|Year : 2022 | Volume
| Issue : 3 | Page : 304-307
Achievement of a 136-day delayed-interval delivery of a second twin with minimum intervention
Aziza H Nassef1, Doaa Ahmed2, Medhat Abd Elwahab2
1 Department of Obstetrics & Gynaecology, Al-Azhar University, Cairo, Egypt
2 Department of Obstetrician & Gynaecologist, Al-Orf Hospital
|Date of Submission||30-Jan-2022|
|Date of Decision||04-Mar-2022|
|Date of Acceptance||04-Apr-2022|
|Date of Web Publication||11-Oct-2022|
MD Aziza H Nassef
Elsheroqu, Cairo 11837
Source of Support: None, Conflict of Interest: None
The rate of multiple pregnancies in the past three decades has increased dramatically. Twin pregnancies have a higher risk of pregnancy loss owing to premature birth. Although the premature delivery of the first twin is usually followed by spontaneous birth of the second twin, there are ways to delay the delivery of the second twin to enhance survival and neonatal outcomes. However, there is insufficient evidence to support the role of any interventions such as cerclage, hospitalization, tocolytics, and/or antibiotics. As a result, the management of delayed interval for the delivery of the second twin varies depending on each case. The purpose of this study was to report the obstetric components of a successful delayed-interval delivery, with an emphasis on the current conflicts around the active management of the delayed interval delivery of the second twin. A case of a 40-year-old, G5P4, woman who had three cesarean sections is presented. She got pregnant with a dichorionic diamniotic twin. At 17 weeks of gestation, she developed sudden severe lower abdominal pain, vaginal bleeding, and spontaneous expulsion of the first fetus weighing 179 g. After delivery of the first twin, the vaginal bleeding became minimal, and the cervix was reconstituted soon, so cervical cerclage was not offered. The umbilical cord of the first fetus was cut at the level of the external cervical os, and the placenta was retained. She received intravenous fluids, anti-D prophylaxis, paracetamol, and antibiotics. The patient was keen to continue with the pregnancy and was informed about the risks and benefits. The management was mainly an outpatient basis after an initial short hospital stay of 6 days before being discharged (upon her request); during the follow-up, she did not develop any clinical manifestations of maternal infection. She was subjected to ANC at the outpatient clinic every 2 weeks, where vaginal culture, complete blood count, prothrombin time, and C-reactive protein levels and serial ultrasonography were checked consistently. The fetus showed adequate growth. After 136 days, she delivered by elective cesarean section a male baby weighing 2850 g at 37 weeks of gestation with good recovery. In certain situations, delayed delivery of the second twin of diamniotic dichorionic twin pregnancy may be a safe, simple with less interventions, and effective option to improve pregnancy outcome.
Keywords: cerclage, delivery, dichorionic diamniotic
|How to cite this article:|
Nassef AH, Ahmed D, Abd Elwahab M. Achievement of a 136-day delayed-interval delivery of a second twin with minimum intervention. Al-Azhar Assiut Med J 2022;20:304-7
|How to cite this URL:|
Nassef AH, Ahmed D, Abd Elwahab M. Achievement of a 136-day delayed-interval delivery of a second twin with minimum intervention. Al-Azhar Assiut Med J [serial online] 2022 [cited 2023 Jan 27];20:304-7. Available from: http://www.azmj.eg.net/text.asp?2022/20/3/304/358040
| Introduction|| |
The rate of multiple pregnancies in the last three decades has increased dramatically . Twin pregnancies have a higher risk of spontaneous miscarriage and premature birth, and premature birth, and a higher risk of morbidity and mortality . Premature delivery of the first twins is usually followed by spontaneous birth of the second twin after an average of 1.1 days . A smaller numbers of case reports show that there are ways to keep the second twin longer after the birth of the first twin in dichorionic diamniotic twin pregnancies, which improves the survival of the second twin. Some studies report the efficacy of certain interventions allowing the second fetus to stay longer in utero after the delivery of the first twin . However, there is insufficient evidence to support the role of those interventions. As a result, the management tends to vary depending on the case and the managing team .
| Case report|| |
A case of a 40-year-old, G5P4, woman who had three cesarean sections is presented. She had ovulation induction for secondary subfertility and got pregnant with dichorionic diamniotic twins (chorionicity was determined by early first trimester scan). She was diagnosed with gestational diabetes, and her blood sugar was well controlled with diet and physical exercise, and her blood group was O negative. She was following her pregnancy in Al-Orf secondary level hospital, Kuwait. At 17 weeks of gestation, she had an ultrasound scan that revealed dichorionic diamniotic twin viable pregnancy, with two placenta one anterior and one posterior. The first fetus had cephalic presentation, with measurements of 17 weeks +4 days, foetal heart rate (FHR) 149/min, and estimated foetal weight (EFW) 191 g, and the second fetus had breech presentation, with measurements of 17 weeks +2 days gestation, FHR 132 bpm, and EFW 186 g. No gross anomalies were detected, and the cervical length was 32 mm. At 4 days after the clinical visit, she developed sudden severe lower abdominal pain, vaginal bleeding, and rupture of membranes of the first fetus. She presented in our emergency room (ER) with vaginal bleeding and spontaneous expulsion of the first fetus weighing 179 g. After the delivery of the first twin, the uterine contractions stopped; the cervix was reconstituted soon after the delivery, the placenta was retained and the vaginal bleeding was minimal. The amniotic membrane of the second twin remained intact. At this point, the mother’s perineum and vagina were disinfected with an antiseptic solution (chlorhexidine), the umbilical cord of the first fetus was cut at the level of the external cervical os, and its placenta was left inside the uterus. After 4 h, an ultrasound showed a single viable second twin, of 17 weeks in size, and two placentae, with adequate liquor and normal cervical length of 38 mm. There were no signs of chorioamnionitis. After discussing the potential benefits and risks of the delayed-interval delivery for the second twin with the obstetric team and the patient, she was keen to continue with the pregnancy, and an informed consent was obtained from both parents. Cervical cerclage was not offered as the cervix was reconstituted, and the vaginal bleeding ceased. The patient stayed in the hospital for 6 days before being discharged (on her request). There was no clinical manifestation of maternal infection (no uterine tenderness and no fever), and maternal laboratory tests confirmed the absence of infection. At the time of admission, laboratory tests indicated normal leukocytic count (8.9×103/μl) and C-reactive protein (CRP) levels of 6.98 mg/l)with upper normal laboratory limit of 6 mg/l). Urinalysis and urinary cultures were both normal. The patient was given intravenous fluids, anti-D prophylaxis, paracetamol injections, and prophylactic broad-spectrum antibiotics, 3 days of ceftriaxone and metronidazole 500 mg intravenous injections every 12 h followed by 7 days of oral amoxicillin 500 mg every 8 h. Clinical examination, ultrasound, and laboratory tests were performed 3 days later. The parents were aware about the risks of chorioamnionitis, subclinical infection, and other fetomaternal risks that needed close monitoring and follow-up. They were also informed about the need to terminate the pregnancy at any time if any complications develop, such as preterm rupture of membranes of the remaining fetus, chorioamnionitis, and severe vaginal bleeding. For that, vaginal culture, complete blood count, prothrombin time, and CRP levels and serial ultrasonography for fetal growth and well-being were consistently checked every 2 weeks. Digital vaginal examinations were avoided as possible. She remained afebrile and showed no signs of chorioamnionitis. Moreover, the fetus showed adequate growth. At 32-week gestation, she was given a repeated dose of anti-D prophylaxis and steroids for lung maturation. Finally, she delivered by planned cesarean section owing to her prior uterine scars a male baby weighing 2850 g at 37 weeks of gestation. Finally, the mother made a good recovery and was discharged from the hospital with her baby after 3 days.
| Discussion|| |
In some cases of premature delivery of twin pregnancies, delaying the delivery of the remaining fetus (es) is feasible . The birth of the first fetus in a multiple pregnancy is commonly followed by the delivery of the remaining fetuses. However, uterine contractions may stop once the first fetus is delivered. The delay of the delivery of the remaining twin may decrease the neonatal morbidity and mortality .
In our case, delayed birth of the second twin presented a challenge for the medical team and the mother till the birth of second twin after 136 days. In literature, the duration of latency period was reported to range from 1 to 152 days . According to several researchers, a longer delivery interval is related to a substantial increase in birth weight and neonatal survival, as well as a decrease in unfavorable outcomes .
The management of multiple pregnancies with delayed interval delivery is not yet standardized. Cervical cerclage, hospitalization, antibiotic treatment, and tocolysis are all hotly debated procedures. In our case, cervical cerclage was not offered as the cervix closed quickly after delivery of the first fetus. The use of cervical cerclage is the most contentious of the therapeutic modalities. Arabin and van Eyck  suggest that cerclage should be best avoided owing to concerns of chorioamnionitis. On the contrary, other authors prefer cerclage because it may improve cervical stability, reduce fetal membrane exposure to vaginal germs and acidity, and lengthen the intertwin delivery interval, all of which may improve newborn morbidity and mortality . On the contrary, others are against this procedure . Furthermore, some writers only recommended cervical placement when cervical incompetence was considered as the cause of preterm labor .
In our case, we just cut the cord at the level of the external os without ligation 1 h after the delivery of the first fetus and the diagnosis of retained placenta. In the literature, it was mostly emphasized that the usual approach is high ligation of umbilical cord of the first fetus .
In our case, the placenta of the first twin was left inside the uterus during the conservative management and the second twin delivery was occurred after 136 days which has no clear relation effect. There is no evidence that the retention of the placenta causes any difference in the management or the occurrence of the maternal complications such as disseminated intravascular coagulopathy ,. Even a large placental mass can be retained inside the uterus and produce no demonstrable clinical manifestation ,. In another case report, the placenta was delivered immediately after the delivery of the first twin followed by McDonald cerclage, and the patient was treated with tocolytics and antibiotics, with a 101-day interval period and delivery at full term . Daniilidis et al.  reported a case with retained placenta of the first twin, with cervical cerclage and tocolytics but with a lag period of 3 weeks only where contractions developed.
Tocolytic treatment was not used in our case as the mother had no uterine activity. In literature, some authors recommend routine tocolysis after the birth of the first twin . However, others considered tocolytic therapy only once viability  and uterine activity  had been shown. Both tocolytics and cerclage appear to prolong the mean delivery interval, but no statistically significant difference was found .
A prophylactic broad-spectrum antibiotic was used in this case for 10 days started immediately after the delivery of the first fetus. However, there is no clear evidence stating that the early antibiotic therapy, tocolytic, and glucocorticoids to stimulate lung maturation may delay delivery and improves perinatal outcomes of the second twin . Antibiotics may have tocolytic effects in complement to protection against ascending infections . Many authors concur that patients should have broad-spectrum antibiotic prophylaxis upon delivery of the first twin ,,,,. However, there is no fixed regimen for the antibiotic of choice, route of administration, and the duration of treatment .
Our management was based on an outpatient follow-up with rest at home with avoidance of strenuous efforts, which was helpful for the prolongation of the gap period with high patient satisfaction. There is no evidence to support or deny the effectiveness of home or hospital management to avoid preterm delivery. Despite bed rest being commonly prescribed as an initial step in the management of preterm delivery, there is no proof that it is effective . The common opinion is that bed rest has little effect on preventing premature delivery in singleton pregnancies  and may be associated with a higher risk of thrombosis. Agreed with our case, some reports permitted patient home management ,,. Our patient was subjected to outpatient follow-up with vaginal culture, full blood count, prothrombin time, and CRP levels every 2 weeks, and this is almost enough to exclude fetal and maternal infections as the patient was afebrile till term. Although many authors stated that monitoring should be limited to a full blood count, CRP, prothrombin time, and fibrin degradation product once a week . Van de Laar et al.  found in their systematic review that although CRP was proven to be a moderate predictor of chorioamnionitis, its utility has not been confirmed. The maternal white blood cell count, according to Popowski et al. , has a low predictive value and when the criterion of 16 000/μl is achieved, it is classified as highly specific. Park et al.  proposed that measuring maternal white blood cell and CRP levels, as well as parity and gestational age, might be useful to predict intra-amniotic infection in singletons with preterm premature rupture of membrane.
In our instance, the second twin showed adequate growth on the serial growth scans and weighed 2850 g at birth at 37 weeks, which was appropriate for its gestational age. This is in contrast to some authors who claimed that a delivery gap of more than 4 weeks was linked to a higher risk of small for gestational age regardless of the gestational age at the first twin’s delivery .
Delayed delivery interval of the second twin in dichorionic diamniotic twin pregnancy may be a safe and effective management option to improve live birth rate of those pregnancies. The evidence and details of the recommended management are lacking. Our case study depicts a successful scenario with minimal intervention and good fetal and maternal outcome, and it can be considered as a model for future studies.
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