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Revista Brasileira de Ginecologia E... Sep 2018Twin pregnancy accounts for 2 to 4% of total births, with a prevalence ranging from 0.9 to 2.4% in Brazil. It is associated with worse maternal and perinatal outcomes.... (Review)
Review
Twin pregnancy accounts for 2 to 4% of total births, with a prevalence ranging from 0.9 to 2.4% in Brazil. It is associated with worse maternal and perinatal outcomes. Many conditions, such as severe maternal morbidity (SMM) (potentially life-threatening conditions and maternal near-miss) and neonatal near-miss (NNM) still have not been properly investigated in the literature. The difficulty in determining the conditions associated with twin pregnancy probably lies in its relatively low occurrence and the need for larger population studies. The use of the whole population and of databases from large multicenter studies, therefore, may provide unprecedented results. Since it is a rare condition, it is more easily evaluated using vital statistics from birth registries. Therefore, we have performed a literature review to identify the characteristics of twin pregnancy in Brazil and worldwide. Twin pregnancy has consistently been associated with SMM, maternal near-miss (MNM) and perinatal morbidity, with still worse results for the second twin, possibly due to some characteristics of the delivery, including safety and availability of appropriate obstetric care to women at a high risk of perinatal complications.
Topics: Female; Humans; Infant, Newborn; Infant, Newborn, Diseases; Morbidity; Pregnancy; Pregnancy Complications; Pregnancy, Twin
PubMed: 30231294
DOI: 10.1055/s-0038-1668117 -
European Journal of Obstetrics,... Jun 2023To review current international clinical guidelines on the antenatal and intrapartum management of twin pregnancies, examining areas of consensus and conflict. (Review)
Review
OBJECTIVES
To review current international clinical guidelines on the antenatal and intrapartum management of twin pregnancies, examining areas of consensus and conflict.
METHODS
We conducted a database search using Medline, Pubmed, Scopus, Academic Search Complete, CINAHL and ERCI Guidelines website. Guidelines were screened for eligibility using our inclusion and exclusion criteria. Those deemed eligible were quality assessed using the AGREE II tool and relevant data was extracted.
RESULTS
We identified 21 relevant guidelines from 16 countries including two international society guidelines. There was consensus in determination of chorionicity and amnionicity within the first trimester, fetal anomaly scan between 18 and 22 weeks and the recommended screening for twin-to-twin transfusion syndrome (TTTS). For those that provided intrapartum guidance, there was agreement in recommending caesarean section to deliver monochorionic monoamniotic (MCMA) twins, epidural anaesthesia for intrapartum analgesia and the use of cardiotocography (CTG) for intrapartum fetal monitoring. The main areas of conflict included cervical length screening, frequency of ultrasound surveillance, timing of delivery of dichorionic twin pregnancies and circumstances for recommending vaginal delivery. There was a lack of advice on intrapartum management.
CONCLUSIONS
This review has highlighted the need for unified international guidance on the management of twin pregnancy. Comparisons of current guidance demonstrates a lack of confidence in the management of labour in twin pregnancies. Further evidence on intrapartum care of twin pregnancies is needed to inform practice guidelines and improve both short and long term maternal and fetal outcomes.
Topics: Pregnancy; Female; Humans; Pregnancy, Twin; Cesarean Section; Ultrasonography, Prenatal; Twins; Prenatal Care
PubMed: 37087836
DOI: 10.1016/j.ejogrb.2023.04.002 -
Romanian Journal of Morphology and... 2018The incidence of multiple pregnancy has significantly increased over the past decades, reaching different statistics to double, triple, or even overcome these numerical... (Review)
Review
The incidence of multiple pregnancy has significantly increased over the past decades, reaching different statistics to double, triple, or even overcome these numerical orders globally. Zygosity and chorionicity are the key elements in the multiple pregnancy but the placentation issue should be correlated primarily with zygosity, unlike chorionicity that should be correlated with the outcome and complications of multifetal gestation. Multiple pregnancy is by itself a special maternal-fetal condition, and the monochorionic one, moreover, due to specific complications. These aspects make early assessment of chorionicity and amnionicity a priority. Ultrasound is essential in pregnancy but pathological placental examination after delivery is complementary, in order to have a complete overview of potential mechanisms and pathogenesis affecting twin gestation. In this review, we highlight both ultrasound aspects specific to multifetal placentation, complemented by macro and microscopic morphological aspects, which underpin the obstetric imaging.
Topics: Female; Humans; Placentation; Pregnancy; Pregnancy, Multiple; Ultrasonography, Prenatal
PubMed: 30173248
DOI: No ID Found -
Fertility and Sterility Oct 2020The health of children born through assisted reproductive technologies (ART) is particularly vulnerable to policy decisions and market forces that play out before they... (Review)
Review
The health of children born through assisted reproductive technologies (ART) is particularly vulnerable to policy decisions and market forces that play out before they are even conceived. ART treatment is costly, and public and third-party funding varies significantly between and within countries, leading to considerable variation in consumer affordability globally. These relative cost differences affect not only who can afford to access ART treatment, but also how ART is practiced in terms of embryo transfer practices, with less affordable treatment creating a financial incentive to transfer more than one embryo to maximize the pregnancy rates in fewer cycles. One mechanism for reducing the burden of excessive multiple pregnancies is to link insurance coverage to the number of embryos that can be transferred; another is to combine supportive funding with patient and clinician education and public reporting that emphasizes a "complete" ART cycle (all embryo transfers associated with an egg retrieval) and penalizes multiple embryo transfers. Improving funding for fertility services in a way that respects clinician and patient autonomy and allows patients to undertake a sufficient number of cycles to minimize moral hazard improves outcomes for mothers and babies while reducing the long-term economic burden associated with fertility treatments.
Topics: Female; Financial Management; Humans; Motivation; Pregnancy; Pregnancy, Multiple; Public Health; Public Reporting of Healthcare Data; Reproductive Techniques, Assisted; Single Embryo Transfer
PubMed: 33040980
DOI: 10.1016/j.fertnstert.2020.08.1405 -
BMC Pregnancy and Childbirth Dec 2023Multiple pregnancies carry an increased risk of maternal and perinatal complications, notably prematurity. Few studies have evaluated the risk factors for preterm births... (Review)
Review
OBJECTIVE
Multiple pregnancies carry an increased risk of maternal and perinatal complications, notably prematurity. Few studies have evaluated the risk factors for preterm births in multiple pregnancies within the Thai population. This study aims to ascertain maternal and perinatal outcomes and identify factors linked to preterm births in multiple pregnancies.
METHODS
This study was carried out at Khon Kaen University, Faculty of Medicine, Department of Obstetrics and Gynecology in Thailand. We reviewed the medical records of women with multiple pregnancies who delivered at a gestational age of more than 20 weeks between January 1, 2012 and December 31, 2021. We excluded patients with incomplete data or those for whom data were missing.
RESULTS
Out of 21,400 pregnancies, 427 were multiple pregnancies, constituting approximately 1.99%. Over the ten-year period, 269 multiple pregnancies (65.1%) resulted in preterm births. Of these, 173 (64.3%) were monochorionic twins, and 96 (35.7%) were dichorionic twins. Monochorionic twins had a notably higher rate of preterm delivery (AOR, 2.06; 95%CI 1.29-3.30). Vaginal delivery was observed in 7.9% of the cases, while cesarean sections were performed for both twins in 91.5% of cases. In 0.5% of the cases, only the second twin was delivered by cesarean section. In terms of neonatal outcomes, 160 infants (19.4%) weighed less than 1,500 g at birth, and there were 78 perinatal deaths (9.4%). Birth asphyxia was noted in 97 cases (20.2%) among monochorionic twins and in 28 cases (8.1%) for dichorionic twins.
CONCLUSION
The prevalence of multiple pregnancies was 1.99%, with 65.1% resulting in preterm births. Neonatal complications were notably more frequent in monochorionic twins. Monochorionic placenta and antepartum complications emerged as significant risk factors for preterm birth.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Infant; Premature Birth; Pregnancy, Twin; Cesarean Section; Retrospective Studies; Thailand; Pregnancy, Multiple; Pregnancy Outcome
PubMed: 38110899
DOI: 10.1186/s12884-023-06186-0 -
Fertility and Sterility Oct 2020In the early years of in vitro fertilization, overall pregnancy rates were low, and it was considered necessary to transfer more than one embryo to increase the chances... (Review)
Review
In the early years of in vitro fertilization, overall pregnancy rates were low, and it was considered necessary to transfer more than one embryo to increase the chances of pregnancy. It was not until advances in assisted reproductive technologies resulting in increased pregnancy rates that the concept of transferring just one embryo was considered possible. A consequence of improvements in implantation rates was also an increase in multiple pregnancies when more than one embryo was transferred. Although some countries have reduced the number of embryos transferred, international data show that in many parts of the world high twin and higher order multiple pregnancy rates still exist. Even in developed countries these problems persist depending on clinical practice, funding of health services, and patient demands. Perinatal and other outcomes are significantly worse with twins compared with singleton pregnancies and there is an urgent need to reduce multiple pregnancy rates to at least 10%. This has been achieved in several countries and clinics by introducing single embryo transfer but there are many barriers to the introduction of this technique in most clinics worldwide. We discuss the background to the high multiple rate in assisted reproduction and the factors that contribute to its persistence even in excellent clinics and in high-quality health services. Practices that may promote single embryo transfer are discussed.
Topics: Female; Fertilization in Vitro; Global Health; Humans; Multiple Birth Offspring; Pregnancy; Pregnancy Rate; Pregnancy, Multiple; Reproductive Techniques, Assisted; Single Embryo Transfer
PubMed: 33010940
DOI: 10.1016/j.fertnstert.2020.09.003 -
The Cochrane Database of Systematic... Mar 2017Strict or partial bed rest in hospital or at home is commonly recommended for women with multiple pregnancy to improve pregnancy outcomes. In order to advise women to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Strict or partial bed rest in hospital or at home is commonly recommended for women with multiple pregnancy to improve pregnancy outcomes. In order to advise women to rest in bed for any length of time, a policy for clinical practice needs to be supported by reliable evidence and weighed against possible adverse effects resulting from prolonged activity restriction.
OBJECTIVES
The objective of this review is to assess the effectiveness of bed rest in hospital or at home to improve perinatal outcomes in women with a multiple pregnancy.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 May 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (30 May 2016) and reference lists of retrieved studies.
SELECTION CRITERIA
We selected all individual and cluster-randomised controlled trials evaluating the effect of strict or partial bed rest at home or in hospital compared with no activity restriction during multiple pregnancy.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trials for inclusion, extracted data and methodological quality. We evaluated the quality of the evidence using the GRADE approach and summarised it in 'Summary of findings' tables.
MAIN RESULTS
We included six trials, involving a total of 636 women with a twin or triplet pregnancy (total of 1298 babies). We assessed all of the included trials as having a low risk of bias for random sequence generation. Apart from one trial with an unclear risk of bias, we judged all remaining trials to be of low risk of bias for allocation concealment.Five trials (495 women and 1016 babies) compared strict bed rest in hospital with no activity restriction at home. There was no difference in the risk of very preterm birth (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.66 to 1.58, five trials, 495 women, assuming complete correlation between twins/triplets, low-quality evidence), perinatal mortality (RR 0.65, 95% CI 0.35 to 1.21, five trials, 1016 neonates, assuming independence between twins/triplets, low-quality evidence) and low birthweight (RR 0.95, 95% CI 0.75 to 1.21, three trials, 502 neonates, assuming independence between twins/triplets, low-quality evidence). We observed no differences for the risk of small-for-gestational age (SGA) (RR 0.75, 95% CI 0.56 to 1.01, two trials, 293 women, assuming independence between twins/triplets, low-quality evidence) and prelabour preterm rupture of the membrane (PPROM) (RR 1.30, 95% CI 0.71 to 2.38, three trials, 276 women, low-quality evidence). However, strict bed rest in hospital was associated with increased spontaneous onset of labour (RR 1.05, 95% CI 1.02 to 1.09, P = 0.004, four trials, 488 women) and a higher mean birthweight (mean difference (MD) 136.99 g, 95% CI 39.92 to 234.06, P = 0.006, three trials, 314 women) compared with no activity restriction at home.Only one trial (141 women and 282 babies) compared partial bed rest in hospital with no activity restriction at home. There was no evidence of a difference in the incidence of very preterm birth (RR 2.30, 95% CI 0.84 to 6.27, 141 women, assuming complete correlation between twins, low-quality evidence) and perinatal mortality (RR 4.17, 95% CI 0.90 to 19.31, 282 neonates, assuming complete independence twins, low-quality evidence) between the intervention and control group. Low birthweight was not reported in this trial. We found no differences in the risk of PPROM and SGA between women receiving partial bed rest and the control group (low-quality evidence). Women on partial bed rest in hospital were less likely to develop gestational hypertension compared with women without activity restriction at home (RR 0.30, 95% CI 0.16 to 0.59, P = 0.0004, 141 women).Strict or partial bed rest in hospital was found to have no impact on other secondary outcomes. None of the trials reported on costs of the intervention or adverse effects such as the development of venous thromboembolism or psychosocial effects.
AUTHORS' CONCLUSIONS
The evidence to date is insufficient to inform a policy of routine bed rest in hospital or at home for women with a multiple pregnancy. There is a need for large-scale, multicenter randomised controlled trials to evaluate the benefits, adverse effects and costs of bed rest before definitive conclusions can be drawn.
Topics: Activities of Daily Living; Bed Rest; Birth Weight; Female; Fetal Membranes, Premature Rupture; Hospitalization; Humans; Infant, Newborn; Infant, Small for Gestational Age; Perinatal Mortality; Pregnancy; Pregnancy Outcome; Pregnancy, Multiple; Pregnancy, Triplet; Pregnancy, Twin; Randomized Controlled Trials as Topic
PubMed: 28262917
DOI: 10.1002/14651858.CD012031.pub2 -
Taiwanese Journal of Obstetrics &... Sep 2022To decrease multiple pregnancy risk and sustain optimal pregnancy chance by choosing suitable number of embryos during transfer, this study aims to construct artificial...
OBJECTIVE
To decrease multiple pregnancy risk and sustain optimal pregnancy chance by choosing suitable number of embryos during transfer, this study aims to construct artificial intelligence models to predict the pregnancy outcome and multiple pregnancy risk after IVF-ET.
MATERIALS AND METHODS
From Jan 2010 to Dec 2019, 1507 fresh embryo transfer cycles contained 20 features were obtained. After eliminating incomplete records, 949 treatment cycles were included in the pregnancy model dataset and 380 cycles in the twin pregnancy model dataset. Six machine learning algorithms were used for model building based on the dataset which 70% of the dataset were randomly selected for training and 30% for validation. Model performances were quantified with the area under the receiver operating characteristic curve (AUC), accuracy, specificity, and sensitivity.
RESULTS
Models built with XGBoost performed best. The pregnancy prediction model produced accuracy of 0.716, sensitivity of 0.711, specificity of 0.719, and AUC of 0.787. The multiple pregnancy prediction model produced accuracy of 0.711, sensitivity of 0.649, specificity of 0.740, and AUC of 0.732.
CONCLUSIONS
The AI models provide reliable outcome prediction and could be a promising method to decrease multiple pregnancy risk after IVF-ET.
Topics: Artificial Intelligence; Embryo Transfer; Female; Fertilization in Vitro; Humans; Pregnancy; Pregnancy Outcome; Pregnancy, Multiple
PubMed: 36088053
DOI: 10.1016/j.tjog.2021.11.038 -
Nutrients Jun 2023Data regarding the nutritional management of preterm small for gestational age (SGA) infants are scarce. In the recent report of ESPGHAN, the recommended energy for very... (Review)
Review
Data regarding the nutritional management of preterm small for gestational age (SGA) infants are scarce. In the recent report of ESPGHAN, the recommended energy for very preterm infants during hospitalization has been increased, yet this may not fit the needs of all preterm infants. It is important to distinguish fetal growth-restricted (FGR) infants from constitutional SGA infants, as well as preterm SGA from preterm AGA infants, since they may have different nutritional needs. Preterm FGR infants, and specifically infants < 29 weeks' gestation, accumulate nutrient deficits due to intrauterine malnutrition, prematurity, morbidities, delayed initiation of feeding, and feeding intolerance. Therefore, these infants may need more aggressive nutrition for optimal catch-up growth and neurologic development. However, a balance should be kept between optimal and excessive catch-up growth, since the combination of intrauterine malnutrition and excessive postnatal growth has been linked with later adverse metabolic consequences. Furthermore, multiple gestation is often complicated by FGR and prematurity. There is controversy in the definition of FGR in multiple gestations, and it should be noted that FGR in multiple gestation usually differs etiologically from FGR in singletons. The aim of this review is to summarize existing knowledge regarding the nutritional needs of preterm FGR and FGR infants of multiple gestation.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Infant; Infant, Premature; Infant, Small for Gestational Age; Fetal Growth Retardation; Pregnancy, Multiple; Gestational Age; Malnutrition
PubMed: 37375640
DOI: 10.3390/nu15122736 -
The Cochrane Database of Systematic... Jul 2010Bed rest used to be widely advised for women with a multiple pregnancy. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Bed rest used to be widely advised for women with a multiple pregnancy.
OBJECTIVES
The objective was to assess the effect of bed rest in hospital for women with a multiple pregnancy for prevention of preterm birth and other fetal, neonatal and maternal outcomes.
SEARCH STRATEGY
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2010).
SELECTION CRITERIA
Randomised trials which compare outcomes in women with a multiple pregnancy and their babies who were offered bed rest in hospital with women only admitted to hospital if complications occurred.
DATA COLLECTION AND ANALYSIS
The review authors carried out assessment for inclusion and risk of bias of the trials. We extracted and double entered data, and used a random-effects model.
MAIN RESULTS
We included seven trials which involved 713 women and 1452 babies. Routine bed rest in hospital for multiple pregnancy did not reduce the risk of preterm birth, or perinatal mortality. There was substantial heterogeneity related to perinatal death and stillbirth unaccounted for by trial quality. There was a suggestion of a decreased number of low birthweight infants (less than 2500 g) born to women in the routinely hospitalised group (risk ratio (RR) 0.92; 95% confidence interval (CI) 0.85 to 1.00). No differences were seen in the number of very low birthweight infants (less than 1500 g). No support for the policy was found for other neonatal outcomes. No information is available on developmental outcomes for infants in any of the trials.For the secondary maternal outcomes reported of developing hypertension and caesarean delivery, no differences were seen. Women's views about the care they received were reported rarely.In the subgroup analyses for women with an uncomplicated twin pregnancy, with cervical dilation prior to labour with a twin pregnancy and with a triplet pregnancy, no differences were seen in any primary and secondary neonatal outcomes and maternal outcomes.
AUTHORS' CONCLUSIONS
There is currently not enough evidence to support a policy of routine hospitalisation for bed rest in multiple pregnancy. No reduction in the risk of preterm birth or perinatal death is evident, although there is a suggestion that fetal growth may be improved. For women with an uncomplicated twin pregnancy the results of this review show no benefit from routine hospitalisation for bed rest. Until further evidence is available, the policy cannot be recommended for routine clinical practice.
Topics: Bed Rest; Female; Hospitalization; Humans; Perinatal Mortality; Pregnancy; Pregnancy Outcome; Pregnancy, Multiple; Premature Birth; Randomized Controlled Trials as Topic
PubMed: 20614420
DOI: 10.1002/14651858.CD000110.pub2