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Twins - Epidemiology, New Advances in Delivery and Treatment 

Only one in fifty twin pregnancies survives as opposed to one in four of the singletons and it is postulated that one in eight human conceptions started as twins. There are probably many of you in this room who started as twins.  Statistics show that the number of twins has increased to over 100,000; we now have about 3000 sets of triplets a year and about 400 to 500 of higher order; all of these are high-risk pregnancies. The reason that we have the dilemma, not only in the United States, but around the world, is because of the trend toward delaying childbirth.

Here is the basis of the problem of multiple pregnancy. Here is a worldwide statistic that has not changed in forty years. These babies are destined to be preterm and low birth weight. Twins are 37 weeks and it goes down the line until you have quintuplets at 26 to 27 weeks. All of our neonatal intensive care work, all the steroids, all the stuff we give.

Now this is English data. I could re-do it using American data. The picture that you see here is perfectly valid; you see four lines. Here are the singletons, here are the twins, here are the triplets and here are the quadruplets. These are the cumulative birth weight distributions. Nothing has changed since they made this slide in about 1990 using 1980 to 1985 data.

Now this slides comes from Holland and it talks about the increasing number of multiples that are occupying the beds in our neonatal intensive care units all over the world. This is now in East Flanders, in Belgium. It is now to a point where they almost have to have reservations for a set of multiples to get into the neonatal intensive care unit. London has a system very similar to the

Now here you have an interesting slide, because it shows you something about twins; 2.6% of live births, but 5 times more likely to be premature, 8-1/2 times more likely to be less than 2500 grams, 9 times more likely to be very low birth weight. In 2006, Greg Alexander, in Clinics of Obstetrics and Gynecology, I recommend this to any of you who want to see in one table the real problem affecting all of us. Here you have U.S. data from birth certificates dated 1991 through 1995 and you have the percentage of less than 37 weeks; for triplets, it is ninety-one

What is the relative risk of adverse birth outcomes? This is from a paper by Barbara Luke and myself in 1992. We standardized the low birth weight risk, the death risk, the handicap risk for the singletons to one. Now we look at the standardized relative risk for twins and triplets. Let's just look at the severe handicapped. The triplets are three and two times as much for severe and moderate, respectively. The twins also have a healthy increased relative risk over the singletons, when everything is standardized to one. Here you have the handicapped rate, the rate of handicaps per thousand neonatal survivors. Any way you want to slice this cake, the higher the order of birth, the greater the risk of overall handicap - severe or moderate.

It is interesting that in France the risk of death, both early and late neonatal deaths, is clearly related to the socioeconomic status of the parents. We do not have a similar study on that subject from the United States. But it gives us pause to think about young girls who are in our

A lot can be said about prolongation of pregnancy. I would tell you that bed rest has never been proven, but it makes sense. Unfortunately, after lecturing on this topic for 20 years, I can't tell you what bed rest is. There isn't a definition in any textbook or in the literature that makes sense. Is it complete bed rest? Is it bathroom privileges? Is it a lounger? Can you get up for meals? No one has ever standardized it. But we do know, based on the French work, that a reduction of

The long-term sequela that is most feared is cerebral palsy. Have you ever met a mother who didn't want to have a healthy child? Have you ever met a mother who comes in and says that she wants children with cerebral palsy? Nonsense. There is not one of them around. Do you know mothers who want their children to be growth restricted? Do you know women who want their children to have language and cognition delays? No. But these are the problems that you see

Now I want to show you some Australian data. The reason I'm showing you Australian data, is that there is no United States data showing you the follow up of all the twins delivered in the last 20 years. In Western Australia, they wanted to know, so they devised a method to have

What are the factors that impinge upon the long-term growth? First of all, there is the birth size. Obviously, that is important. Babies who are born at 6 and 7 pounds are more likely to be adequately grown than babies who are 1500 grams. But no one ever stops to think about the

Lately, here are a few words about maternal fetal nutritional influences. Very few of us take the time, and we are not taught in our residency, about the catch up growth. What happens to these children afterwards. If you need to know more about this, look for the Louisville Twin Study. The growth will catch up after a number of years, so that by age 9, most of the comparisons between singletons and twins are lost. The twins are at their age-adjusted growth rate. The difference between the DZ and the MZ has gone away. The mental test scores increase from

Cervical dilatation at the onset of labor with nulliparous twins was analyzed by Manny Friedman for me for this lecture to tell you something. The twins invariably come in farther dilated. We are not talking about preterm labor. At the onset of labor, they are farther dilated than the singletons. He also showed that the conditions which favor a normal labor in twins are

A word about the second twin. There is no agreement in the literature about this. There is no agreement on when to rupture the membranes; no agreement on the safest delivery route. Most Americans will do a cesarean section at the drop of a hat. Many of the people who come here do not deliver breech twins. That may be because they don't deliver breeches. There is simply no consensus in the United States. It's not the end of the world if the first one comes out

This is another study from Barbara Luke, put together at Rush by Luke and the vice-president of finance of the hospital. Clearly, the cost of these multiples is not because they are multiples, but because of the prematurity. You have here a 28-time differential in the cost per infant from a singleton to a twin at those ages. The parents do not get off easy here. There is depression, there is divorce, there may be a need for charity or state aid, because people can't pay for all the

Should we regulate IVF and ET? Well, they do it in many countries. Should we stop the Wild West atmosphere of putting in seven embryos or letting somebody have intercourse when they have nine follicles about to ripen? Is this good medical ethics, or are we doing the patient no favor? These are some things to think about for the future. Certainly, we will improve the lot of