Predictors of twin pregnancy in in vitro fertilization with intracytoplasmic sperm injection cycles with day 3 double embryo transfer.

OBJECTIVE: The purpose of this study was to identify factors associated with twin pregnancy following day 3 double embryo transfer (DET). METHODS: This retrospective cohort study incorporated data from 16,972 day 3 DET cycles. The participants were women aged between 18 and 45 years who underwent in vitro fertilization with intracytoplasmic sperm injection (IVF/ICSI) at My Duc Assisted Reproduction Technique Unit (IVFMD), My Duc Hospital, located in Ho Chi Minh City, Vietnam. RESULTS: Of the 16,972 day 3 DET cycles investigated, 8,812 (51.9%) resulted in pregnancy. Of these, 6,108 cycles led to clinical pregnancy, with 1,543 (25.3% of clinical pregnancies) being twin pregnancies. Factors associated with twin pregnancy included age under 35 years (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.32 to 1.71; p<0.001) and cycles involving the transfer of at least one grade I embryo. Relative to the transfer of two grade III embryos, the risk of twin pregnancy was significantly elevated following the transfer of two grade I embryos (OR, 1.40; 95% CI, 1.16 to 1.69; p<0.001) or a combination of one grade I and one grade II embryo (OR, 1.27; 95% CI, 1.05 to 1.55; p=0.001). CONCLUSION: By analyzing a large number of IVF/ICSI cycles, we identified several predictors of twin pregnancy. These findings can assist medical professionals in tailoring treatment strategies for couples with infertility.

Risk factors for severe postpartum hemorrhage requiring blood transfusion after cesarean delivery for twin pregnancy: a nationwide cohort study.

BACKGROUND: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality. Twin pregnancy and cesarean delivery are well-known risk factors for PPH. However, few studies have investigated PPH risk factors in mothers who have undergone cesarean delivery for twin pregnancies. Therefore, this study investigated the risk factors associated with severe PPH after cesarean delivery for twin pregnancies. METHODS: We searched and reviewed the Korean Health Insurance Review and Assessment Service's claims data from July 2008 to June 2021 using the code corresponding to cesarean delivery for twin pregnancy. Severe PPH was defined as hemorrhage requiring red blood cell (RBC) transfusion during the peripartum period. The risk factors associated with severe PPH were identified among the procedure and diagnosis code variables and analyzed using univariate and multivariate logistic regressions. RESULTS: We analyzed 31,074 cesarean deliveries for twin pregnancies, and 4,892 patients who underwent cesarean deliveries for twin pregnancies and received RBC transfusions for severe PPH were included. According to the multivariate analysis, placental disorders (odds ratio, 4.50; 95% confidence interval, 4.09- 4.95; P < 0.001), general anesthesia (2.33, 2.18-2.49; P < 0.001), preeclampsia (2.20, 1.99-2.43; P < 0.001), hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome (2.12, 1.22-3.68; P = 0.008), induction failure (1.37, 1.07-1.76; P = 0.014), and hypertension (1.31, 1.18-1.44; P < 0.001) predicted severe PPH. CONCLUSIONS: Placental disorders, hypertensive disorders such as preeclampsia and HELLP syndrome, and induction failure increased the risk of severe PPH after cesarean delivery for twin pregnancy.

Dicavitary twin pregnancy in patient with bicornuate bicollis uterine anomaly.

Key Clinical Message: Twin pregnancies in uterine didelphys and uterus bicornuate bicollis represent dicavitary twin pregnancies that can be managed using similar principles. Consideration must be given to delivery planning including mode of delivery and uterine incision. Abstract: Dicavitary twin pregnancies present unique challenges for obstetric management. This case demonstrates an approach to management of a bicornuate bicollis twin pregnancy and provides a contemporary review of the literature on dicavitary twin pregnancies.

Morfometría en placentas procedentes de embarazos gemelares

Introducción: La disfunción de la placenta puede originar complicaciones fetales, restricción del crecimiento intrauterino y complicaciones maternas, como la preeclampsia. Objetivo: Identificar el patrón morfométrico de las placentas gemelares y su relación con la corionicidad, el peso del recién nacido y las malformaciones plancentarias. Método: Se realizó un estudio descriptivo en una muestra de 16 gestantes con embarazo gemelar, 25 placentas y los 32 recién nacidos. Se estudiaron las variables malformaciones placentarias, tipo de placenta, presencia de calcificaciones, peso del recién nacido, peso de la placenta, volumen placentario, diámetro placentario y espesor placentario; se determinó la asociación del peso del recién nacido, con el tipo de placenta y la presencia de calcificaciones, las malformaciones placentarias, así como espesor, diámetro, volumen y peso, con el tipo de placenta. Resultados: Hubo mayor frecuencia de recién nacidos de placentas monocoriónicas (60 %) sin que la asociación fuera estadísticamente significativa; las malformaciones placentarias se relacionaron de forma significativa con el tipo de placenta, así como el peso del recién nacido y la presencia de calcificaciones placentarias, y el espesor, diámetro, volumen y peso de la placenta, con el tipo de plancenta (p< 0,01). Conclusiones: Son más frecuentes las placentas dicoriónicas y estas tienen menos malformaciones; existe relación entre el bajo peso del recién nacido y la presencia de calcificaciones placentarias, así como entre el espesor, diámetro, volumen y peso de la placenta, con el tipo de placenta.

Introduction: Placental dysfunction can originate fetal complications, intrauterine growth restriction and maternal complications, such as preeclampsia. Objective: To identify the morphometric pattern of twin placentas and its relationship with chorionicity, newborn weight and placental malformations. Methods: A descriptive study was carried out in a sample of 16 pregnant women with twin pregnancy, 25 placentas and 32 newborns. The variables placental malformations, type of placenta, presence of calcifications, newborn weight, placental weight, placental volume, placental diameter and placental thickness were studied; the association of newborn weight with the type of placenta and the presence of calcifications, placental malformations, as well as thickness, diameter, volume and weight, with the type of placenta was determined. Results: There was a higher frequency of newborns with monochorionic placentas (60%) without the association being statistically significant; placental malformations were significantly related to placenta type, as well as newborn weight and the presence of placental calcifications, and placental thickness, diameter, volume and weight, with placenta type (p< 0.01). Conclusions: Dichorionic placentas are more frequent and these have fewer malformations; there is a relationship between low newborn weight and the presence of placental calcifications, as well as between placental thickness, diameter, volume and weight, with the type of placenta.

Factors influencing neonatal outcomes in twin pregnancies undergoing cesarean section: a cross-sectional study

SUMMARY OBJECTIVE: This study aimed to evaluate maternal and fetal characteristics and factors affecting fetal outcomes in twin pregnancies delivered by cesarean section. METHODS: This was a cross-sectional study in a tertiary care referral hospital. The primary outcome was to ascertain the effects of independent factors on the 1st and 5th minute APGAR scores, neonatal intensive care unit admissions, the need for mechanical ventilation, and neonatal mortality. RESULTS: A total of 453 pregnant women and 906 newborns were included in the analysis. The final logistic regression model revealed that early gestational weeks and neonates <3rd weight percentile at the time of delivery were the most significant predictors of all poor outcome parameters in at least one of the twins (p<0.05). General anesthesia for cesarean section was associated with 1st minute APGAR<7 and the need for mechanical ventilation, and emergency surgery was correlated with the need for mechanical ventilation (p<0.05) in at least one of the twins. CONCLUSION: General anesthesia, emergency surgery, early gestational weeks, and birth weight <3rd weight percentile were strongly associated with poor neonatal outcomes in at least one of the twins delivered by cesarean section.

A case of amniotic band syndrome after fetal reduction by radiofrequency ablation / 中华围产医学杂志

This article reported a survived case of amniotic band syndrome (ABS) following fetal reduction by radiofrequency ablation. The woman conceived monochorionic diamniotic twin pregnancy spontaneously. Prenatal ultrasound at 24 weeks of gestation indicated twin-twin transfusion syndrome (stage Ⅲ), and radiofrequency ablation for fetal reduction was successfully performed after formal consent. At 28 +6 weeks, ultrasound reexamination revealed significant edema in the left foot of the fetus, with banding around the ankle, as well as the strangulation mark and narrowing rings. Fetal ABS (ⅡB stage) was diagnosed after multidisciplinary consultation. An immediate emergency cesarean section was performed and a live male baby was born. A thin amniotic band could be seen wrapping around the left ankle of the newborn for several rounds, with obvious strangulation marks about 1 cm deep into the skin, and significant edema on the dorsum and sole of the foot, and the submalleolus area. The amniotic band was released at once, and the edema faded gradually after surgery. After a follow-up of 28 days, the lower limbs of the newborn became normal.

Prediction of preeclampsia in twin pregnancies: a review / 中华围产医学杂志

Incidence of twin pregnancies increases significantly in recent years. Twin pregnancies are likely to have a higher risk of quicker progression and more severe preeclampsia (PE) than singletons, making the prediction and prevention of PE of twin pregnancies even more important. The prediction and screening for PE have evolved from guideline-based risk factor screening to simple models with maternal factors only, and then to complex models with a wider range of indicators. Besides, the modeling algorithms have expanded from logistic regression to complex algorithms such as competing risk models. Continuous improvements have been achieved in the prediction models. This paper presents a comprehensive overview of the applicability and the prospect of these models in this area in twin pregnancies and suggests that the prediction models should be improved by optimizing modeling strategies using localized indicators.

Short-term clinical outcomes of different courses of antenatal corticosteroids for preterm twins / 中国新生儿科杂志

Objective:To study the short-term clinical outcomes of different courses of antenatal corticosteroids (ACS) for preterm twins.Methods:From January 2017 to December 2021, preterm twins with gestational age (GA) 24-34 weeks admitted to the neonatal ward of our hospital and received ACS were retrospectively studied. The infants were assigned into single-course group, partial-course group and multiple-course group according to ACS courses. The short-term clinical outcomes were compared among the groups. SPSS software version 25.0 was used for statistical analysis.Results:A total of 286 infants were enrolled in this study, including 128 in single-course group, 89 in partial-course group and 69 in multiple-course group. Compared with single-course group, the risks of neonatal respiratory distress syndrome (RDS) in both partial-course group ( OR=2.332, 95% CI 1.028-5.293, P=0.043) and multiple-course group ( OR=3.872, 95% CI 1.104-13.584, P=0.034) were higher. The birth length in multiple-course group ( β=-0.016, 95% CI -0.029 - -0.002, P=0.024) was lower than single-course group. Conclusions:The risks of neonatal RDS in preterm twins are higher in partial-course and multiple-course of ACS. A full course of ACS should be used to prevent neonatal RDS until further evidence of effectiveness is available.

Vaginal delivery of second twins: factors predictive of failure and adverse perinatal outcomes.

INTRODUCTION: This study was performed to explore factors associated with adverse perinatal outcomes for second twins and to identify predictive factors for successful vaginal delivery of the second twin after vaginal delivery of the first twin. METHODS: This 10-year retrospective study included 231 cases of twin pregnancies in which vaginal delivery of the second twin was attempted after vaginal delivery of the first twin. The relationships of obstetric characteristics with the composite adverse perinatal outcome of the second twin were analysed. Predictive factors for successful vaginal delivery of the second twin were also explored. RESULTS: Gestational age <32 weeks was the only independent risk factor for the composite adverse perinatal outcome and neonatal intensive care unit admission for the second twin. A longer inter-twin delivery interval was associated with greater risk of caesarean delivery of the second twin, but it did not increase the risk of an adverse perinatal outcome. Non-vertex presentation of the second twin at delivery was independently associated with caesarean delivery (9.0% vs 2.0%, P=0.03). For second twins in breech presentation, caesarean delivery was associated with the presence of less experienced birth attendants. CONCLUSION: Among second twins born to mothers who had attempted vaginal delivery, adverse perinatal outcomes were mainly related to prematurity. The presence of more experienced birth attendants may contribute to successful vaginal delivery of the second twin, particularly for twins in non-vertex presentation.

Comparison of Prenatal and Neonatal Outcomes of Selective Fetal Growth Restriction in Monochorionic Twin Pregnancies with or Without Twin-to-Twin Transfusion Syndrome After Radiofrequency Ablation.

Background: This study aimed to investigate and compare the prenatal and neonatal outcomes of monochorionic twin pregnancies complicated with fetal growth restriction (sFGR) with or without twin-to-twin transfusion syndrome (TTTS) after cord occlusion by radiofrequency ablation (RFA). Methods: This prospective cross-sectional study was conducted in women with monochorionic twin pregnancies of 16 to 26 weeks of gestational age (GA) in an academic hospital from 2016 to 2020. Demographic and obstetrical characteristics such as cervical length, GA of RFA and delivery, amnioreduction, cesarean section (C/S) rate, and maximum vertical pocket as well as prenatal, neonatal, and maternal outcomes were evaluated and compared between groups using Statistical Package for the Social Sciences (SPSS). Mann-Whitney U test or independent t test was used for quantitative data and Chi square test was applied for comparing qualitative variables. The significance level of tests was 0.05. Results: Totally 213 (106 sFGR and 107 TTTS+sFGR) cases were enrolled. The mean of maternal age (P=0.787), body mass index (P=0.932), gestational age at RFA (P=0.265), as well as gestational age of delivery (P=0.482), and C/S rate (P=0.124) were not significant between the two groups, but a significant difference (P<0.001) in cervical length was observed between the two groups. No significant differences were found in newborn and fetal outcomes such as fetal demise (P=0.827), PPROM (P=0.233), abortion (P=0.088), and admission to intensive care unit (P=0.822) between the groups. Conclusion: Although worse fetal and neonatal outcomes were expected in the TTTS+sFGR group after RFA, no significant difference was observed between groups.

¿La progesterona natural micronizada previene el trabajo de parto pretérmino?: Revisión sistemática de literatura / Does Natural Micronized Progesterone Prevent Preterm Labor?: Systematic Literature Review / A progesterona natural micronizada previne o trabalho de parto prematuro?: Revisão sistemática da literatura

Introducción. La progesterona es una hormona que favorece el mantenimiento del embarazo, es la protagonista de la fisiopatología del trabajo de parto pretérmino. De esta manera, se propone realizar una revisión sistemática que permita demostrar la utilidad de la progesterona natural micronizada en la mitigación de los efectos deletéreos del trabajo de parto pretérmino. Metodología. Revisión sistemática en la que se utilizaron los términos "MeSH" y "No ­ MeSH". Se empleó el programa "Publish or Perish" y bases de datos como: Medline, PubMed, Embase, Clinical Key, Cochrane Library, Scopus y Google Scholar. Se incluyeron artículos de revisión, meta-análisis, artículos originales (publicaciones preliminares o completas), resúmenes de congresos, seminarios publicados, libros de texto, protocolos hospitalarios regionales y consensos nacionales, en donde cada autor evaluó individualmente cada artículo y aplicó la herramienta CASPE. Resultados. En la literatura no es posible encontrar pautas concisas internacionales sobre el uso de la progesterona micronizada frente a la amenaza de trabajo de parto pretérmino (TPP). En general, para la mitigación del trabajo de parto, según lo analizado por los autores, se recomienda usar progesterona natural micronizada en cápsulas de 100 a 400 mg/día vía oral o 100 a 200 mg cada 12 a 24 horas vía vaginal. Desde la semana 16 hasta la semana 36 de gestación por vía oral y desde la semana 24 a 34 de gestación por vía vaginal. Discusión. El uso de la progesterona micronizada ha demostrado mitigar complicaciones posteriores al trabajo de parto pretérmino, sin embargo, no hay consenso sobre la dosificación y las vías de administración. Sumado a lo anterior, los estudios analizados pueden contener sesgos, por lo que se deja a elección del clínico el uso este medicamento. Conclusiones. La progesterona natural micronizada podría ser empleada para mitigar el trabajo de parto pretérmino según los artículos analizados por los autores a lo largo de la revisión. Sin embargo, se necesitan más estudios para legitimar dicha hipótesis.

Introduction. Progesterone is a hormone that favors maintaining pregnancy. It is the protagonist of the physiopathology of preterm labor. In this sense, a systematic review is proposed to demonstrate the usefulness of natural micronized progesterone in mitigating the harmful effects of preterm labor. Methodology. A systematic review in which the terms "MeSH" and "No ­ MeSH" were used. The "Publish or Perish" program was used, as well as databases, such as: Medline, PubMed, Embase, Clinical Key, Cochrane Library, Scopus, and Google Scholar. Review and meta-analysis articles, original articles (preliminary or complete publications), congress summaries, published seminars, textbooks, regional hospital protocols and national consensuses were included, in which each author individually assessed each article and applied the CASPE tool. Results. It was not possible to find concise international guidelines on using micronized progesterone for the threat of preterm labor (PTL) in literature. According to what the authors analyzed, for the mitigation of labor it is generally recommended the use of natural micronized progesterone in 100 to 400 mg/day capsules orally or 100 to 200 mg every 12 to 24 hours through the vagina. From week 16 to week 36 of pregnancy orally and from week 24 to 34 through the vagina. Discussion. Using micronized progesterone has demonstrated mitigating complications subsequent to preterm labor. However, there is no consensus on dosage and routes of administration. Added to the above, the analyzed studies may contain biases, reason why using this medication is left to the physician's discretion. Conclusions. Natural micronized progesterone can be used to mitigate preterm labor according to the articles the authors analyzed throughout the review. However, more studies are needed to validate this hypothesis.

Introdução. A progesterona é um hormônio que favorece a manutenção da gravidez, é a protagonista da fisiopatologia do parto prematuro. Dessa forma, propõe-se a realização de uma revisão sistemática que permita demonstrar a utilidade da progesterona natural micronizada na mitigação dos efeitos deletérios do trabalho de parto prematuro. Metodologia. Revisão sistemática em que foram utilizados os termos "MeSH" e "Não­MeSH". Foram utilizados o programa "Publish or Perish" e bases de dados como: Medline, PubMed, Embase, Clinical Key, Cochrane Library, Scopus e Google Scholar. Foram incluídos artigos de revisão, meta-análises, artigos originais (publicações preliminares ou completas), resumos de congressos, seminários publicados, livros didáticos, protocolos hospitalares regionais e consensos nacionais, onde cada autor avaliou individualmente cada artigo e aplicou a ferramenta CASPE. Resultados. Não é possível encontrar na literatura diretrizes internacionais concisas sobre o uso de progesterona micronizada diante da ameaça de trabalho de parto prematuro (TPP). Em geral, para a mitigação do trabalho de parto, conforme analisado pelos autores, recomenda-se o uso de progesterona natural micronizada em cápsulas de 100 a 400mg/dia por via oral ou 100 a 200mg a cada 12 a 24 horas por via vaginal. Da 16ª à 36ª semana de gestação por via oral e da 24ª à 34ª semana de gestação por via vaginal. Discussão. O uso de progesterona micronizada demonstrou mitigar as complicações após o trabalho de parto prematuro, no entanto, não há consenso sobre a dosagem e as vias de administração. Além do exposto, os estudos analisados podem conter vieses, pelo que cabe ao médico escolher o uso deste medicamento. Conclusões. A progesterona natural micronizada poderia ser utilizada para mitigar o trabalho de parto prematuro de acordo com os artigos analisados pelos autores ao longo da revisão. No entanto, mais estudos são necessários para legitimar essa hipótese.

Obstetric and neonatal outcomes of gestational diabetes mellitus in twin pregnancies according to changes in its diagnostic criteria from National Diabetes Data Group criteria to Carpenter and Coustan criteria: a retrospective cohort study.

BACKGROUND: To compare obstetric and neonatal outcomes in twin pregnancies with or without gestational diabetes mellitus (GDM) before and after changes in GDM diagnostic criteria. METHODS: This was a retrospective cohort study of 1,764 twin pregnancies including 130 women with GDM (GDM group) and 1,634 women without GDM (non-GDM group). Patients with pregestational diabetes, unknown GDM status, and fetal death at < 24 gestational weeks were excluded. Obstetric and neonatal outcomes were compared between the two groups by two periods: period 1 (1995-2005) and period 2 (2005-2018) when National Diabetes Data Group criteria and Carpenter and Coustan criteria were used for diagnosis of GDM, respectively. RESULTS: The incidence of GDM in twin pregnancies increased from 4.0% in period 1 to 9.3% in period 2. Composite obstetric complications rate was significantly higher in the GDM group than that in the non-GDM group during period 1 (72.0% vs. 45.5%, P = 0.009). However, it became comparable during period 2 (60.0% vs. 57.4%, P = 0.601). Interaction between GDM and period indicated a significant differential effect of GDM by period on the rate of composite obstetric complications. The rate of composite neonatal complications was similar between the two groups during both periods. The interaction between GDM and period was not significant. CONCLUSION: After changes of GDM diagnostic criteria, the incidence of GDM increased more than twice, and the rate of composite obstetric complications decreased, but the rate of composite neonatal complications did not change significantly.

Neonatal and long-term outcomes of selective fetal growth restricted fetuses / 中华围产医学杂志

Objective:To investigate the short- and long-term outcomes of fetuses with selective fetal growth restriction (sFGR).Methods:A retrospective study was conducted on monochorionic diamniotic (MCDA) twins with sFGR admitted to the Neonatal Intensive Care Unit of Peking University Third Hospital from September 2017 to December 2019. MCDA neonates delivered during the same period without significant complications were selected as the control group. MCDA twins with sFGR were divided into type Ⅰ, Ⅱ, and Ⅲ groups and then further divided into the larger and the smaller fetus subgroups according to the birth weight. These children were followed up by telephone at 2-3 years old. Height-for-age and weight-for-age Z-scores were calculated. Ages and Stages Questionnaire-Third Edition (ASQ-3) was used to determine comprehensive development. Independent sample t-test, one-way analysis of variance, non-parameter test, and Chi-square test (or rank-sum test) were used for statistical analysis. Results:(1) A total of 116 pregnant women with sFGR (232 neonates) were enrolled in this study. There were 43, 40, and 33 mothers and 86, 80, and 66 newborns in type Ⅰ, Ⅱ, and Ⅲ groups, respectively. The control group included 31 pregnant women and 62 neonates. The gestational age at onset of sFGR was younger in the type Ⅱ and Ⅲ groups than in type Ⅰ group [(23.8±4.8) and (24.1±3.1) vs (27.0±6.1) weeks, F=5.19, P<0.05; all P<0.017 during pairwise comparisons]. (2) The incidence of sepsis and treatment abandonment/death in neonates in type Ⅱ and Ⅲ groups were higher than those in type Ⅰ and control groups [neonatal sepsis: 11.3% (9/80) and 6.1% (4/66) vs 2.3% (2/86) and 0.0% (0/62), χ2=6.30, P=0.001; death or treatment abandonment rate:13.8% (11/80) and 10.6% (7/66) vs 3.5% (3/86) and 0.0% (0/62), χ2=4.68, P=0.003; all P<0.017 during pairwise comparisons]. In cases with type Ⅱ or type Ⅲ sFGR, the risk of digestive system diseases was significantly higher in the smaller fetus group than in the larger fetus group [type Ⅱ: 46.2% (37/80) vs 38.7% (31/80), χ2=16.72; type Ⅲ: 47.0% (31/66) vs 34.8% (23/66), χ2=39.69; both P<0.001], while the rate of respiratory system diseases was lower in the smaller fetus group [type Ⅱ: 35.0% (28/80) vs 45.0% (36/80), χ2=36.85; type Ⅲ: 37.9% (25/66) vs 45.4% (30/66), χ2=12.55; both P<0.001]. The incidence of neonatal sepsis in smaller fetuses was higher than that in larger ones in type Ⅱ sFGR [7.5% (6/80) vs 3.7% (3/80), χ2=4.68, P=0.034]. The incidence of neurological complications in larger fetuses was higher than that in smaller ones in type Ⅲ sFGR [15.1% (10/66) vs 4.5% (3/66), χ2=5.72, P<0.001]. (3) In type Ⅱ group, seven neonates died (one case of cerebral hemorrhage, two cases of gastrointestinal perforation, two cases of septic shock, and two cases of necrotizing enterocolitis), and four cases withdrew the treatment. In type Ⅲ group, four neonates died (two cases of necrotizing enterocolitis, one case of gastrointestinal perforation, and one case of cerebral hemorrhage), and three cases withdrew from the treatment. (4) Totally, 71 children in type Ⅰ, 61 in type Ⅱ, and 58 in type Ⅲ group were followed up at the age of 2-3. Children with type Ⅱ or type Ⅲ sFGR lagged behind those in type Ⅰ group and control group in physical growth [ M ( P25- P75), Z-scores:－0.46 (－0.87-0.42),－0.35 (－0.62-0.71), 0.05 (－0.61-0.51), and 0.14 (－0.57-0.75); H=6.20, P=0.001]. In type Ⅱ and Ⅲ groups, the smaller fetuses lagged the larger fetuses in physical growth at 2-3 years of age. ASQ-3 scores in communication, gross motor, fine motor, problem-solving and personal-social areas were all lower in type Ⅱ and Ⅲ groups than in type Ⅰ and control groups. ASQ-3 scores in the five dimensions of the smaller fetuses in the type Ⅱ group were lower than those of the larger fetuses. In the type Ⅲ group, the smaller fetuses had lower ASQ-3 scores in communication and gross motor than the larger ones [communication ability: (42.6±18.8) vs (56.4±9.4) scores, t=19.63, P<0.001; gross motor: (45.5±19.7) vs (54.5±9.7) scores, t=12.64, P=0.003]. Conclusion:The neonatal morbidity is significantly increased in type Ⅱ and Ⅲ sFGR, and babies lagged others in height, weight, and ASQ-3 score at 2-3, which is worthy of early attention.

Association between thyroid function in the first trimester in twin pregnancies and gestational diabetes mellitus / 中华围产医学杂志

Objective:To explore the associations between thyroid function in the first trimester in twin pregnancies and gestational diabetes mellitus (GDM) and the risk factors of twin pregnancies complicated by GDM.Methods:Retrospective analysis was performed on 745 twin pregnancies delivered after 28 weeks at the Third Affiliated Hospital of Sun Yat-sen University from January 2015 to December 2021, and they were divided into GDM group ( n=186) and the control (non-GDM) group ( n=559). Thyroid dysfunction was diagnosed based on the reference range of singleton and twin pregnancies recommended by the Guideline on diagnosis and management of thyroid diseases (2nd edition) in China and the literature, respectively. Independent sample t-test, Chi-square test, or Fisher exact test, and Mann-Whitney U test were used to compare the general clinical characteristics and thyroid function between the two groups. Spearman rank correlation analysis was performed to analyze the correlation between free thyroxine (FT 4), thyroid stimulating hormone (TSH), thyroid peroxidase antibody (TPOAb), and fasting plasma glucose (FPG) in the first trimester as well as glucose levels in 75 g oral glucose tolerance test (OGTT). The associations between FT 4, TSH at different levels, and the detection rate of GDM, and the risk factors of GDM in twin pregnancies were analyzed using logistic regression. Results:(1) The prevalence of GDM in twin pregnancies was 25.0% (186/745). The positive rate of TPOAb was 13.6% (101/745). FPG in the first trimester was higher in the GDM group than that in the control [(4.7±0.5) vs (4.5±0.4) mmol/L, t=－5.08, P<0.001]. (2) No correlation between FT 4, TSH levels, the positive rate of TPOAb in the first trimester and FPG in the first trimester as well as OGTT results was found (all P>0.05). (3) There was no significant difference when using the thyroid function reference range for twin or singleton pregnancy in detecting hypothyroidism [0.5% (4/745) vs 0.4% (3/745)] and subclinical hypothyroidism [1.2% (9/745) vs 1.3% (10/745)] among the included subjects (both P>0.05), however, there were significant differences in the detection rates of hypothyroxinemia alone [25.0% (186/745) vs 12.9% (96/745)], hyperthyroidism [2.4% (18/745) vs 12.9% (96/745)] and subclinical hyperthyroidism [5.8% (43/745) vs 12.1% (90/745)]( χ2 were 35.43, 33.43 and 18.24, all P<0.001). There was no significant difference in the detection rate of thyroid disease between the GDM and control groups (all P>0.05). (4) FT 4 and TSH levels were grouped into quartiles ( Q1, Q2, Q3, and Q4), which showed that the detection rate of GDM was the highest [27.8% (52/187)] in women with FT 4 in Q1 and was the lowest [23.0% (43/187)] in those with FT 4 in Q2. However, the detection rate was the lowest in women with TSH in Q1 [24.1% (45/187)] and was the highest [27.4%(51/186)] in those with TSH in Q4. Taking Q1 of FT 4 and TSH as a reference, the logistic regression model showed that there were no statistically significant differences between FT 4, TSH at different levels, and GDM, even after adjusting for age, preconception-body mass index (pre-BMI), family history of diabetes, mode of conception, and chorionicity (all P>0.05). (5) Multivariate logistic regression analysis showed that maternal age ( OR=1.10, 95% CI: 1.05-1.15), pre-BMI ( OR=1.13, 95% CI: 1.07-1.21), family history of diabetes ( OR=2.73, 95% CI: 1.53-4.85), and FPG in the first trimester ( OR=2.14, 95% CI: 1.38-3.32) were independent risk factors for twin pregnancies complicated by GDM. Conclusions:Twin pregnant women with higher maternal age, pre-BMI, FPG in the first trimester and family history of diabetes were at higher risk of GDM. No significant correlation is found between maternal thyroid function in the first trimester and GDM in twin pregnancies.

Exploration on appropriate fetal weight of twin pregnancies at different gestational weeks and pregnancy complications and outcomes / 中华妇产科杂志

Objective:To explore the appropriate fetal weight of twin pregnancies at different gestational weeks and the association with pregnancy complications and outcomes.Methods:Fetal weight at different gestational weeks and related pregnancy complications and outcomes from 1 225 twin pregnancies, who gave birth at Peking University First Hospital from January 2004 to December 2020, were analyzed in this study, including hypertensive disorders in pregnancy, gestational diabetes mellitus (GDM), fetal growth restriction (FGR), fetal distress, preterm birth and neonatal asphyxia. The appropriate fetal weight of twin pregnancies at different gestational weeks were analysed based on the information from 616 twin pregnancies without complications (except preterm birth), and were expressed as P10~ P90. The chi-square test was used to compare the risk of pregnancy complications and adverse outcomes in large for gestational age (LGA), appropriate for gestational age (AGA) and small for gestational age (SGA) twin pregnancies and the difference in incidence of pregnancy complications and adverse outcomes in different years. Results:The appropriate fetal weights of normal twin pregnancies at 28 to 37 weeks and 38-40 weeks of gestation were 910-1 255 g, 996-1 518 g, 1 105-1 785 g, 1 295-1 825 g, 1 336-2 000 g, 1 754-2 321 g, 1 842-2 591 g, 1 913-2 615 g, 2 150-2 847 g, 2 350-3 130 g and 2 450-3 250 g, respectively. The incidences of hypertensive disorders in pregnancy, FGR, fetal distress and neonatal asphyxia related to SGA twin pregnancies were significantly higher than AGA twin pregnancies (all P<0.05). The incidence of GDM in twin pregnant from 2017 to 2020 was higher than that from 2004 to 2009 or from 2010 to 2016, but the incidence of fetal distress and neonatal asphyxia were lower than those from 2010 to 2016, and the differences were statistically significant (all P<0.05). Conclusions:The appropriate weights of twin fetuses at different gestational weeks are different from singleton. The incidence of pregnancy complications and adverse outcomes in AGA fetuses is significantly lower than that in SGA fetuses under the specific weight standard for twin fetuses, which could provide a practical basis for clinical management of twin pregnancy.

Safety analysis of cesarean myomectomy in twin pregnancies with intramural myomas / 中华妇产科杂志

Objective:To estimate the safety of myomectomy in twin pregnant women with intramural myomas during cesarean section.Methods:The clinical data of 145 cases of twin pregnancies with intramural myomas who were delivered by cesarean section in Beijing Obstetrics and Gynecology Hospital, Capital Medical University from June 2013 to December 2021 were collected. Maternal demographics, fibroids′ characteristics, maternal and fetal outcomes were compared between groups of cesarean section with myomectomy (myomectomy group, 49 cases) and cesarean section only (non-myomectomy group, 96 cases).Results:Compared with non-myomectomy group, myomectomy group had significantly prolonged operative time [50.0 minutes (37.5-57.5 minutes) vs 40.0 minutes (35.0-50.0 minutes), respectively; P=0.007] and significantly longer postoperative hospital stay [4.0 days (3.0-4.0 days) vs 3.0 days (3.0-4.0 days), respectively; P=0.047). Other maternal and fetal outcomes such as estimated blood loss, hemoglobin difference, postpartum hemorrhage, blood transfusion, B-Lynch structure, uterine artery ligation, postoperative fever and neonatal Apgar score showed no significant differences (all P>0.05). For intramural myomas <5 cm, there were no significant differences in maternal and fetal outcomes between myomectomy group and non-myomectomy group (all P>0.05). For intramural myomas ≥5 cm, operative time [55.0 minutes (40.0-60.0 minutes) vs 42.5 minutes (40.0-50.0 minutes), respectively; P=0.019] was significantly prolonged, postoperative hospital stay [4.0 days (4.0-5.0 days) vs 4.0 days (3.0-4.0 days), respectively; P=0.048] was significantly longer in myomectomy group than non-myomectomy group, but there were no significant differences in other maternal and fetal outcomes (all P>0.05). Conclusion:For twin pregnancies with intramural myomas, it is safe and feasible to remove intramural myomas during cesarean section by experienced obstetricians.

Clinical features and perinatal outcomes of twin pregnancies with complete placenta previa / 中华围产医学杂志

Objective:To investigate the clinical features and perinatal outcomes of twin pregnancies with complete placenta previa (CPP).Methods:We conducted a retrospective study on 266 women with CPP, including 62 twin pregnancies (twins group) and 204 singleton pregnancies (singleton group), who gave birth in Peking University Third Hospital from January 2012 to December 2020. T-test, nonparametric test and Chi-square test were adopted for univariate analysis. Differences between the two groups regarding clinical features and perinatal outcomes were compared using multivariate logistic regression or multivariate linear regression. Results:The incidence of twin pregnancy with CPP was 2.11% (62/2 937). Placenta accreta spectrum disorders (PAS) accounted for 48.4% (30/62) and 53.9% (110/204) in the twin and singleton group, respectively, but the difference was not statistically significant ( χ 2=0.58, P>0.05). In terms of antepartum hemorrhage, the proportion of women affected, those with first onset <29 weeks, amount of bleeding ≥200 ml, and the number of episodes of bleeding ≥3 were significantly higher in the twin group than those in the singletons [56.5% (35/62) vs 39.7% (81/204); 35.5% (22/62) vs 12.7% (26/204); 17.7% (11/62) vs 4.9% (10/204); and 21.0% (13/62) vs 10.3% (21/204), χ 2=5.42, 16.62, 10.78, and 4.86, respectively, all P<0.05]. Multivariate Logistic regression analysis showed that compared with the singleton group, the twin group was at higher risk of antepartum hemorrhage volume >200 ml, the number of antepartum hemorrhage episodes ≥3, preterm delivery before 34 weeks and 32 weeks, emergency cesarean section, and emergency cesarean section caused by antepartum hemorrhage [a OR(95% CI)=4.36(1.17-16.30), 3.15(1.01-9.79), 17.24(5.36-55.46), 9.85(2.32-41.77), 3.98(1.72-9.20), and 3.10(1.22-7.85), respectively, all P<0.05]. Multivariate linear regression analysis showed that the gestational week at the emergency cesarean section in the twins group was about 2.22 weeks (0.17-4.27 weeks) earlier than that in the singletons. The postpartum hemorrhage amount and the risk of postpartum hemorrhage after cesarean section, infusion of red blood cells, and hysterectomy did not differ significantly between the two groups. Conclusions:Compared with singleton pregnancies, the proportion of preterm delivery, cesarean sections, especially those caused by antepartum hemorrhage, is significantly higher among twin pregnancies combined with CPP. Accordingly, preterm delivery should be actively prevented, and the timing of cesarean section should be individualized according to the condition of the mothers and babies, and early delivery may be considered.

Clinical value of noninvasive prenatal testing in vanishing twin pregnancies / 中华围产医学杂志

Objective:To analyze the clinical value of noninvasive prenatal testing (NIPT) in vanishing twin (VT) pregnancies.Methods:A total of 164 VT pregnancies that underwent NIPT in Peking University Third Hospital from January 2017 to December 2020 were enrolled. Gestational age at onset of vanishing, results of NIPT and invasive prenatal diagnosis, blood sampling time points, and pregnancy outcomes were retrospectively analyzed using two independent samples t test and Chi-square test. Results:(1) Of the 164 cases, six had positive results for NIPT, but negative results for karyotype analysis or single nucleotide polymorphism genotyping, with a false positive rate of 3.7% (6/164) for NIPT and all of them were delivered at term. Four pregnancies terminated in the second trimester, including two fetal malformation cases and one unexplained intrauterine death whose single nucleotide polymorphisms results are all normal and one inevitable abortion case due to premature rupture of membrane who refused amniocentesis. The other 154 women all gave birth to normal phenotype babies including 12 preterm ones. (2) The false-positive rate of NIPT was lower in VT pregnancies diagnosed at less than eight gestational weeks than those diagnosed after [1.5% (2/134) vs 13.3% (4/30), χ2=6.68, P=0.010]. The false-positive rate was 6.9% (4/58) in women diagnosed at or below eight weeks between the occurrence of VT and blood sampling and was 1.9% (2/106) in those with interval more than eight weeks, but without significant difference ( χ2=1.44, P=0.231). Conclusions:Although VT pregnancies exist false-positive results in NIPT, screening is still recommended based on fully informed consent to reduce unnecessary invasive prenatal diagnosis. The earlier the onset of VT, the lower the NIPT false positive rate, but whether extending the sampling interval would reduce the risk of false-positive needs further study.

Concordance of Congenital Heart Defect in Monozygotic Twins in Brazil

Abstract Tetralogy of Fallot (TOF) consists of four cardiac changes: interventricular communication, pulmonary stenosis, aortic dextroposition and right ventricular hypertrophy. The prevalence is 0.1 per 1,000 live births. A primiparous mother with gestational age of 38 weeks came to the emergency. At the time, it was verified in her twin pregnancy that one fetus had TOF, thus a pregnancy interruption was scheduled for the following day. In the neonatal physical examination of both, localized acrocyanosis, regular heart rhythm with the presence of a heart murmur, and good peripheral perfusion were found. The echocardiogram of twin 1 revealed: patent foramen ovale; a wide perimembranous interventricular communication of misalignment, with the aorta riding the septum by 50%; hypertrophied and long infundibulum with pulmonary infundibulo-valvular stenosis, with a maximum systolic gradient of 66 mm Hg; both pulmonary arteries presented dimensions of 0.35 mm; pulmonary valve annulus: 0.56 mm; and patent ductus arteriosus measuring 0.19 mm. The echocardiogram of twin 2 showed: patent foramen ovale; a wide perimembranous interventricular communication of misalignment, with the aorta riding the septum by 50%; hypertrophied infundibulum with stenosis pulmonary infundibulo-valve, with a maximum systolic gradient of 33 mm Hg; reduced confluent pulmonary arteries; right pulmonary artery measuring 0.40 mm and left pulmonary artery measuring 0.55 mm; pulmonary valve annulus measuring 0.72 mm; a closed arterial canal, and mild aortic regurgitation. Tetralogy of Fallot is a multifaceted syndrome with a high prevalence in pediatrics. This case is the first case of congenital heart defect concordance for TOF in monozygotic twins in Brazil.

Secuencia de perfusión arterial reversa en embarazo gemelar; coagulación de arteria nutricia. Reporte del primer caso en el país / Twin reversed arterial perfusion sequence; coagulation of the umbilical cord. A report on the first case in Uruguay / Seqüência reversa de perfusão arterial na gravidez gemelar; coagulação da artéria nutritiva. Relato do primeiro caso no país

Resumen: La secuencia de perfusión arterial reversa (TRAP) es una complicación muy poco frecuente y grave de los embarazos gemelares monocoriónicos. Generalmente ocurre cuando el corazón de un gemelo de apariencia normal sirve como bomba para uno o más gemelos dismórficos cuya cabeza, órganos torácicos y extremidades superiores no se desarrollan completamente o no se desarrollan en absoluto y, por lo tanto, carecen de actividad cardíaca. La arquitectura placentaria vascular anómala provoca un cambio en el flujo arterial hacia el gemelo acardíaco. Los mecanismos fisiopatológicos exactos que conducen a este fenómeno devastador no se conocen bien. Compartiremos el caso clínico de una paciente de 19 años, cursando un embarazo gemelar monocorial monoamniótico, en que realizamos diagnóstico de TRAPS, y realizamos la coagulación laser de la arteria nutricia del feto acárdico.

Abstract: Twin reversed arterial perfusion sequence (TRAPS) is rather an unusual and severe complication of monochorionic twin pregnancies. It usually occurs when the normal-appearance heart of a twin acts as a pump for one or more dysmorphic twins whose head, thoracic organs and upper limbs fail to totally develop or do not develop at all and thus, have no cardiac activity. The abnormal vascular architecture at the placenta changes the arterial flow towards the acardiac twin. The exact pathophysiological mechanisms that result in this devastating phenomenon are still unknown. The study presents the clinical case of a 19-year- old patient pregnant with monoamniotic, monochorionic twins and a diagnosis of TRAPS, treated by laser coagulation of the acardiac twin's umbilical cord.

Resumo: A seqüência reversa de perfusão arterial (TRAPS) é uma complicação muito rara e grave de gestações gemelares monocoriônicas. Geralmente ocorre quando o coração de um gêmeo de aparência normal serve como uma bomba para um ou mais gêmeos dismórficos cuja cabeça, órgãos torácicos e membros superiores não se desenvolvem totalmente ou não se desenvolvem e, portanto, não têm atividade cardíaca. A arquitetura vascular placentária anormal causa uma mudança no fluxo arterial para o gêmeo acardíaco. Os mecanismos fisiopatológicos exatos que levam a esse fenômeno devastador não são bem compreendidos. Descrevemos o caso clínico de uma paciente de 19 anos, portadora de gestação gemelar monocoriônica monoamniótica, na qual fizemos o diagnóstico de TRAPS e realizamos coagulação a laser da artéria nutritiva do feto acardíaco.