Perinatal outcome in 41 sets of triplets

OBJECTIVE: To determine the perinatal outcome associated with triplet pregnancies and to compare abdominal delivery with vaginal delivery. METHODS: Retrospective analysis of maternal and neonatal medical records of 41 triplets. 21 were delivered vaginally and 20 were delivered by cesarean section. MAIN OUTCOME: To measure perinatal mortality and early neonatal complications. RESULTS: Between January 1, 1994, and June 30, 1999, there were 41 triplets delivered at our institution. Of these 21 triplets were delivered vaginally and 20 triplets were delivered abdominally. The perinatal mortality rate was 32/123 (26.0%), primarily due to the respiratory distress syndrome. The perinatal deaths are mainly at a birth weight of 500-1,500 g (29/32; 90.6%). Breech presentation was associated with a significantly higher perinatal mortality rate than vertex presentation (62.5 vs. 37.5%). Cesarean delivery was associated with a higher perinatal mortality rate than vaginal delivery (30.0 vs. 22. 2%). CONCLUSIONS: Abdominal delivery in triplets is not superior to vaginal delivery in terms of fetal and early neonatal outcome. The perinatal deaths are increased with low birth weight (500-1,500 g) and with breech presentation. The main cause of neonatal mortality is the respiratory distress syndrome.     

Perinatal Outcome in 41 Sets of Triplets in Jordan

Background: Triplet births, which have increased greatly throughout the world in recent years, have a much greater risk of poor birth outcome than singleton births. The purpose of this study was to determine the perinatal outcome associated with triplet pregnancies and to compare abdominal delivery with vaginal delivery. Methods: We conducted a retrospective study of 41 sets of triplets born between January 1, 1994, and June 30, 1999, at the Princess Badee'a Teaching Hospital in Amman, Jordan. The primary outcome measures were perinatal mortality and early neonatal complications. Results: Of these sets, 21 triplets were delivered vaginally and 20 triplets were delivered by cesarean section. The perinatal mortality rate was 260 per 1000 live births in this series, primarily due to respiratory distress syndrome. The perinatal deaths occurred to infants whose birthweights were primarily 500 to 1500 g (90.6%). Breech presentation was associated with a significantly higher perinatal mortality rate than vertex presentation (62.5% vs 37.5%). Cesarean delivery was associated with a higher perinatal mortality rate than vaginal delivery (30.0% vs 22.2%). Conclusions: These results suggested that cesarean delivery in triplets is not superior to vaginal delivery in terms of fetal and early neonatal outcome. The perinatal mortality rate was significantly higher than that in other recent series due to limited resources in Jordan.     

Expectant management of early onset, severe pre-eclampsia: perinatal outcome

Objective To evaluate the perinatal outcome of expectant management of early onset, severe pre-eclampsia.
Design Prospective case series extending over a five-year period.
Setting Tertiary referral centre.
Population All women (   n = 340  ) presenting with early onset, severe pre-eclampsia, where both mother and the fetus were otherwise stable.
Methods Frequent clinical and biochemical monitoring of maternal status with careful blood pressure control. Fetal surveillance included six-hourly heart rate monitoring, weekly Doppler and ultrasound evaluation of the fetus every two weeks. All examinations were carried out in a high care obstetric ward.
Main outcome measures Prolongation of gestation, perinatal mortality rate, neonatal survival and major complications.
Results A mean of 11 days were gained by expectant management. The perinatal mortality rate was 24/1000 (≥ 1000 g/7 days) with a neonatal survival rate of 94%. Multivariate analysis showed only gestational age at delivery to be significantly associated with neonatal outcome. Chief contributors to neonatal mortality and morbidity were pulmonary complications and sepsis. Three pregnancies (0.8%) were terminated prior to viability and only two (0.5%) intrauterine deaths occurred, both due to placental abruption. Most women (81.5%) were delivered by caesarean section with fetal distress the most common reason for delivery. Neonatal intensive care was necessary in 40.7% of cases, with these babies staying a median of six days in intensive care.
Conclusion Expectant management of early onset, severe pre-eclampsia and careful neonatal care led to high perinatal and neonatal survival rates. It also allowed the judicious use of neonatal intensive care facilities. Neonatal sepsis remains a cause for concern.     

Total perinatal wastage. A clarification of priorities

The pregnancy outcome of 16,971 women carrying 17,352 living fetuses after 16 weeks gestation was studied. As well as recording perinatal deaths, all losses before 28 weeks and up to one year after delivery were recorded to give a total perinatal wastage rate of 21.6 per 1000 fetuses alive at 16 weeks compared with a perinatal mortality rate (stillbirths plus early neonatal deaths) of 7.8 per 1000 births. All deaths were then classified according to pathological sub-groups. The concept of auditing perinatal care using perinatal mortality was then compared with that using total perinatal wastage.     

Total perinatal wastage. A clarification of priorities

Summary. The pregrmncy outcome of 16 971 women carrying 17 352 living fetuses after 16 weeks gestation was studied. As well as recording perinatal deaths, all losses before 28 weeks and up to one year after delivery were recorded to give a total perinatal wastage rate of 21.6 per 1000 fetuses alive at 16 weeks compared with a perinatal mortality rate (stillbirths plus early neonatal deaths) of 7.8 per 1000 births. All deaths were then classified according to pathological sub-groups. The concept of auditing perinatal care using perinatal mortality was then compared with that using total perinatal wastage.     

早发型和晚发型重度子痫前期分娩方式及母婴结局分析

目的探讨早发型和晚发型重度子痫前期分娩方式及母婴结局。方法收集1977-2010年在西安交通大学医学院第一附属医院产科住院的重度子痫前期患者4457例,其中早发型860例,晚发型3597例。回顾性分析其分娩方式及母婴结局。结果早发型和晚发型重度子痫前期剖宫产率分别为57.7%和36.9%,早发型明显高于晚发型(P=0.02);胎盘早剥是最常见并发症,在早发型和晚发型重度子痫前期发生率分别为6.7%和4.6%(P<0.05)。早发型和晚发型重度子痫前期围生儿死亡率分别为3.6%和2.2%(P<0.01)。特别是早发型妊娠34周前终止妊娠者,围生儿死亡率高达4.9%。结论子痫前期终止妊娠的主要方式为剖宫产术;发病孕周越早,母婴不良结局发生率越高。     

Planned vaginal delivery of term breech remains an option--result of eight years experience at a single centre.

In order to compare the short term outcome of vaginal and abdominal delivery of babies with breech presentation at term at a single centre, a retrospective study of 299 women presenting with singleton normal breech fetuses at term between 1st January 1996 and 31st December 2003, at a tertiary referral centre, was conducted. The rates of perinatal mortality, neonatal mortality, serious neonatal morbidity and low Apgar scores of neonates delivered after either planned vaginal or planned abdominal delivery were compared. Among 299 women with singleton normal breech at term, 32.1% delivered vaginally and 67.9% had C/S. Successful planned vaginal delivery rate was 97.9%. There was no perinatal or neonatal death in either group and no significant difference in the rates of serious perinatal morbidity between the two groups. We concluded that planned vaginal delivery is associated with no significant adverse perinatal outcome and remains an option for selected term breech presentation.     

分娩全程监护在降低围生儿病死率中的作用探讨

目的：探讨分娩全程监护在降低围生儿病死率中的作用，方法：总结20年围生儿死亡情况，按5年为一个阶段并加以对照，结果：第四阶段新生儿重度窒息发生率及围生儿病死率较前三个阶段均有明显下降；各阶段死产和早期新生儿死亡比呈逐阶段性下降，结论：分娩全程监护可有效地降低死产和早期新生儿死亡，从而降低围生儿病死率。     

Comparison between HELLP syndrome, chronic hypertension, and superimposed preeclampsia on chronic hypertension without HELLP syndrome

AIM: To compare perinatal outcome of patients with HELLP syndrome to that of patients with chronic hypertension and superimposed preeclampsia on chronic hypertension without HELLP syndrome. METHODS: We retrospectively evaluated the perinatal outcome of 147 pregnancies complicated by the HELLP syndrome, chronic hypertension, and superimposed preeclampsia on chronic hypertension without HELLP syndrome. RESULTS: Gestational age at delivery and birthweights were lower among women with HELLP syndrome than among women with superimposed preeclampsia and chronic hypertension (P < 0.05). There were no statistically significant differences among the three groups with respect to intrauterine growth retardation, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, Apgar score, admission to neonatal intensive care unit, overall rate of cesarean delivery and cesarean delivery rate for fetal distress. The total perinatal mortality rate was 17% (28/147) and was more frequent in the HELLP group (27%). Multivariate logistic regression analysis showed that gestational age at delivery (RR 0.45) and birthweight (RR 0.99) were risk factors for adverse outcome. CONCLUSIONS: Perinatal outcome is primarily influenced by gestational age at delivery and birthweight independent of the severity of the hypertensive status of pregnant women.     

Triplet pregnancy: changes in morbidity and mortality

The outcome of 13 sets of triplet infants delivered between January 1, 1981, and December 31, 1988, is analyzed with specific regard to immediate neonatal morbidity. Thirty-nine viable infants were born with no perinatal deaths. Overall, 80% of triplet infants incurred some morbidity, including hyperbilirubinemia (51.3%), hypoglycemia (30.8%), respiratory distress syndrome (28.2%), respiratory compromise (23.1%), anemia (17.9%), patent ductus arteriosus (15.4%), and intraventricular hemorrhage (10.3%). All morbidities occurred in infants who averaged less than 2,000 g and 35 weeks' gestation at birth. As a background to understanding these observations, a review of reports of triplet morbidity and mortality in the United States and Europe is presented. Over the past 80 years, a continual decline in triplet perinatal mortality has occurred despite no change in the average gestational age at delivery over the past 40 years. The triplet perinatal mortality rate is now less than 10%, and prematurity is no longer as influential on perinatal mortality as it is on morbidity. Improvement in neonatal resuscitation and care and delivery by cesarean section are felt to be responsible for lower mortality rates. We believe that the optimum level of care for triplet gestations includes antenatal and neonatal care at tertiary perinatal centers and, except for special circumstances, delivery by cesarean section.     

Subsequent pregnancy outcome after preterm breech delivery,a population based cohort study

Objective: The objective of this study is to investigate the effect of the mode of delivery in women with preterm breech presentation on neonatal and maternal outcome in the subsequent pregnancy.

Methods: Nationwide population-based cohort study in the Netherlands of women with a preterm breech delivery and a subsequent delivery in the years 1999–2007. We compared planned caesarean section versus planned vaginal delivery for perinatal outcomes in both pregnancies.

Results: We identified 1543 women in the study period, of whom 259 (17%) women had a planned caesarean section and 1284 (83%) women had a planned vaginal delivery in the first pregnancy. In the subsequent pregnancy, perinatal mortality was 1.1% (3/259) for women with a planned caesarean section in the first pregnancy and 0.5% (6/1284) for women with a planned vaginal delivery in the first pregnancy (aOR 1.8; 95% CI 0.31–10.1). Composite adverse neonatal outcome was 2.3% (6/259) versus 1.5% (19/1284), (aOR 1.5; 95% CI 0.55–4.2). The average risk of perinatal mortality over two pregnancies was 1.9% (10/518) for planned caesarean section and 2.0% (51/2568) for planned vaginal delivery, (OR 0.98; 95% CI 0.49–1.9).

Conclusion: In women with a preterm breech delivery, planned caesarean section does not reduce perinatal mortality, perinatal morbidity, or maternal morbidity rate over the course of two pregnancies.     

Perinatal outcome of quadruplet pregnancies in relation to chorionicity.

OBJECTIVE: To compare the perinatal outcome of quadruplets in relation to chorionicity. PATIENTS AND METHODS: In this retrospective study, the maternal, neonatal and chorionicity data were collected from 24 sets of quadruplet pregnancies delivered between January 1985 and December 2001. Perinatal and neonatal data were evaluated in relation to chorionicity. RESULTS: Sixteen pregnancies were quadra-chorionic quadramniotic (QC) and eight had at least one monochorionic pair (TC). The median gestational age at delivery was 31 weeks (23 to 34 weeks) with overall perinatal mortality rate of 177 per 1000 total birth. Delivery before 30 weeks (OR 89; 95% CI 9 to 607; P<0.01) and discordant birth weight of >25% (OR 7.6; 95% CI 2 to 29; P<0.01) had independent effects on perinatal loss rate. The perinatal loss was five fold higher in TC quadruplets than those of QC (OR 5.1; 95% CI 1.7 to 15.4; P<0.001). This was attributed to higher risk of very low birth weight (69 vs 13%; P<0.01), delivery before 30 weeks (63 vs 13%; P<0.001) in TC quadruplets compared to QC gestation. CONCLUSIONS: The quadruplets with MC pair have 5 times higher perinatal mortality than quadra-chorionic quadruplet pregnancies owing to preterm delivery and discordant birth weight.     

Term neonatal asphyxial seizures and peripartum deaths: lack of correlation with a rising cesarean delivery rate

OBJECTIVE: The purpose of this analysis was to study the relationship between an increasing cesarean delivery rate and term neonatal seizures and peripartum deaths. STUDY DESIGN: This was a retrospective analysis of annually collated institutional data on cesarean delivery and perinatal outcome. RESULTS: Of 77,350 women who delivered at 37 weeks' gestation or more through 12 years (1989 to 2000), the cesarean rate increased from 6.9% to 15.1%; perinatal mortality at term, average 3.1/1000, was unchanged. The cesarean rate for nulliparas doubled from 8.3% to 17.5%. The overall neonatal term seizure rate (overall 1.3/1000; and for nulliparas 2.5/1000) did not change. The overall peripartum death rate (0.8/1000) was unchanged, although the rate for nulliparas (1.5/1000) showed a significant decline. Overall seizure rate in nulliparas was 5-fold higher than in multiparas; presumed intrapartum asphyxia was associated with 84% of both seizures and neonatal deaths in nulliparas. Among 2547 prelabor cesarean deliveries, there were no peripartum deaths and one neonatal seizure, an incidence comparable with that in multiparas who labored. CONCLUSION: Despite a greater than 2-fold rise in cesarean section rate, the seizure rate and overall peripartum death rate at term did not alter significantly. Neonatal seizures occurred 5 times more often following first deliveries.     

Maternal and neonatal outcome of 100 consecutive triplet pregnancies.

The objective of this study is to determine the maternal and neonatal outcome of a large group of triplet gestations. A retrospective review of 100 triplet gestations managed and delivered between January 1992 and September 1999 by a single perinatal group is examined. These pregnancies were managed on an outpatient basis. Prophylactic interventions were not utilized. Ninety-six percent of the pregnancies had at least one complication, with preterm labor the most common. The median gestational age at delivery was 33 weeks (range 20.4 to 37, SD 4.1 weeks) with 14% of pregnancies delivering prior to 28 weeks' gestation. The corrected perinatal mortality rate was 97/1000. Minimal long-term morbidity was seen with delivery after 27 weeks' gestation. Pregnancy outcome did not vary with birth order or mode of conception. Triplet pregnancy is associated with a high rate ofantenatal complications. Favorable neonatal outcome can be obtained without the use of prophylactic interventions.     

Mode of delivery and outcome of 699 term singleton breech deliveries at a single center

OBJECTIVE: Elective cesarean delivery has been postulated to improve the outcome of term fetuses in breech presentation. We retrospectively compared the short- and long-term outcomes of term infants who were delivered from a breech presentation at a single center. STUDY DESIGN: We reviewed 699 consecutive term breech presentations according to the intended mode of delivery at a single center between January 1993 and December 1999. The short-term outcome measures were perinatal death, neonatal death, or serious neonatal morbidity; the long-term outcome measures were developmental delay and spasticity. RESULTS: The rate of serious perinatal morbidity in the trial-of-labor and cesarean delivery groups was 2.3% and 0.5%, respectively (P =.12). There was no perinatal or neonatal death in either group. With a median follow-up period of 57 months (range, 13-100 months), the rate of developmental delay was 1.9% and 0.5%, respectively (P =.29). Spasticity was not noted in any of the children. CONCLUSION: Our data suggest that planned vaginal delivery remains an option for selected term breech presentations.     

Presence of a single fetal major anomaly in a twin pregnancy does not increase the preterm rate

OBJECTIVE: To evaluate whether the presence of one major anomaly in a twin pregnancy would affect the perinatal outcome of the unaffected co-twin. MATERIALS AND METHODS: From 1992 May to July 2003, a total of 1400 twin pregnancies were included in the present study and there were 35 pairs of twins with one major anomaly. Major anomaly was defined as the anomaly that had a significant impact on neonatal morbidity and mortality. The perinatal outcomes of the affected and unaffected co-twins, the gestational age of diagnosis of the anomaly and the gestational age of delivery were the parameters for evaluation. RESULT: The incidence of a twin with one major anomaly was 2.5%. Nineteen of 35 (54.3%) affected twins and five of the 35 (14.3%) unaffected co-twins suffered a perinatal death. In the five cases of unaffected co-twins suffering a perinatal death, four were intrauterine fetal deaths and one was a neonatal death. Three of the perinatal deaths of the unaffected co-twins could be attributed to twin-to-twin transfusion syndrome. The gestational age at delivery, the perinatal mortality rate, and the incidence of low 5 min Apgar scores of the unaffected co-twins were not different from those in twin pregnancies without a major anomaly. CONCLUSION: The perinatal outcomes of the unaffected co-twin were not affected by the fact that its counterpart had one major anomaly, nor were these twin pregnancies at increased risk of preterm labour.     

Perinatal care improves the outcome of triplets

OBJECTIVE: To compare pregnancy complications and neonatal outcome of 85 triplet gestations cared for during the 15 years in a single perinatal unit. METHODS: Pregnancies were divided in two groups according to the differences in the management plan and their outcomes were compared. Group I (N = 44) consisted of pregnancies cared from 1986 to 1995, using standard model of care: preventive hospitalization from the early second trimester or home bed rest with routine hospitalization after 28-32 weeks of pregnancy, routine clinical and ultrasound examinations, biophysical profile and non-stress tests starting at 28 weeks, expert neonatal care without free access to surfactant or to parenteral nutrition. Group II (N = 41) consisted of pregnancies cared for from 1986 to 2000 using modified care: preventive hospitalization from early second trimester or home bed rest with routine hospitalization after 32 weeks of pregnancy, biophysical profile, non-stress tests and pulsed doppler analysis of fetal umbilical artery, fetal aorta and middle cerebral artery blood flow from as early as 26 weeks, and neonatal care improved by free access to surfactant and parenteral nutrition. RESULTS: The mean gestational age, mean birth weight, the proportion of growth-retarded infants, the incidence of various maternal complications and immediate neonatal conditions as judged by APGAR scores did not differ between the groups. The incidence of deliveries up to 28 weeks was lower in the group II in comparison to group I, but the proportion of term and near term deliveries was lower. The incidence of cesarean sections was high (91.8%), but significantly increased cesarean delivery rate because of fetal distress was observed in the group II (P = 0.014). Infants in the group II had less frequently uneventful early neonatal period, mainly due to significantly increased conatal infection (P = 0.007) and neonatal encephalopathy rate (P = 0.001). However, perinatal mortality was decreased from 235% in the group I to 142% in the group II for newborns that reached 24 weeks of gestation or more. The decrease of perinatal mortality was observed also in the newborns born after 28 weeks of gestation (123% in the group I and 99% in the group II). None of the children weighing <1000 g died in utero in the group II. Early neonatal death of infants weighing >1500 g was significantly reduced in the group II (P = 0.048). CONCLUSION: Advances in neonatal care, but also the delivery of infants in better overall condition must be the explanation for improved outcome of triplet gestations managed by modified care. A higher cesarean section rate because of imminent fetal jeopardy as judged by not only fetal heart rate tracings, but also umbilical, aortic and middle cerebral artery flow analysis, could be the explanation for lowered perinatal mortality and significantly improved outcome in very preterm infants from triplet gestations.     

Effects of hospital delivery during off-hours on perinatal outcome in several subgroups: a retrospective cohort study

ABSTRACT: BACKGROUND: Studies have demonstrated a higher risk of adverse outcomes among infants born or admitted during off-hours, as compared to office hours, leading to questions about quality of care provide during off-hours (weekend, evening or night). We aim to determine the relationship between off-hours delivery and adverse perinatal outcomes for subgroups of hospital births. METHODS: This retrospective cohort study was based on data from the Netherlands Perinatal Registry, a countrywide registry that covers 99% of all hospital births in the Netherlands. Data of 449,714 infants, born at 28 completed weeks or later, in the period 2003 through 2007 were used. Infants with a high a priori risk of morbidity or mortality were excluded. Outcome measures were intrapartum and early neonatal mortality, a low Apgar score (5 minute score of 0--6), and a composite adverse perinatal outcome measure (mortality, low Apgar score, severe birth trauma, admission to a neonatal intensive care unit). RESULTS: Evening and night-time deliveries that involved induction or augmentation of labour, or an emergency caesarean section, were associated with an increased risk of an adverse perinatal outcome when compared to similar daytime deliveries. Weekend deliveries were not associated with an increased risk when compared to weekday deliveries. It was estimated that each year, between 126 and 141 cases with an adverse perinatal outcomes could be attributed to this evening and night effect. Of these, 21 (15 -16%) are intrapartum or early neonatal death. Among the 3100 infants in the study population who experience an adverse outcome each year, death accounted for only 5% (165) of these outcomes. CONCLUSION: This study shows that for infants whose mothers require obstetric interventions during labour and delivery, birth in the evening or at night, are at an increased risk of an adverse perinatal outcomes.     

11. Perinatal mortality

Summary. The perinatal mortality rate in all singleton births was 103 per 1000; 67% of all perinatal deaths were stillbirths and in 77% of stillbirths, intrauterine death had already occurred before admission to hospital. Nine per cent of live births but 40% of stillbirths and 50% of neonatal deaths were of low birthweight (≤2.5 kg). The principal obstetric causes of perinatal deaths were obstructed labour and its consequences, anaemia, antepartum haemorrhage, eclampsia and low fetal birthweight. Nearly half of all perinatal deaths were associated with complicated deliveries of which vaginal breech delivery was by far the most hazardous. Both the proportion of babies with low birthweight and the perinatal mortality rates rose dramatically and progressively with haematocrit <0.30. A raised perinatal mortality rate was also associated with raised haematocrit >0.40. Of the biosocial factors influencing perinatal health, lack of antenatal care, residence outside Zaria, early teenage pregnancy and high parity exerted the most deleterious effect and literacy and antenatal care the most favourable effect on pregnancy outcome.     

Perinatal characteristics and outcomes of pregnancies complicated by twin-twin transfusion syndrome

OBJECTIVE: To assess the outcome of a geographically based cohort of monochorionic twin pregnancies complicated by twin-twin transfusion syndrome managed in a single perinatal center over a 10-year period. METHODS: A prospective cohort design was established in 1992 within a single tertiary obstetric unit. RESULTS: Sixty-nine cases of twin-twin transfusion syndrome were identified during the study period. The median gestation at diagnosis was 22.1 weeks (interquartile range 19.7-25.4). Perinatal outcome was directly related to stage at diagnosis and gestation at delivery. The overall perinatal survival rate was 64.5%. For lesser disease severity (stages I and II) the perinatal survival rate was 76.4%, falling to 51.5% with increasing disease severity (stages III-V) (P =.004). The median gestation at delivery was 29.4 weeks (interquartile range 26.3-33.8). The perinatal survival for those born at less than 28 weeks' gestation was 27.1%, increasing to 84.4% for those born at more than 28 weeks' gestation (P =.001). The incidence of neonatal complications reflected the high preterm birth rate. Amnioreduction was the principal intervention employed in this series, but in 24.6% of cases no therapy was used because of the requirement for immediate delivery or fetal demise. CONCLUSION: Twin-twin transfusion syndrome is a heterogeneous disorder in its clinical manifestations and progress. There remain significant perinatal mortality and morbidity in pregnancies complicated by twin-twin transfusion syndrome, principally related to the high preterm birth rate that typifies this disorder. The severity of disease as assessed by stage and the gestation at delivery are the principal factors in determining perinatal outcome in this condition.