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Importance Monochorionic (MC) twins are hemodynamically connected by vascular anastomoses within the single shared placenta. The transfer of fluid or blood from one fetus to the other may result in development of pathologic complications, such as twin-twin transfusion syndrome, twin anemia polycythemia sequence, selective intrauterine growth restriction, and twin reversed arterial perfusion sequence. Monoamniotic gestations, which comprise a small fraction of MC pregnancies, can also present with unique challenges, particularly antepartum umbilical cord entanglement. All these complications carry a high risk of fetal morbidity and mortality if not recognized and managed in a timely fashion. Objective The purpose of this article is to review evidence-based management of complicated MC twin gestations and propose a standardized approach to surveillance. Evidence Acquisition Monochorionic gestations account for the majority of complications that occur in twin pregnancies; however, there is unclear evidence on the appropriate surveillance for and management of specific complications associated with these pregnancies. Results This article summarizes management for each specific type of MC complication in a structured and clear manner. Conclusions Early pregnancy ultrasound, ideally between 10 and 13 weeks' gestation, is critical for the diagnosis and characterization of twin pregnancies. To improve outcomes for MC twins, appropriate fetal surveillance should be initiated at 16 weeks' gestation and continued until delivery. Relevance Improve perinatal outcomes in MC twin pregnancies. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner should be better able to describe the sonographic findings used to establish the diagnosis of MC twin pregnancies; identify complications unique to MC twins pregnancies, including twin-twin transfusion syndrome, twin reversed arterial perfusion sequence, twin anemia polycythemia syndrome, co-twin demise, cord entanglement, and conjoined twins; and explain the management of complications associated with MC twin pregnancies.

Pregnancy loss affects approximately 20% of couples. The lack of a clear cause complicates half of all miscarriages. Early evidence indicates the maternal immune system and angiogenesis regulation are both key players in implantation success or failure. Therefore, this prospective study recruited women in the first trimester with known viable intrauterine pregnancy and measured blood levels of immune tolerance proteins galectin-9 (Gal-9) and interleukin (IL)-4, and angiogenesis proteins (vascular endothelial growth factors (VEGF) A, C, and D) between 5 and 9 weeks gestation. Plasma concentrations were compared between groups defined based on (a) pregnancy outcome and (b) maternal history of miscarriage, respectively. In total, 56 women were recruited with 10 experiencing a miscarriage or pregnancy loss in the 2nd or 3rd trimester and 11 having a maternal history or miscarriage. VEGF-C was significantly lower among women with a miscarriage or pregnancy loss. Gal-9 and VEGF-A concentrations were decreased in women with a prior miscarriage. Identification of early changes in maternal immune and angiogenic factors during pregnancy may be a tool to improve patient counseling on pregnancy loss risk and future interventions to reduce miscarriage in a subset of women.

AbstractProblemCell‐free fetal DNA (cffDNA) shed from the placenta can be detected in maternal blood and increases incrementally during gestation. Concentrations are further elevated with pregnancy complications. Specific activators of cffDNA release in such complications have not been identified. Here, we use trophoblast cells from early and term placenta to examine cffDNA release following apoptosis, infection, and sterile inflammatory stress.Method of StudyHTR8/SVneo cells were used to model first‐trimester trophoblasts, and term cytotrophoblasts (CTBs) were isolated from placentae collected after uncomplicated deliveries. Trophoblasts were treated with varying concentrations of doxorubicin (DOX), lipopolysaccharide (LPS), or high‐mobility group box protein 1 (HMGB1) for 18 h. Cells or supernatants were quantified for caspase‐3/7 cleavage, pro‐inflammatory cytokine secretion, and cffDNA release.ResultsBoth HTR8/SVneo and CTBs underwent caspase‐3/7 cleavage following DOX treatment, with HTR8/SVneo cells more sensitive to apoptosis than term CTBs. Apoptotic cells released more cffDNA in a dose‐dependent manner. Treatment with LPS resulted in an increase in pro‐inflammatory IL‐6 release, particularly in term CTBs compared to early trophoblasts; however, LPS did not affect cffDNA release. Lastly, while neither cell released more TNF‐α following stimulation with HMGB1, both HTR8/SVneo and CTBs released significantly more cffDNA in the presence of HMGB1.ConclusionsThese data show that apoptosis and sterile inflammation induced by DOX and HMGB1, respectively, cause an increase in cffDNA concentrations in both first‐trimester and term trophoblasts. Understanding physiologic release of cffDNA during healthy and complicated pregnancy can identify new targets for the diagnosis and treatment of gestational complications.

Objective To identify people with history of mental health disorders before the COVID-19 pandemic in the Brazilian population and estimate the prevalence of mood swings and the subjective distress of the pandemic among individuals with or without mental health disorders. Methods Through an online survey, participants were asked about presence or absence of mental health disorders. In addition, they answered the Brunel Mood Scale and the Impact of Event Scale. The mean percentile of mood swing indicators and psychological impact scores were estimated, and data were analyzed by logistic regression. Results 13,248 people participated (70.5% women, mean age 35.4 years, 31.2% with history of mental health disorder). Women and younger people were more likely to be diagnosed with mental health disorder. All participants had significant changes in mood due to the pandemic. Anger, depressed mood, mental confusion, and fatigue were higher among individuals with bipolar disorder or with combined disorders. Individuals with mental health disorders had a greater subjective distress, especially the group with bipolar disorder (OR = 4.89 [3.64–6.56]) and combined disorders (OR = 6.89 [5.21–9.10]). Conclusion Individuals previously diagnosed with mental health disorders at some point in life are more vulnerable to psychological impact from the pandemic.

AbstractObjectiveTo evaluate inter‐rater agreement for sonographic classification of stomach position (as a surrogate for liver herniation) in fetal left congenital diaphragmatic hernia (LCDH) among: (i) fetal medicine specialists from the North American Fetal Therapy Network (NAFTNet) centers within and without the fetal endoscopic tracheal occlusion (FETO) consortium and in comparison to an expert external reviewer (ER1); and (iii) among two expert ERs (ER1 and ER2).MethodsForty‐eight physicians from 26 NAFTNet centers and 2 ERs were asked to assess 13 sonographic clips of isolated LCDH and classify stomach position as “intra‐abdominal,” “anterior left chest,” “mid to posterior left chest,” or “retro‐cardiac" based on the classification published by Basta et al.8 Interrater agreement was assessed by determining proportion of stomach position ratings concordant amongst NAFTNet participants and ER1. Agreement for stomach position between ERs was calculated using kappa statistics.ResultsAgreement for stomach position was 69% (39%–85%; n = 19) and 54% (23%–92%; n = 29) among FETO and non‐FETO NAFTNet participants, respectively, when compared to ER1. Most disagreement in stomach position was related to a discrepancy of one position. ERs were in agreement for stomach position in 5 of 13 cases (38.5%) and inter‐rater agreement was highest for “anterior” stomach position.ConclusionInterrater agreement for stomach position assessment in CDH was poor across NAFTNet and indeed amongst expert reviewers.