Cervical cerclage after prior uterine and cervical surgery.

OBJECTIVE: To evaluate cerclage placement after uterine and cervical surgery. PATIENTS AND METHODS: We compared patients with a prior uterine surgery (with or without cervical surgery) with women having a cerclage for the "classical" indications. Under the classical indications fall history of one or more second-trimester pregnancy losses related to painless cervical dilation, prior cerclage due to painless cervical dilation in the second trimester, painless cervical dilation in the second trimester, ultrasonographic finding with a history of prior preterm birth, prior spontaneous preterm birth at less than 34 weeks of gestation and short cervical length (less than 25 mm) before 24 weeks of gestation. RESULTS: Forty-seven (44.8%) patients had uterine surgery whereas 58 (55.2%) had the "classical" indications for cerclage. The risk of birth at <37 weeks and birth weight <2500 g was similar, but lower for cerclage after previous uterine/cervical surgery for births >37 weeks (OR 0.3, 95% CI 0.1, 0.8) and hence, for birth weights >2500 g (OR 0.4, 95% CI 0.2-0.9). Both groups had similar incidence of preterm rupture of membranes, chorioamnionitis, need for induction of labor, cesarean births as well as low Apgar scores and admission rates to the NICU. CONCLUSIONS: The major goals of reducing births at <37 weeks and low birth weight of <2500 g are achievable with a cerclage in patients with a prior uterine/cervical surgery as it is in patients with a "classical" indication for cerclage placement.

The effect of antenatal corticosteroids on small-for-gestational age preterm neonates.

OBJECTIVE: Treatment of preterm small-for-gestational age (SGA) neonates with antenatal corticosteroids (ACS) is not entirely straightforward. We sought to examine the effect of a full course of ACS on outcomes of SGA and non-SGA preterm singletons. PATIENTS AND METHODS: We compared maternal characteristics and outcomes of preterm births at <28 and 28 + 0-33 + 0 weeks' gestation that received a complete course of ACS within a week before birth. We further divided our cohort into those with or without a SGA neonate. RESULTS: We included 290 infants: 73 (25.2%) and 217 (74.8%) born at <28 and 28 + 0-33 + 0 weeks' gestation, respectively. Analysis of maternal characteristics showed a strong association of maternal body mass index (p = .01), along with smoking during pregnancy (OR 0.4, 95% CI 0.2, 0.9), with being SGA. Spontaneous onset of delivery more commonly occurred in non-SGA preterm neonates, whereas iatrogenic induction of labor prevailed with SGA neonates (p < .01). There was no significant difference between SGA and non-SGA infants in all the tested neonatal variables except for necrotizing enterocolitis, which prevailed in the SGA group. CONCLUSION: A full course of ACS appears to have the same effect in SGA and non-SGA preterm singletons in our studied cohort on all neonatal outcomes but for necrotizing enterocolitis, where its role in SGA preterm neonates seems to be detrimental rather than beneficial to the fetus.

Perinatal outcome of in vitro fertilization pregnancies in women with polycystic ovary syndrome by pregravid BMI.

OBJECTIVES: Given the adverse effects of either polycystic ovary syndrome (PCOS) or overweight/obesity, one could speculate that patients with both would fare worse than others. We sought to evaluate the relationship between pregravid BMI and pregnancy complications in PCOS patients conceived by assisted reproductive techniques (ART). METHODS: Maternal and fetal/neonatal outcomes of singleton pregnancies after assisted reproduction in women with and without PCOS were compared by pregravid body mass index (BMI, <24.9 vs. ≥25 kg/cm2). RESULTS: The study population comprised 185 with a BMI <24.9 kg/cm2 including 39 (21%) with PCOS and 146 (79%) without. We also included 84 patients with BMI ≥25 kg/cm2, involving 34 (40.5%) with PCOS and 50 (59.5%) without. PCOS (total 73 patients) was significantly more common among overweight/obese patients, OR 2.5 (95% CI 1.4, 4.4). Neonates >4,000 g were born only to the overweight/obese mothers in the PCOS group. A higher incidence of gestational diabetes, chronic hypertension, and gestational hypertension was related to pregravid overweight/obesity rather than PCOS. CONCLUSIONS: In this specific subgroup of patients conceived after assisted reproduction, pregravid BMI>25 kg/cm2 rather than PCOS itself appears to be associated with GDM and hypertensive disorders.

First trimester ß-hCG and estradiol levels in singleton and twin pregnancies after assisted reproduction.

Objective To compare levels of ß-hCG and estradiol collected during the first trimester in singleton and twin pregnancies following assisted reproduction technologies (ART). Methods We prospectively evaluated 50 singleton and 47 dichorionic twin pregnancies that eventually ended in live births. Patients were recruited from a single ART center with standard treatment protocols followed by fresh embryo transfers. Hormone measurements were performed within a narrow gestational age range and analyzed in a single laboratory thus minimizing inter- and intra-assay variability. We measured serum ß-hCG at 13 days after embryo transfer as well as samples of ß-hCG and estradiol at 8-9 weeks+6 days. Results No significant differences existed between singletons and twins in respect to demographic and cycle characteristics. ß-hCG and estradiol were all significantly higher in twins (P<0.05). Conclusion The data confirms the higher levels of ß-hCG and estradiol in twins, pointing to the potential role of these placental hormones in early support of a twin pregnancy.

Can early ß-human chorionic gonadotropin predict birth of singletons and twins after in vitro fertilization?

OBJECTIVE: To assess the predictive value for clinical pregnancy outcome of ß-hCG level at 13 d after embryo transfer. METHODS: Retrospective study of IVF clinical pregnancies diagnosed at 6 weeks. We calculated the value of ß-hCG level at 13 d after embryo transfer to predict live births. RESULTS: We analyzed 177 IVF cycles between 2009 and 2014 (50 singleton births, 50 twin births, 27 sets with a vanishing twin, 43 first trimester singleton pregnancy loss and seven first trimester total twin pregnancy loss). Singleton pregnancies with a ß-hCG concentration <85 mIU/mL had an 89% risk of having a first trimester loss whereas a concentration >386 mU/mL had a 91% chance of a live birth. Twin pregnancies with a concentration <207 mIU/mL had only a 33% chance of delivering twins and a 55% risk of having a vanishing twin; whereas a level >768 mIU/mL was associated with a 81% chance of live twin birth and a low risk (19%) of having a vanishing twin. Age, type and duration of infertility, body mass index (BMI) and number of fertilized oocytes did not affect these calculations. CONCLUSIONS: ß-hCG level at 13 d after embryo transfer might predict outcomes in clinical singleton and twin pregnancies following IVF.

Risk factors for preeclampsia in twin pregnancies: a population-based matched case-control study.

OBJECTIVE: To evaluate associated factors for preeclampsia in twin gestations and to compare incidences of pregnancy complications among twin pregnancies with vs. without preeclampsia. PATIENTS AND METHODS: We performed a case-control study using a population dataset of twin pregnancies delivered after 24 weeks of gestation, in Slovenia, between 1997 and 2009. Cases were twin gestations complicated by preeclampsia and controls were cases matched by gestational age, parity, and chorionicity. RESULTS: We identified 181 cases (4.7%) of preeclampsia among 3885 twins and 542 matched controls. High pre-pregnancy body mass index (BMI) and gestational diabetes were significantly associated with preeclampsia [odds ratio (OR) 1.8, 95% CI 1.26, 2.77 for overweight (BMI 25.0-29.9); OR 4.72, 95% CI 2.83, 7.89 for obese (BMI≥30), and OR 2.19, 95% CI 1.03, 4.68 for gestational diabetes]. The association was not significant for preexisting hypertension, maternal age, smoking, and pregnancy following assisted reproduction. Placental complications (previa, abruption, or adherent placenta) were more common, and low birth weight less common in the preeclampsia group (P=0.03 and P=0.01, respectively). CONCLUSIONS: High pre-pregnancy BMI carries an especially high risk for the development of preeclampsia and its complications in twin gestation.

"Masculinizing" effect on respiratory morbidity in girls from unlike-sex preterm twins: a possible transchorionic paracrine effect.

OBJECTIVES: Preterm male infants are at a disadvantage when compared with female infants regarding the incidence of respiratory and neurologic morbidity and mortality. At term, female infants from unlike-sex twin pairs have birth weights that are closer to their male co-twins than to girls from like-sex twin pairs. We hypothesized that if the male disadvantage is mediated via factors that affect fetal lung development, there may be a potential effect on the incidence of respiratory distress syndrome and its complications in female infants from unlike-sex pairs. PATIENTS AND METHODS: In this population-based study we used data from the Israel Neonatal Network, which included data from 8858 very low birth weight (500-1500 g) infants of 24 to 34 weeks' gestation. The incidence of morbidity and mortality was compared in male and female infants from singletons and like-sex and unlike-sex twin pairs. Multivariable analyses were used, accounting for relevant confounding variables. RESULTS: Male singletons and like-sex twins were at increased risk for mortality, respiratory distress syndrome, pneumothorax, bronchopulmonary dysplasia, periventricular-intraventricular hemorrhage, and periventricular leukomalacia. However, in unlike-sex twin pairs, no difference was seen in the incidence of respiratory morbidity between male and female twins. The male disadvantage was maintained for mortality and periventricular-intraventricular hemorrhage. CONCLUSIONS: These findings suggest that the difference in morbidity and mortality between male and female premature infants represents a male disadvantage as opposed to a female advantage and that this disadvantage may be transferred from boys to girls in unlike-sex twin pairs, perhaps via an intrauterine paracrine effect.

Oral contraception and thrombophilia.

PURPOSE OF REVIEW: To describe current knowledge related to the association between oral contraception and the thrombophilias. RECENT FINDINGS: The use of oral contraception increases the risk of venous thromboembolism as well as arterial thrombosis. Third-generation pills seem to increase the risk of venous thromboembolism compared with second-generation pills. This effect seems to be reversed or absent for the risk of arterial thrombosis. The effect of oral contraception on the risk of venous thromboembolism is more pronounced during the first year of use. All these risks are further increased in patients with an inborn or acquired tendency for coagulation (thrombophilia). SUMMARY: Prospective users of oral contraception are potential candidates for screening/testing, because a positive screen may substantially decrease the risk of a thrombotic event. At present, the available testing methods are not cost effective, and the absolute risk is not defined for each thrombophilia. Until these shortcomings are solved, it is not recommended to test every woman who wishes to use oral contraception. Nevertheless, before starting on oral contraception, each patient should be carefully screened by a physician who should identify an increased risk of thrombophilia and tailor the laboratory testing.

Does the use of folic acid increase the risk of twinning?

The increased rates of twinning and the increased consumption of folic acid are two parallel processes described in recent years. However, the possible association between an increased incidence of twin pregnancies and periconceptional folic acid supplementation remains controversial. Whereas the data indicating that when folic acid levels are increased to the range required for reducing the incidence of neural tube defects, the data pertaining to the increase in twinning rate are significantly incoherent and are flawed by serious confounders, such as fertility treatments and maternal age. The only plausible theory connecting methyltetrahydrofolate reductase mutation, folic acid, and twinning has not been confirmed. In addition, temporal and dose-effect relationships have not been established. Because of the lack of coherence, questionable plausibility, and no clear dose-effect and temporal relationships, a cause (folic acid supplementation) and effect (increased twinning rate) association cannot be, at present, accepted. Thus, the established policy of peri-conceptional folic acid supplementation to reduce the incidence of neural tube defects should be continued.

Thrombophilia and women's health: An overview.

Thrombophilia, whether inherited or acquired, is one of the hot topics in women's health. Several factors, some of which are specific to the female patient, enhance thrombus formation in the presence of thrombophilia and include oral contraception, hormone replacement therapy, pregnancy, and puerperium. Thrombotic events are not only restricted to venous thromboembolism but also are believed to cause repeated embryonic loss, fetal loss, placental abruption, intrauterine growth restriction, and severe pre-eclampsia. It seems that some thrombophilias, and a combination of thrombophilic factors, carry a greater risk than others for a given adverse outcome. The addition of LMWH to the armamentarium was associated with conceptual change in the practice of anticoagulation. Care should be exercised in the interpretation of various risks and the potential of anticoagulation as a remedy to reduce that risk.

Down syndrome screening in multiple pregnancies.

First or second trimester screening in twin pregnancies is feasible and still efficacious by using either a combination of ultrasound and maternal serum biochemistry in the first trimester or maternal serum biochemistry in the second trimester. Special care, however, should be emphasized in what concerns biochemical screening, since it is much less sensitive in multiples. These "pseudo-risks" have been challenged for their scientific and clinical validity, however. Until more data are available from larger studies on the distribution of markers in concordant or discordant twins, nuchal translucency estimated for each fetus should be the predominant factor by which women who present with increased risk should be counseled regarding invasive testing. In dizygotic pregnancies, pregnancy-specific risk should be calculated by summing the individual risk estimates for each fetus. In monozygotic twins, the risk should be calculated based on the geometric mean of both nuchal translucency measurements, not forgetting that the false-positive rate of nuchal translucency screening is expectantly higher than in singletons.