Management Of Twin Pregnancies Research Articles

Ultrasound-guided fetal thorax compression to reduce post-fixation twins in the mare.

Management of twin pregnancy after conceptus vesicle fixation in the horse is challenging because the reduction techniques described are either invasive, difficult to perform or associated with disappointing success rates. To evaluate the success of transrectal ultrasound-guided fetal thorax compression for reducing post-fixation twin pregnancy in mares. Retrospective clinical study. Sixteen mares were presented for twin reduction between 51 and 79 days of gestation. History obtained from the owner and/or referring veterinarian detailed information regarding the mare (age, breed), pregnancy (day of gestation, dizygotic versus monozygotic twins, unilateral versus bilateral fixation), treatment and outcome (one live fetus at discharge; live singleton at foaling) after twin reduction. Transrectal fetal thorax compression was performed under ultrasound guidance by two experienced operators. Overall 9 of 16 twin pregnancies were successfully reduced and the likelihood of success was significantly higher in dizygotic than monozygotic twins. The procedure was successful in 9 of 10 dizygotic twins but unsuccessful in all six cases of monozygotic twins. Among the dizygotic twins, two mares lost the pregnancy after discharge from the clinic, seven mares delivered a healthy foal of normal size. Small case number. Transrectal ultrasound-guided fetal thorax compression is a minimally-invasive and successful technique for reducing dizygotic twin pregnancies at approximately 2 months of gestation, but does not lead to any live births in cases of monozygotic twins.

Noninvasive Evaluation of Fetal Zygosity in Twin Pregnancies Involving a Binary Analysis of Single-Nucleotide Polymorphisms

Twin pregnancy constitutes significant risks for maternal and fetal health, which is usually detected by ultrasound examination at early gestation. However, the imaging-based approach may not accurately identify all twins confounded by practical or clinical variables. The analysis of fetal cell-free DNA in noninvasive prenatal screening assays can completement the ultrasound method for twin detection, which differentiates fraternal or identical twins based on their distinct genotypes. Here, a new noninvasive prenatal screening employing high-coverage next-generation sequencing for targeted nucleotide polymorphisms was developed for detection of zygosity and determination of fetal fraction in twin pregnancies. This method utilizes a binary analysis of both the number and allelic fraction of fetus-specific single-nucleotide polymorphisms to infer the zygosity. In 323 samples collected from 215 singleton, 90 dizygotic, and 18 monozygotic twin pregnancies, all 90 dizygotic twins were correctly detected, with a 100% sensitivity and a 100% specificity. In addition, this method can detect complex pregnancies, such as egg donors, contamination, and twins with complete hydatidiform mole. The fetus-specific fetal fraction change was monitored in nine dizygotic twin pregnancies, which demonstrated highly variable dynamics of fetal cell-free DNA turnover up to 7 weeks after twin reduction. Overall, this study provides a new noninvasive prenatal screening strategy for the accurate identification of twin zygosity and quantification of fetal fraction, which has important clinical implications for the management of twin pregnancies.

Does structured obstetric management play a role in the delivery mode and neonatal outcome of twin pregnancies?

PurposeWhile the optimal delivery method of twin pregnancies is debated, the rate of cesarean deliveries is increasing. This retrospective study evaluates delivery methods and neonatal outcome of twin pregnancies during two time periods and aims to identify predictive factors for the delivery outcome.Methods553 twin pregnancies were identified in the institutional database of the University Women’s Hospital Freiburg, Germany. 230 and 323 deliveries occurred in period I (2009–2014) and period II (2015–2021), respectively. Cesarean births due to non-vertex position of the first fetus were excluded. In period II, the management of twin pregnancies was reviewed; adjusted and systematic training with standardized procedures was implemented.ResultsPeriod II showed significantly lower rates of planned cesarean deliveries (44.0% vs. 63.5%, p < 0.0001) and higher rates of vaginal deliveries (68% vs. 52.4%, p = 0.02). Independent risk factors for primary cesarean delivery were period I, maternal age > 40 years, nulliparity, a history with a previous cesarean, gestational age < 37 completed weeks, monochorionicity and increasing birth weight difference (per 100 g or > 20%). Predictive factors for successful vaginal delivery were previous vaginal delivery gestational age between 34 and 36 weeks and vertex/vertex presentation of the fetuses. The neonatal outcomes of period I and II were not significantly different, but planned cesareans in general were associated with increased admission rates to the neonatal intensive care units. Inter-twin interval had no significant impact on neonatal outcome.ConclusionStructured regular training of obstetrical procedures may significantly reduce high cesarean rates and increase the benefit–risk ratio of vaginal deliveries.

Comparison of international guidelines on the management of twin pregnancy

ObjectivesTo review current international clinical guidelines on the antenatal and intrapartum management of twin pregnancies, examining areas of consensus and conflict. MethodsWe conducted a database search using Medline, Pubmed, Scopus, Academic Search Complete, CINAHL and ERCI Guidelines website. Guidelines were screened for eligibility using our inclusion and exclusion criteria. Those deemed eligible were quality assessed using the AGREE II tool and relevant data was extracted. ResultsWe identified 21 relevant guidelines from 16 countries including two international society guidelines. There was consensus in determination of chorionicity and amnionicity within the first trimester, fetal anomaly scan between 18 and 22 weeks and the recommended screening for twin-to-twin transfusion syndrome (TTTS).For those that provided intrapartum guidance, there was agreement in recommending caesarean section to deliver monochorionic monoamniotic (MCMA) twins, epidural anaesthesia for intrapartum analgesia and the use of cardiotocography (CTG) for intrapartum fetal monitoring.The main areas of conflict included cervical length screening, frequency of ultrasound surveillance, timing of delivery of dichorionic twin pregnancies and circumstances for recommending vaginal delivery. There was a lack of advice on intrapartum management. ConclusionsThis review has highlighted the need for unified international guidance on the management of twin pregnancy. Comparisons of current guidance demonstrates a lack of confidence in the management of labour in twin pregnancies. Further evidence on intrapartum care of twin pregnancies is needed to inform practice guidelines and improve both short and long term maternal and fetal outcomes.

Discordance in twins: Association versus prediction.

Weight discordance is among the major determinants of perinatal outcome in twin pregnancies. Weight discordance can occur in each trimester of pregnancy, though the clinical meaning of such finding and the association with adverse perinatal outcome can vary according to the gestational age (GA) at detection of growth discrepancy. Discrepancy in fetal size in the first trimester of pregnancy is associated with an increased risk of anomalies, aneuploidy, and fetal loss, though the predictive accuracy of using discordance to predict perinatal outcome is low. Conversely, discordance in the third trimester of pregnancy can be associated with fetal growth restriction, perinatal mortality, and morbidity. In view of these associations, twin pregnancies should be monitored for the occurrence of growth discrepancy. The present review aims to provide an up-to-date critical appraisal of the diagnosis and clinical management of twin pregnancies complicated by growth discordance according to the trimester at presentation.

The Controversies and Challenges in the Management of Twin Pregnancy: From the Perspective of International Federation of Gynecology and Obstetrics Guidelines

Abstract The rate of multiple pregnancy is increasing, mainly because of the widespread use of assisted reproduction techniques and families’ desire for twins. Twin pregnancy accounts for a higher risk of chromosomal abnormalities, structural malformations, and neonatal adverse events than singleton pregnancy. The presence of artery-vein anastomoses, unbalanced placenta sharing, and abnormal cord insertion in monochorionic twins is associated with twin complications such as twin-to-twin transfusion syndrome, selective intrauterine growth restriction, and twin anemia polycythemia sequence. Although many guidelines and studies have established and improved the processes about the antenatal surveillance and management of twin pregnancy, they also raise more controversies and challenges. This review aims to highlight the international consensus on the antenatal care of twin pregnancies and analyze the controversies and predicaments based on the published International Federation of Gynecology and Obstetrics guidelines and research.

Analysis of risk factors related to severe postpartum hemorrhage of twin pregnancies delivered by cesarean section

ObjectiveTo investigate the risk factors of severe postpartum hemorrhage (PPH) in cesarean section of twin pregnancy, and to provide clinical basis for pregnancy management and perioperative obstetric management of twin pregnancy. MethodsThe clinical data of 631 twin pregnancies with gestational age ≥28 weeks delivered by cesarean section at Peking University People's Hospital (PKUPH) from January 2004 to January 2017 were retrospectively analyzed. Methods of conception, the combined weight of twins, serum albumin level before cesarean section, operation time and other factors on the amount of blood loss during cesarean section were analyzed. ResultsThe proportion of severe PPH was significantly higher in in vitro fertilization-embryo transfer (IVF-ET) group, the combined weight of twins > 6000g group, serum albumin before cesarean section < 30 ​g/dl group than in the natural pregnancy group, 4000–6000g group, < 4000g group and serum albumin ≥30 ​g/dl group respectively (P ​< ​0.05). The proportion of severe PPH in the elective surgery group of twin pregnancy was higher than that in the emergency surgery group, but the difference was not statistically significant (P ​> ​0.05). Moreover, according to the surgical indications, the emergency surgery group was divided into premature rupture of membranes (PROM), labor, fetal distress and others groups, no significant difference were detected among these groups (P>0.05). ConclusionIVF-ET, the combined weight of twins, serum albumin before operation were significantly correlated with severe PPH of twin pregnancies delivered by cesarean section, revealing that it is necessary to strengthen pregnancy management of twin pregnancy.

Vaginal delivery of the second twin: A simulation program for residents in obstetrics and gynecology in a type III university maternity hospital

ObjectiveTo implement a vaginal delivery of the second twin simulation program for obstetric and gynecology residents, to reduce maternal-fetal mortality in the management of twin pregnancies in the delivery room. DesignA prospective education program. The session consisted of a theoretical part, a practical part on a mannequin and an evaluation. The model was designed in a simple and reproducible way. The simulation evaluation was done at several levels according to the validated Kirkpatrick model. SettingA tertiary level university maternity hospital. ParticipantsTen obstetric and gynecology residents participated. ResultsThe resident's personal feelings about their ability to perform the maneuvers increased significantly after participation in the simulation session. Their technical skills in performing the maneuvers were assessed in a second step. The majority of the participants considered the model realistic and the session useful. All agreed that the simulation was an essential part of their learning process. ConclusionA simulated vaginal delivery of the second twin session allows residents to be safely trained in these obstetrical maneuvers, which can be difficult to teach and perform.

Methotrexate for management of twin pregnancy with complete hydatidiform mole and co-existing live fetus: A case report.

Introduction and importanceHere, we discuss novel management with methotrexate for the rare case of a complete hydatidiform mole with a co-existing fetus (CHMCF).The management of CHMCF is controversial, and methotrexate might represent a solution.CHMCF management with methotrexate needs more study, especially its side effects, safe dosage, and the permissible period of pregnancy.Case presentationA 23-year-old Syrian primigravida came to our hospital with vaginal bleeding. The patient was diagnosed with a complete hydatidiform mole with a co-existing fetus. The mother had no complications but elevated B-HCG. After counseling, the decision was made to continue pregnancy with methotrexate to control B-HCG levels. The outcome was favorable though the infant had tetralogy of Fallot.Clinical discussionIn our case, the patient was stable except for the elevation of B-hCG levels, so we considered methotrexate to control it. On the other hand, methotrexate is considered a human teratogen. Case reports and case series of exposure to it during pregnancy began appearing in the 1960s. The sensitive period is suggested to be 6 to 8 weeks after conception. After discussing the choices with the patient, she elected to continue pregnancy and accepted methotrexate exposure to control B-hCG levels despite its risks.ConclusionMethotrexate usage within a safe dosage should be studied more to determine the benefits and risks it carries in cases such as ours.

Results of expectant management in singleton and twin pregnancies complicated by preterm premature rupture of membranes.

This study aimed to examine whether expectant management in twin pregnancies with preterm premature rupture of membranes (pPROM) is as safe as in singleton pregnancies. It was a retrospective cohort study comparing pregnancy course and outcome in singleton (n = 299) and twin pregnancies (n = 49) complicated by preterm premature rupture of membranes. Analysed factors included maternal diseases, gestational age at premature rupture of membranes (PROM), management during hospitalization, latency periods between PROM and delivery, gestational age at delivery, neonatal management and outcome. The difference in the proportion of patients with latency up to 72 hours, latency between 72 hours and seven days, and latency exceeding seven days were insignificant. The percentage of patients who received intravenous tocolysis and antenatal corticosteroids were similar; however, patients in twin pregnancies more often received incomplete steroids dose (p = 0.01). The occurrence of the positive non-stress test result and signs of intrauterine infection were similar between the groups. No statistically significant differences in the prevalence of neonatal complications except transient tachypnoea of the newborn were identified (24% in the singleton vs 13% in the twin group, p = 0.03). Expectant management of pPROM in singleton and twin pregnancies results in similar perinatal and neonatal outcome. Consequently, in case of no evident contraindications, expectant management of twin pregnancies seems to be equally as safe as in singleton pregnancies. Patients in twin pregnancies may be at higher risk of delivery before administration of full antenatal corticosteroids dose, therefore require immediate management initiation and transfer to a tertiary referral centre.

A retrospective study of twin pregnancy management in mares

The aim of the study was to compare three methods of reducing twin pregnancy in mares to maintain a single pregnancy. As multiple pregnancies in mare are always undesirable, early ultrasound diagnosis makes possible management of twin pregnancies and extra embryo removal. In years 2010–2018, 16494 mares were sonographically tested for early pregnancy, finding 868 cases of twins (471 bilateral and 397 unilateral). 260 mares with a confirmed bilateral tween pregnancy were subjected to manual crushing of one embryo and administration of flunixin at a dose of 1.1 mg/kg BW. 186 mares were subjected only to the embryo crushing procedure. 25 mares from this group were on a restrictive diet. In the unilateral twin pregnancy mare group, 62 were subjected to manual embryo reduction with simultaneous treatment with flunixin, 60 had only manual embryonic vesicle crush and 210 had a restrictive diet. Determination of success, measured as the development of a single pregnancy, were monitored 2 weeks after the procedure, between the 50th and 60th day of pregnancy and after the 90th day of pregnancy. In general, warm-blooded mares were more prone to a twin pregnancy, and at the same time, all the procedures used to reduce it to a single pregnancy caused a greater risk of losing both embryos than in the case of cold-blooded mares. The beneficial effect of administering flunixin after manual removal of one embryo on the maintenance of the other has been experimentally proven in both unilateral and bilateral twin pregnancy.

Prevalence and outcomes of twin pregnancies in Botswana: a national birth outcomes surveillance study

ObjectivesThis study aims to evaluate the prevalence and outcome of twin pregnancies in Botswana.SettingThe Tsepamo Study conducted birth outcomes surveillance at 8 government-run hospitals (~45% of all births in Botswana)...

Non-invasive prenatal testing in the management of twin pregnancies.

Twin pregnancies are common and associated with pregnancy complications and adverse outcomes. Prenatal clinical management is intensive and has been hampered by inferior screening and less acceptable invasive testing. For aneuploidy screening, meta‐analyses show that non‐invasive prenatal testing (NIPT) through analysis of cell‐free DNA (cf‐DNA) is superior to serum and ultrasound‐based tests. The positive predictive value for NIPT is driven strongly by the discriminatory power of the assay and only secondarily by the prior risk. Uncertainties in a priori risks for aneuploidies in twin pregnancies are therefore of lesser importance with NIPT. Additional information on zygosity can be obtained using NIPT. Establishing zygosity can be helpful when chorionicity was not reliably established early in pregnancy or where the there is a concern for one versus two affected fetuses. In dizygotic twin pregnancies, individual fetal fractions can be measured to ensure that both values are satisfactory. Vanishing twins can be identified by NIPT. Although clinical utility of routinely detecting vanishing twins has not yet been demonstrated, there are individual cases where cf‐DNA analysis could be helpful in explaining unusual clinical or laboratory observations. We conclude that cf‐DNA analysis and ultrasound have synergistic roles in the management of multiple gestational pregnancies.

Controversies in the management of twin pregnancy.

Despite many advances in antenatal care, twin pregnancies still experience more adverse outcomes, in particular perinatal morbidity and mortality. They also pose a multitude of challenges and controversies, as outlined in this Review. Moreover, they are less likely to be included in clinical trials. Many issues on classification and management remain under debate. Efforts at standardizing diagnostic criteria, monitoring protocols, management and outcome reporting are likely to reduce their perinatal risks. The top 10 most important research uncertainties related to multiple pregnancies have been identified by both clinicians and patients. More robust research in the form of randomized trials and large well-conducted prospective cohort studies is needed to address these controversies. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Successfully delayed delivery of second twin after early second trimester rupture of membranes of the first twin: a case report

Twin pregnancies are high-risk pregnancies accompanied with multiple complications, such as: spontaneous abortion, preterm rupture of the membranes, preterm delivery, intrauterine death of one or both twins etc. There is no consensus about the management of twin pregnancies complicated with preterm rupture of the membranes of one twin and risk of preterm delivery. These cases are rarely found in the literature. We present a case of a 35 years old patient, hospitalized in a tertiary level institution, because of a diamniotic dichorionic twin pregnancy complicated with preterm rupture of the membranes of the first twin at 19 weeks of gestation. She had one delivery with Caesarean section 16 years ago. In consultation with the patient induction of labor was done with delivery of the first twin, a death male fetus. After that, antibiotics and tocolytic therapy were administrated and the patient remained in the hospital about one week. The patient was discharged at home with regular control of her condition and condition of the fetus. The patient was again hospitalized at 33 weeks of gestation with uterine contractions on cardiotocography. After administration of corticosteroid therapy for fetal lung maturation she delivered spontaneously the second twin in a good condition and she was discharged from hospital after 16 days. In twin pregnancies clinicians must think about delayed interval delivery of the second twin, after delivery of the first twin, with an aim to increase chances for survival, especially for pregnancies less than 30 weeks of gestation.

Management of Twin Pregnancies: A Comparative Review of National and International Guidelines

Twin pregnancies are associated with a higher risk of perinatal mortality and morbidity compared with singleton and require more intensive prenatal care. The aim of this study was to review and compare the recommendations from published guidelines on twin pregnancies. A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the National Institute for Health and Care Excellence, the Institute of Obstetricians and Gynaecologists of the Royal College of Physicians of Ireland, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, and the American College of Obstetricians and Gynecologists on the management of twin pregnancies was conducted. All the guidelines highlight the importance of an accurate assessment of chorionicity, amnionicity, and gestational age in the first trimester. They also recommend the performance of nuchal translucency and a detailed anomaly scan. The ultrasound surveillance protocol is similar in all guidelines, that is, every 2 weeks for monochorionic and every 4 weeks for dichorionic twins. On the other hand, there are differences regarding the timing and mode of delivery, especially in monochorionic diamniotic twins, in the definition and management of fetal growth discordance, the use of cervical length to screen for preterm birth, and the timing of corticosteroids' administration. The differences in the reviewed guidelines on the management of twin pregnancies highlight the need for an adoption of an international consensus, in order to improve perinatal outcomes of twin pregnancies.

Systematic management of twin pregnancies to reduce pregnancy complications.

Systematic management of twin pregnancies to reduce pregnancy complications.

Good clinical practice advice: Role of ultrasound in the management of twin pregnancy.

The authors have no conflicts of interest.

Good clinical practice advice: Management of twin pregnancy

Good clinical practice advice: Management of twin pregnancy

Challenge in the Management of Twin Pregnancy with Anencephaly of One Fetus in a Low- Income Country: A Case Presentation

Anencephaly of one twin is a frequent congenital abnormality in a twin pregnancy and it’s associated with a poor prognosis of this pregnancy. In developed countries, the goal standard management calls for an interventional fetal medicine either by injection of a cardiotoxic or by intervention on the umbilical cord. Another option is an expectative management with strict follow-up of pregnant women and delivery organized in a level 3 maternity. There is still a challenge in the management of such high risk pregnancy in low income countries. A 37 years-old female, G3P2002, referred from a clinic for the better management of a 28 weeks and 4 days twin pregnancy in labor. Obstetrical ultrasonography realized in the second trimester revealed dichorionic-diamniotic pregnancy and the presence of anencephaly with hydramnios of one twin. The expectative approach was adopted for the management of this high risk pregnancy, unfortunately the death of the fetus occurred despite all the care provided. This case brings to lamp light the difficulties encountered in providing standard obstetrical care for high risk pregnancies in resource limited settings.