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Fetoplacental Doppler is considered to be a key tool for the diagnosis of placenta-mediated fetal growth restriction(FGR). We aimed to determine the diagnostic accuracy of fetoplacental Doppler for specific placental diseases.A retrospective cohort study of all women with a singleton pregnancy and an antenatal diagnosis of SGA fetus(estimated fetal weight10th centile for gestational age), who underwent fetoplacental Doppler assessment within 2 weeks before birth. Primary exposure was any abnormal Doppler result, defined as an abnormal umbilical artery(UA) Doppler, middle cerebral artery(MCA) Doppler, cerebroplacental-ratio(CPR), or umbilico-cerebral ratio(UCR). Study outcomes were abnormal placental pathology: maternal vascular malperfusion(MVM), villitis of unknown etiology(VUE), or fetal vascular malperfusion(FVM).A total of 558 women with a singleton SGA fetus were included, of whom 239(42.8%) had an abnormal fetoplacental Doppler findings. UA Doppler had the lowest detection rate for abnormal placental pathology. MCA Doppler exhibited a significantly higher detection rate for all types of pathology. CPR and UCR exhibited highest detection rates for all types of placental pathology, however, were also associated with the highest false positive rate. The combination of fetoplacental Doppler with the severity of SGA and maternal hypertensive status achieved a high negative predictive value MVM lesions(97%). In contrast, fetoplacental Doppler did not improve the negative predictive value for non-MVM pathology(VUE or FVM).Among SGA fetuses, the combination of UA and MCA Doppler is highly accurate in ruling out FGR due to MVM placental pathology, but is of limited value in excluding FGR due to underlying non-MVM pathologies.

Intertwin size discordance is an independent risk factor for adverse neonatal outcomes in twin pregnancies. However, size discordance at a given point in gestation fails to take into consideration information, such as the timing of onset and the rate of progression of discordance, that may be of prognostic value.In this study, we aimed to identify distinct patterns of discordant fetal growth in twin pregnancies and to determine whether these patterns are predictive of adverse pregnancy outcomes.This was a retrospective cohort study of women with twin pregnancies in a single tertiary referral center between January 2011 and April 2020, who had at least 3 ultrasound examinations during pregnancy that included assessment of fetal biometry. Size discordance was calculated at each ultrasound examination, and pregnancies were classified into 1 of 4 predetermined patterns based on the timing of onset and the progression of discordance: pattern 1, no significant discordance group (referent); pattern 2, early (24 weeks' gestation) progressive discordance group; pattern 3, early discordance with plateau group; or pattern 4, late (≥24 weeks' gestation) discordance group. The associations of discordance pattern (using pattern 1 as referent) with preterm birth, preeclampsia, size discordance at birth, and birthweight10th percentile were expressed as adjusted relative risk with 95% confidence intervals and were compared with those observed for a single measurement of size discordance at 32 weeks' gestation.Of 2075 women with a twin gestation who were identified during the study period, 1059 met the study criteria. Of the 1059 women, 599 (57%) were classified as no significant discordance (pattern 1), 23 (2%) as early progressive discordance (pattern 2), 160 (15%) as early discordance with plateau (pattern 3), and 277 (26%) as late discordance (pattern 4). The associations of discordance pattern with preterm birth at34 weeks' gestation and preeclampsia were strongest for pattern 2 (rates of 43% [adjusted relative risk, 3.43; 95% confidence interval, 2.10-5.62] and 17% [adjusted relative risk, 5.81; 95% confidence interval, 2.31-14.60], respectively), intermediate for pattern 3 (rates of 23% [adjusted relative risk, 1.82; 95% confidence interval, 1.28-2.59] and 6% [adjusted relative risk, 2.08; 95% confidence interval, 1.01-4.43], respectively), and weakest for pattern 4 (rates of 12% [adjusted relative risk, 0.96; 95% confidence interval, 0.65-1.42] and 4% [adjusted relative risk, 1.41; 0.68-2.92], respectively). In contrast, a single measurement of size discordance at 32 weeks' gestation showed no association with preeclampsia and only a weak association with preterm birth at34 weeks' gestation.We identified 4 distinct discordance growth patterns among twins that demonstrated a dose-response relationship with adverse outcomes and seemed to be more informative than a single measurement of size discordance.

Controversy surrounds the definition of "normal" and "abnormal" labor.In this study, we used contemporary labor charts to explore labor patterns in large obstetric population (2011-2016).Detailed information from electronic medical records of live singleton deliveries at term (≥37 weeks of gestation) was extracted. Cases of elective cesarean deliveries, nonvertex presentation, and cesarean deliveries during the first stage of labor were excluded.Overall, 35,146 deliveries were included, of whom 15,948 deliveries (45.3%) were of nulliparous women. Median cervical dilation at admission was not significantly different between nulliparous (median, 4 cm; interquartile range, 3-5 cm) and multiparous women (median, 4 cm; interquartile range, 3-6 cm). In all, 99.3% of the women delivered vaginally. For nulliparous women, the median duration of the first stage of labor was 274 minutes (interquartile range, 145-441 minutes; 95th percentile, 747.5 minutes). Likewise, for multiparous women, the corresponding duration was 133 minutes (interquartile range, 56-244 minutes; 95th percentile, 494 minutes). During the latent phase (cervical dilation at admission, ≤4 cm), the time elapsed to the second stage of labor was 120-140 minutes longer in nulliparous women, whereas the gap between the groups decreased dramatically with advanced cervical dilation on admission. Nulliparous and multiparous women appeared to progress at a similar pace during the latent phase; however, after 5 cm, labor accelerated faster in multiparous women. Epidural anesthesia lengthens duration first and second stages of labor in all parities. Partograms according to cervical dilation at presentation are proposed.Cervical dilation rate is relatively constant between nulliparous and multiparous pregnant women during the latent phase. Time interval of the first stage was far slower than previously described, which allowed labor to continue for a longer period during this stage. These findings may reduce the rate of intrapartum iatrogenic interventions.

Hypertensive disorders of pregnancy (including preeclampsia or gestational hypertension) are associated with fetal growth restriction in singleton pregnancies, an association that may be attributed to abnormal placentation as the shared etiology between these conditions. Given that the pathogenesis of these conditions in twin pregnancies may involve mechanisms other than abnormal placentation, it is unclear whether a similar association between hypertensive disorders of pregnancy and fetal growth restriction is present in twins. Data on the relationship between hypertensive disorders of pregnancy and fetal growth restriction in twins are limited and conflicting. This controversy may be attributed to limitations of existing studies including the use of a singleton-based birthweight reference to define fetal growth restriction in twins and the lack of a positive control group of singleton gestations.The objective of the study was to determine the association between hypertensive disorders of pregnancy and fetal growth restriction in dichorionic twin gestations, using both a singleton- and a twin-based birthweight reference, and to compare this association with that observed in singleton gestations.We performed a retrospective cohort study of all women with dichorionic twin or singleton gestations giving birth in a single tertiary center during 2003-2015. Fetal growth restriction was defined in separate analyses as birthweight10th percentile for gestational age using either a singleton- or a twin-based birthweight reference. The association between hypertensive disorders of pregnancy and fetal growth restriction was determined separately for twin and singleton gestations and was expressed as adjusted relative risk with 95% confidence interval.A total of 1520 twin and 48,943 singleton gestations were included. In singleton gestations, hypertensive disorders of pregnancy were associated with an increased risk of fetal growth restriction (16.6% vs 7.4%, adjusted relative risk, 2.07, 95% confidence interval, 1.87-2.30). In twins, there was no association between hypertensive disorders of pregnancy and fetal growth restriction when a singleton-based reference was used to define fetal growth restriction. However, when using a twin-based reference to define fetal growth restriction, hypertensive disorders of pregnancy in twin gestations were associated with a similar increase in the risk of fetal growth restriction to that seen in singletons (11.8% vs 4.7%, adjusted relative risk, 2.37, 95% confidence interval, 1.69-3.34). Findings were similar with regard to the reverse association between fetal growth restriction and hypertensive disorders of pregnancy: in women with twin gestations, the increase in the risk of hypertensive disorders of pregnancy in pregnancies complicated by fetal growth restriction of 1 twin was similar to that observed in singletons only when a twin-based reference was used to define fetal growth restriction (twins: 21.3% vs 9.8%, adjusted relative risk, 2.15, 95% confidence interval, 1.63-3.06; singletons: 8.8% vs 3.7%, adjusted relative risk, 2.19, 95% confidence interval, 1.95-2.44).The association between hypertensive disorders of pregnancy and fetal growth restriction in dichorionic twins is similar in magnitude to that observed in singletons so long as appropriate birthweight references are applied. Therefore, women with a twin gestation complicated by one of these conditions should be closely monitored for the other. Our findings suggest that the use of a twin-based reference to diagnose fetal growth restriction in twin gestations may be more informative and clinically relevant than using a singleton-based reference.

Controversy surrounds the impact of the fetal head station on labor duration and mode of delivery. Although an extensive body of evidence has been published evaluating fetal head station in early labor, there is a paucity of data on the impact of fetal head descent during the second stage.This study aimed to explore the association between fetal head station at the diagnosis of the second stage of labor and the second stage duration and the risk of operative delivery.This is a retrospective cohort study of all singleton vertex deliveries in a single tertiary center (2011-2016). Women were grouped according to fetal head station upon the diagnosis of the second stage of labor as follows: above (S0), at the level (S=0), and below (S0) the level of the ischial spine. The duration of the second stage and the risk of operative delivery were compared between the groups and stratified by parity.Overall, 34,334 women met the inclusion criteria. Of these, 18,743 (54.6%) were nulliparous and 15,591 (45.4%) were multiparous. Of the nulliparous women, 8.1%, 35.8%, and 56.1% were diagnosed as having fetal head above, at the level, and below the ischial spine upon second stage diagnosis. Of the multiparous women, 19.7%, 35.6%, and 44.7% were diagnosed as having fetal head above, at the level, and below the ischial spine. Fetal head station upon second stage diagnosis was independently and significantly associated with second stage duration (P.001); however, its contribution was 4.5-fold among nulliparous women compared with multiparous women. In multivariable analysis, after controlling for maternal age, gestational age at delivery, prepregnancy body mass index, epidural anesthesia, and birthweight, the risk of operative delivery was substantially increased in a dose-dependent pattern for both nulliparous and multiparous women.The fetal head station at the first diagnosis of the second stage is significantly and independently associated with the duration of the second stage and correlated with the risk of operative delivery in both nulliparous and multiparous women (P.001).

Background The current literature regarding the recommended mode of delivery of monochorionic-diamniotic twins is limited to small numbers, retrospective studies, and comparisons of outcomes of monochorionic-diamniotic twin pregnancies with those of dichorionic-diamniotic twin pregnancies instead of outcomes of trial of labor vs elective cesarean delivery of monochorionic-diamniotic twins. Objective This study aimed to compare perinatal and maternal outcomes of planned cesarean delivery and planned vaginal delivery of monochorionic-diamniotic twins using the Twin Birth Study data. Study Design This study is a secondary analysis of the Twin Birth Study. Women were randomized from 32 weeks and 0 days gestation to 38 weeks and 6 days gestation to planned cesarean delivery or planned vaginal delivery. Twin A in the cephalic presentation and estimated weight of each twin between 1500 and 4000 grams were the inclusion criteria. Pregnancies complicated by fetal reduction after 13 weeks of gestation, lethal fetal anomaly, or contraindication to vaginal delivery were excluded. Elective delivery was planned between 37 weeks and 5 to 7 days of gestation and 38 weeks and 6 to 7 days of gestation. Perinatal and maternal outcomes of monochorionic-diamniotic twin pregnancies were compared between those randomized for planned cesarean delivery and those randomized for planned vaginal delivery. In addition, outcomes of monochorionic-diamniotic twin pregnancies were compared with those of dichorionic-diamniotic twin pregnancies. Results Out of the 1393 women in each arm, 346 (24.9%) women in the planned cesarean delivery arm and 324 (23.3%) women in the planned vaginal delivery arm had monochorionic-diamniotic twin pregnancies and were eligible for the first analysis. The rate of cesarean delivery was 39.2% in the planned vaginal delivery arm and was 91.3% in the planned cesarean delivery arm. There was no significant difference in gestational age at delivery between the groups (34.4±1.8 weeks vs 34.5±1.8 weeks; P=.78). No difference was found in maternal outcomes. As for perinatal outcomes, the rate of the primary adverse neonatal composite outcomes in twins A or twins B was similar in both the planned vaginal delivery and the planned cesarean delivery arms (twins A, 1.2% vs 1.2% [P=.92]; twins B, 1.2% vs 3.2% [P=.09]). Within the planned cesarean delivery arm, the rate of primary adverse neonatal composite outcome was higher in twins B than twins A (3.2% vs 1.2%; P=.03). There was no difference in the primary adverse neonatal composite outcome between twins A in the monochorionic-diamniotic group and the dichorionic-diamniotic group (1.2% vs 1.3%; P=.89) or between twins B in similar groups (2.3% vs 2.7%; P=.47). Conclusion In monochorionic-diamniotic twin pregnancy between 32 weeks and 0 to 7 days of gestation and 38 weeks and 6 to 7 days of gestation, with twin A in a cephalic presentation, planned cesarean delivery did not decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery.

The reported incidence of combined twin delivery (vaginal delivery of twin A followed by cesarean delivery for twin B) ranges between 5% and 10%. These estimates are based mostly on small studies or retrospective data. We aimed to evaluate to incidence and risk factors for and outcomes of combined twin deliveries, using a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study.The Twin Birth Study included women with twin gestation between 32+0 and 38+6 weeks, with the first twin in vertex presentation at randomization. Women were randomized to planned cesarean delivery or planned vaginal delivery. For the purpose of this subanalysis, we included women who had a vaginal delivery of twin A. Women who had a combined delivery (cesarean delivery for twin B) were compared with women who had a vaginal delivery of both twins. Our primary objective was to identify risk factors for combined twin deliveries. Our secondary objective was to assess the rate of fetal/neonatal death or serious neonatal morbidity in combined deliveries.Of the 2786 women included in the original study, 842 women delivered twin A by a vaginal delivery and were included in the current analysis, of whom 59 (7%) had a combined delivery. Women in the combined delivery group had a lower rate of nulliparity (22.0% vs 34.7%, P = 0.047) and higher rates of noncephalic presentation of twin B at delivery (61.0% vs 27.3%, P0.001) and spontaneous version from presentation at randomization of twin B (72.9% vs 44.3%, P0.0001). In a multivariable model, the only risk factor significantly associated with a combined delivery was transverse/oblique lie of twin B following delivery of twin A (adjusted odds ratio, 47.7; 95% confidence interval, 15.4-124.5). Twins B in the combined delivery group had a higher rate of fetal/neonatal death or serious neonatal morbidity (13.6% vs 2.3%, P0.001), 5-minute Apgar score7, neonatal intensive care unit admission, abnormal level of consciousness, and assisted ventilation.Transverse/oblique lie of twin B following vaginal delivery of twin A is a risk factor for combined delivery. Combined delivery is associated with higher risk of adverse neonatal outcomes of twin B. These data may be used to better counsel women with twin gestation who consider a trial of labor.