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.     

Ultrasonic diagnosis of chorionicity in multiple pregnancies

The management of multiple pregnancies requires a correct diagnosis of chorionicity. This assessment is easy and reliable before 15 weeks of gestation by ultrasonography, but becomes much more difficult during the second and third trimester for same sex foetuses. From 5 to 8 weeks of gestation, the visualization of two gestational sacs assesses bichorionicity. From 8 to 14 weeks, the diagnosis of chorionicity is based on the presence of the lambda sign, completed by the evaluation of the thickness of the inter-twin membrane and the placenta localisation. From 15 weeks onward, the twin peak (or lambda) sign remains the best predictor of dichorionicity but is valuable only if it is present. The measurement of the thickness of the inter-twin membrane and the count of its layers are not available in all cases. From March 1999 to March 2000, we studied 31 multiple pregnancies with same sex foetuses, referred to our centre during the second trimester. The patients were asked for their former ultrasound reports. Chorionicity was mentioned only in 77% of the cases and when mentioned the information was correct in 85% of the cases. Thus, improving on that point is necessary. Prospective studies focusing on ultrasound determination of chorionicity show accuracy close to 100% when the ultrasonography is correctly realized before 15 weeks of gestation.     

A comparative study of obstetric outcomes in electively or spontaneously reduced triplet pregnancies

Purpose

This study aimed at evaluating the pregnancy outcomes of IVF triplets which are spontaneously or electively reduced to twins and to compare them with non-reduced triplets and twins.

Methods

Retrospective analysis of trichorionic triplets and dichorionic twins of IVF pregnancies.

Results

Preeclampsia rate was significantly higher in triplet group (p = 0.014). Premature contractions requiring tocolysis were seen more often in spontaneous reduction and triplet groups compared to elective reduction and twin groups (p < 0.001). Elective reduction and twin groups had significantly lower rate of infants weighing less than 1,500 g than those of triplets (p < 0.001). Highest rate for infants weighing over 2,500 g was found in primary twin group. Preterm delivery rates were significantly lower in both twin and elective reduction groups compared to triplet and spontaneous reduction groups (p < 0.001). Proportion of women giving birth at term was not different in elective reduction and twin groups, and they were significantly higher compared to spontaneous reduction group (p = 0.024). Perinatal mortality rates of both elective reduction and twin groups were significantly less than those in the triplet group (p = 0.045 and p < 0.001, respectively).

Conclusions

Obstetric outcomes of triplets from IVF or ovulation induction cycles undergoing elective reduction are better than ongoing triplet and spontaneous reduction groups and are similar to that of dichorionic twins.     

Maternal morbidity and obstetric complications in triplet pregnancies and quadruplet and higher-order multiple pregnancies

OBJECTIVE: The purpose of this study was to assess the risk of maternal morbidity and obstetric complications in women with triplet pregnancies and quadruplet and higher-order multiple pregnancies. STUDY DESIGN: We compared the outcomes in women with triplet pregnancies (n=5491) and quadruplet and higher-order multiple pregnancies (n=423) with women with twin pregnancies (n=152,238), with the use of the 1995 to 1997 Multiple Birth File of the United States. RESULTS: After an adjustment was made for important confounding factors, the risks of pregnancy-associated hypertension and eclampsia, anemia, diabetes mellitus, abruptio placenta, premature rupture of membrane, and cesarean delivery were increased in women with triplet pregnancies and quadruplet and higher-order multiple gestations than in women with twin pregnancies. A dose-response relationship was observed for pregnancy-associated hypertension, diabetes mellitus, and placental abruption, with higher odds ratios in women with quadruplet and higher-order multiple gestations than in women with triplet pregnancies. CONCLUSION: The risks of maternal morbidity and obstetric complications are increased in triplet pregnancies and quadruplet and higher-order multiple pregnancies than in twin pregnancies; for certain outcomes, there is a dose-response relationship.     

The impact of assisted reproductive technology and chorionicity in twin pregnancies complicated by obstetric cholestasis

Objective: To assess in a cohort of twin pregnancies the prevalence of obstetric cholestasis (OC) and its correlation with the type of conception and chorionicity.

Methods: A retrospective cohort study including all the twin pregnancies delivered between 2005 and 2013 at our University Hospital was carried out. In the study population, the prevalence of OC was investigated in relationship to the impact of assisted reproductive technology (ART) and of chorionicity.

Results: Overall, 569 twin pregnancies were included in the study population. Among those complicated by OC, the rate of ART was 3-fold higher (OR 3.4, 95% CI 1.2–9.5, p?=?0.02), whereas the rate of dichorionicity did not differ significantly (OR 1.6, 95% CI 0.3–7.9, p?=?0.53).

Conclusion: The risk of developing OC seems to be significantly higher among twin pregnancies obtained after ART in comparison with those conceived spontaneously.     

Prenatal screening and diagnosis in multiple pregnancies

Multiple pregnancies account for 1.5% of pregnancies in the UK and both aneuploidies and structural anomalies occur more frequently in twins, compared to singletons. Comprehensive, individualised counselling is key in these challenging situations, requiring clinicians to communicate their knowledge of prenatal screening effectively.Prenatal screening and diagnosis is not straightforward in multiple pregnancies with variable performance of screening tests, choices to be made on diagnostic techniques and sampling, limited robust data on procedure-related risks and potentially complex decision-making in light of results. In this article we will address these issues and provide an up-to-date evidence summary derived from national guidance and published literature.     

Prenatal diagnosis for multiple pregnancies

In multiple pregnancies, first trimester ultrasound is crucial to diagnose chorionicity, to detect major structural defects, and to screen for chromosomal abnormalities based on nuchal translucency measurement. The efficacy of nuchal translucency measurement screening in twins might be improved when combined with first trimester maternal serum screening. In twins as in singletons, the risk of fetal loss attendant to chorionic villi sampling and to amniocentesis are similar. When an invasive procedure is indicated in twins, chorionic villi sampling has, over amniocentesis, the advantage of allowing selective termination to be performed in the first trimester, when the procedure related risk of miscarriage is minimal. It has the disadvantage of leading to ambiguous results in up to 2% of cases. While chorionic villi sampling is the choice technique in pregnancies at very high risk, amniocentesis is still indicated in cases at more moderate risk. In monochorionic pregnancies, selective termination can now be performed using a variety of techniques including bipolar or monopolar cord coagulation, and, in acardiac twins, alcohol ablation. However, selective termination remains more hazardous in monochorionic than in dichorionic pregnancies. The outcome of the twin-to-twin transfusion syndrome has been substantially improved by laser photocoagulation of placental shunts and by amniodrainage, but randomized trials are needed to establish the optimal therapeutic strategy, and further pathophysiologic research might result in new treatments.     

Prenatal diagnosis in multiple pregnancies.

Multiple pregnancy, with its high rate of fetal loss and increasing incidence, merits greater clinical attention and research. Prenatal diagnosis in multiple pregnancy poses particular difficulties in terms of safety and technique of invasive procedures, interpretation of laboratory results, and the human dilemmas produced by the demonstration of discordant abnormality. Recent applications of ultrasound, including Doppler ultrasound, are also discussed in the context of the monochorionic placenta, prediction of preterm labor, and detection of intrauterine growth retardation.     

The association between maternal factors and perinatal outcomes in triplet pregnancies

OBJECTIVE: The purpose of this study was to evaluate the associations between maternal factors and outcomes in triplet pregnancies. STUDY DESIGN: This was a historic cohort study of 194 triplet pregnancies of >or=24 weeks of gestation that were delivered from 1983 through 2001 from five medical centers. RESULTS: In analyses that were limited to pregnancies with all live-born triplets (178 pregnancies), women with a previous good outcome (>2500 g + >37 weeks of gestation) had longer gestations (+7.9 days, P =.03), better rates of fetal growth (+4.9 g/wk, P <.0001), and higher birth weights (+153 g, P <.0001). Maternal weight gains of <36 pounds by 24 weeks of gestation were associated with lower birth weights (-197 g, P <.0001), and fetal growth rates at 相似文献   

Determining chorionicity and amnionicity in twin pregnancies: Pitfalls

Although the accuracy of chorioamnionicity determination in multiple pregnancy is nearly 100%, some pitfalls do exist. These pitfalls may arise from some confusing sonographic appearance or because of certain rare variations of twinning going against the general principles. Pitfalls in chorionicity determination include (1) the disappearance of the twin peak sign with the regression of chorion frondosum and thinning of the intertwin membrane with advancing gestation; (2) fake twin peak sign because of other structures creeping into the intertwin membrane-placental junction; (3) intrauterine septum or synechia being mistaken as a thick intertwin membrane; (4) bipartite placenta in monochorionic twin being misinterpreted as two separate placentas of dichorionic twin; (5) erroneous fetal sex determination in sex chromosome mosaicism, monogenic disorders, and malformed genitalia in one fetus; and (6) rare twinning types such as dizygotic monochorionic twin and sesquizygotic twin. Pitfalls in amnionicity determination are (1) the lack of correlation between the number of yolk sacs and amnionicity and (2) failure to visualize the intertwin membrane because of technical issues.     

Prenatal diagnosis of congenital malformations in 500 pregnancies

The organization, techniques used and diagnostic findings of 500 prenatal diagnoses are reported in detail. In 15 cases the pregnancy was terminated because of abnormal laboratory findings. Follow-up of the remaining pregnancies revealed a perinatal mortality of 1.7%, and the risk of an abortion induced by amniocentesis, performed in the 15–16th wk, to be 1–2%. Serious counseling problems arose in 2 cases with trisomy X, in 2 instances of a balanced chromosome translocation and in 1 case of a de novo translocation.     

Neonatal outcomes in triplet pregnancies: assisted reproduction versus spontaneous conception

AIMS: The purpose of this study is to compare neonatal outcomes of spontaneously conceived triplets with triplets conceived by assisted reproduction. METHODS: This was a retrospective cohort study of all cases from assisted triplet pregnancies and controls from spontaneous triplet pregnancies. A total of 24 triplet pregnancies were studied: six spontaneous and 18 assisted. The following variables were evaluated in all newborns: prematurity, birth-weight, small for gestational age, birth-weight discordance, Apgar scores, major neonatal morbidity and perinatal mortality. RESULTS: Gestational age (33+/-1 vs. 33+/-2 weeks) and birth-weight (1760+/-256 vs. 1907+/-452 g) were similar in spontaneous and assisted triplet pregnancies. There were no significant differences in the rates of small for gestational age, discordance, and major neonatal morbidity. In the assisted reproduction group only the following cases were recorded: 1 surgically treated patent ductus arteriosus, 1 feto-fetal transfusion syndrome, 2 grade II intraventricular hemorrhage, 1 Cri du Chat syndrome and 1 stillbirth with malformations. CONCLUSIONS: This study is unable to assess the influence of assisted reproduction on the neonatal outcomes of triplet pregnancies. However, the results suggest that the incidence of major neonatal morbidity, especially malformations, might increase due to assisted reproduction. This finding requires further confirmation.     

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.     

Prenatal diagnosis, phenotypic and obstetric characteristics of holoprosencephaly

The diagnosis of fetal malformations, especially those of the central nervous system, is strikingly important in the practice of genetic counseling. Early diagnosis is very significant, not only because of the prognosis, but also because of the emotional effects caused by the accompanying craniofacial malformations. The summary of the obstetrical and diagnostical characteristics should be useful in the management of holoprosencephaly. The analysis of the 50 cases we encountered between 1981 and 2000, including the anatomical, diagnostic and clinical aspects, as well as the associated craniofacial malformations, forms the essence of our publication. In one of the examined cases a familiar recurrence was verified.     

Perinatal mortality and morbidity in twin pregnancies: the relation between chorionicity and gestational age at birth

Aim  

To investigate perinatal mortality and morbidity rates of twin pregnancies and to determine the underlying factors responsible for the increase in these rates.     

Prenatal diagnosis of cord entanglement in monoamniotic multiple pregnancies

Monoamniotic (MA) twins occur in about 2-5% of monochorionic (MC) pregnancies. The condition is characterized by late splitting of the developing embryo at around 8-9 days after fertilization and may also occur in higher-order multiples. During the first trimester, ultrasound diagnosis in MC-MA twins is based on visualization of only a single aniotic cavity without an intertwin membrane, and can be confirmed by the presence of only one yolk sac. The visualization of cord entanglement confirms the diagnosis at any stage of pregnancy, and has important implications for further management. Criteria for the proper diagnosis of MC-MA multiple gestation and cord entanglement are given.