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Association Between Planned Cesarean Delivery and Neonatal Mortality and Morbidity in Twin Pregnancies
Thomas Schmitz1, Caroline Prunet, Elie Azria
1Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Service de Gynécologie Obstétrique, Université Paris Diderot, INSERM, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Maternité Notre Dame de Bon Secours, Groupe Hospitalier Saint-Joseph, and Université René Descartes, Paris, Hôpital François Mitterrand, Service de Gynécologie Obstétrique, Pau, CHU de Nice, Service de Gynécologie Obstétrique, and Université de Nice Sophia Antepolis, Nice, CHU de Bordeaux, Service de Gynécologie Obstétrique, Bordeaux, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Service de Gynécologie Obstétrique, and Université d'Aix-Marseille, Marseille, CHRU de Lille, Maternité Jeanne de Flandre, and Université de Lille 2, Lille, CHU de Nîmes, Service de Gynécologie Obstétrique, Nîmes, Université de Montpellier 1, Montpellier, CHU de Caen, Service de Gynécologie Obstétrique, and Université de Caen, Caen, Réseau Aurore, Lyon, CHU d'Amiens, Service de Gynécologie Obstétrique, and Université d'Amiens, Amiens, CHU de Reims, Service de Gynécologie Obstétrique, and Université de Reims, Reims, France; Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Service de Gynécologie Obstétrique, and Université Pierre et Marie Curie, Paris, CHU de Strasbourg, Service de Gynécologie Obstétrique, and Université de Strasbourg, Strasbourg, CHU de Rouen, Service de Gynécologie Obstétrique, and Université de Rouen, Rouen, Maternité Régionale de Nancy, and Université de Nancy, Nancy, CHU de Toulouse, Service de Gynécologie Obstétrique, and Université Toulouse III Paul Sabatier, Toulouse, CHRU de Tours, Service de Gynécologie Obstétrique, and Université de François Rabelais, Tours, CHU de Potiers, Service de Gynécologie Obstétrique, and Université de Poitiers, Poitiers, CHU de Rennes, Service de Gynécologie Obstétrique, and Université de Rennes 1, Rennes, CHU de Besançon, Service de Gynécologie Obstétrique, and Université de Besançon, Besançon, Centre Hospitalier Intercommunal de Poissy, Service de Gynécologie Obstétrique, Poissy, Université de Versailles Saint-Quentin-en-Yvelines, Versailles, Hospices Civiles de Lyon, Hôpital de la Croix Rousse, Service de Gynécologie Obstétrique, and Université de Lyon 1, Lyon, CHU de Dijon, Service de Gynécologie Obstétrique, and Université de Bourgogne, Dijon, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Gynécologie Obstétrique, and Université Paris Sud, Le Kremlin Bicêtre, CHU d'Angers, Service de Gynécologie Obstétrique, and Université d'Angers, Angers, CHU de Clermont-Ferrand, Service de Gynécologie Obstétrique, and Université d'Auvergne, Clermont-Ferrand, CHU de Nantes, Service de Gynécologie Obstétrique, and Université de Nantes, Nantes, and URC-CIC P1419, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Maternité Port-Royal, and and DHU risques et grossesse, Paris, France.
Objective:
To evaluate the association between the planned mode of delivery and neonatal mortality and morbidity in an unselected population of women with twin pregnancies.
Methods:
The JUmeaux MODe d'Accouchement (JUMODA) study was a national prospective population-based cohort study. All women with twin pregnancies and their neonates born at or after 32 weeks of gestation with a cephalic first twin were recruited in 176 maternity units in France from February 2014 to March 2015. The primary outcome was a composite of intrapartum mortality and neonatal mortality and morbidity. Comparisons were performed according to the planned mode of delivery, planned cesarean or planned vaginal delivery. The primary analysis to control for potential indication bias used propensity score matching. Subgroup analyses were conducted, one according to gestational age at delivery and one after exclusion of high-risk pregnancies.
Results:
Among 5,915 women enrolled in the study, 1,454 (24.6%) had planned cesarean and 4,461 (75.4%) planned vaginal deliveries, of whom 3,583 (80.3%) delivered both twins vaginally. In the overall population, composite neonatal mortality and morbidity was increased in the planned cesarean compared with the planned vaginal delivery group (5.2% compared with 2.2%; odds ratio [OR] 2.38, 95% confidence interval [CI] 1.86-3.05). After matching, neonates born after planned cesarean compared with planned vaginal delivery had higher composite neonatal mortality and morbidity rates (5.3% compared with 3.0%; OR 1.85, 95% confidence interval 1.29-2.67). Differences in composite mortality and morbidity rates applied to neonates born before but not after 37 weeks of gestation. Multivariate and subgroup analyses after exclusion of high-risk pregnancies found similar trends.
Conclusion:
Planned vaginal delivery for twin pregnancies with a cephalic first twin at or after 32 weeks of gestation was associated with low composite neonatal mortality and morbidity. Moreover, planned cesarean compared with planned vaginal delivery before 37 weeks of gestation might be associated with increased composite neonatal mortality and morbidity.
