Term delivery in twin pregnancy

We analyzed the data on 55,839 births that taken place in 1998 year in the southeast region of Poland. The incidence of twin pregnancy was about 1%. A half of them delivered before 259 day of gestational age, the beginning of birth occurring norm for human. This means that onset of this norm for singleton pregnancies is the mean of 12 weeks births occurring norm (215-303 days of gestational age) for multifetal pregnancies simultaneously. The particular meaning has prevention of preterm delivery and in this case the computer-aided monitoring of pregnancy and prediction of birth date is a very useful invention.     

Delayed-interval delivery in twin pregnancies

OBJECTIVE: To report on pregnancy outcome in six twin pregnancies with delayed-interval delivery in a single maternal-fetal medicine practice. STUDY DESIGN: All cases of attempted delayed-interval delivery from January 1988 to August 2000 in a single maternal-fetal medicine practice were retrospectively reviewed. Patients were managed with a treatment protocol that included rescue cerclage after delivery of the first born twin, antibiotics, corticosteroids and tocolysis. RESULTS: Five of the six twin gestations resulted in viable birth of the second-born twin. One pregnancy had loss of both fetuses before viability. All first-born twins were nonviable. The median pregnancy prolongation achieved following delivery of the first-born, nonviable twin was 93 days, with a range of 23-153. Three of the five viable, second-born twins had a neonatal intensive care nursery stay of 3, 4 and 35 days (mean, 8.4). No infant required a ventilator. CONCLUSION: Based on our analysis of these six cases, the pregnancy prolongation gained resulted in a clinically significant benefit to the second-born twin, without significant morbidity in the mother.     

Delayed delivery in twin pregnancy

We report the observation of a primigravid patient, presenting a spontaneous twin pregnancy bichorionic and biamniotic. After expulsion of the first twin at 20 weeks and two days, expectancy is adopted and the second twin is born at 31 weeks and three days. In front of this not so frequent obstetrical situation and the absence of consensus, we discuss three points: cerclage, tocolysis and the prophylactic antibiotherapy. We specify that the attempt at differed childbirth is aimed at improving the foetal prognosis of the second twin by bringing it into the viable term, as well as obtaining a survival with the least possible number of sequels.     

Cesarean delivery of the second twin after vaginal delivery of the first twin

Cesarean birth of twin B after the vaginal delivery of twin A is an infrequent event. There is little information in the literature documenting outcome of vaginal-abdominal delivery. We reviewed our 10-year experience in the management of such cases and compared outcomes with twins delivered by repeat cesarean section and vaginal delivery in the same time period. Twenty-one cases of combined vaginal-cesarean section deliveries were managed at our institute in a 10-year period. There was no apparent increase in maternal and perinatal morbidity and mortality when twin B was delivered by cesarean section after vaginal delivery of twin A.     

Anesthesia for twin delivery

The patient presenting for delivery with multiple gestation often produces extreme anxiety for those involved with her care. From the standpoint of anesthesia service, knowledge of what to expect, and better, the knowledge of what to do if and when the various potential problems present is paramount. With close communication and cooperation with the obstetrician and patient, a satisfactory anesthetic and obstetric outcome is achievable. Lumbar epidural anesthesia is highly recommended for pain management when labor and vaginal delivery is anticipated. However, the knowledgeable obstetrician and the knowledgeable anesthesiologist must be present and prepared for all circumstances.     

双胎妊娠分娩时机与分娩方式的选择

近年来,双胎妊娠发生率急剧上升,双胎分娩的处理是具有挑战性的临床问题。双胎妊娠分娩方式与分娩时机应结合母胎情况、当地医疗机构医疗水平和医疗条件进行综合考虑。无并发症单绒毛膜双羊膜囊(monochorionic-diamniotic,MCDA)双胎分娩不超过37周为宜,双绒毛膜双羊膜囊(dichorionic-diamniotic,DCDA)双胎可妊娠至38周,单绒毛膜单羊膜囊(monochorionic-monoamniotic,MCMA)双胎为32～33周分娩。对于无并发症MCDA双胎与DCDA双胎可考虑阴道试产,MCMA双胎则建议剖宫产手术终止妊娠。     

双胎妊娠阴道分娩的管理

双胎妊娠是临床上常见的高危妊娠,根据双胎妊娠的绒毛膜性、胎先露及胎儿体重等因素,选择恰当的分娩时机和分娩方式。阴道试产过程中,要加强第二产程管理,只要胎心监测良好,不必限定双胎的分娩间隔。应建立产房快速反应团队进行双胎阴道分娩管理,降低分娩风险。     

双胎妊娠阴道分娩

双胎妊娠孕妇的合并症和新生儿发病率均较高,其分娩方式的选择虽然目前仍有争议,但在临床处理上仍需结合双胎类型、胎方位、胎儿体重、母体情况和接生者经验等进行综合考虑。阴道分娩过程中应加强监护,尤其注意第二产程的管理,以降低双胎第二胎儿发生宫内窘迫和新生儿窒息的风险。     

Occurrence and predictors of cesarean delivery for the second twin after vaginal delivery of the first twin

OBJECTIVE: To estimate the occurrence and to assess clinical predictors of emergent cesarean delivery in the second twin after vaginal delivery of the first twin. METHODS: We conducted a population-based cohort study, using the 1995-1997 linked mother/infant twin data from the United States. The adjusted risk ratios and population attributable risks of clinical predictors of emergent cesarean delivery in second twins were estimated for the overall study sample and for those born at less than 36 or 36 weeks or more of gestation. RESULTS: Among the 61,845 second twin births with the first twin delivered vaginally, 5,842 (9.45%) were delivered by cesarean. The cesarean delivery rate was increased in infants born to mothers with medical or labor and delivery complications. Breech and other malpresentations were the most important predictors of emergent cesarean delivery for the second twin (population attributable risk 33.2%; 95% confidence interval 31.8%, 34.6%). Operative vaginal delivery of the first twin was associated with a decreased risk of cesarean delivery for the second twin. Prediction of emergent cesarean for the second twin by clinical factors was stronger in term births than preterm births. CONCLUSION: In the general population, the cesarean delivery rate for the second twin after vaginal delivery of the first twin is approximately 9.5%. With the presence of breech and other malpresentations, the need for emergent cesarean delivery of the second twin after vaginal delivery of the first twin is increased by 4-fold. LEVEL OF EVIDENCE: II-2     

Cesarean delivery for the second twin

OBJECTIVE: To examine maternal and infant outcomes after a vaginal delivery of twin A and a cesarean delivery of twin B, and to identify whether the second twin experienced increased short-term morbidity as part of a combined route of delivery. METHODS: Between January 1, 1999, and December 31, 2000, a prospective cohort study of all cesarean deliveries was conducted at 13 university centers. This secondary analysis was limited to women with twin gestations who experienced labor and underwent cesarean delivery. We compared outcomes of the second twin in women who had vaginal delivery of the first twin and a cesarean delivery of the second twin to those who had cesarean delivery of both twins. RESULTS: One thousand twenty-eight twin pregnancies experienced labor and underwent cesarean delivery; 179 (17%) had a combined vaginal/cesarean delivery. Gestational age at delivery was 34.6 weeks in both groups (P=.97). The rupture of membranes to delivery interval was longer in the combined group (3.2 compared with 2.3 hours, P<.001). Endometritis and culture-proven sepsis in the second twin were more common in the combined group, respectively (n=24, odds ratio 1.6, 95% confidence interval, 1.0-2.7; n=15, odds ratio 1.8, 95% confidence interval, 1.0-3.4). These differences were not significant after logistic regression analysis. There were no statistically significant differences in an arterial cord pH of less than 7.0, Apgar score less than or equal to 3 at 5 minutes, seizures, grade III or IV intraventricular hemorrhage, hypoxic ischemic encephalopathy, or neonatal death. CONCLUSION: Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.     

Delayed interval delivery of a second twin

We report a case of diamniotic dichorionic pregnancy at 21 weeks and 5 days of gestation with threatened preterm labor with cervical modification and protrusion into vagina of the amniotic sac of twin one. After 4 days there was a rupture of membrane of the protruding sac and delivery of the first twin. We decided to retain the other one to allow improvement in the outcome for the second twin. The patient was treated with tocolytics, antibiotics and continuously monitored. After 18 days there was increasing uterine contractility and we decided to perform the cesarean section and delivered the second twin.