Delayed Delivery of a Twin Pregnancy and Uterine Atony: Morphological and Clinical Evidence

Abstract

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.■

Prolongation of Second Twin’s Delivery Until Term: A Rare Case of Delayed-Interval Delivery

“…Furthermore, some studies have reported cases of pregnancy prolongation of more than 100 days. 8,[10][11][12] Delay of delivery beyond 36 weeks seems relatively scarce, and our case is an additional one.…”

“…The case with the longest interval between the births of both twins spanned 154 days. 8 Aydin and Celiloglu 9 described a case wherein, after the delivery of the first twin at 21 weeks' gestation, a 3639g infant was delivered with cesarean section at 36 weeks' gestation and had an uneventful neonatal course. Furthermore, some studies have reported cases of pregnancy prolongation of more than 100 days.…”

Parto asincrónico en un embarazo gemelar. Primer reporte de caso en el Perú

“…dIscusIón En 1879, Carson JCL reportó el primer caso de PA, con un intervalo de tiempo entre ambos partos de 44 días (4) . El PA con el intervalo más largo ha sido de 154 días (5) . Lamentablemente, no se conoce la incidencia real, ya que la bibliografía se limita a reportes de casos y series sujetas al sesgo de informar solo los resultados positivos.…”

“…El riesgo de complicaciones maternas puede ser hasta de 38%, siendo las infecciones locales y sepsis las más frecuentes, seguidas por hemorragias posparto, desprendimientos de placenta, histerectomías posparto y fístulas uterovaginales. No se ha comunicado casos de muerte materna (2,5) . Asimismo, un estudio retrospectivo en pacientes con complicaciones graves describió amniocentesis negativas al evaluar la corioamnionitis subclínica, por lo que es importante resaltar que el riesgo podría ser difícil de predecir (11) .…”

Delayed-Interval Delivery in Multifetal Pregnancy: A Review and Guidelines for Management

“…Since then, medical teams across the word have understood the considerable interest in delaying delivery of the remaining multiples after immature delivery. Countless case reports have been published, describing the feasibility of delaying the delivery of twins, triplets or higher-order multiples, the longest delay ever reached being 154 days [2].…”