Delayed interval delivery of two remaining fetuses in quintuplet pregnancy after embryo reduction: report and review of the literature.

Abstract:  In Holland, infertility specialists at Sophia Hospital in Zwolle administered human menotropins chorionic gonadotropin injections to a 26-year old woman to induce ovulation. Donor artificial insemination resulted in conception. At 8 weeks gestation, ultrasonography revealed 5 fetuses. Since quintuplet pregnancies increase the risk of maternal complications and of perinatal morbidity and mortality, she consented to embryo reduction at 11 weeks gestation, resulting in a twin pregnancy. Between 16-18 weeks gestation, she had some vaginal bleeding. At 22.5 weeks gestation, she suffered lower abdominal pain and fluid loss and delivered a 310 fm female who died within a few hours. The physicians ligated the umbilical cord with vicryl near the cervix. The gestational sac of twin B was sticking out of the internal ostium, but she did not deliver twin B. There were no signs of placental separation or of infection. The woman and her husband agreed to postpone delivery of the 2nd fetus. She remained in bed while receiving iv tocolytic drugs (ritodrine R). The physicians also administered iv antibiotics for 3 days (ampicilline and cefotaxim). Weekly ultrasound examination showed that twin B grew normally. A subfebrile temperature and an increase in the white blood cell count resulted in restart of antibiotic therapy. Health workers gave her intramuscular injections of betamethasone to accelerate development of the fetus' lungs at 26 weeks. 2 days later, she went into labor. The physicians ruptured the membranes and delivered a 710 gm male newborn. She later delivered 3 intact amniotic sacs with autolytic fetuses. She recovered uneventfully. The newborn eventually developed bronchopulmonary dysplasia and dies at 3 months. None of the 1st-born infant in 14 delayed interval delivery cases reported in the literature since 1957 survived. 13 of the 17 later born infants did survive. Tocolytic agents were used to postpone delivery in 10 cases. Cervical cerclage was done in the 7 other cases. All but 1 case received broad-spectrum antibiotics.