Previous cesarean delivery and risks of placenta previa and placental abruption

OBJECTIVE: To examine the association between cesarean delivery and previa and abruption in subsequent pregnancies. METHODS: A retrospective cohort study of first 2 (n = 156,475) and first 3 (n = 31,102) consecutive singleton pregnancies using the 1989-1997 Missouri longitudinally linked data were performed. Relative risk (RR) was used to quantify the associations between cesarean delivery and risks of previa and abruption in subsequent pregnancies, after adjusting for several confounders. RESULTS: Rates of previa and abruption were 4.4 (n = 694) and 7.9 (n = 1,243) per 1,000 births, respectively. The pregnancy after a cesarean delivery was associated with increased risk of previa (0.63%) compared with a vaginal delivery (0.38%, RR 1.5, 95% confidence interval [CI] 1.3-1.8). Cesarean delivery in the first and second births conferred a two-fold increased risk of previa in the third pregnancy (RR 2.0, 95% CI 1.3-3.0) compared with first two vaginal deliveries. Women with a cesarean first birth were more likely to have an abruption in the second pregnancy (0.95%) compared with women who had a vaginal first birth (0.74%, RR 1.3, 95% CI 1.2-1.5). Two consecutive cesarean deliveries were associated with a 30% increased risk of abruption in the third pregnancy (RR 1.3, 95% CI 1.0-1.8). A second pregnancy within a year after a cesarean delivery was associated with increased risks of previa (RR 1.7, 95% CI 0.9-3.1) and abruption (RR 1.5, 95% CI 1.1-2.3). CONCLUSION: A cesarean first birth is associated with increased risks of previa and abruption in the second pregnancy. There is a dose-response pattern in the risk of previa, with increasing number of prior cesarean deliveries. A short interpregnancy interval is associated with increased risks of previa and abruption. LEVEL OF EVIDENCE: II-2.     

Is placenta previa more common in multiple gestations?

OBJECTIVE: This study was undertaken to compare the occurrence of placenta previa at delivery between singleton and multiple gestations. STUDY DESIGN: A historical cohort study was performed of placenta previa cases at Good Samaritan Regional Medical Center, Phoenix, Ariz, from January 1, 1997, to December 31, 2000. RESULTS: During the study, 29,268 deliveries (28,372 singleton and 896 multiple gestations) occurred at Good Samaritan Regional Medical Center. Placenta previa complicated 51 (0.18%) singleton gestations and 4 (0.46%) multiple gestations (P =.09). Singleton and multiple gestations with placenta previa were similar with respect to maternal demographic variables, prior uterine surgery (excluding cesarean section), and gestational age at delivery. Multiple gestations with placenta previa were more likely to have had a prior cesarean section (P <.001). There were no differences between the singleton and multiple gestations with placenta previa and need for cesarean hysterectomy and blood transfusion. CONCLUSION: The occurrence and complications of placenta previa do not differ between singleton and multiple gestations.     

Pregnancy outcome of early multifetal pregnancy reduction: triplets to twins versus triplets to singletons

Multifetal pregnancy reduction (MPR) of triplets to twins results in improved pregnancy outcomes compared with triplet gestations managed expectantly. Perinatal outcomes of early transvaginal MPR from triplets to twins were compared with reduction from triplets to singletons. Seventy-four trichorionic triplet pregnancies that underwent early transvaginal MPR at 6–8 weeks gestation were included. Cases were divided into two groups according to the initial procedure: reduction to twin (n = 55) or to singleton (n = 19) gestations. Infants from triplet pregnancies reduced to twins were delivered earlier (36.6 versus 37.9 weeks; P = 0.04) and had lower mean birth weights (2364 g versus 2748 g; P = 0.02) compared with those from triplets reduced to singleton gestations. The rates of pregnancy loss before 24 weeks (3.6% versus 5.3%), as well as of preterm delivery before 32 and 34 weeks of gestation (0% versus 5.3% and 7.3% versus 5.3%, respectively) were similar between the twin and singleton pregnancies. No significant difference was found in the prevalence of gestational diabetes (15.1% versus 5.6%) or gestational hypertension (24.5% versus 16.7%) between the groups. Selective reduction of triplet pregnancies to singleton rather than twin gestations is associated with improved outcomes.     

Clinical Assisted Reproduction: Are Singleton Assisted Reproductive Technology Pregnancies at Risk of Prematurity?

Purpose: Our purpose was to determine the risk of premature delivery among singleton pregnancies derived from assisted reproduction technology (ART).Methods: Ninety-five singleton ART pregnancies and 190 matched spontaneous pregnancies were assessed for preterm delivery rates, pregnancy complications, and cesarean section rates in a retrospective study at an academic medical center.Results: Among the ART singleton deliveries group (n = 95), 19 (20%) were preterm, which was statistically significantly higher than the 4% (8 of 190) found in the control group. Among the pregnancies achieved by intracytoplasmic sperm injection (ICSI) in the severe male-factor infertility subgroup (n = 22), only one preterm delivery occurred (4.5%).Conclusions: Singleton ART pregnancies are at an increased risk of preterm delivery compared to singleton pregnancies after spontaneous conception. The higher rate may be attributed to various infertility cofactors, such as uterine malformations, previous operative procedures that involved cervical dilatation, and a history of pelvic infection. This is supported by the finding that ICSI-derived pregnancies in couples with strict male-factor infertility are not at an increased risk of preterm delivery.     

Infertility, assisted reproductive technology, and adverse pregnancy outcomes: executive summary of a National Institute of Child Health and Human Development workshop

The National Institute of Child Health and Human Development held a workshop on September 12-13, 2005, to summarize the risks for adverse pregnancy outcomes after assisted reproductive technology (ART), develop an approach to counseling couples regarding these risks, and establish a research agenda. Although the majority of ART children are normal, there are concerns about the increased risk for adverse pregnancy outcomes. More than 30% of ART pregnancies are twins or higher-order multiple gestations (triplets or greater) and more than one half of all ART neonates are the products of multifetal gestations, with an attendant increase in prematurity complications. Assisted reproductive technology singleton pregnancies also demonstrate increased rates of perinatal complications-small for gestational age infants, preterm delivery, and perinatal mortality-as well as maternal complications, such as preeclampsia, gestational diabetes, placenta previa, placental abruption, and cesarean delivery. Although it is not possible to separate ART-related risks from those secondary to the underlying reproductive pathology, the overall increased frequency of obstetric complications, including preterm birth and small for gestational age neonates, should be discussed with the couple. Significant gaps in knowledge were identified, and the basic science and clinical and epidemiologic research required to address these gaps is outlined.     

Reduction of twin pregnancy to singleton: does it improve pregnancy outcome?

Objective.?To compare pregnancy complications, obstetrical and neonatal outcome of twin pregnancies reduced to singleton, with both non-reduced twin pregnancies and singleton pregnancies.

Methods.?A retrospective case–control study was performed at the Obstetrics and Gynecology Ultrasound unit of a tertiary referral medical center. Patient's population included 32 bi-chorionic bi-amniotic twin pregnancies reduced to singleton and 35 non-reduced twin pregnancies. Thirty-six patients with singleton pregnancies comprised the second control group. Main outcome measures were rates of pregnancy complications, preterm delivery (both before 37 weeks of gestation and before 34 weeks of gestation), late abortions, intra-uterine growth retardation, cesarean section, mean birth weights, and mean gestational age at delivery.

Results.?The reduced twin pregnancies group had similar rates of total pregnancy complications, preterm deliveries, and cesarean section as non-reduced twins. Gestational age at delivery and mean birth weight were also similar to non-reduced twins and significantly different compared with singletons. Preterm delivery and late abortion incidences were significantly higher when reduction was beyond 15 weeks gestation.

Conclusions.?Reduction of twin pregnancy to singleton does not change significantly pregnancy course and outcome. Favorable obstetrical and neonatal outcomes could be achieved by performing early, first trimester reductions.     

10年32例三胎妊娠的临床分析

目的 分析三胎妊娠的临床特点和影响妊娠结局的因素,为多胎妊娠的围产期保健和并发症防治提供参考,以改善多胎妊娠的妊娠结局.方法 1997年1月1日至2006年12月31日10年间我院28周后共分娩了三胎妊娠共32例(分娩孕周均<37周),选择与每例三胎妊娠在相同月份分娩的同孕周的2～3例双胎妊娠(共68例)及单胎妊娠(共89例)作为对照,比较母儿并发症等情况.结果 10年中三胎妊娠发生率前5年为0.05%,后5年为0.07%(P<0.05).三胎妊娠组孕产妇的各种并发症发病率(如妊娠期高血压疾病、低蛋白血症、贫血)均显著高于双胎及单胎组(P>0.05).三胎妊娠组新生儿各种并发症(如湿肺、肺炎及新生儿窒息等)与双胎及单胎组差异无统计学意义(P>0.05).三胎、双胎及单胎妊娠组的围产儿死亡率分别是135.4‰、60.2‰及56.2‰(P>0.05).三胎、双胎妊娠组剖宫产率分别为90.6%及91.2%,明显高于单胎组的48.3%(P<0.01).三胎妊娠组阴道分娩与剖宫产分娩两组的新生儿死亡率(70.6‰和3/7)、呼吸窘迫综合征发生率(4.7%和3/7)和颅内出血发生率(11.8%和3/7)比较差异有统计学意义(P<0.01或<0.05).结论 多胎妊娠较单胎及双胎妊娠孕妇易发生并发症;早产可能是造成三胎妊娠不良妊娠结局的主要因素;剖宫产可作为三胎妊娠的首选分娩方式.     

Pregnancy outcomes for women with placenta previa in relation to the number of prior cesarean deliveries

OBJECTIVE: To estimate the association between the number of prior cesarean deliveries and pregnancy outcomes among women with placenta previa. METHODS: Women with a placenta previa and a singleton gestation were identified in a concurrently collected database of cesarean deliveries performed at 19 academic centers during a 4-year period. Maternal and perinatal outcomes were analyzed after stratifying by the number of cesarean deliveries before the index pregnancy. RESULTS: Of the 868 women in the analysis, 488 had no prior cesarean delivery, 252 had one prior cesarean delivery, 76 had two prior cesarean deliveries, and 52 had at least three prior cesarean deliveries. Multiple measures of maternal morbidity (eg, coagulopathy, hysterectomy, pulmonary edema) increased in frequency as the number of prior cesarean deliveries rose. Even one prior cesarean delivery was sufficient to increase the risk of an adverse maternal outcome (a composite of transfusion, hysterectomy, operative injury, coagulopathy, venous thromboembolism, pulmonary edema, or death) from 15% to 23%, which corresponded, in multivariable analysis, to an adjusted odds ratio of 1.9 (95% confidence interval 1.2-2.9). Conversely, gestational age at delivery and adverse perinatal outcome (a composite measure of respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3 or 4, seizures, or death) were unrelated to the number of prior cesarean deliveries. CONCLUSION: Among women with a placenta previa, an increasing number of prior cesarean deliveries is associated with increasing maternal, but not perinatal, morbidity. LEVEL OF EVIDENCE: II.     

Risk factors for postpartum hemorrhage requiring transfusion in cesarean deliveries for Japanese twins: comparison with those for singletons

Objective

The aim of this study was to identify the factors associated with the increased risk of postpartum hemorrhage requiring transfusion in Japanese twin pregnancies in comparison with those in Japanese singleton pregnancies.

Methods

We reviewed the obstetric records of all singleton and twin deliveries after 22?weeks’ gestation at the Japanese Red Cross Katsushika Maternity Hospital from 2003 through 2011. Potential risk factors for transfusion due to hemorrhage after cesarean delivery were selected according to previous studies of postpartum hemorrhage or transfusion or both after delivery: maternal age, parity, previous cesarean deliveries, history of infertility therapies such as in vitro fertilization, gestational age at delivery, neonatal birth weight, placenta previa, uterine myoma ≥6?cm, hypertensive disorders, placental abruption, emergency cesarean deliveries and general anesthesia.

Results

Using multiple logistic regression, the independent risk factors for postpartum hemorrhage requiring transfusion in singleton pregnancies were preterm delivery [odds ratio (OR) 2.40, 95?% confidence interval (CI) 1.2–4.6, p?<?0.01], placenta previa (OR 8.08, 95?% CI 3.9–16, p?<?0.01) and placental abruption (OR 12.8, 95?% CI 2.3–76, p?<?0.01). In twin pregnancies, however, the independent risk factors for postpartum hemorrhage requiring transfusion were gestational age at ≥41?weeks (OR 8.20, 95?% CI 1.3–40, p?<?0.01) and hypertensive disorders (OR 5.45, 95?% CI 2.2–14, p?<?0.01).

Conclusions

The factors associated with postpartum hemorrhage requiring transfusion in cesarean deliveries of twins seemed to be different from those in singleton cesarean deliveries.     

Neonatal outcomes with placenta previa

OBJECTIVE: To identify neonatal complications associated with placenta previa. METHODS: This was a population-based, retrospective cohort study involving all singleton deliveries in Nova Scotia from 1988 to 1995. The study group consisted of all completed singleton pregnancies complicated by placenta previa; all other singleton pregnancies were considered controls. Patient information was collected from the Nova Scotia Atlee perinatal database. Neonatal complications were evaluated while controlling for potential confounders. The data were analyzed using chi2, Fisher exact test, and multiple logistic regression. RESULTS: Among 92,983 pregnancies delivered during the study period, 305 cases of placenta previa were identified (0.33%). After controlling for potential confounders, neonatal complications significantly associated with placenta previa included major congenital anomalies (odds ratio [OR] 2.48), respiratory distress syndrome (OR 4.94), and anemia (OR 2.65). The perinatal mortality rate associated with placenta previa was 2.30% (compared with 0.78% in controls) and was explained by gestational age at delivery, occurrence of congenital anomalies, and maternal age. Although there was a higher rate of preterm births in the placenta previa group (46.56% versus 7.27%), there was no difference in birth weights between groups after controlling for gestational age at delivery. CONCLUSION: Neonatal complications of placenta previa included preterm birth, congenital anomalies, respiratory distress syndrome, and anemia. There was no increased occurrence of fetal growth restriction.     

胎盘植入性疾病的危险因素及妊娠结局分析

目的探讨胎盘植入性疾病的危险因素及妊娠结局。 方法回顾性分析2009年1月至2017年12月广州医科大学附属第三医院/广州重症孕产妇救治中心围产资料数据库中信息完整的单胎妊娠孕妇48 650例临床资料,将这些孕妇分为胎盘植入性疾病组和非胎盘植入性疾病组,分析胎盘植入性疾病的危险因素及其妊娠结局。 结果单因素分析显示,年龄≥35岁、高中教育水平及以下、孕次≥3次、经产妇、人工流产史、剖宫产史、体外受精－胚胎移植受孕、合并前置胎盘是胎盘植入性疾病的相关危险因素(P<0.05)。多因素logistic回归分析显示,胎盘植入性疾病的独立危险因素为剖宫产史(OR＝2.254,95%CI：1.917～2.650)、体外受精－胚胎移植受孕(OR＝1.591,95%CI：1.212～2.089)、合并前置胎盘(OR＝28.282,95%CI：24.338～32.866);与非胎盘植入性疾病产妇相比,患有胎盘植入性疾病产妇早产、剖宫产、产后出血、弥散性血管内凝血、产褥期感染、子宫切除、低出生体重儿、新生儿Apgar评分相对较低(1 min)、产妇入住重症监护病房的发生率明显升高(P<0.05)。 结论剖宫产史、辅助生殖受孕、合并前置胎盘是引起胎盘植入性疾病的独立危险因素,胎盘植入性疾病的妊娠结局不良。     

Third-trimester fetal death in triplet pregnancies

During the last decade, 89 sets of triplets were born in Denmark with a gestational age of more than 25 completed weeks. Fifteen pregnancies (16.9%) were complicated by fetal death in the third trimester, with a total of 17 intrauterine deaths. Six neonatal deaths occurred, leaving 22 survivors among these 15 patients. Four triplet gestations were diagnosed as twins until delivery. Eight women conceived spontaneously, two gestations followed assisted fertilization and embryo transfer, and five women had had various forms of ovulation stimulation. The mean maternal age was 27.8 years (range 17-38). Seven women were parous and eight wer nulliparous. Maternal complications included hydramnios (three), preeclampsia/hypertension (three), and anemia (nine). All women delivered preterm. Of the 11 gestations diagnosed as triplets, fetal death was diagnosed at 32.2 +/- 2.9 weeks (mean +/- SD) and delivery occurred at 32.6 +/- 3.0 weeks. Nine of 11 women had cesarean deliveries. Continuation of pregnancy after fetal death could be considered in only three subjects. In eight women, obstetric reasons required immediate delivery. Fetal death was associated with monochorionic or dichorionic placentation, and growth retardation was a frequent complication before fetal death. Anencephaly of one fetus, umbilical cord problems in two, and severe hydrops in two were the only obvious causes of fetal death. Fetal death should not be the sole indication for delivery. In cases with severe prematurity and a stable intrauterine situation, frequent assessments of fetal well-being are recommended, with prompt delivery when indicated.     

Cerebellar growth in normal fetuses of multiple gestations

Objective: The purpose of this study was to compare the cerebellar growth in twin and triplet gestations with cerebellar growth in singleton pregnancies. Methodology: An ultrasound study was conducted in a population of normal pregnant women with singleton, twin and triplet gestations. Routine ultrasound examinations were performed in healthy pregnant women: 951 women with singleton pregnancies; 151 with twin gestations; and 28 with triplet gestations. Although multiple biometric parameters were measured throughout the course of pregnancy, in this study a single measurement (the last measurement before delivery) of the transverse cerebellar diameter (TCD) was used from each patient for statistical analysis. Growth of the TCD was determined in the multiple gestations and compared with growth in singleton pregnancies. Results: A statistically significant relationship was found between TCD and gestational age in all three groups (singleton, twin A and B, and triplets) respectively: R² = 0.963; R² = 0.980; R² = 0.977. No statistical difference was found between the three sets of normative measurements. Conclusions: There was no significant difference observed in cerebellar growth among singleton and multiple gestations. Therefore, nomograms previously established for singleton pregnancies may be useful to assess growth in multifetal pregnancies.     

Obstetric and neonatal risk of pregnancies after assisted reproductive technology: a matched control study

BACKGROUND: The aim of the study was to evaluate the obstetric and neonatal outcome of pregnancies after assisted reproduction technology (ART) in comparison with matched controls from spontaneous pregnancies. METHODS: A total of 12 920 deliveries at the Department of Obstetrics and Gynecology, University of Szeged, from 1 January 1995 to 31 December 2001 were subjected to retrospective analysis. Two hundred and eighty-four singleton, 75 twin and 17 triplet pregnancies after ovulation induction (n = 114; 30.3%), intrauterine insemination (n = 33; 8.8%) and in vitro fertilization (n = 229; 60.9%) were evaluated. The pregnancy outcome of the singleton and twin pregnancies was compared with that for controls matched with regard to age, gravidity and parity and previous obstetric outcome after spontaneous pregnancies. RESULTS: Twenty-four percent of the assisted reproductive pregnancies were multiple pregnancies. The incidences of singleton intrauterine growth retardation (IUGR) and preterm birth were reasonably similar to those among the controls (IUGR: 6.3% vs. 4.2%; preterm births: 13.0% vs. 9.9%, for the cases and the controls, respectively). As compared with the controls, there was an increased incidence of cesarean section among the singleton (41.2% vs. 34.5%, p = 0.12; OR 1.33; 95% CI 0.95-1.87) and twin assisted reproduction pregnancies (66.7% vs. 60.0%), but without significant differences. CONCLUSIONS: Increased obstetric risk could be observed concerning threatened preterm delivery and cesarean section rate in the study group. The perinatal outcome of singleton and twin pregnancies following assisted reproductive techniques is comparable with that of spontaneously conceived, matched pregnancies.     

Complications of in vitro fertilization with intracytoplasmic sperm injection in human immunodeficiency virus serodiscordant couples

INTRODUCTION: Our experience with complications related to in vitro fertilization (IVF), particularly ovarian hyperstimulation syndrome (OHSS) and higher-order multiple gestations, in human immunodeficiency virus (HIV) serodiscordant couples undergoing IVF with intracytoplasmic sperm injection (ICSI) is presented. METHODS: We retrospectively evaluated 132 consecutive IVF-ICSI cycles and the ensuing 43 pregnancies in 74 HIV-seropositive male discordant couples. The diagnosis of moderate and severe OHSS was based on clinical criteria. Higher-order multiple gestations were defined as viable triplets or greater by the end of the first trimester verified by ultrasonography. RESULTS: The incidence of moderate and severe OHSS was 4.5% of initiated IVF cycles. Seven of the 43 (16.3%) pregnancies were higher-order multiple gestations (1 quadruplet and 6 triplet pregnancies), resulting in the delivery of 3 sets of triplets and 3 sets of twins, with an ongoing twin pregnancy. Four patients had undergone multifetal pregnancy reduction to twins. There were no seroconversions in the women and the infants. CONCLUSION: HIV serodiscordant couples undergoing fertility treatment with IVF-ICSI should be made particularly aware of the risks of higher-order multiple gestations and OHSS.     

Effect of maternal age on blood loss during parturition: a retrospective multivariate analysis of 10,053 cases

OBJECTIVE: An extensive study as to whether maternal age itself is a risk factor for blood loss during parturition. METHOD: A total of 10,053 consecutive women who delivered a singleton infant were studied. The excess blood loss was defined separately for women with vaginal and cesarean deliveries as > or = 90th centile value for each delivery mode. The effects of 13 potential risk factors on blood loss were analyzed using multivariate analysis. RESULTS: The 90th centile value of blood loss was 615 ml and 1,531 ml for women with vaginal and cesarean deliveries, respectively. A low lying placenta (odds ratio [OR], 4.4), previous cesarean (3.1), operative delivery (2.6), leiomyoma (1.9), primiparity (1.6), and maternal age > or = 35 years (1.5) were significant independent risk factors for excess blood loss in women with vaginal delivery. Placenta previa (6.3), leiomyoma (3.6), low lying placenta (3.3), and maternal age > or = 35 years (1.8) were significant independent risk factors for excess blood loss in women with cesarean sections. CONCLUSION: A maternal age of > or = 35 years was an independent risk factor for excess blood loss irrespective of the mode of delivery, even after adjusting for age-related complications such as leiomyoma, placenta previa, and low lying placenta.     

Hospitalization vs. outpatient care in the management of triplet gestations.

OBJECTIVE: To compare the course and outcome of triplet gestations under a preventive care strategy that includes hospitalization, surveillance, bed rest, and daily specialized care from the beginning of the second trimester, with pregnancies managed according to the Croatian standard outpatient care protocol for multiplets. METHODS: A retrospective study of 79 triplet pregnancies. Preventive hospitalization from the beginning of the second trimester, with complete bed rest and all necessary interventions, was chosen by 55 women (Group I). The remaining 24 women (Group II) elected the standard outpatient protocol for multiple pregnancies. Outpatient management with prophylactic bed rest was initiated at home as soon as the multiple pregnancy was diagnosed. After 28 weeks of gestation, all outpatients were hospitalized until delivery irrespective of symptoms. RESULTS: There was no difference between the groups regarding maternal age, race, pre-pregnancy weight and height, weight gain during the first 24 weeks of pregnancy, or the proportion of pregnancies achieved with assisted reproductive technology. Four out of 55 women (7.2%) from Group I and 4 out of 24 women (12.5%) from Group II had monochorionic triplet pregnancies (P=n.s.). Nulliparity was more frequent in Group I than in Group II (P=0.006). Elective cesarean delivery was significantly more frequent in Group I (46 out of 55 gestations, 72.7%) than in Group II (9 out of 24 gestations, 37.5%), P=0.024. Gestational age at delivery and mean birth weight were significantly higher in Group I than in Group II (P<0.001). Deliveries up to 28 weeks of pregnancy were infrequent in Group I (P=0.02). Thirty-three gestations in Group I (60%) and 6 (25%) in Group II had a duration of 33-36 weeks (P<0.001). Two out of 55 triplet gestations in Group I (3.6%) and 4 out of 24 in Group II (16.7%) ended in spontaneous abortion (P=0.053). The survival of the three triplets was more frequent in Group I than in Group II (P=0.048). For gestations reaching 24 weeks or more, the fetal and perinatal death rate was significantly lower in Group I (P<0.001). In Group I the intrauterine death rate for fetuses weighing 1500 g or less was also significantly lower (P=0.007), and the early neonatal death rate was almost half (15.8 vs. 28.9%, P=0.157). There were no differences in other pregnancy complications between the two groups except significantly more frequent preterm premature rupture of membranes and preterm labor requiring parenteral tocolysis in Group II (P=0.042 and 0.036, respectively), and significantly more frequent fetal growth retardation in Group I (P<0.001). CONCLUSION: Preventive hospitalization offers a better outcome for triplets even though prolonged hospitalization and all other procedures necessary to achieve optimal pregnancy outcome are also offered in the Croatian standard outpatient care protocol for multiplet pregnancies.     

The origins and outcomes of triplet and quadruplet pregnancies in Nova Scotia: 1980 to 2001

The objective of this study was to determine the rate, origin, maternal and perinatal outcomes, and the associated hospital costs of higher order multiple births in one Canadian province. All higher order multiple pregnancies (triplets and above) in Nova Scotia over a 22-year period (1980 to 2001) were reviewed, and the maternal and perinatal outcomes and hospital costs were compared with singletons and twins in the same hospital population. During the 22-year period, 116,785 infants were delivered, including 3448 twins, 99 triplets, and 16 quadruplets. Of the higher order multiple gestations, 51.4% were conceived through infertility therapy. When compared with mothers of either singletons or twins, mothers of higher order gestations were significantly older, had longer antepartum and postpartum hospital stays, were more likely to have cesarean delivery, preterm labor, preeclampsia, and require intensive care unit admission. Triplets and quadruplets had significantly higher rates of preterm delivery, major anomalies, neonatal intensive care, respiratory distress syndrome, intrauterine growth restriction, serious morbidity, 5-minute Apgar scores < or = 3, and neonatal death than twins or singletons. The estimated hospital costs for this population ranged from 6,750 US dollars for a singleton pregnancy to 278,400 US dollars for a quadruplet pregnancy. Maternal morbidity, perinatal morbidity and mortality, and hospital costs are significantly increased in higher order births compared with both twins and singletons.     

Does preterm cervical dilatation imply imminent labor in multifetal pregnancies?

OBJECTIVE: Women with multifetal pregnancies are at increased risk of preterm labor and delivery compared with singleton pregnancies. Presentation with advanced cervical dilatation of 3-4 cm is generally regarded as being in the midst of the first stage of labor. The purpose of this report is to present our experience in cases of advanced cervical dilatation and arrested preterm labor in multifetal pregnancies. METHODS: This study is a retrospective analysis of threatened preterm deliveries in women with multifetal pregnancies. Fifteen cases with advanced cervical dilatation that remained undelivered for at least 10 days are presented and reviewed. RESULTS: Out of 1219 women presenting with multifetal pregnancies to the high-risk maternity unit, 15 women who presented with advanced cervical dilatation of 3-5 cm and remained undelivered for at least 10 days were identified. Eight women presented with twins and seven with triplets. The mean latency period to delivery was 21.7 days (range 10-43 days). The mean gestational age at diagnosis was 31.3 weeks (range 26.3-35.3 weeks). The mean gestational age at delivery was 34.5 weeks (range 29.5-38.0 weeks). Twelve women delivered vaginally in this group, giving a cesarean section rate of 20%. CONCLUSIONS: In the women presented in this series advanced cervical dilatation did not lead directly to preterm labor and delivery, we believe due to their having a multifetal gestation. It is possible that dilatation of the cervix in these cases is not a result of preterm labor but rather a relative cervical incompetence resulting from overdistention of the uterus in twins or higher-order gestations. This phenomenon may be underdiagnosed because of a tendency to forego frequent digital examinations remote from term without a clear indication. More information is therefore needed on the mechanism of cervical change during multifetal pregnancy.     

Placenta previa in singleton and twin births in the United States, 1989 through 1998: a comparison of risk factor profiles and associated conditions

OBJECTIVE: The purpose of this study was to compare risk factor profiles for placenta previa between singleton and twin live births. STUDY DESIGN: This cohort study was based on United States natality data files (1989 through 1998) and comprised 37,956,020 singleton births and 961,578 twin births. Women who were diagnosed with placenta previa were included only if they were delivered by cesarean delivery. Risk factors for placenta previa that were examined included sociodemographic (age, gravidity, education, marital status, and race), behavioral (prenatal care, smoking, and alcohol use), previous preterm birth, and medical and obstetric factors. Effect modification between maternal age and gravidity and the dose-response relationship with number of cigarettes smoked/day on placenta previa risk were also evaluated. RESULTS: The rate of placenta previa was 40% higher among twin births (3.9 per 1,000 live births, n = 3,793 births) than among singleton births (2.8 per 1,000 live births, n = 104,754 births). Comparison of risk factors for placenta previa between the singleton and twin births revealed fairly similar risk factor profiles. Compared with primigravid women <20 years old, the risk for placenta previa increased by advancing age and by increasing number of pregnancies among both singleton and twin births. The number of cigarettes smoked per day also showed a dose-response trend for placenta previa risk in the two groups. CONCLUSION: The increased rate of placenta previa among twin births underscores the need to monitor carefully such pregnancies with heightened suspicion and awareness for the development of this condition.