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Milazzo R, Garbin M, Consonni D, Casati D, Faiola S, Laoreti A, Mannarino S, Cetin I, Lanna MM. Maternal hemodynamic evaluation in monochorionic twin pregnancy complicated by twin-to-twin transfusion syndrome treated with fetoscopic laser surgery. Am J Obstet Gynecol MFM 2024; 6:101270. [PMID: 38145821 DOI: 10.1016/j.ajogmf.2023.101270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/08/2023] [Accepted: 12/20/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Maternal cardiovascular adaptations are amplified in twin pregnancies to support the metabolic request of the feto-placental unit. Few studies have evaluated the maternal hemodynamics changes after routine use of laser surgery in the treatment of twin-twin transfusion syndrome. OBJECTIVE The aim of our study was to evaluate hemodynamic changes in monochorionic twin pregnancies complicated by twin-twin transfusion syndrome before and after treatment with fetoscopic laser surgery. STUDY DESIGN A prospective observational study from 2020 to 2022, included monochorionic twin pregnancies complicated with twin-twin transfusion syndrome undergoing laser surgery between 16 and 26 weeks of gestation. To assess placental function and perfusion, uterine artery pulsatility index, hemoglobin, hematocrit, and soluble fms-like tyrosine kinase-1/placental growth factor ratio sampling prelaser and 24 hours postlaser were measured. Echocardiography by a single cardiologist evaluated maternal hemodynamics at presurgery, 24 hours, and 1 week postlaser. Those data were crosswise compared with cardiovascular indices of uncomplicated monochorionic pregnancies recruited at the same gestational age using nonparametric tests. Moreover, we fitted random-intercept linear regression models to investigate maternal hemodynamic changes according to the amount of amniotic fluid drained during laser surgery. RESULTS Forty-two twin-twin transfusion syndrome pregnancies with a median gestational age of 19.1 (17.4-20.9) weeks and 15 uncomplicated monochorionic pregnancies at the same gestational age were enrolled. Overall survival rate after laser was 72% with delivery at a median gestational age of 31.5 (27-34) weeks. Significant changes in blood chemistry and placental function were observed in the twin-twin transfusion syndrome group, along with alterations in arterial pressure, heart rate, cardiac output, and ventricular strain, eventually aligning with the uncomplicated group's values by 1 week postlaser. The amount of amniodrainage, with a 1000 ml cut-off, did not significantly impact hemodynamic parameters. Lastly, we detected a percentage of laser surgery complications in agreement with international literature and we did not record any maternal procedure-related problems. CONCLUSION Our analysis highlighted that maternal cardiovascular status in monochorionic twin pregnancy complicated by twin-twin transfusion syndrome was more dynamic and; 1 week after fetoscopic laser ablation of placental anastomosis completed by amniodrainage, maternal hemodynamic parameters restored to values similar to uncomplicated monochorionic twin pregnancies.
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Affiliation(s)
- Roberta Milazzo
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, University of Milan, Milan, Italy (Drs Milazzo and Cetin)
| | - Massimo Garbin
- Pediatric Cardiologic Department, Buzzi Children's Hospital, University of Milan, Milan, Italy (Drs Garbin and Mannarino)
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy (Dr Consonni)
| | - Daniela Casati
- Fetal Therapy Unit "U. Nicolini", Buzzi Children's Hospital, Department of Woman, Mother and Neonate, Buzzi Children's Hospital, University of Milan, Milan, Italy (Drs Casati, Faiola, Laoreti, and Lanna)
| | - Stefano Faiola
- Fetal Therapy Unit "U. Nicolini", Buzzi Children's Hospital, Department of Woman, Mother and Neonate, Buzzi Children's Hospital, University of Milan, Milan, Italy (Drs Casati, Faiola, Laoreti, and Lanna)
| | - Arianna Laoreti
- Fetal Therapy Unit "U. Nicolini", Buzzi Children's Hospital, Department of Woman, Mother and Neonate, Buzzi Children's Hospital, University of Milan, Milan, Italy (Drs Casati, Faiola, Laoreti, and Lanna)
| | - Savina Mannarino
- Pediatric Cardiologic Department, Buzzi Children's Hospital, University of Milan, Milan, Italy (Drs Garbin and Mannarino)
| | - Irene Cetin
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, University of Milan, Milan, Italy (Drs Milazzo and Cetin)
| | - Mariano M Lanna
- Fetal Therapy Unit "U. Nicolini", Buzzi Children's Hospital, Department of Woman, Mother and Neonate, Buzzi Children's Hospital, University of Milan, Milan, Italy (Drs Casati, Faiola, Laoreti, and Lanna).
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Paiva TM, Santana EF, Casati MF, Araujo Júnior E. Neurological morbidity in monochorionic twins with selective fetal growth restriction. Minerva Obstet Gynecol 2023; 75:565-572. [PMID: 35758094 DOI: 10.23736/s2724-606x.22.05068-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The increased risks of various obstetric, maternal and fetal comorbidities of monochorionic twin pregnancies are widely known. However, despite its high prevalence and significance, the assessment of neurological morbidity as more commonly in selective fetal growth restriction (sFGR) is concerned with more health care. This literature review aims to provide more information about such an assessment. To this end, retrospective cases of sFGR were studied in monochorionic twins, already diagnosed, classified and who had the recommended management, published between 2001 and 2018 in 17 scientific articles. In the assessment of fetal mortality, the highest risk of death of the restricted fetus was found in type 3 of sFGR, while type 2 sFGR was responsible for the highest death rates of both fetuses and also the lowest mean gestational age at delivery, 30.9 weeks. Regarding neurological morbidity, however, studies have shown a higher risk of brain damage in the habitually growing twin compared to the restricted one in the case of sFGR. This may be due to prematurity or intermittent diastolic flow on Doppler in type 2 and 3 of sFGR, however, statements about its pathophysiology still lack further studies.
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Affiliation(s)
| | - Eduardo F Santana
- Albert Einstein Medical School, São Paulo, Brazil
- Unit of Fetal Medicine, Albert Einstein Hospital, São Paulo, Brazil
| | - Murilo F Casati
- Department of Obstetrics and Gynecology, ABC Medical School (FMABC), Santo André, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil -
- Municipal University of São Caetano do Sul (USCS), Bela Vista Campus, São Paulo, Brazil
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Sondgeroth KE. Twin Gestation With Spontaneous Reduction To Singleton. Clin Obstet Gynecol 2023; 66:792-803. [PMID: 37910065 DOI: 10.1097/grf.0000000000000820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Twin gestations are at increased risk of single intrauterine fetal death. A first-trimester loss is a common complication in twin gestations. The rate of co-twin morbidity and mortality is higher when a single demise occurs in the second and third trimesters. Monochorionicity strongly influences the prognosis for the surviving co-twin. Fetal ultrasound combined with MRI may be able to help predict neurological injury to the surviving co-twin. The rate of co-twin demise decreases with advancing gestation. After single intrauterine fetal demise, monochorionic gestations should be delivered by 34 weeks and dichorionic by 36 to 37 weeks gestation.
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Lee HS, Abbasi N, Van Mieghem T, Mei-Dan E, Audibert F, Brown R, Coad S, Lewi L, Barrett J, Ryan G. Directive clinique n o 440 : Prise en charge de la grossesse gémellaire monochoriale. J Obstet Gynaecol Can 2023; 45:607-628.e8. [PMID: 37541735 DOI: 10.1016/j.jogc.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
OBJECTIF Cette directive clinique passe en revue les données probantes sur la prise en charge de la grossesse gémellaire monochoriale normale et compliquée. POPULATION CIBLE Les femmes menant une grossesse gémellaire ou multiple de haut rang. BéNéFICES, RISQUES ET COûTS: L'application des recommandations de cette directive devrait améliorer la prise en charge des grossesses gémellaires (ou multiples de haut rang) monochoriales compliquées et non compliquées. Ces recommandations aideront les fournisseurs de soins à surveiller adéquatement les grossesses gémellaires monochoriales ainsi qu'à détecter et prendre en charge rapidement les complications associées de façon optimale afin de réduire les risques de morbidité et mortalité périnatales. Ces recommandations impliquent une surveillance échographique plus fréquente en cas de grossesse monochoriale qu'en cas de grossesse bichoriale. DONNéES PROBANTES: La littérature publiée a été colligée par des recherches dans les bases de données PubMed et Cochrane Library au moyen de termes MeSH pertinents (Twins, Monozygotic; Ultrasonography, Prenatal; Placenta; Fetofetal Transfusion; Fetal Death; Fetal Growth Retardation). Les résultats ont été restreints aux revues systématiques, aux essais cliniques randomisés et aux études observationnelles. Aucune date limite n'a été appliquée, mais les résultats ont été limités aux contenus en anglais ou en français. MéTHODES DE VALIDATION: Les auteurs principaux ont rédigé le contenu et les recommandations et ils se sont entendus sur ces derniers. Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Spécialistes en médecine fœto-maternelle, obstétriciens, radiologues, échographistes, médecins de famille, infirmières, sages-femmes, résidents et autres fournisseurs de soins de santé qui s'occupent de femmes menant une grossesse gémellaire ou multiple de haut rang. RéSUMé POUR TWITTER: Directive canadienne (SOGC) pour le diagnostic, la surveillance échographique et la prise en charge des complications de la grossesse gémellaire monochoriale (p. ex., STT, TAPS, retard de croissance sélectif, cojumeau acardiaque, monoamnionicité et mort d'un jumeau). DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Lee HS, Abbasi N, Van Mieghem T, Mei-Dan E, Audibert F, Brown R, Coad S, Lewi L, Barrett J, Ryan G. Guideline No. 440: Management of Monochorionic Twin Pregnancies. J Obstet Gynaecol Can 2023; 45:587-606.e8. [PMID: 37541734 DOI: 10.1016/j.jogc.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
OBJECTIVE This guideline reviews the evidence-based management of normal and complicated monochorionic twin pregnancies. TARGET POPULATION Women with monochorionic twin or higher order multiple pregnancies. BENEFITS, HARMS, AND COSTS Implementation of these recommendations should improve the management of both complicated and uncomplicated monochorionic (and higher order multiple) twin pregnancies. They will help users monitor monochorionic twin pregnancies appropriately and identify and manage monochorionic twin complications optimally in a timely manner, thereby reducing perinatal morbidity and mortality. These recommendations entail more frequent ultrasound monitoring of monochorionic twins compared to dichorionic twins. EVIDENCE Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate MeSH headings (Twins, Monozygotic; Ultrasonography, Prenatal; Placenta; Fetofetal Transfusion; Fetal Death; Fetal Growth Retardation). Results were restricted to systematic reviews, randomized controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. VALIDATION METHODS The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE Maternal-fetal medicine specialists, obstetricians, radiologists, sonographers, family physicians, nurses, midwives, residents, and other health care providers who care for women with monochorionic twin or higher order multiple pregnancies. TWEETABLE ABSTRACT Canadian (SOGC) guidelines for the diagnosis, ultrasound surveillance and management of monochorionic twin pregnancy complications, including TTTS, TAPS, sFGR (sIUGR), acardiac (TRAP), monoamniotic twins and intrauterine death of one MC twin. SUMMARY STATEMENTS RECOMMENDATIONS.
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Duyos I, Ordás P, Herrero B, Rodriguez R, Cabrero MJ, Fernández-Zubillaga A, Diez Sebastian JB, De La Calle M, Bartha JL, Antolín E. Single fetal demise in monochorionic twins: How to predict cerebral injury in the survivor co-twin? Acta Obstet Gynecol Scand 2023. [PMID: 37270671 PMCID: PMC10378013 DOI: 10.1111/aogs.14604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION The aims of the study were to evaluate perinatal outcome in monochorionic (MC) twins complicated with single intrauterine fetal death, spontaneously versus after fetal therapy, and to assess antenatal events that increase the risk of cerebral injury. MATERIAL AND METHODS Historical cohort study of MC pregnancies with single intrauterine fetal death diagnosed or referred to a tertiary referral hospital (2012-2020). Adverse perinatal outcome included termination of pregnancy, perinatal death, abnormal fetal or neonatal neuroimaging and abnormal neurological development. RESULTS A total of 68 MC pregnancies with single intrauterine fetal death after 14 weeks of gestation were included. Sixty-five (95.6%) occurred in complicated MC pregnancies (twin to twin transfusion syndrome: 35/68 [51.5%]; discordant malformation: 13/68 [19.1%], selective intrauterine growth restriction: 10/68 [14.7%], twin reversed arterial perfusion sequence: 5/68 [7.3%] and cord entanglement in monoamniotic twins: 2/68 [2.94%]). In 52 cases (76.5%) single intrauterine fetal demise occurred after fetal therapy and in 16 (23.5%) occurred spontaneously. Cerebral damage included 14/68 cases (20.6%): 6/68 cases (8.82%) were prenatal lesions and 8/68 cases (11.8%) were postnatal. Risk of cerebral damage tended to be higher in the spontaneous death group (6/16, 37.5%) compared to the therapy-group (8/52, 15.38%) (p = 0.07). The risk increased with gestational age at intrauterine death (OR 1.21, 95% CI: 1.04-1.41, p = 0.014) and was higher in those surviving co-twins who developed anemia (OR 9.27, 95% CI: 1.50-57.12, p = 0.016). Pregnancies complicated with selective intrauterine growth restriction tended to be at higher risk for neurological damage (OR 2.85, 95% CI: 0.68-11.85, p = 0.15). Preterm birth rate (<37 weeks of pregnancy) was 61.7% (37/60). Seven of eight postnatal cerebral lesions (87.5%) were related to extreme prematurity. Overall perinatal survival rate was 88.3% (57/68) and 7% (4/57) of children had an abnormal neurological outcome. CONCLUSIONS Risk of cerebral damage in single intrauterine fetal death is especially high when it occurs spontaneously. Gestational age at single intrauterine fetal death, selective intrauterine growth restriction and anemia of the surviving co-twin are the main predictors for prenatal lesions and might be useful in parent counseling. Abnormal postnatal neurological outcome is closely related to extreme prematurity.
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Affiliation(s)
- Inmaculada Duyos
- Universidad Autónoma de Madrid, Madrid, Spain
- Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain
| | - Polán Ordás
- Universidad Autónoma de Madrid, Madrid, Spain
- Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain
| | - Beatriz Herrero
- Universidad Autónoma de Madrid, Madrid, Spain
- Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain
| | - Roberto Rodriguez
- Universidad Autónoma de Madrid, Madrid, Spain
- Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain
| | - Miguel Jesús Cabrero
- Universidad Autónoma de Madrid, Madrid, Spain
- Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain
| | | | | | - María De La Calle
- Universidad Autónoma de Madrid, Madrid, Spain
- Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain
| | - José Luis Bartha
- Universidad Autónoma de Madrid, Madrid, Spain
- Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain
| | - Eugenia Antolín
- Universidad Autónoma de Madrid, Madrid, Spain
- Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain
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Tollenaar LSA, Slaghekke F, Middeldorp JM, Lopriore E. Fetal anemia in monochorionic twins: a review on diagnosis, management, and outcome. Expert Rev Hematol 2023; 16:9-16. [PMID: 36609186 DOI: 10.1080/17474086.2023.2166921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Monochorionic twins may develop fetal anemia when blood is unequally distributed via the placental vascular anastomoses. This review focuses on the causes of fetal anemia in complicated monochorionic twins and highlights the differences in management and outcome. AREAS COVERED Fetal anemia can occur in the context of twin anemia polycythemia sequence (TAPS), chronic twin-twin transfusion syndrome (TTTS) and acute peripartum TTTS, and in cotwins after single fetal demise. Diagnosis of fetal anemia is based on abnormal Doppler ultrasound measurements. Management options include fetoscopic laser surgery, intrauterine blood transfusion, or expectant management, depending on the type of complication and the severity of the disease. In all complications, fetal anemia may lead to perinatal mortality, neonatal morbidity, severe cerebral injury, and long-term neurodevelopmental impairment. In TAPS specifically, anemic donors may also show bilateral deafness. EXPERT OPINION Knowledge on the diagnosis and optimal treatment in TTTS is nowadays widespread, but caregivers often fail to distinguish TAPS from acute peripartum TTTS at birth. A full blood count including reticulocyte count is required, and placental dye injection is extremely helpful to reach the correct diagnosis and establish the optimal management.
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Affiliation(s)
- L S A Tollenaar
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - F Slaghekke
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Healy EF, Khalil A. Single Intrauterine Death in Twin Pregnancy: Evidenced-based Counselling and Management. Best Pract Res Clin Obstet Gynaecol 2022. [DOI: 10.1016/j.bpobgyn.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022]
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Tedjawirja VN, van Klink JM, Haak MC, Klumper FJ, Middeldorp JM, Miller JL, Rosner M, Baschat AA, Lopriore E, Oepkes D. Questionable benefit of intrauterine transfusion following single fetal death in monochorionic twin pregnancy. Ultrasound Obstet Gynecol 2022; 59:824-825. [PMID: 35137996 DOI: 10.1002/uog.24876] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Affiliation(s)
- V N Tedjawirja
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M van Klink
- Department of Medical Psychology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - M Rosner
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - A A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - E Lopriore
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Shinar S, Harris K, Van Mieghem T, Lewi L, Morency AM, Blaser S, Ryan G. Early imaging predictors of fetal cerebral ischemic injury in monochorionic twin pregnancy complicated by spontaneous single intrauterine death. Ultrasound Obstet Gynecol 2022; 59:497-505. [PMID: 34940985 DOI: 10.1002/uog.24844] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/02/2021] [Accepted: 12/14/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Monochorionic twin pregnancies are at increased risk of single intrauterine death (sIUD) and subsequent brain injury in the surviving twin owing to shared placentation. We assessed the association between middle cerebral artery peak systolic velocity (MCA-PSV) and cerebral injury on magnetic resonance imaging (MRI) and examined the association between cerebral findings on diffusion-weighted imaging (DWI) and those on T2-weighted imaging following spontaneous sIUD. METHODS This was a retrospective cohort study of monochorionic pregnancies complicated by spontaneous sIUD followed at a tertiary center between January 2008 and January 2020. Pregnancies with sIUD following laser treatment, those with selective feticide, double IUD occurring on the same day or sIUD before 14 weeks' gestation were excluded, as were cases in which MCA-PSV was not measured or DWI-MRI was not performed. The ability of MCA-PSV Doppler to predict subsequent cerebral injury on MRI was assessed, and DWI findings were analyzed and compared with those on susceptibility-weighted imaging (SWI) and T2-weighted MRI to determine its diagnostic accuracy. RESULTS We assessed 64 monochorionic pregnancies complicated by spontaneous sIUD. Of these, 47 (73.4%) pregnancies underwent fetal brain MRI and met the inclusion criteria. Sixteen (34.0%) of these fetuses demonstrated cerebral injury on MRI. The median interval between the diagnosis of sIUD and MRI examination was 5 days. Fetuses with increased MCA-PSV > 1.5 multiples of the median (MoM) following sIUD were significantly more likely to demonstrate cerebral injury on MRI than were those with normal MCA-PSV (68.8% vs 38.7%; P = 0.05). The sensitivity and specificity of MCA-PSV > 1.5 MoM for predicting cerebral injury on MRI were 68.8% (95% CI, 41.3-88.9%) and 61.3% (95% CI, 42.2-78.2%), respectively. Patterns of early cerebral injury on T2-weighted and SWI-MRI included acute or subacute tissue swelling (n = 6), parenchymal atrophy (n = 7), loss of cortical ribbon (n = 1) and hemorrhage (n = 8). Early MRI within approximately 2 weeks after the diagnosis of sIUD demonstrated abnormal DWI along with coexisting SWI and T2-weighted sequelae in 56.3% (9/16) of cases. When DWI was normal and a second MRI examination was performed later (n = 7), there were no ischemic changes evident on T2-weighted imaging. CONCLUSIONS Increased MCA-PSV is associated with, but predicts poorly, cerebral injury after sIUD. Early MRI with DWI within approximately 2 weeks after the diagnosis of sIUD is valuable in identifying any cerebral injury. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Shinar
- Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - K Harris
- Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - T Van Mieghem
- Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - A M Morency
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McGill University, Royal Victoria Hospital - MUHC Glen Site, Montreal, QC, Canada
| | - S Blaser
- Department of Diagnostic Imaging, Hospital for Sick Children, Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - G Ryan
- Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Knijnenburg PJC, Lopriore E, Slaghekke F, van Klink JMM. Long-term follow-up of complicated monochorionic twin pregnancies: Focus on neurodevelopment. Best Pract Res Clin Obstet Gynaecol 2022:S1521-6934(22)00053-0. [PMID: 35491308 DOI: 10.1016/j.bpobgyn.2022.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/13/2022] [Indexed: 11/23/2022]
Abstract
Monochorionic twin pregnancies have an increased risk of morbidity and mortality. Due to the advancements in screening and treatment strategies, mortality rates have decreased. Improving survival rates demands a shift in scope toward long-term outcomes. In this review, we focus on neurodevelopmental outcome in survivors from complicated monochorionic twin pregnancies, including twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence (TAPS), acute peripartum TTTS, acute perimortem TTTS, selective fetal growth restriction (sFGR) and monoamnionicity. Our aim is to provide an overview of the current knowledge on the long-term outcome in survivors, including psychomotor development and quality of life, and provide recommendations for future research and follow-up programs.
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Segev M, Djurabayev B, Hadi E, Yinon Y, Rabinowicz S, Hoffmann C, Shrot S. Third Trimester Structural and Diffusion Brain Imaging after Single Intrauterine Fetal Death in Monochorionic Twins: MRI-Based Cohort Study. AJNR Am J Neuroradiol 2022; 43:620-626. [PMID: 35332016 PMCID: PMC8993195 DOI: 10.3174/ajnr.a7475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Single intrauterine fetal death increases the risk of antenatal brain lesions in the surviving twin. We evaluated the prevalence of structural brain lesions, biometry, and diffusivity on routine third trimester MR imaging performed following single intrauterine fetal death. MATERIALS AND METHODS In a retrospective MR imaging-based cohort study, we compared 29 monochorionic twins complicated with single intrauterine fetal death (14 following laser ablation treatment for twin-to-twin transfusion syndrome, 8 following selective fetal reduction, and 7 spontaneous) with 2 control cohorts (49 singleton fetuses and 28 uncomplicated twin fetuses). All fetuses in the single intrauterine fetal death group underwent fetal brain MR imaging as a routine third trimester evaluation. Structural brain lesions were analyzed. Cerebral biometry and diffusivity were measured and compared. RESULTS Brain lesions consistent with the evolution of prior ischemic injury were found in 1 of 29 fetuses, not detected by ultrasound. No acute brain infarction, hemorrhage, or cortical abnormalities were found. Supratentorial biometric measurements in the single intrauterine fetal death group were significantly smaller than those in the singleton group, but not significantly different from those in the uncomplicated twin group. There were no significant differences in ADC values of the cerebral hemispheres, basal ganglia, and pons between the single intrauterine fetal death group and either control group. CONCLUSIONS Although smaller brain biometry was found, normal diffusivity in surviving twins suggests normal parenchymal microstructure. The rate of cerebral structural injury was relatively low in our cohort, arguing against the routine use of fetal brain MR imaging in twin pregnancies complicated with single intrauterine fetal death. Larger prospective studies are necessary to guide appropriate surveillance protocol and parental counseling in twin pregnancies complicated by single intrauterine fetal death.
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Affiliation(s)
- M Segev
- From the Section of Neuroradiology (M.S., B.D., C.H., S.S.)
| | - B Djurabayev
- From the Section of Neuroradiology (M.S., B.D., C.H., S.S.)
| | - E Hadi
- Division of Diagnostic Imaging, Diagnostic Ultrasound Unit of the Institute of Obstetrical and Gynecological Imaging (E.H.)
| | - Y Yinon
- Department of Obstetrics and Gynecology, and Fetal Medicine Unit (Y.Y.), Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat-Gan, Israel.,Sackler School of Medicine (Y.Y., C.H., S.S.), Tel Aviv University, Tel-Aviv, Israel
| | - S Rabinowicz
- Pediatric Neurology Unit (S.R.), The Edmond and Lilly Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - C Hoffmann
- From the Section of Neuroradiology (M.S., B.D., C.H., S.S.).,Sackler School of Medicine (Y.Y., C.H., S.S.), Tel Aviv University, Tel-Aviv, Israel
| | - S Shrot
- From the Section of Neuroradiology (M.S., B.D., C.H., S.S.) .,Sackler School of Medicine (Y.Y., C.H., S.S.), Tel Aviv University, Tel-Aviv, Israel
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Cruciat G, Nemeti GI, Popa-Stanila R, Florian A, Goidescu IG. Imaging diagnosis and legal implications of brain injury in survivors following single intrauterine fetal demise from monochorionic twins - a review of the literature. J Perinat Med 2021; 49:837-846. [PMID: 33882202 DOI: 10.1515/jpm-2020-0566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/18/2021] [Indexed: 12/28/2022]
Abstract
Brain injury of the surviving twin from monochorionic pregnancies following intrauterine fetal demise during the second and third trimesters is a rare but severe complication. Monochorionicity and gestational age at the time of stillbirth seem to be decisive factors in terms of long-term neurologic outcome prediction for the survivor. Magnetic resonance imaging (MRI), diffusion weighted imaging (DWI) in particular, seem to bring the earliest and most accurate diagnosis. Ultrasound detection of brain damage is possible in later stages of fetal brain injury. It is essential to provide early diagnosis and multidisciplinary counsel to the parents to ensure informed decision making. For couples who choose to terminate pregnancy legislation related to late abortion might lead to further distress. Our paper aims to stress the importance of MRI DWI in the evaluation of surviving twins following single intrauterine fetal demise in monochorionic pregnancies and the delicate context of the medical professionals and parents facing this clinical situation, sometimes complicated by legal constraints.
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Affiliation(s)
- Gheorghe Cruciat
- Obstetrics and Gynecology I, Mother and Child Department, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Georgiana Irina Nemeti
- Obstetrics and Gynecology I, Mother and Child Department, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Roxana Popa-Stanila
- Department of Radiology, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andreea Florian
- Obstetrics and Gynecology I, Mother and Child Department, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Iulian Gabriel Goidescu
- Obstetrics and Gynecology I, Mother and Child Department, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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von Kaisenberg C, Klaritsch P, Ochsenbein-Kölble N, Hodel ME, Nothacker M, Hecher K. Screening, Management and Delivery in Twin Pregnancy. Ultraschall Med 2021; 42:367-378. [PMID: 33017845 DOI: 10.1055/a-1248-8896] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The following AWMF guideline (DGGG/AGG & DEGUM responsible) deals with the diagnosis, screening and management of twins as well as the timing and mode of birth.Twin pregnancies can be classified as dichorionic diamniotic (DC DA), monochorionic diamniotic (MC DA) and monochorionic monoamniotic (MC MA) which are always monochorionic.Twin pregnancies can be concordant (both twins are affected) or discordant (only one twin is affected) for chromosomal defects, malformations, growth restriction and hemodynamic disorders.Chorionicity is the prognostically most significant parameter. Monochorial twins have significantly higher risks of intrauterine morbidity and mortality compared to dichorial twins.In particular, general aspects of twin pregnancies such as dating, determination of chorionicity and amnionicity, the labeling of twin fetuses and the perinatal switch phenomenon are discussed.Routine monitoring of MC and DC twin pregnancies with ultrasound at 11-13+ 6 weeks of gestation for chromosomal defects, invasive prenatal diagnosis, first-trimester NT or CRL discrepancies, early diagnosis of fetal anatomical defects, and management of twins with abnormalities, including selective fetocide, is described.Second trimester screening and management for preterm birth, intrauterine selective growth restriction (sFGR), classification of monochorial twins with sFGR, and management of the surviving twin after the death of the co-twin are described.Complications exclusively affecting MC twins include Twin to Twin Transfusion Syndrome (TTTS) with the important topics screening, prognosis, complications of laser therapy, timing of delivery, risks for brain abnormalities and delayed neurological development, Twin Anemia-Polycythemia Sequence (TAPS) and Twin Reversed Arterial Perfusion (TRAP) Sequence. This also includes MC MA twins as well as conjoined twins.Finally, the birth mode and time for DC and MC twin pregnancies are described.The information is summarized in 62 recommendations for action, 4 tables and 8 illustrations with comprehensive background texts.The guideline is an international guideline adaptation (ISUOG, NICE) as well as a systematic literature search and is up-to-date.
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Affiliation(s)
| | - Philipp Klaritsch
- Department of Obstetrics and Gynecology, Medical University Graz, Austria
| | | | | | - Monika Nothacker
- AWMF-Institut für Medizinisches Wissensmanagement (AWMF-IMWi), University of Marburg, Germany
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Abstract
Twin to twin transfusion syndrome (TTTS) is a common complication that typically presents in the second trimester of pregnancy in 10-15% of monochorionic twins due to net transfer of volume and hormonal substances from one twin to the other across vascular anastomoses on the placenta. Without recognition and treatment, TTTS is the greatest contributor to fetal loss prior to viability in 90-100% of advanced cases. Ultrasound diagnosis of monochorionicity is most reliable in the first trimester and sets the monitoring strategy for this type of twins. The diagnosis of TTTS is made by ultrasound with the findings of polyhydramnios due to volume overload and polyuria in one twin and oligohydramnios due to oliguria of the co-twin. Assessment of bladder filling as well as arterial and venous Doppler patterns are required for staging disease severity. Assessment of fetal cardiac function also provides additional insight into the fetal cardiovascular impacts of the disease as well as help identify fetuses that may require postnatal follow up. Fetoscopic laser ablation of the communicating vascular anastomoses between the twins is the standard treatment for TTTS. It aims to cure the condition by interrupting the link between their circulations and making them independent of one another. Contemporary outcome data after laser surgery suggests survival for both fetuses can be anticipated in up to 65% of cases and survival of a single fetus in up to 88% of cases. However, preterm birth remains a significant contributor to postnatal morbidity and mortality. Long term outcomes of TTTS survivors indicate that up to 11% of children may show signs of neurologic impairment. Strategies to minimize preterm birth after treatment and standardized reporting by laser centers are important considerations to improve overall outcomes and understand the long-term impacts of TTTS.
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Affiliation(s)
- Jena L Miller
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
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16
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Morris RK, Mackie F, Garces AT, Knight M, Kilby MD. The incidence, maternal, fetal and neonatal consequences of single intrauterine fetal death in monochorionic twins: A prospective observational UKOSS study. PLoS One 2020; 15:e0239477. [PMID: 32956426 PMCID: PMC7505445 DOI: 10.1371/journal.pone.0239477] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/07/2020] [Indexed: 12/01/2022] Open
Abstract
Objective Report maternal, fetal and neonatal complications associated with single intrauterine fetal death (sIUFD) in monochorionic twin pregnancies. Design Prospective observational study. Setting UK. Population 81 monochorionic twin pregnancies with sIUFD after 14 weeks gestation, irrespective of cause. Methods UKOSS reporters submitted data collection forms using data from hospital records. Main outcome measures Aetiology of sIUFD; surviving co-twin outcomes: perinatal mortality, central nervous system (CNS) imaging, gestation and mode of delivery, neonatal outcomes; post-mortem findings; maternal outcomes. Results The commonest aetiology was twin-twin transfusion syndrome (38/81, 47%), “spontaneous” sIUFD (22/81, 27%) was second commonest. Death of the co-twin was common (10/70, 14%). Preterm birth (<37 weeks gestation) was the commonest adverse outcome (77%): half were spontaneous and half iatrogenic. Only 46/75 (61%) cases had antenatal CNS imaging, of which 33 cases had known results of which 7/33 (21%) had radiological findings suggestive of neurological damage. Postnatal CNS imaging revealed an additional 7 babies with CNS abnormalities, all born at <36 weeks, including all 4 babies exhibiting abnormal CNS signs. Major maternal morbidity was relatively common, with 6% requiring ITU admission, all related to infection. Conclusions Monochorionic twin pregnancies with single IUD are complex and require specialist care. Further research is required regarding optimal gestation at delivery of the surviving co-twin, preterm birth prevention, and classifying the cause of death in twin pregnancies. Awareness of the importance of CNS imaging, and follow-up, needs improvement.
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Affiliation(s)
- R. Katie Morris
- Institute of Applied Health Research, University of Birmingham, Edgbaston, West Midlands, United Kingdom
- Fetal Medicine Centre, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham Women’s Hospital, Mindelsohn Way, Edgbaston, United Kingdom
- * E-mail:
| | - Fiona Mackie
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, United Kingdom
| | - Aurelio Tobías Garces
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, United Kingdom
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Mark D. Kilby
- Fetal Medicine Centre, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham Women’s Hospital, Mindelsohn Way, Edgbaston, United Kingdom
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, United Kingdom
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17
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Eschbach SJ, Tollenaar LSA, Oepkes D, Lopriore E, Haak MC. Intermittent absent and reversed umbilical artery flows in appropriately grown monochorionic diamniotic twins in relation to proximate cord insertion: A harmful combination? Prenat Diagn 2020; 40:1284-1289. [PMID: 32412655 PMCID: PMC7539996 DOI: 10.1002/pd.5736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/28/2023]
Abstract
Objective To compare the prevalence of intermittent absent or reversed end‐diastolic flow (iAREDF) in the umbilical artery in appropriately grown monochorionic diamniotic (MCDA) pregnancies with and without proximate cord insertion (PCI), and to evaluate pregnancy outcome. Methods The prevalence of iAREDF in MCDA pregnancies with PCI (n = 11) was compared with a control group without PCI (n = 33). PCI was defined as a distance between the cord insertions below the fifth percentile. Placental sharing, number, and diameter of anastomoses were assessed by placental examination. Pregnancy outcome was evaluated. Results iAREDF was present in 7/11 PCI pregnancies, compared with 0/33 in the control group (P ≤ .01). All PCI pregnancies and 94% of controls had arterioarterial (AA)‐anastomoses (P = .56), the diameter was larger in the PCI group, respectively 3.3 vs 2.1 mm (P = .03). Three cases with iAREDF had adverse outcome, two resulted in fetal death of which one with brain damage in the co‐twin, another underwent early premature emergency section for fetal distress. Conclusion iAREDF occurs in a large proportion of MCDA pregnancies with PCI and is related to the diameter of the AA anastomosis. We hypothesize that iAREDF in appropriately grown MCDA twin pregnancies reflects an unstable hemodynamic balance with an increased risk for fetal deterioration. Whether outcome in these pregnancies can be improved by altered management requires further investigation.
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Affiliation(s)
- Sanne Johanna Eschbach
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Lisanne S A Tollenaar
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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18
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Gijtenbeek M, Haak MC, Huberts TJP, Middeldorp JM, Klumper FJCM, Slaghekke F, Lopriore E, Oepkes D, van Klink JMM. Perioperative fetal hemodynamic changes in twin-twin transfusion syndrome and neurodevelopmental outcome at two years of age. Prenat Diagn 2020; 40:825-830. [PMID: 32266998 PMCID: PMC7383478 DOI: 10.1002/pd.5690] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 11/21/2022]
Abstract
Objective To investigate whether perioperative fetal hemodynamic changes in twin‐to‐twin transfusion syndrome (TTTS) are associated with neurodevelopmental impairment (NDI) at two years. Methods Doppler parameters of three sonograms (day before, first day after and 1 week after laser surgery for TTTS) were assessed for correlation with neurodevelopmental outcome at two years (2008‐2016). NDI was defined as: cerebral palsy, deafness, blindness, and/or a Bayley‐III cognitive/motor developmental test‐score > 2SD below the mean. Results Long‐term outcome was assessed in 492 TTTS survivors. NDI was present in 5% (24/492). After adjustment for severe cerebral injury (present in 4%), associated with NDI were: middle cerebral artery peak systolic velocity (MCA‐PSV) >1.5 multiples of the median (MoM) 1 day after surgery (odds ratio [OR] 4.96; 95% confidence interval [CI]: 1.17‐21.05, P = .03), a change from normal umbilical artery pulsatility index (UA‐PI) presurgery to UA‐PI >p95 postsurgery (OR 4.19; 95% CI: 1.04‐16.87, P = .04), a change from normal to MCA‐PSV >1.5MoM (OR 4.75; 95% CI: 1.43‐15.77, P = .01). Conclusion Perioperative fetal hemodynamic changes in TTTS pregnancies treated with laser are associated with poor neurodevelopmental outcome. Prospective research on the cerebrovascular response to altered hemodynamic conditions is necessary to further understand the cerebral autoregulatory capacity of the fetus in relation to neurodevelopmental outcome.
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Affiliation(s)
- Manon Gijtenbeek
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique C Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom J P Huberts
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M M van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Spruijt MS, Lopriore E, J Steggerda S, Slaghekke F, Van Klink JMM. Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond. Expert Rev Hematol 2020; 13:259-267. [PMID: 31971028 DOI: 10.1080/17474086.2020.1720643] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Twin-twin transfusion syndrome (TTTS) is a devastating complication of monochorionic twin pregnancy and remains a major challenge for worldwide fetal medicine specialists. In TTTS, intertwin transfusion through vascular anastomoses in the shared placenta leads to severe hemodynamic imbalance. This review summarizes the current knowledge of TTTS.Areas covered: The most recent insights concerning the management of TTTS, as well as fetal and neonatal complications are described. Relevant articles were selected based on a Pubmed search using the keywords below. Understanding of the underlying pathophysiology has improved greatly as a result of placental injection studies. Advancements in antenatal management have led to increased perinatal survival and a decreased incidence of neonatal complications, including brain injury and neurodevelopmental impairment.Expert opinion: Further opportunities for improvement comprise technological innovations in laser procedures and the prevention of preterm rupture of membranes with subsequent prematurity. A noninvasive treatment such as high-intensity focused ultrasound (HIFU) seems to hold promise for the future treatment of TTTS. Fetal MRI studies are important to improve our understanding of fetal brain injury and should relate their findings to long-term neurodevelopment. International collaboration and centralization of care are of paramount importance to ensure the best care for our patients.
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Affiliation(s)
- Marjolijn S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylke J Steggerda
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M M Van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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20
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Casati D, Pellegrino M, Cortinovis I, Spada E, Lanna M, Faiola S, Cetin I, Rustico MA. Longitudinal Doppler references for monochorionic twins and comparison with singletons. PLoS One 2019; 14:e0226090. [PMID: 31809530 PMCID: PMC6897428 DOI: 10.1371/journal.pone.0226090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/19/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To construct monochorionic (MC) twin-specific longitudinal Doppler references for umbilical artery pulsatility index (UA-PI), middle cerebral artery (MCA) PI and peak systolic velocity (PSV) and ductus venosus (DV) PI derived from a strictly selected cohort of uncomplicated MC twins. The secondary aim of the study was to compare our findings with singleton reference charts. METHODS A retrospective evaluation was made of all consecutive uncomplicated MC twin pregnancies referred to our Unit from 2010 to 2018. Fortnightly serial examinations were performed of UA-PI, MCA-PI, MCA-PSV and DV-PI, according with the clinical protocol, from 20 to 37 weeks of gestation. We included cases with at least four ultrasound examinations, delivery at our hospital and complete neonatal follow up. A two-step method was used to trace the estimated centile curves: estimation of the median was performed with appropriate fractional polynomials by a multilevel model and estimation of the external centiles through the residuals (quantile regression). The comparison with singletons was made by plotting the references derived from the present study on the referred charts commonly used for singletons. RESULTS The study group comprised 150 uncomplicated MC twin pairs. Estimated centiles (3rd, 5th, 10th, 50th, 90th, 95th, 97th) of UA-PI, MCA-PI, MCA-PSV and DV-PI in function of the gestational age are presented. The comparison with singletons showed substantial differences, with higher UA-PI and lower MCA-PI and PSV median values in MC twins. Median DV PI values were similar to the values for singletons, while the upper centiles were higher in MC twins. CONCLUSIONS This study sets out MC twin-specific longitudinal references for UA-PI, MCA-PI, MCA-PSV and DV-PI derived from the largest series of uncomplicated MC twin pregnancies presently available. The comparison with singleton reference values underscores the deviation from physiology that is intrinsic to these unique pregnancies and supports the need for MC twin-specific charts.
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Affiliation(s)
- Daniela Casati
- Fetal Therapy Unit 'Umberto Nicolini', Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
- * E-mail:
| | - Marcella Pellegrino
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Ivan Cortinovis
- Laboratory G.A. Maccacaro, Department of Clinical Sciences and Community Health, University of Milan Milan, Italy
| | - Elena Spada
- Neonatal Unit, University of Turin, City of Health and Science of Turin, Turin, Italy
| | - Mariano Lanna
- Fetal Therapy Unit 'Umberto Nicolini', Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Stefano Faiola
- Fetal Therapy Unit 'Umberto Nicolini', Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Irene Cetin
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Maria Angela Rustico
- Fetal Therapy Unit 'Umberto Nicolini', Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
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Wang L, Lin XZ. [Short-term prognosis of the co-twin who survives after single intrauterine fetal demise]. Zhongguo Dang Dai Er Ke Za Zhi 2019; 21:886-889. [PMID: 31506147 PMCID: PMC7390241 DOI: 10.7499/j.issn.1008-8830.2019.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/02/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate the short-term prognosis of the co-twin who survives after single intrauterine fetal demise (sIUFD). METHODS A total of 52 infants who survived after sIUFD were enrolled as the case group, and 104 twins, matched for gestational age, from a pair of live-born twins without sIUFD were enrolled as the control group. Related clinical data were compared between the two groups. RESULTS Among the 52 infants who survived after sIUFD, 42 (80.8%) were preterm infants, 13 (25.0%) had brain injury, and 3 (5.8%) died in the neonatal period. Compared with the control group, the case group had significantly higher incidence rates of meconium stained amniotic fluid/bloody amniotic fluid/polyhydramnios/hypamnion, torsion of cord/nuchal cord, and placenta previa/placenta abruption, as well as significantly higher incidence rates of birth asphyxia, anemia or polycythemia at birth, and coagulation disorder at birth (P<0.05). The case group also had significantly higher incidence rates of nosocomial infection and brain injury than the control group during hospitalization (P<0.05). CONCLUSIONS There is an increase in the incidence rate of complications in the co-twin who survives after sIUFD. Prenatal evaluation and long-term follow-up should be performed for the surviving co-twin.
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Affiliation(s)
- Lian Wang
- Department of Neonatology, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian 361000, China.
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22
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Lanna MM, Consonni D, Faiola S, Izzo G, Scelsa B, Cetin I, Rustico MA. Incidence of Cerebral Injury in Monochorionic Twin Survivors after Spontaneous Single Demise: Long-Term Outcome of a Large Cohort. Fetal Diagn Ther 2019; 47:66-73. [PMID: 31220847 DOI: 10.1159/000500774] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 05/06/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate incidence of cerebral injury and outcome in a large series of monochorionic (MC) twin survivors after spontaneous single fetal demise. METHODS Retrospective analysis of all MC pregnancies with single fetal demise diagnosed at, or referred to, the Fetal Therapy Unit "U. Nicolini," V. Buzzi Children's Hospital, Milan, Italy, from 2004 to 2015. Survivors evaluation protocol included detailed ultrasound (US) of intracranial anatomy, Doppler investigation of peak systolic velocity in the middle cerebral artery (MCA-PSV), and magnetic resonance (MR). Data were collected on pregnancy characteristics, postnatal brain scan, and MR and neurological follow-up. RESULTS Seventy-eight consecutive MC pregnancies were analyzed. Median gestational age (GA) at single fetal demise was 22 weeks (range 15-36); median interval between single demise and live birth was 105 days (range 1-175), with a median GA at birth of 36 weeks (range 23-41). Prenatal MR was performed in 57 of 78 cases (73%). Cerebral injury affected 14/78 (18%) co-twins, 2 of whom were born immediately after single demise, with postnatal diagnosis of cerebral injury; of the other 12 fetuses that were studied before birth, 10 had a prenatal diagnosis of lesion both with US and MR, one only with MR, and in one case, a grade III intraventricular hemorrhage was reported only after delivery, which occurred at 25 weeks, 5 weeks after the single demise. Signs of fetal anemia (MCA-PSV value above 1.55 MoM) were related to a higher risk of prenatal cerebral injury; cases with postnatal diagnosis of lesion were delivered at lower GA. CONCLUSIONS Cerebral injury affects 18% of co-twin survivors after single fetal demise in MC twin pregnancies, and evaluation and follow-up of these cases can improve detection rate of such damage.
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Affiliation(s)
- Mariano Matteo Lanna
- Fetal therapy Unit "U. Nicolini," Vittore Buzzi Children's Hospital, Università di Milano, Milan, Italy,
| | - Dario Consonni
- Unit of Epidemiology, Fondazione IRCCS Ca'Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Faiola
- Fetal therapy Unit "U. Nicolini," Vittore Buzzi Children's Hospital, Università di Milano, Milan, Italy
| | - Giana Izzo
- Department of Pediatric Radiology and Neuroradiology, Buzzi Children's Hospital, Milan, Italy
| | - Barbara Scelsa
- Unit of Pediatric Neurology, Buzzi Children's Hospital, Milan, Italy
| | - Irene Cetin
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Università di Milano, Milan, Italy
| | - Maria Angela Rustico
- Fetal therapy Unit "U. Nicolini," Vittore Buzzi Children's Hospital, Università di Milano, Milan, Italy
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Mackie FL, Rigby A, Morris RK, Kilby MD. Prognosis of the co-twin following spontaneous single intrauterine fetal death in twin pregnancies: a systematic review and meta-analysis. BJOG 2018; 126:569-578. [PMID: 30461179 DOI: 10.1111/1471-0528.15530] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Single intrauterine fetal death affects approximately 6% of twin pregnancies and can have serious sequelae for the surviving co-twin. OBJECTIVES Determine the prognosis of the surviving co-twin following spontaneous single intrauterine fetal death to aid counselling patients and highlight future research areas. SEARCH STRATEGY Medline, Embase, Web of Science, and Cochrane Library, from 1980 to June 2017. SELECTION CRITERIA Studies of five or more cases of spontaneous single intrauterine fetal death after 14 weeks gestation, in diamniotic twin pregnancies. DATA COLLECTION AND ANALYSIS Summary event rates were calculated and stratified by chorionicity. Monochorionic and dichorionic twins, and sub-groups, were compared by odds ratios. MAIN RESULTS In monochorionic twins, when single intrauterine fetal death occurred at less than 28 weeks' gestation, this significantly increased the rate of co-twin intrauterine fetal death [odds ratio (OR) 2.31, 95% confidence interval (CI) 1.02-5.25, I2 = 0.0%, 12 studies, 184 pregnancies] and neonatal death (OR 2.84, 95% CI 1.18-6.77, I2 = 0.0%, 10 studies, 117 pregnancies) compared with when the single intrauterine fetal death occurred at more than 28 weeks' gestation. Neonatal death in monochorionic twins was significantly higher if the pregnancy was complicated by fetal growth restriction (OR 4.83, 95% CI 1.14-20.47, I2 = 0.0%, six studies, 60 pregnancies) or preterm birth (OR 4.95, 95% CI 1.71-14.30, I2 = 0.0%, 11 studies, 124 pregnancies). Abnormal antenatal brain imaging was reported in 20.0% (95% CI 12.8-31.1, I2 = 21.9%, six studies, 116 pregnancies) of surviving monochorionic co-twins. The studies included in the meta-analysis demonstrated small study effects and possible selection bias. CONCLUSIONS Preterm birth was the commonest adverse outcome affecting 58.5 and 53.7% of monochorionic and dichorionic twin pregnancies. Outcomes regarding brain imaging and neurodevelopmental comorbidity are an important area for future research, but meta-analysis may be limited due to different methods of assessment. TWEETABLE ABSTRACT Preterm birth is the highest risk in single co-twin death. Abnormal antenatal brain imaging was found in 1/5 surviving MC twins.
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Affiliation(s)
- F L Mackie
- Centre for Women's and Children Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - A Rigby
- Flinders Medical Centre, Adelaide, SA, Australia
| | - R K Morris
- Centre for Women's and Children Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Edgbaston, UK
| | - M D Kilby
- Centre for Women's and Children Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Edgbaston, UK
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24
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Kirkham FJ, Zafeiriou D, Howe D, Czarpran P, Harris A, Gunny R, Vollmer B. Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins. Eur J Paediatr Neurol 2018; 22:989-1005. [PMID: 30467085 DOI: 10.1016/j.ejpn.2018.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022]
Abstract
Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.
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Affiliation(s)
- Fenella J Kirkham
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom.
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, "Hippokratio' General Hospital, Aristotle University, Thessaloniki, Greece
| | - David Howe
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
| | - Philippa Czarpran
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Ashley Harris
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Roxanna Gunny
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Radiology, St George's hospital, London, United Kingdom
| | - Brigitte Vollmer
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
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25
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Abstract
Perinatal mortality is higher in twins. Effects of twin order have not previously been studied in the context of single fetal demise. Our objective was to determine whether death of the fetus more proximal to the cervix will result in worse perinatal outcomes. Our population included multiple pregnancies with two viable fetuses confirmed prior to 20 weeks' gestation with the subsequent death of at least one twin. All the pregnancies were managed at The Royal Women's Hospital, Melbourne between 2006 and 2014. We excluded pregnancies of higher order multiples, the death of both twins simultaneously, and cases with incomplete outcome data. Maternal and neonatal data were reviewed. Of 46 pregnancies included, in 24 (52%), the dead twin was presenting. Gestational age at delivery was significantly earlier in these cases (mean difference: -5.0 weeks, 95% CI [-7.4, -2.6], p < .001), and emergency cesarean rates were higher 67% versus 32% (OR 4.29, 95% CI [1.25, 14.7], p = .02). There were no differences in the frequency of chorioamnionitis, preterm prelabor rupture of membranes, or placental abruption. Survival rates for co-twins were similar in both groups (presenting 83%; not presenting 91%; OR 0.41, 95% CI [0.07, 2.50], p = .29). The increase in neonatal morbidities was related to prematurity rather than to order. Findings were more common in dichorionic twins. Analysis was limited by a small sample size. If the dead twin is presenting, delivery is likely to occur earlier, with associated morbidity for the survivors. This is especially relevant for dichorionic twin pregnancies.
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26
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Conte G, Righini A, Griffiths PD, Rustico M, Lanna M, Mackie FL, Pinelli L, Prefumo F, Persico N, Igra MS, Parazzini C, Doneda C, Fichera A, Ambrosi C, Kilby M, Severino M, Triulzi F, Rossi A, Skipper N. Brain-injured Survivors of Monochorionic Twin Pregnancies Complicated by Single Intrauterine Death: MR Findings in a Multicenter Study. Radiology 2018; 288:582-590. [PMID: 29688161 DOI: 10.1148/radiol.2018171267] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To describe and classify the range of brain injuries present at prenatal, in-utero magnetic resonance (MR) imaging in co-twin survivors of monochorionic (MC) twin pregnancies complicated by single intrauterine death (SIUD). Materials and Methods This retrospective, observational study from six tertiary fetal medicine centers that perform tertiary-level prenatal in-utero MR studies reviewed cases in which prenatal in-utero MR imaging had shown a brain injury in a surviving co-twin of a twin pregnancy with a MC component complicated by SIUD. Results Forty-two surviving MC twins were described. The primary distinction of brain abnormalities was into nonfocal and focal lesions. The nonfocal lesions included periventricular leukomalacia (group 1; two fetuses), generalized encephalomalacia (group 2; nine fetuses), posterior encephalomalacia (group 3; seven fetuses), and bilateral parasagittal and perisylvian injury (group 4; three fetuses). The focal lesions included nonhemorrhagic lesions (group 5; 14 fetuses) and hemorrhagic lesions (group 6; seven fetuses). Focal brain lesions were more likely to be found in the surviving MC pregnancies complicated by twin-twin transfusion syndrome (TTTS) (odds ratio, 2.4; 95% confidence interval: 1.3, 18.5; P = .01) and in fetuses that underwent an obstetric intervention (odds ratio, 2.8; 95% confidence interval: 1.8, 23.6; P = .006). Conclusion Brain injury of the surviving co-twin after SIUD in MC pregnancies is usually of ischemic origin and spares the brainstem and cerebellum. Focal brain lesions are more frequent in pregnancies complicated by TTTS or in those where an intervention has been performed.
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Affiliation(s)
- Giorgio Conte
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Andrea Righini
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Paul D Griffiths
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Mariangela Rustico
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Mariano Lanna
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Fiona L Mackie
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Lorenzo Pinelli
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Federico Prefumo
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Nicola Persico
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Mark S Igra
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Cecilia Parazzini
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Chiara Doneda
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Anna Fichera
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Claudia Ambrosi
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Mark Kilby
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Mariasavina Severino
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Fabio Triulzi
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Andrea Rossi
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
| | - Nicholas Skipper
- From the Neuroradiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20142, Milan, Italy (G.C., F.T.); Division of Paediatric Radiology and Neuroradiology, Ospedale dei Bambini V. Buzzi, Milan, Italy (G.C., A.R., C.P., C.D.); Academic Unit of Radiology, University of Sheffield, Sheffield, England (P.D.G.); Fetal Therapy Unit Umberto Nicolini, Department of Woman Mother and Neonate, Ospedale dei Bambini V. Buzzi, Milan, Italy (M.R., M.L.); Centre of Women's and Newborn's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, England (F.L.M.); Neuroradiology Unit, Spedali Civili, Brescia, Italy (L.P., C.A.); Department of Obstetrics and Gynecology, Università degli Studi di Brescia, Brescia, Italy (F.P., A.F.); Division of Prenatal Diagnosis, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy (N.P.); Department of Radiology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, England (M.S.I., N.S.); Department of Fetal Medicine, University of Birmingham, Birmingham, England (M.K.); Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy (M.S., A.R.); and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy (F.T.)
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27
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Abstract
Twins represent 1%-2% of all pregnancies, yet continue to account for a disproportionate share of neonatal adverse events including neonatal intensive care admission, morbidity, and mortality. Ultrasonography is central to the proper diagnosis of the type of twinning. Ideally, ultrasonography is performed before 14 weeks of gestation to determine chorionicity and amnionicity. Correct identification of the chorionicity in a twin pregnancy facilitates proper counseling and management of the gestation, including ultrasonography follow-up. Herein, the different types of twinning are reviewed, together with the implications for ultrasonography monitoring of each specific type of twin gestation.
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Affiliation(s)
- Jessica Smith
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Deborah R Berman
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
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Machino H, Iriyama T, Nakayama T, Komatsu A, Nagamatsu T, Osuga Y, Fujii T. A case of a surviving co-twin diagnosed with porencephaly and renal hypoplasia after a single intrauterine fetal death at 21 weeks of gestation in a monochorionic monoamniotic twin pregnancy. Oxf Med Case Reports 2017; 2017:omw096. [PMID: 28116109 PMCID: PMC5241712 DOI: 10.1093/omcr/omw096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 12/10/2016] [Accepted: 12/24/2016] [Indexed: 11/16/2022] Open
Abstract
Monochorionic monoamniotic (MM) twin pregnancy carries a high risk of intrauterine fetal death (IUFD). Single IUFD in an MM twin pregnancy prior to 22 weeks of gestation has been reported to be strongly correlated with double twin demise. To our knowledge, there are no case reports on the natural course of a surviving co-twin in an MM twin pregnancy resulting in live birth after a single IUFD prior to 22 weeks of gestation. Here, we report a case of a surviving co-twin, after a single IUFD at 21 weeks of gestation in a MM twin pregnancy, with an antenatal diagnosis of renal hypoplasia and severe neurological damage leading to porencephaly, and live birth at 36 weeks of gestation.
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Affiliation(s)
- Hidenori Machino
- Department of Obstetrics and Gynecology , The University of Tokyo Hospital , Tokyo , Japan
| | - Takayuki Iriyama
- Department of Obstetrics and Gynecology , The University of Tokyo Hospital , Tokyo , Japan
| | - Toshio Nakayama
- Department of Obstetrics and Gynecology , The University of Tokyo Hospital , Tokyo , Japan
| | - Atsushi Komatsu
- Department of Obstetrics and Gynecology , The University of Tokyo Hospital , Tokyo , Japan
| | - Takeshi Nagamatsu
- Department of Obstetrics and Gynecology , The University of Tokyo Hospital , Tokyo , Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology , The University of Tokyo Hospital , Tokyo , Japan
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology , The University of Tokyo Hospital , Tokyo , Japan
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29
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Abstract
PURPOSE OF REVIEW Twin-to-twin transfusion syndrome (TTTS) is an uncommon, but dangerous, complication of monochorionic diamniotic twin gestations. The purpose of this review is to provide an update on the evolving treatments in TTTS as it pertains primarily to laser photocoagulation, as well as to provide recently published information on outcomes. RECENT FINDINGS The Solomon laser technique, in which selective fetoscopic laser photocoagulation is first performed and then followed by laser of the vascular equator from one side of the placenta to the other, reduces TTTS complications of twin anemia-polycythemia syndrome and recurrent TTTS. The addition of fetal echocardiography to the historical staging of TTTS adds important information that may guide future therapies. The postlaser ablation rate of neurodevelopmental delay in TTTS has recently been reported to be 14%. Cotwin demise is a significant complication of untreated TTTS and survival carries a 25% risk of cystic periventricular leukomalacia, middle cerebral artery infarction, and injury to other central nervous system structures as noted by neuroimaging. SUMMARY Laser therapy for TTTS is clearly the only therapy that halts the disease process, allows both fetuses an opportunity to survive and protects a surviving cotwin in the event of the demise of one twin. Laser techniques have evolved greatly over the last 25 years and recent reports with the addition of the Solomon technique appearing to reduce some postlaser complications (twin anemia-polycythemia sequence and recurrent TTTS). Future focus of TTTS therapy should be centered on understanding the pathophysiology of the disease better with improvement in staging of the disease and on comparison of different laser techniques with the overall goal of not only increasing twin survival rates but also reducing long term neurodevelopmental morbidity.
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Simões T, Queirós A, Marujo AT, Valdoleiros S, Silva P, Blickstein I. Prospective risk of intrauterine death of monochorionic twins: update. J Perinat Med 2016; 44:871-874. [PMID: 26630688 DOI: 10.1515/jpm-2015-0319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/26/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To calculate an updated prospective risk of fetal death in monochorionic-biamniotic (MCBA) twins. STUDY DESIGN We evaluated 520 MCBA twin pregnancies that had intensive prenatal surveillance and delivered in a single Portuguese referral center. The prospective risk of fetal death was calculated as the total number of deaths at the beginning of the gestational period divided by the number of continuing pregnancies at or beyond that period. Data were compared to the 2006 previous report. RESULTS Nearly 80% of the neonates weighed <2500 g, including 13.5% who weighed <1500 g. Half were born at <36 weeks, including 13.8% who were born at <32 weeks. The data indicate an increased IUFD rate over time - 16 fetal deaths per pregnancy (3.1%) and 22 IUFDs per fetus (2.1%). The rate of IUFD after 32-33 weeks, however, was halved (1/187 pregnancies and 1/365 fetuses, 0.5 and 0.3%, respectively). CONCLUSION Intensive prenatal surveillance might decrease the unexpected fetal death rates after 33 week's gestation and our data do not support elective preterm birth for uncomplicated MCBA twins.
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Mackie FL, Morris RK, Kilby MD. Fetal Brain Injury in Survivors of Twin Pregnancies Complicated by Demise of One Twin: A Review. Twin Res Hum Genet 2016; 19:262-7. [DOI: 10.1017/thg.2016.39] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Perinatal mortality is increased considerably in multiple pregnancies compared to singleton pregnancies, with single intrauterine fetal demise (sIUFD) presenting a rare but unique perinatal problem. Monochorionic pregnancies are at particular risk of sIUFD due to bidirectional inter-twin placental vascular anastomoses. The resulting inter-twin blood flow can become unbalanced, causing acute and chronic inter-twin transfusion and profound anemia secondary to fetal exsanguination into the low-pressure circulation of the dead fetus. If the sIUFD occurs after 14 weeks’ gestation it is believed to have the most significant effect on the continuing pregnancy as the co-twin is at increased risk of preterm delivery, long-term neurological complications, and death. This article will focus on fetal brain injury in the surviving co-twin in the case of sIUFD, as it is the most common kind of injury in sIUFD, and one which concerns parents and may be the basis for terminating the pregnancy. We will outline how these brain injuries are thought to occur and describe potential pathophysiological mechanisms. We will discuss risk factors for brain injury in cases of sIUFD, including: chorionicity, cause of the sIUFD (spontaneous or secondary to an underlying pathological process such as twin-to-twin transfusion syndrome), gestation of delivery and how to prevent brain injury in the co-twin. We also review modes of imaging, discuss the difficulties in predicting the long-term outcome for co-twin survivors, and highlight the dearth of research in this area.
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Abstract
Twin-to-twin transfusion syndrome (TTTS) is the major complication of monochorionic (MC) pregnancy. The outcomes of this condition have been significantly improved after the introduction and widespread uptake of fetoscopic laser ablation over the last decade. However, there is still a significant fetal loss rate and morbidity associated with this condition. Improvements in the management of TTTS will require improvements in many areas. They are likely to involve refinements in the prediction of the disease and clarification of the optimum frequency of surveillance and monitoring. Improvements in training for fetoscopic surgery as well as in the technique of fetoscopic laser ablation may lead to better outcomes. New technologies as well as a better understanding of the pathophysiology of TTTS may lead to adjuvant medical therapies that may also improve short- and long-term results.
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Abstract
Background We examined the perinatal outcomes in cases of at least one fetal demise in monochorionic and diamniotic twin pregnancies. Methods We reviewed the obstetric records of all Japanese twin pregnancies managed beyond 9 weeks’ gestation at Japanese Red Cross Katsushika Maternity Hospital between 2008 and 2014. Results The incidence in the monochorionic twin pregnancies was significantly higher than that in the dichorionic twin pregnancies (8.3% vs. 2.6%, odds ratio: 3.40, 95% confidence interval: 1.5 - 7.6, P < 0.01). Of these, 60.0% were diagnosed as fetal demise of both fetuses at the same time (vs. dichorionic twin pregnancy: odds ratio: 12.0, 95% confidence interval: 1.3 - 120, P = 0.04). The rate of “vanishing twin” in cases of at least one fetal demise at 10 - 14 weeks’ gestation in the monochorionic twin pregnancies was significantly lower than that in the diamniotic twin pregnancies (30.0% vs. 88.9%, odds ratio: 0.05, 95% confidence interval: 0.01 - 0.53, P = 0.01). Conclusion The incidence of fetal demise and the influence on the co-twin in monochorionic twin pregnancy is greater than those in dichorionic twin pregnancy.
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Affiliation(s)
- Shunji Suzuki
- Department of Obstetrics and Gynecology, Japanese Red Cross Katsushika Maternity Hospital, 5-11-12 Tateishi, Katsushika-ku, Tokyo 124-0012, Japan.
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34
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Abstract
It is well established that the death of one fetus in a monochorionic twin pregnancy places the surviving twin at significant risk for neuro-developmental delay or death. Although the early 1st trimester "vanishing twin" has not traditionally been considered a major risk, the precise gestational threshold beyond which a surviving twin is at risk remains uncertain. Most experts recommend serial ultrasounds and fetal MRI in the survivor, to look for evidence of ischaemic brain injury. We present a case of early monochorionic twin demise at 14-16 weeks, with evolving ventriculomegaly and ischaemic changes on fetal MRI in the co-twin, leading to termination of pregnancy at 28 weeks.
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Affiliation(s)
- Colin A Walsh
- Department of Fetal MedicineRoyal North Shore HospitalSydneyNew South WalesAustralia; Northern Clinical School University of SydneySydneyNew South WalesAustralia
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35
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Emery SP, Bahtiyar MO, Moise KJ; North American Fetal Therapy Network. The North American Fetal Therapy Network Consensus Statement: Management of Complicated Monochorionic Gestations. Obstet Gynecol 2015; 126:575-84. [PMID: 26244534 DOI: 10.1097/AOG.0000000000000994] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The North American Fetal Therapy Network is a consortium of 30 medical institutions in the United States and Canada with established expertise in fetal therapy and other forms of multidisciplinary care for complex fetal disorders. This publication is the third in a series of articles written by NAFTNet about monochorionic pregnancies. In this article, we provide the general obstetric practitioner with information regarding management options available for complications of monochorionic gestations. This information may be useful for a better understanding of the pathophysiology of the various conditions, for better patient counseling, for timely referral to a regional treatment center, and for ongoing comanagement after treatment.
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36
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van Klink J, Koopman HM, Middeldorp JM, Klumper FJ, Rijken M, Oepkes D, Lopriore E. Long-term neurodevelopmental outcome after selective feticide in monochorionic pregnancies. BJOG 2015; 122:1517-24. [PMID: 26147116 DOI: 10.1111/1471-0528.13490] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the incidence of and risk factors for adverse long-term neurodevelopmental outcome in complicated monochorionic pregnancies treated with selective feticide at our centre between 2000 and 2011. DESIGN Observational cohort study. SETTING National referral centre for fetal therapy (Leiden University Medical Centre, the Netherlands). POPULATION Neurodevelopmental outcome was assessed in 74 long-term survivors. METHODS Children, at least 2 years of age, underwent an assessment of neurologic, motor and cognitive development using standardised psychometric tests and the parents completed a behavioural questionnaire. MAIN OUTCOME MEASURES A composite outcome termed neurodevelopmental impairment including cerebral palsy (GMFCS II-V), cognitive and/or motor test score of <70, bilateral blindness or bilateral deafness requiring amplification. RESULTS A total of 131 monochorionic pregnancies were treated with selective feticide at the Leiden University Medical Centre. Overall survival rate was 88/131 (67%). Long-term outcome was assessed in 74/88 (84%). Neurodevelopmental impairment was detected in 5/74 [6.8%, 95% confidence interval (CI), 1.1-12.5] of survivors. Overall adverse outcome, including perinatal mortality or neurodevelopmental impairment was 48/131 (36.6%). In multivariate analysis, parental educational level was associated with cognitive test scores (regression coefficient B 3.9, 95% CI 1.8-6.0). Behavioural problems were reported in 10/69 (14.5%). CONCLUSIONS Adverse long-term outcome in survivor twins of complicated monochorionic pregnancies treated with selective feticide appears to be more prevalent than in the general population. Cognitive test scores were associated with parental educational level. TWEETABLE ABSTRACT Neurodevelopmental impairment after selective feticide was detected in 5/74 (6.8%, 95% CI 1.1-12.5) of survivors.
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Affiliation(s)
- Jmm van Klink
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - H M Koopman
- Clinical Psychology, Faculty of Social Sciences, Leiden University, Leiden, the Netherlands
| | - J M Middeldorp
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - F J Klumper
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Rijken
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - D Oepkes
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
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