Multiple Pregnancy: Epidemiology and Association with Maternal and Perinatal Morbidity

Santana, Danielly Scaranello; Surita, Fernanda Garanhani; Cecatti, José Guilherme

doi:10.1055/s-0038-1668117

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Review Article • Rev. Bras. Ginecol. Obstet. 40 (09) • Sept 2018 • https://doi.org/10.1055/s-0038-1668117 copy

Multiple Pregnancy: Epidemiology and Association with Maternal and Perinatal Morbidity

Gestação múltipla: epidemiologia e associação com morbidade materna e perinatal

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Twin pregnancy accounts for 2 to 4% of total births, with a prevalence ranging from 0.9 to 2.4% in Brazil. It is associated with worse maternal and perinatal outcomes. Many conditions, such as severe maternal morbidity (SMM) (potentially life-threatening conditions and maternal near-miss) and neonatal near-miss (NNM) still have not been properly investigated in the literature. The difficulty in determining the conditions associated with twin pregnancy probably lies in its relatively low occurrence and the need for larger population studies. The use of the whole population and of databases from large multicenter studies, therefore, may provide unprecedented results. Since it is a rare condition, it ismore easily evaluated using vital statistics from birth e-registries. Therefore, we have performed a literature review to identify the characteristics of twin pregnancy in Brazil and worldwide. Twin pregnancy has consistently been associated with SMM, maternal near-miss (MNM) and perinatal morbidity, with still worse results for the second twin, possibly due to some characteristics of the delivery, including safety and availability of appropriate obstetric care to women at a high risk of perinatal complications.

Keywords:
multiple pregnancies; maternal morbidity; perinatal morbidity; high-risk pregnancy

Neonatal near-miss: at least one of these criteria
Pragmatic diagnostic criteria
Birthweight < 1,750 g
Apgar score < 7 at the 5^th minute
Gestational age < 33 weeks
Management criteria
Use of intravenous antibiotics
Nasal CPAP
Any intubation in the first 7 days
Use of phototherapy in the first 24 hours
Cardiopulmonary resuscitation
Use of any vasoactive drug
Use of anticonvulsants
Use of surfactant
Transfusion of blood derivatives
Use of corticosteroid for treatment of refractory hypoglycemia
Any surgical procedure

Potentially life-threatening conditions
Hemorrhagic disorders	Hypertensive disorders	Other systemic disorders	Severe management indicators
Abruptio placentae Placenta accreta/increta/percreta Ectopic pregnancy Postpartum hemorrhage Ruptured uterus	Severe preeclampsia Eclampsia Severe Hypertension Hypertensive encephalopathy HELLP syndrome	Endometritis Pulmonary edema Respiratory failure Seizures Sepsis Shock Thrombocytopenia < 100,000 Thyroid crisis	Blood transfusion Central venous access Hysterectomy ICU admission Prolonged hospital stay (7 days) No anesthetic intubation Return to operating room Surgical intervention
Maternal near-miss: women who almost die, but survive a complication during pregnancy or childbirth within 42 days after birth
Clinical criteria	Laboratory-based criteria		Management based criteria
Acute cyanosis Gasping Respiratory rate > 40 or < 6/min Shock Oliguria non-responsive to fluids or diuretics Clotting failure Loss of consciousness lasting ≥12 hours Loss of consciousness and absence of pulse/heart beat Stroke Uncontrollable fit/total paralysis Jaundice in the presence of preeclampsia	Oxygen saturation < 90% for ≥60 minutes PaO₂/FiO₂< 200 mm Hg Creatinine ≥ 300 µmol/l or ≥ 3.5 mg/dl Bilirubin > 100µmol/l or 6.0 mg/dl pH < 7.1 Lactate > 5 Acute thrombocytopenia (< 50,000 platelets) Loss of consciousness and the presence of glucose and ketoacidosis in urine		Use of continuous vasoactive drugs Hysterectomy following infection or hemorrhage Transfusion of ≥5 red cell units Intubation and ventilation for ≥60 minutes not related to anesthesia Dialysis for acute renal failure Cardio-pulmonary resuscitation
Severe maternal outcome: refer to all cases of maternal near miss and maternal death
Maternal death: death of a woman while pregnant or within 42 days of the termination of the pregnancy

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E-mail: editorial.office@febrasgo.org.br

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[1] Address for correspondence
José Guilherme Cecatti, PhD, Departamento de Tocoginecologia, Faculdade de Ciências Médicas, Universidade de Campinas, Rua Tessália Vieira de Camargo, 126, 13083-887, Cidade Universitária, Campinas, SP, Brazil (e-mail: cecatti@unicamp.br).