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Delayed interval delivery in a twin pregnancy with monochorionic placenta

      To the Editors:

      We read with interest the article of Minakami et al. (Minakami H, Honma Y, Izumi A, Sayama M, Sato I. Emergency cervical cerclage after the first delivery in a twin pregnancy with dichorionic placenta. Am J Obstet Gynecol 1995;171:345-6) about the delayed delivery in two twin pregnancies with emergency cervical cerclage after the first delivery. The authors stated that this procedure may not be justified in pregnancies with monochorionic placentas because of hemodynamic complexities and recommended it only in pregnancies with dichorionic placentas.
      Lately we succeeded in prolonging the gestation in a monochorionic, diamniotic pregnancy for 10 weeks after the delivery of the first sibling. A 30-year-old nulliparous woman with a spontaneous twin pregnancy had premature rupture of the membranes at 23 weeks' gestation. On ultrasonography only one placenta was seen. At 24 weeks 4 days a 730 gm female infant was delivered. Emergency cervical cerclage after ligation of the umbilical cord close to the internal os was performed. Prophylactic tocolytic therapy with fenoterol and short-term antibiotic therapy with piperacillin were administered. Ten weeks later, at 34 weeks 5 days, the second female infant, with a birth weight of 2260 gm, was delivered vaginally. Both fetuses survived without major sequelae. The pathologic examination confirmed the presence of a diamniotic, monochorionic placenta.
      Delayed deliveries in multifetal pregnancies are rare events and the decision to attempt a prolongation of pregnancy after the first fetus is born should be based on gestational age and the absence of intrauterine infection and abruptio placentae. There are no generally accepted guidelines in the proper selection of pregnancies suited for a delayed delivery in literature, but in our experience, also in a monochorionic multifetal pregnancy, a delayed delivery can be attempted with success.