What is the effect of intertwin delivery interval on the outcome of the second twin delivered vaginally?

Objective: Optimal management of twin deliveries is controversial. We aimed to assess if intertwin delivery interval, after vaginal delivery of the first twin, may have an influence on adverse neonatal outcomes of the second twin

Study design: This is a retrospective observational study including diamniotic twin pregnancies with vaginal delivery of the first twin, between January 2000 and July 2017. Inclusion criteria were diamniotic pregnancies and vaginal delivery of the first twin. We excluded higher twin order, monoamniotic pregnancies, cesarean delivery of the first twin and patients with missing data.

Results: A number of 400 diamniotic twin pregnancies met the inclusion criteria and were divided, considering intertwin delivery interval into (1) ≤30 minutes (n?=?365); and (2) >30?minutes (n?=?35). Considering the two study groups, maternal and first twin characteristics and outcomes were similar. Second twin reported higher incidence of cesarean section and vacuum delivery, but similar incidence of neonatal adverse outcomes, in case of intertwin interval >30 minutes. At multivariate analysis, a difference between second and first twin weight ≥25% was correlated to neonatal adverse outcome, while we did not found this correlation with a cut-off of 30 minutes.

Conclusions: In our study, growth discrepancy between twins was significantly correlated to adverse neonatal outcomes, while intertwin delivery time was not an influencing factor. So, in line with this result, in our clinical practice, we do not use a fixed time in which both twins should be delivered, neither in monochorionic nor in dichorionic pregnancies, when fetal wellbeing was demonstrated during labor.     

Effects of parity and mode of delivery on urinary incontinence among postmenopausal women in Taiwan

ObjectiveTo investigate the association between the prevalence of urinary incontinence and parity or mode of delivery among Taiwanese women aged 60 years or older.MethodsBetween July 1999 and December 2000, a nationwide epidemiologic study was conducted in Taiwan among 2410 women selected by a multistage random sampling method. Face-to-face interviews with 1517 women were conducted. The relationship between the prevalence of urinary incontinence and the number of vaginal deliveries or number of cesarean deliveries was assessed by frequency and Pearson χ² test using a significance level of less than 0.05. Logistic regression was used to investigate the significance of dichotomous dependent variables.ResultsDecades ago, most Taiwanese women (1435 of 1511 respondents, 94.97%,) gave birth via vaginal delivery and the rate of cesarean delivery was low (20 of 1513 respondents, 1.32%). Parity (odds ratio [OR], 2.42; 95% confidence interval [CI], 0.87–6.71; P = 0.091), vaginal delivery (OR, 0.76; 95% CI, 0.39–1.47; P = 0.408), and cesarean delivery (OR, 1.47; 95% CI, 0.59–3.70; P = 0.409) did not increase the risk of urinary incontinence.ConclusionThere was no association between urinary incontinence and parity or mode of delivery among Taiwanese postmenopausal women decades after their first delivery.     

Single-shot ropivacaine wound infiltration during cesarean section for postoperative pain relief

ObjectiveTo assess the efficiency of single-shot ropivacaine wound infiltration during cesarean section for postoperative pain relief, using a prospective, randomized, double-blinded study.Patients and methodsOne hundred consecutive patients with planned cesarean section were enrolled between September 2007 and May 2008 and randomized into two groups: single-shot wound infiltration of 20 mL of ropivacaine 7.5 mg/mL (Group R; n = 56) or single-shot wound infiltration of 20 mL of saline solution (group T; n = 44). The primary goal of this study was the double-blinded evaluation of the postoperative pain after coughing and leg raise using the 100-mm visual analog scales (VAS) during the first 48 postoperative hours after cesarean delivery. The secondary goals were the occurrence of nausea and vomiting and the morphine consumption.ResultsNumerical pain rating scale for pain evaluation was significantly lower (P < 0.05) in the ropivacaine group than in the control group at M0, M20, M40, M60, H2 and H4. But, at H8, H12 and H24, no significant difference for VAS was noted between the two groups. The occurrence of nausea and vomiting and the total morphine consumption were not significantly different between the two groups during the first 48 postoperative hours.Discussion and conclusionSingle-shot ropivacaine wound infiltration during planned cesarean section is a simple and safe procedure that provides effective reduction of post-partum pain within the first 4 hours.     

Inducción del parto en gestaciones gemelares: estudio comparativo de oxitocina vs dinoprostona

IntroductionIn the last few years the number of twin gestations that reach term has increased. Although vaginal delivery route has proven to be a safe alternative to caesarean section when first foetus is in cephalic presentation, available evidence on induction methods applied to this type of pregnancies is limited.MethodsRetrospective observational study conducted in a tertiary hospital. Forty-four pregnant twins, with gestational age greater than 34 weeks, and with the first twin in cephalic presentation, who underwent induction of labour, were included. Vaginal prostaglandins (dinoprostone) were used in 17 cases and intravenous oxytocin in 27 cases, indication was randomised according to daily clinical practice. Results of both groups were compared in terms of safety and efficacy.ResultsNo significant differences were found in the rate of caesarean section due to induction failure between oxytocin and prostaglandins (42.9% vs. 57.1%; P = .3). No differences were found either in terms of neonatal or maternal complications. Two pregnant women presented obstetric haemorrhage, the only maternal complication described, both in oxytocin group. Higher risk of caesarean section was found in women with BMI > 30 kg/m² (P = .001) and pre-induction Bishop's index ≤ 6 (RR: 2.06) (P = .005).ConclusionsBoth vaginal prostaglandins and intravenous oxytocin are similar in efficacy, maternal and neonatal safety when used in twin gestations. Bishop's index ≤ 6 and BMI > 30 are associated with higher probability of induction failure.     

Influence of chorionicity in intra-partum management of twin deliveries

Objective: To analyze morbidity and mortality in twin pregnancies as a function of the type of delivery and chorionicity. Design: Retrospective cohort study. Methods: Analysis of the type of delivery, intertwin time interval, and perinatal variables of >1000 twin deliveries during a 10-year period. Main outcome measure: Influence of delivery type and chorionicity on perinatal outcome. Results: The rate of cesarean sections was 42.4%. No differences were found as a function of chorionicity or as a function of presentation of the second twin. Cesarean sections were performed after vaginal delivery of the first twin in 1.8% of cases, being more common if the second baby was in a non-cephalic presentation (6.9% vs. 0.4%, p < 0.05). The average twin-to-twin delivery time interval was longer in the cases where the second had a cephalic presentation (8.26?±?7.75?min vs. 6.81?±?5.97?min, p < 0.05). The umbilical artery pH was lower the longer the interval between the birth of the twins, both in monochorionic and dichorionic. Conclusions: According to the results, vaginal delivery is as safe as elective caesarean section in twin pregnancies where the first twin is in cephalic presentation and the intrapartum management should not vary due to chorionicity.     

An inflatable ergonomic 3-chamber fundal pressure belt to assist vaginal delivery

ObjectiveTo evaluate whether Baby-guard—a new medical device with an ergonomic 3-chamber inflatable abdominal belt—can reduce complications associated with vaginal delivery.MethodsA randomized controlled single-blind prospective study of 80 pregnant women delivering at term was conducted at San Giuseppe Hospital, Empoli, Italy. In the study group (n = 40), the abdominal belt was inflated to optimal therapeutic pressures. In the control group (n = 40), the abdominal belt was inflated to minimal, non-therapeutic pressures. Factors relating to maternal, fetal, and labor complications during vaginal delivery were evaluated.ResultsCompared with the control group, women in the study group experienced a lower incidence of perineal and cervical lacerations (P < 0.001); reduced use of the Kristeller maneuver (P < 0.001); shorter duration of the second stage of labor (P < 0.001); less psychologic and physical fatigue (P < 0.001); fewer maternal requests for cesarean delivery during labor (P < 0.001); fewer vacuum extractions (P < 0.01); and fewer cesarean deliveries (P < 0.02). No neonatal intensive care unit admissions were recorded in the study group versus 7 in the control group (P < 0.012).ConclusionUse of the ergonomic 3-chamber inflatable abdominal belt system reduced the incidence of risks associated with vaginal labor.Clinical trials.gov identifier: NCT01566331.     

Neonatal hypoxia of the second twin after vaginal delivery of the first twin: what matters?*

Objective: Optimal management of twin deliveries is controversial. We aimed to assess potential risk factors correlated to the development of hypoxia in the second twin after vaginal delivery of the first twin.

Study design: This is a retrospective observational study including diamniotic twin pregnancies delivering at our Institution at 35 weeks of gestational age or more, weighing ≥1800?g. Hypoxia was defined as at least one of the following: Apgar score <5 at 10 minute, neonatal resuscitation for >10 minutes, neonatal acidosis (pH ≤7 and/or BE ≥12?mmol/L).

Results: A number of 275 diamniotic twin pregnancies met the inclusion criteria and were divided within the following groups: (1) second twin not developing neonatal hypoxia (n?=?265); and (2) second twin developing neonatal hypoxia (n?=?10). The rate of second twins with neonatal hypoxia during the study period was 3.6% (10/275). Abnormal cardiotocography during the intertwin delivery interval, defined as ACOG category III, was significantly correlated to second twin hypoxia. Of interest, there was no significant difference in the intertwin delivery interval between the study groups. In addition, breech presentation of the second twin did not show to be a risk factor for neonatal hypoxia. None of the second twins developing neonatal hypoxia was reported to have encephalopathy (follow up of at least 24 months). At multivariate analysis, only abnormal cardiotocography was an independent risk factor for second twin hypoxia (OR 17.8, 95% CI 4.1–77.2).

Conclusions: In our study, neonatal hypoxia was significantly correlated to abnormal cardiotocography, while intertwin delivery interval was not correlated to the development of this adverse neonatal outcome.     

Perinatal complications and cesarean delivery among foreign-born and Australian-born women in Western Australia, 1998-2006

ObjectiveTo determine whether common perinatal complications could explain variation in risk of cesarean among foreign-born and Australian-born women in Western Australia (WA).MethodsComplication prevalence was calculated using the linked records of 208 982 confinements to non-indigenous women in WA between 1998 and 2006. Logistic regression was used to estimate differences in risk of elective cesarean and emergency cesarean compared with vaginal delivery for foreign-born women from different regions.ResultsThe most common complications in emergency cesareans were failure to progress (36.7%) and fetal distress (35.7%). The most common complications in elective cesareans were previous cesarean (56.2%) and malpresentation (16.3%). Women from Sub-Saharan Africa, Southeast Asia, and Southern and Central Asia had an increased risk of emergency cesarean compared with Australian-born women (P < 0.05), whereas women from Oceania, North Africa and the Middle East, and Northeast Asia had a decreased likelihood of elective cesarean compared with Australian-born women (P < 0.05).ConclusionComplication prevalence varied by maternal region of birth. However, variation in these complications does not completely explain differences in mode of delivery among foreign-born and Australian-born women in WA. Sociocultural factors must be considered in future research and when establishing culturally appropriate guidelines for obstetric staff dealing with foreign-born women.     

Delivery in lateral position. Comparative study in low risk pregnancy between lateral and dorsal position for the delivery in eutocic vaginal birth

ObjectiveFor several years in French labour wards, delivery in the lateral decubitus position (LP) has raised great interest. We wanted to assess perineal outcomes and neonatal morbidity following delivery in the lateral LP compared to the dorsal decubitus position (DP).Patients and methodsTwo teams of midwives, in a private and in a public hospital, performed a total of 6800 deliveries in the area of Tours following a training session on the techniques of delivery in the lateral decubitus position. The design was a retrospective case-control study including patients with low obstetrical risks and normal vaginal delivery. We included 645 patients who gave birth from May 1st to September 30th, 2007.ResultsWe showed a significant difference in perineum outcomes, with a lower episiotomy rate (56.7% in LP/40.7% in DP, P = 0.0001), a higher rate of intact perineum (56.7% in LP/40.7% in DP, P = 0.0001) and no differences with respect to perineal laceration. These differences were significant in primiparous (intact perineum: 46.8% in LP/20.2% in DP, P = 0.004; episiotomy: 17% en DL/44.7% en DD, P = 0.006) and secondiparous patients (episiotomy: 8.6% in LP/30.7% in DP, P = 0.0001). We showed significant differences in fetal heart abnormalities during labour in favour of the lateral decubitus position (no anomaly, P = 0.00004; separated decrease, P = 0.04; bradycardia, P = 0.0009; early decrease, P = 0.04).Discussion and conclusionThe neonatal mortality and morbidity did not differ between delivery positions. The lateral position seems to be protective for the perineum without affecting neonatal outcome. Incorporating lateral decubitus deliver into daily practice is possible in large groups of midwives after appropriate training.     

Comparison of intrapartum outcome among immigrant women from Ethiopia and the general obstetric population in Israel

ObjectiveTo compare intrapartum outcome between ethnic Ethiopian women and the general obstetric population in Israel.MethodsIn a retrospective study, computerized data from all Ethiopian women who delivered between January 2004 and August 2011 at a university teaching hospital in Afula, Israel, were assessed. The control group comprised non-Ethiopian Israeli women, who were matched at a ratio of 1:2 on the basis of deliveries that took place immediately before and after delivery by an Ethiopian woman. The primary outcome was incidence of operative delivery.ResultsDuring the study period, 576 Ethiopian women delivered along with 1152 matched control women. Ethiopian women had a higher incidence of pre-eclampsia (6.8% versus 4.0%, P = 0.01) and early postpartum hemorrhage (4.3% versus 1.6%, P = 0.003) than control women. After adjustment for potential confounders, the incidence of vacuum or cesarean delivery was significantly higher among Ethiopian than among control women (odds ratio, 1.68; 95% confidence interval, 1.28–2.20; P = 0.002). The incidence of composite major perinatal morbidity, including Erb palsy and cord pH less than 7.1, tended to be higher among Ethiopian women than among control women (2.3% versus 1.1%; P = 0.053).ConclusionAlthough prepartum and intrapartum care are standardized, Ethiopian women had a less favorable intrapartum outcome.     

Neonatal outcomes of twin pregnancy according to the planned mode of delivery

OBJECTIVES: To assess neonatal morbidity in twin pregnancy according to the planned mode of delivery. METHODS: A retrospective cohort study of 758 consecutive sets of twins born after 35 weeks of gestation with a cephalic-presenting first twin was undertaken in a level III maternity unit in which active management of the second twin delivery is performed routinely. The primary outcome was a composite measure of neonatal mortality and morbidity, including pH less than 7.0, 5-minute Apgar score less than 4, neonatal intensive care unit transfer more than 4 days, pneumothorax, and fracture. Control for potential confounders was performed by excluding from the analysis women who experienced pregnancy complications and by using logistic regression models. RESULTS: Vaginal or cesarean delivery was planned for 657 (86.7%) and 101 (13.3%) women, respectively. Among planned vaginal deliveries, 515 (78.4%) patients delivered both twins vaginally, 139 (21.1%) had a cesarean delivery during labor, and 3 (0.5%) had cesarean delivery for the second twin. After vaginal birth of the first twin, the mean intertwin delivery interval was 4.9+/-3.2 minutes. When patients who experienced pregnancy complications were excluded (n=202), the neonatal composite morbidity for the second twin did not differ between planned cesarean and planned vaginal delivery (5.0% compared with 4.7%, adjusted odds ratio 1.5, 95% confidence interval 0.3-7.4, P=.63). Neonatal composite morbidity of first twins did not differ between groups. CONCLUSION: For twin gestations with a cephalic-presenting first twin, planned vaginal delivery after 35 weeks of gestation in selected women remains a safe option in centers used to active management of the second twin delivery.     

Randomized management of the second nonvertex twin: vaginal delivery or cesarean section

Sixty twin deliveries after the thirty-fifth gestational week with vertex-breech and vertex-transverse presentations were managed according to a randomization protocol. Thirty-three parturient women (21 vertex-breech and 12 vertex-transverse presentations) were allocated for vaginal delivery and 27 for cesarean section (18 vertex-breech and nine vertex-transverse). Six pairs of twins in the vaginal delivery group were delivered in a different mode than requested by the protocol (two women underwent cesarean section; in four cases the second twin spontaneously changed to vertex presentation). There were no significant differences between 1- and 5-minute Apgar scores and incidence of neonatal morbidity between the second-born twins in both study groups. Firstborn twins had higher 1-minute Apgar scores than the second-born infants irrespective of route of delivery (p less than 0.05). No case of birth trauma or neonatal death was recorded. Maternal febrile morbidity was significantly higher in the cesarean section group than in the vaginal delivery group (40.7% versus 11.1%, p less than 0.05). These results suggest that in twins with vertex-breech or vertex-transverse presentations after the thirty-fifth week of gestational age the neonatal outcome of the second twin was not significantly influenced by the route of delivery.     

Excessive use of cesarean section for the second twin?

BACKGROUND: In Sweden, the frequency of cesarean section of the second twin after vaginal birth of the first twin has increased in recent years. METHODS: To investigate the indications for second twin cesarean sections, all twin deliveries at Huddinge University Hospital from 1995 to 1997 were reviewed retrospectively. The rates of cesarean section for the second twin were compared with figures from the whole country, based on the Swedish medical birth register. RESULTS: Thirty-one percent of all twin deliveries had a spontaneous onset and spontaneous vaginal delivery. The total twin cesarean section rate, including cesarean section for the second twin, was 45% at Huddinge University Hospital in 1995-1997 and 44% in Sweden in 1995. Cesarean section for the second twin after vaginal delivery of the first twin occurred in 11%. On review, 2/3 of the cesarean sections for the second twin were considered potentially avoidable. CONCLUSION: In normal twin pregnancies with vertex/nonvertex presentation, the favorable fetal outcome and also the maternal risks associated with cesarean section support vaginal delivery as the recommended delivery route. Extraction or version of a second nonvertex twin should be attempted before cesarean section for this twin is performed.     

Delivery of the second twin.

OBJECTIVE: To determine the likelihood of cesarean for the second twin after vaginal delivery of the first and the risk of vaginal delivery. METHOD: A retrospective analysis of twin deliveries was performed on 10,365 live born twin pairs (20,730 births), using birth certificate data from the State of Illinois from 1997 through 2000. RESULT: The incidence of cesarean for the second twin after vaginal delivery of the first was 10.1%. The greatest incidence of failed vaginal delivery of the second twin was in the vertex/non-vertex group. Five-minute Apgar scores <4 were significantly more frequent in vaginally delivered twins <2000 g compared to those delivered via cesarean (p<0.001). CONCLUSION: Twin presentation type is predictive of the likelihood of a failed vaginal delivery of the second twin. Cesarean appears to significantly reduce the incidence of Apgars <4 for neonates <2000 g.     

Advancing obstetric anesthesia practices in Georgia through clinical education and quality improvement methodologies

ObjectiveTo determine whether an integrated program of clinical education and improvement methods regarding the safe use of regional anesthesia for obstetrics would result in improved and sustained practice change in Georgia.MethodsBetween 2006 and 2009, intervention teams undertook several visits to 5 Georgian hospitals. Rates of regional anesthesia for labor and cesarean delivery prior to and following the intervention were collected from participating and non-participating hospitals. There were multifaceted educational activities and quality improvement activities at intervention sites, including protocol development, social marketing, and supply chain logistics. Host hospitals evaluated the program via a questionnaire.ResultsThe use of general anesthesia for cesarean delivery decreased significantly (P < 0.001) and the use of epidural analgesia for labor increased significantly (P < 0.001); there was no change in non-participating hospitals. Over the course of the program, medication and supply availability improved. Program evaluations were uniformly positive.ConclusionA structured program of education and quality improvement led to an increase in the use of regional anesthesia for vaginal and cesarean deliveries. Achievements were sustained during periods of economic and political turmoil.     

Web-Based Education and Attitude to Delivery by Caesarean Section in Nulliparous Women

ObjectiveTo measure the effect of a web-based educational tool on baseline knowledge of the risks and benefits of delivery by Caesarean section in healthy nulliparous women.MethodsWe constructed a web-based educational tool to provide evidence-based information on the potential benefits and risks of CS for healthy nulliparous women in the second trimester. We included women with an uncomplicated singleton pregnancy who were receiving antenatal care at Mount Sinai Hospital. Eligible women logged into the website to undertake a pretest survey. After completing this survey, they received access to the educational tool, followed by a link to a second survey. The surveys collected baseline demographics and assessed participants’ knowledge of the perceived safety and risks of vaginal delivery and CS, their sources of information, and the influence of these sources on their views.ResultsSeventy-three participants completed both surveys. Participants had a high baseline preference (84%) for vaginal delivery. The mean score for knowledge about vaginal delivery and CS increased significantly between the surveys, from 47% to 76% (P < 0. 001). There was no significant change in preference for mode of delivery between the two surveys. In both surveys, more participants responded that they were a “little fearful” or “not fearful at all” of vaginal deliveries. In the second survey, significantly more responded that they were “very fearful” or “fearful” of CS (P < 0.05). Increased knowledge about specific risks of vaginal delivery did not deter participants from preferring a vaginal delivery. However, knowledge of risks associated with CS made them more likely to have “very favourable” or “somewhat favourable” views of vaginal delivery. Ethnicity and country of birth were not found to have a significant effect on preferred mode of delivery.ConclusionsWe demonstrated that a web-based educational tool significantly increased knowledge of the risks and benefits of vaginal delivery and CS. However, the educational intervention did not significantly change preferences.     

Sustainable scale-up of active management of the third stage of labor for prevention of postpartum hemorrhage in Ecuador

ObjectiveTo analyze the Ecuadorian experience regarding the adoption, scale-up, and institutionalization of active management of the third stage of labor (AMTSL) for prevention of postpartum hemorrhage via continuous quality improvement (CQI) processes.MethodsAverage AMTSL implementation rates for women with vaginal deliveries were compared using unweighted provincial aggregate data from facilities participating in 3 phases of AMTSL programming. Months taken to implement AMTSL at 80% or more and 90% or more compliance were compared across phases.ResultsRate of oxytocin administration during the first 3 months was 5.0% in phase 1, 9.8% in phase 2, and 72.2% in phase 3 (P ≤ 0.001 vs phases 1 and 2). The average number of months provinces took to increase oxytocin administration to 80% or more and 90% or in more women with vaginal deliveries was, respectively, 21.6 ± 18.7 and 30.6 ± 16.4 in phase 1, 23.5 ± 15.1 and 30.1 ± 14.9 in phase 2, and 4.7 ± 4.9 (P ≤ 0.01 vs phase 1; P ≤ 0.001 vs phase 2) and 4.0 ± 3.4 (P ≤ 0.001 vs phases 1 and 2) in phase 3. By December 2009, AMTSL implementation was sustained at 90% or more in all provinces.ConclusionCQI processes identified resistance and operational barriers, and developed mechanisms to overcome them.     

Pregnancy outcome in early-onset severe pre-eclampsia in Trinidad

ObjectiveTo compare 2 different methods—multiple doses of misoprostol and a combination of misoprostol and oxytocin—for termination of pregnancy in the second trimester.MethodsBetween 2006 and 2008, 120 women undergoing termination of second-trimester pregnancy in 2 hospitals in Kermanshah, Iran, were enrolled in a randomized trial comparing 2 treatments. In each treatment group, an initial vaginal dose of 600 μg of misoprostol was placed in the posterior fornix. After 6 hours, an intravenous infusion of concentrated oxytocin was given to women in group A, and 400 μg of vaginal misoprostol was given every 6 hours to women group B, up to a maximum of 4 doses. The outcomes were compared via χ² and independent t tests.ResultsWithin 30 hours, 96.7% of women in group A and 96.7% of women in group B delivered successfully. The average duration between induction and delivery time was 12.3 ± 6.0 hours in group A and 12.1 ± 6.0 hours in group B (P > 0.05).ConclusionThe use of misoprostol with oxytocin, and multiple doses of misoprostol gave similar results for termination of pregnancy in the second trimester.     

Association between placental growth factor levels in early onset preeclampsia with the occurrence of postpartum hemorrhage: A prospective cohort study

ObjectivesTo determine the association between PlGF (placental growth factor) estimation in early second trimester (22–24 weeks of gestation), with the occurrence of postpartum hemorrhage in pregnant women with early onset preeclampsia and whether the mode of delivery (cesarean or vaginal) has any association with increased risk of developing postpartum hemorrhage.Study designA prospective cohort study was conducted on 788 pregnant women with singleton pregnancies diagnosed with early onset preeclampsia between March 2009 and June 2011. Maternal serum PlGF level estimation was done between 22 and 24 weeks of gestation and a cut-off value of <122 pg/ml was determined by receiver operating characteristic (ROC) curve analysis for identifying those at risk of developing postpartum hemorrhage. Association between serum PlGF level <122 pg/ml and cesarean deliveries with the risk of developing postpartum hemorrhage was analyzed by logistic regression analysis and Odds ratio, which were computed. The results were considered statistically significant when P-value <0.05.Main outcome measuresProportion of study population developing postpartum hemorrhage.ResultsLogistic regression analysis showed the association of serum PlGF <122 pg/ml at 22–24 weeks (Odds ratio 8.9516; 95% CI, 5.0728–15.7963) and that of cesarean delivery (Odds ratio 2.4252; 95% CI, 1.4573–4.0360) with the risk of developing postpartum hemorrhage. Both the associations were found to be statistically significant.ConclusionMaternal serum PlGF level <122 pg/ml at 22–24 weeks of gestation and cesarean delivery are both strongly associated with the risk of developing postpartum hemorrhage in pregnant women with early onset preeclampsia.     

Characteristics of hypertensive disorders in twin versus singleton pregnancies

ObjectiveTo determine the characteristics of hypertensive disorders of pregnancy in twin compared with singleton pregnancies.Study designAnalysis of a prospectively recorded database of 4976 hypertensive pregnancies.Main outcome measuresComparison of progression to pre-eclampsia and maternal and neonatal outcomes.ResultsThere were 3942 singleton and 214 twin pregnancies. De novo hypertension in twin pregnancy was diagnosed earlier (p < 0.001). In singleton pregnancies with de novo hypertension (n = 3161), 60% had an initial diagnosis of gestational hypertension (GH) and 40% had pre-eclampsia (PE). In twin pregnancies with de novo hypertension (n = 199), 35% of women were initially diagnosed with GH and 65% with PE (p < 0.001). At delivery, 46% of the singletons had GH and 54% had PE, compared with twin pregnancies where 23% had GH and 77 % had PE (p < 0.001). The progression from GH to PE for twins was twice that of singleton pregnancies (p < 0.001).There were 781 singleton and 15 twin pregnancies with chronic hypertension (CH). Twin pregnancies complicated by CH were more likely to progress to PE than singletons (p < 0.01). The gestation at delivery was earlier for twin pregnancies (p < 0.001) and there were more twins that were smaller for gestational age (p < 0.001). There were no differences in maternal outcomes.ConclusionWomen carrying twins with de novo hypertension are more likely to present earlier, have initial PE and to subsequently progress from GH to PE. Neonatal outcomes are worse in such pregnancies.