Case presentation

This is a case report of a 29-year-old woman who was in her second pregnancy and was diagnosed with a dichorionic diamniotic twin pregnancy (Figure 1).

Figure 1: Twin pregnancy dichorionic diamniotic on ultrasound.

She had a Body Mass Index (BMI) of 27.68 and a venous thromboembolism (VTE) score of 1 [6]. Her ethnic origin was from Africa, and she had a previous normal birth at term in her own country. She gave a history of fibroids. The scan revealed two fibroids: one fundal, 4 x 5 cm, and another on the anterior wall, 3 x 4 cm (Figure 2). She had no symptoms of fibroids, with no evidence of pain or degeneration.

Figure 2: Anterior wall fibroid seen on ultrasound.

Routine antenatal blood investigations were normal except for positive hepatitis B serology. She was referred to a consultant gastroenterologist. Her liver profile was normal, and Hep C was negative. She was diagnosed with cervical incompetence at 17+3 weeks when a physical examination revealed a cervix dilated to 1-2 cm and a length of 1 cm with intact membranes and not bulging. She had an emergency McDonald suture applied under general anaesthesia with Mersilene tape in the form of a purse-string suture at the cervicovaginal junction in a clockwise direction, with all four ends passing through the cervix at approximately the 12, 3, 6, and 9 o'clock positions. It was then secured by tying it down anteriorly, resulting in adequate occlusion of the internal os without being overly tight. No complications were encountered, and she was prescribed the Cyclogest pessary, 400 mg, vaginally.

She had a background history of polycystic ovaries (PCOS) and a family history of diabetes. She was diagnosed with gestational diabetes during the investigations and was started on metformin, 1 g, orally once daily. The scan at 22+2 weeks revealed mild polyhydramnios for the second twin. She was found to be Group B Streptococcus (GBS) positive.

She was admitted at 27+3 weeks due to preterm premature rupture of membranes (PPROM), draining clear liquor, and being in established preterm labour. She was given an IV magnesium sulphate infusion for neuroprotection; IV antibiotics, including GBS cover; and steroids. She progressed from 3 to 5 cm dilatation.

She had an emergency category 1 caesarean section under spinal anaesthesia. Twin 1 was delivered as cephalic. Twin 2 had a transverse lie and was delivered as breech. There were two true knots in the umbilical cord of the second twin. Twin 1 weighed 970 grams and was extubated soon. Twin 2 weighed 900 grams, was ventilated, and then weaned off. Both twins were delivered in plastic bags. The estimated blood loss (EBL) was 300 mL. The cervical cerclage was removed vaginally.

Postoperatively, she developed breathlessness, and the clinical picture was suggestive of pulmonary oedema. The computed tomography pulmonary angiogram (CTPA) was negative for pulmonary embolism (PE), but her echocardiogram was suggestive of mild tricuspid, mitral, and aortic regurgitation. Overall cardiac function was optimal, with good biventricular function and an ejection fraction >55%. During the first month after the babies were born, they remained in the Special Care Baby Unit (SCBU), so she received regular home visits from the community midwife to continue postnatal care. The cardiac review took place at approximately three months postnatal; she was then discharged from cardiology follow-up with no further concerns. At 13 weeks postnatal, she was reviewed in primary care due to her diagnosis of gestational diabetes mellitus; no concerns were identified. The patient and her babies are doing well, as she told me during a recent telephone consultation.