We read with great interest the work of Roman et al that was published in your Journal. It seems that twin pregnancies that are most at risk of preterm delivery, either by presenting “cervical length” through transvaginal ultrasound <15 mm or by manifesting cervical dilation, can benefit from cervical cerclage.

Our group performs emergency cervical cerclage in these situations, with some modifications to those published. The surgical technique is uniform, being a modification of the Shirodkar technique, which in some cases is associated with cervical occlusion. Different surgical techniques have not demonstrated superiority over one another. We believe that the McDonald’s intervention presents some technical limitations. The main limitation is the shortage of remaining cervix. The possibility of recovering the cervix is less in this technique than in that of Shirodkar. Our modification involves leaving the knot in the posterior vaginal fornix, not at the vesicocervical level as in the original technique. We administer a presurgical antibiotic and a rectal dose of 100 mg indomethacin preoperatively, plus 3 doses every 12 hours postoperatively and subsequently micronized progesterone 200 mg/24 hr (vaginal or oral, depending on patient’s choice) until term. Those patients with documented regular uterine dynamics are treated with intravenous atosiban with no anticipated cervical changes, because they had previously presented them.

From 2000-2014, we performed 15 cerclages in twin pregnancies with exposed amniotic membranes: mean gestational age, 23.1 ± 0.86 weeks. The mean cervical length was 11.73 ± 2.27 mm. Patients did not undergo preoperative amniocentesis, which is not to exclude subclinical chorioamnionitis. No accidental rupture of amniotic membranes was presented. Ten of 15 pregnant women (66.67%) required additional tocolysis with atosiban and maturation with corticosteroids. Four of 15 women (26.67%) exceeded 34 weeks gestation, and 7 of 15 women (46.67%) exceeded 32 weeks gestation. Immediate neonatal outcomes were 4 second-trimester miscarriages and 3 neonatal deaths. Results are consistent with those of Roman et al.

We believe that the cervical changes presented by these patients complicate the McDonald cerclage technique. Theoretically, it is more feasible to cross the thickness of the cervical wall with the needle and thus increase the risk of accidental rupture of the amniotic membranes. It does not allow recovery of cervical length after effacement, which leaves amniotic membranes closer to the external os.

In this article, the author does not study the technique of cerclage. Did the author consider assessing the cerclage technique in his trial (protocol available at ClinicalTrials.gov ID#: NCT02490384 )?