In the last ten years, there has been a significant increase in the number of twin pregnancies, particularly in relation to the increased use of assisted reproductive technologies. Concomitantly, the incidence of abortions or of premature births has also increased (Tummers et al., 2003). In the literature, there are reports of twin pregnancies, wherein there is the possibility for expulsion of the first fetus with subsequent continuation of the pregnancy and a positive outcome for the remaining fetus (Wouters et al., 2009). It is in this context that we present a case that occurred in our department of a birth at 38 weeks via cesarean section, followed by uterine atony, after expulsion of the first fetus at 16 weeks.
Materials and MethodsA 31-year-old woman, parity 1-0-0-1, conceived a spontaneous twin pregnancy after a prior singleton delivery by cesarean section for fetal macrosomia. At 13 weeks, she was admitted to the hospital due to pelvic pains, metrorrhagia and risk of abortion. Her body temperature, blood pressure and heart rate were normal. The uterine cervix was closed with discreet vaginal hematic loss. Ultrasound observation was performed. Her hematic values were normal, and tocolysis (isoxsuprine hydrochloride, 60 mg/day) was initiated. After four days of hospitalization, the hematic leaks disappeared. At 16 weeks, the first twin spontaneously aborted, and its placenta was retained RECEIVED within the uterus. After birth of the first twin, tocolysis combined with antibiotics (ceftriaxone sodium, 1 g/day) was continued for 1 month. At 38 weeks, it was decided that hospitalization for extraction of the fetus by an iterative cesarean section would be appropriate. Ultrasound observation was performed. A healthy, male newborn weighing 3,790 g with Apgar scores of 9 and 10 at 1 and 5 min, respectively, was delivered. Subsequently, the placenta of the living fetus (weighing 650 g, regular with respect to form and volume) was easily extracted, while extraction of the atrophic placenta belonging to the fetus expelled at 16 weeks was quite difficult due to its strong attachment to the anterior wall of the uterus. Moreover, postpartum hemorrhage occurred due to atony of the anterior uterine wall, corresponding to the site of the atrophic placenta. Despite the administration of oxytocin (50 IU) and methylergometrine (0.4 mg/M), the atony was only resolved through intravenous administration of sulprostone (0.5 mg). Histological examination of the extracted placentas was performed. This report presents the uncommon case of a 154-day delayed delivery in a spontaneous twin pregnancy associated with uterine atony. After abortion of the first fetus at 16 weeks, a healthy male was born at 38 weeks. Postpartum hemorrhage due to uterine atony, which was successfully treated with prostaglandins, occurred.■
