Perinatal mortality and mode of delivery in monochorionic diamniotic twin pregnancies ≥ 32 weeks of gestation: a multicentre retrospective cohort study.

OBJECTIVE: To study perinatal mortality rates in a cohort of 465 monochorionic (MC) twins without twin-twin transfusion syndrome (TTS) born at 32 weeks of gestation or later since reported interauterine fetal death (IUFD) rates >32 weeks of gestations in the literature vary, leading to varying recommendations on the optimal timing of delivery, and to investigate the relation between perinatal mortality and mode of delivery. DESIGN: Multicentre retrospective cohort study. SETTING: Ten perinatal referral centres in the Netherlands. POPULATION: All MC twin pregnancies without TTTS delivered at ≥ 32 weeks of gestation between January 2000 and December 2005. METHODS: The medical records of all MC twin pregnancies without TTTS delivered at the ten perinatal referral centres in the Netherlands between January 2000 and December 2005 were reviewed. MAIN OUTCOME MEASURES: Perinatal mortality in relation to gestational age and mode of delivery at ≥ 32 weeks of gestation. RESULTS: After 32 weeks of gestation, five out of 930 fetuses died in utero and there were six neonatal deaths (6 per 1000 infants). In women who delivered ≥ 37 weeks, perinatal mortality was 7 per 1000 infants. Trial of labour was attempted in 376 women and was successful in 77%. There were three deaths in deliveries with a trial of labour (8 per 1000 deliveries), of which two were related to mode of delivery. Infants born by caesarean section without labour had an increased risk of neonatal morbidity and respiratory distress syndrome. CONCLUSIONS: In MC twin pregnancies the incidence of intrauterine fetal death is low ≥ 32 weeks of gestation. Therefore, planned preterm delivery before 36 weeks does not seem to be justified. The risk of intrapartum death is also low, at least in tertiary centres.

Placental characteristics of monoamniotic twin pregnancies in relation to perinatal outcome.

OBJECTIVE: To study placental characteristics in relation to perinatal outcome in 55 pairs of monochorionic monoamniotic (MA) twins. METHODS: Between January 1998 and May 2008 55 pairs of MA twins were delivered in 4 tertiary care centers and analysed for mortality, birth weight discordancy and twin-to-twin transfusion syndrome (TTTS) in relation to type of anastomoses, type and distance between cord insertions and placental sharing. Five acardiac twins, 2 conjoined twins, 4 higher order multiples and one early termination of pregnancy were excluded, leaving 43 MA placentas for analysis. Of these 43, one placenta could not be analysed for placental vascular anastomoses due to severe maceration after single intra-uterine demise leaving 42 placentas for analysis of anastomoses. RESULTS: Arterio-arterial (AA), venovenous (VV) and arteriovenous (AV) anastomoses were detected in 98%, 43% and 91% of MA placentas, respectively. Velamentous cord insertion was found in 4% of cases. Small distance between both umbilical cord insertions (<5 cm) was present in 53% of MA placentas. Overall perinatal loss rate was 22% (19/86). We found no association between mortality and type of anastomoses, type and distance between cord insertions and placental sharing. The incidence of TTTS was low (2%) and occurred in the only pregnancy with absent AA-anastomoses. CONCLUSION: Perinatal mortality in MA twins was not related to placental vascular anatomy. The almost ubiquitous presence of compensating AA-anastomoses in MA placentas appears to prevent occurrence of TTTS.

[Tertiary obstetric care: the aims of the planning decree on perinatal care of 2001 have not yet been achieved]. / Derdelijns verloskundige zorg: doelstellingen van het 'planningsbesluit bijzondere perinatologische zorg' uit 2001 nog niet gehaald.

OBJECTIVE: To compare the actual situation in tertiary perinatal care in the Netherlands with the objectives laid down in the 2001 decree on perinatal care by the Dutch Ministry of Health, Welfare and Sport. DESIGN: Descriptive, retrospective. METHOD: Data on tertiary perinatal care, the transfer or refusal of women with very endangered pregnancies and the personnel of obstetric high care (OHC) units in 2006 were compared with the targets laid down in the planning decree on perinatal care and in a report by the Dutch Health Council from 2000. Parameters of tertiary perinatal care output were the number of admissions, and the number of beds in OHC units and neonatal intensive care units (NICU). RESULTS: In 2006, 128 of the 250 beds intended for OHC had been obtained. The degree of capacity utilisation was 94%, while the norm is 80%. 312 women were transferred due to lack of capacity of OHC units and NICU. The number of staff, specialised physicians as well as nurses, was considerably lower than the planned capacity. But training for obstetric perinatologists and OHC nurses was given. CONCLUSION: The targets for the number of beds for tertiary obstetric care and associated medical personnel have not been achieved as yet. As a consequence, the number of transfers is still too high. The funding of OHC units is not attuned to the complexity of tertiary perinatal care. Closer supervision of the execution of the planning decree and an adequate financing system are needed to achieve the objectives of the planning decree in the next 3 years.

Significance of donor anuria differs between monoamniotic and diamniotic twin-twin transfusion syndrome.

Development of severe twin-twin transfusion syndrome (TTTS) in diamniotic-monochorionic twins includes five stages of increasing severity, i.e. recipient polyhydramnios and donor oligohydramnios, donor anuria, abnormal umbilical flow velocities in either twin, hydrops in the recipient, and intrauterine fetal death (IUFD) in either or both twins. In a severe case of TTTS in monoamniotic twins we observed donor anuria to appear after hydrops in the recipient. We conclude that donor anuria is a late and serious symptom in monoamniotic TTTS.

Effects of antenatal corticosteroid administration on mortality and long-term morbidity in early preterm, growth-restricted infants.

OBJECTIVE: To evaluate the effect of antenatal corticosteroids on mortality, morbidity, and disability or handicap rate in early preterm, growth-restricted infants. METHODS: This case-control study in two tertiary care centers included all live-born singleton infants with growth-restriction due to placental insufficiency, who were delivered by cesarean because of cardiotocographic signs of fetal distress before the beginning of labor at a gestational age of 26-32 weeks during the years 1984-1991. Infants who had been treated antenatally with corticosteroids more than 24 hours and less than 7 days before birth were matched by birth weight, sex, and year of birth with infants whose mothers had been admitted more than 24 hours before delivery but were not treated antenatally with steroids. The main outcome measure was survival without disability or handicap at 2 years corrected age. A sample of 60 case-control pairs would give 81% power to demonstrate 50% increase of this outcome [odds ratio (OR) 3.0] by corticosteroid treatment. Behavior and physical growth were evaluated at school age by questionnaire. RESULTS: The study group and control group consisted of 62 infants each. Survival without disability or handicap at 2 years' corrected age was more frequent in the corticosteroid group [OR 3.2, confidence interval (CI) 1.1, 11.2]. In the long-term follow-up at school age there was a statistically significant negative effect on physical growth (OR 5.1, CI 1.4, 23.8), but no differences in behavior were detected. CONCLUSION: Benefits from antenatal corticosteroids for early preterm, growth-restricted infants appear to outweigh possible adverse effects.

Liberal diagnosis and treatment of intrauterine infection reduces early-onset neonatal group B streptococcal infection but not sepsis by other pathogens.

OBJECTIVE: Comparison of the incidence and case fatality of early-onset group B streptococcus sepsis and sepsis caused by other pathogens in neonates after change of management of intrauterine infection. METHODS: All infants delivered from 1988 through 1997 at a gestational age > or = 24 weeks with a birth weight > or = 500 gram without lethal congenital abnormalities were eligible for inclusion. Infants delivered by cesarean section before the onset of labor or rupture of membranes were excluded. During the first period (1988-1991) intrauterine infection was diagnosed by a temperature > 38 degrees C, during the second period (1992-1997) this diagnosis was made at a lower temperature (> or = 37.8 degrees C) or by fetal tachycardia > or = 160/min. Treatment of intrauterine infection was similar during both periods with 3 x 2 gram amoxicillin and 1 x 240 mg gentamicin every 24 hours intravenously during labor. Prophylactic treatment during labor was only given to women with a history of an earlier infant with early-onset group B streptococcus sepsis. RESULTS: During the first period 6,103 infants were included, during the second period 8,504. Intrauterine infection was diagnosed and treated more often in the second period (7.1% vs. 2.6%). The incidence of early-onset group B streptococcus sepsis was significantly lower in the second period than in the first period [0.2% vs. 0.4%; OR 0.5 (0.3-0.9)] and survival without disability higher [80% vs. 52%; OR 4.5 (1.4-16.5)]. However, in both periods the overall incidence of neonatal sepsis (3.6% vs. 3.5%) and overall mortality because of sepsis (14.3% vs.13.1%) were similar. CONCLUSIONS: Although the early detection of clinical signs of intrauterine infection might have been effective for the prevention of serious sequelae of early-onset group B streptococcus sepsis the overall incidence and mortality from neonatal sepsis remained unchanged. Evaluation of preventive measures for early-onset group B streptococcus sepsis should always take the incidence of neonatal sepsis caused by other pathogens into account.

Classification of discordant fetal growth may contribute to risk stratification in monochorionic twin pregnancies.

OBJECTIVES: To determine whether classification of discordant growth between fetal twins allows risk stratification in monochorionic twin pregnancies. METHODS: In 12 twin-to-twin transfusion syndrome (TTTS) pregnancies and 12 cases that were suspected of developing the syndrome, fetal growth was determined by serial standard sonography. Fetal growth was expressed as the difference-average-ratio (DAR), defined as the difference in estimated fetal weight between both twins divided by their average weight. In each case, we determined the maximum value of DAR and the rate of change of DAR using a least squares linear fit of the estimated fetal weights. RESULTS: For the TTTS cases the maximum value of DAR was 0.44 +/- 0.21 versus 0.52 +/- 0.13 for the suspected TTTS cases (P = 0.25). The rate of change of DAR was 0.052 +/- 0.034 per week for the TTTS versus 0.0055 +/- 0.0092 for the suspected TTTS cases (P = 0.0004). After laser therapy, DAR decreased in four successful cases, with a rate of change of -0.0146 +/- 0.0093 per week, but increased further in one unsuccessful case, due to patent anastomoses. In the seven TTTS cases treated with amnioreduction, DAR did not decrease; in one of two suspected TTTS cases the DAR decreased slightly. In the nine amnioreduction cases, the average rate of change of DAR was 0.067 +/- 0.083 per week. This was significantly different from the four successful laser cases (P = 0.01). CONCLUSIONS: The rate of change of DAR, but not DAR itself, has prognostic value for the development of suspected TTTS pregnancies, for the onset and severity of TTTS and for the efficacy of therapy. This parameter is derived from routine sonography examination and may contribute to risk stratification in monochorionic twin pregnancies.

School performance and behaviour in extremely preterm growth-retarded infants.

OBJECTIVE: To describe school performance and behaviour of extremely preterm, growth-retarded infants. DESIGN: Cohort study at two tertiary care centres. Included were all surviving, singleton infants (N= 127) with fetal growth retardation due to placental insufficiency. All were delivered by caesarean section because of signs of fetal distress before the beginning of labour at a gestational age of 26 to 32 weeks during the years 1984-1989. Main outcome measures were special education, mainstream education below the appropriate age level and behaviour according to attention-deficit hyperactivity criteria at school age (4 1/2-10 1/2 yrs). The children were divided into two subgroups according to age at follow-up (> or =7 1/2 and <7 1/2 yr). A logistic regression analysis was performed with special school or repeating a grade and behavioural disturbance as dependent variables and gestational age, birth weight, sex of the infant, neonatal complications (intra cerebral haemorrhage, respiratory distress syndrome, bronchopulmonary dysplasia or sepsis), age category at follow-up and sociodemographic factors as independent variables. RESULTS: 114 (90%) had a complete follow-up. Special education was found in 14% of the assessed children. More children in the older age group than in the younger age group were placed in special school (20% versus 10%). Behavioural problems were scored in 39% of the assessed children attending mainstream education. Special education was related to neonatal complications (bronchopulmonary dysplasia), behavioural problems to the absence of either parent. CONCLUSION: This specific group of growth-retarded children is at serious disadvantage for adequate performance in school, although the incidence of special education and behavioural problems was comparable to other preterm infants. Both special education and behavioural problems were not related to obstetric variables as gestational age and/or birth weight.

Vaginal delivery compared with caesarean section in early preterm breech delivery: a comparison of long term outcome.

OBJECTIVE: To determine the optimum mode of delivery of the early preterm fetus in breech presentation. DESIGN: Retrospective comparison of two cohorts of preterm breech fetus. SETTING: Two tertiary care centres: at one centre the preferred management for preterm breech presentation was vaginal delivery; at the other centre, the preferred method was caesarean section. POPULATION: All singleton infants delivered after breech presentation from 1984 through 1989, at a gestational age of 26 to 31 weeks. Those with lethal congenital abnormalities, placenta praevia, placental abruption, fetal death or fetal distress before the onset of labour were excluded. MAIN OUTCOME MEASURES: Survival without disability or handicap documented at two years corrected age. The influence of a number of relevant variables on this outcome was assessed by logistic regression analysis. RESULTS: There was no difference in survival without disability or handicap between the centres (odds ratio 1.5, 95% CI 0.6-3.9 vaginal delivery compared with caesarean section). Survival without disability or handicap was positively influenced by increasing birthweight and corticosteroids > 24 h before birth, and negatively influenced by footling presentation. CONCLUSION: A policy of caesarean section for early preterm (26-31 weeks) breech delivery is not associated with increased survival without disability or handicap.

Influence of obstetric management on outcome of extremely preterm growth retarded infants.

AIM: To describe the long term outcome of extremely preterm growth retarded infants in relation to obstetric management and various perinatal events. METHODS: A cohort study was undertaken in two tertiary care centres with different obstetric management. All infants with fetal growth retardation due to placental insufficiency and resulting in fetal distress at 26 to 32 weeks of gestation, were included for the years 1984-89. Main outcome measures were impairment, disability, or handicap at 2 years corrected age and at school age (4 1/2 to 10 1/2 years). RESULTS: One hundred and twenty five (98%) were followed up until 2 years corrected age in the outpatient department; 114 (90%) were assessed at school age. Impairments were found in 37% and disabilities or handicaps in 9% of the assessed infants, with no difference between centres. All disabled or handicapped children had already been identified by 2 years corrected age. CONCLUSIONS: Disability or handicap were related to neonatal complications (intracerebral haemorrhage or bronchopulmonary dysplasia) and not to obstetric variables, thus making antenatal prediction impossible. The incidence of disability or handicap in these growth retarded infants was comparable with that of other preterm infants.

Long-term impact of perinatal bereavement. Comparison of grief reactions after intrauterine versus neonatal death.

OBJECTIVE: To investigate possible differences in emotional impact on parents following either a deliberate intrauterine death or a neonatal death in extremely preterm growth retarded infants. DESIGN: Retrospectively matched study by audiotaped semi-structured interview, 3-9 years after the perinatal loss. RESULTS: Nineteen couples (ten in the intrauterine death group and nine in the neonatal death group) consented to participate. More than 50% of the intrauterine death group couples could not share or discuss their emotions. Most partners in this group did not feel the loss of their own child. Discongruent grieving between partners was more pronounced in the intrauterine death group and could be identified as a risk factor for prolonged and abnormal grief reactions. Four couples (three in the intrauterine death group and one in the neonatal death group) developed long-term emotional disturbance and psychosocial problems. Long-term follow-up in both groups was failing remarkably. CONCLUSION: Assimilating a non-intervention policy followed by fetal death requires different skills and is more complicated than grief support around an early neonatal death. Follow-up is essential to identify the couple 'at risk' and to mobilize extra support.

Fetal distress due to placental insufficiency at 26 through 31 weeks: a comparison between an active and a more conservative management.

OBJECTIVE: To compare perinatal mortality and short-term morbidity in extremely preterm infants with fetal distress due to placental insufficiency in two centers with different management attitude. DESIGN: Retrospective cohort study in two university hospitals of all infants with fetal growth retardation due to placental insufficiency resulting in signs of fetal distress at 26 through 31 weeks gestational age, during the years 1984 through 1989. Center A followed a conservative management: in some cases the risk of major handicaps or mortality was estimated so high, based on antenatally estimated fetal weight and gestational age, that the decision was taken to abstain from treatment. In all other cases cesarean section took place, but only if fetal distress was obvious. Center B used a more active management: cesarean section was performed in all cases, sometimes with only minor changes in fetal heart rate variability. RESULTS: Overall survival differed significantly: 55% (center A) versus 72% (center B), largely due to antenatal mortality in center A. Discharge survival rate of liveborn infants was 81% in center A and 72% in center B. More than half of the postnatal mortality was attributed to respiratory causes in both centres. An active management showed a tendency to a higher incidence of short-term morbidity. CONCLUSION: Selection by antenatal prediction of postnatal mortality using estimated fetal weight fails. Even in the group with the lowest birthweight postnatal mortality did not surpass 50%. Early intervention may be associated with higher short-term morbidity. Long-term follow-up of these children is needed to discriminate between both policies with regard to further development of surviving infants.

DNA flow cytometry, histological grade, stage, and age as prognostic factors in human epithelial ovarian carcinomas.

The prognostic value of parameters as determined by DNA flow cytometry, in combination with other parameters, was assessed in 75 patients with ovarian carcinomas (20% in stage I and II). DNA- index of the tumours appeared to predict mainly the degree of differentiation, since the DNA-index only tended to affect prognosis and low grade tumours were mainly diploid. However, with ascites a non-diploid DNA-index was associated with a significantly lower survival in short-term follow-up. Subgroups with a favourable prognosis were defined by an age of patients less than or equal to 40 years, grade 1 tumours, and tumours in stage I or II. Particularly favourable was the combination of a grade 1 tumour, or a tumour in stage I or II, with percentage of cells in G1 greater than 85%. Prognostically poor subgroups were defined by an age greater than 60 years, by grade 2 or 3 tumours and by a clinically advanced stage. The combination of grade 2 or 3, or a clinically advanced stage, with G1-phase fraction less than or equal to 85% identified subgroups with a particularly poor prognosis.