Twin Pregnancy: Prematurity and Perinatal Mortality

EDITORIAL COMMENT: Multiple pregnancy continues to account for approximately 10% of perinatal deaths (72 of 765 in Victoria, 1984); likewise debate continues as to whether or not bed rest in hospital minimizes the onset of premature labour and preeclampsia in these patients. Increased use of ultrasonography has minimized the incidence of unrecognised twins before the onset of labour, which previously occurred in approximately 20% of cases. It is therefore theoretically possible to conduct a controlled trial of rest in a consecutive series of patients with multiple pregnancy. This is not as easy as it sounds because many patients with multiple pregnancy have minimal discomfort and will not agree to rest in hospital before 28–30 weeks' gestation. Likewise, the onset of complications (hyperemesis, gross oedema, premature labour, premature rupture of the membranes, preeclampsia, polyhydramnios, antepartum haemorrhage) will often require admission to hospital irrespective of trial requirements. This paper presents one side of the rest in bed story. The author has shown that a considerable proportion of perinatal deaths in multiple pregnancy occur before the time at which it is customary to admit patients to hospital for rest. Since this paper did not analyse the details of all patients in the series, it did not consider the possible benefit of rest in patients whose babies survived. This paper emphasizes that for rest to be effective in twin pregnancy, it should be effected between 21 and 28 weeks' gestation. A practical compromise could be for patients with multiple pregnancy to be rested in hospital for 2–3 days every 2–4 weeks from 20 weeks' gestation until the dangers of prematurity are past. Summary: An 8‐year (1976–1984) retrospective analysis was undertaken of the management and outcome of 245 twin pregnancies delivered at Flinders Medical Centre, Adelaide. The incidence of twin delivery was 1 in 69 with a perinatal mortality of 85.7 per 1,000 total births. Amongst 42 perinatal deaths, 28 were associated with preterm labour at or before 28 weeks' gestation. If bed rest in hospital is to be implemented as a possible means of improving perinatal outcome in twin pregnancy it needs to be effected between 21 and 28 weeks' gestation; there is no rational theoretical basis for hospitalization beyond this time.