Neonatal Respiratory Morbidity in Twins according to Birth Order and Mode of Delivery

Hyunsoo Kim; Jiyeon Kim; Sun Young Ko; Son Moon Shin; Yeon Kyung Lee

doi:10.14734/PN.2018.29.04.159

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Kim, Kim, Ko, Shin, and Lee: Neonatal Respiratory Morbidity in Twins according to Birth Order and Mode of Delivery

Original Article

Perinatology 2018;29(4):159-164.

Published online: 19 January 2018

DOI: https://doi.org/10.14734/PN.2018.29.04.159

Neonatal Respiratory Morbidity in Twins according to Birth Order and Mode of Delivery

Hyunsoo Kim, MD, Jiyeon Kim, MD, Sun Young Ko, MD, Son Moon Shin, MD, Yeon Kyung Lee, MD

Department of Pediatrics, Cheil General Hospital and Women's Health Care Center, Dankook University College of Medicine, Seoul, Korea

Correspondence to Yeon Kyung Lee, MD Department of Pediatrics, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, 17 Seoae-ro 1-gil, Jung-gu, Seoul 04619, Korea Tel: +82-2-2000-7771 Fax: +82-2-2000-7789 E-mail: ykleeped@hanmail.net

Received 15 June 201813 August 2018 Accepted 26 August 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

To compare neonatal respiratory morbidity of twins according to birth order related to gestational age and mode of delivery.

Methods

We performed the retrospective research of the medical records of 3,224 neonates (1,612 twin pairs) born in a single center from January 2011 to December 2015. Subjects were classified into four gestational age groups: very (<32 weeks), moderate (32-33 weeks), late (34-36 weeks) preterm, and term (≥37 weeks) groups. We investigated clinical characteristics and respiratory morbidity according to birth order related to gestational age group and mode of delivery.

Results

We found increased risk of respiratory morbidity in second-born twin than first-born twin (P=0.039). Second-born twin was associated with increased risk of respiratory distress syndrome (RDS) in late preterm group (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.30-5.95), and transient tachypnea of newborn in term group (OR 1.4, 95% CI 1.03-1.81). In vaginal delivery mode, there was no difference of respiratory morbidity between first and second-born twin in each group, but in cases of Cesarean delivery, second-born twin was related with a greater risk of RDS in late preterm group (OR 2.3, 95% CI 1.07-5.09). Birth order and Cesarean section independently increased the risk of RDS (adjusted OR [aOR] 1.69, 95% CI 1.12-2.54; aOR 2.14, 95% CI 1.25-3.66, respectively).

Conclusion

Second-born twin and Cesarean delivery are associated with increased risk of RDS, especially in late preterm twins.

Keywords: Respiratory distress syndrome, newborn, Cesarean section, Birth order, Twins

REFERENCES

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Table 1.

Characteristics and Respiratory Outcomes of the Study Population (n=3,224)

Variable	1st twin (n=1,612)	2nd twin (n=1,612)	P-value
Birth weight (g)	2,489±401.2	2,421±412.2	<0.001
Height (cm)	45.1±13.5	44.5±8.4	0.104
Head circumference (cm)	32.2±5.4	31.2±6.8	<0.001
Maternal age (years)	34±3	34±3
Gestational age (weeks)	36±2	36±2
<32	33 (2.0)	33 (2.0)
32-33	76 (4.7)	76 (4.7)
34-36	554 (34.4)	554 (34.4)
≥37	949 (58.9)	949 (58.9)
Apgar score
1 minute <7	182 (11.3)	253 (15.7)	<0.001
5 minute <7	9 (0.5)	10 (0.6)	1.0
Sex
Male	830 (51.5)	812 (50.4)	0.526
Female	782 (48.5)	800 (49.6)
Mode of delivery
Vaginal delivery	439 (27.2)	439 (27.2)	1.0
Caesarean delivery	1,173 (72.8)	1,173 (72.8)
Malpresentation	387 (24.0)	656 (40.7)	<0.001
Respiratory morbidity	650 (40.3)	708 (43.9)	0.039
TTN	381 (23.6)	401 (24.9)	0.411
RDS	84 (5.2)	108 (6.7)	0.074
RD	185 (11.5)	199 (12.3)	0.447
Others
IVH (≥grade II)	2 (0.1)	1 (0.0)	1.0
HIE	0 (0.0)	0 (0.0)	-
Cystic PVL	16 (1.0)	10 (0.6)	0.325

Values are presented as mean±standard deviation or number (%). Abbreviations: TTN, transient tachypnea of newborn; RDS, respiratory distress syndrome with surfactant; RD, respiratory distress of newborn with ventilator care; IVH, intraventricular hemorrhage; HIE, hypoxic ischemic encephalopathy; PVL, periventricular leukomalacia.

Table 2.

Difference of Respiratory Morbidity Incidence between 1st and 2nd Twin by Gestational Age and Mode of Delivery

	Twin pairs	1st only	2nd only	OR (95% CI)	McNemar	Vaginal delivery			McNemar	Cesarean delivery			McNemar
	Twin pairs	1st only	2nd only	OR (95% CI)	P-value	1st only	2nd only	OR (95% CI)	P-value	1st only	2nd only	OR (95% CI)	P-value
<32 weeks	33					6	6			27	27
RDS		0	5	11 (0.61-198.94)	0.102	0	0	1 (0.02-50.40)	0.317	0	5	11 (0.61-198.94)	0.102
RD		5	0	0.09 (0.01-1.64)	0.102	0	0	1 (0.02-50.40)	0.317	5	0	0.09 (0.01-1.64)	0.102
32-33 weeks	76					20	20			56	56
TTN		3	2	0.67 (0.11-3.99)	0.656	2	0	0.2 (0.01-4.17)	0.25	1	2	2 (0.18-22.06)	0.625
RDS		8	12	1.5 (0.61-3.67)	0.371	1	3	3 (0.31-28.8)	0.375	7	9	1.29 (0.48-3.45)	0.629
RD		12	11	0.92 (0.40-2.08)	0.835	3	3	1 (0.20-4.95)	0.984	9	8	0.89 (0.34-2.30)	0.808
34-36 weeks	554					150	150			404	404
TTN		73	64	0.88 (0.63-1.23)	0.442	26	20	0.77 (0.43-1.38)	0.376	47	44	0.94 (0.62-1.41)	0.753
RDS		9	25	2.80 (1.30-5.95)	0.01	0	4	9 (0.48-167.17)	0.18	9	21	2.3 (1.07-5.09)	0.03
RD		47	62	1.32 (0.90-1.93)	0.151	14	20	1.43 (0.72-2.83)	0.303	33	42	1.27 (0.81-2.01)	0.299
≥37 weeks	949					263	263			686	686
TTN		83	113	1.40 (1.03-1.81)	0.03	21	31	1.48 (0.85-2.57)	0.166	62	82	1.32 (0.95-1.84)	0.096
RDS		6	5	0.83 (0.25-2.73)	0.763	2	2	1 (0.14-7.10)	0.938	4	3	0.75 (0.17-3.35)	0.719
RD		42	47	1.12 (0.74-1.70)	0.600	8	16	2 (0.86-4.67)	0.102	34	31	0.91 (0.56-1.48)	0.71

Abbreviations: OR, odds ratio; CI, confidence interval; RDS, respiratory distress syndrome with surfactant; RD, respiratory distress of newborn with ventilator care; TTN, transient tachypnea of newborn.

Table 3.

Comparison of Respiratory Morbidity in 1st and 2nd Twin by Mode of Delivery

	Number of twin pairs	VD		CS		VD vs. CS in 1st twin	Chi-square	VD vs. CS in 2nd twin	Chi-square
	Number of twin pairs	1st twin	2nd twin	1st twin	2nd twin	OR (95% CI)	P-value	OR (95% CI)	P-value
<32 weeks	33	6	6	27	27
RDS		6	6	20	25	Not defined		Not defined
RD		0	0	7	2	Not defined		Not defined
32-33 weeks	76	20	20	56	56
TTN		3	1	1	2	0.1 (0.01-1.06)	0.054	0.7 (0.06-8.21)	1.0
RDS		4	6	23	25	2.79 (0.83-9.43)	0.109	1.88 (0.63-5.61)	0.38
RD		9	9	22	21	0.79 (0.28-2.22)	0.394	0.73 (0.26-2.06)	0.747
34-36 weeks	554	150	150	404	404
TTN		51	45	109	106	0.72 (0.48-1.07)	0.13	0.83 (0.55-1.26)	0.438
RDS		1	5	24	36	9.41 (1.26-70.19)	0.005	2.84 (1.09-7.37)	0.028
RD		21	27	77	86	1.45 (0.86-2.44)	0.207	1.23 (0.76-1.99)	0.463
≥37 weeks	949	263	263	686	686
TTN		52	62	165	185	1.29 (0.91-1.82)	0.19	1.2 (0.86-1.67)	0.325
RDS		2	2	4	3	0.77 (0.14-4.20)	0.670	0.57 (0.09-3.45)	0.909
RD		10	18	39	36	1.53 (0.75-3.10)	0.313	0.75 (0.42-1.35)	0.427

Abbreviations: VD, vaginal delivery; CS, cesarean section; OR, odds ratio; CI, confidence interval; RDS, respiratory distress syndrome with surfactant; RD, respiratory distress of newborn with ventilator care; TTN, transient tachypnea of newborn.

Table 4.

Logistic Regression Analysis of the Relative Effects of Birth Order on Respiratory Distress Syndrome by Mode of Delivery

	Number of twin sibling infants	Variable	aOR (95% CI)	P-value
Vaginal delivery only	878	Birth order	2.33 (0.79-6.87)	0.127
Caesarean delivery only	2,346	Birth order	1.65 (1.06-2.58)	0.026
Vaginal and caesarean delivery	3,224	Birth order	1.69 (1.12-2.54)	0.012
		Caesarean delivery	2.14 (1.25-3.66)	0.006

Adjusted for birth weight, head circumference, gestational age, malpresentation. Abbreviations: aOR, adjusted odds ratio; CI, confidence interval.

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