Determinants of Perinatal Mortality and Serious Neonatal Morbidity in the Second Twin

Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada
Obstetrics and Gynecology (Impact Factor: 5.18). 10/2006; 108(3 Pt 1):556-64. DOI: 10.1097/01.AOG.0000227747.37184.0a
Source: PubMed


To identify potential determinants of perinatal mortality and neonatal morbidity among second twins relative to first twins.
A retrospective cohort design was used to study twin deliveries in Nova Scotia from 1988 to 2002. Monoamniotic or conjoined twins and twin pairs with major congenital anomaly or antepartum fetal death of either twin were excluded. The primary outcome was a composite measure of perinatal mortality and neonatal morbidity, including birth asphyxia, respiratory distress, neonatal trauma, and infection. Risk of adverse outcome of second twins relative to first-born co-twins was determined by matched-pair analysis.
Of 1,542 twin pairs, the second twin was at greater risk of composite adverse outcome (relative risk [RR] 1.62, 95% confidence interval [CI] 1.38-1.9) than the first twin. This excess risk was evident independent of presentation, chorionicity, or infant sex but was associated with planned vaginal delivery, birth weight discordance, and prolonged interdelivery interval. Term second twins were less likely to suffer excess morbidity with elective cesarean (RR 1.0, 95% CI 0.14-7.10) than with planned vaginal delivery (RR 3.0, 95% CI 1.47-6.11). The major contributors to neonatal morbidity in the second twin were birth asphyxia at 37 weeks or later and respiratory distress syndrome at less than 37 weeks.
The second twin is at greater risk of adverse perinatal outcome than the first twin, independent of presentation, chorionicity, or infant sex. Planned vaginal delivery, birth weight discordance, and prolonged interdelivery interval increase this infant risk. Elective cesarean delivery at term may improve perinatal outcome for the second twin. However, the number of cesarean births required to prevent one case of composite adverse outcome, assuming causality, was 33.

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    • "The second twin presents non-vertex in approximately 40% of twin gestations prior to the onset of labour [4] and fetal presentation and mode of delivery of the second twin are known determinants of adverse neonatal outcomes [2,5,6]. Intrapartum complications that place the second twin at risk following vaginal delivery of the first twin include placental abruption, intrapartum haemorrhage, cord prolapse, difficulty in monitoring the fetal heart rate and fetal bradycardia [7]. "
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    ABSTRACT: Mode of delivery remains a topic of debate in vertex/non-vertex twin pregnancies. We used the WHO Global Survey dataset to determine the risk of adverse maternal/perinatal outcomes associated with presentation of the second twin, following vaginal delivery of a vertex first twin. We analysed a derived dataset of twin pregnancies >=32 weeks gestation where the first twin was vertex and delivered vaginally. Maternal, delivery and neonatal characteristics and adverse outcomes were reported by presentation of the second twin. Logistic regression models (adjusted for maternal and perinatal confounders, mode of delivery and region) were developed to determine odds of adverse outcomes associated with presentation. 1,424 twin pregnancies were included, 25.9% of these had a non-vertex second twin and Caesarean was more common in non-vertex presentations (6.2% vs 0.9%, p < 0.001). While the odds of Apgar < 7 at 5 minutes were higher in non-vertex presenting second twins (16.0% vs 11.4%, AOR 1.42 95%CI 1.01-2.00), the odds of maternal ICU admission (4.6% vs 1.7%, AOR 1.30, 95%CI 0.88-1.94), blood transfusion (6.0% vs 3.4%, AOR 1.23, 95%CI 0.67-2.25), stillbirth (7.6% vs 4.7%, AOR 1.15, 95%CI 0.72-1.73), early neonatal death (3.8% vs 2.1%, AOR 1.68, 95%CI 0.96-2.94), and NICU admission (26.6% vs 23.2%, AOR 0.93, 95%CI 0.62-1.39) were not. After a vaginal delivery of a vertex first twin, non-vertex presentation of the second twin is associated with increased odds of Apgar <7 at 5 minutes, but not of other maternal/perinatal outcomes. Presentation of the second twin is not as important a consideration in planning twin vaginal birth as previously considered.
    BMC Pregnancy and Childbirth 01/2014; 14(1):55. DOI:10.1186/1471-2393-14-55 · 2.19 Impact Factor
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    • "Especially second twins are at increased risk of neonatal mortality and morbidity; and this does not only depend on the mode of delivery (Wen et al. 2004; Yang et al. 2005; Armson et al. 2006; Bjelic-Radisic et al. 2007; Herbst and Kallen 2008). A signifi cant higher morbidity rate has been continuously observed in second twins compared with fi rst twins (Caukwell and Murphy 2002; Correspondence: F. J. M. E. Roumen, Department of Obstetrics and Gynaecology, Atrium Medical Centre Parkstad, Postbox 4446, 6401 CX Heerlen, the Netherlands. "
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    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.
    Journal of Obstetrics and Gynaecology 07/2012; 32(5):453-7. DOI:10.3109/01443615.2012.669431 · 0.55 Impact Factor
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    • "Meta-analysis did not evidence significant increased adverse neonatal outcome of both twins after vaginal delivery in comparison with cesarean 8,9. Conversely, some suggest systematic planned cesarean delivery for all twin gestations could protect second twins from increased neonatal mortality and morbidity 10,11. Indeed, cesarean delivery may increase the prevalence of fetal and maternal complications 12. Accordingly, additional research on the risk of hypoxia during labor in second twins, and determining whether or not cesarean section may reduce the risk of hypoxia is needed. "
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    ABSTRACT: To compare umbilical arterial gas parameters in the second twin of twin pregnancies according to the mode of delivery. We retrospectively analyzed the medical records of twin deliveries after 34 weeks of gestation for 3 years. Excluding the cases which underwent emergency cesarean delivery during trial of labor, a total of 79 twin gestations had umbilical arterial blood gas values available and were and divided into cesarean delivery group (N=40) and vaginal delivery group (N=39). The mean differences of umbilical arterial blood parameters and the Apgar score between the first and second twin in each pregnancy were compared according the mode of delivery. The differences of umbilical arterial gas parameters between twin siblings showed no significant difference according to the mode of delivery. With regard to the 1 minute and 5 minute Apgar scores, the differences between twin siblings are significantly increased in vaginal delivery group compared to cesarean delivery group (p=0.048, and p=0.038, respectively). In comparing the 28 cases delivered vaginally with an inter-twin delivery interval < 10 minutes and 40 cases delivered by cesarean section, no significant differences were observed in the umbilical arterial gas parameters and Apgar scores. The inter-twin umbilical arterial blood gas parameters according to the mode of delivery showed no difference. For twin deliveries, it is relatively safe to plan for a vaginal delivery, but an effort should be made to reduce the inter-twin delivery interval time.
    International journal of medical sciences 10/2011; 8(8):643-8. · 2.00 Impact Factor
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