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

Delayed-Interval Delivery in Multiple Pregnancy: A Single-Center Experience of Five Cases

Objectives  To describe the obstetric management and perinatal outcomes in multiple pregnancies with delayed-interval delivery (DID) of the cotwin in a tertiary hospital. Methods  This is a retrospective chart review of all cases of DID between December 2021 and 2022 at The Ottawa Hospital. Five cases of DID were identified and reviewed to obtain information on obstetric management and maternal-neonatal outcomes. We included eligible twins and triplets. No multiples were excluded. We obtained ethics approval for this case series. Results  Four sets of dichorionic diamniotic twins and one trichorionic triamniotic triplet were included. Our patients were admitted between 17 3/7 and 21 5/7 weeks of gestation. We achieved an interval delivery range between 1 and 36 days. Four out of six multiples did not survive in DID. The two surviving newborns were born at 23 0/7 and 23 2/7 , stayed in the neonatal intensive care unit (NICU) for 111 and 131 days, discharged with a weight of 3,594 and 2,743 g, respectively. All DID cases were delivered spontaneously except for two patients that required augmentation due to maternal sepsis. Conclusion  Despite the high risk of maternal, fetal, and neonatal morbidity and mortality, if delivery of the first twin occurs before 20 gestational weeks, DID could be considered in selected cases to improve outcomes for the cotwin.

Delayed interval delivery in a quadruplet pregnancy: a case report and literature review

BACKGROUND

As the rate of multiple pregnancies increases, delayed interval delivery (DID) is increasingly being implemented to improve perinatal outcomes. But there are no international guidelines for DID in multiple pregnancies. We report a case of DID in a quadruplet pregnancy and review the relevant literature to summarize the management of DID in multiple pregnancies.

CASE PRESENTATION

A 22-year-old woman, 22 2/7 weeks' gestation, with quadruplets, was admitted to the hospital for a first cervical cerclage due to cervical dilation. Twenty-five days later, it was found that the cervix was dilated again, so after removing the cervical cerclage, the first quadruplet was delivered vaginally (25 6/7 weeks), and a second cervical cerclage was performed. Four days later, due to re-dilation of the cervix, after removal of the cervical cerclage, the second quadruplet was delivered vaginally (26 3/7 weeks), followed by a third cervical cerclage. Six days later, the pregnancy was terminated by cesarean section due to fetal distress, and the third and fourth quadruplets were delivered (27 2/7 weeks). The patient had no postoperative complications, and all four infants were treated in the neonatal intensive care unit and discharged successfully.

CONCLUSION

This case emphasizes that comprehensive management of delayed interval delivery can improve perinatal outcomes in multiple pregnancies, including anti-infection, tocolytic therapy, practice to promote fetal lung, and cervical cerclage.

Delayed-interval delivery in multiple gestation pregnancies: neonatal mortality, morbidity, and development

OBJECTIVE

Delayed-interval delivery (DID) is the delivery of the first fetus in a multiple gestation pregnancy without prompt delivery of the remaining fetus(es). We aimed to assess infant outcomes of DID.

STUDY DESIGN

We performed a retrospective cohort study of infants born 22-28 weeks' gestation or weighing 401-1500 g. DID was defined as a passage of >24 h between the birth of firstborn and retained infants. Rates of mortality, morbidity, and developmental outcomes were compared within DID multiples, to other multiples not born by DID, and all infants in the Generic Database and follow-up datasets (excluding DID-born).

RESULTS

DID-born multiples were younger and smaller than other multiples. Retained infants had no significantly different rates of mortality and morbidities compared to their firstborn counterparts, apart from less bronchopulmonary dysplasia.

CONCLUSIONS

DID showed no evidence of harm and a potential benefit of decreased bronchopulmonary dysplasia mediated by increased gestational age and birthweight.

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.

Controversies in treatment practices of the mother-infant dyad at the limit of viability

In the setting of threatened extreme preterm birth, balancing maternal and fetal risks and benefits in order to choose the best available treatment options is of utmost importance. Inconsistency in treatment practices for infants born between 22 and 24 weeks of gestatotional age may account for inter-hospital variation in survival rates with and without impairment. Most importantly, non-biased and accurate information must be presented to the family as soon as extremely preterm birth is suspected, including counseling on morbidities and mortality associated with delivery at the limits of viability. This review will focus on different therapeutic medical and surgical practices available for threatened extremely preterm birth to improve fetal and maternal outcomes while highlighting the importance of patient-centered approaches.

Delayed-interval-delivery of twins in didelphys uterus complicated with chorioamnionitis: a case report and a brief review of literature

Delayed-Interval-Delivery (DID) of multiple gestations has been attempted with variable degrees of success in normal, as well as, in anomalous uteri. We describe a delayed interval delivery procedure in a dichorionic diamniotic twin pregnancy after removal of both, placenta and fetus from one horn by cesarean delivery at 25 weeks followed by spontaneous delivery of the remaining twin at 35 weeks. This was followed by a review of similar cases reported to the literature. The importance of this case resides in the success of DID in spite of chorioamnionitis. Furthermore, this was the second DID attempt where delivery of the first twin was accomplished by cesarean while that of the second one was done by vaginal route.

Current Resources for Evidence-Based Practice, September 2020

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of “spin” in scientific reporting and its effect on summaries and syntheses of the literature and commentaries on reviews about early versus late amniotomy as part of labor induction protocols and the economic burden associated with maternal morbidity.

Delayed interval delivery of preterm multiples: experience from a large specialized twin center

Objective: Preterm delivery is a recognized complication of twins and higher order multiple pregnancies. Delayed interval delivery is a rarely used management option for pre- or peri-viable preterm labor in these pregnancies. We describe the management and outcomes of 7 delayed interval deliveries over an 8-year period in a large specialized twin center.Study design: A retrospective cohort study of all delayed interval deliveries of preterm multiples from 2009 to 2016, defined as >24 h between deliveries of twins 1 and 2.Results: During the study period there were 68,845 deliveries with 1377 multiple pregnancies comprising 1331 sets of twins and 46 sets of higher-order multiples. 7 of these were identified as being delayed interval deliveries - 6 twin pregnancies and 1 triplet pregnancy. The mean gestation of delivery of the first infant was 23 + 4 weeks (range 22 + 3 to 30 + 0 weeks) with a mean interval of 10 days (range 1.5-39 days). Outcomes for the first infant delivered were poor, with 5 out of 7 (71%) dying from extreme prematurity. However, out of the remaining twins or triplets, 5/8 (62%) survived. The mean gestation of delivery of the remaining infant (or infants in the triplets) was 25 + 0 weeks (range 23 + 0 to 30 + 2 weeks). Only one mother (16%) developed clinical chorioamnionitis requiring iatrogenic delivery of the remaining infant with subsequent neonatal death due to extreme prematurity. There were no cases of severe maternal morbidity - however, there was one maternal death in the cohort due to an amniotic fluid embolism. The neonatal follow up of the surviving infants to date is mostly normal.Conclusion: Delayed interval deliveries can offer hope for survival for the remaining infant(s) with an acceptable risk profile to the mother. Close clinical and laboratory monitoring is essential to reduce the risk of severe maternal morbidity.