title: Actual controversies in twin delivery: from the analysis of the case histories to a reasoned protocol.
abstract: OBJECTIVE
  Twin pregnancy has to be considered a risk pregnancy. One of its most controversial aspects is delivery. There is no agreement on the following topics: gestational age at term (GA), mode of delivery, use of epidural analgesia or oxytocic acceleration, impact of chorionicity and amnionicity. The aim of this study was to develop a twin delivery management protocol.
  
  
  METHODS
  A retrospective study over a cohort population of 481 twin deliveries that occurred in the Department of Obstetrics of the San Raffaele Hospital of Milan (Italy) from 1996 to 2007 was conducted, and the results were compared with those present in literature.
  
  
  RESULTS
  Management of twin pregnancies that exceed the 37 week is controversial. There is an inclination towards fixing bichorionic and monochorionic pregnancy terms at 38 and 35 weeks respectively. In our case history, 73.8% of monochorionic and 15% of bichorionic pregnant women delivered after the 35 and 38 week respectively, without repercussions on the neonatal outcome. A longer gestational age appears to decrease the occurrence of lower Apgar scores and neonatal morbidity. This study, which exclusively considered twin pregnant women with both fetuses in cephalic presentation eligible for a vaginal delivery, did not find any significant differences in neonatal outcome among the types of deliveries. Moreover, the authors observed that the average maternal blood loss in cesarean section (CS) is significantly greater than that of vaginal deliveries.
  
  
  CONCLUSIONS
  In consideration of its safety for mother and fetuses, vaginal delivery of two cephalic fetuses at 38 and 35 weeks for bichorionic and monochorionic pregnancies respectively may be considered as a valid alternative to elective cesarean section.
authors.affiliation: Department of Gynecology and Obstetrics, IRCCS San Raffaele, Milan, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Valsecchi
authors.forename: A
authors.initials: A
authors.lastname: Serafini
authors.forename: L
authors.initials: L
authors.lastname: Maniscalsco
authors.forename: G
authors.initials: G
authors.lastname: Frontino
authors.forename: A
authors.initials: A
authors.lastname: Cardani
authors.forename: P
authors.initials: P
authors.lastname: Cavoretto
mesh_terms: D000328:Adult; D000465:Algorithms; D001720:Birth Injuries / Q000517:prevention & control*; D002585:Cesarean Section / Q000379:methods; D015331:Cohort Studies; D036861:Delivery, Obstetric / Q000379:methods*; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011256:Pregnancy Outcome; D011272:Pregnancy, Multiple; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D014427:Twins; D014429:Twins, Dizygotic; D014430:Twins, Monozygotic