Delivery In Twin Pregnancies Research Articles

Induction of Labor versus Cesarean Delivery in Twin Pregnancies.

This study was aimed to compare maternal and neonatal outcomes between women with twin pregnancies who underwent induction of labor with those women who had planned Cesarean delivery (CD). This is a retrospective cohort study of women with twin pregnancies ≥ 24 weeks with an indication for delivery but not in labor. Two groups were examined, women who underwent induction and women who underwent planned CD. Maternal and neonatal outcomes were compared between groups both for deliveries at gestational age ≥ 37 weeks and < 37 weeks. A total of 453 patients were included. Overall, 212 (46.8%) women underwent induction and 241 (53.2%) underwent planned CD. Women who underwent induction of labor had a high rate of VD, both in the term and preterm groups (69.8 and 73.6%, respectively). Women who underwent induction of labor had reduced maternal length of stay, neonatal length of stay, and blood loss, without any increase in adverse outcomes. Neonatal ventilation of either twin delivered < 37 weeks was higher in the CD compared with induction group (27.5 vs. 9.4%, p < 0.01), but this was not significant on adjusted odds ratio analysis (aOR = 0.71, 95% CI: 0.19-2.66). Labor induction in twin gestations have improved maternal outcomes and similar neonatal outcomes compared with planned CD.

Trial of labor versus elective repeat cesarean delivery in twin pregnancies after a previous cesarean delivery—A systematic review and meta‐analysis

To perform a systematic review of success rates of trial of labor after cesarean (TOLAC) and maternal and neonatal outcomes in twin pregnancy versuselective repeat cesarean delivery (ERCD). We searched MEDLINE, EMBASE, and Web of Science from data inception to May 2018 with no language or regional restrictions, to identify all studies that compared twin TOLAC and ERCD for maternal and/or neonatal outcomes. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. We assessed the pooled relative risk and mean difference using a random-effects model. The pooled event rates for successful VBAC, cesarean deliveryfor twin B after vaginal delivery of twin A, and uterine rupture were determined. Of the 841 citations identified, 10 were eligible for analysis (2336 TOLAC cases and 5763 ERCD cases). The pooled event rates for successful VBAC and uterine rupture during TOLAC were 72.2% (95% CI 59.7%-83.2%) and 0.87% (95% CI 0.51%-1.31%), respectively. TOLAC was associated with a significantly higher risk of neonatal death (RR 3.02 [95% CI 1.07-8.54])with no significant differences in mean gestational age at birth, NICU admission rates, or 5-minute Apgar <7. Although the risk for maternal infectious morbidity was significantly lower with TOLAC(RR 0.48 [95% CI 0.25-0.90]), risks of uterine dehiscence, blood transfusions, and hysterectomy were comparable. Twin TOLAC is associated with a relatively high rate of successful vaginal delivery and a low risk of uterine rupture. The finding of higher neonatalmortality rates may be influenced by prematurity, but requires further investigation.

Twin pregnancy and risk of postpartum hemorrhage

Objective: To identify maternal and peripartum characteristics in twin gestations that are associated with postpartum hemorrhage (PPH) in which one or more units of packed red blood cells (PRBCs) were either administered or recommended but declined (PPH + PRBC).Methods: This retrospective cohort study evaluated all women with twin gestations who delivered at greater than 23 weeks of gestational age at a single, tertiary medical center from 2011 to 2016. Patients were included if they had documentation of estimated blood loss (EBL) at delivery and complete inpatient medical records available for review. Patients with incomplete records or an intrauterine fetal demise of one or both twins were excluded. The primary outcome was PPH + PRBC. Secondary outcomes included PPH with delivery EBL ≥1500 ml, PPH with atony and uterotonic administration, PPH with maternal hemorrhagic morbidity (MHM), and PPH with severe maternal morbidity (SMM). MHM was a composite outcome defined as PPH associated with any of the following: atony requiring uterotonics, any PRBC transfusion (≥1 unit), uterine or hypogastric artery ligation, hysterectomy, compression sutures, intrauterine balloon tamponade, uterine artery embolization, and/or exploratory laparotomy. SMM was a composite outcome defined as PPH associated with any of the following: administration of ≥4 units of PRBC, administration of ≥2 units of PRBC, and ≥2 units of fresh frozen plasma (FFP), return to operating room for any major procedure (excludes dilation and curettage), any peripartum hysterectomy, uterine artery embolization, intrauterine balloon tamponade or compression suture placed and administration of ≥2 units of PRBC, and/or intensive care unit (ICU) admission for invasive monitoring/treatment. A multivariable logistic regression analysis was performed.Results: A total of 1081 women with twin gestations were included. PPH + PRBC occurred in 4.4% (n = 48), delivery EBL ≥1500 ml occurred in 3.9% (n = 42), and atony with uterotonic administration occurred in 12.1% (n = 131) of the study population. The rate of MHM and SMM were 13.9% (n = 150) and 1.9% (n = 20), respectively. Although the rate of cesarean delivery was high overall (83.2%), it was nearly universal in the PPH + PRBC group (97.9%; p < .02). PPH + PRBC occurred at a rate of 0.5% (n = 1/182) among vaginally delivered twins compared to 5.2% (n = 47/899) among those delivered by cesarean (p < .03). The final multivariable logistic regression model to predict PPH + PRBC identified six significant maternal and peripartum factors: nulliparity, either pregestational or gestational diabetes, intrapartum magnesium sulfate, admission hematocrit <30%, admission platelets <100 000/µL and administration of general anesthesia.Conclusions: A number of maternal and peripartum factors are associated with PPH in twin gestations. Optimization of maternal hematologic parameters and chronic medical conditions, and reduction in the rate of cesarean delivery in twin pregnancies may decrease the risk of postpartum hemorrhage.

Risk of severe acute maternal morbidity according to the planned mode of delivery in twin pregnancies

Risk of severe acute maternal morbidity according to the planned mode of delivery in twin pregnancies

324: Induction of labor vs. cesarean delivery in twin pregnancies

324: Induction of labor vs. cesarean delivery in twin pregnancies

799: Neurodevelopmental outcome during the first year in twin neonates according to the mode of delivery

The preferred mode of delivery in twin pregnancy is controversial, and most studies compared the short-term neonatal outcomes between planned vaginal delivery (PVD) and planned cesarean section (PCS). We conducted this study to find out whether the planned mode of delivery is associated with neurodevelopmental outcome during the first year of life in twins. A prospective cohort study was conducted to evaluate the short- and long-term outcomes of twin pregnancy in Seoul National University Hospital. Twins were divided into 2 groups according to the attempted mode of delivery: PVD and PCS. Cases with emergency cesarean section due to fetal distress, major congenital anomaly and twin specific complications such as twin-to-twin transfusion syndrome and one fetal demise were excluded. The neurodevelopmental outcome was evaluated using the Korean - Ages and Stages Questionnaire (K-ASQ). K-ASQ is a Korean version of ASQ modified by standardization in Korea. It is approved as a reliable test that can monitor developmental status with a parent-completed questionnaire form. The abnormal K-ASQ score was defined as the score below 2 standard deviations from the mean for each infant age. Chi-square test, Fisher’s exact test, and Mann-Whitney U test were used as appropriate. We also performed a multivariable analysis. From May 2016 to November 2017, 256 women with twin pregnancy delivered at 27 to 40 weeks of gestation. Among them, 176 women (352 neonates) including 123 women of PVD (246 neonates, 69.9%) and 53 women of PCS (106 neonates, 30.1%) gave a consent and sent a complete questionnaire at least one time. There were no significant differences in demographic characteristics between two groups except the frequency of assisted reproduction (67.5% in PVD; 79.2% in PCS, p=.026) and vertex presented fetuses at delivery [79.3% (195/246) in PVD; 39.6% (42/106) in PCS, p<.001]. No significant differences were found in the rate of twins with one or more abnormal K-ASQ domains between PVD and PCS. After adjustment for the conception method and presentation at the time of delivery, the result showed no difference between two groups. (4 months, 10.2% vs. 11.4%, p=.862; 6 months, 7.0% vs. 11.5%, p=.417; 12 months, 10.3% vs. 14.3%, p=.532) As compared to PCS, PVD in twin pregnancy had no harmful effect on neurodevelopmental outcome during the first year of life, vaginal delivery with cephalic presentation of 1st twin can be encouraged.

771: Neonatal morbi-mortality and planned mode of delivery in twin pregnancies with breech presenting first twins

771: Neonatal morbi-mortality and planned mode of delivery in twin pregnancies with breech presenting first twins

Risk of Severe Acute Maternal Morbidity According to Planned Mode of Delivery in Twin Pregnancies: Correction.

Risk of Severe Acute Maternal Morbidity According to Planned Mode of Delivery in Twin Pregnancies: Correction.

Plasma progesterone, estradiol, and unconjugated estriol concentrations in twin pregnancies: Relation with cervical length and preterm delivery.

The aim of this study was to examine the association between plasma hormone concentrations, cervical length, and preterm delivery in twin pregnancies, including the effect of progesterone treatment. This study included 191 women pregnant with twins from a randomized placebo-controlled trial. A baseline blood sample was collected at 18-24weeks before treatment with vaginal progesterone (n=95) or placebo pessaries (n=96), and 167 (87.4%) women had a second sample collected after 4-8weeks of treatment. At baseline, 155 (81.2%) women had their cervical length measured. Progesterone, estradiol, and unconjugated estriol concentration was measured, and the association between hormone concentrations, cervical length, and gestational age at delivery was examined. Hormone concentrations were compared in the placebo and progesterone group. Statistical analysis included Spearman's rho, Mann-Whitney U test, Cuzick's test for trends, and linear regression analyses. A short cervical length was associated with preterm delivery. Cervical length and hormone concentrations were not associated (Spearman's rho; progesterone -.05, estradiol .04, estriol .08). Decreasing gestational age at delivery was associated with higher progesterone and estradiol concentrations at baseline (P trend; progesterone 0.04, estradiol 0.02) but not in the second sample or in the weekly change between samples. Progesterone treatment did not increase the progesterone concentration. Plasma concentrations of progesterone, estradiol, and unconjugated estriol at 18-24weeks are not associated with cervical length or preterm delivery in twin pregnancies. Vaginal progesterone treatment does not increase the circulating progesterone concentration in twin pregnancies. Cervical length, but not hormone concentration, is predictive of preterm delivery in twin gestations.

EP03.12: The difference in cervical elastography parameters between singleton and twin pregnancy at mid‐pregnancy

The aim of this study was to compare the mid-trimester cervical elastography parameters between singleton and twin pregnancy in asymptomatic women. A prospective observational study of cervical elastography parameters obtained at 18+0 weeks to 27+6 weeks of gestation at the time of cervical length (CL) evaluation between November 2015 and December 2017 was performed. Cervical elastography was obtained at the sagittal plane for CL measurement without compressing the cervix using E-cervixTM (WS80A, Samsung Medison, Seoul, Korea). The quantification of cervical strain was calculated by a data analysis system that directly analyses raw data from the ROI and described as elastographic contrast index (ECI), hardness ratio (HR), mean strain level within 1cm from internal (IOS), and external OS (EOS). Parameters were compared between singleton and twin pregnancy and furthermore, subgroup analysis to evaluate the elastography parameters associated with subsequent preterm birth in twin pregnancy. A total of 40 single and 26 twin pregnant women were analysed. No significant difference in CL between singleton and twin pregnancy was observed. The ECI, IOS, EOS were significantly higher in twin pregnant women compared to those with singleton pregnant women (4.00 versus 2.54, 0.28 versus 0.20, 0.35 versus 0.25, p<0.001) and HR was significantly lower in twin pregnant women compared with singleton pregnant women (57.2% versus 78.8%, p<0.001). Of the 26 twin pregnancy, 21 delivered at term whereas 5 at preterm. The preterm group had a significantly higher ECI (4.78 versus 3.85, p=0.03) and showed a trend towards lower HR (55.6% versus 57.6%, p=0.77). No significant difference in CL between preterm group and term group was observed. The mid-trimester cervical strain in twin pregnancy was different from singleton pregnancy and ECI and HR may be considered useful in predicting preterm delivery in twin pregnancy. However, further study with larger sample size is needed. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Risk of Severe Acute Maternal Morbidity According to Planned Mode of Delivery in Twin Pregnancies.

To evaluate the association between the planned mode of delivery and severe acute maternal morbidity in women with twin pregnancies. In this planned secondary analysis of the JUmeaux MODe d'Accouchement cohort, a national prospective population-based study of twin deliveries conducted from February 2014 to March 2015 in 176 hospitals performing more than 1,500 annual deliveries in France, we included women with twin pregnancies at 24 weeks of gestation or greater with two live fetuses. Women delivering before 24 weeks of gestation, those with recognized indications for cesarean delivery, and those with severe acute maternal morbidity symptomatic before labor were excluded to limit confounding by indication. The primary outcome was a composite measure of intra- or postpartum severe acute maternal morbidity. Multivariate Poisson regression models and propensity score matching were used to control for potential confounding by indication. Analyses were conducted for the overall study cohort as well as stratified by maternal age in years (younger than 30, 30-34, 35 years or older). No adjustments were made for multiple comparisons. Among the 8,124 women included in this analysis, 3,062 (37.7%) had planned cesarean deliveries and 5,062 (62.3%) had planned vaginal deliveries, of whom 4,015 (79.3%) delivered both twins vaginally. No significant overall association was found between the planned mode of delivery and severe acute maternal morbidity (6.1% in the planned cesarean delivery group and 5.4% in the planned vaginal group; adjusted relative risk 1.00, 95% CI 0.81-1.24). In women 35 years or older, the risk of severe acute maternal morbidity was significantly higher for those with planned cesarean delivery than planned vaginal delivery (7.8% vs 4.6%, adjusted relative risk 1.44, 95% CI 1.02-2.06). Propensity score and secondary analyses yielded similar results. In twin pregnancies, there is no overall association between planned mode of delivery and severe acute maternal morbidity. Women older than 35 years may be at higher risk of severe acute maternal morbidity after planned cesarean delivery.

Risk factors for cesarean delivery and adverse neonatal outcome in twin pregnancies attempting vaginal delivery.

Twin vaginal delivery presents a unique clinical challenge for obstetricians. The Twin Birth Study demonstrated the safety of planned vaginal delivery regarding neonatal outcomes. However, that study lacked a description of the risk factors associated with and the outcome of unplanned cesarean section. The aim of this study is to identify potential risk factors for cesarean section and delivery related neonatal morbidity and mortality in women with twin pregnancy attempting vaginal delivery. A retrospective cohort study including 1070 women with twin pregnancy that underwent a trial of labor between 2003 and 2015. The study population was divided according to the mode of delivery: vaginal delivery, combined vaginal-cesarean and intrapartum cesarean delivery of both twins. Several risk factors and neonatal outcomes were examined by both univariate analysis and multinomial logistic regression analysis. The rate of vaginal delivery of both twins was 88.3%, whereas the rates of combined vaginal cesarean and unplanned cesarean delivery were 4.6% and 7.1%, respectively. Nulliparity and nonvertex presentation of twin B were found to be independently associated with cesarean delivery for both twins. Additionally, nonvertex presentation of twin B was independently associated with combined vaginal-cesarean delivery. The proportion of neonates with Apgar score <7 at 5 min was increased for both twins in the combined vaginal-cesarean group compared with those delivered by the vaginal route alone. Nulliparity and nonvertex presentation of twin B were found to be associated with intrapartum cesarean delivery in twin pregnancies.

Preeclampsia acts differently in in vitro fertilization versus spontaneous twins.

To investigate risk factors and pregnancy outcome of spontaneous vs in-vitro fertilization (IVF) twins complicated with preeclampsia. A retrospective population-based cohort study comparing maternal and neonatal outcome in IVF vs spontaneously conceived twins was conducted. Deliveries occurred in a tertiary medical center between the years 1988 and 2010. Women who conceived after ovulation induction and those with chronic hypertension were excluded from the study. Multiple logistic regression models were used to control for confounders. The study population included 4428 twin pregnancies, of these 314 (7.1%) had preeclampsia; 64 (20.3%) were IVF twins and 250 (79.7%) were spontaneous twins. Preeclampsia was more common in IVF compare to spontaneous twins (13.8 vs 7.6%, OR=1.81, CI=1.50-2.17, P<0.001). The mothers of IVF twins were significantly older, and were more likely to be nulliparous. The rate of cesarean delivery was higher among IVF twins. The mean gestational age at delivery and the mean birth weight were significantly lower in IVF twins. While controlling for confounders using a multivariate analysis, IVF was found as an independent risk factor for preterm delivery in twin pregnancies with preeclampsia. However, there was no difference in the perinatal mortality or 5min Apgar scores < 7 between the two groups. Preeclampsia is more common in IVF twins compared to spontaneous twin pregnancies. IVF twins with preeclampsia are at an increased risk for cesarean delivery, preterm delivery and low birth weight.

Influence of weight gain, according to Institute of Medicine 2009 recommendation, on spontaneous preterm delivery in twin pregnancies

BackgroundsMaternal total weight gain during pregnancy influences adverse obstetric outcomes in singleton pregnancies. However, its impact in twin gestation is less understood. Our objective was to estimate the influence of total maternal weight gain on preterm delivery in twin pregnancies.MethodsWe conducted a retrospective cohort study including diamniotic twin pregnancies with spontaneous labor delivered at 28 + 0 weeks or later. We analyzed the influence of total weight gain according to Institute of Medicine (IOM) cut-offs on the development of preterm delivery (both less than 34 and 37 weeks). Outcome were compared between under and normal weight gain and between over and normal weight gain separately using Fisher’s exact test with Holm-Bonferroni correction.ResultsOne hundred seventy five women were included in the study and divided into three groups: under (52.0%), normal (41.7%) and overweight gain (6.3%). Normal weight gain was associated with a reduction in the rate of preterm delivery compared to under and over weight gain [less than 34 weeks: under vs. normal OR 4.97 (1.76–14.02), over vs. normal OR 4.53 (0.89–23.08); less than 37 weeks: OR 3.16 (1.66–6.04) and 6.51 (1.30–32.49), respectively].ConclusionsNormal weight gain reduces spontaneous preterm delivery compared to over and underweight gain.

Spontaneous preterm birth prevention in multiplepregnancy.

Key content Twin pregnancies are associated with a three‐fold greater perinatal mortality than singleton pregnancies. Prematurity is a main contributor, with 50% of twin pregnancies delivering before 37 weeks and 10% delivering before 32 weeks of gestation.The aetiology of preterm delivery in twin pregnancies is likely multifactorial and different from that of singletons.Cervical cerclage reduces preterm birth rates in singletons but has mixed results in twins with some studies showing harm.The use of progesterone to prevent preterm birth in singletons has conflicting results and has not been proven to prevent preterm birth in twins. Studies continue to determine whether the cervical pessary is effective in preventing preterm birth in multiple pregnancies.There is a paucity of data available on the prevention of preterm birth in triplets/higher order multiples but similar principles to twin pregnancy apply. Learning objectives To review the burden of preterm birth in multiple pregnancy.To understand the methods available for preventing preterm birth in multiple pregnancies and the evidence surrounding the use of each one.To be aware of the use of the Arabin pessary.

203: Notable outcomes in twin neonates by planned mode of delivery

The Twin Birth Study (TBS) documented no differences in neonatal deaths and serious neonatal morbidity between planned vaginal delivery (VD) and planned cesarean section (CS) in twin pregnancies. Adverse outcomes that may not result in mortality or severe morbidity are nonetheless noteworthy in the discussion of mode of delivery in twin pregnancies. The objective of our study was to compare these adverse events between planned vaginal delivery and planned CS in twin pregnancy. This was a secondary analysis of the TBS. Women with a twin pregnancy at a gestational age of 34+0 to 38+6 weeks with the first twin in the vertex presentation were randomized to planned CS or planned VD. The primary outcome was a composite of respiratory and neurological morbidities and neonatal care unit admission (Table). Multivariable logistic regression analysis was used to identify factors associated with the composite adverse neonatal outcomes. A total of 1304 women (2588 fetuses) were randomly assigned to planned CS and 1326 women (2632 fetuses) to planned VD. The rate of cesarean section was 90.1% in the planned CS group and 40.3% in the planned VD group. Demographic and obstetrical characteristics were similar between the groups. There was no significant difference in the composite primary outcome between the planned CS group and the planned VD group (Table). Subsequently, sub-analysis by gestational age at delivery revealed that at 34-35 weeks’ gestation, the rate of the primary composite outcome was lower in neonates in the planned CS group49.4% and 56.1%, p=0.02). Stratification by actual mode of delivery found no difference in the composite outcome between the groups, although the respiratory morbidity was higher among those delivered by CS in comparison to those delivered by VD (9.7% and 7.6%, p=0.009). Factors that were independently associated with notable adverse outcome were birth at 34-37 weeks and being 2nd born twin in CS (Table). Our results strengthen the original TBS finding that showed that there are no benefits to planned CS, as compared with planned VD, in twins between 34+0 weeks and 38+6 weeks of gestation if the first twin is in the cephalic presentation. These findings are reassuring for a woman with twin pregnancy choosing planned VD as a mode of delivery.

P01.08: Comparison of preventive measures for preterm deliveries in twin pregnancies between pessary‐progesteron and cerclage alone

P01.08: Comparison of preventive measures for preterm deliveries in twin pregnancies between pessary‐progesteron and cerclage alone

Effect of vaginal progesterone in tocolytic therapy during preterm labor in twin pregnancies: Secondary analysis of a placebo-controlled randomized trial.

Our aim was to investigate the effect of the prophylactic use of vaginal progesterone on the latency period from the initiation of tocolytic therapy to delivery in twin pregnancies with preterm labor. This study was a secondary analysis of a randomized, double-blind, placebo-controlled trial of twin pregnancies in mothers who were exposed to a 200mg vaginal progesterone ovule or a placebo ovule daily from 18 to 34weeks gestation. Patients who were administered tocolysis with Atosiban because of preterm labor were included. The latency from tocolysis to delivery, mean gestational age at delivery and the rates of delivery within 48h and within seven days were compared between progesterone and placebo groups. The analysis included 27 women in the progesterone group and 30 in the placebo group. The baseline characteristics were similar between the groups. Overall, there were no differences in the latency period to delivery (17.54±13.54days and 21.58±13.52days; P=0.289), rates of delivery within 48h (14.8% and 6.7%; P=0.40) or within seven days (29.64% and 23.3%; P=0.76) or mean gestational age at delivery (32.53±3.33 and 34.13±2.87; P=0.08) between the progesterone and placebo groups, respectively. Prophylactic use of 200mg of vaginal progesterone does not influence the latency to delivery in women with twin pregnancies treated with tocolysis because of preterm labor.

Ability of cervical length to predict spontaneous preterm delivery in twin pregnancies using the receiver-operating characteristic curve analysis and an a priori cut-off value

In this retrospective study based on cervical length (CL) measurements between 20 and 24 + 6 weeks, we examined the ability of CL to predict spontaneous preterm birth (SPTB) in 222 twin pregnancies using the receiver-operating curve (ROC) analysis and an a priori cut-off. CL predicted SPTB before 34 weeks. Using the ROC the selected cut-off was 37.5 mm. Positive predictive value (PPV) and negative predictive value (NPV) regarding SPTB before 34 weeks for 37.5 mm were 15.7% and 5.3% respectively. Using the 5th percentile, PPV and NPV regarding SPTB before 34 weeks for 24 mm were 41.7% and 91.4%, respectively. The 5th centile of CL measurements should be employed in clinical practice. CL measurement is an adequate screening tool for SPTB since it has a high NPV. Studies on CL measurement and SPTB should explain which methodology they adopted to obtain a cut-off value and the rationale of their choice.

Induction of labour vs. spontaneous vaginal delivery in twin pregnancy after 36 weeks of gestation

Time for delivery and delivery pathway in twin pregnancies are still in great debate. Our study goal was to compare the characteristics of delivery and maternal-foetal outcome in uncomplicated near-term twin pregnancies undergoing labour induction and those with spontaneous labour. We found no statistical differences in patients with twin pregnancies who underwent labour induction and those with spontaneous labour regarding the history of previous caesarean delivery, parity, pregnancy achieved by assisted reproductive techniques (ART), chorionicity and cervical dilation at the admission as well as maternal and neonatal morbidity, and admission to the neonatal intensive care unit. There were significant differences in the caesarean section rate (60.6 vs. 33.3%, p < .05) and the time interval between delivery of the first and second foetus (9.8 vs. 11.7 min, p = .024). There was an increased incidence of caesarean section after the induction of labour. However, it appears to be a safe option.