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OBSTETRICS

Gestational age at delivery and perinatal

outcomes of twin gestations
Amy E. Doss, MD; Melissa S. Mancuso, MD; Suzanne P. Cliver, BA; Victoria C. Jauk, MPH, BSN; Sheri M. Jenkins, MD
OBJECTIVE: The optimal gestational duration for twin gestations is

unknown. Epidemiologic studies show that the lowest perinatal

mortality rate for twins is at 37-38 weeks, but these studies lack
information on pregnancy complications and neonatal morbidities.
This study evaluates pregnancy characteristics and perinatal outcomes of twins in order to assess the optimal gestational age for
delivery.
STUDY DESIGN: This is a retrospective study of twins delivered

at 36 weeks at our institution from 1991-2009. The composite

rate of perinatal morbidity and mortality (including perinatal death,
respiratory distress, suspected sepsis, and need for neonatal inten-

sive care) was determined for weekly intervals from 36-39

weeks.
RESULTS: There were 377 twin gestations included. Of those 83%

were dichorionic. Fifty-three percent had spontaneous labor and 48%

were delivered by cesarean section. Perinatal outcomes improved as
gestational age advanced to 38 weeks.
CONCLUSION: Perinatal morbidity and mortality rates suggest that the

optimal time for delivery of twins is at 38 weeks or greater.

Key words: delivery, gestational age, perinatal morbidity, perinatal
mortality, twins

Cite this article as: Doss AE, Mancuso MS, Cliver SP, et al. Gestational age at delivery and perinatal outcomes of twin gestations. Am J Obstet Gynecol
2012;207:410.e1-6.

he optimal duration of pregnancy

for twin gestations is unknown and
may be shorter than that of singletons.
Several large epidemiologic studies have
shown that the lowest perinatal mortality rate for twins occurs at an earlier gestational age (GA) than singletons.1-3 A
study of data from the US National Center for Health Statistics, including 11.1
million singleton and 297,622 twin
births, showed that the lowest perinatal
mortality for singletons was at 39 to 41
weeks, but for twins was at 37 to 38
weeks. Moreover, as of 39 weeks, the
prospective risk of fetal death in an ongoing twin pregnancy exceeded the risk
of neonatal death, suggesting that delivFrom the Division of Maternal-Fetal Medicine,
Department of Obstetrics and Gynecology,
University of Alabama School of Medicine,
Birmingham, AL.
Received May 18, 2012; revised July 14, 2012;
accepted Aug. 7, 2012.
The authors report no conflict of interest.
Presented at the 31st annual meeting, Society
for Maternal-Fetal Medicine, San Francisco,
CA, Feb. 7-12, 2011.
Reprints are not available from the authors.
0002-9378/$36.00
2012 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2012.08.012

410.e1

ery by 39 weeks may improve perinatal

outcome.1 Another study of 88,936 infants of multiple gestations (96% twins)
from Japan found that the incidence of
stillbirth and early neonatal death gradually declined until 37-38 weeks and
then increased. These same outcomes for
singletons declined until 39 weeks before
increasing.2 A review of the Swedish
Medical Birth Registry including 32,942
twins showed that perinatal mortality
rates were lowest at 37-38 weeks.3 Other
smaller epidemiologic studies have also
shown that the lowest perinatal mortality rates for twins are at 37-38 weeks.4-6
These epidemiologic studies indicate
that the lowest perinatal mortality rates
for twin pregnancies occur at 37-38
weeks. However, because of their epidemiologic nature, these studies are limited
by lack of information about pregnancy
dating, chorionicity, and pregnancy
complications. In addition, they lack information about the important outcome
of neonatal morbidities. Previous studies
have addressed neonatal morbidities,
but have revealed conflicting results.
Some studies have suggested that twins
mature faster than singletons, and,
therefore, may be better equipped for
earlier delivery.7-9 Other studies have
shown increased neonatal morbidity for

American Journal of Obstetrics & Gynecology NOVEMBER 2012

twins delivered before 38 weeks when

compared with later delivery.5,10,11 Because of this conflicting information
about neonatal morbidities, the limitations of the epidemiologic studies at
evaluating perinatal mortality, and the
lack of major randomized controlled trials, there is no consensus on the optimal
gestational length for twins. This study
was designed to examine the perinatal
morbidity and mortality of twins delivered at or near term at our institution to
determine the optimal gestational duration for twin pregnancies.

M ATERIALS AND M ETHODS

This is a retrospective cohort study that
was approved by our Institutional Review Board. Our electronic obstetric record was queried to identify twin gestations that delivered at the University of
Alabama, Birmingham, from 1991-2009.
Only those twins delivered at 36 completed weeks or beyond were included.
Exclusion criteria were major fetal
anomalies, aneuploidy, and death of 1 or
both twins before 36 weeks. Deliveries
were categorized according to number of
completed weeks of gestation. GA was
determined by obstetric providers with
the use of standard criteria that took into

Obstetrics

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TABLE 1

Maternal demographics, maternal medical and obstetric

complications, and neonatal characteristics
Demographics
Maternal age, y

N 377 (%)
25.9a 6.3, 1449b

..............................................................................................................................................................................................................................................

Race

.....................................................................................................................................................................................................................................

African American

223 (59.2)

White

120 (31.8)

Other

34 (9.0)

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Insurance

.....................................................................................................................................................................................................................................

Public

280 (74.3)

Private

64 (17.0)

None

25 (6.6)

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................

Unknown

8 (2.1)

..............................................................................................................................................................................................................................................

Type of conception

.....................................................................................................................................................................................................................................

Spontaneous

353 (93.6)

.....................................................................................................................................................................................................................................

Assisted

23 (6.1)

Unknown

1 (0.3)

.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Maternal medical and obstetric complications

.....................................................................................................................................................................................................................................

Diabetes

............................................................................................................................................................................................................................

Gestational

21 (5.6)

............................................................................................................................................................................................................................

Preexisting

6 (1.6)

..............................................................................................................................................................................................................................................

Chronic hypertension

25 (6.6)

Smoking

74 (19.7)

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
2

Obesity (BMI 30 kg/m )

131 (34.7)

Gestational hypertension

57 (15.1)

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Preeclampsia

.....................................................................................................................................................................................................................................

Mild

52 (13.8)

.....................................................................................................................................................................................................................................

Severe

7 (1.9)

..............................................................................................................................................................................................................................................

Prior cesarean delivery

60 (15.9)

Fetal growth restriction

43 (11.4)

Oligohydramnios

31 (8.2)

Polyhydramnios

3 (0.8)

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Premature ruptured membranes

17 (4.5)

..............................................................................................................................................................................................................................................

Neonatal characteristics

.....................................................................................................................................................................................................................................

Mean birthweight, g

2594 416

.....................................................................................................................................................................................................................................

Apgar score 7 at 5 min

21 (2.8)

Small for gestational age

193 (25.6)

Neonatal intensive care admission

129 (17.1)

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................

Suspected sepsis

83 (11.0)

Respiratory distress

76 (10.1)

.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

BMI, body mass index.

a

Mean; b Range.

Doss. Gestational age and perinatal outcomes of twins. Am J Obstet Gynecol 2012.

Research

consideration the clinical history and the

results of the earliest ultrasound (US) examination.12 If the findings on US examination were consistent with a GA based
on a certain date of the last menstrual
period (LMP), GA was determined according to the date of the LMP; if the date
of the LMP was uncertain or the findings
on US examination were inconsistent
with a GA based on the date of the LMP,
GA was determined according to the results of the US examination. Specifically,
menstrual dating was used if the US measurements were 7 days from the LMP
before 22 weeks; if the US measurements
were 10 days from the LMP at 22-24
6/7 weeks; and if the US measurements
were 14 days from the LMP above 25
weeks.
Maternal and infant chart review was
used to obtain demographic information,
pregnancy complications, and pregnancy
outcomes. We collected information
about the type of conception (spontaneous vs assisted reproduction), maternal
medical conditions, smoking status, and
obesity rates (body mass index [BMI]
30 kg/m2 at the initial antepartum
visit). We also collected information
about pregnancy and delivery complications including chorioamnionitis, hypertensive disorders, prior cesarean delivery,
fetal growth restriction (FGR) (estimated
fetal weight 10th% for GA based on data
by Brenner et al13), oligohydramnios
(greatest vertical pocket of 2.0 cm), polyhydramnios (greatest vertical pocket of
8 cm), and meconium-stained amniotic fluid. Chorioamnionitis was determined clinically based on maternal temperature of 100.4F, maternal or fetal
tachycardia, and uterine tenderness.
Ampicillin and gentamicin were administered as per our standard treatment
protocol for chorioamnionitis. Gestational hypertension, preeclampsia, and
chronic hypertension were defined as
per guidelines from the American College of Obstetricians and Gynecologists.14,15 Chorionicity was determined
by US criteria and/or pathologic review
of fetal membranes (when available on
chart review). If the mother was given
antenatal corticosteroids during the
pregnancy, the name of the steroid and
number of doses were recorded. The

NOVEMBER 2012 American Journal of Obstetrics & Gynecology

410.e2

Research

Obstetrics

type of labor was determined for each

patient (induction vs spontaneous vs
none for those with planned cesarean delivery) and the indication for induction of
labor was recorded. Mode of delivery and
indication for cesarean delivery were determined. A notation was made regarding
the GA at initiation of antepartum fetal
surveillance and the type of testing received during the pregnancy.
Perinatal morbidity and mortality
rates for twins delivered at each week of
GA were collected. Thirty-nine to 41
week gestations were grouped into 1
group because of low numbers of deliveries beyond 39 weeks (n 6). The primary outcome was the composite rate of
perinatal morbidity and mortality (including perinatal death, any respiratory
distress, suspected sepsis, and neonatal
intensive care unit [NICU] admission)
at weekly intervals from 36 to 39 weeks.
Perinatal death rates included stillbirths
and neonatal deaths up to 28 days. Infants having any respiratory distress
were those admitted to the NICU with a
diagnosis of respiratory distress given by
the admitting physician. A notation was
made of the type of respiratory support
administered, if any was required. The
diagnosis of respiratory distress syndrome (RDS) required signs of respiratory distress, consistent radiologic features, and oxygen therapy with a fraction
of inspired oxygen (FIO2) of 0.40 or
greater for at least 24 hours. Infants had
suspected sepsis if they had clinical
findings suggesting infection and received a sepsis work-up including blood
and/or cerebrospinal fluid cultures and
were given broad-spectrum antibiotics.
Twin perinatal outcomes were compared with a matched group of singletons from our institution in order to determine whether twins appear to mature
earlier than singletons, ie, experience
lower morbidity than singletons at a
given GA. Twins were matched at a 1:1
ratio of randomly selected singletons by
year of delivery, GA week at delivery,
race, and gender of fetus.
Statistical analysis for this study was
performed using SAS statistical software
(version 9.1; SAS Institute Inc., Cary,
NC). Rates of the composite primary
outcome and its components were com410.e3

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TABLE 2

Maternal and obstetric conditions by gestational week of delivery

37 wks, %
(n 118)

38 wks, %
(n 84)

39 wks, %
(n 45)

P value
trend

Condition

36 wks, %
(n 130)

Diabetes

11.5

5.9

6.0

5.4

11.0

4.8

2.2

.43

Gestational HTN

13.1

17.8

15.5

13.3

.85

Preeclampsia

19.2

19.5

10.7

6.7

.02

.01

..............................................................................................................................................................................................................................................

Chronic HTN

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

.01

Steroids received

16.9

10.2

6.0

Spontaneous labor

59.2

53.4

47.6

40.0

.02

Cesarean section

43.9

50.9

50.0

46.7

.54

Growth restriction

15.4

11.9

8.3

4.4

.03

Oligohydramnios

6.2

5.9

13.1

11.1

.08

Polyhydramnios

1.5

0.9

.18

Meconium

4.6

4.3

9.5

13.3

.02

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

HTN, hypertension.
Doss. Gestational age and perinatal outcomes of twins. Am J Obstet Gynecol 2012.

pared using 2, Fisher exact tests, and

tests of trend. These same methods were
used to compare outcomes of twins with
singletons. Regression analysis was performed using general estimating equation framework to control for twin cluster correlations. Odds ratios (OR) were
determined and adjusted for factors that
were most likely to affect perinatal outcome which included race, chorionicity,
FGR, diabetes, chorioamnionitis, steroid
use, induction of labor, and delivery
mode. To further evaluate the role of

chorionicity on outcomes, the BreslowDay test for homogeneity was performed

after stratifying by twin chorionicity. Alpha was set at .05.

R ESULTS
Of the 435 twin gestations initially identified from our electronic obstetric record, 58 were excluded (31 for unknown
GA or GA 36 weeks, 18 for anomalies,
2 for fetal demise of 1 or both twins 36
weeks, 2 for delivery outside of our insti-

TABLE 3

Perinatal outcomes by gestational week of delivery

38 wks, %
(n 168)

39 wks, %
(n 90)

Perinatal outcome

36 wks, %
(n 260)

37 wks, %
(n 236)

Compositea

30.0

15.7

7.1

7.8

.01

NICU admission

28.9

15.3

6.6

7.8

.01

Suspected sepsis

18.5

9.3

5.4

4.4

.01

Any respiratory distress

P value

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

16.2

9.8

3.6

5.6

.01

Respiratory support

5.4

4.2

2.4

2.2

.41

Transient tachypnea

1.9

2.1

3.0

3.3

.76

Hyperbilirubinemia

5.8

1.3

0.6

0.0

.01

31.9

19.0

25.5

32.6

.71

1.2

0.4

0.6

1.1

.79

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

SGA

..............................................................................................................................................................................................................................................

Perinatal death

..............................................................................................................................................................................................................................................

NICU, neonatal intensive care unit; SGA, small for gestational age.
a

Composite includes perinatal death, NICU admission, suspected sepsis, or any respiratory distress.

Doss. Gestational age and perinatal outcomes of twins. Am J Obstet Gynecol 2012.

American Journal of Obstetrics & Gynecology NOVEMBER 2012

Obstetrics

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TABLE 4

ORs and 95% CIs of perinatal outcomes in twin gestationsa

36 wks

37 wks

38 wks

39 wks

6.0 (2.813.0)

2.6 (1.25.9)

Referent

1.6 (0.64.6)

NICU admission

6.3 (2.813.8)

2.8 (1.26.4)

Referent

1.8 (0.65.2)

Suspected sepsis

4.4 (1.711.0)

2.1 (0.85.6)

Referent

1.3 (0.44.7)

Any respiratory distress

4.7 (1.911.2)

3.0 (1.27.9)

Referent

2.1 (0.67.0)

Perinatal outcome
Composite

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

CI, confidence intervals; NICU, neonatal intensive care unit; OR, odds ratio.
a

Adjusted OR with 95% CIs shown (adjusted for race, chorionicity, fetal growth restriction, diabetes, chorioamnionitis, steroid use,
induction of labor, and delivery mode); b Composite includes perinatal death, NICU admission, suspected sepsis, or any
respiratory distress.

Doss. Gestational age and perinatal outcomes of twins. Am J Obstet Gynecol 2012.

tution, 1 for higher order multiple gestation, 3 for multiple exclusions, and 1 for
unknown reason). Three hundred seventy-seven twin gestations (754 infants)
remained that met inclusion and exclusion criteria. Table 1 shows patient demographics. The twin gestations were
dichorionic in 83% of cases and monochorionic in 17%, with 0.8% of all gestations being monoamniotic. The mean
GA at delivery was 37.5 weeks. There
were 5 deliveries at 40 weeks and 1 delivery at 41 weeks.
Fifty-six percent of women (210 of 377
twin gestations) had an uncomplicated
pregnancy, not affected by a maternal
medical condition or obstetric complication. For the 44% of women with a
complication, their coexistent medical
conditions and obstetric complications
are shown in Table 1. There were no elective deliveriesall patients had spontaneous labor or a medically indicated delivery. Specifically, 52.5% of the twin
pregnancies had spontaneous labor,
24.2% had induction of labor, and 23.3%
had no labor. Of the 91 patients who underwent labor induction, the 3 most
common indications were preeclampsia
or gestational hypertension (42 patients,
46.2%), suspected FGR (25 patients,
27.4%), and other maternal medical
complications (21 patients, 23.1%). Delivery was vaginal (operative or spontaneous) for 52% and by cesarean for 48%
of infants. The 2 most common indications for cesarean delivery were malpresentation (58%) or repeat cesarean delivery (27%). Intrapartum complications
were rarethe most frequent were
meconium-stained amniotic fluid (7%)

and chorioamnionitis (4%). Ten percent

of patients received betamethasone at
some point during the pregnancy and
the average number of doses was 2 injections. Ninety-five percent of patients received antepartum fetal monitoring
starting at a mean of 33 weeks and contraction stress tests and nonstress tests
were the most commonly used methods.
There were no cases of twin-twin transfusion syndrome that met the inclusion
criteria; all were excluded for meeting 1
or more of the exclusion criteria.
The neonatal characteristics of the 754
infants are shown in Table 1. The 3 most
common reasons for NICU admission
were respiratory distress or transient
tachypnea (91 infants), suspected sepsis
(83 infants), and small for gestational age
(SGA) (42 infants). Some of the infants
had more than 1 indication for NICU
admission. There were 6 perinatal deaths
(0.8% of all infants) with causes including unknown (1 loss at 38 weeks), a cord
accident (at 37 weeks), loss of a single
fetus in a monochorionic pair (at 36
weeks), and loss of both fetuses from uterine rupture after a motor vehicle collision
(at 36 weeks). Finally, a SGA male infant of
a dichorionic twin pair, born at 40 weeks 0
days, died on day of life 5 because of persistent pulmonary hypertension. His amniotic fluid was meconium-stained.
Univariate analysis of the maternal
diseases and obstetric conditions is
shown in Table 2 and of the perinatal
outcomes is shown in Table 3. The rates
of the composite perinatal outcome,
NICU admission, suspected sepsis, any
respiratory distress, and hyperbilirubinemia decreased as GA advanced. Lo-

Research

gistic regression analysis showed that our

primary outcome (the composite rate of
perinatal death, suspected sepsis, respiratory distress, and NICU admission)
was lowest at 38 weeks gestation. At 38
weeks, perinatal outcomes were significantly better than at 36 or 37 weeks, but
were not statistically significantly different from 39 weeks. Table 4 shows the
corresponding ORs. When stratified by
chorionicity, the Breslow-Day test for
homogeneity showed no significant differences in results for all of the outcomes
between monochorionic and dichorionic twins (P values ranging from .19 to
.70). When outcomes were evaluated for
only the uncomplicated pregnancies
(210 women with no medical or obstetric complications), there was an increased risk for the composite outcome
and NICU admission at 36 weeks compared with 38 weeks, OR, 3.1; 95% confidence interval, 1.27.8 and OR, 3.5;
95% confidence interval, 1.39.3 for
these outcomes, respectively. Results for
37 and 39 weeks were not statistically
different from 38 weeks.
When twin outcomes were matched to
those of similar singletons, Table 5 shows
that there were more perinatal complications in twins at 36 weeks, but outcomes
were similar from 37 weeks onward. Specifically, twins had significantly higher
rates of the composite perinatal outcome
and NICU admission than singletons at
36 weeks; there was also a trend toward a
higher rate of any respiratory distress
and hyperbilirubinemia for twins at 36
weeks. However, there were no statistically significant differences in the primary outcome or the individual outcomes between twins and singletons at
37, 38, or 39 weeks.

C OMMENT
This study showed that the lowest rate of
composite perinatal morbidity and mortality for twin gestations was at 38 weeks.
Compared with 38 weeks, there was a
6-fold increase in the composite outcome at 36 weeks and a nearly 3-fold increase at 37 weeks. The ORs for the individual components of the composite
outcome, including suspected sepsis, any
respiratory distress, and NICU admis-

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410.e4

410.e5

American Journal of Obstetrics & Gynecology NOVEMBER 2012

15.7

15.3

.01

18.8

.01

30.0

Twins, %
(n 236)

P value

Singletons, %
(n 250)

Twins, %
(n 260)
12.3

Singletons, %
(n 228)
.29

P value

7.1

Twins, %
(n 168)

38 wks

7.8

Singletons, %
(n 167)

.83

P value

7.8

6.4

Twins, % Singletons, %
(n 90) (n 126)

.68

P value

28.9

18.5

16.2

5.8

1.2

Suspected sepsis

Any respiratory distress

Hyperbilirubinemia

Perinatal death

18.9

.39

9.3

12.3

9.7

.35

.90

6.6

5.4

7.8

5.4

.66

.99

7.8

4.4

6.4

5.6

.68

.77

.08

9.8

9.7

.97

3.6

6.0

5.6

0.0

.30

.99

3.2

.50

.06

1.3

3.5

0.6

0.6

.11

.99

0.0

0.0

.25

0.4

0.0

.99

1.1

0.0

.42

Composite includes perinatal death, NICU admission, suspected sepsis, or any respiratory distress.

Obstetrics

Doss. Gestational age and perinatal outcomes of twins. Am J Obstet Gynecol 2012.

NICU, neonatal intensive care unit.

............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

0.0

............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2.4

............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

10.8

............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

15.6

............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

NICU admission

............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Composite

Perinatal outcome

37 wks

36 wks

Perinatal outcomes of twins compared with singletons by gestational week of delivery

39 wks

sion, were also lowest at 38 weeks. These

same outcomes were not statistically different from 39 weeks gestation, which
may be the result of too few patients at
the more advanced GAs. Similarly, there
was no difference in perinatal death rates
across GAs, likely because of the low
number of perinatal deaths in the overall
cohort.
Induction of labor in women with singleton pregnancies beyond 41 weeks has
been shown to reduce perinatal mortality.16 For twin pregnancies, the duration
of a prolonged or postterm pregnancy
has not been defined and the role of elective delivery in reducing perinatal mortality has not been evaluated. Epidemiologic studies suggest that the optimal GA
for twin deliveries is at 37-38 weeks
based on the lowest perinatal mortality
rates.1-6 However, these studies do not
address the important outcome of neonatal morbidities. In addition, they lack
specific information about the individual pregnancies that could have influenced their results.
One of the strengths of our study is
that it involves a large population of
twins managed at a single institution
with known individual maternal and
perinatal medical histories. Data were
collected about pregnancy dating, chorionicity, maternal and fetal complications, pregnancy management, and neonatal morbidity and mortality by GA. By
having known pregnancy dating and by
controlling for these other maternal and
fetal factors, our results may be more applicable in the clinical setting than the
previous epidemiologic studies. Our
study provides more complete information about neonatal outcomes in twin
pregnancies at various term or near term
gestational ages, which may allow for improvement in the timing of delivery for
some patients. An additional strength of
our study is that twin outcomes were
matched to similar singletons delivered
at our institution. This matching allowed
us to examine the perinatal morbidity
and mortality rates of twins compared
with singletons at a given GA of delivery.
If perinatal mortality rates for twins were
lower at an earlier GA relative to singletons (as seen in the large epidemiologic
studies) and if perinatal morbidities

TABLE 5

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were lower sooner, it would add support
for earlier delivery of twins.
We do acknowledge limitations of our
study, mostly because of its retrospective
nature. Neonatal complications that occurred after discharge from the initial
hospital stay would not have been available for review. Although we controlled
for chorionicity on the regression analysis and a test for homogeneity did not
suggest a difference in outcomes based
on chorionicity, a larger study would be
necessary to confirm that perinatal outcomes are similar between monochorionic and dichorionic twins, as we had a
limited number of monochorionic twin
sets (64 of 377). In addition, this study
included some patients with pregnancy
complications and thus, the results may
not be fully generalizable to uncomplicated twins gestations that are being considered for elective delivery. However, it
is important to note that slightly more
than half (56%) of the twin gestations in
this study had no maternal medical conditions or obstetric complications. When
this group was analyzed separately, there
remained a higher risk for the composite
outcome and NICU admission in those
infants delivered at 36 weeks compared
with 38 weeks. Lastly, 93.6% of twins included in this study were conceived
spontaneously and thus, the results may
not be generalizable to twins conceived
using assisted reproductive techniques.
Ideally, a large multicenter randomized,
controlled trial would be done to establish the optimal GA for twin deliveries.

In conclusion, the lowest composite

perinatal morbidity and mortality rate
for twin gestations in this study was at 38
weeks gestation. Perinatal morbidity at
38 weeks was lower than at 36 or 37
weeks, and less, but not statistically different from 39 weeks. Our study also
did not show lower perinatal morbidity
for twins relative to matched singletons
at the same GA. In fact, the composite
morbidity and mortality was higher for
twins at 36 weeks than singletons and
was not significantly different from 37
weeks onward. This would suggest that
twins do not necessarily mature earlier
than singletons and that, similar to singletons, early term delivery may increase
risk for neonatal morbidity. Therefore,
the optimal time for twins to deliver apf
pears to be at or beyond 38 weeks.
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