Clinical Conundrums

Short Cervix in a Patient With Twin Gestation

Manisha Gandhi, MD, and Nathan S. Fox, MD

dilation, but data regarding cerclage in twin pregnancies

A 28-year-old woman, gravida 1 para 0, with twin gestation
presents for routine anatomic survey at 20 weeks of
gestation without any complaints. On transabdominal
ultrasonography, the ultrasonographer notes concern for
cervical funneling and proceeds to perform a transvaginal
ultrasonogram, which reveals a short cervix of 18 mm.
(Obstet Gynecol 2017;130:47–9)
DOI: 10.1097/AOG.0000000000002037
THE CONUNDRUM
A short cervical length on ultrasonography is associated
with an increased risk of preterm birth in singleton and
twin pregnancies. There are considerable data for pre-
vention of preterm delivery in singleton gestations, but
the data are limited regarding twin gestations.
In a patient with a singleton pregnancy and
increased risk for preterm birth resulting from a previous
spontaneous preterm birth, weekly injections of 17a-
hydroxyprogesterone caproate from 16 to 36 weeks of
gestation reduce the risk of recurrent preterm birth by
more than 30%,1 but this has not been proven in unse-
lected twin gestations.2 Cerclage appears to reduce the
risk of preterm birth in singletons with a short cervix and
previous preterm birth or those with incidental cervical
See related editorial on page 5.
From the Department of Obstetrics and Gynecology, Baylor College of Medicine,
Houston, Texas; and the Department of Obstetrics, Gynecology and Reproductive
Science, Icahn School of Medicine at Mount Sinai, New York, New York.
The Clinical Conundrums feature is an invited article type developed for clini-
cians who sometimes are faced with either clinical situations or patient questions
for which little (if any) information is available to guide decision-making.
Clinicians have all been faced with a situation in which they approach a trusted
colleague and ask, “Can I run something by you?” The Clinical Conundrums
feature attempts to provide answers to those types of questions.
Corresponding author: Nathan S. Fox, MD, Department of Obstetrics,
Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai,
70 East 90th Street, New York, NY 10128; email: nfox@mfmnyc.com.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2017 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/17
are less compelling. Vaginal progesterone is beneficial
for singleton pregnancies with a short cervix, but the
data are less clear with twins. So when confronted with
this clinical conundrum: 1) How should the patient be
evaluated? 2) What is the evidence to counsel your
patient? 3) What is a reasonable course of action?
THE DATA
How Should the Patient Be Evaluated?
The transvaginal cervical length images should be
reviewed to ensure proper ascertainment of the image,
avoiding excess pressure by the probe and without
evidence of lower uterine segment contraction, which
can mimic funneling. A complete history should be
performed to ensure the patient has no signs of
preterm labor—contractions, vaginal bleeding, or back
pain. Physical examination should be performed to
determine whether there is actual cervical dilation
compared with a closed short cervix.
What Is the Evidence to Counsel Your Patient?
Prolonged Bed Rest
There is no evidence that prolonged bed rest reduces
the risk of preterm birth or perinatal mortality in
multiple gestations.2 Studies have investigated women
with cervical effacement or dilation and still found no
improvement in outcome. In addition, bed rest has
been associated with thromboembolic disease and
deconditioning.2
Weekly 17a-Hydroxyprogesterone Caproate
There is no evidence that routine use of 17a-hydrox-
yprogesterone caproate decreases the risk of pre-
term delivery in twin pregnancies although this
group is at increased risk for preterm delivery. A
meta-analysis investigated more than 2,000 women
with twin gestations treated with 17a-hydroxypro-
gesterone caproate, and a subgroup investigation
(four trials with 552 women) showed no benefit in
reducing adverse perinatal outcomes in women with
a cervical length of 25 mm or less. Furthermore,
women with a cervical length of greater than

VOL. 130, NO. 1, JULY 2017 OBSTETRICS & GYNECOLOGY 47

Copyright ª by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
25 mm who received 17a-hydroxyprogesterone cap-
roate noted a trend toward an increased risk of
adverse perinatal outcomes, which included perina-
tal death and significant neonatal morbidity.3 There-
fore, there is no role for 17a-hydroxyprogesterone
caproate in this clinical scenario.
Vaginal Progesterone
The same meta-analysis noted in the section on 17a-
hydroxyprogesterone caproate also reviewed data
from seven randomized controlled trials for prevention
of preterm birth in asymptomatic twin pregnancies
and showed that treatment with vaginal progesterone
did not reduce the risk of preterm delivery or adverse
perinatal sequelae. However, in a subgroup of women
(n5108) with a cervical length of 25 mm or less treated
before 24 weeks of gestation, a reduction in adverse
perinatal outcomes was noted (relative risk 0.56, 95%
confidence interval [CI] 0.42–0.75).3 These results
should be interpreted with caution because they are
derived from a post hoc analysis, but there might
be a role for vaginal progesterone in this clinical
scenario.
Cervical Pessary
One prospective trial randomized 134 women with
twin pregnancies at 18–22 weeks of gestation with
a cervical length of 25 mm or less to cervical pessary
or to no treatment. The pessary group had a signifi-
cantly reduced risk of preterm birth at less than 34
weeks of gestation (16.2% compared with 39.4%; rel-
ative risk 0.41, 95% CI 0.22–0.76).4 A meta-analysis of
three trials with 481 twin pregnancies demonstrated
no reduction in the rates of spontaneous preterm birth
or adverse neonatal outcomes with the use of a cervical
pessary, specifically the Arabin pessary.5 However,
the meta-analysis is limited by studies that included
twin gestations in women with and without short cer-
vix, along with varying definitions of short cervical
length. Therefore, it is unclear whether the results of
this meta-analysis negate the findings of the single
randomized trial.
Cerclage
A meta-analysis showed that placement of cerclage in
asymptomatic women with twin gestations with an
ultrasonographically detected short cervical length of
less than 25 mm is not associated with reduction of
preterm birth compared with women who do not
receive a cerclage.6 A retrospective review of 140
twin gestations in women with a cervical length of
25 mm or less compared those who did and did not
undergo cerclage and found no difference in preterm
48 Gandhi and Fox Short Cervix in a Twin Pregnancy
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
delivery. However, a planned subanalysis of those
with a cervical length of 15 mm or less showed that
the cerclage was associated with a prolonged gesta-
tion by 12.5 weeks compared with 8.8 weeks in those
with no intervention and a significant reduction in
preterm delivery before 34 weeks of gestation.7 No
differences were noted in rates of preterm delivery at
less than 28, less than 32, or less than 37 weeks of
gestation; perinatal mortality; or gestational age at
delivery. Although these results are intriguing, they
should be interpreted cautiously until they have been
confirmed in a prospective trial. Therefore, in this
patient with a cervical length of 18 mm, there is no
role for cerclage at this time.
What Is a Reasonable Course of Action?
At this time, we know that there are no proven
interventions for twin gestations in women with
short cervical length to prevent preterm birth in this
clinical scenario. Bed rest and 17a-hydroxyproges-
terone caproate are not beneficial. Cervical pessary
may have a role given the results of a single random-
ized trial. Vaginal progesterone in women with
asymptomatic cervical shortening 25 mm or less or
a cerclage in those with cervical length 15 mm or
less may have some role, but more research is
needed to determine the exact benefit for each in
twin pregnancies with a short cervical length. So
what should you tell your patient who you have just
counseled on the increased risk for preterm delivery
or pregnancy loss resulting from her shortened cer-
vical length in the second trimester with a twin
pregnancy?
Patient counseling should include the fact that at
this time, the American College of Obstetricians and
Gynecologists does not recommend any interventions
in women with multiple gestations and a short cervix
and recommends against treatments outside of a for-
mal clinical trial.8 However, new therapies are emerg-
ing, and we believe it is reasonable to offer certain
therapies after a discussion of the potential risks and
benefits.
At less than 24 weeks of gestation with cervical
shortening 25 mm or less, a reasonable option would
be to offer vaginal progesterone or cervical pessary.
If there is evidence of cervical shortening 15 mm or
less, further workup for preterm labor and infection
is recommended with potential evaluation for cerc-
lage. After 24 weeks of gestation, continue close
monitoring for signs of preterm labor with adminis-
tration of antenatal steroids and neuroprotective
magnesium sulfate in these women when preterm
labor is suspected.
OBSTETRICS & GYNECOLOGY
THE BOTTOM LINE
There is still no reliable evidence of interventions for
prevention of preterm delivery in twin gestations in
women with a short cervix. It has been stated that,
when the evidence is not strong or is clearly conflicting,
we should default to assessing treatment effectiveness
while weighing the relative benefits and harms.9
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3. Schuit E, Stock S, Rode L, Rouse DJ, Lim AC, Norman JE, et al.
Effectiveness of progestogens to improve perinatal outcome in
twin pregnancies: an individual participant data meta-analysis.
BJOG 2015;122:27–37.
VOL. 130, NO. 1, JULY 2017
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
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