Diagnosis and management of obstetrical complications unique to multiple gestations

Late selective termination in dichorionic twins: comparing late second and third trimester procedures

RESEARCH QUESTION

Do perinatal outcomes of selective termination performed in the late second versus third trimester differ and what risk factors are associated with subsequent preterm birth?

DESIGN

This is a retrospective cohort study of late selective terminations performed in dichorionic twins between 2009 and 2021. Perinatal outcomes were compared between two groups: group A, late second trimester (20.2 to 24.2 weeks, n = 26), and group B, third trimester (≥28.2 weeks, n = 55) selective terminations. Univariate and multivariate analyses were conducted to identify factors associated with post-procedure preterm birth.

RESULTS

In total, 81 dichorionic twin pregnancies were included. There were no pregnancy losses but 16% (13/81) of cases experienced complications. Group A had a higher median birthweight centile (36.5th versus 15th centile, P = 0.002) and lower rates of intrauterine growth restriction (IUGR) and Caesarean delivery (11.5% versus 32.7%, P = 0.04; and 26.9% versus 61.8%, P = 0.003) than group B. Preterm birth rates were similar (46.2% versus 63.6%, P = 0.15). Multiple regression revealed that reduction of the presenting twin and cervical length ≤35 mm were independently associated with post-procedure preterm birth (odds ratio [OR] 8.7, P = 0.001, 95% confidence interval [CI] 2.5-29.8; OR 3.8, P = 0.015, 95% CI 1.3-11).

CONCLUSIONS

Late second trimester selective termination is associated with a higher birthweight centile and lower rates of IUGR and Caesarean delivery, compared with third trimester selective termination. Cervical length 35 mm or less and reduction of the presenting twin are independent risk factors for post-procedural preterm birth. These findings may help determine the optimal time to perform a late selective termination.

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 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.

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.

Early prenatal diagnosis of thoracopagus twins by ultrasound

Introduction:

Conjoined twins are identical twins joined in utero. It’s a rare phenomenon and present a unique challenge to obstetricians and pediatric surgeons. Conjoined twins are complex complication of monozygotic twinning, which is associated with high perinatal mortality.

Case report:

At our clinic complete anomaly scan was done, the patients was found to have monozygotic twins of 15 weeks gestation and carrying a conjoint twin. Our ultrasound revealed fully developed heads facing each other, joint at the thorax and sharing a common abdomen. These twins share a single heart with two atrium and two ventricle. They decide for termination of pregnancy after taken the opinion of religious people. Termination of pregnancy was performed by many methods and we chose to use cytotec tablets which inserted vaginally and the outcome was conjoint twin with two bodies fused from the upper thorax to lower belly. Both fetuses are female and died immediately after termination of pregnancy.

Cephalothoracoomphalopagus: a rare type of conjoined twin

We present a case of female cephalothoracoomphalopagus conjoind twin, which is extremely rare type of conjoined twins. We also review the contemprory knowledge regarding incidence, etiopathogenesis, antenatal diagnosis and outcone or the prognosis of conjoint twins. The case belong to hindu female, no history of consanguineous marriage, ingestion of drugs or exposure to any radiation. History of one abortion and one twin delivery present. Conjoind twin was cephalothoracoomphalopagus type, delivered vaginaly at 30 wks of gestion to a 25 yrs old multigravida. Management of conjoind twin still remain challenges because of multiple congenital anomalies and poor outcome is seen.

Epidemiology of multiple pregnancy and the effect of assisted conception

Multiple pregnancy is one of the greatest perinatal challenges facing clinicians today. In a society of rising expectations among fertility and maternity service users, the potential for adverse outcomes associated with multiple pregnancy is a source of concern. This article examines the impact of assisted conception on the incidence of multiple pregnancies and associated complications. It explores some of the reasons for the strong association between assisted reproductive technology and multiple pregnancies and suggests possible ways of addressing this continuing problem.

One consequence of infertility treatment: multifetal pregnancy

This article discusses the issue of multifetal pregnancy as a result of fertility treatments. Pregnancies with multiple gestations are associated with serious infant and maternal health risks as well as psychological distress and significant financial consequences, and are a far too common consequence of infertility treatments such as assisted reproductive technology (ART) and ovulation induction drugs. Women with multifetal pregnancies are at a higher risk for multiple pregnancy complications and maternal morbidity/mortality as well as stress, depression, and anxiety disorders, especially when there is the threat of a loss of one or more fetuses. The rise in rates of multifetal gestation and the accompanying increased risk to both mother and fetuses have led the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology to develop guidelines to limit the number of transferred embryos during in vitro fertilization. Nurses who work with infertile women are in a position to educate them about the risks, benefits, and alternatives associated with ARTs and multifetal pregnancies, and should endeavor to learn as much as possible about this topic.

Conjoined twins: Historical perspective and report of a case

In this article we review the historically important cases of conjoined twins (Biddenden Maids, Siamese twins, Blazek sisters) and contemporary knowledge regarding incidence, etiopathogenesis, antenatal diagnosis, antenatal management, and outcome of conjoined twins. We also present a case of male cephalothoracoomphalopagus, which is extremely rare.

Outcomes of preterm premature rupture of membranes in twin pregnancies

OBJECTIVE

To describe outcomes in twin pregnancies with preterm premature rupture of membranes (PPROM).

METHODS

Dichorionic twin pregnancies complicated by PPROM at <34 weeks of gestation for the period 2003 to 2006 were identified. Outcomes were obtained through chart review. The relationship between gestational age at premature rupture of membranes (PROM), latency from PROM to delivery, and infection were examined.

RESULTS

In 49 twin pregnancies, the median gestational age at PROM was 31 weeks with a median latency between PROM and delivery of 0 days (interquartile range 0-6). Latency intervals of >or=2 and >or=7 days were achieved by 40.8% and 22.4%, respectively. PPROM at <30 weeks was associated with significantly higher rates of latency of >or= 2 days (70.6% vs. 25.0%) and >or=7 days (47.1% vs. 9.4%). There was a significant relationship between latency and clinical and histologic signs of infection.

CONCLUSIONS

After 30 weeks, most twin pregnancies with PPROM delivered within 2 days. Infection appears to be a consequence rather than a cause of PPROM in most cases.

Cesarean delivery and its impact on the anomalous infant

Although cesarean deliveries frequently are performed for anomalous fetal conditions, available data do not always support a fetal benefit from this delivery management. The literature on cesarean delivery for anomalous infants reports insufficient information on comorbid neonatal conditions, so these complications are unknown in this population of newborns. In a minority of cases, a cesarean delivery is reasonable to prevent dystocia or optimize outcome. Areas for future investigation include prospective, randomized, controlled trials of prelabor cesarean compared with vaginal deliveries for myelomeningocele and anterior abdominal wall defects. The rarity of other lesions likely precludes randomized controlled trials.