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Prenatal Cardiology

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Preterm Delivery of Twins

Birgit Arabin
  • Corresponding author
  • Clara Angela Foundation, Witten and Berlin, Germany, 2Center for Mother and Child University of Marburg, Germany
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  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2015-12-30 | DOI: https://doi.org/10.12847/09141


The incidence of twin gestation has increased over the past decades and contributes to an increased rate of spontaneous preterm birth and increased mortality and morbidity up to adult age. Prevention of spontaneous preterm birth in twin pregnancies differs from interventions in singleton pregnancies.

Up to now, many treatment modalities have been investigated such as bed rest, tocolytics, antibiotics, cerclage or progestagens, but have failed to prevent prematurity rates in twin gestations or were even combined with harmful effects. Cervical pessaries might be a non-invasive cost-effective option, but it is mandatory to evaluate vaginal progesterone and cervical pessaries in twin gestations with a short cervix in further randomized trials.

Keywords: twin pregnancy; prevention of sponatenous preterm birth; cervical assessment


  • 1. Uldbjerg N, Ulmsten U, Ekman G. The ripening of the human uterine cervix in terms of connective tissue biochemistry. Clin Obstet Gynecol 1983;26(1):14-26.CrossrefGoogle Scholar

  • 2. Romero R, Mazor M, Munoz H, Gomez R, Galasso M, Sherer DM. The preterm labor syndrome. Ann N Y Acad Sci 1994;734:414-29.Google Scholar

  • 3. Guzman ER, Shen-Schwarz S, Benito C, Vintzileos AM, Lake M, Lai YL. The relationship between placental histology and cervical ultrasonography in women at risk for pregnancy loss and spontaneous preterm birth. Am J Obstet Gynecol 1999;181:793-7.Google Scholar

  • 4. Romero R, Shamma F, Avila C, Jimenez C, Callahan R, Nores J, et al. Infection and labor. VI. Prevalence, microbiology, and clinical significance of intraamniotic infection in twin gestations with preterm labor. Am J Obstet Gynecol 1990;163(3):757-61.Google Scholar

  • 5. Newman RB, Godsey RK, Ellings JM, Campbell BA, Eller DP, Miller MC, 3rd. Quantification of cervical change: relationship to preterm delivery in the multifetal gestation. Am J Obstet Gynecol 1991;165(2):264-9; discussion 69-71.Google Scholar

  • 6. Arabin B, Aardenburg R, van Eyck J. Maternal position and ultrasonic cervical assessment in multiple pregnancy. Preliminary observations. J Reprod Med 1997;42(11):719-24.Google Scholar

  • 7. Arabin B, Hübener M, Halbesma JR, van Eyck J. Sonographic Diagnosis of Cervical Incompetence in Twin pregnancies. Ultrasound Review 2001;1:340-9.Google Scholar

  • 8. Bernath T, Brizot ML, Liao AW, Cury L, Banduki Neto JD, Zugaib M. Effect of maternal position on cervical length measurement in twin pregnancies. Ultrasound Obstet Gynecol 2002;20(3):263-6.CrossrefGoogle Scholar

  • 9. Sonek J. Cervical sonography: a review. Ultrasound Obstet Gynecol 1998;11:71-78.CrossrefGoogle Scholar

  • 10. Greco E, Gupta R, Syngelaki A, Poon LC, Nicolaides KH. First-trimester screening for spontaneous preterm delivery with maternal characteristics and cervical length. Fetal Diagn Ther 2012;31(3):154-61.CrossrefGoogle Scholar

  • 11. Iams JD, Goldenberg RL, Meis PJ, Mercer BM, Moawad A, Das A, 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(9):567-72.Google Scholar

  • 12. Vayssiere C, Favre R, Audibert F, Chauvet MP, Gaucherand P, Tardif D, et al. Cervical length and funneling at 22 and 27 weeks to predict spontaneous birth before 32 weeks in twin pregnancies: a French prospective multicenter study. Am J Obstet Gynecol 2002;187(6):1596-604.Google Scholar

  • 13. Papiernik E, Bouyer J, Collin D. Prevention of preterm births: a perinatal study in Haguenau, France. Pediatrics 1985;76:154-8.Google Scholar

  • 14. Bergelin I, Valentin L. Cervical changes in twin pregnancies observed by transvaginal ultrasound during the latter half of pregnancy: a longitudinal, observational study. Ultrasound Obstet Gynecol 2003;21(6):556-63.CrossrefGoogle Scholar

  • 15. Eppel W, Shurz, B., Frigo, P., Adler, A., Aseryanis, E., Kudielka, I., Varva, N., Reinold, E.,. Vaginosonography of the cervix in twin pregnancies. Geburtshilfe Frauenheilkd 1994;54:20-26.CrossrefGoogle Scholar

  • 16. Bega G, Lev-Toaff A, Kuhlman K, Berghella V, Parker L, Goldberg B, et al. Three-dimensional multiplanar transvaginal ultrasound of the cervix in pregnancy. Ultrasound Obstet Gynecol 2000;16(4):351-8.CrossrefGoogle Scholar

  • 17. Goldenberg RL, Iams JD, Miodovnik M, Van Dorsten JP, Thurnau G, Bottoms S, 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):1047-53.Google Scholar

  • 18. Wennerholm UB, Holm B, Mattsby-Baltzer I, Nielsen T, Platz-Christensen J, Sundell G, et al. Fetal fibronectin, endotoxin, bacterial vaginosis and cervical length as predictors of preterm birth and neonatal morbidity in twin pregnancies. Br J Obstet Gynaecol 1997;104(12):1398-404.Google Scholar

  • 19. Crane JM, Van den Hof M, Armson BA, Liston R. Transvaginal ultrasound in the prediction of preterm delivery: singleton and twin gestations. Obstet Gynecol 1997;90(3):357-63.CrossrefGoogle Scholar

  • 20. Imseis HM, Albert TA, 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(5):1149-55.CrossrefGoogle Scholar

  • 21. Souka AP, Heath V, Flint S, Sevastopoulou I, Nicolaides KH. Cervical length at 23 weeks in twins in predicting spontaneous preterm delivery. Obstet Gynecol 1999;94(3):450-4.CrossrefGoogle Scholar

  • 22. Granovski-Gisaru S, Farine D, Barret J, van Eyck N, Ryan G. Is a single ultrasound measurement of cervical length a predictor of the risk of preterm delivery in multifetal pregnancy? Am J Obstet Gynecol 1998(178):191.Google Scholar

  • 23. Althusius S, Dekker G. Short cervical length predicts preterm delivery in twin gestations. Am J Obstet Gynecol 1998;178:194.Google Scholar

  • 24. Weisz B, Soriano D, Seidman DS, Schiff E, Libitz S, Achiron R. Risk factors for premature birth in primigravidae with twin gestation and the role of transvaginal ultrasonographic assessment of the cervix. Am J Obstet Gynecol 2000;182:115.Google Scholar

  • 25. Yang JH, Kuhlman K, Daly S, Berghella V. Prediction of preterm birth by second trimester cervical sonography in twin pregnancies. Ultrasound Obstet Gynecol 2000;15(4):288-91.CrossrefGoogle Scholar

  • 26. Guzman ER, Walters C, O’Reilly-Green C, Kinzler WL, Waldron R, Nigam J, et al. Use of cervical ultrasonography in prediction of spontaneous preterm birth in twin gestations. Am J Obstet Gynecol 2000;183(5):1103-7.CrossrefGoogle Scholar

  • 27. Persutte W, Chyu J, Cioffi-Ragan D, Hobbins JC. Cervical length in twins. Am J Obstet Gynecol 2000;182:118.Google Scholar

  • 28. Vendittelli F, Mamelle N, Munoz F, Janky E. Transvaginal ultrasonography of the uterine cervix in hospitalized women with preterm labor. Int J Gynaecol Obstet 2001;72(2):117-25.CrossrefGoogle Scholar

  • 29. Shapiro JL, Kung R, Barrett JF. Cervical length as a predictor of pre-term birth in twin gestations. Twin Res 2000;3(4):213-6.Google Scholar

  • 30. Iams JD, Goldenberg RL, Mercer BM, Moawad AH, Meis PJ, Das AF, et al. The preterm prediction study: can low-risk women destined for spontaneous preterm birth be identified? Am J Obstet Gynecol 2001;184(4):652-5.Google Scholar

  • 31. Skentou C, Souka AP, To MS, Liao AW, Nicolaides KH. Prediction of preterm delivery in twins by cervical assessment at 23 weeks. Ultrasound Obstet Gynecol 2001;17(1):7-10.CrossrefGoogle Scholar

  • 32. Soriano D, Weisz B, Seidman DS, Chetrit A, Schiff E, Lipitz S, et al. The role of sonographic assessment of cervical length in the prediction of preterm birth in primigravidae with twin gestation conceived after infertility treatment. Acta Obstet Gynecol Scand 2002;81(1):39-43.CrossrefGoogle Scholar

  • 33. Shulman A, Jauniaux E, Holmes A, Maschiach S, Maymon R. Vaginal sonography of the cervix for the prediction of “time to delivery” in ART twins gestations. Twin Res 2002;5(4):255-9.Google Scholar

  • 34. Honest H, Bachmann LM, Coomarasamy A, Gupta JK, Kleijnen J, Khan KS. Accuracy of cervical transvaginal sonography in predicting preterm birth: a systematic review. Ultrasound Obstet Gynecol 2003;22(3):305-22.CrossrefGoogle Scholar

  • 35. Conde-Agudelo A, Romero R, Hassan SS, Yeo L. Transvaginal sonographic cervical length for the prediction of spontaneous preterm birth in twin pregnancies: a systematic review and metaanalysis. Am J Obstet Gynecol 2010;203(2):128 e1-12.Google Scholar

  • 36. Iams JD. Prediction and early detection of preterm labor. Obstet Gynecol 2003;101(2):402-12.CrossrefGoogle Scholar

  • 37. Gordon M RA, McKenna D, Howard B, Barth W. . Cervical length assessment as a resource to identify twins at risk for preterm delivery (clarity study). . Am J Obstet Gynecol 2006(195):S55.Google Scholar

  • 38. Rode L, Tabor A. Prevention of preterm delivery in twin pregnancy. Best practice & research. Clinical obstetrics & gynaecology 2014;28(2):273-83.Google Scholar

  • 39. Crowther CA. Hospitalisation and bed rest for multiple pregnancy (A Cochrane Review). The Cochrane Libary. Oxford: Update Software 2003(2).Google Scholar

  • 40. Gyetvai K, Hannah ME, Hodnett ED, Ohlson A. Tocolytics for preterm labor: a systematic review. The Cochrane Libary. Oxford: Update Software 2003;2.Google Scholar

  • 41. Gabriel R, Harika G, Saniez D, Durot S, Quereux C, Wahl P. Prolonged intravenous ritodrine therapy: a comparison between multiple and singleton pregnancies. Eur J Obstet Gynecol Reprod Biol 1994;57(2):65-71.CrossrefGoogle Scholar

  • 42. Hadi HA, Albazzaz SJ. Measurement of pulmonary capillary pressure during ritodrine tocolysis in twin pregnancies: a new noninvasive technique. Am J Perinatol 1993;10(5):351-3.CrossrefGoogle Scholar

  • 43. Crowley P, Chalmers I, Keirse MJ. The effects of corticosteroid administration before preterm labor. An overview of the evidence from controlled trials. The Cochrane Libary. Oxford: Update Software 2003(2).Google Scholar

  • 44. Ballabh P, Lo ES, Kumari J, Cooper TB, Zervoudakis I, Auld PA, et al. Pharmacokinetics of betamethasone in twin and singleton pregnancy. Clin Pharmacol Ther 2002;71(1):39-45.CrossrefGoogle Scholar

  • 45. Murphy DJ, Caukwell S, Joels LA, Wardle P. Cohort study of the neonatal outcome of twin pregnancies that were treated with prophylactic or rescue antenatal corticosteroids. Am J Obstet Gynecol 2002;187(2):483-8.Google Scholar

  • 46. Mc Donald H, Brocklehurst P, Parsons J, Vignesvaran R. Antibiotics for treating bacterial vaginosis in pregnancy (Cochrane Review). The Cochrane Libary. Oxford: Update Software 2003;2.Google Scholar

  • 47. F. S. Antibiotics for asymptomatic bacteriuria in pregnancy (Cochrane Review). The Cochrane Libary. Oxford: Update Software 2003;2.Google Scholar

  • 48. King JF, Flenady VJ. Prophylactic antibiotics for inhibiting preterm labor with intact memranes. The Cochrane Libary. Oxford: Update Software 2003;2.Google Scholar

  • 49. Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of membranes. The Cochrane Libary. Oxford: Update Software 2003;2.Google Scholar

  • 50. Jacquemyn Y, Noelmans L, Mahieu L, Buytaert P. Twin versus singleton pregnancy and preterm prelabour rupture of the membranes. Clin Exp Obstet Gynecol 2003;30(2-3):99-102.Google Scholar

  • 51. Rizzo G, Capponi A, Angelini E, Vlachopoulou A, Grassi C, Romanini C. The value of transvaginal ultrasonographic examination of the uterine cervix in predicting preterm delivery in patients with preterm premature rupture of membranes. Ultrasound Obstet Gynecol 1998;11(1):23-9.CrossrefGoogle Scholar

  • 52. Marlow N, Pike K, Bower E, Brocklehurst P, Jones D, Kenyon S, et al. Characteristics of children with cerebral palsy in the ORACLE children study. Developmental medicine and child neurology 2012;54(7):640-6.Google Scholar

  • 53. Macnaughton MC, Chalmers IG, Dubowitz V, al. e. Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists. Multicentre Randomised Trial of Cervical Cerclage. Br J Obstet Gynaecol 1993;100:516-23.Google Scholar

  • 54. O’Brien JM, Hill AL, Barton JR. Funneling to the stitch: an informative ultrasonographic finding after cervical cerclage. Ultrasound Obstet Gynecol 2002;20(3):252-5.CrossrefGoogle Scholar

  • 55. Maly Z, Deutinger J. [Decrease in cerclage incidence in multiple pregnancies by vaginal ultrasound monitoring]. Z Geburtshilfe Perinatol 1993;197(4):162-4.Google Scholar

  • 56. Newman RB, Krombach RS, Myers MC, McGee DL. Effect of cerclage on obstetrical outcome in twin gestations with a shortened cervical length. Am J Obstet Gynecol 2002;186(4):634-40.Google Scholar

  • 57. Salomon LJ, Nasr B, Nizard J, Bernard JP, Essaoui M, Bussieres L, et al. Emergency cerclage in cases of twin-to-twin transfusion syndrome with a short cervix at the time of surgery and relationship to perinatal outcome. Prenat Diagn 2008;28(13):1256-61.CrossrefGoogle Scholar

  • 58. Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Obstet Gynecol 2005;106(1):181-9.CrossrefGoogle Scholar

  • 59. Kyvernitakis I, Lotgering F, Arabin B. Abdominal cerclage in twin pregnancy after radical surgical conization. Case reports in obstetrics and gynecology 2014;2014:519826.Google Scholar

  • 60. Arabin B, Halbesma JR, Vork F, Hubener M, van Eyck J. Is treatment with vaginal pessaries an option in patients with a sonographically detected short cervix? J Perinat Med 2003;31(2):122-33.Google Scholar

  • 61. Carreras E, Arevalo S, Bello-Munoz JC, Goya M, Rodo C, Sanchez-Duran MA, et al. Arabin cervical pessary to prevent preterm birth in severe twin-to-twin transfusion syndrome treated by laser surgery. Prenat Diagn 2012;32(12):1181-5.CrossrefGoogle Scholar

  • 62. Liem S, Schuit E, Hegeman M, Bais J, de Boer K, Bloemenkamp K, 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.Google Scholar

  • 63. Arabin B, Alfirevic Z. Cervical pessaries for prevention of spontaneous preterm birth: past, present and future. Ultrasound Obstet Gynecol 2013;42(4):390-9.Google Scholar

  • 64. Cannie MM, Dobrescu O, Gucciardo L, Strizek B, Ziane S, Sakkas E, et al. Arabin cervical pessary in women at high risk of preterm birth: a magnetic resonance imaging observational follow-up study. Ultrasound Obstet Gynecol 2013;42(4):426-33.Google Scholar

  • 65. Romero R, Nicolaides K, Conde-Agudelo A, Tabor A, O’Brien JM, Cetingoz E, et al. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data. Am J Obstet Gynecol 2012;206(2):124 e1-19. Google Scholar

  • 66. Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH. Progesterone and the risk of preterm birth among women with a short cervix. N Engl J Med 2007;357(5):462-9.Google Scholar

  • 67. Aboulghar MM, Aboulghar MA, Amin YM, Al-Inany HG, Mansour RT, Serour GI. The use of vaginal natural progesterone for prevention of preterm birth in IVF/ICSI pregnancies. Reprod Biomed Online 2012;25(2):133-8.CrossrefGoogle Scholar

  • 68. Norman JE, Shennan AH. Prevention of preterm birth--why can’t we do any better? Lancet 2013;381(9862):184-5.Google Scholar

  • 69. Rode L, Klein K, Nicolaides KH, Krampl-Bettelheim E, Tabor A. Prevention of preterm delivery in twin gestations (PREDICT): a multicenter, randomized, placebo-controlled trial on the effect of vaginal micronized progesterone. Ultrasound Obstet Gynecol 2011;38(3):272-80.CrossrefGoogle Scholar

  • 70. Serra V, Perales A, Meseguer J, Parrilla JJ, Lara C, Bellver J, et al. Increased doses of vaginal progesterone for the prevention of preterm birth in twin pregnancies: a randomised controlled double-blind multicentre trial. Bjog 2013;120(1):50-7.CrossrefGoogle Scholar

  • 71. Wood S, Ross S, Tang S, Miller L, Sauve R, Brant R. Vaginal progesterone to prevent preterm birth in multiple pregnancy: a randomized controlled trial. J Perinat Med 2012.Google Scholar

  • 72. Briery CM, Veillon EW, Klauser CK, Martin RW, Chauhan SP, Magann EF, et al. Progesterone does not prevent preterm births in women with twins. Southern medical journal 2009;102(9):900-4.CrossrefGoogle Scholar

  • 73. Combs CA, Garite T, Maurel K, Das A, Porto M. 17-hydroxyprogesterone caproate for twin pregnancy: a double-blind, randomized clinical trial. Am J Obstet Gynecol 2011;204(3):221 e1-8.Google Scholar

  • 74. Lim AC, Schuit E, Bloemenkamp K, Bernardus RE, Duvekot JJ, Erwich JJ, et al. 17alpha-hydroxyprogesterone caproate for the prevention of adverse neonatal outcome in multiple pregnancies: a randomized controlled trial. Obstet Gynecol 2011;118(3):513-20.CrossrefGoogle Scholar

  • 75. Rouse DJ, Caritis SN, Peaceman AM, Sciscione A, Thom EA, Spong CY, et al. A trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twins. N Engl J Med 2007;357(5):454-61.Google Scholar

  • 76. Caritis SN, Simhan HN, Zhao Y, Rouse DJ, Peaceman AM, Sciscione A, et al. Relationship between 17-hydroxyprogesterone caproate concentrations and gestational age at delivery in twin gestation. Am J Obstet Gynecol 2012;207(5):396 e1-8.Google Scholar

  • 77. Schuit E, Stock S, Groenwold RH, Maurel K, Combs CA, Garite T, et al. Progestogens to prevent preterm birth in twin pregnancies: an individual participant data meta-analysis of randomized trials. BMC Pregnancy Childbirth 2012;12:13.Google Scholar

  • 78. Sotiriadis A, Papatheodorou S, Makrydimas G. Perinatal outcome in women treated with progesterone for the prevention of preterm birth: a meta-analysis. Ultrasound Obstet Gynecol 2012;40(3):257-66.CrossrefGoogle Scholar

  • 79. O’Brien JM. The safety of progesterone and 17-hydroxyprogesterone caproate administration for the prevention of preterm birth: an evidence-based assessment. Am J Perinatol 2012;29(9):665-72.Google Scholar

  • 80. Combs CA, Garite T, Maurel K, Das A, Porto M. Failure of 17-hydroxyprogesterone to reduce neonatal morbidity or prolong triplet pregnancy: a double-blind, randomized clinical trial. Am J Obstet Gynecol 2010;203(3):248 e1-9.Google Scholar

  • 81. Arabin B, Kuizenga K, van Zoeren D, Eyck JV. Long-term epidural block treatment in patients with early threatening preterm delivery and vaginal fetal engagement. J Perinat Med 2008;36(6):543-7.Google Scholar

  • 82. Arabin B, van Eyck J. Delayed-interval delivery in twin and triplet pregnancies: 17 years of experience in 1 perinatal center. Am J Obstet Gynecol 2009;200(2):154 e1-8. Google Scholar

About the article

Received: 2014-07-27

Accepted: 2014-07-27

Published Online: 2015-12-30

Published in Print: 2014-09-01

Citation Information: Prenatal Cardiology, Volume 4, Issue 3, Pages 5–12, ISSN (Online) 2353-8201, DOI: https://doi.org/10.12847/09141.

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