Clinical aspects of multiple pregnancy

The natural wonder of multiple pregnancy and birth has fascinated mankind since ancient times and twins figure prominently in legends, folktales and myths. One of the best known traditional stories is that of Romulus and Remus, the twins who were abandoned on the banks of the Tiber and suckled by a she-wolf. Later Romulus founded Rome, the city that still bears his name, after killing his twinbrother. Tales of profound attachment of co-twins, such as Castor and Pollux, as well as those of murderous jealousy, such as between Jacob and Esau, illustrate an early intuitive recognition of the fact that even identical twins have their own personality. A century ago this particular aspect of twinning made Francis Galton realize that twins could also serve as tools for scientific research into the old question of nurture versus nature. His publication "The history of twins, as a criterion of the relative powers of nature and nurture" that appeared in 1875 set the basis for the development of what is now known as the "twin method" in scientific research". The twin method in its simplest form is based on the assumption that the extent to which any given morphologic, biochemical, functional, or behavioral trait or condition exhibits a higher average within-pair similarity in monozygotic than in dizygotic co-twins is a reflection of the extent to which that particular variable is under genetic control'oo. The cause of multiple pregnancy and its clinical hazards have been subject of medical investigation since Hippocrates' time

Hypertensive disorders in twin pregnancy

Objective: To compare the incidence and severity of pregnancy-induced hypertensive disorders in twin pregnancy and in singleton gestation. Study design: Case-control study in the setting of a University Hospital. Each pregnancy of a consecutive series of 187 twin pregnancies attending the antenatal clinic and booked before a gestational age of 24 weeks was matched for maternal age, parity, and gestational age at delivery with a singleton pregnancy delivered in the same year. Primary end points of the analysis of the course and outcome of pregnancy were pregnancy-induced hypertension and proteinuric pre-eclampsi. Results: In the twin pregnancy group, 21% of patients met the criteria for the diagnosis of a pregnancy-induced hypertensive disorder, compared with 13% in the singleton pregnancy group (P < 0.05). The difference was due to a significantly higher incidence of pregnancy-induced hypertension in twin (15%) than in singleton (6%) pregnancy (P < 0.05), in particular in nulliparous women. The incidence of pre-eclampsia was similar in twin (6%) and singleton pregnancies (6.5%), without a difference in severity and in the occurrence of the HELLP syndrome. Conclusion: The incidence of non-proteinuric pregnancy-induced hypertension, but not of proteinuric pre-eclampsia, is increased in twin pregnancy

Maternal and perinatal complications in triplet compared with twin pregnancy

Objective: To compare maternal and perinatal complications in triplet and twin pregnancies. Study design: Case-controlled study in the setting of a University Hospital. Each pregnancy of a consecutive series of 40 triplet pregnancies of 20 weeks or more was matched for parity and maternal age with two sets of twins delivered in the same year. Primary end points of the analysis were maternal complications and perinatal outcome. Results: Of the triplets 82% and of the twins 36% were a result of assisted reproduction. Pre-term labor occurred significantly more often in triplet than in twin gestation. Triplets had a significantly lower median birth-weight (1478 vs. 2030 g) and gestational age at delivery (32 vs. 35.5 weeks). The mean neonatal hospital stay was significantly longer in triplets, mainly related to the lower birth-weight, but there was no significant difference between triplets and twins in the incidence of major neonatal complications. Conclusion: This data of the anticipated perinatal outcome in triplet and twin pregnancies may be used to counsel women with a triplet pregnancy considering selective reduction to twins. All methods of assisted reproduction should aim at prevention of multifetal gestation

Indirect maternal mortality increases in the Netherlands.

Objective. To assess causes, trends, and substandard care in indirect maternal mortality in the Netherlands. Design. Confidential enquiry into causes of maternal death. Setting. Nationwide in the Netherlands. Population. A total of 2,557,208 live births. Methods. Data analysis of indirect maternal deaths in the period 1993-2005. Main outcome measures. Indirect maternal mortality. Results. Of the study subjects, 97 were classified as indirect deaths, representing a maternal mortality ratio of 3.3/ 100,000 live births, a significant increase compared to the preceding enquiry in the period 1983-1992 (MMR 2.4, OR 1.5, 95% CI 1.0-2.1). The percentage of cases not directly reported to the Maternal Mortality Committee decreased from 15 to 5%. Cardiovascular disorders were the leading cause of indirect maternal mortality, followed by cerebrovascular disorders. Vascular dissection (n = 19) was the most frequent specified cause of death. Risk factors were advanced maternal age, non-indigenous origin (Surinam and Dutch Antilles), and medical health risks before pregnancy. Substandard care was present in 35%, mainly being misjudgment of the severity of the condition and delay in initiating therapy. Conclusion. The rise of mortality due to indirect causes is considered a reflection of the change in risk profile of women of childbearing age and the result of demographic alterations concerning ethnicity and maternal age. The identification of high risk groups, preferably by programs of preconception care, should lead to improved care for these women, with a multidisciplinary approach when needed

History of preeclampsia is not associated with an increased risk of thyroid dysfunction

Objective. We evaluated the thyroid function in women with a history of preeclampsia and/or HELLP syndrome at least 2 years after delivery. Design. Observational retrospective study. Setting. University Medical Center Groningen, The Netherlands. Population. Women with a history of preeclampsia and/or HELLP syndrome (n = 310) or uncomplicated pregnancies (n = 363), between January 1990 and February 2003. Methods. Measurement of serum thyroid stimulating hormone (TSH) levels and antibodies to thyroid peroxidase and the use of a questionnaire about relevant history and family history of auto-immune diseases related to thyroid disease. Main outcome measures. Prevalence of primary thyroid dysfunction and antibodies to thyroid peroxidase. Results. Mean serum TSH values were not significantly different between the preeclampsia and control group (1.62 vs. 1.80 mU/l). The percentage of women who have (have had) hypothyroidism and hyperthyroidism, respectively, did not differ significantly between the preeclampsia and the control group (3.3 vs. 6.1% and 10.0 vs. 7.7%). Furthermore the prevalence of antibodies to thyroid peroxidase was not significantly different (6.1 vs. 7.7%). Conclusion. Preeclampsia and/or HELLP syndrome are not associated with an increased risk of thyroid dysfunction in later life

Rise in maternal mortality in the Netherlands

Objective To assess causes, trends and substandard care factors in maternal mortality in the Netherlands. Design Confidential enquiry into the causes of maternal mortality. Setting Nationwide in the Netherlands. Population 2,557,208 live births. Methods Data analysis of all maternal deaths in the period 1993-2005. Main outcome measures Maternal mortality. Results The overall maternal mortality ratio was 12.1 per 100 000 live births, which was a statistically significant rise compared with the maternal mortality ratio of 9.7 in the period 1983-1992 (OR 1.2, 95% CI 1.0-1.5). The most frequent direct causes were (pre-) eclampsia, thromboembolism, sudden death in pregnancy, sepsis, obstetric haemorrhage and amniotic fluid embolism. The number of indirect deaths also increased, mainly caused by an increase in cardiovascular disorders (OR 2.5, 95% CI 1.4-4.6). Women younger than 20 years and older than 45 years, those with high parity or from nonwestern immigrant populations were at higher risk. Most substandard care was found in women with pre-eclampsia (91%) and in immigrant populations (62%). Conclusions Maternal mortality in the Netherlands has increased since 1983-1992. Pre-eclampsia remains the number one cause. Groups at higher risk for complications during pregnancy should be better identified early in pregnancy or before conception, in order to receive preconception advice and more frequent antenatal visits. There is an urgent need for the better education of women and professionals concerning the danger signs, and for the training of professionals in order to improve maternal health care.Research into fetal development and medicin

Rise in maternal mortality in the Netherlands

Objective To assess causes, trends and substandard care factors in maternal mortality in the Netherlands. Design Confidential enquiry into the causes of maternal mortality. Setting Nationwide in the Netherlands. Population 2,557,208 live births. Methods Data analysis of all maternal deaths in the period 1993-2005. Main outcome measures Maternal mortality. Results The overall maternal mortality ratio was 12.1 per 100 000 live births, which was a statistically significant rise compared with the maternal mortality ratio of 9.7 in the period 1983-1992 (OR 1.2, 95% CI 1.0-1.5). The most frequent direct causes were (pre-) eclampsia, thromboembolism, sudden death in pregnancy, sepsis, obstetric haemorrhage and amniotic fluid embolism. The number of indirect deaths also increased, mainly caused by an increase in cardiovascular disorders (OR 2.5, 95% CI 1.4-4.6). Women younger than 20 years and older than 45 years, those with high parity or from nonwestern immigrant populations were at higher risk. Most substandard care was found in women with pre-eclampsia (91%) and in immigrant populations (62%). Conclusions Maternal mortality in the Netherlands has increased since 1983-1992. Pre-eclampsia remains the number one cause. Groups at higher risk for complications during pregnancy should be better identified early in pregnancy or before conception, in order to receive preconception advice and more frequent antenatal visits. There is an urgent need for the better education of women and professionals concerning the danger signs, and for the training of professionals in order to improve maternal health care

Prediction of progression to a high risk situation in women with gestational hypertension or mild pre-eclampsia at term

Objective: To evaluate whether progression to a high-risk situation is predictable in women with gestational hypertension (GH) or mild pre-eclampsia (PE) at term. Methods: Women with a singleton pregnancy, a fetus in cephalic position, between 36 and 41 weeks of gestation, complicated by GH or mild PE that were managed expectantly, were selected from the HYPITAT trial. We evaluated the predictability of progression to a high-risk situation. Logistic regression was used to determine the predictive value of clinical characteristics or laboratory findings and to generate a prediction model for progression to a high-risk situation. The predictive value of this model was assessed with receiver-operating characteristic (ROC) analysis, calibration and internal validation. Results: We included 703 women, of whom 244 (34.7%) had progression to a high-risk situation. After multivariable analysis, nulliparity (OR 1.87), maternal age (OR 1.05 per year), gestational age (OR 0.88 per week), previous abortion (OR 1.26), ethnicity (OR 2.05 for non-Caucasian ethnicity), diastolic (OR 1.04 per mmHg), systolic blood pressure (OR 1.02 per mmHg) and the laboratory parameters proteinuria, haemoglobin, platelets, uric acid and alanine aminotransferase were included in the final model. The area under the ROC curve of this model was 0.71 (95% CI, 0.67-0.74). Even though the goodness of fit was moderate (P = 0.40), internal validation showed the model could hold in the overall population. Conclusion: In the prediction of progression to a high-risk situation, in women with GH or mild PE at term, a distinction can be made between women with a low risk and women with high risk

Prognostic significance of changes in heart rate following uptitration of beta-blockers in patients with sub-optimally treated heart failure with reduced ejection fraction in sinus rhythm versus atrial fibrillation

Background: In patients with heart failure with reduced ejection fraction (HFrEF) on sub-optimal doses of beta-blockers, it is conceivable that changes in heart rate following treatment intensification might be important regardless of underlying heart rhythm. We aimed to compare the prognostic significance of both achieved heart rate and change in heart rate following beta-blocker uptitration in patients with HFrEF either in sinus rhythm (SR) or atrial fibrillation (AF). Methods: We performed a post hoc analysis of the BIOSTAT-CHF study. We evaluated 1548 patients with HFrEF (mean age 67 years, 35% AF). Median follow-up was 21 months. Patients were evaluated at baseline and at 9 months. The combined primary outcome was all-cause mortality and heart failure hospitalisation stratified by heart rhythm and heart rate at baseline. Results: Despite similar changes in heart rate and beta-blocker dose, a decrease in heart rate at 9 months was associated with reduced incidence of the primary outcome in both SR and AF patients [HR per 10 bpm decrease—SR: 0.83 (0.75–0.91), p &lt; 0.001; AF: 0.89 (0.81–0.98), p = 0.018], whereas the relationship was less strong for achieved heart rate in AF [HR per 10 bpm higher—SR: 1.26 (1.10–1.46), p = 0.001; AF: 1.08 (0.94–1.23), p = 0.18]. Achieved heart rate at 9 months was only prognostically significant in AF patients with high baseline heart rates (p for interaction 0.017 vs. low). Conclusions: Following beta-blocker uptitration, both achieved and change in heart rate were prognostically significant regardless of starting heart rate in SR, however, they were only significant in AF patients with high baseline heart rate. © 2019, The Author(s)