SLIDE 1 1
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Twins: Timing and Management of Delivery
Mari-Paule Thiet, MD Director, Division of Maternal-Fetal Medicine Vice-Chair of Patient Safety and Quality Assurance Department of Obstetrics, Gynecology and Reproductive Sciences University of California, San Francisco
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I have nothing to disclose
Disclosures
At what gestational age should uncomplicated well grown monochorionic diamniotic twins be delivered?
3 2 w e e k s 3 4 w e e k s 3 6 w e e k s
0% 90% 10%
- 1. 32 weeks
- 2. 34 weeks
- 3. 36 weeks
Would you allow this patient a trial of labor? 35 year old IVF dichorionic diamniotic twin gestation with v/br twin gestation at 36 weeks gestation who presents in preterm labor at 4 cm with intact membranes?
Y e s N
95%
SLIDE 2 2 Would you allow her to labor if her first twin has an estimated fetal weight of 5 lbs and the 2nd one has an EFW of 6# and is a footling breech?
Y e s N
54%
What if the previous patient had a hx of a previous low transverse c/s?
Y e s , l a b
N
c / s
26% 74%
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Define Incidence/scope of problem Determine optimal gestational age for delivery Monochorionic vs dichorionic Plan optimal route of delivery Delivery considerations Management of 2nd twin
Objectives +Incidence/Scope of the problem
Incidence of multiples increasing ART vs spontaneous Older gravidas Risks Fetal/neonatal complications Maternal complications
SLIDE 3
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+Twins/Multiples
In 2002: 130,000 multiples born Since 1980, 65% increase in twins 500% increase in triplets or > 3% of all births 77% of preterm births Disproportionate share of perinatal M&M ACOG Practice Bulletin, No 56, 2004, US Vital Stats, 2007
+Assisted Reproduction
Responsible for 17% of twins in US Risk of multiples increased 20-40% Clomiphene – 5-10% IVF: # of embryos risk of multiples 1 1.4% 2 17.9% 4 24.1% Higher than expected incidence of MC twins –
3.2% (background - 0.4%)
+Twins: Disproportionate Use of Healthcare Dollars
Costs of twins associated with 2nd trimester
through 1st month of life 5x compared to singleton
$21K singleton $104.8K twins $407K triplets
+Timing of Delivery
25% spontaneous PTD, 25% Indicated PTD
(preeclampsia, IUGR)
Sairam (2002): IUFD >39wks twins = 42 wks
singleton
But mature at same rate
SLIDE 4
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+Recommended timing of delivery: Near-term twins(≥34 weeks)
Twin Clinic at Med. Univ. S. Carolina MFM, U/S, NST, del 37-38 wks 1987-2010: 1779 twin gestations 1011 excluded: PTD <34 wks, unsure chorionicity,
monoamniotic, anomalies
768 twin gestations analyzed 601 di/di: 1 IUFD after 34 wks 167 mo/di: no IUFDs after 34 wks (only 94 went
past 36 wks)
Burgess, American Journal of Obstetrics and Gynecology, 2014
+Neonatal Mortality
Burgess, American Journal of Obstetrics and Gynecology, 2014
+Recommended timing of delivery: Complicated near-term twins (≥34 weeks)
Burgess, American Journal of Obstetrics and Gynecology, 2014
+Recommended timing of delivery: Uncomplicated near-term twins (≥34 weeks)
Burgess, American Journal of Obstetrics and Gynecology, 2014 Spong, NICHD consensus, 2011
SLIDE 5 5
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Timing Planned mode of delivery L&D preparation
Delivery Planning +Twin Presentation
Vtx/Vtx 42.5% Vtx/Non-Vtx 38.4% Non-Vtx/Other 19.1% Ramsey et al., Seminars in Perinatology 2003;27 (1)
+Delivery: Twins
Skilled/experienced
RNs, anesthesia, OB, peds
Continuous EFM Blood products
available
U/S in OR Epidural anesthesia
recommended
Delivery in OR 27% anesth need 6% emergent C/S Carvalho, Int J Anesth 2008
+Mode of Delivery: Vtx/Vtx
Successful VD – 70-80% 8% operative vaginal delivery 5% cesarean delivery 2% internal podalic version No increase in M&M regardless of gestational age
Ramsey & Repke, Seminars on Perinatology, 2003
SLIDE 6 6
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Cesarean Delivery generally recommended Level II-C evidence
Mode of Delivery: Non-Vertex Twin A +Mode of Delivery: Non-Vertex Second Twin
Retrospective cohort, 1542 twin pairs in Nova
Scotia, 1988-2002
2nd twin greater risk adverse outcome
independent of presentation, chorionicity, sex
Armson, B et al. Obstet Gynecol 2006
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Retrospective cohort, 858 twin pairs in France,
>35 wks, 1st twin cephalic, VD if B <125% A
“Active management of 2nd twin” Mean intertwin interval (VD) 4.9 minutes 657 planned VD: 78% V/V
, 21% C/C, 0.5% V/C
Neonatal composite morbidity unchanged (5 vs 4.7%) Level II evidence
Mode of Delivery: Non-Vertex Second Twin
- Schmitz. Obstet Gynecol 2008
+RCT: Mode of Delivery First Twin Cephalic
RCT: planned C/S vs planned VD Toronto/multi-center Twins 32+0-38+6 wks Twin A cephalic Both alive, with EFWs 1500-4000g Excluded MA twins, lethal anomalies, previous
classical or >1 LTCS
OBs “qualified” per their dept head
Barrett, Twin Birth Study Collab. Group NEJM 2013
SLIDE 7
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+RCT: Mode of Delivery First Twin Cephalic
RCT: planned C/S vs planned VD If delivery elective: planned 37+5 to 38+6 wks Continuous EFM Oxytocin, epidural per OB Sono encouraged for delivery If Twin B cephalic, AROM delayed until head
engaged
If B not cephalic, OB chose breech delivery vs
ECV vs C/S
Barrett, Twin Birth Study Collab. Group NEJM 2013
+RCT: Mode of Delivery First Twin Cephalic
RCT: planned C/S n=1393 90% delivered both by C/S 0.8% Vag+C/S 9% both Vag Planned VD n=1393 40% both C/S 4% Vag+C/S 56% both Vag
Barrett, Twin Birth Study Collab. Group NEJM 2013
+RCT: Mode of Delivery Outcomes
Primary outcome (perinatal death or serious
neonatal morbidity)
2.2% planned C/S 1.9% planned VD (p 0.49) Perinatal death 0.9% planned C/S 0.6% planned VD
Barrett, Twin Birth Study Collab. Group NEJM 2013
+RCT: Mode of Delivery Outcomes
Neonatal Morbidity 1.3% in both groups Birth trauma: n=4 vs n=7 (both <0.1%) 5 min Apgar <4: 0.1 vs 0.3% Vent with ETT >24 hrs: n=27 (1%) vs n=17 (0.6%)
Barrett, Twin Birth Study Collab. Group NEJM 2013
SLIDE 8 8
+RCT: Mode of Delivery Outcomes
Maternal M&M: 7% vs 8.5% p 0.29 Maternal Mortality: n=1 in each group Maternal Morbidity: Hemorrhage: 6% C/S vs 7.8% VD 3rd or 4th degree: 0% C/S vs 0.3% VD Infection (wound + non-wound): 3.7% C/S vs
2.6% VD
+RCT: Mode of Delivery
Conclusion:
No benefits of planned cesarean section over planned vaginal delivery for twins between 32-38 weeks if first twin is cephalic
Barrett, Twin Birth Study Collab. Group NEJM 2013
+Trial of Labor in Twins: Previous Cesarean
Small studies No increased risk uterine rupture, maternal
morbidity
Perinatal mortality not increased after adjusting for
confounders
Aaronson, JMFNM 2009 Delaney, JOG Can 2003 Sansregret, JOG Can 2003 Ford, AJOG 2006 Barrett, 2013
+Trial of Labor in Twins: A few studies
38 TOL 28 VD
no ruptures; 2 C/S for 2nd twin repeat C/S had higher SSI morbidity
26 TOL 85% del A vag, 73% del both vag; 71
elective RC/S
No difference in outcomes except LOS
NIS data: 4705 elective repeat, 1805 TOL 45% both twins vag 0.9% uterine rupture rate (= singleton rate)
Delaney, JOG Can 2003 Sansregret, JOG Can 2003 Ford, AJOG 2006
SLIDE 9
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+Twins: A Reasonable Approach
Deliver at 36-37 wks mo/di, 38 wks di/di Route of delivery based on presentation & OB
experience (no benefit to C/S if you are trained to deliver twins)
Epidural anesthesia, OR delivery w/ U/S, peds,
anesthesia, & extra MD/RN help
+ Thank you for your attention.
Questions?
