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PubMedDate not supplied

Pregnancy and birth after assisted reproduction.

Pregnancy and birth after IVF has attracted much critical attention. Overall, pregnancy rates are about 30-40% with three transferred embryos. Abortion rates are high before 19 weeks of gestation, at 8% of established pregnancies, and ectopic pregnancies are regular occurrences. Pregnancy rates are highest (35%) in women aged 20-24 years, declining to 10% at and above age 40. The use of intracytoplasmic sperm injection (ICSI) and blastocyst transfer has transformed the establishment of pregnancies for couples with differing indications. High rates of implantation are achieved with blastocyst transfers, although many embryos die in vitro before this stage. Twins and triplets can result in up to 50% of pregnancies. Heterotopic pregnancies are rare. Abortion afflicts fetuses before 12 weeks (vanishing fetuses). Rates of spontaneous abortion can be as high as 50% with quadruplets and quintuplets, and may be even higher in cases of fetal aneuploidy. At birth, prematurity is high, especially with twins or higher multiple pregnancies. Fetal reduction is used to reduce multiple pregnancies for singletons. Ovarian hyperstimulation is a risk associated with multiple pregnancy.

Abortion, Spontaneous↗
PubMed1990

An agenda for meeting the special needs of multiple birth families.

Over 80,000 multiple birth babies are born each year in the U.S. Their families must cope with a constellation of complex physical and psychosocial challenges, which jeopardizes their health and functioning. The demands of twin pregnancy and the parenting of twins, triplets, quadruplets, quintuplets or more puts these families at disproportionately high risk for infant mortality, birth defects, child abuse, substance abuse, financial problems and marital problems. Health and social service resources must be developed to alleviate the stresses associated with multiple birth and to empower parents to cope well. Guidelines for policies, parent education, professional training and service delivery developed for the California Department of Health Service, Maternal and Child Health Branch, are here offered for the consideration of policy makers and public health planners.

Family↗
PubMed1982

Multiple gestations: management of pregnancy and delivery.

The antenatal management and outcome of 31 higher-order multiple gestations, 24 triplets, six quadruplets, and one set of quintuplets were analyzed. Bedrest was advised as soon as the diagnosis was made; hospitalization along with the administration of betamethasone and phenobarbital was begun during the second trimester. Caesarian section was performed on 13 women (42%). The overall mortality rate was 14.8%; excluding neonates less than 28 weeks of age, however, it became 7.5%. The primary cause of death was respiratory distress syndrome.

Apgar Score↗
PubMed1979

Analysis of multiple birth rates in Japan. 1. Secular trend, maternal age effect, and geographical variation in twinning rates.

Mean twin, triplet, and quadruplet birth rates in Japan from 1951 to 1968 were 6.41, 0.056, and 0.00094 per 1,000, respectively. In 1974 the corresponding figures were 5.83, 0.059, and 0.00329. No quintuplets were born in the former period, but a set was born in the latter year, the rate being 0.47 per million. From 1955 to 1966 the MZ twinning rate increased slightly, but decreased thereafter. This increase was limited to live-born MZ twins, particularly in the higher maternal age groups. The DZ twinning rate declined in the entire period, particularly in higher maternal age groups. This decline appeared to be essentially limited to fetal deaths. Among live births the MZ twinning rate underwent a nearly linear increase with maternal age, whereas the DZ twinning rate attained a mode in the maternal age group 35--39 years. The MZ and the DZ twinning rates among fetal deaths by maternal age had unimodal distributions with modes in maternal age groups 25--29 and 30--34 years, respectively. As to the DZ twinning rate, a geographical cline was noted, with a high rate in the northeast of Japan; the rate was positively correlated with latitude, which also positively correlated with the presence of multiple births among relatives. A negative but nonsignificant correlation was seen between the DZ twinning rate and the proportion of mothers treated with ovulation-inducing hormone. The proportion was higher in mothers of unlike-sexed twins than in those of like-sexed twins and in mothers of triplets than in those of twins. An association between DZ twinning rate and age-specific fertility per married woman is suggested to exist among higher maternal age groups in the northeast part of Japan in earlier years.

Adult↗
PubMed2001

Maternal serum C-reactive protein level does not change significantly after fetal reduction: it could be used as an indicator of chorioamnionitis.

PURPOSE: This study was aimed at investigating the diagnostic value of maternal serum C-reactive protein (CRP) in the recognition of chorioamnionitis in patients undergoing fetal reduction. METHODS: Seventy-one gravidas with high-order multifetal pregnancies, including 46 with triplets, 18 with quadruplets, and 7 with quintuplets, who underwent transabdominal fetal reduction to twins during the 10th-14th gestational week were recruited. The subjects were followed up clinically and ultrasonographically 1 week and 1 month after fetal reduction for signs of infection, premature uterine contraction, and premature rupture of the membranes CRP levels were measured prior to fetal reduction and at follow-up examinations, and were compared. RESULTS: Among the 71 mothers, 65 (92%) were normal after fetal reduction. The CRP levels were not significantly different prior to the procedure (0.27 +/- 0.26 mg/dL), and 1 week (0.23 +/- 0.24 mg/dL) and 1 month (0.24 +/- 0.20 mg/dL) later. There was no correlation between the number of fetuses reduced and the CRP levels. Six (8%) experienced leakage of amniotic fluid after fetal reduction. Three patients had normal CRP levels at that time and at the following tests. The pregnancies continued smoothly after conservative treatment. The other three patients had elevated CRP levels when leakage of amniotic fluid occurred. Fever and uterine irritability developed subsequently despite parenteral antibiotics and tocolytic therapy. Daily checks showed increasing CRP levels. The pregnancies were aborted, and the histology of the placental membranes revealed chorioamnionitis with infiltration of acute inflammatory cells. CONCLUSIONS: The absorption of inactive gestational tissue after fetal reduction did not affect CRP levels. CRP may be used as a marker of intrauterine infection after fetal reduction.

C-Reactive Protein↗
PubMed2001

How to avoid multiple pregnancies in assistive reproductive technologies.

Since 1980, there has been a worldwide dramatic increase in multiple births. This seems to be due to an increase in the age of reproduction, the use of ovulation induction, and the use of in vitro fertilization. Scarce data suggest that each of these causes is responsible for about one-third of the problem, although quintuplets and more are almost invariably due to ovulation induction. There has been little or no effort to issue guidelines or regulations with respect to ovulation induction, but there has been much advice as to how to control the problem in in vitro fertilization by limiting the number of embryos to be transferred. In sum, a good selection of high-quality embryos on day 3 would allow a high rate of pregnancy with the transfer of one or two blastocysts. Good results of cryopreservation must be part of an agreement in an in vitro fertilization program. If singleton live birthrates were considered to be the principal outcome of assisted reproductive technologies reported by centers and registry, twin and triplet rates should also be reported separately. And finally, if financial considerations would not limit the cost of reimbursement to in vitro fertilization procedures, the number of procedures could be increased with fewer embryos transferred.

Adult↗
PubMed2000

Reducing the risk of high-order multiple pregnancy after ovarian stimulation with gonadotropins.

BACKGROUND: The incidence of multiple gestation after therapy for infertility is especially high among women in whom ovulation is induced with gonadotropins. Whether the number of high-order multiple pregnancies (those with three or more fetuses) can be reduced is not known. METHODS: We analyzed data on 3347 consecutive treatment cycles in 1494 infertile women, 441 of which resulted in pregnancy. The data collected included the peak serum estradiol concentration, the number of follicles 16 mm or larger in diameter, and the total number of follicles on the day of induction of ovulation with human chorionic gonadotropin. Receiver-operating-characteristic curves and ordinal logistic-regression analyses were used to identify values that predicted multiple conceptions. RESULTS: Among the 441 pregnancies, 314 resulted from the conception of singletons, 88 of twins, 22 of triplets, 10 of quadruplets, 5 of quintuplets, and 2 of sextuplets. Neither the number of follicles 16 mm or larger nor peak serum estradiol concentrations greater than 2000 or 2500 pg per milliliter (7342 or 9178 pmol per liter) (the cutoff values currently in wide use) were significantly associated with the incidence of high-order multiple pregnancy. However, increasing total numbers of follicles and increasing peak serum estradiol concentrations correlated significantly with an increasing risk of high-order multiple pregnancy (P<0.001), as did younger age (P=0.008). The risk of high-order multiple pregnancy was significantly increased in women with a peak serum estradiol concentration of 1385 pg per milliliter (5084 pmol per liter) or higher (multivariate odds ratio, 1.9; 95 percent confidence interval, 1.3 to 2.8) or with seven or more follicles (multivariate odds ratio, 2.1; 95 percent confidence interval, 1.2 to 3.9) on the day of induction of ovulation. CONCLUSIONS: Gonadotropin stimulation that is less intensive than is currently customary may reduce the incidence of high-order multiple pregnancy in infertile women, though only to a limited extent and at the expense of overall pregnancy rates.

Adult↗
PubMed2000

Ethical theory and principles: do they have any relevance to problems arising in everyday practice?

This review of ethical theories with application to two difficult obstetric cases will allow the practicing obstetrician and gynecologist to use these theories to help resolve difficult ethical dilemmas. In the first case a pregnant human immunodeficiency virus-infected woman refuses to take triple preventive therapy, with potential fetal harm. In the second case a couple with a quintuplet multifetal pregnancy needs assistance to decide about selective termination to effect fetal reduction.

Caregivers↗
PubMed1983

Ovarian follicles of new-born Merino lambs from genetic lines which differ in fecundity.

Ovaries were obtained from 78 new-born lambs (12 singletons, 25 twins, 28 triplets, 10 quadruplets and 3 quintuplets) from flocks selected for (T902, T903 and Booroola) or against (O) multiple births. Sections of the ovaries were examined with a projection microscope and the numbers of all types of follicles were estimated. There were no differences between genetic lines in the number of primordial follicles, after adjustment for litter size and sire; however, there were significantly more of these follicles in single-born lambs than in lambs born in litters of two or more within genetic lines. The number of vesicular follicles was lower in Booroola than in O lambs.

Animals↗
PubMed1986

Evidence on precise time-coded symbols and memory of patterns in monkey cortical neuronal spike trains.

High-resolution examination of pulse sequences generated by single visual cortex cells of the rhesus monkey in response to precisely controlled visual stimuli has disclosed (i) that the outputs of such neurons contain highly improbable (P less than 10(-7) numbers of identical triplets of precisely repeating pulse patterns; (ii) that the precision of such matches is better than 1/6000th of a second; (iii) that there is a similarly improbable high number of precisely matching pairs of triplets and anti-triplets, about half of which are present in symmetrical quadruplets of the form A-B-A, and that precisely replicating quadruplets and quintuplets are similarly generated in improbably large numbers; (iv) that identical triplets occur highly preferentially during immediately succeeding presentation of the same stimulus to the eye; and (v) that identical triplet (and doublet) patterns occur much more frequently in the responses of the same nerve when the eye receives identical or similar stimuli in different experiments than when dissimilar stimuli are applied. From these findings it is concluded (i) that the high precision of pattern replication required for triplets of pulses in time to serve to encode specific inputs and to permit their decoding through spatial summation is met (observations i-iii); (ii) that stimulus-specific triplets symbolize components of responses to specific stimuli (observation iv); (iii) that a temporary memory store of previous responses exists (observations iv and v); and (iv) that the mammalian brain uses precise patterns of discharges in time to represent and store specific data, rather than statistical qualities associated with pulse trains to symbolize qualitative stimulus components.

Action Potentials↗
PubMed1980

The mothering of twins, triplets and quadruplets.

The present investigation was stimulated by the steadily rising incidence of twins, triplets and quadruplets over the last few decades. It set out to obtain mothers' reported reactions when faced with the tidings of the arrival of multiple infants, and to study mothers' means of coping with and their ways of relating to these twins and "supertwins"--Scheinfeld's term for triplets, quadruplets, and quintuplets.

Attitude↗
PubMed1999

Obstetric outcome and psychological follow-up of pregnancies after embryo reduction.

The obstetric outcome and psychological follow-up of the parents after embryo reduction performed at Sahlgrenska University Hospital between 1993 and 1997 in 13 women treated for infertility is described. A comparison is made with non-reduced multiple pregnancies, both spontaneous and multiple pregnancies after assisted reproduction technology. Altogether 10 triplets, two quadruplets and one quintuplet pregnancy underwent embryo reduction. The surgical procedure was performed in gestation week 7-8 by transvaginal, ultrasound-guided aspiration of embryonic tissue. The psychological follow-up included personal interviews and psychological evaluations by a Psychological General Well-being Scale (PGWB) and Beck's Depression Inventory (BDI). In 11 cases reduction was performed to twin pregnancies. In two cases of triplets after in-vitro fertilization and transfer of two embryos, reduction was performed on the monozygotic, monochorionic twins. No complete miscarriages occurred. Ten women delivered twins and three women delivered singletons. The mean gestation length was 40.4 weeks for singletons and 35.9 weeks for twins. The mean birthweight was 3411 g for singletons and 2392 g for twins. No complications related to the reduction were detected in the children.The psychological follow-up showed that the psychological well-being of the parents was good. However, the events around the reduction were experienced as chaotic and emotionally disturbing. One woman regretted the reduction. All couples emphasized that avoidance of high order pregnancies should be of primary importance. In conclusion, embryo reduction appears to improve the perinatal outcome of multiple pregnancies obtained after assisted reproduction technology. It is important that the surgical procedure is performed at a centre with experience of this type of intervention, by a limited number of surgeons and in a regulated manner. Psychologically, however, the intervention is traumatic and psychological management is essential for good final outcome.

Adult↗
PubMed1990

Oligonucleotide correlations between infector and host genomes hint at evolutionary relationships.

The frequencies of oligonucleotides of length 3-6 were studied in 211 sequences of human DNA (659 kilobases), 22 sequences of DNA of human viruses (120 kbs), in 181 sequences of E. coli (442 kbs), and in 42 sequences of phages of E. coli (137 kbs). The sequences were obtained from Genbank(R) 48. The observed frequencies (O) were compared to the expected frequencies (E) obtained in two ways: 1) according to nucleotide composition for each series, and 2) according to first order Markow chains for triplets, second order for quadruplets, and third order for quintuplets and sextuplets. The ratio O/E was obtained for each oligonucleotide. Then, the correlation between the ratio O/E in a pair of series was calculated. Strong correlations were observed for sequences of man and human viruses, and for E. coli and its phages. Other correlations were small. For higher order Markov chains, there is indication of some correlation also between viruses and phages. It was concluded that through analysis of parallel oligonucleotide series it may be possible to infer some of the complex evolutionary relationships existing between cells and their infectors beyond the level of codon usage.

Base Composition↗
PubMed1992

Embryo reduction in multifetal pregnancies using saline injection: comparison between the transvaginal and the transabdominal approach.

A total of 30 patients with multifetal pregnancies, all resulting from treatment with superovulatory agents or assisted reproductive techniques, underwent embryo reduction. All patients had three or more fetuses (one sextuplet, two quintuplets, seven quadruplets and 20 triplets). The procedure was carried out using intra-embryonal injection of 0.9% sodium chloride solution. Embryo reduction was carried out via the transabdominal approach in 10 patients, performed at 11-12 weeks of gestation, and via the transvaginal route in 20 other patients, at 8-10 weeks of gestation. In the transabdominal group, one patient aborted following repeated attempts at embryo reduction while the other nine gave birth to healthy newborns (eight twins and one triplet). In the transvaginal group, four pregnancies are currently ongoing (all beyond 28 weeks of gestation), 14 pregnancies resulted in a delivery of at least one live newborn (13 twins and one singleton), one patient had a late abortion at 24 weeks' gestation and another was delivered at 27 weeks' gestation due to severe pre-eclampsia. Transvaginal ultrasound-guided needle procedures are commonly practised in most in-vitro fertilization units. The employment of this route for embryo reduction, performed at an earlier gestational age and with the use of a non-toxic substance such as 0.9% saline solution, is advocated.

Abdomen↗
PubMed1993

Selective reduction of multifetal pregnancies in the first trimester using colour Doppler ultrasonography.

In pregnancies with multiple gestation, an adverse outcome is directly proportional to the number of fetuses within the uterus, primarily because of an increased predisposition to premature delivery. Although there is a good deal of information about multifetal reduction in triplets and quadruplets and even quintuplets, there is very little on sextuplets, and virtually nothing on septuplets. Among the different techniques proposed for selective termination, two approaches have been more widely adopted: transcervical aspiration and transabdominal needling of the embryo using grey scale ultrasonography, but as yet there is no report on multifetal reduction using colour Doppler ultrasound. A method for selective termination of multiple pregnancy using transabdominal colour Doppler ultrasonography has been described here for the first time in a case of septuplets.

Abortion, Therapeutic↗
PubMed1989

Flexibility plot of proteins.

The flexibility plot of a protein lies on the observation that amino acid residues with the highest turn potential, i.e. located in highly mobile regions of protein surface, also possess the smallest volumes as well as the lowest hydrophobicities. The plot is generated by shifting a five residue window along the protein sequence and calculating the value of the hydrophobicity-volume product for consecutive quintuplets of amino acid residues. The concomitant occurrence of small volumes and low hydrophobicities results in very deep minima. A threshold value has also been introduced in order to discriminate significant minima. To substantiate the interpretation that the selected minima actually indicate very flexible segments of a protein (loops, turns, etc.), we have compared plots obtained for model proteins (lysozyme, myoglobin, ribonuclease, trypsin, thermolysin and T4 lysozyme) with X-ray thermal factors profiles available for the same proteins. When compared to thermal profiles, the majority of flexible segments evidenced by our plots have been found to be in agreement with regions characterized by high thermal factors. Results have also been discussed in the light of local organization possessed by examined proteins.

Amino Acids↗
PubMed1998

Nuclear-cytoplasmic interaction and development of goat embryos reconstructed by nuclear transplantation: production of goats by serially cloning embryos.

The time of pronuclear formation of in vivo-matured oocytes was examined. Maturation-promoting factor (MPF) activity in enucleated and electrically activated oocytes was checked by assessment of nuclear envelope breakdown (NEBD) of fused blastomeres. The effect of stage of the cell cycle of donor cells and recipient oocytes on DNA synthesis and development of reconstructed embryos was studied. MPF activity declined rapidly to approximately 63.2% at 1 h, to 9.7% at 5 h, and to the level at which NEBD cannot occur at 7 h postactivation. All blastomeres that were fused at the time of recipient cytoplasm activation underwent NEBD and subsequent DNA synthesis. However, when blastomeres were fused to enucleated oocytes at 7 h postactivation, no NEBD was observed; DNA was replicated in nuclei at the G1/S border, but in G2 nuclei no DNA replication was observed. The proportion of development to blastocysts of reconstructed goat embryos increased with the decline in MPF activity in fused recipient cytoplasm when reconstruction took place at 0-6 h postactivation of enucleated oocytes. Generations 1, 2, 3, 4, 5, and 6 of cloned goat embryos were produced by a combination of nuclear transplantation and in vitro techniques. After transfer to recipients, 45 kids were obtained, including three pairs of monozygotic twins, three series of monozygotic triplets, two series of monozygotic quadruplets, three series of monozygotic quintuplets, and one series of monozygotic heptaplets. The present study indicates that normal DNA replication of goat blastomere nuclei can be accomplished in enucleated oocytes when MPF activity is low, regardless of the stage of the cell cycle of donor nuclei; induction of NEBD and prematuration chromosome condensation is not essential for further development of reconstructed goat embryos.

Animals↗
PubMed2003

Populations at risk for developing respiratory syncytial virus and risk factors for respiratory syncytial virus severity: infants with predisposing conditions.

According to National Vital Statistics Reports, premature infants (< 36 weeks gestation) account for approximately 7.4% of all births. During the 8 years from 1989 to 1997, multiple births steadily increased across all categories from twin to quintuplet and higher orders. During that same period low birth weight (< 2500 g) births increased almost 12%, and very low birth weight (< 1500 g) births increased approximately 20%.Attendant to these national trends in multiple and preterm births, overall gestation-specific survival rates have improved substantially. This improved outcome can be attributed in large measure to advances in neonatal care and technology. Despite the encouraging statistics on survival, infants born prematurely, at low or very low birth weights and/or with chronic conditions that predispose to lower respiratory tract illness, continue to incur serious risk of long term morbidity and the consumption of inpatient hospital services. In a recent 2-year study of US children, low and very low birth weights were found to be independent risk factors for bronchiolitis-associated mortality. In the past 14 years what defines bronchopulmonary dysplasia (BPD)/chronic lung disease (CLD) has shifted away from clinical, radiographic and pathologic findings in the preterm infant toward the pathophysiology of arrested lung development and the need for supportive care beyond 36 weeks corrected gestational age. The incidence of BPD/CLD ranges from 14 to 43%, with higher rates observed among infants of lower gestational age and birth weight. The health care team approach to the management of BPD directs its efforts toward minimizing pulmonary vascular resistance, alleviating airway obstruction and improving short term lung mechanics. Measures to prevent BPD/CLD attempt to forestall both acute and chronic lung function abnormalities. To that end researchers have investigated the early use of continuous positive airway pressure, vitamin supplementation and recombinant human copper/zinc superoxide dismutase. Despite significant gains in the survival of infants born at lower gestational ages, prematurity, low birth weight and/or underlying chronic pulmonary disease put the pediatric patient at risk for increased frequency and severity of respiratory syncytial virus lower respiratory tract illness and the potential for its long term sequelae.

Airway Obstruction↗