Delayed delivery of multifetal pregnancies with premature rupture of membranes in the second trimester

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.

Successful delayed interval delivery of a triplet pregnancy using conservative management

Preterm birth is a significant cause of perinatal morbidity and mortality, especially in multiple pregnancies. Delayed interval delivery can prolong pregnancy for the remaining fetus(es) in an imminent stillbirth or extremely preterm birth of the first fetus, improving the lastborn's outcomes. We present a case of delayed interval delivery of a triplet pregnancy following preterm prelabour rupture of membranes and progressive cervical insufficiency. Following vaginal delivery of the first fetus at 24+1 gestational weeks, the patient received antibiotics and tocolysis. Cerclage was not conducted as the mother had a vaginal infection. A 15-day delivery interval for the second and third fetuses was achieved. The firstborn required mechanical ventilation and inotropic support, while the others only required continuous positive airway pressure. There is no consensus on the best way to perform delayed interval delivery. We achieved a complications-free interval of 15 days with conservative management in a triplet pregnancy.

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 delivery in multiple pregnancy: about a case and literature review]

Delayed delivery is designed to allow the remaining fetus(es) to develop after premature expulsion of the first twin in the second trimester of pregnancy. This decision is aimed to allow the remaining fetus(es) to reach full fetal growth. We here report a clinical case of delayed delivery in a patient with triple pregnancy in whom the time between the expulsion of the first twin and the birth of the third twin was 10 weeks. The purpose of this study was to highlight the benefit and indications for delayed delivery.

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.

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.

An extremely rare case of hand prolapse with preterm premature rupture in the membrane of one twin

The latency in preterm premature rupture of membranes (PPROM) can last for weeks. We describe an extremely rare case of hand prolapse with PPROM that was exposed for 23 days before delivery. The patient had spontaneous PPROM of twin A at 21.4 weeks of gestation with shoulder presentation. The right arm of the fetus eventually protruded out the vagina and the hand was exposed for extended period of time of 23 days until delivery. Daily dressing by applying collagen to dry skin and silicone to keep moisture was done to the protruding hand to prevent dehydration and desquamation of the skin. Prophylactic antibiotics were used and the patient underwent emergent cesarean section due to uncontrolled preterm labor at 25.2 weeks. To the best of our knowledge, this is the first case of hand prolapse of one twin with extended period of latency before delivery.

Delayed second twin delivery: benefits and risks

BACKGROUND

An increasing number of reports describe the delayed second twin delivery for days, or weeks with good results in the majority of the cases, and different survival rate between centers, without reported randomized controlled trials (RCTs).

OBJECTIVES

This study was designed to evaluate the suggested management of the delayed second twin delivery in the Sabah Maternity Hospital regarding its outcome, possible risks, and benefits.

PATIENTS AND METHODS

Forty-seven twin pregnancies with preterm labor (PTL) of the first fetus between 20-30 weeks, and delayed delivery of the second twin were included in this study. Studied women signed informed consent about the possible risks of keeping the live fetus in the hostile intrauterine environment, and benefits of the prolonged gestation for the second twin. Throughout the conservative treatment of the second twin, the studied women were hospitalized with regular follow up for infections, consumptive coagulopathy parameters, and wellbeing of the second twin.

RESULTS

There was significant difference in the gestational age at delivery between the first and second twin (22.6 ± 3.4 versus 34.3 ± 2.5 weeks; respectively, p = .01). There was significant difference in the birth weight between the first and second twin (435 ± 91.2 versus 1472 ± 61.5 g; respectively, p = .004). The rate of the cesarean delivery was significantly high during delivery of the second twin compared with the first twin (23.4% (11/47) versus 0% (0/47); respectively, p = .0001) with high survival rate for the second twin (85.1% (40/47)) after the delayed second twin delivery.

CONCLUSIONS

The birth weight, the gestational age, and the survival rate of the studied second twin significantly increased after the suggested management of the delayed second twin delivery.

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.

Delayed Interval Delivery following Early Loss of the Leading Twin

This was a case of a nulliparous woman with reduced chance of conception following unilateral salpingectomy and years of infertility. She eventually conceived following ovulation induction resulting in twin pregnancy. She had miscarriage that led to loss of one of the twins at 17 weeks of gestational age. The pregnancy was however continued for 116 days following meticulous management with eventual delivery of a live female baby with good outcome.

[Deferred twin birth: report of two cases observed at the maternity of Creil Hospital Centre]

L'accouchement gémellaire différé définit un accouchement en deux ou plusieurs temps, avec l'expulsion spontanée d'un premier fœtus au deuxième ou au troisième trimestre, et un prolongement de la grossesse pour obtenir un accouchement du ou des fœtus restants en gestation le plus proche possible du terme. Cette technique est mise en œuvre, en cas de grossesse gémellaire pour prévenir la prématurité du fœtus restant après l'expulsion très prématurée d'un premier fœtus. Nous rapportons deux cas observés à la maternité du Centre Hospitalier de Creil avec des latences respectives de 3 et 52 jours pour lesquels nous discutons la prise en charge.

Delayed interval delivery of the second twin: obstetric management, neonatal outcomes, and 2-year follow-up

OBJECTIVES

To evaluate the obstetric management and neonatal outcomes in twin pregnancies with delayed delivery of the second twin, including follow-up.

METHODS

This study is a review of four cases of delayed delivery of the second twin in our hospital from 2009 to 2012. The obstetric management of the cases from the expulsion of the first twin to the delivery of the second twin is analyzed. The neonatal outcomes including follow-up for 2 years were reviewed.

RESULTS

The first twins were delivered between 15 and 25 weeks (average 21 weeks) and the second twins were delivered between 25 and 31 weeks (average 27 weeks). One first twin (25 %) survived, while three (75 %) second twins survived. Two out of the three second twins delivered after 28 weeks were in satisfactory condition.

CONCLUSIONS

The delayed delivery of the second twins which occurred in the third trimester is associated with favorable outcome, however, the risks should not be ignored.

Delayed-interval delivery of an in vitro-fertilized triplet pregnancy with premature rupture of membranes in the second trimester

BACKGROUND

The incidence of multiple pregnancies is increasing with the availability of assisted reproductive techniques. Preterm labor and preterm rupture of membranes are major complications in such pregnancies. Preterm delivery of the first fetus is often followed by delivery of the remaining fetuses. However, conservative management in such circumstances might allow for fetal lung maturity in the remaining fetuses.

CASE

We present a case of conservative management of an in vitro-fertilized triplet pregnancy with early loss of the leading triplet. A 33-year-old woman in the 21st week of a triplet pregnancy delivered her one of the fetuses, 4 days after the preterm rupture of membranes. To save the surviving fetuses, ligation of the umbilical cord at the cervical level was performed. Patient received antibiotics, tocolytics and corticosteroids after then. The second and the third fetuses were successfully delivered by cesarean section in the 28th week of pregnancy, 43 days after the first fetus was born.

CONCLUSION

We can improve the life expectancy of the retained fetuses by conservative management using tocolytics, antenatal steroids to stimulate lung maturation and antibiotics following the delivery of the first fetus.

Delivery of a live newborn in a triplet pregnancy complicated by preeclampsia after intrauterine demise of two and expulsion of one triplet: a case report

Delayed interval delivery in twin pregnancies is an unusual occurrence, even more so in triplet pregnancies. We report on a delayed interval delivery in a dichorionic triamniotic triplet pregnancy after in vitro fertilization (IVF). Because of severe twin to twin transfusion syndrome (TTTS), two fetuses demised at 22 weeks of gestation. One of the two fetuses spontaneously aborted at 25 weeks of gestation. The remaining live fetus and the second demised fetus were delivered by cesarean section 9 weeks later because of the occurrence of preeclampsia. This case indicates that delayed interval delivery in triplets is possible and that preeclampsia can occur after intrauterine demise of two fetuses.

Delayed-interval delivery in twin and triplet pregnancies: 17 years of experience in 1 perinatal center

OBJECTIVE

There are few prospective cohorts of delayed-interval delivery for twin and triplet pregnancies. Nonetheless, the procedure is an option to improve perinatal outcome.

STUDY DESIGN

A standard protocol was designed before candidates for delayed interval were managed by the 2 authors from 1991 to 2007. Perinatal as maternal outcomes were evaluated up to 1 year.

RESULTS

In 93 twin and 34 triplet pregnancies, the inclusion criteria were fulfilled; in 45 twin and 8 triplet pregnancies, there were contraindications to prolong pregnancy; and in 10 twin and 26 triplet pregnancies, asynchronous delivery was not possible because of immediate delivery of the remaining multiples. Thus, the procedure was performed in only 41% (38/93) of twin and 35% (12/34) of triplet pregnancies admitted with threatening early delivery. Among twin pregnancies, the mean delay was 19 (1-107) days. When the first delivery was less than 25 weeks, no first twin but 9 of 18 second twins (50%) survived (P < .001). Survival rate of first twins born beyond 25 weeks was 13 of 20 (65%) compared with 19 of 20 (95%) (P = .03) in corresponding second twins. In 7 of 12 triplet pregnancies with the first born less than 25 weeks, 2 of 14 remaining triplets survived after an interval of 118 days. Beyond 25 weeks, 3 of 5 first and 4 of 10 remaining triplets survived after intervals of 2-13 days (P = n.s.). Delay between second and third triplet was never longer than 2 days. Frequent maternal complications were chorioamnionitis (22%), postpartum hemorrhage, retained placenta (10%), and abruption (6%).

CONCLUSION

Our study provides data to assist physicians in the informed consent process when asynchronous delivery is considered and feasible.

Prolongation of triplet pregnancy after abortion of the presenting fetus

BACKGROUND

The management of delayed delivery in a triplet pregnancy is described.

CASE

A 25-year-old woman with an in vitro fertilization pregnancy aborted the presenting fetus at 19th gestational week. As she decided to carry on, cervical cerclage, tocolysis and antimicrobial prophylaxis were performed. The remaining fetuses survived until 29th gestational week.

CONCLUSION

Prolongation of multiple pregnancies after the abortion of presenting fetuses is a possible approach, which is especially justified in women with a history of infertility.

Delivery of a healthy twin after intrauterine demise and expulsion of a first twin

We report on a diamniotic-dichorionic twin pregnancy after in vitro fertilization. The first twin was diagnosed with Down syndrome and spontaneously aborted at 24 weeks of gestation after intrauterine death at week 18. The second healthy twin was delivered by cesarean section 11 weeks later. We discuss management aspects and review the literature.

Diagnosis and management of obstetrical complications unique to multiple gestations

Obstetrical complications unique to multiple gestations pose a number of unique challenges. The presence of more than one fetus complicates the diagnosis and management of a pregnancy when one fetus has a structural or chromosomal abnormality, intrauterine demise, preterm premature rupture of the membranes, or delivers prematurely. Similarly, the diagnosis and management of monoamniotic twins and conjoined twins is challenging. These obstetrical complications that are unique to multiple gestations require thorough counseling of the expectant parents, as well as care by physicians with expertise in the management of multiple gestations.

Management of Delayed-Interval Delivery in Multiple Gestations

OBJECTIVE

Proving that delayed delivery is possible, debating its modality, suggesting a guideline for its managing.

METHOD

Six cases of delayed delivery were treated at the Maternity Hospital of Nancy, between 1979 and 2001, and the results were compared to a literature review of 148 found thanks to Medline database.

RESULTS

Delayed delivery reduces the risk of neonatal mortality and morbidity. The delivery interval is 2-93 (median 7) days in our experience and 2-153 (median 31) days in the literature. After the first expulsion, cerclage was used in 60% of the cases, prophylactic tocolysis and antibiotics in 79% and 71%, respectively.

CONCLUSION

There is no consensus for its management but it must be performed with precise conditions to restrict both maternal and fetal risks. Our study is supporting an interventionist attitude with cerclage, prophylactic tocolysis and antibiotics.

Delayed interval delivery in twin pregnancies in the United States: Impact on perinatal mortality and morbidity

OBJECTIVE

To estimate the incidence of delayed interval delivery in twin pregnancies in the United States and evaluate the impact of delayed delivery on perinatal outcomes.

STUDY DESIGN

A population-based retrospective cohort study was performed using the U.S. "matched multiple birth" file (1995 to 1998), restricting our analysis to twin sets in which the first twin was delivered vaginally at 22 to 28 weeks (n = 4257). Outcomes examined included perinatal and infant mortality and small-for-gestational-age births. Outcomes of second twins in pregnancies that underwent delayed interval delivery of 1, 2, 3, and >/=4 weeks were compared with those in which both twins were delivered contemporaneously.

RESULTS

In this cohort, 6.1% (n = 258) of twins had delayed delivery (>/=1 week) of the second twin. Decreases in perinatal and infant mortality were observed only when the first twin was delivered at 22 to 23 weeks and when the delivery interval was </=3weeks. However, for intervals >/=4 weeks or when the first twin was delivered at 24 to 28 weeks (regardless of delivery interval), there was no benefit in perinatal or infant mortality. Delayed delivery of >/=4 weeks was associated with increased risk of small-for-gestational-age birth in the second twin, regardless of gestational age at delivery of the first.

CONCLUSION

When a first twin was delivered at 22 to 23 weeks, delayed delivery of the second twin was associated with reduced perinatal and infant mortality of the second twin if the interval was less than 3 weeks. Delayed delivery of the second twin when the first was delivered at >/=24 weeks had no benefit on mortality.

Twin pregnancies discordant for anencephaly—management, pregnancy outcome and review of literature

AIMS AND METHODS

To examine the prognosis of conservative management in twin pregnancies discordant for anencephaly, we review the literature and report on four of our own cases, which were analyzed retrospectively.

RESULTS

In the University Hospital of Erlangen, six twin pregnancies discrepant for anencephaly were observed during an 8-year period (1992-2000). Four of these pregnancies were managed conservatively. Preterm delivery occurred in all of the cases, but the unaffected fetuses all had favorable long-term outcome. Delayed interval delivery was performed in two cases due to extreme immaturity in the healthy fetus.

CONCLUSIONS

Our data show that in twin pregnancies with early diagnosis of anencephaly in one fetus, the risk of premature delivery of the healthy fetus may be more increased than is already known in the literature. Therefore, selective fetocide of the anencephalic fetus is a management option, at least in dichorionic pregnancies, to prevent polyhydramnios and to reduce the risk of preterm delivery.

Delayed delivery of second twin: a multicentre study of 35 cases

OBJECTIVE

The aim of this study was to conduct a statistical analysis to determine the outcome of conservative treatment after delivery of a first fetus in multiple pregnancy and thus define new prognostic factors.

STUDY DESIGN

Multicentre retrospective study involving 12 centers over a 10-year period.

RESULTS

Twenty-eight twin pregnancies and seven triplet pregnancies which were managed conservatively. In twin pregnancies, 79% of the delayed-delivery fetuses survived; only 7% of the first delivered fetuses survived. The mean interval between deliveries was 47 days. No statistical difference was found concerning cerclage, antibiotic therapy, tocolysis and hospitalization. Earlier delivery of the first twin and premature rupture of membranes for the second twin were significantly related to a longer interval between deliveries.

CONCLUSION

Delayed delivery in multifetal pregnancies can be successful if there are no contraindications and these pregnancies are managed in a tertiary perinatal center. Publications limited to successful cases have undoubtedly introduced some bias in assessment.

Cervical cerclage in delayed interval delivery in a multifetal pregnancy: a review of seven case series

OBJECTIVE

To examine whether cervical cerclage after the first delivery prolongs the inter-delivery interval in delayed interval deliveries.

STUDY DESIGN

We identified 66 case reports and case series of delayed interval delivery published between 1880 and 2002. We selected seven case series that identified all cases of delayed interval delivery in their institutions during a specified period.

RESULTS

Despite routine use of broad-spectrum prophylactic antibiotics, the average incidence of clinical intrauterine infection after the first delivery was 36% (95% confidence interval (CI): 26-46%). The incidence of maternal sepsis was 4.9% (95% CI: 0.2-9.6%). Studies in which cerclage was infrequently used reported a shorter inter-delivery interval compared to studies where cerclage was used in all cases (median is equal to 9 days versus 26 days, respectively, P<0.001) despite similar gestational ages at the first delivery, types of antibiotics, tocolytics, and incidence of infection. After controlling for other factors, the use of cerclage did not significantly increase the risk of intrauterine infection (adjusted relative risk=1.1, 95% CI: 0.4-3.5).

CONCLUSION

Cervical cerclage after the first delivery is associated with a longer inter-delivery interval without increasing the risk of intrauterine infection.

Delayed interval delivery in multiple pregnancies

Preterm delivery remains the most important complication of multiple pregnancies. We describe six cases of successful delay of the subsequent child(ren) after very preterm birth of the first-born, with intervals ranging between 14 and 117 days. Based on our findings and on the available literature, we propose a set of guidelines for the management of early preterm multiple birth deliveries, including tocolysis, antimicrobial therapy and corticosteroids.

Delayed interval delivery of a second twin

We report a case of diamniotic dichorionic pregnancy at 21 weeks and 5 days of gestation with threatened preterm labor with cervical modification and protrusion into vagina of the amniotic sac of twin one. After 4 days there was a rupture of membrane of the protruding sac and delivery of the first twin. We decided to retain the other one to allow improvement in the outcome for the second twin. The patient was treated with tocolytics, antibiotics and continuously monitored. After 18 days there was increasing uterine contractility and we decided to perform the cesarean section and delivered the second twin.

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 delivery of second twin after chorioamnionitis and abortion of first twin at 21 weeks gestation

Delayed delivery is a relatively new term used to describe the delivery of one fetus after premature delivery of the first fetus. We describe a case where we used tocolysis and antibiotics to prolong a twin pregnancy for 35 days with excellent fetal outcome, after chorioamnionitis had caused the abortion of the first twin at 21 weeks gestation.

Controversies in the intrapartum management of twin gestations

Advances in reproductive endocrine technology have helped to make twin gestations commonplace; however, as this article suggests, many unanswered questions and areas of controversy about the intrapartum management of twin gestations remain. Continued research in this area and the performance of prospective studies will shed further light on many of these topics.

The retained twin/triplet following a preterm delivery--an analysis of the literature

We summarized the overall experience of the management and outcome of the retained twin/triplet and statistically analyzed the effects of the different variables such as cervical cerclage, tocolysis, use of antibiotics etc. on the retained fetal survival; 45 case reports in English were analyzed. The survival rate of the first born was very poor in contrast to the second and third-born infants. Spontaneous rupture of the membranes was the most common cause of the loss of the first born, whereas for the second born, premature labour was the commonest cause. Despite substantial obstetric events leading to delivery of the first-born infant, interval problems were uncommon. The mean period of retention of the surviving retained twin/triplet was 48.9 +/- 37.9 days compared to 25.7 +/- 31.6 days for the dead retained twins/triplets (p=0.08). The female retained twins/triplets were retained much longer than the males (p=0.008). The pregnancies lasted 45.9 days in the tocolytic group and 37 days in the nontocolytic group (p=0.51). The delivery interval of the second born in the cerclage group was 52 +/- 42 days compared to 34 +/- 30 days in the noncerclage group (p=0.1). The longer the twins/triplets were retained the better was their survival. Tocolysis, cervical cerclage and prophylactic use of antibiotics failed to make a statistically significant difference in the fetal outcome. The birth-weights, gestations and sex of the retained twins/triplets affected their survival significantly.

Delayed delivery of multiple gestations: maternal and neonatal outcomes

OBJECTIVE

The study's aims were to compare neonatal outcomes and to describe maternal complications in patients who underwent delayed delivery of twins or triplets in a preterm gestation.

STUDY DESIGN

A retrospective review was performed on 5 sets of twins and 2 sets of triplets. Maternal morbidity was described. Neonatal outcomes were compared in the initial and subsequent delivery groups.

RESULTS

The percentage of surviving firstborns was 57%, compared with 78% among latter-born infants. The average gestational age of the initial delivery group was 22.6 weeks (18.9-24.7 weeks); gestational age was 27.4 weeks (19.3-37.9 weeks) for the subsequent group (P <.05), a difference of 32.6 days. The average weight gain was 556.1 g. Serious neonatal complications were less frequent among the subsequently delivered siblings (P <.05), and the mean difference in neonatal hospital stay was 77.3 days, with a range of 62.5 to 139.8 (P <.5). Adverse maternal outcomes were represented by 3 patients with abruptio placentae and 3 patients with intra-amniotic infection, 2 of whom had positive blood culture results.

CONCLUSION

On the basis of our experience with 7 multifetal pregnancies, delayed delivery has been demonstrated to increase the likelihood of survival and decrease morbidity among the latter-born siblings. Despite the risk of complications, these data support therapeutic interventions aimed at delayed delivery of subsequent fetuses in cases with the potential for significant morbidity and mortality.

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.

Intentional delayed delivery in twin pregnancy. Two additional cases and literature review

We report two cases of retention of the second twin after delivery of the first one. Both pregnancies were bichorionic, biamniotic. In both cases the first twin was delivered during the second trimester. Tocolysis and antibiotics were used. The two pregnancies had a different outcome. For the first patient with a cerclage, the interval delivery was 67 days, allowing a gestational age of 28 weeks and a weight of 1070 g. The child is now 4 years old and has a normal development. In the second case, the second twin was delivered at 20 1/2 weeks, 8 days after the first, and died shortly after birth. Reviewing the literature, 34 twin pregnancies are reported with intentional delay delivery and 27 infants survived out of 68 fetuses. Cerclage does not seem to be essential for success. Prophylactic antibiotics and tocolysis are admitted. The main problem is infection which defines the prognosis.

Selected issues in premature rupture of the membranes: herpes, cerclage, twins, tocolysis, and hospitalization

A number of issues related to premature rupture of the membranes (PROM) are less common or have not been thoroughly evaluated. Genital herpes simplex colonization carries the potential for significant perinatal morbidity, particularly with primary infection and membrane rupture. Cervical cerclage is both a risk factor for preterm PROM (pPROM) and confounds the management of women with PROM. Twin gestations carry an increased risk of pPROM and earlier membrane rupture. Membrane rupture can involve the presenting or nonpresenting sac. In each case, the fetus with intact membranes is at risk due to brief latency or intrauterine infection after membrane rupture of its sibling. Prophylactic and therapeutic tocolysis remains controversial because of the high risk of intrauterine infection after PROM, and the lack of data demonstrating long-term efficacy. With increased attention to health care costs, home management of pPROM has recently been suggested as an alternative to hospitalization after pPROM. This article reviews the clinical course and management options regarding these issues. Also discussed are those issues for which there is controversy but little available data. Each of these issues offers fruitful ground for discussion and further study.