Evidence-based care of women with a multiple pregnancy

Antenatal care addressing gestational weight gain (GWG): a cross sectional study of pregnant women's reported receipt and acceptability of recommended GWG care and associated characteristics

BACKGROUND

The Australian Clinical Practice Guidelines for Pregnancy Care recommend that during the first and subsequent antenatal visits all pregnant women are weighed; advised of recommended gestational weight gain (GWG), dietary intake and physical activity; and offered referrals for additional support if needed. The extent to which these recommendations are implemented and women's acceptability of recommended care is unknown. This study examines women's reported receipt and acceptability of guideline care for GWG, and characteristics associated with receipt of such care and its acceptability.

METHODS

From September 2018 to February 2019 a telephone survey was undertaken with women who had recently had a baby and received antenatal care from five public maternity services within a health district in Australia. Women self-reported their demographic characteristics, and receipt and acceptability of recommended GWG care. Receipt and acceptability of such care, and their association with the characteristics of women and the maternity service they attended, were examined using descriptive statistics and multivariable logistic regression analyses.

RESULTS

Of 514 women, 13.1% (95%CI:10.3-16.5) reported that they received an assessment of weight at both their first and a subsequent antenatal visit, and less than one third (30.0%; 95%CI:26.0-33.9) received advice on their recommended GWG range, dietary intake and physical activity. Just 6.6% (95%CI:4.8-9.1) of women reported receiving all assessment and advice components of recommended antenatal care, and 9.9% (95%CI:7.6-12.8) of women reported being referred for extra support. Women who were younger (OR = 1.13;95%CI:1.05-1.21), identifying as Aboriginal and Torres Strait Islander (OR = 24.54;95%CI:4.98-120.94), had a higher pre-pregnancy BMI (OR = 1.13;95%CI:1.05-1.21), were experiencing their first pregnancy (OR = 3.36;95%CI:1.27-8.86), and lived in a least disadvantaged area (compared to mid-disadvantaged area (OR = 18.5;95%CI:2.6-130.5) and most disadvantaged area (OR = 13.1;95%CI:2.09-82.4)) were more likely to receive recommended assessment and advice. Most Aboriginal (92%) and non-Aboriginal (93%) women agreed that recommended GWG care is acceptable.

CONCLUSION

Most women perceive antenatal care for GWG as recommended by the Clinical Practice Guidelines as acceptable, but did not receive it. When provided, such care is not delivered consistently to all women regardless of their characteristics or those of the maternity service they attend. There is a need for service-wide practice change to increase routine GWG care in pregnancy for all women.

Maternal Profiles and Pregnancy Outcomes: A Descriptive Cross-Sectional Study from Angola

OBJECTIVES

To characterize pregnant women admitted to Irene Neto Maternity Hospital, Lubango city, Huíla province, and their pregnancy outcomes.

METHODS

We conducted a descriptive cross-sectional facility-based survey between October 2016 and September 2017, involving 500 pregnant women, followed from admission in labor until the end of delivery. Mean (SD) was computed for quantitative variables, while relative and absolute frequencies were determined for categorical variables. Additionally, confidence intervals were estimated.

RESULTS

Among pregnant women 18.3% were adolescents (≤ 19 years) and 14.5% had advanced maternal age (≥ 35 years). Illiteracy was reported by 8.2%. One in three (33.6%) had a short stature (< 1.55 m). Malaria was the most frequent infection during pregnancy (16.3%). Upon admission, 18.1% were anemic (Hb < 11 g/dl) and 36.0% had hypertension (SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg), contrasting with the few cases reported of chronic hypertension and pregnancy-induced hypertension. There were 15 twin pregnancies. Cesarean section was performed in 25.2% of the women, although there was no medical indication for 23.0% of women having cesareans. Two maternal deaths occurred in our sample. Among live births from singleton pregnancies (97.1%), birth asphyxia (Apgar < 7 at 5 min) was observed in 22.7% and 10.3% had low birth weight (< 2.5 kg).

CONCLUSIONS

There are very few studies reporting pregnancy outcomes in Angola. This analysis presents data from Huíla province, the second most populous province. We identified characteristics for higher risk of adverse pregnancy outcomes: adolescence, illiteracy, and short stature. Among newborn outcomes, birth asphyxia and low birth weight demand special attention. Further research is needed to explore the non-medical indications for cesarean section and to better understand the twinning rate in Lubango.

Spontaneous Version of Fetal Presentation in Twin Pregnancies During Third Trimester: Longitudinal Assessment

Little is known about longitudinal changes of the first twin presentation in twin gestations. This is a retrospective cohort study including 411 women who were admitted consecutively and delivered live-born twins at 36 weeks of gestation or more. Longitudinal assessment of the first twin presentation was conducted during gestation and at birth in all cases. Gestational age at antenatal assessment was divided into two intervals: early-third trimester (28-31 weeks) and mid-third trimester (32-35 weeks). Fetal presentation was categorized as vertex or non-vertex. We analyzed change of fetal presentation between antepartum intervals and birth. First twin presentation at early-third trimester had the same presentation at birth in 87.6% (360/411) of the study population. In this 'no change' group, vertex presentation was seen in 95.6% (283/296) and non-vertex was seen in 67.0% (77/115) of cases. In total, 96.1% (395/411) of the study population maintained their presentation between mid-third trimester and birth. Vertex presentation was seen in 98.4% (310/315) and non-vertex was seen in 88.5% (85/96) of cases. When comparing vertex with non-vertex, vertex presentation during third trimester was a more reliable predictor of presentation at birth (p < .001). The only factor that contributed significantly to spontaneous version of the first twin during mid-third trimester and birth was a lower birth weight of the first twin compared with the second twin. In conclusion, first twin presentation with vertex during third trimester is not likely to change into non-vertex at birth. We concluded that vertex presentation in twin gestations at early- and mid-third trimester is very predictable. In contrast, a non-vertex first twin presentation is relatively unstable.

Regimens of ultrasound surveillance for twin pregnancies for improving outcomes

BACKGROUND

Increased ultrasound surveillance of twin pregnancies has become accepted practice due to the higher risk of complications. There is no current consensus however as to the method and frequency of ultrasound monitoring that constitutes optimal care.

OBJECTIVES

To systematically review the effects of different types and frequency of ultrasound surveillance for women with a twin pregnancy on neonatal, fetal and maternal outcomes.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (all searched 11 August 2017), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials (including those published in abstract form) comparing the effects of described antenatal ultrasound surveillance regimens in twin pregnancies. Trials using a cluster-randomised design would have been eligible for inclusion in this review but none were identified. Trials using a cross-over design are not eligible for inclusion in this review.Different types and frequencies of ultrasound testing (for fetal surveillance and detection of specific problems) compared with each other and also compared with no testing. For example, an intervention might comprise a specific approach to ultrasound examination with dedicated components to detect twin-specific pathology. Different interventions could also include a specific type of surveillance at different intervals or different combinations at the same intervals.In this review we only found one study looking at fetal growth (biometry) and Doppler ultrasounds at 25, 30 and 35 weeks' gestation versus fetal growth alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and quality, and extracted data. We checked data for accuracy.

MAIN RESULTS

We included one trial of 526 women with a twin pregnancy of two viable twins, with no known morphological abnormality, in this review. The trial compared women receiving fetal growth and Doppler ultrasounds at 25, 30 and 35 weeks' gestation to fetal growth alone. We judged the included study to be at low risk of bias however the risk of performance and detection bias were unclear.The primary outcome was the perinatal mortality rate (after randomisation), for which there was no evidence of a clear difference between the fetal growth + Doppler and the fetal growth alone groups (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.32 to 2.41, low-quality evidence) with similar rates in both groups (seven events in the Dopper + fetal growth group and eight in the fetal growth alone group). No clear differences were seen between the two regimens for the other outcomes in this review: stillbirth (RR 0.67, 95% CI 0.11 to 3.99), neonatal death (RR 1.01, 95% CI 0.29 to 3.46, low-quality evidence), gestational age at birth (weeks) (mean difference 0.10, 95% CI -0.39 to 0.59, moderate-quality evidence), infant requiring ventilation (RR 0.86, 95% CI 0.59 to 1.25), admission to special care or intensive care units (RR 0.96, 95% CI 0.88 to 1.05), caesarean section (any) (RR 1.00, 95% CI 0.81 to 1.23, high-quality evidence), elective caesarean section (RR 1.06, 95% CI 0.77 to 1.47), emergency caesarean section (RR 0.93, 95% CI 0.66 to 1.32), induction of labour (RR 1.10, 95% CI 0.80 to 1.50, moderate-quality evidence) or antenatal hospital admission (RR 0.96, 95% CI 0.80 to 1.15, high-quality evidence). The number of preterm births before 28 weeks' gestation was not reported in the included study. For the mortality-related outcomes, event numbers were small.The included study did not report the majority of our maternal and infant secondary outcomes. Infant outcomes not reported included fetal acidosis, Apgar scores less than 7 at five minutes and preterm birth before 37 and 34 weeks' gestation. The maternal outcomes; length of antenatal hospital stay, timely diagnosis of significant complications, rate of preterm, prelabour rupture of membranes and women's level of satisfaction with their care were not reported. The study did not classify twin pregnancies according to their chorionicity. An awareness of the chorionicity may have improved applicability of this data set.We downgraded outcomes assessed using GRADE for imprecision of effect estimates.

AUTHORS' CONCLUSIONS

This review is based on one small study which was underpowered for detection of rare outcomes such as perinatal mortality, stillbirth and neonatal death.There is insufficient evidence from randomised controlled trials to inform best practice for fetal ultrasound surveillance regimens when caring for women with a twin pregnancy. More studies are needed to evaluate the effects of currently used ultrasound surveillance regimens in twin pregnancies. Future research could report on the important maternal and infant outcomes as listed in this review.

Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes

BACKGROUND

Regular antenatal care for women with a multiple pregnancy is accepted practice, and while most women have an increase in the number of antenatal visits, there is no consensus as to what constitutes optimal care. 'Specialised' antenatal clinics have been advocated as a way of improving outcomes for women and their infants.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of 'specialised' antenatal clinics compared with 'standard' antenatal care for women with a multiple pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials with reported data that compared outcomes in mothers and babies with a multiple pregnancy who received antenatal care specifically designed for women with a multiple pregnancy (as defined by the trial authors) with outcomes in controls who received 'standard' antenatal care (as defined by the trial authors).

DATA COLLECTION AND ANALYSIS

Two of the review authors independently assessed trials for inclusion and trial quality. Both review authors extracted data. Data were checked for accuracy. We graded the quality of the evidence using GRADEpro software.

MAIN RESULTS

Findings were based on the results of a single study with some design limitations.Data were available from one study involving 162 women with a multiple pregnancy. For the only reported primary outcome, perinatal mortality, we are uncertain whether specialised antenatal clinics makes any difference compared to standard care (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.26 to 4.03; 324 infants, very low quality evidence). Women receiving specialised antenatal care were significantly more likely to birth by caesarean section (RR 1.38; 95% CI 1.06 to 1.81; 162 women, moderate quality evidence). Data were not reported in the study on the following primary outcomes: small-for-gestational age, very preterm birth or maternal death. There were no differences identified between specialised antenatal care and standard care for other secondary outcomes examined: postnatal depression (RR 0.48; 95% CI 0.19 to 1.20; 133 women, very low quality evidence), breastfeeding (RR 0.63; 95% CI 0.24 to 1.68; 123 women, very low quality evidence), stillbirth (RR 0.68; 0.12 to 4.04) or neonatal death (RR 2.05; 95% CI 0.19 to 22.39) (324 infants).

AUTHORS' CONCLUSIONS

There is currently limited information available from randomised controlled trials to assess the role of 'specialised' antenatal clinics for women with a multiple pregnancy compared with 'standard' antenatal care in improving maternal and infant health outcomes. The value of 'specialised' multiple pregnancy clinics in improving health outcomes for women and their infants requires evaluation in appropriately powered and designed randomised controlled trials.

Ultrasound for fetal assessment in early pregnancy

BACKGROUND

Diagnostic ultrasound is a sophisticated electronic technology, which utilises pulses of high-frequency sound to produce an image. Diagnostic ultrasound examination may be employed in a variety of specific circumstances during pregnancy such as after clinical complications, or where there are concerns about fetal growth. Because adverse outcomes may also occur in pregnancies without clear risk factors, assumptions have been made that routine ultrasound in all pregnancies will prove beneficial by enabling earlier detection and improved management of pregnancy complications. Routine screening may be planned for early pregnancy, late gestation, or both. The focus of this review is routine early pregnancy ultrasound.

OBJECTIVES

To assess whether routine early pregnancy ultrasound for fetal assessment (i.e. its use as a screening technique) influences the diagnosis of fetal malformations, multiple pregnancies, the rate of clinical interventions, and the incidence of adverse fetal outcome when compared with the selective use of early pregnancy ultrasound (for specific indications).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Published, unpublished, and ongoing randomised controlled trials that compared outcomes in women who experienced routine versus selective early pregnancy ultrasound (i.e. less than 24 weeks' gestation). We have included quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We used the Review Manager software to enter and analyse data.

MAIN RESULTS

Routine/revealed ultrasound versus selective ultrasound/concealed: 11 trials including 37,505 women. Ultrasound for fetal assessment in early pregnancy reduces the failure to detect multiple pregnancy by 24 weeks' gestation (risk ratio (RR) 0.07, 95% confidence interval (CI) 0.03 to 0.17; participants = 295; studies = 7), moderate quality of evidence). Routine scans improve the detection of major fetal abnormality before 24 weeks' gestation (RR 3.46, 95% CI 1.67 to 7.14; participants = 387; studies = 2,moderate quality of evidence). Routine scan is associated with a reduction in inductions of labour for 'post term' pregnancy (RR 0.59, 95% CI 0.42 to 0.83; participants = 25,516; studies = 8), but the evidence related to this outcome is of low quality, because most of the pooled effect was provided by studies with design limitation with presence of heterogeneity (I² = 68%). Ultrasound for fetal assessment in early pregnancy does not impact on perinatal death (defined as stillbirth after trial entry, or death of a liveborn infant up to 28 days of age) (RR 0.89, 95% CI 0.70 to 1.12; participants = 35,735; studies = 10, low quality evidence). Routine scans do not seem to be associated with reductions in adverse outcomes for babies or in health service use by mothers and babies. Long-term follow-up of children exposed to scan in utero does not indicate that scans have a detrimental effect on children's physical or cognitive development.The review includes several large, well-designed trials but lack of blinding was a problem common to all studies and this may have an effect on some outcomes. The quality of evidence was assessed for all review primary outcomes and was judged as moderate or low. Downgrading of evidence was based on including studies with design limitations, imprecision of results and presence of heterogeneity.

AUTHORS' CONCLUSIONS

Early ultrasound improves the early detection of multiple pregnancies and improved gestational dating may result in fewer inductions for post maturity. Caution needs to be exercised in interpreting the results of aspects of this review in view of the fact that there is considerable variability in both the timing and the number of scans women received.

[Twin pregnancies: where should we manage them? Where should they deliver?]

OBJECTIVES

To define where should twin pregnancies be managed and delivered.

MATERIALS AND METHODS

A literature search was performed using the Pubmed and Cochrane database. Foreign societies guidelines were also consulted.

RESULTS

There is little or no evidence to answer the question. Risk of premature labor and chorionicity are the two main factors involved in twin management. When there is a risk of prematurity, in utero transfer is recommended. Twin care must be performed by a team trained in the specificity of management according to chorionicity. There is not enough evidence to support specialized clinics. Labor and delivery need permanent and immediate disponibility of a perinatal team including an OB-gyn, an anesthesiologist and a pediatrician.

CONCLUSION

Needs assessment and chorionicity are the best indicators to define the optimal place of care and delivery for twin pregnancies. More than a specific location, it seems more logical to define all necessary means to enforce an optimal management of these pregnancies.

Elective single-embryo transfer in women aged 40-44 years

STUDY QUESTION

Is an elective single-embryo transfer (eSET) policy feasible for women aged 40 or older?

SUMMARY ANSWER

For older women (aged 40-44 years) with a good prognosis, an eSET policy can be applied with acceptable cumulative clinical pregnancy rates and live birth rates.

WHAT IS KNOWN ALREADY

Various studies have shown the effectiveness of eSET in women aged <35 years with high cumulative pregnancy rates and low rates of multiple births.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study included 628 women treated between 2000 and 2009.

PARTICIPANTS, SETTING, METHODS

Women aged 40-44 years underwent a fresh cycle of IVF or ICSI treatment with eSET (n = 264) or double-embryo transfer (DET) (n = 364). In the subsequent frozen-thawed embryo transfer cycles, SET/DET was performed in both groups according to the number of embryos available and the opinion of the couple. The study was performed at the Family Federation of Finland Helsinki Fertility Clinic.

MAIN RESULTS AND THE ROLE OF CHANCE

In the fresh cycles, the clinical pregnancy rates were 23.5 and 19.5% in the eSET and DET groups, respectively, and live birth rates were 13.6 and 11.0%, respectively. In the fresh cycles with eSET, there were no twin pregnancies, but in the DET group, there were three sets of twins (7.5%). The cumulative clinical pregnancy rates per oocyte retrieval were 37.1 and 24.2% in the eSET and DET groups, respectively (P < 0.001), and the cumulative live birth rates were 22.7 and 13.2%, respectively (P = 0.002). Cumulative twin rates were 6.7% (n = 4) in the eSET group and 8.3% (n = 4) in the DET group (P = 0.726). All of the twin pregnancies in the eSET group resulted from frozen and thawed DET embryo transfer cycles.

LIMITATIONS

The characteristics of the two patients groups are not comparable because the suitability of eSET was individually assessed by a clinician based on both clinical prognostic factors and the outcome of IVF or ICSI, i.e. the number and quality of embryos.

WIDER IMPLICATIONS OF THE FINDINGS

This study may be generalized to IVF units having experience in eSET and cryopreservation.

Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes

BACKGROUND

Regular antenatal care for women with a multiple pregnancy is accepted practice, and while most women have an increase in the number of antenatal visits, there is no consensus as to what constitutes optimal care. 'Specialised' antenatal clinics have been advocated as a way of improving outcomes for women and their infants.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of 'specialised' antenatal clinics compared with 'standard' antenatal care for women with a multiple pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 April 2012).

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials with reported data that compared outcomes in mothers and babies with a multiple pregnancy who received antenatal care specifically designed for women with a multiple pregnancy (as defined by the trial authors) with outcomes in controls who received 'standard' antenatal care (as defined by the trial authors).

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed trials for inclusion and trial quality. Both review authors extracted data. Data were checked for accuracy.

MAIN RESULTS

There were data available from one study included in the review involving 162 women with a multiple pregnancy. For the only reported primary outcome, perinatal mortality, there were no statistically significant differences identified between specialised antenatal care and standard care (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.26 to 4.03). Women receiving specialised antenatal care were significantly more likely to birth by caesarean section (RR 1.38; 95% CI 1.06 to 1.81). Data was not reported in the study on the following primary outcomes: small-for-gestational age, very preterm birth or maternal death. There were no statistically significant differences identified between specialised antenatal care and standard care for other secondary outcomes examined: postnatal depression (RR 0.48; 95% CI 0.19 to 1.20), breastfeeding (RR 0.63; 95% CI 0.24 to 1.68), still birth (RR 0.68; 0.12 to 4.04) or neonatal death (RR 2.05; 95% CI 0.19 to 22.39).

AUTHORS' CONCLUSIONS

There is currently limited information available from randomised controlled trials to assess the role of 'specialised' antenatal clinics for women with a multiple pregnancy compared with 'standard' antenatal care in improving maternal and infant health outcomes. The value of 'specialised' multiple pregnancy clinics in improving health outcomes for women and their infants requires evaluation in appropriately powered and designed randomised controlled trials.

Ultrasound for fetal assessment in early pregnancy

BACKGROUND

Diagnostic ultrasound is a sophisticated electronic technology, which utilises pulses of high frequency sound to produce an image. Diagnostic ultrasound examination may be employed in a variety of specific circumstances during pregnancy such as after clinical complications, or where there are concerns about fetal growth. Because adverse outcomes may also occur in pregnancies without clear risk factors, assumptions have been made that routine ultrasound in all pregnancies will prove beneficial by enabling earlier detection and improved management of pregnancy complications. Routine screening may be planned for early pregnancy, late gestation, or both. The focus of this review is routine early pregnancy ultrasound.

OBJECTIVES

To assess whether routine early pregnancy ultrasound for fetal assessment (i.e. its use as a screening technique) influences the diagnosis of fetal malformations, multiple pregnancies, the rate of clinical interventions, and the incidence of adverse fetal outcome when compared with the selective use of early pregnancy ultrasound (for specific indications).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009).

SELECTION CRITERIA

Published, unpublished, and ongoing randomised controlled trials that compared outcomes in women who experienced routine versus selective early pregnancy ultrasound (i.e. less than 24 weeks' gestation). We have included quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data for each included study. We used the Review Manager software to enter and analyse data.

MAIN RESULTS

Routine/revealed ultrasound versus selective ultrasound/concealed: 11 trials including 37505 women. Ultrasound for fetal assessment in early pregnancy reduces the failure to detect multiple pregnancy by 24 weeks' gestation (risk ratio (RR) 0.07, 95% confidence interval (CI) 0.03 to 0.17). Routine scan is associated with a reduction in inductions of labour for 'post term' pregnancy (RR 0.59, 95% CI 0.42 to 0.83). Routine scans do not seem to be associated with reductions in adverse outcomes for babies or in health service use by mothers and babies. Long-term follow up of children exposed to scan in utero does not indicate that scans have a detrimental effect on children's physical or cognitive development.

AUTHORS' CONCLUSIONS

Early ultrasound improves the early detection of multiple pregnancies and improved gestational dating may result in fewer inductions for post maturity. Caution needs to be exercised in interpreting the results of aspects of this review in view of the fact that there is considerable variability in both the timing and the number of scans women received.

A review of methodological quality of systematic reviews on multiple pregnancies

We set out to determine the quality of existing systematic reviews on multiple pregnancies. We conducted an electronic search in MEDLINE (1951 - 2005), EMBASE (1974 - 2005) and the Cochrane Database for Systematic reviews (2005:2) and a hand-search of reference lists without any language restrictions to identify relevant reviews. Two reviewers independently selected review articles in which a publicly available database was searched for studies concerning multiple pregnancies, and assessed them for quality of methods of review. Information was extracted on framing of question, literature search and data synthesis. Of 342 citations 14 (4%) eligible reviews were identified. Only 8/14 reviews specified the review question. Adequate literature search without language restriction and the use of a reference list was found in 7/14 reviews, but the risk of missing studies was assessed in only 1/14 reviews. Quality assessment of included studies was reported in 7/14 and tabulation of their findings was reported in 8/14 reviews, but heterogeneity of results was evaluated in only 4/14 reviews. Meta-analysis was employed in 3/14 reviews. Systematic reviews of existing studies on multiple pregnancies are infrequent and it is difficult to generate robust inferences from them as they lack good methodology.

Specialised antenatal clinics for women with a multiple pregnancy to improve maternal and infant outcomes

BACKGROUND

Regular antenatal care for women with a multiple pregnancy is accepted practice, and while most women have an increase in the number of antenatal visits, there is no consensus as to what constitutes optimal care. 'Specialised' antenatal clinics have been advocated as a way of improving outcomes for women and their infants.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of 'specialised' antenatal clinics compared with 'standard' antenatal care for women with a multiple pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2006), the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library 2005, Issue 4), and PubMed (January 1966 to January 2006).

SELECTION CRITERIA

Randomised controlled trials with reported data that compared outcomes in mothers and babies who received 'specialised' antenatal care with outcomes in mothers and babies who received 'standard' antenatal care.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed trial quality and extracted data.

MAIN RESULTS

There are no included studies.

AUTHORS' CONCLUSIONS

There is no information available from randomised controlled trials to support the role of 'specialised' antenatal clinics for women with a multiple pregnancy compared with 'standard' antenatal care in improving maternal and infant health outcomes. The value of 'specialised' multiple pregnancy clinics in improving health outcomes for women and their infants requires evaluation in appropriately powered and designed randomised controlled trials.

Twin gestation pregnancies: genetic counseling and testing experience

We report on the prenatal genetic counseling and testing experience in 343 pregnancies with twin or higher multiple gestations. By self-report, 8% (27/343) parents of these pregnancies reported meeting with a genetic counselor, and 23% (79/343) elected prenatal genetic testing. The most common testing procedures elected were maternal serum analyte screening and amniocentesis to identify fetuses with aneuploidy or neural tube defects. Use of prenatal genetic testing was correlated with advanced maternal age. No association was found between use of genetic testing and use of OI/ART or the length of time needed to conceive. Forty percent (11/27) of those who met with a genetic counselor opted to decline prenatal testing/screening. These data suggest that although clients with multiple gestation pregnancies would likely benefit from genetic counseling, many are not availing themselves of this service. Implications of these data for the genetic counseling profession are discussed.

Obstetric litigation is asphyxiating our maternity services

Obstetric care in the United States, as judged by maternal mortality, neonatal mortality, stillbirth rates, or any other metric, has never been better. Despite this, litigation over "bad outcomes" is threatening the specialty, not only now, but into the future. Despite damage to our specialty, the injured party often benefits little, if at all, from the process. Potential solutions include an emphasis on evidence-based medicine, a qualification and review process for medical experts, and a more rational and fair health court system.