160 research outputs found
A survey of current clinical practice of chorionic villus sampling
No full textObjective
The number of invasive procedures (chorionic villus sampling (CVS) or amniocentesis) for fetal testing is decreasing because of the availability of non‐invasive prenatal test (NIPT) leading to a centralisation of prenatal diagnostic services to accredited fetal medicine centres. A new survey was conducted 10 years after the previous one to update the current clinical practice among clinicians who regularly perform CVS.
Method
Consultants from 32 centres in the United Kingdom were invited to take part in an online survey evaluating: The total number of CVS procedures carried out in the unit in a typical week, the preferred route (transabdominal [TA] vs transcervical [TC]), technique (use of local anaesthetic [LA] and needle technique).
Results
Response rate was 96.9%; TA was the preferred route (96.8%) in all centres except one. Single‐needle technique is used exclusively in half the centres (51.6%). LA is used by most operators (90.3%) before the procedure. Three centres did not routinely use LA for CVS.
Conclusions
Operators across the United Kingdom almost exclusively use the TA route for CVS with single‐needle technique in 51.6% of cases. The use of LA prior to CVS is a very common practice in the United Kingdom
Complete hydatidiform mole in higher-order multiple pregnancies
No full textMolar degeneration of the trophoblast is a rare, yet possible, complication of pregnancies. Complete hydatidiform mole is the most common histological type among all trophoblastic tumors and it is the result of the fertilization of an empty oocyte from two sperms or by one sperm that then duplicates. Complete mole is characterized by hydropic degeneration of abnormal chorionic villi, diffused trophoblast hyperplasia and the absence of identifiable embryonic or fetal tissue; the hyperplastic trophoblast justifies the common finding of high serum beta HCG levels. Twin molar pregnancy is an uncommon obstetric event, and even less frequent are triplet/quadruplet molar pregnancies. We hereby report a case of a complete hydatidiform mole with two coexistent fetuses in a triplet pregnancy after in vitro fertilization procedure; the pregnancy ended with a therapeutic abortion. During the follow-up, the serum beta human chorionic gonadotropin concentration started to rise, and the diagnosis of post-molar gestational trophoblastic neoplasia was made and consequently methotrexate treatment was started. Due to the rarity of this condition, there are no specific guidelines for the management of multiple pregnancies complicated by complete hydatidiform mole. We therefore performed a review of the literature including all reported cases of triplets/quadruplets pregnancies complicated by complete mole of a fetus focusing on ultrasound diagnosis, treatment and outcomes of this rare and life-threatening condition
Incidence and outcome of prenatal brain abnormality in twin-to-twin transfusion syndrome: systematic review and meta-analysis
No full textOBJECTIVES: to ascertain the incidence of antenatally diagnosed brain injuries in twin pregnancies complicated by twin to twin transfusion syndrome (TTTS) and to quantify the perinatal mortality, morbidity and long-term neurodevelopmental outcomes of these fetuses. METHODS: Medline, Embase, Clinicaltrials.gov and Cochrane Library databases were searched. Inclusion criteria were studies reporting on brain abnormalities diagnosed antenatally in twin pregnancies complicated by TTTS. The primary outcome was the incidence of prenatal brain abnormalities. The secondary outcomes were intrauterine demise (IUD), neonatal death, termination of pregnancy (TOP) and long-term morbidity. All these outcomes were explored in the overall population of fetuses with antenatal diagnosis of brain abnormalities. Sub-group analysis according to: type of treatment, gestational age and Quintero stage at diagnosis and/or treatment, co-twin death was planned. Meta-analyses of proportions were used to combine data and reported pooled proportion and their 95% confidence intervals (CI). RESULTS: Thirteen studies including 1573 cases of TTTS and 88 fetuses with an antenatal diagnosis of brain abnormalities were included in the systematic review. The meta-analysis included only studies reporting on brain abnormalities in twin pregnancies complicated by TTTS cases and treated with laser. Overall, brain injuries occurred in 2.2% of fetuses (eight studies (52/2410 fetuses)). These brain abnormalities were reported in 1.03% and 0.82% of recipients or donors, respectively. These abnormalities were mainly ischemic lesions (30.4%, 95%CI 19.1-43), followed by destructive lesions (23.9%, 95%CI 13.7-35.9), ventriculomegaly (19.9%, 95% CI 10.6-31.3) and hemorrhagic (15.3%, 95%CI 7.1-25.8). Spontaneous IUD occurred in 13.4% (95%CI 5.1-24.8) of fetuses, while TOP was chosen by parents in 53.5% (95%CI 38.9-67.8) cases. Neonatal death was reported only by three studies with an incidence of 15.4% (95%CI 2.8-35.4). Finally, only two studies reported on composite morbidity with 20.4% of morbidity reported overall (95%CI 2.5-49.4) which occurred in 29.7% and 20.4% of the recipient and donor fetuses, respectively. Due to the small numbers, only composite morbidity was analyzed and no information on neonatal intensive care unit admission, respiratory distress syndrome or other long-term outcomes such as neurodevelopmental delay or cerebral palsy could be reliably retrieved. CONCLUSIONS: The overall incidence of antenatally diagnosed fetal brain abnormalities in fetuses from twin pregnancies complicated by TTTS treated with laser is around 2%, mainly ischemic (30.4%) in nature. TOP was chosen by parents in almost half of the cases (53.5%). No information could be retrieved on morbidity outcomes, highlighting the urgent need for long-term follow up studies of these children
Hormonal contraception in women with endometriosis: a systematic review
No full textObjective: A systematic review was carried out of studies of women with endometriosis, to examine the evidence for efficacy of the use of hormonal contraception to improve disease-related pain and decrease postoperative risk of disease recurrence. Methods: A search of the Medline/PubMed and Embase databases was performed to identify all published English language studies on hormonal contraceptive therapies (combined hormonal contraceptives [CHCs], combined oral contraceptives [COCs], progestin-only pills [POPs] and progestin-only contraceptives [POCs]) in women with a validated endometriosis diagnosis, in comparison with placebo, comparator therapies or other hormonal therapies. Main outcome measures were endometriosis-related pain (dysmenorrhoea, pelvic pain and dyspareunia), quality of life (QoL) and postoperative rate of disease recurrence during treatment. Results: CHC and POC treatments were associated with clinically significant reductions in dysmenorrhoea, often accompanied by reductions in non-cyclical pelvic pain and dyspareunia and an improvement in QoL. Only two COC preparations (ethinylestradiol [EE]/norethisterone acetate [NETA] and a flexible EE/drospirenone regimen) demonstrated significantly increased efficacy compared with placebo. Only three studies found that the postoperative use of COCs (EE/NETA, EE/desogestrel and EE/gestodene) reduced the risk of disease recurrence. There was no evidence that POCs reduced the risk of disease recurrence. Conclusions: CHCs and POCs are effective for the relief of endometriosis-related dysmenorrhoea, pelvic pain and dyspareunia, and improve QoL. Some COCs decreased the risk of disease recurrence after conservative surgery, but POCs did not. There is insufficient evidence, however, to reach definitive conclusions about the overall superiority of any particular hormonal contraceptive
Perinatal outcomes of twin pregnancies complicated by late twin‐twin transfusion syndrome: A systematic review and meta‐analysis
No full textIntroduction
Untreated twin‐to‐twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity. Laser surgery is recommended before 26 weeks of gestation. However, the optimal management in case of late TTTS (occurring after 26 weeks of gestation) is yet to be established.
Material and methods
We conducted a systematic review and meta‐analysis to evaluate the outcomes of monochorionic‐diamniotic twin pregnancies complicated by late TTTS according to different management options (expectant, laser therapy, amnioreduction, or delivery). The primary outcome was mortality, including single and double intrauterine, neonatal, and perinatal death. Secondary outcomes were composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (ie, free from neurological complications), and preterm birth before <32 weeks of gestation. Outcomes were reviewed according to the management and reported for the overall population of twins and disease status (ie, donor and recipient separately). Random‐effect meta‐analyses of proportions were used to analyze the data.
Results
Nine studies including 796 twin pregnancies affected by TTTS were included. No randomized controlled trials were available for inclusion. TTTS occurred at ≥26 weeks of gestation in 8.7% (95% CI 6.9%‐10.9%; 67/769) of cases reporting TTTS at all gestations. Intrauterine death occurred in 17.7% (95% CI 4.9%‐36.2%) of pregnancies managed expectantly, 5.3% (95% CI 0.9%‐12.9%) of pregnancies treated with laser, and 0% (95% CI 0%‐9%) after amnioreduction. Neonatal death occurred in 42.5% (95% CI 17.5%‐69.7%) of pregnancies managed expectantly, in 2.8% (95% CI 0.3%‐7.7%) of cases treated with laser, and in 20.2% (95% CI 6%‐40%) after amnioreduction. Only one study (10 cases) reported data on immediate delivery after diagnosis with no perinatal deaths. Perinatal death incidence was 55.7% (95% CI 31.4%‐78.6%) in twin pregnancies managed expectantly, 5.6% (95% CI 0.5%‐15.3%) in those treated with laser, and 20.2% (95% CI 6%‐40%) in those after amnioreduction. Intact survival was reported in 44.4%, 96.4%, and 78% of fetuses managed expectantly, with laser or amnioreduction, respectively.
Conclusions
Evidence regarding perinatal mortality and morbidity in twin pregnancies complicated by late TTTS according to the different managements was of very low quality. Therefore further high‐quality research in this field is needed to elucidate the optimal management of these pregnancies
Perinatal outcome of monochorionic twin pregnancy complicated by selective fetal growth restriction according to management: systematic review and meta‐analysis
No full textObjective
To explore the impact of severity and management (expectant, laser treatment or selective reduction) on perinatal outcome of monochorionic twin pregnancies complicated by selective fetal growth restriction (sFGR).
Methods
MEDLINE, EMBASE, CINAHL, ClinicalTrials.gov and The Cochrane Library databases were searched for studies on outcome following expectant management, laser treatment or selective reduction in monochorionic twin pregnancies complicated by sFGR. Only pregnancies affected by sFGR and categorized according to the Gratacós classification (Type I, II or III) were included. The primary outcome was mortality, including single and double intrauterine (IUD), neonatal (NND) and perinatal deaths. Secondary outcomes were neonatal morbidity, abnormal postnatal brain imaging, intraventricular hemorrhage, periventricular leukomalacia, respiratory distress syndrome, admission to neonatal intensive care unit and survival free from neurological complications (intact survival). Meta‐analyses of proportions were used to analyze the extracted data according to management, severity of sFGR and fetal size (smaller vs larger twin).
Results
Sixteen observational studies (786 monochorionic twin pregnancies) were included. In pregnancies complicated by Type‐I sFGR managed expectantly, IUD occurred in 3.1% (95% CI, 1.1–5.9%) of fetuses and 97.9% (95% CI, 93.6–99.9%) of twins had intact survival. In pregnancies complicated by Type‐I sFGR treated using laser therapy, IUD occurred in 16.7% (95% CI, 0.4–64.1%) of fetuses and, in those treated using selective reduction, IUD occurred in 0% (95% CI, 0–34.9%) of cotwins, with no evidence of neurological complications in the survivors. In pregnancies complicated by Type‐II sFGR managed expectantly, IUD occurred in 16.6% (95% CI, 6.9–29.5%) and NND in 6.4% (95% CI, 0.2–28.2%) of fetuses, and 89.3% (95% CI, 71.8–97.7%) of twins survived without neurological compromise. In Type‐II sFGR pregnancies treated using laser therapy, IUD occurred in 44.3% (95% CI, 22.2–67.7%) of fetuses, while none of the affected cases experienced morbidity and survivors were free of neurological complications. Of pregnancies undergoing selective reduction, IUD of the cotwin occurred in 5.0% (95% CI, 0.03–20.5%) and NND in 3.7% (95% CI, 0.2–11.1%), and 90.6% (95% CI, 42.3–94.3%) of surviving cotwins were free from neurological complications. In pregnancies complicated by Type‐III sFGR managed expectantly, IUD occurred in 13.2% (95% CI, 7.2–20.5%) and NND in 6.8% (95% CI, 0.7–18.6%) of fetuses, and 61.9% (95% CI, 38.4–81.9%) of twins had intact survival. In pregnancies complicated by Type‐III sFGR treated with laser therapy, IUD occurred in 32.9% (95% CI, 20.9–46.2%) of fetuses and all surviving twins were without neurological complications. Finally, in pregnancies with Type‐III sFGR treated with selective reduction, NND occurred in 5.2% (95% CI, 0.8–12.8%) of cotwins and 98.8% (95% CI, 93.9–99.9%) had intact survival.
Conclusion
Type‐I sFGR is characterized by good perinatal outcome when managed expectantly, which represents the most reasonable management strategy for the large majority of affected cases. Pregnancies complicated by Type‐II or ‐III sFGR treated with fetoscopic laser ablation have a higher rate of mortality but lower rate of morbidity compared with those managed expectantly, supporting the use of fetal therapy at gestations remote from neonatal viability. Data on outcome following selective reduction are scarce. In view of the lack of evidence from randomized controlled trials, prenatal management of sFGR should be individualized according to gestational age at diagnosis, severity of growth discordance and magnitude of Doppler anomalies
Perinatal and long-term outcome of fetal intracranial hemorrhage: systematic review and meta-analysis
No full textObjective
Fetal intracranial hemorrhage (ICH) is associated with an increased risk of perinatal mortality and morbidity. Healthcare professionals often find it challenging to counsel parents due to its rarity and diverse presentation. The aim of this systematic review and meta-analysis was to investigate the perinatal outcome of fetuses with ICH.
Methods
MEDLINE, EMBASE, ClinicalTrials.gov and The Cochrane Library databases were searched. Inclusion criteria were studies reporting the outcome of fetuses, newborns and infants diagnosed with ICH. The primary outcome was perinatal death (PND), defined as the sum of intrauterine (IUD) and neonatal death (NND). The secondary outcomes were stillbirth, NND, IUD, termination of pregnancy, need for surgery/shunting at birth, cerebral palsy (defined according to the European Cerebral Palsy Network and classified as diplegia, hemiplegia, quadriplegia, dyskinetic or mixed), neurodevelopmental delay and intact survival. All outcomes were explored in the included fetuses with ICH. A subgroup analysis according to the location of the hemorrhage (intra-axial and extra-axial) was also planned. Meta-analysis of proportions was used to combine data, and pooled proportions and their 95% CI were reported.
Results
Sixteen studies (193 fetuses) were included in the meta-analysis. PND occurred in 14.6% (95% CI, 7.3–24.0%) of fetuses with ICH. Among liveborn cases, 27.6% (95% CI, 12.5–45.9%) required shunt placement or surgery after birth and 32.0% (95% CI, 22.2–42.6%) had cerebral palsy. Furthermore, 16.7% (95% CI, 8.4–27.2%) of cases had mild neurodevelopmental delay, while 31.1% (95% CI, 19.0–44.7%) experienced severe adverse neurodevelopmental outcome. Normal neurodevelopmental outcome was reported in 53.6% of fetuses. Subgroup analysis according to the location of ICH showed that PND occurred in 13.3% (95% CI, 5.7–23.4%) of fetuses with intra-axial bleeding and 26.7% (95% CI, 5.3–56.8%) of those with extra-axial bleeding. In fetuses with intra-axial hemorrhage, 25.2% (95% CI, 11.0–42.9%) required shunt placement or surgery after birth and 25.5% (95% CI, 15.3–37.2%) experienced cerebral palsy. In fetuses with intra-axial hemorrhage, mild and severe neurodevelopmental delay was observed in 14.9% (95% CI, 12.0–27.0%) and 32.8% (95% CI, 19.8–47.4%) of cases, respectively, while 53.2% (95% CI, 37.0–69.1%) experienced normal neurodevelopmental outcome. The incidence of mortality and postnatal neurodevelopmental outcome in fetuses with extra-axial hemorrhage could not be estimated reliably due to the small number of cases.
Conclusions
Fetuses with a prenatal diagnosis of ICH are at high risk of perinatal mortality and adverse neurodevelopmental outcome. Postnatal shunt placement or surgery was required in 28% of cases and cerebral palsy was diagnosed in approximately one-third of infants. Due to the rarity of ICH, multicenter prospective registries are warranted to collect high-quality data
Variation in outcome reporting across studies evaluating interventions for selective fetal growth restriction
No full textThe recent investigation of variation in outcome reporting in studies of twin-to-twin transfusion syndrome has highlighted the problem of variable and inconsistently defined outcome reporting in studies of twin-to-twin transfusion syndrome (TTTS).(1) Similar heterogeneity in outcome reporting has been identified across women's and newborn health including pre-eclampsia, childbirth trauma and endometriosis.(2-8) This article is protected by copyright. All rights reserved
Perinatal outcomes of twin pregnancies affected by early twin‐twin transfusion syndrome: A systematic review and meta‐analysis
No full textIntroduction
Twin‐to‐twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity if not treated. However, the optimal timing and management in case of early (occurring < 18 weeks) TTTS has not been established yet.
Material and methods
This is a systematic review and meta‐analysis aiming at evaluating the outcomes of monochorionic diamniotic twin pregnancies complicated by early (ie before 18 weeks) TTTS according to different management options (expectant, laser therapy, amnioreduction or cord occlusion). The primary outcome was mortality, including single and double intrauterine, neonatal and perinatal death. Secondary outcomes were: composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (defined as survival free from neurological complications) and preterm birth < 32 weeks of gestation. All outcomes were reviewed according to the different management options (expectant, laser therapy, amnioreduction or cord occlusion) and reported FOR the overall population of twins, and for the donor and recipient separately. Subgroup analysis for TTTS occurring before 16 weeks of gestation was performed. Random‐effect meta‐analyses of proportions were used to analyse the data.
Results
Thirteen studies were included. Early TTTS occurred in 14.3% (95% confidence interval [CI] 11.9‐17.0) of cases. The incidence of intrauterine death was 19.0% (95% CI 2.6‐45.5) in twins managed expectantly, 32.4% (95% CI 16.5‐50.7) in those who received laser treatment and 12.5% (95% CI 4.8‐23.0) in those treated with amnioreduction. The incidence of neonatal death was 22.6% (95% CI 4.2‐49.8) in twins managed expectantly, 24.7% (95% CI 0.5‐80.3) in those who received laser and 20.2 (95% CI 5.8‐43.4) in those who had amnioreduction; it was not possible to compute the incidence of these outcomes in twins undergoing cord occlusion because of insufficient sample and lack of reporting of most of the observed outcomes. Overall, the incidence of perinatal death was 43.9% (95% CI 5.9‐87.7) in twins managed expectantly, 47.3% (95% CI 21.4‐70.0) in those treated with laser and 28.5% in those who had amnioreduction.
Conclusions
Twin pregnancies affected by early TTTS are at substantial risk of perinatal mortality and morbidity; however, the data come from very small studies with a high risk of selection bias
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