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Table of Contents
GUEST EDITORIAL
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 1-3

Twin Gestation in Spain: Is it a New Epidemy?


Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, University Hospital La Paz, Madrid, Spain

Date of Web Publication5-Jul-2017

Correspondence Address:
J L Bartha
De la Calle M, PhD MD, Bartha JL PhD MD, Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology University Hospital La Paz, Madrid
Spain
M De la Calle
De la Calle M, PhD MD, Bartha JL PhD MD, Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology University Hospital La Paz, Madrid
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.5530/ami.2016.1.1

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How to cite this article:
De la Calle M, Bartha J L. Twin Gestation in Spain: Is it a New Epidemy?. Acta Med Int 2016;3:1-3

How to cite this URL:
De la Calle M, Bartha J L. Twin Gestation in Spain: Is it a New Epidemy?. Acta Med Int [serial online] 2016 [cited 2019 Oct 22];3:1-3. Available from: http://www.actamedicainternational.com/text.asp?2016/3/1/1/209687



Spain is the fourth country in Europe in terms of multiple twin pregnancies. We are witnessing an important increment in the number of twin pregnancies directly related to advanced maternal age and assisted reproductive techniques [Figure 1].[1],[2]
Figure 1: Evolution of the incidence of multiple gestations in University Hospital La Paz, Madrid, Spain from 1965 until 2013

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The likelihood of having an spontaneous twin pregnancy is 2%, and it increases to 25% with assisted reproductive techniques.[2] Spain is the third European country with the largest number of treatments of fertility behind France and Germany, which contributes to the increase in multiple gestations. 80,000 fertility treatments are performed according to data from the Spanish Society of Fertility (SEF). In case of in-vitro fertilization treatments, the transfer of two or more embryos resulted in 92,7% in the year 2012.[2] Therefore, Spanish patients prefer to transfer two or more embryos in order to increase the chance of success. Currently in our country the Assisted Reproduction Law does not allow transferring more than three embryos at a time, and recommends not more than two. Three embryo will only be transferred as a secondary option when the woman has not achieved pregnancy in at least two previous cycles.

Twin pregnancy is associated with higher rates of almost all potential complications of pregnancy, with the exceptions of post-term pregnancy and macrosomia. The most serious risk is spontaneous preterm delivery, which plays a major role in the increased perinatal mortality and both short-term and long-term morbidity observed in these infants.[3],[4] The risk of spontaneous preterm delivery increases in twin pregnancies, due to uterine distension. In our country births occur in 15% of the times before week 34, and 60% before week 37. Prematurity below 37 weeks in twin pregnancies compared to singletons is seven times higher (59.83% vs 8.59%). Extreme prematurity (less than 28 weeks of gestation) is five times higher in twin pregnancies compared to singletons (3.77 vs 0,77). Around 30% of the preterm children admitted in the neonatal care unit are from twin pregnancies. These premature newborns have a high risk of suffering poor neonatal outcomes such as respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular haemorrhage, periventricular leucomalacia and necrotizing enterocolitis. In our practice, we believe that the best strategy to prevent preterm birth in twin pregnancies is the measurement of the cervical length by transvaginal ultrasound between week 20 to week 34. As a protocol for prevention, we use a cervical pessary, when the cervical length is less than 25mm. It will stay in place up to 36 weeks of gestation or until delivery if needed. In our five years's experience, cervical pessary decreases the incidence of preterm birth and its concomitant poor neonatal outcomes in multiple twin gestations.[5],[6] Our hospital allows the use of vaginal progesterone but we do not use this as the first option in twin pregnancies. According to the literature, vaginal progesterone is not useful in twins, but there is an added value in high-risk twin pregnancies, where there is uncertainty in short cervix history.[5],[6],[7] Prevention of preterm birth in twin gestations is therefore a major goal of obstetric care in our hospital. Tocolysis and corticosteroids in case of threatened preterm birth are carried out as usual in our hospital.

Ultrasound examination is the most safe and reliable method for an acute diagnosis and continuous surveillance of twin pregnancies. Early diagnosis with accurate dating, determination of chorionicity, screening for chromosomal and placental evaluation should be completed in the first half of gestation. From the beginning of the pregnancy is mandatory to determine the amniocity and the chorionicity of a twin pregnancy since the management of each kind of twin pregnancy is different. This is critical because monochorionic twins have a shared fetoplacental circulation, which puts them at risk for specific serious pregnancy complications, such as twin-twin transfusion syndrome, twin anemia-polycythemia sequence, selective intrauterine fetal growth restriction and single fetal demise.[3],[7],[8],[9],[10] These complications increase the risk for neurologic morbidity and perinatal mortality in monochorionic twins compared with dichorionic twins and can be lethal or associated with serious morbidity.[3],[4],[7],[8],[9],[10] In addition to the complications associated with monochorionic twins, monoamniotic twins are also at risk for cord entanglement and conjoined twins.[8] Most pregnant women in resource-rich countries as Spain undergo routine screening ultrasound examination. Prenatal ultrasound screening guidelines vary worldwide. The Spanish Society of Gynecology and Obstetrics (SEGO) recommends to perform routine ultrasound examinations every four weeks in dichorionic twin pregnancies and every two weeks in monochorionic twin pregnancies.[11] Higher rates of fetal growth restriction and congenital anomalies also contribute to adverse outcome in twin births. The Spanish Society of Gynecology and Obstetrics (SEGO) recommends routine fetal growth surveillance for twins with complicated anomalies, cervical shortening, growth disturbances or amniotic fluid abnormalities.

Maternal risks and complications increase in twin pregnancies. Although women carrying twins are at higher risk for some adverse outcomes than women carrying singletons, chorionicity does not appear to impact this risk in most studies.[12] Maternal complications observed more often in women with multiple gestation include pulmonary edema, gestational hypertension, preeclampsia, gestational diabetes, pruritic urticarial papules and plaques of pregnancy (PUPPP), acute fatty liver, intrahepatic cholestasis of pregnancy and thrombosis.[13] Women carrying twins have a 20 percent higher cardiac output and 10 to 20 percent higher increase in plasma volume than women with singleton pregnancy. This increases the risk of pulmonary edema.[14] Gestational hypertension and preeclampsia are more common in women carrying twins. An early severe preeclampsia and HELLP syndrome (Hemolysis, Elevated Liver enzymes and Low Platelets) tend to occur more frequently in multiple gestations.[15] The incidence of gestational diabetes increases in twin pregnancies. Nevertheless the management of gestational diabetes is similar to singleton pregnancy.

We agree with expert consensus guidelines for timing of delivery of twin gestations. For normal uncomplicated dichorionic/diamniotic twin pregnancies, we suggest elective delivery between 38 and 39 weeks of gestation. For normal uncomplicated monochorionic/diamniotic twin pregnancies, we suggest elective delivery between 36 and 37 weeks of gestation. Monochorionic/diamniotic twin pregnancies with twin-twin transfusion syndrome are delivered earlier even in cases of successful intrauterine treatment. For monochorionic/monoamniotic twin pregnancies we suggest elective delivery at 32 weeks of gestation because of the high rate of perinatal mortality described in these pregnancies in spite of intensive fetal surveillance, (30 to 70%), which is most probably due to cord entanglement.[16],[17],[18]

Presentation and amniocity determines the route of delivery in twin pregnancies. In our hospital for twins with vertex/vertex and vertex/nonvertex presentation vaginal delivery is the elective route. In twin pregnancies with the first twin in cephalic presentation a planned cesarean delivery has not demonstrated to improve neonatal outcome as compared with planned vaginal delivery.[19] Cesarean is the method of use to deliver monochorionic/monoamniotic twins.

Multiple twin gestations carry significantly higher risks for both the mother and fetuses[20] leading for recommendations for specialized antenatal care for multiple pregnancies.[20],[21] In the year 2007, we created in our hospital a specialized Unit for the antenatal care for women with twin pregnancies. We get to see about 50 twin pregnancies every week in the office and deliver more than 200 twin births per year. It is more than 4% of all the deliveries we have at our hospital. We think that a specialized Twins Clinic can lead to reduce maternal inpatient stay due to fetal or maternal complications, prematurity and cesarean section rates, with a reduction in maternal and neonatal morbidities. Other hospitals have already implemented the model of a twin care clinic.[20],[21]



 
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Adegbite AL, Castille S, Ward S, Bajoria R. Neuromorbidity in preterm twins in relation to chorionicity and discordant birth weight. Am J Obstet Gynecol 2004; 190:156.  Back to cited text no. 3
    
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Fumagalli M, Schiavolin P, Bassi L, Groppo M, Uccella S, De Carli A et al. The impact of Twin Birth on Early Neonatal Outcomes. Am J Perinatol 2015: Aug 21.  Back to cited text no. 4
    
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Hegeman M, Bekedam D, Bloemenkamp K, Kwee A, Paptsonis D, van der Post J et al. Pessaries in multiple pregnancy as a prevention of preterm Barth: the Pro Twin Trial. BMC Pregnancy and Childbirth 2009; 9: 1–5.  Back to cited text no. 5
    
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Brizot ML, Hernández W, Liao AW, Bittar RE, Francisco RP, Krebs VL, Zugaib M. Vaginal progesteron for the prevention of preterm birth in twin gestations: a randomized placebo-controlled double-blind study. Am J Obstet Gynecol 2015; 213: 82.e1–9.  Back to cited text no. 7
    
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Arrieta S, De la Calle M, Omeñaca F, González A. Complicaciones fetales en la gestaciones gemelares moncoriales biamnióticas: estudio de 94 casos. Rev Chil Ginecol 2012; 77(5): 347–54.  Back to cited text no. 8
    
9.
Acosta-Rojas R, Becker J, Munoz-Abellana B et al. Twin chorionicity and the risk of adverse perinatal outcome. Int J Gynecol Obstet 2007; 96: 98.  Back to cited text no. 9
    
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Simpson LL. What you need to know when managing twins: 10 key Facuss. Obstet Gyencol Clin North Am 2015; 42: 225–39.  Back to cited text no. 10
    
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Carter EB, Bishop KC, Goetzinger KR. The impact f chorionicity on maternal pregnancy outcomes. Am J Obstet Gyencol 2015; 31: 1120.  Back to cited text no. 12
    
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Sibai BM, Hauth J, Caritis S. Hypertension disorders in twin versus Singleton gestations. National Institute of Child Health and Human Development network of Maternal-Fetal Medicine Units. Am J Obstet Gynecol 2000; 182: 938.  Back to cited text no. 15
    
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American College of Obstetricians and gynecologists ACOG comité opinión n°560: Medically indicated late-preterm and early-terms deliberéis. Obstet Gynecol 2013; 121: 908.  Back to cited text no. 16
    
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Emery SP, Bahtivar MO, Dashe JS. The North American Fetal Therapy Network Consensus Statement: prenatal Management of uncomplicated monochorionic gestations. Obstet Gynecol 2015; 125: 1236.  Back to cited text no. 17
    
18.
Beasley E, Megerian G, Gerson A, Roberts NS. Monoamniotic twins: case series and proposal for antenatal management. Obstet Gynecol 1999; 93:130.  Back to cited text no. 18
    
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Barret JF, Hannah ME, Hutton EK et al. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl j Med 2013; 369. 1295.  Back to cited text no. 19
    
20.
Henry A, Lees N, Bein KJ, Hall B, Lim V, Chen KQ et al. Pregnancy outcomes before and after institution of a specialised twin clinic: a retrospective cohort study. BMC Pregnancy Childbirth 2015, 11; 15(1): 217  Back to cited text no. 20
    
21.
Dodd JM, Crowther CA. Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes. Cochrane Database Syst Rev 2012;15:8  Back to cited text no. 21
    


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