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The impact of cerclage in twin pregnancies on preterm birth rate before 32 weeks.

Tuesday 04 June 2019, 15:30 - 16:30
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นำเสนอโดย พญ. ธาวินี อาจารย์ที่ปรึกษา อ.เฟื่องลดา

J Matern Fetal Neonatal Med. 2019 Jul;32(13):2143-2151. doi: 10.1080/14767058.2018.1427719. Epub 2018 Jan 23.

The impact of cerclage in twin pregnancies on preterm birth rate before 32 weeks.

Han MN1, O'Donnell BE2, Maykin MM2, Gonzalez JM2, Tabsh K1, Gaw SL2.


PURPOSE: To evaluate whether cerclage in twins reduces the rate of spontaneous preterm birth <32 weeks when compared to expectant management.

METHODS: This is a retrospective cohort study of twin pregnancies with the following indications for cerclage from two institutions: history of prior preterm birth, ultrasound-identified short cervix ≤2.5 cm, and cervical dilation ≥1.0 cm. The "cerclage" cohort received a cerclage from a single provider at a single institution from 2003-2016. The "no cerclage" group included all patients with similar indications that were expectantly managed from 2010-2015, at a second institution where cerclages are routinely not performed in twin pregnancies. The primary outcome was the rate of spontaneous preterm birth at <32 weeks. Secondary outcomes were the rates of spontaneous and overall (including medically indicated) preterm births at 32 weeks,  34 wees, and 36 weeks, choriamnionitis, birth weight, and neonatal mortality within 30 days of life. We also performed a planned subgroup analysis stratified by cerclage indication.

RESULTS: In all, 135 women were included in two cohorts: cerclage (n = 96) or no cerclage (n = 39). The rates of spontaneous preterm birth 32 weeks were 10.4% (n = 10) with cerclage versus 28.2% (n = 11) without cerclage (OR 0.23, CI 0.08-0.70, p = .017). After adjusting fr cerclage indication, clinical history, age, chorionicity, insurance type, race, BMI, in-vitro fertilization, and multifetal reduction, there remained a significant reduction in the cerclage group of spontaneous preterm birth 32 weeks (adjusted odds ratio (aOR) 0.24, CI 0.06-0.90, p = .035), spontaneous preterm birth 36 weeks (aOR 0.34, CI 0.04-0.81, p = .013) as well as in overall preterm birth 32 weeks (aR 0.31, CI 0.1-0.86, p = .018), and overall preterm birth 36 weeks aOR 0.37, CI 0.10-0.84, p = .030). When stratified by shortcervix or cervical dilation in the cerclge versus no cerclage groups, there was a significant decrease in spontaneous preterm birth 32 weeks in the cerclage group with cervical dilation (11.1 versus 41.2%, p = .01) but not in the cerclage group with short cervix only, even for cervical length 1.5 cm. Pregnancy latency was 91 dys in the cerclage group versus 57 days in the no cerclage group (p = .001), with a median gestational age at delivery of 35 ersus 32 weeks (p = .002). There was no increase in chorioamnionitis in the cerclage group. Furthermore, there was a significant increase in birth weight (median 2278 versus 1665 g, p < .001) and decrease in perinatal death 30 days (1.6 versus 12.9%, p = .001).

CONCLUSIONS: Cerclage in twin pregnancies significantly decreased the rate of spontaneous preterm birth 32 weeks compared to expectant management. However, when stratified by cerclage indication, this decreae in primary outcome only remained significant in the group with cervical dilation.

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