Enabling Adherence to Treatment (EAT): a pilot study of a combination intervention to improve HIV treatment outcomes among street-connected individuals in western Kenya.

BACKGROUND: Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya. METHODS: This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants' engagement in EAT and HIV treatment outcomes. We used McNemar's chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p < 0.05. We calculated total, fixed, and variable costs of the intervention. RESULTS: Between July 2018 and February 2020, EAT enrolled 87 participants: 46 (53%) female and 75 (86%) living with HIV. At baseline, 60 out of 75 participants living with HIV (80%) had previously enrolled in HIV care. Out of 60, 56 (93%) had initiated ART, 44 (73%) were active in care, and 25 (42%) were virally suppressed (VL < 1000 copies/mL) at their last VL measure in the 19 months before EAT. After 19 months of follow-up, all 75 participants living with HIV had enrolled in HIV care and initiated ART, 65 (87%) were active in care, and 44 (59%) were virally suppressed at their last VL measure. Among the participants who were enrolled in HIV care before EAT, there was a significant increase in the proportion who were active in HIV care and virally suppressed at their last VL measure during EAT enrollment compared to before EAT enrollment. Participants who enrolled in HIV care concurrently with EAT had a significantly shorter time to initiation of ART and first episode of viral suppression compared to participants who enrolled in HIV care prior to EAT. The total cost of the intervention over 19 months was USD $57,448.64. Fixed costs were USD $3623.04 and variable costs were USD $63.75/month/participant. CONCLUSIONS: This pilot study provided proof of concept that EAT, a combination intervention providing mDOT, food, and peer navigation services, was feasible to implement and may support engagement in HIV care and achievement of viral suppression among SCI living with HIV in an urban setting in Kenya. Future work should focus on controlled trials of EAT, assessments of feasibility in other contexts, and cost-effectiveness studies.

Acceptability and feasibility of community-based provision of urine pregnancy tests to support linkages to reproductive health services in Western Kenya: a qualitative analysis.

BACKGROUND: The majority of women living in rural Kenya access antenatal care (ANC) late in pregnancy, and approximately 20% have an unmet need for family planning (FP). This study aimed to determine whether training community health volunteers (CHVs) to deliver urine pregnancy testing (UPT), post-test counselling, and referral to care was an acceptable and feasible intervention to support timely initiation of ANC and uptake of FP. METHODS: We applied community-based participatory methods to design and implement the pilot intervention between July 2018 and May 2019. We conducted qualitative content analysis of 12 pre-intervention focus group discussions (FGDs) with women, men, and CHVs, and of 4 post-intervention FGDs with CHVs, each with 7-9 participants per FGD group. Using a pragmatic approach, we conducted inductive line-by-line coding to generate themes and subthemes describing factors that positively or negatively contributed to the intervention's acceptability and feasibility, in terms of participants' views and the intervention aims. RESULTS: We found that CHV-delivered point of care UPT, post-test counselling, and referral to care was an acceptable and feasible intervention to increase uptake of ANC, FP, and other reproductive healthcare services. Factors that contributed to acceptability were: (1) CHV-delivery made UPT more accessible; (2) UPT and counselling supported women and men to build knowledge and make informed choices, although not necessarily for women with unwanted pregnancies interested in abortion; (3) CHVs were generally trusted to provide counselling, and alternative counselling providers were available according to participant preference. A factor that enhanced the feasibility of CHV delivering UPT and counselling was CHV's access to appropriate supplies (e.g. carrying bags). However, factors that detracted from the feasibility of women actually accessing referral services after UPT and counselling included (1) downstream barriers like cost of travel, and (2) some male community members' negative attitudes toward FP. Finally, improved financial, educational, and professional supports for CHVs would be needed to make the intervention acceptable and feasible in the long-term. CONCLUSION: Training CHVs in rural western Kenya to deliver UPT, post-test counselling, and referral to care was acceptable and feasible to men, women, and CHVs in this context, and may promote early initiation of ANC and uptake of FP. Additional qualitative work is needed to explore implementation challenges, including issues related to unwanted pregnancies and abortion, the financial burden of volunteerism on CHVs, and educational and professional supports for CHVs.

The opioid crisis is driving mortality among under-served people living with HIV in British Columbia, Canada.

INTRODUCTION: Universal provision of effective antiretroviral medication has been essential to reduce mortality, increase longevity, and reduce onward transmission of HIV. This study aims to illuminate persistent threats to the health and longevity of under-served PLWH in British Columbia (BC), Canada. METHODS: Between 2007 and 2010, 1000 PLWH across BC were enrolled in the Longitudinal Investigation into Supportive and Ancillary health services (LISA) study and completed a cross-sectional survey on their HIV-care experiences and healthcare engagement. The sample generally reflects an under-served population of PLWH. A linkage to the provincial Vital Statistics registry is used in this analysis in order to examine overall mortality and cause-specific mortality trends; probability of death was modeled using logistic regression for participants with ongoing clinical monitoring (n = 910). RESULTS: By June 2017, 208 (20.8%) participants had died. The majority of deaths 57 (27.4%) were attributed to drug-related complications or overdoses, 39 (18.8%) were attributed to HIV-related complications, and 36 (17.3%) to non-AIDS-defining malignancies. We observed elevated odds of death among PLWH who smoked tobacco (aOR: 2.11, 95% CI: 1.38, 3.23), were older (aOR: 1.06 per one-year increase, 95% CI: 1.04, 1.08), indicated heavy alcohol consumption (aOR: 1.57, 95% CI: 1.11, 2.22), and reported unstable housing (aOR: 1.96, 95% CI: 1.37, 2.80); while higher CD4 cell count was protective (aOR: 0.87 per 100-unit increase, 95% CI: 0.79, 0.94) as was male gender), though non-significant (aOR: 0.73, 95% CI: 0.49, 1.07). CONCLUSIONS: Overdose is - the leading cause of mortality among a cohort of under-served PLWH in BC, Canada. Public health efforts to end the HIV epidemic and support the health and well-being of PLWH are being thwarted by persistent health inequities and the enormous and persistent risks facing people who use drugs. Integrated low-barrier primary care is essential for supporting under-served PLWH, and safe drug supply is needed to support PLWH who use drugs.

A Pilot Study of "Peer Navigators" to Promote Uptake of HIV Testing, Care and Treatment Among Street-Connected Children and Youth in Eldoret, Kenya.

Research suggests a burden of HIV among street-connected youth (SCY) in Kenya. We piloted the use of peer navigators (PNs), individuals of mixed HIV serostatus and with direct experience of being street-connected, to link SCY to HIV testing and care. From January 2015 to October 2017, PNs engaged 781 SCY (585 male, 196 female), median age 16 (IQR 13-20). At initial encounter, 52 (6.6%) were known HIV-positive and 647 (88.8%) agreed to HIV testing. Overall, 63/781 (8.1%) SCY engaged in this program were HIV-positive; 4.6% males and 18.4% females (p < 0.001). Of those HIV-positive, 48 (82.8%) initiated ART. As of October 2017, 35 (60.3%) of the HIV-positive SCY were alive and in care. The pilot suggests that PNs were successful in promoting HIV testing, linkage to care and ART initiation. More research is needed to evaluate how to improve ART adherence, viral suppression and retention in care in this population.

Does gestational diabetes affect fetal growth and pregnancy outcome in twin pregnancies?

BACKGROUND: Women with twin pregnancies are at increased risk for fetal growth restriction, which might be attributed to the limited maternal resources that are being shared by >1 fetus. Based on that, it may be hypothesized that the fetal effects of gestational diabetes mellitus (GDM) with respect to accelerated fetal growth may be less pronounced in twin gestations or alternatively may even have a beneficial role in decreasing the risk of fetal growth restriction in these pregnancies. However, available data are conflicting and are limited by the fact that many of the complications associated with GDM are less relevant for twin gestations, and that all women with GDM included in previous studies were monitored and treated to control maternal blood glucose levels. OBJECTIVE: We sought to assess the impact of GDM and milder degrees of glucose intolerance on fetal growth and pregnancy outcome in twin pregnancies. STUDY DESIGN: This was a retrospective cohort study of all women with twin pregnancies who underwent screening for GDM in a single tertiary referral center from October 2003 through December 2014. The diagnosis of GDM during the study period was based on the 2008 Canadian Diabetes Association (CDA) guidelines, which involve universal screening with a 50-g glucose challenge test (GCT) followed by a diagnostic 2-hour 75-g oral glucose tolerance test (OGTT). Fetal growth and pregnancy outcome were compared among 4 groups of women with increasing degree of glucose intolerance: (1) GCT-NEGATIVE, negative 50-g GCT; (2) OGTT-NEGATIVE, positive 50-g GCT followed by a negative 75-g OGTT; (3) GDM-IADPSG, positive 50-g GCT followed by a positive 75-g OGTT according to the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria but not the 2008 CDA criteria-because these women were not considered to have GDM during the study period they were not subjected to any form of treatment; and (4) GDM-CDA, positive 50-g GCT followed by a positive 75-g OGTT according to the 2008 CDA criteria. RESULTS: Overall 1393 women were eligible for the study: 1021 (73.3%) in the GCT-NEGATIVE group, 184 (13.2%) in the OGTT-NEGATIVE group, 99 (7.1%) in the GDM-IADPSG group, and 89 (6.4%) in the GDM-CDA group. There was a continuous relationship between the degree of glucose intolerance and fetal growth as reflected by a right shift of the distribution curve of birthweight percentiles and a greater likelihood of high birthweight percentile: OGTT-NEGATIVE = odds ratio (OR), 1.5; 95% confidence interval (CI), 1.07-2.2; GDM-IADPSG = OR, 1.7; 95% CI, 1.1-2.6; and GDM-CDA = OR, 1.9, 95% CI, 1.3-3.1 (using the GCT-NEGATIVE group as reference). Fetuses of women with glucose intolerance were more likely to experience asymmetric growth as reflected by an elevated abdominal circumference to head circumference ratio. CONCLUSION: GDM and milder degrees of glucose intolerance in twin pregnancies are associated with an increased risk of asymmetric overgrowth in a manner that is related to the degree of glucose intolerance.

Standardized mortality ratios between street-connected young people and the general age-equivalent population in an urban setting in Kenya from 2010 to 2015.

There are currently no published estimates of mortality rates among street-connected young people in Kenya. In this short report, we estimate mortality rates among street-connected young people in an urban setting in Kenya and calculate standardized mortality ratios to assess excess mortality among street-connected young people compared to the general population of Kenyan adolescents. We collected data on deaths among street-connected young people aged 0-29 between 2010 and 2015. We calculated sex-stratified standardized mortality ratios for street-connected young people aged 0-19 and 20-29 from 2010 to 2015, using publicly available Kenya population data as reference. We found that between 2010 and 2015, there were 69 deaths among street-connected young people aged 0 to 29 years in 2013 was 1,248: 341 females (27%) and 907 males (73%). The standardized mortality ratios among street-connected females aged 0-19 and 20-29 years were 2.79 (95% CI 1.44-4.88) and 7.55 (95% CI 3.77-13.51), respectively; standardized mortality ratios among street-connected males aged 0-19 and 20-29 years were 0.71 (95% CI 0.32-1.35) and 5.48 (95% CI 3.86-7.55), respectively. In conclusion, we found that mortality among street-connected young people in an urban setting in Kenya is elevated compared to the general population of Kenyan young people. States should act urgently and take responsibility for protecting street-connected young people's human rights by scaling up programs to prevent morbidity and death associated with youth street involvement.

Severe intimate partner violence is associated with all-cause mortality among women living with HIV.

OBJECTIVE: To examine the independent association between intimate partner violence (IPV) severity and all-cause mortality among women living with HIV (WLHIV). DESIGN: Cross-sectional questionnaire linked to longitudinal vital statistics data. METHODS: We examined the lifetime prevalence of IPV and age-standardized all-cause mortality rates by IPV severity reported by WLHIV. Lifetime IPV (emotional/verbal, physical, or sexual) severity was assessed as a categorical variable: no history of any IPV (none); experienced one or two forms of IPV (moderate); or experienced all three forms of IPV (severe IPV). Two separate logistic regression models examined associations between any IPV (vs. none) as well as IPV severity (none vs. moderate, severe) and all-cause mortality. RESULTS: At the time of interview (2007-2010), 260 participants self-identified as women with a median (Q1-Q3) age of 41 years (35-46). Of these women, the majority were unemployed (85%), 59% reported any IPV and 24% reported severe IPV. Of the 252 women followed until 31 December 2017, 25% (n = 63) died. Age-standardized all-cause mortality rates for WLHIV who experienced severe IPV were two-times higher than women with no history of IPV (44.7 per 1000 woman-years vs. 20.9 per 1000 woman-years). After adjustment for confounding, experiences of severe IPV (vs. none) were significantly associated with all-cause mortality (aOR = 2.42, 95% CI = 1.03-5.70). CONCLUSION: Although we found that any lifetime experience of IPV was not associated with all-cause mortality, women ever experiencing severe IPV were significantly more likely to die during the study period. This may suggest a need for increased trauma- and violence-aware approaches.

Acceptability of a Pilot Intervention of Voluntary Medical Male Circumcision and HIV Education for Street-Connected Youth in Western Kenya.

PURPOSE: Street-connected youth (SCY) in Kenya and elsewhere in sub-Saharan Africa are at high risk of HIV. Voluntary Male Medical Circumcision (VMMC) reduces the risk of female-to-male HIV transmission. Circumcision is also a traditional coming-of-age process in many Kenyan ethnic groups. This paper describes the acceptability of VMMC delivered as part of a ten-day healing, educational, and 'coming-of-age' retreat implemented as a pilot with SCY. METHODS: Male SCY aged between 12 and 24 living on the street for more than 3 months were eligible to participate. The study took place over 10 days. After medical circumcision, youth participated in education modules. Data collected included qualitative semi-structured exit interviews featuring structured and open-ended questions about factors relevant to this intervention's acceptability. RESULTS: There were 116 SCY (median age 14, IQR 13-15) who participated in the study. All were circumcised successfully, with no major complications. The majority of participants (81%) agreed that the circumcision procedure was uncomplicated, and 99% agreed the education was an important part of the initiation process. Thematic analysis of interview data highlighted four factors important to the program's acceptability: providing food, shelter, security; providing a safe place to heal; including traditional elements; and being with peers. CONCLUSIONS: This novel implementation of VMMC was found to be acceptable to SCY participants and could likely be adapted and scaled for HIV prevention and education with SCY elsewhere in Kenya and sub-Saharan Africa where circumcision is part of traditional coming-of-age processes.

Physicians' patient base composition and mortality among people living with HIV who initiated antiretroviral therapy in a universal care setting.

OBJECTIVES: To assess the impact of physicians' patient base composition on all-cause mortality among people living with HIV (PLHIV) who initiated highly active antiretroviral therapy (HAART) in British Columbia (BC), Canada. DESIGN: Observational cohort study from 1 January 2000 to 31 December 2013. SETTING: BC Centre for Excellence in HIV/AIDS' (BC-CfE) Drug Treatment Program, where HAART is available at no cost. PARTICIPANTS: PLHIV aged ≥ 19 who initiated HAART in BC in the HAART Observational Medical Evaluation and Research (HOMER) Study. OUTCOME MEASURES: All-cause mortality as determined through monthly linkages to the BC Vital Statistics Agency. STATISTICAL ANALYSIS: We examined the relationships between patient characteristics, physicians' patient base composition, the location of the practice, and physicians' experience with PLHIV and all-cause mortality using unadjusted and adjusted Cox proportional hazards models. RESULTS: A total of 4 445 PLHIV (median age = 42, Q1, Q3 = 34-49; 80% male) were eligible for our study. Patients were seen by 683 prescribing physicians with a median experience of 77 previously treated PLHIV in the past 2 years (Q1, Q3 = 23-170). A multivariable Cox model indicated that the following factors were associated with all-cause mortality: age (aHR = 1.05 per 1-year increase, 95% CI = 1.04 to 1.06), year of HAART initiation (2004-2007: aHR = 0.65, 95% CI = 0.53 to 0.81, 2008-2011: aHR = 0.46, 95% CI = 0.35 to 0.61, Ref: 2000-2003), CD4 cell count at baseline (aHR = 0.88 per 100-unit increase in cells/mm3, 95% CI = 0.82 to 0.94), and < 95% adherence in first year on HAART (aHR = 2.28, 95% CI = 1.88 to 2.76). In addition, physicians' patient base composition, specifically, the proportion of patients who have a history of injection drug use (aHR = 1.11 per 10% increase in the proportion of patients, 95% CI = 1.07 to 1.15) or Indigenous ancestry (aHR = 1.07 per 10% increase , 95% CI = 1.03-1.11) and being a patient of a physician who primarily serves individuals outside of the Vancouver Coastal Health Authority region (aHR = 1.22, 95% CI = 1.01 to 1.47) were associated with mortality. CONCLUSIONS: Our findings suggest that physicians with a higher proportion of individuals who face potential barriers to care may need additional supports to decrease mortality among their patients. Future research is required to examine these relationships in other settings and to determine strategies that may mitigate the associations between the composition of physicians' patient bases and survival.

HIV, schizophrenia, and all-cause mortality: A population-based cohort study of individuals accessing universal medical care from 1998 to 2012 in British Columbia, Canada.

Schizophrenia is a severe mental illness with important implications for morbidity and mortality. This population-based cohort study examined the impact of schizophrenia diagnoses on all-cause mortality among a sample of people living with HIV (PLHIV) and a 10% random sample of individuals living without HIV (HIV-) in British Columbia (BC), through a data linkage between the BC Centre for Excellence in HIV/AIDS and Population Data BC's data holdings. Schizophrenia diagnoses were identified via International Classification of Diseases version 9 and version 10 codes. Age- and sex-adjusted all-cause mortality rates from January 1st, 1998 to December 31st, 2012 were calculated. Multivariable logistic models assessed (1) HIV status and mortality among individuals diagnosed with schizophrenia, (2) schizophrenia diagnosis and mortality among PLHIV, and (3) correlates of mortality among PLHIV concurrently diagnosed with schizophrenia (HIV+/SZO+). From 1998 to 2012, 6.3% of those with HIV had a schizophrenia diagnosis, compared to 1.1% of those without HIV. While significant declines in mortality rates were observed throughout the study period, mortality rates were highest among HIV+/SZO+. After adjustment for substance use disorder and age at baseline, HIV+/SZO+ had a 2.64 times greater odds of mortality (95% confidence interval [CI] = 2.14-3.25) compared to HIV-/SZO+. For PLHIV, a schizophrenia diagnosis was not associated with mortality after controlling for potential confounders (adjusted odds ratio [aOR] = 0.90, 95%CI = 0.74-1.09). Among HIV+/SZO+, age, history of injection drug use, ever having an AIDS-defining illness, and never being on anti-psychotic medication or accessing psychiatric services were associated with mortality. Efforts should be made to identify and link to care individuals disproportionately affected by schizophrenia and excess mortality, including those living with HIV.

Reconciling ethical and economic conceptions of value in health policy using the capabilities approach: A qualitative investigation of Non-Invasive Prenatal Testing.

When evaluating new morally complex health technologies, policy decision-makers consider a broad range of different evaluations, which may include the technology's clinical effectiveness, cost effectiveness, and social or ethical implications. This type of holistic assessment is challenging, because each of these evaluations may be grounded in different and potentially contradictory assumptions about the technology's value. One such technology where evaluations conflict is Non-Invasive Prenatal Testing (NIPT). Cost-effectiveness evaluations of NIPT often assess NIPT's ability to deliver on goals (i.e preventing the birth of children with disabilities) that social and ethical analyses suggest it should not have. Thus, cost effectiveness analyses frequently contradict social and ethical assessments of NIPT's value. We use the case of NIPT to explore how economic evaluations using a capabilities approach may be able to capture a broader, more ethical view of the value of NIPT. The capabilities approach is an evaluative framework which bases wellbeing assessments on a person's abilities, rather than their expressed preferences. It is linked to extra-welfarist approaches in health economic assessment. Beginning with Nussbaum's capability framework, we conducted a directed qualitative content analysis of interview data collected in 2014 from 27 Canadian women with personal experience of NIPT. We found that eight of Nussbaum's ten capabilities related to options, states, or choices that women valued in the context of NIPT, and identified one new capability. Our findings suggest that women value NIPT for its ability to provide more and different choices in the prenatal care pathway, and that a capabilities approach can indeed capture the value of NIPT in a way that goes beyond measuring health outcomes of ambiguous social and ethical value. More broadly, the capabilities approach may serve to resolve contradictions between ethical and economic evaluations of health technologies, and contribute to extra-welfarist approaches in the assessment of morally complex health technologies.

The natural history of preterm premature rupture of membranes in twin pregnancies.

OBJECTIVE: To compare the characteristics of preterm premature rupture of membranes (PPROM) between twin and singleton pregnancies. METHODS: This was a retrospective study of all women with twin and singleton pregnancies admitted with PPROM between 24-34 weeks of gestation. RESULTS: Overall 698 women with PPROM were eligible for the study: 101 (14.5%) twins and 597 (85.5%) singletons. Twins presented with PPROM at a more advanced gestational age compared with singletons (29.1 ± 2.7 vs. 28.5 ± 2.8 weeks, p = 0.03). The latency period was shorter in twins compared with singletons, especially for women presenting after 28 weeks of gestation (5.0 ± 0.8 vs. 7.0 ± 0.4 days, p = 0.01). Women with twins were more likely to deliver within 48 h (OR: 2.7; 95%CI: 1.7-4.2) and were less likely to deliver within 2-7 days (OR: 0.5; 95%CI: 0.3-0.9) following PPROM. The rate of clinical chorioamnionitis or placental abruption following PPROM was lower in twins compared with singletons (15.8% vs. 26.0%, p = 0.03). CONCLUSIONS: PPROM in twin pregnancies tends to occur at a more advanced gestational age, is associated with a shorter latency period and is less likely to be complicated by chorioamnionitis or placental abruption compared with singletons. This information may be useful for counseling and management decisions in cases of PPROM in women with twins.

Neonatal Outcomes of Low-Risk, Late-Preterm Twins Compared With Late-Preterm Singletons.

OBJECTIVE: To test the hypothesis that the risk of neonatal morbidity among late-preterm twins is similar to that of late-preterm singletons. METHODS: We conducted a retrospective cohort study of all women with twin or singleton pregnancy who gave birth during the late-preterm period in a single tertiary center between 2008 and 2015. Neonatal outcomes of low-risk, late-preterm twins were compared with those of low-risk, late-preterm singletons. The primary outcome was the same primary composite respiratory morbidity variable that was used in the randomized controlled trial of Gyamfi-Bannerman et al on the administration of antenatal corticosteroids during the late-preterm period. RESULTS: A total of 922 singleton and 721 twin late-preterm neonates met the inclusion criteria. The rates of composite respiratory morbidity and severe composite respiratory morbidity were similar for twins and singletons (8.3% compared with 7.4%, P=.5 and 6.8% compared with 6.0%, P=.5, respectively), but were lower than the rates of the same composite respiratory morbidity variable in the randomized controlled study described previously. The odds for respiratory morbidity were similar for twins and singletons for both composite respiratory morbidity (adjusted odds ratio [OR] 0.73, 95% CI 0.48-1.12) and severe composite respiratory morbidity (adjusted OR 0.79, 95% CI 0.50-1.24). CONCLUSION: The risk of respiratory morbidity among late-preterm twins is similar to that of late-preterm singletons. Still, the low absolute rates of the composite respiratory morbidity in our population suggest that administration of antenatal corticosteroids may be mostly justified among neonates born closer to 34 weeks of gestation.

Nonpresenting Dichorionic Twins and Placental Vascular Malperfusion.

OBJECTIVE: To explore the hypothesis that selective placental pathology affecting the nonpresenting twin is a significant contributory factor mediating the smaller size at birth of nonpresenting dichorionic twins. METHODS: We conducted a retrospective cohort study of all dichorionic twin deliveries in a single tertiary center between 2002 and 2015 where by departmental policy, all placentas from multifetal gestations are routinely sent for pathologic examination. Maternal charts, neonatal charts, and pathology reports were reviewed. Placental abnormalities were classified into lesions associated with maternal vascular malperfusion, fetal vascular malperfusion, placental hemorrhage, and chronic villitis. Comparison of neonatal outcomes and placental abnormalities was made between all nonpresenting and all presenting twins as well as within twin pairs. RESULTS: A total of 1,322 women with dichorionic twins were studied. Nonpresenting twins were smaller at birth compared with the presenting cotwin starting at 32 weeks of gestation (birth weight [±standard deviation] 2,224±666 g compared with 2,278±675 g, P=.036). Nonpresenting twins had smaller placentas (361±108 g compared with 492±129 g, P<.001) as early as 24 weeks of gestation. Nonpresenting twins had higher odds for any placental abnormality (adjusted odds ratio [OR] 1.91, 95% confidence interval [95% CI] 1.63-2.23), small placenta (adjusted OR 4.69, 95% CI 3.75-5.88), and maternal vascular malperfusion (OR 2.75, 95% CI 2.32-3.27) compared with their presenting cotwins. In nonpresenting twins, the presence of maternal vascular malperfusion pathology was associated with lower birth weight compared with their presenting cotwin during the third trimester. CONCLUSION: The lower birth weight of nonpresenting fetuses in dichorionic twin pregnancies is correlated with a higher rate of placental maternal vascular malperfusion pathology.

Placental abnormalities differ between small for gestational age fetuses in dichorionic twin and singleton pregnancies.

OBJECTIVE: Twin fetuses grow slower during the third trimester compared with singletons. However, the extent to which the relative smallness of twins is the result of placenta-mediated factors similar to those associated with fetal growth restriction in singletons remains unclear. Our aim was to address this question by comparing placental findings between small for gestational age (SGA) twins and SGA singletons. METHODS: Retrospective cohort study of all SGA non-anomalous newborns from singleton and dichorionic twin pregnancies in a single tertiary referral center between 2002 and 2015. SGA was defined as birth weight <10th percentile for gestational age according to sex-specific national reference charts. Placental findings were compared between SGA twins and SGA singletons and were classified into lesions associated with maternal vascular malperfusion, fetal vascular malperfusion, placental hemorrhage and chronic villitis. RESULTS: A total of 532 SGA twins and 954 SGA singletons met the inclusion criteria. SGA twins had a higher mean placental weight (371 ± 103 g vs. 319 ± 107, p < 0.001) and a lower fetal-placental ratio (6.0 ± 2.5 vs. 6.7 ± 3.2, p < 0.001) compared with SGA singletons. Compared with SGA singletons, SGA twins were less likely to have any placental pathology (aOR 0.37, 95%-CI 0.29-0.46), hypercoiled cord (aOR 0.45, 95%-CI 0.33-0.61), placental weight<10th% (aOR 0.13, 95%-CI 0.08-0.20), maternal vascular malperfusion pathology (aOR 0.24, 95%-CI 0.18-0.30) and fetal vascular malperfusion pathology (aOR 0.62, 95%-CI 0.48-0.82). By contrast, SGA twins had higher odds of a marginal or velamentous cord insertion compared with SGA singletons (aOR 13.82, 95%-CI 10.44-18.30). Similar significant associations were observed in subgroups of SGA fetuses with a birth weight below the 5th and 3rd percentile for gestational age. CONCLUSIONS: Our findings illustrate that the mechanisms underlying reduced fetal growth in dichorionic twins differ from those involved in singletons, and may provide support to the hypothesis that smallness in dichorionic twins may be more benign than in singletons.

Outcomes of Pregnancies Complicated by Preterm Premature Rupture of Membranes Between 20 and 24 Weeks of Gestation.

OBJECTIVE: To assess the natural history and contemporary outcomes in pregnancies complicated by previable preterm premature rupture of membranes (PROM). METHODS: Retrospective study of all women with a singleton or twin pregnancy admitted to a single tertiary referral center who experienced preterm PROM between 20 and 23 6/7 weeks of gestation during 2004-2014 and underwent expectant management. Women electing termination of pregnancy and pregnancies complicated by major fetal anomalies were excluded. Severe neonatal morbidity was defined as a composite of bronchopulmonary dysplasia, severe neurologic injury, or severe retinopathy of prematurity. Long-term follow-up to a corrected age of 18-21 months was available for the majority of surviving neonates. RESULTS: Of the 140 neonates born to women with previable preterm PROM during the study period, 104 were eligible for the study. Overall 51 (49.0%, 95% confidence interval [CI] 39.4-58.6%) newborns survived to discharge, of whom 24 (47.1%, 95% CI 33.4-60.8%) experienced severe neonatal morbidity. The overall rate of long-term morbidity among surviving neonates was 23.3% (95% CI 11.7-34.9%) and was significantly higher among neonates who previously experienced severe neonatal morbidity compared with those who did not (39.1% compared with 10.0%, P=.04). The only two factors that were significantly associated with overall survival and survival without severe neonatal morbidity were gestational age at preterm PROM of 22 weeks or greater (adjusted odds ratio [OR] 12.2, 95% CI 3.3-44.8 and adjusted OR 4.8, 95% CI 1.2-19.3, respectively) and a latency period of greater than 7 days (adjusted OR 10.1, 95% CI 3.2-31.6, and adjusted OR 6.7, 95% CI 2.2-21.0, respectively). Expectant management was associated with maternal risks including placental abruption (17.3%, 95% CI 10.0-24.6%) and sepsis (4.8%, 95% CI 0.7-8.9%). CONCLUSION: Expectant management in pregnancies complicated by previable preterm PROM between 20 and 23 6/7 weeks of gestation is associated with an overall neonatal survival rate of 49.0%, high risk of short- and long-term severe morbidity among survivors, and carries considerable maternal risks.