Clinical indicators associated with the mode of twin delivery : An analysis of 22,712 twin pairs

Objective To identify clinical indicators associated with the planned and actual mode of delivery in women with a twin pregnancy. Study design We performed a retrospective cohort study in women with a twin pregnancy who delivered at a gestational age of 32 + 0-41 + 0 weeks and days between 2000 and 2008 in the Netherlands. Data were obtained from a nationwide database. We identified maternal, pregnancy-related, fetal, neonatal and hospital-related indicators that were associated with planned cesarean section (CS) and, for women with planned vaginal delivery (VD), for intrapartum CS. The associations between indicators and mode of delivery were studied with uni- and multivariate logistic regression analyses. Results We included 22,712 women with a twin pregnancy, of whom 4,310 women (19.0%) had a planned CS. Of the 18,402 women who had a planned VD, 14,034 (76.3%) delivered vaginally, 3,545 (19.3%) had an intrapartum CS, while 823 (4.5%) delivered twin A vaginally and twin B by intrapartum CS. The clinical indicators for a planned CS and an intrapartum CS were comparable: non-cephalic position of both twins (aOR 25.32; 95% CI 22.50-28.50, and aOR 21.94; 95% CI 18.67-25.78, respectively), non-cephalic position of twin A only (aOR 21.67 95% CI 19.12-24.34, and aOR 13.71; 95% CI 11.75-16.00, respectively), previous CS (aOR 3.69; 95% CI 3.12-4.36, and aOR 7.00; 95% CI 5.77-8.49, respectively), nulliparity (aOR 1.51; 95% CI 1.32-1.72, and aOR 4.20; 95% CI 3.67-4.81, respectively), maternal age ≥41 years (aOR 3.00; 95% CI 2.14-4.22, and aOR 2.50; 95% CI 1.75-3.59, respectively), and pre-eclampsia (aOR 2.12; 95% CI 1.83-2.46, and aOR 1.34; 95% CI 1.16-1.56, respectively). Conclusion Both planned and intrapartum CS in twins had comparable predictors: non-cephalic position of both twins or twin A only, previous CS, nulliparity, advanced maternal age, and pre-eclampsia

Repeated cervical length measurements for the verification of short cervical length

Objective: To determine if the verification of short cervical length with a repeated measurement improved the identification of patients with short cervical length at increased risk of preterm delivery. Methods: The present secondary analysis analyzed prospective cohort study data from patients with singleton pregnancies without a history of preterm delivery who presented for obstetric care in the Netherlands and delivered between November 18, 2009, and January 1, 2013. Cervical length was measured during standard anomaly scan and a second measurement was performed if the cervical length was 30 mm of shorter. Logistic regression and Cox proportional hazards modeling were used to evaluate associations between cervical length measurements and spontaneous preterm delivery before 37 weeks of pregnancy. Results: Cervical length measurements from 12 358 patients were included; 221 (1.8%) had an initial cervical length measurement of 30 mm or shorter. A second cervical length measurement was performed for 167 (75.6%) patients; no differences were identified in the odds of spontaneous preterm delivery when evaluated using the first, second, or a mean of both measurements, regardless of whether cervical length was analyzed as a continuous or dichotomous variable. Conclusion: Among patients with singleton pregnancies, verification of short cervical length did not improve the identification of short cervical length

Repeated cervical length measurements for the verification of short cervical length

Objective: To determine if the verification of short cervical length with a repeated measurement improved the identification of patients with short cervical length at increased risk of preterm delivery. Methods: The present secondary analysis analyzed prospective cohort study data from patients with singleton pregnancies without a history of preterm delivery who presented for obstetric care in the Netherlands and delivered between November 18, 2009, and January 1, 2013. Cervical length was measured during standard anomaly scan and a second measurement was performed if the cervical length was 30 mm of shorter. Logistic regression and Cox proportional hazards modeling were used to evaluate associations between cervical length measurements and spontaneous preterm delivery before 37 weeks of pregnancy. Results: Cervical length measurements from 12 358 patients were included; 221 (1.8%) had an initial cervical length measurement of 30 mm or shorter. A second cervical length measurement was performed for 167 (75.6%) patients; no differences were identified in the odds of spontaneous preterm delivery when evaluated using the first, second, or a mean of both measurements, regardless of whether cervical length was analyzed as a continuous or dichotomous variable. Conclusion: Among patients with singleton pregnancies, verification of short cervical length did not improve the identification of short cervical length

Economic analysis comparing induction of labour and expectant management for intrauterine, growth restriction at term (DIGITAT trial)

<p>Objective: Pregnancies complicated by intrauterine growth restriction (IUGR) are at increased risk for neonatal morbidity and mortality. The Dutch nationwide disproportionate intrauterine growth intervention trial at term (DIGITAT trial) showed that induction of labour and expectant monitoring were comparable with respect to composite adverse neonatal outcome and operative delivery. In this study we compare the costs of both strategies.</p><p>Study design: A cost analysis was performed alongside the DIGITAT trial, which was a randomized controlled trial in which 650 women with a singleton pregnancy with suspected IUGR beyond 36 weeks of pregnancy were allocated to induction or expectant management. Resource utilization was documented by specific items in the case report forms. Unit costs for clinical resources were calculated from the financial reports of participating hospitals. For primary care costs Dutch standardized prices were used. All costs are presented in Euros converted to the year 2009.</p><p>Results: Antepartum expectant monitoring generated more costs, mainly due to longer antepartum maternal stays in hospital. During delivery and the postpartum stage, induction generated more direct medical costs, due to longer stay in the labour room and longer duration of neonatal high care/medium care admissions. From a health care perspective, both strategies generated comparable costs: on average (sic)7106 per patient for the induction group (N = 321) and (sic)6995 for the expectant management group (N = 329) with a cost difference of (sic)111 (95%CI: (sic)-1296 to 1641).</p><p>Conclusion: Induction of labour and expectant monitoring in IUGR at term have comparable outcomes immediately after birth in terms of obstetrical outcomes, maternal quality of life and costs. Costs are lower, however, in the expectant monitoring group before 38 weeks of gestation and costs are lower in the induction of labour group after 38 weeks of gestation. So if induction of labour is considered to preempt possible stillbirth in suspected IUGR, it is reasonable to delay until 38 weeks, with watchful monitoring. (C) 2013 Elsevier Ireland Ltd. All rights reserved.</p>

A randomized trial of planned cesarean or vaginal delivery for twin pregnancy

Background: Twin birth is associated with a higher risk of adverse perinatal outcomes than singleton birth. It is unclear whether planned cesarean section results in a lower risk of adverse outcomes than planned vaginal delivery in twin pregnancy.\ud \ud Methods: We randomly assigned women between 32 weeks 0 days and 38 weeks 6 days of gestation with twin pregnancy and with the first twin in the cephalic presentation to planned cesarean section or planned vaginal delivery with cesarean only if indicated. Elective delivery was planned between 37 weeks 5 days and 38 weeks 6 days of gestation. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity, with the fetus or infant as the unit of analysis for the statistical comparison.\ud \ud Results: A total of 1398 women (2795 fetuses) were randomly assigned to planned cesarean delivery and 1406 women (2812 fetuses) to planned vaginal delivery. The rate of cesarean delivery was 90.7% in the planned-cesarean-delivery group and 43.8% in the planned-vaginal-delivery group. Women in the planned-cesarean-delivery group delivered earlier than did those in the planned-vaginal-delivery group (mean number of days from randomization to delivery, 12.4 vs. 13.3; P = 0.04). There was no significant difference in the composite primary outcome between the planned-cesarean-delivery group and the planned-vaginal-delivery group (2.2% and 1.9%, respectively; odds ratio with planned cesarean delivery, 1.16; 95% confidence interval, 0.77 to 1.74; P = 0.49).\ud \ud Conclusion: In twin pregnancy between 32 weeks 0 days and 38 weeks 6 days of gestation, with the first twin in the cephalic presentation, planned cesarean delivery did not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery