http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2015; 28(5): 509–514 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.927430
ORIGINAL ARTICLE
Combined vaginal-cesarean delivery of twins: risk factors and neonatal outcome – a single center experience Amir Aviram1*, Itay Weiser2, Eran Ashwal1*, Jonathan Bar1*, Arnon Wiznitzer1*, and Yariv Yogev1* 1
Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel and 2Department of Reconstructive Surgery, Assaf Harofe Medical Center, Zrifin, Israel Abstract
Keywords
Objective: We aimed to characterize risk factors for combined twin delivery and assess neonatal outcome. Methods: This was a retrospective cohort study of all women admitted for trial of labor (TOL) with twin gestation, in a single, tertiary, university-affiliated medical center. Eligibility was limited to gestations with twin A delivered vaginally. Results: During the study period, 44 263 women delivered in our center, of whom 1307 (2.9%) delivered twins. Overall, 221 out of 247 women (89.5%) undergoing TOL delivered twin A vaginally. Parturients who delivered twin B by cesarean delivery (n ¼ 23) were compared with those delivered twin B vaginally (n ¼ 198). Multivariate analysis demonstrated that risk factors combined delivery were included non-cephalic twin B at admission (aOR 11.5, 95% CI 3.8–34.9, p50.001) or after delivery of twin A (aOR 17.7, 95% CI 6.6–47.2, p50.001), and dichorionic– diamniotic (DCDA) twins (aOR 8.9, 95% CI 1.8–44.0, p ¼ 0.008). Spontaneous version of a cephalic twin B was not found to increase the risk (above the baseline risk of non-cephalic twin B) for combined delivery. Combined delivery was associated with slightly higher risk for hemorrhagic-ischemic encephalopathy of twin B (4.3% versus 0%, p ¼ 0.003). Conclusion: Non-cephalic twin B at admission or following delivery of twin A poses higher risk for combined delivery. Neonatal outcome of twin B following combined delivery are comparable with those of vaginal delivery.
Cesarean delivery, combined delivery, second twin, twins
Introduction Multiple births rate has been rising steadily, with a 76% increase from 1980 to 2009, reaching approximately 3.3%, mostly due to advances in artificial reproductive techniques [1]. Debate exists concerning the optimal mode of delivery of twins, although the cesarean section rates for twins continue to rise about 5% per year, reaching 75% in 2008 [2]. A recent meta-analysis concluded that there was insufficient evidence to support planned cesarean delivery over planned vaginal delivery [3], but it was based on a single randomizedcontrolled study comprised of 60 deliveries. More recently, a large randomized-controlled trial demonstrated that if twin A is in vertex presentation, there is no added maternal or neonatal benefit from planned cesarean delivery over planned vaginal delivery [4]. As for neonatal outcome, it seems that twin B, regardless of mode of delivery or presentation, tends
History Received 2 April 2014 Revised 16 May 2014 Accepted 20 May 2014 Published online 18 June 2014
to exhibit slightly higher rate of adverse outcome when compared with twin A [5]. The rate of combined deliveries (defined as vaginal delivery of the first twin followed by cesarean section of the second twin) ranges from 2.2 to 17% [4,6–15]. The most notable reported predictors and risk factors for combined delivery are malpresentation of twin B [6–12,14–17] and prolapsed umbilical cord [7–10,16]. Most studies are limited by study sample, report fetal presentation only at birth, but not at admission, thus disregarding spontaneous version of the second twin as a risk factor for combined delivery, and a lack uniform twin delivery protocol. Thus, we aimed to characterize risk factors for combined twin delivery and assess neonatal outcome in a single tertiary university affiliated medical center.
Methods Study population
*Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Address for correspondence: Amir Aviram, Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva, Israel. Tel: 972-544301364. E-mail: [email protected]
This was a retrospective cohort study of all women admitted for trial of labor with twin gestation, in a single, tertiary, university-affiliated medical center, between July 2007 and December 2012. Eligibility was limited to twin pregnancies beyond 24 completed weeks of gestation, with two viable
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fetuses, twin A in vertex presentation and no contraindication for vaginal delivery. We further excluded all parturients who underwent cesarean delivery for both twins. The study was approved by the local Institutional Review Board. According to our departmental protocol, women with twin gestations in which twin A is in cephalic presentation are offered elective cesarean delivery or trial of vaginal labor. The choice between the two modes of delivery is at the patient’s discretion, after discussing risks and benefits of each mode of delivery. The most experienced senior physician in the labor suite is present during twin deliveries. Data collection Data were retrieved from the comprehensive computerized databases of the delivery room, and was cross-tabulated using an individualized identification number per patient. Data from the neonatal unit and the neonatal intensive care unit (NICU) were integrated into the delivery room database using the unique admission number assigned to each parturient and her offspring. Data included demographic and obstetrical parameters, sonograms at admission and during delivery, and immediate neonatal outcome. Statistical analysis Statistical analysis was performed using the SPSS software (IBM SPSS statistics version 20.0, Chicago, IL). Comparison between continuous variables was performed with Student’s t-test, and categorical data were compared using 2 test or Fisher’s exact test. Multivariate logistic regression and adjusted odds ratios were calculated where appropriate. A probability value 50.05 was considered significant. In order to identify risk factors associated with combined delivery, we compared parturients who delivered both twins vaginally with parturients who underwent cesarean delivery for twin B. Definitions Gestational age was determined based on maternally reported last menstrual period and was affirmed by the Crown-Ramp length (CRL) measured at a first trimester sonogram. First trimester sonogram was also used to determine chorionicity. Birth weight percentile was calculated using genderspecific local population based birth weight curves [18]. Diagnosis of gestational diabetes mellitus (GDM) was based on abnormal 50-g glucose challenge test (4140 mg/dl) followed by a fasting 100-g oral glucose tolerance test. Diagnosis was established according to the Carpenter and Coustan criteria [19]. Hypertension present at or prior to 20 weeks of gestation that did not progress to preeclampsiatoxemia was classified as chronic hypertension. After 20 weeks of gestation, hypertensive disorders in pregnancy were categorized according to the International Society for the Study of Hypertension in Pregnancy guidelines [20]. All neonatal outcomes were determined by the attending pediatrician according to international and national definitions. Neonatal composite outcome included one or more of the following: neonatal asphyxia, seizures, umbilical artery pH57.05, respiratory distress syndrome or need for
J Matern Fetal Neonatal Med, 2015; 28(5): 509–514
mechanical ventilation, necrotizing enterocolitis, sepsis, hemorrhagic ischemic encephalopathy or cerebral signs.
Results Demographic and obstetrical characteristics During the study period, 44 263 women delivered in our center, of whom 1307 (2.9%) delivered twins. Among women with twin gestation, 247 (18.9%) attempted vaginal delivery and 1060 (81.1%) underwent pre-labor, elective cesarean delivery. Overall, 221 women out of 247 (89.5%) delivered the first twin vaginally, which constituted the study population. The study group was comprised of parturients who delivered twin B by cesarean section (N ¼ 23, 10.4%) whereas in the control group both neonates were delivered vaginally (N ¼ 198, 89.6%) (Figure 1). There were no significant differences between the groups regarding maternal age, gravidity and parity, gestational age at delivery or mode of conception. No differences were found concerning rates of hypertensive disorders or gestational diabetes mellitus, previous cesarean delivery, spontaneous versus induced onset of delivery, the use of oxytocin for augmentation or epidural analgesia. There were no differences between birth weights or birth weight percentiles of twin A or twin B, the weight difference between the two or the rate of gestations in which twin B had higher birth weight than twin A (Table 1). Univariate analysis demonstrated that the rate of dichorionic–diamniotic (DCDA) twins was higher among women in the study group (p ¼ 0.02). The results of multivariate logistic regression model, after adjustment for confounders such as maternal age, parity, co-morbidities and birth weight, revealed that DCDA twins had a nearly nine-fold higher risk for combined delivery in comparison to monochorionic diamniotic twins (p ¼ 0.008) (Table 2). Twin B presentation at admission and delivery Among the cohort, in 195 (88.3%) women, twin B was in vertex presentation at admission. In 179 (91.8%) of those, twin B remained in the vertex presentation until delivery, and in 16 (8.2%) women twin B underwent spontaneous version to breech presentation. In the remaining 26 pregnancies (11.7%), twin B presented in non-vertex presentation at admissions. Of those, 11 neonates (42.3%) were ultimately delivered in the vertex presentations, while 15 (57.7%) were delivered in breech presentation (Figure 2). Non-vertex presentation of twin B at admission was found to be a risk factor for combined twin delivery, with an adjusted odds ratio of 11.5 (95% CI 3.8–34.9, p50.001) (Table 2). Similarly, non-vertex presentation of twin B after the delivery of twin A was also found to pose greater risk for combined delivery, with an adjusted odds ratio of 17.7 (95% CI 6.6–47.2, p50.001). Spontaneous version of twin B We further sought to find if the spontaneous version of a cephalic twin B to non-cephalic presentation is an independent risk factor, in addition to the baseline risk of non-cephalic twin B, for combined delivery. Univariate analysis
Combined delivery of twins
DOI: 10.3109/14767058.2014.927430
Figure 1. Study population.
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44,263 deliveries
Singleton gestations - 42,966 (97.1%)
Twin deliveries - 1,307 (2.9%)
Pre-labor cesarean delivery - 1,060 (81.1%)
Trial of labor - 247 (18.9%) Intrapartum cesarean delivery for both twins - 26 (10.5%)
Vaginal delivery of twin A - 221 (89.5%) (Study population)
Vaginal delivery of twin B - 198 (89.6%)
demonstrated there was no significant difference between the rate of spontaneous version to breech presentation in the study group and the control groups (66.7% versus 42.5%, p ¼ 0.46). Indication for cesarean delivery Out of the 23 patients in the study group, 12 (52.2%) were operated due to breech presentation: in eight due to failed breech extraction (either failure to identify a limb for total breech extraction or contracting cervix), and in other four cases due to physician’s preference. In the 11 remaining cases, twin B was in vertex presentation. Additional indications for cesarean delivery included umbilical cord prolapse (3, 13.0%), non-reassuring fetal heart rate (6, 26.1%) and suspected placental abruption (2, 8.7%) (Figure 2). Short-term neonatal outcome No differences were found between the groups with regards to twin A neonatal outcome (Table 3). As for twin B, combined delivery was associated with higher risk for hemorrhagicischemic encephalopathy (p ¼ 0.003) (Table 4).
Discussion In this study, we aimed to determine which risk factors are associated with combined twin delivery (twin A by vaginal delivery and twin B by cesarean section). Our main findings were: (1) twin B non-vertex presentation at admission or after delivery of twin A poses higher risk for combined delivery; (2) DCDA twins are at nearly nine-fold risk for combined
Cesarean delivery of twin B - 23 (10.4%)
delivery in comparison to monochorionic diamniotic twins; (3) spontaneous version of cephalic twin B to non-cephalic presentation was not found to further increase the risk of a non-vertex twin to undergo combined delivery, and (4) immediate neonatal outcome of both twins are similar between combined and vaginal delivery. The association between non-vertex presentation of twin B following delivery of twin A and combined delivery was established in previous observations. Breathnach et al. [15] reported that 10 out of 14 combined deliveries (71%) among a cohort of 971 women were the result of non-vertex second twin. Suzuki [14] reported a six-fold increased risk for combined delivery among non-vertex second twin, and Ginsberg and Levine [12] compared four groups of twins with different presentations and lies, and found that vertex/ non-vertex twins were the group most prone for combined delivery. Barrett et al. [4], in the appendix section of their recent prospective randomized-controlled study, reported that 42 out of 60 combined deliveries were indicated by malpresentation. Our results corroborate with those, as we found that non-vertex second twin yielded adjusted odds ratio of 17.7 for combined delivery. Breech delivery requires knowledge and expertise in order to safely extract the fetus. Since the publication of the Term Breech Trial (TBT) [21], the rate of singleton breech deliveries decreased substantially. Although it has not been proved that the results of the TBT apply to twin deliveries, a similar trend has been noticed regarding non-cephalic second twin [2]. Furthermore, as the decrease in singleton breech
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Table 1. Demographic and obstetrical characteristics.
Parameter Age, yearsz Gravidity, nz Parity, nz Nulliparity, n (%) Gestational age at delivery, weeksz 37 weeks of gestation, n (%) 34–36 weeks of gestation, n (%) 28–33 weeks of gestation, n (%) 27 weeks of gestation, n (%) Previous cesarean delivery, n (%) DCDA twins, n (%)* Twin A birth weight, gramsz Twin B birth weight, gramsz Birth weight difference, gramsz Twin B4Twin A, n (%) Twin A birth weight percentile, %z Twin B birth weight percentile, %z Twin A male, n (%) Twin B male, n (%) Both twins in vertex presentation at admission, n (%) Spontaneous onset of delivery, n (%) Induction of labor, n (%) Oxytocin for augmentation, n (%) Epidural analgesia, n (%) Hypertensive disorders, n (%)y Gestational diabetes mellitus, n (%) COH, n (%)* IVF, n (%)* Meconium, n (%) Premature rupture of membrane, n (%)
Study (N ¼ 23)
Control (N ¼ 198)
p value
33.3 ± 4.4 3.0 ± 2.1 2.5 ± 1.6 6 (26.1) 35.4 ± 2.7
32.4 ± 4.8 2.8 ± 1.8 2.3 ± 1.4 65 (32.8) 35.8 ± 2.4
0.39 0.47 0.44 0.51 0.41
8 (34.8) 11 (47.8) 4 (17.4) 0 (0) 1 (4.3) 21 (91.3) 2308 ± 600 2251 ± 497 240.0 ± 224.8 11 (47.8) 54.4 ± 26.4
82 (41.4) 93 (47.0) 21 (10.6) 2 (1.0) 5 (2.5) 136 (68.7) 2335 ± 444 2314 ± 493 267.0 ± 218.3 96 (48.5) 53.9 ± 23.2
0.54 0.94 0.33 0.63 0.61 0.02 0.79 0.56 0.58 0.95 0.92
49.9 ± 28.4
52.0 ± 26.2
0.71
15 (65.2) 13 (56.5) 14 (60.9)
105 (53.0) 94 (47.5) 181 (91.4)
0.27 0.41 50.001
21 (91.3)
159 (80.3)
0.2
3 (13.0) 2 (8.7)
36 (18.2) 48 (24.2)
0.54 0.09
15 (65.2) 1 (4.3) 1 (4.3)
159 (80.3) 5 (2.5) 8 (4.0)
0.09 0.61 0.94
6 1 1 2
(26.1) (4.3) (4.3) (8.7)
30 23 4 29
(15.2) (11.6) (2.0) (14.6)
0.19 0.29 0.48 0.44
*DCDA – dichorionic–diamniotic, COH – controlled ovarian hyperstimulation. yHypertensive disorders: chronic hypertension, gestational hypertension, mild or severe pre-eclampsia. zData are presented as mean ± SD.
Table 2. Multivariate logistic regression for combined twin delivery.
Parameterr Dichorionic–diamniotic twins Twin B in non-vertex presentation at admission Twin B in non-vertex presentation after delivery of twin A
Adjusted odds ratio
95% Confidence interval
p value
8.9 11.5
1.844.0 3.8–34.9
0.008 50.001
17.7
6.6–47.2
50.001
deliveries is accompanied by a similar decrease in the care-taker’s expertise in breech extraction, we can expect more and more physicians to lack the proper skills to deliver a non-cephalic second twin. We also analyzed the association of breech presentation at admission with combined delivery, in order to assess the impact of spontaneous version of twin B to non-cephalic
presentation after the extraction of twin A. As expected, non-cephalic twin B at admission was also found to be an independent risk factor for combined delivery, with an adjusted OR of 11.5 (95% CI 3.8–34.9, p50.001). Interestingly, the odds ratio were found to be lower compared with the odds ratio for combined delivery of non-cephalic twin B at delivery (aOR 17.7, 95% CI 6.6–47.2, p50.001). We hypothesize that while breech twin B still poses a challenge for the obstetrician, once it is known from admission and not the result of a less predictable spontaneous version, the awareness and readiness of the staff may increase the chance of successful vaginal extraction. Additionally, spontaneous version of twin B to noncephalic presentation was not found to increase the baseline risk of a non-cephalic twin B to undergo combined delivery. A report by Breathnach et al. [15] indicated that out of 10 combined deliveries, seven (70%) were the result of a spontaneous version to non-cephalic presentation of twin B. In our cohort, only eight out of 23 (34.8%) (Figure 2) combined deliveries resulted from spontaneous version of twin B. This difference may derive from different protocols as in our cohort sonogram was performed immediately at admission to the delivery suite, and in Breathnach’s report sonogram was performed up to two weeks prior to delivery. Furthermore, scarcity of data concerning statistical analysis of the contribution of spontaneous version of twin B exist, thus comparing different reports may prove to be a futile effort. The finding that dichorionic (DC) twins are at higher risk for combined delivery is enigmatic. We found one report addressing this issue [15], which found no relation between chorionicity and mode of delivery. All combined deliveries indicated by malpresentation of twin B occurred among DC twins, as well as all three cases of prolapsed umbilical cord. We may speculate that fetal lies in DC twins and the morphologic structure of the thicker septum may pose greater risk for these indications for interventions, but more substantial data is required to draw further conclusions. When comparing immediate neonatal outcome of twin B between the study and the control group, we found no significant difference between the groups, excluding hemorrhagic ischemic encephalopathy (HIE). This finding should also be interpreted with caution, as statistical significance was demonstrated, but the absolute numbers are quite small (one case in the study group and none in the control group). Nonetheless, a previous report advocated higher morbidity rate among twins in combined delivery than in vaginal delivery or cesarean delivery [5], where morbidity was defined as pH57.0, 5-minutes Apgar score 55 or birth trauma. Conversely, another report found no significant differences in neonatal outcome, including HIE, between cesarean and combined deliveries. While it is plausible to assume some sort of deprived outcome in twin B following urgent intervention, the relatively small number of adverse events among our cohort preclude assumptions concerning neonatal outcome. Our study is not without limitations. Owing to the retrospective nature of our study, data regarding possible confounders such as pre-pregnancy maternal BMI and pregnancy weight change were not available, as well as data concerning care-takers’ expertise in breech extractions or
Combined delivery of twins
DOI: 10.3109/14767058.2014.927430
Figure 2. Presentations at admission and delivery, and indications for cesarean section.
Vx/Vx N = 195 (88.3%)
Presentation
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Vx/Non-Vx N = 26 (11.7%)
Presentation at delivery:
Vx/non-Vx N = 16 (8.2%)
Vx/Vx N = 179 (91.8%)
Vx/non-Vx N = 15 (57.7%)
Vx/Vx N = 11 (42.3%)
Vaginal delivery of twin B:
N = 8 (50%)
N = 173 (96.6%)
N = 11 (73.3%)
N = 6 (54.5%)
Combined delivery of twin B:
N = 8 (50%)
N = 6 (3.4%)
N = 4 (26.3%)
N = 5 (45.5%)
Prolapsed umbilical cord (N=3, 50%)
Failed BE (N=2, 50%)
NRFHR (N=4, 80%)
No trial of BE (N=2, 50%)
Placental abruption (N=1, 20%)
Indications for combined
Failed BE (N=6, 75%) No trial of BE (N=2, 25%)
NRFHR (N=2, 33.3%) Placental abruption (N=1, 16.7%)
Table 3. Neonatal outcome for twin A.
Table 4. Neonatal outcome for twin B.
Parameters
Study (N ¼ 23)
Control (N ¼ 198)
p value
5 minutes Apgar score 57 NICU, n (%)* Asphyxia, n (%) Seizures, n (%) IVH, n (%)* HIE, n (%)* Acidosis, n (%) Hypoglycemia, n (%) TTN, n (%)* RDS, n (%)* Respiratory distress, n (%) Cardiorespiratory failure, n (%) Mechanical ventilation, n (%) Sepsis, n (%) NEC, n (%)* Jaundice, n (%) Composite outcome, n (%)
1 (4.3) 5 (21.7) 0 (0) 0 (0) 1 (4.3) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (4.3) 0 (0) 1 (4.3) 4 (17.4) 0 (0) 1 (4.3) 5 (21.7)
3 (1.5) 39 (19.7) 3 (1.5) 2 (1.0) 8 (4.0) 0 (0) 2 (1.0) 3 (1.5) 5 (2.5) 2 (1.0) 12 (6.1) 1 (0.5) 6 (3.0) 33 (16.7) 6 (3.0) 16 (8.1) 39 (19.7)
0.33 0.82 0.55 0.63 0.94 NS 0.63 0.55 0.44 0.63 0.74 0.73 0.73 0.93 0.40 0.53 0.82
Parameters
Study (N ¼ 23)
Control (N¼198)
5 minutes Apgar score 57 NICU, n (%)* Asphyxia, n (%) Seizures, n (%) IVH, n (%)* HIE, n (%)* Acidosis, n (%) Hypoglycemia, n (%) TTN, n (%)* RDS, n (%)* Respiratory distress, n (%) Cardiorespiratory failure, n (%) Mechanical ventilation, n (%) Sepsis, n (%) NEC, n (%)* Jaundice, n (%) Composite outcome, n (%)
1 6 3 0 2 1 1 1 0 0 3 0 2 6 1 1 8
2 40 8 0 8 0 3 8 6 4 18 1 15 31 6 18 46
(4.3) (26.1) (13.0) (0) (8.7) (4.3) (4.3) (4.3) (0) (0) (13.0) (0) (8.7) (26.1) (4.3) (4.3) (34.3)
(1.0) (20.2) (4.0) (0) (4.0) (0) (1.5) (4.0) (3.0) (2.0) (9.1) (0.5) (7.6) (15.7) (3.0) (9.1) (23.2)
p value 0.19 0.51 0.06 NS 0.31 0.003 0.33 0.94 0.40 0.49 0.54 0.73 0.85 0.21 0.73 0.44 0.22
*NICU – Neonatal intensive care unit, IVH – Intraventricular hemorrhage, TTN – Transient tachypnea of the newborn, RDS – Respiratory distress syndrome, HIE – Hemorrhagic ischemic encephalopathy.
*NICU – Neonatal intensive care unit, IVH – Intraventricular hemorrhage, TTN – Transient tachypnea of the newborn, RDS – Respiratory distress syndrome, HIE – Hemorrhagic ischemic encephalopathy.
long-term neonatal outcome. Nonetheless, our data derives from quite homogenous population in a single center, with the same stringent obstetrical protocol during the study period. In conclusion, our main results indicate that in twin gestations, breech presentation of twin B at admission or following delivery of twin A, is a risk factor for combined deliveries, and that immediate neonatal outcome of twin B following combined delivery are comparable with those of vaginal delivery. This data can be used for counseling couples with twin gestation in planning their desired mode of delivery.
Additional prospective trials are needed to validate these findings [15].
Acknowledgements The authors wish to thank Mrs. Inbar Dabach-Alush and the computer division at Rabin Medical Center for their assistance and support.
Declaration of interest The authors report no conflict of interest.
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ORIGINAL ARTICLE
Combined vaginal-cesarean delivery of twins: risk factors and neonatal outcome – a single center experience Amir Aviram1*, Itay Weiser2, Eran Ashwal1*, Jonathan Bar1*, Arnon Wiznitzer1*, and Yariv Yogev1* 1
Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel and 2Department of Reconstructive Surgery, Assaf Harofe Medical Center, Zrifin, Israel Abstract
Keywords
Objective: We aimed to characterize risk factors for combined twin delivery and assess neonatal outcome. Methods: This was a retrospective cohort study of all women admitted for trial of labor (TOL) with twin gestation, in a single, tertiary, university-affiliated medical center. Eligibility was limited to gestations with twin A delivered vaginally. Results: During the study period, 44 263 women delivered in our center, of whom 1307 (2.9%) delivered twins. Overall, 221 out of 247 women (89.5%) undergoing TOL delivered twin A vaginally. Parturients who delivered twin B by cesarean delivery (n ¼ 23) were compared with those delivered twin B vaginally (n ¼ 198). Multivariate analysis demonstrated that risk factors combined delivery were included non-cephalic twin B at admission (aOR 11.5, 95% CI 3.8–34.9, p50.001) or after delivery of twin A (aOR 17.7, 95% CI 6.6–47.2, p50.001), and dichorionic– diamniotic (DCDA) twins (aOR 8.9, 95% CI 1.8–44.0, p ¼ 0.008). Spontaneous version of a cephalic twin B was not found to increase the risk (above the baseline risk of non-cephalic twin B) for combined delivery. Combined delivery was associated with slightly higher risk for hemorrhagic-ischemic encephalopathy of twin B (4.3% versus 0%, p ¼ 0.003). Conclusion: Non-cephalic twin B at admission or following delivery of twin A poses higher risk for combined delivery. Neonatal outcome of twin B following combined delivery are comparable with those of vaginal delivery.
Cesarean delivery, combined delivery, second twin, twins
Introduction Multiple births rate has been rising steadily, with a 76% increase from 1980 to 2009, reaching approximately 3.3%, mostly due to advances in artificial reproductive techniques [1]. Debate exists concerning the optimal mode of delivery of twins, although the cesarean section rates for twins continue to rise about 5% per year, reaching 75% in 2008 [2]. A recent meta-analysis concluded that there was insufficient evidence to support planned cesarean delivery over planned vaginal delivery [3], but it was based on a single randomizedcontrolled study comprised of 60 deliveries. More recently, a large randomized-controlled trial demonstrated that if twin A is in vertex presentation, there is no added maternal or neonatal benefit from planned cesarean delivery over planned vaginal delivery [4]. As for neonatal outcome, it seems that twin B, regardless of mode of delivery or presentation, tends
History Received 2 April 2014 Revised 16 May 2014 Accepted 20 May 2014 Published online 18 June 2014
to exhibit slightly higher rate of adverse outcome when compared with twin A [5]. The rate of combined deliveries (defined as vaginal delivery of the first twin followed by cesarean section of the second twin) ranges from 2.2 to 17% [4,6–15]. The most notable reported predictors and risk factors for combined delivery are malpresentation of twin B [6–12,14–17] and prolapsed umbilical cord [7–10,16]. Most studies are limited by study sample, report fetal presentation only at birth, but not at admission, thus disregarding spontaneous version of the second twin as a risk factor for combined delivery, and a lack uniform twin delivery protocol. Thus, we aimed to characterize risk factors for combined twin delivery and assess neonatal outcome in a single tertiary university affiliated medical center.
Methods Study population
*Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Address for correspondence: Amir Aviram, Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva, Israel. Tel: 972-544301364. E-mail: [email protected]
This was a retrospective cohort study of all women admitted for trial of labor with twin gestation, in a single, tertiary, university-affiliated medical center, between July 2007 and December 2012. Eligibility was limited to twin pregnancies beyond 24 completed weeks of gestation, with two viable
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fetuses, twin A in vertex presentation and no contraindication for vaginal delivery. We further excluded all parturients who underwent cesarean delivery for both twins. The study was approved by the local Institutional Review Board. According to our departmental protocol, women with twin gestations in which twin A is in cephalic presentation are offered elective cesarean delivery or trial of vaginal labor. The choice between the two modes of delivery is at the patient’s discretion, after discussing risks and benefits of each mode of delivery. The most experienced senior physician in the labor suite is present during twin deliveries. Data collection Data were retrieved from the comprehensive computerized databases of the delivery room, and was cross-tabulated using an individualized identification number per patient. Data from the neonatal unit and the neonatal intensive care unit (NICU) were integrated into the delivery room database using the unique admission number assigned to each parturient and her offspring. Data included demographic and obstetrical parameters, sonograms at admission and during delivery, and immediate neonatal outcome. Statistical analysis Statistical analysis was performed using the SPSS software (IBM SPSS statistics version 20.0, Chicago, IL). Comparison between continuous variables was performed with Student’s t-test, and categorical data were compared using 2 test or Fisher’s exact test. Multivariate logistic regression and adjusted odds ratios were calculated where appropriate. A probability value 50.05 was considered significant. In order to identify risk factors associated with combined delivery, we compared parturients who delivered both twins vaginally with parturients who underwent cesarean delivery for twin B. Definitions Gestational age was determined based on maternally reported last menstrual period and was affirmed by the Crown-Ramp length (CRL) measured at a first trimester sonogram. First trimester sonogram was also used to determine chorionicity. Birth weight percentile was calculated using genderspecific local population based birth weight curves [18]. Diagnosis of gestational diabetes mellitus (GDM) was based on abnormal 50-g glucose challenge test (4140 mg/dl) followed by a fasting 100-g oral glucose tolerance test. Diagnosis was established according to the Carpenter and Coustan criteria [19]. Hypertension present at or prior to 20 weeks of gestation that did not progress to preeclampsiatoxemia was classified as chronic hypertension. After 20 weeks of gestation, hypertensive disorders in pregnancy were categorized according to the International Society for the Study of Hypertension in Pregnancy guidelines [20]. All neonatal outcomes were determined by the attending pediatrician according to international and national definitions. Neonatal composite outcome included one or more of the following: neonatal asphyxia, seizures, umbilical artery pH57.05, respiratory distress syndrome or need for
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mechanical ventilation, necrotizing enterocolitis, sepsis, hemorrhagic ischemic encephalopathy or cerebral signs.
Results Demographic and obstetrical characteristics During the study period, 44 263 women delivered in our center, of whom 1307 (2.9%) delivered twins. Among women with twin gestation, 247 (18.9%) attempted vaginal delivery and 1060 (81.1%) underwent pre-labor, elective cesarean delivery. Overall, 221 women out of 247 (89.5%) delivered the first twin vaginally, which constituted the study population. The study group was comprised of parturients who delivered twin B by cesarean section (N ¼ 23, 10.4%) whereas in the control group both neonates were delivered vaginally (N ¼ 198, 89.6%) (Figure 1). There were no significant differences between the groups regarding maternal age, gravidity and parity, gestational age at delivery or mode of conception. No differences were found concerning rates of hypertensive disorders or gestational diabetes mellitus, previous cesarean delivery, spontaneous versus induced onset of delivery, the use of oxytocin for augmentation or epidural analgesia. There were no differences between birth weights or birth weight percentiles of twin A or twin B, the weight difference between the two or the rate of gestations in which twin B had higher birth weight than twin A (Table 1). Univariate analysis demonstrated that the rate of dichorionic–diamniotic (DCDA) twins was higher among women in the study group (p ¼ 0.02). The results of multivariate logistic regression model, after adjustment for confounders such as maternal age, parity, co-morbidities and birth weight, revealed that DCDA twins had a nearly nine-fold higher risk for combined delivery in comparison to monochorionic diamniotic twins (p ¼ 0.008) (Table 2). Twin B presentation at admission and delivery Among the cohort, in 195 (88.3%) women, twin B was in vertex presentation at admission. In 179 (91.8%) of those, twin B remained in the vertex presentation until delivery, and in 16 (8.2%) women twin B underwent spontaneous version to breech presentation. In the remaining 26 pregnancies (11.7%), twin B presented in non-vertex presentation at admissions. Of those, 11 neonates (42.3%) were ultimately delivered in the vertex presentations, while 15 (57.7%) were delivered in breech presentation (Figure 2). Non-vertex presentation of twin B at admission was found to be a risk factor for combined twin delivery, with an adjusted odds ratio of 11.5 (95% CI 3.8–34.9, p50.001) (Table 2). Similarly, non-vertex presentation of twin B after the delivery of twin A was also found to pose greater risk for combined delivery, with an adjusted odds ratio of 17.7 (95% CI 6.6–47.2, p50.001). Spontaneous version of twin B We further sought to find if the spontaneous version of a cephalic twin B to non-cephalic presentation is an independent risk factor, in addition to the baseline risk of non-cephalic twin B, for combined delivery. Univariate analysis
Combined delivery of twins
DOI: 10.3109/14767058.2014.927430
Figure 1. Study population.
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44,263 deliveries
Singleton gestations - 42,966 (97.1%)
Twin deliveries - 1,307 (2.9%)
Pre-labor cesarean delivery - 1,060 (81.1%)
Trial of labor - 247 (18.9%) Intrapartum cesarean delivery for both twins - 26 (10.5%)
Vaginal delivery of twin A - 221 (89.5%) (Study population)
Vaginal delivery of twin B - 198 (89.6%)
demonstrated there was no significant difference between the rate of spontaneous version to breech presentation in the study group and the control groups (66.7% versus 42.5%, p ¼ 0.46). Indication for cesarean delivery Out of the 23 patients in the study group, 12 (52.2%) were operated due to breech presentation: in eight due to failed breech extraction (either failure to identify a limb for total breech extraction or contracting cervix), and in other four cases due to physician’s preference. In the 11 remaining cases, twin B was in vertex presentation. Additional indications for cesarean delivery included umbilical cord prolapse (3, 13.0%), non-reassuring fetal heart rate (6, 26.1%) and suspected placental abruption (2, 8.7%) (Figure 2). Short-term neonatal outcome No differences were found between the groups with regards to twin A neonatal outcome (Table 3). As for twin B, combined delivery was associated with higher risk for hemorrhagicischemic encephalopathy (p ¼ 0.003) (Table 4).
Discussion In this study, we aimed to determine which risk factors are associated with combined twin delivery (twin A by vaginal delivery and twin B by cesarean section). Our main findings were: (1) twin B non-vertex presentation at admission or after delivery of twin A poses higher risk for combined delivery; (2) DCDA twins are at nearly nine-fold risk for combined
Cesarean delivery of twin B - 23 (10.4%)
delivery in comparison to monochorionic diamniotic twins; (3) spontaneous version of cephalic twin B to non-cephalic presentation was not found to further increase the risk of a non-vertex twin to undergo combined delivery, and (4) immediate neonatal outcome of both twins are similar between combined and vaginal delivery. The association between non-vertex presentation of twin B following delivery of twin A and combined delivery was established in previous observations. Breathnach et al. [15] reported that 10 out of 14 combined deliveries (71%) among a cohort of 971 women were the result of non-vertex second twin. Suzuki [14] reported a six-fold increased risk for combined delivery among non-vertex second twin, and Ginsberg and Levine [12] compared four groups of twins with different presentations and lies, and found that vertex/ non-vertex twins were the group most prone for combined delivery. Barrett et al. [4], in the appendix section of their recent prospective randomized-controlled study, reported that 42 out of 60 combined deliveries were indicated by malpresentation. Our results corroborate with those, as we found that non-vertex second twin yielded adjusted odds ratio of 17.7 for combined delivery. Breech delivery requires knowledge and expertise in order to safely extract the fetus. Since the publication of the Term Breech Trial (TBT) [21], the rate of singleton breech deliveries decreased substantially. Although it has not been proved that the results of the TBT apply to twin deliveries, a similar trend has been noticed regarding non-cephalic second twin [2]. Furthermore, as the decrease in singleton breech
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Table 1. Demographic and obstetrical characteristics.
Parameter Age, yearsz Gravidity, nz Parity, nz Nulliparity, n (%) Gestational age at delivery, weeksz 37 weeks of gestation, n (%) 34–36 weeks of gestation, n (%) 28–33 weeks of gestation, n (%) 27 weeks of gestation, n (%) Previous cesarean delivery, n (%) DCDA twins, n (%)* Twin A birth weight, gramsz Twin B birth weight, gramsz Birth weight difference, gramsz Twin B4Twin A, n (%) Twin A birth weight percentile, %z Twin B birth weight percentile, %z Twin A male, n (%) Twin B male, n (%) Both twins in vertex presentation at admission, n (%) Spontaneous onset of delivery, n (%) Induction of labor, n (%) Oxytocin for augmentation, n (%) Epidural analgesia, n (%) Hypertensive disorders, n (%)y Gestational diabetes mellitus, n (%) COH, n (%)* IVF, n (%)* Meconium, n (%) Premature rupture of membrane, n (%)
Study (N ¼ 23)
Control (N ¼ 198)
p value
33.3 ± 4.4 3.0 ± 2.1 2.5 ± 1.6 6 (26.1) 35.4 ± 2.7
32.4 ± 4.8 2.8 ± 1.8 2.3 ± 1.4 65 (32.8) 35.8 ± 2.4
0.39 0.47 0.44 0.51 0.41
8 (34.8) 11 (47.8) 4 (17.4) 0 (0) 1 (4.3) 21 (91.3) 2308 ± 600 2251 ± 497 240.0 ± 224.8 11 (47.8) 54.4 ± 26.4
82 (41.4) 93 (47.0) 21 (10.6) 2 (1.0) 5 (2.5) 136 (68.7) 2335 ± 444 2314 ± 493 267.0 ± 218.3 96 (48.5) 53.9 ± 23.2
0.54 0.94 0.33 0.63 0.61 0.02 0.79 0.56 0.58 0.95 0.92
49.9 ± 28.4
52.0 ± 26.2
0.71
15 (65.2) 13 (56.5) 14 (60.9)
105 (53.0) 94 (47.5) 181 (91.4)
0.27 0.41 50.001
21 (91.3)
159 (80.3)
0.2
3 (13.0) 2 (8.7)
36 (18.2) 48 (24.2)
0.54 0.09
15 (65.2) 1 (4.3) 1 (4.3)
159 (80.3) 5 (2.5) 8 (4.0)
0.09 0.61 0.94
6 1 1 2
(26.1) (4.3) (4.3) (8.7)
30 23 4 29
(15.2) (11.6) (2.0) (14.6)
0.19 0.29 0.48 0.44
*DCDA – dichorionic–diamniotic, COH – controlled ovarian hyperstimulation. yHypertensive disorders: chronic hypertension, gestational hypertension, mild or severe pre-eclampsia. zData are presented as mean ± SD.
Table 2. Multivariate logistic regression for combined twin delivery.
Parameterr Dichorionic–diamniotic twins Twin B in non-vertex presentation at admission Twin B in non-vertex presentation after delivery of twin A
Adjusted odds ratio
95% Confidence interval
p value
8.9 11.5
1.844.0 3.8–34.9
0.008 50.001
17.7
6.6–47.2
50.001
deliveries is accompanied by a similar decrease in the care-taker’s expertise in breech extraction, we can expect more and more physicians to lack the proper skills to deliver a non-cephalic second twin. We also analyzed the association of breech presentation at admission with combined delivery, in order to assess the impact of spontaneous version of twin B to non-cephalic
presentation after the extraction of twin A. As expected, non-cephalic twin B at admission was also found to be an independent risk factor for combined delivery, with an adjusted OR of 11.5 (95% CI 3.8–34.9, p50.001). Interestingly, the odds ratio were found to be lower compared with the odds ratio for combined delivery of non-cephalic twin B at delivery (aOR 17.7, 95% CI 6.6–47.2, p50.001). We hypothesize that while breech twin B still poses a challenge for the obstetrician, once it is known from admission and not the result of a less predictable spontaneous version, the awareness and readiness of the staff may increase the chance of successful vaginal extraction. Additionally, spontaneous version of twin B to noncephalic presentation was not found to increase the baseline risk of a non-cephalic twin B to undergo combined delivery. A report by Breathnach et al. [15] indicated that out of 10 combined deliveries, seven (70%) were the result of a spontaneous version to non-cephalic presentation of twin B. In our cohort, only eight out of 23 (34.8%) (Figure 2) combined deliveries resulted from spontaneous version of twin B. This difference may derive from different protocols as in our cohort sonogram was performed immediately at admission to the delivery suite, and in Breathnach’s report sonogram was performed up to two weeks prior to delivery. Furthermore, scarcity of data concerning statistical analysis of the contribution of spontaneous version of twin B exist, thus comparing different reports may prove to be a futile effort. The finding that dichorionic (DC) twins are at higher risk for combined delivery is enigmatic. We found one report addressing this issue [15], which found no relation between chorionicity and mode of delivery. All combined deliveries indicated by malpresentation of twin B occurred among DC twins, as well as all three cases of prolapsed umbilical cord. We may speculate that fetal lies in DC twins and the morphologic structure of the thicker septum may pose greater risk for these indications for interventions, but more substantial data is required to draw further conclusions. When comparing immediate neonatal outcome of twin B between the study and the control group, we found no significant difference between the groups, excluding hemorrhagic ischemic encephalopathy (HIE). This finding should also be interpreted with caution, as statistical significance was demonstrated, but the absolute numbers are quite small (one case in the study group and none in the control group). Nonetheless, a previous report advocated higher morbidity rate among twins in combined delivery than in vaginal delivery or cesarean delivery [5], where morbidity was defined as pH57.0, 5-minutes Apgar score 55 or birth trauma. Conversely, another report found no significant differences in neonatal outcome, including HIE, between cesarean and combined deliveries. While it is plausible to assume some sort of deprived outcome in twin B following urgent intervention, the relatively small number of adverse events among our cohort preclude assumptions concerning neonatal outcome. Our study is not without limitations. Owing to the retrospective nature of our study, data regarding possible confounders such as pre-pregnancy maternal BMI and pregnancy weight change were not available, as well as data concerning care-takers’ expertise in breech extractions or
Combined delivery of twins
DOI: 10.3109/14767058.2014.927430
Figure 2. Presentations at admission and delivery, and indications for cesarean section.
Vx/Vx N = 195 (88.3%)
Presentation
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Vx/Non-Vx N = 26 (11.7%)
Presentation at delivery:
Vx/non-Vx N = 16 (8.2%)
Vx/Vx N = 179 (91.8%)
Vx/non-Vx N = 15 (57.7%)
Vx/Vx N = 11 (42.3%)
Vaginal delivery of twin B:
N = 8 (50%)
N = 173 (96.6%)
N = 11 (73.3%)
N = 6 (54.5%)
Combined delivery of twin B:
N = 8 (50%)
N = 6 (3.4%)
N = 4 (26.3%)
N = 5 (45.5%)
Prolapsed umbilical cord (N=3, 50%)
Failed BE (N=2, 50%)
NRFHR (N=4, 80%)
No trial of BE (N=2, 50%)
Placental abruption (N=1, 20%)
Indications for combined
Failed BE (N=6, 75%) No trial of BE (N=2, 25%)
NRFHR (N=2, 33.3%) Placental abruption (N=1, 16.7%)
Table 3. Neonatal outcome for twin A.
Table 4. Neonatal outcome for twin B.
Parameters
Study (N ¼ 23)
Control (N ¼ 198)
p value
5 minutes Apgar score 57 NICU, n (%)* Asphyxia, n (%) Seizures, n (%) IVH, n (%)* HIE, n (%)* Acidosis, n (%) Hypoglycemia, n (%) TTN, n (%)* RDS, n (%)* Respiratory distress, n (%) Cardiorespiratory failure, n (%) Mechanical ventilation, n (%) Sepsis, n (%) NEC, n (%)* Jaundice, n (%) Composite outcome, n (%)
1 (4.3) 5 (21.7) 0 (0) 0 (0) 1 (4.3) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (4.3) 0 (0) 1 (4.3) 4 (17.4) 0 (0) 1 (4.3) 5 (21.7)
3 (1.5) 39 (19.7) 3 (1.5) 2 (1.0) 8 (4.0) 0 (0) 2 (1.0) 3 (1.5) 5 (2.5) 2 (1.0) 12 (6.1) 1 (0.5) 6 (3.0) 33 (16.7) 6 (3.0) 16 (8.1) 39 (19.7)
0.33 0.82 0.55 0.63 0.94 NS 0.63 0.55 0.44 0.63 0.74 0.73 0.73 0.93 0.40 0.53 0.82
Parameters
Study (N ¼ 23)
Control (N¼198)
5 minutes Apgar score 57 NICU, n (%)* Asphyxia, n (%) Seizures, n (%) IVH, n (%)* HIE, n (%)* Acidosis, n (%) Hypoglycemia, n (%) TTN, n (%)* RDS, n (%)* Respiratory distress, n (%) Cardiorespiratory failure, n (%) Mechanical ventilation, n (%) Sepsis, n (%) NEC, n (%)* Jaundice, n (%) Composite outcome, n (%)
1 6 3 0 2 1 1 1 0 0 3 0 2 6 1 1 8
2 40 8 0 8 0 3 8 6 4 18 1 15 31 6 18 46
(4.3) (26.1) (13.0) (0) (8.7) (4.3) (4.3) (4.3) (0) (0) (13.0) (0) (8.7) (26.1) (4.3) (4.3) (34.3)
(1.0) (20.2) (4.0) (0) (4.0) (0) (1.5) (4.0) (3.0) (2.0) (9.1) (0.5) (7.6) (15.7) (3.0) (9.1) (23.2)
p value 0.19 0.51 0.06 NS 0.31 0.003 0.33 0.94 0.40 0.49 0.54 0.73 0.85 0.21 0.73 0.44 0.22
*NICU – Neonatal intensive care unit, IVH – Intraventricular hemorrhage, TTN – Transient tachypnea of the newborn, RDS – Respiratory distress syndrome, HIE – Hemorrhagic ischemic encephalopathy.
*NICU – Neonatal intensive care unit, IVH – Intraventricular hemorrhage, TTN – Transient tachypnea of the newborn, RDS – Respiratory distress syndrome, HIE – Hemorrhagic ischemic encephalopathy.
long-term neonatal outcome. Nonetheless, our data derives from quite homogenous population in a single center, with the same stringent obstetrical protocol during the study period. In conclusion, our main results indicate that in twin gestations, breech presentation of twin B at admission or following delivery of twin A, is a risk factor for combined deliveries, and that immediate neonatal outcome of twin B following combined delivery are comparable with those of vaginal delivery. This data can be used for counseling couples with twin gestation in planning their desired mode of delivery.
Additional prospective trials are needed to validate these findings [15].
Acknowledgements The authors wish to thank Mrs. Inbar Dabach-Alush and the computer division at Rabin Medical Center for their assistance and support.
Declaration of interest The authors report no conflict of interest.
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