Prophylactic cerclage in multiple pregnancies remains controversial, as evidence from studies is mixed. While some observational studies found cerclage decreased rates of preterm birth and low birthweight in triplet pregnancies, other studies found no differences in outcomes between cerclage and non-cerclage groups for twins or triplets. Large randomized controlled trials are still needed due to small sample sizes in past studies and lack of definitive evidence on cerclage's effectiveness. Patients at high risk of preterm birth also remain reluctant to enroll in randomized trials when cerclage is presented as a potentially lifesaving intervention based on observational studies.

1. Veerendrakumar C.M
MD.,DNB.
Associate professor
Dept of OBG,VIMS,Bellary

2. Preterm labor
 One of the major health hazards of humans.
 Carrying a multiple gestation significantly increases
risk of delivering preterm.

3. PNMR increased

4. 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.

5. Strategies
 Bed rest
 Tocolytics
 Cerclage

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

7. …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

8. 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 Gynaecol
first published online: 28 JUN 2008

9. Negative evidence
cerclage 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

10. Cerclage in TRIPLETS
 248 of 3278 women (7.6%) underwent prophylactic
Cerclage
 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.

11. 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

12. 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

13. Green-top Guideline No. 60
May 2011
 The insertion of a history- or ultrasound-
indicated cerclage in women with
multiple pregnancies is not recommended.

14. Green-top Guideline No. 60
May 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.

15. 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

16. 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

17.  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

18.  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.

19. Multifetal pregnancy loss
What Can Be Done?
– Discourage multi-embryo transfers
– Be optimistic !!

20. 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.

21.  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.

22. CAUGHT BETWEEN
EVIDENCE & EXPERIENCE

23. Should we err on the side of
Caution (Cerclage)
or
Hope (Expectant)?
Medical knowledge is always
Incomplete and ambiguous

24. Adopt evidence like swan
extracting the milk

25. 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

26.  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

27.  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

28. Cervical stitch (cerclage) for
preventing preterm birth
in multiple pregnancy (Protocol)
Rafael TJ, Berghella V, Alfirevic Z
The Cochrane Library 2011, Issue 6

29. Cerclage -Yes