Improved perinatal survival of monoamniotic twins with intensive inpatient monitoring (original) (raw)
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American Journal of Obstetrics and Gynecology, 2012
(median 37.0 vs 36.9 weeks), birth weights (median 2538g vs. 2523g), birth weight discordance (median 10% vs. 9% discordance) or neonatal admission rates (44% vs. 46%). Other perinatal outcomes were compared and found not to be statistically significant, including hypoxic ischemic encephalopathy, periventricular leukomalacia, necrotising enterocolitis, respiratory distress syndrome, sepsis and a composite of these outcomes including neonatal deaths (total 15% vs. 19%, p ΟΎ 0.05). We compared perinatal outcomes between the different types assisted conception groups (composed of 1% artificial insemination, 72% in vitro fertilization 10% intracytoplasmic sperm injection and 17% ovulation induction conception) and found no evidence of a difference in perinatal outcomes. CONCLUSION: This study found maternal, neonatal, and perinatal outcomes in twins conceived naturally and by assisted conception were comparable.
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
Prospective risk of fetal death in uncomplicated monochorionic twins
Acta Obstetricia et Gynecologica Scandinavica, 2012
A retrospective cohort study was carried out in a university teaching hospital to determine the prospective risk of unexpected fetal death in uncomplicated monochorionic diamniotic (MCDA) twin pregnancies after viability. All MCDA twins delivered at or after 24 weeks' gestation from July 1999 to July 2007 were included. Pregnancies with twin-twin transfusion syndrome, growth restriction, structural abnormalities, or twin reversed arterial perfusion sequence were excluded. Of the 144 MCDA twin pregnancies included in our analysis, the risk of intrauterine death was 4.9%. The prospective risk of unexpected intrauterine death was 1 in 43 after 32 weeks' gestation and 1 in 37 after 34 weeks' gestation. Our results demonstrate that despite close surveillance, the unexpected intrauterine death rate in uncomplicated MCDA twin pregnancies is high. This rate seems to increase after 34 weeks' gestation, suggesting that a policy of elective preterm delivery warrants evaluation.
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.
Ultrasound in Obstetrics & Gynecology, 2018
Objectives Monoamniotic twin pregnancies are at increased risk of perinatal complications, primarily owing to the risk of cord entanglement. There is no recommendation on whether such pregnancies should be managed in hospital or can be safely managed in an outpatient setting, and the timing of planned delivery is also a subject of debate. The aim of this study was to compare the perinatal outcomes of inpatient vs outpatient fetal surveillance approaches employed among 22 participating study centers, and to calculate the fetal and neonatal death rates according to gestational age, in non-anomalous monoamniotic twins from 26 weeks' gestation. Methods The MONOMONO study was a multinational cohort study of consecutive women with monochorionic monoamniotic twin pregnancies, who were referred to 22 university hospitals in Italy, the USA, the UK and Spain, from January 2010 to January 2017. Only non-anomalous uncomplicated monoamniotic twin pregnancies with two live fetuses at 26 + 0 weeks' gestation were included in the study. In 10 of the centers, monoamniotic twins were managed routinely as inpatients, whereas in the other 12 centers they were managed routinely as outpatients. The primary outcome was intrauterine fetal death. We also planned to assess fetal and neonatal death rates according to gestational age per 1-week interval. Outcomes are presented as odds ratio (OR) with 95% CIs. The main outcome was analyzed using both standard logistic regression analysis, in which each fetus was treated as an independent unit, and a generalized mixed-model approach, with each twin pair treated as a cluster unit, considering that the outcome for a twin is not independent of that of its cotwin.
Prospective risk of intrauterine death of monochorionic-diamniotic twins
American Journal of Obstetrics and Gynecology, 2007
Monochorionic twins Intrauterine death Twin-twin transfusion Antenatal assessment Objective: The purpose of this study was to calculate the prospective risk of fetal death in monochorionic-diamniotic twins. Study design: We evaluated 193 monochorionic diamniotic twin pregnancies that were followed and delivered after 24 weeks. Surveillance included cardiotocography and sonography performed at least once weekly. The prospective risk of fetal death was calculated as the total number of deaths at the beginning of the gestational period divided by the number of continuing pregnancies at or beyond that period. Results: The fetal death rate was 5 of 193 pregnancies (2.6%; 95% CI, 1.1, 5.9); the prospective risk of stillbirth per pregnancy after 32 weeks of gestation was 1.2% (95% CI, 0.3%-4.2%). Conclusion: Under intensive surveillance, the prospective risk of fetal death in monochorionicdiamniotic pregnancies after 32 weeks of gestation is much lower than reported and does not support a policy of elective preterm delivery.
Perinatal Outcome of Monoamniotic Twin Pregnancies
Obstetrics & Gynecology, 2009
OBJECTIVE: To study perinatal mortality and neonatal morbidity in a large cohort of monoamniotic twin pregnancies with special emphasis to the gestational agespecific mortality.