Perinatal outcome after planned vaginal delivery in monochorionic compared with dichorionic twin pregnancy.

To assess, according to chorionicity, the perinatal outcome of twin pregnancy in which vaginal delivery is planned. JUMODA (JUmeaux MODe d'Accouchement) was a national prospective population-based cohort study of twin pregnancies, delivered in 176 maternity units in France, from February 2014 to March 2015. In this planned secondary analysis, we assessed, according to chorionicity, the perinatal outcome of twin pregnancies, in which vaginal delivery was planned, that delivered at or after 32 weeks of gestation with the first twin in cephalic presentation. In order to select a population with well-recognized indications for planned vaginal delivery, we applied the same exclusion criteria as those in the Twin Birth Study, an international randomized trial. Monochorionic twin pregnancies with twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence were defined as complicated and were excluded. The primary outcome was a composite of intrapartum mortality and neonatal morbidity and mortality. Multivariable logistic regression models were used to control for potential confounders. Subgroup analyses were conducted according to birth order (first or second twin) and gestational age at delivery (< 37 or ≥ 37 weeks of gestation). Among 3873 twin pregnancies, in which vaginal delivery was planned, that delivered at ≥ 32 weeks' gestation with the first twin in cephalic presentation, meeting the inclusion criteria of the Twin Birth Study, 729 (18.8%) were uncomplicated monochorionic twin pregnancies and 3144 (81.2%) were dichorionic twin pregnancies. The rate of composite intrapartum mortality and neonatal morbidity and mortality did not differ between uncomplicated monochorionic (27/1458 (1.9%)) and dichorionic (107/6288 (1.7%)) twin pregnancies when adjusting for conception by assisted reproductive technologies (adjusted relative risk, 1.07 (95% CI, 0.66-1.75)). No significant difference in the primary outcome was found between the groups on subgroup analyses according to birth order and gestational age at delivery. When vaginal delivery is planned, and delivery occurs at ≥ 32 weeks of gestation with the first twin in cephalic presentation, uncomplicated monochorionic twin pregnancy is not associated with a higher rate of composite intrapartum mortality and neonatal morbidity and mortality compared with dichorionic twin pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Schmitz T ，Korb D ，Azria E ，Garabédian C ，Rozenberg P ，Sénat MV ，Sentilhes L ，Vayssière C ，Winer N ，Goffinet F ，JUmeaux MODe d'Accouchement (JUMODA) Study Group and the Groupe de Recherche en Obstétrique et Gynécologie (GROG) ... -  《-》

Delivery of monochorionic twins: lessons learned from the Twin Birth Study.

The current literature regarding the recommended mode of delivery of monochorionic-diamniotic twins is limited to small numbers, retrospective studies, and comparisons of outcomes of monochorionic-diamniotic twin pregnancies with those of dichorionic-diamniotic twin pregnancies instead of outcomes of trial of labor vs elective cesarean delivery of monochorionic-diamniotic twins. This study aimed to compare perinatal and maternal outcomes of planned cesarean delivery and planned vaginal delivery of monochorionic-diamniotic twins using the Twin Birth Study data. This study is a secondary analysis of the Twin Birth Study. Women were randomized from 32 weeks and 0 days gestation to 38 weeks and 6 days gestation to planned cesarean delivery or planned vaginal delivery. Twin A in the cephalic presentation and estimated weight of each twin between 1500 and 4000 grams were the inclusion criteria. Pregnancies complicated by fetal reduction after 13 weeks of gestation, lethal fetal anomaly, or contraindication to vaginal delivery were excluded. Elective delivery was planned between 37 weeks and 5 to 7 days of gestation and 38 weeks and 6 to 7 days of gestation. Perinatal and maternal outcomes of monochorionic-diamniotic twin pregnancies were compared between those randomized for planned cesarean delivery and those randomized for planned vaginal delivery. In addition, outcomes of monochorionic-diamniotic twin pregnancies were compared with those of dichorionic-diamniotic twin pregnancies. Out of the 1393 women in each arm, 346 (24.9%) women in the planned cesarean delivery arm and 324 (23.3%) women in the planned vaginal delivery arm had monochorionic-diamniotic twin pregnancies and were eligible for the first analysis. The rate of cesarean delivery was 39.2% in the planned vaginal delivery arm and was 91.3% in the planned cesarean delivery arm. There was no significant difference in gestational age at delivery between the groups (34.4±1.8 weeks vs 34.5±1.8 weeks; P=.78). No difference was found in maternal outcomes. As for perinatal outcomes, the rate of the primary adverse neonatal composite outcomes in twins A or twins B was similar in both the planned vaginal delivery and the planned cesarean delivery arms (twins A, 1.2% vs 1.2% [P=.92]; twins B, 1.2% vs 3.2% [P=.09]). Within the planned cesarean delivery arm, the rate of primary adverse neonatal composite outcome was higher in twins B than twins A (3.2% vs 1.2%; P=.03). There was no difference in the primary adverse neonatal composite outcome between twins A in the monochorionic-diamniotic group and the dichorionic-diamniotic group (1.2% vs 1.3%; P=.89) or between twins B in similar groups (2.3% vs 2.7%; P=.47). In monochorionic-diamniotic twin pregnancy between 32 weeks and 0 to 7 days of gestation and 38 weeks and 6 to 7 days of gestation, with twin A in a cephalic presentation, planned cesarean delivery did not decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery.

Aviram A ，Lipworth H ，Asztalos EV ，Mei-Dan E ，Melamed N ，Cao X ，Zaltz A ，Hvidman L ，Barrett JFR ... -  《-》

Planned Cesarean or planned vaginal delivery for twins: secondary analysis of randomized controlled trial.

To evaluate whether there is a differential benefit of planned Cesarean delivery (CD) over planned vaginal delivery (VD) in women with a twin pregnancy and the first twin in cephalic presentation, depending on prespecified baseline maternal and pregnancy characteristics, and/or gestational age (GA) at delivery. This was a secondary analysis of the Twin Birth Study, which included 2804 women with a twin pregnancy and the first twin (Twin A) in cephalic presentation between 32 + 0 and 38 + 6 weeks' gestation at 106 centers in 25 countries. Women were assigned randomly to either planned CD or planned VD. The main outcome measure was composite adverse perinatal outcome, defined as the occurrence of perinatal mortality or serious neonatal morbidity in at least one twin. The baseline maternal and pregnancy characteristics (markers) considered were maternal age, parity, history of CD, use of antenatal corticosteroids, estimated fetal weight (EFW) of Twin A, EFW of Twin B, > 25% difference in EFW between the twins, presentation of Twin B, chorionicity on ultrasound, method of conception, complications of pregnancy, ruptured membranes at randomization and GA at randomization. Separate logistic regression models were developed for each marker in order to model composite adverse perinatal outcome as a function of the specific marker, planned delivery mode and the interaction between these two terms. In addition, multivariable logistic regression analysis with backward variable elimination was performed separately in each arm of the trial. The association between planned mode of delivery and composite adverse perinatal outcome, according to GA at delivery, was assessed using logistic regression analysis. Of the 2804 women initially randomized, 1391 were included in each study arm. None of the studied baseline markers was associated with a differential benefit of planned CD over planned VD in the rate of composite adverse perinatal outcome. GA at delivery was associated differentially with composite adverse perinatal outcome in the treatment arms (P for interaction < 0.001). Among pregnancies delivered at 32 + 0 to 36 + 6 weeks, there was a trend towards a lower rate of composite adverse perinatal outcome in those in the planned-VD group compared with those in planned-CD group (29 (2.2%) vs 48 (3.6%) cases; odds ratio (OR) 0.62 (95% CI, 0.37-1.03)). In pregnancies delivered at or after 37 + 0 weeks, planned VD was associated with a significantly higher rate of composite adverse perinatal outcome, as compared with planned CD (23 (1.5%) vs 10 (0.7%) cases; OR, 2.25 (95% CI, 1.06-4.77)). The perinatal outcome of twin pregnancies with the first twin in cephalic presentation may differ depending on GA at delivery and planned mode of delivery. At 32-37 weeks, planned VD seems to be favorable, while, from around 37 weeks onwards, planned CD might be safer. The absolute risks of adverse perinatal outcomes at term are low and must be weighed against the increased maternal risks associated with planned CD. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Zafarmand MH ，Goossens SMTA ，Tajik P ，Bossuyt PMM ，Asztalos EV ，Gardener GJ ，Willan AR ，Roumen FJME ，Mol BW ，Barrett YJ ，Twin Birth Study Collaborative Group ... -  《-》

Association Between Planned Cesarean Delivery and Neonatal Mortality and Morbidity in Twin Pregnancies.

Schmitz T ，Prunet C ，Azria E ，Bohec C ，Bongain A ，Chabanier P ，D'Ercole C ，Deruelle P ，De Tayrac R ，Dreyfus M ，Dupont C ，Gondry J ，Graesslin O ，Kayem G ，Langer B ，Marpeau L ，Morel O ，Parant O ，Perrotin F ，Pierre F ，Poulain P ，Riethmuller D ，Rozenberg P ，Rudigoz RC ，Sagot P ，Sénat MV ，Sentilhes L ，Vayssière C ，Venditelli F ，Verspyck E ，Winer N ，Lecomte-Raclet L ，Ancel PY ，Goffinet F ，JUmeaux MODe d'Accouchement (JUMODA) Study Group and the Groupe de Recherche en Obstétrique et Gynécologie (GROG) ... -  《-》

[Delivery of twins : lessons learnt from the national observational prospective comparative study JUMODA].

To summerize the results of the JUMODA study (JUmeaux MODe d'Accouchement) on the planned mode of delivery of twin pregnancy and the management of second twin delivery. JUMODA was a national observational prospective comparative study that took place between february 2014 and march 2015 in 176 french maternity units performing more than 1500 deliveries per year. Its main objectives were the comparison of neonatal and maternal morbidity according to the planned mode of delivery and the determination of the managements of second twin delivery associated with the best neonatal outcomes. To control for potential confounding factors and indication biases, statistical analyses comprized multivariate logistic regressions and matching on propensity scores. The JUMODA study recruited 8823 women with twin delivery at or beyond 22 weeks of gestation. For twin pregnancies with a cephalic first twin at 32 weeks of gestation and beyond, severe neonatal morbidity was higher in the planned cesarean (150/2908 (5.2 %) than in the planned vaginal delivery group (199/8922 (2.2 %), aOR 1.56, 95 % CI 1.19-2.04). Increased neonatal morbidity in the planned cesarean delivery group was explained by higher severe morbidity in neonates born preterm (aOR 1.64, 95 % CI 1.13-2.39, for deliveries between 32+0 and 34+6 weeks of gestation, aOR 2.04, 95 % CI 1.22-3.41, for deliveries between 35+0 SA and 36+6 weeks of gestation) but not in neonates born at term (aOR 1.19, 95 % CI 0.58-2.44). In comparison with planned cesarean delivery, planned vaginal delivery was not associated with increased severe neonatal morbidity in case of breech presenting first twin after 32 weeks of gestation or with decreased survival witout severe neonatal morbidity in case of delivery before 32 weeks of gestation whatever the first twin presentation. In comparison with planned vaginal delivery, planned cesarean delivery was associated with increased severe maternal morbidity only in women aged 35 and higher. Delivery of non cephalic second twin was associated with similar severe neonatal morbidity rate than delivery of cephalic second twin. Finally, in case of cephalic second twin, internal version followed by total breech extraction was associated with less cesarean for the second twin but with higher severe neonatal morbidity in case of preterm birth in comparison with pushing efforts, ocytocin perfusion and artificial rupture of membranes. Planned vaginal delivery is the planned mode of delivery to encourage for the majority of pregnant women with twins, whatever first twin presentation and gestational age at delivery. No management of cephalic second twin appears better than an other, its choice will rest on obstetrician preferences.

Schmitz T ，Goffinet F 《-》