Effects of Twin Gestation on Maternal Morbidity

doi:10.1053/j.semperi.2012.02.007

Seminars in Perinatology

Volume 36, Issue 3, June 2012, Pages 162-168

https://doi.org/10.1053/j.semperi.2012.02.007 Get rights and content

As the incidence of twin gestation increases, it is important to consider the maternal risks associated with carrying multiples. Compared with singleton gestation, there are increased risks to the mother during the antepartum, intrapartum, and postpartum periods. Certain pregnancy complications are more likely to occur during a twin gestation, including preeclampsia and other hypertensive disorders, antepartum hospitalization for preterm labor or abnormal bleeding, nutritional deficiencies, cesarean delivery, and postpartum hemorrhage. Women carrying twins may benefit from early education regarding these issues, close maternal monitoring as well as physical therapy sessions, and nutrition counseling during their pregnancies.

Section snippets

Maternal Physiological Adaptation to Twin Pregnancy

Women with multifetal gestations undergo significant physiological adaptations beyond the expected cardiovascular, hematologic, and metabolic changes for a singleton pregnancy.⁸ These exaggerated responses in twin pregnancies may put women with certain preexisting cardiovascular or pulmonary conditions at higher risk for earlier and severe complications of pregnancy as well as place additional strain on a woman with normal baseline physiology.

Differences in cardiovascular physiological

Hypertensive Disorders/Preeclampsia

Hypertensive disorders occurs in 5%-10%¹⁸ of singleton pregnancies and affect up to 10%-20% of twin gestations.2, 4, 6, 7, 19 Preeclampsia is defined as gestation-related hypertension combined with proteinuria.²⁰ This heterogenous condition has a wide spectrum of clinical presentations and may cause the following maternal morbidities: hypertensive urgency, stroke, seizure, need for obstetrical intervention, cesarean delivery, thrombocytopenia, and hemorrhage.21, 22 A large retrospective

Cesarean Delivery

Although the antepartum period remains a time during which there are increases in certain morbidities, including preeclampsia, placenta previa, and perhaps gestational diabetes, the delivery of twins is accompanied by its own intrapartum risks with higher risks of preterm labor,¹ abruption,1, 4 and malpresentation⁵² and the need for their appropriate management.

Twin gestation have higher rates of cesarean delivery compared with singleton gestation,1, 44 given higher rates of placenta previa,³⁵

Hemorrhage

The risk of postpartum hemorrhage in a twin pregnancy is greater than with a singleton gestation,1, 11 with studies demonstrating risks 2-4 fold above the risk for a singleton pregnancy for all delivery types combined,1, 59 as well as for cesarean delivery alone.⁴⁴ The increased incidence may be secondary to the greater uterine distention and a consequently higher rate of atony.

The risks of blood transfusion are small but can be significant when they occur. Blood transfusion for acute blood

Emotional Impact

Despite a lack of robust data, the emotional impact of any pregnancy on an individual and her family cannot be overstated. Although each pregnancy may carry its own significant emotional stressors for varying individuals, multiple pregnancies carry additional risks of complications that can lead to fetal and neonatal loss or injury, as well as maternal morbidity. Although it may not be appropriate to compare the emotional implications of a twin versus a singleton pregnancy, women carrying a

Conclusions

The majority of twin pregnancies have favorable outcomes. Most patients experience either an uncomplicated pregnancy or one with well-tolerated morbidities, such as iron-deficiency anemia, that can be managed to good effect. However, a twin gestation poses significantly increased risk of complication to the mother during the antepartum, intrapartum, and postpartum periods that are often unavoidable and can alter the course of pregnancy.

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Citation Excerpt :
Surprisingly, obesity was not associated with an increased risk of GDM, Caesarean section, PTD and PPROM, as seen in a previous study (Peeva et al., 2022). The risk of adverse obstetrical outcomes afforded by multiple gestation may overshadow the risk attributed to obesity, as multiple gestation is a known independent risk factor for GDM, Caesarean section, PTD and PPROM (Hiersch et al., 2018; Norwitz et al., 2005; Walker et al., 2004; Young and Wylie, 2012). There are multiple limitations to the current study.
Research question: Does multiple gestation alter the risks for adverse obstetric outcomes in women with polycystic ovary syndrome (PCOS)?
Design: Retrospective population-based cohort study using data from the HCUP-NIS from 2004 to 2014. A total of 14,882 women with PCOS, who delivered within that time period, were identified. The study group comprised women with PCOS who had had a multiple gestation (n = 880); the reference group was comprised of the remaining women with PCOS and singleton gestation (n = 14,002).
Results: In women with PCOS, multiple gestation increased the risks of pregnancy complications including pregnancy-induced hypertension (adjusted odds ratio [aOR] 2.030; 95% confidence interval [CI] 1.676–2.460), pre-eclampsia (aOR 2.879; 95% CI 2.277–3.639), pre-eclampsia and eclampsia superimposed on pre-existing hypertension (aOR 1.917; 95% CI 1.266–2.903) and gestational diabetes (aOR 1.358; 95% CI 1.114–1.656). Multiple gestation increases the risk of preterm premature rupture of membranes (aOR 5.807; 95% CI 4.153–8.119), preterm delivery (aOR 8.466; 95% CI 7.071–10.135), Caesarean section (aOR 5.146; 95% CI 4.184–6.329), post-partum haemorrhage (aOR 1.540; 95% CI 1.065–2.228) and the need for transfusion (aOR 3.268; 95% CI 2.010–5.314), as well as wound complications (aOR 3.089; 95% CI 1.647–5.794). Neonates born to mothers with PCOS and having multiple gestations are more likely to be small for gestational age when compared to singleton neonates born to mothers with PCOS (aOR 4.606; 95% CI 3.480–6.095). Among PCOS women with multiple gestations, obesity increased the risks of developing pregnancy-induced hypertension (P < 0.001), pre-eclampsia (P < 0.001) and wound complications (P = 0.045).
Conclusion: These results highlight the importance of single embryo transfer and ovulation induction to develop a single follicle in women with PCOS. Obesity further increases obstetrical complications.
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Our study showed that SMM rates were almost five-fold higher among women who conceived after ART and had a multifetal pregnancy (compared with women who conceived without ART and had singletons). The increased risk of SMM in multifetal pregnancy is well-recognized,20–23 and added caution is required to ensure that ART practices do not favour multifetal pregnancy.24 The high rate of SMM among women using ART also highlights the need for specific counselling for women with pre-existing medical conditions and chronic disease.
To assess the association between use of assisted reproductive technologies (ART) and severe maternal morbidity and maternal mortality (SMM).
We carried out a cohort study that included all hospital deliveries at ≥20 weeks gestation in Canada (excluding Québec) between April 2009 and March 2018. Outcomes of interest included composite SMM and SMM types (e.g., severe preeclampsia, HELLP syndrome, and eclampsia; severe hemorrhage; acute renal failure). Multivariable regression was used to estimate crude and adjusted rate ratios (RR and aRR) and 95% confidence intervals (CI).
The study included 2 535 056 women, of whom 72 023 (2.8%) delivered following the use of ART. The composite SMM rate for women who used ART was 34.7 per 1000 deliveries (95% CI 33.0–36.0) versus 11.5 per 1000 deliveries (95% CI 11.4–11.6) for women who did not use ART (RR 3.01; 95% CI 2.89–3.14). ART use was associated with SMM types such as severe preeclampsia, HELLP syndrome, and eclampsia (RR 3.50; 95% CI 3.27–3.73), severe hemorrhage (RR 3.58, 95% CI 3.27–3.92), and acute renal failure (RR 6.79; 95% CI 5.78–7.98). Associations between ART and composite SMM were attenuated but remained elevated after adjusting for maternal characteristics (aRR 2.34; 95% CI 2.24–2.45). Women who used ART and had a multi-fetal pregnancy had a 4.7 times higher rate of composite SMM compared with women who did not use ART and delivered singletons.
Women who deliver following the use of ART have increased risks of SMM and require counselling that includes mention of the lower risks of SMM associated with ART-conceived singleton pregnancy.
Évaluer l’incidence du recours aux technologies de procréation assistée (TPA) sur la mortalité et la morbidité maternelle grave (MMMG).
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Preeclampsia (PE) is a complication of pregnancy characterized by hypertension (HTN-Preg), and often proteinuria. If not managed promptly, PE could lead to eclampsia and seizures. PE could also lead to intrauterine growth restriction (IUGR) and prematurity at birth. Although PE is a major cause of maternal and fetal morbidity and mortality, the underlying mechanisms are unclear. Also, there is a wide variability in the incidence of PE, ranging between 2 and 8% of pregnancies in the Eastern, Western and Developing world, suggesting regional differences in the risk factors and predictors of the pregnancy-related disorder. Several demographic, genetic, dietary and environmental factors, as well as maternal circulating biomarkers have been associated with PE. Demographic factors such as maternal race and ethnicity could play a role in PE. Specific genetic polymorphisms have been identified in PE. Maternal age, parity, education and socioeconomic status could be involved in PE. Dietary fat, protein, calcium and vitamins, body weight, and environmental factors including climate changes and air pollutants could also play a role in PE. Several circulating cytoactive factors including anti-angiogenic factors and cytokines have also been associated with PE. Traditional midwifery care is a common practice in local maternity care units, while advanced perinatal care and new diagnostic tools such as uterine artery Doppler velocimetry have been useful in predicting early PE in major medical centers. These PE risk factors, early predictors and diagnostic tools vary vastly in different regions of the Eastern, Western and Developing world. Further understanding of the differences in the demographic, genetic, dietary and environmental factors among pregnant women in different world regions should help in designing a region-specific cluster of risk factors and predictors of PE, and in turn provide better guidance for region-specific tools for early detection and management of PE.
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Despite extensive investigations over the last decade, preeclampsia remains an unpredictable pregnancy complication causing perinatal morbidity and mortality worldwide, particularly in twin pregnancies.
This study aimed to determine the relationship between growth discordance in twin pregnancies and the risk for preeclampsia based on chorionicity.
This was a retrospective single-center study that included 2122 women with twin pregnancies who were admitted to a tertiary hospital between January 2013 and June 2016. Growth discordance was defined as twin birthweight difference ≥20%. Logistic regression models were used to analyze the association between growth discordance and risk for gestational hypertension-preeclampsia in all subjects. Stratified sampling by twin chorionicity (dichorionic and monochorionic) was also conducted. Further analysis was performed to estimate the association between the degree of growth discordance and gestational hypertension-preeclampsia risk in monochorionic and dichorionic twin pregnancies.
The prevalence of growth discordance was 17.6%. In all subjects, growth discordance was associated with increased risk for gestational hypertension-preeclampsia. After stratification by twin chorionicity, growth discordance was associated with an increased risk for gestational hypertension preeclampsia (adjusted odds ratio [AOR], 1.84; 95% confidence interval [CI], 1.26–2.67) and preeclampsia (AOR, 1.82; 95% CI, 1.21–2.73), including mild preeclampsia (AOR, 1.86; 95% CI, 1.02–3.37), severe preeclampsia (AOR, 1.78; 95% CI, 1.06–2.97; P<.05), and early-onset preeclampsia (AOR, 2.98; 95% CI, 1.40–6.32), in the dichorionic twin pregnancy group; however, no significant association was found in the monochorionic twin pregnancy group. A 10% increment of growth discordance in the dichorionic twin pregnancy group was associated with an elevated risk for gestational hypertension preeclampsia (AOR, 1.20; 95% CI, 1.02–1.41) and preeclampsia (AOR, 1.24; 95% CI, 1.04–1.48), including severe preeclampsia (AOR, 1.28; 95% CI, 1.04–1.59) and early-onset preeclampsia (AOR, 1.47; 95% CI, 1.08–2.00), but no significant association was found in the monochorionic twin pregnancy group.
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