Rescue Cerclage in MCDA Twin Pregnancy

Published Date: 19th July 2016

Publication Authors: Cording V, Idama TO, Myagerimath R

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Introduction 

Around one-third of twin pregnancies in the UK are monochorionic. After single fetal death in a monochorionic pregnancy, the risk to the surviving twin is high and management of such pregnancies is complex. We report a case of rescue cerclage in MCDA twin pregnancy with a view to salvage twin-2.

Case 

Thirty-nine years old primigravida with MCDA twins presented at 21 + 3 weeks of gestation with spontaneous miscarriage of twin-1. She was keen to salvage twin-2. Scan confirmed an intact gestational sac of twin-2 with no evidence of amniotic sac herniating through the cervical canal; fetal biometry and dopplers were normal. After discussion with the senior obstetricians, neonatologist and the anesthetist she was consented for Emergency rescue cerclage. Examination under anesthesia at 21 + 5 weeks of gestation confirmed 3–4 cm dilated cervix with an umbilical cord stump protruding through cervical os. McDonald’s cervical suture was inserted; postoperatively she received 100 mg of Indomethacin PR, antibiotics and was advocated bed rest. Steroids were administered at 24 weeks, and she was monitored regularly for evidence of infection. At 26 weeks she PPROM and went on to have Emcs at 26 + 3 weeks of gestation for cord prolapse with footling breech, baby weighed 1040 g and was transferred to NICU; is doing well.

Discussion 

Use and efficacy of rescue cerclage in such cases is highly controversial. Insertion of a rescue cerclage may delay delivery by a further 5 weeks on average compared with expectant management/bed rest alone. It may also be associated with a twofold reduction in the chance of delivery before 34 weeks of gestation. There is no clear evidence that the gestation at which the cerclage is inserted affects the magnitude of prolongation in gestation; however, in cases presenting before 20 weeks of gestation, insertion of a rescue cerclage is highly likely to result in

a preterm delivery before 28 weeks of gestation. Although women are often informed of potential complications associated with cerclage insertion, there is little published evidence to support this.

Conclusion 

Successful rescue cerclage in twin pregnancy is reported before, however its use after miscarriage of twin-1 in MCDA twin remains highly controversial. The decision to place a rescue suture should be individualised, taking into account the gestation at presentation. Role of MDT in managing such highrisk cases is indisputable. To our knowledge this is the first case of its kind in MCDA twin pregnancy.

Myagerimath, R; Idama, T; Cording, V. (2013).  Rescue cerclage in MCDA twin pregnancy to salvage the second twin, an unusual case . BJOG: An International Journal of Obstetrics and Gynaecology. 120 (Supplement), 174-5

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