Simi Gupta

Cervical Pessary and Vaginal Progesterone in Twin Pregnancies With a Short Cervix.

OBJECTIVE: To evaluate cervical pessary as an intervention to prevent preterm birth in twin pregnancies with a short cervix. METHODS: This was a retrospective cohort study of twin pregnancies managed by a single maternal-fetal medicine practice from 2005 to 2015. We included patients at 28 weeks of gestation or less who were diagnosed with a cervical length less than 20 mm. At the time of diagnosis, all patients were prescribed vaginal progesterone. Starting in 2013, they were also offered pessary placement in addition to vaginal progesterone. We compared outcomes between patients who received a pessary and matched women in a control group in a one-to-three ratio. Women in the control group were matched to women in the case group according to cervical length and gestational age (within 5 mm and 1 week, respectively, of the case patient at the time of pessary placement). We excluded patients with cerclage, monochorionic–monoamniotic placentation, major fetal congenital anomalies discovered before or after birth, patients with twin-twin transfusion syndrome, and patients for whom there were no appropriate controls. Chi-square, Fisher exact, and Students t tests were used, as appropriate. Regression analysis was performed to control for significant differences at baseline. RESULTS: Twenty-one patients received a cervical pessary, and they were compared with 63 matched women in the control group. As expected (as a result of matching), baseline gestational age (25.7±2.1 compared with 25.9±2.1 weeks of gestation, P=.671) and cervical length (10.9±3.6 mm compared with 11.9±4.5 mm, P=.327) were similar between the groups. Patients with a pessary had a significantly lower incidence of delivery at less than 32 weeks of gestation (1/21 [4.8%] compared with 18/63 [28.6%], adjusted P=.05), longer interval to delivery (65.2±16.8 compared with 52.1±24.3 days, adjusted P=.025), and a lower incidence of severe neonatal morbidity (2/21 [9.5%] compared with 22/63 [34.9%], adjusted P=.04). CONCLUSION: For twin pregnancies with a short cervix, the addition of a cervical pessary to vaginal progesterone is associated with prolonged pregnancy and reduced risk of adverse neonatal outcomes. A large randomized trial should be performed to verify these retrospective findings.

Effect of oocyte donation on pregnancy outcomes in in vitro fertilization twin gestations

OBJECTIVE To estimate the effect of oocyte donation on pregnancy outcomes in patients with twin pregnancies conceived via IVF. DESIGN Retrospective cohort study. SETTING Patients with IVF twin pregnancies delivered by one maternal-fetal medicine practice from 2005 to 2013. PATIENT(S) Fifty-six patients with IVF twin pregnancies who had oocyte donation and 56 age-matched controls with IVF twin pregnancies who used autologous oocytes. We excluded women aged >50 years because there were no age-matched controls aged >50 years using autologous oocytes. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Gestational hypertension, pre-eclampsia. RESULT(S) The baseline characteristics were similar between the groups, including maternal age, race, parity, chorionicity, and comorbidities. The mean (±SD) age was 43.0 ± 6.0 vs. 41.9 ± 1.7 years. There were no differences in outcomes between the groups in regard to preterm birth, birth weight, or gestational diabetes. There was a greater incidence of gestational hypertension (32.1% vs. 13.0%) and pre-eclampsia (28.3% vs. 13.0%) in the group that underwent IVF with donor oocytes. CONCLUSION(S) In patients who conceive twin pregnancies using IVF, oocyte donation increases the risk of gestational hypertension and pre-eclampsia. However, this did not translate into increased rates of preterm birth or low birth weight. Patients who require oocyte donation should be carefully counseled regarding the increased risk for pre-eclampsia and gestational hypertension but should be reassured that oocyte donation does not seem to lead to other adverse outcomes.

Pregnancy outcomes in patients with prior uterine rupture or dehiscence.

OBJECTIVE: To report obstetric outcomes in a series of women with prior uterine rupture or prior uterine dehiscence managed with a standardized protocol. METHODS: Series of patients delivered by a single maternal-fetal medicine practice from 2005 to 2013 with a history of uterine rupture or uterine dehiscence. Uterine rupture was defined as a clinically apparent, complete scar separation in labor or before labor. Uterine dehiscence was defined as an incomplete and clinically occult uterine scar separation with intact serosa. Patients with prior uterine rupture were delivered at approximately 36–37 weeks of gestation or earlier in the setting of preterm labor. Patients with prior uterine dehiscence were delivered at 37–39 weeks of gestation based on obstetric history, clinical findings, and ultrasonographic findings. Patients with prior uterine rupture or uterine dehiscence were followed with serial ultrasound scans to assess fetal growth and lower uterine segment integrity. Outcomes measured were severe morbidities (uterine rupture, hysterectomy, transfusion, cystotomy, bowel injury, mechanical ventilation, intensive care unit admission, thrombosis, reoperation, maternal death, perinatal death). RESULTS: Fourteen women (20 pregnancies) had prior uterine rupture and 30 women (40 pregnancies) had prior uterine dehiscence. In these 60 pregnancies, there was 0% severe morbidity noted (95% confidence interval [CI] 0.0–6.0%). Overall, 6.7% of patients had a uterine dehiscence seen at the time of delivery (95% CI 2.6–15.9%). Among women with prior uterine rupture, the rate was 5.0% (95% CI 0.9–23.6%), whereas among women with prior uterine dehiscence, the rate was 7.5% (95% CI 2.6–19.9%). CONCLUSION: Patients with prior uterine rupture or uterine dehiscence can have excellent outcomes in subsequent pregnancies if managed in a standardized manner, including cesarean delivery before the onset of labor or immediately at the onset of spontaneous preterm labor. LEVEL OF EVIDENCE: III

Risk factors for cesarean delivery in twin pregnancies attempting vaginal delivery

OBJECTIVE The purpose of this study was to estimate independent risk factors for cesarean delivery in patients with twin pregnancies who attempt vaginal delivery. STUDY DESIGN This was an historic cohort of twin pregnancies that were delivered in 1 practice from June 2005 to February 2014. Baseline characteristics were compared between women who delivered vaginally and women who underwent cesarean delivery in labor. Logistic regression analysis was performed to estimate independent risk factors for cesarean delivery. RESULTS Two hundred eighty-six women with twin pregnancies who had attempted vaginal delivery were included in the study. The overall modes of delivery were vaginal delivery (82.2%), cesarean delivery (17.8%), and combined vaginal-cesarean delivery (0%). The most common indication for cesarean delivery in labor was an arrest disorder (82.4%). The risk factors that were associated independently with cesarean delivery were nulliparity (adjusted odds ratio, 5.78; 95% confidence interval, 2.24-14.88) and advanced maternal age of ≥35 years (adjusted odds ratio, 2.36; 95% confidence interval, 1.16-4.80). The patients at highest risk for cesarean delivery (nulliparous, advanced maternal age, induced labor) still had a 48.6% likelihood of vaginal delivery. CONCLUSION In patients with twin pregnancies who attempt labor, nulliparity and advanced maternal age are associated independently with cesarean delivery in labor. However, even the patients at highest risk for cesarean delivery have nearly a 50% likelihood of successful vaginal delivery and therefore should be allowed to attempt vaginal delivery if it is desired and not otherwise contraindicated.

Early second-trimester sonography to improve the fetal anatomic survey in obese patients.

Fetal anatomic surveys are difficult to perform on obese patients. However, there are limited data available on methods to improve the rate of complete anatomy scans in these patients. The objective of this study was to determine whether the addition of an early second‐trimester fetal anatomy scan improves the rate of complete anatomy scans in obese patients.

The relationship between preeclampsia and intrauterine growth restriction in twin pregnancies

OBJECTIVE Preeclampsia and intrauterine growth restriction (IUGR) are correlated in singleton pregnancies. The objective of this study was to estimate their relationship in twin pregnancies. STUDY DESIGN Cohort of 578 patients with twin pregnancies delivered by 1 maternal fetal medicine practice from 2005-2013. Patients with chronic hypertension, monochorionic-monoamniotic placentation, twin-twin transfusion, and major congenital anomalies were excluded. Standard definitions were used for gestational hypertension and preeclampsia. We defined IUGR as any twin birthweight less than the 5th percentile for gestational age, as well as any twin birthweight less than the 10th percentile for gestational age. RESULTS The incidence of preeclampsia was 14.9%, the incidence of birthweight <10% was 50.0%, and the incidence of birthweight <5% was 27.5%. Comparing patients with and without preeclampsia, the rate of birthweight <5th percentile did not differ (27.9% vs 27.4%, P = .929), nor did the rate of birthweight <10th percentile (48.8% vs 50.2%, P = .815). We had 80% power with an alpha error of 5% to show a difference in the likelihood of IUGR <10th percentile from 50% to 66% and a difference in the likelihood of IUGR <5th percentile from 27% to 42% in patients without and with preeclampsia. CONCLUSION In patients with twin pregnancy, there is no correlation between preeclampsia and IUGR. This suggests that in twin pregnancies, as opposed to singleton pregnancies, the pathophysiology may differ between these 2 common conditions.

Glycemic control in twin pregnancies with gestational diabetes: are we improving or worsening outcomes?

Abstract Objective: To estimate the association between glycemic control and adverse outcomes in twin pregnancies with gestational diabetes (GDM). Study design: A cohort of patients with twin pregnancies and GDM were identified from one maternal–fetal medicine practice from 2005 to 2014. Patients with prepregnancy diabetes were excluded. First, outcomes were compared between patients with GDMA1 and GDMA2 (gestational age at delivery, birthweight, small for gestational age (SGA, birthweight <10th percentile), preeclampsia, and cesarean delivery). Then, finger stick glucose logs were reviewed and correlated with the risk of SGA and preeclampsia. Abnormal finger stick values were defined as: fasting ≥90 mg/dL, 1-h postprandial ≥140 mg/dL, 2-h postprandial ≥120 mg/dL. Results: Sixty-six patients with twin pregnancies and GDM were identified (incidence 9.1%). Comparing the 43 patients with GDMA1 to the 23 patients with GDMA2, outcomes were similar, aside from patients with GDMA1 having lower birthweight of the smaller twin (2184 ± 519 g versus 2438 ± 428 g, p = 0.040). The risk of preeclampsia was not associated with glycemic control. Patients with SGA had lower mean fasting values (83.3 ± 5.5 versus 87.2 ± 7.7 mg/dL, p = 0.033), and a lower percentage of abnormal fasting values (24.0% versus 36.9%, p = 0.040), abnormal post-breakfast values (9.9% versus 27.1%, p = 0.003), and total abnormal values (20.1% versus 27.7%, p = 0.055). Conclusion: In twin pregnancies with GDM, improved glycemic control is not associated with improved outcomes, and is associated with a higher risk of SGA. Prospective trials in twin pregnancies should be performed to establish goals for glycemic control in twin pregnancies.

The association between maternal biomarkers and pathways to preterm birth in twin pregnancies

Abstract Objective: We sought to estimate the association between cervical length (CL) and fetal fibronectin (fFN) and each pathway leading to preterm birth in twin pregnancies. Methods: Cohort study of 560 patients with twin pregnancies who underwent routine serial CL and fFN screening from 22 to 32 weeks in one maternal fetal medicine practice during 2005–2013. We calculated the association between a short CL (≤20 mm) or positive fFN with overall preterm birth <32 weeks, and then subdivided the analysis into preterm birth <32 weeks from preterm labor, preterm premature rupture of membranes (PPROM) and indicated causes. We excluded cases of monochorionic-monoamniotic placentation, vasa previa, twin–twin transfusion and patients with cerclage. Results: The overall rate of preterm birth <32 weeks was 6.9% (3.9% from preterm labor, 1.6% from PPROM and 1.4% indicated). A short cervix was associated with preterm birth <32 weeks arising from preterm labor (12.4% versus 2.0%, p < 0.001), but not PPROM (1.9% versus 1.3%, p = 0.651). Positive fFN was associated with preterm birth <32 weeks both from preterm labor (17.0% versus 2.4%, p < 0.001) as well as from PPROM (5.7% versus 1.0%, p = 0.034). Neither was significantly associated with preterm birth <32 weeks from indicated causes. Conclusions: The mechanism leading toward preterm influences the accuracy of screening tests chosen to assess risk in twin pregnancies. A shortened cervical length and positive fFN is associated with spontaneous preterm labor and birth <32 weeks. However, PPROM does not appear to be preceded by a short cervix, but is preceded by a positive fFN. Neither test is associated with an indicated preterm birth.

Gestational Age at Cervical Length and Fetal Fibronectin Assessment and the Incidence of Spontaneous Preterm Birth in Twins

To estimate the risk of spontaneous preterm birth in twin pregnancies based on transvaginal sonographic cervical length, fetal fibronectin (fFN) testing, and the gestational age at which these tests were performed.

Fetal fibronectin, cervical length, and the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage

Abstract Objective: The objective of this study is to estimate the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage based on the results of fetal fibronectin (fFN) and cervical length (CL) screening. Methods: Retrospective cohort of patients with a singleton pregnancy and an ultrasound or physical exam indicated Shirodkar cerclage placed by one maternal–fetal medicine practice from November 2005 to January 2015. Patients routinely underwent serial CL and fFN testing from 22 to 32 weeks. Based on ROC curve analysis, a short CL was defined as ≤15 mm. All fFN and CL results included are from after the cerclage placement. Results: One hundred and four patients were included. Seventy eight (75%) patients had an ultrasound-indicated cerclage and 26 (25%) patients had a physical exam-indicated cerclage. A positive fFN was associate with preterm birth <32 weeks (15.6% versus 4.2%, p = 0.043),  <35 weeks (37.5% versus 11.1%, p = 0.002),  <37 weeks (65.6% versus 20.8%, p < 0.001), and earlier gestational ages at delivery (35.2 ± 3.9 versus 37.4 ± 2.9, p = 0.001). A short CL was also associated with preterm birth <35 weeks (50.0% versus 11.9%, p < 0.01), preterm birth <37 weeks (55.0% versus 29.8%, p = 0.033), and earlier gestational ages at delivery (34.8 ± 4.1 versus 37.2 ± 3.0, p = 0.004). The risk of preterm birth <32,  <35, and <37 weeks increased significantly with the number of abnormal markers. Conclusion: In patients with an ultrasound or physical exam indicated cerclage, a positive fFN and a short CL are both associated with preterm birth. The risk of preterm birth increases with the number of abnormal biomarkers.