Effective treatment of cervical incompetence in a monochorionic monoamniotic twin pregnancy with a rescue cervical cerclage and pessary – a case report and review of literature

Abstract

A monochorionic monoamniotic (MCMA) twin pregnancy is the rarest form of twin gestation, accounting for around 1:10000 to 1:20000 of all deliveries regardless of the region of the world. All multiple gestations have a higher risk of preterm delivery due to either preterm uterine contractions or asymptomatic cervical shortening (cervical incompetence). A case of a 28-year-old primigravida in MCMA twin pregnancy with cervical incompetence diagnosed at 22 weeks of gestation is presented. After obtaining cervical swabs, negative laboratory infection parameters and confirming concordant gestational age on ultrasound scan with no structural abnormalities of both fetuses, the patient was qualified for an emergency cervical cerclage according to Wurm-Hefner method. Five days after the procedure, a cervical pessary was additionally inserted. She was administered antibiotics and steroids. The wellbeing of both fetuses was strictly monitored by means of cardiotocography tracing and ultrasound examinations, on which they were both eutrophic, with no abnormalities in Doppler blood flow patterns. Spontaneous premature rupture of membranes took place at 32 weeks of gestation, a cesarean section was performed and two female fetuses of 1740g and 1760g were delivered. They both required antibiotics because of congenital pneumonia, but no respiratory support was necessary. The twins were discharged from the hospital 22 days after birth in good general condition. This case of a rescue cervical cerclage and pessary used simultaneously can be an example of an effective method of cervical incompetence treatment in twin pregnancies.