Her twin was delivered at 19 weeks. A cervical stitch saved her life

Dr Nikita Trehan

This Jan, a 34-year-old woman pregnant with IVF-conceived twins was brought to our hospital in New Delhi with severe lower-abdominal pain. She was 19 weeks along. An ultrasound showed that her cervix was opening too early. This condition, called cervical incompetence, occurs when the internal opening of the womb begins to dilate before time.

Her pregnancy had taken years to achieve. Her husband is a cancer survivor, and chemotherapy had reduced his sperm count. To conceive, the couple underwent Micro-TESE, a surgical procedure to retrieve sperm from the testicles, followed by ICSI, where a single sperm is injected directly into an egg. The twins were the result of a long and difficult journey.

By the time the woman reached us, labour had already started. In most such cases, doctors place a vaginal stitch. But this is usually at the external opening of the cervix and when dilation has already progressed, it often fails. The correct point to halt early labour is the internal os (the inner opening of the cervix). It can be reached only by laparoscopy or by an open abdominal technique. So, we decided on a laparoscopic cerclage (stitching the cervix to prevent it from opening too early).

Under anaesthesia, the first twin was delivered prematurely with no signs of life. The placenta did not separate. Removing it would almost certainly have triggered labour and risked the surviving twin. We tied the umbilical cord of the deceased twin, left the placenta inside, and proceeded with the cerclage. The stitch held. Labour stopped.

The patient stayed in hospital for a month. She received antibiotics and daily monitoring. After discharge, she had blood tests and ultrasounds every two weeks. Slowly, the pregnancy stabilised. The retained placenta began functioning normally for the surviving twin. She carried on for another 127 days.

Cervical incompetence has few warning signs. Some women notice watery or mucoid discharge. Many reach hospital only after the process has advanced. Women with a history of second-trimester loss, preterm labour, IVF pregnancies or twin gestations should have cervical-length scans every two weeks from 12 weeks. A vaginal swab to check for infection is also useful in high-risk cases.

Laparoscopic cerclage places the stitch at the right anatomical level and usually allows women to continue normal activity with fewer restrictions. Unlike after vaginal cerclage, strict bed rest or elevating the foot end of the bed is not required. Most women can work from home or take on light tasks, with a long rest after lunch.

In May, she delivered a healthy baby girl weighing 3.27 kg by Caesarean section. Both mother and child went home in good health. A delayed-interval twin delivery with such a long gap is rare. This case shows the value of correct cerclage placement in selected high-risk pregnancies, especially as more women conceive later and IVF twin pregnancies become common. Today, both mother and daughter are doing fine. I now call this case my labour of love.

(Dr Nikita Trehan is a Gynaec-Laparoscopic Surgeon at Sunrise Hospital, Delhi. She spoke to Steffy Thevar)