Cerebral palsy in the surviving twin associated with infant death of the co-twin

BACKGROUND: Monozygotic twins are at greater risk of dying and of serious morbidity than dizygotic twins, and both are at greater risk than singletons. This is only partly explained by the higher proportion of low birthweight infants among twins. AIM: To compare, in same sex and different sex twins, birth weight specific neonatal death rates and cerebral palsy prevalence rates in the surviving twin when the co-twin has died in infancy. METHODS: Analysis of birth and death registration data for same sex and different sex twins for England and Wales 1993-1995 where both were live births. Death certificates of all liveborn twins who died were obtained from the Office for National Statistics. A questionnaire was sent to the general practitioners of all surviving co-twins to determine if the child had any disability. RESULTS: The neonatal death rate in same sex twins was 25.4 and in different sex twins 18.0 per 1000 live births (death rate difference 7.4; 95% confidence interval 4.7 to 10.1; p < 0.001). The higher neonatal death rate in same sex compared with different sex twins is attributable to the higher proportion of same sex twins with low birth weight. Prevalence of cerebral palsy in the low birthweight group (< 1000 g) was marginally higher in same sex (224 per 1000) than different sex (200 per 1000) twin survivors. In the birth weight group 1000-1999 g, same sex twin survivors were at a significantly higher risk of cerebral palsy than those of different sex: 167 v 21 per 1000; difference 145 (95% confidence interval 44 to 231; p < 0.01) per 1000 infant survivors. CONCLUSION: There are two components to the cause of cerebral palsy in twins. Immaturity per se predisposes to cerebral damage. Also, same sex twins may sustain cerebral damage that is in excess of that due to immaturity.     

Childhood pregnancy (10-14 years old) and risk of stillbirth in singletons and twins

OBJECTIVE: To clarify the association between childhood pregnancy and risk of stillbirth. STUDY DESIGN: We analyzed singleton and twin pregnancies that occurred in children (10-14 years old) in the United States from 1989 to 2000. We estimated the absolute and relative risks of stillbirth by using 15- to19-year-old and 20- to 24-year-old mothers as comparison groups. RESULTS: The analysis involved 17.8 million singletons and 337,904 individual twins. The rate of stillbirth was highest in pediatric mothers for both singletons (12.8/1000) and twins (56/1000) compared with adolescent (6.8/1000 in singletons and 29/1000 in twins) and mature (5.5/1000 in singletons and 20/1000 in twins) mothers. After adjusting for confounding characteristics, pediatric mothers continued to exhibit significantly elevated risk for stillbirth in both singletons (odds ratio, 1.57; 95%CI, 1.49-1.66) and twins (odds ratio, 1.97; 95%CI, 1.42-2.73). Preterm birth rather than small size for gestational age was revealed by means of sequential modeling to account for the excess risk of stillbirth observed in pediatric gravidas. CONCLUSION: Pregnancy in childhood is a risk factor for stillbirth; shortened gestation rather than reduction in fetal growth is the mediating pathway.     

The risk of mortality or cerebral palsy in twins: a collaborative population-based study

The purpose of the paper was to describe demographic and clinical factors associated with fetal or neonatal death or cerebral palsy (CP) in twins. Vital statistics from five populations in the United States and Australia, which included information on CP diagnosed after 1 y of age. Information on zygosity was not available. In 1,141,351 births, 25,772 of whom were twins, significant secular trends from 1980 to 1989 included increasing prevalence of twins, increasing proportion of unlike-sex twins, and increasing maternal age. Overall, twins were at an approximately 5-fold increased risk of fetal death, 7-fold increased risk of neonatal death, and 4-fold increased risk of CP compared with singletons. However, at birth weight <2500 g, twins generally did better than singletons, both with respect to mortality and to CP rates. Second-born twins and twins from same-sex pairs were at increased risk of early death but not of CP. Twins from growth-discordant pairs and twins whose co-twin died were at increased risk of both mortality and CP. The highest rates of CP were in surviving twins whose co-twin was still-born (4.7%), died shortly after birth (6.3%) or had CP (11.8%). In this large data set spanning a 10-y period, overall rates of death or cerebral palsy were higher in twins than singletons, although small twins generally did better than small singletons. Co-twin death was a strong predictor of CP in surviving twins. This risk was the same for same- and different-sex pairs, and observed both for preterm and term infants.     

The epidemiology of sudden infant death syndrome.

BACKGROUND: Twins compared to singletons are at increased risk of sudden infant death syndrome (SIDS). AIMS: To compare the epidemiology of SIDS in twins and singletons and to test the hypothesis that monozygous (MZ) were at greater risk of SIDS than dizygous (DZ) twins. METHODS: Data from the Office for National Statistics on all registered live births and infant deaths with registered cause of death "sudden unexpected death in infancy" in England and Wales from 1993 to 1998 were obtained, together with the registered birth weight and, for twins, whether they were of like or unlike sex. RESULTS: The crude relative risk of SIDS in twins is twice that in singletons. There has been a significant temporal decline in SIDS mortality. There is also a significant increase in risk with decreasing birth weight for both twins and singletons. The birth weight specific risk of SIDS in all except for those > or =3000 g is greater in singletons than in twins. There is no significant difference in risk of SIDS in like compared with unlike sex twins. CONCLUSIONS: In spite of a lower risk of SIDS in twins compared with singletons for each birth weight group <3000 g, one component of the higher crude relative risk of SIDS in twins is attributable to the higher proportion of twins that are of low birth weight. A second component is the higher risk in twins compared with singletons for those of birth weight > or =3000 g. Like sex are at no greater risk than unlike sex twins, which suggests that zygosity is not a significant factor in SIDS.     

The epidemiology of sudden infant death syndrome

Background: Twins compared to singletons are at increased risk of sudden infant death syndrome (SIDS). Aims: To compare the epidemiology of SIDS in twins and singletons and to test the hypothesis that monozygous (MZ) were at greater risk of SIDS than dizygous (DZ) twins. Methods: Data from the Office for National Statistics on all registered live births and infant deaths with registered cause of death "sudden unexpected death in infancy" in England and Wales from 1993 to 1998 were obtained, together with the registered birth weight and, for twins, whether they were of like or unlike sex. Results: The crude relative risk of SIDS in twins is twice that in singletons. There has been a significant temporal decline in SIDS mortality. There is also a significant increase in risk with decreasing birth weight for both twins and singletons. The birth weight specific risk of SIDS in all except for those ≥3000 g is greater in singletons than in twins. There is no significant difference in risk of SIDS in like compared with unlike sex twins. Conclusions: In spite of a lower risk of SIDS in twins compared with singletons for each birth weight group <3000 g, one component of the higher crude relative risk of SIDS in twins is attributable to the higher proportion of twins that are of low birth weight. A second component is the higher risk in twins compared with singletons for those of birth weight ≥3000 g. Like sex are at no greater risk than unlike sex twins, which suggests that zygosity is not a significant factor in SIDS.     

Cerebral palsy: effects of twinning, birthweight, and gestational age.

AIMS: To determine the effects of birthweight and gestational age on the risk of cerebral palsy for multiple and singleton births. METHODS: Children on the North East Thames Regional Health Authority Interactive Child Health System, born between 1 January 1980 and 31 December 1986, and notified as having cerebral palsy, were included. Cases of postneonatal onset, of known progressive, or non-cerebral pathology and with only mild signs were excluded. Rates and relative risks were calculated using the most complete data, which related to 1985-86, and comprised 102,059 singletons and 2367 twins. Logistic regression was used to examine the associations between being a twin, gestational age, and birthweight. RESULTS: The crude rate per 1000 survivors at 1 year of age was 1.0 in singletons and 7.4 in twins. The relative risk was greatest in twins weighing more than 2499 g (4.5). However, after adjusting for reduced birthweight of twins it was the relative risk of twins weighing less than 1400 g that was significantly increased. Logistic regression confirmed that lower fetal growth, lower gestational age, and being a twin are all independent risk factors for cerebral palsy. CONCLUSION: The increased risk to twins of cerebral palsy is not entirely explained by their increased risk of prematurity and low birthweight.     

A study of twin births in Jabalpur City

Summary A study to find the occurrence of twin birth was taken up at Jabalpur city, Madhya Pradesh. A total of 43,652 deliveries were studied, covering the period from 1960 to 1969. The frequency of twinning was found to be 0.87 per cent. A majority (87.5 per cent) of the mothers was Hindus. The maximum number of mothers who gave birth to twins belonged to the age group of 21·30 years (59.88 per cent) and the next highest frequency was in the age group of 30–40 years (27.6 per cent). The incidence of twinning was found to increase from the 3rd parity and the highest incidence was in the 6th para. The sex ratio showed a higher incidence of male births than female births. The average weight of the twins was 2.0 kg. The birth weight was more in male infants than in females. A very high mortality was found among twins; 104 per 1000 died within 24 hours after birth and 170.5 per 1000 died within the 1st week of birth. Only 3 couples had a family history of twinning. From the Department of Preventive and Social Medicine, Medical College, Jabalpur.     

Growth and development in premature twins.

A total of 476 infants (386 singletons and 90 twins) born before 32 weeks'' gestation were studied to compare long term growth and development in twins and singletons. At 18 months, after adjusting for confounding social, obstetric, and neonatal factors, twins were not disadvantaged in their neurodevelopmental status, but were 1.6 cm shorter than singletons and had thicker triceps and subscapular skinfolds. No significant differences were found between first and second born twins in later growth or development at 18 months post-term. While preterm twins may have an inherent disadvantage in linear growth it is suggested that in other respects twinning is not a risk factor in preterm infants.     

Oesophageal atresia in twins

The twin incidence is higher in infants with oesophageal atresia (OA) than in the general population. The purpose of this study was to review the twin OA information from five institutions and evaluate possible links between the development of OA and the twinning process. Data were compared, combined, and analysed. There was a total of 1215 infants with OA, of whom 50 were from a twin pregnancy and 1 from a triplet pregnancy. Two sets of twins were concordant for OA. Mean birth weights and gestational ages were lower in the twin infants (P < 0.0005) and survival was lower in twins (65%, P < 0.005) than singletons. The anatomical variant of pure OA without fistula was seen in proportionally fewer twins (4%) than in singletons (7%). Multiple anomalies were present in 40% of twins compared with 33% of singletons, although this did not reach statistical significance. OA in our multicentre population was more common in twins. Several possible mechanisms are put forward to explain the apparent link between twinning and OA. Further analysis of this aspect of OA may aid in understanding the aetiology of this congenital anomaly. Accepted: 14 December 1999     

Cerebral palsy and multiple births.

AIM: To compare the birthweight specific prevalence of cerebral palsy in singleton and multiple births. METHODS: Registered births of babies with cerebral palsy born to mothers resident in the counties of Merseyside and Cheshire during the period 1982 to 1989 were ascertained. RESULTS: The crude prevalence of cerebral palsy was 2.3 per 1000 infant survivors in singletons, 12.6 in twins, and 44.8 in triplets. The prevalence of cerebral palsy rose with decreasing birthweight. The birthweight specific prevalence among those of low birthweight < 2500 g was not significantly different in singleton than in multiple births. Among infants weighing > or = 2500 g, there was a significantly higher risk in multiple than in singleton births. The higher crude cerebral palsy prevalence in multiple births is partly due to the lower birthweight distribution and partly due to the higher risk among normal birthweight infants. CONCLUSIONS: Multiple birth babies are at increased risk of cerebral palsy. There is also an increased risk of cerebral palsy within a twin pregnancy if the co-twin has died in utero.     

Studies on Birth Defects and Twins in Japan*

Abstract: In Japan, the overall incidence rates of birth defects among fetal deaths were 2.5% for singletons and 3.2% for twins during 1979–1985. The difference is significant at the 5% level. The incidence rate of anencephalus among fetal deaths during the period was higher in singletons than twins in each year, whereas the incidence rate of congenital hydrocephalus among twins was similar to that among singletons except in 1985. The concordance rates were 5.7% for anencephalus, 9% for spina bifida, and 15% for congenital hydrocephalus during the period. In two cases one twin had anencephalus and the other congenital hydrocephalus, and in one case one twin had anencephalus and the other spina bifida. Nationwide data on 112 sets of conjoined twins who died as fetuses or in the postnatal period during 1979–1985 were analysed. Female conjoined twins accounted for 60% of cases. The incidence rate of conjoined twins remained constant throughout the period except in 1985. The overall incidence rate was 10 per million births. A maternal age effect was found in mothers over the age of 40, where the highest incidence rate occurred. The incidence rate increased with birth order.     

Cerebral palsy in twins: a national study

BACKGROUND: Cerebral palsy is more common in twins than singletons. Among twins, if one twin suffers a fetal death or dies in infancy, the prevalence of cerebral palsy in the surviving co-twin is considerably increased, and those from like-sex pairs are particularly at high risk. AIM: To compare birthweight specific cerebral palsy prevalence in like-sex and unlike-sex twins where both twins survive infancy and to provide a comparative and composite picture of cerebral palsy prevalence according to whether a co-twin died or where both twins survived. METHODS: Parents of twins born in England and Wales in 1994 and 1995 completed a booklet with open ended questions asking whether their twins had any medical, physical, visual, genetic, or chromosomal problems. Any mention of cerebral palsy, hemiplegia, diplegia, or quadriplegia allowed the child to be included as a case of cerebral palsy. Birthweight specific prevalence rates of cerebral palsy were determined for like and unlike-sex twins in birthweight groups < 1000 g, 1000-1499 g, 1500-1999 g, 2000-2499 g, and > or = 2500 g. RESULTS: When both twins survived infancy, like-sex were at greater risk of cerebral palsy than unlike-sex twins, but the difference was not statistically significant. If both twins survived infancy, the birthweight specific prevalence of cerebral palsy was significantly less than if the co-twin had died. CONCLUSIONS: Among the generality of twins, like-sex compared with unlike-sex twins are at greater risk of cerebral palsy particularly if one twin suffers a fetal or infant death. Although it is not possible to subdivide the twins according to zygosity, it is postulated that monozygosity and, specifically, monochorionicity may be the crucial feature that leads to the higher prevalence of cerebral impairment among like-sex twins.     

Fetal and infant death in mono- and dizygotic twins in England and Wales 1982-91

AIM: To quantify the level of risk for stillbirth and infant death in singleton compared with twin pregnancies, using national data; to determine the independent effects of zygosity, sex, and birthweight on these risks in twin pregnancies. METHODS: A retrospective national study was carried out of all singleton and twin birth and death registrations in England and Wales 1982-91, according to sex and birthweight group. Weinberg's rule was applied to the twin pairs to differentiate mono- from dizygotic twins. Relative risks for mono- compared with dizygous twins for both twins being stillbirths and for one of the pair being a stillbirth were determined. For twins where one was stillborn and the other live born, the relative risk of neonatal and infant mortality in the surviving co-twin was determined. RESULTS: There were 6 563 834 registered singletons and 70772 registered twin pairs for the period under study. Monozygotic twins had a relative risk of: 18.91 (95% CI 12.48-28.64) for both twins being stillborn; 1.63 (95% CI 1.48-1.79) for one twin being a stillbirth; and 2.26 (95% CI 1.45-3.52) for the live born co-twin dying as a neonate. When both twins were live born and among singletons, the odds ratio for neonatal mortality of being male was 1.41 (95% CI 1.37-1.45) and there was a highly significant negative association with birthweight. After adjusting for birthweight group and sex, twins had a reduced neonatal mortality compared with singletons: odds ratio 0.91 (95% CI 0.85-0.96). CONCLUSIONS: Fetal death in one of monozygotic twins has serious implications for survival of the co-twin. Monochorionicity is probably the essential feature of the increased risk to the co-twin. It is imperative that all fetal deaths in multiple pregnancies are recorded and chorionicity determined if parents are to be adequately counselled.     

Language assessment of non‐handicapped twins at 5 years of age

Background: The aim of the present study was to determine language levels in twins and singletons born after at least 34 weeks gestation and without identifiable neurological abnormality and to evaluate whether in vitro fertilization (IVF) affects language development in twin pregnancies. Methods: A prospective study of a large cohort of all children born between 1 January 2001 and 31 December 2003 was carried out at Gazi University Hospital. All live‐born twin pairs in which both twins survived were identified, and a comparable sample of families with pairs of singletons were chosen. The Stanford–Binet Intelligence Scale Form and the translated Turkish form of the Peabody Picture Vocabulary Test were completed at 60 months. Results: Even after excluding the most premature twins and those with diagnosable neurological damage, twins performed worse than singletons on language development tests. Twin girls had better scores than twin boys. A statistically significant difference was found between the scores of term and preterm twins. No significant difference was noted when compared according to birth order. Appropriate for gestational age (AGA) twins did better than small for gestational age (SGA) twins in the test scores. All twin girls did not differ from singleton girls, but all twin boys performed worse than singleton boys. Term twins had similar results with term singletons, but preterm twins had lower scores than preterm singletons. SGA singletons had better scores than SGA twins, while AGA twins and singletons did not differ. When the children were compared with regard to method of conception, IVF children had significantly lower scores on the tests than those in the spontaneous conception group. Conclusion: It is hoped that the present findings could lead to a more precise assessment of children for speech impairment and, above all, to more efficient preventive intervention. Whatever mechanisms are involved, the present results indicate that twins born as a result of IVF, are at a disadvantage in terms of language development in comparison with spontaneously conceived twins.     

A study of perinatal mortality rate from rural based Medical College Hospital

The present study conducted in a rural medical college aimed at analysing the perinatal mortality and its determinants in a rural set up. Fiftyeight still births and sixty two early neonatal deaths among 1107 consecutive deliveries gave a perinatal mortality rate of 108.4 per 1000 deliveries. Fifty percent of the total deliveries were unbooked. The perinatal mortality was higher in unbooked cases (16.3%), twins (33.2%) and preterms (33.9%) as compared to that in booked cases (5.3%), singletons (9.6%) and term deliveries (6.7%). Sixty nine percent of the still births were due to causes like obstructed labour, toxemia of pregnancy, antepartum hemorrhage, hand prolapse, and cord prolapse where timely intervention would have reduced the perinatal mortality significantly. Early neonatal deaths were mainly associated with prematurity and were largely due to birth anoxia, intraventricular hemorrhage, aspiration and infections.     

Physical and mental development of Turkish twins

BACKGROUND: Multiple gestations are known to bring some risks in the prenatal and natal period, but whether it is a risk for development in childhood is a matter of debate. The aim of the present study was to evaluate physical and mental development of Turkish twins and then to assess whether being a twin poses risks for their development. METHODS: Fifty-two twin pairs (104 children) aged between 1 and 5 years were enrolled in the study. The control group consisted of 91 singletons, who were matched according to age, sex, gestational week and maternal educational level. The Denver Developmental Screening Test (DDST) was administered to assess cognitive development. Student t-test and chi2 test were used to compare the two groups. RESULTS: The mean age of the mothers of twins did not differ from that of singleton mothers (P > 0.05). Twins were more frequently born in cases of assisted fertilization and were more often born via cesarean section. The birthweights of twins were lower and they were more frequently hospitalized after birth. The breast feeding period was shorter in twins and they had more chronic diseases than singletons (P < 0.05). Mothers of twins needed more help while caring for their infants. Physical development of twins and singletons did not differ statistically (P > 0.05). Twins had more suspect and delayed results in the DDST, especially in the language section of the test. CONCLUSION: Physical and mental development of twins does not differ significantly from singletons except that twins might have a tendency towards slow language acquisition.     

Risk approach in maternal care: how benificial is this approach in reality?

Community based study was conducted in rural area of comprehensive rural health services Project, Ballabgarh of All India Institute of Medical Sciences to measure the incidence of risk factors (mainly based on interrogation and simple clinical examination) in pregnant women, their distribution and magnitude, the risk of bad outcome and utility of this approach in the field. The incidence of risk factors was 9·6 per cent. Severe anemia in current pregnancy, neonatal death in last pregnancy or more than one neonatal death in previous pregnancies, still birth in last pregnancy or more than one still-birth in previous pregnancies, three or more sucessive abortions, more than ten pregancies accounted for 84·8 per cent of those with single risk factor. The relative risk of bad outcome in pregnancies with risk factor is 4·69 times more than in those without risk factor. Pregnant women with severe anemia in current pregnancy or neonatal death in last pregnancy or more than one neonatal death in previous pregnancies had a relative risk of 4·27 and 7·89 respectively. If the still-births group and abortion group are combined with neonatal death group still the relative risk is high i.e. 6·35. These individual risk factors are easily identifiable by trained paramedicals or health volunteers. But the sensitivity (29·6%) and predictability (17·8%) of this approach are very low.     

Acute respiratory infections in Kangra district: Magnitude and current treatment practices

A review of medical records of health centres in Kangra districts, Himachal Pradesh during October 1984 to September 1985 revealed that of 3,72,000 attendances, 18% were for acute respiratory infections (ARI) and 12% for diarrheal diseases. The annual incidence of visits for ARI among children below five was higher than that of general population (8·2/1000 vs. 6·7/1000). ARI was more common during the post-monsoon period and among people living in mountainous areas. The case fatality rate in hospitalised ARI patients was 10·5%. Interview of health centre physicians regarding ARI management practices indicated that chest indrawing (considered by WHO as pathognomonic of severe ARI) was not recognised as an important sign by majority of physicians. Ninety-one per cent of physicians disagreed (69% in strong terms) with the idea of providing health workers with antimicrobials for management of ARI at the community level.     

Follow-up of twins: health, behaviour, speech, language outcomes and implications for parents

The introduction of assisted reproduction has resulted in a growing number of multiple births. These infants and their parents experience increased, and sometimes unique, medical and psychological risks when compared to singletons. Rates of maternal morbidity, fetal and infant mortality are increased in multiple pregnancies. Twins have a death rate four times higher than singletons and this figure is six times higher for triplets. The main reason is preterm and very preterm birth in multiples, resulting in low and very low birth weight children. Perinatal mortality and morbidity are also more elevated in monozygotic (MZ) twins as compared to dizygotic (DZ) twins. In addition to an increased risk of mortality, multiples have higher rates of morbidity, specifically cerebral palsy and mental subnormality. Language and speech delays are more pronounced in multiples, as are cognitive delays, motor development, behavioural problems and difficulties in parent-child interactions. Depression among parents of multiples is reported to be higher than those of singletons. This paper aims to critically appraise the literature regarding the aforementioned topics, including a comparison between the outcomes for iatrogenic and spontaneously conceived twins and to suggest areas for further research.