Inpatient vs outpatient management and timing of delivery of uncomplicated monochorionic monoamniotic twin pregnancy: the MONOMONO study (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
Clinical indicators associated with the mode of twin delivery: an analysis of 22,712 twin pairs
European journal of obstetrics, gynecology, and reproductive biology, 2015
To identify clinical indicators associated with the planned and actual mode of delivery in women with a twin pregnancy. We performed a retrospective cohort study in women with a twin pregnancy who delivered at a gestational age of 32+0-41+0 weeks and days between 2000 and 2008 in the Netherlands. Data were obtained from a nationwide database. We identified maternal, pregnancy-related, fetal, neonatal and hospital-related indicators that were associated with planned cesarean section (CS) and, for women with planned vaginal delivery (VD), for intrapartum CS. The associations between indicators and mode of delivery were studied with uni- and multivariate logistic regression analyses. We included 22,712 women with a twin pregnancy, of whom 4,310 women (19.0%) had a planned CS. Of the 18,402 women who had a planned VD, 14,034 (76.3%) delivered vaginally, 3,545 (19.3%) had an intrapartum CS, while 823 (4.5%) delivered twin A vaginally and twin B by intrapartum CS. The clinical indicators ...
Acta Obstetricia et Gynecologica Scandinavica, 2008
Aim. Perinatal mortality and morbidity in monochorionic (MC) twins appears to be increasing compared to dichorionic (DC) twins. The aim of our study was to determine the difference in perinatal mortality and morbidity in MC and DC twins born after 37 weeks' gestation. Design. A retrospective, cross-sectional study of medical records. Setting. Large tertiary care centre in the Netherlands. Population. All twins delivered ]37 gestational weeks at the Leiden University Medical Centre between 1988 and 2004 were included in the study. Methods. Perinatal outcome was assessed in all term twins. Differentiation between a MC study group and a DC control group was made based on gender, intertwin membrane histology, or first trimester ultrasound. Main outcome measures. Perinatal mortality and morbidity was assessed. Morbidity was defined as admission to the neonatal nursery. Results. We included 383 DC and 74 MC twin pregnancies. Three fetuses died in utero in two MC pregnancies at 38 gestational weeks. One surviving MC co-twin had a right-sided hemiparesis due to a large parenchymal defect in the left cerebral hemisphere. Perinatal mortality was 2% (3/148) in MC and 0% (0/766) in DC twins (p00.004). The admission rate to the neonatal nursery was 27% in MC and 19% in DC twins (p00.031). Conclusions. At term, MC twins have a higher risk for perinatal mortality and a higher admission rate to the neonatal nursery compared to DC twins. Given the increased mortality, a prospective study is needed to determine the effects of elective delivery in uncomplicated MC twin pregnancies at around 37 weeks' gestation.
Multicentric Multiple Pregnancy Study II : Perinatal Mortality in Twins
2011
Objective: The aim of the study is to determine the relationship between perinatal mortality and clinical demographic characteristics in twin pregnancies. Methods: A questionnary and data obtained from 15 obstetrics centers was used to show the relationship between perinatal mortality and maternal age, parity, maternal morbidity, gestational week at delivery, mode of delivery, fetal or newborn’s weight and sex in twin pregnancies, delivered between the period of 2003 and 2004. Chi-square, Fischer’s exact and Student’s t tests are used for statistical analyses. Results: Perinatal mortality ratio was 107 per thousand in twins. A chance of delivery without fetal or neonatal mortality was assessed in 85% of the twin pregnancies. Mortality was high in cases born before 30th gestational week, and less than 1000g, also in twins with the same sex, in females, in discordant for growth and in small ones. Conclusion: According to the results of 15 different national obstetrics centers, mortali...
Perinatal Outcome of Twins Compared to Singletons of the Same Gestational Age: A Case-Control Study
Twin Research and Human Genetics, 2011
Our objective was to determine the perinatal outcome of first- and second-born twins compared to singletons, born at the same gestational age. To that end we conducted a case-control study in Flanders (Northern Belgium). During a 10-year period (01.01.1999–31.12.2008), the entire twin population — 11,154 first- and 11,118 second-born twins (cases) — was compared to 22,228 singletons (controls) with respect to fetal and neonatal (0–27 days) mortality. Only case and control infants of ≥ 500 grams were included, which explained the unequal number of first- and second-born twins. Mothers and their infants of cases and of controls were derived from the Flemish perinatal database and were matched for maternal age and parity, gestational age and gender of the offspring. The main outcome measures were fetal and neonatal mortality according to gestational age. The frequency of fetal death was statistically significantly less frequent in preterm born twins than in singletons, except at term w...
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.
The hidden mortality of monochorionic twin pregnancies
Bjog-an International Journal of Obstetrics and Gynaecology, 1997
In an ultrasound screening study at 10 to 14 weeks of gestation for measurement of fetal nuchal translucency thickness there were 102 monochorionic and 365 dichorionic twin pregnancies. In the monochorionic compared with the dichorionic pregnancies there was a higher rate of fetal loss before 24 weeks of gestation (12.2%versus 1.8%), perinatal mortality (2.8%versus 1.6%), prevalence of delivery before 32 weeks (9.2%versus 5.5%), and prevalence of birthweight below the 5th centile in both twins (7.5%versus 1.7%). However, the proportion of pregnancies with a birthweight discordancy of more than 25% was similar in the two groups (11.3%versus 12.1%).
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.
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.