Inpatient vs outpatient management and timing of delivery of uncomplicated monochorionic monoamniotic twin pregnancy

the MONOMONO study

The MONOMONO Working Group

Research output: Contribution to journalArticle

Abstract

Objectives: Monoamniotic twin pregnancies are at increased risk of perinatal complications, primarily owing to the risk of cord entanglement. There is no recommendation on whether such pregnancies should be managed in hospital or can be safely managed in an outpatient setting, and the timing of planned delivery is also a subject of debate. The aim of this study was to compare the perinatal outcomes of inpatient vs outpatient fetal surveillance approaches employed among 22 participating study centers, and to calculate the fetal and neonatal death rates according to gestational age, in non-anomalous monoamniotic twins from 26 weeks' gestation. Methods: The MONOMONO study was a multinational cohort study of consecutive women with monochorionic monoamniotic twin pregnancies, who were referred to 22 university hospitals in Italy, the USA, the UK and Spain, from January 2010 to January 2017. Only non-anomalous uncomplicated monoamniotic twin pregnancies with two live fetuses at 26 + 0 weeks' gestation were included in the study. In 10 of the centers, monoamniotic twins were managed routinely as inpatients, whereas in the other 12 centers they were managed routinely as outpatients. The primary outcome was intrauterine fetal death. We also planned to assess fetal and neonatal death rates according to gestational age per 1-week interval. Outcomes are presented as odds ratio (OR) with 95% CIs. The main outcome was analyzed using both standard logistic regression analysis, in which each fetus was treated as an independent unit, and a generalized mixed-model approach, with each twin pair treated as a cluster unit, considering that the outcome for a twin is not independent of that of its cotwin. Results: 195 consecutive pregnant women with a non-anomalous uncomplicated monoamniotic twin gestation (390 fetuses) were included. Of these, 75 (38.5%) were managed as inpatients and 120 (61.5%) as outpatients. The overall perinatal loss rate was 10.8% (42/390) with a peak fetal death rate of 4.3% (15/348) occurring at 29 weeks' gestation. There was no significant difference in mean gestational age at delivery (31 weeks), birth weight (∼1.6 kg), or emergency delivery rate between the inpatient and outpatient surveillance groups. Based on generalized mixed-model analysis, there was no statistically significant difference in fetal death rates between inpatient management commencing from around 26 weeks compared with outpatient surveillance protocols from 30 weeks (3.3% vs 10.8%; adjusted OR 0.21 (95% CI, 0.04–1.17)). Maternal length of stay in the hospital was 42.1 days in the inpatient group, and 7.4 days in the outpatient group (mean difference 34.70 days (95% CI, 31.36–38.04 days). From 32 + 0 to 36 + 6 weeks, no fetal or neonatal death in either group was recorded. 46 fetuses were delivered after 34 + 0 weeks, and none of them died in utero or within the first 28 days postpartum. Conclusion: In uncomplicated monoamniotic twins, inpatient surveillance is associated with similar fetal mortality as outpatient management. After 31 + 6 weeks, and up to 36 + 6 weeks, there were no intrauterine fetal deaths or neonatal deaths.

Original languageEnglish (US)
Pages (from-to)175-183
Number of pages9
JournalUltrasound in Obstetrics and Gynecology
Volume53
Issue number2
DOIs
StatePublished - Feb 1 2019

Fingerprint

Twin Pregnancy
Fetal Death
Inpatients
Outpatients
Fetus
Pregnancy
Gestational Age
Mortality
Odds Ratio
Fetal Mortality
Birth Weight
Spain
Postpartum Period
Italy
Pregnant Women
Length of Stay
Emergencies
Cohort Studies
Logistic Models
Regression Analysis

Keywords

  • Cesarean delivery
  • chorionicity
  • cord accident
  • cord entanglement
  • healthcare
  • monochorionic
  • multiple gestation
  • perinatal death
  • respiratory distress syndrome
  • twin pregnancy

ASJC Scopus subject areas

  • Radiological and Ultrasound Technology
  • Reproductive Medicine
  • Radiology Nuclear Medicine and imaging
  • Obstetrics and Gynecology

Cite this

Inpatient vs outpatient management and timing of delivery of uncomplicated monochorionic monoamniotic twin pregnancy : the MONOMONO study. / The MONOMONO Working Group.

In: Ultrasound in Obstetrics and Gynecology, Vol. 53, No. 2, 01.02.2019, p. 175-183.

Research output: Contribution to journalArticle

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title = "Inpatient vs outpatient management and timing of delivery of uncomplicated monochorionic monoamniotic twin pregnancy: the MONOMONO study",
abstract = "Objectives: Monoamniotic twin pregnancies are at increased risk of perinatal complications, primarily owing to the risk of cord entanglement. There is no recommendation on whether such pregnancies should be managed in hospital or can be safely managed in an outpatient setting, and the timing of planned delivery is also a subject of debate. The aim of this study was to compare the perinatal outcomes of inpatient vs outpatient fetal surveillance approaches employed among 22 participating study centers, and to calculate the fetal and neonatal death rates according to gestational age, in non-anomalous monoamniotic twins from 26 weeks' gestation. Methods: The MONOMONO study was a multinational cohort study of consecutive women with monochorionic monoamniotic twin pregnancies, who were referred to 22 university hospitals in Italy, the USA, the UK and Spain, from January 2010 to January 2017. Only non-anomalous uncomplicated monoamniotic twin pregnancies with two live fetuses at 26 + 0 weeks' gestation were included in the study. In 10 of the centers, monoamniotic twins were managed routinely as inpatients, whereas in the other 12 centers they were managed routinely as outpatients. The primary outcome was intrauterine fetal death. We also planned to assess fetal and neonatal death rates according to gestational age per 1-week interval. Outcomes are presented as odds ratio (OR) with 95{\%} CIs. The main outcome was analyzed using both standard logistic regression analysis, in which each fetus was treated as an independent unit, and a generalized mixed-model approach, with each twin pair treated as a cluster unit, considering that the outcome for a twin is not independent of that of its cotwin. Results: 195 consecutive pregnant women with a non-anomalous uncomplicated monoamniotic twin gestation (390 fetuses) were included. Of these, 75 (38.5{\%}) were managed as inpatients and 120 (61.5{\%}) as outpatients. The overall perinatal loss rate was 10.8{\%} (42/390) with a peak fetal death rate of 4.3{\%} (15/348) occurring at 29 weeks' gestation. There was no significant difference in mean gestational age at delivery (31 weeks), birth weight (∼1.6 kg), or emergency delivery rate between the inpatient and outpatient surveillance groups. Based on generalized mixed-model analysis, there was no statistically significant difference in fetal death rates between inpatient management commencing from around 26 weeks compared with outpatient surveillance protocols from 30 weeks (3.3{\%} vs 10.8{\%}; adjusted OR 0.21 (95{\%} CI, 0.04–1.17)). Maternal length of stay in the hospital was 42.1 days in the inpatient group, and 7.4 days in the outpatient group (mean difference 34.70 days (95{\%} CI, 31.36–38.04 days). From 32 + 0 to 36 + 6 weeks, no fetal or neonatal death in either group was recorded. 46 fetuses were delivered after 34 + 0 weeks, and none of them died in utero or within the first 28 days postpartum. Conclusion: In uncomplicated monoamniotic twins, inpatient surveillance is associated with similar fetal mortality as outpatient management. After 31 + 6 weeks, and up to 36 + 6 weeks, there were no intrauterine fetal deaths or neonatal deaths.",
keywords = "Cesarean delivery, chorionicity, cord accident, cord entanglement, healthcare, monochorionic, multiple gestation, perinatal death, respiratory distress syndrome, twin pregnancy",
author = "{The MONOMONO Working Group} and Gabriele Saccone and Vincenzo Berghella and Mariavittoria Locci and Tullio Ghi and Tiziana Frusca and Mariano Lanna and Stefano Faiola and Anna Fichera and Federico Prefumo and Giuseppe Rizzo and Costanza Bosi and Bruno Arduino and Pietro D'Alessandro and Maria Borgo and Silvana Arduino and Elisabetta Cantanna and Giuliana Simonazzi and Nicola Rizzo and Giorgetta Francesca and Viola Seravalli and Jena Miller and Magro-Malosso, {Elena Rita} and {Di Tommaso}, Mariarosaria and Andrea Dall'Asta and Letizia Galli and Nicola Volpe and Silvia Visentin and Erich Cosmi and Laura Sarno and Claudia Caissutti and Lorenza Driul and Hannah Anastasio and {Di Mascio}, Daniele and Panici, {Pierluigi Benedetti} and Flaminia Vena and Roberto Brunelli and Andrea Ciardulli and Francesco D'Antonio and Corina Schoen and Anju Suhag and Gambacorti-Passerini, {Zita Maria} and Baz, {Maria Angeles Anaya} and Giulia Magoga and Enrico Busato and Elisa Filippi and Su{\'a}rez, {Mar{\'i}a Jos{\'e} Rodriguez} and Alderete, {Francisco Gamez} and Ortuno, {Paula Alonso} and Amerigo Vitagliano and Ahmet Baschat",
year = "2019",
month = "2",
day = "1",
doi = "10.1002/uog.19179",
language = "English (US)",
volume = "53",
pages = "175--183",
journal = "Ultrasound in Obstetrics and Gynecology",
issn = "0960-7692",
publisher = "John Wiley and Sons Ltd",
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TY - JOUR

T1 - Inpatient vs outpatient management and timing of delivery of uncomplicated monochorionic monoamniotic twin pregnancy

T2 - the MONOMONO study

AU - The MONOMONO Working Group

AU - Saccone, Gabriele

AU - Berghella, Vincenzo

AU - Locci, Mariavittoria

AU - Ghi, Tullio

AU - Frusca, Tiziana

AU - Lanna, Mariano

AU - Faiola, Stefano

AU - Fichera, Anna

AU - Prefumo, Federico

AU - Rizzo, Giuseppe

AU - Bosi, Costanza

AU - Arduino, Bruno

AU - D'Alessandro, Pietro

AU - Borgo, Maria

AU - Arduino, Silvana

AU - Cantanna, Elisabetta

AU - Simonazzi, Giuliana

AU - Rizzo, Nicola

AU - Francesca, Giorgetta

AU - Seravalli, Viola

AU - Miller, Jena

AU - Magro-Malosso, Elena Rita

AU - Di Tommaso, Mariarosaria

AU - Dall'Asta, Andrea

AU - Galli, Letizia

AU - Volpe, Nicola

AU - Visentin, Silvia

AU - Cosmi, Erich

AU - Sarno, Laura

AU - Caissutti, Claudia

AU - Driul, Lorenza

AU - Anastasio, Hannah

AU - Di Mascio, Daniele

AU - Panici, Pierluigi Benedetti

AU - Vena, Flaminia

AU - Brunelli, Roberto

AU - Ciardulli, Andrea

AU - D'Antonio, Francesco

AU - Schoen, Corina

AU - Suhag, Anju

AU - Gambacorti-Passerini, Zita Maria

AU - Baz, Maria Angeles Anaya

AU - Magoga, Giulia

AU - Busato, Enrico

AU - Filippi, Elisa

AU - Suárez, María José Rodriguez

AU - Alderete, Francisco Gamez

AU - Ortuno, Paula Alonso

AU - Vitagliano, Amerigo

AU - Baschat, Ahmet

PY - 2019/2/1

Y1 - 2019/2/1

N2 - Objectives: Monoamniotic twin pregnancies are at increased risk of perinatal complications, primarily owing to the risk of cord entanglement. There is no recommendation on whether such pregnancies should be managed in hospital or can be safely managed in an outpatient setting, and the timing of planned delivery is also a subject of debate. The aim of this study was to compare the perinatal outcomes of inpatient vs outpatient fetal surveillance approaches employed among 22 participating study centers, and to calculate the fetal and neonatal death rates according to gestational age, in non-anomalous monoamniotic twins from 26 weeks' gestation. Methods: The MONOMONO study was a multinational cohort study of consecutive women with monochorionic monoamniotic twin pregnancies, who were referred to 22 university hospitals in Italy, the USA, the UK and Spain, from January 2010 to January 2017. Only non-anomalous uncomplicated monoamniotic twin pregnancies with two live fetuses at 26 + 0 weeks' gestation were included in the study. In 10 of the centers, monoamniotic twins were managed routinely as inpatients, whereas in the other 12 centers they were managed routinely as outpatients. The primary outcome was intrauterine fetal death. We also planned to assess fetal and neonatal death rates according to gestational age per 1-week interval. Outcomes are presented as odds ratio (OR) with 95% CIs. The main outcome was analyzed using both standard logistic regression analysis, in which each fetus was treated as an independent unit, and a generalized mixed-model approach, with each twin pair treated as a cluster unit, considering that the outcome for a twin is not independent of that of its cotwin. Results: 195 consecutive pregnant women with a non-anomalous uncomplicated monoamniotic twin gestation (390 fetuses) were included. Of these, 75 (38.5%) were managed as inpatients and 120 (61.5%) as outpatients. The overall perinatal loss rate was 10.8% (42/390) with a peak fetal death rate of 4.3% (15/348) occurring at 29 weeks' gestation. There was no significant difference in mean gestational age at delivery (31 weeks), birth weight (∼1.6 kg), or emergency delivery rate between the inpatient and outpatient surveillance groups. Based on generalized mixed-model analysis, there was no statistically significant difference in fetal death rates between inpatient management commencing from around 26 weeks compared with outpatient surveillance protocols from 30 weeks (3.3% vs 10.8%; adjusted OR 0.21 (95% CI, 0.04–1.17)). Maternal length of stay in the hospital was 42.1 days in the inpatient group, and 7.4 days in the outpatient group (mean difference 34.70 days (95% CI, 31.36–38.04 days). From 32 + 0 to 36 + 6 weeks, no fetal or neonatal death in either group was recorded. 46 fetuses were delivered after 34 + 0 weeks, and none of them died in utero or within the first 28 days postpartum. Conclusion: In uncomplicated monoamniotic twins, inpatient surveillance is associated with similar fetal mortality as outpatient management. After 31 + 6 weeks, and up to 36 + 6 weeks, there were no intrauterine fetal deaths or neonatal deaths.

AB - Objectives: Monoamniotic twin pregnancies are at increased risk of perinatal complications, primarily owing to the risk of cord entanglement. There is no recommendation on whether such pregnancies should be managed in hospital or can be safely managed in an outpatient setting, and the timing of planned delivery is also a subject of debate. The aim of this study was to compare the perinatal outcomes of inpatient vs outpatient fetal surveillance approaches employed among 22 participating study centers, and to calculate the fetal and neonatal death rates according to gestational age, in non-anomalous monoamniotic twins from 26 weeks' gestation. Methods: The MONOMONO study was a multinational cohort study of consecutive women with monochorionic monoamniotic twin pregnancies, who were referred to 22 university hospitals in Italy, the USA, the UK and Spain, from January 2010 to January 2017. Only non-anomalous uncomplicated monoamniotic twin pregnancies with two live fetuses at 26 + 0 weeks' gestation were included in the study. In 10 of the centers, monoamniotic twins were managed routinely as inpatients, whereas in the other 12 centers they were managed routinely as outpatients. The primary outcome was intrauterine fetal death. We also planned to assess fetal and neonatal death rates according to gestational age per 1-week interval. Outcomes are presented as odds ratio (OR) with 95% CIs. The main outcome was analyzed using both standard logistic regression analysis, in which each fetus was treated as an independent unit, and a generalized mixed-model approach, with each twin pair treated as a cluster unit, considering that the outcome for a twin is not independent of that of its cotwin. Results: 195 consecutive pregnant women with a non-anomalous uncomplicated monoamniotic twin gestation (390 fetuses) were included. Of these, 75 (38.5%) were managed as inpatients and 120 (61.5%) as outpatients. The overall perinatal loss rate was 10.8% (42/390) with a peak fetal death rate of 4.3% (15/348) occurring at 29 weeks' gestation. There was no significant difference in mean gestational age at delivery (31 weeks), birth weight (∼1.6 kg), or emergency delivery rate between the inpatient and outpatient surveillance groups. Based on generalized mixed-model analysis, there was no statistically significant difference in fetal death rates between inpatient management commencing from around 26 weeks compared with outpatient surveillance protocols from 30 weeks (3.3% vs 10.8%; adjusted OR 0.21 (95% CI, 0.04–1.17)). Maternal length of stay in the hospital was 42.1 days in the inpatient group, and 7.4 days in the outpatient group (mean difference 34.70 days (95% CI, 31.36–38.04 days). From 32 + 0 to 36 + 6 weeks, no fetal or neonatal death in either group was recorded. 46 fetuses were delivered after 34 + 0 weeks, and none of them died in utero or within the first 28 days postpartum. Conclusion: In uncomplicated monoamniotic twins, inpatient surveillance is associated with similar fetal mortality as outpatient management. After 31 + 6 weeks, and up to 36 + 6 weeks, there were no intrauterine fetal deaths or neonatal deaths.

KW - Cesarean delivery

KW - chorionicity

KW - cord accident

KW - cord entanglement

KW - healthcare

KW - monochorionic

KW - multiple gestation

KW - perinatal death

KW - respiratory distress syndrome

KW - twin pregnancy

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U2 - 10.1002/uog.19179

DO - 10.1002/uog.19179

M3 - Article

VL - 53

SP - 175

EP - 183

JO - Ultrasound in Obstetrics and Gynecology

JF - Ultrasound in Obstetrics and Gynecology

SN - 0960-7692

IS - 2

ER -