Objective: The purpose of this study was to calculate the prospective risk of fetal death in monochorionic-diamniotic twins. Study design: We evaluated 193 monochorionic diamniotic twin pregnancies that were followed and delivered after 24 weeks. Surveillance included cardiotocography and sonography performed at least once weekly. The prospective risk of fetal death was calculated as the total number of deaths at the beginning of the gestational period divided by the number of continuing pregnancies at or beyond that period. Results: The fetal death rate was 5 of 193 pregnancies (2.6%; 95% CI, 1.1, 5.9); the prospective risk of stillbirth per pregnancy after 32 weeks of gestation was 1.2% (95% CI, 0.3% -4.2%). Conclusion: Under intensive surveillance, the prospective risk of fetal death in monochorionicdiamniotic pregnancies after 32 weeks of gestation is much lower than reported and does not support a policy of elective preterm delivery. Ó 2006 Mosby, Inc. All rights reserved.Monochorionic twins, comprising approximately 20% of all spontaneous twins and nearly 5% of iatrogenic twins, 1 are at a substantial higher risk of perinatal morbidity and death than their bichorionic counterparts.2-4 This risk is attributed to the inherent pathologic condition that is associated with delayed zygotic splitting that leads to the increased prevalence of fetal and placental malformations. However, in monochorionicdiamniotic pregnancies, the precise cause of the high rate of adverse perinatal outcomes in pregnancies that are not complicated by congenital anomalies, twin-twin transfusion syndrome (TTTS), and/or growth restriction is not clear.Evidently, not all monochorionic twin pregnancies are complicated a priori. A recent analysis of a large cohort of 455 monochorionic twins showed that 181 (39.8%) twin pairs were considered ''uncomplicated'' (ie, without signs of TTTS and exhibiting appropriate and concordant growth in each of the structurally normal twins). 5 This subset of ''uncomplicated'' monochorionic twins, however, was found to be at a considerable excess
Twin pregnancies complicated by GDM might be associated with pre-pregnancy maternal obesity and are at increased risk of RDS and non-significant increased risk of perinatal death.
We used a prospective cohort to analyze the effect of change in BMI rather than change in weight, in mothers carrying dichorionic twins from a population that did not receive any dietary intervention. A total of 269 mothers (150 nulliparas and 119 multiparas) were evaluated. The average change (%) from the pre-gravid BMI was 7.2 ± 6.1, 17.4 ± 8.2, and 28.7 ± 10.8, at 12–14, 22–25, and 30–34 weeks, respectively, without difference between nulliparas and multiparas. The comparison between maternities below or above the average change from the pregravid BMI failed to demonstrate an advantage (in terms of total twin birthweight and gestational age) of an above average change from the pregravid BMI, even when the lower versus upper quartiles were compared. Our observations reached different conclusions regarding the recommended universal dietary intervention in twin gestations. A cautious approach is advocated towards seemingly harmless excess weight gain, as normal weight women may turn overweight, or even obese, by the end of pregnancy, and be exposed to the untoward effects of obesity on future health and body image.
The efficacy and safety of oral misoprostol for labor induction of twins is unknown. We conducted a retrospective case-control study to evaluate the use of oral misoprostol in near term (> or =35 weeks) twin pregnancies in nulliparas. Eligible cases were given 100 mcg oral misoprostol, which was repeated after 6 h if labor did not start. Either a third dose or diluted oxytocin infusion were given in intractable cases. Diluted oxytocin infusion was used for augmentation. Controls were nulliparas delivered at > or =35 weeks by elective cesarean section. The two groups were comparable in most aspects, except for fetal malpresentation, which was the major reason for avoiding induction. Of the 69 patients in whom labor was induced, 53 (76.8%) had a vaginal birth, 3 (4.3%) had a combined twin delivery, and 13 (18.8%) had a cesarean during labor. The mean length of stay of the neonates was significantly shorter among study cases, without significant difference in the frequency of delayed discharges as an overall proxy for neonatal complications. Labor induction with oral misoprostol could be offered to patients in whom near term vaginal twin delivery is unequivocally permitted and wish to deliver by the vaginal route.
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