From the Guidelines
The management of a retained second twin in a multiple gestation pregnancy requires prompt and careful intervention to minimize risks and ensure the best possible outcomes for both the mother and the twins. When managing a retained second twin, it is crucial to prioritize the well-being and safety of both the mother and the twins, considering the potential complications associated with multiple gestation pregnancies, such as twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia sequence, as discussed in the society for maternal-fetal medicine consult series #72 1. Key considerations in the management of a retained second twin include:
- Continuous fetal heart rate monitoring of the second twin to assess its well-being and detect any potential complications early.
- Administering oxytocin to maintain uterine contractions and facilitate the delivery of the second twin.
- Performing an ultrasound to assess the second twin's position, presentation, and well-being, which is essential in determining the best approach for delivery.
- Considering the potential risks and benefits of different management options, including vaginal delivery, breech extraction, or emergency cesarean section, and selecting the approach that minimizes maternal and fetal morbidity. The primary goal of managing a retained second twin is to ensure the safe delivery of both twins while minimizing risks and complications, and this requires careful consideration of the individual circumstances of each case, as well as the potential long-term pediatric risks associated with TTTS and its treatment, as noted in the society for maternal-fetal medicine consult series #72 1.
From the Research
Management of Retained Second Twin
The management of a retained second twin in a multiple gestation pregnancy can be complex and depends on various factors.
- The decision to deliver the second twin vaginally or via cesarean section depends on the presentation of the second twin and the overall health of the mother and the baby 2.
- In cases where the second twin is retained, active management is crucial to reduce the intertwin interval and minimize complications 3.
- Studies have shown that delayed-interval delivery of the second twin can be performed safely, with careful monitoring and management of the mother and the baby 4, 5.
Factors Affecting Management
Several factors can affect the management of a retained second twin, including:
- The presentation of the second twin, with non-vertex presentations being associated with a higher risk of complications 6.
- The interval between the delivery of the first and second twins, with longer intervals being associated with poorer outcomes 3.
- The use of obstetrical maneuvers, such as vaginal breech extraction, to facilitate delivery of the second twin 2, 3.
Mode of Delivery
The mode of delivery for the second twin depends on various factors, including:
- The presentation of the second twin, with vertex presentations being more likely to be delivered vaginally 2.
- The overall health of the mother and the baby, with cesarean delivery being considered in cases where there are concerns about the well-being of either the mother or the baby 4, 6.
- The availability of trained personnel and equipment to perform obstetrical maneuvers, such as vaginal breech extraction 3.