Twin Pregnancy: Prematurity and Perinatal Mortality

An 8-year (1976-1984) retrospective analysis was undertaken of the management and outcome of 245 twin pregnancies delivered at Flinders Medical Centre, Adelaide. The incidence of twin delivery was 1 in 69 with a perinatal mortality of 85.7 per 1,000 total births. Amongst 42 perinatal deaths, 28 were associated with preterm labour at or before 28 weeks' gestation. If bed rest in hospital is to be implemented as a possible means of improving perinatal outcome in twin pregnancy it needs to be effected between 21 and 28 weeks' gestation; there is no rational theoretical basis for hospitalization beyond this time.     

Causes and consequences of recent increases in preterm birth among twins.

OBJECTIVE: To examine the causes and consequences of the recent increase in preterm birth among twins. METHODS: We studied all twin births among residents of the province of Nova Scotia, Canada, between 1988 and 1997. Rates of preterm birth, preterm labor induction, preterm cesarean, small-for-gestational age (SGA), respiratory distress syndrome (RDS), stillbirth, perinatal mortality, and infant mortality were compared between past and more recent years. Changes in perinatal mortality were examined using logistic regression to adjust for the effects of other determinants. RESULTS: The study included 2516 twin births (73 stillbirths and 2443 live births). The rate of preterm birth increased from 42.3% in 1988-1992 to 48.2% of twin live births in 1993-1997 (14% increase, P =.04). Twin live births born after preterm labor induction increased from 3.5% in 1988-1989 to 8.6% in 1996-1997 (P for trend =.007). Of live births between 34 and 36 weeks' gestation, the proportion born SGA decreased from 17.5% in 1988-1992 to 9.2% in 1993-1997 (P =.005). Over the same period, rates of prophylactic maternal steroid therapy increased substantially and rates of RDS declined. Perinatal mortality rates among pregnancies reaching 34 weeks decreased from 12.9 per 1000 total births in 1988-1992 to 4.2 per 1000 total births in 1993-1997 (P =.05). CONCLUSION: Increases in preterm labor induction appear to be responsible for the recent increase in preterm birth among twins. These changes have been accompanied by decreases in perinatal morbidity and mortality among twin pregnancies that reach 34 weeks' gestation.     

Perinatal characteristics and outcomes of pregnancies complicated by twin-twin transfusion syndrome

OBJECTIVE: To assess the outcome of a geographically based cohort of monochorionic twin pregnancies complicated by twin-twin transfusion syndrome managed in a single perinatal center over a 10-year period. METHODS: A prospective cohort design was established in 1992 within a single tertiary obstetric unit. RESULTS: Sixty-nine cases of twin-twin transfusion syndrome were identified during the study period. The median gestation at diagnosis was 22.1 weeks (interquartile range 19.7-25.4). Perinatal outcome was directly related to stage at diagnosis and gestation at delivery. The overall perinatal survival rate was 64.5%. For lesser disease severity (stages I and II) the perinatal survival rate was 76.4%, falling to 51.5% with increasing disease severity (stages III-V) (P =.004). The median gestation at delivery was 29.4 weeks (interquartile range 26.3-33.8). The perinatal survival for those born at less than 28 weeks' gestation was 27.1%, increasing to 84.4% for those born at more than 28 weeks' gestation (P =.001). The incidence of neonatal complications reflected the high preterm birth rate. Amnioreduction was the principal intervention employed in this series, but in 24.6% of cases no therapy was used because of the requirement for immediate delivery or fetal demise. CONCLUSION: Twin-twin transfusion syndrome is a heterogeneous disorder in its clinical manifestations and progress. There remain significant perinatal mortality and morbidity in pregnancies complicated by twin-twin transfusion syndrome, principally related to the high preterm birth rate that typifies this disorder. The severity of disease as assessed by stage and the gestation at delivery are the principal factors in determining perinatal outcome in this condition.     

Elective hospitalization in the management of twin pregnancies

We sought to evaluate the effectiveness of a policy of early elective hospitalization on the outcomes of 522 consecutive twin gestations delivered at our institution between 1983-1987. During the first 2 years (1983-1985), 237 twin pregnancies were delivered with a policy of elective hospitalization when twin pregnancy was diagnosed between 24-32 weeks' gestation. When possible, elective hospitalization started at 24 weeks' gestation. Electively admitted women remained hospitalized until 34 weeks' gestation, at which time they were discharged unless complications developed requiring continued hospitalization. During 1985-1987, 285 women with twin gestations were intentionally managed as outpatients unless intercurrent complications required hospitalization. A total of 211 twin pregnancies was excluded from analysis because the women did not present for prenatal care (19%) or were undiagnosed until delivery (22%). Of the remaining 311 pregnancies available for study, 134 were managed when the elective admission policy prevailed and 177 when this policy was not in effect. Although the elective admission policy did result in a small reduction in the incidence of low birth weight among the 58 pregnancies hospitalized electively (mean [+/- SEM] gestational age at elective hospitalization 27.7 +/- 0.3 weeks) compared with outpatient management, this policy did not result in an improvement in prematurity (32 versus 36%; P greater than .05) or perinatal morbidity as reflected by requirement for neonatal intensive care (12 versus 11%; P greater than .05) and mechanical ventilation (8 versus 9%; P greater than .05). Moreover, perinatal mortality was actually higher in the electively hospitalized pregnancies (8 versus 2%; P = .01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Perinatal mortality in twin pregnancies: a 3-year analysis in Seine Saint-Denis (France).

OBJECTIVES: Our purpose was to evaluate perinatal mortality in twins and to investigate factors associated with this mortality. STUDY DESIGN: A prospective study on the perinatal mortality was performed in the department of Seine-Saint-Denis. Out of all the perinatal deaths, we have retrospectively isolated those arising from twin pregnancies. RESULTS: There were 54 twin pregnancies complicated with perinatal death. The perinatal mortality rate in twin pregnancy was 78.0 per 1000 twin babies delivered. Out of 86 twin deaths, 38 (44.2%) were born before 28 weeks gestation and out of 82 twin perinatal deaths, 37 (45.1%) weighed less than 1000 g. Chorionicity was recorded in 44 twin pairs: 21 (47.7%) were dichorionic and 23 (52.3%) monochorionic. Finally, out of 48 twin sets there were four (8.3%) monoamniotic pregnancies. CONCLUSIONS: The present data show that extreme prematurity represents nearly half of perinatal mortality in twins. This study indicates also a significant proportion of monochorionic placentation among twin pregnancies with poor outcome.     

Twin pregnancy outcome and chorionicity

BACKGROUND: Based on research of relatively poor quality, it is generally believed that dichorionic twins have lower perinatal mortality than monochorionic twins. We assessed the relationship between the pattern of perinatal loss in twin pregnancy and chorionicity. METHODS: A cohort study of 238 consecutive sets of twin pregnancies registered in our antenatal service over a 2-year period (1996-98) had chorionicity determined by ultrasound at 12-16 weeks' gestation. Follow up included scanning at 20 weeks' gestation for anomaly, and at 2-3-weekly intervals from 24 weeks' gestation onwards for growth and well being. Hazard ratios were computed for comparing the risk of death according to chorionicity. The perinatal loss patterns were analyzed according to gestational age at demize and that at delivery using survival analysis. RESULTS: Overall, 17/238 (7.1%) twin pregnancies suffered mortality: 14/190 (7.3%) amongst the dichorionic and 3/48 (6.2%) amongst the monochorionic twins. The hazard ratio for mortality was 0.89 (95% confidence interval 0.27-2.97, p = 0.85), considering gestational age at demize as the outcome. For gestational age at delivery as the outcome, the hazard ratio for mortality was 0.93 (95% confidence interval 0.27-3.15, p = 0.91). Survival analysis showed that amongst the dichorionic twins the hazard of death continued to rise throughout gestation. In contrast, the hazard of death for the monochorionic twins rose gradually to a maximum at 28 weeks' gestation and was then constant. CONCLUSION: Chorionicity did not affect the overall fetal loss rate amongst the twin pregnancies in our setting. There were differences in patterns of loss according to chorionicity, which require further investigation.     

Use of ultrasound and hormone assays in the diagnosis, management, and outcome of twin pregnancy.

A study of 79 twin pregnancies was conducted between 1973 and 1976 with particular reference to the use of ultrasound and hormone analysis. There were 17 perinatal deaths, a perinatal mortality rate of 107 per 1000 deliveries. The contributing factors were antepartum anoxia (40%), prematurity (30%), congenital abnormalities (18%), and obstetric trauma (12%). During the period of study there was a complete change in the method of confirming twin pregnancies, ie, in 1973, 84% were confirmed by x-ray and in 1976, 86% by ultrasound. About 40% were diagnosed at 28 weeks' gestation or earlier. The ranges (mean +/- 2 SD) for human placental lactogen (hPL) and urinary estrogens have been established for twin pregnancy, and the value of these measurements in the antenatal management of twin gestations is discussed.     

Maternal serum alpha-fetoprotein in twin pregnancy.

Maternal serum alpha-fetoprotein concentration was measured at 14 to 20 weeks' gestation in 138 twin pregnancies. All patients had at least one ultrasonographic examination (86% before 20 weeks' gestation). Two pregnancies were discordant for open fetal defects (one anencephaly, one gastroschisis). The median serum alpha-fetoprotein value in the remaining 136 twin pregnancies paralleled a curve 2.5 times the median curve for singleton pregnancies over the gestational range studied. Higher serum alpha-fetoprotein values correlated significantly with increasing incidence of fetal and neonatal death, premature delivery (less than 35 weeks' gestation), and twin-to-twin birth discordance (greater than 20%), most pronounced at greater than 4 multiples of the singleton median level. A significant negative correlation between alpha-fetoprotein and birth weight was observed (p less than 0.001), but was related more to prematurity than to poor fetal growth. Theoretically, serum alpha-fetoprotein screening detected 56.5% of the twins in this study when a cutoff level of 2.5 multiples of the median was used, enhancing twin detection in the study population by 40%. These data indicate that maternal serum alpha-fetoprotein screening has a valuable role in the management of twin pregnancy, both in the detection of twins and in the prediction of perinatal outcome in twin pregnancy.     

Optimal gestational age for twin delivery.

OBJECTIVE: We evaluated the timing of twin delivery associated with perinatal outcome in gestations of at least 36 completed weeks. STUDY DESIGN: This was a retrospective analysis of infant and maternal hospital records for a consecutive series of twin deliveries at New York Hospital-Cornell Medical Center. The inclusion criteria were delivery after 36 weeks' gestation during a 7-year period (1987 to 1993), without congenital anomalies or early fetal demise. Adverse perinatal outcomes were compared between deliveries before 38 weeks' gestational age and those at or after 38 weeks' gestation. RESULTS: Of 776 twin deliveries during the study period, 329 met the inclusion criteria. Adverse perinatal outcome was significantly higher among the twin pregnancies that delivered before 38 weeks' gestation compared with those that delivered at or after 38 weeks' gestation. Twin pregnancies that delivered between 36 and 37 weeks' gestation were 13 times more likely to require neonatal intensive care compared with those who delivered at or after 38 weeks' gestation (95% confidence interval 1.8 to 95.9; p < 0.001). CONCLUSION: In uncomplicated twin gestations, delivery at between 36 and 37 weeks' gestation was not associated with a reduction in neonatal complications compared with deliveries at or after 38 weeks' gestation.     

Use of umbilical artery Doppler velocimetry in the monitoring of pregnancy in women with pre-existing diabetes

BACKGROUND: The usefulness of umbilical artery Doppler velocimetry for the monitoring of diabetic pregnancies is controversial. The aim of the present study was to assess whether umbilical artery Doppler velocity waveform analysis can predict adverse perinatal outcomes for pregnancies complicated by pre-existing diabetes mellitus. METHODS: All diabetic pregnancies (type 1 and 2) delivered at Mater Mothers' Hospital, Queensland, between 1 January 1995 and 31 December 1999 were included. All pregnant diabetic women were monitored with umbilical artery Doppler velocimetry at 28, 32, 36, and 38 weeks' gestation. Adverse perinatal outcome was defined as pregnancies with one or more of the following: small-for-gestational age, Caesarean section for non-reassuring cardiotocography, fetal acidaemia at delivery, 1-min Apgar of 3 or less, 5-min Apgar of less than 7, hypoxic ischaemic encephalopathy or perinatal death. Abnormal umbilical artery Doppler velocimetry was defined as a pulsatility index of 95th centile or higher for gestation. RESULTS: One hundred and four pregnancies in women with pre-existing diabetes had umbilical arterial Doppler studies carried out during the study period. Twenty-three pregnancies (22.1%) had an elevated pulsatility index. If the scans were carried out within 2 weeks of delivery, 71% of pregnancies with abnormal umbilical Doppler had adverse outcomes (P < 0.01; likelihood ratio, 4.2). However, the sensitivity was 35%; specificity was 94%; positive predictive value was 80%; and negative predictive value was 68%. Only 30% of women with adverse perinatal outcomes had abnormal umbilical arterial Doppler flow. CONCLUSION: Umbilical artery Doppler velocimetry is not a good predictor of adverse perinatal outcomes in diabetic pregnancies.     

Chronic hypertension in pregnancy

The course and outcome of 169 pregnancies in 156 women with chronic hypertension were studied. Antihypertensive medications were given if the diastolic blood pressure exceeded 90 mmHg. A number of major associated medical problems were found. Left ventricular hypertrophy, a serum creatinine greater than 1.0 mg%, and a diastolic pressure greater than 100 mmHg at less than 20 weeks' gestation were high-risk indicators. The overall perinatal mortality was 28.4 of 1000 (versus hospital of 25.6 of 1000). Despite antihypertensive therapy, one-third of the patients developed superimposed preeclampsia. The poorest outcome occurred in patients with superimposed preeclampsia necessitating delivery at 27 to 34 weeks' gestation (perinatal mortality = 238 of 1000). Antepartum fetal heart rate testing was abnormal in 10% of the patients with intrauterine growth retardation occurring in 15%. The incidence of fetal growth retardation was fourfold higher (20 versus 5%) in patients treated with antihypertensive drugs, particularly methyldopa as a single agent. However, this may have been related more to the study design than to a detrimental effect of the drug. The perinatal outcome in this study is similar to the outcome of studies in which antihypertensive therapy was withheld. This indicates that controlling the blood pressure is merely one aspect of the management of chronic hypertension in pregnancy. Accurate dating, attention to associated medical problems, antenatal fetal assessment by ultrasound and heart rate monitoring, and carefully timed delivery are additional important factors.     

Perinatal outcome of twin pregnancies with one structurally affected fetus: a case-control study.

OBJECTIVE: To determine whether one structurally affected fetus of a twin pregnancy further increases the risk of preterm delivery and to compare perinatal morbidity and mortality in these pregnancies with twin gestations with structurally normal fetuses. STUDY DESIGN: The cases (n = 25) included all twin gestations diagnosed from 1991 to 1994 with a sonographically detected fetal anomaly and a structurally normal co-twin delivered after 24 completed weeks' gestation. The control group consisted of 547 twin gestations delivered during the study period with no sonographically detected structural anomalies in either twin. RESULTS: Compared with controls, pregnancies with a single anomalous fetus (cases) delivered at a significantly lower gestational age (mean +/- SD: 34.0 +/- 3.2 weeks versus 35.6 +/- 3.2 weeks; p = 0.019) and had a significantly increased preterm delivery rate (76.0% vs 55.4%; p = 0.042). There was no significant difference in the incidence of intraventricular hemorrhage or respiratory distress syndrome, yet the perinatal mortality (80.0/1000 vs 6.4/1000; p = 0.000) and the average nursery stay (45.5 +/- 43.3 days versus 17.0 +/- 24.0 days; p = 0.003) were significantly increased for cases compared with controls. In addition, a significantly greater birth weight discordancy (> or = 30%) was seen in cases compared with controls (32.0% versus 9.1%; p = 0.002). The normal co-twin did not show any significant difference in the perinatal outcome variables studied when compared with controls. CONCLUSION: Compared with structurally normal twin pairs, twin gestations with a single anomalous fetus are at a significantly increased risk for preterm delivery. In addition, the anomalous fetus, but not the structurally normal co-twin, has a significantly increased mortality rate and a longer nursery stay. Finally, despite the increased risk for preterm delivery in twin pregnancies with one anomalous fetus, it is the nature of the anomaly itself that dictates the perinatal outcome.     

A case-control study of 1253 twin pregnancies from a 1982-1987 perinatal data base

In one regional perinatal network between 1982-1987, 101,506 women delivered infants greater than 500 g, of which 1253 were twin pregnancies (1.2%). This latter group was compared statistically with a 5% random sample of the singletons (N = 5119). The results showed that the women with twin pregnancies were slightly older, had a higher parity, gained more weight during the gestation, and had a heavier body weight at delivery. Twin pregnancies were complicated by increases in hypertension (odds ratio 2.5; 95% confidence interval 2.1-3.1), abruption (odds ratio 3.0; 95% confidence interval 1.9-4.7), and anemia (odds ratio 2.4; 95% confidence interval 1.9-3.0). There was no increased risk of pyelonephritis, placenta previa, or diabetes mellitus in mothers with twins. The twin pregnancies delivered earlier and the infants were smaller, had lower Apgar scores, and were at increased risk for congenital anomalies. Fetal and neonatal mortality rates were significantly increased in the twin infants; the perinatal mortality rates for twin A and twin B were 48.8 and 64.1, respectively, compared with 10.4 per 1000 births for the singleton controls. When the twin infants A and B were of similar weight, they had a similar perinatal mortality (odds ratio 1.0; 95% confidence interval 0.6-1.8). For infants less than 2500 g, twins A and B had lower fetal and neonatal mortality rates than did singletons, but twins heavier than 2500 g were at increased risk of perinatal death.     

Outcomes of twin gestations at the University of Colorado Health Sciences Center, 1973-1983

A retrospective study was undertaken of 341 twin pregnancies over a ten-year period at the University of Colorado Health Sciences Center. The perinatal morbidity and mortality were higher than for singleton gestations, but no difference was found between the first and second twins. Bed rest was effective in prolonging gestation and decreasing perinatal mortality (P less than .05). Delivery of the second twin in noncephalic presentation was accomplished vaginally in 46.5%, with external version successful in five of six attempts. The interval between the birth of each twin did not affect outcome.     

Hypertensive disorders in twin versus singleton gestations. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units

OBJECTIVE: This study was undertaken to compare rates and severity of gestational hypertension and preeclampsia, as well as perinatal outcomes when these complications develop, between women with twin gestations and those with singleton gestations. STUDY DESIGN: This was a secondary analysis of prospective data from women with twin (n = 684) and singleton (n = 2946) gestations enrolled in two separate multicenter trials of low-dose aspirin for prevention of preeclampsia. End points were rates of gestational hypertension, rates of preeclampsia, and perinatal outcomes among women with hypertensive disorders. RESULTS: Women with twin gestations had higher rates of gestational hypertension (relative risk, 2.04; 95% confidence interval, 1.60-2.59) and preeclampsia (relative risk, 2. 62; 95% confidence interval, 2.03-3.38). In addition, women with gestational hypertension during twin gestations had higher rates of preterm delivery at both <37 weeks' gestation (51.1% vs 5.9%; P <. 0001) and <35 weeks' gestation (18.2% vs 1.6%; P <.0001) and also had higher rates of small-for-gestational-age infants (14.8% vs 7. 0%; P =.04). Moreover, when outcomes associated with preeclampsia were compared, women with twin gestations had significantly higher rates of preterm delivery at <37 weeks' gestation (66.7% vs 19.6%; P <.0001), preterm delivery at <35 weeks' gestation (34.5% vs 6.3%; P <.0001), and abruptio placentae (4.7% vs 0.7%; P =.07). In contrast, among women with twin pregnancies, those who remained normotensive had more adverse neonatal outcomes than did those in whom hypertensive complications developed. CONCLUSIONS: Rates for both gestational hypertension and preeclampsia are significantly higher among women with twin gestations than among those with singleton gestations. Moreover, women with twin pregnancies and hypertensive complications have higher rates of adverse neonatal outcomes than do those with singleton pregnancies.     

Twins: prophylactic hospitalization and ward rest at early gestational age

One hundred eighty-nine twin pregnancies were delivered at Wilford Hall United States Air Force Medical Center from July 1977 through December 1985. Among these, 57 were referred from distant bases and were excluded from further analysis. The remaining 132 pregnancies from our local population make up the study group. Sixty-seven women (51%) followed our advice to be hospitalized at or before 28 weeks' gestation for prophylactic ward rest. The remaining 65 women (49%) were not hospitalized until after 28 weeks' gestational age or until a pregnancy complication or labor occurred. Only three of 134 infants (2%) whose mothers were admitted died, versus 11 of 130 infants (8.5%) whose mothers were not admitted (P less than .03). The results suggest that prophylactic ward rest, implemented at or before 28 weeks' gestational age, may reduce perinatal mortality in this condition.     

Maternal and neonatal outcome of 100 consecutive triplet pregnancies.

The objective of this study is to determine the maternal and neonatal outcome of a large group of triplet gestations. A retrospective review of 100 triplet gestations managed and delivered between January 1992 and September 1999 by a single perinatal group is examined. These pregnancies were managed on an outpatient basis. Prophylactic interventions were not utilized. Ninety-six percent of the pregnancies had at least one complication, with preterm labor the most common. The median gestational age at delivery was 33 weeks (range 20.4 to 37, SD 4.1 weeks) with 14% of pregnancies delivering prior to 28 weeks' gestation. The corrected perinatal mortality rate was 97/1000. Minimal long-term morbidity was seen with delivery after 27 weeks' gestation. Pregnancy outcome did not vary with birth order or mode of conception. Triplet pregnancy is associated with a high rate ofantenatal complications. Favorable neonatal outcome can be obtained without the use of prophylactic interventions.     

Selective fetoscopic laser ablation in 100 consecutive pregnancies with severe twin–twin transfusion syndrome

Aims: To report the perinatal outcomes of a large series of twin pregnancies with severe twin–twin transfusion syndrome (TTTS) managed with laser ablation surgery in an Australian tertiary perinatal centre and to compare the outcome with other large cohorts.
Methods: The outcomes of 100 consecutive pregnancies with severe TTTS managed with selective fetoscopic laser ablation from March 2002 to June 2007 were examined. Survival and neonatal morbidity were analysed. Comparisons were made with the results from other studies of laser surgery with at least 100 pregnancies.
Results: There were 100 women with TTTS treated with laser ablation; 34 stage II, 44 stage III and 22 at stage IV. Median gestation at time of laser was 21 weeks (range 18–28) and median gestation at delivery was 31 weeks (range 20–39). Overall perinatal survival rate was 151 of 200 (75.5%). Eighty five per cent had one or more surviving twins. The survival rate for stage IV TTTS was 88.6%, significantly better than for stage II (69.1%) and stage III (73.9%) pregnancies. The perinatal mortality rate for donors (30%) was not significantly different from recipients (19%), but the fetal death rate for donors was significantly greater than that for recipients ( P  = 0.03). Severe cerebral abnormalities were present in only 2.8% of newborns. The overall survival rate was comparable to other large series.
Conclusions: These results for the management of severe TTTS are comparable to the best reported international series. Long-term follow-up is required and more research needs to be undertaken to further improve these results.     

Twin vs. singleton pregnancy. Clinical characteristics and latency periods in preterm premature rupture of membranes.

OBJECTIVE: To compare the clinical characteristics and latency periods (latencies) of preterm premature rupture of the membranes (PPROM) in twin vs. singleton pregnancy. STUDY DESIGN: Between January 1986 and December 1996, data on all women with singleton and twin gestations complicated by PPROM were reviewed. Perinatal morbidity, mortality and latencies between singleton and twin pregnancies were compared. A further division according to PPROM at < 30 and > or = 30 weeks' gestation was made in both groups. Their latencies were compared. RESULTS: A total of 131 singleton and 48 twin pregnancies with PPROM between 20 and 36 weeks' gestation were included in this series. Regardless of the gestational age at PPROM, the mean latencies of singleton and twin pregnancies were statistically similar (4.4 +/- 3.3 vs. 3.4 +/- 2.9 days, nonsignificant). When PPROM occurred at > or = 30 weeks, the latency of twin pregnancies was shorter than that of singleton pregnancies (2.5 +/- 1.9 vs. 3.7 +/- 2.6 days, P < .05). In both groups, the latencies of PPROM at < 30 weeks were longer than that at > or = 30 weeks (singleton, 5.6 +/- 4.0 vs. 3.7 +/- 2.6 days, P < .005; twin, 4.8 +/- 3.5 vs. 2.5 +/- 1.9 days, P < .05). We also observed a higher percentage of deliveries within the initial 48 hours in twin pregnancies: 50% of women delivered within 48 hours after PPROM and 91.7% within 7 days. In contrast, 26.7% and 85.5% of singleton pregnancies with PPROM were delivered within 48 hours and 7 days, respectively. Perinatal and neonatal outcomes in both groups were similar. CONCLUSION: This investigation provides the basis for patient counseling and management in twin pregnancies with PPROM. In general, singleton and twin pregnancies with PPROM had similar latencies. Latency in PPROM at < 30 was longer than that of PPROM at > or = 30 weeks' gestation in both singleton and twin pregnancies. When PPROM occurred at < 30 weeks' gestation, both groups appeared to have similar latencies. In pregnancies with PPROM at > or = 30 weeks' gestation, latency in twins was shorter than in singleton pregnancies. In twin pregnancies with PPROM after 30 weeks' gestation, prompt steroid administration for fetal lung maturity should be considered.     

Determinants of perinatal outcome in pregnancy-induced hypertension with absence of umbilical artery end-diastolic frequencies

Forty-three pregnancies that were complicated by pregnancy-induced hypertension and either absence of umbilical artery end-diastolic frequencies (n = 32) or reversal of umbilical artery end-diastolic frequencies (n = 11) were reviewed. The incidence of perinatal mortality and morbidity was similar for the two Doppler patterns. Perinatal survival was highly dependent on the gestational age when hypertension first appeared. Presentation at greater than or equal to 30 weeks' gestation was associated with a perinatal survival rate of 86%. Presentation at less than 30 weeks' gestation was associated with a perinatal survival rate of 38% (p less than 0.005). Pregnancy-induced hypertension that presented before 30 weeks was more often associated with a 5-minute Apgar score less than 7 (p less than 0.005) and a nonreactive nonstress test (p less than 0.05) compared with pregnancy-induced hypertension that presented at or beyond 30 weeks. For pregnancies that presented before 30 weeks, the only difference between perinatal survivors (n = 11) and perinatal deaths (n = 18) was a higher incidence of birth weight at or below the 10th percentile among deaths (p = 0.02).