Maternal Hemoglobin Decline following an Elective Cesarean Delivery of Women with Twin Gestations

Purpose: To investigate hemoglobin decline following cesarean delivery (CD) in twin gestations. Methods: A retrospective cohort study at a university affiliated tertiary medical center (2011–2022). The study group consisted of women with twin pregnancies who underwent elective CD. Data were compared to a reference group of women with singleton pregnancies who underwent elective CD. Hematological values within 48 hours prior to delivery and up to 6 hours following delivery were compared. Multivariate linear and logistic regression models identified risk factors for hemoglobin decline that was defined as the difference between the pre- and post- operative hemoglobin measurements. Estimated blood loss during surgery was assessed by the surgeon. Results :During the study period, 31,662 women underwent a CD in our center. Of them, 13,657 underwent elective CD, of whom 12,124 (88.7%) with singleton and 1,533 (11.3%) with twin pregnancies. Hemoglobin and hematocrit levels prior and following CD showed no significant differences between twin and singleton pregnancies (hemoglobin prior to CD: 12.11±1.15 g/dLvs.12.15±1.07g/dL,p=0.183; after CD: 11.34±1.46 g/dL vs. 11.38±1.18 g/dL, p=0.252). Delta hemoglobin, defined as the difference between pre- and post-CD levels, did not differ significantly between the study groups (0.79±1.1 g/dL vs.0.78±0.83 g/dL,p=0.825). The rate of hemoglobin decline exceeding 3 g/dL was higher in twin pregnancies in both univariate and multivariate analyses after adjusting for estimated blood loss during surgery evaluated by the surgeon (adjusted OR=1.79, 95% CI 1.01-3.17,p=0.04). Conclusion: Twin gestation is an independent risk factor for a greater hemoglobin decline, specifically more than 3 g/dL, even after controlling for bleeding during surgery.