Prophylactic cerclage in the management of triplet pregnancies Andrei Rebarber, MD, a Ashley S. Roman, MD, MPH, a Niki Istwan, RN, b Debbie Rhea, MPH, b Gary Stanziano, MD b Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, a NYU School of Medicine, New York, NY; Department of Clinical Research, b Matria Healthcare, Marietta, GA Received for publication March 1, 2005; revised May 2, 2005; accepted May 25, 2005 KEY WORDS Triplet pregnancy Cerclage Preterm birth Objective: The purpose of this study was to determine if prophylactic cerclage improves pregnancy outcome in women with triplet pregnancies without a history of cervical insufficiency. Study design: Triplet pregnancies with R1 day of outpatient surveillance beginning before 32 weeks’ gestation were identified from a database of women in the US who received outpatient preterm labor surveillance services between January 1990 and May 2004. Triplet pregnancies managed with prophylactic cerclage were compared with triplet pregnancies in which cerclage was not placed. Patients with a diagnosis of cervical insufficiency in a previous or in the index pregnancy were excluded from analysis. The primary outcome was incidence of preterm birth before 32 weeks. Groups were compared using Fisher exact test, and Student t test with 2-sided P values ! .05 considered statistically significant. Results: Three thousand two hundred seventy-eight triplet pregnancies met criteria for inclusion, of which 248 women (7.6%) received prophylactic cerclage. No significant differences were seen in mean gestational age at delivery, incidence of preterm birth before 32 weeks, birth weight, or neonatal days in the hospital. This study had 80% power to detect a 30% reduction in the primary outcome. Conclusion: Prophylactic cerclage did not result in improved pregnancy or neonatal outcomes in triplet pregnancies without a history of cervical insufficiency. Ó 2005 Mosby, Inc. All rights reserved. The incidence of triplet gestations in the US has increased over 400% between 1980 and 2002, primarily because of the availability of fertility therapies. 1 Spon- taneous triplet pregnancy is estimated to occur in ap- proximately 1 in 6000 to 8000 births. 2 By comparison, the triplet birth rate in 1980 was 37 per 100,000 births and climbed to 184 per 100,000 births in 2002. 1 Only 7% to 18% of triplets arose from spontaneous conceptions in this time period. 3 While the incidence of triplets has increased, the mean gestational age at delivery has remained stable at 32 to 33 weeks. 1,4 Prematurity accounts for a significant proportion of the perinatal morbidity and mortality associated with triplet preg- nancies, with 75% of triplet neonates requiring admis- sion to the neonatal intensive care unit (NICU). 5 Presented at the Twenty-Fifth Annual Meeting of the Society for Maternal Fetal Medicine, February 7-12, 2005, Reno, Nev. Reprints not available from the authors. 0002-9378/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.05.076 American Journal of Obstetrics and Gynecology (2005) 193, 1193–6 www.ajog.org