Delayed Interval Delivery in Multiple Gestations

Abstract

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.

Management of Delayed-Interval Delivery in Multiple Gestations

“…Twenty-two good perinatal evolutions are found among latter-born siblings, 2 months to 6 years later [6,[8][9][10][11][12][14][15][16][17][18][19][20][21][22][23] . Three cases of motor retardation have been noted at 15 [19] and 33 months [17] . In our series, the two latter-born survivors have a normal psychomotor and growth development at 3 years of age.…”

A case report of a delayed-interval delivery in a dichorionic diamniotic twin pregnancy

“…One review discussed the importance of delayed-interval deliveries that took the second sibling past the 24th week, or the week of viability. 8 Of such cases, 24/70 neonates survived and the range of latency was 3-143 days, with a mean latency of 44.8 days. Of the delayed deliveries that resulted in neonatal viability, the mean latency period was 57.5 days.…”

“…5 Although most preterm twin births result in delivery of both fetuses over a short interval, there are cases where the uterus will stop contracting after the first delivery. 8 Given the absence of fetal distress, infection, congenital malformation or placental abruption, this provides an opportunity where delivery of the second fetus can be delayed in order to increase survival rate and decrease morbidity of prematurity of the second twin, assuming a dichorionic diamniotic pregnancy. This method is referred to as a delayedinterval delivery.…”

“…There is currently no consensus regarding technique nor is there statistical significance in techniques currently used. 8 A delayed-interval delivery is indicated when it is believed the delayed arrival of the second twin will improve its outcome. Neonatal survival after preterm delivery correlates directly with the number of days in utero from gestational ages 23 through 28 weeks.…”

“…16 The critical period of perinatal morbidity and mortality is between weeks 23 and 28 of gestation. 8 Case A 37-year old G2P0 with dichorionic diamniotic twin pregnancy resulting from IVF presented at 23w2d to a high risk obstetrics centre after experiencing previous preterm premature rupture of membranes of twin A at 19 weeks gestation with persistent oligohydramnios. The ultrasound examination revealed cephalic presentation for twin A with transverse presentation for twin B.…”