Multiple gestations and preterm birth

Outcomes of dichorionic twin pregnancies with fused versus separate placentas

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.

A history of recurrent pregnancy loss is associated with increased perinatal complications, but not necessarily a longer birth interval: a population study spanning 18 years

STUDY QUESTION

Is there a difference in the time interval between the first and second live births among individuals with and without recurrent pregnancy loss (RPL)?

SUMMARY ANSWER

Primary RPL (two or more pregnancy losses before the first live birth) is associated with a shorter time interval between the first and second live births compared with individuals without RPL, but this association is reversed in patients with secondary RPL (RPL patients with no or one pregnancy loss before the first live birth).

WHAT IS KNOWN ALREADY

There is limited information regarding the ability to have more than one child for patients with RPL. Previous studies have investigated the time to live birth and the live birth rate from the initial presentation to clinical providers. Most of the previous studies have included only patients treated at specialized RPL clinics and thus may be limited by selection bias, including patients with a more severe condition.

STUDY DESIGN, SIZE, DURATION

We conducted a population-based retrospective cohort study of 184 241 participants who delivered in British Columbia, Canada, and had at least two recorded live births between 2000 and 2018. The aim was to study the differences in the time interval between the first and second live births and the prevalence of pregnancy complications in patients with and without RPL. Additionally, 198 319 individuals with their first live birth between 2000 and 2010 were studied to evaluate cumulative second live birth rates.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Among individuals with at least two recorded live births between 2000 and 2018, 12 321 patients with RPL and 171 920 participants without RPL were included. RPL was defined as at least two pregnancy losses before 20 weeks gestation. Patients with primary RPL had at least two pregnancy losses occurring before the first live birth, while patients with secondary RPL had no or one pregnancy loss before the first live birth. We compared the time interval from the first to second live birth in patients with primary RPL, those with secondary RPL, and participants without RPL using generalized additive models to allow for a non-linear relationship between maternal age and time interval between first and second live births. We also compared prevalence of pregnancy complications at the first and second live births between the groups using non-parametric Kruskal-Wallis H test and Fisher's exact test for continuous and categorical variables, respectively. We assessed the cumulative second live birth rates in patients with primary RPL and those without RPL, among participants who had their first live birth between 2000 and 2010. Cox proportional hazards model was used to estimate and compare hazard ratios between the two groups using a stratified modelling approach.

MAIN RESULTS AND THE ROLE OF CHANCE

The adjusted time interval between the first and second live births was the longest in patients with secondary RPL, followed by individuals without RPL, and the shortest time interval was observed in patients with primary RPL: 4.34 years (95% CI: 4.09-4.58), 3.20 years (95% CI: 3.00-3.40), and 3.05 years (95% CI: 2.79-3.32). A higher frequency of pregnancy losses was associated with an increased time interval between the first and second live births. The prevalence of pregnancy complications at the first and second live births, including gestational diabetes, hypertensive disorder of pregnancy, preterm birth, and multiple gestations was significantly higher in patients with primary RPL compared with those without RPL. The cumulative second live birth rate was significantly lower in patients with primary RPL compared with individuals without RPL.

LIMITATIONS, REASONS FOR CAUTION

This study may be limited by its retrospective nature. Although we adjusted for multiple potential confounders, there may be residual confounding due to a lack of information about pregnancy intentions and other factors, including unreported pregnancy losses.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study provide information that will help clinicians in the counselling of RPL patients who desire a second child.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported in part by a grant from the Canadian Institutes of Health Research (CIHR): Reference Number W11-179912. M.A.B. reports research grants from CIHR and Ferring Pharmaceutical. He is also on the advisory board for AbbVie, Pfizer, and Baxter. The other authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

NCT04360564.

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

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

Risk of intrapartum cesarean delivery in twin pregnancies: A retrospective cohort study

OBJECTIVE

To compare the risk of intrapartum cesarean delivery (CD) between patients with twin and singleton pregnancies undergoing a trial of labor and identify risk factors for intrapartum CD in twin pregnancies.

METHODS

The present study was a retrospective cohort study of patients with a twin or singleton pregnancy who underwent a trial of labor at ≥340/7 weeks in a single center (2015-2022). The primary outcome was the rate of intrapartum CD. In twin pregnancies, this outcome was limited to CD of both twins. The association of plurality with intrapartum CD was estimated using multivariable Poisson regression.

RESULTS

A total of 20 754 patients met the study criteria, 669 of whom had a twin pregnancy. Patients with twins had a greater risk of intrapartum CD (of both twins) than those with singleton pregnancies (22.1% vs 15.9%, respectively; aRR 1.38 [95% CI: 1.15-1.66]), primarily due to a greater risk of failure to progress. In addition, 4.1% of the twin pregnancies had a CD for the second twin, resulting in an overall CD rate in twin pregnancies of 26.2%. Variables associated with intrapartum CD in twin pregnancies included nulliparity (aOR 3.50, 95% CI: 2.34-5.25), birthweight discordance >20% (aOR 2.47, 95% CI: 1.27-4.78), and labor induction (aOR 1.64, 95% CI: 1.07-2.53). The rate of intrapartum CD was highest when all three risk factors were present (67% [95% CI: 41%-87%]).

CONCLUSION

Twin pregnancies are associated with a greater risk of intrapartum CD than singleton pregnancies. Information on the individualized risk of intrapartum CD may be valuable when counseling patients with twins regarding mode of delivery.

Children born to subfertile couples, how are they doing? Evidence from research

More than 10 million children have been born with assisted reproductive technology (ART) as we begin to enter the third generation of individuals conceived by ART. Here we summarise key messages from an enlarging body of literature regarding their health. Earlier research had pointed towards increases in perinatal, neonatal and neurological risks, such as preterm birth, low birth weight, congenital malformations and cerebral palsy. Many of these risks have continued to persist in most recent work but have shown reduction. Newer research proposes long-term cardiometabolic and endocrine concerns. Fortunately, most reports conclude there is little or no risk of increased childhood malignancy or abnormal neurodevelopment. Moving forward, new research may benefit from changes in comparator groups and a better understanding of infertility per se in ART, and the confounding role it probably plays in many of the known risk associations, to reliably scan the horizon for health threats for individuals born after ART.

Cervical length as a screening tool for preterm birth in twin pregnancies: a systematic review and critical evaluation of quality clinical practice guidelines

OBJECTIVES

Twin pregnancies are at increased risk of preterm birth (PTB) compared to singletons. Evaluation of cervical length (CL) represents the optimal tool to screen PTB in singleton. Conversely, there is less evidence on the use of CL in twins. Our aim was to evaluate the methodological quality and clinical heterogeneity of clinical practice guidelines (CPGs) on the CL application in twins using AGREE II methodology.

METHODS

MEDLINE, Scopus, and websites of the main scientific societies were examined. The following aspects were evaluated: diagnostic accuracy of CL, optimal gestational age at assessment and interventions in twin pregnancies with reduced CL. The quality of the published CPGs was carried out using "The Appraisal of Guidelines for REsearch and Evaluation (AGREE II)" tool. The quality of guideline was rated using a scoring system. Each considered item was evaluated by the reviewers on a seven-point scale that ranges from 1 (strongly disagree) to 7 (strongly agree). A cut-off >60 % identifies a CPGs as recommended.

RESULTS

The AGREE II standardized domain scores for the first overall assessment had a mean of 74 %. The score was more than 60 % in the 66.6 % of CPGs analyzed indicating an agreement between the reviewers on recommending the use of these CPGs. A significant heterogeneity was found; there was no specific recommendation on CL assessment in about half of the published CPGs. There was also significant heterogeneity on the CL cut-off to prompt intervention.

CONCLUSIONS

Despite the fact that the AGREE II analysis showed that the majority of the included guidelines are of good quality, there was a significant heterogeneity among CPGs as regard as the indication, timing, and cut-off of CL in twins as well as in the indication of interventions.

Association Between Assisted Reproductive Technology and Cerebral Palsy: A Meta-Analysis

BACKGROUND

Since 1978 many children are born thanks to assisted reproductive technology (ART). However, the long-term effects of these therapies are still not fully known. Our objective is to evaluate the risk of cerebral palsy (CP) after ART compared with that in those spontaneously conceived (SC) and to examine this risk in single, multiple, and preterm births and the evolution of the risk over the years.

METHODS

PubMed, Embase, and Web of Science databases were searched until December 2022. Studies were included if they studied CP cases in children born through ART. 16 studies were finally selected. Quality of studies was assessed using Newcastle Ottawa Scale. Pooled OR was estimated by weighting individual OR/RR by the inverse of their variance. A random-effect model was applied. To assess the causes of heterogeneity, we performed meta-regression analyses.

RESULTS

A significantly high risk of CP was found (OR = 1.27; 95% CI 1.12 to 1.43) in children born through ART compared with those SC. This risk increased in singletons (OR = 1.48; 95% CI 1.23 to 1.79) but disappeared in multiple (OR = 1.05; 95% CI 0.93 to 1.18) and preterm births (OR = 1.09; 95% CI 0.87 to 1.37). We found a higher risk of CP in children born before the year 2000 (OR = 3.40; 95% CI 2.49 to 4.63).

CONCLUSIONS

ARTs slightly increase the risk of CP once the effect of multiple gestation is controlled. Further studies are needed to clarify whether the techniques themselves, fertility problems, or associated maternal comorbidities are responsible for this risk.

The association of preconceptional folic acid supplementation with gestational age and preterm birth risk in twin pregnancies: a prospective cohort study in China

PURPOSE

This study aims to explore the association of maternal preconceptional folic acid (FA) supplementation with gestational age and preterm birth in twin pregnancies, and whether the association varies by chorionicity or conception mode.

METHODS

From November 2018 to December 2021, the information of FA supplementation and pregnancy outcomes were collected in twin pregnant women. The linear regression models and the logistic regression were used to test the association of preconceptional FA supplementation with gestational age at delivery and preterm birth and premature rupture of membranes (PROM).

RESULTS

A total of 416 twin pregnancies were included. Compared with no use in twins, maternal preconceptional FA use was associated with a 0.385-week longer gestational age (95% CI 0.019-0.751) and lower risk of preterm birth < 36 weeks (adjusted OR 0.519; 95% CI 0.301-0.895) and PROM (adjusted OR 0.426; 95% CI 0.215-0.845). The protective effect on preterm birth < 36 weeks and PROM is similar whether taking FA supplements alone or multivitamins. However, the associations varied by chorionicity and conception mode of twins or compliance with supplementation. The positive associations between preconceptional FA use and gestational age only remained significant among twins via assisted reproductive technology or dichorionic diamniotic twins. Significant protective effects on preterm birth < 36 weeks and PROM were only found among women who took FA at least 4 times a week before conception.

CONCLUSION

Maternal preconceptional FA supplementation was associated with longer gestation duration and lower risk of preterm birth < 36 weeks and PROM in twin pregnancies. To improve the success of their pregnancies, reproductive women should start taking FA supplements well before conception and with good compliance.

Arginase 1 does not affect RNA m6A methylation in mouse fetal lung

BACKGROUND

Arginase 1 (Arg1) encodes a key enzyme that catalyzes the metabolism of arginine to ornithine and urea. In our recent study, we found that knockdown of Arg1 in the lungs of fetal mice induces apoptosis of epithelial cells and dramatically delays initiation of labor. As the most abundant internal mRNA modification, N6 -methyladenosine (m6 A) has been found to play important roles in lung development and cellular differentiation. However, if the knockdown of Arg1 affects the RNA m6A modification in fetal lungs remains unknown.

METHODS

In the current study, the RNA m6A levels and the expression of RNA m6A related enzymes were validated in 13.0 dpc fetal lungs that Arg1 was knocked down by adeno-associated virus carrying Arg1-shRNA, using western blot, immunofluorescence, and RT-qPCR.

RESULTS

No statistical differences were found in the expression of methyltransferase, demethylases, and binding proteins in the fetal lungs between AAV-shArg1-injected mice and AAV-2/9-injected mice. Besides, there is no significant change of overall RNA m6A level in fetal lungs from AAV-shArg1-injected mice, compared with that from AAV-2/9-injected mice.

CONCLUSIONS

These results indicate that arginase 1 does not affect RNA m6A methylation in mouse fetal lung, and the mechanisms other than RNA m6A modification underlying the effects of Arg1 knockdown on the fetal lung development and their interaction with labor initiation need to be further explored.

Interpregnancy interval and adverse birth outcomes: a population-based cohort study of twins

BACKGROUND

To investigate associations between interpregnancy intervals (IPIs) and adverse birth outcomes in twin pregnancies.

METHODS

This retrospective cohort study of 9,867 twin pregnancies in Western Australia from 1980-2015. Relative Risks (RRs) were estimated for the interval prior to the pregnancy (IPI) as the exposure and after the pregnancy as a negative control exposure for preterm birth (< 37 weeks), early preterm birth (< 34 weeks), small for gestational age (SGA: < 10th percentile of birth weight by sex and gestational age) and low birth weight (LBW: birthweight < 2,500 g).

RESULTS

Relative to IPIs of 18-23 months, IPIs of < 6 months were associated with a higher risk of early preterm birth (aRR 1.41, 95% CI 1.08-1.83) and LBW for at least one twin (aRR 1.16, 95% CI 1.06-1.28). IPIs of 6-11 months were associated with a higher risk of SGA (aRR 1.24, 95% CI 1.01-1.54) and LBW for at least one twin (aRR 1.09, 95% CI 1.01-1.19). IPIs of 60-119 months and ≥ 120 months were associated with an increased risk of preterm birth (RR 1.12, 95% CI 1.03-1.22; and (aRR 1.25, 95% CI 1.10-1.41, respectively), and LBW for at least one twin (aRR 1.17, 95% CI 1.08-1.28; and aRR 1.20, 95% CI 1.05-1.36, respectively). IPIs of ≥ 120 months were also associated with an increased risk of early preterm birth (aRR 1.42, 95% CI 1.01-2.00). After negative control analysis, IPIs ≥ 120 months remained associated with early preterm birth and LBW.

CONCLUSION

Evidence for adverse associations with twin birth outcomes was strongest for long IPIs.

Management of short cervix in twin-to-twin transfusion syndrome: a role for pessary placement following fetoscopic laser surgery?

BACKGROUND

Preterm labor and delivery is a major concern for patients with twin-to-twin transfusion syndrome undergoing fetoscopic laser surgery. A preoperative short cervix is a risk factor for preterm labor. Pessary placement is a short-acting intervention that may be useful to reduce this adverse event.

OBJECTIVE

This study aimed to investigate the relationship between pessary placement and preterm delivery in monochorionic twin pregnancies with twin-to-twin transfusion syndrome and a short cervix before fetoscopic laser surgery.

STUDY DESIGN

This was a retrospective study in 2 centers, including all pregnancies affected by twin-to-twin transfusion syndrome that underwent fetoscopic laser surgery with the Solomon technique between 2013 and 2022 (center A) and 2014 and 2022 (center B) with a preoperative cervical length below 25 mm. This study explored the correlation between cervical length and fetoscopic laser surgery-to-delivery interval following active or expectant management and compared perinatal outcomes between patients managed expectantly and patients managed with pessary placement, using multivariate analysis to control for potential confounders. Patients with a cervical length below 5 mm were not included in the comparative analysis.

RESULTS

Of 685 patients, 134 met the inclusion criteria. Moreover, 21 patients were treated with a cervical cerclage and excluded from the analysis, leaving 113 patients for the final analysis. There was a significant negative correlation between cervical length at fetoscopic laser surgery and the risk of early delivery (adjusted odds ratio, 0.66; 95% confidence interval, 0.49-0.81; P<.001). The use of a pessary correlated with fewer patients delivering before 28 weeks of gestation (adjusted odds ratio, 0.28; 95% confidence interval, 0.09-0.75), fewer double neonatal demise (adjusted odds ratio, 0.2; 95% confidence interval, 0.05-0.75). Posthoc subgroup analysis suggested that these improvements were essentially noticeable for cervical lengths between 5 and 18 mm, where pessary placement was associated with an increased fetoscopic laser surgery-to-delivery interval (+24 days; 95% confidence interval, 0.86-42; P=.042) and later gestational age at delivery (+3.3 weeks; 95% confidence interval, 0.86-42; P=.035).

CONCLUSION

Patients with a moderately shortened cervix, between 5 and 18 mm, may benefit from pessary placement after fetoscopic surgery for twin-to-twin transfusion syndrome, resulting in a reduction of adverse neonatal outcomes, double neonatal demise, and severe preterm delivery.

The inheritance of groin hernias: an updated systematic review with meta-analyses

PURPOSE

The aim of this systematic review was to assess the inheritance of groin hernias.

METHODS

The primary outcome was to assess the inheritance based on the family history of groin hernias. We included studies that reported family history in patients with groin hernias, assessed the development of groin hernias in patients with a positive family history, or assessed the development of groin hernias in twins. Searches were conducted in PubMed, EMBASE, and Cochrane CENTRAL in November 2021. Results were synthesized narratively and with meta-analyses.

RESULTS

Twenty-two studies with unique participants were included. While two twin studies did not show convincing results of a genetic origin in children, database studies with low risk of bias showed that a positive history in parents or siblings increased the risk of inguinal hernia in children, and the risk was highest between mothers and daughters and between sisters. In adults, patients with inguinal hernia had higher odds of having a positive family history compared with patients without groin hernia (odds ratio 5.3, 95% confidence interval 3.3-8.7), and a nationwide study found the highest risk of inguinal hernia repair when a sister had been repaired compared with a brother. This study also found that having a sibling repaired for a groin hernia increased the risk of femoral hernia repair.

CONCLUSION

Despite studies being heterogeneous, there is overwhelming evidence that a positive family history is a risk factor for developing inguinal hernia in both children and adults, seemingly with a pronounced female-female inheritance pattern.

National and international guidelines on the management of twin pregnancies: a comparative review

Twin gestations are associated with increased risk of pregnancy complications. However, high-quality evidence regarding the management of twin pregnancies is limited, often resulting in inconsistencies in the recommendations of various national and international professional societies. In addition, some recommendations related to the management of twin gestations are often missing from the clinical guidelines dedicated to twin pregnancies and are instead included in the practice guidelines on specific pregnancy complications (eg, preterm birth) of the same professional society. This can make it challenging for care providers to easily identify and compare recommendations for the management of twin pregnancies. This study aimed to identify, summarize, and compare the recommendations of selected professional societies from high-income countries on the management of twin pregnancies, highlighting areas of both consensus and controversy. We reviewed clinical practice guidelines of selected major professional societies that were either specific to twin pregnancies or were focused on pregnancy complications or aspects of antenatal care that may be relevant for twin pregnancies. We decided a priori to include clinical guidelines from 7 high-income countries (United States, Canada, United Kingdom, France, Germany, and Australia and New Zealand grouped together) and from 2 international societies (International Society of Ultrasound in Obstetrics and Gynecology and the International Federation of Gynecology and Obstetrics). We identified recommendations regarding the following care areas: first-trimester care, antenatal surveillance, preterm birth and other pregnancy complications (preeclampsia, fetal growth restriction, and gestational diabetes mellitus), and timing and mode of delivery. We identified 28 guidelines published by 11 professional societies from the 7 countries and 2 international societies. Thirteen of these guidelines focus on twin pregnancies, whereas the other 16 focus on specific pregnancy complications predominantly in singletons but also include some recommendations for twin pregnancies. Most of the guidelines are recent, with 15 of the 29 guidelines published over the past 3 years. We identified considerable disagreement among guidelines, primarily in 4 key areas: screening and prevention of preterm birth, using aspirin to prevent preeclampsia, defining fetal growth restriction, and the timing of delivery. In addition, there is limited guidance on several important areas, including the implications of the "vanishing twin" phenomenon, technical aspects and risks of invasive procedures, nutrition and weight gain, physical and sexual activity, the optimal growth chart to be used in twin pregnancies, the diagnosis and management of gestational diabetes mellitus, and intrapartum care.This consolidation of key recommendations across several clinical practice guidelines can assist healthcare providers in accessing and comparing recommendations on the management of twin pregnancies and identifies high-priority areas for future research based on either continued disagreement among societies or limited current evidence to guide care.

Is intimate partner violence and obstetrics characteristics of pregnant women associated with preterm birth in Ethiopia? Umbrella review on preterm birth

BACKGROUND

Preterm birth is a significant contributor to newborns morbidity and mortality. Despite the availability of highly effective and powerful interventions, the burden of preterm birth has not decreased. Given the relevance of the topic to clinical decision-making, strong conclusive and supporting evidence emanating from the umbrella review is required. To this end, this umbrella review study sought to determine the association between intimate partner violence and obstetrics characteristics of women with preterm birth in Ethiopia.

METHODS

Six systematic review and meta-analysis studies searched across multiple databases were included in this umbrella review. The quality of the included systematic review and meta-analysis studies was evaluated using the Assessment of Multiple Systematic Reviews (AMSTAR-2) checklist. STATA version 18 was used for the statistical analysis. A random-effects model was used to calculate the overall effect measurement.

RESULTS

A total of 114 observational studies in the six systematic review and meta-analysis studies involving 75,624 pregnant women were included in this comprehensive analysis. The preterm birth rate among mothers in Ethiopia was 11% (95% CI 10-13%; I2 = 98.08). Preterm birth was significantly associated with intimate partner violence (POR: 2.32; 95% CI 1.74-2.90), multiple pregnancies (POR: 3.36; 95% CI 2.41-4.32), pregnancy-induced hypertension (POR: 4.13; 95% CI 3.17-5.10), anemia (POR: 2.76; 95% CI 1.97-3.56), and premature rupture of pregnancy (POR: 5.1; 95% CI 3.45-6.75).

CONCLUSIONS

More than one out of ten pregnant women experienced preterm birth in Ethiopia. Intimate partner violence is significantly associated with preterm birth. Furthermore, multiple pregnancies, pregnancy-induced hypertension, anemia, and premature rupture of the membrane were significant predictors of preterm birth. Therefore, policymakers should consider further instigations and implementations of policies and strategies closely related to reductions of intimate partner violence. It is also crucial to the early identification and treatment of high-risk pregnancies.

Prematurity and Low Birth Weight and Their Impact on Childhood Growth Patterns and the Risk of Long-Term Cardiovascular Sequelae

Preterm birth (before 37 completed weeks of gestation) is a global health problem, remaining the main reason for neonatal mortality and morbidity. Improvements in perinatal and neonatal care in recent decades have been associated with a higher survival rate of extremely preterm infants, leading to a higher risk of long-term sequelae in this population throughout life. Numerous surveillance programs for formerly premature infants continue to focus on neurodevelopmental disorders, while long-term assessment of the impact of preterm birth and low birth weight on child growth and the associated risk of cardiovascular disease in young adults is equally necessary. This review will discuss the influence of prematurity and low birth weight on childhood growth and cardiovascular risk in children, adolescents and young adults. The risk of cardiovascular and metabolic disorders is increased in adult preterm survivors. In early childhood, preterm infants may show elevated blood pressure, weakened vascular growth, augmented peripheral vascular resistance and cardiomyocyte remodeling. Increased weight gain during the early postnatal period may influence later body composition, promote obesity and impair cardiovascular results. These adverse metabolic alterations contribute to an increased risk of cardiovascular incidents, adult hypertension and diabetes. Preterm-born children and those with fetal growth restriction (FGR) who demonstrate rapid changes in their weight percentile should remain under surveillance with blood pressure monitoring. A better understanding of lifelong health outcomes of preterm-born individuals is crucial for developing strategies to prevent cardiovascular sequelae and may be the basis for future research to provide effective interventions.

Prediction of Preterm Birth among Infants with Orofacial Cleft Defects

OBJECTIVE

To develop risk prediction models for preterm birth among infants with orofacial clefts.

DESIGN

Data from the Texas Birth Defects Registry for infants with orofacial clefts born between 1999-2014 were used to develop preterm birth predictive models. Logistic regression was used to consider maternal and infant characteristics, and internal validation of the final model was performed using bootstrapping methods. The area under the curve (AUC) statistic was generated to assess model performance, and separate predictive models were built and validated for infants with cleft lip and cleft palate alone. Several secondary analyses were conducted among subgroups of interest.

SETTING

State-wide, population-based Registry data.

PATIENTS/PARTICIPANTS

6774 infants with orofacial clefts born in Texas between 1999-2014.

MAIN OUTCOME MEASURE(S)

Preterm birth among infants with orofacial clefts.

RESULTS

The final predictive model performed modestly, with an optimism-corrected AUC of 0.67 among all infants with orofacial clefts. The optimism-corrected models for cleft lip (with or without cleft palate) and cleft palate alone had similar predictive capability, with AUCs of 0.66 and 0.67, respectively. Secondary analyses had similar results, but the model among infants with delivery prior to 32 weeks demonstrated higher optimism-corrected predictive capability (AUC = 0.74).

CONCLUSIONS

This study provides a first step towards predicting preterm birth risk among infants with orofacial clefts. Identifying pregnancies affected by orofacial clefts at the highest risk for preterm birth may lead to new avenues for improving outcomes among these infants.

Multiple pregnancies, the myometrium and the role of mechanical factors in the timing of labour

Multiple pregnancy remains a relatively common occurrence, but it is associated with increased risks of adverse outcomes for the mother and her babies and presents unique challenges to healthcare providers. This review will briefly discuss multiple pregnancies, their aetiology and their problems, including preterm birth, before reviewing the processes leading to normal labour onset and how they may be different in a multiple pregnancy. The mechanisms by which mechanical factors i.e., uterine distension or 'stretch' contribute to uterine excitability and the timing of labour onset will be the major focus, and how over distention may pre-dispose multiple pregnancies to preterm birth. This includes current thinking around the role of mechano (stretch) sensitive ion channels in the myometrium and changes to other important regulators of excitability and contraction which have been identified from studies using in vitro and in vivo models of uterine stretch. Physiological stimuli arising from the fetus(es) and placenta(s) will also be discussed. In reviewing what we know about the myometrium in multiple pregnancy in humans, the focus will be on twin pregnancy as it is the most common type of multiple pregnancy and has been the most studied.

Arginase 1 and L-arginine coordinate fetal lung development and the initiation of labor in mice

Fetal development and parturition are precisely regulated processes that involve continuous crosstalk between the mother and the fetus. Our previous discovery that wild-type mice carrying steroid receptor coactivator (Src)-1 and Src-2 double-deficient fetuses exhibit impaired lung development and delayed labor, which indicates that the signals for parturition emanate from the fetus. In this study, we perform RNA sequencing and targeted metabolomics analyses of the lungs from fetal Src-1/-2 double-knockout mice and find that expression of arginase 1 (Arg1) is significantly decreased, accompanied by increased levels of the Arg1 substrate L-arginine. Knockdown of Arg1 in the lungs of fetal mice induces apoptosis of epithelial cells and dramatically delays initiation of labor. Moreover, treatment of human myometrial smooth muscle cells with L-arginine significantly inhibits spontaneous contractions by attenuating activation of NF-κB and downregulating expression of contraction-associated protein genes. Transcription factors GR and C/EBPβ increase transcription of Arg1 in an Src-1/Src-2-dependent manner. These findings provide new evidence that fetus-derived factors may play dual roles in coordinating fetal lung development and the initiation of labor.

Preterm Birth and Total Health Care Use and Costs in the First 5 Years of Life: A Population-based Study

OBJECTIVES

To investigate the relationship between preterm birth and hospital/out-of-hospital care and costs over the first 5 years of life.

STUDY DESIGN

Birth data from a population-based cohort of 631 532 infants born between 2007 and 2013 were linked probabilistically with data on hospitalizations, primary and secondary care, and the use of medications. We analyzed the distribution of health care use and public health care costs for infants who survived at least 5 years, comparing the outcomes of extremely preterm (<28 weeks of gestation), very preterm (28-32 weeks), moderate to late preterm (32-37 weeks), and term infants (at least 37 weeks). A linear regression model was used to investigate the effect of preterm birth on these outcomes, controlling for important confounders including pregnancy and birth complications, neonatal morbidity, survival, and maternal socioeconomic characteristics.

RESULTS

Preterm birth has a statistically significant and economically relevant effect on health care use and costs in the first 5 years of life. Compared with a term infant, preterm infants born at 32-36 weeks, 28-32 weeks, and <28 weeks of gestation had, respectively, an average of 7.0 (SE 0.06), 41.6 (0.18), and 68.7 (0.35) more hospital days; 3.1 (0.04), 11.0 (0.13), and 13.2 (0.25) more outpatient specialist physician visits; and 1.2-fold (<0.01), 6.8-fold (0.01), and 10.9-fold (0.02) higher 5-year public health care costs. Preterm infants also had statistically significantly higher levels of general practitioner visits and use of medications.

CONCLUSIONS

Higher levels of accessible care are needed for preterm infants across health care settings and over sustained periods. As our understanding of the impact of preterm birth on long-term clinical outcomes continues to improve, clinicians and policymakers should develop an accurate recognition of these needs to enable appropriate resource allocation toward research priorities and early intervention strategies.

Risk Scoring Systems for Preterm Birth and Their Performance: A Systematic Review

Introduction: Nowadays, the risk stratification of preterm birth (PTB) and its prediction remain a challenge. Many risk factors associated with PTB have been identified, and risk scoring systems (RSSs) have been developed to face this challenge. The objectives of this systematic review were to identify RSSs for PTB, the variables they consist of, and their performance. Materials and methods: Two databases were searched, and two authors independently performed the screening and eligibility phases. Records studying an RSS, based on specified variables, with an evaluation of the predictive value for PTB, were considered eligible. Reference lists of eligible studies and review articles were also searched. Data from the included studies were extracted. Results: A total of 56 studies were included in this review. The most frequently incorporated variables in the RSS included in this review were maternal age, weight, history of smoking, history of previous PTB, and cervical length. The performance measures varied widely among the studies, with sensitivity ranging between 4.2% and 92.0% and area under the curve (AUC) between 0.59 and 0.95. Conclusions: Despite the recent technological and scientifical evolution with a better understanding of variables related to PTB and the definition of new ultrasonographic parameters and biomarkers associated with PTB, the RSS's ability to predict PTB remains poor in most situations, thus compromising the integration of a single RSS in clinical practice. The development of new RSSs, the identification of new variables associated with PTB, and the elaboration of a large reference dataset might be a step forward to tackle the problem of PTB.

Nanomedicine strategies to improve therapeutic agents for the prevention and treatment of preterm birth and future directions

The World Health Organisation (WHO) estimates 15 million babies worldwide are born preterm each year, with 1 million infant mortalities and long-term morbidity in survivors. Whilst the past 40 years have provided some understanding in the causes of preterm birth, along with development of a range of therapeutic options, notably prophylactic use of progesterone or uterine contraction suppressants (tocolytics), the number of preterm births continues to rise. Existing therapeutics used to control uterine contractions are restricted in their clinical use due to pharmacological drawbacks such as poor potency, transfer of drugs to the fetus across the placenta and maternal side effects from activity in other maternal systems. This review focuses on addressing the urgent need for the development of alternative therapeutic systems with improved efficacy and safety for the treatment of preterm birth. We discuss the application of nanomedicine as a viable opportunity to engineer pre-existing tocolytic agents and progestogens into nanoformulations, to improve their efficacy and address current drawbacks to their use. We review different nanomedicines including liposomes, lipid-based carriers, polymers and nanosuspensions highlighting where possible, where these technologies have already been exploited e.g. liposomes, and their significance in improving the properties of pre-existing therapeutic agents within the field of obstetrics. We also highlight where active pharmaceutical agents (APIs) with tocolytic properties have been used for other clinical indications and how these could inform the design of future therapeutics or be repurposed to diversify their application such as for use in preterm birth. Finally we outline and discuss the future challenges.

Effects of parity on preterm delivery in twin gestations conceived with in vitro fertilization

Objective

To determine the relationship between prior obstetrical history and gestational age at delivery in a twin pregnancy.

Design

Retrospective cohort study using the United States Society for Assisted Reproductive Technology Clinic Outcomes Reporting System database.

Setting

Clinic-based data.

Patients

Patients undergoing in vitro fertilization (IVF) in the United States with live delivery of twins.

Interventions

None.

Main outcome measures

The main outcome measures are median gestational age at delivery and rate of preterm delivery (before 37 weeks).

Results

The median gestational age at delivery of IVF-conceived twins was 36.3 (interquartile rate 34.4, 37.6) weeks for nulliparous women, 35.9 (34.0, 37.1) weeks for parous women with a prior preterm birth, and 36.7 (35.1, 37.7) weeks for parous women without a prior preterm birth. The rate of preterm delivery was 61% for nulliparous women, 70% for parous women with a prior preterm birth, and 55% for parous women without a prior preterm birth.

Conclusions

Parous women without a history of preterm delivery had lower rates of preterm delivery in a subsequent twin pregnancy than nulliparous women. Nulliparous women had lower rates of preterm delivery compared with parous women with a history of preterm delivery.

Preterm birth characteristics and outcomes in Portugal, between 2010 and 2018-A cross-sectional sequential study

Introduction

According to the World Health Organization, 11% of all children are born prematurely, representing 15 million births annually. An extensive analysis on preterm birth, from extreme to late prematurity and associated deaths, has not been published. The authors characterize premature births in Portugal, between 2010 and 2018, according to gestational age, geographic distribution, month, multiple gestations, comorbidities, and outcomes.

Methods

A sequential, cross-sectional, observational epidemiologic study was conducted, and data were collected from the Hospital Morbidity Database, an anonymous administrative database containing information on all hospitalizations in National Health Service hospitals in Portugal, and coded according to the ICD-9-CM (International Classification of Diseases), until 2016, and ICD-10 subsequently. Data from the National Institute of Statistics was utilized to compare the Portuguese population. Data were analyzed using R software.

Results

In this 9-year study, 51.316 births were preterm, representing an overall prematurity rate of 7.7%. Under 29 weeks, birth rates varied between 5.5% and 7.6%, while births between 33 and 36 weeks varied between 76.9% and 81.0%. Urban districts presented the highest preterm rates. Multiple births were 8× more likely preterm and accounted for 37%-42% of all preterm births. Preterm birth rates slightly increased in February, July, August, and October. Overall, respiratory distress syndrome (RDS), sepsis, and intraventricular hemorrhage were the most common morbidities. Preterm mortality rates varied significantly with gestational age.

Conclusion

In Portugal, 1 in 13 babies was born prematurely. Prematurity was more common in predominantly urban districts, a surprise finding that warrants further studies. Seasonal preterm variation rates also require further analysis and modelling to factor in heat waves and low temperatures. A decrease in the case rate of RDS and sepsis was observed. Compared with previously published results, preterm mortality per gestational age decreased; however, further improvements are attainable in comparison with other countries.

Blastocyst Transplantation Strategies in Women of Different Ages

(1) Background: Single blastocyst transfers (SBT) and double blastocyst transfers (DBT) are widely used in clinical practice. The objective of this study was to investigate the application of these two strategies in women of different ages. (2) Methods: Analysis was carried out on 5477 frozen embryo transfer cycles of women in different ages. All the cycles were divided into three groups according to the age of the included women: <35, 35-39, and >39. The live birth rate (LBR) and multiple birth rate (MBR) between the SBT and DBT among these groups, respectively, were compared. (3) Results: In the women < 35 group, the LBR was similar in SBT and DBT, but the MBR was higher in DBT than SBT. In women 35-39, with >10 oocytes retrieved, the MBR in DBT was significantly higher than SBT, but there was no significant difference in LBR between the two groups; with ≤10 oocytes retrieved, the LBR in DBT were significantly higher than SBT, but the MBT was not significantly different between the two groups. In women > 39, the LBR and MBR were lower in the SBT than DBT, but the differences were not statistically significant. (4) Conclusions: Selective SET is appropriate for most young women, whereas older women are advised to make individualized choices based on the number of oocytes retrieved and blastocyst quality.

Contribution of Preterm Birth to Mortality Among Neonates with Birth Defects

OBJECTIVE

To estimate the proportion of neonatal mortality risk attributable to preterm delivery among neonates with birth defects.

STUDY DESIGN

Using a statewide cohort of live born infants from the Texas Birth Defects Registry (1999-2014 deliveries), we estimated the population attributable fraction and 95% CI of neonatal mortality (death <28 days) attributable to prematurity (birth at <37 weeks vs ≥37 weeks) for 31 specific birth defects. To better understand the overall population burden, analyses were repeated for all birth defects combined.

RESULTS

Our analyses included 169 148 neonates with birth defects, of which 40 872 (24.2%) were delivered preterm. The estimated proportion of neonatal mortality attributable to prematurity varied by birth defect, ranging from 12.5% (95% CI: 8.7-16.1) for hypoplastic left heart syndrome to 71.9% (95% CI: 41.1-86.6) for anotia or microtia. Overall, the proportion was 51.7% (95% CI: 49.4-54.0) for all birth defects combined.

CONCLUSIONS

A large proportion of deaths among neonates with birth defects are attributable to preterm delivery. Our results highlight differences in this burden across common birth defects. Our findings may be helpful for prioritizing future work focused on better understanding the etiology of prematurity among neonates with birth defects and the mechanisms by which prematurity contributes to neonatal mortality in this population.

Ultrasound-Indicated Cerclage in Twin Pregnancies: A Cohort Study

Background

To report the pregnancy and neonatal outcomes in patients with twin pregnancies who underwent ultrasound-indicated cerclage (UIC) and to compare them to patients with singleton pregnancies undergoing the same procedures.

Methods

Patients who underwent UIC between January 2010 and December 2020 at Kangnam Sacred Heart Hospital were reviewed. We compared characteristics, pregnancy, and neonatal outcomes between patients with singleton and twin pregnancies.

Results

A total of 94 women (56 singleton and 38 twin pregnancies) underwent UIC were included. The mean gestational age (GA) at cerclage and preoperative cervical length (CL) were not significantly different. Twin pregnancies were more likely to deliver at earlier median gestations than singletons (singleton, 36 + 1 weeks vs twin, 32 + 6 weeks, and p = 0.004). The frequency of preterm delivery <34 weeks in twin group was higher than in singleton group (15 (26.8%) vs 20 (52.6%) and p =0.016). However, the frequency of preterm delivery <32, <28, and <24 weeks was not significantly different between two groups. Although neonatal weights in singleton pregnancies were heavier than twin pregnancies, neonatal mortality and morbidities were not significantly different between two groups. Among various factors contributing to preterm birth, preoperative CL ≤ 15 mm was independently associated with a higher risk of preterm delivery before 34 weeks. Furthermore, pregnancy and neonatal outcomes of twin pregnancies with cervical length ≤ 15 mm are comparable with those of singleton pregnancies (GA at delivery, singleton, 35 + 1 weeks vs twin, 32 + 5 weeks, and p = 0.24; neonatal mortality, singleton, 3.4% vs twin, 4.8%, and p = 0.64).

Conclusion

The pregnancy and neonatal outcomes of UIC in twin pregnancies were comparable to those in singleton pregnancies, especially when CL is ≤15 mm. UIC might be considered a safe procedure for twin pregnancies.

Clinical analysis on the influencing factors related to preterm twin pregnancy

OBJECTIVE

The aim of this study was to explore the influencing factors of preterm twin pregnancy.

METHODS

In total, 602 twin-pregnant women delivered from February 2016 to February 2020 were analyzed retrospectively. According to whether the pregnant women were preterm or not, they were divided into preterm group (n=363) and term group (n=239). Baseline information, such as maternal age, address, and education level of the pregnant women, were collected. The clinical information of pregnant women, such as chorionic, preeclampsia, gestational diabetes, premature rupture of membranes, abnormal fetal position, and fetal weight, were analyzed. Logistic regression analysis was used to analyze the risk factors. p-value <0.05 was considered statistically significant.

RESULTS

In the preterm group, monochorionic diamniotic comorbidities were significantly higher compared with the control group (p<0.05). Higher risks of preterm group have lower education (p<0.05). Multiple logistic regression analysis demonstrated that education, preeclampsia, and premature rupture of membranes were risk factors for preterm twin pregnancy.

CONCLUSIONS

Preterm birth in twin pregnancy is associated with many risk factors, such as education, preeclampsia, and premature rupture of membranes. Pregnancy supervision and prenatal guidance for twin pregnancy should be strengthened. Furthermore, early detection and diagnosis of comorbidities can improve maternal and neonatal outcomes.

Premature monochorionic monoamniotic twins have lower lung compliance at birth than matched dichorionic diamniotic twins

BACKGROUND: Premature infants are born with immature lungs that demonstrate abnormal pulmonary function with differences in passive respiratory system compliance and resistance, and functional residual capacity. To our knowledge, no studies have evaluated differences in neonatal pulmonary function based on the type of twin gestation, or chorionicity. Given the effect of chorionicity on outcomes, we aimed to study the effect of twin type, monochorionic monoamniotic (MCMA) vs dichorionic diamniotic (DCDA), on neonatal early pulmonary function tests. METHODS: In this prospective cohort study, 5 sets of DCDA twins were matched to 5 sets of MCMA twins on gestational age at delivery, latency from antenatal corticosteroid exposure, birthweight, race and gender. Mean values were compared for passive respiratory system compliance and resistance, functional residual capacity, and tidal volume. RESULTS: MCMA infants had a significantly lower compliance (0.64 vs 1.25 mL/cm H2O /kg; p = 0.0001) and significantly higher resistance (0.130 vs 0.087 cm H2O /mL/sec; p = 0.0003) than DCDA infants. Functional residual capacity was lower for MCMA than DCDA infants (17.5 vs 23.4 mL/kg; p = 0.17). Further, 80% of MCMA infants required intubation for surfactant administration compared to 20% of DCDA infants, indicating the clinical significance of these objective measures. CONCLUSIONS: Due to the matched case-control design, causality cannot be established. However, we speculate that these differences in lung function may derive from differential exposure to preterm labor and endogenous maternal corticosteroid exposure. Further study is necessary to establish the true causal relationship.

Critical window for the association between prenatal environmental tobacco smoke exposure and preterm birth

Although environmental tobacco smoke (ETS) exposure is considered to be a severe public health problem and a modifiable risk factor for preterm birth (PTB), we still lack a comprehensive understanding of the PTB risk associated with trimester-specific prenatal ETS exposure. This study aimed to examine the accumulation of risk across trimester ETS exposure and the critical window of the association between maternal ETS exposure during pregnancy and PTB. A total of 63,038 mother-child pairs were involved in the analysis of the 2017 survey of Longhua Child Cohort Study. Information about socio-demographic characteristics, prenatal ETS exposure, and birth outcomes were collected using a self-report questionnaire. A series of logistic regression models were employed to assess the associations between prenatal ETS exposure and PTB. We found that maternal ETS exposure during pregnancy significantly increased the risk of PTB and this association increased with both the average level of daily ETS exposure and the number of trimesters of ETS exposure. Moreover, mothers who were initially exposed to ETS in the 1st trimester of pregnancy had significant higher risk of PTB (OR = 1.34, 95% CI: 1.25-1.44). Furthermore, mothers exposed to ETS in the 1st trimester only (OR = 1.26, 95%CI: 1.04-1.50), in both 1st and 2nd trimester (OR = 1.35, 95%CI: 1.08-1.67) and throughout pregnancy (OR = 1.35, 95%CI: 1.24-1.46) experienced a significantly high risk of PTB. Prenatal maternal ETS exposure during only the 2nd trimester also resulted in a high risk of PTB with marginal significance (OR = 1.33, 95% CI:0.78-2.13). To conclude, the 1st and early 2nd trimester might be the critical window for prenatal ETS exposure causing PTB.

Birth weight reference for Japanese twins and risk factors for infant mortality: A population-based study

There is no standard birth weight curve for twins in Japan other than a prototype curve based on 1988–1991. Twins have a high perinatal mortality rate than singletons; therefore, we developed a new standard curve for twin birth weight using data from the 1995–2016 Vital Statistics and compared it with previous reports. We used 469,064 cases for analysis, excluding stillbirths and cases with missing values, and created a standard curve using LMS (statistical methods to vary the distribution by using skewness, median, and coefficient of variation) method. In comparison with previous reports, the mean birth weight decreased by 100–200 g. The groups with the lowest neonatal death rates (NDRs) and infant death rates (IDRs) were those with a birth weight of 1,500–2,499 g (NDR: 0.3%, IDR: 0.6%) and those born at 34–36 weeks (NDR: 0.2%, IDR: 0.4%). Compared to these, the IDR was significantly higher in the 2,500–3,999 g group and the 37–39 weeks group (incidence rate ratio (IRR): 1.1 in the 2,500–3,999 g group, IRR: 1.3 in the 37w0d–39w6d group). In particular, the risks of neonatal mortality and infant mortality were higher in infants born at a birth weight above 3,500 g. Infants born at a birth weight above 3,500 g may include recipients of twin-to-twin transfusion syndrome. The most common causes of infant mortality are accidental death and sudden infant death syndrome (SIDS). We considered the possibility that infants treated as healthy newborns and whose mothers were discharged from the hospital without adequate twin care guidance may be more likely to experience unintentional accidents and SIDS at home. The present study suggested that creating a new twin birth weight standard curve and guidance on managing twins at home for full-term and normal birth weight infants may lead to a reduction in infant deaths.

Growth and Development in Preterm Infants and Maternal Parenting Stress after WeChat-Based Extended Care

Objective

WeChat-based extended care has been widely applied in clinical practice such as preoperative assistance in children with congenital heart disease and children with ventricular septal defect. In this study, we aimed to explore the impacts of WeChat-based extended care on the growth and development of preterm infants (PIs) and the nursing satisfaction of their family members.

Methods

From June 2019 to August 2021, 85 PIs and their mothers were selected as the research participants. Among them, 46 pairs receiving WeChat-based extended care were served as the WeChat group, and 39 pairs receiving routine extended care were taken as the control group. After 6 months of intervention, the two groups of PIs were compared in terms of physical development, IQ, and neurological and gastrointestinal functions. For mothers, their psychological states were assessed after intervention using the self-rating anxiety/depression scale (SAS/SDS), and the nursing satisfaction was counted.

Results

After nursing intervention, better physical and IQ development of PIs were observed in the WeChat group compared with the control group (P < 0.05). The WeChat group also had notably reduced level of neuron-specific enolase (NSE) and s100β protein related to nerve function than that in the control group and exhibited significant higher levels of serum gastrin (GAS) and motilin (MTL) associated with gastrointestinal function (P < 0.05). Besides, the WeChat group presented lower SAS and SDS scores and higher nursing satisfaction than the control group in delivery women (P < 0.05).

Conclusion

WeChat-based extended care can effectively improve the growth and development and various physical functions of PIs. At the same time, it is helpful to improve maternal psychological states and nursing satisfaction of delivery women, which is worth of clinical application.

[Factors associated with cesarean delivery of the second twin after vaginal delivery of the first twin: A case-control study]

OBJECTIVES

To identify risk factors for cesarean section of the second twin after vaginal delivery of the first twin.

METHODS

Case-control study conducted between 2004 and 2018 in a tertiary center, CHU Toulouse. Cases were women with twin pregnancy who had vaginal delivery of the first twin and emergency cesarean of the second twin. Controls were women with twin pregnancy who delivered both twins vaginally. Deliveries before 24 weeks of gestation, birth weight of less than 500 grams, fetal death in utero, terminations of pregnancy and delayed delivery were excluded. The association between potential risk factors and cesarean delivery of the second twin was analyzed using multivariable logistic regression.

RESULTS

Twenty-four patients who had vaginal delivery of the first twin and emergency cesarean of the second twin and 48 patients who delivered both twins vaginally were included. Neonatal morbidity was increased in the group of women who had an emergency cesarean of the second twin. In multivariable analysis, overweight (OR=10.5 [95% CI: 1.78-62.03] for women with body mass index above 25 compared to women with body mass index below 25), weight gain during pregnancy (OR=1.27 [95% CI: 1.01-1.48] for each kilogram) and preterm labor (OR=4,43 [IC 95%:1,10-17,80]) were associated with significantly increased risk of cesarean section of the second twin.

CONCLUSION

Overweight and weight gain during pregnancy are associated with increased risk for cesarean section of the second twin.

Association between Maternal Factors, Preterm Birth, and Low Birth Weight of Chilean Singletons

There has been an increase in preterm (PT) births in Western countries in recent years, which is associated with low-birthweight (LBW) children. The aim of this study was to determine the association between maternal factors and PT and LBW Chilean newborns. Methods: This was an analytical cross-sectional study of a national sample of 903,847 newborns and their mothers. The newborn gestational age, birth weight, maternal age, marital status, education, employment situation, and residence were analyzed. A multivariate logistic regression model was applied (α = 0.05) (STATA v.15). The prevalence was 6.8% and 5.0% for PT and LBW, respectively. The probability of the newborns being PT and LBW was 1.18 and 1.22 times if their mothers had <12 years of education and 1.38 and 1.29 times if the mothers were ≥35 years old, respectively. Mothers with <12 years education and ≥35 years were risk factors for PT and LBW newborns. Maternal educational attainment was a protective factor for the Chilean newborns, and a maternal age ≥35 years was a risk factor for PT and LBW.

Four kinds of tocolytic therapy for preterm delivery: Systematic review and network meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Premature birth affects more than 15 million infants, as well as mothers and families around the world. With the relaxation of the two-child policy, the problem of premature birth has become relatively prominent in China. According to statistics, China had a birth population of 15.23 million in 2018, with a considerably large number of premature births. This study aims to evaluate the efficacy and safety of tocolysis in the treatment of preterm delivery, provide clinical evidence for medical staff and promote the self-management of patients with premature births.

METHODS

Four English databases (PubMed, Embase, Cochrane Library and Web of Science) were retrieved by computer, the retrieval time was from the establishment of each database to November 2021, and the randomized controlled trials for the treatment of preterm delivery were screened according to the pre-set natriuretic exclusion criteria. After literature screening, data selection and risk of bias evaluation were independently conducted by two researchers. R 4.1.1 and Stata 17.0 software were used for statistical analysis.

RESULTS AND DISCUSSION

A total of 44 RCTs were included, including 6939 patients. The results of network meta-analysis reveal that in terms of effectiveness, indomethacin was the most effective intervention measure, followed by nifedipine, and the difference was statistically significant; regarding safety, nifedipine was the safest intervention measure, followed by indomethacin, and the difference was statistically significant; and in respect of adverse reactions, ritodrine had the highest probability, and the difference was statistically significant.

WHAT IS NEW AND CONCLUSION

Nifedipine may be better for delayed delivery and less likely to produce adverse pregnancy outcomes, followed by indomethacin. Limited by the number and quality of recipient studies, the aforementioned conclusions need to be verified through more high-quality studies. At the same time, the focus should be on patients with twin pregnancy and patients with clinical manifestations of extreme preterm delivery.

Clinical application of cervical shear wave elastography in predicting the risk of preterm delivery in DCDA twin pregnancy

Background

Limited studies have used cervical shear wave elastography (SWE) as a tool to investigate the predictive effect of cervical changes on preterm delivery (PTD) in twin pregnancy. This study is aimed to predict the risk of PTD by cervical SWE in dichorionic diamniotic (DCDA) twin pregnancy.

Methods

A total of 138 women with dichorionic diamniotic (DCDA) twins were included in this prospective study. The mean SWE value of the cervix was obtained from the inner, middle and outer regions of the anterior and posterior cervical lips using a transvaginal ultrasound transducer and measured consecutively across three different gestations (20–23^+ 6 weeks, 24–27^+ 6 weeks, and 28–32 weeks). Follow-up was performed on all subjects, and we compared the mean SWE value between the PTD and term delivery (TD) groups.

Results

A total of 1656 cervical mean SWE data were collected for analysis. Among the 138 twin pregnant women, only 92 women completed the three elastography examinations; PTD occurred in 58.7% (54/92), and TD in 41.3% (38/92). The mean (SD) maternal age was 33.1 ± 4.1 years, and the mean (SD) body mass index was 21.1 ± 2.6 kg/m². As gestational age increased, the mean SWE value of each part of the cervix decreased. The cervical mean SWE value was lower in the preterm group than in the term group in all three gestations, except for the anterior cervical lip at 28–32 weeks. Receiver operating characteristics (ROC) curves showed the sensitivity of mean SWE value of the anterior cervical lip was 83.3% (95% CI, 70.7–92.1) with a specificity of 57.9% (95% CI, 40.8–73.7) for predicting PTD at a cutoff value of 7.94 kPa. The positive likelihood ratio (LR+) was 1.67 (95% CI, 1.19–2.34), and the negative likelihood ratio (LR–) was 0.33 (95% CI, 0.17–0.64).

Conclusions

There is a significant negative correlation between cervical stiffness and gestational age in DCDA twin pregnancy. SWE is a potential tool for assessing cervical stiffness and predicting PTD in DCDA twin pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04526-0.

Comparison between Cervical Ureaplasma spp. Colonization and the Intensity of Inflammatory Mediators in the Amniotic Fluid Retrieved during Cesarean Delivery in Preterm Birth

We investigated whether cervical Ureaplasma spp. colonization affects the intensity of inflammatory mediators in amniotic fluid retrieved during cesarean delivery in singleton preterm birth. One hundred fifty-three cases in singleton preterm birth with 24-34 weeks' gestation were enrolled. The intensities of seven inflammatory mediators (interleukin (IL)-1β, IL-6, IL-8, IL-10, tumor necrosis factor-α, and matrix metalloproteins (MMP)-8, MMP-9) of amniotic fluid were measured. We tested cervical swab specimens using real-time polymerase chain reaction assays to detect Ureaplasma spp. colonization. Histologic chorioamnionitis (HCA) was diagnosed when acute inflammation was observed in any of the placental tissues. Mean gestational age at delivery and birth weight were 30.9 ± 2.4 weeks and 1567 ± 524 g, respectively. Cervical Ureaplasma spp. colonization was detected 78 cases. The incidence of HCA was 32.3% (43/133). Although the intensities of all inflammatory mediators were significantly different according to presence or absence of HCA, there were no significant differences according to cervical Ureaplasma spp. colonization. In all 43 cases with HCA and 90 cases without HCA, there were no significant differences between cervical Ureaplasma spp. colonization and the intensity of inflammatory mediators. Cervical Ureaplasma spp. colonization did not affect the intensity of inflammatory mediators in the amniotic fluid retrieved during cesarean delivery.

Role of epigenetics in parturition and preterm birth

Preterm birth occurs worldwide and is associated with high morbidity, mortality, and economic cost. Although several risk factors associated with parturition and preterm birth have been identified, mechanisms underlying this syndrome remain unclear, thereby limiting the implementation of interventions for prevention and management. Known triggers of preterm birth include conditions related to inflammatory and immunological pathways, as well as genetics and maternal history. Importantly, epigenetics, which is the study of heritable phenotypic changes that occur without alterations in the DNA sequence, may play a role in linking social and environmental risk factors for preterm birth. Epigenetic approaches to the study of preterm birth, including analyses of the effects of microRNAs, long non-coding RNAs, DNA methylation, and histone modification, have contributed to an improved understanding of the molecular bases of both term and preterm birth. Additionally, epigenetic modifications have been linked to factors already associated with preterm birth, including obesity and smoking. The prevention and management of preterm birth remains a challenge worldwide. Although epigenetic analysis provides valuable insights into the causes and risk factors associated with this syndrome, further studies are necessary to determine whether epigenetic approaches can be used routinely for the diagnosis, prevention, and management of preterm birth.

Cerclage placement in twin pregnancies with cervical dilation: a systematic review and meta-analysis

OBJECTIVE

Existing guidelines and studies on the benefits of cerclage in twin pregnancies with a dilated cervix have low reliability and inconsistent conclusions. New randomized control trials and cohort studies focusing on twin pregnancies with cervical insufficiency were published recently. Therefore, this meta-analysis aimed to compare outcomes of cerclage placement and expectant treatment in twin pregnancies with a dilated cervix using recent data.

METHODS

We screened the PubMed, Web of Science, ClinicalTrials.gov, and Cochrane Library databases to identify randomized controlled trials and cohort studies comparing maternal and perinatal outcomes of twin pregnancies with cervical dilation, with and without cerclage placement, published until December 2020. Estimates were pooled using random-effects or fixed-effect models depending on the heterogeneity. Mean difference, 95% confidence interval, and relative risk were used to compare the outcomes. The risk of bias was assessed using the Cochrane Handbook and the Newcastle-Ottawa Scale. The meta-analyses followed the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines for systematic reviews of observational studies.

RESULTS

Five studies, comprising 275 twin pregnancies, met the inclusion criteria; of those, 167 underwent cerclage and 108 were expectantly managed. Cerclage placement significantly prolonged the interval from the time of diagnosis to delivery and reduced the incidence of preterm delivery, perinatal death, and complications. The fetal outcomes improved significantly in cases managed with cerclage.

CONCLUSION

Therefore, emergent cerclage is a potential option for managing twin pregnancies with cervical dilation of at least 1 cm.

Perinatal outcome of dichorionic and monochorionic-diamniotic Finnish twins: a historical cohort study

INTRODUCTION

Although the perinatal mortality of monochorionic twins has been reported to be higher, the role of chorionicity is debated and data from Finland are still lacking. To examine the effect of chorionicity on the main outcome measures, perinatal and neonatal mortality and neonatal morbidity of Finnish twins, a comprehensive population-based historical cohort study was performed at Helsinki University Hospitals.

MATERIAL AND METHODS

All 1034 dichorionic and monochorionic-diamniotic twin pregnancies managed at Helsinki University Hospital area during 2006, 2010, 2014 and 2018 were collected from patient databases. Information on chorionicity was retrieved from ultrasound reports and all relevant clinical information from patient records. Differences in perinatal and neonatal mortality and neonatal morbidity were analyzed by performing group comparisons between the twins and chorionicity. The role of chorionicity was also assessed in logistic regression analyses.

RESULTS

There were 1034 dichorionic-diamniotic (DCDA, n = 789, 76.3%, 95% confidence interval [CI] 73.6-78.9) and monochorionic-diamniotic (MCDA, n = 245, 23.7%, 95% CI 21.4-26.0) twin pregnancies during the studied years. Most (n = 580, 56.1%, 95% CI 52.8-59.2) twins were born at term, but 151 (61.6%, 95% CI 55.8-67.3) of MCDA twins were preterm and had lower birthweight and Apgar scores and higher risk of death of one twin. Perinatal and neonatal mortality did not differ between twins A and B, but the immediate outcome of twin B was worse, with lower arterial pH and Apgar scores and increased need of neonatal intensive care unit treatment.

CONCLUSIONS

Chorionicity contributes to the perinatal and neonatal outcome in favor of dichorionic twins. This disadvantage of MCDA twinning is likely explained by earlier gestational age at birth and inequal placental sharing. Irrespective of chorionicity, twin B faces more complications.

Special Considerations Regarding Antenatal Care and Pregnancy Complications in Dichorionic Twin Pregnancies

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.

The Etiology of Neonatal Intensive Care Unit Death in Extremely Low Birth Weight Infants: A Multicenter Survey in China

OBJECTIVE

The aim of this study is to identify causes of neonatal intensive care unit (NICU) death in extremely low birth weight (ELBW) infants less than 1,000 g admitted in Chinese tertiary NICUs.

STUDY DESIGN

We retrospectively collected data on 607 ELBW infants from 39 level III NICUs from July 2016 to June 2019. The primary causes of death were compared among different gestation age, postnatal age groups, and areas with variable economic status.

RESULTS

Among all 607 ELBW NICU deaths, 47.1% were multiple gestation with high rate of in vitro fertilization (IVF) (43.3%); 53.4 and 34.1% received any or full course of antenatal corticosteroid (ACS). The most common causes of ELBW NICU death were respiratory distress syndrome-related neonatal respiratory failure (RDS-NRF, 43.5%), severe infection (19.1%), necrotizing enterocolitis or bowel perforation (9.4%), severe central nervous system injury (8.4%), and bronchopulmonary dysplasia-related respiratory failure (BPD-NRF, 7.7%). Causes of ELBW NICU death varied across postnatal age groups. RDS-NRF was the leading cause of early neonatal death, while severe infection in late neonatal death and BPD in postneonatal EBLW NICU death. RDS-NRF, severe brain injury, and asphyxia were most likely to die at early neonatal age (median age [interquartile range], 2 [0-5], 6 [3-9], and 3 [1-6] days, respectively) while severe infection and necrotizing enterocolitis (NEC) at late neonatal age, BPD-NRF at postneonatal age.

CONCLUSION

In Chinese tertiary NICUs, the major causes of death in extremely low birth weight infants were RDS, infection, NEC, brain injury and BPD, and they varied with postnatal age. Developing specific prevention strategies for identified causes of death in ELBW NICU may potentially improve ELBW survival.

Alvarez waves in pregnancy: a comprehensive review

Alvarez waves are local rhythmic contractions of the myometrium with high frequency and low intensity. They can be detected using internal or external tocography and electrohysterography. Some researchers correlate these small contractions with the initiation of labor, since they have been described as a pattern representing the uterine response to prostaglandin production. Other authors either do not validate a causality relation between Alvarez waves and labor or suggest that they have low predictive value for preterm labor. Alvarez waves' research has become a multidisciplinary subject with inputs ranging from medical science, biomedical engineering, and related areas. A comprehensive review is herein conducted to summarize the state of the art regarding Alvarez waves and their role in the initiation of labor, namely in preterm birth. The results show that a large number of studies have analyzed and characterized Alvarez waves without necessarily digging into their relationship with labor. Publications were categorized in three groups: (A) reports about morphology and characterization of Alvarez waves; (B) publications reporting a positive causality relation between Alvarez waves and labor; and (C) publications reporting an absence of causality regarding the previous hypothesis. Studies in group B outnumbered those in group C. A critical analysis is presented.

Development and external validation of a nomogram for predicting preterm birth at < 32 weeks in twin pregnancy

The purpose of this study was to develop a dynamic model to predict the risk of spontaneous preterm birth at < 32 weeks in twin pregnancy. A retrospective clinical study of consecutively asymptomatic women with twin pregnancies from January 2017 to December 2019 in two tertiary medical centres was performed. Data from one centre were used to construct the model, and data from the other were used to evaluate the model. Data on maternal demographic characteristics, transvaginal cervical length and funnelling during 20-24 weeks were extracted. The prediction model was constructed with independent variables determined by multivariate logistic regression analyses. After applying specified exclusion criteria, an algorithm with maternal and biophysical factors was developed based on 88 twin pregnancies with a preterm birth < 32 weeks and 639 twin pregnancies with a delivery ≥ 32 weeks. It was then evaluated among 34 pregnancies with a preterm birth < 32 weeks and 252 pregnancies with a delivery ≥ 32 weeks in a second tertiary centre without specific training. The model reached a sensitivity of 80.00%, specificity of 88.17%, positive predictive value of 50.33% and negative predictive value of 96.71%; ROC characteristics proved that the model was superior to any single parameter with an AUC of 0.848 (all P < 0.005). We developed and validated a dynamic nomogram model to predict the individual probability of early preterm birth to better represent the complex aetiology of twin pregnancies and hopefully improve the prediction and indication of interventions.

Mode of delivery and neonatal outcomes in extremely preterm Vertex/nonVertex twins

BACKGROUND

One of the controversies in the management of twin gestations relates to mode of delivery, especially when the second twin is in a nonvertex presentation (Vertex/nonVertex pairs) and birth is imminent at extremely low gestation.

OBJECTIVE

We hypothesized that, for Vertex/nonVertex twins born before 28 weeks' gestation, cesarean delivery would be associated with a lower risk of adverse neonatal outcomes than trial of vaginal delivery. Our aim was to test this hypothesis by comparing the neonatal outcomes of Vertex/nonVertex twins born before 28 weeks' gestation by mode of delivery using a large national cohort.

STUDY DESIGN

This work is a retrospective cohort study of all twin infants born at 24^0/7 to 27^6/7 weeks' gestation and admitted to level III neonatal intensive care units participating in the Canadian Neonatal Network (2010-2017). Exposure is defined a trial of vaginal delivery for Vertex/nonVertex twins. Nonexposed (control) groups are defined as cases where both twins were delivered by cesarean delivery, either in vertex or nonvertex presentation (control group 1) or owing to the nonvertex presentation of the first twin (control group 2). Outcome measures are defined as a composite of neonatal death, severe neurologic injury, or birth trauma.

RESULTS

A total of 1082 twin infants (541 twin pairs) met the inclusion criteria: 220 Vertex/nonVertex pairs, of which 112 had a trial of vaginal delivery (study group) and 108 had cesarean delivery for both twins (control group 1); 170 pairs with the first twin in nonvertex presentation, all of which were born by cesarean delivery (control group 2); and 151 pairs with both twins in vertex presentation (vertex or nonvertex). In the study group, the rate of urgent cesarean delivery for the second twin was 30%. The rate of the primary outcome in the study group was 42%, which was not significantly different compared with control group 1 (37%; adjusted relative risk, 0.93; 95% confidence interval, 0.71-1.22) or control group 2 (34%; adjusted relative risk, 1.20; 95% confidence interval, 0.92-1.58). The findings remained similar when outcomes were analyzed separately for the first and second twins.

CONCLUSION

For preterm Vertex/nonVertex twins born at <28 weeks' gestation, we found no difference in the risk of adverse neonatal outcome between a trial of vaginal delivery and primary cesarean delivery. However, a trial of vaginal delivery was associated with a high rate of urgent cesarean delivery for the second twin.

Preterm Delivery; Who Is at Risk?

Preterm birth (PTB) is the leading cause of perinatal morbidity and mortality. Adverse effects of preterm birth have a direct correlation with the degree of prematurity, in which infants who are born extremely preterm (24–28 weeks gestation) have the worst outcomes. We sought to determine prominent risk factors for extreme PTB and whether these factors varied between various sub-populations with known risk factors such as previous PTB and multiple gestations. A population-based retrospective cohort study was conducted. Risk factors were examined in cases of extreme PTB in the general population, as well as various sub-groups: singleton and multiple gestations, women with a previous PTB, and women with indicated or induced PTB. A total of 334,415 deliveries were included, of which 1155 (0.35%) were in the extreme PTB group. Placenta previa (OR = 5.8, 95%CI 4.14–8.34, p < 0.001), multiple gestations (OR = 7.7, 95% CI 6.58–9.04, p < 0.001), and placental abruption (OR = 20.6, 95%CI 17.00–24.96, p < 0.001) were the strongest risk factors for extreme PTB. In sub-populations (multiple gestations, women with previous PTB and indicated PTBs), risk factors included placental abruption and previa, lack of prenatal care, and recurrent pregnancy loss. Singleton extreme PTB risk factors included nulliparity, lack of prenatal care, and placental abruption. Placental abruption was the strongest risk factor for extreme preterm birth in all groups, and risk factors did not differ significantly between sub-populations.

Pathologic Basis for the Definition of Discordant Growth in Dichorionic Twins

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.

Hypertensive Disorders during Pregnancy (HDP), Maternal Characteristics, and Birth Outcomes among Japanese Women: A Hokkaido Study

Hypertension during pregnancy causes a greater risk of adverse birth outcomes worldwide; however, formal evidence of hypertensive disorders during pregnancy (HDP) in Japan is limited. We aimed to understand the association between maternal characteristics, HDP, and birth outcomes. In total, 18,833 mother-infant pairs were enrolled in the Hokkaido study on environment and children’s health, Japan, from 2002 to 2013. Medical records were used to identify hypertensive disorders and birth outcomes, namely, small for gestational age (SGA), SGA at full term (term-SGA), preterm birth (PTB), and low birth weight (LBW). The prevalence of HDP was 1.9%. Similarly, the prevalence of SGA, term-SGA, PTB, and LBW were 7.1%, 6.3%, 7.4%, and 10.3%, respectively. The mothers with HDP had increased odds of giving birth to babies with SGA (2.13; 95% Confidence Interval (CI): 1.57, 2.88), PTB (3.48; 95%CI: 2.68, 4.50), LBW (3.57; 95%CI: 2.83, 4.51) than normotensive pregnancy. Elderly pregnancy, low and high body mass index, active and passive smoking exposure, and alcohol consumption were risk factors for different birth outcomes. Therefore, it is crucial for women of reproductive age and their families to be made aware of these risk factors through physician visits, health education, and various community-based health interventions.

Sugammadex Administration in Pregnant Women: A Case Series of Maternal and Fetal Outcomes

Sugammadex, given its high affinity for amino-steroid neuromuscular blockers, offers rapid and reliable neuromuscular blockade reversal, making it a popular reversal agent. This characteristic can be very useful in pregnant women, where incomplete reversal can have poor maternal and fetal outcomes. However, its use antenatally in pregnancy is controversial given concerns for progesterone binding, a hormone that is crucial for maintenance of pregnancy. This case series presents obstetric and fetal outcomes in 25 pregnant women who received sugammadex during the antenatal period, thus highlighting the need for further research into the safety of sugammadex during pregnancy.