Neurodevelopmental outcome and risk factors for disability for twin-twin transfusion syndrome treated with laser surgery.

OBJECTIVE: This study was performed to report the neurodevelopmental outcome of survivors of twin-twin transfusion syndrome (TTTS) treated with laser surgery and to determine the risk factors for neurodevelopmental disability. STUDY DESIGN: A prospective study of TTTS cases treated with laser was performed. Survivors were assessed at 2 years corrected for prematurity. Neurodevelopmental disability was defined as the presence of cerebral palsy, deafness, blindness, or cognitive impairment with a developmental score >2 SDs below the mean. RESULTS: A total of 75 TTTS pregnancies were treated with a perinatal survival rate of 79.3%. A total of 113 survivors were assessed. The rate of cerebral palsy was 4.4% and cognitive impairment was 8%, with a neurodevelopmental disability rate of 12.4%. Quintero stage was the only independent risk factor for neurodevelopmental disability. CONCLUSION: The incidence of neurodevelopmental disability in TTTS survivors treated with laser is considerable, with Quintero stage being an independent risk factor.

Selective fetoscopic laser ablation in 100 consecutive pregnancies with severe twin-twin transfusion syndrome.

AIMS: To report the perinatal outcomes of a large series of twin pregnancies with severe twin-twin transfusion syndrome (TTTS) managed with laser ablation surgery in an Australian tertiary perinatal centre and to compare the outcome with other large cohorts. METHODS: The outcomes of 100 consecutive pregnancies with severe TTTS managed with selective fetoscopic laser ablation from March 2002 to June 2007 were examined. Survival and neonatal morbidity were analysed. Comparisons were made with the results from other studies of laser surgery with at least 100 pregnancies. RESULTS: There were 100 women with TTTS treated with laser ablation; 34 stage II, 44 stage III and 22 at stage IV. Median gestation at time of laser was 21 weeks (range 18-28) and median gestation at delivery was 31 weeks (range 20-39). Overall perinatal survival rate was 151 of 200 (75.5%). Eighty five per cent had one or more surviving twins. The survival rate for stage IV TTTS was 88.6%, significantly better than for stage II (69.1%) and stage III (73.9%) pregnancies. The perinatal mortality rate for donors (30%) was not significantly different from recipients (19%), but the fetal death rate for donors was significantly greater than that for recipients (P = 0.03). Severe cerebral abnormalities were present in only 2.8% of newborns. The overall survival rate was comparable to other large series. CONCLUSIONS: These results for the management of severe TTTS are comparable to the best reported international series. Long-term follow-up is required and more research needs to be undertaken to further improve these results.

Interventions for ketosis during labour.

BACKGROUND: In labour, ketosis (the elevation of ketone bodies in the blood) is a common occurrence, due to increased physical stress, which is often compounded by reduced oral intake. The effect of ketosis on the mother and baby during labour is not clear, therefore, there is uncertainty as to whether ketosis is a normal physiological response or whether women with ketosis in labour require intervention (such as intravenous fluids or increased oral intake) for maternal and infant wellbeing. This uncertainty has resulted in differences in opinion and practice by those providing care for women in labour. OBJECTIVES: To assess the effects on maternal, fetal and neonatal outcomes of intravenous fluids or increased oral intake administered to women in labour for the treatment of ketosis compared with no intervention (defined as no oral intake, ice chips only, or oral intake on demand) and to also assess the effects of different types of intravenous fluids administered. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2008), CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE (1950 to January 2007), EMBASE (1988 to January 2007) and CINAHL (1982 to 2007). SELECTION CRITERIA: All published and unpublished randomised trials in which additional oral intake or intravenous fluids, or both, were used for the treatment of women with ketosis in labour. DATA COLLECTION AND ANALYSIS: Two authors independently assessed potentially eligible trials. The authors sought additional information on trial methods and outcome data to enable consideration of eligibility of studies. However, at the time of the review, no information was received. MAIN RESULTS: We identified six trials as potentially eligible for inclusion in this review. All six studies were excluded. Therefore no trials are included in this review. AUTHORS' CONCLUSIONS: There is no information on which to base practice in the treatment of women with ketosis during labour. Further research is required to identify more clearly the association between ketosis in labour and pregnancy outcome. Future trials should examine the effects of no interventions and different types of intravenous and oral fluids on these clinically important outcomes, and include women's perception and satisfaction with care during labour and birth.

Parenting stress and psychosocial health in mothers with twin-twin transfusion syndrome managed with laser surgery: a preliminary study.

Twin-twin transfusion syndrome (TTTS) is a severe complication of twin pregnancies with high risk for perinatal mortality and long-term morbidity. This cross-sectional cohort study aimed to determine parenting stress and psychosocial health in mothers with a pregnancy complicated by TTTS that had been managed with laser ablation of communicating placental vessels. Questionnaires were sent to the mothers for completion: Parenting Stress Index (PSI), Edinburgh Postnatal Depression Scale (EPDS) and a semi-structured questionnaire related to mental health problems and support received from health professionals. Thirty-seven mothers were sent questionnaires with 32 being returned. The results showed that 47% of women had total scores equal to or greater than the 85th percentile on the PSI, which is considered abnormally high. Twenty-six per cent of mothers had evidence of depression on the EPDS. Mothers of children with prolonged medical conditions or neurological problems had significantly higher scores (p =.011). Parenting stress was not associated with high scores on the EPDS. Medical and midwifery staff were considered to provide high levels of support, with social work providing none or low levels of support. In conclusion, women whose TTTS pregnancy was managed by laser surgery have high levels of parenting stress. As the results showed that parenting stress cannot be predicted at the time of hospitalization, it is suggested that more support should be provided in hospital with further follow-up after discharge.

Perinatal outcomes with laser surgery for twin-twin transfusion syndrome.

The aim of this tertiary hospital-based cohort study was to determine and compare perinatal outcome and neonatal morbidities of pregnancies with twin-twin transfusion syndrome (TTTS) before and after the introduction of a treatment program with laser ablation of placental communicating vessels. Twenty-seven pregnancies with Stage II-IV TTTS treated with amnioreduction were identified (amnioreduction group). The data were compared with that obtained from the first 31 pregnancies with Stage II-IV TTTS managed with laser ablation of placental communicating vessels (laser group). Comparisons were made for perinatal survival and neonatal morbidities including abnormalities on brain imaging. The median gestation at therapy was similar between the two groups (20 vs. 21 weeks, p = .24), while the median gestation at delivery was significantly greater in the laser treated group (34 vs. 28 weeks, p = .002). The perinatal survival rate was higher in the laser group (77.4% vs. 59.3%, p = .03). Neonatal morbidities including acute respiratory distress, chronic lung disease, requirement for ventilatory assistance, patent ductus arteriosus, hypotension, and oliguric renal failure had a lower incidence in the laser group. On brain imaging, ischemic brain injury was seen in 12% of the amnioreduction group and none of the laser group of infants (p = .01). In conclusion, these findings indicate that perinatal outcomes are improved with less neonatal morbidity for monochorionic pregnancies with severe TTTS treated by laser ablation of communicating placental vessels when compared to treatment by amnioreduction.

The fetal tele-ultrasound project in Queensland.

The need for access to tertiary centre experts for those living in rural and remote areas of Queensland is well recognised. With an estimated population of 3.3 million people of whom 55% live outside the capital city, Queensland is ideally suited to telemedicine, as it provides a potential opportunity to improve access to specialist care. Congenital fetal abnormalities are the major causes of perinatal morbidity and mortality. With only two Maternal Fetal Medicine Specialists in Queensland located in a major teaching hospital in Brisbane, the opportunity to use videoconferencing technology to develop a tertiary level tele-ultrasound service presented a challenge--that is, to find a technical and clinical solution to enable such a service. We report on some of our practical experiences and difficulties in establishing such a service.

Risk management considerations and the pregnancy handheld record. An audit of the return rate of the pregnancy handheld record.

PURPOSE: Risk management is integral to the provision of contemporary health care. As maternity practices change and with a commitment on women being at the centre of care, one strategy has been for women to retain their records during the antenatal period. This paper explores the return rate of the pregnancy handheld record in a major tertiary facility and discusses the risk management implications when the record is not available upon presentation to the treating practitioner. PROCEDURE: Four audits were conducted over a 2 year period to determine the return rate of the pregnancy handheld record at time of admission for labour and birth. A total of 1096 records were returned out of a possible 1256 during the study. FINDINGS: A 6.6% increase in the return rate was achieved over the 4 audit periods (82-88.5%) with an overall return rate of 85%. PRINCIPLE CONCLUSIONS: Our audit highlights the need for consumers, clinicians and heath care facilities to consider the advantages and disadvantages of the pregnancy handheld record, as well as the medico-legal responsibilities that ultimately fall back on the health facility.

Maternal position at midwife-attended birth and perineal trauma: is there an association?

BACKGROUND: Most women will sustain some degree of trauma to the genital tract after vaginal birth. This study aimed to examine the association between maternal position at birth and perineal outcome in women who had a midwife-attended, spontaneous vaginal birth and an uncomplicated pregnancy at term. METHODS: Data from 3,756 births in a major public tertiary teaching hospital were eligible for analysis. The need for sutures in perineal trauma was evaluated and compared for each major factor studied (maternal age, first vaginal delivery, induction of labor, not occipitoanterior, use of regional anesthesia, deflexed head and newborn birthweight >3,500 g). Birth positions were compared against each other. Subgroup analysis determined whether birth positions mattered more or less in each of the major factors studied. The chi-square test was used to compare categorical variables. RESULTS: Most women (65.9%) gave birth in the semi-recumbent position. Of the 1,679 women (44.5%) who required perineal suturing, semi-recumbent position was associated with the need for perineal sutures, whereas all-fours was associated with reduced need for sutures; these associations were more marked in first vaginal births and newborn birth weight over 3,500 g. When regional anesthesia was used, semi-recumbent position was associated with a need for suturing, and lateral position associated with a reduced need for suturing. The four major factors significantly related to perineal trauma included first vaginal birth, use of regional anesthesia, deflexed head, and newborn weight more than 3,500 g. CONCLUSIONS: Women should be given the choice to give birth in whatever position they find comfortable. Maternity practitioners have a responsibility to inform women of the likelihood of perineal trauma in the preferred birth position. Ongoing audit of all clinicians attending births is encouraged to further determine effects of maternal birth position and perineal trauma, to investigate women's perception of comfortable positioning at birth, and to measure changes to midwifery practice resulting from this study.