1. The frequency of delivery before 28 weeks was similar between singleton and twin gestations.
2. Greater cervical dilation, prolapsing membranes and short cervical length were risk factors for delivery before 28 weeks.
Evidence Rating Level: 2 (Good)
Study Rundown: This study found that physical exam-indicated cerclage in the 2nd trimester yields similar obstetric outcomes in singleton and twin gestations. Prior studies have demonstrated that cerclage can be useful in prolonging singleton pregnancies but little data exists to support use in twin gestations. Finding of the present work suggest that physical exam-indicated cerclages have similar efficacy in twin as compared to singleton gestations.
Limitations include retrospective design and lack of a control group, permitting comparisons only between cerclage pregnancies. Prospective investigation is warranted to determine whether cerclage yields superior outcomes relative to expectant management in twin gestations.
Study author, Dr. Emily Miller, MD MPH, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine at Northwestern Memorial Hospital talks to 2 Minute Medicine:
“While women with twins are more likely to experience cervical insufficiency compared to women with singletons, there is little evidence to guide the management of this condition in women with a multiple gestation. We compared outcomes of an exam-indicated cerclage in twins to that in singletons and found that rates of extreme prematurity (i.e., delivery before 28 or 32 weeks) did not differ between the two groups. While a randomized trial is needed to truly demonstrate efficacy, these data support the use of an exam-indicated cerclage in properly selected candidates with a twin pregnancy.”
In-Depth [retrospective cohort study]: This study compared obstetric outcomes of women with singleton (n=338) and twin (n=104) pregnancies following physical-exam indicated cerclage between 16 and 24 weeks gestational age. Outcomes evaluated include gestational age at delivery, latency post-cerclage and other complications such as PPROM, chorioamnionitis and NICU admission.
Delivery prior to 28 and 32 weeks did not significantly differ between singleton and twin gestations. Advanced cervical dilation (OR 1.42, CI 1.10-1.84) and membrane prolapse into (OR 2.59, CI 1.48-4.52) or beyond (OR 5.71, CI 2.76-11.79) the cervical canal were associated with increased odds of preterm birth prior to 28 weeks; later gestational age at cerclage placement was protective (OR 0.89, CI 0.81-0.99). Twin gestation was not associated with higher odds of preterm delivery prior to 28 weeks, though digital cervical length <2cm in twin gestations was associated with delivery before 28 weeks (OR 4.44, CI 1.30-15.14).
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