Síndrome HELLP y rotura hepática en un embarazo gemelar: presentación de un caso / HeLLP Syndrome and Hepatic Rupture in a Twin Pregnancy: A Case Report / Síndrome HeLLP e ruptura hepática em gestação gemelar: relato de caso

Introducción: el síndrome HELLP y rotura hepática es una complicación poco frecuente, especialmente en casos de embarazo gemelar. Se presenta el caso de un hematoma subcapsular hepático roto por síndrome HELLP que complicó un embarazo gemelar que requirió una cesárea de emergencia y para el manejo de la hipovolemia, el empaquetamiento hepático. Presentación del caso: mujer de 41 años, con gestación gemelar de 35 semanas, quien acudió al servicio de emergencia, por contracciones uterinas y ausencia de movimientos fetales. Ante una bradicardia severa de ambos fetos, se optó por una cesárea de urgencia. Al abrir la cavidad abdominal, se encontró hemoperitoneo y se logró extraer ambos fetos vivos. Se realizó una laparotomía media, supra e infraumbilical exploradora (poscesárea) y se halló una rotura hepática del lóbulo derecho. Se procedió a un empaquetamiento hepático con compresas y cierre temporal abdominal; entre tanto, el manejo del shock hipovolémico y la preeclampsia se continuó en la unidad de cuidados intensivos. La paciente se fue de alta en buenas condiciones a los 21 días. Conclusión: el síndrome HELLP produce complicaciones graves, como rotura hepática, que si no es tratada de forma correcta, temprana y multidisciplinaria, puede llevar a producir mortalidad materno-perinatal.

Introduction: HELLP syndrome and hepatic rupture are rare complications, especially in the case of twin pregnancy. Here, we present a case of ruptured hepatic subcapsular hematoma due to HELLP syndrome that caused complication in a twin pregnancy. This case required emergency Cesarean section and management of hypo- volemia hepatic packing. Case presentation: A 41-year-old female pregnant with twins (35 weeks) came to the emergency room for uterine contractions and absence of fetal movements. Due to severe bradycardia in both fetuses, emergency Cesarean section was performed. When the abdominal cavity was opened, hemoperitoneum was found, and both fetuses were extracted alive. A median, supra-, and infraumbilical exploratory laparotomy (post Cesarean section) was performed, and right lobe hepatic rupture was found. Subsequently, hepatic packing with compression and temporary abdominal closure was performed. Hypovolemic shock and preeclampsia was continuously managed in the intensive care unit. At 21 days, the patient was discharged in good condition. Conclusion: HELLP syndrome causes serious complications, such as hepatic rupture, which may lead to maternal and perinatal mortality if not correctly treated early in a multidisciplinary manner.

Introdução: a síndrome HELLP e a ruptura hepática são complicações raras, especialmente em casos de gravidez gemelar. Neste artigo, apresentamos o caso de um hematoma subcapsular hepático rompido devido à síndrome HELLP que complicou uma gravidez gemelar que exigiu uma cesariana de emergência e tamponamento hepático para o manejo da hipovolemia. Apresentação do caso: mulher, 41 anos, gestação gemelar de 35 semanas, recorre ao pronto-socorro por contrações uterinas e ausência de movimentos fetais. Devido à bradicardia grave em ambos os fetos, foi decidida uma cesariana de emergência. Ao abrir a cavidade abdominal o hemoperitônio é localizado, sendo possível extrair ambos os fetos vivos. Foi realizada laparotomia exploradora mediana, supra e infraumbilical (pós-cesariana) sendo constatada ruptura hepática do lobo direito. Foi realizado tamponamento hepático com compressas e fechamento abdominal temporário, e o manejo do choque hipovolêmico e da pré-eclâmpsia foi mantido na Unidade de Terapia Intensiva, onde a paciente recebeu alta em boas condições após 21 dias. Conclusão: a síndrome HELLP produz complicações graves como a ruptura hepática que, se não tratada de forma precoce e multidisciplinar, pode levar à mortalidade materna perinatal.

Characteristics of the oral glucose tolerance test in women with different pre-pregnancy body mass index and the effect of gestational diabetes mellitus on twin pregnancy outcomes

Abstract Objective This study aimed to investigate the mid-pregnancy blood glucose levels of women with singleton or twin pregnancies. Method The relationship between blood glucose levels and Gestational Diabetes Mellitus (GDM) was studied in women with different pre-pregnancy Body Mass Index (BMI), and the effect of GDM on twin pregnancy outcomes was analyzed. Women with twin (n= 1,985) and singleton (n= 1,985) pregnancies were categorized into underweight (BMI < 18.5 kg/m2, n= 597), normal weight (BMI: 18.5-23.9 kg/m2, n= 2,575), and overweight/obese (BMI ≥ 24 kg/m2, n= 798) groups. Results The incidence of GDM was 21.01% in women with twin pregnancies. Among the women with GDM in twin pregnancies, 38.37% had at least two abnormal blood glucose levels. The incidence of these parameters increased with preconception BMI, and the incidence of twin pregnancies was higher than that of singleton pregnancies (p < 0.001). In the normal weight and overweight/obese group, the oral glucose tolerance test glucose level and incidence of GDM were higher in women with twin than singleton pregnancies (p < 0.05). For twin pregnancies, the prevalence of selective fetal growth restriction was higher and anemia was lower in the GDM group than in the non-GDM group (all p < 0.05). Conclusion Therefore, a greater emphasis should be placed on BMI before conception, and well-controlled GDM does not increase adverse pregnancy outcomes for twin pregnancies.

Biometry and pathological ultrasound findings in multiple pregnancies / Características ecográficas y hallazgos patológicos en embarazos múltiples

Resumo Objectives: to determine the prevalence of pathological findings according to the type of chorionicity in pregnancies in two institutions in Bogotá, Colombia. Methods: descriptive, retrospective, cohort study. Biometric variables were calculated, and pathological findings were evaluated according to the type of chorionicity in multiple pregnancies. Statistical characterization was performed with absolute frequencies, calculation of relative frequencies in qualitative variables, standard deviation measures, median and interquartile range. In addition, a descriptive analysis of the information was carried out. Results: 528 studies were carried out in 141 pregnant women, 98.5% (n = 139) twins and 1.4% (n = 2) triplets. A prevalence of 35.4% of fetal complications was calculated. The most frequent was fetal growth restriction (p=0.37). According to each type of chorionicity, fetal growth restriction was presented in 50% (1/2) of the trichorionics, 16.6% (7/42) of the monochorionics, and 11.3% (11/97) of the dichorionics. Conclusion: fetal growth restriction was the most common finding, both in trichorionics, monochorionics and dichorionics pregnancies.

Resumen Objetivos: el objetivo del estudio fue determinar la prevalencia de los hallazgos patológicos ecográficos en embarazos múltiples de acuerdo con la corionicidad en dos instituciones en Bogotá-Colombia. Métodos: estudio de cohorte, descriptivo, retrospectivo. Las variables biométricas realizadas y los hallazgos patológicos se evaluaron de acuerdo con el tipo de embarazo gemelar. Se realizó caracterización estadística con frecuencias absolutas, cálculo de frecuencias relativas en variables cualitativas, medidas de desviación estándar, mediana y rango intercuartílico. Además, se realizó análisis descriptivo de la información. Resultados: se realizaron 528 estudios en 141 gestantes, encontrando 98,5% (n=139) gemelares y 1,4% (n=2) triples. Se calculó una prevalencia de 35,4% de complicaciones fetales siendo más frecuente la restricción del crecimiento fetal (p=0,37). Según la corionicidad, esta complicación se presentó en 50% (1/2) de los tricoriónicos, 16,6% (7/42) de los monocoriónicos y 11,3% (11/97) de los dicoriónicos. Conclusión: la restricción del crecimiento fetal fue el hallazgo más común en los embarazos múltiples en la población estudiada.

Embarazo gemelar espontáneo en útero bicorpóreo: una contribución a la experiencia / Spontaneous twin pregnancy in a bicorporeal uterus, a contribution to the experience

Resumen ANTECEDENTES: Las anomalías uterinas congénitas son consecuencia de la formación anormal, fusión o reabsorción de los conductos de Müller durante el desarrollo embriológico. El útero bicorne, unicorne y didelfo (U1, U2, U3 ESHRE-ESGE) son defectos en la unificación con una baja prevalencia en la población general y en la que tiene antecedente de aborto e infertilidad; se estima en alrededor de 0.4 a 1.1%, respectivamente. La presentación del caso puede aportar información útil relacionada con la evolución del embarazo y los desenlaces perinatales cuando aparece esta anomalía. CASO CLÍNICO: Paciente de 35 años, con amenorrea secundaria y prueba inmunológica de embarazo positiva, con antecedentes de dismenorrea primaria severa y anomalía uterina congénita compatible con útero bicorpóreo (U3 completo ESHRE-ESGE), bicorne completo (4a-AFS) y didelfo. El embarazo trascurrió sin complicaciones hasta la semana 37, cuando finalizó mediante cesárea, con hipotonía uterina que no ameritó transfusión de hemoderivados. CONCLUSIÓN: Los embarazos gemelares con útero bicorne son excepcionales y casi todos se logran espontáneamente; los que llegan a término finalizan mediante cesárea electiva.

Abstract BACKGROUND: Congenital uterine anomalies are the result of abnormal formation, fusion, or resorption of the Müllerian ducts during embryological development. The bicornuate, unicornuate and didelphic uterus (U1, U2, U3 ESHRE/ESGE), are unification defects with a low prevalence both in the general population and in the population with a history of abortion and infertility, is estimated at around 0.4 to 1.1%, respectively. The presentation of the case can provide useful information related to with the evolution of the pregnancy and the perinatal outcomes when this anomaly appears. CLINICAL CASE: A 35-year-old patient with secondary amenorrhea and a positive immunological pregnancy test with a history of severe primary dysmenorrhea and previous magnetic resonance imaging with a congenital uterine anomaly compatible with a bicorporeal uterus (U3 complete ESHRE-ESGE), complete bicornuate (4a /AFS) , uterus didelphys (ASRM). The pregnancy was uncomplicated until 37 weeks, when it was terminated by cesarean section, with uterine hypotonia that did not require transfusion of blood products. CONCLUSION: Twin pregnancy with bicornuate uterus is a rare entity, most of them have been achieved spontaneously and those that reach term have been resolved by elective cesarean section.

HPLC-MS/MS method for determination of betamethasone in human plasma with application to a dichorionic twin pregnancy pharmacokinetic and placental transfers studies

Abstract Betamethasone (BET) is a synthetic glucocorticoid recommended for pregnant women at imminent risk of preterm birth before 34 weeks to reduce neonatal complications. There are different techniques to describe BET plasma quantification. However, none quantified the plasmatic concentration of BET in dichorionic (DC) twin pregnancies using LC-MS. Our objectives were to develop and validate a method for quantifying BET by LC-MS for pharmacokinetic (PK) and placental transfer studies in DC twin pregnancies. Blood samples were collected after intramuscular administration of a single BET dose containing 6 mg disodium phosphate + 6 mg acetate. BET was determined in plasma by liquid-liquid extraction. The method showed linearity in the range of 2-250 ng/mL, as well as precision and accuracy with a coefficient of variation and relative standard errors ≤ 15%. Additionally, the method presented selectivity and did not present matrix or carry-over effect. Stability tests also presented coefficient of variation and relative standard errors ≤ 15%. This is the first study which describe maternal and fetal plasma concentrations of BET in a DC twin pregnancy. The BET PK parameters were AUC0-∞, CL/F, Vd/F, Cmax, Tmax of 292.20 h*ng/mL, 39.08 L/h, 278.72 L, 25.55 ng/mL and 0.58 h, respectively. The placental transfer ratios of umbilical vein/maternal vein and intervillous space/maternal vein were 0.14 and 0.19 and 0.40 and 0.27 for both twins, respectively. However, a clinical study with more subjects is imperative to confirm this higher concentration of BET in the intervillous space

Útero bicorporeo - doble cérvix con embarazo gemelar en una sola cavidad uterina: reporte de caso / Bicorporeo uterus - double cervix with twin pregnancy in a single uterine cavity: case report

El embarazo gemelar en una de las cavidades uterinas del útero bicorpóreo es una rara presentación clínica. La viabilidad de este tipo de embarazo es de baja probabilidad, dado que esta malformación puede condicionar parto prematuro, placentación anormal, restricción del crecimiento fetal o progresión anormal del trabajo de parto. Se presenta un caso de un útero bicorpóreo con doble cérvix y una gestación gemelar en unas de las cavidades uterinas, con muerte fetal de uno de los fetos y parto pretérmino de 28 semanas del otro gemelo. Dada la rareza de la presentación se describen el caso y los hallazgos imagenológicos representativos.

Twin pregnancy in one of the uterine cavities of the bicoporous uterus is a rare clinical presentation. The viability of this type of pregnancy is unlikely since this malformation can lead to premature delivery, abnormal placentation, fetal growth restriction or abnormal progression of labor. We present a case of bicoporous uterus with double cervix with twin pregnancy in one of the uterine cavities, with stillbirth of one of the fetuses and preterm delivery of the other twin at 28 weeks. Given the rarity of the presentation, the case and representative imaging findings are described.

Anastomosis placentarias en embarazos gemelares monocoriales: estudio mediante técnicas de inyección vascular y relación con complicaciones fetales / Placental anastomoses in monochorionic twin pregnancies: study using vascular injection techniques and relationship with fetal complications

RESUMEN Introducción. Los embarazos gemelares son clasificados en dos grupos: monocoriónico (MC) y dicoriónico (DC). Los gemelos MC tienen 5 a 6 veces más riesgo de tener un resultado perinatal adverso. Se publica el estudio de un grupo de 22 placentas de pacientes con embarazo gemelar monocoriónico que presentaron complicaciones como síndrome de transfusión feto-fetal (STFF), secuencia de anemia policitemia (TAPS), perfusión arterial reversa (TRAP) y restricción de crecimiento intrauterino selectivo (RCIU-s). Objetivo . Determinar los tipos de anastomosis predominantes en las placentas con síndrome de transfusión feto-fetal, secuencia de anemia policitemia, síndrome de perfusión arterial reversa y restricción de crecimiento selectivo. Metodología . Se aplicó la técnica de inyección vascular placentaria para el reconocimiento de las anastomosis. Resultados . El número medio de anastomosis por placenta en el STFF (que fue la complicación más severa) fue de 8,2 ± 2,2. Las anastomosis AV y VA predominaron en un 83%. Hubo signos de discordancia placentaria en 30% de las placentas, y un 40% de placentas presentaron cordón de inserción velamentosa. Conclusiones. Las anastomosis vasculares no solo están implicadas en la etiología de las principales patologías propias de gestaciones monocoriónicas, sino que también influyen en su manejo. Creemos que un adecuado estudio placentario de cada uno de estos casos mediante la técnica de inyección vascular placentaria sería indispensable en los centros que aspiran a desarrollar manejos diferenciados de terapia fetal para cada una de estas complicaciones.

ABSTRACT Introduction: Twin pregnancies are classified into two groups: monochorionic (MC) and dichorionic (DC). MC twins are 5 to 6 times more likely to have an adverse perinatal outcome. The study of a group of 22 placentas from patients with monochorionic twin pregnancy who presented with complications such as feto-fetal transfusion syndrome (FFTS), twin anemia polycythemia sequence (TAPS), twin reverse arterial perfusion syndrome (TRAP) and selective intrauterine growth restriction (sIUGR) is presented. Objective: To determine the predominant types of anastomoses in placentas with feto-fetal transfusion syndrome, twin anemia polycythemia sequence, reverse arterial perfusion syndrome and selective intrauterine growth restriction. Methodology: The placental injection technique was applied for the recognition of anastomoses. Results: The mean number of anastomoses per placenta in STFF, which was the most severe complication, was 8.2 ± 2.2. The AV and VA anastomoses predominated in 83%. There were signs of placental discordance in 30% of placentas, and 40% of placentas presented velamentous cord insertion. Conclusions: Vascular anastomoses are not only involved in the etiology of the main pathologies of monochorionic gestations, but also influence their management. We believe that an adequate placental study of each of these cases by means of the placental vascular injection technique would be essential in centers that aspire to develop differentiated fetal management for each of these complications.

Value of fetal ultrasonography index in twin fetal heart malformation screening at 11-13 + 6 weeks of gestation / 中华超声影像学杂志

Objective:To investigate the clinical value of fetal ultrasonography in the screening of congenital heart malformations in twins at 11-13 + 6 weeks of gestation. Methods:A retrospective cohort study method was used.Cases were collected from Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital (January 2012 to December 2016) and the Fourth Hospital of Shijiazhuang City (January 2014 to December 2018). The twins with singleton or twins with cardiac malformation were screened out as the cardiac malformation group, and the twins with normal delivery during the same period were selected as the control group. Ultrasound data such as the nuchal translucency (NT), crown-rump-length (CRL), chorionicity, conception method, NT discordance, CRL discordance, NT discordance ≥20% incidence rate between twins, and the CRL discordance ≥10% incidence rate between twins in the two groups at 11-13 + 6 weeks were compared and analyzed. Results:①There were 30 cases in the cardiac malformation group (including 27 twins with singleton cardiac malformation and 3 twins with twin cardiac malformation) and 1 906 cases in the control group. ②The incidence rates of NT value ≥95th percentile and NT value ≥99th percentile in one or two pregnancies were significantly higher in the cardiac malformation group than in the control group (20.00% vs 2.20%, P<0.001; 10.00% vs 0.63%, P=0.002), the area under the ROC curve (AUC) for cardiac malformation screening was 0.589 and 0.549, respectively; CRL discordance in cardiac malformation group was higher than that in control group ( P=0.018), the incidence of CRL discordance ≥10% in the cardiac malformation group was higher than that in the control group (26.67% vs 12.70%, P=0.024), the AUC of cardiac malformation screening was 0.570; there were no significant differences in the incidence of NT discordance, the incidence of NT discordance ≥20%, pregnancy pattern and chorionicity between the two groups (all P>0.05). ③Multivariate Logistic regression analysis was performed using the incidence rates of NT value ≥95% and NT value ≥99%, CRL discordance ≥10%, and NT discordance ≥20%. The incidences of fetal NT value ≥95% and NT value ≥99% were risk factors for cardiac malformation in twins ( OR=11.095, 105.778; 95% CI=4.311-28.558, 16.984-658.796). Conclusions:Ultrasound at 11-13 + 6 weeks of gestation showing thickened value of one or two fetuses, and the CRL discordance≥10%, indicates an increased risk of cardiac malformation in the twins; NT value ≥95% and NT value ≥99% is a risk factor for heart defects in twins.

Clinical analysis on the influencing factors related to preterm twin pregnancy

SUMMARY OBJECTIVE: The aim of this study was to explore the influencing factors of preterm twin pregnancy. METHODS: In total, 602 twin-pregnant women delivered from February 2016 to February 2020 were analyzed retrospectively. According to whether the pregnant women were preterm or not, they were divided into preterm group (n=363) and term group (n=239). Baseline information, such as maternal age, address, and education level of the pregnant women, were collected. The clinical information of pregnant women, such as chorionic, preeclampsia, gestational diabetes, premature rupture of membranes, abnormal fetal position, and fetal weight, were analyzed. Logistic regression analysis was used to analyze the risk factors. p-value <0.05 was considered statistically significant. RESULTS: In the preterm group, monochorionic diamniotic comorbidities were significantly higher compared with the control group (p<0.05). Higher risks of preterm group have lower education (p<0.05). Multiple logistic regression analysis demonstrated that education, preeclampsia, and premature rupture of membranes were risk factors for preterm twin pregnancy. CONCLUSIONS: Preterm birth in twin pregnancy is associated with many risk factors, such as education, preeclampsia, and premature rupture of membranes. Pregnancy supervision and prenatal guidance for twin pregnancy should be strengthened. Furthermore, early detection and diagnosis of comorbidities can improve maternal and neonatal outcomes.

Effects of gestational weight on the association between serum high sensitivity C reaction protein and gestational diabetes mellitus among twin gestations: A cohort study / 北京大学学报(医学版)

OBJECTIVE@#To investigate the association between serum high sensitivity C-reaction protein (hsCRP) in early pregnancy and gestational diabetes mellitus (GDM) among twin pregnant women, and to explore the effects of the pre-pregnant body mass index (BMI) and gestational weight gain (GWG) status on such association.@*METHODS@#Twin pregnant women with pre-pregnant BMI greater than or equal to 18.5 kg/m2 were recruited at Department of Obstetrics and Gynecology of Peking University Third Hospital from March 2017 to December 2020. Serum samples collected in early pregnancy were analyzed for hsCRP using particle-enhanced immunoturbidimetric method. In the following visits, the information about GWG and GDM were prospectively collected in every trimester. The association effect between hsCRP tertiles and GDM were estimated using Logistic regression, and further converted into risk ratio (RR). Cochran-Mantel-Haenszel test and mediation analysis were used to explore the effects of BMI and GWG status on the association.@*RESULTS@#Among the included 570 twin pregnant women, 31.6% deve-loped GDM, 26.1% were pre-pregnant overweight or obesity, and 49.5% with GWG out of referenced range. After adjustment for confounding factors, risk of developing GDM in twin gestations with the middle tertile and highest tertile of serum hsCRP in early pregnancy were 1.42 fold (95%CI: 1.02-1.89) and 1.54 fold (95%CI: 1.12-2.02), respectively, compared with the lowest tertile of serum hsCRP, and there existed significantly linear trend (P=0.022). Findings from mediation analysis illustrated that pre-pregnant BMI had partial mediating effect on the association, and BMI accounted for 23.84% (P < 0.001) of the increasing GDM risks with elevated hsCRP. Joint analysis with hsCRP and GWG found that those who were with GWG out of referenced range accompanied with the higher hsCRP tertiles (>1.21 mg/L) had significantly 2.31 fold increased risk according to those who were with GWG in the referenced range accompanied with the lowest hsCRP tertile (≤1.21 mg/L, P < 0.01).@*CONCLUSION@#Elevated hsCRP in early pregnancy significantly increased GDM risk among twin pregnant women. The hsCRP-GDM association was dependent on GWG status, and pre-pregnant BMI had partial mediating effect on such association. It is suggested that twin pregnant women should consider systemic inflammation and gestational weight at the same time to reduce GDM risk.

Investigation on the incidence and risk factors of fetomaternal hemorrhage syndrome in pregnant women in Changsha / 中国输血杂志

【Objective】 To investigate the incidence and possible risk factors of FMH among pregnant women in Changsha. 【Methods】 A total of pregnant women (6~42 weeks of gestation) who underwent prenatal examinations in our hospital from June 2019 to December 2020 were enrolled as subjects. In this study, the modified Kleihauer-Betke (K-B) test was used for preliminary screening and flow cytometry was applied to confirme initially positive samples to evaluate the incidence of FMH and estimate fetal blood loss. The logistic regression analysis was used to study the risk factors of FMH. 【Results】 The incidence of FMH in pregnant women was 10.45% (183/1 752), the average volume of fetal blood loss was (2.50±3.87)mL, and 0.11% (2/1 752) of the fetal losed blood > 30 mL. Univariate analysis showed that age, twin pregnancy, pregnancy complicated with uterine fibroids, in vitro fertilization, fetal growth restriction, preeclampsia, and number of pregnancies may be risk factors for FMH. Multivariate analysis showed that twin pregnancy (OR 2.274, 95%CI: 1.135-4.458, P<0.05) and preeclampsia (OR 2.341, 95%CI: 1.082-4.837, P<0.05) were independent risk factors for FMH. 【Conclusion】 Maternal age and various physiological and pathological factors during pregnancy may be associated with the risk of FMH, especially twin pregnancy and pre-eclampsia are independent risk factors for FMH.

Applicability of the Institute of Medicine recommendations of gestational weight gain in women with twin pregnancies in Chengdu city / 中华健康管理学杂志

Objective:To analyze the applicability of the Institute of Medicine (IOM) recommendations of gestational weight gain (GWG) in women with twin pregnancies in Chengdu city.Methods:A total of 1 862 women delivering live twins ≥28 weeks of gestation at all midwifery institutions in Chengdu city from January 2013 to December 2019 were selected, and the women were divided into low GWG group (880 women), adequate GWG group (839 women) and excessive GWG group (143 women) according to the IOM recommendations of GWG. Information of the subjects was extracted from Chengdu “One-Card” Maternal and Child Health Information System. Chi-square test and analysis of variance were used to compare the basic information, pregnancy complications and perinatal adverse outcomes among the three groups. Multivariate logistic regression was used to analyze the relationship between GWG and pregnancy complications or perinatal adverse outcomes.Results:Of the women, 72.8% (611/1 862) had normal weight before pregnancy. The weight gain of low, adequate and excessive GWG groups was (11.8±3.4) kg, (18.8±2.6) kg and (26.1±2.9) kg, respectively. The incidence of low birthweight was highest in the low GWG group (71.0%), it was lowest in the excessive GWG group (51.0%), and it was 61.3% in the adequate GWG group ( P<0.001). There was no significant difference in gestational hypertension, gestational diabetes mellitus, premature rupture of membranes, very low birthweight, preterm birth, very premature birth, 5-minute Apgar score<7 and neonatal death within 7 days postpartum among the three groups (all P>0.05). The multivariable logistic regression analysis showed that, compared with women inadequate GWG group, those from the low GWG group tended to deliver infants with low birthweight ( OR=1.62, 95% CI: 1.32-2.00), whereas women from the excessive GWG group were less likely to deliver low birthweight infants ( OR=0.63, 95% CI: 0.44-0.91) (both P<0.05). Conclusion:The IOM recommendations for gestational weight gain are valuable in improving the pregnancy complications and perinatal outcomes of twin pregnancies in Chengdu city to certain extent, especially in improving the low birthweight of newborns.

Bases informacionales para el estudio morfométrico de placentas en embarazos gemelares

RESUMEN Introducción: En Cuba existen muy pocos estudios morfofuncionales de placentas procedentes de embarazos gemelares que permitan establecer un patrón morfométrico general. Implementar estas bases informacionales contribuiría a perfeccionar las acciones del Programa Nacional de Salud Sexual y Reproductiva en el país. Objetivo: Sistematizar información sobre estudios morfométricos en placentas gemelares para construir la base epistémica de la caracterización del patrón morfométrico de las placentas gemelares y su relación con la corionicidad, la función de este órgano y el grado de bienestar fetal y neonatal. Método: Se aplicó una estrategia de búsqueda en el período enero de 2020 hasta abril de 2021, en bases de datos internacionales (Medline, EMBASE, LILACS, Scopus, Google Académico) para la revisión bibliográfica, mediante la utilización del método de análisis y crítica de las fuentes desde el procedimiento de análisis de contenido. Se empleó un algoritmo para la toma de decisiones en torno a la pertinencia, actualidad novedad y aportes. Resultados: Se hallaron 16 fuentes bibliográficas sobre el tema de investigación, entre ellas: solo una tesis (6,25 %) y 4 textos editados (25 %). Predominaron los artículos científicos (68,75 %) de los últimos cinco años (93,75 %). Todas las fuentes contribuyeron a la construcción de los referentes teóricos. Conclusiones: El estudio morfométrico de la placenta en embarazos gemelares es un área insuficientemente desarrollada en el conocimiento de las ciencias básicas biomédicas, dada la escasa producción bibliográfica sobre el tema.

ABSTRACT Introduction: In Cuba there are very few morphofunctional studies of placentas from twin pregnancies that allow establishing a general morphometric pattern. Implementing these informational databases would help to improve the actions of the National Sexual and Reproductive Health Program in the country. Objective: To systematize information on morphometric studies in twin placentas to build the epistemic basis for the characterization of the morphometric pattern of twin placentas and its relationship with chorionicity, the function of this organ and the degree of fetal and neonatal well-being. Method: A search strategy was applied in the period January 2020 to April 2021, in international databases (Medline, EMBASE, LILACS, Scopus, Google Scholar) for the bibliographic review, using the analysis and criticism method. of the sources from the content analysis procedure. An algorithm was used to make decisions about relevance, news, news and contributions. Results: 16 bibliographic sources were found on the research topic, among them: only one thesis (6.25%) and 4 edited texts (25.0%). Scientific articles (68.75%) from the last five years (93.75%) predominated. All the sources contributed to the construction of the theoretical referents. Conclusions: The morphometric study of the placenta in twin pregnancies is an insufficiently developed area in the knowledge of basic biomedical sciences, given the scarce bibliographic production on the subject.

RESUMO Introdução: Em Cuba existem poucos estudos morfofuncionais de placentas de gestações gemelares que permitam estabelecer um padrão morfométrico geral. A implementação desses bancos de dados informativos ajudaria a melhorar as ações do Programa Nacional de Saúde Sexual e Reprodutiva no país. Objetivo: Sistematizar informações sobre estudos morfométricos em placentas gêmeas para construir a base epistêmica para a caracterização do padrão morfométrico de placentas gêmeas e sua relação com a corionicidade, a função desse órgão e o grau de bem-estar fetal e neonatal. Método: Foi aplicada uma estratégia de busca no período de janeiro de 2020 a abril de 2021, em bases de dados internacionais (Medline, EMBASE, LILACS, Scopus, Google Scholar) para a revisão bibliográfica, utilizando o método de análise e crítica das fontes da análise de conteúdo procedimento. Um algoritmo foi usado para tomar decisões sobre relevância, notícias, notícias e contribuições. Resultados: Foram encontradas 16 fontes bibliográficas sobre o tema da pesquisa, entre elas: apenas uma tese (6,25%) e 4 textos editados (25,0%). Predominaram artigos científicos (68,75%) dos últimos cinco anos (93,75%). Todas as fontes contribuíram para a construção dos referentes teóricos. Conclusões: O estudo morfométrico da placenta em gestações gemelares é uma área pouco desenvolvida no conhecimento das ciências biomédicas básicas, dada a escassa produção bibliográfica sobre o assunto.

Importancia social del estudio morfométrico en placentas procedentes de embarazos gemelares / Social importance of the morphometric study in placentas from twin pregnancies / Importância social do estudo morfométrico em placentas de gestações gemelares

RESUMEN Se fundamenta la necesidad de la investigación científica para el estudio morfométrico en placentas procedentes de embarazos gemelares, como aproximación a la correlación entre el patrón morfométrico, la corionicidad y el bienestar fetal y neonatal, en tanto criterios básico/clínicos a tomar en cuenta para perfeccionar las acciones del programa nacional de salud sexual y reproductiva en Cuba. Se destaca la importancia social de un diseño de investigación en este campo, al constatar las carencias epistémicas desde una búsqueda sistematizada de información bibliográfica sobre el tema.

ABSTRACT The need for scientific research for the morphometric study in placentas from twin pregnancies is founded, as an approximation to the correlation between the morphometric pattern, chorionicity and fetal and neonatal well-being, as basic / clinical criteria to be taken into account to improve the actions of the national sexual and reproductive health program in Cuba. The social importance of a research design in this field is highlighted, when verifying the epistemic deficiencies from a systematized search of bibliographic information on the subject.

RESUMO Fundamenta-se a necessidade de pesquisas científicas para o estudo morfométrico em placentas de gestações gemelares, como uma aproximação da correlação entre o padrão morfométrico, corionicidade e bem-estar fetal e neonatal, como critérios básicos / clínicos a serem levados em consideração para melhorar a ações do programa nacional de saúde sexual e reprodutiva em Cuba. Ressalta-se a importância social de um desenho de pesquisa nessa área, ao verificar as deficiências epistêmicas a partir de uma busca sistematizada de informações bibliográficas sobre o assunto.

Thyroid function of first-trimester twin pregnant women and its association with preterm delivery / 北京大学学报(医学版)

OBJECTIVE@#To describe the thyroid function abnormality of first-trimester twin pregnant women according to different references, and to explore its association with preterm delivery.@*METHODS@#Participants, first-trimester twin pregnant women, were recruited at Peking University Third Hospital from March 2017 to February 2020. The thyroid hormone reference for ordinary adults identified on the assay kits by Siemens incorporation, thyroid hormone reference specifically for singleton pregnancy established previously, and thyroid hormone reference specifically for twin pregnancy established previously were used in the description of hypothyroidism and hyperthyroidism for first-trimester twin pregnant women. Thyroid autoantibody reference identified on the assay kits by Siemens incorporation was used in the description of positive thyroid autoantibody. Multivariable log-binomial regression was conducted to examine the association between thyroid function and preterm delivery, in which normal pregnant women according to the three references and normal pregnant women according to twin pregnancy reference accompanied with negative thyroid autoantibody were taken as control respectively.@*RESULTS@#A total of 570 twin pregnant women were finally included. Rates of hypothyroidism according to the three references were 1.2%, 1.6% and 3.5%, respectively. Rates of hyperthyroidism according to the three references were 32.6%, 18.1% and 1.1%, respectively. After adjustment for potential confounding factors, risk of preterm delivery significantly increased in pregnant women with hyperthyroidism according to the twin specific pregnancy reference [adjusted relative risk (ARR)=1.41, 95%CI: 1.14-1.75], while no significant increase was found in those with normal thyroid function according to the twin specific pregnancy reference but hyperthyroidism according to the singleton specific pregnancy reference (ARR=1.00, 95%CI: 0.81-1.25) and in those with hyperthyroidism purely according to the ordinary adult reference (ARR=1.06, 95%CI: 0.85-1.32), compared with those normal according to all the references. Risks of preterm delivery almost significantly or significantly increased in pregnant women with hypothyroidism according to the ordinary adult or singleton specific pregnancy reference (ARR=1.40, 95%CI: 0.88-2.22) and those with hypothyroidism according to the twin specific pregnancy reference (ARR=1.53, 95%CI: 1.03-2.28). Overall analysis of thyroid function according to the twin specific pregnancy reference and thyroid autoantibody showed that risks of preterm delivery almost significantly or significantly increased in pregnant women with simple hypothyroidism (ARR=1.46, 95%CI: 0.93-2.27), simple positive thyroid autoantibody (ARR=1.32, 95%CI: 1.15-1.52), and hypothyroidism accompanied with positive thyroid autoantibody (ARR=1.78, 95%CI: 1.30-2.44), compared with those normal according to the twin specific pregnancy reference with negative thyroid autoantibody.@*CONCLUSION@#The ordinary adult reference and that of singleton pregnancy may lead to under-diagnosis of hypothyroidism and over-diagnosis of hyperthyroidism in first-trimester twin pregnant women. Compared with pregnant women with normal thyroid function, those missed in the diagnosis of hypothyroidism were at a higher risk of preterm delivery, while those over-diagnosed as hyperthyroidism had a similar risk of preterm delivery, indicating a need to develop and generalize twin-pregnancy-specific reference on common indicators of thyroid function. Moreover, the thyroid autoantibody should be taken into consideration in the prenatal diagnosis and treatment to twin pregnant women with hypothyroidism.

Cervical pessary plus progesterone for twin pregnancy with short cervix compared to unselected and non-treated twin pregnancy: a historical equivalence cohort study (EPM twin pessary study) / Pessário cervical associado a progesterona em gestações gemelares com colo curto comparado a gestações gemelares não selecionadas e não tratadas: estudo de coorte histórica de equivalência (Estudo de Pessário em Gêmeos EPM)

Abstract Objective The present study aims to determine if the use of cervical pessary plus progesterone in short-cervix (≤ 25 mm) dichorionic-diamniotic (DC-DA) twin pregnancies is equivalent to the rate of preterm births (PBs) with no intervention in unselected DC-DA twin pregnancies. Methods A historical cohort study was performed between 2010 and 2018, including a total of 57 pregnant women with DC-DA twin pregnancies. The women admitted from 2010 to 2012 (n = 32) received no treatment, and were not selected by cervical length (Non-Treated group, NTG), whereas those admitted from 2013 to 2018 (n = 25), were routinely submitted to cervical pessary plus progesterone after the diagnosis of short cervix from the 18th to the 27th weeks of gestation (Pessary-Progesterone group, PPG). The primary outcome analyzed was the rate of PBs before 34 weeks. Results There were no statistical differences between the NTG and the PPG regarding PB < 34 weeks (18.8%; versus 40.0%; respectively; p = 0.07) and the mean birthweight of the smallest twin (2,037 ± 425 g versus 2,195 ± 665 g; p = 0.327). The Kaplan-Meyer Survival analysis was performed, and there were no differences between the groups before 31.5 weeks. Logistic regression showed that a previous PB (< 37 weeks) presented an odds ratio (OR) of 15.951 (95%; confidence interval [95%;CI]: 1.294-196.557; p = 0.031*) for PB < 34 weeks in the PPG. Conclusion In DC-DA twin pregnancies with a short cervix, (which means a higher risk of PB), the treatment with cervical pessary plus progesterone could be considered equivalent in several aspects related to PB in the NTG, despite the big difference between these groups.

Resumo Objetivo Este estudo tem como objetivo determinar se o uso de pessário cervical associado a progesterona em gestações de gêmeos dicoriônicos-diamnióticos (DC-DAs) com colo do útero curto (≤ 25 mm) apresenta taxa de parto prematuro (PP) equivalente à de gestações gemelares DC-DA sem nenhuma intervenção/não selecionadas. Métodos Um estudo de coorte histórica foi realizado entre 2010 e 2018, incluindo um total de 57 mulheres grávidas com gestações gemelares DC-DA. As mulheres admitidas de 2010 a 2012 (n = 32) não receberam tratamento, e não foram selecionadas pelo comprimento cervical (grupo Não Tratado, GNT), enquanto as admitidas de 2013 a 2018 (n = 25) receberam pessário cervical rotineiramente associado a progesterona após o diagnóstico de colo curto entre a 18a e a 27ª semanas de gestação (grupo Pessário-Progesterona, GPP). O desfecho primário analisado foi a taxa de PP antes de 34 semanas. Resultados Não houve diferenças estatísticas entre o GNT e o GPP em relação ao PP < 34 semanas (respectivamente, 18,8%; versus 40,0%;; p = 0,07) e ao peso médio ao nascer do gêmeo menor (2.037 ± 425 g versus 2.195 ± 665 g; p = 0,327). A análise de Kaplan-Meyer foi realizada, e não houve diferenças entre os grupos antes de 31,5 semanas. A regressão logística demonstrou que o nascimento prematuro anterior (< 37 semanas) apresentou razão de probabilidades (odds ratio, OR) de 15,951 (intervalo de confiança de 95%; [IC95%;]: 1,294-196,557; p = 0,031*) para o nascimento prematuro < 34 semanas no GPP. Conclusão Em gêmeos DC-DA com colo uterino curto (o que significa maior risco de nascimento prematuro), o tratamento com pessário cervical associado a progesterona pode ser considerado equivalente em diversos aspectos relacionados à prematuridade no GNT, apesar da grande diferença entre os grupos.

Twin reversed arterial perfusion in twin pregnancy

An interesting case of twin reversed arterial perfusion “TRAP” from a larger apparently normal pump twin with VACTERL abnormality; to smaller structurally abnormal twin in a monoamniotic monochorionic twin pregnancy resulting in fetal demise with subsequent termination of pregnancy. Defect in early embryogenesis leads to such rare multiple presentations.

Obstetric outcome in twin pregnancies complicated with single intrauterine fetal demise

Background: It has been reported that single intrauterine fetal death in twin pregnancy occurs in 3.7-6.8% all twin pregnancies. The objective of this study was to evaluate the maternal and fetal demographic features and feto-maternal outcomes in twin pregnancies complicated with single intrauterine fetal demise and evaluation of available management guidelines.Methods: This retrospective study was conducted at obstetrics and gynecology department of SGRRIM and HS, Dehradun, Uttarakhand between January 2015 and December 2019. There was a total of 182 twin deliveries at study hospital during this period and 35 of these cases were complicated with single intrauterine fetal demise. Maternal age, parity, chorionicity of twin gestation, gestational age at single intrauterine fetal demise, gestational age at delivery, mode of delivery, birth weight, Apgar Score at birth, neonatal intensive care unit stay of newborn,  maternal fibrinogen levels during pregnancy and delivery time and associated obstetric complications were analyzed in these cases of single intrauterine fetal demise with twin gestation. All monochorionic twin pregnancies were included in the study Group A and dichorionic twin in Group B.Results: The mean age of 32 patients included in study was 29.7±4.6 years. Twenty (62.5%) of these patients were dichorionic and 12 (37.5%) of these were monochorionic twin gestation. Single intrauterine fetal demise occurred in first trimester in 8 (25%) patients, during the second trimester 20 (62.5%) and 4 (12.5%) patients had third trimester single intrauterine fetal demise. Preterm deliveries occurred in 18 (56.3%) of patients and 8 (44.4%) of patients were of monochorionic and 10 (55.6%) of dichorionic twin patients. Among thirty-two patients, 11 (34.4%) patients had caesarean delivery and 21 (65.6%) patient had vaginal birth. No maternal or fetal mortality noted and none of the patients had maternal coagulation disorder.Conclusions: This study indicates that in cases of twin pregnancies with single fetal intrauterine demise with individualized management plan at higher centre and close maternal and fetal surveillance live fetus can be saved without any maternal risk.

Is it correct to trust each ultrasonography report blindly? a case report on misdiagnosis, diagnosis and management of acardiac twin pregnancy

Multifetal gestation is often a high-risk pregnancy and especially the monochorionic twin pregnancy significantly contributes to fetal morbidity and mortality. Acardiac twinning, earlier known as chorioangiopagus parasiticus, is the most extreme manifestation of this condition. An acardiac twin is a rare complication of multifetal pregnancy, in the literature reported at an incidence of 1% of monochorionic twin pregnancies, i.e. 1 of 35,000 pregnancies. Often results from abnormal placental vascular anastomoses. This leads to twin reversal arterial perfusion with complex pathophysiology. Here authors present a case of acardiac twin pregnancy presented at 26 weeks with the ultrasonography report suggested?? Placental teratoma of size 11×11×13 cm with polyhydramnios as there was no reason to suspect something else as the picture described in the USG report with the polyhydramnios was fitting with the diagnosis of placental teratoma but as the scan was done at taluka place and the images provided were not clear authors decided to confirm the diagnosis from fetal medicine specialist as MTP was not the option for the patient as she was 28 weeks who confirmed that as a case of acardiac twin pregnancy and the case was managed accordingly.

Study of obstetric and perinatal outcome of twin pregnancy

Background: Multifetal pregnancy constitutes a significant portion of high-risk pregnancies. This is due to the increasing obstetric and perinatal morbidity and mortality rates associated with it. Maternal and perinatal outcome of twin pregnancies has been evaluated in this study.Methods: Total 30 patients with twin pregnancy and having gestational age more than 28 weeks were included in this observational study.Results: Incidence of twins in the study was found to be 2%. Twin pregnancies were more common in multiparous women aged between 20 and 30 years. Most common foetal presentation was vertex- vertex presentation. Most common maternal complication was preterm labour seen in 67% women, followed by anaemia seen in 50% women. Most of the women were delivered by caesarean section (63.3%). Most common perinatal complication was birth hypoxia (41.6%). Other perinatal complications were jaundice, septicemia, intrauterine growth restriction. 71% of the neonates had birth weight less than 2.5 kg. Perinatal mortality was found to be 11.6%.Conclusions: Twin pregnancies are high risk pregnancies associated with higher obstetric and perinatal morbidity. Perinatal morbidity was more common for the second coming twin. Regular antenatal visits, planned delivery and better NICU facilities can help combat these complications. A team of skilled obstetricians and pediatricians along with a multidisciplinary approach is essential for the effective management of twin pregnancies.