Risk of Cerebral Palsy in Multiple Pregnancies

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Multiple versus singleton birth differences in crude cerebral palsy prevalence

The greater risk of CP in multiple compared with singleton gestations was recognized by Freud more than a century ago [22]. A review of case series reports found that twins comprised 5% to 10% of CP but only 1.6% of all births [23], which indicated a twin:singleton relative risk of approximately 5. The development of population-based registers of CP has enabled prevalence comparisons to be made for multiple and singleton births. Combined data from two registries [24], [25] showed relative risks

Risk factors for cerebral palsy in multiple and singleton gestations

One important risk factor for CP in multiple and singleton births is birth weight, with a sharp rise in prevalence of CP with decreasing birth weight [27]. Combined data from three population-based registries show that the relative risks of CP in birth weight groups of 1000 g, 1000 to 1499 g, and 1500 to 2499 g compared with 2500 g or more are 66.5, 57.4, and 8.9, respectively [28]. The shift to the left in the birth weight frequency distribution of multiple births plays a significant role in

Twinning, zygosity, chorionicity, and cerebral palsy

It has long been recognized that fetal death of a twin is frequently associated with severe morbidity in the surviving co-twin. There are various central nervous system abnormalities, including polymicrogyria [31], [32], [33], [34], multicystic encephalopathy or porencephaly [35], [36], ventriculomegaly or hydranencephaly [37], [38], [39], cortical atrophy [40], and cerebral infarction [41]. Clinically these neurologic pathologies are usually manifest as CP that may vary greatly in its

Pathogenic mechanisms in cerebral palsy

Monochorionicity, with its placental vascular anastomoses, is a common component when there is fetal demise of one twin and CP in the co-twin. Benirschke [60] observed numerous fibrin thrombi occluding blood vessels, which resulted in renal cortical necrosis and cerebral infarction in one case. He proposed that thromboplastin-rich material or thromboemboli were transfused from the dead twin, which led to disseminated intravascular coagulation in the co-twin (Fig. 2A). Although disseminated

Cerebral palsy and assisted reproductive technology

Inevitably, the rise in incidence of multiple gestations as a result of assisted reproductive technology (ART) has raised concerns over the implication it has for the prevalence of CP [72], [73]. Researchers have estimated that there may be approximately an 8% increase in the prevalence of CP in the United States solely because of the increase in multiple births from ART [74]. To the extent that multiple gestations are associated with an increase in prevalence of preterm infants, fetuses

Summary

Multiple compared with singleton gestations are at five- to tenfold increased risk of CP. A major component of the increased risk in CP is associated with the higher proportion of multiple gestation fetuses that are born preterm with cerebral impairment from periventricular hemorrhage or leukomalacia. A greatly increased risk of CP is also associated with MC placentation. It is particularly notable in the surviving twin with fetal or early infant death of the co-twin. The failure to register or

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      Infant low-birth weights, early births, and the increased incidence of stillbirths, neonatal deaths, and birth anomalies are all associated with multiple birth pregnancies.56,57 Ontario’s Expert Panel on Infertility and Adoption concluded that multiple birth infants are 17 times more likely to be born pre-term, to require a caesarean delivery, and to need expensive care at birth and throughout their lives.58 Yet, as this study reveals, Canadian gestational surrogates more frequently receive multiple embryos and until recently were more likely to experience multiple births compared with other IVF patients.

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      Twin births are associated with a greater risk for neonatal morbidity and mortality than singletons. Incidence of long-term disability, such as cerebral palsy, is also increased in twins compared with singletons.8 In our study, the data set from birth registries in the Ministry of the Interior was analyzed.

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      In Canada, the proportion of preterm births secondary to multiple pregnancies has increased from approximately 30% in the 1970s to 58.4% in 2004.49 The risks of perinatal mortality, growth restriction, cerebral palsy, and congenital anomalies are also higher in multiples than in singletons, most notably in monochorionic, but also in dichorionic, twins.49,56,57 The risk of morbidity and mortality increases with each additional fetus in a multiple gestation.58

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    Please note that article originally appeared in Obstetrics and Gynecology Clinics of North America, Vol 32, Issue 1.

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