Case report and review of delayed-interval delivery for dichorionic, diamniotic twins with normal development

Delayed Interval Delivery in Preterm Premature Rupture of Membranes in Dichorionic Triamniotic Triplets: Ethical Considerations for Maternal Health Case Report

Background

Although there are numerous studies on delayed interval delivery in twins, this study is one of few reporting on preterm premature rupture of membranes in triplets and even fewer on dichorionic triamniotic triplet twins. The case presented here highlights the important interplay between informed consent and patient autonomy. Case Presentation. A 37-year-old woman gravida 1, para 0 with a dichorionic triamniotic triplet pregnancy experienced preterm premature rupture of membranes of the singleton triplet at 15 weeks and six days of gestation. Delayed interval delivery was offered to the parents, who chose to continue the pregnancy while acknowledging the risks for maternal and foetal health. The patient was treated with prophylactic intravenous antibiotics and discharged on oral antibiotics after an eight-day admission. Two days after being discharged, she was readmitted with clinical signs of chorioamnionitis. Within six hours, the preterm premature rupture of membranes singleton was delivered. Three days later, she again presented to the hospital with preterm premature rupture of membranes of one of the dichorionic twins. After discussion with the maternal foetal medicine team, the parents chose to terminate the pregnancy. Delayed interval delivery was not successful in this patient, and it is unclear at which gestational age it is too early to offer expectant management.

Conclusions

The case affirmed the very poor foetal survival rate when the first delivery occurs at under 20 weeks' gestation. A standardised management of delayed interval delivery should be established to assist with consistent parental counselling.

Obstetric and neonatal outcomes of delayed interval delivery in cerclage: A retrospective study

OBJECTIVE

Delayed delivery is sometimes selectively performed in twin pregnancy when the first birth occurs inevitably in order to improve the prognosis and decrease the morbidity and mortality of the second twin. The aim of this study is to explore the maternal and fetal outcomes of pregnancies in which cerclage is carried out following the loss of first fetus in twin gestation for delayed interval delivery.

METHODS

Three cases of delayed-interval delivery of dichorionic-diamniotic twin pregnancies were reported in our center between 2017 and 2018 and were retrospectively analyzed. Once the first twin was delivered, the second twin was left in utero and the patient underwent in utero percutaneous umbilical cord ligation, antibiotics, tocolytic therapy and cervical cerclage.

RESULTS

Mean gestational age at delivery of the first fetuses was 21.6 ± 2.9 weeks and 24.8 ± 4.0 weeks for the remaining fetuses, respectively. The mean interval of the delay was 22 days (4-50 days). Mortality of the first fetus was 66.7%, and the retained one was 33.3%. In general, maternal outcome was good, one patient experienced postpartum hemorrhage and placenta accreta. However neonatal aftermath was generally not favorable, probably due to extreme prematurity.

CONCLUSIONS

Cervical cerclage after the first delivery could prolong the pregnancy until an adequate gestational age at which an enhanced prognosis and better perinatal outcome for the second twin can be achieved.

Delayed delivery of the second twin: Case report and literature review of diamniotic dichorionic twin pregnancy with very early preterm premature rupture of membranes

In multiple pregnancies with threatened premature delivery or preterm premature rupture of membranes (pPROM) of a single sac, prolonging pregnancy after the delivery of the first baby may improve the chances of survival of the second baby. We report the delayed delivery of a second baby in a twin pregnancy with pPROM and very premature delivery of the first baby. This condition is exceptional and there are no validated medical protocols for its management; the scientific evidence is still controversial. In our case, after the birth of the first baby, pregnancy was continued for 29 days, with monitoring of maternal and fetal parameters, which enabled the delivery of the second baby with improved neonatal outcomes. This case supports the prolongation of the pregnancy of the second twin.

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Delayed delivery of the second twin could be an option in very early preterm twin pregnancies.

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Delayed delivery could improve the chances of survival of the second twin.

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Delayed delivery could improve the well-being of the second twin.

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It is very important to perform strict monitoring in these pregnancies.

Successful delayed-interval delivery in monochorionic diamniotic twin pregnancy: A case report

Delayed-interval delivery in twin pregnancy is a rare occurrence. It is sometimes performed in twin pregnancies when the first twin is born at the limit of viabililty, to improve outcome for the second twin. It has been suggested that monochorionicity is a contraindication to delayed-interval delivery in multifetal pregnancy. The literature describes only a dozen cases over the last 20 years and only a handful of these reports specify success. We describe a case of a successful delayed-interval delivery of monochorionic diamniotic twins following prelabour rupture of membranes at 20 weeks of gestation. The first twin was previable, delivered at 23 weeks and 2 days of gestation, but the second twin was delivered at 24 weeks and 1 day of gestation and survived. Practitioners could consider delayed-interval delivery in monochorionic diamniotic twin pregnancy in a closely monitored environment if the first twin is born peri-viable, to obtain an improved outcome for the remaining fetus.

Delayed second twin delivery: benefits and risks

BACKGROUND

An increasing number of reports describe the delayed second twin delivery for days, or weeks with good results in the majority of the cases, and different survival rate between centers, without reported randomized controlled trials (RCTs).

OBJECTIVES

This study was designed to evaluate the suggested management of the delayed second twin delivery in the Sabah Maternity Hospital regarding its outcome, possible risks, and benefits.

PATIENTS AND METHODS

Forty-seven twin pregnancies with preterm labor (PTL) of the first fetus between 20-30 weeks, and delayed delivery of the second twin were included in this study. Studied women signed informed consent about the possible risks of keeping the live fetus in the hostile intrauterine environment, and benefits of the prolonged gestation for the second twin. Throughout the conservative treatment of the second twin, the studied women were hospitalized with regular follow up for infections, consumptive coagulopathy parameters, and wellbeing of the second twin.

RESULTS

There was significant difference in the gestational age at delivery between the first and second twin (22.6 ± 3.4 versus 34.3 ± 2.5 weeks; respectively, p = .01). There was significant difference in the birth weight between the first and second twin (435 ± 91.2 versus 1472 ± 61.5 g; respectively, p = .004). The rate of the cesarean delivery was significantly high during delivery of the second twin compared with the first twin (23.4% (11/47) versus 0% (0/47); respectively, p = .0001) with high survival rate for the second twin (85.1% (40/47)) after the delayed second twin delivery.

CONCLUSIONS

The birth weight, the gestational age, and the survival rate of the studied second twin significantly increased after the suggested management of the delayed second twin delivery.

Obstetric Management of Delayed-Interval Delivery

The delayed-interval delivery is a rare, flexible and complex procedure. In light of these facts, there is no consensus on the best approach to achieve it successfully. This case report is of an asynchronous delivery, in a twin pregnancy, with a 32-day interval between births of siblings. Our obstetric management at a critical gestational age improved the outcome of the second newborn. The probability of success of delayed-interval delivery depends on the proper selection of the candidates, the appropriate active management and the continuous monitoring for early detection of complications.

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Asynchronous delivery may be lifesaving for the second twin.

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The proper selection of candidates for delayed-interval delivery is crucial.

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The success depends on the individualized management.

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Continuous monitoring is essential for early detection of complications.

[Deferred twin birth: report of two cases observed at the maternity of Creil Hospital Centre]

L'accouchement gémellaire différé définit un accouchement en deux ou plusieurs temps, avec l'expulsion spontanée d'un premier fœtus au deuxième ou au troisième trimestre, et un prolongement de la grossesse pour obtenir un accouchement du ou des fœtus restants en gestation le plus proche possible du terme. Cette technique est mise en œuvre, en cas de grossesse gémellaire pour prévenir la prématurité du fœtus restant après l'expulsion très prématurée d'un premier fœtus. Nous rapportons deux cas observés à la maternité du Centre Hospitalier de Creil avec des latences respectives de 3 et 52 jours pour lesquels nous discutons la prise en charge.

Delayed interval delivery of the second twin: obstetric management, neonatal outcomes, and 2-year follow-up

OBJECTIVES

To evaluate the obstetric management and neonatal outcomes in twin pregnancies with delayed delivery of the second twin, including follow-up.

METHODS

This study is a review of four cases of delayed delivery of the second twin in our hospital from 2009 to 2012. The obstetric management of the cases from the expulsion of the first twin to the delivery of the second twin is analyzed. The neonatal outcomes including follow-up for 2 years were reviewed.

RESULTS

The first twins were delivered between 15 and 25 weeks (average 21 weeks) and the second twins were delivered between 25 and 31 weeks (average 27 weeks). One first twin (25 %) survived, while three (75 %) second twins survived. Two out of the three second twins delivered after 28 weeks were in satisfactory condition.

CONCLUSIONS

The delayed delivery of the second twins which occurred in the third trimester is associated with favorable outcome, however, the risks should not be ignored.

Neonatal outcome from triplet interval delayed delivery: a case report

In the past decades, we have observed a large increase in the number of multifetal pregnancies, which is mainly associated with the introduction of assisted reproductive techniques. Even though neonatal intensive care of very premature infants has improved significantly, the risk of mortality and long-term morbidity is still much higher among these newborns. A longer interdelivery period may reduce perinatal mortality and morbidity. The authors report the case of a delayed interval delivery in trichorionic, triamniotic triplet pregnancy. After the labor of the first fetus in the 22nd week of gestation, a 75-day interval was achieved before the delayed delivery. To save the surviving fetuses, the umbilical cord was ligated at the cervical level immediately after the first delivery. The patient received antibiotics, tocolytics, and corticosteroids. A baby boy who weighed 1750 g and a girl who weighed 1700 g were successfully delivered by cesarean section in the 33rd week of pregnancy. The babies were discharged home at the age of 28 days. A follow-up examination 20 weeks later showed that their neurological development was normal and without any major problems. The maternal postpartum course was uneventful; the patient stayed in hospital taking care of the babies.