Perinatal outcome and long-term hospitalization of triplets according to birth order

PURPOSE

The association between birth order and adverse perinatal outcomes has been well studied in twin pregnancies. However, little is known about the differences in immediate perinatal outcomes as well as long-term hospitalization of the offspring in triplet pregnancies according to their birth order. As such, we aimed to assess the differences in immediate perinatal outcomes and long-term hospitalizations among triplets by their birth order.

METHODS

In a retrospective hospital-based cohort study, immediate perinatal outcomes and long-term hospitalizations were compared among triplet siblings according to their birth order. Deliveries occurred between the years 1991 and 2021 in a tertiary medical center. The study groups were followed until 18 years of age for cardiovascular, respiratory, neurological, and infection-related hospitalizations. Generalized estimation equation (GEE) models were used to control for confounders. Kaplan-Meier survival curves were used to compare cumulative long-term hospitalization incidences and Cox proportional hazards models were performed to control for confounders.

RESULTS

The study included 117 triplet deliveries. Rates of small for gestational age (SGA) infants increased linearly by birth order (6.0%, 7.7%, and 15.4% for the first, second, and third siblings, respectively; p-value for trends = 0.035). Using a GEE model controlling for maternal age, being born third in a triplet pregnancy was independently associated with SGA (third vs. first sibling, adjusted OR 3.0, 95% CI 1.38-6.59, p = 0.005). No significant differences in cardiovascular, respiratory, neurological, and infection-related hospitalizations were noted among the first, second, and third siblings. Likewise, using Kaplan-Meier survival analyses, no significant differences in the cumulative incidence of long-term pediatric hospitalizations were noted between the siblings. In Cox proportional hazards models, controlling for weight and gender, birth order in a triplet pregnancy did not exhibit an association with long-term hospitalizations of the offspring.

CONCLUSION

Despite the association between birth order and SGA, birth order in triplets does not seem to have an impact on the risk for long-term offspring hospitalization.

The outcome of reduced and non-reduced triplet pregnancies managed in a tertiary hospital during a 15-year-period - a retrospective cohort study

OBJECTIVES

Triplet pregnancies involve several complications, the most important being prematurity as virtually all triplets are born preterm. We conducted this study to compare the outcomes of reduced vs. non-reduced triplet pregnancies managed in the largest tertiary hospital in Finland.

METHODS

This was a retrospective cohort study in the Helsinki University Hospital during 2006-2020. Data on the pregnancies, parturients and newborns were collected from patient records. The fetal number, chorionicity and amnionicity were defined in first-trimester ultrasound screening. The main outcome measures were perinatal and neonatal mortality of non-reduced triplets, compared to twins and singletons selectively reduced of triplet pregnancies.

RESULTS

There were 57 initially triplet pregnancies and 35 of these continued as non-reduced triplets and resulted in the delivery of 104 liveborn children. The remaining 22 cases were spontaneously or medically reduced to twins (9) or singletons (13). Most (54.4 %) triplet pregnancies were spontaneous. There were no significant differences in gestational age at delivery between triplets (mean 33+0, median 34+0) and those reduced to twins (mean 32+5, median 36+0). The survival at one week of age was higher for triplets compared to twins (p<0.00001).

CONCLUSIONS

Most pregnancies continued as non-reduced triplets, which were born at a similar gestational age but with a significantly higher liveborn rate compared to those reduced to twins. There were no early neonatal deaths among cases reduced to singletons. Prematurity was the greatest concern for multiples in this cohort, whereas the small numbers may explain the lack of difference in gestational age between these groups.

Multifetal pregnancy reductions and selective fetocide in a tertiary referral center - a retrospective cohort study

OBJECTIVES

Multiple pregnancies involve several complications, most often prematurity, but also higher anomaly rates. Reducing fetuses generally improves pregnancy outcomes. We conducted this study to evaluate the obstetrical and neonatal results after multifetal pregnancy reduction (MFPR) in the largest tertiary hospital in Finland.

METHODS

This retrospective cohort study included all MFPR managed in Helsinki University Hospital during a 13 year period (2007-2019). Data on pregnancies, parturients and newborns were collected from patient files. The number of fetuses, chorionicities and amnionicities were defined in first-trimester ultrasound screening.

RESULTS

There were 54 MFPR cases included in the final analyses. Most often the reduction was from twins to singletons (n=34, 63 %). Majority of these (25/34, 73.5 %) were due to co-twin anomaly. Triplets (n=16, 29.6 %) were reduced to twins (n=7, 13 %) or singletons (n=9, 16.7 %), quadruplets (n=2, 3.7 %) and quintuplets (n=2, 3.7 %) to twins. Most (33/54, 61.1 %) MFPR procedures were done by 15+0 weeks of gestation. There were six miscarriages after MFPR and one early co-twin miscarriage. In the remaining 47 pregnancies that continued as twins (n=7, 14.9 %) or singletons (n=40, 85.1 %) the liveborn rate was 90 % for one fetus and 71.4 % for two fetuses.

CONCLUSIONS

Most MFPR cases were pregnancies with an anomalous co-twin. The whole pregnancy loss risk was 11.1 % after MFPR. The majority (70.6 %) of twins were spontaneous, whereas all quadruplets, quintuplets, and 56.3 % of triplets were assisted reproductive technologies (ART) pregnancies. Careful counselling should be an essential part of obstetrical care in multiple pregnancies, which should be referred to fetomaternal units for MFPR option.

Birth outcomes of twins after multifetal pregnancy reduction compared with primary twins

BACKGROUND

The introduction of assisted reproductive technology and the trend of increasing maternal age at conception have contributed to a significant rise in the incidence of multiple pregnancies. Multiple pregnancies bear several inherent risks for both mother and child. These risks increase with plurality and type of chorionicity. Multifetal pregnancy reduction is the selective abortion of ≥1 fetuses to improve the outcome of the remaining fetus(es) by decreasing the risk of premature birth and other complications.

OBJECTIVE

This study aimed to compare birth outcomes of trichorionic triplets reduced to twins with those of trichorionic triplets and primary dichorionic twins. The added value of this study is the comparison with an additional control group, namely primary dichorionic twins.

STUDY DESIGN

This was a retrospective cohort study. Data from January 1990 to November 2016 were collected from the East Flanders Prospective Twin Survey, one of the largest European multiple birth registries. A total of 85 trichorionic triplet pregnancies (170 neonates) undergoing multifetal pregnancy reduction to twins were compared with 5093 primary dichorionic twin pregnancies (10,186 neonates) and 104 expectantly managed trichorionic triplet pregnancies (309 neonates). The assessed outcomes were gestational age at delivery, birthweight, and small for gestational age.

RESULTS

Pregnancy reduction from triplets to twins was associated with higher birthweight (+365.44 g; 95% confidence interval, 222.75-508.14 g; P<.0001) and higher gestational age (1.7 weeks; 95% confidence interval, 0.93-2.46; P<.0001) compared with ongoing trichorionic triplets after adjustment for sex, parity, method of conception, birth year, and maternal age. A trend toward lower risk of small for gestational age was observed. Reduced triplets had, on average, lower birthweight (-263.12 g; 95% confidence interval, -371.80 to -154.44 g; P<.0001) and lower gestational age (-1.13 weeks; 95% confidence interval, -1.70 to -0.56; P=.0001) compared with primary twins. No statistically significant difference was observed between primary twins and reduced triplets that reached 32 weeks of gestation.

CONCLUSION

Multifetal pregnancy reduction from trichorionic triplets to twins significantly improved birth outcomes. This suggests that multifetal pregnancy reduction of trichorionic triplets to twins is medically justifiable. However, the birth outcomes of primary twins before 32 weeks of gestation are still better than those of reduced triplets. The process of multifetal pregnancy reduction includes at least 1 fetal death by definition, and thus prevention of higher-order pregnancies is preferable.

Upfront or Deferred Autologous Stem Cell Transplantation for Newly Diagnosed Multiple Myeloma in the Era of Triplet and Quadruplet Induction and Minimal Residual Disease/Risk-Adapted Therapy

The standards of care for the initial treatment of patients with newly diagnosed multiple myeloma (NDMM) who are eligible for high-dose melphalan and autologous stem cell transplantation (HDM-ASCT) include highly active triplet and quadruplet regimens based on proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies. These regimens are resulting in improved outcomes and increasingly high rates of minimal residual disease (MRD)-negative responses without HDM-ASCT as part of the upfront therapy. Furthermore, recent randomized studies have shown that, while transplant-based approaches as a frontline therapy result in significantly longer progression-free survival compared to non-transplant approaches, this has not translated into an overall survival benefit. Given these developments, and in the context of the treatment burden of undergoing HDM-ASCT, in addition to the acute toxicities and long-term sequelae of HDM, which are associated with the genotoxicity of melphalan, there is an increasing rationale for considering deferring upfront HDM-ASCT in select transplant-eligible patients and saving it as a treatment option for later salvage therapy. Here, we review the latest clinical trial data on upfront or deferred HDM-ASCT and on the activity of quadruplet induction regimens, including rates of MRD-negative responses, and summarize emerging treatment approaches in the upfront setting such as the use of MRD-directed therapy and alternatives to HDM-ASCT.

High-Throughput Search for Triplet Point Defects with Narrow Emission Lines in 2D Materials

We employ a first-principles computational workflow to screen for optically accessible, high-spin point defects in wide band gap, two-dimensional (2D) crystals. Starting from an initial set of 5388 point defects, comprising both native and extrinsic, single and double defects in ten previously synthesized 2D host materials, we identify 596 defects with a triplet ground state. For these defects, we calculate the defect formation energy, hyperfine (HF) coupling, and zero-field splitting (ZFS) tensors. For 39 triplet transitions exhibiting particularly low Huang-Rhys factors, we calculate the full photoluminescence (PL) spectrum. Our approach reveals many spin defects with narrow PL line shapes and emission frequencies covering a broad spectral range. Most of the defects are hosted in hexagonal BN (hBN), which we ascribe to its high stiffness, but some are also found in MgI2, MoS2, MgBr2 and CaI2. As specific examples, we propose the defects vSMoS0 and NiSMoS0 in MoS2 as interesting candidates with potential applications to magnetic field sensors and quantum information technology.

Kawasaki Disease Associated with SARS-CoV2 in a Pair of Triplets

The etiology of Kawasaki disease (KD) and its precise genetic basics remain unknown. Genetic variants affecting immunity have been found in some patients. The occurrence of KD in siblings is rare, but KD pedigrees with multiple affected members have been described in Japan and North America. Cases in twins have been documented. We report 2 pairs of trizygotic triplets who developed KD associated with SARS-CoV2 infection from 2 different families. Our cases show that KD is multifactorial in origin, and both infectious etiology (particularly SARS-CoV2 as in our cases) and genetic factors are relevant in the disease.

Butterflies and Ribbons: Supporting Families Experiencing Perinatal Loss in Multiple Gestation

Introduction: In neonatology, multiple pregnancies are common. Unfortunately, it is not rare for one baby to die. Communication with parents in these circumstances has been demonstrated to be sub-optimal. Methods: Two educational programs were evaluated with pre- and post-course surveys, questionnaires administered to participants, and audits. Results: In the online Butterfly project (UK; n = 734 participants), all participants reported that the training exceeded or met their expectations, 97% reported they learned new skills, and 48% had already applied them. Participants expressed gratitude in their open-ended answers: "I feel a lot more confident in supporting parents in this situation". In the Ribbon project (workshop for neonatal clinicians, Quebec; n = 242), 97% were satisfied with the training and reported feeling more comfortable caring for bereaved parents. Knowledge improved pre-post training. Audits revealed that 100% of cases were identified on the incubator and the baby's/babies' admission card, all changed rooms after the death of their co-twin/triplet, and all had the name of their co-twin/triplet on the discharge summary. All clinicians (55) knew what the ribbon symbol meant when asked during surprise audits at the bedside. Conclusion: Different educational strategies to optimize communication with families after the perinatal loss of a co-twin are appreciated and have a positive impact.

Large Chorioangioma in Triplets: An Uncommon Occurrence

A 25-year-old primigravida presented at 26 weeks of gestation by dates, the first time for the routine antenatal checkup. No histories were suggestive of pregnancy-induced hypertension (PIH) and edema. On physical examination, pallor was present with microcytic hypochromic anemia. Raised beta-human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) levels were present. Ultrasonography revealed triples with two thin echogenic intertwining membranes. Anomaly scan did not reveal any abnormality in fetuses. The placenta showed a large oval hypoechoic mass arising from its edge and bulge into the amniotic fluid. A central feeding vessel with a branching pattern and pulsatile color flow like that of the umbilical artery is noted on the color Doppler. She was spontaneously preterm delivered vaginally at 28 weeks of gestation. All three fetuses were stillborn. Histopathological diagnosis of angiomatous chorioangioma was confirmed. This case classically represents a grave complication of the large chorioangioma.

Real-world assessment of the treatment patterns and outcomes among patients with multiple myeloma across different risk stratification criteria in the United States: a retrospective cohort study

This study evaluated prognostic performance of International Staging System (ISS), revised ISS, and chromosomal abnormalities (CA) in newly diagnosed multiple myeloma patients to describe treatment patterns (cohort 1; n = 1979) and survival outcomes (cohort 2; n = 1382). In both cohorts, ∼18%, 41%, and 37% of patients were high-risk according to the R-ISS, ISS, and high-risk CA criteria, respectively. Across all risk stratification criteria, 60% of patients received triplets. In cohort 2, the median modified progression-free survival decreased with each increasing risk stage (23.5, 12.1, and 8.8 months in R-ISS I, II, and III, respectively, and 16.0, 12.7, and 10.4 months in ISS I, II, and III). Similar trends were observed in the proportions of two-year overall survival. In conclusion, R-ISS has greater discriminatory power than ISS or high-risk CA alone and can be implemented in a real-world setting. Accordingly, a more risk-adapted approach can be feasible, with a greater population-level impact.

Structure-preserved dimension reduction using joint triplets sampling for multi-batch integration of single-cell transcriptomic data

Dimension reduction (DR) plays an important role in single-cell RNA sequencing (scRNA-seq), such as data interpretation, visualization and other downstream analysis. A desired DR method should be applicable to various application scenarios, including identifying cell types, preserving the inherent structure of data and handling with batch effects. However, most of the existing DR methods fail to accommodate these requirements simultaneously, especially removing batch effects. In this paper, we develop a novel structure-preserved dimension reduction (SPDR) method using intra- and inter-batch triplets sampling. The constructed triplets jointly consider each anchor's mutual nearest neighbors from inter-batch, k-nearest neighbors from intra-batch and randomly selected cells from the whole data, which capture higher order structure information and meanwhile account for batch information of the data. Then we minimize a robust loss function for the chosen triplets to obtain a structure-preserved and batch-corrected low-dimensional representation. Comprehensive evaluations show that SPDR outperforms other competing DR methods, such as INSCT, IVIS, Trimap, Scanorama, scVI and UMAP, in removing batch effects, preserving biological variation, facilitating visualization and improving clustering accuracy. Besides, the two-dimensional (2D) embedding of SPDR presents a clear and authentic expression pattern, and can guide researchers to determine how many cell types should be identified. Furthermore, SPDR is robust to complex data characteristics (such as down-sampling, duplicates and outliers) and varying hyperparameter settings. We believe that SPDR will be a valuable tool for characterizing complex cellular heterogeneity.

Gestational weight gain in triplet pregnancies in the United States

BACKGROUND

The Institute of Medicine has published national recommendations for optimal pregnancy weight gain ranges for singletons and twins but not for higher-order multiples. A common clinical resource suggests weight gain targets for triplet pregnancies, but they are based on a single, small study conducted over 20 years ago.

OBJECTIVE

We sought to describe contemporary maternal weight gain patterns in triplet gestations in the United States, the weight gain patterns associated with good neonatal outcomes, and how these patterns compare with those of healthy twin pregnancies.

STUDY DESIGN

We used data from 7705 triplet pregnancies drawn from the United States live birth and fetal death files (2012‒2018). We calculated total pregnancy weight gain as weight at delivery minus the prepregnancy weight. A good neonatal outcome was defined as delivery at ≥32 weeks' gestation of 3 liveborn infants weighing ≥1500 g with 5-minute Apgar scores of ≥3. We described the weight gain patterns of triplet pregnancies with good neonatal outcomes by calculating week-specific percentiles of the total weight gain distribution for deliveries at 32 to 37 weeks' gestation. For comparative purposes, we plotted these values against the percentiles of a previously published weight gain chart for monitoring and evaluating twin pregnancies from a referent cohort.

RESULTS

Most participants were over weight (26%) or obese (30%), and 42% were normal weight or underweight. The 50th percentile (25th-75th) of total weight gain in triplet pregnancies was 17 (11-23) kg. As the body mass index category increased, the total weight gain declined: underweight or normal weight, median 19 (14-25) kg; overweight, 17 (12-23) kg; obese, 14 (7.7-20) kg. Approximately 46% of triplet pregnancies had a good neonatal outcome (n=3562). For underweight or normal weight triplet pregnancies with good neonatal outcomes, the 50th percentiles of weight gain at 32 weeks' and 36 weeks' gestation were 12.3 kg and 22.7 kg, respectively. The 10th and 90th percentiles were 12.3 kg and 32.7 kg, respectively, at 32 weeks, and 15.0 kg and 34.1 kg, respectively, at 36 weeks. Triplet pregnancies with prepregnancy overweight or obesity and a good neonatal outcome had lower weight gains. Compared with the reference values for pregnancy weight gain from a twin-specific weight gain chart, the median total weight gain in triplet pregnancies with good neonatal outcomes was approximately 3 to 5 kg more than twins, regardless of body mass index.

CONCLUSION

Our study fills an important gap in understanding how much weight gain can be expected among triplet pregnancies by body mass index category. These descriptive data are a necessary first step to inform science-based triplet gestational weight gain guidelines. Additional research is needed to determine whether monitoring triplet pregnancy weight gain is useful for promoting healthy outcomes for pregnant individuals and children and what targets should be used to optimize maternal and neonatal health.

Spike Timing-Dependent Plasticity with Enhanced Long-Term Depression Leads to an Increase of Statistical Complexity

Synaptic plasticity is characterized by remodeling of existing synapses caused by strengthening and/or weakening of connections. This is represented by long-term potentiation (LTP) and long-term depression (LTD). The occurrence of a presynaptic spike (or action potential) followed by a temporally nearby postsynaptic spike induces LTP; conversely, if the postsynaptic spike precedes the presynaptic spike, it induces LTD. This form of synaptic plasticity induction depends on the order and timing of the pre- and postsynaptic action potential, and has been termed spike time-dependent plasticity (STDP). After an epileptic seizure, LTD plays an important role as a depressor of synapses, which may lead to their complete disappearance together with that of their neighboring connections until days after the event. Added to the fact that after an epileptic seizure the network seeks to regulate the excess activity through two key mechanisms: depressed connections and neuronal death (eliminating excitatory neurons from the network), LTD becomes of great interest in our study. To investigate this phenomenon, we develop a biologically plausible model that privileges LTD at the triplet level while maintaining the pairwise structure in the STPD and study how network dynamics are affected as neuronal damage increases. We find that the statistical complexity is significantly higher for the network where LTD presented both types of interactions. While in the case where the STPD is defined with purely pairwise interactions an increase is observed as damage becomes higher for both Shannon Entropy and Fisher information.

Multiple gestation associated with infertility therapy: a committee opinion

This Committee Opinion provides practitioners with suggestions to reduce the likelihood of iatrogenic multiple gestation resulting from infertility treatment. This document replaces the document of the same name previously published in 2012 (Fertil Steril 2012;97:825-34 by the American Society for Reproductive Medicine).

Fetal Reduction Could Improve but Not Completely Reverse the Pregnancy Outcomes of Multiple Pregnancies: Experience From a Single Center

OBJECTIVE

To investigate the effectiveness and limitations of multifetal pregnancy reduction (MFPR) on the improvement of pregnancy outcomes of triplet or twin pregnancies conceived by in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

METHODS

We performed a cohort study of women undergoing IVF or ICSI from 2002-2016 in reproductive center, women's hospital, Zhejiang University School of Medicine. The cohort included 502 women who underwent MFPR and 9641 non-reduced women. Pregnancy outcomes were gestational age (GA) at delivery, pregnancy loss, preterm delivery, low birth weight (LBW), very low birth weight (VLBW), and small for gestational age (SGA). Multiple linear regression and logistic regression models were used to compare pregnancy outcomes between groups.

RESULTS

Triplets reduced to singletons had a longer median GA (39.07 vs 37.00, P<0.001), and lower rates of LBW (8.9% vs 53.2%, P<0.001) and SGA (17.8% vs 44.7%, P=0.001) than triplets reduced to twins, with a similar pregnancy loss rate (6.7% vs 6.6%, P=0.701). Twins reduced to singletons had a comparable pregnancy loss rate (4.8% vs. 6.5%, P=0.40), a longer median GA (38.79 vs. 37.00, P<0.001), and lower rates of LBW (13.5% vs. 47.0%, P<0.001) and SGA (13.5% vs. 39.6%, P<0.001) than primary twins. Triplets reduced to twins had higher rates of LBW (53.2% vs. 47.0%, P=0.028) and SGA (44.7% vs. 39.6%, P=0.040) than primary twins, with a similar pregnancy loss rate (6.6% vs. 6.5%, P=0.877). Singletons reduced from triplets/twins had higher rates of preterm delivery (15.8% vs. 7.3%, P<0.001), LBW (12.3% vs. 4.32%, P<0.001), VLBW (2.3% vs. 0.4%, P=0.002), and SGA (14.6% vs.6.6%, P<0.001) than primary singletons, with a comparable pregnancy loss rate (5.3% vs. 5.4%, P=0.671).

CONCLUSIONS

This study suggests that the pregnancy loss rate is similar between reduction and non-reduction groups. MFPR improves pregnancy outcomes, including the risk of preterm delivery, LBW, and SGA, but still could not completely reverse the adverse pregnancy outcomes of multiple pregnancies.

Three or less? Decision making for or against selective reduction and psychological outcome in forty women with a triplet pregnancy

OBJECTIVES

The aim of the study was to investigate decision making for or against multifetal pregnancy reduction (MFPR) and psychological outcome in women with a triplet pregnancy.

METHODS

We investigated medical and sociodemographic variables and characteristics of the decision process for or against MFPR in forty women with triplet pregnancies who had either undergone MFPR (MFPR-group: N = 10) or had delivered triplets (triplet-group: N = 30). Moreover, emotional experiences of the reduction procedure were assessed. Psychological outcome was measured using the Beck Depression inventory (BDI) and the 36-Item Short Form Health Survey (SF-36).

RESULTS

Women of the MFPR-group had a higher gestational age at delivery (p = 0.001), shorter NICU stay (p = 0.001), higher educational level (p = 0.010), more frequently utilized psychological counseling during the decision process (p = 0.016), rated their gynecologist as more helpful for the decision (p = 0.045), required more time for their decision (p = 0.016), and were more likely to be in paid employment at follow-up (p = 0.041) than women of the triplet-group. MFPR was experienced as stressful (90%) or terrifying (10%). At 3.2 (±2.2) years after delivery, the vast majority of women in both groups were free from clinically relevant depression.

CONCLUSIONS

MFPR, though associated with emotional distress related to the procedure, results in a satisfactory psychological outcome in the majority of women. The decision for or against MFPR may be related to sociodemographic (such as educational) variables, which further supports the concept of framing in medical decision making. Having triplets most probably is associated with multiple (e.g. social or economic) consequences that may remain poorly investigated.

Supporting multiple birth families: Perceptions and experiences of health visitors

Objective

To explore the current practice and perceptions of health visitors in supporting multiple birth families.

Design and sample

Practicing health visitors across the United Kingdom were invited to complete a cross‐sectional, descriptive, online survey. The questionnaire covered multiple birth caseload, education received about multiples and the experience of working with families. Two‐hundred and ninety health visitors completed the questionnaire. Descriptive and inferential statistics were used for analysis of the quantitative components and thematic analysis for the qualitative data.

Results

Most health visitors had twins on their current workload. Most health visitors had not received any specific training or continuing professional development regarding the needs of multiple birth families. Supporting the families within the confines of reduced time and increased workload was challenging. Daily tasks of caring for multiples were the main areas that health visitors and parents wanted more information about.

Conclusions

In the United Kingdom, health visitors are uniquely positioned to support multiple birth families, in particular during the more challenging early years. However, the findings of this study suggest that many health visitors are aware that the care and support that they are able to provide multiple birth families falls short of meeting their needs

Effect of monochorionicity on perinatal outcome and growth discordance in triplet pregnancy: collaborative multicenter study in England, 2000-2013

OBJECTIVES

To compare perinatal outcome and growth discordance between trichorionic triamniotic (TCTA) and dichorionic triamniotic (DCTA) or monochorionic triamniotic (MCTA) triplet pregnancies.

METHODS

This was a multicenter cohort study using population-based data on triplet pregnancies from 11 Northern Survey of Twin and Multiple Pregnancy (NorSTAMP) maternity units and the Southwest Thames Region of London Obstetric Research Collaborative (STORK) multiple pregnancy cohort, for 2000-2013. Perinatal outcomes (from ≥ 24 weeks' gestation to 28 days of age), intertriplet fetal growth and birth-weight (BW) discordance and neonatal morbidity were analyzed in TCTA compared with DCTA/MCTA pregnancies.

RESULTS

Monochorionic placentation of a pair or trio in triplet pregnancy (n = 72) was associated with a significantly increased risk of perinatal mortality (risk ratio, 2.7 (95% CI, 1.3-5.5)) compared with that in TCTA pregnancies (n = 68), due mainly to a much higher risk of stillbirth (risk ratio, 5.4 (95% CI, 1.6-18.2)), with 57% of all stillbirth cases resulting from fetofetal transfusion syndrome, while there was no significant difference in neonatal mortality (P = 0.60). The associations with perinatal mortality and stillbirth persisted when considering only pregnancies not affected by a major congenital anomaly. DCTA/MCTA triplets had lower BW and demonstrated greater BW discordance than did TCTA triplets (P = 0.049). Severe BW discordance of > 35% was 2.5-fold higher in DCTA/MCTA compared with TCTA pregnancies (26.1% vs 10.4%), but this difference did not reach statistical significance (P = 0.06), presumably due to low numbers. Triplets in both groups were delivered by Cesarean section in over 95% of cases, at a similar gestational age (median, 33 weeks' gestation). The rate of respiratory (P = 0.28) or infectious (P = 0.08) neonatal morbidity was similar between the groups.

CONCLUSIONS

Despite close antenatal surveillance, monochorionic placentation of a pair or trio in triamniotic triplet pregnancy was associated with a significantly increased stillbirth risk, mainly due to fetofetal transfusion syndrome, and with greater size discordance. In liveborn triplets, there was no adverse effect of monochorionicity on neonatal outcome. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

The Effects of Genetic Relatedness on the Preterm Infant Gut Microbiota

The preterm infant gut microbiota is influenced by environmental, endogenous, maternal, and genetic factors. Although siblings share similar gut microbial composition, it is not known how genetic relatedness affects alpha diversity and specific taxa abundances in preterm infants. We analyzed the 16S rRNA gene content of stool samples, ≤ and >3 weeks postnatal age, and clinical data from preterm multiplets and singletons at two Neonatal Intensive Care Units (NICUs), Tampa General Hospital (TGH; FL, USA) and Carle Hospital (IL, USA). Weeks on bovine milk-based fortifier (BMF) and weight gain velocity were significant predictors of alpha diversity. Alpha diversity between siblings were significantly correlated, particularly at ≤3 weeks postnatal age and in the TGH NICU, after controlling for clinical factors. Siblings shared higher gut microbial composition similarity compared to unrelated individuals. After residualizing against clinical covariates, 30 common operational taxonomic units were correlated between siblings across time points. These belonged to the bacterial classes Actinobacteria, Bacilli, Bacteroidia, Clostridia, Erysipelotrichia, and Negativicutes. Besides the influence of BMF and weight variables on the gut microbial diversity, our study identified gut microbial similarities between siblings that suggest genetic or shared maternal and environmental effects on the preterm infant gut microbiota.

The Diversity of the Intestinal Flora Disturbed After Feeding Intolerance Recovery in Preterm Twins

Background: Feeding intolerance (FI) is a common condition in premature infants that results in growth retardation and even necrotizing enterocolitis. The gut microbiome is linked to FI occurrence; however, the outcome after FI recovery is unclear. Methods: Fecal samples were collected from 11 pairs of premature twins/triplets for 16S rRNA gene sequencing. Initial fecal samples were collected shortly after admission, and then every other week until 7 weeks or discharge. Results: After FI recovery, there was no significant difference in the β-diversity of the intestinal flora between the FI group and the feeding tolerance (FT) group. By contrast, there was a significant difference in the β-diversity. Proteobacteria was the predominant phylum in the microbiome of the FI group, whereas Firmicutes was the predominant phylum in the microbiome of the FT group. The predominant bacteria with LDA >4 between the two groups at 13-15 days after birth, 19-28 days after birth, and at discharge were different, with the proportions of Bacillus, Clostridium butyricum, and Clostridium being highest in the FT group and Firmicutes, unidentified_Clostridiales, and Proteobacteria being highest in the FI group. Similarly, there were significant differences in the relative abundances of KEGG pathways, such as fatty acid metabolism, DNA repair and recombination proteins, energy metabolism, and amino acid metabolism, between the two groups (P < 0.01). Conclusions: There was a significant difference in diversity of the intestinal flora after feeding intolerance recovery. Feeding intolerance may disturb the succession of the intestinal bacterial community.

COVID-19 in 28-Week Triplets Caused by Intrauterine Transmission of SARS-CoV-2-Case Report

Since the beginning of the COVID-19 pandemic, in-utero transmission of SARS-CoV-2 remains a rarity and only very few cases have been proven across the world. Here we depict the clinical, laboratory and radiologic findings of preterm triplets born at 28 6/7 weeks to a mother who contracted COVID-19 just 1 week before delivery. The triplets showed SARS-CoV-2 positivity right after birth, developed significant leukopenia and early-onset pulmonary interstitial emphysema. The most severely affected triplet I required 10 days of high-frequency oscillatory ventilation due to failure of conventional invasive ventilation, and circulatory support for 4 days. Despite a severe clinical course in two triplets (triplet I and II), clinical management without experimental, targeted antiviral drugs was successful. At discharge home, the triplets showed no signs of neurologic or pulmonary sequelae. Placental immunohistology with SARS-CoV-2 N-protein localized strongly to syncytiotrophoblast cells and, to a lesser extent, to fetal Hofbauer cells, proving intrauterine virus transmission. We discuss the role of maternal viremia as a potential risk factor for vertical transmission. To the best of our knowledge, our report presents the earliest unequivocally confirmed prenatal virus transmission in long-term surviving children, i.e., at the beginning of the third trimester.

Changes in treatment landscape of relapsed or refractory multiple myeloma and their association with mortality: Insights from German claims database

OBJECTIVES

Emerging treatments for relapsed or refractory multiple myeloma (rrMM) have led to increasing options for many patients. This study aimed to assess changes in utilization of these options in Germany with a focus on modern triplet regimens including new agents, such as carfilzomib, ixazomib, elotuzumab and daratumumab, and to evaluate whether this had an impact on rrMM-related outcomes over time.

METHODS

The study population consisted of 1255 rrMM patients who were assigned to one of the following 6 treatment groups: immunomodulatory drug (IMiD)-based doublets, proteasome inhibitor (PI)-based doublets, daratumumab monotherapy, PI-IMiD-based triplets, monoclonal antibodies (mAbs)-based triplets, or other treatment.

RESULTS

Use of triplet-based therapy regimens increased from 5.9% in 2014 to 31.4% in 2017. In parallel, use of IMiD-based doublets decreased from 74.3% in 2014 to 37.6% in 2017. Over the same time period, the risk of death decreased by 32% and the risk of hospitalization which was reduced by 30%. The risk for serious adverse events remained unchanged.

CONCLUSIONS

Between 2014 and 2017, the use of triplet-based therapy regimens for rrMM in Germany has significantly increased and this was associated with a significant decline in deaths and hospitalizations without an increased incidence of serious adverse events.

Effects of the timing of selective reduction and finishing number of fetuses on the perinatal outcome in triplets: a single-center retrospective study

OBJECTIVE

This study aimed to evaluate the effect of the timing of selective reduction and finishing the number of fetuses on perinatal outcomes in triplets.

METHOD

The study assessed 417 cases of triplets. Perinatal outcomes were compared between selective reduction (SR) performed at 11-14⁺⁶weeks of gestation and SR performed at 15-24⁺⁶weeks of gestation for the same starting and finishing numbers of fetuses. Then, the perinatal outcomes of reduction to singletons and twins were compared for the same range of SR of gestational weeks.

RESULTS

The spontaneous abortion rate was 6.5% and 14.9%, respectively, when SR was performed at 11-14⁺⁶weeks of gestation (214 cases) and at 15-24⁺⁶ weeks of gestation (94 cases) (p = .019). In total, 74 cases of triplets were reduced to singletons and 214 cases were reduced to twins when SR was performed at 11-14⁺⁶weeks of gestation. Preterm labor rates, low birth weight rates, birth weights, and gestational ages at delivery also showed significant differences (p < .001). In total, 35 cases of triplets were reduced to singletons and 94 cases were reduced to twins when SR was performed at 15-24⁺⁶weeks of gestation. The preterm labor rates, low birth weight rates, birth weights and gestational ages at delivery also significantly differed (p < .05).

CONCLUSIONS

When the starting and finishing numbers of fetuses were the same, the timing of SR could affect the spontaneous abortion rates. When the starting number of fetuses was the same, the timing of SR did not affect the neonatal outcome. However, the finishing number of fetuses was the influencing factor.

Different retinopathy of prematurity severity and outcomes in triplets: A case report

In this case report, we discuss the presentation of retinopathy of prematurity in triplets born at 25 + 3 weeks gestational age of whom each had a different birth weight, weight gain and treatment requirements. Triplet A weighed 800 g and his retinopathy of prematurity had resolved with no intervention. Triplet B weighed 630 g at birth and he required bilateral intravitreal ranibizumab injection at 32 + 6 weeks. Triplet C weighed 520 g and required bilateral intravitreal ranibizumab injection at 36 weeks, but after 5 weeks he had recurrence which was treated with bilateral diode laser. Triplet C had the poorest weight gain. The main differences between the triplets are the birth weight and the weight gain. Furthermore, refraction was performed at 10 months; triplet A had a hyperopia of +1.25 spherical equivalent in both eyes, triplet B had mild myopia of −0.25 spherical equivalent and triplet C had a myopia of −3.00 spherical equivalent in the right eye and −2.75 spherical equivalent in the left eye.

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.

Characteristics of and Sources of Support for Women Who Breastfed Multiples for More than 12 Months

Background and Objective: Although rates of breastfeeding initiation for multiples may be similar to those of singletons, breastfeeding duration falls short. Evidence-based interventions tailored to families with multiples may help reduce the gap; however, these do not yet exist and will require a stronger knowledge base about factors related to successful breastfeeding of multiples for long durations. To characterize mothers of multiples who breastfed for >12 months and identify support factors that were important. Materials and Methods: Mothers of multiples who breastfed for >12 months completed an online questionnaire about their breastfeeding experiences. Bivariate statistics and log-binomial regression were used to examine associations among maternal characteristics, influential factors, and sources of breastfeeding support. Results: This sample of 1,173 women commonly cited partner support, the nutritional/health benefits of breastfeeding, building a strong bond, and enjoyment of breastfeeding as important influences on their decision to breastfeed for >12 months. Younger women, women with less education, Hispanic or Latina women, and nonwhite women were more likely to indicate that cost was important in their decision to breastfeed for more than 12 months (all chi-square p < 0.02). Women with more children were less likely to discuss their decision with their friends or partner (e.g., women with 5+ versus 2 children, relative risk for partner = 0.65, 95% confidence interval: 0.52-0.81). Conclusion: Interventions to encourage long-term breastfeeding of multiples might consider promoting the cost, health, and relationship building benefits. Mobilizing a variety of supports-including partners and family-could help mothers of multiples sustain breastfeeding.

Triplet Excitation and Electroluminescence from a Supramolecular Monolayer Embedded in a Boron Nitride Tunnel Barrier

We show that ordered monolayers of organic molecules stabilized by hydrogen bonding on the surface of exfoliated few-layer hexagonal boron nitride (hBN) flakes may be incorporated into van der Waals heterostructures with integral few-layer graphene contacts forming a molecular/two-dimensional hybrid tunneling diode. Electrons can tunnel through the hBN/molecular barrier under an applied voltage V_SD, and we observe molecular electroluminescence from an excited singlet state with an emitted photon energy hν > eV_SD, indicating upconversion by energies up to ∼1 eV. We show that tunneling electrons excite embedded molecules into singlet states in a two-step process via an intermediate triplet state through inelastic scattering and also observe direct emission from the triplet state. These heterostructures provide a solid-state device in which spin-triplet states, which cannot be generated by optical transitions, can be controllably excited and provide a new route to investigate the physics, chemistry, and quantum spin-based applications of triplet generation, emission, and molecular photon upconversion.

[Efficiency of acupuncture and relaxation sessions in improvement of psychophysical state]

A study of the changes in psychophysical function of the human body before and after relaxation sessions and acupuncture application has been conducted. The impact of relaxation sessions on psychophysical performance was studied on a group of university students and postgraduates aged between 18 and 30 years old; the impact of an acupuncture session course - on a group of subjects of a broad age range between 14 and 72, as they underwent rehabilitation therapy for their supportive locomotive apparatus disorders. The recording techniques used included electroencephalography (EEG), psychomotor reaction recording, minute-long time span accuracy reproduction; TST technique (Tactile Solar Test) of meridian and microsystem examination The results of this study suggest that relaxation sessions contribute to the enhancement of neurodynamical performance and mental activity efficiency. After the acupuncture therapy, relaxation effect, and restored tactile sensation on the meridians and microsystems was noted. A conclusion has been made that relaxation sessions and acupuncture may be used to improve psychophysical function.

Circulating Concentrations of Key Regulators of Nitric Oxide Production in Undernourished Sheep Carrying Single and Multiple Fetuses

Simple Summary

The present study aimed to determine the blood concentrations of L-arginine, asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), and L-homoarginine, modulating nitric oxide (NO) synthesis, in single, twin. and triplet pregnancies in ewes undergoing either dietary energy restriction or receiving 100% of their energy requirements. Blood concentrations of L-arginine, of its metabolites. and the ratio between NO synthesis boosters and inhibitors are altered in energy-restricted ewes, these alterations being higher in ewes carrying multiple fetuses.

Abstract

The aim of this study was to investigate the blood concentrations of L-arginine, asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), and L-homoarginine, which are regulators of nitric oxide (NO) synthesis, in single, twin, and triplet pregnancies in ewes undergoing either a dietary energy restriction or receiving 100% of their energy requirements. From day 24 to 100 of pregnancy, the ewes were fed ryegrass hay and two different iso-proteic concentrates fulfilling either 100% of ewes’ energy requirements (control group; n = 30, 14 singleton pregnancies, 12 twin pregnancies, and 4 triplet pregnancies) or only 45% (feed-restricted group; n = 29; 11 singleton pregnancies, 15 twin pregnancies, and 3 triplet pregnancies). Blood samples were collected monthly to measure, by capillary electrophoresis, the circulating concentrations of arginine, ADMA, homoarginine, SDMA, and of other amino acids not involved in NO synthesis to rule out possible direct effects of diet restriction on their concentrations. No differences between groups were observed in the circulating concentrations of most of the amino acids investigated. L-homoarginine increased markedly in both groups during pregnancy (p < 0.001). SDMA (p < 0.01), L-arginine, and ADMA concentrations were higher in feed-restricted ewes than in controls. The L-arginine/ADMA ratio, an indicator of NO production by NOS, decreased towards term without differences between groups. The ADMA/SDMA ratio, an index of the ADMA degrading enzyme activity, was higher in controls than in feed-restricted ewes (p < 0.001). Obtained results show that circulating concentrations of L-arginine, of its metabolites, and the ratio between NO synthesis boosters and inhibitors are altered in energy-restricted ewes, and that these alterations are more marked in ewes carrying multiple fetuses.

The New West Japan Twins and Higher Order Multiple Births Registry

The new West Japan Twins and Higher Order Multiple Births Registry was established by recruiting young twins and multiple births and by referrals from public health centers in the 1990s. The participants included in the survey comprised over 7800 twins and 4241 higher order multiples, and their families. Specifically, the present registry contains one of the largest triplet samples in the world. For these twins and multiples, data on year of delivery, mode of delivery, gestational age, intrapartum complications, longitudinal physical measures, motor milestones, cerebral palsy and feeding methods were obtained from records in the Maternal and Child Health Handbooks and schools. Participating mothers were asked to indicate family structure, parental educational history, maternal sleeping time, maternal health condition, maternal and paternal age at multiple delivery, complications during pregnancy, handedness of multiples and age at menarche of multiples. However, the zygosity differed among the various collaborating public health centers according to factors such as the time of investigation. Follow-up questionnaires have been mailed out every 3-4 years for longitudinal studies. This article describes the goals of this registry, recruitment of multiples and the focus of the study. The goals of this registry are not only to conduct research on human genetics and maternal and child health, but also to contribute to providing appropriate information for families with multiples.

Monozygotic multiple pregnancies after transfer of single in vitro produced equine embryos

Background

Monozygotic multiple pregnancy is rare in horses, but may be more common after transfer of an in vitro produced (IVP) embryo.

Objectives

To determine the occurrence, incidence, characteristics and outcome of monozygotic siblings arising from in vivo and IVP equine embryos.

Study design

Retrospective case series.

Methods

A total of 496 fresh in vivo and 410 frozen‐thawed IVP blastocysts, produced by intracytoplasmic sperm injection (ICSI) of in vitro matured oocytes from Warmblood mares, were transferred into recipient mares. The likelihoods of pregnancy and multiple pregnancy were calculated, and the clinical features and outcome of any multiple pregnancy were recorded.

Results

The likelihood of pregnancy after transfer of a single IVP or in vivo embryo was 62% (254/410) and 83% (413/496) respectively. The incidence of multiple pregnancy was 1.6% (4/254) and 0% (0/413) for IVP and in vivo blastocysts, respectively. More specifically, three IVP blastocysts yielded twin embryo propers/fetuses, and one IVP conceptus developed three distinct embryonic bodies. Interestingly, only one embryonic vesicle was detected at all ultrasonographic examinations prior to embryo proper development. Multiple embryonic bodies only became apparent at later scans to check for an embryo proper and heartbeat, or when the recipient mare aborted. Two twin pregnancies aborted spontaneously at 3 and 9 months, respectively, while the heartbeat was lost from all three embryos in the triplet pregnancy before day 35 of gestation. Twin reduction by per rectum compression of one fetal thorax was attempted at day 50 of gestation in the fourth case; however, both fetuses were lost.

Main limitations

Small number of cases.

Conclusions

In vitro embryo production resulted in a higher incidence of multiple monozygotic pregnancy, which could only be diagnosed after development of the embryo proper and is likely to result in pregnancy loss later in gestation if left untreated.

Breast Milk for Preterm Multiples: More Proteins, Less Lactose

Exclusive breastfeeding is currently recommended until at least 6 months of postnatal age, due to maternal breast milk (BM) unique composition and beneficial properties. In fact, BM modifies itself according to gestational age (GA) at birth, adapting its composition to neonatal requests during lactation. Multiple births represent about 3% of the whole pregnancies; such neonates result more vulnerable than full-term newborns, due to lower GA and birth weight (BW) and the higher incidence of perinatal complications. Although an adequate nutrition is fundamental for twins and other multiples, studies on this topic are lacking. We collected and analyzed BM from mothers of 19 twins and 5 triplets showing GA < 33 weeks and BW < 1500 g, comparing it to a control group of 28 preterm singletons. As a result, at GA ≤ 28 weeks, we observed that protein content is higher in BM for multiples (1.53 vs. 1.29 g per 100 ml), lactose concentration is greater in BM for singletons (6.72 vs. 6.34 g per 100 ml) and GA results the most relevant factor influencing BM protein composition. BM for multiples results higher in proteins and lower in lactose, if compared with singleton's samples; this could promote and sustain growth and organ development in this vulnerable category. BM from multiples shows a trophic and immunologic role, since these neonates often show lower GA and BW instead of singletons. These findings could help in optimizing nutritional strategies and improving BM individualized fortification.

Demographic Seasonality

The seasonality of demographic data has been of great interest. It depends mainly on the climatic conditions, and the findings may vary from study to study. Commonly, the studies are based on monthly data. The population at risk plays a central role. For births or deaths over short periods, the population at risk is proportional to the lengths of the months. Hence, one must analyze the number of births (and deaths) per day. If one studies the seasonality of multiple maternities, the population at risk is the total monthly number of confinements and the number of multiple maternities in a given month must be compared with the monthly number of all maternities. Consequently, when one considers the monthly rates of multiple maternities, the monthly number of births is eliminated and one obtains an unaffected seasonality measure of the rates. In general, comparisons between the seasonality of different data sets presuppose standardization of the data to indices with common means, mainly 100. If one assumes seasonality as 'non-flatness' throughout a year, a chi-squared test would be an option, but this test calculates only the heterogeneity and the same test statistic can be obtained for data sets with extreme values occurring in consecutive months or in separate months. Hence, chi-squared tests for seasonality are weak because of this arbitrariness and cannot be considered a model test. When seasonal models are applied, one must pay special attention to how well the applied model fits the data. If the goodness of fit is poor, nonsignificant models obtained can erroneously lead to statements that the seasonality is slight, although the observed seasonal fluctuations are marked. In this study, we investigate how the application of seasonal models can be applied to different demographic variables.

Triplet therapies - the new standard of care for multiple myeloma: how to manage common toxicities

Introduction: Multiple three drug combination regimens have been approved for the treatment of multiple myeloma in the last few years. Triplets have become the new standard of care for transplant eligible and ineligible patients with newly diagnosed as well as relapsed multiple myeloma. Novel agents have a unique profile of side effects. The management of toxicities is important to maintain quality of life and maximize treatment duration and benefit. Areas covered: This article reviews efficacy data, incidence of key adverse events and provide recommendations and expert opinion regarding how to manage common toxicities in triplet therapies. Relevant publications and abstracts were searched in PubMed, ASH, ASCO and EHA meetings. Guidelines from IMWG, NCCN, ESMO and ASCO, published trial protocols and prescribing information were used to formulate recommendations for the management of toxicities. Expert commentary: Side effects are a critical factor guiding the selection of optimal chemotherapy regimens for multiple myeloma. The majority of toxicities encountered with triplet therapies are reversible and can be readily managed with supportive care and dose modifications.

Rethinking the tools of the RNA world

An artificially evolved ribozyme can catalyse the synthesis of RNA by using trinucleotide triphosphates as building blocks.

The first case of congenital blood chimerism in two of the triplets in Korea

BACKGROUND

Chimeras are composed of two or more different populations that originated from different zygotes. Blood chimerism arising from twins have been reported in the literature. Herein, we report the first blood group chimerism in triplets.

METHODS

ABO blood grouping was carried out by manual tile methods (Merck Millipore, UK) and micro-column agglutination method (Bio-Rad, Cressier sur Morat, Switzerland). Flow cytometric analysis was performed with Anti-A-PE conjugated monoclonal antibodies (BD Biosciences, San Jose, CA, USA) and FACS Canto II (BD Biosciences). Molecular analysis was performed with allele-specific polymerase chain reaction (AS-PCR) and direct sequencing of the exons 6 and 7.

RESULTS

Mixed-field agglutination and weak agglutination against anti-A were revealed by ABO blood grouping. Flow cytometric analysis revealed the presence of both A cells and O cells. AS-PCR and sequencing showed two neonates with chimerism, with each neonate`s genotype being A102/O01/O02.

CONCLUSION

This is the first recorded case of blood chimera from a triplet in Korea. We recommend full investigation of blood group chimerism in neonates with ABO discrepancy, as blood chimerism is subject to certain caution in the clinical environment.

Triplets, birthweight, and handedness

The mechanisms behind handedness formation in humans are still poorly understood. Very low birthweight is associated with higher odds of left-handedness, but whether this is due to low birthweight itself or premature birth is unknown. Handedness has also been linked to development, but the role of birthweight behind this association is unclear. Knowing that birthweight is lower in multiple births, triplets being about 1.5 kg lighter in comparison with singletons, and that multiples have a higher prevalence of left-handedness than singletons, we studied the association between birthweight and handedness in two large samples consisting exclusively of triplets from Japan (n = 1,305) and the Netherlands (n = 947). In both samples, left-handers had significantly lower birthweight (Japanese mean = 1,599 g [95% confidence interval (CI): 1,526-1,672 g]; Dutch mean = 1,794 g [95% CI: 1,709-1,879 g]) compared with right-handers (Japanese mean = 1,727 g [95% CI: 1,699-1,755 g]; Dutch mean = 1,903 g [95% CI: 1,867-1,938 g]). Within-family and between-family analyses both suggested that left-handedness is associated with lower birthweight, also when fully controlling for gestational age. Left-handers also had significantly delayed motor development and smaller infant head circumference compared with right-handers, but these associations diluted and became nonsignificant when controlling for birthweight. Our study in triplets provides evidence for the link between low birthweight and left-handedness. Our results also suggest that developmental differences between left- and right-handers are due to a shared etiology associated with low birthweight.

Cervical-length measurement in mid-gestation to predict spontaneous preterm birth in asymptomatic triplet pregnancy

OBJECTIVE

To assess the predictive value of sonographic cervical-length (CL) measurement in mid-gestation for spontaneous preterm birth (PTB) in asymptomatic triplet pregnancy.

METHODS

This was a retrospective study of asymptomatic triplet pregnancies followed at five Italian tertiary referral centers, between 2002 and 2015. CL was measured transvaginally between 18 and 24 weeks' gestation. Pregnancies with medically indicated PTB were excluded. Demographic and pregnancy characteristics of pregnancies complicated by PTB were analyzed and the distributions of CL measurements in these patients were calculated. Logistic regression analysis was performed to assess the association between CL and PTB, adjusted for confounders. Performance of CL measurement in prediction of PTB < 28, < 30 and < 32 weeks of gestation was assessed.

RESULTS

A total of 120 triplet pregnancies were included in the final analysis. Median CL was 35 (interquartile range (IQR), 29-40) mm measured at a median gestational age of 20 + 2 (IQR, 20 + 0 to 23 + 4) weeks. Overall, 23 (19.2%), 17 (14.2%) and eight (6.7%) patients had a CL < 25, < 20 and < 15 mm, respectively. Spontaneous PTB < 32 weeks occurred in 41 (34.2%) cases, < 30 weeks in 23 (19.2%) and < 28 weeks in 12 (10%) cases. CL < 15 mm was significantly more frequent in the group of patients who delivered < 28 (P = 0.03) and < 30 (P = 0.01) weeks' gestation, compared with those who delivered after 28 and after 30 weeks, respectively, while CL < 20 mm was more common in triplet pregnancies with delivery < 32 weeks compared with those delivered ≥ 32 weeks (P = 0.03). Logistic regression analysis was possible only for PTB < 32 weeks due to the small number of cases that delivered < 30 and < 28 weeks. After adjustment for confounders, CL was not significantly associated with PTB < 32 weeks (adjusted odds ratio, 0.97; 95% CI, 0.94-1.01). CL measurement had an area under the receiver-operating characteristics curve of 0.41 (95% CI, 0.20-0.62), 0.41 (95% CI, 0.26-0.56) and 0.42 (95% CI, 0.31-0.54) for the prediction of spontaneous PTB < 28, < 30 and < 32 weeks, respectively.

CONCLUSION

CL assessed in mid-gestation is a poor predictor of PTB < 28, < 30 and < 32 weeks' gestation in asymptomatic triplet pregnancy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Multifetal pregnancy reduction of triplets to twins compared with non-reduced triplets: a meta-analysis

The current systematic review and meta-analysis evaluate the perinatal outcomes in twin pregnancies following multifetal pregnancy reduction (MPR) compared with non-reduced triplet pregnancies. All studies comparing perinatal outcome of twin pregnancies following MPR to non-reduced triplet pregnancies were considered. MEDLINE, non-indexed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science were searched for relevant published articles up to August 2016. The search yielded 653 publications of which 92 were assessed for eligibility. A total of 24 studies met the inclusion criteria. Overall, the outcomes of pregnancies following MPR were better compared with expectantly managed triplets. The MPR group delivered at a later gestational age and was less likely to be delivered before 32 or 28 weeks' gestation. Newborns in the MPR group had significantly higher birthweight at delivery (mean difference 500 g [95% CI 439.95, 560.04]). Rates of pregnancy loss before 24 weeks' gestation and overall infant survival were comparable between the groups. This meta-analysis suggests that MPR of triplet pregnancies to twins is associated with improved perinatal outcome compared with non-reduced triplets. Should primary prevention of high order multiple pregnancy fail, MPR is an appropriate alternative to minimize the perinatal morbidity and mortality of triplet pregnancies.

The role of serial measurements of cervical length in asymptomatic women with triplet pregnancy

OBJECTIVE

To assess the predictive accuracy of serial measurements of cervical length (CL) for preterm birth in asymptomatic women with triplet pregnancy.

METHODS

A retrospective study of women with triplets who underwent serial sonographic measurements of CL until 28-32 weeks of gestation. The predictive accuracy of CL for preterm birth was determined at 4 periods along gestation: 18-20 weeks (period 1), 21-24 weeks (period 2), 25-27 weeks (period 3) and 28-32 weeks (period 4).

RESULTS

A total of 431 measurements of CL from were analyzed. CL decreased in a linear manner across gestation: 40.8 ± 7.1 mm, 36.5 ± 8.4 mm, 29.9 ± 11.4 mm and 25.0 ± 11.8 mm in periods 1, 2, 3 and 4, respectively. The difference in CL between women who did and did not deliver prematurely was small before 25 weeks (periods 1&2) but became more pronounced later in pregnancy (periods 3&4), mainly due to a rapid cervical shortening between periods 2 and 3 (shortening rate -29.0 ± 20.0% vs. -12.6 ± 20.5%, respectively, p = .01). The best predictors of preterm birth were either a single measurement of CL during period 3 or the degree of cervical shortening between periods 2 and 3.

CONCLUSIONS

Care providers should be aware of the limited predictive value of cervical length before 25 + 0 weeks in triplet pregnancies.

Effect of congenital heart disease on 4-year neurodevelopment within multiple-gestation births

OBJECTIVES

We sought to assess the effect of congenital heart disease requiring infant surgery with cardiopulmonary bypass on neurodevelopmental outcomes and growth at 4 years of age, while matching for gestational age, socioeconomic status, maternal gestational conditions, home environment, and parental intelligence by studying multiple-gestation births.

METHODS

We performed within-family comparison of 14 multiple-gestation births in which 1 child had congenital heart disease requiring surgery with cardiopulmonary bypass at ≤6 months of age. Between 4 and 5 years of age, a comprehensive neurodevelopmental assessment was performed. Paired comparisons were conducted between siblings with and without heart defects using a series of nonparametric tests.

RESULTS

On average, the children qualified as late preterm (mean gestational age 35.4 ± 2.6 weeks). At an average age of 4.8 ± 0.1 years, children with congenital heart disease weighed less than their siblings (median weight for age z score -0.4 vs 0.1, P = .02) and had worse performance for cognition (median full-scale IQ 99 vs 109, P = .02) and fine motor skills (median Wide Range Assessment of Visual Motor Ability, Fine Motor score 94.5 vs 107.5, P < .01).

CONCLUSIONS

After controlling for socioeconomic status, home environment, parental intelligence, and gestational factors by using multiple-gestation births, congenital heart disease requiring surgery with cardiopulmonary bypass at ≤6 months of age is associated with lower weight, cognitive abilities and fine motor skills at 4 years of age.

Efficient Infrared-to-Visible Upconversion with Subsolar Irradiance

Third generation photovoltaics are inexpensive modules that promise power conversion efficiencies exceeding the thermodynamic Shockley-Queisser limit, perhaps by using up- or down-converters, intermediate band solar cells, tandem cells, hot carrier devices, or multiexciton generation. Here, we report the efficient upconversion of infrared to visible light at excitation densities below the solar flux. Colloidally synthesized core-shell lead sulfide-cadmium sulfide nanocrystals in combination with tetracene derivatives absorb near-infrared light and emit visible light at 560 nm with an upconversion quantum yield (QY) of 8.4 ± 1.0%, which is a factor of 4 lower than the maximum upconversion QY possible. This is achieved with 808 nm cw excitation at 3.2 mW/cm², approximately three times lower than the available solar flux. The molecular and nanocrystal engineering here paves the way toward utilizing this hybrid upconversion platform in photovoltaics, photodetectors and photocatalysis.

The greater risk of preterm birth in triplets is mirrored by a more rapid cervical shortening along gestation

BACKGROUND

The risk of preterm birth increases with plurality. However, data are limited about the role of cervical length in triplet pregnancies and how the greater predisposition for preterm birth in triplet pregnancies, compared with twin pregnancies, is reflected by cervical length. Specifically, it is unclear whether the greater predisposition of triplet pregnancies for preterm birth is reflected by a more rapid cervical shortening during gestation compared with twin pregnancies (and therefore a shorter cervical length at any given gestational age), by a greater risk for preterm birth per given cervical length at any given gestational age, or both.

OBJECTIVE

The purpose of the study was to compare the rate of cervical shortening during gestation and the correlation between cervical length and gestational age at birth in asymptomatic women with triplet vs twin pregnancies.

STUDY DESIGN

This was a retrospective study of women with triplet or twin pregnancies who were who were observed in a tertiary center who underwent serial sonographic measurement of cervical length from 16-32 weeks gestation. Change in cervical length during gestation and relationship of cervical length with gestational age at birth were compared between the triplets and twins groups.

RESULTS

A total of 431 measurements of cervical length from 86 women with triplets was analyzed and compared with 2826 measurements of cervical length from 441 women with twins. The rate of cervical shortening among triplet pregnancies was higher than among twin pregnancies starting from 18 weeks of gestation (slope of regression line, -1.297 vs -0.907; P < .001). Similarly, the proportion of women with cervical length of <25 mm or 15 mm was higher among triplet pregnancies than among twin pregnancies (34.0% vs 21.0% [P < .001] and 16.7% vs 8.4% [P = .001]), respectively. For any given cervical length measured after 22 weeks of gestation, the associated gestational length at birth in triplet pregnancies was lower by 2.7 weeks on average compared with twin pregnancies (P < .001).

CONCLUSION

The higher rate of preterm birth in triplet pregnancies, compared with twin pregnancies, is reflected by both a more rapid cervical shortening during gestation and a lower gestational age at birth per any given cervical length.

Perinatal and obstetric outcomes of dichorionic vs trichorionic triplet pregnancies

BACKGROUND

Clinical management and outcome of multiple gestation can be affected by chorionicity. In triplet pregnancies, fetal death has been associated with dichorionic (DC) and monochorionic placentation. Studies evaluating triplet pregnancy outcomes in relation to chorionicity have been few and may not reflect contemporary antenatal and neonatal care.

OBJECTIVE

The objective of this study was to compare obstetric and perinatal outcomes in DC and trichorionic (TC) triplet pregnancies.

STUDY DESIGN

We performed a retrospective cohort study of triplet pregnancies that delivered at ≥20 weeks' gestation at 2 Chicago area hospitals from January 1999 through December 2010. Chorionicity was determined by pathology specimen. Maternal and infant charts were reviewed for obstetric and perinatal outcomes.

RESULTS

The study population included 159 pregnancies (477 neonates) of which 108 were TC (67.9%) and 51 were DC (32.1%). Over 94% of mothers in this study had all 3 infants survive to discharge regardless of chorionicity. No difference was found in perinatal mortality rate between DC and TC triplets (3.3% vs 4.6%; P = .3). DC triplets were significantly more likely to be very low birthweight (41.8% vs 22.2%; odds ratio, 2.2; 95% confidence interval, 1.2-4.2; P = .02) and to deliver at <30 weeks (25.5% vs 8.3%; odds ratio, 6.1; 95% confidence interval, 1.9-19.4; P = .002) compared to TC triplets. Criteria for twin-twin transfusion syndrome (TTTS) were present in 3 DC triplet pregnancies (5.9%). Neonates in pregnancies complicated by TTTS were less likely to survive 28 days as compared to neonates from DC pregnancies that were not affected by TTTS (P = .02) or TC neonates (P = .02) Neonatal survival was similar in DC pregnancies not affected by TTTS and TC pregnancies (98.6% and 96.6%; P = .7).

CONCLUSION

Although perinatal mortality did not correlate with chorionicity, DC pregnancies were more likely to deliver <30 weeks' gestational age and have very low birthweight neonates. Neonatal mortality appears to be mediated by the presence or absence of TTTS as 28-day survival was worse in DC pregnancies complicated by TTTS, but similar between DC pregnancies not affected by TTTS and TC pregnancies.

Fetofetal Transfusion Syndrome in Monochorionic-Triamniotic Triplets Treated with Fetoscopic Laser Ablation: Report of Two Cases and A Systematic Review

Objective This study aims to determine the clinical outcomes of monochorionic-triamniotic (MT) pregnancies complicated by severe fetofetal transfusion undergoing laser photocoagulation. Study Design We report two cases of MT triplets complicated by fetofetal transfusion syndrome (FFTS) and a systematic review classifying cases into different subtypes: MT with two donors and one recipient, MT with one donor and two recipients, MT with one donor, one recipient, and one unaffected triplet. The number of neonatal survivors was analyzed based on this classification as well as Quintero staging. Results A total of 26 cases of MT triples complicated by FFTS were analyzed. In 56% of the cases, the FFTS involved all three triplets, 50% of whom had an additional donor and 50% an additional recipient. Among the 24 cases that survived beyond 1 week after the procedure, the average gestational age of delivery was 29.6 weeks, and the average interval from procedure to delivery was 10.1 weeks. The overall neonatal survival rate was 71.7%, with demises occurring equally between donor and recipient triplets. Overall neonatal survival including survival of at least two fetuses occurred with equal frequency between the different groups. Conclusion Significant neonatal survival can be achieved in most cases of MT triplets with FFTS.

Excitons and the lifetime of organic semiconductor devices

While excitons are responsible for the many beneficial optical properties of organic semiconductors, their non-radiative recombination within the material can result in material degradation due to the dumping of energy onto localized molecular bonds. This presents a challenge in developing strategies to exploit the benefits of excitons without negatively impacting the device operational stability. Here, we will briefly review the fundamental mechanisms leading to excitonic energy-driven device ageing in two example devices: blue emitting electrophosphorescent organic light emitting devices (PHOLEDs) and organic photovoltaic (OPV) cells. We describe strategies used to minimize or even eliminate this fundamental device degradation pathway.

Dramatic Enhancement of Power Conversion Efficiency in Polymer Solar Cells by Conjugating Very Low Ratio of Triplet Iridium Complexes to PTB7

Various low ratios of triplet iridium complexes (0, 0.5, 1, 1.5, 2.5, and 5 mol%) are conjugated to the backbone of the famous champion donor polymer PTB7. At the same conditions, the power conversion efficiency for polymer containing 1% of Ir increases by 45%, 39%, and 31% in three batches of devices compared with control Ir-free PTB7.

Healthcare expenses associated with multiple vs singleton pregnancies in the United States

OBJECTIVE

The purpose of this study was to document cost that is associated with multiple births vs singleton births in the United States.

STUDY DESIGN

This was a retrospective cohort study that used a claims database. Women 19-45 years old with live-born infants from 2005-2010 were identified. Infant deliveries were identified by International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. The cost entailed all payment made by insurers and patients. For mothers, the cost included expenses from 27 weeks before delivery to 1 month after delivery. For infants, the cost contained all expenses until their first birthday. Adjusted cost was estimated by generalized linear models after adjustment for the potential confounding variables with a gamma distribution and a log link.

RESULTS

The analysis included 437,924 eligible deliveries. Of them, 97.02% were singletons; 2.85% were twins, and 0.13% was triplets or more. Women with multiple pregnancies had higher systemic and localized comorbidities compared with women with singleton pregnancies (P < .0001). Twins and triplets or more were more likely to have stayed in a neonatal intensive care unit than were singletons (P < .0001). On average, adjusted total all-cause health care cost was $21,458 (95% confidence interval [CI], $21,302-21,614) per delivery with singletons, $104,831 (95% CI, $103,402-106,280) with twins, and $407,199 (95% CI, $384,984-430,695) with triplets or more.

CONCLUSION

Pregnancies with the delivery of twins cost approximately 5 times as much when compared with singleton pregnancies; pregnancies with delivery of triplets or more cost nearly 20 times as much.

[Neonatal morbidity and hospital mortality of preterm triplets.]

Background: multiple gestations have caused an increase in vulnerable preterm births. Our objective was to analyze neonatal morbidity and mortality in preterm triplets. Methods: we analyzed a cohort of 30 triplets in an obstetrics and gynecology hospital. Data were obtained during pregnancy, childbirth and neonatal period: birth order, sex, weight, height, malformations, advanced resuscitation, assisted ventilation, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pulmonary hypertension, bronchopulmonary dysplasia, days of hospitalization, and death. Results: 90 infants were analyzed. There was an omphalopagus con-joined twins case; 42 (70 %) had between 30-33 weeks and six between 24-29; 19 (21 %) had low weight for gestational age, and 18 (30 %) had a major malformation; 27 % required ventilatory support, 33 % sepsis, 32 % necrotizing enterocolitis, 21 % pulmonary hypertension, 14 % bronchopulmonary dysplasia and 2 % intraventricular hemorrhage, without statistically significant differences related to the order, presentation at birth, sex and number of placentas and amniotic sacs. Eight 24-week triplets died, four over 28 weeks, and a siamese (p = 38). There was no difference in hospital days between triplets. Conclusions: the triplets mortality is low and mainly associated with extreme prematurity, intrauterine growth restriction and sepsis.