BackgroundTwin pregnancy was associated with significantly higher rates of adverse neonatal and perinatal outcomes, especially for the second twin. In addition, the maternal complications (potentially life-threatening conditions-PLTC, maternal near miss-MNM, and maternal mortality-MM) are directly related to twin pregnancy and independently associated with adverse perinatal outcome. The objective of the preset study is to evaluate perinatal outcomes associated with twin pregnancies, stratified by severe maternal morbidity and order of birth.MethodsSecondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), a cross-sectional study implemented in 29 countries. Data from 8568 twin deliveries were compared with 308,127 singleton deliveries. The occurrence of adverse perinatal outcomes and maternal complications were assessed. Factors independently associated with adverse perinatal outcomes were reported with adjusted PR (Prevalence Ratio) and 95%CI.ResultsThe occurrence of severe maternal morbidity and maternal death was significantly higher among twin compared to singleton pregnancies in all regions. Twin deliveries were associated with higher rates of preterm delivery (37.1%), Apgar scores less than 7 at 5th minute (7.8 and 10.1% respectively for first and second twins), low birth weight (53.2% for the first and 61.1% for the second twin), stillbirth (3.6% for the first and 5.7% for the second twin), early neonatal death (3.5% for the first and 5.2% for the second twin), admission to NICU (23.6% for the first and 29.3% for the second twin) and any adverse perinatal outcomes (67% for the first twin and 72.3% for the second). Outcomes were consistently worse for the second twin across all outcomes. Poisson multiple regression analysis identified several factors independently associated with an adverse perinatal outcome, including both maternal complications and twin pregnancy.ConclusionTwin pregnancy is significantly associated with severe maternal morbidity and with worse perinatal outcomes, especially for the second twin.

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Analysis 3.12. Comparison 3 Indomethacin compared with any COX-2 inhibitors, Outcome 12 Neonatal sepsis.. Analysis 3.13. Comparison 3 Indomethacin compared with any COX-2 inhibitors, Outcome 13 Maternal adverse drug reaction.

draw. Moreover, the authors did not report whether there were changes in the rates of emergency CD (or CP risk) over the 40-year time period in which the overall CP rate remained stable.Any type of cesarean delivery in term newborns (5 studies, 1985 to 2010) was also associated with increases in CP (OR, 1.6, 95% CI, 1.05-2.44), but CD in preterm infants (6 studies, 1974 to 2011) resulted in no change in the incidence of CP. However, further subanalysis of infants born by CD at <33 weeks' gestation showed a significant decrease in the rate of CP (OR, 0.52; 95% CI, 0.38-0.70). The authors cautioned that this subanalysis was not prespecified and involved only small numbers. Nevertheless, the trend toward less CP in preterm neonates having CD (OR, 0.81; 95% CI, 0.47-1.40), combined with the findings from the subanalysis, is consistent with the theory that many cases of CP result from early neonatal intraventricular hemorrhage. The authors suggest that CD may be the preferred route of delivery in the very early preterm infant because CD results in less trauma to the delicate microvasculature of the neuronal glial precursor cells of the germinal matrix.The fact that both elective and emergent CD were associated with higher rates of CP in term neonates (OR, 1.6) seems to substantiate the existing body of literature suggesting the majority of CP cases are not related to acute intrapartum hypoxic events. The positive correlation of CP to emergency cesarean sections (OR, 2.17; I 2 = 46%), may suggest some evidence of intrapartum CP etiologies. Perhaps fetuses with antenatal CP are simply more likely to exhibit signs of fetal distress resulting in emergency cesarean delivery. Unfortunately, these possibilities cannot be intelligently addressed by data included in this study or perhaps by any retrospective study.This meta-analysis may serve as evidence to aid obstetricians in reducing the number of cesarean interventions over concerns about CP, particularly in the term infant. Although not without potential confounders, this study, as well as data collected over the past 40 years demonstrating stable CP rates despite dramatic increases in CD rates, backs the authors' conclusion that, overall, CD for the prevention of CP is not supported by the literature. It may be, however, that CD is sometimes indicated. This confusion is why CD rates are likely to remain high.

BackgroundThe call for women‐centred approaches to reduce labour interventions, particularly primary caesarean section, has renewed an interest in gaining a better understanding of natural labour progression.ObjectiveTo synthesise available data on the cervical dilatation patterns during spontaneous labour of ‘low‐risk’ women with normal perinatal outcomes.Search strategyPubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies.Selection criteriaObservational studies and other study designs.Data collection and analysisTwo authors extracted data on: maternal characteristics; labour interventions; the duration of labour centimetre by centimetre; and the duration of labour from dilatation at admission through to 10 cm. We pooled data across studies using weighted medians and employed the Bootstrap‐t method to generate the corresponding confidence bounds.Main resultsSeven observational studies describing labour patterns for 99 971 women met our inclusion criteria. The median time to advance by 1 cm in nulliparous women was longer than 1 hour until a dilatation of 5 cm was reached, with markedly rapid progress after 6 cm. Similar labour progression patterns were observed in parous women. The 95th percentiles for both parity groups suggest that it was not uncommon for some women to reach 10 cm, despite dilatation rates that were much slower than the 1‐cm/hour threshold for most part of their first stage of labours.ConclusionAn expectation of a minimum cervical dilatation threshold of 1 cm/hour throughout the first stage of labour is unrealistic for most healthy nulliparous and parous women. Our findings call into question the universal application of clinical standards that are conceptually based on an expectation of linear labour progress in all women.Funding UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, and the United States Agency for International Development (USAID).Tweetable abstractCervical dilatation threshold of 1 cm/hour throughout labour is unrealistic for most women, regardless of parity.

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RESUMOObjetivos: aplicar um escore de gravidade em casuística de morbidade materna grave (MMG) e comparar os critérios para classificação. Métodos: estudo caso-controle como análise secundária de casuística de MMG de maternidade terciária em período de 12 meses. Nos casos identificados de MMG, aplicou-se escore específico para graduação da gravidade. Vinte casos de morbidade materna near miss (maior gravidade) foram comparados com 104 controles (menor gravidade) de outras morbidades, quanto a fatores de risco, determinantes primários e demanda assistencial. A análise incluiu o cálculo de médias e proporções, utilizando os testes estatísticos t de Student, Wilcoxon, χ 2 e estimativas de OR e IC 95%. Resultados: a maior gravidade (near miss) foi identificada em 16,1% da casuística e o antecedente de aborto foi o único fator significativamente a ela associado (OR=3,41; IC 95%=1,08-10,79). Os indicadores de complexidade de assistência foram de fato mais freqüentes no grupo de near miss, que também apresentou número menor de casos com hipertensão (30% contra 62,5%) e maior com hemorragia (35,5% contra 10,6%) como fatores determinantes primários de morbidade grave. Conclusões: a maior gravidade da morbidade materna associou-se ao antecedente de aborto e à hemorragia como causa. O escore aplicado conseguiu identificar um subgrupo de maior gravidade (near miss) e que demanda atendimento profissional e institucional mais complexo para evitar a ocorrência do óbito. PALAVRAS-CHAVE:Complicações na gravidez; Mortalidade materna; Morbidade; Cuidados intensivos ABSTRACT Purpose: to apply a severity score to cases of severe maternal morbidity (SMM) and to compare the classification criteria. Methods: a control-case study was performed as a secondary analysis of cases of SMM in a tertiary level maternity unit for a period of 12-month. A specific score for assessing the degree of severity was applied to cases identified as SMM. Twenty cases of near miss maternal morbidity (higher severity) were compared to 104 control cases (lower severity) of other severe morbidities, regarding risk factors, primary determinants and assistance requirements. Analyses were performed with means and proportions, using Student's t, Wilcoxon and χ 2 statistical tests, and estimations of OR and 95% CI. Results: the higher severity (near miss) was identified in 16.1% of cases and the history of abortion was the only factor statistically associated with it (OR=3.41, 95% CI 1.08-10.79). In fact, the indices of assistance complexity were more frequent in the near-miss morbidity group, which also presented less hypertension (30% against 62.5%) and more hemorrhage (35.5% against 10.6%) as primary determinant factors of severe morbidity. Conclusions: the higher severity of maternal morbidity was associated with a history of abortion and with hemorrhage as a cause. The applied score was able to identify a higher severity subgroup (near miss), which needs more complex professional and institutional care in order to avoid the occurrence of death.