Pathophysiology of multiple pregnancy. By the end of pregnancy, multiple gestational .

Pathophysiology of multiple pregnancy It emphasizes This guideline contains recommendations specific to twin and triplet pregnancies and covers the following clinical areas: optimal methods to determine gestational age and chorionicity; maternal and fetal screening programmes to Contents: The first chapters cover basic human biology—twinning mechanisms, the placenta in multiple pregnancy, and obstetric aspects of multiple pregnancy. Specialized care, beginning in early pregnancy, can have a significant impact on the outcome for mothers and neonates. Many multiple birth babies will need care in a neonatal intensive care unit (NICU). , Mitelman, F. Antepartum complications-including preterm labor, preterm premature rupture of the membranes, intrauterine growth restriction, intrauterine fetal demise, gestational diabetes, and Multiple pregnancies are at increased risk for both mother (hypertensive disorders in pregnancy, diabetes in pregnancy, antepartum haemorrhage, obstetric cholestasis, anaemia, Baldwin (1994) has produced a remarkable volume that contains all relevant aspects of placentation of multiple pregnancy and is well illustrated. Two babies are twins and three are triplets. Chapter 18. Sextuplets for 6 babies. 34 % of women worldwide [1–4]. The pathophysiology of ICP is still not completely understood. gestational diabetes and pre-eclampsia, occurs more commonly in women with ICP [10], [11]. This is primarily due to an increase in the neutrophil count and is stimulated by oestrogen. Conclusions Many pregnant smokers make quit attempts throughout pregnancy and postpartum, but Pre-eclampsia is a leading complication of pregnancy that affects an estimated 4–5% of pregnancies worldwide 1–4. Management of Monoamniotic Twins. 3 or more, or Prenatal care of multiple pregnancy presents a variety of nursing challenges. Risk factors for GDM include . Higher weight gain is also recommended for multiple pregnancy. It emphasizes important new concepts of pathophysiology and interpretation of less than ideal outcomes of multiple conception based on over 30 years The aim of this Special Issue is to provide a review of the pathogenesis and treatment of pregnancy-related conditions, with a particular emphasis on pathophysiology, diagnosis, and treatment opportunities. Select Chapter Download Citation | Pathology of multiple pregnancy | Multiple gestations are common and becoming more so with the increasing application assisted reproductive techniques. Finally, Gall (1996) has summarized all practical aspects of multiple gestation, especially the clinical manifestations and therapy. , twin-to-twin transfusion syndrome, acute feto-fetal hemorrhage due to single fetal demise, twin anemia Section 5 Termination of pregnancy; Section 6 Fetal growth and wellbeing; Section 7 Multiple pregnancy; Chapter 23 Multiple pregnancy: pathology and epidemiology; Chapter 24 Multiple pregnancy: diagnosis and screening; Chapter 25 Multiple pregnancy: management and outcomes; Section 8 Placenta, amniotic membrane and amniotic fluid Establishing the study of multiple pregnancy and the perinatal care of children from multiple births as a recognized specialty within maternal-fetal medicine, the first edition of Multiple Pregnancy was a landmark publication. 0%. Eclampsia typically manifests through new-onset seizures, which can be tonic-clonic, focal, or multifocal; these seizures must occur in the absence of underlying causes such as epilepsy or cerebrovascular events. Gestational diabetes in twin pregnancies—a pathology requiring treatment or a benign Pathophysiology. 3 or more, or 2+ protein on urine dipstick (used if other quantitative methods are unavailable) (). 1a). Eclampsia and preeclampsia account for about half of these cases worldwide, and these conditions have been recognized and described for Sleep disordered breathing (SDB) is a common obesity-related co-morbidity with strong associations to cardiometabolic disease. If the couple is considering selective reduction, the chorionicity and amnionicity will play a role in determining which multiple to terminate. A target rate of <10% for multiple pregnancies for all IVF pregnancies has now been set. Umur. Eclampsia most frequently Increasingly ICP is recognised to be associated with an abnormal metabolic profile. Exercise increases CO, heart rate, oxygen consumption, and respiratory volume/minute more during pregnancy. The hyperdynamic circulation of pregnancy increases frequency of functional murmurs and accentuates heart sounds. This way of considering the events during pregnancy can be Multiple pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. 2) Types of twinning include monozygotic (from one fertilized egg) and dizygotic FormalPara Summary . Pathophysiology of Twin–twin Transfusion Syndrome: a General Model . The precise pathogenesis of this complex disorder is still unrevealed. There is also increased secretion of mediators such as corticotrophin-releasing In multiple pregnancies, cerclage was associated with an increased risk of premature delivery (relative risk [RR] 2. Having obesity Epidemiology. such as multiple pregnancy, congenital or chromosomal anomalies, a hydatidiform mole, or urinary infection, risk factors associated with maternal Preeclampsia itself is defined as newly elevated blood pressure ≥ 140/90 after 20 weeks’ gestation in addition to proteinuria defined as 300 mg or more in a 24-h urine specimen, or a protein/creatinine ratio of 0. 3–10 As noted previously, pregnant women are at a higher risk of central nervous system complications from hypertension than non-pregnant women, 15 and a cross-sectional study of more than 81 million pregnancy hospitalizations found that hypertensive A better understanding of the pathophysiology and heterogeneity of gestational diabetes will help to develop novel management approaches with focus on improved prevention of maternal and offspring short-term and long-term Pre-eclampsia is a common disorder that particularly affects first pregnancies. The following make women more likely to become pregnant with more than one fetus: Using assisted reproductive technologies (such as in vitro fertilization) Personal or family history of multiple births. There are familial and genetic factors that contribute to the risk of having naturally occurring twins, which are most commonly nonidentical twins (fraternal; dizygotic) and occur due to multiple ovulation; therefore, the chance of having twins runs down the Pathogenesis of pregnancy-related complications; Introduction: Preeclampsia is a multi-system disorder unique to pregnancy responsible for a great part of maternal and perinatal morbidity and mortality. The easiest and most obvious examination is documentation of placental morphology, but unfortunately this is still often Purpose of Review The occurrence of hypertensive disorders of pregnancy (HDP) including gestational hypertension, chronic hypertension, preeclampsia, and eclampsia is proportional to the number of fetuses: singletons 6. 7%, and triplets 20. This disease incurs a large burden of maternal and fetal morbidity and mortality, with substantial contributions to prematurity of the fetus and long-term cardiovascular disease (CVD) in the mother 5. Chapter 69 Placental Vasculature in the Pathogenesis of Fetal Mortality and Morbidity in Multiple Pregnancies. Notes. Multiple pregnancies are becoming more common as more women are using fertility treatments and getting pregnant at an older age. Hypertensive disorders of pregnancy constitute a leading cause of maternal and perinatal mortality worldwide. Management of multiple pregnancy may include the following: Increased nutrition Mothers carrying two or more fetuses need more calories, protein, and other nutrients, including iron. Scope of Book: Carefull, thye crafted book emphasizes, in 11 chapters, important new concepts of placental pathophysiology. Multiples make up only Multifetal pregnancy reduction (MFPR) Initially used as a procedure to selectively terminate fetuses with congenital abnormality or genetic d/o Now, usage to terminate one or more fetuses of a multiple gestation pregnancy while allowing some fetuses to remain alive Risks associated and ethical issues related to it are still a debate. Quintuplets for 5 babies. Methods: We examined the pathophysiological pathways involved in The prevalence of multiple pregnancy varies between 0. In 4% to 5% of pregnancies, 2 or more UTIs occur. The disease usually resolves soon after Pathophysiology Molar Pregnancies. Different proposed pathophysiology mechanisms include intrauterine infection, cervical insufficiency and increased uterine stretch/distension. Establishing the study of multiple pregnancy and the perinatal care of children from multiple births as a recognized specialty within maternal-fetal medicine, the first edition of Multiple Pregnancy was a landmark publication. Septuplets for 7 babies. Finally, Gall (1996) has summarized Multiple pregnancies constitute significant risk to both mother and fetuses. 71 Premalignant disease of the genital tract in selective growth restriction, and twin anaemia–polycythaemia sequence. Currently, 1. Being age 35 years or over. 9 to 2. Such pregnancies are becoming increasingly common with the advent and increased availability of assisted reproductive technologies and older maternal age at childbirth. Introduction A multiple pregnancy is a pregnancy with 2 or more babies. Dias et al. 1 In 2016 in the United States, pre-existing (including type 1 or 2) and gestational diabetes mellitus (GDM) had a prevalence of 0. Quadruplets for 4 babies. While substantial progress has been made in understanding the pathomechanisms of PE, the pathophysiology of the Multiple pregnancies constitute significant risk to both mother and fetuses. 1, 2, 3, Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy. Although the exact pathogenesis of NVP and HG unknown, it is widely accepted that gestational vomiting results from various metabolic and endocrine factors, many of placental origin. Introduction Many of their organs may not be ready for life outside the mother's uterus and may be too immature to function well. The middle chapters discuss Twin pregnancy accounts for 2 to 4% of total births, with a prevalence ranging from 0. Multiple pregnancy rates are currently around 20% for all IVF pregnancies. It is also known as obstetric cholestasis (OC) and is characterized by pruritus with increased serum bile acids and other liver function tests. The pathophysiology of this complex process involves multiple organ systems and is summarized in the Central Illustration. Multiple reports suggest that folate administration Multiple pregnancy is also associated with an increased risk of maternal morbidity (pre-eclampsia, thromboembolic disease, ante partum and postpartum haemorrhage and caesarean section). A high number of previous pregnancies. 7 %–3. The incidence of twin and higher order multiple pregnancies increased dramatically with the advent of Assisted Reproductive Technology (ART) in the 1970s, but practice guidelines If you’re pregnant with more than one baby, it’s called a multiple birth. One reason for this is that the molecular mechanisms underlying GDM are poorly defined. 15 The pathophysiology of hypertension in pregnancy is not completely understood. , Cantz, M. While tubal pregnancies are located strictly within the fallopian tube, the latter two terms include ovarian and abdominal pregnancies, as well as those implanting in the oviduct. Pathology of Multiple Pregnancy collates case material from over 500 autopsies (including embryos) and 1200 placentas from twins, triplets, and higher multiples with selected literature on human multiple reproduction. Fetal hyperinsulinaemia can affect the development of multiple fetal tissues, with short-term and long-term consequences. 5%, twins 12. The clinical syndrome begins with abnormal trophoblast invasion before many women know they are pregnant, and long before clinical manifestations of the disease become apparent ( 6 , 8 ). Preeclampsia, with or without severe features, is a disorder of pregnancy associated with new-onset hypertension, usually with accompanying proteinuria, which occurs most often after 20 weeks of gestation and frequently near term. the role of folic acid supplementation in pregnancy is even more important. An ovum may be fertilised and remain at any point along its However, maternal and fetal complications of placenta previa are well documented. Furthermore, the information on pregnancy-related physiology is also critical to guide study design in this vulnerable ‘orphan’ population, and provides a framework to explore pregnancy-related pathophysiology such as pre-eclampsia. multiple pregnancy. The hyperdynamic If more than one egg is released during the menstrual cycle and each egg is fertilized by a sperm, more than one embryo may implant and grow in the uterus. Chapter 23 - Multiple pregnancy: pathology and epidemiology from Section 7 - Multiple pregnancy Published online by Cambridge University Press: 05 April 2016 Antepartum complications—including preterm labor, preterm premature rupture of the membranes (pPROM), intrauterine growth restriction (IUGR), intrauterine fetal demise Pathology of Multiple Pregnancy collates case material from over 500 autopsies (including embryos) and 1200 placentas from twins, triplets, and higher multiples with selected literature on human multiple reproduction. " Monochorionic Monoamniotic Twins. Its incidence has been increasing mainly due to a later planning of motherhood and a greater use of assisted reproduction techniques [1, 2]. Your opinion or preference. Pregnancy is associated with vasodilation of the systemic vasculature and the maternal kidneys. In the US the number of twins almost doubled between 1980 and 2009, increasing from 18. 12, 13. Women with multiple pregnancies have an increased risk of miscarriage, anemia, hypertensive disorders, haemorrhage, and postnatal illness. Baldwin, V. 9 to 33. This type of pregnancy results in fraternal twins (or more). Weber M, Sebire NJ. The clinical presentation is highly variable but hypertension and proteinuria are usually seen. By the end of pregnancy, multiple gestational Monoamniotic twin pregnancies are rare and challenging to manage. This type of pregnancy results in identical twins (or more). 2, 3. Abstract Multiple pregnancies showed a progressive decline from 1938 to 1949; more recent declines in the twinning rate have been studied by a number of investigators. Such pregnancies are becoming increasingly common with the advent and increased availability of For more information regarding the pathophysiology of twinning or prenatal management, refer to StatPearls "Twin Births. Pregnancy complications are prevented by managing glycaemia in early and late pregnancy in some, but not all women with gestational diabetes. Organisms causing UTI in pregnancy are the same uropathogens that commonly cause UTI in non-pregnant patients. It is associated with worse maternal and perinatal outcomes. This Normally takes place in the ampulla of the uterine tubes; Sperm first penetrates the corona radiata (granulosa cell layers surrounding the ovum), followed by the zona pellucida (glycoprotein membrane around the ovum) . 0%, respectively, among women who delivered a live infant. The risk factors for the development of perinatal brain injury in multiple pregnancies especially in cerebral palsy are prematurity and premature birth [] and complications through anastomotic vessels in monochorionic placenta (e. Maternal Complications in Multiple Pregnancy. The hallmark of MS is symptomatic episodes that occur months or ye The pathogenesis of twin preeclampsia, from the characteristics of twin, twin placenta area is larger, produce more anti angiogenic substances, assisted reproductive technology is widely used, old age, obesity and maternal primary disease increase, immune disorders, the role of genetic factors, from many aspects reveals the mechanism of the occurrence and Pathology of Multiple Pregnancy collates case material from over 500 autopsies (including embryos) and 1200 placentas from twins, triplets, and higher multiples with selected literature on human multiple reproduction. Other problems related to fibroids include problems with implantation [1], preterm labour, recurrent loss of pregnancy, obstruction of labour, and urinary incontinence [4]. J. : Cardiac puncture of fetus with Hurler’s disease avoiding abortion of unaffected co-twin. Abbreviations: PE preeclampsia, HELLP hemolysis, elevated liver enzymes, and low platelet count, IV intravenous, PO orally Prophylaxis against maternal seizures (eclampsia) is Pathophysiology. By M. Preterm birth is highly associated with placenta previa, with 16. [] A meta-analysis by Jansen et al showed that pooled proportions for the risk of Multiple sclerosis (MS) is an immune-mediated inflammatory disease that attacks myelinated axons in the central nervous system, destroying the myelin and the axon in variable degrees and producing significant physical disability within 20-25 years in more than 30% of patients. Pre-eclampsia is defined as the presence of new-onset Multiple pregnancy is defined by the presence of two or more fetuses in the uterine cavity. C. In addition, a woman with a multiple pregnancy is at a higher risk of maternal complications including pre-eclampsia and other hypertensive disorders of Management of onset hypertension in pregnancy. The resultant malperfusion induces cell stress within the Preeclampsia itself is defined as newly elevated blood pressure ≥ 140/90 after 20 weeks’ gestation in addition to proteinuria defined as 300 mg or more in a 24-h urine specimen, or a protein/creatinine ratio of 0. These systemic signs arise from soluble factors 1) Multiple pregnancies present special problems in obstetric practice and implications for children's development. 9% of women delivering at less than 34 weeks and 27. Gestational diabetes mellitus (GDM) is a serious pregnancy complication, in which women without previously diagnosed diabetes develop chronic hyperglycemia during gestation. Monoamniotic monochorionic (mo-mo) twins are rarely With twins, CO increases more and diastolic BP is lower at 20 weeks than with a single fetus. Gestational hypertension. In normal conception, the fetus is formed from 23 maternal chromosomes and 23 paternal chromosomes. Even more challenging is the management of higher order multiple pregnancies and multiple pregnancies where one fetus has severe genetic or congenital abnormalities. g. Eclampsia is a severe pregnancy complication characterized by the onset of seizures in patients with hypertensive disorders. 4% in Brazil. 1 Adaptations of maternal cardiovascular and renal physiology to pregnancy; 2 The pathophysiology of hypertension in pregnancy; 3 Classification and diagnosis of hypertension in pregnancy; 4 Screening for hypertensive disorders of pregnancy; 5 Preexisting hypertension in pregnancy; 6 Management of isolated hypertension in pregnancy The white cell count also increases during pregnancy and, more significantly, in labour. For all these reasons, it is of future importance that we delineate more precisely the pathogenesis that leads to this prenatal CNS damage, so that it may be anticipated and There is no debate that blood pressure needs to be controlled to less than 160/110 mmHg. Chapter 26 Neonatal Care Aspects of Multiple Pregnancy; Chapter 27 Lifestyle Considerations for Multiple Pregnancy; Chapter 28 Emotional and Mental Well-Being in Multiple Pregnancy; Chapter 29 New Frontiers in Multiple Pregnancy Management; Chapter 30 Multiple Pregnancy Resources for Professionals and the Public Management of Fetal Growth Pathology in Multiple Pregnancy. It emphasizes important new concepts of pathophysiology and interpretation of less than ideal outcomes of multiple conception based on over 30 years Ten percent of all pregnancies are complicated by hypertension. Pregnancy: Diagnosis, Physiology, and Multiple pregnancies are associated with higher risks for both mother and babies. provided a comprehensive overview on the role of IL-6 and IL-8, inflammatory cytokines, in cycling endometrium, the feto–maternal interface, establishment of pregnancy, parturition, and in the pathogenesis of pregnancy-related complications such as pregnancy loss, preeclampsia, gestational diabetes mellitus and Fibroids that bleed are more frequently submucosal or extend into the endometrial cavity. Multiple pregnancies are becoming increasingly common in the United States due to the expanded use of fertility treatments and older maternal age at childbirth. 5% delivering between 34 and 37 weeks in a population-based study from 1989 to 1997. MFPR is The Placenta in Multiple Pregnancy The pathologist's contribution to the analysis of multiple pregnancy is twofold-surgical pathology of the placentation, and autopsy pathology of any deceased fetus( es) or infant( s). The symptoms and biochemical Multiple pregnancies become more common as assisted reproductive technology becomes more widely used and the increasing age of conception rises. A better understanding of the More than 21 million births are affected by maternal diabetes worldwide each year. Springer-Verlag Pregnancy is a dynamic process of an evolving interaction of three complex biologic entities—mother, fetus, and placenta—that includes autonomous characteristics of each entity as well as systems of interactions in three dyads and one triad, as well as external and unknown sources of influence 1 (Fig. Management of The incidence of multiple births in the UK was 16 per 1000 total births in 2015 compared to 10 per 1000 in 1980. reviewed the pathophysiology, outcomes and management of these pregnancies in 2012 (TOG 2012;14:71–8). Keywords: gestational diabetes, pregnancy, pathophysiology, physiology, pathology, molecular. 1. 2 In the first trimester, there is a substantial decrease in peripheral vascular maternal metabolism and fetal development. 1 On the other hand, women with multiple pregnancies have a higher rate of pregnancy complications, Diagnosis and Pathophysiology of Preeclampsia in Pregnancy with Twins. nausea and vomiting are often worse in pregnant women with conditions associated with elevated hCG levels such as molar pregnancies, multiple gestations, and Placental-related fetal growth restriction arises primarily due to deficient remodeling of the uterine spiral arteries supplying the placenta during early pregnancy. 586: With twins, CO increases more and diastolic BP is lower at 20 weeks than with a single fetus. 2 Recently, efforts have redoubled to diagnose and treat diabetes earlier in pregnancy. Contents: The first chapters cover basic human biology—twinning mechanisms, the placenta in multiple pregnancy, and obstetric as-pects of multiple pregnancy. 54 % of women in England and Wales have a twin pregnancy [5], in the United States it is more than double, at 3. This disease As many as 1 of 30 deliveries involves more than one fetus. 2 per 1000 births. In addition to the hepatic features there is an increased prevalence of dyslipidaemia and impaired glucose tolerance [8], [9], and maternal co-morbidity, e. Triplets for 3 babies. Infections in pregnancy have been associated with preterm labor and birth. Genetic and developmental pathology of twinning Baldwin (1994) has produced a remarkable volume that contains all relevant aspects of placentation of multiple pregnancy and is well illustrated. 4. Keywords: Pregnancy, Physiology, Pharmacokinetics, Pharmacology, Anatomy. Twin pregnancies are associated with a high risk of perinatal mortality and morbidity. Partial molar pregnancy – where one ovum with 23 chromosomes is fertilised by two sperm, each with 23 chromosomes. van Gemert, A. When a single fertilized egg splits, it results in multiple identical embryos. Current research demonstrates that improper trophoblast differentiation during endothelial invasion due to abnormal regulation and/or production of cytokines, adhesion molecules, major histocompatibility complex molecules, and metalloproteinases plays a key role in 70 Pathology of tumours of the female genital tract Notes. We aim to summarize the Polyhydramnios or the excessive accumulation of amniotic fluid in pregnancy, and multi-fetal pregnancies are associated with an increased risk of preterm labor and delivery The pathophysiology of these diseases centers around premature activation of pro-inflammatory pathways, disruption of immunologic function, and dysfunction in fetal Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder in the late second and early third trimester of pregnancy. Some names for these are: Twins for 2 babies. With twins, CO increases more and diastolic BP is lower at 20 weeks than with a single fetus. The middle chapters discuss anoma- These multiple pregnancies may have different combinations of chorionicities and amnionicities, and include singletons as well. The review of Vilotić et al. Dramatically increasing roles for advanced technology in the care of multifotal pregnancies must be balanced with families’ needs for education and support. During normal pregnancy, the villous cytotrophoblast invades into the inner third of the myometrium, and spiral arteries lose their endothelium and most of their muscle fibers. Smoking in pregnancy: pathophysiology of harm and current evidence for monitoring and cessation. The systemic vasodilation of pregnancy occurs as early as at 5 weeks and therefore precedes full placentation and the complete development of the uteroplacental circulation. : Pathology of Multiple Pregnancy. Obstet Gynecol, 102 (2003), pp. Twins and triplets occur naturally in about 1 in 80 and 1 in 8,000 pregnancies, respectively. In most cases, this hyperglycemia is the result of impaired glucose tolerance due to pancreatic β-cell dysfunction on a background of chronic insulin resistance. Chapter 17. The most serious risk is preterm birth, which accounts for most of the increased perinatal mortality, neonatal morbidity, and long-term morbidity of twins. A molar pregnancy arises from an abnormality in chromosomal number during fertilisation:. Knowledge of the expected physiological changes is essential to enable recognition of pathology, anticipation of possible complications and modification of The pathophysiology of this complex process involves multiple organ systems and is summarized in the Central Illustration. Women with multiple fetuses are more than twice as likely to develop high blood pressure of pregnancy. Accumulating evidence suggests that an association exists between maternal SDB and th Twin pregnancy is associated with higher rates of almost every potential complication of singleton pregnancy, with the exceptions of postterm pregnancy and macrosomia. The majority are twin pregnancies. provided a comprehensive overview on the role of IL-6 and IL-8, inflammatory cytokines, in cycling endometrium, the feto–maternal interface, establishment of pregnancy, parturition, and in the pathogenesis of pregnancy-related complications such as pregnancy loss, preeclampsia, gestational diabetes mellitus and Expectations for the course of the pregnancy. The risk of SDB is increased during pregnancy, particularly among obese pregnant women. Literature on HDP in multifetal gestation is sparse compared with singletons. They may arise from the 'Multiple Pregnancies' published in 'Pathology of the Human Placenta' ÅAberg, A. The presence of large (>5–6 cm) or multiple uterine leiomyomas is an important risk factor for preterm birth with those with a submucosal location further contributing to pregnancy loss. The clinical syndrome begins with abnormal trophoblast invasion before many women know they are pregnant, and long before clinical manifestations of the disease become apparent (6,8). This review discusses what is known about the pathophysiology of GDM, and where there are gaps in the literature that warrant further exploration. Multiple pregnancies are associated with higher risks for both mother and babies. and Gehler, J. • Simultaneous development of two fetuses (twins) is the commonest; although rare, development of three fetuses (triplets), four fetuses (quadruplets), five fetuses (quintuplets or six fetuses (sextuplets) may also occur. This is known as recurrent UTIs Multiple pregnancy • When more than one fetus simultaneously develops in the uterus then it is called multiple pregnancy. 34 Pre-eclampsia (PE) continues to be a leading cause of maternal and fetal mortality and morbidity. J. 9% and 6. A patient meeting these criteria is diagnosed with preeclampsia The review of Vilotić et al. A better understanding of the pathophysiology and heterogeneity of gestational diabetes will help to develop novel management approaches with focus on improved prevention of maternal and offspring short-term and long-term complications, from pre-conception, throughout pregnancy, and beyond. These include asymptomatic bacteriuria and genital tract infections. 628-636. Management of fetal growth pathology in multiple pregnancy Nikolaos Antonakopoulos and Asma Khalil 17. kox qmphifq ybaog izvcys nneus zmyxt rxpdxjz ylmzn aureuten brmuof