Nuchal Cord Research Articles

Impact of a prenatally diagnosed nuchal cord on obstetrical outcome in an unselected population

Objective: Evaluate the outcome of prenatally diagnosed nuchal cord.Methods: A retrospective study on all cases of prenatally diagnosed nuchal cord. Study end points were gestational age at delivery, intrapartum fetal heart rate (FHR) abnormalities, mode of delivery, intrauterine fetal growth retardation (IUGR), intrauterine fetal demise (IUFD), and the rate of labor induction.Results: This study included 44 cases; 86% were diagnosed at second trimester scan, confirmed by Color Doppler and 3D ultrasound. Mean gestational age at delivery was 39 weeks.18/44 cases (41%) underwent labor induction mostly as a result of parental anxiety. Primary cesarean rate was 34% (15/44), and 16% (7/44) had intrapartum FHR abnormalities with no impact for induction of labor. Instrumental vaginal delivery was used in 5 cases. IUGR was present in 7% (3/44), and none had IUFD. Nuchal cord was confirmed at birth in all cases. Correct prenatal diagnosis was in only one case of the 5/44 (11%) with multiple loops.Conclusion: Prenatal diagnosis of nuchal cord is feasible with difficulty in determining multiple loops. Outcome is favorable, but parental anxiety is common and may increase induction rates, without leading to difference in cesarean rates or FHR abnormalities.

Risk Factors for Neonatal Arterial Ischemic Stroke: The Importance of the Intrapartum Period

To investigate risk factors for neonatal arterial ischemic stroke (NAIS), and compare them with those present in term controls and infants with hypoxic-ischemic encephalopathy (HIE). Antepartum and intrapartum data were collected at presentation from 79 infants with NAIS and compared with 239 controls and 405 infants with HIE. The relationships between risk factors and NAIS were explored using univariable and multivariable regression. Compared with controls, infants with NAIS more frequently had a family history of seizures/neurologic diseases, primiparous mothers, and male sex. Mothers of infants with NAIS experienced more intrapartum complications: prolonged rupture of membranes (21% vs 2%), fever (14% vs 3%), thick meconium (25% vs 7%), prolonged second stage (31% vs 13%), tight nuchal cord (15% vs 6%), and abnorm8al cardiotocography (67% vs 21%). Male sex (OR 2.8), family history of seizures (OR 6.5) or neurologic diseases (OR 4.9), and ≥1 (OR 5.8) and ≥2 (OR 21.8) intrapartum complications were independently associated with NAIS. Infants with NAIS and HIE experienced similar rates though different patterns of intrapartum complications. Maternal fever, prolonged rupture of membranes, prolonged second stage, tight nuchal cord, and failed ventouse delivery were more common in NAIS; thick meconium, sentinel events, and shoulder dystocia were more frequent in HIE. Abnormal cardiotocography occurred in 67% of NAIS and 77.5% of infants with HIE. One infant with NAIS and no infant with HIE was delivered by elective cesarean (10% of controls). NAIS is multifactorial in origin and shares risk factors in common with HIE. Intrapartum eventsmay play a more significant role in the pathogenesis of NAIS than previously recognized.

Forty cases of twin reversed arterial perfusion sequence treated with radio frequency ablation using the multistep coagulation method: a single-center experience.

To report the pregnancy outcomes of patients with twin reversed arterial perfusion (TRAP) sequence treated by radiofrequency ablation (RFA). This was a retrospective study of TRAP sequences treated in a single center between March 2002 and February 2015. Forty patients underwent RFA with expandable tines through a multistep coagulation method between 15 and 26 gestational weeks. The primary outcome was neonatal survival to discharge. The overall survival of the pump twin was 85%. The survival rates in monochorionic-monoamniotic (MCMA) pregnancies and monochorionic-diamniotic pregnancies were 66.7% (4/6) and 87.9% (29/33), respectively. One triplet was treated successfully and delivered at 36 weeks of gestation. One of 35 live births (2.9%) had preterm premature rupture of membranes less than 34 weeks, resulting in infant death. In five intrauterine pump twin deaths, two cases were MCMA twins with cord entanglement, and three cases were MCDA twins with acardius anceps. Our study supports the effectiveness of RFA for TRAP sequence after 15 weeks of gestation. The presence of MCMA twins or acardius anceps is associated with a high risk of pump twin death after RFA. © 2016 John Wiley & Sons, Ltd.

Severe antenatal strangulation and sudden fetal death occurs in term: case report

The authors report a case of a sudden antenatal death, by severe strangulation, unlikely related in a term pregnancy; multiple loops of nuchal umbilical cord (UC) (ten), rarely describe in literature, were observed around the fetal neck. The in utero fetal death (IFD) was suspected by the non-attendance of fetal movements and confirmed by US scan. The tight nuchal cord around the neck (tCAN) diagnostic was made during caesarean delivery, as it was not discovered in pregnancy US scan monitoring nor in the US scan made in emergency. The newborn examination shows severe fetal strangulation by the presence of many spires of a too long UC (1.50 m). Autopsy was not been accepted by the family. Through this reported case the authors wanted to show the difficulties of its diagnosis in less developed Sub-Saharan country were US scan practice is not usual.

ISUOG Practice Guidelines: role of ultrasound in twin pregnancy.

ISUOG Practice Guidelines: role of ultrasound in twin pregnancy.

A rare case of six loops of nuchal cord

Nuchal cord is defined as ≥360° wrapping of the umbilical cord around the fetal neck. Despite good prognosis in majority of cases, nuchal cord may be associated with variable fetal heart rate deceleration, decreased fetal movements, fetal distress& even intrauterine fetal demise. We present a primigravida woman, who delivered a healthy male baby with five loops of cord around neck. A 26 years old primigravida woman presented with 38 weeks of pregnancy. She had hydramnios, fibroid complicating pregnancy with breech presentation. At the time of delivery of the head it was observed that the baby had five loops of cords around the neck & there was no knot in the cord. Baby cried immediately after birth and had good tone & activity. Risk factors for a nuchal cord include Long umbilical cord length, baby being large for gestational age, Multiple gestation pregnancies, Nutritional deficiencies affecting the structure and protective barrier of the umbilical cord, hydramnios, Abnormal fetal presentation during delivery, such as breech or shoulder presentation. Sensitivity of ultrasound diagnosis of a nuchal cord prior to induction of labour at term is low around 37.5%. Colour doppler has a senstivity of 60% to 95% with a false positive rate of 19% in diagnosis.Our patient was monitored with regular biophysical profiles, non-stress tests & Doppler assessment of the umbilical artery hence delivered a healthy baby.

Prenatal diagnosis of placenta and umbilical cord pathologies by three-dimensional ultrasound: pictorial essay.

The authors present their experience in prenatal diagnosis of placental and umbilical cord pathologies, using three-dimensional ultrasound (3DUS) in the rendering and tomography ultrasound imaging (TUI) modes, associated with color Doppler in some cases. Cases of placenta accreta/placenta previa, circumvallate placenta, succenturiate lobe, true knot of the umbilical cord, nuchal cord, and marginal/velamentous umbilical cord insertion are presented. 3DUS can contribute to improve the accuracy of prenatal diagnosis of placenta and umbilical cord pathologies.

Maternal and perinatal outcomes by mode of delivery in mainland China: a cross-sectional study

BackgroundA perception that caesarean delivery is safer than vaginal delivery might be causing China's high rates of caesarean delivery. The aim of this study was to analyse maternal and perinatal outcomes by mode of delivery to elucidate the relative short-term safety of delivery choices. MethodsWe did a cross-sectional analysis of all deliveries from 2011 from 39 hospitals in three regions of Mainland China. Univariate and multilevel analysis were performed to study the association between the mode of delivery and the maternal and neonatal outcome. In the multivariate analysis, risks of maternal and neonatal outcomes associated with delivery outcomes were presented by adjusted odds ratios (OR) with corresponding 95% CIs. Maternal outcomes included postpartum haemorrhage, maternal death, combined severe outcomes (maternal death, transfusion, hysterectomy), and perinatal outcomes included neonatal death, perinatal death, ICU admission, 5 min Apgar less than 4, respiratory distress syndrome, infection, hypoxic ischaemic encephalopathy, birth trauma, and meconium aspiration. Ethical approval was not required with use of this pre-existing de-identified database. FindingsOf 109 806 deliveries, 59 561 (54%) were by caesarean delivery, 19 428 (18%) were antepartum non-indicated, 19 339 (18%) were antepartum indicated, 3251 (3%) were intrapartum non-indicated, and 17 543 (16%) were intrapartum indicated. 22 679 (38%) of caesarean deliveries were non-indicated, including 13 792 (23%) caesareans on maternal request, and 8887 (16%) caesareans for antepartum cephalo-pelvic disproportion, maternal age of more than 35 years, myopia, isolated nuchal cord, or precious baby (defined as in-vitro pregnancy or poor obstetric history such as prior fetal death, neonatal death, or anomaly). Compared with spontaneous vaginal delivery, antepartum non-indicated caesarean delivery had lower rates of postpartum haemorrhage (OR 0·76 [95% CI 0·68–0·75]), and we found no significant difference in rates of maternal death or combined severe outcomes (death, transfusion, hysterectomy). Labours resulting in intrapartum caesarean delivery had a higher rate of postpartum haemorrhage than vaginal delivery (1·6 [1·46–1·75]). Compared with spontaneous vaginal delivery, antepartum non-indicated caesarean delivery had low rates of neonatal death (0·21 [0·11–0·41]), perinatal death (0·15 [0·09–0·26]), admission to ICU (0·54 [0·42–0·69]), 5 min apgar of less than four (0·18 [0·9–0·36]), and respiratory distress syndrome (0·36, 0·22–0·59). Rates of infection, hypoxic ischaemic encephalopathy, birth trauma, or meconium aspiration did not differ between births by spontaneous vaginal delivery and antepartum non-indicated caesarean delivery. Labours resulting in intrapartum caesarean delivery had low rates of neonatal death (0·15 [0·09–0·28]), perinatal death (0·08 [0·05–0·11]), and 5 min apgar of less than four (0·13 [0·1–0·19]) but increased rates of admission to ICU (1·29 [1·10–1·52]), respiratory distress syndrome (1·42 [1·11–1·82]), infection (2·33 [1·32–4·10]), and meconium aspiration (2·23 [1·3–3·09]) than delivery by spontaneous vaginal delivery. InterpretationScheduled non-indicated caesarean delivery was associated with short-term maternal and perinatal outcomes that were as safe or safer than scheduled vaginal delivery or labour resulting in caesarean delivery. This safety profile might change as more repeat cesarean deliveries are performed given the liberalisation of the one-child policy in 2013, allowing more women to have a second pregnancy. FundingHealth industry special funds for Public Benefit Research Foundation from the Ministry of Health, China (grant number 201002013).

EP01.11: Pregnant women's view on the impact of nuchal cord on fetal outcomes in Nigeria

EP01.11: Pregnant women's view on the impact of nuchal cord on fetal outcomes in Nigeria

Managing Monoamniotic Twin Pregnancies

Monoamniotic twins comprise a rare but important subset of twins at risk of unique and serious complications, placing them at the highest risk of perinatal mortality of all twin gestations. In addition to risks faced by all twins (prematurity, selective growth restriction), all monochorionic twins (twin-twin transfusion syndrome), and all monozygotic twins (congenital anomalies), monoamniotic twins face the unique risk of cord entanglement. Accordingly, early diagnosis, screening for fetal anomalies, surveillance for twin-twin transfusion syndrome, decisions related to monitoring after viability, and timing and route of delivery are all critical. Herein, we present recommendations for optimal management.

Перинатальні фактори ризику гіпоксично-ішемічної енцефалопатії у доношених новонароджених із нормальною та низькою до терміну гестації масою тіла

На базі відділення патології новонароджених обласної дитячої клінічної лікарні м. Чернівців обстежено 41 доношену дитину, хвору на гіпоксично-ішемічну енцефалопатію, з метою вивчення перинатальних факторів ризику захворювання залежно від маси тіла при народженні. Встановлено, що основними предикторами розвитку гіпоксично-ішемічної енцефалопатії у маловагових до терміну гестації новонароджених є: проживання матерів у міських поселеннях (46,2 %); наявність хронічної патології (анемії, захворювань щитоподібної залози) у матерів під час вагітності (46,6 %); супутні вроджені аномалії розвитку у третини (30,8 %) новонароджених; розвиток респіраторних порушень при народженні, що потребували проведення штучної вентиляції легень (61,5 %); проблеми вигодовування новонароджених (61,5 %). Гіпоксично-ішемічному ураженню центральної нервової системи у доношених новонароджених із нормальною відносно терміну гестації масою тіла передували: патологічний перебіг інтранатального періоду (розвиток дистресу плода в пологах унаслідок обвиття пуповиною у чверті випадків і патологічний перебіг пологів у третині (32,1 %) спостережень), що асоціював із народженням третини малюків в асфіксії (констеляція Апгар-тесту на 1-й хвилині ≤ 4 бали), яка часто призводила до розвитку кардіогенних ускладнень (28,6 %), поліорганної недостатності (14,3 %) і судомного синдрому (17,9 %).

LA CARDIOTOCOGRAFIA EN EL DIAGNOSTICO DE PATOLOGIA FUNICULAR

Se estudiaron los trazados de los monitoreos electrónicos de 153 gestantes con más de 30 semanas de embarazo, que fueron monitorizadas en la Unidad de Fisiología Obstétrica (UFO) del Hospital Maternidad de Lima, del Instituto Nacional Materno Infantil (INAMI) , para ver la existencia o no, de desaceleraciones variables y luego del parto comprobar la existencia de circulares del cordón umbilical en el recién nacido, con el fin de establecer la bondad del método diagnóstico. La presencia de 6 embarazos gemelares dio un total de 159 RN. En 38 de los 159 casos (23.3%) se encontraron 1 a 2 circulares de cordón umbilical al cuello o cuerpo. El Valor predictivo Negativo y la Especificidad del monitoreo, fueron altas (80.2% y 82.1% respectivamente). El valor Predictivo Positivo (36.4%) y la Sensibilidad del método diagnóstico (32.4%), fueron menores para las circulares. En los casos que hubo ausencia de desaceleraciones variables en los trazados, aún en casos en que hubo circular de cordón, el Apgar en el 96% de los RN fué igual o mayor de 7 al minuto del nacimiento. Puede considerarse que la cardiotocografía es un método de alta especificidad para negar la existencia de circulares de cordón y la negatividad del test no stressante es un buen predictor del bienestar fetal y del RN.

Severe Pancreatitis Exacerbation in a Perinatal Patient with Severe Preeclampsia

<h2>Poster Presentation</h2><h3>Background</h3> Pancreatitis in pregnancy is rare, and when complicated, mortality may exceed 10%. The subject of this case report also had severe preeclampsia, which stimulated discussion of the new guidelines from the Task Force on Hypertension in Pregnancy. This poster presentation will provide education about a rare condition and also review important points in the hypertension guidelines. <h3>Case</h3> The woman presented at 39 weeks gestation with abdominal pain, nausea, and vomiting but no scotoma or headache. Her blood pressure was 180–190/110–120. Labs were unremarkable, except for lipase, which was >4000 (normal 20–300). Prior to pregnancy her lipase was 9500, and pancreatectomy and islet cell transplantation were recommended, but she did not follow up. Instead, the woman had been using narcotics daily at home via a peripherally inserted central catheter (PICC). She was treated for preeclampsia with antihypertensives and magnesium sulfate. Consults were ordered with pain management, surgery, gastroenterology, maternal‐fetal medicine (MFM), and neonatology. The attending physician on call wanted to perform an emergency cesarean, but MFM recommended stabilization, and the surgery consult concurred. A male was born with a tight nuchal cord, was intubated, and was transported to the neonatal intensive care unit (NICU). The woman's postpartum course consisted primarily of nutrition support and pain management, but on postpartum Day 3 she needed a transfusion due to hemoglobin of 6.1. On Day 6, creatinine levels rose to 1.7 and her blood pressure became elevated again, so a nephrology consult was added. On Day 7, she developed a headache and 3+ pretibial edema, so magnesium sulfate was restarted. The newborn underwent body cooling due to hypoxic ischemic encephalopathy but was discharged at 12 days of life in stable condition. The woman was finally discharged on postpartum Day 15, with oral analgesics and on total parenteral nutrition. She was to follow up with the same specialists who recommended the pancreatectomy. <h3>Conclusion</h3> Pancreatitis is an inflammatory state that can cause respiratory failure, renal failure, and cardiac complications due to the pancreatic enzymes being released into the circulation. Treatment is to alleviate the inflammation and symptoms. Perinatal nurses need to know that a more typically seen condition in pregnancy‐gallbladder disease can precipitate pancreatitis. Two points that stood out in this scenario were the insistence on stabilization of the woman prior to cesarean, which is always recommended in the literature but not always practiced. Second, magnesium sulfate was restarted because of an earnest attempt at our institution to follow the taskforce guidelines.

Experience of fetoscopic laser photocoagulation and cord transection for twin-reversed arterial perfusion sequence.

The purpose of this study was to evaluate the usefulness of fetoscopic laser photocoagulation of placental communicating vessels or umbilical cord for twin-reversed arterial perfusion (TRAP) sequence. We report a retrospective case series of all cases of TRAP sequence identified from 2006 to 2014 at out institutions. Fetoscopic laser photocoagulation of placental arterioarterial and venovenous anastomoses was performed in diamniotic twins, and in cases of monoamniotic twins we performed laser photocoagulation and transection of the umbilical cord of the acardiac twin to prevent cord entanglement. Pregnancy and perinatal outcomes were estimated. Ten cases were included in the study. The median gestational age at procedure was 21.3 weeks (range, 16.7-27.3 weeks). All cases completed the procedure. Two cases were treated with laser photocoagulation and transection of the umbilical cord of the acardiac twin. No major immediate complications were noted. Preterm rupture of membranes occurred in four cases (40%). One case resulted in miscarriage. The other fetuses were delivered alive. Median gestational age at delivery was 35.4 weeks (range, 25.6-42.0 weeks). Median interval of treatment to delivery was 85 days (range, 43-153 days). Five out four infants were delivered preterm. The overall neonatal survival was 9/10. This case series demonstrated favorable outcome, and fetoscopic laser photocoagulation seems to be a useful treatment for TRAP sequence. In particular, transection of the umbilical cord is effective to prevent cord entanglement of monoamniotic twins.

Validación del ultrasonido como prueba diagnóstica para circular de cordón durante el trabajo de parto. Estudio preliminar

OBJETIVO: Comparar la capacidad diagnóstica del ultrasonido abdominal en la detección de circular de cordón. DISEÑO: Estudio clínico analítico. MATERIAL Y MÉTODOS: Se estudió 57 pacientes con gestación a término y en trabajo de parto. Previo, a su hospitalización, a cada paciente se le efectuó ultrasonografía abdominal obstétrica (USO), para identificar la presencia o ausencia de circular de cordón, lo que fue comparado con los hallazgos al momento del parto o la cesárea (estándar de oro). RESULTADOS: La prevalencia de circular de cordón en embarazos a término diagnosticados por USO fue 21,1%. La sensibilidad de la prueba fue 80% (IC 95%, 72,7 a 87,3), la especificidad 96% (IC 95%, 92,9 a 99,1) y los valores predictivos, positivos y negativos fueron 87% y 94%, respectivamente. La exactitud de la prueba fue de 92%. La Xi cuadrada de McNemar para el análisis de las discordancias entre las dos pruebas no fue significativo (p=0,7236). Las razones de verosimilitud para resultados positivos y negativos fueron 20 y 0,20, respectivamente. CONCLUSIONES: El estudio ultrasonográfico durante el trabajo de parto para el diagnóstico de circular de cordón es altamente específico (96%), la cual le permite ser utilizado como prueba de tamizaje para identificar los embarazos de riesgo alto con circular de cordón.

Diagnóstico prenatal ultrasonográfico de circular de cordón con repercusión asfíctica fetal

OBJETIVO: Demostrar que la medición ultrasonográfica transabdominal anteparto de la profundidad y amplitud de la muesca del cordón y de la distancia perpendicular del punto medio de la muesca a la calota fetal puede predecir la presencia de asfixia por circular de cordón al cuello en fetos únicos a término con presentación de vértice. MATERIALES Y MÉTODOS: En el Instituto Especializado Materno Perinatal, entre diciembre 2002 y febrero 2003, se realizó un estudio observacional analítico de tipo casos y controles en gestantes con fetos vivos a término en presentación de vértice, sin malformaciones congénitas. Se comparó 120 gestantes con sospecha ultrasonográfica prenatal de circular de cordón al cuello fetal, confirmada al nacimiento dentro de las 48 horas del examen, con 135 gestantes sin circular de cordón. RESULTADOS: Las medias de amplitud y profundidad de la muesca del cordón umbilical fueron 23,1 mm ± 5,9 DE y 8,3 mm ± 2,9 DE), respectivamente. La medida de la distancia perpendicular del punto medio de la muesca a la calota fetal fue 12,1 ± 4.8 mm DE. La media del pH fue 7,23 ± 0,45 DE en pacientes con sospecha ecográfica de circular de cordón confirmada al nacimiento y 7,24 ± 0,72 DE en pacientes sin circular. No se encontró diferencia estadísticamente significativa (p&gt;0,05). Existió relación entre líquido amniótico meconial al nacimiento y la presencia de circular de cordón; p=0,000001 (RR=2,81;IC al 95% 1,78 a 44,4) y entre el valor del pH ± 7,20 y la presencia de circular de cordón, con diferencia estadísticamente significativa; p=0,002 (RR=11,25; IC al 95% 1,46 a 86,6). CONCLUSIONES: La profundidad de la muesca del cordón umbilical se relacionó con pH ± 7,20. Para encontrar un pH±7,20, la profundidad de la muesca mínima debe ser 7,55 mm.

Cesarean Delivery in China

INTRODUCTION: Since the 1990s, China's cesarean delivery rate has risen from less than 10% to one of the highest cesarean delivery rates in the world, estimated at around 50%. The rate of cesarean delivery without medical indication has increased from 0.6% to 21–27%. The objective of this study was to analyze the cesarean deliveries without indication. METHODS: A large retrospective review of discharge summaries and chart review of all deliveries in 39 hospitals in three geographic regions of Mainland China from January 1 to December 31, 2011, was evaluated for cesarean delivery rates and indications for delivery. RESULTS: A survey of a total of 112,138 women at delivery with gestation ages greater than 24 weeks was analyzed. The cesarean delivery rate was 54.5% (61,084), with regional variation from 51.1% to 65.6%. Only 7.8% of cesarean deliveries were repeat. Sixty-five percent of the cesarean deliveries were scheduled and performed before labor. Overall, 20.9% of deliveries or 38.4% of cesarean deliveries were performed without internationally recognized medical indications, with the highest rate (52% of cesarean deliveries) in central China. Of the cesarean deliveries without indication, 85% were performed before labor. Maternal request accounted for 57% of cesarean deliveries without indication. Other physician diagnoses accounted for the remainder of nonindicated cesarean deliveries, including antepartum determination of cephalopelvic disproportion (20.2%), age older than 35 years (11.2%), “precious baby” (3.2%), nuchal cord without fetal distress (1.45%), and myopia (1%). CONCLUSION: Efforts to reduce cesarean delivery rates in China may focus on scheduled cesarean deliveries without indication, but relative safety of delivery choices needs further analysis.

Planned early delivery versus expectant management for monoamniotic twins.

Monoamniotic twin pregnancies are formed when a single egg is fertilised and the resulting inner cell mass splits to form twins sharing the same amniotic sac. This condition is rare and affects about one in 10,000 pregnancies overall. Monoamniotic twin pregnancies are susceptible to complications including cord entanglement, increased congenital anomalies, intrauterine growth restriction, twin-to-twin transfusion syndrome and increased perinatal mortality. All twin pregnancies also carry additional maternal risks including pre-eclampsia, anaemia, antepartum haemorrhage, postpartum haemorrhage and operative delivery.The optimal timing for the delivery of monoamniotic twins is not known. The options include 'planned early delivery' between 32 and 34 weeks, or alternatively awaiting spontaneous labour at least up until the usual time of planned delivery for other monochorionic twins (approximately 36 to 38 weeks' gestation), unless there is a specific indication for earlier delivery. To assess whether routine early delivery in monoamniotic twin pregnancies improves fetal, neonatal or maternal outcomes compared with 'expectant management'. Expectant management means awaiting spontaneous labour at least up until the usual time of planned delivery for other monochorionic twins (approximately 36 to 38 weeks' gestation in many centres), unless a specific indication for delivery occurs in the meantime, e.g. for non-reassuring antenatal testing. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015). Published and unpublished randomised controlled trials (including cluster-randomised trials) comparing outcomes for women and infants who were randomised to planned early delivery of a monoamniotic twin pregnancy with outcomes for women and infants who were randomised to either planned term delivery or expectant management. However, we did not identify any trials for inclusion in this review.Quasi-randomised controlled trials, trials published in abstract form only, and trials using a cross-over design are not eligible for inclusion in this review. No trials were identified by the search strategy. No trials were identified by the search strategy. Monoamniotic twins are rare, and there is insufficient randomised controlled evidence on which to draw strong conclusions about the best management. In their absence, we can refer to historical case series and expert consensus. Management plans should take into consideration the availability of high-quality neonatal care if early delivery is chosen. Women and their families should be involved in the decision making about these high-risk pregnancies.Ongoing, multicentre audits of maternal and perinatal outcomes for monoamniotic twins are needed in order to inform families and clinicians about up-to-date perinatal outcomes with contemporary obstetric practice. Research should consider the social and economic implications of planned interventions, as well as the perinatal outcomes.

Prenatal diagnosis and management of monoamniotic twins.

The purpose of this article is to investigate the perinatal outcomes of monoamniotic twins under current standards of prenatal management involving intensive fetal surveillance. The incidence of perinatal mortality in monoamniotic twins has fallen over the last 2 decades. Umbilical cord entanglement has long been considered one of the main causes of poor outcome among monoamniotic twins; however, new evidence shows that it appears to be less important than prematurity and congenital anomalies. If intensive fetal surveillance is provided, the risk of perinatal mortality is acceptably low regardless of setting. In uncomplicated monoamniotic twin pregnancies, delivery at around 33 weeks of gestation might reduce the risk of neonatal adverse events without increasing the risk of perinatal death. Perinatal outcome in monoamniotic twins improved if intensive fetal surveillance was performed under either outpatient or inpatient management. Planned delivery in uncomplicated monoamniotic twin pregnancies can be considered at around 33 weeks of gestation.

Early second trimester transvaginal ultrasound anomaly scan does not cause adverse perinatal outcome

ObjectiveDuring an early second-trimester transvaginal ultrasound anomaly scan, pressure is applied to the uterus, and the fetus is often rotated manually to allow scanning of its various organs. This study was designed to determine if performing a transvaginal ultrasound anomaly scan during the early second trimester of pregnancy is associated with adverse perinatal outcome or cord entanglement. MethodsDuring the 4.5year study period we prospectively collected cases of routine ultrasound scans at 14–17weeks gestation performed as anomaly screening, together with perinatal outcome. The study population consisted of 164 women who underwent a transvaginal approach, and the control population consisted of 224 women in which a transabdominal approach was used. Data on perinatal parameters was collected from delivery charts from the four local hospitals. ResultsThere were more operative deliveries (vaginal or Cesarean) in the transvaginal scan group (32% vs. 23%, p=0.05). However, on multiple logistic regression analysis vaginal scans were not associated with increased operative delivery rates with an adjusted odds ratio of 1.47 and a 95% confidence interval of 0.85–2.54. There were no other clinically significant differences in perinatal outcomes, or in cord entanglement. ConclusionsTransvaginal ultrasound anomaly scan conducted in the early second trimester of pregnancy is a safe procedure for the fetus.