Predictors of adverse perinatal outcome in twins delivered at < 37 weeks.

OBJECTIVE: Multiple gestations are at increased risk for prematurity as well as perinatal mortality and morbidity. The aim of this study was to identify the independent risk factors for adverse perinatal outcome in a large uniform population of twins delivered preterm. METHODS: We accessed a cohort of twin gestations for the period 1990-2000 delivered at < 37.0 weeks gestation. Chorionicity was established by ultrasound assessment of the dividing membrane, neonatal gender and histologic examination of the placenta at birth. Adverse perinatal outcome was defined as stillbirth, neonatal death, or major neonatal complications. Statistical analysis used contingency tables, Student's t test, one-way ANOVA and logistic regression, with a two-tailed p < 0.05 considered significant. RESULTS: A total of 356 twin gestations (712 twins) were included in the database, and 183 twins (25.7%) had adverse perinatal outcome. Logistic regression analysis demonstrated that gestational age at delivery (p < 0.001), premature rupture of membranes (PROM) (p = 0.004), birth weight discordance (p = 0.009), and 5-min Apgar scores (p = 0.001) were significant and independent predictors of adverse perinatal outcome, whereas monochorionicity and twin-twin transfusion syndrome were not. CONCLUSIONS: Gestational age at delivery and birth weight discordance are the most important independent predictors of perinatal mortality or morbidity among preterm twins.

Randomized study on removable PGE2 vaginal insert versus PGE2 cervical gel for cervical priming and labor induction in low-Bishop-score pregnancy.

BACKGROUND: Dinoprostone vaginal insert has been compared to Dinoprostone cervical gel in few studies, whose cases presented different Bishop scores and gestational ages at admission, and various treatment strategies in control arms. The present study compares the vaginal insert to the cervical gel in patients with low Bishop score at term. METHODS: Prospective multicenter randomized trial, with parity-based randomization. Admission criteria: single pregnancy with Bishop score of 0-4, gestational age of 37-41 weeks, intact membranes, no previous cesarean section, no bleeding or abnormal cardiotocography at admission. RESULTS: Vaginal prostaglandins were required as a second-line induction procedure in 25% of study patients versus 47.1% of controls (p < 0.03, chi2). Study patients experienced shorter induction-to-delivery time (920 +/- 428 versus 1,266 +/- 740 min, p <0,01), with a mean difference of 5 h and 46 min between the groups. Even though patients that received vaginal insert showed a trend of increased incidence of abnormal cardiotocography during labor (12% versus 6.3%) and hyperkinetic labor (11.8% versus 2.1%), the incidence of cesarean sections (21.4% versus 21.6%), cesareans for fetal distress (12.5% versus 11.8%), and umbilical artery pH <7.10 (4.9% versus 2.5%) was comparable between the two groups. CONCLUSIONS: Dinoprostone vaginal insert is more efficient than cervical gel in promoting cervical priming and labor induction in low-Bishop-score patients at term. The vaginal insert placement seems to be safe for the mother and the newborn, although larger studies are required to investigate uterine hyperstimulation incidence.

Prognostic value of change in amniotic fluid color during labor.

OBJECTIVE: Evidence of meconium-stained amniotic fluid (AF) during labor suggests implementation of close monitoring of fetal well-being. We have investigated whether the presence of meconium in the AF on admission for labor is as important a predictor of neonatal outcome as a change in AF color during labor. METHODS: AF characteristics on admission for labor at term (37-42 weeks) and their changes during labor were recorded in all singleton pregnancies during an 8-year period (1992-1999). Excluded were stillbirths on admission, congenital anomalies, and elective cesarean sections. The presence of meconium and its consistency (light or thick) were documented on admission by inspection with transcervical amnioscopy in women with intact membranes or in the vaginal pool in those with ruptured membranes. Changes in AF color or consistency during labor were recorded and correlated with the obstetric and neonatal outcome. Statistical analysis utilized chi(2) for trend, with p < 0.05 considered significant. RESULTS: 19,090 women were admitted in labor at term during the study period and fulfilled the study inclusion criteria and had amniotic fluid evaluation available. The appearance of meconium or worsening in thickness of meconium during labor was associated with higher rates of Apgar scores <7 at 5 min (clear AF on admission and at delivery 0.6%; light or thick meconium on admission and no change at delivery 0.8%; clear AF on admission and light or thick meconium at delivery 3.2%, and light meconium on admission and thick meconium at delivery 2.5%; p < 0.001) and umbilical artery pH <7.10 (the respective rates in the four groups were 1.7, 1.8, 3.6, and 3.8%; p < 0.001). CONCLUSION: The appearance or thickening of meconium during labor has a greater predictive ability for depressed neonates than the presence of meconium on admission.

Preterm twins: what threshold of birth weight discordance heralds major adverse neonatal outcome?

OBJECTIVE: This study was undertaken to establish the optimal threshold of birth weight discordance for prediction of adverse outcome in liveborn, non-malformed preterm twins. STUDY DESIGN: We accessed a cohort of twin gestations for the period 1990 through 2000 delivered at less than 37.0 weeks' gestation. Adverse neonatal outcome was defined as stillbirth or occurrence of major morbidities. RESULTS: A total of 335 twin gestations (670 twins) were included, of which 104 (31%) experienced adverse neonatal outcome. The average birth weight discordance was 12.4% +/- 10.6% versus 19.4% +/- 14.8% in those with good versus adverse outcome (P < .001). Birth weight discordance was a significant predictor of adverse neonatal outcome that was independent of gestational age at delivery, small for gestational age, and chorionicity. Receiver operating characteristic curve analysis suggested that optimal thresholds of birth weight discordance for clinical use should take into account gestational age. CONCLUSION: Birth weight discordance is an independent predictor of adverse neonatal outcome in liveborn, non-malformed preterm twins.