Vielba M, De Bonrostro Torralba C, Espiau Romera A, Roca Arquillue M, Campillos Maza JM, Castán Mateo S. Uterocervical angle as a predictor of spontaneous preterm birth in twin pregnancies. J Matern Fetal Neonatal Med 2020; 35:1878-1885. [PMID: 32466704 DOI: 10.1080/14767058.2020.1771553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Objective: To assess the ability of uterocervical angle (UCA) compared with cervical length (CL) to predict the risk of spontaneous preterm birth (sPTB) in twin pregnancies and its performance when it was included in a combined predictive model of clinical and ultrasonographic parameters.Methods: We conducted a retrospective cohort study of twin pregnancies undergoing transvaginal ultrasound between 19+0-21+6 weeks to measure CL during routine second trimester scan from January 2015 through December 2016. Recorded ultrasound images of CL were reassessed to evaluate UCA. Medical and obstetric data were also collected for statistical analysis. A logistic regression model was created for predicting sPTB including UCA and other variables.Results: A total of 177 women were included. The rates of sPTB rate below 28, 32 and 34 weeks of gestation were 4.5%, 6.8% and 12.4%, respectively. ROC curves showed a better area under the curve (AUC) for UCA at all gestational ages compared with CL (AUC for sPTB <28 weeks 0.840 (p = .005) vs 0.627 (p = .388); AUC for sPTB <32 weeks 0.706 (p = .022) vs 0.619 (p = .255); AUC for sPTB <34 weeks 0.674 (p = .008) vs 0.568 (p = .344). UCA >117 degrees was significantly associated with sPTB <28 weeks (p = .002; OR 15.3; CI 1.66-142.37; NPV, 99.2%), <32 weeks (OR 3.84; p = .031) and <34 weeks of gestation (OR 3.10; p = .016). Based on multivariate analyses, the best predictive model included uterocervical angle (p = .032), cervical length (p = .002) and maternal height (p = .001) (Nagelkerke R2 0.944).Conclusion: In our study, an UCA > 117 degrees allowed to identify those women with twin pregnancies at risk of sPTB and performed better than CL measurement. Our combined prediction model was able to adequately predict the risk of sPTB in the twin pregnancies of our research.
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Affiliation(s)
- Marta Benito Vielba
- Department of Obstetrics and Gynecology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Andrea Espiau Romera
- Department of Obstetrics and Gynecology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - Sergio Castán Mateo
- Department of Obstetrics and Gynecology, Hospital Universitario Miguel Servet, Zaragoza, Spain
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Ponce J, Benítez L, Baños N, Goncé A, Muñoz M, Cobo T, Palacio M. Latencia al parto tras cerclaje de emergencia en gestación múltiple. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2020. [DOI: 10.1016/j.gine.2019.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Berger R, Abele H, Bahlmann F, Bedei I, Doubek K, Felderhoff-Müser U, Fluhr H, Garnier Y, Grylka-Baeschlin S, Helmer H, Herting E, Hoopmann M, Hösli I, Hoyme U, Jendreizeck A, Krentel H, Kuon R, Lütje W, Mader S, Maul H, Mendling W, Mitschdörfer B, Nicin T, Nothacker M, Olbertz D, Rath W, Roll C, Schlembach D, Schleußner E, Schütz F, Seifert-Klauss V, Steppat S, Surbek D. Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and the Management of Preterm Premature Rupture of Membranes. Geburtshilfe Frauenheilkd 2019; 79:813-833. [PMID: 31423017 PMCID: PMC6690742 DOI: 10.1055/a-0903-2735] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 01/25/2023] Open
Abstract
Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). Recommendations Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.
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Affiliation(s)
- Richard Berger
- Frauenklinik, Marienhaus Klinikum Neuwied, Neuwied, Germany
| | - Harald Abele
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Franz Bahlmann
- Frauenklinik, Bürgerhospital Frankfurt, Frankfurt am Main, Germany
| | - Ivonne Bedei
- Frauenklinik, Klinikum Frankfurt Höchst, Frankfurt am Main, Germany
| | | | - Ursula Felderhoff-Müser
- Klinik für Kinderheilkunde I/Perinatalzentrum, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
| | - Herbert Fluhr
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Yves Garnier
- Frauenklinik, Klinikum Osnabrück, Osnabrück, Germany
| | | | - Hanns Helmer
- Universitätsklinik für Frauenheilkunde, Medizinische Universität Wien, Wien, Austria
| | - Egbert Herting
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Markus Hoopmann
- Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Irene Hösli
- Frauenklinik, Universitätsspital Basel, Basel, Switzerland
| | - Udo Hoyme
- Frauenklinik, Ilm-Kreis-Kliniken, Arnstadt, Germany
| | | | - Harald Krentel
- Frauenklinik, Annahospital Herne, Elisabethgruppe Katholische Kliniken Rhein Ruhr, Herne, Germany
| | - Ruben Kuon
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Wolf Lütje
- Frauenklinik, Evangelisches Amalie Sieveking-Krankenhaus Hamburg, Hamburg, Germany
| | - Silke Mader
- European Foundation for the Care of the Newborn Infants
| | - Holger Maul
- Frauenklinik, Asklepios Kliniken Hamburg, Hamburg, Germany
| | - Werner Mendling
- Deutsches Zentrum für Infektionen in Gynäkologie und Geburtshilfe an der Frauenklinik, Helios Universitätsklinikum Wuppertal, Wuppertal, Germany
| | | | | | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, Berlin, Germany
| | - Dirk Olbertz
- Abteilung Neonatologie und neonatologische Intensivmedizin, Klinikum Südstadt Rostock, Rostock, Germany
| | - Werner Rath
- Emeritus, Universitätsklinikum Aachen, Aachen, Germany
| | - Claudia Roll
- Vestische Kinder- und Jugendklinik Datteln, Universität Witten/Herdecke, Datteln, Germany
| | - Dietmar Schlembach
- Klinik für Geburtsmedizin, Klinikum Neukölln/Berlin Vivantes Netzwerk für Gesundheit, Berlin, Germany
| | | | - Florian Schütz
- Frauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | | | - Daniel Surbek
- Universitäts-Frauenklinik, Inselspital, Universität Bern, Bern, Switzerland
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Huang X, Saravelos SH, Li TC, Huang R, Xu R, Zhou Q, Ma N, Xia E. Cervical cerclage in twin pregnancy. Best Pract Res Clin Obstet Gynaecol 2019; 59:89-97. [PMID: 31331744 DOI: 10.1016/j.bpobgyn.2019.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
Cervical cerclage in women with twin pregnancy is not routinely indicated but appears to be beneficial in subjects with a history of preterm birth or very short cervix or dilated cervix. There is a paucity of literature data regarding transabdominal or laparoscopic cervical cerclage (LCC) in twin pregnancy. It is uncertain whether LCC is more effective than transvaginal cerclage. Our own experience of 24 cases of LCC in twin pregnancy showed encouraging results. Further, well-planned studies are required to answer whether, when, and how cervical cerclage should be performed in women with twin pregnancy.
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Affiliation(s)
- Xiaowu Huang
- Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing, China
| | - S H Saravelos
- IVF Unit, Hammersmith Hospital, Imperial College, London, UK
| | - Tin-Chiu Li
- Assisted Reproductive Technology Unite, Prince of Wales Hospital, The Chinese University of HongKong, HongKong
| | - Rui Huang
- Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing, China
| | - Ruonan Xu
- Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing, China
| | - Qiaoyun Zhou
- Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing, China
| | - Ning Ma
- Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing, China
| | - Enlan Xia
- Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing, China.
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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; 32:2143-2151. [PMID: 29363371 PMCID: PMC6251764 DOI: 10.1080/14767058.2018.1427719] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/03/2018] [Accepted: 01/10/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate whether cerclage in twins reduces the rate of spontaneous preterm birth <32 weeks when compared to expectant management. METHODS This is a retrospective cohort study of twin pregnancies with the following indications for cerclage from two institutions: history of prior preterm birth, ultrasound-identified short cervix ≤2.5 cm, and cervical dilation ≥1.0 cm. The "cerclage" cohort received a cerclage from a single provider at a single institution from 2003-2016. The "no cerclage" group included all patients with similar indications that were expectantly managed from 2010-2015, at a second institution where cerclages are routinely not performed in twin pregnancies. The primary outcome was the rate of spontaneous preterm birth at <32 weeks. Secondary outcomes were the rates of spontaneous and overall (including medically indicated) preterm births at <32 weeks, < 34 weeks, and <36 weeks, chorioamnionitis, birth weight, and neonatal mortality within 30 days of life. We also performed a planned subgroup analysis stratified by cerclage indication. RESULTS In all, 135 women were included in two cohorts: cerclage (n = 96) or no cerclage (n = 39). The rates of spontaneous preterm birth <32 weeks were 10.4% (n = 10) with cerclage versus 28.2% (n = 11) without cerclage (OR 0.23, CI 0.08-0.70, p = .017). After adjusting for cerclage indication, clinical history, age, chorionicity, insurance type, race, BMI, in-vitro fertilization, and multifetal reduction, there remained a significant reduction in the cerclage group of spontaneous preterm birth <32 weeks (adjusted odds ratio (aOR) 0.24, CI 0.06-0.90, p = .035), spontaneous preterm birth <36 weeks (aOR 0.34, CI 0.04-0.81, p = .013) as well as in overall preterm birth <32 weeks (aOR 0.31, CI 0.1-0.86, p = .018), and overall preterm birth <36 weeks (aOR 0.37, CI 0.10-0.84, p = .030). When stratified by short cervix or cervical dilation in the cerclage versus no cerclage groups, there was a significant decrease in spontaneous preterm birth <32 weeks in the cerclage group with cervical dilation (11.1 versus 41.2%, p = .01) but not in the cerclage group with short cervix only, even for cervical length <1.5 cm. Pregnancy latency was 91 days in the cerclage group versus 57 days in the no cerclage group (p = .001), with a median gestational age at delivery of 35 versus 32 weeks (p = .002). There was no increase in chorioamnionitis in the cerclage group. Furthermore, there was a significant increase in birth weight (median 2278 versus 1665 g, p < .001) and decrease in perinatal death <30 days (1.6 versus 12.9%, p = .001). CONCLUSIONS Cerclage in twin pregnancies significantly decreased the rate of spontaneous preterm birth <32 weeks compared to expectant management. However, when stratified by cerclage indication, this decrease in primary outcome only remained significant in the group with cervical dilation.
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Affiliation(s)
- Michelle N Han
- a Department of Obstetrics & Gynecology , University of California , Los Angeles , CA , USA
| | - Betsy E O'Donnell
- b Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences , University of California , San Francisco , CA , USA
| | - Melanie M Maykin
- b Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences , University of California , San Francisco , CA , USA
| | - Juan M Gonzalez
- b Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences , University of California , San Francisco , CA , USA
| | - Khalil Tabsh
- a Department of Obstetrics & Gynecology , University of California , Los Angeles , CA , USA
| | - Stephanie L Gaw
- b Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences , University of California , San Francisco , CA , USA
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20
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Cerclage for women with twin pregnancies: a systematic review and metaanalysis. Am J Obstet Gynecol 2019; 220:543-557.e1. [PMID: 30527942 DOI: 10.1016/j.ajog.2018.11.1105] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/21/2018] [Accepted: 11/24/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE DATA This study was conducted to estimate whether cerclage could extend the prolongation of pregnancy, reduce the risk of preterm birth, and improve perinatal outcomes in women with twin pregnancies. STUDY ELIGIBILITY CRITERIA We included randomized controlled trials and cohort studies comparing the efficacy of cerclage with no cerclage for women with twin pregnancies. STUDY APPRAISAL AND SYNTHESIS METHODS The following databases were searched for all published studies that compared cerclage placement with expectant management in twin pregnancies from inception to July 2018: Medline, EMBASE, Scopus, ClinicalTrials.gov, Web of Science, and Cochrane Library. Each report was reviewed for inclusion or exclusion standard, and data extraction was performed by 2 authors independently. RESULTS A total of 16 studies with 1211 women that met the inclusion criteria were included in the final analysis. Our outcomes indicated that cerclage placement for twin pregnancies with a cervical length of <15 mm was associated with significant prolongation of pregnancy by a mean difference of 3.89 weeks of gestation (95% confidence interval, 2.19-5.59; P=.000; I2=0%) and a reduction of preterm birth at <37 weeks of gestation (risk ratio, 0.86; 95% confidence interval, 0.74-0.99; P=.040; I2=0%), <34 weeks of gestation (risk ratio, 0.57; 95% confidence interval, 0.43-0.75; P=.000; I2=0%) and <32 weeks of gestation (risk ratio, 0.61; 95% confidence interval, 0.41-0.90; P=.010; I2=0%), compared with those pregnancies in the control group. For women with a dilated cervix of >10 mm, cerclage placement was associated with significant prolongation of pregnancy by a mean difference of 6.78 weeks of gestation (95% confidence interval, 5.32-8.24; P=.000; I2=0%); a reduction of preterm birth at <34 weeks of gestation (risk ratio, 0.56; 95% confidence interval, 0.45-0.69; P=.000; I2=28%), <32 weeks of gestation (risk ratio, 0.50; 95% confidence interval, 0.38-0.65; P=.000; I2=14%), <28 weeks of gestation (risk ratio, 0.41; 95% confidence interval, 0.20-0.85; P=.030; I2=80%), and <24 weeks of gestation (risk ratio, 0.35; 95% confidence interval, 0.18-0.67; P=.001; I2=24%), and improvement of perinatal outcomes compared with those in the control group. However, for twin pregnancies with a normal cervical length (eg, cerclage for an indication for women with a history of preterm birth or twin alone), the efficacy of cerclage placement was less certain because of the limited data. CONCLUSION Our metaanalysis indicates that cerclage placement is beneficial for the reduction of preterm birth and the prolongation of pregnancy in twin pregnancies with a cervical length of <15 mm or dilated cervix of >10 mm. However, the benefit of history-indicated or twin alone-indicated cerclage is less certain in twin pregnancies with normal cervical length according to current literature. Further high-quality studies were needed to confirm the findings.
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Effects of emergency cerclage on the neonatal outcomes of preterm twin pregnancies compared to preterm singleton pregnancies: A neonatal focus. PLoS One 2018; 13:e0208136. [PMID: 30475916 PMCID: PMC6258419 DOI: 10.1371/journal.pone.0208136] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/12/2018] [Indexed: 11/19/2022] Open
Abstract
Objective To evaluate the efficacy and safety of emergency cerclage (EC) in preterm twins by comparing neonatal outcomes of preterm twins with those of preterm singletons. Study design This is a single-institution retrospective study of preterm infants born to women who underwent EC from 2008 to 2014. We compared various maternal and neonatal factors. The primary and secondary goals were to compare the maternal and neonatal morbidities and neonatal mortality, respectively. Results One hundred fifty-three infants were included comprising 32(21%) twins and 121(79%) singletons. The mean gestational age (GA) at the time of EC and the number of days from EC to delivery were not significantly different (47.9±27.5 vs. 48.3±35.5). The rate of preterm delivery at ≤32 weeks GA (69% vs. 79%) and ≤28 weeks GA (50% vs. 55%), and other prematurity-associated morbidities were not significantly different. The survival rate during hospitalization was 75% (24/32) in twins and 88% (107/121) in singletons (P = 0.054). Death within 7 days after birth occurred in 8 twins (25%) and 7 singletons (6%) (P = 0.001). All of the infants were <1,000 g with a GA of ≤27 weeks. Conclusion Compared to EC in singleton pregnancies, EC in twin pregnancies resulted in a higher mortality rate for preterm babies. EC might be considered a salvage procedure for selective twin pregnancies with cervical insufficiency.
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Park JY, Cho SH, Jeon SJ, Kook SY, Park H, Oh KJ, Hong JS. Outcomes of physical examination-indicated cerclage in twin pregnancies with acute cervical insufficiency compared to singleton pregnancies. J Perinat Med 2018; 46:845-852. [PMID: 29116935 DOI: 10.1515/jpm-2017-0218] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/02/2017] [Indexed: 11/15/2022]
Abstract
Objectives To compare pregnancy outcomes of physical examination-indicated cerclage in twin pregnancies with acute cervical insufficiency with that of singletons. Methods This retrospective cohort study included 88 consecutive women (17 twins and 71 singletons) who had undergone physical examination-indicated cerclage because of acute cervical insufficiency (defined as painless cervical dilation with (1) prolapsed and/or visible membranes at the external cervical os on speculum examination and (2) a functional cervical length of zero on transvaginal ultrasound) between 160/7 and 236/7 weeks. The primary outcome measure was preterm delivery <34 weeks. Results (1) The frequency of preterm delivery <34 weeks was not significantly different between the two groups [twins, 56% (9/16) vs. singleton, 53% (37/70), P>0.999]. (2) The perinatal mortality was 21% (7/34) in twins and 32% (23/71) in singletons. (3) The median gestational age at delivery for twin pregnancies was 31.0 weeks (IQR, 22.6-36.5 weeks), which was similar to that of singleton pregnancies (median 32.4 weeks; IQR 22.3-38.3 weeks). (4) There were no significant differences in preterm delivery before 28 and 32 weeks, interval from cerclage to delivery within 1, 2, 4 and 8 weeks and neonatal morbidities between the two groups. Conclusion The obstetric and neonatal outcomes of physical examination-indicated cerclage in twin pregnancies were comparable to those in singleton pregnancies.
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Affiliation(s)
- Jee Yoon Park
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Soo-Hyun Cho
- Health Promotion Center, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Se Jeong Jeon
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Song Yi Kook
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Hyunsoo Park
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Kyung Joon Oh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Joon-Seok Hong
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
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Mitric C, Ponette V. Successful Rescue Cerclage in a Monochorionic Diamniotic Twin Pregnancy at 20 Weeks: Case Report and Overview of Literature. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:473-475. [PMID: 29503249 DOI: 10.1016/j.jogc.2017.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND In twin pregnancies, elective cerclage placement based on obstetrical history or ultrasound findings has been shown to be ineffective and even harmful. There are currently no guidelines for the use of rescue cervical cerclage in twin pregnancies. CASE The current report presents the case of a 33-year-old patient with monochorionic diamniotic twins (MCDA) found to have dilated cervix at 3.5cm with exposed membranes upon physical examination at 19 weeks and 3 days. An emergency McDonald cerclage was placed at 20 weeks and the patient carried the current pregnancy until 35weeks 6 days. CONCLUSION Rescue cerclage represents an important option to consider in order to preserve twin pregnancies regardless of chorionicity.
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Affiliation(s)
- Cristina Mitric
- Department of Obstetrics and Gynecology, McGill University, Montreál, QC.
| | - Vincent Ponette
- Department of Obstetrics and Gynecology, McGill University, Montreál, QC
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A comparison of pregnancy outcome of modified transvaginal cervicoisthmic cerclage performed prior to and during pregnancy. Arch Gynecol Obstet 2018; 297:645-652. [PMID: 29302808 DOI: 10.1007/s00404-017-4636-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To compare the pregnancy outcome of the modified transvaginal cerclage performed preconception and during pregnancy. METHODS A retrospective trial was carried out in the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital in Zhejiang, China. A total of 604 women with cervical incompetence underwent the cerclage, and the time of the operation was decided by the patients or depended on when the patient presented. Main outcome measures were the gestational age and the fetal outcome. RESULTS After the cerclage, the mean gestational age at delivery and the term delivery rate were significantly higher in history-indicated conception cerclage compared to preconception cerclage (36.8 ± 3.7 vs 35.8 ± 4.7, p < 0.01; 76.1 vs 66.9%, p < 0.05). The mean gestational age at delivery and the term delivery rate were significantly higher in ultrasound-indicated compared to physical examination-indicated conception cerclage (35.0 ± 5.7 vs 31.0 ± 5.5, p < 0.01; 63.2 vs 23.3%, p < 0.001). The fetal survival rate had no difference in these two comparisons, respectively. CONCLUSIONS The modified transvaginal cervicoisthmic cerclage is a promising and safe technique to improve obstetric outcomes in women with cervical incompetence in different cerclage indications, and history-indicated conception cerclage appears to have better pregnancy outcome.
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Abstract
Cervical insufficiency can be defined by a combination of obstetric history, cervical dilation on exam, and/or short cervical length in women with prior preterm birth. Options for mechanical intervention include cerclage and pessary. There is evidence to support the benefit of a cervical cerclage in women with singleton gestations who have a diagnosis of cervical insufficiency either based on second trimester painless cervical dilatation leading to recurrent early preterm births, or a history of early spontaneous preterm birth and a second trimester transvaginal ultrasound short cervical length or cervical dilation on exam. For women with multiple gestations, the benefit of a cerclage is uncertain, and further study is warranted. The pessary has also been studied for mechanical prevention of preterm birth in various populations, however the results so far have been mixed and warrants further study prior to routine use.
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Affiliation(s)
- Rupsa C Boelig
- Sidney Kimmel Medical College, Thomas Jefferson University Division of Maternal Fetal Medicine, Philadelphia, PA.
| | - Vincenzo Berghella
- Sidney Kimmel Medical College, Thomas Jefferson University Division of Maternal Fetal Medicine, Philadelphia, PA
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Abbasi N, Barrett J, Melamed N. Outcomes following rescue cerclage in twin pregnancies. J Matern Fetal Neonatal Med 2017; 31:2195-2201. [DOI: 10.1080/14767058.2017.1338260] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Nimrah Abbasi
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Jon Barrett
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Nir Melamed
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
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AlBasri SF, Shouib GM, Bajouh OS, Nasrat HA, Ahmad E, AlGreisi FM. Maternal and neonatal outcomes in twin and triplet gestations in Western Saudi Arabia. Saudi Med J 2017; 38:657-661. [PMID: 28578447 PMCID: PMC5541191 DOI: 10.15537/smj.2017.6.17699] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 02/15/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Tocompare maternal and neonatal complications in twin and triplet gestations at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Methods: Retrospective medical records of 165 women with 144 twin and 21 triplet pregnancies from 2004 to 2011 were analyzed. Comparisons were carried out for maternal complications, gestational age at birth, neonatal birth weight, and neonatal intensive care admission. Results: Most common complications were preterm birth (49%), gestational diabetes mellitus (13.3%), and premature rupture of membrane (4.8%). All triplet pregnancies and 42% twin pregnancies terminated in preterm birth. Gestational length was longer (p less than 0.001) in twin births (36.0 ± 3.05 weeks) than for triplet births (32 ± 3.81 weeks). Rates for in vitro fertilization, ovulation induction, and cesareans were higher in women with triplets than in those with twins. Neonatal intensive care unit (NICU) admission was higher (p less than 0.001) for triplets (76.2%) than for twins (23.6%). The mean weight of twins was 2333.83 ± 558.69 grams and triplets was 1553.41 ± 569.73 grams. Hyaline membrane disease, neonatal jaundice, and neonatal sepsis were most common neonatal complications. Conclusion: Neonates from triplet pregnancies were preterm, had low birth weight and needed more often NICU admission in comparison to those from twin pregnancies.
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Affiliation(s)
- Samera F AlBasri
- Department of Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia. E-mail.
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Roman A, Rochelson B, Martinelli P, Saccone G, Harris K, Zork N, Spiel M, O’Brien K, Calluzzo I, Palomares K, Rosen T, Berghella V, Fleischer A. Cerclage in twin pregnancy with dilated cervix between 16 to 24 weeks of gestation: retrospective cohort study. Am J Obstet Gynecol 2016; 215:98.e1-98.e11. [PMID: 26827881 DOI: 10.1016/j.ajog.2016.01.172] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 01/10/2016] [Accepted: 01/20/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cervical dilation in the second trimester is associated with a greater than 90% rate of spontaneous preterm birth and a poor perinatal prognosis. OBJECTIVE To compare the perinatal outcomes of twin pregnancies with dilated cervix in women who underwent either cerclage or expectant management. STUDY DESIGN Retrospective cohort study of asymptomatic twin pregnancies identified with cervical dilation of ≥1 cm at 16-24 weeks (1997-2014) at 7 institutions. Exclusion criteria were genetic or major fetal anomaly, multifetal reduction at >14 weeks, prior cerclage placement, monochorionic-monoamniotic placentation, active vaginal bleeding, labor, chorioamnionitis, elective termination of pregnancy, or medically indicated preterm birth. The primary outcome was incidence of spontaneous preterm birth at <34 weeks. Secondary outcomes were incidence of spontaneous preterm birth at <32 weeks, <28 weeks, and <24 weeks; perinatal mortality; and composite adverse neonatal outcome (respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and sepsis). RESULTS A total of 76 women with twin pregnancy with dilated cervix of 1.0-4.5 cm were managed with either cerclage (n = 38) or expectant management (n = 38). Demographic characteristics were not significantly different. Analysis was adjusted for amniocentesis and vaginal progesterone use. In the cerclage group, 29 women (76%) received prophylactic indomethacin and 36 (94%) received prophylactic antibiotics, whereas the expectant management group did not. Interval from time at diagnosis of open cervix to delivery in the cerclage group was 10.46 ± 5.6 weeks vs 3.7 ± 3.2 weeks in the expectant management group, with a mean difference of 6.76 weeks (95% confidence interval [CI], 4.71-8.81). There were significant decreases in spontaneous preterm birth at <34 weeks (52.6% vs 94.7%; adjusted odds ratio [aOR], 0.06; 95% CI, 0.03-0.34), at <32 weeks (44.7% vs 89.4%; aOR, 0.08; 95% CI, 0.03-0.34); at <28 weeks (31.6% vs 89.4%; aOR, 0.05; 95% CI, 0.01-0.2); and at <24 weeks (13.1% vs 47.3%; aOR, 0.17; 95% CI, 0.05-0.54). There were also significant reductions in perinatal mortality (27.6% vs 59.2%; aOR, 0.24; 95% CI, 0.11-0.5), neonatal intensive care unit admission (75.9% vs 97.6%; aOR, 0.07; 95% CI, 0.01-0.66), and composite adverse neonatal outcome (33.9% vs 90.5%; aOR, 0.05; 95% CI, 0.01-0.21). CONCLUSION Cerclage, indomethacin, and antibiotics in twin pregnancies with dilated cervix ≥1 cm before 24 weeks were associated with significant longer latency period from diagnosis to delivery (6.7 weeks), decreased incidence of spontaneous preterm birth at any given gestational age, and improved perinatal outcome when compared with expectant management.
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Emergency Cerclage: Outcomes, Patient Selection, and Operative Considerations. Clin Obstet Gynecol 2016; 59:286-94. [DOI: 10.1097/grf.0000000000000197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
The number of multiple gestations has increased over the last several decades and preterm birth is one of the leading causes of perinatal morbidity and mortality for these pregnancies. While screening and treatment strategies have achieved moderate success in singleton gestations, screening strategies are less effective in multiple gestations. In addition, to date no intervention aimed at preventing preterm birth has been conclusively shown to either prolong gestation or improve neonatal outcomes for multiple gestations. As in singleton gestations, cervical length is one of the strongest predictors of preterm birth. While not conclusive, emerging data suggest that vaginal progesterone or cervical pessary may be able to prevent preterm birth in twin gestations with a short cervix.
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Cervical Pessary and Vaginal Progesterone in Twin Pregnancies With a Short Cervix. Obstet Gynecol 2016; 127:625-630. [DOI: 10.1097/aog.0000000000001300] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Doger E, Cakiroglu Y, Ceylan Y, Kole E, Ozkan S, Caliskan E. Obstetric and neonatal outcomes of delayed interval delivery in cerclage and non-cerclage cases: An analysis of 20 multiple pregnancies. J Obstet Gynaecol Res 2014; 40:1853-61. [DOI: 10.1111/jog.12435] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 02/20/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Emek Doger
- Department of Obstetrics and Gynecology; School of Medicine; Kocaeli University; Kocaeli Turkey
| | - Yigit Cakiroglu
- Department of Obstetrics and Gynecology; School of Medicine; Kocaeli University; Kocaeli Turkey
| | - Yasin Ceylan
- Department of Obstetrics and Gynecology; School of Medicine; Kocaeli University; Kocaeli Turkey
| | - Emre Kole
- Department of Obstetrics and Gynecology; School of Medicine; Kocaeli University; Kocaeli Turkey
| | - Sebiha Ozkan
- Department of Obstetrics and Gynecology; School of Medicine; Kocaeli University; Kocaeli Turkey
| | - Eray Caliskan
- Department of Obstetrics and Gynecology; School of Medicine; Kocaeli University; Kocaeli Turkey
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Cerclage in twins: we can do better! Am J Obstet Gynecol 2014; 211:5-6. [PMID: 24972530 DOI: 10.1016/j.ajog.2014.03.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 03/14/2014] [Indexed: 11/21/2022]
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Miller ES, Rajan PV, Grobman WA. Outcomes after physical examination-indicated cerclage in twin gestations. Am J Obstet Gynecol 2014; 211:46.e1-5. [PMID: 24657791 DOI: 10.1016/j.ajog.2014.03.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 02/15/2014] [Accepted: 03/14/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To compare outcomes of physical examination-indicated cerclage in women with twin gestations to those with singleton gestations and to identify whether risk factors for extremely preterm birth (before 28 weeks) differ between these 2 groups. STUDY DESIGN This is a single institution retrospective cohort study of women who underwent a physical examination-indicated cerclage between Jan. 1, 1980, and Aug. 15, 2012. Differences in characteristics and outcomes were compared between women with twin and singleton gestations. A multivariable analysis was performed to examine whether twin gestation was independently associated with delivery before 28 weeks and whether any effect modification was present between risk factors for preterm birth and the presence of a twin gestation. RESULTS Of the 442 women who underwent a cerclage during the period of study, 104 (23.5%) had twins. Mean gestational age and digital cervical length at placement did not differ by plurality. Although twins were more likely to deliver at a slightly earlier median gestation than singletons (31.9 weeks; interquartile range, 24.9-35.1 vs 32.7 weeks; interquartile range, 24.6-38.3; P = .015), the frequency of delivery before 28 weeks did not differ between these 2 groups (33.7% vs 35.8%, P = .69). Greater cervical dilation and prolapsing membranes were identified as risk factors for birth <28 weeks in both groups; digital cervical length <2 cm appeared to be a risk factor particularly for women with twin gestations. CONCLUSION Women with a twin pregnancy who received a physical examination-indicated cerclage had similar risk factors for extreme preterm birth and may experience similar obstetric outcomes as women with singleton gestations.
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Holcomb WL, Amon E, Albert JH. The effect of cerclage in twin gestations with short cervix: a Bayesian evaluation. J Matern Fetal Neonatal Med 2014; 28:448-53. [PMID: 24797964 DOI: 10.3109/14767058.2014.921151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Bayesian inference allows the revision of prior clinical estimates of treatment effectiveness based on current data. We apply it to a published dataset evaluating the effect of cerclage upon preterm delivery in twin gestations with a short cervix. STUDY DESIGN Prior probability distributions for delivery <35 weeks gestation for the control group and the treatment (cerclage) group were constructed under assumptions ranging from treatment having no effect (prior A) to halving early deliveries (prior C). Likelihood functions were calculated based on a published meta-analysis. Posterior probability densities were derived from which risk ratios for early delivery were computed, with 95% credible intervals and the probability of cerclage benefit. RESULTS Median posterior risk ratios (95% credible intervals) for delivery <35 weeks with cerclage are 1.51 (1.02-2.33) for prior A and 1.11 (0.72-1.77) for prior C. The probability of cerclage benefit ranged from 2.1% for prior A to 31.4% for prior C. By comparison, the conventional risk ratio (95% confidence interval) for early delivery, based on the data alone, is 2.08 (1.18-3.69). CONCLUSIONS As might be anticipated, those with low expectation of cerclage benefit remain more convinced of the ineffectiveness (or harm) of the procedure than those with higher expectations.
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Affiliation(s)
- William L Holcomb
- Maternal-Fetal Medicine Consultant, St. Joseph Health Center , St. Charles, MO , USA
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