New radiofrequency ablation procedure for selective reduction in complicated monochorionic twin or triplet pregnancy using multistep, incremental expansion technique

OBJECTIVE

Radiofrequency ablation (RFA) is the preferred approach for selective reduction in complex monochorionic (MC) multiple pregnancies owing to the ease of operation and minimal invasiveness. To optimize the RFA technique and reduce the risk of adverse pregnancy outcome resulting from the heat-sink effect of RFA therapy, we used an innovative RFA method, in which an electrode needle was expanded incrementally and stepwise. This study aimed to assess the efficacy and safety profile of this novel multistep incremental expansion RFA method for selective fetal reduction in MC twin and triplet pregnancies.

METHODS

This was a single-center retrospective cohort study of all MC multiple pregnancies undergoing RFA between March 2016 and October 2022 at our center. The multistep RFA technique involved the use of an expandable needle, which was gradually expanded during the RFA procedure until cessation of umbilical cord blood flow was achieved. The needle used for the single-step RFA method was fully extended from the start of treatment.

RESULTS

In total, 132 MC multiple pregnancies underwent selective reduction using RFA, including 50 cases undergoing multistep RFA and 82 cases undergoing single-step RFA. The overall survival rates were not significantly different between the multistep and single-step RFA groups (81.1% vs 72.3%; P = 0.234). Similarly, the rates of preterm prelabor rupture of the membranes within 2 weeks after RFA, procedure-related complications, spontaneous preterm delivery and pathological findings on cranial ultrasound, as well as gestational age at delivery and birth weight, did not differ between the two groups. However, there was a trend towards a prolonged procedure-to-delivery interval following multistep RFA compared with single-step RFA (median, 109 vs 99 days; P = 0.377). Moreover, the fetal loss rate within 2 weeks after RFA in the multistep RFA group was significantly lower than that in the single-step RFA group (10.0% vs 24.4%; P = 0.041). The median ablation time was shorter (5.3 vs 7.8 min; P < 0.001) and the median ablation energy was lower (10.2 vs 18.0 kJ; P < 0.001) in multistep compared with single-step RFA. There were no significant differences in neonatal outcomes following multistep vs single-step RFA.

CONCLUSIONS

Overall survival rates were similar between the two RFA methods. However, the multistep RFA technique was associated with a lower risk of fetal loss within 2 weeks after RFA. The multistep RFA technique required significantly less ablation energy and a shorter ablation time compared with single-step RFA in selective fetal reduction of MC twin and triplet pregnancies. Additionally, there was a trend towards a prolonged procedure-to-delivery interval with the multistep RFA technique. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Considering multifetal pregnancy reduction in triplet pregnancies: do we forget the emotional impact on fathers? A qualitative study from The Netherlands

STUDY QUESTION

What factors influence the decision-making process of fathers regarding multifetal pregnancy reduction or maintaining a triplet pregnancy, and how do these decisions impact their psychological well-being?

SUMMARY ANSWER

For fathers, the emotional impact of multifetal pregnancy reduction or caring for triplets is extensive and requires careful consideration.

WHAT IS KNOWN ALREADY

Multifetal pregnancy reduction is a medical procedure with the purpose to reduce the number of fetuses to improve chances of a healthy outcome for both the remaining fetus(es) and the mother, either for medical reasons or social considerations. Aspects of the decision whether to perform multifetal pregnancy reduction have been rarely investigated, and the impact on fathers is unknown.

STUDY DESIGN, SIZE, DURATION

Qualitative study with semi-structured interviews between October 2021 and February 2023.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Fathers either after multifetal pregnancy reduction from triplet to twin or singleton pregnancy or ongoing triplet pregnancies 1-6 years after the decision were included. The interview schedule was designed to explore key aspects related to (i) the decision-making process whether to perform multifetal pregnancy reduction and (ii) the emotional aspects and psychological impact of the decision. Thematic analysis was used to identify patterns and trends in the father's data. The process involved familiarization with the data, defining and naming themes, and producing a final report. This study was a collaboration between a regional secondary hospital (OLVG) and a tertiary care hospital (Amsterdam University Medical Center, Amsterdam UMC), both situated in Amsterdam, The Netherlands.

MAIN RESULTS AND THE ROLE OF CHANCE

Data saturation was achieved after 12 interviews. Five main themes were identified: (i) initial responses and emotional complexity, (ii) experiencing disparities in counselling quality and post-decision care, (iii) personal influences on the decision journey, (iv) navigating parenthood: choices, challenges, and emotional adaptation, and (v) shared wisdom and lessons. For fathers, the decision whether to maintain or reduce a triplet pregnancy is complex, in which medical, psychological but mainly social factors play an important role. In terms of psychological consequences after the decision, this study found that fathers after multifetal pregnancy reduction often struggled with difficult emotions towards the decision; some expressed feelings of doubt or regret and were still processing these emotions. Several fathers after an ongoing triplet had experienced a period of severe stress in the first years after the pregnancy, with major consequences for their mental health. Help in emotional processing was not offered to any of the fathers after the decision or birth.

LIMITATION, REASONS FOR CAUTION

While our study focuses on the multifetal pregnancy reduction process in the Amsterdam region, we recognize the importance of further investigation into how this process may vary across different regions in The Netherlands and internationally. We acknowledge the potential of selection bias, as fathers with more positive experiences might have been more willing to participate. Caution is needed in interpreting the role of the mother in the recruitment process. Additionally, the time span of 1-6 years between the decision and the interviews may have influenced emotional processing and introduced potential reporting bias.

WIDER IMPLICATIONS OF THE FINDINGS

The emotional impact of multifetal pregnancy reduction or caring for triplets is significant, emphasizing the need for awareness among caregivers regarding the emotional challenges faced by fathers. A guided trajectory might optimize the decision-making and primarily facilitate the provision of appropriate care thereafter to optimize outcomes around decisions with potential traumatic implications.

STUDY FUNDING/COMPETING INTEREST(S)

This study received no funding. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Multiple pregnancy with complete hydatidiform mole and coexisting normal fetus in a retrospective cohort of 141 patients

BACKGROUND

Multiple pregnancy with a complete hydatidiform mole and a normal fetus is prone to severe obstetrical complications and malignant transformation after birth. Prognostic information is limited for this rare form of gestational trophoblastic disease.

OBJECTIVE

This study aimed to determine obstetrical outcomes and the risk of gestational trophoblastic neoplasia in women with multiple pregnancy with complete hydatidiform mole and coexisting normal fetus, and to identify risk factors for poor obstetrical and oncological outcomes to improve patient information and management.

STUDY DESIGN

This was a retrospective national cohort study of 11,411 records from the French National Center for Trophoblastic Disease registered between January 2001 and January 2022.

RESULTS

Among 11,411 molar pregnancies, 141 involved histologically confirmed multiple pregnancy with complete hydatidiform mole and coexisting normal fetus. Roughly a quarter of women (23%; 33/141) decided to terminate pregnancy because of presumed poor prognosis or by choice. Among the 77% of women (108/141) who continued their pregnancy, 16% of pregnancies (17/108) were terminated because of maternal complications, and 37% (40/108) ended in spontaneous miscarriage before 24 weeks' gestation. The median gestational age at delivery in the remaining 47% of pregnancies (51/108) was 32 weeks. The overall neonatal survival rate at day 8 was 36% (39/108; 95% confidence interval, 27-46) after excluding elective pregnancy terminations. Patients with free beta human chorionic gonadotropin levels <10 multiples of the median were significantly more likely to reach 24 weeks' gestation compared with those with free beta human chorionic gonadotropin levels >10 multiples of the median (odds ratio, 7.0; 95% confidence interval, 1.3-36.5; P=.022). A lower free beta human chorionic gonadotropin level was also associated with better early neonatal survival (the median free beta human chorionic gonadotropin level was 9.4 multiples of the median in patients whose child was alive at day 8 vs 20.0 multiples of the median in those whose child was deceased; P=.02). The overall rate of gestational trophoblastic neoplasia after a multiple pregnancy with complete hydatidiform mole and a normal fetus was 26% (35/136; 95% confidence interval, 19-34). All 35 patients had low-risk International Federation of Gynecology and Obstetrics scores, and the cure rate was 100%. Termination of pregnancy on patient request was not associated with lower risk of gestational trophoblastic neoplasia. Maternal complications such as preeclampsia and postpartum hemorrhage were not associated with higher risk of gestational trophoblastic neoplasia, and neither were high human chorionic gonadotropin levels or newborn survival at day 8.

CONCLUSION

Multiple pregnancy with complete hydatidiform mole and coexisting fetus carries a high risk of obstetrical complications. In patients who continued their pregnancy, approximately one-third of neonates were alive at day 8, and roughly 1 in 4 patients developed gestational trophoblastic neoplasia. Therefore, the risk of malignant transformation appears to be higher compared with singleton complete moles. Low levels of free beta human chorionic gonadotropin may be indicative of better early neonatal survival, and this relationship warrants further study.

History of multifetal gestation and long-term maternal mortality

BACKGROUND

Multifetal gestation could be associated with higher long-term maternal mortality because it increases the risk of pregnancy complications such as preeclampsia and preterm birth, which are in turn linked to postpartum cardiovascular risk.

OBJECTIVES

We examined whether spontaneously conceived multifetal versus singleton gestation was associated with long-term maternal mortality in a racially diverse U.S.

COHORT

METHODS

We ascertained vital status as of 2016 via linkage to the National Death Index and Social Security Death Master File of 44,174 mothers from the Collaborative Perinatal Project (CPP; 1959-1966). Cox proportional hazards models with maternal age as the time scale assessed associations between history of spontaneous multifetal gestation (in the last CPP observed pregnancy or prior pregnancy) and all-cause and cardiovascular mortality, adjusted for demographics, smoking status, and preexisting medical conditions. We calculated hazard ratios (HR) for all-cause and cause-specific mortality over the study period and until age 50, 60, and 70 years (premature mortality).

RESULTS

Of eligible participants, 1672 (3.8%) had a history of multifetal gestation. Participants with versus without a history of multifetal gestation were older, more likely to have a preexisting condition, and more likely to smoke. By 2016, 51% of participants with and 38% of participants without a history of multifetal gestation had died (unadjusted all-cause HR 1.14, 95% confidence interval [CI] 1.07, 1.23). After adjustment for smoking and preexisting conditions, a history of multifetal gestation was not associated with all-cause (adjusted HR 1.00, 95% CI 0.93, 1.08) or cardiovascular mortality (adjusted HR 0.99, 95% CI 0.87, 1.11) over the study period. However, history of multifetal gestation was associated with an 11% lower risk of premature all-cause mortality (adjusted HR 0.89, 95% CI 0.82, 0.96).

CONCLUSIONS

In a cohort with over 50 years of follow-up, history of multifetal gestation was not associated with all-cause mortality, but may be associated with a lower risk of premature mortality.

Comparison of two cancellation strategies to lower the risk of multiple pregnancies in gonadotropin stimulated intrauterine insemination cycles

OBJECTIVE

To compare two cancellation policies in controlled ovarian stimulation-intrauterine insemination (COS-IUI) cycles to lower the risk of multiple pregnancies (MP).

DESIGN

We performed a bicentric retrospective cohort study in two academic medical centers: Angers (group A) and Besançon (group B) University Hospitals. We included 7056 COS-IUI cycles between 2011 and 2019. In group A, cancellation strategy was based on an algorithm taking into account the woman's age, the serum estradiol level, and the number of follicles of 14 mm or greater on ovulation trigger day. In group B, cancellation strategy was case-by-case and physician-dependent, based on the woman's age, number of follicles of 15 mm or greater, and the previous number of failed COS-IUI cycles, without any predefined cut-off. Our main outcome measures were the MP rate (MPR) and the live-birth rate (LBR).

RESULTS

We included 884 clinical pregnancies (790 singletons, 86 twins, and 8 triplets) obtained from 6582 COS-IUI cycles. MPR was significantly lower in group A compared with group B (8.1% vs 13.3%, P = 0.01), but LBR were comparable (10.8% vs 11.8%, P = 0.19). Multivariate logistic regression found the following to be risk factors for MP: the "cancellation strategy" effect (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.02-2.60) and the number of follicles of 14 mm or greater (aOR 1.39, 95% CI 1.16-1.66). Cycle cancellation rate for excessive response was significantly lower in group A compared with group B (1.3% vs 2.4%, P < 0.001).

CONCLUSIONS

The use of an algorithm based on the woman's age, serum estradiol level and number of follicles of at least 14 mm on trigger day allows the MPR to be reduced without impacting the LBR.

Major postpartum haemorrhage after frozen embryo transfer: A population-based study

OBJECTIVE

To investigate the effect on major postpartum haemorrhage (PPH) of mode of conception, differentiating between naturally conceived pregnancies, fresh embryo in vitro fertilisation (fresh-IVF) and frozen embryo transfer (frozen-IVF).

DESIGN

Retrospective cohort study.

SETTING

The French Burgundy Perinatal Network database, including all deliveries from 2006 to 2020, was linked to the regional blood centre database.

POPULATION OR SAMPLE

In all, 244 336 women were included, of whom 240 259 (98.3%) were singleton pregnancies.

METHODS

The main analyses were conducted in singleton pregnancies, including 237 608 naturally conceived, 1773 fresh-IVF and 878 frozen-IVF pregnancies. Multivariate logistic regression models adjusted on maternal age, body mass index, smoking, parity, induction of labour, hypertensive disorders, diabetes, placenta praevia and/or accreta, history of caesarean section, mode of delivery, birthweight, birth place and year of delivery, were used.

MAIN OUTCOME MEASURES

Major PPH was defined as PPH requiring blood transfusion and/or emergency surgery and/or interventional radiology.

RESULTS

The prevalence of major PPH was 0.74% (n = 1749) in naturally conceived pregnancies, 1.92% (n = 34) in fresh-IVF pregnancies, and 3.30% (n = 29) in frozen-IVF pregnancies. The risk of major PPH was higher in frozen-IVF pregnancies than in both naturally conceived pregnancies (adjusted odds ratio [aOR] 2.63, 95% CI 1.68-4.10) and fresh-IVF pregnancies (aOR 2.78, 95% CI 1.44-5.35).

CONCLUSIONS

We found that frozen-IVF pregnancies have a higher risk of major PPH and they should be subject to increased vigilance in the delivery room.

Effect of small follicles on clinical pregnancy and multiple pregnancy rates in intrauterine insemination: a cohort study

STUDY QUESTION

What is the effect of small follicles on clinical pregnancy and multiple pregnancy rates in women undergoing IUI with ovarian stimulation (IUI-OS)?

SUMMARY ANSWER

The presence of ≥2 small follicles with a diameter of 10-12 or 12-14 mm was associated with an increased chance of clinical pregnancy and the presence of any 12-14 mm or larger follicles, but not smaller follicles, was statistically significantly associated with an increased risk for multiple pregnancy.

WHAT IS KNOWN ALREADY

IUI-OS is widely used as the first-line treatment for unexplained or mild male factor infertility. However, IUI is associated with the risk of multiple pregnancy. While the positive association between the number of follicles ≥14 mm and the chance of pregnancy and the risk of multiple pregnancy is known, the impact of smaller follicles is uncertain.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study that included women undergoing IUI cycles from January 2007 to May 2021 in one assisted reproduction center.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We studied the impact of the number and size of follicles on trigger day on clinical pregnancy and multiple pregnancy rates. Generalized estimation equation regression models were used to compute unadjusted and adjusted odds ratios and 95% CI in all women and only women who achieved clinical pregnancy separately. The chance of clinical pregnancy and multiple pregnancy for different numbers of small follicles in cycles with one >18-mm follicle was calculated using marginal effects estimate.

MAIN RESULTS AND THE ROLE OF CHANCE

This cohort included 12 933 IUI cycles in 7504 women. The overall clinical pregnancy rate was 16.1% (2081/12 933), with a multiple pregnancy rate of 10.5% (218/2081). In the adjusted analysis, the chance of clinical pregnancy increased significantly with the increase in the number of follicles with the diameter of 14-16, 16-18, and 18-20 mm. As for 10-12 mm [adjusted odds ratio (aOR) 1.22, 95% CI 1.02-1.46] and 12-14 mm (aOR 1.29, 95% CI 1.07-1.56) follicles, only groups with ≥2 follicles of those sizes showed significantly increased chance of clinical pregnancy. In cycles that led to pregnancy, follicles with the diameter of 12-14 mm were associated with an increased risk of multiple pregnancy (aOR 1.73, 95% CI 1.19-2.53 for one such follicle; aOR 2.27, 95% CI 1.44-3.56 for ≥2 such follicles), while 10- to 12-mm follicles were not significantly associated with multiple pregnancy (aOR 1.18, 95% CI 0.72-1.95 for ≥2 such follicles). The associations of multiple pregnancy were similar when including all cycles.

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective observational study from a single center. The records of follicle diameter in our center were of a 2-mm interval which limited our ability to analyze the size of follicle as a continuous variable. Also, the number of cycles with a high number of small follicles was still limited which impeded more detailed analysis on the ≥2 follicles subgroup. Similarly, the value of some parts of the marginal probability estimation for multiple pregnancy versus pregnancy according to size and number of follicles was also limited by the low sample size of certain combinations.

WIDER IMPLICATIONS OF THE FINDINGS

Follicles larger than 10 mm, especially those ≥12 mm, may need to be clearly recorded during transvaginal ultrasound surveillance and their potential effects on both pregnancy and multiple pregnancy can be discussed with couples undergoing IUI.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Natural Science Foundation of China (Grant numbers 82201912, 82371651, and 82071615) and Shanghai Sailing Program (21YF1423200). B.W.M. is supported by an NHMRC Investigator grant (GNT1176437). B.W.M. reports consultancy for ObsEva and Merck and travel support from Merck. B.W.M. has received research funding from Ferring and Merck. The authors declare no other competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Steroid Metabolome Analysis in Dichorionic Diamniotic Twin Pregnancy

Steroid hormones have diverse roles in pregnancy; some help stabilise pregnancy and influence the stability of pregnancy and the onset of labour. Changes and disorders in steroidogenesis may be involved in several pregnancy pathologies. To date, only a few studies have performed a very limited steroid analysis in multiple pregnancies. Our teams investigated multiple pregnancies regarding the biosynthesis, transport, and effects of steroids. We recruited two groups of patients: pregnant women with multiple pregnancies as the study group, and a control singleton pregnancies group. Blood samples were drawn from the participants and analysed. Information about the mother, foetus, delivery, and newborn was extracted from medical records. The data were then analysed. The gestational age of twin pregnancies during delivery ranged from 35 + 3 to 39 + 3 weeks, while it was 38 + 1 to 41 + 1 weeks for the controls. Our findings provide answers to questions regarding the steroidome in multiple pregnancies. Results demonstrate differences in the steroidome between singleton and twin pregnancies. These were based on the presence of two placentae and two foetal adrenal glands, both with separate enzymatic activity. Since every newborn was delivered by caesarean section, analysis was not negatively influenced by changes in the steroid metabolome associated with the spontaneous onset of labour.

New insights into the (epi)genetics of twinning

Spontaneous dizygotic (DZ) twins, i.e. twins conceived without the use of ARTs, run in families and their prevalence varies widely around the globe. In contrast, monozygotic (MZ) twins occur at a constant rate across time and geographical regions and, with some rare exceptions, do not cluster in families. The leading hypothesis for MZ twins, which arise when a zygote splits during preimplantation stages of development, is random occurrence. We have found the first series of genes underlying the liability of being the mother of DZ twins and have shown that being an MZ twin is strongly associated with a stable DNA methylation signature in child and adult somatic tissues. Because identical twins keep this molecular signature across the lifespan, this discovery opens up completely new possibilities for the retrospective diagnosis of whether a person is an MZ twin whose co-twin may have vanished in the early stages of pregnancy. Here, we summarize the gene finding results for mothers of DZ twins based on genetic association studies followed by meta-analysis, and further present the striking epigenetic results for MZ twins.

Anesthetic Management of Cesarean Section in the Case of a Sextuplet Pregnancy and Polycystic Ovarian Syndrome

Cesarean section in a mother with a sextuplet pregnancy is challenging for an anesthesiologist. Several perioperative complications are likely because of the overdistended uterus and associated changes in the mother. We are reporting the case of a woman with a sextuplet pregnancy who came for an emergency cesarean. She also had a background history of polycystic ovarian syndrome (PCOS) and ovulation induction for conception. Early pregnancy was complicated by ovarian hyperstimulation syndrome. She required cervical cerclage in early pregnancy. The emergency cesarean was done as she went into preterm labor and six premature babies were delivered at 29 weeks of gestation. Cesarean was done under spinal anesthesia. Preeclampsia and postpartum hemorrhage complicated the perioperative period.

Risk factors associated with stillbirth and adverse perinatal outcomes in dichorionic twin pregnancies complicated by selective fetal growth restriction: a cohort study

OBJECTIVE

The main aim of this study was to investigate the perinatal outcomes of dichorionic twin pregnancies complicated by selective fetal growth restriction (sFGR).

DESIGN

Retrospective cohort study.

SETTING

Tertiary reference centre.

POPULATION

Dichorionic twin pregnancies complicated by sFGR between 2000 and 2019 in St George's University Hospital.

METHODS

Regression analyses were performed using generalised linear models and mixed-effects generalised linear models where appropriate to account for pregnancy level dependency in variables. Time to event analyses were performed with mixed-effects Cox regression models.

MAIN OUTCOME MEASURES

Stillbirth, neonatal death or neonatal unit admission with morbidity in one or both twins.

RESULTS

A total of 102 (of 2431 dichorionic twin pregnancies) pregnancies complicated by sFGR were included in the study. The Cochrane-Armitage test revealed a significant trend for increased adverse perinatal outcome rates with more severe forms of umbilical artery flow impedance, i.e. reversed, absent, positive with resistant flow and positive flow without resistance. A multivariable model including maternal and conception characteristics had poor predictive accuracy for stillbirth (area under the curve: 0.68, 95% confidence interval [CI] 0.55-0.81) and composite adverse perinatal outcomes (area under the curve: 0.58, 95% CI 0.47-0.70). When umbilical artery Doppler parameters were added to the models, the area under the curve values improved to 0.95 (95% CI 0.89-0.99) and 0.83 (95% CI 0.73-0.92) for stillbirth and composite adverse perinatal outcomes, respectively.

CONCLUSION

In dichorionic twin pregnancies complicated by sFGR, the umbilical artery Z-scores were associated with both intrauterine death and adverse perinatal outcomes.

The needs of multiple birth families during the first 1001 critical days: A rapid review with a systematic literature search and narrative synthesis

OBJECTIVE

Supporting families during the first 1001 days from conception to the age of two is vital for setting the emotional, cognitive, and physical building blocks for children's futures. Families with twins, triplets, or higher order multiples (multiple birth families) have unique challenges due to caring for more than one baby at the same time. Therefore, identifying the needs of multiple birth families is necessary to provide optimum support during the first 1001 critical days.

DESIGN

A rapid review was undertaken to synthesize knowledge of the needs of multiple birth families in the United Kingdom (UK) during the first 1001 critical days. Findings from five databases (MEDLINE, APA PsycArticles, APA PsycInfo, CINAHL, and Web of Science) for peer-reviewed studies and grey literature published between 2012 and 2022 were synthesized. Fifteen studies were reviewed using narrative synthesis.

RESULTS

Multiple birth families have unique and complex emotional and practical needs across the first 1001 critical days, and in particular, the first-year post birth, impacted further by complicated pregnancies and prematurity. Needs were identified within the four key themes: high risk pregnancy and birth; transformed reality of raising multiples; inadequate support; and positively affecting experiences. Health professional support was inconsistent and particularly lacking in intrapartum, postnatal, and community care including transition.

CONCLUSION

Multiple birth families' needs should be considered in the design and delivery of care within the first 1001 critical days, especially within the first year after birth. Multiples specific advice across the first 1001 critical days is needed and training for health professionals to adapt universal advice for this population is one way to achieve this. Further research is needed to ensure this advice is evidence based and effective.

Are Cervical Pessaries Effective in Preventing Preterm Birth?

Preterm births are a significant concern, as they can have serious consequences for both infants and mothers. It is crucial to identify risk factors associated with preterm birth and to implement effective interventions, such as progesterone, cervical pessary, and cervical cerclage, to prevent it. This systematic review aims to evaluate the efficacy of cervical pessary in reducing spontaneous preterm delivery. However, cervical pessaries have limited research and conflicting findings when compared to other interventions for preventing preterm labor. Therefore, this review seeks to analyze various studies to evaluate their overall effectiveness and better understand their role in treating this vulnerable population. The literature search was conducted using PubMed between January and September 2023, and the systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The results of this review highlight the importance of continued research into mitigation strategies for preterm birth. There is some evidence that indicates that using cervical pessaries before 34 weeks can be effective. While some studies have reported positive outcomes when cervical pessaries are combined with other treatments like progesterone, there is no solid statistical evidence to support this claim. Furthermore, additional research is needed to comprehend the impact of singleton pregnancies and long-term outcomes for both mothers and infants.

Risk factors for adverse outcomes in twin pregnancies: a narrative review

PURPOSE

Globally, the incidence of twin pregnancies is rising owing to the use of assisted reproductive technologies (ART), emigration and deferment of pregnancy until advanced maternal age (AMA). While twin pregnancies have higher absolute risks of adverse outcomes, including miscarriage, stillbirth, neonatal death and preterm delivery, the impact of specific exposures and risk factors related to these outcomes may differ between twin pregnancies and singleton pregnancies. Regarding modifiable factors, data are sometimes based on evidence extrapolated from singleton or whole obstetric populations. Therefore, targeted evidence is required to provide care tailored to twin pregnancies to prevent adverse outcomes. We aimed to comprehensively review the association between different risk factors and adverse outcomes in twin pregnancies, including data on chorionicity, and to compare these to singletons.

MATERIALS AND METHODS

This review examines the risks associated with chorionicity, AMA, body mass index (BMI), socioeconomic and ethnic inequalities, maternal smoking, use of ART, maternal perception of fetal movement, and maternal comorbidities, including hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM). Adverse outcomes reported were preterm birth, admission to the neonatal intensive care unit (NICU), stillbirth and neonatal mortality. As such, fetal mortality and morbidity will be under-represented, as pregnancy loss before 22-24 weeks is omitted.

RESULTS

Monochorionicity increases the risk of stillbirth, NICU admission, and preterm delivery in twin pregnancy. AMA predisposes twin pregnancies to higher risks of mortality, admission to the NICU, and preterm birth than singleton pregnancies do. Conversely, the impact of BMI, socioeconomic inequalities, smoking, ART, and HDP on adverse outcomes appears to be lower in twin pregnancies than in singleton pregnancies. This attenuation might be explained by the higher baseline risk of adverse outcomes such as preterm birth in twin pregnancies. Some exposures, such as ART use and GDM, appear to be "protective" against perinatal mortality in twin pregnancies, despite being established risk factors for adverse outcomes in singleton pregnancies, potentially related to access to specialist care. There is a paucity of evidence available to counsel mothers of twin pregnancies regarding reduced fetal movement.

CONCLUSIONS

Overall, the risk factors for adverse pregnancy outcomes differ between twin and singleton pregnancies. This highlights the need for further studies to examine the association between risk factors and adverse outcomes in twin pregnancies. The resulting data would facilitate tailored guidance for twin pregnancies, contribute to improved antenatal care, and inform wider public health strategies.

Fetal sex and the development of gestational diabetes mellitus in gravidae with multiple gestation pregnancies

INTRODUCTION

There is an increasing incidence of pregnancies with twin gestations. One outcome more likely to occur with multiple gestations is gestational diabetes mellitus. Studies have suggested that in singleton pregnancies, fetal sex may affect insulin resistance. However, the effects of fetal sex in twins and the development of gestational diabetes mellitus are unknown. We hypothesized that rates of gestational diabetes mellitus and degree of insulin resistance might vary in twin gestations based on the fetal sex pairing: male-male, male-female or female-female. We aimed to employ a large population-based database to ascertain any correlations between fetal sex and gestational diabetes mellitus in multifetal gestations.

MATERIAL AND METHODS

A two-hospital, single academic institution database comprised of over 39 000 participants with pregnancy data from August 2011 to January 2022 was employed. All twin deliveries of live-born neonates >24 weeks' gestational age from gravidae without preexisting diabetes or twin-twin transfusion syndrome were included. Entries were then grouped based on the fetal sex of the pairing. The presence or absence of gestational diabetes and type of gestational diabetes - diet-controlled (gestational diabetes mellitus classification A1) vs medication-controlled (gestational diabetes mellitus classification A2) - were identified. Statistical analysis was performed using a generalized linear mixed method, and a P-value ≤0.05 was considered statistically significant.

RESULTS

We identified 1924 twin deliveries that met the inclusion criteria in our database (male-male =652; male-female = 638; female-female = 634). We found no association between fetal sex pairing and the development of gestational diabetes mellitus. There was a significant association between the fetal sex pairing and the type of gestational diabetes mellitus developed, with 32.0% of male-male twins, 33.3% of male-female twins and 58.3% of the female-female twin deliveries associated with medication-controlled gestational diabetes classification A2: male-female vs female-female (P = 0.05) and male-male vs female-female (P = 0.046).

CONCLUSIONS

While gestational diabetes mellitus is of multifactorial origin, we found a significant association between the fetal sex pairing and the treatment needed for gravidae with twins who develop gestational diabetes mellitus. A higher proportion of female-female twins was associated with gestational diabetes classification A2 compared with male-female or male-male deliveries. Further research on the physiology driving this association is warranted.

Australian intended parents' decision-making and characteristics and outcomes of surrogacy arrangements completed in Australia and overseas

Markets for international surrogacy often arise in jurisdictions with limited regulations regarding assisted reproductive technologies. In some countries, like Australia, regulated domestic surrogacy services are often sidestepped for international providers. This study describes how Australian intended parents decide where to pursue surrogacy and compares the characteristics and outcomes of arrangements completed within and outside of Australia. The findings show that, although intended parents preferred undergoing surrogacy in Australia, perceiving the process as too long and complicated was a common reason to pursue an international arrangement. Multiple embryo transfer, anonymous gamete donation, and a lack of counselling were common in international surrogacy arrangements. When compared to surrogacy arrangements completed in Australia, where single embryo transfer is mandatory for surrogacy cycles, the rates of multiple birth, preterm birth and neonatal intensive care in international surrogacy were higher. These findings raise concerns about the health and welfare of international surrogacy participants, particularly the surrogates and children. In lieu of any international instrument regulating surrogacy, improving access to surrogacy at a domestic level would reduce the number of people engaging with international arrangements and in turn, reduce the potential for harm.

Multiple Gestation as a Risk Factor for SARS-CoV-2-Associated Adverse Maternal Outcome: Data From the COVID-19 Related Obstetric and Neonatal Outcome Study (CRONOS)

Introduction

Studies have shown that pregnant women with COVID-19 have a higher risk of intensive care unit admission and invasive mechanical ventilation support than non-pregnant women. Pregnancy-associated physiological changes in respiratory function may contribute to the elevated risk. Alteration in lung volumes and capacities are attributed to the mechanical impediment caused by the growing fetus. Multiple pregnancies may therefore compromise functional lung capacity earlier than singleton pregnancies and contribute to severe respiratory symptoms of COVID-19.

Materials and Methods

A total of 5514 women with a symptomatic SARS-CoV-2 infection during pregnancy registered in the COVID-19 Related Obstetric and Neonatal Outcome Study were included. The COVID-19-related adverse maternal outcomes were compared in 165 multiple versus 5349 singleton pregnancies. Combined adverse maternal outcome was defined as presence of COVID-19-related hospitalization and/or pneumonia and/or oxygen administration and/or transfer to ICU and/or death. Multivariate logistic regression was used to estimate the odds ratios and 95% confidence intervals were calculated.

Results

The frequency of dyspnea, likelihood of developing dyspnea in a defined pregnancy week and duration of the symptomatic phase of the COVID-19 infection did not differ between the two groups. On average, COVID-19-related combined adverse outcome occurred earlier during pregnancy in women expecting more than one child than in singleton pregnancies. The overall incidence of singular and combined COVID-19-associated adverse maternal outcomes was not significantly different between groups. However, regression analysis revealed that multiple gestation, preconceptional BMI > 30 kg/m 2 and gestational age correlated significantly with an increased risk of combined adverse maternal outcome. Conversely, maternal age and medically assisted reproduction were not significant risk factors for combined adverse maternal outcome.

Conclusion

Our data show that multiple gestation alone is a risk factor for COVID-19-associated combined adverse maternal outcome. Moreover, severe courses of COVID-19 in women expecting more than one child are observed earlier in pregnancy than in singleton pregnancies.

Pregnancy outcomes in preterm multiple gestations: Results from a prospective study in India and Pakistan (PURPOSe)

OBJECTIVE

To evaluate perinatal outcomes in preterm multiple compared with singleton pregnancies in India and Pakistan.

DESIGN

Prospective, observational study.

SETTINGS

Study hospitals in India and Pakistan.

POPULATION

We evaluated 3897 preterm pregnancies. These mothers gave birth to 3615 (92.8%) singleton infants, 267 (6.8%) sets of twins, 14 (0.4%) sets of triplets and one set of quadruplets.

MAIN OUTCOME MEASURES

Neonatal mortality, stillbirth, cause of death.

RESULTS

Of the singleton infants, 691 (19.1%) were stillborn and 2924 (80.9%) live born. Of the 534 infants from twin pregnancies, 41 (7.7%) were stillborn and 493 (92.3%) were live born. Of the 267 sets of twins, in 14 cases (5.2%) both were stillborn, in 13 cases (4.8%) one was stillborn and one live born, and in 240 cases (90.0%) both were live born. In both preterm twins and preterm singletons, the three most common causes of death were intrauterine hypoxia, infections acquired prior to birth and infections acquired at or after birth. The preterm twins appeared less likely to have died from intrauterine hypoxia but more likely to have died from infections acquired at or after birth. Respiratory distress syndrome (RDS) was less likely considered by the panel to be the primary cause of death in either the twins (9.6%) or singletons (9.7%). Congenital anomalies were also not often judged to be the cause of death in either the preterm twins 2 (2.4%) or singletons 27 (5.3%).

CONCLUSION

In the PURPOSe study, neonatal mortality rates in preterm twins compared with singletons when evaluated by sex, GA, birthweight and SGA, were generally similar to rates of preterm singleton neonatal mortality in those groups. Thus, the higher rate of mortality in live-born twin infants is related to the fact that these infants were more likely to be born earlier rather than to any inherent characteristics of the babies themselves.

Cerebral palsy in children born after assisted reproductive technology in Norway: Risk, prevalence, and clinical characteristics

INTRODUCTION

The aim was to investigate the risk, prevalence, and clinical characteristics of cerebral palsy among children born after assisted reproductive technology (ART) in Norway.

MATERIAL AND METHODS

All liveborn children from 2002 to 2015 were included. Information was collected from the Medical Birth Registry of Norway, linked to the Norwegian Quality and Surveillance Registry for Cerebral Palsy as of December 31, 2022. Logistic regression analyses were used to calculate the prevalence of cerebral palsy per 1000 live births after ART and natural conception with birth year as covariate, crude odds ratios (OR) for cerebral palsy among children born after ART using children born after natural conception as reference, and OR adjusted for potential confounders, with 95% confidence intervals (CI). Potential mediators of the association were studied in stratified analyses. Descriptive statistics were used to compare proportions in clinical characteristics among children with cerebral palsy born after ART and natural conception.

RESULTS

Among 833 645 livebirths, 23 645 children were born after ART and of the latter 97 were diagnosed with cerebral palsy. The overall prevalence of cerebral palsy after ART was 4.10 per 1000 live births (95% CI 3.36-5.00), decreasing from 7.79 per 1000 in 2002 to 3.55 in 2015. Compared with children born after natural conception, the OR for cerebral palsy was 2.01 (95% CI 1.63-2.47) adjusted for mother's age at birth, parity, and pre-pregnancy health. When restricted to singletons born at term, the adjusted OR for cerebral palsy was 1.13 (95% CI 0.76-1.69). The distribution of cerebral palsy subtypes and the severity of gross and fine motor function and associated impairments did not differ significantly between children with cerebral palsy born after ART and natural conception.

CONCLUSIONS

Children born after ART had a risk of cerebral palsy that was twice that of children born after natural conception. The increased risk of cerebral palsy after ART is likely attributed to multiple pregnancies and preterm births. The prevalence of cerebral palsy after ART decreased significantly during the study period, despite an increased use of ART in the population. The distribution of clinical characteristics did not differ between children with cerebral palsy born after ART and those born after a natural conception, suggesting that the risk factors for, and causes of cerebral palsy were similar.

Cardiac findings in newborn twins

AIMS

To evaluate cardiac findings in newborn twins from the general population and investigate if newborn twins may require systematic evaluation of cardiac parameters.

METHODS

Prospective cohort study of newborns with cardiac evaluation performed during the first month of life. Cardiac findings were compared 1:3 with matched singletons.

RESULTS

We included 412 newborn twins (16% monochorionic; 50% boys) and 1236 singletons. Comparing cardiac findings showed twins had an increased prevalence of non-severe structural heart disease (most common: ventricular septal defects in both groups), thinner left ventricular posterior wall in diastole (LVPWd; 1.82 vs. 1.87 mm, p = 0.02), smaller diameter of the left atrium (10.6 vs. 11.1 mm, p = 0.04), higher heart rate (148 vs. 144 bpm, p = 0.04), more left-shifted QRS axis (106 vs. 111°, p < 0.001), and lower maximum R-wave amplitude in V1 (927 vs. 1015 μV, p = 0.02) compared to singletons. After multifactorial adjustment for potential confounders, the effect of twinning on cardiac parameters persisted only for LVPWd (p < 0.05).

CONCLUSION

Despite contemporary surveillance, we found an increased prevalence of non-severe structural heart disease in a population-based cohort of newborn twins. However, the effect of twinning on cardiac parameters was modest and generally did not persist after correction for likely confounding factors.

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.

Factors affecting elective cesarean section in women with multiple pregnancy in Caruban, Indonesia

Background: Caesarean sections have become the most popular method for delivering twin babies because of the safety concerns associated with a natural birth. This study aims to identify the maternal characteristics and obstetric parameters that serve as risk factors influencing caesarean delivery in twin pregnancies by comparing women delivering via caesarean section and vaginal birth. Methods: A retrospective chart review design was used to analyse 47 women with multiple pregnancies from the medical records at a primary referral hospital in East Java, Indonesia. Women delivering vaginally were then compared with women who underwent a caesarean section to identify any differences between the groups. Results: In our study, more women delivered by caesarean section (n=35) than by vaginal birth (n=12). Women were more likely to undergo a caesarean section if they had a previous history of undergoing a caesarean section (OR 16.5; 95% CI 1.91-142.49; p=0.02). Similar to previous studies, we found that foetal malpresentation significantly increase the risk of caesarean delivery (OR 8.25; 95%CI 0.95-71.09; p=0.03), while labour augmentation decrease the likelihood of caesarean section (OR 0.20; 95% CI 0.49-0.81; p=0.03). There was also a significant older patients in the caesarean section groups (OR 1.26; 95% CI 1.09-1.45 ; p=0.00). Conclusions: The percentage of multiple pregnancies delivered via caesarean section is quite high. Other larger cohort study are warranted, since many factors were involved in the decision of caesarean section.

Classification and Special Nutritional Needs of SGA Infants and Neonates of Multiple Pregnancies

Data regarding the nutritional management of preterm small for gestational age (SGA) infants are scarce. In the recent report of ESPGHAN, the recommended energy for very preterm infants during hospitalization has been increased, yet this may not fit the needs of all preterm infants. It is important to distinguish fetal growth-restricted (FGR) infants from constitutional SGA infants, as well as preterm SGA from preterm AGA infants, since they may have different nutritional needs. Preterm FGR infants, and specifically infants < 29 weeks' gestation, accumulate nutrient deficits due to intrauterine malnutrition, prematurity, morbidities, delayed initiation of feeding, and feeding intolerance. Therefore, these infants may need more aggressive nutrition for optimal catch-up growth and neurologic development. However, a balance should be kept between optimal and excessive catch-up growth, since the combination of intrauterine malnutrition and excessive postnatal growth has been linked with later adverse metabolic consequences. Furthermore, multiple gestation is often complicated by FGR and prematurity. There is controversy in the definition of FGR in multiple gestations, and it should be noted that FGR in multiple gestation usually differs etiologically from FGR in singletons. The aim of this review is to summarize existing knowledge regarding the nutritional needs of preterm FGR and FGR infants of multiple gestation.

Preliminary Study of Iron Concentration in the Human Placenta in Twin Pregnancies

BACKGROUND

Pregnancy significantly increases the demand for iron (Fe) in the female body to facilitate maternal blood volume expansion, placental development, and fetal growth. As Fe flux in pregnancy is significantly influenced by the placenta, the aim of this study was to determine the dependencies between the Fe concentration in the placenta, the infant's morphometric parameters and the woman's morphological blood parameters in the last trimester.

METHODS

The study was conducted on 33 women with multiple (dichorionic-diamniotic) pregnancies from whom the placentas were drawn, and their 66 infants, including pairs of monozygotic (n = 23) and mixed-sex twins (n = 10). Fe concentrations were determined based on inductively coupled plasma atomic emission spectroscopy (ICP-OES) using ICAP 7400 Duo, Thermo Scientific.

RESULTS

The results of the analysis showed that lower placental Fe concentrations were associated with deteriorated morphometric parameters of infants, including weight and head circumference. Although we found no statistically significant dependencies between Fe concentration in the placenta and the women's morphological blood parameters, higher Fe concentration in the placenta of mothers supplemented with Fe correlated with better morphometric parameters in infants compared to those whose mothers received no Fe supplementation.

CONCLUSIONS

The research adds additional knowledge for placental iron-related processes during multiple pregnancies. However, many limitations of the study do not allow detailed conclusions to be assessed, and statistical data should be assessed conservatively.

Preterm Prelabour Rupture of Membranes before Viability in Twin Pregnancies: What Can We Expect?

Preterm prelabour rupture of membranes (PPROMs) before viability carries significant perinatal mortality and morbidity. Clinical management and prenatal counselling are a challenge, especially in twin pregnancies, due to scarce evidence on how previable PPROM affects this population. The aim of this study was to describe pregnancy outcomes of twin pregnancies complicated with previable PPROM and evaluate potential prognostic factors that may predict perinatal mortality. A retrospective cohort including dichorionic and monochorionic diamniotic twin pregnancies complicated with PPROM before 24 + 0 weeks of pregnancy was evaluated. Perinatal outcomes of pregnancies managed expectantly were described. Factors predicting perinatal mortality or reaching periviability (defined from 23 + 0 weeks onwards) were evaluated. Of the 45 patients included, 7 (15.6%) spontaneously delivered within the first 24 h after diagnosis. Two patients (5.3%) requested selective termination of the affected twin. In the 36 ongoing pregnancies that opted for expectant management, the overall survival rate was 35/72 (48.6%). There were 25/36 (69.4%) patients who delivered after 23 + 0 weeks of pregnancy. When periviability was achieved, neonatal survival increased up to 35/44 (79.5%). Gestational age at delivery was the only independent risk factor of perinatal mortality. The overall survival rate of twin pregnancies complicated with previable PPROM is poor but similar to singletons. No prognostic factors, apart from achieving periviability, were identified as individual predictors of perinatal mortality.

The impact of a three-phase education-support-follow-up program on the mothers' perceptions of the needs of their multiple infants: A protocol study for a clinical trial

BACKGROUND

Infertility, a problematic issue to the newly married couples, should be treated as no couple should be deprived of having children. The treatment, however, poses new challenges to the multiples and subsequent preterm births, health system, and families. Therefore, the aim of this study is to investigate the effect of an education-support-follow-up program on the mothers' perceptions of their multiples' needs.

MATERIALS AND METHODS

This research is a three-phase interventional study. The first phase develops an educational program through review of the literature and using the opinions of experts. In the second phase, the developed program will be implemented in the neonatal intensive care unit (NICU) for the mothers of multiples. In the third phase, based on the developed plan, the required support will be applied and followed up. The data collection tool is a researcher-made questionnaire which is completed by the mothers (N = 30) before and after the intervention. Convenience sampling method will be used, and the mothers will be allocated randomly. Data gathering started from September 2020 and would continue until the sample collection is completed. Data will be analyzed through the descriptive and analytical statistics with Statistical Package for the Social Sciences (SPSS) version 21.

RESULTS

The present study can address the needs of the multiple infants based on the implementation of an education-support-follow-up program for mothers and their families.

CONCLUSION

The mothers of multiple infants are required to specify unique physical and developmental needs of their infants, while their perceptions of these needs may be different based on the education-support-follow-up program. The researchers designed the program to help them define highly specialized needs of multiples and also examined their perceptions of these needs.

Odds and Predictors of Monozygotic Twinning in a Multicentre Cohort of 25,794 IVF Cycles

The rate of monozygotic twinning (MZT) has seen a gradual increase in recent years. Numerous parameters involved in ART procedures are blamed for this surge, even though the exact explanation is as yet unknown. Our study's objectives were to determine the risk variables for monozygotic twinning after ART and to estimate their prevalence. We examined 25,794 IVF cycles for the incidence of monozygotic twinning in this observational analysis. Our study, which was carried out across seven tertiary IVF centres over the course of four years, found an overall MZT rate of 0.37% per embryo transfer procedure and 0.88% of all pregnancies. Monozygotic twinning was more commonly seen in fresh single-embryo transfer (SET) and blastocyst transfer cycles. Larger multicentre studies are needed to explore the potential risk variables.

Multiple Pregnancy and the Risk of Postpartum Hemorrhage: Retrospective Analysis in a Tertiary Level Center of Care

The aim of our study was to identify characteristics associated with postpartum hemorrhage (PPH defined as blood loss >1000 mL) in twin pregnancies in order to select patients at higher risk to be treated. This retrospective study includes multiple pregnancies between 2015 and 2020. The possible association between pregnancy characteristics and the primary endpoint (occurrence of PPH) was conducted using chi-square or Fisher exact test and Wilcoxon test. Then, univariate logistic models were performed considering as outcome the PPH, and the odds ratios with 95% CI were estimated. Finally, a multivariate logistic model was implemented, including all significant covariates. Seven hundred seven twin pregnancies giving birth beyond 32 weeks were included and of those, 120 (16.97%) had a PPH. The univariate analysis showed that factors significantly associated with PPH were: Preterm delivery, episiotomy, neonatal weight, and mode of delivery. The multivariate analysis showed that the most important factors were episiotomy and neonatal weight. The results show that the performance of episiotomy and the neonatal weight are the factors that most impact the risk of PPH in twin pregnancies. The correct identification of factors associated with PPH in twins could ideally allow to modify the clinical management and positively affect the rate of complications.

Open Questions on Gestational Diabetes Mellitus in Twin Pregnancies

BACKGROUND

The concurrent, recent increase in prevalence of Gestational Diabetes Mellitus (GDM) and twin pregnancy, in combination with the shared risk factors, has led to speculation that multiples are a risk factor for GDM and, GDM may contribute to twin complications. Twin pregnancies have different physiology and greater obstetric risks compared to singletons, including prematurity and growth restriction. However, in twins methods of GDM screening, thresholds for diagnosis and treatment, as well as glycaemic control targets, have been predominantly extrapolated from singletons. Studies investigating the impact of GDM on pregnancy outcomes in twin pregnancies are conflicting.

OBJECTIVE

To provide a comprehensive, critical overview of evidence on GDM in twin pregnancies with an emphasis on prevalence, methods of screening, thresholds for diagnosis, risk of pregnancy complications and the impact of treatment on perinatal outcomes.

METHODS

Review of retrospective and prospective cohort, case-control, and case-series studies on twin pregnancies with GDM published between 1980 and 2021.

RESULTS

Glucose tolerance in twin pregnancies is poorly studied. Specific guidance for screening, diagnosis, and treatment of GDM in twins is lacking. Studies evaluating pregnancy outcomes in twins with GDM are few and heterogeneous. The absolute risk of maternal complications is greater in twins with GDM compared to singletons; conversely, differences in risks between twins with and without GDM may be due to maternal confounders rather than to GDM. Most studies agree on a positive effect of GDM on neonatal outcomes in twins, likely mediated by the hyperglycaemia improving fetal growth. The impact of lifestyle-measures versus medical management on pregnancy outcomes in twins with GDM is unknown.

CONCLUSION

Larger longitudinal studies evaluating glucose tolerance, pregnancy outcomes and the impact of treatment both in mono and di-chorionic twins with GDM are warranted to gain further insight into the pathophysiology of this condition and guide optimal management.

Tranexamic acid for the prevention of blood loss after cesarean among women with twins: a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery randomized clinical trial

BACKGROUND

Although prophylactic tranexamic acid administration after cesarean delivery resulted in a lower incidence of calculated estimated blood loss of >1000 mL or red cell transfusion by day 2, its failure to reduce the incidence of hemorrhage-related secondary clinical outcomes (TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial) makes its use questionable. The magnitude of its effect may differ in women at higher risk of blood loss, including those with multiple pregnancies.

OBJECTIVE

This study aimed to compare the effect of tranexamic acid vs placebo to prevent blood loss after cesarean delivery among women with multiple pregnancies.

STUDY DESIGN

This was a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial data, a double-blind, randomized controlled trial from March 2018 to January 2020 in 27 French maternity hospitals, that included 319 women with multiple pregnancies. Women with a cesarean delivery before or during labor at ≥34 weeks of gestation were randomized to receive intravenously 1 g of tranexamic acid (n=160) or placebo (n=159), both with prophylactic uterotonics. The primary outcome was a calculated estimated blood loss of >1000 mL or a red blood cell transfusion by 2 days after delivery. The secondary outcomes included clinical and laboratory blood loss measurements.

RESULTS

Of the 4551 women randomized in this trial, 319 had a multiple pregnancy and cesarean delivery, and 298 (93.4%) had primary outcome data available. This outcome occurred in 62 of 147 women (42.2%) in the tranexamic acid group and 67 of 152 (44.1%) receiving placebo (adjusted risk ratio, 0.97; 95% confidence interval, 0.68-1.38; P=.86). No significant between-group differences occurred for any hemorrhage-related clinical outcomes: gravimetrically estimated blood loss, provider-assessed clinically significant hemorrhage, additional uterotonics, postpartum blood transfusion, arterial embolization, and emergency surgery (P>.05 for all comparisons).

CONCLUSION

Among women with a multiple pregnancy and cesarean delivery, prophylactic tranexamic acid did not reduce the incidence of any blood loss-related outcomes.

Transfer of a poor-quality along with a good-quality embryo on in vitro fertilization/intracytoplasmic sperm injection-embryo transfer clinical outcomes: a systematic review and meta-analysis

OBJECTIVE

To investigate the effect on the pregnancy rate of transfer of a good-quality embryo (GQE) and a poor-quality embryo (PQE) in comparison with a single GQE transfer.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Infertility patients undergoing in vitro fertilization/intracytoplasmic sperm injection- embryo transfer.

INTERVENTION(S)

Three major electronic databases (PubMed, Embase, and Cochrane Library) for studies those compared single GQE transfer to double embryo transfer of a GQE + PQE were searched. The Newcastle-Ottawa Quality Assessment Scale was used to evaluate the study quality. Random-effect meta-analysis was performed on all data for an overall analysis, followed by a subgroup analysis (fresh cleavage-stage embryos, fresh blastocysts, frozen-thawed blastocysts, and the same assessment criteria for blastocyst quality).

MAIN OUTCOME MEASURE(S)

The primary outcome was clinical pregnancy rate (CPR).

RESULT(S)

A total of 17 studies with 17,612 cycles for GQE transfer and 6,431 cycles for GQE + PQE transfer were included in the meta-analysis. No significant differences were found in CPR (relative risk [RR] = 1.02; 95% confidence interval [CI], 0.91-1.14) and live birth rate (RR = 0.96; 95% CI, 0.87-1.07) between GQE + PQE and GQE transfers. However, the transfer of GQE + PQE increased multiple pregnancy rate (RR = 0.14; 95% CI, 0.09-0.20) and multiple birth rate (RR = 0.08; 95% CI, 0.06-0.12), when compared with the patients undergoing a single GQE transfer. Subgroup analyses by type of embryo for transfer and assessment criteria for embryo quality showed similar trends.

CONCLUSION(S)

Double embryo transfer with GQE + PQE does not result in increased or decreased CPR and live birth rate when compared with a single GQE transfer but leads to a higher multiple pregnancy rate and multiple birth rate.

CLINICAL TRIAL REGISTRATION NUMBER

Prospero CRD42022296681 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=296681) registered on January 7, 2022.

Early detection of ischemic brain injuries by diffusion-weighted imaging after radiofrequency ablation for fetal reduction in monochorionic pregnancies

BACKGROUND

This study aimed to investigate the additional advantages of magnetic resonance imaging (MRI), particularly diffusion-weighted imaging (DWI) over fetal ultrasound in the detection of acute ischemic cerebral injuries in complicated monochorionic (MC) pregnancies that underwent selective reduction by radiofrequency ablation (RFA).

METHODS

This prospective cohort study was conducted on 40 women with complicated MC pregnancies who were treated by RFA. Fetal brain imaging by DWI and conventional MRI was performed either in the early (within 10 days after RFA) or late phase (after 3-6 weeks) in the surviving fetuses to detect both acute and chronic ischemic injuries. The presence of anemia after RFA was also evaluated by Doppler ultrasound.

RESULTS

Overall, 13 of the total 43 fetuses (30.23%) demonstrated MRI abnormalities with normal brain ultrasound results including germinal matrix hemorrhage (GMH), extensive cerebral ischemia, and mild ventriculomegaly. Although seven fetuses with GMH eventually survived, fetuses that demonstrated ischemic lesions and ventriculomegaly on MRI died in the uterus.

CONCLUSION

The absence of abnormal cerebral lesions or anemia on ultrasound and Doppler exams does not necessarily rule out fetal brain ischemia. Performing early MRI, particularly DWI seems to be a reasonable option for detection of early intracranial ischemic changes and better management of complicated multiple pregnancies which were treated by RFA.

Prediction of fetal death in monochorionic twin pregnancies complicated by Type-III selective fetal growth restriction

OBJECTIVE

Monochorionic diamniotic twin pregnancies complicated by Type-III selective fetal growth restriction (sFGR) are at high risk of fetal death. The aim of this study was to identify predictors of fetal death in these pregnancies.

METHODS

This was an international multicenter retrospective cohort study. Type-III sFGR was defined as fetal estimated fetal weight (EFW) of one twin below the 10^th percentile and intertwin EFW discordance of ≥ 25% in combination with intermittent absent or reversed end-diastolic flow in the umbilical artery of the smaller fetus. Predictors of fetal death were recorded longitudinally throughout gestation and assessed in univariable and multivariable logistic regression models. The classification and regression trees (CART) method was used to construct a prediction model of fetal death using significant predictors derived from the univariable analysis.

RESULTS

A total of 308 twin pregnancies (616 fetuses) were included in the analysis. In 273 (88.6%) pregnancies, both twins were liveborn, whereas 35 pregnancies had single (n = 19 (6.2%)) or double (n = 16 (5.2%)) fetal death. On univariable analysis, earlier gestational age at diagnosis of Type-III sFGR, oligohydramnios in the smaller twin and deterioration in umbilical artery Doppler flow were associated with an increased risk of fetal death, as was larger fetal EFW discordance, particularly between 24 and 32 weeks' gestation. None of the parameters identified on univariable analysis maintained statistical significance on multivariable analysis. The CART model allowed us to identify three risk groups: a low-risk group (6.8% risk of fetal death), in which umbilical artery Doppler did not deteriorate; an intermediate-risk group (16.3% risk of fetal death), in which umbilical artery Doppler deteriorated but the diagnosis of sFGR was made at or after 16 + 5 weeks' gestation; and a high-risk group (58.3% risk of fetal death), in which umbilical artery Doppler deteriorated and gestational age at diagnosis was < 16 + 5 weeks' gestation.

CONCLUSIONS

Type-III sFGR is associated with a high risk of fetal death. A prediction algorithm can help to identify the highest-risk group, which is characterized by Doppler deterioration and early referral. Further studies should investigate the potential benefit of fetal surveillance and intervention in this cohort. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Sexual and/or gender minority disparities in obstetrical and birth outcomes

BACKGROUND

Many sexual and/or gender minority individuals build families through pregnancy and childbirth, but it is unknown whether they experience different clinical outcomes than those who are not sexual and/or gender minority individuals.

OBJECTIVE

To evaluate obstetrical and birth outcomes comparing couples who are likely sexual and/or gender minority patients compared with those who are not likely to be sexual and/or gender minority patients.

STUDY DESIGN

We performed a population-based cohort study of live birth hospitalizations during 2016 to 2019 linked to birth certificates in California. California changed its birth certificate in 2016 to include gender-neutral fields such as "parent giving birth" and "parent not giving birth," with options for each role to specify "mother," "father," or "parent." We classified birthing patients in mother-mother partnerships and those who identified as a father in any partnership as likely sexual and/or gender minority and classified birthing patients in mother-father partnerships as likely not sexual and/or gender minority. We used multivariable modified Poisson regression models to estimate the risk ratios for associations between likely sexual and/or gender minority parental structures and outcomes. The models were adjusted for sociodemographic factors, comorbidities, and multifetal gestation selected by causal diagrams. We replicated the analyses after excluding multifetal gestations.

RESULTS

In the final birthing patient sample, 1,483,119 were mothers with father partners, 2572 were mothers with mother partners, and 498 were fathers with any partner. Compared with birthing patients in mother-father partnerships, birthing patients in mother-mother partnerships experienced significantly higher rates of multifetal gestation (adjusted risk ratio, 3.9; 95% confidence interval, 3.4-4.4), labor induction (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3), postpartum hemorrhage (adjusted risk ratio, 1.4; 95% confidence interval, 1.3-1.6), severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.2-1.8), and nontransfusion severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.1-1.9). Severe morbidity was identified following the Centers for Disease Control and Prevention "severe maternal morbidity" index. Gestational diabetes mellitus, hypertensive disorders of pregnancy, cesarean delivery, preterm birth (<37 weeks' gestation), low birthweight (<2500 g), and low Apgar score (<7 at 5 minutes) did not significantly differ in the multivariable analyses. No outcomes significantly differed between father birthing patients in any partnership and birthing patients in mother-father partnerships in either crude or multivariable analyses, though the risk of multifetal gestation was nonsignificantly higher (adjusted risk ratio, 1.5; 95% confidence interval, 0.9-2.7). The adjusted risk ratios for the outcomes were similar after restriction to singleton gestations.

CONCLUSION

Birthing mothers with mother partners experienced disparities in several obstetrical and birth outcomes independent of sociodemographic factors, comorbidities, and multifetal gestation. Birthing fathers in any partnership were not at a significantly elevated risk of any adverse obstetrical or birth outcome considered in this study.

Fetal reduction and twins

Infertility treatments have allowed millions of couples to have their own children, but resultant multiple pregnancies with their increased morbidity and mortality have been a significant complication. Fetal reduction was developed to ameliorate this issue. Over 30 years of publications show that fetal reduction has been highly successful in substantially reducing both mortality and morbidity related to multiple pregnancies. As with most radically new techniques, initial cases were in the "nothing to lose" category. With experience, indications liberalize, and quality of life issues gain relevance. The overall risks of twin pregnancy are not twice that of singleton pregnancy; they are about 4 to 5 times higher. In experienced hands, the combination of genetic testing by chorionic villus sampling followed by fetal reduction has made the outcomes of most multiple pregnancies statistically equivalent to those of pregnancies with lower fetal numbers. Use of microarray analysis to better determine fetal genetic health before deciding on which fetus(es) to keep or reduce further improves pediatric outcomes. With increasing experience and lower average starting numbers, the proportion of fetal reductions to a singleton has increased considerably. Twins to a singleton fetal reductions now constitute an increasing proportion of cases performed. Data on such cases show improved outcomes, and we believe fetal reduction should be at least discussed and offered to all patients with a dichorionic twin pregnancy or higher. With the increasing reliance on elective single-embryo transfers, monochorionic twins, which have much higher complication rates than dichorionic twins, have increased substantially. Furthermore, monochorionic twins cannot be readily and safely reduced, so the adverse perinatal statistics of elective single-embryo transfer are a major setback for good outcomes. Although elective single-embryo transfer is appropriate for some, we believe that for many couples, the transfer of 2 embryos is generally a more rational approach.

Vanquishing multiple pregnancy in in vitro fertilization in the United States-a 25-year endeavor

The practice of in vitro fertilization has changed tremendously since the birth of the first in vitro fertilization infant in 1978. With the success of early in vitro fertilization programs in the United States, there was a substantial rise in twin births nationwide. In the mid-1990s, more than 30% of in vitro fertilization cycles resulted in twin or higher-order multifetal pregnancies. Since that time, we not only have witnessed improvements in laboratory and treatment efficacy but also have seen a dramatic impact on pregnancy outcomes, specifically regarding twin pregnancies. Because the field evolved and the risks of multifetal pregnancies became more salient, in 2019, the rate of twin pregnancies had dropped to <7% of cycles. This improvement was largely because of technical advancements and revised professional guidance: culturing embryos longer before transfer, improved freezing technology, embryo preimplantation genetic testing, and revised professional guidance regarding the number of embryos to transfer. These developments have led to single-embryo transfer becoming the standard of care in most scenarios. We used national in vitro fertilization surveillance data of all autologous in vitro fertilization cycles from 1996 to 2019 to illustrate trends in the following improved outcomes: autologous embryo transfer cycles involving blastocyst-stage embryos, vitrified embryos, preimplantation genetic testing cycles, total number of embryos being transferred per cycle, and single-embryo transfer usage over time. Among deliveries from autologous embryo transfers, we highlighted trends in singleton births over time and proportion of deliveries involving twins, triplets, quadruplets, or greater. The notable progress in reducing the rate of multifetal pregnancies with in vitro fertilization was largely attributed to a series of technical and clinical actions, culminating in an 80% reduction in the incidence of multiple births without a loss in overall treatment effectiveness.

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).

Dosage escalation of antenatal steroids in preterm twin pregnancies does not improve long-term outcome

OBJECTIVES

To analyze long-term effects of antenatal betamethasone (≤16 mg, =24 mg and >24 mg) in preterm twins on infant and childhood morbidity.

METHODS

Retrospective cohort study among 198 preterm twins. Three follow up time points, including a total of 84 outcomes, were evaluated: first neonatal examination after birth and in the neonatal period up to 10 days after birth using data from the clinic charts; examination from the 21st to the 24th month of life and examination from the 60th to the 64th months, using data from copies of the children's examination booklets sent back by the parents. Dosage-dependent and sex-specific long-term effects of antenatal betamethasone treatment on neonatal, infant and early childhood development and morbidity up to 5.3 years of age were analyzed.

RESULTS

Dosage escalation of >24 mg was not associated with improved neonatal, infant or early child hood outcome, independent of twin pair structure. In contrast, higher doses >24 mg were significantly linked to increased rates of congenital infections (OR 5.867, 95% CI 1.895-18.167). Male sex as a factor was obvious for lower rates of apnea-bradycardia-syndrome in neonates, higher rates of no free steps after 15 months in infancy and highest rates of motor clumsiness in early childhood.

CONCLUSIONS

Betamethasone dosage escalation >24 mg in twins born between 23⁺⁵ and 33⁺⁶ weeks of gestation did not improve neonatal, infant or early childhood morbidity. In contrast, higher doses >24 mg total dose resulted in significantly higher rates of congenital infections and are not recommended. For males, 24 mg betamethasone appears to be the preferable dose.

Steroid metabolome and multiple pregnancy

Steroid biosynthesis occurs in adrenal, gonadal, brain, liver, and placental tissues. Depending on the location of their activity, steroids can be divided into two groups - intracellular and extracellular. Intracellular ones act as transcription factors, suppressing or activating gene expression - they have a so-called genomic effect and therefore their onset of action is slow. Steroids acting extracellularly (non-genome effect) bind to neurotransmitter receptors located on the cytoplasmic cell membrane and thus affect the permeability of the ion channels, the effect of which is much faster, and we refer to them as neuroactive steroids or neurosteroids. While neuroactive steroids can be produced in different tissues of the body, or can be administered externally, neurosteroids are synthetized in cells of the nervous system. Some neuroactive steroids whose levels are extremely elevated in pregnancy (progesterone and its metabolites) are crucial in stabilizing pregnancy and changes in their concentration may influence the onset of parturition. Steroidogenic disorders may be involved in a number of pregnancy pathologies such as premature birth, pre-eclampsia, intrahepatic cholestasis in pregnancy, etc. Our research in collaboration with the Department of Steroids and Proteofactors of the Institute of Endocrinology in Prague also focuses on the investigation of multiple pregnancies in terms of biosynthesis, transport, and the effects of steroids. Studies available in the literature so far have not provided a comprehensive analysis of the steroidome in children and mothers in multiple pregnancies. The aim of our research is therefore to clarify the relationships between fetuses and mothers and between fetuses from the point of view of steroid synthesis and transport as well as the physiology and pathophysiology of human pregnancy and childbirth.

Triple pregnancy - etiology and early diagnosis

OBJECTIVE

To provide an overview of the etiology and early dia-gnosis of triple pregnancy, with emphasis on the possibilities of ultrasound and magnetic resonance (MR) imaging.

METHODOLOGY

Processing of data from the available literature on the issue of triple pregnancy.

CONCLUSION

Spontaneous triple pregnancy conception is rare. In most cases, it is a concept associated with assisted reproduction methods. Multiple pregnancy is associated with a higher incidence of complications during pregnancy and childbirth, but it also has its own specific complications. Chorionicity and amnionicity of multiple pregnancies are two important parameters in determining the strategy of dispensary care in pregnancy and management of childbirth. The use of ultrasound and MR imaging is crucial for their accurate determination in early pregnancy.

Aspiration of excess follicles before intrauterine insemination in high response cycles

Purpose

To assess the outcome of excess follicle aspiration before intrauterine insemination (EFABI) in intrauterine insemination (IUI) cycles with 4-6 follicles ≥14 mm.

Methods

A retrospective case-control study with 1559 patients undergoing IUI (donor and husband's sperm), of whom 86 underwent EFABI. We studied also an historical series of 2213 patients before EFABI implementation. For 3.5 years, all women undergoing IUI developing 4-6 follicles ≥14 mm were offered EFABI on the day of hCG administration. Pregnancy rates (PRs), multiple PRs, and adverse effects were measured.

Results

EFABI was associated with a similar multiple PR (17.8% vs 17.5% in non-EFABI cases), with no triplets in EFABI patients. Live birth rates were significantly higher in EFABI cycles in IUI overall (25.5% vs 15.2%). When considered separately, the performance of EFABI resulted in significantly increased live birth rates in IUI-donor cycles (32.5% vs 18.5%), whereas the differences in IUI-husband cycles (19.5% vs 12.9%) did not reach statistical significance. The PR was 21.2% during the EFABI implementation period and 19.4% in the pre-EFABI period.

Conclusions

EFABI in cycles in which 4-6 follicles reach ≥14 mm is a simple option that reduces cycle cancellation rates, results in higher PRs than cycles with 1-3 follicles, and lowers the risk of multiple pregnancy.

Maternal thyroid function in multiple pregnancies - a systematic review

BACKGROUND

The function of the thyroid gland during pregnancy undergoes physiological changes to ensure the proper amount of thyroid hormones for both the pregnant woman and the fetus. Multiple pregnancies (MP) are characterized by specific differences compared to single pregnancies, e.g., higher concentrations of human chorionic gonadotropin, which also affect thyroid function. The aim was to collect available knowledge on maternal thyroid function in MP.

METHODS

We have systematically searched three databases: the PubMed/MEDLINE, Scopus and the Cochrane Library. The last search was run on the 4th of August 2022. We included full-text original observational and experimental studies written in English. Case reports, editorials, letters, conference abstracts, reviews and meta-analyses were excluded. No time criterion was established. Studies were considered eligible if at least one maternal thyroid function test was performed and reported. Studies on MP with a co-existing mole were excluded. The risk of bias was assessed with the use of the AXIS tool. The qualitative synthesis of evidence was applied.

RESULTS

The search strategy resulted in the identification of 821 manuscripts. After removing duplicates, we screened the titles and abstracts of 552 articles, out of which 57 were selected for full-text analysis. Finally, 12 articles were included in the review. They were conducted in 6 different countries and published between the years 1997 and 2022. The number of examined women with MP ranged from 9 to 1 626.

DISCUSSION AND CONCLUSIONS

Thyroid function differs between women with MP and SP. Scarce data are available on the topic, but MPs are most likely characterized by higher HCG levels, which influences thyroid-stimulating hormone and free thyroid hormone levels. These differences are mainly expressed in the 1st trimester of pregnancy. Separate population-based reference ranges are needed to correctly diagnose thyroid diseases in MP and to avoid unnecessary treatment. Further research is needed to fill the knowledge gaps.

Monochorionic monoamniotic twin pregnancies

Monoamniotic twin pregnancies are rare, but early diagnosis of such pregnancies is critical, as the incidence of complications in these pregnancies is much higher than in diamniotic or dichorionic twin pregnancies. Overall, only 70% of all monoamniotic twins will survive. Furthermore, approximately half of fetal deaths in these pregnancies are because of the high incidence of fetal anomalies (15%-25%), such as twin reversed arterial perfusion sequence and conjoined twinning. Therefore, early anatomy screening in the first trimester of pregnancy is recommended. Other causes of fetal death in these pregnancies include twin-twin transfusion syndrome, tight cord entanglement, or acute hemodynamic imbalances through the large placental vascular anastomoses. After viability, fetal surveillance can be intensified, as this decreases the risk of in utero death. Both inpatient and outpatient surveillance are reasonable. If otherwise uncomplicated, monoamniotic twins should be delivered at 33 to 34 weeks' gestation. Most centers will deliver by cesarean delivery, but some continue to advocate for vaginal delivery. Lastly, neonatal morbidity is high in monoamniotic twin pregnancies and is mainly related to prematurity.

Dispensing of clomiphene citrate to treat infertility: medication supplied and population prevalence of assisted pregnancies and multiple births

OBJECTIVE

To determine the proportion of pregnancies resulting in birth that were conceived with the use of clomiphene citrate (CC) and the frequency of multiple pregnancy.

DESIGN

Whole-of-population cohort study, constructed through data linkage. Comprehensive Australian Government records of dispensed medications were linked to state Perinatal Registry records for all births of at least 20 weeks' gestation.

SETTING

The state of South Australia.

PATIENT(S)

Women who maintained pregnancy for at least 20 weeks and gave birth between July 2003 and December 2015, a total of 150,713 women with 241,561 pregnancies.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy occurring in proximity to CC, defined as dispensing from 90 days before to the end of a conception window derived from newborn date of birth and gestational age.

RESULT(S)

Linkage to dispensed prescription records was achieved for 97.9% of women. Women who conceived with CC tended to be older and socioeconomically advantaged and more likely than other women to have a history of miscarriage. Ongoing pregnancies associated with CC comprised 1.6% of the total; 5.7% were multiple births (mostly twins, 94.6%) compared with 1.5% in the remainder (98.5% twins).

CONCLUSION(S)

In South Australia, 1.6% of pregnancies (1 in 60) of at least 20 weeks' gestation were conceived proximal to CC dispensing. Of these, 5.7% were multiple pregnancies. This takes the proportion of women who achieved an ongoing pregnancy with medical assistance from 4.4%, based on reports from assisted reproductive technology clinics, to 6% in total.

Associations of Respiratory Distress Syndrome Severity and Other Factors With Transient Hypothyroxinemia of Prematurity

Aim

This study examined the associations of respiratory distress syndrome (RDS) severity and other factors on thyroid hormone levels in very low birth weight (VLBW) infants.

Methods

The demographic characteristics, clinical course, morbidity, and initial thyroid function test results of VLBW infants diagnosed with RDS between July 2016 and September 2018 were obtained retrospectively. RDS severity was determined according to the requirement for multiple surfactants. Patients were divided into groups without and with hypothyroxinemia, and variables of interest were compared between the two groups.

Results

Our study involved 98 infants meeting the inclusion criteria; the incidence of hypothyroxinemia was 56.1%. Free T4 (fT4) levels were found to be negatively correlated with gestational week (p < 0.001) and birth weight (p < 0.001). The fT4 levels were significantly lower in infants requiring multiple surfactant doses. In infants with hypothyroxinemia, the duration of invasive mechanical ventilation and oxygen treatment was longer and hemodynamically significant patent ductus arteriosus, grade ≥ 3 intraventricular hemorrhage, and moderate to severe bronchopulmonary dysplasia were more common. Multiple pregnancy (odds ratio (OR) = 5.616, 95%; confidence interval (CI): 1.765-17.874) and the duration of invasive mechanical ventilation (OR = 1.05, 95%; CI: 1.005-1.096) were significant risk factors for the development of hypothyroxinemia in logistic regression analysis.

Conclusions

Transient hypothyroxinemia of prematurity is associated with RDS severity and early morbidities of prematurity. In the presence of multiple pregnancy, patients should be followed up more closely due to the possibility of hypothyroxinemia.

Perinatal outcome after selective termination in dichorionic twins discordant for congenital anomalies

INTRODUCTION

Our objective was to evaluate the perinatal outcome of selective termination of dichorionic twin pregnancies with discordant anomalies, according to gestational age at time of procedure.

MATERIAL AND METHODS

Retrospective review of 147 dichorionic twin pregnancies referred to our Fetal Medicine Unit between 2003 and 2018 for selective termination. Gestational age at delivery, fetal loss, and overall and 28-day post-delivery survival rates, were evaluated according to gestational age at time of procedure. Selective termination procedure was defined as early, intermediate, and late when performed before 18 weeks, between 18 and 23 weeks, and after 23 weeks, respectively. Kruskal-Wallis and chi-squared test were used to compare groups.

RESULTS

Overall survival at 28 days post-delivery, pregnancy loss, and preterm delivery before 32 weeks of gestation rates were 93.4%, 6.9%, and 15.5%, respectively. When stratified by gestational age at procedure, intermediate selective termination was associated with a lower survival rate than early and late procedures (86% vs. 96.9% and 100%, respectively; p = 0.035), and a nonsignificant trend for higher pregnancy loss (12% vs. 3.1%). Preterm delivery before 32 weeks of gestation occurred in 27% of late procedures, which was significantly higher than in early (9.5%) and intermediate (18.2%) procedures.

CONCLUSIONS

Selective termination in dichorionic twin pregnancies with discordant fetal anomaly is associated with low pregnancy loss and preterm delivery rate, primarily when performed before 18 weeks. When legally possible, late procedures can be a good alternative, particularly in those cases diagnosed beyond the 18th week of gestation.

Clinical outcomes in higher-order multiples reduced to dichorionic diamniotic (DCDA) twins compared with primary twins and singletons: A prospective observational study

OBJECTIVE

To compare outcomes in higher-order multiple pregnancies reduced to dichorionic diamniotic (DCDA) twins with primary DCDA twins and singleton pregnancies.

METHODS

This prospective observational study included all higher-order multiple pregnancies that underwent ultrasound-guided transabdominal fetal reduction at 11-13 weeks of gestation from January 2018 to June 2020. Outcomes were compared with 100 primary DCDA twins and 1078 singletons.

RESULTS

Sixty-four higher-order multiples underwent reduction at mean gestational age of 11.46 weeks. Of the reduced pregnancies, 3.12% resulted in miscarriage before 24 weeks compared with 2% (2/100) of primary twins and 0.74% of singletons (P = 0.09). The mean gestational age at delivery was 33.48 weeks for reduced twins, 34.52 weeks for primary twins (P = 0.10) and 38.14 weeks for singletons (P < 0.001). Compared with primary twins, the adjusted odds of preterm delivery before 34 weeks and before 36 weeks for reduced twins were 0.56 (95% confidence interval [CI] 0.48-3.54, P = 0.62) and 0.84 (95% CI 0.78-8.85, P = 0.08), respectively. There was no significant difference in rates of pre-eclampsia, Cesarean delivery, birth weight below the 10th and 3rd centiles, and perinatal mortality among primary and reduced twins. All risks were significantly lower in singleton pregnancies.

CONCLUSION

Reduced twins have similar obstetric and perinatal outcomes as primary twins, but adverse outcomes are significantly higher in both groups when compared with singleton pregnancies.

Mode of delivery in multiple pregnancies

The mode of delivery in multiple pregnancies has been subject to vigorous debates during the last few decades. Although observational and retrospective data were accumulated, it was not until the publication of the Twin Birth Study that evidence-based recommendations could emerge. However, although some of the most pressing questions were answered by the Twin Birth Study, other questions were left outside the scope of the study. The questions were of great interest and included the following topics: the impact of gestational age, the influence of chorionicity, and the generalizability of the results for women with a previous uterine scar. The current evidence supported a trial of labor in dichorionic-diamniotic or monochorionic-diamniotic twin pregnancies in which the first twin is in cephalic presentation at ≥32 weeks' gestation. Dichorionic-diamniotic, monochorionic-diamniotic, and monochorionic-monoamniotic twins should be delivered at 37 0/7 to 38 0/7, 36 0/7 to 37 0/7, and 32 0/7 to 34 0/7 weeks' gestation, respectively. Breech extraction done by a competent healthcare provider seemed to offer a higher chance of successful vaginal delivery of the second twin than the external cephalic version. The current data did not allow for a clear recommendation regarding the mode of delivery in very preterm birth of low birthweight twins, but most studies did not demonstrate a clear benefit of cesarean delivery vs trial of labor. Furthermore, a trial of labor seemed safe in women with a previous cesarean delivery. Cesarean delivery is likely beneficial for twin pregnancies with the first twin in breech presentation, monochorionic-monoamniotic twins, and higher-order multiple pregnancies. In all multiple pregnancies, delivery should be performed by an experienced practitioner competent in multiple pregnancy deliveries.

Outcome of radiofrequency ablation for selective fetal reduction before vs at or after 16 gestational weeks in complicated monochorionic pregnancy

OBJECTIVE

To investigate whether gestational age at intervention (< or ≥ 16 weeks) and other factors affect the risk of loss of the cotwin after selective fetal reduction using radiofrequency ablation (RFA) in monochorionic (MC) pregnancy.

METHODS

This was a single-center retrospective analysis of 63 consecutive RFA procedures performed at our institution from January 2011 to October 2019 for selective fetal reduction in complicated MC pregnancies. Indications for RFA were twin reversed arterial perfusion sequence (13 cases), twin-to-twin transfusion syndrome (12 cases), twin anemia-polycythemia sequence (two cases), selective fetal growth restriction (10 cases), discordant anomalies (17 cases) and multifetal pregnancy reduction in triplets or quadruplets with a MC pair (nine cases). Twenty-six (41.3%) of these procedures were performed before and 37 (58.7%) after 16 weeks. Potential factors that could affect the risk of loss of the cotwin, including gestational age at RFA, order of multiple pregnancy, amnionicity, indication for RFA and number of ablation cycles, were assessed first by univariate analysis and then by multivariate analysis.

RESULTS

There were 17 (27.0%) cotwin losses. Ablation cycles numbering four or more was the only factor among those investigated to be associated with loss of the cotwin after RFA (P = 0.035; odds ratio, 5.21), while the indication for RFA, order of multiple pregnancy, amnionicity and gestational age at RFA had no effect. Comparing RFA performed at < 16 vs ≥ 16 weeks, there was no difference in the rate of cotwin loss (23.1% vs 29.7%; P = 0.558) or preterm prelabor rupture of the membranes before 34 weeks (7.7% vs 5.4%; P = 0.853), or in the median gestational age at delivery (36.2 vs 37.3 weeks; P = 0.706).

CONCLUSIONS

RFA is a promising tool for early selective fetal reduction in MC pregnancy before 16 weeks. Four or more ablation cycles is a major risk factor for cotwin loss. Careful assessment pre- and post-RFA, together with proficient operative skills to minimize the number of ablation cycles, are the mainstay to ensure that this procedure is effective and safe. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.