Obstetric Management of Delayed-Interval Delivery

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 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 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.

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.