Clinical factors affecting the timing of delivery in twin pregnancies

OBJECTIVE: To investigate clinical factors affecting the timing of delivery in twin pregnancies in order to minimize perinatal complications. METHODS: A retrospective study involved 163 twin pregnancies delivered from January 2006 to September 2011 at Gachon University Gil Medical Center. These cases were divided into three groups based on the delivery timing: less than 32 weeks' gestation (group A), between 32 and 35+6 weeks' gestation (group B), and over 36 weeks' gestation (group C). Clinical factors including maternal age, parity, presence of premature uterine contraction, presence of premature rupture of membrane, white blood cell, high sensitive C-reactive protein level, cervical dilatation, maternal complication, chorionicity, twin specific complication, and perinatal complication were analyzed for each group. RESULTS: In group B, the timing of delivery was postponed for 14 days or more from the time of admission, and there were fewer numbers of babies with low Apgar score at birth compared with other groups. The frequency of uterine contraction (P<0.001), presence of premature rupture of membranes (P=0.017), dilatation of cervix (P<0.001), increased white blood cell and high sensitive C-reactive protein levels (P=0.002, P<0.001) were important clinical factors during decision making process of delivery timing in twin pregnancies. Twin specific fetal conditions, such as twin-twin transfusion syndrome and discordant growth (over 25% or more) were shown more frequently in group A. However, there were no significant statistical differences among three groups (P=0.06, P=0.14). CONCLUSION: Proper management for preventing premature contraction and inflammation can be essential in twin pregnancies until 32 weeks' gestation, and may decrease maternal and perinatal complications.

The perinatal outcome of vaginal delivery in twin pregnancy / 대한산부인과학회지

OBJECTIVE: To evaluate the perinatal outcome of vaginal delivery in twin pregnancy according to the presentation of the fetus. METHODS: A total of 274 cases suitable to this objective were selected from the 301 cases of twin pregnancy delivered between March 2000 and February 2005. They were categorized into 3 groups according to the presentation of the fetus; vertex/vertex as the group A (133 cases), vertex/nonvertex as the group B (80 cases), nonvertex in the first twin as the group C (61 cases). And then each group also was divided into 2 subgroups according to the mode of delivery; vaginal delivery and cesarean delivery. The difference between the subgroups in each group as to perinatal outcome was retrospectively compared and analyzed for statistical significance. RESULTS: The incidence of vaginal delivery in group A (46/133, 34.6%) was significantly higher than in group B (5/80, 6.3%) and C (5/61, 8.2%). A total of 218 (79.6%) cases were underwent the cesarean delivery and the most common indication of cesarean delivery was elective twin cesarean delivery in all 3 groups (65.4%, 93.8%, 91.8% respectively). The incidence of neonatal admission to the neonatal intensive care unit was, however, higher in vaginal delivery (40.2%) than in cesarean delivery (32.8%) in group A. The most common cause for neonatal intensive care unit admission was low birth weight for simple observation, and average admission dates of vaginal delivery was 17.0 days and cesarean delivery was 16.8 days. CONCLUSION: Vaginal delivery of twins depends on the presentation of the fetus, but no significant difference in perinatal outcome of group A were observed between the mode of delivery. Therefore attempt to decrease the incidence of elective twin cesarean delivery in group A is demanded.

The Hemodynamic Change of Doppler Flow Velocimetry to Developing of Twin Growth Discordance in Relation to Placental Chorionisity, Placental Weight and Umbilical Cord Insertion / 대한산부인과학회잡지

OBJECTIVE: To evaluate hemodynamic change in growth discordant twins using a ratio of middle cerebral artery/umbilical artery resistance index and to assess the relationship between Doppler hemodynamic and the influence of placental chorionisity and umbilical cord insertion. METHODS: 118 live born twin pairs whose birthweight discordance below or above 20% between March 2000 and March 2002 were included in our study. And we divided the two groups in which above 20% of growth discordance (GD) group was GD and below 20% of GD group was control. Chorionisity and umbilical cord insertion in all study subjects within 24 hours after delivery were investigated. And then we classified to monochorionic (MONO), and dichorionic (DI) placenta and the type of insertion of umbilical cord were also classified central, marginal and velamentous type. 56 of twin pairs were performed 153 Doppler flow velocimetry between smaller and larger fetus prenatally. Resistance index (RI) of middle cerebral artery and umbilical artery in each fetus were measured and standardized as a ratio of middle cerebral artery/umbilical artery (MCA/UmA). ANOVA, Mann-Whitney U test, and chi-square test, were performed and p<0.05 was considered as statistically significant. RESULTS: Mean birthweight in monochorionic twins had lighter than those of dichorionic twins (p<0.01). The mean growth discordant ratios were 14.1% in monochorionic twin and 12.1% in dichorionic twins. In monochorionic twin, the smaller fetus in GD group showed lower value of MCA/UmA RI ratio than those of the larger fetus, significantly (1.09 vs. 1.28 p<0.05). And in monochorionic twins, the smaller fetus in GD group showed lower value of MCA/UmA RI ratio than the smaller fetus in control group, significantly (1.09 vs. 1.27 p<0.05). The placental weight in dichorionic twin was correlated the birthweight in infants in GD group, positively. Monochorionic twins in GD group had a significantly higher incidence of peripheral cord insertion than those of dichorionic twins in GD group (50.0% vs. 35.7% p<0.01). But dichorionic twins had a significantly higher incidence of central cord insertion than those of monochorionic twins in control group (69.2 vs. 57.4 p<0.05). CONCLUSION: The higher middle cerebral artery blood flows in smaller fetuses of monochorionic twins proved to be circulatory redistribution of the fetus in inadequate intrauterine condition. And these change of middle cerebral blood flow might be understood the part of mechanisms fetal growth and adaptation. Placental weight, number and umbilical cord insertion were also important factors which affected to develop the growth discordance of twin pregnancy.

The Hemodynamic Change of Doppler Flow Velocimetry to Developing of Twin Growth Discordance in Relation to Placental Chorionisity, Placental Weight and Umbilical Cord Insertion / 대한산부인과학회잡지

OBJECTIVE: To evaluate hemodynamic change in growth discordant twins using a ratio of middle cerebral artery/umbilical artery resistance index and to assess the relationship between Doppler hemodynamic and the influence of placental chorionisity and umbilical cord insertion. METHODS: 118 live born twin pairs whose birthweight discordance below or above 20% between March 2000 and March 2002 were included in our study. And we divided the two groups in which above 20% of growth discordance (GD) group was GD and below 20% of GD group was control. Chorionisity and umbilical cord insertion in all study subjects within 24 hours after delivery were investigated. And then we classified to monochorionic (MONO), and dichorionic (DI) placenta and the type of insertion of umbilical cord were also classified central, marginal and velamentous type. 56 of twin pairs were performed 153 Doppler flow velocimetry between smaller and larger fetus prenatally. Resistance index (RI) of middle cerebral artery and umbilical artery in each fetus were measured and standardized as a ratio of middle cerebral artery/umbilical artery (MCA/UmA). ANOVA, Mann-Whitney U test, and chi-square test, were performed and p<0.05 was considered as statistically significant. RESULTS: Mean birthweight in monochorionic twins had lighter than those of dichorionic twins (p<0.01). The mean growth discordant ratios were 14.1% in monochorionic twin and 12.1% in dichorionic twins. In monochorionic twin, the smaller fetus in GD group showed lower value of MCA/UmA RI ratio than those of the larger fetus, significantly (1.09 vs. 1.28 p<0.05). And in monochorionic twins, the smaller fetus in GD group showed lower value of MCA/UmA RI ratio than the smaller fetus in control group, significantly (1.09 vs. 1.27 p<0.05). The placental weight in dichorionic twin was correlated the birthweight in infants in GD group, positively. Monochorionic twins in GD group had a significantly higher incidence of peripheral cord insertion than those of dichorionic twins in GD group (50.0% vs. 35.7% p<0.01). But dichorionic twins had a significantly higher incidence of central cord insertion than those of monochorionic twins in control group (69.2 vs. 57.4 p<0.05). CONCLUSION: The higher middle cerebral artery blood flows in smaller fetuses of monochorionic twins proved to be circulatory redistribution of the fetus in inadequate intrauterine condition. And these change of middle cerebral blood flow might be understood the part of mechanisms fetal growth and adaptation. Placental weight, number and umbilical cord insertion were also important factors which affected to develop the growth discordance of twin pregnancy.