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Concept: Multiple birth


To describe the incidence and nature of prenatal brain damage following fetoscopic laser selective coagulation (FLSC) of placental vessels for twin-to-twin transfusion syndrome (TTTS).

Concepts: Surgery, Obstetrics, Syndromes, Twin-to-twin transfusion syndrome, Multiple birth, Fetoscopy, Laser surgery, Polyhydramnios


Background The standard therapy for women with unexplained infertility is gonadotropin or clomiphene citrate. Ovarian stimulation with letrozole has been proposed to reduce multiple gestations while maintaining live birth rates. Methods We enrolled couples with unexplained infertility in a multicenter, randomized trial. Ovulatory women 18 to 40 years of age with at least one patent fallopian tube were randomly assigned to ovarian stimulation (up to four cycles) with gonadotropin (301 women), clomiphene (300), or letrozole (299). The primary outcome was the rate of multiple gestations among women with clinical pregnancies. Results After treatment with gonadotropin, clomiphene, or letrozole, clinical pregnancies occurred in 35.5%, 28.3%, and 22.4% of cycles, and live birth in 32.2%, 23.3%, and 18.7%, respectively; pregnancy rates with letrozole were significantly lower than the rates with standard therapy (gonadotropin or clomiphene) (P=0.003) or gonadotropin alone (P<0.001) but not with clomiphene alone (P=0.10). Among ongoing pregnancies with fetal heart activity, the multiple gestation rate with letrozole (9 of 67 pregnancies, 13%) did not differ significantly from the rate with gonadotropin or clomiphene (42 of 192, 22%; P=0.15) or clomiphene alone (8 of 85, 9%; P=0.44) but was lower than the rate with gonadotropin alone (34 of 107, 32%; P=0.006). All multiple gestations in the clomiphene and letrozole groups were twins, whereas gonadotropin treatment resulted in 24 twin and 10 triplet gestations. There were no significant differences among groups in the frequencies of congenital anomalies or major fetal and neonatal complications. Conclusions In women with unexplained infertility, ovarian stimulation with letrozole resulted in a significantly lower frequency of multiple gestation but also a lower frequency of live birth, as compared with gonadotropin but not as compared with clomiphene. (Funded by the National Institutes of Health and others; number, NCT01044862 .).

Concepts: Pregnancy, Childbirth, Reproduction, Embryo, Uterus, Infertility, Abortion, Multiple birth


Statistics reflect that pregnancies are occurring at a later age, multiple births are becoming more common, and a sizeable population-with a keen interest in nutrition, fitness, and a continued desire to retain a youthful figure-is aging. Consequently, postpartum reshaping is a priority for many women, enough so that the phrase “mommy makeover” has entered the vernacular. In this article, the senior author’s practice was evaluated to explore patient goals, methods, and outcomes in reshaping the postpartum abdomen. A literature review was conducted to assess the state of the art in methods to meet these goals. The postpartum patient often uses her prepregnancy appearance as a barometer for her postpregnancy goals. Although aging is one force motivating women to pursue abdominoplasty, the majority desires the correction of changes related to pregnancy. The abdomen and breasts are the regions most visibly affected by pregnancy, although numerous aesthetic units of the trunk and surrounding regions concern patients seeking postpartum body contouring and they may be part of the patient’s perception and idealization of her appearance. Abdominoplasty is central to postpartum body contouring, and numerous strategies such as concurrent flap, flank, or mons pubis liposuction and waistline enhancement methods are integral components of it. Consideration should also be given to the multiple body areas affected by pregnancy that may enhance the patient’s overall appearance. In the appropriate context, multiple procedures can be safely and effectively combined to address the various regions affected by postpartum changes.

Concepts: Pregnancy, Childbirth, Patient, Infertility, Pelvis, Multiple birth, Vulva, Mons pubis


Alitretinoin (9-cis-retinoic acid) is a synthetic vitamin A derivative with immunomodulatory and anti-inflammatory activity recently licensed as a treatment for refractory chronic hand eczema(1) . Here, we report the successful use of oral alitretinoin in two women of childbearing age with Darier’s disease (DD). DD (OMIM 124200) is an autosomal dominant disorder of keratinisation characterised by multiple discrete or confluent warty papules and plaques in seborrhoeic areas, palmoplantar pits and distinctive nail dystrophy(2) of teenage or adult onset.

Concepts: Pregnancy, Childbirth, Energy, Folic acid, Multiple birth, Retinol, Vitamin A


In twin-to-twin transfusion syndrome (TTTS), genetically identical twins are exposed to different haemodynamic conditions during fetal life, which are considered to be the cause of prenatal and postnatal cardiovascular differences between the donor and the recipient.

Concepts: Pregnancy, Obstetrics, Syndromes, Twin-to-twin transfusion syndrome, Twins, Multiple birth, Fetoscopy, Polyhydramnios


Preeclampsia is a multisystem disorder affecting 2% to 8% of pregnancies and a leading cause of maternal and perinatal morbidity and mortality worldwide. Recent investigations have improved our understanding of the pathogenesis of this potentially life-threatening disease, especially in its early-onset form of manifestation. Despite these advances, therapeutic options are still limited and no effective pharmacologic interventions are currently available. Ongoing lines of research indicate some potential novel treatments targeting specific pathogenic steps. In this article we provide an updated overview of the multiple therapeutic approaches under preclinical and clinical assessment for the treatment of early-onset preeclampsia.

Concepts: Medicine, Pregnancy, Obstetrics, Breastfeeding, Multiple birth


In 2017, of the 22.5 million parenting adolescents (ages 15-19) in 60 countries, approximately 4.1 million gave birth to a second or higher-order child. Adolescent pregnancy in general, and rapid repeat pregnancies specifically, expose young mothers and their children to multiple health and socioeconomic risks. The purpose of this article is to review the impact of interventions designed to prevent unintended, rapid repeat pregnancies among adolescents, including those aimed at changing norms to postpone “intended” closely spaced pregnancies to promote healthy spacing.

Concepts: Pregnancy, Childbirth, Childhood, Abortion, Adolescence, Multiple birth, Hazard prevention, Pregnancy over age 50


Peripartum cardiomyopathy (PPCM) is an often fatal disease that affects pregnant women who are near delivery, and it occurs more frequently in women with pre-eclampsia and/or multiple gestation. The aetiology of PPCM, and why it is associated with pre-eclampsia, remain unknown. Here we show that PPCM is associated with a systemic angiogenic imbalance, accentuated by pre-eclampsia. Mice that lack cardiac PGC-1α, a powerful regulator of angiogenesis, develop profound PPCM. Importantly, the PPCM is entirely rescued by pro-angiogenic therapies. In humans, the placenta in late gestation secretes VEGF inhibitors like soluble FLT1 (sFLT1), and this is accentuated by multiple gestation and pre-eclampsia. This anti-angiogenic environment is accompanied by subclinical cardiac dysfunction, the extent of which correlates with circulating levels of sFLT1. Exogenous sFLT1 alone caused diastolic dysfunction in wild-type mice, and profound systolic dysfunction in mice lacking cardiac PGC-1α. Finally, plasma samples from women with PPCM contained abnormally high levels of sFLT1. These data indicate that PPCM is mainly a vascular disease, caused by excess anti-angiogenic signalling in the peripartum period. The data also explain how late pregnancy poses a threat to cardiac homeostasis, and why pre-eclampsia and multiple gestation are important risk factors for the development of PPCM.

Concepts: Pregnancy, Childbirth, Reproduction, Angiogenesis, Uterus, Vascular endothelial growth factor, Obstetrics, Multiple birth


-Few studies have investigated the combination of pregnancy complications that predict risk for cardiovascular disease (CVD) death and how risk changes with age. This report presents a comprehensive investigation of the relation of the occurrence of multiple pregnancy complications to CVD death over 5 decades in a large pregnancy cohort.

Concepts: Medicine, Pregnancy, Disease, Death, Senescence, Demography, Infertility, Multiple birth


Patients with multiple sclerosis (MS) or Crohn’s disease (CD) being treated with natalizumab (Tysabri®, Biogen) who are planning to become pregnant or discover they are pregnant after exposure to natalizumab are currently advised to balance the potential benefits and potential risks of exposure when considering treatment options. This study was undertaken to evaluate pregnancy outcomes of women with MS or CD who were exposed to natalizumab at any time within 3 months prior to conception or during pregnancy. A pregnancy registry was created to better understand the effect of natalizumab exposure on pregnancy outcomes.

Concepts: Pregnancy, Multiple sclerosis, Crohn's disease, In vitro fertilisation, Implantation, Multiple birth, Low dose naltrexone, Natalizumab