1
|
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
|
2
|
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
|
3
|
Scher MS. "The First Thousand Days" Define a Fetal/Neonatal Neurology Program. Front Pediatr 2021; 9:683138. [PMID: 34408995 PMCID: PMC8365757 DOI: 10.3389/fped.2021.683138] [Citation(s) in RCA: 39] [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: 03/19/2021] [Accepted: 05/27/2021] [Indexed: 01/11/2023] Open
Abstract
Gene-environment interactions begin at conception to influence maternal/placental/fetal triads, neonates, and children with short- and long-term effects on brain development. Life-long developmental neuroplasticity more likely results during critical/sensitive periods of brain maturation over these first 1,000 days. A fetal/neonatal program (FNNP) applying this perspective better identifies trimester-specific mechanisms affecting the maternal/placental/fetal (MPF) triad, expressed as brain malformations and destructive lesions. Maladaptive MPF triad interactions impair progenitor neuronal/glial populations within transient embryonic/fetal brain structures by processes such as maternal immune activation. Destructive fetal brain lesions later in pregnancy result from ischemic placental syndromes associated with the great obstetrical syndromes. Trimester-specific MPF triad diseases may negatively impact labor and delivery outcomes. Neonatal neurocritical care addresses the symptomatic minority who express the great neonatal neurological syndromes: encephalopathy, seizures, stroke, and encephalopathy of prematurity. The asymptomatic majority present with neurologic disorders before 2 years of age without prior detection. The developmental principle of ontogenetic adaptation helps guide the diagnostic process during the first 1,000 days to identify more phenotypes using systems-biology analyses. This strategy will foster innovative interdisciplinary diagnostic/therapeutic pathways, educational curricula, and research agenda among multiple FNNP. Effective early-life diagnostic/therapeutic programs will help reduce neurologic disease burden across the lifespan and successive generations.
Collapse
Affiliation(s)
- Mark S Scher
- Division of Pediatric Neurology, Department of Pediatrics, Fetal/Neonatal Neurology Program, Emeritus Scholar Tenured Full Professor in Pediatrics and Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| |
Collapse
|
4
|
Nunes JS, Sousa M, Montenegro N, Matias A. Twin Pregnancies, Crown-rump Length and Birthweight Discordancy: The Influence of Chorionicity. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2020; 42:529-534. [PMID: 32559796 PMCID: PMC10309241 DOI: 10.1055/s-0040-1712128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE The purpose of the present study was to analyze the influence of chorionicity in the biometric parameters crown-rump length (CRL), birthweight (BW), crown-rump length discordancy (CRLD) and birthweight discordancy (BWD), determine the correlation between these latter two in cases of intertwin discordancy, and to analyze the influence of chronicity in the presence of these discordancies with clinical relevance (> 10% and > 15%, respectively). METHODS The present study was a retrospective study based on the twin pregnancy database of the Centro Hospitalar S. João (2010-2015), including 486 fetuses among 66 monochorionic (MC) and 177 dichorionic gestations (DC). The inclusion criteria were multiple pregnancies with 2 fetuses and healthy twin gestations. The exclusion criteria were trichorionic gestations and pregnancies with inconclusive chorionicity, multiple pregnancy with ≥ 3 fetuses and pathological twin gestations. RESULTS No statistically significant difference was found in BW (p = 0.09) and in its discordancy (p = 0.06) nor in CRL (p = 0.48) and its discordancy (p = 0.74) between MCs and DCs. Crown-rump length discordancy and birthweight discordancy were correlated by the regression line "BWD = 0.8864 x CRLD + 0.0743," with r2 = 0.1599. Crown-rump length discordancy > 10% was found in 7.58% of monochorionic and in 13.56% of dichorionic twins. Birthweight discordancy > 15% was detected in 16.67% of monochorionic and in 31.64% of dichorionic twins. CONCLUSION No statistically significant influence of chorionicity was identified in both birthweight and birthweight discordancy, as in crown-rump length and crown-rump length discordancy. Birthweight discordancy was correlated to crown-rump length discordancy in 20% of cases.
Collapse
Affiliation(s)
- Joana Sousa Nunes
- Obstetrics & Gynecology Department, Senhora da Oliveira Hospital, Guimarães, Portugal.,Obstetrics & Gynecology Department, Faculty of Medicine, Minho University, Braga, Portugal
| | - Mário Sousa
- Laboratory of Cell Biology, Microscopy Department, Porto Hospital Centre, Institute of Biomedical Sciences Abel Salazar, Porto University, Porto, Portugal
| | - Nuno Montenegro
- Obstetrics & Gynecology Department, São João Hospital & University Centre, Porto, Portugal
| | - Alexandra Matias
- Obstetrics & Gynecology Department, São João Hospital & University Centre, Porto, Portugal
| |
Collapse
|
5
|
Ferraz Liz C, Domingues S, Guedes A, Lopes L. The impact of chorionicity and assisted reproductive therapies in obstetric and neonatal outcomes. J Matern Fetal Neonatal Med 2020; 35:1439-1444. [PMID: 32326779 DOI: 10.1080/14767058.2020.1757060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Multiple gestations' incidence have raised worldwide in the last years, much due to assisted reproductive therapies (ART). The goal of this study was to analyze obstetric and neonatal outcomes of twin pregnancies in a level 3 maternity.Methods: A retrospective study including all twins born in a period of 12 years in a level 3 maternity was conducted. Analysis comparing spontaneous monochorionic and dichorionic twins and spontaneous and ART dichorionic twins were performed. A p value < .05 was considered statistically significant.Results: The sample included 1783 newborns from 875 mothers. Mean maternal age was 31 years, with 616 spontaneous pregnancies and 259 through ART. Prematurity occurred in 77%. Congenital malformations were found in 6%, and the mortality rate was 3%. Monochorionic twins had higher prematurity (79% vs 72%) and very low birthweight (VLBW) rate (19% vs 14%). Congenital anomalies (9% vs 6%), Respiratory Distress Syndrome (23% vs 18%), patent ductus arteriosus (7% vs 4%), anemia (11% vs 5%), periventricular hemorrhage (5% vs 3%), mechanical ventilation (16% vs 10%) and mortality (4% vs 2%) were higher in monochorionic twins. Although congenital malformations were more frequent in the ART group, the difference was not statistically significant. The effect of ART in neonatal and obstetric outcomes was related to maternal age.Conclusion: Monochorionic pregnancies were associated with worst obstetric and neonatal outcomes. Although congenital malformations were more frequent in the ART group, the difference was not statistically significant. Most obstetric and neonatal complications were related to advanced maternal age.
Collapse
Affiliation(s)
| | - Sara Domingues
- Neonatal Intensive Care Unit, Centro Materno Infantil do Norte, Porto, Portugal
| | - Ana Guedes
- Neonatal Intensive Care Unit, Centro Materno Infantil do Norte, Porto, Portugal
| | - Luísa Lopes
- Neonatal Intensive Care Unit, Centro Materno Infantil do Norte, Porto, Portugal
| |
Collapse
|
6
|
Carlin A, Kadji C, Cannie MM, Resta S, Kang X, Jani JC. The use of magnetic resonance imaging in the prediction of birthweight. Prenat Diagn 2019; 40:125-135. [PMID: 31319434 DOI: 10.1002/pd.5530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/05/2019] [Accepted: 07/08/2019] [Indexed: 01/11/2023]
Abstract
Extremes of fetal growth can increase adverse pregnancy outcomes, and this is equally applicable to single and multiple gestations. Traditionally, these cases have been identified using simple two-dimensional ultrasound which is quite limited by its low precision. Magnetic resonance imaging (MRI) has now been used for many years in obstetrics, mainly as an adjunct to ultrasound for congenital abnormalities and increasingly as part of the post-mortem examination. However, MRI can also be used to accurately assess fetal weight as first demonstrated by Baker et al in 1994, using body volumes rather than standard biometric measurements. This publication was followed by several others, all of which confirmed the superiority of MRI; however, despite this initial promise, the technique has never been successfully integrated into clinical practice. In this review, we provide an overview of the literature, detail the various techniques and formulas currently available, discuss the applicability to specific high-risk groups and present our vision for the future of MRI within clinical obstetrics.
Collapse
Affiliation(s)
- Andrew Carlin
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Caroline Kadji
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Mieke M Cannie
- Department of Radiology, University Hospital Brugmann, Brussels, Belgium.,Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Serena Resta
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Xin Kang
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques C Jani
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
7
|
Mackie FL, Whittle R, Morris RK, Hyett J, Riley RD, Kilby MD. First-trimester ultrasound measurements and maternal serum biomarkers as prognostic factors in monochorionic twins: a cohort study. Diagn Progn Res 2019; 3:9. [PMID: 31093579 PMCID: PMC6507122 DOI: 10.1186/s41512-019-0054-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/20/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Monochorionic twin pregnancies are at high risk of adverse outcomes, but it is not possible to predict which pregnancies will develop complications. The aim of the study was to evaluate, in monochorionic twin pregnancies, whether first-trimester ultrasound (nuchal translucency [NT], crown-rump length [CRL]), and maternal serum biomarkers (alpha-fetoprotein [AFP], soluble fms-like tyrosine kinase-1 [sFlt-1] and placental growth factor [PlGF]), are prognostic factors for fetal adverse outcome composite, twin-twin transfusion syndrome (TTTS), growth restriction, and intrauterine fetal death (IUFD). METHODS A cohort study of 177 monochorionic diamniotic twin pregnancies. Independent prognostic ability of each factor was assessed by multivariable logistic regression, adjusting for standard prognostic factors. Factors were analysed as continuous data; thus, the reported ORs relate to either 1% change in NT or CRL inter-twin percentage discordance or one unit of measure in each serum biomarker. RESULTS The odds of the fetal adverse outcome composite were significantly associated with increased NT inter-twin percentage discordance (adjusted OR 1.03 [95% CI 1.01, 1.06]) and CRL inter-twin percentage discordance (adjusted OR 1.17 [95% CI 1.07, 1.29]). TTTS was significantly associated with increased NT discordance (adjusted OR 1.06 [95% CI 1.03, 1.10]) and decreased PlGF (adjusted OR 0.42 [95% CI 0.19, 0.93]). Antenatal growth restriction was significantly associated with increased CRL discordance (adjusted OR 1.20 [95% CI 1.08, 1.34]). Single and double IUFD were associated with decreased PlGF (adjusted OR 0.34 [95% CI 0.12, 0.98]) and (adjusted OR 0.18 [95%CI 0.05, 0.58]) respectively. CONCLUSIONS This study has identified potential individual prognostic factors in the first trimester (fetal biometric and maternal serum biomarkers) that show promise but require further robust evaluation in a larger, prospective series of MC twin pregnancies, so that their usefulness both individually and in combination can be defined. TRIAL REGISTRATION ISRCTN 13114861 (retrospectively registered).
Collapse
Affiliation(s)
- Fiona L. Mackie
- Centre for Women’s and Newborn Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT UK
- Fetal Medicine Department, Birmingham Women’s and Children’s NHS Foundation Trust, Edgbaston, Birmingham, B15 2TG UK
| | - Rebecca Whittle
- Centre for Prognosis Research, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - R. Katie Morris
- Centre for Women’s and Newborn Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT UK
- Fetal Medicine Department, Birmingham Women’s and Children’s NHS Foundation Trust, Edgbaston, Birmingham, B15 2TG UK
| | - Jon Hyett
- Department of Women and Babies, Royal Alfred Hospital, University of Sydney, Sydney, Australia
| | - Richard D. Riley
- Centre for Prognosis Research, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Mark D. Kilby
- Centre for Women’s and Newborn Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT UK
- Fetal Medicine Department, Birmingham Women’s and Children’s NHS Foundation Trust, Edgbaston, Birmingham, B15 2TG UK
| |
Collapse
|
8
|
Hiersch L, Okby R, Freeman H, Rosen H, Nevo O, Barrett J, Melamed N. Differences in fetal growth patterns between twins and singletons. J Matern Fetal Neonatal Med 2019; 33:2546-2555. [PMID: 30501543 DOI: 10.1080/14767058.2018.1555705] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objective: Twin fetus growth is delayed during the third trimester compared to singletons. Whether this phenomenon should be considered a normal physiologic characteristic of twins or a pathologic process inherent to twin pregnancies is currently unclear. Information on the growth rate of the individual fetal biometric indices may provide more insight into the mechanisms underlying these differences between twins and singletons. Our aim was to compare fetal growth pattern between twin and singleton fetuses.Methods: This was a retrospective study of women with an uncomplicated twin pregnancy who underwent sonographic fetal weight estimation between 16 and 38 weeks' gestation in a single referral center. Twins-specific regression models were generated for biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL) and fetal weight as a function of gestational age and were compared to published singletons-based curves.Results: Overall 543 women were eligible for the study and underwent a total of 3401 sonographic weight estimations. Estimated weight of twin fetus emerged as lower than that of singletons starting at 26 weeks of gestation, and these differences increased with gestational age, reaching a mean difference of 300-350 g or of ∼10% at term. The growth of all four biometric indices was slower in twins compared to singletons, but the differences were most pronounced for AC which had the largest relative contribution to the lower fetal weight in twins (51.7 ± 7.3%), while the relative contribution of FL, HC, and BPD was smaller (26.4 ± 10.7, 15.5 ± 3.0, and 6.4%±5.7%, respectively). This was also reflected by a higher HC/AC ratio in twins compared with singletons starting at 22 weeks of gestation. The likelihood of a twin fetus being diagnosed as small for gestational age (fetal weight <10th percentile) was significantly lower when the newly developed twins-based curves (rather than singletons-based curves) were used (OR: 0.39, 95%-CI: 0.34-0.44).Conclusion: Twin fetus experience slowing of growth beginning at ∼26 weeks of gestation and a greater degree of asymmetric growth pattern compared with singletons. These findings suggest that the slower growth of twins may reflect a state of "relative growth restriction" compared with singleton gestations.
Collapse
Affiliation(s)
- Liran Hiersch
- Sackler Faculty of Medicine, Lis Maternity Hospital affiliated to Tel Aviv University, Tel Aviv, Israel
| | - Rania Okby
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Howie Freeman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Hadar Rosen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Ori Nevo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| |
Collapse
|
9
|
Bamberg C, Hecher K. Update on twin-to-twin transfusion syndrome. Best Pract Res Clin Obstet Gynaecol 2019; 58:55-65. [PMID: 30850326 DOI: 10.1016/j.bpobgyn.2018.12.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/31/2018] [Indexed: 12/20/2022]
Abstract
Twin-to-twin transfusion syndrome (TTTS) is a serious complication that affects 10-15% of monochorionic multiple pregnancies. Communicating placental vessels on the chorionic plate between the donor and recipient twin are responsible for the imbalance of blood flow. There is evidence for the superiority of fetoscopic laser ablation over serial amnioreductions regarding survival and neurological outcome for stages II-IV TTTS. However, the optimal management of stage I is still debated. The "Solomon" technique showed a significant reduction in recurrent TTTS and post laser twin anemia-polycythemia sequence (TAPS) in comparison to the selective laser method without improvement in perinatal mortality or neonatal morbidity. Survival rates after fetoscopic laser surgery have significantly increased over the last 25 years. High volume centers report up to 70% double survival and at least one survivor in >90%. Long-term neurodevelopmental impairment occurs in about 10% of children after laser surgery. In this review we discuss the optimal management, innovations in laser technique, long-term neurodevelopmental outcome, and future aspects of TTTS treatment.
Collapse
Affiliation(s)
- Christian Bamberg
- University Medical Center Hamburg-Eppendorf, Department of Obstetrics and Fetal Medicine, Hamburg, Germany.
| | - Kurt Hecher
- University Medical Center Hamburg-Eppendorf, Department of Obstetrics and Fetal Medicine, Hamburg, Germany
| |
Collapse
|
10
|
Scher MS. Fetal neurology: Principles and practice with a life-course perspective. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:1-29. [PMID: 31324306 DOI: 10.1016/b978-0-444-64029-1.00001-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Clinical service, educational, and research components of a fetal/neonatal neurology program are anchored by the disciplines of developmental origins of health and disease and life-course science as programmatic principles. Prenatal participation provides perspectives on maternal, fetal, and placental contributions to health or disease for fetal and subsequent neonatal neurology consultations. This program also provides an early-life diagnostic perspective for neurologic specialties concerned with brain health and disease throughout childhood and adulthood. Animal models and birth cohort studies have demonstrated how the science of epigenetics helps to understand gene-environment interactions to better predict brain health or disease. Fetal neurology consultations provide important diagnostic contributions during critical or sensitive periods of brain development when future neurotherapeutic interventions will maximize adaptive neuroplasticity. Age-specific normative neuroinformatics databases that employ computer-based strategies to integrate clinical/demographic, neuroimaging, neurophysiologic, and genetic datasets will more accurately identify either symptomatic patients or those at risk for brain disorders who would benefit from preventive, rescue, or reparative treatment choices throughout the life span.
Collapse
Affiliation(s)
- Mark S Scher
- Division of Pediatric Neurology, Case Western Reserve University, Cleveland, OH, United States.
| |
Collapse
|
11
|
Mariet AS, Mauny F, Pujol S, Thiriez G, Sagot P, Riethmuller D, Boilleaut M, Defrance J, Houot H, Parmentier AL, Vasseur-Barba M, Benzenine E, Quantin C, Bernard N. Multiple pregnancies and air pollution in moderately polluted cities: Is there an association between air pollution and fetal growth? ENVIRONMENT INTERNATIONAL 2018; 121:890-897. [PMID: 30347371 DOI: 10.1016/j.envint.2018.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 10/10/2018] [Accepted: 10/10/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Multiple pregnancies (where more than one fetus develops simultaneously in the womb) are systematically excluded from studies of the impact of air pollution on pregnancy outcomes. This study aims to analyze, in a population of multiple pregnancies, the relationship between fetal growth restriction (FGR), small for gestational age (SGA) and exposure to air pollution in moderately polluted cities. METHODS All women with multiple pregnancies living in the city of Besançon or in the urban area of Dijon and who delivered at a university hospital between 2005 and 2009 were included. FGR and SGA were obtained from medical records. Outdoor residential nitrogen dioxide (NO2) exposure was assessed using the mother's address, considering a 50 m radius buffer over the following defined pregnancy periods: each trimester, entire pregnancy and two months before delivery. Logistic regression analyses were performed. RESULTS This study included 249 multiple pregnancies with 506 newborns. The median of NO2 concentration considering a 50 m radius buffer during entire pregnancy was 23.1 μg/m3 (minimum at 10.1 μg/m3 and maximum at 46.7 μg/m3). No association was observed between NO2 and SGA whatever the pregnancy period (the odds ratio (OR) range 0.78 to 0.88). Regarding FGR, the OR associated with an increase of 10 μg/m3 of NO2 exposure during entire pregnancy was 1.52 (95% Confidence Interval (CI): 1.02-2.26). Similar results were observed for NO2 exposure during the various pregnancy periods. CONCLUSIONS These results are in line with an association between NO2 and fetal growth in multiple pregnancies for an exposure mostly below the threshold set out in European legislation.
Collapse
Affiliation(s)
- Anne-Sophie Mariet
- CHU Dijon Bourgogne, Service de Biostatistiques et d'Information Médicale, F-21000 Dijon, France; CHU Dijon Bourgogne, Inserm, Clinical Investigation Center of Dijon (Inserm CIC 1432), F-21000 Dijon, France; Université Bourgogne Franche-Comté, Inserm, Biostatistique, Biomathématique, Pharmacoépidémiologie et Maladies Infectieuses (B2PHI), UMR 1181, F-21000 Dijon, France
| | - Frédéric Mauny
- CHU de Besançon, Unité de Méthodologie en Recherche Clinique, Épidémiologie et Santé Publique, INSERM CIC 1431, F-25000 Besançon, France; Université de Bourgogne Franche-Comté, CNRS, Laboratoire Chrono-Environnement UMR 6249, F-25000 Besançon, France.
| | - Sophie Pujol
- CHU de Besançon, Unité de Méthodologie en Recherche Clinique, Épidémiologie et Santé Publique, INSERM CIC 1431, F-25000 Besançon, France; Université de Bourgogne Franche-Comté, CNRS, Laboratoire Chrono-Environnement UMR 6249, F-25000 Besançon, France
| | - Gérard Thiriez
- CHU de Besançon, Service de Réanimation Pédiatrique, Néonatalogie et Urgences Pédiatriques, F-25000 Besançon, France
| | - Paul Sagot
- CHU Dijon Bourgogne, Service de Gynécologie-Obstétrique, F-21000 Dijon, France
| | - Didier Riethmuller
- CHU de Besançon, Service de Gynécologie-Obstétrique, F-25000 Besançon, France
| | | | - Jérôme Defrance
- Centre Scientifique et Technique du Bâtiment, Pôle Acoustique et Eclairage, F-38400 Saint Martin d'Hères, France
| | - Hélène Houot
- Université de Bourgogne Franche-Comté, CNRS, Laboratoire ThéMA UMR 6049, F-25000 Besançon, France
| | - Anne-Laure Parmentier
- CHU de Besançon, Unité de Méthodologie en Recherche Clinique, Épidémiologie et Santé Publique, INSERM CIC 1431, F-25000 Besançon, France; Université de Bourgogne Franche-Comté, CNRS, Laboratoire Chrono-Environnement UMR 6249, F-25000 Besançon, France
| | - Marie Vasseur-Barba
- CHU de Besançon, Unité de Méthodologie en Recherche Clinique, Épidémiologie et Santé Publique, INSERM CIC 1431, F-25000 Besançon, France; Université de Bourgogne Franche-Comté, CNRS, Laboratoire Chrono-Environnement UMR 6249, F-25000 Besançon, France
| | - Eric Benzenine
- CHU Dijon Bourgogne, Service de Biostatistiques et d'Information Médicale, F-21000 Dijon, France; CHU Dijon Bourgogne, Inserm, Clinical Investigation Center of Dijon (Inserm CIC 1432), F-21000 Dijon, France
| | - Catherine Quantin
- CHU Dijon Bourgogne, Service de Biostatistiques et d'Information Médicale, F-21000 Dijon, France; CHU Dijon Bourgogne, Inserm, Clinical Investigation Center of Dijon (Inserm CIC 1432), F-21000 Dijon, France; Université Bourgogne Franche-Comté, Inserm, Biostatistique, Biomathématique, Pharmacoépidémiologie et Maladies Infectieuses (B2PHI), UMR 1181, F-21000 Dijon, France
| | - Nadine Bernard
- Université de Bourgogne Franche-Comté, CNRS, Laboratoire Chrono-Environnement UMR 6249, F-25000 Besançon, France; Université de Bourgogne Franche-Comté, CNRS, Laboratoire ThéMA UMR 6049, F-25000 Besançon, France
| |
Collapse
|
12
|
Walker AR, Waites BT, Caughey AB. Twins versus singleton pregnancies: outcomes in small for gestational age late preterm deliveries. J Matern Fetal Neonatal Med 2018; 33:895-900. [PMID: 30078342 DOI: 10.1080/14767058.2018.1508438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Compared to singleton pregnancies, small for gestational age (SGA) and twin gestations experience adverse maternal and neonatal outcomes. Specific data regarding outcomes in late preterm SGA twin gestations are lacking.Objective: This study sought to compare pregnancy outcomes of late preterm (≥34 and <37 weeks) SGA twins versus singletons. In addition, we sought to stratify the comparisons by <10 and <5 percentile categories.Study design: In this retrospective cohort of 1.85 million pregnancies, we identified 10,646 nonanomalous, SGA, late preterm singleton and twin pregnancies. Births at gestational ages <34 and ≥37 weeks were excluded. Multivariate regression analyses and Chi-squared test were used for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance.Results: After controlling for race, education, parity, prenatal care, diabetes, and hypertensive disease, twin pregnancies were less likely to experience neonatal death (aOR 0.14; 95% CI 0.03-0.63; p = .01) and intrauterine fetal demise (IUFD) (aOR 0.16; 95% CI 0.08-0.31; p < .001) compared to SGA <10 percentile singletons. Cesarean rates were higher in SGA <10 [percentile twin pregnancies (aOR 3.40; 95% CI 3.01-3.90; p < .001) as were postpartum hemorrhage (aOR 2.01; 95% CI 1.52-2.67; p < .001) and transfusion (aOR 1.54; 95% CI 1.52-2.67; p = .024).Conclusion: Late preterm SGA twin pregnancies were more like to be complicated by cesarean delivery, postpartum hemorrhage, and maternal transfusion compared to singleton pregnancies. However, neonatal death and IUFD were less common in SGA twin gestations.
Collapse
Affiliation(s)
- Allison R Walker
- Department of Obstetrics and Gynecology, Oregon Health & Sciences University, Portland, OR, USA
| | - Bethany T Waites
- Department of Obstetrics and Gynecology, Oregon Health & Sciences University, Portland, OR, USA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Sciences University, Portland, OR, USA
| |
Collapse
|
13
|
Magnus MC, Ghaderi S, Morken NH, Magnus P, Bente Romundstad L, Skjærven R, Wilcox AJ, Eldevik Håberg S. Vanishing twin syndrome among ART singletons and pregnancy outcomes. Hum Reprod 2017; 32:2298-2304. [PMID: 29025107 PMCID: PMC5850786 DOI: 10.1093/humrep/dex277] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/28/2017] [Accepted: 08/15/2017] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Among babies born by ART, do singleton survivors of a vanishing twin have lower birth weight than other singletons? SUMMARY ANSWER Vanishing twin syndrome (VTS) was associated with lower birth weight among ART singletons; a sibship analysis indicated that the association was not confounded by maternal characteristics that remain stable between deliveries. WHAT IS KNOWN ALREADY Previous studies indicate that ART singletons with VTS have increased risk of adverse pregnancy outcomes, compared with other ART singletons. The potential contribution of unmeasured maternal background characteristics has been unclear. STUDY DESIGN, SIZE AND DURATION This was a Norwegian population-based registry study, including 17 368 mothers with 20 410 ART singleton deliveries between January 1984 and December 2013. PARTICIPANTS/MATERIALS, SETTING, METHODS The study population included 17 291 ART singletons without VTS, 638 ART singletons with VTS and 2418 ART singletons with uncertain vanishing twin status. We estimated differences in birth weight and gestational age comparing ART singletons with VTS first to all ART singletons without VTS, and subsequently to their ART siblings without VTS, using random- and fixed-effects linear regression, respectively. The corresponding comparisons for the associations with preterm birth and small for gestational age (SGA) were conducted using random-and fixed-effects logistic regression. The sibling analysis of preterm birth included 587 discordant siblings, while the sibling analysis of SGA included 674 discordant siblings. MAIN RESULTS AND THE ROLE OF CHANCE ART singletons with VTS had lower birth weight when compared to all ART singletons without VTS, with an adjusted mean difference (95% CI) of -116 g (-165, -67). When we compared ART singletons with VTS to their ART singletons sibling without VTS, the adjusted mean difference was -112 g (-209, -15). ART singletons with VTS also had increased risk of being born SGA, with an adjusted odds ratio (OR) (95% CI) of 1.48 (1.07, 2.03) compared to all ART singletons without VTS, and 2.79 (1.12, 6.91) in the sibship analyses. ART singletons with VTS were also more likely to be born preterm, although this difference did not reach statistical significance. LIMITATIONS REASONS FOR CAUTION We did not have information on maternal socio-economic status, but this factor is accounted for in the sibship analyses. We also had no information on whether fresh or frozen embryos were replaced. WIDER IMPLICATIONS OF THE FINDINGS The reduction in birth weight and increased risk of SGA in ART singletons with VTS may suggest the presence of harmful intrauterine factors with long-term health impact. While vanishing twins are not routinely observed in naturally conceived pregnancies, loss of a twin is potentially a risk factor for the surviving foetus in any pregnancy. This could be further explored in large samples of naturally conceived pregnancies with the necessary information. STUDY FUNDING/COMPETING INTEREST(S) The authors of this study are supported in part by the UK Medical Research Council, US National Institute of Environmental Health Sciences and the Norwegian Research Council. The authors have no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
Collapse
Affiliation(s)
- Maria C Magnus
- Division for Mental and Physical Health, Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway
- MRC Integrative Epidemiology Unit at the University of Bristol, Oakfield House, Oakfield Grove, BS8 2BN Bristol, UK
- School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, BS8 2BN Bristol, UK
| | - Sara Ghaderi
- Division for Mental and Physical Health, Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway
| | - Nils-Halvdan Morken
- Department of Global Public Health and Primary Care, University of Bergen, P.O. Box 7804, N-5020 Bergen, Norway
- Department of Clinical Science, University of Bergen, P.O. Box 7804, N-5020 Bergen, Norway
| | - Per Magnus
- Centre for Fertility and Health (CeFH), Centre of Excellence at Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway
- Institute for Health and Society, University of Oslo, P.O. Box 1130 Blindern, N-0403 Oslo, Norway
| | - Liv Bente Romundstad
- Department of Obstetrics and Gynaecology, IVF Unit, St Olav's University Hospital, P.O. Box 3250 Sluppen, N- 7006 Trondheim, Norway
- Department of Public Health and Nursing, Norwegian University of Science and Technology, P.O. Box 8905, N-7491 Trondheim, Norway
| | - Rolv Skjærven
- Department of Global Public Health and Primary Care, University of Bergen, P.O. Box 7804, N-5020 Bergen, Norway
- Division for Health Data and Digitalization, Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway
| | - Allen J Wilcox
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina NC 27709, USA
| | - Siri Eldevik Håberg
- Centre for Fertility and Health (CeFH), Centre of Excellence at Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway
| |
Collapse
|