Twin pregnancy in each half of a didelphys uterus with delayed delivery and review of literature

Abstract

Didelphys uterus results from an incomplete fusion of mullerian ducts and corresponds to the class III of mullerian abnormalities of the American Fertility Society. We describe the case of a spontaneous twin pregnancy developed in each cavity of a didelphys uterus. At 29 weeks of gestation and 6 days, the patient had preterm rupture of membranes in the right horn. She went into spontaneous labor and delivered vaginally the first “right” twin. Delivery was complicated with post-partum hemorrhage on uterine atonia treated with a Bakri balloon. She was tocolyzed to pursue the fetal lung maturity of the second twin. She had a rupture of the second membranes at 30 weeks and 3 days and had a preterm vaginal delivery at 32 weeks and 1 day of the second twin. Twin pregnancy in both horns of a uterus is extremely rare, about 1 in 1,000,000. Pregnancies on congenital abnormalities of the paramesonephric duct present frequently poor obstetrical outcomes and many complications. There are no guidelines about the follow-up of these high-risk patients or the mode of delivery. INTRODUCTION Didelphys uterus results from a complete failure of fusion of the two mullerian ducts in the female genital tract formation during the embryonic development. There is then two hemiuterus, each one with a uterine cavity, two cervices, and a vaginal septum. Twin pregnancies with a fetus in each cavity are extremely rare, approximately 1 in 1,000,000. We describe the case of a spontaneous twin pregnancy developed in each cavity of a didelphys uterus, with a premature vaginal delivery, and a delayed interval delivery of 16 days between the two twins. CASE The 26-year-old woman, gravida 2, para 0 has a bicornis bicollis uterus with a vaginal septum and initially an imperforated obstructed hemivagina on the right side which was diagnosed at the age of 14 following chronic pelvic pain. She had a vaginal septum resection at the age of 25. Diagnosis of an evolutive dichorionic diamniotic twin pregnancy with a fetus in each horn of the uterus was made on ultrasound at 8-week gestation (Figure 1). By convention, we named TA the fetus in the right horn, and TB the fetus in the left horn. This situation being of high risk of premature delivery, the patient was monthly followed by a clinical and sonographic evaluation. At 25 weeks, fetal lung maturation was undertaken by an injection of 12 mg of betamethasone repeated 24 hours later. She had a premature rupture of the membranes on TA at 29 weeks and 6 days. On digital cervical examination the right cervix was posterior, short, soft, admitting one finger, and the right fetus cephalic presentation was high and mobile (Bishop score = 3). The left cervix was the same as the right one. Speculum examination Figure 1. Ultrasound at eight gestational weeks. SOR-MED