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Aviram A, Barrett J, Mei-Dan E, Yoon EW, Melamed N. A prediction tool for mode of delivery in twin pregnancies-a secondary analysis of the Twin Birth Study. Am J Obstet Gynecol 2024; 231:124.e1-124.e11. [PMID: 37979823 DOI: 10.1016/j.ajog.2023.11.1230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND One of the controversies regarding the management of twin gestations relates to the mode of delivery. Currently, counseling regarding the mode of delivery and the chance of successful vaginal twin delivery is based on the average risk for intrapartum cesarean delivery in the general population of twin pregnancies. Decision support tools that provide an individualized risk for intrapartum cesarean delivery based on the unique characteristics of each patient can improve counseling and decision-making regarding the choice of mode of delivery in twin pregnancies. OBJECTIVE This study aimed to develop and validate a prediction model to determine the risk for intrapartum cesarean delivery in twin pregnancies. STUDY DESIGN In this secondary analysis of the Twin Birth Study, a multicenter randomized controlled trial, we considered the subgroup of individuals who underwent a trial of vaginal delivery. Candidate predictors included maternal age, parity, previous cesarean delivery, conception method, chorionicity, diabetes and hypertension in pregnancy, gestational age at birth, the onset of labor, presentation of the second twin, sonographic fetal weight estimation, and fetal sex. The co-primary outcomes were overall intrapartum cesarean delivery and cesarean delivery of the second twin. Multivariable logistic regression models were used to estimate the probability of the study outcomes. Model performance was evaluated using measures of discrimination (the area under the receiver operating characteristic curve), calibration, and predictive accuracy. Internal validation was performed using the bootstrap resampling technique. RESULTS A total of 1221 individuals met the study criteria. The rate of overall intrapartum cesarean delivery and cesarean delivery for the second twin was 25.4% and 5.7%, respectively. The most contributory predictor variables were nulliparity, term birth (≥37 weeks), a noncephalic presentation of the second twin, previous cesarean delivery, and labor induction. The models for overall intrapartum cesarean delivery and cesarean delivery of the second twin had good overall discriminatory accuracy (area under the receiver operating characteristic curve, 0.720; 95% confidence interval, 0.688-0.752 and 0.736; 95% confidence interval, 0.669-0.803, respectively) and calibration (as illustrated by the calibration plot and Brier scores of 0.168; 95% confidence interval, 0.156-0.180 and 0.051; 95% confidence interval, 0.040-0.061, respectively). The models achieved good specificity (66.7% and 81.6%, respectively), high negative predictive value (86.0% and 96.9%, respectively), and moderate sensitivity (68.1% and 57.1%, respectively). CONCLUSION The prediction models developed in this study may assist care providers in counseling individuals regarding the optimal timing and mode of delivery in twin pregnancies by providing individualized estimates of the risk for intrapartum cesarean delivery.
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Affiliation(s)
- Amir Aviram
- Division of Maternal-Fetal Medicine, DAN Women and Babies Program, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada.
| | - Jon Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Elad Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North York General Hospital, University of Toronto, Ontario, Canada, (d)Maternal-infant Care (MiCare) Research Centre, Mount Sinai Hospital, Toronto, Canada
| | - Eugene W Yoon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North York General Hospital, University of Toronto, Ontario, Canada, (d)Maternal-infant Care (MiCare) Research Centre, Mount Sinai Hospital, Toronto, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, DAN Women and Babies Program, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
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Yoles I, Sheiner E, Wainstock T. Long term respiratory morbidity of cesarean-delivered second twin compared to their vaginally-delivered sibling: A retrospective population-based cohort study. Pediatr Pulmonol 2023; 58:3542-3548. [PMID: 37721028 DOI: 10.1002/ppul.26688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 08/09/2023] [Accepted: 09/03/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Offspring born via cesarean delivery (CD) may be more prone to develope long-term respiratory diseases, compared to those delivered vaginally (VD). In this study, we compared the rates of respiratory diseases between first twins VD and second twins delivered via CD. METHODS This was a retrospective database study. All twin deliveries encompassed at the Soroka University Medical Center, a large tertiary hospital in southern Israel, between 1991 and 2020, in which the first twin was VD and the second via CD were included. Respiratory diseases included respiratory tract diseases such as bronchiolitis and bronchial asthma. The cumulative incidence of respiratory diseases was compared between the twins using Kaplan-Meier survival analysis and multivariable Cox models to adjust for confounding variables. RESULTS A total of 395,408 deliveries occurred during the study period, with 13,402 (3.4%) of all deliveries being twins. Of these, 184 (1.4%) were first twins VD and second twins delivered via CD. The second CD twin was more likely to have a non-reassuring fetal heart rate pattern and an Apgar score less than 7 at 5 min. No other differences were found between the siblings. The incidence of long-term respiratory diseases was not statistically different between the CD and VD siblings (7.6% vs. 9.4%, respectively; OR = 0.54; 95% CI: 0.23-1.26). Similarly, the cumulative incidence of respiratory diseases was not statistically different (Kaplan-Meier, log-rank, p = .59), and in the multivariable analysis which adjusted for birthweight and fetal distress during delivery (adjusted hazard ratio = 1.06; 95% CI: 0.43-26.25). CONCLUSIONS While the immediate outcomes for the CD twin were slightly worse compared to the VD twin, there was no difference in long-term respiratory diseases between the siblings.
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Affiliation(s)
- Israel Yoles
- Department of Obstetrics and Gynaecology, Soroka University Medical Centre, Beer-Sheva, Israel
- Clalit Health Services, The Central District, Rishon Le Tzion, Israel
| | - Eyal Sheiner
- Department of Obstetrics and Gynaecology, Soroka University Medical Centre, Beer-Sheva, Israel
| | - Tamar Wainstock
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Topcu EG, McClenahan P, Pule K, Khattak H, Karsli SE, Cukelj M, Ubom AE, Algurjia E, Ozpinar K, Perez YR, Bunu R, Sanabria LS, Portilla FJR, Pumpure E, Roy P, Fogarty P. FIGO best practice guidance in surgical consent. Int J Gynaecol Obstet 2023; 163:795-812. [PMID: 37807812 DOI: 10.1002/ijgo.15174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Obtaining medical consent preoperatively is one of the key steps in preparing for surgery, and is an important step in informed decision making with the patient. According to good medical practice guidelines, doctors are required to have the knowledge and skills to treat patients as well as inform them, respect their wishes, and establish trust between themselves and their patients. Valid consent includes elements of competence, disclosure, understanding, and voluntariness. Documentation of these elements is also very important. The International Federation of Gynecology and Obstetrics (FIGO) Education Communication and Advocacy Consortium (ECAC) has realized that the quality of consent varies considerably across the world and has developed simple guidelines regarding consent and procedure-specific checklists for the most common obstetric and gynecological procedures.
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Affiliation(s)
- E Goknur Topcu
- Department of Obstetrics and Gynecology, Istanbul Health and Technology University, Istanbul, Turkey
| | - Phil McClenahan
- Department of Obstetrics and Gynecology, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Koketso Pule
- Department of Obstetrics and Gynecology, Wits University, Johannesburg, South Africa
| | - Hajra Khattak
- Department of Obstetrics and Gynecology, UCL EGA Institute for Women's Health, London, UK
| | - S Eda Karsli
- Department of Obstetrics and Gynecology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Marijo Cukelj
- Department of Obstetrics and Gynecology, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Akaninyene E Ubom
- Department of Obstetrics and Gynecology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
| | - Esraa Algurjia
- Department of Obstetrics and Gynecology, Al-Elwya Maternity Hospital, Baghdad, Iraq
| | - Kubra Ozpinar
- Department of Obstetrics and Gynecology, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Yotin Ramon Perez
- Department of Obstetrics and Gynecology, Hospital Central de las Fuerzas, Santo Domingo, Dominican Republic
| | - Rashid Bunu
- Department of Obstetrics and Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Leopoldo S Sanabria
- Department of Obstetrics and Gynecology, Unidad Medica de Alta Especialidad, Mexico City, Mexico
| | - Francisco J R Portilla
- Department of Obstetrics and Gynecology, Instituto Nacional de Perinatologia, Mexico City, Mexico
| | - Elizabete Pumpure
- Department of Obstetrics and Gynecology, Riga East Clinical University, Riga, Latvia
| | - Priyankur Roy
- Department of Obstetrics and Gynecology, Roy's Clinic, Siliguri, West Bengal, India
| | - Paul Fogarty
- International Federation of Gynecology and Obstetrics (FIGO), London, UK
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Rissanen AS, Loukovaara M, Gissler M, Nupponen IK, Nuutila ME, Jernman RM. Mode of delivery of Finnish dichorionic and monochorionic-diamniotic twins: A retrospective observational study including a risk score for intrapartum cesarean birth. Health Sci Rep 2023; 6:e1236. [PMID: 37181664 PMCID: PMC10167911 DOI: 10.1002/hsr2.1236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/06/2023] [Accepted: 04/18/2023] [Indexed: 05/16/2023] Open
Abstract
Background and Aims Trial of labor is considered safe also among twins, yet nearly 50% are born via cesarean section in Finland. While planned cesarean births have declined among twins, intrapartum cesarean deliveries have risen, postulating evaluation of criteria for trial of labor. The objective of this study was to create an outline of the mode of delivery of dichorionic and monochorionic-diamniotic Finnish twins. By evaluating risk factors for intrapartum cesarean delivery (CD), we aimed at creating a risk score for intrapartum cesarean birth for twins. Methods A retrospective observational study based on a cohort of dichorionic and monochorionic-diamniotic twin pregnancies considered as candidates for trial of labor in 2006, 2010, 2014, and 2018 (n = 720) was performed. Differences between parturients with vaginal delivery and intrapartum CD to identify potential risk factors for intrapartum CD were assessed. Logistic regression analysis (n = 707) was used to further define risk score points for recognized risk factors. Results A total of 23.8% (171/720, 95% confidence interval [CI] = 20.7-26.9) of parturients experienced intrapartum CD. Induction of labor, primiparity, fear of childbirth, artificial reproductive technology, higher maternal age, and other than cephalic/cephalic presentation independently associated with intrapartum CD. The achieved total risk score ranged from 0 to 13 points with significantly higher points among the CD group (6.61 vs. 4.42, p < 0.001). Using ≥8 points as a cut-off, 51.4% (56/109) were delivered by intrapartum CD (sensitivity = 33.73%, specificity = 90.20%, positive predictive value = 51.38%, negative predictive value = 81.61%). The total risk score had a fair predictive capability for intrapartum CD (area under the curve = 0.729, 95% CI = 0.685-0.773). Conclusion Fair-level risk stratification could be achieved with higher maternal age, primiparity, induction of labor, artificial reproductive technology, fear of childbirth, and other than cephalic/cephalic presentation increasing the risk. Parturients with low-risk score (0-7 points) appear to be the best candidates for trial of labor with acceptable CD rates in this group (18.4%).
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Affiliation(s)
- Annu‐Riikka S. Rissanen
- Department of Obstetrics and GynecologyUniversity of HelsinkiHelsinkiFinland
- Department of Obstetrics and GynecologyWelfare District of Päijät‐HämeLahtiFinland
| | - Mikko Loukovaara
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Mika Gissler
- Finnish Institute for Health and WelfareHelsinkiFinland
- Karolinska InstituteStockholm and Region StockholmSweden
| | - Irmeli K. Nupponen
- Children's HospitalUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Mika E. Nuutila
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Riina M. Jernman
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
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Mei JY, Mallampati D, Pluym ID, Han CS, Afshar Y. Twin Vaginal Deliveries in Labor Rooms: A Cost-Effectiveness Analysis. Am J Perinatol 2023; 40:290-296. [PMID: 33878770 DOI: 10.1055/s-0041-1727213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR. STUDY DESIGN We conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY). RESULTS In the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis. CONCLUSION Twin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources. KEY POINTS · Cost effectiveness of twin VDs in the LDR versus OR was assessed.. · Twin VDs in the LDR are cost effective based on current neonatal outcome data.. · Attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis..
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Affiliation(s)
- Jenny Y Mei
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
| | - Divya Mallampati
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Ilina D Pluym
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
| | - Christina S Han
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
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Desseauve D, Daelemans C, Farin A, Jauvion IBM, Ceccaldi PF. Internal podalic version of second twin: Improving feet identification using a simulation model. Eur J Obstet Gynecol Reprod Biol 2022; 275:9-11. [PMID: 35691221 DOI: 10.1016/j.ejogrb.2022.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/16/2022] [Accepted: 05/30/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Podalic version and breech extraction require high obstetrical expertise. Identifying fetal extremities is the first crucial step for trainees. When this skill is not polished enough, it increases the inter-twin delivery interval and can even jeopardize the whole manoeuver. MATERIAL AND METHODS We present a model for simulating and training this specific skill, with obstetrical mannequin, and 3D printed hands and feet. Five feet and five hands (five rights and five lefts of each one) were printed in 3D after initial ultrasound acquisition of a near term fetus. Each foot and hand, was individually set in a condom filled with 100 cc of water and closed with a knot. A Sophie's Mum Birth Simulator Version 4.0 de MODEL-med was placed on the edge of the table. Each hand and foot was inserted into the pelvic mannequin. An evaluation of the students' skills using this model was performed. A significant reduction of the global mean to extract the first foot and all the feet was noticed at three month of interval. CONCLUSION This model is an option to train and assess a crucial skill for version and breech extraction.
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Affiliation(s)
- David Desseauve
- Women-Mother-Child Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland.
| | - Caroline Daelemans
- Women-Mother-Child Department, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Alexandre Farin
- Obstetric Unit, Riviera-Chablais Hospital, Rennaz, Switzerland
| | - Imane Ben M'Bareck Jauvion
- Department of Simulation, Université de Paris, Paris, France; Obstetrics and Gynecology Service, Assistance Publique - Hôpitaux de Paris, Hôpital Beaujon, Clichy La Garenne, France
| | - Pierre-François Ceccaldi
- Department of Simulation, Université de Paris, Paris, France; Obstetrics and Gynecology Service, Assistance Publique - Hôpitaux de Paris, Hôpital Beaujon, Clichy La Garenne, France
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Mei JY, Muñoz HE, Kim JS, Szlachta-McGinn A, Blat C, Rao R, Han CS, Irani RA, Afshar Y. Rates of Cesarean Conversion and Associated Predictors and Outcomes in Planned Vaginal Twin Deliveries. Am J Perinatol 2022; 39:601-608. [PMID: 33032326 DOI: 10.1055/s-0040-1718368] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to investigate the rates of conversion to CD for planned twin VDs and identify predictors and outcomes of conversion. STUDY DESIGN A retrospective cohort study of all women who underwent a planned twin VD at two large academic medical centers over 4 years. Demographic and outcome data were chart abstracted. Various statistical tests were used to evaluate the influence of perinatal variables on mode of delivery and identify possible predictors of conversion. RESULTS Eight hundred and eighty-five twin deliveries were identified, of which 725 (81.9%) were possible candidates for VD. Of those, 237 (32.7%) underwent successful VD of twin A. Ninety-five (40.1%) had a nonvertex second twin at time of delivery. Conversion to CD occurred in 10 planned VDs (4.2%). Conversions were higher with spontaneous labor (relative risk [RR]: 2.1; 95% confidence interval [CI] 1.6-2.7; p = 0.003), and having an intertwin delivery interval greater than 60 minutes (RR: 5.1; 95% CI: 2.5-10.8; p < 0.001). Nonvertex presentation of twin B, type of delivery provider, or years out in practice of delivery provider were not significantly different between groups. There were no significant differences in neonatal outcomes between VD and conversion groups. There was a significant association between use of forceps for twin B and successful VD (p = 0.02), with 84.6% in the setting of a nonvertex twin B. CONCLUSION Successful VD was achieved in planned VD of twins in 95.8% of cases, and there were no significant differences in maternal and fetal outcomes between successful VD and conversion to CD for twin B. With the optimal clinical scenario and shared decision-making, performing vaginal twin deliveries in labor and delivery rooms should be discussed. KEY POINTS · There is a propensity to perform twin vaginal deliveries in the operating room.. · Rates of conversion to cesarean section are very low.. · There are no significant differences in perinatal outcomes with conversion..
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Affiliation(s)
- Jenny Y Mei
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
| | - Hector E Muñoz
- Department of Bioengineering, University of California, Los Angeles, California
| | - Jessica S Kim
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California
| | - Alec Szlachta-McGinn
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
| | - Cinthia Blat
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California
| | - Rashmi Rao
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
| | - Christina S Han
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
| | - Roxanna A Irani
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
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Aviram A, Barrett JFR, Melamed N, Mei-Dan E. Mode of delivery in multiple pregnancies. Am J Obstet Gynecol MFM 2021; 4:100470. [PMID: 34454159 DOI: 10.1016/j.ajogmf.2021.100470] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/25/2021] [Accepted: 08/18/2021] [Indexed: 11/25/2022]
Abstract
The mode of delivery in multiple pregnancies has been subject to vigorous debates during the last few decades. Although observational and retrospective data were accumulated, it was not until the publication of the Twin Birth Study that evidence-based recommendations could emerge. However, although some of the most pressing questions were answered by the Twin Birth Study, other questions were left outside the scope of the study. The questions were of great interest and included the following topics: the impact of gestational age, the influence of chorionicity, and the generalizability of the results for women with a previous uterine scar. The current evidence supported a trial of labor in dichorionic-diamniotic or monochorionic-diamniotic twin pregnancies in which the first twin is in cephalic presentation at ≥32 weeks' gestation. Dichorionic-diamniotic, monochorionic-diamniotic, and monochorionic-monoamniotic twins should be delivered at 37 0/7 to 38 0/7, 36 0/7 to 37 0/7, and 32 0/7 to 34 0/7 weeks' gestation, respectively. Breech extraction done by a competent healthcare provider seemed to offer a higher chance of successful vaginal delivery of the second twin than the external cephalic version. The current data did not allow for a clear recommendation regarding the mode of delivery in very preterm birth of low birthweight twins, but most studies did not demonstrate a clear benefit of cesarean delivery vs trial of labor. Furthermore, a trial of labor seemed safe in women with a previous cesarean delivery. Cesarean delivery is likely beneficial for twin pregnancies with the first twin in breech presentation, monochorionic-monoamniotic twins, and higher-order multiple pregnancies. In all multiple pregnancies, delivery should be performed by an experienced practitioner competent in multiple pregnancy deliveries.
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Affiliation(s)
- Amir Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan).
| | - Jon F R Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
| | - Elad Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
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Korb D, Deneux-Tharaux C, Goffinet F, Schmitz T. Severe maternal morbidity by mode of delivery in women with twin pregnancy and planned vaginal delivery. Sci Rep 2020; 10:4944. [PMID: 32188879 PMCID: PMC7080743 DOI: 10.1038/s41598-020-61720-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 02/19/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Diane Korb
- Université de Paris, Epidemiology and Statistics research Center/CRESS, INSERM, INRA, F-75004, Paris, France.
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France.
| | - Catherine Deneux-Tharaux
- Université de Paris, Epidemiology and Statistics research Center/CRESS, INSERM, INRA, F-75004, Paris, France
| | - François Goffinet
- Université de Paris, Epidemiology and Statistics research Center/CRESS, INSERM, INRA, F-75004, Paris, France
- Port-Royal maternity unit, Cochin Hospital, APHP, Paris, France
| | - Thomas Schmitz
- Université de Paris, Epidemiology and Statistics research Center/CRESS, INSERM, INRA, F-75004, Paris, France
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France
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Rissanen ARS, Jernman RM, Gissler M, Nupponen IK, Nuutila ME. Perinatal outcomes in Finnish twins: a retrospective study. BMC Pregnancy Childbirth 2019; 20:2. [PMID: 31892322 PMCID: PMC6938609 DOI: 10.1186/s12884-019-2670-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/10/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND To establish the changes in perinatal morbidity and mortality in twin pregnancies in Finland, a retrospective register research was conducted. Our extensive data from a 28-year study period provide important information on the outcome of twin pregnancies in Finland that has previously not been reported to this extent. METHODS All 23,498 twin pregnancies with 46,996 children born in Finland during 1987-2014 were included in the study. Data were gathered from the Medical Birth Register and the Hospital Discharge Register (Finnish Institute for Health and Welfare, Finland) regarding perinatal mortality (PNM) and morbidity. For statistical analysis, binomial regression analysis and crosstabs were performed. The results are expressed in means, percentages and ranges with comparison to singletons when appropriate. Odds ratios from binomial regression analysis are reported. A p-value <0.05 was considered statistically significant. RESULTS There were 46,363 liveborn and 633 stillborn twins in Finland during 1987-2014. Perinatal mortality decreased markedly, from 45.1 to 6.5 per 1000 for twin A and from 54.1 to 11.9 per 1000 for twin B during the study period. Yet, the PNM difference between twin A and B remained. Early neonatal mortality did not differ between twins, but has decreased in both. Asphyxia, respiratory distress syndrome, need for antibiotics and Neonatal Intensive Care Unit (NICU) stay were markedly more common in twin B. CONCLUSIONS In Finland, PNM and early neonatal mortality in twins decreased significantly during 1987-2014 and are nowadays very low. However, twin B still faces more complications. The outline provided may be used to further improve the monitoring and thus perinatal outcome of twins, especially twin B.
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Affiliation(s)
- Annu-Riikka Susanna Rissanen
- Department of Obstetrics and Gynecology, University of Helsinki and Welfare District of Päijät-Häme, Keskussairaalankatu 7, 15850, Lahti, Finland.
| | - Riina Maria Jernman
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 2, PL 140, 00029 HUS, Helsinki, Finland
| | - Mika Gissler
- Finnish Institute for Health and Welfare, Mannerheimintie 166, PL 30, 00271, Helsinki, Finland
- Karolinska Institute, Stockholm, Sweden
| | - Irmeli Katriina Nupponen
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, PL 347, 00029 HUS, Helsinki, Finland
| | - Mika Erkki Nuutila
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 2, PL 140, 00029 HUS, Helsinki, Finland
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Aviram A, Lipworth H, Asztalos EV, Mei-Dan E, Cao X, Melamed N, Zaltz A, Anastasio HB, Berghella V, Barrett JFR. The worst of both worlds-combined deliveries in twin gestations: a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study. Am J Obstet Gynecol 2019; 221:353.e1-353.e7. [PMID: 31254526 DOI: 10.1016/j.ajog.2019.06.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/12/2019] [Accepted: 06/20/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The reported incidence of combined twin delivery (vaginal delivery of twin A followed by cesarean delivery for twin B) ranges between 5% and 10%. These estimates are based mostly on small studies or retrospective data. We aimed to evaluate to incidence and risk factors for and outcomes of combined twin deliveries, using a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study. STUDY DESIGN The Twin Birth Study included women with twin gestation between 32+0 and 38+6 weeks, with the first twin in vertex presentation at randomization. Women were randomized to planned cesarean delivery or planned vaginal delivery. For the purpose of this subanalysis, we included women who had a vaginal delivery of twin A. Women who had a combined delivery (cesarean delivery for twin B) were compared with women who had a vaginal delivery of both twins. Our primary objective was to identify risk factors for combined twin deliveries. Our secondary objective was to assess the rate of fetal/neonatal death or serious neonatal morbidity in combined deliveries. RESULTS Of the 2786 women included in the original study, 842 women delivered twin A by a vaginal delivery and were included in the current analysis, of whom 59 (7%) had a combined delivery. Women in the combined delivery group had a lower rate of nulliparity (22.0% vs 34.7%, P = 0.047) and higher rates of noncephalic presentation of twin B at delivery (61.0% vs 27.3%, P < 0.001) and spontaneous version from presentation at randomization of twin B (72.9% vs 44.3%, P < 0.0001). In a multivariable model, the only risk factor significantly associated with a combined delivery was transverse/oblique lie of twin B following delivery of twin A (adjusted odds ratio, 47.7; 95% confidence interval, 15.4-124.5). Twins B in the combined delivery group had a higher rate of fetal/neonatal death or serious neonatal morbidity (13.6% vs 2.3%, P < 0.001), 5-minute Apgar score <7, neonatal intensive care unit admission, abnormal level of consciousness, and assisted ventilation. CONCLUSION Transverse/oblique lie of twin B following vaginal delivery of twin A is a risk factor for combined delivery. Combined delivery is associated with higher risk of adverse neonatal outcomes of twin B. These data may be used to better counsel women with twin gestation who consider a trial of labor.
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Affiliation(s)
- Amir Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada.
| | - Hayley Lipworth
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Elizabeth V Asztalos
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Elad Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Xingshan Cao
- Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Arthur Zaltz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Hannah B Anastasio
- Division of Maternal Fetal Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA
| | - Vincenzo Berghella
- Division of Maternal Fetal Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA
| | - Jon F R Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Rissanen ARS, Jernman RM, Gissler M, Nupponen I, Nuutila ME. Maternal complications in twin pregnancies in Finland during 1987-2014: a retrospective study. BMC Pregnancy Childbirth 2019; 19:337. [PMID: 31533649 PMCID: PMC6751578 DOI: 10.1186/s12884-019-2498-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 09/10/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND To investigate the trends and changes in the incidence and overall outcome of twin pregnancies in Finland, a retrospective study was conducted with emphasis on maternal complications, covering a 28-year study period. METHODS All 23,498 twin pregnancies with 46,363 live born and 633 stillborn children in Finland during 1987-2014 were included in the study. Data were collected from the national Medical Birth Register and the Care Register on Hospital Care (Finnish Institute for Health and Welfare, Finland) regarding the parturients' characteristics and incidences of several pregnancy and childbirth complications. The incidences of twin pregnancies and maternal complications during pregnancy and childbirth are the main outcome measures of the study. The results are expressed in percentages, means, medians, ranges and standard deviations (SD), when appropriate. RESULTS Twins comprised 1.4% of all births in Finland in 1987-2014. Parturients' mean age has remained stable, but the share of over 35 year-old parturients is increasing. The incidences of pre-eclampsia, intrahepatic cholestasis of pregnancy, gestational diabetes and postpartum haemorrhage have risen during the study period. Almost half (44.9%) of twins were born preterm, almost half via Caesarean section (47.1%), and 27.7% of twin labours were induced. CONCLUSIONS Several pregnancy complications increased during the study period. Advanced maternal age among twin parturients has risen, enhancing the risks for developing complications in a pregnancy already of a high-risk category, and predisposing to preterm delivery. National and international guidelines are necessary to improve the overall outcome of twin pregnancies.
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Affiliation(s)
- Annu-Riikka S Rissanen
- Obstetrics and Gynecology, University of Helsinki and Welfare District of Päijät-Häme, Keskussairaalankatu 7, 15850, Lahti, Finland.
| | - Riina M Jernman
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 2, P.O. BOX 140, 00029 HUS, Helsinki, Finland
| | - Mika Gissler
- Finnish Institute for Health and Welfare, P.O. BOX 30, 00271, Helsinki, Finland.,Karolinska Institute; Department of Neurobiology, Care Sciences and Society, Stockholm, Sweden
| | - Irmeli Nupponen
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 11, P.O. BOX 281, 00029 HUS, Helsinki, Finland
| | - Mika E Nuutila
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 2, P.O. BOX 140, 00029 HUS, Helsinki, Finland
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Twin Pregnancy in Brazil: A Profile Analysis Exploring Population Information from the National Birth E-Registry on Live Births. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9189648. [PMID: 30515417 PMCID: PMC6236661 DOI: 10.1155/2018/9189648] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 10/24/2018] [Indexed: 11/21/2022]
Abstract
Birth records as SINASC (Brazilian Live Birth Information System) are highlighted in uncommon conditions such as twin pregnancy whose prevalence rarely exceeds 2 to 3% of the total number of births. The objective of this study was to assess the prevalence of twin pregnancies in Brazil and their maternal and perinatal characteristics using data from the national birth e-Registry. All births in Brazil from 2011 to 2014 were assessed. Prevalence of twin pregnancies per region was assessed and correlated with the Human Development Index (HDI). Sociodemographic and obstetric factors and main perinatal outcomes were assessed for the first and second twin, in comparison to singletons, and the second twin compared to the first twin, with PR and 95%CI. A multiple logistic regression analysis was conducted to identify factors independently associated with a low 5-minute Apgar score in twin pregnancies. Twin pregnancy occurred in 1.13% in Brazil, with a higher prevalence in regions with a higher HDI. It was associated with a complete higher level of education (22.9% versus 16.3% for singles) and maternal age > 35 years (17.5% versus 11.4% for singles). Preterm birth <32 weeks (prevalence ratio-PR 12.13 [11.93 – 12.33]), low birth weight (PR 17.8 [17.6-18.0] for the first and PR 20.1 [19.8-20.3] for the second twin), and low Apgar score (PR 2.9 [2.8-3.0] for the first and PR 2.7 [2.6-2.8] for the second twin) were the most important perinatal outcomes associated with twin pregnancies. A 5-minute Apgar score < 7 among twins was associated with inadequate prenatal care, extreme preterm birth, vaginal delivery, intrapartum cesarean, and combined delivery. Twin pregnancy in Brazil is associated with worse perinatal outcomes, especially for the second twin.
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Schachter-Safrai N, Karavani G, Haj-Yahya R, Ofek Shlomai N, Porat S. Risk factors for cesarean delivery and adverse neonatal outcome in twin pregnancies attempting vaginal delivery. Acta Obstet Gynecol Scand 2018; 97:845-851. [DOI: 10.1111/aogs.13333] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/15/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Natali Schachter-Safrai
- Department of Obstetrics and Gynecology; Hadassah-Hebrew University Medical Center; Jerusalem
| | - Gilad Karavani
- Department of Obstetrics and Gynecology; Hadassah-Hebrew University Medical Center; Jerusalem
| | - Rani Haj-Yahya
- Department of Obstetrics and Gynecology; Hadassah-Hebrew University Medical Center; Jerusalem
| | - Noa Ofek Shlomai
- Department of Neonatology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Shay Porat
- Department of Obstetrics and Gynecology; Hadassah-Hebrew University Medical Center; Jerusalem
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Hunter T, Shah J, Synnes A, Shivananda S, Ryan G, Shah PS, Murphy KE. Neonatal outcomes of preterm twins according to mode of birth and presentation. J Matern Fetal Neonatal Med 2017; 31:682-688. [DOI: 10.1080/14767058.2017.1295441] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Tiffany Hunter
- Department of Obstetrics & Gynaecology, University of Toronto, Toronto, Canada
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Canada
| | - Jyotsna Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Anne Synnes
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | | | - Greg Ryan
- Department of Obstetrics & Gynaecology, University of Toronto, Toronto, Canada
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Canada
| | - Prakesh S. Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Kellie E. Murphy
- Department of Obstetrics & Gynaecology, University of Toronto, Toronto, Canada
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Canada
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Abstract
BACKGROUND Twin pregnancies are associated with increased perinatal mortality, mainly related to prematurity, but complications during birth may contribute to perinatal loss or morbidity. The option of planned caesarean section to avoid such complications must therefore be considered. On the other hand, randomised trials of other clinical interventions in the birth process to avoid problems related to labour and birth (planned caesarean section for breech, and continuous electronic fetal heart rate monitoring), have shown an unexpected discordance between short-term perinatal morbidity and long-term neurological outcome. The risks of caesarean section for the mother in the current and subsequent pregnancies must also be taken into account. OBJECTIVES To determine the short- and long-term effects on mothers and their babies, of planned caesarean section for twin pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 November 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials comparing a policy of caesarean section with planned vaginal birth for women with twin pregnancy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility, quality and extracted data. Data were checked for accuracy. For important outcomes the quality of the evidence was assessed using the GRADE approach. MAIN RESULTS We included two trials comparing planned caesarean section versus planned vaginal birth for twin pregnancies.Most of the data included in the review were from a multicentre trial where 2804 women were randomised in 106 centres in 25 countries. All centres had facilities to perform emergency caesarean section and had anaesthetic, obstetrical, and nursing staff available in the hospital at the time of planned vaginal delivery. In the second trial carried out in Israel, 60 women were randomised. We judged the risk of bias to be low for all categories except performance (high) and outcome assessment bias (unclear).There was no clear evidence of differences between women randomised to planned caesarean section or planned vaginal birth for maternal death or serious morbidity (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.67 to 1.11; 2844 women; two studies; moderate quality evidence). There was no significant difference between groups for perinatal or neonatal death or serious neonatal morbidity (RR 1.15, 95% CI 0.80 to 1.67; data for 5565 babies, one study, moderate quality evidence). No studies reported childhood disability.For secondary outcomes there was no clear evidence of differences between groups for perinatal or neonatal mortality (RR 1.41, 95% CI 0.76 to 2.62; 5685 babies; two studies, moderate quality evidence), serious neonatal morbidity (RR 1.03, 95% CI 0.65 to 1.64; 5644 babies; two studies, moderate quality evidence) or any of the other neonatal outcomes reported.The number of women undergoing caesarean section was reported in both trials. Most women in the planned caesarean group had treatment as planned (90.9% underwent caesarean section), whereas in the planned vaginal birth group 42.9% had caesarean section for at least one twin. For maternal mortality; no events were reported in one trial and two deaths (one in each group) in the other. There were no significant differences between groups for serious maternal morbidity overall (RR 0.86, 95% CI 0.67 to 1.11; 2844 women; two studies) or for different types of short-term morbidity. There were no significant differences between groups for failure to breastfeed (RR 1.14, 95% CI 0.95 to 1.38; 2570 women, one study; moderate quality evidence) or the number of women with scores greater than 12 on the Edinbugh postnatal depression scale (RR 0.95, 95% CI 0.78 to 1.14; 2570 women, one study; moderate quality evidence). AUTHORS' CONCLUSIONS Data mainly from one large, multicentre study found no clear evidence of benefit from planned caesarean section for term twin pregnancies with leading cephalic presentation. Data on long-term infant outcomes are awaited. Women should be informed of possible risks and benefits of labour and vaginal birth pertinent to their specific clinical presentation and the current and long-term effects of caesarean section for both mother and babies. There is insufficient evidence to support the routine use of planned caesarean section for term twin pregnancy with leading cephalic presentation, except in the context of further randomised trials.
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Affiliation(s)
- G Justus Hofmeyr
- Walter Sisulu University, University of Fort Hare, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | - Jon F Barrett
- Sunnybrook Health Sciences Centre60 Grosvenor StreetTorontoONCanadaM5S 1B6
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePrivate Bag 9201985 Park RoadAucklandNew Zealand
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18
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Risk factors predicting an emergency cesarean delivery for the second twin after vaginal delivery of the first twin. Arch Gynecol Obstet 2015; 292:531-6. [PMID: 25716669 DOI: 10.1007/s00404-015-3667-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 02/16/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To investigate obstetrical risk factors predicting failure of vaginal delivery and an emergency cesarean section (CS) for the second twin after vaginal delivery of the first twin. In addition, the study was aimed to define perinatal outcomes of the second twin. STUDY DESIGN A retrospective study was conducted, comparing all deliveries of twins in which CS was performed for the second twin to those in which both twins were delivered vaginally during the years 1988-2010. Women with multiple gestations in which a CS was performed for both twins were excluded from the study. RESULTS During the study period, 1966 vaginal deliveries of the first twin were recorded; 192 involved emergency CS for the second twin. Risk factors for emergency CS of the second twin were preterm delivery, previous CS, placental abruption and breech presentation of the second twin. Perinatal outcomes did not differ between the groups. CONCLUSION Risk factors for emergency cesarean section of the second twin are preterm delivery, previous CS, placental abruption and breech presentation. Nevertheless, short-term perinatal outcomes are comparable to twins delivered vaginally.
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19
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Aviram A, Weiser I, Ashwal E, Bar J, Wiznitzer A, Yogev Y. Combined vaginal-cesarean delivery of twins: risk factors and neonatal outcome – a single center experience. J Matern Fetal Neonatal Med 2014; 28:509-14. [DOI: 10.3109/14767058.2014.927430] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Hammad IA, Chauhan SP, Magann EF, Abuhamad AZ. Peripartum complications with cesarean delivery: a review of Maternal-Fetal Medicine Units Network publications. J Matern Fetal Neonatal Med 2013; 27:463-74. [DOI: 10.3109/14767058.2013.818970] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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21
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Engelbrechtsen L, Nielsen EH, Perin T, Oldenburg A, Tabor A, Skibsted L. Cesarean section for the second twin: a population-based study of occurrence and outcome. Birth 2013; 40:10-6. [PMID: 24635419 DOI: 10.1111/birt.12023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although management of twin deliveries has been a topic of discussion for decades, a consensus on how to deliver twins is lacking. The objective of this study was to examine short-term neonatal outcome of the second twin delivered by cesarean section after vaginal delivery of the first-born twin (combined delivery) and to identify predictors of combined delivery. METHODS This study was a 3-year, population-based, retrospective cohort investigation of 1,254 twin births in Denmark. The twin births were divided into three groups: vaginal deliveries, planned cesarean deliveries, and combined deliveries. Data were extracted from medical records, a fetal medicine software program (Astraia), and the National Birth Registry. Short-term poor neonatal outcome was measured as a 5-minute Apgar score ≤ 7, umbilical cord pH ≤ 7.10, and admission to neonatal intensive care unit for more than 3 days. RESULTS Vertex-nonvertex fetal presentations were more prevalent in combined deliveries than vaginal deliveries (OR 4.4, 2.5-7.8). Nonvertex second twins born by combined delivery had a higher risk of Apgar score ≤ 7 and umbilical cord pH ≤ 7.10 compared with vaginal delivery, unadjusted OR 6.2 (2.1-18), and unadjusted OR 3.9 (1.6-9.5). Prenatal ultrasound scans were evaluated in combined deliveries, of which 48 percent were vertex-vertex at the last ultrasound scan in pregnancy (mean gestational age 34 + 0) and 37 percent were vertex-vertex at birth. CONCLUSIONS Vertex-nonvertex presenting twins have an increased risk of combined delivery. Combined deliveries are associated with increased neonatal morbidity for the second twin.
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Affiliation(s)
- Line Engelbrechtsen
- Department of Obstetrics and Gynecology,University Hospital Roskilde, Roskilde, Denmark
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van der Garde M, Winkens B, Roumen FJME. Increased elective caesarean section rate is not associated with a decreased serious morbidity rate for twins ≥ 32 weeks' gestation. J OBSTET GYNAECOL 2012; 32:453-7. [PMID: 22663317 DOI: 10.3109/01443615.2012.669431] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To assess neonatal and maternal morbidity in twins ≥ 32 weeks' gestation, related to the changes in planned mode of delivery, a retrospective cohort study was performed, including 185 twin births delivered in the Atrium Medical Centre, Heerlen, during the years 2003-2008. The results were compared with those of an earlier study from our department during the period 1999-2002. Compared with the 1999-2002 cohort, the elective caesarean section rate significantly increased from 17.7% to 36.8%. The secondary caesarean rate significantly decreased from 15.9% to 8.8%, but increased from 1.2% to 3.3% for only twin B. No significant differences in serious neonatal morbidity rates for twins A and B were found between both study periods, neither in the elective caesarean group, nor in the planned vaginal birth group. Serious maternal morbidity was not significantly increased in both groups compared with the 1999-2002 cohort.
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Affiliation(s)
- M van der Garde
- Department of Obstetrics and Gynaecology, Atrium Medical Centre Parkstad, Heerlen The Netherlands
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Biswas A, Su LL, Mattar C. Caesarean section for preterm birth and, breech presentation and twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2012; 27:209-19. [PMID: 23062593 DOI: 10.1016/j.bpobgyn.2012.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 09/11/2012] [Indexed: 11/25/2022]
Abstract
Caesarean section incidence is steadily rising worldwide; the major contributor to this rise is pregnancies with previous caesarean section. Hence, it is important to scrutinise carefully the indication of primary caesarean sections. Preterm births, breech presentation and twin pregnancies together complicate 12-18% of all births. The role of caesarean section in these pregnancies is controversial and lacks good evidence-based guidelines. Policy on mode of delivery in these three important obstetric groups is bound to influence overall primary caesarean section rates. In this chapter, we review the evidence on the place of caesarean delivery in these three important groups.
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Affiliation(s)
- Arijit Biswas
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, National University Health Systems and National University of Singapore, Level 12, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore.
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Rebufa-Dhenin E, Flandrin A, Reyftmann L, Dechaud H, Burlet G, Boulot P. [Rupture of membranes in case of internal podalic version: a risk for cesarean section on the second twin]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2012; 40:402-5. [PMID: 22727740 DOI: 10.1016/j.gyobfe.2012.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Accepted: 10/31/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate if internal version with ruptured membranes is a risk factor of cesarean section for the second twin. PATIENTS AND METHODS Two hundred and fifty-nine twins vaginal deliveries after 33 weeks of gestation from 1997 to 2009 in a level 3 maternity. A retrospective case-control study comparing two groups: cases of cesarean section on second twin and five twins vaginal deliveries following the case. Active management of the second twin delivery was performed with a short intertwin delivery. RESULTS Eleven cesarean sections on the second twin were performed (4.2%). The main indication was failure of internal version. The risk of cesarean section was significantly greater when the internal version was performed with ruptured membranes (OR: 25.4 IC 95% [2.3-275.7] P<0.003) and when intertwin time delivery interval was increased (8.1±5.1 vs 16.7±6.3, P<0.001). DISCUSSION AND CONCLUSION The rupture of amniotic membranes before or during the internal podalic version is associated with a risk of failure and cesarean for the second twin. We recommend to perform the internal podalic version with unruptured membranes according to the French recommendations.
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Affiliation(s)
- E Rebufa-Dhenin
- Département de gynécologie-obstétrique, hôpital Arnaud-de-Villeneuve, CHU de Montpellier, 371 avenue Doyen-Gaston-Giraud, Montpellier, France.
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Abstract
The aim of this article is to review current information regarding the management of twin gestations and discuss optimal pregnancy length and considerations regarding route of delivery. Limited data are available on the timing and mode of delivery for twins. For apparently uncomplicated twin pregnancies, current recommendations suggest the optimal length of gestation is 38 weeks for dichorionic diamniotic twins, 34-36 weeks for monochorionic diamniotic twins, and 32-34 weeks for monoamniotic twins. In general, vaginal trial of labor may be considered for cephalic-cephalic twins and in cases of cephalic-noncephalic twins where the provider's skills and experience allow. Cesarean is recommended in twin gestations with monoamnionicity, noncephalic presenting fetus, and those at high risk for combined vaginal-abdominal delivery. The optimal management of twin deliveries is controversial, with timing and mode of delivery dependent on multiple factors, including chorionicity, amnionicity, provider experience, and fetal presentation.
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Affiliation(s)
- Young Mi Lee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA.
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Abstract
BACKGROUND Twin pregnancies are associated with increased perinatal mortality, mainly related to prematurity, but complications during birth may contribute to perinatal loss or morbidity. The option of planned caesarean section to avoid such complications must therefore be considered. On the other hand, randomised trials of other clinical interventions in the birth process to avoid problems related to labour and birth (planned caesarean section for breech, and continuous electronic fetal heart rate monitoring), have shown an unexpected discordance between short-term perinatal morbidity and long-term neurological outcome. The risks of caesarean section for the mother in the current and subsequent pregnancies must also be taken into account. OBJECTIVES To determine the short- and long-term effects on mothers and their babies, of planned caesarean section for twin pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011). SELECTION CRITERIA Randomised trials comparing a policy of caesarean section with planned vaginal birth for women with twin pregnancy. DATA COLLECTION AND ANALYSIS Two researchers independently assessed eligibility, quality and extracted data. Data were checked for accuracy. MAIN RESULTS One small trial with unconfirmed allocation concealment compared caesarean section with planned vaginal birth in 60 women with vertex/non-vertex twin pregnancies. There were no differences in perinatal outcome. The trial was too small to exclude the possibility of clinically meaningful benefits of either approach. There is one additional trial currently ongoing. AUTHORS' CONCLUSIONS There is a lack of robust evidence to guide clinical advice regarding the method of birth for twin pregnancies. Women should be informed of possible benefits and risks of either approach, including short-term and long-term consequences for both mother and babies. Future research should aim to provide unbiased evidence, including long-term outcomes.
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Affiliation(s)
- G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, East London, South Africa
| | | | - Caroline A Crowther
- ARCH: Australian Research Centre for Health of Women and Babies, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia
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Breathnach FM, McAuliffe FM, Geary M, Daly S, Higgins JR, Dornan J, Morrison JJ, Burke G, Higgins S, Dicker P, Manning F, Carroll S, Malone FD. Prediction of safe and successful vaginal twin birth. Am J Obstet Gynecol 2011; 205:237.e1-7. [PMID: 21784400 DOI: 10.1016/j.ajog.2011.05.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 04/25/2011] [Accepted: 05/18/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of the study was to establish predictors of vaginal twin birth and evaluate perinatal morbidity according to mode of delivery. STUDY DESIGN One thousand twenty-eight twin pregnancies were prospectively recruited. For this prespecified secondary analysis, obstetric characteristics and a composite of adverse perinatal outcome were compared according to the success or failure of a trial of labor and further compared with those undergoing elective cesarean delivery. Perinatal outcomes were adjusted for chorionicity and gestational age using a linear model for continuous data and logistic regression for binary data. RESULTS Nine hundred seventy-one twin pregnancies met the criteria for inclusion. A trial of labor was considered for 441 (45%) and was successful in 338 of 441 (77%). The cesarean delivery rate for the second twin was 4% (14 of 351). Multiparity and spontaneous conception predicted vaginal birth. No statistically significant differences in perinatal morbidity were observed. CONCLUSION A high prospect of successful and safe vaginal delivery can be achieved with trial of twin labor.
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Vendittelli F, Rivière O, Crenn-Hébert C, Riethmuller D, Schaal JP, Dreyfus M. Is a planned cesarean necessary in twin pregnancies? Acta Obstet Gynecol Scand 2011; 90:1147-56. [PMID: 21426308 DOI: 10.1111/j.1600-0412.2011.01130.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Evaluation of elective cesarean section for twin delivery as a standard of care. DESIGN Historical cohort in a national database (2 597 twin pregnancies). SETTING France. SAMPLE Twins with first child in cephalic presentation. METHODS Decision analysis. MAIN OUTCOME MEASURES All neonatal complications, i.e. death, whether intrapartum or in the delivery room or the immediate postpartum period, or neonatal transfer to intensive (or special) care, or trauma, of one or both twins. RESULTS When we focused on neonatal complications for either or both twins, the strategy of planned vaginal delivery was preferable; the weight of its decision tree branch was lower than that for planned cesarean (26.5 vs. 31.7). If only twin 2 was considered, vaginal delivery was also preferred (weight of vaginal delivery=27.6 vs. 32.7 for planned cesarean). As long as the morbidity and mortality of twin 1 or twin 2 or both during a cesarean for twin 2 in the case of planned vaginal delivery does not exceed 31.5%, all else being equal, vaginal delivery should be preferred to a planned cesarean for twin 1 and twin 2. The two-variable sensitivity analysis confirmed the robustness of the results. CONCLUSIONS The results of our study do not support a policy of planned cesarean delivery for twin pregnancies at and after 34 weeks of gestation. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Françoise Vendittelli
- AUDIPOG (Association of Health Workers Using an Electronic File in Paediatrics, Obstetrics and Gynaecology), Medical University RTH Laennec, Lyon, France.
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Christopher D, Robinson BK, Peaceman AM. An evidence-based approach to determining route of delivery for twin gestations. REVIEWS IN OBSTETRICS & GYNECOLOGY 2011; 4:109-116. [PMID: 22229063 PMCID: PMC3252881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Approximately 50% of twin pregnancies deliver preterm, and major complications associated with prematurity include respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, and sepsis. These complications drive the perinatal mortality rate of twins to seven times that of singletons. Although delivery may take place due to iatrogenic or spontaneous etiologies-no matter what the indication-optimizing the route of delivery for twins is an important component of care that must be thoughtfully considered.
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