Emergency cervical cerclage after miscarriage of the first fetus in dichorionic twin pregnancies: obstetric and neonatal outcomes of delayed delivery interval

Delayed interval delivery and survivability of the second twin with and without emergency cerclage in dichorionic diamniotic pregnancy. A systematic review

BACKGROUND

There are no systematic reviews analyzing cervical cerclage's role in improving the perinatal outcome of the second twin in dichorionic diamniotic (DCDA) pregnancies following a second trimester or very early preterm birth of the first twin.

OBJECTIVE

The primary objective of this systematic review was to evaluate the effect of rescue cervical cerclage on delaying the delivery of the second twin after the delivery of the first twin in DCDA twin pregnancies. The secondary objective was to analyze the effect of rescue cervical cerclage on the perinatal outcome of the second twin in DCDA pregnancies compared to the non-cerclage group.

METHODS

A literature search was performed using PubMed, Medline databases, and the Cochrane Library. The studies selected were limited to human subjects and published online by December 2023. Two sets of results in this systematic review are described; the first set includes the outcomes of pregnancies with a DCDA twin pregnancy from the cohort of case series. The meta-analysis was performed for the cohort, and a combined narrative report was provided for the second set of results for the case reports.

RESULTS

A literature search resulted in 27 case series and 36 case reports. The case series analysis demonstrated that the mean gestation age of twin 2 at delivery with cervical cerclage (27.5 weeks) compared to those without cervical cerclage (24.4 weeks) was statistically significant (p < 0.001). Furthermore, analysis of the case series showed that twin 2 with cerclage had a statistically significant increase in latency period (days 44.7 vs 23.67) and birth weight (grams 3320 vs 2460) compared to the group without cerclage (p = -value was 0.001 and 0.01, respectively). It is difficult to draw any significant conclusion with complications of cervical cerclage; however, there were slightly more chorioamnionitis and respiratory distress syndrome in the cerclage group. The case report analysis showed no significant difference with or without cervical cerclage.

CONCLUSIONS

From this review, it can be concluded that in DCDA twin pregnancies, cervical cerclage insertion after the extremely premature delivery or miscarriage of twin 1 may increase the gestational age at delivery, prolong the delivery interval, and increase the birth weight of twin 2. However, a large prospective multicenter randomized control trial should be performed to assess the benefit of cervical cerclage in DCDA twins to improve the delivery interval latency period and perinatal outcome of twin 2 after the delivery of twin 1.

Emergency cervical cerclage in delayed-interval delivery of twin pregnancies: a scoping review

BACKGROUND

The protocol for delayed-interval delivery of the second twin in twin pregnancies has not been standardized. Cervical cerclage is often performed, but its use is debated. To conduct a scoping review on cervical cerclage for prolonging the intertwin delivery interval and improving second twin survival and maternal outcomes after preterm delivery or spontaneous abortion of the first twin in twin pregnancies.

METHODS

Seven Chinese and English language databases were searched from inception to March 1, 2023, including PubMed, The Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP Chinese Science Journal Database, and Sinomed. Relevant observational studies that assessed the effectiveness of the use of cervical cerclage in delayed-interval delivery of twins were screened and selected, and raw data were extracted, and descriptive statistics and chi-square analysis were performed.

RESULTS

A total of 102 articles were retrieved. After screening and exclusion of duplicate and irrelevant articles, 22 articles meeting the inclusion criteria were obtained. Studies in which cerclage was performed reported longer intertwin delivery intervals than those that did not perform cerclage, and the difference was statistically significant. The cerclage group also tended to have lower rates of chorioamnionitis and maternal complications, but the difference between the two groups was not statistically significant.

CONCLUSION

After excluding patients with contraindications, emergency cervical cerclage can be considered in cases of spontaneous abortion of the first twin in twin pregnancies to prolong the gestation and improve the prognosis of the remaining fetus until it becomes viable and increases its birth weight.

[Delayed-Interval Delivery of an Extremely Preterm Twin after Abort of the First Twin and Emergency Total Cervical Occlusion at 19+1 Weeks of Gestation - a Case Report]

We report on the obstetric and neonatal course of a 34-year-old woman pregnant with twins, who presented at our clinic at 16+1 weeks of gestation with preterm premature rupture of membranes. We started intravenous antibiotic therapy with inpatient monitoring owing to the vitality and regular development of both twins, with anhydramnios in the leading twin. After a missed abortion of the leading twin at 19+1 weeks of gestation we decided on surgical intervention with assisted delivery of the aborted twin, leaving the placenta in situ with subsequent emergency total cervical occlusion. Afterwards, the single pregnancy could be continued until the 24th week of gestation. An urgent Caesarean section for early labor, premature rupture of membranes, and increasing signs of maternal infection was later performed. Overall, the postnatal course of the extremely preterm neonate was a success considering the gestational age. We conclude that the option of surgical interventions should be taken into account in similar cases in the future.

Risk of preterm birth and neonatal outcomes after cerclage placement in triplet pregnancies

BACKGROUND

The number of triplet pregnancies in the United States has increased significantly. Perinatal morbidity and mortality are higher in these pregnancies mainly due to higher preterm birth rates. Interventions to decrease the risk of preterm delivery in this population are needed. Evidence regarding cerclage placement in triplets is limited. We performed a population-based, retrospective cohort study to study the risk of preterm birth and neonatal outcomes after cerclage placement in triplet pregnancies.

METHODS

All U.S. triplet deliveries from 2006 to 2013 with risk factors for cervical insufficiency were selected, excluding cases with indicated preterm delivery. Cases were categorized according to cerclage placement status. The risk of preterm birth and adverse neonatal outcomes were calculated using propensity score analysis, generalized linear, and logistic regression models.

RESULTS

From ∼33 million deliveries, 43,000 were triplets, and 7308 fulfilled eligibility criteria. There was no difference in the gestational age at delivery between the cerclage and noncerclage groups, aOR (95% CI) = 1.0(0.9-1.0). The difference between the risk of preterm delivery at <34 weeks and <32 weeks was not statistically significant. The risk of the composite outcome of neonatal complications was higher in the cerclage compared to the noncerclage group, aOR (95% CI) = 1.5 (1.1-2.2).

CONCLUSIONS

Cerclage placement in triplet pregnancies does not appear to decrease preterm birth rates and seems to increase the risk of neonatal complications.

Effect of delayed interval delivery of remaining fetus(es) in multiple pregnancies on survival: a systematic review and meta-analysis

BACKGROUND

The management of the pregnancy after delivery of the first fetus during a second-trimester miscarriage or very early preterm birth has not been well defined.

OBJECTIVE

The objective of the study was to evaluate whether delayed interval delivery of the remaining fetus(es) in twins/triplets is associated with improved survival, when compared with immediate delivery, after miscarriage or very preterm birth of the first fetus in multiple pregnancy.

DATA SOURCES

PubMed, MEDLINE, and Cochrane Library were systematically searched through January 2019. STUDY ELIGIBILITY CRITERIA (STUDY DESIGN, POPULATIONS, AND INTERVENTIONS): The following eligibility criteria applied: full-text original article; included at least 5 cases of delayed interval delivery for remaining fetus(es); and reported the survival rate of the first-born and the remaining fetus(es).

STUDY APPRAISAL AND SYNTHESIS METHODS

K.W.C. and W.W. searched, screened, and reviewed the articles. The quality of the studies was assessed according to the Strengthening the Reporting of Observational studies in Epidemiology checklist. If possible, data were stratified for assigned chorionicity. Effect sizes were pooled through a meta-analysis.

RESULTS

A total of 2295 published article and abstracts were identified. Only 16 studies met inclusion criteria. Meta-analysis of 492 pregnancies (432 twins [88%], 56 triplets [11%], 3 quadruplets and 1 quintuplets) showed that delayed interval delivery significantly improved the perinatal survival of remaining fetus(es) compared with the first born (odds ratio, 5.22, 95% confidence interval, 2.95-9.25, I² = 53%), before 20+0 weeks (odds ratio, 6.32, 95% confidence interval, 1.99-20.13, I² = 0%), between 20+0 and 23+6 weeks (odds ratio, 3.31, 95% confidence interval, 1.95-5.63, I² = 0%), and after 24+0 weeks (odds ratio, 1.92, 95% confidence interval, 1.21-3.05, I² = 0%), in dichorionic twin pregnancy (odds ratio, 14.89, 95% confidence interval, 6.19-35.84, I² = 0%), and unselected triplet pregnancy (odds ratio, 2.33, 95% confidence interval, 1.02-5.32, I² = 0%. ). Among the survivors, there were no significant differences in the short-term and long-term neonatal morbidities between the first-born and the remaining fetus(es). Serious maternal morbidity was reported in 39% of pregnancy after delayed interval delivery (71 of 183). In addition, 2 cases were managed by postpartum hysterectomy and 1 reported postoperative uterovaginal fistula. There were no recorded cases of maternal mortality.

CONCLUSION

Delayed interval delivery when a fetus has delivered in a multiple pregnancy is an effective management option to increase the survival rate of the remaining fetus(es). About 39% of women may experience morbidity following this management option.

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.

Prolongation of Second Twin's Delivery Until Term: A Rare Case of Delayed-Interval Delivery

Although some cases describing delayed birth of the second twin have been published recently, delay of delivery beyond 36 weeks seems scarce. We report a case of delayed-interval delivery wherein prolongation of the second twin's delivery until term with a subsequent favorable infantile outcome. In this case, the stillbirth of the first twin occurred at 25 weeks' gestation. Prophylactic tocolysis was performed with ritodrine and magnesium sulfate, and a McDonald cerclage was performed 2 days after delivery of the first twin. Ampicillin and gentamicin were also administered for the purpose of prevention of intrauterine infection. No clinical sign of chorioamnionitis was found thereafter, and full term uneventful delivery was achieved. With this experience, we believe that delayed-interval delivery can be effective in prolonging gestation and should be an option if the first twin developed an extreme preterm 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.

A Case of Delayed Interval Delivery with a Successful Hospital Move

This report is the first case of delayed interval twin delivery in which the first infant and mother survived without major morbidity following transport to another facility. In addition, this case is only the second report of asynchronous delivery in which both twins survived and neither suffered any major morbidity. A 30-year-old G5P1031 African American female with a diamniotic/dichorionic twin pregnancy presented to U.S. Naval Hospital Okinawa, Japan, at 22 + 5 weeks due to vaginal bleeding. At 23 + 2 weeks, Twin A was born secondary to advanced cervical dilation. Twin A's birth weight was 650 g with APGAR scores of 6 (1 min) and 7 (5 min). Following delivery of Twin A, Placenta A was left in utero with high ligation of the umbilical cord. Due to a scheduled hospital move, the mother and Twin A were transported to the new facility at Camp Foster. Three weeks later, Twin B was delivered at 26 + 4 weeks. Twin B's birth weight was 930 g with APGAR scores of 3 (1 min) and 7 (5 min). Both twins were discharged without IVH, PVL, ROP, or CLD. This case demonstrates the possibility of transporting both the mother and surviving infant A to a higher level of care prior to delivery of subsequent fetuses.

A Triplet Pregnancy With Spontaneous Delivery of a Fetus at Gestational Age of 20 Weeks and Pregnancy Continuation of Two Other Fetuses Until Week 33

INTRODUCTION

The prevalence of pregnancies with triplet or more has been increased due to using assisted reproductive treatments. Meanwhile, multiple pregnancies have higher risks and long-term maternal-fetal complications compared to twin and singleton pregnancies. Delayed interval delivery (DID) is a new approach in the management of multiple pregnancies following delivery or abortion. The purpose of this paper is to evaluate the benefits of DID and present a case that used this method.

METHODS

This paper covers a report on a case of triplet pregnancy resulting from assisted reproductive techniques with spontaneous delivery of a fetus at gestational age of 20 weeks and the use of conservative DID for two other fetuses until the 33rd week.

RESULTS

In our case, the delivery of two other fetuses occurred spontaneously at gestational age of 33 weeks after the delivery of the first fetus at week 20.

CONCLUSIONS

Using DID is a useful and reliable method, but requires careful monitoring, especially in patients with a history of infertility.

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.