Routine Cervical Cerclage in Higher Order Multiple Gestation — Does It Prolong the Pregnancy?

Abstract

P reterm birth following cervical dilatation is the greatest threat to infants of a multiple pregnancy. Lacking reliable data concerning the effect of prophylactic cerclage, we compared a study group to controls for maternal and perinatal outcome. Sixteen of 94 triplet-, 9 of 18 quadruplet/quintupletpregnancies, treated with prophylactic cerclage, were retrospectively compared to those without cervical cerclage respectively. Kruskal-Wallis test and Mann-Whitney-U test were performed as non-parametric one way analysis of variance. For the analysis of frequencies Chi Square test or Fisher's exact test were performed. Odds ratio with 95% confidence interval was used to compare the need for intravenous tocolysis as well as perinatal morbidity and mortality. Gestational age at delivery was not different from the controls in all studied groups. Birth weight revealed a 200g dominance for the "no cerclage-triplets", while this significant difference was inverted for quadruplets/quintuplets (1245g vs. 1069g). With respect to gestational age at birth, need for hospitalisation or medical intervention no benefit was achieved. Moreover, perinatal outcome analysed by arterial pH, APGARScore and perinatal mortality was not altered by a prophylactic cerclage. Perinatal morbidity for quadruplets and quintuplets was even higher in cerclage pregnancies. Therefore, these retrospective results disclaim a positive impact of cervical cerclage on pregnancy management or perinatal outcome in multifetal pregnancies.Prematurity has the highest impact on the outcome of multiple pregnancies. The risk of preterm birth and analogous adverse fetal outcome increases with the number of fetuses. For twins, it is up to four times that in singletons (Day et al., 1997). The incidence of preterm delivery is reported to be 30-50% in twins and 66-100% in higher order multiples (Crowther, 1998). Preterm labor, premature preterm rupture of the membranes (PPROM) or cervical dilatation can lead to preterm delivery. Effective prevention of preterm birth would be the major breakthrough with a significant impact on the outcome of multiple pregnancies.Cervical dilatation is a frequent complication particularly in case of multiple pregnancies and is sometimes considered an indication for prophylactic cervical cerclage. The true incidence of the cervical affection is difficult to assess. In the literature, a range from 8-15% is reported.Several prenatal interventions aimed at prolonging multiple pregnancies have been validated. Two trials that assessed the value of prophylactic cervical cerclage in 50 and 194 twin pregnancies found no difference concerning the risk of preterm birth or perinatal mortality (Dor et al., 1982;Rush et al., 1984). Nevertheless, the presented data is too sparse to give any clear picture of the potential effects of routine cerclage in twins.The aim of this study is to evaluate the effect of prophylactic cervical cerclage on perinatal outcome of higher order multiple pregnancies in order to clarify the "cerclage dilemma". Materials and M...

Cervical Length in the Early Second Trimester for Detection of Triplet Pregnancies at Risk for Preterm Birth

“…The limited success (if any) of these intervention policies in singletons and twins is not promising with respect to triplets. [16][17][18] The lack of efficacious intervention led to extreme measures such as MFPR to improve perinatal outcome by some, whereas others found such measures ineffective. 19,20 In conclusion, with establishment of secondtrimester cervical length as a valid tool for early detection of high-risk multifetal gestations, obstetricians should continue their quest for efficacious intervention to prevent prematurity and its ensuing morbidity.…”

Comprimento do colo uterino e dilatação do orifício interno avaliados pela ultra-sonografia bidimensional e tridimensional

“…De acordo com a revisão dos artigos indexados no Medline até março de 2006, oito pesquisas foram encontradas [11][12][13][14][18][19][20][21] . Quatro 11,19-21 delas relataram a aferição do volume da cérvice em gravidez única ou múltipla; quatro [12][13][14]18 focaram a medida do comprimento cervical.…”

Costs of maternal and neonatal medical care for triplet and quadruplet pregnancies in Japan

“…There are no reports of randomized controlled trials with large subject numbers, although several reports have demonstrated that prophylactic cervical ligature does not affect the gestational age at delivery of triplets. 10,11 The average cost for prophylactic cervical ligature, with a hospital stay of 2 weeks, was approximately ¥350 000 at this institution. If in the future it is definitively shown that prophylactic cervical ligature is not effective in preventing premature delivery in triplets, this cost can be eliminated without affecting medical outcomes.…”