Saudi Journal for Health Sciences

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 7  |  Issue : 3  |  Page : 163--166

Appraisal of maternal outcome of twin gestation


Obinna Izuchukwu Oraekwe 
 Department of Obstetrics and Gynaecology, Federal Medical Centre, Umuahia, Abia State, Nigeria

Correspondence Address:
Dr. Obinna Izuchukwu Oraekwe
Department of Obstetrics and Gynaecology, Federal Medical Centre, Umuahia, Abia State
Nigeria

Abstract

Background: Twin gestation with its attendant complications has been on the rise worldwide. Its periodic evaluation is necessary to update the extent of its contribution to maternal morbidities. Objective: To determine the incidence and maternal antepartum, intrapartum, and postpartum complications associated with twin pregnancies. Materials and Methods: This was a retrospective study carried out in the Federal Medical Centre, Umuahia, Abia state, Nigeria, over a 5-year period from January 1, 2009, to December 31, 2013. During the period of study, there were 264 twin pregnancies, but only 186 folders had enough information for data analysis. Data were analyzed using WinPepi version 11.65. Statistical significance was calculated using Chi-square test with level of significance set at P < 0.05. Results: The incidence of twin pregnancy was 3.2% (32/1000 deliveries). The mean age was 29.5 ± 5 years. Most of the patients (35.5%) were aged between 25 and 29 years. Most of the patients (64.5%) were booked. Preterm delivery accounted for 30.6% of antenatal complications, while hypertensive disorders of pregnancy made up 14.5%. Majority of the patients (54.3%) had cesarean delivery, and the most common indication for cesarean delivery was malpresentation of the leading twin which accounted for 40.6% of the indications for cesarean deliveries. Anemia was the most common postpartum complication noted in 25.3% of patients and that was followed by primary postpartum hemorrhage with a rate of 10.8%. Conclusion: This study has highlighted the high incidence of twin pregnancy in our environment. It has also affirmed the significant maternal morbidities associated with this obstetric condition.



How to cite this article:
Oraekwe OI. Appraisal of maternal outcome of twin gestation.Saudi J Health Sci 2018;7:163-166


How to cite this URL:
Oraekwe OI. Appraisal of maternal outcome of twin gestation. Saudi J Health Sci [serial online] 2018 [cited 2019 Jul 20 ];7:163-166
Available from: http://www.saudijhealthsci.org/text.asp?2018/7/3/163/251591


Full Text



 Introduction



Twin gestation is a high-risk pregnancy due to the increased adverse feto-maternal events associated with it.[1] Its incidence has been on the rise over the last 30 years due to increased use of assisted reproductive technologies and delayed childbearing.[2] Twin pregnancy refers to the implantation of two fetuses within the endometrial lining of the uterus. It can either be monozygotic which results from a single fertilized ovum or dizygotic resulting from fertilization of two different ova.[3]

Predisposing factors to twin pregnancy include race, diet, heredity (family history of twinning, especially in a first-degree relative on the maternal side), increasing maternal age and parity, maternal height and weight, previous twin deliveries, and pregnancy soon after cessation of long-term oral contraceptive use.[3]

The clinical importance of twin gestation lies in its increased attendant obstetric complications, and these women have been documented to have a sixfold chance of being hospitalized for these complications compared to singleton gestation.[1] Virtually, all complications of pregnancy are increased in twin gestation, except prolonged pregnancy, fetal macrosomia, and cephalopelvic disproportion.[4] These complications include excessive vomiting, gestational diabetes mellitus, hypertension disorders of pregnancy, preterm deliveries, anemia, operative deliveries, and antepartum and postpartum hemorrhage.[5],[6]

Twin pregnancy shows a wide racial variation worldwide. It has been noted to be the lowest in Asia with a frequency of 1.3/1000 births in Japan, while the highest rate of 49/1000 births has been documented in Western Nigeria.[3] Twin gestation contributes significantly to the burden of maternal morbidity, especially in our society where the highest incidence of twin pregnancy has been noted, and this underscores the need to periodically review twin gestation so as to give up to date information to healthcare providers.

This study therefore aims to determine the incidence and maternal morbidities associated with twin gestation in the Federal Medical Centre, Umuahia.

 Materials and Methods



This was a retrospective, descriptive study carried out in Federal Medical Centre, Umuahia, Abia state, Nigeria, over a 5-year period from January 1, 2009, to December 31, 2013. The data of women with twin gestation were retrieved from patients' case notes in the medical records department. Data obtained included age, parity, ethnic group, booking status, and antenatal, intrapartum, and postpartum complications. Anemia was diagnosed when the hemoglobin concentration was <10 g/dl. The retrospective nature of this work made ethical approval not applicable. Data were analyzed using WinPepi version 11.65 (Brixton Health, London).[7] Statistical significance was calculated using Chi-square test with level of significance set at P < 0.05 at 95% confidence interval.

 Results



There were 8289 deliveries during the period of study with 264 twin pregnancies. This gave an incidence of 3.2% (32/1000 deliveries). However, only 186 folders had enough information for data analysis.

The mean age of the women was 29.5 ± 5 years. The modal age group was 25–29 years which contributed to 35.5% (66), while multiparous women accounted for 40.9% (76) of the patients. The predominant ethnic group was Igbo which made up 98.4% (183) of the patients. Booked women accounted for 64.5% (120) of the subjects [Table 1].{Table 1}

Preterm delivery accounted for 30.6% (57) of the antenatal complications, while hypertensive disorders of pregnancy were noted in 14.5% (27) as shown in [Table 2].{Table 2}

Cesarean section was the mode of delivery in 54.3% (101) of the subjects, however, only 3 (1.6%) had vacuum delivery [Figure 1]. There was no significant difference in the mode of delivery for booked women compared with unbooked (χ2 = 0.13, df = 2, P = 0.94).{Figure 1}

For those who underwent cesarean delivery, the most common indication was malpresentation of the leading twin which was documented in 40.6% (41) of the women, and this was followed by severe preeclampsia/eclampsia which accounted for 21.7% (22) as depicted in [Figure 2].{Figure 2}

Anemia was the most common postpartum complication noted in 25.3% (47) of the patients, while 10.8% (10) had primary postpartum hemorrhage [Table 3].{Table 3}

 Discussion



The incidence of twin gestation obtained in this study was 3.2% (32/1000 deliveries). This was higher than that in the United States and England,[1] as well as that obtained by Attah et al. in Northwestern Nigeria.[3] However, it was similar to that obtained by Okunade et al. in Southwestern Nigeria.[8] This high incidence is in keeping with the fact that the highest incidence of twinning occurs in Nigeria.[1],[4] The mean age of the patients in this study was 29.5 ± 5 years, while most of the women were aged between 25 and 29 years. This was comparable to the studies done by Bassey and Inimgba[4] and Pyrbot and Agarwal.[6] Even though advanced maternal age is associated with twin pregnancy,[9] this group of women is more likely to have completed their family size which may have accounted for their relatively less representation in our study. Multiparous women in this study had the highest frequency of twinning which is similar to what was noted by Singh and Trivedi[10] and Tomar et al.[11] Twinning has been known to be associated with increasing parity which tends to plateau at the seventh birth.[3] Most of the women were booked and this is in agreement with the work by other researchers,[1],[8] where most of the women studied were booked. Unlike what is obtainable in our subregion, this relatively high rate of antenatal attendance may be explained by the fact that caregivers of women with twin gestation may have appreciated that it is at a higher risk than singleton pregnancy,[12] therefore necessitating the need to seek medical attention.

Preterm delivery accounted for most of the antenatal complications, while hypertensive disorders of pregnancy were the second most common complications. This was similar to the finding by Shetty et al.[13] These complications associated with twin pregnancy result from exaggerated physiological response, overdistension of uterus, and hyperplacentosis.[14] Hypertensive disorders in pregnancy which are more common in multiple than in singleton pregnancies are likely to present early with higher risk of complications including preterm delivery.[5] Furthermore, pregnancies complicated with hypertensive disorders are generally subject to increased obstetric interventions with consequent preterm birth. Prevention of preterm delivery with its associated perinatal morbidity has been met with discouraging results. Available evidence is insufficient to support a policy of routine hospitalization for bed rest in multiple pregnancy because no reduction in the risk of preterm birth has been observed; furthermore, there is also no evidence that prophylactic cerclage improves outcome.[4],[5],[14]

The best method of delivery of twins remains controversial; however, there is an increasing trend towards cesarean section, and in most studies, 50% of the twins are delivered abdominally.[6] Similarly, majority of the patients (54.3%) in this study had cesarean delivery. In those who had cesarean delivery, the most common indication was malpresentation of the leading twin which accounted for 40.6% of the cesarean deliveries. These findings were similar to other studies in which malpresentation was the most common indication for cesarean delivery.[4],[13] The indications for cesarean delivery are similar in both the booked and unbooked women in our study as no statistical significant difference was noted between them. The choice of cesarean delivery in malpresentation of the leading twin, especially the breech/vertex combination, may be related to the rare complication of locked twins which has high perinatal morbidity and mortality when vaginal delivery is undertaken.[14] Expediting delivery in the setting of severe hypertensive disorders of pregnancy may further explain the higher rate of cesarean delivery in this group of women.

Anemia was the most common postpartum complication documented in the patients, which was similar to the findings by Pyrbot and Agarwal.[6] In addition to profound plasma volume expansion which far exceeds increased red blood cell volume resulting in physiologic anemia, twin gestations generate a great demand for elemental iron, of which sufficient quantity might not be available in many diets, especially in our resource-poor setting.[14] These physiologic mechanisms, together with primary postpartum hemorrhage which was the second most common complication in this study, may further elucidate the high rate of anemia noted in this study. Uterine overdistention, operative interventions, and pharmacologic effects of medications such as magnesium sulfate, which is commonly used in the management of preeclampsia/eclampsia, predispose these women to primary postpartum hemorrhage with subsequent anemia.

This study is limited by its hospital-based design which may have omitted uncomplicated twin pregnancies in the community. The study is also limited by its retrospective nature which may have affected data analysis due to inadequate documentation.

 Conclusion



This study has documented the high incidence of twin pregnancy in our environment. It has also underscored the significant maternal morbidities associated with this obstetric condition. Adequate health education, good antenatal coverage, and early detection of these complications may ameliorate the maternal morbidities associated with this high-risk pregnancy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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