Turning the problem of breech Twin A on its head

Introduction:

External Cephalic Version (ECV) for the leading breech Twin A reduces the need for cesarean section. The cesarean section rate when the leading Twin A is in breech is up to 92%. ECV is normally recommended for singleton fetuses in breech, however, this option is not usually considered for the leading Twin A when it is in breech. We present a case series in dichorial-diamnial twin pregnancies using a modified technique for successful ECV for breech Twin A.

Method:

We describe a new technique of planned ECV for breech Twin A performed antenatally in dichorionic-diamniotic twins. We present the outcomes of 4 cases of dichorial-diamnial twin pregnancies where external cephalic version for the breech leading Twin A was successfully performed. The modified technique involves adequate counseling and planning for ECV in the 34 – 36 week of pregnancy. The use of tocolytic medication though normally recommended is purposefully avoided to reduce the risk of complications such as maternal hypotension and palpitations. Ultrasound examination is essential to confirm normal growth parameters, Doppler values, liquor volume, placenta location and umbilical cord location and importantly to identify twin on twin orientation, and relationship of the separating chorioamniotic membrane. Lateral positioning and optimizing access to Twin A with the patients lying on the side reduces aorto-caval compression and provides better access to Twin A affording a greater surface area for palpation. All ECVs were performed with maternal comfort as a priority.

Results:

Of the 4 cases where ECV for breech Twin A was attempted, all were successful. This represents the largest successful case series of ECV for breech Twin A in twin pregnancies described in the literature.

Conclusion:

ECV for breech Twin A is possible, avoids cesarean section and promotes vaginal delivery in twins. ECV for breech Twin A should be considered using the technique described in selected cases.