Do multiple gestations raise the risk of cerebral palsy?

Is the Early Screening of Lower Genital Tract Infections Useful in Preventing Adverse Obstetrical Outcomes in Twin Pregnancy?

Objectives: Twin pregnancy implies a higher risk of preterm birth and, consequently, higher neonatal morbidity and mortality. In singleton pregnancies, infections of the lower genital tract (LGTIs) and bacterial vaginosis are associated with preterm labor, and their early detection has been proven effective in reducing complications like the preterm premature rupture of membranes (pPROM) and preterm delivery. The same evidence, however, is lacking for twin pregnancies. This study aimed to evaluate whether the early identification and treatment of LGTIs or bacterial vaginosis in asymptomatic women with twin pregnancy could reduce the rate of miscarriages, pPROM, and preterm birth. Methods: This study performed a retrospective comparison of 285 women with a multiple pregnancy submitted for a cervico-vaginal swab only at 20-22 weeks (Single Test Group, STG), and 199 women who underwent the swab at 12-14 and again at 20-22 weeks (Double Test Group, DTG). All women included in the study had a twin pregnancy and were followed up at Sant'Anna Hospital, Turin (Italy), between September 2012 and February 2021. Results: In STG, 21.7% of patients had a positive swab; in DTG, 19.9% had an early positive swab that was immediately treated by targeted antibiotics; and 16.7% had a mid-pregnancy positive swab. The DTG showed a significantly lower incidence of pPROM in univariate analysis (14.4% vs. 23.1%, p = 0.021), which was confirmed by multivariate analysis (OR 0.55, CI 0.33-0.93, p = 0.025). Conclusions: Our study suggests that, in asymptomatic women with twin pregnancy, the early screening of LGTIs and bacterial vaginosis by a cervico-vaginal swab at 12-14 weeks of gestational age is effective in reducing the risk of pPROM.

Vaginal progesterone decreases preterm birth and neonatal morbidity and mortality in women with a twin gestation and a short cervix: an updated meta-analysis of individual patient data

OBJECTIVE

To assess the efficacy of vaginal progesterone for the prevention of preterm birth and neonatal morbidity and mortality in asymptomatic women with a twin gestation and a sonographic short cervix (cervical length ≤ 25 mm) in the mid-trimester.

METHODS

This was an updated systematic review and meta-analysis of individual patient data (IPD) from randomized controlled trials comparing vaginal progesterone with placebo/no treatment in women with a twin gestation and a mid-trimester sonographic cervical length ≤ 25 mm. MEDLINE, EMBASE, POPLINE, CINAHL and LILACS (all from inception to 31 December 2016), the Cochrane Central Register of Controlled Trials, Research Registers of ongoing trials, Google Scholar, conference proceedings and reference lists of identified studies were searched. The primary outcome measure was preterm birth < 33 weeks' gestation. Two reviewers independently selected studies, assessed the risk of bias and extracted the data. Pooled relative risks (RRs) with 95% confidence intervals (CI) were calculated.

RESULTS

IPD were available for 303 women (159 assigned to vaginal progesterone and 144 assigned to placebo/no treatment) and their 606 fetuses/infants from six randomized controlled trials. One study, which included women with a cervical length between 20 and 25 mm, provided 74% of the total sample size of the IPD meta-analysis. Vaginal progesterone, compared with placebo/no treatment, was associated with a statistically significant reduction in the risk of preterm birth < 33 weeks' gestation (31.4% vs 43.1%; RR, 0.69 (95% CI, 0.51-0.93); moderate-quality evidence). Moreover, vaginal progesterone administration was associated with a significant decrease in the risk of preterm birth < 35, < 34, < 32 and < 30 weeks' gestation (RRs ranging from 0.47 to 0.83), neonatal death (RR, 0.53 (95% CI, 0.35-0.81)), respiratory distress syndrome (RR, 0.70 (95% CI, 0.56-0.89)), composite neonatal morbidity and mortality (RR, 0.61 (95% CI, 0.34-0.98)), use of mechanical ventilation (RR, 0.54 (95% CI, 0.36-0.81)) and birth weight < 1500 g (RR, 0.53 (95% CI, 0.35-0.80)) (all moderate-quality evidence). There were no significant differences in neurodevelopmental outcomes at 4-5 years of age between the vaginal progesterone and placebo groups.

CONCLUSION

Administration of vaginal progesterone to asymptomatic women with a twin gestation and a sonographic short cervix in the mid-trimester reduces the risk of preterm birth occurring at < 30 to < 35 gestational weeks, neonatal mortality and some measures of neonatal morbidity, without any demonstrable deleterious effects on childhood neurodevelopment. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Prediction of preterm birth in twin gestations using biophysical and biochemical tests

The objective of this study was to determine the performance of biophysical and biochemical tests for the prediction of preterm birth in both asymptomatic and symptomatic women with twin gestations. We identified a total of 19 tests proposed to predict preterm birth, mainly in asymptomatic women. In these women, a single measurement of cervical length with transvaginal ultrasound before 25 weeks of gestation appears to be a good test to predict preterm birth. Its clinical potential is enhanced by the evidence that vaginal progesterone administration in asymptomatic women with twin gestations and a short cervix reduces neonatal morbidity and mortality associated with spontaneous preterm delivery. Other tests proposed for the early identification of asymptomatic women at increased risk of preterm birth showed minimal to moderate predictive accuracy. None of the tests evaluated in this review meet the criteria to be considered clinically useful to predict preterm birth among patients with an episode of preterm labor. However, a negative cervicovaginal fetal fibronectin test could be useful in identifying women who are not at risk for delivering within the next week, which could avoid unnecessary hospitalization and treatment. This review underscores the need to develop accurate tests for predicting preterm birth in twin gestations. Moreover, the use of interventions in these patients based on test results should be associated with the improvement of perinatal outcomes.

Risk factors affecting Tests of Infant Motor Performance (TIMP) in pre-term infants at post-conceptional age of 40 weeks

OBJECTIVE

The purpose of this study is to correlate clinical factors with the Test of Infant Motor Performance (TIMP) in pre-term infants at a post-conceptional age of 40 weeks.

METHODS

The study enrolled 80 pre-term infants admitted to the Neonatal Intensive Care Unit (NICU). Data on birth weight, multiple birth, sex, delivery type, Apgar scores at 1 minute and 5 minutes, neonatal seizures and Intraventricular Haemorrhage (IVH) as assessed by echoencephalography were retrospectively analysed through a review of relevant medical records.

RESULTS

IVH was the clinical factor most strongly correlated with the TIMP scores. Other clinical factors which significantly affected the TIMP scores were caesarean section, neonatal seizures, low birth weight and multiple births.

CONCLUSIONS

When pre-term infants exhibit risk factors of developmental delay, it is suggestd that TIMP is performed early in life among pre-term infants and the results can be used to select infants for early interventions.

The role of birthweight discordance in the intellectual and motor outcome for triplets at early school age

AIM

We assessed motor and intellectual outcome in triplets at school age and investigated the predictive value of perinatal and demographic factors.

METHODS

Seventy-one live-born newborn infants (24 triplet pregnancies) were prospectively enrolled at birth. At the age of 6 years, 58 children (31 males, 27 females; mean gestational age 31.2 wks [SD 2.2 wks]; mean birthweight 1622 g [SD 440 g]) returned for a neurodevelopmental examination. A comparison group for triplets born before 32 gestational weeks comprising 26 gestational age-, birthweight-, and sex-matched singletons was also recruited (mean gestational age 30.1 wk [SD 1.5 wk]; mean birthweight 1142 g [SD 210 g]; 12 males, 14 females). The Zurich Neuromotor Assessment was used to examine motor performance, and intellectual abilities were assessed with the Kaufman Assessment Battery for Children (K-ABC).

RESULTS

Motor performance and movement quality in these individuals was significantly reduced compared with the test norms for all motor tasks (p<0.001) other than static balance. The mean values on the Mental Processing Composite (95.3, SD 8.4) and the Achievement Scale (90.1, SD 13.8) of the K-ABC were also lower than those in the test reference (p<0.05 and p<0.01 respectively). Triplets born at less than 32 weeks' gestation showed poorer pure motor and adaptive gross motor performance (both p<0.05) than, but similar intellectual performance to, the gestational age-, birthweight- and sex-matched singletons. Poor outcome was predicted by low socio-economic status and by intertriplet birthweight discordance (both p<0.01).

INTERPRETATION

Triplets were at an increased risk of mild motor and intellectual impairments. This finding is important for tailoring therapeutic interventions for these children and for parental counselling. Very preterm triplets showed similar outcomes to the singleton comparison children, except that they had poorer motor performance. Low socio-economic status was a major risk factor for impaired intellectual development. In addition, birthweight discordance may also be considered a predictor for poor long-term motor and intellectual outcome in triplets.

Follow-up issues with multiples

The rate of multiple pregnancy has increased in developed countries, a finding usually attributed to more widespread use of assisted reproductive technologies. Multiple pregnancies are associated with a greater risk of pregnancy complications, including intrauterine growth restriction of one or more of the fetuses, vascular communications within a shared monochorionic placenta and premature delivery. Surviving infants are at significantly greater risk of developing cerebral palsy due to a combination of a higher proportion of them being preterm or of low birth weight, and complications associated with chorionicity. These infants are also at greater risk for abnormal cognitive development and learning disabilities for the same reasons. Parenting styles and family dynamics may also differ with multiples compared with singletons, which may affect long-term behaviour and development.Thus, infants of multiple pregnancies should receive careful neurodevelopmental follow-up. For larger, lower risk infants, this follow-up may be provided by general paediatricians within the community. However, for infants with birth weights of less than 1000 g or with a complicated antenatal or neonatal course, follow-up should be in a high-risk neonatal follow-up clinic with appropriate multidisciplinary support.

The risk of cerebral palsy in survivors of multiple pregnancies with cofetal loss or death

OBJECTIVE

This study investigated the risks for cerebral palsy in survivors of multiple pregnancies with cofetal loss (< 20 weeks' gestation) or cofetal death (>or= 20 weeks' gestation).

STUDY DESIGN

The total Western Australian population-based case-control study included 741 cases of cerebral palsy.

RESULTS

Antenatal cofetal loss or death occurred in 3% of all cases of cerebral palsy, which is a small but significant contribution. The odds ratio for cerebral palsy in survivors of cofetal loss that included iatrogenic pregnancy reduction was 2.65 (95% confidence interval [CI], 0.78-8.98), which gave a population-attributable proportion of 7.28% (95% CI, 0-27.5), compared with 4.25 (95% CI, 1.12-16.10) and 10.6% (95% CI, 1.0-35.6) for survivors of cofetal death.

CONCLUSION

This study quantifies the contribution of cofetal death to cerebral palsy and suggests that cofetal loss makes a similar, although somewhat smaller, contribution to the risk for cerebral palsy in survivors of multiple pregnancies.

Litigation in multiple pregnancy and birth

Multiple birth rates have increased in most developed countries. The potential of a medical legal dispute increases when complications are common. Failure to perform the basic and standard care follow-up often misses the complication and the chance of a timely referral to a center experienced in the diagnosis and management of these complexities of a multiple pregnancy. In this article, several examples are discussed in which departure from the standard of care of multiple pregnancies were the basis of the allegation.