Successful cervical cerclage in a dichorionic diamniotic twi

• Twin cervical cerclage can be appropriate in selected cases with significant cervical shortening and dilatation on ultrasound and examination, without previous history of cervical insufficiency or pre-term birth

• Careful monitoring with serial ultrasounds is required

• Progesterone pessaries may be increased to twice daily and have a route of administration change from vaginal to rectal

A 26-year-old primigravid woman presented with a dichorionic diamniotic twin pregnancy after 7 years of infertility. No formal ultrasound was performed until a morphology check at 19 weeks and 4 days of gestation, at which time a shortened cervix was identified. The patient was already on vaginal progesterone pessaries from conception, as per her infertility specialist, and was advised to change to a rectal route of administration. At 20 weeks and 5 days, progesterone pessaries were increased to twice daily. A repeat scan at 21 weeks and 4 days showed a funnelled cervix 29 mm in length, a closed portion of 4-6 mm, and bulging membranes. A speculum examination at this time showed a shortened cervix, 5 mm open, with visible membranes. A cervical cerclage was placed at 21 weeks and 5 days. The patient was given oral antibiotics for 1 week and was continued on progesterone pessaries. The patient was managed through the twin's clinic and had serial ultrasound scans throughout the pregnancy. She went on to develop gestational diabetes and pre-eclampsia. She had a cesarean section at 33 weeks and 4 days due to pre-eclampsia, with abnormal doppler scans. Cervical cerclage was removed at the time of the cesarean section. Both twins were admitted to the nursery for prematurity and progressed well. This case report illustrates how a cervical cerclage can be utilized successfully in a primigravid dichorionic diamniotic twin pregnancy.