The potential of repeated mean arterial pressure measurements for predicting early- and late-onset pre-eclampsia in twin pregnancies: Prediction model study.

OBJECTIVE: To investigate the contribution of longitudinal mean arterial pressure (MAP) measurement during the first, second, and third trimesters of twin pregnancies to the prediction of pre-eclampsia. METHODS: A retrospective cohort study was conducted on women with twin pregnancies. Historical data between 2019 and 2021 were analyzed, including maternal characteristics and mean artery pressure measurements were obtained at 11-13, 22-24, and 28-33 weeks of gestation. The outcome measures included pre-eclampsia with delivery <34 and ≥34 weeks of gestation. Models were developed using logistic regression, and predictive performance was evaluated using the area under the curve, detection rate at a given false-positive rate of 10%, and calibration plots. Internal validation was conducted via bootstrapping. RESULTS: A total of 943 twin pregnancies, including 36 (3.82%) women who experienced early-onset pre-eclampsia and 93 (9.86%) who developed late-onset pre-eclampsia, were included in this study. To forecast pre-eclampsia during the third trimester, the most accurate prediction for early-onset pre-eclampsia resulted from a combination of maternal factors and MAP measured during this trimester. The optimal predictive model for late-onset pre-eclampsia includes maternal factors and MAP data collected during the second and third trimesters. The areas under the curve were 0.937 (95% confidence interval [CI] 0.894-0.981) and 0.887 (95% CI 0.852-0.921), respectively. The corresponding detection rates were 83.33% (95% CI 66.53%-93.04%) for early-onset pre-eclampsia and 68.82% (95% CI 58.26%-77.80%) for late-onset pre-eclampsia. CONCLUSION: Repeated measurements of MAP during pregnancy significantly improved the accuracy of late-onset pre-eclampsia prediction in twin pregnancies. The integration of longitudinal data into pre-eclampsia screening may be an effective and valuable strategy.

Mothers of twins had higher old-age survival than mothers of singletons in Estonian 19th-century birth cohorts.

STUDY QUESTION: Do the mothers of twins and singletons differ regarding post-partum and old-age mortality? SUMMARY ANSWER: Twin deliveries were associated with higher post-partum maternal mortality than singleton deliveries, but the lifetime post-partum mortality risk was similar for mothers of twins and singletons; survival of twinners was higher than survival of the mothers of singletons after the 67th lifespan percentile. WHAT IS KNOWN ALREADY: Twinning is typically associated with higher post-partum maternal mortality. The evidence about whether twinning incurs long-term survival costs of reproduction or is a trait pertinent to long-lived women is scarce and contradictory. STUDY DESIGN, SIZE, DURATION: The study is based on the data of the Estonian Family Register (operating from 1926 to 1943) and involves 5565 mothers of twins and 119 613 mothers of singletons born between 1850 and 1899. The subset for comparing maternal lifespans included 1703-1884 mothers of twins and 19 747-36 690 mothers of singletons. PARTICIPANTS/MATERIALS, SETTING, METHODS: Post-partum maternal mortality was analyzed in the whole sample (including mothers of a single child) by logistic regression. Most of the analyses were performed in samples where each mother of twins was matched against mothers of singletons based on parity (or number of deliveries), urban versus rural and inland versus coastal origin, whether their lifespan was known, date of birth and age at first birth. Lifespans were compared in linear mixed models. Quantile regression was used to analyze age-dependent variations in maternal mortality rates. All models were adjusted for relevant biodemographic covariates. MAIN RESULTS AND THE ROLE OF CHANCE: The twinning rate in the whole sample was 4.4%. During the year after giving birth, maternal mortality for twin deliveries was 0.75% (17/2273) and 0.37% (449/122 750) for singleton deliveries (OR = 2.05, 95% CI = 1.21-3.23). However, the lifetime post-partum mortality risk for mothers of twins (0.51%; 28/5557) and singletons (0.37%; 438/119 466) did not differ significantly (OR = 1.38, 95% CI = 0.91-1.98). The life spans of the mothers of twins and singletons did not differ in matched samples. Past the 67th lifespan percentile, the odds of survival were significantly higher for mothers of twins than mothers of singletons, as indicated by non-overlapping 95% confidence intervals. LIMITATIONS, REASONS FOR CAUTION: Relatively low number of individuals (22 802-28 335) with known age at death in matched datasets due to discontinuation of the register after 1943. WIDER IMPLICATIONS OF THE FINDINGS: The finding that mothers of twins had higher odds of old-age survival than mothers of singletons is consistent with the contention that twinners represent a non-random subset of women whose robust phenotypic quality allows them to outlive the mothers of singletons in old age. STUDY FUNDING/COMPETING INTEREST(S): The study was funded by the Estonian Research Council grants PRG1137, PRG2248, and PSG669. The authors declare no competing interests. TRIAL REGISTRATION NUMBER: N/A.

Anencephaly in a triplet pregnancy: Unprecedented spontaneous reabsorption in-utero and subsequent normal delivery via c-section: A rare case report.

Multiple pregnancies are infrequently encountered, with the incidence of spontaneous triplet pregnancies estimated at approximately 1 in 7000 pregnancies. Triplet gestations are recognized for their propensity to bring about a spectrum of pregnancy related complexities, encompassing fetal structural abnormalities, neurological anomalies, disturbances in amniotic fluid levels, preterm labor, and suboptimal neonatal outcomes. Anencephaly is a serious congenital defect where the brain and skull do not fully develop, often leading to a poor prognosis. It's a preventable neural tube defect (NTD) with timely intake of folic acid, is caused by the incomplete closure of the neural tube during fetal development, resulting in the absence of the cerebrum (responsible for thinking and coordination) and the front part of the brain (forebrain) in affected infants. While anencephaly in a triplet is scarcely reported, spontaneous reabsorption of an anencephalic fetus in utero is a rare and unexpected event, with no documented cases in triplet pregnancies until now. We report a case of anencephaly in a triplet pregnancy where the mother presented late during her third trimester, the reabsorption of the anencephalic fetus in utero is an unprecedented event, highlighting the unique nature of this triplet pregnancy.

Delayed-Interval Delivery in Multiple Pregnancy: A Single-Center Experience of Five Cases.

Objectives To describe the obstetric management and perinatal outcomes in multiple pregnancies with delayed-interval delivery (DID) of the cotwin in a tertiary hospital. Methods This is a retrospective chart review of all cases of DID between December 2021 and 2022 at The Ottawa Hospital. Five cases of DID were identified and reviewed to obtain information on obstetric management and maternal-neonatal outcomes. We included eligible twins and triplets. No multiples were excluded. We obtained ethics approval for this case series. Results Four sets of dichorionic diamniotic twins and one trichorionic triamniotic triplet were included. Our patients were admitted between 17 3/7 and 21 5/7 weeks of gestation. We achieved an interval delivery range between 1 and 36 days. Four out of six multiples did not survive in DID. The two surviving newborns were born at 23 0/7 and 23 2/7 , stayed in the neonatal intensive care unit (NICU) for 111 and 131 days, discharged with a weight of 3,594 and 2,743 g, respectively. All DID cases were delivered spontaneously except for two patients that required augmentation due to maternal sepsis. Conclusion Despite the high risk of maternal, fetal, and neonatal morbidity and mortality, if delivery of the first twin occurs before 20 gestational weeks, DID could be considered in selected cases to improve outcomes for the cotwin.

Late selective termination in dichorionic twins: comparing late second and third trimester procedures.

RESEARCH QUESTION: Do perinatal outcomes of selective termination performed in the late second versus third trimester differ and what risk factors are associated with subsequent preterm birth? DESIGN: This is a retrospective cohort study of late selective terminations performed in dichorionic twins between 2009 and 2021. Perinatal outcomes were compared between two groups: group A, late second trimester (20.2 to 24.2 weeks, n = 26), and group B, third trimester (≥28.2 weeks, n = 55) selective terminations. Univariate and multivariate analyses were conducted to identify factors associated with post-procedure preterm birth. RESULTS: In total, 81 dichorionic twin pregnancies were included. There were no pregnancy losses but 16% (13/81) of cases experienced complications. Group A had a higher median birthweight centile (36.5th versus 15th centile, P = 0.002) and lower rates of intrauterine growth restriction (IUGR) and Caesarean delivery (11.5% versus 32.7%, P = 0.04; and 26.9% versus 61.8%, P = 0.003) than group B. Preterm birth rates were similar (46.2% versus 63.6%, P = 0.15). Multiple regression revealed that reduction of the presenting twin and cervical length ≤35 mm were independently associated with post-procedure preterm birth (odds ratio [OR] 8.7, P = 0.001, 95% confidence interval [CI] 2.5-29.8; OR 3.8, P = 0.015, 95% CI 1.3-11). CONCLUSIONS: Late second trimester selective termination is associated with a higher birthweight centile and lower rates of IUGR and Caesarean delivery, compared with third trimester selective termination. Cervical length 35 mm or less and reduction of the presenting twin are independent risk factors for post-procedural preterm birth. These findings may help determine the optimal time to perform a late selective termination.

Diagnóstico de malformación del desarrollo cortical en embarazo gemelar monocorial: reporte de caso

Introducción: Las malformaciones del desarrollo cortical se deben a alteraciones en la migración del neuroblasto durante la formación de la corteza cerebral. Se desconoce su frecuencia en embarazos monocoriales. Objetivo: Reportar el caso de un embarazo monocorial con diagnóstico de malformación del desarrollo cortical en uno de los fetos y revisar la literatura referente a su diagnóstico y pronóstico. Método: Mujer de 19 años, embarazo monocorial biamniótico de 26 semanas, que acudió con estudio ecográfico y resonancia fetal que evidenció en uno de los fetos asimetría de los hemisferios cerebrales, hipoplasia de la cisura de Silvio izquierda con simplificación del patrón giral por focos de paquigiria y polimicrogiria, con confirmación posnatal de alteración en la migración neuronal asociada a hipoplasia vermiana. Resultados: Se encontraron en la literatura tres casos de embarazo múltiple monocorial con trastorno de la migración neuronal con recién nacidos vivos. Los hallazgos más comunes fueron microcefalia, lisencefalia e hipoplasia cerebelosa. Conclusiones: El diagnóstico prenatal del trastorno de la migración neuronal se realiza con ecografía y resonancia fetal. La más frecuente es la alteración de la migración neuronal tipo II. El pronóstico depende del tipo de alteración; sin embargo, la mayoría de los casos presentan trastornos epileptiformes con alteraciones del neurodesarrollo.

Introduction: Malformations of cortical development are the result from alterations in the neuroblast migration during the cerebral cortex formation. Its frequency in monochorial multiple pregnancies remains unknown. Objective: To report a case of monochorial multiple pregnancy with diagnosis of malformation of the cortical development in one of the fetuses. In addition, to review the literature regarding the diagnosis and prognosis of this entity. Method: A 19-year-old female with a monochorial diamniotic pregnancy of 26 weeks gestation, arrived with an ultrasound anatomy scan visit, and fetal magnetic resonance imaging, we detected asymmetry in the cerebral hemispheres one of the fetuses, hypoplasia of the left sulcus of Sylvius with simplification of the gyrus pattern due to clusters of pachygyria and polymicrogyria. Those findings were confirmed afterbirth, with a definite diagnosis of neuronal migration disorder associated with vermian hypoplasia. Results: Three cases of monochorial pregnancy with neuronal migration disorder with live newborn, common findings like microcephaly, lissencephaly and vermian hypoplasia. Conclusions: Prenatal diagnosis with neuronal migration disorder is done via ultrasound and magnetic resonance imaging. Neuronal migration disorders type II are the most common of them. Prognosis depends on the type of disorder; however, most patients have epileptiform activity and neurodevelopment impairment.

Exploring the lived experiences of women with multiple gestations in Iran: a phenomenological study.

BACKGROUND: Multiple gestations present numerous physical, psychological, social, and economic challenges for women. Understanding the problem-solving experiences of pregnant women carrying multiple can be invaluable. This study aimed to explore the experiences of Iranian women with multiple gestations. METHODS: This descriptive phenomenological study utilized purposive sampling and continued until data saturation. Data collection involved in-depth semi-structured interviews, with analysis performed using Colaizzi's 7-step method. MAXQDA software was employed for data management. RESULTS: This study involved 12 women with multiple gestations. The average age of the participants was 33.76 ± 6.22 years, and 9 were pregnant with triplets. The data were categorized into four primary themes: the paradox of emotions, the pregnancy prison, immersion in fear, and the crystallization of maternal love, encompassing 17 sub-themes. CONCLUSION: Pregnant women with multiple gestations undergo various changes and experience conflicting emotions. Enhancing their ability to adapt to and accept numerous pregnancies can be achieved through supportive, personalized, and family-centered care, along with improvements and revisions in care policies for multiple gestations.

Comparison of two cancellation strategies to lower the risk of multiple pregnancies in gonadotropin stimulated intrauterine insemination cycles.

OBJECTIVE: To compare two cancellation policies in controlled ovarian stimulation-intrauterine insemination (COS-IUI) cycles to lower the risk of multiple pregnancies (MP). DESIGN: We performed a bicentric retrospective cohort study in two academic medical centers: Angers (group A) and Besançon (group B) University Hospitals. We included 7056 COS-IUI cycles between 2011 and 2019. In group A, cancellation strategy was based on an algorithm taking into account the woman's age, the serum estradiol level, and the number of follicles of 14 mm or greater on ovulation trigger day. In group B, cancellation strategy was case-by-case and physician-dependent, based on the woman's age, number of follicles of 15 mm or greater, and the previous number of failed COS-IUI cycles, without any predefined cut-off. Our main outcome measures were the MP rate (MPR) and the live-birth rate (LBR). RESULTS: We included 884 clinical pregnancies (790 singletons, 86 twins, and 8 triplets) obtained from 6582 COS-IUI cycles. MPR was significantly lower in group A compared with group B (8.1% vs 13.3%, P = 0.01), but LBR were comparable (10.8% vs 11.8%, P = 0.19). Multivariate logistic regression found the following to be risk factors for MP: the "cancellation strategy" effect (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.02-2.60) and the number of follicles of 14 mm or greater (aOR 1.39, 95% CI 1.16-1.66). Cycle cancellation rate for excessive response was significantly lower in group A compared with group B (1.3% vs 2.4%, P < 0.001). CONCLUSIONS: The use of an algorithm based on the woman's age, serum estradiol level and number of follicles of at least 14 mm on trigger day allows the MPR to be reduced without impacting the LBR.

Maternal and perinatal outcomes in twin pregnancies following assisted reproduction: a systematic review and meta-analysis involving 802 462 pregnancies.

BACKGROUND: ART is associated with higher rates of twin pregnancies than singleton pregnancies. Whether twin pregnancies conceived following ART have additional maternal and neonatal complications compared with non-ART twin pregnancies is not known. OBJECTIVE AND RATIONALE: The objective was to quantify the risk of adverse maternal and perinatal outcomes among twin pregnancies conceived following ART compared with non-ART and natural conception. Existing reviews vary in the reported outcomes, with many studies including triplet pregnancies in the study population. Therefore, we aimed to perform an up-to-date review with an in-depth analysis of maternal and perinatal outcomes limited to twin pregnancies. SEARCH METHODS: We searched electronic databases MEDLINE and EMBASE from January 1990 to May 2023 without language restrictions. All cohort studies reporting maternal and perinatal outcomes following ART compared with non-ART twin pregnancies and natural conception were included. Case-control studies, case reports, case series, animal studies, and in vitro studies were excluded. The Newcastle-Ottawa Scale was used to assess the methodological quality of the studies. Using random-effects meta-analysis, the estimates were pooled and the findings were reported as odds ratios (OR) with 95% CI. OUTCOMES: We included 111 studies (802 462 pregnancies). Twin pregnancies conceived following ART were at higher risk of preterm birth at <34 weeks (OR 1.33, 95% CI 1.14-1.56, 29 studies, I2 = 73%), <37 weeks (OR 1.26, 95% CI 1.19-1.33, 70 studies, I2 = 76%), hypertensive disorders in pregnancy (OR 1.29, 95% CI 1.14-1.46, 59 studies, I2 = 87%), gestational diabetes mellitus (OR 1.61, 95% CI 1.48-1.75, 51 studies, I2 = 65%), and caesarean delivery (OR 1.80, 95% CI 1.65-1.97, 70 studies, I2 = 89%) compared with non-ART twins. The risks for the above maternal outcomes were also increased in the ART group compared with natural conception. Of the perinatal outcomes, ART twins were at significantly increased risk of congenital malformations (OR 1.17, 95% CI 1.05-1.30, 39 studies, I2 = 59%), birthweight discordance (>25% (OR 1.31, 95% CI 1.05-1.63, 7 studies, I2 = 0%)), respiratory distress syndrome (OR 1.32, 95% CI 1.09-1.60, 16 studies, I2 = 61%), and neonatal intensive care unit admission (OR 1.24, 95% CI 1.14-1.35, 32 studies, I2 = 87%) compared with non-ART twins. When comparing ART with natural conception, the risk of respiratory distress syndrome, intensive care admissions, and birthweight discordance >25% was higher among the ART group. Perinatal complications, such as stillbirth (OR 0.83, 95% CI 0.70-0.99, 33 studies, I2 = 49%), small for gestational age <10th centile (OR 0.90, 95% CI 0.85-0.95, 26 studies, I2 = 36%), and twin-twin transfusion syndrome (OR 0.45, 95% CI 0.25-0.82, 9 studies, I2 = 25%), were reduced in twin pregnancies conceived with ART versus those without ART. The above perinatal complications were also fewer amongst the ART group than natural conception. WIDER IMPLICATIONS: ART twin pregnancies are associated with higher maternal complications than non-ART pregnancies and natural conception, with varied perinatal outcomes. Women seeking ART should be counselled about the increased risks of ART twin pregnancies and should be closely monitored in pregnancy for complications. We recommend exercising caution when interpreting the study findings owing to the study's limitations.

The addition of the sFlt-1/PlGF ratio to the protein/creatinine ratio in multiple pregnancy: Post-hoc analysis of the PREPARE cohort study.

OBJECTIVE: To assess the predictive accuracy of the sFlt-1/PlGF ratio cut-off 38 in addition to the standard-of-care spot urine protein/creatinine ratio (PCr) for multiple pregnancies in women with suspected pre-eclampsia. STUDY DESIGN: Post-hoc analysis of a prospective cohort study. MAIN OUTCOME MEASURES: Primary outcome was the occurrence of pre-eclampsia in one and four weeks after presentation with suspected pre-eclampsia. Test characteristics with 95% confidence intervals (CI) were calculated on pre-eclampsia development in one and four weeks. RESULTS: Twenty-three multiple pregnancies with suspected pre-eclampsia between 20 and 37 weeks gestation were included for analysis. Women who eventually developed pre-eclampsia had a significantly higher PCr (34.0 vs. 16.5, p = 0.015), sFlt-1 (17033 vs. 5270 pg/ml, p = 0.047) and sFlt-1/PlGF ratio (99 vs. 25, p = 0.033) at baseline. Furthermore, PCr ≥ 30 and sFlt-1/PlGF ratio > 38 was respectively seen in 1/16 (6.3 %) and 3/16 (18.8 %) of the women who did not develop pre-eclampsia. For predicting pre-eclampsia within one week the sFlt-1/PlGF ratio sensitivity was 75.0 % [95 % CI 19.4-99.4] and the negative predictive value 93.8 % [73.0-98.8], while no pre-eclampsia developed when PCr was < 30. Consequently, the combination of these tests did not lead to an improvement in test characteristics, with non-significant differences in positive predictive value (50.0 % [29.5-70.5] versus 80.0 % [37.3-96.4]) compared to PCr alone for pre-eclampsia development in one week. CONCLUSIONS: In addition to standard-of-care spot urine PCr measurements, this study has not been able to demonstrate that the sFlt-1/PlGF ratio cut-off 38 is of added value in the prediction of pre-eclampsia in multiple pregnancy. TRIAL REGISTRATION: Netherlands Trial Register (NL8308).

Steroid Metabolome Analysis in Dichorionic Diamniotic Twin Pregnancy.

Steroid hormones have diverse roles in pregnancy; some help stabilise pregnancy and influence the stability of pregnancy and the onset of labour. Changes and disorders in steroidogenesis may be involved in several pregnancy pathologies. To date, only a few studies have performed a very limited steroid analysis in multiple pregnancies. Our teams investigated multiple pregnancies regarding the biosynthesis, transport, and effects of steroids. We recruited two groups of patients: pregnant women with multiple pregnancies as the study group, and a control singleton pregnancies group. Blood samples were drawn from the participants and analysed. Information about the mother, foetus, delivery, and newborn was extracted from medical records. The data were then analysed. The gestational age of twin pregnancies during delivery ranged from 35 + 3 to 39 + 3 weeks, while it was 38 + 1 to 41 + 1 weeks for the controls. Our findings provide answers to questions regarding the steroidome in multiple pregnancies. Results demonstrate differences in the steroidome between singleton and twin pregnancies. These were based on the presence of two placentae and two foetal adrenal glands, both with separate enzymatic activity. Since every newborn was delivered by caesarean section, analysis was not negatively influenced by changes in the steroid metabolome associated with the spontaneous onset of labour.

Anesthetic Management of Cesarean Section in the Case of a Sextuplet Pregnancy and Polycystic Ovarian Syndrome.

Cesarean section in a mother with a sextuplet pregnancy is challenging for an anesthesiologist. Several perioperative complications are likely because of the overdistended uterus and associated changes in the mother. We are reporting the case of a woman with a sextuplet pregnancy who came for an emergency cesarean. She also had a background history of polycystic ovarian syndrome (PCOS) and ovulation induction for conception. Early pregnancy was complicated by ovarian hyperstimulation syndrome. She required cervical cerclage in early pregnancy. The emergency cesarean was done as she went into preterm labor and six premature babies were delivered at 29 weeks of gestation. Cesarean was done under spinal anesthesia. Preeclampsia and postpartum hemorrhage complicated the perioperative period.

Considering multifetal pregnancy reduction in triplet pregnancies: do we forget the emotional impact on fathers? A qualitative study from The Netherlands.

STUDY QUESTION: What factors influence the decision-making process of fathers regarding multifetal pregnancy reduction or maintaining a triplet pregnancy, and how do these decisions impact their psychological well-being? SUMMARY ANSWER: For fathers, the emotional impact of multifetal pregnancy reduction or caring for triplets is extensive and requires careful consideration. WHAT IS KNOWN ALREADY: Multifetal pregnancy reduction is a medical procedure with the purpose to reduce the number of fetuses to improve chances of a healthy outcome for both the remaining fetus(es) and the mother, either for medical reasons or social considerations. Aspects of the decision whether to perform multifetal pregnancy reduction have been rarely investigated, and the impact on fathers is unknown. STUDY DESIGN, SIZE, DURATION: Qualitative study with semi-structured interviews between October 2021 and February 2023. PARTICIPANTS/MATERIALS, SETTING, METHODS: Fathers either after multifetal pregnancy reduction from triplet to twin or singleton pregnancy or ongoing triplet pregnancies 1-6 years after the decision were included. The interview schedule was designed to explore key aspects related to (i) the decision-making process whether to perform multifetal pregnancy reduction and (ii) the emotional aspects and psychological impact of the decision. Thematic analysis was used to identify patterns and trends in the father's data. The process involved familiarization with the data, defining and naming themes, and producing a final report. This study was a collaboration between a regional secondary hospital (OLVG) and a tertiary care hospital (Amsterdam University Medical Center, Amsterdam UMC), both situated in Amsterdam, The Netherlands. MAIN RESULTS AND THE ROLE OF CHANCE: Data saturation was achieved after 12 interviews. Five main themes were identified: (i) initial responses and emotional complexity, (ii) experiencing disparities in counselling quality and post-decision care, (iii) personal influences on the decision journey, (iv) navigating parenthood: choices, challenges, and emotional adaptation, and (v) shared wisdom and lessons. For fathers, the decision whether to maintain or reduce a triplet pregnancy is complex, in which medical, psychological but mainly social factors play an important role. In terms of psychological consequences after the decision, this study found that fathers after multifetal pregnancy reduction often struggled with difficult emotions towards the decision; some expressed feelings of doubt or regret and were still processing these emotions. Several fathers after an ongoing triplet had experienced a period of severe stress in the first years after the pregnancy, with major consequences for their mental health. Help in emotional processing was not offered to any of the fathers after the decision or birth. LIMITATION, REASONS FOR CAUTION: While our study focuses on the multifetal pregnancy reduction process in the Amsterdam region, we recognize the importance of further investigation into how this process may vary across different regions in The Netherlands and internationally. We acknowledge the potential of selection bias, as fathers with more positive experiences might have been more willing to participate. Caution is needed in interpreting the role of the mother in the recruitment process. Additionally, the time span of 1-6 years between the decision and the interviews may have influenced emotional processing and introduced potential reporting bias. WIDER IMPLICATIONS OF THE FINDINGS: The emotional impact of multifetal pregnancy reduction or caring for triplets is significant, emphasizing the need for awareness among caregivers regarding the emotional challenges faced by fathers. A guided trajectory might optimize the decision-making and primarily facilitate the provision of appropriate care thereafter to optimize outcomes around decisions with potential traumatic implications. STUDY FUNDING/COMPETING INTEREST(S): This study received no funding. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Clinical value of high-intensity focused ultrasound in fetal reduction.

Complex twin reduction surgery is a common but challenging procedure that aims to reduce the risks and complications of multiple pregnancies. The search for safer and more effective methods has led to the development of high-intensity focused ultrasound (HIFU) technology in the field of fetal reduction. This technology utilizes high-energy sound waves to focus precisely on specific areas, achieving non-invasive therapeutic effects. This paper discusses the principles and features of HIFU technology, as well as its application in complex twin reduction surgery. The paper aims to elucidate the important role of this technology in improving surgical outcomes and reducing risks, explore the current limitations of the modality, and propose directions for future development. Through these investigations, it is hoped to improve overall understanding of HIFU, and thereby promote the application of this technology in the field of fetal reduction.

Are Cervical Pessaries Effective in Preventing Preterm Birth?

Preterm births are a significant concern, as they can have serious consequences for both infants and mothers. It is crucial to identify risk factors associated with preterm birth and to implement effective interventions, such as progesterone, cervical pessary, and cervical cerclage, to prevent it. This systematic review aims to evaluate the efficacy of cervical pessary in reducing spontaneous preterm delivery. However, cervical pessaries have limited research and conflicting findings when compared to other interventions for preventing preterm labor. Therefore, this review seeks to analyze various studies to evaluate their overall effectiveness and better understand their role in treating this vulnerable population. The literature search was conducted using PubMed between January and September 2023, and the systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The results of this review highlight the importance of continued research into mitigation strategies for preterm birth. There is some evidence that indicates that using cervical pessaries before 34 weeks can be effective. While some studies have reported positive outcomes when cervical pessaries are combined with other treatments like progesterone, there is no solid statistical evidence to support this claim. Furthermore, additional research is needed to comprehend the impact of singleton pregnancies and long-term outcomes for both mothers and infants.

Major postpartum haemorrhage after frozen embryo transfer: A population-based study.

OBJECTIVE: To investigate the effect on major postpartum haemorrhage (PPH) of mode of conception, differentiating between naturally conceived pregnancies, fresh embryo in vitro fertilisation (fresh-IVF) and frozen embryo transfer (frozen-IVF). DESIGN: Retrospective cohort study. SETTING: The French Burgundy Perinatal Network database, including all deliveries from 2006 to 2020, was linked to the regional blood centre database. POPULATION OR SAMPLE: In all, 244 336 women were included, of whom 240 259 (98.3%) were singleton pregnancies. METHODS: The main analyses were conducted in singleton pregnancies, including 237 608 naturally conceived, 1773 fresh-IVF and 878 frozen-IVF pregnancies. Multivariate logistic regression models adjusted on maternal age, body mass index, smoking, parity, induction of labour, hypertensive disorders, diabetes, placenta praevia and/or accreta, history of caesarean section, mode of delivery, birthweight, birth place and year of delivery, were used. MAIN OUTCOME MEASURES: Major PPH was defined as PPH requiring blood transfusion and/or emergency surgery and/or interventional radiology. RESULTS: The prevalence of major PPH was 0.74% (n = 1749) in naturally conceived pregnancies, 1.92% (n = 34) in fresh-IVF pregnancies, and 3.30% (n = 29) in frozen-IVF pregnancies. The risk of major PPH was higher in frozen-IVF pregnancies than in both naturally conceived pregnancies (adjusted odds ratio [aOR] 2.63, 95% CI 1.68-4.10) and fresh-IVF pregnancies (aOR 2.78, 95% CI 1.44-5.35). CONCLUSIONS: We found that frozen-IVF pregnancies have a higher risk of major PPH and they should be subject to increased vigilance in the delivery room.

History of multifetal gestation and long-term maternal mortality.

BACKGROUND: Multifetal gestation could be associated with higher long-term maternal mortality because it increases the risk of pregnancy complications such as preeclampsia and preterm birth, which are in turn linked to postpartum cardiovascular risk. OBJECTIVES: We examined whether spontaneously conceived multifetal versus singleton gestation was associated with long-term maternal mortality in a racially diverse U.S. METHODS: We ascertained vital status as of 2016 via linkage to the National Death Index and Social Security Death Master File of 44,174 mothers from the Collaborative Perinatal Project (CPP; 1959-1966). Cox proportional hazards models with maternal age as the time scale assessed associations between history of spontaneous multifetal gestation (in the last CPP observed pregnancy or prior pregnancy) and all-cause and cardiovascular mortality, adjusted for demographics, smoking status, and preexisting medical conditions. We calculated hazard ratios (HR) for all-cause and cause-specific mortality over the study period and until age 50, 60, and 70 years (premature mortality). RESULTS: Of eligible participants, 1672 (3.8%) had a history of multifetal gestation. Participants with versus without a history of multifetal gestation were older, more likely to have a preexisting condition, and more likely to smoke. By 2016, 51% of participants with and 38% of participants without a history of multifetal gestation had died (unadjusted all-cause HR 1.14, 95% confidence interval [CI] 1.07, 1.23). After adjustment for smoking and preexisting conditions, a history of multifetal gestation was not associated with all-cause (adjusted HR 1.00, 95% CI 0.93, 1.08) or cardiovascular mortality (adjusted HR 0.99, 95% CI 0.87, 1.11) over the study period. However, history of multifetal gestation was associated with an 11% lower risk of premature all-cause mortality (adjusted HR 0.89, 95% CI 0.82, 0.96). CONCLUSIONS: In a cohort with over 50 years of follow-up, history of multifetal gestation was not associated with all-cause mortality, but may be associated with a lower risk of premature mortality.

New insights into the (epi)genetics of twinning.

Spontaneous dizygotic (DZ) twins, i.e. twins conceived without the use of ARTs, run in families and their prevalence varies widely around the globe. In contrast, monozygotic (MZ) twins occur at a constant rate across time and geographical regions and, with some rare exceptions, do not cluster in families. The leading hypothesis for MZ twins, which arise when a zygote splits during preimplantation stages of development, is random occurrence. We have found the first series of genes underlying the liability of being the mother of DZ twins and have shown that being an MZ twin is strongly associated with a stable DNA methylation signature in child and adult somatic tissues. Because identical twins keep this molecular signature across the lifespan, this discovery opens up completely new possibilities for the retrospective diagnosis of whether a person is an MZ twin whose co-twin may have vanished in the early stages of pregnancy. Here, we summarize the gene finding results for mothers of DZ twins based on genetic association studies followed by meta-analysis, and further present the striking epigenetic results for MZ twins.

The needs of multiple birth families during the first 1001 critical days: A rapid review with a systematic literature search and narrative synthesis.

OBJECTIVE: Supporting families during the first 1001 days from conception to the age of two is vital for setting the emotional, cognitive, and physical building blocks for children's futures. Families with twins, triplets, or higher order multiples (multiple birth families) have unique challenges due to caring for more than one baby at the same time. Therefore, identifying the needs of multiple birth families is necessary to provide optimum support during the first 1001 critical days. DESIGN: A rapid review was undertaken to synthesize knowledge of the needs of multiple birth families in the United Kingdom (UK) during the first 1001 critical days. Findings from five databases (MEDLINE, APA PsycArticles, APA PsycInfo, CINAHL, and Web of Science) for peer-reviewed studies and grey literature published between 2012 and 2022 were synthesized. Fifteen studies were reviewed using narrative synthesis. RESULTS: Multiple birth families have unique and complex emotional and practical needs across the first 1001 critical days, and in particular, the first-year post birth, impacted further by complicated pregnancies and prematurity. Needs were identified within the four key themes: high risk pregnancy and birth; transformed reality of raising multiples; inadequate support; and positively affecting experiences. Health professional support was inconsistent and particularly lacking in intrapartum, postnatal, and community care including transition. CONCLUSION: Multiple birth families' needs should be considered in the design and delivery of care within the first 1001 critical days, especially within the first year after birth. Multiples specific advice across the first 1001 critical days is needed and training for health professionals to adapt universal advice for this population is one way to achieve this. Further research is needed to ensure this advice is evidence based and effective.

Multiple pregnancy with complete hydatidiform mole and coexisting normal fetus in a retrospective cohort of 141 patients.

BACKGROUND: Multiple pregnancy with a complete hydatidiform mole and a normal fetus is prone to severe obstetrical complications and malignant transformation after birth. Prognostic information is limited for this rare form of gestational trophoblastic disease. OBJECTIVE: This study aimed to determine obstetrical outcomes and the risk of gestational trophoblastic neoplasia in women with multiple pregnancy with complete hydatidiform mole and coexisting normal fetus, and to identify risk factors for poor obstetrical and oncological outcomes to improve patient information and management. STUDY DESIGN: This was a retrospective national cohort study of 11,411 records from the French National Center for Trophoblastic Disease registered between January 2001 and January 2022. RESULTS: Among 11,411 molar pregnancies, 141 involved histologically confirmed multiple pregnancy with complete hydatidiform mole and coexisting normal fetus. Roughly a quarter of women (23%; 33/141) decided to terminate pregnancy because of presumed poor prognosis or by choice. Among the 77% of women (108/141) who continued their pregnancy, 16% of pregnancies (17/108) were terminated because of maternal complications, and 37% (40/108) ended in spontaneous miscarriage before 24 weeks' gestation. The median gestational age at delivery in the remaining 47% of pregnancies (51/108) was 32 weeks. The overall neonatal survival rate at day 8 was 36% (39/108; 95% confidence interval, 27-46) after excluding elective pregnancy terminations. Patients with free beta human chorionic gonadotropin levels <10 multiples of the median were significantly more likely to reach 24 weeks' gestation compared with those with free beta human chorionic gonadotropin levels >10 multiples of the median (odds ratio, 7.0; 95% confidence interval, 1.3-36.5; P=.022). A lower free beta human chorionic gonadotropin level was also associated with better early neonatal survival (the median free beta human chorionic gonadotropin level was 9.4 multiples of the median in patients whose child was alive at day 8 vs 20.0 multiples of the median in those whose child was deceased; P=.02). The overall rate of gestational trophoblastic neoplasia after a multiple pregnancy with complete hydatidiform mole and a normal fetus was 26% (35/136; 95% confidence interval, 19-34). All 35 patients had low-risk International Federation of Gynecology and Obstetrics scores, and the cure rate was 100%. Termination of pregnancy on patient request was not associated with lower risk of gestational trophoblastic neoplasia. Maternal complications such as preeclampsia and postpartum hemorrhage were not associated with higher risk of gestational trophoblastic neoplasia, and neither were high human chorionic gonadotropin levels or newborn survival at day 8. CONCLUSION: Multiple pregnancy with complete hydatidiform mole and coexisting fetus carries a high risk of obstetrical complications. In patients who continued their pregnancy, approximately one-third of neonates were alive at day 8, and roughly 1 in 4 patients developed gestational trophoblastic neoplasia. Therefore, the risk of malignant transformation appears to be higher compared with singleton complete moles. Low levels of free beta human chorionic gonadotropin may be indicative of better early neonatal survival, and this relationship warrants further study.