Cerclage for multiple pregnancy YES!

Veerendrakumar C.M MD.,DNB.

Associate professorDept of OBG,VIMS,Bellary

Preterm labor

One of the major health hazards of humans.

Carrying a multiple gestation significantly increases risk of delivering preterm.

PNMR increased

Mechanism for early preterm birth unclear.

Pathological mechanical stretching of uterus is the most common etiology causing twin preterm birth

Hodgson EJ, Preterm birth: a complex Disease,

Oxford: Wiley-Blackwell, 2010:8–16.

Strategies

Bed rest Tocolytics Cerclage

Very few weapons in our armamentarium One of the commonly performed surgical

interventions.

…and the positive evidence

Prophylactic cerclage decreased significantly the incidence of extremely LBW neonates in triplet pregnancies. The proportion of neonates delivered at 31 weeks or more, and at 32 weeks or more was higher in the cerclage group.

  1999 May-Jun;8(3):119-22.J maternal fetal

medicine

Is Elective Cerclage Justified in the Management of Triplet and Quadruplet Pregnancy?It seems that elective cervical suture is a definite contribution to the successful management of multiple pregnancies with more than two fetuses.

Gil A. Goldman et al,Australian and New Zealand J of Obstet and Gynaecolfirst published online: 28 JUN 2008

Negative evidencecerclage in twins.. In cerclage group, 45% delivered

prematurely; neonatal death rate 18.2%

In non-cerclage group, 48% delivered preterm; neonatal death rate 15.2%

Dor et al. Gynecol Obstet Invest 1982; 13:55

Cerclage in TRIPLETS

248 of 3278 women (7.6%) underwent prophylacticCerclage No differences in GA at delivery, birth at <32

weeks,birthweight, or neonatal outcomes

Rebarber et al. Am J Obstet Gynecol 2005;193:1193-6.

But.. Even for singletons cerclage did not prevent preterm birth in

women with a short cervix but their results should be confirmed in larger trials

Berghella V et al, Am J Obstet Gynecol 2004;191:1311-7.To et al. Lancet 2004;363:1849-53

Cochrane library Overall, no reduction in pregnancy loss or

preterm delivery rates with prophylactic cerclage.

Cerclage associated with higher rates of febrile

morbidity, tocolysis, and hospitalization

Cochrane Database Syst Rev. 2003;(1):CD003253

Green-top Guideline No. 60May 2011

The insertion of a history- or ultrasound-indicated cerclage in women with

multiple pregnancies is not recommended.

Green-top Guideline No. 60May 2011

…however, they were of insufficient number ….to draw conclusions…regarding the effect of cerclage in preventing preterm birth.

… the results should be interpreted with caution owing to the relatively small number of women included.

Clinical aspects of cervical insufficiency

There is a need for more basic knowledge of cervical ripening, objective assessment of cervical visco-elastic properties, and

randomized controlled trials of technical aspects of cervical cerclage

Frederik K Lotgering BMC Pregnancy and Childbirth 2007, 7(Suppl 1):S17

why no large-scale randomized controlled trials ?

To definitively prove the effectiveness of cervical cerclage,

when there is obvious need for such studies

Frederik K Lotgering BMC Pregnancy and Childbirth 2007, 7(Suppl 1):S17

patients at high risk …

are unwilling to give their consent to randomization ….informed that…

observational studies have shown approximately 90% infant viability after cerclage and a low rate of procedure related complications.

BMC Pregnancy and Childbirth 2007, 7(Suppl 1):S17

lack of effectiveness in a low risk population is falsely extrapolated

to high-risk patients who, in contrast to low-risk patients, were not studied and might well benefit from such a procedure.

Multifetal pregnancy lossWhat Can Be Done?

– Discourage multi-embryo transfers

– Be optimistic !!

CL measurement for the prediction of PT birth in MFG: a systematic review and bivariate meta-analysis.

In the absence of effective preventive strategies, there is currently no place in clinical practice for cervical length measurement in this population.

However, future studies should evaluate preventive interventions in women with multiple pregnancies and a short cervix, and

cervical length should be measured in any trial studying preventive strategies in multiple pregnancies.

ultrasound obstet gynecol 2011

Jul;38(1):10-7.

Despite published meta-analyses and other studies demonstrating the lack of efficacy of cerclage in multiple gestations recent U.S. data indicates roughly 10% of triplets, and 1.3% of twins are still receiving cerclages

Menacker F, National Vital Statistics Reports 2008;

Vol.56, issue 13.

CAUGHT BETWEEN EVIDENCE & EXPERIENCE

Should we err on the side of

Caution (Cerclage)

or Hope (Expectant)?

Medical knowledge is always

Incomplete and ambiguous

Adopt evidence like swan extracting the milk

Patient speaks..

I will tell you a lot of MFMs will delay cerclages to the last minute point of no return type deal.

In my opinion, the risks of "wait and see" are far greater than any potential risks of having a preventative cerclage.

I'm still very nervous … but I do feel a little more secure now that the cerclage is in place.

www.fertilethoughts.com/forum

Oh Lord!! Please don't wait!! I lost twins because my EX-OB said... " Let's wait and just weekly check it“

HAD my doc done the cerclage.. I Strongly Believe, my twins would be here now!

Waiting to long to do the cerclage can be more dangerous!

Another reason is Infection is WAY higher later in rescue cerclages than ones done before 16wks.

www.fertilethoughts.com/forum

 All I cared about was having a living child and wanted any and all treatments that would increase our chances. If that meant a cerclage that so be it.

also why they would not consider a cerclage if only for our peace of mind.

www.fertilethoughts.com/forum

Cervical stitch (cerclage) for preventing preterm birth in multiple pregnancy (Protocol)

Rafael TJ, Berghella V, Alfirevic Z

The Cochrane Library 2011, Issue 6

Cerclage -Yes