Twin Gestations Research Articles

Inducción del parto en gestaciones gemelares: estudio comparativo de oxitocina vs dinoprostona

IntroductionIn the last few years the number of twin gestations that reach term has increased. Although vaginal delivery route has proven to be a safe alternative to caesarean section when first foetus is in cephalic presentation, available evidence on induction methods applied to this type of pregnancies is limited. MethodsRetrospective observational study conducted in a tertiary hospital. Forty-four pregnant twins, with gestational age greater than 34weeks, and with the first twin in cephalic presentation, who underwent induction of labour, were included. Vaginal prostaglandins (dinoprostone) were used in 17 cases and intravenous oxytocin in 27 cases, indication was randomised according to daily clinical practice. Results of both groups were compared in terms of safety and efficacy. ResultsNo significant differences were found in the rate of caesarean section due to induction failure between oxytocin and prostaglandins (42.9% vs. 57.1%; P=.3). No differences were found either in terms of neonatal or maternal complications. Two pregnant women presented obstetric haemorrhage, the only maternal complication described, both in oxytocin group. Higher risk of caesarean section was found in women with BMI >30kg/m2 (P=.001) and pre-induction Bishop's index ≤6 (RR: 2.06) (P=.005). ConclusionsBoth vaginal prostaglandins and intravenous oxytocin are similar in efficacy, maternal and neonatal safety when used in twin gestations. Bishop's index ≤6 and BMI >30 are associated with higher probability of induction failure.

Accurate diagnosis of isolated iliac vein thrombosis in third trimester pregnancy with clues on great saphenous vein reflux: a case report and review of literature

BackgroundPregnancy is known to be a risk factor for venous thromboembolism (VTE). We report the case of a pregnant patient with difficult to diagnose iliac vein thrombosis, establishing a definite diagnosis by clues of great saphenous vein reflux.Case presentationA 37-year-old G1P0 woman at 35 weeks of assisted twin gestation presented with a complaint of persistent left lower limb edema and tenderness. A vascular ultrasound was used to examine the bilateral lower limb. Doppler of left lower extremity revealed continuous great saphenous vein reflux. Right saphenofemoral veins demonstrated venous stasis and no reflux. Unilateral continuous great saphenous vein reflux suggested left iliac veins obstruction or extrinsic compression. Anterograde venography showed a completely occlusive filling defect of the left external iliac vein, which is the definitive diagnosis of acute deep venous thrombosis. The patient underwent a cesarean delivery following inferior vena cava filter (IVCF) placement, and no signs of deep venous thrombosis (DVT) or pulmonary embolism (PE) were reported after delivery.ConclusionIn pregnant women with suspected deep vein thrombosis, it is imperative to assess the presence of unilateral continuous great saphenous vein reflux.

Pregnancy Outcomes in Patients After Completion of the mRNA Coronavirus Disease 2019 (COVID-19) Vaccination Series Compared With Unvaccinated Patients.

To compare frequency of perinatal death between pregnant patients who completed the mRNA coronavirus disease 2019 (COVID-19) vaccination series and unvaccinated patients. This retrospective cohort study included 15,865 pregnant patients who delivered 16,132 newborns after 20 weeks of gestation within a large regional health system between January 1, 2021, and December 31, 2021. Patients who received two doses of mRNA vaccine (Pfizer-BioNTech [BNT162b2] or Moderna [mRNA-1273]) were included in the vaccinated group and were compared with unvaccinated patients. Exclusions included partial vaccination, viral-vector vaccine, major congenital anomalies, and higher-order multiple gestation. Our primary outcome was perinatal death, including stillbirth and neonatal death, which was evaluated by logistic regression. Unadjusted odds ratios and adjusted odds ratios (aORs) were reported, controlling for age, body mass index (BMI), diabetes, hypertension, smoking, twin gestation, and insurance status. Propensity score matching was also performed. A total of 15,865 patients were included in the final analysis: 2,069 in the vaccination group and 13,796 in the control group. Only 13.0% of the cohort was included in the vaccination group; however, the vaccination rate increased over the course of the study period as the vaccine became more widely available and accepted. Vaccinated patients were older, with higher rates of people of non-Black racial non-Hispanic ethnic backgrounds, people with private insurance, and those with higher BMIs. Vaccination was associated with a lower incidence of perinatal death (0.5% vaccinated group vs 0.8% unvaccinated group, aOR 0.20 0.05-0.88). Vaccination against COVID-19 was also associated with lower rates of preterm delivery (aOR 0.63, 0.48-0.82), neonates with very low birth weight (aOR 0.35, 0.15-0.84), and neonatal intensive care unit (NICU) admission (aOR 0.66, 0.52-0.85). The association between vaccination and lower rates of perinatal death was no longer significant after propensity score matching. In a large retrospective cohort study, receipt of the primary mRNA COVID-19 vaccination series was associated with a lower rate of several adverse pregnancy outcomes, including perinatal death, preterm delivery, neonates with very low birth weight, and NICU admission. Although the decreased rates of perinatal death did not remain significant after propensity score matching, there was evidence of directional benefit for vaccinated patients.

The role of antenatal corticosteroids in twin pregnancy.

Twin pregnancy was associated with significantly higher rates of adverse neonatal and perinatal outcomes. One of the underlying causes is that twins are prone to preterm birth. Antenatal corticosteroids are widely used for reducing the incidence of neonatal respiratory distress syndrome initially and other neonatal mortality and morbidities subsequently. As it is widely used as a prophylactic treatment for potential premature births, there remain controversies of issues relating to twin gestations, including window for opportunity, timing of use, repeat course, optimal administration-to-delivery intervals, dosage, and type of corticosteroid. Thus, we present a thorough review of antenatal corticosteroids usage in twin gestation, emphasizing the aforementioned issues and attempting to offer direction for future investigation and clinical practice.

A Case of Sex Discordant Dichorionic Diamniotic Twins after Single Embryo Transfer and the Importance of Zygosity Testing

Single embryo transfer (SET) is a technique used in assisted reproductive treatment (ART) that is used to promote singleton pregnancies. To date, there are five reported cases of dizygotic twin pregnancies with mothers who underwent SET. Here, we present a sixth case of a dichorionic, diamniotic twin pregnancy with sex discordance. The patient is a 34-year-old woman with unexplained secondary infertility who underwent in vitro fertilization (IVF) and frozen-thawed embryo transfer from a SET. The ultrasonographic images from the first and second trimester scans identified dichorionic, diamniotic twin gestations. The delivery was full term and postnatal genetic testing confirmed 46, XX, and 46, XY offspring. Pathology reports of the placental and membrane findings reported diamniotic, dichorionic twins. There was no zygosity testing conducted, thus it is unknown if the twins are monozygotic or dizygotic. Two possible etiologies for sex-discordant twins, in this case, are concurrent natural conception via breakthrough ovulation at the time of SET, or discordant postzygotic nondisjunction of a single embryo. Multiple gestations may still occur in the setting of SET and zygosity testing in these instances would better elucidate our understanding of this occurrence. Moreover, improved data on the zygosity of multiple gestations following SET may enhance patient counseling.

New-Onset Type 1 Diabetes Mellitus (T1DM) in a Pediatric Patient with Beckwith-Wiedemann Syndrome

Abstract Introduction Beckwith-Wiedemann Syndrome (BWS) is the most common overgrowth syndrome with up to 50% of infants found to have hypoglycemia which has been believed to be related to hyperinsulinemia. However, our case report highlights a patient with the unusual presentation of concurrent BWS and T1DM along with the discussion of genetic factors that may contribute to the pathogenesis. Clinical Case We present the case of a 4-year-old African American female with a past medical history of BWS, twin gestation, prematurity, omphalocele, and patent ductus arteriosus. Her BWS had been diagnosed at birth via genetic testing which found a loss of methylation on the maternal chromosome at imprinting center 2 (IC2) on chromosome 11. During her newborn period, she did not have hypoglycemia. She presented to her primary care physician with a 2.4-kilogram weight loss, new-onset headaches, polyuria, and polydipsia for three months. She also had a viral upper respiratory tract infection a month prior to presentation. Her twin sister did not have similar complaints. Her physical exam including vital signs was reassuring. With the concern for diabetes, further work-up was done which showed an elevated serum glucose level of 681 mg/dL, and hemoglobin A1C of 12.4%. She was admitted for new-onset diabetes. Further labs on admission also showed elevated transglutaminase IgG and positive glutamic acid decarboxylase 65 (GAD65) antibody (level: 444 nmol/L, normal: ≤0.02 nmol/L). Notably, no acidosis was detected in the initial investigations and, unfortunately, due to laboratory error the diabetes antibody panel was cancelled. She was started on a basal-bolus insulin regimen with the diagnosis of new-onset T1DM without ketoacidosis. BWS does not have T1DM as a known characteristic. Hypoglycemia secondary to hyperinsulinemia rather than the opposite, such as our case, is associated with BWS. Due to this, our case is rare, and we found a case report from Europe describing a similar phenomenon. Our patient had a GAD65 antibody being positive which explains having T1DM although there are no studies showing the association of BWS with a positive GAD65 antibody. Our patient also had a viral infection prior to the diagnosis of T1DM which may have triggered autoimmunity. Further, IC2 loss of methylation present in our patient regulates the expression of CDKN1C which has been previously reported to be associated with diabetes. Conclusion Further studies will be required to identify the possible case of T1DM in a patient with BWS. We plan on obtaining a diabetes antibody panel to further assess the genetics of our patient.

A Case of Monochorionic-Diamniotic Twin Pregnancy with Differing Phenotypic Sex

A 37 year old Asian woman G2P0010 with a known twin gestation at 30 weeks 2 days by in vitro fertilization dating, immigrated to the United States from China to continue her prenatal care. She had three embryos conceived by intracytoplasmic sperm injection (ICSI) that were transferred on day 3. First-trimester ultrasound reports from China revealed monochorionic diamniotic twin pregnancy. On presentation, to our office, an ultrasound showed Twin A with male genitalia and Twin B with female genitalia and a thin dividing membrane which was consistent with monochorionicity. Placental pathology also confirmed monochorionicity. This case explores a potential mechanism for differing fetal sexes in a case of monochorionic-diamniotic twins due to fusion chimera formation. Chimera formation has been thought to occur via disruption of the zona pellucida during the ICSI process and transfer of cells between different embryos. As assisted reproductive technologies become more prevalent, exploring the developmental pathogenesis and genetics of twinning is warranted to better understand discordant findings from prenatal ultrasound and genetics. The interactions of the transferred embryos could lead to sustained stem cell chimerism that is present after birth.

Effects of parity on preterm delivery in twin gestations conceived with in vitro fertilization

To determine the relationship between prior obstetrical history and gestational age at delivery in a twin pregnancy. Retrospective cohort study using theUnited States Society for Assisted Reproductive Technology Clinic Outcomes Reporting System database. Clinic-based data. Patients undergoing invitro fertilization (IVF) in the United States with live delivery of twins. None. The main outcome measures are median gestational age at delivery and rate of preterm delivery (before 37 weeks). The median gestational age at delivery of IVF-conceived twins was 36.3 (interquartile rate 34.4, 37.6) weeks for nulliparous women, 35.9 (34.0, 37.1) weeks for parous women with a prior preterm birth, and 36.7 (35.1, 37.7) weeks for parous women without a prior preterm birth. The rate of preterm delivery was 61% for nulliparous women, 70% for parous women with a prior preterm birth, and 55% for parous women without a prior preterm birth. Parous women without a history of preterm delivery had lower rates of preterm delivery in a subsequent twin pregnancy than nulliparous women. Nulliparous women had lower rates of preterm delivery compared with parous women with a history of preterm delivery.

Is bigger better? A comparison of growth restriction rates using the crown-rump length derived due date from the smaller versus larger twin

Although the smaller twin's crown-rump length is most accurate in establishing the estimated due date in dichorionic gestations, societal guidelines favor the use of the larger twin measurements based on concern for missing a diagnosis of fetal growth restriction. This study aimed to compare the accuracy of the diagnosis of early- and late-onset fetal growth restriction in dichorionic twin gestations conceived by assisted reproductive technology using the estimated due date as established by the crown-rump length of the smaller vs larger twin. This was a 10-year retrospective cohort study of nonanomalous, dichorionic gestations conceived with assisted reproductive technology at 2 institutions. The incidence of early-onset (<32 weeks of gestation) and late-onset (≥32 weeks of gestation) growth restriction derived from the Hadlock formula using the smaller and larger crown-rump length estimated due date was compared with the true estimated due date by assisted reproductive technology. Statistical significance was determined using the Fisher exact test. The incidence of missed fetal growth restriction cases, false-positive rate, and error were calculated along with the relative risk for a missed diagnosis using the smaller crown-rump length. A total of 176 subjects were screened: 81 had a fetal growth ultrasound at 24 to <32 weeks of gestation, and 58 had a fetal growth ultrasound at ≥32 weeks of gestation. There was a significant difference in the incidence of fetal growth restriction using the 3 dating strategies in both gestational age ranges (P<.001) with the smaller crown-rump length estimated due date more closely approximating the true rate. Before 32 weeks of gestation, the smaller crown-rump length estimated due date missed 2.5% of fetal growth restriction cases, whereas the larger crown-rump length estimated due date missed 0.6% of fetal growth restriction cases, with false-positive and error rates of 1.2% and 3.7% and 5.5% and 6.2%, respectively. After 32 weeks of gestation, the smaller crown-rump length estimated due date missed 1.8% of cases, whereas the larger crown-rump length estimated due date missed 0% of cases, with false-positive and error rates of 2.6% and 4.4% and 5.3% and 5.3%, respectively. The relative risk for a missed diagnosis of fetal growth restriction using the smaller crown-rump length estimated due date was 1.77 for early-onset growth restriction and 1.22 for late-onset growth restriction. Using the estimated due date derived from the smaller twin led to a more accurate detection of fetal growth restriction at a cost of a higher missed diagnosis rate.

Multicystic dysplastic kidney and contralateral renal agenesis in a twin gestation: A case report

Multicystic dysplastic kidney (MCDK) is a common congenital condition in neonates caused by the abnormal formation of renal tissue into multiple fluid-filled cysts that are often dysplastic, affecting kidney function. [1] It has an incidence of 1:4300 live births and is more common in males than females, most often presenting unilaterally with a slightly higher percentage of cases affecting the left kidney. We present a case of a monochorionic diamniotic twin female, with twin A having multicystic dysplastic kidneys on the left and twin B having agenesis of the right kidney. Documented cases involving twins rarely involve both twins or, if so, infrequently in the contralateral kidneys of each twin, highlighting the complexity of renal development in utero.

Prevalence and factors associated with preterm births among postnatal mothers at Soroti Regional Referral Hospital, Eastern Uganda

BackgroundGlobally, prematurity is the leading cause of death in neonates and therefore a major contributor to the under 5-year mortality. The study assesses the prevalence and risk factors associated with preterm birth at a Regional Referral Hospital in Eastern Uganda. MethodsThis was a descriptive cross-sectional study conducted at a Regional Referral Hospital in Eastern Uganda. A questionnaire was used to capture data on maternal socio-demographic features, and obstetrical causes of preterm birth. Additional information was got from maternal medical records. In total, 350 mother-baby pairs were studied. Bivariate and multivariate logistic regression models were fitted so as to establish the factors associated with preterm birth. A p-value < 0.05 was considered statistically significant. ResultsPrevalence of preterm birth at Soroti Regional Referral Hospital was 24.6% (86/350). Factors associated with preterm birth included: Fewer than 3 antenatal attendances (aOR = 3.115, 95% CI [1.659–5.849], P = 0.038), twin gestation (aOR = 6.973, 95% CI [1.128–43.097], P = 0.016), antepartum hemorrhage (aOR = 4.743, 95% CI[806–12.458], P < 0.001) and PPROM (aOR = 18.902, 95% CI[7.267–49.167], P < 0.001). Maternal mid upper arm circumference (MUAC) measurement ≥24 cm was a protective factor against preterm birth (aOR = 0.155, 95% CI[0.0686–0.352], P < 0.001). ConclusionPreterm births in Soroti-RH in Eastern Uganda were associated with poor maternal nutrition status, low antenatal attendance, twin gestation, antepartum hemorrhage, and preterm premature rupture of membranes. Health education on proper nutrition and routine monthly antenatal visits by healthcare workers is important for early screening and detection of high risk pregnancies.

Prenatal diagnostic testing decisions in twin pregnancies in the era of cell-free DNA screening

Rates of diagnostic procedures in singleton pregnancies have declined since cell-free DNA (cfDNA) became commercially available. However, the impact of cfDNA on the uptake of diagnostic testing in twin gestations is unclear. We aimed to describe the rate of invasive diagnostic procedures in twin pregnancies after cfDNA screening with and without fetal structural abnormalities. This is a secondary analysis of data from a multicenter retrospective cohort study from 12/2011- 02/2020 that aimed to evaluate cfDNA screening performance in twin pregnancies. For this analysis, we excluded cases with a vanishing twin. cfDNA results were reported as positive, negative, or non-reportable. Structural abnormalities were defined as a major or minor anomaly, including an increased nuchal translucency >3mm. Rates of diagnostic testing were analyzed via chi-squared with odds ratio calculated by logistic regression. A total of 112 (6.6%) of 1,696 patients with twin pregnancies had cfDNA results and diagnostic procedures performed: 82 amniocenteses and 29 chorionic villus samplings (CVS). Diagnostic procedures were more frequent in patients that were older, had private insurance and conceived via IVF (Table 1). Patients with diagnostic testing were more likely to have positive or non-reportable cfDNA results compared to those without diagnostic testing. As noted in Figure 1A, 50% of positive cfDNA, 4.8% of negative cfDNA and 20% of non-reportable cfDNA ultimately had diagnostic testing. Figure 1B details the frequency of diagnostic procedures performed for each combination of cfDNA result and the presence of a structural abnormality. Diagnostic testing was more common if a structural abnormality was present (15.0% vs 4.5%, aOR 4.30 95% CI 2.71-6.83) and if there was an abnormal cfDNA result (32.8% vs 4.7%, aOR 8.72 95% CI 5.16-14.74), when adjusted for demographic factors. Cell-free DNA results and the presence of structural abnormalities greatly impact the decision to pursue diagnostic testing in patients with twin gestations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Clinical implications of first trimester crown-rump length discordance in dichorionic twin gestations

First trimester crown-rump length (CRL) discordance (≥10% difference in CRL) in monochorionic twins is associated with adverse perinatal outcomes (APO). However, data are limited on clinical implications of CRL discordance in dichorionic (DC) twins. We therefore aimed to evaluate if first trimester CRL discordance in DC twins is associated with APOs or aneuploidy in either twin. This is a secondary analysis of data from a multicenter retrospective cohort study, evaluating cfDNA performance for common trisomies in patients with twin pregnancies from 12/2011-02/2020. We included live DC pregnancies with CRL measurements between 11-14 weeks gestation. The primary composite APO outcome was defined as any 1 of the following: preterm birth or severe preeclampsia < 34 weeks, birthweight discordance ≥ 20%, birthweight < 10%ile of either twin, or stillbirth >20 weeks in one or both twins. The secondary outcome was the rate of composite aneuploidy (T21, T18, T13) in either twin. Outcomes between twin pairs were compared via chi-squared and t-test as appropriate. Multivariable logistic regression was used to calculate odds ratios and adjust for confounders. Of the 1,110 DC twin gestations meeting inclusion criteria, 156 (14.1%) had discordant CRLs. There were no differences in demographics between twins with and without CRL discordance (Table 1). The mean maternal age for the cohort was 35 and 33% were nulliparous. The rate of APO was higher with discordant CRLs after adjusting for aneuploidy (73.1% vs 60.0%, aOR 1.73, 95% CI 1.18-2.53), driven mostly by birthweight outcomes (Table 2). The overall rate of aneuploidy was 3.9% and twins with discordant CRLs had more than 3-fold increased odds of aneuploidy (9.6% vs 3.2%, OR 3.16, 95% CI 1.66-6.01). CRL discordance in DC twin pregnancies is associated with increased risk for adverse perinatal outcomes and aneuploidy. This data may prove useful in decisions about aneuploidy screening or diagnostic testing, and in the identification of DC pregnancies that require increased surveillance.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Inpatient versus outpatient management of gestational hypertension or preeclampsia without severe features

To compare maternal and neonatal outcomes along with gestational latency, in patients diagnosed with a hypertensive disorder of pregnancy (HDP) (gestational hypertension or preeclampsia), without severe features managed inpatient versus outpatient setting. A retrospective, cohort study of patients with HDP without severe features before 37 weeks from 2014-2021. Patients were managed inpatient or outpatient at discretion of obstetric provider. Patients with initial presentation with severe features were excluded. The primary outcome was severe maternal morbidity (SMM) as defined by the 21 CDC maternal morbidity identifiers. Secondary outcomes included maternal ICU admission, development of severe features, placental abruption, time from diagnosis to delivery, preterm birth< 37 weeks, low birthweight (< 2500g), 5-minute Apgar score < 7, and stillbirth. A total of 279 patients met the inclusion criteria with 236 (84.6%) being managed outpatient and 43 (15.4%) being managed inpatient. In univariate analysis, SMM rates were higher in inpatient compared to outpatient group (14.0% vs. 2.3%, p=0.001). Maternal ICU admission was higher in the inpatient management group (7.0% vs. 0.4%, p< 0.001). Frequencies of placental abruption and development of severe features did not differ between the groups. Time from diagnosis to delivery was longer in the outpatient compared to inpatient group (13d vs. 3d, p< 0.001). Low birth weight and preterm birth were more frequent in the inpatient group (Table 1). In multivariate analyses, controlling for gestational age at HDP diagnosis, HDP type, twin gestation, maternal diabetes, BMI, and residential distance from the hospital, SMM did not differ between the groups (aOR 0.17, 95% CI 0.02-1.78) Secondary outcomes did not differ between outpatient and inpatient management groups (Table 2). Outpatient management of gestational hypertension or preeclampsia without severe features was not associated with adverse maternal or neonatal outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Severe maternal morbidity in singleton and twin gestations

Severe maternal morbidity in singleton and twin gestations

Twin gestation with abnormal placental cord insertion associated with poor outcome

Twin gestation with abnormal placental cord insertion associated with poor outcome

Elective induction of labor following prior cesarean delivery

Following the ARRIVE trial, induction of labor at 39 weeks has increased in the United States. The risk of uterine rupture and optimal timing of elective induction in those women with a prior cesarean delivery is not well described, and they were not included in the ARRIVE trial. We aimed to estimate the risk of uterine rupture in those women undergoing elective induction of labor with a prior cesarean delivery. This was a retrospective cohort of women with a prior cesarean delivery from 1996 to 2000. Women were included if they had ≤ 2 prior cesareans. Women were excluded if they had a history of an unknown prior incision, a classical incision, gestational age < 39 weeks, any diabetes, chronic hypertension, twin gestation, collagen or vascular disease, or HIV. Those undergoing expectant management were compared to those undergoing elective induction with no medical or obstetrical indications for delivery. Analysis was performed at three gestational age groups: 39 weeks, 40 weeks, and 41 weeks. The primary outcome was uterine rupture. Secondary outcomes included vaginal delivery and a composite major morbidity. Comparisons were made using Student’s t-test or χ2 test as appropriate. At 39 weeks, 618 (10.3%) elective inductions were compared to 5365 (89.7%) undergoing expectant management; uterine rupture occurred more frequently (2.1% vs. 0.9%; P=0.006) with fewer successful VBAC (66.8% vs. 75%; P< 0.001). The risk of uterine rupture was similar between groups at 40 (0.8% vs. 1.2%; P=0.387) and 41 weeks (1.4% vs. 0.8%; P=0.448). Among elective inductions, the risk of rupture or major morbidity was not significantly different by timing, although 39 weeks was associated with more vaginal deliveries. Women undergoing elective induction of labor with a prior cesarean scar had an increased risk of uterine rupture when compared to expectant management at 39 weeks, with fewer successful VBAC. However, when induction is compared across all age groups, the risk of a major maternal morbidity is not increased.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Hapless Foetal Outcome in Twin-Twin transfusion syndrome: A case report

Twin-Twin transfusion syndrome (TTTS), a complication of Monochorionic twin gestation is a worldwide cause of perinatal mortality, with a high incidence of impairment in surviving twins. We report a recent case of TTTS at 28 weeks resulting in poor outcomes after birth.

Previable Premature Rupture of Membranes in Dichorionic Diamniotic Twin Gestation, Loss of Leading Twin, Emergency Cervical Cerclage and Ceaserean Delivery at Term

Introduction: Multiple pregnancies have a higher risk of premature delivery and a weakened cervix has been associated with it. In most cases, emergency cerclage has proved to be beneficial as the birth of the first twin is usually followed by the unavoidable delivery of the second twin and most fetus dies shortly after delivery. Studies have noted that delayed delivery of the second fetus in a twin pregnancy is an effective management choice and the use of cervical cerclage after the first delivery is associated with a longer inter-delivery interval. We present a case of previable premature rupture of membrane of a dichorionic diamniotic twin gestation leading to the loss of the leading twin and subsequently having emergency cervical cerclage for the second twin and caesarean delivery at term. Case Presentation: She was a case of a 29 years old, G6P1+4 with 1 living child at a gestational age of 17 weeks plus 5 days who initially was diagnosed with dichorionic diamniotic twin gestation following an early ultrasound but presented with a history of bleeding and passage of liquor per vaginam. Ultrasound done on admission showed cervical funneling and a stable state of the second twin. She subsequently had emergency cervical cerclage after stabilization on account of previable premature rupture of membrane of a dichorionic diamniotic twin gestation with the loss of the leading twin. A repeat ultrasound done prior to discharge showed closed cervical os and a good state of the fetus. She then had elective caesarean delivery at term with a good feto-maternal outcome. Conclusion: Emergency cervical cerclage should be part of the options of management after stabilization in cases of previable premature rupture of membrane in a dichorionic or multichoronic gestation so as to save the viable once.

Severe Maternal Morbidity in Twins.

While twin gestations are at increased risk of severe maternal morbidity (SMM), there is limited information about timing and causes of SMM in twins. Furthermore, existing data rely on screening definitions of SMM because a gold standard approach requires chart review. We sought to determine the timing and cause of SMM in twins using a gold standard definition outlined by the American College of Obstetricians and Gynecologists (ACOG). We used a perinatal database to identify all twin deliveries from 1998 to 2013 at a single academic medical center (n = 2,367). Deliveries were classified as screen positive for SMM if they met any of the following criteria: (1) one of the Centers for Disease Control and Prevention (CDC) International Classification of Diseases Ninth Revision diagnosis and procedure codes for SMM; (2) a prolonged postpartum length of stay (>3 standard deviations beyond mean length of stay by mode of delivery); or (3) maternal intensive care unit admission. We identified true cases of SMM through medical record review of all screen-positive deliveries using the definition of SMM outlined in the ACOG Obstetric Care Consensus. We also determined cause and timing of SMM. A total of 165 (7%) of twin deliveries screened positive for SMM. After chart review of all screen-positive cases, 2.4% (n = 56) were classified as a true case of SMM using the ACOG definition for a positive predictive value of 34%. The majority of SMM occurred postpartum (65%). Hemorrhage was the most common cause of SMM, followed by hypertensive and pulmonary etiologies. Commonly used approaches to screen for SMM perform poorly in twins. This has important implications for quality initiatives and epidemiologic studies that rely on screening definitions of maternal morbidity. Our study demonstrates that the immediate postpartum period is a critical time for maternal health among women with twin pregnancies. · Screening approaches for SMM have low positive predictive value in twins.. · Hemorrhage, hypertensive, and pulmonary complications were the most common morbidities.. · SMM was most common postpartum..