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Clinical Management of Twin and Multiple Pregnancies

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Obstetrics & Gynecology".

Deadline for manuscript submissions: closed (20 August 2023) | Viewed by 11740

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Prof. Dr. Liran Hiersch

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Guest Editor

1. Department of Maternal-Fetal Medicine, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
2. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Interests: twin pregnancies; preterm birth; obstetrics; placenta-related complications; fetal; labor
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Special Issue Information

Dear Colleagues,

Multiple gestations account for about 3.3% of all deliveries in the United States, with the majority of them being dichorionic diamniotic (DCDA) twin pregnancies. The risk of almost all perinatal complications is increased in multiple gestations, mainly preterm birth and inadequate fetal growth. Therefore, twin pregnancies necessitate closer antenatal surveillance in order to improve obstetrics outcome. The scope of this Special Issue is to provide an overview of recent advances in the field of multiple gestations and twin pregnancies with a focus on the clinical aspects of prediction, prevention, and potential treatment of adverse outcome. Therefore, researchers in the field of obstetrics and maternal-fetal medicine are encouraged to submit an original article or review to this Special Issue (case reports and short reviews are not accepted).

Prof. Dr. Liran Hiersch
Guest Editor

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Keywords

twin pregnancies
multiple gestations
screening
prevention
management
biomarkers
postpartum
overweight
type 2 diabetes mellitus

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Published Papers (6 papers)

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Editorial

Jump to: Research

2 pages, 168 KiB

Open AccessEditorial

Twin Pregnancies—More to Be Done

by Matan Anteby and Liran Hiersch

J. Clin. Med. 2022, 11(21), 6358; https://doi.org/10.3390/jcm11216358 - 27 Oct 2022

Viewed by 1003

Abstract

Over the past few decades, we have been experiencing an increase in the incidence of multiple gestations, mostly due to the widespread use of assisted reproduction technologies [...] Full article

(This article belongs to the Special Issue Clinical Management of Twin and Multiple Pregnancies)

Research

Jump to: Editorial

10 pages, 282 KiB

Open AccessFeature PaperArticle

Perinatal Outcomes of Monochorionic Twin Pregnancies Conceived Naturally Versus through Assisted Reproductive Techniques

by Alicia Martínez-Varea, Martha Martínez-Gómez, Blanca Novillo, Josep Domenech, José Morales-Roselló and Vicente Diago-Almela

J. Clin. Med. 2023, 12(18), 6097; https://doi.org/10.3390/jcm12186097 - 21 Sep 2023

Cited by 1 | Viewed by 1441

Abstract

Objective: It has been reported that monochorionic twin pregnancies conceived through assisted reproductive techniques (ART) display a higher risk of second-trimester miscarriage, cesarean delivery, and neonatal death than those conceived naturally. The aim of this study was to compare the perinatal outcomes of monochorionic diamniotic (MCDA) twin pregnancies conceived naturally and through ART in a tertiary hospital. Methods: This was a retrospective cohort study of all MCDA twin pregnancies that received obstetric care and delivered at La Fe University and Polytechnic Hospital between 2015 and 2021. MCDA pregnancies that were referred to the tertiary hospital for specialized management, follow-up, and delivery were also included. The study was approved by The Health Research Institute Hospital La Fe (IIS La Fe). Results: Among the 184 MCDA pregnancies, 149 (81%) had a natural conception, and 35 (19%) were conceived through ART. Patients with an MCDA pregnancy who conceived through ART had a significantly older maternal age (38.0 [35.5–42.5] vs. 32.0 [29.0–36.0], p < 0.001) and an elevated rate of nulliparity (80.0% vs. 50.3%, p = 0.001). Regarding pregnancy complications, MCDA pregnancies through ART were associated with a significantly higher incidence of gestational diabetes (22.9% vs. 2.7%, p < 0.001), hypertensive disorders during pregnancy (22.9% vs. 9.4%, p = 0.04), and other pregnancy complications such as threatened labor or preterm prelabor rupture of membranes (14.3% vs. 36.2%, p = 0.015), than naturally conceived MCDA pregnancies. No differences were found in the incidence of twin-to-twin transfusion syndrome (20% vs. 33.6%, p = 0.155). MCDA pregnancies through natural conception had a greater rate of vaginal delivery than MCDA through ART (16.8% vs. 2.9%, p = 0.032). When adjusted for confounding factors, MCDA pregnancies through ART were only more likely to develop gestational diabetes than those naturally conceived (aOR 7.86, 95% CI 1.55–39.87). No differences were found regarding neonatal outcomes between groups. Conclusions: Compared with naturally conceived MCDA twin pregnancies, those conceived through ART displayed a significantly higher risk of developing gestational diabetes. No differences regarding other pregnancy complications, mode of delivery, or neonatal outcomes were found between groups. Full article

(This article belongs to the Special Issue Clinical Management of Twin and Multiple Pregnancies)

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11 pages, 730 KiB

Open AccessArticle

Preterm Prelabour Rupture of Membranes before Viability in Twin Pregnancies: What Can We Expect?

by Júlia Ponce, Teresa Cobo, Clara Murillo, Anna Gonce, Nadia Domínguez, Francesca Crovetto, Laura Guirado, Montse Palacio and Mar Bennasar

J. Clin. Med. 2023, 12(8), 2949; https://doi.org/10.3390/jcm12082949 - 18 Apr 2023

Cited by 2 | Viewed by 3144

Abstract

Preterm prelabour rupture of membranes (PPROMs) before viability carries significant perinatal mortality and morbidity. Clinical management and prenatal counselling are a challenge, especially in twin pregnancies, due to scarce evidence on how previable PPROM affects this population. The aim of this study was to describe pregnancy outcomes of twin pregnancies complicated with previable PPROM and evaluate potential prognostic factors that may predict perinatal mortality. A retrospective cohort including dichorionic and monochorionic diamniotic twin pregnancies complicated with PPROM before 24 + 0 weeks of pregnancy was evaluated. Perinatal outcomes of pregnancies managed expectantly were described. Factors predicting perinatal mortality or reaching periviability (defined from 23 + 0 weeks onwards) were evaluated. Of the 45 patients included, 7 (15.6%) spontaneously delivered within the first 24 h after diagnosis. Two patients (5.3%) requested selective termination of the affected twin. In the 36 ongoing pregnancies that opted for expectant management, the overall survival rate was 35/72 (48.6%). There were 25/36 (69.4%) patients who delivered after 23 + 0 weeks of pregnancy. When periviability was achieved, neonatal survival increased up to 35/44 (79.5%). Gestational age at delivery was the only independent risk factor of perinatal mortality. The overall survival rate of twin pregnancies complicated with previable PPROM is poor but similar to singletons. No prognostic factors, apart from achieving periviability, were identified as individual predictors of perinatal mortality. Full article

(This article belongs to the Special Issue Clinical Management of Twin and Multiple Pregnancies)

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9 pages, 514 KiB

Open AccessArticle

Short Interpregnancy Interval Following a Multifetal Pregnancy: Maternal and Neonatal Outcomes

by Ari Weiss, Hen Y. Sela, Sorina Grisaru-Granovsky and Misgav Rottenstreich

J. Clin. Med. 2023, 12(7), 2576; https://doi.org/10.3390/jcm12072576 - 29 Mar 2023

Viewed by 1803

Abstract

Objective: To evaluate the maternal and neonatal outcomes of women with short interpregnancy intervals (IPI < 6 months) following a multifetal pregnancy. Study design: A multicenter retrospective cohort study of women with an index multifetal delivery and a subsequent singleton gestation between 2005 and 2021. The obstetrical outcomes of pregnancies following short IPI (<6 months) were compared to those with an IPI of 18–48 months. Additional analyses were also conducted for the other IPI groups: 7–17 months, and longer than 49 months, while women with an IPI of 18–48 months served as the reference group. The primary outcome was preterm birth (<37 weeks) rate. Secondary outcomes were other adverse maternal and neonatal outcomes. Univariate and multiple logistic regression analyses were performed. Results: Overall, 2514 women had a primary multifetal delivery with a subsequent singleton gestation at our medical centers; 160 (6.4%) had a short IPI, and 1142 (45.4%) had an optimal IPI. Women with a singleton gestation following a short IPI were younger, with lower rates of previous cesarean and fertility treatments. Women in the short IPI group had significantly higher rates of preterm birth <37 weeks, anemia (Hb < 11 gr%) on admission to the delivery room, and placental abruption. Multivariable logistic regression analysis demonstrated that short IPI is associated with an increased risk for preterm birth (aOR 2.39, 95% CI 1.12–5.11, p = 0.03). Conclusion: Short IPI following a multifetal gestation is associated with an increased risk for preterm birth in subsequent singleton pregnancy. Full article

(This article belongs to the Special Issue Clinical Management of Twin and Multiple Pregnancies)

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11 pages, 242 KiB

Open AccessArticle

Induction of Labor in Twins—Double Trouble?

by Miriam Lopian, Lior Kashani-Ligumsky, Ronnie Cohen, Izaak Wiener, Bat-Chen Amir, Yael Gold Zamir, Ariel Many and Hadar Rosen

J. Clin. Med. 2023, 12(5), 2041; https://doi.org/10.3390/jcm12052041 - 4 Mar 2023

Cited by 3 | Viewed by 1995

Abstract

Objective: To determine and compare the safety and efficacy of different methods of induction of labor in twin gestations and their effect on maternal and neonatal outcomes. Methods: A retrospective observational cohort study was conducted at a single university-affiliated medical center. Patients with a twin gestation undergoing induction of labor at >32 + 0 weeks comprised the study group. Outcomes were compared to patients with a twin gestation at >32 + 0 weeks who went into labor spontaneously. The primary outcome was cesarean delivery. Secondary outcomes included operative vaginal delivery, postpartum hemorrhage, uterine rupture, 5 min APGAR < 7, and umbilical artery pH < 7.1. A subgroup analysis comparing outcomes for the induction of labor with oral prostaglandin E1 (PGE1), IV Oxytocin ± artificial rupture of membranes (AROM), and extra-amniotic balloon (EAB)+ IV Oxytocin was performed. Data were analyzed using Fisher’s exact test, ANOVA, and chi-square tests. Results: 268 patients who underwent induction of labor with a twin gestation comprised the study group. 450 patients with a twin gestation who went into labor spontaneously comprised the control group. There were no clinically significant differences between the groups for maternal age, gestational age, neonatal birthweight, birthweight discordancy, and non-vertex second twin. There were significantly more nulliparas in the study group compared to the control group (23.9% vs. 13.8% p < 0.001). The study group was significantly more likely to undergo a cesarean delivery of at least one twin (12.3% vs. 7.5% OR, 1.7 95% CI 1.04–2.85 p = 0.03). However, there was no significant difference in the rate of operative vaginal delivery (15.3% vs. 19.6% OR, 0.74, 95% CI 0.5–1.1 p = 0.16), PPH (5.2% vs. 6.9% OR, 0.75 95% CI 0.39–1.42 p = 0.37), 5-min APGAR scores < 7 (0% vs. 0.2% OR, 0.99 95%CI 0.99–1.00 p = 0.27), umbilical artery pH < 7.1 (1.5% vs. 1.3% OR, 1.12 95% CI 0.3–4.0), or combined adverse outcome (7.8% vs. 8.7% OR, 0.93 95% CI 0.6–1.4 p = 0.85). Furthermore, there were no significant differences in the rates of cesarean delivery or combined adverse outcomes in patients undergoing induction with oral PGE1 compared to IV Oxytocin ± AROM (13.3% vs. 12.5% OR, 1.1 95% CI 0.4–2.0 p = 1.0) (7% vs. 9.3% OR, 0.77 95% CI 0.5–3.5 p = 0.63 ) or EAB+ IV Oxytocin (13.3% vs. 6.9% OR, 2.1 95% CI 0.1–2.1 p = 0.53) (7% vs. 6.9% OR, 1.4 95% CI 0.15–3.5 p = 0.5) or between patients undergoing induction of labor with IV Oxytocin ± AROM and EAB+ IV Oxytocin (12.5% vs. 6.9% OR, 2.1 95% CI 0.1–2.4 p = 0.52) (9.3% vs. 6.9% OR, 0.98 95% CI 0.2–4.7 p = 0.54). There were no cases of uterine rupture in our study. Conclusions: Induction of labor in twin gestations is associated with a two-fold increased risk of cesarean delivery, although this is not associated with adverse maternal or neonatal outcomes. Furthermore, the method of induction of labor used does not affect the chances of success nor the rate of adverse maternal or neonatal outcomes. Full article

(This article belongs to the Special Issue Clinical Management of Twin and Multiple Pregnancies)

10 pages, 1204 KiB

Open AccessArticle

Effect of Gestational Age at Fetoscopic Laser Photocoagulation on Perinatal Outcomes for Patients with Twin–Twin Transfusion Syndrome

by Li-Chun Chiu, Yao-Lung Chang, An-Shine Chao, Shuenn-Dyh Chang, Po-Jen Cheng and Yi-Chiao Liao

J. Clin. Med. 2023, 12(5), 1900; https://doi.org/10.3390/jcm12051900 - 28 Feb 2023

Cited by 1 | Viewed by 1674

Abstract

Purpose: The aim of this study was to evaluate the effect of gestational age (GA) at the time of fetoscopic laser photocoagulation (FLP) for severe twin–twin transfusion syndrome (TTTS) on perinatal outcomes in a single center in Taiwan. Materials and methods: Severe TTTS was defined as a diagnosis of TTTS before a GA of 26 weeks. Consecutive cases of severe TTTS treated at our hospital with FLP between October 2005 and September 2022 were included. The evaluated perinatal outcomes were preterm premature rupture of membranes (PPROM) within 21 days of FLP, survival 28 days after delivery, GA at delivery, and neonatal brain sonographic imaging findings within 1 month of delivery. Results: We included 197 severe TTTS cases; the mean GA at the time of FLP was 20.6 weeks. After the cases were divided into cases of FLP at early (below 20 weeks) and late GAs (more than 20 weeks), the early-GA group was discovered to be associated with a deeper maximum vertical pocket in the recipient twin, a higher rate of PPROM development within 21 days of FLP, and lower rates of survival of one or both twins. In the cases of stage I TTTS, the rate of PPROM within 21 days of FLP was higher in the group that underwent FLP at an early GA than in the group that underwent FLP at a late GA (50% (3/6) vs. 0% (0/24), respectively, p = 0.005). Logistic regression analysis revealed that the GA at the time of FLP and the cervical length before FLP is implemented are significantly associated with the survival of one twin and the incidence of PPROM development within 21 days of FLP. The GA at the time of FLP, the cervical length before FLP, and TTTS being stage III TTTS were associated with the survival of both twins after FLP. Neonatal brain image anomalies were associated with GA at delivery. Conclusions: FLP being performed at an earlier GA is a risk factor for lower fetal survival and PPROM development within 21 days of FLP in cases of severe TTTS. Delaying FLP for cases involving stage I TTTS diagnosed at an early GA without risk factors, such as maternal symptoms, cardiac overload in the recipient twin, or a short cervical length, may be considered, but whether delaying FLP would improve surgical outcomes and, if so, how long the delay should be may need further trials to answer. Full article

(This article belongs to the Special Issue Clinical Management of Twin and Multiple Pregnancies)

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