Burden, associated risk factors and adverse outcomes of gestational diabetes mellitus in twin pregnancies in Al Ain, UAE.

BACKGROUND: Gestational diabetes mellitus (GDM) in singleton pregnancies represent a high-risk scenario. The incidence, associated factors and outcomes of GDM in twin pregnancies is not known in the UAE. METHODS: This was five years retrospective analysis of hospital records of twin pregnancies in the city of Al Ain, Abu Dhabi, UAE. Relevant data with regards to the pregnancy, maternal and birth outcomes and incidence of GDM was extracted from two major hospitals in the city. Regression models assessed the relationship between socio-demographic and pregnancy-related variables and GDM, and the associations between GDM and maternal and fetal outcomes at birth. RESULTS: A total of 404 women and their neonates were part of this study. The study population had a mean age of 30.1 (SD: 5.3), overweight or obese (66.5%) and were majority multiparous (66.6%). High incidence of GDM in twin pregnancies (27.0%). While there were no statistical differences in outcomes of the neonates, GDM mothers were older (OR: 1.09, 95% CI: 1.06-1.4) and heavier (aOR: 1.02, 95% CI: 1.00 -1.04). They were also likely to have had GDM in their previous pregnancies (aOR: 7.37, 95% CI: 2.76-19.73). The prognosis of mothers with twin pregnancies and GDM lead to an independent and increased odds of cesarean section (aOR: 2.34, 95% CI: 1.03-5.30) and hospitalization during pregnancy (aOR: 1.60, 95% CI: 1.16-2.20). CONCLUSION: More than a quarter of women with twin pregnancies were diagnosed with GDM. GDM was associated with some adverse pregnancy outcomes but not fetal outcomes in this population. More studies are needed to further investigate these associations and the management of GDM in twin pregnancies.

Prevalence, antenatal management and perinatal outcome of monochorionic monoamniotic twin pregnancy: a collaborative multicenter study in England, 2000-2013.

OBJECTIVES: To determine the prevalence of monochorionic monoamniotic (MCMA) twin pregnancy and to describe perinatal outcome and clinical management of these pregnancies. METHODS: In this multicenter cohort study, the prevalence of MCMA twinning was estimated using population-based data on MCMA twin pregnancies, collected between 2000 and 2013 from 11 Northern Survey of Twin and Multiple Pregnancy (NorSTAMP) maternity units. Pregnancy outcome at < 24 weeks' gestation, antenatal parameters and perinatal outcome (from ≥ 24 weeks to the first 28 days of age) were analyzed using combined data on pregnancies confirmed to be MCMA from NorSTAMP and the Southwest Thames Region of London Obstetric Research Collaborative (STORK) multiple pregnancy cohort for 2000-2013. RESULTS: The estimated total prevalence of MCMA twin pregnancies in the North of England region was 8.2 per 1000 twin pregnancies (59/7170), and the birth prevalence was 0.08 per 1000 pregnancies overall (singleton and multiple). Using combined data from NorSTAMP and STORK, the rate of fetal death (at < 24 weeks' gestation), including terminations of pregnancy and selective feticide, was 31.8% (54/170); the overall perinatal mortality rate was 14.7% (17/116), ranging from 69.2% at < 30 weeks to 4.5% at ≥ 33 weeks' gestation. MCMA twins that survived in utero beyond 24 weeks were delivered, usually by Cesarean section, at a median of 33 (interquartile range, 32-34) weeks of gestation. CONCLUSIONS: In MCMA twins surviving beyond 24 weeks of gestation, there was a higher survival rate compared with in previous decades, presumably due to early diagnosis, close surveillance and elective birth around 32-34 weeks of gestation. High perinatal mortality at early gestations was attributed mainly to extreme prematurity due to preterm spontaneous labor. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Twins and socioeconomic factors: changes in the last 20 years.

BACKGROUND: Socioeconomic factors associated with twins/multiples have been sparsely studied. METHODS: Data, regarding twin out of total births from 1996 to 2015, were extracted from databases of the Hellenic Statistical Authority and analyzed. RESULTS: Twinning rate in Greece has increased from 1996 and onwards, in parallel with advanced maternal age and decline in total births. Higher twin rates are associated with higher maternal education, better paid parental occupations, and thus wealthier families, married maternal status, while immigrants present a lower twinning rate than Greeks. Lastly, the years of the economic crisis, starting in the year 2008 and still continuing, are characterized by a higher percentage of twins. CONCLUSIONS: Our findings should be mainly attributed to the postponement of fertility, as well as the treatment of infertility with transfer of multiple embryos, when assisted reproductive technologies are applied.

The association between maternal race and adverse outcomes in twin pregnancies with similar healthcare access.

OBJECTIVE: To compare twin pregnancy outcomes between white and nonwhite women with similar access to health care. METHODS: Retrospective cohort study of all twin pregnancies delivered by a single maternal-fetal medicine practice from 2005-2016. All patients had private health insurance and equal access to physician care. Outcomes were compared between white and nonwhite women using logistic regression to adjust for differences at baseline. RESULTS: Of the 858 women included, 730 (85.1%) were white and 128 (14.9%) were nonwhite. Univariate analysis demonstrated that nonwhite women had higher rates of preterm birth <32 weeks (12.5 versus 6.7%, p = .022), cesarean delivery (78.1% versus 61.4% of all women, p < .001 and 43.5% versus 16.1% of women who attempted labor, p < .001), preeclampsia (22.4% versus 14.5%, p = .029) and gestational diabetes (23.2% versus 7.3%, p < .001). On adjusted analysis, nonwhite race remained significantly associated with cesarean delivery in women who attempted labor (aOR 2.27, 95% CI: 1.09, 4.71) and gestational diabetes (aOR 2.61, 95% CI: 1.53, 4.45). CONCLUSIONS: Nonwhite women with twin pregnancies have an increased risk of adverse outcomes that cannot be explained by access to care. Although improving access to care is an important goal for health care systems, our data suggest that this alone will not eliminate all disparities in health care outcomes between women of different races.

Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States.

BACKGROUND: There is little agreement on who is a good candidate for community (home or birth center) birth in the United States. METHODS: Data on n=47 394 midwife-attended, planned community births come from the Midwives Alliance of North America Statistics Project. Logistic regression quantified the independent contribution of 10 risk factors to maternal and neonatal outcomes. Risk factors included: primiparity, advanced maternal age, obesity, gestational diabetes, preeclampsia, postterm pregnancy, twins, breech presentation, history of cesarean and vaginal birth, and history of cesarean without history of vaginal birth. Models controlled additionally for Medicaid, race/ethnicity, and education. RESULTS: The independent contributions of maternal age and obesity were quite modest, with adjusted odds ratios (AOR) less than 2.0 for all outcomes: hospital transfer, cesarean, perineal trauma, postpartum hemorrhage, low/very-low Apgar, maternal or neonatal hospitalization, NICU admission, and fetal/neonatal death. Breech was strongly associated with morbidity and fetal/neonatal mortality (AOR 8.2, 95% CI, 3.7-18.4). Women with a history of both cesarean and vaginal birth fared better than primiparas across all outcomes; however, women with a history of cesarean but no prior vaginal births had poor outcomes, most notably fetal/neonatal demise (AOR 10.4, 95% CI, 4.8-22.6). Cesarean births were most common in the breech (44.7%), preeclampsia (30.6%), history of cesarean without vaginal birth (22.1%), and primipara (11.0%) groups. DISCUSSION: The outcomes of labor after cesarean in women with previous vaginal deliveries indicates that guidelines uniformly prohibiting labor after cesarean should be reconsidered for this subgroup. Breech presentation has the highest rate of adverse outcomes supporting management of vaginal breech labor in a hospital setting.

Twins less frequent than expected among male births in risk averse populations.

Male twin gestations exhibit higher incidence of fetal morbidity and mortality than singleton gestations. From an evolutionary perspective, the relatively high rates of infant and child mortality among male twins born into threatening environments reduce the fitness of these gestations, making them more vulnerable to fetal loss. Women do not perceive choosing to spontaneously abort gestations although the outcome may result from estimates, made without awareness, of the risks of continuing a pregnancy. Here, we examine whether the non-conscious decisional biology of gestation can be linked to conscious risk aversion. We test this speculation by measuring the association between household surveys in Sweden that gauge financial risk aversion in the population and the frequency of twins among live male births. We used time-series regression methods to estimate our suspected associations and Box-Jenkins modeling to ensure that autocorrelation did not confound the estimation or reduce its efficiency. We found, consistent with theory, that financial risk aversion in the population correlates inversely with the odds of a twin among Swedish males born two months later. The odds of a twin among males fell by approximately 3.5% two months after unexpectedly great risk aversion in the population. This work implies that shocks that affect population risk aversion carry implications for fetal loss in vulnerable twin pregnancies.

Racial disparities in outcomes of twin pregnancies: elective cesarean or trial of labor?

OBJECTIVE: The objective of the study was to determine the relationships between maternal race and obstetric outcomes in twin gestations by planned mode of delivery. STUDY DESIGN: We performed a secondary analysis of the Consortium on Safe Labor data. Patients with twin gestations in vertex-vertex presentation greater than 32 weeks' gestational age were grouped according to race. Demographic information and neonatal and maternal outcomes were analyzed according to planned mode of delivery: elective cesarean or trial of labor (with subsequent vaginal delivery, unplanned cesarean, or combined delivery). The primary outcome was unplanned cesarean. Secondary outcomes included maternal and neonatal outcomes. RESULTS: One thousand nine vertex-vertex twin pregnancies were identified. There were no significant differences across ethnicities in the rate of unplanned cesarean delivery, which occurred in 233 of patients undergoing trial of labor (27%). Elective cesarean occurred in 151 patients (15%). African American women were less likely to have an elective cesarean compared with whites (odds ratio, 0.5; 95% confidence interval, 0.3-0.8), and Asian women were more likely to have an elective cesarean compared with whites (odds ratio, 2.0; 95% confidence interval, 1.2-3.4. Combined delivery occurred in 67 patients (8%) and did not differ among the groups. Subgroup analysis did not reveal any significant differences in neonatal outcomes. Adverse maternal outcomes were rare across ethnicities. CONCLUSION: Unplanned cesarean delivery rates are similar in twin pregnancies, regardless of race. Maternal and neonatal outcomes in twin gestations are similar across ethnicities, regardless of mode of delivery.

[Pronostic risk assessment of delivery, in patients admitted for threatened preterm birth, in a tertiary care maternity center]. / Étude pronostique du risque d'accouchement, des patientes hospitalisées pour menace d'accouchement prématuré, dans une maternité de niveau III.

OBJECTIVES: To assess preterm birth rate, in patients admitted for threatened preterm birth (TPB) in a tertiary care maternity center and evaluate our diagnostic and therapeutic tools. MATERIALS AND METHODS: A retrospective cohort study, in a tertiary care maternity center (Marseille, France), reviewed all admissions for TPB from January 1 to December 31, 2009. RESULTS: We recorded 224 admissions for TPB (181 single pregnancies and 43 twin pregnancies), 43.8% of TPB admissions were from materno-fetal transfer. Preterm birth rate was 44.9% (n=89), 39% (n=66) for single pregnancy and 76.6% (n=23) for twins. The 15 mm threshold for transvaginal sonography cervical length (CL) was the most relevant to predict the risk of preterm delivery, 77.3% (85/110) of patients with CL>15 mm having full term delivery. CONCLUSION: For single pregnancy, most of the patients with cervical length>15 mm have full term delivery. It seems important to us to develop the use of more efficient predictive markers of risk-premature labor in order to improve the diagnosis and management of TPB.

First birth interval, an indicator of energetic status, is a predictor of lifetime reproductive strategy.

OBJECTIVES: Women should differ in their reproductive strategies according to their nutritional status. We tested a hypothesis that women who have a good nutritional status early in life, as indicated by a shorter waiting time to the first birth (first birth interval, FBI), are able to afford higher costs of reproduction than women who have worse nutritional condition. METHODS: We collected data on 377 women who got married between the years 1782 and 1882 in a natural fertility population in rural Poland. The study group was divided into tertiles based on the length of FBI. RESULTS: Women with the shortest FBI had a higher number of children (P = 0.005), higher number of sons (P = 0.01), and shorter mean interbirth intervals (P = 0.06). Women who had ever given birth to twins had shorter FBI than women of singletons (20.1 and 26.1 months, respectively; P = 0.049). Furthermore, women with a shorter FBI, despite having higher costs of reproduction, did not have a different lifespan than women with a longer FBI. CONCLUSIONS: Our results suggest that women who were in better energetic condition (shorter length of FBI), achieved higher reproductive success without reduction in lifespan. FBI reflects interindividual variation, which may result from variation in nutritional status early in life and thus may be a good predictor of subsequent reproductive strategy. We propose to use FBI as an indicator of women's nutritional status in studies of historical populations, especially when information about social status is not available.

Twins born over weekends: are they at risk for elevated infant mortality?

OBJECTIVE: To assess the impact of the day of birth on twin mortality in a population sample. METHODS: We analyzed weekend versus weekday twin births from the United States national twin birth data for the periods 1989-2002. We computed adjusted hazard ratios (HR) and 95% confidence intervals (CI) to assess the association between infant mortality and weekday of birth using the Cox proportional hazards model. RESULTS: The crude rates for all types of mortality were found to be significantly higher for twins born on weekends than on weekdays. After adjustment, only post-neonatal mortality risk was higher on weekends as compared to weekdays [Hazards ratio (HR)=1.19, CI: 1.04, 1.36]. Twins of white mothers were at greater risk for neonatal death (HR=1.16, CI: 1.08, 1.24) but were less likely to experience post-neonatal death (HR=0.68, CI: 0.64, 0.76) as compared to twins of black mothers. We found an interaction between maternal age and weekday of birth. Twins born on weekends to teenage mothers (age<18) had a 35% greater risk for neonatal death (HR=1.35, CI: 1.06, 1.71) while those born on weekends to older mothers did not show elevated risk for any of the mortality indices. CONCLUSION: Increased risks for post-neonatal death are significantly higher amongst twins born on weekends as compared to weekdays. Further research is required to identify the detailed differences in structure and procedures that result in the disadvantage associated with weekend birth.

How twins differ: multiple pregnancy and the use of health care in the 2008 Nigeria Demographic and Health Survey.

OBJECTIVES: To (i) document the incidence of multiplicity in Nigeria, (ii) compare healthcare utilization during pregnancy and at delivery for singleton and multiple pregnancies (iii)and investigate whether antenatal care modifies the relationship between multiplicity and likelihood of having skilled attendance. METHODS: This observational study was a secondary analysis of the 2008 Nigeria Demographic and Health Survey and included 17,635 women who gave birth to a live infant between 2003 and 2008. Multivariate logistic regression with adjustment for weighting, clustering and confounding was used to investigate associations and look for effect modification. RESULTS: There were 18.5 multiple pregnancies per 1000 maternities. Multiple births had nearly six times the chance of neonatal mortality (AOR 5.74). Mothers with multiple births had more skilled attendance (AOR 1.75), but similar antenatal care utilization (AOR 0.95) as women with a singleton pregnancy. Women with multiple pregnancies attending antenatal care had more visits (mean 9.0 vs. 8.2), blood pressure checks (OR 1.52) and urine tests (OR 1.51). Although antenatal care was strongly associated with skilled attendance, there was no evidence that this was more so for twins than singletons. CONCLUSIONS: Multiplicity in Nigeria is not just a common occurrence, but an indicator of a high-risk pregnancy. The fact that the use of antenatal care by women with a multiple pregnancy is not associated with a disproportionately greater use of skilled delivery care raises questions about the quality of antenatal services. Services should encourage and link all women and especially high-risk women to skilled attendance at delivery.