Acasa > Reviste de specialitate > Ginecologia.ro > Prognosticul neonatal şi matern în naşterea întârziată intenţionat a celui de-al doilea făt din sarcina dizigotică. Caz clinic şi revizuirea literaturii

Prognosticul neonatal şi matern în naşterea întârziată intenţionat a celui de-al doilea făt din sarcina dizigotică. Caz clinic şi revizuirea literaturii

 Neonatal and maternal outcomes after intentional delayed delivery for the second twin in dyzigotic pregnancy. Case report and literature review

Prof. univ. dr. Manuela Russu, D. Dobriţoiu, Simona Svasta, Anca Tudor, A. Crăciun

First published: 15 aprilie 2016

Editorial Group: MEDICHUB MEDIA

Abstract

Intentional delayed delivery of second twin in dizygotic pregnancy is rare. There are analyzed the peculiarities regarding maternal, short-term neonatal outcomes in a 41-year-old mother, admitted in a tertiary university maternity, diagnosed with: IVG IIP 24 weeks + 3 days dizygotic pregnancy, alive fetuses (A. breech presentation, 690 g, palpable amniotic sac; B. cephalic presentation, intact membranes, EFWs of 690/700 g - ultrasound). At 26 weeks of gestation, after PROM, short positive trial of labor for planned vaginal delivery, under continuous CTG, Bracht maneuver for breech presentation which records the birth of female fetus A, 920 g, Apgar score 5/6. Sectioned umbilical cord is introduced in the vagina. At 50 days of close monitoring and treatment for both mother and fetus B, it is done caesarean section for female fetus B, 1870 g (34 weeks of gestation), Apgar score 8, placentae A/B: 200/450g. Maternal postoperative evolution is normal. Baby A is admitted at Neonatal Intensive Care Unit (NICU) for moderate hypoxia at birth, repeated apnea crisis, without functional respiratory syndrome, anemia being corrected with blood derivates, 70 days, with gastric-tube nutrition, antibiotics, stage I retinopathy, bilateral hip risk; the weight of fetus B was 1550 g at the cesarean section and 2250 when discharged. Baby B had a favorable evolution (breastfeeding plus formula milk). Conclusions. Vaginal delivery at a multipara can be assumed in breech presentation, after a precise protocol, followed by experienced obstetrical/neonatological teams, and an intentional delayed CS delivery is feasible. Fetus B is larger at delivery than fetua A at the same moment (1870 g vs. 1550 g), and at discharge (2250 g vs. 2975 g), with a very short admission in NICU/preterm wards. No maternal complication appeared.
 

Keywords
intentional delayed delivery, dizygotic pregnancy, preterm delivery, outcome

Rezumat

Sarcina gemelară dizigotică - cu riscurile şi costurile crescute ale mortalităţii şi morbidităţii perinatale, induse de prematuritate, complicaţiile fetale/materne intrapartum - impune decizii dificile pentru terminarea naşterii, dictate de vârsta gestaţională, calităţile colului, starea membranelor, prezentaţiile şi starea feţilor. Operaţia cezariană planificată pentru prezentaţia pelviană şi monitorizarea CTG intrapartum nu au fost urmate de succesul scontat, ci de discordanţa dintre morbiditatea perinatală pe termen scurt şi prognosticul neurologic pe termen lung. MG, de 41 de ani, UM 15 mai 2014, internată în 2.11.2014 pentru CUD sistematizate, suspiciune de membrane fisurate, diagnosticată cu: IVG II P, sarcină gemelară dizigotică de 24 săptămâni + 3 zile, feţi vii (A. prezentaţie pelviană, 690 g, pungă amniotică palpabilă; B. prezentaţie craniană, 700 g, membrane intacte ecografic). În 17.11.2014 se rup membranele la fătul A, iar după un travaliu de 4 ore se expulzează cu ajutor manual Bracht un făt feminin de 920 g, scor Apgar 5/6, se pensează cordonul, gravida este menţinută sub supraveghere/tratament continuu, cu evoluţie favorabilă, fără decolarea placentei fătului A, spitalizat la NICU (hipoxie moderată la naştere, adaptare cu crize de apnee, fără sindrom funcţional respirator, anemie plurifactorială, antibioterapie complexă cu spectru larg, gavaj 70 de zile, retinopatie stadiul I, risc bilateral de şold). La 50 de zile de la naştere, la 33 de săptămâni şi 4 zile (cronologic, sonografic), se decide extragerea fătului B prin operaţie cezariană: sex feminin, 1870 g, scor Apgar =8; placenta A de 200 g, placenta B de 450 g. Evoluţia post-partum este normală, cu prelungirea spitalizării cu alte 23 de zile, din cauza prematurităţii fetale. La data operaţiei cezariene fătul A cântărea 1550 g şi apoi 2250 g la externare. Fătul B are evoluţie favorabilă, cu 2975 g la externare, alimentat mixt (la sân şi biberon). Concluzii. Monitorizarea extrem de atentă a sarcinii dizigotice, la secundipară, poate permite alegerea naşterii pe cale vaginală a primului făt în prezentaţie pelviană după un protocol precis, urmat de o echipă obstetricală experimentată, iar operaţia cezariană intenţionat amânată este folositoare; fătul B este cu greutate mai mare la naştere (1820 g vs. 1550 g) şi la externare (2975 g vs. 2250 g) comparativ cu fratele şi cu o durată redusă de spitalizare la NICU/neonatologie în prima perioadă postnatală; nu a existat nici o complicaţie maternă.
 

Cuvinte cheie
naştere întârziată intenţionat sarcină gemelară dizigotică naştere prematură prognostic

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