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Obstervational study of Perinatal and Maternal Outcome of Planned Twin Deliveries in Hospital Sultanah Aminah, Johor Bahru

Quek Y.S. (1), Woon S.Y. (1), Ravichandan N. (2), Kaliammah MK (1), Shantala V. (3), Ravichandran J. (1)

1. Hospital Sultanah Aminah Johor Bahru, Malaysia 2. Singapore General Hospital 3. Kokilaben Dhuribhai Ambani Hospital, India (Visiting MFM Consultant)

Objectives Results Conclusions

References

Results

OPTIONALLOGO HERE

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Methods

This is a prospective observational study which included 113 sets of

twins delivered at ≥ 36 weeks from January to December 2009.

Monochorionic monoamniotic (MCMA) twins were excluded. The

primary outcome was a measure of perinatal and maternal outcome in

different planned mode of delivery.

The groups were compared for differences in maternal characteristics

and perinatal outcomes by using Student t test, chi square analysis or

Fisher exact test when appropriate. The level of significance was set at

p value < 0.05.

Results

Total 71 sets of twins had planned vaginal delivery whereas 42 sets had

planned caesarean delivery (Figure 1). Both groups are similar for

maternal demographic characteristics (Table 1).

Data presented as mean ± SD or n (%).

1. Rossi AC, Mullin PM, Chmaitb RH. Neonatal outcomes of twins

according to birth order, presentation and mode of delivery: a

systematic review and meta-analysis. BJOG 2011; 118:523-532

2. Herbst A, Ka¨lle´n K. Influence of mode of delivery on neonatal

mortality in the second twin, at and before term. BJOG

2008;115:1512–1517.

Data presented as n (%).

Planned Vaginal Delivery(n = 71)

Planned Caesarean Delivery (n = 42)

Psychological Well-being Happy 65 (91.5) 40 (95.2) Unhappy 6 (8.5) 2 (4.8)Preferred type of pregnancy Singleton 61 (85.9) 36 (85.7) Twin 10 (14.1) 6 (14.3)Preferred mode of delivery Vaginal delivery 59 (83.1) 30 (71.4) Caesarean delivery 12 (16.9) 12 (28.6)

Table 4. Psychological aspects in different planned mode of deliver

Data presented as mean ± SD or n (%). *Non-significance **constant data

Characteristics Planned Vaginal Delivery (n = 71)

Planned Caesarean Delivery (n = 42)

1st twin 2nd twin p-value

1st twin 2nd twin p-value

Birth weight (kg) 2.42 ± 0.36

2.41 ± 0.34

NS* 2.46 ± 0.46

2.41 ± 0.51

NS*

Apgar Score 9.0 ** 8.91 ± 0.17

NS* 9.0 ** 8.98 ± 0.15

NS*

Umbilical Arterial Blood pH 7.34 ±

0.0547.29 ± 0.094

NS* 7.33 ± 0.049

7.31 ± 0.057

NS*

Base Excess (BE) -3.46 ± 2.91

- 5.32 ± 4.85

NS* - 2.86 ± 2.29

-3.79 ± 2.82

NS*

Admission to neonatal ward

18 (25.4) 18 (25.4) NS* 18 (42.9) 20 (47.6) NS*

Mean length of ward stay (days)

2.5 ** 2.5 ** NS* 1.17 ** 1.17 ** NS*

Table 3. Neonatal Outcomes in different planned mode of delivery

Data presented as mean ± SD or n (%). *Non-applicable

Characteristics Planned Vaginal Delivery (n = 71)

Planned Caesarean Delivery (n = 42)

1st Twin 2nd Twin 1st Twin 2nd Twin

Gestational Age of Delivery (weeks) 37.31 ± 0.88 37.26 ± 0.86

Final mode of delivery

Vaginal Delivery 52 (73.2) NA*

Emergency Caesarean Delivery 19 (26.8) 18 (42.9)

Elective Caesarean Delivery NA* 24 (57.1)

In successful Vaginal Delivery

Spontaneous Vertex Delivery 48 (92.3) 22 (42.3) NA*

Vacuum assisted delivery 3 (5.8) 5 (9.6) NA*

Forceps assisted delivery 1 (1.9) 1 (1.9) NA*

Assisted Breech delivery NA* 24 (46.2) NA*

Estimated Blood Loss 423.24 ± 323.25 502.38 ± 338.57

Post-partum haemorrhage 8 (11.3) 6 (14.3)

Blood Transfusion required 3 (4.2) 3 (7.1)

Table 2. Obstetric Outcomes of different planned mode of delivery

Characteristics Planned Vaginal Delivery (n = 71)

Planned Caesarean Delivery (n = 42)

P-value

Maternal Age 29.03 ± 5.23 29.90 ± 5.30 0.342

Ethnic Groups 0.062

Malay 50 (70.4) 18 (42.9)

Chinese 13 (18.3) 13 (31.0)

Indian 5 (7.0) 5 (11.9)

Others 3 (4.2) 6 (14.3)

Weight (kg) 62.12 ± 13.57 66.04 ± 12.33 0.243

Height (metre) 1.58 ± 0.06 1.57 ± 0.07 0.126

BMI (kg/m2) 24.75 ± 5.08 26.69 ± 4.80 0.459

Type of Chorionicity 0.151

Monochorionic Diamniotic 42 (59.2) 19 (45.2)

Dichorionic Diamniotic 29 (40.8) 23 (54.8)

Table 1. Demographic characteristics in different planned mode of delivery

There is general consensus that vaginal delivery for twin is safe when

both twin are in vertex presentation, whereas planned caesarean section

is typically indicated for breech presentation of the first twin1. In fact,

studies on the effect of presentation, mode of delivery and birth order

have produced conflicting results. The only randomized study of mode

of delivery in twin pregnancy was performed towards the end of 1980s

and demonstrated that there was little difference in neonatal morbidity

between twins delivered vaginally and those delivered by caesarean

section1.

The objective of this study is to compare the perinatal and maternal

outcome with different planned mode of delivery for twin pregnancies.

Nineteen cases of planned vaginal delivery group had emergency

caesarean with fetal distress being the commonest indication. Among

those with successful vaginal delivery, instrumental delivery was

required in 2 occasions for 1st twin only, 2 occasions for 2nd twin

only, 2 occasions for both twins. There were no significant

differences in obstetric outcomes in both groups (Table 2).

Overall, there were no significant differences in the perinatal

outcomes (umbilical arterial blood parameters) between twin siblings

who were scheduled for planned vaginal delivery versus planned

caesarean (Table 3). All infants have 5-minute Apgar score >8.

Generally, all mothers were happy and entire cohort preferred

singleton with vaginal delivery in next pregnancy (Table 4).

Twin pregnancy is a high risk pregnancy associated with increased

maternal morbidity and increase perinatal morbidity and mortality.

There is a need for specialised prenatal care to reduce complications

and adverse outcome in multiple pregnancies, and the need for

ongoing social and medical care beyond the prenatal and perinatal

periods2.

 

In our hospital, twins delivered vaginally had comparable maternal

and perinatal outcomes compared to twins delivered via caesarean.

With appropriate patient selection, antenatal care, intra-partum fetal

surveillance, good co-operation with neonatal team and patient

counselling, planned vaginal delivery still remains a safe mode of

delivery.