First Experience Using Brazilian Ingamed ® Cervical Pessary in Twin Pregnancy : A Case Series

Background: The rate of prematurity in twin pregnancies is higher than 50%. Due to its multifactorial nature, different strategies are necessary to reduce the incidence of premature birth or to increase the gestational age at birth of pregnancies at risk. In this context, cervical pessary may be indicated in twin pregnancies with short cervix. Methods: In this case series, we describe six twin pregnancies that were considered as high-risk for preterm labor due to short cervix (CL < 30 mm) at second trimester and multiple risk factors for prematurity. Several strategies were associated for the goal of delaying gestational age at birth. The main strategies were: removal of labor activities, treatment of infections, vaginal micronized progesterone 400 mg/day and vaginal pessary insertion (Ingamed Brazil). Results: The gestational age of insertion of the pessary ranged from 16 to 24 weeks. The gestational age of birth ranged from 26 to 34 weeks. Three of the pregnancies were delivered due to spontaneous onset of labor, and three were delivered due to medical reasons. The mean length of pregnancy since pessary insertion to birth was 9 weeks (range 2 to 17 weeks). All infants without severe fetal malformation were discharged from the hospital without major sequelae. Conclusion: The use of cervical pessaries associated to micronized progesterone at a dose of 400 mg/day may be an option in the management of twins at risk for preterm birth. More controlled studies are needed to evaluate the simultaneous use of cervical pessary and progesterone on twin pregnancies. How to cite this paper: Vettorazzi, J., Salazar, C.C., Valério, E.G., Isotton, A.L., Petermann, A., Rosa, M.W. and Rostirolla, G.F. (2018) First Experience Using Brazilian Ingamed® Cervical Pessary in Twin Pregnancy: A Case Series. Open Journal of Obstetrics and Gynecology, 8, 1282-1288. https://doi.org/10.4236/ojog.2018.813130 Received: September 3, 2018 Accepted: October 29, 2018 Published: November 1, 2018 Copyright © 2018 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access J. Vettorazzi et al. DOI: 10.4236/ojog.2018.81313


Introduction
The number of twin births has increased in recent years [1].About 50% of these are born before 37 weeks, which implies important fetal morbidity and mortality.
As prematurity can be considered a multifactorial syndrome, preventive measures and management of cases at risk usually include actions related to the main contributing factors for preterm labor.One of the several factors which increase preterm birth is the presence of short cervix.Shortening of the cervical length (CL) is a predictor of preterm birth in singleton and twin pregnancies.The risk of preterm delivery is inversely related to cervical length (CL) assessed at 22 -26 weeks of gestation, and a CL ≤ 25 mm is associated with 28% risk for birth before 28 weeks [2] [3].The cut-off measure to classify a cervix as short in the second trimester is controversial for twin pregnancies.Different studies describe cut-off measures of 38 mm, 30 mm or 25 mm [2] [4] [5] [6].In our clinical practice, a CL below 30 mm in twin pregnancies is considered as short.The cervical length is not routinely measured in Brazil's public health care system, and there is no national recommendation on this topic.Nevertheless, the medical staff responsible for the prenatal care of the patients described on this paper followed the International Society of Ultrasound in Obstetrics and Gynecology guidelines [7].Currently, there are different strategies to manage twin pregnancies with short cervix (TPSC), most of them with no proven effectiveness.Cervical cerclage has been associated with increase in the frequency of adverse outcomes in twin pregnancies [8].A systematic review and meta-analysis showed that vaginal progesterone reduced the rate of preterm delivery in TPSC [9] [10].Likewise, a randomized study associated the use of cervical pessary in twin pregnancies of mothers with a short cervix with significant reduction of prematurity [9].In other recent meta-analysis, intravaginal progesterone 400 mg/day was more effective than in the doses of 100 or 200 mg in cases of TPSC [11].

Patients and Methods
In this case series we describe six twin pregnancies that were considered as high-risk for preterm labor due to short cervix (CL < 30 mm) at second trimester.The patients were selected from one of the authors' private clinic (J.V.), after screening for short cervix on second trimester.
Cervical length was obtained between 20 and 24 weeks of pregnancy by transvaginal ultrasound, using a General Electric (GE) VOLUSON E8, with an endocavity transducer at a frequency of 7.5 MHz.Ultrasound was performed with the patient in a dorsal lithotomy position and with empty bladder.The cervix was measured along its longitudinal axis.The cervix occupied approximately 50% -75% of the image and pressure from the probe on the cervix was as little as possible.Cervical measurement was obtained by placing calipers at the external and internal OS, using a straight line between both of them.If the cervix was curved and the straight-line cervical length measurement was short, measurement obtained in two or more segments was performed to provide a more accurate estimation.The examination lasted from 3 to 5 minutes to detect possible changes in cervical length, and at least 3 measurements were obtained along that period.
The patients were managed on an individual basis.Some of them had multiple risk factors for prematurity, mostly previous infections.All patients had a cervical pessary (Ingamed  Brazil) inserted, received vaginal micronized progesterone at a dose of 400 mg/day and were removed from their work activities.The main baseline characteristics, CL, gestational age at pessary insertion and individual risk factors are described on Table 1.

Results and Discussion
The main maternal and fetal outcomes are described on Table 1 (range 26 -34), half of them due to spontaneous onset of labor.In three cases the decision to deliver was due to fetal conditions and not due to preterm labor: one because of non-reassuring well-being test and two because of intrauterine growth retardation associated to abnormal Doppler ultrasound.The mean length of pregnancy since pessary insertion to birth was 9 weeks (range 2 to 17 weeks).
All pregnancies were delivered by caesarean, and all patients received antenatal corticosteroids for fetal pulmonary maturation before delivery.Patients with a positive group B streptococcal colonisation test at the onset of preterm labor received antimicrobial prophylaxis.The neonatal mortality rate was 8%, and the newborns who deceased had important anatomical problems (gastroschisis).
The risk of spontaneous preterm birth increases significantly with the number of risk factors for prematurity [12].In our group of patients, we observed that in the two cases where birth occurred before 28 weeks there were multiple factors related to prematurity such as polyhydramnios, hypothyroidism, first-trimester

Table 1 .
. The mean CL and gestational age at pessary insertion were respectively 21 mm (range 10 -28 mm) and 22 weeks (range 16 -24 weeks).Mean age of delivery was 31 weeks Case series: Twin pregnant with short cervix.