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Silvano A, Sisti G, Seravalli V, Strambi N, Parenti A, Amedei A, Witkin SS, Di Tommaso M. Changes in cytokine and sequestosome-1 levels during twin pregnancy progression: Association with outcome. Cytokine 2024; 180:156668. [PMID: 38851146 DOI: 10.1016/j.cyto.2024.156668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/07/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Twin pregnancies are associated with complications and adverse outcomes. The number of twin pregnancies has increased in the last decades, due to the use of assisted reproductive techniques and delayed childbearing. Analysis of changes that occur during twin pregnancy progression and their association with outcome will lead to improved clinical interventions. OBJECTIVE We evaluated if the plasma concentration of select cytokines and the level of sequestosome-1 (p62) in peripheral blood mononuclear cells (PBMCs) during each trimester of twin gestations was predictive of pregnancy outcome. STUDY DESIGN This prospective, observational study was conducted at Careggi University Hospital, Florence, Italy. Plasma from 82 women with twin pregnancies was collected in each trimester for measurement of interleukin (IL)-1β, IL-6, IL-10, IL-12 and tumor necrosis factor (TNF)-α. The intracellular PBMC concentration of p62, a protein involved in autophagy, kinase activity and cell differentiation, was also determined. RESULTS IL-1β (p < 0.001), IL-6 (p < 0.001), TNF-α (p < 0.001) and p62 (p < 0.05) increased from the 1st to the 2nd to the 3rd trimester. The TNF-α level was correlated with the IL-1β concentration in the 1st and 3rd trimesters p < 0.01) and with the IL-6 concentration in each of the three trimesters (p < 0.01). The intracellular p62 level in PBMCs was negatively correlated with the concentration of IL-1β in the 2nd trimester (p < 0.05) and negatively correlated with the IL-6 level in the 3rd trimester (p < 0.05). The TNF-α level was significantly higher in the 2nd (p < 0.05) and 3rd (p < 0.001) trimester in women with a spontaneous preterm delivery. The TNF-α concentrations in the 2nd (p < 0.05) and 3rd (p < 0.01) trimester, respectively, and 3rd trimester IL-6 (p < 0.01), were negatively associated with gestational age at delivery. The concentration of IL-6 was highest in the 2nd (p < 0.05) and 3rd (p < 0.05) trimesters in women who utilized assisted reproductive technologies. An elevated IL-1β level in the 3rd trimester was associated with gestational diabetes mellitus (p < 0.05). CONCLUSION Variations in cytokine levels between individual women during the three trimesters of twin gestations are predictive of spontaneous preterm delivery and the onset of gestational diabetes.
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Affiliation(s)
- Angela Silvano
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Florence, Italy
| | - Giovanni Sisti
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine, University of Arizona, USA
| | - Viola Seravalli
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Florence, Italy
| | - Noemi Strambi
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Florence, Italy
| | - Astrid Parenti
- Department of Health Sciences, Clinical Pharmacology and Oncology Section, University of Florence, Italy
| | - Amedeo Amedei
- Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Steven S Witkin
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, NY, USA; Department of Infectious Diseases and Parasitology, Laboratory of Virology, University of Sao Paulo Faculty of Medicine, Sao Paulo, Brazil
| | - Mariarosaria Di Tommaso
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Florence, Italy.
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van Gils L, de Boer MA, Bosmans J, Duijnhoven R, Schoenmakers S, Derks JB, Prins JR, Al-Nasiry S, Lutke Holzik M, Lopriore E, van Drongelen J, Knol MH, van Laar JOEH, Jacquemyn Y, van Holsbeke C, Dehaene I, Lewi L, van der Merwe H, Gyselaers W, Obermann-Borst SA, Holthuis M, Mol BW, Pajkrt E, Oudijk MA. Study protocol for two randomised controlled trials evaluating the effects of Cerclage in the reduction of extreme preterm birth and perinatal mortality in twin pregnancies with a short cervix or dilatation: the TWIN Cerclage studies. BMJ Open 2024; 14:e081561. [PMID: 38729756 PMCID: PMC11097875 DOI: 10.1136/bmjopen-2023-081561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/03/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Twin pregnancies have a high risk of extreme preterm birth (PTB) at less than 28 weeks of gestation, which is associated with increased risk of neonatal morbidity and mortality. Currently there is a lack of effective treatments for women with a twin pregnancy and a short cervix or cervical dilatation. A possible effective surgical method to reduce extreme PTB in twin pregnancies with an asymptomatic short cervix or dilatation at midpregnancy is the placement of a vaginal cerclage. METHODS AND ANALYSIS We designed two multicentre randomised trials involving eight hospitals in the Netherlands (sites in other countries may be added at a later date). Women older than 16 years with a twin pregnancy at <24 weeks of gestation and an asymptomatic short cervix of ≤25 mm or cervical dilatation will be randomly allocated (1:1) to both trials on vaginal cerclage and standard treatment according to the current Dutch Society of Obstetrics and Gynaecology guideline (no cerclage). Permuted blocks sized 2 and 4 will be used to minimise the risk of disbalance. The primary outcome measure is PTB of <28 weeks. Analyses will be by intention to treat. The first trial is to demonstrate a risk reduction from 25% to 10% in the short cervix group, for which 194 patients need to be recruited. The second trial is to demonstrate a risk reduction from 80% to 35% in the dilatation group and will recruit 44 women. A cost-effectiveness analysis will be performed from a societal perspective. ETHICS AND DISSEMINATION This study has been approved by the Research Ethics Committees in the Netherlands on 3/30/2023. Participants will be required to sign an informed consent form. The results will be presented at conferences and published in a peer-reviewed journal. Participants will be informed about the results. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT05968794.
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Affiliation(s)
- Lissa van Gils
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marjon A de Boer
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Judith Bosmans
- Department of Health Sciences, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
| | - Ruben Duijnhoven
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Sam Schoenmakers
- Department of Obstetrics and Gynaecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan B Derks
- Department of Obstetrics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jelmer R Prins
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, Groningen, The Netherlands
| | - Salwan Al-Nasiry
- Department of Obstetrics and Gynaecology, Maastricht UMC+, Maastricht, The Netherlands
| | - Margo Lutke Holzik
- Department of Obstetrics and Gynecology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Neonatology and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynecology, Radboud Universiteit, Nijmegen, The Netherlands
| | - Marieke H Knol
- Department of Obstetrics and Gynaecology, Isala Zwolle, Zwolle, The Netherlands
| | - Judith O E H van Laar
- Department of Obstetrics & Gynaecology, Máxima Medical Center, Veldhoven, The Netherlands
| | | | | | | | - Liesbeth Lewi
- Fetal Medicine Unit, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Hannes van der Merwe
- Fetal Medicine Unit, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Wilfried Gyselaers
- Department of Obstetrics and Gynecology, Hospital Oost-Limburg, Genk, Belgium
| | | | - Mayella Holthuis
- Patient organization 'Extreme Vroeggeboorte', Amsterdam, The Netherlands
| | - Ben W Mol
- department of obstetrics and gynaecology, school of medicine, Monash University, Melbourne, Victoria, Australia
| | - Eva Pajkrt
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
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Kashani-Ligumsky L, Cohen R, Many A, Elmalech A, Neiger R, Lopian M. High-Order Parity Improves the Perinatal Outcome of Twin Deliveries. Am J Perinatol 2024; 41:e1486-e1490. [PMID: 36894157 DOI: 10.1055/a-2051-4284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
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..
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Affiliation(s)
- Lior Kashani-Ligumsky
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak, Israel
- Department of Obstetrics and Gynecology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronnie Cohen
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak, Israel
- Department of Obstetrics and Gynecology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Many
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak, Israel
- Department of Obstetrics and Gynecology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avshalom Elmalech
- Department of Information Science, Bar-Ilan University, Ramat Gan, Israel
| | - Ran Neiger
- Department of Obstetrics and Gynecology, University of South Carolina, Columbia, South Carolina
| | - Miriam Lopian
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak, Israel
- Department of Obstetrics and Gynecology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Vlachadis N, Stavros S, Machairiotis N, Vrachnis D, Loukas N, Antonakopoulos N, Fotiou A, Maroudias G, Drakakis P, Vrachnis N. The Contribution of Multiple Pregnancies in Stillbirths in Greece: A Time-Trend Analysis. Cureus 2024; 16:e54628. [PMID: 38523936 PMCID: PMC10959416 DOI: 10.7759/cureus.54628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction Multiple pregnancy is an established risk factor for fetal death. This study aimed to examine the impact of multifetal pregnancies on stillbirth rates (SBRs) in the Greek population. Methods Data on live births and stillbirths by multiplicity were derived from the Hellenic Statistical Authority, covering a 65-year period from 1957 to 2021. The SBR for multiple and single gestations, and the population attributable risk (%) (PAR (%)) stillbirth attributable to multifetal gestations were calculated, and temporal trends were assessed using joinpoint regression analysis, with annual percentage changes (APC) and 95% confidence interval (95% CI). Results In the period 1957-2021, multiple pregnancies accounted for 9.4% of total stillbirths in Greece and the overall relative risk of fetal death among multifetal gestations was 3.34, in comparison with singletons. The SBR in multiple births remained unchanged from 1957 to 1976 and showed downward trends from 1976 to 2021 (APC = -3.0, 95% CI: -3.4 to -2.7, p < 0.001). PAR (%), after two decades of stability, showed an increasing trend over the period 1975-2011 (APC = 3.4, 95% CI: 2.8 to 4.0, p < 0.001), which was reversed in the more recent decade 2011-2021 (APC = -6.1, 95% CI: -9.6 to -2.5, p = 0.001), with PAR (%) decreasing from a historical high of 19.3% in 2012 to 8.6% in 2021. Conclusion The high incidence of multiple births has a considerable impact on stillbirth rates in the Greek population. The recent downward trends of SBR and PAR (%) of multiple gestations are encouraging, however more measures and targeted interventions are needed to improve perinatal outcomes in multifetal gestation.
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Affiliation(s)
- Nikolaos Vlachadis
- Department of Obstetrics and Gynecology, General Hospital of Messinia, Kalamata, GRC
| | - Sofoklis Stavros
- Third Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Attiko Hospital, Athens, GRC
| | - Nikolaos Machairiotis
- Third Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Attiko Hospital, Athens, GRC
| | - Dionysios Vrachnis
- Third Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Attiko Hospital, Athens, GRC
| | - Nikolaos Loukas
- Third Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Attiko Hospital, Athens, GRC
| | | | - Alexandros Fotiou
- Third Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Attiko Hospital, Athens, GRC
| | - Georgios Maroudias
- Third Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Attiko Hospital, Athens, GRC
| | - Petros Drakakis
- Third Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Attiko Hospital, Athens, GRC
| | - Nikolaos Vrachnis
- Third Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Attiko Hospital, Athens, GRC
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Bonanni G, Longo VL, Airoldi C, Meli F, Familiari A, Romanzi F, Pellegrino M, Visconti D, Serio A, Lanzone A, Bevilacqua E. Is the mental health of couples with twins more at risk? Results from an Italian cohort study. Front Psychiatry 2024; 15:1284090. [PMID: 38347879 PMCID: PMC10859489 DOI: 10.3389/fpsyt.2024.1284090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 01/08/2024] [Indexed: 02/15/2024] Open
Abstract
Introduction Our retrospective study aimed to investigate whether parents of twins encounter heightened psychological and emotional distress one year after childbirth, in comparison to parents of singletons within an Italian cohort. Methods Exclusion criteria included multiparity, preterm birth, congenital anomalies, stillbirth, >2 fetus pregnancies, and pre-existing maternal mental health disorders. Out of the 300 couples (600 parents) invited to participate, 286 parents (158 mothers, 128 fathers) successfully completed a self-administered survey. We analyzed three scores separately for mothers and fathers, differentiating between singleton and twin pregnancies: the Edinburgh Postnatal Depression Scale (EPDS) score, the State and Trait Anxiety Inventory (STAI)-Y1 score, and the STAI-Y2 score. Results Logistic models were used to assess the influence of age, BMI, marital status, education, and employment on the three binary scores (EPDS, STAI-Y1, and STAI-Y2), revealing no significant differences in absolute scores between parents of singletons and twins. Paired analysis revealed significantly higher EPDS (mean increase: 3.8, SD: 6.5), STAI-Y1 (mean increase: 5.4, SD: 12.5), and STAI-Y2 (mean increase: 4.5, SD: 12.4) scores for mothers (p < 0.0001). Approximately 10% of women and 8% of men reported suicidal thoughts. Discussion Contrary to expectations, no substantial psychological differences emerged between parents of twins and singletons. Adjusting for confounders through univariate analysis maintained nonsignificant trends. Nevertheless, caution in interpretation is warranted due to strict inclusion criteria favoring twin pregnancies with better outcomes. Unintended bias could have resulted from routine psychological support offered to mothers of twins in our clinic. This presents an important framework for future research, including randomized controlled trials comparing parents of multiples with psychological support to those without.Finally, the elevated prevalence of depression symptoms and suicidal thoughts in our cohort underscores the importance of mental health during pregnancy and early parenting. We advocate for the screening of parents for postpartum depression and various psychological conditions, encompassing a spectrum of anxiety disorders. Those at elevated risk of mental distress should be proactively offered appropriate support.
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Affiliation(s)
- Giulia Bonanni
- Unit of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Valentina Laurita Longo
- Unit of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Chiara Airoldi
- Department of Translation Medicine, University of Piemonte Orientale, Novara, Italy
| | - Federica Meli
- Unit of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandra Familiari
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Federica Romanzi
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marcella Pellegrino
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Daniela Visconti
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Annamaria Serio
- Department of Clinical Psychology, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Lanzone
- Unit of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Elisa Bevilacqua
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Kawaguchi H, Kuritani Y, Yamamoto R, Hayashi S, Ishii K. Neonatal respiratory complications in twins at 36-38 weeks of gestation. Pediatr Int 2024; 66:e15767. [PMID: 38924178 DOI: 10.1111/ped.15767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 02/20/2024] [Accepted: 03/12/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Twin pregnancies are associated with a high risk of perinatal mortality and morbidity. Late preterm or early term delivery is frequently performed to avoid unexpected fetal death in uncomplicated twin pregnancies. Nonetheless, delivery before full term is associated with neonatal respiratory complications. This study aimed to evaluate perinatal respiratory complications in twins delivered between 36 and 38 weeks of gestation. METHODS A retrospective cohort study was conducted on twins delivered between 36 and 38 weeks of gestation from January 2008 to June 2020. The primary outcomes were the incidence of composite neonatal respiratory morbidity, which included respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, mechanical ventilation or continuous positive airway pressure according to gestational age at delivery, and chorionicity. The relationship between gestational age at delivery and composite neonatal respiratory morbidity was evaluated using multivariate logistic regression analysis adjusted for potential confounders. RESULTS This study included 1608 twins (614 monochorionic diamniotic twins, 994 dichorionic diamniotic twins). At 36, 37, and 38 weeks of gestation, the frequencies of composite neonatal respiratory morbidity were 19.4%, 10.7%, and 9.2% in dichorionic diamniotic twins and 13.6%, 8.7%, and 9.4% in monochorionic diamniotic twins, respectively. In dichorionic diamniotic twins, the composite neonatal respiratory morbidity rate was higher for twins delivered at 36 weeks of gestation than for those delivered at 37 weeks. No significant differences between monochorionic diamniotic twins were detected. CONCLUSIONS In uncomplicated dichorionic diamniotic twin pregnancies, delivery should be considered after 37 weeks of gestation to reduce neonatal respiratory complications.
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Affiliation(s)
- Haruna Kawaguchi
- Department of Maternal-Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yoshihiro Kuritani
- Department of Obstetrics/Gynecology, Osaka General Medical Center, Osaka, Japan
| | - Ryo Yamamoto
- Department of Maternal-Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Shusaku Hayashi
- Department of Maternal-Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Ishii
- Department of Maternal-Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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Berger DS, Lee YM. Timing of Delivery for Twins. Clin Obstet Gynecol 2023; 66:884-890. [PMID: 37910137 DOI: 10.1097/grf.0000000000000813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
The optimal gestational age for delivery of twin gestations balances the risk to the mother with the risks to the fetus and newborn. Primary considerations should include chorionicity and the presence or absence of other obstetrical complications such as fetal growth restriction or hypertensive disorders of pregnancy. More than half of twin gestations will deliver preterm, and a significant portion will be due to spontaneous labor or medical indications, such that the timing of delivery for twins is typically less determined by the provider discretion. Future studies are needed to assist in clarifying the optimal timing for delivery of twin pregnancies.
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Affiliation(s)
- Dana Senderoff Berger
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, NYU Grossman School of Medicine
| | - Young Mi Lee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, Maternal Fetal Care Center, New York, New York
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Whittaker M, Greatholder I, Kilby MD, Heazell AEP. Risk factors for adverse outcomes in twin pregnancies: a narrative review. J Matern Fetal Neonatal Med 2023; 36:2240467. [PMID: 37518183 DOI: 10.1080/14767058.2023.2240467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE Globally, the incidence of twin pregnancies is rising owing to the use of assisted reproductive technologies (ART), emigration and deferment of pregnancy until advanced maternal age (AMA). While twin pregnancies have higher absolute risks of adverse outcomes, including miscarriage, stillbirth, neonatal death and preterm delivery, the impact of specific exposures and risk factors related to these outcomes may differ between twin pregnancies and singleton pregnancies. Regarding modifiable factors, data are sometimes based on evidence extrapolated from singleton or whole obstetric populations. Therefore, targeted evidence is required to provide care tailored to twin pregnancies to prevent adverse outcomes. We aimed to comprehensively review the association between different risk factors and adverse outcomes in twin pregnancies, including data on chorionicity, and to compare these to singletons. MATERIALS AND METHODS This review examines the risks associated with chorionicity, AMA, body mass index (BMI), socioeconomic and ethnic inequalities, maternal smoking, use of ART, maternal perception of fetal movement, and maternal comorbidities, including hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM). Adverse outcomes reported were preterm birth, admission to the neonatal intensive care unit (NICU), stillbirth and neonatal mortality. As such, fetal mortality and morbidity will be under-represented, as pregnancy loss before 22-24 weeks is omitted. RESULTS Monochorionicity increases the risk of stillbirth, NICU admission, and preterm delivery in twin pregnancy. AMA predisposes twin pregnancies to higher risks of mortality, admission to the NICU, and preterm birth than singleton pregnancies do. Conversely, the impact of BMI, socioeconomic inequalities, smoking, ART, and HDP on adverse outcomes appears to be lower in twin pregnancies than in singleton pregnancies. This attenuation might be explained by the higher baseline risk of adverse outcomes such as preterm birth in twin pregnancies. Some exposures, such as ART use and GDM, appear to be "protective" against perinatal mortality in twin pregnancies, despite being established risk factors for adverse outcomes in singleton pregnancies, potentially related to access to specialist care. There is a paucity of evidence available to counsel mothers of twin pregnancies regarding reduced fetal movement. CONCLUSIONS Overall, the risk factors for adverse pregnancy outcomes differ between twin and singleton pregnancies. This highlights the need for further studies to examine the association between risk factors and adverse outcomes in twin pregnancies. The resulting data would facilitate tailored guidance for twin pregnancies, contribute to improved antenatal care, and inform wider public health strategies.
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Affiliation(s)
- Maya Whittaker
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Isabelle Greatholder
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mark D Kilby
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Birmingham, UK
- Emeritus Professor of Fetal Medicine, College of Medical & Dental Sciences, University of Birmingham, Edgbaston, UK
- Illumina UK, Cambridge, UK
| | - Alexander E P Heazell
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Shea SK, Newman RB. Fetal Growth and Antenatal Testing in Uncomplicated Multiple Gestations. Clin Obstet Gynecol 2023; 66:864-883. [PMID: 37910097 DOI: 10.1097/grf.0000000000000815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Multiple gestations experience a slowing of fetal growth in the third trimester and have been described as having a higher risk of growth restriction. Whether this increased diagnosis of fetal growth restriction is physiological or pathologic is controversial. In an attempt to better identify those fetuses most at risk, twin-specific growth charts have been developed and tested. In addition, there are data to suggest that multiple gestations experience an increased risk of unexpected third-trimester stillbirth in apparently uncomplicated pregnancies. This chapter reviews the current data and recommendations for fetal growth assessment, antenatal surveillance, and delivery timing in uncomplicated multiple gestations.
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Affiliation(s)
- Sarah K Shea
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Medical University of South Carolina, Charleston, South Carolina
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Pauphilet V, Goffinet F, Korb D, Zeitlin J, Torchin H, Schmitz T. Mother-child separation after twin birth in a maternity unit with an appropriate level of neonatal care. Int J Gynaecol Obstet 2023; 163:563-571. [PMID: 37194441 DOI: 10.1002/ijgo.14851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/11/2023] [Accepted: 04/24/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE To evaluate the mother-child separation rate in twin pregnancies delivered in maternity units offering an appropriate level of neonatal care. METHODS JUMODA is a French, prospective, population-based cohort study of twin deliveries, including 7998 women who gave birth in maternity units with appropriate levels of neonatal care based on thresholds for weeks of gestational age (wGA) and birth weight according to French guidelines: level I (≥36 wGA), IIA (≥34 wGA), IIB (≥32 wGA and ≥ 1500 g), and IIII (<32 wGA or < 1500 g). The primary outcome was mother-child separation, defined as the transfer of at least one twin or the mother to another hospital. RESULTS Mother-child separation occurred in 2.1% of pregnancies. This rate was significantly higher in level I (4.8%, 95% confidence interval [CI] 1.5-12.5) and IIA (3.4%, 95% CI 2.4-4.7) compared with level IIB (1.6%, 95% CI 1.1-2.3) and level III maternity units (2.1%, 95% CI 1.9-2.8). In level IIA units, the rate of mother-child separation was higher for babies born between 34 and 36 wGA (8.3%) than for those born at 36 wGA or beyond (1.7%). In level IIb, the rate of mother-child separation for babies born between 32 and 34 wGA (7.5%) was higher than for those born between 34 and 36 wGA (2.1%) and at 36 wGA or beyond (0.9%). CONCLUSION Mother-child separation rates were low but differed by level of care. By using specific thresholds for twins to define levels of care, rather than data from singleton births, one-fifth of mother-child separations could have been avoided.
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Affiliation(s)
- Victoire Pauphilet
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Service de Gynécologie Obstétrique, Paris, France
- Université de Paris, Paris, France
- INSERM, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
| | - François Goffinet
- Université de Paris, Paris, France
- INSERM, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
- Assistance Publique-Hôpitaux de Paris, Maternité Port-Royal, Paris, France
| | - Diane Korb
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Service de Gynécologie Obstétrique, Paris, France
- Université de Paris, Paris, France
- INSERM, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
| | - Jennifer Zeitlin
- Université de Paris, Paris, France
- INSERM, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
| | - Heloïse Torchin
- Université de Paris, Paris, France
- INSERM, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
- Assistance Publique-Hôpitaux de Paris, Maternité Port-Royal, Paris, France
| | - Thomas Schmitz
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Service de Gynécologie Obstétrique, Paris, France
- Université de Paris, Paris, France
- INSERM, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
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Prasad S, Khalil A. Twin charts should be the standard reference to assess growth in twin pregnancy. Curr Opin Obstet Gynecol 2023; 35:403-410. [PMID: 37560793 DOI: 10.1097/gco.0000000000000898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
PURPOSE OF REVIEW Twin pregnancies are characterized by slower growth velocity compared with singletons, especially during the third trimester and, therefore, tend to be smaller than singletons. Growth surveillance is instrumental in the identification of twin pregnancies at risk of adverse outcomes. Whether the phenomenon of slow growth is an adaptive physiological response or represents pathological growth lag, is controversial. In this review, we focus on the evidence related to the types of growth charts employed for twin pregnancies. RECENT FINDINGS Consistent evidence has emerged over the past few years from large independent cohorts in different countries suggesting that twin-specific standards perform better in identifying growth-restricted twin pregnancies at risk of adverse perinatal outcomes, without resulting in an increase in interventions or iatrogenic prematurity. SUMMARY The current evidence supports the use of twin-specific reference charts. Concerted efforts should be made to derive prospective evidence from large multicentre studies on various aspects of the implementation of twin-specific standards.
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Affiliation(s)
- Smriti Prasad
- Fetal Medicine Unit, St George's University Hospital
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London
- Twins and Multiples Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospital
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London
- Twins and Multiples Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
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Liu X, Yang J, Ran R, Long F, Yang Y, Dong X, Saffery R, Novakovic B, Mousa H, Wei Y, Hu L, Han TL. Chorionicity-associated variation in metabolic phenotype of cord blood in twin. Nutr Metab (Lond) 2023; 20:31. [PMID: 37443030 DOI: 10.1186/s12986-023-00744-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 04/13/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Monochorionic (MC) twins present a higher incidence of unfavorable clinical perinatal outcomes than dichorionic (DC) twins, often in association with placental vascular anastomosis. In this study, we profiled the umbilical cord plasma metabolomes of uncomplicated MC and DC twin pregnancies and related these to several offspring outcomes, previously associated with birthweight. METHODS Umbilical vein blood samples were collected at birth from 25 pairs of uncomplicated MC twins and 24 pairs of uncomplicated DC twins. The samples were subjected to gas chromatography-mass spectrometry-based metabolomics. 152 metabolites were identified from the cord plasma samples of MC and DC twins. Partial least squares discriminant analysis and pathway analysis were performed to compare within DC/MC twin pairs and between DC and MC twins. A generalized estimating equation (GEE) model was utilized to explore the correlation between metabolic differences and birthweight discordance within and between twin pairs. RESULTS Our study revealed clear differences between the metabolite profiles of umbilical cord plasma of MC and DC twins. Metabolite profiles in MC within twin pairs and DC within twin pairs were characterized by the differences in 2 - hydroxyglutaramic acid levels and nicotinamide levels, respectively. The metabolic pathways of GSH, tryptophan, and fatty acid metabolism, were significantly downregulated in MC twins compared to DC twins. In addition, the concentration of caffeine and decamethyl-cyclopentasiloxane (D5) was positively correlated with birthweight in MC and DC twins. CONCLUSION This study demonstrated that the altered metabolites in umbilical plasma made contributions to the different chorionicities between uncomplicated MC twins and DC twins. The chorionicity of twins seems to affect the metabolic cross-talk between co-twin pairs and be related to birthweight discordance of twins.
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Affiliation(s)
- Xiaoyu Liu
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Yang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Rui Ran
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fei Long
- State Key Laboratory of Ultrasound Engineering in Medicine Co-Founded by Chongqing and the Ministry of Science and Technology, School of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Yang Yang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaojing Dong
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Richard Saffery
- Molecular Immunity, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Boris Novakovic
- Molecular Immunity, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Hatem Mousa
- University of Leicester, NHS Trust, Leicester, UK
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.
| | - Lina Hu
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Ting-Li Han
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
- Mass Spectrometry Centre of Maternal Fetal Medicine, Life Science Institution, Chongqing Medical University, Chongqing, China.
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13
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Timing of Delivery for Twins With Growth Discordance and Growth Restriction: An Individual Participant Data Meta-analysis. Obstet Gynecol 2022; 139:1155-1167. [PMID: 35675615 DOI: 10.1097/aog.0000000000004789] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/17/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVE First, to evaluate the risks of stillbirth and neonatal death by gestational age in twin pregnancies with different levels of growth discordance and in relation to small for gestational age (SGA), and on this basis to establish optimal gestational ages for delivery. Second, to compare these optimal gestational ages with previously established optimal delivery timing for twin pregnancies not complicated by fetal growth restriction, which, in a previous individual patient meta-analysis, was calculated at 37 0/7 weeks of gestation for dichorionic pregnancies and 36 0/7 weeks for monochorionic pregnancies. DATA SOURCES A search of MEDLINE, EMBASE, ClinicalTrials.gov, and Ovid between 2015 and 2018 was performed of cohort studies reporting risks of stillbirth and neonatal death in twin pregnancies from 32 to 41 weeks of gestation. Studies from a previous meta-analysis using a similar search strategy (from inception to 2015) were combined. Women with monoamniotic twin pregnancies were excluded. METHODS OF STUDY SELECTION Overall, of 57 eligible studies, 20 cohort studies that contributed original data reporting on 7,474 dichorionic and 2,281 monochorionic twin pairs. TABULATION, INTEGRATION, AND RESULTS We performed an individual participant data meta-analysis to calculate the risk of perinatal death (risk difference between prospective stillbirth and neonatal death) per gestational week. Analyses were stratified by chorionicity, levels of growth discordance, and presence of SGA in one or both twins. For both dichorionic and monochorionic twins, the absolute risks of stillbirth and neonatal death were higher when one or both twins were SGA and increased with greater levels of growth discordance. Regardless of level of growth discordance and birth weight, perinatal risk balanced between 36 0/7-6/7 and 37 0/7-6/7 weeks of gestation in both dichorionic and monochorionic twin pregnancies, with likely higher risk of stillbirth than neonatal death from 37 0/7-6/7 weeks onward. CONCLUSION Growth discordance or SGA is associated with higher absolute risks of stillbirth and neonatal death. However, balancing these two risks, we did not find evidence that the optimal timing of delivery is changed by the presence of growth disorders alone. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42018090866.
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Hiersch L, Barrett J, Fox NS, Rebarber A, Kingdom J, Melamed N. Should twin-specific growth charts be used to assess fetal growth in twin pregnancies? Am J Obstet Gynecol 2022; 227:10-28. [PMID: 35114185 DOI: 10.1016/j.ajog.2022.01.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/24/2022] [Accepted: 01/24/2022] [Indexed: 11/17/2022]
Abstract
One of the hallmarks of twin pregnancies is the slower rate of fetal growth when compared with singleton pregnancies during the third trimester. The mechanisms underlying this phenomenon and whether it represents pathology or benign physiological adaptation are currently unclear. One important implication of these questions relates to the type growth charts that should be used by care providers to monitor growth of twin fetuses. If the slower growth represents pathology (ie, intrauterine growth restriction caused uteroplacental insufficiency), it would be preferable to use a singleton growth chart to identify a small twin fetus that is at risk for perinatal mortality and morbidity. If, however, the relative smallness of twins is the result of benign adaptive mechanisms, it is likely preferable to use a twin-based charts to avoid overdiagnosis of intrauterine growth restriction in twin pregnancies. In the current review, we addressed this question by describing the differences in fetal growth between twin and singleton pregnancies, reviewing the current knowledge regarding the mechanisms responsible for slower fetal growth in twins, summarizing available empirical evidence on the diagnostic accuracy of the 2 types of charts for intrauterine growth restriction in twin pregnancies, and addressing the question of whether uncomplicated dichorionic twins are at an increased risk for fetal death when compared with singleton fetuses. We identified a growing body of evidence that shows that the use of twin charts can reduce the proportion of twin fetuses identified with suspected intrauterine growth restriction by up to 8-fold and can lead to a diagnosis of intrauterine growth restriction that is more strongly associated with adverse perinatal outcomes and hypertensive disorders than a diagnosis of intrauterine growth restriction based on a singleton-based chart without compromising the detection of twin fetuses at risk for adverse outcomes caused by uteroplacental insufficiency. We further found that small for gestational age twins are less likely to experience adverse perinatal outcomes or to have evidence of uteroplacental insufficiency than small for gestational age singletons and that recent data question the longstanding view that uncomplicated dichorionic twins are at an increased risk for fetal death caused by placental insufficiency. Overall, it seems that, based on existing evidence, the of use twin charts is reasonable and may be preferred over the use of singleton charts when monitoring the growth of twin fetuses. Still, it is important to note that the available data have considerable limitations and are primarily derived from observational studies. Therefore, adequately-powered trials are likely needed to confirm the benefit of twin charts before their use is adopted by professional societies.
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Affiliation(s)
- Liran Hiersch
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lis Maternity Hospital, Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jon Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nathan S Fox
- Icahn School of Medicine at Mount Sinai, New York, NY; Maternal Fetal Medicine Associates, PLLC, New York, NY
| | - Andrei Rebarber
- Icahn School of Medicine at Mount Sinai, New York, NY; Maternal Fetal Medicine Associates, PLLC, New York, NY
| | - John Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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15
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O'Connor C, Leitao S, O'Donoghue K. A protocol for a systematic review of clinical practice guidelines for the antenatal management of dichorionic diamniotic twin pregnancy. HRB Open Res 2021; 4:115. [PMID: 38873346 PMCID: PMC11170067 DOI: 10.12688/hrbopenres.13418.1] [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] [Accepted: 10/08/2021] [Indexed: 06/15/2024] Open
Abstract
Overview: The protocol outlines the process designed to systematically review clinical practice guidelines (CPGs), addressing the antenatal management of dichorionic diamniotic (DCDA) twin pregnancies. Background: CPGs are statements that include recommendations intended to optimise patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. CPGs are typically created by scientific institutes, organisations and professional societies, and high-quality CPGs are fundamental to improve patient outcomes, standardise clinical practice and improve the quality of care. While CPGs are designed to improve the quality of care, to achieve this, the identification and appraisal of current international CPGs is required. Because twin pregnancies are identified as high-risk pregnancies, a systematic review of the CPGs in this field is a useful first step for establishing the required high level of care. Aim: The aim of the systematic review is to identify, appraise and examine published CPGs for the antenatal management of DCDA twin pregnancies, within high-income countries. Methods: We will identify published CPGs addressing any aspect of antenatal management of care in DCDA twin pregnancies, appraise the quality of the identified CPGs using the Appraisal of Guidelines for Research and Evaluation version 2 (AGREE II) the Appraisal of Guidelines Research and Evaluation - Recommendations excellence (AGREE-REX) instruments and examining the recommendations from the identified CPGs. Ultimately, this protocol aspires to clearly define the process for a reproducible systematic review of CPGs within a high-income country, addressing any aspect of antenatal management of DCDA twin pregnancies. PROSPERO registration: CRD42021248586 (24/06/2021).
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Affiliation(s)
- Caroline O'Connor
- Infant Centre, University College Cork, Cork, Ireland
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | - Sara Leitao
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- National Perinatal Epidemiology Centre (NPEC), University College Cork, Cork, Ireland
| | - Keelin O'Donoghue
- Infant Centre, University College Cork, Cork, Ireland
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
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Moore V, Rumbold A, Fernandez R, McElroy H, Moore L, Giles L, Grzeskowiak L, Roughead E, Stark M, Davies M. Dispensing of clomiphene citrate to treat infertility: medication supplied and population prevalence of assisted pregnancies and multiple births. Fertil Steril 2021; 117:202-212. [PMID: 34656304 DOI: 10.1016/j.fertnstert.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/30/2021] [Accepted: 08/16/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the proportion of pregnancies resulting in birth that were conceived with the use of clomiphene citrate (CC) and the frequency of multiple pregnancy. DESIGN Whole-of-population cohort study, constructed through data linkage. Comprehensive Australian Government records of dispensed medications were linked to state Perinatal Registry records for all births of at least 20 weeks' gestation. SETTING The state of South Australia. PATIENT(S) Women who maintained pregnancy for at least 20 weeks and gave birth between July 2003 and December 2015, a total of 150,713 women with 241,561 pregnancies. INTERVENTION(S) Not applicable. MAIN OUTCOME MEASURE(S) Ongoing pregnancy occurring in proximity to CC, defined as dispensing from 90 days before to the end of a conception window derived from newborn date of birth and gestational age. RESULT(S) Linkage to dispensed prescription records was achieved for 97.9% of women. Women who conceived with CC tended to be older and socioeconomically advantaged and more likely than other women to have a history of miscarriage. Ongoing pregnancies associated with CC comprised 1.6% of the total; 5.7% were multiple births (mostly twins, 94.6%) compared with 1.5% in the remainder (98.5% twins). CONCLUSION(S) In South Australia, 1.6% of pregnancies (1 in 60) of at least 20 weeks' gestation were conceived proximal to CC dispensing. Of these, 5.7% were multiple pregnancies. This takes the proportion of women who achieved an ongoing pregnancy with medical assistance from 4.4%, based on reports from assisted reproductive technology clinics, to 6% in total.
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Affiliation(s)
- Vivienne Moore
- School of Public Health, The University of Adelaide, South Australia; Robinson Research Institute, The University of Adelaide, South Australia.
| | - Alice Rumbold
- Robinson Research Institute, The University of Adelaide, South Australia; South Australian Health and Medical Research Institute, South Australia
| | - Renae Fernandez
- Robinson Research Institute, The University of Adelaide, South Australia; Discipline of Obstetrics and Gynaecology, The University of Adelaide, South Australia
| | - Heather McElroy
- Discipline of Obstetrics and Gynaecology, The University of Adelaide, South Australia
| | - Lynette Moore
- SA Pathology, Women's and Children's Hospital, Adelaide, South Australia; Discipline of Medical Sciences, The University of Adelaide, South Australia
| | - Lynne Giles
- School of Public Health, The University of Adelaide, South Australia; Robinson Research Institute, The University of Adelaide, South Australia
| | - Luke Grzeskowiak
- Robinson Research Institute, The University of Adelaide, South Australia; South Australian Health and Medical Research Institute, South Australia; Discipline of Obstetrics and Gynaecology, The University of Adelaide, South Australia; College of Medicine and Public Health, Flinders University, South Australia
| | - Elizabeth Roughead
- Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, South Australia
| | - Michael Stark
- Robinson Research Institute, The University of Adelaide, South Australia; Discipline of Obstetrics and Gynaecology, The University of Adelaide, South Australia
| | - Michael Davies
- Robinson Research Institute, The University of Adelaide, South Australia; Discipline of Obstetrics and Gynaecology, The University of Adelaide, South Australia
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van Dongen J, Gordon SD, McRae AF, Odintsova VV, Mbarek H, Breeze CE, Sugden K, Lundgren S, Castillo-Fernandez JE, Hannon E, Moffitt TE, Hagenbeek FA, van Beijsterveldt CEM, Jan Hottenga J, Tsai PC, Min JL, Hemani G, Ehli EA, Paul F, Stern CD, Heijmans BT, Slagboom PE, Daxinger L, van der Maarel SM, de Geus EJC, Willemsen G, Montgomery GW, Reversade B, Ollikainen M, Kaprio J, Spector TD, Bell JT, Mill J, Caspi A, Martin NG, Boomsma DI. Identical twins carry a persistent epigenetic signature of early genome programming. Nat Commun 2021; 12:5618. [PMID: 34584077 PMCID: PMC8479069 DOI: 10.1038/s41467-021-25583-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 07/19/2021] [Indexed: 02/08/2023] Open
Abstract
Monozygotic (MZ) twins and higher-order multiples arise when a zygote splits during pre-implantation stages of development. The mechanisms underpinning this event have remained a mystery. Because MZ twinning rarely runs in families, the leading hypothesis is that it occurs at random. Here, we show that MZ twinning is strongly associated with a stable DNA methylation signature in adult somatic tissues. This signature spans regions near telomeres and centromeres, Polycomb-repressed regions and heterochromatin, genes involved in cell-adhesion, WNT signaling, cell fate, and putative human metastable epialleles. Our study also demonstrates a never-anticipated corollary: because identical twins keep a lifelong molecular signature, we can retrospectively diagnose if a person was conceived as monozygotic twin.
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Affiliation(s)
- Jenny van Dongen
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Reproduction and Development (AR&D) Research Institute, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Scott D Gordon
- Queensland Institute of Medical Research Berghofer, Brisbane, QLD, Australia
| | - Allan F McRae
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
| | - Veronika V Odintsova
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development (AR&D) Research Institute, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Hamdi Mbarek
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development (AR&D) Research Institute, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | | | - Karen Sugden
- Department of Psychology and Neuroscience and Center for Genomic and Computational Biology, Duke University, Durham, NC, USA
| | - Sara Lundgren
- Institute for Molecular Medicine Finland FIMM, University of Helsinki, Helsinki, Finland
| | | | - Eilis Hannon
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Terrie E Moffitt
- Department of Psychology and Neuroscience and Center for Genomic and Computational Biology, Duke University, Durham, NC, USA
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Fiona A Hagenbeek
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Catharina E M van Beijsterveldt
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jouke Jan Hottenga
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Pei-Chien Tsai
- Department of Twin Research and Genetic Epidemiology, Kings College London, London, UK
| | - Josine L Min
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gibran Hemani
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Erik A Ehli
- Avera Institute for Human Genetics, Sioux Falls, SD, USA
| | - Franziska Paul
- Institute of Molecular and Cellular Biology, A*STAR, Singapore, Singapore
| | - Claudio D Stern
- Department of Cell and Developmental Biology, University College London, London, UK
| | - Bastiaan T Heijmans
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - P Eline Slagboom
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia Daxinger
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Eco J C de Geus
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Gonneke Willemsen
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Grant W Montgomery
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
| | - Bruno Reversade
- Institute of Molecular and Cellular Biology, A*STAR, Singapore, Singapore
- Genome Institute of Singapore, A*STAR, Singapore, Singapore
- Medical Genetics Department, KOC University, School of Medicine, Istanbul, Turkey
| | - Miina Ollikainen
- Institute for Molecular Medicine Finland FIMM, University of Helsinki, Helsinki, Finland
| | - Jaakko Kaprio
- Institute for Molecular Medicine Finland FIMM, University of Helsinki, Helsinki, Finland
| | - Tim D Spector
- Department of Twin Research and Genetic Epidemiology, Kings College London, London, UK
| | - Jordana T Bell
- Department of Twin Research and Genetic Epidemiology, Kings College London, London, UK
| | - Jonathan Mill
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Avshalom Caspi
- Department of Psychology and Neuroscience and Center for Genomic and Computational Biology, Duke University, Durham, NC, USA
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nicholas G Martin
- Queensland Institute of Medical Research Berghofer, Brisbane, QLD, Australia
| | - Dorret I Boomsma
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development (AR&D) Research Institute, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Indications for Outpatient Antenatal Fetal Surveillance: ACOG Committee Opinion, Number 828. Obstet Gynecol 2021; 137:e177-e197. [PMID: 34011892 DOI: 10.1097/aog.0000000000004407] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
ABSTRACT The purpose of this Committee Opinion is to offer guidance about indications for and timing and frequency of antenatal fetal surveillance in the outpatient setting. Antenatal fetal surveillance is performed to reduce the risk of stillbirth. However, because the pathway that results in increased risk of stillbirth for a given condition may not be known and antenatal fetal surveillance has not been shown to improve perinatal outcomes for all conditions associated with stillbirth, it is challenging to create a prescriptive list of all indications for which antenatal fetal surveillance should be considered. This Committee Opinion provides guidance on and suggests surveillance for conditions for which stillbirth is reported to occur more frequently than 0.8 per 1,000 (the false-negative rate of a biophysical profile) and which are associated with a relative risk or odds ratio for stillbirth of more than 2.0 compared with pregnancies without the condition. Table 1 presents suggestions for the timing and frequency of testing for specific conditions. As with all testing and interventions, shared decision making between the pregnant individual and the clinician is critically important when considering or offering antenatal fetal surveillance for individuals with pregnancies at high risk for stillbirth or with multiple comorbidities that increase the risk of stillbirth. It is important to emphasize that the guidance offered in this Committee Opinion should be construed only as suggestions; this guidance should not be construed as mandates or as all encompassing. Ultimately, individualization about if and when to offer antenatal fetal surveillance is advised.
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Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies: ACOG Practice Bulletin, Number 231. Obstet Gynecol 2021; 137:e145-e162. [PMID: 34011891 DOI: 10.1097/aog.0000000000004397] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The incidence of multifetal gestations in the United States has increased dramatically over the past several decades. For example, the rate of twin births increased 76% between 1980 and 2009, from 18.9 to 33.3 per 1,000 births (1). However, after more than three decades of increases, the twin birth rate declined 4% during 2014-2018 to 32.6 twins per 1,000 total births in 2018 (2). The rate of triplet and higher-order multifetal gestations increased more than 400% during the 1980s and 1990s, peaking at 193.5 per 100,000 births in 1998, followed by a modest decrease to 153.4 per 100,000 births by 2009 (3). The triplet and higher-order multiple birth rate was 93.0 per 100,000 births for 2018, an 8% decline from 2017 (101.6) and a 52% decline from the 1998 peak (193.5) (4). The long-term changes in the incidence of multifetal gestations has been attributed to two main factors: 1) a shift toward an older maternal age at conception, when multifetal gestations are more likely to occur naturally, and 2) an increased use of assisted reproductive technology (ART), which is more likely to result in a multifetal gestation (5). A number of perinatal complications are increased with multiple gestations, including fetal anomalies, preeclampsia, and gestational diabetes. One of the most consequential complications encountered with multifetal gestations is preterm birth and the resultant infant morbidity and mortality. Although multiple interventions have been evaluated in the hope of prolonging these gestations and improving outcomes, none has had a substantial effect. The purpose of this document is to review the issues and complications associated with twin, triplet, and higher-order multifetal gestations and present an evidence-based approach to management.
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Khalil A, Liu B. Controversies in the management of twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:888-902. [PMID: 32799348 DOI: 10.1002/uog.22181] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/18/2020] [Accepted: 07/30/2020] [Indexed: 06/11/2023]
Abstract
Despite many advances in antenatal care, twin pregnancies still experience more adverse outcomes, in particular perinatal morbidity and mortality. They also pose a multitude of challenges and controversies, as outlined in this Review. Moreover, they are less likely to be included in clinical trials. Many issues on classification and management remain under debate. Efforts at standardizing diagnostic criteria, monitoring protocols, management and outcome reporting are likely to reduce their perinatal risks. The top 10 most important research uncertainties related to multiple pregnancies have been identified by both clinicians and patients. More robust research in the form of randomized trials and large well-conducted prospective cohort studies is needed to address these controversies. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Khalil
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - B Liu
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
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21
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Li S, Gao J, Liu J, Hu J, Chen X, He J, Tang Y, Liu X, Cao Y. Perinatal Outcomes and Risk Factors for Preterm Birth in Twin Pregnancies in a Chinese Population: A Multi-center Retrospective Study. Front Med (Lausanne) 2021; 8:657862. [PMID: 33968962 PMCID: PMC8096908 DOI: 10.3389/fmed.2021.657862] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/24/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Twin pregnancies are associated with an increased risk of adverse maternal and neonatal outcomes, mainly owing to prematurity. Few studies have evaluated the risk factors for preterm birth (PTB) in Chinese population. The objective of this study is to present the short-term maternal-neonatal outcomes, investigating the potential risk factors associated with preterm birth in Chinese twin pregnancies. Methods: A multi-center retrospective study of women pregnant with twins ≥28 weeks of gestation was conducted. Maternal and neonatal outcomes were analyzed. Logistic regression was used to identify potential risk factors for PTB before 37, 34, and 32 weeks, respectively. Results: A total of 3,288 twin pregnancies and 6,576 neonates were included in 99,585 pregnancies. The rate of twin pregnancy was 3.3%, while the PTB rate before 37, 34, and 32 weeks among this population were 62.1, 18.8, and 10.4%, respectively. Logistic regression revealed that monochorionicity [Odds ratio (OR) 3.028, 95% confident interval (CI) 2.489–3.683, P < 0.001], gestational weight gain (GWG) <10 kg (OR 2.285, 95% CI 1.563–3.339, P < 0.001) and GWG between 10 and 15 kg (OR 1.478, 95% CI 1.188–1.839, P < 0.001), preeclampsia (PE) (OR 3.067, 95% CI 2.142–4.390, P < 0.001), and intrahepatic cholestasis of pregnancy (ICP) (OR 3.122, 95% CI 2.121–4.596, P < 0.001) were the risk factors for PTB before 37 weeks. Monochorionicity (OR 2.865, 95% CI 2.344–3.501, P < 0.001), age < 25 years (OR 1.888, 95% CI 1.307–2.728, P = 0.001), and GWG <10 kg (OR 3.100, 95% CI 2.198–4.372, P < 0.001) were risk factors for PTB before 34 weeks. Monochorionicity (OR 2.566, 95% CI 1.991–3.307, P < 0.001), age younger than 25 years (OR 1.964, 95% CI 1.265–3.048, P = 0.003), and GWG <10 kg (OR 4.319, 95% CI 2.931–6.364, P < 0.001) were the risk factors for PTB before 32 weeks. Conclusions: Monochorionicity and GWG <10 kg were two major risk factors for PTB before 32, 34, and 37 weeks, whereas maternal age, PE, and ICP were also risk factors for PTB in specific gestational age.
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Affiliation(s)
- Sijian Li
- Department of Obstetrics and Gynecology, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jinsong Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jing Hu
- Department of Obstetrics and Gynecology, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Xiaoxu Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jing He
- Department of Obstetrics and Gynecology, School of Medicine, Women's Hospital, Zhejiang University, Zhejiang, China
| | - Yabing Tang
- Department of Obstetrics and Gynecology, Hunan Maternal and Child Health Care Hospital, Changsha, China
| | - Xinghui Liu
- Department of Obstetrics and Gynecology, Sichuan University West China Second Hospital, Chengdu, China
| | - Yinli Cao
- Department of Obstetrics and Gynecology, Northwest Women and Children's Hospital, Xi'an, China
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Abstract
OBJECTIVES To provide an investigation protocol to help health care providers determine the cause of a fetal death. OPTIONS Consideration has been given to protocols for the investigation of fetal death that are currently available in Canada and in other countries. OUTCOMES Identification of possible causes of stillbirth and their relationship to future pregnancies. EVIDENCE Articles related to the etiology of fetal death were identified in a search of PubMed (June 2006 to September 2018), the Cochrane Library, and investigation protocols from the American College of Obstetricians and Gynecologists, the International Stillbirth Alliance Collaborative for Improving Classification of Perinatal Deaths, the Royal College of Obstetricians and Gynaecologists, the Queensland clinical guidelines, and the Reproductive Care Program of Nova Scotia. BENEFITS To provide better advice for women regarding possible causes of fetal death and implications for future pregnancies. VALIDATION The evidence obtained was reviewed and evaluated by the Maternal-Fetal Medicine Committee and the Clinical Practice Obstetrics Committee of the Society of Obstetricians and Gynaecologists of Canada. The level of evidence and quality of the recommendation made was described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care. RECOMMENDATIONS
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Chen Y, Sun L, Hua X, Li M, Yu S, Zhang J. Defining intertwin birth weight discordance and optimal delivery time in dichorionic twins: a retrospective cohort study. J Matern Fetal Neonatal Med 2020; 35:3915-3922. [PMID: 33249949 DOI: 10.1080/14767058.2020.1843627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND A high birth weight discordance (BWD) places twins at high risks of adverse perinatal outcomes; however, there is no commonly accepted definition of intertwin BWD. Given that gestational age (GA) is closely associated with both BWD and adverse neonatal outcomes, the aim of our study is to develop a measure that takes both BWD and GA into account to define BWD and explore the potentially optimal delivery time in dichorionic twins, with the balance against the risk of intrauterine demise and adverse neonatal outcomes. METHODS About 99,000 mixed gender twin pairs from the US matched multiple birth file from 1995 to 2000 were enrolled in our study. We set up a two-dimensional matrix model to select the BWD cutoff point related to outcomes. The optimal delivery time was identified based on the risks of adverse neonatal outcomes and fetal death by GA. RESULTS The combination of BWD and GA had a higher predictive performance for adverse neonatal outcomes than BWD alone (area under ROC curve (AUC): 0.816 vs. 0.523, p < .001). When GA was controlled for, the growth discordant cutoff point was BWD at the 40% level. The optimal delivery time suggested in dichorionic twins with BWD higher than 40% was identified at 33-34 gestational weeks. CONCLUSIONS The combination of BWD and GA was a better predictor for adverse neonatal outcomes than BWD alone. In dichorionic twins with BWD >40%, pregnancy may be continued till 33-34 gestation weeks if there is no indication for immediate delivery.
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Affiliation(s)
- Yan Chen
- Department of Neonatology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Luming Sun
- Department of Fetal Medicine, First Maternity and Infant Hospital Affiliated to Shanghai Tongji University, Shanghai, China
| | - Xiaolin Hua
- Department of Obstetrics, First Maternity and Infant Hospital Affiliated to Shanghai Tongji University, Shanghai, China
| | - Meng Li
- MOE-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stella Yu
- Center for Global Health and Health Policy, Global Health and Education Projects, Inc, Riverdale, MD, USA
| | - Jun Zhang
- MOE-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Marleen S, Dias C, Nandasena R, MacGregor R, Allotey J, Aquilina J, Khalil A, Thangaratinam S. Association between chorionicity and preterm birth in twin pregnancies: a systematic review involving 29 864 twin pregnancies. BJOG 2020; 128:788-796. [PMID: 32888235 DOI: 10.1111/1471-0528.16479] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The perinatal mortality and morbidity among twins vary by chorionicity. Although it is considered that monochorionicity is associated with an increased risk of preterm birth in twin pregnancies, no systematic review exists evaluating this association. OBJECTIVES This systematic review was undertaken to assess the association between preterm birth and chorionicity in twin pregnancies. SEARCH STRATEGY We searched the electronic databases from January 1990 to July 2019 without language restrictions. SELECTION CRITERIA All studies on twin pregnancies where chorionicity and preterm birth were evaluated were included. DATA COLLECTION AND ANALYSIS Findings are reported as odds ratios with 95% confidence intervals. The estimates are pooled using random-effects meta-analysis. MAIN RESULTS From 13 156 citations, we included 39 studies (29 864 pregnancies). Monochorionicity was significantly associated with increased risk of preterm birth at ≤28, ≤32, ≤34 and <37 weeks in women asymptomatic and symptomatic for preterm labour (odds ratio [OR] 2.14, 95% CI 1.52-3.02, I2 = 46%, OR 1.55, 95% CI 1.27-1.89 I2 = 68%, OR 1.47, 95% CI 1.27-1.69, I2 = 60%, OR 1.66, 95% CI 1.43-1.93, I2 = 65%, respectively). Among those asymptomatic for preterm labour, significantly increased odds of preterm birth were seen for monochorionicity at gestations ≤34 weeks (OR 1.85, 95% CI 1.42-2.40, I2 = 25%) and <37 weeks (OR 1.75, 95% CI 1.22-2.53, I2 = 61%). Sensitivity analysis showed significantly increased odds of spontaneous preterm birth at ≤34 and <37 weeks for monochorionicity (OR 1.25, 95% CI 1.01-1.55, I2 = 0% and OR 1.41, 95% CI 1.13-1.78, I2 = 0%). CONCLUSIONS Monochorionicity is significantly associated with preterm birth at all gestations. TWEETABLE ABSTRACT In twin pregnancies, monochorionicity is associated with an increased risk of preterm birth at all gestations.
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Affiliation(s)
- S Marleen
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Sri Jayewardenepura Postgraduate Teaching Hospital, Nugegoda, Sri Lanka
| | - C Dias
- Sri Jayewardenepura Postgraduate Teaching Hospital, Nugegoda, Sri Lanka
| | - R Nandasena
- Sri Jayewardenepura Postgraduate Teaching Hospital, Nugegoda, Sri Lanka
| | - R MacGregor
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - J Allotey
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - J Aquilina
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - A Khalil
- St George's University Hospitals NHS Foundation Trust, London, UK.,Molecular and Clinical Sciences Research Institute, St George's Medical School, University of London, London, UK
| | - S Thangaratinam
- World Health Organization (WHO) Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Lian Q, Ni J, Zhang J, Little J, Luo S, Zhang L. Maternal exposure to Wenchuan earthquake and prolonged risk of offspring birth outcomes: a natural experiment study. BMC Pregnancy Childbirth 2020; 20:552. [PMID: 32962638 PMCID: PMC7510090 DOI: 10.1186/s12884-020-03206-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/24/2020] [Indexed: 12/13/2022] Open
Abstract
Background The prolonged effects of disasters on reproductive outcomes among the survivors are less studied, and the findings are inconsistent. We examined the associations of maternal exposure to the 2008 Wenchuan earthquake years before conception with adverse birth outcomes. Methods We included 73,493 women who delivered in 96 hospitals in 24 provinces and autonomous regions from the 2015/16 China Labor and Delivery Survey. We weighted the multivariable logistic models based on the combination of coarsened exact matching (CEM) weight and survey weight, and performed sex-stratified analysis to test whether associations of maternal earthquake exposure with adverse birth outcomes (Stillbirth, preterm birth [PTB], low birthweight [LBW], and small for gestational age [SGA]) varied by sex. Results The bivariate models showed that the weighted incidence of each adverse birth outcome was higher in exposed group than unexposed group: stillbirth (2.00% vs. 1.33%), PTB (14.14% vs. 7.32%), LBW (10.82% vs. 5.76%), and SGA (11.32% vs. 9.52%). The multivariable models showed maternal earthquake exposure was only associated significantly with a higher risk of PTB in offspring among all births (adjusted risk ratio [aRR](95%CI):1.25(1.06–1.48), P = 0.010). The sex-stratified analysis showed the association was significant among male births (aRR (95%CI): 1.40(1.12–1.75),P = 0.002),but unsignificant among female births. The sensitivity analysis reported similar findings. Conclusions The 2008 Wenchuan earthquake exposure has a long-term effect on PTB. Maternal acute exposure to disasters could be a major monitor for long-term reproductive outcomes. More attention should be paid to the underlining reasons for disaster-related adverse birth outcomes.
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Affiliation(s)
- Qiguo Lian
- NHC Key Lab. of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Fudan University, Shanghai, 200237, China
| | - Jiaying Ni
- Obstetric and Gynecology Department, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Jun Zhang
- MOE-Shanghai Key Lab of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Julian Little
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, K1N 6N5, Canada
| | - Shan Luo
- West China Second University Hospital, Sichuan University, Chengdu, 610041, China
| | - Lin Zhang
- Obstetric and Gynecology Department, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China. .,Obstetrics Department, International peace maternity and child health hospital of China, Shanghai Jiao Tong University School of Medicine, 910 Hengshan Road, Shanghai, 200030, China.
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Gulati N, Mackie FL, Cox P, Marton T, Heazell A, Morris RK, Kilby MD. Cause of intrauterine and neonatal death in twin pregnancies (CoDiT): development of a novel classification system. BJOG 2020; 127:1507-1515. [PMID: 32359214 DOI: 10.1111/1471-0528.16291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Twin pregnancies have a significantly higher perinatal mortality than singleton pregnancies. Current classification systems for perinatal death lack twin-specific categories, potentially leading to loss of important information regarding cause of death. We introduce and test a classification system designed to assign a cause of death in twin pregnancies (CoDiT). DESIGN Retrospective cross-sectional study. SETTING Tertiary maternity unit in England with a perinatal pathology service. POPULATION Twin pregnancies in the West Midlands affected by fetal or neonatal demise of one or both twins between 1 January 2005 and 31 December 2016 in which postmortem examination was undertaken. METHODS A multidisciplinary panel designed CoDiT by adapting the most appropriate elements of singleton classification systems. The system was tested by assigning cause of death in 265 fetal and neonatal deaths from 144 twin pregnancies. Cause of death was validated by another obstetrician blinded to the original classification. MAIN OUTCOME MEASURES Inter-rater, intra-rater, inter-disciplinary agreement and cause of death. RESULTS Cohen's Kappa demonstrated 'strong' (>0.8) inter-rater, intra-rater and inter-disciplinary agreement (95% CI 0.70-0.91). The commonest cause of death irrespective of chorionicity was the placenta; twin-to-twin transfusion syndrome (TTTS) was the commonest placental cause in monochorionic twins and acute chorioamnionitis in dichorionic twins. CONCLUSIONS This novel classification system records causes of death in twin pregnancies from postmortem reports with high inter-user agreement. We highlight differences in aetiology of death between monochorionic and dichorionic twins. TWEETABLE ABSTRACT New classification system for #twin cause of death 'CoDiT' shows high rater agreement.
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Affiliation(s)
- N Gulati
- Institute of Metabolism & Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK
| | - F L Mackie
- Institute of Metabolism & Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK
| | - P Cox
- Cellular Pathology Department, Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - T Marton
- Cellular Pathology Department, Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Aep Heazell
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, UK.,St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R K Morris
- Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK.,Institute of Applied Health Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - M D Kilby
- Institute of Metabolism & Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK
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Directive clinique No 394 - Investigation sur la mortinaissance. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:100-108. [DOI: 10.1016/j.jogc.2019.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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28
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Lam JR, Liu B, Bhate R, Fenwick N, Reed K, Duffy JMN, Khalil A. Research priorities for the future health of multiples and their families: The Global Twins and Multiples Priority Setting Partnership. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:715-721. [PMID: 31600847 DOI: 10.1002/uog.20858] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 08/17/2019] [Accepted: 08/23/2019] [Indexed: 05/27/2023]
Affiliation(s)
- J R Lam
- Twins Research Australia, The University of Melbourne, Melbourne, Australia
| | - B Liu
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - R Bhate
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - N Fenwick
- Twins and Multiple Births Association, London, UK
| | - K Reed
- Twins and Multiple Births Association, London, UK
| | - J M N Duffy
- Institute for Women's Health, University College London, London, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Wright RG, Macindoe C, Green P. Placental Abnormalities Associated With Childbirth. Acad Forensic Pathol 2019; 9:2-14. [PMID: 34394786 DOI: 10.1177/1925362119851113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/24/2018] [Indexed: 11/17/2022]
Abstract
Pathologists are faced with a variety of problems when considering placental tissue in cases of stillbirth. It is recognized that there are changes which occur following fetal demise and which can complicate the assessment and may coexist with other morphological changes. It is recognized that up to 25% of stillbirths may have a recognizable abnormality causing fetal demise. A systematic review of placental tissue allows many of these disorders to be identified. This review considers macroscopic and microscopic features of placental pathology in stillbirth together with clinicopathological correlation. Stillbirth definitions, general aspects of macroscopic assessment of placentas, placental changes after fetal demise, and some recognizable causes of fetal demise are considered.
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30
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Hanson C, Munjanja S, Binagwaho A, Vwalika B, Pembe AB, Jacinto E, Chilinda GK, Donahoe KB, Wanyonyi SZ, Waiswa P, Gidiri MF, Benova L. National policies and care provision in pregnancy and childbirth for twins in Eastern and Southern Africa: A mixed-methods multi-country study. PLoS Med 2019; 16:e1002749. [PMID: 30779738 PMCID: PMC6380547 DOI: 10.1371/journal.pmed.1002749] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/22/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND High-risk pregnancies, such as twin pregnancies, deserve particular attention as mortality is very high in this group. With a view to inform policy and national guidelines development for the Sustainable Development Goals, we reviewed national training materials, guidelines, and policies underpinning the provision of care in relation to twin pregnancies and assessed care provided to twins in 8 Eastern and Southern African countries: Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. METHODS AND FINDINGS We located policies and guidelines by reviewing national repositories and by contacting experts to systematically map country-level maternal and newborn training materials, guidelines, and policies. We extracted recommendations for care for twins spanning ante-, intra-, and postpartum care that typically should be offered during twin pregnancies and childbirth. We compared care provided for mothers of twins to that provided for mothers of singletons during the ante-, intra-, and postpartum period and computed neonatal mortality rates using the most recent Demographic and Health Surveys (DHS) data for each country. There was a paucity of guidance on care specifically for twin or multiple pregnancies: None of the countries provided clear guidance on additional number of antenatal care visits or specific antenatal content, while 7 of the 8 countries recommended twins to be delivered in a comprehensive emergency obstetric and neonatal care facility. These results were mirrored by DHS results of 73,462 live births (of which 1,360 were twin) indicating that twin pregnancies did not receive more frequent or intensified antenatal care. The percentage of twin deliveries in hospitals varied from 25.3% in Mozambique to 63.0% in Kenya, and women with twin deliveries were between 5 and 27 percentage points more likely to deliver in hospitals compared to women with singleton live births; this difference was significant in 5 of the 8 countries (t test p < 0.05). The percentage of twin deliveries by cesarean section varied from 9% in Mozambique to 36% in Rwanda. The newborn mortality rate among twins, adjusted for maternal age and parity, was 4.6 to 7.2 times higher for twins compared to singletons in all 8 countries. CONCLUSIONS Despite the limited sample size and the limited number of clinically relevant services evaluated, our study provided evidence that mothers of twins receive insufficient care and that mortality in twin newborns is very high in Eastern and Southern Africa. Most countries have insufficient guidelines for the care of twins. While our data do not allow us to make a causal link between insufficient guidelines and insufficient care, they call for an assessment and reconceptualisation of policies to reduce the unacceptably high mortality in twins in Eastern and Southern Africa.
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Affiliation(s)
- Claudia Hanson
- Department of Disease Control, London School of Hygiene &Tropical Medicine, London, United Kingdom
- Department of Public Health Sciences–Global Health, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Stephen Munjanja
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Andrea B. Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Elsa Jacinto
- Women’s and Children’s Health Department, National Directorate for Public Health, Ministry of Health, Maputo, Mozambique
| | - George K. Chilinda
- Department of Obstetrics and Gynaecology, Medical College, Blantyre, Malawi
| | | | - Sikolia Z. Wanyonyi
- Department of Obstetrics and Gynecology, Aga Khan University, Nairobi, Kenya
| | - Peter Waiswa
- Department of Public Health Sciences–Global Health, Karolinska Institutet, Stockholm, Sweden
- College of Health Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Muchabayiwa F. Gidiri
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Khalil A. Unprecedented fall in stillbirth and neonatal death in twins: lessons from the UK. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:153-157. [PMID: 30152183 DOI: 10.1002/uog.20107] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 08/22/2018] [Indexed: 06/08/2023]
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Korlesky C, McPherson E. Early demise of twins in a cohort of stillbirths and second trimester miscarriages. Am J Med Genet A 2019; 179:350-355. [PMID: 30663217 DOI: 10.1002/ajmg.a.61014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/08/2018] [Accepted: 11/16/2018] [Indexed: 11/11/2022]
Abstract
Twins, particularly monochorionic (MC) pairs, are at increased risk for fetal death. Whereas previous work has sought to understand the mechanisms for this increased mortality, most studies analyze viable twin pregnancies or liveborn twin cohorts. In the Wisconsin Stillbirth Service Program cohort of 3,137 stillbirths and second trimester miscarriages, we identified 175 twin pregnancies for a twinning rate of 56/1,000, which is approximately double the general population. The excess of twins among miscarriages and stillbirths was attributable to MC pairs as the incidence of dizygotic (DZ) twinning was not increased compared to livebirth data. The leading causes of fetal demise among twins were twin-twin transfusion, acardia, and twin-twin disruption. Maternal causes of death, primarily premature rupture of membranes, were moderately increased in both MC and DZ twins relative to singletons. Although deceased twins were smaller than expected for viable twins at comparable gestational ages, placenta weights of deceased MC pairs were large compared to combined fetal weight, which indicates placental inefficiency likely due to vascular shunting. Co-twin survival was much lower for MC than for DZ pairs. Therefore, earlier diagnosis and treatment of MC twinning complications may decrease prenatal mortality.
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Affiliation(s)
- Colin Korlesky
- Center for Human Genetics, Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | - Elizabeth McPherson
- Center for Human Genetics, Marshfield Clinic Research Institute, Marshfield, Wisconsin
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Deng C, Dai L, Yi L, Li X, Deng K, Mu Y, Wang K, Tao J, Li Q, Xu L. Temporal trends in the birth rates and perinatal mortality of twins: A population-based study in China. PLoS One 2019; 14:e0209962. [PMID: 30650106 PMCID: PMC6334899 DOI: 10.1371/journal.pone.0209962] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 12/15/2018] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Until now, little was known about the epidemiological characteristics of twins in China due to a lack of reliable national data. In this study, we aimed to analyze temporal trends and perinatal mortality of twins from China. METHODS Data on twins between 2007 and 2014 were obtained from the China National Population-Based Birth Defects Surveillance System. Twin and singleton deliveries after at least 28 weeks of gestation were recruited and followed until postnatal day 42. Twinning rates were defined as the number of twin individuals per 1000 births(stillbirths and live births). The Weinberg's differential method was utilized to estimate the number of monozygotic and dizygotic twins. RESULTS During 2007-2014, the twinning rate increased by 32.3% from 16.4 to 21.7 per 1000 total births with an average of 18.8‰. Among twins, both the perinatal mortality rate (26.1 per 1000 total births) and neonatal death rate (15.7 per 1000 live births) presented a downward tendency but remained at a high level. Large urban-rural and geographic disparities were identified in twinning rates, in perinatal and neonatal mortality, and in their temporal trends. CONCLUSIONS The upward trend of twinning rates in China paired with the relatively high rates of perinatal and neonatal mortality among twins highlights the need for improved perinatal care in the light of socio-demographic differences.
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Affiliation(s)
- Changfei Deng
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Li Dai
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Ling Yi
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaohong Li
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kui Deng
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Mu
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ke Wang
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jing Tao
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qi Li
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Liangzhi Xu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
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Ko HS, Choi SK, Wie JH, Park IY, Park YG, Shin JC. Optimal Timing of Delivery Based on the Risk of Stillbirth and Infant Death Associated with Each Additional Week of Expectant Management in Multiple Pregnancies: a National Cohort Study of Koreans. J Korean Med Sci 2018; 33:e80. [PMID: 29495143 PMCID: PMC5832943 DOI: 10.3346/jkms.2018.33.e80] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 12/15/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The purpose of this study was to compare the fetal/infant mortality risk associated with each additional week of expectant management to that associated with immediate delivery in women with multiple gestations. METHODS This was a retrospective national cohort study of 94,170 multiple deliveries, 92,619 (98.4%) twin and 1,352 (1.44%) triplet pregnancies, between 32 0/7 and 42 6/7 weeks of gestation recorded in the Korean vital statistics database. We investigated the risks of stillbirth and infant death after birth in Korea according to the week of gestation in twin and triplet pregnancies. RESULTS The risk of stillbirth significantly increased between 34 and 35 weeks of gestation and between 37 and 38 weeks of gestation in twin pregnancies and between 34 and 37 weeks of gestation in triplet pregnancies. The risk of infant death following delivery gradually decreased as pregnancies approached full term. Week-by-week differences were statistically significant between 33 and 34 weeks, with decreasing risks of infant death at advancing gestational ages in twin pregnancies. At 37 weeks of gestation, the relative risk of mortality was significantly higher with expectant management compared with immediate delivery (relative risk, 3.00; 95% confidence interval, 1.41-6.38). CONCLUSION In twin pregnancies, delivery at 37 weeks of gestation can minimize the risks of stillbirth and infant death in uncomplicated cases, although individual maternal and fetal characteristics must be considered when determining the optimal timing of delivery. In multiple pregnancies, close fetal surveillance is needed after 34 weeks of gestation.
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Affiliation(s)
- Hyun Sun Ko
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sae Kyung Choi
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong Ha Wie
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Yang Park
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Yong Gyu Park
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Chul Shin
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Algeri P, Pelizzoni F, Bernasconi DP, Russo F, Incerti M, Cozzolino S, Mastrolia SA, Vergani P. Influence of weight gain, according to Institute of Medicine 2009 recommendation, on spontaneous preterm delivery in twin pregnancies. BMC Pregnancy Childbirth 2018; 18:6. [PMID: 29298662 PMCID: PMC5751880 DOI: 10.1186/s12884-017-1645-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 12/21/2017] [Indexed: 11/17/2022] Open
Abstract
Backgrounds Maternal total weight gain during pregnancy influences adverse obstetric outcomes in singleton pregnancies. However, its impact in twin gestation is less understood. Our objective was to estimate the influence of total maternal weight gain on preterm delivery in twin pregnancies. Methods We conducted a retrospective cohort study including diamniotic twin pregnancies with spontaneous labor delivered at 28 + 0 weeks or later. We analyzed the influence of total weight gain according to Institute of Medicine (IOM) cut-offs on the development of preterm delivery (both less than 34 and 37 weeks). Outcome were compared between under and normal weight gain and between over and normal weight gain separately using Fisher’s exact test with Holm-Bonferroni correction. Results One hundred seventy five women were included in the study and divided into three groups: under (52.0%), normal (41.7%) and overweight gain (6.3%). Normal weight gain was associated with a reduction in the rate of preterm delivery compared to under and over weight gain [less than 34 weeks: under vs. normal OR 4.97 (1.76–14.02), over vs. normal OR 4.53 (0.89–23.08); less than 37 weeks: OR 3.16 (1.66–6.04) and 6.51 (1.30–32.49), respectively]. Conclusions Normal weight gain reduces spontaneous preterm delivery compared to over and underweight gain.
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Affiliation(s)
- Paola Algeri
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, S. Gerardo Hospital, MBBM Foundation, Via Pergolesi 33, Monza, 20900, Monza, Monza e Brianza, Italy.
| | - Francesca Pelizzoni
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, S. Gerardo Hospital, MBBM Foundation, Via Pergolesi 33, Monza, 20900, Monza, Monza e Brianza, Italy
| | - Davide Paolo Bernasconi
- Department of Health Sciences, Center of Biostatistic for Clinical Epidemiology, University of Milan-Bicocca, Via Pergolesi 33, Monza, 20900, Monza, Monza e Brianza, Italy
| | - Francesca Russo
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, S. Gerardo Hospital, MBBM Foundation, Via Pergolesi 33, Monza, 20900, Monza, Monza e Brianza, Italy
| | - Maddalena Incerti
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, S. Gerardo Hospital, MBBM Foundation, Via Pergolesi 33, Monza, 20900, Monza, Monza e Brianza, Italy
| | - Sabrina Cozzolino
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, S. Gerardo Hospital, MBBM Foundation, Via Pergolesi 33, Monza, 20900, Monza, Monza e Brianza, Italy
| | - Salvatore Andrea Mastrolia
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, S. Gerardo Hospital, MBBM Foundation, Via Pergolesi 33, Monza, 20900, Monza, Monza e Brianza, Italy
| | - Patrizia Vergani
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, S. Gerardo Hospital, MBBM Foundation, Via Pergolesi 33, Monza, 20900, Monza, Monza e Brianza, Italy
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Bjørnholt SM, Leite M, Albieri V, Kjaer SK, Jensen A. Maternal smoking during pregnancy and risk of stillbirth: results from a nationwide Danish register-based cohort study. Acta Obstet Gynecol Scand 2017; 95:1305-1312. [PMID: 27580369 DOI: 10.1111/aogs.13011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 08/29/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Maternal smoking during pregnancy has been associated with an increased risk of stillbirth. Only a few studies have been conducted to determine whether smoking affects the risk of antepartum and intrapartum stillbirth differently or whether smoking cessation in early pregnancy reduces the risk. Previous results are inconclusive. We addressed these questions in a large Danish population-based cohort study. MATERIAL AND METHODS From the Danish Medical Birth Register, we identified 841 228 singleton births in Denmark between 1997 and 2010 and gathered detailed information on maternal smoking during pregnancy and the vital status of the infant. Associations (odds ratios with 95% confidence intervals) between maternal smoking and risk of stillbirth overall and separately for antepartum and intrapartum stillbirth were analyzed using logistic regression models (generalized estimating equations), adjusting for potential confounders. RESULTS Any smoking during pregnancy increased the risk of stillbirth, both overall (odds ratio 1.42, 95% confidence interval 1.30-1.55) and for antepartum (odds ratio 1.38, 95% confidence interval 1.25-1.53) and intrapartum (odds ratio 1.52, 95% confidence interval 1.18-1.96) stillbirths. Women who quit smoking at the beginning of the second trimester at the latest had no increased risk of stillbirth overall (odds ratio 1.03, 95% confidence interval 0.80-1.32). CONCLUSIONS Maternal smoking during pregnancy increases the risk of stillbirth, both overall and for antepartum and intrapartum stillbirth separately. Women who quit smoking in the beginning of their pregnancy reduce their risk compared with that of non-smokers.
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Affiliation(s)
- Sarah M Bjørnholt
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Mimmi Leite
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Vanna Albieri
- Statistics, Bioinformatics and Registry, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Susanne K Kjaer
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Allan Jensen
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark.
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Simões T, Queirós A, Marujo AT, Valdoleiros S, Silva P, Blickstein I. Prospective risk of intrauterine death of monochorionic twins: update. J Perinat Med 2016; 44:871-874. [PMID: 26630688 DOI: 10.1515/jpm-2015-0319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/26/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To calculate an updated prospective risk of fetal death in monochorionic-biamniotic (MCBA) twins. STUDY DESIGN We evaluated 520 MCBA twin pregnancies that had intensive prenatal surveillance and delivered in a single Portuguese referral center. The prospective risk of fetal death was calculated as the total number of deaths at the beginning of the gestational period divided by the number of continuing pregnancies at or beyond that period. Data were compared to the 2006 previous report. RESULTS Nearly 80% of the neonates weighed <2500 g, including 13.5% who weighed <1500 g. Half were born at <36 weeks, including 13.8% who were born at <32 weeks. The data indicate an increased IUFD rate over time - 16 fetal deaths per pregnancy (3.1%) and 22 IUFDs per fetus (2.1%). The rate of IUFD after 32-33 weeks, however, was halved (1/187 pregnancies and 1/365 fetuses, 0.5 and 0.3%, respectively). CONCLUSION Intensive prenatal surveillance might decrease the unexpected fetal death rates after 33 week's gestation and our data do not support elective preterm birth for uncomplicated MCBA twins.
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Cheong-See F, Schuit E, Arroyo-Manzano D, Khalil A, Barrett J, Joseph KS, Asztalos E, Hack K, Lewi L, Lim A, Liem S, Norman JE, Morrison J, Combs CA, Garite TJ, Maurel K, Serra V, Perales A, Rode L, Worda K, Nassar A, Aboulghar M, Rouse D, Thom E, Breathnach F, Nakayama S, Russo FM, Robinson JN, Dodd JM, Newman RB, Bhattacharya S, Tang S, Mol BWJ, Zamora J, Thilaganathan B, Thangaratinam S. Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis. BMJ 2016; 354:i4353. [PMID: 27599496 PMCID: PMC5013231 DOI: 10.1136/bmj.i4353] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine the risks of stillbirth and neonatal complications by gestational age in uncomplicated monochorionic and dichorionic twin pregnancies. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, and Cochrane databases (until December 2015). REVIEW METHODS Databases were searched without language restrictions for studies of women with uncomplicated twin pregnancies that reported rates of stillbirth and neonatal outcomes at various gestational ages. Pregnancies with unclear chorionicity, monoamnionicity, and twin to twin transfusion syndrome were excluded. Meta-analyses of observational studies and cohorts nested within randomised studies were undertaken. Prospective risk of stillbirth was computed for each study at a given week of gestation and compared with the risk of neonatal death among deliveries in the same week. Gestational age specific differences in risk were estimated for stillbirths and neonatal deaths in monochorionic and dichorionic twin pregnancies after 34 weeks' gestation. RESULTS 32 studies (29 685 dichorionic, 5486 monochorionic pregnancies) were included. In dichorionic twin pregnancies beyond 34 weeks (15 studies, 17 830 pregnancies), the prospective weekly risk of stillbirths from expectant management and the risk of neonatal death from delivery were balanced at 37 weeks' gestation (risk difference 1.2/1000, 95% confidence interval -1.3 to 3.6; I(2)=0%). Delay in delivery by a week (to 38 weeks) led to an additional 8.8 perinatal deaths per 1000 pregnancies (95% confidence interval 3.6 to 14.0/1000; I(2)=0%) compared with the previous week. In monochorionic pregnancies beyond 34 weeks (13 studies, 2149 pregnancies), there was a trend towards an increase in stillbirths compared with neonatal deaths after 36 weeks, with an additional 2.5 per 1000 perinatal deaths, which was not significant (-12.4 to 17.4/1000; I(2)=0%). The rates of neonatal morbidity showed a consistent reduction with increasing gestational age in monochorionic and dichorionic pregnancies, and admission to the neonatal intensive care unit was the commonest neonatal complication. The actual risk of stillbirth near term might be higher than reported estimates because of the policy of planned delivery in twin pregnancies. CONCLUSIONS To minimise perinatal deaths, in uncomplicated dichorionic twin pregnancies delivery should be considered at 37 weeks' gestation; in monochorionic pregnancies delivery should be considered at 36 weeks. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014007538.
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Affiliation(s)
- Fiona Cheong-See
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London E1 2AB, UK
| | - Ewoud Schuit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, Netherlands Stanford Prevention Research Center, Stanford University, Palo Alto, Stanford, CA 94305, USA
| | - David Arroyo-Manzano
- Clinical Biostatistics Unit, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Asma Khalil
- Fetal Medicine Unit, St George's Healthcare NHS Trust, London SW17 0QT, UK
| | - Jon Barrett
- Evaluative Clinical Sciences, Women and Babies Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - K S Joseph
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC V6Z 2K5, Canada
| | - Elizabeth Asztalos
- Department of Newborn and Developmental Paediatrics, Women and Babies Research Program, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Karien Hack
- Department of Gynaecology and Obstetrics, Diakonessenhuis, 3582 KE Utrecht, Netherlands
| | - Liesbeth Lewi
- Department of Obstetrics-Gynaecology, University Hospitals, 3000 Leuven, Belgium Department of Development and Regeneration: Pregnancy, Fetus and Neonate, KU Leuven, Belgium
| | - Arianne Lim
- Department of Obstetrics and Gynaecology, Academic Medical Centre, 1105 AZ Amsterdam, Netherlands
| | - Sophie Liem
- Department of Obstetrics and Gynaecology, Academic Medical Centre, 1105 AZ Amsterdam, Netherlands
| | - Jane E Norman
- University of Edinburgh MRC Centre for Reproductive Health, Queen's Medical Research Institute, Edinburgh EH16 4TY, UK
| | - John Morrison
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
| | - C Andrew Combs
- Obstetrix Collaborative Research Network, Center for Research, Education and Quality, Mednax National Medical Group, FL 33323, USA
| | - Thomas J Garite
- Obstetrix Collaborative Research Network, Center for Research, Education and Quality, Mednax National Medical Group, FL 33323, USA University of California Irvine, Irvine, CA 92697, USA
| | - Kimberly Maurel
- Obstetrix Collaborative Research Network, Center for Research, Education and Quality, Mednax National Medical Group, FL 33323, USA
| | - Vicente Serra
- Maternal-Fetal Medicine Unit, Instituto Valenciano de Infertilidad, University of Valencia, Spain Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Valencia, Jefe Servicio Obstetricia Hospital U P La FE, Torre F, Valencia, Espana
| | - Alfredo Perales
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Valencia, Jefe Servicio Obstetricia Hospital U P La FE, Torre F, Valencia, Espana Department of Obstetrics, University Hospital La Fe, Valencia, 46026 València, Spain
| | - Line Rode
- Centre of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Katharina Worda
- Department of Obstetrics and Gynaecology, Medical University of Vienna, 1090 Wien, Austria
| | - Anwar Nassar
- Department of Obstetrics and Gynaecology, American University of Beirut Medical Centre, Riad El Solh, Beirut 1107 2020, Lebanon
| | - Mona Aboulghar
- The Egyptian IVF Centre, Maadi and Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Oula, Giza, Egypt
| | - Dwight Rouse
- Department of Obstetrics and Gynecology, Women and Infants Hospital, Brown University Women and Infants Hospital, Providence, RI 02905, USA
| | - Elizabeth Thom
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Republic of Ireland
| | - Fionnuala Breathnach
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Republic of Ireland
| | - Soichiro Nakayama
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka 594-1101, Japan
| | - Francesca Maria Russo
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, 20126 Milan, Italy
| | - Julian N Robinson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jodie M Dodd
- Robinson Research Institute, and Discipline of Obstetrics and Gynaecology, University of Adelaide, North Adelaide SA 5006, Australia
| | - Roger B Newman
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC 29403, USA
| | - Sohinee Bhattacharya
- University of Aberdeen, Dugald Baird Centre for Research on Women's Health, Aberdeen Maternity Hospital, Aberdeen AB25 2ZL, UK
| | - Selphee Tang
- Department of Obstetrics and Gynecology, Alberta Health Services, Calgary, AB T2N 2T9, Canada
| | - Ben Willem J Mol
- Australian Research Centre for Health of Women and Babies, Robinson Institute, University of Adelaide, North Adelaide, SA 5006, Australia
| | - Javier Zamora
- Clinical Biostatistics Unit, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | | | - Shakila Thangaratinam
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London E1 2AB, UK
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Crawford S, Boulet SL, Mneimneh AS, Perkins KM, Jamieson DJ, Zhang Y, Kissin DM. Costs of achieving live birth from assisted reproductive technology: a comparison of sequential single and double embryo transfer approaches. Fertil Steril 2015; 105:444-50. [PMID: 26604068 DOI: 10.1016/j.fertnstert.2015.10.032] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 09/30/2015] [Accepted: 10/20/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess treatment and pregnancy/infant-associated medical costs and birth outcomes for assisted reproductive technology (ART) cycles in a subset of patients using elective double embryo (ET) and to project the difference in costs and outcomes had the cycles instead been sequential single ETs (fresh followed by frozen if the fresh ET did not result in live birth). DESIGN Retrospective cohort study using 2012 and 2013 data from the National ART Surveillance System. SETTING Infertility treatment centers. PATIENT(S) Fresh, autologous double ETs performed in 2012 among ART patients younger than 35 years of age with no prior ART use who cryopreserved at least one embryo. INTERVENTION(S) Sequential single and double ETs. MAIN OUTCOME MEASURE(S) Actual live birth rates and estimated ART treatment and pregnancy/infant-associated medical costs for double ET cycles started in 2012 and projected ART treatment and pregnancy/infant-associated medical costs if the double ET cycles had been performed as sequential single ETs. RESULT(S) The estimated total ART treatment and pregnancy/infant-associated medical costs were $580.9 million for 10,001 double ETs started in 2012. If performed as sequential single ETs, estimated costs would have decreased by $195.0 million to $386.0 million, and live birth rates would have increased from 57.7%-68.0%. CONCLUSION(S) Sequential single ETs, when clinically appropriate, can reduce total ART treatment and pregnancy/infant-associated medical costs by reducing multiple births without lowering live birth rates.
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Affiliation(s)
- Sara Crawford
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Sheree L Boulet
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Allison S Mneimneh
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kiran M Perkins
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Denise J Jamieson
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yujia Zhang
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dmitry M Kissin
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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