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9 - Management of preterm labour with specific complications

Published online by Cambridge University Press:  07 August 2009

By
Mark Kilby  and
David Somerset
Edited by
Jane Norman  and
Ian Greer
Mark Kilby
Affiliation:
Birmingham Women's Hospital
David Somerset
Affiliation:
Birmingham Women's Hospital
Jane Norman
Affiliation:
University of Glasgow
Ian Greer
Affiliation:
University of Glasgow
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Summary

Multiple pregnancy

Aetiology and incidence

Dizygotic twinning arises when two separate ova are fertilised and implanted. This results in non-identical twins with separate amniotic sacs, chorions and placentae (although the placental masses may fuse together). Monozygotic twinning arises when a single embryo splits to yield genetically identical twins. Depending on the timing of division relative to conception, it may result in diamniotic, dichorionic pregnancy (~33%), a diamniotic, monochorionic pregnancy (~66%), a monoamniotic, monochorionic pregnancy (~1%) or conjoined twins (rare). Chorionicity may be accurately determined by ultrasound at 11–14 weeks' gestation, but becomes more difficult thereafter. The incidence of monozygotic twinning is relatively stable worldwide at around 3.5 per 1000 births, whilst the incidence of dizygotic twining varies with race and maternal age (~8.5 per 1000 births in Europe and North America) (Little and Thompson 1988). Dizygotic twinning may also result from assisted conception techniques, leading to a higher incidence in some centres. For the UK as a whole, the incidence of multiple births has increased from 10.4 per 1000 maternities in 1985 to 14.4 per 1000 in 1997, with higher-order pregnancies tripling from 0.14 to 0.45 per 1000, reflecting the increasing use of assisted conception techniques (Taylor and Fisk 2000).

Preterm delivery is considered the most important complication of multiple pregnancy and it is responsible for the majority of the increased perinatal morbidity and mortality. The Scottish Twins Study (Patel et al. 1984) reported delivery before 37 completed weeks in 44% of twins (vs. 6% of singletons), and delivery before 32 completed weeks in 10%.

Type
Chapter
Information
Preterm Labour
Managing Risk in Clinical Practice
 , pp. 210 - 234
Publisher: Cambridge University Press
Print publication year: 2005

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References

Anumba, D. O. and Robson, S. C. (1999) Management of pre-eclampsia and haemolysis, elevated liver enzymes, and low platelets syndrome. Curr. Opin. Obstet. Gynecol. 11, 149–56.CrossRefGoogle ScholarPubMed
Badawi, N., Kurinczuk, J. J., Keogh, J. M.et al. (1998) Antepartum risk factors for newborn encephalopathy: the Western Australian case-control study. BMJ 317, 1554–8CrossRefGoogle ScholarPubMed
Bajoria, R., Wee, L. Y., Anwar, S. and Ward, S. (1999) Outcome of twin pregnancies complicated by single intrauterine death in relation to vascular anatomy of the monochorionic placenta. Hum. Reprod. 14, 2124–30.CrossRefGoogle ScholarPubMed
Barrett, J. M., Staggs, S. M., Hooydonk, J. E.et al. (1982) The effect of type of delivery upon neonatal outcome in premature twins. Am. J. Obstet. Gynecol. 143, 360–7.CrossRefGoogle ScholarPubMed
Bell, D., Johansson, D., McLean, F. H. and Usher, R. H. (1986) Birth asphyxia, trauma, and mortality in twins: has Cesarean section improved outcome?Am. J. Obstet. Gynecol. 154, 235–9.CrossRefGoogle ScholarPubMed
Bennett, C. C., Lal, M. K., Field, D. J. and Wilkinson, A. R. (2002) Maternal morbidity and pregnancy outcome in a cohort of mothers transferred out of perinatal centres during a national census. BJOG 109, 663–6.CrossRefGoogle Scholar
Bobrow, C., Holmes, R. and Soothill, P. W. (1998) Aetiology of small for gestational age fetuses. In Studd, J., ed. Progress in Obstetrics and Gynaecology 13. Edinburgh: Churchill Livingstone, pp. 113–26.Google Scholar
Boylan, P. C., and Parisi, V. M. (1994) Fetal acid-base balance. In Creasy, R. K. and Resnik, R., eds., Maternal Fetal Medicine. Philadelphia: W. B. Saunders, pp. 349–58.Google Scholar
Brocklehurst, P., Gates, S., McKenzie-McHarg, K., Alfirevic, Z. and Chamberlain, G. (1999) Are we prescribing multiple courses of antenatal corticosteroids? A survey of practice in the UK. BJOG 106, 977–9.CrossRefGoogle ScholarPubMed
Brown, M. A., Lindeheimer, M. D., Suite, M., Assche, A. and Moutquin, J-M. (2001) The classification and diagnosis of hypertensive disorders of pregnancy: statement from the International Society for the Study of Hypertension in Pregnancy (ISSHP). Hypertens. Pregnancy 20, ix–xiv.CrossRefGoogle Scholar
Caspi, E., Ronen, J., Schreyer, P. and Goldberg, M. D. (1976) The outcome of pregnancy after gonadotrophin therapy. BJOG 83, 967–73.CrossRefGoogle ScholarPubMed
Chang, T. C., Robson, S. C., Spencer, J. A. and Gallivan, S. (1993) Identification of fetal growth retardation: comparison of Doppler waveform indices and serial ultrasound measurements of abdominal circumference and fetal weight. Obstet. Gynecol. 82, 230–6.Google ScholarPubMed
Collins, M. S. and Bley, J. A. (1990) Seventy-one quadruplet pregnancies: management and outcome. Am. J. Obstet. Gynecol. 162, 1384–91.CrossRefGoogle ScholarPubMed
Confidential Enquiry into Stillbirths and Deaths in Infancy. (1995) Annual report for 1993. London: Dept. of Health.
Crowley, P., (2000) Prophylactic corticosteroids for preterm birth. Cochrane Database Syst. Rev. 2, CD000065.
Crowther, C. A. and Hamilton, R. A. (1989) Triplet pregnancy: a 10-year review of 105 cases at Harare Maternity Hospital, Zimbabwe. Acta Genet. Med. Gemellol. (Roma) 38, 271–8.CrossRefGoogle Scholar
Crowther, C. A., (2001) Hospitalisation and bed rest for multiple pregnancy. Cochrane Database Syst. Rev. 1, CD000110.CrossRef
Crowther, C. A., Verkuyl, D. A., Ashworth, M. F., Bannerman, C. and Ashurst, H. M. (1991) The effects of hospitalization for bed rest on duration of gestation, fetal growth and neonatal morbidity in triplet pregnancy. Acta Genet. Med. Gemellol. (Roma) 40, 63–8.CrossRefGoogle ScholarPubMed
Davison, L., Easterling, T. R., Jackson, J. C. and Benedetti, T. J. (1992) Breech extraction of low-birthweight second twins: can cesarean section be justified?Am. J. Obstet. Gynecol. 166, 497–502.CrossRefGoogle ScholarPubMed
Dommergues, M., Mahieu-Caputo, D., Mandelbrot, L.et al.(1995) Delivery of uncomplicated triplet pregnancies: is the vaginal route safer? A case-control study. Am. J. Obstet. Gynecol. 172, 513–17.CrossRefGoogle ScholarPubMed
Doyle, L. W., Hughes, C. D., Guaran, R. L., Quinn, M. A. and Kitchen, W. H. (1988) Mode of delivery of preterm twins. Aust. N. Z. J. Obstet. Gynaecol. 28, 25–8.CrossRefGoogle ScholarPubMed
Draper, E. S., Manktelow, B., Field, D. J. and James, D. (2003) Tables for predicting survival for preterm births are updated. BMJ 327, 872.CrossRefGoogle ScholarPubMed
Dyson, D. C., Crites, Y. M., Ray, D. A. and Armstrong, M. A. (1991) Prevention of preterm birth in high-risk patients: the role of education and provider contact versus home uterine monitoring. Am. J. Obstet. Gynecol. 164, 756–62.CrossRefGoogle ScholarPubMed
Dyson, D. C., Danbe, K. H., Bamber, J. A. (1998) Monitoring women at risk for preterm labour. N. Engl. J. Med. 338, 15–19.CrossRefGoogle Scholar
Elliott, J. P., O'Keeffe, D. F., Greenberg, P. and Freeman, R. K. (1979) Pulmonary edema associated with magnesium sulfate and betamethasone administration. Am. J. Obstet. Gynecol. 134, 717–19.CrossRefGoogle ScholarPubMed
Fabre, E., Gonzalez de Aguero, R., Agustin, J. L., Perez-Hiraldo, M. P. and Bescos, J. L. (1988) Perinatal mortality in twin pregnancy: an analysis of birthweight-specific mortality rates and adjusted mortality rates for birthweight distributions. J. Perinat. Med. 16, 85–91.CrossRefGoogle Scholar
Gardner, M. O., Goldenberg, R. L., Cliver, S. P.et al.(1995) The origin and outcome of preterm twin pregnancies. Obstet. Gynecol. 85, 553–7.CrossRefGoogle ScholarPubMed
Goldenberg, R. L., Iams, J. D., Miodovnik, M.et al. (1996) The preterm prediction study: risk factors in twin gestations. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Am. J. Obstet. Gynecol. 175, 1047–53.CrossRefGoogle ScholarPubMed
Grant, A., (1989) Cervical cerclage to prolong pregnancy. In Chalmers, I., Enkin, M. and Keirse, M. J. N. C., eds., Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, pp. 633–45.Google Scholar
Green, P. M. and Wilkinshaw, S. (2002) Management of breech deliveries. The Obstetrician and Gynaecologist 4, 87–91.CrossRefGoogle Scholar
Hannah, M. E., Hannah, W. J., Hewson, S. A. (2000) Planned Caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 356, 1375–83.CrossRefGoogle ScholarPubMed
Heikkila, A., Makkonen, N., Heinonen, S. and Kirkinen, P. (2001) Elevated maternal serum hCG in the second trimester increases prematurity rate and need for neonatal intensive care in primiparous preeclamptic pregnancies. Hypertens. Pregnancy 20, 99–106.CrossRefGoogle ScholarPubMed
Higgins, J. R. and Swiet, M. (2001) Blood-pressure measurement and classification in pregnancy. Lancet 357, 131–5.CrossRefGoogle ScholarPubMed
Howie, P. W., (1995) The coagulation and fibrinolytic systems, and their disorders in obstetrics and gynaecology. In Whitfield, C. R., ed., Dewhurst's Textbook of Obstetrics and Gynaecology for Postgraduates. Oxford: Blackwell Science Ltd., pp. 510–26.Google Scholar
Isler, C. M., Barrilleaux, P. S., Magann, E. F., Bass, J. D. and Martin, J. N. Jr. (2001) A prospective, randomized trial comparing the efficacy of dexamethasone and betamethasone for the treatment of antepartum HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Am. J. Obstet. Gynecol. 184, 1332–7.CrossRefGoogle ScholarPubMed
Keirse, M. J. N. C., Grant, A. and King, J. F. (1989) Preterm labour. In Chalmers, I., Enxkin, M. and Keirse, M. J. N. C., eds., Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, pp. 694–749.Google Scholar
Kiely, J. L. (1990) The epidemiology of perinatal mortality in multiple births. Bull. N. Y. Acad. Med. 66, 618–37.Google ScholarPubMed
Krebs, C., Macara, L. M., Leiser, R.et al.(1996) Intrauterine growth restriction with absent end-diastolic flow velocity in the umbilical artery is associated with maldevelopment of the placental terminal villous tree. Am. J. Obstet. Gynecol. 175, 1534–42.CrossRefGoogle ScholarPubMed
Lin, C. C.Su, S. J. and River, L. P. (1991) Comparison of associated high-risk factors and perinatal outcome between symmetric and asymmetric fetal intrauterine growth retardation. Am. J. Obstet. Gynecol. 164, 1535–41.CrossRefGoogle ScholarPubMed
Little, J. and Thompson, B. (1988) Descriptive epidemiology. In MacGillivray, I., Campbell, D. M. and Thompson, B., eds., Twinning and Twins. Chichester: John Wiley, pp. 37–66.Google Scholar
Long, P. A., Abell, D. A. and Beischer, N. A. (1980) Fetal growth retardation and pre-eclampsia. BJOG 87, 13–18.CrossRefGoogle ScholarPubMed
Low, J. A., Galbraith, R. S., Muir, D. W.et al. (1992) Mortality and morbidity after intrapartum asphyxia in the preterm fetus. Obstet. Gynecol. 80, 57–61.Google ScholarPubMed
Luke, B., Brown, M. B., Misiunas, R.et al. (2003) Specialized prenatal care and maternal and infant outcomes in twin pregnancy. Am. J. Obstet. Gynecol. 189, 934–8.CrossRefGoogle ScholarPubMed
Luthy, D. A., Shy, K. K., Belle, G.et al. (1987) A randomized trial of electronic fetal monitoring in preterm labour. Obstet. Gynecol. 69, 687–95.Google Scholar
Macones, G. A., Sehdev, H. M., Berlin, M., Morgan, M. A. and Berlin, J. A. (1997) Evidence for magnesium sulfate as a tocolytic agent. Obstet. Gynecol. Surv. 52, 652–8.CrossRefGoogle ScholarPubMed
Moodley, J., Koranteng, S. A. and Rout, C. (1993) Expectant management of early onset of severe pre-eclampsia in Durban. S. Afr. Med. J. 83, 584–7.Google ScholarPubMed
Morales, W. J., O'Brien, W. F., Knuppel, R. A., Gaylord, S. and Hayes, P. (1989) The effect of mode of delivery on the risk of intraventricular hemorrhage in nondiscordant twin gestations under 1500 g. Obstet Gynecol. 73, 107–10.Google ScholarPubMed
Mordel, N., Zajicek, G., Benshushan, A.et al. (1993) Elective suture of uterine cervix in triplets. Am. J. Perinatol. 10, 14–16.CrossRefGoogle ScholarPubMed
Murphy, D. J., Caukwell, S., Joels, L. A. and Wardle, P. (2002) Cohort study of the neonatal outcome of twin pregnancies that were treated with prophylactic or rescue antenatal corticosteroids. Am. J. Obstet. Gynecol. 187, 483–8.CrossRefGoogle ScholarPubMed
Neilson, J. P., (2001) Hypertensive diseases of pregnancy. In Lewis, G., ed., Why Mothers die 1997–1999. The Fifth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press, pp. 76–93.Google Scholar
Newman, R. B., Krombach, R. S., Myers, M. C. and McGee, D. L. (2002) Effect of cerclage on obstetrical outcome in twin gestations with a shortened cervical length. Am. J. Obstet. Gynecol. 186, 634–40.CrossRefGoogle ScholarPubMed
Nicolaides, K. H., Economides, D. L. and Soothill, P. W. (1989) Blood gases, pH, and lactate in appropriate- and small-for-gestational- age fetuses. Am. J. Obstet. Gynecol. 161, 996–1001.CrossRefGoogle ScholarPubMed
Nyberg, D. A., Filly, R. A., Golbus, M. S. and Stephens, J. D. (1984) Entangled umbilical cords: a sign of monoamniotic twins. J. Ultrasound Med. 3, 29–32.CrossRefGoogle ScholarPubMed
O'Connor, M. C., Murphy, H. and Dalrymple, I. J. (1979) Double blind trial of ritodrine and placebo in twin pregnancy. BJOG 86, 706–9.CrossRefGoogle ScholarPubMed
Oconnor, R. A., and Hiadzi, E. (1996) The intrapartum management of twin pregnancies. In Studd, J., ed., Progress in Obstetrics and Gynaecology, vol. 12. Edinburgh: Churchill Livingstone, pp. 121–34.Google Scholar
Odendaal, H. J., Pattinson, R. C. and du Toit, R. (1987) Fetal and neonatal outcome in patients with severe pre-eclampsia before 34 weeks. S. Afr. Med. J. 71, 555–8.Google ScholarPubMed
Odendaal, H. J., Pattinson, R. C., Bam, R., Grove, D. and Kotze, T. J. (1990) Aggressive or expectant management for patients with severe preeclampsia between 28–34 weeks' gestation: a randomized controlled trial. Obstet. Gynecol. 76, 1070–5.Google ScholarPubMed
Paruk, F. and Moodley, J. (2000) Treatment of severe pre-eclampsia/eclampsia syndrome. In Studd, J., ed., Progress in Obstetrics and Gynaecology 14. Edinburgh: Churchill Livingstone, pp. 102–19.Google Scholar
Patel, N., Barrie, W., Campbell, D. et al. (1984) Scottish twin study; preliminary report. Glasgow, University of Glasgow.
Peek, M. J., McCarthy, A., Kyle, P., Sepulveda, W. and Fisk, N. M. (1997) Medical amnioreduction with sulindac to reduce cord complications in monoamniotic twins. Am. J. Obstet. Gynecol. 176, 334–6.CrossRefGoogle ScholarPubMed
Rasanen, J. and Jouppila, P. (1995) Fetal cardiac function and ductus arteriosus during indomethacin and sulindac therapy for threatened preterm labour: a randomized study. Am. J. Obstet. Gynecol. 173, 20–5.CrossRefGoogle ScholarPubMed
Royal College of Obstetricians and Gynaecologists (RCOG) (2001) RCOG Guideline No 20: The management of breech presentation. London: RCOG.
Royal College of Obstetricians and Gynaecologists (RCOG) Clinical Effectiveness Support Unit. (2001) The use of electronic fetal monitoring: the use and interpretation of cardiotocography in intrapartum fetal surveillance. London: RCOG Press.
Rydhstrom, H. (1990) Prognosis for twins with birthweight less than 1500 gm: the impact of cesarean section in relation to fetal presentation. Am. J. Obstet. Gynecol. 163, 528–33.Google ScholarPubMed
Seki, H., Kuromaki, K., Takeda, S. and Kinoshita, K. (2000) Prophylactic cervical cerclage for the prevention of early premature delivery in nulliparous women with twin pregnancies. J. Obstet. Gynaecol. Res. 26, 151–2.CrossRefGoogle ScholarPubMed
Sheppard, B. L. and Bonnar, J. (1981) An ultrastructural study of utero-placental spiral arteries in hypertensive and normotensive pregnancy and fetal growth retardation. BJOG 88, 695–705.CrossRefGoogle ScholarPubMed
Shy, K. K., Luthy, D. A., Bennett, F. C.et al. (1990) Effects of electronic fetal-heart-rate monitoring, as compared with periodic auscultation, on the neurologic development of premature infants. N. Engl. J. Med. 322, 588–93.CrossRefGoogle ScholarPubMed
Sibai, B. M., Taslimi, M., Abdella, T. N.et al. (1985) Maternal and perinatal outcome of conservative management of severe pre-eclampsia in midtrimester. Am. J. Obstet. Gynecol. 152, 32–7.CrossRefGoogle ScholarPubMed
Smith, G. C., Pell, J. P. and Dobbie, R. (2002) Birth order, gestational age, and risk of delivery related perinatal death in twins: retrospective cohort study. BMJ 325, 1004–9.CrossRefGoogle ScholarPubMed
Strauss, A., Heer, I. M., Janssen, U.et al. (2002) Routine cervical cerclage in higher-order multiple gestation - does it prolong the pregnancy?Twin Res. 5, 67–70.CrossRefGoogle ScholarPubMed
Sutton, D. M. C., Hauser, R., Kulapong, P. and Bachmann, F. (1971) Intravascular coagulation in abruptio placentae. Am. J. Obstet. Gynecol. 109, 604–14.CrossRefGoogle ScholarPubMed
Taylor, M. J. O. and Fisk, N. M. (2000) Multiple pregnancy. The Obstetrician and Gynaecologist 2, 4–10.CrossRefGoogle Scholar
The Chums Group. (1995) A multicenter randomized controlled trial of home uterine monitoring: active versus sham device. The Collaborative Home Uterine Monitoring Study (CHUMS) Group. Am. J. Obstet. Gynecol. 173, 1120–7.CrossRef
The Collaborative Eclampsia Trial Group. (1995) Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet 345, 1455–63.CrossRef
The GRIT Study Group. (2003) A randomised trial of timed delivery for the compromised preterm fetus: short term outcomes and Bayesian interpretation. BJOG 110, 27–32.CrossRef
The Magpie Trial Collaboration Group. (2002) Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 359, 1877–90.CrossRef
Tompkins, M. J. and Thiagarajah, S. (1999) HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome: the benefit of corticosteroids. Am. J. Obstet. Gynecol. 181, 304–9.CrossRefGoogle ScholarPubMed
Vintzileos, A. M., Ananth, C. V., Smulian, J. C. and Scorza, W. E. (2003) The impact of prenatal care on preterm births among twin gestations in the United States, 1989–2000. Am. J. Obstet. Gynecol. 189, 818–23.CrossRefGoogle ScholarPubMed
Walker, J. J., (1998) Current thoughts on the pathophysiology of pre-eclampsia/eclampsia. In Studd, J., ed., Progress in Obstetrics and Gynaecology 13. Edinburgh: Churchill Livingstone, pp. 177–90.Google Scholar
Wapner, R., Cotton, D., Artal, R., Librizzi, R. and Ross, M. (1995) A randomized multicenter trial assessing a home uterine activity monitoring device used in the absence of daily nursing contact. Am. J. Obstet. Gynecol. 172, 1026–34.CrossRefGoogle ScholarPubMed
Wennerholm, U. B., Holm, B., Mattsby-Baltzer, I. (1997) Fetal fibronectin, endotoxin, bacterial vaginosis and cervical length as predictors of preterm birth and neonatal morbidity in twin pregnancies. BJOG 104, 1398–404.CrossRefGoogle ScholarPubMed
Westgren, M., Hormquist, P., Ingemarsson, I. and Svenningsen, N. (1984) Intrapartum fetal acidosis in preterm infants: fetal monitoring and long-term morbidity. Obstet. Gynecol. 63, 355–9.Google ScholarPubMed
Yang, J. H., Kuhlman, K., Daly, S. and Berghella, V. (2000) Prediction of preterm birth by second trimester cervical sonography in twin pregnancies. Ultrasound Obstet. Gynecol. 15, 288–91.CrossRefGoogle ScholarPubMed
Yeast, J. D., Halberstadt, C., Meyer, B. A., Cohen, G. R. and Thorp, J. A. (1993) The risk of pulmonary edema and colloid osmotic pressure changes during magnesium sulfate infusion. Am. J. Obstet. Gynecol. 169, 1566–71.CrossRefGoogle ScholarPubMed
Zweifel, P., (1916) Eclampsie. In Doderlein, A., ed., Handbuch der Gerburtshilfe, II. Wiesbarden: Bergman, pp. 672–6.Google Scholar

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