Oral Concurrent Session 3 Essay

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Outcome after embryo reduction in triplet pregnancy compared to ongoing triplet pregnancies and primary twins

OBJECTIVE: To assess in triplet pregnancies the effectiveness of selective reduction to twins.
STUDY DESIGN: We studied in a retrospective study consecutive cases of triplet pregnancies that were reduced to twins in all fetal medicine units in the Netherlands (2000-2010). All reductions were performed for social indication, transabdominally by intracardiac KCl injection between 10-15 weeks. The outcome was compared to ongoing triplet pregnancies retrieved from the Dutch Perinatal Registration (PRN), and to twin pregnancies collected from a previous RCT comparing progesterone to placebo (AMPHIA ISRCTN 40512715). The three groups were compared for mean gestation age, pregnancy loss <24 weeks, delivery <32 weeks, neonatal birth weight and number of stillbirths. Statistical test were performed in SPSS 18. One Way ANOVA test was use to compare mean gestational age and Chi Square test to compare delivery <24 and <32 weeks, neonatal birth weight and number of stillbirths.

RESULTS: We identified 76 triplet pregnancies reduced to twins. Mean gestational age at delivery was 33.7 weeks (SD 5.5). For ongoing triplets and primary twins this was 32.8 weeks (SD 3.8) and 35.6 weeks (SD 3.7), resp. Mean neonatal birth weight of the first child was 2123.5 grams (SD 811.6) in the reduced group, 1883.2 (703.8) and 2383.7 (657.7) grams in ongoing triplets and primary twins, resp. Preterm delivery  24 and  32 weeks was not different for ongoing triplets and triplets reduced to twins (3.8% vs 7.9% and 26.8% vs 22.4% resp.)
but there was a significant difference between the reduction group and primary twins for delivery 24 and 32 weeks (7.9% vs 2.6% and 22.4% vs 11.1 % resp.). In the reduction group there were 9 stillbirths (16%), for ongoing triplets and primary twins this was significantly lower, 22 (4%) and 15 (2%) resp.
CONCLUSION: Embryo reduction from triplet to twin did not improve
gestational age and neonatal outcome and these twins are not comparable to primary twins. Since the risk of pregnancy loss <24 weeks increases in reduced twins, improvement in obstetric outcome should not be used as an argument for reduction.

Effects on (neuro)developmental and behavioral outcome at 2 years of age of induced labor compared with expectant management in intra-uterine growth restricted infants–long term outcomes of the DIGITAT-trial

Dutch Consortium for Studies in Women’s Health and Reproductivity, Obstetrics, Leiden, Netherlands

OBJECTIVE: To study, in pregnancies complicated by intra-uterine growth restriction (IUGR) at term, the effect of being randomized to induction of labor on long-term developmental- and behavioral- outcomes, and to study the effect of neonatal condition at birth on these developmental outcomes.
STUDY DESIGN: We studied children included in a nationwide randomized controlled-trial comparing induction of labor with expectant management in pregnancies with IUGR at term. Parents of children included in the trial were asked to fill out two postal questionnaires at the age of 2-years: the Ages and Stages (ASQ) and Child Behaviour Checklist (CBCL). The ASQ is designed to detect developmental delay and the CBCL is a standardized parental report of children’s behavior.
We compared the number of children with an abnormal outcome in both arms, as well as the effect of perinatal morbidity, morbidity assessment index for newborns (MAIN score), gestational age at birth and birth weight on long-term outcome. Perinatal morbidity was defined as a 5 minute Apgar score <7, umbilical arterial pH <7.05 or NICU admission. The MAIN score is a validated numeric index of early neonatal outcomes.
RESULTS: We approached 488 (75%) of the 660 parents of children randomized in the trial. The response rate was 60%. 27% and 14% of the children had an abnormal score on the ASQ and CBCL, respectively (Table 1). Results of the questionnaires were comparable for both interventions. However, poor neonatal condition after birth and the MAIN score both strongly increased the chance of an abnormal ASQ score (Odds Ratios of 18 (95% CI 1.5-212, p0.02) and 1.005 (95% CI 1.002; 1.005, p0.01), respectively). We found no association between birth weight or gestational age at birth and the outcome of the ASQ or CBCL.
CONCLUSION: In women with IUGR at term, a policy of induction of labor does not affect developmental and behavioral outcome when compared to expectant management. However, in both policies adverse neonatal outcome and MAIN score (corrected for other possible variables) both have negative effects on the outcome on the long-term child development.



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