Objectives Conclusions

References1. Tzafettas JM, Farmakides G, Delkos D, et al.

Asynchronous delivery of twins and triplets with a delivery interval ranging from 48 hours to 19 weeks. Clin Exp Obstet Gynecol. 2004

2. Zhang J, Hamilton B, Martin J, Trumble A. Delayed interval delivery and infant survival : a population based study.AmJ Obstet Gynecol 2004;191:470.

3. Minakami, H, Honma, Y, Izumi, A, Sayama, M. Emergency cervical cerclage after the first delivery in a twin pregnancy with dichorionic placenta. Am J Obstet Gynecol 1995; 173:345.

The incidence of twin pregnancy has markedly increased with the prevalence of assisted reproductive techniques and increasing maternal age .Multiple pregnancy poses risk for both mother and fetuses. The greatest risk is preterm delivery followed by the increase in neonatal morbidity and mortality associated with prematurity. Recently, attention has been paid to the methods of delaying the birth of the second twin to improve neonatal outcome and decrease neonatal morbidity and mortality in multiple pregnancies. We experienced a case of six weeks delayed interval delivery in dichorionic-diamniotic twin in our unit with good neonatal outcome for both twins.

The aim of this report is to add our experience regarding the best management of this serious obstetrical problem.

We report a case of 40 year old primigravida presented to our unit at 25weeks 5 days gestation with diamniotic dichorionic pregnancy and premature preterm rupture of 1st amniotic sac. She had history of 17 years of primary infertility due to male factor and had 4 failed ICSI during that time . In 5th ICSI she fortunately conceived with triplet and had fetal reduction to twins at 10 weeks gestation . She was known hypertensive and was on antihypertensive medication and also Gestational Diabetes controlled on diet.

In our case, the pregnancy prolongation resulted in a clinically significant benefit to the 2nd twin without significant morbidity to the mother. The unavoidable birth of one premature neonate led our efforts to aim for a delayed interval delivery for the other twin. Based on the case presented ,we conclude that although delayed interval delivery impose a greater challenge to the Obstetrician and a psychological stress to the mother , but a properly selected ,well counseled ,sensible and vigilance approach can result in a successful and reasonable outcome ,without a significant morbidity to mother. In spite of these we still need more studies and a prolonged follow up of these twins to support our view and ideal management protocol for delayed interval twin delivery.

A written informed consent was obtained from patient for publication of this case report .

On admission she was having mild uterine contractions and draining clear liquor. On speculum examination internal os was close and cervix was shortened. Ultrasound revealed 1st twin cephalic presentation ,oligohydramnios and estimated fetal weight 800 gm with 2 different placenta .On investigation WBC count 14 x109/l , Hemoglobin 11 g/dl and high vaginal swab revealed heavy growth of Candida but no bacterial growth.She was treated with bed rest ,Intravenous antibiotics ,tocolytic (tractocile) infusion, corticosteroids and local antifungal. She remained a febrile .3 days later at 26 weeks gestation she had vaginal delivery of male infant of 720 gm with apgar score of 4 at 1 minute . Successful attempt was made to ligate the umbilical cord with silk ,as high as possible in the cervix under aseptic conditions and placenta was left inside uterus. Cervix became 4 cm dilated with unruptured 2nd twin amnion. Ultrasound revealed alive fetus with normal liquor amount. Intravenous tocolysis was re administered along with antibiotics Once the uterine contractions ceased ,McDonald cervical encerclage was placed after 24 hours delivery of 1st twin. Plan was made to intervene if there is any fetal or maternal indication otherwise to deliver 2nd twin at 32 gestation. Apart from maternal emotional upset, clinically and biochemically mother and fetus biophysical profile remain satisfactory. Cervical suture was removed at 30 weeks because of spontaneous rupture of second sac and there was no signs of chorioamnionitis.

At 32 weeks gestation after 40 days of delivery of 1st twin ,she underwent spontaneous vaginal delivery of male infant weighing 1.5 kg with apgar score 8 &9 at 1 minute and 5 minute.3rd fetus (fetus paparyceous) delivered soon after delivery of second twin. Second placenta were delivered manually under General anesthesia. Postnatal maternal recovery was uneventful .1ST infant stayed in NICU for nearly 2 months and 2nd infant for 48 hours for antibiotic cover. Both twin infants were discharged from hospital and followed up later with no signs of physical and neurological morbidity until now.

Delayed interval deliveries have been the subject of limited case reports and review and there is no consistent data regarding the best management and outcomes of these multiple pregnancies. Each case is unique medical situation that must be met with best possible situation.

Most of the modern management protocols including intravenous tocolysis, corticosteroids ,antibiotics and rescue cerclage after the delivery of 1st twin would appear to be important in overall success of treatment. The multicentre studies about delayed interval deliveries identified that one year survival rate in the delayed delivery group was twice higher than non delayed interval deliveries

Case Description

Discussion

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