Surgical complications in pregnancy after bariatric surgery; a case series.

BACKGROUND: Obesity is a rising world-wide problem and bariatric surgery, also in the reproductive age, is increasingly performed. Bariatric procedures are associated with surgical complications during pregnancy, such as internal herniation. CASES: In this case series three cases with severe surgical complications after Roux-Y gastric bypass are described. In all three cases surgery was needed to prevent further complications. In one case subtotal bowel resection had to be performed because of extensive necrosis and intra-uterine fetal death was found. CONCLUSION: Though surgical complications after Roux-Y gastric bypass are not very common, complications can be very serious and lead to severe morbidity and even mortality for mother and fetus. Because of the severity of complications, delaying bariatric surgery or considering alternative bariatric techniques with fewer (severe) complications should be considered in obese women in childbearing age.

Perinatal outcome of monochorionic and dichorionic twins after spontaneous and assisted conception: a retrospective cohort study.

INTRODUCTION: The aim of this study was to compare pregnancy outcomes in twin pregnancies after assisted conception and spontaneous conception, according to chorionicity. MATERIAL AND METHODS: Retrospective cohort study of 1305 twin pregnancies between 1995 and 2015. All spontaneous (n = 731) and assisted conception conceived (n = 574) twin pregnancies with antenatal care and delivery in University Medical Center Utrecht, the Netherlands, a tertiary obstetric care center were studied according to chorionicity. RESULTS: Maternal age and incidence of nulliparity were higher among the assisted conception twins. Hypertensive disorders also appeared to be more frequent in assisted conception pregnancies, which could largely be explained by the higher proportion of elderly nulliparous women in this group. Spontaneously conceived twins were born earlier than twins after assisted conception, with subsequent lower birthweights and more admissions to a neonatal intensive care unit with increased neonatal morbidity. Monochorionic twins had worse pregnancy outcomes compared with dichorionic twins, irrespective of mode of conception; monochorionic twins conceived by assisted reproduction had more neonatal morbidity (mainly respiratory distress syndrome and necrotizing enterocolitis) and late neonatal deaths compared with spontaneously conceived monochorionic twins. CONCLUSIONS: Spontaneously conceived twins have worse pregnancy outcome compared with twins after assisted conception, probably due to a lower incidence of monochorionicity in the assisted conception group. The already increased perinatal risks in monochorionic twins are even higher in monochorionic twins conceived after infertility treatments compared with spontaneously conceived monochorionic twins, which warrants extra attention to these high-risk pregnancies.

Increased stillbirth in uncomplicated monochorionic twin pregnancies: a systematic review and meta-analysis.

OBJECTIVE: To estimate the risk of stillbirth in apparently uncomplicated monochorionic-diamniotic twin pregnancies by systematic review and meta-analysis and compare it with that in uncomplicated dichorionic pregnancies. DATA SOURCES: We performed an electronic search (January 1985 to April 2012) of Medline, PubMed, Embase, and ClinicalTrials.gov databases. METHODS OF STUDY SELECTION: Studies detailing gestational-age specific stillbirth rates after 24 weeks of gestation in monochorionic-diamniotic twin pregnancies uncomplicated by twin-twin transfusion syndrome, growth restriction, or major anomalies. The rate and risk of stillbirth were calculated in 2-week gestational age blocks and compared in controlled studies with dichorionic pregnancies. TABULATION, INTEGRATION, AND RESULTS: We evaluated 361 studies to include nine informative studies, four after additional data from the investigators. The rate of stillbirth per 1,000 uncomplicated monochorionic-diamniotic pregnancies at 32-33, 34-35, and 36-37 weeks of gestation was 5.1, 6.8, and 6.2, respectively. The risk of stillbirth per pregnancy at 32, 34, and 36 weeks of gestation was 1.6%, 1.3% and 0.9%, respectively. Compared with uncomplicated dichorionic pregnancies, the odds ratio for stillbirth per pregnancy at 32, 34, and 36 weeks of gestation was 4.2 (95% confidence interval [CI] 1.4-12.6), 3.7 (CI 1.1-12.0), and 8.5 (CI 1.6-44.7), respectively. CONCLUSION: Uncomplicated monochorionic twin pregnancies are at substantial risk of stillbirth throughout the third trimester, which is severalfold higher than in dichorionic twin pregnancies. Given the risk of fetal death to the cotwin, these data should inform decisions around timing of delivery in seemingly normal monochorionic twin pregnancies.

Long-term outcome in relationship to neonatal transfusion volume in extremely premature infants: a comparative cohort study.

BACKGROUND: In premature born infants red blood cell (RBC) transfusions have been associated with both beneficial and detrimental sequels. Upon RBC transfusion, improvement in cerebral blood flow and oxygenation have been observed, while a more liberal transfusion policy may be associated with a better developmental outcome. The effect of the transfusion volume on long-term outcome is not known. METHODS: Observational follow-up study of a cohort of extremely premature born infants, treated in 2 neonatal intensive care units using a different transfusion volume (15 ml/kg in Unit A and 20 ml/kg in Unit B). The primary outcome was a composite of post discharge mortality, neuromotor developmental delay, blindness or deafness, evaluated at a mean corrected age (CA) of 24 months related to the transfusion volume/kg bodyweight administered during the postnatal hospital stay. RESULTS: Despite the difference in transfusion volume in clinically comparable groups of infants, they received a similar number of transfusions (5.5 ± 3.2 versus 5.5 ± 2.3 respectively in Unit A and B). The total transfused volume in unit A was 79 ± 47 ml/kg and 108 ± 47 ml/kg in unit B (p = 0.02). Total transfused RBC volume per kg bodyweight was not an independent predictor of the composite outcome (p = 0.96, OR 1.0 (CI 0.9-1.1). CONCLUSION: There was no relationship between the composite outcome at 24 months CA and transfusion volume received during the post natal hospital stay. As there was no clinical advantage of the higher transfusion volume, a more restrictive volume will reduce total transfusion volume and donor exposure. Future research on the optimal transfusion volume per event to extreme preterm infants should include larger, prospective studies with a longer follow-up period through to childhood or even adolescence.

Long-term neurodevelopmental outcome of monochorionic and matched dichorionic twins.

BACKGROUND: Monochorionic (MC) twins are at increased risk for perinatal mortality and serious morbidity due to the presence of placental vascular anastomoses. Cerebral injury can be secondary to haemodynamic and hematological disorders during pregnancy (especially twin-to-twin transfusion syndrome (TTTS) or intrauterine co-twin death) or from postnatal injury associated with prematurity and low birth weight, common complications in twin pregnancies. We investigated neurodevelopmental outcome in MC and dichorionic (DC) twins at the age of two years. METHODS: This was a prospective cohort study. Cerebral palsy (CP) was studied in 182 MC infants and 189 DC infants matched for weight and age at delivery, gender, ethnicity of the mother and study center. After losses to follow-up, 282 of the 366 infants without CP were available to be tested with the Griffiths Mental Developmental Scales at 22 months corrected age, all born between January 2005 and January 2006 in nine perinatal centers in The Netherlands. Due to phenotypic (un)alikeness in mono-or dizygosity, the principal investigator was not blinded to chorionic status; perinatal outcome, with exception of co-twin death, was not known to the examiner. FINDINGS: Four out of 182 MC infants had CP (2.2%) - two of the four CP-cases were due to complications specific to MC twin pregnancies (TTTS and co-twin death) and the other two cases of CP were the result of cystic PVL after preterm birth - compared to one sibling of a DC twin (0.5%; OR 4.2, 95% CI 0.5-38.2) of unknown origin. Follow-up rate of neurodevelopmental outcome by Griffith's test was 76%. The majority of 2-year-old twins had normal developmental status. There were no significant differences between MC and DC twins. One MC infant (0.7%) had a developmental delay compared to 6 DC infants (4.2%; OR 0.2, 95% 0.0-1.4). Birth weight discordancy did not influence long-term outcome, though the smaller twin had slightly lower developmental scores than its larger co-twin. CONCLUSIONS: There were no significant differences in occurrence of cerebral palsy as well as neurodevelopmental outcome between MC and DC twins. Outcome of MC twins seems favourable in the absence of TTTS or co-twin death.

The natural course of monochorionic and dichorionic twin pregnancies: a historical cohort.

Current early diagnosis, surveillance and intervention options make it hard to determine the natural course of twin pregnancies, especially regarding spontaneous preterm delivery and perinatal mortality. We studied the natural course in monochorionic (MC) and dichorionic (DC) twin pregnancies in a historical cohort. Twin pregnancies were studied in a unique database of 651 twin pairs born in the period 1907 to 1938. We examined the effect of chorionicity on gestational age, birthweight, perinatal mortality, intertwin birthweight differences, the incidence of preeclampsia and maternal mortality. Perinatal mortality was 27.7% for MC and 15.8% for DC twins (p < .001). Gestational age and birthweight were stronger predictors of perinatal mortality than chorionicity. Perinatal outcome was poorer for the second twin, especially in DC twins. Delivery before 37 weeks of gestation occurred more often in MC twin pregnancies (48.8% compared to 33.3% in DC twin pregnancies). DC twins were on average 288 g (95% confidence interval 201-376) heavier than MC twins. Severe birthweight discordancy occurred equally in MC and DC twins (18.1%). However, if present, mortality was only increased in MC twins. The birthweight of girls was not affected by the presence of a male co-twin. In this historical cohort MC twin pregnancies had a higher perinatal mortality, caused by a high incidence of low birthweight mainly due to preterm delivery. Mortality did not differ in deliveries after 31 weeks of gestation, which is in contrast to recent data. Apparently, modern obstetrics is more effective in reducing mortality in DC twins.