Rates Of Intrauterine Fetal Demise Research Articles

Cost Effectiveness of Inpatient vs Outpatient Fetal Monitoring in Monochorionic-Monoamniotic Twin Gestations [30R

INTRODUCTION: To determine the cost-effectiveness of inpatient, continuous fetal monitoring versus outpatient management of monochorionic-monoamniotic (MCMA) twin gestations. METHODS: A decision-analytic model was created comparing continuous fetal monitoring versus outpatient daily nonstress test (NST) in a theoretical cohort of 250 MCMA pregnancies. The two arms were broken down based on gestational age beginning at 26 weeks gestation. All probabilities, utilities, and costs were derived from the literature. The primary outcome was the incremental cost per quality-adjusted life year (QALY). Rates of intrauterine fetal demise (IUFD), neonatal death, and cerebral palsy were also investigated. The cost-effectiveness threshold was set at $100,000 per QALY. Univariate and multivariate analyses were used to investigate model robustness. RESULTS: Inpatient continuous fetal monitoring results in improved neonatal outcomes and decreased cost. Compared to outpatient management, inpatient management would lead to 43 fewer cases of single IUFD, 7 fewer cases of double IUFD, 34 fewer neonatal deaths and 5 fewer neonates with cerebral palsy. Inpatient management improved effectiveness by 4.500 QALYs and saved $6.6 million (primary strategy improved outcomes). Inpatient management remained the dominant strategy as our estimated cost of per week was doubled to $8,325/week, and remained cost-effective up to five-times our estimated cost. CONCLUSION: Inpatient management is a cost-effective strategy for antenatal management of MCMA twin gestations that can reduce perinatal morbidity and mortality. Hospitalization of 5 patients would prevent an IUFD and 8 patients would prevent one neonatal death.

236: When to deliver monochorionic-monoamniotic twins undergoing inpatient continuous fetal monitoring -- A decision analysis

To determine the optimal gestational age of delivery for women undergoing inpatient management for monochorionic-monoamniotic (MCMA) twin gestations. We developed a decision-analytic model to determine the optimal timing of delivery for MCMA pregnancies undergoing continuous inpatient fetal monitoring beginning at 26 weeks. Gestational age at time of induction of labor ranged from 28 weeks to 34 weeks. Strategies involving expectant management accounted for the probabilities of intrauterine fetal demise (IUFD) and spontaneous delivery at each successive week. Outcomes examined included quality adjusted life years (QALYs), IUFD, cerebral palsy and neonatal death. All probabilities, utilities, and costs were derived from the literature. Univariate and multivariate analyses were used to investigate the robustness of the model results. In a theoretical cohort of 250 MCMA twin pregnancies, the lowest rates of neonatal death (2) and cerebral palsy (8) were associated with delivery at 34 weeks of gestation, whereas the rate of intrauterine fetal demise (6 total IUFD) was lowest at 28 weeks. The optimal strategy was delivery at 31 weeks of gestation, which led to the greatest QALYs (21,146). Delivery at 31 weeks would prevent 5 neonatal deaths and 15 cases of cerebral palsy compared to delivery at 28 weeks gestation, and would prevent 5 gestations affected by at least one stillbirth compared to delivery at 34 weeks. Sensitivity analysis demonstrated that 31 weeks of gestation remained the optimal strategy until risk of neonatal death in an inpatient setting was increased 2.5-fold or the risk of IUFD decreased by 35 percent. Delivering at 31 weeks gestation optimizes perinatal outcomes and total QALYs in MCMA twin gestations undergoing continuous inpatient management. A better understanding of the factors affecting the risk of IUFD would help guide the timing of delivery. The economic consequences of this strategy should be examined in future analyses.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The sFlt-1/PlGF ratio as a predictor for poor pregnancy and neonatal outcomes

Soluble fms-like tyrosine kinase receptor-1 (sFlt-1)/placental growth factor (PlGF) ratio has been studied extensively as a predictive marker for pre-eclampsia. However, its usefulness for predicting neonatal outcomes remains unknown. This study aimed to evaluate the association of sFlt-1/PlGF ratio with pregnancy outcomes, neonatal morbidities and short-term postnatal growth patterns in pregnant women and their babies. sFlt-1 and PlGF were measured in women with fetal intrauterine growth retardation (IUGR) or pre-eclampsia during gestational age (GA) of 16-36 weeks. These women were classified into high- and low-ratio groups with a sFlt-1/PlGF cut-off ratio of 85. The maternal and neonatal outcomes were retrospectively reviewed and compared between the two groups. A total of 25 pregnant women were recruited. Thirteen of them had a sFlt-1/PlGF ratio over 85 and twelve had a ratio of less than 85. The median duration from elevation of sFlt-1/PlGF to delivery was 4.5 weeks. Women in the high SFlt-1/PlGF ratio group had higher rates of intrauterine fetal demise (2/13 vs. 0/12) and early termination (1/13 vs. 0/12). The surviving offspring in this group had a higher incidence of preterm birth (GA: 31.4±2.9 weeks vs. 37.3±1.3 weeks, p<0.001), lower birth weight (1142±472g vs. 2311±236g, p<0.001), higher incidence of respiratory distress syndrome (6/10 vs. 0/12, p=0.002) and bronchopulmonary dysplasia (4/10 vs. 0/12, p=0.01). However, the percentile of body weight, height and head circumference at 28 days of age, 56 days of age and the corrected age of 6 months were comparable between groups. High sFlt-1/PlGF ratio in pregnant women is associated with poor pregnancy and neonatal outcomes. Therefore, the monitoring of sFlt-1/PlGF ratio in pregnant women with fetal IUGR and timely management for placenta-associated diseases are recommended.

Comparing Pregnancy Outcomes in Obese Diabetic and Obese Non Diabetic Women - A Retrospective Study [33C

INTRODUCTION: The purpose of this study was to compare the pregnancy outcomes between obese pregnant women with and without diabetes. METHODS: Data from labor and delivery records gathered between 1/1/2010 and 9/1/2013 were studied. Women with BMI greater than 40 and with either gestational or type I diabetes mellitus (DM) were included and separated into two groups: Obese with DM (Group 1) and Obese without DM (Group 2). RESULTS: Compared to group 2: 23% of Group 1 delivered prematurely vs 14% (P &lt; .05). Group 1 had cesarean deliveries 94% of the time vs 55% (P &lt; .05). NICU admissions occurred in 14% of Group 1 vs 8% (P &lt; .05) Neonates had a lower neonatal weight (3409 g ± 811 vs 3270 g ± 703 P &lt; .05), slightly lower Apgar scores (7.0 ± 2.0 vs 7.4 ± 1.6) and neonatal pH (7.23 ± 0.9 vs 7.26 ± 0.18) compared to Group 2. 14 % of Group 1 patients developed preeclampsia vs 8% (P &lt; .05). There was no significant difference in intrauterine fetal demise rates or shoulder dystocia rates between the two groups. CONCLUSION: In our study, women who are obese with DM had a higher risk of undergoing a cesarean section, delivering prematurely, developing preeclampsia, having a NICU admission, low fetal weight, low Apgar scores, and pH compared with obese women with no DM. This highlights the importance of recognizing and treating both obesity and DM in pregnancy as it has a large impact in both maternal and neonatal morbidity, as well as healthcare cost.

Cost-effectiveness of State Policies Banning Pregnancy Termination After Down Syndrome Diagnosis [28A

INTRODUCTION: Three states have passed recent laws prohibiting abortion in cases of fetal abnormality, most notably Down syndrome. Data to demonstrate the impact of these restrictions are lacking. Our study sought to evaluate the cost-effectiveness of these policies for pregnancies affected by Down syndrome. METHODS: A decision-analytic model was constructed using TreeAge 2016 software. Probabilities, costs and utilities were derived from the literature. Our primary outcome was cost, and our secondary outcomes included: cost per quality adjusted life year (QALY), procedure-related fetal loss (PRL), births affected by Down syndrome, intrauterine fetal demise (IUFD), and pregnancy termination. The cost-effectiveness threshold was set to $100,000 per QALY. Sensitivity analysis was performed to determine the robustness of the model. RESULTS: In a theoretical cohort of 159,936 women representing annual live births in states affected by this ban, this policy results in an additional annual cost of $340 million, which corresponds to $2,124 per pregnant woman. It also results in a greater number of live births affected by Down syndrome—223 compared to 124 with no policy. The policy would not be expected to change the rates of PRL and IUFD, while 99 fewer abortions would be expected with a decrease of 494 QALYs. CONCLUSION: Although policies restricting abortion in cases of a Down syndrome diagnosis result in fewer pregnancy terminations, they do lead to a greater economic burden. States should keep this in mind along with the ethical implications of these policies when deciding whether to enact them.

Effect of Chronic Kidney Disease Stage on Pregnancy Outcomes [10B

INTRODUCTION: This study aims to estimate the risk of adverse pregnancy outcomes in women with stages 1-5 chronic kidney disease (CKD). METHODS: This is a retrospective cohort study of 2,039,870 singleton, non-anomalous pregnancies recorded in the California Birth Registry from 2006 to 2010, of which 93 were complicated by CKD. 27 women were classified as stage 1 or 2, 21 as stage 3, 10 as stage 4 and 35 as stage 5 CKD. Outcomes included: preeclampsia, preterm delivery, intrauterine fetal demise (IUFD), small for gestational age neonates (SGA), and mode of delivery. Results were stratified by parity and analyzed with Pearson Chi-squared Tests and multivariable logistic regression analyses. RESULTS: Compared to the general population, all stages of CKD resulted in higher rates of adverse pregnancy outcomes. Women with stage 4 CKD experienced the highest rates of preeclampsia, preterm delivery, and IUFD (60.0%, 100.0%, and 10.0% respectively, all P. CONCLUSION: Although all stages of CKD are associated with worse pregnancy outcomes compared with the general population, there was a non-linear relationship between the severity of pregnancy outcomes and degree of kidney dysfunction. Those with more progressed disease on renal replacement therapy may account for the improved outcomes. Further research with a larger cohort is needed to better understand the impact of this chronic disease on pregnancy.

Trysomy 18: an update on prenatal diagnosis and management. A case report

Trisomy 18, also known as Edward’s syndrome, represents the second most common chromosomal abnormality after trisomy 21 or Down’s Syndrome, with an incidence of 1:6000 live births. However, the prevalence of the condition in the general population is significantly higher (i.e. 1:2000 pregnancies), and this is due mainly to the prenatal natural history of the condition which associates high rates of intrauterine fetal demise and pregnancy termination due to poor outcome. Although the prevalence of the condition has increased over the past 20 years mostly due to advanced maternal age at conception, the number of life births has decreased. Most obstetricians would agree that trisomy 18 is a lethal abnormality and would therefore counsel for termination of pregnancy leaving little, is any cases as evidence on the prenatal natural history of the condition. Interestingly, over the last couple of years, case report regarding infancy survival of children with trisomy 18 and their internet spread success-stories have begun to shift parental perception on the lethality of the condition. This case report of trisomy 18 is important because it presents the late third trimester diagnosis based on ultrasound features that are highly specific. It also reviews the few options of management available in a country were late termination is illegal.

Type-2 diabetes mellitus: does prenatal care affect outcomes?

Objective: To determine if prenatal care affects adverse perinatal outcomes in pregnant women with Type-2 diabetes mellitus (T2DM).Study design: This was a retrospective cohort study of pregnant women with pregestational diabetes mellitus pregnancies in the state of California between 1997 and 2006, using vital statistics data linked to birth certificates. Women were stratified by time of presentation to care and we compared those who presented in the first trimester, third trimester, and those who had no prenatal care prior to delivery. Perinatal outcomes looked at included: preeclampsia, macrosomia, preterm delivery, cesarean delivery, and intrauterine fetal demise (IUFD). The two groups were compared with chi-squared testing to determine statistical significance.Results: In women with pregestational diabetes those who presented at time of delivery had an 11.3% risk of IUFD compared to 0.9% in those who presented in the first trimester. There was also an increased rate of preterm birth in the late presentation cohort (29.4% at time of delivery versus 21.0% in the first trimester). After adjusting for possible confounding variables using logistic regression models, rates of IUFD and preterm delivery were still found to be statistically significant with adjusted odds ratios of 11.37 (95% CI: 6.10–21.16) and 1.55 (95% CI: 1.03–2.32), respectively. There were no differences in rates of macrosomia or preeclampsia between the three cohorts.Conclusions: Treatment of T2DM throughout pregnancy leads to improved maternal and neonatal outcomes.

Rates of Intrauterine Fetal Demise and Respiratory Morbidity at Term

Rates of Intrauterine Fetal Demise and Respiratory Morbidity at Term

Rates of intrauterine fetal demise and neonatal morbidity at term: determining optimal timing of delivery

Objective: To examine rates of unexplained intrauterine fetal demise (IUFD) and neonatal morbidity in uncomplicated term pregnancies to identify the optimal gestational age for delivery.Methods: A retrospective case control study was performed with singleton pregnancies delivered between 37 0/7 weeks and 42 6/7 weeks. Exclusion criteria were “complicated pregnancies”: emergency deliveries, maternal hypertension, diabetes, infection, fetal disease/malformations and placental abnormalities.Results: Nineteen thousand two hundred and sixty-four maternal/infant pairs were examined. The overall rate of NICU admission was 2.7% and the rate of unexplained IUFD was 2.02 per 1000 births. The lowest rate of IUFD was found at 39 weeks (1.40 per 1000 births). Odds ratios adjusted for maternal smoking, ethnicity, age and mode of delivery showed 2.74 (95% CI 0.35–21.83) risk of IUFD at 42 versus 39 weeks, 2.09 (1.47–2.98) risk of NICU admission at 37 versus 38 weeks, 2.54 (1.62–3.97) risk of respiratory morbidity at 37 versus 38 weeks and 3.38 (1.84–6.18) risk of transient tachypnea of the newborn or respiratory distress syndrome at 37 versus 38 weeks.Conclusions: Neonatal respiratory morbidity was lowest for deliveries at 38–39 weeks. IUFD was 2.74 times more likely at 42 weeks versus 39 weeks. Our findings support current guidelines advising clinicians when to deliver term pregnancies.

Percutaneous umbilical blood sampling: current trends and outcomes

ObjectivesTo report our contemporary experience with PUBS, including indications and complications, stratified by the presence of hydrops fetalis. Study designAll PUBS performed from 1988 to 2013 at a single tertiary care center were identified using a comprehensive ultrasound database. We recorded patient demographics, relevant obstetric, fetal and neonatal data, indication for and success of PUBS and any complications. Data were analyzed using SAS, version 9.3 (SAS Institute Inc., Cary, NC). Results455 PUBS were performed on 208 pregnant women, 97.8% of which were successful. The average gestational age at the time of PUBS was 26.7 weeks (SD 5.1 weeks, range 17.5–41.3 weeks). Indications were available for 441: 245 (55.6%) isoimmunization, 77 (17.5%) non-immune hydrops fetalis (NIHF), 98 (22.2%) chromosomal diagnosis, and 21 (4.8%) other indications. Isoimmunization was a less common indication for PUBS in 2008–2013 as compared to 1988–1992 (51.7% vs 66.2%, p=0.07). Amongst PUBS performed in the setting of hydrops, isoimmunization was much less common in the later time period (61.1% vs 0%, respectively; p<0.01). The procedure complication rate (bradycardia or fetal demise at procedure) of 2.5% was stable over the study period and was most common with NIHF (2.0% without hydrops, 0% with immune hydrops and 6.3% with NIHF; p=0.04). Of the 208 women with a PUBS performed, 74 had more than one PUBS procedure (mean 2.2, max 18). Transfusions were performed in 233 of the 455 (51.2%). Overall, 10.2% of the pregnancies had an intrauterine fetal demise (IUFD) within 2 weeks of the procedure, which was most common in pregnancies with NIHF (3.2% without hydrops, 9.1% with immune hydrops and 31.7% with NIHF; p<0.01). The IUFD rate was 60% (3/5) in fetuses with parvovirus-mediated NIHF. ConclusionsPUBS has a high likelihood of success with a relatively low complication rate. The complication rate is highest in pregnancies with NIHF, and these pregnancies are also at a significantly higher risk of IUFD, particularly those patients with parvovirus-mediated NIHF. Our findings can be used when counseling patients who are considering PUBS for diagnostic or therapeutic purposes.

Intrauterine fetal demise after prenatal diagnosis of congenital heart disease: assessment of risk

Elective deliveries in fetal congenital heart disease (CHD) attempt to balance fetal and neonatal risk with the goal of optimizing overall outcome. However, the magnitude of the risk for intrauterine fetal demise (IUFD) is unclear. This study aimed to (1) determine the rate of IUFD and (2) identify fetal risk factors associated with IUFD. Retrospective review of pregnancies complicated by CHD between 1998 and 2010. Data were collected regarding pregnancy outcome, extracardiac anomalies (ECA), genetic and cardiac diagnoses, severity of valve regurgitation, gestational age at birth and birth weight. Fisher's exact test and odds ratios were used to compare outcomes between groups. A total of 501 pregnancies analyzed resulted in 445 live births, 22 IUFD, 16 terminations and 18 unknown outcomes. Amongst IUFD, 27% had a genetic diagnosis, 50% had an ECA and 27% had severe valve regurgitation. IUFD odds increased threefold with ECA and sevenfold with severe valve regurgitation. IUFD occurred in 1.2% without risk factors. IUFD in fetuses with CHD is associated with ECA, genetic syndromes and severe valve regurgitation. In absence of these fetal characteristics, the occurrence of IUFD is low, although it remains higher than in fetuses without CHD.

Intrauterine Fetal Demise and Postneonatal Death Stratified by Maternal Education Level and Gestational Age [152

INTRODUCTION: To evaluate the association between maternal education and the rates of intrauterine fetal demise and postneonatal death stratified by gestational age in a cohort of otherwise healthy women. METHODS: A retrospective cohort study was conducted using 2005 U.S. national linked birth certificate and death certificate data. Maternal education was defined as less than or equal to some level of high school education compared with college education or beyond. Intrauterine fetal demise was defined as death occurring at or after 20 weeks of gestation. Postneonatal death was defined as death from day 29 to 365 of life. Results were expressed as number of deaths per 10,000 live births. RESULTS: Overall, perinatal death rates per 10,000 were at least double in women receiving a high school education or less compared with the more educated cohort. Specifically, the rate of intrauterine fetal demise was 0.0029 compared with 0.0018 (P<.001), neonatal death was 0.0021 compared with 0.0012 (P<.001), postneonatal death was 0.0028 compared with 0.0011 (P<.001), and infant death was 0.0049 compared with 0.0024 (P<.001). However, when examined by week of gestation, although the rates of intrauterine fetal demise and postneonatal death were greater at every gestational age in those with a high school education or less, rates of neonatal death and infant death were quite similar between the two educational groups. CONCLUSION AND IMPLICATION: Rates of intrauterine fetal demise and post neonatal death were greater for every gestational age in less educated women when compared with their more educated cohort. Given that rates of neonatal death were approximately the same regardless of level of education brings up an interesting discrepancy. Environmental factors, inability to navigate the health care system, or lack of education in prenatal and postnatal care may all be contributing factors and would require further investigation.

The Effect of the 39-Week Initiative on Intrauterine Demise

INTRODUCTION: Published studies have shown mixed results regarding the risks of intrauterine fetal demise after implementation of guidelines for reduction of nonmedically indicated deliveries before 39 weeks of gestation. Our objective was to describe the variation in rates of intrauterine fetal demise in a high-risk patient population after implementation of guidelines eliminating nonmedically indicated deliveries before 39 weeks of gestation. METHOD: This was a retrospective chart review of patients with intrauterine fetal demise delivering at or beyond 20 weeks of gestation or birth weight 350 g or more when the gestational age was unknown between March 4, 2012, and July 31, 2014, at Hurley Medical Center in Flint, Michigan. RESULTS: A total of 6,561 deliveries were performed during the study period. Group 1: 2,846 deliveries before implementation of the guidelines with 16 cases of intrauterine fetal demise. Group 2: 3,715 deliveries after the guidelines with 29 cases of intrauterine fetal demise. Despite a small sample size, the most concerning observation is that the rate of intrauterine fetal demise between 37 and 39 weeks of gestation increased from 0.35 to 1.35 per 1,000 births after implementation of the guidelines. CONCLUSION: In our institute, the rate of stillbirth has increased since implementation of and strict adherence to guidelines for the elimination of elective induction of labor or cesarean delivery before 39 weeks of gestation were instituted. This is a disturbing trend that needs further evaluation, especially in medical centers caring for a high-risk pool of patients for whom all medical indications are not covered by the lists of approved indications.

Chorioamniotic membrane separation over the cervical os ("moon sign") in twin-twin transfusion syndrome.

To determine whether chorioamniotic membrane separation from the internal cervical os, the "moon sign," is associated with preterm premature rupture of membranes (PPROM) in twin-twin transfusion syndrome (TTTS). A retrospective study of patients with TTTS treated with laser surgery was performed. Membrane separation before and after surgery was tested against any PPROM, PPROM within 7 days, and PPROM within 21 days. Because intrauterine fetal demise (IUFD) was weakly associated with PPROM, these cases were studied separately. Among 304 consecutive patients, 247 patients (81.3%) had no IUFD, and preoperative and postoperative membrane separation rates were 13.4% and 13.0%, respectively. In 7 cases (2.8%), preoperative membrane separation disappeared postoperatively, and in 6 cases (2.4%), membrane separation appeared postoperatively; 26 cases (10.5%) had membrane separation at both times. Rates of PPROM did not differ between those who did and did not have preoperative membrane separation (30.3% versus 28.0%; P= .9511). Among those with and without postoperative membrane separation, the rates of any PPROM were 34.4% and 27.4%, respectively (P = .5473), and the rates of PPROM within 21 days were 15.6% and 5.6% (P = .0524). Those with postoperative membrane separation were 3 times more likely to have PPROM within 21 days (odds ratio, 3.13; 95% confidence interval, 1.02-9.58; P= .0453). Preterm premature rupture of membranes was not associated with preoperative or postoperative membrane separation in patients with IUFD. The preoperative moon sign does not appear to be associated with PPROM in TTTS. Postoperatively, membrane separation may be weakly associated with PPROM at 21 days, but further research is required to confirm this association.

What is the optimal gestational age for women with gestational diabetes type A1 to deliver?

Type A1 gestational diabetes mellitus (A1GDM), also known as diet-controlled gestational diabetes, is associated with an increase in adverse perinatal outcomes such as macrosomia and Erb palsy. However, it remains unclear when to deliver these women because optimal timing of delivery requires balancing neonatal morbidities from early term delivery against the risk of intrauterine fetal demise (IUFD). We sought to determine the optimal gestational age (GA) for women with A1GDM to deliver. A decision-analytic model was built to compare the outcomes of delivery at 37-41 weeks in a theoretical cohort of 100,000 women with A1GDM. Strategies involving expectant management until a later GA accounted for probabilities of spontaneous delivery, indicated delivery, and IUFD during each week. GA-associated risks of neonatal complications included cerebral palsy, infant death, and Erb palsy. Probabilities were derived from the literature, and total quality-adjusted life years were calculated. Sensitivity analyses were used to investigate the robustness of the baseline assumptions. Our model showed that induction at 38 weeks maximized quality-adjusted life years. Within our cohort, delivery at 38 weeks would prevent 48 stillbirths but lead to 12 more infant deaths compared to 39 weeks. Sensitivity analysis revealed that 38 weeks remains the optimal timing of delivery until IUFD rates fall <0.3-fold of our baseline assumption, at which point expectant management until 39 weeks is optimal. By weighing the risks of IUFD against infant deaths and neonatal morbidities from early term delivery, we determined that the ideal GA for women with A1GDM to deliver is 38 weeks.

Optimal Timing of Delivery in Obese Women

INTRODUCTION: Maternal obesity complicates over 20% of pregnancies in the United States and increases the risk of many adverse perinatal outcomes. However, limited data exist on the timing of delivery in such cases. The purpose of this study was to determine the optimal gestational age of delivery in an obese patient. METHODS: A decision-analytic model was created using TreeAge software to determine the optimal timing of delivery in a theoretical cohort of 100,000 singleton pregnancies in obese women. Model options ranged from delivery at 37 weeks to 41 weeks of gestation. Strategies involving expectant management until a later gestational age accounted for the probabilities of spontaneous delivery and intrauterine fetal demise at each successive week. Neonatal complications included permanent brachial plexus injury, cerebral palsy, and neonate death. All probability estimates were derived from the literature, and total quality-adjusted life-years were calculated. RESULTS: The lowest rates of neonate death and cerebral palsy were associated with delivery at 39 weeks of gestation, whereas rates of intrauterine fetal demise and brachial plexus injuries were lowest at earlier gestational ages (Table 1). Balancing these outcomes, the optimal strategy was delivery at 38 weeks of gestation, which maximized quality-adjusted life-years. Delivery at 38 weeks of gestation would prevent 203 intrauterine fetal demises compared with expectant management until 41 weeks of gestation. Sensitivity analysis found that 38 weeks of gestation remained the optimal strategy until the risks of neonate death and intrauterine fetal demise were 5.57-fold and 1.25-fold, respectively, our baseline assumptions.CONCLUSIONS: Weighing the risks of intrauterine fetal demise against the risks of neonate death and significant neonatal morbidities, the ideal gestational age to deliver obese women is 38 weeks.

Timing of planned delivery in uncomplicated monochorionic diamniotic twin pregnancies: a review of the literature

Monochorionic diamniotic (MCDA) twins comprise of 20–30% of twin pregnancies; roughly 50% will be undelivered and ‘uncomplicated’ beyond 32 weeks gestation. This review details accumulating data regarding the risk of intrauterine fetal demise (IUFD) in ‘uncomplicated’ MCDA twins and risks associated with prematurity. ‘Uncomplicated’ MCDA twins are at increased risk for IUFD, even when under intensified surveillance in tertiary care centers. The prospective risk of IUFD in uncomplicated MCDA varies among different studies, with reported rates of up to 3.3% at 34 weeks and 2.2% at 36 weeks. If single IUFD occurs, it exposes the surviving co-twin to potential significant morbidity and mortality. It had been suggested that elective preterm delivery would eliminate this risk, but recent evidence of prematurity morbidity are accumulating. With more intensified monitoring from 32 weeks, it is possible that the rate of IUFD is lower than anticipated. We reviewed the data regarding these risks and their contribution to the decision-making process.

Cord occlusion followed by laser cord transection in monochorionic monoamniotic discordant twins

To compare the outcomes of a consecutive case series of monochorionic (MC) monoamniotic (MA) discordant twins treated with umbilical cord occlusion and transection, with those of a cohort of MC diamniotic (DA) twins treated with conventional cord occlusion. This study included 17 MCMA twins (12 true MA and five iatrogenic) treated with cord occlusion and transection and a control group of 72 MCDA discordant twins treated during the same period with cord occlusion in a single center. Duration of surgery, rates of preterm delivery (PTD) or preterm premature rupture of membranes (PPROM) < 32 weeks and intrauterine fetal demise (IUFD), perinatal outcome and neonatal survival were prospectively recorded in both groups. Median durations of surgery were 28.5 (range, 14.0-74.0) min and 24.0 (3.0-60.0) min in the cord transection and control groups, respectively (P = 0.24). There were no significant differences between cord transection and control groups in the rates of PPROM (35.3% vs. 20.8%, P = 0.22), PTD (41.2% vs. 28.2%, P = 0.29), IUFD (0% vs. 2.8%, P = 1.0) and neonatal survival (76.5% vs. 80.6%, P = 1.0). Gestational age at delivery (median 35.0 (24.5-39.0) vs. 37.1 (26.2-41.0) weeks, P = 0.21) and fetal birth weight (2215 (800-3200) g vs. 2605 (588-3830) g, P = 0.51) were similar between study groups. Cord occlusion and transection in MCMA discordant twins resulted in similar perinatal outcomes to those of MCDA discordant twins treated with cord occlusion.

Do Assisted Reproductive Techniques Increase Vanishing Twin Syndrome?

BACKGROUND: Vanishing twin syndrome (VTS) is the loss of a twin, resulting in delivery of a singleton. The occurrence of a vanishing twin has been shown to adversely affect the resulting singleton pregnancy, including low birth weight, preterm birth, and increased rates of intrauterine fetal demise. Previous reports have identified that up to 15-30% of singleton pregnancies from ART start as a higher order gestation. The objective of this investigation is to determine the incidence of VTS among various ART procedures.