Tracking the trajectory of cervical length dynamics in uncomplicated dichorionic diamniotic twin pregnancies: A retrospective cohort study

Abstract

Objective:

We hypothesised that distinct patterns of serial cervical length change in dichorionic diamniotic twin pregnancies are associated with differential risks of preterm birth.

Methods:

A retrospective cohort study was conducted at the Twins Clinic of a tertiary fetal medicine unit. In total, 389 women with uncomplicated dichorionic diamniotic twin pregnancies underwent four weekly cervical length measurements. Changes in cervical length were classified into Pattern I (stable cervical length), Pattern II (early rapid shortening), Pattern III (late shortening) and Pattern IV (early shortening with a plateau). Association of each pattern with preterm delivery was assessed.

Results:

Pattern I was observed in 37.5% cases, Pattern II in 11.8%, Pattern III in 32.6% and Pattern IV in 18%. The proportion of patients delivering preterm was significantly higher in Pattern II (early rapid shortening), followed by Pattern III (late shortening). The mean period of gestation at delivery was 35.5 weeks in cases of Pattern I (stable cervical length), 30.7 weeks in Pattern II (early rapid shortening), 34.2 weeks in Pattern III (late shortening) and 34.9 weeks in Pattern IV (early shortening with a plateau). Patients in Pattern II (early rapid shortening) had a significantly shorter mean cervical length at both the nuchal scan and between 20–24 weeks, as well as a significantly greater decline in cervical length between these two time points, compared with those in Pattern IV (early shortening with a plateau).

Conclusion:

Distinct patterns of cervical length shortening in uncomplicated dichorionic diamniotic twin pregnancies are linked to varying risks of preterm birth, thus making serial assessment more predictive than single measurements.

Keywords

diagnostic imaging cervical length measurement multiple pregnancy reproductive science: cervical function preterm labour: clinical research

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References

Perin

Mulick

Yeung

, et al. Global, regional, and national causes of under-5 mortality in 2000-19: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet Child Adolesc Health 2022; 6: 106–115.

Villar

Restrepo-Méndez

McGready

, et al. Association between preterm-birth phenotypes and differential morbidity, growth, and neurodevelopment at age 2 years: results from the INTERBIO-21st newborn study. JAMA Pediatr 2021; 175: 483–493.

Ananth

Chauhan

SP.

Epidemiology of twinning in developed countries. Semin Perinatol 2012; 36: 156–161.

McClamrock

Jones

Jr Adashi

EY.

Ovarian stimulation and intrauterine insemination at the quarter centennial: implications for the multiple births epidemic. Fertil Steril 2012; 97: 802–809.

Care

Nevitt

Medley

, et al. Interventions to prevent spontaneous preterm birth in women with singleton pregnancy who are at high risk: systematic review and network meta-analysis. BMJ 2022; 376: e064547.

Roman

Ramirez

Fox

NS.

Screening for preterm birth in twin pregnancies. Am J Obstet Gynecol MFM 2022; 4: 100531.

Goldenberg

Iams

Das

, et al. The Preterm Prediction Study: sequential cervical length and fetal fibronectin testing for the prediction of spontaneous preterm birth. National Institute of Child Health and Human Development Maternal–fetal Medicine Units Network. Am J Obstet Gynecol 2000; 182: 636–643.

Martin

Hamilton

Ventura

, et al. Births: final data for 2011. Natl Vital Stat Rep 2013; 62: 1–69.

Iams

Goldenberg

Meis

, et al. The length of the cervix and the risk of spontaneous premature delivery. National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network. N Engl J Med 1996; 334: 567–572.

10.

Goldenberg

Iams

Miodovnik

, et al. The preterm prediction study: risk factors in twin gestations. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Am J Obstet Gynecol 1996; 175(4 Pt. 1): 1047–1053.

11.

Brubaker

Gyamfi

Prediction and prevention of spontaneous preterm birth in twin gestations. Semin Perinatol 2012; 36: 190–194.

12.

Makrydimas

Sotiriadis

Prediction of preterm birth in twins. Best Pract Res Clin Obstet Gynaecol 2014; 28: 265–272.

13.

Conde-Agudelo

Romero

Prediction of preterm birth in twin gestations using biophysical and biochemical tests. Am J Obstet Gynecol 2014; 211: 583–595.

14.

Premru-Srsen

Verdenik

Steblovnik

, et al. Early prediction of spontaneous twin very preterm birth: a population based study 2002-2012. J Matern Fetal Neonatal Med 2015; 28: 1784–1789.

15.

Collins

Shennan

A clinical opinion on how to manage the risk of preterm birth in twins based on literature review. J Matern Fetal Neonatal Med 2016; 29: 1125–1130.

16.

Liem

Schuit

Hegeman

, et al. Cervical pessaries for prevention of preterm birth in women with a multiple pregnancy (ProTWIN): a multicentre, open-label randomised controlled trial. Lancet 2013; 382: 1341–1349.

17.

Goya

de la Calle

Pratcorona

, et al. Cervical pessary to prevent preterm birth in women with twin gestation and sonographic short cervix: a multicenter randomized controlled trial (PECEP-Twins). Am J Obstet Gynecol 2016; 214: 145–152.

18.

Schuit

Stock

Rode

, et al. Effectiveness of progestogens to improve perinatal outcome in twin pregnancies: an individual participant data meta-analysis. BJOG 2015; 122: 27–37.

19.

Reicher

Fouks

Yogev

Cervical assessment for predicting preterm birth-cervical length and beyond. J Clin Med 2021; 10(4): 627.

20.

Crane

Hutchens

Transvaginal sonographic measurement of cervical length to predict preterm birth in asymptomatic women at increased risk: a systematic review. Ultrasound Obstet Gynecol 2008; 31: 579–587.

21.

Melamed

Pittini

Hiersch

, et al. Do serial measurements of cervical length improve the prediction of preterm birth in asymptomatic women with twin gestations? Am J Obstet Gynecol 2016; 215: 616.e1–616.e14.

22.

Wang

Value of serial cervical length measurement in prediction of spontaneous preterm birth in post-conization pregnancy without short mid-trimester cervix. Sci Rep 2018; 8: 15305.

23.

Conde-Agudelo

Romero

Predictive accuracy of changes in transvaginal sonographic cervical length over time for preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol 2015; 213: 789–801.

24.

Khalil

Rodgers

Baschat

, et al. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247–263.

25.

Gong

, et al. Longitudinal cervical length measurements and spontaneous preterm birth in singleton and twin pregnancies. JAMA Netw Open 2024; 7: e244592.

26.

Coutinho

Sotiriadis

Odibo

, et al. ISUOG practice guidelines: role of ultrasound in the prediction of spontaneous preterm birth. Ultrasound Obstet Gynecol 2022; 60(3): 435–456.

27.

Akar

Ceylan

Kahraman

, et al. Centile charts of cervical length in singleton and twin pregnancies between 16 and 24 weeks of gestation. J Turk Ger Gynecol Assoc 2023; 2: 114–119.

28.

Pagani

Stagnati

Fichera

, et al. Cervical length at mid-gestation in screening for preterm birth in twin pregnancy. Ultrasound Obstet Gynecol 2016; 48: 56–60.

29.

Sperling

Kiil

Larsen

, et al. How to identify twins at low risk of spontaneous preterm delivery. Ultrasound Obstet Gynecol 2005; 26: 138–144.

30.

Khalil

Alzahrani

Ullah

The use of cervical length and change in cervical length for prediction of spontaneous preterm birth in asymptomatic twin pregnancies. Eur J Obstet Gynecol Reprod Biol 2013; 169: 193–196.

31.

Levêque

Vayssière

Favre

, et al. Cervical length in asymptomatic twin pregnancies: prospective multicenter comparison of predictive indicators. J Matern Fetal Neonatal Med 2015; 28: 37–40.

32.

Imseis

Albert

Iams

JD.

Identifying twin gestations at low risk for preterm birth with a transvaginal ultrasonographic cervical measurement at 24 to 26 weeks’ gestation. Am J Obstet Gynecol 1997; 177: 1149–1155.

33.

Gibson

Macara

Owen

, et al. Prediction of preterm delivery in twin pregnancy: a prospective, observational study of cervical length and fetal fibronectin testing. Ultrasound Obstet Gynecol 2004; 23: 561–566.

34.

Lim

Hegeman

Huis

‘T Veld

, et al. Cervical length measurement for the prediction of preterm birth in multiple pregnancies: a systematic review and bivariate meta-analysis. Ultrasound Obstet Gynecol 2011; 38: 10–17.

35.

Fox

Saltzman

Klauser

, et al. Prediction of spontaneous preterm birth in asymptomatic twin pregnancies with the use of combined fetal fibronectin and cervical length. Am J Obstet Gynecol 2009; 201: 313.e1–5.

36.

Arabin

Roos

Kollen

, et al. Comparison of transvaginal sonography in recumbent and standing maternal positions to predict spontaneous preterm birth in singleton and twin pregnancies. Ultrasound Obstet Gynecol 2006; 27: 377–386.

37.

Fonseca

Molina

, et al. Maternal characteristics and cervical length in the prediction of spontaneous early preterm delivery in twins. Am J Obstet Gynecol 2006; 194: 1360–1365.

38.

Romero

Conde-Agudelo

Rehal

, et al. Vaginal progesterone for the prevention of preterm birth and adverse perinatal outcomes in twin gestations with a short cervix: an updated individual patient data meta-analysis. Ultrasound Obstet Gynecol 2022; 59: 263–266.

39.

Ferro

Diago

, et al. The effectiveness of cervical cerclage in twin pregnancies with a mid-trimester short cervix: a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2024; 294: 33–38.

40.

Rehal

Benkő

De Paco Matallana

, et al. Early vaginal progesterone versus placebo in twin pregnancies for the prevention of spontaneous preterm birth: a randomized, double-blind trial. Am J Obstet Gynecol 2021; 224: 86.e1–19.

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