The IX t h Makassed Medical Congress - American University of Beirut

T h e I X t h M a k a s e d M e d i c a l C o n g r e s s
The short text of the guidelines is available on the CNGOF website at http://www.cngof.asso.
fr/D_TELE/RPC%20GEMELLAIRE_2009.pdf (in French) and http://www.cngof.asso.fr/D_TELE/RPC_
Gemel_en.pdf (in english). The full guidelines have been published in the December 2009 issue of
the “Journal de Gynécologie Obstétrique et Biologie de la Reproduction”. Because many areas of
practice have not been well studied, the level of evidence and strength of the recommendations
are low. Indeed, many of the recommendations are made on best opinion of the experts group
but not on best evidence. However, we hope that these guidelines will improve twin gestation
management and prognosis. In addition, these guidelines highlighted several questions that will
lead to conduct further multicenter clinical studies.
DELAYED INTERVAL DELIVERY: OUR CASE SERIES AT MGH
Mohamad Khaled Ramadan MD
It has been a frequent encounter to receive pregnant ladies in the emergency room presenting
with full cervical dilatation or premature rupture of membranes rendering these unsalvageable in
most cases of previability or severe prematurity in spite of efforts to rescue such pregnancies that
are sometimes very precious and difficult to attain.
This disparate situation has increased several folds owing to the surge in the number of multiple
pregnancies in recent two decades. However, though the risk of preterm labor and preterm
premature rupture of membranes is increased in multiple pregnancies, yet having more than
one fetus especially with independent sacs and placentas provide a second or more chances
of rescuing this pregnancy. A concept named delayed interval-delivery.
We describe the outcome of six attempts at (Delayed Interval-Delivery) at our service with
varying degrees of success. Four twins, one triplet and one quadruplet gestations were managed
with this intention during the past thirteen years. Five of these six pregnancies presented with
advanced cervical dilation due to PTL with the leading member of multiple gestation within its
bulging membranes while one was due to PPROM. Four were previable and two were at the limits
of viability.
Two cases developed chorioamnionitis/septicemia and were delivered of the remaining
members within 8 days after initial presentation. In all cases delivery of the latter sibling/s could be
delayed and the range was 6-141 days. In all cases, except one twin gestation, the first member
died immediately after delivery due to severe prematurity, while in 2 twin pregnancies the latter
survived. In one case (25 weeks +1 day) the delivery of the second twin could be delayed 9
days with a 200g weight gain and 30 days less stay in the NICU together with better growth and
neurodevelopment during the first year of life. The only case with impressive outcome was a
delay of 141 days of the second twin following delivery of the first member at 19 weeks gestation.
The salvage rate was 16% (1/6). There is no consensus as to the optimal management protocol of
delayed interval-delivery and many components are still the grounds of debate.
In spite of the complications inherent in such management plan, and in the absence of any
specific well-detailed action plan for such hopeless cases, we recommend a minimally invasive
management plan to postpone delivery of the second/more member of multiple gestation, and
cannot but agree to the principle that multiple gestations might represent multiple chances for
survival in pregnancies doomed to perish if it were a single gestation.
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