BACKGROUND
Twin pregnancies with a progressively shortening cervix in the midterm pregnancy have
an increasing risk for spontaneous preterm birth. Currently, there is no known effective
method to prevent preterm birth among those women, and the use of an ultrasound-indicated
cerclage in twin pregnancies is still controversial.
OBJECTIVE
This study aimed to estimate whether a combination of ultrasound-indicated cerclage,
indomethacin, and antibiotics in twin pregnancies between 18 and 26 weeks’ gestation
could extend the pregnancy, reduce the risk for spontaneous preterm birth, and improve
perinatal and neonatal outcomes.
STUDY DESIGN
A retrospective cohort study was conducted. The ultrasound-indicated cerclage group
included twin pregnancies with a transvaginal cervical length <25 mm that underwent
cerclage at 18 to 26 weeks of gestation in the Women's Hospital, Zhejiang University
School of Medicine, from December 2015 through August 2021. Twin pregnancies in our
study that underwent cerclage also received antibiotics and indomethacin. A control
group of twin pregnancies that were managed expectantly were matched with the treatment
group in terms of transvaginal cervical length at diagnosis (±3 mm), gestational age
at presentation of diagnosis (±3 weeks), and maternal age (±5 years). An additional
subanalysis was performed in which the patients were divided into 2 subgroups based
on transvaginal cervical length of either <15 mm or between 15 and 24 mm. The primary
outcome was gestational age at delivery. The secondary outcomes were pregnancy latency,
the rate of spontaneous preterm birth at <28, <32, <34, <36 weeks’ gestation, and
neonatal outcomes.
RESULTS
A total of 90 twin pregnancies with a transvaginal cervical length <25 mm were managed
with either a cerclage (ultrasound-indicated cerclage group, n=45) or expectantly
(control group, n=45). Demographic characteristics were not significantly different
between the groups. When compared with the control group, the gestational age at delivery
was significantly higher (33.11±3.16 vs 30.22±4.12 weeks; P=.001) and the pregnancy latency was significantly longer (72.40±22.51 vs 45.56±28.82
days; P<.001) in the ultrasound-indicated cerclage group. The rates of spontaneous preterm
birth at <28, <32, <34, and <36 weeks’ gestation were significantly lower in the ultrasound-indicated
cerclage group than in the control group. In terms of neonatal outcomes, there were
significant reductions in the overall perinatal mortality (4.4% vs 20.0%; P<.001), neonatal intensive care unit admissions (69.0% vs 92.6%; P<.001), and composite adverse neonatal outcomes (43.7% vs 64.7%; P=.010) for the ultrasound-indicated cerclage group when compared with the control
group. In the subgroup of women with a transvaginal cervical length of between 15
and 24 mm (with 21 in the ultrasound-indicated cerclage group vs 21 controls), the
data were adjusted for maternal age, pregestational body mass index, in vitro fertilization,
operative hysteroscopy, previous cervical surgery, previous spontaneous preterm birth,
white blood cell counts, C-reactive protein level, neutrophil to lymphocyte ratio,
and the shortest transvaginal cervical length measured at diagnosis. In ultrasound-indicated
cerclage group, gestational age at delivery was significantly higher (32.95±3.81 vs
30.24±4.01 weeks; beta, 3.34; 95% confidence interval, 0.14–6.55; P=.042), pregnancy latency was significantly prolonged (77.19±24.81 vs 48.52±29.67
days; beta, 33.81; 95% confidence interval, 12.29–55.34; P=.003), and the rates of spontaneous preterm birth <36 weeks’ gestation (57.1% vs
95.2%; adjusted odds ratio, 0.03; 95% confidence interval, 0.01–0.69; P=.029) was significantly decreased, and for neonatal outcomes, there were significant
reductions in neonatal intensive care unit admissions (53.7% vs 96.7%; adjusted odds
ratio, 0.04; 95% confidence interval, 0.01–0.32; P=.003) and the composite adverse neonatal outcomes (39.0% vs 73.3%; adjusted odds
ratio, 0.24; 95% confidence interval, 0.08–0.68; P=.008) in the ultrasound-indicated cerclage group when compared with the control group.
In the subgroup of women with a transvaginal cervical length <15 mm, gestational age
at delivery was higher (33.25±2.52 vs 30.00±4.33 weeks; beta, 3.96; 95% confidence
interval, 1.51–6.42; P=.002), pregnancy latency was significantly prolonged (68.21±19.85 vs 42.96±28.43
days; beta, 30.11; 95% confidence interval, 12.42–47.81; P=.001), rates of spontaneous preterm birth at <32 weeks (16.7% vs 54.2%; adjusted
odds ratio, 0.10; 95% confidence interval, 0.01–0.61; P=.020) and <34 weeks (54.2% vs 83.3%, adjusted odds ratio, 0.08; 95% confidence interval,
0.01–0.66; P=.019) of gestation was significantly decreased, and neonatal birthweight was significantly
increased (2023.96±510.35 vs 1421.77±611.40 g; beta, 702.40; 95% confidence interval,
297.02–1107.78; P=.001) in the ultrasound-indicated cerclage group when compared with the control group.
CONCLUSION
Cerclage among women with twin pregnancies with a transvaginal cervical length <25
mm may reduce the rate of spontaneous preterm birth and improve perinatal and neonatal
outcomes when compared with expectant management. It is worth noting that even with
a short transvaginal cervical length of 15 to 24 mm, cerclage will significantly decrease
the risk of delivery at <36 weeks’ gestation and prolong pregnancy latency. Among
women with a short transvaginal cervical length <15 mm, cerclage will significantly
decrease the risk of delivery at <32 and <34 weeks’ gestation and prolong pregnancy
latency.
Key words
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Article info
Publication history
Published online: January 10, 2023
Accepted:
December 20,
2022
Received in revised form:
November 27,
2022
Received:
September 28,
2022
Footnotes
L.Q., M.L., and C.C. contributed equally to this manuscript.
The authors report no conflict of interest.
This study was funded by the National Key Research and Development Program of China under grant number 2018YFC1004603. The sponsors or funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Cite this article as: Qiu L, Lv M, Chen C, et al. Efficacy of ultrasound-indicated cerclage in twin pregnancies: a retrospective case-control study matched by cervical length. Am J Obstet Gynecol MFM 2023;XX:x.ex–x.ex.
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