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PubMed2004

Outcome of pregnancies achieved by in vitro fertilisation techniques and diagnosed as twins at the 6 week ultrasound.

BACKGROUND: To bring the success rate of in vitro fertilisation (IVF) procedures to an acceptable level, multiple embryos have historically been replaced. This has resulted in an 'epidemic' of multiple births. The pendulum has now swung full circle and the number of embryos transferred is now being limited. Such high numbers of IVF twins will not be produced in the future. AIM: To review retrospectively the outcome of a series of pregnancies achieved by IVF where the 6 week ultrasound showed the presence of two sacs. METHODS: Retrospective study in a university IVF programme that produced 746 IVF pregnancies with twins at 6 weeks of gestation (1991-1999). RESULTS: The main outcome measures were perinatal mortality, pregnancy outcome, gestation at delivery and obstetrics complications reported. Interestingly, by 20 weeks gestation, 184 (24.7%) of pregnancies spontaneously reduced to a singleton, whereas 49 (6.6%) lost both twins. Of the 513 (68.8%) viable twin pregnancies (>20 weeks), 154 (20.6%) went on to term (>37 weeks), whereas 250 (33.5%) delivered between 33 and 36 weeks gestation. The perinatal mortality per 1000 births was 6.5 over 37 weeks, 8.0 for 33-36 weeks, 41.7 for 29-32 weeks and 500 for under 28 weeks.

Adult↗
PubMed1992

Fluorescent in situ hybridization: use of whole chromosome paint probes to identify unbalanced chromosome translocations.

By identifying structural chromosome anomalies, the clinical cytogenetics laboratory can play a critical role in the diagnosis and treatment of patients with birth defects. Although many new staining techniques have been developed throughout the years to aid in the detection of anomalous chromosomes, some abnormalities still pose a special challenge to cytogeneticists. This difficulty is especially evident in patients with an abnormal chromosome that does not produce a recognizable banding pattern by conventional staining techniques. We describe a recently discovered method of identifying chromosomes by using whole chromosome-specific DNA probes and fluorescent in situ hybridization and provide examples of how this new procedure facilitated the identification of chromosome abnormalities in two patients with multiple birth defects.

Adult↗
PubMed1984

Retinopathy of prematurity: a risk factor analysis with univariate and multivariate statistics.

Seventy-three out of 639 ophthalmoscopically examined newborns (11.4%) showed varying degrees of retinopathy of prematurity (ROP). Three infants were blind (0.5%). Sixty-six patients were matched with controls according to gestational age, birth weight, birth date and neonatal unit. Using univariate statistics, the variables representing the extent of O2-exposure, elevated paO2, elevated paCO2, paCO2-fluctuations, acidosis, blood transfusions, and artificial ventilation were found to be significantly associated with ROP. In contrast, the variables representing hypocapnia, Hb-levels, parenteral fluid administration and fluid retention showed no correlation with ROP. When a multivariate statistical method was used, the variables representing gestational age, elevated paO2, elevated paCO2 and paCO2-fluctuations as well as the ones defining blood transfusions lost their association with ROP. Episodes of acidosis, multiple birth, birth weight, total hours with Fio2 greater than 0.4, and total duration of artificial ventilation remained in the regression, and hypocapnia gained a significant negative correlation with ROP. This comparative survey based on univariate and multivariate statistics demonstrates that significance levels of identically defined biological and therapeutic variables obtained from the same population of patients are to be interpreted with caution. This fact may also explain contrasting opinions on risk factors in the literature. Multivariate statistical analyses are useful for a relative comparison of significance within a given set of variables. Conclusions on a possible causal relationship as well as on prophylactic measures are not possible.

Humans↗
PubMed1999

Maternal occupational exposure to chemical substances and the risk of infants small-for-gestational-age.

BACKGROUND: The association between maternal occupational exposure to specific chemical substances (organic solvents, carbon tetrachloride, herbicides, chlorophenols, polychlorinated biphenyls, aromatic amines, lead and lead compounds, mercury and mercury compounds) and birth of small-for-gestational-age (SGA) infants was evaluated using data from a prospective cohort study of 3,946 pregnant women in West Germany from 1987 to 1988. METHODS: Occupational, medical, and psychosocial information was gathered through a questionnaire from pregnant women who were recruited between 15 and 28 gestational weeks. Exposure to chemical substances at the current workplace was assessed by a job-exposure matrix constructed by Pannett in 1985 and weighted for the number of working hours per week. Women not working at the time of the interview, women with multiple births, and women with stillbirths were excluded from analysis. Data were analyzed using dichotomous and polytomous logistic regression to control for age, smoking status, alcohol consumption, body mass index, and number of former births. RESULTS: The results of the dichotomous logistic regression analysis suggest that leather work might be associated with the birth of infants small-for-gestational-age through exposure to chlorophenols (P = 0.02) and aromatic amines (P = 0.05). In the polytomous logistic regression analysis, only the association between exposure to mercury and growth retardation reached statistical significance (P = 0.02); however, the power of the study is limited. Further adjustment for income, shift work, and heavy physical work had no substantial effect on the results. CONCLUSIONS: These findings suggest that maternal exposure to specific chemicals at work may be a risk factor for the birth of SGA infants.

Adolescent↗
PubMed2000

Reproductive factors, subfertility, and risk of neural tube defects: a case-control study based on the Oxford Record Linkage Study Register.

Periconceptual exposure to subfertility treatments is increasingly common, raising concerns about the possibility of malformations in the offspring. The authors conducted a case-control study to determine whether subfertility or its treatment was associated with increased risk of neural tube defects (NTDs). Cases were 694 women diagnosed with an NTD-affected pregnancy in Oxfordshire or West Berkshire, England, between 1970 and 1987. Cases were individually matched on maternal year of birth and year of index pregnancy to controls randomly selected from a computerized database. Data on demographic, reproductive, and obstetric factors were abstracted from patient hospital records. Overall, the period prevalences of subfertility and of subfertility treatment were 7% and 3%, respectively, No evidence was found that the risk of NTD-affected pregnancies was increased by either subfertility (odds ratio (OR) = 1.2, 95% confidence interval (CI): 0.7, 2.1) or its treatment (OR = 0.9, 95% CI: 0.4, 2.0). After adjustment, NTD-affected pregnancies were associated with female offspring (OR = 2.3, 95% CI: 1.8, 3.1), multiple birth (OR = 4.8, 95% CI: 1.2, 18.8), and higher numbers of pregnancies (p for trend = 0.005). The findings from this large, population-based study were wholly consistent with those from smaller studies that found no increased risk of NTD associated with exposure to fertility treatments but reported associations with various pregnancy outcomes.

Adult↗
PubMed2003

Iatrogenic multiple pregnancies. Do they complicate perinatal care?

This review addresses questions related to medicosocial concerns surrounding the care of women with multiple births and their infants. Relevant articles and texts on twin and triplet pregnancies were reviewed. Population-based data were selected for inclusion whenever possible. Relevant tables were simplified from original sources. The review clarifies obstetric and perinatal questions in a manner that is helpful to clinicians and their patients.

Female↗
PubMed2004

[High perinatal mortality in the Netherlands compared to the rest of Europe].

In the Peristat-project, a European collaborative study, a set of indicators has been defined for monitoring perinatal health outcomes. For a group of 10 core indicators, with variables for subgroup analysis, national registry data from 15 European member states were collected and compared. The Netherlands was found to have the highest perinatal mortality in Europe: the foetal and neonatal mortality amounted to 7.4 and 3.5 per 1000 births, respectively. European countries differ in registration practices. Some countries do not register perinatal deaths occurring before a duration of amenorrhoea of 28 weeks. Therefore, the Peristat mortality data should be compared with 28 weeks of gestation as a cut-off point. With this cut-off point, The Netherlands has the second highest perinatal mortality. A number of factors may have contributed to this relatively high mortality, such as differences in registration practices, the profile of the Dutch childbearing population and the characteristics of Dutch perinatal care. The Netherlands has a relatively high proportion of older mothers, multiple births and mothers belonging to an ethnic minority. Also, Dutch neonatologists are known to be conservative in their treatment of premature newborns, which reduces their chances of survival. There is also less prenatal screening for congenital abnormalities in The Netherlands than in many other European countries. Further analysis of the Dutch data, as well as continued monitoring at the European level, can serve as a basis for future policy decisions to enhance the health of Dutch mothers and newborns.

Data Collection↗
PubMed1998

Assessing the role of case mix in cesarean delivery rates.

OBJECTIVE: Implicit in comparisons of unadjusted cesarean rates for hospitals and providers is the assumption that differences result from management practices rather than differences in case mix. This study proposes a method for comparison of cesarean rates that takes the effect of case mix into account. METHODS: All women delivered of infants at our institution from December 1, 1994, through July 31, 1995, were classified according to whether they received care from community-based practitioners (N=3913) or from the hospital-based practice that serves a higher-risk population (N=1556). Women were categorized according to both obstetric history (nulliparas, multiparas without a previous cesarean, multiparas with a previous cesarean) and the presence of obstetric conditions influencing the risk of cesarean delivery (multiple birth, breech presentation or transverse lie, preterm, no trial of labor for a medical indication). We determined the percent of women in each parity-obstetric condition subgroup and calculated a standardized cesarean rate for the hospital-based practice using the case mix of the community-based practitioners as the standard. RESULTS: The crude cesarean rate was higher for the hospital-based practice (24.4%) than for the community-based practitioners (21.5%), a rate difference of 2.9% (95% confidence interval=0.4%, 5.4%; P=.02). However, the proportion of women falling into categories conferring a high risk of cesarean delivery (multiple pregnancy, breech presentation or transverse lie, preterm, no trial of labor permitted) was twice as high for the hospital-based practice (24.4% hospital, 12.1% community). The standardization indicates that if the hospital-based practitioners had the same case mix as community-based practitioners, their overall cesarean rate would be 20.1%, similar to the 21.5% rate of community providers (rate difference=-1.4%, 95% confidence interval =-3.1%, 0.3%; P=.11). CONCLUSION: Standardization for case mix provides a mechanism for distinguishing differences in cesarean rates resulting from case mix from those relating to differences in practice. The methodology is not complex and could be applied to facilitate fairer comparisons of rates among providers and across institutions.

Cesarean Section↗
PubMed1976

Update on the safety and efficacy of clomiphene citrate as a therapeutic agent.

Fifteen years have passed since our group first proposed the use of clomiphene citrate as an ovulation-inducing agent. Our 15-year experience with over 2,000 patients has not dampened our enthusiasm for this drug. The benefits have far outweighted the minor side effects or the possibility of multiple births. Serious birth defects were minimal and have been no greater than what one may expect in the general population. Clomiphene citrate has been a boon to womankind and deserves the confidence of both patient and physician: it is a drug with a record of utility and with but minor risks.

Abnormalities, Drug-Induced↗
PubMed2002

Trends in mortality and morbidity for very low birth weight infants, 1991-1999.

BACKGROUND: Medical care for very low birth weight (VLBW) infants and their mothers has changed dramatically during the 1990s, yet it is unclear how these changes have affected mortality and morbidity. OBJECTIVE: We used the Vermont Oxford Network Database to identify trends in clinical practice and patient outcomes for VLBW infants born from 1991 to 1999. METHODS: Logistic regression was used to evaluate temporal trends in practices and outcomes while adjusting for patient characteristics and accounting for clustering of cases within hospitals. RESULTS: There were 118 448 infants 501 to 1500 g from 362 neonatal intensive care units enrolled in the Network Database from 1991 to 1999. Prenatal care, cesarean section, multiple births, antenatal steroids, and 1-minute Apgar scores increased during this period, as did the use of nasal continuous positive airway pressure, high-frequency ventilation, surfactant, and postnatal steroids. The proportion of white infants decreased; the proportions of Hispanic infants and those of other races increased. The crude and adjusted rates of mortality, pneumothorax, intraventricular hemorrhage (IVH), and severe IVH declined from 1991 to 1995, whereas from 1995 to 1999, the rates of mortality, IVH, and severe IVH did not change significantly, and pneumothorax increased. CONCLUSIONS: There have been major changes in both obstetric and neonatal care during the 1990s. These changes were associated with decreases in mortality and morbidity for VLBW infants during the first half of the decade. However, since 1995, no additional improvements in mortality or morbidity have been seen, ending a decades-long trend of improving outcomes for these infants.

Female↗
PubMed1998

Infant mortality statistics from the linked birth/infant death data set--1995 period data.

OBJECTIVES: This report presents infant mortality statistics from the linked birth/infant death data set (linked file)-1995 period data by a variety of maternal and infant characteristics. Trends in birthweight-specific infant mortality rates from 1985-95 are also discussed. METHODS: Descriptive tabulations of data from the linked file are presented. The data include infant deaths in 1995, which are linked to their corresponding birth certificates, whether the birth occurred in 1995 or 1994. The denominator used to compute infant mortality rates is the National Center for Health Statistics (NCHS) natality file, which includes all births in 1995. Data are weighted to compensate for the 2.5 percent of infant death records that could not be linked to their corresponding birth certificates. RESULTS: In general, mortality rates were lowest for infants born to Asian and Pacific Islander mothers, followed by white, American Indian, and black mothers. Rates for infants of Hispanic origin mothers were slightly lower than or comparable to those for infants of white mothers, except for infants of Puerto Rican mothers who had higher infant mortality rates. Infant mortality rates were higher for those infants whose mothers began prenatal care after the first trimester of pregnancy, were teenagers or 40 years of age or older, did not complete high school, were unmarried, or smoked during pregnancy. Infant mortality was also higher for male infants, multiple births, and infants born preterm or at low birthweight. In 1995, 63 percent of all infant deaths occurred to the 7.3 percent of infants born at low birthweight. From 1985-95, birthweight-specific infant mortality rates declined most rapidly for infants weighing 750-1,499 grams at birth. The leading causes of infant death varied considerably by race and Hispanic origin. For infants of black mothers, Disorders related to short gestation and unspecified low birthweight was the leading cause of infant death, with an infant mortality rate 4.5 times higher than that for infants of white mothers. For infants of American Indian mothers, rates for Sudden infant death syndrome were 2.9 times and for Accidents and adverse effects 3.6 times higher than those for infants of white mothers. For infants of Hispanic mothers, mortality rates from Sudden infant death syndrome were one-third lower than those for infants of white mothers.

Adolescent↗
PubMed2005

Anthropometric measurements for neonates, 23 to 29 weeks gestation, in the 1990s.

Reference data describing weight, length, and head circumference (anthropometric measurements) at birth were published by Lubchenco and Usher before 1970. Few attempts have been made to investigate whether these data are appropriate for today's cohort of preterm neonates. We analysed anthropometric data for neonates born between 23 and 29 weeks' gestation. Reference charts were developed from the measurements obtained from neonatal records, and gestational age, obtained from maternal charts, on 975 neonates delivered at four neonatal centres in Michigan during 1992 and 1997. The analysis was confined to children with gestational age that was consistent or within 7 days by last menstrual period, obstetric examination, ultrasound and neonatal determinations. At 23 to 29 weeks' gestation, ethnicity and multiple births did not have any significant impact on birthweight but girls were lighter. We compared our anthropometric charts with those presently being used at many neonatal centres. In our study, physical measurements at birth of preterm neonates born between 1992 and 1997 were significantly different from those currently used to assess growth status. Furthermore data derived from published studies that utilised birth certificates with gestational age based on last menstrual period seem to overestimate birthweight. For preterm infants, our findings are concordant with recently published values from 18 states of the US. Because of improved survival, gestational age assessment and perinatal care of preterm neonates, development of new reference anthropometric measurements for neonates is overdue. Our Michigan data of 23-29 weeks preterm provides new national reference values, which we recommend for use in US neonatal centres for extremely preterm neonates.

Anthropometry↗
PubMed1996

Growth and physical outcome of children conceived by in vitro fertilization.

OBJECTIVE: To determine the growth and physical outcome at 2 years of age for children born after assisted reproductive techniques in the state of Victoria. DESIGN: Using a case-matched control study between January 1991 and July 1993, 314 children (196 singletons, 47 sets of twins, 8 sets of triplets) conceived after in vitro fertilization (IVF) and related techniques at the Monash IVF and Royal Women's Hospital Reproductive Biology Unit and 150 control children (113 singletons, 17 sets of twins, 1 set of triplets) randomly selected from the general population using the Victorian Perinatal Data Collection Unit records were enrolled to be examined for minor dysmorphic and major organ abnormalities. Singleton and twin cases were matched for plurality and gestation and date of birth. Triplets were not matched. RESULTS: IVF status was not a significant independent factor for physical outcomes, including malformation rates, nor for days of hospitalization postdischarge and operations. There was no significant interaction between IVF status and mean percentiles for weight and head circumference. The IVF group had a greater mean length percentile. Twins in both groups had significantly poorer physical outcomes than singletons on some measures. CONCLUSION: This study did not demonstrate an independent IVF effect on the growth and physical outcome of children at 2 years of age when matched for plurality and gestation. The poor outcomes where noted were related to the effects of multiple births. These findings must be viewed in context of the response rates and therefore representativeness of the data. The need for longitudinal studies is demonstrated.

Adult↗
PubMed2002

Hospital care utilization of infants born after IVF.

BACKGROUND: Infants born after IVF are often twins, and singleton IVF babies have an increased risk for preterm birth. Both conditions are likely to increase morbidity. We examined the frequency and duration of hospitalization required by babies born after IVF, and compared this information with all infants born in Sweden during the same time period. METHODS: We used a nationwide registration of IVF pregnancies from 1984 to 1997 and a nationwide register of all in-patient care up to the end of 1998. We identified 9056 live born infants after IVF treatment and compared them with 1 417 166 non-IVF live born infants. RESULTS: The highest odds ratio (OR approximately 3) was seen for neonatal hospitalization, but an increased OR (1.2-1.3) was noted for children up to 6 years of age. The OR for being hospitalized after IVF was 1.8, but when the analysis was restricted to term infants it was 1.3 and this excess was then explainable by maternal subfertility. Statistically significant increased ORs were seen for hospitalization for cerebral palsy (1.7), epilepsy (1.5), congenital malformation (1.8) or tumour (1.6), but also for asthma (1.4) or any infection (1.4). When information from the Swedish Cancer Registry was used, no excess risk for childhood cancer was found. The average number of days spent in hospital by IVF and non-IVF children was 9.5 and 3.6 respectively. CONCLUSIONS: The increased hospitalization of IVF children is, to a large extent, due to the increased incidence of multiple births. Therefore, the increased costs associated with this may be reduced by the use of single embryo transfers, with the savings in health care costs being offset against the increased number of embryo transfer cycles required to maintain the pregnancy rate.

Birth Rate↗
PubMed1981

Some production traits of the West African Dwarf goat.

A study of West African Dwarf goats over a 5 year period indicated that these animals are not seasonal breeders but kid throughout the year. Sixty-five per cent of does kidded twice a year and multiple births accounted for 59% of all births. Seventy-two per cent of all deaths were of kids under 3 months of age. Pneumonia and starvation were the main causes of death. It is suggested that this is potentially a prolific breed which with proper husbandry and selection could help to meet the need for animal protein in sub-Saharan West Africa.

Animals↗
PubMed1984

[Kaufmann syndrome or VACTERL association? Discussion of a differential diagnosis].

The authors describe a dysmature female newborn, with multiple birth defects, who died soon after birth. At first polydactyly and hydrometrocolpos let think of a Kaufman syndrome, with autosomal recessive inheritance. But due to the presence of other malformations and since polydactyly is preaxial, the whole clinical and anatomical picture may be put into the frame of VACTERL association, mainly sporadic. Thus seemingly hydrometrocolpos and urogenital sinus have to be added, although rarely, to the other known defects of the VACTERL association.

Abnormalities, Multiple↗
PubMed1990

[Multiple pregnancies. III. Therapeutic, psychologic and social aspects].

The authors analyse a series of 23 multiple pregnancies (19 triplet pregnancies, 3 quadruplets and 1 quintuplet). The first objective is to fight prematurity. Over and above all use of drugs as tocolytics (beta-mimetic drugs and progesterone) should routinely be advised and as soon as there is any threat of premature labour hospitalisation is needed. Twenty one of the 23 patients had prophylactic cerclage (Shirodkar's stitch). In 77% of the cases respiratory distress in the newborn was avoided by using cortico-therapy. Vaginal delivery can be carried out under certain conditions in triplet pregnancies. If certain precautions are taken there does not seem to be any immediate difference in the post delivery period of these children if they are born vaginally or by caesarean. Perinatal mortality is raised (at 5.6% for triplets and 58.3% for quadruplets). The psychological implications of these pregnancies are important. Problems appear as soon as the diagnosis is made and continue for years afterwards. On the social level, help given by the social services are usually inadequate. If the couples belong to the National Association for Mutual Aid of Parents of Children of Multiple Births, a system of mutual support is available. We recommend that these pregnancies should be looked after by several disciplines. These consist not only of obstetricians, paediatricians, anaesthetists, those who resuscitate together, but also psychologists, dietitians, social workers, community workers and physiotherapists.

Clinical Protocols↗