Wednesday, February 6, 2013

Twins and Cervical Insufficiency/Incompetent Cervix: Top 5 Things to Know for Moms Expecting Multiples

In the world of blogs, everyone loves a top 5 list, right? And as I have spent a lot of time participating in various online communities related to incompetent cervix/cervical insufficiency, I see a lot of the same questions again and again. So I thought I'd write up a quick post to respond to a lot of things that Moms expecting multiples with diagnosed IC or with suspected/possible IC should know. Just some little odds and ends we learned along the way during our journey in talking to a very large number of doctors, and doing lots of our own research as well.

1. Typical Transvaginal Cerclage approaches (McDonald and Shirodkar stitches) have NOT been definitively shown to help for multiples (and some studies even showed worse results with TVC vs. no TVC).
For ladies who have had a prior IC-related loss (or unknown cause/possible IC loss) in a single or multiple pregnancy, it is very common for doctors to suggest a cerclage in a subsequent pregnancy. However, there are studies that suggest that these types of cerclage don't actually help with twins, especially for women who only have a short cervix as seen via ultrasound and no other risk factors. Like this study, for example. Or this one. On the other hand, other studies (like this one and this one) have shown better results with cerclages. There are other studies that have shown no significant difference. The long and short is that, so far, research has not conclusively concluded whether or not the traditional cerclage approaches are beneficial for multiple pregnancies, harmful for multiple pregnancies, or doesn't really help or hurt. So it is really a difficult, case-by-case type situation that needs to be managed closely by each individual doctor.

2. Transabdominal Cerclage (TAC) has shown better results for multiples in limited studies, while there isn't much published on the Transvaginal Cervicoisthmic Cerclage (TVCIC) for multiples.
There is not yet a great deal of published data on the TAC for multiples, and even less on the TVCIC. However, what is published has shown that these approaches absolutely do make a world of difference in multiple pregnancies, as evidenced by studies like this one. I've read stories on AbbyLoopers of women with IC successfully carrying quadruplets with a TAC. A properly placed TAC really is a "game-changer" for a woman with IC--it "cures" the problem in many cases.

There's basically nothing published on the TVCIC specifically related to multiples, but the limited mentions in studies like this one have shown good results, and anecdotally some of the top cerclage doctors who participate in communities like AbbyLoopers seem to suggest that they believe the success rates for TVCIC are better than for other vaginal approaches. Unfortunately, many doctors are wholly unaware of the TVCIC and will not offer a TAC outside of very specific instances (namely, multiple prior losses and at least one prior failed TVC). So while a TAC or TVCIC might be what is best for a woman carrying multiples with IC risks, it isn't always easy to get that--and the burden to be an educated advocate for yourself and your baby falls to the parents.

3. Multiples do not necessarily have to be born at the same time--this is called Delayed Interval Delivery.
Just as our story shows, it is very possible to delay the birth of later multiples for days, weeks, and even months if a first multiple must be born previability or prematurely. There have been a lot of studies done on Delayed Interval Delivery, and I've summed up most of the findings on the page on this blog about it. The key takeaways are that it has been shown to provide benefits when done as early as 16-17 weeks, and as late as 28 weeks. For higher-order multiples, there have even been multiple-delay pregnancies where babies were born on 3 separate days. Any delay, even just a day or two, can drastically improve the chances for babies born prior to 28 weeks. And with proper management by medical professionals, the risks to the mother for trying to delay have been shown to be very minimal. Sadly, many doctors are not well educated about this option, so it is really imperative that a patient is well-informed and can present this option to their doctor.

4. Progesterone (17P) has not been shown to help with multiples.
Although many doctors will prescribe it anyway (as ours did), progesterone injections haven't actually been shown to reduce pre-term delivery rates with multiple (though it absolutely has been shown to help for singletons). Interestingly, in our case, while Laurie started on 17P at 16 weeks, it did not help her avoid cervical change or pre-term labor with the twins. However, after we lost Thomas, she continued weekly progesterone until week 35, and she had no pre-term labor issues with just Milo after the TVCIC was placed. Was it the progesterone, the cerclage, the modified bedrest, or just a long overdue lucky break? Who knows. But in our case, even on progesterone it didn't stop us from losing Thomas. Yet maybe it helped save Milo. There do not seem to be many negative side effects, so many doctors prescribe 17P just because it doesn't seem to hurt and it may be helping.

5. Women carrying multiple are at greater risk for IC.
I guess this last point should be fairly obvious, as it is just basic physics. But to put it simply, the more weight that the cervix needs to bear, the greater the risk of CI/IC. A cervix that may be fully adequate to carry a single pregnancy to term may fail prematurely under the weight of multiple babies. This just means that women carrying multiples really need to educate themselves on the risks and learn about the treatment options. Part of the reason why we were able to save Milo was because Dan had done so much research early in the pregnancy even when things seemed to be going well, so when our crisis occurred, we already knew most of the basic facts and it didn't take much more digging to find out about other options we could consider.

So, the quick summary, as with almost everything you'll see on this blog: be an educated advocate for yourself and your baby. In many ways, being an involved parent starts before conception. You can do amazing things for your child months before you meet them, if you take the time to learn about the risks you might face and educate yourself about the options available if one of those risks turns into a moment of crisis.


  1. Thank you for taking the time to compile all of this information, we just lost our first babies three weeks ago due to IC and I had no idea what it was until I was in the hospital on bedrest dilated to a 3 at 19 weeks. I have been doing as much research as I can to try to prepare ourselves for our next pregnancy, especially because we also use fertility drugs to get pregnant and another multiples pregnancy is a possibility. I wish I had known about delayed interval delivery and the possibility that maybe we could have saved our daughter after the birth of our son, but I will be much more prepared with the right questions in a subsequent pregnancy! Thanks!

    1. Hi Amanda. Very sorry for your losses and I'm happy you were able to find information that may be helpful for you in a future pregnancy. I hope you are able to heal both physically and emotionally from your losses and I wish you a boring, easy pregnancy next time around.

  2. Thank you for posting this. I lost my twins in January, and it is unclear whether I have IC or not. We went through IVF to get pregnant, and my doctors have strongly advised to never transfer more than one embryo ever again. It is nice to know, however, that if I ever had twins that a TAC may work if we get surprised with identical twins.