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Am J Perinatol 2023; 40(07): 704-710
DOI: 10.1055/a-1974-4449
SMFM Fellowship Series Article

Severe Maternal Morbidity in Twins

Anna Binstock
1   Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
,
Lisa M. Bodnar
2   Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
,
Katherine P. Himes
1   Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
3   Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
› Author Affiliations Funding This work was supported by NIH Grant (grant no.: R01 NR014245) to L.M.B. (PI) and K.P.H. (Co-I). The funding source had no role in the design of this study or manuscript preparation.
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Abstract

Objective While twin gestations are at increased risk of severe maternal morbidity (SMM), there is limited information about timing and causes of SMM in twins. Furthermore, existing data rely on screening definitions of SMM because a gold standard approach requires chart review. We sought to determine the timing and cause of SMM in twins using a gold standard definition outlined by the American College of Obstetricians and Gynecologists (ACOG).

Study Design We used a perinatal database to identify all twin deliveries from 1998 to 2013 at a single academic medical center (n = 2,367). Deliveries were classified as screen positive for SMM if they met any of the following criteria: (1) one of the Centers for Disease Control and Prevention (CDC) International Classification of Diseases Ninth Revision diagnosis and procedure codes for SMM; (2) a prolonged postpartum length of stay (>3 standard deviations beyond mean length of stay by mode of delivery); or (3) maternal intensive care unit admission. We identified true cases of SMM through medical record review of all screen-positive deliveries using the definition of SMM outlined in the ACOG Obstetric Care Consensus. We also determined cause and timing of SMM.

Results A total of 165 (7%) of twin deliveries screened positive for SMM. After chart review of all screen-positive cases, 2.4% (n = 56) were classified as a true case of SMM using the ACOG definition for a positive predictive value of 34%. The majority of SMM occurred postpartum (65%). Hemorrhage was the most common cause of SMM, followed by hypertensive and pulmonary etiologies.

Conclusion Commonly used approaches to screen for SMM perform poorly in twins. This has important implications for quality initiatives and epidemiologic studies that rely on screening definitions of maternal morbidity. Our study demonstrates that the immediate postpartum period is a critical time for maternal health among women with twin pregnancies.

Key Points

  • Screening approaches for SMM have low positive predictive value in twins.

  • Hemorrhage, hypertensive, and pulmonary complications were the most common morbidities.

  • SMM was most common postpartum.

Keywords

severe maternal morbidity - twin gestations - postpartum period

Supplementary Material



Publication History

Received: 22 April 2022

Accepted: 01 November 2022

Accepted Manuscript online:
08 November 2022

Article published online:
21 December 2022

© 2022. Thieme. All rights reserved.

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