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

Discussion

It is well known that twin pregnancies are associated with a higher risk of preterm delivery, and at a significantly earlier gestational age than singletons, resulting in infant morbidity and mortality.1 Delivery of the presenting fetus in twin gestation is usually followed by delivery of the second fetus within a short period of time. Traditionally, this situation is managed by delivery of both fetuses, either vaginally or by cesarean section. However, gestational age is the most important predictor of neonatal survival in immature infants. Especially, extreme prematurity – before 25 weeks of gestation – is associated with poor postnatal outcome. Prolongation of gestational period and increase in fetal weight significantly improve the outcome. Considering these, in recent years, an attempt to prolong the pregnancy for the second twin, even after the first twin’s delivery, has increasingly been discussed, and a large number of cases with good results have been published. According to a prospective study published by Arabin and van Eyck2 with obstetric follow-up of 50 cases of multiple pregnancies, the delayed birth of the second twin is associated with better perinatal results if the birth of the first twin happens between weeks 20 and 29.

The reported intervals varied widely. In a population-based study that included 200 pregnancies with delayed delivery, Zhang et al3 reported that the median duration of delay was 6 days. An average interval delivery of 6.33 days (1–14 days) was also reported in a case series by Benito Vielba et al.4 Since delayed-interval delivery is an attempt applied during the extreme preterm period, prolonging a pregnancy by 6 days must contribute to improvement of the infantile outcome. Several investigators have reported longer intervals. Rosbergen et al5 published a study of 24 cases of attempted delayed-interval delivery and described that the mean of the delay was 19.9 days. Kalchbrenner et al6 published a study of seven cases and reported delayed delivery of the second twin with a mean of delivery interval of 36.2 days. Fayad et al7 reported a study of 35 cases with a mean interval of 47 days. Meanwhile, remarkable prolongation has been reported in a few cases. The case with the longest interval between the births of both twins spanned 154 days.8 Aydin and Celiloglu9 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.8,10–12 Delay of delivery beyond 36 weeks seems relatively scarce, and our case is an additional one.

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Figure 2

Placenta of the dead twin was atrophic in comparison with placenta of the viable twin

There is no established management strategy for delayed interval delivery. This technique may involve severe complications, primarily chorioamnionitis and abruptio placentae.2,13 Therefore, after the delivery of the first fetus, the patient must have clinical follow-up and blood tests for clinical complications like chorioamnionitis and placenta abruptio. Prevention of chorioamnionitis is believed to be the most important key for a successful outcome. To avoid ascending infection, the cord of the first-born twin should be ligated with an absorbable suture as close to the cervix as possible, under aseptic conditions. Empiric broad spectrum antibiotic treatment should be initiated from the delivery. The control cervicovaginal cultures should be sampled on a periodic basis, and culture-directed antibiotic therapy according to the antibiogram is recommended until negative cultures are confirmed. The most controversial issue in management of delayed-interval delivery is whether cervical cerclage is necessary under these circumstances. Some authors have accentuated the positive effect of cerclage.3,6,11,14 Cerclage may provide stability to the cervix; furthermore, it may minimize the exposure of fetal membranes to vaginal bacteria and acidity. We also had a management policy of cervical cerclage, and a favorable outcome was achieved. On the other hand, some authors have taken a negative stance.2,4,10,15 No randomized controlled trials regarding the efficacy of cervical cerclage in delayed interval delivery are reported in the literature. Consequently, each situation should be individualized, depending on possible risks, patient wishes, and contraindications. In our case, we performed cervical cerclage even though the gestational age was 25 weeks, because in our country (Japan), therapeutic cerclage is usually considered a possible option if the gestational age is <26 weeks.16 Furthermore, in our case, two tocolytic agents were simultaneously administered over a prolonged period with close and careful observation for maternal complications. A Japanese study has recently suggested that maintenance tocolysis using a combination of tocolytic agents may be effective in a few cases including in women undergoing cerclage;17 however, long-term use of tocolytic agents in pregnancy can be associated with an increased risk of maternal adverse effects. Thus, in our opinion, further studies are necessary to gain a better understanding regarding the appropriate use of tocolytic agents in cases of delayed-interval delivery.

We reported a case of delayed-interval delivery, wherein prolongation of the second twin’s delivery until term with a subsequent favorable infantile outcome could be obtained. We believe that delayed-interval delivery can be effective in prolonging gestation and should be an option if the first twin developed an extreme preterm delivery.