Multiple Pregnancy Delivery Research Articles

Obstetric and fetal short- and long-term outcomes of delayed-interval delivery in multiple pregnancies

IntroductionMultiple pregnancies are at higher risk of preterm birth. However, both children do not necessarily have to be born and exposed to the morbidity of prematurity. One option is a delayed-interval delivery with reduction of morbidity and mortality for the second twin. The present case series demonstrates the feasibility and safety of this procedure including the long-term outcome of the surviving children compared to the overall outcome of premature born children at the same perinatal center. MaterialRetrospective evaluation of all cases of delayed-interval deliveries in multiple pregnancies from 2003 to 2020 at the Women's and Children's Hospital of the University Hospital Ulm. ResultsIn 17 cases, the delivery of the second twin could be delayed, on average by 36 days. Pregnancies with delivery of the first twin before 22 weeks of gestation had a longer prolongation than pregnancies with delivery of the first twin after 22 weeks (53 vs. 22 days). If a cerclage was placed after the delivery of the first twin a longer prolongation interval could be achieved (45 vs. 19 days). No severe maternal morbidity occurred, and the short- and long-term outcome of the second twin did not differ from age-matched controls. ConclusionsIn multiple pregnancies with extremely preterm birth of the first twin, delivery of the second twin can in some cases be successfully postponed without serious maternal morbidity or additional fetal complications. Delivery of the first twin before 22 weeks of gestation and placement of a cerclage is associated with a longer prolongation interval.

Obstetric and perinatal aspects of multiple pregnancy

The article presents epidemiological data, modern terminology, features of the course of gestation, as well as obstetric and perinatal outcomes of childbirth in women with multiple pregnancy. The relevance of study this problem is due to the fact that the course of multiple pregnancy in almost all patients is accompanied by various complications, and their prognosis and prevention are of paramount importance. Despite the attention paid to multiple pregnancy, the complication rate remains high. Their treatment should be carried out in III level of perinatal care facilities. Attention is focused on the features of childbirth of pregnant women in accordance with the procedure for providing medical care to women with multiple pregnancies. An important issue remains to determine the time and tactic of delivery in multiple pregnancy. The choice of childbirth method depends on the obstetric anamnesis, gestational age, position and presentation of fetuses, estimated weight and size of fetuses, chorionicity, fetal and maternal condition, and the presence/absence of indications for caesarean section also matters. The optimal delivery time for uncomplicated twins is 37 weeks of pregnancy (monochorionic diamniotic twins — 36–37 weeks, dichorionic — 37–38 weeks), since in this period of pregnancy, the risks of antenatal fetal death and early neonatal death are minimal. Delivery of women with monochorionic monoamniotic twins is performed at the full 32 weeks of pregnancy by caesarean section. Among other indications for caesarean section are triplets and a larger number of fetuses, as well as conjoined twins, transverse or breech presentation of the first fetus, twins in combination with a scar on the uterus, an unsuccessful attempt of external-internal rotation of the second fetus in a transverse position after the birth of the first fetus, and others. An analysis of domestic and foreign publications was carried out in the article, which indicates the need for in-depth research in this direction, namely the elucidation of new pathogenetic links in multiple pregnancies, depending on the type of placentation, the search for new ways of management and the development of diagnostic criteria for the childbirth of this contingent of women.

Current views on the possibility of cervical insufficiency correction

The main role in spontaneous abortion in 2nd and 3d trimesters is assigned to cervical insufficiency. According to a number of researchers, bed rest, elevated lower limbs, restriction of physical activity, tocolysis, antibacterial therapy do not affect the prolongation of pregnancy and are ineffective for preventing premature spontaneous labor. Correction of cervical insufficiency can be carried out by a vaginal form of progesterone, cerclage, pessary. The use of vaginal progesterone is justified in women with recurrent miscarriage, a history of premature birth, and shortening of the cervix to less than 25 mm. Indications for surgical correction are limited to patients with habitual loss of pregnancy due to cervical weakness or a history of premature birth. In the absence of significant obstetric history, cerclage has no advantages over the use of progesterone. The optimal time for cerclage is up to 20 weeks of pregnancy. Unlike progesterone cerclage has complications, the frequency and severity of which are attributable to the timing and indications for correction. Transabdominal cerclage is performed only when there is a technical impossibility of vaginal access due to the absence of a vaginal part of the cervix or after unsuccessful attempts of vaginal cerclages. Most often, the use of a pessary is associated with the diagnosis of a short cervix in terms of more than 24 weeks of gestation in the absence of an aggravated history. The combined use of gestagens, pessary and cerclage does not increase the efficiency of carrying a singleton pregnancy. Methods for the prevention of preterm delivery in multiple pregnancy, such as the introduction of a specialized outpatient service, bed rest, antibacterial therapy, progesterone, preventive cerclage or the insertion of a pessary do not change the incidence and mortality of newborns.

Cervical pessaries for the prevention of preterm birth: a systematic review and meta-analysis

Objective: The objective of this study is to evaluate the effectiveness and safety of cervical pessaries for the prevention of preterm birth.Methods: We searched PubMed, Embase, Web of Science, and other sources from inception to July 2016. This analysis referred to pregnant women with singleton/multiple viable fetus/fetuses, with or without cervical pessary placement.Results: Six randomized control trials and five cohort studies involving 3911 participants were included. Overall, cervical pessary placement was slightly associated with the decrease of spontaneous delivery less than 34 weeks (relative risk 0.65 [95% CI: 0.44–0.96]) and increased gestational age at delivery (weighted mean difference 1.03 weeks [95% CI: 0.37–1.70]) in multiple pregnancies, but not with poor perinatal outcomes. Pessary placement in singleton pregnancies did not show any difference. A planned subgroup analysis showed multiple pregnancies with shorter cervical length (≤25 mm) had a longer prolongation of pregnancy (weighted mean difference 2.08 weeks [95% CI: 1.35–2.82]).Conclusion: This meta-analysis suggested pessary placement could slightly reduce the rate of spontaneous preterm delivery before 34 weeks, and increase gestational age at delivery in multiple pregnancies, but not in singleton pregnancies. More studies of high quality with detailed records are urgent to confirm the efficacy of this procedure.

The combined use of various forms of micronized progesterone in the treatment of the threat of termination of pregnancy in multiple pregnancies

The article highlights the data on the features of the etiology and pathogenesis of the threat of premature birth in a multiple pregnancy. The results of a clinical study of the effectiveness of combined therapy in the threat of termination of pregnancy in women with multiple pregnancies with sublingual and vaginal forms of micronized progesterone are presented.In the course of the study 120 twins pregnancies with signs of miscarriage in terms of 14–28 weeks were analyzed. The first group consisted of 40 women who were offered a sublingual form of natural micronized progesterone in combination with the vaginal form (drug Luteina) in the scheme of treatment and prophylactic measures. The second group included 40 women, who received a synthetic progesterone preparation (dydrogesterone) for treatment of the threat of termination of pregnancy. The control group consisted of 40 pregnant women, who were treated according to the current clinical protocols.The results of the study showed that the effect of the use of the sublingual form of micronized progesterone in the period of severe clinical symptoms of the threat of premature delivery in multiple pregnancy came out twice as fast compared to the oral form of synthetic dydrogesterone, what contributes the rapid elimination of clinical symptoms, regression of ultrasound markers of the threat of miscarriages and prevents further progression of cervix structural changes. The presence of sublingual and vaginal form of micronized progesterone allows, if necessary, to go from one form to another, and also combine both forms to quickly saturate the body of pregnant woman by progesterone in conditions of gestagen deficiency in order to eliminate the symptoms of the threat of pregnancy termination.Therefore, complex therapy of the threat of premature birth with the use of sublingual and vaginal forms of micronized progesterone has a significant therapeutic effect, contributes to a shorter period of inpatient stay, a reduction in the number of complications compared to other progestins and can be recommended for widespread use. The use of natural micronized progesterone in women with the threat of interruption of pregnancy in multiple pregnancies significantly reduces the risk of preterm labor and improves perinatal outcomes.

MULTIPLE PREGNANCY, ANTENATAL CARE PROBLEMS AND THEIR SOLUTIONS RESULTS

Aim of the work. The aim of our study is to summarize the course of pregnancy and delivery in multiple pregnancies in modern conditions. Materials and methods. The analysis of the pregnancy course, labor and perinatal outcomes was carried out in 182 women with diochorionic and 86 patients with monochorionic twins and 40 women with a singleton pregnancy. Multiple pregnancies were proved to be a monochorionic (MH) and diochorionic (DH) that is a high risk factor for perinatal complications. The research included clinical and laboratory examination metods, study of hormonal function of fetoplacental complex (FPC), transvaginal ultrasound examination. Statistical processing of data was carried out using the package of applied programs Microsoft Office Excel 2010 and StatSoft Statistica 6.1. Results and discussion. In the analysis of pregnancy the abortion threat was detected in 51 (59.3%) women with monochorionic and 34 (62%) women with diochorionic twins. Preeclampsia during pregnancy complicated in 26 (30.2%) and 43 (23.6%) patients, with monochorionic and diochorionic placentation type, respectively. A frequent complication of both the MH and DH twins was anemia, which was found in more than half of the surveyed (56.9 and 51%, respectively). Delivery in the case of multiple pregnancies is also much more complicated and is terminated surgically three times more often than in singleton births. The most frequent indications for operative delivery were first breech fetus, fetal distress during pregnancy and childbirth, FGR, severe preeclampsia, premature detachment of normally situated placenta, anomalies of labor activity. These perinatal losses were equally observed both after cesarean section and after spontaneous labor and amounted to 4% at monochorionic and 1.7% at diochorionic twins. The frequency dependence of identified lesions at pregnancy with twins was established by chorionic. Careful observation of the patients with multiple pregnancies in the antenatal period, the prevention of the most frequent complications, ultrasound monitoring of early pregnancy allows a differentiated approach to the management of pregnancy and childbirth, helping to reduce perinatal morbidity and mortality. Conclusions. Multiple pregnancies occur with a large number of complications compared with singletons. Thus, the increase of frequency of multiple pregnancy influences the obstetric and perinatal indicators, pushing this issue in a number of the most pressing issues of modern obstetrics and perinatology.

PP.94 Delayed Interval Delivery in Multiple Pregnancy: A Case Report

We present a very unusual case of a set of twins delivering 87 days apart and with a birth weight difference of 1990 g with survival of both.A 33 year...

99: Mid-pregnancy cervical length and the risk of cesarean delivery in multiple pregnancies

Research has shown that a long cervix in mid-pregnancy increases the risk of cesarean delivery at term in nulliparous women (Smith et al, NEJM 2008). The aim of this study was to identify factors that can predict the mode of delivery in women with a multiple pregnancy who are not delivered by elective caesarean section.

Delayed interval delivery in twin pregnancy without cerclage: Case Report

This report describes a patient-counselling approach and non-surgical management of a dichorionic, diamniotic twin pregnancy where the delivery of the second twin followed the delivery of the first by 59 days. An initial ultrasound scan at twenty and a half weeks gestational age suggested cervical dilatation with protruding amniotic membrane of a dead first twin, and a viable second twin. She aborted the dead fetus at 21 weeks’ gestation and delivered a healthy female infant weighing 1300g at twenty nine and a half weeks gestation. After the loss of the first foetus, delayed delivery in multiple pregnancies can be successful in selected cases as exemplified by the case presentation. In well prepared perinatal centers, with physically and psychologically balanced patients who are well informed about the risks and benefits of the procedure, delayed interval delivery in twin pregnancy without cerclage may be a reasonable strategy.

Pessaries in multiple pregnancy as a prevention of preterm birth: the ProTwin Trial

BackgroundMultiple pregnancies are at high risk for preterm birth, and therefore an important cause of infant mortality and morbidity. A pessary is a simple and potentially effective measure for the prevention of preterm birth. Small studies have indicated its effectiveness, but large studies with sufficient power on the subject are lacking. Despite this lack of evidence, the treatment is at present applied by some gynaecologists in The Netherlands.Methods/DesignWe aim to investigate the hypothesis that prophylactic use of a cervical pessary will be effective in the prevention of preterm delivery and the neonatal mortality and morbidity resulting from preterm delivery in multiple pregnancy. We will evaluate the costs and effects of this intervention. At study entry, cervical length will be measured. Eligible women will be randomly allocated to receive either a cervical pessary or no intervention. The cervical pessary will be placed in situ at 16 to 20 weeks, and will stay in situ up to 36 weeks gestation or until delivery, whatever comes first.The primary outcome is composite bad neonatal condition (perinatal death or severe morbidity). Secondary outcome measures are time to delivery, preterm birth rate before 32 and 37 weeks, days of admission in neonatal intensive care unit, maternal morbidity, maternal admission days for preterm labour and costs. We need to include 660 women to indicate a reduction in bad neonatal outcome from 7.2% without to 3.9% with a cervical pessary, using a two-sided test with an alpha of 0.05 and a power of 0.80.DiscussionThis trial will provide evidence on whether a cervical pessary will decrease the incidence of early preterm birth and its concomitant bad neonatal outcome in multiple pregnancies.Trial registrationCurrent Controlled Trials: NTR 1858

Proteomic technology and delayed interval delivery in multiple pregnancies

Although delayed interval delivery is associated with improved survival after birth for the fetus(es) allowed to remain in the uterus published case reports on this approach are often criticized for their selection bias. Successful outcomes are rare perhaps because of underlying intra-amniotic fluid inflammation (IAI). Proteomic technology—surface-enhanced laser desorbtion-ionization (SELDI) and mass-restricted (MR) score—may allow to rapidly and accurately identify inflammation in the absence of clinical or laboratory signs of chorioamnionitis. (excerpt)

Delayed interval delivery in multiple pregnancies

Preterm delivery remains the most important complication of multiple pregnancies. We describe six cases of successful delay of the subsequent child(ren) after very preterm birth of the first-born, with intervals ranging between 14 and 117 days. Based on our findings and on the available literature, we propose a set of guidelines for the management of early preterm multiple birth deliveries, including tocolysis, antimicrobial therapy and corticosteroids.

Book Review: Iatrogenic Multiple Pregnancy: Clinical Implications

Individuals may pay large sums of money for assisted conceptions but it is usually the State that picks up the extra bill for neonatal care. In Iatrogenic Multiple Pregnancy, an attractive book full of personality, Blickstein and Keith offer a bold reminder that pregnancy at any cost is not necessarily in the best interests of couples, their children or society. We liked the way they allowed their contributors to express clear opinions. Although the needs of women undergoing assisted conception are sensitively acknowledged, a recurrent theme throughout the book is the risk associated with multiple pregnancy. In the USA the rate of multiple pregnancy has risen, though the role of assisted reproductive technologies in this is uncertain. The authors call for wider reporting, particularly of oral ovulation agent induced pregnancies. They particularly advocate limitation of higher-order multiple gestations, to improve outcome, and they stress that these difficult pregnancies should be managed in large units with specialist experience. Clearly, care should be transferred at the time of the diagnosis, not when the woman is in labour. The chapters on recognition of multiple pregnancies, planning of the pregnancy, diagnosis of abnormality, fetal reduction and multiple pregnancy delivery are all useful. Much stress is rightly put on early diagnosis of the pregnancy number, by careful uterine mapping and determination of chorionicity by ultrasound. Screening for fetal abnormality is also best undertaken early. We felt that the nuchal translucency issues were rather superficially described (e.g. without description of the different calculations by chorionicity). Especially important chapters are those on counselling parents and the implications for families of having high-order pregnancies—sometimes serious even if all the infants are born in good medical condition. There is a good account of the views of various religious faiths on assisted reproduction and the ethical considerations facing parents and health professionals involved in the care of these pregnancies. Finally, the legal implications of iatrogenic higher-order pregnancies are reviewed. The book is unusually illustrated with striking, nonscientific, black and white photographs (mostly of twins) which adorn each chapter and the cover. These are surprising, attractive and even at times distracting; on balance we felt they did not add to the book although they do remind the reader of the wonder of reproduction. The price is not so high that one resents this artistic addition. Another unusual feature is the inclusion of numerous ‘inserts’, including case histories, controversial discussions (such as cloning) and diagnostic pitfalls. This structure can break the reading flow, especially when a substantial proportion of a chapter is in these separate boxes. Sometimes the inserts give the impression they are updates, with references more recent than those in the body of the text. At other times the inserts seem to reflect difficulties with the structure of the book. For example, at the end there are eight ‘left-over’ sections on controversial points such as prolonged delayed delivery between multiples and discordant growth, grouped together. We felt that these sections would have been better integrated into the main text. Those with a particular interest in this area will wish to read Iatrogenic Multiple Pregnancy from cover to cover. It will also be a valuable occasional reference for any specialist involved in reproductive, fetal or maternal medicine as well as for neonatologists and some midwives.

Delayed Interval Delivery in Multiple Pregnancies. Is Optimism Justified?

Delayed Interval Delivery in Multiple Pregnancies. Is Optimism Justified?

Delayed interval delivery inmultiple pregnancies. Is optimism justified?

Evaluation of the success of delayed interval delivery in multiple pregnancies. Retrospective analyses of all multiple pregnancies with the birth of one child at a gestational age of 16-31 weeks (n=80). Three groups were defined: group I, unsuccessful attempt to temporize delivery, group II, interval between the first child and the other child or children 3 hours or more, with delivery of the remaining children before 28 weeks and group III, prolongation of pregnancy beyond 28 weeks. In 15 multiple pregnancies (ten sets of twins, five sets of triplets), the aim was to postpone the delivery of the second (and third) child. The mean gestational age at admittance was 25 weeks. Delay of the delivery of the second child was achieved in ten cases, five in group II and five in group III. In groups II and III, the mean interval of delivery was 12 days; the gestational age at the delivery of the remaining children in these ten patients was 27 5/7 weeks. No relation could be found between the reason for admittance and the interval in delivery between the first and the other children. The only severe maternal complication was blood loss exceeding 2 liters. In the neonatal outcome of first and second children (with a gestational age of 28 weeks or more) no striking differences were observed. Delayed delivery in multiple pregnancies after the birth of the first child is only successful in a minority of patients and should be considered prior to the birth of the first child.

Prolongation of pregnancy in multiple pregnancy

Objective: The purpose of the study was to determine whether the use of prophylactic oral ritodrine or hospitalization for bed rest can prolong pregnancy in multiple pregnancy. Methods: The study was conducted over a period of 8 years and included 189 cases of multiple pregnancy, all of which were delivered at the King Fahd Hospital of the University, Al-Khobar, Saudi Arabia, between July 1986 and August 1994. The patients were divided into three groups: the first group included 64 patients who received oral ritodrine from the 25th to the end of the 37th week of gestation; the second group included 57 patients who were hospitalized from the 28th to the 32nd week of gestation; and the third group, considered the control group, included 68 patients who were managed on an outpatient basis only. Forty-six cases of multiple pregnancy were excluded from the study for a variety of reasons. Results: The study showed an increase in gestational age at delivery, an increase in mean birth weight and a reduction in preterm delivery in the group treated with prophylactic ritodrine ( P = 0.03). In the hospitalized group there was no effect on duration of gestation or reduction in preterm delivery, but there was an increase in mean birth weight ( P = 0.04). Several patients experienced troublesome side effects with ritodrine. Conclusion: Our study indicates that the prophylactic use of β-sympathomimetics is more effective, beneficial and less expensive than hospitalization for bed rest in prevention of preterm labor and delivery in multiple pregnancy.

Fetal fibronectin as a screening test for premature delivery in multiple pregnancies

Objective: To evaluate fetal fibronectin as a screening test for premature delivery in asymptomatic women with multiple pregnancies. Method: In the mid-second trimester, the concentrations of fetal fibronectin in the cervical and vaginal secretions of 68 patients with multiple gestations were sampled weekly by monoclonal antibody immunoassay in order to predict preterm labor. Results: The results for the prediction of preterm labor differ according to whether we consider a single positive result (fetal fibronectin >50 ng/ml) as predictive of preterm labor or whether we only consider at least two consecutive positive results as predictive of preterm labor. The fetal fibronectin test had a sensitivity for preterm birth before 37 weeks of 90.9% and 86.6%, respectively, with a specificity of 68.5% vs. 78.9% and positive and negative values of 73.1% vs. 76.4% and 88.8% vs. 88.2%, respectively. Similar results were obtained for preterm birth before 34 weeks. Conclusion: In a condition such as multiple pregnancy which is already at risk for premature delivery the possibility of raising the specificity of the test with virtually no decrease in sensitivity guarantees better recognition of patients likely to develop premature labor. This possibility can be achieved simply by considering two positive consecutive samples as predictive of preterm labor.

Delayed Interval Delivery in Multiple Pregnancies

Delayed Interval Delivery in Multiple Pregnancies

Conditions of delivery in multiple pregnancy. Observations on the Danzig population over twenty years.

An analysis of the conditions of delivery in multiple pregnancy, with special respect to the parity of the woman, has been carried out on a sample of 619 deliveries from multiple pregnancy in the Danzig population.