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

Maternal and fetal outcomes after planned cesarean or vaginal delivery in twin pregnancy: a comparison between 2 third level birth centers

BACKGROUND

Twin pregnancy is associated with higher risks of adverse perinatal outcomes for both the mother and the babies. Among the many challenges in the follow-up of twin pregnancies, the mode of delivery is the last but not the least decision to be made, with the main influencing factors being amnionicity and fetal presentation. The aim of the study was to compare perinatal outcomes in two European centers using different protocols for twin birth in case of non-cephalic second twin; the Italian patients being delivered mainly by cesarean section with those in Belgium being routinely offered the choice of vaginal delivery (VD).

METHODS

This was a dual center international retrospective observational study. The population included 843 women with a twin pregnancy ≥ 32 weeks (dichorionic or monochorionic diamniotic pregnancies) and a known pregnancy outcome. The population was stratified according to chorionicity. Demographic and pregnancy data were reported per pregnancy, whereas neonatal outcomes were reported per fetus. We used multiple logistic regression models to adjust for possible confounding variables and to compute the adjusted odds ratio (adjOR) for each maternal or neonatal outcome.

RESULTS

The observed rate of cesarean delivery was significantly higher in the Italian cohort: 85% for dichorionic pregnancies and 94.4% for the monochorionic vs 45.2% and 54.4% respectively in the Belgian center (p-value < 0.001). We found that Belgian cohort showed significantly higher rates of NICU admission, respiratory distress at birth and Apgar score of < 7 after 5 min. Despite these differences, the composite severe adverse outcome was similar between the two groups.

CONCLUSION

In this study, neither the presentation of the second twin nor the chorionicity affected maternal and severe neonatal outcomes, regardless of the mode of delivery in two tertiary care centers, but VD was associated to a poorer short-term neonatal outcome.

[Delivery of twins : lessons learnt from the national observational prospective comparative study JUMODA]

OBJECTIVES

To summerize the results of the JUMODA study (JUmeaux MODe d'Accouchement) on the planned mode of delivery of twin pregnancy and the management of second twin delivery.

METHODS

JUMODA was a national observational prospective comparative study that took place between february 2014 and march 2015 in 176 french maternity units performing more than 1500 deliveries per year. Its main objectives were the comparison of neonatal and maternal morbidity according to the planned mode of delivery and the determination of the managements of second twin delivery associated with the best neonatal outcomes. To control for potential confounding factors and indication biases, statistical analyses comprized multivariate logistic regressions and matching on propensity scores.

RESULTS

The JUMODA study recruited 8823 women with twin delivery at or beyond 22 weeks of gestation. For twin pregnancies with a cephalic first twin at 32 weeks of gestation and beyond, severe neonatal morbidity was higher in the planned cesarean (150/2908 (5.2 %) than in the planned vaginal delivery group (199/8922 (2.2 %), aOR 1.56, 95 % CI 1.19-2.04). Increased neonatal morbidity in the planned cesarean delivery group was explained by higher severe morbidity in neonates born preterm (aOR 1.64, 95 % CI 1.13-2.39, for deliveries between 32+0 and 34+6 weeks of gestation, aOR 2.04, 95 % CI 1.22-3.41, for deliveries between 35+0 SA and 36+6 weeks of gestation) but not in neonates born at term (aOR 1.19, 95 % CI 0.58-2.44). In comparison with planned cesarean delivery, planned vaginal delivery was not associated with increased severe neonatal morbidity in case of breech presenting first twin after 32 weeks of gestation or with decreased survival witout severe neonatal morbidity in case of delivery before 32 weeks of gestation whatever the first twin presentation. In comparison with planned vaginal delivery, planned cesarean delivery was associated with increased severe maternal morbidity only in women aged 35 and higher. Delivery of non cephalic second twin was associated with similar severe neonatal morbidity rate than delivery of cephalic second twin. Finally, in case of cephalic second twin, internal version followed by total breech extraction was associated with less cesarean for the second twin but with higher severe neonatal morbidity in case of preterm birth in comparison with pushing efforts, ocytocin perfusion and artificial rupture of membranes.

CONCLUSIONS

Planned vaginal delivery is the planned mode of delivery to encourage for the majority of pregnant women with twins, whatever first twin presentation and gestational age at delivery. No management of cephalic second twin appears better than an other, its choice will rest on obstetrician preferences.

Cesarean sections and early-term births according to Robson classification: a population-based study with more than 17 million births in Brazil

BACKGROUND

Cesarean section (CS) rates are increasing worldwide and are associated with negative maternal and child health outcomes when performed without medical indication. However, there is still limited knowledge about the association between high CS rates and early-term births. This study explored the association between CSs and early-term births according to the Robson classification.

METHODS

A population-based, cross-sectional study was performed with routine registration data of live births in Brazil between 2012 and 2019. We used the Robson classification system to compare groups with expected high and low CS rates. We used propensity scores to compare CSs to vaginal deliveries (1:1) and estimated associations with early-term births using logistic regression.

RESULTS

A total of 17,081,685 live births were included. Births via CS had higher odds of early-term birth (OR 1.32; 95% CI 1.32-1.32) compared to vaginal deliveries. Births by CS to women in Group 2 (OR 1.50; 95% CI 1.49-1.51) and 4 (OR 1.57; 95% CI 1.56-1.58) showed the highest odds of early-term birth, compared to vaginal deliveries. Increased odds of an early-term birth were also observed among births by CS to women in Group 3 (OR 1.30, 95% CI 1.29-1.31), compared to vaginal deliveries. In addition, live births by CS to women with a previous CS (Group 5 - OR 1.36, 95% CI 1.35-1.37), a single breech pregnancy (Group 6 - OR 1.16; 95% CI 1.11-1.21, and Group 7 - OR 1.19; 95% CI 1.16-1.23), and multiple pregnancies (Group 8 - OR 1.46; 95% CI 1.40-1.52) had high odds of an early-term birth, compared to live births by vaginal delivery.

CONCLUSIONS

CSs were associated with increased odds of early-term births. The highest odds of early-term birth were observed among those births by CS in Robson Groups 2 and 4.

Postpartum severe acute maternal morbidity according to gestational age at delivery in twin pregnancies: A prospective cohort study

OBJECTIVE

To assess the association between gestational age at delivery and postpartum severe acute maternal morbidity (SAMM) in twin pregnancies.

METHODS

Secondary analysis of the JUMODA cohort, a national, prospective, population-based study of twin pregnancies in France. We excluded women with delivery before 32 weeks of pregnancy, with a fetal death or medical termination, with antepartum SAMM, or with antepartum conditions responsible for postpartum SAMM. The primary outcome was a composite of postpartum SAMM. We assessed the association between gestational age at delivery and SAMM by using multivariable multilevel modified Poisson regression modeling.

RESULTS

Among the 7713 women included, 410 (5.3%) developed postpartum SAMM. Compared with the reference category of 37 weeks of pregnancy, the risk of postpartum SAMM was significantly lower for all categories of earlier gestational age at delivery (from an adjusted relative risk [RR] of 0.34, 95% confidence interval [CI] 0.17-0.68 at 32 weeks to an adjusted RR of 0.71, 95% CI 0.54-0.94 at 36 weeks), and did not differ for later gestational ages.

CONCLUSION

In twin pregnancies, compared with delivery at 37 weeks of pregnancy, delivery at earlier gestational ages was associated with a lower risk of postpartum SAMM. Continuing pregnancy beyond 37 weeks of pregnancy is not associated with an increased risk of postpartum SAMM.

Risk of Severe Postpartum Hemorrhage in Twin Pregnancies According to the Sum of Birth Weights

OBJECTIVE

To characterize the strength and patterns of association between birth weights and severe postpartum hemorrhage in twin pregnancies.

METHODS

This was a secondary analysis of the JUMODA (JUmeaux Mode d'Accouchement) cohort, a national, prospective, population-based study of twin deliveries, conducted from February 2014 to March 2015 in France. We excluded patients with a fetal death, medically indicated termination of pregnancy, antepartum hemorrhage, placenta previa, placental abruption, or missing birth weight. The primary outcome was severe postpartum hemorrhage , defined as a postpartum hemorrhage requiring at least one of the following: transfusion of 4 or more units of red blood cells, uterine artery embolization, uterine balloon tamponade, vascular ligation, uterine suture, emergency hysterectomy, admission to an intensive care unit, or postpartum hemorrhage considered severe by the obstetrician or leading to maternal death. The exposure was the sum of the birth weights of the two twins. To assess the association between the sum of twins' birth weights and severe postpartum hemorrhage, we used multilevel multivariable modified Poisson regression modeling. Analyses were conducted for the overall population and by planned and actual mode of delivery.

RESULTS

A total of 8,373 patients were analyzed. Severe postpartum hemorrhage occurred in 4.5% (379/8,372, 95% CI 4.1-5.0), from 2.1% (15/722) for a sum of twins' birth weights less than 3,000 g up to 8.8% (12/136) for a sum exceeding 6,500 g. In the multivariable analysis, the association between the sum of the twins' birth weights and severe postpartum hemorrhage was linear, with an adjusted relative risk of severe postpartum hemorrhage of 1.36 (95% CI 1.24-1.49) for each 500-g increase in the sum of twins' birth weights.

CONCLUSION

In twin pregnancies, the risk of severe postpartum hemorrhage increased linearly with the sum of the twins' birth weights.

[Factors associated with cesarean delivery of the second twin after vaginal delivery of the first twin: A case-control study]

OBJECTIVES

To identify risk factors for cesarean section of the second twin after vaginal delivery of the first twin.

METHODS

Case-control study conducted between 2004 and 2018 in a tertiary center, CHU Toulouse. Cases were women with twin pregnancy who had vaginal delivery of the first twin and emergency cesarean of the second twin. Controls were women with twin pregnancy who delivered both twins vaginally. Deliveries before 24 weeks of gestation, birth weight of less than 500 grams, fetal death in utero, terminations of pregnancy and delayed delivery were excluded. The association between potential risk factors and cesarean delivery of the second twin was analyzed using multivariable logistic regression.

RESULTS

Twenty-four patients who had vaginal delivery of the first twin and emergency cesarean of the second twin and 48 patients who delivered both twins vaginally were included. Neonatal morbidity was increased in the group of women who had an emergency cesarean of the second twin. In multivariable analysis, overweight (OR=10.5 [95% CI: 1.78-62.03] for women with body mass index above 25 compared to women with body mass index below 25), weight gain during pregnancy (OR=1.27 [95% CI: 1.01-1.48] for each kilogram) and preterm labor (OR=4,43 [IC 95%:1,10-17,80]) were associated with significantly increased risk of cesarean section of the second twin.

CONCLUSION

Overweight and weight gain during pregnancy are associated with increased risk for cesarean section of the second twin.

Prospective observational study investigating the effectiveness, safety, women’s experiences and quality of life at 3 months regarding cervical ripening methods for induction of labor at term—The MATUCOL study protocol

Background

The purposes of successful induction of labor (IOL) are to shorten the time for IOL to delivery, increase the vaginal delivery rate, and reduce the rate of maternal and neonatal morbidity. In cases of unfavorable cervix (Bishop score <6), cervical ripening is advised to improve vaginal delivery rate. It may be initiated by mechanical (double balloon catheter (DBC), synthetic osmotic dilator) or pharmacologic (prostaglandins) methods, and the problem is complex due to the multitude of cervical ripening methods. We are constantly looking for the optimal protocol of cervical ripening for each woman. The present study aims to elucidate whether cervical ripening method is associated with increase rate of vaginal delivery, good women’s experience and unaltered long-term quality of life after cervical ripening at term regarding maternal and obstetric characteristics.

Methods and design

The MATUCOL study is a monocentric, prospective, observational study of all consecutive women who required cervical ripening (Bishop score <6) using different methods (DBC, vaginal dinoprostone, oral misoprostol) with a live fetus at term (≥37 weeks) between January 2020 and August 2021. The outcomes will be mode of delivery, maternal and neonatal morbidity, discomfort/pain assessments during cervical ripening, women’s experience and satisfaction, and the impact of cervical ripening on the health-related quality of life at 3 months. If it reports a significant efficacy/safety/perinatal morbidity/women’s satisfaction/quality of life at 3 months post-delivery associated with a method of cervical ripening in a specific situation (gestational and/or fetal disease) using a multivariate analysis, its use should be reconsidered in clinical practice.

Discussion

This study will reveal that some cervical ripening methods will be more effectiveness, safe, with good women’s experiences and QOL at 3 months compared to others regarding maternal and obstetric characteristics.

Trial registration

This study is being performed at La Roche sur Yon Hospital following registration as GNEDS on January 8, 2020.

Screening, Management and Delivery in Twin Pregnancy

The following AWMF guideline (DGGG/AGG & DEGUM responsible) deals with the diagnosis, screening and management of twins as well as the timing and mode of birth.Twin pregnancies can be classified as dichorionic diamniotic (DC DA), monochorionic diamniotic (MC DA) and monochorionic monoamniotic (MC MA) which are always monochorionic.Twin pregnancies can be concordant (both twins are affected) or discordant (only one twin is affected) for chromosomal defects, malformations, growth restriction and hemodynamic disorders.Chorionicity is the prognostically most significant parameter. Monochorial twins have significantly higher risks of intrauterine morbidity and mortality compared to dichorial twins.In particular, general aspects of twin pregnancies such as dating, determination of chorionicity and amnionicity, the labeling of twin fetuses and the perinatal switch phenomenon are discussed.Routine monitoring of MC and DC twin pregnancies with ultrasound at 11-13^+ 6 weeks of gestation for chromosomal defects, invasive prenatal diagnosis, first-trimester NT or CRL discrepancies, early diagnosis of fetal anatomical defects, and management of twins with abnormalities, including selective fetocide, is described.Second trimester screening and management for preterm birth, intrauterine selective growth restriction (sFGR), classification of monochorial twins with sFGR, and management of the surviving twin after the death of the co-twin are described.Complications exclusively affecting MC twins include Twin to Twin Transfusion Syndrome (TTTS) with the important topics screening, prognosis, complications of laser therapy, timing of delivery, risks for brain abnormalities and delayed neurological development, Twin Anemia-Polycythemia Sequence (TAPS) and Twin Reversed Arterial Perfusion (TRAP) Sequence. This also includes MC MA twins as well as conjoined twins.Finally, the birth mode and time for DC and MC twin pregnancies are described.The information is summarized in 62 recommendations for action, 4 tables and 8 illustrations with comprehensive background texts.The guideline is an international guideline adaptation (ISUOG, NICE) as well as a systematic literature search and is up-to-date.

Increased risk of severe maternal morbidity in women with twin pregnancies resulting from oocyte donation

STUDY QUESTION

Is there a difference in the risk of serious maternal complications during pregnancy and the postpartum in twin pregnancies according to mode of conception: natural conception, non-IVF fertility treatment, IVF, ICSI or oocyte donation?

SUMMARY ANSWER

Women with twin pregnancies after medically assisted reproduction (MAR) had an overall risk of serious maternal complications 30% higher compared with women with natural twin pregnancies, and this association varied according to the MAR procedure; the risk was increased by 50% with IVF using autologous oocytes and by 270% with oocyte donation.

WHAT IS KNOWN ALREADY

IVF has been reported as a risk factor for serious maternal complications in several concordant studies of singleton pregnancies. For twin pregnancies, this association is less well documented with imprecise categorisation of the mode of conception, and results are contradictory.

STUDY DESIGN, SIZE, DURATION

This is a secondary analysis of the national, observational, prospective, population-based cohort study of twin pregnancies (JUmeaux Mode d'Accouchement), which took place in France from 10 February 2014 through 1 March 2015. All French maternity units performing more than 1500 annual deliveries were invited to participate, regardless of their academic, public or private status or level of care. Of the 191 eligible units, 176 (92%) participated.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with a twin pregnancy who gave birth at or after 22 weeks of gestation were eligible (N = 8823 women included). We excluded women whose mode of conception was unknown (n = 75). Serious maternal complications were regrouped within the recently emerged concept of severe acute maternal morbidity (SAMM), as a binary composite outcome. The exposure of interest was the mode of conception, studied in five classes: natural conception (reference group), non-IVF fertility treatment including insemination and ovarian stimulation, IVF with autologous oocyte, ICSI with autologous oocyte and oocyte donation. To assess the association between the mode of conception and SAMM, we used multivariate logistic regression to adjust for confounders. Structural equation modelling (SEM) was used to explore the contribution to this association of potential intermediate factors, i.e. factors possibly caused by the mode of conception and responsible for SAMM: non-severe pre-eclampsia, placenta praevia and planned mode of delivery.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 8748 women of the study population, 5890 (67.3%) conceived naturally, 854 (9.8%) had non-IVF fertility treatment, 1307 (14.9%) had IVF with autologous oocytes, 368 (4.2%) had ICSI with autologous oocytes and 329 (3.8%) used oocyte donation. Overall, 538 (6.1%) developed SAMM. Women with twin pregnancy after any type of MAR had a higher risk of SAMM than those with a natural twin pregnancy, after adjustment for confounders (7.9% (227/2858) compared to 5.3% (311/5890), adjusted odds ratio (aOR) 1.3, 95% CI 1.1-1.6). This association varied according to the MAR procedure. The risk of SAMM was higher among women with IVF using either autologous oocytes (8.3%; 108/1307) or oocyte donation (14.0%; 46/329) compared with the reference group (respectively aOR 1.5, 95% CI 1.1-1.9 and aOR 2.7, 95% CI 1.8-4.1) and higher after oocyte donation compared with autologous oocytes (aOR 1.7, 95% CI 1.1-2.6). Conversely, the risk of SAMM for women with non-IVF fertility treatment (6.2%; 53/854) and with ICSI using autologous oocytes (5.4%; 20/368) did not differ from that of the reference group (5.3%; 311/5890) (respectively aOR 1.1, 95% CI 0.8-1.5 and aOR 0.9, 95% CI 0.6-1.5). The tested intermediate factors poorly explained these increased risks.

LIMITATIONS, REASONS FOR CAUTION

Beyond the confounders and intermediate factors considered in our analysis, specific causes of infertility and specific aspects of infertility treatments may explain the differences in the risk of SAMM by mode of conception. However, these data were not available.

WIDER IMPLICATIONS OF THE FINDINGS

Our study showed an increased risk of SAMM in women with twin pregnancies after MAR, notably after IVF using autologous oocytes and particularly after oocyte donation. To avoid unnecessary exposure to the high-risk combination of MAR and multiple pregnancies, transfer of a single embryo should be encouraged whenever possible. Knowledge of these differential risks may inform discussions between clinicians and women about the mode of conception and help to optimise obstetric care for women in subgroups at higher risk.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a grant from the French Ministry of Health (Programme Hospitalier de Recherche Clinique, AOM2012). There are no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Perinatal outcome after planned vaginal delivery in monochorionic compared with dichorionic twin pregnancy

OBJECTIVE

To assess, according to chorionicity, the perinatal outcome of twin pregnancy in which vaginal delivery is planned.

METHODS

JUMODA (JUmeaux MODe d'Accouchement) was a national prospective population-based cohort study of twin pregnancies, delivered in 176 maternity units in France, from February 2014 to March 2015. In this planned secondary analysis, we assessed, according to chorionicity, the perinatal outcome of twin pregnancies, in which vaginal delivery was planned, that delivered at or after 32 weeks of gestation with the first twin in cephalic presentation. In order to select a population with well-recognized indications for planned vaginal delivery, we applied the same exclusion criteria as those in the Twin Birth Study, an international randomized trial. Monochorionic twin pregnancies with twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence were defined as complicated and were excluded. The primary outcome was a composite of intrapartum mortality and neonatal morbidity and mortality. Multivariable logistic regression models were used to control for potential confounders. Subgroup analyses were conducted according to birth order (first or second twin) and gestational age at delivery (< 37 or ≥ 37 weeks of gestation).

RESULTS

Among 3873 twin pregnancies, in which vaginal delivery was planned, that delivered at ≥ 32 weeks' gestation with the first twin in cephalic presentation, meeting the inclusion criteria of the Twin Birth Study, 729 (18.8%) were uncomplicated monochorionic twin pregnancies and 3144 (81.2%) were dichorionic twin pregnancies. The rate of composite intrapartum mortality and neonatal morbidity and mortality did not differ between uncomplicated monochorionic (27/1458 (1.9%)) and dichorionic (107/6288 (1.7%)) twin pregnancies when adjusting for conception by assisted reproductive technologies (adjusted relative risk, 1.07 (95% CI, 0.66-1.75)). No significant difference in the primary outcome was found between the groups on subgroup analyses according to birth order and gestational age at delivery.

CONCLUSION

When vaginal delivery is planned, and delivery occurs at ≥ 32 weeks of gestation with the first twin in cephalic presentation, uncomplicated monochorionic twin pregnancy is not associated with a higher rate of composite intrapartum mortality and neonatal morbidity and mortality compared with dichorionic twin pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Delivery of Twin Gestation (≥ 32.0 Weeks): The Vaginal Route as a Practicable and Safe Alternative to Cesarean Section

Objective The appropriate delivery mode for twins is discussed controversially in the literature. The aim of this study was to investigate delivery modes and short-term neonatal outcomes of twin pregnancies delivered in University Hospital Leipzig.

Material and Methods A total of 274 twin pregnancies (32.0 to 39.4 weeks of gestation) delivered between 2015 and 2017 were analyzed retrospectively with regard to the planned and final delivery mode as well as neonatal outcomes. The inclusion and exclusion criteria for vaginal delivery were comparable to those of the Twin Birth Study.

Results The spontaneous birth rate for births planned as vaginal deliveries was 78.5%; the rate of secondary cesarean section was 19.4%. The final total cesarean rate was 58.8%, and the rate of vaginal deliveries was 41.2%. Vertex or non-vertex position of the second twin had no significant effect on neonatal outcome or mean delivery interval between the birth of the first and second twin. Chorionicity, neonatal weight and gender had no significant impact on delivery mode. However, successful vaginal delivery was associated with higher gestational age and both fetuses in vertex position. The combined neonatal outcome for both twins was significantly worse if they were delivered by cesarean section compared to spontaneous birth. In addition, the leading twin in monochorionic/diamniotic (MC/DA) pregnancies was intubated more frequently after cesarean delivery and had significantly lower Apgar scores.

Conclusion Vaginal delivery in twin pregnancies is a practicable and safe option in specific defined conditions and when the appropriate infrastructure and clinical experience is available.

Internal Version Compared With Pushing for Delivery of Cephalic Second Twins

OBJECTIVE

To assess neonatal morbidity and mortality according to whether cephalic second twins were born after internal version followed by total breech extraction or after instructions to push. We hypothesized that interval version would result in shorter intertwin delivery intervals and lower cesarean delivery rates for the second twin and therefore better neonatal outcomes.

METHODS

These planned analyses of the JUMODA (JUmeaux MODe d'Accouchement) cohort, a national prospective population-based study of twin deliveries, examined births of cephalic second twins after vaginal birth of the first twin at or after 32 weeks of gestation. The internal version group of second twins born in breech presentation after obstetric maneuvers was compared with the pushing group, comprising those born in cephalic presentation. The primary outcome was a composite of neonatal morbidity and mortality. Multivariate modified Poisson regression models were used to control for potential confounders.

RESULTS

Of 2,256 cephalic second twins, 487 (21.6%) were born in breech presentation after internal version and total breech extraction and 1,769 (78.4%) in cephalic presentation after pushing. Composite neonatal morbidity and mortality was not lower in the internal version (17/487 [3.5%]) compared with the pushing group (38/1,769 [2.1%]; adjusted relative risk [aRR] 1.73 [95% CI 0.98-3.05]), although median [quartile 1-quartile 3] intertwin delivery intervals were shorter (5 [4-8] vs 8 [5-12] minutes, P<.001) and the cesarean delivery rate for the second twin lower (5/487 [1.0%] vs 66/1,769 [3.7%], P=.002). Subgroup analyses showed no difference between groups at or after 37 weeks of gestation but higher composite neonatal morbidity and mortality after internal version before 37 weeks (14/215 [6.5%] vs 26/841 [3.1%]; aRR 2.18 [95% CI 1.15-4.13]). Secondary analyses according to center expertise in the overall population and stratified by gestational age yielded concordant results.

CONCLUSION

Although our sample size precluded a robust assessment for small differences in outcomes between groups, internal version followed by total breech extraction of cephalic second twins was not associated with better neonatal outcomes than pushing.

First Twin in Breech Presentation and Neonatal Mortality and Morbidity According to Planned Mode of Delivery

OBJECTIVE

To compare neonatal mortality and morbidity of first twins according to the planned mode of delivery when the first twin is in breech presentation, in a country where planned vaginal delivery is an option.

METHODS

This is a planned secondary analysis of the JUMODA (JUmeaux MODe d'Accouchement) cohort, a national prospective population-based study of twin deliveries conducted in 176 French hospitals. We analyzed pregnancies with first twins in breech presentation and applied the inclusion criteria of the Twin Birth Study (except the criterion for first-twin presentation): both fetuses alive, with a birth weight between 1,500 g and 4,000 g, at or after 32 0/7 weeks of gestation. The primary outcome was a composite of neonatal mortality and morbidity. We used multivariate Poisson regression models to control for potential confounders and propensity score analyses, that is, matching and inverse probability of treatment weighting to control for indication bias.

RESULTS

Among the 1,467 women with a breech-presenting first twin included in this analysis, 1,169 (79.7%) had planned cesarean and 298 (20.3%) planned vaginal births, of whom 185 (62.1%) delivered both twins vaginally. The neonatal mortality and severe morbidity rate for first twins was 1.7% (5/298) in the planned vaginal and 1.9% (22/1,169) in the planned cesarean delivery groups (crude relative risk [RR] 0.90, 95% CI 0.34-2.34). Planned vaginal delivery was not associated with higher neonatal mortality and morbidity than planned cesarean delivery, regardless of the statistical method used: adjusted RR 0.71, 95% CI 0.27-1.86; RR 0.61, 95% CI 0.20-1.83 after matching for propensity score; RR 0.63, 95% CI 0.23-1.74 with inverse probability of treatment weighting. Analyses of neonatal mortality and morbidity of second twins yielded similar results.

CONCLUSION

Although our sample size precluded a robust assessment for small differences in outcomes between planned cesarean and planned vaginal delivery in twin pregnancies in which the first twin was in breech presentation, in our cohort planned vaginal delivery was not associated with higher neonatal mortality and morbidity for either twin.

Severe maternal morbidity by mode of delivery in women with twin pregnancy and planned vaginal delivery

Planned vaginal delivery in twin pregnancies has three potential outcomes: vaginal or cesarean delivery of both twins, or cesarean for the second twin. Our objective was to assess the association between delivery mode and severe acute maternal morbidity (SAMM) in women with twin pregnancies and planned vaginal deliveries. We limited this planned secondary analysis of the JUMODA cohort, a national prospective population-based study of twin deliveries, to women with planned vaginal delivery at or after 24 weeks of gestation who gave birth to two live fetuses at hospital. The association between delivery mode and SAMM was estimated from multivariate Poisson regression models. Of 5,055 women with planned vaginal delivery, 4,007 (79.3%) delivered both twins vaginally, 134 (2.6%) had cesarean for the second twin and 914 (18.1%) cesarean for both twins. Compared to vaginal delivery of both twins, the risk of SAMM was significantly higher after cesarean for the second twin (9.0% versus 4.5%; aRR 2.22, 95% CI 1.27-3.88) and for both twins (9.4% versus 4.5%, aRR 1.56, 95% CI 1.16-2.10). In twin pregnancies with planned vaginal delivery, cesarean deliveries for the second twin and for both twins are associated with higher risks of SAMM than vaginal delivery.

Outcomes of 'one-day trial of vaginal delivery of twins' at 36-37 weeks' gestation in Japan

Objective

The lack of obstetricians in Japan has prevented the implementation of a 24-hour delivery monitoring system for high-risk deliveries such as twin vaginal delivery at many obstetric facilities. To examine the outcomes of a 1-day trial of the vaginal delivery of twins at 36-37 weeks' gestation.

Methods

We induced the vaginal delivery of twins at 36-37 weeks' gestation of 256 women who provided consent between January 2007 and December 2016 using the following protocol: 1) administration of 0.5 mg oral prostaglandin E2 every 1 hour (maximum: 1.5 mg) in the morning; 2) intravenous administration of oxytocin and amniotomy in the afternoon; and 3) selection of caesarean delivery when vaginal delivery was not expected by evening. We examined their perinatal outcomes in a chart review.

Results

The completion rates of vaginal delivery in total, nulliparous, and multiparous women were 79%, 72%, and 84%, respectively. There were no cases of neonatal asphyxia. The total incidence of neonatal respiratory disorders was 2.1%, but there were no cases of persistent pulmonary hypertension. The total incidence of postpartum hemorrhage requiring transfusion was 2.7%.

Conclusion

The 1-day planned vaginal delivery of twins at 36-37 weeks' gestation appears valid and safe, and our findings suggest that it can be an option for the delivery of twins.

Severe Acute Maternal Morbidity in Twin Compared With Singleton Pregnancies

OBJECTIVE

To investigate the association between twin pregnancy and severe acute maternal morbidity, overall and by timing (before, during or after delivery) and underlying causal condition.

METHODS

We conducted a cohort-nested case-control analysis from the EPIMOMS prospective study conducted in six French regions from 2012-2013 (N=182,309 deliveries). The case group comprised 2,500 women with severe acute maternal morbidity (defined by a national expert consensus process) occurring from 22 weeks of gestation and up to 42 days postpartum. A random sample of 3,650 women who gave birth without severe acute maternal morbidity made up the control group. The association between twin pregnancy and severe acute maternal morbidity was analyzed with multilevel multivariable logistic regression. The role of cesarean delivery as an intermediate factor between twin pregnancy and severe acute maternal morbidity was assessed by path analysis.

RESULTS

The population-based incidence of severe acute maternal morbidity was 6.2% (n=197/3,202, 95% CI 5.3-7.1) in twin pregnancies, and 1.3% (n=2,303/179,107, 95% CI 1.2-1.3) in singleton pregnancies. After controlling for confounders, the risk of severe acute maternal morbidity was higher in twin than in singleton pregnancies (adjusted odds ratio [OR] 4.2, 95% CI 3.1-5.8), both antepartum and intrapartum or postpartum, and regardless of the category of causal condition (severe hemorrhage, severe hypertensive complications, or other conditions). The association was also found for the most severe near-miss cases (adjusted OR 5.1, 95% CI 3.5-7.3). In path analysis, cesarean delivery mediated 20.6% (95% CI 12.9-28.2) of the total risk of intrapartum or postpartum severe acute maternal morbidity associated with twin pregnancy.

CONCLUSION

Compared with women with singleton pregnancies, women with twin pregnancies have a fourfold increased risk for severe maternal complications both before and after delivery. About one fifth of the association between twin pregnancy and intrapartum or postpartum severe acute maternal morbidity may be mediated by cesarean delivery.