Gestational Age In Twins Research Articles

Preterm birth or small for gestational age in a singleton pregnancy and risk of recurrence in a subsequent twin pregnancy.

To evaluate whether a history of preterm birth or small for gestational age (SGA) in a singleton pregnancy is associated with an increased risk of recurrence of the same condition in a subsequent twin pregnancy. Retrospective cohort study of twin pregnancies delivered in one maternal-fetal medicine practice from 2005 to 2014. Patients with a history of singleton preterm birth at less than 37 weeks of gestation were compared with patients with a history of singleton term birth and nulliparous patients. A similar analysis was performed for a history of SGA (birth weight less than 10%). Six hundred forty-seven twin pregnancies were included. The prior singleton gestational age at delivery was significantly positively correlated with the twin gestational age at delivery (P<.001), and the prior singleton birth weight was significantly positively correlated with the birth weight of the larger twin (P<.001) and the smaller twin (P<.001). The rate of twin preterm birth before 32 weeks of gestation was 3.5% in patients with a prior term birth, 9.2% in nulliparous patients, and 26% in patients with a prior preterm birth (P<.001). The rate of SGA in patients with a prior birth not complicated by SGA was 42.1%, in nulliparous women it was 54.4%, and in patients with a history of SGA it was 65.2% (P=.007). On regression analysis, prior preterm birth and SGA of a singleton pregnancy were independently associated with recurrence of the same condition in a subsequent twin pregnancy. Prior preterm birth and SGA in a singleton pregnancy increase the risk of the same condition in a subsequent twin pregnancy. We postulate that the extrinsic mechanism responsible for the pathophysiology of adverse outcomes in twin pregnancies overlaps with that in singleton pregnancies.

Active management of selective intrauterine growth restriction with abnormal Doppler in monochorionic diamniotic twin pregnancies diagnosed in the second trimester of pregnancy

This study aims to compare outcomes of active management of monochorionic diamniotic twin pregnancies complicated with severe intrauterine growth restriction (IUGR) of one twin before 24 weeks with continuous or intermittent absent or reversed end-diastolic flow (AREDF) in the umbilical artery, with or without twin-to-twin transfusion syndrome (TTTS). This study is a retrospective comparison of 45 consecutive cases of severe selective IUGR (s-IUGR) defined as an estimated fetal weight at or below the fifth centile with a >25% weight discordance and AREDF in the umbilical artery before 24 weeks and 166 consecutive cases of TTTS stage III, with AREDF in the donor (TTTS3D) and also with s-IUGR. These were treated by either selective laser photocoagulation of chorionic vessels (SLPCV) or cord coagulation (CC). The 166 cases of TTTS3D were treated by SLPCV, whereas 23 and 22 cases of s-IUGR were treated by SLPCV and CC, respectively. Overall survival was 52.17% or 45.45% in s-IUGR treated by SLPCV or CC, respectively, and 48.49% in TTTS3D. The survival of appropriately grown for gestational age (AGA) twins following CC (90.9%) was higher than that following SLPCV in s-IUGR (74%) or in recipient twins of TTTS3D (55.42%) (p = 0.001). Survival of the IUGR twin was 30% and 41.56% with SLPCV in s-IUGR and TTTS3D, respectively. Active management of severe IUGR with AREDF in the umbilical artery seems beneficial. Survival rates with SLPCV were similar in s-IUGR and TTTS3D. However, there was a trend for higher survival rates in the AGA twin for CC. The choice of the technique should be driven by objective counseling on survival of both IUGR and AGA twins and therefore by the utility-based ethical values expressed by the pregnant woman.

Study on the relevant factors of neonatal hypoglycemia

Objective To investigate the relevant factors of neonatal hypoglycemia and the clinical features,to provide the basis for clinical diagnosis and treatment.Methods All 80 newborns with hypoglycemia in department of neonatal intensive care unit (NICU) of Jiangmem Central Hospital were consecutively recruited from 2010 to 2012.Other 80 orthoglycemic newborns in NICU were included in the study to characterize their clinical features,perinatal condition,birth condition and common neonatal complications.Laboratory tests included blood glucose.Results The relevant factors of neonatal hypoglycemia were hypertensive disorders in pregnancy,gestational diabetes mellitus,preterrm infant,Small for gestational age infant,twins or multiple births,day-old ≤ 3 days,low birth weight infant and asphyxia of newborn.Concltsions For the newborn with risk factors,they should be monitored with blood glucose and intervened early,to prevent neonatal hypoglycemia and incidence and reoccurrence of brain injury. Key words: Newborn; Hypoglycemia; Brain injury

Placenta Share Discordance and Umbilical Artery Doppler Change After Antenatal Betamethasone Administration in Monochorionic Twins With Selective Intrauterine Growth Restriction: Is There a Link?

This study was designed to evaluate the degree of placenta share discordance in relation to the betamethasone-induced return of positive end-diastolic flow in monochorionic twin pregnancies with selective intrauterine growth restriction (sIUGR) and abnormal umbilical artery Doppler. Monochorionic twins with sIUGR was defined as one twin having an estimated fetal weight below the 10th percentile combined with an estimated fetal weight discordance >25%. The umbilical artery Doppler directly prior to (D0) and 24 hours (D1) and 48 hours (D2) after the first dose of betamethasone administration was recorded. The estimated individual placental weight in monochorionic twins was obtained by cutting the placenta along the vascular equator into two territories; the placenta share discordance was calculated as [(estimated individual placental weight of appropriated for gestational age twin- estimated individual placental weight of growth restricted twin)/estimated individual placental weight of appropriated for gestational age twin] × 100%. Six (23.1%) of the 26 included cases achieved betamethasone-induced return of positive umbilical artery end-diastolic flow. The difference of placenta share discordance and birth weight discordance were not significantly different between twins with and without betamethasone-induced return of positive umbilical artery end-diastolic flow. Thus, according to our study results, it was proposed that although the placenta share discordance correlated with the abnormal umbilical artery Doppler in the IUGR fetus in monochorionic twin, the betamethasone-induced return of positive umbilical artery end-diastolic flow, however, did not reveal the similar relationship with the severity of placenta share discordance.

Non anthrax bacillus species meningo-encephalitis with diabetes insipidus in a preterm infant

Bacillus cereus, a Gram-positive, aerobic spore forming rod, is ubiquitous. Isolation ofBacillus cereus from a normally sterile site (i.e. blood or cerebrospinal fluid) is often disregarded by clinicians as a specimen contamination. We report a case of a 32-week small for gestational age twin preterm infant, of 839 grams birth weight, with non-anthrax bacillus species meningitis. There have been very few reports of meningitis and brain abscesses with these bacteria in low risk preterm infants. Our case was unusual with the development of central diabetes insipidus following bacillus meningoencephalitis and brain abscess. It draws attention to the severe morbidity caused by a relatively benign and usually ignored organism.

Language assessment of non‐handicapped twins at 5 years of age

The aim of the present study was to determine language levels in twins and singletons born after at least 34 weeks gestation and without identifiable neurological abnormality and to evaluate whether in vitro fertilization (IVF) affects language development in twin pregnancies. A prospective study of a large cohort of all children born between 1 January 2001 and 31 December 2003 was carried out at Gazi University Hospital. All live-born twin pairs in which both twins survived were identified, and a comparable sample of families with pairs of singletons were chosen. The Stanford-Binet Intelligence Scale Form and the translated Turkish form of the Peabody Picture Vocabulary Test were completed at 60 months. Even after excluding the most premature twins and those with diagnosable neurological damage, twins performed worse than singletons on language development tests. Twin girls had better scores than twin boys. A statistically significant difference was found between the scores of term and preterm twins. No significant difference was noted when compared according to birth order. Appropriate for gestational age (AGA) twins did better than small for gestational age (SGA) twins in the test scores. All twin girls did not differ from singleton girls, but all twin boys performed worse than singleton boys. Term twins had similar results with term singletons, but preterm twins had lower scores than preterm singletons. SGA singletons had better scores than SGA twins, while AGA twins and singletons did not differ. When the children were compared with regard to method of conception, IVF children had significantly lower scores on the tests than those in the spontaneous conception group. It is hoped that the present findings could lead to a more precise assessment of children for speech impairment and, above all, to more efficient preventive intervention. Whatever mechanisms are involved, the present results indicate that twins born as a result of IVF, are at a disadvantage in terms of language development in comparison with spontaneously conceived twins.

Kangaroo Care and Behavioral and Physiologic Pain Responses in Very-Low-Birth-Weight Twins: A Case Study

The purpose of this case study was to describe pain responses in three study conditions: longer (30 minutes) kangaroo care (KC) before and throughout heel stick (KC30), shorter (15 minutes) KC before and throughout heel stick (KC15), and incubator care throughout heel stick (IC) in 28-week gestational age twins. Pain responses were measured by crying time, Preterm Infant Pain Profile (PIPP), and heart rate variability indexes, including low-frequency power (LF, representing sympathetic activity), high-frequency power (HF, parasympathetic activity), and LF/HF ratio (sympathetic-parasympathetic balance). Both twins cried more and had higher PIPP pain scores and tachycardia during heel stick in the IC condition. Infant B had an incident of apnea and tachycardia by the end of the heel stick and a bradycardia episode during recovery in the IC condition. The twins had lower LF/HF ratios (better autonomic nervous system balance) during recovery in both longer and shorter KC conditions compared with the IC condition. Infant B had difficulty returning to LF/HF ratio baseline level after the painful procedure in the IC condition. These data suggest that both longer and shorter KC before and throughout painful procedures can be helpful in reducing behavioral and physiologic pain responses in preterm infants.

Neuroinvasive Salmonellosis in a Level III Neonatal Intensive Care Unit

Thirty-week gestational age twins were born in Hospital A and admitted to the Level III NICU. On day of life (DOL) #20, Twin B began to display signs and symptoms of sepsis. Blood and CSF cultures were obtained and both specimens were culture positive for Salmonella species. At the time of illness onset in Twin B, Twin A was in the Level II NICU without any signs and symptoms of infection. Stool cultures were obtained on Twin A to determine if the patient was asymptomatically colonized. On DOL #23, the stool sample tested positive for Salmonella species in Twin A. Due to evidence of Salmonella species in both twins, it was determined that a shared exposure source was likely.

Perinatal and Neonatal Outcomes of Twin Pregnancies in Turkey

This study was conducted for the purpose of assessing, in the light of results of other research carried out in the present researchers' clinic and in Turkey, the status of twin pregnancies in Turkey, the incidence of twin births, perinatal and mortality rates associated with twin pregnancies, and the problems experienced in Turkey in cases of multiple and twin pregnancies. The outcomes of twin births that occurred at the researchers' clinic during the period 2001-2009 were studied retrospectively. Seventeen studies conducted in Turkey on multiple and twin pregnancies during the years 1991-2010 were included in the study. It was observed that the mean multiple pregnancy rate in Turkey is 1.9% and the mean twin birth rate is 1.7%. It was also observed that a large majority (80-97.3%) of multiple pregnancies in Turkey are twin pregnancies. It was noted from Turkish literature that the mean gestational age of twins at birth varies between 33-36.2 weeks and that mean birthweights are 2065-2327 grams for the first-born twin and 1887-2262 grams for the second-born. These findings were observed to be lower than what is indicated in the literature. Perinatal and neonatal mortality, at 58-156/1000 and 40-98/1000 respectively, were seen to be higher than in the literature. It can be seen that preterm birth rates for twin pregnancies in Turkey are higher than what is indicated in the literature and that prenatal and neonatal mortality rates are also similarly higher.

Second‐trimester assessment of gestational age in twins: validation of singleton biometry charts

To determine the accuracy of dating twin pregnancies, of between 16 and 26 weeks' gestation, using singleton head circumference (HC) formulae. This was a retrospective study of 269 singleton and 119 twin non-anomalous pregnancies conceived by in-vitro fertilization (IVF) with a known embryo transfer date. Fetal ultrasound biometry data for HC, obtained using different formulae, were compared with expected fetal HC size for gestation calculated from the date of conception. Similar comparisons were undertaken for femur length (FL) and for transverse cerebellar diameter. The mean differences in HC between observed ultrasound measurements and those expected from the IVF history were small (1-4 mm) and within the measurement error for both singletons and twins for all formulae. All measurements from the larger and the smaller twins straddled those of singletons, regardless of biometry and formula used. Negative skewing of FL measurements in the smaller twin suggests that fetal growth restriction may occur at this gestation and supports the practice of dating using the HC of the larger twin. Singleton pregnancy HC charts can be used to date reliably twin pregnancies. The data of the study also suggest that the HC of the larger twin is the most reliable measurement for use in dating.

Increasing rates of preterm twin births coincide with improving twin pair survival

To examine trends in twin gestational age over time, with adjustment for potential confounding factors, and to assess twin pair mortality and respiratory support over time. Rates of preterm births, respiratory support, and neonatal mortality were calculated for 21,569 twin pairs born from 1980 to 2005 in Washington State, using birth certificate and hospital discharge data. Fetal death risks were determined on a "per-pair-at-risk" basis. While the proportion of twins born at 24-31 weeks remained stable at 8%, the proportion born at 32-36 weeks increased from 28% to 48%, and the proportion at 37-42 weeks declined from 64% to 44% (P<0.0001). Controlling individually for a variety of factors, such as maternal age, race, parity, and mode of delivery did not diminish the highly significant trend of increasing preterm births (P<0.0001 for each). Twin pair neonatal mortality decreased significantly through time (P<0.0001); however, the rate of pairs with one or both infants requiring oxygen or ventilation increased significantly through time (P<0.0001). Fetal death risks declined for term twins. The proportion of twins born at 32-36 weeks' gestation has increased over time, along with requirement for respiratory support. Twin pair mortality decreased from 1980 to 2005.

Severity of prematurity risk in spontaneous and in vitro fertilization twins: does conception mode serve as a risk factor?

Because assisted reproductive technology (ART) contributes to world-wide increases in twin pregnancies, we retrospectively evaluated whether preterm twin gestations after ART are at higher risk for delivery at earlier gestational ages compared with naturally conceived twins. The evaluation of 204 dichorial twin pregnancies, 102 after natural conception and 102 after ART, matched for maternal age, demonstrated comparable severity of prematurity risk in both groups.

Triplet Infants with Birthweight ≤ 1250 Grams: How Well Do They Compare with Twin and Singleton Infants at 36 to 48 Months of Age?

The purpose of this study was to determine if triplet infants with birthweight < or = 1250 g were at increased risk of long-term disability compared with similar birthweight and gestational age singletons and twins. This was a retrospective cohort study of < or = 1250-g infants admitted to a regional neonatal intensive care unit from 1986 to 2001 with follow-up to 36 to 48 months corrected gestational age. Outcomes studied were cognitive ability, cerebral palsy, and neurosensory impairment at 36 to 48 months. Enrollment was 1717 infants: 59 triplets, 402 twins, and 1256 singletons. Triplet infants differed from twin or singleton infants because they were more likely to have older, married mothers (relative risk [RR] 3.62, 95% CI 1.31, 5.94), be products of assisted reproductive technology pregnancies (RR 29.59, 95% CI 13.97, 62.68), be exposed to antenatal steroids (RR 1.55, 95% CI 1.38, 1.75), and were all delivered by cesarean section. Triplet infants had lower risk of having intraventricular hemorrhage (RR 0.19, 95% CI 0.05, 0.75). The risk of cerebral palsy, cognitive delay, total major disability, or chronic lung disease was similar in triplet and twin infants compared with singleton infants. The lower risk of having intraventricular hemorrhage in triplet infants may have been due to the use of antenatal corticosteroids and cesarean section delivery.

Full Length Article

On January 14, 2006, at approximately 10 am, our service—Neonatal Emergency Transport Service of Liguria Region, Gaslini Children's Hospital, Genoa University, Italy—received a request for neonatal transport from Pontremoli, Tuscan Region, back to our neonatal intensive care unit (NICU). Unfortunately, our NICU had no available beds, so we decided to fly from Pontremoli to the NICU at Santa Chiara Hospital in Pisa. Pontremoli is a little village close to mountains on the way to the largest Italian plain, Padana plain, and to the city of Parma. The patients were micropreemie twins of uncertain gestational age (approximately 23–24 weeks).

Fetal transcerebellar diameter measurement for prediction of gestational age in twins

This study was undertaken to determine the accuracy of our previously published and prospectively validated institution-specific singleton transcerebellar diameter (TCD) nomogram in the prediction of gestational age (GA) in twin pregnancies. We further evaluated whether the prediction of GA in twin gestations using the singleton TCD nomogram differs between monochorionic and dichorionic twins. In our previously published studies, we retrospectively constructed a cross-sectional nomogram using TCD measurements in 24,026 well-dated, singleton fetuses, and prospectively validated the nomogram using 2,597 singleton fetuses. The current study comprised of 1,278 well-dated twins (19.6% monochorionic) seen in our ultrasound unit between August 1994 and May 2003, and the singleton TCD nomogram was validated in these twin gestations. The actual GA was subtracted from the GA predicted by the TCD nomogram and the concordance between actual and predicted GAs was assessed on the basis of the Pearson's correlation coefficient (r). This was performed separately for monochorionic and dichorionic twins. Concordance between the actual and predicted twin TCD measurements based on our previously published singleton TCD nomogram was high (Pearson's correlation, r = 0.95, P < .0001). Between 16 and 23 weeks' gestation, the predicted mean GA was within 6 days of actual GA. Between 24 and 30 weeks, the predicted mean GA was within 3 days, and at 32 weeks or more, the predicted mean GA was within 5 days of the actual GA. Prediction of GA based on the singleton TCD nomogram was equally accurate in both monochorionic and dichorionic twin gestations (P = .686). This study demonstrates that our previously validated singleton TCD nomogram is reliable and accurate in twins irrespective of placental chorionicity.

Sonographic dating of twin pregnancy using singleton data

Generally multiple births occur more frequently in Africans particularly in Nigeria where approximately 1 of every 22—35 deliveries are twins. Accurate knowledge of gestation age helps in the successful management of labour and care of the newborn baby in the neonatal period particularly in twins where premature delivery is common. In the assessment of gestational age in twin pregnancy two Biparietal diameters (BPD) are encountered and reported data concerning the use of singleton normogram to assess gestational age in twins is conflicting. Our center and many other ultrasound laboratories in this country assesses gestational age in twins using singleton derived BPD normograms. The accuracy of this practice has not been determined before this report. (excerpt)

Placental pathology and perinatal outcome associated with small for gestational age twins

To determine the differences in placental pathology between small for gestational age (SGA) twins and appropriate for gestational age (AGA) twins. The perinatal outcomes of these twins will also be described.

Neonatal outcome in discordant eutrophic twins:: Twin growth

Objective: To compare maternal characteristics and neonatal outcome in discordant twin gestations (DT) and concordant twin gestation (CT). Method: Maternal and neonatal data base of live twins >25 weeks’ gestation ( N=351 pairs) were reviewed for antepartum complications, labor beginning, mode of delivery, neonatal complications, malformations and perinatal mortality. The chi-squared analysis and Student t-tests were used to analyze the differences between discordant and concordant premature and term twin pairs, and appropriate for gestational age (AGA) twins, separately. Results: DT occurred in 15.1% of all twin pregnancies. In preterm and term DT there were significantly more elective cesareans. Growth discordance among preterm and term eutrophic twins was not connected with increased neonatal death or other complications, except higher incidence of early neurological signs in term DT. Conclusion: We strongly believed that prematurity and not discordant growth of eutrophic twins has important influence on neonatal outcome.

Fetal trans-cerebellar diameter measurement in predicting gestational age in twins

Fetal trans-cerebellar diameter measurement in predicting gestational age in twins

Challenges in Providing Developmentally Supportive Care: A Case Presentation

A developmentally supportive family-centered approach to care is extremely valuable for even the most critically ill infant. This case presentation of Martha, a severely small for gestational age twin born at 30 weeks gestation, highlights three major areas in which clinical care is enhanced through the integration of neurobehavioral observation: self-regulation, comfort, and family advocacy. The ethical principles of autonomy, beneficence, and integrity were relied upon to ensure her humane care. A developmentally supportive family-centered approach to care is extremely valuable for even the most critically ill infant. This case presentation of Martha, a severely small for gestational age twin born at 30 weeks gestation, highlights three major areas in which clinical care is enhanced through the integration of neurobehavioral observation: self-regulation, comfort, and family advocacy. The ethical principles of autonomy, beneficence, and integrity were relied upon to ensure her humane care.