The following is a summary of “Management of short cervix in twin-to-twin transfusion syndrome: a role for pessary placement following fetoscopic laser surgery?,” published in the January 2024 issue of Obstetrics and Gynecology by Bartin, et al.
Patients with twin-to-twin transfusion syndrome (TTTS) undergoing fetoscopic laser surgery are at risk of preterm labor and delivery, especially if they have a short cervix preoperatively. Pessary placement, as a supportive intervention, may mitigate this risk. For a study, researchers sought to examine the association between pessary placement and preterm delivery in monochorionic twin pregnancies with TTTS and a preoperative cervical length below 25 mm before undergoing fetoscopic laser surgery.
The study included patients from two centers who underwent fetoscopic laser surgery with the Solomon technique between 2013 and 2022 (center A) and 2014 and 2022 (center B). Patients were included if they had a preoperative cervical length below 25 mm. The correlation between cervical length and the interval from fetoscopic laser surgery to delivery was explored, comparing perinatal outcomes between expectant management and pessary placement groups. Multivariate analysis controlled for potential confounders, excluding patients with a cervical length below 5 mm from the comparative analysis.
Out of 685 patients, 134 met the study’s inclusion criteria. Additionally, 21 patients underwent cervical cerclage and were excluded from the analysis, resulting in a final cohort of 113 patients. A significant negative correlation was observed between cervical length during fetoscopic laser surgery and the risk of early delivery (adjusted odds ratio: 0.66; 95% CI: 0.49–0.81; P < .001). Furthermore, the use of a pessary was associated with a reduced likelihood of delivery before 28 weeks of gestation (adjusted odds ratio: 0.28; 95% CI: 0.09–0.75) and fewer instances of double neonatal demise (adjusted odds ratio: 0.2; 95% CI: 0.05–0.75). Subsequent subgroup analysis revealed these benefits to be particularly evident for patients with cervical lengths between 5 and 18 mm. In this subgroup, pessary placement was linked to an extended interval from fetoscopic laser surgery to delivery (+24 days; 95% CI: 0.86–42; P = .042) and a later gestational age at delivery (+3.3 weeks; 95% CI: 0.86–42; P = .035).
Pessary placement following fetoscopic surgery for TTTS in patients with moderately shortened cervixes (5-18 mm) may lead to improved neonatal outcomes, reduced double neonatal demise, and decreased severe preterm delivery. The findings suggested a potential benefit of pessary placement in the population.