Delivery of monochorionic twins in the absence of complications: analysis of neonatal outcomes and costs

Induction of Labour. Guideline of the DGGG, OEGGG and SGGG (S2k, AWMF Registry No. 015-088, December 2020)

Aim The aim of this official guideline published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG) in cooperation with the Austrian Society of Gynaecology and Obstetrics (OEGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG) is to provide a consensus-based overview of the indications, methods and general management of induction of labour by evaluating the relevant literature. Methods This S2k guideline was developed using a structured consensus process which included representative members from various professions; the guideline was commissioned by the guidelines commission of the DGGG, OEGGG and SGGG. Recommendations The guideline provides recommendations on the indications, management, methods, monitoring and special situations occurring in the context of inducing labour.

Delivery timing after laser surgery for twin-twin transfusion syndrome

OBJECTIVE

To compare outcomes of twin-twin transfusion syndrome (TTTS) patients who underwent early elective delivery vs. expectant management.

STUDY DESIGN

Retrospective study of monochorionic diamniotic twins who underwent laser surgery for TTTS and had dual survivors at 32 weeks. Patients who underwent elective delivery between 32 0/7 to 35 6/7 weeks ("early elective group") were compared with all patients who delivered ≥36 0/7 weeks ("expectant management group"). The primary outcome was a composite of fetal and neonatal morbidity.

RESULTS

The final study population was comprised of 15 early elective and 119 expectant management patients. Those in the early elective group were seven times more likely to experience the primary outcome (OR 7.38 [2.01-27.13], p = 0.0026).

CONCLUSION

Among patients who underwent laser surgery for TTTS who had dual survivors at 32 weeks, elective delivery prior to 36 weeks did not appear to be protective.

Developmental and behavioral outcomes of uncomplicated monochorionic diamniotic twins born in the third trimester

BACKGROUND

Relatively little is known about the neurodevelopmental and behavioral outcomes of monochorionic diamniotic (MCDA) twin pregnancies where there are no antenatal complications peculiar to monochorionicity or prematurity.

METHODS

Twenty-two MCDA twins (44 children) with an average age of 4.3 years, and with no antenatal complications detected by 28 weeks of gestation, were recruited from a feto-maternal unit database. Parents completed a battery of neurodevelopmental and behavioral assessment questionnaires.

RESULTS

Eighteen children (41%) were identified as having developmental or behavioral concerns, predominantly of mild severity, which in turn were associated with a lower birth weight of medium effect size (Cohen's d=0.59).

CONCLUSION

MCDA twins delivered in the third trimester with no antenatal monochorionic complications in the first two trimesters appear to be at risk for subtle neurodevelopmental difficulties, associated with a lower birth weight. Ongoing developmental surveillance of these children during preschool-age is indicated for early identification and intervention.

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 (until December 2015).

REVIEW METHODS

Databases were searched without language restrictions for studies of women with uncomplicated twin pregnancies that reported rates of stillbirth and neonatal outcomes at various gestational ages. Pregnancies with unclear chorionicity, monoamnionicity, and twin to twin transfusion syndrome were excluded. Meta-analyses of observational studies and cohorts nested within randomised studies were undertaken. Prospective risk of stillbirth was computed for each study at a given week of gestation and compared with the risk of neonatal death among deliveries in the same week. Gestational age specific differences in risk were estimated for stillbirths and neonatal deaths in monochorionic and dichorionic twin pregnancies after 34 weeks' gestation.

RESULTS

32 studies (29 685 dichorionic, 5486 monochorionic pregnancies) were included. In dichorionic twin pregnancies beyond 34 weeks (15 studies, 17 830 pregnancies), the prospective weekly risk of stillbirths from expectant management and the risk of neonatal death from delivery were balanced at 37 weeks' gestation (risk difference 1.2/1000, 95% confidence interval -1.3 to 3.6; I(2)=0%). Delay in delivery by a week (to 38 weeks) led to an additional 8.8 perinatal deaths per 1000 pregnancies (95% confidence interval 3.6 to 14.0/1000; I(2)=0%) compared with the previous week. In monochorionic pregnancies beyond 34 weeks (13 studies, 2149 pregnancies), there was a trend towards an increase in stillbirths compared with neonatal deaths after 36 weeks, with an additional 2.5 per 1000 perinatal deaths, which was not significant (-12.4 to 17.4/1000; I(2)=0%). The rates of neonatal morbidity showed a consistent reduction with increasing gestational age in monochorionic and dichorionic pregnancies, and admission to the neonatal intensive care unit was the commonest neonatal complication. The actual risk of stillbirth near term might be higher than reported estimates because of the policy of planned delivery in twin pregnancies.

CONCLUSIONS

To minimise perinatal deaths, in uncomplicated dichorionic twin pregnancies delivery should be considered at 37 weeks' gestation; in monochorionic pregnancies delivery should be considered at 36 weeks.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014007538.

The risk of stillbirth and infant death by each additional week of expectant management in twin pregnancies

OBJECTIVE

The objective of the study was to compare the fetal/infant mortality risk associated with each additional week of expectant management with the mortality risk of immediate delivery in women with twin gestations.

STUDY DESIGN

A retrospective cohort study was performed utilizing 2006-2008 National linked birth certificate and death certificate data. The incidence of stillbirth and infant death were determined for each week of pregnancy from 32 0/7 weeks' through 40 6/7 weeks' gestation. Pregnancies complicated by fetal anomalies were excluded. These measures were combined to estimate the theoretic risk of remaining pregnant an additional week by adding the risk of stillbirth during the extra week of pregnancy with the risk of infant death encountered with delivery during the following week. This composite fetal/infant mortality risk was compared with the risk of infant death associated with delivery at the corresponding gestational age.

RESULTS

The risk of stillbirth increased with increasing gestational age, for example, between 37 and 38 weeks' gestation (12.5 per 10,000 vs 22.5 per 10,000; P<.05). As expected, the risk of infant death following delivery gradually decreased as pregnancies approached term gestation. Week-by-week differences were statistically significant (P<.05) between 32 and 36 weeks with decreasing risk of infant death at advancing gestational ages. The composite risk of stillbirth and infant death associated with an additional week of pregnancy had a significant increase from 37 to 38 weeks' gestation (43.9 per 10,000 vs 59.2 per 10,000; P<.05). At 37 weeks' gestation, the relative risk of mortality was statistically significantly lower with immediate delivery as compared with expectant management (relative risk, 0.87; 95% confidence interval, 0.77-0.99).

CONCLUSION

Our results suggest that fetal/infant death risk is minimized at 37 weeks' gestation; however, individual maternal and fetal characteristics must also be taken into account when determining the optimal timing of delivery for twin pregnancies.

Risk of late-preterm stillbirth and neonatal morbidity for monochorionic and dichorionic twins

OBJECTIVE

The purpose of this study was to determine the prospective risk of intrauterine fetal death (IUFD) at ≥34 weeks' gestation for monochorionic and dichorionic twins receiving intensive antenatal fetal surveillance. The secondary objective was to calculate the incidence of prematurity-related neonatal morbidity/mortality rates that have been stratified by gestational week and chorionicity.

STUDY DESIGN

A retrospective cohort study of all twins at ≥34 weeks' gestation who were delivered at the Medical University of South Carolina (1987-2010) was performed. Twins were cared for in a longstanding Twin Clinic with standardized treatment and surveillance protocols and supervised by a consistent Maternal-Fetal Medicine specialist. Gestational age-specific fetal/neonatal mortality rates and composite neonatal morbidity rates were compared by chorionicity. A generalized linear mixed model was used to identify variables that were associated with increased composite neonatal morbidity.

RESULTS

Among 768 twin gestations (601 dichorionic and 167 monochorionic), only 1 dichorionic IUFD occurred. The prospective risk of IUFD at ≥34 weeks' gestation was 0.17% for dichorionic twins and 0% for monochorionic twins. Composite neonatal morbidity decreased with each gestational week (P < .0001). Morbidity was increased by white race, gestational diabetes mellitus, and elective indication for delivery. The nadir of composite neonatal morbidity occurred at 36/0-36/6 weeks' gestation for monochorionic twins and 37/0-37/6 weeks' gestation for dichorionic twins.

CONCLUSION

Our data do not support concern for an increased risk of stillbirth in uncomplicated intensively monitored monochorionic twins at ≥34 weeks' gestation. However, our data do show significantly increased rates of neonatal morbidity in late preterm monochorionic twins that cannot be justified by a corresponding reduction in the risk of stillbirth. We believe that our data support delivery of uncomplicated monochorionic twins at 37 weeks' gestation.

Fetal sex pairing and adverse perinatal outcomes in twin gestations

PURPOSE

To assess the association between fetal sex pairing in twin pregnancies and adverse perinatal and infant outcomes.

METHODS

A retrospective cohort study of 9770 infants from 4885 twin pregnancies delivered in 2007 was conducted with a statewide hospital discharge database for Texas. Log-binomial regression models based on generalized estimating equations were used to calculate relative risks (RR) and 95% confidence intervals (95% CI) for the following dichotomous outcomes: breech presentation, hospital mortality, intrauterine growth restriction (IUGR), low birth weight, prolonged length of stay (>4 days), receipt of mechanical ventilation, and respiratory distress syndrome (RDS).

RESULTS

The sample was composed of 4918 females and 4852 males. An approximately equal number of infants were from a female-female pregnancy (n = 3270), mixed-sex pregnancy (n = 3296), and a male-male pregnancy (n = 3204). Twins of either sex from mixed-sex pairs were 45% less likely to die in the hospital compared with females from a female-female pregnancy (RR, 0.55, 95% CI, 0.31-0.98). Males from a male-male pair were 33% less likely than females from female-female pairs to experience IUGR (RR, 0.67; 95% CI, 0.53-0.83). The incidence of RDS was significantly increased in males from male-male twin pairs versus females from female-female pairs (RR, 1.21; 95% CI, 1.05-1.41).

CONCLUSIONS

Male infants from male-male twin pairs were more likely to develop RDS and be placed on a ventilator but less likely to experience IUGR than female infants from female-female pairs.