Iron deficiency and anemia are prevalent in women with multiple gestations.

BACKGROUND: Little attention has been placed on the unique iron demands that may exist in women with multiple gestations. This merits attention because iron deficiency (ID) during pregnancy is associated with adverse pregnancy outcomes that are known to be more prevalent in multiple births. OBJECTIVE: We characterized longitudinal changes in iron status across pregnancy in a cohort of healthy women with multiple gestations and identified determinants of maternal ID and anemia. DESIGN: A group of 83 women carrying twins, triplets, or quadruplets (aged 20-46 y) was recruited from 2011 to 2014. Blood samples obtained during pregnancy (∼24 wk; n = 73) and at delivery (∼35 wk; n = 61) were used to assess hemoglobin, serum ferritin (SF), soluble transferrin receptor (sTfR), hepcidin, serum iron, erythropoietin, serum folate, vitamin B-12, C-reactive protein, and interleukin-6. RESULTS: The prevalence of tissue ID (sTfR >8.5 mg/L) increased significantly from pregnancy to delivery (9.6% compared with 23%, P = 0.03). Women with depleted iron stores (SF <12 µg/L, n = 20) during pregnancy had a 2-fold greater risk of anemia at delivery, and 25% (n = 5) developed iron deficiency anemia (IDA). Overall, 44.6% of women studied (n = 37/83) were anemic at delivery, and 18% of women (n = 11/61) had IDA. Erythropoietin during pregnancy was significantly negatively associated with hemoglobin at delivery. Women with erythropoietin >75th percentile during pregnancy exhibited a 3-fold greater risk of anemia, suggesting that erythropoietin is a sensitive predictor of anemia at delivery. Inflammation was present at delivery, which limited the utility of ferritin or hepcidin as iron-status indicators at delivery. CONCLUSIONS: ID and anemia are highly prevalent in women with multiple gestations. Additional screening and iron supplementation may be warranted in this high-risk population given the known associations between ID anemia and adverse maternal and neonatal outcomes. This trial was registered at clinicaltrials.gov as NCT01582802.

Pregnancy and beta-thalassemia: an Italian multicenter experience.

BACKGROUND: Recent advances in the management of thalassemia have significantly improved life expectancy and quality of life of patients with this hemoglobinopathy, with a consequent increase in their reproductive potential and desire to have children. DESIGN AND METHODS: We describe the methods of conception and delivery, as well as the course and outcome of pregnancy including transfusions, iron overload and chelation in 46 women with thalassemia major (58 pregnancies) and in 11 women with thalassemia intermedia (17 pregnancies). Conception was achieved after gonadotrophin-induced ovulation in 33 of the women with thalassemia major and spontaneously in all of those with thalassemia intermedia. RESULTS: Among the women with thalassemia major, 91% of the pregnancies resulted in successful delivery of 45 singleton live-born neonates, five sets of twins and one set of triplets. No secondary complications of iron overload developed or worsened during pregnancy. When considering only the singleton pregnancies, the proportion of babies with intrauterine growth retardation did not differ from that reported in the general Italian population. The high prevalence of pre-term births (32.7%) was mostly related to multiple pregnancies and precautionary reasons. Pregnancy was safe in most women with thalassemia major or intermedia. However, women with thalassemia intermedia who had never previously been transfused or who had received only minimal transfusion therapy were at risk of severe alloimmune anemia if blood transfusions were required during pregnancy. CONCLUSIONS: Provided that a multidisciplinary team is available, pregnancy is possible, safe and usually has a favorable outcome in patients with thalassemia. In women with hypogonadotropic hypogonadism, gonadal function is usually intact and fertility is usually retrievable.

Successful multiple pregnancy (triplets) in a kidney transplant recipient: a case report.

Renal failure generally accompanies an alteration in reproduction function. Even though a renal transplantation does in fact improve this function, there are few cases described in medical literature of multiple pregnancies in transplant patients that ended in a successful manner. In addition, there is a greater incidence of complications such as hypertension, preeclampsia, and premature delivery. This article describes a 31-year-old patient who became pregnant with triplets at 3 years and 6 months after receiving a renal transplant from a cadaver. The patient received treatment with cyclosporine, azathioprine, and prednisolone. During the pregnancy, there was a increase in hypertension, proteinuria, cholestasia gravidic symptoms, and premature delivery. Pregnancy control included evaluation of the fetoplacental unit together with hypertensive management and adjustment of immunosuppressant treatment, especially the cyclosporine dose, seeking to facilitate greater fetal maturity. Three newborns of 840, 860, and 1020 were delivered by cesarean section. The newborns spent 6 to 8 weeks in the neonatal unit and were released without complications. The newborns have presented adequate psychomotor and physical development to date. The triplets are now 4 years old. The transplant recipient has a creatinine clearance of 81 mL/min at 7 years after transplantation.

Massive acute haemolysis and severe neonatal hyperbilirubinemia in glucose-6-phosphate dehydrogenase-deficient preterm triplets.

Premature triplets (2 boys and 1 girl) were delivered at 34 weeks, with both boys identified as Glucose-6-phosphate dehydrogenase (G6PD) deficient. Despite having similar quantitative levels of G6PD in their cord blood, only one boy had severe hyperbilirubinemia and anaemia caused by acute haemolysis requiring exchange transfusion. G6PD-deficient infants with the similar genetic, demographic, maternal, clinical factors and G6PD quantification levels can have different severity of presentation of neonatal jaundice in similar environmental set up. This supports the massive acute haemolysis can occur in infant with G6PD deficiency in the absence of any obvious blood group incompatibilities, infection, or ingestion of oxidising agents known to trigger haemolysis.

[Ear acupuncture points in newborn triplets]. / Akupunkturpunkte am Ohr bei neugeborenen Drillingen.

The current study demonstrates for the first time the presence of ear acupuncture points in prematurely delivered triplets of 31 weeks and two days gestational age. Pregnancy was an IVF pregnancy and caesarean section was performed because of preeclampsia. Ear acupuncture points were determined with the Svesa point selector 1070 and correlated well with the clinical state of the neonates meaning that the sickest child demonstrated the most active ear points. Psychotropic points were not found. For the future ear acupuncture points may be further used for diagnostics and therapy in neonates.

Skeletal demineralization and fractures caused by fetal magnesium toxicity.

Two surviving female infants, born from a triplet pregnancy at 30 weeks gestation, were noted to have severe osteopenia and multiple fractures diagnosed at 20 days of age. Their mother had been treated for preterm labor with intravenous magnesium sulfate from week 22 until their birth at 30 weeks gestation. At birth, the triplets exhibited craniotabes with enlarged fontanelles and sutures. All developed Respiratory Distress Syndrome (RDS) and the two surviving infants required prolonged respiratory support. Serum calcium and phosphate levels were normal and alkaline phosphatase levels were increased. The infants were treated with supplements of calcium and phosphorous, with resultant healing of the multiple fractures without deformity. Fetal magnesium toxicity impairs bone mineralization and can lead to serious bone demineralization that may cause fractures in the newborn period that complicate recovery from respiratory disease. Early recognition and treatment may minimize complications related to osteopenia caused by fetal magnesium toxicity.

Antiepileptic drugs: a case report in a pregnancy with a neural tube defect.

While receiving lamotrigine, a patient pregnant with triplets suffered a double fetal neural tube defect. Plasma homocysteine, folate, vitamins B12 and B6 (pyridoxal phosphate), and red cell folate levels were measured in samples while she was receiving folic acid therapy for 1 month during the second trimester of pregnancy. Some mutations were sought, involved in homocysteine metabolism and linked with the folate metabolism. Her results were compared with those of a pregnant woman with normal triplets and with those of 58 pregnant women, with a normal pregnancy. Results indicated a decrease in vitamin B12 and B6 values in plasma in the patient, and a genotype AG (polymorphism A66G) was observed, but was not found in the pregnant woman with normal triplets. Even if lamotrigine therapy is not known to be associated with significant changes in red cells or in serum folate, periconceptional folic acid supplementation is counseled for women, along with periconceptional B12 and B6 vitamin supplementation when their plasma values are decreased.

Nutrition and multiple gestation.

Multiple pregnancy represents a state of magnified nutritional requirements, resulting in a greater nutrient drain on maternal resources and an accelerated depletion of nutritional reserves. The accelerated starvation which occurs in pregnancy is exaggerated with a multiple gestation, particularly during the second half of pregnancy, with more rapid depletion of glycogen stores and resultant metabolism of fat between meals and during an overnight fast. A reduced glucose stream from mother to fetus results in slower fetal growth, smaller birth size, as well as a higher risk of preterm labor and preterm birth. For this reason, diet therapy with a diabetic regimen of 20% of calories from protein, 40% of calories from carbohydrate, and 40% of calories from fat may be particularly useful. Iron-deficiency anemia has also been linked to preterm delivery and other adverse pregnancy outcomes. Mobilization of maternal iron stores, in addition to an adequate amount and pattern of gestational weight gain (including BMI-specific weight gain goals by 20 and 28 weeks gestation), has been associated with significantly better fetal growth and longer gestations in twin pregnancies. Supplementation with calcium, magnesium, and zinc, as well as multivitamins and essential fatty acids may also reduce pregnancy complications and improve postnatal health for infants born from a multiple gestation. Diet therapy for women pregnant with multiples is an important component of effective prenatal care.

Hypoparathyroidism-retardation-dysmorphism (HRD) syndrome in triplets.

We report female triplets with the clinical and biochemical manifestations of hypoparatyroidism-retardation-dysmorphism (HRD) syndrome also known as Sanjad-Sakati syndrome. They were born at 35 weeks gestation after assisted pregnancy (in vitro fertilization). The parents are first degree cousins from Saudi Arabia.

Neonatal outcome of triplet versus twin and singleton pregnancies: a matched case control study.

OBJECTIVE: To determine the neonatal outcome of triplet gestations versus that of singletons and twins matched for gestational age. STUDY DESIGN: All live born triplet gestations delivered between 1 April 1993 and 31 March 2000 were compared to an age matched control group consisting of live born twins and singletons. The neonatal outcome of 116 sets of triplets was compared to that of 116 sets of twins and 116 singletons. RESULTS: During a 7-year period 116 sets of triplet pregnancies were reviewed. Of 116 sets of live born triplets (348 newborns), 70.67% triplets were born between 33- and 36-week gestation, 28.44% between 28 and 32 weeks and 0.86% less than 28 weeks. Triplets were smaller in weight than singletons but not twins. Apgar score, use of prenatal steroid and sex ratio were similar in the three groups. Incidence of respiratory distress syndrome (RDS), use of surfactant, infants requiring intubation, pneumothorax, patent ductus arteriosus, sepsis, intraventricular hemorrhage, periventricular leucomalacia, retinopathy of prematurity, necrotizing enterocolitis, gastroesophageal reflux and jaundice requiring phototherapy were not statistically different among the three groups. Incidence of major and minor congenital anomalies, percent neonatal intensive care unit (NICU) admissions, and mean duration of NICU stay were also similar. There was no influence of birth order on neonatal outcome of triplet pregnancy and outcome did not significantly change over 7 years of the study period. CONCLUSIONS: Triplets have a similar outcome to twins and singletons when matched for gestational age. Since outcome is dependent on gestational age, the closer the gestational age is to term the better is the outcome.

Triplet pregnancy achieved through intracytoplasmic sperm injection with spermatozoa obtained by prostatic massage of a paraplegic patient: case report.

Spinal cord-injured men with ejaculation disorders can have children thanks to assisted reproduction techniques. Spermatozoa from these patients are usually obtained through vibratory stimulation, electroejaculation or by puncturing the seminal duct or the testicle. We present the first published case, as far as we are aware, of spermatozoa obtained through prostatic massage of a paraplegic patient. Penile vibratory stimulation was unsuccessful in this patient. In-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) with spermatozoa obtained through electroejaculation was performed at another centre but pregnancy was not achieved. Through prostatic massage, we obtained a total semen volume of 6 ml containing a total count of 12.32x10(6) spermatozoa (6.24x10(6) with tails), 8% of which had motility (graded + and ++); and 16% of which had normal morphology. The spermatozoa obtained were then used to perform IVF with ICSI and a triplet pregnancy was achieved. Prostatic massage appears to be an easy, non-traumatic and risk-free method to obtain spermatozoa from paraplegic patients.

Long-term magnesium sulfate tocolysis and maternal osteoporosis in a triplet pregnancy: a case report.

Prolonged infusion of magnesium sulfate has been used for the treatment of refractory preterm labor. Long-term magnesium sulfate tocolytic therapy either alone or in combination with other tocolytic agents has been reported to be safe and effective with minimal maternal side effects. There has been only one previous report of a disturbance in maternal calcium homeostasis, which included decreased distal radius bone density and hypercalciuria as a result of prolonged magnesium sulfate infusion. This article reports the first case of bilateral fracture of the calcanei in the postpartum period secondary to osteoporosis associated with prolonged magnesium sulfate tocolysis and bed rest. A 35-year-old white female with a triplet pregnancy of 25 weeks' gestation was admitted in preterm labor. Bed rest, intravenous magnesium sulfate tocolysis, and intermittent subcutaneous terbutaline were necessary to maintain uterine quiescence for 65 days. The patient received weekly betamethasone for 6 weeks for the acceleration of fetal lung maturation. Daily prenatal multivitamins and low-dose subcutaneous heparin for thromboprophylaxis were given. Efforts at tocolysis were ultimately not successful and the patient underwent a cesarean section delivery at 34 2/7 weeks' gestation. The patient's postoperative course was complicated by osteoporosis and bilateral stress fractures of the calcanei. This case report demonstrates that stress fractures secondary to osteoporosis may be associated with prolonged magnesium sulfate therapy and bed rest in higher order multiple pregnancy. Other possible contributing factors to osteoporosis include heparin thromboprophylaxis and suboptimal calcium supplementation. Therefore, in circumstances of prolonged bed rest and magnesium sulfate tocolysis, additional daily calcium supplementation would be well advised.

Multiple pregnancy: factors contributing to early infant's breast-feeding--own experience.

The aims of the study were as follows: 1. to evaluate the effectiveness of current program to promote breast-feeding in our population of infants from multiple pregnancy; 2. to define factors responsible for failure in early breast-feeding establishing and/or maintaining breast-feed during the hospitalization of the babies in neonatal department. 122 newborn infants (2 sets of triplets and 58 twin pairs) born in the Clinic for Pathology of Pregnancy and Labor in Szczecin, Poland, in the years 1995 (January)-1999 (May) from multiple pregnancy were included in the study. In the examined material there were estimated neonatal conditions at birth, neonatal complications, which may disturb successful breast-feeding as well as other factors contributing to early breast-feeding, the way of feeding the babies during neonatal period and the mean time of starting breast-feeding. It was found that most of the examined babies were born with the features of prematurity: mean gestational age was 35.6 +/- 2.2 weeks and mean birthweight--2225.3 +/- 193.2 grams. Only 57.4% of babies were born in good conditions according to Apgar scores. Factors which influence in a negative way early breast-feeding were as follows: respiratory disturbance (22.1%), temporary oral nutrition intolerance due to sickness of the baby or early onset of infections (27.5%), operative delivery (62.3%), medicine taken by mothers (13.9%) and failure in maternal lactation (8.2%). Factors disturbing a normal course of breast-feeding were: phototherapy due to hyperbilirubinemia (20.5%) and late onset of infections (1.6%). In most cases breast-feeding was started 3-4 days after birth and the most frequent way of feeding was formula followed or in combination with maternal milk (at discharge in 86.9% of babies). We concluded that exclusive breast-feeding, despite program of promotion, is a rarity in population of newborn babies born from multiple pregnancy; time to start breast-feeding in this population is usually 3-4 days after delivery. Most pre-term and full-term twins are discharged from neonatal department on maternal milk--exclusively or in combination with formula in situation of scarce maternal milk for two or more infants--what should be considered as our professional success.

Experience in autologous and allogeneic cord blood banking.

Transplantation and gene therapy offer the hope of treating thousands of individuals with various malignancies and genetic disorders. However, if this approach is to become a reality, there must be readily available sources of suitable HLA-A typed stem cells. Cord blood has been demonstrated to be a suitable source of hematopoietic stem cells that can be used in place of bone marrow stem cells for transplant. However, to implement the widespread clinical use of cord blood, it is necessary to establish both autologous and allogeneic cord blood banks from which stem cell specimens can be obtained. These cord blood banks must be large in size, reflect the ethnic diversity of the patient populations in need, and be financially and logistically feasible. At the Cord Blood Stem Cell Bank at the University of Arizona, we have addressed many of these issues and have taken the necessary steps to create both autologous and allogeneic cord blood banks. We have developed simple, efficient, and reproducible methods for cord blood collection that can be used by any physician without need for previous training. Further, we have developed methodologies to process the cord blood specimen so that samples can be stored in cryovials. This approach to cord blood banking allows for the storage of more than 10,000 independent cord blood specimens in a single liquid nitrogen freezer, reducing the costs and physical space requirements for such a facility. We also have developed the use of electronic integration of laboratory worksheets and controlled rate freezers that permit high laboratory throughput with reduced problems of reproducibility, data entry, and management errors. In terms of allogeneic cord blood banking, we have based our bank on several important assumptions regarding HLA haplotype frequency, ethnic diversity, and the need for less than perfect HLA matching between donor and recipient. These assumptions have allowed us to begin to create an allogeneic cord blood bank that can rapidly attain the size needed for clinical utility without exorbitant costs or time involved. Results of our efforts in autologous and allogeneic cord blood banking are presented (including factors that positively and negatively affect cord blood collection and banking).

Coffee intake and other factors in relation to multiple deliveries: a study in Greece.

We conducted a case-control study of factors that may be related to the prevalence of multiple births with at least one liveborn. Over a period of 15 months during 1991-1992 in Athens, Greece, we identified 380 women who had a multiple birth that was delivered in one of the six larger maternity hospitals in the area. We selected as controls 380 livebirth singleton pregnancies delivered at the same hospitals immediately following a multiple pregnancy. All mothers were interviewed in the maternity wards or at home, and zygosity was ascertained through the similarity method. The odds ratio for ovulation-inducing drugs was not elevated for monozygotic twins, but it was 9-fold for dizygotic twins and 90-fold for triplets or quadruplets. We excluded drug-induced pregnancies, twins of indeterminable zygosity, and all triplets from further analyses. We found no remarkable association between any of the study variables and the occurrence of monozygotic twins, with the exception of an increasing trend with age. For dizygotic twins, we found weak associations in the expected directions with maternal age (positive) and height (positive) as well as with parity and number of induced abortions (positive). A history of oral contraceptive use was inversely, but weakly, associated with dizygotic twinning. Each cup of coffee per day was associated with an increment in the odds ratio of 1.23-fold. (95% confidence interval = 1.05-1.43). Restriction of the analysis to dizygotic twins of different gender increased the point estimate of the odds ratio to 1.31 for each cup of coffee consumed daily.(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic control of von Gierke disease (glycogen storage disease type Ia) in pregnancy: maintenance of euglycemia with cornstarch.

In patients with glycogen storage disease type Ia, glucose-6-phosphatase deficiency reduces the liver's ability to generate free glucose from glycogen. Without a continuous, exogenous source of glucose, severe hypoglycemia and subsequent metabolic perturbations occur. Our observations of a patient with glycogen storage disease type Ia, who also had a clomiphene-induced triplet gestation, suggest that cornstarch, which can be catabolized by debranching enzymes, may be used to maintain a constant state of maternal and fetal euglycemia and correct many metabolic abnormalities. Our data suggest that patients with glycogen storage disease type Ia can be safely managed in pregnancy under a tightly monitored and regulated protocol of raw cornstarch feedings.