Twin Pregnancy in Women 45 Years or Older

With advances in assisted reproductive technology including In-vitro fertilization (IVF) and egg donation, women are now able to conceive well into their 40’s and 50’s.  However, uncertainty exists regarding the safety of these pregnancies for women and their newborns.  Additionally, twin pregnancy is a common result of IVF, and all twin pregnancies are higher-risk pregnancies.

Pregnancy Outcomes in Patients With Prior Uterine Rupture or Dehiscence

Women with a history of uterine rupture in labor or women with a uterine “window” (extreme thinning of the lower uterine portion) are often told that they should not conceive again because the risks are too great.  In this study, we reported excellent outcomes in a cohort of women with prior uterine rupture or uterine window.  With close monitoring and early delivery, none of the women in this study had any severe complications.

Rescue Corticosteroids in Twin Pregnancies and Short-Term Neonatal Outcomes

Singleton babies born prematurely, particularly those born prior to 34 weeks, have improved outcomes if their mothers received antenatal corticosteroids (AQCS) prior to delivery.   Recent studies suggest that a second (“rescue”) course of ACS further improve outcomes.   Twin pregnancies have a far higher risk of preterm birth, but there are less data examining the effect of corticosteroids and rescue corticosteroids on neonatal outcomes.  In this study, we found that twins born prior to 34 weeks had improved short-term outcomes if their mothers were exposed to a rescue course of ACS.

Type of Congenital Uterine Anomaly and Adverse Pregnancy Outcomes

A uterine anomaly (also called mullerian anomaly) refers to  a uterus that does not have normal shape (pear-shaped0.  There are several subtypes of uterine anomalies and each can have a different impact pregnancy for women with these uterine abnormalities.  In this study, we report pregnancy complication rates in a large cohort of women with uterine anomalies, based on the whether the defect was minor or major.

The Independent Associations of a Short Cervix, Positive Fetal Fibronextin, Amniotic Fluid Sludge, and Cervical Funneling with Spontaneous Preterm Birth in Twin Pregnancies

In twin pregnancies, a short cervical length on ultrasound, as well as a positive fetal fibronectin test, are both associated with an increased risk of preterm birth.  In this study, we found that the presence of amniotic fluid sludge (particulate matter seen on ultrasound just above the cervix) also increased the risk of preterm birth.

Antenatal Surveillance in Twin Pregnancies Using the Biophysical Profile

Twin pregnancies are at increased for stillbirth and warrant close surveillance, particularly towards the end of pregnancy.  In singleton pregnancies, it has been shown that a Biophysical profile (BPP), which is an ultrasound assessment of fetal well-being, is superior to a NonStress Test (NST), which involves 20-40 minutes of fetal heart rate monitoring.  In this study, we examined the utility of BPP testing in twin pregnancies and found that a normal test is associated with an extremely low rate of stillbirth and that there are few false positive results (false scares).

Preterm Birth or Small for Gestational Age in a Singleton Pregnancy and Risk of Recurrence 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.

What is New in Medical Student and Resident Education?

Published in the July issue of Obstetrics and Gynecology, Dr. Fox discusses four recent publications, which are concluded with a “bottom line” meant to be the take-home message. Recent publications include: “National Cluster-Randomized Trial of Duty Hour Flexibility in Surgical Training,” “Preparedness of Obstetrics and Gynecology Residents for Fellowship Training,” “Structured Teaching of Early Pregnancy Counseling,” and “Effectiveness of Labor Cervical Examination Simulation in Medical Student Education.”

Fetal fibronectin, cervical length, and the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage

In patients with an ultrasound or physical exam indicated cerclage, a positive fFN and a short cervical length are both associated with preterm birth. The risk of preterm birth increase with the number of abnormal biomarkers.

Cervical Pessary and Vaginal Progesterone in Twin Pregnancies with a Short Cervix

For twin pregnancies with a short cervix, the addition of a cervical pessary to vaginal progesterone is associated with prolonged pregnancy and reduced risk of adverse neonatal outcomes. A large randomized trial should be performed to verify these retrospective findings.