Fruit of the Womb
Fruit of the Womb

A Loss of Twins and Missed Opportunities for Cerclage

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Recently, a reader left the comment below. The value and use of cervical cerclage continues to come into question. There are major institutions in this country where it is not considered to be a useful procedure and have abandoned or severely limited its use to selective patients in deference to ‘conservative management’, often now involving the administration of progesterone during the pregnancy. I have addressed my feelings on cerclage in a series published on this site many months ago (between August 18 and September 26, 2008). My feelings have not changed. There is a big difference between getting a couple of extra weeks to an extremely early pregnancy, or holding off delivery long enough to ‘get steroids on board’ for fetal lung maturation, and delivering a baby beyond 30 weeks gestation when the risk of long-term complications of prematurity are greatly diminished. Barely a week goes by on our service when a patient would have lost a pregnancy in the manner detailed below except for the timely recognition of cervical insufficiency and the placement of a cerclage in later midtrimester…

On June 10 Anonymous wrote:
I have read one of your previous articles regarding cervical cerclage. I was diagnosed with endometriosis, treated with laproscopy and subsequently underwent many IUIs and one cycle of IVF without success. My second IVF cycle was successful, but due to preterm premature rupture of membranes (PPROM) at 21 weeks, lost healthy twins. No history of diabetes or hypertension. Doctors could not diagnose the reason for PPROM, may be due to cervical incompetence. I was on total bed rest, but had some vaginal bleeding at 11 weeks. I just wanted to know if cervical incompetence could have been diagnosed before and cervical cerclage would have been useful. What are my chances of undergoing normal conception?


To anonymous June 10:
Conception and successful carriage of a pregnancy are separate issues. It sounds like you had (and may still have) cervical insufficiency with the twin pregnancy. I firmly believe that all multiple gestations, particularly those resulting in infertility patients, should be carefully evaluated for premature cervical changes by transvaginal ultrasound beginning as early as 16 weeks. If cervical changes were picked up early enough, a cerclage may well have been successful in preventing your pregnancy loss.

Twenty-five years ago, detecting and treating cervical incompetence in a 'first pregnancy' was rarely successful. The diagnosis of cervical incompetence (insufficiency) was a diagnosis of exclusion, usually after one or more premature deliveries or midtrimester pregnancy losses. But because of the increased surveillance by ultrasound, it is almost a weekly event on our service.

With a subsequent pregnancy, I would recommend serial cervical evaluation by ultrasound even if you have a single baby. You might also be a candidate for an elective/prophylactic cerclage at 13-14 weeks if you have any other risk factors such as a congenital uterine abnormality or previous cervical surgery (e.g., LEEP or conization). In addition, even if you and your providers decide only upon serial ultrasound evaluation, you might consider weekly injections with 17-OH-progesterone caproate beginning at 16-18 weeks as well. I am sorry for your loss, but with careful follow-up and pregnancy management, you should be successful in the future.
Kind regards,
Dr T
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About the Author

Dr. Trofatter is an expert on maternal-fetal medicine.

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