Controversies in the management of twin pregnancy.

Despite many advances in antenatal care, twin pregnancies still experience more adverse outcomes, in particular perinatal morbidity and mortality. They also pose a multitude of challenges and controversies, as outlined in this Review. Moreover, they are less likely to be included in clinical trials. Many issues on classification and management remain under debate. Efforts in standardizing diagnostic criteria, monitoring protocols, management and outcome reporting are likely to reduce their perinatal risks. The top 10 most important research uncertainties related to multiple pregnancies have been identified by both clinicians and patients. More robust research in the form of randomized trials and large well-conducted prospective cohort studies is needed to address these controversies. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology

Maternal and perinatal outcomes in women planning vaginal birth after caesarean (VBAC) at home in England:secondary analysis of the Birthplace national prospective cohort study

Objective To compare vaginal birth rates in women planning vaginal birth after caesarean (VBAC) at home versus in an obstetric unit (OU) and explore transfer rates in women planning home VBAC. Design Prospective cohort study. Setting OUs and planned home births in England. Population 1436 women planning VBAC in the Birthplace cohort, including 209 planning home VBAC. Methods We used Poisson regression to calculate relative risks adjusted for maternal characteristics. Main outcome measures Main outcomes: (i) vaginal birth and (ii) transfer from planned home birth to OU during labour or immediately after birth. Secondary outcomes: (i) composite of maternal blood transfusion or admission to higher level care, (ii) stillbirth or Apgar score <7 at 5 minutes, (iii) neonatal unit admission. Results Planned VBAC at home was associated with a statistically significant increase in the chances of having a vaginal birth compared with planned VBAC in an OU (adjusted relative risk 1.15, 95% confidence interval 1.06–1.24). The risk of an adverse maternal outcome was around 2–3% in both settings, with a similar risk of an adverse neonatal outcome. Transfer rates were high (37%) and varied markedly by parity (para 1, 56.7% versus para 2+, 24.6%). Conclusion Women in the cohort who planned VBAC at home had an increased chance of a vaginal birth compared with those planning VBAC in an OU, but transfer rates were high, particularly for women with only one previous birth, and the risk of an adverse maternal or perinatal outcome was around 2–3%. No change in guidance can be recommended. Tweetable abstract Higher vaginal birth rates in planned VBAC at home versus in OU but 2–3% adverse outcomes and high transfer rate

Labour induction near term for women aged 35 or over: an economic evaluation

Objective Induction of labour at 39 weeks for nulliparous women aged 35 years and over may prevent stillbirths and does not increase caesarean births, so it may be popular. But the overall costs and benefits of such a policy have not been compared. Design A cost–utility analysis alongside a randomised controlled trial (the 35/39 trial). Setting Obstetric departments of 38 UK National Health Service hospitals and one UK primary-care trust. Population Nulliparous women aged 35 years or over on their expected due date, with a singleton live fetus in a cephalic presentation. Methods Costs were estimated from the National Health Service and Personal Social Services perspective and quality-adjusted life-years (QALYs) were calculated based on patient responses to the EQ-5D at baseline and 4 weeks. Main outcome measures Data on antenatal care, mode of delivery, analgesia in labour, method of induction, EQ-5D (baseline and 4 weeks postnatal) and participant-administered postnatal health resource use data were collected. Results The intervention was associated with a mean cost saving of £263 and a small additional gain in QALYs (though this was not statistically significant), even without considering any possible QALY gains from stillbirth prevention. Conclusion A policy of induction of labour at 39 weeks for women of advanced maternal age would save money

Maternal genome-wide DNA methylation profiling in gestational diabetes shows distinctive disease-associated changes relative to matched healthy pregnancies

Several recent reports have described associations between gestational diabetes (GDM) and changes to the epigenomic landscape where the DNA samples were derived from either cord or placental sources. We employed genome-wide 450Karray analysis to determine changes to the epigenome in a unique cohort of maternal blood DNA from 11 pregnant women prior to GDM development relative to matched controls. Hierarchical clustering segregated the samples into two distinct clusters comprising GDM and healthy pregnancies. Screening identified 100 CpGs with a mean β-value difference of ≥0.2 between cases and controls. Using stringent criteria, 5 CpGs (within COPS8, PIK3R5, HAAO, CCDC124, and C5orf34 genes) demonstrated potentials to be clinical biomarkers as revealed by differential methylation in 8 of 11 women who developed GDM relative to matched controls. We identified, for the first time, maternal methylation changes prior to the onset of GDM that may prove useful as biomarkers for early therapeutic intervention

The economic costs of intrapartum care in Tower Hamlets: a comparison between the cost of birth in a freestanding midwifery unit and hospital for women at low risk of obstetric complications

Objective To compare the economic costs of intrapartum maternity care in an inner city area for ‘low risk’ women opting to give birth in a freestanding midwifery unit compared with those who chose birth in hospital. Design Micro-costing of health service resources used in the intrapartum care of mothers and their babies during the period between admission and discharge, data extracted from clinical notes Setting The Barkantine Birth Centre, a freestanding midwifery unit and the Royal London Hospital’s consultant-led obstetric unit, both run by the former Barts and the London NHS Trust in Tower Hamlets, a deprived inner city borough in east London, England, 2007-2010. Participants Maternity records of 333 women who were resident in Tower Hamlets and who satisfied the Trust’s eligibility criteria for using the Birth Centre. Of these, 167 women started their intrapartum care at the Birth Centre and 166 started care at the Royal London Hospital. Measurements and findings Women who planned their birth at the Birth Centre experienced continuous intrapartum midwifery care, higher rates of spontaneous vaginal delivery, greater use of a birth pool, lower rates of epidural use, higher rates of established breastfeeding and a longer post-natal stay, compared with those who planned for care in the hospital. The total average cost per mother-baby dyad for care where mothers started their intrapartum care at the Birth Centre was £1296.23, approximately £850 per patient less than the average cost per mother and baby who received all their care at the Royal London Hospital. These costs reflect intrapartum throughput using bottom up costing per patient, from admission to discharge, including transfer, but excluding occupancy rates and the related running costs of the units. Key conclusions and implications for practice The study showed that intrapartum throughput in the Birth Centre could be considered cost-minimising when compared to hospital. Modelling the financial viability of midwifery units at a local level is important because it can inform the appropriate provision of these services. This finding from this study contribute a local perspective and thus further weight to the evidence from the Birthplace Programme in support of freestanding midwifery unit care for women without obstetric complications

Birthweight discordance and neonatal morbidity in twin pregnancies: Analysis of the STORK multiple pregnancy cohort.

OBJECTIVES: The main aim of this study was to investigate the relationship between weight discordance and neonatal morbidity in twin pregnancies progressing beyond 34 weeks of gestation. The secondary aim was to determine the predictive accuracy of different weight discordant cut-offs in predicting neonatal morbidity in twin pregnancies. METHODS: This was a retrospective multicentre cohort study of all twin pregnancies booked for antenatal care in four hospitals in the Southwest Thames region of London Obstetric Research Collaborative (STORK) over a period of ten years. The ultrasound data were obtained by a computerized search of each hospital's obstetric ultrasound computer database, while the outcome details were obtained from the computerized maternity and neonatal records. The primary outcome was the incidence of composite neonatal morbidity in twin pregnancies with birthweight discordance. Logistic regression was used to identify and adjust for potential confounders, while the receiver operating characteristic curve was used to determine the predictive accuracy. RESULTS: Nine hundred and thirty-nine twin pregnancies (760 Dichorionic, 179 Monochorionic) were included. The gestation at birth and birthweight decile were significantly lower in the pregnancies complicated by neonatal morbidity compared to those which were not (p<0.001 for both). At multivariable logistic regression, gestation at birth (p<0.001), birthweight decile (p=0.029), birthweight discordance (p=0.019) but not chorionicity (p=0.477) or the presence of at least one small for gestational age twin (p=0.245), were independently associated with the risk of neonatal morbidity. There was a progressive increase in the risk of neonatal morbidity with increasing birthweight discordance. Despite this association, birthweight discordance showed an overall poor predictive accuracy in detecting neonatal morbidity, with an AUC of 0.58 (95% CI 0.53-0.63) with an optimal cut-off of 17.6%, showing a sensitivity and a specificity of 35.2% (95% CI 27.8-43.2) and 83.2% (95% CI 80.0-85.8), respectively. CONCLUSION: Inter-twin birthweight discordance is independently associated with the risk of neonatal morbidity in twins born after 34 weeks' gestation, irrespective of the chorionicity or the diagnosis of SGA in either twin. However, its predictive accuracy for neonatal morbidity is poor

Service configuration, unit characteristics and variation in intervention rates in a national sample of obstetric units in England: an exploratory analysis

Objectives: To explore whether service configuration and obstetric unit (OU) characteristics explain variation in OU intervention rates in "low-risk" women. Design: Ecological study using funnel plots to explore unit-level variations in adjusted intervention rates and simple linear regression, stratified by parity, to investigate possible associations between unit characteristics/configuration and adjusted intervention rates in planned OU births. Characteristics considered: OU size, presence of an alongside midwifery unit (AMU), proportion of births in the National Health Service (NHS) trust planned in midwifery units or at home and midwifery "under" staffing. Setting: 36 OUs in England. Participants: "Low-risk" women with a "term" pregnancy planning vaginal birth in a stratified, random sample of 36 OUs. Main outcome measures: Adjusted rates of intrapartum caesarean section, instrumental delivery and two composite measures capturing birth without intervention ("straightforward"and "normal" birth). Results: Funnel plots showed unexplained variation in adjusted intervention rates. In NHS trusts where proportionately more non-OU births were planned, adjusted intrapartum caesarean section rates in the planned OU births were significantly higher (nulliparous: R2=31.8%, coefficient=0.31, p=0.02; multiparous: R2=43.2%, coefficient=0.23, p=0.01), and for multiparous women, rates of "straightforward" (R2=26.3%, coefficient=-0.22, p=0.01) and "normal" birth (R2=17.5%, coefficient=0.24, p=0.01) were lower. The size of the OU (number of births), midwifery "under" staffing levels (the proportion of shifts where there were more women than midwives) and the presence of an AMU were associated with significant variation in some interventions. Conclusions: Trusts with greater provision of non-OU intrapartum care may have higher intervention rates in planned "low-risk" OU births, but at a trust level this is likely to be more than offset by lower intervention rates in planned non-OU births. Further research using high quality data on unit characteristics and outcomes in a larger sample of OUs and trusts is required

How do men in the United Kingdom decide to dispose of banked sperm following cancer treatment?

Current policy in the UK recommends that men bank sperm prior to cancer treatment, but very few return to use it for reproductive purposes or agree to elective disposal even when their fertility recovers and their families are complete. We assessed the demographic, medical and psychological variables that influence the decision to dispose by contacting men (n = 499) who banked sperm more than five years previously, and asked them to complete questionnaires about their views on sperm banking, fertility and disposal. From 193 responses (38.7% response rate), 19 men (9.8%) requested disposal within four months of completing the questionnaire. Compared with men who wanted their sperm to remain in storage, they were significantly more confident that their fertility had recovered (OR = 1.78, 95% CI = 1.05-3.03, p = 0.034), saw fertility monitoring (semen analysis) as less important (OR = 0.61, 95% CI = 0.39-0.94, p = 0.026), held more positive attitudes to disposal (OR = 5.71, 95% CI = 2.89-11.27, p < 0.001), were more likely to have experienced adverse treatment side-effects (OR = 4.37, CI = 1.61-11.85, p = 0.004) and had less desire for children in the future (OR = 0.41, 95% CI = 0.26-0.64, p < 0.001). Information about men's reasons to dispose of banked sperm may be helpful in devising new strategies to encourage men to engage with sperm banking clinics and make timely decisions about the fate of their samples