A Case of Delayed Interval Delivery with a Successful Hospital Move

Delayed-Interval Delivery in Multifetal In Vitro Fertilization (IVF) Pregnancies: Two Case Reports

Delayed-interval delivery in twin pregnancies is a rare but increasingly recognized obstetric intervention aimed at improving neonatal outcomes, particularly in cases of preterm labor. The rise in multiple gestations associated with in-vitro fertilization (IVF) has contributed to the need for optimized management strategies in such cases. However, there remains no consensus on standardized protocols for delayed twin delivery. We present two cases of dichorionic-diamniotic twin pregnancies obtained via IVF, where the birth of the second twin was delayed by 5 and 30 days. In the first case, a 31-year-old nulliparous woman presented at 24 weeks of gestation with preterm labor. Despite initial tocolysis and antibiotic prophylaxis, the first twin was delivered at 24 weeks, while the second twin was successfully retained until 28 weeks. The first neonate developed severe retinopathy of prematurity, while the second twin exhibited normal neurodevelopmental outcomes. In the second case, a 52-year-old multiparous woman with an IVF pregnancy and donor oocytes experienced premature rupture of membranes at 25 weeks, leading to immediate vaginal delivery of the first twin. Conservative management, including tocolysis and antibiotics, enabled the extension of the pregnancy for five additional days. The first neonate had a favorable postnatal course, while the second twin developed posthemorrhagic hydrocephalus requiring ventriculoperitoneal shunting. The decision to delay twin delivery is contingent upon multiple factors, including maternal stability, absence of chorioamnionitis, and the viability of the remaining fetus. Current literature suggests that prolonged latency between twin deliveries is associated with reduced neonatal morbidity when managed with strict maternal monitoring, tocolysis, and infection control. However, the benefits must be weighed against maternal and fetal risks, particularly the potential for intrauterine infection and placental dysfunction.  Asynchronous twin delivery remains a complex but potentially beneficial intervention for improving neonatal outcomes in cases of preterm labor, especially in IVF pregnancies. These cases highlight the importance of individualized management, vigilant maternal-fetal surveillance, and further research to establish standardized protocols for optimizing perinatal outcomes.

Optimal management strategies for promoting gestational extension in dichorionic diamniotic twin pregnancies

Background

Preterm birth is a significant concern in multiple pregnancies, warranting effective strategies to improve outcomes. Delaying delivery of the second fetus is crucial for reducing perinatal mortality rates.

Case Presentation

In a dichorionic diamniotic twin pregnancy, one fetus experienced premature rupture of membranes (PROM) at 16+6 weeks gestation. Proactive fetal reduction through potassium chloride injection and emergency cervical cerclage at 19+1 week successfully extended the pregnancy to 39+5 weeks, resulting in a notable 160-day prolongation. Postoperative management encompassed comprehensive tocolytic therapy.

Conclusion

The combined approach of proactive fetal reduction and emergency cervical cerclage proved successful in managing PROM in dichorionic diamniotic twin pregnancies. This innovative strategy offers a promising clinical solution for optimizing outcomes and prolonging gestation in high-risk multiple pregnancies, underscoring the importance of tailored interventions in complex obstetric scenarios.

Delayed-Interval Delivery of Twin Gestation via Cesarean Section: A Case Report

BACKGROUND Multifetal pregnancies are at high risk for preterm delivery. Under certain circumstances, delayed vaginal delivery of the second twin is performed to improve morbidity and mortality. Most of the information on optimal management of delayed-interval delivery comes from published case reports in which the first twin was delivered vaginally. This case report is unique in that twin A was delivered via cesarean section. CASE REPORT Our patient was a 21-year-old G2P1, with dichorionic diamniotic twins of unknown gestational age, with prenatal care at a different facility, who presented with preterm prelabor rupture of membranes and cord prolapse. Twin A, with an estimated weight by ultrasound of 528 g, was delivered via cesarean section and twin B was left in utero until the patient went into preterm labor 10 days later. Obstetrical management included tocolytic protocol from the Management of Myelomeningocele Study trial, preterm prelabor rupture of membrane antibiotics with broad-spectrum coverage, and judicious use of fetal lung maturity steroids and magnesium sulfate. CONCLUSIONS This case is important as we have demonstrated that cesarean section in the setting of delayed-interval delivery may be an option to improve survival at the limits of viability. We also discussed our treatment approach and how we delayed delivery of the second twin by 10 days. Unexpectedly, the surviving twin was the one born first, at 22 4/7 weeks determined 2 days after birth by prenatal records.

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.