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Biweekly ultrasound examinations, with special attention to the amniotic fluid compartments of both fetuses, combined with detailed patient instructions to report the onset of symptoms resulted in timely diagnosis of all TTTS cases and appears to be a safe program for monitoring monochorionic twin pregnancies.

Objective To compare fetoscopic laser surgery with amniodrainage in the treatment of twin-to-twin transfusion syndrome (TTTS) diagnosed after 26 weeks of gestation.Design A retrospective cohort study.Setting Leiden University Medical Centre, a tertiary referral hospital for fetal therapy.Population Between January 1991 and February 2006, 21 TTTS cases were diagnosed and treated after 26 weeks of gestation.Methods Treatment of TTTS consisted of either amniodrainage or fetoscopic laser coagulation of vascular anastomoses.Main outcome measures Primary outcome: adverse outcome (intrauterine or neonatal death, major neonatal morbidity and/or severe cerebral injury). Secondary outcome: gestational age at birth.Results Eleven TTTS cases were treated with amniodrainage and ten with laser surgery. Median gestational age at birth in the amniodrainage group and in the laser surgery group was 29 and 31 weeks, respectively (P = 0.17) All infants were born alive. Major neonatal morbidity occurred more often in the amniodrainage group than in the laser surgery group, 27% (6/22) and 0% (0/20), respectively (P = 0.02). Severe cerebral injury in the amniodrainage group and in the laser surgery group occurred in 23% (5/22) and 15% (3/20) of infants, respectively (P = 0.70). Neonatal mortality in the amniodrainage group and in the laser surgery group was 14% (3/22) and 0% (0/20), respectively (P = 0.23). Overall adverse outcome was 36% (8/22) in the amniodrainage group and 15% (3/20) in the laser surgery group (P = 0.17).Conclusion In TTTS diagnosed after 26 weeks of gestation, amniodrainage and laser surgery both result in 100% survival. However, infants born after laser surgery have less major neonatal morbidity.

Objective To describe the outcome of pregnancies with fetal and neonatal alloimmune thrombocytopenia (FNAIT) in relation to the invasiveness of the management protocol.Design Retrospective analysis of prospectively collected data from a national cohort.Setting Leiden University Medical Centre, the national centre for management of severe red cell and platelet alloimmunisation in pregnancy.Population Ninety-eight pregnancies in 85 women with FNAIT having a previous child with thrombocytopenia with (n = 16) or without (n = 82) an intracranial haemorrhage (ICH).Methods Our management protocol evolved over time from (1) serial fetal blood samplings (FBS) and platelet transfusion (n = 13) via (2) combined FBS with maternal intravenous immunoglobulins (n = 33) to (3) completely noninvasive treatment with immunoglobulins only (n = 52 pregnancies, resulting in 53 neonates). Perinatal outcome was assessed according to the three types of management.Main outcome measures Occurrence of ICH, perinatal survival, gestational age at birth and complications of FBS.Results All but one of 98 pregnancies ended in a live birth; none of the neonates had an ICH. The median gestational age at birth was 37 weeks (range 32-40). In groups 1 and 2, three emergency caesarean sections were performed after complicated FBS, resulting in two healthy babies and one neonatal death.Conclusion Noninvasive antenatal management of pregnancies complicated by FNAIT appears to be both effective and safe.

Objective To compare vaginal misoprostol with dinoprostone for induction of labour.Design Randomised multicentre trial.Setting Labour wards of one university hospital and two teaching hospitals.Population Six hundred and eighty-one women with indication for labour induction at 36 weeks of gestation, singleton pregnancy and no previous ceasarean section. Methods Misoprostol (25 mcg, hospital-prepared capsule) in the posterior vaginal fornix, every four hours, maximum three times daily or dinoprostone gel (1 mg) every four hours. Oxytocin was administered if necessary. Main outcome measures Primary: 'adverse neonatal outcome' (5-minute Apgar score <7 and/or umbilical cord pH <7.15). Secondary: labour duration, mode of delivery and patient satisfaction. Results Three hundred and forty-one women received misoprostol and 340 dinoprostone. The median induction-delivery interval was longer in the misoprostol group compared with the dinoprostone group (25 versus 19 hours, P ¼ 0.008). The caesarean section rate was lower in the misoprostol group: 16.1% versus 21%, but this difference was not statistically significant RR ¼ 0.8 (95% CI 0.6 -1.04). 'Adverse neonatal outcome' was found to be similar in both groups: 21% in the misoprostol and 23% in the dinoprostone groups. Significantly fewer neonates were admitted to NICU in the misoprostol group compared with dinoprostone 19% versus 26% (RR ¼ 0.7, 95% CI 0.5 -0.98). Conclusions Misoprostol in this dosing regimen is a safe method of labour induction. NICU admission rates were lower in the misoprostol group. No difference could be detected in patient satisfaction between groups.