Perinatal outcomes of twin pregnancies affected by early twin‐twin transfusion syndrome: A systematic review and meta‐analysis

Introduction Twin‐to‐twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity if not treated. However, the optimal timing and management in case of early (occurring < 18 weeks) TTTS has not been established yet. Material and methods This is a systematic review and meta‐analysis aiming at evaluating the outcomes of monochorionic diamniotic twin pregnancies complicated by early (ie before 18 weeks) TTTS according to different management options (expectant, laser therapy, amnioreduction or cord occlusion). The primary outcome was mortality, including single and double intrauterine, neonatal and perinatal death. Secondary outcomes were: composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (defined as survival free from neurological complications) and preterm birth < 32 weeks of gestation. All outcomes were reviewed according to the different management options (expectant, laser therapy, amnioreduction or cord occlusion) and reported FOR the overall population of twins, and for the donor and recipient separately. Subgroup analysis for TTTS occurring before 16 weeks of gestation was performed. Random‐effect meta‐analyses of proportions were used to analyse the data. Results Thirteen studies were included. Early TTTS occurred in 14.3% (95% confidence interval [CI] 11.9‐17.0) of cases. The incidence of intrauterine death was 19.0% (95% CI 2.6‐45.5) in twins managed expectantly, 32.4% (95% CI 16.5‐50.7) in those who received laser treatment and 12.5% (95% CI 4.8‐23.0) in those treated with amnioreduction. The incidence of neonatal death was 22.6% (95% CI 4.2‐49.8) in twins managed expectantly, 24.7% (95% CI 0.5‐80.3) in those who received laser and 20.2 (95% CI 5.8‐43.4) in those who had amnioreduction; it was not possible to compute the incidence of these outcomes in twins undergoing cord occlusion because of insufficient sample and lack of reporting of most of the observed outcomes. Overall, the incidence of perinatal death was 43.9% (95% CI 5.9‐87.7) in twins managed expectantly, 47.3% (95% CI 21.4‐70.0) in those treated with laser and 28.5% in those who had amnioreduction. Conclusions Twin pregnancies affected by early TTTS are at substantial risk of perinatal mortality and morbidity; however, the data come from very small studies with a high risk of selection bias

SARS-CoV-2 infection in pregnancy: A systematic review and meta-analysis of clinical features and pregnancy outcomes.

Background: Perform a systematic review and meta-analysis of SARS-CoV-2 infection and pregnancy. Methods: Databases (Medline, Embase, Clinicaltrials.gov, Cochrane Library) were searched electronically on 6th April and updated regularly until 8th June 2020. Reports of pregnant women with reverse transcription PCR (RT-PCR) confirmed COVID-19 were included. Meta-analytical proportion summaries and meta-regression analyses for key clinical outcomes are provided. Findings: 86 studies were included, 17 studies (2567 pregnancies) in the quantitative synthesis; other small case series and case reports were used to extract rarely-reported events and outcome. Most women (73.9%) were in the third trimester; 52.4% have delivered, half by caesarean section (48.3%). The proportion of Black, Asian or minority ethnic group membership (50.8%); obesity (38.2%), and chronic co-morbidities (32.5%) were high. The most commonly reported clinical symptoms were fever (63.3%), cough (71.4%) and dyspnoea (34.4%). The commonest laboratory abnormalities were raised CRP or procalcitonin (54.0%), lymphopenia (34.2%) and elevated transaminases (16.0%). Preterm birth before 37 weeks' gestation was common (21.8%), usually medically-indicated (18.4%). Maternal intensive care unit admission was required in 7.0%, with intubation in 3.4%. Maternal mortality was uncommon (~1%). Maternal intensive care admission was higher in cohorts with higher rates of co-morbidities (beta=0.007, p<0.05) and maternal age over 35 years (beta=0.007, p<0.01). Maternal mortality was higher in cohorts with higher rates of antiviral drug use (beta=0.03, p<0.001), likely due to residual confounding. Neonatal nasopharyngeal swab RT-PCR was positive in 1.4%. Interpretation: The risk of iatrogenic preterm birth and caesarean delivery was increased. The available evidence is reassuring, suggesting that maternal morbidity is similar to that of women of reproductive age. Vertical transmission of the virus probably occurs, albeit in a small proportion of cases. Funding: N/A

Effect of Different Musical Types on Patient\u27s Relaxation, Anxiety and Pain Perception During Shock Wave Lithotripsy: A Randomized Controlled Study

PURPOSE: The aim of this study was to investigate the effects of listening to different music types during extracorporeal shock wave lithotripsy (SWL) on the patients\u27 pain control, anxiety level, and satisfaction. MATERIALS AND METHODS: This study was a prospective single-blinded, paral-lel-group randomized clinical trial with balanced ran-domization [1:1]. A total of 150 patients who underwent first-session SWL were included in the study. The patients were randomly divided in to five groups (30 participants in each group) as follows: headphones were not put on and no music was played in Group 1 (control group); headphones were put on but no music was played in Group 2; Turkish art music was listened to with headphones in Group 3; Western classical music was listened to with headphones in Group 4; thetype of music the patient liked was listened to with headphones in Group 5. Demographic data related to patients and procedure, State-Trait Anxiety Inventory-State Anxiety (STAI-SA), Visual Analog Scale (VAS) scores, willingness to repeat procedure (0: never 4: happily), and patient satisfaction rates (0: poor 4: excellent) were recorded immediately after the procedure. RESULTS: There was a statistically significant difference between groups in terms of median VAS scores (7, 6, 4.5, 5, and 4, respectively, P\u3c .001), whereas the VAS scores in Groups 3, 4, and 5 were significantly lower than those in Group 1 and 2 (P\u3c .001). The median STAI-SA scores between the groups were significantly different (45, 45, 42, 45, and 40, respectively, P\u3c .001), while the anxiety levels in Groups 3, 4, and 5 were significantly lower than those in Group 1 (P=.008, P=.018, and P\u3c .001, respectively). Moreover, there were statistically significant differences between the groups in terms of willingness to repeat the procedure and patient satisfaction rates (P\u3c .001). CONCLUSIONS: Music therapy during SWL reduced the patients\u27 pain and anxiety scores, moreover listening to the patient\u27s preferred music type provided greater satisfaction. Listening to the patient\u27s preferred music type could be standardized and routinely used during SWL

Perinatal outcomes of twin pregnancies complicated by late twin‐twin transfusion syndrome: A systematic review and meta‐analysis

Introduction Untreated twin‐to‐twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity. Laser surgery is recommended before 26 weeks of gestation. However, the optimal management in case of late TTTS (occurring after 26 weeks of gestation) is yet to be established. Material and methods We conducted a systematic review and meta‐analysis to evaluate the outcomes of monochorionic‐diamniotic twin pregnancies complicated by late TTTS according to different management options (expectant, laser therapy, amnioreduction, or delivery). The primary outcome was mortality, including single and double intrauterine, neonatal, and perinatal death. Secondary outcomes were composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (ie, free from neurological complications), and preterm birth before <32 weeks of gestation. Outcomes were reviewed according to the management and reported for the overall population of twins and disease status (ie, donor and recipient separately). Random‐effect meta‐analyses of proportions were used to analyze the data. Results Nine studies including 796 twin pregnancies affected by TTTS were included. No randomized controlled trials were available for inclusion. TTTS occurred at ≥26 weeks of gestation in 8.7% (95% CI 6.9%‐10.9%; 67/769) of cases reporting TTTS at all gestations. Intrauterine death occurred in 17.7% (95% CI 4.9%‐36.2%) of pregnancies managed expectantly, 5.3% (95% CI 0.9%‐12.9%) of pregnancies treated with laser, and 0% (95% CI 0%‐9%) after amnioreduction. Neonatal death occurred in 42.5% (95% CI 17.5%‐69.7%) of pregnancies managed expectantly, in 2.8% (95% CI 0.3%‐7.7%) of cases treated with laser, and in 20.2% (95% CI 6%‐40%) after amnioreduction. Only one study (10 cases) reported data on immediate delivery after diagnosis with no perinatal deaths. Perinatal death incidence was 55.7% (95% CI 31.4%‐78.6%) in twin pregnancies managed expectantly, 5.6% (95% CI 0.5%‐15.3%) in those treated with laser, and 20.2% (95% CI 6%‐40%) in those after amnioreduction. Intact survival was reported in 44.4%, 96.4%, and 78% of fetuses managed expectantly, with laser or amnioreduction, respectively. Conclusions Evidence regarding perinatal mortality and morbidity in twin pregnancies complicated by late TTTS according to the different managements was of very low quality. Therefore further high‐quality research in this field is needed to elucidate the optimal management of these pregnancies

Incidence and outcome of prenatal brain abnormalities in twin-to-twin transfusion syndrome: systematic review and meta-analysis.

OBJECTIVES: to ascertain the incidence of antenatally diagnosed brain injuries in twin pregnancies complicated by twin to twin transfusion syndrome (TTTS) and to quantify the perinatal mortality, morbidity and long-term neurodevelopmental outcomes of these fetuses. METHODS: Medline, Embase, Clinicaltrials.gov and Cochrane Library databases were searched. Inclusion criteria were studies reporting on brain abnormalities diagnosed antenatally in twin pregnancies complicated by TTTS. The primary outcome was the incidence of prenatal brain abnormalities. The secondary outcomes were intrauterine demise (IUD), neonatal death, termination of pregnancy (TOP) and long-term morbidity. All these outcomes were explored in the overall population of fetuses with antenatal diagnosis of brain abnormalities. Sub-group analysis according to: type of treatment, gestational age and Quintero stage at diagnosis and/or treatment, co-twin death was planned. Meta-analyses of proportions were used to combine data and reported pooled proportion and their 95% confidence intervals (CI). RESULTS: Thirteen studies including 1573 cases of TTTS and 88 fetuses with an antenatal diagnosis of brain abnormalities were included in the systematic review. The meta-analysis included only studies reporting on brain abnormalities in twin pregnancies complicated by TTTS cases and treated with laser. Overall, brain injuries occurred in 2.2% of fetuses (eight studies (52/2410 fetuses)). These brain abnormalities were reported in 1.03% and 0.82% of recipients or donors, respectively. These abnormalities were mainly ischemic lesions (30.4%, 95%CI 19.1-43), followed by destructive lesions (23.9%, 95%CI 13.7-35.9), ventriculomegaly (19.9%, 95% CI 10.6-31.3) and hemorrhagic (15.3%, 95%CI 7.1-25.8). Spontaneous IUD occurred in 13.4% (95%CI 5.1-24.8) of fetuses, while TOP was chosen by parents in 53.5% (95%CI 38.9-67.8) cases. Neonatal death was reported only by three studies with an incidence of 15.4% (95%CI 2.8-35.4). Finally, only two studies reported on composite morbidity with 20.4% of morbidity reported overall (95%CI 2.5-49.4) which occurred in 29.7% and 20.4% of the recipient and donor fetuses, respectively. Due to the small numbers, only composite morbidity was analyzed and no information on neonatal intensive care unit admission, respiratory distress syndrome or other long-term outcomes such as neurodevelopmental delay or cerebral palsy could be reliably retrieved. CONCLUSIONS: The overall incidence of antenatally diagnosed fetal brain abnormalities in fetuses from twin pregnancies complicated by TTTS treated with laser is around 2%, mainly ischemic (30.4%) in nature. TOP was chosen by parents in almost half of the cases (53.5%). No information could be retrieved on morbidity outcomes, highlighting the urgent need for long-term follow up studies of these children. This article is protected by copyright. All rights reserved

Perinatal outcomes of twin pregnancies affected by early twin‐twin transfusion syndrome: a systematic review and meta‐analysis

Introduction:&nbsp;Twin‐to‐twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity if not treated. However, the optimal timing and management in case of early (occurring &lt;18 weeks) TTTS has not been established yet. Material and Methods:&nbsp;This is a systematic review and meta‐analysis aiming at evaluating the outcomes of monochorionic diamniotic (MCDA) twin pregnancies complicated by early (i.e. before 18 weeks) TTTS according to different management options (expectant, laser therapy, amnioreduction or cord occlusion). The primary outcome was mortality, including single and double intra‐uterine, neonatal and perinatal death. Secondary outcomes were: composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (defined as survival free from neurological complications) and preterm birth &lt;32 weeks' gestation. All outcomes were reviewed according to the different management options (expectant, laser therapy, amnioreduction or cord occlusion) and reported in the overall population of twins, and in the donor and recipient separately. Sub‐group analysis for TTTS occurring before 16 weeks of gestation was performed. Random‐effect meta‐analyses of proportions were used to analyze the data. Results:&nbsp;Thirteen studies were included. Early TTTS occurred in 14.3% (95% CI 11.9‐17.0) of cases. Mortality: The incidence of intra‐uterine death was 19.0% (95% CI 2.6‐45.5) in twins managed expectantly, 32.4% (95% CI 16.5‐50.7) in those who received laser treatment and 12.5% (95% CI 4.8‐23.0) in those treated with amnioreduction. The incidence of neonatal death was 22.6% (95% CI 4.2‐49.8) in twins managed expectantly, 24.7% (95% CI 0.5‐80.3) in those who received laser and 20.2 (95% CI 5.8‐43.4) in those who had amnioreduction, while it was not possible to compute the incidence of these outcomes in twins undergoing cord occlusion because of insufficient sample and lack of reporting of most of the observed outcomes. Overall, the incidence of perinatal death was 43.9% (95% CI 5.9‐87.7) in twins managed expectantly, 47.3% (95% CI 21.4‐70.) in those treated with laser and 28.5% in those who had amnioreduction. Conclusions:&nbsp;Twin pregnancies affected by early TTTS are at substantial risk of perinatal mortality and morbidity; however data comes from very small studies with high risk of selection bias.</p