The rate of twin birth is declining

Preserving Fertility in People With Rheumatic Diseases

ABSTRACT

Rheumatology patients historically were told they "can't" or "shouldn't" become pregnant. Improved rheumatic diagnostics and treatments have led to decreased morbidity and mortality and increased quality of life resulting in an opportunity to focus on fertility and its preservation. In the same vein as rheumatic disease care, assisted reproductive technology (ART), which includes freezing of egg and sperm as well as in vitro fertilization, has made considerable strides in the recent past. ART is safe for those with rheumatic diseases and has comparable outcomes to the general public, but may take additional effort due to optimal timing, rheumatic medications, and other nuances. In a specialty that treats chronic inflammatory diagnoses using teratogens and gonadotoxins, it is important to address family building desires with patients so their goals can be met.Rheumatologists have little knowledge of ART and how it impacts or applies to their patients; however, patients want their rheumatologist to be the source of knowledge for this information (Arthritis Rheumatol. 2022;74:suppl 9). Many barriers to ART exist and will be explored, with the financial burden being paramount (Glob J Health Sci. 6;1:181-191). Future efforts to examine the future fertility of rheumatology patients in an era of biologics and "treat-to-target" are needed to better understand who would most benefit from this costly and not without risk medical treatment. Given the changing landscape of financial support for ART due to insurance mandates, rheumatologists should not modify counseling based on the anticipated ability of patients to afford care. Preservation should also be broached with patients without partners and those from the LGBTQAI+ community. In addition to expanding the education of rheumatologists regarding this topic and its incorporation into clinical care, advocacy for ART access and insurance coverage is a much-needed future direction.

Association between interpregnancy interval and adverse perinatal outcomes among subsequent twin pregnancies: a nationwide population-based study

BACKGROUND

The existing evidence on the association between interpregnancy interval (IPI) and pregnancy outcomes primarily focuses on singleton pregnancies, with limited research on twin pregnancies.

OBJECTIVE

This study aimed to investigate the association between IPI and adverse perinatal outcomes in twin pregnancies.

STUDY DESIGN

This population-based, retrospective cohort study analyzed data from the National Center for Health Statistics in the United States between 2016 and 2020. We included multiparous women aged 18 to 45 years with live-born twins without congenital anomalies, born between 26 and 42 weeks of gestation. Poisson regression models, adjusted for potential confounders, were used to evaluate the associations between IPI and adverse outcomes, including preterm birth (PTB) <36 weeks, small for gestational age (SGA), neonatal intensive care unit (NICU) admission, neonatal composite morbidity, and infant death. Missing data on covariates were managed using multiple imputations. Dose-response analyses were performed using the restricted cubic splines (RCS) approach. Subgroup analyses were stratified by maternal age, parity, and combination of neonatal sex. Sensitivity analyses were conducted using complete data and excluding pregnancies with intervening events during the IPI.

RESULTS

A total of 143,014 twin pregnancies were included in the analysis. Compared to the referent group (IPI of 18-23 months), an IPI of less than 6 months was associated with an increased risk of PTB<36 weeks (RR, 1.21; 95% confidence interval [95% CI]: 1.17-1.25), SGA (RR, 1.11; 95% CI: 1.03-1.18), neonatal composite morbidity (RR, 1.19; 95% CI: 1.12-1.27), NICU admission (RR, 1.18; 95% CI: 1.14-1.22), and infant death (RR, 1.29; 95% CI: 1.05-1.60). An IPI of 5 years or more was associated with an increased risk of PTB<36 weeks (RR, 1.18; 95% CI: 1.15-1.21), SGA (RR, 1.24; 95% CI: 1.18-1.30), neonatal composite morbidity (RR, 1.10; 95% CI: 1.05-1.15), and NICU admission (RR, 1.14; 95% CI: 1.11-1.17). The dose-response analyses showed that these outcomes had U-shaped or J-shaped associations with IPI. The associations between IPI and the outcomes slightly differed by advanced maternal age, parity, and combination of neonatal sex. The sensitivity analyses yielded similar results to the main findings.

CONCLUSION

Extreme IPI, less than 6 months or more than 5 years, was associated with adverse outcomes in twin pregnancies. IPI could be used as a predictor for risk stratification in high-risk twin pregnancies.

The Role of MALAT1 in Regulating the Proangiogenic Functions, Invasion, and Migration of Trophoblasts in Selective Fetal Growth Restriction

Epigenetic regulation is an important entry point to study the pathogenesis of selective fetal growth restriction (sFGR), and an understanding of the role of long noncoding RNAs (lncRNAs) in sFGR is lacking. Our study aimed to investigate the potential role of a lncRNA, metastasis-associated lung adenocarcinoma transcript 1 (MALAT1), in sFGR using molecular biology experiments and gain- or loss-of-function assays. We found that the levels of MALAT1, ERRγ, and HSD17B1 were downregulated and that of miR-424 was upregulated in the placental shares of the smaller twins. Moreover, angiogenesis was impaired in the placental share of the smaller fetus and MALAT1 could regulate the paracrine effects of trophoblasts on endothelium angiogenesis and proliferation by regulating miR-424. In trophoblasts, MALAT1 could competitively bind to miR-424 to regulate the expression of ERRγ and HSD17B1, thus regulating trophoblast invasion and migration. MALAT1 overexpression could decrease apoptosis and promote proliferation, alleviating cell damage induced by hypoxia. Taken together, the downregulation of MALAT1 can reduce the expression of ERRγ and HSD17B1 by competitively binding to miR-424, impairing the proangiogenic effect of trophoblasts, trophoblast invasion and migration, and the ability of trophoblasts to compensate for hypoxia, which may be involved in the pathogenesis of sFGR through various aspects.

Maternal and perinatal outcomes in twin pregnancies following assisted reproduction: a systematic review and meta-analysis involving 802 462 pregnancies

BACKGROUND

ART is associated with higher rates of twin pregnancies than singleton pregnancies. Whether twin pregnancies conceived following ART have additional maternal and neonatal complications compared with non-ART twin pregnancies is not known.

OBJECTIVE AND RATIONALE

The objective was to quantify the risk of adverse maternal and perinatal outcomes among twin pregnancies conceived following ART compared with non-ART and natural conception. Existing reviews vary in the reported outcomes, with many studies including triplet pregnancies in the study population. Therefore, we aimed to perform an up-to-date review with an in-depth analysis of maternal and perinatal outcomes limited to twin pregnancies.

SEARCH METHODS

We searched electronic databases MEDLINE and EMBASE from January 1990 to May 2023 without language restrictions. All cohort studies reporting maternal and perinatal outcomes following ART compared with non-ART twin pregnancies and natural conception were included. Case-control studies, case reports, case series, animal studies, and in vitro studies were excluded. The Newcastle-Ottawa Scale was used to assess the methodological quality of the studies. Using random-effects meta-analysis, the estimates were pooled and the findings were reported as odds ratios (OR) with 95% CI.

OUTCOMES

We included 111 studies (802 462 pregnancies). Twin pregnancies conceived following ART were at higher risk of preterm birth at <34 weeks (OR 1.33, 95% CI 1.14-1.56, 29 studies, I2 = 73%), <37 weeks (OR 1.26, 95% CI 1.19-1.33, 70 studies, I2 = 76%), hypertensive disorders in pregnancy (OR 1.29, 95% CI 1.14-1.46, 59 studies, I2 = 87%), gestational diabetes mellitus (OR 1.61, 95% CI 1.48-1.75, 51 studies, I2 = 65%), and caesarean delivery (OR 1.80, 95% CI 1.65-1.97, 70 studies, I2 = 89%) compared with non-ART twins. The risks for the above maternal outcomes were also increased in the ART group compared with natural conception. Of the perinatal outcomes, ART twins were at significantly increased risk of congenital malformations (OR 1.17, 95% CI 1.05-1.30, 39 studies, I2 = 59%), birthweight discordance (>25% (OR 1.31, 95% CI 1.05-1.63, 7 studies, I2 = 0%)), respiratory distress syndrome (OR 1.32, 95% CI 1.09-1.60, 16 studies, I2 = 61%), and neonatal intensive care unit admission (OR 1.24, 95% CI 1.14-1.35, 32 studies, I2 = 87%) compared with non-ART twins. When comparing ART with natural conception, the risk of respiratory distress syndrome, intensive care admissions, and birthweight discordance >25% was higher among the ART group. Perinatal complications, such as stillbirth (OR 0.83, 95% CI 0.70-0.99, 33 studies, I2 = 49%), small for gestational age <10th centile (OR 0.90, 95% CI 0.85-0.95, 26 studies, I2 = 36%), and twin-twin transfusion syndrome (OR 0.45, 95% CI 0.25-0.82, 9 studies, I2 = 25%), were reduced in twin pregnancies conceived with ART versus those without ART. The above perinatal complications were also fewer amongst the ART group than natural conception.

WIDER IMPLICATIONS

ART twin pregnancies are associated with higher maternal complications than non-ART pregnancies and natural conception, with varied perinatal outcomes. Women seeking ART should be counselled about the increased risks of ART twin pregnancies and should be closely monitored in pregnancy for complications. We recommend exercising caution when interpreting the study findings owing to the study's limitations.

High-Order Parity Improves the Perinatal Outcome of Twin Deliveries

OBJECTIVE

Twin gestations are associated with an increased risk of obstetric and perinatal complications. We studied the association between parity and the rate of maternal and neonatal complications in twins deliveries.

STUDY DESIGN

We performed a retrospective analysis of a cohort of twin gestations delivered between 2012 and 2018. Inclusion criteria consisted of twin gestation with two nonanomalous live fetuses at ≥24 weeks' gestation and no contraindications to vaginal delivery. Women were divided into three groups based on parity: primiparas, multiparas (parity of 1-4), and grand multiparas (parity ≥5). Demographic data were collected from electronic patient records and included maternal age, parity, gestational age at delivery, need for induction of labor, and neonatal birth weight. The primary outcome was mode of delivery. Secondary outcomes were maternal and fetal complications.

RESULTS

The study population included 555 twin gestations. One hundred and three were primiparas, 312 were multiparas, and 140 were grand multiparas. Sixty-seven (65%) primiparas delivered the first twin vaginally, as did 294 (94%) multiparas and 133 (95%) grand multiparas (p <0.05). Thirteen (2.3%) women required delivery of the second twin by cesarean section. Among those who delivered both twins vaginally, there was no significant difference in the average time interval between the delivery of the first and the second twins between the groups. The need for transfusion of blood products was higher in the primiparous group compared with the other two groups (11.6 vs. 2.5 and 2.8%, p < 0.05). The rate of adverse maternal composite outcomes was higher among primiparous women compared with multiparous and grand multiparous (12.6, 3.2, and 2.8%, respectively, p < 0.05). The gestational age at delivery was earlier in the primiparous group compared with the other two groups, and the rate of preterm labor at <34 weeks' gestation was higher among the primiparas. The rate of second twin's 5-minute Apgar's score <7 and the composite adverse neonatal outcome among the primiparous group were significantly higher than the multiparous and grand multiparous groups.

CONCLUSION

Our study demonstrates that there is an association between high-parity and good obstetric outcomes in twin pregnancies; high parity seems to serve as a protective, rather than a risk factor for adverse maternal and neonatal outcomes.

KEY POINTS

· There is an association between high-parity and good obstetric outcome in twin pregnancies.. · High parity serves as a protective factor for adverse maternal outcomes in twin deliveries.. · High parity serves as a protective factor for adverse neonatal outcomes in twin deliveries..

The Transport of Respiratory Distress Syndrome Twin Newborns: The 27-Year-Long Experience of Gaslini Neonatal Emergency Transport Service Using Both Single and Double Ventilators

OBJECTIVE

Twin pregnancy rates have increased in the past 30 years. We describe the experience of the Neonatal Emergency Transport Service of the Gaslini Hospital, Genoa, Italy, in the transport of twin newborns.

METHODS

This was a retrospective study (1996-2021); 7,852 medical charts from the Neonatal Emergency Transport Service were reviewed. We included all twin newborns who were transported with respiratory distress syndrome in the study. We split the included patients into 2 groups (group A and group B) based on if they were simultaneously ventilated by a single ventilator or by 2 different ventilators, and then each group was split by the different types of ventilation (nasal continuous positive airway pressure or intermittent positive pressure ventilation). The pH level, base excess, O₂ saturation, Pco₂, body temperature, plasma glucose, and Transport Risk Index of Physiologic Stability score were recorded at departure and arrival.

RESULTS

One hundred thirty-six patients were included (68 pairs of twins); group A consisted of 92 newborns and group B 44 newborns. Although some significant differences were observed (statistic), none of these had real clinical significance.

CONCLUSION

Transporting respiratory distress syndrome twin newborns is challenging. Our study provided a 27-year experience in the field. Transporting twins by a single ventilator is possible, but, in our opinion, using 2 ventilators mounted on the same transport module is the best possible choice in terms of clinical performance, logistics, and cost.

Temporal trends and adverse perinatal outcomes of twin pregnancies at differing gestational ages: an observational study from China between 2012-2020

BACKGROUND

With the development of assisted reproductive technology, the twinning rate in China has been increasing. However, little is known about twinning from 2014 onwards. In addition, previous studies analysing optimal gestational times have rarely considered maternal health conditions. Therefore, whether maternal health conditions affect the optimal gestational time remains unclear.

METHODS

Data of women delivered between January 2012 and December 2020 were collected through China's National Maternal Near Miss Surveillance System. Interrupted time series analysis was used to determine the rates of twinning, stillbirth, smaller than gestational age (SGA), and low Apgar scores (< 4) among twins in China. To estimate the risk of each adverse perinatal outcome for separate gestational weeks, a multivariate generalised linear model was used. Infants born at 37 weeks of gestational age or foetuses staying in utero were used as reference separately. The analyses were adjusted for the sampling distribution of the population and the cluster effect at the hospital and individual levels were considered.

RESULTS

There were 442,268 infants enrolled in this study, and the adjusted rates for twinning, stillbirth, SGA, and low Apgar scores were 3.10%, 1.75%, 7.70%, and 0.79%, respectively. From 2012 to 2020, the twinning rate showed an increasing trend. Adverse perinatal outcomes, including stillbirth, SGA, and low Apgar scores showed a decreasing trend. A gestational age between 34 and 36 weeks decreased most for rate of stillbirth (average changing rate -9.72%, 95% confidence interval [CI] -11.41% to -8.00%); and a gestational age of between 37 and 38 weeks decreased most for rates of SGA (average changing rate -4.64%, 95% CI -5.42% to -3.85%) and low Apgar scores (average changing rate -17.61%, 95% CI -21.73% to -13.26%). No significant difference in changes in twinning rate or changes of each perinatal outcome was observed during periods of different fertility policies. Infants born at 37 weeks of gestation had a decreased risk of stillbirth, SGA, and low Apgar scores. Maternal antepartum or medical complications increased the risk of SGA and low Apgar scores in different gestational weeks.

CONCLUSION

China's twinning rate showed an increasing trend, while adverse perinatal outcomes decreased from 2012 to 2020. Fertility policy changes have had little effect on the twinning rate or the rate of adverse perinatal outcomes such as stillbirth, SGA, or low Apgar scores. The optimal gestational age for twins was 37 weeks. Women pregnant with twins and with antepartum or medical complications should be cautious due to an increased risk of SGA and low Apgar scores.

Controversies in the management of twin pregnancy

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.