1,721,333 research outputs found
Survival rates in pregnancies complicated by twin-to-twin transfusion syndrome undergoing laser therapy: a systematic review and meta-analysis: Survival rates in twin-to-twin transfusion syndrome
No full textObjectives: Twin-to-twin transfusion syndrome (TTTS) is associated with excess perinatal mortality and morbidity. Even though Quintero staging is commonly used to assess its severity, the limitations of its prognostic value have been highlighted by researchers over the years. Recent literature indicates that fetal survival, whether for both twins or at least one, following fetoscopic laser photocoagulation of the placental anastomoses is similar in TTTS Quintero stages I and II (combined) and III and IV (combined). In this context we perform a systematic review and meta-analysis of the published literature to elucidate the survival rate of twins according to the stage of TTTS and to compare the survival rates in pregnancies complicated by stage I and II (combined) vs those with stages III and IV (combined). Data sources: Medline, Embase and Cochrane databases were searched. Study eligibility criteria: The inclusion criteria were studies reporting the outcome of MCDA twin pregnancies with TTTS undergoing laser therapy according to the Quintero stage of the disease. The primary outcome was double survival at birth. The secondary outcomes were no survival, and survival of at least one twin. All the explored outcomes were reported according to the Quintero staging system. Furthermore, we aimed to compare all the observed outcomes in pregnancies complicated by TTTS affected by stage I and II vs those with stages III and IV. Study appraisal and synthesis methods: Random-effect meta-analyses were used to combine data, and the results reported as pooled proportions or odd ratios (OR) with their 95% confidence intervals (CI). Results: 26 studies were included. Survival of both fetuses was observed in 72.9% (95% CI 68.2-77.3) of pregnancies complicated by stage I, 67.9% (95% CI 62.3-73.3) with stage II, 48.1% (95% CI 42.5-53.8) with stage III, and 53.4% (95% CI 42.5-64.3) with stage IV TTTS (Table 3). At least one survivor was reported in 89.4% (95% CI 86.9-91.9) of cases with stage I, 87.1% (95% CI 82.9-90.7) with stage II, 77.3% (95% CI 71.7-82.5) with stage III, and 80.1% (95% CI 69.4-89.0) with stage 4. The corresponding figures for no survivors were 10.7% (95% CI 7.7-14.0), 11.4% (95% CI 7.8-15.6), 20.4% (95% CI 15.6-25.8), and 16.7% (95% CI 8.3-27.2), respectively. When comparing the different outcomes according to the different TTTS stages, there was no significant difference in the incidence of double survival (p=0.933), at least one survivor (p=0.688), and no survivors (p=0.866) between stages I and II TTTS. There was also no significant difference in the incidence of double survival (p=0.201), at least one survivor (p=0.380), and no survivors (p=0.947) between stages III and IV. Conversely, when comparing the outcome of pregnancies with stage I/II (combined) vs stages III/IV (combined), the incidence of double survival was significantly higher in pregnancies with stages I/II (OR 2.19; 95% CI 1.9-2.6, p<0.001) (Table 5). Likewise, the incidence of at least one survivor was significantly higher (OR 1.85, 95% CI 1.5-2.6, p<0.001) while that of no survivor (OR 0.56, 95% CI 0.4-0.7, p<0.001) significantly lower in pregnancies with stages I/II compared to III/IV. Conclusion: Perinatal survival of MCDA twin pregnancies complicated by TTTS and treated with fetoscopic laser coagulation of placental anastomoses is not significantly different between stages I and II, or between stages III and IV, apart from a higher chance of one survivor in stage III compared to stage IV. The findings from this systematic review will be useful in individualised risk assessment of twin pregnancies complicated by TTTS and tailored counselling of the parents. It also highlights the need for studies aimed at better characterizing the prenatal risk factors for mortality in pregnancies complicated by TTTS. Condensation: Perinatal survival of MCDA twin pregnancies complicated by TTTS and treated with fetoscopic laser coagulation of placental anastomoses is not significantly different between stages I and II, or between stages III and IV
FERN: is it possible to conduct a randomised controlled trial of intervention or expectant management for early-onset selective fetal growth restriction in monochorionic twin pregnancy - protocol for a prospective multicentre mixed-methods feasibility study
No full textIntroduction: selective fetal growth restriction (sFGR) in monochorionic twin pregnancy, defined as an estimated fetal weight (EFW) of one twin <10th centile and EFW discordance ≥25%, is associated with stillbirth and neurodisability for both twins. The condition poses unique management difficulties: on the one hand, continuation of the pregnancy carries a risk of death of the smaller twin, with a high risk of co-twin demise (40%) or co-twin neurological sequelae (30%). On the other, early delivery to prevent the death of the smaller twin may expose the larger twin to prematurity, with the associated risks of long-term physical, emotional and financial costs from neurodisability, such as cerebral palsy.When there is severe and early sFGR, before viability, delivery is not an option. In this scenario, there are currently three main management options: (1) expectant management, (2) selective termination of the smaller twin and (3) placental laser photocoagulation of interconnecting vessels. These management options have never been investigated in a randomised controlled trial (RCT). The best management option is unknown, and there are many challenges for a potential RCT. These include the rarity of the condition resulting in a small number of eligible pregnancies, uncertainty about whether pregnant women will agree to participate in such a trial and whether they will agree to be randomised to expectant management or active fetal intervention, and the challenges of robust and long-term outcome measures. Therefore, the main objective of the FERN study is to assess the feasibility of conducting an RCT of active intervention vs expectant management in monochorionic twin pregnancies with early-onset (prior to 24 weeks) sFGR.Methods and analysis: the FERN study is a prospective mixed-methods feasibility study. The primary objective is to recommend whether an RCT of intervention vs expectant management of sFGR in monochorionic twin pregnancy is feasible by exploring women’s preference, clinician’s preference, current practice and equipoise and numbers of cases. To achieve this, we propose three distinct work packages (WPs). WP1: A Prospective UK Multicentre Study, WP2A: a Qualitative Study Exploring Parents’ and Clinicians’ Views and WP3: a Consensus Development to Determine Feasibility of a Trial. Eligible pregnancies will be recruited to WP1 and WP2, which will run concurrently. The results of these two WPs will be used in WP3 to develop consensus on a future definitive study. The duration of the study will be 53 months, composed of 10 months of setup, 39 months of recruitment, 42 months of data collection, and 5 months of data analysis, report writing and recommendations. The pragmatic sample size for WP1 is 100 monochorionic twin pregnancies with sFGR. For WP2, interviews will be conducted until data saturation and sample variance are achieved, that is, when no new major themes are being discovered. Based on previous similar pilot studies, this is anticipated to be approximately 15–25 interviews in both the parent and clinician groups. Engagement of at least 50 UK clinicians is planned for WP3.Ethics and dissemination: this study has received ethical approval from the Health Research Authority (HRA) South West—Cornwall and Plymouth Ethics Committee (REC reference 20/SW/0156, IRAS ID 286337). All participating sites will undergo site-specific approvals for assessment of capacity and capability by the HRA. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. The results from the FERN project will be used to inform future studies.Trial registration number: this study is included in the ISRCTN Registry (ISRCTN16879394) and the NIHR Central Portfolio Management System (CPMS), CRN: Reproductive Health and Childbirth Specialty (UKCRN reference 47201)
Mobile Health Applications for Prenatal Assessment and Monitoring
No full textBackground: A mobile health application is an exciting, fast-paced domain that is likely to improve prenatal care. Methods: In this narrative review, we summarise the use of mobile health applications in this setting with a special emphasis on both the benefits of remote monitoring devices and the potential pitfalls of their use, highlighting the need for robust regulations and guidelines before their widespread introduction into prenatal care. Results: Remote monitoring devices for four areas of prenatal care are reported: (1) cardio-tocography; (2) blood glucose levels; (3) blood pressure; and (4) prenatal ultrasound. The majority of publications are pilot projects on remote consultation, education, coaching, screening, monitoring and selective booking, mostly reporting potential medical and/or economic benefits by mobile health applications over conventional care for very specific situations, indications and locations, but not always generalizable. Conclusions: Despite the potential advantages of these devices, some caution must be taken when implementing this technology into routine daily practice. To date, the majority of published research on mobile health in the prenatal setting consists of observational studies and there is a need for high-quality randomized controlled trials to confirm the reported clinical and economic benefits as well as the safety of this technology. There is also a need for guidance and governance on the development and validation of new apps and devices and for the implementation of mobile health technology into healthcare systems in both high and low-income settings. Finally, digital communication technologies offer perspectives towards exploration and development of the very new domain of tele-pharmacology
Standardization in the definition and management of late fetal growth restriction is needed to optimize perinatal outcome
No full textCongenital Cytomegalovirus Infection: Management Update
Full text linkPurpose of review
Until recently, management options in congenital cytomegalovirus (cCMV) infection have been either
conservative or termination of pregnancy. However, medical therapies aimed at reducing the risk of
infection and/or its severity have recently been investigated.
Recent findings
In a phase 2 open label, nonrandomized trial, valaciclovir (ValACV) was given to women carrying a
CMV-infected fetus. ValACV was associated with a greater proportion of asymptomatic neonates when
compared with a historical cohort (82 vs. 43%). However, the study design and the small number of
treated women limit its applicability. Even though initial observational data suggested that hyperimmune
globulin (HIG) therapy in pregnancy was associated with a significantly lower risk of cCMV, its efficacy
has not been borne out in a subsequent phase 2 randomized, placebo controlled, double-blind study
[cCMV 30% in the HIG group, 44% in the placebo group (
P=0.13)]. Furthermore, 11% of fetuses in the
HIG group had transient or permanent abnormalities, compared with 16% in the placebo group.
Summary
ValACV might have a promising role in the antenatal treatment of cCMV infection, but definitive
recommendations require further research. The use of HIG should currently be limited to the research
setting.
Video abstract http://links.lww.com/COID/A18
Diagnosis and management of selective fetal growth restriction in monochorionic twin pregnancies: a cross‐sectional international survey
No full textObjective: To identify current practices in the management of selective fetal growth restriction (sFGR) in monochorionic diamniotic (MCDA) twin pregnancies. Design: Cross-sectional survey. Setting: International. Population: Clinicians involved in the management of MCDA twin pregnancies with sFGR. Methods: A structured, self-administered survey. Main Outcome Measures: Clinical practices and attitudes to diagnostic criteria and management strategies. Results: Overall, 62.8% (113/180) of clinicians completed the survey; of which, 66.4% (75/113) of the respondents reported that they would use an estimated fetal weight (EFW) of <10th centile for the smaller twin and an inter-twin EFW discordance of >25% for the diagnosis of sFGR. For early-onset type I sFGR, 79.8% (75/94) of respondents expressed that expectant management would be their routine practice. On the other hand, for early-onset type II and type III sFGR, 19.3% (17/88) and 35.7% (30/84) of respondents would manage these pregnancies expectantly, whereas 71.6% (63/88) and 57.1% (48/84) would refer these pregnancies to a fetal intervention centre or would offer fetal intervention for type II and type III cases, respectively. Moreover, 39.0% (16/41) of the respondents would consider fetoscopic laser surgery (FLS) for early-onset type I sFGR, whereas 41.5% (17/41) would offer either FLS or selective feticide, and 12.2% (5/41) would exclusively offer selective feticide. For early-onset type II and type III sFGR cases, 25.9% (21/81) and 31.4% (22/70) would exclusively offer FLS, respectively, whereas 33.3% (27/81) and 32.9% (23/70) would exclusively offer selective feticide. Conclusions: There is significant variation in clinician practices and attitudes towards the management of early-onset sFGR in MCDA twin pregnancies, especially for type II and type III cases, highlighting the need for high-level evidence to guide management.</p
Number of episodes of reduced fetal movement at term: Association with adverse perinatal outcome
No full textObjective The aims of this study were evaluation of the association of reduced fetal movements (RFM) and small-for-gestational-age (SGA) birth at term and to explore if fetal and maternal outcomes are different with single vs repeated episodes of RFM and normal fetal assessment test results. Study Design This was a retrospective cohort study of all singleton pregnancies referred for RFMs at a tertiary fetal medicine unit from January 2008 through September 2014. Ultrasound and Doppler indices were obtained from a computerized ultrasound database and pregnancy outcome was collected from hospital records. Results Of the 21,944 women with a singleton pregnancy booked for maternity care during the study period, 1234 women (5.62%) reported RFMs >36+0 weeks. Of these, 1029 women (83.4%) reported a single episode of RFM and 205 (16.6%) had ≥2 presentations for RFM. Women with repeated RFMs had a significantly higher mean uterine artery pulsatility index in the second trimester. The prevalence of SGA baby at birth in women presenting with a single episode as compared to repeated episodes of RFM was 9.8% and 44.2%, respectively (odds ratio, 7.3; 95% confidence interval, 5.1-10.4; P <.05). Conclusion Repeated episodes of RFMs at term are more likely to occur in women with high second-trimester uterine artery Doppler resistance indices and are strongly associated with the birth of SGA infants. Women presenting with repeated episodes of RFM should be treated as being at high risk of placental dysfunction irrespective of the results of prenatal ultrasound and Doppler assessment
What is the role of intrauterine transfusion after single intrauterine death in monochorionic twin pregnancies? Evidence from a systematic review and meta-analysis
No full textObjective: To investigate the role of intrauterine transfusion (IUT) in affecting the outcome of the surviving twin showing sign of fetal anemia after a single intrauterine fetal death (IUFD) in monochorionic (MC) twin pregnancies. Methods: PubMed, Medline and Embase databases were searched (2010-2024). The inclusion criteria were studies reporting the outcome of fetuses showing signs of fetal anemia, defined as the presence of the peak systolic velocity (PSV) of the middle cerebral artery (MCA) >1.5 MoM, after single IUFD receiving compared to those not receiving IUT. The outcomes observed were preterm birth (PTB) <34 and 28 weeks of gestation, either iatrogenic or spontaneous, co-twin intra-IUFD, co-twin neonatal death (NND), anomalies at pre- or post-natal brain imaging, abnormal neurodevelopmental outcome. Risk of bias of the included studies was assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. The GRADE methodology was used to assess the quality of the body of retrieved evidence. Random effect meta-analyses of proportions were used to analyze the data. Results: Six studies (78 twin pregnancies complicated by single IUFD showing signs of fetal anemia) were included in the systematic review. Assessment of risk of bias of observational studies according to the ROBINS-I tool is presented. Only one study reported a non-matched comparison between anemic fetuses undergoing compared to those not undergoing IUT, so we could not calculate the summary odd ratios, and we reported the results as pooled proportions. PTB occurred in 51.25% (95% CI 35.76-66.62) of cases < 34 weeks and in 17.99% (95% CI 5.84-34.91) < 28 weeks of gestation. Co-twin IUFD and NND were reported in 8.02% (95% CI 2.30-16.78) and 15.49% (95% CI 7.89-25.05), while abnormal findings at pre-or post-natal brain imaging in 20.30% (95% CI 11.61-30.69). Abnormal neurodevelopmental outcome was reported in 5.93% (95% CI 2.50-18.30). Conclusion: There is a very low grade of evidence that IUT can affect the outcome of anemic fetuses after single IUFD in MC pregnancies. The findings how this systematic review, in view of the limitations of the included studies, highlighted the need for large multicenter studies sharing objective protocols of prenatal management and post-natal assessment of pregnancies complicated by single IUFD are needed to report whether IUT in the anemic fetus after single IUFD can prevent mortality and neuromorbidity
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