Case report
A 30-year-old woman who was pregnant with diamniotic dichorionic twins
at 22 2/7 weeks gestation was admitted to the delivery room for preterm
labor. She experienced bleeding, and her membranes had ruptured 23 hours
before admission. Her condition was complicated by chorioamnionitis,
fever, tachycardia, and elevated inflammatory markers. She had a white
blood cell count of 24 × 109/L, an absolute neutrophil
count of 23 ×109/L, a C-reactive protein level of
105 mg/L, and a negative test result for procalcitonin. Both fetuses
exhibited good cardiac activity and active movements. The mother had
conceived after undergoing in vitro fertilization (IVF) and embryonal
transfer. She is a mother of healthy 3-year-old twins, who were also
conceived by IVF. The medical team offered antenatal comfort and
counseling regarding resuscitation and intensive care to the parents,
who requested that all available life-support measures be applied,
despite their complete understanding of the risks and long-term expected
problems.
The decision of the parents for initiating full resuscitation was unique
to our unit. A complete plan, with some flexibility under our policy,
was adopted in consultation with the obstetricians and the parents.
After completing the antenatal steroid course, a live female (Twin A)
weighing 504 g with Apgar scores of 4, 5, and 7 at 1, 5, and 10 min,
respectively, was spontaneously delivered. Then, a live male infant
(Twin B), weighing 475 g, was delivered with breech presentation and
Apgar scores of 3, 5, and 7 at 1, 5, and 10 min, respectively. Both
newborns were resuscitated, intubated, and given one dose of surfactant.
Twin A required six weeks of mechanical ventilation. She initially
received conventional support but eventually needed high-frequency
oscillation. She was extubated to non-invasive positive airway pressure
ventilation at 28 weeks and two days post-conception and was eventually
supported by nasal high-flow oxygen. Two weeks later, Twin B was
extubated to biphasic positive airway pressure. However, he required
re-intubation and ventilation after a few days. His second intubation
lasted for three weeks due to bilateral irreducible inguinal hernias
that required an urgent herniotomy. Finally, he was extubated
successfully after 11 weeks of ventilation to continuous positive airway
pressure on day 92 (33 weeks and three days post-conception). He was
weaned to nasal high-flow oxygen after three weeks.
Parenteral nutrition was started on the first day of life via an
umbilical venous catheter and continued via a peripheral venous catheter
for both twins. The mother’s breast milk was initially administered on
their second day of life by trophic feeding through a nasogastric tube.
This was continued with a gradual, incremental increase in volume until
full feeding was tolerated. For Twin B, oral feeding was suspended
several times due to intolerance and abdominal distension. However, his
serial abdominal radiographs exhibited non-specific findings.
Eventually, the gastric tube was removed for both twins, and
breastfeeding was successful upon discharge.
Their serial cranial ultrasound scans were normal. On echocardiography,
Twin A had normal heart anatomy, while Twin B had a patent ductus
arteriosus with a maximum size of 2.5 mm. This was conservatively
managed with fluid restriction. Follow-up echocardiography revealed a
closed ductus arteriosus in Twin B. Twin B, the male twin, had a more
complicated course. He had a right femur fracture due to osteopenia of
prematurity, bilateral retinopathy of prematurity treated with
ranibizumab (Lucentis ®, Genentech, South San Francisco, CA, USA)
injections, and bilateral inguinal hernias that were treated surgically.
Four months after birth, respiratory support was weaned at the
postconceptional age of 40 weeks and five days for Twin A and 43 weeks
and two days for Twin B. Both twins are currently in excellent
condition. They have returned home without respiratory or feeding
support (Table 1).
At discharge, Twin A weighed 3708 g (47.35 centile), her length was
50 cm (16.27 centile), and her head circumference was 33.5 cm (5.21
centile). Twin B was discharged with a weight of 4120 g (3.52 centile),
length of 49 cm (< 1st centile), and head
circumference of 34.8 cm (< 1st centile).
Their neurological examination at a chronological age of 12 months,
which corresponded to the corrected age of 8 months and two days, was
normal and without focal deficit. Moreover, an age-appropriate
neurodevelopmental test did not exhibit developmental delay in all
domains for both infants considering their corrected age. Their growth
is being monitored, and their parents are satisfied with their progress
(Table 2).