Is routine prophylactic cervical cerclage associated with significant prolongation of triplet gestation?

Vaginal delivery of triplets after emergency transvaginal cerclage: A case report and literature review

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.

Risk of preterm birth and neonatal outcomes after cerclage placement in triplet pregnancies

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.

Triplet pregnancy: What do we tell the prospective parents

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.

Cervical-length measurement in mid-gestation to predict spontaneous preterm birth in asymptomatic triplet pregnancy

OBJECTIVE

To assess the predictive value of sonographic cervical-length (CL) measurement in mid-gestation for spontaneous preterm birth (PTB) in asymptomatic triplet pregnancy.

METHODS

This was a retrospective study of asymptomatic triplet pregnancies followed at five Italian tertiary referral centers, between 2002 and 2015. CL was measured transvaginally between 18 and 24 weeks' gestation. Pregnancies with medically indicated PTB were excluded. Demographic and pregnancy characteristics of pregnancies complicated by PTB were analyzed and the distributions of CL measurements in these patients were calculated. Logistic regression analysis was performed to assess the association between CL and PTB, adjusted for confounders. Performance of CL measurement in prediction of PTB < 28, < 30 and < 32 weeks of gestation was assessed.

RESULTS

A total of 120 triplet pregnancies were included in the final analysis. Median CL was 35 (interquartile range (IQR), 29-40) mm measured at a median gestational age of 20 + 2 (IQR, 20 + 0 to 23 + 4) weeks. Overall, 23 (19.2%), 17 (14.2%) and eight (6.7%) patients had a CL < 25, < 20 and < 15 mm, respectively. Spontaneous PTB < 32 weeks occurred in 41 (34.2%) cases, < 30 weeks in 23 (19.2%) and < 28 weeks in 12 (10%) cases. CL < 15 mm was significantly more frequent in the group of patients who delivered < 28 (P = 0.03) and < 30 (P = 0.01) weeks' gestation, compared with those who delivered after 28 and after 30 weeks, respectively, while CL < 20 mm was more common in triplet pregnancies with delivery < 32 weeks compared with those delivered ≥ 32 weeks (P = 0.03). Logistic regression analysis was possible only for PTB < 32 weeks due to the small number of cases that delivered < 30 and < 28 weeks. After adjustment for confounders, CL was not significantly associated with PTB < 32 weeks (adjusted odds ratio, 0.97; 95% CI, 0.94-1.01). CL measurement had an area under the receiver-operating characteristics curve of 0.41 (95% CI, 0.20-0.62), 0.41 (95% CI, 0.26-0.56) and 0.42 (95% CI, 0.31-0.54) for the prediction of spontaneous PTB < 28, < 30 and < 32 weeks, respectively.

CONCLUSION

CL assessed in mid-gestation is a poor predictor of PTB < 28, < 30 and < 32 weeks' gestation in asymptomatic triplet pregnancy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Effectiveness of Prophylactic Cervical Cerclage in Prolonging Higher-Order Multiple Pregnancies

OBJECTIVES

This study aimed to assess the value of prophylactic cervical cerclage in prolonging higher-order multiple pregnancies.

METHODS

This retrospective study included all women with higher-order multiple pregnancies beyond 24 gestational weeks treated at the King Abdullah University Hospital in Irbid, Jordan, and King Fahad Medical City in Riyadh, Saudi Arabia, between February 2014 and January 2015. Selected maternal characteristics and obstetric outcomes were compared between women who received prophylactic cervical cerclage and those who did not.

RESULTS

A total of 146 women with higher-order multiple pregnancies were included in the study; of these, 94 (64.4%) underwent a prophylactic cervical cerclage insertion procedure and 52 (35.6%) women did not. No significant difference was found between the two groups with regards to maternal age, parity or number of fetuses. However, the mean gestational age at delivery was significantly higher for women without compared to those with prophylactic cervical cerclage (32.9 weeks versus 31.7 weeks) according to both univariate and multivariate analyses (P = 0.013 and 0.046, respectively). Additionally, 40.4% of women without and 14.9% of women with prophylactic cervical cerclage gave birth after 34 gestational weeks (P = 0.003).

CONCLUSION

Overall, prophylactic cervical cerclage was not associated with prolongation of the pregnancy among women with higher-order multiple pregnancies in the current study.

Current practices in the prediction and prevention of preterm birth in patients with higher-order multiple gestations

OBJECTIVE

We sought to determine the interventions utilized by maternal-fetal medicine specialists in the prediction and prevention of preterm labor in higher-order multiple (HOM) gestations.

STUDY DESIGN

Online questionnaires and email surveys were sent to all the maternal-fetal medicine specialists in Canada (n=122). Questionnaire items included interventions physicians routinely recommended for HOM gestations including: (1) bed rest; (2) cervical length measurement on transvaginal ultrasound; (3) corticosteroids use; (4) cerclage; and (5) tocolytic therapy.

RESULTS

Response rate was 66% (81/122), with 68% of respondents in practice for >10 years. Of physicians, 91% did not routinely recommend bed rest (95% confidence interval [CI], 84.7-97.2). In all, 82% (95% CI, 73.63-90.4%) recommended routine cervical length assessment with 32.3% (95% CI, 20.7-43.2) and 37.1% (95% CI, 25.3-48.6) of this group suggesting assessment at 16-18 and 19-21 weeks, respectively. Frequency of assessment varied from biweekly (53.3%; 95% CI, 40.9-65.0), to monthly (23.3%; 95% CI, 12.8-33.1), to a single measurement repeated only if abnormal (12.5%; 95% CI, 4.5-20.8). In all, 28% (95% CI, 18.2-37.8) recommended routine administration of corticosteroids for lung maturation. Timing of administration varied, with 24% initiating steroids between 24-26 weeks, 59% between 27-28 weeks, and 17% after 28 weeks. None reported routine cerclage placement. However, 71% (95% CI, 61.1-80.8) would perform cerclage based on history or ultrasound. Of respondents, 81% (95% CI, 72.4-89.5) would consider using tocolytic agents for threatened preterm labor including calcium channel blockers (94%), nonsteroidal antiinflammatory drugs (5%), and nitroglycerin transdermal patch (24%).

CONCLUSION

The variable practice guidelines and paucity of data for management of HOM pregnancy places the onus on individual practitioners to develop their own management schemes. This results in heterogeneous management, which is based on conflicting international guidelines, studies, expert opinion, or past experience.

Use of cerclage in triplet pregnancies with an asymptomatic short cervix

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.

Variable outcome in quintuplets pregnancy based on obstetric care

The incidence of multiple pregnancies has increased dramatically over the last few years in developed countries, largely attributed to delayed childbearing and the increasing use of assisted reproduction technologies and ovulation inducing hormones. Relatively few countries have population-based statistics covering birth statistics. Of those that do, the numbers of quintuplet pregnancies rose sharply in the nineties while, at the same time, their delivery rates decreased greatly because of the use of fetal reduction. Fetal reduction is not possible or legal in some countries, Poland being one of them, and therefore obstetricians are faced with the challenges of quintuplet deliveries. Conservative treatment and management is difficult, and outcomes often vary greatly. Despite this, expert care provided at tertiary care centers can positively influence outcomes. The objective of this article is to present different care options and their consequences in two illustrative cases, as well as to establish a set of obstetric care and management goals that would allow prolongation of the gestation time. Quintuplet pregnancy is rare but poses relevant clinical problems to both the obstetrician and the neonatologist. It should be managed with close cooperation between all concerned. Due to the extreme and invariable risk of premature delivery associated with quintuplet pregnancies, we recommend early diagnosis, adequate prenatal care at one tertiary medical center, routine hospitalization and bed rest, repeated ante partum ultrasound surveillance with tests of fetal well-being, tocolytic therapy at first signs of the risk of premature labor, and specialized neonatology care after delivery.

The role of ultrasound-indicated cerclage in triplets

OBJECTIVES

Preterm delivery is the leading cause of major perinatal morbidity and mortality associated with triplet pregnancies. The objective of this study was to evaluate the efficacy of ultrasound-indicated cervical cerclage in triplet pregnancies that are diagnosed with cervical shortening on biweekly transvaginal sonography (TVS).

METHODS

A retrospective review of all triplets who were followed with biweekly TVS for measurement of cervical length was conducted. Cervical shortening was defined as cervical length <or= 2.5 cm. Outcomes of interest included cervical cerclage placement, gestational age at delivery and birth weight.

RESULTS

In our population of 24 triplet pregnancies, 13 had cervical shortening. Of these, 54% underwent cervical cerclage at a mean gestational age of 20 weeks. Overall, patients without cervical shortening delivered on average 17 days later than those with cervical shortening (32 + 2 weeks vs. 29 + 6 weeks, P = 0.034). Moreover, infants of patients without cervical shortening weighed on average 456 g more at birth than did those with cervical shortening (1751 g vs. 1295 g, P = 0.039) and had a lower percentage of very low birth weight infants (30.3% vs. 69.2%, P = 0.002). Within the subset of patients with cervical shortening, there was no statistical difference in any of the outcomes studied between patients who underwent cervical cerclage and those who did not.

CONCLUSIONS

Triplet pregnancies complicated by cervical shortening diagnosed on biweekly TVS surveillance do not appear to benefit from placement of cervical cerclage, based on assessment of gestational age at delivery, birth weight and incidence of very low birth weight infants.

Twenty-six triplet pregnancies: a retrospective analysis

METHODS

Twenty-six triplet pregnancies were delivered over 6 years.

RESULTS

Over 80% of pregnancies resulted after infertility treatment (21/26). Mean maternal age was 32. On average, the infants were delivered after 32 + 0 weeks; in 4 cases delivery was at <28 weeks. In 1 case, the leading triplet was delivered spontaneously, the remaining babies by Caesarean. Main indications for Caesarean were: premature membrane rupture, premature contractions, maternal hospitalisation for foetal lung maturation/tocolysis/antibiotics. Mean birth weights were (triplet I-III): 1,730, 1,630 and 1,550 g. Hydrops fetalis and renal agenesis resulted in IUFD of the leading triplet in two cases. All newborns were cared for by neonatology.

CONCLUSIONS

Triplet pregnancies are challenging for all specialities involved. They should be managed from an early stage in cooperation with an experienced centre, allowing outpatient care for as long as possible if there are no complications. This also has a cost-reducing impact.