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

Vaginal delivery of triplets after emergency transvaginal cerclage: A case report and literature review

RATIONALE

To report a peculiar case of vaginal delivery of a triplet after emergency transvaginal cerclage and to find a way to optimize some extreme situations encountered in clinical practice after evaluating feasibility.

PATIENT CONCERNS

A 33-year-old gravida 6, para 0050 woman at 21 + 6 weeks of gestation was referred to the obstetric department for opening of the cervical canal. An emergency McDonald cerclage was performed at 22 weeks of gestation after a comprehensive assessment, and the pregnancy ended with vaginal delivery at 24 + 6 weeks of gestation. The postpartum period was normal, and the newborns were discharged to home care after treatment in the neonatal intensive care unit.

INTERVENTIONS

After discussing the risks, the patient requested emergency transvaginal McDonald cerclage at 22 weeks of gestation.

OUTCOMES

Emergency McDonald cerclage was performed at 22 weeks of gestation, and the pregnancy ended with vaginal delivery at 24 + 6/25 weeks of gestation, successfully prolonging gestation by 20/21 days. The postpartum period had no exceptional circumstances, and newborns were discharged to home care after treatment in the neonatal intensive care unit for 104/98/104 days.

LESSONS

Emergency cerclage seems to be impossible in multiple pregnancies. However, in this case, after a comprehensive assessment, it was feasible to extend the gestational age by emergency cerclage, and prompt and accurate evaluation is important to avoid complications and individualize the following management. In this case, we may find a way to optimize some extreme situations encountered in clinical practice and offer a glimmer of hope for families challenged with multiple pregnancies at risk of preterm delivery. However, more high-quality studies are needed to prove the effectiveness and safety of emergency cerclages in triplets.

Successful delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a twin pregnancy

There has been a significant increase in the number of multiple pregnancies that are associated with a high risk of preterm delivery among Korean women. However, to date, delayed-interval delivery in women with multiple pregnancy is rare. We report a case of delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a dichorionic diamniotic twin pregnancy. The patient presented with vaginal leakage of amniotic fluid at 16 weeks of gestation and was diagnosed with a preterm premature rupture of membranes. Three days later, the first twin was delivered, but the neonate died soon after. The second twin remained in utero, and we decided to retain the fetus in utero to reduce the morbidity and mortality associated with a preterm birth. The patient was managed with antibiotics and tocolytics. Cervical cerclage was not performed. The second twin was delivered vaginally at 34 weeks and 5 days of gestation, 128 days after the delivery of the first-born fetus. This neonate was healthy and showed normal development during the 1-year follow-up period. Based on our experience with this case, we propose that delayed-interval delivery may improve perinatal survival and decrease morbidity in the second neonate in highly selected cases.

Delayed interval delivery in a triplet gestation

A 27-year-old Ghanaian primigravida with a known triamniotic trichorionic triplet pregnancy presented at 17 weeks gestation following a miscarriage of one triplet at home. Examination and investigation revealed no signs of imminent delivery or infection. After careful counselling with regard to prognosis and options available for management, the couple opted for intervention including rescue cerclage. The patient received antibiotic prophylaxis for five days and daily progesterone suppositories until delivery. An ultrasound scan was performed every three weeks to monitor fetal growth and cervical length. At 24 weeks corticosteroids for fetal lung maturity were given. At 31 weeks gestation she experienced spontaneous rupture of membranes followed by active labour and forceps delivery. There were no maternal complications. Both babies were born in a good condition, but required ventilatory support for 72 h.

Management of Multiple Pregnancy: Prenatal Care???Part I

Over the past 20 years, the number and rate of multiple births have dramatically increased in the United States. The rise in multiple births is mainly attributable to the increased use of ovulation-inducing drugs and the newly developed assisted reproductive technologies such as in vitro fertilization. Multifetal gestation is associated with an increased risk of perinatal morbidity and mortality. Multiple births account for an increasing percentage of low-birth-weight infants, preterm births, and infant mortality. In this section, we address the management of the multifetal pregnancy, focusing on the maternal physiology, the diagnosis, the pregnancy outcomes, and the antenatal management of multiple gestation.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the effects of the rising rate of multiple pregnancies on perinatal morbidity and mortality, to recall the complications of diagnosing and treating abnormalities of multiple pregnancies, and to list the many changes that occur in both the mother and the fetuses in multiple pregnancies.

Delayed interval delivery and infant survival: a population-based study

OBJECTIVE

Delaying delivery of the remaining fetus(es) in a multifetal pregnancy is feasible in some cases. However, the impact of this procedure on infant survival is unclear.

STUDY DESIGN

We used the US 1995-1998 Matched Multiple Birth File. We identified 200 twin pregnancies in which the first twin was delivered between 17 and 29 weeks of gestation and the second twin was delivered 2 or more days later. We individually matched the delayed deliveries with 374 twin pregnancies in which the second twin was delivered on the same or next calendar day. Perinatal outcomes and infant survival were compared between the delayed and nondelayed twins.

RESULTS

Among the 200 pregnancies with delayed delivery, the mean gestational age at first delivery was 23 weeks and the median duration of delay was 6 days (ranging from 2-107 days). One week of delay in delivery was associated with an increase in infant birth weight of 131 g on average (95% CI: 115-147 g). Moreover, 56% of the delayed second twins survived to 1 year of age, whereas only 24% of the nondelayed second twins survived to 1 year of age (P <.001). However, 11% of the second twin in delayed delivery (95% CI: 6%-16%) experienced fetal death before 24 weeks.

CONCLUSION

Delayed delivery of the remaining fetus(es) before 30 weeks of gestation for 2 or more days was associated with improved infant survival.