Ruta Misiunas

Specialized prenatal care and maternal and infant outcomes in twin pregnancy

OBJECTIVE This study was undertaken to evaluate the effect of a prenatal nutrition and education program on twin pregnancy, neonatal, and early childhood outcomes. STUDY DESIGN This prospective intervention study of women who participated in a specialized program (Program Pregnancies) versus nonparticipants included twice-monthly visits, dietary prescription of 3000 to 4000 kcal per day, multimineral supplementation, and patient education. RESULTS Program Pregnancies were associated with improved pregnancy outcomes (preeclampsia, adjusted odds ratio [AOR] 0.41, 95% CI, 0.23-0.75; preterm premature rupture of membranes, AOR 0.35, 95% CI, 0.20-0.60; delivery <36 weeks, AOR 0.62, 95% CI, 0.43-0.89; low birth weight, AOR 0.42, 95% CI, 0.29-0.61), significantly longer gestations (+7.6 days), higher birth weights (+220 g), lower neonatal morbidity (retinopathy of prematurity, necrotizing enterocolitis, intraventricular hemorrhage, or ventilator support, AOR 0.44, 95% CI, 0.31-0.62), length of stay (-5.3 days), and cost per twin (-14,023 dollars). Through 3 years of age, program children were significantly less likely to be rehospitalized (AOR 0.31, 95% CI, 0.11-0.91) or to be developmentally delayed (AOR 0.65, 95% CI, 0.44-0.96). CONCLUSION Program participation was associated with improved outcomes at birth and through age 3 years.

Antenatal factors associated with significant birth weight discordancy in twin gestations.

OBJECTIVE The purpose of this study was to evaluate factors that are associated with significant birth weight discordancy. STUDY DESIGN As a part of an ongoing collaborative study of twins, maternal and fetal data were obtained from the medical records of twin gestations at eight medical centers. The study population was divided into groups by difference in birth weight discordancy (>or=20%, >or=25%, and >or=30%) RESULTS Severe birth weight discordancy was associated with fetal growth deceleration by 20 to 28 weeks (adjusted odds ratio, 4.90; 95% CI, 3.15-7.64) and between 28 weeks to birth (adjusted odds ratio, 3.48; 95% CI, 1.72-7.06). Antenatal bleeding (adjusted odds ratio, 1.86; 95% CI, 1.08-3.21), preeclampsia (adjusted odds ratio, 1.70, 95% CI, 1.21-2.41), and monochorionicity (adjusted odds ratio, 2.35, 95% CI, 11.71-3.23) were also associated with birth weight discordancy. CONCLUSION These data demonstrate the importance of the early diagnosis of placental chorionicity, because monochorionicity is associated with a 2-fold increase in birth weight discordancy in twin gestations.

Perinatal and Early Childhood Outcomes of Twins Versus Triplets

The purpose of this prospective cohort study of twins and triplets was to evaluate perinatal and early childhood outcomes through 18 months of age. The study population included 141 twin pregnancies (282 twin children) and 8 triplet pregnancies (24 triplet children) recruited between May, 1996 and June, 2001. Mothers of triplets versus twins were significantly more likely to have infertility treatments, to be overweight or obese before conception, to be admitted antenatally, and to deliver by cesarean section. Length of gestation for triplets was significantly shorter (-2.31 weeks, p < .0001), and more likely to be less than 35 weeks (Adjusted Odds Ratio [AOR] 9.38, 95% confidence interval [CI] 3.22-27.29). Average birthweight for triplets was significantly lighter (-495 grams, p < .0001), and more likely to be low birthweight (AOR 11.38, 95% CI 3.11-41.61). Triplets were also more likely to be admitted to neonatal intensive care (AOR 7.97, 95% CI 2.13-29.77), to require mechanical ventilation (AOR 5.67, 95% CI 2.05-15.65), to develop respiratory distress syndrome (AOR 12.50, 95% CI 3.89-40.20), or a major morbidity (retinopathy of prematurity, necrotizing enterocolitis, ventilator support, or grade III or IV intraventricular hemorrhage, AOR 5.67, 95% CI 2.05-15.65). Weight, length, and head circumference was significantly smaller at birth for triplets compared to twins, and these differences remained through 18 months of age, along with lower mental developmental scores at the oldest age. Compared to twins, triplets have greater neonatal morbidity, and through 18 months of age lower mental and motor scores, slower postnatal growth and more residual stunting, particularly of length and head circumference.

Feasibility of a longitudinal study of women anticipating first pregnancy and assessed by multiple pelvic exams: Recruitment and retention challenges

OBJECTIVE To better understand the relationship between childbirth and pelvic floor disorders the ideal study design would begin with data collection prior to but close in time to first pregnancy and follow participants through postpartum. We conducted a feasibility study to determine the following: a) whether women desiring to get pregnant would agree to pre-pregnancy data collection including a one-time urethral catheter measure and repeat pelvic exams to ascertain a baseline within 6 months of pregnancy; b) effectiveness of various recruitment and retention methods, c) number achieving pregnancy, and then d) number expressing willingness to continue follow-up through pregnancy and postpartum. METHODS Advertising included newspaper ads, targeted emails and flyers. Post-enrollment, four data collection visits were scheduled and occurred every 6 months or until pregnant. If pregnancy occurred, women were asked to indicate their willingness to continue assessments. RESULTS The most successful advertising strategy for both recruitment and retention was local newspaper ads. Ninety-four women inquired about the study, 30 enrolled. Post-baseline retention was 23 women at 6 months, 17 at 12 months, and 13 at 18 months. Nine of the 30 women achieved pregnancy; two remained eligible and willing to participate through pregnancy and postpartum. CONCLUSIONS This study provides data on feasibility of recruiting women to establish near-pregnancy clinical baseline measures that include pelvic exams. Close to 30% reached pregnancy within 2 years of study start and within 6 months of most recent pelvic exam measure. Of those who became pregnant, 22% expressed willingness to continue follow-up into the childbearing year.

The Hispanic paradox in twin pregnancies.

The objective of this study was to compare length of gestation, fetal growth, and birthweight by race/ethnicity and pregravid weight groups in twin pregnancies. Three thousand and thirty-six twin pregnancies of 28 weeks or more gestation were divided by race/ethnicity (White, Black and Hispanic), and pregravid body mass index (BMI) groups (less than 25.0 vs. 25.0 or more). Outcomes were modeled using multiple regression, controlling for confounders, with White non-Hispanic women as the reference group. Hispanic women had the highest average birthweight and the longest gestation, as well as the lowest proportions of low birthweight, very low birthweight, preterm and early preterm births of the 3 race/ethnicity groups. In the multivariate analyses, Hispanic women had significantly longer gestations (by 7.8 days) and faster rates of fetal growth midgestation (20 to 28 weeks, by 17.4 g/week) and late gestation (after 28 weeks, by 5.3 g/week), whereas Black women had significantly slower rates of fetal growth (by 5.7 g/week and by 4.5 g/week, respectively). These findings in twins reflect the racial and ethnic disparities previously shown in singletons, including the Hispanic paradox of longer gestations and higher rates of fetal growth.