Perinatal morbidity and early neonatal mortality in twin pregnancies

Corinna Peter, Paul Wenzlaff, Jan Kruempelmann, Gerhard Alzen, Eva Bueltmann, Susanne E. Gruessner

Center for Quality Assurance and Management in Health Care, Hannover, Germany.
Department for Trauma and Orthopaedic Surgery, Insurance Accident and Prevention Clinic, Frankfurt am Main, Germany.
Department of Obstetrics and Gynaecology, Justus-Liebig University of Giessen, Giessen, Germany&Department of Obstetrics, Gynaecology and Reproductive Medicine, Hannover Medical School, Hannover, Germany.
Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.
Department of Pediatric Radiology, University of Giessen, Giessen, Germany.
Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany.

DOI: 10.4236/ojog.2013.31017                

Abstract

Purpose: The purpose of this study was to investigate the impact of maternal, fetal and obstetric parameters in twin pregnancies due to chorionicity, perinatal morbidity and early neonatal mortality. Methods: Early neonatal outcome parameters were retrospectively analysed in 240 twin pregnancies (51 monochorionic [MC], 189 dichorionic [DC] twins) over a 7.5 years period. Beside chorionicity, we focused on risk factors affecting perinatal morbidity and early neonatal outcome in the overall study cohort and subgroups 1) late preterm and 2) pregnancies conceived by artificial fertilization (IVF/ICSI). Mixed effects logistic regression models were used for multivariate risk analyses. Results: MC vs DC pregnancies showed significantly lower birth weights (p < 0.01), decreased gestational ages (p < 0.01), increased rates of mechanical ventilation (p < 0.05) and higher early neonatal mortality rates (p < 0.05). Additional risk factors for perinatal morbidity and adverse early neonatal outcome were prematurity (<36 completed weeks of gestation), severe intertwin birth weight discordance >25% and amniotic inflammation (amniotic infection syndrome [AIS]). A gestational age >36 completed weeks was accompanied by a decrease of early neonatal complications (p < 0.05). Pregnancies conceived by IVF/ ICSI didn’t differ from the overall study cohort regarding the investigated risk factors. Conclusions: Twin pregnancies complicated by prematurity, AIS and severe intertwin birth weight discordance are associated with higher perinatal morbidity and adverse early neonatal outcome. In addition, MC twins are jeopardized by an increased early neonatal mortality and therefore represent considerable challenges to both obstetricians and neonatologists. Based on our results, we recommend such twin pregnancies to be monitored and delivered at tertiary perinatal care centres to minimize perinatal morbidity and adverse early neonatal outcomes.

Keywords

Twins; Chorionicity; Obstetric Outcome; Perinatal Morbidity; Early Neonatal Outcome

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Hack, K.E., Derks, J., Elias, S., Franx, A., Roos, E., Voerman, S., Bode, C., Koopman-Esseboom, C. and Visser, G. (2008). Increased perinatal mortality and morbidity in monochorionic versus dichorionic twin pregnancies: Clinical implications of a large Dutch cohort study. British Journal of Obstetrics & Gynaecology, 115, 58-67. doi:10.1111/j.1471-0528.2007.01556.x
[2]	Hack, K.E., Koopman-Esseboom, C., Derks, J.B., Elias, S.G., de Kleine, M.J., Baerts, W., Go, A.T., Schaap, A.H., van der Hoeven, M.A., Eggink, A.J., Sollie, K.M., Weisglas-Kuperus, N. and Visser, G.H. (2009) Long-term neurodevelopmental outcome of monochorionic and matched dichorionic twins. PLoS One, 4, Article ID: e6815. doi:10.1371/journal.pone.0006815
[3]	Adegbite, A., Castille, S., Ward, S. and Bajoria, R. (2004) Neuromorbidity in preterm twins in relation to chorionicity and discordant birth weight. American Journal of Obstetrics and Gynecology, 190, 156-163. doi:10.1016/j.ajog.2003.07.004
[4]	Glinianaia, S.V., Obeysekera, M.A., Sturgiss, S. and Bell, R. (2011) Stillbirth and neonatal mortality in monochorionic and dichorionic twins: A population-based study. Human Reproduction, 26, 2549-2557. doi:10.1093/humrep/der213
[5]	Shrim, A., Weisz, B., Gindes, L. and Gagnon, R. (2010) Parameters associated with outcome in third trimester monochorionic diamniotic twin pregnancies. Journal of Obstetrics and Gynaecology Canada, 32, 429-434.
[6]	Sperling, L., Kiil, C., Larsen, L., Qvist, I., Schwartz, M., Jorgensen, C., Skajaa, K., Bang, J. and Tabor, A. (2006) Naturally conceived twins with monochorionic placentation have the highest risk of fetal loss. Ultrasound in Obstetrics & Gynecology, 28, 644-652. doi:10.1002/uog.3820
[7]	Adler-Levy, Y., Lunenfeld, E. and Levy, A. (2007) Obstetric outcome of twin pregnancies conceived by in vitro fertilization and ovulation induction compared with those conceived spontaneously. European Journal of Obstetrics & Gynecology and Reproductive Biology, 133, 173-178. doi:10.1016/j.ejogrb.2006.08.010
[8]	McDonald, S.D., Han, Z., Mulla, S., Ohlsson, A., Beyene, J., Murphy, K.E. and Knowledge Synthesis Group (2010) Preterm birth and low birth weight among in vitro fertilization twins: A systematic review and meta-analyses. European Journal of Obstetrics & Gynecology and Reproductive Biology, 148, 105-13. doi:10.1016/j.ejogrb.2009.09.019
[9]	Luke, B., Brown, M.B., Alexandre, P.K., Kinoshi, T., O’Sullivan, M.J., Martin, D., Misiunas, R.B., Nugent, C., van de Ven, C., Newman, R.B., Mauldin, J.G. and Witter, F.R. (2005) The cost of twin pregnancy: Maternal and neonatal factors. American Journal of Obstetrics and Gynecology, 192, 909-915. doi:10.1016/j.ajog.2004.05.057
[10]	Blickstein, I., Goldman, R.D., Smith-Levitin, M., Greenberg, M., Sherman, D. and Rydhstroem, H. (1999) The relation between inter-twin birth weight discordance and total twin birth weight. Obstetrics & Gynecology, 93, 113-116. doi:10.1016/S0029-7844(98)00343-3
[11]	Papile, L., Burstein, J., Burstein, R. and Koffer, H. (1978) Incidence and evolution of subependymal and intraventricular hemorrhage. A study of infants with birth weight less than 1500 grams. The Journal of Pediatrics, 92, 529-534. doi:10.1016/S0022-3476(78)80282-0
[12]	Ananth, C.V., Platt, R.W. and Savitz, D.A. (2005) Regression models for clustered binary responses: Implications of ignoring the intracluster correlation in an analysis of perinatal mortality in twin gestations. Annals of Epidemiology, 15, 293-301. doi:10.1016/j.annepidem.2004.08.007
[13]	Statistical Software Stata 12. http://www.stata.com/help.cgi?xtmelogit
[14]	Rde, C.A.M., Brizot Mde, L., Liao, A.W., Krebs, V.L. and Zugaib, M. (2009) Early neonatal morbidity and mortality in growth-discordant twins. Acta Obstetricia et Gynecologica Scandinavica, 88, 167-171. doi:10.1080/00016340802649808
[15]	Bagchi, S. and Salihu, H.M. (2006) Birth weight discordance in multiple gestations: Occurrence and outcomes. Journal of Obstetrics and Gynaecology, 26, 291-296. doi:10.1080/01443610600594724
[16]	Lopriore, E., Slaghekke, F., Vandenbussche, F.P., Middeldorp, J.M., Walther, F.J. and Oepkes, D. (2008) Cerebral injury in monochorionic twins with selective intrauterine growth restriction and/or birthweight discordance. American Journal of Obstetrics and Gynecology, 199, 628.e1-628.e5. doi:10.1016/j.ajog.2008.06.008
[17]	Refuerzo, J.S., Momirova, V., Peaceman, A.M., Sciscione, A., Rouse, D.J., Caritis, S.N., Spong, C.Y., Varner, M.W., Malone, F.D., Iams, J.D., Mercer, B.M., Thorp Jr., J.M., Sorokin, Y., Carpenter, M.W., Lo, J. and Harper, M. (2010) Neonatal outcomes in twin pregnancies delivered moderately preterm, late preterm, and term. American Journal of Perinatology, 27, 537-542. doi:10.1055/s-0030-1248940
[18]	Sela, H.Y. and Simpson, L.L. (2011) Preterm premature rupture of membranes complicating twin pregnancy: Management considerations. Clinical Obstetrics and Gynecology, 54, 321-329. doi:10.1097/GRF.0b013e318217d60d
[19]	Ananth, C.V., Smulian, J.C., Srinivas, N., Getahun, D. And Salihu, H.M. (2005) Risk of infant mortality among twins in relation to placental abruption: contributions of preterm birth and restricted fetal growth. Twin Research and Human Genetics, 8, 524-531. doi:10.1375/twin.8.5.524
[20]	Hartley, R.S., Hitti, J. and Emanuel, I. (2002) Size-discordant twin pairs have higher perinatal mortality rates than nondiscordant pairs. American Journal of Obstetrics and Gynecology, 187, 1173-1178. doi:10.1067/mob.[phone]
[21]	Tan, H., Wen, S.W., Fung, K.F.K., Walker, M. and Demissie, K. (2005) The distribution of intra-twin birth weight discordance and its association with total twin birth weight, gestational age, and neonatal mortality. European Journal of Obstetrics & Gynecology and Reproductive Biology, 121, 27-33. doi:10.1016/j.ejogrb.2004.10.012
[22]	Smith, N.A., Wilkins-Haug, L., Santolaya-Forgas, J., Acker, D., Economy, K.E., Benson, C.B. and Robinson, J.N. (2010) Contemporary management of monochorionic diamniotic twins: Outcomes and delivery recommendations revisited. American Journal of Obstetrics and Gynecology, 203, 133.e1-133.e6. doi:10.1016/j.ajog.2010.02.066
[23]	Tobe, R.G., Mori, R., Shinozuka, N., Kubo, T. and Itabashi, K. (2010) Birthweight discordance, risk factors and its impact on perinatal mortality among Japanese twins: Data from a national project during 2001-2005. Twin Research and Human Genetics, 13, 490-494. doi:10.1375/twin.13.5.490
[24]	Royal College of Obstetricians Gynaecologists (2008) Management of monochorionic twins. http://www.aogm.org.mo/assets/Uploads/aogm/Guidelines/RCOG-UK/T51-Management-Monochorionic-Twin-Pregnancy2008a.pdf
[25]	Melamed, N., Yogev, Y. and Glezerman, M. (2009) Effect of fetal sex on pregnancy outcome in twin pregnancies. Obstetrics & Gynecology, 114, 1085-1092. doi:10.1097/AOG.0b013e3181bd8874
[26]	Choi, S.J., Song, S.E., Seo, E.S., Oh, S.Y., Kim, J.H. and Roh, C.R. (2009) The effect of single or multiple courses of antenatal corticosteroid therapy on neonatal respiratory distress syndrome in singleton versus twin pregnancies. The Australian and New Zealand Journal of Obstetrics and Gynaecology, 49, 173-179. doi:10.1111/j.1479-828X.2009.00970.x
[27]	Baghdadi, S., Gee, H., Whittle, M.J. and Khan, K.S. (2003) Twin pregnancy outcome and chorionicity. Acta Obstetricia et Gynecologica Scandinavica, 82, 18-21. doi:10.1034/j.1600-0412.2003.820103.x
[28]	Jain, V. and Fisk, N.M. (2004) The twin-twin transfusion syndrome. Clinical Obstetrics and Gynecology, 47, 181-202. doi:10.1097/00003081-200403000-00020
[29]	Lewi, L., Gucciardo, L., Huber, A., Jani, J., Van Mieghem, T., Doné, E., Cannie, M., Gratacós, E., Diemert, A., Hecher, K., Lewi, P. and Deprest, J. (2008) Clinical outcome and placental characteristics of monochorionic diamniotic twin pairs with early-and late-onset discordant growth. American Journal of Obstetrics and Gynecology, 199, 511.e1-511.e7. doi:10.1016/j.ajog.2008.04.022