Background
Material and methods
Study design, setting and population
Outcomes
Enrolment criteria
Inclusion criteria | Exclusion criteria |
---|---|
PVD between 32.0 and 37.6 weeks | Stillbirth Congenital anomaly Severe preeclampsia Antepartum cardiotocography pathology Severe IUGR Selective IUGR Twin-to-twin transfusion syndrome Twin anemia-polycytemia sequence Gestational age less than 32 weeks or greater than 38 at the time of delivery Uncertainty about the gestational age at birth |
• Spontaneous onset of labor (between 32.0–37.6 weeks) or induced onset of labor (between 35.0–37.6 weeks) in uncomplicated MCDA twin pregnancy with no contraindication for vaginal delivery | |
PCS between 32.0 and 37.6 weeks | |
• Spontaneous onset of labor in uncomplicated MCDA twin pregnancy with contraindication for vaginal delivery (non-vertex first twin, at least two previous CS, weight discordance > 15% when first twin was smaller, vasa previa, estimated fetal weight of twin A < 1500 g and/or any other condition like active herpes genital infection) • In non-vertex presentation of the second twin: gestational age at delivery < 32.0, previous CS, and/or intertwin weight discordance > 15% | |
PCS regarding to: ° Previous CS (in induced onset of labor) ° Positional placental anomaly ° First twin in non-vertex presentation ° Another obstetric non-urgent indication for PCS |
Exposures
Data source
Statistical analysis
Ethical approval
Results
Participants characteristics
Variable | PVD group n = 42 (58.3%) | PCS group n = 30 (41.7%) | P-value |
---|---|---|---|
Maternal age, years | 40 ± 4.96 | 40 ± 6.23 | 0.83 |
Maternal weight, kilograms | 65.9 ± 16.77 | 63.4 ± 12.84 | 0.78 |
Body Mass Index (BMI), kg/m2 | 23.9 ± 5.22 | 24.5 ± 5.14 | 0.44 |
Previous CS, n(%) | 1 (2.4%) | 10 (33.3%) | < 0.001 |
Previous vaginal birth, n(%) | 18 (42.9%) | 8 (26.7%) | 0.16 |
IVF pregnancy, n(%) | 8 (19.0%) | 6 (20.0%) | 0.92 |
Pregestational diabetes, n(%) | 0 (0%) | 1 (3.3%) | 0.42 |
Gestational diabetes, n(%) | 3 (7.1%) | 1 (3.3%) | 0.49 |
Smoking habit, n(%) | 11 (26.2%) | 8 (26.7%) | 0.96 |
Gestational age at delivery, weeks | 36.2 ± 1.28 | 35.3 ± 2.05 | 0.15 |
Gestational age at delivery < 36.0 weeks, n(%) | 14 (33.3%) | 15 (50%) | 0.04 |
Gestational age at delivery < 34.0 weeks, n(%) | 2 (4.8%) | 8 (26.7%) | < 0.001 |
Intertwin birth interval, min | 5.0 ± 6.10 | 2.0 ± 2.41 | < 0.001 |
First twin birthweight, grams | 2,413 ± 384.10 | 2,228 ± 456.68 | 0.07 |
Second twin birthweight, grams | 2,385 ± 437.22 | 2,134 ± 447.62 | 0.02 |
Obstetric outcomes in PVD and PCS groups
Perinatal outcomes in PVD and PCS groups
Overall n = 144 | PVD group n = 84 | PCS group n = 60 | P-value | OR (95% CI) | aOR (95% CI)b | |
---|---|---|---|---|---|---|
Composite perinatal morbidity, n(%) | 8 (5.6) | 3 (3.6) | 5 (8.3) | 0.22 | 2.46 (0.56–10.69) | 1.36 (0.24–7.81) |
First twin | 4/77 (5.6) | 2/42 (4.8) | 2/30 (3.3) | 0.73 | 1.43 (0.19–10.75) | 0.77 (0.074–8.04) |
Second twin | 4/77 (5.6) | 1/42 (2.4) | 3/30 (5) | 0.16 | 4.56 (0.45–46.11) | 3.20 (0.16–65.88) |
> 34 week’s | 4/124 (3.2) | 2/80 (2.5) | 2/44 (4.5) | 0.54 | 1.86 (0.25–13.66) | 4.69 (0.85–25.81) |
> 36 week’s | 3/86 (3.5) | 1/56 (1.8) | 2/30 (6.7) | 0.24 | 3.93 (0.34–45.22) | 5.21 (0.49–55.63) |
5-min Apgar score < 4 | 0 | 0 | 0 | - | a | a |
5-min Apgar score < 7 | 1 (0.7) | 1 (1.2) | 0 | > 0.99 | a | a |
Neonatal death | 0 | 0 | 0 | - | a | a |
Respiratory morbidity (respiratory distress síndrome and/or bronchopulmonary dysplasia) | 0 | 0 | 0 | - | a | a |
Intraventricular hemorrhage | 5 (3.5) | 2 (2.4) | 3 (5.0) | 0.40 | 2.16 (0.35–13.33) | 1.64 (0.19–14.57) |
Periventricular leukomalacia | 1 (0.7) | 0 | 1 (1.7) | 0.42 | a | a |
Necrotizing enterocolitis | 1 (0.7) | 0 | 1 (1.7) | 0.42 | a | a |
Sepsis | 0 | 0 | 0 | - | a | a |
2-year-Neurodevelopmental impairment, n(%) | 10/140 (7.1) | 4/81 (4.9) | 6 / 59 (10.2) | 0.26 | 2.11 (0.57–7.84) | 1.53 (0.37–6.29) |
Severe neurodevelopmental impairment | 2/140 (1.4) | 0 | 2 / 59 (3.4) | 0.18 | a | a |
Overall n = 84 | Induced onset of labor n = 48 | Spontaneous onset of labor n = 36 | P-value | |
---|---|---|---|---|
Gestational age at delivery, weeks (± SD) | 36.2 ± 1.28 | 36.6 ± 0.70 | 35.4 ± 1.39 | 0.001 |
Composite perinatal morbidity, n(%) | 3 (3.6) | 0 | 3 (8.3) | 0.08 |
First twin | 2/42 (4.8) | 0 | 2/18 (11.1) | 0.18 |
Second twin | 1/42 (2.4) | 0 | 1/18 (5.6) | 0.43 |
> 34 week’s | 2/80 (2.5) | 0/48 | 2/32 (6.3) | 0.16 |
> 36 week’s | 1/56 (1.8) | 0/42 | 1/14 (7.1) | 0.25 |
5-min Apgar score < 4 | 0 | 0 | 0 | - |
5-min Apgar score < 7 | 1 (1.2) | 0 | 1 (2.9) | 0.43 |
Neonatal death | 0 | 0 | 0 | - |
Respiratory morbidity (respiratory distress síndrome and/or bronchopulmonary dysplasia) | 0 | 0 | 0 | - |
Intraventricular hemorrhage | 2 (2.4) | 0 | 2 (5.6)* | 0.18 |
Periventricular leukomalacia | 0 | 0 | 0 | - |
Necrotizing enterocolitis | 0 | 0 | 0 | - |
Sepsis | 0 | 0 | 0 | - |
2-year-Neurodevelopmental impairment, n(%) | 4/81 (4.9) | 0/47 | 4/34 (11.8) | 0.03 |
Severe neurodevelopmental impairment | 0/81 | 0/47 | 0/34 | - |
Overall n = 108 | Induced onset of labor n = 48 | PCS n = 60 | P-value | |
---|---|---|---|---|
Composite perinatal morbidity, n(%) | 5 | 0 | 5 (8.3) | 0.06 |
First twin | 2/54 | 0 | 2/30 (3.3) | 0.50 |
Second twin | 3/54 | 0 | 3/30 (5) | 0.25 |
> 34 week’s | 2 | 0/48 | 2/44 (4.5) | 0.23 |
> 36 week’s | 2 | 0/42 | 2/30 (6.7) | 0.17 |
5-min Apgar score < 4 | 0 | 0 | 0 | - |
5-min Apgar score < 7 | 0 | 0 | 0 | - |
Neonatal death | 0 | 0 | 0 | - |
Respiratory morbidity (respiratory distress síndrome and/or bronchopulmonary dysplasia) | 0 | 0 | 0 | - |
Intraventricular hemorrhage | 3 | 0 | 3 (5.0) | 0.25 |
Periventricular leukomalacia | 1 | 0 | 1 (1.7) | > 0.99 |
Necrotizing enterocolitis | 1 | 0 | 1 (1.7) | > 0.99 |
Sepsis | 0 | 0 | 0 | - |
2-year-Neurodevelopmental impairment, n(%) | 6/106 (5.7) | 0 / 47 | 6/59 (10.2) | 0.03 |
Severe neurodevelopmental impairment | 2/106 (1.9) | 0 / 47 | 2/59 (3.4) | 0.50 |
2-year-neurodevelopment status
Discussion
Main findings
Interpretation and comparison to current literature
Design of study | Centers involved | GA | n | PVD | PCS | Difference induced labor from spontaneous onset | Items included | OR (CI 95%) | P-value | Results | ||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Retrospective cohort study | Single-center | ≥ 24 weeks | 60 | Not defined | Not defined | No | 5-min Apgar score, umbilical pH, respiratory distress syndrome, mortality, ventilation | - (-) | (-) | Differences in composite morbidity not defined | ||
Secondary analysis of a retrospective cohort study | Multicenter | ≥ 32 weeks | 902 | 752 | 150 | No | 5-min Apgar score, pH, respiratory distress syndrome, intrauterine fetal demise, mortality | 2.0 (1.0–4.2) | (-) | No significant differences between: - PVD vs. PCS | ||
Retrospective cohort study | Multicenter | 36 weeks | 115 | 63 | 52 | No | 5-min Apgar score, pH, mortality | 0.9 (0.3–3.0) | 0.83 | No significant differences between: - PVD vs. PCS | ||
Retrospective cohort study | Single-center | 35 + 0–37 + 6 weeks | 89 | 38 | 511 | No (only in average of vaginal delivery, not morbidity) | 5-min Apgar score, pH, respiratory distress syndrome, sepsis, mortality | - (-) | 0.24 | No significant differences between: - PVD vs. PCS | ||
Retrospective cohort study | Single-center | ≥ 36 weeks | 295 | 187 | 108 | No | 5-min Apgar scores < 7, intrauterine fetal demise after 36 weeks’ gestation, neonatal death, umbilical artery pH < 7.1, hypoxic ischemic encephalopathy, meconium aspiration syndrome, respiratory distress syndrome, or acute feto-fetal hemorrhage | 0.4 (0.1–2.0) | 0.29 | No differences between PVD vs. PCS (univariate analysis of perinatal factors for the composite adverse outcome, but no comparation between groups) | ||
Secondary analysis of a retrospective cohort study | Single-center | ≥ 37 weeks | 73 | 59 | 14 | No | 5-min Apgar < 4, 5-min Apgar < 7, umbilical artery pH < 7.05 and < 7.00, NICU admission | - (-) | > 0.99 | No significant differences between: - PVD vs. PCS | ||
Secondary analysis of a retrospective cohort study | Single-center | Not specified to this cohort (primary cohort – mono and dichorionic: 32 + 0– 36 + 6 weeks of gestation) | 55 | 40 | 15 | No | 5-min Apgar < 4, 5-min Apgar < 7, umbilical artery pH < 7.05, NICU admission, intracerebral hemorrhage gr. III-IV, respiratory morbidity, composite neonatal morbidity | - (-) | 0.18 | No significant differences between: - PVD vs. PCS | ||
Secondary analysis of a randomized, controlled trial (Twin Birth Study, Barret et al. 2013) | Multicenter | 32 + 0– 37 + 6 weeks | 670 | 324 | 346 | No | 5-min Apgar < 4, Stillborn, neonatal death, primary, umbilical artery pH < 7.0, NICU admission > 48 h, assisted ventilation, necrotizing enterocolitis, periventricular leukomalacia, composite outcome | - (-) | 0.25 | No significant differences between: - PVD vs. PCS - Twin A vs. Twin B - Monochorionic vs. Dichorionic |