1. Is Cesarean Section necessary for Twin pregnancy ? Mazen EL Zibdeh MD. DRCPI.MRCOG.FRCOG Senior consultant Ob.Gyn.. Gardens hospital- Amman.Jordan 1 st September 2016,JSOG.

2. Introduction: The incidence of multiple births in the developed world has increased dramatically over the past few decades. From 1 in 100 to about one in 60 deliveries. 2-3 fold rise in higher order multiple births. Triplets and higher order increased more than 400% (153/100,000) in 2009. Over 97% of multiple pregnancies are twin pregnancies.

3. Causes of increased incidence of multiple gestation 1.Increased use of ART. With ovulation induction 9-14%. In IVF: correlates with number of embryos transferred. – 17.9% for 2 ET – 24% after 4 or more ET 2.Shift towards an older maternal age at conception.

4. Risks of multiple pregnancy Multiple pregnancy is high risk for both mother and infant. This lecture will concentrate on twin pregnancy and not the higher order.

5. Types of Twins: 1.Dizygotic, Dichrionic: when two ova fertilized by two sperms. 2.Monozygotic: one sperm fertilizes one ovum then divides. – Dichorionic at ------------------------------- 0 day – Monochorionic diamniotic ----------------at day 3 – Monochorionic monoamniotic---------- day 9 – Conjoined -------------------------------------day 13 Monozygotic twin incidence is relatively constant 3-5/1000 births. Dizygotic twin rate and higher order births vary widely and affected by parity, age, racial background and use of ART.

6. Risks associated with twin pregnancy Maternal risk Fetal risk

7. Maternal Risks 1.Increased symptoms of early pregnancy x3 times 2.Increased risk of miscarriage x2 3.Intrauterine death of one twin: vanishing twin syndrome. 4.Increase in severity of pregnancy minor disorders. 5.Anemia (Iron and folate demands and more). 6.Preterm labor and delivery – Delivery at <37 weeks gestation occur in 50% of all twins. – 10% of these births occur prior to 33 weeks. – Maternal risk (hospitalization, use of tocolytic agents)

8. Maternal Risks (cont.2) 7.Hypertension. PG with twin has 5 times increased risk of PET. 8.Ante partum hemorrhage due to placenta previa and abruption. 9.Hydramnios -About 12% twins. -Acute polyhydramnious may occur with monochorionic twins and often associated with TTTS. 10.10. Need for hospitalization (PTB, Hypertension, PET, IUGR) 11.Single fetal death in utero -Risk 2-6% -Risk of cerebral, renal lesion with surviving twin.

9. Maternal Risks (cont.3) 12. Risk of operative vaginal delivery for both or one delivery. 13. Postnatal problems: -increased depression -increased demand of two children. 14. Maternal mortality: increased by tow folds as in singleton

10. Fetal risks associated with multiple pregnancy 1.Still birth and neonatal death 2.Single fetal death 3.preterm labor and delivery 4.IUGR 5.Congenital anomalies (in one twin, conjoined twin) 6.Cord accidents 7.Hydramnios 8.T T T S 9.Risks of asphyxia 10.Operative vaginal demands 11.Twin entrapment 12.Cerebral Palsy

11. Intra partum risk of twins Twin birth is associated with high risk of adverse perinatal outcome than singleton birth The influence of birth on neonatal outcome is still unclear. Second twin is generally considered at higher risk of adverse morbidity and mortality because of obstetric complications that may develop during labor and after delivery of the first twin. placental separation Cord accidents Uterine atony Cervical spasm Long interval delivery Birth weight discordance, Very low birth.

12. Twin pregnancy and birth option Twin birth is associated with higher risk of adverse perinatal outcome than singleton birth. The influence of birth on neonatal outcome is still unclear in spite of large number of studies.

13. Factors affecting decision on mode of delivery Fetal presentation Chorionicity Difference in weight of both twin Maternal choice??

14. Fetal presentation 40% of twin presents as cephalic/Cephalic 35% as cephalic/non cephalic 25% non cephalic 1st twin/ other presentation Grisarn D. AmJ Perinatol 2001

15. General consensus on twin delivery If twin A is presenting by breech, there is good agreement that delivery should be by C-section. If twin A is cephalic and twin B in non cephalic the delivery option is controversial. For twin A presenting with cephalic and twin B is cephalic,most clinicians continue to recommend planned vaginal birth. This consensus is based on expert opinion rather than RCT. Blackstein I 2000 Journal of Perinatology Yang et al 2006

16. What is the evidence based- on Twin delivery The global increase in C-section rate for twin has been studied by many authors. Factors affecting decision(Planned vaginal verses planned C Section.) – Defensive behavior on part of obstetrician should birth pathology be indicated. – The term breech trial with its influence on the practice of breech delivery by C. Section. Hannah M. 2000 Lancet

17. The policy of planned vaginal birth for women with a twin pregnancy is associated with 30-40 % rate of emergency CS. When the first twin is born vaginal, there is still a risk of emergency CS for the birth of the second twin 7%. Persad V Obstet Gynecol 2001 Despite the demonstrated safety of trial of labor for pregnancies with vertex presenting twin and clinical guidelines is support of this plan, the rate of planned CS delivery for twin pregnancy remain high. This high rate and variation in CS rate for twin pregnancies across providers may be influenced strongly by concern about delivery of second twin particularly when it is in non vertex presentation Easter SR AmJ Obstet Gyn 2016

18. What determines the decision for mode of delivery 1.Maternal factors: – Age – History of infertility – Patient’s request – Maternal complications: PET, Hypertension, Placenta previa, abruptio placenta, IUGR, CPD – Patient with previous C-Section 2.Specific factors related to twins: – Presentation – Chorionicity – Difference in weight of both twins 3.Facilities and trained obstetricians on twins delivery, extraction or internal version, and breech delivery.

19. Planned C-Section Most recommend that when first twin is presenting by breech, delivery should be by planned C-Section. Also planned elective C-Section done due to maternal or obstetrical indication.

20. Chorionicity Monochorionic-Diamniotic twins have double risk of IUFD than Dichorionic Twins to risk of T T TS. Glinianaia SV, Human Reprod 2011 In Monoamniotic twins – Increased cord accidents. – Increased risk of IUFD Dodd JM et al 205 Current Opinion Obstet- Gynecol.

21. Difference in weight of both twins When second twin weight is more than 20% of the first, morbidity increased three times as higher than the first. Armson et al. 2006. SweedishStudy: – A difference of 300g or more increased non viability by 50% in monochorionic and 5 % in diachornionic San A. et al.BJOG 113,2006.

22. Fetal Presentation Cochrane Data base review 2011 Objective: To determine the short and long term effects on mother and babies of planned C section for twin pregnancy. Conclusion: No significant differences based on planned CS Vs planned vaginal birth with regards to second twin being non vertex. Recent Studies state no advantage in elective C. section over vaginal delivery in case of twin when 1 st is cephalic and 2 nd is non cephalic. Atis A etal J Obstet Gynecol 2011 Winn HN Obstet Gynecol 2011

23. Risk of combined delivery (C-Section for 2 nd Twin) Morbidity and mortality was studied by Yang 2006 on 86041 pair of twins when both were in cephalic presentation. – Babies born after 36 weeks : – When both delivered vaginally: ------- Mortality 0.08%. – When second twin delivered by CS:---- Mortality 0.9% – When CS done as elective and both delivered by CS :---------------- Mortality 0.03

24. Neonatal outcomes in twins according to presentation Discussed by Ross and Mullin Systemic review and meta analysis published in BJOG, 2011: 39571 pair of twins and 18 articles included: Conclusion: – Twins with vertex/vertex presentation vaginal delivery is safer than C-Section for the first twin and no differences were observed for the second twin after vaginal or C section. – Only in case of C-Section following the vaginal birth of the 1 st twin,the NN morbidity of 2 nd twin significantly higher compared to vaginal birth and planed CS.

25. Twin Birth Study

26. The Twin Birth Study This is a large multicentre prospective randomized study carried out to compare the delivery strategies for twins between 32-38 weeks of gestation. The first twin in cephalic presentation and both are alive with estimated weight between 1500g and 4000g – Dept of ObGyn CMICR Synny brook Research institution Toronto. Canada

27. The Twin Birth Study Excluded from the study; – Mono amniotic twins. – Fetal anomalies. – Contra indication to vaginal labor of vaginal delivery. – Second twin substantially larger than the first twin.

28. Prerequisites for planned vaginal birth US examination to rule out fetal death, lethal anomalies and to assess fetal weight. CTG control. C-Section possible within 30 minutes. Anesthesia, obstetrician skilled in fetal version, breech and twin delivery.

29. 2804 women enrolled. – 1398 randomized to planned C-Section (2783 fetuses.) – 1406 randomized to planned vaginal delivery (fetuses2782)

30. Fetal or neonatal outcomes of TBS P ValuePlanned Vaginal Delivery Planned C-SectionFetal Death of serious neonatal morbidity 27822783No of fetuses included 0.491.9%2.2%Composite primary outcome(fetal or NN mortality or severe NN morbidity) Death 0.30.5In labor 0.30.4NN death

31. Serious Neonatal Morbidity- TBS Planned Vaginal DeliveryPlanned C-SectionSerious Neonatal Morbidity 0.10Long bone fracture <0.1 Other bone fracture <0.10Facial nerve injury <0.10.1Intra cerebral Hemorrhage 0.30.1Low Apgar Score < 4 at 5 minutes <0.10Coma 0.1 Seizures 0.1<0.1Neonatal Sepsis

32. Maternal Outcome of TBS P ValuePlanned vaginalPlanned C.SMaternal Outcome of TBS NS0.1% Maternal death or serious morbidity NS7.8%6%Hemorrhage NS0.4%0.7%Laparotomy NS0. 4%0.2%Genital tract injury NS0.1%0.4%Thrombo embolism NS1ز3%1ز3%1.8%Infection Other complications like amniotic fluid embolism, wound dehiscence, bowel obstruction, blood transfusion were all non significant.

33. Results of TBS Frequency of composite primary outcome did not differ significantly between planned CS and planned vaginal delivery group.( 2.2% and 1.9%.) There was no significant difference between planned C. section delivery and planned vaginal delivery groups with regards to frequency of maternal composite outcome (7.43% and 8.5% p.value 0.29).

34. Conclusions of the TBS. Planned C section did not reduce the risk of fetal or neonatal death or serious neonatal morbidity as compared to planned vaginal delivery. Risk for second twin is higher than risk of delivery for the first twin. However planned C Section did not reduce this risk. There is controversy regarding the safest method for delivery of twins at or near term. A policy of planned C section for twin gained support after the publication of the Term Breech Trial, which showed that planned C section was associated with reduced risk of an adverse perinatal outcome in full term breech presentation.

35. Conclusion: Support for planned C-Section came from cohort studies of twin showing reduced risk of an adverse perinatal outcome with elective C. Section as compared to vaginal delivery or emergency C.Section. Most large randomized studies were not in agreement with this. Therefore, no benefit found with planned C. Section as compared with planned vaginal delivery for twin between 32-38 weeks of gestation if the first twin is in the cephalic presentation.

36. Thank You