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Somiya A, Tsuda H, Tsugeno E, Nakamura Y, Kuroyanagi M, Araki H, Masahashi Y, Suzuki M, Fukuhara N, Ito Y, Tezuka A, Ando T, Mizuno K. Prevalence, Risk Factors, and Perinatal Outcomes of Velamentous Umbilical Cord Insertion in Twin Pregnancies: A Single-Center Retrospective Study. J Clin Med 2024; 13:1396. [PMID: 38592212 PMCID: PMC10932138 DOI: 10.3390/jcm13051396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 02/25/2024] [Accepted: 02/25/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND The effect of velamentous cord insertion (VCI) on perinatal outcomes in twin pregnancies is unclear due to conflicting findings. This retrospective study aimed to examine VCI prevalence and related risk factors in twin pregnancies and its association with adverse perinatal outcomes. METHODS Women with twin pregnancies who delivered between January 2012 and December 2021 in a single tertiary hospital were included. The participants were divided into dichorionic (DC) and monochorionic diamniotic (MCDA) groups, and their maternal and fetal characteristics and VCI rates were compared. Logistic regression models were used to identify risk factors for VCI and VCI-related perinatal outcomes. RESULTS Among the 694 twin pregnancies included in this study, the VCI rate was significantly higher in MCDA than in DC twins. Body mass index and MCDA twins were significant risk factors for VCI, whereas assisted reproductive technology pregnancy was a significant protective factor against VCI. In DC twins, VCI did not affect perinatal outcomes. In MCDA twins, VCI was a significant risk factor for fetal growth restriction, twin-to-twin transfusion syndrome, and preterm birth at <36 weeks. CONCLUSIONS VCI was a prominent risk factor for adverse perinatal outcomes only in MCDA twins. Antenatal sonographic assessment of the umbilical cord insertion site would be beneficial.
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Affiliation(s)
| | - Hiroyuki Tsuda
- Department of Obstetrics and Gynecology, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya 453-85511, Japan; (A.S.); (E.T.); (Y.N.); (M.K.); (H.A.); (Y.M.); (M.S.); (N.F.); (Y.I.); (A.T.); (T.A.); (K.M.)
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2
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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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3
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Clark A, Flouri D, Mufti N, James J, Clements E, Aughwane R, Aertsen M, David A, Melbourne A. Developments in functional imaging of the placenta. Br J Radiol 2023; 96:20211010. [PMID: 35234516 PMCID: PMC10321248 DOI: 10.1259/bjr.20211010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/26/2022] [Accepted: 02/22/2022] [Indexed: 12/21/2022] Open
Abstract
The placenta is both the literal and metaphorical black box of pregnancy. Measurement of the function of the placenta has the potential to enhance our understanding of this enigmatic organ and serve to support obstetric decision making. Advanced imaging techniques are key to support these measurements. This review summarises emerging imaging technology being used to measure the function of the placenta and new developments in the computational analysis of these data. We address three important examples where functional imaging is supporting our understanding of these conditions: fetal growth restriction, placenta accreta, and twin-twin transfusion syndrome.
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Affiliation(s)
- Alys Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | | | | | - Joanna James
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Eleanor Clements
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Rosalind Aughwane
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Michael Aertsen
- Department of Radiology, University Hospitals KU Leuven, Leuven, Belgium
| | - Anna David
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
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4
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Esposito G, Cantarutti A, Mauri PA, Franchi M, Fedele F, Corrao G, Parazzini F, Persico N. Prevalence and Factors Associated With Intertwin Birth Weight Discordance Among Same-Sex Twins in Lombardy, Northern Italy. Twin Res Hum Genet 2023; 26:177-183. [PMID: 37189213 DOI: 10.1017/thg.2023.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
This population-based cohort study investigated the prevalence, potential risk factors, and consequences of birth weight discordance (BWD) among same-sex twins. We retrieved data from the automated system of healthcare utilization databases of Lombardy Region, Northern Italy (2007-2021). BWD was defined as 30% or more disparity in birth weights between the larger and the smaller twin. Multivariate logistic regression was used to analyze the risk factors of BWD in deliveries with same-sex twins. In addition, the distribution of several neonatal outcomes was assessed overall and according to BWD level (i.e., ≤20%, 21-29, and ≥30%). Finally, a stratified analysis by BWD was performed to assess the relationship between assisted reproductive technologies (ART) and neonatal outcomes. We identified 11,096 same-sex twin deliveries; 556 (5.0%) pairs of twins were affected by BWD. Multivariate logistic regression analysis showed that maternal age ≥35 years (OR 1.26, 95% CI [1.05,5.51]), low level of education (OR 1.34, 95% CI [1.05, 1.70]), and ART (OR 1.16, 95% CI [0.94, 1.44], almost significant due to the low power) were independent risk factors for BWD in same-sex twins. Conversely, parity (OR 0.73, 95% CI [0.60, 0.89]) was inversely related. All the adverse outcomes observed were more common among BWD pairs than non-BWD ones. Instead, a protective effect of ART was observed for most neonatal outcomes considered among BWD twins. Our results suggest that conception after ART increases the risk of developing a high disparity between the weights of the two twins. However, the presence of BWD may complicate twin pregnancies, compromising neonatal outcomes, regardless of the modality of conception.
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Affiliation(s)
- Giovanna Esposito
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Anna Cantarutti
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, Milan, Italy
| | - Paola Agnese Mauri
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Woman, Newborn and Child, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Franchi
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, Milan, Italy
| | - Francesco Fedele
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanni Corrao
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, Milan, Italy
| | - Fabio Parazzini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Nicola Persico
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Woman, Newborn and Child, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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5
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Kozinszky Z, Surányi A. The High-Risk Profile of Selective Growth Restriction in Monochorionic Twin Pregnancies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040648. [PMID: 37109605 PMCID: PMC10141888 DOI: 10.3390/medicina59040648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/13/2023] [Indexed: 04/29/2023]
Abstract
The present review aims to provide a critical appraisal of the sonographic diagnosis and follow-up and to evaluate the optimal clinical management of monochorionic twin pregnancies where one of the twins is complicated by selective fetal growth restriction (sFGR). The classification is based on the umbilical artery (UA) diastolic flow reflecting the outcome. If the sFGR twin has positive diastolic flow (Type I) then the prognosis is good, and it does not require close surveillance. Biweekly or weekly sonographic and Doppler surveillance and fetal monitoring are recommended strategies to detect unpredictable complications in type II and type III forms, which are defined by persistently absent/reverse end-diastolic flow (AREDF) or cyclically intermittent absent/reverse end-diastolic flow (iAREDF) in the umbilical waveforms, respectively. The latest forms are associated with an increased risk of unexpected fetal demise of the smaller twin and 10-20% risk of neurological injury in the larger twin in addition to the overall risk of prematurity. The clinical course can be affected by elective fetal therapy ('dichorinization' of the placenta with laser or selective fetal reduction) or elective delivery in the presence of severe fetal deterioration. The prediction of the clinical outcome in complicated cases of type II and III sFGR cases remains elusive. Novel routines in fetal and placental scans in order to predict neurological impairments and unexpected fetal death to optimize the delivery time-point are needed.
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Affiliation(s)
- Zoltan Kozinszky
- Department of Obstetrics and Gynaecology, Danderyds Hospital, 182 88 Stockholm, Sweden
| | - Andrea Surányi
- Department of Obstetrics and Gynaecology, Albert Szent-Györgyi Medical School, University of Szeged, 6725 Szeged, Hungary
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6
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Zhong Q, Chu H, Wang G, Zhang C, Li R, Guo F, Meng X, Lei X, Zhou Y, Ren R, Tao L, Li N, Gao N, Wei Y, Qiao J, Hang J. Structural insights into the covalent regulation of PAPP-A activity by proMBP and STC2. Cell Discov 2022; 8:137. [PMID: 36550107 PMCID: PMC9780223 DOI: 10.1038/s41421-022-00502-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 11/25/2022] [Indexed: 12/24/2022] Open
Abstract
Originally discovered in the circulation of pregnant women as a protein secreted by placental trophoblasts, the metalloprotease pregnancy-associated plasma protein A (PAPP-A) is also widely expressed by many other tissues. It cleaves insulin-like growth factor-binding proteins (IGFBPs) to increase the bioavailability of IGFs and plays essential roles in multiple growth-promoting processes. While the vast majority of the circulatory PAPP-A in pregnancy is proteolytically inactive due to covalent inhibition by proform of eosinophil major basic protein (proMBP), the activity of PAPP-A can also be covalently inhibited by another less characterized modulator, stanniocalcin-2 (STC2). However, the structural basis of PAPP-A proteolysis and the mechanistic differences between these two modulators are poorly understood. Here we present two cryo-EM structures of endogenous purified PAPP-A in complex with either proMBP or STC2. Both modulators form 2:2 heterotetramer with PAPP-A and establish extensive interactions with multiple domains of PAPP-A that are distal to the catalytic cleft. This exosite-binding property results in a steric hindrance to prevent the binding and cleavage of IGFBPs, while the IGFBP linker region-derived peptides harboring the cleavage sites are no longer sensitive to the modulator treatment. Functional investigation into proMBP-mediated PAPP-A regulation in selective intrauterine growth restriction (sIUGR) pregnancy elucidates that PAPP-A and proMBP collaboratively regulate extravillous trophoblast invasion and the consequent fetal growth. Collectively, our work reveals a novel covalent exosite-competitive inhibition mechanism of PAPP-A and its regulatory effect on placental function.
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Affiliation(s)
- Qihang Zhong
- grid.411642.40000 0004 0605 3760Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Assisted Reproduction, Ministry of Education, Beijing, China ,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproduction, Beijing, China ,grid.411642.40000 0004 0605 3760National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Honglei Chu
- grid.411642.40000 0004 0605 3760Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Assisted Reproduction, Ministry of Education, Beijing, China ,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproduction, Beijing, China ,grid.411642.40000 0004 0605 3760National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Guopeng Wang
- grid.11135.370000 0001 2256 9319State Key Laboratory of Membrane Biology, School of Life Sciences, Peking University, Beijing, China
| | - Cheng Zhang
- grid.412474.00000 0001 0027 0586Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Rong Li
- grid.411642.40000 0004 0605 3760Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Assisted Reproduction, Ministry of Education, Beijing, China ,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproduction, Beijing, China ,grid.411642.40000 0004 0605 3760National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Fusheng Guo
- grid.11135.370000 0001 2256 9319Beijing National Laboratory for Molecular Sciences, State Key Laboratory of Natural and Biomimetic Drugs, Key Laboratory of Bioorganic Chemistry and Molecular Engineering of Ministry of Education, Department of Chemical Biology, College of Chemistry and Molecular Engineering, Synthetic and Functional Biomolecules Center, Peking University, Beijing, China ,grid.11135.370000 0001 2256 9319Peking-Tsinghua Center for Life Sciences, Peking University, Beijing, China
| | - Xinlu Meng
- grid.411642.40000 0004 0605 3760Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xiaoguang Lei
- grid.11135.370000 0001 2256 9319Beijing National Laboratory for Molecular Sciences, State Key Laboratory of Natural and Biomimetic Drugs, Key Laboratory of Bioorganic Chemistry and Molecular Engineering of Ministry of Education, Department of Chemical Biology, College of Chemistry and Molecular Engineering, Synthetic and Functional Biomolecules Center, Peking University, Beijing, China ,grid.11135.370000 0001 2256 9319Peking-Tsinghua Center for Life Sciences, Peking University, Beijing, China ,grid.510951.90000 0004 7775 6738Institute for Cancer Research, Shenzhen Bay Laboratory, Shenzhen, Guangdong China
| | - Youli Zhou
- grid.10784.3a0000 0004 1937 0482School of Life and Health Sciences, The Chinese University of Hong Kong, Shenzhen, Guangdong China
| | - Ruobing Ren
- grid.10784.3a0000 0004 1937 0482School of Life and Health Sciences, The Chinese University of Hong Kong, Shenzhen, Guangdong China ,grid.8547.e0000 0001 0125 2443Shanghai Key Laboratory of Metabolic Remodeling and Health, Institute of Metabolism and Integrative Biology, Fudan University, Shanghai, China
| | - Lin Tao
- grid.412636.40000 0004 1757 9485Department of Orthopedics, First Hospital of China Medical University, Shenyang, Liaoning China
| | - Ningning Li
- grid.11135.370000 0001 2256 9319State Key Laboratory of Membrane Biology, School of Life Sciences, Peking University, Beijing, China
| | - Ning Gao
- grid.11135.370000 0001 2256 9319State Key Laboratory of Membrane Biology, School of Life Sciences, Peking University, Beijing, China ,grid.11135.370000 0001 2256 9319Peking-Tsinghua Center for Life Sciences, Peking University, Beijing, China
| | - Yuan Wei
- grid.411642.40000 0004 0605 3760Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Assisted Reproduction, Ministry of Education, Beijing, China ,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproduction, Beijing, China ,grid.411642.40000 0004 0605 3760National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Jie Qiao
- grid.411642.40000 0004 0605 3760Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Assisted Reproduction, Ministry of Education, Beijing, China ,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproduction, Beijing, China ,grid.411642.40000 0004 0605 3760National Clinical Research Center for Obstetrics and Gynecology, Beijing, China ,grid.11135.370000 0001 2256 9319Peking-Tsinghua Center for Life Sciences, Peking University, Beijing, China
| | - Jing Hang
- grid.411642.40000 0004 0605 3760Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Assisted Reproduction, Ministry of Education, Beijing, China ,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproduction, Beijing, China ,grid.411642.40000 0004 0605 3760National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
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Selective Fetal Growth Restriction in Monochorionic Diamniotic Twins: Diagnosis and Management. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Can S, Has R, Turkyilmaz G, Aktoz F, Yuksel A. Intertwin membrane cord insertion in dichorionic twin pregnancy: The description and comparison with other umbilical cord insertion types. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:958-963. [PMID: 35665512 DOI: 10.1002/jcu.23246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/19/2022] [Accepted: 04/23/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Multiple pregnancy is associated with high perinatal mortality and morbidity. Abnormal cord insertions more common in twin pregnancies compared to singleton pregnancies and velamentous cord insertion is related with poor pregnancy outcomes. There is no definition of velamentous cord insertion into the intertwine membrane between two fetuses in the literature. METHODS In our single-center cross-sectional study, monochorionic-diamniotic and dichorionic-diamniotic twins who were admitted to our clinic between 18 + 0 and 23 + 6 weeks of pregnancy were enrolled in this study. We evaluated fetal, placental, and umbilical cord abnormalities in addition to fetal growth restrictions and weight discordance by ultrasonography. RESULTS Although abnormal cord insertion frequency was significantly higher in monochorionic twins (p = 0.003), intertwin membrane cord insertion could only occur in dichorionic twins. In cases with cord insertion anomaly; FGR and weight discordance was observed more frequently (p < 0.001 and p = 0.003, respectively). Weight discordance, the presence of abnormal cord insertion and abnormal UAD were found as statistically significant predictors of FGR (p < 0.001, p = 0.021, and p < 0.001, respectively). CONCLUSION Intertwin membrane insertion is a novel umbilical cord insertion abnormality. The presence of abnormal umbilical cord insertion is a risk factor for poor pregnancy outcomes in twin pregnancies.
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Affiliation(s)
- Sultan Can
- Department of Obstetrics and Gynecology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Recep Has
- Division of Perinatology, Department of Obstetrics and Gynecology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Gurcan Turkyilmaz
- Division of Perinatology, Department of Obstetrics and Gynecology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Fatih Aktoz
- Department of Obstetrics and Gynecology, VKV American Hospital, Istanbul, Turkey
| | - Atil Yuksel
- Division of Perinatology, Department of Obstetrics and Gynecology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
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9
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Espinoza J, Belfort MA, Shamshirsaz AA, Nassr AA, Sanz Cortes M, Donepudi R, Espinoza AF, Ostovar-Kermani TG, Johnson RM, Harman C, Ozdemir H, Turan O. Intertwin differences in umbilical artery pulsatility index are associated with infant survival in twin-to-twin transfusion syndrome. J Perinat Med 2021; 49:1122-1128. [PMID: 34118799 DOI: 10.1515/jpm-2021-0060] [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: 02/02/2021] [Accepted: 05/27/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the association of intertwin differences in umbilical artery pulsatility index (DUAPI) and infant survival in twin-to-twin transfusion syndrome (TTTS). METHODS Absolute DUAPI was calculated prior to laser surgery. Receiver-operating characteristics (ROC) curve analysis provided an intertwin DUAPI cutoff of 0.4 for the prediction of double twin survival to 30 days of life. Infant survival was compared between women with an intertwin DUAPI <0.4 and ≥0.4 in the whole cohort, in TTTS cases with Quintero stages I/II and in those with Quintero stages III/IV. Regression analyses were performed to evaluate the association of intertwin DUAPI <0.4 and infant survival adjusted for confounders. RESULTS In total, 349 TTTS cases were included. Double twin survival to 30 days was observed in 67% (234/349) of cases. Significant differences in double twin survival was seen between intertwin DUAPI groups in the whole cohort (76.8 vs. 52.2%; p<0.001), in women with TTTS Quintero stage I or II (77.8 vs. 58.5%; p=0.015) as well as in women with TTTS Quintero stage III or IV (75 vs. 49.5%; p=0.001). Intertwin DUAPI <0.4 conferred a threefold increased chance for double twin survival. CONCLUSIONS Small intertwin DUAPI is associated with increased double infant survival in early and advanced TTTS stages.
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Affiliation(s)
- Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Andres F Espinoza
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Rebecca M Johnson
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Christopher Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Halis Ozdemir
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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10
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Lee HM, Lee S, Park MK, Han YJ, Kim MY, Boo HY, Chung JH. Clinical Significance of Velamentous Cord Insertion Prenatally Diagnosed in Twin Pregnancy. J Clin Med 2021; 10:jcm10040572. [PMID: 33546368 PMCID: PMC7913476 DOI: 10.3390/jcm10040572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/19/2021] [Accepted: 01/30/2021] [Indexed: 12/16/2022] Open
Abstract
Background: The purpose of this study was to evaluate the prevalence of velamentous cord insertion (VCI) and the actual association between pathologically confirmed VCI and perinatal outcomes in twins based on the chorionicity. Methods: All twin pregnancies that received prenatal care at a specialty clinic for multiple pregnancies, from less than 12 weeks of gestation until delivery in a single institution between 2015 and 2018 were included in this retrospective cohort study. Results: A total of 941 twins were included in the study. The prevalence of VCI in dichorionic (DC) twins and monochorionic diamniotic (MCDA) twins was 5.8% and 7.8%, respectively (p = 0.251). In all study population, the prevalence of vasa previa and placenta accreta spectrum was higher in VCI group than that of non-VCI group (p = 0.008 and 0.022). In MCDA twins with VCI, birth weight, 1 and 5-min Apgar score were lower than DC twins with VCI (p = 0.010, 0.002 and 0.000). There was no significant association between VCI and selective fetal growth restriction (p = 0.486), twin-to-twin transfusion syndrome (p = 0.400), and birth-weight discordance (>20% and >25%) (p = 0.378 and 0.161) in MCDA twins. Conclusion: There was no difference in the incidence of VCI in twins based on the chorionicity. Moreover, VCI was not a risk factor for adverse perinatal outcomes excepting vasa previa and placenta accreta spectrum, which had a high incidence in twins with VCI.
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Affiliation(s)
- Hyun-Mi Lee
- Department of Obstetrics and Gynecology, CHA Ilsan Medical Center, CHA University, Goyang 10414, Korea; (H.-M.L.); (H.Y.B.)
| | - SiWon Lee
- Department of Obstetrics and Gynecology, Mount Sinai Medical Center, Miami Beach, FL 33109, USA;
| | - Min-Kyung Park
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul 03722, Korea;
| | - You Jung Han
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul 06135, Korea; (Y.J.H.); (M.Y.K.)
| | - Moon Young Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul 06135, Korea; (Y.J.H.); (M.Y.K.)
| | - Hye Yeon Boo
- Department of Obstetrics and Gynecology, CHA Ilsan Medical Center, CHA University, Goyang 10414, Korea; (H.-M.L.); (H.Y.B.)
| | - Jin Hoon Chung
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
- Correspondence: ; Tel.: +82-2-3010-3654
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11
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Hayward DA, Pomares F, Casey KF, Ismaylova E, Levesque M, Greenlaw K, Vitaro F, Brendgen M, Rénard F, Dionne G, Boivin M, Tremblay RE, Booij L. Birth weight is associated with adolescent brain development: A multimodal imaging study in monozygotic twins. Hum Brain Mapp 2020; 41:5228-5239. [PMID: 32881198 PMCID: PMC7670633 DOI: 10.1002/hbm.25188] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 01/20/2023] Open
Abstract
Previous research has shown that the prenatal environment, commonly indexed by birth weight (BW), is a predictor of morphological brain development. We previously showed in monozygotic (MZ) twins associations between BW and brain morphology that were independent of genetics. In the present study, we employed a longitudinal MZ twin design to investigate whether variations in prenatal environment (as indexed by discordance in BW) are associated with resting‐state functional connectivity (rs‐FC) and with structural connectivity. We focused on the limbic and default mode networks (DMNs), which are key regions for emotion regulation and internally generated thoughts, respectively. One hundred and six healthy adolescent MZ twins (53 pairs; 42% male pairs) followed longitudinally from birth underwent a magnetic resonance imaging session at age 15. Graph theoretical analysis was applied to rs‐FC measures. TrackVis was used to determine track count as an indicator of structural connectivity strength. Lower BW twins had less efficient limbic network connectivity as compared to their higher BW co‐twin, driven by differences in the efficiency of the right hippocampus and right amygdala. Lower BW male twins had fewer tracks connecting the right hippocampus and right amygdala as compared to their higher BW male co‐twin. There were no associations between BW and the DMN. These findings highlight the possible role of unique prenatal environmental influences in the later development of efficient spontaneous limbic network connections within healthy individuals, irrespective of DNA sequence or shared environment.
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Affiliation(s)
- Dana A Hayward
- Sainte-Justine Hospital Research Centre, Montreal, Canada.,Department of Psychology, Concordia University, Montreal, Canada
| | - Florence Pomares
- Sainte-Justine Hospital Research Centre, Montreal, Canada.,Department of Psychology, Concordia University, Montreal, Canada
| | - Kevin F Casey
- Sainte-Justine Hospital Research Centre, Montreal, Canada.,Department of Psychology, Concordia University, Montreal, Canada
| | - Elmira Ismaylova
- Sainte-Justine Hospital Research Centre, Montreal, Canada.,Department of Psychology, Concordia University, Montreal, Canada
| | | | - Keelin Greenlaw
- Sainte-Justine Hospital Research Centre, Montreal, Canada.,Department of Psychology, Concordia University, Montreal, Canada
| | - Frank Vitaro
- Sainte-Justine Hospital Research Centre, Montreal, Canada.,School of Psychoeducation, University of Montreal, Montreal, Canada
| | - Mara Brendgen
- Department of Psychology, University of Quebec in Montreal, Montreal, Canada
| | - Felix Rénard
- Grenoble Hospital, University of Grenoble, Grenoble, France
| | - Ginette Dionne
- Department of Psychology, University Laval, Quebec, Canada
| | - Michel Boivin
- Department of Psychology, University Laval, Quebec, Canada
| | - Richard E Tremblay
- Sainte-Justine Hospital Research Centre, Montreal, Canada.,Department of Psychology and Pediatrics, University of Montreal, Montreal, Canada.,School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Linda Booij
- Sainte-Justine Hospital Research Centre, Montreal, Canada.,Department of Psychology, Concordia University, Montreal, Canada.,Department of Psychiatry, McGill University, Montreal, Canada.,Department of Psychiatry and Addiction, University of Montreal, Montreal, Canada
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12
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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: 9] [Impact Index Per Article: 2.3] [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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13
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Yang J, Wei Y, Qi H, Yin N, Yang Y, Li Z, Xu L, Wang X, Yuan P, Li L, Han TL, Zhao Y. Neonatal hair profiling reveals a metabolic phenotype of monochorionic twins with selective intrauterine growth restriction and abnormal umbilical artery flow. Mol Med 2020; 26:37. [PMID: 32357834 PMCID: PMC7193362 DOI: 10.1186/s10020-020-00160-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/20/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Selective intrauterine fetal growth restriction (sIUGR) in monochorionic diamniotic twins, especially types 2&3 with abnormal umbilical artery Doppler, results in increased risk of fetal/perinatal mortality and postnatal disability. We investigate whether the hair metabolome profiles of neonates were associated with the pathophysiological differences across the different clinical forms of sIUGR in twins. METHODS Hair samples were collected at delivery from 10 pairs of type 1 sIUGR twins, 8 pairs of types 2&3 sIUGR twins, and 11 pairs of twins without sIUGR. The hair metabolome was characterized using gas chromatography-mass spectrometry. RESULTS Our results demonstrated that the hair metabolite profiles of the different sIUGR subclinical forms were associated with the averaged fetal growth rate after 28 weeks of gestation but not with birthweight. The hair profiles were capable of discriminating type2&3 sIUGR twins from twins without sIUGR. In particular, the metabolites 2-aminobutyric acid, cysteine, alanine, and tyrosine all displayed areas under the receiver operating characteristic curve were above 0.9. The metabolic pathway analysis highlighted the associations of sIUGR twins with abnormal umbilical artery flow with increased metabolites from a nutrient depletion pathway, glutathione metabolism, and nerve development. CONCLUSION This study offers novel insight into the severity of intrauterine ischemia and hypoxia for T2&3 sIUGR twins, through evaluation of the neonatal hair metabolome.
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Affiliation(s)
- Jing Yang
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China
| | - Yuan Wei
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China
| | - Hongbo Qi
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China.,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China
| | - Nanlin Yin
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China
| | - Yang Yang
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China.,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China
| | - Zailing Li
- Department of Pediatrics, Peking University Third Hospital, Beijing, 100191, China
| | - Lili Xu
- Department of Pediatrics, Peking University Third Hospital, Beijing, 100191, China
| | - Xueju Wang
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China
| | - Pengbo Yuan
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China
| | - Luyao Li
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China
| | - Ting-Li Han
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China. .,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China. .,Liggins Institute, University of Auckland, Auckland, 1142, New Zealand.
| | - Yangyu Zhao
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China.
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14
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Rotar IC, Zaharie G, Staicu A, Preda A, Mureşan D. Fetal cardiovascular alterations in twin-to-twin transfusion syndrome. Med Pharm Rep 2020; 93:5-11. [PMID: 32133441 PMCID: PMC7051825 DOI: 10.15386/mpr-1481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/15/2019] [Accepted: 12/30/2019] [Indexed: 11/23/2022] Open
Abstract
Twin-to-twin transfusion syndrome (TTTS) is the consequence of vascular anastomoses of the shared placenta of monochorionic twin pregnancies. Both circulating inter-twin blood flow and vasoactive mediators imbalance cause hypovolemia in the donor and hypervolemia in the recipient fetus. If left untreated, TTTS has a high perinatal mortality rate and adverse long-term outcomes mainly cardiovascular and neurological. The recipient has cardiovascular changes including atrioventricular valve regurgitation, diastolic dysfunction and pulmonary stenosis/atresia. The maladaptive response to vascular changes determines a constant decreased blood flow in the donor that permanently modifies the arterial structure leading to postnatal alterations in the vascular system. Fetoscopic LASER surgery of placental vascular anastomoses may disrupt the underlying pathophysiology and improves cardiovascular function with normalization of systolic and diastolic function within weeks after treatment. The impact of cardiovascular changes is relevant for the safety of the management of a TTTS case. The improvement of the perinatal survival after intrauterine surgery leads to viable infants with the longer-term sequelae. Therefore accurate quantification of cardiovascular involvement is essential for clinicians for pregnancy management but also for patient counseling about the potential treatment options the outcome.
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Affiliation(s)
- Ioana Cristina Rotar
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,1 Clinic of Obstetrics and Gynecology, Emergency County Hospital, Cluj-Napoca, Romania
| | - Gabriela Zaharie
- Neonatal Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Neonatal Department, Emergency County Hospital, Cluj-Napoca, Romania
| | - Adelina Staicu
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andreia Preda
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Daniel Mureşan
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,1 Clinic of Obstetrics and Gynecology, Emergency County Hospital, Cluj-Napoca, Romania
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15
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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: 0.5] [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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16
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The impact of chorionicity and the type of twin growth on the early neonatal outcome in twin pregnancies - 20 years of experience from one tertiary perinatal center. Taiwan J Obstet Gynecol 2020; 58:482-486. [PMID: 31307737 DOI: 10.1016/j.tjog.2019.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Twin pregnancies are associated with higher neonatal mortality and morbidity. Growth discordance and monochorionicity are among the factors that worsen the course of pregnancy. The study aimed to assess neonatal conditions and mortality in relation to growth type and chorionicity. MATERIALS AND METHODS Data from 820 pregnant women with twin pregnancies and their 1640 newborns were analyzed. The Apgar score and umbilical artery blood pH, as well as the rate of complications, were compared between dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twins with symmetric and discordant growth. The Student's t-test and the Pearson chi-square test were used for comparisons. RESULTS There were 576 (70.2%) DCDA pregnancies, including 421 (73.1%) with symmetric growth and 155 (26.9%) with discordant growth, and 244 (29.8%) MCDA pregnancies, including 110 (45.1%) with symmetric growth and 134 (54.9%) with discordant growth. A significantly greater percentage of twins with discordant growth occurred in women older than 34 years than in those that were younger. An Apgar score of ≤7 was significantly more common among MCDA discordant twins, while an arterial umbilical blood pH of <7.2 was more common among MCDA twins with symmetric growth. Early neonatal deaths (n = 29; 1.8%), respiratory disorders, and a birth weight of <1500 g were significantly more common in MCDA twins than in DCDA twins. CONCLUSION MCDA twins with growth discordance are burdened with a higher risk of neonatal morbidity and mortality than symmetric DCDA twins. Chorionicity and growth discordancy are important determinants of the outcome of twin pregnancy.
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17
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Aughwane R, Ingram E, Johnstone ED, Salomon LJ, David AL, Melbourne A. Placental MRI and its application to fetal intervention. Prenat Diagn 2020; 40:38-48. [PMID: 31306507 PMCID: PMC7027916 DOI: 10.1002/pd.5526] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/18/2019] [Accepted: 07/08/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Magnetic resonance imaging (MRI) of placental invasion has been part of clinical practice for many years. The possibility of being better able to assess placental vascularization and function using MRI has multiple potential applications. This review summarises up-to-date research on placental function using different MRI modalities. METHOD We discuss how combinations of these MRI techniques have much to contribute to fetal conditions amenable for therapy such as singletons at high risk for fetal growth restriction (FGR) and monochorionic twin pregnancies for planning surgery and counselling for selective growth restriction and transfusion conditions. RESULTS The whole placenta can easily be visualized on MRI, with a clear boundary against the amniotic fluid, and a less clear placental-uterine boundary. Contrasts such as diffusion weighted imaging, relaxometry, blood oxygenation level dependent MRI and flow and metabolite measurement by dynamic contrast enhanced MRI, arterial spin labeling, or spectroscopic techniques are contributing to our wider understanding of placental function. CONCLUSION The future of placental MRI is exciting, with the increasing availability of multiple contrasts and new models that will boost the capability of MRI to measure oxygen saturation and placental exchange, enabling examination of placental function in complicated pregnancies.
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Affiliation(s)
| | - Emma Ingram
- Division of Developmental Biology & MedicineUniversity of ManchesterManchesterUK
| | - Edward D. Johnstone
- Division of Developmental Biology & MedicineUniversity of ManchesterManchesterUK
| | - Laurent J. Salomon
- Hôpital Necker‐Enfants Malades, AP‐HP, EHU PACT and LUMIERE PlatformUniversité Paris DescartesParisFrance
| | - Anna L. David
- Institute for Women's HealthUniversity College LondonLondonUK
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Andrew Melbourne
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Medical Physics and Biomedical EngineeringUniversity College LondonLondonUK
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18
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Abstract
The increase in multiple gestation pregnancies has resulted in significant health care implications for both mother and child. Our ability to diagnose and intervene on an at-risk multi-gestation pregnancy has dramatically improved. It is important for the pediatric surgeon to be equipped with a basic fund of knowledge concerning these pregnancies. An understanding of amnionicity and chorionicity will equip the practitioner with the ability to identify which pregnancies are at risk for specific complications. This article highlights multi-gestation pregnancies that are monochorionic (single shared placenta) and can be complicated by twin-twin transfusion syndrome (TTTS), twin reversed arterial perfusion (TRAP) sequence, twin anemia polycythemia sequence (TAPS), or selective fetal intrauterine growth restriction (sIUGR). The risk of fetal demise is significant in these pregnancies. Understanding recommended surveillance and warning signs can alert surgeons to developing complications. Specialized fetal care centers possess the ability to intervene on these pregnancies in utero.
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Affiliation(s)
- Ahmed I Marwan
- Division of Pediatric Surgery, University of Colorado School of Medicine, Children's Hospital of Colorado, Colorado Fetal Care Center, United States
| | - Micheal Zaretsky
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Children's Hospital of Colorado, Colorado Fetal Care Center, United States
| | - Brad Feltis
- Children's Minnesota, Midwest Fetal Care Center, United States.
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19
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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: 0.6] [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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20
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Lu J, Cheng YKY, Ting YH, Law KM, Leung TY. Pitfalls in assessing chorioamnionicity: novel observations and literature review. Am J Obstet Gynecol 2018; 219:242-254. [PMID: 29462630 DOI: 10.1016/j.ajog.2018.02.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/07/2018] [Accepted: 02/12/2018] [Indexed: 11/26/2022]
Abstract
Accurate diagnosis of chorioamnionicity in multiple pregnancies is the key to appropriate clinical management of multiple gestation. Although prenatal ultrasound assessment of chorioamnionicity is well established and highly accurate if performed in early pregnancy, exceptions and artifacts arise from anatomic variations in multiple pregnancies and unusual sonographic features do exist. We have summarized our own experiences and reports from the literature on these pitfalls as follows: (1) discordant fetal sex in monochorionic pregnancies due to sex chromosome abnormalities, genital malformation in 1 fetus, or dizygotic twins forming a monochorionic placenta; (2) separate placental masses in monochorionic pregnancies due to bipartite placenta; (3) false-negative and false-positive λ sign can arise for various reasons, and in partial monochorionic/dichorionic placentas both T and λ sign may co-exist; (4) intrauterine synechia appearing as a thick and echogenic intrauterine septum may lead to erroneous diagnosis of dichorionic twins; and (5) errors in ascertaining amnionicity by the visualization of thin intertwin amniotic membranes and the number of yolk sacs. The ultrasound techniques to reduce inaccuracy in prenatal determination of chorioamnionicity and the use of single nucleotide polymorphisms based on noninvasive prenatal test to determine zygosity are also reviewed.
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Kalafat E, Thilaganathan B, Papageorghiou A, Bhide A, Khalil A. Significance of placental cord insertion site in twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:378-384. [PMID: 28976606 DOI: 10.1002/uog.18914] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/14/2017] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To investigate the association between abnormal cord insertion and the development of twin-specific complications, including birth-weight discordance, selective fetal growth restriction (sFGR) and twin-to-twin transfusion syndrome (TTTS). METHODS This was a single center retrospective cohort study of twin pregnancies. Abnormal cord insertion was defined as either marginal (umbilical cord attachment site less than 2 cm to the nearest margin of the placental disc) or velamentous (cord attached to the membrane before reaching the placental disc with clear evidence of vessels traversing the membranes to connect with the placental disc), as described in placental pathology reports. Twins with major structural or chromosomal abnormalities and monochorionic monoamniotic twins were not included in the study. Information on the pregnancies, ultrasound findings, prenatal investigations and interventions was obtained from the electronic ultrasound database, while data on placental histopathological findings, pregnancy outcome, mode of delivery, birth weight, gestational age at delivery and admission to the neonatal intensive care unit were obtained from maternity records. Categorical variables were compared using the chi-square or Fisher's exact test, while continuous variables were compared using the Student's t-test, ANOVA for multiple comparisons and the Kruskal-Wallis test. RESULTS Of the 497 twin pregnancies included in the analysis, 351 (70.6%) were dichorionic and 146 (29.4%) were monochorionic. The incidence of birth-weight discordance of 25% or more was significantly higher in pregnancies with velamentous and those with marginal cord insertions compared to those with normal cord insertion (24.0%, 15.3% vs 7.6%, P < 0.001 and P = 0.020, respectively). In pregnancies with birth-weight discordance of 25% or more, the smaller twins had significantly higher prevalence of velamentous (13.8%) and marginal (34.2%) cord insertions compared with the larger twins (1.8% and 18.5%, respectively, P < 0.001). The smaller twins of the monochorionic diamniotic pregnancies showed an even higher prevalence of velamentous (29.5%) and marginal (40.9%) cord insertions compared with the larger twins (2.3% and 31.5%, respectively, P < 0.001). Compared with the normal cord insertion group, only velamentous insertion was associated significantly with the risk of sFGR (odds ratio (OR), 9.24 (95% CI, 2.05-58.84), P < 0.001) and birth-weight discordance of 20% or more (OR, 4.34 (95% CI, 1.36-14.61), P = 0.007) and 25% or more (OR, 6.81 (95% CI, 1.67-34.12), P = 0.003) in monochorionic twin pregnancies. There was no significant association between velamentous cord insertion and TTTS (P = 0.591), or between marginal cord insertion and the development of sFGR (P = 0.233), birth-weight discordance of 25% or more (P = 0.114) or TTTS (P = 0.487). Subgroup analysis of dichorionic twins showed that abnormal cord insertion was not associated with the risk of birth-weight discordance (P = 0.999), sFGR (P = 0.308), composite neonatal adverse outcome (P = 0.637) or intrauterine death (P = 0.349). CONCLUSION Monochorionic twins with velamentous cord insertion are at increased risk of birth-weight discordance and sFGR. Sonographic delineation of placental cord insertion could be of value in the antenatal stratification of twin pregnancies. Prospective studies are required to assess the value and predictive accuracy of this potential screening marker. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Kalafat
- Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Papageorghiou
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Bhide
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Couck I, Mourad Tawfic N, Deprest J, De Catte L, Devlieger R, Lewi L. Does site of cord insertion increase risk of adverse outcome, twin-to-twin transfusion syndrome and discordant growth in monochorionic twin pregnancy? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:385-389. [PMID: 29024208 DOI: 10.1002/uog.18926] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/15/2017] [Accepted: 09/29/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES It is not currently well known to what extent the sites of cord insertion influence the risk of complicated outcome in monochorionic twin pregnancy. The objectives of this study were to examine whether the sites of cord insertion, as determined on prenatal ultrasound examination, affect the risks of adverse outcome, twin-to-twin transfusion syndrome (TTTS) and discordant growth, and whether discordance in insertion sites or velamentous insertion in one or both twins best predicts risk. METHODS This was a retrospective cohort study of monochorionic diamniotic twin pregnancies followed from the first trimester. The cohort was divided into three groups of increasing discordance in cord insertion sites: concordant (normal-normal; marginal-marginal; velamentous-velamentous), intermediate (normal-marginal; marginal-velamentous) and discordant (normal-velamentous). Adverse outcome was defined as fetal or neonatal loss or birth prior to 32 weeks. The associations of adverse outcome, TTTS and discordant growth were assessed using logistic regression analysis with the following predictors: the three groups of insertion sites and velamentous insertion in one or both twins. RESULTS Included in the analysis were 518 pregnancies. On univariate analysis, both discordant and velamentous insertions in one twin increased the risk of adverse outcome, TTTS and discordant growth. Intermediate insertion only increased the risk of discordant growth. Velamentous insertion in both twins increased the risk of adverse outcome and TTTS, but not of discordant growth. Multivariate logistic regression analysis showed velamentous insertion in one or both twins to independently predict adverse outcome and TTTS. For discordant growth, both intermediate/discordant and velamentous cord insertion in one twin were independent predictors. CONCLUSIONS Velamentous cord insertion in one or both twins increases the risk of adverse outcome and TTTS, irrespective of discordance in the insertion sites, whereas the risk of discordant growth is determined by both discordance in insertion sites and velamentous cord insertion in one twin. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I Couck
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - N Mourad Tawfic
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London Hospital, London, UK
| | - L De Catte
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - R Devlieger
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - L Lewi
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Jahanfar S, Lim K. Is there a relationship between fetal sex and placental pathological characteristics in twin gestations? BMC Pregnancy Childbirth 2018; 18:285. [PMID: 29973164 PMCID: PMC6031115 DOI: 10.1186/s12884-018-1896-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/13/2018] [Indexed: 11/13/2022] Open
Abstract
Background Placenta plays a central role in mediating growth and development of fetuses. Sex-specific placentas may complicate this role. Methods The study aimed at investigating the association between fetal sex and placental pathological findings in twin gestations using generalized estimating equation modeling. We used a large population-based clinical data born in British Columbia (BC) and linked the fetal-maternal data to hand-searched pathology reports of 1493 twin placentas from twins born in BC Women hospital. We analyzed the data using generalized estimating equations taking the cluster nature of twins into consideration. Results About 26.5% of twins were monochorionic and 73.5% were dizygotic. Most twins were male (51.3%). About 2/3 of twins were sex concordant (66.6%). Of the sex concordant twins, similar percentages were male-male (34.7%) and female-female (31.2%). Of the sex discordant twins, the male-female (33.3%) group constituted about 1/3 of the whole population. Adjusted for chorionicity, birth weight discordance ≥30% and gestational age, the odds of chorionitis (1.38, 95% CI = 1.04–1.84), anastomosis (1.63, 95% CI = 1.22–2.19), unequal sharing of placenta (1.72, 95% CI = 1.11–2.64), placental inflammation (1.30, 95% CI = 1.05–1.62) and lesions (1.83, 95% CI = 1.02–3.31) were higher in male twins compared with females. Twins of either sex from sex-discordant pairs were less likely to have placental anastomosis compared to the reference category. Males from male-male pairs had higher odds of unequal placental sharing (74% higher) and composite inflammation (52% higher) compared with the reference twins. Conclusion Our findings suggest a relationship between sex and placental pathological results.
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Affiliation(s)
- Shayesteh Jahanfar
- School of Health Sciences Building 2242, Central Michigan University, Mount Pleasant, MI, 48859, USA.
| | - Kenneth Lim
- Division of Maternal Fetal Medicine, BC Women's Hospital, Vancouver, Canada
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Bennasar M, Eixarch E, Martinez JM, Gratacós E. Selective intrauterine growth restriction in monochorionic diamniotic twin pregnancies. Semin Fetal Neonatal Med 2017; 22:376-382. [PMID: 28532678 DOI: 10.1016/j.siny.2017.05.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Selective intrauterine growth restriction (sIUGR) affects 10-15% of all monochorionic pregnancies. Early severe forms are associated with intrauterine demise or neurological adverse outcome for both twins. The characteristics of umbilical artery (UA) Doppler in the IUGR fetus determine three clinical types: (I) normal UA Doppler and associated with good prognosis; (II) persistently absent/reverse UA end-diastolic flow and associated with early deterioration of the IUGR twin and very preterm delivery; (III) intermittently absent/reverse end-diastolic flow in the UA, and associated with unexpected fetal demise or neurological injury in one or both twins. Types II and III pose important challenges for management. Placental laser or cord occlusions do not seem to increase survival, but they might improve the outcomes of the larger twin. The use of an algorithm with severity criteria may help in counseling and planning management.
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Affiliation(s)
- Mar Bennasar
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Elisenda Eixarch
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Josep Maria Martinez
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Eduard Gratacós
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain.
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25
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Current Strategy of Fetal Therapy II: Invasive Fetal Interventions. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0132-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Ylilehto E, Palomäki O, Huhtala H, Uotila J. Term twin birth - impact of mode of delivery on outcome. Acta Obstet Gynecol Scand 2017; 96:589-596. [PMID: 28240343 DOI: 10.1111/aogs.13122] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 02/16/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The main aims of this study were to compare maternal and neonatal outcomes in term twin birth according to the planned mode of delivery and to study the effects of chorionicity and inter-twin delivery time on neonatal outcome. MATERIAL AND METHODS A single-center cohort study of 495 women with twin deliveries at ≥37+0 weeks of gestation. Term twin deliveries were divided into a trial of labor group (TOL, 69.3%) and a planned cesarean section (CS) group (30.7%). The primary outcomes were maternal and neonatal morbidity. RESULTS 80.8% of women attempting TOL achieved vaginal birth. In the TOL group, mothers had less bleeding [median 500 mL (range 150-2700 mL) vs. 950 mL (range 150-3500 mL), p < 0.001) and fewer surgical complications (3.2% vs. 8.6%, p = 0.011), whereas second twins more often had five-minute Apgar scores of <7 (5.0% vs. 0%, p = 0.002) or umbilical artery pH < 7.05 (5.7% vs. 0%, p = 0.003), compared with the planned CS group. There was a slight, non-significant tendency for more NICU admissions in the TOL group, yet the need for NICU treatment was infrequent in the whole study material. Outcomes among dichorionic (DC) second twins were similar to those in the whole material, but among monochorionic (MC) second twins there were no differences between the TOL and planned CS groups. In secondary analysis, a five-minute Apgar score <7 occurred significantly more often in the DC group among second twins if the inter-twin delivery time exceeded 30 min. CONCLUSIONS TOL is a good option for women with twin pregnancy at term, regardless of chorionicity. Active management of labor for the second twin is important, also in DC births. Maternal outcomes were more favorable with TOL and although low Apgar scores and low umbilical blood pH may be more frequent after TOL - especially with the second twin - serious neonatal morbidity is rare and does not differ from that after planned CS.
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Affiliation(s)
- Elina Ylilehto
- School of Medicine, University of Tampere, Tampere, Finland.,Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Outi Palomäki
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Jukka Uotila
- School of Medicine, University of Tampere, Tampere, Finland.,Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
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Placental Up-Regulation of Leptin and ARMS2 is Associated with Growth Discordance in Monochorionic Diamniotic Twin Pregnancies. Twin Res Hum Genet 2017; 20:169-179. [DOI: 10.1017/thg.2017.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Fetal growth discordance is a relatively common complication of monochorionic diamniotic (MCDA) twin pregnancies and is caused by a combination of maternal and placental factors. The aim of the study was to survey placental gene expression patterns and identify genes associated with growth discordance. Clinical samples comprised eight growth-discordant MCDA twin placentas (31+3–34+4 weeks gestational age) and six growth-concordant twin placentas (31+2–37 weeks gestational age). Gene expression libraries were constructed from placental biopsy samples and analyzed by RNA-sequencing. The distribution and relative abundance of mRNA transcripts expressed in the smaller and larger placentas from growth-discordant and concordant MCDA twins was remarkably similar. However, leptin (LEP) and age-related maculopathy susceptibility 2 (ARMS2) mRNA levels were exclusively up-regulated in all of the eight smaller growth-discordant twin placentas. Quantitative real-time PCR of independent biopsy samples confirmed the levels of differential mRNA expression for both genes. Immunohistochemical analysis of tissue sections from matching twin placentas showed increased leptin expression in 5–10% of blood vessel cells of the smaller placenta and marginally higher levels of ARMS2 expression in the microvillous membrane of the smaller placenta. Based on these findings, we speculate that up-regulation of leptin and ARMS2 forms part of an important survival mechanism to compensate for placental growth discordance. Since, leptin and ARMS2 are both expressed as soluble proteins, they may have clinical potential as measurable biomarkers for predicting the onset of growth discordance in MCDA twin pregnancies.
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Long L, Yan J, Li Q, Zhou Z, Deng H, Wang C, Zou Y, Cai J. Intrauterine fetal death in triplet gestation caused by feto-fetal transfusion syndrome - a case report. Forensic Sci Res 2016; 2:213-217. [PMID: 30483645 PMCID: PMC6197143 DOI: 10.1080/20961790.2016.1264915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 11/21/2016] [Indexed: 10/24/2022] Open
Abstract
Feto-fetal transfusion syndrome (FFTS) severely affects monochorionic (MC) multiple pregnancies and affects 1 in 1600 pregnancies overall. The number of increasing disputed obstetrics cases in China is related to unavailability of prompt diagnosis of FFTS. We present here a woman with a MC triplet pregnancy with intrauterine fetal death at 33 weeks of gestation due to FFTS. Subsequent pathological anatomy showed that the MC placenta contained vascular anastomoses, including arterio-arterial anastomosis and arterio-venous anastomosis. These anastomoses led to unidirectional blood flow with the absence of adequate compensatory counter-transfusion and bi-directional flow. When encountering such challenging conditions, medical practitioners should discreetly compare the fetuses' characteristics with features of placental blood vessels and consult morphological and pathological findings. Furthermore, they should perform ultrasound examinations, particularly focussing on fetal size differences and the maximum vertical pocket in the diagnosis of FFTS, especially in MC multiple pregnancies with abdominal symptoms.
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Affiliation(s)
- Lingling Long
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Jie Yan
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China.,Department of Forensic Pathology, Hunan Xiangya Judicial Identification Center, Changsha, China
| | - Qiyan Li
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Ziqi Zhou
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Haixiao Deng
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Chudong Wang
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Ying Zou
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China.,Department of Forensic Pathology, Hunan Xiangya Judicial Identification Center, Changsha, China
| | - Jifeng Cai
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China.,Department of Forensic Pathology, Hunan Xiangya Judicial Identification Center, Changsha, China
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Kawamura H, Ishii K, Mabuchi A, Yamamoto R, Hayashi S, Mitsuda N. Perinatal outcome of monochorionic diamniotic twin pregnancies complicated with isolated amniotic fluid volume abnormality of one twin less than 26 weeks of gestation. J Obstet Gynaecol Res 2016; 42:1657-1665. [DOI: 10.1111/jog.13106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/18/2016] [Accepted: 06/19/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Hiroshi Kawamura
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
| | - Aki Mabuchi
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
| | - Shusaku Hayashi
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
| | - Nobuaki Mitsuda
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
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30
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Twin-to-Twin Transfusion Syndrome: Definition, Staging, and Ultrasound Assessment. Twin Res Hum Genet 2016; 19:175-83. [DOI: 10.1017/thg.2016.34] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objective: The purpose of this article is to review the definition of twin-to-twin transfusion syndrome (TTTS) and the sonographic diagnostic assessment of these cases prior to therapy.Materials and Methods: The article addresses the terminology used to refer to the condition and describes the systematic ultrasound assessment of the condition, including the ultrasound diagnosis, the staging of the disease, cervical assessment and pre-operative mapping.Results: From an etymologic and medical point of view, the term ‘fetofetal transfusion’ is more appropriate than ‘TTTS’. However, as the latter, and its attendant acronym TTTS, have been widely adopted in the English language, it is impractical to change at this point. TTTS is defined sonographically in the combined presence of a maximum vertical pocket (MVP) of 8 cm or greater in one sac and 2 cm or less in the other sac, regardless of the gestational age at diagnosis. Staging of the condition using the Quintero staging system is practical, reproducible, and accepted. Transvaginal cervical length assessment should be an integral part of the ultrasound evaluation. Pre-operative mapping to anticipate the location of the placental vascular anastomoses and avoid injuring the dividing membrane is also discussed.Conclusions: The term ‘TTTS’ can continue to be used in the English medical literature. The condition can be diagnosed and assessed following a systematic ultrasound methodology. The use of such ultrasound methodology breaks the examination into a distinct set of components, assuring a comprehensive examination and proper communication among caregivers.
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Velamentous cord insertion in dichorionic and monochorionic twin pregnancies - Does it make a difference? Placenta 2016; 42:87-92. [PMID: 27238718 DOI: 10.1016/j.placenta.2016.04.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/03/2016] [Accepted: 04/05/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To estimate the prevalence of velamentous cord insertion (VCI) in dichorionic (DC) and monochorionic (MC) twins with and without twin-twin transfusion syndrome (TTTS), and to study the associated outcomes. METHODS We recorded the type of umbilical cord insertion in all consecutive DC and MC placentas examined in two European tertiary medical centers. The association between VCI and perinatal outcomes was estimated and compared. RESULTS A total of 1498 twin placentas were included in this study (DC placentas n = 550, MC placentas without TTTS n = 513 and MC placentas with TTTS n = 435). The prevalence of VCI in DC, MC without TTTS and MC with TTTS groups was 7.6%, 34.7% and 36.1%, respectively (P < 0.001). In MC twins (non-TTTS and TTTS groups), VCI was associated with severe birth weight discordance (odds ratio [OR] 4.76 95% CI 2.43, 10.47 and OR 4.52 95% CI 1.30, 28.59, respectively). In MC twins without TTTS, VCI was associated with small for gestational age (OR 1.66, 95% CI 1.12, 2.50). VCI was significantly associated with increased risk of intrauterine fetal demise in MC twins, and this effect was greater in the non-TTTS group (OR 2.71 95% CI 1.38, 5.47). These associations did not occur in DC group. Gestational age at birth was lower in the presence of VCI in the DC and MC twins without TTTS. CONCLUSION Our findings confirm that the prevalence of VCI is higher in MC twins than in DC twin pregnancies. VCI is an important indicator of adverse perinatal outcome, particularly in MC twins.
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Wohlmuth C, Gardiner HM, Diehl W, Hecher K. Fetal cardiovascular hemodynamics in twin-twin transfusion syndrome. Acta Obstet Gynecol Scand 2016; 95:664-71. [PMID: 26872246 DOI: 10.1111/aogs.12871] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 01/08/2016] [Indexed: 01/31/2023]
Abstract
Twin-twin transfusion syndrome (TTTS) complicates 10-15% of monochorionic-diamniotic (MCDA) pregnancies. It originates from unbalanced transfer of fluid and vasoactive mediators from one twin to its co-twin via placental anastomoses. This results in hypovolemia in the donor and hypervolemia and vasoconstriction in the recipient twin. Consequently, the recipient demonstrates cardiovascular alterations including atrioventricular valve regurgitation, diastolic dysfunction, and pulmonary stenosis/atresia that do not necessarily correlate with Quintero-stages. Selective fetoscopic laser photocoagulation of placental vascular anastomoses disrupts the underlying pathophysiology and usually improves cardiovascular function in the recipient with normalization of systolic and diastolic function within weeks after treatment. Postnatal studies have demonstrated early decreased arterial distensibility in ex-donor twins, but 10-year follow up is encouraging with survivors showing normal cardiovascular function after TTTS. However, prediction and appropriate early management of TTTS remain poor. Assessment of the cardiovascular system provides additional insight into the pathophysiology and severity of TTTS and may permit more targeted early surveillance of MCDA pregnancies in future. It should form an integral part of the diagnostic algorithm.
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Affiliation(s)
- Christoph Wohlmuth
- The Fetal Center, UT Health School of Medicine, Houston, TX, USA.,Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria
| | | | - Werner Diehl
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Zhao D, Cambiaso O, Otaño L, Lewi L, Deprest J, Sun L, Duan T, Oepkes D, Shapiro S, De Paepe M, Lopriore E. Veno–venous anastomoses in twin–twin transfusion syndrome: A multicenter study. Placenta 2015; 36:911-4. [DOI: 10.1016/j.placenta.2015.05.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 05/15/2015] [Accepted: 05/19/2015] [Indexed: 11/26/2022]
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van Gemert MJ, van den Wijngaard JP, Vandenbussche FP. Twin reversed arterial perfusion sequence is more common than generally accepted. ACTA ACUST UNITED AC 2015; 103:641-3. [DOI: 10.1002/bdra.23405] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 06/02/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Martin J.C. van Gemert
- Department of Biomedical Engineering & Physics; Academic Medical Center; Amsterdam The Netherlands
| | - Jeroen P.H.M. van den Wijngaard
- Department of Biomedical Engineering & Physics; Academic Medical Center; Amsterdam The Netherlands
- Department of Clinical Chemistry and Laboratory Medicine; Leiden University Medical Center; Leiden The Netherlands
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Correlation between veno-venous anastomoses, TTTS and perinatal mortality in monochorionic twin pregnancies. Placenta 2015; 36:603-6. [DOI: 10.1016/j.placenta.2015.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 02/18/2015] [Accepted: 02/20/2015] [Indexed: 11/30/2022]
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Yonetani N, Ishii K, Kawamura H, Mabuchi A, Hayashi S, Mitsuda N. Significance of Velamentous Cord Insertion for Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2015; 38:276-81. [PMID: 25925425 DOI: 10.1159/000381639] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 03/12/2015] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The objective of this study was to evaluate the actual association between velamentous cord insertion (VCI) and twin-twin transfusion syndrome (TTTS) in the native cohort concerning the natural history of monochorionic twin pregnancies. MATERIAL AND METHODS All monochorionic diamniotic twin pregnancies who received prenatal care from <16 weeks of gestation until delivery at our center between 2004 and 2013 were included in this retrospective cohort study. Macroscopically defined cord insertion site was recorded as velamentous, marginal, or central. The effects of VCI on TTTS and a composite of adverse outcomes, including abortion, death, and neurological morbidities ≤28 days of age, were evaluated with a multiple logistic regression model. RESULTS A total of 357 monochorionic diamniotic twin pregnancies were analyzed. VCI in both twins was noted in 2.5% of cases and VCI in at least one twin was noted in 22.1% of cases. The incidence of TTTS was 8.4%; the incidence of a composite of adverse outcomes in at least one twin was 9.8%. There was no correlation between VCI and TTTS as well as a composite of adverse outcomes. DISCUSSION VCI in monochorionic twin pregnancies was not a risk factor for TTTS and severe perinatal morbidities.
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Affiliation(s)
- Naoto Yonetani
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
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Monochorionic placentas with proximate umbilical cord insertions: Definition, prevalence and angio-architecture. Placenta 2015; 36:221-5. [DOI: 10.1016/j.placenta.2014.11.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 11/10/2014] [Accepted: 11/24/2014] [Indexed: 11/23/2022]
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Patil AS, Martin J, Tsukahara K, Skljarevski A, Miller K, Towns R, Schubert FP. Pseudomonoamniotic Pregnancy: Case Report and Review of Etiologic Considerations. Fetal Pediatr Pathol 2015; 34:413-21. [PMID: 26359803 DOI: 10.3109/15513815.2015.1075633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Pseudomonoamniotic gestations are increasingly recognized through sonographic surveillance of monochorionic twins, though etiologic factors remain undefined. We present a case of spontaneous pseudomonoamniotic twins and propose umbilical cord insertion proximity as a sonographic marker. Systematic review of the literature was performed and additional cases with similar findings were noted. Approximately 75% of reported cases (28/37) were deemed spontaneous and several included short inter-cord distances. Shunting of blood away from the membranes in the region between the cord insertions may be responsible for membrane rupture. Further investigation is needed into short inter-cord distance as a marker for monochorionic twins at risk to become a pseudomonoamniotic gestation.
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Affiliation(s)
- Avinash S Patil
- a Division of Maternal-Fetal Medicine , Indiana University School of Medicine , Indianapolis , Indiana , USA
| | - Jessica Martin
- b Department of Obstetrics & Gynecology , Indiana University School of Medicine , Indianapolis , Indiana , USA
| | | | - Anja Skljarevski
- c Indiana University School of Medicine , Indianapolis , Indiana , USA
| | - Katherine Miller
- c Indiana University School of Medicine , Indianapolis , Indiana , USA
| | - Rachel Towns
- b Department of Obstetrics & Gynecology , Indiana University School of Medicine , Indianapolis , Indiana , USA
| | - Frank P Schubert
- a Division of Maternal-Fetal Medicine , Indiana University School of Medicine , Indianapolis , Indiana , USA
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Villa CR, Habli M, Votava-Smith JK, Cnota JF, Lim FY, Divanovic AA, Wang Y, Michelfelder EC. Assessment of fetal cardiomyopathy in early-stage twin-twin transfusion syndrome: comparison between commonly reported cardiovascular assessment scores. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:646-651. [PMID: 24151229 DOI: 10.1002/uog.13231] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/15/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To assess the relationship between commonly reported fetal cardiomyopathy scoring systems in early-stage twin-twin transfusion syndrome (TTTS). METHODS We reviewed retrospectively 100 cases of Quintero Stages I and II TTTS referred to our center for evaluation from 2008 to 2010. The cases were divided into groups of 25, representing each of four grades of TTTS cardiomyopathy as assessed by Cincinnati stage: no cardiomyopathy, Stage IIIa, Stage IIIb and Stage IIIc. Spearman correlation (rs ) was calculated between the Children's Hospital of Philadelphia (CHOP) score, cardiovascular profile score (CVPS), Cincinnati stage and myocardial performance index (MPI). RESULTS There was a weak correlation between the Cincinnati stage and the CHOP score (rs = 0.36) and CVPS (rs = -0.39), while correlation was strong between the CHOP score and CVPS (rs = -0.72). MPI elevation was concordant with Cincinnati stage more frequently (82% of cases) than were ventricular hypertrophy (43%) or atrioventricular valve regurgitation (28%). 51% of fetuses with minimally elevated CHOP score (0-1) and 48% of fetuses with minimally depressed CVPS (9-10) had significant elevation (Z-score ≥ +3) in right ventricular or left ventricular MPI. CONCLUSIONS MPI has a strong influence on grading the severity of fetal cardiomyopathy using the Cincinnati stage among fetuses with mild TTTS. Furthermore, significant elevation of the MPI is common among fetuses with mild disease as assessed by the CHOP score and CVPS. These differences should be understood when assessing and grading cardiomyopathy in TTTS, particularly in early (Quintero Stages I and II) disease.
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Affiliation(s)
- C R Villa
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Zhao D, Cohen D, Middeldorp J, Klumper F, Haak M, Oepkes D, Lopriore E. The role of veno-venous anastomoses in twin–twin transfusion syndrome. Placenta 2014; 35:334-6. [DOI: 10.1016/j.placenta.2014.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/01/2014] [Accepted: 03/05/2014] [Indexed: 11/30/2022]
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Dias T, Akolekar R. Timing of birth in multiple pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:319-26. [DOI: 10.1016/j.bpobgyn.2013.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 11/25/2013] [Indexed: 10/26/2022]
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Murata M, Ishii K, Taguchi T, Mabuchi A, Kawaguchi H, Yamamoto R, Hayashi S, Mitsuda N. The prevalence and clinical features of twin-twin transfusion syndrome with onset during the third trimester. J Perinat Med 2014; 42:93-8. [PMID: 23985427 DOI: 10.1515/jpm-2013-0101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 07/26/2013] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the incidence and clinical features of twin-twin transfusion syndrome (TTTS) with third trimester onset. METHODS We performed a retrospective chart review of monochorionic diamniotic (MD) twin pregnancies delivered during a recent 4-year period. The inclusion criterion was women who received prenatal care at our center from the first trimester onward. Serial ultrasound examinations were performed at least every 2 weeks until delivery to evaluate fetal growth as well as to estimate amniotic fluid volume. The prevalence of TTTS onset after 28 weeks of gestation and clinical features, including neonatal outcomes and placental findings, were elucidated. RESULTS Meeting our inclusion criterion were 143 MD twin pregnancies, including 15 TTTS cases (10%). Five cases (4%) developed TTTS during the third trimester and underwent a cesarean section immediately after the diagnosis. All of these women exhibited either abdominal distension or uterine contractions. Recipient twins tended to require more intensive cardiopulmonary treatment than donors, however, neither a recipient nor a donor twin suffered neonatal death or neurological impairment. Placental arterio-arterial anastomoses were detected in three out of five cases. Arteriovenous anastomoses were present in all cases, however, venovenous anastomoses were not found in any case. CONCLUSIONS TTTS is a relatively rare complication during the third trimester. It is imperative to be observant for the development of TTTS in MD twin pregnancies with any abdominal symptoms, even if they appear insignificant.
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Oostveen MP, Hack KEA, Pistorius LR, Nikkels PGJ, Koopman-Esseboom C. Congenital anomalies presenting in utero as TTTS: a case series report and review of literature. J OBSTET GYNAECOL 2013; 33:901-3. [PMID: 24219740 DOI: 10.3109/01443615.2013.821969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- M P Oostveen
- University Medical Centre Utrecht, Department of Obstetrics and Gynecology , Utrecht , The Netherlands
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Costa-Castro T, De Villiers S, Montenegro N, Severo M, Oepkes D, Matias A, Lopriore E. Velamentous cord insertion in monochorionic twins with or without twin–twin transfusion syndrome: Does it matter? Placenta 2013; 34:1053-8. [DOI: 10.1016/j.placenta.2013.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 08/09/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022]
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Laser surgery in twin-twin transfusion syndrome with proximate cord insertions. Placenta 2013; 34:1159-62. [PMID: 24157353 DOI: 10.1016/j.placenta.2013.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/24/2013] [Accepted: 10/05/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To estimate the prevalence of proximate cord insertions in twin-twin transfusion syndrome (TTTS) and evaluate the outcome after fetoscopic laser coagulation surgery. METHODS We included all TTTS cases treated with laser at our center between 2002 and 2013. Placentas were examined after birth and injected with colored dye. TTTS cases without complete placental injection study were excluded. We recorded the presence of proximate cord insertions (distance < 5 cm) after birth and the presence and types of residual anastomoses. We compared the clinical outcome and placental findings in cases with and without proximate cord insertions. RESULTS The prevalence of proximate cord insertions in TTTS placentas was 2% (4/252). Perinatal mortality in the TTTS group with and without proximate cord insertions was 13% (1/8) and 12% (61/496), respectively (P = 1.0). Residual anastomoses were detected in all placentas with proximate cord insertions (100%, 4/4) compared to 27% (66/248)(P < .01) in TTTS placentas without proximate cord insertions. CONCLUSION Fetoscopic laser coagulation in TTTS cases with proximate cord insertions is challenging due to technical difficulties in visualizing the vascular equator and results in an increased risk of incomplete laser treatment.
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Nakayama S, Ishii K, Kawaguchi H, Yamamoto R, Murata M, Hayashi S, Mitsuda N. Perinatal complications of monochorionic diamniotic twin gestations with discordant crown-rump length determined at mid-first trimester. J Obstet Gynaecol Res 2013; 40:418-23. [PMID: 24118742 DOI: 10.1111/jog.12178] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 05/03/2013] [Indexed: 11/27/2022]
Abstract
AIM The aim of this study was to investigate the value of discordance of crown-rump length (DCRL) at mid-first trimester to predict adverse outcomes in monochorionic diamniotic twin gestations (MD). MATERIAL AND METHODS This was a retrospective cohort study of the perinatal outcome in MD pregnancies managed from the first trimester onward. DCRL was evaluated between 8 and 10 weeks of gestation. The association between DCRL and perinatal complications, including fetal death, twin-twin transfusion syndrome, severe discordant birthweight (DB), and twin anemia-polycythemia sequence, was assessed. RESULTS Among 126 cases, a single fetal demise occurred in two (2%) and demise of both fetuses occurred in eight (6%). Five pregnancies (4%) were complicated with twin-twin transfusion syndrome; one case (1%) was twin anemia-polycythemia sequence and 13 (10%) were DB. Neonatal death occurred in one pair. At 28 days of age, in 115 cases (91%) both twins were alive. In 117 cases (93%), at least one twin survived until 28 days of age. DCRL >12.0% was not related to any perinatal complications but DB (P < 0.01; relative risk: 1.40; 95% confidence interval: 1.06-1.84). CONCLUSIONS DCRL in MD during the mid-first trimester might be useful for predicting DB.
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Affiliation(s)
- Soichiro Nakayama
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan; Department of Obstetrics and Gynecology, Tokushima University, Tokushima, Japan
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Abstract
The objective of this review is to assess the evidence that supports the use of ultrasound in twin pregnancies. Although many of the indications for obstetric ultrasound are the same in both singleton and multiple gestations, there are special considerations as well as unique conditions in twins that require additional imaging studies. The reasons for ultrasound in twins include pregnancy dating, determination of chorionicity, nuchal translucency assessment, anatomical survey, placental evaluation, cervical length assessment, routine fetal growth, and serial surveillance of pregnancies complicated by anomalies, cervical shortening, fetal growth disturbances, and amniotic fluid abnormalities. Twins with monochorionic placentation require heightened scrutiny for monoamnionicity, conjoined twins, twin reversed arterial perfusion (TRAP) syndrome, twin-twin transfusion syndrome, unequal placental sharing with discordant twin growth or selective intrauterine fetal growth restriction (IUGR), twin anemia-polycythemia sequence (TAPS), and single fetal demise. Ultrasound is essential for the detection and management of conditions that can complicate dichorionic and monochorionic twin pregnancies.
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Affiliation(s)
- Lynn L Simpson
- Department of Obstetrics and Gynecology, Columbia University Medical Center, 622 W 168th St, PH-16, NY 10032.
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Maternal Perception of Decreased Fetal Movement in One Twin: A Clue Leading to the Early Detection of Absent Variability due to Acute Twin-to-Twin Transfusion Syndrome. Case Rep Obstet Gynecol 2013; 2013:345808. [PMID: 23984131 PMCID: PMC3741951 DOI: 10.1155/2013/345808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Accepted: 07/14/2013] [Indexed: 11/17/2022] Open
Abstract
Decreased fetal movement (DFM) perceived by pregnant women sometimes indicates imminent fetal jeopardy. It is unknown whether this also holds true for twin pregnancy. A 27-year-old primiparous woman with monochorionic diamniotic (MD) pregnancy had a slight difference of amniotic fluid volume at 31(2/7) weeks of gestation. DFM only in one twin at 31(4/7) weeks of gestation prompted her to receive urgent consultation. Since cardiotocogram indicated absent variability of one twin, we performed Cesarean section. Male infants weighing 2060 g and 1578 g were delivered; hemoglobin was 20.7 versus 10.8 g/dL, respectively; cardiothoracic ratio was 70% versus 44%, respectively, indicating acute twin-to-twin transfusion syndrome (TTTS). The recipient infant had heart failure, which was still observed at 1 month postpartum. In conclusion, maternal perception of DFM indicated imminent fetal death or jeopardy caused by acute TTTS, suggesting that education regarding DFM for women with twin pregnancy may be clinically important.
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50
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Loke YJ, Galati JC, Morley R, Joo EJH, Novakovic B, Li X, Weinrich B, Carson N, Ollikainen M, Ng HK, Andronikos R, Aziz NKA, Saffery R, Craig JM. Association of maternal and nutrient supply line factors with DNA methylation at the imprinted IGF2/H19 locus in multiple tissues of newborn twins. Epigenetics 2013; 8:1069-79. [PMID: 23917818 DOI: 10.4161/epi.25908] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Epigenetic events are crucial for early development, but can be influenced by environmental factors, potentially programming the genome for later adverse health outcomes. The insulin-like growth factor 2 (IGF2)/H19 locus is crucial for prenatal growth and the epigenetic state at this locus is environmentally labile. Recent studies have implicated maternal factors, including folate intake and smoking, in the regulation of DNA methylation at this locus, although data are often conflicting in the direction and magnitude of effect. Most studies have focused on single tissues and on one or two differentially-methylated regions (DMRs) regulating IGF2/H19 expression. In this study, we investigated the relationship between multiple shared and non-shared gestational/maternal factors and DNA methylation at four IGF2/H19 DMRs in five newborn cell types from 67 pairs of monozygotic and 49 pairs of dizygotic twins. Data on maternal and non-shared supply line factors were collected during the second and third trimesters of pregnancy and DNA methylation was measured via mass spectrometry using Sequenom MassArray EpiTyper analysis. Our exploratory approach showed that the site of umbilical cord insertion into the placenta in monochorionic twins has the strongest positive association with methylation in all IGF2/H19 DMRs (p<0.05). Further, evidence for tissue- and locus-specific effects were observed, emphasizing that responsiveness to environmental exposures in utero cannot be generalized across genes and tissues, potentially accounting for the lack of consistency in previous findings. Such complexity in responsiveness to environmental exposures in utero has implications for all epigenetic studies investigating the developmental origins of health and disease.
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Affiliation(s)
- Yuk Jing Loke
- Department of Paediatrics; University of Melbourne; Parkville, VIC Australia; Early Life Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
| | - John C Galati
- Clinical Epidemiology and Biostatistics Unit; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia; Department of Mathematics and Statistics; La Trobe University; Melbourne, VIC Australia
| | - Ruth Morley
- Early Life Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
| | - Eric Ji-Hoon Joo
- Department of Paediatrics; University of Melbourne; Parkville, VIC Australia; Cancer, Disease and Developmental Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
| | - Boris Novakovic
- Department of Paediatrics; University of Melbourne; Parkville, VIC Australia; Cancer, Disease and Developmental Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
| | - Xin Li
- Early Life Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
| | - Blaise Weinrich
- Early Life Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
| | - Nicole Carson
- Early Life Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
| | - Miina Ollikainen
- Hjelt Institute; Department of Public Health; University of Helsinki; Helsinki, Finland
| | - Hong-Kiat Ng
- Cancer, Disease and Developmental Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
| | - Roberta Andronikos
- Department of Paediatrics; University of Melbourne; Parkville, VIC Australia; Early Life Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
| | - Nur Khairunnisa Abdul Aziz
- Department of Paediatrics; University of Melbourne; Parkville, VIC Australia; Early Life Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
| | - Richard Saffery
- Department of Paediatrics; University of Melbourne; Parkville, VIC Australia; Cancer, Disease and Developmental Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
| | - Jeffrey M Craig
- Department of Paediatrics; University of Melbourne; Parkville, VIC Australia; Early Life Epigenetics Group; Murdoch Childrens Research Institute (MCRI); Royal Children's Hospital; Parkville, VIC Australia
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