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Objectives: Per a recent expert definition, diagnosis of selective fetal growth restriction (sFGR) in monochorionic diamniotic twins is based on an estimated fetal weight (EFW) <3% as sole criterion and/or combinations of 4 contributory criteria (1 twin EFW <10%; 1 twin abdominal circumference <10%; EFW discordance ≥25%; and smaller twin umbilical artery [UA] pulsatility index >95th percentile). We assessed these criteria in sFGR Type III (intermittent absent or reversed end‐diastolic flow of the UA [iAREDF]) patients to test whether meeting the more stringent parameters of the consensus definition had worse outcomes, that is, progression to sFGR Type II (persistent AREDF) or twin‐twin transfusion syndrome; or secondarily, decreased dual survivorship. Methods: This was a retrospective study of referred sFGR Type III patients (2006–2017). Patients were retrospectively categorized using consensus criteria for 2 comparisons: 1) EFW <3% versus remaining cohort; 2) EFW <3% or met all 4 contributory criteria versus remaining cohort. Results: Forty‐eight patients were studied. Comparison 1: EFW <3% patients (58.3%) were not more likely to demonstrate disease progression (46.4% versus 65.0%, P =.2489) or worse dual survivorship (78.6% versus 85.0%, P =.7161). Comparison 2: EFW <3% or met all 4 contributory criteria (75.0%) patients were not more likely than the others to demonstrate progression (44.4% versus 83.3%, P =.0235) or worse dual survivorship (80.6% versus 83.3%, P = 1.0000). Conclusions: In a referred cohort of sFGR Type III patients, there was no evidence that meeting more stringent parameters of the consensus definition was associated with disease progression or dual survivorship. [ABSTRACT FROM AUTHOR]

Objective: A recent randomized controlled trial (RCT) demonstrated no difference in 6 month survival in expectantly managed stage I twin‐twin transfusion syndrome (TTTS) patients and those undergoing immediate laser surgery. We aimed to describe outcomes following immediate laser surgery at a single fetal surgery center. Methods: A retrospective study of monochorionic diamniotic twins diagnosed with stage I TTTS who underwent laser surgery between 16 and 26 gestational weeks from 2006 to 2019. The primary outcome was 6 month survivorship. Intact survival was also assessed. Secondarily, outcomes were compared to the RCT expectant management group. Results: Of 126 consecutive stage I TTTS patients, 114 (90.5%) met inclusion criteria. Median (range) gestational age at delivery was 34.1 (20.6–39.4) weeks. At 6 months, the proportion of patients with at‐least‐one survivor in the single‐center‐laser cohort was 97.4%, with 88.6% dual survivorship. Neurological morbidity outcomes were available in 110 pregnancies (220 fetuses). Severe neurological morbidity occurred in 2.7% (6/220), and 6 month survival without severe neurological morbidity was 90.0%. Outcomes compared favorably with the RCT expectant management group. Conclusions: Given favorable survival and neurological outcomes, laser surgery is a reasonable treatment option for stage I TTTS at experienced fetal surgery centers. Further study is warranted to optimize treatment strategies. Key points: What is already known? Optimal treatment strategy for stage I twin‐twin transfusion syndrome (TTTS) is controversialA recent randomized controlled trial (RCT) showed no difference in 6‐month survival in stable stage I TTTS treated with immediate laser surgery versus expectant management What does this study add to the literature? Present study suggests laser surgery remains a reasonable first‐line treatment for stage I TTTS, despite procedure‐related risks [ABSTRACT FROM AUTHOR]

Objective: To evaluate all individual cases of dual twin demise following laser surgery for twin‐twin transfusion syndrome (TTTS). Method: This is an analysis of all monochorionic diamniotic twin gestations with TTTS complicated by dual demise following laser surgery from 2006 to 2019. Cases were reviewed by (1) a fetal surgeon researcher and (2) a panel of independent experienced maternal‐fetal medicine specialists to code an etiology of demise for the donor and recipient, and to assess for possible preventability. Results: Of 753 twins that underwent laser surgery for TTTS, 52 (6.9%) had postoperative dual demise. In this subgroup, gestational age at surgery was 19.5 (16.1–24.9) weeks, and 36 (69.2%) patients were Quintero stage III and IV. The most common etiology was the spectrum of disorders leading to preterm delivery, which included cervical insufficiency, preterm premature rupture of membranes, and preterm labor (44.2% and 48.1%, donor and recipient, respectively). Some degree of preventability was estimated for 23.1% of dual demises. Conclusions: The most common cause of dual demise post laser surgery for TTTS was preterm birth, reinforcing the need for studies regarding the etiology and prevention of post‐fetoscopy prematurity. Nearly one‐quarter of dual demise cases were deemed potentially preventable. Key points: What's already known about this topic? Dual twin demise is an uncommon outcome following laser surgery for twin‐twin transfusion syndrome (TTTS), and limited data have been reported regarding these patients. What does this study add? Through the use of an expert panel, this study reviews both the causes and potential preventability of dual demise following laser surgery for TTTS. [ABSTRACT FROM AUTHOR]

Introduction: Abundant research has reported twin-twin transfusion syndrome (TTTS) outcomes following fetal therapy. Our research describes TTTS patients who did not undergo fetal therapy.Methods: Records from TTTS pregnancies evaluated at 16 to 26 gestational weeks were reviewed between January 2006 and March 2017. The study population comprised subjects who did not undergo fetal therapy. Based on initial consultation, patients were grouped as nonsurgical vs surgical candidates. TTTS progression and perinatal outcomes were assessed.Results: Of 734 TTTS patients evaluated, 68 (9.3%) did not undergo intervention. Of these, 62% were nonsurgical candidates and 38% were surgical candidates. Nonsurgical candidates were ineligible for treatment because of fetal demise or maternal factors (placental abruption, severe membrane separation, and preterm labor). Of surgical candidates, 11 underwent expectant management, eight elected pregnancy termination, and seven planned fetal intervention but had a complication before the procedure. TTTS progression occurred in 10 (15.2%) of 66 cases. Neonatal survival in 64 cases was as follows: in 41 (64%), no survivors; in 11 (17.2%), one survivor; and in 12 (18.8%), two survivors.Conclusion: Nine percent of referred TTTS patients did not undergo fetal therapy, with many ineligible because of morbidity between referral and consultation. Studies of TTTS should acknowledge this subgroup and circumstances leading to lack of treatment. [ABSTRACT FROM AUTHOR]

Objective: To develop a conceptual framework and preliminary item bank for childbirth-specific patient-reported outcome (PRO) domains.Data Sources: Women, who were U.S. residents, ≥18 years old, and ≥20 weeks pregnant, were surveyed regarding their childbirth values and preferences (V&P) using online panels.Study Design: Using community-based research techniques and Patient-Reported Outcomes Management Information System (PROMIS® ) methodology, we conducted a comprehensive literature review to identify self-reported survey items regarding patient-reported V&P and childbirth experiences and outcomes (PROs). The V&P/PRO domains were validated by focus groups. We conducted a cross-sectional observational study and fitted a multivariable logistic regression model to each V&P item to describe "who" wanted each item.Principal Findings: We identified 5,880 V&P/PRO items that mapped to 19 domains and 58 subdomains. We present results for the 2,250 survey respondents who anticipated a vaginal delivery in a hospital. Wide variation existed regarding each V&P item, and personal characteristics, such as maternal confidence and ability to cope well with pain, were frequent predictors in the models. The resulting preliminary item bank consisted of 60 key personal characteristics and 63 V&P/PROs.Conclusions: The conceptual framework and preliminary (PROMIS® ) item bank presented here provide a foundation for the development of childbirth-specific V&P/PROs. [ABSTRACT FROM AUTHOR]

Objective: To present outcomes of fetuses with congenital pulmonary airway malformation (CPAM) treated with sclerotherapy.Methods: Retrospective study of 8 patients with a prenatal diagnosis of CPAM type II or III with secondary hydrops treated with percutaneous sclerotherapy using 5% ethanolamine oleate (EO). All patients underwent ultrasonic measurement of the CPAM volume ratio. Results are expressed as median (range).Results: Gestational age at initial sclerotherapy was 22.0 weeks (19.6-31.4); 3 patients underwent 2 procedures. Intrauterine fetal demise (IUFD) occurred in 4 cases; 2 died on postoperative day #1 (one from inadvertent intravascular EO injection); 2 died >6 weeks after the procedure. Preoperative CPAM volume ratio was 3.6 (1.6-7.8) in survivors and 2.7 (1.7-4.7) in those with IUFD. The volume of EO at the initial sclerotherapy procedure was 3 mL (2-5) in survivors and 7 mL (6-10) in IUFD cases. The gestational age at delivery of the 4 survivors was 38.4 weeks (37.4-39.3); all underwent postnatal resection.Conclusion: The efficacy of percutaneous sclerotherapy for CPAM types II and III remains in question. Further studies are needed to determine the optimal dose of sclerotherapy agent and the safety and efficacy of this procedure. [ABSTRACT FROM AUTHOR]

Objective: To compare outcomes between 2 umbilical cord occlusion (UCO) methods: radiofrequency ablation (RFA) versus fetoscopic-guided laser photocoagulation.Methods: Retrospective study of all monochorionic diamniotic multiple gestations that underwent UCO with RFA (preferred after 2014) or laser (preferred before 2014). In bivariate analysis, patients treated with RFA were compared with laser. Risk factors for intrauterine fetal demise (IUFD) and 30-day survival of the co-twin were identified, and multiple logistic models were fitted to examine whether the UCO method was associated with these outcomes.Results: Of 60 UCO cases, 18 (30%) underwent RFA and 42 (70%) underwent laser surgery. The RFA method was associated with co-twin IUFD after surgery (6/18 [33.3%] vs 1/42 [2.4%], P = 0.0021). In logistic regression models, patients who underwent RFA were more likely than patients who underwent laser to have an IUFD of the co-twin (OR 13.2, 1.23-142.62, P = 0.0331). These patients were also less likely to have 30-day survival of the co-twin, although this was not statistically significant (OR 0.20, 0.04-1.15, P = 0.0710).Conclusion: Despite clear technical advantages of RFA compared with laser, we found that RFA appeared to be associated with increased risk of post-procedure fetal demise. Further studies should be conducted to confirm these findings. [ABSTRACT FROM AUTHOR]

Objective: To quantify and assess potential risk factors for transplacental passage of fetal red blood cells (RBCs) into the maternal circulation (fetomaternal bleeding, FMB) after laser surgery for twin-twin transfusion syndrome (TTTS).Study Design: A retrospective study of Rhesus-D negative patients that underwent laser surgery for TTTS. Patients with and without postoperative detectable fetal RBCs on Kleihauer-Betke (KB) testing were compared to determine risk factors for FMB. Patients were further sub-classified into those with a FMB < 20% and ≥20% of estimated fetoplacental blood volume.Results: Of 60 studied patients, 26/60 (43%) had a positive postoperative KB test. The median fetal:adult RBC ratio was 0.00125, estimated to be a FMB volume of 6.25 mL. There were 17/26 (65%) of patients with FMB < 20% and 9/26 (35%) patients with ≥20% of the fetoplacental blood volume. Stage III-Recipient and III-Recipient/Donor patients were more likely to have a positive KB test (14/21 [66.7%] vs 12/39 [30.8%], OR = 4.50 [1.27-16.54], P = 0.0162). No other risk factors for FMB were apparent.Conclusions: Fetomaternal bleed appears to be a common finding after laser surgery for TTTS. TTTS Stage, particularly stage III-Recipient and III-Recipient/Donor, appears to be a risk factor for FMB. [ABSTRACT FROM AUTHOR]

Objectives To evaluate risk for congenital heart disease (CHD) in recipient twins with circular shunt physiology (CSP). Methods This prospective study enrolled twin-twin transfusion syndrome (TTTS) cases from 2006 to 2015. Fetal echocardiography (FE) was performed before laser surgery when cardiac involvement was suspected. Diagnosis of recipient twin CSP required tricuspid and pulmonary regurgitation, right ventricular dysfunction, and flow reversal in the ductus arteriosus. Outcomes were assessed at 30 days after birth. Results Of the 496 TTTS pregnancies, 20 (4%) met the criteria for CSP. Among those born alive, who had documented cardiac outcomes (n = 457), patients with CSP were more likely to have CHD, specifically right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 22 of 439 [5.0%], odd ratio [OR] 7.29, 95% confidence interval [CI] 2.05-24.72, P = .0025). Of the recipient twins with preoperative FE (n = 259, 52%) who were born alive and had documented cardiac outcomes (n = 242), those with CSP were still more likely to have right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 14 of 224 [6.3%], OR 5.77, CI 1.54-20.92, P = .0077). With both analyses, twins with CSP had higher Quintero stage, but similar patient characteristics and 30-day mortality compared with those without CSP. Subgroup analyses of the CSP cohort identified no differences in preoperative characteristics or FE findings predictive of CHD. Conclusions Recipient twins with preoperative CSP were at increased risk for postnatal right ventricular outflow tract obstruction, but appeared to have comparable survival after fetal laser surgery despite these dramatic pathophysiological prenatal findings. Preoperative FE in TTTS remains important for prediction of postnatal CHD. [ABSTRACT FROM AUTHOR]

Objective: To develop a methodology to identify indications and normative rates for elective primary cesarean delivery using administrative data.Data Sources/study Setting: All delivery discharges in 1995, as reported to the California Office of Statewide Health Planning and Development (secondary data).Study Design: Retrospective population based study.Data Collection/extraction: Data were entered into a recursive partitioning algorithm to develop a hierarchy of conditions by which patients with multiple conditions could be sorted with respect to the binary outcome of labor or elective primary cesarean without labor. This hierarchy was examined for its clinical consistency, validated on a second sample, and compared with results obtained from logistic regression.Principal Findings: Four percent (19,664) of delivery discharges in 1995 underwent elective primary cesarean. Twelve clinical conditions contributed to the hierarchy, and accounted for 92.9 percent of all women experiencing elective primary cesarean delivery. The remaining 7.1 percent of the elective primary cesarean cases were classified as "unspecified."Conclusions: A standardized methodology (utilizing recursive partitioning algorithms) for assigning indications for elective primary cesarean is presented. This methodology relies on administrative data, classifies women with complex comorbidity patterns into clinically relevant subpopulations, and can be used to establish normative rates for benchmarking specific indications for cesarean delivery. [ABSTRACT FROM AUTHOR]

Background We propose a methodology for identifying and analysing 'elective' preterm births ( PTBs) using administrative data, and apply this methodology to California data with the objective of providing a framework to further explore the potential rationales for early delivery. Methods Using the California linked birth cohorts for 1999, 2002 and 2005, singleton PTBs were identified using birth certificate gestational age ≥ 24 and <37 weeks. Through a hierarchical scheme that first removed cases with standard or 'hard' indications for early delivery (e.g. severe preeclampsia, placenta previa), cases of 'elective' PTB were identified with coding for medical intervention, that is, elective caesarean or labour induction. We calculated rates of elective PTB, with subanalyses of early (<34 weeks of gestational age) and late PTB (34 to <37 weeks of gestational age) using hierarchical logistic regression models. Results Of 1 387 565 singleton deliveries, 99 614 (7.2%) were preterm. Elective PTBs increased 27.7% over the 6-year study period, with nearly all cases confined to the late PTB stratum; elective late PTB rates rose from 10.5% to 13.5% of all late PTBs ( P < 0.0001). Indications for delivery in this Elective Group ('soft indications') included prior pelvic floor repair, mental health conditions, fetal anomalies, malpresentation and oligohydramnios. Six per cent of patients with a late PTB had a medical intervention with no hard or soft indication for delivery. Conclusions Using administrative data, we developed a method for identifying and trending the proportion of PTBs that is 'elective'. This method can be used to explore and monitor potential strategies for the prevention of elective PTB. [ABSTRACT FROM AUTHOR]

Objective To assess postnatal prevalence of congenital heart disease (CHD) in surviving twins treated for twin-twin transfusion syndrome (TTTS) with laser surgery. Methods Patients who underwent laser surgery for TTTS at a single institution were prospectively enrolled between January 2009 and May 2010. Preoperative fetal echocardiography was performed. Perinatal outcomes were obtained via postnatal echocardiograms and review of medical records. CHD was defined as unequivocal structural cardiac pathology; patent foramen ovale and patent ductus arteriosus were excluded. Results Fifty pregnancies with TTTS were enrolled, with the following Quintero stage distribution: stage I, 10%; stage II, 22%; stage III, 50%; and stage IV, 18%. Of the 88 fetuses born alive, 84 patients (95.5%) completed postnatal cardiac evaluation. Overall postnatal prevalence of CHD was 15.5% (13 of 84): 15.6% of recipient twins and 15.4% of donor twins. Three patients required cardiac intervention during infancy. Among liveborn twins with CHD, the overall prenatal detection rate was 30.8% (4/13), comprising 16.7% (1/6) of donors compared with 42.9% (3/7) of recipients. Conclusion Following successful laser surgery for TTTS, an increased and comparable postnatal prevalence of CHD occurs among both former recipients and donors. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The caesarean delivery rate has become a commonly used measure intended to reflect the quality of obstetric care. At least 25% of all primary caesarean deliveries occur electively, i.e. to women who are not in labour. This study is intended to validate a previously published model designed to use ICD-9-CM codes to identify and categorise cases of elective primary caesarean delivery by their indication. ICD-9-CM codes were compared with diagnoses written in the medical record for all women without a prior caesarean who delivered in the same month in a single hospital to examine the accuracy of the codes for 12 potential elective primary caesarean indications derived by the published model: malpresentation; bleeding; genital herpes; severe hypertension; uterine scar; multiple gestation; macrosomia; unengaged fetus; maternal soft tissue conditions; other hypertensive conditions; prematurity; and chromosomal anomalies. Of 440 eligible women, a total of 26 (5.9%) had an elective primary caesarean by medical record review vs. [27] (6.1%) by administrative data. Using medical record data as the gold standard, the sensitivity, specificity, and accuracy of administrative data for the identification of elective primary caesarean delivery were 73.1%, 98.1%, and 96.6%, respectively. Administrative coding for all of the 12 conditions was highly specific, although wide variability existed in its sensitivity; its accuracy ranged between 83.9% and 100%. These results suggest that, despite widespread use of caesarean delivery rates obtained through administrative data, more experience is needed to determine which obstetric codes may be sufficiently specific, sensitive, or prevalent to serve a monitoring or surveillance function reflecting the quality of obstetrical care. The results support continued efforts to use administrative data to monitor elective primary caesarean delivery. [ABSTRACT FROM AUTHOR]