Advances in Clinical and Experimental Medicine

Title abbreviation: Adv Clin Exp Med
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5-Year Impact Factor – 2.135
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MEiN – 70 pts

ISSN 1899–5276 (print)
ISSN 2451-2680 (online)
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Advances in Clinical and Experimental Medicine

2019, vol. 28, nr 2, February, p. 237–242

doi: 10.17219/acem/90765

Publication type: original article

Language: English

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Postnatal condition of the second twin in respect to mode of delivery, chorionicity and type of fetal growth

Jerzy S. Florjański1,A,B,C,D,E,F, Wojciech Homola1,A,B,C,D,F, Tomasz Fuchs1,B,E,F, Agata Pawłosek2,B,E,F, Mariusz Kasperski2,B,E,F

1 II Department of Gynecology and Obstetrics, Faculty of Medicine, Wroclaw Medical University, Poland

2 Clinic of Gynecology and Obstetrics, Jan Mikulicz-Radecki University Teaching Hospital, Wrocław, Poland


Background. The increased use of assisted reproductive techniques (ART) contributes to the increased rate of twin pregnancies, which are burdened with a higher risk of complications. Factors that affect the condition of the second twin are understudied.
Objectives. The objective of this study was to assess the impact of the delivery mode, chorionicity, amnionicity, and the type of fetal growth on the postnatal condition of the second twin.
Material and Methods. The study included data from 475 pregnant women with twin pregnancies. Maternal age, parity, chorionicity, amnionicity, type of fetal growth, mode of delivery, gestational weeks at delivery, Apgar score, and umbilical arterial blood pH were retrospectively analyzed. Data normality was checked with the Kolmogorov-Smirnov test. The paired Wilcoxon signed-rank test and χ2 test were used for comparisons between groups. To check predictive value of the analyzed variables multiple linear regression was used.
Results. The mean maternal age was 29.22 (standard deviation (SD) ±5.19) years. The maternal age and gestational age at delivery did not differ significantly between women who delivered by cesarean section (CS) and vaginal delivery (VD). In the second twin, the Apgar score and values of arterial umbilical blood pH were lower in infants delivered by VD than in those delivered by CS (6.30 ±2.83 and 7.30 ±0.12; p = 0.0209 and 7.26 ±0.12 and 7.30 ±0.11; p = 0.0236, respectively). In monochorionic diamniotic twins with asymmetric growth, the second twin achieved significantly lower outcome than the first twin. Vaginal delivery was a predictive factor for a lower Apgar score and lower values of umbilical arterial blood pH in second twins, while not in first twins. Symmetrical fetal growth of twins was a predictive factor for better postnatal condition for both twins.
Conclusion. In twin pregnancies, VD, but not CS, is associated with increased risk of worse postnatal condition of the second twin. In monochorionic diamniotic pregnancies complicated by growth discordance, CS seems to be a reasonable mode of delivery.

Key words

twin pregnancy, mode of delivery, chorionicity, type of twin growth, postnatal condition of the second twin

References (33)

  1. Collins J. Global epidemiology of multiple birth. Reprod Biomed Online. 2007;15(Suppl 3):45–52.
  2. Martin JA, Hamilton BE, Osterman MJ, Driscoll AK, Mathews TJ. Births: Final data for 2015. Natl Vital Stat Rep. 2017;66(1):1.
  3. Huang JY, Rosenwaks Z. Assisted reproductive techniques. Methods Mol Biol. 2014;1154:171–231.
  4. Rzyska E, Ajay B, Chandraharan E. Safety of vaginal delivery among dichorionic diamniotic twins over 10 years in a UK teaching hospital. Int J Gynaecol Obstet. 2017;136(1):98–101.
  5. Kong CW, To WWK. The predicting factors and outcomes of caesarean section of the second twin. J Obstet Gynaecol. 2017;37(6):709–713.
  6. Qin JB, Wang H, Sheng X, Xie Q, Gao S. Assisted reproductive technology and risk of adverse obstetric outcomes in dichorionic twin pregnancies: A systematic review and meta-analysis. Fertil Steril. 2016;105(5):1180–1192.
  7. Rao A, Sairam S, Shehata H. Obstetric complications of twin pregnancies. Best Pract Res Clin Obstet Gynaecol. 2004;18(6):557–576.
  8. Sato Y, Emoto I, Maruyama S, Taga A, Fujii T. Twin vaginal delivery is associated with lower umbilical arterial blood pH of the second twin and less intrapartum blood loss. J Matern Fetal Neonatal Med. 2016;29(19):3067–3071.
  9. Kosińska-Kaczyńska K, Szymusik I, Bomba-Opoń D, et al. Perinatal outcome according to chorionicity in twins: A Polish multicenter study. Ginekol Pol. 2016;87(5):384–389.
  10. Shinwell ES, Blickstein I, Lusky A, Reichman B. Effect of birth order on neonatal morbidity and mortality among very low birthweight twins: A population based study. Arch Dis Child Fetal Neonatal Ed. 2004;89(2):F145–F148.
  11. Barrett JF, Hannah ME, Hutton EK, et al; Twin Birth Study Collaborative Group. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med. 2013;369(14):1295–1305.
  12. Schmitz T, Prunet C, Azria E, et al; JUmeaux MODe d’Accouchement (JUMODA) Study Group and the Groupe de Recherche en Obstétrique et Gynécologie (GROG). Association between planned cesarean delivery and neonatal mortality and morbidity in twin pregnancies. Obstet Gynecol. 2017;129(6):986–995.
  13. Sadeh-Mestechkin D, Daykan Y, Bustan M, Markovitch O, Shechter-Maor G, Biron-Shental T. Trial of vaginal delivery for twins: Is it safe? A single center experience. J Matern Fetal Neonatal Med. 2018;31(15):1967–1971.
  14. Rossi AC, Mullin PM, Chmait RH. Neonatal outcomes of twins according to birth order, presentation and mode of delivery: A systematic review and meta-analysis. BJOG. 2011;118(5):523–532.
  15. Breathnach FM, McAuliffe FM, Geary M, et al; Perinatal Ireland Research Consortium. Definition of intertwin birth weight discordance. Obstet Gynecol. 2011;118(1):94–103.
  16. Kiely JL. The epidemiology of perinatal mortality in multiple births. Bull N Y Acad Med. 1990;66(6):618–637.
  17. Barrett JF. Twin delivery: Method, timing and conduct. Best Pract Res Clin Obstet Gynaecol. 2014;28(2):327–338.
  18. Asztalos EV, Hannah ME, Hutton EK, et al. Twin Birth Study: 2-year neurodevelopmental follow-up of the randomized trial of planned cesarean or planned vaginal delivery for twin pregnancy. Am J Obstet Gynecol. 2016;214:371.
  19. Smith GC, Shah I, White IR, Pell JP, Dobbie R. Mode of delivery and the risk of delivery-related perinatal death among twins at term: A retrospective cohort study of 8073 births. BJOG. 2005;112(8):1139–1144.
  20. Easter SR, Robinson JN, Lieberman E, Carusi D. Association of intended route of delivery and maternal morbidity in twin pregnancy. Obstet Gynecol. 2017;129(2):305–310.
  21. Zipori Y, Smolkin T, Makhoul IR, Weissman A, Blazer S, Drugan A. Optimizing outcome of twins by routine cesarean section beyond 37 weeks. Am J Perinatol. 2011;28(1):51–56.
  22. Hartley RS, Hitti J. Please exit safely: Maternal and twin pair neonatal outcomes according to delivery mode when twin A is vertex. J Matern Fetal Neonatal Med. 2017;30(1):54–59.
  23. Jhaveri RR, Nadkarni TK. Perinatal outcome of second twin with respect to mode of delivery: An observational study. J Clin Diagn Res. 2016;10(12):QC26–QC28.
  24. Ylilehto E, Palomäki O, Huhtala H, Uotila J. Term twin birth: Impact of mode of delivery on outcome. Acta Obstet Gynecol Scand. 2017;96(5):589–596.
  25. Malin GL, Morris RK, Khan KS. Strength of association between umbilical cord pH and perinatal and long term outcomes: Systematic review and meta-analysis. BMJ. 2010;340:c1471.
  26. Leung TY, Tam WH, Leung TN, Lok IH, Lau TK. Effect of twin-to-twin delivery interval on umbilical cord blood gas in the second twins. BJOG. 2002;109(1):63–67.
  27. Leung TY, Lok IH, Tam WH, Leung TN, Lau TK. Deterioration in cord blood gas status during the second stage of labour is more rapid in the second twin than in the first twin. BJOG. 2004;111(6):546–549.
  28. Hollier LM, McIntire DD, Leveno KJ. Outcome of twin pregnancies according to intrapair birth weight differences. Obstet Gynecol. 1999;94(6):1006–1010.
  29. Demissie K, Ananth CV, Martin J, Hanley ML, MacDorman MF, Rhoads GG. Fetal and neonatal mortality among twin gestations in the United States: The role of intrapair birth weight discordance. Obstet Gynecol. 2002;100(3):474–480.
  30. Kontopoulos EV, Ananth CV, Smulian JC, Vintzileos AM. The influence of mode of delivery on twin neonatal mortality in the US: Variance by birth weight discordance. Am J Obstet Gynecol. 2005;192(1):252–256.
  31. Canpolat FE, Yurdakök M, Korkmaz A, Yigit S, Tekinalp G. Birthweight discordance in twins and the risk of being heavier for respiratory distress syndrome. Twin Res Hum Genet. 2006;9(5):659–663.
  32. Usta IM, Nassar AH, Abu Musa AA, Awwad JT, Yunis KA, Seoud MA. Perinatal outcome of vaginally delivered twin gestations with a larger twin B. J Perinatol. 2003;23(5):409–413.
  33. Dashe JS, McIntire DD, Santos-Ramos R, Leveno KJ. Impact of head-to-abdominal circumference asymmetry on outcomes in growth-discordant twins. Am J Obstet Gynecol. 2000;183(5):1082–1087.