Twin Pregnancy Gestational Length Prolongation and Neonatal Morbidity and Mortality Reduction by Cervical Pessary with or Without Vaginal Progesterone

Purpose: The purpose of this mini review is to elucidate if cervical pessary, with or without progesterone is applicable to twin pregnancies. One-quarter of preterm births (PTB) are twin pregnancies. Cervical cerclage, progesterone, and cervical pessary decrease the PTB incidence in singleton pregnancies. Retrospective cohorts suggest that cervical cerclage is not harmful, and is possibly beneficial in twin pregnancies, whereas meta-analysis found cervical cerclage harmful in twin pregnancies. Methods: Three significant articles from January to April, 2016 were selected for evidence-based practice review. Hand search was performed as needed to complete the subject background. Results: An American retrospective case-control study suggests that the Arabin cervical pessary with vaginal progesterone reduces twin pregnancy PTB at < 34 weeks estimated gestational age (EGA), to 23.8% from 44.4% for controls. The mean cervical length was ≤ 11 mm at 25 weeks mean EGA. A European multicenter randomized control trial (RCT) reduced PTB at < 34 weeks EGA, from 40.9% in controls to 17.6% in Arabin pessary patients, p = .002. However, an international RCT found equivalent PTB rates at < 34 weeks EGA, 13.6% in Arabin pessary patients and 12.9% in controls, accompanied by similar neonatal morbidity and mortality, and similar proportions of newborn birth weight < 2,500 grams. Conclusion: The Arabin cervical pessary with, or without vaginal progesterone may be most beneficial in twin pregnancies with cervical length ≤ 11 mm. Further RCT are needed to clarify which PTB prevention modalities are most beneficial in twin pregnancy. Twin Pregnancy Gestational Length Prolongation and Neonatal Morbidity and Mortality Reduction by Cervical Pessary with or Without Vaginal Progesterone Twin pregnancies lead to 25% of preterm births (PTB), but are 1.5% of all pregnancies [1]. The twin pregnancy gestational age-based PTB rate can be 5 to 10 times that of singleton pregnancies [2]. The increased risk of PTB in twin pregnancies, in turn, proportionally raises perinatal morbidity and mortality compared to that of singleton pregnancies [3]. Twin pregnancies’ rising incidence from 19.8 to 33.1 per 1,000 births from 1980 to 2012 compounds the incidence of perinatal morbidity and mortality attributed to twin, not singleton pregnancies [4]. Three mechanisms exist to reduce PTB in singleton pregnancies: Cervical cerclage, progesterone, and cervical pessary (Table 1). Of these, it is possible that only cervical pessary with or without progesterone prevents PTB in twin pregnancies.