Twin pregnancy represents a unique obstetric entity associated with increased maternal and perinatal risks when compared to singleton gestations. The physiological adaptations required to support two fetuses place additional strain on maternal systems, predisposing women to a higher incidence of complications such as anemia, hypertensive disorders, hemorrhage, and operative delivery [1]. The global incidence of twin pregnancies has increased over the past few decades, largely due to the widespread use of assisted reproductive technologies and delayed childbearing [2].

Maternal complications in twin pregnancies can occur throughout the continuum of pregnancy, including the antepartum, intrapartum, and postpartum periods. Antepartum complications such as anemia, preeclampsia, gestational diabetes, and preterm labor are reported more frequently in twin gestations [3]. Intrapartum risks include malpresentation, dysfunctional labor, and increased rates of cesarean delivery [4]. The postpartum period is particularly critical, with postpartum hemorrhage being one of the leading causes of maternal morbidity due to uterine overdistension and atony [5].

Despite advances in obstetric care, twin pregnancies continue to contribute disproportionately to maternal morbidity, particularly in low- and middle-income countries where access to specialized care may be limited [6]. Tertiary care centers play a pivotal role in managing such high-risk pregnancies by providing multidisciplinary care, advanced monitoring, and timely interventions.

There is a need for institution-based prospective data to better understand maternal outcomes in twin pregnancies within specific populations. Such data can guide clinical protocols, resource allocation, and patient counseling. The present study, conducted at a tertiary care center, aims to systematically evaluate maternal outcomes in twin pregnancies, focusing on demographic factors, significant history, and complications occurring during the antepartum, intrapartum, and postpartum periods.

OBJECTIVE

To study maternal outcomes in twin pregnancies managed at a tertiary care centre, with emphasis on maternal demographics, significant obstetric history, and antepartum, intrapartum, and postpartum complications.

MATERIALS AND METHODS

This prospective observational study was conducted at a tertiary care teaching hospital. All pregnant women diagnosed with twin gestation and admitted for antenatal care or delivery during the study period were included. All women with ultrasonographically confirmed twin pregnancy were enrolled into the study. Women with higher-order multiple pregnancies were excluded.

Detailed maternal data were collected using a predesigned proforma, including age, obstetric and medical history, and complications during pregnancy, labor, and the postpartum period. Maternal outcomes were categorized as antepartum, intrapartum, and postpartum complications. Data were entered and analyzed descriptively. Results were expressed as numbers and percentages and presented in tabular and narrative form.

RESULTS

A total of 100 women with twin pregnancies were included in the present prospective observational study. The maternal age of women with twin pregnancy ranged from 19 to 38 years, with a mean age of 26.18 ± 4.64 years. The majority of cases belonged to the 21–25-year age group (42%), followed by 26–30 years (29%). Together, 71% of women were between 21 and 30 years of age. Women aged less than 20 years constituted 9%, while 18% were in the 31–35-year age group. Only 2% of women were aged more than 35 years (Table 1).

Most women (75%) had no significant past history and conceived spontaneously. A history of treatment for infertility was present in 18% of cases. Family history of twin pregnancy was noted in 4%, while 3% had a past history of twin pregnancy (Table 2).

Table 1: Distribution of Cases According to Maternal Age

Table 2: Distribution of Cases According to Significant History

Table 3: Antepartum Complications in Mothers with Twin Pregnancy

Table 4: Intrapartum Complications in Mothers with Twin Pregnancy

Table 5: Postpartum Complications in Mothers with Twin Pregnancy

Antepartum complications were common among women with twin pregnancies. The most frequent complication was preterm labour, observed in 38% of cases. Pregnancy-induced hypertension (PIH) occurred in 30%, while preterm premature rupture of membranes (PPROM) was seen in 20%. Anemia was documented in 13% of women. PROM was present in 10%, antepartum eclampsia in 2%, and placenta previa and abruptio placentae were observed in 1% each (Table 3).

Intrapartum complications were observed in a subset of cases, with malpresentation being the most common, occurring in 31% of women. Prolonged labour and deep transverse arrest (DTA) were each noted in 2% of cases. Hand prolapse, cord presentation, and non-progress of labour (NPOL) were seen in 1% each. Obstetric hysterectomy was required in 1% of cases. There was no maternal mortality reported in the study population (Table 4).

Postpartum complications occurred in 13% of women. The most common postpartum complication was postpartum hemorrhage (PPH), affecting 11% of cases. Atonic PPH was observed in 7%, while traumatic PPH and mixed PPH occurred in 2% each. Postpartum eclampsia was noted in 2% of women. The majority of women (87%) had no postpartum complications (Table 5).

DISCUSSION

The present study demonstrates that twin pregnancies are associated with a substantial burden of maternal morbidity spanning the antepartum, intrapartum, and postpartum periods. The predominance of women in the 21–30-year age group reflects peak reproductive age and is consistent with earlier Indian studies on twin gestations [7]. Increasing use of fertility treatments and improved access to antenatal care may also contribute to this age distribution.

Antepartum complications were frequent in the present cohort, with anemia and hypertensive disorders emerging as the most common conditions. This finding aligns with prior literature reporting significantly higher rates of anemia and pregnancy-induced hypertension in twin pregnancies due to increased nutritional demands, expanded placental mass, and exaggerated physiological changes [8,9]. Similar trends have been reported in prospective Indian cohorts evaluating maternal risk profiles in multiple gestations [10,11].

Intrapartum morbidity remains an important concern in twin pregnancies. Increased obstetric interventions and labor-related complications observed in this study are well documented in previous studies, which attribute these outcomes to malpresentation, uterine overdistension, and dysfunctional labor patterns common in twin gestations [4,12]. Data from tertiary care centers in India have similarly reported higher intrapartum complication rates among twin pregnancies compared to singletons, emphasizing the need for skilled intrapartum monitoring and timely decision-making [13].

Postpartum complications were observed in 13% of women in the present study, with postpartum hemorrhage being the most common adverse outcome. Uterine atony secondary to overdistension remains the leading mechanism underlying postpartum hemorrhage in twin gestations [14]. Comparable rates of postpartum hemorrhage have been reported in recent Indian observational studies on twin pregnancy outcomes, reinforcing the need for active management of the third stage of labor and preparedness for obstetric emergencies [10,15]. The occurrence of postpartum eclampsia, though limited, highlights the persistence of hypertensive risk beyond delivery and underscores the importance of continued postpartum surveillance [16].

Recent Indian literature further supports the findings of this study. Prospective observational studies conducted at tertiary care centers have demonstrated that twin pregnancies are consistently associated with higher maternal complication rates, particularly anemia, hypertensive disorders, operative deliveries, and postpartum hemorrhage [10,11]. These studies emphasize that maternal morbidity in twin gestations remains a major clinical challenge even in well-equipped healthcare settings.

Overall, the findings of the present study are concordant with contemporary national and international evidence, reaffirming that twin pregnancies should be managed as high-risk from early gestation through the postpartum period. Institutional delivery at tertiary care centers with multidisciplinary expertise remains central to improving maternal outcomes.

CONCLUSION

Twin pregnancies are associated with increased maternal morbidity across all stages of pregnancy. Anemia, hypertensive disorders, and postpartum hemorrhage remain the leading contributors to adverse maternal outcomes. Early risk identification, vigilant monitoring, and delivery in tertiary care settings are essential to improve maternal safety.

ACKNOWLEDGEMENT

The authors acknowledge the Department of Obstetrics and Gynecology, GMC, Kota and all participants for their cooperation during the study. The authors also thank Dr. Shailendra Vashistha (Assistant Professor, Dept of IH&TM, GMC, Kota) and The VAssist Research Team (www.thevassist.com) for their contribution in manuscript editing and submission process.

DECLARATION

Conflicts of interests: The authors declare no conflicts of interest.

Author contribution: All authors have contributed in the manuscript.

Author funding: Nill.

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