{"id":42786,"date":"2022-03-31T11:02:15","date_gmt":"2022-03-31T11:02:15","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=42786"},"modified":"2022-04-08T06:34:29","modified_gmt":"2022-04-08T06:34:29","slug":"a-retrospective-study-of-maternal-and-fetal-outcomes-of-twin-pregnancy","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol15no1\/a-retrospective-study-of-maternal-and-fetal-outcomes-of-twin-pregnancy\/","title":{"rendered":"A Retrospective Study of Maternal and Fetal Outcomes of Twin Pregnancy"},"content":{"rendered":"

Introduction<\/strong><\/p>\n

Globally, in the last two decades, with advances in assisted reproductive technology (ART), older maternal age and widespread use of ovulation inducers, the incidence of twin gestation\u00a0has witnessed a steep increase 1<\/sup>. In India, the occurrence of twin gestation is approximately 1% of all gestations but accounts for 10% of perinatal mortality. There is 2.5-fold increased\u00a0risk of maternal mortality in twin gestation than in singleton pregnancies 2<\/sup>. The incidence of twins varies with ethnicity and geographical distribution 3<\/sup>.<\/p>\n

Twin gestation has increased risk of maternal and fetal morbidity and mortality. The maternal complications commonly observed in twin gestation are anemia, gestational diabetes mellitus\u00a0(GDM), pre-eclampsia, pregnancy induced hypertension, antepartum hemorrhage, preterm labor, premature rupture of membrane (PROM), placental abruption and polyhydramnios.\u00a0The combination of increased plasma volume, anemia and hypertensive disorders during pregnancy contributes to the risk of pulmonary edema, which further leads to maternal\u00a0 morbidity and mortality 4<\/sup>. Consequently, these complications account for repeated antenatal admissions, longer hospital stays and blood transfusions 5<\/sup>.<\/p>\n

The main causes of adverse neonatal outcomes in multiple pregnancies are related to low birth weight (LBW), intrauterine fetal demise (IUD), intrauterine growth restriction (IUGR),\u00a0twin transfusion syndrome (TTTS), congenital malformations, birth asphyxia and neonatal death 6<\/sup>. All these factors contribute to higher perinatal complications observed in multifetal\u00a0gestations which is five to six times greater compared to singleton pregnancy 7<\/sup>.<\/p>\n

In India, there is disparity in the prevalence of twin pregnancy and their complications reported in the literature [8,9,10]<\/sup>. Considering the difference in incidence of twin pregnancies,\u00a0this study was undertaken to study the prevalence of twins, to examine the high-risk factors associated with twin pregnancies and also to determine the maternal and fetal outcomes in\u00a0twin gestations.<\/p>\n

Materials and methods<\/strong><\/p>\n

Study design<\/strong><\/p>\n

This observational retrospective study was carried out at the Department of Obstetrics and Gynaecology in a tertiary care hospital, Karad, Maharashtra, extended over a period of two\u00a0years from October 2016 to October 2018. Ethical clearance was obtained by the Institutional Ethical Committee. The study population considered in our study was women admitted with\u00a0years from October 2016 to October 2018. Ethical clearance was obtained by the Institutional Ethical Committee. The study population considered in our study was women admitted with\u00a0twin pregnancy.<\/p>\n

Selection criteria<\/strong><\/p>\n

Inclusion criteria included all women admitted during antenatal period or during labor with twin gestation after 28 weeks gestation. Women with gestational age less than 28 weeks and\u00a0with chronic medical illness namely diabetes mellitus, chronic obstructive pulmonary disease (COPD), bronchial asthma and coronary artery diseases were excluded from the study.<\/p>\n

Data collection<\/strong><\/p>\n

Using a pre-designed structured proforma, data on maternal and neonatal data were collected from the labor room delivery data entry register and detailed information related to mode of\u00a0delivery and neonatal outcome was gathered from hospital records. Maternal data consists of maternal age, duration of pregnancy (gestational age), parity, mode of conception, maternal\u00a0interventions and mode of delivery. Fetal data consisted of fetal death, IUGR, twin to twin transfusion, NICU admissions, birth asphyxia (indexed by Apgar scores of <7 at one minute\u00a0and five minutes), LBW, septicemia, respiratory distress. Early neonatal deaths occurring after discharge were not captured in the dataset.<\/p>\n

Definitions<\/strong><\/p>\n

Gestational age was calculated from the first day of the last menstrual period (LMP) and the date of delivery expressed in weeks. Preterm labor was determined as onset of labor less than\u00a037 weeks of gestation. IUGR was determined as below the 10th<\/sup> percentile for gestational age using an ultrasound. LBW was defined as birth weight < 2500 g and very low birth weight\u00a0was defined as less than 1500 g.<\/p>\n

Capsule<\/strong><\/p>\n

Twin pregnancy is associated with increased risk of maternal and fetal morbidity and mortality. Early detection and anticipation of complications of twin gestation can greatly\u00a0improve maternal and fetal outcomes.<\/p>\n

Statistical analysis<\/strong><\/p>\n

Data related to the maternal and fetal outcomes were analyzed by R software and was presented in percentages and mean \u00b1 standard deviation.<\/p>\n

Results<\/strong><\/p>\n

Out of 5492 deliveries 108 (1.9%) subjects had twin gestation. The distribution of maternal demographic data is shown in Table 1. Large numbers of women (56.48%) with twin\u00a0gestation were between 21-30 years of age. The average age is 29.11\u00b14.68 years. Twin gestation was observed most in multiparous women (51.85%). Most women have completed\u00a034-36 weeks of gestation (48.15%) with average gestational age of 34.97\u00b12.35 weeks.<\/p>\n

Table 1: Maternal demographic data<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Variables<\/strong><\/td>\nNumber (n=108) (%)<\/strong><\/td>\n<\/tr>\n
Maternal age (years)<\/strong><\/td>\n<\/tr>\n
\u226420<\/td>\n2 (1.85)<\/td>\n<\/tr>\n
21-30<\/td>\n61 (56.48)<\/td>\n<\/tr>\n
\u226531<\/td>\n45 (41.67)<\/td>\n<\/tr>\n
Parity<\/strong><\/td>\n<\/tr>\n
Primipara<\/td>\n52 (48.15)<\/td>\n<\/tr>\n
Multipara<\/td>\n56 (51.85)<\/td>\n<\/tr>\n
Gestational age (weeks)<\/strong><\/td>\n<\/tr>\n
\u226433<\/td>\n30 (27.78)<\/td>\n<\/tr>\n
34-36<\/td>\n52 (48.15)<\/td>\n<\/tr>\n
\u2265 37<\/td>\n26 (24.07)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Malpresentations (37.96%) followed by preterm labor (35.1%) was the most common maternal complication in this study. Interventions such as antenatal corticosteroids and\u00a0cervical cerclage were performed during the antenatal period. 16 pregnancies (14.8%) were conceived by ART and the rest were conceived spontaneously (85.2%). Cesarean section\u00a0(62.04%) was the most frequent mode of delivery.<\/p>\n

Table 2: Antepartum complications and interventions during pregnancy.<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Variable<\/strong><\/td>\nNumber (n=108) (%)<\/strong><\/td>\n<\/tr>\n
Maternal complications<\/strong><\/td>\n<\/tr>\n
Anemia<\/td>\n11 (10.19)<\/td>\n<\/tr>\n
Pre-eclampsia<\/td>\n34 (31.48)<\/td>\n<\/tr>\n
Polyhydramnios<\/td>\n4 (3.7)<\/td>\n<\/tr>\n
Malpresentations<\/td>\n41 (37.96)<\/td>\n<\/tr>\n
PROM<\/td>\n9 (8.3)<\/td>\n<\/tr>\n
Preterm labor<\/td>\n38 (35.1)<\/td>\n<\/tr>\n
Interventions<\/strong><\/td>\n<\/tr>\n
Antenatal steroids<\/td>\n12 (11.11)<\/td>\n<\/tr>\n
Cerclage<\/td>\n7 (6.48)<\/td>\n<\/tr>\n
Mode of conception<\/strong><\/td>\n<\/tr>\n
Spontaneous<\/td>\n92 (85.2)<\/td>\n<\/tr>\n
ART<\/td>\n16 (14.8)<\/td>\n<\/tr>\n
Mode of delivery<\/strong><\/td>\n<\/tr>\n
Vaginal delivery<\/td>\n34 (31.48)<\/td>\n<\/tr>\n
Assisted vaginal delivery<\/td>\n7 (6.48)<\/td>\n<\/tr>\n
C-section<\/td>\n67 (62.04)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

ART- Assisted reproductive technology, C- Cesarean, PROM- Premature rupture of membrane<\/p>\n

Fetal complications associated with twin gestation are mentioned in the Table 3. One fetal death (37.5%) in twin pregnancy was the most common complication compared to both fetal\u00a0death. Most neonates had LBW (92.34%) and required NICU admissions (19.6%). Neonatal mortality in this study was due to birth asphyxia, septicemia, pulmonary hemorrhage and\u00a0disseminated intravascular coagulation (DIC) listed in the table below. Among this, birth asphyxia (42.85%) was the most frequent cause of neonatal mortality. The total rate of neonatal mortality is 3.34%.<\/p>\n

Table 3: Foetal complications of pregnancy<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Variables<\/strong><\/td>\nNumber (n=209) (%)<\/strong><\/td>\n<\/tr>\n
Fetal complications<\/strong><\/td>\n<\/tr>\n
One fetal death<\/td>\n3 (37.5)<\/td>\n<\/tr>\n
Both fetal death<\/td>\n2 (25)<\/td>\n<\/tr>\n
IUGR (any fetus)<\/td>\n2 (25)<\/td>\n<\/tr>\n
Twin to twin transfusion<\/td>\n1 (12.5)<\/td>\n<\/tr>\n
Anomalies (any fetus)<\/td>\n0<\/td>\n<\/tr>\n
Neonatal outcomes<\/strong><\/td>\n<\/tr>\n
NICU admissions<\/td>\n41 (19.6)<\/td>\n<\/tr>\n
Birth asphyxia<\/td>\n6 (2.87)<\/td>\n<\/tr>\n
LBW<\/td>\n193 (92.34)<\/td>\n<\/tr>\n
Septicemia<\/td>\n16 (7.65)<\/td>\n<\/tr>\n
RDS<\/td>\n15 (7.17)<\/td>\n<\/tr>\n
Neonatal mortality<\/strong><\/td>\n<\/tr>\n
Birth asphyxia<\/td>\n3 (42.85)<\/td>\n<\/tr>\n
Septicemia<\/td>\n1 (14.28)<\/td>\n<\/tr>\n
Pulmonary hemorrhage<\/td>\n2 (28.57)<\/td>\n<\/tr>\n
DIC<\/td>\n1 (14.28)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

IUGR- Intrauterine growth restriction, NICU- Neonatal intensive care unit, LBW- Low birth weight, RDS-Respiratory distress syndrome, DIC-Disseminated intravascular coagulation<\/p>\n

Discussion<\/strong><\/p>\n

There is substantial difference in the prevalence rate of twin gestations and their complications observed throughout the years. Despite the advancements in obstetric care, twin gestation is still a high-risk pregnancy. Hence, this research was aimed to study the\u00a0prevalence of twins and examine the high-risk factors associated with twin pregnancies<\/p>\n

The incidence rate of twinning was 1.9% in this study. The is complying with the incidence rate (1.9%) reported by Upreti et al. [9]<\/sup> and but contradicting with Smitha et al. [11]<\/sup> (1.64%).\u00a0The high incidence of twin pregnancy in this study could be due to increased use of ART and also referral of cases to this tertiary care centre for better management. The distribution of\u00a0age shows most women had twin gestations in their twenties. The number of primigravida and multigravida with twin gestation were almost equal in this study, similar to Bangal et al.\u00a07<\/sup>. The mean gestational age in this study is similar to a study by Vanaja et al. 12<\/sup>\u00a0with 35 weeks.<\/p>\n

Intrapartum management of twin gestation is greatly determined by their presentation in labor 13<\/sup>. The most frequent maternal complication in this study seemed to be malpresentation at\u00a0delivery. Sarojini et al. [14]<\/sup> have observed 42.7% of patients had malpresentation which is comparable to our study. Malpresentation affects the mode of delivery and the outcome of\u00a0pregnancy 15<\/sup>. As for the other complications, preterm labor rate is 35.1%. Preterm delivery is one of the most pressing problems that leads to perinatal morbidity and mortality in\u00a0obstetric practice 16<\/sup>. For those patients who were at a risk of delivering before 34 weeks of gestation were given antenatal steroids. An increased incidence of twin gestation in recent\u00a0years exists due to ART. In this study, ART was reported to be responsible for 14.8% of twin gestation. Dubey et al. 17<\/sup>\u00a0have observed a rate of 13.4% of twin gestation due to ART.<\/p>\n

There is a rising trend in cesarean section in twin gestation over the last decade 18<\/sup>. The rate of cesarean section in this study was also high at 62.04%. This is consistent with Chaudary et\u00a0al.19<\/sup>\u00a0who reported cesarean section rate of 67.4%. On the contrary, Arora et al.20<\/sup>\u00a0reported cesarean section rate of 20.32% which is much lower than our study. The reason for high rate\u00a0of cesarean section in this study is due to malpresentation and fetal distress.<\/p>\n

The ratio of one fetal death to both fetal deaths is 3:2. One fetal death was more common in the current study. The incidence of LBW was higher in this study. The increased LBW could\u00a0be due to poor maternal nutritional status and younger age 21<\/sup>. The neonatal mortality rate reported in this study is 3.34%, which is due to various factors like birth asphyxia,\u00a0septicemia, pulmonary hemorrhage and DIC. Birth asphyxia (42.85%) was the most common reason for neonatal deaths. However, this is higher when compared to Sheela et al. 22<\/sup>\u00a0who\u00a0 reported rate of birth asphyxia of 13.3%. NICU admissions were required in 19.6% of the\u00a0neonates due to LBW and prematurity. This is in contrast with Nandmer et al. 23<\/sup>\u00a0who\u00a0reported much higher rate of NICU admission (50%).<\/p>\n

The findings of the study highlight the necessity of appropriate treatment protocols for counselling, routine antenatal check-ups, early maternal admission and appropriate care\u00a0throughout intrapartum and immediate postpartum periods.<\/p>\n

However, there were a few limitations in this study such as there were no information regarding the chorionicity of the pregnancy which could be linked to perinatal outcomes and\u00a0early neonatal deaths occurring after discharge were not captured in the dataset.<\/p>\n

Conclusion<\/strong><\/p>\n

Twin gestation necessitates special attention as they contribute to maternal and fetal morbidity and mortality. Regardless of its simplicity and limitations, this research adds to the\u00a0existing literature by providing the Indian data findings on the prevalence of twin pregnancy and maternal and fetal outcomes in twin gestation. Further studies on the subject would be\u00a0appropriated, particularly to determine whether specialized obstetric and neonatal care would mitigate the incidence of certain complications and thus enhance maternal and perinatal outcomes.<\/p>\n

Acknowledgement<\/strong><\/p>\n

None<\/p>\n

Conflict of interest<\/strong><\/p>\n

Authors have no conflict of interests.<\/p>\n

Funding sources<\/strong><\/p>\n

The study was not funded by any government or private organization<\/p>\n

References<\/strong><\/p>\n

    \n
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    Introduction Globally, in the last two decades, with advances in […]<\/p>\n","protected":false},"author":15,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[97],"tags":[],"class_list":["post-42786","post","type-post","status-publish","format-standard","hentry","category-vol15no1"],"_links":{"self":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/42786","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/users\/15"}],"replies":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/comments?post=42786"}],"version-history":[{"count":6,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/42786\/revisions"}],"predecessor-version":[{"id":43769,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/42786\/revisions\/43769"}],"wp:attachment":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/media?parent=42786"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/categories?post=42786"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/tags?post=42786"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}