Case Reports in Women's Health 21 (2018) e00093

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Case Reports in Women's Health

journal homepage: www.elsevier.com/locate/crwh

Successful delayed-interval delivery in monochorionic diamniotic twin

pregnancy: A case report
Tanja Baltus ⁎, Maria Luisa Martin
Department of Obstetrics and Gynaecology, Blacktown Hospital, New South Wales, 18 Blacktown Road, Blacktown, NSW 2148, Australia

a r t i c l e i n f o a b s t r a c t

Keywords: Delayed-interval delivery in twin pregnancy is a rare occurrence. It is sometimes performed in twin pregnancies
Delayed-interval delivery when the first twin is born at the limit of viabililty, to improve outcome for the second twin. It has been suggested
Twin pregnancy that monochorionicity is a contraindication to delayed-interval delivery in multifetal pregnancy. The literature
Monochorionic describes only a dozen cases over the last 20 years and only a handful of these reports specify success.
Diamniotic
We describe a case of a successful delayed-interval delivery of monochorionic diamniotic twins following
prelabour rupture of membranes at 20 weeks of gestation. The first twin was previable, delivered at 23 weeks
and 2 days of gestation, but the second twin was delivered at 24 weeks and 1 day of gestation and survived.
Practitioners could consider delayed-interval delivery in monochorionic diamniotic twin pregnancy in a closely
monitored environment if the first twin is born peri-viable, to obtain an improved outcome for the remaining
fetus.
© 2018 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction Following extensive multidisciplinary discussion, a collective deci-

sion was made not to initiate active resuscitation until 24 weeks of ges-
Delayed-interval delivery (DID) is sometimes considered in selected tation. The patient was discharged from hospital for close outpatient
twin pregnancies when the first twin is born peri-viable after an insuf- management at 22 weeks of gestation following 2 weeks of admission.
ficient period of gestation. As neonatal morbidity and mortality are The patient was stable on discharge with a closed cervix and unchanged
often dependent on gestational age at birth, the aim of DID is to improve AFI. Fetal monitoring consisted of biophysical assessment at regular in-
outcome for the second twin. Monochorionicity is often regarded as a tervals; no abnormalities were detected. Maternal monitoring consisted
contraindication to DID in twin pregnancy due to the risks to the re- of regular serum inflammatory markers and rotating antibiotics.
maining fetus [1]. Because of the overall rarity of DID in twin pregnancy The patient was re-admitted at 23 weeks of gestation with TPL. Spec-
and as most studies exclude monochorionicity, high-quality data are ulum examination revealed an open cervix with the first twin in breech
lacking. We present a case of successful DID of monochorionic presentation. At 23 weeks and 2 days of gestation, a 555-g female infant
diamniotic (MCDA) twins. was delivered via spontaneous vaginal breech delivery and no resuscita-
tion was initiated. After delivery of the first twin, the umbilical cord was
ligated high in the vagina. The family was counselled regarding the op-
2. Case Presentation
tions for the second twin and the family opted for DID. A cervical
cerclage was not performed. The patient was given steroids at
A 33-year-old woman, gravida 2 para 1, with a MCDA twin preg-
23 weeks and 5 days of gestation and she was transferred to a tertiary
nancy presented at 20 weeks of gestation with preterm premature rup-
obstetrics unit.
ture of membranes (PPROM). Diagnosis of PPROM was confirmed
Due to suspected chorioamnionitis she was induced with an oxyto-
clinically based on the large amount of amniotic fluid visible in the pos-
cin infusion at 24 weeks and 1 day of gestation. The patient was given
terior fornix and by means of a positive AmniSure rupture of membrane
intravenous magnesium sulphate for fetal neuro-protection.
test. The amniotic fluid index (AFI) on admission was satisfactory, with
A 698-g female neonate was delivered via vaginal breech delivery
the deepest pocked being greater than 4 cm for both twins. There were
with Apgar scores of 3 at 1 min and 5 at 5 min; the umbilical arterial
no signs of threatened preterm labour (TPL) on admission. Antibiotic
blood pH was not recorded. The neonate received full resuscitation
coverage was started as well as analytic and ultrasound monitoring.
and immediate life-support. The fused placenta was spontaneously
⁎ Corresponding author.
delivered.
E-mail addresses: [email protected] (T. Baltus), There were no maternal complications and the neonate was
[email protected] (M.L. Martin). discharged after 3 months and remained well at the time of writing.
2 T. Baltus, M.L. Martin / Case Reports in Women's Health 21 (2018) e00093

3. Discussion Contributors

The incidence of twin pregnancy is increasing, partially due to in- Tanja Baltus MD and Maria Luisa Martin MBBS were equal and sole
creasing maternal age and medically assisted reproductive techniques. contributors.
Currently, multiple gestations comprise approximately 4% of all live
births. One of the most serious risks of twin pregnancy is preterm deliv-
Conflict of Interest
ery (PTD). The incidence of PTD in twin pregnancies is up to 60% and is a
major factor in perinatal morbidity and mortality [2].
The authors declare that they have no conflict of interest regarding
The causes of PTD are broadly classified into three subtypes: PTD
the publication of this case report.
after PPROM; spontaneous onset of labour; and iatrogenic PTD for ma-
ternal for fetal indications. In our case, PPROM was associated with
PTD. PPROM has been shown to complicate up to 8% of twin pregnan- Funding
cies, of which 15–20% occur before fetal viability [3]. Although the treat-
ment of PPROM in twin pregnancies is similar to that in singleton No funding was sought or secured in relation to this case report.
pregnancies there may be additional challenges, such as the possibility
of DID if the first twin is born peri-viable after an insufficient period of Patient Consent
gestation. Our patient was admitted with PPROM at 20 weeks of gesta-
tion and we undertook close outpatient monitoring from 22 weeks of Written informed consent was obtained from the patient for the
gestation. However, we would like to specify that this is feasible only publication of this case report.
in strict selected cases, where maternal-fetal wellbeing can be assured,
depending on individual patient characteristics, local health-care infra-
structure and multidisciplinary approval. Provenance and Peer Review
The success of DID in terms of neonatal outcome is variable, and, due
to the rarity of DID in twin pregnancies, there are no large-scale studies This case report was peer reviewed.
and no formal guidelines. The majority of published studies see
monochorionicity as a contraindication to DID as the vascular anasto- References
moses in the retained placenta may cause complications for the retained
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