Twin discordance: a study of volumetric fetal brain MRI and neurodevelopmental outcome.

OBJECTIVE: This study employed magnetic resonance imaging (MRI) to compare brain volumes of discordant twins and examined their neurodevelopment after birth by using a validated exam. STUDY DESIGN: A prospective historical cohort study of discordant dichorionic diamniotic (DCDA) or monochorionic diamniotic (MCDA) twin fetuses, who undergone an MRI scan to evaluate growth restriction in the discordant twin (weight < 10th centile) during 6 years period, at a single tertiary center. Twenty-seven twin pairs were included in the volumetric study and 17 pairs were included in the neurodevelopmental outcome examination. The volumes of the supratentorial brain region, both hemispheres, eyes, and the cerebellum were measured by 3D MRI semi-automated volume measurements. Volumes were plotted on normal growth curves and discordance was compared between weight at birth and brain structure volumes. Neurodevelopmental outcome was evaluated using the VABS-II questionnaire at a mean age of 4.9 years. RESULTS: The volume of major brain structures was significantly larger in the appropriate-for-gestational-age twins (AGA) compared to the small-for-gestational-age (SGA) co-twins (p < 0.001). The birth weight discordance was 32.3% (24.9-48.6) and was significantly greater (p < 0.001) than the discordance of the prenatal supratentorial brain (13.6% [5.6-18]), cerebellum volume (21.7% [9.5-30.8]). Further neurodevelopmental outcome evaluation found no significant difference between the AGA twin and the SGA twin. CONCLUSION: In discordant twins, the smaller twin showed a "brain-preserving effect," which in our study was not associated with a worse neurodevelopmental outcome. The use of MRI in such cases may aid in decision-making and parental consultation. KEY POINTS: • Weight discordance at birth was significantly greater compared to intrauterine brain volume discordance measured by 3D MRI. • Small-for-gestational-age (SGA) fetuses preserve brain development. • In highly discordant twins, there was no long-term difference in neurodevelopmental outcome at a mean age of 4.9 years.

A decade's experience in primipara, term, singleton, vertex parturients with a sustained low rate of CD.

Background Cesarean delivery (CD) in primiparas with a term singleton vertex fetus (PTSV) is a sentinel event for the future mode of delivery and determinant of repeat CD risk. We aimed to evaluate the risk factors for primary CD in a population with a decade of sustained low rate of intrapartum CD. Methods This was a retrospective single-center cohort study between 2005 and 2014. The primary outcome of the study was the mode of delivery. PTSV who attempted vaginal delivery were identified and categorized according to the mode of delivery: vaginal delivery vs. CD. Risk factors for intrapartum CD adjusted odds ratio (aOR) [95% confidence interval (CI)] in multivariate analysis were reported. Results During the study, 121,483 deliveries were registered; 26,301 (21.6%) PTSV were admitted in labor, of which 1944 (7.4%) had an intrapartum CD. Significantly in multivariate analysis, this group had a unique risk profile as compared to those who delivered vaginally; non modifiable risks included advanced maternal age: 3.06 (2.16-4.33), P < 0.001; prior multiple (≥3) miscarriages: 1.94 (1.04-3.62), P = 0.04; low (<6) modified admission cervical score: 2.41 (2.07-2.82), P < 0.001; low birth weight (BW): 1.42 (1.00-2.01), P = 0.05 or macrosomia: 2.38 (1.77-3.21), P < 0.001; modifiable risks included induction of labor: 1.79 (1.51-2.13), P < 0.001 and oxytocin labor augmentation: 8.36 (6.84-10.22), P < 0.001. Conclusion In a population of PTSV with a sustained low risk for intrapartum cesarean maintained by a strict labor management, induction of labor remains a significant and sole potentially modifiable risk factor for CD.

Delivering elsewhere between the first and second deliveries is a risk marker for obstetric complications in the second delivery.

PURPOSE: We speculate that parturients who deliver elsewhere between the first and second deliveries compose a unique clinical group, characterized by higher rates of cesarean section (CS) both in the first and second deliveries, compared with parturients who deliver both deliveries at the same hospital. METHODS: A retrospective study conducted at Shaare Zedek Medical Center in a tertiary university-affiliated hospital. The cohort included all women in the second delivery, aged ≤24 years with a singleton pregnancy who delivered their second child in our medical center during 2010-2012. Parturients who delivered both the first and second children in our medical center ("stayers") were compared with parturients who delivered their first child in a different hospital ("switchers"). Groups were compared in regard to history of CS in the first delivery and obstetric complications in the second delivery, including CS, instrumental vaginal delivery (IVD), preterm delivery (PTD), and postpartum hemorrhage (PPH). Logistic regressions were constructed to study if delivering elsewhere between the first and second deliveries was a risk for adverse pregnancy outcome, followed by multivariate analysis controlling for confounders. RESULTS: In all, 4166 parturients were included: "stayers" = 3163 and "switchers" = 1003. History of CS in the first delivery was approximately twice as prevalent in "switchers" (12 versus 6.3 %, p < 0.000). "Switchers" experienced higher rates of CS: OR = 1.8 (95 % CI 1.2-2.3); IVD: OR = 1.3 (95 % CI 0.8-2.1); and PTD (<37w): OR = 1.4 (95 % CI 1.0-1.9). CONCLUSIONS: Parturients who deliver elsewhere between the first and second childbirth are at increased risk for CS and PTD in the second delivery; hence, the decision to deliver elsewhere after the first delivery should be considered as a risk marker for obstetric complication.

The effect of oral probiotics on glycemic control of women with gestational diabetes mellitus-a multicenter, randomized, double-blind, placebo-controlled trial.

BACKGROUND: Gestational diabetes mellitus should be treated adequately to avoid maternal hyperglycemia-related complications. Previously, probiotic supplements were suggested to improve fasting blood glucose in women with gestational diabetes mellitus. However, a major limitation of previous studies was that preprandial and especially postprandial glucose values, which are important predictors of pregnancy outcomes, were not studied. OBJECTIVE: This study aimed to examine the effect of a mixture of probiotic strains on maternal glycemic parameters, particularly preprandial and postprandial glucose values and pregnancy outcomes among women with gestational diabetes mellitus. STUDY DESIGN: A multicenter prospective randomized, double-blind, placebo-controlled trial was conducted. Women newly diagnosed with gestational diabetes mellitus were randomly allocated into a research group, receiving 2 capsules of oral probiotic formula containing Bifidobacterium bifidum, B lactis, Lactobacillus acidophilus, L paracasei, L rhamnosus, and Streptococcus thermophilus (>6 × 109/capsule), and a control group, receiving a placebo (2 capsules/day) until delivery. Glycemic control was evaluated by daily glucose charts. After 2 weeks, pharmacotherapy was started in case of poor glycemic control. The primary outcomes were the rate of women requiring medications for glycemic control and mean daily glucose charts after 2 weeks of treatment with the study products. RESULTS: Forty-one and 44 women were analyzed in the treatment and placebo cohorts, respectively. Mean daily glucose during the first 2 weeks in the probiotics and placebo groups was 99.7±7.9 and 98.0±9.3 mg/dL, respectively (P=.35). The rate of women needing pharmacotherapy because of poor glycemic control after 2 weeks of treatment in the probiotics and placebo groups was 24 (59%) and 18 (41%), respectively (P=.10). Mean preprandial and postprandial glucose levels throughout the study period were similar between the groups (P>.05). There were no differences in maternal and neonatal outcomes, including birthweight and adverse effect profile between the groups. CONCLUSION: The oral probiotic product tested in this study did not affect glycemic control of women with gestational diabetes mellitus.

The added value of third trimester fetal brain MRI in cases of isolated ventriculomegaly.

OBJECTIVES: To assess the added value of third trimester fetal brain MRI, performed in one tertiary referral center, in cases of isolated ventriculomegaly as established by a dedicated multiplanar neurosonography. METHODS: Fetal brain MRI scans performed in a single tertiary center during a 3-year period were assessed for possible inclusion. Only cases diagnosed with ventriculomegaly without additional findings in a neurosonography preceding the MRI were included. Fetal MRI was performed at a median gestational of 32 weeks (IQR 31-34 weeks). RESULTS: A total of 68 cases met the inclusion criteria. Of them, in four cases MRI identified additional findings including three cases of intraventricular hemorrhage and one case of cortical infarction. The overall rate of MRI-findings in the study population was (5.9%, 95% CI 2.3-14.2%). No additional findings were detected in cases of mild ventriculomegaly, 6.1% in moderate and 25% in severe ventriculomegaly. The combined rate of additional findings in mild to moderate ventriculomegaly was 3.3% (95%CI 0.9-11.4%). CONCLUSIONS: MRI was able to detect additional findings in 5.9% of cases with seemingly isolated ventriculomegaly after a dedicated neurosonography. The severity of ventriculomegaly is associated with a higher chance of detecting abnormalities in fetal brain MRI.