Retention of the second twin: a viable option? Case reports

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.

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-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 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.

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-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.

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).

Intrapartum management of multiple gestation

The intrapartum management of multiple gestation continues to challenge the obstetric profession. In general, attempted vaginal delivery is appropriate for vertex-vertex twins. The options of external version, breech delivery, and cesarean delivery are analyzed for vertex-nonvertex twins. Special considerations in the intrapartum management of multiple gestation include monoamniotic twins, conjoined twins, and triplet pregnancies.

Delayed interval delivery in quadruplets

Prolonged interdelivery periods in preterm twin and triplet gestations have resulted in a good outcome for the fetus(es) remaining in utero. This is the second reported case of delayed delivery intervals in quadruplets who were born on 3 separate days. We report on a set of quadruplets following gonadotropin induction of ovulation, in which preterm delivery of the first infant occurred at 26 weeks' gestation. Active uterine contractions ceased and ultrasonography confirmed the remaining triplets to be in separate amniotic sacs with satisfactory heart rate tracings. With bed rest and tocolysis, the delivery of the second infant did not occur until 8 days later. After a further 36-h delay, placental abruption prompted cesarean delivery of the remaining twins. The first infant died of sequelae of prematurity at 7 months, while the remaining triplets survived and are neuro-developmentally normal 1 year after delivery. This report demonstrates the feasibility of prolonging the delivery interval of the fetus(es) in higher order multiple gestations, using tocolysis and watchful expectancy, after the preterm birth of one or more fetuses.

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

OBJECTIVE

Premature rupture of membranes in multifetal gestations during the second trimester has an ominous prognosis and the majority of the fetuses die after preterm delivery.

STUDY DESIGN

We used cervical cerclage, tocolysis, and antibiotic therapy after vaginal delivery of the fetus with ruptured membranes in eight patients with multifetal pregnancies to extend the intrauterine life and improve the outcome of the remaining fetuses.

RESULTS

Survival of six fetuses was achieved in five of the eight pregnancies (four originally twins and one originally triplets). The mean +/- SD gestational age of the fetuses first delivered was 19.6 +/- 2.6 weeks, and it was 26.7 +/- 6.8 weeks in the fetuses with delayed delivery (exact two-tailed p = 0.01). The mean +/- SD birth weight of the fetuses delivered first was 306 +/- 149 gm and it was 1029 +/- 947 gm for the fetuses who had delayed delivery (exact two-tailed p = 0.05). The mean +/- SD prolongation of pregnancy was 48.8 +/- 42.06 days (range 8 to 114 days).

CONCLUSIONS

Intervention with tocolysis, antibiotics, and cervical cerclage after delivery of the first fetus is a reasonable option for some patients with multifetal pregnancies and premature rupture membranes in the second trimester.