Abstract
STUDY QUESTION
What is the evidence to guide the management of women who wish to conceive following abdominopelvic radiotherapy (AP RT) or total body irradiation (TBI)?
SUMMARY ANSWER
...Pregnancy is possible, even following higher doses of post-pubertal uterine radiation exposure; however, it is associated with adverse reproductive sequelae and pregnancies must be managed in a high-risk obstetric unit.
WHAT IS KNOWN ALREADY
In addition to primary ovarian insufficiency, female survivors who are treated with AP RT and TBI are at risk of damage to the uterus. This may impact on its function and manifest as adverse reproductive sequelae.
STUDY DESIGN, SIZE, DURATION
A review of the literature was carried out and a multidisciplinary working group provided expert opinion regarding assessment of the uterus and obstetric management.
PARTICIPANTS/MATERIALS, SETTING, METHODS
Reproductive outcomes for postpubertal women with uterine radiation exposure in the form of AP RT or TBI were reviewed. This included Pubmed listed peer-reviewed publications from 1990 to 2019, and limited to English language..
MAIN RESULTS AND THE ROLE OF CHANCE
The prepubertal uterus is much more vulnerable to the effects of radiation than after puberty. Almost all available information about the impact of radiation on the uterus comes from studies of radiation exposure during childhood or adolescence.
An uncomplicated pregnancy is possible, even with doses as high as 54 Gy. Therefore, tumour treatment doses alone cannot at present be used to accurately predict uterine damage.
LIMITATIONS, REASONS FOR CAUTION
Much of the data cannot be readily extrapolated to adult women who have had uterine radiation and the publications concerning adult women treated with AP RT are largely limited to case reports.
WIDER IMPLICATIONS OF THE FINDINGS
This analysis offers clinical guidance and assists with patient counselling. It is important to include patients who have undergone AP RT or TBI in prospective studies to provide further evidence regarding uterine function, pregnancy outcomes and correlation of imaging with clinical outcomes.
STUDY FUNDING/COMPETING INTEREST(S)
This study received no funding and there are no conflicts of interest.
TRIAL REGISTRATION NUMBER
N/A.
Monochorionic triplet pregnancies are extremely rare and information on these pregnancies and their complications are limited. We aimed to investigate the risk of early and late pregnancy ...complications, perinatal outcomes, and the timing and methods of fetal intervention in monochorionic triplet pregnancies.
This was a multicenter retrospective cohort study including monochorionic triamniotic (MCTA) triplet pregnancies. The exclusion criteria were twins, or multiple pregnancies with higher order than triplets (e.g. quadruplets, quintuplets), and dichorionic or trichorionic triplet pregnancies. Data on maternal age, mode of conception, diagnosis of major fetal structural anomalies or aneuploidy, gestational age (GA) at diagnosis of anomalies, twin to twin transfusion syndrome (TTTS), twin anemia polycythemia syndrome (TAPS), twin reversed arterial perfusion sequence (TRAP), or selective fetal growth restriction (sFGR) were ascertained from the patient records. Data on antenatal interventions were collected, including selective (fetal) reduction (3 to 2 or 3 to 1), laser surgery, or any active fetal intervention (including amniodrainage). Finally, perinatal outcomes included livebirth, intrauterine demise (IUD), neonatal death (NND), perinatal death (PND) and termination of pregnancy (TOP). Neonatal data such as GA at birth, birthweight, neonatal intensive care unit (NICU) admission, and neonatal morbidity were also collected.
In our cohort of MCTA triplet pregnancies (n=153 after excluding early miscarriages, TOP and loss to follow-up), the majority (90%) were managed expectantly. The incidence of fetal abnormalities and TRAP was 13.7% and 5.2%, respectively. The most common antenatal complication related to chorionicity was TTTS, which complicated just over a quarter (27.6%) of the pregnancies, followed by sFGR (16.4%), while TAPS (both spontaneous and post-laser) occurred in only 3.3%; no antenatal complication was recorded in 49.3% of pregnancies. Survival was largely associated with the development of these complications: 85.1%, 100% and 47.6% of pregnancies had at least one surviving newborn in those without antenatal complications, complicated by sFGR, or complicated by TTTS, respectively. The overall rates of preterm birth prior to 28 weeks and prior to 32 weeks' gestation were 14.5% and 49.2%, respectively.
MCTA triplet pregnancies represent a challenge in counseling, surveillance and management as monochorionicity-related complications occur in almost half of these pregnancies, which negatively impact their perinatal outcomes. This article is protected by copyright. All rights reserved.
The mechanisms responsible for twinning and disorders of twin gestations have been the subject of considerable interest by physicians and scientists, and cases of atypical twinning have called for a ...reexamination of the fundamental theories invoked to explain twin gestations. This article presents a review of the literature focusing on twinning and atypical twinning with an emphasis on the phenomena of chimeric twins, phenotypically discordant monozygotic twins, mirror-image twins, polar body twins, complete hydatidiform mole with a coexistent twin, vanishing twins, fetus papyraceus, fetus in fetu, superfetation, and superfecundation. The traditional models attributing monozygotic twinning to a fission event, and more recent models describing monozygotic twinning as a fusion event, are critically reviewed. Ethical restrictions on scientific experimentation with human embryos and the rarity of cases of atypical twinning have limited opportunities to elucidate the exact mechanisms by which these phenomena occur. Refinements in the modeling of early embryonic development in twin pregnancies may have significant clinical implications. The article includes a series of figures to illustrate the phenomena described.
Seventeen fetuses were diagnosed with isolated congenital talipes equinovarus (CTEV) on mid‐trimester ultrasound at the Royal Women's Hospital, Melbourne, between January, 1992 and December 1995. ...Sixteen of the 17 cases had an amniocentesis performed and all karyotypes were normal. The remaining case was phenotypically normal, except for a clubfoot. None of the pregnancies was complicated by any of the recognized intrauterine environmental causes of CTEV. Four of the babies were delivered prematurely and all survived the neonatal period. Six (35%) infants did not have CTEV at birth, although 2 had postural varus feet. Nine of the 11 infants who did have CTEV at birth were treated within days of birth with plaster of Paris for periods of 6 to 12 weeks. Two infants required no further treatment, 5 required orthotics and 2 required surgery. The other 2 infants with CTEV at birth were treated with orthotics at 8 weeks of age. All infants were considered to have an excellent result at the 2 year follow‐up. Seven (41%) of the prospective parents received antenatal counselling by an orthopaedic surgeon and the lack of study on outcome following an ultrasound diagnosis of CTEV was the impetus for our work.
An abnormal early intrapartum cardiotocogram was found to have a sensitivity of 26.4% and a positive predictive value of 28.3% for the detection of fetal acidaemia at birth and a sensitivity of 27.3% ...and a positive predictive value of 3.3% for the prediction of 5-minute Apgar scores below 7. The presence of meconium in the liquor amnii improved the predictive properties of the test. Although an abnormal early intrapartum feta heart rate pattern indicated a higher risk group, the majority of patients with abnormal early intrapartum cardiograms had a favourable outcome. A normal pattern does not exclude an adverse outcome.
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