Twin pregnancy with sudden heart failure and pulmonary hypertension after atrial septal defect repair: A case report

BACKGROUND Pulmonary arterial hypertension(PAH)in pregnancy is one of the major obstetric complications and is considered a contraindication to pregnancy as it is classified as a class IV risk in the revised risk classification of pregnancy by the World Health Organisation.Pregnancy,with its adaptive and expectant mechanical and hormonal changes,negatively affects the cardiopulmonary circulation in pregnant women.Do patients with repaired simple congenital heart disease(CHD)develop other pulmonary and cardiac complications during pregnancy?Can pregnant women with sudden pulmonary hypertension be treated and managed in time?In this paper,we present a case of a 39-year-old woman who underwent cesarean section at 33 wk'gestation and developed PAH secondary to repaired simple CHD.Our research began by a PubMed search for"pulmonary hypertension"and"pregnancy"and"CHD"case reports.Three cases were selected to review PAH in pregnancy after correction of CHD defects.These studies were reviewed,coupled with our own clinical experience.CASE SUMMARY Herein,a case involving a woman who underwent atrial septal defect repair at the age of 34,became pregnant five years later,and had a sudden onset of PAH and right heart failure secondary to symptoms of acute peripheral edema in the third trimester of her pregnancy.As a result,the patient underwent a cesarean section and gave birth to healthy twins.Within three days after cesarean delivery,her cardiac function deteriorated as the pulmonary artery pressure increased.Effec-tive postpartum management,including diuresis,significant oxygen uptake,vasodilators,capacity and anticoagulants management,led to improvements in cardiac function and oxygenation.The patient was discharged from hospital with a stable recovery and transferred to local hospitals for further PAH treatment.CONCLUSION This case served as a reminder to obstetricians of the importance of pregnancy after repair of CHD.It is crucial for patients with CHD to receive early correction.It suggests doctors should not ignore edema of twin pregnancy.Also,it provides a reference for the further standardization of antenatal,in-trapartum and postpartum management for patients with CHD worldwide.

Effect of Third Interstitial Fluid on Adverse Outcomes in Patients with Severe Pre-eclampsia and Twin Pregnancy:A 5-year Single-center Retrospective Study

Objective This study aims to identify the effect of third interstitial fluid on adverse outcomes in twin pregnancies with severe pre-eclampsia,and explore the differences in bad ending between twins and singletons.Methods The present retrospective cohort study was conducted on patients with severe pre-eclampsia,who delivered in Tongji Hospital,Wuhan,China,between 2017 and 2022.The adverse outcomes in singleton and twin pregnancies with severe pre-eclampsia were initially investigated.Then,the diverse maternal and fetal consequences between singleton and twin pregnancies in patients with severe pre-eclampsia were compared after merging with the third interstitial fluid.Results A total of 709 patients were included for the present study.Among these patients,68 patients had twin pregnancies,and 641 patients had singleton pregnancies.The rate of postpartum hemorrhage(2.81%vs.13.24%,P<0.001),and admission rate to the Neonatal Intensive Care Unit(NICU)after birth(30.73%vs.63.24%,P=0.011)were significantly higher in twin pregnancies.The neonatal weight of twins was statistically lower than singletons(1964.73±510.61 g vs.2142.92±731.25 g,P=0.008).For the groups with the third interstitial fluid,the delivery week(P=0.001)and rate of admission to the NICU after birth were significantly advanced in twin pregnancy group,when compared to singleton pregnancy group(P=0.032),and the length of hospital stay was shorter(P=0.044).Furthermore,there was no statistically significant difference between the twin pregnancy group and the singletony pregnancy group without the third interstitial fluid.Conclusion The maternal and fetal adverse outcomes of patients with severe pre-eclampsia increased in twin pregnancies,when compared to singleton pregnancies.Thus,when patients develop the third interstitial fluid,twin pregnancies would more likely lead to adverse fetal outcomes,when compared to singleton pregnancies,and there would be no significant difference in maternal adverse outcomes.More attention should be given to patients who merge with the third interstitial fluid.

Acute myocardial infarction in twin pregnancy after assisted reproduction:A case report

BACKGROUND Acute myocardial infarction(AMI)during pregnancy is rare,especially in twin pregnancy,and it can endanger the lives of the mother and children.Except for conventional cardiovascular risk factors,pregnancy and assisted reproduction can increase the risk of AMI during pregnancy.AMI develops secondary to different etiologies,such as coronary spasm and spontaneous coronary artery dissection.CASE SUMMARY A 33-year-old woman,with twin pregnancy in the 31st week of gestation,presented to the hospital with intermittent chest tightness for 12 wk,aggravation for 1 wk,and chest pain for 4 h.Combined with the electrocardiogram and hypersensitive troponin results,she was diagnosed with acute ST-elevation myocardial infarction.Although the patient had no related medical history,she presented several risk factors,such as age greater than 30 years,assisted reproduction,and hyperlipidemia.After diagnosis,the patient received antiplatelet and anticoagulant treatment.Cesarean section and coronary angiography performed 7 d later showed stenosis and thrombus shadow of the right coronary artery.After receiving medication,the patient was in good condition.CONCLUSION This case suggests that,with the widespread use of assisted reproductive technology,more attention should be paid to perinatal healthcare,especially when chest pain occurs,to facilitate early diagnosis and intervention of AMI,and the etiology of AMI in pregnancy needs to be differentiated,especially between coronary spasm and spontaneous coronary artery dissection.

Single vs. Double Dose Iron Supplementation for Prevention of Iron Deficiency Anemia in Twin Pregnancy: A Randomized Controlled Clinical Trial

Introduction: It is estimated that about 18% of pregnant women suffer from iron deficiency anemia throughout their whole pregnancy. In twin pregnancy, owing to the relatively greater feto-placental requirements and greater expansion in maternal plasma volume and red cell mass, iron requirements are magnified 1.8 times compared to singleton pregnancies. However, for prevention of iron deficiency in twin pregnancy, only sparse data exist regarding the sufficiency of the standard antenatal iron supplementation dose used in singleton pregnancies to meet the increased iron demand. In this study, we investigate the effect of single and double dose iron supplementation for prevention of iron deficiency anemia in twin pregnancy. Methods: A randomized controlled clinical trial was conducted at our center in the period between February 2019 and October 2020, and included 450 eligible healthy non-anemic women aged 18 - 35 years, with twin pregnancy at 12 - 16 weeks of gestation. After informed consent, eligible women were randomized to receive either single dose 27 mg, or double dose 54 mg elemental iron supplementation. Monitoring of hemoglobin concentration was done at fixed time points during gestation: at enrollment, 24 weeks, 32 weeks and before delivery. The primary outcome of the study was the incidence of iron deficiency anemia during follow up until delivery. Results: The incidence of iron deficiency anemia in the two groups did not differ significantly between the single dose group (19.1%) and the double dose group (24.0%). In women who did not develop Iron Deficiency Anemia, hemoglobin concentration varied significantly along the different gestational ages during the follow up period. In contrast, they did not show an overall statistically significant difference in the hemoglobin concentrations between the single or double dose groups. Conclusion: This clinical trial did not demonstrate an added benefit for doubling prophylactic iron supplementation dose in non-anemic women with twin pregnancy.

Sonography Cervical Assessment in Twin Pregnancy Correlation with Gestational Age at Delivery

Objective: Observe and correlate the funneling of upper cervical canal by ultrasound and likelihood of cervical incompetence and premature delivery in twin pregnancy. Materials and methods: Retrospective study in twin pregnancies deliveries in 1997, in king Faisal specialist hospital and research center, Riyadh, Saudi Arabia. A total of 67 twin pregnancies underwent routine ultrasound for fetal assessment, when the cervix closed, long;and short, funneling. The time of ultrasound was divided in three groups by gestational age: from 18 to 22 weeks;from 22 to 26 weeks and from 26 to 30 weeks. The gestational age at delivery was our outcome parameter and subdivided the patients in 4 groups, group 1: patients delivered before 24 weeks (n = 4);group 2: delivered between 24 and 34 weeks (n = 16);group 3: delivered between 34 weeks and 36 weeks and 6 days (n = 18);and group 4: delivered with gestational age equal or above 37 weeks (n = 29). The data was analyzed statistically using Pearson chi square method and p value below 0.05 was considered significant. Results: There was no significant difference among the 4 subgroups in maternal age, body mass index, parity, previous history of preterm delivery or presence of urinary/vaginal infection in actual pregnancy. There was stronger history of mid trimester abortion in patients delivered before 34 weeks of gestational age. Considering the cervical sonographic findings, the diagnosis of funneling between 18 - 22 weeks was higher among the group delivered before 34 weeks of gestational age (1 and 2) comparing to other groups (3 and 4) with p value equal to 0.016. The finding in ultrasound justifies the results of higher aggressive management in patients from groups 1 and 2 comparing with groups 3 and 4;admission to hospital (p = 0.007);emergency cerclage (p = 0.04), complete hospital bed rest (p = 0.002). Conclusion: Cervical assessment during routine ultrasound in twins pregnancy seems to be useful for prediction of preterm delivery and counseling the patient without risk factors regarding cervical cerclage. Because of restricted number of patients, especially group 1 (11 = 4), we suggest further study with bigger sample and prospective trial for valued conclusion.

Twin Pregnancy with Omphalocele: Challenges in Detection and Management

Twins are more likely to have congenital anomalies than singletons. Omphalocele is still a life-threatening congenital abnormality that requires adequate antenatal diagnosis and early treatment. A 31-year-old woman presented with labor pains in the eighth pregnancy month. There was a clear, watery discharge from the birth canal 4 hours before admission. She was previously diagnosed with twins, with one cotwin having suffered omphalocele through a 6-month-ultrasound examination. At admission, the condition was diagnosed as monochorionic-diamniotic twins at 32 - 33 weeks in the 2nd stage of labor: the first baby cephalic presentation;second breech presentation with omphalocele. She vaginally gave birth to twin infants, with those having Apgar 5’ of 6/7, respectively. Both infants were admitted to the intensive care unit and under treatment.

Evaluation on the Influence of the Timing of Twin Pregnancy Termi­nation on the Outcome of Mother and Infants

Objective:Objective:To observe the maternal and infant outcomes of pregnant women with twins terminating their pregnancy at different timings.Methods:Among the twin pregnant women admitted to our hospital from August 2019 to August 2020,50 primiparous women who opted to terminate their pregnancies at 5 different timings of“34--34^(+6) weeks”,“35--35^(+6) weeks”,“36--36^(+6) weeks”,“37--37^(+6) weeks”,“38--38^(+6) weeks”were selected as the research subjects.According to the timing of pregnancy termination,they were divided into 5 groups,each with 10 cases of pregnant women,and the impact of the timing of pregnancy termination on the outcome of the mothers and infants were compared.Results:The“37--37^(+6) weeks”group had the largest amount of postpartum hemorrhage,and the difference in Hb level before and after delivery was the largest.With the increase in gestational week,the weight of both large and small fetuses increased.In terms of neonatal diseases,the comparison between“34--34^(+6) weeks”,“35--35^(+6) weeks”,“36--36^(+6) weeks”and“37--37^(+6) weeks”,“38--38^(+6) weeks”,P<0.05,the comparison between“37--37^(+6) weeks”and“38--38^(+6) weeks”,P>0.05.Conclusions:The extension of the gestational week of twin pregnancies has no effect on postpartum hemorrhage,but it can improve the outcome of infants.

Twin pregnancy and partial hydatidiform mole following in vitro fertilization and embryos transfer： a novel case of placental mosaicism

Twin pregnancy with mosaic partial hydatidiform mole （PHM） and survival of two healthy fetuses following in vitro fertilization and embryos transfer （IVF-ET） is a rare situation and is considered a challenge for management. A 32-year-old Chinese woman conceived twin pregnancy following IVF-ET. At 22 weeks＇ gestation, an additional intrauterine echogenic mass with features of PHM were shown by successive ultrasound examinations. At 35 weeks＇ gestation, two live male infants and two placentas were delivered by caesarean section （CS）. Histologic examination of the abnormal placenta confirmed mosaic PHM. Genetic study showed the abnormal placental mosaicism （expressed in molar-69XXY and normal vili-46XY）, co-existing with a hypospadia new-born （46XY） in one amniotic sac. However, the other one was normal. Serial serum β-hCG levels showed a declining trend and serum β-human chorionic gonadotropin （hCG） were undetectable at 6 months after delivery. The case demonstrated that it is possible to prolonged gestation by PHM under close surveillance during the entire pregnancy.

Retained Placenta Creta After Selective Fetal Reduction in Twin Pregnancy:A Case Report

Placenta accreta spectrum(PAS)disorders are severe obstetric complications and can cause life-threatening hemorrhage,hysterectomy,or even death.PAS disorders in one of dichorionic diamniotic twins are rare to be seen in clinical practice and lack of standard management strategies.We reported a case of retained placenta creta after selective fetal reduction in one of dichorionic diamniotic twins.A 32-year-old woman with a history of cesarean section was diagnosed with placenta increta in one of dichorionic diamniotic twins at 16 weeks of gestation.After discussion,the couple required to be hospitalized for selective fetal reduction.She received selective termination by ultrasound-guided single fetal intracardiac injection of potassium chloride.The follow-up prenatal ultrasound examinations detected the placenta of the reduced fetus did not stop invade the myometrium of the uterus but developed from placenta increta to placenta percreta.The patient was diagnosed with placental percreta by prenatal ultrasound signs and surgical findings.The patient underwent scheduled cesarean delivery at 34^(+5)gestational weeks.The outcome of maternal and fetal was satisfactory for our elaborate operation and optimal management.PAS disorders are severe obstetric complications with an increasing incidence.Combined with twin pregnancy makes PAS disorders more intractable.We should learn that selective fetal reduction probably cannot solve it thoroughly.Intensive and standard management is essential to promote maternal and fetal outcomes.

True Nodes of the Umbilical Cords of a Mono-Amniotic Pregnancy

The incidence of twin pregnancies, has increased due to assisted reproductive technologies [1]. We note a doubling between 1970 and 2010 from less than 8‰ to nearly 16‰ of pregnancies (Pison et al., 2014;Pison et al., 2015) in developed countries [2] and 17‰ to 20‰ in sub-Saharan Africa. Monozygotic twins are the product of fertilization of a single egg by a single sperm, with the egg splitting into two within the first few days after fertilization. If the division takes place after the 8th day, the pregnancy is mono-chorionic mono-amniotic (less 1% of cases of monozygotic pregnancies) and represents 1 in 30,000 pregnancies. It is the development of two fetuses within the same amniotic sac, representing the rarest type of twin pregnancy (1% of monozygotic twin pregnancies) but being the one with the highest fetal and maternal morbidity. The main complication feared is coiling and knots of the umbilical cords responsible for abnormal heartbeat, fetal suffering and eventual fetal death. We report the case of in utero fetal death of twins from a mono choral mono amniotic pregnancy secondary to knots and coiling of the cord in order to discuss the diagnostic and therapeutic aspects.

Pregnancy Outcomes Following Transvaginal Cerclage for Cervical Insufficiency：Results From a Single-center Retrospective Study

To study maternal and perinatal outcomes after cervical cerclage in both singleton and twin pregnancies,we retrospectively reviewed women undergoing cervical cerclage for cervical insufficiency at Tongji Hospital,Wuhan,China from January 1,2010 to July 31,2015 to evaluate primary and secondary outcomes for subgroups with cervical length（CL） ≤15,〉15 to 〈25,and ≥25 mm.Of 166 patients who underwent cervical cerclage,after exclusion of patients with missed abortion and continuing pregnancy,141 patients（121 singleton and 20 twin pregnancies） were included in the analysis.Mean gestational age at birth was 34.22 and 28.27 weeks for singleton and twin pregnancies,respectively.There were 17（14.05%） and 13（33.33%） neonatal deaths in singleton and twin pregnancies,respectively.Mean age（31.60±4.62 vs.31.22±4.63 years,P=0.39） and gestational weeks at cerclage（18.50±4.62 vs.19.31±4.99,P=0.47） were similar for both groups.Mean gestational weeks at delivery（34.22±5.77 vs.28.27±6.17,P〈0.001） and the suture to delivery interval（15.72±7.15 vs.8.96±6.70,P〈0.001） were significantly longer in the singleton group.These variables indicate a linear negative correlation with the degree of CL shortening,with better outcomes in patients with CL ≥25 mm who underwent cerclage,both in singleton and twin pregnancies.No difference in mode of delivery existed between the singleton group and twin group.Our results indicate a high risk of preterm delivery in both groups,especially in the twin group.Patients with a history of preterm labor and CL 〉25 mm in the current pregnancy,possibly in a twin pregnancy,could benefit from elective cervical cerclage;however,cervical cerclage was inadvisable for twin pregnancies with a CL 〉15 and 〈25 mm.Our data emphasize the importance of re-evaluating the efficacy of cervical cerclage for twin pregnancies in well-designed clinical trials.

Significance of highly phosphorylated insulin-like growth factor binding protein-1 and cervical length for prediction of preterm delivery in twin pregnancies

BACKGROUND A twin pregnancy can carry greater risks than singleton pregnancies.About 60 in 100 twin pregnancies result in spontaneous birth before 37 wk,which is associated with several complications in the premature babies.Clinical detection of biomarkers may help to predict the possibility of premature birth so that corresponding interventions can be given to the pregnant women in a timely manner,in order to reduce the risk of preterm birth and improve the outcomes of the newborn infants.AIM To explore the clinical value of transvaginal ultrasound measurement of cervical length combined with insulin-like growth factor binding protein-1(IGFBP-1)hyperphosphorylation in cervical secretions as predictors of preterm delivery in twin pregnancies.METHODS A total of 254 pregnant women with twin pregnancies,who were admitted to Hainan General Hospital and underwent maternity examination,were selected as the study subjects from January 2015 to December 2018.All participants received transvaginal ultrasound measurement of cervical length and phosphorylated IGFBP-1(phIGFBP-1)test between 24 and 34 wk gestation.The pregnancy outcomes were analyzed.RESULTS Of the women with a positive phIGFBP-1 test result,preterm birth rate was higher in those with a cervical length≤25 mm than those with a cervical length>25 mm(all P<0.05).Similarly,in women with a negative phIGFBP-1 test result,preterm birth rate was higher in those with a cervical length≤25 mm than those with a cervical length>25 mm(all P<0.05).The sensitivity,specificity,and positive and negative predictive values of the phIGFBP-1 test combined with the cervical length test were 95.71%,91.21%,95.12%and 92.22%,respectively,for the prediction of preterm birth.CONCLUSION Cervical length combined with phIGFBP-1 tests is of value for the prediction of outcomes of preterm delivery in twin pregnancies.

Successful Deliveries of Twins from Two Pregnant Women Following Preterm Prelabor Rupture of Membranes in the Early Second-Trimester Pregnancy

The management of preterm prelabor rupture of membranes (PPROM) before 34 weeks of gestation is intractable, due to pulmonary immaturity, many complications, poor pregnancy outcomes. In particular, the pre-viable PPROM (<23 weeks of gestation) is much more difficult to be treated. The clinical recommendation is to terminate the pregnancy as soon as possible. The pregnancy outcomes of PPROM in the early second-trimester of two twin pregnant women in our hospital were reported to explore the treatment protocols. The pregnancies of the two women developed PROM at 12 and 16 weeks of gestation, respectively. After expectant treatment, they were deliveried successfully at 34+6 and 34+4 weeks of gestation, respectively. The assessment of growth and development of infants was normal during the following six months after birth. Therefore, if PPROM occurs in the early second-trimester of pregnancy, the management of PPROM should be individualized, it’s a long process which should include comprehensive communication between patients and families regarding alternative treatment options (including expectant management) and risks and benefits of the procedure. In the absence of spontaneous labor or occurrence of complications that would prompt delivery (intra-amniotic infection, abruptio placenta, cord prolapse), and fetal status is normal, the patients should proceed with expectant treatment, induction of labor is commonly performed in pregnancies with PPROM ≥34 weeks of gestation.

Maternal weight,blood lipids,and the offspring weight trajectories during infancy and early childhood in twin pregnancies

Background The intrauterine environment has a profound and long-lasting influence on the health of the offspring.However,its impact on the postnatal catch-up growth of twin children remains unclarified.Therefore,this study aimed to explore the maternal factors in pregnancy associated with twin offspring growth.Methods This study included 3142 live twin children born to 1571 mothers from the Beijing Birth Cohort Study conducted from 2016 to 2021 in Beijing,China.Original and corrected weight-for-age standard deviation scores of the twin offspring from birth to 36 months of age were calculated according to the World Health Organization Child Growth Standards.The corresponding weight trajectories were identified by the latent trajectory model.Maternal factors in pregnancy associated with the weight trajectories of the twin offspring were examined after adjustment for potential confounders.Results Five weight trajectories of the twin children were identified,with 4.9%(154/3142)exhibiting insufficient catch-up growth,30.6%(961/3142),and 46.8%(1469/3142)showing adequate catch-up growth from different birth weights,and 15.0%(472/3142)and 2.7%(86/3142)showing various degrees of excessive catch-up growth.Maternal short stature[adjusted odds ratio(OR)=0.691,95%confidence interval(CI)=0.563–0.848,P=0.0004]and lower total gestational weight gain(GWG)(adjusted OR=0.774,95%CI=0.616–0.972,P=0.03)were associated with insufficient catch-up growth of the offspring.Maternal stature(adjusted OR=1.331,95%CI=1.168–1.518,P<0.001),higher pre-pregnancy body mass index(BMI)(adjusted OR=1.230,95%CI=1.090–1.387,P<0.001),total GWG(adjusted OR=1.207,95%CI=1.068–1.364,P=0.002),GWG rate(adjusted OR=1.165,95%CI=1.027–1.321,P=0.02),total cholesterol(TC)(adjusted OR=1.150,95%CI=1.018–1.300,P=0.03)and low-density lipoprotein-cholesterol(LDL-C)(adjusted OR=1.177,95%CI=1.041–1.330)in early pregnancy were associated with excessive growth of the offspring.The pattern of weight trajectories was similar between monochorionic and dichorionic twins.Maternal height,pre-pregnancy BMI,GWG,TC and LDL-C in early pregnancy were positively associated with excess growth in dichorionic twins,yet a similar association was observed only between maternal height and postnatal growth in monochorionic twins.Conclusion This study identified the effect of maternal stature,weight status,and blood lipid profiles during pregnancy on postnatal weight trajectories of the twin offspring,thereby providing a basis for twin pregnancy management to improve the long-term health of the offspring.

Comparison of second-trimester maternal serum free-p-human chorionic gonadotropin and a-fetoprotein between normal singleton and twin pregnancies： a population-based study

Background The second-trimester maternal serum screening in twin pregnancy is still controversial, as the serum marker levels in twins are not as clear as those in singletons. This study aimed to evaluate the relationship between the levels of the second-trimester maternal serum free β-human chorionic gonadotropin （free β-HCG） and a-fetoprotein （AFP） in normal twin and singleton pregnancies and to estimate feasible analysis methods for utilizing these markers in second trimester screening for twin pregnancy. Methods On the basis of a prospective population-based study of second-trimester maternal serum screening, the concentrations of maternal serum AFP and free β-HCG of 195 normal twin pregnancy and 26 512 singleton controls at gestational weeks 15 to 20 were measured by time-resolved fluoroimmunoassay in one laboratory. The levels of markers were compared between the twins and singletons using weight-correction and gestational age-specific model. Results According to the research protocol, 95 communities were randomly sampled, which covered the whole Jiangsu province, the east of China. A total of 26 803 pregnant women （98%）, from the target population accepted prenatal screening for maternal serum AFP, β-HCG detection, and all babies were followed up for at least six months. There were 197 （0.73%） twin pregnancies, of which one case had fetal trisomy 18, and one case with fetal anencephaly. The others were normal twin pregnancy. From a total enrollment of 26 803 women participants, 26 512 women with normal singleton pregnancies were selected as the model controls. The other 291 pregnancies, including trisomy 21, neural tube defect （NTD）, trisomy 18, and other fetal abnormalities, were excluded. No significant differences were found in the medians of gestational age-specific maternal serum free β-hCG and AFP in normal twin pregnancy comparing with twice those in model controls with the exception of the medians for free β-hCG during the 16th gestational week （P=0.012）. Conclusion The weight-correction and gestational age-specific levels of Chinese Han population maternal serum free β-hCG and AFP in normal twins were twice the levels as those in the singleton controls during the 17-19 gestational weeks.

Development of fetal growth charts in twins stratified by chorionicity and mode of conception:a retrospective cohort study in China

Background:Twin pregnancies continue to increase worldwide;however,the current clinical prenatal evaluation for the intrauterine growth of twins still relies on the growth standards of singletons.We attempted to establish a set of fetal biometric references for Chinese twin pregnancies,stratified by chorionicity and conception mode as spontaneously conceived monochorionic diamniotic(SC-MCDA),spontaneously conceived dichorionic diamniotic(SC-DCDA),and assisted reproductive technology dichorionic diamniotic(ART-DCDA)twins.Methods:From 2016 to 2019,the ultrasonographic fetal biometric measurements were longitudinally collected in pregnant women,including fetal weight,biparietal diameter,head circumference,abdominal circumference,femur length,and humerus length.The linear mixed models were used to test the difference of growth patterns between groups,and the growth curve of each biometric parameter was modeled by a generalized additive model for location scale and shape.Results:A total of 929 twin pregnant women and 2019 singleton pregnant women,met the inclusion criteria.Among twin pregnancies,148 were SC-MCDA,215 were SC-DCDA,and 566 were ART-DCDA twins.Overall,SC-DCDA twins grew faster than SC-MCDA twins,while slower than ART-DCDA twins(all P<0.05),and all of the three groups showed significant differences comparing with singletons,especially during the third trimester.Hence,the customized fetal growth charts of each fetal biometric parameter were,respectively,constructed for SC-MCDA,SC-DCDA,and ART-DCDA twins.Conclusions:The fetal biometric trajectories demonstrated characteristic patterns according to chorionicity and conception mode.To fill the gap,we modeled fetal biometric parameters for Chinese SC-MCDA,SC-DCDA,and ART-DCDA twin pregnancies,hoping to provide a reference for the further establishment of fetal growth reference values for Chinese twin fetuses.

Perinatal risk factors and neonatal complications in discordant twins admitted to the neonatal intensive care unit

Background Many studies have shown a relationship between birth weight discordance and adverse perinatal outcomes. This study aimed to investigate the perinatal risk factors and neonatal complications of discordant twins who are admitted to the neonatal intensive care unit. Methods A total of 87 sets of twins were enrolled in this retrospective study, of which 22 sets were discordant twins and 65 sets were concordant twins. Binary Logistic regression analysis was used to identify the risk factors associated with the occurrence of discordant twins. The common neonatal complications of discordant twins were also investigated. Results Multivariate analysis showed that the use of assisted reproductive techniques, pregnancy-induced hypertension, and unequal placental sharing were risk factors for the occurrence of discordant twins. The incidence of small for gestational age infants and very low birth weight infants of discordant twins was significantly higher, while the birth weight of discordant twins was significantly lower than those of concordant twins. The duration of hospitalization of discordant twins was longer than that of concordant twins. The incidence of several neonatal complications, such as neonatal respiratory distress syndrome and intracranial hemorrhage, was higher in discordant twins than that in concordant twins. The percentage of those requiring pulmonary surfactant and mechanical ventilation was significantly higher in discordant twins than that in concordant twins. Conclusions Use of assisted reproductive techniques, pregnancy-induced hypertension, and unequal placental sharing are perinatal risk factors of discordant twins who are admitted to the neonatal intensive care unit. These infants are also much more likely to suffer from various neonatal complications, especially respiratory and central nervous system diseases. It is important to prevent the occurrence of discordant twins by decreasing these risk factors and timely treatment should be given to discordant twins.

Complications of Monochorionic Diamniotic Twins: Stepwise Approach for Early Identification, Differential Diagnosis, and Clinical Management

One in three monochorionic twins may develop complications during pregnancy. Monochorionic twins, especially monochorionic diamniotic (MCDA), present specific problems caused by the presence of interfetal placental anastomoses. The first critical step in the management of MCDA twins is identification in the first trimester. Secondly, close follow-up every 2 weeks is mandatory to allow early diagnosis and timely treatment of twin-twin transfusion syndrome. Other potentially severe complications include selective fetal growth restriction, twin anemia polycythemia syndrome or single fetal death. Thirdly, a correct differential diagnosis is critical to establish the best therapy. This may represent a clinical challenge since MCDA twin complications often overlap. A simple diagnostic algorithm may be of great help to establish the right diagnosis and management option. In this review we summarize the main steps for the clinical follow-up, differential diagnosis, and targeted management of MCDA twins complications.

Analysis of risk factors related to severe postpartum hemorrhage of twin pregnancies delivered by cesarean section

Objective:To investigate the risk factors of severe postpartum hemorrhage(PPH)in cesarean section of twin pregnancy,and to provide clinical basis for pregnancy management and perioperative obstetric management of twin pregnancy.Methods:The clinical data of 631 twin pregnancies with gestational age
28 weeks delivered by cesarean section at Peking University People's Hospital(PKUPH)from January 2004 to January 2017 were retrospectively analyzed.Methods of conception,the combined weight of twins,serum albumin level before cesarean section,operation time and other factors on the amount of blood loss during cesarean section were analyzed.Results:The proportion of severe PPH was significantly higher in in vitro fertilization-embryo transfer(IVF-ET)group,the combined weight of twins>6000g group,serum albumin before cesarean section<30 g/dl group than in the natural pregnancy group,4000–6000g group,<4000g group and serum albumin
30 g/dl group respectively(P<0.05).The proportion of severe PPH in the elective surgery group of twin pregnancy was higher than that in the emergency surgery group,but the difference was not statistically significant(P>0.05).Moreover,according to the surgical indications,the emergency surgery group was divided into premature rupture of membranes(PROM),labor,fetal distress and others groups,no significant difference were detected among these groups(P>0.05).Conclusion:IVF-ET,the combined weight of twins,serum albumin before operation were significantly correlated with severe PPH of twin pregnancies delivered by cesarean section,revealing that it is necessary to strengthen pregnancy management of twin pregnancy.

Association of an Increased Risk of Pre-eclampsia and Fetal Growth Restriction in Singleton and Twin Pregnancies with Female Fetuses

Objective: To investigate whether the fetal gender affects the incidence of pre-eclampsia (PE) and fetal growth restriction (FGR) in singleton and twin pregnancies.Methods: This was a 10-year single-center, retrospective, cohort study from January 2009 to January 2019. A total of 57,129 singleton and 3699 twin pregnancies aged between 18-55 years old were recruited at the Third Affiliated Hospital of Guangzhou Medical University, China. We used multivariable logistic regression to analyze the effect of fetal gender on the incidence of PE and FGR.Results: In singleton pregnancies, the incidence rates of PE and FGR with a female fetus were higher than those with a male fetus (6.4% (1713/26,793)vs. 5.9% (1803/30,336),P < 0.05 and 3.5% (932/26,793)vs. 2.4% (745/30,336),P < 0.05, respectively). A female fetus was an independent risk factor for either PE or FGR (adjusted odds ratio: 1.169 or 1.563;95% confidence interval: 1.036-1.319 or 1.349-1.810, respectively). In twin pregnancies, the incidence of early-onset PE was greater in pregnancies with two females compared with two males or one male plus one female (4.6% (46/1003)vs. 4.1% (54/1305)vs. 2.4% (33/1391),P < 0.05). Female-female twins was an independent risk factor for PE (adjusted odds ratio: 1.367, 95% confidence interval: 1.011-1.849), especially early-onset PE.Conclusion: The female fetus was associated with PE in both singleton and twin pregnancies and was also a risk factor of FGR in singleton pregnancies.