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Spekman JA, Ros E, Lewi L, Slaghekke F, Verweij EJTJ, Noll ATR, van Klink JMM, Haak MC, van der Meeren LE, Groene SG, Lopriore E. Proximate cord insertion in monochorionic twins with selective fetal growth restriction. Am J Obstet Gynecol MFM 2025; 7:101598. [PMID: 39761751 DOI: 10.1016/j.ajogmf.2024.101598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2024] [Accepted: 12/13/2024] [Indexed: 01/24/2025]
Abstract
BACKGROUND Monochorionic (MC) twins share a single placenta which can be unequally shared, leading to selective fetal growth restriction (sFGR). Limited data is available on the prevalence and clinical consequences of proximate cord insertion (PCI) in sFGR pregnancies. OBJECTIVE We aimed to investigate the prevalence of PCI in MC placentas with and without sFGR and per type of sFGR, and study the placental characteristics and perinatal outcome of PCI in sFGR pregnancies. STUDY DESIGN In this multicenter retrospective cohort study, we included all consecutive placentas of MC twin pregnancies with and without sFGR evaluated between 2002-2023. We excluded MC twins with twin-twin transfusion syndrome, twin anemia polycythemia sequence and monoamnionicity. Our primary outcome included the prevalence of PCI (distance between cord insertions ≤4 cm) and type of cord insertions categorized as concordant, intermediate or discordant. Secondary outcomes consisted of type and size of placental vascular anastomoses and short-term clinical outcomes including fetal demise and birth weight discordance (BWD). RESULTS Of 813 MC placentas, 468 were from uncomplicated twins and 345 from sFGR twins (187 type I, 41 type II and 117 type III sFGR). The prevalence of PCI in uncomplicated versus sFGR placentas was 3.8% (18/468) and 4.6% (16/345), respectively (p=0.58). PCI in sFGR type I, II and III was detected in 0.5% (1/187), 0% (0/41) and 12.8% (15/117), respectively (p<0.0001). The prevalence of discordant cord insertions (velamentous-paracentral) in uncomplicated twin placentas and sFGR placentas was 19.9% (93/468) and 45.5% (157/345), respectively (p<0.0001). Diameter of arterio-arterial (AA) anastomoses in sFGR placentas with and without PCI was 3.0 mm (IQR 2.7-5.0) versus 2.2 mm (IQR 1.4-3.1; p<0.0061). BWD in sFGR twins with PCI was 18.5% (IQR 16.4-21.0) and without PCI was 28.0% (IQR 21.8-35.9; p<0.0001). Fetal demise occurred in 12.5% (2/16) of pregnancies with PCI and 6.1% (20/329) of sFGR pregnancies without PCI (p=0.27). CONCLUSION sFGR type III placentas exhibit a high prevalence of PCI, requiring increased awareness due to the presence of larger AA anastomoses and a potentially higher risk of fetal demise.
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Affiliation(s)
- Jip A Spekman
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands (Spekman, Ros, van Klink, Groene, and Lopriore).
| | - Eva Ros
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands (Spekman, Ros, van Klink, Groene, and Lopriore)
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium (Lewi and Noll); Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (Lewi)
| | - Femke Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands (Slaghekke, Verweij, Noll, and Haak)
| | - E J T Joanne Verweij
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands (Slaghekke, Verweij, Noll, and Haak)
| | - Anne T R Noll
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium (Lewi and Noll); Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands (Slaghekke, Verweij, Noll, and Haak); Center for Fetal Medicine, Pregnancy Care and Delivery, Karolinska University Hospital, Stockholm, Sweden (Noll)
| | - Jeanine M M van Klink
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands (Spekman, Ros, van Klink, Groene, and Lopriore)
| | - Monique C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands (Slaghekke, Verweij, Noll, and Haak)
| | - Lotte E van der Meeren
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands (van der Meeren); Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands (van der Meeren)
| | - Sophie G Groene
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands (Spekman, Ros, van Klink, Groene, and Lopriore)
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands (Spekman, Ros, van Klink, Groene, and Lopriore)
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Jha P, Feldstein VA, Poder L, Strachowski LM, Bulas DI, Burger I, Laifer-Narin SL, Oliver ER, Wang EY, Zelop CM, Kang SK. ACR Appropriateness Criteria® Multiple Gestations: 2024 Update. J Am Coll Radiol 2024; 21:S413-S432. [PMID: 39488352 DOI: 10.1016/j.jacr.2024.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Accepted: 08/26/2024] [Indexed: 11/04/2024]
Abstract
The incidence of twin pregnancies has been rising, largely attributable to increasing use of artificial reproductive techniques. Ultrasound plays a critical role in establishing the chorionicity and amnionicity of multiple gestations, a key predictor of the expected risk and complications, along with guiding future clinical and imaging follow-up examinations and intervals. People carrying multiple gestations will typically undergo more ultrasound examinations (and occasionally fetal MRI) than those carrying singletons, at minimum including a first trimester dating scan, nuchal translucency scan at 11 to 14 weeks, an anatomy scan at 18 to 22 weeks, and other scans in the second and third trimesters for growth and surveillance. This document clarifies the most appropriate imaging guidelines for multiple gestations for seven clinical scenarios/variants, which range from initial imaging, follow-up imaging, growth and surveillance for uncomplicated multiple gestations, and those complicated by a known abnormality or discordance between fetuses. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Priyanka Jha
- Stanford University School of Medicine, Stanford, California.
| | | | - Liina Poder
- Panel Chair, University of California San Francisco, San Francisco, California
| | | | - Dorothy I Bulas
- Children's National Hospital and George Washington University, Washington, District of Columbia
| | | | | | - Edward R Oliver
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eileen Y Wang
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; American College of Obstetricians and Gynecologists
| | - Carolyn M Zelop
- Valley Hospital, Ridgewood, New Jersey and NYU School of Medicine, New York, New York; American College of Obstetricians and Gynecologists
| | - Stella K Kang
- Specialty Chair, New York University Medical Center, New York, New York
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Noll ATR, Lof FC, Groene SG, Haak MC, Lopriore E, Russo FM, Slaghekke F, Tollenaar LSA, Van der Merwe J, Verweij EJT, Lewi L. Artery-to-vein anastomoses in unequally divided placentas and their association with birthweight discordance. Placenta 2024; 146:58-63. [PMID: 38181521 DOI: 10.1016/j.placenta.2023.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/07/2024]
Abstract
INTRODUCTION This study investigated the impact of the shared intertwin circulation in unequally divided monochorionic (MC) placentas on fetal growth. METHODS This retrospective analysis included color-dyed, unequally shared placentas from two tertiary centers. Exclusions included twin-twin transfusion syndrome, twin anemia polycythemia sequence, and lethal anomalies. Measurement of the external diameters and areas of the artery-to-artery (AA), artery-to-vein (AV), and vein-to-vein (VV) anastomoses was performed. The ratio of the shared circulation (AV ratio) was determined by comparing the areas of the summed venous components of shared AV anastomoses to those in the individual AV anastomoses of the smaller placental part. The birth weight ratio/placental ratio (BWR/PR), total AV size areas and net AV transfusion were calculated. Univariable and multivariable linear regressions were performed to assess the relationship between BWR/PR, the AV ratio, the areas of the different anastomoses and cord insertion discordance. RESULTS Among 352 placentas, 97 % (340) had intertwin AV anastomoses, and 50 % (176) were from pregnancies with selective growth restriction. The AV ratio, AA, VV, total AV areas, and cord insertion discordance negatively correlated with BWR/PR. Multivariable linear regression confirmed the independent negative association between BWR/PR and the AV ratio, suggesting that a larger shared circulation benefits the twin with the smaller placental part. Type III sFGR placentas exhibited the highest AV ratio, resulting in the lowest BWR/PR. DISCUSSION A larger shared circulation mitigates the impact of an unequally divided placenta on fetal growth. This effect surpasses the influence of AA and VV diameters and is most prominent in Type III sFGR placentas.
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Affiliation(s)
- A T R Noll
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands; Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F C Lof
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - S G Groene
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
| | - M C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
| | - F M Russo
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - L S A Tollenaar
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
| | - J Van der Merwe
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - E J T Verweij
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.
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Pinho BB, Neves M, Pasion R, Matias A. Velamentous cord insertion in monochorionic twin pregnancies: a step forward in screening for twin to twin transfusion syndrome and birthweight discordance? J Perinat Med 2023; 51:1147-1153. [PMID: 37323000 DOI: 10.1515/jpm-2023-0161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/11/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Two major complications of monochorionic diamniotic (MCDA) twin pregnancies are twin to twin transfusion syndrome (TTTS) and birthweight discordance. The current screening ultrasound test for these pathologies combines the detection of nuchal translucency discrepancy and abnormal ductus venosus in at least one twin, in the first trimester. We aim to determine whether combining the presence of velamentous cord insertion in at least one twin increases screening efficiency. METHODS This was a retrospective cohort with a sample of 136 MCDA twin pregnancies followed at Centro Hospitalar Universitário São João, during a 16-year period. RESULTS The combination of abnormal ductus venosus in at least one twin and nuchal translucency discrepancy is associated with the development of TTTS with an OR of 10.455, but not with birthweight discordance. The combination of these first trimester markers with velamentous cord insertion is not associated with the development of either outcome. CONCLUSIONS The presence of velamentous cord insertion in MCDA pregnancies is not associated to TTTS development. Therefore, the addition of this marker to the first trimester screening would not effectively predict the development of birthweight discordance or TTTS. However, a positive currently used screening test increases the risk of developing TTTS by about ten times.
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Affiliation(s)
- Beatriz B Pinho
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mafalda Neves
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Rita Pasion
- HEI-LAB, Lusófona University, Porto, Portugal
| | - Alexandra Matias
- Department of Obstetrics and Gynecology, University Hospital of S. João, Faculty of Medicine, i3S, Porto, Portugal
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Bonanni G, Airoldi C, Romanzi F, Passananti E, Torcia E, Di Marco G, Felici F, Familiari A, Meli F, Visconti D, Lanzone A, Bevilacqua E. The impact of placental anastomoses and umbilical cord insertions' sites on monochorionic twin pregnancy outcomes: Evidence from color-dye injection studies. Placenta 2023; 143:110-116. [PMID: 37879258 DOI: 10.1016/j.placenta.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 09/07/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Our knowledge of monochorionic pregnancies' complications is largely based on the extensive ongoing research on monochorionic placental structure. Previous studies on the concordance of umbilical cord insertions are limited. This study aimed to evaluate placental anastomoses and cord insertions as independent risk factors for neonatal adverse outcomes. METHODS This was a prospective study conducted at Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy from April 2021 to December 2022. Seventy-six women with a monochorionic pregnancy were enrolled at their first-trimester scan. After delivery, all placentas that were confirmed to be monochorionic were analyzed according to standard protocols, including those of complicated monochorionic twin pregnancies. The primary outcomes were a Composite Monochorionic Pregnancy Outcome (CMPO) and a Composite Neonatal Adverse Outcome (CNAO). The secondary outcome was the birth weight discordance between the neonates. RESULTS The CMPO occurred in 15.8 % pregnancies, and the CNAO occurred in 67.1 % pregnancies. The analysis confirmed a significant association between velamentous cord insertions and neonatal adverse events (p = 0.003). Also, a significant positive association (p = 0.0326) between twin birth weight discordance and discordance in twins umbilical cord insertions' sites was found. No significant association between the number and type of the anastomoses and both the CMPO or CNAO was detected. DISCUSSION Our data suggest that the routine sonographic assessment of umbilical cords' insertion sites during the first trimester could be helpful in predicting fetal and neonatal adverse events. We believe that this sonographic assessment should start to be implemented in our routine care of monochorionic pregnancies.
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Affiliation(s)
- Giulia Bonanni
- Unit of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Chiara Airoldi
- Department of Translation Medicine, University of Piemonte Orientale, Novara, Italy
| | - Federica Romanzi
- Unit of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Elvira Passananti
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Eleonora Torcia
- Unit of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulia Di Marco
- Unit of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Felici
- Unit of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandra Familiari
- Unit of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Federica Meli
- Unit of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Daniela Visconti
- Unit of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Lanzone
- Unit of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Elisa Bevilacqua
- Unit of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
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Wen L, Zhong Q, Mei L, Gao L, Lan X, Xiong J, Luo S, Wang L. Associations between velamentous or marginal cord insertion and risk of adverse perinatal outcomes in twin pregnancies: a retrospective cohort study. BMC Pregnancy Childbirth 2023; 23:648. [PMID: 37684596 PMCID: PMC10486129 DOI: 10.1186/s12884-023-05963-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Velamentous cord insertion (VCI) and marginal cord insertion (MCI) are well-known risk factors for adverse perinatal outcomes in singleton pregnancies. However, the potential links between VCI or MCI and perinatal outcomes in twin pregnancies have yet to be systematically evaluated. This study aimed to investigate the relationships between VCI or MCI and perinatal outcomes in twin pregnancies. METHODS This retrospective single-center cohort study included women with twin pregnancies who gave birth in a tertiary hospital in Southwest, China between January 2017 and December 2022. VCI and MCI were identified by abdominal ultrasound and confirmed after placental delivery. Logistic regression, multinomial logit regression and generalized estimation equation models were used to evaluate the association between VCI or MCI and perinatal outcomes. RESULTS A total of 3682 twin pregnancies were included, including 100 (2.7%) pregnancies with VCI and 149 (4.0%) pregnancies with MCI. Compared to pregnancies with normal cord insertion, both monochorionic and dichorionic pregnancies with VCI were associated with an increased risk of preterm delivery 32-34 weeks (aRRR 2.94, 95% CI 1.03-8.39; aRRR 2.55, 95% CI 1.19-5.46, respectively), while pregnancies with MCI were not associated with preterm delivery. VCI was associated with a higher incidence of placental previa (aOR 6.36, 95% CI 1.92-21.04) in monochorionic pregnancies and placental accreta (aOR 1.85, 95% CI 1.06-3.23) in dichorionic pregnancies. MCI was associated with an increased risk of preeclampsia (aOR 3.07, 95% CI 1.49-6.32), intertwin birthweight discordance ≥ 20% (aOR 2.40, 95% CI 1.08-5.60) and selective fetal growth restriction (aOR 2.46, 95% CI 1.08-5.60) in monochorionic pregnancies and small-for-gestational age neonates (aOR 1.97, 95% CI 1.24-3.14) in dichorionic pregnancies. CONCLUSIONS VCI was associated with an increased risk of preterm delivery in twin pregnancies irrespective of chorionicity, whereas MCI was associated with an increased preeclampsia risk, significant intertwin birthweight discordance in monochorionic pregnancies and small-for-gestational age neonates in dichorionic pregnancies.
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Affiliation(s)
- Li Wen
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing, 401147, China
| | - Qimei Zhong
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing, 401147, China
| | - Lingwei Mei
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing, 401147, China
| | - Li Gao
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing, 401147, China
| | - Xia Lan
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing, 401147, China
| | - Jing Xiong
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing, 401147, China
| | - Shujuan Luo
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing, 401147, China
| | - Lan Wang
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China.
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing, 401147, China.
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Chen L, Zhou W, Zhang Y, Zhao W, Wen H. Natural evolution and risk factors for adverse outcome in selective intrauterine growth restriction under expectant management: A retrospective observational study. Int J Gynaecol Obstet 2023. [PMID: 36651697 DOI: 10.1002/ijgo.14679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/06/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the natural evolution of and risk factors for the adverse outcome of monochorionic twins with selective intrauterine growth restriction (sIUGR) under expectant management. METHODS Retrospective study conducted in a single tertiary referral center. The clinical characteristics and neonatal outcomes of 153 patients with sIUGR under expectant management were evaluated, and the risk factors leading to adverse outcomes were explored. RESULTS Fifty-one patients (33.3%) showed a changed pattern in umbilical artery Doppler at the last examination, occurring in all types of sIUGR. Compared with type Ia, the gestational age of diagnosis was earlier, the estimated fetal body weight difference at diagnosis was greater, and the rate of severe neonatal complications in both fetuses was significantly higher in type Ib (P < 0.05). Univariate and multivariate logistic regression analyses showed that type II (odds ratio [OR] 5.41, 95% confidence interval [CI] 2.34-12.51; P < 0.001) and type III (OR 9.11, 95% CI 3.02-27.50; P < 0.001) were associated with adverse perinatal outcomes in sIUGR. CONCLUSION Type II and III sIUGR are independent risk factors predicting adverse outcomes of sIUGR. Different types of sIUGR could convert to each other. The outcome of type Ib is poorer than that of type Ia.
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Affiliation(s)
- Lu Chen
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Weixiao Zhou
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Yanhua Zhang
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Wei Zhao
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Hong Wen
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
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Gu Y, Yu C, Zhang L, Weng Y, Zhou F, Yu Q, Zhang H. Abnormal umbilical cord insertion and birth weight discordancy in monochorionic diamniotic twins: A retrospective study. Medicine (Baltimore) 2022; 101:e32316. [PMID: 36550827 PMCID: PMC9771205 DOI: 10.1097/md.0000000000032316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
To investigate the relationship between abnormal umbilical cord insertion and birthweight discordance in monochorionic diamnionic (MCDA) twins. A total of 137 pairs of MCDAs were retrospectively analyzed who delivered and survived in Hangzhou Women's Hospital from January 2016 to December 2021. According to different insertion methods, they were divided into normal cord insertion group (n = 57), marginal cord insertion (MCI) group (n = 34) and velamentous cord insertion (VCI) group (n = 46). The correlation was analyzed between different insertion methods of umbilical cord and the discordant birth weight of MCDAs. The gestational age of delivery with velamentous cord insertion was significantly earlier than those with normal and marginal insertion (P < .05). There were significant differences in birthweight between large fetus (F1) and small fetus (F2) with different umbilical insertion methods (P < .05). The birthweight of F1 and F2 in normal insertion group was significantly higher than those in MCI and VCI group (P < .05). Logistic regression analysis showed that VCI was significantly associated with birth weight in F1/F2, birthweight discordance ≥ 20%, and birthweight discordance ≥ 25%, however MCI and VCI were not an independent factor for discordance in birthweight of MCDAs (P > .05). Umbilical cord insertion method can lead to inconsistency in birthweight of MCDA twins, however they were not an independent factor for discordance in birthweight.
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Affiliation(s)
- Yunxia Gu
- Department of Ultrasound, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Cheng Yu
- Department of Ultrasound, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Lidan Zhang
- Department of Ultrasound, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Yinan Weng
- Department of Ultrasound, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Fangfang Zhou
- Department of Ultrasound, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Qing Yu
- Department of Obstetrics, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Hongyan Zhang
- Department of Reproductive Medicine Center, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
- * Correspondence: Hongyan Zhang, Department of Reproductive Medicine Center, Hangzhou Women’s Hospital, Hangzhou, Zhejiang 310008, China (e-mail: )
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Van Grambezen A, Steenhaut P, Van Grambezen B, Debiève F, Bernard P, Hubinont C. The Umbilical Cord and Complications of Twin Gestations. MATERNAL-FETAL MEDICINE 2022; 4:276-285. [PMID: 40406688 PMCID: PMC12087890 DOI: 10.1097/fm9.0000000000000173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/25/2022] [Indexed: 11/05/2022] Open
Abstract
The rate of twin pregnancies has increased over the last decades, largely because of the ongoing development of assisted reproductive technology and increased maternal age at childbearing. Twins have a higher risk of adverse outcomes during pregnancy and the perinatal period. The prevalence of umbilical cord abnormalities is higher for twin pregnancies compared with singleton pregnancies. Some of these abnormalities are nonspecific to twinning and can also be found in singleton gestations (such as velamentous cord insertion, vasa previa, and single umbilical artery). Other abnormalities are associated with monochorionic twins, such as umbilical cord entanglement, and umbilical proximate cord insertion. Most of these abnormalities can be detected by ultrasound evaluation. The early and accurate ultrasound diagnosis of chorionicity, amnionicity, and placental and umbilical cord characteristics is crucial if we are to predict the risk of complications and to determine the best management for twin pregnancies. Histopathological examination of the placenta and umbilical cord after delivery can help to confirm prenatal diagnosis and to provide a better understanding of the physiopathology of their abnormalities. The aim of this review was to emphasize the role that the umbilical cord plays in twin complications and to describe the management of these high-risk pregnancies.
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Affiliation(s)
| | - Patricia Steenhaut
- Department of Obstetrics, Saint Luc University Hospital, Brussels B-1200, Belgium
| | | | - Frédéric Debiève
- Department of Obstetrics, Saint Luc University Hospital, Brussels B-1200, Belgium
| | - Pierre Bernard
- Department of Obstetrics, Saint Luc University Hospital, Brussels B-1200, Belgium
| | - Corinne Hubinont
- Department of Obstetrics, Saint Luc University Hospital, Brussels B-1200, Belgium
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10
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Wang X, Li L, Yuan P, Zhao Y, Wei Y. Effect of fetoscopic laser surgery on the placental characteristics and birth-weight discordance of twins with twin-to-twin transfusion syndrome. Front Med (Lausanne) 2022; 9:942816. [PMID: 36250079 PMCID: PMC9556886 DOI: 10.3389/fmed.2022.942816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022] Open
Abstract
Objective This study explored the effect of fetoscopic laser surgery on the placental structure and birth-weight discordance of twin-to-twin transfusion syndrome (TTTS). Methods A retrospective cohort study was conducted in TTTS patients who were admitted to the Peking University Third Hospital between April 2014 and April 2020. The patients were divided into two groups: laser group and control group. Placentas with twin survival were injected, and pregnancy outcomes and placental characteristics of the two groups were compared. The correlation between the birth-weight discordance and placental characteristics in each group was analyzed. Results The gestational age at first diagnosis in the laser group was significantly smaller than that in the control group (21.6 ± 2.8 weeks vs. 27.7 ± 3.0 weeks, p < 0.001). The proportion of patients with TTTS stage-I in the laser group was significantly lower than the control group (9.4 vs. 64.0%, p < 0.001). The gestational age at delivery in the laser group was significantly larger than that in the control group (33.6 ± 2.1 weeks vs. 31.4 ± 2.5 weeks, p = 0.001). In the laser group, the birth-weight discordance ratio was positively correlated with the placental territory discordance ratio (Spearman coefficient = 0.556; p = 0.001). Conclusion The birth-weight discordance is positively correlated with placental territory discordance in TTTS patients after FLS.
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Affiliation(s)
| | | | | | | | - Yuan Wei
- *Correspondence: Yuan Wei, ; orcid.org/0000-0003-3387-7549
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11
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Grisolia G, Bianchi A. Intertwin-membrane insertion: An ultrasound marker of defective growth in dichorionic/diamniotic twins. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:964-966. [PMID: 36069466 DOI: 10.1002/jcu.23245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 05/19/2022] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Gianpaolo Grisolia
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Carlo Poma, ASST Mantova, Italy, Strada Largo Paiolo, 10, Mantova, Lombardy, 46100, Italy
| | - Annalisa Bianchi
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Carlo Poma, ASST Mantova, Via Largo Paiolo, 10, Mantova, Lombardy, 46100, Italy
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12
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Van Lierde A, Delagrange H, Russo FM, Van der Merwe J, Devlieger R, Lewi L. Are there differences between monochorionic twin placentas after spontaneous and assisted conception? Placenta 2022; 126:171-174. [PMID: 35842947 DOI: 10.1016/j.placenta.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION No data are available on the placental characteristics of monochorionic twin pregnancies conceived by in vitro fertilization (IVF). This study investigates the differences between placentas from monochorionic diamniotic (MCDA) twin pregnancies conceived spontaneously and those conceived after IVF. METHODS This is a retrospective analysis of placental data from a consecutive series of MCDA twin pregnancies followed from the first trimester. The following placental characteristics were compared between IVF versus spontaneous MCDA pregnancies: placental sharing and birth weight discordance relative to placental sharing, the placental angioarchitecture (number, type, and size of anastomoses), and the umbilical cord insertion types. RESULTS Of the 256 MCDA placentas included in this analysis, 32 (12%) were conceived through IVF and 224 (88%) spontaneously. MCDA twin placentas after IVF did not differ significantly from MCDA twin placentas after spontaneous conception regarding placental sharing, birthweight discordance relative to sharing discordance, and angioarchitecture. There was a trend toward more discordant cord insertions (combination eccentric and velamentous) in IVF (25%) than in spontaneously conceived placentas (12%) (P = 0.05). DISCUSSION No differences could be demonstrated between MCDA placentation after spontaneous conception and IVF. Any differences in pregnancy outcome between spontaneous and IVF conceived MCDA twins may not be related to differences in placental sharing, angioarchitecture and cord insertion type.
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Affiliation(s)
- Anette Van Lierde
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Hannelore Delagrange
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Francesca Maria Russo
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | | | - Roland Devlieger
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Department of Obstetrics and Gynecology, University Hospitals Leuven, Belgium
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Department of Obstetrics and Gynecology, University Hospitals Leuven, Belgium.
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13
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Lewi L. What fetal medicine specialists should know about the monochorionic placenta. Best Pract Res Clin Obstet Gynaecol 2022; 84:17-32. [PMID: 35430160 DOI: 10.1016/j.bpobgyn.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/07/2022] [Indexed: 11/28/2022]
Abstract
Monochorionic twins are at risk of transfusion imbalances as long as they are connected to the shared placenta during their intrauterine journey. This review article addresses the macroscopic examination of the monochorionic placenta at the time of birth and explains placental dye injection studies to document the vascular anastomoses and placental sharing. We elaborate on the different types of anastomoses, the importance of how the placenta is divided between the twins, and the angioarchitecture in twin-twin transfusion syndrome, twin anemia polycythemia sequence and selective fetal growth restriction.
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Affiliation(s)
- Liesbeth Lewi
- Fetal Medicine Unit, Dept. Obstetrics and Gynecology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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14
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Couck I, Cauwberghs B, Van Aelst M, Vivanti AJ, Deprest J, Lewi L. The association between vein-to-vein anastomoses and birth weight discordance in relation to placental sharing in monochorionic twin placentas. Placenta 2022; 118:16-19. [PMID: 34995916 DOI: 10.1016/j.placenta.2021.12.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/19/2021] [Accepted: 12/29/2021] [Indexed: 01/14/2023]
Abstract
INTRODUCTION This study aims to examine the association between the presence and size of a vein-to-vein (VV) anastomosis and birth weight discordance relative to placental discordance in monochorionic diamniotic twin pregnancies. METHODS Placentas of two previous prospective studies were included in this retrospective analysis. After injection with color dye, we measured the placental surface of each twin and VV, artery-to-artery (AA), and artery-to-vein (AV) anastomoses on a digital photograph. We calculated the birth weight ratio (BWR), placental ratio (PR), and birth weight ratio/placenta ratio (BWR/PR), as well as total AV size and net AV transfusion. Placental characteristics were compared between placentas with and without VV anastomoses. We performed univariate analyses to assess the following predictors for BWR/PR: VV size, AA size, total AV size, and net AV transfusion. Multivariate analysis was then performed, including the variables significant in univariate analysis. RESULTS We analyzed 247 placentas: 58 (23%) with VV anastomoses and 189 without (77%). The BWR and PR were higher in the group with VV. In contrast, BWR/PR was lower in the group with VV anastomoses than in those without. The size of AA anastomoses was larger in placentas with VV anastomoses than in those without. In univariate analysis, VV size and AA size were significantly associated with BWR/PR. However, in multivariate regression, only VV size remained significantly associated with the BWR/PR. DISCUSSION VV anastomoses are associated with a decreased birth weight discordance relative to the placental sharing discordance, independent of the AA anastomoses.
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Affiliation(s)
- Isabel Couck
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Alexandre Joseph Vivanti
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Obstetrics and Gynecology, Antoine Béclère Hospital, Paris Saclay University, APHP, Clamart, France
| | - Jan Deprest
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; Institute for Women's Health University College London Hospital, London, United Kingdom
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.
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15
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Wang X, Shi H, Li L, Yuan P, Zhao Y, Wei Y. A study on the correlation of placental characteristics and the onset of selective intrauterine growth restriction. Sci Prog 2022; 105:368504221086358. [PMID: 35275497 PMCID: PMC10358541 DOI: 10.1177/00368504221086358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the correlation between placental characteristics and the onset of selective intrauterine growth restriction (sIUGR) and to explore the influence of placental characteristics on sIUGR onset. METHODS A retrospective cohort study was conducted at our hospital from April 2013 to April 2019. The pregnancy data and placental perfusion of 114 sIUGR patients who had received conservative treatment and delivered in our hospital were included. Correlation analysis was conducted between the total diameter of placental anastomoses, placental territory discordance, umbilical cord insertion point distance ratio, and the onset time of sIUGR. RESULTS The prevalence of AA anastomoses was 88.6% (101/114), with an average total diameter of 2.8 ± 1.5 mm, the prevalence of AV anastomoses was 93.9% (107/114), with an average diameter of 5.4 ± 3.6 mm, and the prevalence of VV anastomoses was 18.4% (21/114), with an average diameter of 4.0 ± 1.9 mm. There was a significant negative correlation between the time of sIUGR onset and the placental territory discordance ratio with a Spearman correlation coefficient of -0.306 (P = 0.001). CONCLUSIONS The larger the placental territory discordance, the earlier onset time of sIUGR.
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Affiliation(s)
- Xueju Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing 100191, China
| | - Huifeng Shi
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing 100191, China
| | - Luyao Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing 100191, China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing 100191, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing 100191, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing 100191, China
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16
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Sherer DM, Al-Haddad S, Cheng R, Dalloul M. Current Perspectives of Prenatal Sonography of Umbilical Cord Morphology. Int J Womens Health 2021; 13:939-971. [PMID: 34703323 PMCID: PMC8541738 DOI: 10.2147/ijwh.s278747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/04/2021] [Indexed: 12/15/2022] Open
Abstract
The umbilical cord constitutes a continuation of the fetal cardiovascular system anatomically bridging between the placenta and the fetus. This structure, critical in human development, enables mobility of the developing fetus within the gestational sac in contrast to the placenta, which is anchored to the uterine wall. The umbilical cord is protected by unique, robust anatomical features, which include: length of the umbilical cord, Wharton’s jelly, two umbilical arteries, coiling, and suspension in amniotic fluid. These features all contribute to protect and buffer this essential structure from potential detrimental twisting, shearing, torsion, and compression forces throughout gestation, and specifically during labor and delivery. The arterial components of the umbilical cord are further protected by the presence of Hyrtl’s anastomosis between the two respective umbilical arteries. Abnormalities of the umbilical cord are uncommon yet include excessively long or short cords, hyper or hypocoiling, cysts, single umbilical artery, supernumerary vessels, rarely an absent umbilical cord, stricture, furcate and velamentous insertions (including vasa previa), umbilical vein and arterial thrombosis, umbilical artery aneurysm, hematomas, and tumors (including hemangioma angiomyxoma and teratoma). This commentary will address current perspectives of prenatal sonography of the umbilical cord, including structural anomalies and the potential impact of future imaging technologies.
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Affiliation(s)
- David M Sherer
- The Division of Maternal Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Sara Al-Haddad
- The Division of Maternal Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Regina Cheng
- The Division of Maternal Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
| | - Mudar Dalloul
- The Division of Maternal Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USA
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17
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Monochorionic diamniotic twin pregnancies. Am J Obstet Gynecol MFM 2021; 4:100501. [PMID: 34649016 DOI: 10.1016/j.ajogmf.2021.100501] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/07/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
About one in five twin pregnancies are monochorionic diamniotic. In these twins, transfusion imbalances may develop due to the invariably present vascular anastomoses. The most severe imbalance is twin-twin transfusion syndrome, which presents as a significant amniotic fluid difference diagnosed on ultrasound scan, usually before 26 weeks. Another transfusion imbalance is twin anemia polycythemia sequence, a severe hemoglobin difference occurring mainly after 26 weeks in previously uncomplicated pregnancies. Fetoscopic laser coagulation of the anastomoses addresses the cause of these transfusion imbalances. Besides transfusion imbalances, the monochorionic placenta may be unevenly divided, or one part may be dysfunctional, leading to an intertwin growth difference of more than 20%. Here, laser ablation of the anastomoses will usually not cure the problem but aims to protect the appropriately growing twin if the growth-restricted co-twin dies. In monochorionic twins, structural anomalies are twice as common as in singleton pregnancies, probably due to a teratogenic effect of the embryonic splitting or because of transfusion imbalances. In contrast, chromosomal anomalies appear less common, possibly because they more likely result in an early demise. Selective reduction is feasible in monochorionic pregnancies but carries increased risks of loss, miscarriage, and early birth than a selective reduction in a dichorionic setting. Finally, if one monochorionic twin dies spontaneously, its co-twin may acutely exsanguinate into the demised co-twin, which may result in the loss of both twins or brain damage in the surviving twin. This update addresses the pathophysiology, diagnosis, and management of these common complications in monochorionic diamniotic twin pregnancies.
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Ochsenbein-Kölble N. Twin pregnancies. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:246-269. [PMID: 33622004 DOI: 10.1055/a-1344-4812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Twin pregnancies, resulting in 2-3 % of all deliveries, are high risk pregnancies which need specialized care. A correct dating of pregnancy and the assessment of the chorionicity/amnionicity in the first trimester (< = 13 + 6 gestational weeks, GW) is essential for further monitoring. During first trimester risk stratification of monochorionic pregnancies includes evaluation of discordance of crown-rump-lengths, nuchal translucencies and amniotic fluid. At 16 GW sonographic risk evaluation of monochorionic twins involves differences in amniotic fluid and abdominal circumferences and detection of a velamentous cord insertion. A screening for fetal malformations with cervical length measurement as screening for preterm birth (cut-off < 25 mm) should be offered all twin pregnancies around 20 GW. In uncomplicated dichorionic pregnancies US examination should be performed every 4 weeks onwards to check fetal growth and amniotic fluid. An intertwin weight discordance > 20 % identifies pregnancies at increased risk of adverse outcome. Monochorionic pregnancies should be followed at least every two weeks for screening of twin-twin transfusion syndrome (TTTS), twin-anemia-polycythemia-sequence (TAPS) and selective fetal growth retardation (sFGR) with a start at 16 GW. The type 1-3 classification of sFGR in monochorionic twins depends on the pattern of end-diastolic velocity at the umbilical artery Doppler. The diagnosis of TTTS requires the presence of an oligyohydramnios (deepest vertical pocket (DVP) < 2 cm) in the donor twin and a polyhydramnios (DVP > 8 cm) in the recipient twin. However, the diagnosis of TAPS is based on the finding of discordant MCA Doppler values with a delta-MCA PV > 0.5 MoM.
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Affiliation(s)
- Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zürich and University of Zurich, Zurich, Switzerland
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19
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Kim R, Lee MY, Won HS, Kim JM, Lee YJ, Jeong BD, Kim HJ. Perinatal outcomes and factors affecting the survival rate of fetuses with twin-to-twin transfusion syndrome treated with fetoscopic laser coagulation: a single-center seven-year experience. J Matern Fetal Neonatal Med 2021; 35:5595-5606. [PMID: 33879028 DOI: 10.1080/14767058.2021.1888286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This single-center study aimed to assess the perinatal outcomes and its associated factors in fetuses with twin-to-twin transfusion syndrome (TTTS) treated by fetoscopic laser coagulation (FLC). METHODS In this retrospective study, we included fetuses prenatally diagnosed with TTTS at Asan Medical Center, Seoul, Korea, between October 2011 and December 2018. All patients with TTTS stage II or higher and those with stage I TTTS coupled with symptomatic polyhydramnios or cardiac dysfunction were eligible for FLC. RESULTS A total of 172 cases of monochorionic diamniotic twins and one case of dichorionic triamniotic triplets were prenatally diagnosed with TTTS and treated with FLC. The median gestational ages (GAs) at diagnosis and FLC were 20.3 and 20.5 weeks, respectively. The median GA of survivors at delivery was 32.5 weeks. The overall at least one twin- and double-survival rates within 28 days after birth were 82.1% and 55.5%, respectively. The GAs at diagnosis and FLC, Quintero stage, inter-twin weight discordance, associated selective intrauterine growth restriction (sIUGR), procedure time, volume of amnioreduction, preterm prelabor rupture of membranes (PPROM) within one week after FLC, intraoperative intrauterine bleeding, and chorioamnionitis were significant predictive factors of perinatal death. Associated sIUGR, absent end-diastolic flow of umbilical artery, and abnormal cord insertion were significantly associated with donor demise in utero, whereas lower GA at diagnosis and FLC, smaller twins at FLC, pulsatile umbilical vein, and presence of mitral regurgitation were significantly associated with recipient demise in utero. Since the application of the Solomon technique, the survival rate has improved from 75.4% to 88.8%. The FLC before 17 weeks was associated with PPROM within one week after FLC and lower survival rate, whereas that after 24 weeks was associated with twin anemia-polycythemia sequence and higher survival rate. We reached a survival rate of 82% for at least one survival with only 12 procedures. CONCLUSIONS FLC is an effective treatment for TTTS. The learning curve reached the acceptable target faster than in previous studies. Several prenatal parameters are identified as predictive factors of fetal survival in TTTS treated with FLC.
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Affiliation(s)
- Rina Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jung-Min Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yoo-Jin Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ba-Da Jeong
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hwa-Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Republic of Korea
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20
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Couck I, Ponnet S, Deprest J, Devlieger R, De Catte L, Lewi L. Outcome of monochorionic twin pregnancy with selective fetal growth restriction at 16, 20 or 30 weeks according to new Delphi consensus definition. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:821-830. [PMID: 31945801 DOI: 10.1002/uog.21975] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/24/2019] [Accepted: 12/31/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To report the outcome of selective fetal growth restriction (sFGR) diagnosed according to the new Delphi consensus definition, and determine potential predictors of survival, in a cohort of unselected monochorionic diamniotic twin pregnancies. METHODS This was a retrospective study of monochorionic diamniotic twin pregnancies followed from the first trimester onward, which were diagnosed with sFGR at 16, 20 or 30 weeks' gestation. sFGR was defined according to the new Delphi consensus criteria as presence of either an estimated fetal weight (EFW) < 3rd centile in one twin or at least two of the following: EFW of one twin < 10th centile, abdominal circumference of one twin < 10th centile, EFW discordance ≥ 25% or umbilical artery pulsatility index of the smaller twin > 95th centile. The primary outcomes were the overall survival rate (up to day 28 after birth) and risk of loss of one or both twins. We further determined possible predictors of survival using uni- and multivariate generalized estimated equation modeling. RESULTS We analyzed 675 pregnancies, of which 177 (26%) were diagnosed with sFGR at 16, 20 or 30 weeks. The overall survival rate was 313/354 (88%) with 146/177 (82%) pregnancies resulting in survival of both twins, 21/177 (12%) in survival of one twin and 10/177 (6%) in loss of both twins. Subsequent twin anemia-polycythemia sequence (TAPS) developed in 6/177 (3%) and twin-twin transfusion syndrome (TTTS) in 17/177 (10%) pregnancies. All TAPS fetuses survived. The survival rate in sFGR pregnancies that subsequently developed TTTS was 65% (22/34), compared with 91% (279/308) in those with isolated sFGR (no subsequent TAPS or TTTS) (P < 0.001). The majority of sFGR cases were Type I (110/177 (62%)) and had a survival rate of 96% (212/220), as compared with a survival of 55% (12/22) in those with Type-II (P < 0.001) and 83% (55/66) in those with Type-III (P = 0.006) sFGR. The majority of sFGR pregnancies (130/177 (73%)) were first diagnosed at 16 or 20 weeks (early onset), with a survival rate of 85% (221/260), as compared with a survival of 98% (92/94) in sFGR first diagnosed at 30 weeks (late onset) (P = 0.04). A major anomaly in at least one twin was present in 28/177 (16%) sFGR cases. In these pregnancies, survival was 39/56 (70%), compared with 274/298 (92%) in those without an anomaly (P < 0.001). Subsequent development of TTTS (odds ratio (OR), 0.18 (95% CI, 0.06-0.52)), Type-II sFGR (OR, 0.06 (95% CI, 0.02-0.24)) and Type-III sFGR (OR, 0.21 (95% CI, 0.07-0.60)) and presence of a major anomaly in at least one twin (OR, 0.12 (95% CI, 0.04-0.34)), but not gestational age at first diagnosis, were independently associated with decreased survival. CONCLUSIONS Isolated sFGR is associated with a 90% survival rate in monochorionic diamniotic twin pregnancies. The subsequent development of TTTS, absent or reversed end-diastolic flow in the umbilical artery of the smaller twin and the presence of a major anomaly adversely affect survival in sFGR. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I Couck
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - S Ponnet
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London Hospital, London, UK
| | - R Devlieger
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L De Catte
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L Lewi
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
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21
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Yamamoto R, Nakanishi K, Kawaguchi H, Hayashi S, Ishii K. Prevalence of Extraplacental Anastomoses in Monochorionic Twin Pregnancies. Fetal Diagn Ther 2020; 48:24-27. [PMID: 33059349 DOI: 10.1159/000510636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the prevalence of extraplacental anastomoses (EPA) and the factors associated. METHODS A retrospective study including 144 placentas from monochorionic diamniotic (MCDA) twins delivering at one institution was performed. EPA were defined as any intertwin anastomosis located outside the chorionic plate on macroscopic inspection. The association with perinatal factors and with umbilical cord insertion site was analyzed. RESULTS The prevalence of EPA was 4.9% (7/144). Velamentous cord insertion of both twins was significantly associated with the presence of EPA in the multivariate logistic regression model (p = 0.045). DISCUSSION EPA was found in ≈5% of MCDA twin pregnancies.
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Affiliation(s)
- Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan,
| | - Kentaro Nakanishi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Haruna Kawaguchi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Shusaku Hayashi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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22
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Study of the placental characteristics and time of onset of twin-to-twin transfusion syndrome. Placenta 2020; 103:10-15. [PMID: 33068961 DOI: 10.1016/j.placenta.2020.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/29/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION To investigate the correlation between placental superficial anastomoses, placental territory and the umbilical cord attachment site with the time of onset of twin-to-twin transfusion syndrome (TTTS), and to explore the influence of placental characteristics on the time of onset of TTTS. METHODS A retrospective analysis was performed on 48 cases of TTTS managed conservatively at the Obstetrics Department of Peking University Third Hospital from April 2014 to April 2019. Placental superficial anastomoses, placental territory, the distance between the insertion points of the umbilical cord were measured after placental dye injection. Correlation analysis was conducted between placental characteristics and the time of onset of TTTS. RESULTS (1) The incidence of AA anastomoses was 33.3% (16/48) with a mean total diameter of 2.3 ± 1.4 mm, that of AV anastomoses was 95.8% (46/48) with a mean total diameter of 1.2 ± 0.4 mm, and that of VV anastomoses 22.9% (11/48) with a mean total diameter of 2.3 ± 1.1 mm (2) The time of onset of TTTS was positively correlated with the umbilical insertion ratio (Spearman correlation coefficient = 0.404, P = 0.004), but not correlated with the total diameter of anastomoses in the three different types, or with placental territory discordance. DISCUSSION The time of onset of TTTS was positively correlated with the umbilical insertion ratio, which suggest that the distance between umbilical cord insertion sites may affect the time of onset of TTTS. The smaller the distance between the umbilical cord insertion sites, the earlier the time of onset of TTTS is likely to be.
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23
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Pandya VM, Colmant C, Stirnemann J, Salomon LJ, Ville Y. Comparison of crown-rump length discordance and abnormal cord insertions as first-trimester predictors of poor outcome in monochorionic diamniotic twin pregnancies. J Matern Fetal Neonatal Med 2020; 35:3254-3258. [PMID: 32933362 DOI: 10.1080/14767058.2020.1818199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This is a retrospective study to determine the predictive value and comparison of first trimester (1) crown-rump length discordance and (2) abnormal cord insertion as screening tests for poor outcome in monochorionic diamniotic twin pregnancies. RESULTS Retrospective data were collected over last 10 years from a single center (2009-2018). A total of 261 patients were a part of this study. CRL discordance or abnormal cord insertions are not accurate predictors of twin-to-twin transfusion syndrome, which corresponds to previously published data on the same subject. Both CRL discordance and abnormal cord insertions are strongly associated with selective fetal growth restriction (sFGR) as defined according to conventional criteria or the newer consensus criteria. A combination of these two markers substantially improves the screening rates, with a positive likelihood ratio of 10.33 for sFGR. However, this combination fails to distinguish the type 1 sFGR cases from the type 2/3, which typically have poorer outcomes. CONCLUSION CRL discordance and abnormal cord insertions are strongly associated with the development sFGR in monochorionic pregnancies. A combination of these two markers shows promising potential as a screening test to identify pregnancies at a high risk for development of sFGR. Earlier diagnosis can help plan timely fetal intervention and improve the overall outcomes of these pregnancies. These markers need to be validated in larger studies before being adopted for screening of monochorionic pregnancies.
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Affiliation(s)
- Viral M Pandya
- Department of Obstetrics, Fetal Medicine and Surgery, Hôpital Necker Enfants Malades, AP-HP, Université de Paris, Paris, France
| | - Claire Colmant
- Department of Obstetrics, Fetal Medicine and Surgery, Hôpital Necker Enfants Malades, AP-HP, Université de Paris, Paris, France
| | - Julien Stirnemann
- Department of Obstetrics, Fetal Medicine and Surgery, Hôpital Necker Enfants Malades, AP-HP, Université de Paris, Paris, France
| | - Laurent J Salomon
- Department of Obstetrics, Fetal Medicine and Surgery, Hôpital Necker Enfants Malades, AP-HP, Université de Paris, Paris, France
| | - Yves Ville
- Department of Obstetrics, Fetal Medicine and Surgery, Hôpital Necker Enfants Malades, AP-HP, Université de Paris, Paris, France
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24
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Jha P, Morgan TA, Kennedy A. US Evaluation of Twin Pregnancies: Importance of Chorionicity and Amnionicity. Radiographics 2020; 39:2146-2166. [PMID: 31697621 DOI: 10.1148/rg.2019190042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The twin birth rate is increasing in the United States. Twin pregnancies can be dichorionic or monochorionic (MC). MC twins account for 20% of twin pregnancies but 30% of all-cause pregnancy-related complications. This article describes the imaging findings that establish chorionicity and amnionicity. Ideally, these are established in the first trimester when accuracy is high, but they can also be determined later in pregnancy. Complications unique to MC twin pregnancy include twin-twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion sequence, and selective fetal growth restriction. The US features, staging systems, and management of these complications are reviewed, and the consequences of MC twin demise are illustrated. Ongoing surveillance for these conditions starts at 16 weeks gestation. Monoamniotic (MA) twins are a small subset of MC twins. In addition to all of the MC complications, specific MA complications include cord entanglement and conjoined twinning. Radiologists must be able to determine chorionicity and amnionicity and should be aware of potential complications so that patients may be referred to appropriate regional specialized centers. A proposed algorithm for referral to specialized fetal treatment centers is outlined. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Tara A Morgan
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Anne Kennedy
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
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25
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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: 0.4] [Reference Citation Analysis] [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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26
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Buchanan-Hughes A, Bobrowska A, Visintin C, Attilakos G, Marshall J. Velamentous cord insertion: results from a rapid review of incidence, risk factors, adverse outcomes and screening. Syst Rev 2020; 9:147. [PMID: 32576295 PMCID: PMC7313176 DOI: 10.1186/s13643-020-01355-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 04/12/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Velamentous cord insertion (VCI) is an umbilical cord attachment to the membranes surrounding the placenta instead of the central mass. VCI is strongly associated with vasa praevia (VP), where umbilical vessels lie in close proximity to the internal cervical os. VP leaves the vessels vulnerable to rupture, which can lead to fatal fetal exsanguination. Screening for VP using second-trimester transabdominal sonography (TAS) to detect VCI has been proposed. We conducted a rapid review investigating the quality, quantity and direction of evidence available on the epidemiology, screening test accuracy and post-screening management pathways for VCI. METHODS MEDLINE, Embase and the Cochrane Library were searched on 5 July 2016 and again on 11 October 2019, using general search terms for VP and VCI. Only peer-reviewed articles reporting on the epidemiology of VCI, the accuracy of the screening test and/or downstream management pathways for VCI pregnancies were included. Quality and risk of bias of each included study were assessed using pre-specified tools. RESULTS Forty-one relevant publications were identified; all but one were based on non-UK pregnancy cohorts, and most included relatively few VCI cases. The estimated incidence of VCI was 0.4-11% in singleton pregnancies, with higher incidence in twin pregnancies (1.6-40%). VCI incidence was also increased among pregnancies with one or more other risk factors, including in vitro fertilisation pregnancies or nulliparity. VCI incidence among women without any known risk factors was unclear. VCI was associated with adverse perinatal outcomes, most notably pre-term birth and emergency caesarean section in singleton pregnancies, and perinatal mortality in twins; however, associations varied across studies and the increased risk was typically low or moderate compared with pregnancies without VCI. In studies on limited numbers of cases, screening for VCI using TAS had good overall accuracy, driven by high specificity. No studies on post-screening management of VCI were identified. CONCLUSIONS Literature on VCI epidemiology and outcomes is limited and low-quality. The accuracy of second-trimester TAS and the benefits and harms of screening cannot be determined without prospective studies in large cohorts. Modelling studies may indicate the feasibility and value of studying the epidemiology of VCI and the potential impact of detecting VCI as part of a population screening programme for VP.
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Affiliation(s)
| | | | | | - George Attilakos
- Institute for Women’s Health, University College London, London, UK
- Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
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27
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Lewi L. Monochorionic diamniotic twins: What do I tell the prospective parents? Prenat Diagn 2020; 40:766-775. [PMID: 32279339 DOI: 10.1002/pd.5705] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 12/31/2022]
Abstract
Monochorionic diamniotic twins occur in about 1 in 300 pregnancies. Compared with dichorionic twins, they face increased risks because of the shared circulation. In about 15%, an imbalance in blood exchange occurs, such as twin-twin transfusion syndrome and twin anemia polycythemia sequence. In this review, we summarize the latest evidence on the management of monochorionic diamniotic twin pregnancies and their specific complications, with a focus on information that is relevant for prospective parents.
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Affiliation(s)
- Liesbeth Lewi
- Department of Development and Regeneration, KULeuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
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28
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Saito M, Tokunaka M, Takita H, Goto M, Machi M, Sekiya B, Arakaki T, Hamada S, Oba T, Matsuoka R, Sekizawa A. Impact of first trimester determination of abnormal cord insertion on twin-to-twin transfusion syndrome and other adverse outcomes in monochorionic diamniotic twins: A retrospective cohort study. Prenat Diagn 2020; 40:507-513. [PMID: 31875322 DOI: 10.1002/pd.5633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 11/14/2019] [Accepted: 11/19/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To assess the influence of abnormal cord insertion (CI) detected by first trimester ultrasonography on the development of twin-to-twin transfusion syndrome (TTTS) in monochorionic diamniotic (MCDA) twins. METHOD In this retrospective cohort study, consecutive patients with MCDA twins who underwent fetal ultrasound screening in the first trimester between January 2011 and January 2017 were enrolled. The CI sites were evaluated between 11 + 0 and 13 + 6 weeks' gestation. All twin pairs were assigned to the abnormal CI group (twin pair with velamentous cord insertion (VCI) and/or marginal cord insertion (MCI) in one or both twins) or the normal CI group (twin pair with both normal CI). The relationships of adverse outcomes in two groups were analyzed. RESULTS A total of 109 MCDA twin pairs were examined; 15 cases were classified into the abnormal CI group and 94 cases into the normal CI group. The incidence of TTTS was significantly higher in the abnormal than in the normal CI group (26.7% vs 7.45%, P = .04). In patients who developed TTTS, all donors had VCI. CONCLUSION Ultrasound evaluation of abnormal CI at 11 + 0 to 13 + 6 weeks' gestation in MCDA twins is valuable in the assessment of the risk for TTTS.
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Affiliation(s)
- Mizue Saito
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Mayumi Tokunaka
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Hiroko Takita
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Minako Goto
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Maya Machi
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Bunbu Sekiya
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Tatsuya Arakaki
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Shoko Hamada
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Tomohiro Oba
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Ryu Matsuoka
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
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29
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Wang L, Horiuchi I, Kuwata T, Takagi K. Velamentous insertion of the umbilical cord in monochorionic triplet pregnancy: life-saving condition? BMJ Case Rep 2019; 12:12/4/e229643. [PMID: 31040147 DOI: 10.1136/bcr-2019-229643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Liangcheng Wang
- Obstetrics and Gynecology, Saitama Medical Center, Jichi Medical University, Saitama-shi, Japan
| | - Isao Horiuchi
- Obstetrics and Gynecology, Saitama Medical Center, Jichi Medical University, Saitama-shi, Japan
| | - Tomoyuki Kuwata
- Obstetrics and Gynecology, Saitama Medical Center, Jichi Medical University, Saitama-shi, Japan
| | - Kenjiro Takagi
- Obstetrics and Gynecology, Saitama Medical Center, Jichi Medical University, Saitama-shi, Japan
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30
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Lin D, Fan D, Wu S, Rao J, Zhang H, Chen T, Liu J, Ye S, Zeng M, Liu Y, Guo X, Liu Z. Role of velamentous cord insertion in monochorionic twin pregnancies: a PRISMA-compliant systematic review and meta-analysis of observational studies. J Matern Fetal Neonatal Med 2019; 33:2377-2386. [PMID: 30458694 DOI: 10.1080/14767058.2018.1551350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background: Velamentous cord insertion (VCI) has been proposed to be associated with some specific complications among monochorionic (MC) twin pregnancies. This meta-analysis and systematic review aims to determine the role of VCI in MC twin pregnancies.Methods: The PubMed, Embase and Web of Science databases and reference lists were searched for relevant studies. Outcomes of interest included twin-to-twin transfusion syndrome (TTTS), birthweight discordance (BWD) and selective intrauterine growth restriction (sIUGR). The methodological quality of the included studies was assessed by using the Newcastle-Ottawa Scale. The pooled results were calculated by means of a random or fixed effect model to obtain odds ratio with 95% confidential interval (CI). Subgroup analyses were utilized to detect the sources of heterogeneity.Results: Twenty studies were eligible for inclusion. The pooled result suggested a significant association between VCI and TTTS (OR, 1.542; 95% CI, 1.116-2.129) with a moderate level of heterogeneity (Q test: p = .024; I2 = 50.2%). Subgroup analysis reported single-center study, methodological quality and exclusion of laser-coagulated TTTS as the sources of heterogeneity. Another analysis revealed an increased risk of BWD among twin pregnancies with VCI (OR, 2.945; 95% CI, 2.176-3.984) with a low heterogeneity (Q test: p = .347; I2 = 10.5%). None of study level characteristics was found to be an influencing factor. Three studies reporting on sIUGR suggested a significant association between VCI and sIUGR.Conclusions: The meta-analysis and systematic review suggests an association between VCI and BWD and sIUGR. However, the association between VCI and TTTS may be overestimated and high-quality studies with a representative sample are needed in further research.
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Affiliation(s)
- Dongxin Lin
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China.,Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | - Dazhi Fan
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China.,Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | - Shuzhen Wu
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China.,Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | - Jiaming Rao
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China.,Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | - Huishan Zhang
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China.,Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | - Ting Chen
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | - Juan Liu
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | - Shaoxin Ye
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | - Meng Zeng
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | - Yan Liu
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | - Xiaoling Guo
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China.,Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | - Zhengping Liu
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China.,Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
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31
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Townsend R, D'Antonio F, Sileo FG, Kumbay H, Thilaganathan B, Khalil A. Perinatal outcome of monochorionic twin pregnancy complicated by selective fetal growth restriction according to management: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:36-46. [PMID: 30207011 DOI: 10.1002/uog.20114] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/26/2018] [Accepted: 09/03/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To explore the impact of severity and management (expectant, laser treatment or selective reduction) on perinatal outcome of monochorionic twin pregnancies complicated by selective fetal growth restriction (sFGR). METHODS MEDLINE, EMBASE, CINAHL, ClinicalTrials.gov and The Cochrane Library databases were searched for studies on outcome following expectant management, laser treatment or selective reduction in monochorionic twin pregnancies complicated by sFGR. Only pregnancies affected by sFGR and categorized according to the Gratacós classification (Type I, II or III) were included. The primary outcome was mortality, including single and double intrauterine (IUD), neonatal (NND) and perinatal deaths. Secondary outcomes were neonatal morbidity, abnormal postnatal brain imaging, intraventricular hemorrhage, periventricular leukomalacia, respiratory distress syndrome, admission to neonatal intensive care unit and survival free from neurological complications (intact survival). Meta-analyses of proportions were used to analyze the extracted data according to management, severity of sFGR and fetal size (smaller vs larger twin). RESULTS Sixteen observational studies (786 monochorionic twin pregnancies) were included. In pregnancies complicated by Type-I sFGR managed expectantly, IUD occurred in 3.1% (95% CI, 1.1-5.9%) of fetuses and 97.9% (95% CI, 93.6-99.9%) of twins had intact survival. In pregnancies complicated by Type-I sFGR treated using laser therapy, IUD occurred in 16.7% (95% CI, 0.4-64.1%) of fetuses and, in those treated using selective reduction, IUD occurred in 0% (95% CI, 0-34.9%) of cotwins, with no evidence of neurological complications in the survivors. In pregnancies complicated by Type-II sFGR managed expectantly, IUD occurred in 16.6% (95% CI, 6.9-29.5%) and NND in 6.4% (95% CI, 0.2-28.2%) of fetuses, and 89.3% (95% CI, 71.8-97.7%) of twins survived without neurological compromise. In Type-II sFGR pregnancies treated using laser therapy, IUD occurred in 44.3% (95% CI, 22.2-67.7%) of fetuses, while none of the affected cases experienced morbidity and survivors were free of neurological complications. Of pregnancies undergoing selective reduction, IUD of the cotwin occurred in 5.0% (95% CI, 0.03-20.5%) and NND in 3.7% (95% CI, 0.2-11.1%), and 90.6% (95% CI, 42.3-94.3%) of surviving cotwins were free from neurological complications. In pregnancies complicated by Type-III sFGR managed expectantly, IUD occurred in 13.2% (95% CI, 7.2-20.5%) and NND in 6.8% (95% CI, 0.7-18.6%) of fetuses, and 61.9% (95% CI, 38.4-81.9%) of twins had intact survival. In pregnancies complicated by Type-III sFGR treated with laser therapy, IUD occurred in 32.9% (95% CI, 20.9-46.2%) of fetuses and all surviving twins were without neurological complications. Finally, in pregnancies with Type-III sFGR treated with selective reduction, NND occurred in 5.2% (95% CI, 0.8-12.8%) of cotwins and 98.8% (95% CI, 93.9-99.9%) had intact survival. CONCLUSION Type-I sFGR is characterized by good perinatal outcome when managed expectantly, which represents the most reasonable management strategy for the large majority of affected cases. Pregnancies complicated by Type-II or -III sFGR treated with fetoscopic laser ablation have a higher rate of mortality but lower rate of morbidity compared with those managed expectantly, supporting the use of fetal therapy at gestations remote from neonatal viability. Data on outcome following selective reduction are scarce. In view of the lack of evidence from randomized controlled trials, prenatal management of sFGR should be individualized according to gestational age at diagnosis, severity of growth discordance and magnitude of Doppler anomalies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Townsend
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - F D'Antonio
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, Tromsø, Norway
| | - F G Sileo
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - H Kumbay
- GKT School of Medicine, King's College, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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