[Modes of deliveries of twins as a function of their presentation. A study of 371 pregnancies]

Mode of delivery and neonatal outcomes in extremely preterm Vertex/nonVertex twins

BACKGROUND

One of the controversies in the management of twin gestations relates to mode of delivery, especially when the second twin is in a nonvertex presentation (Vertex/nonVertex pairs) and birth is imminent at extremely low gestation.

OBJECTIVE

We hypothesized that, for Vertex/nonVertex twins born before 28 weeks' gestation, cesarean delivery would be associated with a lower risk of adverse neonatal outcomes than trial of vaginal delivery. Our aim was to test this hypothesis by comparing the neonatal outcomes of Vertex/nonVertex twins born before 28 weeks' gestation by mode of delivery using a large national cohort.

STUDY DESIGN

This work is a retrospective cohort study of all twin infants born at 24^0/7 to 27^6/7 weeks' gestation and admitted to level III neonatal intensive care units participating in the Canadian Neonatal Network (2010-2017). Exposure is defined a trial of vaginal delivery for Vertex/nonVertex twins. Nonexposed (control) groups are defined as cases where both twins were delivered by cesarean delivery, either in vertex or nonvertex presentation (control group 1) or owing to the nonvertex presentation of the first twin (control group 2). Outcome measures are defined as a composite of neonatal death, severe neurologic injury, or birth trauma.

RESULTS

A total of 1082 twin infants (541 twin pairs) met the inclusion criteria: 220 Vertex/nonVertex pairs, of which 112 had a trial of vaginal delivery (study group) and 108 had cesarean delivery for both twins (control group 1); 170 pairs with the first twin in nonvertex presentation, all of which were born by cesarean delivery (control group 2); and 151 pairs with both twins in vertex presentation (vertex or nonvertex). In the study group, the rate of urgent cesarean delivery for the second twin was 30%. The rate of the primary outcome in the study group was 42%, which was not significantly different compared with control group 1 (37%; adjusted relative risk, 0.93; 95% confidence interval, 0.71-1.22) or control group 2 (34%; adjusted relative risk, 1.20; 95% confidence interval, 0.92-1.58). The findings remained similar when outcomes were analyzed separately for the first and second twins.

CONCLUSION

For preterm Vertex/nonVertex twins born at <28 weeks' gestation, we found no difference in the risk of adverse neonatal outcome between a trial of vaginal delivery and primary cesarean delivery. However, a trial of vaginal delivery was associated with a high rate of urgent cesarean delivery for the second twin.

[Delivery of twin pregnancy and materno-fetal prognosis in a level 3 Tunisian University Center: a retrospective study about 399 cases]

En dépit des progrès obstétricaux et pédiatriques, les grossesses gémellaires représentent une situation à haut risque aussi bien pour le déroulement de la grossesse que pour l´accouchement et reste encore une situation angoissante pour l´équipe obstétricale. Le but de cette étude était de décrire la pratique des accouchements des grossesses gémellaires au service de gynécologie obstétrique de Sousse, de décrire le pronostic maternel et fœtal et d´analyser les facteurs pouvant l´influencer. Nous avons réalisé une étude descriptive, rétrospective portant sur les accouchements des grossesses gémellaires sur une période de deux ans. Ont été incluses dans l´étude les grossesses gémellaires ayant atteint au moins 28 semaines d´aménorrhée (SA) et les femmes ayants une grossesse gémellaire compliquée d'une mort fœtale in utéro. Ont été exclues les femmes ayant une grossesse gémellaire et ayant accouchés avant 28 SA. Les grossesses bi-choriales bi-amniotiques représentaient 67% des cas, contre seulement 11,5% de grossesses mono-choriales bi-amniotiques et 3% de grossesses mono-choriale mono-amniotique. Nous avons recensé 52 césariennes programmées. Le travail a été spontané dans 304 cas. Il a été déclenché dans 43 cas. Au total 178 parturientes ont accouché par voie basse (44,6%), contre 215 par voie haute (53,9%). Le taux de césarienne pour le deuxième jumeau était de 1,5%. Quand l'accouchement était par voie basse, 19 cas de complications ont été observés (10,7%). Nous avons analysé le score d'Apgar du premier jumeau et du deuxième jumeau en fonction du mode d'accouchement. Il n'y a pas eu de différence statistiquement significative du score d'Apgar entre les deux voies d'accouchement. La morbi-mortalité périnatale est plus importante pour le deuxième jumeau que pour le premier jumeau. La morbidité maternelle en cas d´accouchement par voie basse était supérieur à la morbidité en cas d´accouchement par césarienne. Il n´y a pas de différences significatives dans le score d´Apgar selon que les enfants sont nés par voie basse ou par césarienne.

Mode of delivery of twin pregnancies with the first twin in breech position after the introduction of a policy of planned caesarean delivery for nulliparous women

INTRODUCTION

To evaluate the impact of the mode of delivery of twin pregnancies with the first twin in breech position for all parities combined after introduction of a policy of planned caesarean section in 38 weeks' gestation in nulliparas.

MATERIAL AND METHODS

A retrospective study of the mode of delivery of twin pregnancies with the first twin in breech position was conducted from January 2007 to December 2015 after the implementation of a planned caesarean section in 38 weeks' gestation in nulliparas. Maternal and neonatal outcomes were compared according to the decision of attempted vaginal or planned caesarean delivery.

RESULTS

Among the 134 women included, an attempted vaginal delivery was decided for 30.6% women (n = 41), with 95% (n = 39) who delivered vaginally and 5% (n = 2) by caesarean section during labour. Among the 69.4% women (n = 93) with a planned caesarean section, 64.5% (n = 60) and 11.8% (n = 11) delivered by caesarean before labour and during labour, respectively, and 23.7% (n = 22) delivered vaginally. The overall vaginal delivery rate was 45.5%, and the overall rate of caesarean section was 54.5% for all parities combined. In nulliparous women, the rate of caesarean section during labour was 33%. There were no significant differences in maternal mortality or morbidity between the two groups.

CONCLUSION

A selective policy of attempted vaginal delivery based on parity for twin pregnancies with the first twin in breech position can lead to a reduction in the overall rate of caesarean section in this population.

What is the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs? A systematic review and meta-analyses

Background

Given the controversy around mode of delivery, our objective was to assess the evidence regarding the safest mode of delivery for actively resuscitated extremely preterm cephalic/non-cephalic twin pairs before 28 weeks of gestation.

Methods

We searched Cochrane CENTRAL, MEDLINE, EMBASE and http://clinicaltrials.gov from January 1994 to January 2017. Two reviewers independently screened titles, abstracts and full text articles, extracted data and assessed risk of bias. We included randomized controlled trials and observational studies. Our primary outcome was a composite of neonatal death (<28 days of life) and severe brain injury in survivors (intraventricular hemorrhage grade ≥ 3 or periventricular leukomalacia). We performed random-effects meta-analyses, generating odds ratios with 95% confidence intervals for the first and second twin separately, and for both twins together. We assessed the risk of bias using a modified Newcastle Ottawa Scale (NOS) for observational studies and used Grading of Recommendations Assessment, Development and Evaluation approach (GRADE).

Results

Our search generated 2695 articles, and after duplicate removal, we screened 2051 titles and abstracts, selecting 113 articles for full-text review. We contacted 36 authors, and ultimately, three observational studies met our inclusion criteria. In cephalic/non-cephalic twin pairs delivered by caesarean section compared to vaginal birth at 24⁺⁰–27⁺⁶ weeks the odds ratio for our composite outcome of neonatal death and severe brain injury for the cephalic first twin was 0.35 (95% CI 0.00–92.61, two studies, I² = 76%), 1.69 for the non-cephalic second twin (95% CI 0.04–72.81, two studies, I² = 55%) and 0.83 for both twins (95% CI 0.05–13.43, two studies, I² = 56%). According to the modified Newcastle Ottawa Scale we assessed individual study quality as being at high risk of bias and according to GRADE the overall evidence for our primary outcomes was very low.

Conclusion

Our systematic review on the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs found very limited existing evidence, without significant differences in neonatal death and severe brain injury by mode of delivery.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1554-7) contains supplementary material, which is available to authorized users.

Linear association between maternal age and spontaneous breech presentation in singleton pregnancies after 32 weeks gestation

PURPOSE

To investigate the association between maternal age and spontaneous breech presentation.

MATERIAL AND METHODS

Fifteen-year observational study over (2001-2015). All consecutive singleton births delivered at the Centre Hospitalier Universitaire Sud Reunion's maternity. The only single exclusion criterion was uterine malformations (N = 123) women.

RESULTS

Of the 60,963 singleton births, there was a linear association (χ² for linear trend, p< 0.0001) between maternal age and spontaneous breech presentation. Overall rate of breech presentation was 2.7% in deliveries over 32 weeks gestation, while it was 1.9% in women aged 15 to 19 years and 4.0% in women aged 45+, with a linear progression for each 5-year age category. This linearity remained significant controlling for early prematurity (<33 weeks) and severe fetal malformations (χ² for linear trend = 64, p < 0.0001). Controlling in a multiple logistic regression model for other major risk factors gestational age, female sex, primiparity, maternal age remained significantly an independent risk factor, p < 0.0001.

CONCLUSION

Maternal age (x) is an independent factor for breech presentation in singleton pregnancies after 32 weeks gestation with a linear association that may be approximated at y = 0.1x. (y: incidence, percent).

[Perinatal outcome of monochorionic and dichorionic twin gestations: a study of 775 pregnancies at Reunion Island]

OBJECTIVES

To compare the perinatal mortality and morbidity of infants born from monochorionic versus dichorionic twin pregnancies (TP).

PATIENTS AND METHODS

Retrospective, comparative study of monochorionic and dichorionic TP over 10 years in the south of Reunion Island. Information regarding demographic, gestational and perinatal variables of mothers and infants was collected from the hospital perinatal database.

RESULTS

Six hundred and twenty dichorionic and 155 monochorionic TP were analyzed. In case of monochorionic TP, mothers had higher rates of pregnancy-related hypertension (OR=1.82, 95%CI=[1.02-3.29] ; P=0.03) and hospitalization (OR=1.48, 95%CI=[1.02-2.16]; P=0.03). Newborns from monochorionic TP had higher morbidity for : very preterm birth (birth before 33 weeks gestation) (OR=1.65, 95%CI=[1.02-2.66]; P=0.02), very low birth weight (birth weight<1500g) (OR=1.73, 95%CI=[1.57-3.13]; P<0.001), Apgar<7 at 1 minute (OR=1.76, 95%CI=[1.18-2.61]; P<0.01) and hospitalization (OR=2.08, 95%CI=[1.58-2.73]; P<0.001). Perinatal mortality was also significantly higher (OR=2.47, 95%CI=[1.54-3.94]; P<0.001), as well intrauterine fetal death (OR=3.96, 95%CI=[1.95-8.05]; P<0.001) CONCLUSION: This study confirms that few differences exist among dichorionic and monochorionic TP with regard to maternal morbidity, while neonatal morbidity and mortality are higher in twins born from monochorionic pregnancies.