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.     

Fetal programming: prevention of perinatal acquired predispositions of diseases in later life

Alterations of the metabolic and hormonal environment of the fetus may cause predispositions to the development of disorders and diseases in later life. The timing, duration, severity, and type of insult during development determines the specific physiological outcome. Intrauterine programming of physiological systems occurs at the gene, cell, tissue, organ, and system levels and causes permanent structural and functional changes. Elevated insulin concentrations during critical periods of perinatal life may induce a lasting 'malprogramming' of neuroendocrine systems regulating body weight, food intake, and metabolism. Similar characteristics may occur due to perinatal hyperleptinism, hypercortisolism. Diagnosis and therapy of gestational diabetes in time may prevent metabolic and cardiovascular diseases in later life. This concept has new important implications for chances and challenges of perinatal preventive medicine in the future.     

Gestational diabetes: the consequences of not treating

OBJECTIVE: Untreated gestational diabetes mellitus carries significant risks of perinatal morbidity at all severity levels; treatment will enhance outcome. STUDY DESIGN: A matched control of 555 gravidas, gestational diabetes mellitus diagnosed after 37 weeks, were compared with 1110 subjects treated for gestational diabetes mellitus and 1110 nondiabetic subjects matched from the same delivery year for obesity, parity, ethnicity, and gestational age at delivery. The nondiabetic subjects and those not treated for gestational diabetes mellitus were matched for prenatal visits. RESULTS: A composite adverse outcome was 59% for untreated, 18% for treated, and 11% for nondiabetic subjects. A 2- to 4-fold increase in metabolic complications and macrosomia/large for gestational age was found in the untreated group with no difference between nondiabetic and treated subjects. Comparison of maternal size, parity, and disease severity revealed a 2- to 3-fold higher morbidity rate for the untreated groups, compared with the other groups. CONCLUSION: Untreated gestational diabetes mellitus carries significant risks for perinatal morbidity in all disease severity levels. Timely and effective treatment may substantially improve outcome.     

Changing panorama of perinatal and infant mortality in diabetic pregnancy

In a 21-year study covering 1960 to 1980, perinatal and infant mortality in 237 infants of diabetic mothers were analysed. The study was divided into three 7-year periods related to changes in management. In period I (1960-66) the perinatal mortality was 24.3%, decreasing to 5.0% in period II (1967-73) and to 1.1% in period III (1974-80). The corresponding figures for infant mortality were 31.4%, 7.5% and 4.6% respectively. Today the difference between the perinatal mortality rate in diabetic vs. non-diabetic pregnancies is almost negligible. However, perinatal mortality may give a false impression of pregnancy outcome, since owing to the high rate of lethal malformations in period III, infant mortality was still twice that of the non-diabetic population. During the 21-year period studied, complications of diabetic pregnancies such as severity and duration according to the White classification, hypertension and pyelonephritis in pregnancy and preterm delivery all decreased. Consequently the influence of these complicating factors on the overall outcome of diabetic pregnancies has declined.     

A Safer and More Effective Treatment Regimen for Eclampsia

Summary: In a prospective controlled trial 91 consecutive women with eclampsia were randomly allocated either to a magnesium sulphate and nifedipine regime or to a lytic cocktail and nifedipine group. The type and severity of disease, details of labour and delivery, and the maternal and perinatal outcomes and complications related to the 2 treatment regimens were compared. Recurrence of fits, aspiration pneumonia and sudden hypotension were signficantly reduced when patients were treated with the new magnesium sulphate and nifedipine regimen compared with the lytic cocktail plus nifedipine regimen. No patient treated with the new regimen died or had respiratory depression; in the other group there were 2 maternal deaths plus 1 case of severe hypoxic brain damage. No difference was observed in duration of labour or mode of delivery. Perinatal mortality was significantly lower in the magnesium sulphate plus nifedipine treated group. The synergistic action of magnesium sulphate and nifedipine in the dosage employed in this study may be used to reduce maternal and perinatal mortality and morbidity in women with eclampsia.     

Chronic hypertension in pregnancy.

Women with chronic hypertension who are considering pregnancy should undergo extensive evaluation and work-up prior to conception. This evaluation is important to establish the cause and severity of the hypertension. The patient should be seen early in pregnancy and counseled regarding the possible adverse effects of hypertension and the importance of adherence to prenatal visits and prescribed medications. Patients classified to have high-risk hypertension are at increased risk for significant maternal and perinatal complications. These patients should have intensive antenatal follow-up and will require antihypertensive therapy irrespective of the severity of the hypertension. In contrast, in women with mild uncomplicated hypertension, good perinatal outcome is expected with proper obstetric care, without the use of antihypertensive drugs. Finally, most of the poor perinatal outcome in such pregnancies is related to the development of superimposed preeclampsia.     

Hypertension in pregnancy.

Pregnancies complicated by hypertension require a well-formulated management plan. Women with chronic hypertension should be evaluated prior to pregnancy. At onset of pregnancy, they should be classified into low-risk and high-risk groups. The majority of pregnant women identified as low-risk hypertensives will have good perinatal outcome without the use of antihypertensive drugs. In general, antihypertensive medications should be reserved for those considered as having high-risk hypertension. In either case, all these women should have close follow-up of maternal and fetal conditions throughout pregnancy. All women with diagnosed preeclampsia should be hospitalized at the time of diagnosis for evaluation of maternal and fetal well-being. Subsequent management will then depend on gestational age and the severity of the disease process. An individualized management plan and a referral to a tertiary care center will improve maternal and perinatal outcome in those women who are remote from term and in those with the HELLP syndrome.     

Prenatal diagnosis and management of congenital heart disease

Thirty-two fetuses were diagnosed as having congenital heart disease (CHD). The major indications for level II echocardiography other than suspected cardiac abnormalities were fetal malformations, nonimmune hydrops and cardiac arrhythmia. Only three patients had a previous history of fetal CHD. No false-abnormal diagnosis of severe CHD was made. Aortic arch anomalies represented the major diagnostic problem among the six correct but incomplete diagnoses. Sixty-one percent of the fetuses were growth retarded, thus confirming the severity of their CHD. Chromosomal anomalies and extracardiac malformations were associated in 19% and 44% of the fetuses, respectively. Obstetric management and fetal prognosis in cases of extracardiac malformations were greatly influenced by the diagnosis of CHD. The poorest perinatal outcome was associated with heart failure. The only intrauterine deaths occurred in that group, and only one neonate survived. The outcome was more favorable in neonates without other malformations or heart failure. Four of ten (40%) of those neonates survived, while the overall perinatal survival rate was 24%.     

Lactic Dehydrogenase: A Biochemical Marker for Preeclampsia–Eclampsia

Objectives

To correlate the severity of the disease, maternal and perinatal outcome with Lactic Dehydrogenase (LDH) levels in serum in patients of preeclampsia and eclampsia.

Methods

A prospective comparative study was conducted in the department of Obstetrics and Gynecology in the collaboration with department of Pathology, CSM Medical University, Lucknow. Out of 146 women studied, 39 were normal pregnant women, 35 were of mild preeclampsia, 36 of severe preeclampsia and 36 of eclampsia. The statistical analysis was done by Chi-square test (for proportional data) analysis of variance and sample “t” test (for parametric data).

Results

LDH levels were significantly elevated in women with preeclampsia and eclampsia (<0.001). Higher LDH levels had significant correlation with high blood pressure (P < 0.10) as well as poor maternal and perinatal outcome.

Conclusion

High serum LDH levels correlate well with the severity of the disease and poor outcomes in patients of preeclampsia and eclampsia.     

Short-term outcome of newborn infants: spinal versus general anesthesia for elective cesarean section. A prospective randomized study.

OBJECTIVE: To compare general and spinal anesthesia with respect to the short-term outcome of newborns born by elective cesarean deliveries. METHODS: Pregnant women admitted to our hospital from January 1999 to July 2000, for whom elective repeat cesareans were planned after 37 weeks gestation, were allocated randomly after their informed consent to spinal anesthesia or general anesthesia. Maternal age, gestational age, birth weight, Apgar's score, hospital stay duration, and duration of cesarean section time were all noted. The rate of the neonatal respiratory depression, perinatal asphyxia, and admittance to the neonatal intensive care unit of the infants were documented. We also studied arterial samples withdrawn from the cord for the pH, bicarbonate, PaO(2) (oxygen pressure, arterial), and PaCO(2) (carbon dioxide pressure, arterial). The serum levels of creatine kinase with myocardial-specific isoform, aspartate aminotransferase, alanine aminotransferase, and total cortisol levels of the newborns were measured and served in ruling out perinatal stress and in confirming the diagnosis of perinatal asphyxia (and of myocardial damage). Statistical analyses was performed with the use of an unpaired Student's t-test, Chi-square test, and a power calculation was done. RESULTS: From the randomly selected patients, we had 38 (45.2%) infants for general anesthesia and 46 (54.8%) for spinal anesthesia. None of our primary endpoints favored any of the study groups, and the clinical short-term outcome of the infants was similar in the neonates born both by spinal and general anesthesia (P>0.05). The biochemical assays did not rule out or confirm any differences in the occurrence of perinatal stress (P>0.05). CONCLUSION: Anesthesia type does not seem to influence the short-term outcome of the newborn infants for the elective cesarean deliveries. We believe that both spinal and general anesthesia could be performed in elective term cesarean deliveries without any risk to the newborn infants.     

Major congenital heart disease in Northern Norway: shortcomings of pre- and postnatal diagnosis

BACKGROUND: Congenital heart disease (CHD) is a significant cause of perinatal mortality and morbidity worldwide. Prenatal detection rate of CHD remains low in most European countries and a substantial proportion of infants with serious heart disease are diagnosed only after discharge from hospital after birth. Earlier recognition of treatable abnormalities may improve the perinatal outcome. The purpose of this study was to evaluate the incidence, pre- and postnatal diagnosis and outcome of major CHD in two northern-most counties of Norway. MATERIALS AND METHODS: All cases of major CHD were identified by reviewing the records of all fetal and neonatal echocardiographies and all perinatal autopsies performed during the study period. Data were obtained on maternal age, associated risk factors, time of diagnosis, type of CHD and outcome. RESULTS: Ninety-one fetal and 52 neonatal echocardiographies and 77 perinatal autopsies were performed during the 2-year study period. There was a total of 5658 births during this period. Twenty-five cases of major CHD were identified. Six of them were diagnosed prenatally, 18 after birth, and one additional case was identified from the perinatal autopsy register. The incidence of major CHD in Northern Norway was 4.4 per 1000 births. The prenatal detection rate was 24% (6/25). In 39% (7/18) of cases diagnosed postnatally the diagnosis was made following a second admission after the baby has been initially discharged from hospital after birth. The mortality among liveborn infants with major CHD was 17.4% (4/23). CONCLUSION: Despite almost universal prenatal ultrasound screening and at least one neonatal examination before discharge, the diagnosis of major CHD is made after a relevant delay in a substantial proportion of cases.     

孕中期血清PLGF、sFlt-1、sEng、sCD40L与子痫前期及胎儿不良结局的关系研究#br#

目的探讨孕中期血清胎盘生长因子(PLGF)、可溶性血管内皮生长因子受体1(sFlt-1)、可溶性内皮因子(s Eng)、可溶性CD40配体(sCD40L)与子痫前期及胎儿不良结局的关系。方法选取河北省唐山市妇幼保健院收治的子痫前期患者、健康孕妇各192例作为研究对象,采集两组孕妇孕20~24周的血液标本,测定血清PLGF、sFlt-1、sEng、sCD40L水平,对比检测结果。跟踪子痫前期孕妇的围产结局,对比不同围产结局孕妇的各项血清指标检测结果。结果与对照组相比,观察组孕妇的血清PLGF水平更低,sFlt-1、sEng、sCD40L水平更高(P<0.05)。轻度子痫前期、重度子痫前期与PLGF水平均呈负相关,与sFlt-1、sEng、sCD40L、Hcy水平均呈正相关(P<0.05)。相比轻度子痫前期,重度子痫前期与各血清学指标的相关性更强。胎儿妊娠结局良好162例(84.38%),结局不良30例(15.63%)。结局不良组的PLGF水平显著低于结局良好组,sFlt-1、sEng、sCD40L、Hcy水平显著高于结局良好组(P<0.05)。子痫前期患者胎儿不良结局与PLGF水平呈负相关,与sFlt-1、sEng、sCD40L、Hcy水平均呈正相关(P<0.05)。结论子痫前期的发生、进展及围产结局均与血清PLGF、s Flt-1、sEng、sCD40Ly水平密切相关,监测孕中期血清PLGF、sFlt-1、sEng、sCD40L水平变化可为临床评估子痫前期病情程度、预测胎儿不良结局提供参考依据。     

不同类型卵巢过度刺激综合征对妊娠结局的影响

目的:分析卵巢过度刺激综合征(OHSS)发病早晚、病情轻重、病程长短对妊娠结局的影响。方法:对于行IVF-ET而发生中、重度OHSS的132例患者(早发型83例,晚发型49例;中度34例,重度98例;短病程103例,长病程29例;妊娠72例)临床资料进行回顾性分析。结果:①OHSS患者妊娠丢失与双胎、OHSS发病早晚、病情轻重、病程长短无显著性相关(P>0.05),但在晚发型妊娠丢失比率高于早发型、重度比率高于中度、病程长者比率高于病程短者。②早产与双胎有显著性相关(P<0.01),与OHSS发病早晚、病情轻重、病程长短无显著性相关(P>0.05)。③低体重儿与双胎有显著性相关(P<0.01),与OHSS发病早晚、病情轻重、病程长短无显著性相关(P>0.05)。结论:OHSS患者的流产比率与发病早晚、病情轻重、病程长短也无显著性相关,但在发病晚、病情重、病程长者比率略高;低体重儿、早产与双胎有显著性相关,与发病早晚、病情轻重、病程长短无相关性。     

Epidural analgesia and the course of delivery in term primiparas

OBJECTIVES: Epidural analgesia provides the most effective pain control during labor. Of great concern is its influence on the course of delivery and perinatal complications. DESIGN: The aim of the study was to assess the effect of epidural analgesia on the course of delivery and perinatal outcome. MATERIALS AND METHODS: 609 deliveries among 1334 (323 women with epidural analgesia (53%) and 548 without epidural analgesia (47%)) met the following criteria: primipara, singleton, live pregnancy, > =37 weeks' gestation, cephalic presentation of a fetus, lack of contraindication for vaginal delivery. The incidence of instrumental deliveries and fetal distress, duration of the first, second and third stage of labor, perinatal outcome, perinatal complications and perinatal blood loss and were analyzed. RESULTS: The incidence of fetal distress during second stage of labor was significantly higher in the epidural group (12.69 vs. 6.99%, P=0.02). The incidence of fetal distress during first stage of labor did not differ in both groups (10.53% vs. 8.74%, NS). Cesarean sections rate was similar in epidural and non-epidural group (17.7 vs. 18.2%, NS). Among vaginal deliveries duration of the first and second stage of labor was longer in epidural group (6.5+/-2.4 vs. 5.4+/-2.5 godz., P=0,000003 and 47.3+/-34.8 vs. 29.1+/-25.8 min., P=0.000003) and this was independent of period of time between onset of first stage of labor and epidural analgesia. Oxitocin use was significantly more frequent in the epidural group (20.6 vs. 10.3%, P<0.004). There were no statistically significant differences in the rates of instrumental vaginal deliveries, 1 and 5-minute Apgar scores, length of third stage of labor and perinatal blood loss in patients with and without epidural analgesia. Perinatal outcome did not depend on previous use of epidural analgesia or mode of analgesia for the operation in cesarean section subgroup. CONCLUSION: Epidural labor analgesia is associated with slower progress of labor but has no adverse effect on perinatal outcome and perinatal complications.     

Course of pregnancy, delivery in adolescents treated in I Clinical Unit of Obstetrics and Gynecology in Bytom (1997-2001)

OBJECTIVES: The subject of our analysis was pregnancy, delivery and perinatal outcome in adolescent girls treated in I Clinical Unit of Obstetrics and Gynecology in Bytom in the period 1997-2001. MATERIAL AND METHODS: Our materials were 164 pregnant adolescent girls aged 14-18. Course of pregnancy, type of delivery, perinatal outcome and the recourse to cesarean section were retrospectively analysed in our study. RESULTS: Mean age of adolescent patients in this study was 16 years and 10 months. 141 pregnancies were conducted by natural birth and 23 (14%) by cesarean section. The rate of preterm birth in this analysis was 15.85%. CONCLUSIONS: 1. Adolescent patient pregnancy need special perinatal care. 2. The perinatal outcome of analysed cases were similar to other authors.     

Pregnancy in sickle cell disease in Bahrain.

OBJECTIVE: To review the maternal and fetal complications in pregnant women with sickle cell disease and to compare their pregnancy outcome with those of controls. DESIGN: A case-control study. SETTING: Ministry of Health hospitals in Bahrain. SUBJECTS: 147 pregnancies in 140 women with sickle cell disease and 294 controls matched for age and parity. MAIN OUTCOME MEASURES: The characteristics of women who had crises, the frequency of the crises, hypertensive disorders of pregnancy, infection, diabetes, perinatal mortality and the delivery statistics in the index and control women. RESULTS: Maternal mortality was 1.4% and perinatal mortality was 73.3/1000 total births in women with sickle cell disease, there were no maternal deaths and the perinatal mortality was 6.8/1000 births in the control group. Anaemia was treated by blood transfusion in 47% of women with sickle cell disease and, of these, 39% had a crisis that appeared to have been precipitated by the transfusion in the absence of any other predisposing factors. The presence of raised HbF did not decrease the number of crises but reduced their severity. CONCLUSION: Pregnancy in women with sickle cell disease should be monitored very closely as it constitutes a high risk to both the mother and the baby.     

Antepartum transabdominal amnioinfusion.

OBJECTIVE: To determine the usefulness of antepartum transabdominal amnioinfusion (APTA) in reducing perinatal morbidity and mortality due to oligohydramnios. METHODS: In this case-control study of 100 pregnant women with oligohydramnios, 50 received APTA and 50 were treated conservatively. These controls were matched for age, parity, and pregnancy duration with the case patients. RESULTS: There was a mean 4.02-cm increase in amniotic fluid index (AFI) after amnioinfusion. Only 18% of case patients required cesarean sections vs. 46% of controls. The perinatal mortality rate was 18% among controls and 4% among case patients, and the difference was significant. CONCLUSION: Antepartum amnioinfusion is a useful procedure to reduce complications resulting from decreased intra-amniotic volume. It is especially useful in preterm pregnancies, where the procedure allows for a better perinatal outcome by prolonging the duration of pregnancy.     

Perinatal outcome of ICSI pregnancies compared with a matched group of natural conception pregnancies in Flanders (Belgium): a cohort study

A retrospective cohort study was conducted with an intracytoplasmic sperm injection (ICSI) group and a naturally conceived comparison group. A total of 1655 singleton and 1102 twin ICSI births were studied with regard to perinatal outcome. Control subjects (naturally conceived pregnancies) were selected from a regional registry and were matched for maternal age, parity, place of delivery, year of birth and fetal sex. The main outcome measures were duration of pregnancy, birth weight, Apgar score <5 after 5 min, neonatal complications, perinatal death and congenital malformations. Twin births, when compared with singletons, carry a much higher risk of poor perinatal outcome. For both ICSI singletons and ICSI twins, no significant difference was found between ICSI and naturally conceived pregnancies for all investigated parameters. After excluding like-sex twin pairs, ICSI twin pregnancies were at increased risk for perinatal mortality (OR = 2.74, CI = 1.26-5.98), prematurity (OR = 1.38, CI = 1.10-1.75) and low birth weight (OR = 1.34, CI = 1.06-1.69) compared with spontaneously conceived different-sex twin pairs. In conclusion, the perinatal outcome of ICSI singleton and twin pregnancies was very similar to that of spontaneously conceived pregnancies in this large cohort study. After excluding like-sex twin pairs, ICSI twins were at increased risk for prematurity, low birth weight and higher perinatal mortality compared with the natural conception comparison group.     

Oestriol Excretion in the Pregnancy Complicated by Diabetes Mellitus

Summary: Urinary oestriol excretion was studied throughout 93 diabetic pregnancies. Low levels of excretion (38%) were common to all clinical categories of diabetes and were not influenced by either the duration or severity of the disease.
The overall perinatal loss was 13%; the incidence was 7% in patients with normal excretion values and 23% in those with low values. Six of the 8 deaths associated with low oestriol excretion occurred after birth and all were due to the respiratory distress syndrome. Low assays may warn of impending intra-uterine death, but intervention may not be possible. A normal excretion level should not, however, permit a complacent attitude.     

Perinatal outcome of twin pregnancies after in vitro fertilization

BACKGROUND: There are conflicting data concerning perinatal outcome of twin, in vitro fertilization (IVF) pregnancies. The aim of this study was to evaluate and compare perinatal and neonatal outcomes in twin IVF pregnancies to those of spontaneously conceived twin gestations. METHODS: The medical files of 73 IVF and 148 naturally conceived twin pregnancies were studied retrospectively. Data concerning maternal characteristics, obstetric complications, and neonatal outcome were recorded and compared by chi2 test. The one-way analysis of variance (anova) was used to compare the means of groups. RESULTS: Mean maternal age, the proportion of nulliparous women, and the incidence of premature rupture of membranes, cesarean section, and premature delivery were significantly higher in the study group. The mean birthweight was significantly lower, the frequency of admission to the intensive care unit and the duration of hospitalization were significantly higher in the study group. The incidence of intraventricular hemorrhage was significantly higher in the IVF group. The number of perinatal deaths was similar. CONCLUSION: IVF twin pregnancies are at greater risk for obstetric complications and adverse neonatal outcome in comparison with naturally conceived twin gestations.