Advertisement

Mode of delivery and neonatal outcomes in extremely preterm Vertex/nonVertex twins

Published:December 08, 2020DOI:https://doi.org/10.1016/j.ajog.2020.12.002

      Background

      One of the controversies in the management of twin gestations relates to mode of delivery, especially when the second twin is in a nonvertex presentation (Vertex/nonVertex pairs) and birth is imminent at extremely low gestation.

      Objective

      We hypothesized that, for Vertex/nonVertex twins born before 28 weeks’ gestation, cesarean delivery would be associated with a lower risk of adverse neonatal outcomes than trial of vaginal delivery. Our aim was to test this hypothesis by comparing the neonatal outcomes of Vertex/nonVertex twins born before 28 weeks’ gestation by mode of delivery using a large national cohort.

      Study Design

      This work is a retrospective cohort study of all twin infants born at 240/7 to 276/7 weeks’ gestation and admitted to level III neonatal intensive care units participating in the Canadian Neonatal Network (2010–2017). Exposure is defined a trial of vaginal delivery for Vertex/nonVertex twins. Nonexposed (control) groups are defined as cases where both twins were delivered by cesarean delivery, either in vertex or nonvertex presentation (control group 1) or owing to the nonvertex presentation of the first twin (control group 2). Outcome measures are defined as a composite of neonatal death, severe neurologic injury, or birth trauma.

      Results

      A total of 1082 twin infants (541 twin pairs) met the inclusion criteria: 220 Vertex/nonVertex pairs, of which 112 had a trial of vaginal delivery (study group) and 108 had cesarean delivery for both twins (control group 1); 170 pairs with the first twin in nonvertex presentation, all of which were born by cesarean delivery (control group 2); and 151 pairs with both twins in vertex presentation (vertex or nonvertex). In the study group, the rate of urgent cesarean delivery for the second twin was 30%. The rate of the primary outcome in the study group was 42%, which was not significantly different compared with control group 1 (37%; adjusted relative risk, 0.93; 95% confidence interval, 0.71–1.22) or control group 2 (34%; adjusted relative risk, 1.20; 95% confidence interval, 0.92–1.58). The findings remained similar when outcomes were analyzed separately for the first and second twins.

      Conclusion

      For preterm Vertex/nonVertex twins born at <28 weeks’ gestation, we found no difference in the risk of adverse neonatal outcome between a trial of vaginal delivery and primary cesarean delivery. However, a trial of vaginal delivery was associated with a high rate of urgent cesarean delivery for the second twin.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Christopher D.
        • Robinson B.K.
        • Peaceman A.M.
        An evidence-based approach to determining route of delivery for twin gestations.
        Rev Obstet Gynecol. 2011; 4: 109-116
        • Glass H.C.
        • Costarino A.T.
        • Stayer S.A.
        • Brett C.M.
        • Cladis F.
        • Davis P.J.
        Outcomes for extremely premature infants.
        Anesth Analg. 2015; 120: 1337-1351
        • Fuchs F.
        • Senat M.V.
        Multiple gestations and preterm birth.
        Semin Fetal Neonatal Med. 2016; 21: 113-120
        • Hiersch L.
        • Berger H.
        • Okby R.
        • et al.
        Incidence and risk factors for gestational diabetes mellitus in twin versus singleton pregnancies.
        Arch Gynecol Obstet. 2018; 298: 579-587
        • Martin J.A.
        • Hamilton B.E.
        • Osterman M.J.K.
        • Driscoll A.K.
        • Drake P.
        Births: final data for 2016.
        Natl Vital Stat Rep. 2018; 67: 1-55
        • Blickstein I.
        Controversial issues in the management of multiple pregnancies.
        Twin Res. 2001; 4: 165-167
        • Rossi A.C.
        • Mullin P.M.
        • Chmait R.H.
        Neonatal outcomes of twins according to birth order, presentation and mode of delivery: a systematic review and meta-analysis.
        BJOG. 2011; 118: 523-532
        • Dagenais C.
        • Lewis-Mikhael A.M.
        • Grabovac M.
        • Mukerji A.
        • McDonald S.D.
        What is the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs? A systematic review and meta-analyses.
        BMC Pregnancy Childbirth. 2017; 17: 397
        • Schmitz T.
        • Korb D.
        • Battie C.
        • et al.
        Neonatal morbidity associated with vaginal delivery of noncephalic second twins.
        Am J Obstet Gynecol. 2018; 218: 449.e1-449.e13
        • Bodmer B.
        • Benjamin A.
        • McLean F.H.
        • Usher R.H.
        Has use of cesarean section reduced the risks of delivery in the preterm breech presentation?.
        Am J Obstet Gynecol. 1986; 154: 244-250
        • Dani C.
        • Poggi C.
        • Bertini G.
        • et al.
        Method of delivery and intraventricular haemorrhage in extremely preterm infants.
        J Matern Fetal Neonatal Med. 2010; 23: 1419-1423
        • García I.E.
        • de la Vega A.
        • García Fragoso L.
        Long bone fractures in extreme low birth weight infants at birth: obstetrical considerations.
        P R Health Sci J. 2002; 21: 253-255
        • Phillips R.R.
        • Lee S.H.
        Fractures of long bones occurring in neonatal intensive therapy units.
        BMJ. 1990; 301: 225-226
        • Barrett J.F.
        Twin delivery: method, timing and conduct.
        Best Pract Res Clin Obstet Gynaecol. 2014; 28: 327-338
        • Barrett J.F.
        • Hannah M.E.
        • Hutton E.K.
        • et al.
        A randomized trial of planned cesarean or vaginal delivery for twin pregnancy.
        N Engl J Med. 2013; 369: 1295-1305
        • Barzilay E.
        • Mazaki-Tovi S.
        • Amikam U.
        • et al.
        Mode of delivery of twin gestation with very low birthweight: is vaginal delivery safe?.
        Am J Obstet Gynecol. 2015; 213: 219.e1-219.e8
        • Yang Q.
        • Wen S.W.
        • Chen Y.
        • Krewski D.
        • Fung Kee Fung K.
        • Walker M.
        Neonatal death and morbidity in vertex-nonvertex second twins according to mode of delivery and birth weight.
        Am J Obstet Gynecol. 2005; 192: 840-847
        • Hunter T.
        • Shah J.
        • Synnes A.
        • et al.
        Neonatal outcomes of preterm twins according to mode of birth and presentation.
        J Matern Fetal Neonatal Med. 2018; 31: 682-688
        • Malloy M.H.
        Impact of cesarean section on neonatal mortality rates among very preterm infants in the United States, 2000-2003.
        Pediatrics. 2008; 122: 285-292
        • Boukerrou M.
        • Robillard P.Y.
        • Gérardin P.
        • et al.
        Présentations et modes d'accouchements de 371 grossesses gémellaires [Modes of deliveries of twins as a function of their presentation. A study of 371 pregnancies].
        Gynecol Obstet Fertil. 2011; 39: 76-80
        • Leveno K.J.
        • Quirk J.G.
        • Whalley P.J.
        • Herbert W.N.
        • Trubey R.
        Fetal lung maturation in twin gestation.
        Am J Obstet Gynecol. 1984; 148: 405-411
        • Shah P.S.
        • Seidlitz W.
        • Chan P.
        • et al.
        Internal audit of the Canadian Neonatal Network data collection system.
        Am J Perinatol. 2017; 34: 1241-1249
        • Papile L.A.
        • Burstein J.
        • Burstein R.
        • Koffler H.
        Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm.
        J Pediatr. 1978; 92: 529-534
        • Shennan A.T.
        • Dunn M.S.
        • Ohlsson A.
        • Lennox K.
        • Hoskins E.M.
        Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period.
        Pediatrics. 1988; 82: 527-532
        • Bell M.J.
        • Ternberg J.L.
        • Feigin R.D.
        • et al.
        Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging.
        Ann Surg. 1978; 187: 1-7
        • Kramer M.S.
        • Platt R.W.
        • Wen S.W.
        • et al.
        A new and improved population-based Canadian reference for birth weight for gestational age.
        Pediatrics. 2001; 108: E35