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PubMed2003

Birthweight discordance in multiple pregnancy.

This paper reviews several aspects of discordant growth in multiple pregnancies. Discordant growth is not a chance event and therefore several patterns can be discerned. About 75% of twins exhibit < 15% discordance (concordant), 20% are 15-25% (mildly) discordant, and about 5% are more than 25% (severely) discordant. Higher frequencies and increased severity are seen among triplets. Five observations regarding discordance became generally accepted: (a) not all discordant pairs are similar; (b) the larger the discordance level the greater is the risk for an adverse outcome; (c) discordant growth does not necessarily represent growth restriction; (d) a discordance level may have a different clinical implication in different gestational ages; and (e) the smaller fetuses in severely discordant pairs are at disproportionate risk for neonatal mortality. Mild discordance may represent a normal variation between sibs whereas severely discordant pairs often exhibit patterns of growth restriction. Not infrequently, discordance may represent an adaptation to the limited intrauterine space in order to increase gestational age.

Birth Weight↗
PubMed2003

Breastfeeding rights of multiple birth families and guidelines for health professionals.

Increasing numbers of women wish to breastfeed their multiple birth children. Breastfeeding of preterm and fullterm multiple birth infants is complex and demanding for the families and presents distinct challenges for health professionals. Families require sustained assistance from health care providers who are encouraging, knowledgeable, skilled, and committed to the breastfeeding of multiple birth children. Seven breastfeeding rights of multiple birth families are presented for the continuum of pregnancy to early childhood and are in accordance with the Declaration of Rights and Statement of Needs of Twins and Higher Order Multiples (Council of Multiple Birth Organizations of the International Society for Twin Studies, 1995). Guidelines for each of the rights have been developed to assist health professionals provide "best practices" in community and hospital settings. The guidelines are based on the existing body of breastfeeding of multiples' research, empirical findings, and consultations with parents and care providers with experience and/or expertise in breastfeeding multiples. The rights and guidelines suggest direction for providing assistance, implementing programs and services, conducting research, and evaluating the effectiveness of multiples-specific breastfeeding care during the prenatal, infancy, and toddlerhood periods.

Breast Feeding↗
PubMed2004

Why zygosity of multiple births is not always obvious: an examination of zygosity testing requests from twins or their parents.

This paper examines why parents of twins or adult twins themselves request zygosity testing. Of 405 multiples including 8 sets of triplets, the majority (93%) were monozygotic. Age of testing ranged from 0 days to 73 years. About 50% of requests came from parents or twins who were curious about, or expressed a need to be certain of, their zygosity. Other reasons included health concerns (current or future), other twins in the family, and misinformation about zygosity, frequently because of the erroneous assumption that all dichorionic twins are dizygotic. Parents of monozygotic twins may expect their twins to be 'identical' and believe their twins to be dizygotic because of minor phenotypic differences between them. Dizygotic twins like other siblings may share a phenotypic resemblance. Health professionals should be aware that zygosity of multiples may not always be obvious to parents and that accurate knowledge of zygosity may be justified.

Adolescent↗
PubMed2004

Comparison of feeding among multiple birth infants.

Mothers of multiples who choose to feed their infants breast milk are faced with a seemingly overwhelming set of circumstances. Since mothers of multiples could potentially feed their infants differing proportions of breast milk, current methods of obtaining breastfeeding data for mothers of singletons may not adequately describe the breastfeeding behaviors of mothers of twins and triplets. The goal of our study was to determine the proportion of breast milk each infant of a multiple set was fed over a six-month period and compare the feeding regimens of sibling infants. Results of this retrospective study based on maternal reports indicated that there was almost complete agreement in the proportion of breast milk fed to siblings born from the same pregnancy, regardless of stratification based on gestational age, plurality, or location of the infants (hospital vs. home). The Pearson correlation coefficient for duration of breast-milk feeding between sibling twins was 0.99 (p < .0001); among sibling triplets the values were .97, .98 and .99 (p < .0001). A better understanding of the process by which twins and triplets are fed breast milk sets the stage for future research and can ultimately lead to the development of strategies to increase breast-milk feeding rates for multiple birth children.

Age Factors↗
PubMed2004

The Western Australian Register of Childhood Multiples: effects of questionnaire design and follow-up protocol on response rates and representativeness.

Twin registers have been established worldwide to study the roles of genes and the environment in health and behaviour. While questionnaire surveys are thought to be the most cost-effective way of collecting large amounts of data, low response rates can result in response bias. Many different strategies have been proposed to maximise response rates. A register of all multiple births occurring in Western Australia (WA) from 1980 onwards has been established using probabilistic record linkage techniques. Families who had not experienced the death of one or more of their multiples were invited to participate in the Western Australian Twin Child Health (WATCH) study, which studied the genetic and environmental determinants of childhood asthma and atopy. Several questionnaire designs and follow-up methods were assessed. We have shown that it was feasible to use a population-based register of multiple births to contact families for a questionnaire study. Questionnaire length, mode of follow-up, the number of responses required and the of participants all seemed to affect response.

Follow-Up Studies↗
PubMed2004

Twin research, and its multiple births and expressions: a short, personal voyage through its scope, history, and organization.

The notion of twins and twinning involves a multiplicity of meanings and contexts that altogether encompass an unexpectedly wide and significant part of human experience, culture, and endeavor. This cultural polysemy is, to some extent, also an attribute of twin research, which has structured itself around a multiplicity of scientific areas of enquiry, and across time, throughout a multiplicity of births and rebirths, periodically declining and resurging as a phoenix from its ashes. What is proposed is a short voyage through this polysemy and phoenixity of twinning and twin research, and through the structuring process that has accompanied its developments, international scope, and organization. No claim to completeness, but an attempt to dig into personal memory and experience, and share some recollections of the main steps of the process, and particularly the evolution of the journal, the society, the international meetings, and their role in supporting the area's persistence and continuous revivals and adaptations until today.

Congresses as Topic↗
PubMed1998

The East Flanders Prospective Twin Survey (Belgium): a population-based register.

The East Flanders Prospective Twin Survey (EFPTS), started in 1964, is unique among the 17 major European twin registers because it is population based, the twins (and higher order births) are ascertained at birth, basic perinatal data are collected, chorion type is established and, when appropriate, genetic markers including DNA fingerprints, are determined. The total number of sets is 5089 twin, 158 triplet and 14 of higher order. Zygosity has been diagnosed on the basis of sex, placental structure and genetic markers in more than 95% of pairs. The EFPTS is the only large register that includes placental data and allows differentiation of three subtypes of monozygotic twins based on the time of the initial zygotic division: the dichorionic-diamnionic pairs (early), the monochorionic-diamnionic pairs (intermediate), and the monochorionic-monoamnionic pairs (late). Methodology and basic results in twins are considered in this article; detailed studies will be reported later. The sex proportion in dizygotic (DZ) twins is the same as in singletons, whereas monozygotic (MZ) twins number more girls than boys. The difference in perinatal mortality between DZ and MZ twins is limited to the monochorionic MZ subgroup. Birth weight is highest in DZ twins and diminishes stepwise in MZ dichorionic and MZ monochorionic twins. Duration of pregnancy follows the same trend but is limited to a few days. Iatrogenic pregnancies are increasing to the point of representing almost 50% of the twin births in 1997.

Amnion↗
PubMed1999

Constant multiple birth rates in the Czech Republic and the Slovak Republic until recently, 1972-1995.

Using vital statistics, yearly changes in the twinning and triplet rates by zygosity were investigated in the Czech Republic and the Slovak Republic during the period 1972-1995. Monozygotic (MZ) twinning rates in both countries had remained nearly constant (about 3 per 1000 total births) during that period. With a few exceptions, the dizygotic (DZ) twinning rates remained constant from 1972 to 1994, and increased in 1995 for both countries. MZ twinning rates for both countries were the lowest in Europe. As for triplet rates, overall rates increased significantly year by year in the Czech Republic, but not in the Slovak Republic. The triplet rate was significantly higher in 1995 than in the period 1972-1982 for both countries. The MZ triplet rate remained constant during that period in the Czech Republic. The trizygotic (TZ) triplet rates increased 3-fold for the Czech Republic and 4-fold for the Slovak Republic in 1972-1976 and 1992-1995. In the later period, the TZ rate was 1.5-fold higher in the Czech Republic than in the Slovak Republic. The quadruplet rate increased 2.3-fold from 2.9 per million births in 1982-1986 to 6.7 in 1992-1995 in the Czech Republic. The corresponding values were 2.7, 2.20 and 5.9-fold in the Slovak Republic. Both the Czech and the Slovak Republics were not affected by fertility drugs and assisted reproductive techniques until recently.

Birth Rate↗
PubMed2006

Stillbirth rates in singletons, twins and triplets in Sweden, 1869 to 2001.

The temporal variation in the stillbirth rates (SBR), measured as the number of stillborn per 1000 total births, among singletons, twins and triplets was studied on Swedish birth data for the period 1869 to 2001 and comparisons with data from other populations were made. Among both single and multiple births there were marked, almost monotonously decreasing trends in the stillbirth rates. Among singletons the stillbirth rate decreased from 29.5 per 1000 in the period 1869 to 1878 to 3.4 in the period 1991 to 2001. Among twins the stillbirth rate decreased from 94 per 1000 in 1869 to 1878 to a minimum of 8.2 in 1991 to 2001 and among triplets from 166 per 1000 to a minimum of 19.8. The relative declining pattern in the SBRs was almost the same, being 88% among singletons, 91% among twins and 88% among triplets. In the 1980s and 1990s the definition of the stillbirth rate was changed in many countries, including Finland, but no changes in the definition of stillbirths have been made in Sweden. The effect of the artificial reproduction techniques, including in vitro fertilization, on the rates of multiple maternities is also discussed. It was noted especially that they had a more marked effect on the triplet than on the twinning rate.

Female↗
PubMed2006

Fetal death registration in multiple births: anomalies and clinical significance.

Trends in the civil registration of fetal death in multiple gestations that has occurred before, but expelled from the womb after, 24 weeks' gestation are examined using England and Wales 1993-2004 registration obtained from the Office for National Statistics. Count was made of fetal death registrations in which fetus papyraceous, fetal death before 24 weeks' gestation or fetocide before 24 weeks' gestation was recorded. There were 3700 fetal death registrations among 217,595 twin, triplet and higher order multiple births in England and Wales between 1993 and 2004. In 354 (9.6%) of these fetal deaths, death was recorded as having occurred before 24 weeks' gestation. There has been a three-fold increase in such fetal death registrations. It is a legal requirement of parents to register a fetal death. The definition of a fetal death that meets formal registration criteria is that the fetus is expelled from the womb after 24 weeks' gestation. However, if the fetal death occurs before 24 weeks, there is confusion, nationally and internationally, whether or not registration is legally required. Fetal death in a multiple gestation has serious clinical implications for a surviving co-conceptus and failure to inform parents of an early death in a multiple gestation may have important repercussions. Legal definition for the registration of fetal death requires international agreement and application.

Female↗
PubMed2003

Impaired adrenocortical function in very low birth weight infants after multiple pregnancies.

OBJECTIVE: To evaluate the differences in adrenal function between very low birth weight (VLBW) infants from singleton and multiple pregnancies. DESIGN AND METHODS: Forty infants of birth weights less than 1500 g underwent an ACTH test. Thirty infants born from singleton pregnancies (singleton group) and ten born from multiple pregnancies (multiple group) were enrolled. A baseline blood sample was drawn for cortisol measurement and thereafter serum cortisol was measured 1 and 2 h after an i.v. injection of ACTH. RESULTS: In multiple pregnancies, the median basal cortisol level of the infants was significantly lower than that in the singletons. The median cortisol level at 1 and 2 h after administration of ACTH was significantly lower in infants from multiple gestations than in singletons. Of infants from the multiple gestation group six, and of the singleton infants 12, had baseline cortisol levels lower than the reference values (P=0.48). One hour after ACTH stimulation all multiple and 53% of the singleton group infants showed a subnormal (<500 nmol/l, P=0.007) cortisol response. Two hours after ACTH, nine multiple group patients and 43% of the singletons had subnormal (<500 nmol/l, P=0.01) stimulated cortisol levels. CONCLUSIONS: We have concluded that VLBW infants from multiple gestations seem to be at an increased risk of insufficient postnatal adrenocortical function. In the future, specific attention should be paid to evaluate further newborn infants from multiple pregnancies with regard to a possible benefit of hydrocortisone substitution in stressful clinical situations.

Adrenal Cortex↗
PubMed1998

Annual summary of vital statistics-1997.

Many positive trends in the health of Americans continued into 1997. In 1997, the preliminary birth rate declined slightly to 14.6 births per 1000 population, and the fertility rate, births per 1000 women 15 to 44 years of age, was unchanged from the previous year (65.3). These indicators suggest that the downward trend in births observed since the early 1990s may have abated. Fertility rates for white, black, and Native American women were essentially unchanged between 1996 and 1997. Fertility among Hispanic women declined 2% in 1997 to 103.1, the lowest level reported since national data for this group have been available. For the sixth consecutive year, birth rates dropped for teens. Birth rates for women 30 years or older continued to increase. The proportion of births to unmarried women (32.4%) was unchanged in 1997. The trend toward earlier utilization of prenatal care continued for 1997; 82.5% of women began prenatal care in the first trimester. There was no change in the percentage with late (third trimester) or no care in 1997. The cesarean delivery rate rose slightly to 20.8% in 1997, a reversal of the downward trend observed since 1989. The percentage of low birth weight (LBW) infants rose again in 1997 to 7.5%. The percentage of very low birth weight was up only slightly to 1.41%. Among births to white mothers, LBW increased for the fifth consecutive year, to 6.5%, whereas the rate for black mothers remained unchanged at 13%. Much, but not all, of the rise in LBW for white mothers during the 1990s can be attributed to an increase in multiple births. In 1996, the multiple birth rate rose again by 5%, and the higher-order multiple birth rate climbed by 20%. Infant mortality reached an all time low level of 7.1 deaths per 1000 births, based on preliminary 1997 data. Both neonatal and postneonatal mortality rates declined. In 1996, 64% of all infant deaths occurred to the 7.4% of infants born at LBW. Infant mortality rates continue to be more than two times greater for black than for white infants. Among all the states in 1996, Maine, Massachusetts, and New Hampshire had the lowest infant mortality rates. Despite declines in infant mortality, the United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a new high in 1997 of 76.5 years for all gender and race groups combined. Age-adjusted death rates declined in 1997 for diseases of the heart, accidents and adverse affects (unintentional injuries), homicide, suicide, malignant neoplasms, cerebrovascular disease, chronic liver disease and cirrhosis, and diabetes. In 1997, mortality due to HIV infection declined by 47%. Death rates for children from all major causes declined again in 1997. Motor vehicle traffic injuries and firearm injuries were the two major causes of traumatic death. A large proportion of childhood deaths continue to occur as a result of preventable injuries.

Adolescent↗
PubMed1999

Multiple-birth infants at higher risk for development of deformational plagiocephaly.

OBJECTIVE: Deformational plagiocephaly refers to the development of an abnormal head shape in infants resulting from externally applied molding forces, which may occur either prenatally or postnatally. We have observed that an unexpectedly high number of multiple-birth infants have presented to our center with this condition. The purposes of this investigation were to: 1) determine the significance of this observation; and 2) examine the risk factors that may make this population more susceptible to the development of plagiocephaly. MATERIALS AND METHODS: A retrospective review of our database was performed to identify those infants who were of multiple-birth origin. The parents of these infants were contacted by phone to complete a survey regarding the prenatal and postnatal history of their child. Similar information was obtained for the state of Arizona from the Office of Vital Statistics. A chi2 analysis was used to compare the incidence of multiple births in Arizona with the incidence of multiple births in our treatment population. RESULTS: Between 1993 and 1996, 69 (8.6%) of the 801 infants treated for deformational plagiocephaly at our Phoenix center were of multiple-birth origin. Four infants who had been treated postoperatively after surgery for craniosynostosis, as well as 5 patients who had been referred from out of state, were excluded from further study. The chi2 analysis of the remaining 60 patients confirmed that a statistically significant number of plural-birth infants had presented with deformational plagiocephaly. Four risk factors were identified as having occurred at high frequency in this population: in utero constraint, supine sleeping position, torticollis, and prematurity. CONCLUSIONS: The current findings of this investigation confirm that a significant number of multiple-birth infants have presented to our clinic with deformational plagiocephaly. Compared with their singleton counterparts, plural infants seem to be at higher risk for the development of deformational plagiocephaly, because they are more likely to be exposed to multiple risk factors.deformational plagiocephaly, multiple birth, plurality.

Female↗
PubMed2001

The epidemiology of mental retardation of unknown cause.

OBJECTIVE: To describe selected infant and maternal characteristics for children with mild and severe mental retardation (MR) of unknown cause. STUDY DESIGN: Children with MR of unknown cause born in California between 1987 and 1994 were identified through service agency records and compared with the total population of California live births for selected characteristics recorded on the birth certificate. RESULTS: For both children with mild and severe MR, risk was increased among males, low birth weight children, and children born to women of black race, older age at delivery, and lower level of education. Increased risk for mild MR was found for multiple births, second or later-born children, and children whose mothers were born outside of California. Increased risk for severe MR was observed among children born to Hispanic mothers; children born to Asian mothers also had increased risk for severe MR but decreased risk for mild MR. CONCLUSIONS: These results provide clues for understanding the underlying causes of MR and suggest that both biological and social factors are important.

Adolescent↗
PubMed2002

Delayed childbearing and its impact on population rate changes in lower birth weight, multiple birth, and preterm delivery.

OBJECTIVE: This study quantified the impact of delayed childbearing (maternal age greater-than-or-equal to 35 years) on population rate changes in low birth weight (LBW; < 2500 g), preterm delivery (< 37 weeks), multiple births, and small for gestational age (SGA; < 10th percentile) in Alberta, Canada, between 1990 (N = 42 930) and 1996 (N = 37 710). METHODS: Data were obtained from the provincial notification of a live or stillbirth. Analyses included relative risk estimates and chi(2) tests for trend. Potential confounding attributable to in vitro fertilization was investigated. RESULTS: The proportion of births to women greater-than-or-equal to 35 years of age was 8.4% in 1990 and 12.6% in 1996, a 51.2% increase. Among these women, LBW delivery increased 11%, and preterm delivery increased 14%. Delayed childbearing accounted for 78% of the change in LBW rate in the population and 36% of the change in preterm delivery rate in the population. Provincial multiple birth rates increased by 15% for twins and 14% for triplets. Delayed childbearing accounted for 15% of the twin increase and 69% of the triplet increase. When in vitro fertilization pregnancies were excluded, the change was 43% for preterm rates, 100% for LBW, 14% for twins, and 9% for triplets. Delayed childbearing did not contribute to changes in singleton SGA deliveries. CONCLUSIONS: The findings suggest that the recent increase in LBW and preterm delivery is partly related to the population phenomenon of delayed childbearing. Maternal age was not related to changes in SGA, suggesting that the age effect is through pregnancy complications that lead to preterm delivery and LBW. Prospective parents should be informed about the higher risk for neonatal morbidity associated with delayed childbearing. Health care providers should be aware of the impact of delayed childbearing on health care resources.

Adult↗