title: Efficacy of ultrasound-indicated cerclage in twin pregnancies.
abstract: OBJECTIVE
  We sought to compare the perinatal outcomes in twin pregnancies with short cervical length (CL) with ultrasound-indicated cerclage (UIC) vs no cerclage (control).
  
  
  METHODS
  This was a retrospective cohort study of asymptomatic twin pregnancies with transvaginal ultrasound (TVU) CL ≤25 mm at 16-24 weeks from 1995 through 2012 at 4 separate institutions. Exclusion criteria were: genetic or major fetal anomaly, multifetal reduction >14 weeks, monochorionic-monoamniotic placentation, or medically indicated preterm birth (PTB). Primary outcome was spontaneous PTB (SPTB) <34 weeks. Secondary outcome was SPTB <28, <32, and <37 weeks. We also planned to evaluate primary and secondary outcome for the subgroup of twin pregnancies with CL ≤15 mm.
  
  
  RESULTS
  In all, 140 women with twin pregnancy and TVU-CL ≤25 mm were managed with either UIC (n = 57) or no cerclage (n = 83). Demographic characteristics were not significantly different except women who underwent UIC presented at an earlier gestational age (GA) at diagnosis of short CL. After adjusting for GA at presentation, there were no differences in GA at delivery or SPTB <28 weeks: 12 (21.2%) vs 20 (24.1%) (adjusted odds ratio [aOR], 0.3; 95% confidence interval [CI], 0.68-1.37), <32 weeks: 22 (38.6%) vs 36 (43.4%) aOR, 0.34; 95% CI, 0.1-1.13), or <34 weeks: 29 (50.9%) vs 53 (63.9%) (aOR, 0.37; 95% CI, 0.16-1.1). In the subgroup of women with CL ≤15 mm (32 with UIC and 39 controls) the interval between diagnosis to delivery was significantly prolonged by 12.5 ± 4.5 vs 8.8 ± 4.6 weeks (P < .001); SPTB <34 weeks was significantly decreased: 16 (50%) vs 31 (79.5%) (aOR, 0.51; 95% CI, 0.31-0.83) as was admission to neonatal intensive care unit: 38/58 (65.5%) vs 63/76 (82.9%) (aOR, 0.42; 95% CI, 0.24-0.81) when the UIC group was compared with the control group, respectively.
  
  
  CONCLUSIONS
  UIC in asymptomatic twin pregnancies with TVU-CL ≤25 mm was not associated with significant effects on perinatal outcomes compared to controls. However, in the planned subgroup analysis of asymptomatic twin pregnancies with TVU-CL ≤15 mm before 24 weeks, UIC was associated with a significant prolongation of pregnancy by almost 4 more weeks, significantly decreased SPTB <34 weeks by 49%, and admission to neonatal intensive care unit by 58% compared with controls.
authors: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA. Electronic address: amanda.roman@jefferson.edu.
authors: Amanda
authors: A
authors: Roman
authors: Division of Maternal-Fetal Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY.
authors: Burton
authors: B
authors: Rochelson
authors: Maternal Fetal Medicine Associates, PLLC, New York, NY.
authors: Nathan S
authors: NS
authors: Fox
authors: Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, DE.
authors: Matthew
authors: M
authors: Hoffman
authors: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.
authors: Vincenzo
authors: V
authors: Berghella
authors: Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, DE.
authors: Vrunda
authors: V
authors: Patel
authors: Department of Obstetrics and Gynecology, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY.
authors: Ilia
authors: I
authors: Calluzzo
authors: Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.
authors: Gabriele
authors: G
authors: Saccone
authors: Division of Maternal-Fetal Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY.
authors: Adiel
authors: A
authors: Fleischer
mesh_terms: D000328:Adult; D023802:Cerclage, Cervical; D054791:Cervical Length Measurement; D015331:Cohort Studies; D005260:Female; D006801:Humans; D011247:Pregnancy; D011248:Pregnancy Complications / Q000000981:diagnostic imaging* / Q000601:surgery*; D011256:Pregnancy Outcome; D059285:Pregnancy, Twin; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: cervical length; preterm birth; twin pregnancy; ultrasound-indicated cerclage