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.

Prevalence and adverse outcomes of twin pregnancy in Eastern Africa: a systematic review and meta-analysis

INTRODUCTION

Multiple pregnancies are much more common today than they were in the past. Twin pregnancies occur in about 4% of pregnancies in Africa. Adverse pregnancy outcome was more common in twin pregnancy than in singleton pregnancy. There is no pooled evidence on the burden and adverse pregnancy outcome of twin pregnancy in eastern Africa. Thus, this systematic review and meta-analysis were conducted to assess the prevalence and adverse pregnancy outcomes of twin pregnancies.

METHODS

This systematic review and meta-analysis covers published and unpublished studies searched from different databases (PubMed, CINAHL (EBSCO), EMBASE, DOAJ, Web of Sciences, MEDLINE, Cochrane Library, SCOPUS, Google Scholar, and Google search). Finally, 34 studies were included in this systematic review and meta-analysis. JBI checklist was used to assess the quality of included papers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Data synthesis and statistical analysis were conducted using STATA Version 14 software. Heterogeneity and publication bias were assessed. A forest plot was used to present the pooled prevalence using the random effect model.

RESULTS

The prevalence of twin pregnancy in eastern Africa was 3% [95% CI: 2, 3]. The adverse pregnancy outcomes like neonatal intensive care unit admission (78%), low birth weight (44%), low APGAR score (33%), prematurity (32%), stillbirth (30%), neonatal mortality (12%) and maternal complications like hypertensive disorder of pregnancy (25%), postpartum hemorrhage (7%), Cesarean section (37%), premature rupture of membrane (12%) and maternal mortality are more common among twin pregnancy than singleton pregnancy.

CONCLUSION

One in every 33 children born a twin in east Africa; admission to neonatal intensive care unit, low birth weight, low APGAR score, prematurity, stillbirth, neonatal mortality and maternal complications are its associated adverse birth outcomes. Since twin pregnancy is a high-risk pregnancy, special care is needed during pregnancy, labor and delivery to reduce adverse pregnancy outcomes.

Vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in twin gestations: a systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of vaginal progesterone for the prevention of preterm birth and adverse perinatal outcomes in twin gestations.

DATA SOURCES

MEDLINE, Embase, LILACS, and CINAHL (from their inception to January 31, 2023), Cochrane databases, Google Scholar, bibliographies, and conference proceedings.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials that compared vaginal progesterone to placebo or no treatment in asymptomatic women with a twin gestation.

METHODS

The systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions. The primary outcome was preterm birth <34 weeks of gestation. Secondary outcomes included adverse perinatal outcomes. Pooled relative risks with 95% confidence intervals were calculated. We assessed the risk of bias in each included study, heterogeneity, publication bias, and quality of evidence, and performed subgroup and sensitivity analyses.

RESULTS

Eleven studies (3401 women and 6802 fetuses/infants) fulfilled the inclusion criteria. Among all twin gestations, there were no significant differences between the vaginal progesterone and placebo or no treatment groups in the risk of preterm birth <34 weeks (relative risk, 0.99; 95% confidence interval, 0.84-1.17; high-quality evidence), <37 weeks (relative risk, 0.99; 95% confidence interval, 0.92-1.06; high-quality evidence), and <28 weeks (relative risk, 1.00; 95% confidence interval, 0.64-1.55; moderate-quality evidence), and spontaneous preterm birth <34 weeks of gestation (relative risk, 0.97; 95% confidence interval, 0.80-1.18; high-quality evidence). Vaginal progesterone had no significant effect on any of the perinatal outcomes evaluated. Subgroup analyses showed that there was no evidence of a different effect of vaginal progesterone on preterm birth <34 weeks of gestation related to chorionicity, type of conception, history of spontaneous preterm birth, daily dose of vaginal progesterone, and gestational age at initiation of treatment. The frequencies of preterm birth <37, <34, <32, <30, and <28 weeks of gestation and adverse perinatal outcomes did not significantly differ between the vaginal progesterone and placebo or no treatment groups in unselected twin gestations (8 studies; 3274 women and 6548 fetuses/infants). Among twin gestations with a transvaginal sonographic cervical length <30 mm (6 studies; 306 women and 612 fetuses/infants), vaginal progesterone was associated with a significant decrease in the risk of preterm birth occurring at <28 to <32 gestational weeks (relative risks, 0.48-0.65; moderate- to high-quality evidence), neonatal death (relative risk, 0.32; 95% confidence interval, 0.11-0.92; moderate-quality evidence), and birthweight <1500 g (relative risk, 0.60; 95% confidence interval, 0.39-0.88; high-quality evidence). Vaginal progesterone significantly reduced the risk of preterm birth occurring at <28 to <34 gestational weeks (relative risks, 0.41-0.68), composite neonatal morbidity and mortality (relative risk, 0.59; 95% confidence interval, 0.33-0.98), and birthweight <1500 g (relative risk, 0.55; 95% confidence interval, 0.33-0.94) in twin gestations with a transvaginal sonographic cervical length ≤25 mm (6 studies; 95 women and 190 fetuses/infants). The quality of evidence was moderate for all these outcomes.

CONCLUSION

Vaginal progesterone does not prevent preterm birth, nor does it improve perinatal outcomes in unselected twin gestations, but it appears to reduce the risk of preterm birth occurring at early gestational ages and of neonatal morbidity and mortality in twin gestations with a sonographic short cervix. However, more evidence is needed before recommending this intervention to this subset of patients.

The parent trap: desire for multifetal gestation among patients treated for infertility

Objective

To evaluate predictors for patient preference regarding multifetal or singleton gestation among women presenting for infertility care.

Design

Cross-sectional study.

Setting

Academic university hospital-based infertility clinic.

Patient(s)

Five hundred thirty-nine female patients with infertility who presented for their initial visit.

Main outcome measure(s)

Demographic characteristics, infertility history, insurance coverage, desired treatment outcome, acceptability of multifetal reduction, and knowledge of the risks of multifetal pregnancies were assessed using a previously published 41-question survey. Univariate analysis was performed to assess patient factors associated with the desire for multiple births. Independent factors associated with this desire were subsequently assessed by multivariate logistic regression analysis.

Result(s)

Nearly a third of women preferred multiples over a singleton gestation. Nulliparity, lower annual household income, older maternal age, marital status, larger ideal family size, openness to multifetal reduction, and lack of knowledge of the maternal/fetal risks of twin pregnancies were associated with pregnancy desire. Older age (OR (95% CI) 1.66 (1.20–2.29)), nulliparity (OR (95% CI) 0.34 (0.20–0.58)), larger ideal family size (OR (95% CI) 2.34 (1.73–3.14)), and lesser knowledge of multifetal pregnancy risk (OR (95% CI) 0.67 (0.55–0.83)) were independently associated with desire.

Conclusion(s)

A large number of patients undergoing fertility treatment desire multifetal gestation. Although a lack of understanding of the risks associated with higher order pregnancies contributes to this desire, additional individual specific variables also contribute to this trend. Efforts to reduce the incidence of multiples should focus not only on patient education on comparative risks of multiples vs singleton pregnancies but also account for individual specific reservations.

Is guided, targeted information about the risks of twin pregnancy able to increase the acceptance of single embryo transfer among IVF couples? A prospective study

OBJECTIVE

To assess whether receiving information about twin pregnancy in the form of oral presentation given by a physician could affect the acceptance of single embryo transfer (SET) by couples undergoing IVF.

STUDY DESIGN

Prospective interventional study.

SETTING

University hospital IVF unit.

PATIENTS

One hundred and forty patients (70 couples) undergoing IVF.

INTERVENTIONS

A questionnaire to measure patients' emotions about twin pregnancy was administered to IVF patients just before and immediately after attending a slide presentation in which the risks of twin pregnancy were explained. Patients scored (1 to 6) ten adjectives linked either to positive or negative emotions; scores before and after presentation were compared. The patients' preference between double embryo transfer (DET) and SET was also registered before and after the presentation.

RESULTS

The presentation about twin pregnancy caused a significant (p < 0.001) shift of the score distribution toward lower values for positive adjectives referred to twin pregnancy and higher values for negative adjectives. Information impacted similarly on women and men. Despite the relevant change in the emotional attitude, after presentation, 45.7% of women and 48.6% of men were still favorable to DET, whereas 24.3% of women and 37.1% of men preferred SET.

CONCLUSIONS

Oral information on the risks of twin pregnancy can affect the emotional attitude of patients toward twin pregnancy, but the wish of getting pregnant after fresh embryo transfer overcomes all rational consideration, and the majority of patients still prefer DET.

Single or double embryo transfer? Decision-making process in patients participating in an oocyte donation program

In IVF/ICSI programs, after receiving the information about the success results of single embryo transfer (SET) vs double embryo transfer (DET) and the risks of multiple pregnancy, a significant number of patients opt for SET. Up to date, no comparable studies have been published in oocyte recipients. The aim of this study was to evaluate if the counseling provided to oocyte recipients influence their decision on the number of embryos to be transferred. Fifty-five recipients expressed their preference and the relevance for the decision-making process that they attribute to certain factors through an anonymous questionnaire completed pre and post-counseling. Before counseling, 32 out of 55 recipients preferred DET, 13 preferred SET and 10 were undecided. From the 32 recipients who preferred DET, 16 (50%) maintained their preference after counseling, 13 (40.6%) changed their decision to SET and 3 (9.4%) changed to undecided (McNemar's test: p < .05). After counseling, the patients attached less importance to the probability of pregnancy and more importance to maternal and perinatal risks (p < .05). We conclude that after counseling, a significant number of recipients changed their preferences from DET to SET.

Vaginal progesterone decreases preterm birth and neonatal morbidity and mortality in women with a twin gestation and a short cervix: an updated meta-analysis of individual patient data

OBJECTIVE

To assess the efficacy of vaginal progesterone for the prevention of preterm birth and neonatal morbidity and mortality in asymptomatic women with a twin gestation and a sonographic short cervix (cervical length ≤ 25 mm) in the mid-trimester.

METHODS

This was an updated systematic review and meta-analysis of individual patient data (IPD) from randomized controlled trials comparing vaginal progesterone with placebo/no treatment in women with a twin gestation and a mid-trimester sonographic cervical length ≤ 25 mm. MEDLINE, EMBASE, POPLINE, CINAHL and LILACS (all from inception to 31 December 2016), the Cochrane Central Register of Controlled Trials, Research Registers of ongoing trials, Google Scholar, conference proceedings and reference lists of identified studies were searched. The primary outcome measure was preterm birth < 33 weeks' gestation. Two reviewers independently selected studies, assessed the risk of bias and extracted the data. Pooled relative risks (RRs) with 95% confidence intervals (CI) were calculated.

RESULTS

IPD were available for 303 women (159 assigned to vaginal progesterone and 144 assigned to placebo/no treatment) and their 606 fetuses/infants from six randomized controlled trials. One study, which included women with a cervical length between 20 and 25 mm, provided 74% of the total sample size of the IPD meta-analysis. Vaginal progesterone, compared with placebo/no treatment, was associated with a statistically significant reduction in the risk of preterm birth < 33 weeks' gestation (31.4% vs 43.1%; RR, 0.69 (95% CI, 0.51-0.93); moderate-quality evidence). Moreover, vaginal progesterone administration was associated with a significant decrease in the risk of preterm birth < 35, < 34, < 32 and < 30 weeks' gestation (RRs ranging from 0.47 to 0.83), neonatal death (RR, 0.53 (95% CI, 0.35-0.81)), respiratory distress syndrome (RR, 0.70 (95% CI, 0.56-0.89)), composite neonatal morbidity and mortality (RR, 0.61 (95% CI, 0.34-0.98)), use of mechanical ventilation (RR, 0.54 (95% CI, 0.36-0.81)) and birth weight < 1500 g (RR, 0.53 (95% CI, 0.35-0.80)) (all moderate-quality evidence). There were no significant differences in neurodevelopmental outcomes at 4-5 years of age between the vaginal progesterone and placebo groups.

CONCLUSION

Administration of vaginal progesterone to asymptomatic women with a twin gestation and a sonographic short cervix in the mid-trimester reduces the risk of preterm birth occurring at < 30 to < 35 gestational weeks, neonatal mortality and some measures of neonatal morbidity, without any demonstrable deleterious effects on childhood neurodevelopment. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Prediction of preterm birth in twin gestations using biophysical and biochemical tests

The objective of this study was to determine the performance of biophysical and biochemical tests for the prediction of preterm birth in both asymptomatic and symptomatic women with twin gestations. We identified a total of 19 tests proposed to predict preterm birth, mainly in asymptomatic women. In these women, a single measurement of cervical length with transvaginal ultrasound before 25 weeks of gestation appears to be a good test to predict preterm birth. Its clinical potential is enhanced by the evidence that vaginal progesterone administration in asymptomatic women with twin gestations and a short cervix reduces neonatal morbidity and mortality associated with spontaneous preterm delivery. Other tests proposed for the early identification of asymptomatic women at increased risk of preterm birth showed minimal to moderate predictive accuracy. None of the tests evaluated in this review meet the criteria to be considered clinically useful to predict preterm birth among patients with an episode of preterm labor. However, a negative cervicovaginal fetal fibronectin test could be useful in identifying women who are not at risk for delivering within the next week, which could avoid unnecessary hospitalization and treatment. This review underscores the need to develop accurate tests for predicting preterm birth in twin gestations. Moreover, the use of interventions in these patients based on test results should be associated with the improvement of perinatal outcomes.

Epidemic of plurality and contributions of assisted reproductive technology therein

A commentary on contributions of ART to the pandemic of multiple gestations is presented and mechanistic aspects therein are explored.

Is folic acid good for everyone?

Fortification of food with folic acid to reduce the number of neural tube defects was introduced 10 y ago in North America. Many countries are considering whether to adopt this policy. When fortification is introduced, several hundred thousand people are exposed to an increased intake of folic acid for each neural tube defect pregnancy that is prevented. Are the benefits to the few outweighed by possible harm to some of the many exposed? In animals, a folic acid-rich diet can influence DNA and histone methylation, which leads to phenotypic changes in subsequent generations. In humans, increased folic acid intake leads to elevated blood concentrations of naturally occurring folates and of unmetabolized folic acid. High blood concentrations of folic acid may be related to decreased natural killer cell cytotoxicity, and high folate status may reduce the response to antifolate drugs used against malaria, rheumatoid arthritis, psoriasis, and cancer. In the elderly, a combination of high folate levels and low vitamin B-12 status may be associated with an increased risk of cognitive impairment and anemia and, in pregnant women, with an increased risk of insulin resistance and obesity in their children. Folate has a dual effect on cancer, protecting against cancer initiation but facilitating progression and growth of preneoplastic cells and subclinical cancers, which are common in the population. Thus, a high folic acid intake may be harmful for some people. Nations considering fortification should be cautious and stimulate further research to identify the effects, good and bad, caused by a high intake of folic acid from fortified food or dietary supplements. Only then can authorities develop the right strategies for the population as a whole.

Aging-related occurrence in Ashkenazi Jews of leukocyte heteroplasmic mtDNA mutation adjacent to replication origin frequently remodeled in Italian centenarians

Our previous observation that a mitochondrial DNA (mtDNA) homoplasmic C150T transition adjacent to the heavy strand replication origin at position 151 is greatly increased in frequency in Italian centenarians, as compared to the rest of the population, has prompted us to analyze a genetically distinct population to determine how robust the association of the C150T mutation with longevity is. In particular, we have analyzed leukocyte mtDNA from three groups of an Ashkenazi Jew population, namely, a large number (124) of female centenarians and near-centenarians (95-108 years-old), their mixed gender offspring, and mixed gender control subjects. This analysis revealed a very low incidence of the C150T transition in the probands and the other two groups, and by contrast, the fairly high frequency of a homoplasmic T152C transition and of a homoplasmic T195C transition in all three groups of subjects. Furthermore, most significantly, an aging-related increase in incidence of the heteroplasmic T152C transition, presumably resulting from somatic events, was demonstrated in the Ashkenazi Jews. The T152C transition was not associated with a change in the replication origin at position 151, unlike the C150T transition in the Italian centenarians.

Guidelines for the number of embryos to transfer following in vitro fertilization

OBJECTIVE

To review the effect of the number of embryos transferred on the outcome of in vitro fertilization (IVF), to provide guidelines on the number of embryos to transfer in IVF-embryo transfer (ET) in order to optimize healthy live births and minimize multiple pregnancies.

OPTIONS

Rates of live birth, clinical pregnancy, and multiple pregnancy or birth by number of embryos transferred are compared.

OUTCOMES

Clinical pregnancy, multiple pregnancy, and live birth rates.

EVIDENCE

The Cochrane Library and MEDLINE were searched for English language articles from 1990 to April 2006. Search terms included embryo transfer (ET), assisted reproduction, in vitro fertilization (IVF), ntracytoplasmic sperm injection (ICSI), multiple pregnancy, and multiple gestation. Additional references were identified through hand searches of bibliographies of identified articles.

VALUES

Available evidence was reviewed by the Reproductive Endocrinology and Infertility Committee and the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada and the Board of the Canadian Fertility and Andrology Society, and was qualified using the Evaluation of Evidence Guidelines developed by the Canadian Task Force on the Periodic Health Exam.

BENEFITS, HARMS, AND COSTS

This guideline is intended to minimize the occurrence of multifetal gestation, particularly high-order multiples (HOM), while maintaining acceptable overall pregnancy and live birth rates following IVF-ET.

Trends in embryo transfer practices and multiple gestation for IVF procedures in the USA, 1996-2002

BACKGROUND

Increasing use of IVF in the USA has been a major contributor to the rising national multiple birth rate. Many have advocated that reducing the number of embryos transferred is essential for addressing the IVF-associated multiple birth problem.

METHODS

A population-based sample of 506 072 IVF transfers performed in the USA in 1996-2002 was used to investigate trends in embryo transfer practices and to determine whether any changes in practice patterns have impacted the multiple gestation risk associated with IVF.

RESULTS

The proportion of procedures in which >or=3 embryos were transferred declined significantly for most patient groups between 1996 and 2002. However, declines for some groups were not sizeable (from 79 to 73% and from 76 to 71% for fresh, non-donor procedures among women aged 38-40 and 41-42 years respectively) and transferring >or=3 embryos remained the norm for all groups. As of 2002, single embryo transfer had not increased for most groups and remained uncommon. Some declines in overall multiple gestation rates were observed, although multiple gestation risk associated with 2 embryos transferred increased significantly for all groups.

CONCLUSIONS

Despite changes in embryo transfer practices, multiple gestation risk remains high, in part due to increased multiple gestation rates associated with the transfer of two embryos.

Explanation for cessation of breastfeeding in mothers of twins

This study used content analysis to examine reasons for cessation of breastfeeding of twins by 2 time points: 9.4 weeks and 28.3 weeks of age. From a convenience sample of 123 mothers, 110 initiated breastfeeding for their twins. Thirty women had stopped breastfeeding by time 1, with an additional 37 women stopping by time 2. Three major themes were identified regarding weaning: factors related to breastfeeding process, to mother's role and health, and to infant behavior and health. Subcategories were identified for each theme, with additional subcategories emerging at time 2. Cited reasons are similar to those given by singleton mothers; however, mothers of twins identified unique issues related to infants' behaviors, challenges presented by growth and development, and time commitments that interfered with breastfeeding continuation. Implications of the study suggest the need for continued lactation support as the twins grow and develop and new breastfeeding issues arise.

Number of transferred embryos: how to reduce multiple pregnancies

Because the diagnostic tools for predicting whether an early cleavage stage embryo can lead to a viable pregnancy are still elusive, transfer of more than one embryo remains quite common. However, the only way to reduce multiple pregnancies, considered as the main adverse effect of assisted reproductive technology, is to transfer a single embryo. In countries such as Switzerland and Germany, the law allows cryopreservation only at the 2-pronuclear stage. This restricts considerably the possibility of selecting the embryos to be transferred. Therefore, a good cryopreservation program at the 2-pronuclear stage is an essential tool to optimize the efficiency of in vitro fertilization (IVF). We therefore recommend the Cumulated Singleton Delivery Rate (CUSIDERA) as a measure of standard IVF efficiency. This rate averages approximately 23.5% when calculated over the last 10 years in our unit and reaches a value above 35% for patients with more than 10 zygotes. Elective single-embryo transfers and the decrease of iatrogenic multiple pregnancies in IVF remain dependent on better prognostic tools for the appropriate selection of patients, gametes, and zygotes.

Folic acid supplementation and the occurrence of congenital heart defects, orofacial clefts, multiple births, and miscarriage

Key research findings relative to the question of whether maternal use of folic acid before and during pregnancy reduces the chance that offspring will be born with a congenital heart defect or an orofacial cleft are reviewed in this paper. Observational studies in general support an association between maternal use of multivitamins containing folic acid and a reduction in the occurrence of congenital heart defects and orofacial clefts. Results from one randomized controlled trial (RCT) provide the strongest evidence that multivitamins prevent congenital heart defects, but this RCT did not provide evidence that multivitamins prevent orofacial clefts. In addition, most observational and interventional studies are not designed to detect an independent effect from folic acid. Early studies suggested that periconceptional multivitamin use was associated with an increased occurrence of both miscarriages and multiple births, which has resulted in a great deal of controversy about the safety of folic acid use during pregnancy. We also review reports that were designed to answer these questions with more definitive data. When more substantial evidence about the effect of periconceptional folic acid on the occurrence of congenital heart defects and orofacial clefts is reported, we will have additional support for promoting folic acid intervention programs. All women capable of becoming pregnant should continue to consume 400 mug/d of folic acid in addition to a healthy diet as advised.

Prenatal attachment and other correlates of postnatal maternal attachment to twins

PURPOSE

To determine the relationship of prenatal attachment and other selected perinatal contextual variables (method of delivery, maternal self-reported health, depression, infant birthweight, need for neonatal intensive care unit [NICU] admission) to postnatal attachment in mothers of twins.

SUBJECTS

Two hundred fourteen women were initially recruited from a national mothers of twins support group for a study of maternal prenatal attachment. Of the 168 women who agreed to be contacted after delivery, 142 returned completed questionnaires (82.7% response rate), with 139 study-eligible women included in the analysis for this report.

STUDY DESIGN

Correlational design with longitudinal follow-up at 1 month after expected delivery date.

METHODS

Self-administered, mailed questionnaires completed by women with twin gestations prenatally and postnatally 1 month after their expected delivery dates. Descriptive analysis, correlations, and regression equations were performed.

MAIN OUTCOME MEASURES

The Maternal Attachment Inventory.

PRINCIPLE RESULTS

A modest correlation was found between prenatal and postnatal attachment ( r = 0.38, P < 0.001). Prenatal attachment and postpartum depression explained 26.1% of the variance in postnatal attachment ( F = 5.06, P < 0.001). Depression, method of delivery, and need for admission to the NICU had moderator effects on the relationship between prenatal attachment and postnatal attachment. The addition of these interaction terms nominally increased the adjusted R 2 to explain 27.9% to 29.6% of the variance in postnatal attachment.

CONCLUSIONS

Although the study findings support a modest relationship between prenatal and postnatal attachment in mothers of twins, maternal depression was also significant in explaining postnatal attachment. Postpartum depression, having a cesarean delivery, and the experience of a NICU admission for 1 or both twins further influenced the relationship between prenatal attachment and postnatal attachment. When fostering attachment in mothers of twins, nurses should assess for symptoms of depression and pay particular attention to those women who have an infant requiring a NICU admission.

Predictors of Prenatal Attachment in Mothers of Twins

OBJECTIVES

To explore the predictive relationship between prenatal attachment and selected demographic and biopsychosocial factors and to compare these predictors to those identified in previous research on maternal attachment in singleton pregnancies.

DESIGN

A predictive correlational descriptive design.

SETTING

Data were obtained via mailed surveys.

PARTICIPANTS

214 women expecting twins were recruited from a national mother of twins support group.

MAIN OUTCOME MEASURES

Instruments included the Rosenberg Self-Esteem Scale, Norwood Social Support Apgar, Miller Prenatal Attachment Inventory, and a demographic data tool to collect data on perinatal factors of gestational age, infertility history, perceived risk status, fetal movement, and planning of pregnancy.

RESULTS

Women who were younger, with lower income, a history of infertility, greater self-esteem, who had experienced quickening, and were further along in their pregnancy reported greater prenatal attachment to their twins (Adjusted R2 = 19.4%, p < .001). Perceived risk, social support, and planning of pregnancy did not predict level of attachment.

CONCLUSION

Factors that influence attachment in women experiencing a twin pregnancy are complex, and much is still unknown. Development and testing of theory is needed to guide future research and practice.

Cost analysis of singleton versus twin pregnancies after in vitro fertilization

OBJECTIVE

To determine the difference in costs between singleton and twin pregnancies after IVF treatment from pregnancy to 6 weeks after delivery from a health care perspective.

DESIGN

Retrospective cost analysis.

SETTING

IVF department at the University Medical Center Nijmegen, The Netherlands.

PATIENT(S)

A representative sample of singleton and twin pregnancies after IVF treatment between 1995 and 2001 at the University Medical Center Nijmegen.

INTERVENTION(S)

IVF with or without intracytoplasmic sperm injection and with or without cryopreservation.

MAIN OUTCOME MEASURE(S)

Medical costs per singleton and twin pregnancy after IVF.

RESULT(S)

In patients pregnant with twins, the incidence of hospital antenatal care, complicated vaginal deliveries, and cesarean sections was higher and was associated with more frequent and longer maternal and neonatal hospital admissions. Maternal and neonatal hospital admissions were the major cost drivers. The medical cost per twin pregnancy was found to be more than five times higher than per singleton pregnancy, 13,469 and 2,550, respectively.

CONCLUSION(S)

The medical cost per twin pregnancy was more than 10,000 higher than per singleton pregnancy. A reduction in the number of twin pregnancies by elective single ET will save substantial amounts of money. This money might be used for the additional IVF cycles that will probably be needed to achieve similar success rates between single ET and two-embryo transfer.

Multiple births from assisted reproductive technologies: a challenge that must be met

The success of assisted reproductive technologies (ART) has been accompanied by dramatic increases in multiple births and their associated costs. Physicians who perform ART must develop effective treatment paradigms to reduce multiple births or risk regulatory intervention.

The desire of infertile patients for multiple births

OBJECTIVE

To determine the proportion of infertile women who prefer a multiple birth over a singleton, patient characteristics associated with this desire, and patient knowledge about the risks of multiple births.

DESIGN

Prospective analysis.

SETTING

Academic university hospital-based infertility center and private general gynecology clinic.

PATIENT(S)

Four hundred sixty-four female patients with infertility who presented for their initial visit.

MAIN OUTCOME MEASURE(S)

Demographic characteristics, infertility history, desire regarding multiple births, knowledge of the risks of multiple births, and goals of infertility evaluation and treatment were determined by using a 41-question survey. Univariate analysis was performed to assess patient characteristics associated with the desire for multiple births. Independent factors associated with this desire were assessed by multivariable logistic regression analysis.

RESULT(S)

20.3% of women desired multiples over a singleton gestation. Nulliparity, lower family income, younger patient age, prior evaluation for infertility, longer duration of infertility, and lack of knowledge regarding risks of twin gestations were associated with this desire. Only nulliparity and lower family income were independently associated.

CONCLUSION(S)

A sizable minority of infertility patients prefers a multiple birth as their treatment outcome. Patient education may be an effective strategy to reduce the incidence of twin and higher-order multiple pregnancies.

Does insurance coverage decrease the risk for multiple births associated with assisted reproductive technology?

OBJECTIVE

To determine whether insurance coverage for ART is associated with transfer of fewer embryos and decreased risk of multiple births.

DESIGN

Retrospective cohort study of a population-based sample of IVF procedures performed in six U.S. states during 1998.

SETTING

Three states with mandated insurance coverage (Illinois, Massachusetts, and Rhode Island) and three states without coverage (Indiana, Michigan, and New Jersey).

PARTICIPANT(S)

Seven thousand, five hundred sixty-one IVF transfer procedures in patients < or = 35 years of age.

MAIN OUTCOME MEASURE(S)

Number of embryos transferred, multiple-birth rate, triplet or higher order birth rate, and triplet or higher order gestation rate.

RESULT(S)

A smaller proportion of procedures included transfer of three or more embryos in Massachusetts (64%) and Rhode Island (74%) than in the noninsurance states (82%). The multiple-birth rate in Massachusetts (38%) was less than in the noninsurance states (43%). The insurance states all had protective odds ratios for triplet or higher order births, but only the odds ratio (0.2) for Massachusetts was significant. This decreased risk in Massachusetts resulted from several factors, including a smaller proportion of patients with three or more embryos transferred, lower implantation rates when three or more embryos were transferred, and greater rates of fetal loss among triplet or higher order gestations.

CONCLUSION(S)

Insurance appears to affect embryo transfer practices. Whether this translates into decreased multiple birth risk is less clear.

Strikingly higher frequency in centenarians and twins of mtDNA mutation causing remodeling of replication origin in leukocytes

The presence of a genetic component in longevity is well known. Here, the association of a mtDNA mutation with a prolonged life span in humans was investigated. Large-scale screening of the mtDNA main control region in leukocytes from subjects of an Italian population revealed a homoplasmic C150T transition near an origin of heavy mtDNA-strand synthesis in approximately 17% of 52 subjects 99-106 years old, but, in contrast, in only 3.4% of 117 younger individuals (P = 0.0035). Evidence was obtained for the contribution of somatic events, under probable nuclear genetic control, to the striking selective accumulation of the mutation in centenarians. In another study, among leukocyte mtDNA samples from 20 monozygotic and 18 dizygotic twins, 60-75 years old, 30% (P = 0.0007) and 22% (P = 0.011), respectively, of the individuals involved exhibited the homoplasmic C150T mutation. In a different system, i.e., in five human fibroblast longitudinal studies, convincing evidence for the aging-related somatic expansion of the C150T mutation, up to homoplasmy, was obtained. Most significantly, 5' end analysis of nascent heavy mtDNA strands consistently revealed a new replication origin at position 149, substituting for that at 151, only in C150T mutation-carrying samples of fibroblasts or immortalized lymphocytes. Considering the aging-related health risks that the centenarians have survived and the developmental risks of twin gestations, it is proposed that selection for a remodeled replication origin, inherited or somatically acquired, provides a survival advantage and underlies the observed high incidence of the C150T mutation in centenarians and twins.