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TIMING and MODE of DELIVERY in TWINS: the Ongoing Controversy Helena Teresinha Fernandes Simões

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TIMING and MODE of DELIVERY in TWINS: the Ongoing Controversy Helena Teresinha Fernandes Simões Universidade de Lisboa Faculdade de Medicina de Lisboa TIMING AND MODE OF DELIVERY IN TWINS: The ongoing controversy Helena Teresinha Fernandes Simões Doutoramento em Medicina Especialidade em Ginecologia e Obstetrícia 2014 Universidade de Lisboa Faculdade de Medicina de Lisboa TIMING AND MODE OF DELIVERY IN TWINS: The ongoing controversy Helena Teresinha Fernandes Simões Orientador:Professor Doutor Luís Graça Co-orientador:Professor Doutor Isaac Blickstein Doutoramento em Medicina Especialidade em Ginecologia e Obstetrícia 2014 Todas as afirmações efectuadas no presente documento são da exclusiva responsabilidade do seu autor,não cabendo qualquer responsabilidade à Faculdade de Medicina de Lisboa pelos conteúdos nele apresentados Dissertação apresentada à Faculdade de Medicina da Universidade de Lisboa, para obtenção do grau de Doutor em Medicina. A impressão desta dissertação foi aprovada pela Comissão Coordenadora do Conselho Científico da Faculdade de Medicina da Universidade de Lisboa em reunião de 18 de Março de 2014. To my parents To my sons Frederico and Guilherme To all parents of twins General Index General Index ............................................................................................................................... iii Index of Figures ............................................................................................................................. v Index of Tables ............................................................................................................................. vii Acknowledgements ....................................................................................................................... ix List of Abbreviations ...................................................................................................................... xi Resumo ........................................................................................................................................ xiii Summary ..................................................................................................................................... xiv Chapter I. Introduction .................................................................................................................. 1 Chapter II. Twin Pregnancy In Perspective .................................................................................... 7 1. Definition ........................................................................................................................... 9 2. Epidemiology ................................................................................................................... 10 3. Maternal problems of twin pregnancies ......................................................................... 17 A. Preterm delivery .......................................................................................................... 17 B. Hypertensive disorders ................................................................................................ 23 C. Gestational diabetes .................................................................................................... 24 D. Intrahepatic cholestasis ............................................................................................... 24 E. Pruritic urticarial papules and plaques of pregnancy (PUPPP Syndrome) .................. 26 F. Excess weight gain ....................................................................................................... 26 G. Other maternal problems ............................................................................................ 30 4. Fetal problems in twin pregnancies ................................................................................ 34 A. Fetal anomalies ............................................................................................................ 34 B. Discordant twin growth ............................................................................................... 37 C. Twin-twin transfusion Syndrome (TTTS)...................................................................... 39 D. The Vanishing twin syndrome ..................................................................................... 46 E. Neurological morbidity in twin neonates .................................................................... 51 5. Timing and mode of delivery ........................................................................................... 52 Chapter III. Aims .......................................................................................................................... 75 Chapter IV. Published Studies .................................................................................................... 83 Chapter V. Discussion ................................................................................................................ 111 1. Abdominal circumference ratio for the diagnosis of intertwin birth weight discordance…. ....................................................................................................................... 118 iii 2. Perinatal Outcome and Change in Body Mass Index in Mothers of Dichorionic Twins: A Longitudinal Cohort Study ..................................................................................................... 120 3. Gestational Diabetes Mellitus Complicating Twin Pregnancies. ................................... 123 4. Prospective Risk of Intrauterine Death of Monochorionic Diamniotic Twins. .............. 126 5. Induction of Labor with Misoprostol in Nulliparous Mothers of Twins. ....................... 133 6. Puerperal Complications Following Elective Cesarean Sections for Twin Pregnancies. 143 Chapter VI. Conclusion .............................................................................................................. 151 References ................................................................................................................................. 155 iv Index of Figures Figure 1 - Twin birth rate: based on maternal ethnicity and age. ............................................... 11 Figure 2 - Mean maternal age by mode of conception. .............................................................. 12 Figure 3 - Etiology of twins at Maternidade Dr. Alfredo da Costa (1994-2012) ......................... 14 Figure 4 - Twin deliveries and birth rate: United States 1980-2006 ........................................... 15 Figure 5 - Etiology of triplets at Maternidade Dr. Alfredo da Costa (1994-2012) ....................... 16 Figure 6 - Costs for Multiple Pregnancies and their Newborn (MAC-2007) ............................... 18 Figure 7 - Preterm Birth in 2006: Twins versus Singletons. ........................................................ 19 Figure 8 - Gestational age-specific mortality for twins, singletons and triplets. NICU. .............. 20 Figure 9 - Rate of spontaneous delivery before 33 weeks according to cervical length at 23 weeks of gestation. ..................................................................................................................... 21 Figure 10 - Pruritic urticarial papules and plaques of pregnancy in the abdomen (PUPP syndrome) ................................................................................................................................... 26 Figure 11 - Gestational weight gain by pre-pregnancy BMI among twins. ................................. 28 Figure 12 - Normal birth weight by gestational weight gain among twins. ................................ 29 Figure 13 - Pregnancy and delivery problems according to BMI (MAC) ..................................... 30 Figure 14 - TRAP twin (MAC) ....................................................................................................... 35 Figure 15 - Conjoined twins (United Kingdom) ........................................................................... 37 Figure 16 - Fetus-in-fetu (India) .................................................................................................. 37 Figure 17 - Survivor cerebral lesion prevalence by gestational age. ........................................... 42 Figure 18 - MC twins gestational age at delivery according to complications during pregnancy (MAC) .......................................................................................................................................... 43 Figure 19 - Laser therapy at 20 wks because of TTTS stage IV. Right lower limb injury occurred in a recipient twin first noted on US at 28 weeks’gestation. ...................................................... 45 Figure 20 - Ultrasound of a vanishing twin pregnancy ............................................................... 47 Figure 21 - Spontaneous loss rates after ART. ............................................................................ 49 Figure 22 - Maternal problems, Vanishing twins versus DC twins (MAC-2012) ......................... 50 v Figure 23 - Perinatal death rate, pair fetal death and neonatal death rate. .............................. 54 Figure 24 - Pair RDS incidence according to gestational age at delivery. ................................... 54 Figure 25 - Pair rates of long (≥5 days) hospital stays according to gestational age at delivery among twin pairs with hospital stay that were discharged home. ............................................. 55 Figure 26 - Gestational age distribution curve. ..........................................................................
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