Risk Factors for Prolonged Intertwin Delivery Interval and Associated Maternal and Second Twin Morbidity

Abstract

Objective This work aimed to identify possible risk factors and the morbidity associated with prolonged intertwin delivery interval (IDI).

Study Design A retrospective cohort study at a single tertiary care center. Women with twin gestations who reached the second stage of labor between January 2010 and December 2019 were included in the study. Demographic and clinical characteristics were compared between short IDI (≤15 minutes) and prolonged IDI (>15 minutes). The primary outcome was the rate of 5-minute Apgar score ≤ 7.

Results A total of 461 women were included; 312 of whom were in the short IDI group and 149 were in the prolonged IDI group. Rates of 5-minute Apgar score ≤ 7 and neonatal acidemia were significantly higher in the prolonged IDI group (3.5 vs. 9.7%, p = 0.008; 4.3 vs. 15.7%, p = 0.01, respectively). Vaginal delivery was less likely to occur in the prolonged IDI group (75.8 vs. 93.3%). Placental abruption and hemoglobin drop ≥ 3 g/dL were more prevalent in the prolonged IDI group (4 vs. 1%, p = 0.03; 39.1 vs. 24.7%, p = 0.01, respectively). In the multivariate analysis, age ≥ 30 years (adjusted odds ratio [aOR]: 1.76, p = 0.01), nulliparity (aOR: 1.66, p = 0.03), and birth weight ratio ≥ 1.2 (aOR: 1.92, p < 0.05) were associated with prolonged IDI.

Conclusion Prolonged IDI is associated with an increased risk for neonatal acidemia and low 5-minute Apgar score, and with an increased rate of cesarean delivery, placental abruption, and hemoglobin drop ≥ 3 g/dL. Advanced maternal age, nulliparity, and twin birth weight ratio ≥ 1.2 are associated with prolonged IDI.

Key Points

• Prolonged was found to be associated with higher neonatal acidemia and lower 5-minute Apgar score.

• Prolonged IDI is also associated with increased rate of cesarean delivery, placental abruption, and blood loss.

• Advanced maternal age, birth weight discordancy, and nulliparity were associated with prolonged IDI.

Keywords

intertwin delivery interval - maternal morbidity - neonatal morbidity - risk factors - twin gestations

Publication History

Received: 13 April 2023

Accepted: 10 July 2023

Article published online:
09 August 2023

• References

• 1 Robinson C, Chauhan SP. Intrapartum management of twins. Clin Obstet Gynecol 2004; 47 (01) 248-262
• 2 Felder L, McCurdy R, Berghella V. External cephalic version of the non-cephalic presenting twin: a systematic review. J Matern Fetal Neonatal Med 2022; 35 (09) 1712-1718
• 3 Aviram A, Barrett JFR, Melamed N, Mei-Dan E. Mode of delivery in multiple pregnancies. Am J Obstet Gynecol MFM 2022; 4 (2S): 100470
• 4 Barrett JFR, Hannah ME, Hutton EK. et al; Twin Birth Study Collaborative Group. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med 2013; 369 (14) 1295-1305
• 5 Schmitz T, Korb D, Azria E. et al; JUmeaux MODe d'Accouchement (JUMODA) Study Group and the Groupe de Recherche en Obstétrique et Gynécologie (GROG). Perinatal outcome after planned vaginal delivery in monochorionic compared with dichorionic twin pregnancy. Ultrasound Obstet Gynecol 2021; 57 (04) 592-599
• 6 Zafarmand MH, Goossens SMTA, Tajik P. et al; Twin Birth Study Collaborative Group. Planned cesarean or planned vaginal delivery for twins: secondary analysis of randomized controlled trial. Ultrasound Obstet Gynecol 2021; 57 (04) 582-591
• 7 Stein W, Misselwitz B, Schmidt S. Twin-to-twin delivery time interval: influencing factors and effect on short-term outcome of the second twin. Acta Obstet Gynecol Scand 2008; 87 (03) 346-353
• 8 Mekki D, Mourali M, Mekaouer L, Hemila F, El Fekih C. What are the prognostic factors in the delivery of the second twin?. Tunis Med 2016; 94 (05) 349-355
• 9 Lindroos L, Elfvin A, Ladfors L, Wennerholm UB. The effect of twin-to-twin delivery time intervals on neonatal outcome for second twins. BMC Pregnancy Childbirth 2018; 18 (01) 36
• 10 Leung TY, Tam WH, Leung TN, Lok IH, Lau TK. Effect of twin-to-twin delivery interval on umbilical cord blood gas in the second twins. BJOG 2002; 109 (01) 63-67
• 11 Algeri P, Callegari C, Mastrolia SA. et al. What is the effect of intertwin delivery interval on the outcome of the second twin delivered vaginally?. J Matern Fetal Neonatal Med 2019; 32 (20) 3480-3486
• 12 Edris F, Oppenheimer L, Yang Q, Wen SW, Fung Kee Fung K, Walker M. Relationship between intertwin delivery interval and metabolic acidosis in the second twin. Am J Perinatol 2006; 23 (08) 481-485
• 13 Mok SL, Lo TK. Long term outcome of second twins born to mothers who attempted vaginal delivery a retrospective study. Eur J Obstet Gynecol Reprod Biol 2020; 254: 1-5
• 14 Rayburn WF, Lavin Jr JP, Miodovnik M, Varner MW. Multiple gestation: time interval between delivery of the first and second twins. Obstet Gynecol 1984; 63 (04) 502-506
• 15 Schneuber S, Magnet E, Haas J. et al. Twin-to-twin delivery time: neonatal outcome of the second twin. Twin Res Hum Genet 2011; 14 (06) 573-579
• 16 Hartley RS, Hitti J. Birth order and delivery interval: analysis of twin pair perinatal outcomes. J Matern Fetal Neonatal Med 2005; 17 (06) 375-380
• 17 Khalil A, Rodgers M, Baschat A. et al. ISUOG practice guidelines: role of ultrasound in twin pregnancy. Ultrasound Obstet Gynecol 2016; 47 (02) 247-263
• 18 Suh YH, Park KH, Hong JS. et al. Relationship between twin-to-twin delivery interval and umbilical artery acid-base status in the second twin. J Korean Med Sci 2007; 22 (02) 248-253
• 19 McGrail CD, Bryant DR. Intertwin time interval: how it affects the immediate neonatal outcome of the second twin. Am J Obstet Gynecol 2005; 192 (05) 1420-1422
• 20 Armson BA, O'Connell C, Persad V, Joseph KS, Young DC, Baskett TF. Determinants of perinatal mortality and serious neonatal morbidity in the second twin. Obstet Gynecol 2006; 108 (3 pt 1): 556-564
• 21 Srivastava S, Borgohain D. Neonatal outcome of second baby versus first baby in twins delivered vaginally: a comparative study. Int J Reprod Contracept Obstet Gynecol 2019; 8 (10) 3893-3897
• 22 Bjelke M, Thurn L, Oscarsson M. Prolonged passive second stage of labor in nulliparous women-prevalence and risk factors: a historical cohort study. Acta Obstet Gynecol Scand 2022; 101 (05) 499-505
• 23 Papadias K, Christopoulos P, Deligeoroglou E. et al. Maternal age and the duration of the second stage of labor. Ann N Y Acad Sci 2006; 1092: 414-417
• 24 Hutchison J, Mahdy H, Hutchison J. Stages of labor. In: StatPearls. StatPearls Publishing; 2022. Accessed November 03, 2022 at: http://www.ncbi.nlm.nih.gov/books/NBK544290/