Effect of twin pregnancy chorionic properties on maternal and fetal outcomes

Clinical Factors for Predicting Pharmacotherapy in Twin Pregnancies Complicated by Gestational Diabetes Mellitus

Controlling blood glucose levels is the main target in pregnant women with gestational diabetes mellitus (GDM). Twin pregnancies are offered the same screening selection and have the same diagnostic criteria as well as treatment of gestational diabetes as singleton pregnancies, even though the risks for pregnancy complications are increased. The aim of this study was to assess the association between predicting factors, OGTT glucose levels and pharmacotherapy requirements in twin pregnancies with GDM. This retrospective cohort study included 446 GDM patients with twin pregnancies (246 managed with lifestyle modifications and 200 requiring pharmacotherapy) over a time period of 18 years. An evaluation of maternal characteristics and a standardized 75 g oral glucose test (OGGT) for glucose concentrations at fasting, 1 h and 2 h were conduced. OGTT glucose levels at fasting (=0 min, p < 0.01) and 1 h (p < 0.01) were significantly associated with the later requirement of pharmacotherapy. Also, clinical risk factors (pre-pregnancy BMI p < 0.01, multiparity p < 0.05, GDM in previous pregnancy p < 0.01, assisted reproduction p < 0.05) showed a predictive accuracy for insulin therapy in twin pregnancies complicated by GDM, whereas age and chorionicity had no effect. OGTT glucose measures in addition to clinical risk factors are promising variables for risk stratification in mothers with GDM and twin pregnancy.

Clinical Study on Different Delivery Methods of Twin Pregnancy

OBJECTIVE

To investigate the effect of different methods of delivery on the outcome of twin pregnancies.

STUDY DESIGN

This is a retrospective cohort review of 627 twin pregnancies with delivery from January 2016 to December 2019. According to the clinical guidelines for cesarean section, the cesarean section and vaginal delivery groups were determined. Finally, the baseline information, delivery method, pregnancy outcome, and maternal and infant complications of the two groups were compared.

RESULTS

For different delivery methods, the incidence of preeclampsia was significantly higher in the cesarean section group than in the vaginal delivery group (X 2 = 4.405, p < 0.05). There were 23 fetal growth ratios (FGR) in the cesarean section group, which were significantly higher than the vaginal delivery group (X 2 = 4.740, p < 0.05). However, the incidence of preterm premature rupture of membranes (PPROM) in the vaginal delivery group was significantly higher than in the cesarean section group (X 2 = 5.235, p < 0.05). In addition, the volume of postpartum bleeding in the vaginal delivery group was significantly higher than in the cesarean section group (t = 4.723, p < 0.001). The neonatal weights and 5-minute Apgar scores of the vaginal delivery group were lower than the cesarean section group, and the difference was statistically significant. In the vaginal delivery group, 48 and 26 neonates were transferred to the intensive care and neonatal units, respectively, which were significantly higher than in the cesarean section group (X 2 = 5.001, p < 0.05).

CONCLUSION

The major complications of a twin pregnancy are gestational diabetes mellitus and PPROM. Cesarean section can reduce the rate of neonatal asphyxia in twins and improve the pregnancy outcome.

KEY POINTS

· Twin pregnancy.. · Delivery methods.. · Pregnancy outcomes..

Can maternal serum midkine level predict chorionicity in twin pregnancies?

Sometimes it can be difficult to chorionicity determination in twin pregnancies. This study aimed to compare maternal serum midkine levels between twin and singleton pregnancies. We also evaluated the relationship between chorionicity and maternal serum midkine level in twin pregnancies. The present prospective cohort study included 16 patients with monochorionic diamniotic twin pregnancies, 38 with dichorionic diamniotic twin pregnancies, and 66 healthy singleton pregnancies admitted to Ankara City Hospital Perinatology Clinic between June 2021 and June 2022. Demographic features, clinical characteristics, and serum midkine levels were compared between the groups. Additionally, a receiver operator characteristics (ROC) analysis was performed to assess the performance of midkine for detecting chorionicity. The median maternal serum midkine level was found to be 0.64 ng/ml in twin pregnancies and 0.26 ng/ml in singleton pregnancies (p < 0.001). When twin pregnancies were compared in terms of chorionicity, serum midkine level was determined as 1.20 ng/ml in the monochorionic diamniotic group and 0.50 ng/ml in the dichorionic diamniotic group (p = 0.034). An optimal cut-off value of 1.03 ng/ml was found for the determination of chorionicity (AUC: 0.68, p = 0.03, 95% CI: 0.53-0.83, %56.3 sensitivity, 76.3% specificity). In advanced weeks of pregnancy, biomarkers can be used as helpful parameters for ultrasonography in the diagnosis of twin pregnancies. Maternal serum midkine levels might be used to determine chorionicity in equivocal cases.

Chorionicity and neurodevelopmental outcomes in twin pregnancy: a systematic review and meta-analysis

OBJECTIVE

Through a systematic review and meta-analyses, we aimed to analyze the impact of chorionicity on neurodevelopment outcomes.

STUDY DESIGN

We conducted a comprehensive search strategy through Medline, Embase, Web of Science, and reference lists of the retrieved studies until August 2022. Studies that examined the association between chorionicity and children's neurodevelopment outcomes were included.

RESULTS

Twelve studies were included. Monochorionic (MC) twins increased the odds of neurodevelopment impairment, cerebral palsy compared to dichorionic (DC) twins. The differences in neurodevelopmental impairment and cerebral palsy between the two groups disappeared after excluding infants with twin-twin transfusion (TTTS). After fetoscopic laser surgery (FLS) for MC twins, there were no differences too.

CONCLUSIONS

Compared to DC twins, MC twins were associated with an increased risk of neurodevelopment impairment. MC twins complicated by TTTS were at high risk of neurologic disability, and FLS was an acceptable treatment modality for them.

The role of obstetric pessary and micronized progesteron in early preterm birth prevention in patients with multiple pregnancy

Background. Multiple pregnancy is a well-established risk factor for preterm birth. Prevention of early termination of pregnancy is a priority problem in obstetric practice.The aim. To evaluate the role of an obstetric pessary and micronized progesterone in the prevention of early preterm labor in patients with multiple pregnancies.Materials and methods. A prospective controlled study was conducted with the inclusion of 146 pregnant women with multiple pregnancies, which, depending on the methods of treatment, were divided into three groups: Group I (n = 67) – pregnant women who received micronized progesterone in combination with an obstetric pessary; Group II (n = 57) included women who received micronized progesterone; Group III (n = 22) consisted of patients with multiple pregnancies without therapy.Results. In Group I, the complex of an obstetric pessary and micronized progesterone allowed to reduce the frequency of preterm birth by 2.3 times (p = 0.008) in comparison with Group III, the frequency of births at gestational age ≤ 34 weeks – by 8.1 times (p = 0.005) in compared with Group III and 2.7 times (p < 0.01) compared with Group II. In 70.4 % of pregnant women, the use of a complex of an obstetric pessary with micronized progesterone made it possible to prevent the formation of isthmiccervical insufficiency, which, according to sonography, was expressed in the dynamics of the utero-cervical angle towards a more obtuse one.Conclusion. The use of an obstetric pessary with micronized progesterone made it possible to reduce the risks of isthmic-cervical insufficiency by 7.7 % compared with patients who received only micronized progesterone therapy, and by 17.1 % compared with pregnant women who did not receive therapy.

Current status of unplanned readmission of neonates within 31 days after discharge from the neonatal intensive care unit and risk factors for readmission

OBJECTIVES

To investigate the current status of unplanned readmission of neonates within 31 days after discharge from the neonatal intensive care unit (NICU) and risk factors for readmission.

METHODS

A retrospective analysis was performed on the medical data of 1 561 infants discharged from the NICU, among whom 52 infants who were readmitted within 31 days were enrolled as the case group, and 104 infants who were not readmitted after discharge during the same period of time were enrolled as the control group. Univariate analysis and multivariate logistic regression analysis were performed to identify the risk factors for readmission.

RESULTS

Among the 1 561 infants, a total of 63 readmissions occurred in 52 infants, with a readmission rate of 3.33%. hyperbilirubinemia and pneumonia were the main causes for readmission, accounting for 29% (18/63) and 24% (15/63) respectively. The multivariate logistic regression analysis showed that that gestational age <28 weeks, birth weight <1 500 g, multiple pregnancy, mechanical ventilation, and length of hospital stay <7 days were risk factors for readmission (OR=5.645, 5.750, 3.044, 3.331, and 1.718 respectively, P<0.05).

CONCLUSIONS

Neonates have a relatively high risk of readmission after discharge from the NICU. The medical staff should pay attention to risk factors for readmission and formulate targeted intervention measures, so as to reduce readmission and improve the quality of medical service.

First-Trimester Screening for Gestational Diabetes Mellitus in Twin Pregnancies

We previously reported a logistic regression model for prediction of GDM from maternal characteristics and medical history in 75,161 singleton pregnancies. In this study of 1376 twin and 13,760 singleton pregnancies recruited at 11-13 weeks' gestation, we extend the model to include terms for twin pregnancies. We found the respective odds of GDM in dichorionic and monochorionic twin pregnancies to be 1.36 (95% CI: 1.02-1.81) and 2.78 (95% CI: 1.72-4.48) times higher than in singleton pregnancies. In both singleton and twin pregnancies, the risk for GDM increased with maternal age and weight and birth weight z-score of a baby in a previous pregnancy and is higher in women with a previous pregnancy complicated by GDM; in those with a first- or second-degree relative with diabetes mellitus; in women of Black, East Asian, and South Asian racial origin; and in pregnancies conceived through the use of ovulation-induction drugs. In singleton pregnancies, at 10% and 20% false-positive rate, the detection rate was 43% and 58%, respectively. In twin pregnancies, using risk cut-offs corresponding to 10% and 20% false-positive rates in singletons, the respective false-positive rates were 27% and 47%, and the detection rates were 63% and 81%.

Risk factors and adverse maternal and perinatal outcomes for women with dichorionic twin pregnancies complicated by gestational diabetes mellitus: A retrospective cross-sectional study

AIMS/INTRODUCTION

The association between gestational diabetes mellitus (GDM) and adverse maternal and perinatal outcomes in twin pregnancies remains unclear. This study was undertaken to highlight risk factors for GDM in women with dichorionic (DC) twins, and to determine the association between GDM DC twins and adverse maternal and perinatal outcomes in a large homogeneous Taiwanese population.

MATERIALS AND METHODS

A retrospective cross-sectional study was carried out on 645 women with DC twins, excluding pregnancies complicated by one or both fetuses with demise (n = 22) or congenital anomalies (n = 9), who gave birth after 28 complete gestational weeks between 1 January 2001 and 31 December 2018. Univariable and multiple logistic regression analyses were carried out.

RESULTS

Maternal age >34 years (adjusted odds ratio 2.52; 95% confidence interval 1.25-5.07) and pre-pregnancy body mass index >24.9 kg/m2 (adjusted odds ratio 2.83, 95% confidence interval 1.47-5.46) were independent risk factors for GDM in women with DC twins. Newborns from women with GDM DC twins were more likely to be admitted to the neonatal intensive care unit (adjusted odds ratio 1.70, 95% confidence interval 1.06-2.72) than newborns from women with non-GDM DC twins. Other pregnancy and neonatal outcomes were similar between the two groups.

CONCLUSIONS

Advanced maternal age and pre-pregnancy overweight or obesity are risk factors for GDM in women with DC twins. Except for a nearly twofold increased risk of neonatal intensive care unit admission of newborns, the pregnancy and neonatal outcomes for women with GDM DC twins are similar to those for women with non-GDM DC twins.

Perinatal outcomes and offspring growth profiles in twin pregnancies complicated by gestational diabetes mellitus: A longitudinal cohort study

AIMS

To evaluate the influence of gestational diabetes mellitus (GDM) on the perinatal outcomes of twin pregnancies and its impact on fetal growth profiles of twin offspring from 6 weeks to 12 months of corrected age.

METHODS

A longitudinal cohort study was conducted among pregnant women with twins and their twin offspring. All information on perinatal outcomes and child growth trajectories from 6 weeks to 12 months of corrected age were obtained and analyzed using a general linear model and logistic regression models.

RESULTS

GDM was not correlated with adverse perinatal outcomes of twin pregnancies; however, in monochorionic diamniotic (MCDA), but not dichorionic diamniotic (DCDA) twin pregnancies, GDM was correlated with gestational hypertension disorder and a fetus being small for gestational age (OR, 2.68; 95% CI 1.16-6.04 and OR, 0.35; 95% CI 0.16-0.76, respectively). In both MCDA and DCDA groups, GDM was positively associated with a higher risk of childhood overweight at 6 months of corrected age (2.32 [1.05, 5.09] and 2.00 [1.13, 3.53]).

CONCLUSIONS

GDM had a greater impact on MCDA twin pregnancies in terms of maternal gestational hypertension disease and small for gestational age of newborns. Additionally, twin offspring exposed to GDM had a higher risk of being overweight at 6 months of corrected age irrespective of chorionicity.

CLINICAL TRIAL REGISTRATION

ChiCTR-OOC-16008203.

The curious incident of a cavum velum interpositum cyst in twins of a mother carrying May-Hegglin anomaly: a case report and short literature review

Background

May-Hegglin anomaly is an autosomal dominant inherited condition, characterized by thrombocytopenia, giant platelets and Dohle-like bodies. Incidence is unknown and affected individuals can show from mild to moderate-severe haemorrhagic symptoms. The cyst of cavum veli interpositi (a virtual space filled with fluid within the third ventricle) is rarely reported in the foetal period. Furthermore, it is unclear whether isolated cavum veli interpositi cysts are a normal variant or developmental malformations. The simultaneous presence of these two anomalies was never described.

Case presentation

We describe a very rare case of a twin monochorionic pregnancy in a woman with the May-Hegglin anomaly, whose foetuses carried cavum veli interpositi cysts. Since childhood, our patient had shown macro-thrombocytopenia, deafness and bleeding (epistaxis and menorrhagia), but she was misdiagnosed until the age of 30 years when our Centre identified a de novo allelic variant in the gene MYH9 coding for the non-muscle myosin heavy chain IIa. Our patient bled neither during the pregnancy, nor in the peripartum period. Children are now eight-months-old and have never bled, although both inherited the MYH9 variant and have thrombocytopenia with giant platelets. Furthermore, none of them developed psychomotor disorders.

Conclusions

To the best of our knowledge, this is the sixth case of twin pregnancy in a woman carrying May-Hegglin anomaly and the first one with cavum veli interpositi cysts in the neonates. We speculate that MYH9 could have, at least in part, played a role in the development of both conditions, as this gene has a pleiotropic effect.

Birthweight is an independent predictor of birth asphyxia in twins: A retrospective cross-sectional cohort study of 5337 Chinese twins

OBJECTIVE

Few studies are available on birth asphyxia risks in twin neonates. This retrospective multi-center cross-sectional study determined the birthweight percentiles of 5337twins and birth asphyxia incidence of the twin population.

METHODS

We retrieved sociodemographic and obstetric data from the electronic records systems of participating centers. Neonate birthweight was measured within 24 h of birth. Perinatal asphyxia was diagnosed if 5-minute Apgar score was ≤5, or resuscitation was required 10 min after birth. The primary outcome was the incidence of birth asphyxia.

RESULTS

Totally 5337 neonates were eligible. The mean neonatal birthweight was 2227.1 ± 608.99 g and the 5th, 50th, and 95th percentiles of birthweight were 970, 2400, and 3080 g, respectively. The mean Apgar score was 9.06 ± 1.73 at 1 min and 8.99 ± 1.74 at 5 min. Totally 13.5 % (705/5222) twins had asphyxia and 9.35 % and 4.16 % twins had moderate and severe asphyxia, respectively. Twins with a birthweight< 1500 g had the highest asphyxia rate (64.8 %) and twins with a birthweight between 2500 and 3000 g had the lowest asphyxia rate (3.6 %). Stepwise logistic regression analysis revealed that higher birthweight was associated with a significantly reduced risk of asphyxia [OR 0.772 (95 %CI 0.755, 0.789), P < 0.001]. The AUROC for mean twin birthweight was 0.86±0.01 (95 %CI 0.84, 0.88) using a cutoff of 1950 g, with a sensitivity of 0.84 and a specificity of 0.78.

CONCLUSION

Twins have lower birthweight versus singletons and a significant proportion of twins, especially twins with lower birthweight, are at risk of birth asphyxia. Birthweight is an independent predictor of asphyxia and should be further explored as a predictive marker for stratifying asphyxia risks in twin neonates.

Association between chorionicity and preterm birth in twin pregnancies: a systematic review involving 29 864 twin pregnancies

BACKGROUND

The perinatal mortality and morbidity among twins vary by chorionicity. Although it is considered that monochorionicity is associated with an increased risk of preterm birth in twin pregnancies, no systematic review exists evaluating this association.

OBJECTIVES

This systematic review was undertaken to assess the association between preterm birth and chorionicity in twin pregnancies.

SEARCH STRATEGY

We searched the electronic databases from January 1990 to July 2019 without language restrictions.

SELECTION CRITERIA

All studies on twin pregnancies where chorionicity and preterm birth were evaluated were included.

DATA COLLECTION AND ANALYSIS

Findings are reported as odds ratios with 95% confidence intervals. The estimates are pooled using random-effects meta-analysis.

MAIN RESULTS

From 13 156 citations, we included 39 studies (29 864 pregnancies). Monochorionicity was significantly associated with increased risk of preterm birth at ≤28, ≤32, ≤34 and <37 weeks in women asymptomatic and symptomatic for preterm labour (odds ratio [OR] 2.14, 95% CI 1.52-3.02, I²  = 46%, OR 1.55, 95% CI 1.27-1.89 I²  = 68%, OR 1.47, 95% CI 1.27-1.69, I²  = 60%, OR 1.66, 95% CI 1.43-1.93, I²  = 65%, respectively). Among those asymptomatic for preterm labour, significantly increased odds of preterm birth were seen for monochorionicity at gestations ≤34 weeks (OR 1.85, 95% CI 1.42-2.40, I²  = 25%) and <37 weeks (OR 1.75, 95% CI 1.22-2.53, I²  = 61%). Sensitivity analysis showed significantly increased odds of spontaneous preterm birth at ≤34 and <37 weeks for monochorionicity (OR 1.25, 95% CI 1.01-1.55, I²  = 0% and OR 1.41, 95% CI 1.13-1.78, I²  = 0%).

CONCLUSIONS

Monochorionicity is significantly associated with preterm birth at all gestations.

TWEETABLE ABSTRACT

In twin pregnancies, monochorionicity is associated with an increased risk of preterm birth at all gestations.

Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins

Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.