Embarazo triple espontáneo en una paciente con útero didelfo: reporte de un caso y revisión de la bibliografía / Spontaneous triplet pregnancy in a patient with uterus didelphys: report of a case and review of the literature

Resumen ANTECEDENTES: Las anomalías müllerianas implican la desviación de la anatomía normal del aparato reproductor femenino debido a un desarrollo embriológico alterado. Padecer alguna de estas anomalías, en cualquier escenario de su amplio espectro, suele asociarse con infertilidad o desenlaces obstétricos adversos, como la pérdida gestacional temprana o el parto pretérmino. CASO CLÍNICO: Paciente de 21 años, sin antecedentes patológicos relevantes, con dos embarazos finalizados: el primero por cesárea y el segundo por parto (la cesárea se indicó por la presentación podálica, a las 32 semanas). Acudió a un centro de referencia de la ciudad de Medellín, Colombia (Clínica Universitaria Bolivariana) a la primera consulta prenatal a las 17 semanas y 4 días de embarazo, motivada por un cuadro clínico de cólico biliar, sin requerimiento de intervenciones. Se trataba de embarazo triple, monocorial, triamniótico, con diagnóstico de útero didelfo a las 17 semanas y 1 día, con ambos cuellos uterinos reportados en 38 mm. La gestación finalizó a las 28 semanas y 4 días con el nacimiento de tres niños, quienes luego de superar los retos de la prematurez, en la actualidad llevan una vida normal. CONCLUSIONES: Las anomalías müllerianas, en su amplio espectro de manifestación clínica, son una condición que se asocia con una mayor frecuencia de desenlaces adversos materno-perinatales que se incrementan cuando la anomalía se relaciona con un embarazo múltiple. En la bibliografía actual no abundan los reportes de casos que combinen ambas condiciones, ni con recomendaciones oficiales estandarizadas para la atención médica de las pacientes, sobre todo para el escenario de embarazo triple y útero didelfo.

Abstract BACKGROUND: Müllerian anomalies involve deviation from the normal anatomy of the female reproductive tract due to altered embryological development. Having any of these anomalies, in any of their broad spectrum, is often associated with infertility or adverse obstetric outcomes, such as early gestational loss or preterm delivery. CLINICAL CASE: 21-year-old female patient, with no relevant pathological history, with two pregnancies terminated: the first by cesarean section and the second by delivery (the cesarean section was indicated due to breech presentation, at 32 weeks). She attended a referral center in the city of Medellín, Colombia (Clínica Universitaria Bolivariana) for the first prenatal consultation at 17 weeks and 4 days of pregnancy, motivated by a clinical picture of biliary colic, without requiring interventions. The pregnancy was triple, monochorionic, triamniotic, with a diagnosis of didelphic uterus at 17 weeks and 1 day, with both cervix reported at 38 mm. The gestation was terminated at 28 weeks and 4 days with the birth of three infants, who after overcoming the challenges of prematurity, are now living normal lives. CONCLUSIONS: Mullerian anomalies, in their broad spectrum of clinical presentation, are a condition that is associated with an increased frequency of adverse maternal-perinatal outcomes that are increased when the anomaly is associated with multiple pregnancy. The current literature does not abound with case reports combining both conditions, nor with standardized official recommendations for patient care, especially in the setting of triple pregnancy and didelphic uterus.

Application value of non-invasive prenatal genetic testing technology in twin pregnancy / 中国医师进修杂志

Objective:To explore the application value of non-invasive prenatal testing (NIPT) technology in twin pregnancy.Methods:A total of 339 twin pregnant women who underwent NIPT at Dalian Municipal Women and Children′s Medical Center(Group), Dalian Jinpu New District Maternity and Child Health Hospital, and Dalian Lvshunkou District People′s Hospital from July 1, 2019 to June 30, 2021 were continuously retrospectively included. The clinical characteristics and test results of pregnant women with high-risk and low-risk were analyzed.Results:Among 339 pregnant women, 336 were successfully tested, with a success rate of 99.12%(336/339); 6 pregnant women were at high risk of NIPT, with a positive screening rate of 1.77%(6/339), including 1 case of high risk of trisomy 13, 2 cases of high risk of trisomy 18, and 3 cases of high risk of Trisomy 21; the results of amniocentesis for 2 high-risk pregnant women were not abnormal.Conclusions:NIPT technology is non-invasive, safe and efficient, and is suitable for large-scale prenatal screening. However, the detection accuracy of pregnant women with twin pregnancy needs to be improved.

Effect of selective feticide at different gestational weeks in double chorionic twin pregnancies on pregnant women and perineonates outcomes / 中国医师进修杂志

Objective:To compare and analyze the pregnant women and perineonates outcomes of selective feticide at different gestational weeks in double chorionic twin pregnancies.Methods:The clinical data of 86 patients with double chorionic twin pregnancies who underwent selective feticide from January 2015 to June 2021 in the General Hospital of Northern War Zone were retrospectively analyzed. The patients were divided into two groups according to different gestational weeks of selective feticide: 23 cases at 14 +3 to 19 +6 gestational weeks (group A), 31 cases at 20 to 27 +6 gestational weeks (group B), 32 cases and at ≥28 gestational weeks (group C). The gestational weeks of delivery, abortion, preterm birth, full-term birth, liveborn infants, surviving infants, birth body mass of liveborn infants, birth body mass of surviving infants, complications in pregnant women, pregnant women and perineonates outcomes and neonatal prognosis were recorded. Results:There were no statistical differences in gestational weeks of delivery, incidence of complications in pregnant women, abortion rate and neonatal survival rate among three groups ( P>0.05); there were statistical differences in preterm birth rate, full-term birth rate, liveborn infants rate, birth body mass of liveborn infants and birth body mass of surviving infants among three groups ( P<0.05). The preterm birth rate in group A was significantly lower than that in group C: 21.7% (5/23) vs. 68.8% (22/32), the full-term birth rate was significantly higher than that in group C: 69.6% (16/23) vs. 28.1% (9/32); the birth body mass of liveborn infants and birth body mass of surviving infants in group A were significantly higher than those in group B and group C: (2 905.7 ± 580.9) g vs. (2 284.4 ± 416.7) and (2 293.8 ± 456.2) g, (2 905.7 ± 580.9) g vs. (2 457.1 ± 527.8) and (2 359.2 ± 482.4) g, the liveborn infants rate in group C was significantly higher than that in group B: 96.9% (31/32) vs. 77.4% (24/31), and there were statistical differences ( P<0.05). The 72 surviving infants were followed up for 3 months to 4 years, and no motor dysfunction and neurological abnormalities occurred. Conclusions:Selective feticide in patients with double chorionic twin pregnancies before 20 weeks of gestation has less complications in pregnant women and good perineonates clinical outcome.

Dissecção espontânea da artéria coronária em gestação gemelar no terceiro trimestre: relato de caso / Spontaneous coronary artery dissection in a twin pregnancy in the third trimester: a case report

O infarto agudo do miocárdio no período gravídico-puerperal é uma condição rara em que a principal causa é a dissecção espontânea da artéria coronária. É um evento comumente subdiagnosticado, com pouca literatura disponível e elevado índice de morbimortalidade. Esse relato descreve o caso de uma gestante de 36 semanas de gravidez gemelar, monocoriônica-diamniótica, com infarto agudo do miocárdio secundário à dissecção espontânea da artéria coronária. As equipes de cirurgia cardíaca e obstetrícia optaram pela realização de parto cesariano e histerectomia subtotal, seguido da revascularização da artéria mamária descendente anterior. Discutem-se as orientações adotadas na dissecção espontânea da artéria coronária, bem como a abordagem terapêutica e a conduta obstétrica, quando essa condição ocorre durante a gravidez.(AU)

Acute myocardial infarction in the pregnancy-puerperal period is a rare condition the main cause of which is the spontaneous coronary artery dissection. A commonly underdiagnosed event with little available literature and a high rate of morbidity and mortality. This case reports a 36-week pregnant woman of mono-chorionic-diamniotic pregnancy who had a myocardial infarction secondary to a spontaneous coronary artery dissection. In a joint discussion between the team of cardiac surgery and obstetrics, it was decided to perform a cesarean delivery and subtotal hysterectomy followed by revascularization of the mammary anterior descendant. It discusses the conducts to be adopted in a case of spontaneous coronary artery dissection as well as therapeutic approaches and obstetric conducts to be taken in a case of dissection during pregnancy.(AU)

Días de gestación ganados con diferentes técnicas de cerclaje en pacientes con insuficiencia cervical / Gestational days gained with different cerclage techniques in patients with cervical incompetence

Resumen OBJETIVO: Reportar la experiencia en la práctica de cerclajes con indicación profiláctica y terapéutica en pacientes con embarazo único o múltiple, con insuficiencia cervical. Además, informar los días de gestación ganados y comparar las técnicas quirúrgicas con los cerclajes. MATERIALES Y MÉTODOS: Estudio retrospectivo, descriptivo, comparativo y transversal efectuado entre enero de 2011 y enero de 2018. Criterios de inclusión: pacientes a quienes se efectuó un cerclaje y el embarazo finalizó en nuestra unidad. Variables de estudio: edad, IMC, embarazos, abortos, días de gestación ganados, días en que se efectuó el procedimiento quirúrgico, semanas de gestación cumplidas a la finalización del embarazo, tiempo quirúrgico, medicamentos (tocolíticos y antibióticos), complicaciones a partir del cerclaje hasta la finalización del embarazo. Para el análisis descriptivo se utilizó el paquete estadístico IBM SPSS (versión 22); la distribución se obtuvo con t de Student, se aplicó la prueba de normalidad Shapiro-Wilk y las variables con distribución normal se analizaron, comparativamente, con ANOVA y las de distribución anormal con la prueba Kruskal-Wallis. RESULTADOS: Se analizaron 37 casos en los que el cerclaje prolongó 116.14 ± 47.4 días la gestación, con finalización promedio del embarazo a los 246.41 ± 26.54 días. El cerclaje Shirodkar fue superior: prolongó la gestación 134.69 días con finalización del embarazo a las 36 ± 2 semanas. CONCLUSIONES: En pacientes con insuficiencia cervical el cerclaje es una opción para prolongar el embarazo. La técnica Shirodkar tuvo márgenes de mayor seguridad hasta la finalización del embarazo (más de 34 semanas). El comportamiento en embarazos múltiples es similar, por lo que en caso de insuficiencia cervical debe aplicarse.

Abstract OBJECTIVE: To report the experience in the practice of cerclages with prophylactic and therapeutic indication in patients with single or multiple pregnancy, with cervical incompetence. In addition, report the days of pregnancy gained, compare surgical techniques and cerclages in single and multiple gestations. MATERIALS AND METHODS: Retrospective, descriptive, comparative and cross-sectional study carried out between January 2011 and January 2018. Inclusion criteria: patients who had a cerclage and the pregnancy ended in our unit. Study variables: age, BMI, pregnancies, abortions, days of gestation earned, days in which they were placed, weeks of gestation completed at the end of pregnancy, surgical time, medications (tocolytics and antibiotics), complications from the placement of the cerclage until the end of pregnancy. For the descriptive analysis the statistical package IBM SPSS (version 22) was used; the distribution was obtained with Student's t test, the Shapiro-Wilk normality test was applied and the variables with normal distribution were analyzed, comparatively, with ANOVA and those with abnormal distribution with the Kruskal-Wallis test. RESULTS: 37 cases were analyzed in which the placement of cerclage prolonged 116.14 ± 47.4 days gestation, with an average termination of pregnancy at 246.41 ± 26.54 days. The Shirodkar cerclage was superior: it extended gestation 134.69 days with the end of pregnancy at 36 ± 2 weeks. CONCLUSIONS: In patients with cervical incompetence cerclages are an option to prolong pregnancy. The Shirodkar technique had higher safety margins until the end of pregnancy (more than 34 weeks). The behavior in multiple pregnancies is similar, so in case of cervical incompetence should be applied.

Optimal Timing of Delivery Based on the Risk of Stillbirth and Infant Death Associated with Each Additional Week of Expectant Management in Multiple Pregnancies: a National Cohort Study of Koreans

BACKGROUND: The purpose of this study was to compare the fetal/infant mortality risk associated with each additional week of expectant management to that associated with immediate delivery in women with multiple gestations. METHODS: This was a retrospective national cohort study of 94,170 multiple deliveries, 92,619 (98.4%) twin and 1,352 (1.44%) triplet pregnancies, between 32 0/7 and 42 6/7 weeks of gestation recorded in the Korean vital statistics database. We investigated the risks of stillbirth and infant death after birth in Korea according to the week of gestation in twin and triplet pregnancies. RESULTS: The risk of stillbirth significantly increased between 34 and 35 weeks of gestation and between 37 and 38 weeks of gestation in twin pregnancies and between 34 and 37 weeks of gestation in triplet pregnancies. The risk of infant death following delivery gradually decreased as pregnancies approached full term. Week-by-week differences were statistically significant between 33 and 34 weeks, with decreasing risks of infant death at advancing gestational ages in twin pregnancies. At 37 weeks of gestation, the relative risk of mortality was significantly higher with expectant management compared with immediate delivery (relative risk, 3.00; 95% confidence interval, 1.41–6.38). CONCLUSION: In twin pregnancies, delivery at 37 weeks of gestation can minimize the risks of stillbirth and infant death in uncomplicated cases, although individual maternal and fetal characteristics must be considered when determining the optimal timing of delivery. In multiple pregnancies, close fetal surveillance is needed after 34 weeks of gestation.

Safety and efficacy of radiofrequency fetal ablation for monozygotic triplet and quadruplet pregnancies / 中华围产医学杂志

Objective To investigate the safety and efficacy of radiofrequency fetal ablation (RFA) in the treatment of monozygotic triplet and quadruplet pregnancies. Methods We analyzed retrospectively the clinical data of eight gravidas, including seven monozygotic triplets and one monozygotic quadruplets admitted to the Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong University from March 2014 to January 2017. All of the eight women accepted ultrasound-guided selective fetal reduction by RFA to reduce to twins. Descriptive methods were used to analyze the perioperative status of the gravidas, maternal and fetal outcomes and neonatal follow-up. Results (1) In seven cases, the fetuses were deprived of blood flow after one heating cycle of radiofrequency ablation, while in the other, blood flow was stopped after two heating cycles. Heart beats of the reduced fetuses slowed down gradually after RFA, and stopped at 10, 20-25 and 40 minutes after operation in one, four and three cases, respectively. The conserved fetus showed normal heartbeats. (2) All patients accepted regular obstetrical examination after RFA. One was diagnosed with gestational diabetes mellitus at 26 weeks, and hospitalized for 4 d because of preterm labor at 30+6weeks. One women was hospitalized to receive a two-week tocolysis treatment one day after surgery, and diagnosed with severe preeclampsia at 35 weeks. One patient who had a fever six days after surgery and was hospitalized for antiinfection treatment progressed to inevitable abortion on the day of admission. The other five pregnant women had no abnormalities. (3) Except for one miscarriage, the rest seven cases all continued the pregnancy until delivery by cesarean, among which two with preterm premature rupture of membranes eventually delivered before term (35+1and 33 weeks), one with severe preeclampsia also preterm delivered (35+4weeks) and four term deliveries. Apgar scores at 1 and 5 minutes of all newborns were over 7. Three of the 14 newborns were hospitalized and recovered, including one pathological jaundice, one laryngeal stridor and one premature. The last follow-up in September 2018 of all 14 babies did not show any abnormalities. Conclusions RFA is a feasible treatment for monozygotic triplets and quadruplets.

Ectopic twin pregnancy in right fallopian tube: a case report and literature review / 中华全科医师杂志

One case of ectopic twin pregnancy in right fallopian tube after in vitro fertilization embryo transfer (IVF-ET) was admitted in our hospital.The development was in synchrony and the mainly manifestation was vaginal bleeding after menopause and abdominal pain.After surgery,the patient recovered well.Six cases reported in domestic literature occurred after assisted reproductive technology,including 4 cases after IVF-ET and 2 cases after artificial insemination.Two cases developed synchronously with the main manifestation of menopausal vaginal bleeding and recovered well after treatment.In 4 cases of non-synchronous embryos,after medical or surgical treatment irregular vaginal bleeding occurred,adnexal mass on the other side was found by gynecological ultrasound and blood hCG level increased significantly.Three cases recovered well after drug and/or surgical treatment and 1 case lost follow-up.

Imperfect twinning: a clinical and ethical dilemma / Gemelizacionimperfecta: un dilema clinico y etico / Gemelaridade imperfeita: um dilema clinico e etico

OBJECTIVE To review the history, epidemiology, etiology, gestational aspects, diagnosis and prognosis of imperfect twinning. DATA SOURCES Scientific articles were searched in PubMed, SciELO and Lilacs databases, using the descriptors "conjoined twins", "multiple pregnancy", "ultrasound", "magnetic resonance imaging" and "prognosis". The research was not delimited to a specific period of time and was supplemented with bibliographic data from books. DATA SYNTHESIS: The description of conjoined twins is legendary. The estimated frequency is 1/45,000-200,000 births. These twins are monozygotic, monochorionic and usually monoamniotic. They can be classified by the most prominent fusion site, by the symmetry between the conjoined twins or by the sharing structure. The diagnosis can be performed in the prenatal period or after birth by different techniques, such as ultrasound, magnetic resonance imaging and echocardiography. These tests are of paramount importance for understanding the anatomy of both fetuses/children, as well as for prognosis and surgical plan determination. CONCLUSIONS Although imperfect twinning is a rare condition, the prenatal diagnosis is very important in order to evaluate the fusion site and its complexity. Hence, the evaluation of these children should be multidisciplinary, involving mainly obstetricians, pediatricians and pediatric surgeons. However, some decisions may constitute real ethical dilemmas, in which different points should be discussed and analyzed with the health team and the family. .

OBJETIVO Revisar los aspectos históricos, epidemiológicos, etiológicos, gestacionales, diagnósticos y pronósticos de la gemelización imperfecta. FUENTES DE DATOS Se buscaron artículos científicos en los portales PubMed, SciELO y Lilacs, utilizando los descriptores "conjoinedtwins", "multiplepregnancy", "ultrasound", "magneticresonanceimaging" y "prognosis". La investigación no se limitó a un periodo determinado y específico de tiempo. Se complementó la revisión con material bibliográfico presente en libros. SÍNTESIS DE LOS DATOS La descripción de gemelos fusionados es legendaria. Se estima que la frecuencia sea alrededor de 1/45.000-200.000 nacidos vivos. Son gemelos monocigóticos, monocoriónicos y usualmente monoaminióticos, que pueden clasificarse conforme al local de fusión más prominente, con la simetría entre los gemelos fusionados o con la estructura de compartimiento. Se puede realizar el diagnóstico todavía en el periodo prenatal o después del nacimiento mediante diferentes técnicas, como ultrasonografía, resonancia magnética y ecocardiografía. Esos exámenes son de suma importancia para el entendimiento de la anatomía del feto/bebé, así como para la determinación del pronóstico y del plan quirúrgico. CONCLUSIONES Aunque la gemelización imperfecta sea una condición rara, el diagnóstico prenatal es muy importante para evaluar el local de fusión y su complexidad. Así, la evaluación de esos bebés debe ser multidisciplinaria, implicando principalmente a obstetras, pediatras y cirujanos pediátricos. Sin embargo, algunas decisiones pueden constituirse en verdaderos dilemas éticos, en los que distintos aspectos deben discutirse y analizarse juntamente con el equipo de salud y la familia del niño. .

OBJETIVO Revisar os aspectos históricos, epidemiológicos, etiológicos, gestacionais, diagnósticos e prognósticos da gemelaridade imperfeita. FONTES DE DADOS: Pesquisaram-se artigos científicos nos portais PubMed, SciELo e Lilacs, utilizando-se os descritores "conjoined twins", "multiple pregnancy", "ultrasound", "magnetic resonance imaging" e "prognosis". A pesquisa não se delimitou a um período específico de tempo. Complementou-se a revisão com material bibliográfico presente em livros. SÍNTESE DOS DADOS A descrição de gêmeos fusionados é lendária. Estima-se que a frequência seja em torno de 1/45.000-200.000 nascidos vivos. São gêmeos monozigóticos, monocoriônicos e usualmente monoamnióticos, que podem ser classificados de acordo com o local de fusão mais proeminente, com a simetria entre os gêmeos fusionados ou com a estrutura de compartilhamento. Pode-se realizar o diagnóstico ainda no período pré-natal ou depois do nascimento por meio de diferentes técnicas, como ultrassonografia, ressonância magnética e ecocardiografia. Tais exames são de suma importância para o entendimento da anatomia do feto/criança, bem como para a determinação do prognóstico e do plano cirúrgico. CONCLUSÕES Embora a gemelaridade imperfeita seja uma condição rara, o diagnóstico pré-natal é muito importante para avaliar o local de fusão e sua complexidade. Logo, a avaliação dessas crianças deve ser multidisciplinar, envolvendo principalmente obstetras, pediatras e cirurgiões pediátricos. Contudo, algumas decisões podem se constituir em verdadeiros dilemas éticos, nos quais diferentes aspectos devem ser discutidos e analisados juntamente com a equipe de saúde e a família da criança. .

Inserção velamentosa do cordão umbilical: diagnóstico intraparto / Velamentous insertion of the umbilical cord: intrapartum diagnosis

Relata-se a inserção velamentosa do cordão umbilical diagnosticada durante o parto gemelar normal, evento raro e com mais incidência em gestações múltiplas. É, em geral, assintomático, quando a paciente não entra em trabalho de parto, devendo a gestação ser interrompida por cesariana. A vasa prévia constitui-se em sua complicação rara, podendo ser letal. A ultrassonografia é fundamental para a realização de seu diagnóstico.

A report of velamentous insertion of the umbilical cord diagnosed during a normal twin delivery, a rare event with higher incidence in multiple pregnancies. Because it is generally asymptomatic, when the mother does not go into labor, pregnancy must be interrupted by performing a caesarean delivery. Previous vasa is a rare complication and can be lethal. Ultrasound is crucial for diagnosis.

Pregnancy outcomes of 131 twin pregnancies complicated with severe pre-eclampsia / 中华围产医学杂志

Objective To explore the clinical characteristics and pregnancy outcomes of twin pregnancies complicated with severe preeclampsia.Methods The pregnant outcomes of 131 twin pregnancies (twin group) and 572 singleton pregnancies (singleton group),all complicated with severe preeclampsia,were analyzed retrospectively.All patients were treated in the Department of Obstetrics and Gynecology,West China Second University Hospital,Sichuan University from June 2007 to June 2011.The patients' age,onset of disease,gestational weeks at delivery,mean duration of expectant treatment,blood pressure,laboratory parameters and incidence of pregnancy complications,including placental abruption,heart failure,pulmonary edema,postpartum hemorrhage,uteroplacental apoplexy,eclampsia,HELLP syndrome (hemolysis,elevated liver enzymes and low platelets syndrome),hypoproteinemia,retinopathy,intracranial hemorrhage and renal insufficiency,were compared between the two groups.Perinatal outcomes such as premature delivery,perinatal mortality,neonatal intensive care unit (NICU) hospitalization,fetal distress,hypoxic-ischemic encephalopathy (HIE),asphyxia neonatorum,neonatal pneumonia,hyperbilirubinemia and neonatal hypoglycemia of two groups were also compared.Chi-square test,Fisher's exact test or t-test were used for statistical analysis.Results The severe preeclampsia incidence of twin pregnancies (5.03％,131/2604) was higher than that (1.94％,572/29 452) of singleton pregnancy (x2=106.40,P＜0.001).The onset time [(33.6±1.8) weeks] and gestations at delivery [(34.6±2.9) weeks] in twin group were earlier than those in singleton group [(34.4± 2.0) weeks,t=2.364,P＜0.05; (35.6±3.2) weeks,t=3.902,P＜0.05].The duration of expectant treatment of twin group [(6.4±0.3) d] were shorter than that of singleton group [(7.4± 0.5) d,t=5.314,P＜0.01].The incidence of placental abruption [9.9％ (13/131) vs 4.2％ (24/572),x2=7.013,P＜0.01],heart failure [11.5％ (15/131) vs 3.2％ (18/572),x2=16.430,P＜0.01],pulmonary edema [4.6％ (6/131) vs 0.9％ (5/572),x2=9.505,P＜0.01],postpartum hemorrhage [16.0％ (21/131) vs 7.0％ (40/572),x2 =10.990,P ＜ 0.01] and uteroplacental apoplexy [5.3％ (7/131) vs 0.5％ (3/572),x2 =17.650,P＜0.01] of twin group were higher than those of singleton group,respectively.The incidence of premature delivery [77.1％ (202/262) vs 29.9％ (171/572),x2=162.000,P＜0.05],NICU hospitalization [76.2％ (205/262) vs 58.4％(332/572),x2 =31.980,P＜0.05] and HIE [8.4％ (22/262) vs 4.7％ (27/572),x2 =4.392,P＜0.05] of twin group were higher than those of singleton group,respectively.Conclusions Twin pregnancy women are more likely to be complicated with severe preeclampsia and more vulnerable to suffer from severe complications,resulting in poor perinatal outcomes.More attentions should be paid on the management of twin pregnancy.Once hypertensive disorders complicating pregnancy is diagnosed,active management should be provided and timing of termination should be considered.

Timing of selective multifetal pregnancy reduction in second trimester and pregnant outcomes / 中华围产医学杂志

Objective To compare the outcomes of multifetal pregnancy reduction (MFPR)performed at different gestational ages,and to analyze the influence on pregnancy outcomes.Methods Data of 302 women with multifetal pregnancies conceived after assisted reproductive technology (ART) from January 2002 to February 2012 in Department of Obstetrics and Gynecology of Provincial Hospital Affiliated to Shandong University were collected and divided into two groups.The study group involved 152 multifetal pregnancy cases (triplets or quadruplets),which were further divided into three subgroups according to the timing of MFPR to twins,12-13 +6 (n=91),14-15+6(n=32) and 16-24+6 gestational weeks (n=29).The control group involved 150 twin pregnancy cases.MFPR was performed by trans abdominal intra cardiac injection of 10％ potassium chloride (KCl) solution under ultrasound guidance.Gestational age of delivery,birth weight,incidence of gestational diabetes mellitus (GDM) and hypertensive disorder complicating pregnancy (HDCP) were analyzed by t test,one-way ANOVA or Chi-square test.Results Pregnancy loss rate of the study group (14.5％,22/152) was higher than that (6.7％,10/150) of control group,x2=4.857,P＜0.05.Pregnancy loss rate of the subgroup undergoing MFPR during 16-24+6 gestational weeks (31.0％,9/29) was higher than that during 12-13 +6 gestational weeks (8.8％,8/91,x2=7.212,P＜0.05) and that of control group (x2=12.749,P＜0.05).There were no differences in pregnancy loss rate between control group and MFPR during 12-13+6 gestational weeks (x2=0.370,P＞0.05),and during 14-15+6 gestational weeks (15.6％,5/32,x2 =1.739,P＞0.05).No statistically significant difference was found between the study group and control group in mean gcstational age at delivery[(36.9±l.8) weeksvs (37.0±1.8) weeks,t =-0.346,P＞0.05],mean birth weight of large babies [(2720.4±455.0) g vs (2729.1±413.8) g,t =-0.163,P＞0.05] and small babies [(2409.2±412.6) g vs (2416.2±436.8) g,t=-0.136,P＞0.05].There were no differences between the study group and control group in delivery rate at 28-34 gestational weeks [6.2％ (8/130)vs6.4％ (9/140),x2 =0.009,P＞0.05],birth weight discordance rate [12.3％ (16/130) vs11.4％ (16/140),x2=0.050,P＞0.05],GDMrate[3.1％ (4/130) vs2.1％ (3/140),x2 =0.659,P＞0.05] and HDCP rate [11.5％ (15/130) vs 8.6％ (12/140),x2 =0.010,P＞0.05].Conclusions There is risk of pregnancy loss after MFPR,but MFPR before 16 weeks of gestation might decrease the risk.

Lesão vascular da placenta condicionando RCIU e hidropisia fetal não imune em gestação gemelar / Placental vascular lesion as cause of IUGR and nonimmune fetal hydrops in twin pregnanc

As lesões vasculares da placenta constituem um grupo de entidades distintas, mas inter-relacionadas, em que se incluem os corioangiomas e a corangiomatose multifocal difusa. O corioangioma é uma lesão nodular expansiva com incidência de cerca de 1 por cento. A corangiomatose multifocal difusa é rara (0,2 por cento) e predominante em placentas em idade gestacional inferior a 32 semanas. Os autores apresentam um caso de gestação gemelar monocoriônica/biamniótica, no qual um dos fetos, à 26ª semana de gestação, apresentou quadro de restrição de crescimento intrauterino, hidropisia e anemia associado à formação tumoral da placenta com vascularização aumentada verificada pela doplervelocimetria. O estudo anatomopatológico da placenta permitiu o diagnóstico de corangiomatose multifocal difusa. Este raro caso de corioangiomatose multifocal difusa com forma de apresentação pré-natal mimetizando a de um corioangioma comprova que a detecção ultrassonográfica de um tumor da placenta com vascularização aumentada deve suscitar outras hipótese diagnóstica, além do corioangioma.

Placenta vascular lesions are a group of distinct yet related entities that include chorangiomas and diffuse multifocal chorangiomatosis. Chorangioma is an expansive nodular lesion with an incidence of about 1 percent. Diffuse multifocal chorangiomatosis is rare (0.2 percent) and mostly seen in placentas before the 32nd gestational week. The authors present a case of a monochorionic/biamniotic twin pregnancy, in which, at the 26th gestational week, one fetus developed intrauterine growth restriction (IUGR), hydrops, and anemia associated with a tumor of the placenta with increased vascularization in the Doppler study. Pathological examination of the placenta diagnosed diffuse multifocal chorangiomatosis. This rare case report of diffuse multifocal chorangiomatosis with prenatal manifestations resembling those of a chorangioma proves that prenatal ultrasound detection of a placenta tumor, with increased vascularization at Doppler study, must raise other diagnostic possibilities beside chorangioma.

Gêmeos unidos e autorização judicial para o aborto / Conjoined twins and legal authorization for abortion

OBJETIVO: Descrever casos de gravidez de gêmeos unidos de acordo com a solicitação de autorização judicial para interrupção gravidez. MÉTODOS: Análise retrospectiva das gestações de gêmeos unidos, sem possibilidade de sobrevida extrauterina ou de separação cirúrgica pós-natal, atendidos em um hospital terciário, entre 1998 e 2010. RESULTADOS: Entre 30 casos observados durante o período do estudo, seis (20,0 por cento) casais decidiram continuar com a gravidez, e, em cinco (16,7 por cento) casos, a autorização para interrupção da gestação não foi solicitada devido à idade gestacional avançada (> 25 semanas). A autorização para interromper a gravidez foi solicitada em 19 (63,3 por cento) casos: a permissão foi concedida em 12 (63,2 por cento), indeferida em cinco (26,3 por cento), e não se teve a informação do resultado em dois (10,5 por cento) casos. Nos casos submetidos à interrupção legal da gestação, o parto vaginal foi realizado em 83,3 por cento, e no grupo em que a autorização não foi concedida, a cesárea foi realizada em todos os casos (p < 0,01). CONCLUSÃO: A solicitação da autorização judicial para o aborto é uma alternativa na gravidez de gêmeos unidos sem prognóstico de sobrevida pós-natal. Além disso, o sucesso de um parto vaginal pode ser obtido na maioria dos casos antes do terceiro trimestre, reduzindo os riscos à saúde da mulher e o sofrimento do casal.

OBJECTIVE: To describe pregnancies with conjoined twins according to the request for legal termination of pregnancy. METHODS: Retrospective review of pregnancies with conjoined twins, with no possibility of extrauterine survival or postnatal surgical separation, observed at a tertiary teaching hospital, between 1998 and 2010. RESULTS: Amongst 30 cases seen during the study period, six (20.0 percent) couples decided to continue with the pregnancy, termination of pregnancy was not requested due to advanced gestational age (> 25weeks) in 5 cases (16.7 percent). Legal authorization to terminate the pregnancy was requested in 19 (63.3 percent) cases: permission was granted in 12 (63.2 percent), denied in five (26.3 percent) and information was missing in two (10.5 percent) cases. A successful vaginal delivery was performed in 83.3 percent of the cases undergoing termination of pregnancy and a cesarean section was performed in all the remaining cases (p < 0.01). CONCLUSION: In pregnancies with conjoined twins and without fetal prognosis, legal termination of the pregnancy is an alternative. Moreover, a successful vaginal delivery can be performed in most cases before the third trimester, further reducing maternal risks and parental suffering.

Referencias poblacionales argentinas de peso al nacer según multiplicidad del parto, sexo y edad gestacional / Reference birthweights for the Argentine population by multiplicity of birth, sex, and gestational age

OBJETIVO: Desarrollar referencias nuevas y mejoradas de peso al nacer según la edad gestacional (EG), el sexo y la multiplicidad del parto, para la población argentina en su conjunto. MÉTODOS: La población de estudio incluyó a todos los nacidos vivos de partos simples (n = 3 478 286) y dobles (n = 57 654) en Argentina durante el período 2003-2007. Los probables errores en la clasificación de la EG basada en la fecha de la última menstruación fueron corregidos con el uso de modelos de distribuciones normales mixtas. Los percentiles se obtuvieron mediante la regresión de cuantiles, que además posibilitó el suavizamiento de las curvas. RESULTADOS: Se obtuvieron curvas de peso al nacer para partos simples entre las semanas 22 y 43 de gestación y para partos dobles entre las semanas 24 y 41, según el sexo del neonato. Comparadas con estudios previos, estas referencias no sobreestiman la proporción de nacidos vivos grandes para su EG. Se observó también un aumento del peso al nacer a lo largo del período de estudio. CONCLUSIONES: Las curvas propuestas tienen las ventajas de basarse en grandes números, de ser representativas de los nacimientos argentinos más recientes, de distinguir el tipo de parto y el sexo de los neonatos, y de minimizar los errores de clasificación de la EG. Constituyen por lo tanto una herramienta útil para medir desigualdades y así identificar grupos poblacionales con mayor riesgo de eventos perinatales adversos.

OBJECTIVE: To develop new and improved reference birthweights for the Argentine population as a whole with a breakdown by gestational age (GA), sex and multiplicity of birth. METHODS: The population studied included all live births resulting from single (n = 3,478,286) and double (n = 57,654) births in Argentina during the period 2003- 2007. The probable errors in classifying GA on the basis of last menstruation were corrected using normal mixture models. The percentiles were obtained by quantile regression, which also made it possible to smooth out the curves. RESULTS: Birthweight curves for single births were obtained between weeks 22 and 43 of gestation, and curves for double births between weeks 24 and 41, with a breakdown by the sex of the neonate. Compared with those of previous studies, these reference birthweights do not overestimate the proportion of live births large for their GA. An increase in birthweight was also observed during the period of study. CONCLUSIONS: The proposed curves have the advantages of being based on large numbers, of being representative of the most recent Argentine births, of distinguishing the number of births and the sex of the neonates, and of minimizing GA classification errors. They are therefore a useful tool for measuring inequalities and thus identifying population groups at higher risk of adverse perinatal events.

Ultrassonografia obstétrica entre a 11ª e a 14ª semanas: além do rastreamento de anomalias cromossômicas / Obstetric ultrasound between the 11th and 14th weeks: beyond the screening for chromosomal abnormalities

Esta é uma revisão tradicional (narrativa) que teve como objetivo salientar a contribuição da ultrassonografia (USG) obstétrica entre a 11ª e a 14ª semana de gravidez, comumente denominada ultrassonografia morfológica de primeiro trimestre. Além do rastreamento de anomalias cromossômicas, a USG pode ser empregada neste período para: confirmação ou determinação da idade gestacional; avaliação da anatomia fetal; diagnóstico de malformações; rastreamento de anormalidades estruturais maiores e de síndromes gênicas; definição do prognóstico da gravidez; diagnóstico e caracterização das gestações múltiplas; e rastreamento da pré-eclampsia e da restrição de crescimento intrauterino. Foram incluídos os principais estudos sobre o tema publicados entre 1990 e 2010, pesquisados nas bibliotecas eletrônicas Cochrane e PubMed, e que podem ser incorporados nos níveis de evidência científica I a III.

This is a traditional (narrative) review with the objective of highlighting the contribution of obstetric ultrasonography (US) between the 11th and 14th week of pregnancy, commonly called first trimester anomaly scan. In addition to being used for the screening of chromosomal anomalies, US can be employed during this period to confirm or determine gestational age, evaluate fetal anatomy, diagnose malformations, screen major structural abnormalities and genetic syndromes, define the prognosis of pregnancy, diagnose and characterize multiple pregnancies, and screen preeclampsia and intrauterine growth restriction. The most important studies about this subject published between 1990 and 2010 in the Cochrane and PubMed libraries were included. The selected studies can be classified with scientific levels I to III.

Impact on outcome of frozen-thawed embryo transfer by reducing numbers of transferred embryos / 中华妇产科杂志

Objective To study the impact on pregnant outcome of reducing the number of embryos transferred from three to two in women at age less than 35 who received frozen-thawed embryo transfer (FET). Methods The analysis was performed on 90 FET cycles (77 infertile couples,less than 35 years old) with slow-freezing/rapid-thawing method, including 48 cycles with two embryos transferred and 42 cycles with three embryos transferred. The embryo survival rate, high quality embryo rate, clinical pregnancy rate, implantation rate and multiple pregnancies rate were analyzed. Results No significant differences in embryo survival rate (88.9% versus 88.1%), high quality embryo rate (89.6% versus 81.0%), clinical pregnancy rate (37.5% versus 42.9%), implantation rate (26.0% versus 18.3%) and multiple pregnancy rate (38.9% versus 16.7%) were observed between two and three embryos transferred group (all P > 0.05). However, there were 2 triple pregnancies in three embryos transferred group while none in two embryos transferred group. Conclusion Reducing the number of high quality embryos transferred from three to two in women at age of less than 35 years old who received FET,could decrease the incidence of triple pregnancy and keep the similar clinical pregnancy rate.

Ablação dos vasos placentários com laser para tratamento da síndrome de transfusão feto-fetal grave: experiência de um centro universitário no Brasil / Laser ablation of placental vessels for treatment of severe twin-twin transfusion syndrome: experience from an university center in Brazil

OBJETIVO: descrever os resultados do tratamento da síndrome de transfusão feto-fetal grave com a ablação vascular placentária a laser em um centro universitário do Brasil. MÉTODOS: estudo observacional retrospectivo que incluiu pacientes tratadas na Universidade Estadual de Campinas entre 2007 e 2009. A ablação vascular placentária foi realizada em casos de transfusão feto-fetal grave (estágios II, III e IV de Quintero) diagnosticados até a 26ª semana de gravidez. As principais variáveis avaliadas foram a idade gestacional no parto, a sobrevida (alta do berçário) de pelo menos um gêmeo e o comprometimento neurológico nos sobreviventes. Regressão logística foi utilizada para investigar a influência do comprimento do colo uterino, da idade gestacional e do estágio da doença (antes da cirurgia) sobre o parto/abortamento e o óbito fetal após a intervenção, sobre o parto pré-termo extremo e a sobrevida. RESULTADOS: em toda a amostra, pelo menos uma criança sobreviveu em 63,3 por cento dos casos (19/30). Entre as gestantes que não tiveram parto/abortamento após à cirurgia, a sobrevida de pelo menos um gêmeo foi 82,6 por cento (19/23). Nesse subgrupo (n=23), a idade gestacional média no parto foi 31,9 semanas e o comprometimento neurológico ocorreu em um neonato (1/31; 3,2 por cento). O comprimento do colo uterino influenciou na ocorrência de parto/abortamento após a cirurgia (valor de p=0,008). Entre sete pacientes (7/30; 23,3 por cento) que apresentaram essa complicação, cinco (5/7; 71,4 por cento) tinham medidas do colo uterino menores do que 15 mm. Entre as 23 gestantes que não tiveram parto/abortamento após a cirurgia, os estágios mais avançados da doença (III e IV) aumentaram o risco de parto antes de 32 semanas (valor de p=0,025) e diminuíram a chance de sobrevida de ambas as crianças (valor de p=0,026). CONCLUSÕES: os resultados são semelhantes aos descritos na literatura. Na presente amostra, os principais fatores associados a piores resultados foram o colo uterino curto (menor do que 15 mm) e os estágios mais avançados da doença (III e IV) no momento em que o tratamento foi realizado.

PURPOSE: to describe the results of laser ablation of placental vessels for the treatment of severe twin-to-twin transfusion syndrome in an university center in Brazil. METHODS: retrospective observational study of patients treated at UNICAMP from 2007 to 2009. Laser ablation of placental vessels was performed in cases of severe twin-twin transfusion syndrome (Quintero stages II, III and IV) diagnosed before 26 complete weeks of gestation. The main variables evaluated in this series were gestational age at delivery, survival (discharge from the nursery) of at least one twin and neurological damage in survivors. Logistic regression was used to investigate the influence of cervical length, gestational age and stage of the disease (before the surgery) on the occurrence of delivery/abortion and fetal death after the intervention, and the influence on severe preterm birth and survival. RESULTS: in the whole series, at least one twin survived in 63.3 percent of cases (19/30). Among patients who did not have delivery/abortion after surgery, the survival of at least one twin was 82.6 percent (19/23). In this subgroup (n=23), mean gestational age in delivery was 31.9 weeks and neurological damage was identified in one neonate (1/31; 3.2 percent). Cervix length influenced the occurrence of delivery/abortion after surgery (p-value=0.008). Among seven patients (7/30; 23.3 percent) who carried this complication, five (5/7; 71.4 percent) had cervix length lower than 15 mm. Among the 23 patients who did not have delivery/abortion as a result of the surgery, the highest stages of the disease (III and IV) increased the risk of delivery prior to 32 complete weeks of gestation (p-value=0.025) and decreased the chance of survival of both twins (p-value=0.026). CONCLUSIONS: the results are similar to those available in the literature. In our series, the main factors associated with poorer results were short cervix (lower than 15 mm) and the highest stages of the disease (III and IV) at the time of the treatment.

Combination of ultrasonography and magnetic resonance image in diagnosing monochorionic multifetal malformations-report of 14 cases / 中华围产医学杂志

Objective To demonstrate the value of eombined application of prenatal ultrasonography with fetal magnetic resonance imaging(MRI) in the diagnosis of monochorionic muhifetal realformations. Methods Fourteen cases of muhifetal malformations,detected by prenatal ultrasonography,received MRI within 48 h afterwards.All diagnosis were confirmed after delivery or mid-term termination.All imaging results of the 14 cases were retrospectively reviewed. Results Among the 14 cases,there were 7 acardias,5 Conjoined twins and 2 demise of multifetuses.Comparing ultrasound with MRI,we found that:(1)In cases with acardia and demise of multifetusea,ultrasound could diagnose correctly and be an important tool for follow-up,while MRI could demonstrate organs and structures of the acardiac recipient more clearly and detect the secondary changes of brain in the donor and survived fetus.(2)In Conjoined twins,ultrasound was superior to MRI in demonstrating the structure and function of cardiovascular system : and equivalent to MRI in identifying stomach,kidney,bladder and limbs;but inferior to MRI in identifying esophagus,lung,liver and intestinal,especially in the brain. And MRI could demonstrate two fetuses and the relationship between them in COnjoined twins simultaneously. Conclusions Prenatal ultrasonography and MRI have their own advantages and disadvantages in diagnosing monochorionic multifetal malformations.But the combination of prenatal ultrasonography and fetal MRI may be more valuable.

A 10-year survey on birth defects after In vitro fertilization-embryo transfer In Shanghai / 中华妇产科杂志

Objective To survey birth defects of neonates conceived by using various types of in vitro fertilization and embryo transfer (IVF-ET) between 1998 and 2007 in Shanghai. Methods From 1998 to 2007, 8507 neonates from 6551 pregnancies conceived through assistant reproductive technology (ART) from 7 reproductive medicine center in Shanghai were enrolled in this retrospective study, including Shanghai Ji-Ai Genetics and IVF Institute, Shanghai Jiaotong University School of Medicine affiliated Renji Hospital,Buijin Hospital, China Welfare Institute International Maternal and Infant Health Hospital, Shanghai First Maternity and Infant Health Hospital, Shanghai the Ninth People's Hospital and the Second Military Medical University affiliated Changhal Hospital. The clinical data about the type and incidence of birth defect were analyzed. Meanwhile, the factors associated with birth defect were investigated, such as various ART,gender, mother age, numbers of gestational sac, the source and quality of sperm. Results The birth defect rate was 1.08% (92/8507) and the most remarkable malformation occurred in circulation system [34% (31/92)]. The rates of major congenital malformations were 1.21% (34/2799) in fresh conventional IVF-ET, 1.07% (20/1871) in IVF-frozen-thawed embryo transfer(IVF-FET), 1.04% (23/2212) in fresh intracyto plasmic sperm injection (ICSI)-ET and 0.92% (15/1625) in ICSI-FET, which did not show statistical difference (P>0.05). There was also no significantly different incidence of malformations between 1.12% (49/4371) in male neonates and 1.02% (42/4136) in female neonates (P >0.05).However, the occurrence of congenital malformation is positively related with maternal age, the rates were 0.84% (41/4884) in mother's age less than 30 years and 1.77% (16/902) in mother' age more than 35 years, which reached statistical difference (P < 0.05). It also showed remarkable different incidence among 0.53% (25/4679) in singletons, 1.59% (57/3576) in twins and 3.97% (10/252) in triplets (P< 0.05). No remarkable difference of malformation rate among sperm sources used in fertilization were observed, including 1.09% (81/7419)in ejaculated sperm, 1.21% (7/579)in percutaneous epididymal aspiration (PESA) and 0. 79% (4/509) in donor sperm (P>0.05). Conclusions The overall incidence of birth defect in neonates from ART is similar to those conceived naturally and is not associated with different types of IVF-ET, embryo cryopreservation, sperm sources. However, maternal age and multiple pregnancies coder the higher possibility of birth defect.