We read with interest the manuscript “Efficacy of ultrasound-indicated cerclage in twin pregnancies” by Roman et al. In their retrospective study, the authors assessed the outcome of 140 asymptomatic twin pregnancies with a short cervix (<25 mm) detected by ultrasound between 16-24 weeks. A total of 83 women were managed expectantly while the remaining 57 received an ultrasound-indicated cerclage (UIC). Interestingly, although the overall risk of preterm delivery <28, <32, and <34 weeks was comparable between the 2 groups, in the subgroup of women with cervical length <15 mm, the interval between diagnosis and delivery was prolonged by almost 4 weeks, and both the risk of delivery <34 weeks and admission to neonatal intensive care unit were significantly decreased in the UIC group.

These results seem to be in contrast with previous studies and a recent metaanalyses documenting a significantly higher risk of preterm delivery, low birthweight, and neonatal respiratory distress in twin pregnancies with UIC compared to controls.

Because of these data, the practice of offering a cerclage to asymptomatic women with a short cervix carrying a twin gestation has been widely dismissed.

In this context, we would like to recall our own experience with the use of UIC in twin pregnancies.

In a retrospective observational study on 42 twin pregnancies receiving cerclage <24 weeks, 28 procedures were performed for a cervical length <20 mm: the mean gestational age at delivery was 34 weeks, and the rates of preterm delivery <34, <32, and <28 weeks were 32%, 21%, and 6%, respectively. Our data seem comparable to those reported by Roman et al in the subgroup of women with a cervix ≤15 mm. This suggests that there may be a role for UIC in twin gestations in selected patients.

This needs to be addressed by a properly designed clinical trial.