Comparing two different placental transfusion strategies for very preterm infants at birth: a matched-pairs study

OBJECTIVE

To evaluate the clinical outcomes of using the extra-uterine placental transfusion (EPT) approach in very preterm infants (VPIs, gestational age <32 weeks) and compare this to delayed cord clamping (DCC) after birth.

METHODS

In this matched pairs study, we compared the clinical outcomes of the EPT group to those of the DCC group. EPT were performed in fifty-three VPIs, of whom 27 were singletons and 25 were twins. The singleton VPIs were matched for gestational age (±5 days) and delivery mode, and the twin VPIs were matched between each other with the first twin subjected to DCC and the second twin to EPT. Data on the infants were collected and analysed as an overall group. A twin subgroup consisting of DCC and EPT groups was also analysed separately. The primary study outcome was either death or major morbidities.

RESULTS

In total, 100 infants were included (n = 50 EPT group, n = 50 DCC group). The gestational ages of the DCC and EPT groups were (29.16 ± 1.76) and (29.12 ± 1.84) weeks, respectively. There were no differences in either deaths or major morbidities and other clinical outcomes, including the resuscitation variables, haemoglobin levels and red blood cell transfusion, between the two groups. In twin subgroups (gestational age 29.05 ± 1.89 weeks), EPT was associated with a higher rate of necrotizing enterocolitis (NEC) when compared with DCC (odds ratio = 7 (95% CI, 1.06 to 56.89), p = 0.031).

CONCLUSIONS

In twin subgroups, the incidence of NEC was higher in the EPT group when compared to the DCC group and therefore based on an abundance of caution the use of EPT in very preterm twins is not recommended.

A retrospective study investigating the association of parity, breed, calving month and year, and previous parity milk yield and calving interval with twin births in US dairy cows

Twinning costs the dairy industry an estimated $96 million each year. Twin pregnancy occurrence in high-producing dairy cows is primarily a result of multiple ovulations associated with low circulating concentrations of progesterone due to high milk production. The present retrospective observational study aimed to identify associations between (1) previous parity milk yield and subsequent twin birth prevalence, (2) twin birth with same parity milk production and calving interval (CInt), and (3) twin birth and the subsequent twin calving. The final data set included almost 2.9 million US dairy calving and production records between 2001 and 2020. Variables considered were parity, breed, milk production, CInt, calving month, and year. Logistic and linear regression modeling were used to assess the effects of predictors on outcomes. Herd within state was used as a random effect for all regression models. Twin birth probability increased for cows with increased previous parity milk yield independent of breed or parity. Third and greater parity (3+) compared with second parity (2) and all breeds compared with Jerseys were associated with greater twin probability. Calving between April and September that corresponded to conceiving in July through December was associated with greater twin birth probability. Twin births were associated with decreased milk production following the birth event in Holsteins and parity 2 cows and in the calving months between June and September. Surprisingly, twin births in parity 3+ cows were associated with an increased 305-d milk yield. Cows that had a twin birth were more likely to calve twins in the subsequent parity and had a greater risk of having a CInt between 413 and 600 d. The hazard to subsequent calving after single births was greater compared with twin births. These data can be instrumental in guiding research focus on reducing twinning in lactating dairy cows.

A rare case of heteropaternal twin calves after natural mating in Brazil

Twin birth is a complex condition observed in most livestock animals, when the female gives birth to two or more offspring, generally out of the same mating. In cattle, it is a rare condition (3 to 5%) and depends on the genetic background and environmental factors. Twin birth is a result of multiple ovulations, being more common in dairy rather than in beef cattle. Calves could be monozygous or dizygous, with the same or of different sexes. When twins are born with different sexes, a sexual condition called Freemartinism occurs in between 90 to 97% of pregnancies, causing infertility in the female calf. Knowing that the twin rate is rare in commercial beef cattle, here we present an even rarer case of twin birth from two different sires after natural mating, also called heteropaternal superfecundation.

Risk factors of unsuccessful vaginal twin delivery

INTRODUCTION

Twin trial of labor presents a challenge to obstetricians, as it is associated with a greater number of adverse birth outcomes compared with singleton deliveries. The risk of poor outcome has shown to be highest with unsuccessful vaginal twin delivery. The purpose of this study was to identify the clinical risk factors associated with intrapartum cesarean section in late preterm and term twin births.

MATERIAL AND METHODS

All live diamniotic twin deliveries of at least 35⁺⁰ weeks of gestation with planned vaginal delivery were included in this retrospective single-center cohort study. Maternal and newborn characteristics were compared between a vaginal delivery group and an intrapartum cesarean section group. Logistic regression analysis was carried out to determine independent risk factors of intrapartum cesarean section. Further, maternal and neonatal outcomes were compared between groups of vaginal delivery and cesarean section for both twins and also between groups of vaginal delivery and cesarean section for the second twin only (combined delivery). The impact of presentation of the second twin on the mode of twin delivery and on neonatal outcome was also examined.

RESULTS

Among 821 twin pregnancies, 581 mothers (70.8%) attempted trial of labor and were eligible for the study. With a cephalic-presenting first twin, the trial of labor rate was 89.3% and vaginal delivery was successful in 82.8%. Nulliparity (odds ratio [OR] 3.2, 95% confidence interval [CI] 2.0-5.1) and non-cephalic presentation of the second twin (OR 3.0, 95% CI 1.9-4.8) were found to be independent risk factors of cesarean section. However, 76.1% of mothers with non-cephalic second twins achieved vaginal delivery and perinatal outcomes were comparable with cases of cephalic-presenting second twins. When comparing delivery modes, maternal outcomes were more favorable with vaginal delivery, whereas combined delivery increased the second twin's risk of adverse neonatal outcome.

CONCLUSIONS

This study, with high rates of trial of labor and successful vaginal twin delivery, found nulliparity and non-cephalic presentation of the second twin to be risk factors of intrapartum cesarean section in twin pregnancies.

Mode of birth in twins: data and reflections

Our primary objective was to compare neonatal and maternal outcomes in women with twin pregnancies, beyond 32 weeks, having a planned vaginal birth or a planned caesarean section (CS). This was a retrospective cohort study from a single tertiary centre over nine years. 534 sets of twins ≥32 + 0 weeks of gestation were included. 401 sets were planned vaginally and 133 sets were planned by CS. We compared a composite adverse perinatal outcome (perinatal mortality or serious neonatal morbidity; five minute APGAR score ≤4, neurological abnormality and need for intubation) and a composite maternal adverse outcome (major haemorrhage, trauma or infection) between the groups. There were no significant differences. Given the similarity of these results with several other larger studies of twin birth, we sought to look at reasons why there is still a rising rate of CS for twin births. We further make suggestions for keeping this rate to a sensible minimum. Impact statement What is already known on this subject? The largest randomised controlled study comparing planned vaginal birth with planned CSs for lower risk twins between 32 and 39 weeks of gestation, showed no added safety from planned CS. However, in most of the Western countries this conclusion has failed to increase the number of planned vaginal births for lower risk twins. What do the results of this study add? This observational study from a single tertiary centre provides external validation of the twin trial results in a practical day-to-day setting. It also provides insights as to how planned vaginal birth can be developed and maintained, with a key focus on safety and maternal participation in decision making. It does focus on consent and providing accurate data. What are the implications of these findings for clinical practice and/or further research? There are good grounds to encourage vaginal birth for low-risk twin pregnancies. The trend of rising caesarean rates in low-risk twin pregnancies worldwide will erode important skills for the conduct of vaginal births without any clear benefit for mothers or babies. The current situation demands careful thought about implementing innovative training opportunities for younger obstetricians. Finally, we need intelligent responses to many non-evidence-based factors which can drive clinical practice.

Embryo cryopreservation and preeclampsia risk

OBJECTIVE

To determine whether assisted reproductive technology (ART) cycles involving cryopreserved-warmed embryos are associated with the development of preeclampsia.

DESIGN

Retrospective cohort study.

SETTING

IVF clinics and hospitals.

PATIENT(S)

A total of 15,937 births from ART: 9,417 singleton and 6,520 twin.

INTERVENTION(S)

We used linked ART surveillance, birth certificate, and maternal hospitalization discharge data, considering resident singleton and twin births from autologous or donor eggs from 2005-2010.

MAIN OUTCOME MEASURE(S)

We compared the frequency of preeclampsia diagnosis for cryopreserved-warmed versus fresh ET and used multivariable logistic regression to adjust for confounders.

RESULT(S)

Among pregnancies conceived with autologous eggs resulting in singletons, preeclampsia was greater after cryopreserved-warmed versus fresh ET (7.51% vs. 4.29%, adjusted odds ratio = 2.17 [95% CI 1.67-2.82]). Preeclampsia without and with severe features, preeclampsia with preterm delivery, and chronic hypertension with superimposed preeclampsia were more frequent after cryopreserved-warmed versus fresh ET (3.99% vs. 2.55%; 2.95% vs. 1.41%; 2.76 vs. 1.48%; and 0.95% vs. 0.43%, respectively). Among pregnancies from autologous eggs resulting in twins, the frequency of preeclampsia with severe features (9.26% vs. 5.70%) and preeclampsia with preterm delivery (14.81% vs. 11.74%) was higher after cryopreserved versus fresh transfers. Among donor egg pregnancies, rates of preeclampsia did not differ significantly between cryopreserved-warmed and fresh ET (10.78% vs. 12.13% for singletons and 28.0% vs. 25.15% for twins).

CONCLUSION(S)

Among ART pregnancies conceived using autologous eggs resulting in live births, those involving transfer of cryopreserved-warmed embryos, as compared with fresh ETs, had increased risk for preeclampsia with severe features and preeclampsia with preterm delivery.

Exploring Women's Preferences for the Mode of Delivery in Twin Gestations: Results of the Twin Birth Study

OBJECTIVE

The Twin Birth Study, an international, multi-center randomized controlled trial was conducted to compare the risks of planned cesarean with planned vaginal delivery for twin pregnancies. The aim of this component of the trial was to understand participants' perspectives of study participation and preferences for the mode of delivery.

METHODS

A mixed-methods questionnaire was distributed to study participants 3 months after giving birth. The questionnaire contained Likert scales and open-ended questions about the experience of being enrolled in a clinical trial and of childbirth, including the mode of delivery. Quantitative data were analyzed using SAS to generate descriptive statistics. Qualitative data were analyzed to identify categories and themes.

RESULTS

Ninety-one percent of trial participants completed the questionnaire. Across all groups, the majority of women would participate in a study like this one again if given the opportunity. Main benefits of participating were as follows: benefits to one and one's babies, altruism, and receiving quality care. Randomization for the mode of delivery was challenging for women because of the desire to be involved in decision-making. Findings related to childbirth experience and the mode of delivery demonstrated a preference for vaginal birth across all groups. Those who had a vaginal birth were more satisfied with their birth experience.

CONCLUSIONS

This study provides evidence to inform practitioners about what women who have twin pregnancies like or dislike about birth and their desire for involvement in decision-making. Vaginal birth was preferred across all study groups and was associated with greater satisfaction with childbirth experience.

Twin Birth Considering the Current Results of the "Twin Birth Study"

The rate of caesarean sections in multiple births has grown sharply worldwide. The reason for this may be the results of large retrospective cohort studies from the 1990s, which displayed an increased risk of mortality and morbidity, especially for the second twin, in the case of vaginal births. Multiple monocentric analyses have not been able to confirm this. As a prospective, multi-centre randomised study, the Twin Birth Study published in 2013, in which 105 clinics in 25 countries took part, showed that, under optimum conditions, there was no difference in neonatal and maternal mortality and morbidity if the birth was planned to be vaginal or via caesarean. Detailed analyses, which would be helpful in choosing the type of birth method and obstetric management in the event of vaginal birth, have not previously been published. Retrospective studies must be referred to for this.

Genetic analysis of twinning rate and milk yield using a threshold-linear model in Japanese Holsteins

The objective of this study was to estimate genetic parameters and breeding values for the twinning rate of the first three parities (T1, T2 and T3) and 305-day milk yield in first lactation (MY), using a four-trait threshold-linear animal model in Japanese Holsteins. Data contained 1 323 946 cows calving between 1990 and 2007. Twinning was treated as a binary character: 'single' or 'twin or more'. Reported T1, T2 and T3 were 0.70%, 2.87%, and 3.73%, respectively. Individual 305-day milk yield was computed using a multiple trait prediction for cows with at least eight test-day records. (Co)variance components were estimated via Gibbs sampling for randomly sampled subsets. Posterior means of heritabilities for T1, T2 and T3 were 0.11, 0.16 and 0.14, respectively. Genetic correlations between parities were 0.92 or greater. Genetic correlations of MY with twinning rate were not 'significant' (i.e. their 95% highest probability density intervals contained zeros). Multiple births at different parities were considered as the same genetic trait. The average evaluations of T1 (T2) for sires born before 1991 was 0.48% (2.25%) compared with a mean of 0.76% (3.37%) for sires born after 1992. A recent increase in the reported twinning rate reflects the positive genetic trend for sires in Japanese Holsteins.

Impact of monozygotic twinning on multiple births resulting from in vitro fertilization in the United States, 2006-2010

OBJECTIVE

To determine the contribution of monozygotic twining to in vitro fertilization multiple births.

STUDY DESIGN

We performed a retrospective analysis of the incidence of monozygotic twining in multiple births resulting from fresh embryo transfers using 2006-2010 data from the Society for Reproductive Technology Clinic Outcome Reporting System.

RESULTS

The number of embryos transferred were fewer than the number of births in 0.5% (223/40950) of twin, 29% (659/2289) of triplet, and 64% (43/67) of quadruplet births resulting from transfer of fresh embryos from 2006 to 2010. In 2010, 37% of triplets and 100% of quadruplet births occurred when fewer than 3 and fewer than 4 embryos respectively were transferred.

CONCLUSION

Monozygotic twinning plays a key role in the development of triplet and quadruplet pregnancies achieved through in vitro fertilization.

Intimate partner violence and the association with very preterm birth

BACKGROUND

Intimate partner violence is a major public health problem. It occurs commonly in pregnancy, resulting in adverse events for women and their fetus or children. The objective of this study was to examine the association between intimate partner violence and very preterm birth.

METHODS

This population-based, case-control study was conducted in Victoria, Australia, from 2002 to 2004. Interviews were conducted with 603 women who had a singleton very preterm birth (20-31 weeks' gestation), 770 women who had a singleton term birth (37 or more completed weeks' gestation), 139 women who had a very preterm twin birth, and 214 women who had a term twin birth. Intimate partner violence was measured using the Composite Abuse Scale, and questions were also asked about fear of partners and violence from others.

RESULTS

Prevalence of intimate partner violence in the past 12 months was 14.9 percent in singleton case women, 11.7 percent in singleton control women, 9.5 percent in twin case women, and 14.7 percent in twin control women. Fear of a previous partner and reporting similar violence experience with someone else were more likely in singleton births (AOR = 1.36; 95% CI 1.03, 1.79) and (AOR = 1.44; 95% CI 1.12, 1.86), respectively. No differences between twin case women and twin control women were observed. When the precipitating cause of very preterm birth was investigated, antepartum hemorrhage was significantly associated with intimate partner violence and all its subscales.

CONCLUSIONS

The heterogeneity of causes of very preterm birth may explain the lack of association found with intimate partner violence in pregnancy. Pregnant women have a significant risk of intimate partner violence, which should be a serious concern for all care providers.