Clinical features and antenatal risk factors for postpartum-onset hypertensive disorders.

OBJECTIVE: To identify the clinical features and risk factors for diagnosis of a postpartum-onset hypertensive disorder. METHODS: A retrospective cohort study of singleton pregnancies. Clinical features of postpartum-onset hypertensive disorders were evaluated, and prenatal risk factors were also identified with a multivariate logistic regression model. RESULTS: Of 1,964 women, 57 (2.9%) developed hypertensive disorder after delivery. The independent risk factors were assisted reproductive technology, pre-pregnancy body mass index, chronic nephritis, hypothyroidism, high-normal blood pressure before or at delivery, and cesarean section. CONCLUSION: Careful monitoring of blood pressure should be considered for women with the identified risk factors even after delivery.

Clinical features and prenatal risk factors for hypertensive disorders in twin pregnancies.

AIM: The aim of this study was to identify the incidence, clinical features, and prenatal risk factors for hypertensive disorders, including gestational hypertension (GH) and pre-eclampsia (PE), in twin pregnancies. MATERIAL AND METHODS: We carried out a retrospective cohort study of twin pregnancies managed from the first trimester onward at a single center from 2002 through 2011. We retrospectively evaluated the incidence, severity, time-point onset of GH or PE, as well as maternal and neonatal outcomes. Prenatal risk factors for disease were also analyzed with a multivariable logistic regression model. RESULTS: Of 742 twin pregnancies, 165 (22%) were diagnosed with GH or PE. Five women developed GH or PE at <32 weeks' gestation (early onset), and the remaining 160 developed them at ≥ 32 weeks (late onset). Of all 165 cases, 110 women (66.7%) developed their disease during the intrapartum or postpartum period. The significant risk factors associated with developing a hypertensive disorder in a twin pregnancy were primiparity (adjusted odds ratio [aOR]: 1.77; 95% confidence interval [CI]: 1.21-2.61), pregestational high body mass index (aOR 1.35, 95%CI: 1.08-1.70), family history of hypertension (aOR: 1.50; 95%CI: 1.02-2.17) and previous history of GH or PE (aOR 8.85; 95%CI: 2.70-29.0). CONCLUSIONS: One-fifth of the twin pregnancies developed GH or PE. Furthermore, more than half of the patients were diagnosed with the disease during the intrapartum or postpartum period. Significant risk factors for GH or PE in twin pregnancies were primiparity, pregestational body mass index, family history of hypertension, and history of a hypertensive disorder during a previous pregnancy. The significance of monitoring blood pressure after delivery for a twin pregnancy is stressed.

Adverse perinatal outcomes related to the delivery mode in women with monochorionic diamniotic twin pregnancies.

AIMS: The association between the planned delivery mode and adverse perinatal outcomes of monochorionic diamniotic (MCDA) twin pregnancies at ≥36 weeks' gestation was evaluated. METHODS: This retrospective cohort study included uncomplicated MCDA twin pregnancies delivered after 36 weeks' gestation during a 10-year period. Cases were classified into the trial of labor (TOL) or cesarean section (CS) group according to the planned delivery mode. The primary outcome was a composite of adverse outcomes for at least one twin, including intrauterine fetal death (IUFD) after 36 weeks, neonatal death, umbilical artery pH<7.1, 5-min Apgar scores<7, hypoxic ischemic encephalopathy (HIE), meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), or acute feto-fetal hemorrhage (AFFH). The relationship between outcomes and the planned delivery mode was evaluated using a multiple logistic regression analysis. RESULTS: We included the 310 pregnancies delivered after 36 weeks' gestation. After excluding 15 patients, the final analysis included 295 MCDA pregnancies: 63% had delivered through TOL and 37% through CS. The incidences of composite adverse outcomes in the TOL and CS groups were 4.3% and 1.9%, respectively. No IUFD, neonatal death, MAS, RDS, or AFFH was observed; two infants in each group developed HIE. Adverse outcomes were not significantly associated with any risk factor, including delivery through TOL. CONCLUSION: TOL may not influence the perinatal outcomes of MCDA twin pregnancies delivered at ≥36 weeks' gestation.

The prevalence and clinical features of twin-twin transfusion syndrome with onset during the third trimester.

OBJECTIVE: To describe the incidence and clinical features of twin-twin transfusion syndrome (TTTS) with third trimester onset. METHODS: We performed a retrospective chart review of monochorionic diamniotic (MD) twin pregnancies delivered during a recent 4-year period. The inclusion criterion was women who received prenatal care at our center from the first trimester onward. Serial ultrasound examinations were performed at least every 2 weeks until delivery to evaluate fetal growth as well as to estimate amniotic fluid volume. The prevalence of TTTS onset after 28 weeks of gestation and clinical features, including neonatal outcomes and placental findings, were elucidated. RESULTS: Meeting our inclusion criterion were 143 MD twin pregnancies, including 15 TTTS cases (10%). Five cases (4%) developed TTTS during the third trimester and underwent a cesarean section immediately after the diagnosis. All of these women exhibited either abdominal distension or uterine contractions. Recipient twins tended to require more intensive cardiopulmonary treatment than donors, however, neither a recipient nor a donor twin suffered neonatal death or neurological impairment. Placental arterio-arterial anastomoses were detected in three out of five cases. Arteriovenous anastomoses were present in all cases, however, venovenous anastomoses were not found in any case. CONCLUSIONS: TTTS is a relatively rare complication during the third trimester. It is imperative to be observant for the development of TTTS in MD twin pregnancies with any abdominal symptoms, even if they appear insignificant.

Therapy by laser equatorial placental dichorionization for early-onset spontaneous twin anemia-polycythemia sequence.

We report a case of twin anemia-polycythemia sequence (TAPS) treated by fetoscopic laser equatorial placental dichorionization, also known as the 'Solomon technique', at 24 weeks of gestation. TAPS was present despite the absence of fetoscopically visualized chorionic anastomoses from the donor to the recipient twin. The goal of this procedure was to prevent post-laser TAPS in cases of twin-twin transfusion syndrome. The surgery and subsequent intrauterine blood transfusion to the donor twin could result in the survival of both twins without hematologic or neurological complications. Following the surgery, a placental injection test revealed no residual anastomoses. At present, laser therapy is not always feasible for TAPS, primarily because of its difficulty. However, laser therapy using the Solomon technique could be a viable approach for early-onset TAPS, especially in difficult situations in which undetectable vascular anastomoses related to TAPS are present.

Laser therapy for twin-twin transfusion syndrome in the absence of fetoscopically visible placental vascular anastomoses.

Fetoscopic laser photocoagulation (FLP) was performed at 22 weeks of gestation for a pregnancy complicated with twin-twin transfusion syndrome (TTTS) and an anterior placenta. However, vascular anastomoses could not be identified by the fetoscope. To dichotomize the circulation between the twins, the terminal ends of the paired artery and vein of the recipient twin were coagulated. In addition, a line was drawn with the laser connecting the dots, which had been coagulated. The Doppler waveform as well as the amniotic fluid volume of each twin normalized after the procedure. The twins were delivered by cesarean section subsequent to onset of labor at gestational week 30; the recipient twin weighed 1,350 g and the donor twin weighed 550 g. Both twins had a normal neurologic exam at 6 months of age. Patent placental vascular anastomoses could not be detected. This case demonstrates that vascular anastomoses in TTTS may not be identified by a fetoscope and that FLP to coagulate the entire vascular equator closer to the area of the recipient twin was effective in this rare situation.