Complicated Twin Pregnancies Research Articles

Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis

Objective To determine the risks of stillbirth and neonatal complications by gestational age in uncomplicated monochorionic and dichorionic twin pregnancies.Design Systematic review and meta-analysis.Data sources Medline, Embase, and Cochrane databases...

Color-dye injection of monochorionic placentas and correlation with pregnancy complications

IntroductionVascular anastomoses in monochorionic (MC) twin placenta can be easily identified with color-dye injection. The aim of this study is to analyze the relationship between different type of anastomoses and twin pregnancy complications. MethodsFrom January 2011 to October 2014, MC placentas were analyzed with color-dye injection and five group of pregnancies were identified: those that were not complicated (NC), those complicated with selective intrauterine growth restriction (sIUGR), twin–twin transfusion syndrome (TTTS), or twin anemia-polycitemia sequence (TAPS) and those with amniotic fluid discordance (AFD) between twins. Cases of TTTS treated with endoscopic laser coagulation of placenta anastomoses or cases with in utero death of one twin were excluded. ResultsA total of 118 MC placentas were observed, 58 (49%) NC, 35 (30%) sIUGR, 10 (8%) TTTS, 13 (11%) AFD and 2 (2%) TAPS. The median number of anastomoses was 7 (range 1–15), 8 (2–18), 4 (2–11), 7 (2–13) and 1 (1–1), respectively. At least one artero-venous anastomoses was found in the placenta observed, while the prevalence of artero-arterial anastomoses was 95% for NC, 91% for sIUGR, 60% for TTTS, and 77% for AFD; no TAPS placenta had this type of anastomoses. The diameter of arteroarterial anastomoses was greater in the AFD group (3.3 mm), compared to the NC, sIUGR and TTTS groups (2.3, 2.5 and 1.4 respectively, p 0.04). DiscussionIn this large serie of MC placenta analyzed with color-dye injection, a specific distribution of anastomoses emerged for twins with amniotic fluid discordance, which points to a need for intensive surveillance.

The diagnostic algorithm in twin pregnancy

This paper presents the diagnostic algorithm in twin pregnancy. The most important sonographic parameters in the assessment of twins have been discussed. Moreover, the most significant complications of twin pregnancy as well as diagnostic possibilities and management, have been also presented and defined.

Amniotic lamellar body count: predicting and distinguishing neonatal respiratory complications in twin pregnancies

BackgroundTwin pregnancies have a higher rate of preterm births, making precise prediction of neonatal respiratory disorders essential. We herein examined the amniotic lamellar body count (LBC) and found it to be an accurate predictor of respiratory disorders in twin pregnancies. MethodsFive hundred fourteen amniotic fluid samples, comprising 132 dichorionic twin (DCT) and 125 monochorionic twin (MCT) gestations, were obtained at cesarean section performed at 29 to 38 gestational weeks. Samples were analyzed immediately without centrifugation. ResultsThere were 26 neonates (5.1%) with respiratory distress syndrome (RDS) and 43 (8.4%) with transient tachypnea of the newborn (TTN). The LBC in neonates with TTN (5.12×104/μl) was between the counts in RDS (1.26×104/μl) and controls (10.6×104/μl), which differed significantly. Twin concordance rates were significantly higher for TTN in MCT gestations than DCT gestations (p=0.003) and delta LBC value was significantly smaller in MCT (3.15±0.4×104/μl) than DCT (5.17±0.5×104/μl) gestations (p=0.003). ConclusionsThe amniotic LBC is useful for predicting respiratory disorders, including RDS and TTN, in twin pregnancies. The data in this study may indicate a genetic predisposition to TTN among MCTs.

Examination of the twin placenta

Twin birth rates have increased dramatically over the past three decades, and twins currently account for 3% of all pregnancies. Twin pregnancies of any type are at risk for prematurity. In addition, monochorionic twin pregnancies (25–30% of all twin pregnancies) are predisposed to a specific set of complications, including twin-to-twin transfusion syndrome (TTTS), twin reversed arterial perfusion syndrome (TRAP), malformations, and intertwin growth discordance. This article reviews the basic mechanisms underlying the twinning process, the relationship between zygosity and chorionicity, and the various types of twinning. We describe the major complications of monochorionic twinning in association with their reported placental characteristics (or lack thereof). Finally, a rational, evidence-based approach to examination of the twin placenta is presented. It is essential for the pathologist to understand the value, strengths, and limitations of examination of the twin placenta in order to provide a meaningful clinicopathological correlation in complicated (monochorionic) twin pregnancies.

English

INTRODUCTION: Twin pregnancy is a rare phenomenon and significantly related to increased maternal & fetal morbidity and mortality as compared to singleton pregnancy. It is important that every physician must know the complications related to twin pregnancy and how to manage these complications. DESIGN: Prospective observational study AIMS AND OBJECTIVE: (1) To study incidence of various obstetric complications in twin pregnancy (2) To study outcome of twin pregnancy in terms of average duration of gestation, mode of delivery & neonatal outcome. METHODS: 59 Patients with sonographically confirmed twin pregnancy attending ante-natal care outpatient department (ANC OPD) & labor room at a tertiary care hospital in our Unit in specified period of 18 months as mentioned above were enrolled in this study and followed till delivery and thereafter in the neonatal period. RESULTS: In this study twin pregnancies were slightly more in multigravida. The rate of preterm delivery was 77.9%.PIH & Anaemia was more common in primigravida. Monochorionic twins had more complications than dichorionic twins. NICU admission rate in this study was 23.6%, perinatal mortality rate was 16.9% and neonatal mortality rate was 12.2%. CONCLUSION: Twinning in pregnancy is a high risk factor which can cause various maternal as well fetal complications. Prompt ANC care and timely intervention is required to avoid these complications.

OP11.03: Prediction of monochorioncity‐related vascular complications in twin pregnancies presenting with amniotic fluid discordance

<scp>OP</scp>11.03: Prediction of monochorioncity‐related vascular complications in twin pregnancies presenting with amniotic fluid discordance

Maternal and neonatal complications of twin pregnancy in different modes of conception

Objective To explore the differences in maternal and neonatal complications of twin pregnancies in different modes of conception. Methods Retrospective analysis was performed to compare the differences in mother's gestation history, childbirth and neonatal complications among 102 cases of in vitro fertilization-embryo transfer(IVF-ET) pregnancy twins, 16 cases of simple ovulation induction(OI) pregnancy twins and 96 cases of spontaneous conception(SC) pregnancy twins. Results 1.The maternal age[(32.51±4.03) years vs (31.25±3.38) years vs (30.20±4.13) years, F=8.061, P<0.05] and birthrate of full-term infants(21.5% vs 0 vs 10.4%, χ2=7.566, P<0.05) of IVF-ET group were significantly higher than that of OI group and SC group.The body weight at birth of OI group was significantly lower than that of IVF-ET group and SC group [(1 918.1±516.4) g vs (2 228.3±454.2) g vs (2 164.4±442.5) g, F=3.293, P<0.05]. The birthrate of late preterm infant(87.5% vs 51.0% vs 64.6%, χ2=9.322, P<0.05) and the incidence of twin discordance(50.0% vs 21.6% vs 18.8%, χ2=7.781, P<0.05) of OI group were significantly higher than that of IVF-ET group and SC group, while the incidence of monozygotic twins of SC group was significantly higher than that of IVF-ET group and OI group(52.1% vs 5.9% vs 0, χ2=58.016, P<0.05).2.The incidence of pregnancy induced hypertension of OI group was significantly higher than those of IVF-ET group and SC group(50.0% vs 17.6% vs 22.9%, χ2=8.344, P<0.05). The incidence of gestational diabetes mellitus of OI group and spontaneous group was significantly higher than that of IVF-ET group(12.5% vs 14.6% vs 3.9%, χ2=6.838, P<0.05).3.The incidence of twin transfusion syndrome of SC group was significantly higher than that of the other groups(6.3% vs 0 vs 0, χ2=7.588, P<0.05), but the incidence of apnea of prematurity of OI group was significantly higher than that of IVF-ET group and SC group(43.8% vs 15.7% vs 24.0%, χ2=7.081, P<0.05). The incidence of asphyxia, transient tachypnea of the newborn, hypoglycemia, intracranial hemorrhage and septicemia of OI group were higher than that of IVF-ET group and SC group, but there was no significantly difference among 3 groups. Conclusions IVF-ET conceived twin pregnancies are not at greater risk for pregnancy complications and adverse perinatal outcome than SC twin pregnancies.But the incidence of some adverse maternal and neonatal complications of simple OI twin pregnancies is higher than that of IVF-ET group and SC group.More attention should be paid to the perinatal health care of OI conception twins, which is important to avoid serious complications. Key words: Assisted reproductive techniques; In vitro fertilization-embryo transfer; Ovulation induction; Twin pregnancy; Complication

Maternal postpartum complications according to delivery mode in twin pregnancies

OBJECTIVE:We aimed to examine maternal postpartum complications of twin deliveries according to mode of delivery and investigate the associated risk factors.METHODS:This was a retrospective cohort review of twin pregnancies with delivery after 26 weeks at a tertiary teaching hospital (1993-2008). The rates of maternal postpartum complications were compared among vaginal, elective cesarean and emergency cesarean deliveries. Significant predictors of complications were investigated with stepwise regression analysis and relative risks were calculated.RESULTS:A total of 90 complications were observed in 56/817 (6.9%) deliveries: 7/131 (5.3%) vaginal, 10/251 (4.0%) elective cesarean and 39/435 (9.0%) emergency cesarean deliveries. Significant predictors included high-risk pregnancy, gestational age at birth and delivery mode. The occurrence of complications was significantly increased in emergency compared to elective cesarean deliveries (RR = 2.34).CONCLUSIONS:Maternal postpartum complications in twin pregnancies are higher in emergency compared to elective cesarean deliveries and are also related to preexisting complications and earlier gestational age at delivery.

Fetal surgery: an overview.

In utero fetal surgery interventions are currently considered in selected cases of congenital diaphragmatic hernia, cystic pulmonary abnormalities, amniotic band sequence, selected congenital heart abnormalities, myelomeningocele, sacrococcygeal teratoma, obstructive uropathy, and complications of twin pregnancy. Randomized controlled trials have demonstrated an advantage for open fetal surgery of myelomeningocele and for fetoscopic selective laser coagulation of placental vessels in twin-to-twin transfusion syndrome. The evidence for other fetal surgery interventions, such as tracheal occlusion in congenital diaphragmatic hernia, excision of lung lesions, fetal balloon cardiac valvuloplasty, and vesicoamniotic shunting for obstructive uropathy, is more limited. Conditions amenable to intrauterine surgical treatment are rare; the mother may consider termination of pregnancy as an option for many of them; treatment can be lifesaving but in itself carries risks to both the infant (preterm premature rupture of the membranes, preterm delivery) and the mother. This makes conducting prospective or randomized trials difficult and explains the relative lack of good-quality evidence in this field. Moreover, there is scanty information on long-term outcomes. It is recommended that fetal surgery procedures be performed in centers with extensive facilities and expertise. The aims of this review were to describe the main fetal surgery procedures and their evidence-based results and to provide generalist obstetricians with an overview of current indications for fetal surgery.

Improvement in neurodevelopmental outcome in survivors of twin-twin transfusion syndrome treated with laser surgery

To compare the incidence of neurodevelopmental impairment in surviving children from pregnancies with twin-twin transfusion syndrome (TTTS) treated with laser surgery between 2time periods. We compared the neurodevelopmental outcome between the first consecutive cohort of TTTS pregnancies treated with laser surgery from 2000 to 2005, with a cohort treated between 2008 and 2010. Neurologic, cognitive, and motor development was evaluated using Bayley scales at 2 years of age corrected for prematurity. A total of 229 twin pregnancies were treated with laser surgery, 113 in the first cohort and 106 in the recent cohort. Overall survival increased from 70% (158/226) to 80% (170/212) (P= .014). The incidence of neurodevelopmental impairment decreased from 18% (28/152) to 6% (10/155) (P < .01). In multivariate analysis, severe cerebral injury at birth was independently associated with neurodevelopmental impairment (odds ratio, 34.86; 95% confidence interval, 11.83-102.75; P < .01). Overall survival in TTTS has improved over time, with a concomitant reduction in the incidence of neurodevelopmental impairment. Research focused on prevention of cerebral injury is needed to further improve outcomes of these complicated twin pregnancies.

A review of twin deliveries in Aminu Kano Teaching Hospital, North-West Nigeria

Background: Twin pregnancy remains a high risk one, and its incidence varies from one ethnic group to the other. Twin delivery is also associated with increased neonatal and maternal morbidity and mortality. Objective: To det ermine the current incidence and document the complication of twin pregnancy in Kano, northwest Nigeria. Materials and Methods: A retrospective analysis of 231 cases of twin deliveries between 1 st January 2007 to 31 st December 2009, in Aminu Kano Teaching Hospital (AKTH) Kano was carried out. Results: During this study period, there were 15,233 deliveries and 353 cases of twin deliveries, giving an incidence of 2.3% or 1 in 43 deliveries. The mean maternal age and parity were 29.0 years and 2.6 respectively. The mean gestational age at delivery was 36.9 weeks, with a mean birth weight of 2.4 kg and 2.3 kg for the first and second twin respectively. Male twins constituted 50.3% of twin births. The commonest presentation of twins was Cephalic-cephalic in 52.2%. This was followed by breech-cephalic in 29.6%, cephalic-breech in 12.6% and breech- breech in 5.2%. Mode of delivery was vaginal in 57.4% while 40.0% delivered by Caesarean section. The commonest indication for the Caesarean section was due to breech presentation in the leading twin (75.0%). Hypertensive disorder in pregnancy was the commonest maternal complication accounting for 63.16%, increasing maternal morbidity and mortality, while prematurity was the leading cause of perinatal mortality. Conclusion: This study has shown that the incidence of twin pregnancy is high in Aminu Kano Teaching Hospital, Kano, northwest of Nigeria. It has also shown that twin delivery is associated with prematurity, malpresentations and operative delivery, therefore increased perinatal and maternal morbidity. It is therefore recommended that twin pregnancy should be supervised in a tertiary centre under a specialist care and where facility for neonatal support is available to improve its outcome and reduce perinatal morbidity and mortality.

Secuencia de perfusión arterial reversa en embarazo gemelar (TRAP) monocoriónico con feto ac árdico

las patologías asociadas a las complicaciones del embarazo gemelar monocoriónico, que puede mostrar discordancia del volumen de líquido amniótico entre los fetos y hasta coexistencia de un feto acárdico con uno sano. Se comunica el caso de un síndrome de perfusión arterial reversa TRAP diagnosticado en el segundo trimestre del embarazo y se discute el manejo realizado en el servicio, así como los resultados perinatales asociados. Palabras clave: Feto acárdico, secuencia de perfusión arterial reversa, secuencia TRAP, gestación gemelar monocoriónica.

Obstetrical complications associated with first‐trimester screening markers in twin pregnancies

The aim of this retrospective study was to investigate the relation between perinatal complications in twin pregnancies and the combination of first-trimester maternal serum pregnancy-associated plasma protein-A (PAPP-A) and free beta-human chorionic gonadotrophin (β-hCG) levels. The study was conducted at the Perinatology Department of Baskent University between January 2005 and December 2011. In total, 104 patients with twin pregnancies were recruited. The association of first-trimester maternal serum-screening markers with perinatal complications was investigated for small-for-gestational-age (SGA) fetuses or intrauterine growth restriction (IUGR), preterm delivery (before 34 weeks of gestation), pregnancy-induced hypertension (PIH), and growth discordance between fetuses. Low serum PAPP-A (below 10th percentile) levels were not correlated with preterm labor, PIH, or IUGR in twin gestations. Elevated free β-hCG levels (>90th percentile) were linked to increased rates of PIH and small-for-gestational-age fetuses or IUGR. Elevated first-trimester free β-hCG was related to adverse pregnancy outcomes in twin pregnancies, whereas low PAPP-A levels were not linked to adverse pregnancy outcomes.

Effect of maternal chronic disease on obstetric complications in twin pregnancies in a United States cohort

To evaluate the effect of maternal chronic disease on obstetric complications among twin pregnancies. Multicenter, retrospective, observational study. Clinical centers (19 hospitals). Twin pregnancies (n = 4,821) delivered ≥ 23 weeks of gestation and classified by maternal chronic disease (either none or any of the following: asthma, depression, hypertension, diabetes, and heart, thyroid, gastrointestinal or renal disease). None. Gestational age at delivery, gestational hypertension, pre-eclampsia, gestational diabetes, placental abruption, placenta previa, hemorrhage, chorioamnionitis, maternal postpartum fever, premature rupture of membranes, labor onset (spontaneous vs. nonspontaneous), route of delivery, and maternal admission to intensive care unit. Women with chronic disease delivered earlier (mean gestational length, 34.1 vs. 34.6 weeks) and were less likely to have term birth (risk ratio 0.80; 95% confidence interval 0.70-0.90). Cesarean delivery after spontaneous labor (risk ratio 1.20; 95% confidence interval 1.05-1.37) was also increased with chronic disease. No statistically significant effects were observed for other complications studied. Women who used assisted reproductive technology were more likely to hemorrhage, independent of chronic disease, but other findings were generally similar to the non-assisted reproductive technology sample. Chronic disease was associated with additional risk of earlier delivery and cesarean section after spontaneous labor in a nationwide sample of US twin pregnancies.

Effect of maternal chronic disease on obstetric complications in twin pregnancies in a United States cohort

Effect of maternal chronic disease on obstetric complications in twin pregnancies in a United States cohort

Perinatal Complications in Twin Pregnancies after 34 Weeks: Effects of Gestational Age at Delivery and Chorionicity

To evaluate the perinatal outcome of twins approaching term in relation to chorionicity and gestational age at delivery. We accessed data pertaining to a cohort of 471 twin pregnancies with certain chorionicity delivered at > 34.0 weeks' gestation. Twin gestation per se, estimated fetal weight below the 10th percentile, or any intertwin discordance was not an indication for delivery before 40.0 weeks. Predictors of adverse perinatal outcome were identified using logistic regression analysis. There were no stillbirths. Adverse neonatal outcome occurred in 27% of monochorionic versus 16% of dichorionic gestations. At multivariate analysis, lower gestational age at delivery (odds ratio [OR] 0.70, 95% confidence interval [CI] 0.57 to 0.87), monochorionicity (OR 2.06, 95% CI 1.16-3.63), and either twin being growth-restricted (OR 2.35, 95% CI 1.22 to 4.54) were independent predictors of adverse neonatal outcome. Analysis of adverse neonatal outcome stratified by gestational age and chorionicity identified 36 to 37 weeks as optimal timing for delivery of monochorionic twins, and dichorionic twin pregnancies should be allowed to continue until term. Among twin gestations delivered after 34 weeks with appropriate fetal growth, reassuring fetal status at weekly assessment, and absence of obstetric complications, delivery after 36 weeks for monochorionic twins and at term for dichorionic twins minimizes the risk of stillbirths and neonatal morbidity.

W321 INFLUENCE OF MODE OF DELIVERY ON NEONATAL COMPLICATIONS IN TWIN PREGNANCIES AT AND AFTER 28 WEEKS OF GESTATION

International Journal of Gynecology & ObstetricsVolume 119, Issue S3 p. S809-S809 Poster presentations W321 INFLUENCE OF MODE OF DELIVERY ON NEONATAL COMPLICATIONS IN TWIN PREGNANCIES AT AND AFTER 28 WEEKS OF GESTATION S. Latifi Hoxha, S. Latifi HoxhaSearch for more papers by this authorS. Lulaj, S. LulajSearch for more papers by this authorM. Hoxha, M. HoxhaSearch for more papers by this authorV. Ademi, V. AdemiSearch for more papers by this authorN. Berisha, N. BerishaSearch for more papers by this author S. Latifi Hoxha, S. Latifi HoxhaSearch for more papers by this authorS. Lulaj, S. LulajSearch for more papers by this authorM. Hoxha, M. HoxhaSearch for more papers by this authorV. Ademi, V. AdemiSearch for more papers by this authorN. Berisha, N. BerishaSearch for more papers by this author First published: 22 October 2012 https://doi.org/10.1016/S0020-7292(12)62044-XAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume119, IssueS3Abstracts of XX FIGO World Congress of Gynecology and ObstetricsOctober 2012Pages S809-S809 RelatedInformation

Diagnostic Dilemma in Twin-Reversed Arterial Perfusion Sequence

The twin-reversed arterial perfusion (TRAP) sequence is a rare complication of twin pregnancies. The anatomically normal twin is termed the pump twin; the recipient twin is malformed and is known as acardiac twin. It functions as a parasite to the pump twin and receives retrograde blood flow of poorly oxygenated blood from the pump twin via the abdominal aorta, resulting in a wide spectrum of malformations. The abnormal haemodynamics created in this situation can result in congestive heart failure, hydrops and consequent premature delivery of the pump twin such that the mortality rate may be as high as 50 %. We present a case of TRAP sequence in a twin pregnancy which was diagnosed at 35 weeks of gestation. It highlights the risk of monochorionicity-associated morbidity in multiple pregnancies.

Chorionicity and perinatal complications in twin pregnancy: a 10 years case series

OVERVIEW AND AIMS: Multiple pregnancy accounts for about 3% of all pregnancies. The monochorionic pregnancy presents a relatively constant incidence (1:250 pregnancies) unlike the dichorionic, which is influenced by race, heredity, maternal age, parity and medically assisted procreation. The purpose of this work was to evaluate the impact of chorionicity on perinatal morbidity of twin pregnancy. Retrospective, longitudinal, descriptive and analytical study of women with twin pregnancy whose birth occurred in our maternity hospital since January/1999 until December/2008. monochorionic and dichorionic twin pregnancies confirmed by ultrasound. monochorionic monoamniotic gestation. Demographic data, delivery variables and perinatal morbidity and mortality were studied. Data were evaluated using the χ2 test (qualitative variables), t-Student (continuous quantitative variables) and Mann-Whitney test (quantitative discrete variables). We studied 504 pregnancies (356 dichorionic diamniotic and 148 monochorionic diamniotic). The monochorionic pregnancy had a higher incidence of threatened preterm labor (43,9% vs 31,5%, p<0,05), of oligohydramnios/hydramnios (9,8% vs 3,3%, p<0,001), discordant fetal growth (26,8% vs 14,8%, p<0,001) and intrauterine growth restriction (7,4% vs 3,7%, p<0,05). Prematurity was more common in the monochorionic group (p<0,001). The cesarean delivery rate was higher in monochorionic pregnancy (58,8% vs 50,3%, p<0,05) and the average weight of newborns was lower in monochorionic pregnancies (1983g vs 2233g, p<0,001). Newborns in the monochorionic group had higher incidence of hyaline membrane disease (5,8% vs 2,8%, p<0,05) and intraventricular haemorrhage (2,1% vs 0,4%, p<0,05). The perinatal mortality was higher in the monochorionic group (7,8% vs 1,8%, p<0,001). As the morbidity and mortality associated with monochorionic pregnancies are higher, it is essential to perform an early detection of chorionicity by ultrasound (11-13 weeks) in order to place differentiated prenatal and appropriate peripartum surveillance.