1
|
Silvano A, Sisti G, Seravalli V, Strambi N, Parenti A, Amedei A, Witkin SS, Di Tommaso M. Changes in cytokine and sequestosome-1 levels during twin pregnancy progression: Association with outcome. Cytokine 2024; 180:156668. [PMID: 38851146 DOI: 10.1016/j.cyto.2024.156668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/07/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Twin pregnancies are associated with complications and adverse outcomes. The number of twin pregnancies has increased in the last decades, due to the use of assisted reproductive techniques and delayed childbearing. Analysis of changes that occur during twin pregnancy progression and their association with outcome will lead to improved clinical interventions. OBJECTIVE We evaluated if the plasma concentration of select cytokines and the level of sequestosome-1 (p62) in peripheral blood mononuclear cells (PBMCs) during each trimester of twin gestations was predictive of pregnancy outcome. STUDY DESIGN This prospective, observational study was conducted at Careggi University Hospital, Florence, Italy. Plasma from 82 women with twin pregnancies was collected in each trimester for measurement of interleukin (IL)-1β, IL-6, IL-10, IL-12 and tumor necrosis factor (TNF)-α. The intracellular PBMC concentration of p62, a protein involved in autophagy, kinase activity and cell differentiation, was also determined. RESULTS IL-1β (p < 0.001), IL-6 (p < 0.001), TNF-α (p < 0.001) and p62 (p < 0.05) increased from the 1st to the 2nd to the 3rd trimester. The TNF-α level was correlated with the IL-1β concentration in the 1st and 3rd trimesters p < 0.01) and with the IL-6 concentration in each of the three trimesters (p < 0.01). The intracellular p62 level in PBMCs was negatively correlated with the concentration of IL-1β in the 2nd trimester (p < 0.05) and negatively correlated with the IL-6 level in the 3rd trimester (p < 0.05). The TNF-α level was significantly higher in the 2nd (p < 0.05) and 3rd (p < 0.001) trimester in women with a spontaneous preterm delivery. The TNF-α concentrations in the 2nd (p < 0.05) and 3rd (p < 0.01) trimester, respectively, and 3rd trimester IL-6 (p < 0.01), were negatively associated with gestational age at delivery. The concentration of IL-6 was highest in the 2nd (p < 0.05) and 3rd (p < 0.05) trimesters in women who utilized assisted reproductive technologies. An elevated IL-1β level in the 3rd trimester was associated with gestational diabetes mellitus (p < 0.05). CONCLUSION Variations in cytokine levels between individual women during the three trimesters of twin gestations are predictive of spontaneous preterm delivery and the onset of gestational diabetes.
Collapse
Affiliation(s)
- Angela Silvano
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Florence, Italy
| | - Giovanni Sisti
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine, University of Arizona, USA
| | - Viola Seravalli
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Florence, Italy
| | - Noemi Strambi
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Florence, Italy
| | - Astrid Parenti
- Department of Health Sciences, Clinical Pharmacology and Oncology Section, University of Florence, Italy
| | - Amedeo Amedei
- Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Steven S Witkin
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, NY, USA; Department of Infectious Diseases and Parasitology, Laboratory of Virology, University of Sao Paulo Faculty of Medicine, Sao Paulo, Brazil
| | - Mariarosaria Di Tommaso
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Florence, Italy.
| |
Collapse
|
2
|
Antunes M, Matias A. Association between first-trimester uterine artery Doppler and crown-rump length with growth discordance: does it make a difference. J Perinat Med 2024; 52:638-644. [PMID: 38753440 DOI: 10.1515/jpm-2024-0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES The purpose of this study was to investigate the association between first-trimester uterine artery pulsatility index (UtA-PI) and crown-rump length discordance (CRLD) with growth discordance (GD) in twins and analyze the influence of chorionicity in these parameters. METHODS This retrospective analysis integrated data from the twin pregnancy database of Centro Hospitalar São João (2019-2023), including 184 fetuses, with 19 monochorionic and 73 dichorionic gestations. To determine the association between UtA-PI and CRLD with GD, correlation analyses were computed and linear regression models were carried out. Separate analyses were conducted for each type of placentation. Logistic regression analysis was carried out to determine the association of mean UtA-PI and CRLD with severe GD, defined as discordance ≥25 %. RESULTS GD≥25 % was detected in 9.80 % of pregnancies. A statistically significant difference between monochorionic and dichorionic gestations was found in crown-rump length (p=0.009), CRLD (p<0.001) and birth weight (p=0.025), but not in mean UtA-PI (p=0.853) or GD (p=0.556). Mean UtA-PI was significantly higher in discordant than in concordant pairs (p<0.001), but that association was not seen in CRLD (p=0.931). Mean UtA-PI and GD were correlated by the regression line "GD=3.844 × UtA-PI + 6.638", with R2 0.027. CRLD and GD were correlated by the regression line "GD=0.280 × CRLD + 10.79", with R2 0.010. Mean UtA-PI, but not CRLD, was significantly associated with severe GD (odds ratio, 22.753; p=0.002). CONCLUSIONS Mean UtA-PI, but not CRLD, is associated with GD. The prevalence of severe GD increases significantly with increasing mean UtA-PI.
Collapse
Affiliation(s)
- Maria Antunes
- Faculty of Medicine, 26705 University of Porto , Porto, Portugal
| | - Alexandra Matias
- Obstetrics and Gynecology, Faculty of Medicine, 26705 University of Porto , Porto, Portugal
| |
Collapse
|
3
|
Sabag DN, Pariente G, Sheiner E, Miodownik S, Wainstock T. Perinatal outcome and long-term hospitalization of triplets according to birth order. Birth 2024; 51:424-431. [PMID: 37975499 DOI: 10.1111/birt.12798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE The association between birth order and adverse perinatal outcomes has been well studied in twin pregnancies. However, little is known about the differences in immediate perinatal outcomes as well as long-term hospitalization of the offspring in triplet pregnancies according to their birth order. As such, we aimed to assess the differences in immediate perinatal outcomes and long-term hospitalizations among triplets by their birth order. METHODS In a retrospective hospital-based cohort study, immediate perinatal outcomes and long-term hospitalizations were compared among triplet siblings according to their birth order. Deliveries occurred between the years 1991 and 2021 in a tertiary medical center. The study groups were followed until 18 years of age for cardiovascular, respiratory, neurological, and infection-related hospitalizations. Generalized estimation equation (GEE) models were used to control for confounders. Kaplan-Meier survival curves were used to compare cumulative long-term hospitalization incidences and Cox proportional hazards models were performed to control for confounders. RESULTS The study included 117 triplet deliveries. Rates of small for gestational age (SGA) infants increased linearly by birth order (6.0%, 7.7%, and 15.4% for the first, second, and third siblings, respectively; p-value for trends = 0.035). Using a GEE model controlling for maternal age, being born third in a triplet pregnancy was independently associated with SGA (third vs. first sibling, adjusted OR 3.0, 95% CI 1.38-6.59, p = 0.005). No significant differences in cardiovascular, respiratory, neurological, and infection-related hospitalizations were noted among the first, second, and third siblings. Likewise, using Kaplan-Meier survival analyses, no significant differences in the cumulative incidence of long-term pediatric hospitalizations were noted between the siblings. In Cox proportional hazards models, controlling for weight and gender, birth order in a triplet pregnancy did not exhibit an association with long-term hospitalizations of the offspring. CONCLUSION Despite the association between birth order and SGA, birth order in triplets does not seem to have an impact on the risk for long-term offspring hospitalization.
Collapse
Affiliation(s)
- David Nadav Sabag
- Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Gali Pariente
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Shayna Miodownik
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Tamar Wainstock
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| |
Collapse
|
4
|
D'Antonio F, Khalil A. Reply. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:708. [PMID: 38695212 DOI: 10.1002/uog.27656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/01/2024] [Indexed: 06/22/2024]
Affiliation(s)
- F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
| |
Collapse
|
5
|
D'antonio F, Prasad S, Masciullo L, Eltaweel N, Khalil A. Selective fetal growth restriction in dichorionic diamniotic twin pregnancy: systematic review and meta-analysis of pregnancy and perinatal outcomes. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:164-172. [PMID: 37519089 DOI: 10.1002/uog.26302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/27/2023] [Accepted: 06/05/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE Most of the published literature on selective fetal growth restriction (sFGR) has focused on monochorionic twin pregnancies. The aim of this systematic review was to report on the outcome of dichorionic diamniotic (DCDA) twin pregnancies complicated by sFGR. METHODS MEDLINE, EMBASE and The Cochrane Library databases were searched. The inclusion criteria were DCDA twin pregnancies complicated by sFGR. The outcomes explored were intrauterine death (IUD), neonatal death and perinatal death (PND), survival of at least one and both twins, preterm birth (PTB) (either spontaneous or iatrogenic) prior to 37, 34, 32 and 28 weeks' gestation, pre-eclampsia (PE) or gestational hypertension, neurological, respiratory and infectious morbidity, Apgar score < 7 at 5 min, necrotizing enterocolitis, retinopathy of prematurity and admission to the neonatal intensive care unit (NICU). A composite outcome of neonatal morbidity, defined as the occurrence of respiratory, neurological or infectious morbidity, was also evaluated. Random-effects meta-analysis was used to analyze the data, and results are reported as pooled proportion or odds ratio (OR) with 95% CI. RESULTS Thirteen studies reporting on 1339 pregnancies with sFGR and 6316 pregnancies without sFGR were included. IUD occurred in 2.6% (95% CI, 1.1-4.7%) of fetuses from DCDA pregnancies with sFGR and 0.6% (95% CI, 0.3-9.7%) of those from DCDA pregnancies without sFGR, while the respective values for PND were 5.2% (95% CI, 3.5-7.3%) and 1.7% (95% CI, 0.1-5.7%). Spontaneous or iatrogenic PTB before 37 weeks complicated 84.1% (95% CI, 55.6-99.2%) of pregnancies with sFGR and 69.1% (95% CI, 45.4-88.4%) of those without sFGR. The respective values for PTB before 34, 32 and 28 weeks were 18.4% (95% CI, 4.4-38.9%), 13.0% (95% CI, 9.5-17.1%) and 1.5% (95% CI, 0.6-2.3%) in pregnancies with sFGR and 10.2% (95% CI, 3.1-20.7%), 7.8% (95% CI, 6.8-9.0%) and 1.8% (95% CI, 1.3-2.4%) in those without sFGR. PE or gestational hypertension complicated 19.9% (95% CI, 12.4-28.6%) of pregnancies with sFGR and 12.8% (95% CI, 10.4-15.4%) of those without sFGR. Composite morbidity occurred in 28.2% (95% CI, 7.8-55.1%) of fetuses from pregnancies with sFGR and 13.9% (95% CI, 6.5-23.5%) of those from pregnancies without sFGR. When stratified according to the sFGR status within a twin pair, composite morbidity occurred in 39.0% (95% CI, 11.1-71.5%) of growth-restricted fetuses and 29.9% (95% CI, 3.5-65.0%) of appropriately grown fetuses (OR, 1.9 (95% CI, 1.7-3.1)), while the respective values for PND were 3.0% (95% CI, 1.8-4.5%) and 1.6% (95% CI, 0.9-2.6%) (OR, 2.1 (95% CI, 1.0-4.1)). On risk analysis, DCDA pregnancies complicated by sFGR had a significantly higher risk of IUD (OR, 5.2 (95% CI, 3.2-8.6)) and composite morbidity or admission to the NICU (OR, 3.2 (95% CI, 1.9-5.6)) compared to those without sFGR, while there was no difference in the risk of PTB before 34 weeks (P = 0.220) or PE/gestational hypertension (P = 0.210). CONCLUSIONS DCDA twin pregnancies complicated by sFGR are at high risk of perinatal morbidity and mortality. The findings of this systematic review are relevant for counseling and management of complicated DCDA twin pregnancies, in which twin-specific, rather than singleton, outcome data should be used. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- F D'antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - S Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London, UK
| | - L Masciullo
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London, UK
| | - N Eltaweel
- Division of Biomedical Science, Warwick Medical School, University of Warwick, University Hospital of Coventry and Warwickshire, Coventry, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
| |
Collapse
|
6
|
Li S, Wu K, Zhou S, Yin B, Bai X, Zhu B. Predictive value of maternal serum placental growth factor levels for discordant fetal growth in twins: a retrospective cohort study. BMC Pregnancy Childbirth 2024; 24:10. [PMID: 38166739 PMCID: PMC10759688 DOI: 10.1186/s12884-023-06212-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Accurate prenatal recognition of discordant fetal growth in twins is critical for deciding suitable management strategies. We explored the predictive value of the level of maternal second-trimester placental growth factor (PLGF) as a novel indicator of discordant fetal growth. METHODS A total of 860 women pregnant with twins were enrolled, including 168 women with monochorionic twins (31 cases of discordant fetal growth and 137 without) and 692 with dichorionic twins (79 cases of discordant fetal growth and 613 without). Maternal second-trimester PLGF concentrations were measured via immunofluorescence. RESULTS Maternal second-trimester PLGF levels were significantly lower in women pregnant with twins who subsequently developed discordant fetal growth than in those who did not (monochorionic twin pregnancy: P < 0.001; dichorionic twin pregnancy: P < 0.001). A 3-4 fold difference in median PLGF concentrations was detected between the two groups with both monochorionic and dichorionic twin pregnancies. Maternal second-trimester PLGF levels were significantly correlated with birth weight differences (monochorionic twin pregnancy: r = - 0.331, P < 0.001; dichorionic twin pregnancy: r = - 0.234, P < 0.001). A receiver operating characteristic curve was used to evaluate the predictive efficiency. In monochorionic twin pregnancies, the area under the curve (AUC) was 0.751 (95% confidence interval [CI]: 0.649-0.852), and the cutoff value was 187.5 pg/mL with a sensitivity of 77.4% and specificity of 71.0%. In dichorionic twin pregnancies, the AUC was 0.716 (95% CI; 0.655-0.777), and the cutoff value was 252.5 pg/mL with a sensitivity of 65.1% and specificity of 69.6%. Based on the above cutoff values, univariate and multivariate logistic regression analyses were performed to calculate the odds ratios (OR) for the PLGF levels. After adjustment for potential confounding factors, low PLGF concentrations still significantly increased the risk of discordant fetal growth (monochorionic twin pregnancy: adjusted OR: 7.039, 95% CI: 2.798-17.710, P < 0.001; dichorionic twin pregnancy: adjusted OR: 4.279, 95% CI: 2.572-7.120, P < 0.001). CONCLUSIONS A low maternal second-trimester PLGF level is considered a remarkable risk factor and potential predictor of discordant fetal growth. This finding provides a complementary screening strategy for the prediction of discordant fetal growth and offers a unique perspective for the subsequent research in this field.
Collapse
Affiliation(s)
- Shuai Li
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, 310006, China
- Department of Clinical Laboratory, Jilin Hospital of Women's Hospital, School of Medicine, Zhejiang University, 555 Xiwuma Road, Changchun, 130042, China
| | - Kaiqi Wu
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, 310006, China
| | - Shaomin Zhou
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, 310006, China
| | - Binbin Yin
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, 310006, China
| | - Xiaoxia Bai
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, 310006, China.
- Traditional Chinese Medicine for Reproductive Health Key Laboratory of Zhejiang Province, 1 Xueshi Road, Hangzhou, 310006, China.
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, 1 Xueshi Road, Hangzhou, 310006, China.
- Key Laboratory of Women's Reproductive Health, 1 Xueshi Road, Hangzhou, 310006, China.
| | - Bo Zhu
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, 310006, China.
| |
Collapse
|
7
|
Pinho BB, Neves M, Pasion R, Matias A. Velamentous cord insertion in monochorionic twin pregnancies: a step forward in screening for twin to twin transfusion syndrome and birthweight discordance? J Perinat Med 2023; 51:1147-1153. [PMID: 37323000 DOI: 10.1515/jpm-2023-0161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/11/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Two major complications of monochorionic diamniotic (MCDA) twin pregnancies are twin to twin transfusion syndrome (TTTS) and birthweight discordance. The current screening ultrasound test for these pathologies combines the detection of nuchal translucency discrepancy and abnormal ductus venosus in at least one twin, in the first trimester. We aim to determine whether combining the presence of velamentous cord insertion in at least one twin increases screening efficiency. METHODS This was a retrospective cohort with a sample of 136 MCDA twin pregnancies followed at Centro Hospitalar Universitário São João, during a 16-year period. RESULTS The combination of abnormal ductus venosus in at least one twin and nuchal translucency discrepancy is associated with the development of TTTS with an OR of 10.455, but not with birthweight discordance. The combination of these first trimester markers with velamentous cord insertion is not associated with the development of either outcome. CONCLUSIONS The presence of velamentous cord insertion in MCDA pregnancies is not associated to TTTS development. Therefore, the addition of this marker to the first trimester screening would not effectively predict the development of birthweight discordance or TTTS. However, a positive currently used screening test increases the risk of developing TTTS by about ten times.
Collapse
Affiliation(s)
- Beatriz B Pinho
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mafalda Neves
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Rita Pasion
- HEI-LAB, Lusófona University, Porto, Portugal
| | - Alexandra Matias
- Department of Obstetrics and Gynecology, University Hospital of S. João, Faculty of Medicine, i3S, Porto, Portugal
| |
Collapse
|
8
|
Giouleka S, Tsakiridis I, Mamopoulos A, Kalogiannidis I, Athanasiadis A, Dagklis T. Fetal Growth Restriction: A Comprehensive Review of Major Guidelines. Obstet Gynecol Surv 2023; 78:690-708. [PMID: 38134339 DOI: 10.1097/ogx.0000000000001203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Importance Fetal growth restriction (FGR) is a common pregnancy complication and a significant contributor of fetal and neonatal morbidity and mortality, mainly due to the lack of effective screening, prevention, and management policies. Objective The aim of this study was to review and compare the most recently published influential guidelines on the management of pregnancies complicated by FGR. Evidence Acquisition A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine, the International Federation of Gynecology and Obstetrics, the International Society of Ultrasound in Obstetrics and Gynecology, the Royal College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada (SOGC), the Perinatal Society of Australia and New Zealand, the Royal College of Physicians of Ireland, the French College of Gynecologists and Obstetricians (FCGO), and the German Society of Gynecology and Obstetrics on FGR was carried out. Results Several discrepancies were identified regarding the definition of FGR and small-for-gestational-age fetuses, the diagnostic criteria, and the need of testing for congenital infections. On the contrary, there is an overall agreement among the reviewed guidelines regarding the importance of early universal risk stratification for FGR to accordingly modify the surveillance protocols. Low-risk pregnancies should unanimously be evaluated by serial symphysis fundal height measurement, whereas the high-risk ones warrant increased sonographic surveillance. Following FGR diagnosis, all medical societies agree that umbilical artery Doppler assessment is required to further guide management, whereas amniotic fluid volume evaluation is also recommended by the ACOG, the SOGC, the Perinatal Society of Australia and New Zealand, the FCGO, and the German Society of Gynecology and Obstetrics. In case of early, severe FGR or FGR accompanied by structural abnormalities, the ACOG, the Society for Maternal-Fetal Medicine, the International Federation of Gynecology and Obstetrics, the Royal College of Obstetricians and Gynecologists, the SOGC, and the FCGO support the performance of prenatal diagnostic testing. Consistent protocols also exist on the optimal timing and mode of delivery, the importance of continuous fetal heart rate monitoring during labor, and the need for histopathological examination of the placenta after delivery. On the other hand, guidelines concerning the frequency of fetal growth and Doppler velocimetry evaluation lack uniformity, although most of the reviewed medical societies recommend an average interval of 2 weeks, reduced to weekly or less when umbilical artery abnormalities are detected. Moreover, there is a discrepancy on the appropriate timing for corticosteroids and magnesium sulfate administration, as well as the administration of aspirin as a preventive measure. Cessation of smoking, alcohol consumption, and illicit drug use are proposed as preventive measures to reduce the incidence of FGR. Conclusions Fetal growth restriction is a clinical entity associated with numerous adverse antenatal and postnatal events, but currently, it has no definitive cure apart from delivery. Thus, the development of uniform international protocols for the early recognition, the adequate surveillance, and the optimal management of growth-restricted fetuses seem of paramount importance to safely guide clinical practice, thereby improving perinatal outcomes of such pregnancies.
Collapse
Affiliation(s)
| | | | | | | | | | - Themistoklis Dagklis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| |
Collapse
|
9
|
Xia S, You K, Lin M, Huang L, He Z, Huang X, Luo Y. Intertwin nuchal translucency difference predicts the chance of co-twin death after fetal reduction in dichorionic triplet pregnancies: a retrospective analysis study. BMC Pregnancy Childbirth 2023; 23:747. [PMID: 37872490 PMCID: PMC10594729 DOI: 10.1186/s12884-023-06064-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/12/2023] [Indexed: 10/25/2023] Open
Abstract
OBJECTIVES To compare the clinical outcomes of different multifetal pregnancy reduction (MFPR) programs in dichorionic (DC) triplets, and explore the association between early ultrasound characteristics and co-twin death after potassium chloride (KCl) injection into one monochorionic (MC) twin. METHODS We retrospectively reviewed the data of DC triplets who underwent MFPR at our center during 2012-2021. Patients were grouped as follows: intracardiac KCl injection into one MC twin (group A), intracardiac KCl injection into both MC twins simultaneously (group B), and reduction of the singleton fetus (group C) and pregnancy outcomes were compared. Logistic regression was used to determine whether ultrasound measurements at 11-13+6 weeks predicted co-twin death and the receiver operator characteristic (ROC) analysis was conducted to assess the predictive performance. RESULTS Finally, we enrolled 184 patients. 153 cases were in group A, and 18, 13 cases were in group B and C respectively. Gestational age at the time of MFPR did not differ among the 3 groups (median: [Formula: see text] weeks). The survival rate was 89.6%, 88.9%, and 92.3% in group A, B, and C respectively, which was comparable among groups. Preterm birth was more common in group C (10/12, 83.3%). After KCl injection into one MC twin, co-twin death occurred in 86.3% cases (132/153) within 1 day; however, 3 patients had 2 live births each, with normal postnatal development. Intertwin nuchal translucency (NT) difference/discordance significantly predicted co-twin death within 1 day after MFPR, and the areas under the ROC curve were 0.694 and 0.689, respectively. CONCLUSIONS For MFPR in DC triplet pregnancies, reduction of the MC twins results in less preterm birth, and women with KCl injection into either one or both MC twins had similar outcomes. Large intertwin NT difference/discordance was associated with co-twin death within 1 day after KCl injection into one of the MC twins.
Collapse
Affiliation(s)
- Shuting Xia
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Kaniok You
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Minhuan Lin
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Linhuan Huang
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Zhiming He
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Xuan Huang
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Yanmin Luo
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China.
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China.
| |
Collapse
|
10
|
Lin J, Zhu Y, Wang B, Du T, Zhang K, Zhu Q, Lin J. Relationships between birth weight discordance and maternal and perinatal risks among twin pregnancies conceived following frozen embryo transfer. Hum Reprod 2023; 38:2011-2019. [PMID: 37451672 DOI: 10.1093/humrep/dead146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/18/2023] [Indexed: 07/18/2023] Open
Abstract
STUDY QUESTION Is intertwin birth weight discordance associated with adverse maternal and perinatal outcomes following frozen embryo transfer (FET)? SUMMARY ANSWER For twins conceived following FET, intertwin birth weight discordance is related to elevated risks of neonatal mortality irrespective of chorionicity, and the risk of hypertensive disorders of pregnancy (HDP) is elevated for the mothers of dichorionic twins affected by such birth weight discordance. WHAT IS KNOWN ALREADY While the relationships between intertwin birth weight discordance and adverse maternal or fetal outcomes have been studied for naturally conceived twins, similarly comprehensive analyses for twins conceived using ART remain to be performed. STUDY DESIGN, SIZE, DURATION This was a retrospective cohort study of all twin births from 2007 to 2021 at Shanghai Ninth People's Hospital in Shanghai, China that were conceived following FET (N = 6265). PARTICIPANTS/MATERIALS, SETTING, METHODS Intertwin birth weight discordance was defined as a 20% difference in neonatal birth weights. The primary study outcome was the incidence of HDP and neonatal death while secondary outcomes included gestational diabetes, placenta previa, placental abruption, intrahepatic cholestasis of pregnancy, preterm premature rupture of the membranes, Cesarean delivery, gestational age, birth weight, stillbirth, birth defect, neonatal jaundice, necrotizing enterocolitis, and pneumonia incidence. Logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% CIs for maternal and neonatal outcomes. Subgroup analyses were conducted, and Kaplan-Meier survival analysis was used to estimate the survival probability. The sensitivity analysis was performed with a propensity score-based patient-matching model, an inverse probability weighting model, a restricted cubic spline analysis, and logistic regression models using other percentage cutoffs for discordance. MAIN RESULTS AND THE ROLE OF CHANCE Of 6101 females that gave birth to dichorionic twins during the study interval, birth weight discordance was observed in 797 twin pairs (13.1%). In this cohort, intertwin birth weight discordance was related to an elevated risk of HDP (aOR 1.56; 95% CI 1.21-2.00), and this relationship was confirmed through sensitivity analyses. Hypertensive disease risk rose as the severity of this birth weight discordance increased. Discordant birth weight was also linked to increased odds of neonatal mortality (aOR 2.13; 95% CI 1.03-4.09) and this risk also increased with the severity of discordance. Of the 164 women with monochorionic twins, the discordant group exhibited an elevated risk of neonatal death compared to the concordant group (crude OR 9.00; 95% CI 1.02-79.3). LIMITATIONS, REASONS FOR CAUTION The limitations of this study are its retrospective nature and the fact that the available data could not specify which twins were affected by adverse outcomes. There is a lack of an established reference birth weight for Chinese twins born at a gestational age of 24-41 weeks. WIDER IMPLICATIONS OF THE FINDINGS These findings suggest that twins exhibiting a birth weight discordance are related to an elevated risk of adverse maternal and perinatal outcomes, emphasizing a potential need for higher levels of antenatal surveillance in these at-risk pregnancies. STUDY FUNDING/COMPETING INTEREST(S) Authors declare no conflict of interest. This study was funded by the Clinical Research Program of Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine (JYLJ202118) and the National Natural Science Foundation of China (Grant Nos 82271693 and 82273634). TRIAL REGISTRATION NUMBER N/A.
Collapse
Affiliation(s)
- Jing Lin
- Center for Reproductive Medicine, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanwen Zhu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bian Wang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tong Du
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kai Zhang
- Department of Interventional Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Qianqian Zhu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiaying Lin
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
11
|
Choi ES, Jung YM, Cho KD, Ha S, Sohn J, Hong SJ, Oh MJ, Park CW, Park JS, Jun JK, Lee SM, Cho GJ. Long-term adverse neurodevelopmental outcomes of discordant twins delivered at term: A nationwide population-based study. BJOG 2023; 130:1370-1378. [PMID: 37077036 DOI: 10.1111/1471-0528.17494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/14/2022] [Accepted: 03/26/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE To evaluate long-term adverse neurodevelopmental outcomes of discordant twins delivered at term. DESIGN Retrospective cohort study. SETTING Nationwide (Republic of Korea). POPULATION All twin children delivered at term between 2007 and 2010. METHODS The study population was divided into two groups according to inter-twin birthweight discordancy: the 'concordant twin group', twin pairs with inter-twin birthweight discordancy less than 20%; and the 'discordant twin group', twin pairs with inter-twin birthweight discordancy of 20% or more. The risk of long-term adverse neurodevelopmental outcomes was compared between the concordant twin group and the discordant twin group. Long-term adverse neurodevelopmental outcomes between smaller and larger twin children within twin pairs were further analysed. The composite adverse neurodevelopmental outcome was defined as the presence of at least one of the following: motor developmental delay, cognitive developmental delay, autism spectrum disorders/attention deficit hyperactivity disorders, tics/stereotypical behaviour or epileptic/febrile seizure. MAIN OUTCOME MEASURES Long-term adverse neurodevelopmental outcome. RESULTS Of 22 468 twin children (11 234 pairs) included, 3412 (15.19%) twin children were discordant. The risk of composite adverse neurodevelopmental outcome was higher in the discordant twin group than in the concordant twin group (adjusted hazard ratio [HR] 1.13, 95% CI 1.03-1.24). The long-term adverse neurodevelopmental outcomes were not significantly different between smaller and larger twin children in discordant twin pairs (adjusted HR 1.01, 95% CI 0.81-1.28). CONCLUSION In twin pairs delivered at term, an inter-twin birthweight discordancy of 20% or greater was associated with long-term adverse neurodevelopmental outcomes; and long-term adverse neurodevelopmental outcomes were not significantly different in smaller or larger twin children in discordant twin pairs.
Collapse
Affiliation(s)
- Eun-Saem Choi
- Department of Obstetrics and Gynaecology, Seoul National University Hospital, Seoul, Korea
- Department of Obstetrics and Gynaecology, Korea University Hospital, Seoul, Korea
| | - Young Mi Jung
- Department of Obstetrics and Gynaecology, Seoul National University Hospital, Seoul, Korea
- Department of Obstetrics and Gynaecology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu-Dong Cho
- Big Data Department, National Health Insurance Service, Gangwon-do, Korea
| | - Sungyeon Ha
- Graduate School of Statistics, Sungkyunkwan University, Seoul, Korea
| | - Jeongwon Sohn
- Department of Obstetrics and Gynaecology, Seoul National University Hospital, Seoul, Korea
| | - Su Jung Hong
- Department of Obstetrics and Gynaecology, Korea University Hospital, Seoul, Korea
| | - Min-Jeong Oh
- Department of Obstetrics and Gynaecology, Korea University Hospital, Seoul, Korea
| | - Chan-Wook Park
- Department of Obstetrics and Gynaecology, Seoul National University College of Medicine, Seoul, Korea
| | - Joong Shin Park
- Department of Obstetrics and Gynaecology, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Kwan Jun
- Department of Obstetrics and Gynaecology, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Mi Lee
- Department of Obstetrics and Gynaecology, Seoul National University Hospital, Seoul, Korea
- Department of Obstetrics and Gynaecology, Seoul National University College of Medicine, Seoul, Korea
- Innovative Medical Technology Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Geum Joon Cho
- Department of Obstetrics and Gynaecology, Korea University Hospital, Seoul, Korea
| |
Collapse
|
12
|
D'Antonio F, Marinceu D, Prasad S, Eltaweel N, Khalil A. Outcome following laser surgery of twin-twin transfusion syndrome complicated by selective fetal growth restriction: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:320-327. [PMID: 37204823 DOI: 10.1002/uog.26252] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE The published literature reports mostly on the outcome of twin pregnancies complicated by twin-twin transfusion syndrome (TTTS) without considering whether the pregnancy is also complicated by another pathology, such as selective fetal growth restriction (sFGR). The aim of this systematic review was to report on the outcome of monochorionic diamniotic (MCDA) twin pregnancies undergoing laser surgery for TTTS that were complicated by sFGR and those not complicated by sFGR. METHODS MEDLINE, EMBASE and Cochrane databases were searched. The inclusion criteria were studies reporting on MCDA twin pregnancies with TTTS undergoing laser therapy that were complicated by sFGR and those not complicated by sFGR. The primary outcome was the overall fetal loss following laser surgery, defined as miscarriage and intrauterine death. The secondary outcomes included fetal loss within 24 h after laser surgery, survival at birth, preterm birth (PTB) prior to 32 weeks of gestation, PTB prior to 28 weeks, composite neonatal morbidity, neurological and respiratory morbidity, and survival free from neurological impairment. All outcomes were explored in the overall population of twin pregnancies complicated by sFGR vs those not complicated by sFGR in the setting of TTTS and in the donor and recipient twins separately. Random-effects meta-analysis was used to combine data and the results are reported as pooled odds ratios (OR) with 95% CI. RESULTS Five studies (1710 MCDA twin pregnancies) were included in the qualitative synthesis and four in the meta-analysis. The overall risk of fetal loss after laser surgery was significantly higher in MCDA twin pregnancies with TTTS complicated by sFGR (20.90% vs 14.42%), with a pooled OR of 1.6 (95% CI, 1.3-1.9) (P < 0.001). The risk of fetal loss was significantly higher in MCDA twin pregnancies with TTTS and sFGR for the donor but not for the recipient twin. The rate of live twins was 79.1% (95% CI, 72.6-84.9%) in TTTS pregnancies with sFGR and 85.6% (95% CI, 81.0-89.6%) in those without sFGR (pooled OR, 0.6 (95% CI, 0.5-0.8)) (P < 0.001). There was no significant difference in the risk of PTB prior to 32 weeks of gestation (P = 0.308) or prior to 28 weeks (P = 0.310). Assessment of short- and long-term morbidity was affected by the small number of cases. There was no significant difference in the risk of composite (P = 0.506) or respiratory (P = 0.531) morbidity between twins complicated by TTTS with vs those without sFGR, while the risk of neurological morbidity was significantly higher in those with TTTS and sFGR (pooled OR, 1.8 (95% CI, 1.1-2.9)) (P = 0.034). The risk of neurological morbidity was significantly higher for the donor twin (pooled OR, 2.4 (95% CI, 1.1-5.2)) (P = 0.029) but not for the recipient twin (P = 0.361). Survival free from neurological impairment was observed in 70.8% (95% CI, 45.0-91.0%) of twin pregnancies with TTTS complicated by sFGR and in 75.8% (95% CI, 51.9-93.3%) of those not complicated by sFGR, with no difference between the two groups. CONCLUSIONS sFGR in MCDA pregnancies with TTTS represents an additional risk factor for fetal loss following laser surgery. The findings of this meta-analysis may be useful for individualized risk assessment of twin pregnancy complicated by TTTS and tailored counseling of the parents prior to laser surgery. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - D Marinceu
- Department of Obstetrics and Gynecology, The York Hospital, York, UK
| | - S Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - N Eltaweel
- Division of Biomedical Science, Warwick Medical School, University of Warwick, University Hospital Coventry and Warwickshire, Coventry, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
| |
Collapse
|
13
|
D’Antonio F, Eltaweel N, Prasad S, Flacco ME, Manzoli L, Khalil A. Cervical cerclage for prevention of preterm birth and adverse perinatal outcome in twin pregnancies with short cervical length or cervical dilatation: A systematic review and meta-analysis. PLoS Med 2023; 20:e1004266. [PMID: 37535682 PMCID: PMC10456178 DOI: 10.1371/journal.pmed.1004266] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 08/25/2023] [Accepted: 06/23/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND The optimal approach to prevent preterm birth (PTB) in twins has not been fully established yet. Recent evidence suggests that placement of cervical cerclage in twin pregnancies with short cervical length at ultrasound or cervical dilatation at physical examination might be associated with a reduced risk of PTB. However, such evidence is based mainly on small studies thus questioning the robustness of these findings. The aim of this systematic review was to determine the role of cervical cerclage in preventing PTB and adverse maternal or perinatal outcomes in twin pregnancies. METHODS AND FINDINGS Key databases searched and date of last search: MEDLINE, Embase, and CINAHL were searched electronically on 20 April 2023. Eligibility criteria: Inclusion criteria were observational studies assessing the risk of PTB among twin pregnancies undergoing cerclage versus no cerclage and randomized trials in which twin pregnancies were allocated to cerclage for the prevention of PTB or to a control group (e.g., placebo or treatment as usual). The primary outcome was PTB <34 weeks of gestation. The secondary outcomes were PTB <37, 32, 28, 24 weeks of gestation, gestational age at birth, the interval between diagnosis and birth, preterm prelabor rupture of the membranes (pPROM), chorioamnionitis, perinatal loss, and perinatal morbidity. Subgroup analyses according to the indication for cerclage (short cervical length or cervical dilatation) were also performed. Risk of bias assessment: The risk of bias of the included randomized controlled trials (RCTs) was assessed using the Revised Cochrane risk-of-bias tool for randomized trials, while that of the observational studies using the Newcastle-Ottawa scale (NOS). Statistical analysis: Summary risk ratios (RRs) of the likelihood of detecting each categorical outcome in exposed versus unexposed women, and (b) summary mean differences (MDs) between exposed and unexposed women (for each continuous outcome), with their 95% confidence intervals (CIs) were computed using head-to-head meta-analyses. Synthesis of the results: Eighteen studies (1,465 twin pregnancies) were included. Placement of cervical cerclage in women with a twin pregnancy with a short cervix at ultrasound or cervical dilatation at physical examination was associated with a reduced risk of PTB <34 weeks of gestation (RR: 0.73, 95% CI [0.59, 0.91], p = 0.005 corresponding to a 16% difference in the absolute risk, AR), <32 (RR: 0.69, 95% CI [0.57, 0.84], p < 0.001; AR: 16.92%), <28 (RR: 0.54, 95% [CI 0.43, 0.67], 0.001; AR: 18.29%), and <24 (RR: 0.48, 95% CI [0.23, 0.97], p = 0.04; AR: 15.57%) weeks of gestation and a prolonged gestational age at birth (MD: 2.32 weeks, 95% [CI 0.99, 3.66], p < 0.001). Cerclage in twin pregnancy with short cervical length or cervical dilatation was also associated with a reduced risk of perinatal loss (RR: 0.38, 95% CI [0.25, 0.60], p < 0.001; AR: 19.62%) and composite adverse outcome (RR: 0.69, 95% CI [0.53, 0.90], p = 0.007; AR: 11.75%). Cervical cerclage was associated with a reduced risk of PTB <34 weeks both in women with cervical length <15 mm (RR: 0.74, 95% CI [0.58, 0.95], p = 0.02; AR: 29.17%) and in those with cervical dilatation (RR: 0.68, 95% CI [0.57, 0.80], p < 0.001; AR: 35.02%). The association between cerclage and prevention of PTB and adverse perinatal outcomes was exclusively due to the inclusion of observational studies. The quality of retrieved evidence at GRADE assessment was low. CONCLUSIONS Emergency cerclage for cervical dilation or short cervical length <15 mm may be potentially associated with a reduction in PTB and improved perinatal outcomes. However, these findings are mainly based upon observational studies and require confirmation in large and adequately powered RCTs.
Collapse
Affiliation(s)
- Francesco D’Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Nashwa Eltaweel
- Division of Biomedical Science, Warwick Medical School University of Warwick, University Hospital of Coventry and Warwickshire, Coventry, United Kingdom
| | - Smriti Prasad
- Fetal Medicine Unit, St George’s Hospital, London, United Kingdom
| | - Maria Elena Flacco
- Department of Environmental and Preventive Sciences, University of Ferrara, Ferrara, Italy
| | - Lamberto Manzoli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Asma Khalil
- Fetal Medicine Unit, St George’s Hospital, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George’s University of London, London, United Kingdom
- Twins Trust Centre for Research and Clinical Excellence, St George’s Hospital, London, United Kingdom
- Fetal Medicine Unit, Liverpool Women’s Hospital, University of Liverpool, Liverpool, United Kingdom
| |
Collapse
|
14
|
Esposito G, Cantarutti A, Mauri PA, Franchi M, Fedele F, Corrao G, Parazzini F, Persico N. Prevalence and Factors Associated With Intertwin Birth Weight Discordance Among Same-Sex Twins in Lombardy, Northern Italy. Twin Res Hum Genet 2023; 26:177-183. [PMID: 37189213 DOI: 10.1017/thg.2023.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
This population-based cohort study investigated the prevalence, potential risk factors, and consequences of birth weight discordance (BWD) among same-sex twins. We retrieved data from the automated system of healthcare utilization databases of Lombardy Region, Northern Italy (2007-2021). BWD was defined as 30% or more disparity in birth weights between the larger and the smaller twin. Multivariate logistic regression was used to analyze the risk factors of BWD in deliveries with same-sex twins. In addition, the distribution of several neonatal outcomes was assessed overall and according to BWD level (i.e., ≤20%, 21-29, and ≥30%). Finally, a stratified analysis by BWD was performed to assess the relationship between assisted reproductive technologies (ART) and neonatal outcomes. We identified 11,096 same-sex twin deliveries; 556 (5.0%) pairs of twins were affected by BWD. Multivariate logistic regression analysis showed that maternal age ≥35 years (OR 1.26, 95% CI [1.05,5.51]), low level of education (OR 1.34, 95% CI [1.05, 1.70]), and ART (OR 1.16, 95% CI [0.94, 1.44], almost significant due to the low power) were independent risk factors for BWD in same-sex twins. Conversely, parity (OR 0.73, 95% CI [0.60, 0.89]) was inversely related. All the adverse outcomes observed were more common among BWD pairs than non-BWD ones. Instead, a protective effect of ART was observed for most neonatal outcomes considered among BWD twins. Our results suggest that conception after ART increases the risk of developing a high disparity between the weights of the two twins. However, the presence of BWD may complicate twin pregnancies, compromising neonatal outcomes, regardless of the modality of conception.
Collapse
Affiliation(s)
- Giovanna Esposito
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Anna Cantarutti
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, Milan, Italy
| | - Paola Agnese Mauri
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Woman, Newborn and Child, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Franchi
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, Milan, Italy
| | - Francesco Fedele
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanni Corrao
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, Milan, Italy
| | - Fabio Parazzini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Nicola Persico
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Woman, Newborn and Child, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
15
|
Caira-Chuquineyra B, Fernandez-Guzman D, Giraldez-Salazar H, Urrunaga-Pastor D, Bendezu-Quispe G. Association between inadequate prenatal care and low birth weight of newborns in Peru: Evidence from a peruvian demographic and health survey. Heliyon 2023; 9:e14667. [PMID: 37064470 PMCID: PMC10102233 DOI: 10.1016/j.heliyon.2023.e14667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 04/05/2023] Open
Abstract
Objective To assess the association between inadequate prenatal care (IPNC) and Low birth weight (LBW) in newborns of singleton gestation mothers in Peru. Methods We performed a secondary analysis of data from the 2019 Demographic and Health Survey. We included a total of 10,186 women of reproductive age (15 - 49 years) who had given birth to a singleton child in the last 5 years. The dependent variable was LBW (< 2500 g). The independent variables were IPNC (inadequate: when at least one of the IPNC components was absent [number of PNC visits ≥ 6, first PNC visit during the first trimester, compliance with PNC visit contents, and PNC visits provided by trained health personnel]) and each of its components. We evaluated the association using logistic regression models to estimate crude odds ratios and adjusted odds ratios (aOR) and their respective 95% confidence intervals (95% CI). Results We found that approximately six out of 100 live births had LBW and that seven out of 10 women had received IPNC. We observed that receiving IPNC (aOR: 1.39; 95% CI: 1.09 - 1.77) and having less than six prenatal control visits (aOR: 3.20; 95% CI: 2.48 - 4.13) were associated with higher odds of LBW regardless of the mother's age, educational level, occupation, wealth, region, rural origin, ethnicity, sex of the newborns, and place of delivery. While, regarding to the other PNC components, first prenatal control in the first trimester (aOR: 0.99; 95% CI: 0.76 - 1.28) and compliance with prenatal control contents (aOR: 1.07; 95% CI: 0.86 - 1.34), they were associated with lower and higher odds of LBW, respectively, regardless of the same adjustment variables, but it was not statistically significant. Conclusions IPNC and having less than six PNC visits were associated with higher odds of LBW. Therefore, it is very important to implement strategies that ensure access to quality prenatal care is necessary to reduce the consequences of LBW.
Collapse
|
16
|
Kozinszky Z, Surányi A. The High-Risk Profile of Selective Growth Restriction in Monochorionic Twin Pregnancies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040648. [PMID: 37109605 PMCID: PMC10141888 DOI: 10.3390/medicina59040648] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/13/2023] [Indexed: 04/29/2023]
Abstract
The present review aims to provide a critical appraisal of the sonographic diagnosis and follow-up and to evaluate the optimal clinical management of monochorionic twin pregnancies where one of the twins is complicated by selective fetal growth restriction (sFGR). The classification is based on the umbilical artery (UA) diastolic flow reflecting the outcome. If the sFGR twin has positive diastolic flow (Type I) then the prognosis is good, and it does not require close surveillance. Biweekly or weekly sonographic and Doppler surveillance and fetal monitoring are recommended strategies to detect unpredictable complications in type II and type III forms, which are defined by persistently absent/reverse end-diastolic flow (AREDF) or cyclically intermittent absent/reverse end-diastolic flow (iAREDF) in the umbilical waveforms, respectively. The latest forms are associated with an increased risk of unexpected fetal demise of the smaller twin and 10-20% risk of neurological injury in the larger twin in addition to the overall risk of prematurity. The clinical course can be affected by elective fetal therapy ('dichorinization' of the placenta with laser or selective fetal reduction) or elective delivery in the presence of severe fetal deterioration. The prediction of the clinical outcome in complicated cases of type II and III sFGR cases remains elusive. Novel routines in fetal and placental scans in order to predict neurological impairments and unexpected fetal death to optimize the delivery time-point are needed.
Collapse
Affiliation(s)
- Zoltan Kozinszky
- Department of Obstetrics and Gynaecology, Danderyds Hospital, 182 88 Stockholm, Sweden
| | - Andrea Surányi
- Department of Obstetrics and Gynaecology, Albert Szent-Györgyi Medical School, University of Szeged, 6725 Szeged, Hungary
| |
Collapse
|
17
|
Zhu J, An P, Zhao H, Zhao Y, Zhou J, Zhou Q, Li X, Xiong Y. Optimal cutoffs of growth discordance for the risk of preeclampsia in twin pregnancies: A single-center retrospective cohort study. Front Cardiovasc Med 2023; 9:1073729. [PMID: 36727028 PMCID: PMC9884673 DOI: 10.3389/fcvm.2022.1073729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023] Open
Abstract
Objective To explore the optimal cutoffs of growth discordance for the risk of preeclampsia in twin pregnancies. Methods A retrospective cohort study in a university hospital which included twins delivered from February 2013 to September 2020. Restrictive cubic spline (RCS) model was applied to the trend of intertwin birthweight difference (BWD) with the risk of preeclampsia. Logistic regression and subgroup analysis were performed to find the cut-off with statistical significance and clinical meaningfulness. Results A total of 2,631 women pregnant with twins were enrolled. RCS showed a nonlinear upward trend of preeclampsia with BWD, and the BWD of 15% was the initial rising point. With the confounders adjusted, only the group with BWD ≥ 25% was found to be significantly associated with an increased risk of preeclampsia (adjusted odds ratio [aOR], 2.44; 95% confidence interval [CI]: 1.74-3.42). Additionally, subgroup analysis showed that both monochorionic (MC) and small for gestational age (SGA) twins were more likely to complicate with preeclampsia. Conclusion The growth discordance of 15% during pregnancy may be the preventive point of preeclampsia, and 25% may be the interventional point.
Collapse
Affiliation(s)
- Jie Zhu
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China,The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Ping An
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China,The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Huanqiang Zhao
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China,The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Ying Zhao
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China,The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Jizi Zhou
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China,The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Qiongjie Zhou
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China,The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Xiaotian Li
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China,The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China,Xiaotian Li,
| | - Yu Xiong
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China,The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China,*Correspondence: Yu Xiong,
| |
Collapse
|
18
|
Mei H, Deng L, Xie J, Li X, Wu N, Hu L, Huang G, Mo F, Chen D, Xiao H, Yang P. Co-exposure to phenols and phthalates during pregnancy with the difference of body size in twins at one month old. CHEMOSPHERE 2023; 311:136991. [PMID: 36306967 DOI: 10.1016/j.chemosphere.2022.136991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/08/2022] [Accepted: 10/20/2022] [Indexed: 06/16/2023]
Abstract
Humans are simultaneously exposed to phenols and phthalates (PAEs). However, the mixture effect of phenols and PAEs on the body size of twins is lacking. From 2016 to 2018, we recruited 228 pregnant twins and collected up to three urine samples. A total of 8 PAE metabolites and 7 phenols were detected in urine by liquid chromatography-tandem mass spectrometry. Chemical individual and mixture effects were estimated. Multivariable linear regression results presented the percentage change in twins' growth differences at one month old with maternal PAE and phenol exposure. These chemicals were positively associated with weight differences during the entire trimester. Moreover, the quantile g-computed model showed that increased urinary concentrations of all chemicals by one quartile were associated with a 22.85% (95%CI: 11.21-35.72%), 22.60% (95%CI: 12.31-33.83%), and 24.05% (95%CI: 13.11-36.05%) larger weight difference within twins in each trimester, respectively. Increasing all PAE metabolites and phenols by one quantile across the entire trimester, weight differences increased by 26.61% (95% CI: 15.79%, 38.44%), and height differences increased by 15.84% (95%CI: 3.92%, 29.13%). Co-exposure to PAEs and phenols may primarily play a role in twins' growth.
Collapse
Affiliation(s)
- Hong Mei
- Institute of Maternal and Child Health, Wuhan Children's Hospital Wuhan Maternal and Child Healthcare Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Langjing Deng
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, 510632, Guangdong, PR China
| | - Jinying Xie
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, 510632, Guangdong, PR China
| | - Xiaojie Li
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, 510632, Guangdong, PR China
| | - Nanxin Wu
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, 510632, Guangdong, PR China
| | - Liqin Hu
- Institute of Maternal and Child Health, Wuhan Children's Hospital Wuhan Maternal and Child Healthcare Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Guangtong Huang
- School of Medicine, Jinan University, Guangzhou, 510632, Guangdong, PR China
| | - Fanyu Mo
- School of Medicine, Jinan University, Guangzhou, 510632, Guangdong, PR China
| | - Da Chen
- Guangdong Key Laboratory of Environmental Pollution and Health, School of Environment, Jinan University, Guangzhou, 510632, Guangdong, PR China
| | - Han Xiao
- Institute of Maternal and Child Health, Wuhan Children's Hospital Wuhan Maternal and Child Healthcare Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
| | - Pan Yang
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, 510632, Guangdong, PR China; Guangdong Key Laboratory of Environmental Pollution and Health, School of Environment, Jinan University, Guangzhou, 510632, Guangdong, PR China.
| |
Collapse
|
19
|
Anderson JN, Deter RL, Datoc IA, Mack L, Gandhi M, Lee W, Blumenfeld YJ. Second-trimester growth velocities in twin and singleton pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:33-39. [PMID: 36273412 DOI: 10.1002/uog.26102] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/04/2022] [Accepted: 10/14/2022] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Previous small studies used individualized growth assessment (IGA) to characterize prenatal growth velocities of singletons and twins. We aimed to compare second-trimester growth velocities of individual anatomical parameters between monochorionic diamniotic (MCDA) twins, dichorionic diamniotic (DCDA) twins and singleton fetuses in a larger study. METHODS This was a study of a novel cohort of 222 MCDA twins and previously published cohorts of 40 DCDA twins and 118 singletons with serial ultrasound data. Fetal biometric measurements of biparietal diameter, head circumference, abdominal circumference and femur diaphysis length from prenatal ultrasound examinations were used to calculate second-trimester growth velocities using direct calculation or linear regression analysis. Linear fit was assessed based on the coefficient of determination (R2 ). Mean growth velocities and variances were compared among the three groups. RESULTS The majority of cases underwent three second-trimester ultrasound examinations with fetal biometry available. All fetuses had linear growth, with R2 > 99% for all parameters. Only 1-2% of all MCDA and DCDA anatomical parameters had abnormal growth velocity scores outside the 95% reference range for singletons. There were no significant differences in mean growth velocity for any parameter between MCDA twins and singletons. Femur diaphysis length growth velocity was significantly lower in DCDA twins than in both MCDA twins and singletons. There were no other significant differences among the groups. CONCLUSIONS Expanding on prior work using IGA, we found that second-trimester growth velocity of the four major anatomical parameters overall was similar between twins and singletons and between MCDA and DCDA twins, supporting the use of singleton-derived growth standards for IGA in twins. Twin growth potential appears to be similar to that of singletons in the second trimester, suggesting that subsequent growth divergence may be due to third-trimester physiological or pathological changes in twin pregnancies. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- J N Anderson
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Stanford, CA, USA
| | - R L Deter
- Baylor College of Medicine/Texas Children's Pavilion for Women, Department of Obstetrics and Gynecology, Houston, TX, USA
| | - I A Datoc
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Stanford, CA, USA
| | - L Mack
- Baylor College of Medicine/Texas Children's Pavilion for Women, Department of Obstetrics and Gynecology, Houston, TX, USA
| | - M Gandhi
- Baylor College of Medicine/Texas Children's Pavilion for Women, Department of Obstetrics and Gynecology, Houston, TX, USA
| | - W Lee
- Baylor College of Medicine/Texas Children's Pavilion for Women, Department of Obstetrics and Gynecology, Houston, TX, USA
| | - Y J Blumenfeld
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Stanford, CA, USA
| |
Collapse
|
20
|
Metabolic dysfunction-associated fatty liver disease as a risk factor for adverse outcomes in subsequent pregnancy: a nationwide cohort study. Hepatol Int 2022; 17:367-376. [PMID: 36542262 DOI: 10.1007/s12072-022-10458-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE A recent international expert consensus opinion suggested that metabolic dysfunction-associated fatty liver disease (MAFLD) replaces nonalcoholic fatty liver disease (NAFLD), since MAFLD is a better predictor of cardiovascular disease. We estimated the prevalence of FLD in fertile females and evaluated the clinical impact of either NAFLD or MAFLD on maternal and fetal outcomes during subsequent pregnancy. METHODS The study population included fertile females who underwent health examinations and became pregnant within 1 year of health examination. Hepatic steatosis was defined as a fatty liver index of ≥ 30. The fertile females were divided into four groups: neither-FLD, NAFLD-only, MAFLD-only, and both-FLDs. During subsequent pregnancy, the risks of adverse pregnancy outcomes, including gestational diabetes, pregnancy-associated hypertension, preterm birth, and low birthweight, were compared among the four groups. RESULTS The study population comprised 762,401 females, including 720,606 with neither-FLD, 318 with NAFLD-only, 14,371 with MAFLD-only, and 27,106 with both-FLDs. Compared to females with neither-FLD, the risk of adverse pregnancy outcomes was higher in females with any FLD, with an adjusted OR of 1.73 (95% CI 1.25-2.41) in the NALFD-only group, 2.65 (2.53-2.77) in the MAFLD-only group, and 2.39 (2.31-2.48) in the both-FLDs group. Pregnancy outcomes (cesarean delivery, gestational diabetes, and low birthweight) were worse in females with MAFLD compared with NAFLD. CONCLUSION Any form of FLD is a risk factor for adverse pregnancy outcomes. These data suggest that MAFLD is associated with a higher risk of adverse pregnancy outcomes for both mother and fetus than NAFLD.
Collapse
|
21
|
Gu Y, Yu C, Zhang L, Weng Y, Zhou F, Yu Q, Zhang H. Abnormal umbilical cord insertion and birth weight discordancy in monochorionic diamniotic twins: A retrospective study. Medicine (Baltimore) 2022; 101:e32316. [PMID: 36550827 PMCID: PMC9771205 DOI: 10.1097/md.0000000000032316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
To investigate the relationship between abnormal umbilical cord insertion and birthweight discordance in monochorionic diamnionic (MCDA) twins. A total of 137 pairs of MCDAs were retrospectively analyzed who delivered and survived in Hangzhou Women's Hospital from January 2016 to December 2021. According to different insertion methods, they were divided into normal cord insertion group (n = 57), marginal cord insertion (MCI) group (n = 34) and velamentous cord insertion (VCI) group (n = 46). The correlation was analyzed between different insertion methods of umbilical cord and the discordant birth weight of MCDAs. The gestational age of delivery with velamentous cord insertion was significantly earlier than those with normal and marginal insertion (P < .05). There were significant differences in birthweight between large fetus (F1) and small fetus (F2) with different umbilical insertion methods (P < .05). The birthweight of F1 and F2 in normal insertion group was significantly higher than those in MCI and VCI group (P < .05). Logistic regression analysis showed that VCI was significantly associated with birth weight in F1/F2, birthweight discordance ≥ 20%, and birthweight discordance ≥ 25%, however MCI and VCI were not an independent factor for discordance in birthweight of MCDAs (P > .05). Umbilical cord insertion method can lead to inconsistency in birthweight of MCDA twins, however they were not an independent factor for discordance in birthweight.
Collapse
Affiliation(s)
- Yunxia Gu
- Department of Ultrasound, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Cheng Yu
- Department of Ultrasound, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Lidan Zhang
- Department of Ultrasound, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Yinan Weng
- Department of Ultrasound, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Fangfang Zhou
- Department of Ultrasound, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Qing Yu
- Department of Obstetrics, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Hongyan Zhang
- Department of Reproductive Medicine Center, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
- * Correspondence: Hongyan Zhang, Department of Reproductive Medicine Center, Hangzhou Women’s Hospital, Hangzhou, Zhejiang 310008, China (e-mail: )
| |
Collapse
|
22
|
D'Antonio F, Herrera M, Oronzii L, Khalil A. Solomon technique vs selective fetoscopic laser photocoagulation for twin-twin transfusion syndrome: systematic review and meta-analysis of maternal and perinatal outcomes. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:731-738. [PMID: 36240516 DOI: 10.1002/uog.26095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To ascertain maternal and perinatal outcomes of monochorionic twin pregnancies complicated by twin-twin transfusion syndrome (TTTS) treated with the Solomon technique compared with selective fetoscopic laser photocoagulation (SFLP) of placental anastomoses. METHODS MEDLINE, EMBASE and The Cochrane Library were searched to identify relevant studies. The outcomes observed were perinatal loss and survival, preterm prelabor rupture of membranes (PPROM), preterm birth (PTB), gestational age (GA) at delivery, interval between laser treatment and delivery, maternal bleeding, septostomy or chorioamniotic separation, placental abruption, twin anemia-polycythemia sequence (TAPS), recurrence of TTTS, neonatal morbidity and neurological morbidity. Random-effects head-to-head meta-analyses were used to analyze the data. Pooled odds ratios (OR) and mean differences (MD) and their 95% CIs were calculated. RESULTS Nine studies were included in the systematic review. There was generally no difference in the main maternal and pregnancy characteristics between pregnancies treated using the Solomon technique and those treated using SFLP of placental anastomoses. The risks of fetal loss (pooled OR, 0.69 (95% CI, 0.50-0.95); P = 0.023), neonatal death (pooled OR, 0.37 (95% CI, 0.16-0.84); P = 0.018) and perinatal loss (pooled OR, 0.56 (95% CI, 0.38-0.83); P = 0.004) were significantly lower in pregnancies treated using the Solomon technique than in those treated with SFLP. Likewise, pregnancies treated using the Solomon technique had a significantly higher chance of survival of at least one twin (pooled OR, 2.31 (95% CI, 1.03-5.19); P = 0.004) and double survival (pooled OR, 2.18 (95% CI, 1.29-3.70); P = 0.001). There was no difference in the risk of PPROM (P = 0.603), PPROM within 10 days from laser surgery (P = 0.982), PTB (P = 0.207), maternal bleeding (P = 0.219), septostomy or chorioamniotic separation (P = 0.224) or chorioamnionitis (P = 0.135) between the two groups, while the risk of placental abruption was higher in pregnancies treated using the Solomon technique (pooled OR, 2.90 (95% CI, 1.55-5.44); P = 0.001). In the Solomon technique group, pregnancies delivered at a significantly earlier GA than did those treated with SFLP (pooled MD, -0.625 weeks (95% CI, -0.90 to -0.35 weeks); P < 0.001), while there was no difference in the interval between laser treatment and delivery (P = 0.589). The rate of recurrence of TTTS was significantly lower in pregnancies undergoing the Solomon technique (pooled OR, 0.43 (95% CI, 0.22-0.81); P < 0.001), while there was no difference in the risk of TAPS between the two groups (P = 0.792). Finally, there was no difference in the overall risk of neonatal morbidity (P = 0.382) or neurological morbidity (P = 0.247) between the two groups. CONCLUSIONS Monochorionic twin pregnancies complicated by TTTS undergoing laser treatment using the Solomon technique had a significantly higher survival rate and lower recurrence rate of TTTS but were associated with an increased risk of placental abruption and earlier GA at delivery compared to those treated with SFLP. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - M Herrera
- Maternal Fetal Medicine Department, Colsanitas Clinic, Colombian University Clinic - Pediatric Clinic, Bogota, Colombia
- Maternal Fetal Medicine Foundation, Fetal Health Foundation, Bogota, Colombia
| | - L Oronzii
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
| |
Collapse
|
23
|
Yang J, Hou L, Wang J, Xiao L, Zhang J, Yin N, Yao S, Cheng K, Zhang W, Shi Z, Wang J, Jiang H, Huang N, You Y, Lin M, Shang R, Wei Y, Zhao Y, Zhao F. Unfavourable intrauterine environment contributes to abnormal gut microbiome and metabolome in twins. Gut 2022; 71:2451-2462. [PMID: 35387876 PMCID: PMC9664093 DOI: 10.1136/gutjnl-2021-326482] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/28/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Fetal growth restriction (FGR) is a devastating pregnancy complication that increases the risk of perinatal mortality and morbidity. This study aims to determine the combined and relative effects of genetic and intrauterine environments on neonatal microbial communities and to explore selective FGR-induced gut microbiota disruption, metabolic profile disturbances and possible outcomes. DESIGN We profiled and compared the gut microbial colonisation of 150 pairs of twin neonates who were classified into four groups based on their chorionicity and discordance of fetal birth weight. Gut microbiota dysbiosis and faecal metabolic alterations were determined by 16S ribosomal RNA and metagenomic sequencing and metabolomics, and the long-term effects were explored by surveys of physical and neurocognitive development conducted after 2~3 years of follow-up. RESULTS Adverse intrauterine environmental factors related to selective FGR dominate genetics in their effects of elevating bacterial diversity and altering the composition of early-life gut microbiota, and this effect is positively related to the severity of selective FGR in twins. The influence of genetic factors on gut microbes diminishes in the context of selective FGR. Gut microbiota dysbiosis in twin neonates with selective FGR and faecal metabolic alterations features decreased abundances of Enterococcus and Acinetobacter and downregulated methionine and cysteine levels. Correlation analysis indicates that the faecal cysteine level in early life is positively correlated with the physical and neurocognitive development of infants. CONCLUSION Dysbiotic microbiota profiles and pronounced metabolic alterations are associated with selective FGR affected by adverse intrauterine environments, emphasising the possible effects of dysbiosis on long-term neurobehavioural development.
Collapse
Affiliation(s)
- Jing Yang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Lingling Hou
- Beijing Institutes of Life Science, Chinese Academy of Sciences, Beijing, China
| | - Jinfeng Wang
- Beijing Institutes of Life Science, Chinese Academy of Sciences, Beijing, China
| | - Liwen Xiao
- Beijing Institutes of Life Science, Chinese Academy of Sciences, Beijing, China,University of Chinese Academy of Sciences, Beijing, China
| | - Jinyang Zhang
- Beijing Institutes of Life Science, Chinese Academy of Sciences, Beijing, China
| | - Nanlin Yin
- Center for Reproductive Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Su Yao
- China Center of Industrial Culture Collection, China National Research Institute of Food and Fermentation Industries Co Ltd, Beijing, China
| | - Kun Cheng
- China Center of Industrial Culture Collection, China National Research Institute of Food and Fermentation Industries Co Ltd, Beijing, China
| | - Wen Zhang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Zhonghua Shi
- Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Jing Wang
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, China
| | - Hai Jiang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Nana Huang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yanxia You
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Mingmei Lin
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Ruiyan Shang
- Department of Obstetrics and Gynecology, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Fangqing Zhao
- Beijing Institutes of Life Science, Chinese Academy of Sciences, Beijing, China .,University of Chinese Academy of Sciences, Beijing, China.,State Key Laboratory of Integrated Management of Pest Insects and Rodents, Institute of Zoology, Chinese Academy of Sciences, Beijing, China.,Key Laboratory of Systems Biology, Hangzhou Institute for Advanced Study, University of Chinese Academy of Sciences, Beijing, China
| |
Collapse
|
24
|
Zhu J, Zhang J, Wu Y, Gao L, Zhao X, Cheng W, Wang Y. Intertwin growth discordance throughout gestation and hypertensive disorders of pregnancy. Am J Obstet Gynecol 2022:S0002-9378(22)02178-0. [PMID: 36403860 DOI: 10.1016/j.ajog.2022.11.1290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous studies have established the association between intertwin birthweight discordance and hypertensive disorders of pregnancy. However, longitudinal fetal size discordance concerning gestational hypertension or preeclampsia remains unclear. OBJECTIVE This study aimed to compare the patterns of estimated fetal weight discordance throughout gestation among normotensive women, women with gestational hypertension, and women with preeclampsia and to evaluate the association between crown-rump length discordance at 11 to 14 weeks of gestation and hypertensive disorders of pregnancy. STUDY DESIGN This was a retrospective cohort study of women with twin pregnancies who had antenatal care visits and delivered at a tertiary hospital between January 2013 and June 2021. The crown-rump length was measured at 11 to 14 weeks of gestation. Estimated fetal weight was calculated based on ultrasound examinations of fetal biometrics at 16 to 18, 20 to 24, 28 to 32, and ≥34 weeks of gestation, respectively. Crown-rump length and estimated fetal weight discordances were calculated: (larger crown-rump length - smaller crown-rump length)/larger crown-rump length × 100% and (larger estimated fetal weight - smaller estimated fetal weight)/larger estimated fetal weight × 100%, respectively. Multiple imputation was used to handle missing data, and all models accounted for the imputation. Multilevel model analysis was used to compare the differences in estimated fetal weight discordances throughout gestation among normotensive women, women with gestational hypertension, and women with preeclampsia. Generalized linear models were used to evaluate the association between crown-rump length discordance and hypertensive disorders of pregnancy, assuming a Poisson distribution. The possible nonlinear relationship between continuous crown-rump length discordance and hypertensive disorders of pregnancy was examined by generalized additive models. All analyses were stratified by chorionicity. RESULTS Of the 3280 women with twin pregnancies who met the inclusion criteria, 187 (5.7%) developed gestational hypertension, and 436 (13.3%) developed preeclampsia, including 125 (3.8%) early-onset preeclampsia and 311 (9.5%) late-onset preeclampsia. In women with dichorionic twin pregnancies, compared with normotensive women, a substantial progression of estimated fetal weight discordance throughout pregnancy was identified in women who developed preeclampsia, and a large progression of estimated fetal weight discordance in late pregnancy was identified in women who developed gestational hypertension. In women with monochorionic twin pregnancies, estimated fetal weight discordances were more progressive from 20 to 24 weeks of gestation onward in women who developed preeclampsia than in normotensive women. Crown-rump length discordance at 11 to 14 weeks of gestation was associated with an increased risk of preeclampsia (relative risk, 1.03; 95% confidence interval, 1.00-1.05), particularly early-onset preeclampsia (relative risk, 1.09; 95% confidence interval, 1.04-1.13). A crown-rump length discordance of ≥10% had 1.2 times the increased risk of developing early-onset preeclampsia (relative risk, 2.27; 95% confidence interval, 1.28-4.03). This association was identified in dichorionic twins, but not in monochorionic twins. CONCLUSION Our study demonstrated distinct growth discordant patterns among normotensive women, women with gestational hypertension, and women with preeclampsia in twin pregnancies. Intertwin crown-rump length discordance at 11 to 14 weeks of gestation was associated with an increased risk of preeclampsia, especially early-onset preeclampsia in dichorionic twin pregnancies, with a dose-response pattern.
Collapse
Affiliation(s)
- Jing Zhu
- International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Wu
- International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Li Gao
- International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Xinrong Zhao
- International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Weiwei Cheng
- International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Yanlin Wang
- International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.
| |
Collapse
|
25
|
The Controversies and Challenges in the Management of Twin Pregnancy: From the Perspective of International Federation of Gynecology and Obstetrics Guidelines. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
26
|
Delima.khairudin, Khalil A. MONOCHORIONIC monoamniotic twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2022; 84:96-103. [DOI: 10.1016/j.bpobgyn.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 11/25/2022]
|
27
|
Liu XS, Su XJ, Li GH, Huang SJ, Liu Y, Sun HX, Du QL. Maternal Thyroid Function and Birth Weight in Twins. Endocrinology 2022; 163:6596543. [PMID: 35642607 PMCID: PMC9237444 DOI: 10.1210/endocr/bqac082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Indexed: 11/26/2022]
Abstract
CONTEXT Thyroid hormones are associated with birth weight in singleton pregnancy. Twin pregnancies need more thyroid hormones to maintain the normal growth and development of the fetuses compared with single pregnancy. OBJECTIVE We aimed to investigate the association of thyroid hormones and birth weight in twins. METHODS This was a retrospective cohort study in a Chinese population. Pregnant women who received regular antenatal health care and delivered live-born twins from 2014 to 2019 were included (n = 1626). Linear mixed model with restricted cubic splines and logistic regression models were used to estimate the association of thyroid hormones with birth weight and birth weight discordance in twins. RESULTS We observed that both thyrotropin (TSH) and free thyroxine (FT4) were not associated with birth weight in twins overall, while when stratifying on fetal sex or chorionicity, there were nonlinear association between FT4 levels and birth weight in boys (Pnonlinear < .001) and in dichorionic (DC) twins (Pnonlinear = 0.03). Women with levels of FT4 lower than the 10th percentile had a higher risk of birth weight discordance in their offspring than women with normal FT4 levels (range, 2.5 to 97.5 percentiles) (odds ratio = 1.58; 95% CI, 1.05-2.33). CONCLUSION Our study suggests there was an association of FT4, but not TSH, with birth weight and birth weight discordance varied by sex and chorionicity. These findings could have implications for obstetricians to be aware of the importance of FT4 levels in preventing birth weight discordance in twin pregnancy.
Collapse
Affiliation(s)
| | | | - Guo Hua Li
- Department of Reproductive Immunology, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Shi Jia Huang
- Department of Obstetrics, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yang Liu
- Department of Obstetrics, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Han Xiang Sun
- Department of Obstetrics, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Qiao Ling Du
- Correspondence: Qiao Ling Du, PhD, Department of Obstetrics, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, No. 2699, Wt Gaoke Rd, Shanghai, 200092 China.
| |
Collapse
|
28
|
Discordance in twins: association versus prediction. Best Pract Res Clin Obstet Gynaecol 2022; 84:33-42. [DOI: 10.1016/j.bpobgyn.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/14/2022] [Indexed: 11/16/2022]
|
29
|
The role of obstetric pessary and micronized progesteron in early preterm birth prevention in patients with multiple pregnancy. ACTA BIOMEDICA SCIENTIFICA 2022. [DOI: 10.29413/abs.2022-7.3.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background. Multiple pregnancy is a well-established risk factor for preterm birth. Prevention of early termination of pregnancy is a priority problem in obstetric practice.The aim. To evaluate the role of an obstetric pessary and micronized progesterone in the prevention of early preterm labor in patients with multiple pregnancies.Materials and methods. A prospective controlled study was conducted with the inclusion of 146 pregnant women with multiple pregnancies, which, depending on the methods of treatment, were divided into three groups: Group I (n = 67) – pregnant women who received micronized progesterone in combination with an obstetric pessary; Group II (n = 57) included women who received micronized progesterone; Group III (n = 22) consisted of patients with multiple pregnancies without therapy.Results. In Group I, the complex of an obstetric pessary and micronized progesterone allowed to reduce the frequency of preterm birth by 2.3 times (p = 0.008) in comparison with Group III, the frequency of births at gestational age ≤ 34 weeks – by 8.1 times (p = 0.005) in compared with Group III and 2.7 times (p < 0.01) compared with Group II. In 70.4 % of pregnant women, the use of a complex of an obstetric pessary with micronized progesterone made it possible to prevent the formation of isthmiccervical insufficiency, which, according to sonography, was expressed in the dynamics of the utero-cervical angle towards a more obtuse one.Conclusion. The use of an obstetric pessary with micronized progesterone made it possible to reduce the risks of isthmic-cervical insufficiency by 7.7 % compared with patients who received only micronized progesterone therapy, and by 17.1 % compared with pregnant women who did not receive therapy.
Collapse
|
30
|
Mei-Dan E, Jain V, Melamed N, Lim KI, Aviram A, Ryan G, Barrett J. Directive clinique no 428 : Prise en charge de la grossesse gémellaire bichoriale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:835-851.e1. [DOI: 10.1016/j.jogc.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
31
|
Miremberg H, Nassar M, Herman HG, Marelly C, Feldstein O, Barber E, Schreiber L, Bar J, Kovo M. Is there an impact of fetal sex in dichorionic discordant twins on placental histopathological abnormalities? Eur J Obstet Gynecol Reprod Biol 2022; 274:166-170. [PMID: 35661538 DOI: 10.1016/j.ejogrb.2022.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 05/16/2022] [Accepted: 05/25/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Growth discordancy in dichorionic diamniotic (DCDA) twin gestations is a known complication associated with adverse neonatal outcomes. We aimed to study the differences in placental pathology, in relation to fetal sex, in DCDA twin gestations complicated with growth discordancy. METHODS The medical files of all DCDA twin deliveries complicated by growth discordancy between 2010 and 2020 were reviewed. Growth discordance was defined as a gap between twin birthweights > 20%. A comparison was made between female vs. male growth discordant twins. Placental lesions were classified as lesions related to maternal or fetal malperfusion lesions (MVM, FVM), vascular and villous changes, and inflammatory lesions. RESULTS Included 174 DCDA twins. Eighty-eight were in the discordant female group and eighty-six in the discordant male group. The groups did not differ in maternal demographics, pregnancy characteristics, and neonatal outcome. The discordant male group had a higher rate of placental MVM lesions as compared to the discordant female group (p = 0.003). The increased rate of placental MVM lesions in the discordant male group compared to the discordant female group did not change whether its co-twin was of similar or opposite sex. DISCUSSION Higher rate of MVM lesions characterizes growth discordant male neonates in DCDA twin gestations. This finding could represent a different adaptation of male fetuses to a hostile intrauterine environment.
Collapse
Affiliation(s)
- Hadas Miremberg
- Department of Obstetrics & Gynecology, The Edith Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Marwa Nassar
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Hadas Ganer Herman
- Department of Obstetrics & Gynecology, The Edith Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Cindy Marelly
- Department of Obstetrics & Gynecology, The Edith Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Ohad Feldstein
- Department of Obstetrics & Gynecology, The Edith Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Elad Barber
- Department of Obstetrics & Gynecology, The Edith Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Letizia Schreiber
- Department of Pathology, The Edith Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Jacob Bar
- Department of Obstetrics & Gynecology, The Edith Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Michal Kovo
- Department of Obstetrics & Gynecology, The Edith Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel.
| |
Collapse
|
32
|
Mei-Dan E, Jain V, Melamed N, Lim KI, Aviram A, Ryan G, Barrett J. Guideline No. 428: Management of Dichorionic Twin Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:819-834.e1. [PMID: 35798461 DOI: 10.1016/j.jogc.2022.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To review evidence-based recommendations for the management of dichorionic twin pregnancies. TARGET POPULATION Pregnant women with a dichorionic twin pregnancy. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in this guideline may improve the management of twin pregnancies and reduce neonatal and maternal morbidity and mortality. EVIDENCE Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (e.g., twin, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date limits, but results were limited to English- or French-language materials. VALIDATION METHODS The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE Obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, radiologists, and other health care providers who care for women with twin pregnancies. SUMMARY STATEMENTS RECOMMENDATIONS.
Collapse
|
33
|
Timing of Delivery for Twins With Growth Discordance and Growth Restriction: An Individual Participant Data Meta-analysis. Obstet Gynecol 2022; 139:1155-1167. [PMID: 35675615 DOI: 10.1097/aog.0000000000004789] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/17/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVE First, to evaluate the risks of stillbirth and neonatal death by gestational age in twin pregnancies with different levels of growth discordance and in relation to small for gestational age (SGA), and on this basis to establish optimal gestational ages for delivery. Second, to compare these optimal gestational ages with previously established optimal delivery timing for twin pregnancies not complicated by fetal growth restriction, which, in a previous individual patient meta-analysis, was calculated at 37 0/7 weeks of gestation for dichorionic pregnancies and 36 0/7 weeks for monochorionic pregnancies. DATA SOURCES A search of MEDLINE, EMBASE, ClinicalTrials.gov, and Ovid between 2015 and 2018 was performed of cohort studies reporting risks of stillbirth and neonatal death in twin pregnancies from 32 to 41 weeks of gestation. Studies from a previous meta-analysis using a similar search strategy (from inception to 2015) were combined. Women with monoamniotic twin pregnancies were excluded. METHODS OF STUDY SELECTION Overall, of 57 eligible studies, 20 cohort studies that contributed original data reporting on 7,474 dichorionic and 2,281 monochorionic twin pairs. TABULATION, INTEGRATION, AND RESULTS We performed an individual participant data meta-analysis to calculate the risk of perinatal death (risk difference between prospective stillbirth and neonatal death) per gestational week. Analyses were stratified by chorionicity, levels of growth discordance, and presence of SGA in one or both twins. For both dichorionic and monochorionic twins, the absolute risks of stillbirth and neonatal death were higher when one or both twins were SGA and increased with greater levels of growth discordance. Regardless of level of growth discordance and birth weight, perinatal risk balanced between 36 0/7-6/7 and 37 0/7-6/7 weeks of gestation in both dichorionic and monochorionic twin pregnancies, with likely higher risk of stillbirth than neonatal death from 37 0/7-6/7 weeks onward. CONCLUSION Growth discordance or SGA is associated with higher absolute risks of stillbirth and neonatal death. However, balancing these two risks, we did not find evidence that the optimal timing of delivery is changed by the presence of growth disorders alone. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42018090866.
Collapse
|
34
|
Cao X, Luo Y, Zhou S, Zhao Q, Qin X, Liu Z, Xu Z. Twin Growth Discordance and Risk of Postpartum Hemorrhage: A Retrospective Cohort Study. Front Med (Lausanne) 2022; 9:876411. [PMID: 35692549 PMCID: PMC9174790 DOI: 10.3389/fmed.2022.876411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/25/2022] [Indexed: 11/30/2022] Open
Abstract
Background In recent years, the incidence of postpartum hemorrhage has increased globally. Multiple pregnancies and cesarean sections are well-known risk factors for postpartum hemorrhage. No studies have evaluated the associations between fetal growth anomalies and postpartum hemorrhage in women with twin pregnancies undergoing cesarean section. This study aimed to identify the relationship between fetal growth anomalies and postpartum hemorrhage in women with twin pregnancies undergoing cesarean section. Methods This retrospective single-center study included 3,180 women with twin pregnancies at a tertiary hospital between August 2013 and July 2020. Singleton reference charts were used to assess fetal growth restriction at birth. Discordant growth was defined as an intertwin birth weight difference of ≥20%. Logistic regression analyses were used to evaluate the association between fetal growth anomalies and postpartum hemorrhage. Additionally, sensitivity analysis of abnormal placenta and stratification by twin chorionicity were conducted. Results The overall incidence of postpartum hemorrhage was 4.3%. Twin growth discordance, especially with fetal growth restriction, was associated with an increased risk of postpartum hemorrhage (adjusted odds ratio [AOR] = 1.62, 95% confidence interval [CI], 1.05-2.51, P = 0.031; AOR = 1.71; 95% CI, 1.08-2.70, P = 0.022; AOR = 1.98, 95% CI, 1.21-3.25, P = 0.006, respectively). After stratification, this relationship persisted in dichorionic twins (OR = 1.71, 95% CI, 1.04-2.82, P = 0.036; OR = 1.90, 95% CI, 1.13-3.21, P = 0.016; OR = 2.48, 95% CI, 1.41-4.38, P = 0.002, respectively). However, no significant association was observed in monochorionic twin pregnancies. Conclusion Growth discordance, especially complicated by fetal growth restriction, was associated with an increased risk of postpartum hemorrhage in women with twin pregnancies undergoing cesarean section, and was more evident in patients with dichorionic twins.
Collapse
Affiliation(s)
- Xiuhong Cao
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ye Luo
- Department of Research and Education, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shuangqiong Zhou
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qingsong Zhao
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xuewei Qin
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhiqiang Liu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhendong Xu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| |
Collapse
|
35
|
Kim YR, Kim N, Ahn EH, Jung SH, Park G, Jung I, Cho HY. The association of maternal serum biomarkers and birth weight in twin pregnancy: a retrospective cohort study. J OBSTET GYNAECOL 2022; 42:1793-1798. [DOI: 10.1080/01443615.2022.2039904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Young Ran Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center CHA University School of Medicine, Seongnam, Korea
| | - Nari Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center CHA University School of Medicine, Seongnam, Korea
| | - Eun Hee Ahn
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center CHA University School of Medicine, Seongnam, Korea
| | - Sang Hee Jung
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center CHA University School of Medicine, Seongnam, Korea
| | - Goeun Park
- Department of Biomedical Systems Informatics, Division of Biostatistics, Yonsei University College of Medicine, Seoul, Korea
| | - Inkyung Jung
- Department of Biomedical Systems Informatics, Division of Biostatistics, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Young Cho
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center CHA University School of Medicine, Seoul, Korea
| |
Collapse
|
36
|
Batsry L, Yinon Y. The vanishing twin: Diagnosis and implications. Best Pract Res Clin Obstet Gynaecol 2022; 84:66-75. [PMID: 35450773 DOI: 10.1016/j.bpobgyn.2022.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/13/2022] [Indexed: 11/30/2022]
Abstract
Vanishing twin syndrome (VTS), defined by first-trimester spontaneous loss of a twin, is a common phenomenon with a reported prevalence of 15-35% of twin pregnancies. The etiology of VTS is obscure. Still, several risk factors have been identified, including an increased number of embryos transferred in pregnancies conceived by in vitro fertilization, an initial increased number of gestational sacs and advanced maternal age. The effect of VTS on obstetric and perinatal outcomes is controversial. Several studies have reported that pregnancies with VTS were associated with increased risk for preterm birth and small for gestational age neonates compared to singleton pregnancies, while others showed no difference in perinatal outcomes. The prevalence of placental vascular and anatomic abnormalities such as small placentas was higher in VTS. These findings lay an essential foundation for understanding how this phenomenon affects obstetric and perinatal outcomes of the surviving pregnancy.
Collapse
Affiliation(s)
- Linoy Batsry
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Yinon
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| |
Collapse
|
37
|
Ye S, Fan D, Li P, Chen G, Rao J, Zhang H, Zhou Z, Feng J, Luo C, Guo X, Liu Z, Lin D. Assessment of different thresholds of birthweight discordance for early neonatal outcomes: retrospective analysis of 2348 twin pregnancies. BMC Pregnancy Childbirth 2022; 22:93. [PMID: 35105310 PMCID: PMC8808974 DOI: 10.1186/s12884-022-04417-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 01/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background The optimal threshold of birthweight discordance (BWD) remains controversial. This study aimed to evaluate the associations between BWD at different thresholds and early neonatal outcomes and to assess their predictive accuracy. Methods This was a retrospective cohort study using a birthweight data with the chorionicity information of 2348 liveborn twin pairs at a gestational age of ≥26 weeks, from 2012 to 2018. The percentage of BWD was calculated by dividing the actual birthweight difference by the weight of the larger twin and multiplying by 100. Outcomes of interest included neonatal intensive care unit (NICU) admission, neonatal respiratory distress syndrome (NRDS), ventilator support and a composite outcome combining major morbidities and neonatal death. Logistic regression models were performed to estimate the association between neonatal outcomes and BWD with different thresholds (≥15.0%, ≥20.0%, ≥25% and ≥ 30%). Generalized estimated equation (GEE) models were used to address intertwin correlation. Restrictive cubic spline (RCS) models were established to draw the dose-response relationship between BWD and the odds ratios of outcomes. Clustered receiver operating characteristic (ROC) curve analyses were performed to assess the predictive accuracy. Results Of 2348 twin pairs, including 1946 dichorionic twin pairs and 402 monochorionic twin pairs, BWD was significantly associated with NICU admission, regardless of the thresholds used. The incidence of NRDS, ventilator support and the composite outcome were significantly higher when a threshold of ≥20% or greater was chosen. The dose-response relationship showed nonlinear growth in the risk of adverse neonatal outcomes with increasing BWD. ROC analyses showed a low significant AUROC of 0.569 (95% CI: 0.526–0.612) for predicting NICU admission but no significant AUROCs for predicting other outcomes. A BWD of ≥30% provided a moderate increase in the likelihood of NICU admission [positive likelihood ratio (LR+) = 5.77]. Conclusion Although BWD is independently associated with adverse neonatal outcomes, it is not a single predictor for neonatal outcomes given the weak discriminative ability to predict neonatal outcomes. A cutoff of 30% is more practical for risk stratification among twin gestations. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04417-4.
Collapse
Affiliation(s)
- Shaoxin Ye
- Foshan Institute of Fetal Medicine, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, 11 Renminxi Road, Foshan, 528000, Guangdong, China.,Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China
| | - Dazhi Fan
- Foshan Institute of Fetal Medicine, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, 11 Renminxi Road, Foshan, 528000, Guangdong, China.,Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China
| | - Pengsheng Li
- Foshan Institute of Fetal Medicine, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, 11 Renminxi Road, Foshan, 528000, Guangdong, China.,Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China
| | - Gengdong Chen
- Foshan Institute of Fetal Medicine, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, 11 Renminxi Road, Foshan, 528000, Guangdong, China.,Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China
| | - Jiaming Rao
- Foshan Institute of Fetal Medicine, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, 11 Renminxi Road, Foshan, 528000, Guangdong, China.,Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China
| | - Huishan Zhang
- Foshan Institute of Fetal Medicine, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, 11 Renminxi Road, Foshan, 528000, Guangdong, China.,Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China
| | - Zixing Zhou
- Foshan Institute of Fetal Medicine, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, 11 Renminxi Road, Foshan, 528000, Guangdong, China.,Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China
| | - Jinping Feng
- Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China
| | - Caihong Luo
- Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China
| | - Xiaoling Guo
- Foshan Institute of Fetal Medicine, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, 11 Renminxi Road, Foshan, 528000, Guangdong, China.,Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China
| | - Zhengping Liu
- Foshan Institute of Fetal Medicine, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, 11 Renminxi Road, Foshan, 528000, Guangdong, China. .,Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China.
| | - Dongxin Lin
- Foshan Institute of Fetal Medicine, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, 11 Renminxi Road, Foshan, 528000, Guangdong, China. .,Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, 528000, Guangdong, China.
| |
Collapse
|
38
|
Wang Y, Zeng H, Liu J, Zhang F. Gestational hypertensive disease and birthweight discordance in twin pregnancies: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2021; 35:8869-8877. [PMID: 34818972 DOI: 10.1080/14767058.2021.2005572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The objective of this systematic review was to explore the association between gestational hypertensive disease (GHD) and birthweight discordance in twin pregnancies. METHODS PubMed, Embase, Web of Science and Cochrane Library were systematically searched for studies reporting the risk of birthweight discordance in twin pregnancies complicated compared with those not complicated by GHD from establishment until July 2021. Risk of bias was assessed with the Newcastle-Ottawa Scale. According to the classification of GHD, sub-group analyses reporting cases with gestational hypertension (GH), chronic hypertension (CH) and preeclampsia (PE) were performed separately. Stratification by twin chorionicity (dichorionic (DC) and monochorionic (MC)) was also conducted. When there was substantial heterogeneity (I2 ≥ 50%), the random effect mode was used to estimate the pooled risk ratio, otherwise the fixed effect model was used. RESULTS Nine studies (303,204 twin pregnancies) were included. GHD (OR 1.45, 95% CI 1.41-1.49) was a risk factor for intertwin birthweight discordance [PE (OR 1.69, 95% CI 1.33-2.16); CH (OR 1.59, 95% CI 1.46-1.73); GH (OR1.45, 95%Cl 1.10-1.92]. After stratification, birthweight discordance was related to GHD (OR 2.51, 95% CI 2.01-3.14), GH (OR 2.08, 95% CI 1.33-3.25) and PE (OR 2.74, 95% CI 2.09-3.61) in DC pregnancies, but no longer associated with GHD and PE in MC group. CONCLUSIONS Twin gestations complicated with GHD, especially in DC pregnancies, were at significantly higher risk of birthweight discordance.
Collapse
Affiliation(s)
- Yuan Wang
- Medical College, Nantong University, Nantong City, China
| | - Hongying Zeng
- Department of Gynaecology and Obstetrics, Jianhu Hospital Affiliated to Nantong University, Yancheng City, China
| | - Jing Liu
- Medical College, Nantong University, Nantong City, China
| | - Feng Zhang
- Medical College, Nantong University, Nantong City, China
| |
Collapse
|
39
|
Abstract
Along with the rise of assisted reproductive technology, multifetal gestations increased dramatically. Twin pregnancies account for 97% of multifetal pregnancies and 3% of all births in the United States. Twins and higher-order multiples carry increased risks of obstetric, perinatal, and maternal complications; these risks increase with increasing fetal number. Neonatal morbidity and mortality in multifetal gestations is driven primarily by prematurity. Both spontaneous and indicated preterm births are increased in multifetal gestations, and only a limited number of strategies are available to mitigate this risk. No single intervention has been shown to decrease the rate of spontaneous preterm birth in most twin pregnancies. Low-dose aspirin prophylaxis is recommended in all multifetal pregnancies to reduce the risk of preeclampsia and its associated complications. Antenatal management of multifetal gestations depends on chorionicity, which should be established using ultrasonography in the first trimester. Unlike dichorionic twin gestations, monochorionic pregnancies experience unique complications because of their shared vascular connections, and therefore, need frequent ultrasound surveillance. Even uncomplicated twin gestations have higher rates of unanticipated stillbirth compared with singletons. Delivery of twin pregnancies is generally indicated in the late preterm to early term period depending on chorionicity and other clinical factors. For most diamniotic twin pregnancies with a cephalic presenting fetus, vaginal delivery after 32 weeks' gestation is a safe and reasonable option with high rates of success and no increased risk of perinatal morbidity.
Collapse
Affiliation(s)
- Cassandra R Duffy
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
| |
Collapse
|
40
|
Isaacson A, Diseko M, Mayondi G, Mabuta J, Davey S, Mmalane M, Makhema J, Jacobson DL, Luckett R, Shapiro RL, Zash R. Prevalence and outcomes of twin pregnancies in Botswana: a national birth outcomes surveillance study. BMJ Open 2021; 11:e047553. [PMID: 34675010 PMCID: PMC8532549 DOI: 10.1136/bmjopen-2020-047553] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 09/24/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This study aims to evaluate the prevalence and outcome of twin pregnancies in Botswana. SETTING The Tsepamo Study conducted birth outcomes surveillance at 8 government-run hospitals (~45% of all births in Botswana) from August 2014 to June 2018 and expanded to 18 hospitals (~70% of all births in Botswana) from July 2018 to March 2019. PARTICIPANTS Data were collected for all live-born and stillborn in-hospital deliveries with a gestational age (GA) greater than 24 weeks. This analysis included 117 593 singleton and 3718 twin infants (1859 sets (1.6%)) born to 119 477 women between August 2014 and March 2019 and excluded 73 higher order multiples (23 sets of triplets and 1 set of quadruplets). OUTCOMES MEASURED Our primary outcomes were preterm delivery (<37 weeks GA), very preterm delivery (<32 weeks GA) and stillbirth (APGAR (Appearance, Pulse, Grimace, Activity, Respiration) score of 0, 0, 0). RESULTS Women with twin pregnancies had a similar median number of antenatal care visits (9 vs 10), but were more likely to deliver in a tertiary centre (54.8% vs 45.1%, p<0.001) and more likely to have a cesarean-section (54.6% vs 22.0%, p<0.001) than women with singletons. Compared with singletons, twin pregnancies had a higher risk of preterm delivery (<37 weeks GA) (47.6% vs 16.7%, adjusted risk ratio (aRR) 2.8, 95% CI 2.7 to 2.9) and very preterm delivery (<32 weeks) (11.8% vs 4.0%, aRR 3.0 95% CI 2.6 to 3.4). Among all twin pregnancies, 128 (6.9%) had at least one stillborn infant compared with 2845 (2.4%) stillbirths among singletons (aRR 2.8, 95% CI 2.3 to 3.3). CONCLUSION Adverse birth outcomes are common among twins in Botswana, and are often severe. Interventions that allow for earlier identification of twin gestation and improved antenatal management of twin pregnancies may improve infant and child survival.
Collapse
Affiliation(s)
- Arielle Isaacson
- Harvard Medical School, Boston, Massachusetts, USA
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Modiegi Diseko
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Gloria Mayondi
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Judith Mabuta
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Sonya Davey
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mompati Mmalane
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joseph Makhema
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Denise L Jacobson
- Center for Biostatistics and AIDS Research, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Rebecca Luckett
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Roger L Shapiro
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Rebecca Zash
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
41
|
Special Considerations Regarding Antenatal Care and Pregnancy Complications in Dichorionic Twin Pregnancies. Am J Obstet Gynecol MFM 2021; 4:100500. [PMID: 34637959 DOI: 10.1016/j.ajogmf.2021.100500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/18/2021] [Accepted: 10/04/2021] [Indexed: 02/07/2023]
Abstract
Twin pregnancies account for about 3.3% of all deliveries in the United States with the majority of them being dichorionic diamniotic (DCDA). Maternal physiological adaption in twin pregnancies is exaggerated and the rate of almost every maternal and fetal complication is higher when compared to singleton pregnancies. Therefore, twin pregnancies necessitate closer antenatal surveillance by care providers who are familiar with the specific challenges unique to these pregnancies, and there is evidence that following women with twins in a specialized twin clinic can result in improved obstetrical outcomes. The importance of the first antenatal visit in twin pregnancies cannot be over emphasized and should preferably take place early in gestation as it is the optimal period to correctly identify the number of fetuses and the type of placentation (chorionicity and amnionicity). This will allow the patients, families, and caregivers to make the appropriate modifications and to tailor an optimal antenatal follow-up plan. This plan should focus on general recommendations such as weight gain and level of activity, education regarding complications specific to twin pregnancies along with the relevant symptoms and indications to seek care, as well as on close maternal and fetal monitoring. In this review, we summarize available evidence and current guidelines regarding antenatal care in DCDA twin pregnancies.
Collapse
|
42
|
Hiersch L, Barrett J, Aviram A, Mei-Dan E, Yoon EW, Zaltz A, Kingdom J, Melamed N. Patterns of discordant growth and adverse neonatal outcomes in twins. Am J Obstet Gynecol 2021; 225:187.e1-187.e14. [PMID: 33508311 DOI: 10.1016/j.ajog.2021.01.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Intertwin size discordance is an independent risk factor for adverse neonatal outcomes in twin pregnancies. However, size discordance at a given point in gestation fails to take into consideration information, such as the timing of onset and the rate of progression of discordance, that may be of prognostic value. OBJECTIVE In this study, we aimed to identify distinct patterns of discordant fetal growth in twin pregnancies and to determine whether these patterns are predictive of adverse pregnancy outcomes. STUDY DESIGN This was a retrospective cohort study of women with twin pregnancies in a single tertiary referral center between January 2011 and April 2020, who had at least 3 ultrasound examinations during pregnancy that included assessment of fetal biometry. Size discordance was calculated at each ultrasound examination, and pregnancies were classified into 1 of 4 predetermined patterns based on the timing of onset and the progression of discordance: pattern 1, no significant discordance group (referent); pattern 2, early (<24 weeks' gestation) progressive discordance group; pattern 3, early discordance with plateau group; or pattern 4, late (≥24 weeks' gestation) discordance group. The associations of discordance pattern (using pattern 1 as referent) with preterm birth, preeclampsia, size discordance at birth, and birthweight<10th percentile were expressed as adjusted relative risk with 95% confidence intervals and were compared with those observed for a single measurement of size discordance at 32 weeks' gestation. RESULTS Of 2075 women with a twin gestation who were identified during the study period, 1059 met the study criteria. Of the 1059 women, 599 (57%) were classified as no significant discordance (pattern 1), 23 (2%) as early progressive discordance (pattern 2), 160 (15%) as early discordance with plateau (pattern 3), and 277 (26%) as late discordance (pattern 4). The associations of discordance pattern with preterm birth at <34 weeks' gestation and preeclampsia were strongest for pattern 2 (rates of 43% [adjusted relative risk, 3.43; 95% confidence interval, 2.10-5.62] and 17% [adjusted relative risk, 5.81; 95% confidence interval, 2.31-14.60], respectively), intermediate for pattern 3 (rates of 23% [adjusted relative risk, 1.82; 95% confidence interval, 1.28-2.59] and 6% [adjusted relative risk, 2.08; 95% confidence interval, 1.01-4.43], respectively), and weakest for pattern 4 (rates of 12% [adjusted relative risk, 0.96; 95% confidence interval, 0.65-1.42] and 4% [adjusted relative risk, 1.41; 0.68-2.92], respectively). In contrast, a single measurement of size discordance at 32 weeks' gestation showed no association with preeclampsia and only a weak association with preterm birth at <34 weeks' gestation. CONCLUSION We identified 4 distinct discordance growth patterns among twins that demonstrated a dose-response relationship with adverse outcomes and seemed to be more informative than a single measurement of size discordance.
Collapse
|
43
|
von Kaisenberg C, Klaritsch P, Ochsenbein-Kölble N, Hodel ME, Nothacker M, Hecher K. Screening, Management and Delivery in Twin Pregnancy. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:367-378. [PMID: 33017845 DOI: 10.1055/a-1248-8896] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The following AWMF guideline (DGGG/AGG & DEGUM responsible) deals with the diagnosis, screening and management of twins as well as the timing and mode of birth.Twin pregnancies can be classified as dichorionic diamniotic (DC DA), monochorionic diamniotic (MC DA) and monochorionic monoamniotic (MC MA) which are always monochorionic.Twin pregnancies can be concordant (both twins are affected) or discordant (only one twin is affected) for chromosomal defects, malformations, growth restriction and hemodynamic disorders.Chorionicity is the prognostically most significant parameter. Monochorial twins have significantly higher risks of intrauterine morbidity and mortality compared to dichorial twins.In particular, general aspects of twin pregnancies such as dating, determination of chorionicity and amnionicity, the labeling of twin fetuses and the perinatal switch phenomenon are discussed.Routine monitoring of MC and DC twin pregnancies with ultrasound at 11-13+ 6 weeks of gestation for chromosomal defects, invasive prenatal diagnosis, first-trimester NT or CRL discrepancies, early diagnosis of fetal anatomical defects, and management of twins with abnormalities, including selective fetocide, is described.Second trimester screening and management for preterm birth, intrauterine selective growth restriction (sFGR), classification of monochorial twins with sFGR, and management of the surviving twin after the death of the co-twin are described.Complications exclusively affecting MC twins include Twin to Twin Transfusion Syndrome (TTTS) with the important topics screening, prognosis, complications of laser therapy, timing of delivery, risks for brain abnormalities and delayed neurological development, Twin Anemia-Polycythemia Sequence (TAPS) and Twin Reversed Arterial Perfusion (TRAP) Sequence. This also includes MC MA twins as well as conjoined twins.Finally, the birth mode and time for DC and MC twin pregnancies are described.The information is summarized in 62 recommendations for action, 4 tables and 8 illustrations with comprehensive background texts.The guideline is an international guideline adaptation (ISUOG, NICE) as well as a systematic literature search and is up-to-date.
Collapse
Affiliation(s)
| | - Philipp Klaritsch
- Department of Obstetrics and Gynecology, Medical University Graz, Austria
| | | | | | - Monika Nothacker
- AWMF-Institut für Medizinisches Wissensmanagement (AWMF-IMWi), University of Marburg, Germany
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
44
|
Khalil A, Liu B. Controversies in the management of twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:888-902. [PMID: 32799348 DOI: 10.1002/uog.22181] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/18/2020] [Accepted: 07/30/2020] [Indexed: 06/11/2023]
Abstract
Despite many advances in antenatal care, twin pregnancies still experience more adverse outcomes, in particular perinatal morbidity and mortality. They also pose a multitude of challenges and controversies, as outlined in this Review. Moreover, they are less likely to be included in clinical trials. Many issues on classification and management remain under debate. Efforts at standardizing diagnostic criteria, monitoring protocols, management and outcome reporting are likely to reduce their perinatal risks. The top 10 most important research uncertainties related to multiple pregnancies have been identified by both clinicians and patients. More robust research in the form of randomized trials and large well-conducted prospective cohort studies is needed to address these controversies. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- A Khalil
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - B Liu
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
45
|
Sobhani NC, Sparks TN, Gosnell KA, Rand L, Gonzalez JM, Feldstein VA. Outcomes of Monochorionic, Diamniotic Twin Pregnancies with Prenatally Diagnosed Intertwin Weight Discordance. Am J Perinatol 2021; 38:649-656. [PMID: 33321536 PMCID: PMC8164970 DOI: 10.1055/s-0040-1721697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Monochorionic, diamniotic (MCDA) twin pairs are predisposed to various pregnancy complications due to the unique placental angioarchitecture of monochorionicity. Few studies have evaluated the outcomes of weight-discordant MCDA pairs without selective fetal growth restriction (SFGR) or the risk factors for development of SFGR. This study aims to describe the natural history of expectant, noninvasive management of weight-discordant MCDA twins and to evaluate risk factors associated with progression to SFGR. STUDY DESIGN This was a retrospective cohort study at a single, tertiary care center in the United States. All MCDA twins with isolated intertwin weight discordance (ITWD) ≥ 20% diagnosed before 26 weeks' gestational age (GA) were included. The primary outcome of descriptive analyses was overall pregnancy outcome, incorporating both survival to delivery and GA at delivery, as defined by the North American Fetal Therapy Network. The secondary outcome was SFGR in one twin (defined as estimated fetal weight < 10% for GA) and factors associated with this progression. Only those with fetal ultrasound (US) within 4 weeks of delivery were included in this secondary analysis. RESULTS Among 73 MCDA pairs with ITWD, 73% had a good pregnancy outcome, with dual live delivery at a median GA of 33 weeks. Among the 34 pairs with adequate US follow-up, 56% developed SFGR. There were no differences in GA at delivery or discordance at birth between those who did and those who did not develop SFGR. There was a nonsignificant association between increasing ITWD at diagnosis and subsequent development of SFGR. CONCLUSION Expectant, noninvasive management can be considered in MCDA twin pregnancies with ITWD ≥ 20% diagnosed before 26 weeks. This approach is associated with a good pregnancy outcome in the majority of cases, even after the development of SFGR in the smaller twin. KEY POINTS · Nearly 75% of weight-discordant mo/di twins have a good pregnancy outcome.. · Weight-discordant mo/di twins deliver at a mean gestational age of 33 weeks without invasive therapy.. · Noninvasive management should be considered for weight-discordant mo/di twins..
Collapse
Affiliation(s)
- Nasim C. Sobhani
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - Teresa N. Sparks
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California,Fetal Treatment Center, University of California San Francisco, San Francisco, California
| | - Kristen A. Gosnell
- Fetal Treatment Center, University of California San Francisco, San Francisco, California
| | - Larry Rand
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California,Fetal Treatment Center, University of California San Francisco, San Francisco, California
| | - Juan M. Gonzalez
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California,Fetal Treatment Center, University of California San Francisco, San Francisco, California
| | - Vickie A. Feldstein
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California,Fetal Treatment Center, University of California San Francisco, San Francisco, California,Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| |
Collapse
|
46
|
Ochsenbein-Kölble N. Twin pregnancies. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:246-269. [PMID: 33622004 DOI: 10.1055/a-1344-4812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Twin pregnancies, resulting in 2-3 % of all deliveries, are high risk pregnancies which need specialized care. A correct dating of pregnancy and the assessment of the chorionicity/amnionicity in the first trimester (< = 13 + 6 gestational weeks, GW) is essential for further monitoring. During first trimester risk stratification of monochorionic pregnancies includes evaluation of discordance of crown-rump-lengths, nuchal translucencies and amniotic fluid. At 16 GW sonographic risk evaluation of monochorionic twins involves differences in amniotic fluid and abdominal circumferences and detection of a velamentous cord insertion. A screening for fetal malformations with cervical length measurement as screening for preterm birth (cut-off < 25 mm) should be offered all twin pregnancies around 20 GW. In uncomplicated dichorionic pregnancies US examination should be performed every 4 weeks onwards to check fetal growth and amniotic fluid. An intertwin weight discordance > 20 % identifies pregnancies at increased risk of adverse outcome. Monochorionic pregnancies should be followed at least every two weeks for screening of twin-twin transfusion syndrome (TTTS), twin-anemia-polycythemia-sequence (TAPS) and selective fetal growth retardation (sFGR) with a start at 16 GW. The type 1-3 classification of sFGR in monochorionic twins depends on the pattern of end-diastolic velocity at the umbilical artery Doppler. The diagnosis of TTTS requires the presence of an oligyohydramnios (deepest vertical pocket (DVP) < 2 cm) in the donor twin and a polyhydramnios (DVP > 8 cm) in the recipient twin. However, the diagnosis of TAPS is based on the finding of discordant MCA Doppler values with a delta-MCA PV > 0.5 MoM.
Collapse
Affiliation(s)
- Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zürich and University of Zurich, Zurich, Switzerland
| |
Collapse
|
47
|
Azcorra H, Rodriguez L, Méndez N. The association between maternal and foetal factors with birth weight discordance in twins from Yucatan, Mexico. Ann Hum Biol 2021; 48:153-156. [PMID: 33900131 DOI: 10.1080/03014460.2021.1921847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Birth weight discordance (BWD) is not an uncommon event in twin pregnancies and can be associated with maternal and newborn characteristics. We aimed to analyse the association between maternal sociodemographic and newborn characteristics with BWD in twin infants born in Yucatan, Mexico, during 2008-2017 (n = 2091 pairs). BWD was calculated as the percentage of birth weight of the heavier twin. We defined three categories of BWD: concordant twins: <15%, mild-discordant: 15-24%, and severe discordant: ≥25%. A multinomial logistic regression model was used to analyse the association between maternal sociodemographic and newborn characteristics with BWD. Seventy-four percent (n = 1547) of twin pairs were classified as concordant, 17% (n = 356) met the criteria for mild-discordance and 9% (n = 188) for severe discordance. The odds for mild-discordance were significantly lower for mothers with medium level of education and in the highest quartile of total twin birth weight (TBW). Opposite-sex twin pairs showed increased odds for mild-discordance compared with same-sex pairs. The odds for severe discordance increased as mothers were in older age groups and decreased as TBW increased. Our rates of BWD are similar to those reported in populations from wealthier countries and maternal age and education, infants' sex, and TBW are associated with BWD.
Collapse
Affiliation(s)
- Hugo Azcorra
- Centro de Investigaciones Silvio Zavala, Universidad Modelo, Mérida, México
| | - Luis Rodriguez
- Faculta de Matemáticas, Universidad Autónoma de Yucatán, Mérida, México
| | - Nina Méndez
- Hospital Regional de Alta Especialidad de la Península de Yucatán, Mérida, México
| |
Collapse
|
48
|
Batsry L, Matatyahu N, Avnet H, Weisz B, Lipitz S, Mazaki-Tovi S, Yinon Y. Perinatal outcome of monochorionic diamniotic twin pregnancy complicated by selective intrauterine growth restriction according to umbilical artery Doppler flow pattern: single-center study using strict fetal surveillance protocol. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:748-755. [PMID: 32573847 DOI: 10.1002/uog.22128] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/05/2020] [Accepted: 06/15/2020] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To determine the perinatal outcome of monochorionic diamniotic (MCDA) twin pregnancies complicated by selective intrauterine growth restriction (sIUGR), which were classified according to the umbilical artery (UA) Doppler flow pattern of the IUGR twin. METHODS This was a retrospective cohort study of all MCDA twin pregnancies diagnosed with sIUGR and managed at a single tertiary referral center between 2012 and 2018. Cases were classified according to the UA Doppler flow pattern of the IUGR twin as Type I (positive end-diastolic flow), Type II (persistently absent/reversed end-diastolic flow) or Type III (intermittently absent/reversed end-diastolic flow). Patients with Type-II or -III sIUGR were hospitalized at 26-28 weeks of gestation for increased fetal surveillance. Perinatal and immediate and long-term neurodevelopmental outcomes were stratified according to the UA Doppler flow pattern at the final examination. Intact survival rate was defined as the number of infants surviving without neurological impairment, divided by the total number of fetuses. Composite adverse outcome, defined as any mortality, presence of severe brain lesions on postnatal transcranial ultrasound or severe neurological morbidity, was also assessed. RESULTS Of 88 MCDA twin pregnancies with sIUGR included in the study, 28 underwent selective termination by cord occlusion using radiofrequency ablation, resulting in a perinatal survival rate of 89.3% and a median gestational age (GA) at delivery of 33.8 (interquartile range (IQR), 28.8-38.2) weeks for the large cotwin. Expectant management was employed in 60 cases. In 26 (43.3%) cases in the expectant-management group, the classification according to the UA Doppler flow pattern changed during gestation, resulting in 26 (43.3%) cases of Type-I, 22 (36.7%) cases of Type-II and 12 (20.0%) cases of Type-III sIUGR at the final examination. The perinatal survival rate of both twins with sIUGR Types I, II and III at the final examination was 100%, 81.8% and 75.0%, respectively (P = 0.04). Two cases of double fetal death and one case of single fetal death occurred 1-4 weeks after the Doppler pattern had changed from Type I or Type II to Type III. The median GA at delivery was 34.8 (IQR, 33.1-35.7) weeks in Type I, 30.3 (IQR, 28.6-32.1) weeks in Type II and 32.0 (IQR, 31.3-32.6) weeks in Type III (P < 0.01). The total intact survival rate was 100% for Type I, 77.3% for Type II and 75.0% for Type III (P < 0.001). Multivariate analysis demonstrated that early GA at diagnosis (odds ratio (OR), 0.83 (95% CI, 0.69-0.99); P = 0.04) and the presence of Type II or III vs Type I at the last examination (OR, 13.16 (95% CI, 1.53-113.32); P = 0.02) were associated with preterm birth < 32 weeks' gestation. Early GA at diagnosis was also associated with the composite adverse outcome (OR, 0.60 (95% CI, 0.36-0.99); P = 0.04). CONCLUSIONS The classification system of MCDA pregnancy complicated by sIUGR, according to the UA Doppler flow pattern of the IUGR twin at final examination, is associated with perinatal outcome. Importantly, the UA Doppler flow pattern can change during gestation, which has an impact on the risk of fetal death. Nevertheless, under strict fetal surveillance, the perinatal outcome of these pregnancies is favorable. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- L Batsry
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - N Matatyahu
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Avnet
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - B Weisz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Lipitz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Mazaki-Tovi
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Yinon
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
49
|
Melamed N, Baschat A, Yinon Y, Athanasiadis A, Mecacci F, Figueras F, Berghella V, Nazareth A, Tahlak M, McIntyre HD, Da Silva Costa F, Kihara AB, Hadar E, McAuliffe F, Hanson M, Ma RC, Gooden R, Sheiner E, Kapur A, Divakar H, Ayres‐de‐Campos D, Hiersch L, Poon LC, Kingdom J, Romero R, Hod M. FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction. Int J Gynaecol Obstet 2021; 152 Suppl 1:3-57. [PMID: 33740264 PMCID: PMC8252743 DOI: 10.1002/ijgo.13522] [Citation(s) in RCA: 175] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.
Collapse
Affiliation(s)
- Nir Melamed
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologySunnybrook Health Sciences CentreUniversity of TorontoTorontoONCanada
| | - Ahmet Baschat
- Center for Fetal TherapyDepartment of Gynecology and ObstetricsJohns Hopkins UniversityBaltimoreMDUSA
| | - Yoav Yinon
- Fetal Medicine UnitDepartment of Obstetrics and GynecologySheba Medical CenterTel‐HashomerSackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and GynecologyAristotle University of ThessalonikiThessalonikiGreece
| | - Federico Mecacci
- Maternal Fetal Medicine UnitDivision of Obstetrics and GynecologyDepartment of Biomedical, Experimental and Clinical SciencesUniversity of FlorenceFlorenceItaly
| | - Francesc Figueras
- Maternal‐Fetal Medicine DepartmentBarcelona Clinic HospitalUniversity of BarcelonaBarcelonaSpain
| | - Vincenzo Berghella
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Amala Nazareth
- Jumeira Prime Healthcare GroupEmirates Medical AssociationDubaiUnited Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and ChildrenDubai Health AuthorityEmirates Medical AssociationMohammad Bin Rashid University for Medical Sciences, Dubai, United Arab Emirates
| | | | - Fabrício Da Silva Costa
- Department of Gynecology and ObstetricsRibeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoSão PauloBrazil
| | - Anne B. Kihara
- African Federation of Obstetricians and GynaecologistsKhartoumSudan
| | - Eran Hadar
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Fionnuala McAuliffe
- UCD Perinatal Research CentreSchool of MedicineNational Maternity HospitalUniversity College DublinDublinIreland
| | - Mark Hanson
- Institute of Developmental SciencesUniversity Hospital SouthamptonSouthamptonUK
- NIHR Southampton Biomedical Research CentreUniversity of SouthamptonSouthamptonUK
| | - Ronald C. Ma
- Department of Medicine and TherapeuticsThe Chinese University of Hong KongHong Kong SARChina
- Hong Kong Institute of Diabetes and ObesityThe Chinese University of Hong KongHong Kong SARChina
| | - Rachel Gooden
- FIGO (International Federation of Gynecology and Obstetrics)LondonUK
| | - Eyal Sheiner
- Soroka University Medical CenterBen‐Gurion University of the NegevBe’er‐ShevaIsrael
| | - Anil Kapur
- World Diabetes FoundationBagsværdDenmark
| | | | | | - Liran Hiersch
- Sourasky Medical Center and Sackler Faculty of MedicineLis Maternity HospitalTel Aviv UniversityTel AvivIsrael
| | - Liona C. Poon
- Department of Obstetrics and GynecologyPrince of Wales HospitalThe Chinese University of Hong KongShatinHong Kong SAR, China
| | - John Kingdom
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologyMount Sinai HospitalUniversity of TorontoTorontoONCanada
| | - Roberto Romero
- Perinatology Research BranchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMDUSA
| | - Moshe Hod
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| |
Collapse
|
50
|
Song H, Fang F, Larsson H, Pedersen NL, Magnusson PK, Almqvist C, Valdimarsdóttir UA. Loss of a co-twin at birth and subsequent risk of psychiatric disorders. eLife 2021; 10:63514. [PMID: 33507148 PMCID: PMC7843130 DOI: 10.7554/elife.63514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 01/21/2021] [Indexed: 02/05/2023] Open
Abstract
Twins suffering a co-twin loss at birth have reported feelings of loneliness and grief while it remains unexplored if they suffer increased risk of psychiatric disorders. We contrasted rate of first-onset psychiatric disorders among all Swedish-born twins whose co-twin died within 60 days after birth between 1973 and 2011 (n = 787) to that of 3935 matched unexposed twins, 3935 matched singletons (both matched to the exposed twins by birth year, sex, and birth characteristics), and 880 full siblings of the exposed twins. During a median of 19-year follow-up, exposed twins were at increased risk of first-onset psychiatric disorders (hazard ratio = 1.56, 95%CI 1.30–1.87) compared with unexposed twins. We observed the strongest association for emotional disorders and for psychiatric disorders diagnosed before the age of 25. Comparisons with matched singletons and the twin’s full siblings rendered similar results, corroborating an association of loss of a co-twin at birth with subsequent risk of psychiatric disorders.
Collapse
Affiliation(s)
- Huan Song
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Sichuan, China.,Center of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Fang Fang
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Nancy L Pedersen
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Psychology, University of Southern California, Los Angeles, United States
| | - Patrik Ke Magnusson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Unnur A Valdimarsdóttir
- Center of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, United States
| |
Collapse
|