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Whittaker M, Greatholder I, Kilby MD, Heazell AEP. Risk factors for adverse outcomes in twin pregnancies: a narrative review. J Matern Fetal Neonatal Med 2023; 36:2240467. [PMID: 37518183 DOI: 10.1080/14767058.2023.2240467] [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: 04/27/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE Globally, the incidence of twin pregnancies is rising owing to the use of assisted reproductive technologies (ART), emigration and deferment of pregnancy until advanced maternal age (AMA). While twin pregnancies have higher absolute risks of adverse outcomes, including miscarriage, stillbirth, neonatal death and preterm delivery, the impact of specific exposures and risk factors related to these outcomes may differ between twin pregnancies and singleton pregnancies. Regarding modifiable factors, data are sometimes based on evidence extrapolated from singleton or whole obstetric populations. Therefore, targeted evidence is required to provide care tailored to twin pregnancies to prevent adverse outcomes. We aimed to comprehensively review the association between different risk factors and adverse outcomes in twin pregnancies, including data on chorionicity, and to compare these to singletons. MATERIALS AND METHODS This review examines the risks associated with chorionicity, AMA, body mass index (BMI), socioeconomic and ethnic inequalities, maternal smoking, use of ART, maternal perception of fetal movement, and maternal comorbidities, including hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM). Adverse outcomes reported were preterm birth, admission to the neonatal intensive care unit (NICU), stillbirth and neonatal mortality. As such, fetal mortality and morbidity will be under-represented, as pregnancy loss before 22-24 weeks is omitted. RESULTS Monochorionicity increases the risk of stillbirth, NICU admission, and preterm delivery in twin pregnancy. AMA predisposes twin pregnancies to higher risks of mortality, admission to the NICU, and preterm birth than singleton pregnancies do. Conversely, the impact of BMI, socioeconomic inequalities, smoking, ART, and HDP on adverse outcomes appears to be lower in twin pregnancies than in singleton pregnancies. This attenuation might be explained by the higher baseline risk of adverse outcomes such as preterm birth in twin pregnancies. Some exposures, such as ART use and GDM, appear to be "protective" against perinatal mortality in twin pregnancies, despite being established risk factors for adverse outcomes in singleton pregnancies, potentially related to access to specialist care. There is a paucity of evidence available to counsel mothers of twin pregnancies regarding reduced fetal movement. CONCLUSIONS Overall, the risk factors for adverse pregnancy outcomes differ between twin and singleton pregnancies. This highlights the need for further studies to examine the association between risk factors and adverse outcomes in twin pregnancies. The resulting data would facilitate tailored guidance for twin pregnancies, contribute to improved antenatal care, and inform wider public health strategies.
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Affiliation(s)
- Maya Whittaker
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Isabelle Greatholder
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mark D Kilby
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Birmingham, UK
- Emeritus Professor of Fetal Medicine, College of Medical & Dental Sciences, University of Birmingham, Edgbaston, UK
- Illumina UK, Cambridge, UK
| | - Alexander E P Heazell
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Chen Y, Liu M, Zhang Y, Chen Z, Mei H, Liu Y, Wu H, Zhou A. Gestational weight gain and neonatal outcomes in different zygosity twins: a cohort study in Wuhan, China. BMJ Open 2023; 13:e056581. [PMID: 36627159 PMCID: PMC9835877 DOI: 10.1136/bmjopen-2021-056581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To evaluate whether twin zygosity influences the association between neonatal outcomes and gestational weight gain (GWG) based on the Chinese guidelines in twin-pregnancy women. DESIGN A retrospective cohort study. And it is not a clinical trial. SETTING Women with twin pregnancies living in Wuhan, China. PARTICIPANTS A total of 5140 women who delivered live and non-malformed twins from 1 January 2011 to 31 August 2017 were included in this study. MAIN OUTCOME MEASURE The primary neonatal outcomes included paired small for gestational age (SGA, <10 th percentile birth weight for gestational age and sex), low birth weight (LBW, <2500 g) and gestational age (<33 weeks and <37 weeks). The association between GWG and neonatal outcomes was examined by Logistic regression analyses. RESULTS A total of 5140 women were included, of whom 22.24%, 54.78% and 22.98% were below, within and above the Chinese guidelines, respectively. Among the including 10 280 infants, 26.28% of them were monozygotic (MZ) twins and 73.72% of them were dizygotic (DZ) twins. Women with low GWG had a significantly higher proportion of LBW/LBW and LBW/NBW infants, a greater likelihood of SGA/SGA and SGA/appropriate for gestational age (AGA) infants and a higher incidence of preterm birth. The associations persisted both in MZ and DZ twins, and twin zygosity influenced the degree of association between GWG and SGA, LBW and preterm birth. High GWG was associated with significant risk reductions in SGA/AGA pairs, LBW/LBW or LBW/NBW pairs, and less than 33 gestational weeks. However, high GWG was only associated with reduced risk of LBW/LBW pairs both in MZ and DZ twins. CONCLUSIONS GWG below the Chinese recommendations increased the risk of SGA, LBW and preterm birth in both MZ and DZ twins. The effect was more pronounced in MZ twins than that in DZ twin pairs. A high GWG only reduced the risk of LBW/LBW pairs both in MZ and DZ twins.
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Affiliation(s)
- Yawen Chen
- Health Care Department, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mingzhu Liu
- Health Care Department, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yiming Zhang
- Information Department, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhong Chen
- Health Care Department, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Mei
- Institute of Maternal and Child Health, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Liu
- Health Care Department, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongling Wu
- Health Care Department, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - AiFen Zhou
- Health Care Department, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Chen Y, Liu Y, Zhang Y, Hu R, Qian Z, Xian H, Vaughn MG, Liu M, Cao S, Gan Y, Zhang B. Gestational Weight Gain per Pre-Pregnancy Body Mass Index and Birth Weight in Twin Pregnancies: A Cohort Study in Wuhan, China. Sci Rep 2018; 8:12496. [PMID: 30131497 PMCID: PMC6104075 DOI: 10.1038/s41598-018-29774-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/18/2018] [Indexed: 02/07/2023] Open
Abstract
To assess the relationship between gestational weight gain (GWG) of twin-pregnancy women and twin birth weights, as well as to evaluate whether pre-pregnancy body mass index (BMI) influences this relationship. A cohort study was conducted in Wuhan, China, between 1/01/2011 and 8/31/2017. Women with twin pregnancies who delivered live and non-malformed twins were included (6,925 women and 13,850 infants), based on the Wuhan Maternal and Child Health Management Information System. Logistic regression models were employed to examine the association between GWG and paired small for gestational age (SGA, defined as birth weight <10th percentile for gestational age and sex)/SGA and linear regression models were utilized to explore the relationship between GWG and sum of birth weights. The associations of GWG based on both the IOM and Chinese recommendations and SGA/SGA pairs were obtained, as well as the stratified analyses by pre-pregnancy BMI. Additionally, the sum birth weight of one twin pair increased by 15.88 g when the GWG increased by 1 kg. GWG below the IOM and Chinese recommendations was associated with an increased risk of SGA/SGA pairs in all pre-pregnancy BMI categories. However, in underweight, overweight, and obese women, the association between GWG above the IOM and Chinese recommendations and SGA/SGA pairs changed with adjustment.
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Affiliation(s)
- Yawen Chen
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, No. 100 Hongkong Road, Wuhan, 430014, Hubei, People's Republic of China
| | - Yan Liu
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, No. 100 Hongkong Road, Wuhan, 430014, Hubei, People's Republic of China
| | - Yiming Zhang
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, No. 100 Hongkong Road, Wuhan, 430014, Hubei, People's Republic of China
| | - Ronghua Hu
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, No. 100 Hongkong Road, Wuhan, 430014, Hubei, People's Republic of China
| | - Zhengmin Qian
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, 3545 Lafayette Avenue, Saint Louis, MO, 63104, United States of America
| | - Hong Xian
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, 3545 Lafayette Avenue, Saint Louis, MO, 63104, United States of America
| | - Michael G Vaughn
- School of Social Work, College for Public Health and Social Justice, Saint Louis University, Tegeler Hall, 3550 Lindell Boulevard, Saint Louis, MO, 63103, United States of America
| | - Mingzhu Liu
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, No. 100 Hongkong Road, Wuhan, 430014, Hubei, People's Republic of China
| | - Shiyi Cao
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, NO. 13 Hangkong Road, Wuhan, 430030, Hubei, People's Republic of China
| | - Yong Gan
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, NO. 13 Hangkong Road, Wuhan, 430030, Hubei, People's Republic of China
| | - Bin Zhang
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, No. 100 Hongkong Road, Wuhan, 430014, Hubei, People's Republic of China.
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Management of Fetal Growth Arrest in One of Dichorionic Twins: Three Cases and a Literature Review. Obstet Gynecol Int 2015; 2015:289875. [PMID: 26839551 PMCID: PMC4709681 DOI: 10.1155/2015/289875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/03/2015] [Accepted: 11/15/2015] [Indexed: 11/18/2022] Open
Abstract
Progressive fetal growth restriction (FGR) is often an indication for delivery. In dichorionic diamniotic (DD) twin pregnancy with growth restriction only affecting one fetus (selective fetal growth restriction: sFGR), the normal twin is also delivered prematurely. There is still not enough evidence about the optimal timing of delivery for DD twins with sFGR in relation to discordance and gestational age. We report three sets of DD twins with sFGR (almost complete growth arrest affecting one fetus for ≥2 weeks) before 30 weeks of gestation. The interval from growth arrest to delivery was 21-24 days and the discordance was 33.7-49.8%. A large-scale study showed no difference of overall mortality or the long-term outcome between immediate and delayed delivery for FGR, while many studies have identified a risk of developmental delay following delivery of the normal growth fetus before 32 weeks. Therefore, delivery of DD twins with sFGR should be delayed if the condition of the sFGR fetus permits in order to increase the gestational age of the normal growth fetus.
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Bodnar LM, Pugh SJ, Abrams B, Himes KP, Hutcheon JA. Gestational weight gain in twin pregnancies and maternal and child health: a systematic review. J Perinatol 2014; 34:252-63. [PMID: 24457254 PMCID: PMC4046859 DOI: 10.1038/jp.2013.177] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 11/07/2013] [Accepted: 12/04/2013] [Indexed: 11/08/2022]
Abstract
Our objective was to systematically review the data interrogating the association between gestational weight gain (GWG) and maternal and child health among women with twin gestations. We identified 15 articles of twin gestations that studied GWG in relation to a maternal, perinatal or child health outcome and controlled for gestational age at delivery and prepregnancy body mass index. A positive association between GWG and fetal size was consistently found. Evidence on preterm birth and pregnancy complications was inconsistent. The existing studies suffer from serious methodological weaknesses, including not properly accounting for the strong correlation between gestational duration and GWG and not controlling for chorionicity. In addition, serious perinatal outcomes were not studied, and no research is available on the association between GWG and outcomes beyond birth. Our systematic review underscores that GWG in twin gestations is a neglected area of research. Rigorous studies are needed to inform future evidence-based guidelines.
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Affiliation(s)
- L M Bodnar
- 1] Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA [2] Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA [3] Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - S J Pugh
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - B Abrams
- Division of Epidemiology, School of Public Health, University of California at Berkeley, Berkeley, CA, USA
| | - K P Himes
- 1] Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA [2] Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - J A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
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Selective and non-selective intrauterine growth restriction in twin pregnancies: high-risk factors and perinatal outcome. Arch Gynecol Obstet 2011; 285:973-8. [DOI: 10.1007/s00404-011-2119-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Accepted: 10/11/2011] [Indexed: 10/16/2022]
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