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...

Efficacy of cervical cerclage as a prophylactic measure in the management of triplet gestations

“…No statistically significant difference was produced in terms of birth age, neonate mortality and morbidity rate, including fetal blood pH. [9] However, all 3 studies were limited by a relatively small sample size. The more recent study by Rebarber, Roman, Istwan, Rhea and Stanziano used a significantly larger sample, therefore containing more power than the previous studies and reducing the chance of type II error.…”

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

“…8,13,19 The criteria for patient and sample size selection and hospitalisation in previous research is not uniform. 10,[19][20][21] Some studies have demonstrated that prophylactic cerclage is of no value in prolonging gestation in high-order multiple pregnancies. 10,14,19,22 In contrast, other studies have found that prophylactic cerclage significantly increases the mean gestational age and decreases the incidence of extreme prematurity.…”

“…10,14,19,22 In contrast, other studies have found that prophylactic cerclage significantly increases the mean gestational age and decreases the incidence of extreme prematurity. [20][21][22] Nevertheless, routine prophylactic cervical cerclage is not recommended for every woman with a multiple pregnancy and the safety and efficacy of the procedure as a form of preterm birth prevention should be appraised on a case-by-case basis according to obstetric history and cervical assessment. 12,14 In a study of current practices to prevent preterm births, Baker et al found that the majority of Canadian specialists (82%) recommended routine cervical length assessment at 16-21 gestational weeks, with none supporting routine cerclage insertion; however, 71% stated that they would perform cerclage based on the patient's history or an ultrasound.…”

Transabdominal cervical cerclage in triplet pregnancies and risk of extreme prematurity and neonatal loss

“…To date, reports have been pessimistic with regard to prophylactic vaginal cerclage in reducing extreme prematurity in multifetal pregnancies (Berg et al 1983;Bernasko et al 2006;Dor et al 1982;Itzkowic 1979;Lipitz et al 1989;Mordel et al 1993;Rebarber et al 2005;Roman et al 2005;Ron-El et al 1981;Ron-El et al 1992;Strauss et al 2002;Zakut et al 1977). Only Goldman et al (1989) and Elimian et al (1999) reported improved pregnancy outcomes in triplet pregnancies undergoing vaginal cerclage.…”

“…Several retrospective studies have evaluated the use of elective transvaginal cerclage (TVC) to prolong triplet pregnancy, with conflicting results (Bernasko et al 2006;Elimian et al 1999;Goldman et al 1989;Itzkowic 1979;Lipitz et al 1989;Mordel et al 1993;Rebarber et al 2005;Strauss et al 2002;Zakut et al 1977), However, no studies have evaluated the use of prophylactic transabdominal cerclage (TAC) in this population. The purpose of this study was to compare gestational age and incidence of extreme pre-term delivery among triplet pregnancies who underwent a prophylactic TAC to those who underwent a prophylactic TVC and those that did not have a cerclage.…”