The analysis of twin pregnancy and labour in the Department of Obstetrics, Medical Academy, Gdańsk

OBJECTIVES: According to the literature the frequency of twins is increasing due to technics af assisted reproduction. Many complications of pregnancy and delivery are more likely to develop during multiple pregnancy. DESIGN: Aim of the study was to analyze labour and delivery in multiple pregnancy and assess the neonate's condition. MATERIALS AND METHODS: Authors analyzed labour and delivery and neonate's condition in twin pregnancies in Medical University of Gdansk, Poland in 1991-1995 with birth weight at least 1000g. We assessed women's age, fetuses presentation, week of pregnancy at the delivery, mode of delivery, Apgar score, weight and crown-rump length after birth and early neonatal period. RESULTS: Mean age of pregnant women was 30.0 years (18-43). Mean birth weight for the first fetus was 2412 + 601 g and for the second one--2485 + 630 g. Mean SI for the first fetus was 49.8 + 4.4cm, for the second one--50.0 + 4.15 cm. Apgar core was analyzed separately for the first and the second twin according to the presentation and mode of delivery--we found better condition of the second babies delivered from transverse presentation by the cesarean section comparing to those born vaginally. 73% of the pregnancies with the first fetus in the cephalic presentation were delivered vaginally, in other situations--cesarean section was preferred. CONCLUSIONS: At the transverse presentation of the second twin elective cesarean section seems better for the second twin.     

The influence of delivery methods for twins on obstetric results

The analysis covered 100 twin gestations over the years 1996-1998 in the material of Gynecology and Obstetrics Clinic in Bydgoszcz. The authors estimated the relations between the mode of delivery and presentations of the twins. Abnormal foetal presentation occurred in 68 pregnancies (68%), and was more often in the second twin (61.8%). The highest percentage of cesarean sections (29%) we have observed in the case of an abnormal presentation of the first twin. The condition of the twins in their first minute after the birth was estimated according to the birth weight, the gestational age, and the mode of surgical procedures performed. Better condition after the birth of the second twin with the birth weight above 1000 g comparing to the first twin was established in cesarean sections, not in other obstetrical procedures. There was no essential difference between the mortality rate of the first and the second twin. Early diagnosis of the twin pregnancy using USG helps us to choose a suitable management during pregnancy and an optimal mode of delivery.     

Twin pregnancy with a complete hydatidiform mole and co-existent live fetus: two case reports and review of the literature

Introduction  The aim of this study was to report the clinical features, management, and outcome of two cases of complete hydatidiform mole with a coexisting viable fetus and to review the literature. Case reports  In this article, we report on the well-documented follow-up of two cases of twin pregnancies with complete hydatidiform mole and a normal fetus. Genetic amniocentesis showed normal fetal karyotype in both of two cases. In the first case, a live male infant was delivered by a cesarean section because of severe maternal bleeding at 29 weeks of gestation. In the second case, termination of pregnancy was performed due to early onset of severe preeclampsia and vaginal hemorrhage. Conclusion  The chances of a live birth have been estimated between 30 and 35% and the risk of persistent trophoblastic disease is similar to singleton molar pregnancies in complete mole with coexisting fetus pregnancy. Therefore, in these pregnancies, expectant management instead of termination of pregnancy can be suggested.     

Mode d’accouchement des grossesses gémellaires

The assessment of optimal delivery for twin gestations is complex due to the relatively high frequency of obstetrical complications and to the heterogeneity of delivery management in these conditions. The extern validity of the Anglo-Saxon studies is limited in particular because delivery management of the second twin (approach of external cephalic version) differs from the French one (approach of internal version and/or total breech extraction) in cases of non-vertex second twin. Anglo-Saxon studies suggest that a planned vaginal delivery is associated to an increased risk of neonatal morbidity for second twin compared to first twin at term, in particular in cases of combined vaginal-cesarean birth. To reduce the interval twin-to-twin delivery interval and the number of combined vaginal-cesarean births, in our opinion, one must stop to perform external cephalic version and recommend a routinely active management for the second non-vertex twin delivery. With this active management, there is no evidence to support planned cesarean section for twins. Nevertheless, active management requires training as internal version might be difficult to perform, and therefore it is essential to pursue to teach junior obstetrician these obstetric maneuvers. There is limited role for trial of labor after cesarean delivery in twin gestation with a policy of active management.     

Influence of chorionicity in intra-partum management of twin deliveries

Objective: To analyze morbidity and mortality in twin pregnancies as a function of the type of delivery and chorionicity. Design: Retrospective cohort study. Methods: Analysis of the type of delivery, intertwin time interval, and perinatal variables of >1000 twin deliveries during a 10-year period. Main outcome measure: Influence of delivery type and chorionicity on perinatal outcome. Results: The rate of cesarean sections was 42.4%. No differences were found as a function of chorionicity or as a function of presentation of the second twin. Cesarean sections were performed after vaginal delivery of the first twin in 1.8% of cases, being more common if the second baby was in a non-cephalic presentation (6.9% vs. 0.4%, p < 0.05). The average twin-to-twin delivery time interval was longer in the cases where the second had a cephalic presentation (8.26?±?7.75?min vs. 6.81?±?5.97?min, p < 0.05). The umbilical artery pH was lower the longer the interval between the birth of the twins, both in monochorionic and dichorionic. Conclusions: According to the results, vaginal delivery is as safe as elective caesarean section in twin pregnancies where the first twin is in cephalic presentation and the intrapartum management should not vary due to chorionicity.     

Course of twin pregnancies and labors in the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw

DESIGN: The aim of the study was to analyze the course of twin pregnancies and labors in the I Department of Obstetrics and Gynaecology, Medical University of Warsaw. MATERIALS AND METHODS: 124 cases of multiple pregnancy and labor that occurred in the I Department of Obstetrics and Gynecology within the period from 1994 to 2001 were retrospectively analyzed. RESULTS: The study revealed high risk of premature labor, premature rupture of the membranes (PROM), intrauterine growth retardation (IUGR) and pregnancy induced hypertension (PIH) in twin pregnancy. High incidence of cesarean sections was seen both in premature and at-term labors. Significant differences between the mean birth weight and Apgar score of I and II twin were observed. Differences in condition of the neonates were smaller in the group of twins born by cesarean section. CONCLUSIONS: The higher incidence of both obstetrical complications and cesarean sections is associated with twin pregnancies. An increased obstetrical risk and lower Apgar score are observed in case of vaginal delivery of the second twin. Cesarean section seems to improve obstetric results and diminish the differences in condition between the neonates.     

Maternal and neonatal outcome of twin pregnancies complicated by single fetal death.

OBJECTIVE: To study the maternal and neonatal outcome of twin pregnancies complicated by the intrauterine death of one fetus after 20 weeks of gestation. DESIGN: Retrospective, observational study of 7 twin pregnancies out of 185 twin pregnancies with the diagnosis of a single intrauterine death over a 5-years period in a university hospital. RESULTS: The incidence of single fetal death in twin gestation after 20 weeks was 3.8% in the study population with a high incidence of intrauterine growth retardation (IUGR) of the remaining fetus and preeclampsia in the further course of pregnancy. The incidence of preterm delivery was 71% with a mean gestational age of 33.0 +/- 1.0 weeks. The median interval from diagnosis of single fetal death to delivery was 10.2 +/- 4.1 days (range 1-28 days). 5 of 7 (71%) cases were delivered by cesarean section for standard obstetrical reasons. Neither perinatal nor neonatal death of the remaining twin were observed. Two cases of neurologic injury were diagnosed after delivery by ultrasound and MRI. No maternal coagulopathy related to single fetal death occurred. CONCLUSION: Expectant management of single fetal death in twin pregnancies might be advisible under close surveillance of both, mother and the surviving fetus.     

The problem of double abnormalities

Twin monsters are rare obstetrical events. The article reports on the course and the termination of pregnancy of a fetus with epignathus (non separated asymmetrical twin monster) and a fetus with thoracopagus (non separated symmetrical twin monster). In this connection the importance of an early prenatal diagnosis is discussed.     

Good perinatal outcome in selective vaginal breech delivery at term

BACKGROUND AND AIM: To compare perinatal outcome in groups of planned vaginal breech delivery, elective cesarean section with the fetus in breech presentation, and planned vaginal delivery with the fetus in cephalic presentation in a university hospital with a tradition of managing breech deliveries by the vaginal route. METHODS: A cohort study from a 7-year period 1995-2002, including 590 planned vaginal deliveries with a term (> 37 weeks) singleton fetus in breech presentation, 396 elective cesarean sections with a term singleton fetus in breech presentation, and 590 control women intending vaginal delivery with a singleton term fetus in cephalic presentation. RESULTS: The Apgar scores were lower in the group of planned vaginal breech delivery, but in other outcome measures there were no significant intergroup differences. The overall neonatal morbidity was small (1.2% vs. 0.5% vs. 0.3% in the respective study groups) if compared to a recently published randomized multicenter study. CONCLUSIONS: Selective vaginal breech deliveries may be safely undertaken in units having a tradition of vaginal breech deliveries.     

Hydatidiform mole with coexistent fetus. Cytogenetic features, diagnosis, and management

Hydatidiform mole with coexistent fetus is an unusual entity caused by two distinct types of pregnancy: the first one is a partial hydatidiform mole, while the second is a twin pregnancy in which a mole coexists with a normal fetus. In these two separate genetic entities, the counseling and the mother-fetus prognosis are different. Two cases of mole with coexistent fetus are reported: a partial hydatidiform mole typically tripliod and a partial mole with unusual diploid karyotype. Prenatal diagnosis is remarkable for the evaluation of fetus development related with his karyotype. Triplody excludes all hope of a non-malformed surviving child and termination of pregnancy is desirable, while normal karyotype the possibility of a continuation of pregnancy may be considered.     

Improving pregnancy outcome in twin gestations with one malformed fetus by postponing selective feticide in the third trimester.

OBJECTIVE: To examine the course of pregnancy and fetal outcome in patients with twin gestations in which one abnormal fetus underwent selective feticide in the third trimester of pregnancy. DESIGN: A study of 23 consecutive late selective feticide procedures. SETTING: Department of Obstetrics and Gynecology, Rabin Medical Center, Israel. PATIENT(S): Twenty-three patients with twin pregnancies with one malformed fetus. INTERVENTION(S): Selective feticide with intracardiac injection of KCl was performed at 28-33 weeks of gestation after the diagnosis of fetal genetic (56.5%) or structural (43.5%) malformations made in the second trimester (18-24 weeks). All procedures were performed at the patient's request and on approval of a committee for fetal termination late in pregnancy. Betamethasone treatment was initiated to enhance lung maturity 3 weeks before selective feticide. All patients were placed on complete bed rest until 35 weeks' gestation. MAIN OUTCOME MEASURE(S): Early and late complications related to the procedure; outcome of pregnancy and fetal survival. RESULT(S): All 23 twin pregnancies had an uneventful course after selective feticide performed at 28-33 weeks. All birth weights were > 2,000 g (mean +/- SD, 2,628 +/- 646 g), indicating an excellent chance of survival. CONCLUSION(S): Our results suggest that late selective feticide in twin gestations is safe and efficient and results in a favorable outcome for the surviving fetus. This procedure should be performed at 28-30 weeks after treatment for enhancement of lung maturity.     

Twin pregnancy with single fetal death due to triploidy--a case report

The incidence of multiple pregnancies is associated with the increased risk in maternal and fetal complications. Intrauterine death of one twin in the second trimester is a rare obstetric complication. Authors report a case of a twin pregnancy with triploidy of one fetus and no chromosomal anomaly of the other twin in a dichorionic diamniotic twin pregnancy. Amniocentesis at 16th weeks disclosed triploidy of this fetus who died afterwards at 20th week of gestation. The pregnancy was continued with special care of the mother and the alive fetus. The second twin was successfully delivered by cesarean section in the 41st week of pregnancy due to the intrauterine fetal distress.     

Discordance of fetal genotype or phenotype in monozygotic twins: a report of 2 cases

BACKGROUND: Discordance of fetal genotype or phenotype in a monozygotic twin pregnancy is rare. CASE: In case 1, a 28-year-old woman at 15 weeks' gestation was found to have a dichorionic twin pregnancy with 1 fetus affected with hydrop fetalis. The result of chromosomal study showed that the structurally normal fetus was 46,XY and that the hydropic fetus was 45,X. One week after selective termination of the hydropic fetus at 19 weeks' gestation, the cotwin died in utero. In case 2, a 30-year-old woman at 20 weeks' gestation, was found to have a monochorionic twin pregnancy with 1 fetus presenting with omphalocele. The result of chromosomal study showed that both fetuses were 46,XX. The fetus with omphalocele died in utero at 29 weeks' gestation, and the normal cotwin was delivered later due to fetal distress. Analysis by short tandem repeat markers in both cases indicated that they were monozygotic twins. CONCLUSION: These cases emphasize the importance of zygosity/chorionicity identification in twin pregnancy even though discordance of fetal genotype or phenotype was found. In monozygotic monochorionic twins, the normal cotwin is at risk for an adverse fetal outcome after 1 spontaneous intrauterine fetal death or selective termination. In monozygotic dichorionic twins, the risk of intrauterine fetal demise of the cotwin after selective termination still exists.     

Trial of vaginal delivery for twins – is it safe? a single center experience

Purpose: This study assessed our hospital protocol of vaginal delivery for twins and evaluated whether trial of vaginal delivery (unless contraindicated) was as safe as elective cesarean. Risk factors leading to failed trial of labor (TOL) were characterized to improve our ability to advise patients and select cases for TOL.

Methods: This retrospective, cohort study included women >32 weeks gestation, with twin A in cephalic presentation and no contraindications for vaginal delivery. Controls were women with twin pregnancy and planned cesarean delivery (PCD). Maternal and neonatal morbidity between TOL and PCD were compared. TOL group was subcategorized by vaginal or cesarean delivery to characterize pre-labor risk factors for failed TOL.

Results: Of the 411 twins, 215 had TOL and 196 had PCD. Among TOL, 196/215 (91%) delivered vaginally. TOL was more likely to have spontaneous pregnancy, pregnancy complications and tended to deliver earlier. More TOL had postpartum hemorrhage (p?Conclusions: The results support the contemporary practice of TOL for twins at term when the first is in cephalic presentation with no other contraindications.     

Placental location and its influence on the position of the fetus in the uterus

There are different opinions concerning the influence of the placental localization on the position of the fetus in the uterus. Two options are suggested in breech presentation--placenta praevia and cornual localization as possible causes for breech presentation. The aim of the present prospective study is to establish the influence of placental localization on the fetal position in the uterus. Two groups of pregnant women were examined--the first with cephalic resentation (n = 125) and the second with breech presentation (n = 124). All of the pregnant women examined were nulliparas, with term pregnancy (37-40 weeks). Uterine and fetal abnormalities were excluded. The localization of the placenta was determined by ultrasonography. The cornu-fundal localization of the placenta was found in 4.8% in the pregnant women with cephalic presentation and 62.6% in pregnant women with breach presentation. Placenta praevia or low insertion of the placenta was found in 3.2% of the cases with breech presentation and in none of the cases with cephalic presentation. The authors conclude on the basis of the data in the study that the localization of the placenta influences the fetal position in the uterus.     

A twin pregnancy in a bicornuate uterus]

A case of twin pregnancy in bicornuate uterus with a fetus in each horn is presented. During the second trimester, the rudimentary horn ruptured. This horn was extirpated and two non viable fetus were delivered by cesarean section. Later on, the patient had another pregnancy in the unicornuate uterus. She was delivered at 36th week of pregnancy by cesarean section. The baby was in good condition.     

Neonatal outcomes of twin pregnancy according to the planned mode of delivery

OBJECTIVES: To assess neonatal morbidity in twin pregnancy according to the planned mode of delivery. METHODS: A retrospective cohort study of 758 consecutive sets of twins born after 35 weeks of gestation with a cephalic-presenting first twin was undertaken in a level III maternity unit in which active management of the second twin delivery is performed routinely. The primary outcome was a composite measure of neonatal mortality and morbidity, including pH less than 7.0, 5-minute Apgar score less than 4, neonatal intensive care unit transfer more than 4 days, pneumothorax, and fracture. Control for potential confounders was performed by excluding from the analysis women who experienced pregnancy complications and by using logistic regression models. RESULTS: Vaginal or cesarean delivery was planned for 657 (86.7%) and 101 (13.3%) women, respectively. Among planned vaginal deliveries, 515 (78.4%) patients delivered both twins vaginally, 139 (21.1%) had a cesarean delivery during labor, and 3 (0.5%) had cesarean delivery for the second twin. After vaginal birth of the first twin, the mean intertwin delivery interval was 4.9+/-3.2 minutes. When patients who experienced pregnancy complications were excluded (n=202), the neonatal composite morbidity for the second twin did not differ between planned cesarean and planned vaginal delivery (5.0% compared with 4.7%, adjusted odds ratio 1.5, 95% confidence interval 0.3-7.4, P=.63). Neonatal composite morbidity of first twins did not differ between groups. CONCLUSION: For twin gestations with a cephalic-presenting first twin, planned vaginal delivery after 35 weeks of gestation in selected women remains a safe option in centers used to active management of the second twin delivery.     

Pregnancy in a woman with a prior myocardial infarction: a case report]

Myocardial infarction during pregnancy is a rare event but is considered to be associated with very high mortality of both mother and fetus. We report uncomplicated cesarean section in the 3rd pregnancy in woman with a prior myocardial infarction that occurred during the first hours after cesarean section delivery of the 2nd pregnancy. Intensive cardiological and obstetrical supervision are required for correct management of the pregnancy.     

Strategies of antenatal diagnosis and management of pathologies related to multiple pregnancies

In the first trimester, ultrasound is crucial to screen for aneuploidies based on nuchal translucency, to diagnose major birth defects, and to establish chorionicity. Indeed prenatal diagnosis strategies as well as obstetrical management options are largely based on placental type. In the second trimester, maternal serum screening is not as effective, and ultrasound screening is more difficult in twins than in singletons. When a severe abnormality in found in one twin, selective termination of pregnancy may be considered. This technique is safe in dichorionic twins, but hazardous in monochorionic pregnancies. Selective termination in dichorionic twins is safer in the first trimester, underscoring the need for early prenatal diagnosis in twins. Monochorionic twin pregnancies carry specific risks, such as the twin-to-twin transfusion syndrome, which can be treated by endoscopic photo-coagulation of intertwin anastomoses in the severe early onset cases, or by amnioreduction in milder cases.     

Disseminated intravascular coagulation following selective termination in a twin pregnancy. A case report

OBJECTIVE: Coagulation abnormalities after single fetal demise are well described, but similar cases had not been previously reported following therapeutic selective termination. CASE: A 23-year-old G(3) P(2001) with a monochorionic-diamnionic twin pregnancy underwent selective termination at 20 4/7 weeks for severe twin-twin transfusion syndrome. Her fibrinogen thereafter decreased and she developed disseminated intravascular coagulopathy with pathological bleeding during a cesarean section. The maternal coagulopathy resolved postpartum. CONCLUSION: Coagulation disorders can follow selective termination. Recommendations to serially follow coagulation parameters after these procedures, however, cannot be based upon a single case.