In twin pregnancies where the presenting twin is not cephalic, cesarean delivery is the standard of care. External cephalic version (ECV) has been used for malpresenting singleton pregnancies with low risk of complications. ECV in twin pregnancies is poorly studied.To assess feasibility and report any complications of ECV of a malpresenting twin before labor.This is a prospective cohort of twin pregnancies with malpresenting first twin. Inclusion criteria included English or Spanish speaking women. Exclusions included cases where there was a contraindication to vaginal delivery. ECV was performed according to the institutional singleton protocol. Fetal testing of both twins was performed before and after procedure. A vaginal hand was used during ECV as needed. The primary outcome was success of the procedure. Secondary outcomes included delivery characteristics and neonatal outcomes.Five patients were enrolled in this study. Four patients underwent successful ECV and vaginal delivery occurred in 2 of the 4 patients. ECV procedure was performed at a mean gestational age of 36+0 weeks in the successful ECV group and 36+6/7 weeks for the unsuccessful group. Latency to delivery was 4.5 days in the successful ECV group and 1 day in the unsuccessful ECV group. No maternal or neonatal complications occurred in any participating women.ECV in twin pregnancies where the first twin is malpresenting was feasible in our cohort. More research is needed to better characterizer the safety and efficacy of this procedure in this patient population.
Prevalence of spontaneous monochorionic triplet pregnancy is 1 in 7000 pregnancies with a 50–60% incidence of growth restriction. We report a case of 25 year old G1 P0 hospitalized at 24 6/7 weeks for one fetus with selective intrauterine growth restriction (IUGR) with absent or reversed end diastolic flow in the free loop of umbilical artery (FLUA). The estimated growths of the three fetuses were < 10%, 28% and 38%. There was no evidence of structural or functional cardiac abnormalities in any of the fetuses. There was no evidence of twin-twin transfusion syndrome. The patient was managed with bed rest, oxygen by nasal cannula, steroids and followed with daily biophysical profile and non-stress test, weekly Doppler and amniotic fluid evaluations. After eleven days, the IUGR fetus showed improvement in the ductus venosus and middle cerebral artery pulsatility index (PI) while FLUA showed mildly elevated PI. The plan was to prolong delivery of the triplets until after 32 weeks gestation, if possible. The antenatal course remained uneventful while on maternal oxygen therapy. At 32 weeks, the smaller fetus had grown to 37% percentile with all Doppler values within normal limits while on maternal oxygen and the delivery was conducted by scheduled cesarean section. The placental pathology showed a monochorionic placenta with one eccentric and two central insertions of the three vessel umbilical cords. The newborns weighed 1015 grams (g), 1350 g and 1530 g with normal Apgar score at 5 minutes. All of the triplets received continuous positive airway pressure and parenteral support in the newborn period. We conclude that oxygen therapy improved the Doppler flow pattern in the IUGR fetus of this triplet pregnancy and allowed for substantial growth in that fetus, thereby successfully prolonging the delivery date.
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