Comparison of neonatal outcome including cerebral palsy between abruptio placentae and placenta previa

OBJECTIVE: Our purpose was to evaluate the neonatal prognosis after abruptio placentae and placenta previa during pre-term gestation. STUDY DESIGN: A case-control study was performed using a logistic regression model. A poor outcome was defined as neonatal death occurring before hospital discharge or a diagnosis of cerebral palsy. RESULTS: A poor outcome was more frequent in cases of abruptio placentae (11/42, 26.2%) than in placenta previa (2/72, 2.8%) and pre-term labor (1/120, 0.8%). The difference was mainly due to the incidence of cerebral palsy. A significant association of abruptio placentae (odds ratio (OR) 61.0, 95% confidence interval (CI 3.4-1084), delivery at <31 weeks of gestation (OR 19.0, CI 2.8-128.8), and low Apgar score (<7) at 5min (OR 70.8, CI 16.5-304.9) with increased risk of poor outcome was found in the logistic regression model that controlled for confounding effects. In abruptio placentae, a low Apgar score (<7) at 5min (OR 19.8, CI 2.0-197.8) was associated with increased risk of poor outcome in the logistic regression model. CONCLUSION: From the standpoint of poor perinatal outcome including cerebral palsy, abruptio placentae was the most significant clinical entity in pre-term gestation.     

Bladder visualisation as a prognostic sign in oligohydramnios-polyhydramnios sequence in twin pregnancies treated using therapeutic amniocentesis

Oligohydramnios-polyhydramnios sequence in twin pregnancies may be managed by aggressive amniocentesis and is described in nine consecutive cases. In four of the nine pregnancies both twins survived, one pair died in the neonatal period, and the other four pairs all suffered intrauterine death. The median number of amnioreductions performed was five (range 2–7). In this series the reaccumulation of urine in the bladder of the 'stuck twin' was a predictive prognostic marker of survival in both twins, with a sensitivity and specificity of 100%.     

Equalization of amniotic fluid volumes after decompression amniocentesis for treatment of the twin oligohydramnios-polyhydramnios sequence

OBJECTIVE: To measure acute and chronic changes in the placenta and amniotic fluid associated with performance of decompression amniocentesis in pregnancies with the twin oligohydramnios-polyhydramnios sequence (TOPS). METHODS: Amniotic fluid pressures, placental thickness, placental perfusion, and amniotic fluid volumes were measured in each sac of a monochorionic diamniotic twin gestation before and after decompression amniocentesis. Indigo carmine was injected into the polyhydramnic sac after decompression, and fluid from the oligohydramnic sac was sampled after equilibration. Spectrophotometric analysis of amniotic fluid specimens was performed for dye detection. Amniotic fluid volume and placental perfusion studies were repeated 1 week later. RESULTS: Three patients with TOPS were enrolled, and decompression amniocentesis was performed in the midtrimester. After decompression, amniotic fluid volume decreased in the polyhydramnic sac, amniotic fluid pressures decreased in both sacs, placental thickness increased, and umbilical artery Doppler velocimetry was unaffected. The amniotic fluid volume increased acutely in only one oligohydramnic sac after decompression, and ultrasonographic examination, amniotic fluid spectrophotometric analysis, and placental pathologic examination all identified interfetal membrane disruption as the etiology. CONCLUSIONS: Decompression amniocentesis as a treatment for TOPS does not result in acute or chronic changes in the amniotic fluid volume of the oligohydramnic sac in the absence of interfetal membrane disruption.     

Fetal phenotypes and neonatal and early childhood outcomes in twins

OBJECTIVES: The purpose of this study was to evaluate factors associated with, and postnatal consequences of, altered patterns of fetal growth in twins. STUDY DESIGN: Fetal growth was measured at 28 weeks' gestation on 218 twins, including head circumference, abdominal circumference, and femur length, and characterized as > or < or =10th %ile; children were followed up until the age of three years. Logistic regression was used to generate odds ratios of perinatal factors associated with reduced fetal growth. RESULTS: Maternal height <62 inches was associated with reductions in femur length (adjusted odds ratio [AOR] 3.88, 95% CI 1.42-10.57) and abdominal circumference (AOR 8.63, 95% CI 2.41-30.94), while primiparity had a protective effect on both of these fetal measurements (AOR 0.28, 95% CI 0.13-0.64, and AOR 0.18, 95% CI 0.06-0.60, respectively), as well as head circumference (AOR 0.32, 95% CI 0.15-0.69). Smoking adversely affected femur and head growth (AOR 24.10, 95% CI 3.69-157.57, and AOR 10.82, 95% CI 1.73-67.79, respectively). Fetal reduction adversely affected femur and abdomen growth (AOR 5.85, 95% CI 1.52-22.51 and AOR 4.90, 95% CI 1.01-23.86, respectively), and monochorionicity and maternal weight gain <0.65 lb/wk before 20 weeks adversely affected femur growth (AOR 5.47, 95% CI 1.65-18.10, and AOR 3.39, 95% CI 1.34-8.59, respectively). At age 3 years, all categories of twins with reduced growth by 28 weeks' gestation were significantly shorter in height, and those with reduced abdominal circumference or head circumference at 28 weeks were also significantly lighter in weight compared with twins with adequate fetal growth by 28 weeks' gestation. CONCLUSION: These data identify short maternal height, smoking, monochorionicity, fetal reduction, and inadequate weight gain before 20 weeks as risk factors associated with reduced twin fetal growth by 28 weeks' gestation and significant residual reductions in height and weight through 3 years of age.     

Impacts of operative delivery for the first twin on neonatal outcomes in the second twin

We assess the impacts of operative delivery for the first twins with vertex presentation on neonatal outcomes in second twins using the 1995 to 1997 twin registry data of the United States. A total of 102,554 eligible twin pairs with vertex presentation for the first twin were included in the analysis. Of these, 50,748 (49.5%) first twins had a normal vaginal delivery, 43,504 (42.4%) were delivered by cesarean section, and 8302 (8.1%) were delivered by vaginal operation (vacuum extraction or forceps). In term twins, the risks of asphyxia-related mortality (odds ratio [OR], 3.08; 95% CI, 1.07 to 8.45), newborn injury (OR, 2.10; 95% 1.39 to 3.12), low Apgar score at 5 minutes (OR, 1.49; 95% 1.24 to 1.78), and mechanical ventilation use (OR, 1.34; 95% 1.20 to 1.51) were increased in the second twins whose co-twins were delivered by vaginal operation compared with those whose co-twins who had normal vaginal delivery. In contrast, the risks of asphyxia-related mortality (OR, 0.55; 95% 0.17 to 1.57), newborn injury (OR, 0.20; 95% 0.11 to 0.34), low Apgar score at 5 minutes (OR, 0.51; 95% 0.44 to 0.60), and mechanical ventilation use (OR, 0.77; 95% 0.71 to 0.83) were decreased in the second twins whose co-twins were delivered by cesarean section compared with those whose co-twins had a normal vaginal delivery. In conclusion, vaginal operative delivery for the first twins is related to the adverse neonatal outcomes of their co-twins, whereas cesarean delivery for the first twins is associated with the beneficial neonatal outcomes of their co-twins.     

Suggestions for practice to accompany neonatal encephalopathy and cerebral palsy

Based largely on the data in the 2003 The American College of Obstetricians and Gynecologists/American Academy of Pediatrics publication, Neonatal Encephalopathy and Cerebral Palsy, we offer 12 suggestions for practice. Familiarity with the publication and implementation of these suggested practices-by all personnel in an obstetric-neonatal unit-are important risk management techniques.     

The effect of maternal anemia on maternal and neonatal outcomes in twin pregnancies

Objective: The objective of this study is to investigate the effect of second trimester anemia on maternal and perinatal outcomes in twin pregnancies.

Methods: A retrospective population-based study was conducted, comparing maternal and neonatal outcomes in women carrying twins, with second trimester anemia (defined as hemoglobin?<?10?g/dl) to those without anemia (defined as hemoglobin?>?or equal to 10?g/dl). Deliveries occurred in a tertiary medical center in 2013.

Results: During the study period, there were 307 twin deliveries. Hemoglobin levels were available for 247 (80.4%) twins; 66 (26.7%) of these had anemia (<10?g/dl) during the second trimester. Women with second trimester anemia had a higher parity (p=?0.03), and needed more blood transfusions than those with hemoglobin level >?or equal to 10?g/dl (OR?=?1.6; 95% CI 1.11–2.43, p?<?0.001). No significant differences were noted between the groups regarding other obstetrical outcomes or regarding perinatal outcomes.

Conclusion: Second trimester anemia in women carrying twins is associated with a high parity and increases the risk for blood transfusions. However, in our population, maternal anemia in twin gestations does not increase the risk for adverse perinatal outcome.     

Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy

The topics of neonatal encephalopathy and cerebral palsy, as well as hypoxic-ischemic encephalopathy, are of paramount importance to anyone who ventures to deliver infants. Criteria sufficient to define an acute intrapartum hypoxic event as sufficient to cause cerebral palsy have been advanced previously by both The American College of Obstetricians and Gynecologists (ACOG) and the International Cerebral Palsy Task Force. ACOG convened a task force that over the past 3 years reviewed these criteria based upon advances in scientific knowledge. In this review, we cover the slow but steady progression toward defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy. Four essential criteria are also advanced as prerequisites if one is to propose that an intrapartum hypoxic-ischemic insult has caused a moderate to severe neonatal encephalopathy that subsequently results in cerebral palsy. Importantly, all four criteria must be met: 1) evidence of metabolic acidosis in fetal umbilical cord arterial blood obtained at delivery (pH less than 7 and base deficit of 12 mmol/L or more), 2) early onset of severe or moderate neonatal encephalopathy in infants born at 34 or more weeks' gestation, 3) cerebral palsy of the spastic quadriplegic or dyskinetic type, and 4) exclusion of other identifiable etiologies, such as trauma, coagulation disorders, infectious conditions, or genetic disorders. Other criteria that together suggest intrapartum timing are also discussed.     

Fetal and neonatal cerebral circulation: a pulsed Doppler study.

We studied the relation between the fetal cerebral circulation and changes in the cerebral circulation directly after birth. With a combined real time ultrasound/pulsed Doppler technique flow velocity waveforms from the fetal umbilical- and carotid-circulation were monitored. Pulsatility Index (PI) was computed and the ratio between Umbilical PI and Carotid PI was calculated. Flow velocity waveforms of the cerebral circulation before birth were related to anterior cerebral artery flow velocity waveforms recorded immediately after birth. The study shows that changes in flow velocity waveforms associated with the intra uterine brain-sparing effect are related to poor obstetrical outcome. Furthermore is shown that the brain-sparing effect in the fetal period is associated with higher PI values in the cerebrovascular circulation in the neonatal period. It is suggested that changes in these PI values, representing changes in cerebrovascular resistance, might be indicative of cerebral ischemia in the neonate.     

Effect on neonatal outcomes in gestational hypertension in twin compared with singleton pregnancies

OBJECTIVE: We tested the hypothesis that gestational hypertension may have a more benign effect on neonatal outcomes in twin compared with singleton pregnancies, because the elevated blood pressure in twin pregnancies may partly or merely reflect the extra demand for blood supply. METHODS: A retrospective cohort study of 102,988 twin and 5,523,797 singleton live births using the U.S. birth cohort linked birth and infant death data sets, 1998-2000. Main outcomes are relative risks (RRs) of adverse neonatal outcomes: preterm birth, intrauterine growth restriction (less than the third percentile), low 5-minute Apgar score (less than 4), and neonatal death comparing gestational hypertensive with no-event healthy pregnancies for twins and singletons. RESULTS: For singletons, crude RRs (95% confidence intervals) comparing gestational hypertensive with healthy pregnancies were 2.23 (2.20-2.25) for preterm birth (17.4 compared with 7.8%), 2.49 (2.45-2.53) for intrauterine growth restriction (7.4 compared with 3.0%), 1.33 (1.21-1.45) for low 5-minute Apgar score (2.6 compared with 2.0 per 1,000), and 1.07 (0.96-1.19) for neonatal death (1.9 compared with 1.8 per 1,000), respectively. For twins, the corresponding RRs were much lower or showed reversed associations: 1.21 (1.19-1.24) (63.6 compared with 52.4%), 1.04 (0.98-1.11) (16.4 compared with 16.4%), 0.32 (0.23-0.46) (4.1 compared with 12.7 per 1,000), and 0.21 (0.14-0.30) (3.6 compared with 17.2 per 1,000), respectively. The adjusted odds ratios showed a similar risk pattern in twin compared with singleton pregnancies after controlling for maternal race, age, education, marital status, parity, smoking, alcohol use, perinatal care use, and mode of delivery. CONCLUSION: Gestational hypertension has a much more benign effect on neonatal outcomes in twin compared with singleton pregnancies. There might be a need for twin- or multiple fetus-specific recommendations for hypertension management in pregnancy, but further interventional studies are needed to test the hypothesis. LEVEL OF EVIDENCE: II-2.     

Maternal and neonatal outcomes in women with twin pregnancies with excessive gestational weight gain

Objective: To determine if an excessive rate of gestational weight gain (GWG) in twin pregnancies is associated with adverse obstetric outcomes.

Methods: Retrospective cohort study of twin pregnancies delivered at the University of California, San Diego 2001–2014. Women were included if they had adequate or excessive rates of GWG as determined by Institute of Medicine guidelines. Demographic and outcome variables were collected by chart review.

Results: Four hundred and eighty-nine twin pregnancies met inclusion criteria. Of which, 40.5% had adequate rates of GWG and 41.5% had excessive rates of GWG. The rates of preterm birth and gestational diabetes were similar between the two groups. Gestational hypertension and preeclampsia were more common in women with excessive GWG (37.9% versus 19.7%; p?<?0.01). This finding persisted in multivariate analysis. The mean birth weight percentiles were higher in the excessive GWG group and these women were also less likely to have an infant with a birth weight <10th percentile (21.4% versus 35.9%, p?<?0.01).

Conclusions: Excessive GWG is associated with a higher risk for gestational hypertension and preeclampsia, but no other adverse perinatal outcomes. Infants born to mothers with excessive GWG are less likely to be small for gestational age than those born to women with adequate GWG.     

Fetal lung maturation in twin gestation

Clear amnionic fluid was collected at cesarean section and the lecithin/sphingomyelin (L/S) ratio was used to evaluate fetal lung maturation in 42 twin gestations. The L/S ratios of twin pairs were usually similar in both numerical value and predictive accuracy except when the greater L/S ratio from one member of a pair indicated borderline lung maturity. Twin fetal lung maturation was found to be independent of sex, zygosity, and birth weight discordance. Comparison of mean L/S ratios in twins to those of uncomplicated singleton pregnancies revealed that fetal lung maturation occurred several weeks earlier in twins.     

Fetal growth disorders in twin gestations

Twin growth is frequently mismatched. This review serves to explore the pathophysiologic mechanisms that underlie growth aberrations in twin gestations, the prenatal recognition of abnormal twin growth, and the critical importance of stratifying management of abnormal twin growth by chorionicity. Although poor in utero growth of both twins may reflect maternal factors resulting in global uteroplacental dysfunction, discordant twin growth may be attributed to differences in genetic potential between co-twins, placental dysfunction confined to one placenta only, or one placental territory within a shared placenta. In addition, twin-twin transfusion syndrome represents a distinct entity of which discordant growth is a common feature. Discordant growth is recognized as an independent risk factor for adverse perinatal outcome. Intertwin birth weight disparity of 18% or more should be considered to represent a discordance threshold, which serves as an independent risk factor for adverse perinatal outcome. At this cutoff, perinatal morbidity is found to increase both for the larger and the smaller twin within a discordant pair. There remains uncertainty surrounding the sonographic parameters that are most predictive of discordance. Although heightening of fetal surveillance in the face of discordant twin growth follows the principles applied to singleton gestations complicated by fetal growth restriction, the timing of intervention is largely influenced by chorionicity.     

Fetal weight estimation in twin pregnancies

In this study the fetal weight was estimated by ultrasound measurements of the biparietal (BPD) and abdominal diameters (AD) in 154 consecutive twin pregnancies. In 80 twins an attempt to estimate fetal weight was made 0-4 days before delivery (26% of all twins examined). In 84% (67 infants) it was possible to estimate the fetal weight using the formula (0.0108 X AD1.72 X BPD0.99). 60% of the birth weights deviated less than 10% from the estimated fetal weight and 83% deviated less than 15%. The prediction error was nearly constant, expressed as percent of actual weight in the different weight groups (8.5-9.8%). In 19 LGA infants, 69% of the birth weights deviated less than 10% from the estimated fetal weight and 70% deviated less than 15%.     

Fetal biophysical profile in twin gestations

The fetal biophysical profile (nonstress test, fetal breathing movements, fetal movements, fetal tone, amniotic fluid volume, placental grading) was assessed in 49 consecutive referred high-risk patients with twin gestations. The relationship between the last fetal biophysical profile score before delivery was compared with the pregnancy outcome--as reflected by the presence of fetal distress and perinatal death. These data suggest that the fetal biophysical profile is a useful tool for observing fetal status in patients with twin gestations, and could be reliably used as a means of follow-up of nonreactive nonstress testing in these patients.