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Noll ATR, Lof FC, Groene SG, Haak MC, Lopriore E, Russo FM, Slaghekke F, Tollenaar LSA, Van der Merwe J, Verweij EJT, Lewi L. Artery-to-vein anastomoses in unequally divided placentas and their association with birthweight discordance. Placenta 2024; 146:58-63. [PMID: 38181521 DOI: 10.1016/j.placenta.2023.12.023] [Citation(s) in RCA: 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: 10/13/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/07/2024]
Abstract
INTRODUCTION This study investigated the impact of the shared intertwin circulation in unequally divided monochorionic (MC) placentas on fetal growth. METHODS This retrospective analysis included color-dyed, unequally shared placentas from two tertiary centers. Exclusions included twin-twin transfusion syndrome, twin anemia polycythemia sequence, and lethal anomalies. Measurement of the external diameters and areas of the artery-to-artery (AA), artery-to-vein (AV), and vein-to-vein (VV) anastomoses was performed. The ratio of the shared circulation (AV ratio) was determined by comparing the areas of the summed venous components of shared AV anastomoses to those in the individual AV anastomoses of the smaller placental part. The birth weight ratio/placental ratio (BWR/PR), total AV size areas and net AV transfusion were calculated. Univariable and multivariable linear regressions were performed to assess the relationship between BWR/PR, the AV ratio, the areas of the different anastomoses and cord insertion discordance. RESULTS Among 352 placentas, 97 % (340) had intertwin AV anastomoses, and 50 % (176) were from pregnancies with selective growth restriction. The AV ratio, AA, VV, total AV areas, and cord insertion discordance negatively correlated with BWR/PR. Multivariable linear regression confirmed the independent negative association between BWR/PR and the AV ratio, suggesting that a larger shared circulation benefits the twin with the smaller placental part. Type III sFGR placentas exhibited the highest AV ratio, resulting in the lowest BWR/PR. DISCUSSION A larger shared circulation mitigates the impact of an unequally divided placenta on fetal growth. This effect surpasses the influence of AA and VV diameters and is most prominent in Type III sFGR placentas.
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Affiliation(s)
- A T R Noll
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands; Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F C Lof
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - S G Groene
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
| | - M C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
| | - F M Russo
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - L S A Tollenaar
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
| | - J Van der Merwe
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - E J T Verweij
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.
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Faiola S, Casati D, Nelva Stellio L, Laoreti A, Corti C, Mannarino S, Lanna M, Cetin I. Congenital heart defects in monochorionic twin pregnancy complicated by selective fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:504-510. [PMID: 36273402 DOI: 10.1002/uog.26098] [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: 05/04/2022] [Revised: 09/02/2022] [Accepted: 10/12/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To evaluate the prevalence, subtypes and postnatal outcomes of congenital heart defects (CHD) in a cohort of monochorionic diamniotic (MCDA) twin pregnancies complicated by selective fetal growth restriction (sFGR), and to compare this population with a cohort of uncomplicated MCDA pregnancies evaluated during the same period. METHODS This was a retrospective analysis of all consecutive MCDA pregnancies referred between 2009 and 2018, including those complicated by sFGR (Group A) and those without complications (Group B). All neonates delivered in our center were screened for CHD before discharge. Discharge letters for all those delivered elsewhere were retrieved. Pregnancies with complications other than sFGR and those without perinatal follow-up were excluded. Pregnancies in Group A were divided into three types according to the Gratacós system of sFGR classification. RESULTS A total of 870 MCDA twin pregnancies were included: 296 in Group A and 574 in Group B. In Group A, the prevalence of CHD was 3.7% (22/592 twins), with no significant difference in CHD frequency between the three types of sFGR (Type I, 3.7%; Type II, 3.2%; Type III, 4.2%; P = 0.55). Of four Type-III sFGR pregnancies with CHD, one had pulmonary stenosis (PS) in the larger twin and isolated coarctation of the aorta in the smaller cotwin, and three had PS in the larger twin only. No Type-III sFGR pregnancies in which only the smaller twin was affected by CHD were observed. Of 11 CHD cases in the larger twin, 10 (91%) were right ventricular outflow tract abnormalities (RVOTA), and one (9%) was a ventricular septal defect. In the smaller twins, 11 cases of CHD were observed, covering a broad spectrum of cardiac abnormalities. In Group B, the CHD prevalence was 1.1% (13/1148 twins), which was similar to that in the general population, according to the EUROCAT registry for the same period and geographical area of the study (0.96%; P = 0.579). The CHD prevalence was significantly higher in Group A compared with Group B (3.7% vs 1.1%; P = 0.0002; odds ratio, 3.57 (95% CI, 1.78-7.22)). In all pregnancies with CHD in the study population, the anomaly was discordant. CONCLUSIONS In MCDA twin pregnancy, sFGR was associated with a three-fold higher prevalence of CHD. Women with such pregnancies should be referred to a tertiary care hospital for pre- and postnatal cardiac evaluation, treatment and long-term follow-up. In larger twins, the only major CHD observed was RVOTA, while a broad spectrum of CHD was noted in smaller twins. The higher risk of CHD in MCDA pregnancies appears to be due to the typical complications of the monochorionic pregnancy, rather than to the monochorionic nature of the pregnancy itself. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Faiola
- Fetal Therapy Unit 'Umberto Nicolini', Buzzi Children's Hospital, Milan, Italy
- Department of Women, Mother and Newborn, Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - D Casati
- Fetal Therapy Unit 'Umberto Nicolini', Buzzi Children's Hospital, Milan, Italy
- Department of Women, Mother and Newborn, Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - L Nelva Stellio
- Department of Women, Mother and Newborn, Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - A Laoreti
- Fetal Therapy Unit 'Umberto Nicolini', Buzzi Children's Hospital, Milan, Italy
- Department of Women, Mother and Newborn, Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - C Corti
- Paediatric Cardiology Unit, Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - S Mannarino
- Paediatric Cardiology Unit, Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - M Lanna
- Fetal Therapy Unit 'Umberto Nicolini', Buzzi Children's Hospital, Milan, Italy
- Department of Women, Mother and Newborn, Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - I Cetin
- Department of Women, Mother and Newborn, Buzzi Children's Hospital, University of Milan, Milan, Italy
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