Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item The influence of chorionicity and gestational age at single fetal loss on the risk of preterm birth in twin pregnancies: analysis of the STORK multiple pregnancy cohort(Wiley, 2017) D'Antonio, F.; Thilaganathan, B.; Dias, T.; Khalil, A.; Southwest Thames Obstetric Research Collaborative (STORK)BACKGROUND: Single intrauterine death (sIUD) in twin pregnancies is associated with a significant risk of co-twin demise and pretermbirth (PTB), especially in monochorionic (MC) twins. However, it is yet to be established whether the gestational age at loss may influence the pregnancy outcome. The aim of this study was to explore the risk of PTB according to the gestational age at the diagnosis of sIUD. METHODS: A cohort study of all twin pregnancies from a large regional network of 9 hospitals over a ten-year period. Ultrasound data was matched to hospital delivery records and a mandatory national register for perinatal losses (CMACE). Cases with double fetal loss at the time of the scan were not included in the analysis. The cumulative rates of PTB before 34, 32 and 28 weeks of gestation was assessed in pregnancies which did vs those which did not experience sIUD. The risk of PTB was stratified according to the gestationalage at the diagnosis of sIUD. RESULTS: The analysis included 3013 twin gestations (2469 DC and 544 MC) . Median gestational age at birth was lower in the pregnancies complicated by sIUD compared to those which were not (32.0 weeks, IQR 29.0-34.3 vs 36.7 weeks, IQR 35.0-37.6; p < 0.001) and this difference persisted when stratifying the analysis according to chorionicity (p < 0.0001 for both MC and DC pregnancies). The risk of PTB before 34 weeks (RR: 4.3, 95% CI 3.5-5.2), before 32 weeks (RR: 6.1, 95% CI 4.6-8.1) and before 28 weeks (RR: 12.40, 95% CI 6.9-22.2) was higher in pregnancies complicated by a sIUD compared to those which did not experience any fetal loss. This association was observed both in MC and DC twin gestations. When compared to DC pregnancies, MC twins affected by sIUD were not at significantly increased risk of PTB either before 34, 32 or 28 weeks of gestation. The risk of PTB before 34 weeks of gestation was higher when the sIUD occurred at a later gestational age (Chi-square test for trend, p < 0.001). CONCLUSION: Twin pregnancies complicated by sIUD, regardless of the chorionicity, have a significantly higher risk of PTB before 34, 32 and 28 weeks of gestation. The risk of PTB before 34 weeks of gestation was higher when the sIUD occurred in the second half of the pregnancy. Large prospective multicenter studies with shared protocols for prenatal management are needed to ascertain the actual risk of spontaneous PTB in twin pregnancies affected by sIUD.Item Use of ultrasound in predicting the success of intrauterine contraceptive device (Copper T) insertion immediately after delivery(John Wiley and Sons, 2015) Dias, T.; Abeykoon, S.; Kumarasiri, S.; Gunawardena, C.; Padeniya, T.; D'Antonio, F.OBJECTIVES: To assess by ultrasound examination the success of insertion of an intrauterine contraceptive device (IUD) immediately after delivery and to determine the optimal distance between the lower end of the IUD and the internal os in predicting successful retention of an IUD. METHODS: This was a prospective study carried out between December 2012 and April 2013. Two ultrasound examinations, transabdominal and transvaginal, were performed prior to hospital discharge following delivery and again at 6 weeks following delivery in women who received a postpartum IUD. Distance from the internal os to the lower end of the IUD was measured at each examination and compared in unsuccessful and successful cases of postvaginal delivery (PVD) and post-Cesarean section (PCS) IUD insertion. Logistic regression and receiver-operating characteristics (ROC) curve analysis were used to determine the difference in success between the two modes of delivery and to determine the optimal cut-off of the internal os-to-IUD distance for successful retention, respectively. RESULTS: Ninety-one women were included in the study, comprising 60 PVD and 31 PCS IUD insertions. Thirteen PVD (22.4%) and eight PCS (25.8%) IUDs were either expelled spontaneously or removed at the 6-week scan because of improper placement. Mean distance from the internal os to the lower end of the IUD on ultrasound examination immediately after insertion was significantly greater in successful cases than in those in which IUDs were subsequently expelled/displaced (mean difference after PVD insertion, 20.1 mm (P = 0.006); mean difference after PCS insertion, 10.3 mm (P = 0.05)). Logistic regression analysis demonstrated that mode of delivery was not independently associated with successful retention of the IUD (P = 0.72; OR, 0.831 (95% CI, 0.301-2.189)). The distance from the lower end of the IUD to the internal os measured at ultrasound examination prior to hospital discharge provided reasonable predictive accuracy for determining retention of the IUD, with an area under the ROC curve of 0.74 (95% CI, 0.60-0.88) and an optimal cut-off of ≥ 30 mm (sensitivity, 64.71% (95% CI, 52.17-75.92%) and specificity, 80.95% (95% CI, 58.09-94.55%)). CONCLUSIONS: IUD insertion immediately postpartum is feasible but carries a substantial risk of unsuccessful IUD retention. Ultrasound examination after insertion of an IUD could be considered for predicting the success of IUD retention. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.