A Case Report of Successful Pregnancy Maintenance Following Emergency Cervical Cerclage after Radiofrequency Ablation for Twin-to-Twin Transfusion Syndrome: A Systematic Literature Review

A Case Report of Successful Pregnancy Maintenance Following Emergency Cervical Cerclage after Radiofrequency Ablation for Twin-to-Twin Transfusion Syndrome: A Systematic Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Case Report of Successful Pregnancy Maintenance Following Emergency Cervical Cerclage after Radiofrequency Ablation for Twin-to-Twin Transfusion Syndrome: A Systematic Literature Review Manqi Chen, Hui Xie, Qi Xu, Huimin Yi, Shuning Zhang, Shuai Fu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6657212/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background： Radiofrequency ablation (RFA) represents an effective intrauterine therapeutic option for monochorionic diamniotic（MCDA） twin pregnancies complicated by severe complications.Cervical cerclage represents an effective therapeutic approach for addressing cervical insufficiency.However, to date, there have been no documented cases of successful pregnancy maintenance following emergency cervical cerclage after intrauterine treatment.Therefore, this study presents a case of a patient who underwent laparoscopic preventive cervical cerclage prior to pregnancy, subsequently developed twin-to-twin transfusion syndrome (TTTS) stage II during gestation, successfully underwent radiofrequency ablation for treatment, and concurrently required an emergency vaginal cervical cerclage, ultimately resulting in delivery at 31 weeks and 6 days of gestation. Case presentation： This case report presents a patient with cervical insufficiency characterized by repeated painless mid-trimester miscarriages due to cervical dilation. Prior to conception, the patient underwent laparoscopic prophylactic cervical cerclage. This pregnancy was achieved via assisted reproductive technology and was further complicated by gestational diabetes mellitus. During the course of pregnancy, the patient experienced recurrent vaginal bleeding, which was subsequently followed by the onset of twin-to-twin transfusion syndrome (TTTS).A case of successful pregnancy maintenance following sequential interventions of amnioreduction, selective fetal reduction via radiofrequency ablation and emergency transvaginal cervical cerclage. The pregnant woman delivered at 31 weeks and 6 days of gestation, 93 days after undergoing radiofrequency ablation and 63 days following an emergency cervical cerclage. The newborn weighed 1.59 kg at birth and received Apgar scores of 9 and 10 at 1 minute and 5 minutes, respectively. The mother was discharged from the hospital on the fourth day post-delivery, while the newborn remained hospitalized in the Neonatal Intensive Care Unit（NICU） for 35 days. Conclusion: The success of this case is attributable to the close collaboration between fetal medicine and traditional obstetrics.This is currently the first case of successful pregnancy preservation after emergency transvaginal cervical cerclage following intrauterine treatment. It demonstrates that intrauterine treatment is not contraindicated for patients with cervical insufficiency and recurrent vaginal bleeding during pregnancy. Continued emergency cervical cerclage may potentially achieve better outcomes in extending gestational age. Therefore, it is recommended that pregnancy management be tailored and personalized, with careful consideration given to both maternal and fetal conditions. Twin-to-twin transfusion syndrome Emergency Cervical Cerclage Radiofrequency Ablation Figures Figure 1 Figure 2 Background Twin-to- twin transfusion syndrome (TTTS) represents one of the most severe complications in monochorionic diamniotic(MCDA)twin pregnancies, with an incidence ranging from 1 to 3 per 10,000 among all pregnancies [ 1 ] .The pathogenesis of TTTS is complex and may be attributed to the monochorionic twins sharing a single placenta with extensive vascular anastomoses at the placental level. When a fetus in MCDA pregnancy exhibits abnormal development or is nearing demise, it may pose a risk to the co-twin. In such scenarios, fetal reduction surgery can be considered as an intervention to remove the compromised fetus, thereby safeguarding the healthy fetus and improving the overall prognosis for both the mother and the remaining fetus.Radiofrequency ablation (RFA) for fetal reduction is considered a safe and efficacious technique, and it has been extensively adopted for multifetal pregnancy reduction, particularly in cases involving MCDA twins.The survival rate of at least one fetus following RFA is significantly higher. Additionally, the procedure boasts a shorter operation time, ease of execution, and relatively fewer postoperative complications.Cervical insufficiency is defined as a condition wherein the cervix is incapable of maintaining its closed state during pregnancy due to an anatomical or functional defect, resulting in miscarriage or preterm birth.The treatment for cervical insufficiency is mainly effective with cervical cerclage.There have been no documented cases of successful pregnancy termination following intrauterine treatment with emergency transvaginal cervical cerclage. Consequently, this study reports a unique case involving laparoscopic prophylactic cervical cerclage performed prior to pregnancy, successful RFA conducted during pregnancy for stage II twin-to-twin transfusion syndrome, concurrent emergency vaginal cervical cerclage, and ultimately, successful delivery at 31 weeks and 6 days of gestation. Case presentation The patient, a 30-year-old woman at 22 weeks and 5 days of gestation, was admitted to the hospital on May 8, 2024, due to hypogastric pain. She had a history of three second-trimester miscarriages. In her first pregnancy in 2018, she experienced an inevitable miscarriage at 19 weeks of gestation. Similarly, during her second pregnancy in 2020, she underwent an inevitable miscarriage at 22 weeks of gestation.In 2021, the patient underwent a "preventive transvaginal cervical cerclage" at 14 weeks of gestation at another medical institution but subsequently experienced an inevitable abortion at 24 weeks of gestation. In November 2021, a laparoscopic cervical cerclage was performed at another medical institution. The current pregnancy resulted from in vitro fertilization and embryo transfer (IVF-ET), with one D5 blastocyst transferred on December 20, 2023. On January 7, 2024, she was admitted to the hospital due to "minimal vaginal bleeding." During her hospitalization, she received "progesterone injections" as part of her treatment regimen. After 10 days of hospitalization, the symptoms of vaginal bleeding were alleviated. This pregnancy was achieved through in vitro fertilization and embryo transfer.On December 20, 2023, a single blastocyst was transferred on the fifth day of development.On January 7, 2024, the patient presented to the hospital with "minimal vaginal bleeding" and was subsequently treated with progesterone injections. The symptoms resolved, and the patient was discharged on January 17, 2024.She underwent an ultrasound examination on January 16, 2024, which indicated: "Intrauterine twin pregnancy (monochorionic), embryo survival, both approximately 6 + weeks old".She was re-examined on February 22, 2024, and the results suggested: "Intrauterine twin pregnancy, MCDA, fetus 1 CRL: 56mm/50mm, fetus 2 NT: 1.6mm/1.2mm". On March 2, 2024, the pregnant woman experienced vaginal bleeding once more without any apparent cause. The blood was bright red and approximately 20ml in volume. She sought medical attention at our hospital on the same day. On January 16, 2024, she underwent an ultrasound examination, which revealed the following: "Intrauterine twin pregnancy (monochorionic), viable embryos, both approximately 6 + weeks of gestation." A follow-up examination was conducted on February 22, 2024, with results indicating: "Intrauterine twin pregnancy, MCDA,The crown-rump length (CRL) measurements are 56 mm and 50 mm, respectively, while the nuchal translucency (NT) thicknesses are 1.6 mm and 1.2 mm, respectively. "This indicates that the developmental stages of the twins are within the expected range. On March 2, 2024, the patient experienced unprovoked vaginal bleeding characterized by bright red blood with an estimated volume of approximately 20ml. She sought immediate medical evaluation at our hospital on the same day. After admission, the patient received the following treatments: "Dydrogesterone" 10 mg orally twice daily for luteal phase support; "Atosiban Injection" 0.9 mL via intravenous infusion; "Atosiban acetate inj 20 mL + 0.9% Sodium Chloride Injection 180 mL" infused at an initial rate of 24 mL/hour intravenously, with the rate subsequently adjusted to 8 mL/hour to maintain intravenous infusion and inhibit uterine contractions. Additionally, "Aminocaproic Acid 4 g + 0.9% Sodium Chloride Injection 100 mL" was administered once daily via intravenous infusion; "Adrenal Color Hydrazone Tablet" 5 mg orally three times daily to control bleeding; and "Cefuroxime Sodium 0.5 g + 0.9% Sodium Chloride Injection 100 mL" was given to prevent infection. During her hospital stay, she underwent an extensive series of routine medical evaluations, including blood tests, urine analysis, assessments of thyroid and liver function, renal function tests, screenings for chlamydia and mycoplasma, bacterial cultures of vaginal secretions, comprehensive immune analyses (including the antinuclear antibody spectrum and lupus-related tests), rapid screening for systemic lupus erythematosus, testing for anti-phosphatidylserine/prothrombin antibodies, measurement of glycosylated hemoglobin, and an electrocardiogram. None of these tests revealed any significant abnormalities.On March 7, 2024, the patient underwent a glucose tolerance test, with results of 6.1 mmol/L, 9.8 mmol/L, and 11.9 mmol/L at fasting, one hour, and two hours post-glucose ingestion, respectively. Based on these findings, she was diagnosed with gestational diabetes mellitus (GDM). The healthcare team recommended dietary adjustments as part of her blood glucose management plan. On March 12, 2024, the patient was discharged from the hospital following the resolution of vaginal bleeding symptoms. Post-discharge, she occasionally experienced mild abdominal tightness and minimal vaginal bleeding, which was only apparent upon wiping. As a result, she continued to take Dydrogesterone and Adrenal hydrazone tablets as prescribed. On March 14, 2024, a pregnant woman presented with nasal congestion. On March 17, 2024, she developed a fever with a body temperature of 37.5°C, accompanied by symptoms including a dry throat, hoarseness, increased phlegm production, mild dizziness, chest tightness, and two episodes of vomiting of gastric contents. Subsequently, the patient experienced lower abdominal pain, which worsened after eating but could be relieved when lying in the lateral decubitus position. Additionally, there were small amounts of light brown vaginal discharge. On March 17, 2024, she was hospitalized in our hospital due to "15 weeks and 2 days of pregnancy after embryo transfer, fever for 4 hours, and lower abdominal pain for 1 hour". After admission, the blood routine examination, CRP test, and influenza virus antigen test all yielded normal results. The patients were administered the following treatments: expectorants, "omeprazole enteric-coated tablet" (20 mg qd orally) for gastric protection, "atroceban acetate" to inhibit uterine contractions (as previously prescribed), and "Adrenal color hydrazone tablet" (5 mg tid orally) as part of a hemostatic regimen. Subsequently, self-induced fever was observed. The symptoms of abdominal pain and vaginal bleeding were significantly alleviated.Subsequently, her symptoms of abdominal pain and vaginal bleeding were significantly alleviated, and the fever subsided. From March 21, 2024, to March 25, 2024, the pregnant woman monitored her fasting fingertip blood glucose levels, which fluctuated between 7.3-8.0 mmol/L, and her blood glucose levels 2 hours after meals, which ranged from 5.3–13.4 mmol/L.Due to insufficient physical activity among pregnant women and inadequate dietary management of blood sugar levels, insulin therapy was initiated on March 26, 2024, to control blood sugar in pregnant women. On April 3, 2024, the patient underwent a re-examination with B-ultrasound, and the results indicated:Fetus A exhibited polyhydramnios with a deepest vertical pocket (DVP)of 87 mm. In contrast, Fetus B demonstrated oligohydramnios with a DVP of 17 mm. Notably, the bladder of Fetus B was not visualized. These findings are consistent with a history of TTTS Stage II. The placenta in pregnant women is located on the anterior wall of the uterus, which renders fetal endoscopic surgery to present a relatively high level of complexity. This complexity is further compounded by cervical insufficiency and recurrent vaginal bleeding during pregnancy, potentially increasing the risk of premature rupture of membranes and miscarriage. After thorough communication with the pregnant woman and her family regarding the clinical condition, the attending physician opted for "RFA for selective fetal reduction," a technically challenging procedure that ensures the retention of at least one fetus.Due to the excessive accumulation of amniotic fluid in the recipient fetus, the donor fetus was compressed against the posterior uterine wall. This positioning rendered it difficult for the puncture needle to reach the donor fetus, thereby posing a significant challenge to performing direct RFA. Consequently, on April 4, 2024, an initial procedure combining amniocentesis for prenatal diagnosis with amniotic fluid reduction surgery was conducted. During this procedure, 40 mL of amniotic fluid was aspirated for karyotype analysis and chromosomal microarray analysis (CMA). Additionally, approximately 1000 mL of amniotic fluid was reduced. Following the amniotic fluid reduction surgery, the uterine relaxant atosiban was administered to prevent potential uterine contractions. On April 8, 2024, the laboratory reported that there were no significant abnormalities in the QF-PCR results of the amniotic fluid, and the "radiofrequency ablation of fetal reduction" was performed on the same day. The procedure utilized an AngioDynamics-RITA1500X radio-frequency ablation generator and a RITA StarBurst SDE electrode needle. The needle's length was 12cm, and the ablation diameter was 2cm. Under ultrasound guidance, the RFA probe was inserted into the umbilical cord of the blood donor fetus, and the target temperature was set between 100 to 110°C. The radio frequency cycle was performed. The operation was halted upon the observation of fetal bradycardia via B-ultrasound and the cessation of cord blood flow. The procedure lasted 5 minutes and was conducted smoothly. "Cefuroxime sodium" was administered post-surgery to prevent infection, and "Atosiban" was continued to prevent uterine contractions. B-ultrasonography was regularly reviewed post-surgery, with no significant shortening of the cervix observed.On April 12, 2024, the laboratory returned the CMA results for the amniotic fluid, indicating arr(1–22)×2,(X,N)×1. The chromosome analysis of the amniotic fluid also showed 46, XN. Consequently, the pregnant woman was discharged from the hospital on April 30, 2024. On May 7, 2024, the pregnant woman experienced swelling and pain in the lower abdomen without a clear cause. An ultrasound examination conducted the following day revealed: "The internal and external os of the cervix were fully dilated, with the internal diameter of the internal os measuring approximately 10mm. The amniotic sac protrudes into the cervical canal, measuring approximately 37×28 mm in size. Spot-like areas of strong echogenicity are observed on the anterior and posterior walls of the cervix, located approximately 24 mm (anterior) and 25 mm (posterior) from the external os of the cervix." On May 8, 2024, she was readmitted to the hospital due to "22 weeks and 5 days pregnant, experiencing one day of lower abdominal pain following laparoscopic cervical cerclage surgery."Physical examination: Irregular uterine contractions, varying in intensity from weak to moderate, are palpable in the abdomen. A moderate amount of white vaginal discharge is noted. The cervical os is dilated to approximately 2 cm, with the amniotic sac protruding through the external cervical os. On May 8, 2024, an emergency procedure consisting of "amniotic fluid reduction" and "transvaginal emergency cervical cerclage" was performed. Postoperatively, atosiban was administered to inhibit uterine contractions. On June 19, 2024, a fetal head MRI was conducted for the pregnant patient, and no significant abnormalities were detected. Due to the increasingly frequent contractions of the pregnant woman, from July 7, 2024, to July 9, 2024, magnesium sulfate was administered to protect the fetal brain and nerves, and dexamethasone was given to promote fetal lung maturation. On July 10, 2024 (31 weeks and 6 days of pregnancy), the irregular contractions in the lower abdomen of the pregnant woman worsened, and the doctor advised her to terminate the pregnancy. The attending physician informed the pregnant woman and her family of the relevant conditions and they agreed on the method of delivery.The pregnant woman and her family requested a cesarean section to terminate the pregnancy. So, on July 10, 2024, a "Cesarean section with concomitant removal of cervical cerclage sutures" was performed. A live baby was delivered at 11:46 on July 10, 2024, with a birth weight of 1.59 kg and an Apgar score of 9 at 1 minute and 10 at 5 minutes. Due to "premature birth," the newborn was immediately transferred to the NICU after birth. A plain MRI scan of the head was performed on August 13, 2024, which revealed no obvious abnormalities, and the newborn was discharged on August 14, 2024. The growth of the newborn was satisfactory, and the weight at discharge was 2.05 kg. Discussion TTTS is one of the more serious complications in MCDA twin pregnancies, with an incidence ranging from 8–15%, occurring in approximately 1 to 3 out of every 10,000 pregnancies, typically between the 16th and 26th weeks of gestation [ 1 ] . The pathogenesis of TTTS remains unclear, but it may be associated with monochorionic twins sharing a placenta that has a large number of vascular anastomoses at the placental level. Due to these anastomotic vessels in the placenta, there is a continuous blood exchange between the fetuses, which can lead to the final recipient fetus experiencing anemia, intrauterine growth restriction, oligohydramnios, cardiac insufficiency, neurological complications, and even intrauterine fetal death. The donor fetus often faces a heavy circulatory load, which can manifest as excessive amniotic fluid, bladder overfilling, and congestive heart failure, posing a life-threatening risk to both fetuses. If TTTS is left untreated before 24 weeks of pregnancy, the fetal mortality rate can reach 90%-100%, and the surviving fetuses may have neurological sequelae at a rate of 17%-33% [ 2 ] . Regarding the staging of TTTS, Quintero staging is currently the most widely used. Stage I involves excessive amniotic fluid (with the maximum depth of amniotic fluid before 20 weeks of pregnancy being greater than 8cm, and after 20 weeks being greater than 10cm), whereas the maximum depth of amniotic fluid in blood donors is less than 2cm. Stage II is characterized by an ultrasound observation over 60 minutes, during which the bladder of the donor twin does not become visible. Stage III includes Doppler flow abnormalities in any fetus, such as absent or reversed end-diastolic flow in the umbilical artery, venous flow abnormalities, middle cerebral artery flow abnormalities, or pulsatile umbilical vein flow. Stage IV is marked by edema in any fetus, and Stage V signifies intrauterine death of one or both fetuses.However, recent suggestions have been made to revise the criteria for diagnosing TTTS prior to 18 weeks [ 3 ] , as one study found, the volume of amniotic fluid in monochorionic diamniotic sac twins was monitored from early pregnancy through to delivery. It was determined that at 16–17 weeks of gestation, an amniotic fluid thickness of 6 cm represented the 90th percentile, whereas an amniotic fluid thickness of 7 cm corresponded to the 97.5th percentile.Therefore, it is suggested that 6 cm of amniotic fluid thickness may be more sensitive than 8 cm before 18 weeks of gestation [ 4 ] . The Quintero staging system is based on the severity of the disease; however, it is not entirely correlated with fetal prognosis. The natural progression of TTTS does not strictly follow the stages. It may exhibit skip-stage development, stabilize at a particular stage, or even demonstrate potential for reversal [ 5 ] . Moreover, the Quintero staging system is not suitable for evaluating the treatment outcomes of TTTS and does not indicate changes in fetal cardiovascular function. Once TTTS occurs, its natural prognosis is typically poor. Currently, treatment options for TTTS include expectant management, serial amnioreduction, laser ablation under fetal endoscopic guidance, and radiofrequency ablation. Expectant management is primarily used for Quintero stage I patients with stable conditions, but between 10.0% and 45.0% of these cases may experience disease progression, necessitating a switch to alternative treatments. Serial amnioreduction aims to decrease amniotic cavity pressure and, subsequently, the placental venous pressure of the recipient fetus, which can improve placental circulation and extend the gestational period. The post-surgery survival rate for at least one fetus is between 50% and 60%..However, repeated amniocentesis increases the risk of infection and premature rupture of the fetal membranes. Fetal cardiovascular and nervous system injuries due to vascular circulation have not been effectively mitigated. Studies indicate that in cases of sequential amniotic fluid reduction, the rate of neurodevelopmental injury among surviving newborns can reach 25% [ 6 ] . The Fetal Medicine Group of the Perinatal Medicine Branch of the Chinese Medical Association recommends that fetal laser therapy should be the first choice for treating TTTS in Quintero stage II and above, particularly between 16 to 26 weeks of pregnancy. In recent years, numerous fetal medical centers in China have conducted fetoscopic laser surgeries, with results indicating that the survival rate for at least one fetus and two fetuses of TTTS patients treated with fetal laser surgery was between 81.0–88.0% and 56.0–59.0%, respectively. Additionally, the average gestational week of delivery surpasses 32 weeks [ 7 ] . RFA was initially utilized in fetal medicine in 2002 to address twin anemia-polycythemia sequence. The survival rate of at least one fetus post-radiofrequency ablation is higher, the operation time is shorter, it is easier to perform, and postoperative complications are relatively fewer. However, radiofrequency ablation is not considered the primary treatment for TTTS from an ethical standpoint. Nonetheless, the patient experienced repeated vaginal bleeding during pregnancy and continued to bleed, having suffered three previous miscarriages in mid-pregnancy. She also had a history of cervical insufficiency. Although "laparoscopic cervical cerclage" had been performed prior to the pregnancy, the cervix was still progressively shortening, posing an extremely high risk of miscarriage and premature delivery. Moreover, due to the presence of uterine cervical cerclage in the patient's abdominal cavity, the failure to save the fetus would mean that the patient would have to endure another blow - "hysterotomy" with its evident trauma. Due to the placenta of pregnant women being situated on the anterior wall of the uterus, selective coagulation of placental vascular communication branches under a fetal microscope is challenging. RFA, which relies on the thermal effect of a puncture needle, is utilized to block the fetal blood flow from a specific site, thereby foetal reduction. This method aims to minimize the impact on the other fetus, effectively reducing the risk to the healthier fetus and saving the less viable one, thus preserving only one fetus. In certain situations, selective termination of one fetus may be necessary to decrease the risk to the other or to enhance the likelihood of survival for the remaining fetus. Current reports indicate that the survival rate of fetuses following radiofrequency ablation ranges from 70.0–88.6% [ 8 ] . The survival rate can vary due to differences in sample size, fetal reduction indicators, and surgical methods, as indicated by various literature sources. In the study conducted by Paramasivam et al [ 9 ] , the survival rates of the retained fetuses following RFA were reported as 90.9%, 100.0%, 80.0%, 100.0%, and 77.8%, respectively, for cases with the lowest survival rates due to TTTS, selective intrauterine growth restriction (sIUGR), twin reversed arterial perfusion sequence (TRAPS), family requests for fetal reduction, and fetal reduction owing to structural malformations in one of the twins. In the study of Hongmei Wang et al, the overall technical success rate of RFA for fetal reduction was 76.7%, with the TTTS group exhibiting the lowest survival rate at 57.8% [ 10 ] . Common complications associated with radiofrequency ablation include preterm birth, preterm premature rupture of membranes (PPROM) and miscarriage. Cervical insufficiency refers to the inability of the cervix to maintain a pregnancy in the absence of contractions, due to anatomical or functional defects, which can result in miscarriage or premature birth. The incidence of cervical incompetence is estimated to affect 0.1-2% of pregnant women, with 8% of second-trimester miscarriages and premature births being linked to this condition [ 11 ] . Cervical cerclage is the most effective treatment for cervical incompetence. Depending on the timing of the surgery, it can be categorized into prophylactic cerclage (indicated by medical history), elective cerclage (indicated by ultrasound findings), and emergency cerclage (indicated by physical examination). Surgical methods can be further classified into transvaginal cerclage and transabdominal cerclage. Transabdominal cervical cerclage is primarily indicated for patients with cervical insufficiency who require cerclage but are not suitable candidates for transvaginal cervical cerclage due to anatomical constraints, such as prior cervical resection, an excessively short cervix, or a history of failed transvaginal cerclage procedures. The 2023 SMFM guidelines recommend the provision of transabdominal cervical cerclage (GRADE 1B) for patients with a history of prior transvaginal cervical cerclage (based on medical history or ultrasound indications) followed by subsequent spontaneous singleton deliveries before 28 weeks of gestation [ 12 ] .The 2019 SOGC guidelines recommend that, for women with cervical dilation of less than 4 cm and the absence of uterine contractions prior to 24 weeks of gestation, emergency cervical cerclage (II-3C) may be considered as a potential intervention [ 13 ] .The 2022 RCOG guidelines recommend that emergency cerclage for singleton pregnancies with dilation of the uterine cervix extend the gestational age by an average of 34 days [ 14 ] . In this case,this pregnant individual experienced an inevitable miscarriage at 19 weeks of gestation in 2018, another inevitable miscarriage at 22 weeks of gestation in 2022, and yet another inevitable miscarriage at 24 weeks of gestation in 2021, despite having undergone prophylactic transvaginal cervical cerclage at 14 weeks of gestation at a different medical facility.Due to pregnancy loss after transvaginal cervical cerclage, the pregnant woman received transabdominal cervical cerclage before this pregnancy. However, cervical dilation still occurred at 22 weeks and 5 days of gestation. A vaginal examination revealed that the uterine orifice was dilated by 2cm and the amniotic sac protruded from the external cervix. An "emergency transvaginal cervical cerclage " was performed at 22 weeks and 5 days of gestation. The gestational age was successfully prolonged by 63 days after the operation, and delivery occurred at 31 weeks and 6 days of gestation。 This suggests that pregnant women who experience dilation of the uterine orifice after abdominal cervical cerclage may still achieve better outcomes in prolonging gestational weeks by undergoing emergency cervical cerclage again. The patient gave birth 93 days after radiofrequency ablation, at 31 weeks and 6 days of gestation. The newborn's birth weight was 1.59kg, with Apgar scores of 9 at 1 minute and 10 at 5 minutes. The newborn was discharged from the NICU 35 days after birth, weighing 2.05kg at discharge. Conclusions To summarize, this article presents the case of a pregnant woman who experienced multiple mid-pregnancy miscarriages due to cervical insufficiency and a history of multiple uterine cavity procedures. During the current pregnancy, she conceived through assisted reproductive technology and was subsequently diagnosed with gestational diabetes, recurrent vaginal bleeding, and TTTS stage II. Prior to conception, a laparoscopic prophylactic cervical cerclage was performed. Following conception, interventions including amniotic fluid reduction, radiofrequency ablation for fetal reduction, and an emergency cervical cerclage were implemented sequentially. The pregnancy was successfully maintained until delivery at 31 weeks and 6 days of gestation. This case highlights the efficacy of targeted and personalized fetal maintenance strategies tailored to the specific conditions of the pregnant woman and fetus. Furthermore, it demonstrates that intrauterine treatment is not contraindicated in patients with cervical insufficiency and recurrent vaginal bleeding during pregnancy. Abbreviations RFA Radiofrequency ablation TTTS Twin-to-twin transfusion syndrome MCDA monochorionic diamniotic NICU Neonatal Intensive Care Unit DVP deepest vertical pocket CMA microarray analysis sIUGR selective intrauterine growth restriction PPROM preterm premature rupture of membranes (PPROM) Declarations Ethics approval and consent to participate: The use of sample from the patients was approved by the Institutional Ethics Committee of Shenshan Medical Center, Memorial Hospital of Sun Yat-sen university and informed consent has been obtained from patients prior to analysis. Approval Number :2025-SSKY-029-01. Consent for publication ： Written informed consent to publish this information was obtained from study participant.The written consent form for publication has been obtained from the patients. Availability of data and materials ： The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author. Competing interests ： The authors have no competing interest to disclose Funding ： Not applicable. Authors' contributions ： MQC and HX conceived the study and drafted the manuscript. QX and HMY carried out the patient follow up. SF and SNZconceived the study, participated in its design and coordination, and helped draft the manuscript. All authors read and approved the final manuscript. Acknowledgements ： Not applicable. Authors' information: 1 Department of Obstetrics and Gynecology, Sun Yat-sen memorial hospital, Sun Yat-sen university,Guangzhou 2 Department of Obstetrics and Gynecology, Shenshan medical center, memorial hospital of Sun Yat-sen university 3 Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases References Yin Shaowei, Liu Caixia, Zhang Zhitao, et al. Guidelines for the Diagnosis, Treatment, and Management of Twin-to-Twin Transfusion Syndrome (2020) [J]. Chinese Journal of Practical Gynecology and Obstetrics, 2020, 36(8): 714-721. DOI: 10.19538/j.fk2020080112. Bamberg, C, Hecher, K. Update on twin-to-twin transfusion syndrome. BEST PRACT RES CL OB. 2019; 58 BEST PRACT RES CL OB. doi: 10.1016/j.bpobgyn.2018.12.011 Khalil, A. Modified diagnostic criteria for twin-to-twin transfusion syndrome prior to 18 weeks' gestation: time to change? ULTRASOUND OBST GYN. 2017; 49 (6): 804-805. doi: 10.1002/uog.17443 Dekoninck, P, Deprest, J, Lewi, P, et al. Gestational age-specific reference ranges for amniotic fluid assessment in monochorionic diamniotic twin pregnancies. ULTRASOUND OBST GYN. 2013; 41 (6): 649-52. doi: 10.1002/uog.12387 Duryea, EL, Happe, SK, McIntire, DD, et al. The natural history of twin-twin transfusion syndrome stratified by Quintero stage. J MATERN-FETAL NEO M. 2016; 29 (21): 3411-5. doi: 10.3109/14767058.2015.1131263 van Klink, JM, Koopman, HM, van Zwet, EW, et al. Cerebral injury and neurodevelopmental impairment after amnioreduction versus laser surgery in twin-twin transfusion syndrome: a systematic review and meta-analysis. FETAL DIAGN THER. 2013; 33 (2): 81-9. doi: 10.1159/000341814 Twin pregnancy clinical treatment guidelines (update) in 2020 [J]. Chinese journal of prenatal diagnosis (electronic), 2021, 13 (01) : 51-63. DOI:10.13470/j.cnki.cjpd.2021.01.011 Shi Xiaomei, Rao Tengzi, Liu Qian, et al. Multiple pregnancy line radiofrequency ablation reduction among and influence factors analysis [J]. Chinese journal of obstetrics and gynecology, 2019, (11) : 736-740. The DOI: 10.3760 / cma. J.i SSN. 0529? X. 567 2019.11.004 Paramasivam, G, Wimalasundera, R, Wiechec, M, et al. OP09.05: Radiofrequency ablation for selective reduction in complex monochorionic pregnancies ULTRASOUND OBST GYN. 2009; 34 (S1): 89-90. doi: 10.1002/uog.6733 Wang, H, Zhou, Q, Wang, X, et al. Influence of indications on perinatal outcomes after radio frequency ablation in complicated monochorionic pregnancies: a retrospective cohort study. BMC Pregnancy Childbirth. 2021; 21 (1): 41. doi: 10.1186/s12884-020-03530-6 Roman, A, Suhag, A, Berghella, V. Cerclage: Indications and Patient Counseling. CLIN OBSTET GYNECOL. 2016; 59 (2): 264-9. doi: 10.1097/GRF.0000000000000185 Temming, L, Mikhail, E. Society for Maternal-Fetal Medicine Consult Series #65: Transabdominal cerclage. AM J OBSTET GYNECOL. 2023; 228 (6): B2-B10. doi: 10.1016/j.ajog.2023.02.018 Brown, R, Gagnon, R, Delisle, MF. No. 373-Cervical Insufficiency and Cervical Cerclage. J OBSTET GYNAECOL CA. 2019; 41 (2): 233-247. doi: 10.1016/j.jogc.2018.08.009 Shennan, A.H. and L. Story, Cervical Cerclage. BJOG: An International Journal of Obstetrics & Gynaecology, 2022. 129(7): p. 1178-1210. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6657212","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":497650752,"identity":"9d4eb54c-f394-4b16-831b-0c0e7de8e8b7","order_by":0,"name":"Manqi Chen","email":"","orcid":"","institution":"Sun Yat-sen memorial hospital, Sun Yat-sen university","correspondingAuthor":false,"prefix":"","firstName":"Manqi","middleName":"","lastName":"Chen","suffix":""},{"id":497650753,"identity":"f2027de1-9a9e-46d6-a336-cb30a591130a","order_by":1,"name":"Hui Xie","email":"","orcid":"","institution":"Shenshan Medical Center, Memorial Hospital of Sun Yat-sen university","correspondingAuthor":false,"prefix":"","firstName":"Hui","middleName":"","lastName":"Xie","suffix":""},{"id":497650754,"identity":"e8a3626b-aa5a-4885-a991-cb90bf3952bd","order_by":2,"name":"Qi Xu","email":"","orcid":"","institution":"Sun Yat-sen memorial hospital, Sun Yat-sen university","correspondingAuthor":false,"prefix":"","firstName":"Qi","middleName":"","lastName":"Xu","suffix":""},{"id":497650755,"identity":"2ea24118-96d1-42a1-a057-b8c4018f83c6","order_by":3,"name":"Huimin Yi","email":"","orcid":"","institution":"Shenshan Medical Center, Memorial Hospital of Sun Yat-sen university","correspondingAuthor":false,"prefix":"","firstName":"Huimin","middleName":"","lastName":"Yi","suffix":""},{"id":497650756,"identity":"bef38eec-bf30-4303-9788-8845898e9392","order_by":4,"name":"Shuning Zhang","email":"","orcid":"","institution":"Sun Yat-sen memorial hospital, Sun Yat-sen university","correspondingAuthor":false,"prefix":"","firstName":"Shuning","middleName":"","lastName":"Zhang","suffix":""},{"id":497650757,"identity":"49f50ac7-8e0f-4ef8-a7cf-25793b2cae3d","order_by":5,"name":"Shuai Fu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYBAC9gYGNuY/FQwMbOxwsQT8WngOMLAx8JwBamEmSQtvG5BFvBaJ9GcPJOdtk+djZmD+zPPnMAM/e44Bw88d+LTkmBsYbrtt2MbMwCbN23aYQbLnjQFj7xncWuwlctgkErfdZgRpYeZtOMxgcCPHgJmxDb/DJA7OuW3fBnOYPWEtCWaSjQ23E4FaGKR52IC2SBDSwvPGTJrh2O3kNqAyyblt6TwSZ54VHOzFp4U9/Zk0Q81t2/ntzYc/vPljLcffnrzxwU88WpAAYwMTD9AMEPMAURrAmn4QrXQUjIJRMApGEgAA4v5G9bB5MwkAAAAASUVORK5CYII=","orcid":"","institution":"Sun Yat-sen memorial hospital, Sun Yat-sen university","correspondingAuthor":true,"prefix":"","firstName":"Shuai","middleName":"","lastName":"Fu","suffix":""}],"badges":[],"createdAt":"2025-05-13 15:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6657212/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6657212/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88836343,"identity":"a33c7068-1d3f-4f9f-985e-235b82a51450","added_by":"auto","created_at":"2025-08-12 01:13:53","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":144403,"visible":true,"origin":"","legend":"\u003cp\u003eFetal A had excessive amniotic fluid with a deepest vertical pocke of 87mm\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6657212/v1/dc3de49bd0429203d86cf522.jpeg"},{"id":88836345,"identity":"45584b42-d40c-44d2-9637-929511729911","added_by":"auto","created_at":"2025-08-12 01:13:53","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":194828,"visible":true,"origin":"","legend":"\u003cp\u003eFetal B had oligohydramniotic fluid with a deepest vertical pocket of 17mm\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6657212/v1/b6557d345907c28dfe78e073.jpeg"},{"id":88837019,"identity":"05d4420d-7dbd-43a8-85f4-6b99207f9a9b","added_by":"auto","created_at":"2025-08-12 01:21:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":784114,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6657212/v1/21132fd1-0d05-4743-907c-7c1d6bd3fb94.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eA Case Report of Successful Pregnancy Maintenance Following Emergency Cervical Cerclage after Radiofrequency Ablation for Twin-to-Twin Transfusion Syndrome: A Systematic Literature Review\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eTwin-to- twin transfusion syndrome (TTTS) represents one of the most severe complications in monochorionic diamniotic(MCDA)twin pregnancies, with an incidence ranging from 1 to 3 per 10,000 among all pregnancies \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e.The pathogenesis of TTTS is complex and may be attributed to the monochorionic twins sharing a single placenta with extensive vascular anastomoses at the placental level. When a fetus in MCDA pregnancy exhibits abnormal development or is nearing demise, it may pose a risk to the co-twin. In such scenarios, fetal reduction surgery can be considered as an intervention to remove the compromised fetus, thereby safeguarding the healthy fetus and improving the overall prognosis for both the mother and the remaining fetus.Radiofrequency ablation (RFA) for fetal reduction is considered a safe and efficacious technique, and it has been extensively adopted for multifetal pregnancy reduction, particularly in cases involving MCDA twins.The survival rate of at least one fetus following RFA is significantly higher. Additionally, the procedure boasts a shorter operation time, ease of execution, and relatively fewer postoperative complications.Cervical insufficiency is defined as a condition wherein the cervix is incapable of maintaining its closed state during pregnancy due to an anatomical or functional defect, resulting in miscarriage or preterm birth.The treatment for cervical insufficiency is mainly effective with cervical cerclage.There have been no documented cases of successful pregnancy termination following intrauterine treatment with emergency transvaginal cervical cerclage. Consequently, this study reports a unique case involving laparoscopic prophylactic cervical cerclage performed prior to pregnancy, successful RFA conducted during pregnancy for stage II twin-to-twin transfusion syndrome, concurrent emergency vaginal cervical cerclage, and ultimately, successful delivery at 31 weeks and 6 days of gestation.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient, a 30-year-old woman at 22 weeks and 5 days of gestation, was admitted to the hospital on May 8, 2024, due to hypogastric pain. She had a history of three second-trimester miscarriages. In her first pregnancy in 2018, she experienced an inevitable miscarriage at 19 weeks of gestation. Similarly, during her second pregnancy in 2020, she underwent an inevitable miscarriage at 22 weeks of gestation.In 2021, the patient underwent a \"preventive transvaginal cervical cerclage\" at 14 weeks of gestation at another medical institution but subsequently experienced an inevitable abortion at 24 weeks of gestation. In November 2021, a laparoscopic cervical cerclage was performed at another medical institution. The current pregnancy resulted from in vitro fertilization and embryo transfer (IVF-ET), with one D5 blastocyst transferred on December 20, 2023. On January 7, 2024, she was admitted to the hospital due to \"minimal vaginal bleeding.\" During her hospitalization, she received \"progesterone injections\" as part of her treatment regimen. After 10 days of hospitalization, the symptoms of vaginal bleeding were alleviated. This pregnancy was achieved through in vitro fertilization and embryo transfer.On December 20, 2023, a single blastocyst was transferred on the fifth day of development.On January 7, 2024, the patient presented to the hospital with \"minimal vaginal bleeding\" and was subsequently treated with progesterone injections. The symptoms resolved, and the patient was discharged on January 17, 2024.She underwent an ultrasound examination on January 16, 2024, which indicated: \"Intrauterine twin pregnancy (monochorionic), embryo survival, both approximately 6\u0026thinsp;+\u0026thinsp;weeks old\".She was re-examined on February 22, 2024, and the results suggested: \"Intrauterine twin pregnancy, MCDA, fetus 1 CRL: 56mm/50mm, fetus 2 NT: 1.6mm/1.2mm\". On March 2, 2024, the pregnant woman experienced vaginal bleeding once more without any apparent cause. The blood was bright red and approximately 20ml in volume. She sought medical attention at our hospital on the same day. On January 16, 2024, she underwent an ultrasound examination, which revealed the following: \"Intrauterine twin pregnancy (monochorionic), viable embryos, both approximately 6\u0026thinsp;+\u0026thinsp;weeks of gestation.\" A follow-up examination was conducted on February 22, 2024, with results indicating: \"Intrauterine twin pregnancy, MCDA,The crown-rump length (CRL) measurements are 56 mm and 50 mm, respectively, while the nuchal translucency (NT) thicknesses are 1.6 mm and 1.2 mm, respectively. \"This indicates that the developmental stages of the twins are within the expected range. On March 2, 2024, the patient experienced unprovoked vaginal bleeding characterized by bright red blood with an estimated volume of approximately 20ml. She sought immediate medical evaluation at our hospital on the same day. After admission, the patient received the following treatments: \"Dydrogesterone\" 10 mg orally twice daily for luteal phase support; \"Atosiban Injection\" 0.9 mL via intravenous infusion; \"Atosiban acetate inj 20 mL\u0026thinsp;+\u0026thinsp;0.9% Sodium Chloride Injection 180 mL\" infused at an initial rate of 24 mL/hour intravenously, with the rate subsequently adjusted to 8 mL/hour to maintain intravenous infusion and inhibit uterine contractions. Additionally, \"Aminocaproic Acid 4 g\u0026thinsp;+\u0026thinsp;0.9% Sodium Chloride Injection 100 mL\" was administered once daily via intravenous infusion; \"Adrenal Color Hydrazone Tablet\" 5 mg orally three times daily to control bleeding; and \"Cefuroxime Sodium 0.5 g\u0026thinsp;+\u0026thinsp;0.9% Sodium Chloride Injection 100 mL\" was given to prevent infection. During her hospital stay, she underwent an extensive series of routine medical evaluations, including blood tests, urine analysis, assessments of thyroid and liver function, renal function tests, screenings for chlamydia and mycoplasma, bacterial cultures of vaginal secretions, comprehensive immune analyses (including the antinuclear antibody spectrum and lupus-related tests), rapid screening for systemic lupus erythematosus, testing for anti-phosphatidylserine/prothrombin antibodies, measurement of glycosylated hemoglobin, and an electrocardiogram. None of these tests revealed any significant abnormalities.On March 7, 2024, the patient underwent a glucose tolerance test, with results of 6.1 mmol/L, 9.8 mmol/L, and 11.9 mmol/L at fasting, one hour, and two hours post-glucose ingestion, respectively. Based on these findings, she was diagnosed with gestational diabetes mellitus (GDM). The healthcare team recommended dietary adjustments as part of her blood glucose management plan. On March 12, 2024, the patient was discharged from the hospital following the resolution of vaginal bleeding symptoms. Post-discharge, she occasionally experienced mild abdominal tightness and minimal vaginal bleeding, which was only apparent upon wiping. As a result, she continued to take Dydrogesterone and Adrenal hydrazone tablets as prescribed.\u003c/p\u003e\u003cp\u003eOn March 14, 2024, a pregnant woman presented with nasal congestion. On March 17, 2024, she developed a fever with a body temperature of 37.5\u0026deg;C, accompanied by symptoms including a dry throat, hoarseness, increased phlegm production, mild dizziness, chest tightness, and two episodes of vomiting of gastric contents. Subsequently, the patient experienced lower abdominal pain, which worsened after eating but could be relieved when lying in the lateral decubitus position. Additionally, there were small amounts of light brown vaginal discharge. On March 17, 2024, she was hospitalized in our hospital due to \"15 weeks and 2 days of pregnancy after embryo transfer, fever for 4 hours, and lower abdominal pain for 1 hour\". After admission, the blood routine examination, CRP test, and influenza virus antigen test all yielded normal results. The patients were administered the following treatments: expectorants, \"omeprazole enteric-coated tablet\" (20 mg qd orally) for gastric protection, \"atroceban acetate\" to inhibit uterine contractions (as previously prescribed), and \"Adrenal color hydrazone tablet\" (5 mg tid orally) as part of a hemostatic regimen. Subsequently, self-induced fever was observed. The symptoms of abdominal pain and vaginal bleeding were significantly alleviated.Subsequently, her symptoms of abdominal pain and vaginal bleeding were significantly alleviated, and the fever subsided. From March 21, 2024, to March 25, 2024, the pregnant woman monitored her fasting fingertip blood glucose levels, which fluctuated between 7.3-8.0 mmol/L, and her blood glucose levels 2 hours after meals, which ranged from 5.3\u0026ndash;13.4 mmol/L.Due to insufficient physical activity among pregnant women and inadequate dietary management of blood sugar levels, insulin therapy was initiated on March 26, 2024, to control blood sugar in pregnant women. On April 3, 2024, the patient underwent a re-examination with B-ultrasound, and the results indicated:Fetus A exhibited polyhydramnios with a deepest vertical pocket (DVP)of 87 mm. In contrast, Fetus B demonstrated oligohydramnios with a DVP of 17 mm. Notably, the bladder of Fetus B was not visualized. These findings are consistent with a history of TTTS Stage II.\u003c/p\u003e\u003cp\u003eThe placenta in pregnant women is located on the anterior wall of the uterus, which renders fetal endoscopic surgery to present a relatively high level of complexity. This complexity is further compounded by cervical insufficiency and recurrent vaginal bleeding during pregnancy, potentially increasing the risk of premature rupture of membranes and miscarriage. After thorough communication with the pregnant woman and her family regarding the clinical condition, the attending physician opted for \"RFA for selective fetal reduction,\" a technically challenging procedure that ensures the retention of at least one fetus.Due to the excessive accumulation of amniotic fluid in the recipient fetus, the donor fetus was compressed against the posterior uterine wall. This positioning rendered it difficult for the puncture needle to reach the donor fetus, thereby posing a significant challenge to performing direct RFA. Consequently, on April 4, 2024, an initial procedure combining amniocentesis for prenatal diagnosis with amniotic fluid reduction surgery was conducted. During this procedure, 40 mL of amniotic fluid was aspirated for karyotype analysis and chromosomal microarray analysis (CMA). Additionally, approximately 1000 mL of amniotic fluid was reduced. Following the amniotic fluid reduction surgery, the uterine relaxant atosiban was administered to prevent potential uterine contractions. On April 8, 2024, the laboratory reported that there were no significant abnormalities in the QF-PCR results of the amniotic fluid, and the \"radiofrequency ablation of fetal reduction\" was performed on the same day. The procedure utilized an AngioDynamics-RITA1500X radio-frequency ablation generator and a RITA StarBurst SDE electrode needle. The needle's length was 12cm, and the ablation diameter was 2cm. Under ultrasound guidance, the RFA probe was inserted into the umbilical cord of the blood donor fetus, and the target temperature was set between 100 to 110\u0026deg;C. The radio frequency cycle was performed. The operation was halted upon the observation of fetal bradycardia via B-ultrasound and the cessation of cord blood flow. The procedure lasted 5 minutes and was conducted smoothly. \"Cefuroxime sodium\" was administered post-surgery to prevent infection, and \"Atosiban\" was continued to prevent uterine contractions. B-ultrasonography was regularly reviewed post-surgery, with no significant shortening of the cervix observed.On April 12, 2024, the laboratory returned the CMA results for the amniotic fluid, indicating arr(1\u0026ndash;22)\u0026times;2,(X,N)\u0026times;1. The chromosome analysis of the amniotic fluid also showed 46, XN. Consequently, the pregnant woman was discharged from the hospital on April 30, 2024.\u003c/p\u003e\u003cp\u003eOn May 7, 2024, the pregnant woman experienced swelling and pain in the lower abdomen without a clear cause. An ultrasound examination conducted the following day revealed: \"The internal and external os of the cervix were fully dilated, with the internal diameter of the internal os measuring approximately 10mm. The amniotic sac protrudes into the cervical canal, measuring approximately 37\u0026times;28 mm in size. Spot-like areas of strong echogenicity are observed on the anterior and posterior walls of the cervix, located approximately 24 mm (anterior) and 25 mm (posterior) from the external os of the cervix.\" On May 8, 2024, she was readmitted to the hospital due to \"22 weeks and 5 days pregnant, experiencing one day of lower abdominal pain following laparoscopic cervical cerclage surgery.\"Physical examination: Irregular uterine contractions, varying in intensity from weak to moderate, are palpable in the abdomen. A moderate amount of white vaginal discharge is noted. The cervical os is dilated to approximately 2 cm, with the amniotic sac protruding through the external cervical os.\u003c/p\u003e\u003cp\u003eOn May 8, 2024, an emergency procedure consisting of \"amniotic fluid reduction\" and \"transvaginal emergency cervical cerclage\" was performed. Postoperatively, atosiban was administered to inhibit uterine contractions. On June 19, 2024, a fetal head MRI was conducted for the pregnant patient, and no significant abnormalities were detected. Due to the increasingly frequent contractions of the pregnant woman, from July 7, 2024, to July 9, 2024, magnesium sulfate was administered to protect the fetal brain and nerves, and dexamethasone was given to promote fetal lung maturation. On July 10, 2024 (31 weeks and 6 days of pregnancy), the irregular contractions in the lower abdomen of the pregnant woman worsened, and the doctor advised her to terminate the pregnancy. The attending physician informed the pregnant woman and her family of the relevant conditions and they agreed on the method of delivery.The pregnant woman and her family requested a cesarean section to terminate the pregnancy. So, on July 10, 2024, a \"Cesarean section with concomitant removal of cervical cerclage sutures\" was performed. A live baby was delivered at 11:46 on July 10, 2024, with a birth weight of 1.59 kg and an Apgar score of 9 at 1 minute and 10 at 5 minutes. Due to \"premature birth,\" the newborn was immediately transferred to the NICU after birth. A plain MRI scan of the head was performed on August 13, 2024, which revealed no obvious abnormalities, and the newborn was discharged on August 14, 2024. The growth of the newborn was satisfactory, and the weight at discharge was 2.05 kg.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTTTS is one of the more serious complications in MCDA twin pregnancies, with an incidence ranging from 8\u0026ndash;15%, occurring in approximately 1 to 3 out of every 10,000 pregnancies, typically between the 16th and 26th weeks of gestation \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The pathogenesis of TTTS remains unclear, but it may be associated with monochorionic twins sharing a placenta that has a large number of vascular anastomoses at the placental level. Due to these anastomotic vessels in the placenta, there is a continuous blood exchange between the fetuses, which can lead to the final recipient fetus experiencing anemia, intrauterine growth restriction, oligohydramnios, cardiac insufficiency, neurological complications, and even intrauterine fetal death. The donor fetus often faces a heavy circulatory load, which can manifest as excessive amniotic fluid, bladder overfilling, and congestive heart failure, posing a life-threatening risk to both fetuses. If TTTS is left untreated before 24 weeks of pregnancy, the fetal mortality rate can reach 90%-100%, and the surviving fetuses may have neurological sequelae at a rate of 17%-33%\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eRegarding the staging of TTTS, Quintero staging is currently the most widely used. Stage I involves excessive amniotic fluid (with the maximum depth of amniotic fluid before 20 weeks of pregnancy being greater than 8cm, and after 20 weeks being greater than 10cm), whereas the maximum depth of amniotic fluid in blood donors is less than 2cm. Stage II is characterized by an ultrasound observation over 60 minutes, during which the bladder of the donor twin does not become visible. Stage III includes Doppler flow abnormalities in any fetus, such as absent or reversed end-diastolic flow in the umbilical artery, venous flow abnormalities, middle cerebral artery flow abnormalities, or pulsatile umbilical vein flow. Stage IV is marked by edema in any fetus, and Stage V signifies intrauterine death of one or both fetuses.However, recent suggestions have been made to revise the criteria for diagnosing TTTS prior to 18 weeks\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e, as one study found, the volume of amniotic fluid in monochorionic diamniotic sac twins was monitored from early pregnancy through to delivery. It was determined that at 16\u0026ndash;17 weeks of gestation, an amniotic fluid thickness of 6 cm represented the 90th percentile, whereas an amniotic fluid thickness of 7 cm corresponded to the 97.5th percentile.Therefore, it is suggested that 6 cm of amniotic fluid thickness may be more sensitive than 8 cm before 18 weeks of gestation\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. The Quintero staging system is based on the severity of the disease; however, it is not entirely correlated with fetal prognosis. The natural progression of TTTS does not strictly follow the stages. It may exhibit skip-stage development, stabilize at a particular stage, or even demonstrate potential for reversal\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Moreover, the Quintero staging system is not suitable for evaluating the treatment outcomes of TTTS and does not indicate changes in fetal cardiovascular function.\u003c/p\u003e\u003cp\u003eOnce TTTS occurs, its natural prognosis is typically poor. Currently, treatment options for TTTS include expectant management, serial amnioreduction, laser ablation under fetal endoscopic guidance, and radiofrequency ablation. Expectant management is primarily used for Quintero stage I patients with stable conditions, but between 10.0% and 45.0% of these cases may experience disease progression, necessitating a switch to alternative treatments. Serial amnioreduction aims to decrease amniotic cavity pressure and, subsequently, the placental venous pressure of the recipient fetus, which can improve placental circulation and extend the gestational period. The post-surgery survival rate for at least one fetus is between 50% and 60%..However, repeated amniocentesis increases the risk of infection and premature rupture of the fetal membranes. Fetal cardiovascular and nervous system injuries due to vascular circulation have not been effectively mitigated. Studies indicate that in cases of sequential amniotic fluid reduction, the rate of neurodevelopmental injury among surviving newborns can reach 25%\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe Fetal Medicine Group of the Perinatal Medicine Branch of the Chinese Medical Association recommends that fetal laser therapy should be the first choice for treating TTTS in Quintero stage II and above, particularly between 16 to 26 weeks of pregnancy. In recent years, numerous fetal medical centers in China have conducted fetoscopic laser surgeries, with results indicating that the survival rate for at least one fetus and two fetuses of TTTS patients treated with fetal laser surgery was between 81.0\u0026ndash;88.0% and 56.0\u0026ndash;59.0%, respectively. Additionally, the average gestational week of delivery surpasses 32 weeks\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. RFA was initially utilized in fetal medicine in 2002 to address twin anemia-polycythemia sequence. The survival rate of at least one fetus post-radiofrequency ablation is higher, the operation time is shorter, it is easier to perform, and postoperative complications are relatively fewer. However, radiofrequency ablation is not considered the primary treatment for TTTS from an ethical standpoint. Nonetheless, the patient experienced repeated vaginal bleeding during pregnancy and continued to bleed, having suffered three previous miscarriages in mid-pregnancy. She also had a history of cervical insufficiency. Although \"laparoscopic cervical cerclage\" had been performed prior to the pregnancy, the cervix was still progressively shortening, posing an extremely high risk of miscarriage and premature delivery. Moreover, due to the presence of uterine cervical cerclage in the patient's abdominal cavity, the failure to save the fetus would mean that the patient would have to endure another blow - \"hysterotomy\" with its evident trauma.\u003c/p\u003e\u003cp\u003eDue to the placenta of pregnant women being situated on the anterior wall of the uterus, selective coagulation of placental vascular communication branches under a fetal microscope is challenging. RFA, which relies on the thermal effect of a puncture needle, is utilized to block the fetal blood flow from a specific site, thereby foetal reduction. This method aims to minimize the impact on the other fetus, effectively reducing the risk to the healthier fetus and saving the less viable one, thus preserving only one fetus. In certain situations, selective termination of one fetus may be necessary to decrease the risk to the other or to enhance the likelihood of survival for the remaining fetus.\u003c/p\u003e\u003cp\u003eCurrent reports indicate that the survival rate of fetuses following radiofrequency ablation ranges from 70.0\u0026ndash;88.6%\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. The survival rate can vary due to differences in sample size, fetal reduction indicators, and surgical methods, as indicated by various literature sources. In the study conducted by Paramasivam et al\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, the survival rates of the retained fetuses following RFA were reported as 90.9%, 100.0%, 80.0%, 100.0%, and 77.8%, respectively, for cases with the lowest survival rates due to TTTS, selective intrauterine growth restriction (sIUGR), twin reversed arterial perfusion sequence (TRAPS), family requests for fetal reduction, and fetal reduction owing to structural malformations in one of the twins. In the study of Hongmei Wang et al, the overall technical success rate of RFA for fetal reduction was 76.7%, with the TTTS group exhibiting the lowest survival rate at 57.8%\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Common complications associated with radiofrequency ablation include preterm birth, preterm premature rupture of membranes (PPROM) and miscarriage.\u003c/p\u003e\u003cp\u003eCervical insufficiency refers to the inability of the cervix to maintain a pregnancy in the absence of contractions, due to anatomical or functional defects, which can result in miscarriage or premature birth. The incidence of cervical incompetence is estimated to affect 0.1-2% of pregnant women, with 8% of second-trimester miscarriages and premature births being linked to this condition\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Cervical cerclage is the most effective treatment for cervical incompetence. Depending on the timing of the surgery, it can be categorized into prophylactic cerclage (indicated by medical history), elective cerclage (indicated by ultrasound findings), and emergency cerclage (indicated by physical examination). Surgical methods can be further classified into transvaginal cerclage and transabdominal cerclage.\u003c/p\u003e\u003cp\u003eTransabdominal cervical cerclage is primarily indicated for patients with cervical insufficiency who require cerclage but are not suitable candidates for transvaginal cervical cerclage due to anatomical constraints, such as prior cervical resection, an excessively short cervix, or a history of failed transvaginal cerclage procedures. The 2023 SMFM guidelines recommend the provision of transabdominal cervical cerclage (GRADE 1B) for patients with a history of prior transvaginal cervical cerclage (based on medical history or ultrasound indications) followed by subsequent spontaneous singleton deliveries before 28 weeks of gestation\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.The 2019 SOGC guidelines recommend that, for women with cervical dilation of less than 4 cm and the absence of uterine contractions prior to 24 weeks of gestation, emergency cervical cerclage (II-3C) may be considered as a potential intervention\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.The 2022 RCOG guidelines recommend that emergency cerclage for singleton pregnancies with dilation of the uterine cervix extend the gestational age by an average of 34 days\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn this case,this pregnant individual experienced an inevitable miscarriage at 19 weeks of gestation in 2018, another inevitable miscarriage at 22 weeks of gestation in 2022, and yet another inevitable miscarriage at 24 weeks of gestation in 2021, despite having undergone prophylactic transvaginal cervical cerclage at 14 weeks of gestation at a different medical facility.Due to pregnancy loss after transvaginal cervical cerclage, the pregnant woman received transabdominal cervical cerclage before this pregnancy. However, cervical dilation still occurred at 22 weeks and 5 days of gestation. A vaginal examination revealed that the uterine orifice was dilated by 2cm and the amniotic sac protruded from the external cervix. An \"emergency transvaginal cervical cerclage \" was performed at 22 weeks and 5 days of gestation. The gestational age was successfully prolonged by 63 days after the operation, and delivery occurred at 31 weeks and 6 days of gestation。\u003c/p\u003e\u003cp\u003eThis suggests that pregnant women who experience dilation of the uterine orifice after abdominal cervical cerclage may still achieve better outcomes in prolonging gestational weeks by undergoing emergency cervical cerclage again. The patient gave birth 93 days after radiofrequency ablation, at 31 weeks and 6 days of gestation. The newborn's birth weight was 1.59kg, with Apgar scores of 9 at 1 minute and 10 at 5 minutes. The newborn was discharged from the NICU 35 days after birth, weighing 2.05kg at discharge.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTo summarize, this article presents the case of a pregnant woman who experienced multiple mid-pregnancy miscarriages due to cervical insufficiency and a history of multiple uterine cavity procedures. During the current pregnancy, she conceived through assisted reproductive technology and was subsequently diagnosed with gestational diabetes, recurrent vaginal bleeding, and TTTS stage II. Prior to conception, a laparoscopic prophylactic cervical cerclage was performed. Following conception, interventions including amniotic fluid reduction, radiofrequency ablation for fetal reduction, and an emergency cervical cerclage were implemented sequentially. The pregnancy was successfully maintained until delivery at 31 weeks and 6 days of gestation. This case highlights the efficacy of targeted and personalized fetal maintenance strategies tailored to the specific conditions of the pregnant woman and fetus. Furthermore, it demonstrates that intrauterine treatment is not contraindicated in patients with cervical insufficiency and recurrent vaginal bleeding during pregnancy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRFA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRadiofrequency ablation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTTTS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTwin-to-twin transfusion syndrome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMCDA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emonochorionic diamniotic\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNICU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNeonatal Intensive Care Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDVP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edeepest vertical pocket\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCMA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emicroarray analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003esIUGR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eselective intrauterine growth restriction\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePPROM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epreterm premature rupture of membranes (PPROM)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003eThe use of sample from the patients was approved by the Institutional Ethics Committee of Shenshan Medical Center, Memorial Hospital of Sun Yat-sen university and informed consent has been obtained from patients prior to analysis. Approval Number :2025-SSKY-029-01.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eWritten informed consent to publish this information was obtained from study participant.The written consent form for publication has been obtained from the patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe authors have no competing interest to disclose\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eMQC and HX conceived the study and drafted the manuscript. QX and HMY carried out the patient follow up. SF and SNZconceived the study, participated in its design and coordination, and helped draft the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Obstetrics and Gynecology, Sun Yat-sen memorial hospital, Sun Yat-sen university,Guangzhou\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eDepartment of Obstetrics and Gynecology, Shenshan medical center, memorial hospital of Sun Yat-sen university\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eGuangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYin Shaowei, Liu Caixia, Zhang Zhitao, et al. Guidelines for the Diagnosis, Treatment, and Management of Twin-to-Twin Transfusion Syndrome (2020) [J]. Chinese Journal of Practical Gynecology and Obstetrics, 2020, 36(8): 714-721. DOI: 10.19538/j.fk2020080112.\u003c/li\u003e\n\u003cli\u003eBamberg, C, Hecher, K. Update on twin-to-twin transfusion syndrome. BEST PRACT RES CL OB. 2019; 58 BEST PRACT RES CL OB. doi: 10.1016/j.bpobgyn.2018.12.011\u003c/li\u003e\n\u003cli\u003eKhalil, A. Modified diagnostic criteria for twin-to-twin transfusion syndrome prior to 18 weeks\u0026apos; gestation: time to change? ULTRASOUND OBST GYN. 2017; 49 (6): 804-805. doi: 10.1002/uog.17443\u003c/li\u003e\n\u003cli\u003eDekoninck, P, Deprest, J, Lewi, P, et al. Gestational age-specific reference ranges for amniotic fluid assessment in monochorionic diamniotic twin pregnancies. ULTRASOUND OBST GYN. 2013; 41 (6): 649-52. doi: 10.1002/uog.12387\u003c/li\u003e\n\u003cli\u003eDuryea, EL, Happe, SK, McIntire, DD, et al. The natural history of twin-twin transfusion syndrome stratified by Quintero stage. J MATERN-FETAL NEO M. 2016; 29 (21): 3411-5. doi: 10.3109/14767058.2015.1131263\u003c/li\u003e\n\u003cli\u003evan Klink, JM, Koopman, HM, van Zwet, EW, et al. Cerebral injury and neurodevelopmental impairment after amnioreduction versus laser surgery in twin-twin transfusion syndrome: a systematic review and meta-analysis. FETAL DIAGN THER. 2013; 33 (2): 81-9. doi: 10.1159/000341814\u003c/li\u003e\n\u003cli\u003eTwin pregnancy clinical treatment guidelines (update) in 2020 [J]. Chinese journal of prenatal diagnosis (electronic), 2021, 13 (01) : 51-63. DOI:10.13470/j.cnki.cjpd.2021.01.011\u003c/li\u003e\n\u003cli\u003eShi Xiaomei, Rao Tengzi, Liu Qian, et al. Multiple pregnancy line radiofrequency ablation reduction among and influence factors analysis [J]. Chinese journal of obstetrics and gynecology, 2019, (11) : 736-740. The DOI: 10.3760 / cma. J.i SSN. 0529? X. 567 2019.11.004\u003c/li\u003e\n\u003cli\u003eParamasivam, G, Wimalasundera, R, Wiechec, M, et al. OP09.05: Radiofrequency ablation for selective reduction in complex monochorionic pregnancies ULTRASOUND OBST GYN. 2009; 34 (S1): 89-90. doi: 10.1002/uog.6733\u003c/li\u003e\n\u003cli\u003eWang, H, Zhou, Q, Wang, X, et al. Influence of indications on perinatal outcomes after radio frequency ablation in complicated monochorionic pregnancies: a retrospective cohort study. BMC Pregnancy Childbirth. 2021; 21 (1): 41. doi: 10.1186/s12884-020-03530-6\u003c/li\u003e\n\u003cli\u003eRoman, A, Suhag, A, Berghella, V. Cerclage: Indications and Patient Counseling. CLIN OBSTET GYNECOL. 2016; 59 (2): 264-9. doi: 10.1097/GRF.0000000000000185\u003c/li\u003e\n\u003cli\u003eTemming, L, Mikhail, E. Society for Maternal-Fetal Medicine Consult Series #65: Transabdominal cerclage. AM J OBSTET GYNECOL. 2023; 228 (6): B2-B10. doi: 10.1016/j.ajog.2023.02.018\u003c/li\u003e\n\u003cli\u003eBrown, R, Gagnon, R, Delisle, MF. No. 373-Cervical Insufficiency and Cervical Cerclage. J OBSTET GYNAECOL CA. 2019; 41 (2): 233-247. doi: 10.1016/j.jogc.2018.08.009\u003c/li\u003e\n\u003cli\u003eShennan, A.H. and L. Story, Cervical Cerclage. BJOG: An International Journal of Obstetrics \u0026amp; Gynaecology, 2022. 129(7): p. 1178-1210.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Twin-to-twin transfusion syndrome, Emergency Cervical Cerclage, Radiofrequency Ablation","lastPublishedDoi":"10.21203/rs.3.rs-6657212/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6657212/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground：\u003c/strong\u003e Radiofrequency ablation (RFA) represents an effective intrauterine therapeutic option for monochorionic diamniotic（MCDA） twin pregnancies complicated by severe complications.Cervical cerclage represents an effective therapeutic approach for addressing cervical insufficiency.However, to date, there have been no documented cases of successful pregnancy maintenance following emergency cervical cerclage after intrauterine treatment.Therefore, this study presents a case of a patient who underwent laparoscopic preventive cervical cerclage prior to pregnancy, subsequently developed twin-to-twin transfusion syndrome (TTTS) stage II during gestation, successfully underwent radiofrequency ablation for treatment, and concurrently required an emergency vaginal cervical cerclage, ultimately resulting in delivery at 31 weeks and 6 days of gestation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation：\u003c/strong\u003eThis case report presents a patient with cervical insufficiency characterized by repeated painless mid-trimester miscarriages due to cervical dilation. Prior to conception, the patient underwent laparoscopic prophylactic cervical cerclage. This pregnancy was achieved via assisted reproductive technology and was further complicated by gestational diabetes mellitus. During the course of pregnancy, the patient experienced recurrent vaginal bleeding, which was subsequently followed by the onset of twin-to-twin transfusion syndrome (TTTS).A case of successful pregnancy maintenance following sequential interventions of amnioreduction, selective fetal reduction via radiofrequency ablation and emergency transvaginal cervical cerclage. The pregnant woman delivered at 31 weeks and 6 days of gestation, 93 days after undergoing radiofrequency ablation and 63 days following an emergency cervical cerclage. The newborn weighed 1.59 kg at birth and received Apgar scores of 9 and 10 at 1 minute and 5 minutes, respectively. The mother was discharged from the hospital on the fourth day post-delivery, while the newborn remained hospitalized in the Neonatal Intensive Care Unit（NICU） for 35 days.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eThe success of this case is attributable to the close collaboration between fetal medicine and traditional obstetrics.This is currently the first case of successful pregnancy preservation after emergency transvaginal cervical cerclage following intrauterine treatment. It demonstrates that intrauterine treatment is not contraindicated for patients with cervical insufficiency and recurrent vaginal bleeding during pregnancy. Continued emergency cervical cerclage may potentially achieve better outcomes in extending gestational age. Therefore, it is recommended that pregnancy management be tailored and personalized, with careful consideration given to both maternal and fetal conditions.\u003c/p\u003e","manuscriptTitle":"A Case Report of Successful Pregnancy Maintenance Following Emergency Cervical Cerclage after Radiofrequency Ablation for Twin-to-Twin Transfusion Syndrome: A Systematic Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-12 01:13:49","doi":"10.21203/rs.3.rs-6657212/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-08-21T12:23:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263729560194410781376829830703915822856","date":"2025-08-20T03:18:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-06T10:28:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-10T17:37:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-15T09:15:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-15T09:12:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-05-13T15:48:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95e7d77c-e763-4cac-9dbe-8114fb02171a","owner":[],"postedDate":"August 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-12T01:13:49+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-12 01:13:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6657212","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6657212","identity":"rs-6657212","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}