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

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 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.

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.

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.

A twin pregnancy provided with ICSI, an abortion of the first fetus at the 18th week and live birth of the second fetus at the end of the 36th week: a case report and literature review

OBJECTIVE

The aim of this report was to evaluate and present the fourth longest delay among twin and multiple pregnancies described in the literature.

METHODS

How can we optimize the health of the remaining fetus or fetuses after spontaneous abortion of the first fetus in multiple pregnancies? By considering one of our cases, we try to answer that question in light of the published literature.

RESULTS

In our case, the second fetus was born at the end of the 36th week after abortion of the first fetus at the beginning of the 18th week. Delayed interval delivery was postponed 132 gestational days.

CONCLUSIONS

The implementation of delayed intentional delivery is a reliable and required approach especially for infertility patients when they are selected carefully and monitored closely.

Delayed interval delivery of a second twin after the preterm labor of the first one in twin pregnancies: delayed delivery in twin pregnancies

A diamnionic dichorionic twin pregnant women (due to in vitro fertilization) admitted to emergency department at the 21st week of gestation because of regular contractions. By gynecological examination, we observed 8 cm dilated cervix with 80% effacement. Amniotic membrane was also bulging through the cervix. After evaluation delivery of the presenting fetus occurred quickly. The baby's weight was 610 gr and no heart activity was detected. Placenta of the first fetus expulsed immediately. We decided to retain the second fetus to allow the improvement in the outcome. McDonald cerclage was performed and the patient treated with tocolytics and antibiotics, and she was continuously monitored up to the 28th week of pregnancy. After she was discharged in the 28th week, she was controlled weekly in obstetrics clinic. At the 36th gestational week which was 101 days after the cerclage procedure, 3639 g male fetus was delivered with cesarean section and had an uneventful neonatal course. Delayed-interval delivery is useful and acceptable therapeutic option for the management of the remaining fetus in twin pregnancies even after the expulsion of the placenta. Antibiotic and tocolytic administration with cervical cerclage application can be associated with longer interdelivery interval.

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.

Effect of inter-twin delivery interval on neonatal haemoglobin concentration

The aim of this study was to examine the effect of the inter-twin delivery interval on neonatal haemoglobin concentration. We retrospectively analysed 108 twin deliveries over a 5-year period. Chorionicity was determined by first trimester ultrasound or placental histopathology. The mode of delivery, time of delivery and cord/neonatal blood counts were recorded. A total of 88 sets of dichorionic and 20 sets of monochorionic twins were studied. There was no correlation between inter-twin delivery interval and haemoglobin difference (rho = 0.020, p = 0.857). In monochorionic twin pregnancies, there was a trend towards increasing inter-twin hemoglobin differences with prolonged delivery intervals. However, this trend did not reach statistical significance (rho = -0.303, p = 0.193). In monochorionic twins, there is a trend towards a lower haemoglobin concentration in the twin delivered second. This haemoglobin deficit appears to be related to the inter-twin delivery interval.

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.

Delayed interval delivery in a triplet pregnancy

Due to a surge in the availability of assisted reproductive techniques (ART), the incidence of multiple pregnancies is increasing. Preterm labor is a major complication in such pregnancies. Preterm delivery of the first fetus is often followed by delivery of the remaining fetuses. However, conservative management and delayed interval delivery in the remaining fetuses might allow for fetal lung maturity and would reduce perinatal morbidities. A 32-year-old female had a quadruplet pregnancy after receiving ART. Fetal reduction to triplet pregnancy was performed at 11 weeks of gestation. The remaining triplet pregnancy was stable until 29 weeks of gestation, when the first triplet was delivered after spontaneous rupture of membranes. Under intensive monitoring, the remaining 2 fetuses were delivered by cesarean section at 31 weeks of gestation. Only the first fetus had retinopathy after discharge. In conclusion, delayed interval delivery of the remaining fetuses should be attempted after preterm delivery of the first fetus.

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 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.

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.

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.