{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T19:10:58Z","timestamp":1790190658685,"version":"4.1.0"},"reference-count":38,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2023,3,4]],"date-time":"2023-03-04T00:00:00Z","timestamp":1677888000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Objective: To determine and compare the safety and efficacy of different methods of induction of labor in twin gestations and their effect on maternal and neonatal outcomes. Methods: A retrospective observational cohort study was conducted at a single university-affiliated medical center. Patients with a twin gestation undergoing induction of labor at &gt;32 + 0 weeks comprised the study group. Outcomes were compared to patients with a twin gestation at &gt;32 + 0 weeks who went into labor spontaneously. The primary outcome was cesarean delivery. Secondary outcomes included operative vaginal delivery, postpartum hemorrhage, uterine rupture, 5 min APGAR &lt; 7, and umbilical artery pH &lt; 7.1. A subgroup analysis comparing outcomes for the induction of labor with oral prostaglandin E1 (PGE1), IV Oxytocin \u00b1 artificial rupture of membranes (AROM), and extra-amniotic balloon (EAB)+ IV Oxytocin was performed. Data were analyzed using Fisher\u2019s exact test, ANOVA, and chi-square tests. Results: 268 patients who underwent induction of labor with a twin gestation comprised the study group. 450 patients with a twin gestation who went into labor spontaneously comprised the control group. There were no clinically significant differences between the groups for maternal age, gestational age, neonatal birthweight, birthweight discordancy, and non-vertex second twin. There were significantly more nulliparas in the study group compared to the control group (23.9% vs. 13.8% p &lt; 0.001). The study group was significantly more likely to undergo a cesarean delivery of at least one twin (12.3% vs. 7.5% OR, 1.7 95% CI 1.04\u20132.85 p = 0.03). However, there was no significant difference in the rate of operative vaginal delivery (15.3% vs. 19.6% OR, 0.74, 95% CI 0.5\u20131.1 p = 0.16), PPH (5.2% vs. 6.9% OR, 0.75 95% CI 0.39\u20131.42 p = 0.37), 5-min APGAR scores &lt; 7 (0% vs. 0.2% OR, 0.99 95%CI 0.99\u20131.00 p = 0.27), umbilical artery pH &lt; 7.1 (1.5% vs. 1.3% OR, 1.12 95% CI 0.3\u20134.0), or combined adverse outcome (7.8% vs. 8.7% OR, 0.93 95% CI 0.6\u20131.4 p = 0.85). Furthermore, there were no significant differences in the rates of cesarean delivery or combined adverse outcomes in patients undergoing induction with oral PGE1 compared to IV Oxytocin \u00b1 AROM (13.3% vs. 12.5% OR, 1.1 95% CI 0.4\u20132.0 p = 1.0) (7% vs. 9.3% OR, 0.77 95% CI 0.5\u20133.5 p = 0.63 ) or EAB+ IV Oxytocin (13.3% vs. 6.9% OR, 2.1 95% CI 0.1\u20132.1 p = 0.53) (7% vs. 6.9% OR, 1.4 95% CI 0.15\u20133.5 p = 0.5) or between patients undergoing induction of labor with IV Oxytocin \u00b1 AROM and EAB+ IV Oxytocin (12.5% vs. 6.9% OR, 2.1 95% CI 0.1\u20132.4 p = 0.52) (9.3% vs. 6.9% OR, 0.98 95% CI 0.2\u20134.7 p = 0.54). There were no cases of uterine rupture in our study. Conclusions: Induction of labor in twin gestations is associated with a two-fold increased risk of cesarean delivery, although this is not associated with adverse maternal or neonatal outcomes. Furthermore, the method of induction of labor used does not affect the chances of success nor the rate of adverse maternal or neonatal outcomes.<\/jats:p>","DOI":"10.3390\/jcm12052041","type":"journal-article","created":{"date-parts":[[2023,3,6]],"date-time":"2023-03-06T02:06:43Z","timestamp":1678068403000},"page":"2041","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["Induction of Labor in Twins\u2014Double Trouble?"],"prefix":"10.3390","volume":"12","author":[{"given":"Miriam","family":"Lopian","sequence":"first","affiliation":[{"name":"Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel"},{"name":"Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lior","family":"Kashani-Ligumsky","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel"},{"name":"Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ronnie","family":"Cohen","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel"},{"name":"Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Izaak","family":"Wiener","sequence":"additional","affiliation":[{"name":"Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bat-Chen","family":"Amir","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel"},{"name":"Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yael","family":"Gold Zamir","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel"},{"name":"Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ariel","family":"Many","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel"},{"name":"Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hadar","family":"Rosen","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel"},{"name":"Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,3,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1069","DOI":"10.1056\/NEJMc1400242","article-title":"Fertility treatments and multiple births in the United States","volume":"370","author":"Gleicher","year":"2014","journal-title":"N. Engl. J. Med."},{"key":"ref_2","first-page":"1","article-title":"Births: Final data for 2020","volume":"70","author":"Osterman","year":"2021","journal-title":"Natl. Vital Stat. Rep."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"938","DOI":"10.1016\/S0002-9378(00)70350-4","article-title":"Hypertensive disorders in twin versus singleton gestations","volume":"182","author":"Sibai","year":"2000","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1002\/uog.17470","article-title":"Hidden high rate of pre-eclampsia in twin compared with singleton pregnancy","volume":"50","author":"Francisco","year":"2017","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"912","DOI":"10.1016\/S0002-9378(99)70324-8","article-title":"Gestational diabetes mellitus: Metabolic and blood glucose parameters in singleton versus twin pregnancies","volume":"181","author":"Schwartz","year":"1999","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1097\/00003081-199803000-00017","article-title":"What are the fetal growth patterns of singletons, twins, and triplets in the United States?","volume":"41","author":"Alexander","year":"1998","journal-title":"Clin. Obstet. Gynecol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"221.e1","DOI":"10.1016\/j.ajog.2016.04.044","article-title":"Dichorionic twin trajectories: The NICHD Fetal Growth Studies","volume":"215","author":"Grantz","year":"2016","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"569","DOI":"10.1111\/1471-0528.15530","article-title":"Prognosis of the co-twin following spontaneous single intrauterine fetal death in twin pregnancies: A systematic review and meta-analysis","volume":"126","author":"Mackie","year":"2018","journal-title":"BJOG Int. J. Obstet. Gynaecol."},{"key":"ref_9","first-page":"1","article-title":"Births: Final Data for 2018","volume":"68","author":"Martin","year":"2019","journal-title":"Natl Vital Stat Rep."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1107","DOI":"10.1093\/aje\/152.12.1107","article-title":"Mortality of twins and singletons by gestational age: A varying-coefficient approach","volume":"152","author":"Cheung","year":"2000","journal-title":"Am. J. Epidemiol."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"American College of Obstetricians and Gynecologists\u2019 Committee on Practice Bulletins\u2014Obstetrics, Society for Maternal-Fetal Medicine (2021). Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies. Obstet. Gynecol., 137, e145\u2013e162.","DOI":"10.1097\/AOG.0000000000004397"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1167","DOI":"10.1097\/01.AOG.0000260387.69720.5d","article-title":"Intrapartum management of twin gestations","volume":"109","author":"Cruikshank","year":"2007","journal-title":"Obstet. Gynecol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1053\/j.semperi.2012.02.004","article-title":"Delivery of Twins","volume":"36","author":"Lee","year":"2012","journal-title":"Semin. Perinatol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1181","DOI":"10.1016\/S0002-9378(98)70128-0","article-title":"Progression of labor in twin versus singleton gestations","volume":"179","author":"Schiff","year":"1998","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"664","DOI":"10.1097\/AOG.0000000000004308","article-title":"Length of the Second Stage of Labor in Women Delivering Twins","volume":"137","author":"Levin","year":"2021","journal-title":"Obstet. Gynecol."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Turton, P., Arrowsmith, S., Prescott, J., Ballard, C., Bricker, L., Neilson, J., and Wray, S. (2013). A comparison of the contractile properties of myometrium from singleton and twin pregnancies. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0063800"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1016\/j.ejogrb.2019.04.005","article-title":"Risk of cesarean after induction of labor in twin compared to singleton pregnancies","volume":"237","author":"Loscul","year":"2019","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1097\/AOG.0b013e31825f3643","article-title":"Induction of labor in twin compared with Singleton Pregnancies","volume":"120","author":"Taylor","year":"2012","journal-title":"Obstet. Gynecol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1804","DOI":"10.3109\/14767058.2013.804047","article-title":"Is induction of labor risky for twins compare to singleton pregnancies?","volume":"26","author":"Okby","year":"2013","journal-title":"J. Matern. Neonatal Med."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Mei-Dan, E., Asztalos, E.V., Willan, A.R., and Barrett, J.F.R. (2017). The effect of induction method in twin pregnancies: A secondary analysis for the twin birth study. BMC Pregnancy Childbirth, 17.","DOI":"10.1186\/s12884-016-1201-8"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Jonsson, M. (2015). Induction of twin pregnancy and the risk of caesarean delivery: A cohort study. BMC Pregnancy Childbirth, 15.","DOI":"10.1186\/s12884-015-0566-4"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"100724","DOI":"10.1016\/j.srhc.2022.100724","article-title":"Induction of labor in twin pregnancies\u2014A retrospective cohort study","volume":"32","author":"Mikaelsen","year":"2022","journal-title":"Sex. Reprod. Healthc."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"106.e1","DOI":"10.1016\/j.ajog.2014.07.056","article-title":"Risk factors for cesarean delivery in twin pregnancies attempting vaginal delivery","volume":"212","author":"Fox","year":"2015","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Davey, M.-A., and King, J. (2016). Caesarean section following induction of labour in uncomplicated first births- a population-based cross-sectional analysis of 42,950 births. BMC Pregnancy Childbirth, 16.","DOI":"10.1186\/s12884-016-0869-0"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"304","DOI":"10.1016\/j.ajog.2019.02.046","article-title":"Elective induction of labor at 39 weeks compared with expectant management: A meta-analysis of cohort studies","volume":"221","author":"Grobman","year":"2019","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1016\/S0029-7844(97)00213-5","article-title":"Oxytocin labor stimulation of twin gestations: Effective and efficient","volume":"90","author":"Bardettfausett","year":"1997","journal-title":"Obstet. Gynecol."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Santana, D.S., on behalf of the WHO Multi-Country Survey on Maternal and Newborn Health Research Network, Silveira, C., Costa, M.L., Souza, R.T., Surita, F.G., Souza, J.P., Mazhar, S.B., Jayaratne, K., and Qureshi, Z. (2018). Perinatal outcomes in twin pregnancies complicated by maternal morbidity: Evidence from the WHO Multicountry Survey on Maternal and Newborn Health. BMC Pregnancy Childbirth, 18.","DOI":"10.1186\/s12884-018-2082-9"},{"key":"ref_28","first-page":"663","article-title":"Perinatal problems in multiple births","volume":"107","author":"Dudenhausen","year":"2010","journal-title":"Dtsch. Arztebl. Int."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"ACOG Committee on Practice Bulletins\u2014Obstetrics (2009). ACOG Practice Bulletin No. 107: Induction of Labor. Obstet. Gynecol., 114, 386\u2013397.","DOI":"10.1097\/AOG.0b013e3181b48ef5"},{"key":"ref_30","first-page":"CD014484","article-title":"Low-dose oral misoprostol for induction of labour","volume":"2021","author":"Kerr","year":"2021","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_31","unstructured":"(2023, February 25). The Israeli Drug Registry, Available online: https:\/\/israeldrugs.health.gov.il\/#!\/medDetails\/037%2078%2025161%2000."},{"key":"ref_32","unstructured":"Israeli Ministry of Health Policy Updates (2023, February 25). Approval of Medicinal Preparations According to Rule 29 of the Israeli Pharama-cology Guidelines\u20141986, Available online: https:\/\/www.gov.il\/he\/departments\/policies\/mk19-2007."},{"key":"ref_33","unstructured":"The Israeli Society for Maternal and Fetal Medicine (2023, February 25). Guideline Number 11. Induction of Labor and Cervical Ripening. Available online: https:\/\/gynecology.mednet.co.il\/\u05de\u05d9\u05d9\u05dc\u05d3\u05d5\u05ea-\u05e0\u05d9\u05d9\u05e8\u05d5\u05ea-1-30\/."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1080\/14767050500463582","article-title":"Is misoprostol safe for labor induction in twin gestations?","volume":"19","author":"Bush","year":"2006","journal-title":"J. Matern. Neonatal Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1159\/000010114","article-title":"Case series of labor induction in twin gestations with an Intrauterine Balloon catheter","volume":"47","author":"Manor","year":"1999","journal-title":"Gynecol. Obstet. Investig."},{"key":"ref_36","first-page":"940","article-title":"Trial of labour in twin pregnancies: A retrospective cohort study","volume":"123","author":"Haas","year":"2015","journal-title":"BJOG Int. J. Obstet. Gynaecol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"882","DOI":"10.1016\/S0002-9378(99)70319-4","article-title":"Uterine rupture during induced or augmented labor in gravid women with one prior cesarean delivery","volume":"181","author":"Zelop","year":"1999","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"e110","DOI":"10.1097\/AOG.0000000000003078","article-title":"ACOG Practice Bulletin No. 205: Vaginal Birth after Cesarean Delivery","volume":"133","year":"2019","journal-title":"Obstet. Gynecol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/5\/2041\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T18:47:48Z","timestamp":1760122068000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/5\/2041"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,3,4]]},"references-count":38,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2023,3]]}},"alternative-id":["jcm12052041"],"URL":"https:\/\/doi.org\/10.3390\/jcm12052041","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,3,4]]}}}