Emergency cervical cerclage after the first delivery in a twin pregnancy with dichorionic placenta

[Delayed delivery in twin pregnancy]

We report the observation of a primigravid patient, presenting a spontaneous twin pregnancy bichorionic and biamniotic. After expulsion of the first twin at 20 weeks and two days, expectancy is adopted and the second twin is born at 31 weeks and three days. In front of this not so frequent obstetrical situation and the absence of consensus, we discuss three points: cerclage, tocolysis and the prophylactic antibiotherapy. We specify that the attempt at differed childbirth is aimed at improving the foetal prognosis of the second twin by bringing it into the viable term, as well as obtaining a survival with the least possible number of sequels.

Delayed-interval delivery: extended series from a single maternal-fetal medicine practice

OBJECTIVE

Our purpose was to review the extended experience of a single maternal-fetal medicine practice with delayed-interval delivery.

STUDY DESIGN

We completed a retrospective review of our maternal-fetal medicine practice database from January 1991 through March 1999. Patients were derived from both primary and consultative practices. All patients were managed with tocolysis, antibiotics, and cerclage after delivery of the first fetus(es). Retained siblings were investigated by amniocentesis to exclude intra-amniotic infection.

RESULTS

Twenty-four consecutive patients had attempted delayed-interval delivery. Exclusion criteria for delayed-interval delivery included monochorionicity, abruptio placentae, severe preeclampsia, and the need for hysterotomy. The mean latency interval was 36 days, with a range of 3 to 123 days. Additionally, patients with previous cerclage(s) had significantly shorter mean latency intervals than patients without previous cerclage(s). Patients with long latency intervals (> or =49 days) had earlier births of the first fetus.

CONCLUSION

Selected multichorionic pregnancies may benefit from delayed-interval delivery. Patients with previous cervical cerclage(s) during the index pregnancy are less likely to achieve significant latency intervals. Even modest intervals between births of siblings at critical gestational ages can improve neonatal survival and decrease neonatal morbidity.

Delayed interval delivery in multiple gestations

The incidence of higher-order gestations is increasing primarily as a result of menstrual cycle manipulation, with concomitant increased risk in maternal and fetal complications. Perinatal mortality rates range between 47 and 120 per 1000 births for twins and 93 to 203 per 1000 births for triplets. The critical period of perinatal mortality and morbidity is between weeks 23 and 28 of gestation. Attention has recently turned to methods of delaying the birth of second and higher order fetuses to improve newborn survival and decrease neonatal morbidity in these high-risk pregnancies. We report two cases of delayed interval delivery. Neither pregnancy involved a monochorionic/monoamniotic gestation. The first case was a twin gestation delivered at 21 weeks with an interval of 5 days and extreme prematurity of both twins. The second case was a triplet gestation delivered at 21 weeks with an interval of 5 days. Triplet A was stillborn; triplets B and C succumbed in extreme prematurity. Preterm labor in multiple gestations usually results in delivery of all fetuses. On occasion, the uterus will spontaneously cease to contract after the birth of one or more premature infants. Review of the literature now reports 48 twin pregnancies exposed to delayed interval delivery with 40 surviving infants of 96 fetuses. Whereas delaying the delivery of remaining fetuses improves their prognosis, there is currently no consensus regarding technique nor is there statistical significance in techniques currently used. Furthermore, study is indicated to reduce preterm birth and associated costs.

Delayed-interval delivery in multifetal pregnancy

OBJECTIVE

Our goal was to review a single subspecialty practice experience with a uniform approach to delayed-interval delivery.

STUDY DESIGN

A 66-month retrospective review of our maternal-fetal medicine practice database was completed. Fifty-nine sets of twins or triplets delivered at < 30 weeks' gestation were identified. No cases of twins or triplets who came to our care, either in consultation or as primary providers, were excluded.

RESULTS

Forty-three patients were excluded as candidates for delayed-interval delivery because of monochorionicity, abruptio placentae, severe preeclampsia, and the need for hysterotomy. Sixteen pregnancies were identified as candidates for delayed-interval delivery, and we actually attempted to delay delivery in 9 of them. The details of the interval deliveries are summarized; there was a mean latency interval of 34 days with a range of 3 to 76 days. Pregnancies in which delayed-interval deliveries wer attempted were significantly less mature at the time of presentation than those managed by delivery of all infants initially. Perinatal mortality was significantly lower in the retained fetuses.

CONCLUSIONS

This retrospective consecutive case review from a single maternal-fetal practice documents that selected multichorionic pregnancies may benefit from delayed-interval delivery. Modest intervals between siblings during critical gestational ages can improve newborn survival and decrease neonatal morbidity.