Don’t place a cerclage in women with short cervix who are pregnant with twins.*
Women with a short cervical length who are pregnant with twins are at very high risk for delivering preterm, but the scientific data, including a meta-analysis of data published on this issue, shows that cerclage in this clinical situation not only is not beneficial, but may in fact be harmful, i.e., associated with an increase in preterm births.
This statement is being withdrawn based on recently published data that provides equipoise on the use of cerclage in patients with twin gestations and short cervix. The first study was a retrospective cohort of twin pregnancies with a cervix <2.5cm or cervix dilated > 1cm that demonstrated a decrease in the rate of spontaneous preterm birth <32 weeks of gestation with cerclage compared to those managed expectantly, especially in patients with cervical dilation. In a multicenter open-label randomized controlled trial, twin gestation with asymptomatic cervical dilation (defined as <5cm) between 16 and 23 6/7 of weeks gestation who received a physical exam indicated cerclage was observed to have a 50% decrease in preterm birth at <28 weeks of gestation and 78% reduction in perinatal mortality. These recent data are not an indication to recommend this intervention, however, is sufficient to remove any recommendation against it.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
As a national medical specialty society, the Society for Maternal-Fetal Medicine relies on the input of any number of its committees in the development of various documents. In the case of the items included in this list, the Publications Committee reviewed the literature and evidence from SMFM’s published documents for possible topics. For SMFM’s first set of five recommendations a sub-group of the Committee initially developed a list of 10 items that the Committee then ranked for the top five with input and suggestions by the Society’s Executive Committee. For SMFM’s second set of recommendations, the sub-group of the Committee developed a list of 12 items that the Committee then ranked for the top five, again soliciting input and suggestions by the Society’s Executive Committee. For SMFM’s third set of five recommendations, the sub-group of the Publications Committee developed a list of 10 items that the Committee ranked for the top five, again soliciting input and suggestions by the Society’s Executive Committee. The final lists have been reviewed and approved by the Society’s Document Review Committee and Executive Committee.
SMFM’s disclosure and conflict of interest policy can be found at www.smfm.org
Han MN, O’Donnell BE, Maykin MM, Gonzalez JM, Tabsh K, Gaw SL. The impact of cerclage in twin pregnancies on preterm birth rate before 32 weeks.J Matern Fetal Neonatal Med. 2019;32(13):2143-2151. doi:10.1080/14767058.2018.1427719
Roman A, Zork N, Haeri S, Schoen CN, Saccone G, Colihan S, Zelig C, Gimovsky AC, Seligman NS, Zullo F, Berghella V. Physical examination-indicated cerclage in twin pregnancy: a randomized controlled trial. Am J Obstet Gynecol. 2020 Jun 25:S0002-9378(20)30672-4. doi: 10.1016/j.ajog.2020.06.047. Epub ahead of print.