In 2014,
ACOG technical bulletin states "Women with
monoamniotic twin gestations should undergo cesarean delivery to avoid an
umbilical cord complication of the nonpresenting twin at the time of the
initial twin's delivery."
New research findings from
investigators at the Cooper Medical School of Rowan University, Camden, NJ, led by Dr. Khandelwal, Professor of
Obstetrics and Gynecology have shown that vaginal delivery is feasible in
monamniotic monochorionic (MoMo) twins who are appropriately identified.
Dr.
Khandelwal opined that while theoretical risks form the basis of current
guidelines and recommendations, the current study offers important data on
safety of vaginal deliveries as an alternative to Cesarean section. A large
study recently found that cord entanglement occurs in almost all the cases, but
it contributes very little to the neonatal morbidity and mortality.
This award-winning
paper was presented at the American College of Obstetricians and Gynecologists
(ACOG) 2016 annual meeting at Washington D.C. The study was also published in Obstet Gynecol. 2016 May; (127 Suppl
1:3S. doi: 10.1097/01.AOG.0000483625.92567.88.)
It was a
retrospective cohort study at two tertiary care hospitals. The researchers
reviewed data for all viable twins delivered beyond 24 weeks for the last 15
years at these centers.
Outcomes
were compared between attempted vaginal delivery and planned cesarean delivery.
A total of
29 patients with MoMo twins were included in the study, out of which 15
underwent planned Cesarean Delivery and in 14 patients’ vaginal delivery was
attempted, out of which 6 patient had Induction of labor(IOL). 10 patients had
successful vaginal deliveries of both neonates with median interval of 3
minutes between the twins; 3 had to undergo cesarean section for
non-reassuring fetal CTG tracing and one had to undergo cesarean section for 2nd of the twin.
It was also
seen that despite being nearly delivered at the same gestational age (32.7 vs
33.3 weeks) incidence of intracranial hemorrhage and respiratory complication
was much lower in vaginally delivered neonates.
Three
fetuses died before birth – one in the planned vaginal delivery group (7%) and
two in the planned cesarean delivery group (13%). In 28 of all 29 pregnancies,
entangled umbilical cords were observed at birth. Apgar at 5 minutes was 6.6 in
the vaginal delivery group and 8.3 in the cesarean group.
It was observed
that patients who had prior CD, opted out for repeat CD more often. But, the
composite maternal outcome was similar in both the groups.
Successful
vaginal delivery of both twins occurred in 71% of patients who chose to attempt
it.
“This is a small study but it does add
valuable data on the safety of vaginal delivery in [monoamniotic-monochorionic]
twins,” Dr. Khandelwal said. “Vaginal delivery can be considered a safe option
in tertiary care centers.
She further
added “ACOG guidelines are used as ‘standard of care’ by most practitioners; so
it is important that they discourage ‘expert opinion’ statements in their
guidelines and encourage evidence-based medicine.”
References:
http://www.ncbi.nlm.nih.gov/pubmed/27176162
http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Meeting
No comments:
Post a Comment