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6 - Risks and complications of multiple gestations

from Section 2 - Pregnancy, labor, and delivery complications causing brain injury

Published online by Cambridge University Press:  12 January 2010

David K. Stevenson
Affiliation:
Stanford University School of Medicine, California
William E. Benitz
Affiliation:
Stanford University School of Medicine, California
Philip Sunshine
Affiliation:
Stanford University School of Medicine, California
Susan R. Hintz
Affiliation:
Stanford University School of Medicine, California
Maurice L. Druzin
Affiliation:
Stanford University School of Medicine, California
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Summary

Introduction

In the United States in 2004, 3.4% of all births were multiple births. Between 1994 and 2004, the multiple birth ratio in the United States increased by 32% (from 2.6% to 3.4%), largely due to increased use of assisted reproductive technology. This increase in multiple birth rates has had a tremendous impact on prematurity. In 2004, one in eight babies (12.5% of live births) was born prematurely; and of multiple gestations, 61.4% were born preterm, 58.5% were low birthweight (less than 2500 g), and 11.5% were very low birthweight (less than 1500 g). Infants from multiple gestations thus carry a tremendous economic burden, in 2005 the annual cost of prematurity in the United States was well over $26 billion.

Among multiple gestations, the highest incidence is contributed by twins. Besides prematurity, twins, regardless of type, are at higher risk for neurological injury. Over the years, several studies have correlated cerebral palsy with multiple gestations. A recently published large case–control study based on the Swedish Medical Birth Registry between 1984 and 1998 showed a 1.4 odds ratio (95% CI 1.1–1.6) of cerebral palsy in twin gestations relative to their singleton counterparts.

Besides their effect on society, twins pose interesting and challenging diagnostic and management dilemmas. From conception to delivery, and even beyond, twin gestations behave remarkably differently from their singleton counterparts, and have a myriad of unique physiologic changes and pathologic conditions that one must consider when caring for these special pregnancies.

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Publisher: Cambridge University Press
Print publication year: 2009

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References

March of Dimes. Peri Stats. www.marchofdimes.com/peristats. Accessed February, 2008.
Alberman, ED. Cerebral palsy in twins. Guys Hosp Rep 1964; 113: 285–95.Google ScholarPubMed
Goodman, R. Cerebral palsy in twins. Dev Med Child Neurol 1993; 35: 370.Google ScholarPubMed
Livinec, F, Ancel, PY, Marret, S, et al. Prenatal risk factors for cerebral palsy in very preterm singletons and twins. Obstet Gynecol 2005; 105: 1341–7.CrossRefGoogle ScholarPubMed
Petterson, B, Nelson, KB, Watson, L, et al. Twins, triplets, and cerebral palsy in births in Western Australia in the 1980s. BMJ 1993; 307: 1239–43.CrossRefGoogle ScholarPubMed
Pharoah, PO. Twins and cerebral palsy. Acta Paediatr Suppl 2001; 90: 6–10.CrossRefGoogle ScholarPubMed
Thorngren-Jerneck, K, Herbst, A. Perinatal factors associated with cerebral palsy in children born in Sweden. Obstet Gynecol 2006; 108: 1499–505.CrossRefGoogle ScholarPubMed
Cunningham, FG, Williams, JW, eds. Williams Obstetrics, 21st edn. New York, NY: McGraw-Hill, 2001.Google Scholar
Sadler, TW, Langman, J, eds. Langman's Medical Embryology, 10th edn. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.Google Scholar
Monteagudo, A, Timor-Tritsch, IE, Sharma, S. Early and simple determination of chorionic and amniotic type in multifetal gestations in the first fourteen weeks by high-frequency transvaginal ultrasonography. Am J Obstet Gynecol 1994; 170: 824–9.CrossRefGoogle ScholarPubMed
Scardo, JA, Ellings, JM, Newman, RB. Prospective determination of chorionicity, amnionicity, and zygosity in twin gestations. Am J Obstet Gynecol 1995; 173: 1376–80.CrossRefGoogle ScholarPubMed
,ACOG Practice Bulletin #56: Multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy. Obstet Gynecol 2004; 104: 869–83.Google Scholar
Gardner, MO, Goldenberg, RL, Cliver, SP, et al. The origin and outcome of preterm twin pregnancies. Obstet Gynecol 1995; 85: 553–7.CrossRefGoogle ScholarPubMed
Newman, RB, Iams, JD, Das, A, et al. A prospective masked observational study of uterine contraction frequency in twins. Am J Obstet Gynecol 2006; 195: 1564–70.CrossRefGoogle ScholarPubMed
Romero, R, Espinoza, J, Kusanovic, JP, et al. The preterm parturition syndrome. BJOG 2006; 113: 17–42.CrossRefGoogle ScholarPubMed
Nassar, AH, Usta, IM, Rechdan, JB, et al. Pregnancy outcome in spontaneous twins versus twins who were conceived through in vitro fertilization. Am J Obstet Gynecol 2003; 189: 513–18.CrossRefGoogle ScholarPubMed
Goldenberg, RL, Iams, JD, Das, A, et al. The Preterm Prediction Study: sequential cervical length and fetal fibronectin testing for the prediction of spontaneous preterm birth. National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Am J Obstet Gynecol 2000; 182: 636–43.CrossRefGoogle ScholarPubMed
Lockwood, CJ, Senyei, AE, Dische, MR, et al. Fetal fibronectin in cervical and vaginal secretions as a predictor of preterm delivery. N Engl J Med 1991; 325: 669–74.CrossRefGoogle ScholarPubMed
Gibson, JL, Macara, LM, Owen, P, et al. Prediction of preterm delivery in twin pregnancy: a prospective, observational study of cervical length and fetal fibronectin testing. Ultrasound Obstet Gynecol 2004; 23: 561–6.CrossRefGoogle ScholarPubMed
Goldenberg, RL, Iams, JD, Miodovnik, M, et al. The preterm prediction study: risk factors in twin gestations. National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Am J Obstet Gynecol 1996; 175: 1047–53.CrossRefGoogle ScholarPubMed
Ruiz, RJ, Fullerton, J, Brown, CE. The utility of fFN for the prediction of preterm birth in twin gestations. J Obstet Gynecol Neonatal Nurs 2004; 33: 446–54.CrossRefGoogle ScholarPubMed
Berghella, V, Odibo, AO, To, MS, et al. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Obstet Gynecol 2005; 106: 181–9.CrossRefGoogle ScholarPubMed
Dor, J, Shalev, J, Mashiach, S, et al. Elective cervical suture of twin pregnancies diagnosed ultrasonically in the first trimester following induced ovulation. Gynecol Obstet Invest 1982; 13: 55–60.CrossRefGoogle ScholarPubMed
,Interim report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists multicentre randomized trial of cervical cerclage. MRC/RCOG Working Party on Cervical Cerclage. Br J Obstet Gynaecol 1988; 95: 437–45.Google Scholar
Eskandar, M, Shafiq, H, Almushait, MA, et al. Cervical cerclage for prevention of preterm birth in women with twin pregnancy. Int J Gynaecol Obstet 2007; 99: 110–12.CrossRefGoogle ScholarPubMed
Roman, AS, Rebarber, A, Pereira, L, et al. The efficacy of sonographically indicated cerclage in multiple gestations. J Ultrasound Med 2005; 24: 763–71.CrossRefGoogle ScholarPubMed
Newman, RB, Krombach, RS, Myers, MC, et al. Effect of cerclage on obstetrical outcome in twin gestations with a shortened cervical length. Am J Obstet Gynecol 2002; 186: 634–40.CrossRefGoogle ScholarPubMed
Meis, PJ, Klebanoff, M, Thom, E, et al. Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone caproate. N Engl J Med 2003; 348: 2379–85.CrossRefGoogle ScholarPubMed
Rouse, DJ, Caritis, SN, Peaceman, AM, et al. A trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twins. N Engl J Med 2007; 357: 454–61.CrossRefGoogle ScholarPubMed
,ACOG Committee Opinion. Use of progesterone to reduce preterm birth. Obstet Gynecol 2003; 102: 1115–16.Google Scholar
Hales, KA, Matthews, JP, Rayburn, WF, et al. Intravenous magnesium sulfate for premature labor: comparison between twin and singleton gestations. Am J Perinatol 1995; 12: 7–10.CrossRefGoogle ScholarPubMed
O'Leary, JA. Prophylactic tocolysis of twins. Am J Obstet Gynecol 1986; 154: 904–5.CrossRefGoogle Scholar
Lyell, DJ, Pullen, K, Campbell, L, et al. Magnesium sulfate compared with nifedipine for acute tocolysis of preterm labor: a randomized controlled trial. Obstet Gynecol 2007; 110: 61–7.CrossRefGoogle ScholarPubMed
Bajoria, R, Wigglesworth, J, Fisk, NM. Angioarchitecture of monochorionic placentas in relation to the twin–twin transfusion syndrome. Am J Obstet Gynecol 1995; 172: 856–63.CrossRefGoogle ScholarPubMed
Lutfi, S, Allen, VM, Fahey, J, et al. Twin–twin transfusion syndrome: a population-based study. Obstet Gynecol 2004; 104: 1289–97.CrossRefGoogle ScholarPubMed
Quintero, RA, Morales, WJ, Allen, MH, et al. Staging of twin–twin transfusion syndrome. J Perinatol 1999; 19: 550–5.CrossRefGoogle ScholarPubMed
Chescheir, NC, Seeds, JW. Polyhydramnios and oligohydramnios in twin gestations. Obstet Gynecol 1988; 71: 882–4.Google ScholarPubMed
Luks, FI, Carr, SR, Plevyak, M, et al. Limited prognostic value of a staging system for twin-to-twin transfusion syndrome. Fetal Diagn Ther 2004; 19: 301–4.CrossRefGoogle ScholarPubMed
Mari, G, Roberts, A, Detti, L, et al. Perinatal morbidity and mortality rates in severe twin–twin transfusion syndrome: results of the International Amnioreduction Registry. Am J Obstet Gynecol 2001; 185: 708–15.CrossRefGoogle ScholarPubMed
Senat, MV, Deprest, J, Boulvain, M, et al. Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. N Engl J Med 2004; 351: 136–44.CrossRefGoogle ScholarPubMed
Crombleholme, TM, Shera, D, Lee, H, et al. A prospective, randomized, multicenter trial of amnioreduction vs. selective fetoscopic laser photocoagulation for the treatment of severe twin–twin transfusion syndrome. Am J Obstet Gynecol 2007; 197: 396.e1–9.CrossRefGoogle ScholarPubMed
Adegbite, AL, Castille, S, Ward, S, et al. Neuromorbidity in preterm twins in relation to chorionicity and discordant birth weight. Am J Obstet Gynecol 2004; 190: 156–63.CrossRefGoogle ScholarPubMed
Degani, S, Leibovitz, Z, Shapiro, I, et al. Instability of Doppler cerebral blood flow in monochorionic twins. J Ultrasound Med 2006; 25: 449–54.CrossRefGoogle ScholarPubMed
Lopriore, E, Nagel, HT, Vandenbussche, FP, et al. Long-term neurodevelopmental outcome in twin-to-twin transfusion syndrome. Am J Obstet Gynecol 2003; 189: 1314–19.CrossRefGoogle ScholarPubMed
Graef, C, Ellenrieder, B, Hecher, K, et al. Long-term neurodevelopmental outcome of 167 children after intrauterine laser treatment for severe twin–twin transfusion syndrome. Am J Obstet Gynecol 2006; 194: 303–8.CrossRefGoogle ScholarPubMed
Lopriore, E, Middeldorp, JM, Sueters, M, et al. Long-term neurodevelopmental outcome in twin-to-twin transfusion syndrome treated with fetoscopic laser surgery. Am J Obstet Gynecol 2007; 196: 231.e1–4.Google ScholarPubMed
Amaru, RC, Bush, MC, Berkowitz, RL, et al. Is discordant growth in twins an independent risk factor for adverse neonatal outcome?Obstet Gynecol 2004; 103: 71–6.CrossRefGoogle ScholarPubMed
Branum, AM, Schoendorf, KC. The effect of birth weight discordance on twin neonatal mortality. Obstet Gynecol 2003; 101: 570–4.Google ScholarPubMed
Demissie, K, Ananth, CV, Martin, J, et al. Fetal and neonatal mortality among twin gestations in the United States: the role of intrapair birth weight discordance. Obstet Gynecol 2002; 100: 474–80.Google ScholarPubMed
Gratacos, E, Carreras, E, Becker, J, et al. Prevalence of neurological damage in monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic umbilical artery flow. Ultrasound Obstet Gynecol 2004; 24: 159–63.CrossRefGoogle ScholarPubMed
Gulmezoglu, AM, Hofmeyr, GJ. Bed rest in hospital for suspected impaired fetal growth. Cochrane Database Syst Rev 2000; 2: CD000034.Google Scholar
Milki, AA, Jun, SH, Hinckley, MD, et al. Incidence of monozygotic twinning with blastocyst transfer compared to cleavage-stage transfer. Fertil Steril 2003; 79: 503–6.CrossRefGoogle ScholarPubMed
Moayeri, SE, Behr, B, Lathi, RB, et al. Risk of monozygotic twinning with blastocyst transfer decreases over time: an 8-year experience. Fertil Steril 2007; 87: 1028–32.CrossRefGoogle Scholar
Bejar, R, Vigliocco, G, Gramajo, H, et al. Antenatal origin of neurologic damage in newborn infants. II. Multiple gestations. Am J Obstet Gynecol 1990; 162: 1230–6.CrossRefGoogle ScholarPubMed
Bahtiyar, MO, Dulay, AT, Weeks, BP, et al. Prevalence of congenital heart defects in monochorionic/diamniotic twin gestations: a systematic literature review. J Ultrasound Med 2007; 26: 1491–8.CrossRefGoogle ScholarPubMed
Okumura, A, Hayakawa, F, Kato, T, et al. Brain malformation of the surviving twin of intrauterine co-twin demise. J Child Neurol 2007; 22: 85–8.CrossRefGoogle ScholarPubMed
Morokuma, S, Tsukimori, K, Anami, A, et al. Brain injury of the survivor diagnosed at 18 weeks of gestation after intrauterine demise of the co-twin: a case report. Fetal Diagn Ther 2007; 23: 138–40.Google ScholarPubMed
Righini, A, Salmona, S, Bianchini, E, et al. Prenatal magnetic resonance imaging evaluation of ischemic brain lesions in the survivors of monochorionic twin pregnancies: report of 3 cases. J Comput Assist Tomogr 2004; 28: 87–92.CrossRefGoogle ScholarPubMed
Ezra, Y, Shveiky, D, Ophir, E, et al. Intensive management and early delivery reduce antenatal mortality in monoamniotic twin pregnancies. Acta Obstet Gynecol Scand 2005; 84: 432–5.CrossRefGoogle ScholarPubMed
Minakami, H, Sato, I. Reestimating date of delivery in multifetal pregnancies. JAMA 1996; 275: 1432–4.CrossRefGoogle ScholarPubMed
Kahn, B, Lumey, LH, Zybert, PA, et al. Prospective risk of fetal death in singleton, twin, and triplet gestations: implications for practice. Obstet Gynecol 2003; 102: 685–92.Google ScholarPubMed
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.CrossRefGoogle ScholarPubMed
Chasen, ST, Spiro, SJ, Kalish, RB, et al. Changes in fetal presentation in twin pregnancies. J Matern Fetal Neonatal Med 2005; 17: 45–8.CrossRefGoogle ScholarPubMed
Yang, Q, Wen, SW, Chen, Y, et al. Neonatal death and morbidity in vertex–nonvertex second twins according to mode of delivery and birth weight. Am J Obstet Gynecol 2005; 192: 840–7.CrossRefGoogle ScholarPubMed
Chasen, ST, Chervenak, FA. Delivery of twin gestations. UpToDate; 2007.Google Scholar
Davison, L, Easterling, TR, Jackson, JC, et al. Breech extraction of low-birth-weight second twins: can cesarean section be justified?Am J Obstet Gynecol 1992; 166: 497–502.CrossRefGoogle ScholarPubMed
Morales, WJ, O'Brien, WF, Knuppel, RA, et al. The effect of mode of delivery on the risk of intraventricular hemorrhage in nondiscordant twin gestations under 1500 g. Obstet Gynecol 1989; 73: 107–10.Google ScholarPubMed
Ford, AA, Bateman, BT, Simpson, LL. Vaginal birth after cesarean delivery in twin gestations: a large, nationwide sample of deliveries. Am J Obstet Gynecol 2006; 195: 1138–42.CrossRefGoogle ScholarPubMed
Miller, DA, Mullin, P, Hou, D, et al. Vaginal birth after cesarean section in twin gestation. Am J Obstet Gynecol 1996; 175: 194–8.CrossRefGoogle ScholarPubMed
Sansregret, A, Bujold, E, Gauthier, RJ. Twin delivery after a previous caesarean: a twelve-year experience. J Obstet Gynaecol Can 2003; 25: 294–8.CrossRefGoogle ScholarPubMed

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