Clinical characteristics of fetal and neonatal outcomes in twin pregnancy with preeclampsia in a retrospective case-control study: A STROBE-compliant article

Impact of hypertensive disorders of pregnancy on maternal and neonatal outcomes of twin gestation: a systematic review and meta-analysis

Background

The impact of hypertensive disorders of pregnancy (HDP) on outcomes of twin gestations is not clear. We aimed to collate data via this meta-analysis to examine how HDP alters maternal and neonatal outcomes of twin gestations.

Methods

Studies comparing pregnancy outcomes of twin gestations based on HDP and published on the databases of PubMed, CENTRAL, Scopus, Web of Science, and Embase between 1 January 2000 to 20 March 2023 were eligible for inclusion.

Results

Twelve studies were included. A cumulative of 355,129 twin gestations were analyzed in the current meta-analysis. The pooled analysis found that the presence of HDP increases the risk of preterm birth (OR: 1.86 95% CI: 1.36, 2.55 I2 = 99%) and cesarean section in twin gestations (OR: 1.36 95% CI: 1.20, 1.54 I2 = 89%). Meta-analysis showed a significantly increased risk of low birth weight (OR: 1.30 95% CI: 1.10, 1.55 I2 = 97%), small for gestational age (OR: 1.30 95% CI: 1.09, 1.55 I2 = 96%) and neonatal intensive care unit admissions (OR: 1.77 95% CI: 1.43, 2.20 I2 = 76%) with HDP in twin gestations. There was no difference in the incidence of 5-min Apgar scores <7 (OR: 1.07 95% CI: 0.87, 1.38 I2 = 79%) but a lower risk of neonatal death (OR: 0.39 95% CI: 0.25, 0.61 I2 = 62%) with HDP.

Conclusion

HDP increases the risk of preterm birth, cesarean sections, low birth weight, SGA, and NICU admission in twin gestations. Contrastingly, the risk of neonatal death is reduced with HDP. Further studies are needed to corroborate the current results.

Systematic Review Registration

PROSPERO (CRD42023407725).

Gestational hypertensive disease and small for gestational age infants in twin pregnancy: A systematic review and meta-analysis

AIM

The review is to explore the connection between gestational hypertension diseases (GHD) and small for gestational age (SGA) in twin pregnancies.

METHODS

According to the recommendations of PRISMA, relevant studies were systematically searched through PubMed, Web of Science, Cochrane Library, Embase from inception until January 16, 2022. Subgroup analysis was performed according to chorionicity and diagnostic criteria of SGA. Odds ratios (OR) were assessed to judge the link between GHD and SGA in twin pregnant women. A random-effect model was used to estimate the pooled hazard ratio when there was significant heterogeneity (I²  > 50%); otherwise, a fixed-effect model was conducted.

RESULTS

Seven articles containing 470 589 twin pregnant women were included. The increased risk of SGA was connected to the twin pregnancies complicated with GHD (OR = 1.57, 95% confidence interval [CI] = 1.10-2.24, p = 0.01). After subgroup analysis, the connection between SGA and GHD had no statistical significance (OR = 1.17, 95% CI = 0.95-1.44, p = 0.14) when the enrolled studies using the SGA diagnosis referred to singleton birth weight, but significant (OR = 2.14, 95% CI = 1.77-2.60, p<0.001) in the group using the SGA diagnosis referred to twin birth weight. Stratified by chorionicity, SGA was relevant to GHD in the dichorionic (DC) group (OR = 1.68, 95% CI = 1.17-2.42, p = 0.005), while not in the monochorionic (MC) group (OR = 1.68, 95% CI = 0.93-3.03, p = 0.09). More future articles are warranted to confirm these outcomes.

CONCLUSIONS

Our review demonstrated that GHD in DC twin pregnancies was related to an enlarged risk of SGA. Two SGA diagnosis references led to different results. Twin pregnancies complicated with GHD were at significantly higher risk of SGA when twin birth weight reference was used.

Delivery timing in dichorionic diamniotic twin pregnancies complicated by preeclampsia: a decision analysis

OBJECTIVE

To determine the optimal timing of delivery in Dichorionic-diamniotic (DCDA) pregnancies complicated by preeclampsia without severe features.

METHODS

A decision-analytic model was created to compare outcomes of expectant management vs. delivery from 34 to 37w0d. Outcomes included quality-adjusted life years (QALYs), development of severe preeclampsia, maternal mortality, maternal stroke, small for gestational age (SGA) due to fetal growth restriction (FGR) detected antenatally, stillbirth, cerebral palsy (CP), and neonatal mortality. Probabilities, utilities, and life expectancies were derived from the literature. Univariate analysis was used to evaluate the impact of delivery at various gestational ages. Maternal and neonatal outcomes were calculated for a theoretical cohort of 10,000 DCDA pregnancies with preeclampsia.

RESULTS

The optimal gestational age for delivery was 36w0d when the total QALYs (868,112) were highest. Delivery at 34w0d resulted in the fewest cases of severe preeclampsia, maternal mortality, and maternal stroke (0, 4, and 15 cases per 10,000, respectively). The incidence of each of these adverse outcomes increased with gestational age, with the greatest number of adverse outcomes at 37w0d (2452 cases of severe preeclampsia, eight maternal deaths, and 31 cases of maternal stroke per 10,000). Delivery at 34w0d resulted in the fewest cases of severe preeclampsia (0), maternal stroke (15), maternal mortality (4), stillbirth (0), and SGA (1183). However, this strategy was also associated with most cases of neonatal CP (91) and neonatal mortality (87).

CONCLUSION

DCDA twin pregnancies complicated by preeclampsia without severe features appear to have the best outcomes when delivered at 36w0d. Specifically, when compared to delivery at 37w0d, this strategy reduced maternal and neonatal morbidity and mortality.

Screening for preeclampsia in twin pregnancies

Twin pregnancies are an important risk factor for preeclampsia, a hypertensive disorder of pregnancy that is associated with a significant risk of maternal and perinatal morbidity. Given the burden of preeclampsia, the identification of women at high risk in early pregnancy is essential to allow for preventive strategies and close monitoring. In singleton pregnancies, the risk factors for preeclampsia are well established, and a combined first-trimester prediction model has been shown to adequately predict preterm disease. Furthermore, intervention with low-dose aspirin at 150 mg/day in those identified as high-risk reduces the rate of preterm preeclampsia by 62%. In contrast, risk factors for preeclampsia in twin pregnancies are less established, the proposed screening models have shown poor performance with high false-positive rates, and the benefit of aspirin for the prevention of preeclampsia is not clearly demonstrated. In this review, we examine the literature assessing prediction and prevention of preeclampsia in twin pregnancies.

Gestational hypertensive disease and birthweight discordance in twin pregnancies: a systematic review and meta-analysis

INTRODUCTION

The objective of this systematic review was to explore the association between gestational hypertensive disease (GHD) and birthweight discordance in twin pregnancies.

METHODS

PubMed, Embase, Web of Science and Cochrane Library were systematically searched for studies reporting the risk of birthweight discordance in twin pregnancies complicated compared with those not complicated by GHD from establishment until July 2021. Risk of bias was assessed with the Newcastle-Ottawa Scale. According to the classification of GHD, sub-group analyses reporting cases with gestational hypertension (GH), chronic hypertension (CH) and preeclampsia (PE) were performed separately. Stratification by twin chorionicity (dichorionic (DC) and monochorionic (MC)) was also conducted. When there was substantial heterogeneity (I² ≥ 50%), the random effect mode was used to estimate the pooled risk ratio, otherwise the fixed effect model was used.

RESULTS

Nine studies (303,204 twin pregnancies) were included. GHD (OR 1.45, 95% CI 1.41-1.49) was a risk factor for intertwin birthweight discordance [PE (OR 1.69, 95% CI 1.33-2.16); CH (OR 1.59, 95% CI 1.46-1.73); GH (OR1.45, 95%Cl 1.10-1.92]. After stratification, birthweight discordance was related to GHD (OR 2.51, 95% CI 2.01-3.14), GH (OR 2.08, 95% CI 1.33-3.25) and PE (OR 2.74, 95% CI 2.09-3.61) in DC pregnancies, but no longer associated with GHD and PE in MC group.

CONCLUSIONS

Twin gestations complicated with GHD, especially in DC pregnancies, were at significantly higher risk of birthweight discordance.

The influence of hypertensive disorders during pregnancy on the perinatal outcome of different chorionic twins

OBJECTIVE

To investigate the influence of hypertensive disorders of pregnancy (HDP) on the perinatal outcomes in twin pregnancies.

METHODS

This was a retrospective single-center study in which, 2160 twin pregnancies delivered between January 2016 and December 2019 were analyzed, 1661 of which were dichorionic (DC) and 499 monochorionic (MC). The perinatal outcomes were compared in 404 twin pregnancies with HDP, including 157 gestational hypertension (GH), 107 mild pre-eclampsia (MPE), 140 severe pre-eclampsia (SPE), and 1756 twins without hypertensive disorders of pregnancy (no-HDP). Multiple linear regression was performed to analyze the association between perinatal outcome and HDP. Stratified sampling by twin chorionicity (DC and MC) was also conducted.

RESULTS

There were 330 (19.9%) DC cases complicated with HDP and 74 (14.8%) MC with HDP, and the difference between the two groups was statistically significant (p=.011). After stratification by chorionicity, in the DC twin, there were significantly more deliveries in the GH group, MPE group, and SPE group before 37 weeks than in the no-HDP group (p=.000). Statistically significant differences were found among the four groups in the average small fetus birthweight, the intertwin weight difference, the relative weight discordance, the growth discordance, the incidence of very low birth weight (VLBW), low birth weight (LBW), and the Apgar scores of the small fetus (p<.05). In MC twins, By comparison only on the average gestational age at delivery, the average small fetus birthweight, Apgar scores of large and small fetuses among the four groups, the difference was statistically significant (p<.05). According to multiple linear regression analysis, after controlling for multiple confounding factors, it was found when the degree of HDP in DC twins increased by one grade, the small fetus birthweight decreased by an average of 19.044 g (p=.007), the intertwin weight difference increased by an average of 14.311 g (p=.034), the relative weight discordance increased by an average of 0.6% (p=.013), and the gestational age at delivery decreased by an average of 0.160 weeks (p=.001).

CONCLUSIONS

The perinatal outcomes of different chorionic twins with HDP are different. HDP has a greater impact on the perinatal outcomes of DC twins. The risk of adverse perinatal outcomes in DC twin pregnancy will increase accordingly with each increase in the grade of HDP, but HDP has little or no relevance on the perinatal outcomes of MC twins.

Association of microRNA-155, interleukin 17A, and proteinuria in preeclampsia

BACKGROUND

This study aimed to explore the correlation between microRNA-155 (miR-155), interleukin 17A (IL-17), and late preeclampsia (PE) using biochemical parameters in maternal serum and urine.

METHODS

Sixty patients with PE were recruited to this study and were divided into 3 groups according to levels of urinary protein: mild urinary protein group (group A); moderate urinary protein group (group B); and severe urinary protein group (group C). All subjects presented with late onset PE (≥32 weeks). In addition, 20 healthy pregnant women were recruited as a normal group (NP). Maternal serum and urine samples were obtained from all participants and assayed using immunofluorescence, transmission electron and immune electron microscopy, and western blot. Furthermore, placentas were also collected and miR-155 and IL-17 expression was measured using an enzyme-linked immunosorbent assay.

RESULTS

Levels of miR-155 and IL-17 expression were found to be increased in PE placentas and serum, compared to the normal group (P <.05). IL-17 levels and podocytes had a positive association in the serum of patients with PE. In addition, over-expression of miR-155 resulted in increased IL-17 production by CD4+ T cells in vitro, and nephrin expression was decreased in podocytes. Furthermore, IL-17 reduced nephrin expression in podocytes and podocyte apoptosis in a dose and time-dependent manner.

CONCLUSION

The results of this study demonstrate a correlation between miR-155 and IL-17 in the formation of proteinuria during late onset PE.