Perinatal Complications in Twin Pregnancies after 34 Weeks: Effects of Gestational Age at Delivery and Chorionicity

Abstract

Objective To evaluate the perinatal outcome of twins approaching term in relation to chorionicity and gestational age at delivery.

Study Design We accessed data pertaining to a cohort of 471 twin pregnancies with certain chorionicity delivered at > 34.0 weeks' gestation. Twin gestation per se, estimated fetal weight below the 10th percentile, or any intertwin discordance was not an indication for delivery before 40.0 weeks. Predictors of adverse perinatal outcome were identified using logistic regression analysis.

Results There were no stillbirths. Adverse neonatal outcome occurred in 27% of monochorionic versus 16% of dichorionic gestations. At multivariate analysis, lower gestational age at delivery (odds ratio [OR] 0.70, 95% confidence interval [CI] 0.57 to 0.87), monochorionicity (OR 2.06, 95% CI 1.16–3.63), and either twin being growth-restricted (OR 2.35, 95% CI 1.22 to 4.54) were independent predictors of adverse neonatal outcome. Analysis of adverse neonatal outcome stratified by gestational age and chorionicity identified 36 to 37 weeks as optimal timing for delivery of monochorionic twins, and dichorionic twin pregnancies should be allowed to continue until term.

Conclusion Among twin gestations delivered after 34 weeks with appropriate fetal growth, reassuring fetal status at weekly assessment, and absence of obstetric complications, delivery after 36 weeks for monochorionic twins and at term for dichorionic twins minimizes the risk of stillbirths and neonatal morbidity.

Keywords

twins - chorionicity - delivery - neonatal outcome

• References

• 1 Dodd JM, Crowther CA. Should we deliver twins electively at 37 weeks' gestation?. Curr Opin Obstet Gynecol 2005; 17: 579-583
• 2 Lee YM, Wylie BJ, Simpson LL, D'Alton ME. Twin chorionicity and the risk of stillbirth. Obstet Gynecol 2008; 111 (2 Pt 1) 301-308
• 3 Hartley RS, Hitti J. Increasing rates of preterm twin births coincide with improving twin pair survival. J Perinat Med 2010; 38: 297-303
• 4 Cheung YB, Yip P, Karlberg J. Mortality of twins and singletons by gestational age: a varying-coefficient approach. Am J Epidemiol 2000; 152: 1107-1116
• 5 Rydhstroem H, Heraib F. Gestational duration, and fetal and infant mortality for twins vs singletons. Twin Res 2001; 4: 227-231
• 6 Hatkar PA, Bhide AG. Perinatal outcome of twins in relation to chorionicity. J Postgrad Med 1999; 45: 33-37
• 7 Hack KE, Derks JB, Elias SG , et al. Increased perinatal mortality and morbidity in monochorionic versus dichorionic twin pregnancies: clinical implications of a large Dutch cohort study. BJOG 2008; 115: 58-67
• 8 Lopriore E, Stroeken H, Sueters M, Meerman RJ, Walther F, Vandenbussche F. Term perinatal mortality and morbidity in monochorionic and dichorionic twin pregnancies: a retrospective study. Acta Obstet Gynecol Scand 2008; 87: 541-545
• 9 Refuerzo JS, Momirova V, Peaceman AM , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Neonatal outcomes in twin pregnancies delivered moderately preterm, late preterm, and term. Am J Perinatol 2010; 27: 537-542
• 10 Smith NA, Wilkins-Haug L, Santolaya-Forgas J , et al. Contemporary management of monochorionic diamniotic twins: outcomes and delivery recommendations revisited. Am J Obstet Gynecol 2010; 203: 133 , e1–e6
• 11 Blickstein I, Arabin B, Lewi L , et al. A template for defining the perinatal care of monochorionic twins: the Istanbul international ad hoc committee. J Perinat Med 2010; 38: 107-110
• 12 Hadlock FP, Harrist RB, Martinez-Poyer J. In utero analysis of fetal growth: a sonographic weight standard. Radiology 1991; 181: 129-133
• 13 Vergani P, Locatelli A, Ratti M , et al. Preterm twins: what threshold of birth weight discordance heralds major adverse neonatal outcome?. Am J Obstet Gynecol 2004; 191: 1441-1445
• 14 Quintero RA, Morales WJ, Allen MH, Bornick PW, Johnson PK, Kruger M. Staging of twin-twin transfusion syndrome. J Perinatol 1999; 19 (8 Pt 1) 550-555
• 15 Arduini D, Rizzo G, Boccolini MR, Romanini C, Mancuso S. Functional assessment of uteroplacental and fetal circulations by means of color Doppler ultrasonography. J Ultrasound Med 1990; 9: 249-253
• 16 Breathnach FM, McAuliffe FM, Geary M , et al; Perinatal Ireland Research Consortium. Optimum timing for planned delivery of uncomplicated monochorionic and dichorionic twin pregnancies. Obstet Gynecol 2012; 119: 50-59
• 17 Barigye O, Pasquini L, Galea P, Chambers H, Chappell L, Fisk NM. High risk of unexpected late fetal death in monochorionic twins despite intensive ultrasound surveillance: a cohort study. PLoS Med 2005; 2: e172
• 18 Hack KE, Derks JB, Elias SG , et al. Perinatal mortality and mode of delivery in monochorionic diamniotic twin pregnancies ≥ 32 weeks of gestation: a multicentre retrospective cohort study. BJOG 2011; 118: 1090-1097
• 19 Lewi L, Gucciardo L, Van Mieghem T , et al. Monochorionic diamniotic twin pregnancies: natural history and risk stratification. Fetal Diagn Ther 2010; 27: 121-133