European Journal of Cardiovascular Medicine

Twin pregnancy-characterized by the simultaneous development of two fetuses within the uterus-has long captivated human curiosity, evoking both admiration and apprehension across diverse cultures. Twins exhibit distinct biological and social differences from singletons, and their occurrence embodies intricate reproductive dynamics. The majority of twin gestations are dizygotic (fraternal), originating from the fertilization of two separate ova, whereas monozygotic (identical) twins result from the division of a single fertilized ovum.¹ Globally, the prevalence of twin pregnancies has risen markedly in recent decades, a trend largely attributed to assisted reproductive technologies (ART), advanced maternal age, and the widespread use of ovulation-inducing agents.² In India, twin pregnancies account for approximately 1% of all gestations but contribute to nearly 10% of perinatal deaths.

The perinatal complications in MC twin pregnancies are higher than DC twins.³ Twin gestations are inherently high-risk, characterized by a heightened incidence of complications that endanger both maternal and neonatal health. Maternal complications frequently encompass anemia, preeclampsia, gestational diabetes mellitus, polyhydramnios, preterm labor, antepartum and postpartum hemorrhage, and increased rates of operative delivery. Among fetal complications, preterm birth remains the predominant determinant of perinatal morbidity and mortality, followed by low birth weight, intrauterine growth restriction (IUGR), congenital malformations, and perinatal asphyxia. Notably, approximately one-fourth of twins necessitate neonatal intensive care, highlighting the imperative for rigorous perinatal surveillance and management.

Historically, twin births were relatively uncommon; however, epidemiological data now demonstrate a substantial upward trend. For example, between the 1980s and 1990s, studies reported a 28–45% escalation in twin birth rates across developed countries, with the United States reaching 32.2 per 1,000 live births by 2004. Although this surge reflects advancements in reproductive medicine, it concurrently raises significant concerns regarding the associated maternal and neonatal health burdens. There is 2.5-fold increased risk of maternal mortality in twin gestation than in singleton pregnancies.⁴

Given the multifaceted challenges inherent to twin pregnancies, comprehensive antenatal, intrapartum, and postnatal care is indispensable. The present study endeavors to examine the epidemiological patterns, maternal and fetal outcomes, and complication spectrum associated with twin gestations, underscoring the critical importance of early diagnosis, vigilant monitoring, and timely intervention to optimize maternal and perinatal health outcomes.

AIMS AND OBJECTIVES

To study and evaluate following factors in relation to twin pregnancy and its outcome at Tezpur medical college and hospital, Tezpur.

1.  
2. Antepartum, Intrapartum and Postpartum Complications.
3. Maternal Morbidity and Mortality.
4. Neonatal Outcome Morbidity and Mortality.

To suggest ways and means for improving obstetrical outcome

Study Setting

This study was designed as a prospective observational analysis conducted in the Department of Obstetrics and Gynaecology at Tezpur Medical College and Hospital, Tezpur, over a period of one year. The study population comprised all women with twin pregnancies who had completed more than 28 weeks of gestation and were admitted for delivery in the labour ward during the study period.

Prior to initiation, approval was obtained from the Institutional Ethical Committee of Tezpur Medical College and Hospital. Written informed consent was obtained from each participant before enrollment.

Inclusion Criteria

Encompassed all pregnant women with clinically and ultrasonographically confirmed twin gestations beyond 28 weeks of gestation.

Exclusion Criteria

Included women with singleton pregnancies, triplets or higher-order multiples, pregnancies below 28 weeks of gestation, and women with pre-existing chronic medical conditions such as hypertension, diabetes mellitus, cardiac disease, renal disorders, or connective tissue diseases, as these could confound outcome assessment.

A pre-structured and peer-reviewed proforma was used for data collection. The patient’s detailed obstetric, menstrual, and medical histories were recorded, including age, parity, gestational age, family history of twinning, and use of assisted reproductive technologies. A thorough general, systemic, and obstetric examination was carried out for every participant. Routine investigations such as complete blood count, urine analysis, and blood grouping were performed, alongside specific tests indicated by individual clinical conditions. Ultrasonography played a crucial role in confirming the diagnosis of twin pregnancy, determining gestational age, assessing fetal growth, detecting anomalies, evaluating chorionicity, and monitoring for complications like discordant growth or twin-to-twin transfusion syndrome.

All women were managed as per standard obstetric protocols, with hospitalization whenever clinically indicated to prevent or manage complications. Labour was carefully monitored, with all deliveries conducted under the supervision of senior obstetricians and with neonatal resuscitation facilities readily available. The mode of delivery—whether vaginal or cesarean section-was decided based on fetal presentation, gestational age, maternal condition, and fetal well-being.

After delivery, both maternal and neonatal outcomes were meticulously recorded. Maternal outcomes assessed included premature labour, hypertensive disorders, anemia, antepartum and postpartum hemorrhage, gestational diabetes mellitus, polyhydramnios, premature rupture of membranes, and maternal mortality. Fetal outcomes were evaluated in terms of birth weight, congenital anomalies, intrauterine fetal demise (IUFD), neonatal intensive care unit (NICU) admissions, and neonatal mortality. The interval between the delivery of the first and second twin, mode of conception (spontaneous or ART-related), and booking status (booked or unbooked cases) were also noted.

Statistical Analysis and Data Analysis was performed using the software Statistical Package for the Social Sciences (IBM SPSS v.20). Data were compiled and presented in terms of frequency and percentage distributions. Continuous variables such as maternal age and gestational age were expressed as means and standard deviations. The results were compared with findings from previously published national and international studies to identify similarities and variations in incidence and outcomes.

During the study period, a total of 13,737 deliveries were recorded, among which 100 were twin gestations, giving an incidence of 0.7%. The remaining 13,637 cases (99.3%) were singleton pregnancies. All twin pregnancies included in this study were spontaneously conceived, with no cases resulting from assisted reproductive technologies (ART), indicating that natural conception remained the predominant mode in this population.

The maternal age distribution revealed that the majority of women (73%) were between 20 and 29 years, reflecting the peak reproductive age group. Women aged 30–39 years accounted for 20%, while younger mothers under 20 years and older mothers above 40 years represented 4% and 3%, respectively. Regarding antenatal booking status, 56% of women were booked cases who had attended regular antenatal checkups, whereas 44% were unbooked and presented directly in labour or with complications. When analysing the gestational age at delivery, it was seen that about 30% of mothers delivered between 28–34 weeks, and 54% delivered between 34–37 weeks, while only 16% carried their pregnancies beyond 37 weeks. In terms of parity, 49% of the participants were primigravidae and 51% were multigravida. The interval between delivery of the first and second twin was generally short, with 93% of second twins delivered within 30 minutes, and only 7% exceeding that duration. (Table 1)

Among maternal risk factors, anemia emerged as the most prevalent, affecting 72% of women. Hypertensive disorders of pregnancy were observed in 24%, while gestational diabetes mellitus and polyhydramnios were noted in 6% and 2%, respectively. In terms of maternal complications, premature labour was the leading issue, occurring in 76% of patients. Premature rupture of membranes (PROM) was reported in 20%, while antepartum haemorrhage (APH) and postpartum haemorrhage (PPH) were observed in 4% and 8% of cases respectively. Maternal mortality was documented in 2% of cases. The mode of delivery varied according to clinical indications and fetal presentation. Caesarean section (LSCS) was performed in 54% of women, while 46% delivered vaginally. (Table 2)

Concerning perinatal outcomes, intrauterine fetal demise (IUFD) occurred in 3% of first twins and 5% of second twins, while congenital malformations were rare, detected in only 1% of second twins and absent among the first. Examination of birth weights revealed that low birth weight was almost universal among twins. Among first twins, 21% weighed less than 1.5 kg, and 59% weighed between 1.5–2.49 kg. Only 20% weighed more than 2.5 kg. In comparison, the second twins were even smaller, with 25% under 1.5 kg, 65% between 1.5–2.49 kg, and only 10% exceeding 2.5 kg. None of the second twins weighed above 3.5 kg. The requirement for neonatal intensive care was notably high. Fifty-two percent of first twins and 56% of second twins required NICU admission immediately after birth, predominantly due to prematurity, respiratory distress, and low birth weight. (Table 3)

The incidence of twin pregnancies in the present study was 0.7%, aligning with reports from Indian institutions where the frequency typically ranged between 0.7% and 2% (Upreti, 2018; Gupta et al., 2017). The lower incidence compared to Western data, such as the 3.2% rate reported by Oraekwe et al.⁵ (2018), reflected regional differences in the use of assisted reproductive technologies and demographic factors such as maternal age and parity. All cases in the present study were naturally conceived, similar to the findings by Upreti (2018),⁶ who also noted that spontaneous conception predominated in twin gestations in tertiary centers with limited ART exposure.

Most mothers in the study belonged to the 20–29-year age group, which corresponded with observations by Gajera et al,⁷ (2015) and Oraekwe et al,⁵ (2018), both of whom found that twin pregnancies were most common in younger women within this reproductive age range. This finding suggested that in Indian and African populations, twinning was less influenced by advanced maternal age, contrasting with trends in developed nations where delayed motherhood and fertility treatments had contributed to increased twinning rates.

In the present analysis, 56% of women were booked cases, while 44% were unbooked. Similar trends were reported by Upreti (2018),⁶ who found 74.3% unbooked cases, indicating that inadequate antenatal supervision remained a contributing factor to complications in twin gestations. This emphasized the importance of consistent antenatal surveillance to identify and manage maternal and fetal risks early in pregnancy.

Premature labour emerged as the most frequent maternal complication in this study, affecting 76% of patients. Comparable findings were noted by Gupta et al,⁸ (2017), who reported that the risk of preterm labour was nine times higher in twin pregnancies than in singletons. Similarly, Gajera et al.⁷ (2015) documented that 46% of twin pregnancies delivered between 33 and 36 weeks, while Chowdhury et al⁹ (2011) and Bangal et al.¹⁰ (2012) reported preterm delivery rates of 44% and 88%, respectively. These consistent observations across multiple studies underscored the inherent predisposition of twin gestations to preterm birth due to uterine overdistension and hormonal triggers.

Anemia, observed in 72% of mothers, represented another significant maternal morbidity. This prevalence was higher than that reported by Oraekwe et al⁵ (2018), who found postpartum anemia in 25.3% of cases. The higher burden in the present study could be attributed to nutritional deficits and increased iron demands associated with twin gestation. The association between anemia and twin pregnancies highlighted the importance of early screening and supplementation during antenatal care.

Hypertensive disorders of pregnancy were reported in 24% of women in the present study, a rate consistent with the 14.5% reported by Oraekwe et al.⁵ (2018) and the 2.28-fold increased risk found by Gupta et al.⁷ (2017). The pathophysiological mechanisms underlying these disorders-placental overactivity and endothelial dysfunction-were exacerbated in multifetal gestations, explaining their frequent occurrence and contribution to maternal morbidity.

Regarding the mode of delivery, 54% of mothers underwent caesarean section, consistent with the 54.3% reported by Oraekwe et al⁵ (2018). Malpresentation of the leading twin and fetal distress were the predominant indications for operative delivery, echoing the findings of Gupta et al⁸ (2017), who noted a threefold increase in malpresentation among twin pregnancies. Although vaginal delivery remained feasible in many cases, careful intrapartum monitoring and institutional support were essential to minimize neonatal risks.

Premature rupture of membranes occurred in 20% of cases, which was also highlighted by Gupta et al⁸ (2017) as being 2.74 times more common in twin gestations. Antepartum and postpartum hemorrhage were less frequent (4% and 8%, respectively), yet still clinically significant. Gajera et al. (2015) similarly observed hemorrhagic complications in a minority of twin cases, emphasizing that timely obstetric intervention could mitigate such outcomes.

Perinatal outcomes in the study mirrored global findings on twin gestations. Low birth weight was nearly universal, with 80% of first twins and 90% of second twins weighing below 2.5 kg. These findings paralleled those of Gajera et al⁷ (2015), who reported 94% of twins as low birth weight, and Upreti⁶ (2018), who found 83.4% affected. The weight disparity between first and second twins observed here was also consistent with Upreti’s⁶ (2018) report, suggesting a persistent risk of discordant growth and nutritional insufficiency for the second twin. Intrauterine fetal demise was recorded in 3% and 5% of first and second twins, respectively, comparable to the mortality patterns described by Gajera et al⁷ (2015) and Gupta et al⁸ (2017), who both attributed such losses to prematurity and asphyxia.

Neonatal intensive care unit (NICU) admission rates were notably high-52% for first twins and 56% for second twins—primarily due to prematurity and respiratory distress. Similar NICU admission trends were reported by Gajera et al. (2015) and Gupta et al. (2017), reaffirming the vulnerability of twins to perinatal complications. The frequent need for neonatal resuscitation highlighted the importance of multidisciplinary perinatal management, including round-the-clock pediatric support in delivery units.

The findings of this study indicated that in the study area, twin pregnancies continued to exhibit high rates of preterm delivery, anemia, hypertensive disorders, and low birth weight, resulting in elevated NICU admissions and perinatal morbidity.

1. Corsello G, Piro E. The world of twins: an update. J Matern Fet al. Neonatal Med 2010;23 Suppl 3:59-62.
2. Daftary SN, Desai SV. Multiple fetal gestations. In: Daftary SN, Desai SV, eds. Textbook of Selected Topics in Obstetrics and Gynaecology-2, for Postgraduates and Practitioners. 19^th New Delhi: BI Publications Pvt Ltd 2004:52-72.
3. Chitrit Y, Filidori M, Pons JC, et al. Perinatal mortality in twin pregnancies: a 3-year analysis in Seine Saint-Denis (France). Eur J Obstet Gynecol Reprod Med 1999;86:23-8.
4. National Institute for Health and Clinical Excellence. Multiple pregnancy. The management of twin and triplet pregnancies in the antenatal period. NICE clinical Guideline. 2011. Available from: http://guidance.nice.org.uk/cg129
5. Oraekwe OI. Appraisal of maternal outcome of twin gestation. Saudi Journal for Health Sciences 2018;7(3):163.
6. Upreti P. Twin pregnancies: incidence and outcomes in a tertiary health centre of Uttarakhand, Int J Reprod Contracept Obstet Gynecol 2018;7(9):3520-5.
7. Gajera AV, Basavannayya HP, Kavitha C, et al. Feto-maternal outcome in twin Int J Reprod Contracept Obstet Gynecol 2015;4(6):1836-9.
8. Gupta D, Mital P, Meena BS, et al. Comparative assessment of fetomaternal outcome in twin pregnancy with singleton pregnancy at tertiary care centre. Int J Reprod Contracept Obstet Gynecol 2017;6(6):2395-400.
9. Choudhary R, Kumaru G. An observational study on maternal and foetal outcome in twin Pregnancy. JMSCR 2018;6(9):493-8.
10. Bangal VB, Patel SM, Khairnar DN. Study of maternal and fetal outcome in twin gestation at tertiary care teaching IJBAR 2012;03(10):758-61.