Obstetrical and neonatal outcomes of triplet births - spontaneous versus assisted reproductive technology conception

Comparison of maternal, fetal, obstetric and neonatal outcomes for 234 triplet pregnancies conceived in vivo versus IVF and ICSI conceptions

RESEARCH QUESTION

Is there a difference in maternal, fetal, obstetric and neonatal outcomes for triplet pregnancies when comparing in vivo conceptions with those conceived by assisted reproductive technology (ART)?

DESIGN

This single-centre, retrospective cohort study included all triplet pregnancies followed up at La Paz University Hospital, Madrid between 2000 and 2022. The characteristics of the pregnant women, and maternal, fetal, obstetric and perinatal outcomes were examined. Univariate and multivariate statistical analyses were performed.

RESULTS

In total, 234 triplet pregnancies were analysed: 92 in the natural and assisted insemination conception group (in-vivo conception) and 142 in the in vitro fertilization and intracytoplasmic sperm injection conception group (ART conception). ART triplet pregnancies were more common between 2000 and 2010 (P = 0.003). The percentage of monochorionic triamniotic pregnancies was significantly higher (P = 0.02) in the in-vivo conception group, and the percentage of dichorionic triamniotic pregnancies was significantly higher (P = 0.003) in the ART conception group. After adjusting for confounders, intrauterine growth restriction (IUGR) remained significantly more common in the ART conception group (adjusted odds ratio 8.65, 95% CI 1.66-45.03; P = 0.01). Differences in maternal age (P = 0.61), threatened preterm labour (P = 0.10), Apgar score ≤5 at 5 min (P = 0.99), umbilical cord pH <7.20 (P = 0.99) and fetal death (P = 0.99) disappeared after adjustment for confounders.

CONCLUSION

ART triplet pregnancies had a higher rate of IUGR than in vivo triplet pregnancies. This could be related to higher maternal age, and higher rates of Apgar score ≤5 at 5 min and umbilical cord pH <7.20 in these pregnancies. In these cases, placental examination could provide valuable information.

Maternal, Perinatal and Neonatal Outcomes of Triplet Pregnancies According to Chorionicity: A Systematic Review of the Literature and Meta-Analysis

Triplet pregnancies are rare events that affect approximately 93 in 100,000 deliveries in the world, especially due to the increased use of assisted reproductive techniques and older maternal age. Triplet pregnancies are associated with a higher risk of fetal and maternal morbidity and mortality compared to twins and singletons. Chorionicity has been proposed as a major determinant of perinatal and maternal outcomes in triplet pregnancies, although further evidence is needed to clarify the extent and real influence of this factor. Thus, the aim of this study was to conduct a systematic review of the literature and a meta-analysis of the maternal and perinatal outcomes of triplet pregnancies, evaluating how chorionicity may influence these results. A total of 46 studies with 43,653 triplet pregnancies and 128,145 live births were included. Among the main results of our study, we found a broad spectrum of fetal and maternal complications, especially in the group of monochorionic and dichorionic pregnancies. Risk of admission to NICU, respiratory distress, sepsis, necrotizing enterocolitis, perinatal and intrauterine mortality were all found to be higher in non-TCTA pregnancies than in TCTA pregnancies. To date, our meta-analysis includes the largest population sample and number of studies conducted in this field, evaluating a wide variety of outcome measures. The heterogeneity and retrospective design of the studies included in our research represent the main limitations of this review. More evidence is needed to fully assess outcome measures that could not be studied in this review due to scarcity of publications or insufficient sample size.

Prevalence of Gestational Diabetes in Triplet Pregnancies: A Retrospective Cohort Study and Meta-Analysis

Background: Over the last decades, there has been a substantial increase in the incidence of higher-order multiple gestations. Twin pregnancies are associated with an increased risk of gestational diabetes mellitus (GDM). The literature on GDM rates in triplet pregnancies is scarce. Methods: A retrospective cohort study was performed to assess the prevalence of GDM in women with a triplet pregnancy. GDM was defined through an abnormal oral glucose tolerance test (OGTT). A meta-analysis of GDM prevalence was also carried out. Results: A cohort of 60 women was included in the analysis. Of these, 19 (31.7%) were diagnosed with GDM. There were no differences in pregnancy outcomes between women with and without GDM. In the meta-analysis of 12 studies, which used a sound GDM definition, an estimated pooled prevalence of 12.4% (95% confidence interval: 6.9–19.1%) was found. In a leave-one-out sensitivity analysis, the estimated GDM prevalence ranged from 10.7% to 14.1%. Conclusion: The rate of GDM seems increased in women with triplets compared to singleton pregnancies. However, GDM did not impact short-term pregnancy outcomes.

Assisted reproductive technology and the risk of gestational diabetes mellitus: a systematic review and meta-analysis

Background

The use of assisted reproductive technology (ART) is increasing worldwide, and observational studies have indicated that women who conceived by ART have an increased risk of pregnancy complications including gestational diabetes mellitus (GDM). We aimed to determine the risk of GDM among women who conceived with ART by systematic review and meta-analysis.

Main text

A systematic literature search was conducted in ISI Web of Knowledge, MEDLINE, Scopus, and Embase through May 2017 for English-language articles using a list of keywords. All studies comparing GDM in women conceived by ART and those who conceived spontaneously were included. Data extraction was performed by two authors independently and discrepancies were resolved by discussion. In total, 48 studies with 91,487 pregnancies conceived through ART and 2,525,234 spontaneously conceived met the inclusion criteria. There was evidence of substantial heterogeneity among these studies (P < 0.001, I2 = 98.6%). Random effects meta-analysis showed a significant increase in GDM among those who conceived by ART compared with those who conceived spontaneously (pooled relative risk = 1.51, 95% confidence interval = 1.18–1.93). Visual inspection of the funnel plot did not reveal any publication bias, which was supported by Egger’s test and Begg’s test.

Conclusion

The findings of this systematic review indicate that the use of ART treatment is associated with a 1.51-fold increase in GDM. Women need to be counselled carefully before undergoing ART treatment about the possibility and risk of GDM.

Risk of gestational diabetes mellitus following assisted reproductive technology: systematic review and meta-analysis of 59 cohort studies

OBJECTIVE

The use of assisted reproductive technology (ART) has been associated with an increased risk of gestational diabetes mellitus (GDM) in previous studies, but its risk has not been consistent. Therefore, we aimed to estimate the risk of GDM in women who conceived with ART via a systematic review and meta-analysis of cohort studies.

METHODS

ISI Web of Knowledge, Medline/PubMed, Scopus, and Embase databases were searched to identify studies that evaluated the risk of GDM through May 2017 using the relevant keywords. Two reviewers independently performed the screening, data extraction, and quality assessment. Meta-analysis was performed with a random effects model.

RESULTS

The search yielded 957 records relating to GDM and use of ART, from which 59 eligible cohorts were selected for meta-analysis (n = 96,785). There was evidence of substantial heterogeneity among these studies (χ₍₅₈₎² = 3072.34, p < .001; I²=98.1%). The pooled estimate of GDM risk using the random effects model was 9.00% (95% CI: 7.90-10.20). Visual inspection of the funnel plot indicated the presence of low publication bias, but Egger's test did not reveal publication bias.

CONCLUSIONS

The findings revealed that the risk of GDM was very high among women who conceived with ART treatment. GDM screening, management, and improved care are vital in ART pregnancy.

Assisted reproductive technology and the risk of preeclampsia: an updated systematic review and meta-analysis

Background

The objective of this systematic review and meta-analyses was to assess the risk of preeclampsia among women who conceived with assisted reproductive technology (ART).

Methods

We searched the ISI Web of Knowledge, Medline/PubMed, Scopus, and Embase (from inception to May 2017) for English language articles using a list of key words. In addition, reference lists from identified studies and relevant review articles were also searched. Data extraction was performed by two authors, and the study quality was assessed using the Newcastle–Ottawa Scale. Random-effects model meta-analysis was applied to pool the relative risks (RR) across studies.

Results

A total of 48 studies (5 case-control studies and 43 cohort studies) were included in this meta-analysis. The Cochran Q test and I² statistics revealed substantial heterogeneity (Q = 26,313.92, d.f. = 47, p < 0.001 and I² = 99.8%). Meta-analysis showed a significant increase in preeclampsia in women who conceived by ART compared with those who conceived spontaneously (RR = 1.71, 95% CI = 1.11–2.62, p = 0.015).

Conclusions

The findings of this systematic review indicate that the use of ART treatment is associated with a 1.71-fold increase in preeclampsia.

Risk of preeclampsia following assisted reproductive technology: systematic review and meta-analysis of 72 cohort studies

Objective: Previous studies have indicated that women with assisted reproductive technology (ART) pregnancy have an increased risk of preeclampsia. The aim of this current study was to estimate, through a systematic review and meta-analysis of cohort studies, the risk of preeclampsia in women who conceived with ART.Materials and methods: We searched ISI Web of Knowledge, Medline/PubMed, Scopus and Embase up to August 2017 for English-language articles pertaining to risk of preeclampsia in ART pregnancy using standard keywords. Data extraction was conducted by two authors and quality of the studies was assessed using the Newcastle-Ottawa Scale. A random-effects model was used for the meta-analysis.Results: In total, 72 cohort studies (n = 164 870) were included. The results of Cochran test and I² statistic indicated considerable heterogeneity among studies (Q = 15 415.61, df = 71, p < .001, I²=99.5%). The pooled estimate of preeclampsia risk using the random effects model was 10.8% (95% CI: 9.10-12.5). Furthermore, the funnel plot and Begg's test showed evidence of publication bias.Conclusions: We found that the risk of preeclampsia was very high among women who conceived with ART. Women should be counseled carefully before undergoing ART treatment.

Excessive Neutrophil Activity in Gestational Diabetes Mellitus: Could It Contribute to the Development of Preeclampsia?

Gestational diabetes mellitus is a transient form of glucose intolerance occurring during pregnancy. Pregnancies affected by gestational diabetes mellitus are at risk for the development of preeclampsia, a severe life threatening condition, associated with significant feto-maternal morbidity and mortality. It is a risk factor for long-term health in women and their offspring. Pregnancy has been shown to be associated with a subliminal degree of neutrophil activation and tightly regulated generation of neutrophil extracellular traps (NETs). This response is excessive in cases with preeclampsia, leading to the presence of large numbers of NETs in affected placentae. We have recently observed that circulatory neutrophils in cases with gestational diabetes mellitus similarly exhibit an excessive pro-NETotic phenotype, and pronounced placental presence, as detected by expression of neutrophil elastase. Furthermore, exogenous neutrophil elastase liberated by degranulating neutrophils was demonstrated to alter trophoblast physiology and glucose metabolism by interfering with key signal transduction components. In this review we examine whether additional evidence exists suggesting that altered neutrophil activity in gestational diabetes mellitus may contribute to the development of preeclampsia.