Puerperal morbidity following repeat cesarean delivery in twin pregnancies.

OBJECTIVE: To evaluate the puerperal complications following twin deliveries. STUDY DESIGN: We conducted a population-based analysis of puerperal delivery-related complications of twins born in Slovenia for comparing three groups of births (vaginal, elective and emergent cesarean). RESULTS: A total of 1,001 elective, 1,109 emergent cesarean sections, and 2,204 vaginal twin births were evaluated. No differences were found between the complications after emergent and elective cesareans. Uterine atony was more frequent after vaginal births (OR 1.8-2.0, 95 % CI 1.1-1.2, 2.9-3.3). Vaginal births had a higher frequency of endometritis compared with elective cesarean (OR 4.1, 95 % CI 1.2, 13.6). Conversely, vaginal deliveries were less frequently associated with anemia, hematoma formation, and need for blood transfusion as compared to both modes of cesarean deliveries. CONCLUSION: No solid data exist to show a clear advantage or disadvantage in terms of puerperal complications of an elective cesarean over vaginal birth for twins.

Correlates of the trend of cesarean section rates in twin pregnancies.

OBJECTIVE: To examine the population-based trend for cesarean births in twin pregnancies for the last 13 years in Slovenia, and to find correlates for this trend. METHODS: We evaluated data from the Slovenian national perinatal information system (NPIS) of all twin pairs born at ≥24 weeks during the period 1997-2009 (n=3916 pairs). RESULTS: We noted a significant and steady increase of about 1.1% cesarean births/year, concomitant with significant increased birth rates at 34-36 weeks, but with a significant decrease over time in neonatal mortality. These trends were neither associated with any particular maternal characteristic nor with increased neonatal morbidity. CONCLUSIONS: An association exists between an increased cesarean birth rate, increased preterm births at 33-36 weeks and concomitant significantly reduced neonatal mortality in twins.

No "masculinization" effect of a male on birth weight of its female co-twin.

OBJECTIVE: To test the hypothesis that the presence of a male affects birth weight of its female co-twin. PATIENTS AND METHODS: We evaluated a large population dataset of bichorionic twins after exclusion of potential confounders and after controlling for parity and gestational age. We tested the hypotheses that males (M) are heavier than females (F) irrespective of gender mix, parity and gestational age, and the hypothesis that birth weight of twins might be influenced by the gender of the co-twin. RESULTS: There were 819 MM pairs, 777 FF pairs and 1097 MF sets, for a total of 2735 males and 2651 female twins. Male twins were heavier than female twins, irrespective of parity or gestational age; twins born to multiparas were heavier than twins born to nulliparas, except for very preterm births (≤32 weeks); males from MF pairs were heavier than males from MM pairs, but the mean birth weight of females from MF was not different from that of females from FF sets suggesting no "masculinization" effect of the male on birth weight of its female co-twin, irrespective of parity and gestational age. CONCLUSIONS: After exclusion of potential confounders and controlling for chorionicity, parity, and gestational age, our data do not support the presence of a "masculinization" effect on birth weight.

Risk factors for preeclampsia in twin pregnancies: a population-based matched case-control study.

OBJECTIVE: To evaluate associated factors for preeclampsia in twin gestations and to compare incidences of pregnancy complications among twin pregnancies with vs. without preeclampsia. PATIENTS AND METHODS: We performed a case-control study using a population dataset of twin pregnancies delivered after 24 weeks of gestation, in Slovenia, between 1997 and 2009. Cases were twin gestations complicated by preeclampsia and controls were cases matched by gestational age, parity, and chorionicity. RESULTS: We identified 181 cases (4.7%) of preeclampsia among 3885 twins and 542 matched controls. High pre-pregnancy body mass index (BMI) and gestational diabetes were significantly associated with preeclampsia [odds ratio (OR) 1.8, 95% CI 1.26, 2.77 for overweight (BMI 25.0-29.9); OR 4.72, 95% CI 2.83, 7.89 for obese (BMI≥30), and OR 2.19, 95% CI 1.03, 4.68 for gestational diabetes]. The association was not significant for preexisting hypertension, maternal age, smoking, and pregnancy following assisted reproduction. Placental complications (previa, abruption, or adherent placenta) were more common, and low birth weight less common in the preeclampsia group (P=0.03 and P=0.01, respectively). CONCLUSIONS: High pre-pregnancy BMI carries an especially high risk for the development of preeclampsia and its complications in twin gestation.

Prospective risk of stillbirth in monochorionic-diamniotic twin gestations: a population based study.

OBJECTIVE: To calculate a population-based prospective risk of fetal death in monochorionic-diamniotic twins. STUDY DESIGN: We evaluated 387 monochorionic-diamniotic twin pregnancies that were followed and delivered after 24 weeks in Slovenia during the period 1997-2007. Surveillance was not standardized. The prospective risk of fetal death was calculated as the total number of deaths after the beginning of the gestational period divided by the number of continuing pregnancies at or beyond that period. RESULTS: Fetal death rate was 32 of 774 fetuses (4.1%; 95% confidence interval (CI), 3.0%-5.9%); the prospective risk of stillbirth per pregnancy after 33 weeks of gestation was 6.2% (95% CI, 4.2%-9.1%). CONCLUSION: The Slovenian population-based prospective risk of fetal death in monochorionic-diamniotic pregnancies that remained undelivered after 33 weeks' gestation is higher than previously reported from hospital-based studies.

Obstetrics and gynaecology training in Europe needs a next step.

Changing societal demands on doctors necessitate changes in the training of gynaecologists. Adapting this training will need well-thought-out and comprehensive planning that addresses the needs of the major stakeholders: society, patients, and doctors themselves. Doctors need to be cognizant of societal issues such as rapidly rising healthcare costs and budgetary crises, and be able to participate in the solutions. This demands effective medical leadership, which has been a neglected area in postgraduate training. It has become increasingly evident that a holistic view of the patient rooted in proper teamwork and systems-based practice is essential to provide patient-centered care. Specialists need to expand their skill set to participate in this kind of care. Furthermore, the feminisation of the medical profession and a new generation of doctors rejecting the constraints of the traditional model of medical care introduce new professional perspectives. This manuscript briefly reviews the challenges faced in the training of European gynaecologists in an effort to provoke discussion about how to best train the gynaecologists of the future.

The contribution of twins conceived by assisted reproduction technology to the very preterm birth rate: a population-based study.

OBJECTIVE: To assess the contribution of ART twins to the very preterm birth rate in Slovenia. STUDY DESIGN: In this retrospective population-based study we stratified by plurality and gestational age (<32 weeks vs >32 week) all deliveries >24 weeks in women who conceived by ART. We counted the frequencies of all ART liveborn twins among all liveborn infants and among all liveborn twins and frequencies in the subgroup of very preterm births. RESULTS: During the period 1987-2010, there were 13,293 twins (2.73%, range 1.93-3.62%, a nearly 2-fold increase from 1987 to 2010), 6939 infants born after ART (1.42%, range 0.03-2.62%, an 87-fold increase from 1987 to 2010), including 2317 (33.4%, range 14.28-44.83%, a 3-fold increase from 1987 to 2010) twins (0.47% of all deliveries). A total of 425 twin infants (0.99%, range: 1.07-1.2%, insignificant increase) were born at <32 weeks' gestation, including 261 after ART (61.4%, range 20-100%, 5-fold increase). Twins after ART born at <32 weeks comprised 0.05% of all births (range 0.004-0.11%) and increased 27-fold from 1987 to 2010. CONCLUSIONS: The incidence of twins after ART born at <32 weeks increased 27-fold from 1987 to 2010 and has not reduced from its peak incidence over the last decade.