|Year : 2014 | Volume
| Issue : 1 | Page : 3-7
A review of twin deliveries in Aminu Kano Teaching Hospital, North-West Nigeria
Raphael Avidime Attah, Zakari Mohammed, Maimuna Gobir
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria
|Date of Web Publication||7-Apr-2014|
Raphael Avidime Attah
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano - PMB 3452
Source of Support: None, Conflict of Interest: None
Background: Twin pregnancy remains a high risk one, and its incidence varies from one ethnic group to the other. Twin delivery is also associated with increased neonatal and maternal morbidity and mortality. Objective: To det ermine the current incidence and document the complication of twin pregnancy in Kano, northwest Nigeria. Materials and Methods: A retrospective analysis of 231 cases of twin deliveries between 1 st January 2007 to 31 st December 2009, in Aminu Kano Teaching Hospital (AKTH) Kano was carried out. Results: During this study period, there were 15,233 deliveries and 353 cases of twin deliveries, giving an incidence of 2.3% or 1 in 43 deliveries. The mean maternal age and parity were 29.0 years and 2.6 respectively. The mean gestational age at delivery was 36.9 weeks, with a mean birth weight of 2.4 kg and 2.3 kg for the first and second twin respectively. Male twins constituted 50.3% of twin births. The commonest presentation of twins was Cephalic-cephalic in 52.2%. This was followed by breech-cephalic in 29.6%, cephalic-breech in 12.6% and breech- breech in 5.2%. Mode of delivery was vaginal in 57.4% while 40.0% delivered by Caesarean section. The commonest indication for the Caesarean section was due to breech presentation in the leading twin (75.0%). Hypertensive disorder in pregnancy was the commonest maternal complication accounting for 63.16%, increasing maternal morbidity and mortality, while prematurity was the leading cause of perinatal mortality. Conclusion: This study has shown that the incidence of twin pregnancy is high in Aminu Kano Teaching Hospital, Kano, northwest of Nigeria. It has also shown that twin delivery is associated with prematurity, malpresentations and operative delivery, therefore increased perinatal and maternal morbidity. It is therefore recommended that twin pregnancy should be supervised in a tertiary centre under a specialist care and where facility for neonatal support is available to improve its outcome and reduce perinatal morbidity and mortality.
Keywords: Complications, incidence, Kano, pregnancy, twin
|How to cite this article:|
Attah RA, Mohammed Z, Gobir M. A review of twin deliveries in Aminu Kano Teaching Hospital, North-West Nigeria. Niger J Basic Clin Sci 2014;11:3-7
|How to cite this URL:|
Attah RA, Mohammed Z, Gobir M. A review of twin deliveries in Aminu Kano Teaching Hospital, North-West Nigeria. Niger J Basic Clin Sci [serial online] 2014 [cited 2019 Feb 17];11:3-7. Available from: http://www.njbcs.net/text.asp?2014/11/1/3/130148
| Introduction|| |
Multiple pregnancies are high-risk pregnancies that are associated with more complications in the antenatal period, labour and delivery than that found with singleton pregnancy.  These pregnancies make a disproportionate contribution to perinatal morbidity and mortality far in excess of that due to multiplication of singleton risks by foetal numbers.  The perinatal mortality rate in twins is 3-5 times higher, , and in triplets, it is 10 times higher  than in singletons. Maternal complications also occur more frequentlyand are more severe. ,
Twin gestation results from either the division of a single fertilised ovum as in monozygotic twins (identical twins) or fertilisation of two separate ova as in dizygotic twins (fraternal twins). 
The incidence of monozygotic twins is constant at 3.9 per 1000 births worldwide,  and that of higher multiple (more than two) can be derived from Hellin's rule (1 in 80 n−1 pregnancies),  where n is the number of foetuses. The incidence of dizygotic twin gestation shows a racial variation, being lowest in Asia, intermediate in Whites, and highest in Blacks. It varies from 1.3 per 1000 births in Japan and 12 per 1000 births in the United States to 49 per 1000 births in western Nigeria.  The incidence of twins and higher-order multiple gestation has increased significantly over the past 15 years primarily because of the availability and increased use of ovulation-inducing drugs and assisted reproductive technology (ART).  Other risk factors for dizygotic twin pregnancy include: Age, race, parity and genetic and environmental factors.  The positive effect of increasing maternal age and parity has been demonstrated.  This is particularly true of women of about 40 years of age and with parity up to 7, while women of younger age (less than 20) and no previous children have twins less common compared to older multigravid women.  Twin-prone women are more easily fecundable, their average time of conception being estimated to be 2.2 months shorter than that of mothers of singletons.  Maternal size is also known to influence the frequency of twinning. Dizygotic twinning, for example, is reportedly more common in large and tall women than in small women and this may be related more to nutrition than just body size. ,, Twinning is, however, not influenced by the social class of women, ,,, but by previous history of twins and family history through the female descendants. , Dizygotic twinning is also more common among women who become pregnant soon after cessation of long-term oral contraception. This may be a reflection of high "rebound" gonadotrophin secretion. ,,
In view of the increasing incidence of twin pregnancy worldwide and its attendant foetal and maternal complications, it is important to constantly study this high-risk pregnancy. Hence, this study was conducted with an aim to determine the incidence and complications of twin pregnancy in AKTH.
| Materials and Methods|| |
This is a retrospective study of 231 cases of twin deliveries managed at AKTH over a 3-year period from 1 January 2007 to 31 December 2009. Data were obtained from the delivery records in labour room, the maternity operation theatre records and the patients' folders. The information obtained included the age of the patient, booking status, the parity, the gestational age at delivery, presentation of the foetuses, mode of delivery, birth weights, foetal outcomes and maternal complications. The data obtained were analysed using SPSS version 11, with the level of significance set at P < 0.05.
| Results|| |
The total number of deliveries during the 3-year period was 15,233 and there were 353 twin deliveries, giving an incidence of 1 in 43 deliveries (2.3%). However, only 231 case notes were available for evaluation and analysis, giving a retrieval rate of 65.4%. The mean age was 30.5 ± 5.28 years, as shown in [Table 1]. Majority of the women (47.2%) were in the age group 28-32 years; about 59.7% of the women were multiparous, with 40.3% being grand multiparous (parity of ≥ 5).
About 198 patients (85.7%) booked in AKTH, 27 (11.7%) booked elsewhere, and 6 (2.6%) did not book for antenatal care. The gestational age of twins at delivery ranged from 28.0 to 42.0 weeks with a mean of 36.9 weeks. The presentations of twins were cephalic-cephalic in 51.9%, breech-cephalic in 29.4%, cephalic-breech in 12.6%, and breech-breech in 5.2%.
One hundred and thirty-two (57.1%) twins were delivered by spontaneous vaginal delivery, 92 (39.8%) by caesarean section and 7 were delivered by instrumental vaginal deliveries, i.e. 2 forceps and 5 vacuum deliveries (3.0%) [Table 2].
|Table 2: Distribution of twins by foetal presentation and mode of delivery|
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The commonest indication for caesarean section in twin pregnancies was breech presentation in the leading twin [Table 3].
Maternal complications during pregnancy and intrapartum occurred in 10% of twin pregnancies of which hypertensive disorder [pregnancy-induced hypertension (PIH), pre-eclampsia, eclampsia] in pregnancy accounted for 43.5%, followed by preterm labour in 21.7% [Table 4].
The overall mean birth weight of the babies in this study was 2.4 ± 0.54 kg. The first twin had an average weight of 2.40 ± 0.55 kg while the second had an average weight of 2.35 ± 0.53 kg. There was no statistically significant difference between their mean birth weights (P = 0.05) [Table 5].
One hundred and ninety (50.27%) foetuses were males, while 188 (49.73%) were females.
There were 23 perinatal deaths in this study, giving a perinatal mortality rate of 100 per 1000 births; 11 (47.8%) and 9 (39.1%) occurred in the first and second twin, respectively, and 3 (13.0%) in both twins. Majority of the deaths (70.3%) occurred in preterm foetuses, while 29.7% were term infants. There was no maternal death in this study.
| Discussion|| |
The incidence of twinning reported from different geographical zones and within the same geographical regions of Nigeria varied widely. The incidence of twin deliveries in AKTH was 1 in 43 deliveries. This is lower than those reported from Afikpo, a south-eastern  region, and Ile-Ife in south-western , part of Nigeria. The incidence is, however, similar to that reported in Jos (1:43).  But it is higher than those reported among Caucasians, i.e. 1:67 or more. ,,,,,,,,
This suggests that the incidence of twinning is higher in the southern part of the country when compared to the northern part. The twinning rate in Nigeria appears to be influenced by ethnicity, with the Yorubas of south-western Nigeria having the highest twinning rate in the world.  This is possibly due to the high consumption of yam tubers which has been found to contain some clomiphene-like substance. , Twin deliveries are documented to occur more commonly with increasing maternal age up to mid-thirties, after which it drops sharply due to increasing follicle stimulating hormone level. ,
It is also common among grand multiparous women;  but in this study, the converse was the case as most of the patients were multiparous and aged between 28 and 32 years. However, this study was hospital based, and therefore, results of the study may not entirely reflect what may be obtained in the larger community.
The mean gestational age was 36.9 weeks, which is similar to the gestational age of 36 weeks reported in Ile-Ife  and by other authors, , although it is slightly higher than 35 weeks reported in the western world.  This little difference may be explained by the larger sample size used in the latter studies.
The commonest foetal presentation in twin pregnancy is cephalic-cephalic. This was observed in this study also as 51.9% of the foetal presentations were cephalic-cephalic. Non-cephalic presentation increases the risk of operative delivery.
The caesarean section rate was 40.0%. This specifies the high-risk nature of twin pregnancy. Breech presentation in the leading twin accounted for 75.0% of the caesarean section deliveries. In order to prevent foetal interlocking and its very high attendant foetal mortality, most obstetricians advocate delivery by caesarean section when the leading twin is breech and the second is cephalic. , This caesarean section rate is lower than 46% reported in USA  and much higher than 12.60% reported in Sagamu.  In the USA study, some twins with cephalic/breech presentation were delivered by caesarean section because it has been shown in a studies that the risk of anoxia to the second twin increases with vaginal delivery;  this may explain the difference observed in the caesarean section rate in this study. The difference with the Sagamu study may be because of the smaller sample size of that study.
The mean birth weights of the first and second twins were 2.40 ± 0.55 kg and 2.35 ± 0.53 kg, respectively, while the overall mean birth weight was 2.4 ± 0.54 kg. These are slightly higher than the mean birth weight reported in Malumfashi, northern Nigeria.  This might have been as a result of better nutrition and improvement in the attendance at the antenatal clinic in Kano, which is an urban setting, compared with Malumfashi, which is a rural area.
Maternal complications occurred in 10% of twin pregnancies in this study. This is much lower than the finding reported in Ile-Ife, Nigeria.  This may be due to the higher incidence of twinning in Ile-Ife compared to Kano where this study was done.
The commonest complication was hypertensive disorders which occurred in 43.5%, followed by preterm labour (21.7%). This is in contrast to the report from Ile-Ife in which prelabour rupture of membranes was the commonest complication.  This attests to the fact that hypertensive disease is a very common complication in pregnancy in the north-western part of Nigeria and is also among the top five causes of maternal mortality in this region.  Prematurity is a major contributor to perinatal morbidity and mortality in twin gestation worldwide,  and about 22.3% of foetuses in this study were delivered preterm. This is lower than the finding reported in Ilorin (33.3%), north-central Nigeria. 
| Conclusion|| |
Twin pregnancy remains a high-risk pregnancy with high caesarean section rate, high perinatal mortality, and high foetal, neonatal and maternal morbidity. It is, therefore, recommended that pregnant women should be educated on the risks of twin gestation and the need to have a supervised pregnancy and delivery in facilities with good neonatal support. Further study comparing the complication in singleton pregnancy with that of twin pregnancy is advocated. 
| References|| |
|1.||Olatunji AO. Twinning: A retrospective study at Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria. Nig Med Pract 2002;41:52-5. |
|2.||Fisk NM. Multiple pregnancies. In: Edmonds DK, editor. Dewhurst's Textbook of Obstetrics and Gynaecology. 7 th ed. Oxford: Blackwell Science Ltd (Publishers); 2008. p. 298-307. |
|3.||Bush MC, Pernoll ML. Multiple pregnancy. In: DeCherney AH, Nathan L, Goodwin TM, Laufer N, editors. Current Diagnosis and Treatment Obstetrics and Gynaecology. 10 th ed. New York: McGraw-Hill, International edition; 2007. p. 301-17. |
|4.||Campbell S, Lees C. Multiple gestations. Cited from Obstetrics by Ten Teachers. 18 th ed. CRC Press; 2006. p. 187-95. |
|5.||Leszczyñska-Gorzelak B, Oleszczuk YY, Kiczyñska A, Sawulicka-Oleszczuk H, Keith LG. Peculiarities of multiple pregnancy: Epidemiology. Ginekol Pol 2000;71:1327-33. |
|6.||Nkyekyer K. Multiple pregnancy. In: Kwawukume EY, Emuveyan EE, editors. Comprehensive Obstetrics in the Tropics. 1 st ed. Asante and Hittscher Printing Press Limited; 2002. p. 162-72. |
|7.||Bassey EA, Abasiattai AM, Udoma EJ, Asuquo EE. Outcome of twin pregnancy in Calabar, Nigeria. Global J Med Sci 2004;3:13-5. |
|8.||Aniekan MA, Aniefiok JU, Ntiense MU, Dolapo GS. Incidence and mode of delivery of twin pregnancies in Uyo, Nigeria. Nig Med J 2010;51:170-2. |
|9.||Kuti O, Owolabi AT, Fasubaa OB. Outcome of twin pregnancies in a Nigerian teaching hospital. Trop J Obstet Gynaecol 2006;23: |
|11.||Nwobodo EI, Bobzom DN, Obed J. Twin births at University of Maiduguri Teaching Hospital: Incidence, pregnancy complications and outcome. Niger J Med 2002;11:67-9. |
|12.||Mutihir JT, Pam VC. Obstetric outcome of twin pregnancies in Jos, Nigeria. Niger J Clin Pract 2007;10:15-8. |
|13.||Garite TJ, Clark RH, Elliot JP, Thorp JA. Twins and triplets: The effect of plurality and growth on neonatal outcome compared with singleton infants. Am J Obstet Gynecol 2004;191:700-7. |
|14.||American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Obstetrics; Society for Maternal-Fetal Medicine; ACOG Joint Editorial Committee. ACOG Practice Bulletin #56: Multiple gestation: Complicated twin, triplet, and high-order multifetal pregnancy. Obstet Gynecol 2004;104: |
|16.||Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap II LC, Wenstrom KD, editors. Multifetal gestation. In: Williams Obstetrics. 22 nd edition. McGrawHill; 2005. p. 911-48. |
|17.||Büscher U, Horstkamp B, Wessel J, Chen FC, Dudenhausen JW. Frequency and significance of preterm delivery in twin pregnancies. Int J Gynaecol Obstet 2000;69:1-7. |
|18.||Sunday-Adeoye I, Twomey ED, Egwuatu VE. A 20-year review of twin births at Mater Misericordiae Hospital, Afikpo, South Eastern Nigeria. Nig J Cli Pract 2008;11:231-4. |
|19.||Ilesanmi AO, Obisesan KA, Arowojolu AO, Fawole O, Roberts AO. Relative birth weight in twins. Nig Med J 2000;38:14-5. |
|20.||Prisilla D, Stephen O. Twin pregnancy: Controversies in management. RCOG 2010;12:179-85. |
|21.||El Kateb A, Ville Y. Update on twin-to-twin transfusion syndrome. Best Pract Res Clin Obstet Gynaecol 2008;22:63-75. |
|22.||Onyiriuka AN. Twin delivery: Comparison of incidence and foetal outcome in two health institutions in Benin City, Nigeria. Nig Q J Hosp Med 2009;19:1-5. |
|23.||Blondel B, Kaminski M. Trends in the occurrence, determinants, and consequences of multiple births. Semin Perinatol 2002;26:239-49. |
|24.||Shebl O, Ebner T, Sir A, Sommergruber M, Tews G. The role of mode of conception in the outcome of twin pregnancies. Minerva Ginecol 2009;61:141-52. |
|25.||Obiechina NJ, Okolie VE, Eleje G, Okechukwu Z, Anemeje O. Twin versus singleton pregnancies: The incidence, pregnancy complications, and obstetric outcomes in a Nigerian tertiary hospital. Int J Womens Health 2011;3:227-30. |
|26.||Qiu X, Lee SK, Tan K, Piedboeuf B, Canning R; Canadian Neonatal Network. Comparison of singleton and multiple-birth outcomes of infants born at or before 32 weeks of gestation. Obstet Gynecol 2008;111:365-71. |
|27.||Zhang J, Hamilton B, Martin J, Trumble A. Delayed interval delivery and infant survival: A population-based study. Am J Obstet Gynaecol 2004;191:470-6. |
|28.||Bryan E. The impact of multiple preterm births on the family. BJOG 2003;110(Suppl 20):24-8. |
|29.||Adeoye S, Ogbonnaya LU, Umeorah OU, Asiegbu O. Concurrent use of multiple antenatal care providers by women utilizing free antenatal care at Ebonyi State University Teaching Hospital, Abakaliki. Afr J Reprod Health 2005;9:101-6. |
|30.||Shinwell ES. Neonatal morbidity of very low birth weight infants from multiple pregnancies. Obstet Gynecol Clin North Am 2005;32:29-38, viii. |
|31.||Abasiattai AM, Bassey EA, Umoiyoho AJ. Foetal interlocking complicating twin pregnancy: A case report. Trop J Ostet Gynaecol 2006;23:183-4. |
|32.||Onah H. An overview of the medical causes of maternal morbidity and mortality. In: Leadership Training Module on Safe Motherhood in Nigeria. Benin City: Society of Gynaecology and Obstetrics of Nigeria (SOGON); 2005. p. 8-15. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]