Intrapartum pyrexia, cardiotocography traces and histologic chorioamnionitis: a case-control study.

OBJECTIVES: To compare characteristics of labor, cardiotocography traces, and maternal and neonatal outcomes, in a cohort of pregnancies at term complicated by maternal intrapartum pyrexia, with or without a histologic diagnosis of chorioamnionitis. METHODS: This is a retrospective case-control study including pregnancies at term with detection of maternal intrapartum pyrexia, delivered between January 2020 and June 2021. Cardiotocography traces were entirely evaluated, since admission till delivery, and classified according to the International Federation of Obstetrics and Gynecology (FIGO) guideline. Maternal and neonatal outcomes were also recorded as secondary outcomes. Placentas have been studied according to the Amniotic Fluid Infection Nosology Committee. RESULTS: Forty four patients met the inclusion criteria and were included in the study cohort. There was a significant association between the use of oxytocin augmentation in labor and the histologic diagnosis of chorioamnionitis. A significative recurrence of loss and/or absence of accelerations at the point of pyrexia was also documented in women with histological chorioamnionitis compared to the others. CONCLUSIONS: Chorioamnionitis appears to be associated with myometrial disfunction, as suggested by the increased use of oxytocin augmentation during active labor of women at term with intrapartum pyrexia and histologic diagnosis of chorioamnionitis.

Small-for-gestational-age fetus diagnosed in the second trimester: Possible etiologies and short-term neonatal outcomes.

INTRODUCTION: The aim of our study was to investigate the causes of fetal growth <10th centile diagnosed <26 weeks' gestation in singleton pregnancies and compare pregnancy outcomes in relation to the identified etiology. MATERIAL AND METHODS: Historical cohort study conducted in two Italian hospitals which included all small-for-gestational-age fetuses diagnosed between 18+0 and 26+0 weeks over a 10-year period. Fetuses were divided into three groups depending on the prenatally suspected etiology: chromosomal abnormalities (Group 1), malformations (Group 2) and isolated (Group 3). These groups were compared regarding pregnancy outcomes. Fetuses in Group 3 were divided into small-for-gestational-age and fetal growth restriction following the Delphi Consensus criteria and the outcomes were further compared. Fisher's Exact or Mann-Whitney test were used for comparison of groups. RESULTS: In all, 435 fetuses were included. Of these, 20 cases (4.6%) were associated with chromosomal abnormalities (Group 1), 98 (22.5%) with fetal malformations (Group 2) and 317 (72.9%) were isolated (Group 3). A higher percentage of live births was reported for Group 3 (P < 0.001). Termination of pregnancy was more common in Group 1 (P < 0.001). No differences in gestational age at delivery, birthweight, intrauterine death or neonatal death were detected within groups. Growth-restricted fetuses had lower gestational age at delivery, birthweight and number of live births (P < 0.001), higher rates of termination of pregnancy, intrauterine death (P < 0.001) and neonatal death <10 days (P = 0.002) compared to small-for-gestational-age. In 17 cases a chromosomal abnormality, genetic syndrome or adverse neurological outcome was diagnosed after birth: six from Group 2 (11.3% of live births in this group) and 11 from Group 3 (4.3%). CONCLUSIONS: We report that fetal growth <10th percentile diagnosed before 26 weeks is not isolated before birth in 27% of cases. Malformations and chromosomal abnormalities are common etiologies; therefore, detailed anomaly scans and invasive testing should be offered. In addition, there is a residual risk of neonatal death and postnatal diagnosis of a genetic syndrome or neurodevelopmental impairment despite normal prenatal tests. These results expand the small amount of information on the outcome of cases with very early diagnosis of impaired fetal growth currently available and highlight the importance of detailed counseling with couples.

Prevalence, Outcome, and Prevention of Congenital Cytomegalovirus Infection in Neonates Born to Women With Preconception Immunity (CHILd Study).

BACKGROUND: Human cytomegalovirus (HCMV) is the leading infectious cause of congenital disabilities. We designed a prospective study to investigate the rate, outcome, and risk factors of congenital CMV (cCMV) infection in neonates born to immune women, and the potential need and effectiveness of hygiene recommendations in this population. METHODS: The study was composed of 2 sequential parts: an epidemiology (part 1) and a prevention (part 2) study. Performance of part 2 depended upon a cCMV rate >0.4%. Women enrolled in part 1 did not receive hygiene recommendations. Newborns were screened by HCMV DNA testing in saliva and cCMV was confirmed by urine testing. RESULTS: Saliva swabs were positive for HCMV DNA in 45/9661 newborns and cCMV was confirmed in 18 cases. The rate of cCMV was .19% (95% confidence interval [CI]: .11-.29%), and 3 out of 18 infants with cCMV had symptoms of CMV at birth. Age, nationality, occupation, and contact with children were similar between mothers of infected and noninfected newborns. Twin pregnancy (odds ratio [OR]: 7.2; 95% CI: 1.7-32.2; P = .037) and maternal medical conditions (OR: 3.9; 95% CI: 1.5-10.1; P = .003) appeared associated with cCMV. Given the rate of cCMV was lower than expected, the prevention part of the study was cancelled. CONCLUSIONS: Newborns from women with preconception immunity have a low rate of cCMV, which appears to be mostly due to reactivation of the latent virus. Therefore, serological screening in childbearing age would be pivotal to identify HCMV-seropositive women, whose newborns have a low risk of cCMV. CLINICAL TRIALS REGISTRATION: www.clinicaltrials.gov (NCT03973359).

An update of diagnostic efficacy of ultrasound and magnetic resonance imaging in the diagnosis of clinically significant placenta accreta spectrum disorders.

PURPOSE OF REVIEW: Systematic screening and diagnosis of placenta accreta spectrum disorder (PAS) either by ultrasound or magnetic resonance imaging (MRI) would allow referral of high-risk women to specialized multidisciplinary teams. We aimed to report recent findings regarding the diagnostic accuracy of ultrasound and magnetic resonance imaging in the diagnosis of PAS. RECENT FINDINGS: Recent evidence from the literature shows that both ultrasound and MRI are good tests to identify PAS in high-risk populations. Ultrasound can also be used safely to guide management decisions, concentrating greater resources in patients with the higher risk of clinically significant PAS requiring complex peripartum management. Moreover, there are increasing data showing that routine contingent screening for PAS disorders based on the finding of a placenta implanted low in the uterine cavity and previous uterine surgery is effective in a public healthcare setting. A contingent screening strategy for PAS is feasible if placental location is routinely assessed during routine scans, and may even start from the first trimester of pregnancy. SUMMARY: Ultrasound is an effective tool to screen pregnancies at high risk of PAS. In such pregnancies, ultrasound and MRI are effective imaging modalities for guiding management.

Timing of intra-fetal laser therapy for twin reversed arterial perfusion (TRAP) sequence: Retrospective series and systematic review and meta-analysis.

OBJECTIVE: To estimate the neonatal survival rate after intra-fetal laser (IFL) treatment for twin reversed arterial perfusion (TRAP) sequence, and to investigate the effect of gestational age at the time of procedure. METHODS: Retrospective cohort study of TRAP sequences followed at our institution from 2013-2020. Systematic review and meta-analysis of the neonatal survival rate after IFL was conducted. Both diamniotic and monoamniotic monochorionic pregnancies were included. A subgroup analysis to compare outcomes according to gestational age at procedure (<16+0 weeks or ≥16+0 weeks) was planned. RESULTS: Thirteen pregnancies were followed at our center and seven were treated with IFL: the survival rate was 57%. Ten studies published between 2008 and 2020 for a total of 156 cases were included in the meta-analysis. The overall neonatal survival after IFL was 79% (95% CI 0.72-0.86, I2 22%). A random-effects model comparing neonatal survival for IFL performed <16+0 weeks versus ≥16+0 weeks showed no significant difference between the two groups (OR = 0.93; 95% CI 0.37-2.33). CONCLUSION: IFL is a safe and minimally invasive technique for the treatment of TRAP sequence, with a survival rate of 79%. Gestational age at treatment (before or after 16 weeks) does not seem to affect neonatal survival rate.

Chorionicity, birth weight discordance and neonatal morbidity in uncomplicated twin pregnancies delivered from 36 weeks.

OBJECTIVES: To investigate the association between chorionicity, birth weight discordance and neonatal morbidity in uncomplicated twin pregnancies progressing to at least 36 weeks of gestation. STUDY DESIGN: This was a retrospective single centre cohort study of all twin pregnancies referred to our twin clinic between 2011 and 2018. Outcome details were obtained from the computerized maternity and neonatal records. The primary outcome was incidence of composite neonatal morbidity according to chorionicity. We also determined the incidence of composite neonatal morbidity in pregnancies with birth weight discordance. Logistic regression was used to identify and adjust for potential confounders. RESULTS: Three hundred and eighty-five twin pregnancies (286 dichorionic, 99 monochorionic) were included. Gestational age at birth was significantly lower in pregnancies complicated by neonatal morbidity (p = 0.013) compared with those which were not. On multivariable logistic regression analysis, gestational age at birth (p = 0.031) and birth weight discordance (p = 0.004), but not chorionicity (p = 0.626) were independently associated with neonatal morbidity. CONCLUSION(S): In uncomplicated twin pregnancies chorionicity is not associated with neonatal morbidity. Gestational age at birth is the major determinant of neonatal outcome while the clinical impact of weight discordance seems marginally significant.

Fetoscopic laser ablation therapy in monochorionic diamniotic twin pregnancies with twin-to-twin transfusion syndrome treated at a single centre over 10 years: a retrospective study.

OBJECTIVES: To review experience with fetoscopic laser ablation of placental anastomoses to treat monochorionic diamniotic (MCDA) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) in a single centre over a ten-year period. METHODS: A retrospective study on 142 MCDA twin pregnancies complicates by TTTS treated with equatorial laser ablation of placental anastomoses (2008-2018). Solomon technique was also applied after 2013. Survival rates, neonatal outcome, intraoperative and post-laser complications were recorded, and prognostic factors analysed. RESULTS: A total of 133 cases were included in the final analysis; 41 patients were at stage II (30.8%), 73 were at stage III (62.9%), while only 12 (9%) at stage I and two patients (1.7%) at stage IV. Solomon technique was applied in 39 cases (29.3%). Survival of both twins was 51.1% (68/133), of a single twin 20.3% (27/133), and of at least one 71.5% (95/133), with an overall survival of 61.3% (163/266). TAPS and recurrent TTTS occurred in 8 (6%) and 15 (11.3%) patients. Survival of both fetuses increased over time (44.6 vs. 57.3%). A posterior placenta (p<0.003) and the use of the Solomon technique (p<0.02) were more frequent in cases with survival of both fetuses, while TTTS recurrence was significantly associated to the loss of one or two fetuses (p<0.01). Such associations were confirmed at logistic regression analysis. CONCLUSIONS: Survival of both twins can improve over time and seems to be favourably associated with a placenta in the posterior location and the use of the Solomon technique.

Obstetric consequences of a false-positive diagnosis of large-for-gestational-age fetus.

OBJECTIVE: To compare delivery outcomes between true-positive (TP) and false-positive (FP) large-for-gestational-age (LGA) fetuses, appropriate-for-gestational-age (AGA) fetuses, and false-negative (FN) LGA fetuses. METHODS: Retrospective cohort study of singleton pregnancies at risk for macrosomia without contraindication to vaginal delivery, receiving an ultrasound scan at 34-37 weeks of pregnancy. RESULTS: In all, 430 pregnancies were included: 155 TP LGA, 87 FP LGA, 177 AGA and 11 FN LGA newborns. Cesarean section rate during labor was significantly higher in FP LGA than in AGA (19% vs. 8.7%) but not significantly different between FP LGA and TP LGA (19% vs. 32.4%). Median birth weight z score was significantly higher in TP LGA (1.9) compared with the FP LGA and AGA (0.91 and 0.84, respectively), whereas no significant differences were found between FP LGA and AGA. Admission to a neonatal intensive care unit was significantly more frequent in TP LGA than AGA, whereas shoulder dystocia, postpartum hemorrhage, and third- to fourth-degree perineal tears were similar between the different groups. CONCLUSION: A false-positive diagnosis of LGA fetus is associated with a significant increase of cesarean section during labor. Therefore, a suspicious ultrasound may result in reduction of the clinical threshold for the diagnosis of abnormal labor.

Ultrasound and magnetic resonance imaging in the diagnosis of clinically significant placenta accreta spectrum disorders.

OBJECTIVES: We aimed to assess the performance of ultrasound (US) and magnetic resonance imaging (MRI) signs for antenatal detection of placenta accreta spectrum (PAS) disorders in women with placenta previa (placental edge ≤2 cm from the internal uterine orifice, ≥260/7 weeks' gestation) with and without a history of previous Caesarean section. METHODS: Single center prospective observational study. US suspicion of PAS was raised in the presence of obliteration of the hypoechoic space between uterus and placenta, interruption of the hyperechoic uterine-bladder interface and/or turbulent placental lacunae on color Doppler. All MRI studies were blindly evaluated by a single operator. PAS was defined as clinically significant when histopathological diagnosis was associated with at least one of: intrauterine balloon placement, compressive uterine sutures, peripartum hysterectomy, uterine or hypogastric artery ligature, uterine artery embolization. RESULTS: A total of 39 women were included: 7/39 had clinically significant PAS. There were 6/18 cases of PAS with anterior placenta: hypoechoic space interruption and placental lacunae were the most sensitive sonographic signs (83%), while abnormal hyperechoic interface was the most specific (83%). On MRI, focal myometrial interruption and T2 intraplacental dark bands showed the best sensitivity (83%), bladder tenting had the best specificity (100%). 1/21 women with posterior placenta had PAS. There was substantial agreement between US and MRI in patients with anterior placenta (κ=0.78). CONCLUSIONS: US and MRI agreement in antenatal diagnosis of clinically significant PAS was maximal in high-risk women. Placental lacunae on ultrasound scan and T2 intraplacental hypointense bands on MRI should trigger the suspicion of PAS.

Uterine artery Doppler for the prediction of outcome in pregnancies complicated by hypertensive disorders of pregnancy.

OBJECTIVES: To evaluate, in pregnancies complicated by hypertensive disorders of pregnancy (HDP), the predictive role of uterine artery (UtA) Doppler for pregnancy outcome compared to the definition of preeclampsia (PE) established by ISSHP recommendations. STUDY DESIGN: Retrospective cohort study including singleton pregnancies diagnosed with HDP, who underwent UtA Doppler assessment at admission in 2011-2017. The study population was classified considering the presence or absence of PE and according to the presence or absence of abnormal UtA Doppler (mean pulsatility index > 95th percentile). MAIN OUTCOME MEASURES: Pregnancy outcome, maternal and fetal complications, evaluated as composite outcomes (CO), and duration of pregnancy (from admission to delivery). RESULTS: A total of 311 mother-infant couples was included.The diagnostic ability of the two classifications was analysed comparing the relative likelihood ratio in the Biggerstaff graph. ISSHP definition turned out to be more efficient in detecting maternal adverse CO in comparison to UtA Doppler, relative positive likelihood ratio 1.50 (1.35-1.66) and 1.31 (1.07-1.60). UtA Doppler classification resulted more efficient in predicting adverse neonatal CO than PE definition, relative positive likelihood ratio 2.21 (1.77-2.75) and 1.61 (1.37-1.90). UtA Doppler was significantly associated with delivery at earlier gestational ages both for patients affected by PE and for women affected by HDP without superimposed PE (respectively p = 0.009 and p = 0.037). CONCLUSIONS: UtA Doppler at HDP diagnosis is a useful bedside marker of fetal/neonatal complications, and is associated with pregnancy duration.

Preeclampsia and late fetal growth restriction.

There is a strong but complex relationship between fetal growth restriction and preeclampsia. According to the International Society for the Study of Hypertension in Pregnancy the coexistence of gestational hypertension and fetal growth restriction identifies preeclampsia with no need for other signs of maternal organ impairment. While early-onset fetal growth restriction and preeclampsia are often strictly associated, such association becomes looser in the late preterm and term periods. The incidence of preeclampsia decreases dramatically from early preterm fetal growth restriction (39-43%) to late preterm fetal growth restriction (9-32%) and finally to term fetal growth restriction (4-7%). Different placental and cardiovascular mechanism underlie this trend: isolated fetal growth restriction has less frequent placental vascular lesions than fetal growth restriction associated with preeclampsia; moreover, late preterm and term fetal growth restriction show different patterns of maternal cardiac output and peripheral vascular resistance in comparison with preeclampsia. Consequently, current strategies for first trimester screening of placental dysfunction, originally implemented for preeclampsia, do not perform well for late-onset fetal growth restriction: the sensitivity of first trimester combined screening for small-for-gestational age newborns delivered at less than 32 weeks is 56-63%, and progressively decreases for those delivered at 32-36 weeks (43-48%) or at term (21-26%). Moreover, while the test is more sensitive for small-for-gestational age associated with preeclampsia at any gestational age, its sensitivity is much lower for small-for-gestational age without preeclampsia at 32-36 weeks (31-37%) or at term (19-23%).

Effects of Antenatal Betamethasone on Fetal Doppler Indices and Short Term Fetal Heart Rate Variation in Early Growth Restricted Fetuses.

PURPOSE: To investigate the effects of the antenatal administration of betamethasone on fetal Doppler and short term fetal heart rate variation (CTG-STV) in early growth restricted (FGR) fetuses. MATERIALS AND METHODS: Post hoc analysis of data derived from the TRUFFLE study, a prospective, multicenter, randomized management trial of severe early onset FGR. Repeat Doppler and CTG-STV measurements between the last recording within 48 hours before the first dose of betamethasone (baseline value) and for 10 days after were evaluated. Multilevel analysis was performed to analyze the longitudinal course of the umbilico-cerebral ratio (UC ratio), the ductus venosus pulsatility index (DVPIV) and CTG-STV. RESULTS: We included 115 fetuses. A significant increase from baseline in CTG-STV was found on day + 1 (p = 0.019) but no difference thereafter. The DVPIV was not significantly different from baseline in any of the 10 days following the first dose of betamethasone (p = 0.167). Multilevel analysis revealed that, over 10 days, the time elapsed from antenatal administration of betamethasone was significantly associated with a decrease in CTG-STV (p = 0.045) and an increase in the DVPIV (p = 0.001) and UC ratio (p < 0.001). CONCLUSION: Although steroid administration in early FGR has a minimal effect on increasing CTG-STV one day afterwards, the effects on Doppler parameters were extremely slight with regression coefficients of small magnitude suggesting no clinical significance, and were most likely related to the deterioration with time in FGR. Hence, arterial and venous Doppler assessment of fetal health remains informative following antenatal steroid administration to accelerate fetal lung maturation.

Twin Reversed Arterial Perfusion Sequence: Current Treatment Options.

Twin reversed arterial perfusion (TRAP) sequence is a specific and severe complication of monochorionic multiple pregnancy, characterized by vascular anastomosis and partial or complete lack of cardiac development in one twin. Despite its rarity, interest in the international literature is rising, and we aimed to review its pathogenesis, prenatal diagnostic features and treatment options. Due to the parasitic hemodynamic dependence of the acardiac twin on the pump twin, the management of these pregnancies aims to maximize the pump twin's chances of survival. If treatment is needed, the best timing of intervention is still debated, although the latest studies encourage intervention in the first trimester of pregnancy. As for the technique of choice to interrupt the vascular supply to the acardiac twin, ultrasound-guided laser coagulation and radiofrequency ablation of the intrafetal vessels are usually the preferred approaches.

Ductus venosus Doppler waveform pattern in fetuses with early growth restriction.

INTRODUCTION: We aimed to assess if maximum velocities of the ductus venosus flow velocity waveform are associated with adverse outcomes in early-onset fetal growth restriction. MATERIAL AND METHODS: Retrospective cohort study from two tertiary referral units, including singleton fetuses with estimated birthweight or fetal abdominal circumference ≤10th centile and absent or reversed end-diastolic velocity in the umbilical artery delivered between 26+0 and 34+0  weeks of gestation. Pulsatility index for veins, and maximum velocities of S-, D-, v- and a-waves, were measured in the ductus venosus within 24 hours of birth. Logistic regression was used to describe the relation between severe neonatal morbidity or neonatal death and clinical independent predictors. RESULTS: The study population included 132 early-onset fetal growth restriction fetuses. Newborns with neonatal morbidity or neonatal death had significantly lower values of v/D maximum velocity ratio multiples of the median (0.86 vs 095; P = 0.006) within 24 hours of birth. The v/D ratio remained a significant predictor of neonatal death or severe neonatal morbidity after adjusting for gestational age and birthweight (adjusted odds ratio 0.065, 95% confidence interval 0.004-0.957). CONCLUSIONS: Assessment of ductus venosus v/D maximum velocity ratio might help to identify fetal growth restriction fetuses at increased risk for neonatal death or severe neonatal morbidity. Confirmation in prospective studies is necessary.

Labor induction with misoprostol vaginal insert compared with dinoprostone vaginal insert.

INTRODUCTION: Misoprostol vaginal insert could lead to a significant reduction in the time to vaginal delivery, and an increase in the proportion of women achieving vaginal delivery, compared with dinoprostone vaginal insert. We compared the delivery outcomes of misoprostol 200 µg vaginal insert and dinoprostone 10 mg vaginal insert for induction of labor in women with an unfavorable cervix. MATERIAL AND METHODS: This is a retrospective observational study conducted on a cohort of 220 women with a Bishop score ≤4 admitted for induction of labor at a single institution. Of these, 109 (49.5%) received the misoprostol vaginal insert and 111 (50.5%) received the dinoprostone vaginal insert. The primary outcome was the vaginal delivery rate. Secondary outcomes were time from induction to vaginal delivery, time to any delivery mode, time from induction to the onset of active labor, oxytocin use, uterine tachysystole and need for tocolysis. RESULTS: The vaginal delivery rate was 88% in the misoprostol insert group, compared with 74% in the dinoprostone insert group (P < 0.007). The average time from drug administration to the beginning of labor was shorter in the misoprostol compared with the dinoprostone group (855 min vs 1740 min, P < 0.0001). Also, the average time from administration to delivery was shorter for women receiving misoprostol compared with dinoprostone (1113 min vs 2150 min, P < 0.0001). The use of misoprostol reduced the need for oxytocin compared with dinoprostone (30.2% vs 43.2%, P = 0.046). Finally, compared with dinoprostone, the misoprostol insert was associated with more uterine tachysystole (38% vs 12%, P < 0.001), but the rate of tachysystole requiring tocolysis was not significantly different between the 2 groups (51.2% vs 46.1%, P = 0.1). Multivariate analysis showed that Bishop score and method of induction, but not maternal body mass index or gestational age at induction, were independently associated with mode of delivery. CONCLUSIONS: The cesarean section rate was significantly lower in the misoprostol insert group. The use of misoprostol was also associated with reduced time to vaginal delivery and time to onset of active labor and with decreased use of oxytocin. Tachysystole was a frequent complication during induction of labor with the misoprostol insert.

Fetal anemia: Diagnosis and management.

Fetal anemia has been known for many years as a dangerous complication of pregnancy. Its most common causes are maternal alloimmunization and parvovirus B19 infection, although it can be associated with many different pathological conditions including fetal aneuploidies, vascular tumors, and arteriovenous malformations of the fetus or placenta and inherited conditions such as alpha-thalassemia or genetic metabolic disorders. Doppler ultrasonographic assessment of the peak velocity of systolic blood flow in the middle cerebral artery for the diagnosis of fetal anemia and intravascular intrauterine transfusion for its treatment are the current practice standards. Live birth rates as high as 95% have been reported in recent years. The additional role of intravenous immunoglobulin therapy and the long-term consequences of the condition are the subjects of active ongoing research.

The use of ultrasound-indicated cerclage or cervical pessary in asymptomatic twin pregnancies with a short cervix at midgestation.

INTRODUCTION: Spontaneous preterm birth in women with a twin pregnancy is one of the main causes of perinatal mortality and morbidity. Our aim was to review the perinatal outcome of asymptomatic twin pregnancies with a sonographic short cervical length during the second trimester treated with an ultrasound-indicated cerclage or cervical pessary. MATERIAL AND METHODS: Retrospective study on asymptomatic twin pregnancies with a short cervix (≤ 25 mm) at transvaginal ultrasound examination during the second trimester treated with a cervical cerclage or pessary (2001-2017). The rate of preterm birth < 28, 32 and 34 weeks of gestation, neonatal mortality, neonatal morbidity and composite adverse neonatal outcome were compared in the groups of women treated with cerclage or pessary. RESULTS: Seventy-four twin pregnancies underwent a cerclage while a cervical pessary was inserted in 34 women with twins at our Department: 36 women with an ultrasound-indicated cerclage and 20 with a pessary were included in the analysis. Median gestational age at delivery was higher in women treated with cerclage compared with those with pessary placement (P = .02) and the rate of preterm birth before 34 weeks of gestation was lower in the cerclage group (P = .03). Admissions to the Neonatal Intensive Care Unit were more frequent in pregnancies with pessary (P = .01), the length of admission was longer (P = .005) and composite adverse neonatal outcome occurred more often (P = .03) compared with the cerclage group. CONCLUSIONS: Ultrasound-indicated cerclage appears to reduce the rate of preterm birth before 34 weeks of gestation in asymptomatic twin pregnancies with a short cervix during the second trimester, and also the composite adverse neonatal outcome compared with pessary.