Fertility and Pregnancy in Turner Syndrome.

Turner syndrome (TS) occurs in one in 2500 live female births and is one of the most common chromosomal abnormalities in women. Pregnancies in women with TS, conceived with either autologous or donated oocytes, are considered high risk because of the associated miscarriages and life-threatening cardiovascular complications (aortic dissection, severe hypertension). Therefore, it is imperative to conduct a full preconception evaluation and counselling that includes cardiac assessment with Holter blood pressure monitoring, echocardiography, and thoracic MRI. Abnormal findings, such an aortic dilatation, mandate close monitoring throughout the pregnancy and the immediate postpartum period and could possibly contraindicate pregnancy. When in vitro fertilization using donated oocytes is performed in these women, only a single embryo should be transferred. Women with a Turner mosaic karyotype appear to have a lower risk of obstetrical and cardiovascular complications but should nevertheless undergo the full preconception evaluation. In this article, we offer guidelines on the management of women with TS in the preconception period, during pregnancy, and postpartum.

Predicting preterm birth in twin pregnancy: was the previous birth preterm? A Canadian experience.

OBJECTIVE: Most studies determining risk of preterm birth in a twin pregnancy subsequent to a previous preterm birth are based on linkage studies or small sample size. We wished to identify recurrent risk factors in a cohort of mothers with a twin pregnancy, eliminating all known confounders. METHODS: We conducted a retrospective cohort study of twin births at a tertiary care centre in Montreal, Quebec, between 1994 and 2008, extracting information, including chorionicity, from patient charts. To avoid the effect of confounding factors, we included only women with a preceding singleton pregnancy and excluded twin-to-twin transfusion syndrome, fetal chromosomal/structural anomalies, fetal demise, and preterm iatrogenic delivery for reasons not encountered in both pregnancies. We used multiple regression and sensitivity analyses to determine recurrent risk factors. RESULTS: Of 1474 twin pregnancies, 576 met the inclusion criteria. Of these, 309 (53.6%) delivered before 37 weeks. Preterm birth in twins was strongly associated with preterm birth of the preceding singleton (adjusted OR 3.23; 95% CI 1.75 to 5.98). The only other risk factors were monochorionic twins (adjusted OR 1.82; 95% CI 1.21 to 2.73) and oldest or youngest maternal ages. Chronic or gestational hypertension, preeclampsia, and insulin-dependent diabetes during the singleton pregnancy did not significantly affect risk. CONCLUSION: Preterm birth in a previous singleton pregnancy was confirmed as an independent risk factor for preterm birth in a subsequent twin pregnancy. This three-fold increase in risk remained stable regardless of year of birth, inclusion/exclusion of pregnancies following assisted reproduction, or defining preterm birth as < 34 or < 37 weeks' gestational age. Until the advent of optimal preventive strategies, close obstetric surveillance of twin pregnancies is warranted.

Objectif : La plupart des études qui cherchent à déterminer le risque d'accouchement préterme dans le cadre d'une grossesse gémellaire se déroulant à la suite d'un accouchement préterme sont fondées sur des études de liaison ou des échantillons de faible envergure. Nous souhaitions identifier les facteurs de risque récurrents au sein d'une cohorte de mères connaissant une grossesse gémellaire, en éliminant toutes les variables de confusion connues. Méthodes : Nous avons mené une étude de cohorte rétrospective qui portait sur les grossesses gémellaires ayant donné lieu à un accouchement au sein d'un centre de soins tertiaires de Montréal, au Québec, entre 1994 et 2008; nous avons extrait les données requises (dont la chorionicité) des dossiers des patientes. Pour éviter l'effet des facteurs de confusion, nous n'avons inclus que des femmes ayant déjà connu une grossesse monofœtale et avons exclu les cas de syndrome transfuseur-transfusé, d'anomalies chromosomiques / structurelles fœtales, de décès fœtal et d'accouchement préterme iatrogène pour des motifs n'ayant pas été constatés au cours des deux grossesses. Nous avons fait appel à des analyses de régression multiple et de sensibilité pour déterminer les facteurs de risque récurrents. Résultats : Parmi les 1 474 grossesses gémellaires recensées, 576 ont satisfait aux critères d'inclusion. Parmi celles-ci, 309 (53,6 %) accouchements ont eu lieu avant 37 semaines. L'accouchement préterme dans le cadre d'une grossesse gémellaire à été fortement associé au fait d'avoir connu un accouchement préterme dans le cadre de la grossesse monofœtale précédente (RC corrigé, 3,23; IC à 95 %, 1,75 - 5,98). Les seuls autres facteurs de risque ont été les jumeaux monozygotes (RC corrigé, 1,82; IC à 95 %, 1,21 - 2,73) et les âges maternels les plus vieux ou les plus jeunes. La présence d'une hypertension chronique ou gestationnelle, d'une prééclampsie et d'un diabète insulino-dépendant au cours de la grossesse monofœtale n'a pas exercé un effet significatif sur le risque. Conclusion : Le fait d'avoir connu un accouchement préterme dans le cadre d'une grossesse monofœtale précédente a été confirmé comme étant un facteur de risque indépendant d'accouchement préterme dans le cadre d'une grossesse gémellaire subséquente. Ce triplement du risque est demeuré stable, peu importe l'année de naissance, l'inclusion / exclusion des grossesses attribuables à la procréation assistée ou la définition de l'accouchement préterme comme étant < 34 ou < 37 semaines de gestation. Jusqu'à ce que des stratégies de prévention optimales soient mises au point, la mise en œuvre d'une étroite surveillance obstétricale s'avère justifiée dans les cas de grossesse gémellaire.

Duration of Expulsive Efforts and Risk of Postpartum Hemorrhage in Nulliparous Women: A Population-Based Study.

OBJECTIVE: To assess the specific association between the duration of expulsive efforts and the risk of postpartum hemorrhage. METHODS: Population-based cohort-nested case-control study of nulliparous women delivering vaginally in 106 French maternity units between December 2004 and November 2006, including 3,852 women with PPH (blood loss ≥ 500 mL and/or peripartum Hb decrease ≥ 2 g/dL), 1,048 of them severe (peripartum Hb decrease ≥ 4 g/dL or transfusion of ≥ 2 units of red blood cells), and 762 controls from a representative sample of deliveries without hemorrhage in the same population. The association between duration of expulsive efforts and postpartum hemorrhage was estimated by multilevel logistic regression models adjusted for individual and hospital characteristics. RESULTS: Median duration of expulsive efforts was 18 minutes among controls, 20 minutes among postpartum hemorrhage and 23 minutes among severe postpartum hemorrhage (p<0.01). Duration of expulsive efforts was significantly, positively, and linearly associated with both postpartum hemorrhage and severe postpartum hemorrhage. After adjustment for other risk factors, every additional 10 minutes of expulsive efforts was associated with about a 10% increase in the risk of postpartum hemorrhage (aOR = 1.11 [1.02-1.21]) and severe postpartum hemorrhage (aOR = 1.14 [1.03-1.27]). Oxytocin during labor, duration of active phase of labor, forceps use, episiotomy, perineal tears, and birth weight were also independently associated with both risks. CONCLUSION: Duration of expulsive efforts was independently associated with postpartum hemorrhage and severe postpartum hemorrhage. Interventions to shorten the duration of this stage, such as oxytocin, forceps, and episiotomy, are also associated with higher risks of postpartum hemorrhage. Beyond duration, other aspects of the management of active second stage should be evaluated as some might allow it to last longer with a minimal increase in postpartum hemorrhage risk.

Placental growth factor for the prediction of adverse outcomes in patients with suspected preeclampsia or intrauterine growth restriction.

BACKGROUND: The circulating concentration of PlGF is reported to be lower in patients experiencing preeclampsia and patients delivering a small for gestational age (SGA) neonate. To evaluate the predictive value of circulating PlGF for preeclampsia and adverse outcome in patients with suspected preeclampsia or intrauterine growth restriction (IUGR). METHODOLOGY/PRINCIPAL FINDINGS: A double blind prospective study. We enrolled 96 women for suspected preeclampsia or IUGR, and measured plasma levels of PlGF (Triage®) at enrolment. We defined adverse outcome as severe preeclampsia, SGA neonate (<10(th) centile) or elective delivery for maternal or fetal complication. Severe adverse outcome was studied among patients included <34 weeks gestation (WG) and defined as eclampsia, HELLP syndrome, very SGA (<3(rd) centile) or elective delivery <34 WG. The mean logtransformed PlGF level was lower for women who experienced preeclampsia (2.9 vs 3.7, p = 0.02), and was markedly lower for patients who experienced adverse outcome (2.9 vs 4.3, p<0.001). The odds of presenting an adverse outcome were higher for the lowest tertile of PlGF compared to the higher (OR = 13 , 95% CI [3-50]). For severe adverse outcome, odds were respectively for the lowest and intermediate tertile as compared with the higher tertile : OR = 216, 95% CI [18-2571]; and OR = 17, 95% CI [3-94]. When included <34 WG, patients with a PlGF level <12 pg/ml experienced a severe adverse outcome in 96% of cases (24/25), and only 1 of 20 patients with a PlGF level >5(th) centile experienced a severe adverse outcome within 15 days (5%). CONCLUSIONS/SIGNIFICANCE: Among women with suspected preeclampsia or IUGR, PlGF helps identify women who will experience an adverse outcome and those who will not within a time period of 15 days.