Nir Melamed

Maternal and neonatal mortality and morbidity rates uncover major global health disparities. Despite ongoing efforts, the rates of maternal and neonatal complications remain substantially higher in low‐ and middle‐income countries (LMICs) compared to high‐income countries (HICs). These high rates are the result of several unmet needs in LMICs, including limited access to quality antenatal care, health worker shortages, unreliable infrastructure, sociocultural barriers, low health literacy, environmental and nutritional challenges, and affordability. In addition, while the greatest burden of these complications lies in LMICs, it is crucial to recognize that similar disparities exist in rural and remote areas of large, higher‐income countries. FemTech (female technology), which refers to a wide range of digital tools and technologies designed specifically to support women's health, has the potential to address these unmet needs in LMICs. In many LMIC settings, mobile connectivity may represent the most scalable digital infrastructure available to women, often reaching communities long before formal health system expansion. However, the uptake of these in LMICs remains limited by infrastructure, regulatory, affordability, and sociocultural constraints. Introducing these digital solutions to LMICs without careful adaptations to these unique factors is more likely to widen rather than narrow inequities. Many international guidelines advocating the implementation of advanced technologies have not taken into account these unique LMIC‐specific challenges. This gap underscores the need to develop strategies for the implementation of FemTech in LMIC settings. FIGO and its partners are well placed to coordinate the development of dedicated global guidance tailored to resource‐limited settings. This document is a first step toward this goal.

Objective: To determine the risk of placental dysfunction associated with different ultrasound‐based phenotypes of impaired fetal growth in dichorionic twin pregnancies. Design: Retrospective cohort study. Setting: Single tertiary centre. Population: Patients with dichorionic twin pregnancies delivered at ≥ 32 ^0/7 (2011–2023) ( N = 753). Methods: Each twin fetus was classified into a distinct exposure group based on combinations of fetal weight percentile (categorised as AGA, mild SGA, or severe SGA) based on singleton‐ or twin‐specific growth chart, weight discordance and Doppler. Main Outcome Measures: Abnormal placental histopathology known to be associated with FGR. Results: The rate of the primary outcome in the reference group (AGA, concordant growth, normal Doppler) was 12.8%. When using a singleton chart, isolated discordance and mild SGA were not associated with the primary outcome. Only isolated severe SGA (28.8%, aRR 2.47[1.52–4.03]), followed by severe SGA with discordant growth (41.9%, aRR 3.53[2.15–5.79]) and abnormal Doppler (54.7%, aRR 4.33[2.90–6.48]) showed significant associations with the primary outcome. In contrast, when using a twin‐specific chart, both isolated discordance (32.4%, aRR 2.63[1.46–4.73]) and mild SGA (28.2%, aRR 2.43[1.30–4.51]) were associated with the primary outcome. We propose three risk categories for late‐onset placenta‐mediated FGR based on the likelihood of the primary outcome: (1) possible small increase (< 2‐fold); (2) moderate increase (2–3 fold); and (3) highest risk (> 4‐fold). Conclusion: The risk categories proposed in the current study can serve as a framework to inform the design of future trials and contribute to the development of guidelines for managing twin pregnancies affected by late‐onset FGR.

Objective: To explore the contribution of selected methodological factors to the heterogeneity in published umbilical artery pulsatility index (UA‐PI) reference charts. Methods: Cross‐sectional study of uncomplicated singleton pregnancies that underwent assessment of UA Doppler at a single center. We explored the effects of the cohort characteristics (parity and estimated fetal weight [EFW] centile cut‐off) and the statistical modeling approach used to construct the UA‐PI centile reference charts. Results: 25 069 UA‐PI measurements from 12 394 patients were analyzed. UA‐PI centile values decreased as the minimal EFW centile inclusion cut‐off of the study cohort increased. Interpretation of UA‐PI using charts constructed from fetuses with EFW > 25th or 50th centiles resulted in a higher proportion of examinations with UA‐PI > 95th centile compared with the chart based on fetuses with EFW⟩10th centile (11.5% and 13.2% versus 10.6% of the subgroup of small‐for‐gestational‐age fetuses, respectively, P < 0.001). In contrast, parity and the statistical method used to construct the chart had minimal impact on the UA‐PI centile reference charts. Considerable heterogeneity was identified among published UA‐PI reference charts. Conclusion: Variation in the distribution of EFW centiles across the populations used to construct the UA‐PI reference chart may contribute to the heterogeneity observed in published charts.

Objective: The purpose of this cost‐utility analysis was to model the clinical and economic impact of three cervical‐length screening strategies among low‐risk twin pregnancies: two‐step universal screening (at 18–20 and 20–22 weeks), one‐step universal screening (at 18–20 weeks) and no screening. Methods: This study used a decision‐analytic model (decision tree and cohort state transition model) with a 100‐year time horizon in a Canadian context. The population included dichorionic diamniotic twin pregnancies without a history of preterm birth or prophylactic progesterone or cerclage. The model assumed that vaginal progesterone was initiated for cervical length ≤ 25 mm and that cervical cerclage was performed plus vaginal progesterone treatment for cervical length ≤ 15mm. The primary outcomes were total lifetime health‐related costs (in 2023 Canadian dollars ($)), quality‐adjusted life years (QALYs) and incremental cost‐effectiveness ratios. Clinical outcomes included the probability of preterm birth (≤ 28 and ≤ 34 weeks), probability of stillbirth and life expectancy. Probabilistic and deterministic sensitivity analyses were carried out. Results: Base‐case and probabilistic sensitivity analysis showed that, when compared with no screening, the two‐step screening strategy increased the QALYs modestly (0.62 (95% credible interval (CrI), −0.16 to 1.41)) and decreased lifetime costs (−$2460 (95% CrI, −$4850 to $251)) by reducing the rate of preterm birth. The one‐step screening strategy, although inferior to the two‐step screening strategy, also increased the QALYs and reduced costs. Findings consistent with these were obtained on testing of the model assumptions with deterministic sensitivity analysis. Conclusions: This cost‐utility analysis supports a universal two‐step screening strategy for twin pregnancies in a Canadian context. Although the conclusions of this analysis are robust in terms of the sensitivity analysis, more reliable predictions of long‐term costs and quality of life require more twin‐specific lifetime data. Additionally, cost‐utility analyses in other healthcare contexts are needed. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Importance: Antenatal corticosteroids (ACS) are accepted to be most effective in reducing prematurity-related neonatal mortality and morbidity when administered 1 to 7 days before birth. However, precise data on the optimal timing of administration are scarce.Objective: To investigate the association between ACS administration to birth interval as a continuous variable and neonatal outcomes among preterm neonates.Design, Setting, and Participants: This national retrospective cohort study was conducted from 2018 to 2021 at level III neonatal intensive care units participating in the Canadian Neonatal Network. Participants included singleton and twin neonates born from 23 weeks 0 days’ to 31 weeks 6 days’ gestation. Data were analyzed from November 29, 2023, to March 8, 2024.Exposure: ACS administration to birth interval.Main Outcomes and Measures: The primary outcome was neonatal mortality. The secondary outcome was a composite of mortality or severe neurologic injury. Associations of the ACS administration to birth interval with the study outcomes were modeled using restricted cubic splines with 5 knots.Results: A total of 7950 neonates met the study criteria, from 7124 pregnancies (mean [SD] maternal age, 31.1 [5.7] years). Compared with individuals who received ACS, those who did not were younger and had lower rates of nulliparity, twin pregnancy, hypertension, and gestational diabetes. The overall rates of neonatal mortality and the composite outcome were 8% (670 of 7950) and 14% (1132 of 7950), respectively. ACS exposure was associated with reduced neonatal mortality as early as 2 hours after administration (adjusted risk ratio [ARR], 0.83 [95% CI, 0.70-1.00]). The reduction in mortality risk increased to a plateau 12 hours following exposure (ARR, 0.56 [95% CI, 0.40-0.78]), remained stable for the first 2 weeks following exposure, and gradually decreased after that. The association with reduced mortality was no longer observed at 4 weeks after administration (ARR, 0.82 [95% CI, 0.56-1.20]), and the ARR approached the null 5 weeks after administration (ARR, 0.99 [95% CI, 0.56-1.73]). This pattern was not affected by gestational age at birth or the number of fetuses.Conclusions and Relevance: In this cohort of neonates born from 23 weeks 0 days’ gestation to 31 weeks 6 days’ gestation, ACS administration was associated with a reduction in neonatal mortality as early as 2 hours after the administration of the first dose. The interval associated with the greatest reduction in neonatal mortality was between 12 hours and 14 days before birth, which was wider than the currently accepted optimal interval of 1 to 7 days. These findings may have important clinical implications for the management of pregnancies at risk of preterm birth, particularly regarding the administration of ACS even in cases in which preterm birth is imminent, and the timing of repeat courses of ACS.

Several professional societies have published guidelines on twin pregnancies over the past few years. These documents provide recommendations on antenatal surveillance and management of twin pregnancies. At the same time, these guidelines identify several key areas where evidence is limited and additional research is needed. In the present review, we summarize available evidence regarding some of these key areas, including the screening and prevention of preterm birth, the definition and management of fetal growth restriction, the diagnosis and management of gestational diabetes, the optimal maternal gestational weight gain, and the mode and timing of delivery. In addition, we describe several online tools related to these areas that can empower individuals with twin pregnancies and assist care providers in counseling these patients.

Objective: To determine the accuracy of estimated fetal weight (EFW) and abdominal circumference (AC) discordance in diagnosing large birthweight (BW) discordance and selective fetal growth restriction (sFGR). Methods: Retrospective cohort study of patients with twin pregnancies followed at a tertiary center ( N = 1065). We determined the accuracy of intertwin fetal size discordance (based on either EFW or fetal AC) at the last ultrasound exam before birth in estimating birthweight discordance and in diagnosing sFGR at birth. Results: EFW discordance was more accurate than AC discordance in estimating BW discordance as reflected by a smaller systematic error (−0.97% vs. −6.43%, respectively, P < 0.001) and mean absolute percentage error (5.70% vs. 7.35%, respectively, P < 0.001), and a larger proportion of cases with discordance within 5%, 10%, or 15% of BW discordance (53.1% vs. 45.4%, 84.3% vs. 72.4%, and 95.1% vs. 87.0%, respectively). Still, both EFW discordance and AC discordance had low diagnostic accuracy for large BW discordance and sFGR. For example, EFW discordance >20% had a sensitivity of 49.1% and a positive predictive value of 57.0% for BW discordance >20%, and the antenatal diagnosis of sFGR had a sensitivity of 45.8%–54.4% and a positive predictive value of 50.9%–55.2% for the postnatal diagnosis of sFGR. Conclusion: While EFW discordance was more accurate than AC discordance in estimating BW discordance, both measures had low diagnostic accuracy for large BW discordance and sFGR. Care providers should consider the limited diagnostic accuracy when making management decisions on the timing and mode of delivery.