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Naeh A, Maor-Sagie E, Hallak M, Toledano Y, Gabbay-Benziv R. Greater risk of type 2 diabetes progression in multifetal gestations with gestational diabetes: the impact of obesity. Am J Obstet Gynecol 2024; 231:259.e1-259.e10. [PMID: 38360449 DOI: 10.1016/j.ajog.2023.11.1246] [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: 08/31/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND The relationship between gestational diabetes mellitus and adverse outcomes in multifetal pregnancies is complex and controversial. Moreover, limited research has focused on the risk of gestational diabetes mellitus progression to type 2 diabetes mellitus specifically in multifetal pregnancies, resulting in conflicting results from existing studies. OBJECTIVE This study aimed to assess the risk of gestational diabetes mellitus progression to type 2 diabetes mellitus between singleton and multifetal pregnancies in a large cohort of parturients with a 5-year follow-up. STUDY DESIGN A retrospective study was conducted on a prospective cohort of pregnant individuals with pregnancies between January 1, 2017, and December 31, 2020, followed up to 5 years after delivery. Glucose levels during pregnancy were obtained from the Meuhedet Health Maintenance Organization laboratory system and cross-linked with the Israeli National Diabetes Registry. The cohort was divided into 4 groups: singleton pregnancy without gestational diabetes mellitus, singleton pregnancy with gestational diabetes mellitus, multifetal pregnancy without gestational diabetes mellitus, and multifetal pregnancy with gestational diabetes mellitus. Gestational diabetes mellitus was defined according to the American Diabetes Association criteria using the 2-step strategy. Univariate analyses, followed by survival analysis that included Kaplan-Meier hazard curves and Cox proportional-hazards models, were used to assess differences between groups and calculate the adjusted hazard ratios with 95% confidence intervals for progression to type 2 diabetes mellitus. RESULTS Among 88,611 parturients, 61,891 cases met the inclusion criteria. The prevalence of type 2 diabetes mellitus was 6.5% in the singleton pregnancy with gestational diabetes mellitus group and 9.4% in the multifetal pregnancy with gestational diabetes mellitus group. Parturients with gestational diabetes mellitus, regardless of plurality, were older and had higher fasting plasma glucose levels in the first trimester of pregnancy. The rates of increased body mass index, hypertension, and earlier gestational age at delivery were significantly higher in the gestational diabetes mellitus group among patients with singleton pregnancies but not among patients with multifetal pregnancies. Survival analysis demonstrated that gestational diabetes mellitus was associated with adjusted hazard ratios of type 2 diabetes mellitus of 4.62 (95% confidence interval, 3.69-5.78) in singleton pregnancies and 9.26 (95% confidence interval, 2.67-32.01) in multifetal pregnancies (P<.001 for both). Stratified analysis based on obesity status revealed that, in parturients without obesity, gestational diabetes mellitus in singleton pregnancies increased the risk of type 2 diabetes mellitus by 10.24 (95% confidence interval, 6.79-15.44; P<.001) compared with a nonsignificant risk in multifetal pregnancies (adjusted hazard ratio, 9.15; 95% confidence interval, 0.92-90.22; P=.059). Among parturients with obesity, gestational diabetes mellitus was associated with an increased risk of type 2 diabetes mellitus for both singleton and multifetal pregnancies (adjusted hazard ratio, 3.66; [95% confidence interval, 2.81-4.67; P<.001] and 9.31 [95% confidence interval, 2.12-40.76; P=.003], respectively). CONCLUSION Compared with gestational diabetes mellitus in singleton pregnancies, gestational diabetes mellitus in multifetal pregnancies doubles the risk of progression to type 2 diabetes mellitus. This effect is primarily observed in patients with obesity. Our findings underscore the importance of providing special attention and postpartum follow-up for patients with multifetal pregnancies and gestational diabetes mellitus, especially those with obesity, to enable early diagnosis and intervention for type 2 diabetes mellitus.
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Affiliation(s)
- Amir Naeh
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
| | - Esther Maor-Sagie
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Meuhedet Health Maintenance Organization, Haifa, Israel
| | - Mordechai Hallak
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Meuhedet Health Maintenance Organization, Haifa, Israel
| | - Yoel Toledano
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Meuhedet Health Maintenance Organization, Haifa, Israel
| | - Rinat Gabbay-Benziv
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
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Aldhaheri S, Stratulat V, Melamed N. Outcomes of dichorionic twin pregnancies with fused versus separate placentas. Arch Gynecol Obstet 2024; 310:213-219. [PMID: 38727816 DOI: 10.1007/s00404-024-07548-5] [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: 04/16/2024] [Accepted: 05/02/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE In a certain proportion of dichorionic twin pregnancies, the two placentas are fused. The clinical significance of this finding remains unclear. Our objective was to compare outcomes of dichorionic twin pregnancies with fused versus separate placentas as determined on first-trimester ultrasound. METHODS Retrospective study of patients with dichorionic twins followed at a tertiary center between 2014 and 2022. The co-primary outcomes were fetal growth restriction and preeclampsia. Associations between fused placentas and the study outcomes were estimated using multivariable Poisson regression and were reported as adjusted relative risk (aRR) with a 95%-confidence interval (CI). RESULTS Of the 328 eligible patients, 175 (53.4%) and 153 (46.6%) had fused and separate placentas, respectively. Compared with pregnancies with separate placentas, patients with fused placentas had a lower risk of preeclampsia [aRR 0.48 (95%-CI 0.24-0.97)] but a higher risk of fetal growth restriction [aRR 1.23 (95%-CI 1.02-1.48)] and admission to the neonatal intensive care unit [aRR 1.31 (95%-CI 1.01-1.71)]. In addition, pregnancies with fused placentas were more likely to have a total placental weight below the 10th percentile than those with separate placentas [aRR 1.93 (95%-CI 1.16-3.21)]. DISCUSSION Dichorionic twin pregnancies with fused placentas have a lower risk of preeclampsia but are more likely to be complicated by fetal growth restriction, observations that may be attributed to the lower total placentas mass in pregnancies with fused compared with separate placentas. Fused placentas can be used as a potential biomarker for the prediction of pregnancy complications in dichorionic twin pregnancies.
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Affiliation(s)
- Sarah Aldhaheri
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Vasilica Stratulat
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
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Berezowsky A, Ardestani S, Hiersch L, Shah BR, Berger H, Halperin I, Retnakaran R, Barrett J, Melamed N. Glycemic control and neonatal outcomes in twin pregnancies with gestational diabetes mellitus. Am J Obstet Gynecol 2023; 229:682.e1-682.e13. [PMID: 37393013 DOI: 10.1016/j.ajog.2023.06.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Preliminary data suggest that strict glycemic control in twin pregnancies with gestational diabetes mellitus may not improve outcomes but might increase the risk of fetal growth restriction. OBJECTIVE This study aimed to investigate the association of maternal glycemic control with the risk of gestational diabetes mellitus-related complications and small for gestational age in twin pregnancies complicated by gestational diabetes mellitus. STUDY DESIGN This was a retrospective cohort study of all patients with a twin pregnancy complicated by gestational diabetes mellitus in a single tertiary center between 2011 and 2020, and a matched control group of patients with a twin pregnancy without gestational diabetes mellitus in a 1:3 ratio. The exposure was the level of glycemic control, described as the proportion of fasting, postprandial, and overall glucose values within target. Good glycemic control was defined as a proportion of values within target above the 50th percentile. The first coprimary outcome was a composite variable of neonatal morbidity, defined as at least 1 of the following: birthweight >90th centile for gestational age, hypoglycemia requiring treatment, jaundice requiring phototherapy, birth trauma, or admission to the neonatal intensive care unit at term. A second coprimary outcome was small for gestational age, defined as birthweight <10th centile or <3rd centile for gestational age. Associations between the level of glycemic control and the study outcomes were estimated using logistic regression analysis and were expressed as adjusted odds ratio with 95% confidence interval. RESULTS A total of 105 patients with gestational diabetes mellitus in a twin pregnancy met the study criteria. The overall rate of the primary outcome was 32.4% (34/105), and the overall proportion of pregnancies with a small for gestational age newborn at birth was 43.8% (46/105). Good glycemic control was not associated with a reduction in the risk of composite neonatal morbidity when compared with suboptimal glycemic control (32.1% vs 32.7%; adjusted odds ratio, 2.06 [95% confidence interval, 0.77-5.49]). However, good glycemic control was associated with higher odds of small for gestational age compared with nongestational diabetes mellitus pregnancies, especially in the subgroup of diet-treated gestational diabetes mellitus (65.5% vs 34.0%, respectively; adjusted odds ratio, 4.17 [95% confidence interval, 1.74-10.01] for small for gestational age <10th centile; and 24.1% vs 7.0%, respectively; adjusted odds ratio, 3.97 [95% confidence interval, 1.42-11.10] for small for gestational age <3rd centile). In contrast, the rate of small for gestational age in gestational diabetes mellitus pregnancies with suboptimal control was not considerably different when compared with non-gestational diabetes mellitus pregnancies. In addition, in cases of diet-treated gestational diabetes mellitus, good glycemic control was associated with a left-shift of the distribution of birthweight centiles, whereas the distribution of birthweight centiles among gestational diabetes mellitus pregnancies with suboptimal control was similar to that of nongestational diabetes mellitus pregnancies. CONCLUSION In patients with gestational diabetes mellitus in a twin pregnancy, good glycemic control is not associated with a reduction in the risk of gestational diabetes mellitus-related complications but may increase the risk of a small for gestational age newborn in the subgroup of patients with mild (diet-treated) gestational diabetes mellitus. These findings further question whether the gestational diabetes mellitus glycemic targets used in singleton pregnancies also apply to twin pregnancies and support the concern that applying the same diagnostic criteria and glycemic targets in twin pregnancies may result in overdiagnosis and overtreatment of gestational diabetes mellitus and potential neonatal harm.
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Affiliation(s)
- Alexandra Berezowsky
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Shakiba Ardestani
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Liran Hiersch
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Baiju R Shah
- Division of Endocrinology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Howard Berger
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Ilana Halperin
- Department of Endocrinology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Ravi Retnakaran
- Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada; Division of Endocrinology, University of Toronto, Toronto, Canada
| | - Jon Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
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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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Lin N, Shen P, Hu H, Song W, Hu Y, Dai Y, Zhou YH. Maternal and Neonatal Outcomes of Twin Pregnant Women With Anemia. Twin Res Hum Genet 2023:1-6. [PMID: 37650223 DOI: 10.1017/thg.2023.33] [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: 09/01/2023]
Abstract
The aim of this study was to investigate the prevalence of anemia in twin pregnancies and the influence of anemia on maternal and neonatal outcomes. This retrospective study included twin pregnant women who delivered in a tertiary hospital in China from January 2018 to December 2018. Patients were divided by WHO criteria (hemoglobin <11.0 g/dL): the anemic and nonanemic groups. Patients with anemia were further classified as recovered or unrecovered subgroup after oral iron therapy. Maternal and neonatal outcomes in women carrying twins were compared using Student's t test and the chi-squared test or the Fisher exact test. Univariable and multivariable logistic regression models were used to determine the association of maternal and neonatal characteristics with anemia. Linear regression analysis was used to estimate mean birth weight and gestational week. The prevalence of anemia was 42.6% (182/427) in twin pregnancies. The anemic group had higher rates of low 1-minute Apgar score (4.4% vs. 1.8%, p = .028), perinatal death (1.9% vs. 0.2%, p = .012) and neonatal intensive care unit (NICU) admission (27.2% vs. 20.2%, p = .017; adjusted OR, 1.478; 95% CI [1.07, 2.044]). The recovered subgroup had lower NICU admission rate (13.5% vs. 30.3%, p = .006; OR, 0.388; 95% CI [0.186, 0.809]), higher gestational week and birth weight (β, 0.954 week; 95% CI [0.114, 1.794] and β, 171.01 g; 95% CI [9.894, 332.126] respectively). The prevalence of anemia in twin gestation is high. Anemia is associated with adverse neonatal outcomes, and correction of anemia significantly improved the pregnancy outcomes.
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Affiliation(s)
- Nacheng Lin
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Ping Shen
- Department of Laboratory Medicine, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Huilian Hu
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Wenying Song
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yali Hu
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yimin Dai
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yi-Hua Zhou
- Department of Laboratory Medicine, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
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Šantić K, Biljan B, Kos M, Serdarušić I, Rajc J, Kardum D. Placental Findings in Infants Gestational Age < 34 Weeks and Impact on Short-Term Outcomes. JOURNAL OF MOTHER AND CHILD 2023; 27:168-175. [PMID: 37920111 PMCID: PMC10623114 DOI: 10.34763/jmotherandchild.20222601.d-23-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 09/29/2023] [Indexed: 11/04/2023]
Abstract
AIM To analyse placental changes in infants' gestational age < 34 weeks and its correlation to short-term respiratory outcomes or death until hospital discharge. MATERIAL AND METHODS Information regarding all in-house born preterm infants born before 34 weeks gestation and born from January 2009 until December 2014 were collected and included among others, placental pathology and relevant data on demographics and outcomes of infants. RESULTS Placental abnormalities was found in 157/253 (65.05%) cases. Acute placental inflammation was found to be the most common in both groups of premature neonates, followed by maternal vascular underperfusion. Maternal vascular underperfusion was significantly more common in GA ≤ 27 weeks compared to infants GA 28-33 weeks (35.2% vs. 13.7%; p = 0.018). Similarly, chronic placental inflammation was more common in infants GA ≤ 27 weeks compared to infants GA 28-33 weeks (14.3% vs. 3.3%; p = 0.014). Infants with placental pathology had a lower median birth weight (1460g vs. 1754g; p = 0.001, and were of shorter median GA at birth (31 vs. 32; p = 0.001). Infants with any placental disease had higher rates of death until hospital discharge (10.2% vs. 3.1%; p = 0.039) and higher rates of any stage of bronchopulmonary dysplasia (41.4% vs. 26.0%; p = 0.013). There were no significant differences in mechanical ventilation rates, duration of mechanical ventilation and duration of supplemental oxygen therapy. CONCLUSION Identifiable placental abnormalities were found in most infants born < 34 weeks gestation. Placental pathology is associated with increased rates of bronchopulmonary dysplasia and death until hospital discharge.
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Affiliation(s)
- Krešimir Šantić
- Department of Pediatrics, University Hospital Centre Osijek, J. Huttlera 4, 31000Osijek, Croatia
- Faculty of Medicine, University J. J. Strossmayer Osijek, J. Huttlera 4, 31000Osijek, Croatia
| | - Borna Biljan
- Department of Pediatrics, University Hospital Centre Osijek, J. Huttlera 4, 31000Osijek, Croatia
- Faculty of Medicine, University J. J. Strossmayer Osijek, J. Huttlera 4, 31000Osijek, Croatia
| | - Martina Kos
- Department of Pediatrics, University Hospital Centre Osijek, J. Huttlera 4, 31000Osijek, Croatia
- Faculty of Medicine, University J. J. Strossmayer Osijek, J. Huttlera 4, 31000Osijek, Croatia
| | - Ivana Serdarušić
- Department of Pediatrics, University Hospital Centre Osijek, J. Huttlera 4, 31000Osijek, Croatia
- Faculty of Medicine, University J. J. Strossmayer Osijek, J. Huttlera 4, 31000Osijek, Croatia
| | - Jasmina Rajc
- Faculty of Medicine, University J. J. Strossmayer Osijek, J. Huttlera 4, 31000Osijek, Croatia
- Clinical Institute for Pathology and Forensic Medicine, University Hospital Centre Osijek, J. Huttlera 4, 31000Osijek, Croatia
| | - Darjan Kardum
- Faculty of Medicine, University J. J. Strossmayer Osijek, J. Huttlera 4, 31000Osijek, Croatia
- Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital Centre Osijek, J. Huttlera 4, 31000Osijek, Croatia
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O'Connor C, O'Connor E, Leitao S, Barrett S, O'Donoghue K. Clinical practice guidelines for the antenatal management of dichorionic diamniotic twin pregnancies: a systematic review. BMC Pregnancy Childbirth 2023; 23:347. [PMID: 37179347 PMCID: PMC10182673 DOI: 10.1186/s12884-023-05652-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
OBJECTIVE This review aimed to identify guidelines with recommendations applicable to the antenatal management of dichorionic diamniotic twin pregnancies within high-income countries, appraise their methodological quality, and discuss the similarities and variability across guidelines. METHOD A systematic literature review of electronic databases was performed. Manual searches of guideline repositories and websites of professional organisations were performed to identify additional guidelines. The protocol for this systematic review was registered on PROSPERO (CRD42021248586, 25 June 2021). AGREE II and AGREE-REX tools were applied to assess the quality of eligible guidelines. A narrative and thematic synthesis described and compared the guidelines and their recommendations. RESULTS Twenty-four guidelines were included, from which 483 recommendations were identified across 4 international organisations and 12 countries. Guidelines addressed eight themes and recommendations were classified accordingly: chorionicity and dating (103 recommendations), fetal growth (105 recommendations), termination of pregnancy (12 recommendations), fetal death (13 recommendations), fetal anomalies (65 recommendations), antenatal care (65 recommendations), preterm labour (56 recommendations) and birth (54 recommendations). Guidelines showed significant variability in recommendations, with conflicting recommendations regarding non-invasive preterm testing, definitions surrounding selective fetal growth restriction, screening for preterm labour and the timing of birth. Guidelines lacked a focus on standard antenatal management of DCDA twins, management of discordant fetal anomaly and single fetal demise. CONCLUSIONS Specific guidance for dichorionic diamniotic twins is overall indistinct and access to guidance regarding the antenatal management of these pregnancies is currently difficult. Management of discordant fetal anomaly or single fetal demise needs greater consideration.
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Affiliation(s)
- Caroline O'Connor
- INFANT Research Centre, University College Cork, Cork, Ireland.
- Pregnancy Loss Research Group, Department of Obstetrics & Gynecology, University College Cork, Cork, Ireland.
- Department of Obstetrics and Gynecology, Cork University Maternity Hospital, 5th Floor, Wilton Road, Cork, Ireland.
| | - Emily O'Connor
- INFANT Research Centre, University College Cork, Cork, Ireland
- Pregnancy Loss Research Group, Department of Obstetrics & Gynecology, University College Cork, Cork, Ireland
- National Perinatal Epidemiology Center (NPEC), University College Cork, Cork, Ireland
| | - Sara Leitao
- Pregnancy Loss Research Group, Department of Obstetrics & Gynecology, University College Cork, Cork, Ireland
- National Perinatal Epidemiology Center (NPEC), University College Cork, Cork, Ireland
| | - Shauna Barrett
- Cork University Hospital Library, Cork University Hospital, Cork, Ireland
| | - Keelin O'Donoghue
- INFANT Research Centre, University College Cork, Cork, Ireland
- Pregnancy Loss Research Group, Department of Obstetrics & Gynecology, University College Cork, Cork, Ireland
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Blumenfeld YJ, Anderson JN. Fetal growth disorders in twin gestations. Curr Opin Obstet Gynecol 2023; 35:106-112. [PMID: 36912334 DOI: 10.1097/gco.0000000000000856] [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: 03/14/2023]
Abstract
PURPOSE OF REVIEW Twin gestations account for approximately 3% of all births. Although there appear to be physiologic differences in the third trimester growth of twins compared with singleton gestations, reasons for this remain unclear. As growth-restricted fetuses and neonates are at increased risk for adverse outcomes, there is a clinical need to optimize our ability to delineate normally from pathologically grown twins. RECENT FINDINGS Recent studies have addressed current limitations in the way growth restriction is diagnosed in twin gestations. Twin-specific fetal and neonatal growth charts have been shown to decrease the number of cases inappropriately labeled as growth restricted compared with singleton nomograms. In addition, individual growth assessment (IGA) is a promising method of diagnosing pathological growth using each fetus's growth potential rather than a comparison of the estimated fetal weight with population nomograms. SUMMARY There is a recent focus on improving our understanding of physiologic and pathologic twin growth. The increased use of twin-specific growth curves is likely to result in a decrease in the incidence of FGR diagnosis among twin gestations and could improve the outcomes of twins currently misclassified as FGR. Future research will hopefully clarify the reasons behind differences seen in twin versus singleton third trimester twin growth.
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Affiliation(s)
- Yair J Blumenfeld
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California
| | - Jill N Anderson
- Department of Obstetrics & Gynecology, New York Presbyterian-Weill Cornell Medical Center, New York, New York, USA
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Liu Y, Li D, Wang Y, Qi H, Wen L. Impact of Gestational Diabetes and Hypertension Disorders of Pregnancy on Neonatal Outcomes in Twin Pregnancies Based on Chorionicity. J Clin Med 2023; 12:jcm12031096. [PMID: 36769744 PMCID: PMC9917532 DOI: 10.3390/jcm12031096] [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: 12/12/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES The objective of this study was to investigate the impact of the co-existence of gestational diabetes (GDM) and hypertension disorders of pregnancy (HDP) on neonatal outcomes in twin pregnancies based on chorionicity. METHODS A retrospective study of 1398 women with twin pregnancies was performed between January 2016 and December 2021. The effects of GDM and HDP on neonatal outcomes were assessed by logistic regression models. An additional stratified analysis was conducted to estimate the effects based on chorionicity (monochorionic (MC) and dichorionic (DC)). RESULTS The incidence of the co-existence of GDM and HDP was 3.8%. The presence of GDM increased the likelihood of HDP only in women with MC twin pregnancies (OR, 2.13; 95% CI 1.08-4.19). After adjustments, co-existence of GDM and HDP was positively associated with gestational age (β, 1.06; 95% CI 0.43-1.69) and birthweight (β, 174.90; 95% CI 8.91-340.89) in MC twin pregnancies, while no associations were found between co-existence of GDM and HDP and neonatal outcomes in DC twin pregnancies. However, HDP was negatively associated with birthweight (β, -156.97; 95% CI (-257.92, -56.02)) and positively associated with small-for-gestational-age (SGA) (OR, 2.03; 95% CI 1.02-4.03) and discordant twins (OR, 2.83; 95% CI 1.78-4.48) in DC twin pregnant women without GDM. CONCLUSIONS Our results suggested that GDM leads to an increased risk of HDP only in MC twin pregnancies, but GDM seemed to attenuate the adverse effects of HDP on perinatal outcomes in both MC and DC twin pregnancies. Further investigation is needed to explain these intriguing findings.
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Affiliation(s)
- Yi Liu
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Women and Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Dayan Li
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Women and Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yang Wang
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Women and Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Hongbo Qi
- Women and Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Correspondence: (H.Q.); (L.W.); Tel.: +86-23-89011101 (H.Q.); +86-23-89011798 (L.W.)
| | - Li Wen
- Women and Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Correspondence: (H.Q.); (L.W.); Tel.: +86-23-89011101 (H.Q.); +86-23-89011798 (L.W.)
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Zhang B, Mi B, Liu D, Liu H, Wang Y, Shi G, Jing H, Kang Y, Yang J, Dang S, Yan H. Association of maternity formula supplementation during pregnancy with small for gestational age birth in Chinese newborns. Nutrition 2023; 105:111856. [PMID: 36334530 DOI: 10.1016/j.nut.2022.111856] [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: 10/17/2021] [Revised: 09/16/2022] [Accepted: 09/21/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES This study aimed to explore the association between maternity formula supplementation and small for gestational age (SGA) status in Chinese newborns. METHODS Data were from a population-based cross-sectional survey conducted in Shaanxi, Northwest China between August and December 2013. A total of 27 780 women pregnant with singletons and 356 with twins were included in this survey. Information on use of maternity formulas fortified with vitamins, folic acid, pantothenic acid, calcium, iron, zinc, and docosahexaenoic acid (DHA) was collected. SGA was defined as birthweight <10th percentile of fetal growth. Generalized linear models and estimating equation models were used to estimate crude odds ratios (ORs) or adjusted ORs with 95% confidence intervals (CIs) for SGA. RESULTS The rate of maternity formula supplementation during the entire pregnancy was 13.0% in the overall population. There was no significant association between maternal formula supplementation during pregnancy and the risk of total SGA birth (OR: 1.00; 95% CI, 0.90-1.11; P = 0.950). However, maternity formula supplementation during pregnancy was related to a lower risk of SGA for twins (OR: 0.49; 95% CI, 0.31-0.80; P = 0.004), twin A (OR: 0.50; 95% CI, 0.25-0.98; P = 0.045), and twin B (OR: 0.48; 95% CI, 0.25-0.95; P = 0.034). Furthermore, maternity formula supplementation during the first trimester was inversely associated with the risk of SGA birth of twins (OR: 0.32; 95% CI, 0.15-0.65; P = 0.002). CONCLUSIONS No significant association was observed between maternity formula supplementation and total SGA birth. However, women supplemented with maternal formula during pregnancy, especially during the first trimester, may have a reduced risk of SGA birth of twins.
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Affiliation(s)
- Binyan Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Baibing Mi
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Danmeng Liu
- Translational Medicine Center, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Huimeng Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Yutong Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Guoshuai Shi
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Hui Jing
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Yijun Kang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Jiaomei Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Shaonong Dang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China.
| | - Hong Yan
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China.
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Wang M, Wang X, Chen Z, Zhang F. Gestational hypertensive disease and small for gestational age infants in twin pregnancy: A systematic review and meta-analysis. J Obstet Gynaecol Res 2022; 48:2677-2685. [PMID: 35975304 DOI: 10.1111/jog.15401] [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: 03/31/2022] [Revised: 07/12/2022] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
AIM The review is to explore the connection between gestational hypertension diseases (GHD) and small for gestational age (SGA) in twin pregnancies. METHODS According to the recommendations of PRISMA, relevant studies were systematically searched through PubMed, Web of Science, Cochrane Library, Embase from inception until January 16, 2022. Subgroup analysis was performed according to chorionicity and diagnostic criteria of SGA. Odds ratios (OR) were assessed to judge the link between GHD and SGA in twin pregnant women. A random-effect model was used to estimate the pooled hazard ratio when there was significant heterogeneity (I2 > 50%); otherwise, a fixed-effect model was conducted. RESULTS Seven articles containing 470 589 twin pregnant women were included. The increased risk of SGA was connected to the twin pregnancies complicated with GHD (OR = 1.57, 95% confidence interval [CI] = 1.10-2.24, p = 0.01). After subgroup analysis, the connection between SGA and GHD had no statistical significance (OR = 1.17, 95% CI = 0.95-1.44, p = 0.14) when the enrolled studies using the SGA diagnosis referred to singleton birth weight, but significant (OR = 2.14, 95% CI = 1.77-2.60, p<0.001) in the group using the SGA diagnosis referred to twin birth weight. Stratified by chorionicity, SGA was relevant to GHD in the dichorionic (DC) group (OR = 1.68, 95% CI = 1.17-2.42, p = 0.005), while not in the monochorionic (MC) group (OR = 1.68, 95% CI = 0.93-3.03, p = 0.09). More future articles are warranted to confirm these outcomes. CONCLUSIONS Our review demonstrated that GHD in DC twin pregnancies was related to an enlarged risk of SGA. Two SGA diagnosis references led to different results. Twin pregnancies complicated with GHD were at significantly higher risk of SGA when twin birth weight reference was used.
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Affiliation(s)
- Mingbo Wang
- Medical School of Nantong University, Nantong, China
| | - Xin Wang
- Medical School of Nantong University, Nantong, China
| | - Zhifang Chen
- Nantong Maternity and Child Health Care Hospital Affiliated to Nantong University, Nantong, China
| | - Feng Zhang
- Medical School of Nantong University, Nantong, China
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Mei-Dan E, Jain V, Melamed N, Lim KI, Aviram A, Ryan G, Barrett J. Directive clinique no 428 : Prise en charge de la grossesse gémellaire bichoriale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:835-851.e1. [DOI: 10.1016/j.jogc.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Mei-Dan E, Jain V, Melamed N, Lim KI, Aviram A, Ryan G, Barrett J. Guideline No. 428: Management of Dichorionic Twin Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:819-834.e1. [PMID: 35798461 DOI: 10.1016/j.jogc.2022.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To review evidence-based recommendations for the management of dichorionic twin pregnancies. TARGET POPULATION Pregnant women with a dichorionic twin pregnancy. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in this guideline may improve the management of twin pregnancies and reduce neonatal and maternal morbidity and mortality. EVIDENCE Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (e.g., twin, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date limits, but results were limited to English- or French-language materials. VALIDATION METHODS The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE Obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, radiologists, and other health care providers who care for women with twin pregnancies. SUMMARY STATEMENTS RECOMMENDATIONS.
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Cao X, Luo Y, Zhou S, Zhao Q, Qin X, Liu Z, Xu Z. Twin Growth Discordance and Risk of Postpartum Hemorrhage: A Retrospective Cohort Study. Front Med (Lausanne) 2022; 9:876411. [PMID: 35692549 PMCID: PMC9174790 DOI: 10.3389/fmed.2022.876411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/25/2022] [Indexed: 11/30/2022] Open
Abstract
Background In recent years, the incidence of postpartum hemorrhage has increased globally. Multiple pregnancies and cesarean sections are well-known risk factors for postpartum hemorrhage. No studies have evaluated the associations between fetal growth anomalies and postpartum hemorrhage in women with twin pregnancies undergoing cesarean section. This study aimed to identify the relationship between fetal growth anomalies and postpartum hemorrhage in women with twin pregnancies undergoing cesarean section. Methods This retrospective single-center study included 3,180 women with twin pregnancies at a tertiary hospital between August 2013 and July 2020. Singleton reference charts were used to assess fetal growth restriction at birth. Discordant growth was defined as an intertwin birth weight difference of ≥20%. Logistic regression analyses were used to evaluate the association between fetal growth anomalies and postpartum hemorrhage. Additionally, sensitivity analysis of abnormal placenta and stratification by twin chorionicity were conducted. Results The overall incidence of postpartum hemorrhage was 4.3%. Twin growth discordance, especially with fetal growth restriction, was associated with an increased risk of postpartum hemorrhage (adjusted odds ratio [AOR] = 1.62, 95% confidence interval [CI], 1.05-2.51, P = 0.031; AOR = 1.71; 95% CI, 1.08-2.70, P = 0.022; AOR = 1.98, 95% CI, 1.21-3.25, P = 0.006, respectively). After stratification, this relationship persisted in dichorionic twins (OR = 1.71, 95% CI, 1.04-2.82, P = 0.036; OR = 1.90, 95% CI, 1.13-3.21, P = 0.016; OR = 2.48, 95% CI, 1.41-4.38, P = 0.002, respectively). However, no significant association was observed in monochorionic twin pregnancies. Conclusion Growth discordance, especially complicated by fetal growth restriction, was associated with an increased risk of postpartum hemorrhage in women with twin pregnancies undergoing cesarean section, and was more evident in patients with dichorionic twins.
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Affiliation(s)
- Xiuhong Cao
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ye Luo
- Department of Research and Education, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shuangqiong Zhou
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qingsong Zhao
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xuewei Qin
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhiqiang Liu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhendong Xu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
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Giorgione V, Melchiorre K, O'Driscoll J, Khalil A, Sharma R, Thilaganathan B. Maternal echocardiographic changes in twin pregnancies with and without pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:619-626. [PMID: 35000243 DOI: 10.1002/uog.24852] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/23/2021] [Accepted: 12/22/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Twin pregnancies are at increased risk of developing hypertensive disorders of pregnancy (HDP) compared with singleton pregnancies, resulting in a substantially higher rate of maternal and perinatal complications. The strain caused by twin pregnancy on the maternal cardiovascular system has not been studied extensively. The objective of this study was to evaluate the changes in maternal cardiac morphology and diastolic function in a cohort of women with normotensive and those with hypertensive twin pregnancies. METHODS This was a cross-sectional study conducted at a tertiary referral university center. Women with singleton or twin pregnancy were enrolled prospectively to undergo maternal transthoracic echocardiography throughout pregnancy. Multiples of the median (MoM) were calculated for each index using a reference group of uncomplicated singleton pregnancies (n = 411) in order to adjust for changes associated with gestational age. Cardiac findings were indexed for body surface area and compared among normotensive twin pregnancies, singleton pregnancies complicated by HDP and twin pregnancies complicated by HDP. RESULTS The total cohort included 119 HDP singleton pregnancies, 52 normotensive twin pregnancies and 24 HDP twin pregnancies. Left ventricular mass index (LVMi) MoM (median (interquartile range)) did not differ between singleton pregnancies complicated by HDP and normotensive twin pregnancies, but was significantly higher in HDP twin compared with HDP singleton pregnancies (1.31 (1.08-1.53) vs 1.17 (0.98-1.35), P = 0.032). Two diastolic indices, left atrial volume index MoM (1.12 (0.66-1.38) vs 0.65 (0.55-0.84), P = 0.003) and E/e' MoM (1.29 (1.09-1.54) vs 0.99 (0.99-1.02), P = 0.036), were significantly higher in HDP twin compared with normotensive twin pregnancies. In normotensive twin compared with HDP singleton pregnancies, stroke volume index (SVi) MoM was higher (1.20 (1.03-1.36) vs 1.00 (0.81-1.15), P = 0.004) and total vascular resistance index (TVRi) was lower (0.73 (0.70-0.86) vs 1.29 (1.04-1.56), P < 0.0001). In contrast, SVi MoM was lower (1.10 (1.02-1.35) vs 1.20 (1.03-1.36), P = 0.018) and TVRi was higher (1.00 (0.88-1.31) vs 0.73 (0.70-0.86), P = 0.029) in HDP twin compared with normotensive twin pregnancies. CONCLUSION The maternal cardiovascular system is altered severely in twin pregnancy with or without HDP. Despite the low total vascular resistance, cardiac changes in normotensive twin pregnancies are comparable to those seen in singleton pregnancies complicated by HDP, reflecting the high cardiovascular demand imposed by twin pregnancy. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Giorgione
- 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
| | - K Melchiorre
- Department of Obstetrics and Gynaecology, Spirito Santo Tertiary Level Hospital of Pescara, Pescara, Italy
| | - J O'Driscoll
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
- School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, 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
| | - R Sharma
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - B Thilaganathan
- 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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16
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Ashwal E, Ferreira F, Mei-Dan E, Aviram A, Sherman C, Zaltz A, Kingdom J, Melamed N. The accuracy of Fetoplacental Doppler in distinguishing between growth restricted and constitutionally small fetuses. Placenta 2022; 120:40-48. [DOI: 10.1016/j.placenta.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/17/2021] [Accepted: 02/07/2022] [Indexed: 01/05/2023]
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17
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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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Lipworth H, Barrett J, Murphy KE, Redelmeier D, Melamed N. Gestational weight gain in twin gestations and pregnancy outcomes: a systematic review and meta-analysis. BJOG 2021; 129:868-879. [PMID: 34775675 DOI: 10.1111/1471-0528.17011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Data on the association of inappropriate gestational weight gain (GWG) and adverse outcomes in twin pregnancies are limited and inconsistent. OBJECTIVES To perform a systematic review and meta-analysis on the association between GWG and adverse outcomes in twin pregnancies. SEARCH STRATEGY Ovid, Medline, EMBASE and Cochrane Central databases from 1 January 1990 until 23 September 2020. SELECTION CRITERIA Interventional and observational studies evaluating the association between GWG and adverse outcomes in twin pregnancies. DATA COLLECTION AND ANALYSIS Data were extracted by two independent reviewers. Summary odds ratios (OR) were calculated using a random-effects model in a subset of studies that analysed GWG as a categorical variable in relation to the Institute of Medicine (IOM) recommendations. The primary outcome was preterm birth. MAIN RESULTS From 277 citations, 19 studies involving 36 023 women with twin pregnancies were included in the qualitative analysis, of which 14 were included in the meta-analysis. Overall, 56.8% of women experienced inappropriate GWG: 35.4% (95% CI 30.0-41.0%) gained weight below and 21.4% (95% CI 14.2-29.5%) gained weight above IOM recommendations. Compared with GWG within IOM guidelines, GWG below IOM guidelines was associated with preterm birth before 32 weeks of gestation (OR 3.38; 95% CI 2.05-5.58), and a reduction in the risk of pre-eclampsia (OR 0.68; 95% CI 0.48-0.97). GWG above IOM guidelines was associated with an increased risk of pre-eclampsia that was consistent across all body mass index categories. CONCLUSIONS Inappropriate GWG affects over half of twin pregnancies, so is a common and potentially modifiable risk factor for preterm birth and pre-eclampsia.
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Affiliation(s)
- H Lipworth
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Jfr Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
| | - K E Murphy
- Division of Maternal-Fetal Medicine, Departments of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - D Redelmeier
- Department of Medicine and Institute for Health Policy, Management and Evaluation, Institute for Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - N Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Special Considerations Regarding Antenatal Care and Pregnancy Complications in Dichorionic Twin Pregnancies. Am J Obstet Gynecol MFM 2021; 4:100500. [PMID: 34637959 DOI: 10.1016/j.ajogmf.2021.100500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/18/2021] [Accepted: 10/04/2021] [Indexed: 02/07/2023]
Abstract
Twin pregnancies account for about 3.3% of all deliveries in the United States with the majority of them being dichorionic diamniotic (DCDA). Maternal physiological adaption in twin pregnancies is exaggerated and the rate of almost every maternal and fetal complication is higher when compared to singleton pregnancies. Therefore, twin pregnancies necessitate closer antenatal surveillance by care providers who are familiar with the specific challenges unique to these pregnancies, and there is evidence that following women with twins in a specialized twin clinic can result in improved obstetrical outcomes. The importance of the first antenatal visit in twin pregnancies cannot be over emphasized and should preferably take place early in gestation as it is the optimal period to correctly identify the number of fetuses and the type of placentation (chorionicity and amnionicity). This will allow the patients, families, and caregivers to make the appropriate modifications and to tailor an optimal antenatal follow-up plan. This plan should focus on general recommendations such as weight gain and level of activity, education regarding complications specific to twin pregnancies along with the relevant symptoms and indications to seek care, as well as on close maternal and fetal monitoring. In this review, we summarize available evidence and current guidelines regarding antenatal care in DCDA twin pregnancies.
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Yokouchi-Konishi T, Ohta-Ogo K, Kamiya CA, Shionoiri T, Nakanishi A, Iwanaga N, Ohuchi H, Kurosaki K, Ichikawa H, Noguchi T, Ishibashi-Ueda H, Yoshimatsu J. Clinicopathologic Study of Placentas From Women With a Fontan Circulation. Circ J 2021; 86:138-146. [PMID: 34497162 DOI: 10.1253/circj.cj-21-0133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Pregnant women with a Fontan circulation have a high risk of obstetric complications, such as preterm delivery and small for gestational age (SGA), which may be affected by low blood flow to the placenta and hypoxia. This study investigated placental pathology in a Fontan circulation.Methods and Results:Eighteen pregnancies in 11 women with a Fontan circulation were reviewed. Pregnancy outcomes showed 9 miscarriages and 9 live births, with 4 preterm deliveries. Five neonates were SGA (<5th percentile). Eight placentas from live births in 7 women were available for the study. Five placentas had low weight placenta for gestational age, and 7 grossly showed a chronic subchorionic hematoma. Histological examination revealed all placentas had some form of histological hypoxic lesions: maternal vascular malperfusion in 7, fetal vascular malperfusion in 1, and other hypoxia-related lesions in 8. Quantitative analyses, including immunohistochemistry (CD31, CD68, and hypoxia inducible factor-1α antibodies) and Masson's trichrome staining, were also performed and compared with 5 control placentas. Capillary density and the area of fibrosis were significantly greater in placentas from women with a Fontan circulation than in control placentas. CONCLUSIONS Placentas in a Fontan circulation were characterized by a high frequency of low placental weight, chronic subchorionic hematoma, and constant histological hypoxic changes, which could reflect altered maternal cardiac conditions and lead to poor pregnancy outcomes.
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Affiliation(s)
- Tae Yokouchi-Konishi
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center.,Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Keiko Ohta-Ogo
- Department of Pathology, National Cerebral and Cardiovascular Center
| | - Chizuko A Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Tadasu Shionoiri
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Atsushi Nakanishi
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Naoko Iwanaga
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Hideo Ohuchi
- Department of Pediatrics Cardiology, National Cerebral and Cardiovascular Center
| | - Kenichi Kurosaki
- Department of Pediatrics Cardiology, National Cerebral and Cardiovascular Center
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Hatsue Ishibashi-Ueda
- Department of Pathology, National Cerebral and Cardiovascular Center.,NCVC Biobank, National Cerebral and Cardiovascular Center
| | - Jun Yoshimatsu
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
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21
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Matthews KC, Fox NS, Rebarber A. The Association between Placental Histopathology, Fetal Growth Restriction, and Preeclampsia in Twin Pregnancies. Am J Perinatol 2021; 38:784-790. [PMID: 31891953 DOI: 10.1055/s-0039-3402716] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This study aims to estimate the association between abnormal placental histopathology, fetal growth restriction (FGR), and preeclampsia (PEC) in twin pregnancies. STUDY DESIGN Retrospective cohort study of women with diamniotic twin pregnancies with live births at ≥24 weeks of gestation and available placental pathology. Findings were compared between women with and without FGR, which was defined as a birthweight <10th percentile, using singleton and twin growth curves, and those with and without PEC. The primary study outcome was a composite of abnormal placental histopathology. Chi-square, Fisher's exact, and Student's t-tests were used for analysis. RESULTS Among 859 patients with diamniotic twins, 806 (93.8%) had placental pathology. A total of 422 (52.4%) women had at least one twin with FGR, using a singleton growth curve. FGR affected 136 (16.9%) pregnancies when a twin growth curve was applied. There was no significant difference in composite outcome between groups, using either growth curve (45.5 vs. 44.8%, p = 0.84; adjusted odds ratio (aOR): 1.06, 95% CI: 0.79-1.40 and 52.2 vs. 43.7%, p = 0.07; aOR: 1.44, 95% CI: 0.90-2.10). A total of 122 of 789 (15.5%) patients developed PEC. There was no significant difference in composite outcome between patients with and without PEC (41.8 vs. 45.4%, p = 0.46; aOR: 0.79, 95% CI: 0.53-1.18). CONCLUSION In twin pregnancies, FGR and PEC are not associated with abnormal placental histopathology. This suggests that the pathologic placental manifestations of these conditions may differ in twins and include factors other than those commonly described in singletons.
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Affiliation(s)
- Kathy C Matthews
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York Presbyterian-Weill Cornell Medicine, New York, New York
| | - Nathan S Fox
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York.,Maternal Fetal Medicine Associates, PLLC, New York, New York
| | - Andrei Rebarber
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York.,Maternal Fetal Medicine Associates, PLLC, New York, New York
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22
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Hiersch L, Shah BR, Berger H, Geary M, McDonald SD, Murray-Davis B, Guan J, Halperin I, Retnakaran R, Barrett J, Melamed N. DEVELOPING twin-specific 75-g oral glucose tolerance test diagnostic thresholds for gestational diabetes based on the risk of future maternal diabetes: a population-based cohort study. BJOG 2021; 128:1975-1985. [PMID: 34032350 DOI: 10.1111/1471-0528.16773] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To develop twin-specific outcome-based oral glucose tolerance test (OGTT) diagnostic thresholds for GDM based on the risk of future maternal type-2 diabetes. DESIGN A population-based retrospective cohort study (2007-2017). SETTING Ontario, Canada. METHODS Nulliparous women with a live singleton (n = 55 361) or twin (n = 1308) birth who underwent testing for gestational diabetes mellitus (GDM) using a 75-g OGTT in Ontario, Canada (2007-2017). We identified the 75-g OGTT thresholds in twin pregnancies that were associated with similar incidence rates of future type-2 diabetes to those associated with the standard OGTT thresholds in singleton pregnancies. RESULTS For any given 75-g OGTT value, the incidence rate of future maternal type-2 diabetes was lower for women with a twin than women with a singleton pregnancy. Using women with a negative OGTT as reference, the risk of future maternal type-2 diabetes in twin pregnancies with a positive OGTT based on the standard OGTT thresholds (9.86 per 1000 person years, adjusted hazard ratio (aHR) 4.79, 95% CI 2.69-8.51) was lower than for singleton pregnancies with a positive OGTT (18.74 per 1000 person years, aHR 8.22, 95% CI 7.38-9.16). The twin-specific OGTT fasting, 1-hour and 2-hour thresholds identified in the current study based on correlation with future maternal type-2 diabetes were 5.8 mmol/l (104 mg/dl), 11.8 mmol/l (213 mg/dl) and 10.4 mmol/l (187 mg/dl), respectively. CONCLUSIONS We identified potential twin-specific OGTT thresholds for GDM that are associated with a similar risk of future type-2 diabetes to that observed in women diagnosed with GDM in singleton pregnancies based on standard OGTT thresholds. TWEETABLE ABSTRACT Potential twin-specific OGTT thresholds for GDM were identified.
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Affiliation(s)
- L Hiersch
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Lis Maternity Hospital, Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - B R Shah
- Department of Medicine and Institute for Health Policy, Management and Evaluation, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada.,Division of Endocrinology, Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
| | - H Berger
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - M Geary
- Rotunda Hospital, Dublin, Ireland
| | - S D McDonald
- Division of Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - B Murray-Davis
- Division of Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - J Guan
- ICES, Toronto, ON, Canada
| | - I Halperin
- Department of Endocrinology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - R Retnakaran
- Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.,Division of Endocrinology, University of Toronto, Toronto, ON, Canada
| | - J Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - N Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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23
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Placental Lesions and Pregnancy Outcome in Anterior as Compared to Posterior Placenta Previa. Reprod Sci 2021; 28:3241-3247. [PMID: 33825166 DOI: 10.1007/s43032-021-00558-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
The uterine location of placenta previa (PP), anterior vs. posterior has an impact on pregnancy outcome. We aimed to study maternal and neonatal outcome and placental histopathology lesions in anterior vs. posterior PP. The medical records and histopathology reports of all singleton cesarean deliveries (CD) performed due to PP, from 24 to 41 weeks, between 12.2008 and 10.2018, were reviewed. Placental lesions were classified into maternal and fetal vascular malperfusion lesions (MVM, FVM), maternal and fetal inflammatory responses (MIR, FIR). Gestational age (GA) at delivery was similar between the anterior PP (n = 67) and posterior PP (n = 105) groups. As compared to the posterior PP group, the anterior PP group had higher rate of previous CD (p < 0.001), placental accreta spectrum (p = 0.04), lower neonatal Hb at birth (p = 0.03), higher rate of neonatal blood transfusion (p = 0.007) and prolonged maternal hospitalization (p = 0.02). Placentas from the anterior PP group had lower weights (p = 0.035), with increased rate of MVM lesions (p = 0.017). The anterior PP location is associated with increased adverse maternal and neonatal outcome, lower placental weights and increased rate of malperfusion lesions. Abnormal placentation in the scarred uterine wall probably has an impact on placental function.
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24
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Ashwal E, Hiersch L, Berger H, Aviram A, Zaltz A, Kingdom J, Barrett J, Melamed N. Pathologic Basis for the Definition of Discordant Growth in Dichorionic Twins. Fetal Diagn Ther 2021; 48:279-287. [PMID: 33780952 DOI: 10.1159/000514328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 01/09/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the current study was to identify the optimal cutoff that should define discordance in dichorionic twin gestations through correlation with abnormal placental pathology as a specific measure of fetal growth restriction of the smaller twin. METHODS We performed a retrospective cohort study of all women with dichorionic twin pregnancies who gave birth in a single center between 2002 and 2015. We investigated the association between the level of growth discordance and maternal vascular malperfusion (MVM) pathology in the placenta of the smaller twin, with and without adjustment for whether the smaller twin is small for gestational age (SGA). RESULTS A total of 1,198 women with dichorionic twin gestation met the study criteria. The rate of MVM pathology in the placenta of the smaller twin increased with the level of discordance and was most obvious for discordance ≥25% (rate of MVM 12.0% compared with 2.8% in cases with discordance <10%, adjusted relative risk [aRR] 3.71, 95% confidence interval [CI] 1.97-6.99). When the analysis was adjusted for SGA of the smaller twin, discordance was independently associated with MVM pathology only when growth discordance was ≥25% (aRR 2.18, 95%-CI 1.01-4.93), while SGA was strongly associated with MVM pathology irrespective of the level of discordance. CONCLUSION Our findings suggest that discordant growth in dichorionic twins should raise the concern of fetal growth restriction of the smaller twin, irrespective of whether the smaller twin is SGA, only when the discordance s ≥25%. The association of lower levels of discordance with abnormal placental pathology is mainly driven by the confounding effect of SGA of the smaller twin.
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Affiliation(s)
- Eran Ashwal
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv, Israel.,Sourasky Medical Center, Tel Aviv, Israel. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv, Israel.,Sourasky Medical Center, Tel Aviv, Israel. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Howard Berger
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Amir Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Arthur Zaltz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - John Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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25
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Dancey S, Mery E, Esteves A, Oltean I, Hayawi L, Tang K, Bainbridge S, El Demellawy D. Placenta pathology in recipient versus donor oocyte derivation for in vitro fertilization in a setting of hypertensive disorders of pregnancy and IUGR. Placenta 2021; 108:114-121. [PMID: 33865182 DOI: 10.1016/j.placenta.2021.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Assisted reproductive technology including in vitro fertilization (IVF) and oocyte donation (OD) may increase risk for placenta-mediated diseases. Comprehensive analysis of histopathological placental lesions according to source of oocytes used in the IVF procedure - recipient derived (RD-IVF) vs oocyte donation (OD-IVF), has not been conducted in a population with a hypertensive disorder of pregnancy (HDP) and/or intrauterine growth restriction (IUGR). METHODS A retrospective cohort study of archived placenta specimens from RD-IVF and OD-IVF pregnancies affected by HDP and/or IUGR was conducted with blinded histopathological placental examination. Three categories of lesions were differentiated and defined as main outcomes: maternal vascular malperfusion (MVM), chronic inflammation, and fetal vascular malperfusion (FVM). To determine the relationship between conception method and placental lesions, multivariable regressions were performed with maternal age, gestational age, HDP, birth and placental weight percentiles as model covariates. RESULTS 115 placentas were included 83 (72.2%) RD-IVF, 32 (27.8%) OD-IVF. Adjusted OR (aOR) for conception method was 5.05 (95%CI 0.58-43.90, p=0.142) for MVM, 1.87 (95%CI 0.68-5.15, p=0.228) for chronic inflammatory and 0.61 (95%CI 0.15-2.37, p=0.471) for FVM lesions. Multiple gestation demonstrated borderline association with MVM (aOR=0.24, 95%CI 0.04-1.51, p=0.129) and total pathology score (aRR=0.79, 95%CI 0.62-1.01, p=0.058). Subgroup analysis suggested greater odds of villitis of unknown etiology (VUE) for OD-IVF (aOR=2.98, 95%CI 1.12-7.93, p=0.029). DISCUSSION Source of oocyte derivation demonstrated no evidence of association with main outcomes in cases of HDP and/or IUGR. Subgroup analysis demonstrated increased rates of inflammatory lesions for OD-IVF. Multiple gestation may be associated with decreased MVM and total lesions.
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Affiliation(s)
- Sonia Dancey
- Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, ON K1H 8M5, Canada.
| | - Erika Mery
- Faculty of Health Sciences, University of Ottawa, 25 University Private, Ottawa, ON K1N 7K4, Canada.
| | - Ashley Esteves
- Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, ON K1H 8M5, Canada.
| | - Irina Oltean
- Department of Pathology, University of Ottawa, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1, Canada.
| | - Lamia Hayawi
- Clinical Research Unit, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1, Canada.
| | - Ken Tang
- Clinical Research Unit, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1, Canada.
| | - Shannon Bainbridge
- Faculty of Health Sciences, University of Ottawa, 25 University Private, Ottawa, ON K1N 7K4, Canada.
| | - Dina El Demellawy
- Department of Pathology, University of Ottawa, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1, Canada.
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26
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Melamed N, Baschat A, Yinon Y, Athanasiadis A, Mecacci F, Figueras F, Berghella V, Nazareth A, Tahlak M, McIntyre HD, Da Silva Costa F, Kihara AB, Hadar E, McAuliffe F, Hanson M, Ma RC, Gooden R, Sheiner E, Kapur A, Divakar H, Ayres‐de‐Campos D, Hiersch L, Poon LC, Kingdom J, Romero R, Hod M. FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction. Int J Gynaecol Obstet 2021; 152 Suppl 1:3-57. [PMID: 33740264 PMCID: PMC8252743 DOI: 10.1002/ijgo.13522] [Citation(s) in RCA: 175] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.
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Affiliation(s)
- Nir Melamed
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologySunnybrook Health Sciences CentreUniversity of TorontoTorontoONCanada
| | - Ahmet Baschat
- Center for Fetal TherapyDepartment of Gynecology and ObstetricsJohns Hopkins UniversityBaltimoreMDUSA
| | - Yoav Yinon
- Fetal Medicine UnitDepartment of Obstetrics and GynecologySheba Medical CenterTel‐HashomerSackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and GynecologyAristotle University of ThessalonikiThessalonikiGreece
| | - Federico Mecacci
- Maternal Fetal Medicine UnitDivision of Obstetrics and GynecologyDepartment of Biomedical, Experimental and Clinical SciencesUniversity of FlorenceFlorenceItaly
| | - Francesc Figueras
- Maternal‐Fetal Medicine DepartmentBarcelona Clinic HospitalUniversity of BarcelonaBarcelonaSpain
| | - Vincenzo Berghella
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Amala Nazareth
- Jumeira Prime Healthcare GroupEmirates Medical AssociationDubaiUnited Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and ChildrenDubai Health AuthorityEmirates Medical AssociationMohammad Bin Rashid University for Medical Sciences, Dubai, United Arab Emirates
| | | | - Fabrício Da Silva Costa
- Department of Gynecology and ObstetricsRibeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoSão PauloBrazil
| | - Anne B. Kihara
- African Federation of Obstetricians and GynaecologistsKhartoumSudan
| | - Eran Hadar
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Fionnuala McAuliffe
- UCD Perinatal Research CentreSchool of MedicineNational Maternity HospitalUniversity College DublinDublinIreland
| | - Mark Hanson
- Institute of Developmental SciencesUniversity Hospital SouthamptonSouthamptonUK
- NIHR Southampton Biomedical Research CentreUniversity of SouthamptonSouthamptonUK
| | - Ronald C. Ma
- Department of Medicine and TherapeuticsThe Chinese University of Hong KongHong Kong SARChina
- Hong Kong Institute of Diabetes and ObesityThe Chinese University of Hong KongHong Kong SARChina
| | - Rachel Gooden
- FIGO (International Federation of Gynecology and Obstetrics)LondonUK
| | - Eyal Sheiner
- Soroka University Medical CenterBen‐Gurion University of the NegevBe’er‐ShevaIsrael
| | - Anil Kapur
- World Diabetes FoundationBagsværdDenmark
| | | | | | - Liran Hiersch
- Sourasky Medical Center and Sackler Faculty of MedicineLis Maternity HospitalTel Aviv UniversityTel AvivIsrael
| | - Liona C. Poon
- Department of Obstetrics and GynecologyPrince of Wales HospitalThe Chinese University of Hong KongShatinHong Kong SAR, China
| | - John Kingdom
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologyMount Sinai HospitalUniversity of TorontoTorontoONCanada
| | - Roberto Romero
- Perinatology Research BranchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMDUSA
| | - Moshe Hod
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
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27
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Predictive Accuracy of Singleton Versus Customized Twin Growth Chart for Adverse Perinatal Outcome: A Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18042016. [PMID: 33669723 PMCID: PMC7921915 DOI: 10.3390/ijerph18042016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/06/2021] [Accepted: 02/16/2021] [Indexed: 11/17/2022]
Abstract
Background: Fetal growth of twins differs from singletons. The objective was to assess the fetal growth in twin gestations in relation to singleton charts and customized twin charts, respectively, followed by a comparison of the frequency of neonatal complications in small-for-gestational-age (SGA) twins. Methods: We performed an analysis of twin pregnancies with established chorionicity with particular emphasis on postnatal adverse outcomes in newborns classified as SGA. Neonatal birth weight was comparatively assessed using both singleton and twin growth charts with following percentile estimation. Using a statistical model, we established the prediction strength of neonatal complications in SGA twins for both methods. Results: The dataset included 322 twin pairs (247 cases of dichorionic and 75 cases of monochorionic diamniotic gestations). Utilization of twin-specific normograms was less likely to label twins as SGA—nevertheless, this diagnosis strongly correlated with risk of observing adverse outcomes. Using a chart dedicated for twin pregnancies predicted newborn complications in the SGA group with higher sensitivity and had better positive predictive value regarding postnatal morbidity. Conclusions: Estimating twin growth with customized charts provides better prognosis of undesirable neonatal events in the SGA group comparing to singleton nomograms and consequently might determine neonatal intensive care prenatal approach.
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28
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Giorgione V, Bhide A, Bhate R, Reed K, Khalil A. Are Twin Pregnancies Complicated by Weight Discordance or Fetal Growth Restriction at Higher Risk of Preeclampsia? J Clin Med 2020; 9:jcm9103276. [PMID: 33066110 PMCID: PMC7600839 DOI: 10.3390/jcm9103276] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023] Open
Abstract
Studies have reported controversial findings on the association between fetal growth restriction (FGR) or intertwin weight discordance and the risk of hypertensive disorders of pregnancy (HDP) in twin pregnancies. The aim of this study was to investigate the association between twin growth disorders and HDP. Twin pregnancies resulting in two live births at St George’s Hospital between 2000 and 2019 were included. FGR or small-for-gestational-age (SGA) at birth was assessed using singleton and twin reference charts. Intertwin discordance [(large birthweight − small birthweight)/(large birthweight) × 100%)] was calculated. Logistic regression models were performed. SGA (aOR 2.34, 95% CI 1.60–3.44, p < 0.001), intertwin discordance ≥25% (aOR 2.10, 95% CI 1.26–3.49, p = 0.004) and their co-existence (aOR 2.03, 95% CI 1.16–3.54, p = 0.013) were significantly associated with HDP. After adjusting for the known maternal risk factors of HDP and the intertwin discordance, SGA (using the twin charts) was the strongest independent risk factor associated with HDP (aOR 2.12, 95% CI 1.40–3.22, p < 0.001) and preeclampsia (aOR 2.34, 95% CI 1.45–3.76, p < 0.001). This study highlights that the presence of at least one SGA twin is significantly associated with HDP during pregnancy. Therefore, maternal blood pressure should be closely monitored in twin pregnancies complicated by SGA with or without intertwin discordance.
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Affiliation(s)
- Veronica Giorgione
- Twins Trust Centre for Research and Clinical Excellence, St George’s University Hospitals NHS Foundation Trust, London SW17 0RE, UK; (V.G.); (A.B.); (R.B.)
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George’s University of London, London SW17 0RE, UK
- Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London SW17 0RE, UK
| | - Amar Bhide
- Twins Trust Centre for Research and Clinical Excellence, St George’s University Hospitals NHS Foundation Trust, London SW17 0RE, UK; (V.G.); (A.B.); (R.B.)
- Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London SW17 0RE, UK
| | - Rohan Bhate
- Twins Trust Centre for Research and Clinical Excellence, St George’s University Hospitals NHS Foundation Trust, London SW17 0RE, UK; (V.G.); (A.B.); (R.B.)
- Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London SW17 0RE, UK
| | - Keith Reed
- Twins Trust, The Manor House, Aldershot GU12 4JU, UK;
| | - Asma Khalil
- Twins Trust Centre for Research and Clinical Excellence, St George’s University Hospitals NHS Foundation Trust, London SW17 0RE, UK; (V.G.); (A.B.); (R.B.)
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George’s University of London, London SW17 0RE, UK
- Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London SW17 0RE, UK
- Correspondence: ; Tel.: +44-2032998256
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29
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Qiao P, Zhao Y, Jiang X, Xu C, Yang Y, Bao Y, Xie H, Ying H. Impact of growth discordance in twins on preeclampsia based on chorionicity. Am J Obstet Gynecol 2020; 223:572.e1-572.e8. [PMID: 32247845 DOI: 10.1016/j.ajog.2020.03.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/13/2020] [Accepted: 03/25/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite extensive investigations over the last decade, preeclampsia remains an unpredictable pregnancy complication causing perinatal morbidity and mortality worldwide, particularly in twin pregnancies. OBJECTIVE This study aimed to determine the relationship between growth discordance in twin pregnancies and the risk for preeclampsia based on chorionicity. STUDY DESIGN This was a retrospective single-center study that included 2122 women with twin pregnancies who were admitted to a tertiary hospital between January 2013 and June 2016. Growth discordance was defined as twin birthweight difference ≥20%. Logistic regression models were used to analyze the association between growth discordance and risk for gestational hypertension-preeclampsia in all subjects. Stratified sampling by twin chorionicity (dichorionic and monochorionic) was also conducted. Further analysis was performed to estimate the association between the degree of growth discordance and gestational hypertension-preeclampsia risk in monochorionic and dichorionic twin pregnancies. RESULTS The prevalence of growth discordance was 17.6%. In all subjects, growth discordance was associated with increased risk for gestational hypertension-preeclampsia. After stratification by twin chorionicity, growth discordance was associated with an increased risk for gestational hypertension preeclampsia (adjusted odds ratio [AOR], 1.84; 95% confidence interval [CI], 1.26-2.67) and preeclampsia (AOR, 1.82; 95% CI, 1.21-2.73), including mild preeclampsia (AOR, 1.86; 95% CI, 1.02-3.37), severe preeclampsia (AOR, 1.78; 95% CI, 1.06-2.97; P<.05), and early-onset preeclampsia (AOR, 2.98; 95% CI, 1.40-6.32), in the dichorionic twin pregnancy group; however, no significant association was found in the monochorionic twin pregnancy group. A 10% increment of growth discordance in the dichorionic twin pregnancy group was associated with an elevated risk for gestational hypertension preeclampsia (AOR, 1.20; 95% CI, 1.02-1.41) and preeclampsia (AOR, 1.24; 95% CI, 1.04-1.48), including severe preeclampsia (AOR, 1.28; 95% CI, 1.04-1.59) and early-onset preeclampsia (AOR, 1.47; 95% CI, 1.08-2.00), but no significant association was found in the monochorionic twin pregnancy group. CONCLUSION Growth discordance is associated with an increased risk for preeclampsia in dichorionic but not in monochorionic twin pregnancy. In addition, the prevalence of preeclampsia increases significantly with increasing degree of growth discordance, reflecting a dose-response relationship in dichorionic twin pregnancy.
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Affiliation(s)
- Ping Qiao
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Yan Zhao
- Department of Women & Children's Health Care, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xiang Jiang
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Chuanlu Xu
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Yingying Yang
- Department of Women & Children's Health Care, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Yirong Bao
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Han Xie
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Hao Ying
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China.
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Hiersch L, Lipworth H, Kingdom J, Barrett J, Melamed N. Identification of the optimal growth chart and threshold for the prediction of antepartum stillbirth. Arch Gynecol Obstet 2020; 303:381-390. [PMID: 32803394 DOI: 10.1007/s00404-020-05747-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 08/10/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To evaluate the effect of the choice growth chart and threshold used to define small for gestational age (SGA) on the predictive value of SGA for placenta-related or unexplained antepartum stillbirth. METHODS A retrospective cohort study of all women with a singleton pregnancy who gave birth > 24 week gestation in a single center (2000-2016). The exposure of interest was SGA, defined as birth weight < 10th or < 25th centile according to three fetal growth charts (Hadlock et al., Radiology 181:129-133, 1991; intergrowth-21st (IG21), WHO 2017, and a Canadian birthweight-based reference-Kramer et al., Pediatrics 108:E35, 2001). The outcome of interest was antepartum stillbirth due to placental dysfunction or unknown etiology. Cases of stillbirth attributed to other specific etiologies were excluded. RESULTS A total of 49,458 women were included in the cohort. There were 103 (0.21%) cases of stillbirth due to placental dysfunction or unknown etiology. For cases in the early stillbirth cluster (≤ 30 weeks), the detection rate was high and was similar for the three ultrasound-based fetal growth charts of Hadlock, IG21, and WHO (range 83.3-87.0%). In contrast, the detection rate of SGA for cases in the late stillbirth cluster (> 30 weeks) was low, being highest for WHO and Hadlock (36.7% and 34.7%, respectively), and lowest for IG21 (18.4%). Using a threshold of the 25th centile increased the detection rate for stillbirth by approximately 15-20% compared with that achieved by the 10th centile cutoff. CONCLUSION At > 30 week gestation, the Hadlock or WHO fetal growth charts provided the best balance between detection rate and false positive rate for stillbirth.
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Affiliation(s)
- Liran Hiersch
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada. .,Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, M5G 1X8, Canada. .,Lis Hospital for Women, Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Hayley Lipworth
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - John Kingdom
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, M5G 1X8, Canada.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada.,Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada.,Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, M5G 1X8, Canada
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Children Born with Congenital Heart Defects and Growth Restriction at Birth: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17093056. [PMID: 32354021 PMCID: PMC7246925 DOI: 10.3390/ijerph17093056] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/16/2020] [Accepted: 04/20/2020] [Indexed: 12/12/2022]
Abstract
Newborns with congenital heart defects tend to have a higher risk of growth restriction, which can be an independent risk factor for adverse outcomes. To date, a systematic review of the relation between congenital heart defects (CHD) and growth restriction at birth, most commonly estimated by its imperfect proxy small for gestational age (SGA), has not been conducted. Objective: To conduct a systematic review and meta-analysis to estimate the proportion of children born with CHD that are small for gestational age (SGA). Methods: The search was carried out from inception until 31 March 2019 on Pubmed and Embase databases. Studies were screened and selected by two independent reviewers who used a predetermined data extraction form to obtain data from studies. Bias was assessed using the Critical Appraisal Skills Programme (CASP) checklist. The database search identified 1783 potentially relevant publications, of which 38 studies were found to be relevant to the study question. A total of 18 studies contained sufficient data for a meta-analysis, which was done using a random effects model. Results: The pooled proportion of SGA in all CHD was 20% (95% CI 16%–24%) and 14% (95% CI 13%–16%) for isolated CHD. Proportion of SGA varied across different CHD ranging from 30% (95% CI 24%–37%) for Tetralogy of Fallot to 12% (95% CI 7%–18%) for isolated atrial septal defect. The majority of studies included in the meta-analysis were population-based studies published after 2010. Conclusion: The overall proportion of SGA in all CHD was 2-fold higher whereas for isolated CHD, 1.4-fold higher than the expected proportion in the general population. Although few studies have looked at SGA for different subtypes of CHD, the observed variability of SGA by subtypes suggests that growth restriction at birth in CHD may be due to different pathophysiological mechanisms.
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Maternal folic acid supplementation and more prominent birth weight gain in twin birth compared with singleton birth: a cross-sectional study in northwest China. Public Health Nutr 2020; 23:2973-2982. [PMID: 32301402 DOI: 10.1017/s1368980019004580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To investigate the association of folic acid (FA) supplementation with birth weight, the risk of small for gestational age (SGA) and low birth weight (LBW) in singleton and twin pregnancy. DESIGN A population-based cross-sectional survey. SETTING Twenty counties and ten districts in Shaanxi Province of northwestern China, 2013. PARTICIPANTS 28 174 pregnant women with their infants, covering 27 818 single live births and 356 twin live births. RESULTS The prevalence of FA supplementation in singletons and twins was 63·9 and 66·3 %. The mean birth weight was 3267 (sd 459·1) g, 2525 (sd 534·0) g and 2494 (sd 539·5) g; the prevalence of SGA was 14·3, 51·4 and 53·4 %; the prevalence of LBW was 3·4, 42·4 and 46·6 % among singleton, twin A and twin B, respectively. Compared with non-users, women with FA supplementation were (β 17·3, 95 % CI 6·1, 28·4; β 166·3, 95 % CI 69·1, 263·5) associated with increased birth weight, lower risk of SGA (OR 0·85, 95 % CI 0·80, 0·92; OR 0·45, 95 % CI 0·30, 0·68) and LBW (OR 0·82, 95 % CI 0·71, 0·95; OR 0·50, 95 % CI 0·33, 0·75) in singletons and twins, and more prominent effects in twins. Moreover, there were significant interactions between FA supplementation and plurality on birth weight, SGA and LBW. CONCLUSIONS The present study suggests the association of periconceptional 0·4 mg/d FA supplementation with increased birth weight and reduced risk of SGA and LBW in both singletons and twins, and this association may be more prominent in twins.
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Franklin A, Yallapragada S, Birkett R, Grobman W, Ernst LM, Mestan K. The impact of placental pathology discordance in multiple gestation pregnancies on bronchopulmonary dysplasia-associated pulmonary hypertension. Pulm Circ 2020; 10:2045894020910674. [PMID: 32215199 PMCID: PMC7065289 DOI: 10.1177/2045894020910674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/01/2020] [Indexed: 11/16/2022] Open
Abstract
Bronchopulmonary dysplasia-associated pulmonary hypertension (BPD-PH) may either be concordant or discordant between multiple gestation births. Abnormal placental development, particularly maternal vascular malperfusion, may account for discordance in BPD-PH through fetal programming mechanisms. Maternal vascular malperfusion is a placental histologic lesion associated with intrauterine growth restriction and BPD-PH. We conducted a retrospective longitudinal cohort study of infants born <29 weeks gestation with available placental histology at Prentice Women's Hospital in Chicago from 2005-2012. The primary outcome was discordant BPD-PH associated with placental maternal vascular malperfusion. We secondarily assessed whether the risk of BPD-PH and placental lesions was different among infants of multiple (compared to singleton) gestations. The cohort consisted of 135 multiple gestation infants and 355 singletons. In a separate cohort of 39 singletons and 35 multiples, associations between 12 cytokines and angiogenic growth factors in cord blood plasma for biomarker discordance, maternal vascular malperfusion, and bronchopulmonary dysplasia were explored. Among multiples, discordant maternal vascular malperfusion was not associated with BPD-PH (OR = 1.9 (0.52, 6.9); p = 0.33) in infants exposed to placental maternal vascular malperfusion. However, singleton infants were more likely to develop BPD-PH (compared to multiples) after adjusting for mode of delivery, chorioamnionitis, chronic hypertension, placental abruption, small-for-gestational age birth weight, and gestational age (aOR = 2.7 (1.2, 5.8); p = 0.038). Singletons were more likely to be small-for-gestational age (11% vs 4%, p = 0.025) and have placental lesions compared to their multiple-gestation counterparts (96% vs 81%, p < 0.001), principally severe maternal vascular malperfusion (17% vs 4%, p < 0.001) and chronic inflammation (32% vs 11%, p < 0.001). Increased risk of BPD-PH in singleton pregnancies <29 weeks gestation compared to multiples may be related to increased frequency of these histologic lesions. Placental pathology in singleton and multiple gestation pregnancies may serve as an early biomarker to predict BPD-PH.
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Affiliation(s)
- Andrew Franklin
- Department of Pediatrics, NorthShore University HealthSystem, Evanston, IL, USA
| | | | - Robert Birkett
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - William Grobman
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Linda M Ernst
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Karen Mestan
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Association between hypertensive disorders and fetal growth restriction in twin compared with singleton gestations. Am J Obstet Gynecol 2019; 221:251.e1-251.e8. [PMID: 31029663 DOI: 10.1016/j.ajog.2019.04.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/16/2019] [Accepted: 04/19/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hypertensive disorders of pregnancy (including preeclampsia or gestational hypertension) are associated with fetal growth restriction in singleton pregnancies, an association that may be attributed to abnormal placentation as the shared etiology between these conditions. Given that the pathogenesis of these conditions in twin pregnancies may involve mechanisms other than abnormal placentation, it is unclear whether a similar association between hypertensive disorders of pregnancy and fetal growth restriction is present in twins. Data on the relationship between hypertensive disorders of pregnancy and fetal growth restriction in twins are limited and conflicting. This controversy may be attributed to limitations of existing studies including the use of a singleton-based birthweight reference to define fetal growth restriction in twins and the lack of a positive control group of singleton gestations. OBJECTIVE The objective of the study was to determine the association between hypertensive disorders of pregnancy and fetal growth restriction in dichorionic twin gestations, using both a singleton- and a twin-based birthweight reference, and to compare this association with that observed in singleton gestations. STUDY DESIGN We performed a retrospective cohort study of all women with dichorionic twin or singleton gestations giving birth in a single tertiary center during 2003-2015. Fetal growth restriction was defined in separate analyses as birthweight <10th percentile for gestational age using either a singleton- or a twin-based birthweight reference. The association between hypertensive disorders of pregnancy and fetal growth restriction was determined separately for twin and singleton gestations and was expressed as adjusted relative risk with 95% confidence interval. RESULTS A total of 1520 twin and 48,943 singleton gestations were included. In singleton gestations, hypertensive disorders of pregnancy were associated with an increased risk of fetal growth restriction (16.6% vs 7.4%, adjusted relative risk, 2.07, 95% confidence interval, 1.87-2.30). In twins, there was no association between hypertensive disorders of pregnancy and fetal growth restriction when a singleton-based reference was used to define fetal growth restriction. However, when using a twin-based reference to define fetal growth restriction, hypertensive disorders of pregnancy in twin gestations were associated with a similar increase in the risk of fetal growth restriction to that seen in singletons (11.8% vs 4.7%, adjusted relative risk, 2.37, 95% confidence interval, 1.69-3.34). Findings were similar with regard to the reverse association between fetal growth restriction and hypertensive disorders of pregnancy: in women with twin gestations, the increase in the risk of hypertensive disorders of pregnancy in pregnancies complicated by fetal growth restriction of 1 twin was similar to that observed in singletons only when a twin-based reference was used to define fetal growth restriction (twins: 21.3% vs 9.8%, adjusted relative risk, 2.15, 95% confidence interval, 1.63-3.06; singletons: 8.8% vs 3.7%, adjusted relative risk, 2.19, 95% confidence interval, 1.95-2.44). CONCLUSION The association between hypertensive disorders of pregnancy and fetal growth restriction in dichorionic twins is similar in magnitude to that observed in singletons so long as appropriate birthweight references are applied. Therefore, women with a twin gestation complicated by one of these conditions should be closely monitored for the other. Our findings suggest that the use of a twin-based reference to diagnose fetal growth restriction in twin gestations may be more informative and clinically relevant than using a singleton-based reference.
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Hiersch L, Okby R, Freeman H, Rosen H, Nevo O, Barrett J, Melamed N. Differences in fetal growth patterns between twins and singletons. J Matern Fetal Neonatal Med 2019; 33:2546-2555. [PMID: 30501543 DOI: 10.1080/14767058.2018.1555705] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objective: Twin fetus growth is delayed during the third trimester compared to singletons. Whether this phenomenon should be considered a normal physiologic characteristic of twins or a pathologic process inherent to twin pregnancies is currently unclear. Information on the growth rate of the individual fetal biometric indices may provide more insight into the mechanisms underlying these differences between twins and singletons. Our aim was to compare fetal growth pattern between twin and singleton fetuses.Methods: This was a retrospective study of women with an uncomplicated twin pregnancy who underwent sonographic fetal weight estimation between 16 and 38 weeks' gestation in a single referral center. Twins-specific regression models were generated for biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL) and fetal weight as a function of gestational age and were compared to published singletons-based curves.Results: Overall 543 women were eligible for the study and underwent a total of 3401 sonographic weight estimations. Estimated weight of twin fetus emerged as lower than that of singletons starting at 26 weeks of gestation, and these differences increased with gestational age, reaching a mean difference of 300-350 g or of ∼10% at term. The growth of all four biometric indices was slower in twins compared to singletons, but the differences were most pronounced for AC which had the largest relative contribution to the lower fetal weight in twins (51.7 ± 7.3%), while the relative contribution of FL, HC, and BPD was smaller (26.4 ± 10.7, 15.5 ± 3.0, and 6.4%±5.7%, respectively). This was also reflected by a higher HC/AC ratio in twins compared with singletons starting at 22 weeks of gestation. The likelihood of a twin fetus being diagnosed as small for gestational age (fetal weight <10th percentile) was significantly lower when the newly developed twins-based curves (rather than singletons-based curves) were used (OR: 0.39, 95%-CI: 0.34-0.44).Conclusion: Twin fetus experience slowing of growth beginning at ∼26 weeks of gestation and a greater degree of asymmetric growth pattern compared with singletons. These findings suggest that the slower growth of twins may reflect a state of "relative growth restriction" compared with singleton gestations.
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Affiliation(s)
- Liran Hiersch
- Sackler Faculty of Medicine, Lis Maternity Hospital affiliated to Tel Aviv University, Tel Aviv, Israel
| | - Rania Okby
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Howie Freeman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Hadar Rosen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Ori Nevo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
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Maymon R, Meiri H, Svirski R, Weiner E, Cuckle H. Maternal serum screening marker levels in twin pregnancies affected by gestational diabetes. Arch Gynecol Obstet 2018; 299:655-663. [DOI: 10.1007/s00404-018-5010-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
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Barber E, Weiner E, Feldstein O, Dekalo A, Mizrachi Y, Gonullu DC, Bar J, Schreiber L, Kovo M. The differences in placental pathology and neonatal outcome in singleton vs. twin gestation complicated by small for gestational age. Arch Gynecol Obstet 2018; 298:1107-1114. [PMID: 30284621 DOI: 10.1007/s00404-018-4921-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/27/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We aimed to compare placental histopathology and neonatal outcome between dichorionic diamniotic (DCDA) twins and singleton pregnancies complicated by small for gestational age (SGA). METHODS Medical files and placental pathology reports from all deliveries between 2008 and 2017 of SGA neonates, (birthweight < 10th percentile), were reviewed. Comparison was made between singleton pregnancies complicated with SGA (singletons SGA group) and DCDA twin pregnancies (Twins SGA group), in which only one of the neonates was SGA. Placental diameters were compared between the groups. Placental lesions were classified into maternal and fetal vascular malperfusion lesions (MVM and FVM), maternal (MIR) and fetal (FIR) inflammatory responses, and chronic villitis. Neonatal outcome parameters included composite of early neonatal complications. RESULTS The twins SGA group (n = 66) was characterized by a higher maternal age (p = 0.011), lower gestational age at delivery (34.9 ± 3.1 vs. 37.7 ± 2.6 weeks, p < 0.001), and a higher rate of preeclampsia (p = 0.010), compared to the singletons SGA group (n = 500). Adverse composite neonatal outcome was more common in the twins SGA group (p < 0.001). Placental villous lesions related to MVM (p < 0.001) and composite MVM lesions (p = 0.04) were more common in the singletons SGA group. On multivariate logistic regression analysis, the singletons SGA group was independently associated with placental villous lesions (aOR 3.6, 95% CI 1.9-7.0, p < 0.001) and placental MVM lesions (aOR 2.44, 95% CI 1.29-4.61, p = 0.006). CONCLUSION Placentas from SGA singleton pregnancies have more MVM lesions as compared to placentas from SGA twin pregnancies, suggesting different mechanisms involved in abnormal fetal growth in singleton and twin gestations.
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Affiliation(s)
- Elad Barber
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, P.O. Box 5, Holon, 58100, Tel Aviv, Israel.
| | - Eran Weiner
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, P.O. Box 5, Holon, 58100, Tel Aviv, Israel
| | - Ohad Feldstein
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, P.O. Box 5, Holon, 58100, Tel Aviv, Israel
| | - Ann Dekalo
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, P.O. Box 5, Holon, 58100, Tel Aviv, Israel
| | - Yossi Mizrachi
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, P.O. Box 5, Holon, 58100, Tel Aviv, Israel
| | - Damla Celen Gonullu
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, P.O. Box 5, Holon, 58100, Tel Aviv, Israel
| | - Jacob Bar
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, P.O. Box 5, Holon, 58100, Tel Aviv, Israel
| | - Letizia Schreiber
- Department of Pathology, Wolfson Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Holon, Tel Aviv, Israel
| | - Michal Kovo
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, P.O. Box 5, Holon, 58100, Tel Aviv, Israel
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The role of placental malperfusion in the pathogenesis of preeclampsia in dichorionic twin and singleton pregnancies. Placenta 2018; 70:41-49. [PMID: 30316326 DOI: 10.1016/j.placenta.2018.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 08/10/2018] [Accepted: 09/05/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION In singletons, the pathogenesis of hypertensive disorders of pregnancy (HDP) is attributed to abnormal placentation, characterized by maternal vascular malperfusion (MVM) lesions. Whether MVM plays a similar role in twin pregnancies is unclear. The purpose of the study was to compared placental pathology findings between dichorionic-twin and singleton pregnancies complicated by HDP. METHODS Retrospective cohort study of women with dichorionic-twin or singleton pregnancies complicated by HDP who gave birth in a single tertiary center between 2001 and 2015. Placental abnormalities were classified into lesions associated with MVM, fetal vascular malperfusion, placental hemorrhage and chronic villitis. Placental findings and neonatal outcomes were compared between twin and singleton pregnancies. RESULTS A total of 144 women with twins and 768 women with a singleton pregnancy met the inclusion criteria. Compared with HDP singletons, twins with HDP had higher mean birth weights, were less likely to be small for gestational age and be born at <34 and at <32 weeks. Twins had lower odds for placental weight below <10th percentile (aOR 0.49, 95%CI 0.33-0.71), for MVM pathology (aOR 0.28, 95%CI 0.20-0.39) and for fetal vascular malperfusion pathology (aOR 0.65, 95%CI 0.45-0.93). These finding remained significant in the subpopulation of early onset HDP (<34 weeks) and small for gestational newborn. DISCUSSION Our findings support the hypothesis that MVM are less relevant to the pathogenesis of HDP in twin pregnancies and suggest that other placental or non-placental factors are responsible for the increased risk of HDP in twin pregnancies.
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Fitzgerald B. Histopathological examination of the placenta in twin pregnancies. APMIS 2018; 126:626-637. [DOI: 10.1111/apm.12829] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/30/2018] [Indexed: 11/26/2022]
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