Twin pregnancy: report of a case with 35 days between deliveries

A prolonged interval between the births of the first and second of twins is rare and only a few reports are found in the literature. This paper reports a patient with twins with an interval of 35 days between the births of the 2 infants, who, due to prematurity and complications, were both stillborn. Three months later the patient became pregnant again and after an uneventful pregnancy gave birth to a healthy baby. However, due to breech presentation an abdominal delivery was undertaken.     

Combined vaginal-cesarean delivery of twins: risk factors and neonatal outcome – a single center experience

Objective: We aimed to characterize risk factors for combined twin delivery and assess neonatal outcome.

Methods: This was a retrospective cohort study of all women admitted for trial of labor (TOL) with twin gestation, in a single, tertiary, university-affiliated medical center. Eligibility was limited to gestations with twin A delivered vaginally.

Results: During the study period, 44?263 women delivered in our center, of whom 1307 (2.9%) delivered twins. Overall, 221 out of 247 women (89.5%) undergoing TOL delivered twin A vaginally. Parturients who delivered twin B by cesarean delivery (n?=?23) were compared with those delivered twin B vaginally (n?=?198). Multivariate analysis demonstrated that risk factors combined delivery were included non-cephalic twin B at admission (aOR 11.5, 95% CI 3.8–34.9, p?<?0.001) or after delivery of twin A (aOR 17.7, 95% CI 6.6–47.2, p?<?0.001), and dichorionic–diamniotic (DCDA) twins (aOR 8.9, 95% CI 1.8–44.0, p?=?0.008). Spontaneous version of a cephalic twin B was not found to increase the risk (above the baseline risk of non-cephalic twin B) for combined delivery. Combined delivery was associated with slightly higher risk for hemorrhagic-ischemic encephalopathy of twin B (4.3% versus 0%, p?=?0.003).

Conclusion: Non-cephalic twin B at admission or following delivery of twin A poses higher risk for combined delivery. Neonatal outcome of twin B following combined delivery are comparable with those of vaginal delivery.     

Is the risk of obstetric anal sphincter injuries increased in vaginal twin deliveries?

Objective: Vaginal twin deliveries have a higher rate of intrapartum interventions. We aimed to determine whether these characteristics are associated with an increased rate of obstetric anal sphincter injuries compared with singleton.

Study design: Retrospective study of all twin pregnancies undergoing vaginal delivery trial was conducted from January 2000–September 2014. Sphincter injury rate compared with all concurrent singleton vaginal deliveries. Multivariable analysis was used to determine twin delivery association with sphincter injuries while adjusting for confounders.

Results: About 717 eligible twin deliveries. Outcome was compared with 33?886 singleton deliveries. Twin pregnancies characterized by a higher rate of nulliparity (54.8% versus 49.5%, p?=?0.005), labor induction (42.7% versus 29.1%, p?<?0.001), and instrumental deliveries (27.5% versus 16.7%, p?<?0.001), lower gestational (34.6?±?3.3 versus 38.8?±?2.3, p?<?0.001), and lower birth weight. Total breech extraction was performed in 29.0% (208/717) of twin deliveries. Overall obstetric sphincter injury rate was significantly lower in the twins group (2.8% versus 4.4%, p?=?0.03, OR?=?0.6, 95% CI 0.4–0.9), due to lower rate of 3rd degree tears in twins versus singletons (2.2% versus 4.0%, p?=?0.02), rate of 4th degree tears similar among the groups (0.6% versus 0.4%, p?=?0.5). In multivariable analysis, sphincter injuries were associated with nulliparity (OR?=?3.9, 95% CI 3.4–4.5), forceps (OR?=?6.8, 95% CI 5.8–7.8), vacuum (OR?=?2.9, 95% CI 2.5–3.3), earlier gestational age (OR?=?0.2, 95% CI 0.1–0.3), episiotomy (OR?=?0.8, 95% CI 0.7–0.9), and birth weight over 3500?g (OR?=?1.8, 95% CI 1.6–2.0). However, the association between twins (versus singletons) deliveries and sphincter injuries was lost after adjustment for delivery gestational age (OR?=?0.7, 95% CI 0.4–1.2).

Conclusion: Despite a higher rate of intrapartum interventions, the rate of sphincter injuries is lower in twins versus singleton deliveries, mainly due to a lower gestational age at delivery.     

Delayed second twin delivery: benefits and risks

Background: An increasing number of reports describe the delayed second twin delivery for days, or weeks with good results in the majority of the cases, and different survival rate between centers, without reported randomized controlled trials (RCTs).

Objectives: This study was designed to evaluate the suggested management of the delayed second twin delivery in the Sabah Maternity Hospital regarding its outcome, possible risks, and benefits.

Patients and methods: Forty-seven twin pregnancies with preterm labor (PTL) of the first fetus between 20–30 weeks, and delayed delivery of the second twin were included in this study. Studied women signed informed consent about the possible risks of keeping the live fetus in the hostile intrauterine environment, and benefits of the prolonged gestation for the second twin. Throughout the conservative treatment of the second twin, the studied women were hospitalized with regular follow up for infections, consumptive coagulopathy parameters, and wellbeing of the second twin.

Results: There was significant difference in the gestational age at delivery between the first and second twin (22.6?±?3.4 versus 34.3?±?2.5 weeks; respectively, p?=?.01). There was significant difference in the birth weight between the first and second twin (435?±?91.2 versus 1472?±?61.5?g; respectively, p?=?.004). The rate of the cesarean delivery was significantly high during delivery of the second twin compared with the first twin (23.4% (11/47) versus 0% (0/47); respectively, p?=?.0001) with high survival rate for the second twin (85.1% (40/47)) after the delayed second twin delivery.

Conclusions: The birth weight, the gestational age, and the survival rate of the studied second twin significantly increased after the suggested management of the delayed second twin delivery.     

双胎妊娠适宜的分娩时机与分娩方式

双胎妊娠的分娩仍是产科最具挑战性的事件。双胎妊娠的分娩时机与分娩方式应根据孕周、当地的医疗条件（产科条件是否为区域性医疗中心、新生儿重症监护病房救治水平等）及母胎的具体情况（绒毛膜性,有无并发症或合并症、复杂双胎等,甚至患者经济情况）等综合考虑,制定适宜的个体化分娩方案。对于无并发症及合并症的双绒毛膜双羊膜囊双胎,38～39+6周分娩较适宜;对于无并发症及合并症的单绒毛膜双羊膜囊双胎,适宜的分娩时机为37～38周;复杂性双胎（如单羊膜囊双胎、双胎输血综合征、选择性胎儿生长受限、贫血-红细胞增多序列征、单绒毛膜双胎减胎术或宫内治疗后）,需结合孕妇及胎儿的具体情况制定个体化的分娩方案,分娩时机为32～36周。双胎择期剖宫产指征包括单羊膜囊双胎、连体双胎（除外早中孕者）、第一胎非头位、具有单胎的剖宫产指征者,除此之外,均可考虑阴道分娩。     

Transvaginal cervical length measurement at 22- to 26-week pregnancy in prediction of preterm births in twin pregnancies

Objective: To investigate the predictive role of transvaginal ultrasonographic measurement of cervical length (CL) at 22–26 weeks of gestation in determining preterm deliveries in twin pregnancies.

Methods: The study included 150 twin pregnancies. CL was measured by transvaginal ultrasonography at 22–26 weeks. Signs of preterm labor, ruptured membranes, vaginal bleeding, patients with systemic disease, and cervical incompetencies were excluded. The patients had monthly digital cervical examinations but no routine TVCL ultrasound examinations. The primary outcome was spontaneous preterm birth at before 37 weeks of gestation.

Results: Ninety-two percent of twin pregnancies delivered by cesarean section and 16% babies had a neonatal intensive care unit requisitioned. Ninety-two patients were delivered in smaller than 37 gestational weeks and the mean CL measurement (CLM) was <37.64?±?6.23?mm. According to the ROC curve analysis, CLM was found to be a discriminating parameter in patients. The area under the curve, cutoff values, sensitivity, and specificity were 0.794, 34.95, and 70–80%; respectively (p?=?0.029).

Conclusion: In women with twin pregnancy, the risk of preterm birth can be evaluated using the ultrasonographic measurement of CL at 22–26 weeks of gestation.     

双胎阴道分娩的管理

双胎妊娠属于高危妊娠范畴,常合并其他妊娠并发症及合并症,母儿不良结局发生率高。双胎妊娠如何选择适宜的分娩时机和分娩方式仍是产科最具挑战性的事件之一。文章以国内外双胎妊娠阴道分娩的最新文献、指南为基础,结合双胎妊娠阴道分娩经验进行阐述,旨在促进自然分娩,为有效控制剖宫产率提供帮助。     

Delayed-interval delivery in twin pregnancies: report of three cases and literature review

Introduction: Delayed delivery is sometimes performed in selected multifetal pregnancies when the first twin birth occurs inevitably. The aim of this procedure is to improve the prognosis and decrease the morbidity and mortality of the second twin. We report three cases of delayed-interval delivery of dichorionic–diamniotic twin pregnancies assisted in our center between 2015 and 2017. After the first twin delivery, the second twin was left in utero and the patient received tocolytic therapy and antibiotics. Cervical cerclage was not performed.

Results: Our patients were admitted between 21?+?3 and 23?+?6 weeks of gestation. We achieved an average interval delivery of 6.33 d. Four out of six twins did not survive the delayed interval procedure. The average stay of the first and second twins that were admitted to the neonatal intensive care unit (NICU) was of 72?d (28–116) and 39.5?d (12–67), respectively. The first twin birth was vaginal in all cases, while the second twin delivery was performed by cesarean section in two out of our three patients. Our neonatal results are not favorable, probably due to the extreme prematurity.

Conclusions: Delayed delivery of the second twin before 28 weeks of gestation can be an alternative for the obstetrician since it could prolong the pregnancy until a gestational age which confers a better prognosis and a better perinatal outcome for the second twin.     

Effect of inter‐twin delivery interval on umbilical artery pH and Apgar score in the second twin

Background

To examine the effect of inter‐twin delivery interval on umbilical artery pH and Apgar score of the second twin after vaginal delivery of the first twin.

Methods

Retrospective study conducted at a single teaching hospital. All pregnant women with twin gestation who delivered the first twin vaginally at more than 24 weeks between 1995 and 2015 were included. Major malformations and intrauterine deaths of one or both twins were excluded. Women were divided into those who had an inter‐twin delivery interval of less than 30 minutes (group 1) or 30 minutes or more (group 2). Primary outcome was umbilical artery pH less than 7.1 and/or Apgar score less than 7 at 5 minutes of the second twin. Generalized linear regression with log was performed to evaluate the association with delivery interval.

Results

Of 88 145 deliveries during this period, 1955 (2.2%) were twins. Overall, 713 twin pregnancies, 596 (83.6%) in group 1 and 117 (16.4%) in group 2, were eligible and included. Mean inter‐delivery interval was 11.0 ± 6.5 and 52.5 ± 31.5 minutes in groups 1 and 2, respectively. After adjusting for variables found significantly different between the groups in univariate analysis, inter‐delivery interval of less than 30 minutes or 30 minutes or more was not a significant risk factor for pH less than 7.1 and/or Apgar less than 7 (P = .91). The cesarean rate for delivery of the second twin after vaginal delivery of the first twin was 4.3% overall, with a higher rate among group 2 compared with group 1 (18.2% and 3.2%, respectively; P = .001).

Conclusions

The second twin's Apgar score and cord artery pH are probably not affected when the inter‐twin delivery interval exceeds 30 minutes.     

Dizygotic twin delivery following in vitro fertilization and transfer of thawed blastocysts cryopreserved at day 6 and 7

OBJECTIVE: To report the first conception and delivery following transfer of thawed human blastocysts maintained in extended in vitro culture with cryopreservation at day 6 and 7. DESIGN: Case report. SETTING: Major urban infertility referral center. PATIENT(S): A 26-year-old woman with pelvic endometriosis and two prior unsuccessful in vitro fertilization/embryo transfer (IVF-ET) attempts. INTERVENTION(S): The patient underwent controlled ovarian hyperstimulation using a combined FSH + hMG protocol, and 24 oocytes were retrieved. MAIN OUTCOME MEASURE(S): Dizygotic twin delivery after IVF and intracytoplasmic sperm injection (ICSI), assisted embryo hatching, and ultrasound-guided transfer of cryopreserved blastocysts. RESULT(S): After three embryos were subjected to assisted hatching, they were transferred fresh on day 3, but no implantation occurred. All nontransferred embryos (n = 11) were observed during extended in vitro culture and three blastocysts were selected for cryopreservation on day 6 and 7; thaw and transfer occurred the following month and a pregnancy was achieved. Dizygotic twins (female/female) were delivered by cesarean in the early third trimester. CONCLUSION(S): Substantial advancements have been made in the field of embryo cryogenics and in vitro fertilization, but controversy remains regarding the value of freezing late-developing human blastocysts. Here we describe the first reported live births with IVF after extended in vitro culture and cryopreservation at day 6 and 7 after fertilization.     

Retrospective study of outcome on vaginal and abdominal delivery in twin pregnancy in which twin 1 is presenting by the breech

We retrospectively reviewed the perinatal outcome of twin pregnancies cohere the first baby was presenting by the breech. 21 were delivered vaginally and 37 abdominally. Differences in perinatal outcome, as measured by Apgar score and mortality, were not apparently different. Received: 24 March 1997 / Accepted: 4 September 1997     

Neonatal hypoxia of the second twin after vaginal delivery of the first twin: what matters?*

Objective: Optimal management of twin deliveries is controversial. We aimed to assess potential risk factors correlated to the development of hypoxia in the second twin after vaginal delivery of the first twin.

Study design: This is a retrospective observational study including diamniotic twin pregnancies delivering at our Institution at 35 weeks of gestational age or more, weighing ≥1800?g. Hypoxia was defined as at least one of the following: Apgar score <5 at 10 minute, neonatal resuscitation for >10 minutes, neonatal acidosis (pH ≤7 and/or BE ≥12?mmol/L).

Results: A number of 275 diamniotic twin pregnancies met the inclusion criteria and were divided within the following groups: (1) second twin not developing neonatal hypoxia (n?=?265); and (2) second twin developing neonatal hypoxia (n?=?10). The rate of second twins with neonatal hypoxia during the study period was 3.6% (10/275). Abnormal cardiotocography during the intertwin delivery interval, defined as ACOG category III, was significantly correlated to second twin hypoxia. Of interest, there was no significant difference in the intertwin delivery interval between the study groups. In addition, breech presentation of the second twin did not show to be a risk factor for neonatal hypoxia. None of the second twins developing neonatal hypoxia was reported to have encephalopathy (follow up of at least 24 months). At multivariate analysis, only abnormal cardiotocography was an independent risk factor for second twin hypoxia (OR 17.8, 95% CI 4.1–77.2).

Conclusions: In our study, neonatal hypoxia was significantly correlated to abnormal cardiotocography, while intertwin delivery interval was not correlated to the development of this adverse neonatal outcome.     

Healthy twin delivery after day 7 blastocyst transfer coupled with assisted hatching

OBJECTIVE: To report a normal twin delivery after transfer of two fresh day 7 blastocysts. DESIGN: Case report. SETTING: Private infertility clinic. PATIENT(S): A 35-year-old woman with a 6-year history of primary infertility with significant pelvic adhesions. INTERVENTION(S): Review of individual IVF-ET therapy cycle. MAIN OUTCOME MEASURE(S): Full-term delivery after day 7 blastocyst transfer. RESULT(S): During the patient's first IVF-ET cycle, the decision was made to undertake blastocyst transfer after extended culture. No blastocysts had formed until late on day 6, by which time the patient had been hospitalized with a renal stone. Subsequently, on day 7, the patient was asymptomatic and presented for embryo transfer, and after assisted hatching, two expanded blastocysts were transferred to her uterus under ultrasound guidance. After confirmation of implantation of a viable twin, pregnancy was uneventful with no obstetrical complications, and a dizygotic twin was delivered vaginally at 38 weeks of gestation. CONCLUSION(S): Few reports have been made regarding viability of more slowly developing blastocysts; however, this case indicates that blastocysts that did not fully expand until day 7 of extended in vitro culture are still able to implant after superovulation and IVF-ET therapy. Assisted hatching of these embryos may have been beneficial in achieving this successful outcome by hastening the blastocyst hatching, allowing more rapid contact with the endometrium.     

The influence of obstetric variables on school achievement,intelligence and neuropsychological development in a sample of Spanish twins at the age of six: a retrospective study

Objectives: The increasing number of multiple pregnancies in recent years has raised a particular concern about the problems associated to these pregnancies. It still remains unclear whether twin deliveries, as currently conceived, provide the same future health chances to both fetuses. In this regard, it is worth mentioning that the effects of obstetric and neonatal care beyond the perinatal period have not often been evaluated. The main objective of this research was to analyze the impact of obstetric and perinatal variables on postnatal neuropsychological development, intelligence and school achievement of twin children.

Methods: We conducted a cross-sectional and observational study on 62 pairs of 6-year-old twins, who were on their first year of primary education. All 124 children and their mother were individually assessed and perinatal clinical data were collected. A stratified multivariate analysis was performed using multiple linear regressions.

Results: The type of birth was the best predicting variable, so that the best results were achieved in children born in spontaneous vaginal deliveries. Comparatively, however, poorer scores were seen in males second twins born by the vaginal route in spatial structuring, non-verbal development and total development areas, especially in case of delivery before 37 weeks.

Conclusions: Our study confirms the impact of some obstetric variables on school achievement and psychological development of twins.     

Induction of labor in twin pregnancies with oral misoprostol versus vaginal dinoprostone – is it effective and safe?

Objective: To compare the effectiveness and safety of oral misoprostol versus vaginal dinoprostone for the induction of labor in twin pregnancies.

Methods: All twin pregnancies ≥?34 weeks 0 days that were induced with either misoprostol or dinoprostone in St. Hedwig Hospital between 2002 and 2013 were included in this retrospective study. Length of induction, mode of delivery, maternal and neonatal outcomes were compared between the two groups.

Results: After identifying 186 twin mothers matching the inclusion criteria, 154 women were induced with misoprostol (group A) and 32 with dinoprostone (group B). There were no differences in demographic data between the groups. Rates of successful vaginal delivery (53.9% versus 56.3%) and length of induction to delivery (30.2?h versus 26.9?h) were also similar. There were slightly higher rates of postpartum hemorrhage in group B (16.6% versus 10.8%), but without reaching statistical significance. Neonatal outcomes regarding umbilical artery pH <7.20 and one minute Apgar also were without significant differences.

Conclusions: Study data indicate that oral misoprostol and vaginal dinoprostone are similarly effective and safe for the induction of labor in twin gestations. Further trials with larger series are needed to confirm these results.     

What is the effect of intertwin delivery interval on the outcome of the second twin delivered vaginally?

Objective: Optimal management of twin deliveries is controversial. We aimed to assess if intertwin delivery interval, after vaginal delivery of the first twin, may have an influence on adverse neonatal outcomes of the second twin

Study design: This is a retrospective observational study including diamniotic twin pregnancies with vaginal delivery of the first twin, between January 2000 and July 2017. Inclusion criteria were diamniotic pregnancies and vaginal delivery of the first twin. We excluded higher twin order, monoamniotic pregnancies, cesarean delivery of the first twin and patients with missing data.

Results: A number of 400 diamniotic twin pregnancies met the inclusion criteria and were divided, considering intertwin delivery interval into (1) ≤30 minutes (n?=?365); and (2) >30?minutes (n?=?35). Considering the two study groups, maternal and first twin characteristics and outcomes were similar. Second twin reported higher incidence of cesarean section and vacuum delivery, but similar incidence of neonatal adverse outcomes, in case of intertwin interval >30 minutes. At multivariate analysis, a difference between second and first twin weight ≥25% was correlated to neonatal adverse outcome, while we did not found this correlation with a cut-off of 30 minutes.

Conclusions: In our study, growth discrepancy between twins was significantly correlated to adverse neonatal outcomes, while intertwin delivery time was not an influencing factor. So, in line with this result, in our clinical practice, we do not use a fixed time in which both twins should be delivered, neither in monochorionic nor in dichorionic pregnancies, when fetal wellbeing was demonstrated during labor.     

Management of Nonvertex Second Twin

Objectives

The objective of the current study is to compare outcomes of twin pregnancies with attempted labor and active second-stage management with twin pregnancies delivered by planned cesarean delivery.

Material and Methods

Two hundred and eighty-three patients with twin pregnancy meeting the inclusion criteria were reviewed. They were followed for success of ECV and/or IPV in planned vaginal group and abdominal mode of delivery. Fetal outcome was assessed by APGAR score of both twins as well as NICU admission, if needed.

Results

Out of 283 patients, 116 patients (40.9 %) had planned cesarean section, and 167 patients (59.01 %) had planned vaginal delivery. Out of 167 patients, 148 patients (88.6 %) had a vagi nal delivery of both twins. ECV was successful in 36 patients (25.3 %), and IPV was successful in 102 (95.3 %). IPV failed in five patients (4.6 %), and hence resorted to emergency cesarean section. There was no significant difference in the rates of twin B having a 5-min Apgar score lower than 7 or an arterial cord pH below 7.20 in both the groups. Among the patients in the planned vaginal delivery group, the cesarean delivery rate was 8.3 %, out of which combined vaginal—cesarean delivery rate was 4.6 %.

Conclusion

Active second-stage management is associated with neonatal outcomes similar to those with planned cesarean delivery and a low risk of combined vaginal—cesarean delivery.     

Relative birth weight in twins

A total of 579 sets of twins delivered in an obstetric population of 26,111 over a 10-year period were studied to reassess the veracity of the commonly held opinion that the first twin delivered is usually the heavier. Among the 579 sets of twins, 32 (5%) were of equal weight, while in 247 (42%) cases, twin I was heavier than twin II. In 235 (41%) cases, twin II was larger than twin I, in 65 (11%) the weight could not be compared. The mean birth weight of twin I was 2440 g, while that of twin II was 2410 (P greater than 0.05). Thus, even though twin I had the weight advantage more often than twin II, the difference is not statistically significant (t = 0.431).