**2.3. Cerclage**

Prophylactic cervical cerclage in multiple pregnancies is controversial, since the systematic review of randomized trials was not convincing in proving its efficacy in reducing perinatal death and neonatal morbidity. Even ultrasound-indicated cerclage (i.e., in short cervix) does not seem to show benefit in twin gestations. However, care must be taken in this analysis, once there are few trials and the number of patients included was not so impressive [27]. On the other hand, one author suggested improvement in perinatal outcome when cervical cerclage is indicated in asymptomatic twin pregnant women that present cervical dilatation (physical examination-indicated cerclage) at 16–24 weeks [28].

ACOG does not recommend cerclage in the incidental short cervix [7], but there is some evidence of benefit of this procedure when short cervix occurs in suspicious but not typical history of cervical insufficiency. The diagnosis can be performed by weekly transvaginal ultrasound since the 16th week. So, cerclage could be performed after shortening of the cervix in these cases, except in exposed membranes, chorioamnionitis, sepsis, and when there is no cervical length measurable [16].
