Arty H. P. Schaap

Vaginal delivery compared with caesarean section in early preterm breech delivery: a comparison of long term outcome

Objective To determine the optimum mode of delivery of the early preterm fetus in breech presentation.

Placental Characteristics of Monoamniotic Twin Pregnancies in Relation to Perinatal Outcome

OBJECTIVE To study placental characteristics in relation to perinatal outcome in 55 pairs of monochorionic monoamniotic (MA) twins. METHODS Between January 1998 and May 2008 55 pairs of MA twins were delivered in 4 tertiary care centers and analysed for mortality, birth weight discordancy and twin-to-twin transfusion syndrome (TTTS) in relation to type of anastomoses, type and distance between cord insertions and placental sharing. Five acardiac twins, 2 conjoined twins, 4 higher order multiples and one early termination of pregnancy were excluded, leaving 43 MA placentas for analysis. Of these 43, one placenta could not be analysed for placental vascular anastomoses due to severe maceration after single intra-uterine demise leaving 42 placentas for analysis of anastomoses. RESULTS Arterio-arterial (AA), venovenous (VV) and arteriovenous (AV) anastomoses were detected in 98%, 43% and 91% of MA placentas, respectively. Velamentous cord insertion was found in 4% of cases. Small distance between both umbilical cord insertions (<5 cm) was present in 53% of MA placentas. Overall perinatal loss rate was 22% (19/86). We found no association between mortality and type of anastomoses, type and distance between cord insertions and placental sharing. The incidence of TTTS was low (2%) and occurred in the only pregnancy with absent AA-anastomoses. CONCLUSION Perinatal mortality in MA twins was not related to placental vascular anatomy. The almost ubiquitous presence of compensating AA-anastomoses in MA placentas appears to prevent occurrence of TTTS.

Perinatal mortality and mode of delivery in monochorionic diamniotic twin pregnancies >= 32 weeks of gestation: a multicentre retrospective cohort study

Please cite this paper as: Hack K, Derks J, Elias S, van Mameren F, Koopman‐Esseboom C, Mol B, Lopriore E, Schaap A, Arabin B, Duvekot J, Go A, Wieselmann E, Eggink A, Willekes C, Vandenbussche F, Visser G. Perinatal mortality and mode of delivery in monochorionic diamniotic twin pregnancies ≥32 weeks of gestation: a multicentre retrospective cohort study. BJOG 2011;118:1090–1097.

School performance and behaviour in extremely preterm growth-retarded infants.

OBJECTIVE To describe school performance and behaviour of extremely preterm, growth-retarded infants. DESIGN Cohort study at two tertiary care centres. Included were all surviving, singleton infants (N= 127) with fetal growth retardation due to placental insufficiency. All were delivered by caesarean section because of signs of fetal distress before the beginning of labour at a gestational age of 26 to 32 weeks during the years 1984-1989. Main outcome measures were special education, mainstream education below the appropriate age level and behaviour according to attention-deficit hyperactivity criteria at school age (4 1/2-10 1/2 yrs). The children were divided into two subgroups according to age at follow-up (> or =7 1/2 and <7 1/2 yr). A logistic regression analysis was performed with special school or repeating a grade and behavioural disturbance as dependent variables and gestational age, birth weight, sex of the infant, neonatal complications (intra cerebral haemorrhage, respiratory distress syndrome, bronchopulmonary dysplasia or sepsis), age category at follow-up and sociodemographic factors as independent variables. RESULTS 114 (90%) had a complete follow-up. Special education was found in 14% of the assessed children. More children in the older age group than in the younger age group were placed in special school (20% versus 10%). Behavioural problems were scored in 39% of the assessed children attending mainstream education. Special education was related to neonatal complications (bronchopulmonary dysplasia), behavioural problems to the absence of either parent. CONCLUSION This specific group of growth-retarded children is at serious disadvantage for adequate performance in school, although the incidence of special education and behavioural problems was comparable to other preterm infants. Both special education and behavioural problems were not related to obstetric variables as gestational age and/or birth weight.

Fetal distress due to placental insufficiency at 26 through 31 weeks: a comparison between an active and a more conservative management

OBJECTIVE To compare perinatal mortality and short-term morbidity in extremely preterm infants with fetal distress due to placental insufficiency in two centers with different management attitude. DESIGN Retrospective cohort study in two university hospitals of all infants with fetal growth retardation due to placental insufficiency resulting in signs of fetal distress at 26 through 31 weeks gestational age, during the years 1984 through 1989. Center A followed a conservative management: in some cases the risk of major handicaps or mortality was estimated so high, based on antenatally estimated fetal weight and gestational age, that the decision was taken to abstain from treatment. In all other cases cesarean section took place, but only if fetal distress was obvious. Center B used a more active management: cesarean section was performed in all cases, sometimes with only minor changes in fetal heart rate variability. RESULTS Overall survival differed significantly: 55% (center A) versus 72% (center B), largely due to antenatal mortality in center A. Discharge survival rate of liveborn infants was 81% in center A and 72% in center B. More than half of the postnatal mortality was attributed to respiratory causes in both centres. An active management showed a tendency to a higher incidence of short-term morbidity. CONCLUSION Selection by antenatal prediction of postnatal mortality using estimated fetal weight fails. Even in the group with the lowest birthweight postnatal mortality did not surpass 50%. Early intervention may be associated with higher short-term morbidity. Long-term follow-up of these children is needed to discriminate between both policies with regard to further development of surviving infants.

Influence of obstetric management on outcome of extremely preterm growth retarded infants

AIM To describe the long term outcome of extremely preterm growth retarded infants in relation to obstetric management and various perinatal events. METHODS A cohort study was undertaken in two tertiary care centres with different obstetric management. All infants with fetal growth retardation due to placental insufficiency and resulting in fetal distress at 26 to 32 weeks of gestation, were included for the years 1984–89. Main outcome measures were impairment, disability, or handicap at 2 years corrected age and at school age (4 ½ to 10 ½ years). RESULTS One hundred and twenty five (98%) were followed up until 2 years corrected age in the outpatient department; 114 (90%) were assessed at school age. Impairments were found in 37% and disabilities or handicaps in 9% of the assessed infants, with no difference between centres. All disabled or handicapped children had already been identified by 2 years corrected age. CONCLUSIONS Disability or handicap were related to neonatal complications (intracerebral haemorrhage or bronchopulmonary dysplasia) and not to obstetric variables, thus making antenatal prediction impossible. The incidence of disability or handicap in these growth retarded infants was comparable with that of other preterm infants.

Discordant Fetal Growth Patterns in Monochorionic Twin Pregnancies Described by Simple Algebraic Relations

Objective: To test whether twin-twin transfusion syndrome (TTTS) and non-TTTS cases that were suspect but not confirmatory for developing the syndrome (non-TTTS-with-symptoms) have discordant fetal growth patterns that correlate with our previously derived algebraic relations. Methods: In 25 monochorionic twin pregnancies, fetal growth was determined by standard ultrasonography. The difference between estimated fetal weights (dEFW) as well as the difference divided by the average of the two weights, the difference average ratio (DAR), were fitted to the predicted trends of discordant fetal growth for TTTS and non-TTTS pregnancies. The best fits were compared with the clinical data. Results: Out of 13 TTTS cases, dEFW analysis correctly correlated with 8 (62%) and DAR analysis correctly with 10 (77%). Out of 12 non-TTTS-with-symptoms cases, dEFW analysis correctly correlated with 7 (58%) and DAR analysis correctly with 9 (75%). If TTTS correlated best, dEFW analysis was correct in 8/12 (67%), and DAR analysis in 10/11 (91%) cases. If non-TTTS correlated best, dEFW analysis was correct in 7/9 (78%), and DAR analysis in 9/12 (75%). The likelihood ratios of TTTS and non-TTTS were 1.9 and 0.26, respectively, with dEFW analysis, and 9.2 and 0.31 with DAR analysis. Conclusion: The simple algebraic relations derived to identify trends of fetal discordant growth show evidence that clinical TTTS and non-TTTS manifestations are quantifiable. The relations may contribute to future risk stratification in monochorionic twin pregnancies, e.g., by prospectively distinguishing between cases that will develop TTTS and those that will not, despite presenting with symptoms.

Perinatal mortality and mode of delivery in monochorionic diamniotic twin pregnancies >= 32 weeks of gestation

Please cite this paper as: Hack K, Derks J, Elias S, van Mameren F, Koopman‐Esseboom C, Mol B, Lopriore E, Schaap A, Arabin B, Duvekot J, Go A, Wieselmann E, Eggink A, Willekes C, Vandenbussche F, Visser G. Perinatal mortality and mode of delivery in monochorionic diamniotic twin pregnancies ≥32 weeks of gestation: a multicentre retrospective cohort study. BJOG 2011;118:1090–1097.

P37Ileal atresia and thrombo‐embolic liver calcifications, a possible complication after treatment with intrauterine laser coagulation therapy for twin to twin transfusion syndrome

Background