Perinatal outcomes between immediate vs deferred selective termination in dichorionic twin pregnancies with fetal congenital anomalies: a French multicenter study.

BACKGROUND: Because selective termination for discordant dichorionic twin anomalies carries a risk of pregnancy loss, deferring the procedure until the third trimester can be considered in settings where it is legal. OBJECTIVE: To determine whether perinatal outcomes were more favorable following deferred rather than immediate selective termination. STUDY DESIGN: A French multicenter retrospective study from 2012 to 2023 on dichorionic twin pregnancies with selective termination for fetal conditions, which were diagnosed before 24 weeks gestation. Pregnancies with additional risk factors for late miscarriage were excluded. We defined 2 groups according to the intention to perform selective termination within 2 weeks after the diagnosis of the severe fetal anomaly was established (immediate selective termination) or to wait until the third trimester (deferred selective termination). The primary outcome was perinatal survival at 28 days of life. Secondary outcomes were pregnancy losses before 24 weeks gestation and preterm delivery. RESULTS: Of 390 pregnancies, 258 were in the immediate selective termination group and 132 in the deferred selective termination group. Baseline characteristics were similar in both groups. Overall survival of the healthy co-twin was 93.8% (242/258) in the immediate selective termination group vs 100% (132/132) in the deferred selective termination group (P<.01). Preterm birth <37 weeks gestation was lower in the immediate than in the deferred selective termination group (66.7% vs 20.2%; P<.01); preterm birth <28 weeks gestation and <32 weeks gestation did not differ significantly (respectively 1.7% vs 0.8%; P=.66 and 8.26% vs 11.4%; P=.36). In the deferred selective termination group, an emergency procedure was performed in 11.3% (15/132) because of threatened preterm labor, of which 3.7% (5/132) for imminent delivery. CONCLUSION: Overall survival after selective termination was high regardless of the gestational age at which the procedure was performed. Postponing selective termination until the third trimester seems to improve survival, whereas immediate selective termination reduces the risk of preterm delivery. Furthermore, deferred selective termination requires an expert center capable of performing the selective termination procedure on an emergency basis if required.

Impact of history of myomectomy on preterm birth risk in women with a leiomyomatous uterus: a propensity score analysis.

BACKGROUND: To evaluate if women with a history of myomectomy have a modified preterm birth risk compared to women with myomas during pregnancy. METHODS: Retrospective cohort study including all women with a history of myomectomy (operated group) or uterine myomas during pregnancy (unoperated group) who delivered in a tertiary center between January, 2011 and December, 2017. The operated group included women who had a myomectomy history with or without myomas during the ongoing pregnancy. The unoperated group included women with uterine myoma(s) seen on at least one ultrasound during pregnancy without history of myomectomy. The primary outcome was preterm birth < 37 weeks, and the secondary outcome spontaneous preterm birth < 37 weeks. To control for confounding factors, a propensity score approach was used. Two sensitivity analysis were performed, one repeating the analysis using the propensity score after excluding operated women with persistent myomas and one using a classical multivariable logistic regression model. RESULTS: The cohort included 576 women: 283 operated women and 293 unoperated women. The rate of preterm birth was similar in the two groups: 12.6% in the unoperated group and 12.0% in the operated group (p = 0.82). No difference in preterm birth risk was shown between unoperated and operated women in the cohort matched on the propensity score: OR 0.86; 95%CI [0.47-1.59]. These results were consistent for spontaneous preterm birth (OR 1.61; 95%CI [0.61-4.23]) and for the sensitivity analyses. CONCLUSION: In women with a leiomyomatous uterus, a history of myomectomy is not associated with a reduced preterm birth risk.

When can obstetric risk be predicted?

OBJECTIVE: The aim of the study was to assess the chronology of the appearance of perpartum obstetric risk factors (POR) in order to define the best moment to evaluate the type of management to which women will be oriented. We have secondarily studied the extent to which inappropriate medical interventions play a role in the genesis of some complications in the deliveries of women who are in principle at low risk. MATERIALS AND METHODS: We conducted a prospective cohort study from January 1 to June 30, 2015 at the Croix-Rousse Hospital of Lyon, a level III maternity, and the Valence Hospital Center, a level II maternity, including all women giving birth at 24 to 42 weeks of gestation at hospital. The women were divided into two groups : one with no known perpartum obstetric risk (POR-) and the other with at least one obstetrical perpartum risk factor (POR+), defined at three different stages (at the last pregnancy monitoring consultation, at the onset of labor at the admission in the delivery room, and at the end of labor just before expulsive efforts). We observed medical interventions and foeto-maternal complications in each group. A non-simple delivery was a delivery involving a medical intervention, or a maternal or neonatal complication, or any combination of these. A secondary retrospective analysis of the practices and management was made for women initially considered POR- at the onset of labor but who had a non-simple delivery to assess adherence to current guidelines according to an audit schedule. RESULTS: Among 1975 women, we identified 32% women as POR- at end of pregnancy, 21% at start of labor and 20% at end of labor. Among the POR- women at start of labor, 16% had a non-simple delivery. 35% of these non-simple deliveries might perhaps have been avoided by closer adherence to current recommendations. Nonetheless 54% of these women still had an unpredictable and inevitable non-simple delivery that in some cases required an extremely rapid intervention. CONCLUSION: Determining and predicting pregnant women who will need additional resources in addition to the usual obstetric and neonatal care is difficult. This identification should be made at the admission for delivery and this risk should be reassessed during labor. There are no women at zero risk of intervention. Therefore, delivery in demedicalized units should not take place in isolated or distant free-standing facilities.

The many faces of prenatal imaging diagnosis of primitive aqueduct obstruction.

OBJECTIVE: To describe the different prenatal imaging patterns related to primary aqueduct obstruction throughout pregnancy and their impact on prenatal counseling. METHOD: Retrospective review of consecutive prenatal cases of isolated aqueduct obstruction diagnosed over a seven-year period (2010-2016). Prenatal imaging findings, postnatal imaging, pathological data and postnatal outcome, were analyzed. RESULTS: Twelve cases were included. In four cases, termination of pregnancy was performed, due to early severe ventriculomegaly in three cases suggestive of complete aqueduct obstruction. In eight cases in which pregnancy was continued, three different evolving imaging patterns were demonstrated. In three cases the ventriculomegaly evolved rapidly during third trimester and were subsequently associated with abnormal white matter changes on fetal MRI. Theses cases led to premature delivery in two cases and early surgical care in all, with focal cystic parenchymal damage shown on follow-up MRI in two cases. Slowly evolving ventriculomegaly in three cases diagnosed in the second and the third trimester which required delayed surgery during the first year of life. Stable ventriculomegaly in two cases which did not require any surgical procedure. CONCLUSION: The diagnosis of primary aqueduct obstruction may be based on different prenatal imaging patterns that include either severe early ventriculomegaly, stable, slowly or rapidly evolving ventriculomegaly.