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Optimal surgical management of monochorionic diamniotic twins complicated by selective intrauterine growth restriction (SIUGR) type II is unknown. Surgical management may involve selective laser photocoagulation of communicating vessels (SLPCV), which offers the possibility of dual twin survivors versus umbilical cord occlusion (UCO) of the SIUGR twin. To identify patient characteristics associated with SIUGR twin survival for those undergoing SLPCV. All patients studied were those who underwent fetal treatment for SIUGR type II at our center from 2006–2018. SIUGR type II was defined as an estimated fetal weight <10th percentile with persistent absent and/or reversed end diastolic flow in the umbilical artery of the SIUGR twin, in the absence of twin-twin transfusion syndrome. Patients were offered SLPCV versus UCO, and those undergoing SLPCV, patient characteristics associated with 30-day survival of the SIUGR twin were examined using bivariate analysis and multiple logistic regression models. Fifty-four consecutive SIUGR type II patients were treated, 45 via SLPCV and nine via UCO. Of the 45 SLPCV cases, there were 16 (35.6%) with SIUGR twin (and dual) survival. SIUGR twin survival appeared associated with middle cerebral artery (MCA) peak systolic velocity (psv) <1.5 multiples of the median, and forward atrial systolic flow in the ductus venosus (DV). In a post hoc analysis, we subsequently categorized patients as: SIUGR type IIa (N = 32 (71.1%)): normal MCA psv, and normal DV waveform, versus SIUGR type IIb (N = 13 (28.9%)): MCA psv ≥1.5 multiples of the median, and/or DV with absent or reversed atrial systolic flow. Thirty-day survival of the SIUGR twin was 50% for type IIa and 0% for type IIb. Over one-third of SIUGR type II patients experienced dual survival after treatment with laser surgery. Normal MCA psv and normal DV waveforms were associated with SIUGR type II survival of the SIUGR twin. Post hoc exploration and subclassification of SIUGR type II patients by preoperative Doppler indices created two groups, one (type IIa) with 50% survival and one (type IIb) with 0% survival of the SIUGR twin after laser surgery. Upon further confirmation, these findings may provide guidance for counseling patients and conducting fetal therapy. [ABSTRACT FROM AUTHOR]

Objective: To describe the antenatal course of selective intrauterine growth restriction (SIUGR) type III patients.Study Design: Retrospective study of monochorionic diamniotic twins with SIUGR type III. Patients were divided into those who did and did not progress to SIUGR type II or twin-twin transfusion syndrome (TTTS) (Groups A and B, respectively). Patient characteristics and perinatal survival were compared by Group, and continuous data are reported as median (range).Results: Forty-eight patients were studied; Group A [26 (54.2%)] and Group B [22 (45.8%)]. The difference in 30-day survivorship for the appropriate for gestational age twin (88.5 vs. 100%, p = .2394) and for the SIUGR twin (73.1 vs. 95.5%, p = .0551) was not statistically significant. However, dual survivorship was lower in Group A compared to Group B (69.2 vs. 95.4%, p = .0276).Conclusions: Approximately half of the SIUGR type III patients had antenatal progression. Lack of antenatal progression was associated with 95% dual survivorship.Rationale: The antenatal course of monochorionic diamniotic twins complicated by SIUGR type III is not well-understood and antenatal management remains a clinical dilemma. We provide pregnancy outcomes in a referred group of SIUGR type III patients, including the rate of progression to SIUGR type II and TTTS. [ABSTRACT FROM AUTHOR]

Objective: To describe the natural history and perinatal outcomes of monochorionic diamniotic twins with midtrimester isolated oligohydramnios (iOligo). Materials and methods: We performed a retrospective study of iOligo patients who were initially referred for the management of evolving twin-twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR). iOligo was defined as a maximum vertical pocket of amniotic fluid of ≤2 cm in the iOligo twin's sac and normal fluid level (>2 and <8 cm) in the co-twin's sac. "Group A" patients did not subsequently develop TTTS or sIUGR Type II (umbilical artery persistent absent or reversed end-diastolic flow), and "Group B" patients did develop TTTS or sIUGR Type II. Results are reported as median (range). Results: Of the 828 patients with complicated monochorionic twin gestations referred for possible TTTS or sIUGR, 36 (4.3%) were initially diagnosed with iOligo. After initial consultation, two patients terminated and one was lost to follow-up, resulting in a final study population of 33. Group A had 10 patients (30.3%) and Group B had 23 patients (69.7%). In Group A, nine of the 10 were expectantly managed, resulting in a median gestational age (GA) at delivery of 34.7 (18.0-36.4) weeks, a 30-day perinatal survival of at-least-one twin of 88.9% (8/9), and dual 30-day survivors in 8/9 (88.9%). In Group B, 12 (52.2%) developed TTTS and 11 (47.8%) developed sIUGR Type II. Fifteen Group B patients had laser surgery, resulting in a median GA at delivery of 33.7 (26.4-37.1) weeks, a 30-day perinatal survival of at-least-one twin of 100% (15/15), and dual survivorship of 46.7% (7/15). Conclusions: Our findings show that the majority of patients with midtrimester iOligo have fetal growth restriction of the affected twin and subsequently progress to TTTS or sIUGR Type II. [ABSTRACT FROM AUTHOR]

Objective: To describe the natural history and perinatal outcomes of monochorionic diamniotic twins with midtrimester isolated oligohydramnios (iOligo). Materials and methods: We performed a retrospective study of iOligo patients who were initially referred for the management of evolving twin-twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR). iOligo was defined as a maximum vertical pocket of amniotic fluid of ≤2 cm in the iOligo twin's sac and normal fluid level (>2 and <8 cm) in the co-twin's sac. "Group A" patients did not subsequently develop TTTS or sIUGR Type II (umbilical artery persistent absent or reversed end-diastolic flow), and "Group B" patients did develop TTTS or sIUGR Type II. Results are reported as median (range). Results: Of the 828 patients with complicated monochorionic twin gestations referred for possible TTTS or sIUGR, 36 (4.3%) were initially diagnosed with iOligo. After initial consultation, two patients terminated and one was lost to follow-up, resulting in a final study population of 33. Group A had 10 patients (30.3%) and Group B had 23 patients (69.7%). In Group A, nine of the 10 were expectantly managed, resulting in a median gestational age (GA) at delivery of 34.7 (18.0-36.4) weeks, a 30-day perinatal survival of at-least-one twin of 88.9% (8/9), and dual 30-day survivors in 8/9 (88.9%). In Group B, 12 (52.2%) developed TTTS and 11 (47.8%) developed sIUGR Type II. Fifteen Group B patients had laser surgery, resulting in a median GA at delivery of 33.7 (26.4-37.1) weeks, a 30-day perinatal survival of at-least-one twin of 100% (15/15), and dual survivorship of 46.7% (7/15). Conclusions: Our findings show that the majority of patients with midtrimester iOligo have fetal growth restriction of the affected twin and subsequently progress to TTTS or sIUGR Type II. [ABSTRACT FROM AUTHOR]

Objective: To describe the natural history and perinatal outcomes of monochorionic diamniotic twins with midtrimester isolated oligohydramnios (iOligo).Materials and Methods: We performed a retrospective study of iOligo patients who were initially referred for the management of evolving twin-twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR). iOligo was defined as a maximum vertical pocket of amniotic fluid of ≤2 cm in the iOligo twin's sac and normal fluid level (>2 and <8 cm) in the co-twin's sac. "Group A" patients did not subsequently develop TTTS or sIUGR Type II (umbilical artery persistent absent or reversed end-diastolic flow), and "Group B" patients did develop TTTS or sIUGR Type II. Results are reported as median (range).Results: Of the 828 patients with complicated monochorionic twin gestations referred for possible TTTS or sIUGR, 36 (4.3%) were initially diagnosed with iOligo. After initial consultation, two patients terminated and one was lost to follow-up, resulting in a final study population of 33. Group A had 10 patients (30.3%) and Group B had 23 patients (69.7%). In Group A, nine of the 10 were expectantly managed, resulting in a median gestational age (GA) at delivery of 34.7 (18.0-36.4) weeks, a 30-day perinatal survival of at-least-one twin of 88.9% (8/9), and dual 30-day survivors in 8/9 (88.9%). In Group B, 12 (52.2%) developed TTTS and 11 (47.8%) developed sIUGR Type II. Fifteen Group B patients had laser surgery, resulting in a median GA at delivery of 33.7 (26.4-37.1) weeks, a 30-day perinatal survival of at-least-one twin of 100% (15/15), and dual survivorship of 46.7% (7/15).Conclusions: Our findings show that the majority of patients with midtrimester iOligo have fetal growth restriction of the affected twin and subsequently progress to TTTS or sIUGR Type II. [ABSTRACT FROM AUTHOR]

Objective: To describe the natural history and perinatal outcomes of monochorionic diamniotic twins with midtrimester isolated oligohydramnios (iOligo).Materials and Methods: We performed a retrospective study of iOligo patients who were initially referred for the management of evolving twin-twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR). iOligo was defined as a maximum vertical pocket of amniotic fluid of ≤2 cm in the iOligo twin's sac and normal fluid level (>2 and <8 cm) in the co-twin's sac. "Group A" patients did not subsequently develop TTTS or sIUGR Type II (umbilical artery persistent absent or reversed end-diastolic flow), and "Group B" patients did develop TTTS or sIUGR Type II. Results are reported as median (range).Results: Of the 828 patients with complicated monochorionic twin gestations referred for possible TTTS or sIUGR, 36 (4.3%) were initially diagnosed with iOligo. After initial consultation, two patients terminated and one was lost to follow-up, resulting in a final study population of 33. Group A had 10 patients (30.3%) and Group B had 23 patients (69.7%). In Group A, nine of the 10 were expectantly managed, resulting in a median gestational age (GA) at delivery of 34.7 (18.0-36.4) weeks, a 30-day perinatal survival of at-least-one twin of 88.9% (8/9), and dual 30-day survivors in 8/9 (88.9%). In Group B, 12 (52.2%) developed TTTS and 11 (47.8%) developed sIUGR Type II. Fifteen Group B patients had laser surgery, resulting in a median GA at delivery of 33.7 (26.4-37.1) weeks, a 30-day perinatal survival of at-least-one twin of 100% (15/15), and dual survivorship of 46.7% (7/15).Conclusions: Our findings show that the majority of patients with midtrimester iOligo have fetal growth restriction of the affected twin and subsequently progress to TTTS or sIUGR Type II. [ABSTRACT FROM AUTHOR]

Objective: Current recommendations for timing of blood pressure measurement in ambulatory pregnant women vary and are based on studies in the nonpregnant population. The objective of this study was to determine if there is a difference in systolic blood pressure (SBP) and diastolic blood pressure (DBP) between minute-5 and minute-10. Methods: A prospective study was conducted at our prenatal care clinics. Participants had their blood pressure measured upon sitting and every 5 minutes for 15 minutes. Initial SBP and DBP were compared to measurements at each time point. Additionally, the SBP and DBP at minute-5 were compared to minute-10. All statistical tests were two-sided. Results: Data from 400 patients were analyzed. Of these, 34.0% were in the first, 30.7% were in the second trimester, and 35.2% were in the third trimester. In each trimester, there was a significant difference in the SBP and DBP at minute-5 compared to minute-0. At minute-10 compared to minute-5, there was no further drop for all trimesters, except for a small drop in DBP in the second trimester (-1.3 ± 6.0, p=0.012). Conclusion: In an ambulatory setting, 5minutes after sitting appears to be an appropriate time point to measure blood pressure in pregnancy. [ABSTRACT FROM AUTHOR]

Objectives: Amniopatch is a proposed treatment of iatrogenic preterm premature rupture of membranes (iPPROM). We studied characteristics associated with successful amniopatch treatment of iPPROM after fetoscopic laser surgery for twin-twin transfusion syndrome.Methods: Patients with iPPROM within 15 days of laser surgery treated with an amniopatch were studied. Factors associated with amniopatch success (i.e. cessation of leakage with normalization of amniotic fluid volume) were tested univariately and in multivariate logistic regression models. Continuous variables are expressed as median (range).Results: Of 1124 patients undergoing laser surgery, 19 (1.7%) had iPPROM and subsequent amniopatch. Twelve (63.2%) were successful. Latency in days from iPPROM to delivery was greater in the successful group (114.0 [87.0-141.0]) versus (44.0 [3.9-88.0], p = 0.0005), which translated into greater gestational age (GA) (weeks) at delivery (35.1 [30.9-39.4] versus 28.1 [22.0-31.0], p = 0.0005). The 30-day survival of the affected recipient twin was improved (100% versus 57.1%, p = 0.0361). After multivariate testing, GA < 20 weeks at the time of the amniopatch placement was the only variable that remained associated with successful sealing of the membranes.Conclusions: Treatment of iPPROM via amniopatch was successful in almost two-thirds of cases and was associated with higher GA at delivery and improved perinatal survival. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of selective intrauterine growth restriction (SIUGR) on monochorionic multiples treated with selective laser photocoagulation of communicating vessels (SLPCVs) for twin-twin transfusion syndrome (TTTS). Methods: Perinatal survival was compared among TTTS patients with and without SIUGR. The TTTS + SIUGR group was defined as TTTS patients with donor twin weight <10th percentile. Multivariable logistic regression analyses identified factors associated with 30-day survival. Results: Of 369 patients, 65% (N = 241) had TTTS + SIUGR. Thirty-day donor twin survival for the TTTS-only group was 84% versus 75% in the TTTS + SIUGR group (p = 0.0348). Stage III donor involved (stage III donor, donor/recipient) TTTS + SIUGR patients (N = 110) had 66% 30-day donor survival. Multivariable logistic regression demonstrated that the TTTS-only group was twice as likely to achieve donor survival compared to the TTTS + SIUGR group (OR 2.01, 95% CI 1.11–3.66,p = 0.0214). In the TTTS + SIUGR group, patients not classified as stage III donor-involved were twice as likely to achieve donor survival as stage III donor-involved patients (OR 2.02, 95% CI 1.10–3.71,p = 0.0226). Conclusions: SIUGR, present in two-thirds of TTTS patients, was a risk factor for decreased donor survival. Patients with donor SIUGR and umbilical artery persistent or reversed end-diastolic flow (Quintero Stage III Donor-involved) were especially at risk. [ABSTRACT FROM AUTHOR]

Objective: To describe the association between maternal and fetal physical signs and symptoms (signs/symptoms) and childbirth outcomes in women with prior cesarean delivery (CD).Methods: Cases of uterine rupture at a single institution were reviewed to examine risk factors for experiencing signs/symptoms and poor childbirth outcomes.Results: Among 21 014 deliveries, 3252 (15.5%) had prior CD, and 75 (2.3%) had uterine rupture. Of these, 66 (88.0%) labored. Among those who labored, 51 (77.3%) demonstrated signs/symptoms prior to delivery. Signs/symptoms included vaginal bleeding, abdominal pain, fetal bradycardia and decreased fetal heart rate (FHR) variability. Laboring patients with signs/symptoms were seven times more likely than those without them to have poor maternal/neonatal outcome (27/51 [52.9%] versus 2/15 [13.3%], OR = 7.31 [95% CI 1.34-52.43], p = 0.0155). In multivariate analysis, risk factors for poor fetal outcome were cervical ripening (OR 4.99 [95% CI 0.86-28.99, p = 0.0735) and prolonged FHR deceleration/bradycardia (OR 2.78 [95% CI 0.86-9.10], p = 0.0905). Fetal tachycardia was a risk factor for poor maternal outcome (OR 8.10 [95% CI 1.40-46.84], p = 0.0195).Conclusions: Among laboring women with uterine rupture, 77% demonstrated maternal or fetal signs/symptoms before delivery. The presence of at least one sign/symptom identified nearly all laboring patients (27/29 [93.1%]) with poor outcomes. [ABSTRACT FROM AUTHOR]

Objective: To determine the composite risk of maternal and neonatal morbidity in pregnancies with suspected fetal macrosomia. Methods: In a retrospective study of laboring women delivering singleton, term neonates, we defined 3 groups of patients by estimated fetal weight (EFW) in grams, using ultrasound: (1) <4000, (2) 4000-4499, and (3) 4500+, and tested them for association with a composite outcome using multivariable logistic regression models. The measure of composite morbidity included: shoulder dystocia, third/fourth degree perineal laceration, postpartum hemorrhage, maternal length of stay (LOS)≥ 5 days, neonatal birth trauma, meconium aspiration syndrome, perinatal infection, and neonatal LOS ≥ 5 days. Because of potential interactions between diabetes and birthweight, women with maternal diabetes were examined separately. Results: Of 8,843 deliveries, the proportion with composite morbidity by group was: (1): 26.2%, (2): 41.2%, and (3): 63.6% ( p < 0.0001). The OR (95% CI) for groups (2) and (3) were: 1.9 (1.2-2.9) and 2.1 (0.6-7.2), for diabetics (9.7% of the final study population), and 2.3 (1.9-2.7) and 3.9 (2.2-6.9), for non-diabetics. Conclusions: Suspected fetal macrosomia appeared associated with increased risk for a composite measure of childbirth morbidity. [ABSTRACT FROM AUTHOR]

Objective. Multiple observational studies have emphasized the increased risk of elective induction versus spontaneous labor. We estimated the risks of elective induction before 39 weeks compared to expectant management. Methods. Using a single institution's delivery data (1996--2004), we identified women with uncomplicated term gestations who underwent elective induction before 39 weeks (Early Induction Group). A comparison group of women eligible for elective induction before 39 weeks but who were managed expectantly was created by identifying the remaining deliveries ≥≥39 weeks and excluding women with ''established'' pregnancy complications such as diabetes or heart disease (Expectant Management Group), but retaining women with complications that may have developed while waiting, e.g. gestational hypertension or abruption. Results. Pregnancies in the Early Induction Group were generally not at increased risk for morbidity when compared to the entire Expectant Management Group, in whom 49%% developed pregnancy complications or went postdates. These pregnancies had poorer maternal and neonatal outcomes when compared to patients who remained uncomplicated with spontaneous labor onset, thus reducing the overall benefit of expectant management. Conclusions. Failure to account for the large proportion of women who develop late pregnancy complications can falsely elevate the estimated risk of elective induction prior to 39 weeks. [ABSTRACT FROM AUTHOR]

Objective. The purpose of this study was to analyze the relationship of 1-h post-glucola (PG) screening results and the need for insulin therapy in women with gestational diabetes (GDM). Methods. The study group was comprised of women with GDM treated at a single institution during calendar years 2000--2004. Women with singleton, term (≥≥37 weeks gestation), liveborn fetuses were included. The association of 1-h PG results and other perinatal risk factors to the need for subsequent insulin therapy was analyzed using multivariable logistic regression models. Results. Of the 1451 women were included in the analysis, 18.1%% required insulin treatment. The mean 1-h PG result was 170.0 ±± 26.1 mg/dl (range 140--414 mg/dl). We determined that a 1-h PG ≥≥ 190 mg/dl ( p < 0.0001), an obese body mass index (BMI) ( p < 0.0001), an overweight BMI ( p == 0.0019), prior GDM ( p == 0.0019), and prior macrosomia ( p == 0.0210) were each highly associated with the need for subsequent insulin therapy during the pregnancy. Conclusions. A 1-h PG ≥≥ 190 mg/dl was strongly associated with the need for insulin therapy in women with GDM. These data may be helpful in counseling and managing women with GDM. [ABSTRACT FROM AUTHOR]

Objective. To describe our experience with preferential use of sequential selective laser photocoagulation of communicating vessels (SQLPCV) in women with twin-twin transfusion syndrome (TTTS). Methods. Women with TTTS received treatment using the SQLPCV technique whenever possible. SQLPCV mandates ablation of all donor-to-recipient arteriovenous communications first, in comparison to the standard non-sequential selective technique. Results. Of 99 consecutive women treated, 64 received SQLPCV. Overall survival of one or both twins was 91% and dual survival was 72%. Higher dual survival rates (80 vs. 57%, p = 0.0317) and donor survival rates (83 vs. 63%, p = 0.0489) were noted in the SQLPCV group. Multivariable logistic regression demonstrated that the SQLPCV technique was highly associated with dual survivorship (OR = 4.64 [1.57–13.74], p = 0.0056), when controlling for gestational age at surgery, duration of laser treatment and number of anastomoses lasered. Neither Quintero stage, placental location, preoperative discordance prior to surgery, nor preoperative cervical length contributed to this equation. The SQLPCV technique was also associated with donor survivorship (OR = 4.43 [1.44–13.67], p = 0.0095), when controlling for the same covariates. Conclusion. Treatment of TTTS via SQLPCV technique was associated with higher dual survival and donor twin survival rates as compared to standard SLPCV. [ABSTRACT FROM AUTHOR]

Objective. To examine the relationship between prolonged second stage and postpartum hemorrhage (PPH). Methods. We conducted a retrospective case-control study of all cases of PPH which occurred at four Southern California hospitals in 2003. Cases were identified by ICD-9 codes and confirmed by chart reviews, and non-cases were randomly selected as controls. The relationship between PPH and prolonged second-stage was examined using bivariate and multivariate analyses. Results. The sample consisted of 91 cases and 323 controls. Cases were significantly more likely than controls to have had a prolonged second stage of labor, over a range of definitions for PPH and prolonged second stage. In multivariable analyses, prolonged second stage was associated with greater than three-fold (OR = 3.35; 95% CI 1.22-9.19) increased risk for PPH. Conclusion. Prolonged second stage is an important risk factor for PPH. Close supervision is warranted for women with a prolonged second stage. [ABSTRACT FROM AUTHOR]

Objective. Recent research has suggested that a nucleated red blood cell (NRBC) count ≥26 per 100 white blood cells (%) or the development of a platelet count ≤100 000 per mm3 within five days of birth is characteristic of neonates who have experienced acute birth asphyxia. Study design. Study cases were from the population defined in a prior publication (Prenat Neonat Med 1997;2:286). The impaired neonates were separated into three groups: group 1, persistent non-reactive fetal heart rate (FHR) pattern from admission until delivery; group 2, reactive FHR pattern on admission followed by a tachycardia, non-reactivity, repetitive variable or late decelerations, and usually a loss of variability; group 3, cases with a reactive FHR pattern on admission followed by a sudden, rapid and sustained deterioration of the FHR usually in response to a hypoxic sentinel event that lasted until delivery or a bradycardia on admission. The FHR pattern in group 3 is considered most consistent with acute birth asphyxia. We then examined these FHR groups with respect to the presence of hematologic injury. Chi-square testing was used to describe differences among the study populations. Results. Of the original 52 cases, sufficient hematologic data were available for 47. Of these, the proportion of cases with NRBC ≥26% was: group 1, 10/21 (47.6%); group 2, 0/14 (0%); group 3, 0/12 (0%). Those with a platelet count ≤100 000 per mm3: group 1, 11/21 (52.4%); group 2, 2/14 (14.3%); group 3, 0/12 (0%). Group 1 was significantly more likely to have an NRBC count ≥26% than group 3 (p=0.0135). A platelet count ≤100 000 per mm3 within five days of birth was also significantly more likely to be encountered in group 1 as compared with group 3 (p=0.0072). Conclusion. In cases of acute birth asphyxia, hematologic injury was infrequently encountered. Our findings suggest that a neonatal NRBC count ≥26% and/or a platelet count ≥100 000 per mm3 within five days of birth is inconsistent with acute birth asphyxia. [ABSTRACT FROM AUTHOR]