Teresinha Simões

Perinatal Outcome and Change in Body Mass Index in Mothers of Dichorionic Twins: A Longitudinal Cohort Study

We used a prospective cohort to analyze the effect of change in BMI rather than change in weight, in mothers carrying dichorionic twins from a population that did not receive any dietary intervention. A total of 269 mothers (150 nulliparas and 119 multiparas) were evaluated. The average change (%) from the pre-gravid BMI was 7.2+/-6.1, 17.4+/-8.2, and 28.7+/-10.8, at 12-14, 22-25, and 30-34 weeks, respectively, without difference between nulliparas and multiparas. The comparison between maternities below or above the average change from the pregravid BMI failed to demonstrate an advantage (in terms of total twin birthweight and gestational age) of an above average change from the pregravid BMI, even when the lower versus upper quartiles were compared. Our observations reached different conclusions regarding the recommended universal dietary intervention in twin gestations. A cautious approach is advocated towards seemingly harmless excess weight gain, as normal weight women may turn overweight, or even obese, by the end of pregnancy, and be exposed to the untoward effects of obesity on future health and body image.

Puerperal complications following elective cesarean sections for twin pregnancies

Abstract Objective: To estimate the maternal puerperal morbidity in elective and emergent cesareans in twins. Study design: We evaluated postpartum complications among patients who underwent elective cesarean birth for twin pregnancy. This group was compared to matched singletons and to emergent cesareans in twins. Results: During the period September 1994–March 2006 there were 299 (47.4%) elective and 80 (12.7%) emergent cesarean sections in twin pregnancies, for a total of 379 (60.1%) cesarean births for both twins. Controls included 299 cases of elective cesareans in singletons. The comparison between elective and emergent cesareans and between elective cesareans in twins and in singletons found no significant differences in postpartum fever, scar infection, and postpartum hemorrhage. Venous thromboembolism occurred in two twin pregnancies, one in the elective and one in the emergent cesarean group. Postpartum hysterectomy was required in a singleton pregnancy following an elective cesarean birth. Conclusion: At present, no data exist to show a disadvantage for a planned cesarean birth for twins.

Induction of labor with oral misoprostol in nulliparous mothers of twins

Abstract The efficacy and safety of oral misoprostol for labor induction of twins is unknown. We conducted a retrospective case-control study to evaluate the use of oral misoprostol in near term (≥35 weeks) twin pregnancies in nulliparas. Eligible cases were given 100 mcg oral misoprostol, which was repeated after 6 h if labor did not start. Either a third dose or diluted oxytocin infusion were given in intractable cases. Diluted oxytocin infusion was used for augmentation. Controls were nulliparas delivered at ≥35 weeks by elective cesarean section. The two groups were comparable in most aspects, except for fetal malpresentation, which was the major reason for avoiding induction. Of the 69 patients in whom labor was induced, 53 (76.8%) had a vaginal birth, 3 (4.3%) had a combined twin delivery, and 13 (18.8%) had a cesarean during labor. The mean length of stay of the neonates was significantly shorter among study cases, without significant difference in the frequency of delayed discharges as an overall proxy for neonatal complications. Labor induction with oral misoprostol could be offered to patients in whom near term vaginal twin delivery is unequivocally permitted and wish to deliver by the vaginal route.

Abdominal circumference ratio for the diagnosis of intertwin birth weight discordance.

Abstract Objectives: We assessed the accuracy of predicting severe twin birth weight discordance (>25%) using the estimated fetal weights (EFW) and abdominal circumference (AC) ratio. Method: A cohort of twin gestations underwent ultrasound examinations within two weeks from birth. We focused on the accuracy of EFW and on the diagnosis of severe birth weight discordance by the difference in EFWs and the AC ratio. Results: The 661 eligible twin pairs included 51 (7.7%) severely discordant pairs. The accuracy of an EFW to predict the actual birth weight was quite poor, with an acceptable specificity (96.4%), but low sensitivity (28.6–40.5%), to detect severely discordant pairs, whereas an AC ratio of 1.3 detected these discordant pairs with sensitivity and specificity of 97.3–100% and 99.6–99.7%, respectively. Conclusion: By comparing EFWs, 59.5–71.4% of discordant pairs >25% are missed, whereas an AC ratio >1.3 would identify almost all cases.

Prediction of birth weight discordance from fetal weight estimations at 21-24 weeks' scans in monochorionic and dichorionic twins.

Abstract Objective: To evaluate if inter-twin estimated fetal weight (EFW) differences at 21–24 weeks’ scans predict birth weight discordance in monochorionic and dichorionic twins born at three gestational age periods. Methods: We counted the number of pairs with discordant EFWs (EFWs greater than the mean + 1SD; i.e. a difference above 12% in dichorionic and 21% in monochorionic twins) derived during a 21–24 weeks’ scan as compared to actual discordant birth weight (>25%) in monochorionic and dichorionic pairs born at ≤32, 33–36 and >36 weeks. Results: We studied 416 dichorionic and 244 monochorionic twins. The frequency of EFWs discordance at 21–24 weeks was the same for dichorionic and monochorionic twins but the total number of birth weight discordant pairs was significantly smaller among dichorionic twins (OR 0.2, 95% CI 0.1, 0.6). Generally, the positive predictive values for birth weight discordance by using the EFWs difference were quite poor, but always better in monochorionic than in dichorionic twins. Whereas the negative predictive value and hence the sensitivity for monochorionic twins was 100% irrespective of gestational age at birth, it was much lower in the dichorionic pairs. Conclusion: Concordant EFWs at 21–24 weeks exclude discordant birth weight in monochorionic twins whereas discordant EFWs are poor predictors of birth weight discordance especially in dichorionic twins irrespective when the twins were born.

Concurrence of gestational diabetes and pre-gravid obesity (“diabesity”) in twin gestations

Abstract Objective: To assess the effect of the concurrence of gestational diabetes mellitus (GDM) and pre-gravid obesity in twin gestations (“diabesity”). Methods: We compared perinatal outcomes of twin gestation in mothers with GDM and pre-gravid obesity (1.7%), mothers with GDM but with normal BMI (6.2%), and obese mothers without GDM (7.0%). Results: Twin pregnancies with “diabesity” were associated with significantly higher incidence of stillbirth (OR = 6.4; 95%CI = 1.4, 33.4) and existing chronic hypertension (OR = 4.2; 95%CI = 1.2, 14.8) than in GDM pregnancies without obesity, and with births at 33–36 weeks as compared with the other groups. Otherwise, the comparisons showed remarkable similar results in terms of gestational age, birth weight, preeclampsia, cesarean section rate, and fetal-neonatal outcomes. Conclusion: It appears that diabesity has a relatively minor effect in twins. If this will be confirmed by other studies, it would be important to elucidate how twins ameliorate the adverse outcomes of diabesity.

Perinatal outcome of dichorionic-triamniotic as compared to trichorionic triplets

Abstract Objective: To evaluate if the perinatal outcomes of dichorionic-triamniotic (DC) triplets are significantly different than that of trichorionic (TC) triplets. Study design: Comparison of maternal and neonatal data of 44 DC to 46 TC triplets, using univariate analysis. Results: DC triplets were significantly more common after spontaneous conception but all other maternal characteristics as well complications and cesarean section rates were similar. Both groups had similar incidence of birth at <32 and <28 weeks as well as similar incidence of very low and extremely low birth weight. There was similar incidence of neonatal morbidity except for twin-twin transfusion syndrome (13.6%) in the DC group. The stillbirth rate was 45/1000 and 29/1000, the early neonatal mortality rates were 63/1000 and 45/1000, and the perinatal mortality rate was 106/1000 and 72/1000 for DC and TC triplets, respectively (all not significantly different). Conclusions: Our data indicate that DC twins are not significantly disadvantaged compared to TC triplets and the similar outcomes might be reassuring for those who consider continuing their DC triplet pregnancy.

Prospective risk of intrauterine death of monochorionic twins: update.

Abstract Objective: To calculate an updated prospective risk of fetal death in monochorionic-biamniotic (MCBA) twins. Study design: We evaluated 520 MCBA twin pregnancies that had intensive prenatal surveillance and delivered in a single Portuguese referral center. The prospective risk of fetal death was calculated as the total number of deaths at the beginning of the gestational period divided by the number of continuing pregnancies at or beyond that period. Data were compared to the 2006 previous report. Results: Nearly 80% of the neonates weighed <2500 g, including 13.5% who weighed <1500 g. Half were born at <36 weeks, including 13.8% who were born at <32 weeks. The data indicate an increased IUFD rate over time – 16 fetal deaths per pregnancy (3.1%) and 22 IUFDs per fetus (2.1%). The rate of IUFD after 32–33 weeks, however, was halved (1/187 pregnancies and 1/365 fetuses, 0.5 and 0.3%, respectively). Conclusion: Intensive prenatal surveillance might decrease the unexpected fetal death rates after 33 week’s gestation and our data do not support elective preterm birth for uncomplicated MCBA twins.