Delayed delivery of multifetal pregnancies with premature rupture of membranes in the second trimester*,**,*

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Abstract

OBJECTIVE: Premature rupture of membranes in mutifetal gestations during the second trimester has an ominous prognosis and the majority of the fetuses die after preterm delivery. STUDY DESIGN: We used cervical cerclage, tocolysis, and antibiotic therapy after vaginal delivery of the fetus with ruptured membranes in eight patients with multifetal pregnancies to extend the intrauterine life and improve the outcome of the remaining fetuses. RESULTS: Survival of six fetuses was achieved in five of the eight pregnancies (four originally twins and one originally triplets). The mean ± SD gestational age of the fetuses first delivered was 19.6 ± 2.6 weeks, and it was 26.7 ± 6.8 weeks in the fetuses with delayed delivery (exact two-tailed p = 0.01). The mean ± SD birth weight of the fetuses delivered first was 306 ± 149 gm and it was 1029 ± 947 gm for the fetuses who had delayed delivery (exact two-tailed p = 0.05). The mean ± SD prolongation of pregnancy was 48.8 ± 42.06 days (range 8 to 114 days). CONCLUSIONS: Intervention with tocolysis, antibiotics, and cervical cerclage after delivery of the first fetus is a reasonable option for some patients with multifetal pregnancies and premature rupture membranes in the second trimester. (AM J OBSTET GYNECOL 1994;170:1233-7.)

Section snippets

MATERIAL AND METHODS

We treated eight patients, six with twins and two with triplets. Their mean age was 27.6 years (range 20 to 35). Six patients were nulliparous. In all cases premature rupture of membranes was diagnosed by pooling of the amniotic fluid in the vagina, positive Nitrazine paper and fern testing, and a decreased amount of amniotic fluid around the first presenting fetus by ultrasonographic examination. Each fetus was considered to have its own chorion if ultrasonographic examination revealed two

RESULTS

Five of the fetuses delivered first were male and four were female. Six of them were born dead and two died shortly after birth. In all cases the cause of death was extreme prematurity. The mean ± SD duration of the interval between the first and second deliveries was 48.8 ± 42 days with a low value of 8 days and a high value of 114 days. Five of the eight patients had cervical cultures for group B streptococci with negative results.

A comparison of the gestational age and the birth weight of

COMMENT

The natural history of second-trimester premature rupture of membranes in multifetal pregnancies is delivery of all the fetuses after a relatively short latency period. This occurs in most cases because the events leading to delivery of the first fetus continue and finish with delivery of the remaining fetuses. In those rare occasions when the uterus becomes quiescent after delivery of the first fetus, the risk of ascending infection and severe chorioamnionitis is significant, and most

ADDENDUM

Since this manuscript was submitted for publication, we have attempted to prolong pregnancy in three additional patients with multifetal pregnancies and premature rupture of membranes. One patient had triplets and premature rupture of membranes at 17 weeks. The first fetus was delivered after a latency period of 1 day and had a birth weight of 180 gm. The other two fetuses were delivered 11 days later. Birth weights were 220 and 240 gm. A second patient had twins and premature rupture of

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*

From the Department of Obstetrics and Gynecology, St. John's Mercy Medical Center.

**

Reprint requests: Fernando Arias, MD, Department of Obstetrics and Gynecology, St. John's Mercy Medical Center, St. Louis, MO 63141.

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0002-9378/94 $3.00 + 0 6/1/52865

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