Page 175 - Hospital Authority Convention 2018

Masterclasses

M16.3 Reduction of Perinatal Morbidity and Mortality 14:30 Theatre 2

Improved Management of Multiple Pregnancies
Leung WC
Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong
There is an increasing number of multiple pregnancies (mainly twins) over the decades, which is undoubtedly related to HOSPITAL AUTHORITY CONVENTION 2018
assisted reproduction technology. Hospital Authority (HA) territory-wide data showed 626 pairs of twins (1.6% maternities) in
2007, which was increased to 781 pairs (2.0% maternities) in 2016. The improved management of multiple pregnancies is best
illustrated via the modern obstetric journey for twin pregnancy.

The new algorithms in prenatal diagnosis are also applying well to twin pregnancy. First trimester ultrasound to determine
chorionicity is the most important starting point. For high order multiple pregnancies e.g. triplets, multifetal pregnancy
reduction to twins can be offered to improve the overall pregnancy outcomes. Both the conventional 1st trimester Down
screening (nuchal translucency for each fetus + maternal serum markers) and the contemporary non-invasive prenatal test
with maternal plasma for free fetal DNA can apply to twin pregnancy. Routine fetal anomaly ultrasound around 20 weeks
is essential although more time consuming for multiple fetuses. If one of the twins is affected by severe chromosomal or
structural abnormalities, selective feticide with intrauterine intracardiac KCl injection, radiofrequency ablation, bipolar cord
coagulation or umbilical cord ligation can be considered, depending on the chorionicity.
In general, twin pregnancy by itself is high risk – miscarriage, gestational hypertensive diseases, gestational diabetes
mellitus, intrauterine growth retardation, preterm labour, fetal malpresentation at delivery, and others (except post-date).
Specific complications in monochorionic twins include monochorionic monoamniotic twins (including the rare conjoined
twins), twin reversed arterial perfusion sequence, twin-twin transfusion syndrome (TTTS), twin anaemia polycythaemia
sequence and selective IUGR of one twin. Fetoscopic laser photocoagulation to divide the communicating vessels within the
placenta for TTTS has been proven by randomised controlled trial. Special Twin Clinic is available in HA Obstetric Units to
offer antenatal monitoring for these complications with corresponding prevention and treatment measures. The frequency
of antenatal follow-ups plus ultrasound depends again on the chorionicity and the occurrence of complications, which also
determines the gestation for delivery. Mode of delivery (Caesarean section vs. vaginal delivery) for twin pregnancy needs
special consideration. Risk of postpartum haemorrhage is increased. Last but not least, breastfeeding should be encouraged.

M16.4 Reduction of Perinatal Morbidity and Mortality 14:30 Theatre 2

Improved Mortality, Morbidity and Early Neurodevelopmental Outcomes of Extreme-low-birth Weight Infants
Chee WYY, Wong RMS
Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Hong Kong

We studied the mortality, morbidity and early neurodevelopmental outcomes of the cohort of infants born with birth weight
less than 1,000 grams born at Queen Mary Hospital from year 2008 to 2015. Perinatal and outcome data were collected
from Vermont Oxford Network Database. Outcomes of neurodevelopmental assessment performed at Duchess of Kent
Children’s Hospital were retrieved from the Clinical Management System. A total of 217 infants were born during the eight-
year study period, 176 survived and among them 143 infants underwent neurodevelopmental assessment at corrected age
of 18-22 months. 40 (28.0%) of them has neurodevelopmental impairment, which was defined as either one of the followings:
(1) cerebral palsy; (2) profound visual impairment; (3) profound hearing impairment; (4) Griffiths scale scores <2 SD overall or Tuesday, 8 May 2018
in any of the subsets. We compared these data with the published data from our earlier cohort of ELBW infants born from
year 1993 to 2002. Overall survival rate has improved significantly from 71.4% to 81.1% (p=0.02) over these two periods with
greatest improvement seen in infants with birth weight 500-750 grams. More infants received antenatal steroid in our current
cohort and fewer infants were born with first Apgar score <3. There were significantly fewer infants with severe complications
of intraventricular haemorrhage (grade 3 or 4) and necrotising enterocolitis. Duration of mechanical ventilation was also
shorter and length of hospital stay dropped from average of 110 days to 82 days. More encouragingly, cerebral palsy rate
has dropped significantly from 13.4% to 4.2% (p=0.01), visual impairment rate from 10.3% to 2.1% (p=0.01), rate of having
overall Griffiths development score < 2SD from 16.7% to 7.7% (P=0.04). Our study has shown that over last 20 years with
advancement of perinatal and neonatal intensive care support, both the survival and quality of survival of these ELBW infants
has improved significantly.

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