THE GREATER RISK OF PRETERM BIRTH IN

TRIPLETS IS MIRRORED BY A MORE RAPID

CERVICAL SHORTENING ALONG GESTATION
LIRAN

HIERSCH, MD,
FREEMAN, JON

H A D A R R O S E N , M D , R A N I A O K B Y, M D , H O W I E
B A R R E T T, M D , N I R M E L A M E D , M D , M S C

INTRODUCTION
Preterm birth (PTB) is the leading cause of perinatal mortality
and morbidity
Rate of PTB before 34 and 32 weeks in triplet pregnancies is
50% and 30% compared with 17% and 9% in twins
Early prediction of PTB is of major importance, and sonographic
cervical length (CL) is one of the important predictors
Our aim was to compare the rate of cervical shortening along
gestation and the relationship between CL and gestational age

METHODS
Study population
All women with triplets who were followed in the Multiple Gestations Clinic
of a single tertiary referral center between January 2000 and December
2014.
Monitoring of cervical length
Transvaginal measurement of CL every 2-3 weeks between 18 weeks and
32 weeks of gestation.
All
sonographic
examinations
were
performed
by
experienced
sonographers.
Cervical cerclage was performed in selected cases of women with
suspected mechanical cervical incompetence and these cases were
excluded from the analysis.
At least three measurements were obtained and the shortest measurement
was recorded.

Data collection
Data were extracted from the electronic
ultrasound reports and the electronic medical
charts and included demographic and
obstetrical
characteristics,
chorionicity,
validation of gestational age by 1st trimester
ultrasound,
pregnancy
complications,
presence of cervical cerclage, and neonatal
outcome.

Statistical analysis
Chi-square test was used to compare categorical variables between
the triplets and twins.
Students t-test and Mann-Whitney U-test were used for continuous
variables.
Change in CL as a function of gestational age as well as the
relationship between gestational at birth as a function of CL were
compared between women in the triplets and twins groups and were
described using mixed linear modeling to account for the repeated
measurements of CL in each patient.
Analysis of covariance (ANCOVA) procedure was used to compare the
regression
lines
of
the
triplets
and
twins
groups.
All p-values in were two-sided. The level for declaring statistical
significance was set to 0.05.

RESULTS
Characteristics of the study population :
The triplets and twins groups were similar with
respect to their baseline characteristics, except
for a lower gestational age at birth in the triplets
group (32.23.6 vs. 35.42.4, p<0.001).

CHARACTERISTICS AND OUTCOMES OF THE TRIPLETS AND TWINS

GROUPS
Characteristic

Triplets
N=86

Twins
N=441

P-value

Maternal age (years)

33.2 4.8

32.9 4.1

0.5

26 (30.2)

170 (38.5)

0.1

Nulliparity

56 (65.1)

252 (57.1)

0.2

Number of cervical
length
measurements

5 (3-9)

6 (5-8)

0.3

GA at birth (weeks)

32.2 3.6

35.4 2.4

<0.001

<34 weeks

48 (55.8)

70 (15.9)

<0.001

<32 weeks

29 (33.7)

35 (7.9)

<0.001

86 (100.0)

295 (66.9)

<0.001

>35 years

Cesarean delivery

GESTATIONAL AGE AT BIRTH IN THE TRIPLETS AND TWINS GROUPS

The distribution of
gestational age at
birth is presented
for women with
triplet (red line)
and twin (black
line) pregnancies.

Change in cervical length along gestation :

Starting at 18 weeks, CL became shorter among
triplets and the difference in CL increased with
gestation.
The proportion of women with CL<25mm and
CL<15mm was higher in triplets starting from 22
weeks (34.0% vs. 21.0%, p<0.001, Figure 3A) and 24
weeks (16.7% vs. 8.4%, p=0.001, Figure 3B),

Cervical shortening along

gestation in the triplets
and twins groups
Mean cervical length at each
gestational week is presented
for asymptomatic women with
triplet (solid red line) and
twin
(solid
black
line)
pregnancies.

Proportion of women with a short cervix along gestation

in the triplets and twins groups
The proportion of asymptomatic women with a cervical length below 25
mm (A) or 15 mm (B) at each gestational week is presented for the
triplets (red line) and twins (black line) groups.

Relationship
between
cervical
length
and
gestational age at birth :
For any given CL measured at 22 weeks, gestational
at birth for triplets was lower by 1.9 weeks on average
compared with twins.
For any given CL measured after 22 weeks, gestational
at birth for triplets was lower by 2.7 weeks on average
than in twins

Relationship between cervical length and

gestational age at birth in the triplets and twins
groups

The relationship between cervical length and gestational age at birth is presented
for
asymptomatic women with triplet (red line) and twin (black line) pregnancies.
Data are stratified by gestational age at the time of cervical length measurement:
(A) 22 weeks, (B) 23-24 weeks, (C) 25-26 weeks, and (D) 27 weeks.

Relationship between cervical length and

gestational age at birth in the triplets and twins
groups

The relationship between cervical length and gestational age at birth is presented
for
asymptomatic women with triplet (red line) and twin (black line) pregnancies.
Data are stratified by gestational age at the time of cervical length measurement:
(A) 22 weeks, (B) 23-24 weeks, (C) 25-26 weeks, and (D) 27 weeks.

 This relationship is also reflected by the correlation

between CL at the different time points along
gestation and gestational age at birth.
For CL measurement performed after 22 weeks of
gestation, the correlation with gestational age at birth
among triplets was relatively constant (0.55-0.60) and
was significantly stronger than that observed in twins
(0.26-0.32).

Correlation between cervical length and gestational age at

birth in the triplets and twins groups

Gestational age
at
measurement
of cervical
length

Correlation between cervical length and

gestational age at birth*
Triplets
(N=86)

Twins (N=441)

P-value

22 weeks

0.26 (0.12-0.39)

0.18 (0.13-0.23)

0.3

23-24 weeks

0.55 (0.39-0.66)

0.28 (0.19-0.37)

0.02

25-26 weeks

0.60 (0.42-0.73)

0.26 (0.17-0.35)

0.002

27 weeks

0.57 (0.41-0.68)

0.31 (0.23-0.39)

0.02

COMMENT

CONCLUSION

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