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OBJECTIVE: There is a lack of consensus about the management of twins with significant cervical length (CL) shortening, especially if CL is above 25 mm. Therefore, it is important to define "abnormal" CL change over time, and to compare the performance of different strategies. The aim of this study was twofold, to describe the performance of the cervical shortening and that of an integrated strategy that includes both the cervical shortening and a fixed CL cutoff <25 mm in any measurement as predictor of spontaneous PTB (sPTB) < 34 weeks in uncomplicated twin pregnancies. MATERIAL AND METHODS: Retrospective cohort study of twins followed in our Twins Clinic at Hospital Italiano de Buenos Aires from 2013 to 2017. Inclusion criteria were dichorionic or monochorionic diamniotic twins with CL measurement between 18 and 33 + 6 weeks with available data of the delivery. Exclusion criteria included any of the following complications: iatrogenic preterm delivery <34 weeks, cerclage, fetal growth restriction, fetal death, structural anomalies, polyhydramnios, twin-twin transfusion syndrome, selective fetal growth restriction, twin anemia-polycythemia sequence, and twin reversed arterial perfusion sequence. Spontaneous preterm birth was defined as spontaneous delivery <34 weeks. Cervical shortening was analyzed in the following periods: 20-24 weeks, 20-28 weeks, 24-28 weeks, 24-32 weeks and 28-32 weeks. Cervical changes were analyzed as velocity of shortening over time (mm/week) and as the ratio of shortening over time (%/week). ROC curves for each period were constructed and two different cutoffs were used to classify changes of the CL as positive or negative screening: a) the shortening of CL associated to the highest value of the Youden Index and b) fixing a 10% false positive rate (FPR). For the second objective, we analyzed an integrated strategy considering a fixed cutoff of 25 mm at any GA and/or a significant shortening. The screening was considered positive if any CL measurement was <25 mm at any GA or there was a shortening of the CL ≥ the cutoff obtained for each period. We report sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio and area under the ROC curve. RESULTS: We included 378 patients and 1417 measurements, 284 (75%) dichorionic and 94 (25%) monochorionic. Between 20 and 28 weeks, with a change in CL cutoff = 1.6 mm/week or 4.1%/week the detection rate was 54.2% (32.8-74.4%) and the specificity 80.5% (75.1-85.1%) and 83.5% (78.5-87.8%) respectively. In the integrated strategy, the detection rate was 65.7% (47.8-80.9%) and the specificity 69 (63.7-74). All the ROC curves of the periods studied showed an AUC < 0.7. In the group of patients that delivered preterm the initial mean CL was shorter than in the term group, 39 (±12) mm vs. 43 (± 7.7) mm (p = .02) and the most important change in CL was at 20-24 weeks both in the velocity and in the ratio of shortening over time. Conversely, patients that delivered at term showed a higher change in CL in the third trimester. CONCLUSION: The performance of all the strategies analyzed as a predictor of sPTB <34 weeks was moderate. The period 20-28 weeks detected half of the patients at risk with a FPR around 10-20% and the integrated strategy increased the sensitivity up to a detection of two thirds of the patients at risk but with a FPR of â¼30%. Future analyses need to explore other strategies to improve the performance and to really identify the patients at higher risk.
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Nascimento Prematuro , Incompetência do Colo do Útero , Gravidez , Feminino , Humanos , Recém-Nascido , Nascimento Prematuro/diagnóstico , Nascimento Prematuro/etiologia , Estudos Retrospectivos , Retardo do Crescimento Fetal , Medida do Comprimento Cervical , Gravidez de GêmeosRESUMO
OBJECTIVE: While cervical length (CL) provides an effective screening tool for spontaneous preterm birth in singletons, the performance in twins is still controversial. Our aim was twofold. First, to compare the performance of a single CL measurement at mid-gestation (â¼20 weeks) versus serial measurements as a predictor of spontaneous preterm birth < 34 weeks in uncomplicated twin pregnancies. Second, to describe the performance of a single CL at â¼24, â¼28 and â¼32 weeks. MATERIAL AND METHODS: cohort study of twins followed at Hospital Italiano de Buenos Aires from 2013 to 2017. Inclusion criteria were dichorionic or monochorionic diamniotic twins with CL measurement between 18 and 33 + 6 weeks with available data of the delivery. Exclusion criteria included any of the following complications: iatrogenic preterm delivery <34 weeks, cerclage, fetal growth restriction, fetal death, structural anomalies, polyhydramnios, twin-twin transfusion syndrome, selective fetal growth restriction, twin anemia-polycythemia sequence, and twin reversed arterial perfusion sequence. Spontaneous preterm birth was defined as spontaneous delivery < 34 weeks. Two different cutoffs were used to classify CL as short (positive screening) or normal (negative screening): (a) a fixed cutoff of 25 mm at any gestational age (GA). The screening was considered positive if any CL measurement was <25 mm; and (b) a GA adjusted cutoff to a 10% false positive rate (FPR). The 10% FPR for each GA was calculated and the screening was considered positive if any of the CL measurements were below this 10% FPR cutoff. We report sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio and area under the ROC curve. RESULTS: Among 777 twins followed in our Unit, 381 met exclusion criteria and 18 were excluded due to incomplete follow-up. We included 378 patients, 284 (75%) dichorionic and 94 (25%) monochorionic. The performance of one CL at 20 weeks showed a sensitivity ≤ 20% with an area under the ROC curve of 0.58 (95% CI, 0.45-0.70), while the performance of serial measurements showed a sensitivity of 58.8% (95% CI, 40.7-75.4) with an area under the ROC curve of 0.70 (95% CI, 0.61-0.79) (p < .001). The analyses of the performance of a single CL at â¼24, â¼28 and â¼32 weeks showed similar AUC than the serial measurements and, for a FPR = 10%, the performance of one measurement at 24 and 32 weeks showed a sensitivity of 30% (95% CI, 14.7-49.4) and 31.6% (95% CI, (12.6-56.6), while the measurement at 28 weeks showed a sensitivity of 48.3% (95% CI, (29.4-67.5). CONCLUSION: Serial measurements showed a better performance than a single one in mid-gestation. Moreover, among single measurements the CL in mid-gestation showed the poorest performance, while the 28 weeks assessment detected half of the preterm deliveries. However, all the strategies showed modest performances.
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Nascimento Prematuro , Medida do Comprimento Cervical , Estudos de Coortes , Feminino , Retardo do Crescimento Fetal , Idade Gestacional , Humanos , Recém-Nascido , Gravidez , Gravidez de GêmeosRESUMO
OBJECTIVE: To determine whether deferred cord clamping (DCC) compared with early cord clamping (ECC) was associated with reduction in death and/or severe neurologic injury among twins born at <30 weeks of gestation. STUDY DESIGN: We performed a retrospective cohort study including all liveborn twins of <30 weeks admitted to a tertiary-level neonatal intensive care unit (NICU) in Canada between 2015 and 2018 using the Canadian Neonatal/Preterm Birth Network database. We compared DCC ≥30 seconds vs ECC <30 seconds. Our primary outcome was a composite of death and/or severe neurologic injury (severe intraventricular hemorrhage grade III/IV and/or periventricular leukomalacia). Secondary outcomes included neonatal morbidity and health care utilization outcomes. We calculated aORs and ß coefficients for categorical and continuous variables, along with 95% CI. Models were fitted with generalized estimated equations accounting for twin correlation. RESULTS: We included 1597 twins (DCC, 624 [39.1%]; ECC, 973 [60.9%]). Death/severe neurologic injury occurred in 17.8% (n = 111) of twins who received DCC and in 21.7% (n = 211) of those who received ECC. The rate of death/severe neurologic injury did not differ significantly between the DCC and ECC groups (aOR 1.07; 95% CI, 0.78-1.47). DCC was associated with reduced blood transfusions (adjusted ß coefficient, -0.49; 95% CI, -0.86 to -0.12) and NICU length of stay (adjusted ß coefficient, -4.17; 95% CI, -8.15 to -0.19). CONCLUSIONS: The primary composite outcome of death and/or severe neurologic injury did not differ between twins born at <30 weeks of gestation who received DCC and those who received ECC, but DCC was associated with some benefits.
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Parto Obstétrico/métodos , Doenças do Prematuro/mortalidade , Cordão Umbilical , Adulto , Canadá , Constrição , Bases de Dados Factuais , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Gravidez , Estudos Retrospectivos , Fatores de Tempo , GêmeosRESUMO
Background: Despite improvements in fetal survival for pregnancies affected by twin-twin transfusion syndrome since the introduction of laser photocoagulation, prematurity remains a major source of neonatal morbidity and mortality. Objective: To investigate the indications and factors influencing the timing of delivery following laser treatment, we collected delivery information regarding twin-twin transfusion syndrome cases in a large multicenter cohort. Study Design: Eleven North American Fetal Therapy Network (NAFTNet) centers conducted a retrospective review of twin-twin transfusion syndrome patients who underwent laser photocoagulation. Clinical, demographic and ultrasound variables including twin-twin transfusion syndrome stage, and gestational age at treatment and delivery were recorded. Primary and secondary maternal and fetal indications for delivery were identified. Univariate analysis was used to select candidate variables with significant correlation with latency and GA at delivery. Multivariable Cox regression with competing risk analysis was utilized to determine the independent associations. Results: A total of 847 pregnancies were analyzed. After laser, the average latency to delivery was 10.11 ± 4.8 weeks and the mean gestational age at delivery was 30.7 ± 4.5 weeks. Primary maternal indications for delivery comprised 79% of cases. The leading indications included spontaneous labor (46.8%), premature rupture of membranes (17.1%), and placental abruption (8.4%). Primary fetal indications accounted for 21% of cases and the most frequent indications included donor non-reassuring status (20.5%), abnormal donor Dopplers (15.1%), and donor growth restriction (14.5%). The most common secondary indications for delivery were premature rupture of membranes, spontaneous labor and donor growth restriction. Multivariate modeling found gestational age at diagnosis, stage, history of prior amnioreduction, cerclage, interwin membrane disruption, procedure complications and chorioamniotic membrane separation as predictors for both gestational age at delivery and latency. Conclusion: Premature delivery after laser therapy for twin-twin transfusion syndrome is primarily due to spontaneous labor, preterm premature rupture of membranes and non-reassuring status of the donor fetus. Placental abruption was found to be a frequent complication resulting in early delivery. Future research should be directed toward the goal of prolonging gestation after laser photocoagulation to further reduce morbidity and mortality associated with twin-twin transfusion syndrome.
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Terapias Fetais , Transfusão Feto-Fetal , Terapia a Laser , Feminino , Transfusão Feto-Fetal/cirurgia , Fetoscopia , Humanos , Recém-Nascido , Terapia a Laser/efeitos adversos , Placenta , Gravidez , Estudos Retrospectivos , Estados UnidosRESUMO
Resumen Antecedentes: el embarazo molar coexistente con un feto vivo es una rareza y un reto médico porque se asocia con complicaciones maternas graves que ponen en riesgo la vida de la madre y su hijo. Casos clínicos: Caso 1: paciente con embarazo gemelar, con mola completa coexistente con feto vivo y terminación del embarazo por cesárea a las 33 semanas, nació una niña viva, de 1530 g, que sobrevivió sin complicaciones. Caso 2: paciente con mola parcial, embarazo complicado con preeclampsia severa, hipertiroidismo y placenta previa. La gestación se interrumpió por cesárea a las 24 semanas, el feto pesó 625 g y no sobrevivió a las maniobras de reanimación neonatal. Conclusiones: en las pacientes con embarazo molar coexistente con feto vivo deben valorarse las complicaciones presentes o potenciales que condicionan el riesgo de muerte materna y perinatal. La atención médica debe ser multidisciplinaria y siempre de común acuerdo con los padres.
Abstract Background: Coexistance of molar pregnancy and alive fetus is an extremely rare condition but a medical challenge when it is present. Several maternal medical complications are associated with these pregnancies including both mother and fetus life-threatening conditions. Clinical case: Two cases of molar pregnancies are presented in this paper. First was a twin pregnancy with a complete hydatidiform coexisting with a live fetus and cesarean birth at 33 weeks of gestation of a live female weighing 1,530 g. that survived without complications. Second case was an incomplete mole complicated with severe pre-eclampsia, hypertiroidism, and placenta previa; pregnancy was interrupted at 24 weeks of gestation and a fetus weighing 625 g was extracted by cesarean section, the neonate did not survive. Conclusion: In the presence of molar pregnancy coexisting with a live viable fetus, the present or potential complications that determine the risk of maternal and perinatal death, must be carefully assessed. A third-level perinatal facilities must be available for this kind of pregnancy complication.
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Introducción: Los recién nacidos de los embarazos múltiples se consideran de alto riesgo, debido a que estos tienen un mayor impacto en los sistemas de salud, por la mayor frecuencia de complicaciones. Objetivo: Describir los recién nacidos de embarazos múltiples en 3 hospitales de Paraguay desde el año 2014 al 2016. Materiales y Métodos: Estudio observacional, descriptivo, de corte transversal. Formulario electrónico que contenía las variables de interés, respecto a la madre y los recién nacidos. El análisis se realizó con Stata v.14.0. Resultados: Fueron incluidos 407 recién nacidos, producto de 202 pacientes con embarazo múltiple natural, de las cuales 199 fueron embarazos dobles, 3 triples; la mediana de edad de la madre fue de 26 años, el 59,71% (120) estaba en unión libre. El 63,95% (128) tenían un control prenatal insuficiente. El 53% (106) presentó ITU y 18% (36) HTA asociada al embarazo. El 81,57% (164) de los partos fue por cesárea. El 55,28% (225) fueron del sexo femenino, la mediana de los pesos fue de 2250 gr. El 49.39% (201) nació entre 31 y 36 semanas, y 11,55%(47) menor a 30 semanas. El 98,77% (402) no presentó malformaciones. El 46,40% (187) fueron sanos, mientras que el 28,78% (116) presentó EMH, y 18% (73) asociado a Sospecha de Sepsis. La Mortalidad neonatal fue 14,25% (58). Conclusión: La incidencia de embarazos gemelares fue de 1,1 por cada 100 recién nacidos vivos. La mayoría nació en la semana 35 de gestación, resolviéndose primordialmente por vía cesárea, con un deficiente control prenatal en un 64% de las embarazadas. Los productos nacieron con un peso promedio de 2200 gr. La morbilidad más importante fue la EMH y la Sepsis Precoz, llegando a defunciones del orden del 14,25%.
Introduction: Newborns of multiple gestations pregnancies are considered to be high risk, as they consume greater health system resources, due to the greater frequency of complications. Objective: To describe newborns of multiple gestation pregnancies in 3 hospitals in Paraguay from 2014 to 2016. Materials and Methods: This was an observational, descriptive and cross-sectional study. We used an electronic form that tracked the variables of interest, regarding the mother and newborns. The analysis was performed using Stata v.14.0. Results: A total of 407 newborns, the products of 202 patients with natural multiple gestation pregnancies, were included, of which 199 were double pregnancies and 3 were triples; the median age of the mothers was 26 years. 59.71% (120) were in free unions. 63.95% (128) had insufficient prenatal control. 53% (106) presented UTI and 18% (36) had hypertensive disease of pregnancy. 81.57% (164) of deliveries were by cesarean section. 55.28% (225) were female, the median of the weights was 2250 gr. 49.39% (201) were born between 31 and 36 weeks gestation, and 11.55% (47) were delivered at less than 30 weeks gestation. 98.77% (402) did not present malformations. 46.40% (187) were healthy, whereas 28.78% (116) presented HMD, and 18% (73) underwent evaluation for Sepsis. Neonatal mortality was 14.25% (58). Conclusion: The incidence of twin pregnancies was 1.1 per 100 live births. The majority was born in the 35th week of gestation, being delivered mainly by cesarean section, with deficient prenatal control noted in 64% of the pregnant women. Infants weighed an average of 2200 grams at birth. The most important morbidity were HMD and Neonatal Sepsis, reaching deaths in 14.25%.
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OBJECTIVE: The objective of the present study was to evaluate adverse perinatal outcome in a group of high order pregnancies pared with singletons by BW and GA at birth. METHODS: Data was reviewed for all admissions of triplets and quadruplets in a 7 year period. For each study neonate we selected two singleton infants to constitute a control group. Variables analyzed included: respiratory distress syndrome, patent ductus arteriosus, intraventricular hemorrhage, necrotizing enterocolitis (NEC), bronchopulmonary dysplasia, retinopathy of prematurity and periventricular leukomalacia. RESULTS: We studied a total of 128 multiple and 260 singleton infants. Mean gestational age and birth weight were similar in both groups (31.3 ± 2,5 wks e 31.5 ± 2,8 wks; 1470 ± 461âg vs 1495 ± 540âg). There was no significant difference between the groups in the majority of main morbidities. The incidence of NEC was higher in triplets (6.3 vs 0.8%, p value <0.01). Mortality was higher in singletons (9.6 vs 3.1%, p value <0.037). CONCLUSIONS: Results show that major neonatal outcomes are very similar between multiples and singletons births when paired by gestational age and birth weight. NEC remained a significant morbidity in infants born from multiple gestations after adjustment for maternal and neonatal risk factors.
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Maternidades , Doenças do Prematuro/epidemiologia , Resultado da Gravidez , Gravidez Múltipla/estatística & dados numéricos , Trigêmeos/estatística & dados numéricos , Peso ao Nascer , Brasil/epidemiologia , Displasia Broncopulmonar/epidemiologia , Displasia Broncopulmonar/terapia , Permeabilidade do Canal Arterial/epidemiologia , Permeabilidade do Canal Arterial/terapia , Enterocolite Necrosante/epidemiologia , Enterocolite Necrosante/terapia , Feminino , Idade Gestacional , Maternidades/estatística & dados numéricos , Humanos , Recém-Nascido , Doenças do Prematuro/terapia , Terapia Intensiva Neonatal/estatística & dados numéricos , Leucomalácia Periventricular/epidemiologia , Leucomalácia Periventricular/terapia , Gravidez , Síndrome do Desconforto Respiratório do Recém-Nascido/epidemiologia , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Estudos RetrospectivosRESUMO
La muerte fetal única en el contexto de una gestación múltiple es un evento poco frecuente pero con severas consecuencias para el cogemelo. Es más frecuente en el primer trimestre, denominándose el cuadro clínico como feto evanescente, pudiendo afectar el normal desarrollo del otro feto. El entendimiento de la complejidad de las anastomosis vasculares en la gestación monocorial ha ayudado a dilucidar la fisiopatología de la muerte fetal y del daño cerebral, siendo la explicación la exsanguíneo transfusión de un gemelo a otro. Ello determina la probabilidad de muerte del feto sobreviviente y/o daño neurológico, que están estrechamente relacionados a la edad gestacional de ocurrencia del evento, prematuridad al nacimiento y monocorionicidad. Estos casos exigen un seguimiento individualizado del feto sobreviviente, con neurosonografía y resonancia magnética.
Single twin demise in the context of multiple pregnancy is rare but with severe consequences for the other twin. This event is more common in the first trimester and is clinically called vanishing twin; it may affect the normal development of the other twin. Understanding the complexity of vascular anastomosis in monochorionic gestation has helped to elucidate the pathophysiology of fetal death and brain damage, explained by exchange transfusion from one twin to the other, and determining the probability of death of the surviving fetus and neurological damage related to gestational age of occurrence, premature birth and monochorionicity. These cases require individual monitoring of the su rviving fetus, neurosonography and magnetic resonance imaging.
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OBJECTIVE: To determine if early pregnancy serum biomarkers in high-risk women who develop preeclampsia vary according to risk factor. STUDY DESIGN: We performed a secondary analysis of the Maternal-Fetal Medicine Units Network randomized controlled trial of low-dose aspirin for the prevention of preeclampsia in high-risk women. Serum biomarker levels at enrollment (before initiation of aspirin or placebo) were compared between women who did and did not develop preeclampsia, both for the group as a whole and within each of 4 high-risk groups (insulin-dependent diabetes, hypertension, multiple gestation, and previous preeclampsia) using a regression model adjusting for gestational age at collection and prepregnancy body mass index. RESULTS: 1258 women were included (233 with insulin-dependent diabetes, 387 with chronic hypertension, 315 with a multiple gestation, 323 with previous preeclampsia). Multiple early pregnancy serum biomarkers differed between women who did and did not develop preeclampsia. Each high-risk group had a unique and largely nonoverlapping pattern of biomarker abnormality. Differences between those who did and did not develop preeclampsia were noted in vascular cell adhesion molecule in the diabetes group; human chorionic gonadotropin, soluble tumor necrosis factor receptor-2, tumor necrosis factor-alpha, selectin and angiogenin in the chronic hypertension group; interleukin-6, placental growth factor, soluble fms-like tyrosine kinase plus endoglin to placental growth factor ratio in the multiple gestation group; and angiogenin in the previous preeclampsia group. CONCLUSION: Patterns of serum biomarkers vary by high-risk group. These data support the hypothesis that multiple pathogenic pathways lead to the disease recognized clinically as preeclampsia.