Prenatal Management of Monoamniotic Twin Pregnancies (original) (raw)
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BACKGROUND: Monoamniotic twins are at increased risk of perinatal complications. Perinatal mortality has been reported to be high, primarily related to cord entanglement. International guidelines made no recommendation regarding whether these women should be managed in the hospital or can be safely managed in outpatient settings. Moreover, timing of planned delivery in these women is also a subject of debate. OBJECTIVE: To compare the perinatal outcomes of inpatient versus outpatient fetal surveillance approaches employed among 22 participating study centers; and to calculate the fetal and neonatal death rate according to gestational age in non-anomalous monoamniotic twins from 26 weeks' gestation. STUDY DESIGN: The MONOMONO study was a multinational cohort study. Clinical records of all consecutive women with monochorionic monoamniotic twin pregnancies, who were referred to 22 university hospitals in Italy, the United States, the United Kingdom, and Spain, from January 2010 to January 2017, were included in the study. Only non-anomalous uncomplicated monoamniotic twins with both fetuses alive at 26 0/7 weeks were included in the study. Management of monoamniotic twins was different in the different included centers. In 10 centers all monoamniotic twins were routinely managed inpatient. In 12 centers all monoamniotic twins were routinely managed as outpatients. The primary outcome was intrauterine fetal death in the inpatient versus outpatient group. We also planned to assess the fetal death rate and the neonatal death rate according to gestational age per 1-week interval. Outcomes were presented as odds ratio (OR) with the 95% of confidence interval (CI). In addition to the standard logistic regression analysis, we used a generalized mixed model approach, with twin pair as the cluster unit. This model was used because the outcomes of each twin were not independent of the co-twin. RESULTS: 195 consecutive pregnant women with non-anomalous uncomplicated monoamniotic twin gestations (390 fetuses) were included. Of them, 75 (38.5%) were managed as inpatients and 120 (61.5%) were managed as outpatients. The overall perinatal loss rate was 10.8% (42/390) with the peak fetal death rate occurring at 29 weeks gestation (15/348, 4.3%). There was no significant difference in mean gestation age at delivery (31 weeks), birth weight (~1.6 kg), or emergency delivery rate between the inpatient and outpatient surveillance groups. There was no statistically significant difference in fetal death rates between inpatient surveillance protocols commencing from around 26 weeks compared with outpatient surveillance protocols from 30 weeks (3.3% vs 10.8%; adjusted OR 0.21, 95% CI 0.04 to 1.17). Maternal LOS in the hospital was 42.1 days in the inpatient group, and 7.4 days in the outpatient group (MD 34.70 days, 95% CI 31.31 to 38.09). From 32 0/7 to 36 6/7 weeks, no fetal or neonatal death in either group was recorded. 46 fetuses delivered after 34 0/7 weeks, and none of them died in utero or within the first 28 days of life. CONCLUSION: In uncomplicated monoamniotic twins, when compared with outpatient management, inpatient surveillance is associated with similar fetal mortality. After 31 6/7 weeks there were no intrauterine fetal deaths or neonatal deaths even up to 36 6/7 weeks
Improved perinatal survival of monoamniotic twins with intensive inpatient monitoring
American Journal of Obstetrics and Gynecology, 2005
Objective: The purpose of this study was to evaluate the impact of routine hospitalization for fetal monitoring on the perinatal survival and neonatal morbidity of monoamniotic twins. Study design: This was a multicenter retrospective cohort analysis of 96 monoamniotic twin gestations from 11 university and private perinatal practices. Overall mortality rates were calculated. The risk of intrauterine fetal death and neonatal morbidity was compared among women who were observed as inpatients versus outpatients. Results: The overall mortality rate from enrollment was 19.8% (mean gestational age at enrollment, 17.4 weeks). The perinatal mortality and corrected perinatal mortality rates were 15.4% and 12.6%, respectively. Eighty-seven women had both twins who were surviving at 24 weeks of gestation; 43 women were admitted electively for inpatient surveillance at a median gestational age of 26.5 weeks; the remainder of the women were followed as outpatients and admitted only for routine obstetric indications (median gestational age, 30.1 weeks). No intrauterine fetal deaths occurred in any hospitalized patient. The risk of intrauterine fetal death in women who were followed as outpatients was 14.8% (13/88) versus 0 for women who were followed as inpatients (P !.001). There also were statistically significant improvements in birth weight, gestational age at delivery, and neonatal morbidity for women who were followed as inpatients. Conclusion: We observed improved neonatal survival and decreased perinatal morbidity among women who were admitted electively for inpatient fetal monitoring. Ó 2005 Elsevier Inc. All rights reserved.
Archives of Gynecology and Obstetrics, 2020
Purpose Monoamniotic twin pregnancies are at high risk of perinatal complications and fetal loss. The objective of this study is to describe the management and outcomes of monoamniotic twin pregnancies in a French university obstetrics department. Methods Retrospective review of all consecutive monoamniotic twin pregnancies managed between 1992 and 2018 in a level-3 university hospital maternity unit. Antenatal variables, gestational age and other neonatal characteristics at delivery, mode of delivery, and its reason were recorded, together with outcomes, including a composite adverse neonatal outcome. Results Overall, 46 monoamniotic twin pregnancies (92 fetuses) were identified during the study period. Among them, 27 fetal losses and 2 early neonatal deaths were reported. Congenital abnormalities accounted for 33.3% of the 27 fetal losses, and unexpected fetal deaths for 29.6%. Among the 37 women who gave birth to 65 live infants at 23 or more weeks of gestation, 17 had cesarean and 19 vaginal deliveries. Overall and composite adverse neonatal outcomes did not differ significantly for the 33 children born vaginally and the 31 by cesarean deliveries. The prospective risk of intrauterine death in all 92 fetuses reached its nadir of 1.8% at 33 6/7 weeks. Conclusion This series confirms the still high risk of fetal and neonatal death of these twins and shows that congenital abnormalities but also unexpected fetal deaths account for the majority of pre-and postnatal mortality. Our data suggest that vaginal delivery of monoamniotic twins is safe and that delivery for uncomplicated monoamniotic twins should be considered around 33 weeks of gestation, but not later than 35 weeks.
Obstetrics and gynecology, 2003
To evaluate the prospective risk of fetal death in singleton, twin, and triplet pregnancies and to compare this risk with fetal and neonatal death rates. We analyzed 11,061,599 singleton, 297,622 twin, and 15,375 triplet gestations drawn from the 1995-1998 National Center for Health Statistics linked birth and death files. Prospective risk of fetal death was expressed as a proportion of all fetuses still at risk at a given gestational age and compared with fetal death rate. Fetal death risk and neonatal death rates were represented graphically for singletons, twins, and triplets. The prospective risk of fetal death at 24 weeks was 0.28 per 1000, 0.92 per 1000, and 1.30 per 1000 for singletons, twins, and triplets, respectively. At 40 weeks, the corresponding risk was 0.57 per 1000 and 3.09 per 1000 for singletons and twins, respectively and, at 38 or more weeks, 13.18 per 1000 for triplets. Plots of gestation-specific prospective risk of fetal death and neonatal mortality converged ...
American Journal of Perinatology, 2013
Objective We sought to compare neonatal outcomes in twin pregnancies following moderately preterm birth (MPTB), late preterm birth (LPTB), and term birth and determine the indications of LPTB. Study Design We performed a retrospective cohort study. MPTB was defined as delivery between 32 0/7 and 33 6/7 weeks and LPTB between 34 0/7 and 36 6/7 weeks. The composite neonatal adverse respiratory outcome was defined as respiratory distress syndrome and/or bronchopulmonary dysplasia. The composite neonatal adverse nonrespiratory outcome included early onset culture-proven sepsis, necrotizing enterocolitis, retinopathy of prematurity, intraventricular hemorrhage, or periventricular leukomalacia. LPTB cases were categorized as spontaneous (noniatrogenic), evidence-based iatrogenic, and non-evidence-based (NEB) iatrogenic. Results Of the 747 twin deliveries during the study period, 453 sets met the inclusion criteria with 22.7% (n ¼ 145) MPTB, 32.1% (n ¼ 206) LPTB, and 15.9% (n ¼ 102) term births. Compared with term neonates, the composite neonatal adverse respiratory outcome was increased following MPTB (relative risk [RR] 24; 95% confidence interval [CI] 3.0 to 193.6) and LPTB (RR 13.7; 95% CI 1.8 to 101.8). Compared with term neonates, the composite neonatal adverse nonrespiratory outcome was increased following MPTB (RR 22.3; 95% CI 3.9 to 127.8) and LPTB (RR 5.5; 95% CI 1.1 to 27.6). Spontaneous delivery of LPTB was 63.6% (n ¼ 131/206) and the rate of iatrogenic delivery was 36.4% (n ¼ 75/206). The majority, 66.6% (n ¼ 50/75), of these iatrogenic
Journal of the Turkish-German Gynecological Association, 2019
Objective: The objective of this study was to assess maternal and perinatal outcomes of twin pregnancies with single fetal demise in terms of chorionicity and fetal death time. Material and Methods: All deliveries between January 2008 and July 2015 were reviewed retrospectively and 85 twin pregnancies with single fetal demise were included. These cases were grouped according to chorionicity and fetal death time. Results: The incidence of single fetal demise was 4.7%. The mean delivery week was later in the dichorionic group (34.16±4.65) than in the monochorionic group (31.1±3.83). The ratios of deliveries before the 34 th gestational week were 71.4% in monochorionics and 35% in dichorionics. Monochorionics had a 13 times greater risk for having delivery before the 37 th gestational week and a 4 times greater risk for having delivery before the 34 th gestational week compared with dichorionics. Furthermore, monochorionics had a 7 times greater risk for having abruptio placenta compared with dichorionics. The newborn intensive care unit admission ratios were 61.3% in dichorionics and 85.7% in monochorionics. Also, monochorionics had a 3.7 times greater risk for admission to newborn intensive care unit compared with dichorionics. Conclusion: We recommend follow-up of twin pregnancies with single fetal demise in terms of premature birth, regardless of chorionicity. Also, close monitoring is recommended for monochorionic twin pregnancies with single fetal demise in terms of premature birth before 34 weeks of gestation, abruptio placenta, the need for neonatal intensive care, and respiratory distress syndrome.
American Journal of Obstetrics and Gynecology, 2012
We sought to assess neonatal morbidity and mortality of elective cesarean section (CS) of uncomplicated twin pregnancies per week of gestation >35(+0). We performed a retrospective cohort study in our nationwide database including all elective CS of twin pregnancies. Two main composite outcome measures were defined, ie, severe adverse neonatal outcome and mild neonatal morbidity. We report on 2228 neonates. More than 17% were born <37(+0) weeks of gestation. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for severe adverse neonatal outcome at 35(+0-6), 36(+0-6), and 37(+0-6) weeks were, OR, 9.4; 95% CI, 3.2-27.6; OR, 1.7; 95% CI, 0.5-5.3; and OR, 0.7; 95% CI, 0.2-2.0, respectively; and for mild neonatal morbidity, OR, 4.7; 95% CI, 2.6-8.7; OR, 4.9; 95% CI, 3.1-7.9; and 1.4; 95% CI, 0.9-2.1, respectively, compared to neonates born ≥38(+0) weeks of gestation. In uncomplicated twin pregnancies elective CS can best be performed between 37(+0) and 39(+6) weeks of gestation.
Acta Obstetricia et Gynecologica Scandinavica
Introduction: Monoamniotic twin pregnancies are high-risk pregnancies, and management by inpatient or frequent outpatient care is recommended. We report the outcomes of a national cohort of monoamniotic twin pregnancies managed primarily as outpatients. Material and methods: We analyzed prospectively recorded data from the Danish Fetal Medicine Database, local databases, and medical records of all monoamniotic twin pregnancies diagnosed at the first trimester scan or later, and managed at the six major fetal medicine centers in Denmark over a 10 year period. Results: Sixty-one monoamniotic twin pregnancies were included. Thirteen pregnancies were terminated early. Of the remaining 48 pregnancies with a normal first trimester scan, there were 36 fetal losses (25 spontaneous miscarriages <22+0 weeks, three late terminations and eight intrauterine deaths >22 weeks) and 60 live-born children (62.5%), all of whom were delivered by cesarean delivery at a median gestational age of 33+0 weeks. Three children had minor malformations and there was one pregnancy with twin-to-twintransfusion-syndrome. After 26+0 weeks, 78.8% were managed as outpatients. Intrauterine death occurred in 3.8% of outpatients and in 28.6% of inpatients (admitted due to complications). At weeks 32, 33, and 34, the prospective risk of intrauterine death was 6.9%, 4.2%, and 5.9%, respectively. Conclusion: In this nationwide, unselected population, only Accepted Article This article is protected by copyright. All rights reserved. 62.5% of fetuses with a normal first trimester scan were born alive. In contrast, the mortality was 3.8% after 26 weeks among the 78.8% of the cohort that was managed as outpatients. More knowledge is still needed to predict which pregnancies are at the highest risk of intrauterine death.
(Mandujano, 2013) The risk of fetal death_ current concepts of best gestational age for delivery
To compare the risk of fetal death (FD) between 34 and 41 weeks' gestational age (GA) with the neonatal mortality rate to examine the best GA for delivery. STUDY DESIGN: Linked birth and infant death data for the US from the National Center for Health Statistics analyzed nonanomalous singleton pregnancies between 2003 and 2005. Pregnancies were classified as high risk or low risk based on preexisting maternal complications. Outcomes of 8,785,132 live births and 12,777 FDs between 34 and 42 completed weeks' gestation were examined. The risk of FD was determined using the following equation: