422 research outputs found
Preliminary experience with microwave ablation for selective feticide in monochorionic twin pregnancies
Twin reversed arterial perfusion sequence: current treatment options
Twin reversed arterial perfusion (TRAP) sequence is a specific and severe complication of monochorionic multiple pregnancy, characterized by vascular anastomosis and partial or complete lack of cardiac development in one twin. Despite its rarity, interest in the international literature is rising, and we aimed to review its pathogenesis, prenatal diagnostic features and treatment options. Due to the parasitic hemodynamic dependence of the acardiac twin on the pump twin, the management of these pregnancies aims to maximize the pump twinâs chances of survival. If treatment is needed, the best timing of intervention is still debated, although the latest studies encourage intervention in the first trimester of pregnancy. As for the technique of choice to interrupt the vascular supply to the acardiac twin, ultrasound-guided laser coagulation and radiofrequency ablation of the intrafetal vessels are usually the preferred approaches
Cervical cerclage in twin pregnancies
Purpose To evaluate the outcomes of cervical cerclage
(CC) in twin pregnancies.
Methods Retrospective analysis of twin pregnancies
undergoing CC between January 2001 and December 2009
at our Institution. CC was offered in case of a cervical
length measurement B20 mm (ultrasound-indicated CC) or
in case of cervical dilatation with membranes at or beyond
the external cervical os (physical examination-indicated
CC). Cervicovaginal and rectal swabs were obtained preoperatively.
Perioperative antibiotics and tocolysis were
administered.
Results There were 28 cases of ultrasound-indicated and
14 of physical examination-indicated CC. Positive swab
cultures were observed in 21 % of cases. The incidence of
preterm delivery\34 weeks was 32 % [95 % confidence
interval (CI) 16â52 %] and 50 % (95 % CI 23â77 %) in
the ultrasound-indicated and physical examination-indicated
CC group, respectively. The incidence of premature
rupture of membranes \34 weeks was 21 % (95 % CI
8â41 %) and 29 % (95 % CI 8â58 %) in the ultrasoundindicated
and physical examination-indicated CC group,
respectively. Perinatal survival was 96 % (95 % CI
88â100 %) in the ultrasound-indicated CC group, and
86 % (95 % CI 67â96 %) in the physical examinationindicated
CC group.Conclusions We showed a high-risk of preterm delivery
in both groups, but with a high overall perinatal survival.
Our data stress the importance of re-evaluating the efficacy
of CC in twin pregnancies by properly designed clinical
trials, particularly if it is physical examination indicated
OC09.04: Crownârump length and abdominal circumference discrepancy as early predictors of late adverse pregnancy outcome in monochorionic diamniotic pregnancies
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Weight discordance and perinatal mortality in twin pregnancy: systematic review and metaâanalysis
Objectives
The primary aim of this systematic review was to explore the strength of association between birthâweight (BW) discordance and perinatal mortality in twin pregnancy. The secondary aim was to ascertain the contribution of gestational age and growth restriction in predicting mortality in growthâdiscordant twins.
Methods
MEDLINE, EMBASE, CINAHL and ClinicalTrials.gov databases were searched. Only studies reporting on the risk of mortality in twin pregnancies affected compared with those not affected by BW discordance were included. The primary outcomes explored were incidence of intrauterine death (IUD), neonatal death (NND) and perinatal death. Outcome was assessed separately for monochorionic (MC) and dichorionic (DC) twin pregnancies. Analyses were stratified according to BW discordance cutâoff (â„ 15%, â„ 20%, â„ 25% and â„ 30%) and selected gestational characteristics, including incidence of IUD or NND before and after 34 weeks' gestation, presence of at least one smallâforâgestational age (SGA) fetus in the twin pair and both twins being appropriateâforâgestational age. Risk of mortality in the larger vs smaller twin was also assessed. Metaâanalyses using individual data randomâeffects logistic regression and metaâanalyses of proportion were used to analyze the data.
Results
Twentyâtwo studies (10 877 twin pregnancies) were included in the analysis. In DC pregnancies, a higher risk of IUD, but not of NND, was observed in twins with BW discordance â„ 15% (odds ratio (OR) 9.8, 95% CI, 3.9â29.4), â„ 20% (OR 7.0, 95% CI, 4.15â11.8), â„ 25% (OR 17.4, 95% CI, 8.3â36.7) and â„ 30% (OR 22.9, 95% CI, 10.2â51.6) compared with those without weight discordance. For each cutâoff of BW discordance explored in DC pregnancies, the smaller twin was at higher risk of mortality compared with the larger one. In MC twin pregnancies, excluding cases affected by twinâtwin transfusion syndrome, twins with BW discordance â„ 20% (OR 2.8, 95% CI, 1.3â5.8) or â„ 25% (OR 3.2, 95% CI, 1.5â6.7) were at higher risk of IUD, compared with controls. MC pregnancies with â„ 25% weight discordance were also at increased risk of NND (OR 4.66, 95% CI, 1.8â12.4) compared with those with concordant weight. The risk of IUD was higher when considering discordant pregnancies involving at least one SGA fetus. The overall risk of mortality in MC pregnancies was similar between the smaller and larger twin, except in those with BW discordance â„ 20%.
Conclusion
DC and MC twin pregnancies discordant for fetal growth are at higher risk of IUD but not of NND compared with pregnancies with concordant BW. The risk of IUD in BWâdiscordant DC and MC twins is higher when at least one fetus is SGA
Current practice in the diagnosis and management of fetal growth restriction: An international survey
Introduction The aim of this survey was to evaluate the current practice in respect of diagnosis and management of fetal growth restriction among obstetricians in different countries. Material and methods An e-questionnaire was sent via REDCap with "click thru" links in emails and newsletters to obstetric practitioners in different countries and settings with different levels of expertise. Clinical scenarios in early and late fetal growth restriction were given, followed by structured questions/response pairings. Results A total of 275 participants replied to the survey with 87% of responses complete. Participants were obstetrician/gynecologists (54%; 148/275) and fetal medicine specialists (43%; 117/275), and the majority practiced in a tertiary teaching hospital (56%; 153/275). Delphi consensus criteria for fetal growth restriction diagnosis were used by 81% of participants (223/275) and 82% (225/274) included a drop in fetal growth velocity in their diagnostic criteria for late fetal growth restriction. For early fetal growth restriction, TRUFFLE criteria were used for fetal monitoring and delivery timing by 81% (223/275). For late fetal growth restriction, indices of cerebral blood flow redistribution were used by 99% (250/252), most commonly cerebroplacental ratio (54%, 134/250). Delivery timing was informed by cerebral blood flow redistribution in 72% (176/244), used from >= 32 weeks of gestation. Maternal biomarkers and hemodynamics, as additional tools in the context of early-onset fetal growth restriction (<= 32 weeks of gestation), were used by 22% (51/232) and 46% (106/230), respectively. Conclusions The diagnosis and management of fetal growth restriction are fairly homogeneous among different countries and levels of practice, particularly for early fetal growth restriction. Indices of cerebral flow distribution are widely used in the diagnosis and management of late fetal growth restriction, whereas maternal biomarkers and hemodynamics are less frequently assessed but more so in early rather than late fetal growth restriction. Further standardization is needed for the definition of cerebral blood flow redistribution
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