147: Risk factors of severe maternal morbidity in twin pregnancy: national population-based cohort study in France

Abstract

Compared to women with singletons, women with twin pregnancy are at higher risk of maternal complications. However, among women with twin pregnancy, risk factors for maternal morbidity and subgroups at higher risk of severe maternal outcomes have been poorly characterized. Our objective was to estimate the incidence, causes and risk factors of severe acute maternal morbidity (SAMM) in women with twin pregnancy In a national prospective population-based study of twin deliveries, the JUMODA cohort, all women with twin pregnancies at or after 22 weeks of gestation were recruited in 176 hospitals performing more than 1,500 annual deliveries in France from 02/2014 to 03/2015. SAMM was a composite criterion which combines diagnoses, organ dysfunctions and interventions. The incidence of SAMM was estimated, its timing of occurrence and its causes described. Multilevel multivariate Poisson regression modeling was used to determine risk factors of SAMM and regression tree (CART) analysis to identify high-risk clinical subgroups. Among the 8,823 women with twin pregnancy of the JUMODA cohort, 542 developed SAMM, ie a global incidence of 6.14% (95% CI 5.64-6.64). Most SAMM events occurred during the postpartum period (79.6%). The leading cause was severe obstetric hemorrhage (77.5%; 4.8 for 100 twin maternities). Admission to an Intensive Care Unit occurred in 121 women (1.4 for 100 twin maternities). Women at higher risk of developing severe acute maternal morbidity were those born in Sub-Saharan Africa (aRR 1.44, 95% CI 1.01-2.07), nulliparous (aRR 1.48, 95% CI 1.18-1.85), with pregnancy obtained by vitro fertilization with autologous oocyte (aRR 1.25, 95% CI 1.01-1.55) or with oocyte donation (aRR 1.65, 95% CI 1.17-2.31), with preeclampsia (aRR 2.48, 95% CI 1.94-3.17), placenta praevia (aRR 3.48, 95% CI 2.27-5.32) or macrosomia for either twins (aRR 1.67, 95% CI 1.34-2.07). CART identified women with preeclampsia and oocyte donation as those with the highest risk (28.9%), and multiparous without preeclampsia, placenta praevia and macrosomia as those with the lowest risk (3.8%). About one woman with twin pregnancy out of 17 will develop severe acute maternal morbidity. Identification of subgroups of women at increased risk will allow accurate information of women carrying twins early in and along pregnancy as well as anticipation and potentially prevention of these events in antenatal care and at delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)