CASE REPORT

Successful Rescue Cerclage in a

Monochorionic Diamniotic Twin Pregnancy at
20 Weeks: Case Report and Overview of
Literature
Cristina Mitric, MD; Vincent Ponette, MD
Department of Obstetrics and Gynecology, McGill University, Montreál, QC

Abstract
J Obstet Gynaecol Can 2018;■■(■■):■■–■■
Background: In twin pregnancies, elective cerclage placement
based on obstetrical history or ultrasound findings has been https://doi.org/10.1016/j.jogc.2017.10.025
shown to be ineffective and even harmful. There are currently no
guidelines for the use of rescue cervical cerclage in twin
pregnancies. INTRODUCTION
Case: The current report presents the case of a 33-year-old patient
with monochorionic diamniotic twins (MCDA) found to have dilated
cervix at 3.5cm with exposed membranes upon physical
examination at 19 weeks and 3 days. An emergency McDonald
T win gestations have higher risks of preterm deliveries
regardless of chorionicity. To date, there is no evi-
dence that a prophylactic cerclage reduces this risk.1 As such,
cerclage was placed at 20 weeks and the patient carried the
current pregnancy until 35weeks 6 days. the SOGC advised against the use of prophylactic cer-
Conclusion: Rescue cerclage represents an important option to clage in multiple gestations.1 There are currently no guidelines
consider in order to preserve twin pregnancies regardless of for the use of rescue cervical cerclage in twin pregnancies,
chorionicity. and a few sources in the literature discuss successful place-
ment when membranes are exposed.2–5
Résumé
Contexte : Chez les grossesses gémellaires, le cerclage planifié The current case report presents the case of a 19 + 3 week
fondé sur les antécédents obstétricaux ou les constatations monochorionic diamniotic (MCDA) pregnancy with physi-
échographiques s’est révélé inefficace, voire néfaste, et le cal exam findings of 3.5 cm dilated cervix, successfully treated
cerclage d’urgence n’a fait l’objet d’aucune ligne directrice.
with a rescue cervical cerclage.
Cas : Nous présentons le cas d’une femme de 33 ans chez qui un
examen physique effectué à 19 semaines et 3 jours d’une
grossesse monochoriale biamniotique a révélé que le col utérin
était dilaté de 3,5 cm et que les membranes étaient exposées. Un THE CASE
cerclage d’urgence a été réalisé à 20 semaines selon la technique
de McDonald, et la grossesse s’est poursuivie jusqu’à 35 The patient presented in the current report provided in-
semaines et 6 jours. formed consent for participation. A 33-year-old G4P2A1L1
Conclusion : Le cerclage d’urgence est une option intéressante à patient with a spontaneous MCDA pregnancy presented to
envisager pour assurer la poursuite d’une grossesse gémellaire, the Birthing Centre at 19 weeks and 3 days with per vaginal
peu importe la chorionicité.
spotting. Her obstetrical history was remarkable for a Cae-
Copyright © 2017 The Society of Obstetricians and Gynaecologists of sarean section at 32 weeks due to pre-eclampsia, a first
Canada/La Société des obstétriciens et gynécologues du Canada.
Published by Elsevier Inc. All rights reserved. trimester miscarriage, and a therapeutic abortion at 26 + 1
weeks for hypoplastic left heart syndrome. Her medical
Key Words: Cervical incompetence, emergency cerclage, twin history was unremarkable, with no prior cervical proce-
pregnancy dures. The pregnancy was uneventful with a 42 mm cervical
Corresponding Author: Dr. Cristina Mitric, Department of length at 16 + 5 weeks. Upon presentation, she had one
Obstetrics and Gynecology, McGill University, Montreal, QC.
cristina.mitric@mail.mcgill.ca
episode of a painless, small amount vaginal bleeding, with
Competing interests: None declared.
no contractions or other abnormal vaginal discharge. On
speculum exam, the cervix was dilated at 3.5 cm with bulging
Received on August 25, 2017
intact membranes. The investigations including white cell
Accepted on October 25, 2017
count, C-reactive protein, urine culture, and vaginal culture

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CASE REPORT

Table. Physical exam indicated cerclage in twin pregnancies—effects on pregnancy prolongation and neonatal survival
# Twin GA at cerclage Time interval to
Author, year Indication for cerclage pregnancies (weeks) delivery (days) Perinatal survival
e c
Rebarber et al. 2014 Dilated cervix or exposed membranes 12 19.9 92 (26–105) 83.3%
Miller et al. 2014 Dilated cervix 104 16–24b 69 (21–99)c 66.3% delivery after
28 weeksd
Aguilera et al. 2013 Exposed membranes 10 20.6 ± 2.5a 56.4 ± 31.8a 70%
Levin et al. 2012 More than 50% effacement or cervical 14 20.1 ± 2.5a 71.1 ± 44.6a 75%
dilatation
Roman et al. 2016 Dilated cervix 1.0–4.5 cm 38 16–24b 73.2 ± 39.2a 73.4%
b c
Zanardini et al. 2013 Cervical dilatation with exposed 14 16–26 69.3 (3–125) 86%
membranes
GA: gestational age.
a
Mean ± standard deviation.
b
Range of weeks.
c
Mean in days (range of days).
d
Neonatal survival not reported.
e
Standard deviation not reported.

were negative other than positive Group B streptococcus. DISCUSSION

The transabdominal ultrasound confirmed high placental lo-
cation and hourglass membranes of 4 × 4 cm with no cord
present, as well as 3.5-cm cervical dilatation. The patient was
admitted and put on strict bedrest.
Following a lengthy discussion with the family about the
outcome of conservative management and the risks and
benefits of a rescue cerclage, the parents opted for the
latter. After two days of indomethacin and intravenous
ampicillin and erythromycin, a McDonald cerclage was
placed at 20 + 0 weeks with no intra or postoperative
complications. The patient received 24 additional hours of
indomethacin tocolysis, as well as eight additional days of
ampicillin and erythromycin, and seven days of metroni-
dazole. The patient was started on 200 mg vaginal progestin
twice-daily and remained admitted on complete bedrest with
prophylactic low molecular weight heparin..
Mrs. J. was discharged home at 30 weeks and returned to
the hospital at 35 + 6 weeks for a scheduled repeat Caesar-
ean section with tubal ligation. Twin A’s weight was 2550 g
and Twin B’s weight was 2610 g. Both twins’ APGAR scores
were 9 and 9 at 1 and 5 minutes respectively. Cords pH was
7.27 for Twin A and 7.31 for Twin B. The cerclage was
removed at the time of the Caesarean section without com-
plication. The postpartum course was complicated by a
readmission for mild pre-eclampsia, which resolved with an-
tihypertensive medications.
ABBREVIATION
MCDA monochorionic diamniotic
Currently, the use of cerclage represents an ongoing debate
in the obstetrical literature and even more so in the context
of twin pregnancies. The use of cerclage for the sole indi-
cation of multiple pregnancy is shown not to be an efficient
prophylactic method for preventing preterm delivery5,6 and
possibly even harmful.7–10 The current Canadian guide-
lines for cervical insufficiency and cerclage advice against
the use of cerclage in multiple gestation even when there
is a history of preterm birth, or evidence of ultrasound-
based cervical shortening. 1 There are, however, no
recommendations regarding the use of emergency cer-
clage in the context of physical exam findings of dilated
cervix and exposed membranes in twin gestation.
Sometimes, clinicians are encountering clinical situations with
limited evidence-based data and limited recommendations,5
such as the patient with a twin gestation and painless cer-
vical dilatation in the second trimester presented in the
current case report. In this specific scenario with no signs
of bleeding, labour, or infection, three management options
are available: offering termination of pregnancy due to poor
prognosis and conservative management with bedrest with
or without cerclage. As it is unclear which management
option would optimize outcome, it is very difficult to counsel
patients in such situations.
Rescue cervical cerclage for dilated cervix with exposed mem-
branes is known to be effective in singleton pregnancies.11,12
In twin pregnancies, studies in the literature also seem to
suggest a positive effect in pregnancy prolongation and neo-
natal survival as illustrated in Table. Rebarber et al. found
that pregnancy prolongation outcomes were similar between

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 Successful Rescue Cerclage in a Monochorionic Diamniotic Twin Pregnancy at 20 Weeks
12 twins and 31 singleton pregnancies, with 92 days in twin
and 106 in singleton pregnancies.5 Similarly, Miller et al. com-
pared 104 twin with 338 singleton pregnancies with cervical
dilation and found that risks and obstetrical outcomes were
similar in both groups, with twins being more likely to be
admitted to the NICU.4 When looking specifically at twin
pregnancies, several studies with limited statistical power show
evidence of good obstetrical outcome for rescue cervical
cerclage.2,3,13 Aguilera et al. present evidence of prolonged
pregnancy by 56.4 days in 10 twin pregnancies with emer-
gency cerclage placed at average GA of 20.6 weeks with a
significant increase in neonatal survival and weight.2 A dif-
ferent study shows 71.1 days prolongation in 14 twin
pregnancies at 20.1 weeks,3 while yet another study of cer-
clage placed in 14 twin pregnancies with exposed membranes
on physical exam resulted in 86% perinatal survival.14 On
the other side, a recent literature review did not encounter
any studies where twin emergency cerclage was detrimen-
tal; however, this could represent a publication bias.
CONCLUSION
In summary, the report presented the case of a successful
pregnancy prolongation in a MCDA pregnancy with exposed
membranes and cervical dilation at 3.5 cm at 19 weeks and
three days. The case supports literature findings of suc-
cessful rescue cerclage in twins, and in this particular case,
monochorionic twins. Given the limited medical options at
this early non-viable GA, rescue cerclage represents an im-
portant option to consider in order to preserve such twin
pregnancies regardless of chorionicity.
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