Maternal complications in twin pregnancies in Finland during 1987-2014: a retrospective study

The association between neonatal birthweight discordance and preeclampsia in twin pregnancy

PURPOSE

To investigate the association between neonatal birthweight (NBW) discordance and preeclampsia (PE) in twin pregnancy.

METHODS

This was a single-center retrospective cohort study. Women with two live births in the First Affiliated Hospital of Sun Yat-sen University from January 2011 to June 2020 were eligible. They were classified into four groups based on the quartiles of NBW discordance in monochorionic (MC) and dichorionic (DC) twin pregnancy. The relationship between NBW discordance and the risk of PE was assessed by logistic regression, subgroup analyses was further analyzed.

RESULTS

A total of 1566 women were eligible for the final analysis, there were 445 MC cases and 1121 DC cases. No matter in monochorionic or dichorionic pregnancy, higher NBW discordance quartiles were associated with increased risks of PE. Compared with women in the lowest NBW discordance quartile, women in the highest NBW discordance quartile had approximately 3.6 and 6.0 times risk of PE in monochorionic and dichorionic pregnancy respectively. The association between quartiles of NBW discordance and the risk of PE were higher in dichorionic pregnancy than in monochorionic pregnancy. No matter in MC or DC pregnancy, no significant interaction effects were identified for maternal age, pregnancy body mass index, mode of conception and whether complicated with gestational diabetes mellitus.

CONCLUSIONS

The increased NBW discordance quartile was related to an increased risk of PE. Assessing estimated fetal weight discordance by using ultrasound in clinical practice to predict PE remained to be further researched.

Recurrent preterm delivery following twin versus singleton preterm delivery: A retrospective cohort

OBJECTIVE

The main risk factor for preterm delivery (PTD; <37 gestational weeks) is having a history of PTD. The aim of this research was to compare the risk for recurrent PTD following twin versus singleton gestation PTD.

METHODS

A retrospective population-based cohort study was performed, including all women who had two consecutive pregnancies, the first of which ended with PTD. The incidence of PTD recurrence was compared between women with PTD in twin versus singleton gestation. Multivariable logistic models were used to study the association between twinning status and PTD recurrence, and specifically by gestational age of the first PTD, inter-pregnancy interval (IPI), and mode of conception.

RESULTS

The study population included 15 590 women, of whom 1680 (10.8%) had twins in their index pregnancy and 13 910 (89.2%) had singletons. The incidence of recurrent PTD was 10.5% (n = 177) following twin PTD versus 21.9% (n = 3044) following singleton PTD (adjusted odds ratio = 0.50, 95% confidence interval 0.32-0.76, while controlling for confounding variables). The results were consistent while stratifying by IPI, gestational age of the first PTD, or mode of conception.

CONCLUSIONS

Women with PTD in twin gestations are at lower risk for recurrent PTD compared with women with singleton PTD.

Prevalence and adverse outcomes of twin pregnancy in Eastern Africa: a systematic review and meta-analysis

INTRODUCTION

Multiple pregnancies are much more common today than they were in the past. Twin pregnancies occur in about 4% of pregnancies in Africa. Adverse pregnancy outcome was more common in twin pregnancy than in singleton pregnancy. There is no pooled evidence on the burden and adverse pregnancy outcome of twin pregnancy in eastern Africa. Thus, this systematic review and meta-analysis were conducted to assess the prevalence and adverse pregnancy outcomes of twin pregnancies.

METHODS

This systematic review and meta-analysis covers published and unpublished studies searched from different databases (PubMed, CINAHL (EBSCO), EMBASE, DOAJ, Web of Sciences, MEDLINE, Cochrane Library, SCOPUS, Google Scholar, and Google search). Finally, 34 studies were included in this systematic review and meta-analysis. JBI checklist was used to assess the quality of included papers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Data synthesis and statistical analysis were conducted using STATA Version 14 software. Heterogeneity and publication bias were assessed. A forest plot was used to present the pooled prevalence using the random effect model.

RESULTS

The prevalence of twin pregnancy in eastern Africa was 3% [95% CI: 2, 3]. The adverse pregnancy outcomes like neonatal intensive care unit admission (78%), low birth weight (44%), low APGAR score (33%), prematurity (32%), stillbirth (30%), neonatal mortality (12%) and maternal complications like hypertensive disorder of pregnancy (25%), postpartum hemorrhage (7%), Cesarean section (37%), premature rupture of membrane (12%) and maternal mortality are more common among twin pregnancy than singleton pregnancy.

CONCLUSION

One in every 33 children born a twin in east Africa; admission to neonatal intensive care unit, low birth weight, low APGAR score, prematurity, stillbirth, neonatal mortality and maternal complications are its associated adverse birth outcomes. Since twin pregnancy is a high-risk pregnancy, special care is needed during pregnancy, labor and delivery to reduce adverse pregnancy outcomes.

Twin birth rates and obstetric interventions in Iceland: A nationwide study from 1997 to 2018

OBJECTIVE

Twin pregnancies are associated with increased antepartum and intrapartum risks. Limited multiple embryo transfers are associated with decreased twin birth rates. We aimed to study the effect of 2009 Icelandic regulations on twin birth rates and examine obstetric intervention rates for twin births during the study period.

METHODS

The study included all births (N = 94 028) in Iceland during 1997-2018. Twin birth rates and obstetric intervention rates were compared over birth year periods using modified Poisson regression adjusted for confounders.

RESULTS

An observed decrease in the twin birth rate trend was most notable from 2006 until 2009. Twin birth decreased in 2009-2013 (prevalence ratio [PR] 0.74, 95% confidence interval [CI] 0.64-0.86) and in 2014-2018 (PR 0.74, 95% CI 0.64-0.86) compared with 1997-2002. This decrease was only evident for women aged 30+ years in stratified analysis. Induction of labor rates increased from 26% in 1997-2002 to 44% in 2014-2018 (adjusted rate ratio [ARR] 2.10, 95% CI 1.72-2.57) whereas elective cesarean section (ARR 0.80, 95% CI 0.59-1.07) and urgent cesarean section (ARR 0.79, 95% CI 0.63-1.00) rates appeared to decline.

CONCLUSION

Twin births decreased during the study period. International guidelines published before the Icelandic regulations may have affected twin birth rates in Iceland. Induction of labor rates for twins increased while cesarean section rates decreased.

Intersectional inequities in the birthweight gap between twin and singleton births: A random effects MAIHDA analysis of 2012-2018 New York City birth data

Birthweight is a widely-used biomarker of infant health, with inequities patterned intersectionally by maternal age, race/ethnicity, nativity/immigration status, and socioeconomic status in the United States. However, studies of birthweight inequities almost exclusively focus on singleton births, neglecting high-risk twin births. We address this gap using a large sample (N = 753,180) of birth records, obtained from the 2012-2018 New York City (NYC) Department of Health and Mental Hygiene, Bureau of Vital Statistics, representing 99% of all births registered in NYC, and a novel random coefficients intersectional MAIHDA (Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy) model. Our results show evidence of intersectional inequities in birthweight outcomes for both twin and singleton births by maternal age, race/ethnicity, education, and nativity status. Twins have considerably lower predicted birthweights than singletons overall (-930 g on average), and this is especially true for babies born to mothers who are younger (11-19 years), older (40+), racial/ethnic minoritized, foreign-born, and have lower education. However, the magnitude of this birthweight 'gap' between twins and singletons varies considerably across social identity strata, ranging between 830.8 g (observed among 40+ year old Black foreign-born mothers with high school degrees) and 1013.7 g (observed among 30-39 year old Hispanic/Latina foreign-born mothers with less than high school degrees). This study underscored the needs of a high-risk population and the need for aggressive social policies to address health inequities and dismantle intersectional systems of marginalization, oppression, and socioeconomic inequality. In addition to our substantive contributions, we add to the growing methods literature on intersectional quantitative analysis by demonstrating how to apply intersectional MAIHDA with random coefficients and random slopes. We conclude with a discussion of the significant potential for this methodological extension in future research on inequities.

Mode of delivery of Finnish dichorionic and monochorionic-diamniotic twins: A retrospective observational study including a risk score for intrapartum cesarean birth

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%).

Twins versus singletons-Long-term health outcomes

INTRODUCTION

Multiple gestations are a risk factor for most pregnancy complications. The current study aimed to study whether offspring born after twin pregnancies are at increased risk for long-term health complications.

MATERIAL AND METHODS

A retrospective cohort study was conducted in a large medical center, including all offspring born between the years 1991-2021, which were followed-up until 18 years of age. Hospital-based diagnoses of the offspring were categorized into main groups of morbidities: cardiac, respiratory, infectious, neurological, malignancy, and metabolic. Incidence of hospitalization with diagnoses from each main group was compared between twins and singletons, as well as time to first hospitalization. Cox proportional hazard models were used to study the association between twins versus singletons and hospitalizations by grouped morbidities, while adjusting for maternal age, ethnicity and gender, besides maternal recurrence in the cohort.

RESULTS

A total of 369 478 offspring were included in the analysis; of these 11 986 (3.2%) were twins and 357 492 (96.8%) were singletons. Twins were more likely to be delivered preterm (odds ratio = 17.65, 95% CI: 16.74-18.60), by cesarean delivery and following infertility treatments. Incidence of hospitalizations with all morbidity groups was slightly, some significantly, higher among twins, including cardiac: 1.9% versus 1.5%, respiratory; 8.4% versus 7.1%, neurological: 7.7% versus 7.4%, infectious: 26.0% versus 24.1%, and malignancies: 0.7% versus 0.4%. The risk remained higher in the multivariable analyses (adjusted hazard ratios ranging between 1.09-1.75). When stratifying by gestational age at delivery, the risk for most morbidities was lower among twins versus singletons born in similar gestational ages.

CONCLUSIONS

Twins as compared to singletons are at increased risk for most morbidities due to their risk of being born earlier.

Effects of antenatal corticosteroids on neonatal outcomes in twin and singleton pregnancies: a Korean national cohort study

OBJECTIVE

To investigate whether effects of antenatal corticosteroids on neonatal outcomes in preterm infants with very low birth weight were different by plurality.

DESIGN

Nationwide prospective cohort study.

PATIENTS

Twins and singletons with very low birth weight (<1500 g) who were born between 23+0 and 33+6 weeks of gestation and registered in the Korean Neonatal Network from January 2014 to December 2019.

MAIN OUTCOME MEASURES

Morbidity and mortality before discharge from neonatal intensive care unit.

RESULTS

Among a total of 9531 preterm infants with very low birth weight, there were 2364 (24.8%) twins and 7167 (75.2%) singletons. While 83.9% of singletons were exposed to at least one dose of antenatal corticosteroids, so were 87.9% of twins.Interaction analysis demonstrated that there was no significant difference in the effect of antenatal corticosteroids on morbidities or mortality between twins and singletons in either gestational age group (23-28 weeks or 29-33 weeks).Antenatal corticosteroids significantly decreased the risk of surfactant use (adjusted relative risk (aRR): 0.972 (95% CI: 0.961 to 0.984)), high-grade intraventricular haemorrhage (aRR: 0.621 (95% CI: 0.487 to 0.794)), periventricular leucomalacia (aRR: 0.728 (95% CI: 0.556 to 0.954)) and mortality (aRR: 0.758 (95% CI: 0.679 to 0.846)) in the gestational age group of 23-28 weeks. In the gestational age group of 29-33 weeks, antenatal corticosteroids significantly decreased the risk of surfactant use (aRR: 0.914 (95% CI: 0.862 to 0.970)) and mortality (aRR: 0.409 (95% CI: 0.269 to 0.624)) but increased the risk of sepsis (aRR: 1.416 (95% CI: 1.018 to 1.969)).

CONCLUSION

This study demonstrates that effect of antenatal corticosteroids on neonatal outcomes of preterm infants with very low birth weight does not differ significantly by plurality (twin or singleton pregnancy).

Higher odds of gestational diabetes among women with multiple pregnancies: a nationwide register-based cohort study in Finland

INTRODUCTION

The association between multiple pregnancies and the risk of gestational diabetes mellitus (GDM) has been moderately studied. The aim of this study is to evaluate whether women with multiple pregnancies are at a higher risk of developing GDM using nationwide high-quality registers.

MATERIALS AND METHODS

In this retrospective cohort study, data from the National Medical Birth Register (MBR) was used to evaluate the odds of GDM as a result of multiple pregnancies. We included all pregnancies with a tested GDM recorded in the MBR between 2004 and 2018. A total of 397,810 pregnancies were included in this study. Logistic regression model was used to assess the odds for GDM among multiple pregnancies, when compared to singleton pregnancies. Odds ratios (ORs) and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) between the groups were compared. The model was adjusted with maternal BMI and in vitro fertilisation (IVF) treatments.

RESULTS

A total of 5825 multiple pregnancies and a tested GDM were observed. In the control group, there were 391,985 singleton pregnancies with a tested GDM. Of these, 1791 (30.7%) multiple pregnancies were associated with a diagnosis of GDM. GDM was more common among women with multiple pregnancies (30.7 vs. 25.9%, aOR 1.28; CI 1.21-1.36).

CONCLUSION

The results of this study show that women with multiple pregnancies have a higher odds of developing GDM and should be monitored to prevent the development of GDM.

Intertwin growth discordance throughout gestation and hypertensive disorders of pregnancy

BACKGROUND

Previous studies have established the association between intertwin birthweight discordance and hypertensive disorders of pregnancy. However, longitudinal fetal size discordance concerning gestational hypertension or preeclampsia remains unclear.

OBJECTIVE

This study aimed to compare the patterns of estimated fetal weight discordance throughout gestation among normotensive women, women with gestational hypertension, and women with preeclampsia and to evaluate the association between crown-rump length discordance at 11 to 14 weeks of gestation and hypertensive disorders of pregnancy.

STUDY DESIGN

This was a retrospective cohort study of women with twin pregnancies who had antenatal care visits and delivered at a tertiary hospital between January 2013 and June 2021. The crown-rump length was measured at 11 to 14 weeks of gestation. Estimated fetal weight was calculated based on ultrasound examinations of fetal biometrics at 16 to 18, 20 to 24, 28 to 32, and ≥34 weeks of gestation, respectively. Crown-rump length and estimated fetal weight discordances were calculated: (larger crown-rump length - smaller crown-rump length)/larger crown-rump length × 100% and (larger estimated fetal weight - smaller estimated fetal weight)/larger estimated fetal weight × 100%, respectively. Multiple imputation was used to handle missing data, and all models accounted for the imputation. Multilevel model analysis was used to compare the differences in estimated fetal weight discordances throughout gestation among normotensive women, women with gestational hypertension, and women with preeclampsia. Generalized linear models were used to evaluate the association between crown-rump length discordance and hypertensive disorders of pregnancy, assuming a Poisson distribution. The possible nonlinear relationship between continuous crown-rump length discordance and hypertensive disorders of pregnancy was examined by generalized additive models. All analyses were stratified by chorionicity.

RESULTS

Of the 3280 women with twin pregnancies who met the inclusion criteria, 187 (5.7%) developed gestational hypertension, and 436 (13.3%) developed preeclampsia, including 125 (3.8%) early-onset preeclampsia and 311 (9.5%) late-onset preeclampsia. In women with dichorionic twin pregnancies, compared with normotensive women, a substantial progression of estimated fetal weight discordance throughout pregnancy was identified in women who developed preeclampsia, and a large progression of estimated fetal weight discordance in late pregnancy was identified in women who developed gestational hypertension. In women with monochorionic twin pregnancies, estimated fetal weight discordances were more progressive from 20 to 24 weeks of gestation onward in women who developed preeclampsia than in normotensive women. Crown-rump length discordance at 11 to 14 weeks of gestation was associated with an increased risk of preeclampsia (relative risk, 1.03; 95% confidence interval, 1.00-1.05), particularly early-onset preeclampsia (relative risk, 1.09; 95% confidence interval, 1.04-1.13). A crown-rump length discordance of ≥10% had 1.2 times the increased risk of developing early-onset preeclampsia (relative risk, 2.27; 95% confidence interval, 1.28-4.03). This association was identified in dichorionic twins, but not in monochorionic twins.

CONCLUSION

Our study demonstrated distinct growth discordant patterns among normotensive women, women with gestational hypertension, and women with preeclampsia in twin pregnancies. Intertwin crown-rump length discordance at 11 to 14 weeks of gestation was associated with an increased risk of preeclampsia, especially early-onset preeclampsia in dichorionic twin pregnancies, with a dose-response pattern.

Single-embryo transfer implies quality of care in reproductive medicine

This review appraises evidence on the difference between single- and double-embryo transfer (SET, DET) in assisted reproductive technology (ART) regarding the four healthcare quality dimensions most important to fertility patients and doctors. Regarding safety, not only does DET create the uncontested perinatal risks of twin pregnancies, but compelling evidence has added that singleton pregnancies after a vanishing twin also have poorer perinatal outcomes. SET is as effective as DET, as shown by meta-analyses of randomized controlled trials, comparing two cycles of SET versus DET and shown by cumulative live birth rates of entire ART trajectories of up to six cycles. Proposing SET, which is safer than DET and as effective, as the gold standard is not irreconcilable with patient-centred care if patients are thoroughly informed on the reasoning behind the proposition and welcomed to challenge whether it fits their personal values. The cost-efficiency of SET is clearly higher, which has even induced certain countries to start reimbursing ART on the condition that SET is used. In conclusion, SET should be the gold standard offered to all patients. The question is not whether to apply SET but how to apply it in terms of patient selection, patient-centred counselling and coverage of treatment.

Twin Growth Discordance and Risk of Postpartum Hemorrhage: A Retrospective Cohort Study

Background

In recent years, the incidence of postpartum hemorrhage has increased globally. Multiple pregnancies and cesarean sections are well-known risk factors for postpartum hemorrhage. No studies have evaluated the associations between fetal growth anomalies and postpartum hemorrhage in women with twin pregnancies undergoing cesarean section. This study aimed to identify the relationship between fetal growth anomalies and postpartum hemorrhage in women with twin pregnancies undergoing cesarean section.

Methods

This retrospective single-center study included 3,180 women with twin pregnancies at a tertiary hospital between August 2013 and July 2020. Singleton reference charts were used to assess fetal growth restriction at birth. Discordant growth was defined as an intertwin birth weight difference of ≥20%. Logistic regression analyses were used to evaluate the association between fetal growth anomalies and postpartum hemorrhage. Additionally, sensitivity analysis of abnormal placenta and stratification by twin chorionicity were conducted.

Results

The overall incidence of postpartum hemorrhage was 4.3%. Twin growth discordance, especially with fetal growth restriction, was associated with an increased risk of postpartum hemorrhage (adjusted odds ratio [AOR] = 1.62, 95% confidence interval [CI], 1.05-2.51, P = 0.031; AOR = 1.71; 95% CI, 1.08-2.70, P = 0.022; AOR = 1.98, 95% CI, 1.21-3.25, P = 0.006, respectively). After stratification, this relationship persisted in dichorionic twins (OR = 1.71, 95% CI, 1.04-2.82, P = 0.036; OR = 1.90, 95% CI, 1.13-3.21, P = 0.016; OR = 2.48, 95% CI, 1.41-4.38, P = 0.002, respectively). However, no significant association was observed in monochorionic twin pregnancies.

Conclusion

Growth discordance, especially complicated by fetal growth restriction, was associated with an increased risk of postpartum hemorrhage in women with twin pregnancies undergoing cesarean section, and was more evident in patients with dichorionic twins.

Association between cesarean section rate and maternal age in twin pregnancies

OBJECTIVES

To evaluate the effect of maternal age to the cesarean section rate of twin pregnancies in late preterm and term gestation.

METHODS

A retrospective study was performed on twin pregnancies delivered at Seoul National University Bundang Hospital from June 2003 to December 2020. Preterm births before 34 weeks of gestation were excluded, and only live births were analyzed. The patients were classified into four groups according to maternal age (<30, 30-34, 35-39, and ≥40 years). The primary outcome was the rate of cesarean section.

RESULTS

The median value of maternal body mass index, the rate of assisted reproductive technology, dichorionic twin pregnancy, preeclampsia, and gestational diabetes increased significantly according to the maternal age group (all p<0.05). Among a total of 2,075 twin pregnancies, the rates of cesarean section were 65, 74, 80, and 95% for groups with maternal age under 30, 30-34, 35-39, and ≥40 years, respectively (p<0.001). The cesarean section rates after a trial of labor were 22, 22, 28, and 63%, respectively (p=0.032). Maternal old age was an independent risk factor for cesarean section after a trial of labor in both nulliparous and multiparous women after adjusting for confounding factors.

CONCLUSIONS

The rate of cesarean section in twin pregnancies significantly increased as maternal age increased, even in multiparous women.

The impact of assisted reproductive technology in twin pregnancies complicated by intrahepatic cholestasis: a five-year retrospective study

Background

Intrahepatic cholestasis of pregnancy is one of the common complications during pregnancy, and ursodeoxycholic acid has been recommended as the first-line drug. However, if the assisted reproductive technology may increase adverse perinatal outcomes of twin pregnancies complicated by intrahepatic cholestasis is disputed, we aimed to investigate perinatal outcomes between twin pregnancies by assisted reproductive technology versus spontaneous conception, based on these women accepted ursodeoxycholic acid treatment.

Methods

From January 2014 to January 2019, we retrospectively analysed the clinical data of twin pregnant women with intrahepatic cholestasis, excluding those who did not receive ursodeoxycholic acid treatment. In total, 864 women were included, among whom 500 conceived by assisted reproductive technology and 364 conceived by spontaneous conception. The primary assessment for perinatal outcomes included premature birth, meconium-stained amniotic fluid, low Apgar score, neonatal intensive care unit and still birth, and secondary indicators were serum bile acid and liver enzymes level during medication, so we also finished subgroup analysis based on different elevated bile acid level and drug usage. The statistical analysis was performed by SPSS 22.0.

Results

The study demonstrated that compared to spontaneous conception, assisted reproductive technology conceived twin pregnancies diagnosed as intrahepatic cholestasis earlier (p = 0.003), and lower birth weight (p = 0.001), less incidence of preterm delivery (p = 0.000) and neonatal intensive care unit admission (p = 0.001), but the rate of meconium-stained amniotic fluid, low Apgar score and still birth have no statistic differences. Moreover, the subgroup analysis showed no significant difference in elevated bile acid levels and medication between assisted reproductive technology and spontaneous conception groups.

Conclusions

The assisted reproductive technology may increase the risk of early-onset intrahepatic cholestasis in twin pregnancies, but it does not seem to increase adverse effects on bile acid levels and perinatal outcomes. Regardless of ursodeoxycholic acid used alone or combination, the effect of bile acid reduction and improving perinatal outcomes in twin pregnancies is limited. Our conclusions still need more prospective randomized controlled studies to confirm.

Mode of birth in monochorionic versus dichorionic twin pregnancies: a retrospective study from a large tertiary centre in Germany

Background

Optimal mode of birth for twins, in particular monochorionic twins, has been the subject of much debate. This retrospective study compared maternal and newborn outcomes after vaginal birth in monochorionic and dichorionic twins, utilizing a large institutional database.

Methods

Retrospective analysis focusing on 98 monochorionic-diamniotic (MC-DA) and 540 dichorionic-diamniotic (DC-DA) twin births extracted from the perinatal database of a large German hospital. Pregnancies ≥36 weeks of gestation with two viable foetuses born between 2004 and 2014 divided into planned vaginal and planned caesarean delivery were included. Descriptive analysis was performed for maternal characteristics. Odds ratios (OR) with 95% confidences intervals (CI) tested the predictive effect of vaginal birth on neonatal and maternal outcomes.

Results

51.0% MC-DA and 46.7% DC-DA twin pregnancies were planned vaginal births and 44.0% MC-DA mothers and 43.7% DC-DA mothers actually gave birth vaginally. The overall rate of caesarean section (CS) during the years under observation was 79.6% for MC-DA and 77.0% for DC-DA pregnancies. There were no significant differences in neonatal outcome between the subsamples, although acidosis was observed more often in the second DC-DA twin and Apgar scores < 7 were observed more often in MC-DA twins.

Conclusion

Vaginal birth may be recommended as an option to women with monochorionic twins as no significant differences in outcomes were found between MC-DA and DC-DA twins. However, over half of planned vaginal twin births resulted in CS.

Maternal thyroid function in multiple pregnancies - a systematic review

BACKGROUND

The function of the thyroid gland during pregnancy undergoes physiological changes to ensure the proper amount of thyroid hormones for both the pregnant woman and the fetus. Multiple pregnancies (MP) are characterized by specific differences compared to single pregnancies, e.g., higher concentrations of human chorionic gonadotropin, which also affect thyroid function. The aim was to collect available knowledge on maternal thyroid function in MP.

METHODS

We have systematically searched three databases: the PubMed/MEDLINE, Scopus and the Cochrane Library. The last search was run on the 4th of August 2022. We included full-text original observational and experimental studies written in English. Case reports, editorials, letters, conference abstracts, reviews and meta-analyses were excluded. No time criterion was established. Studies were considered eligible if at least one maternal thyroid function test was performed and reported. Studies on MP with a co-existing mole were excluded. The risk of bias was assessed with the use of the AXIS tool. The qualitative synthesis of evidence was applied.

RESULTS

The search strategy resulted in the identification of 821 manuscripts. After removing duplicates, we screened the titles and abstracts of 552 articles, out of which 57 were selected for full-text analysis. Finally, 12 articles were included in the review. They were conducted in 6 different countries and published between the years 1997 and 2022. The number of examined women with MP ranged from 9 to 1 626.

DISCUSSION AND CONCLUSIONS

Thyroid function differs between women with MP and SP. Scarce data are available on the topic, but MPs are most likely characterized by higher HCG levels, which influences thyroid-stimulating hormone and free thyroid hormone levels. These differences are mainly expressed in the 1st trimester of pregnancy. Separate population-based reference ranges are needed to correctly diagnose thyroid diseases in MP and to avoid unnecessary treatment. Further research is needed to fill the knowledge gaps.

Management of Intrahepatic Cholestasis of Pregnancy: Recommendations of the Working Group on Obstetrics and Prenatal Medicine - Section on Maternal Disorders

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease specific to pregnancy. The cardinal symptom of pruritus and a concomitant elevated level of bile acids in the serum and/or alanine aminotransferase (ALT) are suggestive for the diagnosis. Overall, the maternal prognosis is good. The fetal outcome depends on the bile acid level. ICP is associated with increased risks for adverse perinatal outcomes, including preterm delivery, meconium-stained amniotic fluid, and stillbirth. Acute fetal asphyxia and not chronic uteroplacental dysfunction leads to stillbirth. Therefore, predictive fetal monitoring is not possible. While medication with ursodeoxycholic acid (UDCA) improves pruritus, it has not been shown to affect fetal outcome. The indication for induction of labour depends on bile acid levels and gestational age. There is a high risk of recurrence in subsequent pregnancies.

Trends in Prevalence of Diabetes among Twin Pregnancies and Perinatal Outcomes in Catalonia between 2006 and 2015: The DIAGESTCAT Study

The aims of our study were to evaluate the trends in the prevalence of diabetes among twin pregnancies in Catalonia, Spain between 2006 and 2015, to assess the influence of diabetes on perinatal outcomes of twin gestations and to ascertain the interaction between twin pregnancies and glycaemic status. A population-based study was conducted using the Spanish Minimum Basic Data Set. Cases of gestational diabetes mellitus (GDM) and pre-existing diabetes were identified using ICD-9-CM codes. Data from 743,762 singleton and 15,956 twin deliveries between 2006 and 2015 in Catalonia was analysed. Among twin pregnancies, 1088 (6.82%) were diagnosed with GDM and 83 (0.52%) had pre-existing diabetes. The prevalence of GDM among twin pregnancies increased from 6.01% in 2006 to 8.48% in 2015 (p < 0.001) and the prevalence of pre-existing diabetes remained stable (from 0.46% to 0.27%, p = 0.416). The risk of pre-eclampsia was higher in pre-existing diabetes (15.66%, p = 0.015) and GDM (11.39%, p < 0.001) than in normoglycaemic twin pregnancies (7.55%). Pre-existing diabetes increased the risk of prematurity (69.62% vs. 51.84%, p = 0.002) and large-for-gestational-age (LGA) infants (20.9% vs. 11.6%, p = 0.001) in twin gestations. An attenuating effect on several adverse perinatal outcomes was found between twin pregnancies and the presence of GDM and pre-existing diabetes. As a result, unlike in singleton pregnancies, diabetes did not increase the risk of all perinatal outcomes in twins and the effect of pre-existing diabetes on pre-eclampsia and LGA appeared to be attenuated. In conclusion, prevalence of GDM among twin pregnancies increased over the study period. Diabetes was associated with a higher risk of pre-eclampsia, prematurity and LGA in twin gestations. However, the impact of both, pre-existing diabetes and GDM, on twin pregnancy outcomes was attenuated when compared with its impact on singleton gestations.

Maternal and Perinatal Factors Associated With Twin Pregnancies in Ecuador

There are few studies on twins in Ecuador and Latin America. It requires a better understanding of perinatal conditions, especially from an ethnic perspective. This work aims to assess perinatal factors related to twin pregnancy in Ecuadorian Mestizo individuals. We performed an epidemiological, observational and cross-sectional study at the Hospital San Francisco and Hospital Nueva Aurora in Quito, Ecuador, from November 2019 to January 2020. It included 203 newborns from twin pregnancies, including mothers with and without pathological history. The average gestational age was 31 weeks, and the APGAR score at first minute was 6.86, with significant differences. Regarding the metabolic balance, the mean pH was 6.14; and bicarbonate was 11.57, with significant differences. Twins had intrauterine growth restriction in 6.9% of cases, with significant differences (p = .003); 81.4% required supplemental oxygen, with significant differences (p = .002); 93% required noninvasive mechanical ventilation (NIMV), with significant differences (p = . 003); 93% required inotropic and sedation, with substantial differences; 69% required antibiotics (≥21 days), with significant differences (p = .014); and 17.2% needed between 8 to 14 days of hospitalization, and 51% more than 28 days, with significant differences. The studied mothers' demographic profile was mostly Mestizos, with an average age of 32 years, and 93% had a poverty status. Most of the twins were diamniotic monochorial and were discordant twins. It found jaundice, premature anemia and sepsis in 100% of twins and hyaline membrane disease in 89.66% of twins. Twins of women with relevant prenatal care had more premature births (30.4 ± 2.6 weeks), more acid-base imbalance, APGAR at ≥7 min in 90% of cases, and patent ductus arteriosus in all. There was also a greater need for double intensive phototherapy than twins of healthy women.

Micronutrients in Multiple Pregnancies-The Knowns and Unknowns: A Systematic Review

Maternal diet and nutritional status are of key importance with regard to the short- and long-term health outcomes of both the mother and the fetus. Multiple pregnancies are a special phenomenon in the context of nutrition. The presence of more than one fetus may lead to increased metabolic requirements and a faster depletion of maternal macro- and micro- nutrient reserves than in a singleton pregnancy. The aim of this systematic review was to gather available knowledge on the supply and needs of mothers with multiple pregnancies in terms of micronutrients and the epidemiology of deficiencies in that population. It was constructed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA). The authors conducted a systematic literature search with the use of three databases: PubMed/MEDLINE, Scopus and Embase. The last search was run on the 18 October 2020 and identified 1379 articles. Finally, 12 articles and 1 series of publications met the inclusion criteria. Based on the retrieved studies, it may be concluded that women with multiple pregnancies might be at risk of vitamin D and iron deficiencies. With regard to other microelements, the evidence is either inconsistent, scarce or absent. Further in-depth prospective and population studies are necessary to determine if nutritional recommendations addressed to pregnant women require adjustments in cases of multiple gestations.

Correction to: Maternal complications in twin pregnancies in Finland during 1987–2014: a retrospective study

An amendment to this paper has been published and can be accessed via the original article.

Obstetric outcomes of twin pregnancies presenting with a complete hydatidiform mole and coexistent normal fetus: a systematic review and meta-analysis

BACKGROUND

Epidemiological data on obstetric and oncologic complications in twin pregnancies combining a complete hydatidiform mole (CHM) coexisting with a normal fetus and placenta are limited.

OBJECTIVES

To evaluate perinatal and obstetric outcomes for mother and fetus and risk of gestational trophoblastic neoplasia (GTN) in twin pregnancies including a CHM.

SEARCH STRATEGY

PubMed, MEDLINE and EMBASE and the grey literature were searched for articles published between May 1980 and May 2019 using a protocol designed a priori and registered on PROSPERO (CRD42018112524).

SELECTION CRITERIA

Observational cohort studies of four or more cases confirmed by histopathology and providing data on pregnancy outcomes and GTN.

DATA COLLECTION AND ANALYSIS

Two reviewers independently reviewed abstracts and full-text articles. The quality of the studies was assessed with the Newcastle-Ottawa scale and a meta-analysis was performed.

MAIN RESULTS

Of the 344 abstracts identified, 14 studies (244 cases) met the eligibility criteria. The incidence of maternal complication in ongoing pregnancies was 80.8% and included vaginal bleeding, hyperthyroidism and pre-eclampsia. There were overall 91 (50%) live births in ongoing pregnancies and 83 (34%) of the total cases were subsequently diagnosed with GTN. Substantial and significant (P < 0.001) heterogeneity was found for the incidence of preeclampsia indicating variability in reporting the incidence of some obstetric complications between studies.

CONCLUSIONS

Patients diagnosed with a twin pregnancy combining a CHM and an apparently normal fetus have a high risk of perinatal complications, low live-birth rates and around a third of them will develop a GTN and should be managed by specialised multidisciplinary teams.

TWEETABLE ABSTRACT

Our study indicates a high rate of obstetric and oncologic complications in patients presenting with a complete hydatidiform mole and coexistent normal fetus.

Perinatal outcomes in Finnish twins: a retrospective study

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.