Outcome following selective fetoscopic laser ablation for twin to twin transfusion syndrome: an 8 year national collaborative experience.

OBJECTIVE: With the recognition of the role of fetoscopic laser ablation for twin to twin transfusion syndrome (TTTS), there is a requirement for auditable standards for this technically challenging and specialized treatment. The purpose of this study is to report on the perinatal and medium-term neurodevelopmental outcomes following an 8-year national single center experience in the management of TTTS using the selective fetoscopic laser ablation technique. STUDY DESIGN: An audit of all cases of TTTS treated with selective laser ablation by a single national fetal medicine team was performed. Overall perinatal survival and medium-term neurodevelopmental outcomes were reported and correlated with gestational age at diagnosis, placental location, volume of amnio-reduction, Quintero staging and percentage inter-twin growth discordance. Procedure-related complications were recorded. RESULTS: The overall fetal survival for the first 105 consecutive cases of TTTS was 61% (128/210 fetuses). Dual survival occurred in 47% (49/105) of cases, and with a single survival rate of 28% (30/105), perinatal survival of least one infant was achieved in 75% (79/105) of cases. No correlation was found between any clinical or sonographic marker and perinatal outcome, although dual survival was noted to be significantly decreased with increasing Quintero stage (p=0.041). Currently, 86% of survivors have been reported to have a normal medium-term neurological outcome. CONCLUSION: Fetoscopic laser ablation is the established optimal treatment for severe twin to twin transfusion syndrome (TTTS). We report comparable short and medium-term outcomes following the selective fetoscopic technique comparing results from our national program with internationally published single-center outcomes, supporting the efficacy and safety of this treatment at our center.

Endothelial progenitor cells in mothers of low-birthweight infants: a link between defective placental vascularization and increased cardiovascular risk?

CONTEXT: Offspring birthweight is inversely associated with future maternal cardiovascular mortality, a relationship that has yet to be fully elucidated. Endothelial progenitor cells (EPCs) are thought to play a key role in vasculogenesis, and EPC numbers reflect cardiovascular risk. OBJECTIVE: Our objective was to ascertain whether EPC number or function was reduced in mothers of low-birthweight infants. DESIGN AND SETTING: This was a prospective cohort study in a general antenatal department of a university maternity hospital. PARTICIPANTS: Twenty-three mothers of small for gestational age (SGA) infants (birthweight < 10th centile) and 23 mothers of appropriate for gestational age (AGA) infants (birthweight ≥ 10th centile) were recruited. MAIN OUTCOME MEASURES: Maternal EPC number and function, conventional cardiovascular risk markers, and cord blood adiponectin were measured. RESULTS: Median EPC count was lower (294 vs. 367, P = 0.005) and EPC migration was reduced (0.91 vs. 1.59, P < 0.001) in SGA compared with AGA infants, with no difference in EPC adhesion (0.221 vs. 0.284 fluorescence units, P = 0.257). Maternal triglyceride levels were higher in SGA than AGA infants (0.98 vs. 0.78 mmol/liter, P = 0.006), but there was no difference in cholesterol, glucose, insulin, glycosylated hemoglobin, adiponectin, or blood pressure. There was a moderate monotone (increasing) relationship between birthweight and umbilical cord blood adiponectin (r = 0.475, P = 0.005). CONCLUSION: Giving birth to an SGA infant was associated with lower maternal EPC number and reduced migratory function. Cord blood adiponectin was significantly correlated with birthweight.

Correlation between birth weight and maternal body composition.

OBJECTIVE: To estimate which maternal body composition parameters measured using multifrequency segmental bioelectric impedance analysis in the first trimester of pregnancy are predictors of increased birth weight. METHODS: Nondiabetic women were recruited after ultrasonographic confirmation of an ongoing singleton pregnancy in the first trimester. Maternal body composition was measured using bioelectric impedance analysis. Multivariable linear regression analysis was performed to identify the strongest predictors of birth weight, with multiple logistic regression analysis performed to assess predictors of birth weight greater than 4 kg. RESULTS: Data were analyzed for 2,618 women, of whom 49.6% (n=1,075) were primigravid and 16.5% (n=432) were obese based on a body mass index (BMI) of 30 or higher. In univariable analysis, maternal age, BMI, parity, gestational age at delivery, smoking, fat mass, and fat-free mass all correlated significantly with birth weight. In multivariable regression analysis, fat-free mass remained a significant predictor of birth weight (model R=0.254, standardized ß=0.237; P<.001), but no relationship was found between maternal fat mass and birth weight. After adjustment for confounding variables, women in the highest fat-free mass quartile had an adjusted odds ratio of 3.64 (95% confidence interval 2.34-5.68) for a birth weight more than 4 kg compared with those in the lowest quartile. CONCLUSIONS: Based on direct measurements of body composition, birth weight correlated positively with maternal fat-free mass and not adiposity. These findings suggest that, in nondiabetic women, interventions intended to reduce fat mass during pregnancy may not prevent large-for-gestational-age neonates and revised guidelines for gestational weight gain in obese women may not prevent large-for-gestational-age neonates. LEVEL OF EVIDENCE: : III.

Platelet reactivity and pregnancy loss.

OBJECTIVE: We sought to critically evaluate platelet function in recurrent miscarriage (RM). STUDY DESIGN: We conducted a prospective study comparing 30 patients with unexplained recurrent first-trimester pregnancy loss with 30 control subjects matched for age and serum progesterone level. Platelet function was determined using a modified assay of light transmission aggregometry with multiple agonists at different concentrations. Dose-response curves were created and half-maximal effective concentration values were calculated. RESULTS: At test completion the half-maximal effective concentration values for arachidonic acid in the patients with RM were significantly less than in the control subjects (0.153 vs 0.230; P = .0099). The dose-response curves were tightly matched for the other agonists. CONCLUSION: This novel measurement of platelet function has demonstrated that patients with unexplained RM have significantly increased platelet aggregation in response to arachidonic acid. The enhanced response to this agonist provides an empirical rationale for the use of aspirin in management of this clinical condition.