*For medical professionals only
A tough "fetal war"
Recently, 22-year-old pregnant woman Pan Pan (pseudonym) gave birth to 4 ultra-premature babies in three times.
In late February this year, Pan Pan, who was 22 weeks pregnant, suddenly felt uncomfortable in her stomach, accompanied by a feeling of falling. Because the pregnant woman was pregnant with quadruplets, the local doctors thought that the situation was serious, and Pan Pan rushed from Jining, Shandong Province, to Qilu Hospital of Shandong University for medical treatment.
According to Ma Yuyan, chief physician of the second ward of the maternity ward of Qilu Hospital of Shandong University, when the pregnant woman first arrived, she already had symptoms of threatened miscarriage and was diagnosed with cervical insufficiency. In order to allow the fetus to spend more time in the mother's womb, doctors performed a cervical cerclage for her.
On 22 March, the pregnant woman gave birth to a fetus with a gestational age of 25 weeks + 6 days. After 4 days, another baby is born. The night before, after a cesarean section, the two fetuses born at the latest were 27 weeks + 2 days pregnant. All four fetuses are currently being treated in the hospital's neonatal intensive care unit.
Figure 1 Ultrasound report on March 25
A tough "fetal war"
Ma Yuyan told the "medical community" that when pregnant women first arrived, they already had symptoms of threatened miscarriage. "We wonder if she is due to uterine orifice dilation caused by contractions, or her own cervical insufficiency", and the effect of using drugs that inhibit contractions is not obvious. Cervical insufficiency is diagnosed.
Cervical insufficiency is one of the main causes of late miscarriage. It generally occurs at 18-25 weeks' gestation, and its incidence is about 1% of pregnancy, and it accounts for about 15% of recurrent miscarriages at 16-28 weeks of gestation.
Ma Yuyan performed cervical cerclage for the pregnant woman. Cervical cerclage can maintain the length of the cervix to some extent and strengthen the internal cervical opening to prevent miscarriage.
"Since the gestational age is less than 23 weeks, if all four children come out at that time, it will be very difficult to survive, and there will be a series of complications." Ma Yuyan said.
Medically, premature babies born less than 28 weeks in gestational age are called ultra-preterm babies. Ultra-premature infants are extremely immature in organ development, prone to various comorbidities after birth, and have a high rate of mortality and disability in the past, and have always been classified as late miscarriages in the mainland.
With the development of perinatal medicine, especially neonatal critical care medicine, the survival rate of newborns over 24 weeks has now improved, but the gestational age of 22-24 weeks is still within the limit of treatment.
On 22 March, Pan Pan showed signs of childbirth and was rushed to the operating room. "After the water is broken, the fetus is in the head position plus the uterine orifice is dilated, and the first fetus is soon delivered."
The first born boy weighed more than 700 grams and was 25 weeks + 6 days pregnant, belonging to ultra-preterm and ultra-low birth weight babies. His body's various functions were not yet perfect, and he was sent to the intensive care unit of the neonatology department for treatment.
Fig. 2 Footprints of a newborn baby
"According to the past law, usually four children will be born together. However, considering the various risks, coupled with the fact that the contractions of pregnant women are not obvious, we fully communicated with our families and did an emergency cervical cynthesis for pregnant women. Ma Yuyan said.
After 4 days, Pan Pan broke the water again, and the second baby was naturally born with the help of the doctor.
The second baby weighed more than 800 grams and was also transferred to the neonatology department for treatment.
The pediatric intensive care unit was expensive, and after consulting with the family, the remaining 2 babies were conceived in the mother's womb for 6 days. Until the evening of April 1, Pan Pan once again had a rupture of membranes, and the fetal heart rate slowed down. After the cesarean section, the 2 newborn fetuses, one 1030 grams and one 1050 grams, were far below normal.
Ma Yuyan told the "medical community" that at present, 4 babies are treated in the intensive care unit of the neonatology department, and the mother's condition is relatively stable.
Delayed interval deliveries
This quadruplet pregnant woman in Shandong, the child was born on different dates, which is medically called delayed interval delivery.
Although multiple births are rare, they have become a relatively mature way of fetal preservation in medicine. As early as 1880, there were reports of the first case of a twin with a delayed interval of 44 days.
According to the "Popular Science China" report, the pair of twins with the longest delay interval delivery time are both alive in Germany, and the sister's birth date is November 17, 2018, while the younger sister is February 22, 2019, which is 96 days delayed!
The obstetrics medical team of Qilu Hospital of Shandong University has carried out delayed delivery for twins and triplets many times, and it is the first time that delayed delivery for quadruplets.
"How long delayed delivery can be delayed, there is no average statistic, our hospital can extend about 3-9 weeks." Ma Yuyan said.
Delayed interval deliveries include cervical cerclage, antibiotic + tocolytic tomic agent therapy, and dynamic monitoring of intrauterine fetal conditions, infection markers, and contractions. Cervical cerclage, used by the obstetrics team at Qilu Hospital of Shandong University, is only performed in cases of cervical insufficiency due to preterm birth. This technique lacks forward-looking, multi-center clinical studies and is controversial.
It has been suggested that cervical cerclage is used for the treatment of cervical insufficiency, mainly because it can maintain the length of the cervix to a certain extent and strengthen the cervical internal mouth barrier to prevent the occurrence of ascending infection. Scholars who hold the opposite view believe that cervical cerclage is an invasive surgical procedure that increases the risk of maternal infection, chorioamnionitis, and premature rupture of membranes.
Gestational age is the most important predictor of newborn survival. Every 1 day of prolongation significantly increases the survival rate of perinatal infants and improves fetal prognosis.
From 25 weeks + 6 days of pregnancy to 27 weeks + 2 days of pregnancy, from 700g to 1050g, at present, Pan Pan's 4 babies are still treated in intensive care unit, "long-term complications are not yet known".
Ma Yuyan stressed that from a medical point of view, multiple pregnancies are not advocated. Because multiple pregnancies have more complications and are high-risk pregnancies. Pregnant women with multiple births or more should try to reduce the number of fetuses in the first trimester (before 12 weeks) or in the first trimester (before 28 weeks) to avoid complications of multiple births.
bibliography:
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4. Zhong Liuying, Song Tianrong, He Yutian, et al.Maternal and infant outcome analysis of delayed interval delivery in eight cases of multiple pregnancy[J].Journal of Practical Obstetrics and Gynecology,2015,31(8):4.
5. Set a record! Twins were born 97 days apart: why did they stay so apart? Popular Science China
Source of this article: Medical community
Author: Wan Shunshun
Editor-in-Charge: CiCi