Fetoscopic laser ablation for twin-to-twin transfusion syndrome in Malaysia: A 15-month retrospective cohort review from an emerging centre in South East Asia.

INTRODUCTION: The authors aim to review the early outcomes of fetostopic laser ablation (FLA) to improve outcomes for twin-to-twin transfusion syndrome (TTTS) in an emerging national centre in Malaysia. MATERIALS AND METHODS: This is a retrospective cohort study of 17 monochorionic diamniotic (MCDA) twin pregnancies with severe TTTS treated by FLA over 15 months in a single centre by a single operator after performing simulations. RESULT: The overall survival rate at day 28 after birth for at least one twin was 76% while the dual-twin survival was 64%. The survival rates at day 28 after birth for at least one twin for stages II, III and IV were 90% vs 40% vs 100% (p=0.054) while dual survival rates were 80% vs 0% vs 100% (p=0.05), respectively. The rate of miscarriage was higher with anterior placentation compared to posterior placentation (33% vs 18%, p=0.660). There was one case of recurrent TTTS and no twin anaemia-polycythaemia sequence post-FLA. The fetal medicine unit in Ipoh is the national centre in Malaysia which covers the whole country, including the western coast of the Borneo Island (Sabah, Sarawak and Labuan) accessible only by air travel. All three cases from Borneo Island had resolved TTTS after FLA and dual neonatal survival at day 28 after birth. CONCLUSION: This data from an emerging new fetoscopic laser centre in Malaysia indicates results consistent with the published international learning curve and within the limits of good clinical governance.

Planned Cesarean or planned vaginal delivery for twins: secondary analysis of randomized controlled trial.

OBJECTIVE: To evaluate whether there is a differential benefit of planned Cesarean delivery (CD) over planned vaginal delivery (VD) in women with a twin pregnancy and the first twin in cephalic presentation, depending on prespecified baseline maternal and pregnancy characteristics, and/or gestational age (GA) at delivery. METHODS: This was a secondary analysis of the Twin Birth Study, which included 2804 women with a twin pregnancy and the first twin (Twin A) in cephalic presentation between 32 + 0 and 38 + 6 weeks' gestation at 106 centers in 25 countries. Women were assigned randomly to either planned CD or planned VD. The main outcome measure was composite adverse perinatal outcome, defined as the occurrence of perinatal mortality or serious neonatal morbidity in at least one twin. The baseline maternal and pregnancy characteristics (markers) considered were maternal age, parity, history of CD, use of antenatal corticosteroids, estimated fetal weight (EFW) of Twin A, EFW of Twin B, > 25% difference in EFW between the twins, presentation of Twin B, chorionicity on ultrasound, method of conception, complications of pregnancy, ruptured membranes at randomization and GA at randomization. Separate logistic regression models were developed for each marker in order to model composite adverse perinatal outcome as a function of the specific marker, planned delivery mode and the interaction between these two terms. In addition, multivariable logistic regression analysis with backward variable elimination was performed separately in each arm of the trial. The association between planned mode of delivery and composite adverse perinatal outcome, according to GA at delivery, was assessed using logistic regression analysis. RESULTS: Of the 2804 women initially randomized, 1391 were included in each study arm. None of the studied baseline markers was associated with a differential benefit of planned CD over planned VD in the rate of composite adverse perinatal outcome. GA at delivery was associated differentially with composite adverse perinatal outcome in the treatment arms (P for interaction < 0.001). Among pregnancies delivered at 32 + 0 to 36 + 6 weeks, there was a trend towards a lower rate of composite adverse perinatal outcome in those in the planned-VD group compared with those in planned-CD group (29 (2.2%) vs 48 (3.6%) cases; odds ratio (OR) 0.62 (95% CI, 0.37-1.03)). In pregnancies delivered at or after 37 + 0 weeks, planned VD was associated with a significantly higher rate of composite adverse perinatal outcome, as compared with planned CD (23 (1.5%) vs 10 (0.7%) cases; OR, 2.25 (95% CI, 1.06-4.77)). CONCLUSION: The perinatal outcome of twin pregnancies with the first twin in cephalic presentation may differ depending on GA at delivery and planned mode of delivery. At 32-37 weeks, planned VD seems to be favorable, while, from around 37 weeks onwards, planned CD might be safer. The absolute risks of adverse perinatal outcomes at term are low and must be weighed against the increased maternal risks associated with planned CD. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Waiting times and patient satisfaction in the accident and emergency department.

A survey of the waiting times and patients' opinions of these times was undertaken in a busy district general hospital A&E department. The various components of the overall waiting time are analysed and specific points of the patients' attendance, where waiting times were prolonged, are identified. Standards are derived which is hoped may result in 75% of patients being satisfied with the duration of their wait. The current levels of achievement are compared with these standards. Suggested and actual improvements to the department to improve our performance are described.