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Objective\ud The use of twin-specific vs singleton growth charts in the assessment of twin pregnancy has been controversial. The aim of this study was to assess whether a diagnosis of small-for-gestational age (SGA) made using twin-specific estimated-fetal-weight (EFW) and birth-weight (BW) charts is associated more strongly with adverse neonatal outcomes in twin pregnancies, compared with when the diagnosis is made using singleton charts.\ud \ud Methods\ud This was a cohort study of twin pregnancies delivered at St George's Hospital, London, between January 2007 and May 2020. Twin pregnancies complicated by intrauterine death of one or both twins, fetal aneuploidy or major abnormality, twin–twin transfusion syndrome or twin anemia–polycythemia sequence and those delivered before 32 weeks' gestation, were excluded. SGA was defined as EFW or BW below the 10th centile, and was assessed using both twin-specific and singleton EFW and BW charts. The main study outcome was composite adverse neonatal outcome. Mixed-effects logistic regression analysis with random pregnancy-level intercepts was used to test the association between SGA classified using the different charts and adverse neonatal outcome.\ud \ud Results\ud A total of 1329 twin pregnancies were identified, of which 913 (1826 infants) were included in the analysis. Of these pregnancies, 723 (79.2%) were dichorionic and 190 (20.8%) were monochorionic. Using the singleton charts, 33.3% and 35.7% of pregnancies were classified as SGA based on EFW and BW, respectively. The corresponding values were 5.9% and 5.6% when using the twin-specific charts. Classification as SGA based on EFW using the twin charts was associated significantly with composite adverse neonatal outcome (odds ratio (OR), 4.78 (95% CI, 1.47–14.7); P = 0.007), as compared with classification as appropriate-for-gestational age (AGA). However, classification as SGA based on EFW using the singleton standard was not associated significantly with composite adverse neonatal outcome (OR, 1.36 (95% CI, 0.63–2.88); P = 0.424). Classification as SGA based on EFW using twin-specific standards provided a significantly better model fit than did using the singleton standard (likelihood ratio test, P

Aim\ud To evaluate the clinical factors associated with false-negative RT-PCR results and to report the outcome of a cohort of pregnant women with COVID-19.\ud \ud Methods\ud This cohort study was conducted in a tertiary referral pandemic hospital and included 56 pregnant women. A study including pregnant women with either a laboratory or clinical diagnosis for COVID-19 were included in the study. The primary outcome was clinical factors associated with false-negative RT-PCR results defined as a positive immunoglobulin M assessed by rapid testing in clinically diagnosed patients. Clinical outcomes of laboratory diagnosed patients were also reported.\ud \ud Results\ud In total, 56 women with either RT-PCR or clinical COVID-19 diagnosis were included in the study. Forty-three women either had RT-PCR positivity or IgM positivity. The clinical outcome of these pregnancies was as follows: mean maternal age 27.7, immunoglobulin M positive patients 76.7%, RT-PCR positive patients 55.8%, maternal comorbidities 11.5%, complications in patients below 20 weeks 34.8%, complications in patients above 20 weeks 65.1%, elevated CRP 83.7%, lymphopenia 30.2%, time from hospital admission to final follow-up days 37 and stillbirth 8.3%. The proportion of women who tested positive for SARS-CoV-2 immunoglobulin M was 100% in the RT-PCR positive group and 56.5% in the clinical diagnosis group (P = .002). The symptom onset to RT-PCR testing interval longer than a week (risk ratio: 2.72, 95% CI: 1.14-5.40, P = .003) and presence of dyspnoea (risk ratio: 0.38, 95% CI: 0.14-0.89, P = .035) were associated with false-negative RT-PCR tests. The area under the curve of these parameters predicting false-negative RT-PCR was 0.73 (95% CI: 0.57-0.89).\ud \ud Conclusions\ud Symptomatic women with a negative RT-PCR should not be dismissed as potential COVID-19 patients, especially in the presence of prolonged symptom onset-test interval and in women without dyspnoea.

BACKGROUND: Women with a history of hypertensive disorders of pregnancy (HDP) are at increased long-term risk of cardiovascular disease. However, there has been increasing evidence on the same risks in the months following birth. OBJECTIVES: This review aims to estimate the incidence of hypertension in the first 2 years after HDP. SEARCH STRATEGY: MEDLINE, Embase and Cochrane databases were systematically searched in October 2019. SELECTION CRITERIA: Observational studies comparing hypertension rate following HDP and normotensive pregnancies up to 2 years. DATA COLLECTION AND ANALYSIS: A meta-analysis to calculate the odds ratio (OR) with a 95% confidence interval (CI) and a sub-group analysis excluding women with chronic hypertension were performed. MAIN RESULTS: Hypertension was diagnosed within the first 2 years following pregnancy in 468/1646 (28.4%) and 584/6395 (9.1%) of the HDP and control groups, respectively (OR 6.28; 95% CI 4.18-9.43; I2 = 56%). The risk of hypertension in HDP group was significantly higher in the first 6 months following delivery (OR 18.33; 95% CI 1.35-249.48; I2 = 84%) than at 6-12 months (OR 4.36; 95% CI 2.81-6.76; I2 = 56%) or between 1-2 years postpartum (OR 7.24; 95% CI 4.44-11.80; I2 = 9%). A sub-group analysis demonstrated a similar increase in the risk of developing postpartum hypertension after HDP (OR 5.75; 95% CI 3.92-8.44; I2 = 49%) and pre-eclampsia (OR 6.83; 95% CI 4.25-10.96; I2 = 53%). CONCLUSIONS: The augmented risk of hypertension after HDP is highest in the early postpartum period, suggesting that diagnosis and targeted interventions to improve maternal cardiovascular health may need to be commenced in the immediate postpartum period. TWEETABLE ABSTRACT: The risk of hypertension within 2 years of birth is six-fold higher in women who experienced pre-eclampsia.

OBJECTIVE: Identification of the fetus at risk of intrapartum compromise has many benefits. Impaired maternal cardiovascular function is associated with placental hypoperfusion intrapartum fetal distress. The main aim of this study was to assess the predictive accuracy of maternal hemodynamics for the risk of operative delivery due to presumed fetal compromise in women undergoing induction of labour (IOL). METHODS: In this prospective cohort study patients were recruited between November 2018 and January 2019. Women undergoing IOL were invited to participate in the study. A non-invasive ultrasonic cardiac output monitor (USCOM-1A) was used for the cardiovascular evaluation. The study outcome was operative delivery due to presumed fetal compromise, which included cesarean or instrumental delivery for abnormal fetal heart monitoring. Regression analysis was used to test the association between cardivascular markers, as well as the maternal characteristics and the risk of operative delivery for presumed fetal compromise. The ROC curve analysis was used to assess the predictive accuracy of the cardivascular markers for the risk of operative delivery for presumed fetal compromise. RESULTS: A total of 99 women were recruited and four women were later excluded from the analysis due to semi-elective cesarean section (n=2) and failed IOL (n=2). The rate of operative delivery due to presumed fetal compromise was 28.4% (27/95). Women who delivered without suspected fetal compromise were more likely to be multiparous (52.9% vs 18.5%, p=0.002). Women who underwent operative delivery due to presumed fetal compromise had significantly lower cardiac index (CI) (median: 2.50 L/min/m2 vs. 2.60 L/min/m2 , p=0.039) and higher systemic vascular resistance (SVR) (median: 1480.0 mmHg.min.mL-1 /m2 vs. 1325.0 mmHg.min.mL-1 /m2 , p=0.044) compared to controls. The baseline model (multiparity only) showed poor predictive accuracy with an area under the curve (AUC) value of 0.67 (95% CI: 0.58-0.77). The addition of stroke volume index (SVI) 7.2 logs or SVR index (SVRI) >7.7 logs significantly improved the baseline model (p=0.012, p=0.026 and p=0.012, respectively). CONCLUSION: In this pilot study, we demonstrated that pre-labour maternal cardiovascular assessment in women undergoing IOL could be useful for assessing the risk of intrapartum fetal compromise necessitating operative delivery. The addition of SV, SVR and SVRI significantly improved the predictive accuracy of the baseline antenatal model. This article is protected by copyright. All rights reserved.

OBJECTIVE: Twin pregnancy is associated with 2-3 fold increased risk of stillbirth compared to singletons. Despite the fact that the growth pattern has been shown to differ in twins compared to singletons, it is controversial whether twin-specific growth charts should be routinely used. A major goal of prenatal ultrasound is to identify fetuses suffering from growth restriction at risk of stillbirth. The main aim of this study was to compare the performance of chorionicity-specific twin charts with singleton charts, both customized and non-customized, in the antenatal prediction of small-for-gestational age (SGA) stillborn and liveborn fetuses. METHODS: This was a multicenter cohort study analyzing data from the Southwest Thames Obstetric Research Collaborative (STORK) multiple pregnancy cohort (2000-2009) and a second cohort of twin pregnancies at St. George's University Hospital (SGH) (2011-2016). The former cohort was used to compare the performance of the twin and non-customized (Poon) singleton charts. The latter cohort was used to compare the performance of the twin, customized (Gestation Related Optimal Weight [GROW]) and non-customized (Poon) singleton charts. The primary outcome was the prediction of SGA cases that were stillborn and liveborn in twin pregnancies. The estimated fetal weight (EFW) available from the last scan (24 weeks' gestation and onwards) before delivery or demise was used to classify the fetuses as SGA (

Objective\ud To identify key factors associated with adverse perinatal outcome in monochorionic diamniotic twin pregnancy complicated by selective fetal growth restriction (sFGR).\ud \ud Methods\ud This was a retrospective cohort study of all monochorionic diamniotic twin pregnancies diagnosed with sFGR at ≥ 16 weeks' gestation, in a single tertiary referral center between March 2000 and May 2015. The presence of coexisting twin–twin transfusion syndrome (TTTS) was noted. Fetal biometry and Doppler indices, including those of the umbilical artery (UA) and ductus venosus (DV), were recorded at the time of diagnosis. The type of sFGR was diagnosed according to the pattern of end‐diastolic flow in the UA of the smaller twin. DV pulsatility indices for veins (DV‐PIV) were converted to Z‐scores and estimated fetal weight values to centiles, to correct for gestational age (GA). Cox proportional hazards model was used to examine for independent predictors of adverse perinatal outcome, which was defined according to survival and included both intrauterine fetal demise and neonatal death of the FGR twin.\ud \ud Results\ud We analyzed 104 pregnancies, of which 66 (63.5%) were diagnosed with Type‐I and 38 (36.5%) with Type‐II sFGR at initial presentation. In pregnancies complicated by Type‐II sFGR, the diagnosis of sFGR was made earlier than in those complicated by Type‐I sFGR (mediam GA, 19.6 vs 21.5 weeks; P = 0.012), and Type‐II sFGR was associated with increased risk of adverse perinatal outcome (intrauterine demise of the smaller twin, 34.2% vs 10.6%; P = 0.004). Twin pregnancies complicated by sFGR resulting in perinatal demise had a significantly earlier diagnosis (P = 0.002) and lower birth‐weight centile of the smaller twin (P 0.05 for both). Earlier GA at diagnosis (hazard ratio (HR), 0.70 (95% CI, 0.56–0.88); P = 0.002), Type‐II sFGR (HR, 3.53 (95% CI, 1.37–9.07); P = 0.008) and higher DV‐PIV Z‐score (HR, 1.36 (95% CI, 1.12–1.65); P = 0.001) were significantly associated with increased risk of adverse perinatal outcome of the smaller twin.\ud \ud Conclusions\ud Pregnancies complicated by Type‐II sFGR are diagnosed significantly earlier and are associated with increased risk of adverse perinatal outcome compared with those with Type‐I sFGR. Coexisting TTTS has no significant impact on the perinatal outcome of pregnancies diagnosed with either Type‐I or Type‐II sFGR. Earlier GA at diagnosis, Type‐II sFGR and higher DV‐PIV Z‐score are associated significantly with increased risk of adverse perinatal outcome of the smaller twin.

OBJECTIVE: To assess the agreement between home blood-pressure monitoring (HBPM) and blood-pressure measurements in a clinic setting, in a cohort of pregnant women with hypertensive disorders of pregnancy (HDP). METHODS: This was a cohort study of 147 pregnant women with HDP conducted at St George's Hospital, University of London, London, UK, between 2016 and 2017. Inclusion criteria were chronic hypertension, gestational hypertension or high risk of developing pre-eclampsia, no significant proteinuria and no hematological or biochemical abnormalities. Each included patient was prescribed a personalized schedule of hospital visits and blood-pressure measurements, according to their individual risk as per UK National Institute for Health and Care Excellence guidelines. The blood-pressure measurement at the clinic and the HBPM reading obtained closest to that hospital visit were paired for analysis. Only one pair of measurements was used per patient. Differences between home and clinic blood-pressure measurements were tested using the Wilcoxon signed rank test or paired t-test, and were also assessed visually using Bland-Altman plots. Comparison of the binary outcomes was performed using McNemar's chi-square test. Subgroup analysis was performed in the following gestational-age windows