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Introduction: Our study compared the prospective risks of intrauterine fetal death (IUFD), neonatal death (NND), perinatal death (PND), and neonatal morbidities in monochorionic diamniotic (MCDA) and dichorionic diamniotic (DCDA) twin pregnancies. Methods: This retrospective cohort study included twin pregnancies who had antenatal care and delivery in a public hospital from 2011 to 2018. Exclusion criteria included monoamnionicity, one/both twin miscarriage, twin‐twin transfusion syndrome, or lethal congenital abnormalities. All twins were managed in multiple pregnancy clinic with standardized protocols. Gestational age‐specific IUFD, NND, PND, and neonatal morbidity rates were compared according to chorionicity. Results: Three hundred seventy‐eight MCDA and 1282 DCDA twins were included. MCDA twins had higher risks of PND (1.9% vs. 0.7% in DCDA twins, p = 0.05), composite neonatal morbidity (p = 0.01), preterm delivery (p < 0.01), and low birth weight (p < 0.01). The prospective risk of IUFD was 0.6% and 0.4% for MCDA and DCDA twins, respectively after 34 weeks' gestation. No NND occurred among deliveries after 30 weeks. The risk of neonatal morbidity of MCDA twins fell from 22.7% at 34 weeks to 2.7% at 37 weeks (p < 0.01). For DCDA twins, the risk of morbidity fell insignificantly from 36 to 38 weeks (4.0% vs. 3.4%, p = 0.60). Logistic regression analysis suggested that the increased risk of perinatal morbidities was related to the higher rate of preterm delivery in MCDA twins rather than chorionicity. Conclusion: With close fetal monitoring, the risk of late IUFD in twin pregnancies without major complications is low. Perinatal morbidity can be minimized by avoiding late preterm deliveries in twin pregnancies. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the theme trends and knowledge structure of multifetal pregnancy reduction (MPR)‐related literature by using bibliometric analysis. Methods: Published scientific papers regarding MPR were retrieved from the PubMed database. Data extraction and statistics were conducted using Bibliographic Item Co‐Occurrence Matrix Builder (BICOMB). Furthermore, gCLUTO software was used in the study for bi‐clustering analysis and strategic diagram analysis. Results: According to the search strategy, 906 total papers were included. Among all the extracted MeSH terms, 41 high frequency ones were identified and hotspots were clustered into four categories. In the strategic diagram, research on intrauterine treatment of MPR was most well developed. In contrast, statistical data on the sequelae of fetal reduction surgery and applications of MPR in assisted reproductive technologies were relatively immature. Conclusion: The analysis of common terms among the high‐frequency network terms in multiparous pregnancy reduction can help researchers and clinicians understand the hotspots, key topics, and issues to be discovered on MPR. Research on intrauterine treatment of MPR was most well developed. [ABSTRACT FROM AUTHOR]

Aims: To investigate whether the Institute of Medicine (IOM) guidelines for optimal gestational weight gain (GWG) in twin pregnancies are applicable to Japanese women. Methods: This was a retrospective study involving women who delivered full‐term twins at our tertiary center diagnosed with a normal prepregnancy body mass index. The women were divided into two groups, according to the optimal GWG recommended by the IOM (16.8–24.5 kg): the adequate GWG (AGWG) group with GWG meeting the guidelines and the low GWG (LGWG) group with GWG below the guidelines. Next, the women were divided into two groups according to birthweight: a group with both twins born appropriate for gestational age (AGA group) and a group with one or both twins born small for gestational age (SGA group). Their GWG as well as their pregnancy outcomes were compared. Results: A total of 265 women were included. The AGWG group had a significantly higher proportion of hypertensive disorders of pregnancy than the LGWG group. There was no significant difference in the proportion of women with both twins born AGA or the rate of admission to the neonatal intensive care unit. Meanwhile, the median GWG in the AGA group was 13.6 kg, which was significantly higher than 12.0 kg in the SGA group. And even the median GWG in the AGA group was below the lower limit of the IOM guidelines. Conclusion: The optimal GWG for Japanese women with twin pregnancies may be below the IOM guidelines. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to evaluate the feasibility and outcome of intrauterine transfusion (IUT) for the surviving co‐twin in monochorionic diamniotic (MCDA) twin gestations involving single intrauterine fetal death (sIUFD). Methods: Cases of MCDA twin gestations involving emergent IUT for co‐twins experiencing acute feto‐fetal hemorrhage (AFFH) subsequent to sIUFD during the second trimester were reviewed. Fetal anemia was confirmed via fetal blood sampling, and perinatal data were retrieved from medical charts to determine the outcomes of surviving co‐twins. A poor outcome at 28 days of age was defined as fetal death, neonatal death or neurological impairment such as severe intraventricular hemorrhage or cystic periventricular leukomalacia (PVL). Results: This study included 16 cases of sIUFD diagnosed at a median of 22.5 weeks of gestation (range: 18–25 weeks). The median interval in hours between diagnosis of fetal demise and IUT was approximately 4.2 (0–22) hours. All cases achieved IUT without significant intraoperative complications. Four cases experienced a fetal loss of the co‐twin, whereas 12 co‐twins were born alive (including 9 preterm births), with only 1 poor outcome in a preterm infant with PVL. Conclusion: IUT may be a feasible prenatal intervention for surviving co‐twins with AFFH. However, more extensive or pooled studies are needed to determine the efficacy of this intervention. [ABSTRACT FROM AUTHOR]

Aim: To compare the outcome of intracytoplasmic sperm injection (ICSI) pregnancies complicated by spontaneous loss of a dichorionic co‐twin with that of singleton ICSI pregnancies. Methods: The study group included dichorionic ICSI pregnancies with co‐twin loss (n = 33) and the control group included ICSI pregnancies with a singleton from the beginning (n = 327). Primary outcome measures were obstetric complications, including preterm delivery, newborn small for gestational age, gestational diabetes, gestational hypertensive disorders and abruptio placenta; admission to neonatal intensive care unit (NICU) and perinatal mortality observed in the study and control groups. Statistical analysis was performed using spss for Windows, version 22.0. Results: In the study group, there were 26 cases of first trimester (early) and 7 cases of second or third trimester (late) co‐twin losses. Mean gestational age at delivery and mean birth weight were significantly lower in the whole study group compared to control (P < 0.05). Preterm delivery and NICU admission rates were significantly higher in the whole study group, compared to control (39.3% vs 14.6% and 36.36% vs 11.69% respectively, P < 0.05), but did not show significant difference between early loss subgroup and control (P > 0.05). Preterm delivery rate was significantly higher in the late loss subgroup compared to the early loss subgroup (85.71% vs 26.92% P < 0.05). Conclusion: Loss of a co‐twin in dichorionic ICSI pregnancies is associated with increased risk of preterm birth. This risk is significantly higher in cases with late loss compared to the early loss cases. [ABSTRACT FROM AUTHOR]

Aim: The yolk sac (YS) has been reported as a reliable predictor of adverse pregnancy outcomes, however, it has always been evaluated cross‐sectionally with a single ultrasound per patient. We sought to validate the use of YS dimensions in serial ultrasounds throughout the first 10 weeks of singleton and multiple gestations. Methods: This was a prospective cohort study where YS diameters were serially obtained with 2D ultrasound in singleton and multiple gestations from 5 to 11 weeks. Nonparametric test were used for comparisons with P < 0.05 indicating significance. Results: One hundred ninety‐three patients were included, 42 twins (3 monochorionic and 39 dichorionic), 2 triplets (monochorionic twins plus a singleton) and 148 singleton pregnancies (238 total fetuses). There was no difference in YS dimensions in singleton versus multiple pregnancies. Starting at 5 weeks' gestation, the YS increased 0.4 mm (95% CI 0.3–0.5 mm) per week until 10 weeks' gestation. Forty‐five fetuses were lost in the first trimester. The risk of pregnancy loss was higher with a large YS until 8 weeks (P ≤ 0.001), while after 8 weeks it was higher with a small YS (P < 0.005). Conclusion: We established a nomogram of YS development during the first 10 weeks of pregnancy. The YS reliably detected pregnancies that ended in loss as early as 6 weeks' gestation. The YS was either smaller or larger than in ongoing pregnancies. While all pregnancies with large YS were lost within 10 weeks, those with smaller YS were lost beyond the first 10 weeks. [ABSTRACT FROM AUTHOR]

Aim: The aim of the survey is to investigate current practice and complications of percutaneous umbilical cord blood sampling (PUBS) in Japan. Methods: In this retrospective survey, data including perioperative information, indications, details of the procedure and procedure‐related complications were collected for patients who underwent PUBS between 2012 and 2016 in Japanese perinatal care centers. Results: One hundred and fifty‐three patients underwent PUBS and a total of 223 procedures were analyzed in this study. Fetal anemia was the most common indication for PUBS, representing greater than 70% of all cases. Anemia specific to monochorionic twins, such as acute feto‐fetal hemorrhage subsequent to single intrauterine fetal death (IUFD) and twin anemia‐polycythemia sequence, were the leading causes of suspected fetal anemia. Maternal anesthetics were given during the procedure in 70% of cases. The PTC needle (Hakko, Japan) was most commonly used in the procedure. The most frequent complication was bleeding from the umbilical cord puncture site; however, it did not require immediate delivery during or after the procedure in any case. IUFD occurred in 11 (4.9%) procedures, 7 of which appeared to be related to the underlying fetal disease. The overall completion rate of the procedure was 97%. Conclusion: Percutaneous umbilical cord blood sampling was most commonly performed for the evaluation of fetal anemia, usually due to complications of monochorionic twins, followed by the measurement of fetal thyroid function. The safety and the completion rate of the procedure in Japan appear satisfactory. [ABSTRACT FROM AUTHOR]

Monochorionic triplet pregnancy is a rare condition, and twin‐reversed arterial perfusion (TRAP) sequence and severe selective fetal growth restriction (FGR) are associated with high perinatal morbidity and mortality rates. We report a case of TRAP sequence and selective FGR typeIIconcurrently complicating a monochorionic triplet pregnancy. Fetoscopic laser surgery (FLS) was performed at 16 + 1 weeks of gestation and was technically successful. Inter‐fetus placental anastomoses were coagulated. The pregnancy continued until 28 + 4 weeks of gestation, when the patient presented with preterm rupture of membranes and preterm labor. Two live female newborns were delivered by a cesarean section, and their postnatal course of the neonates was uneventful and in accordance with their gestational age at birth. To our knowledge, this is the first case report of FLS resulting in favorable outcomes for a monochorionic triplet pregnancy concurrently complicated with TRAP sequence and selective FGR type II. [ABSTRACT FROM AUTHOR]

Aim: The present study investigates the procedure‐related fetal loss rate and obstetrical outcomes of selective feticide in dichorionic twins. Methods: We retrospectively analyzed the data of 44 cases of dichorionic twins. Two different indications for selective feticide were set: (i) the presence of genetic or congenital anomaly; and (ii) an obstetrical indication specified as a past maternal history of preterm delivery that caused fetal death or cerebral palsy of the child. Primarily, data on procedure‐related fetal loss and obstetrical outcomes were retrieved. Additionally, data on obstetrical outcomes by reduction time and by indication of SF were obtained. Results: Selective feticide was performed in 44 cases – specifically, in 23 cases with genetic or congenital anomaly and in 21 cases with obstetrical indications. The median gestational age at delivery was 38 + 4 weeks. One pregnancy loss (2.3%, 1/44) occurred within 4 weeks after the procedure. The overall pregnancy loss rate throughout the pregnancy term was 2.3% (1/44). When selective feticide was performed at 15 weeks and beyond, the birth weight was significantly decreased compared with when selective feticide was performed earlier than 15 weeks. Conclusion: Transabdominal ultrasound‐guided selective feticide in dichorionic twins is an effective and safe procedure. If a patient desires to maximize her chances of having a healthy child and decrease the risk of prematurity, the option of selective feticide should be considered in certain cases of twin pregnancies. Selective feticide may be a reasonable alternative to expectant management or termination of the whole twin pregnancy. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the effect of adjuvant low‐dose aspirin therapy on clinical pregnancy rate and uterine perfusion in women undergoing frozen‐thawed embryo transfer (FET) cycles. Methods: This study was performed as a pilot randomized, double‐blind placebo‐controlled trial, from May 2012 to February 2015. Overall, 60 available eligible women who were candidates for FET were randomly assigned to two groups receiving either 100 mg oral aspirin (n =30) or placebo (n =30). The primary outcome measure was clinical pregnancy rate. Secondary outcome measures were pulsatility index (PI), resistance index (RI), implantation rate, live birth rate and miscarriage rate. Results: There was no significant difference in endometrial thickness, PI and RI. However, the study group had higher rates of clinical pregnancy, implantation, live birth (P = 0.042, P = 0.031 and P = 0.007, respectively) and lower rate of miscarriage (P = 0.020) as compared to the control group. Twin birth rate was comparable between the two groups. Conclusion: Our pilot study demonstrated that administration of low‐dose aspirin in FET cycles results in better pregnancy, implantation and live birth rates without changing the uterine hemodynamics or endometrial thickness. However, further randomized clinical studies in larger populations are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Abstract: Aim: The purpose of this study was to describe the characteristics of women with twin pregnancies who undergo noninvasive prenatal testing (NIPT) as well as the post‐partum and neonatal outcomes of such cases in Japan. Methods: The study population consisted of women who were pregnant with twins and who underwent NIPT using massively parallel sequencing (MPS) at Nagoya City University Hospital between April 2013 and June 2016. Questionnaires were completed pre‐NIPT and post‐partum. Results: Among 4009 women who underwent NIPT during the study period, 75 women (1.9%) were pregnant with twins. Fifteen women (20%) experienced vanishing twin/intrauterine fetal deaths at <22 weeks, and 60 women (80%) had normal twin pregnancies at the time of genetic counseling for NIPT. The use of NIPT was correlated with increased proportions of women using assisted reproductive technology (ART). The test had a high performance, with a false‐positive rate of 1.7% and no false negatives. Conclusion: In this study, NIPT had a high performance, with a false positive rate of 1.7% and no false negatives. When treating women with twin pregnancies, the efficacy of NIPT should be explained during genetic counseling. Further larger studies are required to assess the reliability and validity of NIPT in twin pregnancies. [ABSTRACT FROM AUTHOR]

Abstract: The aim of this study was to review fetoscopic laser photocoagulation (FLP), which ablates placental vascular anastomoses to treat twin–twin transfusion syndrome (TTTS). A review of studies reporting on the procedures, outcomes, complications and nonconventional applications of FLP for TTTS was conducted. FLP has been established as the primary treatment for monochorionic twin pregnancy associated with TTTS at 16–26 weeks. FLP is the only therapy that directly addresses the underlying pathophysiology. The recent technique modification of FLP, referred to as the ‘Solomon technique’, induces selective coagulation to connect the anastomoses ablation sites and has been introduced to reduce residual anastomoses. The perinatal survival following FLP improved significantly with advances in the technique after its introduction. The recent survival rates of both twins and at least one twin are 70% and more than 90%, respectively. However, there is still an 11–14% risk of long‐term neurodevelopment impairment. The premature rupture of membranes that leads to preterm labor is a common complication after FLP. FLP is a valuable treatment option for feto‐fetal transfusion syndrome in triplets and for TTTS after 26 weeks. FLP for selective intrauterine growth restriction may be potentially beneficial when accompanied by abnormal Doppler findings and oligohydramnios. FLP is the optimal treatment option for TTTS at 16–26 weeks of gestation. FLP appears to be applicable in triplets, TTTS after 26 weeks and cases of selective intrauterine growth restriction with abnormal Doppler findings and oligohydramnios. FLP is the most common and successful fetal intervention. Improvement in the neurodevelopmental outcomes after FLP is a future focus. [ABSTRACT FROM AUTHOR]

Abstract: We report a rare case of placental mesenchymal dysplasia (PMD) with fetal growth restriction (FGR) in one placenta of a dichorionic diamniotic (DD) twin pregnancy. A 24‐year‐old woman was referred to our hospital at 24 weeks’ gestation due to FGR and ipsilateral placental abnormality in DD twins. Ultrasound and magnetic resonance imaging showed one placenta of the FGR fetus was bulky and had multiple cysts, while the other fetus placenta appeared normal. Cesarean section was performed at 32 weeks’ gestation; the first and second neonates weighted 1799 and 1215 g, respectively. Macroscopically, chorionic vessels on the placental surface of the second neonate were prominently enlarged. Pathological findings demonstrated swelling stem villi with enlarged vessels and increased interstitial cells without trophoblast proliferation. Immunostaining for p57kip2 was negative in interstitial cells and cytotrophoblasts of the swelling stem villi. This suggested that PMD occurred in one placenta of the DD twin, leading to early‐onset FGR. [ABSTRACT FROM AUTHOR]

Aim This study investigated the feasibility and safety of fetoscopic laser photocoagulation (FLP) for amniotic fluid discordance (AFD) bordering on twin-twin transfusion syndrome (TTTS) with an absent or reverse end-diastolic velocity (AREDV) in the umbilical artery (UA), and evaluated the perinatal and long-term outcomes. Methods A prospective intervention study was performed between 20 + 0 and 25 + 6 weeks of gestation (UMIN000004165). AFD bordering on TTTS was defined as maximum vertical pocket (MVP) of amniotic fluid in one twin's sac ≤3 cm and amniotic fluid MVP in the other twin's sac ≥7 cm excluding TTTS. Neurodevelopmental outcome was evaluated at 6 months and at 3 years of age. Results Eleven women were treated without complications between September 2010 and July 2011. In all cases amnioinfusion was required, with a median surgical time of 70 min. There were nine cases of selective intrauterine growth restriction in which the growth discordant rate was >25%. The survival rates of the donor and recipient twins were 27.3% (3/11) and 100% (11/11), respectively. None of the surviving donor twins and two of the 11 recipient twins had hemiplegia at 6 months of age. One additional recipient twin had developmental delay at 3 years of age. Conclusions Fetoscopic laser photocoagulation for AFD bordering on TTTS with AREDV in the UA was feasible without complications but frequently resulted in donor twin death and a high survival rate of the recipient twin, albeit with neurodevelopmental abnormalities in some cases. FLP does not seem to be a promising treatment option for AFD bordering on TTTS. [ABSTRACT FROM AUTHOR]

Aim To evaluate the incidence of twin-twin transfusion syndrome (TTTS) and the perinatal outcome at 28 days of age in monochorionic diamniotic (MCDA) pregnancies complicated with isolated polyhydramnios (I-Poly) and isolated oligohydramnios (I-Oligo) diagnosed < 26 weeks of gestation. Methods This was a retrospective study of women with MCDA pregnancies diagnosed with I-Poly or I-Oligo before 26 weeks of gestation over a period of six years. The incidence of subsequent TTTS and neonatal outcome in terms of intact survival (IS) at 28 days of age were evaluated. Intact survival was defined as being alive without any neurological complications at 28 days of age. Results There were 30 cases of I-Poly and 53 of I-Oligo that were eligible as per the inclusion criteria. Subsequent TTTS were complicated in six (20.0%) of the I-Poly and 26 (49.0%) of the I-Oligo cases. Among subjects with I-Poly, 17 had spontaneously normalized amniotic fluid volume. Prolonged oligohydramnios until intrauterine death, delivery or the onset of emerging TTTS was noted in 16 cases of I-Oligo. Both the twins exhibited IS in 26 (86.7%) cases of I-Poly and 31 (58.4%) cases of I-Oligo. Conclusion One-fifth of I-Poly and half of I-Oligo MCDA twins at < 26 weeks of gestation potentially develop TTTS. I-Oligo in particular should be regarded as a high-risk condition as neonatal IS is less than 60%. [ABSTRACT FROM AUTHOR]

Aims To develop a model based on clinical and ultrasound parameters to predict the risk of cesarean delivery after labor induction in near-term twin gestations. Methods This retrospective cohort study included 189 consecutive women with twin gestations at ≥ 36.0 weeks scheduled for labor induction. The Bishop score and transvaginal ultrasonographic measurements of cervical length were obtained immediately before labor induction. Parameters studied included maternal age, height, weight, parity, gestational age, Bishop score, cervical length, epidural analgesia, method of conception, chorionicity and birth weight. Prostaglandin E2 (dinoprostone) and oxytocin were used for labor induction. Logistic regression analysis and receiver operating characteristic curve were used to generate a predictive model for cesarean delivery. Results Fifty (26.5%) of the 189 women had cesarean deliveries. According to logistic regression analysis, maternal height ( P = 0.004), parity ( P = 0.005) and cervical length ( P = 0.016), but not Bishop score ( P = 0.920), were identified as independent predictors of cesarean delivery. A risk score based on a model of these three parameters was calculated for each patient. The model was shown to have an adequate goodness of fit ( P = 0.201) and the area under the curve was 0.722, indicating fairly good discrimination. Conclusions Maternal height, parity and cervical length were independent parameters for predicting the risk of cesarean delivery after labor induction in twin gestations. A predictive model using these parameters may provide useful information for deciding whether or not to induce labor. [ABSTRACT FROM AUTHOR]

Herein, we report the first case of successful term delivery of twins in a patient with bicorporeal septate uterus via natural conception. The patient had been diagnosed with complete septate, didelphys and bicornuate uterus during different phases of her three pregnancies. Based on follow-up data at six weeks and then six months post-partum of the last pregnancy, we found that the abnormalities presented in our case did not fit the criteria of any categories following American Fertility Society and European Society of Human Reproduction and Embryology-European Society for Gynaecological Endoscopy classification systems. After comprehensive review of the uterine morphologic characteristics, embryology and pregnancy outcome, we considered 'bicorporeal septate uterus' the most appropriate diagnosis. This case emphasized the atypical changes of uterine shape as twin pregnancy advances and its influence on productive performance and pregnancy outcome in uterine malformation. It also raised concern regarding the usability and comprehensiveness of the two most popular classification systems. [ABSTRACT FROM AUTHOR]

Aim The purpose of this study was to investigate neonatal outcome of dichorionic diamniotic twins born beyond 32 weeks' gestation according to mode of delivery at a major tertiary center in Australia. Methods This was a retrospective cohort study of women with dichorionic diamniotic twins delivering at ≥32 weeks' gestation at a large tertiary maternity center in Australia using data from a maternity database. Primary and secondary outcomes included mode of delivery, birthweight, stillbirth, Apgar score, neonatal unit admission, neonatal resuscitation, death and respiratory distress. Results Of 1261 women, 82.9% (1045/1261; 2090 babies) delivered at ≥32 weeks' gestation. The mode of delivery for these babies was as follows: normal vaginal delivery, 419 (20%); instrumental delivery, 179 (8.6%); emergency cesarean section, 658 (31.5%); and elective cesarean section, 834 (39.9%). Babies delivered by emergency cesarean section or instrumental vaginal delivery had worse outcome. In contrast, the lowest complications were seen in the uncomplicated vaginal delivery and elective cesarean section cohorts. Conclusions Neonatal outcome was worse for those delivering via emergency cesarean section or instrumental vaginal delivery compared with elective cesarean section or uncomplicated vaginal delivery. The rate of uncomplicated vaginal delivery, however, was low, with only 14.8% of women delivering both babies vaginally without any form of intervention. [ABSTRACT FROM AUTHOR]

Aim This study aimed to clarify the feasibility and perinatal outcomes of fetoscopic laser photocoagulation (FLP) for monochorionic twin gestation with selective intrauterine growth restriction (sIUGR) accompanied by both abnormal umbilical artery Doppler waveforms and isolated severe oligohydramnios of the sIUGR twin. Methods In this prospective clinical trial, which included 10 cases with absent or reversed end-diastolic flow in the umbilical artery and severe oligohydramnios of the sIUGR twin, the main outcomes investigated were the feasibility of FLP and the rate of severe FLP-related maternal complications. The survival rate and incidence of neurological abnormalities of the twins at 28 days of age were also evaluated. Results FLP was completed for all cases without major intraoperative maternal complications, although one case experienced threatened preterm labor requiring intensive treatment after the procedure. Three sIUGR and 10 larger twins were alive without neurological abnormalities at 28 days of age, while intrauterine fetal death occurred in the remaining seven sIUGR twins. Conclusion FLP for monochorionic twins with sIUGR, especially when accompanied by abnormal Doppler and severe oligohydramnios of the sIUGR twin, appears to be feasible and potentially beneficial for the larger twin, as well as for some sIUGR twins. [ABSTRACT FROM AUTHOR]

Aim The purpose of this study was to evaluate the usefulness of fetoscopic laser photocoagulation of placental communicating vessels or umbilical cord for twin-reversed arterial perfusion (TRAP) sequence. Material and Methods We report a retrospective case series of all cases of TRAP sequence identified from 2006 to 2014 at out institutions. Fetoscopic laser photocoagulation of placental arterioarterial and venovenous anastomoses was performed in diamniotic twins, and in cases of monoamniotic twins we performed laser photocoagulation and transection of the umbilical cord of the acardiac twin to prevent cord entanglement. Pregnancy and perinatal outcomes were estimated. Results Ten cases were included in the study. The median gestational age at procedure was 21.3 weeks (range, 16.7-27.3 weeks). All cases completed the procedure. Two cases were treated with laser photocoagulation and transection of the umbilical cord of the acardiac twin. No major immediate complications were noted. Preterm rupture of membranes occurred in four cases (40%). One case resulted in miscarriage. The other fetuses were delivered alive. Median gestational age at delivery was 35.4 weeks (range, 25.6-42.0 weeks). Median interval of treatment to delivery was 85 days (range, 43-153 days). Five out four infants were delivered preterm. The overall neonatal survival was 9/10. Conclusion This case series demonstrated favorable outcome, and fetoscopic laser photocoagulation seems to be a useful treatment for TRAP sequence. In particular, transection of the umbilical cord is effective to prevent cord entanglement of monoamniotic twins. [ABSTRACT FROM AUTHOR]

Pre-eclampsia has a progressive clinical course, and is only cured by delivery of the placenta. We report a 30-year-old G1P0 with dichorionic twins, discordant growth and chronic hypertension who developed superimposed pre-eclampsia in her 21st week of gestation. After intrauterine demise of the severely growth-restricted twin, the superimposed pre-eclampsia resolved. The surviving twin initially had absent end diastolic flow, which resolved after the demise. A healthy 1935-g neonate with Apgar 9/9 was delivered at 34 weeks. Antenatal resolution of pre-eclampsia is extremely rare and resolution of superimposed pre-eclampsia has not, to our knowledge, been reported. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to identify the risk factors of twin gestation in fresh double day-3 embryo transfer cycles. Material and Methods Out of a total of 386 cycles of fresh double embryo transfers on day 3 between 2006 and 2013 at a single center, 72 women with single intrauterine gestational sac (GS) (single-GS group) and 32 women with double GS (double-GS group) were identified. The patients' clinical characteristics and laboratory results were extracted from electronic medical records and were compared. Results The double-GS group had a significantly younger age ( P = 0.012), and higher bodyweight ( P = 0.033) compared with the single-GS group. The total number of blastomeres ( P = 0.013) and cumulative embryo score ( P = 0.012) were higher in the double-GS group. By receiver-operator curve analysis, maternal age ≤ 35 years, maternal bodyweight > 60 kg, total number of blastomeres > 14, and cumulative embryo score > 49 were the cut-off values to predict twin pregnancy. Among eight women with all four risk factors, the twin pregnancy rate was 87.5%. There was no twin pregnancy among seven women with no risk factors. Conclusion Younger age, higher bodyweight, and better embryo quality are all associated with a higher incidence of twin pregnancy after double embryo transfer on day 3. Single embryo transfer might be advisable for couples with risk factors for twin pregnancy. [ABSTRACT FROM AUTHOR]

Aim Our aim was to determine factors that affect maternal serum magnesium (Mg) levels, to help ensure the safety and efficacy of long-term magnesium sulfate (MgSO4) therapy for threatened preterm labor in singleton and twin pregnancies. Material and Methods We retrospectively and arbitrarily studied 100 patients (singleton pregnancy, n = 65; twin pregnancy, n = 35) who received i.v. MgSO4 for >48 h for tocolysis of threatened preterm labor. We used multiple regression analysis to investigate the functional relations between the candidate factors and maternal serum Mg levels. Results MgSO4 was administered as a loading dose of 3 g for 1 h followed by a maintenance dose of 1.0-2.0 g/h. There were no maternal severe adverse events related to the elevated Mg levels in any of the subjects. The results of multiple regression analysis revealed that total dose of MgSO4 for 24 h before blood collection (g/day), total serum protein level (g/dL), serum total calcium level (mg/dL), serum creatinine level (mg/dL) and maternal bodyweight (kg) significantly affected maternal serum Mg levels in both singleton and twin pregnancies (all P-values were < 0.001). Gestational age (weeks) and period of MgSO4 administration (days) at blood collection had no significant effect in singleton or twin pregnancies. Conclusion Our study statistically shows that dose of MgSO4, total serum protein level, serum total calcium level, serum creatinine level and maternal bodyweight are key factors to achieving safe and effective long-term tocolysis with MgSO4 in not only singleton but also twin pregnancies. [ABSTRACT FROM AUTHOR]

Aim The purpose of this study was to prospectively estimate the incidence of spontaneous twin anemia-polycythemia sequence ( TAPS) in monochorionic-diamniotic twin pregnancies. Methods We prospectively examined umbilical cord hemoglobin ( Hb) and reticulocyte count of consecutive monochorionic-diamniotic twin pregnancies delivered at Seirei Hamamatsu General Hospital from December 2006 to September 2013. We excluded cases of twin-twin transfusion syndrome, intrauterine fetal demise, and missing data (Hb and reticulocyte count missing from the medical record). TAPS was diagnosed using the postnatal criteria of intertwin Hb difference >8.0 g/dL and reticulocyte count ratio >1.7. Acute feto-fetal hemorrhage was defined as Hb difference >7 g/dL and reticulocyte count ratio <1.7. Results A total of 185 monochorionic-diamniotic twin pregnancies were included in this study. Three fulfilled the diagnostic criteria for postnatal TAPS, and one fulfilled the diagnostic criteria for acute feto-fetal hemorrhage. Conclusion The incidence of spontaneous TAPS in monochorionic-diamniotic twin pregnancies was 1.6% (3/185) at Seirei Hamamatsu General Hospital. [ABSTRACT FROM AUTHOR]

Aim To assess the use of magnetic resonance imaging ( MRI) for prenatal differentiation between complete hydatidiform mole with a twin live fetus ( CHMTF) and placental mesenchymal dysplasia ( PMD). Methods Three CHMTF cases and three PMD cases, from two institutions over a 6-year period, were retrospectively included in this study. Clinical findings including age, pregnancy history, serum h CG level, ultrasonography findings, complications of the mother, outcome of the fetus, and results of chromosomal study of fetus, amniotic fluid and lesion, if possible, were noted. MRI findings were evaluated by two radiologists with respect to the location of the disease (intra- or extra-fetal sac), the presence of multicystic component, and presence of intra- or extra-lesional hemorrhage. Results In all six cases, the diseases were recognized as multicystic lesions by ultrasonography and MRI. In two of three CHMTF cases, patients continued with the pregnancy, which resulted in spontaneous abortion. In one case of CHMTF, the patient underwent artificial abortion, after which the mole progressed into an invasive mole with lung metastases. All three PMD patients had live births, and two of the three babies had fetal growth restriction. By MRI, CHMTF was located within an extra-fetal sac accompanied by intra- and/or extra-lesional hemorrhage, while PMD was located within the placenta in the fetal sac without hemorrhage. Conclusion MRI could provide important information about the prenatal differential diagnosis of CHMTF and PMD, based on the pathophysiology and characteristics of the diseases. [ABSTRACT FROM AUTHOR]

Takotsubo cardiomyopathy ( TCM) primarily affects postmenopausal women and is an important differential diagnosis of acute coronary syndrome. We describe a rare case of post-partum TCM, and present a published work review of the cases of pregnancy-associated TCM. A 24-year-old Japanese woman pregnant with twins suffered from premature membrane rupture at 31 gestational weeks. Following emergency cesarean delivery, she complained of sudden dyspnea. Transthoracic echocardiography revealed an inverted Takotsubo pattern (ejection fraction, 46%). On post-delivery day 8, wall motion abnormalities subsided, and she was discharged on post-delivery day 16. We reviewed 18 relevant cases of peripartum TCM from the published work. Among them, 16 cases were post-partum and two cases occurred during pregnancy. Most women (81%) underwent cesarean delivery, and the first symptoms of TCM appeared during surgery in 38% of the cases. The dominant symptoms were chest pain (44%) and dyspnea (28%). Most cases (94%) exhibited electrocardiogram abnormalities, including ST changes and T-wave inversion. Serum levels of cardiac enzymes were abnormally high in 92% of the cases. Repeated echocardiography documented normalized left ventricular systolic function within 6 months in all cases. This case and review emphasize that TCM may be concealed in post-partum women by symptoms undistinguishable from acute coronary syndrome, peripartum cardiomyopathy or pulmonary thromboembolism, and that echocardiography may be a useful tool to distinguish them. [ABSTRACT FROM AUTHOR]

Heterotopic cesarean scar pregnancy ( CSP) usually follows assisted reproductive technologies ( ART) in women who have already delivered by cesarean section. It is extremely rare: thus far, there have been only 12 individual case reports. However, over the last 20 years, the rate of cesarean delivery has increased and ART have become more common; hence, heterotopic CSP will be more prevalent in the future. Currently available data suggest that the early selective termination of CSP by medical or surgical methods is the most reliable treatment in the hemodynamically stable heterotopic CSP women because of the serious complications of continuing the CSP. We present the first case report of heterotopic CSP in a spontaneous cycle with expectant management that resulted in full-term twin deliveries. [ABSTRACT FROM AUTHOR]

The mechanism of synchronizing uterine contractions is not fully understood. We present a case of twin pregnancy in a uterus didelphys and objectively analyze the synchrony of bilateral uterine contractions. A 32-year-old woman, with a history of vaginal septal resection during her previous vaginal delivery, became pregnant with twins in a uterus didelphys in which each uterine horn had one fetus. At 37 weeks and 6 days, the first baby was delivered vaginally. The second baby was delivered by cesarean section due to recurrent late decelerations. Operative findings confirmed the didelphys uterus. We retrospectively reviewed the timing of contractions of both uteruses. The timing was determined by visual analysis as synchronous if both uteruses contracted within 5 s. Otherwise, contractions were considered solitary. Both uterine horns contracted independently in 90% of the incidence throughout labor and delivery. From this rare case of an 'experiment by nature', we speculated that the myometrium must be histologically connected in order to synchronize uterine contractions. [ABSTRACT FROM AUTHOR]

Interstitial pregnancy is considered one of the most hazardous types of ectopic pregnancies, with a mortality rate of 2-2.5%. We describe a case of a viable monochorionic twin pregnancy in a 35-year-old woman successfully treated with systemic methotrexate associated with bilateral uterine arteries' embolization. β-hCG was undetectable 67 days after the first administration of methotrexate and the ultrasonography performed on day 67 showed the remnant of the gestational sac in the right uterine horn, a thin endometrium and a normal myometrial vascularization. Conservative treatment allowed us to avoid surgical treatment and to preserve the patient's fertility. [ABSTRACT FROM AUTHOR]

Aim To assess the outcome of monochorionic diamniotic ( MD) twins with the aid of the MD-twin score. Methods We enrolled 112 MD-twin women in a tertiary perinatal center from 1997 to 2009. The MD-twin score was prospectively applied once per week to women who did not have twin-to-twin transfusion syndrome ( TTTS) after 26 weeks of gestation. The MD-twin score consists of five variables: (i) fetal weight discordance; (ii) amniotic fluid discordance; (iii) hydrops fetalis; (iv) umbilical cord insertion; and (v) fetal heart rate monitoring. Normal was assigned a value of 0, abnormal was assigned 1, and total score was used for evaluation. Women with scores of 2 at 26 weeks gestation were managed expectantly until the score reached 3. Outcome measures were fetal death, neonatal death and neurological sequelae. The incidence of poor outcome according to score was investigated. The characteristics of MD twins with poor outcome were investigated. Results MD-twin scores were applied to 90 women. Among them, 79 had scores of 2 or less and all had good outcomes. There were 11 women with a score of 3, four of whom had adverse outcome for at least one twin. Neonates born to women with scores of 0-2 had good outcomes without respect to birthweight percentile, while neonates with scores of 3 had poor outcomes when their birthweight percentile was less than the third percentile. Conclusion The MD-twin score is applicable to 90% of MD twins without TTTS. An MD-twin score of 2 is reassuring, while a score of 3 indicates increased risks for adverse outcome. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to investigate the value of discordance of crown-rump length ( DCRL) at mid-first trimester to predict adverse outcomes in monochorionic diamniotic twin gestations ( MD). Material and Methods This was a retrospective cohort study of the perinatal outcome in MD pregnancies managed from the first trimester onward. DCRL was evaluated between 8 and 10 weeks of gestation. The association between DCRL and perinatal complications, including fetal death, twin-twin transfusion syndrome, severe discordant birthweight ( DB), and twin anemia-polycythemia sequence, was assessed. Results Among 126 cases, a single fetal demise occurred in two (2%) and demise of both fetuses occurred in eight (6%). Five pregnancies (4%) were complicated with twin-twin transfusion syndrome; one case (1%) was twin anemia-polycythemia sequence and 13 (10%) were DB. Neonatal death occurred in one pair. At 28 days of age, in 115 cases (91%) both twins were alive. In 117 cases (93%), at least one twin survived until 28 days of age. DCRL >12.0% was not related to any perinatal complications but DB ( P < 0.01; relative risk: 1.40; 95% confidence interval: 1.06-1.84). Conclusions DCRL in MD during the mid-first trimester might be useful for predicting DB. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to determine the distribution and associations of birthweight in twin pairs among a population of pregnant women in south India. Material and Methods: This was a retrospective case record analysis of 705 twin pair pregnancies during the period 2008-2012. Associations of birthweight with maternal age, parity, pregnancy-induced hypertension ( PIH), gestational diabetes, obesity, chorionicity and sex of the twin pairs was explored using bivariate and multivariate analysis. Results: The median birthweight (4250 g, interquartile range 3530-4810) of dichorionic twins was significantly higher ( P < 0.0001) than monochorionic twins (3880 g, interquartile range 3000-4380). Birthweight was associated with chorionicity (t = 4.04, P < 0.001), obesity (t = 2.44, P = 0.03), nulliparity (t = −2.87, P = 0.004), and PIH (t = −2.11, P = 0.04) in a multivariate linear regression model. Birthweights did not differ significantly between female-male and female-female pairs (t = 0.11, P = 0.81), female-male and male-male pairs (t = −0.62, P = 0.54) or female-female and male-male pairs (t = −0.78, P = 0.43) in a multivariate linear regression model. The highest birthweight of the twin pair did not differ significantly (t = 1.27, P = 0.21) by sex of the twin. Conclusions: Birthweight of twins was significantly associated with chorionicity, obesity, PIH and nulliparity in this population. A potential masculinization effect was not found as the total birthweights did not differ significantly by sex of the twin pairs. [ABSTRACT FROM AUTHOR]

During pregnancy spontaneous rupture of the dividing membrane of monochorionic diamniotic twins is extremely rare and difficult to diagnose prenatally. We report a case of pseudo-monoamniotic twins derived from monochorionic diamniotic twin gestation. A 37-year-old woman pregnant with monochorionic diamniotic twins initially confirmed by the first trimester ultrasonography, was suspected to have a dividing membrane not visualized on ultrasound examinations at 27 gestational weeks. The woman did not undergo any invasive procedure during pregnancy and did not have notable symptoms. We considered the possibility of spontaneous rupture of the dividing membrane and cord entanglement, and managed the rest of her gestational period as a monoamniotic twin gestation. Concordantly grown healthy male babies were born at 35 weeks and 1 day by elective cesarean section. The mother had complex entangled umbilical cords and a small trace of amniotic membrane in the placenta. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to evaluate the perinatal outcome of monochorionic diamniotic (MD) twin gestations managed from early gestation onward at a single center. Material and Methods: This was a retrospective single-cohort study, spanning 6 years, of 219 MD twin pregnancies who received prenatal care before 14 weeks of gestation and delivered at our center. The subjects were all under the same perinatal management protocol. The incidence of fetal or neonatal death, major neurological complications at 28 days of age, twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence, and discordant birth was evaluated. Laser surgery was offered for TTTS at less than 26 weeks; however, selective feticide was not performed. Results: Pregnancy termination was selected in two cases. Miscarriage occurred in two (1%) of the cases and preterm delivery occurred in 91 (42%). In regard to perinatal outcome at 28 days of age, 195 (89%) women possessed two live infants and 205 (94%) possessed at least one live infant. The overall survival rate was 92% (403/438). The prevalence of TTTS was 17 cases (8%), seven of whom underwent laser surgery. Four cases of twin anemia-polycythemia sequence were diagnosed postnatally (2%); discordant birth was diagnosed in 24 (12%). Major neonatal neurological abnormalities were noted in six cases (2%). Conclusions: The incidence of perinatal complications in 219 sets of MD twins managed from early gestational age to the neonatal period in one perinatal center was demonstrated. The incidence of TTTS was 8%; the survival rate was 89% at 28 days of age. [ABSTRACT FROM AUTHOR]

We report a case of delayed-interval delivery of a dichorionic, diamniotic twin pregnancy with the survival of both twins. The patient presented at 22 weeks and 1 day of gestation with vaginal bleeding and preterm labor. Five days later, the first twin was born. The second twin remained in utero. The management consisted of careful monitoring of both maternal and fetal status. Nine days later, the second twin was delivered vaginally. Both twins received full resuscitation and immediate life-support intervention; at 7 years of age both twins exhibited normal development. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to assess the miscarriage and fetal loss rates of twin pregnancies after amniocentesis. Material and Methods: The outcome of 140 twin pregnancies that had amniocentesis performed from 1997 to 2006 was reviewed. Results: Among 140 twin pregnancies with amniocentesis, 35 were excluded (fetuses with structural anomalies, post-selective feticide, abnormal fetal karyotype, twin-twin transfusion syndrome [TTTS], termination of pregnancy, and unknown outcome). For the remaining 105 twin pregnancies, 102 had live births of all fetuses. One dichorionic twin had silent miscarriage of one fetus at 23 weeks. Another dichorionic twin had intrauterine death of one fetus at unknown gestation. One patient had preterm delivery at 32 weeks with neonatal death of one twin due to severe intrauterine growth restriction. The miscarriage rate (one or both fetuses) for twins before 24 weeks was 0.96% (1/105), the pregnancy loss (one or both fetuses) within 4 weeks of amniocentesis was 0.96% (1/105). The total fetal loss rate was 0.96% (2/210) for twins. Conclusion: Our cohort showed a low fetal loss rate after amniocentesis for uncomplicated twin pregnancies. [ABSTRACT FROM AUTHOR]

Aim: To evaluate fetal hemodynamic changes following maternal betamethasone administration in monochorionic twin pregnancies featuring one twin with selective intrauterine growth restriction (sIUGR) and absence of end-diastolic velocity in umbilical artery (UA) Doppler. Material and Methods: sIUGR was defined as fetal weight below the 10th percentile in one twin and inter-twin birth weight discordance >25%. The results of Doppler examinations including UA, middle cerebral artery (MCA) and ductus venosus directly prior to (D0), at 24 h (D1) and 48 h (D2) after administration of the first dose of betamethasone were recorded. Cerebral-placenta ratio was defined as MCA pulsatility index (PI) divided by UA-PI. Results: In four (20%) of the 20 cases, the UA Doppler of the growth-restricted twin returned to positive end-diastolic velocity after betamethasone administration. The UA-PI and MCA-PI of the sIUGR twin changed significantly after betamethasone administration: UA-PI was decreased at D1, theMCA-PI was reduced at both D1 and D2, and the cerebral-placenta ratio was not altered after betamethasone administration in the sIUGR twin. Conclusion: The hemodynamic changes after betamethasone administration were different between the two monochorionic twin fetuses where one presented with sIUGR and absence of UA end-diastolic velocity. The etiology of a low rate of return of end-diastolic velocity in the sIUGR twin needs further evaluation. [ABSTRACT FROM AUTHOR]

Neural tube defects (NTD) are a group of congenital malformations of the brain and spine, the etiology of which is still debated. Although presumed to be the consequence of interactions between genetic and environmental factors, so far, it is not known which genes are involved in the pathogenesis of these malformations. NTD affecting both fetuses in a twin gestation is a rare event. In view of this rarity, we present a case of dichorionic diamniotic twin pregnancy with spina bifida in both fetuses concordantly. This gestation was preceeded by another dichorionic diamniotic twin pregnancy that was complicated by placental abruption. [ABSTRACT FROM AUTHOR]

Spontaneous spinal epidural hematoma without discernable underlying conditions is a rare complication during pregnancy. We report a pregnant woman who developed the hematoma at 16 weeks of pregnancy; the earliest occurrence ever reported. A 36-year-old Japanese primipara with twins felt shoulder, neck and back pain at 16+1 weeks with progressive quadriplegia. Magnetic resonance imaging revealed a mass in the C3-7 epidural space, compatible with a spinal epidural hematoma, and decompression was performed 9 h after symptom onset. Rehabilitation started and she gave birth abdominally to healthy twin infants at the 29th week. Motor, sensory and sphincter disturbances remained. This case demonstrates that spinal epidural hematoma can occur even without known underlying conditions and even at an early gestational age. [ABSTRACT FROM AUTHOR]

A case of primary ovarian twin pregnancy is presented. A 30-year-old woman, gravida 3 para 2, was admitted to Medical College Hospital, Jabalpur, for postdated pregnancy with intrauterine fetal demise. Ultrasonography showed a break in the continuity of the uterus suggestive of a ruptured uterus. On laparotomy, twin ovarian pregnancy was discovered. One fetus was postdated, showing signs of maceration. The bones of the other fetus were discovered in the sac, suggestive of an autolysed fetus of approximately 26 to 28 weeks of gestation. [ABSTRACT FROM AUTHOR]

Clinical guidelines for obstetrical practice were first published by the Japan Society of Obstetrics and Gynecology (JSOG) and the Japan Association of Obstetricians and Gynecologists (JAOG) in 2008, and a revised version was published in 2011. The aims of this publication include the determination of current standard care practices for pregnant women in Japan, the widespread use of standard care practices, the enhancement of safety in obstetrical practice, the reduction in burdens associated with medico-legal and medico-economical problems, and a better understanding between pregnant women and maternity-service providers. These guidelines include a total of 87 Clinical Questions followed by several Answers (CQ&A), a Discussion, a List of References, and some Tables and Figures covering common problems and questions encountered in obstetrical practice. Each answer with a recommendation level of A, B or C has been prepared based principally on 'evidence' or a consensus among Japanese obstetricians in situations where 'evidence' is weak or lacking. Answers with a recommendation level of A or B represent current standard care practices in Japan. All 87 CQ&A are presented herein to promote a better understanding of the current standard care practices for pregnant women in Japan. [ABSTRACT FROM AUTHOR]

Aim: In singletons, neonatal small-for-gestational age (SGA) status is an unfavorable postpartum outcome leading to cesarean section (CS) and increasing the possibility of maternal operative complications. Perinatal characteristics of SGA newborns in dichorionic (DC) twins were investigated for the prognostic impact on their mothers. Methods: A retrospective study was performed from 2004 to 2009 on 329 DC twins with two live births. Neonates were classified as SGA if they weighed less than the 10th percentile at birth according to Japanese singleton norms. Statistical differences between DC twins delivering appropriate-for-gestational age (AGA)/ AGA pairs (control group) and AGA/SGA, SGA/AGA or SGA/SGA pairs (the first/second twins) were analyzed. Results: The median (range) of the gestational ages at delivery for AGA/AGA, AGA/SGA, SGA/AGA and SGA/SGA pairs were 37.1 (27.1–40.3), 37.2 (29.0–40.9), 37.1 (28.1–40.7) and 37.3 (33.3–40.4) weeks, and the complete vaginal delivery rates of both fetuses were 66.2% (43/65), 84.8% (28/33), 82.4% (14/17) and 70.0% (7/10), respectively. Compared with AGA/AGA pairs, AGA/SGA pairs showed a higher incidence of spontaneous vaginal births of both fetuses (31.3% [26/83] vs 19.9% [37/186], OR 1.84, 95% CI 1.4 –4.73) and a lower incidence of emergent CS (25.3% [21/83] vs 38.7% [72/186], OR 0.53, 95% CI 0.30–0.95). Conclusion: The relatively small size of SGA fetuses allows both fetuses to remain inside the uterus for a longer time and to easily pass through the maternal parturient canal for complete vaginal delivery. Neonatal SGA status is a favorable factor for avoiding operative complications of CS and optimizing maternal perinatal outcomes. [ABSTRACT FROM AUTHOR]

To investigate the maternal risk factors for small-for-gestational age (SGA) newborns in Japanese dichorionic (DC) twins. A retrospective study was conducted from 2003 to 2008 on 340 DC twin pregnancies resulting in two live births. Newborns were classified as SGA if their birth weight was below the 10th percentile according to Japanese singleton norms. Statistical differences were evaluated between pregnancies resulting in appropriate-for-gestational age (AGA) pairs and those resulting in at least one SGA neonate. The study population consisted of AGA/AGA (50.8%), AGA/SGA (37.0%) and SGA/SGA pairs (12.0%). Logistic regression analysis identified significant interrelations for SGA with maternal nulliparity (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.30-0.91), smoking (OR 3.25, 95% CI 1.09-9.66), assisted reproductive technology (OR 0.52, 95% CI 0.30-0.89), pregnancy-induced hypertension (OR 2.00, 95% CI 1.01-4.31), pregravid weight (kg) (unitary OR 0.94, 95% CI 0.91-0.97) and monthly weight gain (kg/month) (unitary OR 0.25, 95% CI 0.14-0.44). Bivariable receiver operating characteristic curves were generated for monthly weight gain (area under the curve [AUC] 0.626, cutoff 1.41 kg/month, P < 0.001) and total weight gain (AUC 0.615, cutoff 14.0 kg, P < 0.001). Cigarette smoking and weight gain control are relatively modifiable factors for which interventional management is necessary to avoid perinatal problems arising from SGA pregnancy. Further studies are needed to investigate optimal nutrition, health guidance and subsequent weight gain control that lead to concrete improvement in maternal and infant prognoses. [ABSTRACT FROM AUTHOR]

Middle cerebral artery-peak systolic velocity (MCA-PSV) has been reported to predict fetal anemia with similar accuracy as amniotic ΔOD450 assay. Alloimmunized dizygotic twin pregnancy allows us to compare anemic and non-anemic twins in the same intrauterine environment. We herein present a case of Rh (E)-incompatible dizygotic twin pregnancy, where MCA-PSV could precisely detect the anemia in one of the twins. A 36-year-old woman, whose previous child required exchange transfusion due to hemolytic anemia of newborn (HFDN), conceived twins after in vitro fertilization-embryo transfer. At 24 weeks' gestation, MCA-PSV of twin A and twin B were 23.9 cm/s (0.8 multiples of median; MoM) and 30.7 cm/s (1.0 MoM), respectively. At 31 weeks' gestation, MCA-PSV values of both twins were sharply elevated to nearly 1.4 MoM. Thereafter, MCA-PSV of twin A fell to 1.0 MoM, whereas MCA-PSV of twin B exceeded 1.5 MoM at 34 weeks' gestation. Development of fetal anemia was suspected and emergency cesarean section was performed. Twin B showed moderate anemia with positive direct Coombs' test and was diagnosed as HFDN due to anti-E alloimmunization. Twin B required phototherapy and red cell transfusion, but exchange transfusion was safely obviated. [ABSTRACT FROM AUTHOR]

Cervico-isthmic pregnancy is a rare form of ectopic pregnancy and is defined as the implantation of a fertilized ovum in the cervico-isthmic portion. The cause is unknown; local pathology related to previous cervical or uterine surgery may play a role, given an apparent association with a prior history of curettage or cesarean delivery. Transvaginal ultrasonography and β-human chorionic gonadotrophin assays are useful for diagnosis. Here we report a case of spontaneous twin cervico-isthmic pregnancy in a grand multiparous patient who was diagnosed early in the first trimester with transvaginal ultrasonography. The pregnancy was terminated successfully with methotrexate. Methotrexate seems to be most successful at early gestational ages. [ABSTRACT FROM AUTHOR]

Aim: To describe the longitudinal changes in canal length at 16-35 weeks' gestation in cases of twin pregnancy with preterm labor and delivery. Methods: We studied 22 cases of twin pregnancy that were delivered at <36 weeks and/or that underwent preterm labor requiring tocolysis. We also studied 44 cases of twin pregnancy delivered at ≥36 weeks without tocolysis (non-tocolysis twin pregnancy). Controls were 82 cases of normal singleton pregnancy. Canal length was longitudinally measured using transvaginal ultrasonography. The observational period of 16-35 weeks was divided into 4-week periods for analysis. Results: From 28 to 31 weeks onwards the canal length of non-tocolysis twin pregnancies was shorter than that of normal singleton pregnancies ( P < 0.05). The canal length of twin pregnancies with preterm labor and delivery was shorter than that of non-tocolysis twin pregnancies at 16-19 weeks and decreased rapidly until 24-27 weeks ( P < 0.01). Conclusions: A short canal length at 16-19 weeks followed by rapid canal length shortening in the second trimester are specific characteristics in preterm labor and delivery of twin pregnancies. Sequential measurements of canal length in the second trimester starting at <20 weeks may be a suitable parameter to predict preterm labor and delivery in twin pregnancies. [ABSTRACT FROM AUTHOR]

Reversal of twin-twin transfusion syndrome (TTTS) is a rare complication of monochorionic pregnancy. Diagnostic criteria and satisfactory therapeutic options have not been reported. We make a suggestion of diagnosis and therapy for reversal of TTTS. We report two cases of reversal of TTTS. Measurement of the fetal urine production rate was useful for management and better comprehension of the cases. In case 1, double intrauterine fetal demise occurred before the criteria for TTTS were fulfilled, in which each fetal urine production rate reversed prior to the change of amniotic fluid volume. In case 2, elevated urine production was noted prior to progressive polyhydroamnios and congestive heart failure in the new recipient and the fetoscopic laser photocoagulation of the placental communicating vessels was performed successfully before the criteria for TTTS were fulfilled. Both infants required intensive care, but developed normally and showed no neurologic complications at 2 years after birth. Hourly fetal urine production rate was useful for immediate diagnosis of reversal of TTTS, and laser photocoagulation of the placental communicating vessels is thus a method for the correction of the fetal blood flow imbalance in cases of reversal of the donor-recipient phenotype in TTTS. [ABSTRACT FROM AUTHOR]

Aim: The clinical importance of preterm premature rupture of the membranes (PPROM) is its relationship to maternal and neonatal mortality and morbidity, especially in twin pregnancies. The aim of this study was to determine and compare the role of inflammatory factors as predictors of the PPROM outcome between singleton and twin pregnancies. Methods: The medical records of 22 twins delivered between 28 and 34 weeks and complicated by PPROM were reviewed at the Al-Zahra Hospital in Tabriz, Iran. Also among singletons, 55 cases of matched gestational age were randomly selected as a control group. Three laboratory indices of neonatal white blood cell (WBC) count and C-reactive protein (CRP) in the two groups were measured immediately after delivery and the effects of two factors on neonatal outcome were assessed. Results: In singletons, there was adverse relationship between the mean of WBC count and duration of latency ( P = 0.007). Also, a positive relationship between the means of ventilation time and WBC count in second twins was found ( P = 0.034). Positive CRP was the main predictor of neonatal intensive care unit admission in both singletons (odds ratio: 4.929, P = 0.042) and first twins (odds ratio: 9.000, P = 0.005). However, positive CRP did not influence the existence of metabolic acidosis or duration of latency in either of the two groups. Conclusion: Neonatal WBC count was a predictor for the duration of latency in singletons and for ventilation time in twins. Positive neonatal CRP was an important factor for the prediction of neonatal intensive care unit admission in both types of pregnancy; its role in twins is clearer than in singletons. [ABSTRACT FROM AUTHOR]

Aim: The purpose of the present study was to elucidate the change of D-dimer and the possibility of deep vein thrombosis screening by D-dimer during pregnancy. Methods: One thousand, one hundred and thirty-one pregnant women were enrolled in the study from April 2006 to March 2007. D-dimer was measured by latex immunoassay at 6 to 14 and 30 to 36 weeks of gestation, respectively, and the veins of the lower extremities were examined by ultrasound at 30 to 36 weeks of gestation. Results: The mean and standard error of D-dimer was 1.1 ± 1.0 µg/mL in the first trimester and 2.2 ± 1.1 µg/mL in the third trimester, and both values were significantly higher than adult values. In addition, D-dimer significantly increased during pregnancy. D-dimer was not significantly different between singleton and twin pregnancies in the first trimester, but in the third trimester, the values of twin pregnancies were higher than singleton pregnancies (2.2 ± 1.6 vs 3.7 ± 2.5 µg/mL). The mean value of D-dimer of ultrasonographically positive women was 2.6 ± 2.0 µg/mL, which was significantly higher than the value for negative woman during the third trimester (2.2 ± 1.6 µg/mL). The positive predictive value was 7.4% and negative predictive value was 95.5% for ultrasonographically positive women when D-dimer was set at 3.2 µg/mL. Conclusion: We clearly found a change of D-dimer during pregnancy. When D-dimer was higher than 3.2 µg/mL, the percentage of ultrasonographically positive women was high. We propose that women with D-dimer higher than 3.2 µg/mL are closely monitored for prevention of pulmonary thromboembolism. [ABSTRACT FROM AUTHOR]

Twin ectopic pregnancy is a rare occurrence, with an estimated incidence of 1 in 20 000 spontaneous pregnancies. We describe a case of unilateral twin ectopic pregnancy in which the gravid fallopian tube showed no signs of tubal rupture despite marked tubal distension. A 25-year-old woman presented with clinical features suggestive of large right-sided tubal ectopic pregnancy. Serum β-human chorionic gonadotropin was 10 800 IU/mL. Laparotomy revealed markedly distended right fallopian tube. There was no hemoperitoneum. The tube contained twin gestational sacs. The crown-rump length of the embryos was 2 cm. The ectopic gestation was thus unique, in that despite marked tubal distension, the trophoblastic invasion was not significant to cause tubal rupture. There may be a role for medical management based on individual gestational sac size in selected cases of twin tubal pregnancy in which there is no evidence of hemoperitoneum. [ABSTRACT FROM AUTHOR]