Fetal Growth and Antenatal Testing in Uncomplicated Multiple Gestations.

Multiple gestations experience a slowing of fetal growth in the third trimester and have been described as having a higher risk of growth restriction. Whether this increased diagnosis of fetal growth restriction is physiological or pathologic is controversial. In an attempt to better identify those fetuses most at risk, twin-specific growth charts have been developed and tested. In addition, there are data to suggest that multiple gestations experience an increased risk of unexpected third-trimester stillbirth in apparently uncomplicated pregnancies. This chapter reviews the current data and recommendations for fetal growth assessment, antenatal surveillance, and delivery timing in uncomplicated multiple gestations.

Dichorionic twin-specific vs singleton growth references for diagnosis of fetal growth restriction.

BACKGROUND: Fetal growth restriction is associated with an increased risk for adverse neonatal outcomes. The Hadlock singleton growth reference is widely used to determine the estimated fetal weight percentile for both twin and singleton gestations. The Eunice Kennedy Shriver National Institute of Child Health and Human Development's twin-specific growth reference accounts for the different growth trajectory that twins follow during gestation. There is a lack of research comparing these different growth references in their ability to identify fetal growth restriction that is associated with adverse neonatal outcomes in dichorionic twin gestations. OBJECTIVE: This study aimed to compare a twin-specific growth reference (the Eunice Kennedy Shriver National Institute of Child Health and Human Development's twin-specific growth reference) and a singleton growth reference (Hadlock) in their ability to identify fetal growth restriction associated with adverse neonatal outcomes in dichorionic twin gestations. STUDY DESIGN: This was a retrospective cohort study of dichorionic twin gestations at ≥32 weeks' gestation delivered at a single institution between 2004 and 2019 with the serial growth ultrasounds and neonatal outcomes data available for analysis. Using their last growth ultrasound before delivery, twins were classified into the following 3 categories: fetal growth restriction according to both the Hadlock and Eunice Kennedy Shriver National Institute of Child Health and Human Development references, fetal growth restriction according to the Hadlock reference only, and no fetal growth restriction according to either reference, with fetal growth restriction defined as an estimated fetal weight of <10th percentile for gestational age. Multivariable generalized linear mixed models were used to assess the adverse neonatal outcomes via pair-wise comparisons between the groups, with a random-effects component to account for twin-pair correlations. RESULTS: A total of 1460 dichorionic twin infants were included with 8.1% (n=118) of cases classified as fetal growth restricted by both the Eunice Kennedy Shriver National Institute of Child Health and Human Development and Hadlock references, 8.8% (n=129) of cases classified as fetal growth restricted by the Hadlock reference only, and 83.1% (n=1213) of cases classified as no fetal growth restriction by either reference. Compared with twins with no fetal growth restriction by either reference, twins with fetal growth restriction by both references were more likely to experience mild (adjusted odds ratio, 2.38; confidence interval, 1.38-4.13) or severe (adjusted odds ratio, 2.82; confidence interval, 1.16-6.88) composite neonatal morbidity. Compared with twins with fetal growth restriction according to the Hadlock reference only, twins with fetal growth restriction according to both references were more likely to experience mild (adjusted odds ratio, 2.03; confidence interval, 1.00-4.14) but not severe (adjusted odds ratio, 3.70; confidence interval, 0.72-18.90) composite neonatal morbidity. Composite neonatal morbidity was not different between twins with fetal growth restriction according to the Hadlock reference only and those with no fetal growth restriction by either growth reference. CONCLUSION: The Eunice Kennedy Shriver National Institute of Child Health and Human Development's twin-specific growth reference better identifies the risk for adverse neonatal outcomes in dichorionic twin gestations diagnosed with fetal growth restriction. The use of the Hadlock singleton growth reference more than doubles the number of dichorionic twins identified with fetal growth restriction who seem to be at a low-risk for neonatal morbidity, leading to unnecessary maternal anxiety, increased antenatal testing, and possibly iatrogenic preterm delivery.

Prevention of Cesarean Delivery Surgical Site Infections.

IMPORTANCE: Surgical site infection (SSI) is a common complication of cesarean delivery. Seen in up to 12% of cesarean deliveries, it is a major cause of prolonged hospital stay and a burden to the healthcare system. Interventions and techniques must be identified to decrease the risk of cesarean delivery SSIs. OBJECTIVE: We review the categories of SSI, current studies that have focused on various interventions to decrease SSI, and preoperative, intraoperative, and postoperative recommendations for cesarean delivery SSI prevention. EVIDENCE ACQUISITION: A thorough search of PubMed for all current literature was performed. Various surgical interventions and techniques were reviewed. We included studies that looked at preoperative, intraoperative, and postoperative interventions for SSI prevention. RESULTS: We have summarized several surgical interventions and techniques as well as current consensus statements to aid the practitioner in preventing SSIs after cesarean delivery. CONCLUSIONS AND RELEVANCE: Upon analysis of current data and consensus statements pertaining to cesarean deliveries, there are certain preoperative, intraoperative, and postoperative interventions and techniques that can be recommended to decrease the risk of cesarean delivery SSI.