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Nichols AR, Haeri S, Rudine A, Burns N, Rathouz PJ, Hedderson MM, Abrams SA, Foster SF, Rickman R, McDonnold M, Widen EM. Prenatal Weight Change Trajectories and Perinatal Outcomes among Twin Gestations. Am J Perinatol 2024; 41:1445-1454. [PMID: 37164320 PMCID: PMC10782825 DOI: 10.1055/a-2091-1254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Despite an increase in twin pregnancies in recent decades, the Institute of Medicine twin weight gain recommendations remain provisional and provide no guidance for the pattern or timing of weight change. We sought to characterize gestational weight change trajectory patterns and examine associations with birth outcomes in a cohort of twin pregnancies. STUDY DESIGN Prenatal and delivery records were examined for 320 twin pregnancies from a maternal-fetal medicine practice in Austin, TX 2011-2019. Prenatal weights for those with >1 measured weight in the first trimester and ≥3 prenatal weights were included in analyses. Trajectories were estimated to 32 weeks (mean delivery: 33.7 ± 3.3 weeks) using flexible latent class mixed models with low-rank thin-plate splines. Associations between trajectory classes and infant outcomes were analyzed using multivariable Poisson or linear regression. RESULTS Weight change from prepregnancy to delivery was 15.4 ± 6.3 kg for people with an underweight body mass index, 15.4 ± 5.8 kg for healthy weight, 14.7 ± 6.9 kg for overweight, and 12.5 ± 6.4 kg for obesity. Three trajectory classes were identified: low (Class 1), moderate (Class 2), or high gain (Class 3). Class 1 (24.7%) maintained weight for 15 weeks and then gained an estimated 6.6 kg at 32 weeks. Class 2 (60.9%) exhibited steady gain with 13.5 kg predicted total gain, and Class 3 (14.4%) showed rapid gain across pregnancy with 21.3 kg predicted gain. Compared to Class 1, Class 3 was associated with higher birth weight z-score (β = 0.63, 95% confidence interval [CI]: 0.31,0.96), increased risk for large for gestational age (IRR = 5.60, 95% CI: 1.59, 19.67), and birth <32 weeks (IRR = 2.44, 95% CI: 1.10, 5.4) that was attenuated in sensitivity analyses. Class 2 was associated with moderately elevated birth weight z-score (β = 0.24, 95% CI: 0.00, 0.48, p = 0.050). CONCLUSION Gestational weight change followed a low, moderate, or high trajectory; both moderate and high gain patterns were associated with increased infant size outcomes. Optimal patterns of weight change that balance risk during the prenatal, perinatal, and neonatal periods require further investigation, particularly in high-risk twin pregnancies. KEY POINTS · A majority gained weight below IOM twin recommendations.. · Three patterns of GWC across pregnancy were identified.. · Moderate or high GWC was associated with infant size..
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Affiliation(s)
- Amy R Nichols
- Department of Nutritional Sciences, The University of Texas at Austin, Austin, Texas
| | - Sina Haeri
- Women's Center of Texas, St. David's Healthcare, Austin, Texas
| | - Anthony Rudine
- Office of Research, St. David's Healthcare, Austin, Texas
| | - Natalie Burns
- Department of Statistics, University of Florida, Gainesville, Florida
| | - Paul J Rathouz
- Department of Population Health and Biomedical Data Science Hub, The University of Texas at Austin Dell Medical School, Austin, Texas
| | - Monique M Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Steven A Abrams
- Department of Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas
| | - Saralyn F Foster
- Department of Nutritional Sciences, The University of Texas at Austin, Austin, Texas
| | - Rachel Rickman
- Department of Nutritional Sciences, The University of Texas at Austin, Austin, Texas
| | | | - Elizabeth M Widen
- Department of Nutritional Sciences, The University of Texas at Austin, Austin, Texas
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Post AL. Managing Monoamniotic Twin Pregnancies. Clin Obstet Gynecol 2023; 66:841-853. [PMID: 37910073 DOI: 10.1097/grf.0000000000000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Monoamniotic twins comprise a rare subset of twins at risk of unique and serious complications. In addition to the risks faced by all twins (premature birth, growth restriction), all monochorionic twins (twin-to-twin transfusion syndrome), and all monozygotic twins (congenital anomalies), monoamniotic twins face the unique risk of cord entanglement, in addition to a markedly increased risk of congenital anomalies. Early diagnosis, screening for fetal anomalies and surveillance for twin-twin transfusion syndrome are critical. After fetal viability, frequent fetal monitoring reduces the risk of intrauterine fetal demise.
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Shea SK, Newman RB. Fetal Growth and Antenatal Testing in Uncomplicated Multiple Gestations. Clin Obstet Gynecol 2023; 66:864-883. [PMID: 37910097 DOI: 10.1097/grf.0000000000000815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Multiple gestations experience a slowing of fetal growth in the third trimester and have been described as having a higher risk of growth restriction. Whether this increased diagnosis of fetal growth restriction is physiological or pathologic is controversial. In an attempt to better identify those fetuses most at risk, twin-specific growth charts have been developed and tested. In addition, there are data to suggest that multiple gestations experience an increased risk of unexpected third-trimester stillbirth in apparently uncomplicated pregnancies. This chapter reviews the current data and recommendations for fetal growth assessment, antenatal surveillance, and delivery timing in uncomplicated multiple gestations.
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Affiliation(s)
- Sarah K Shea
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Medical University of South Carolina, Charleston, South Carolina
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Monari F, Chiossi G, Ballarini M, Menichini D, Gargano G, Coscia A, Baronciani D, Facchinetti F. Perinatal outcomes in twin late preterm pregnancies: results from an Italian area-based, prospective cohort study. Ital J Pediatr 2022; 48:101. [PMID: 35710441 PMCID: PMC9204959 DOI: 10.1186/s13052-022-01297-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multiple gestations represent a considerable proportion of pregnancies delivering in the late preterm (LP) period. Only 30% of LP twins are due to spontaneous preterm labor and 70% are medically indicated; among this literature described that 16-50% of indicated LP twin deliveries are non-evidence based. As non-evidence-based delivery indications account for iatrogenic morbidity that could be prevented, the objective of our observational study is to investigate first neonatal outcomes of LP twin pregnancies according to gestational age at delivery, chorionicity and delivery indication, then non evidence-based delivery indications. METHODS Prospective cohort study among twins infants born between 34 + 0 and 36 + 6 weeks, in Emilia Romagna, Italy, during 2013-2015. The primary outcome was a composite of adverse perinatal outcomes. RESULTS Among 346 LP twins, 84 (23.4%) were monochorionic and 262 (75.7%) were dichorionic; spontaneous preterm labor accounted for 85 (24.6%) deliveries, preterm prelabor rupture of membranes for 66 (19.1%), evidence based indicated deliveries were 117 (33.8%), while non-evidence-based indications were 78 (22.5%). When compared to spontaneous preterm labor or preterm prelabor rupture of membranes, pregnancies delivered due to maternal and/or fetal indications were associated with higher maternal age (p < 0.01), higher gestational age at delivery (p < 0.01), Caucasian race (p 0.04), ART use (p < 0.01), gestational diabetes (p < 0.01), vaginal bleeding (p < 0.01), antenatal corticosteroids (p < 0.01), diagnosis of fetal growth restriction (FGR) (p < 0.01), and monochorionic (p < 0.01). Two hundred twenty-six pregnancies (65.3%) had at least one fetus experiencing one composite of adverse perinatal outcome. Multivariate analysis confirmed that delivery indication did not affect the composite of adverse perinatal outcomes; the only characteristic that affect the outcome after controlling for confounding was gestational age at delivery (p < 0.01). Moreover, there was at least one adverse neonatal outcome for 94% of babies born at 34 weeks, for 73% of those born at 35 weeks and for 46% of those born at 36 weeks (p < 0.01). CONCLUSION Our study suggests that the decision to deliver or not twins in LP period should consider gestational age at delivery as the main determinant infants' prognosis. Delivery indications should be accurately considered, to avoid iatrogenic early birth responsible of preventable complications.
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Affiliation(s)
- Francesca Monari
- Obstetrics and Gynecology Unit, Mother-Infant and Adult Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41125, Modena, Italy.
| | - Giuseppe Chiossi
- Obstetrics and Gynecology Unit, Mother-Infant and Adult Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41125, Modena, Italy
| | - Michela Ballarini
- Obstetrics and Gynecology Unit, Mother-Infant and Adult Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41125, Modena, Italy
| | - Daniela Menichini
- Department of Biomedical, Metabolic and Neural Sciences, International Doctorate School in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41125, Modena, Italy
| | - Giancarlo Gargano
- Department of Obstetrics and Pediatrics, Neonatal Intensive Care Unit, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Alessandra Coscia
- Department of Public Health and Pediatrics, Neonatology Unit, Università degli Studi di Torino, 10126, Turin, Italy
| | - Dante Baronciani
- Health Facilities, Technologies and Information Systems Unit, Emilia-Romagna Region, Viale Aldo Moro 21, 40127, Bologna, Italy
| | - Fabio Facchinetti
- Obstetrics and Gynecology Unit, Mother-Infant and Adult Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41125, Modena, Italy
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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: 22] [Impact Index Per Article: 11.0] [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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Abstract
Full-term deliveries are defined as occurring between 39 weeks and 40 weeks and 6 days. Because contemporary research suggests improved outcomes with delivery in the term period compared with the early term period, nonindicated delivery should be pursued no earlier than 39 weeks. There are, however, multiple medical, obstetric, and fetal indications for delivery before 39 weeks, and the obstetric provider must weigh the risks and benefits of delivery versus expectant management on both the mother and fetus. This review serves to provide a basic framework of evidentiary support toward optimizing the term delivery.
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Affiliation(s)
- Timothy Wen
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94158, USA
| | - Amy L Turitz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 West 168th Street, New York, NY 10032, USA.
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Eschbach SJ, Tollenaar LSA, Oepkes D, Lopriore E, Haak MC. Intermittent absent and reversed umbilical artery flows in appropriately grown monochorionic diamniotic twins in relation to proximate cord insertion: A harmful combination? Prenat Diagn 2020; 40:1284-1289. [PMID: 32412655 PMCID: PMC7539996 DOI: 10.1002/pd.5736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/28/2023]
Abstract
Objective To compare the prevalence of intermittent absent or reversed end‐diastolic flow (iAREDF) in the umbilical artery in appropriately grown monochorionic diamniotic (MCDA) pregnancies with and without proximate cord insertion (PCI), and to evaluate pregnancy outcome. Methods The prevalence of iAREDF in MCDA pregnancies with PCI (n = 11) was compared with a control group without PCI (n = 33). PCI was defined as a distance between the cord insertions below the fifth percentile. Placental sharing, number, and diameter of anastomoses were assessed by placental examination. Pregnancy outcome was evaluated. Results iAREDF was present in 7/11 PCI pregnancies, compared with 0/33 in the control group (P ≤ .01). All PCI pregnancies and 94% of controls had arterioarterial (AA)‐anastomoses (P = .56), the diameter was larger in the PCI group, respectively 3.3 vs 2.1 mm (P = .03). Three cases with iAREDF had adverse outcome, two resulted in fetal death of which one with brain damage in the co‐twin, another underwent early premature emergency section for fetal distress. Conclusion iAREDF occurs in a large proportion of MCDA pregnancies with PCI and is related to the diameter of the AA anastomosis. We hypothesize that iAREDF in appropriately grown MCDA twin pregnancies reflects an unstable hemodynamic balance with an increased risk for fetal deterioration. Whether outcome in these pregnancies can be improved by altered management requires further investigation.
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Affiliation(s)
- Sanne Johanna Eschbach
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Lisanne S A Tollenaar
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Changes in the perinatal outcomes of twin pregnancies delivered at a tertiary referral center in Korea during a 24-year period from 1995 to 2018. Obstet Gynecol Sci 2020; 63:251-260. [PMID: 32489969 PMCID: PMC7231938 DOI: 10.5468/ogs.2020.63.3.251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/24/2019] [Accepted: 10/04/2019] [Indexed: 11/15/2022] Open
Abstract
Objective To analyze the changes in the clinical characteristics and perinatal outcomes of twin pregnancies delivered at a tertiary referral center in Korea during a 24-year period. Methods This was a retrospective cohort study of twin pregnancies delivered at 24–40 weeks of gestation, from 1995 to 2018. The subjects were divided into 4 groups according to the year of delivery: 1995–2000, 2001–2006, 2007–2012, and 2013–2018. The trends in the changes in the twin birth rate, maternal age, assisted reproductive technology (ART) pregnancy rate, chorionicity, obstetric complications, delivery outcomes, and neonatal outcomes over the periods were analyzed. Results A total of 2,133 twin pregnancies were included in the study. The twin birth rate increased from 16.7/1,000 in 1995–2000 to 42.2/1,000 in 2001–2006, 49.5/1,000 in 2007–2012, and 61.8/1,000 in 2013–2018. The maternal age and ART pregnancy and dichorionic twin rates increased, while the monochorionic twin rate decreased over the periods. The incidence of fetal congenital anomalies, cervical incompetence, gestational diabetes mellitus, preeclampsia, and placental abruption increased over the periods. The preterm birth (PTB) rate significantly decreased owing to the decreasing elective late-PTB rate; however, the early-PTB rate significantly increased. Conclusion This study found that twin pregnancies increased steadily over the last 24 years and that the increase was related to increased maternal age and ART pregnancy rate. The incidence of obstetric complications increased over the periods; however, the neonatal intensive care unit admission rate decreased, along with decreases in the elective late-PTB rate.
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Delivery timing after laser surgery for twin-twin transfusion syndrome. J Perinatol 2020; 40:248-255. [PMID: 31611614 DOI: 10.1038/s41372-019-0532-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/12/2019] [Accepted: 08/19/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare outcomes of twin-twin transfusion syndrome (TTTS) patients who underwent early elective delivery vs. expectant management. STUDY DESIGN Retrospective study of monochorionic diamniotic twins who underwent laser surgery for TTTS and had dual survivors at 32 weeks. Patients who underwent elective delivery between 32 0/7 to 35 6/7 weeks ("early elective group") were compared with all patients who delivered ≥36 0/7 weeks ("expectant management group"). The primary outcome was a composite of fetal and neonatal morbidity. RESULTS The final study population was comprised of 15 early elective and 119 expectant management patients. Those in the early elective group were seven times more likely to experience the primary outcome (OR 7.38 [2.01-27.13], p = 0.0026). CONCLUSION Among patients who underwent laser surgery for TTTS who had dual survivors at 32 weeks, elective delivery prior to 36 weeks did not appear to be protective.
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Comparison of perinatal outcomes in late preterm birth between singleton and twin pregnancies. Obstet Gynecol Sci 2017; 60:421-426. [PMID: 28989917 PMCID: PMC5621070 DOI: 10.5468/ogs.2017.60.5.421] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/20/2017] [Accepted: 03/27/2017] [Indexed: 12/17/2022] Open
Abstract
Objective To determine whether late preterm twin neonates have a more favorable perinatal outcome than singleton late preterm neonates. Methods We studied 401 late preterm births between 34+0 and 36+6 weeks of gestation, from January 2011 to December 2014 in our institution. We compared the maternal and neonatal characteristics and perinatal outcomes between singleton and twin pregnancies. Perinatal outcomes included Apgar score, admission to the neonatal intensive care unit (NICU) or special care nursery, duration of NICU stay, and the rate of composite morbidity (antibiotic use, hypoglycemia, hypocalcemia, hyperbilirubinemia requiring phototherapy, respiratory support, and respiratory distress syndrome). Results A total of 289 neonates were in the singleton group and 112 in the twin group. The twin group showed smaller mean birth weight despite of longer gestational age at delivery. In addition, there were significant differences in the indication of delivery and cesarean section rate between the 2 groups. Overall, the risk of composite morbidity was similar between 2 groups (odds ratio, 1.4; 95% confidence interval, 0.8 to 2.4). Conclusion Our findings suggest that late preterm twins do not show a more favorable outcome than singleton late preterm births.
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Guo Y, Sun Y, Yang H. Growth discordance of monoamniotic twin because of difference of cords diameter in forked umbilical cord: Case report. Medicine (Baltimore) 2017; 96:e8042. [PMID: 28906394 PMCID: PMC5604663 DOI: 10.1097/md.0000000000008042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A case of monochorionic-monoamniotic (MCMA) twin pregnancy with growth discordance because of difference of cord diameter in forked umbilical cord is reported.MCMA twins were diagnosed at 12 weeks of gestation and twin growth discordance was considered during the follow-up twice-weekly visits to the ultrasound and prenatal care units. The pregnancy was terminated at 34 weeks. Two live female babies weighing 2510 g and 1940 g were delivered. Examination of placenta and umbilical cords after birth showed that the 2 cords merged into a conjoint cord 1 cm from insertion to the placenta (forked umbilical cord). Placental color injection showed that the 2 fetuses shared the same placenta area. The diameters of the 2 cords were significantly different (1.5 vs 0.8 cm). This caused an unequal distribution of blood and nutrients, which is the real reason of twin growth discordance in this case.This case reveals that the diameter discordance of cords can be an important factor for twin growth discordance. Few relevant cases have previously been reported. Cords diameter measurement is suggested for ultrasound surveillance of twin growth discordance.
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Sung JH, Kim SH, Kim YM, Kim JH, Kim MN, Lee HR, Lee HJ, Lee EJ, Choi SJ, Oh SY, Roh CR, Kim JH. Neonatal outcomes of twin pregnancies delivered at late-preterm versus term gestation based on chorionicity and indication for delivery. J Perinat Med 2016; 44:903-911. [PMID: 27149198 DOI: 10.1515/jpm-2015-0401] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 03/31/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the neonatal outcomes of twin pregnancies delivered at late-preterm versus term gestation based on chorionicity and indication for delivery. STUDY DESIGN This is a retrospective cohort study of women with twin pregnancies delivered at ≥34 weeks of gestation from 1995 to 2014. Subjects were categorized into two groups according to gestational age at delivery: late-preterm group (34-36 weeks) and term group (≥37 weeks). Neonatal outcome measures including neonatal intensive care unit (NICU) admission, mechanical ventilator support, and respiratory distress syndrome (RDS) were compared between the late-preterm and term group based on chorionicity (monochorionic or dichorionic) and delivery indication (elective or non-elective). RESULTS A total of 1198 twin pregnancies were included in the study: 679 in the late-preterm group and 519 in the term group. Late-preterm twin infants had higher rates of NICU admission, mechanical ventilator support, and RDS than did term twin infants, regardless of the chorionicity and indication for delivery. In the multivariable analysis, late-preterm birth, monochorionicity, and non-elective delivery were independently associated with a significantly higher risk of NICU admission and mechanical ventilator support. CONCLUSION The late-preterm birth was associated with a higher risk of adverse neonatal outcome regardless of chorionicity and indication for delivery, and showed significantly increased risk by monochorionicity and non-elective delivery.
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Abstract
Monoamniotic twins comprise a rare but important subset of twins at risk of unique and serious complications, placing them at the highest risk of perinatal mortality of all twin gestations. In addition to risks faced by all twins (prematurity, selective growth restriction), all monochorionic twins (twin-twin transfusion syndrome), and all monozygotic twins (congenital anomalies), monoamniotic twins face the unique risk of cord entanglement. Accordingly, early diagnosis, screening for fetal anomalies, surveillance for twin-twin transfusion syndrome, decisions related to monitoring after viability, and timing and route of delivery are all critical. Herein, we present recommendations for optimal management.
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Gestational age at delivery and neonatal outcome in uncomplicated twin pregnancies: what is the optimal gestational age for delivery according to chorionicity? Obstet Gynecol Sci 2016; 59:9-16. [PMID: 26866030 PMCID: PMC4742483 DOI: 10.5468/ogs.2016.59.1.9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/17/2015] [Accepted: 08/25/2015] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the neonatal outcome according to the gestational age at delivery and to determine the optimal timing for delivery in uncomplicated monochorionic and dichorionic twin pregnancies. Methods This is a retrospective cohort study of women with uncomplicated twin pregnancies delivered at or beyond 35 weeks of gestation from 1995 to 2013. The primary outcome was neonatal composite morbidity, which was defined as when either one or both twins have one or more of the followings: fetal death after 35 weeks gestation, admission to neonatal intensive care unit, mechanical ventilator requirement, respiratory distress syndrome and neonatal death. To determine the optimal gestational age for delivery according to chorionicity, we compared the neonatal composite morbidity rate between women who delivered and women who remained undelivered at each gestational week in both monochorionic and dichorionic twin pregnancies. Results A total of 697 twin pregnancies were included (171 monochorionic and 526 dichorionic twins). The neonatal composite morbidity rate significantly decreased with advancing gestational age at delivery and its nadir was observed at 38 and ≥39 weeks of gestation in monochorionic and dichorionic twins, respectively. However, the composite morbidity rate did not differ between women who delivered and women who remained undelivered ≥36 and ≥37 weeks in monochorionic and dichorionic twins, respectively. Conclusion Our data suggest that the optimal gestational age for delivery was at ≥36 and ≥37 weeks in uncomplicated monochorionic and dichorionic twin pregnancies, respectively.
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Agarwal K. Uncomplicated Monochorionic Twins––Is Elective Preterm Delivery Mandatory? JOURNAL OF FETAL MEDICINE 2014. [DOI: 10.1007/s40556-014-0020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
The study aimed at investigating the impact of late prematurity (LPT) on neonatal outcome in twins and neonatal morbidity and mortality within LPT with regard to the completed weeks of gestation. The study was conducted in six tertiary obstetric departments from different provinces of Poland (Warsaw, Lublin, Poznan, Wroclaw, Bytom). It included 465 twin deliveries in the above centers in 2012. A comparative analysis of maternal factors, the course of pregnancy and delivery and neonatal outcome between LPT (34 + 0-36 + 6 weeks of gestation) and term groups (completed 37 weeks) was performed. The neonatal outcome included short-term morbidities. The analysis of neonatal complication rates according to completed gestational weeks was carried out. Out of 465 twin deliveries 213 (44.8%) were LPT and 156 (33.55%) were term. There were no neonatal deaths among LPT and term twins. One-third of LPT newborns suffered from respiratory disorders or required antibiotics, 40% had jaundice requiring phototherapy, and 30% were admitted to NICU. The analysis of neonatal morbidity with regard to each gestational week at delivery showed that most analyzed complications occurred less frequently with the advancing gestational age, especially respiratory disorders and NICU admissions. The only two factors with significant influence on neonatal morbidity rate were neonatal birth weight (OR = 0.43, 95% CI = 0.2-0.9, p = .02) and gestational age at delivery (OR = 0.62, 95% CI = 0.5-0.8, p < .01). LPT have a higher risk of neonatal morbidity than term twins. Gestational age and neonatal birth weight seem to play a crucial role in neonatal outcome in twins.
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Ovine fetal renal development impacted by multiple fetuses and uterine space restriction. J Dev Orig Health Dis 2014; 4:411-20. [PMID: 24159370 DOI: 10.1017/s2040174413000329] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Intrauterine growth restriction (IUGR) from uteroplacental dysfunction causes impaired nephrogenesis and ultimately hypertension, but it is unknown whether IUGR caused by insufficient space for placental development seen in uterine anomalies and/or multifetal gestation exerts the same effects. Fetal renal development and metabolism were studied in an ovine space-restriction model by combining unilateral horn surgical ligation and/or multifetal gestation. Reduced placental attachment sites and placental weight per fetus defined space-restricted (USR) v. control nonrestricted (NSR) fetuses. Space-restricted fetuses exhibited evidence for decreased plasma volume, with higher hematocrit and plasma albumin at gestational day (GD) 120, followed by lower blood pO2, and higher osmolarity and creatinine at GD130, P < 0.05 for all. By combining treatments, fetal kidney weight relative to fetal weight was inversely related to both fetal weight and plasma creatinine levels, P < 0.05 for both. At GD130, space-restricted fetal kidney weights, cortical depths and glomerular generations were decreased, P < 0.05 for all. Space-restricted kidneys underwent an adaptive response by prolonging active nephrogenesis and increasing maculae densa number, P < 0.05 for both. The major renal adaptations in space-restricted IUGR fetuses included immaturity in both development and endocrine function, with evidence for impaired renal excretory function.
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Masheer S, Maheen H, Munim S. Perinatal outcome of twin pregnancies according to chorionicity: an observational study from tertiary care hospital. J Matern Fetal Neonatal Med 2014; 28:23-5. [DOI: 10.3109/14767058.2014.899576] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Shek NWM, Hillman SC, Kilby MD. Single-twin demise: Pregnancy outcome. Best Pract Res Clin Obstet Gynaecol 2014; 28:249-63. [DOI: 10.1016/j.bpobgyn.2013.11.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 10/24/2013] [Accepted: 11/21/2013] [Indexed: 12/01/2022]
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Abstract
A major justification for the intentional delivery of a pregnancy before 39 weeks' gestation is a reduction in stillbirth. However, there is a considerable downside to late preterm or early term deliveries. Infants born before 39 weeks' gestation are at increased risk for numerous complications and even death. Thus, it is critical to identify which medical problems and circumstances place the fetus at high enough risk for stillbirth so as to justify late preterm or early term birth. This article highlights information pertinent to the pros and cons of iatrogenic preterm birth in pregnancies at risk for stillbirth.
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Affiliation(s)
- Sean F Edmunds
- Department of Obstetrics & Gynecology, University of Utah School of Medicine, 30 North 1900 East 2B200 SOM, Salt Lake City, UT 84132, USA
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Russo FM, Pozzi E, Pelizzoni F, Todyrenchuk L, Bernasconi DP, Cozzolino S, Vergani P. Stillbirths in singletons, dichorionic and monochorionic twins: a comparison of risks and causes. Eur J Obstet Gynecol Reprod Biol 2013; 170:131-6. [DOI: 10.1016/j.ejogrb.2013.06.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 05/05/2013] [Accepted: 06/09/2013] [Indexed: 10/26/2022]
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Abraham RJ. The protective effect of oligohydramnios in a case of missed diagnosis of spontaneous septostomy in monochorionic diamniotic twins. J OBSTET GYNAECOL 2013; 33:205-7. [DOI: 10.3109/01443615.2012.740530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
It is well recognised that birth before 32 weeks of gestation is associated with substantial neonatal morbidity and mortality and these risks have been extensively reported. The focus of perinatal research for many years has therefore been very preterm and extremely preterm delivery, since the likelihood and severity of adverse neonatal outcomes are highest within this group. In contrast, until recently, more mature preterm infants have been understudied and indeed, almost ignored by researchers.
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Abstract
Multiple gestations have an increased risk of pregnancy complications compared with singletons. Delay in childbearing and assisted reproductive techniques have remained common reasons for the increase in multiple gestations over the last few decades. Higher rates of both spontaneous and indicated preterm birth in twins and triplets lead to a significant proportion of the moderate preterm birth and late preterm birth rates. The article is a review of the causes of preterm birth and morbidities associated with these pregnancies.
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Affiliation(s)
- Jerrie S Refuerzo
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, 6431 Fannin, Suite 3.270, Houston, TX 77030, USA.
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Corbett SL, Shmorgun D. Yolk sac number does not predict reliably amnionicity in monochorionic twin pregnancies: a case of a monochorionic monoamniotic twin pregnancy with two distinct yolk sacs on early first-trimester ultrasound. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:607-608. [PMID: 22461300 DOI: 10.1002/uog.11160] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- S L Corbett
- The Ottawa Fertility Centre, University of Ottawa, Ottawa, Ontario, Canada.
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