Paulo Moura

Should apparently uncomplicated monochorionic twins be delivered electively at 32 weeks

Objectives. We aimed to estimate the optimal time of delivery and investigated the residual risk of fetal death after viability in otherwise uncomplicated monochorionic diamniotic twin pregnancies. Study design. A database of 576 completed multiple pregnancies that were managed in our tertiary referral fetal medicine department between 1996 and 2007 was reviewed and the uncomplicated 111 monochorionic and the 290 dichorionic diamniotic twin pregnancies delivered after 24 weeks were selected. The rate of fetal death was derived for two-week periods starting at 24 weeks’ gestation and the prospective risk of fetal death was calculated by determining the number of intrauterine fetal deaths that occurred within the two-week block divided by the number of continuing uncomplicated monochorionic twin pregnancies during that same time period. Results. The unexpected single intrauterine deaths rate was 2.7% versus 2.8% in previously uncomplicated monochorionic and dichorionic diamniotic pregnancies, respectively. The prospective risk of unexpected stillbirth after 32 weeks of gestation was 1.3% for monochorionic and 0.8% for dichorionic pregnancies. Conclusions. In otherwise apparently uncomplicated monochorionic diamniotic pregnancies this prospective risk of fetal death after 32 weeks of gestation is lower than reported and similar to that of dichorionic pregnancies, so does not sustain the theory of elective preterm delivery.

Progesterone use after successful treatment of threatened pre-term delivery

Pre-term delivery is the leading cause of neonatal morbidity, mortality and long-term sequels. This is an open label randomised controlled trial with women with confirmed threatened pre-term labour (TPTL) after efficient tocolytic therapy with atosiban. The main outcome measure of this study was the latency period until delivery and secondary outcomes were the number of recurrent episodes of TPTL and fetal and maternal morbidity. Patients were assigned to treatment or control groups using a computer generated randomisation table. The treatment group received 200 mg vaginal progesterone daily until delivery and the control group received no therapy or placebo. The study cohort comprised 52 pregnant women, 26 in each arm, showing similar characteristics; the treatment group had a longer latency period until delivery and this was statistically significant (55 vs 38 days, p = 0.024). This study points to the benefits of the vaginal administration of progesterone, especially in prolonging latency period until delivery.

Membrane progesterone receptors in human regulatory T cells: a reality in pregnancy

To provide evidence of the existence of membrane progesterone receptor alpha (mPRα) on regulatory T cells (Treg) in peripheral blood during pregnancy, postulating a possible explanation for the effect of progesterone on preterm birth.

Can membrane progesterone receptor α on T regulatory cells explain the ensuing human labour

Progesterone acts as an immunosteroid by contributing to the establishment of a pregnancy-protective milieu. It seems that it is the responsibility of progesterone to evade the inflammatory events that lead to parturition. T regulatory lymphocytes (Treg cells) could further explain the inhibition of the inflammatory mechanisms that lead to labour through the rapid action of progesterone on this cell subset. We investigated Treg cells and the membrane progesterone receptor α (mPRα) in these immune cells with in relationship to human parturition. This pilot cohort study was conducted in a single-centre tertiary obstetrical unit with 20 normal pregnant women. Variation in the absolute and relative frequency of CD4(+) T cells, Treg cells, and of mPR(α+) Treg cells was calculated by flow cytometry on three occasions (second and third trimesters; delivery day). Our results show that during normal pregnancy there is a generalised increase in Treg cells and mPR(α+) Treg cells, from the second to the third trimesters (23.4% vs. 52.3% and 4.3% vs. 8.3%, respectively). On the contrary, on delivery day, compared with the values in the third trimester, there is a sudden decrease in both Treg cells (52.3% vs. 17.4%) and mPR(α+) Treg cells (8.3% vs. 6.1%). Our findings suggest that human labour may develop as a consequence of a decline in mPR(α+) Treg cells, which reduces progesterone anti-inflammatory action through Treg cells.

Impact of induced pregnancies in the obstetrical outcome of twin pregnancies.

OBJECTIVE To compare obstetric outcomes of induced twins with those spontaneously conceived. DESIGN A prospective observational study was conducted in twin pregnancies delivered over 16 years. SETTING A tertiary obstetric center with differentiated perinatal support. PATIENT(S) A total of 180 induced twins and 698 spontaneously conceived were included. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Comparison of demographic factors, obstetrical complications, gestational age at delivery, mode of delivery, birth weight, and immediate newborn outcome. RESULT(S) First-trimester bleeding was higher in the induced group (6.0% vs. 12.2%), as were gestational diabetes (4.4% vs. 8.3%) and discordant intrauterine growth (4.3% vs. 11.1%). Preterm premature rupture of membranes was less frequent (23.9% vs. 12.8%) as was preterm delivery ≤32 weeks (22.5% vs. 14.0%). Cesarean section rate was higher (50.6% vs. 63.9%). Other obstetrical complications, newborn data, and puerperal complications were not statistically different. Except for first-trimester bleeding (significantly associated with monochorionicity), these results were independent from chorionicity. Regarding the induced method (ovulation induction, IVF, or ICSI), IVF is a predictor for first-trimester bleeding and IVF or ICSI a predictor for cesarean section. CONCLUSION(S) The higher rates found with induced twins of first-trimester bleeding, gestational diabetes, and discordant growth do not contribute to different neonatal immediate outcomes and do not contribute to higher rates of prematurity, low birth weight, or other major perinatal complications.

Monoamniotic twins discordant for body stalk anomaly

Abstract Body stalk anomaly is a rare malformation. This anomaly in monozygotic twins is extremely unusual. We describe a case of monoamniotic pregnancy discordant for body stalk anomaly diagnosed at 11 weeks. Ultrasound showed a fetus with a large anterior abdominal wall defect, anomaly of the spine and no evidence of lower extremities and other with a normal morphology. As far as our concern, only three monoamniotic pregnancies discordant for this malformation were reported. Our case represents the fourth reported monoamniotic pregnancy discordant for body stalk anomaly with diagnosis made by ultrasound and the second diagnosed in the first trimester.

Monochorionic versus dichorionic twins: Are obstetric outcomes always different?

This prospective cohort study compared obstetric, perinatal and postpartum outcomes of monochorionic diamniotic (n = 228) versus (vs.) dichorionic (n = 598) twin pregnancies. Statistical analysis was performed using software SPSS® v19.0.0.2. Chi square, Fischers exact, Students t and Mann-Withney tests were applied. Obstetrical complications rates were 85.5% vs. 75.1% (p < 0.01). Differences were found in preterm premature rupture of membranes (26.3% vs. 19.3%, p < 0.05) and intrauterine growth restriction (19.7% vs. 10.5%, p < 0.01). Twin-to-twin transfusion syndrome (TTTS) occurred in 7.9% of monochorionic pregnancies. Vaginal delivery occurred in 47.4% vs. 43.1%. Monochorionic pregnancies had earlier gestational ages at delivery and subsequently lower birthweights (p < 0.01). There was no difference in Apgar scores. Admission rate of at least one of the newborns in intensive care unit (NICU) was 50% vs. 38.9% (p < 0.05). Postpartum complications were similar. These results were the same excluding TTTS cases, except for admission in NICU (46.8% vs. 34.9%, p > 0.05). Analysing only the uncomplicated pregnancies (33 vs. 149), there were no differences in perinatal outcomes. We conclude that monochorionic pregnancies had higher rates of obstetrical complications, which were independent of TTTS occurrence in our sample. However, considering only the uncomplicated pregnancies till delivery, there were no significant differences in perinatal outcomes.

Does progesterone administration in preterm labor influence Treg cells

Abstract Objectives: The aim of this study was to determine if the actions of progesterone on preterm labor are accomplished through modulation of the percentage of regulatory T-cells (Treg). Methods: The study was a cohort pilot study made in a single center tertiary obstetrical unit with women in preterm labor arrested with tocolytic treatment. Variation of the number and percentage of Treg cells obtained from peripheral blood samples of women with preterm labor were calculated by flow cytometry, before and after progesterone administration. Results: In the paired samples for each patient, there was a significant difference in the Treg cell pool after progesterone treatment, with an increase in both their percentage (48.9 vs. 53; P=0.07) and absolute number (14.8 vs. 56.5 cells/μL; P=0.046). Conclusions: This research demonstrated a considerable increase in the Treg cell pool after progesterone treatment. This indicates a possible mechanism for progesterone treatment benefits in preterm labor, potentially increasing its more rational use.

Do induced twin pregnancies influence the obstetric and neonatal results of multiple births born before 32 weeks? Comparison to spontaneous gestation

PURPOSE To compare obstetric outcomes of induced preterm twin births (under 32 weeks gestation) with those spontaneously conceived. METHODS Prospective study of twin pregnancies (25 induced and 157 spontaneously conceived) developed over a period of 16 years in a tertiary obstetric center. Demographic factors, obstetric complications, gestational age at delivery, mode of delivery, birth weight and immediate newborn outcome were compared. RESULTS The analysis of obstetrical complications concerning urinary or other infections, hypertensive disorders of pregnancy, gestational diabetes, fetal malformations, intrauterine fetal death, intrauterine growth restriction and intrauterine discordant growth reveal no significant statistical differences between the two groups. First trimester bleeding was higher in the induced group (24 versus 8.3%, p=0.029). The cesarean delivery rate was 52.2% in spontaneous gestations and 64% in induced gestations. Gestational age at delivery, birth weight, Apgar scores at first and fifth minutes, admissions to Neonatal Intensive Care Unit and puerperal complications show no statistically significant differences between the two groups. These results were independent of chorionicity and induction method. CONCLUSION The mode of conception did not influence obstetric and neonatal outcomes. Although induced pregnancies have higher risk of first trimester bleeding, significant differences were not observed regarding other obstetric and puerperal complications and neonatal results.

318. Ideal interval between renal transplantation and pregnancy regarding obstetric outcomes

Introduction The optimal timing for pregnancy after kidney transplant remains uncertain, due to the risk of allograft failure. In the last consensus of American Transplant Society, this interval decreased from 2 years to 1 year, due to advanced maternal age with fewer childbearing years and lower risk of rejection with the more recent and potent immunosuppressive strategies. Objective/hypothesis Analyze whether the interval between transplantation and pregnancy (TTPI) influences obstetric outcomes. Methods Medical records from a retrospective cohort of pregnancies following kidney transplanted in our department, since 1989 (n = 41), were analyzed. Obstetric and neonatal outcomes were compared according to transplantation-to-pregnancy interval (TTPI). Statistical analysis was performed using SPSS® version 22.0 (p = 0,05). Results The study includes 41 pregnant patients after kidney transplant, 4 (10%) in the first year, 7 (17%) in second year and 30 (73%) after 24 months. Within the first year after transplantation, we observed a higher incidence of fetal growth restriction (66,7% vs 18,2%, p = 0,06), preterm labor (100% vs 54,5%, p = 0,06) and low and very low birth weight (100% vs 51,5%, p = 0,05 and 66,7% vs 6,1%, p = 0,013). Mean gestational age (32,3 ± 0,6 [32–33] vs 35,8 ± 2,5 [29–39] weeks, p = 0,04) and weight at delivery (1500 ± 282[1300–1700] vs 2523 ± 642[885–3740], p = 0,04) were significantly lower 1 year after transplant. In the second year, the incidence of gestational hypertension (57%) is similar to first year (33%), but significantly higher when compared with TTPI  >  24 months (15%, p = 0,03). With a transplantation-to-pregnancy interval higher than 2 years, the incidence of urinary infections is higher (27% vs 0%, p = 0,02). Discussion Regarding the obstetric outcomes and according to our results, the ideal time for pregnancy after transplantation is between 12 and 24 months, with a lower risk of urinary infections, restriction of fetal growth, preterm birth and low birth weight.