Extreme Asynchronous Twins

Background This report describes a patient counseling approach, conservative and surgical management (cervical cerclage) of a dichorionic-diamniotic twin pregnancy, where delivery of the second twin followed the delivery of the first by 104 days. Case presentation A 35-year-old Indian lady, with 10 years of primary infertility, conceived twins, following ovulation induction with gonadotropin therapy. At 19 weeks and 4 days gestation, she aborted a female fetus of 410 gm. Tocolytic therapy was initiated; the placenta remained in situ and the umbilical cord of twin A was ligated high and McDonald's cerclage was placed and prophylactic antibiotics initiated. But since the patient's uterus continued to be irritable and the cerclage appeared to be under tension, at 20 weeks 6 days the stitch was taken out and all conservative treatment stopped for 24 hours, but reinitiated after this period, since the uterus remained quiescent. After 3 weeks of uterine inactivity, at 23 weeks 6 days gestation, McDonald's suture was reapplied following which conservative management was offered after counseling for possible risks associated with maternal sepsis, coagulopathy, need for extended hospitalization and potential for hysterectomy. Reassuring fetal status was observed for twin B without evidence of contractions or chorioamnionitis. A viable male infant (1800 gm) was delivered vaginally at 34 weeks and 4 days gestation. Conclusion This report outlines a counseling approach useful for patients with premature delivery of one twin, and presents application of conservative obstetrical management principles for the aftercoming twin, even when delivery interval is extreme.