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External cephalic version of a breech Twin A is possible
Accepted Manuscript Title: External cephalic version of a breech twin A is possible Authors: Larry Hinkson, Wolfgang Henrich PII: DOI: Reference:
S0301-2115(17)30310-X http://dx.doi.org/doi:10.1016/j.ejogrb.2017.06.033 EURO 9956
To appear in:
EURO
Received date:
19-6-2017
Please cite this article as: Hinkson Larry, Henrich Wolfgang.External cephalic version of a breech twin A is possible.European Journal of Obstetrics and Gynecology and Reproductive Biology http://dx.doi.org/10.1016/j.ejogrb.2017.06.033 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
External cephalic version of a breech twin A is possible
Larry Hinkson1, Wolfgang Henrich1
Department of Obstetrics Charité – Universitätsmedizin Campus Mitte, Berlin 10117, Germany
1
Correspondence: Larry Hinkson MBBS, MRCOG, FRCOG, MD Department of Obstetrics Charité- Universitätsmedizin Berlin Campus Mitte Charitéplatz 1 Berlin 10117 Germany Phone 0049-30-450664710 Fax 0049-30-450564901 Email [email protected]
Abstract
Normally, a twin pregnancy with a non-cephalic presentation of Twin A is routinely scheduled for cesarean section in up to 92% of cases. Whilst the external cephalic version (ECV) is a recommendation for singleton pregnancies, there is a paucity of data in the literature on the consideration of this option in twin pregnancies where twin A is in breech. We demonstrate a technique where it was possible to perform electively an ECV on a breech twin A giving the mother the option of vaginal delivery. We found this procedure to be effective in the 35th week of pregnancy. A detailed sonographic examination to identify the location and orientation of the separating chorioamniotic membrane, growth parameters, liquor volume, placenta location, umbilical cord location and position and orientation of both twins was essential in planning the ECV. Tocolysis was avoided. The ECV of the breech twin A was performed with the patient lying on the side avoiding aorto-caval compression and affording more surface area access for palpation of the leading twin. There was no evidence of fetal distress and no pain relief was required. The patient went on to have an uncomplicated vaginal delivery. Promoting safe vaginal delivery in twins is important in reducing the high cesarean section rates. ECV for breech twin A is possible and can avoid cesarean section.
Key words: “external cephalic version”, “breech”, “twin pregnancy”, “breech twin A”
Dear Editor, External Cephalic Version (ECV) for the leading breech Twin A is possible. We describe a modified technique for successful planned ECV for breech Twin A in a dichorial-diamnial twin pregnancy avoiding cesarean section. We know that when the leading twin is in breech the rate of cesarean section is up to 92%.1 Whilst ECV is recommended for singleton fetuses in breech, there is no consideration given to ECV for the leading twin when it is in breech.2 In the literature there is only one report of ECV of twin A performed in labor.3 This is the first description of a technique of planned ECV for breech twin A performed antenatally and avoiding cesarean section in a healthy dichorionic-diamniotic twins. A 28year-old patient who had one normal previous vaginal delivery, presented in the 29 4/7 weeks of gestation with dichorionic-diamniotic twin pregnancy. The pregnancy was uneventful and both twins were appropriately grown with Twin A in breech and Twin B in cephalic presentation. The patient expressed a desire to consider an ECV for twin A in order to avoid a cesarean section. The ECV was planned with the following steps:
Counseling and planning. She was counselled and consented by the consultant responsible for the dedicated ECV clinic at the Charité University Hospital in Berlin. An ECV was planned for the 34 4/7 weeks of gestation. A review by Hutton et al. has shown that early ECV at 34-35 weeks is as effective in achieving vaginal cephalic delivery as when performed beyond 37 weeks.4 Avoiding tocolysis. The use of tocolytic medication though normally recommended was purposefully avoided to reduce the risk of complications such as maternal hypotension and palpitations.2 Cardiotogographic examinations were performed to ensure fetal well being. Ultrasound examination. This confirmed normal growth parameters, Doppler values, liquor volume, placenta location and umbilical cord location. Identifying fetal orientation. Twin A was found in breech position with flexed legs lying on the maternal left side with the back facing laterally and posteriorly. There was no nuchal cord. Twin B was lying in cephalic presentation on the maternal right side with the back facing the maternal right. Identifying the separating chorioamniotic membrane and placenta. The separating membrane between the twins was clearly identified and found to be from the uterine fundus left side to the lower uterine segment maternal right side. The placenta for Twin A was on the posterior uterine wall and for Twin B in the fundus. Lateral positioning and optimizing access to Twin A. Lying on her right side reduced the aortocaval compression and provided better access to twin A affording a greater surface area for palpation. Maintaining comfort and safety. The mother required no pain relief and experienced the procedure as being comfortable. The procedure took 5 mins and was done gently under ultrasound guidance in a relaxed atmosphere with immediate access to the operating theatre if required. A video demonstration of this case is shown here (Video 1.) Follow up. The cardiotocograph and Doppler examinations after ECV were normal and the fetal positions could be demonstrated showing both twins in cephalic presentation (Figure 1.) The patient was discharged on the same day.
The patient presented later in the 38 0/7 weeks of gestation for induction of labor with prostaglandin vaginal gel and had an uncomplicated vaginal delivery. ECV for breech twin A is possible, avoids cesarean section and promotes vaginal delivery in twins.5 ECV for breech twin A should be considered using the technique described in selected cases.
References 1. Bateni ZH, Clark SL, Sangi-Haghpeykar H, et al. Trends in the delivery route of twin pregnancies in the United States, 2006-2013.Eur J Obstet Gynecol Reprod Biol. 2016 Oct;205:120-6. doi:10.1016/j.ejogrb.2016.08.031. Epub 2016 Aug 24. 2. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 161: External Cephalic Version. Obstet Gynecol. 2016 Feb;127(2):e54-61. doi: 10.1097/AOG.0000000000001312. 3. Bloomfield MM1, Philipson EH. External cephalic version of twin A. Obstet Gynecol. 1997 May;89(5 Pt 2):814-5. 4. Hutton EK, Hofmeyr GJ, Dowswell T.External cephalic version for breech presentation before term.Cochrane Database Syst Rev. 2015 Jul 29;(7):CD000084. doi: 10.1002/14651858.CD000084.pub3. Review 5. Easter SR, Lieberman E, Carusi D.Fetal presentation and successful twin vaginal delivery.Am J Obstet Gynecol. 2016 Jan;214(1):116.e1-116.e10. doi: 10.1016/j.ajog.2015.08.017. Epub 2015 Aug 18.
S0301-2115(17)30310-X http://dx.doi.org/doi:10.1016/j.ejogrb.2017.06.033 EURO 9956
To appear in:
EURO
Received date:
19-6-2017
Please cite this article as: Hinkson Larry, Henrich Wolfgang.External cephalic version of a breech twin A is possible.European Journal of Obstetrics and Gynecology and Reproductive Biology http://dx.doi.org/10.1016/j.ejogrb.2017.06.033 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
External cephalic version of a breech twin A is possible
Larry Hinkson1, Wolfgang Henrich1
Department of Obstetrics Charité – Universitätsmedizin Campus Mitte, Berlin 10117, Germany
1
Correspondence: Larry Hinkson MBBS, MRCOG, FRCOG, MD Department of Obstetrics Charité- Universitätsmedizin Berlin Campus Mitte Charitéplatz 1 Berlin 10117 Germany Phone 0049-30-450664710 Fax 0049-30-450564901 Email [email protected]
Abstract
Normally, a twin pregnancy with a non-cephalic presentation of Twin A is routinely scheduled for cesarean section in up to 92% of cases. Whilst the external cephalic version (ECV) is a recommendation for singleton pregnancies, there is a paucity of data in the literature on the consideration of this option in twin pregnancies where twin A is in breech. We demonstrate a technique where it was possible to perform electively an ECV on a breech twin A giving the mother the option of vaginal delivery. We found this procedure to be effective in the 35th week of pregnancy. A detailed sonographic examination to identify the location and orientation of the separating chorioamniotic membrane, growth parameters, liquor volume, placenta location, umbilical cord location and position and orientation of both twins was essential in planning the ECV. Tocolysis was avoided. The ECV of the breech twin A was performed with the patient lying on the side avoiding aorto-caval compression and affording more surface area access for palpation of the leading twin. There was no evidence of fetal distress and no pain relief was required. The patient went on to have an uncomplicated vaginal delivery. Promoting safe vaginal delivery in twins is important in reducing the high cesarean section rates. ECV for breech twin A is possible and can avoid cesarean section.
Key words: “external cephalic version”, “breech”, “twin pregnancy”, “breech twin A”
Dear Editor, External Cephalic Version (ECV) for the leading breech Twin A is possible. We describe a modified technique for successful planned ECV for breech Twin A in a dichorial-diamnial twin pregnancy avoiding cesarean section. We know that when the leading twin is in breech the rate of cesarean section is up to 92%.1 Whilst ECV is recommended for singleton fetuses in breech, there is no consideration given to ECV for the leading twin when it is in breech.2 In the literature there is only one report of ECV of twin A performed in labor.3 This is the first description of a technique of planned ECV for breech twin A performed antenatally and avoiding cesarean section in a healthy dichorionic-diamniotic twins. A 28year-old patient who had one normal previous vaginal delivery, presented in the 29 4/7 weeks of gestation with dichorionic-diamniotic twin pregnancy. The pregnancy was uneventful and both twins were appropriately grown with Twin A in breech and Twin B in cephalic presentation. The patient expressed a desire to consider an ECV for twin A in order to avoid a cesarean section. The ECV was planned with the following steps:
Counseling and planning. She was counselled and consented by the consultant responsible for the dedicated ECV clinic at the Charité University Hospital in Berlin. An ECV was planned for the 34 4/7 weeks of gestation. A review by Hutton et al. has shown that early ECV at 34-35 weeks is as effective in achieving vaginal cephalic delivery as when performed beyond 37 weeks.4 Avoiding tocolysis. The use of tocolytic medication though normally recommended was purposefully avoided to reduce the risk of complications such as maternal hypotension and palpitations.2 Cardiotogographic examinations were performed to ensure fetal well being. Ultrasound examination. This confirmed normal growth parameters, Doppler values, liquor volume, placenta location and umbilical cord location. Identifying fetal orientation. Twin A was found in breech position with flexed legs lying on the maternal left side with the back facing laterally and posteriorly. There was no nuchal cord. Twin B was lying in cephalic presentation on the maternal right side with the back facing the maternal right. Identifying the separating chorioamniotic membrane and placenta. The separating membrane between the twins was clearly identified and found to be from the uterine fundus left side to the lower uterine segment maternal right side. The placenta for Twin A was on the posterior uterine wall and for Twin B in the fundus. Lateral positioning and optimizing access to Twin A. Lying on her right side reduced the aortocaval compression and provided better access to twin A affording a greater surface area for palpation. Maintaining comfort and safety. The mother required no pain relief and experienced the procedure as being comfortable. The procedure took 5 mins and was done gently under ultrasound guidance in a relaxed atmosphere with immediate access to the operating theatre if required. A video demonstration of this case is shown here (Video 1.) Follow up. The cardiotocograph and Doppler examinations after ECV were normal and the fetal positions could be demonstrated showing both twins in cephalic presentation (Figure 1.) The patient was discharged on the same day.
The patient presented later in the 38 0/7 weeks of gestation for induction of labor with prostaglandin vaginal gel and had an uncomplicated vaginal delivery. ECV for breech twin A is possible, avoids cesarean section and promotes vaginal delivery in twins.5 ECV for breech twin A should be considered using the technique described in selected cases.
References 1. Bateni ZH, Clark SL, Sangi-Haghpeykar H, et al. Trends in the delivery route of twin pregnancies in the United States, 2006-2013.Eur J Obstet Gynecol Reprod Biol. 2016 Oct;205:120-6. doi:10.1016/j.ejogrb.2016.08.031. Epub 2016 Aug 24. 2. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 161: External Cephalic Version. Obstet Gynecol. 2016 Feb;127(2):e54-61. doi: 10.1097/AOG.0000000000001312. 3. Bloomfield MM1, Philipson EH. External cephalic version of twin A. Obstet Gynecol. 1997 May;89(5 Pt 2):814-5. 4. Hutton EK, Hofmeyr GJ, Dowswell T.External cephalic version for breech presentation before term.Cochrane Database Syst Rev. 2015 Jul 29;(7):CD000084. doi: 10.1002/14651858.CD000084.pub3. Review 5. Easter SR, Lieberman E, Carusi D.Fetal presentation and successful twin vaginal delivery.Am J Obstet Gynecol. 2016 Jan;214(1):116.e1-116.e10. doi: 10.1016/j.ajog.2015.08.017. Epub 2015 Aug 18.