Rania Okby

Reversal of Mirror Syndrome After Selective Feticide of a Hydropic Fetus in a Dichorionic Diamniotic Twin Pregnancy

A 26-year-old patient, gravida 4, para 2, with a spontaneous dichorionic diamniotic twin gestation was referred to our hospital at a gestational age of 23 weeks 3 days due to high blood pressure of 160/90 mm Hg and severe bilateral lower-leg edema. On admission, the patient felt well, with no specific symptoms. Her physical examination revealed blood pressure of 144/82 mm Hg, marked peripheral edema, and 3+ urine protein by a dipstick test. Laboratory studies at admission disclosed mild anemia, along with a mildly elevated creatinine level. A sonographic examination confirmed dichorionic diamniotic twins. Twin A had severe hydrops, polyhydramnios, a hypoplastic left heart, a brachycephalic head with hypomineralization, abnormal gyration, bilateral femoral fractures, and placenomegaly. Twin B had normal anatomic findings, was appropriate for gestational age, and had a normal amniotic fluid volume. Doppler studies of the umbilical artery, middle cerebral artery, and uterus yielded normal findings for both fetuses. Given the young gestational age and the presence of a normal dichorionic twin along with the hydropic fetus, we proposed that the patient undergo a selective reduction of the hydropic twin. The patient agreed to the recommended intervention, and informed consent was provided, in accordance with the Israeli law, a selective termination of the hydropic twin was performed by intracardiac injection of potassium chloride. Despite our recommendation to do diagnostic amniocenteses for both fetuses, the patient refused to do so. Because of the severity of her preeclampsia, reflected by 4.5 g of protein/24 h and gross hematuria, the patient was treated with magnesium sulfate for 72 hours. Fundoscopy was done after the patient had blurred vision and revealed normal findings. At 24 weeks’ gestation (3 days after feticide) the patient received antenatal corticosteroids for fetal lung maturation.

The effect of maternal anemia on maternal and neonatal outcomes in twin pregnancies.

Abstract Objective: The objective of this study is to investigate the effect of second trimester anemia on maternal and perinatal outcomes in twin pregnancies. Methods: A retrospective population-based study was conducted, comparing maternal and neonatal outcomes in women carrying twins, with second trimester anemia (defined as hemoglobin < 10 g/dl) to those without anemia (defined as hemoglobin > or equal to 10 g/dl). Deliveries occurred in a tertiary medical center in 2013. Results: During the study period, there were 307 twin deliveries. Hemoglobin levels were available for 247 (80.4%) twins; 66 (26.7%) of these had anemia (<10 g/dl) during the second trimester. Women with second trimester anemia had a higher parity (p= 0.03), and needed more blood transfusions than those with hemoglobin level > or equal to 10 g/dl (OR = 1.6; 95% CI 1.11–2.43, p < 0.001). No significant differences were noted between the groups regarding other obstetrical outcomes or regarding perinatal outcomes. Conclusion: Second trimester anemia in women carrying twins is associated with a high parity and increases the risk for blood transfusions. However, in our population, maternal anemia in twin gestations does not increase the risk for adverse perinatal outcome.

Gestational Diabetes Mellitus is Associated with Adverse Outcomes in Twin Pregnancies

BACKGROUND: Among singleton pregnancies, gestational diabetes mellitus is associated with adverse outcomes. In twin pregnancies, this association may be attenuated, given the higher rate of prematurity and the a priori increased risk of some of these complications. OBJECTIVE: Our aim was to test the hypothesis that gestational diabetes mellitus is less likely to be associated with adverse pregnancy outcomes in twin compared with singleton gestations. METHODS: This retrospective cohort study comprised all twin and singleton live births in Ontario, Canada, 2012–2016. Pregnancy outcomes were compared between women with vs without gestational diabetes mellitus, analyzed separately for twin and singleton births. Adjusted risk ratios and 95% confidence intervals were generated using modified Poisson regression, adjusting for maternal age, nulliparity, smoking, race, body mass index, preexisting hypertension, and assisted reproductive technology. RESULTS: A total of 270,843 women with singleton (n = 266,942) and twin (n = 3901) pregnancies met the inclusion criteria. In both the twin and singleton groups, gestational diabetes mellitus was associated with (adjusted risk ratio, [95% confidence interval]) cesarean delivery (1.11 [1.02–1.21] and 1.20 [1.17–1.23], respectively) and preterm birth at <370/7 weeks (1.21 [1.08–1.37] and 1.48 [1.39–1.57]) and at <340/7 weeks (1.45 [1.03–2.04] and 1.25 [1.06–1.47]). In singletons, but not twins, gestational diabetes mellitus was associated with gestational hypertension (1.66 [1.55–1.77]) and preeclampsia. With respect to neonatal outcomes, gestational diabetes mellitus was associated with birthweight greater than the 90th percentile in both twins and singletons, with the risk being 2‐fold higher in twins (2.53 [1.52‐4.23] vs 1.18 [1.13‐1.23], respectively, P = .004). Gestational diabetes mellitus was associated with jaundice in both twins (1.56 [1.10–2.21]) and singletons (1.49 [1.37–1.62) but was associated with the following complications only in singletons: neonatal intensive care unit admission (1.44 [1.38–1.50]), respiratory morbidity (1.09 [1.02–1.16]), and neonatal hypoglycemia (3.20 [3.01–3.40]). CONCLUSION: In contrast to singleton pregnancies, gestational diabetes mellitus in twins was not associated with hypertensive complications and certain neonatal morbidities. Still, the current study highlights that gestational diabetes mellitus is associated with some adverse pregnancy outcomes including accelerated fetal growth also in twin pregnancies.

Twin pregnancy: is it a risk factor for long-term cardiovascular disease?

Abstract Objective: To investigate whether twin pregnancy increases the risk for long-term maternal cardiovascular disease (CVD). Study design: A retrospective population-based cohort study compared the incidence of long-term CVD in a cohort of women with and without a previous twin delivery. Setting: Deliveries occurred between the years 1988 and 2012. Patients: Patients who had a twin birth between years 1988 and 2012 were included in the study, patient that had a singleton delivery included in the control group. Main outcome measures: CVD was divided into four categories according to severity and type. Kaplan–Meier survival curve was used to estimate cumulative incidence of cardiovascular hospitalizations. Cox proportional hazards model was used to estimate the adjusted hazard ratios (HR) for CVD. Results: During the study period, there were 100 387 women that met the inclusion criteria, 4.6% (n = 4647) delivered twins at least once during the period. The incidence of CVD was 1% in women who had a twin delivery and 1.12% in women who had a singleton delivery. There was no difference in the cumulative incidence of cardiovascular hospitalizations among women who had twin deliveries as compared with singletons. When performing a Cox proportional hazard model, a history of twin delivery did not increase the risk for long-term maternal cardiovascular hospitalizations (adjusted HR = 1.0, 95% CI = 0.8–1.1, p = 0.698). Conclusions: Twin pregnancy is not associated with an increased risk for long-term maternal CVD.