From the Guidelines
A triplet pregnancy alone does not automatically indicate the need for cervical cerclage. The decision to place a cerclage should be based on specific risk factors such as a history of cervical insufficiency, previous preterm birth, or evidence of cervical shortening on ultrasound (typically less than 25mm before 24 weeks) 1. While triplet pregnancies do carry a higher risk of preterm birth compared to singleton pregnancies, this increased risk is multifactorial and not solely due to cervical insufficiency.
Key Considerations
- The Society for Maternal-Fetal Medicine recommends against routine use of progesterone, pessary, or cerclage for the treatment of cervical shortening in twin gestations outside the context of a clinical trial (GRADE 1B) 1.
- Cerclage placement for cervical shortening in twin gestations has been discouraged based on meta-analysis data; however, data from several retrospective cohort studies suggest a potential benefit to cerclage in the setting of a very short cervix (10 mm) 1.
- A recent randomized trial enrolled 30 patients with twin gestation, a CL of 10 mm, and cervical dilation of at least 1 cm to cerclage or expectant management and reported a 70% reduction in PTB at <34 weeks of gestation (70% vs 100%; RR, 0.71; 95% CI, 0.52e0.96) in those who received cerclage 1.
Management Approach
If a patient with triplets shows signs of cervical shortening during routine transvaginal ultrasound monitoring, or has other risk factors for cervical insufficiency, then cerclage might be considered. However, the procedure itself carries risks including infection, bleeding, membrane rupture, and preterm labor. Management of triplet pregnancies typically includes more frequent prenatal visits, ultrasound monitoring of cervical length, and possibly progesterone therapy, with cerclage being reserved for specific indications rather than used prophylactically based solely on the presence of triplets.
Recommendations
- Cervical cerclage should not be routinely recommended for triplet pregnancies without evidence of cervical shortening or other risk factors for cervical insufficiency 1.
- Patients with triplet pregnancies should be closely monitored with regular ultrasound assessments of cervical length and should be considered for cerclage placement if they meet specific criteria, such as a history of cervical insufficiency or significant cervical shortening 1.
From the Research
Triplet Pregnancy and Cervical Cerclage
- The use of cervical cerclage in triplet pregnancies is a topic of debate, with some studies suggesting it may not be effective in preventing preterm birth or improving neonatal outcomes 2, 3, 4, 5.
- A study published in 2005 found that prophylactic cerclage did not improve pregnancy or neonatal outcomes in triplet pregnancies without a history of cervical insufficiency 2.
- A 2014 Cochrane review found that cervical cerclage did not reduce the risk of preterm birth or perinatal deaths in multiple gestations, including triplet pregnancies 3.
- A 2009 study found that ultrasound-indicated cerclage in triplet pregnancies with cervical shortening did not improve outcomes, including gestational age at delivery and birth weight 4.
- A 2022 study found that cerclage placement in triplet pregnancies did not decrease preterm birth rates and may increase the risk of neonatal complications 5.
Indications for Cervical Cerclage
- The American College of Obstetricians and Gynecologists (ACOG) and other medical societies recommend history-indicated cerclage for women with a history of prior spontaneous preterm delivery or mid-trimester miscarriage 6.
- Ultrasound-indicated cerclage is recommended for women with a short cervical length detected on ultrasound, but its effectiveness in triplet pregnancies is unclear 6.