Delayed interval delivery of two remaining fetuses in quintuplet pregnancy after embryo reduction: report and review of the literature

Tocolytics used as adjunctive therapy at the time of cerclage placement: a systematic review

OBJECTIVE

To review the published literature on whether the use of empiric perioperative tocolytic medications could provide additional benefit when used in combination with cerclage.

STUDY DESIGN

Systematic review of published medical literature reporting the efficacy of empiric tocolytics used as a perioperative adjunct to vaginal cerclage in high-risk patients. A PubMed search without date criteria of various tocolytics and cerclage yielded 42 studies. Review articles were excluded, as were reports of abdominal cerclage, emergent cerclage, or cerclage for the purpose of delayed interval delivery in twin gestations.

RESULT

Only five publications on the topic of perioperative tocolytic use at the time of history or ultrasound-indicated vaginal cerclage placement were identified. These included zero clinical trials, three retrospective cohort studies, one case series and one case report. Only one cohort study compared cerclage with indomethacin and cerclage without indomethacin and suggested no difference between the groups. The other two published cohort studies had no referent group who received cerclage without tocolysis. One case series and one case report were also published reporting cerclage with empiric beta-mimetic and progesterone adjunctive therapy.

CONCLUSION

There is a paucity of published data on the topic of adjunctive perioperative tocolytics with cerclage. Adequately powered clinical trials on perioperative use of tocolysis with cerclage compared with a standard cerclage placement alone are needed to establish efficacy. Until adequately studied, this practice should be considered investigational.

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.

Long-term and short-term outcome after delayed-interval delivery in multi-fetal pregnancies

OBJECTIVE

To assess a possible difference in the short- and long-term outcome between infants born from a delayed-interval delivery.

STUDY DESIGN

We included all neonates that were either born between November 1991 and December 2000 from a delayed-interval delivery in the Isala Clinics, Zwolle, The Netherlands, or admitted to our clinic after birth. Gestational age, time of delay, birth weight, mortality, morbidity, long-term development and adverse outcome were compared between groups. Moreover, the 'delayed infants' group was compared to a reference group. The following statistical tests were used: prevalence ratio, the Wilcoxon test and the t-test.

RESULTS

Twenty-nine delivery-delaying procedures were successfully performed in our hospital. We included 17 sets of twins and 3 sets of triplets. The mean delay of 19.6 days accounted for a significant increase in birth weight and neonatal survival as well as a decrease in adverse outcome and presence of a number of disease; a negative effect on long-term development could not be shown. The reference group showed less sepsis than the delayed infants group. No serious maternal complications were observed.

CONCLUSION

Delaying the delivery of a second or third infant has a positive effect on short-term outcome. Long-term outcome is comparable to children with the same gestational age.

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.

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.

Delayed interval delivery after intrauterine infection and immature birth of twin 1--a case report and literature review

We report a case of delayed interval delivery in a twin pregnancy complicated by rupture of membranes, intrauterine infection and birth of one twin at 21 weeks gestation. Tocolysis combined with antibiotics and corticosteroids successfully prolonged pregnancy for 73 days, allowing the second twin to mature and reach viability. At 31.5 weeks gestation, a 1890 g healthy male neonate was born with good Apgar scores. His postnatal course was uneventful. A literature review of several other cases of delayed interval delivery is presented. When multifetal pregnancies are complicated by immature birth of one fetus, delayed interval delivery may offer survival chances and favourable outcome for the remaining fetus(es).