Discussion

Preterm delivery in twin pregnancies reflects a complex interplay of mechanical, inflammatory, and hormonal factors. Twin pregnancies now account for 3% of all pregnancies, an annual increase in occurrence brought on by assisted reproductive technologies. About 50% of twin pregnancies deliver at less than 37 weeks of gestation, and 14% of preterm births have been noted at less than 33 weeks of gestation. Furthermore, the rates of preterm births (PTBs) at less than 32 weeks of gestation are eight times greater than those of singletons. The burden on nations and families has increased significantly due to the rise in the prevalence of both short- and long-term newborn problems and mortality. Thus, concerns of utmost importance to obstetricians are preventing preterm birth and enhancing newborn outcomes [7].

More recent research has shown that cerclage may offer an advantage in some twin pregnancies due to structural changes in the cervix. The systematic review conducted by Liu et al. [8] demonstrated that perinatal outcomes improved and spontaneous preterm birth decreased among women who received cerclage for cervical shortening. Additionally, several observational studies reported that emergency cerclage in twins extended gestational age to a similar extent as in singleton deliveries [9]. Subsequent cohort studies have provided evidence that cerclage may be beneficial to neonatal outcomes in asymptomatic patients with a shortened cervix [10].

Uterine fibroids have been associated with an increased risk of adverse obstetric outcomes, including spontaneous preterm birth, malpresentation, and caesarean delivery [11]. While causality cannot be established from a single case, it is plausible that the combination of rescue cervical cerclage and vaginal progesterone supplementation contributed to prolonging the pregnancy by approximately 10 weeks, thereby improving neonatal outcomes [12,13].

Despite the promising results observed in this case, several challenges remain in the management of twin pregnancies with cervical insufficiency. The decision to proceed with cerclage must be individualised, taking into account gestational age, degree of cervical change, the presence of additional risk factors such as uterine fibroids, and the patient's preferences. Although the fibroids in this patient were relatively small, their coexistence with twin gestation and cervical insufficiency likely compounded the overall risk of spontaneous preterm birth [11-13].

However, several randomised trials and meta-analyses have found no significant benefit or even a possible increase in adverse outcomes when cerclage is used routinely in unselected twin pregnancies, particularly in those without clear evidence of cervical insufficiency. For instance, the meta-analysis by Berghella et al. and guidance from major obstetric societies caution against the universal use of cerclage in twin pregnancies due to a lack of proven efficacy and potential risks [5,14,15]. Thus, the current body of evidence is inconsistent due to differences in study designs and populations, as well as a paucity of robust randomised trials, so conclusions about efficacy should be drawn with caution.

Current guidelines from international societies do not universally recommend cerclage in unselected twin pregnancies, citing the lack of robust randomised controlled trial data and the potential for increased procedural risks. Rescue cerclage has shown promise in a few specific situations; however, it was used here due to cervical shortening/dilatation in the absence of labour or infection. Data from observational studies and meta-analyses indicate that rescue cerclage may be associated with a longer gestational age in appropriately selected patients; therefore, it may improve neonatal outcomes when performed in suitable candidates [5,8].

In addition, the multidisciplinary team approach (maternal-foetal medicine, neonatology, and anaesthesia) used in this patient's case provided optimal surveillance for potential complications and optimised maternal well-being and preparedness for the challenges of preterm birth. The multidisciplinary care model likely contributed to positive maternal and neonatal outcomes.

This case also demonstrates the value of using multiple modalities to manage high-risk pregnancy, including adjunctive therapy (vaginal progesterone) and administration of corticosteroids and magnesium sulphate at the time they are needed. Nevertheless, the interpretation of this case should acknowledge its limitations, including the inability to generalise outcomes from a single-patient experience and the inherent risk of bias. Large-scale, prospective studies are required to define patient selection criteria better and clarify the relative benefits and risks of rescue cerclage in twin gestations [14,15]. Until such data are available, clinical judgement, shared decision-making, and individualised care remain paramount.