The Use of Mid-Pregnancy Cervical Length to Predict Preterm Birth in Brazilian Asymptomatic Twin Gestations / O uso da medida do colo uterino no segundo trimestre de gestantes brasileiras como preditor de prematuridade na gestação gemelar

Abstract Objective To describe a reference curve for cervical length (CL) in mid-trimester twin gestations using transvaginal ultrasound (TVU) and to investigate whether short CL increases spontaneous preterm birth (sPTB) in asymptomatic twin pregnancies. Methods This was a prospective cohort study performed at 17 outpatient antenatal facilities of Brazil with women at 18 0/7 to 22 6/7 weeks of gestation who participated in a randomized clinical trial screening phase (P5 trial) between July 2015 and March 2019. TVU was performed to provide CL measurement in all screened women. Almost all women with CL ≤ 30 mm received vaginal progesterone 200mg/day and they were also randomized to receive cervical pessary or not. We considered data from the CL distribution among asymptomatic twin pregnancies and analyzed CL and its association with PTB generating receiver operating characteristics (ROC) curves and Kaplan-Meier curves. Results A total of 253 pregnant women with twins were included in the distribution curve. The mean CL was 33.7 mm and median was 35.5mm. The 10th percentile was 17.8mm. We identified a PTB rate of 73.9% (187/253) with 33.6% of sPTB < 37 (85/253) and 15% (38/253) of sPTB < 34 weeks. The best cutoff point to predict sPTB < 37 was 24.15 mm. However, the ROC curve showed a poor performance (0.64). The Kaplan-Meier survival curves identified that only CL values ≤ 20mm were associated to sPTB < 34 weeks. Conclusion A cutoff point of CL ≤ 20 mm can be interesting point to identify short cervix in Brazilian twin pregnancies. However, in Brazilian asymptomatic twin pregnancies, CL does not show a good performance to predict PTB.

Resumo Objetivo Descrever uma curva de referência da medida do colo uterino no Segundo trimestre de gestações gemelares através de ultrassonografia transvaginal (TVU) e investigar a correlação entre a medida do colo uterino (CL) e o parto prematuro espontâneo (sPTB) em pacientes assintomáticas. Métodos Foi realizado uma coorte prospectiva multicêntrica em 17 centros de referência do Brasil com mulheres com gestação gemelar entre 18 0/7 a 22 6/7 semanas de gestação que participaram da primeira fase de um ensaio clínico randomizado (P5 trial) entre Julho/2015 a Março/2019. TVU foi realizada para obter a medida do colo uterino em todas as mulheres. A maioria das mulheres com CL ≤30 mm receberam progesterona por via vaginal 200mg/dia e estas foram randomizadas para receber ou não um pessário cervical. Este estudo considerou dados da medida do colo uterino entre mulheres assintomáticas, desenvolvendo uma curva de referência para gestantes gemelares e sua capacidade de predição do parto prematuro através de curva ROC (receiver operating characteristics) e curvas de sobrevida de Kaplan-Meyer. Resultados O total de 253 gestantes foram incluídos no estudo, A média do CL foi 33.7mm e a mediana 35.5mm. O Percentil 10 do CL foi 17.8mm. A taxa de parto prematuro foi de 73.9% (187/253) com 33.6% de sPTB < 37 (85/253) e 15% (38/253) de sPTB < 34 semanas. O melhor ponto de corte para predizer sPTB < 37 foi 24.15 mm, entretanto a curva ROC demonstrou baixa performance (0.64). A curva de Kaplan-Meier para sPTB identificou que apenas CL ≤ 20 mm estavam associados a sPTB < 34 semanas. Conclusão Colo uterino ≤20 mm pode ser um interessante ponto de corte para identificar colo curto entre gestações gemelares assintomáticas brasileiras. Entretanto, a medida do colo uterino não apresentou boa performance para predizer parto prematuro.

One Plus One is Better than Two: An Approach Towards a Single Blastocyst Transfer Policy for All IVF Patients / Um mais um é melhor que dois: Uma abordagem pela prática da transferência de embrião único para todos os pacientes de FIV

Abstract Objective It is known that the single embryo transfer (SET) is the best choice to reduce multiples and associated risks. The practice of cryopreserving all embryos for posterior transfer has been increasingly performed for in vitro fertilization (IVF) patients at the risk of ovarian hyperstimulation syndrome or preimplantation genetic testing for aneuploidy. However, its widespread practice is still controverse. The aim of this study was to evaluate how effective is the transfer of two sequential SET procedures compared with a double embryo transfer (DET) in freeze-only cycles. Methods This retrospective study reviewed 5,156 IVF cycles performed between 2011 and 2019, and 506 cycles using own oocytes and freeze-only policy with subsequent elective frozen-thawed embryo transfers (eFET) were selected for this study. Cycles having elective SET (eSET, n = 209) comprised our study group and as control group we included cycles performed with elective DET (eDET, n = 291). In the eSET group, 57 couples who had failed in the 1st eSET had a 2nd eFET, and the estimated cumulative ongoing pregnancy rate was calculated and compared with eDET. Results After the 1st eFET, the ongoing pregnancy rates were similar between groups (eSET: 35.4% versus eDET: 38.5%; p =0.497), but the estimated cumulative ongoing pregnancy rate after a 2nd eFET in the eSET group (eSET + SET) was significantly higher (48.8%) than in the eDET group (p < 0.001). Additionally, the eSET +SET group had a 2.7% rate of multiple gestations, which is significantly lower than the eDET group, with a 30.4% rate (p < 0.001). Conclusion Our study showed the association of freeze-only strategy with until up to two consecutive frozen-thawed eSETs resulted in higher success rates than a frozenthawed DET, while drastically reducing the rate of multiple pregnancies.

Resumo Objetivo Sabe-se que a transferência de embrião único (SET) é a melhor escolha para reduzir as gestações múltiplas e riscos associados. A prática da criopreservação de todos os embriões para transferência posterior tem sido cada vez mais utilizada para fertilização in vitro (FIV), em especial quando há risco de síndrome de hiperestimulação ovariana ou realização de teste genético pré-implantacional. Entretanto, sua utilização disseminada ainda é controversa. O objetivo deste estudo foi avaliar a eficácia de duas SET sequenciais em comparação com uma transferência de embrião dupla (DET) em ciclos de FIV onde todos os embriões foram criopreservados. Métodos Neste estudo retrospectivo foram revisados 5.156 ciclos de FIV realizados entre 2011 e 2019, e 506 ciclos usando oócitos próprios e criopreservação de todos os embriões com transferências eletivas subsequentes de embriões descongelados, foram selecionados para este estudo. Ciclos com transferência eletiva de embrião único (eSET, n = 209) compuseram nosso grupo de estudo e como grupo de controle incluímos os ciclos com transferência eletiva de dois embriões (eDET, n = 291). No grupo eSET, 57 casais que falharam na 1ª tentativa de eSET tiveram uma 2ª eFET e a taxa de gravidez em curso cumulativa foi estimada para o grupo eSET e comparada com o grupo eDET. Resultados Após a 1ª eFET, as taxas de gravidez em curso foram semelhantes entre os grupos (eSET: 35,4% versus eDET: 38,5%; p = 0,497), mas a taxa de gravidez em curso cumulativa estimada após a 2ª eFET no grupo eSET (eSET + SET) foi significativamente maior (48,8%) do que no grupo eDET (p <0,001). Além disso, as taxas de gestação múltipla foram expressivamente inferiores no grupo eSET + SET (2,7%) quando comparado ao grupo eDET (30,4%; p < 0,001). Conclusão Nosso estudo mostrou que a associação das estratégias de congelamento de todos os embriões com até duas eSETs sequenciais resultou em maiores taxas de sucesso do que uma DET com embriões descongelados, além de reduzir drasticamente a ocorrência de gestações múltiplas.

Parto asincrónico en un embarazo gemelar. Primer reporte de caso en el Perú / Asynchronous delivery in a twin pregnancy. First case report in Peru

RESUMEN El parto asincrónico (PA) o parto diferido (PD) es una presentación poco prevalente de la gestación múltiple. Este ocurre cuando un feto nace por vía vaginal y el -o losfetos restantes se mantienen intraútero y nacen con una diferencia de días o semanas. Se realiza el primer reporte en el Perú de una gestante cuyo primer parto fue a las 20,1 semanas y el segundo a las 24,4 semanas, y se detalla el manejo y los resultados perinatales del caso. La evidencia sugiere que un PD mejora la supervivencia y reduce la morbimortalidad del segundo feto. Es imprescindible continuar la investigación en este tema para describir su prevalencia real, identificar candidatas ideales, estandarizar el manejo obstétrico y así optimizar resultados maternos y fetales.

ABSTRACT Asynchronous delivery (AD) or delayed interval delivery (DID) is a rare presentation of multiple gestation. This occurs when one fetus is delivered vaginally and the remaining fetus or fetuses are kept in utero and are born with a difference of days or weeks. This is the first report in Peru of a pregnant woman whose first delivery was at 20.1 weeks and the second at 24.4 weeks, and the management and perinatal results of the case are detailed. The evidence suggests that a DID improves survival and reduces morbidity and mortality of the second fetus. Further research on this topic is essential to describe its real prevalence, identify ideal candidates, standardize obstetric management and thus optimize maternal and fetal outcomes.

Alteraciones oftalmológicas en pacientes de 3 a 6 años de edad, productos de embarazos múltiples / Ophthalmological alterations in patients from 3 to 6 years of age, products of multiple pregnancies

Resumen Objetivo: Determinar alteraciones oftalmológicas en pacientes de 3-6 años de edad, productos de embarazo múltiple, técnicas de reproducción asistida (PPEM TRA) y espontáneos (PPEM E). Métodos: Estudio retrospectivo, observacional, descriptivo y transversal de enero de 1996 a julio del 2019. Muestra compuesta por 202 PPEM con exploración oftalmológica completa: 78 PPEM TRA y 124 PPEM E. Se distribuyeron por TRA, semanas de gestación, retinoscopia, edad y frecuencia de alteraciones anatómicas. Resultados: Las ametropías más frecuentes fueron astigmatismo mixto (A.Mx), astigmatismo hipermetrópico compuesto (AHC), astigmatismo hipermetrópico simple (AHS) y astigmatismo miópico simple (AMS). Conclusiones: Los defectos refractivos diagnosticados son similares a lo obtenido por diversos autores del ámbito nacional e internacional. La frecuencia de alteraciones oftalmológicas es más frecuente en PPEM TRA, pero más diversas en pacientes PPEM E.

Abstract Objective: To determine ophthalmological alterations in patients of 3-6 years of age, products of Multiple Pregnancy Assisted Reproduction Techniques (MPPP ART) and Spontaneous (MPPP S). Methods: Retrospective, observational, descriptive, and cross-sectional study from January 1996 to July 2019. Sample composed of 202 Multiple Pregnancy Product Patients with complete ophthalmological examination 78 MPPP ART and 124 MPPP S. They were distributed by ART, weeks of gestation, retinoscopy, age, and frequency of anatomical alterations. Results: The most frequent ametropias were mixed astigmatism (A.Mx), compound hyperopic astigmatism (CHA), simple hyperopic astigmatism (SHA) and simple myopic astigmatism (SMA). Conclusions: The refractive defects diagnosed are similar to those obtained by various national and international authors. The frequency of ophthalmological alterations is more frequent in MPPP ART, but more diverse in MPPP S patients.

Parto gemelar diferido: a propósito de un caso / Delayed twin birth: case report

INTRODUCCIÓN: Se presenta el caso de un parto diferido en una gestación gemelar en la que se consigue retrasar el parto del segundo gemelo 45 días con manejo conservador. CASO CLÍNICO: Mujer de 25 años, gestación gemelar bicorial biamniótica, con diagnóstico de muerte fetal del primer gemelo en semana 24+3 y parto del mismo tras una semana de evolución. Se decide la opción de tratamiento conservador expectante, con reposo absoluto, manteniendo tocolisis intravenosa, controles analíticos seriados, controles cardiotocográficos diarios, profilaxis antibiótica y antitrombótica. Con ello se consigue diferir el parto un total de 45 días. CONCLUSIÓN: El parto diferido en gestaciones gemelares es una práctica poco habitual, por lo que se carece de protocolos y actuaciones específicas. La bibliografía disponible difiere en cuanto al manejo de dichos casos y en el total de días que se consigue diferir el parto, pero en todos los estudios se reporta el beneficio en términos de resultados perinatales al conseguir aumentar la edad gestacional del segundo gemelo. En nuestro caso se consiguió una mejora sustancial del resultado perinatal asociado a la prematuridad sin importantes efectos adversos maternos y tras el periodo de latencia indicado.

INTRODUCTION: We report a delayed delivery of a dichorionic diamniotic twin pregnancy, in which the birth of the second twin was postponed 45 days. CASE REPORT: At 24+3 weeks of gestation, a 25-year-old woman with dichorionic diamniotic twin pregnancy presented with preterm premature rupture of membranes and intrauterine dead of the first fetus. Spontaneous delivery of the first death twin, occurred al 25+2 weeks. Tocolysis, antibiotic, antithrombotic prophylaxis, absolute rest, serial blood tests and fetal cardiotocography controls, were performed. The second twin was delivered at 31+5 weeks, after a the preterm premature rupture of membranes triggered the labor. The interval between the first and second birth was 45 days. CONCLUSION: Delayed delivery in twin pregnancies, is an uncommon clinical situation, so there are not validated medical protocols. Available bibliography offers different practices related to its management. Most studies confirm the better survival rate and perinatal outcomes of the postponed birth twin.

Maternal and perinatal outcomes in multiple versus singleton pregnancies in Dakar, Senegal: a cross sectional study over 10 years

Background: The birth of twins is a singular event in most societies, and even more when it comes to multiple births. The objective of this study was to investigate maternal and perinatal outcomes in multiple versus singleton pregnancies.Methods: Cross-sectional study carried out at Philippe Maguilen Senghor health center in Dakar, Senegal from January 1, 2011 to June 30, 2019. Data were extracted from this E-perinatal electronic database and then analyzed in statistical package for social science software (SPSS 24, Mac version).Results: A total 42,870 mothers delivered 44,149 newborns including 1250 twins (2.8%) and 29 triplets. The mean maternal age was 27 years. Mothers with multiple pregnancies had 3 times the odds of poor maternal outcome compared to mothers with single pregnancies (OR 2.42, 95% CI; 1.98-2.94, p <0.001, for high blood pressure; OR, 2.66; 95% CI, 2.11-3.32, p= <0.001, for severe pre-eclampsia; and OR, 3.04; 95% CI, 1.64-5.66, p <0.001, for postpartum hemorrhage). Likewise, women with multiple gestations had significantly higher rates of preterm birth (OR 5.62; 95% CI: 4.91-6.41, p <0.001), breech presentations (OR = 11.02; CI = 9.68-12.53, p <0.001) and neonatal deaths (OR = 2.94; CI = 9.6852-12.5328 p= 0.004) as compared to women with singleton gestations. Furthermore, women with multifetal gestations had increased risk for caesarean section (OR 2.14; 95% CI: 1.91-2.41, p <0.001) compared with their singleton counterparts. The risks for episiotomy and perineal injuries were higher for women with singleton gestations as compared to multiple gestation mothers.Conclusions: This study results are in line with previous findings and contradict others. Particular attention should always be paid to multiple pregnancies’ management. However, the pattern of certain complications traditionally correlated with multiple pregnancies is to be confirmed.

Comparison of fresh and frozen thawed embryo transfer in terms of clinical pregnancy rate

Background: In a standard IVF (in-vivo fertilization) procedure, the embryos formed after the fertilization of male and female gametes are allowed to grow for 3-5 days and then transferred back to the uterine cavity of the female, where they might get attached and start to grow. Objective of this study was to compare clinical pregnancy rate of fresh embryo transfers and frozen-thawed embryo transfers.Methods: This is a retrospective case control study in patients undergoing IVF /ICSI cycles from January 2018 to December 2018 were enrolled in assisted reproduction. Total of 200 women which contains 118 fresh embryo transfers and 82 frozen-thawed embryo transfers are studied.Results: Clinical pregnancy rates of fresh cleavage-stage embryo transfers compared with frozen-thawed cleavage-stage embryo transfers, were (53.3% versus 39.6%). Ectopic pregnancy is also significant in comparison. In patients under 35 years of ages and (57.1% versus 12.5%). In patients older than 35 years old, respectively. The multiple pregnancy rates, abortion rates and ectopic pregnancy rates did not differ significantly among the groups. Multiple pregnancy rate and abortion rate is significantly high in frozen-thawed blastocyst transfer than fresh embryo transfer. Whereas the ectopic pregnancy rates had no difference in both groups.Conclusions: The clinical pregnancy rates in fresh embryo transfer is high than that of frozen-thawed blastocyst.

Single embryo transfer and multifetal pregnancy reduction: perception and attitude of women seeking assisted reproduction in Nigeria

Background: In-vitro fertilization (IVF) is associated with increased multiple pregnancy and its attendant complications. This study evaluates the attitude and acceptance of single embryo transfer (SET) and multifetal pregnancy reduction (MFPR) by clients assessing assisted reproduction in this region.Methods: A cross sectional survey of patients selected for IVF was conducted. Information on demography, knowledge of IVF procedure and their perception, attitude and acceptability of multiple pregnancy as well as their knowledge, attitude and perception to single embryo transfer and multifetal pregnancy reduction were extracted for statistical analysis.Results: Seventy-three women participated in the study. The mean age was 39 years and mean duration of infertility was 8.6 years. Only 3 (4.1%) respondents agreed to have SET as the overwhelming majority (70) 95.9% preferred 2 or more and they felt the more number of embryo transferred the better the chances of achieving pregnancy. Similarly most respondents, 38.4% (28) did not accept MFPR. Most respondents considered age (63%) and duration of infertility (78.1%) as major influencing factor for rejecting SET. Over 75% of respondents said they will still accept multiple embryos transferred despite knowledge of the possible complications.Conclusions: While most infertile women in our sub region appear to recognize the risks with multiple pregnancy, they are less interested in SET or MFPR because they perceive more embryos transferred as a means to maximize treatment outcome. Government funding, client education and a blastocyst transfer protocol may improve acceptability as well as overall preference for less number of embryos transferred in our environment.

Obstetric outcome in elderly gravida

Background: Maternal age is an important determinant of the outcome of pregnancy. Advanced maternal age generally signify age after 35 years at the time of delivery. It is associated with decreased fertility and increased risk. Elderly gravida is associated with many complications during pregnancy, labour and also for the baby. In recent times women has changed their lifestyles such as pursuit of higher education and entry into work forces and career advancement outside the home.Methods: This was a retrospective study done in 57 elderly pregnant women more than 33 years age, over a period of 18 months, conducted in a multi-specialty hospital.Results: 57 elderly pregnant women were selected for the study. 47% were in age group of 33-35 years and 42% were in age group of 36-40 years. 61.40% patients were housewives and 38.59% were employed. 50.8% of patients had history of previous abortions and 35% were conceived after treatment for sterility. 64.9% of patients conceived spontaneously and 35% by assisted reproductive technology. Majority of patients (33.3%) required Invitro-fertilization. Multiple pregnancy was high- 21.05%. Hypertension was observed in 26.3% of patients, Antepartum haemorrhage in 4.34%,  Preterm delivery  49.1%, Induction of labour in 10.52%, Normal vaginal delivery only in14%. Majority of patients (80.7%) were delivered by caesarean section.Conclusions: Elderly pregnant patients have higher risks of specific pregnancy complications which contribute to a higher frequency of maternal morbidity and greater health care costs. The risks are due to Hypertension, diabetes, multiple pregnancy, preterm labour, antepartum haemorrhage, PROM, malpresentation, prolonged labour, increased caesarean section rate and postpartum haemorrhage.

Spontaneous heterotopic triplet pregnancy with a two viable intrauterine embryos and an ectopic one with right tubal rupture / Gravidez heterópica tripla espontânea com dois embriões intrauterinos viáveis e um ectópico com ruptura da tuba uterina direita

Abstract Heterotopic pregnancy (HP) is defined as the simultaneous development of an intra- and an extra uterine gestation. The occurrence of a spontaneous triplet HP is an exceptionally rare medical condition. We report the case of a young woman with spontaneous heterotopic triplets at 8weeks of gestation, with amisdiagnosis of topic twins and acute appendicitis. The ectopic tubal pregnancy was ruptured and a salpingectomy was performed by laparotomy. The intrauterine pregnancy progressed uneventfully. The two healthy babies were delivery by cesarean section at 36 ± 2 weeks of gestation. Heterotopic triplets with ruptured tubal ectopic pregnancy represent a special diagnostic and therapeutic challenge for the obstetrician. A high rate of clinical suspicion and timely treatment by laparotomy or laparoscopy can preserve the intrauterine gestation with a successful outcome of the pregnancy.

Resumo A gravidez heterotópica é definida como o desenvolvimento simultâneo de uma gestação intra- e extra-uterina. A ocorrência de gravidez tripla heterotópica espontânea é uma condição médica excepcionalmente rara. Relatamos o caso de uma jovem com gravidez tripla espontânea, às 8 semanas de gestação, com um diagnóstico errôneo de gêmeos tópicos e apendicite aguda. A gravidez tubária ectópica estava rota e uma salpingectomia foi realizada por laparotomia. A gravidez intrauterina progrediu sem intercorrências. Os bebês nasceramsaudáveis por cesariana realizada às 36 semanas de gestação.Agravidez de heterotópicos comectopia e rotura tubária é umdesafio diagnóstico e terapêutico.Umalto índice de suspeita e tratamento oportuno por laparotomia ou laparoscopia podem preservar a gestação intrauterina com um resultado bem sucedido da gravidez tópica.

Parto diferido o asincrónico del segundo gemelo: un caso clínico con buen desenlace neonatal / Delayed interval delivery or asynchronous birth of the second twin: a case report with a good outcome neonatal

Resumen ANTECEDENTES: El parto diferido o asincrónico ocurre cuando los fetos de un embarazo múltiple nacen con una diferencia de días o semanas. La finalidad es incrementar la edad gestacional del segundo gemelo y aumentar la tasa de supervivencia. CASO CLÍNICO: Paciente primigesta de 39 años, con embarazo gemelar bicorial, biamniótico logrado mediante fertilización in vitro. En la semana 23 + 2 acudió a urgencias por sangrado vaginal y dolor abdominal. En la especuloscopia se observó líquido amniótico claro y dilatación cervical de 4-5 cm. El registro cardiotocográfico reportó dinámica uterina franca. En la ecografía se visualizaron dos fetos: el primero en presentación podálica sin latido cardiaco y el segundo en transversa con latido cardiaco. Después del nacimiento del primer gemelo se observó la retracción del cuello uterino y desaparición de la dinámica uterina. El estudio ecográfico mostró la bolsa amniótica íntegra, sin signos de desprendimiento placentario ni pérdida del bienestar fetal. Se propuso a la pareja la posibilidad de realizar un cerclaje cervical y diferir el parto del segundo gemelo, hecho que fue aceptado. Se consiguió prolongar la gestación del segundo gemelo 77 días, que nació mediante parto, sin morbilidad materna ni fetal. CONCLUSIONES: El parto diferido es una práctica adecuada para incrementar la tasa de supervivencia del feto o fetos retenidos. Los protocolos asociados con este tipo de partos son variados. Se requieren estudios adicionales para establecer los criterios de tratamiento de este tipo de partos.

Abstract BACKGROUND: Delayed Interval delivery or asynchronous birth is when a multiple pregnancy`s fetuses are not born simultaneously, and with several day´s difference between their births. This practice´s objective is to increase the second twin´s gestational age and, as such, improve its survival rate. CLINICAL CASE: A 39 years-old patient with bicorial biamniotic twin pregnancy achieved by in vitro fertilization. At 23 + 2 weeks of pregnancy assisted to Emergency service for vaginal bleeding and abdominal pain. In the speculoscopy a clear amniotic fluid and cervical dilation of 4-5 cm was observed. The cardiotocographic record reported frank uterine dynamics. In the ultrasound, two files are displayed: the first in the syntax presentation in the heartbeat and the second in the transversal with heartbeat. After the birth of the first twin, retraction of the cervix and the disappearance of uterine dynamics were observed. The ecological study showed the amniotic bag intact, without signs of placental detachment or loss of fetal well-being. It was proposed to the couple the possibility of performing the cervical fence and the other part of the second day, which was accepted. It was possible to prolong the gestation of the second year to 77 days, which was born through childbirth, without registering maternal or fetal morbidity. CONCLUSIONS: Delayed Interval delivery is a good practice to increase the survival rate of a retained fetus or retained fetuses. The protocols associated with this type of births are varied. Additional studies are required to establish treatment criteria for this type of births.

Successful delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a twin pregnancy / 영남의대학술지

There has been a significant increase in the number of multiple pregnancies that are associated with a high risk of preterm delivery among Korean women. However, to date, delayed-interval delivery in women with multiple pregnancy is rare. We report a case of delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a dichorionic diamniotic twin pregnancy. The patient presented with vaginal leakage of amniotic fluid at 16 weeks of gestation and was diagnosed with a preterm premature rupture of membranes. Three days later, the first twin was delivered, but the neonate died soon after. The second twin remained in utero, and we decided to retain the fetus in utero to reduce the morbidity and mortality associated with a preterm birth. The patient was managed with antibiotics and tocolytics. Cervical cerclage was not performed. The second twin was delivered vaginally at 34 weeks and 5 days of gestation, 128 days after the delivery of the first-born fetus. This neonate was healthy and showed normal development during the 1-year follow-up period. Based on our experience with this case, we propose that delayed-interval delivery may improve perinatal survival and decrease morbidity in the second neonate in highly selected cases.

Experience of Decision Making about Selective Fetal Reduction among Women Who Conceived through Assisted Reproductive Techniques / 임상간호연구

PURPOSE: This study aimed to explore and understand the experience of decision making among women undergoing or forgoing selective fetal reduction who have higher-order multiple pregnancies through assisted reproductive techniques. METHODS: A qualitative study was conducted from August 1, to October 30, 2013. Eight participants were interviewed and the interviews were audio-recorded and transcribed verbatim. Six persons participated in in-depth interviews in person and two participated over the telephone. A thematic analysis was conducted. RESULTS: Four themes were identified and carefully named: Confusion after higher-order multiple pregnancy; Obstacles to choice: Uncertain safety; Weighing between reality and ideality and; Influences of medical professionals. CONCLUSION: The results demonstrated a wide range of factors considered by women when making decisions about selective fetal reduction, and mothers'feelings of conflict and distress in the decision-making process. The results suggest that it is important for nurses to provide emotional support and consolation, in addition to sufficient information. These findings will help nurses improve their counseling techniques by understanding the situation of infertile couples.

Gestación cuádruple: reporte de caso y revisión de la literatura / Quadruplet pregnancy: case report and review of the literature

RESUMEN Objetivo: Reportar un caso de embarazo cuádruple y revisar la literatura disponible con respecto a la edad gestacional en la que se identifica el tipo de placenta (mono o policoriónica) en la que finaliza el embarazo, el peso del recién nacido y la frecuencia del cuidado prenatal de este tipo de gestaciones. Materiales y métodos: Se presenta del caso de una mujer con embarazo cuádruple secundario a técnica de reproducción asistida, atendida en una institución de cuarto nivel de complejidad, ubicada en la ciudad de Bucaramanga, Colombia. Se realizó una revisión de la literatura publicada en las bases de datos Medline vía PubMed, Embase, SciELO y UptoDate® con los términos de búsqueda: "embarazo múltiple", "cuádruples", "atención prenatal" y "resultado perinatal". La búsqueda se limitó por idioma (artículos en inglés y español). Resultados: Se recuperaron 19 referencias que cumplían con los criterios de inclusión y de exclusión. No hay información sobre la frecuencia con la que se debe hacer el control prenatal. El tipo de placenta se pudo establecer entre las semanas 9 y 25; la edad gestacional varió entre 26 y 34 semanas. El peso varió entre 1.076 y 1.770 g. Los embarazos multigestación se acompañan frecuentemente de complicaciones maternas y perinatales. Conclusiones: El diagnóstico del embarazo cuádruple puede hacerse temprano en la gestación. Frecuentemente se acompaña de prematuridad y bajo peso al nacer. Se requieren estudios que evalúen el manejo más seguro y efectivo de esta condición.

ABSTRACT Objective: To report the case of a quadruplet pregnancy and conduct the review of the available literature regarding gestational age at which the type of placenta (monochorionic or polychorionic) is identified, the gestational age at which the pregnancy comes to an end, the weight of the neonate, and the frequency of prenatal care in this type of gestation. Materials and methods: Case report of a woman with a quadruplet pregnancy secondary to assisted reproduction technique, seen at a Level IV complexity centre in the city of Bucaramanga, Colombia. A review of the literature was conducted in Medline vía PubMed, Embase, SciELO and UptoDate® databases using the search terms "multiple pregnancy," "quadruplets," "prenatal care," and "perinatal outcome". The search was limited by language to articles in English and Spanish. Results: Overall, 19 references that met the inclusion and exclusion criteria were retrieved. There is no information on the required frequency of prenatal visits. It was possible to identify the type of placenta between 9 and 25 weeks; gestational age varied between 26 and 34 weeks. Weight varied between 1,076 and 1,770 g. Multigestation pregnancies are frequently associated with maternal and perinatal complications. Conclusions: Quadruplet pregnancies may be diagnosed early in the gestation. They are frequently associated with prematurity and low birth weight. Further studies are required in order to assess the safest and most effective way of managing this condition.

Clinical outcomes of single versus double blastocyst transfer in fresh and vitrified-warmed cycles / 대한생식의학회지

OBJECTIVE: Assisted reproductive technology has been associated with an increase in multiple pregnancies. The most effective strategy for reducing multiple pregnancies is single embryo transfer. Beginning in October 2015, the National Supporting Program for Infertility in South Korea has limited the number of embryos that can be transferred per in vitro fertilization (IVF) cycle depending on the patient's age. However, little is known regarding the effect of age and number of transferred embryos on the clinical outcomes of Korean patients. Thus, this study was performed to evaluate the effect of the number of transferred blastocysts on clinical outcomes. METHODS: This study was carried out in the Fertility Center of CHA Gangnam Medical Center from January 2013 to December 2014. The clinical outcomes of 514 women who underwent the transfer of one or two blastocysts on day 5 after IVF and of 721 women who underwent the transfer of one or two vitrified-warmed blastocysts were analyzed retrospectively. RESULTS: For both fresh and vitrified-warmed cycles, the clinical pregnancy rate and live birth or ongoing pregnancy rate were not significantly different between patients who underwent elective single blastocyst transfer (eSBT) and patients who underwent double blastocyst transfer (DBT), regardless of age. However, the multiple pregnancy rate was significantly lower in the eSBT group than in the DBT group. CONCLUSION: The clinical outcomes of eSBT and DBT were equivalent, but eSBT had a lower risk of multiple pregnancy and is, therefore, the best option.

Pregnancy outcomes and nursing of 204 cases of multiple pregnancies undergoing transvaginal multifetal pregnancy reduction / 现代临床护理

Objective To analyze the pregnancy outcomes of 204 cases of multiple pregnancies following early transvaginal fetal reduction and sum up the experiences of peri-operation nursing care. Methods A total number of 204 twin and triplet pregnancies under treatment in the reproductive medical center from Jan. 2009 to Dec. 2012 were involved in the study. All patients underwent transvaginal multifetal pregnancy reduction during pregnancy of 7 to 8 weeks . The pregnancy outcomes were analyzed , and the nursing measures including preoperative preparation , intraoperative cooperation and postoperative nursing were analyzed . Result The successful rate of multifetal reduction was 100%, and the rate for taking the infants home reached 77.0% ~ 92.3%. Conclusion The outcomes of multifetal reduction for the twin or triplet pregnancy are good . Such nursing measures as perioperative mental care , intraoperative cooperation and postoperative follow-up are key to the alleviation of mental pressure during operation , raise of the success rate of fetal reduction and prevention of postoperative complications.

Ethical Consideration about Assisted Reproductive Technology Implementation / 中国医学伦理学

Through ethical analysis of the conflicts appearing in four special cases in the four steps of assisted reproductive technology implementations, this paper pointed out the measures to solve them in the perspective of le-gal protection, standardized management, ethical supervision, and self-regulation for making the research and ap-plication of assisted reproductive technology serve patients better and promoting the healthy development of assisted reproductive technology.

Implicancias epidemiológicas de la gestación múltiple en la salud pública

En los últimos años la gestación múltiple ha experimentado un aumento en su incidencia, posiblemente en relación a factores sociodemográficos, entre los cuales toma relevancia la postergación de la maternidad y también factores médicos (tratamientos de infertilidad), teniendo como consecuencia el aumento de las complicaciones y riesgos asociados, entre las cuales destaca la prematuridad, el riesgo de parálisis cerebral y complicaciones tales como la enfermedad hipertensiva de la gestación, hiperémesis, diabetes gestacional, entre otras.

Multiple gestation pregnancy rates have increased in recent years possibly related to socio-demographic factors including deferral of motherhood and some medical factors like fertility treatments. Associated complications including prematurity, cerebral palsy, hypertensive disease of pregnancy, hyperemesis, gestational diabetes have also increased.

Preclampsia en la gestación múltiple

Se presenta una reseña de lo conocido sobre la asociación de la preeclampsia y el embarazo múltiple, haciendo una somera actualización sobre la fisiopatología de la preeclampsia y su ocurrencia en el embarazo múltiple de acuerdo a la variedad y número de fetos, señalando la importancia de su detección temprana con la historia clínica, factores asociados, la flujometría Doppler y los marcadores bioquímicos actualmente utilizados. Se destaca el aumento del embarazo múltiple en las últimas décadas por los tratamientos de fertilización asistida, la prevención asumida por los centros de fertilidad en la transferencia de embriones y el manejo oportuno de estos casos obstétricos complejos.

An outline of what is known on the association of preeclampsia and multiple pregnancy is presented including a short review on the pathophysiology of preeclampsia, its occurrence according to the variety and number of fetuses, its importance of early detection byeither clinical associated factors, Doppler velocimetry and biochemical markers. Emphasis is done on the increase of multiple pregnancy in the last decades due to assisted reproduction tech­ niques that has resulted in preventive measures in fertility centers on the number of embryos transferred. Timely management of this complex obstetrical problem is suggested.

Evaluación y manejo del embarazo múltiple en el centro obstétrico del Hospital Carlos Andrade Marín 2012 - 2014 / Evaluation and handling of multiple pregnancy in the Obstetric Center of Carlos Andrade Marin Hospital 2012 ­ 2014

Introducción: el embarazo múltiple constituye una condición gestacional cada vez más frecuente. Materiales y métodos: es un estudio retrospectivo de fuente documentada, revisando los libros del Centro Obstétrico y los datos obtenidos de las Historias Clínicas, mediante el formato electrónico AS400. Resultados: se presenta el análisis de los últimos 3 años de evolución del Centro Obstétrico del Hospital Carlos Andrade Marín, en el cual se determina factores relacionados a este tipo de embarazo. Sorprende la alta tasa de embarazos múltiples en primigestas (82%), pero igualmente se encuentra que existe una buena planificación para su ingreso desde la Consulta Externa, consiguiendo disminuir significativamente la morbilidad. La edad gestacional y los pesos de los neonatos, son bastante satisfactorios, situación que permite concluir que la atención brindada a las pacientes y sus recién nacidos es óptima. Como siempre se acompañan patologías, como las contracciones prematuras y la preeclampsia, como las patologías predominantes. Conclusiones: el Centro Obstétrico del Hospital Carlos Andrade Marín, tiene un manejo preventivo y adecuado para el embarazo múltiple, disminuyendo en forma notable los riesgos maternos y perinatales.

Introduction: multiple pregnancy is an increasingly common gestational condition. Materials and methods: a retrospective study of documented sources, reviewing the logs of the Obstetric Center and the data obtained from clinical histories, using the electronic form AS400. Results: the analysis of the last three years of evolution of Obstetric Center of the Carlos Andrade Marín Hospital in which factors related to this type of pregnancy is determined is presented. Surprised by the high rate of multiple pregnancies in primiparous (82%), but also that there is good planning for income from the Outpatient, achieving significantly reduced morbidity. Gestational age and weights of infants are quite satisfactory, which concludes that the situation of care provided to patients and their newborns is optimal. As always, pathologies such as preterm labor and preeclampsia, as the prevailing conditions are attached. Conclusions: the Obstetric Center at the Carlos Andrade Marin Hospital has a prevention and adequate management of multiple pregnancies, dramatically reducing maternal and perinatal risks.