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D'Antonio F, Thilaganathan B, Laoreti A, Khalil A. Birth-weight discordance and neonatal morbidity in twin pregnancy: analysis of STORK multiple pregnancy cohort. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:586-592. [PMID: 29028139 DOI: 10.1002/uog.18916] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 09/10/2017] [Accepted: 09/25/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To investigate the relationship between weight discordance and neonatal morbidity in twin pregnancy progressing to at least 34 weeks of gestation. The secondary aim was to determine the predictive accuracy of different weight discordance cut-offs in predicting neonatal morbidity in twin pregnancy. METHODS This was a retrospective multicenter cohort study of all twin pregnancies booked for antenatal care at four hospitals in the Southwest Thames region of London Obstetric Research Collaborative (STORK) over a period of 10 years. Ultrasound data were obtained by a search of each hospital's obstetric ultrasound computer database, while outcome details were obtained from the computerized maternity and neonatal records. The primary outcome was incidence of composite neonatal morbidity in twin pregnancy with birth-weight discordance. Logistic regression was used to identify and adjust for potential confounders, while a receiver-operating characteristics (ROC) curve was used to determine predictive accuracy. RESULTS Nine hundred and thirty-nine twin pregnancies (760 dichorionic, 179 monochorionic) were included. Gestational age at birth and birth-weight decile were significantly lower in pregnancies complicated by neonatal morbidity compared with those which were not (P < 0.001 for both). On multivariable logistic regression analysis, gestational age at birth (P < 0.001), birth-weight decile (P = 0.029) and birth-weight discordance (P = 0.019), but not chorionicity (P = 0.477) or presence of at least one small-for-gestational-age (SGA) twin (P = 0.245), were associated independently with the risk of neonatal morbidity. There was a progressive increase in the risk of neonatal morbidity with increasing birth-weight discordance. Despite this association, birth-weight discordance showed an overall poor predictive accuracy for neonatal morbidity, with an area under the ROC curve of 0.58 (95% CI, 0.53-0.63) with an optimal cut-off of 17.6%, showing sensitivity and specificity of 35.2% (95% CI, 27.8-43.2%) and 83.2% (95% CI, 80.4-85.8%), respectively. CONCLUSION Intertwin birth-weight discordance is associated independently with the risk of neonatal morbidity in twins born after 34 weeks' gestation, irrespective of chorionicity or diagnosis of SGA in either twin. However, its predictive accuracy for neonatal morbidity is poor. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F D'Antonio
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Laoreti
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Townsend R, Khalil A. Ultrasound surveillance in twin pregnancy: An update for practitioners. ULTRASOUND (LEEDS, ENGLAND) 2018; 26:193-205. [PMID: 30479634 PMCID: PMC6243450 DOI: 10.1177/1742271x18794013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 06/28/2018] [Indexed: 01/31/2023]
Abstract
Ultrasound has revolutionised the management of multiple pregnancies and their complications. Increasing frequency of twin pregnancies mandates familiarity of all clinicians with the relevant pathologies and evidence-based surveillance and management protocols for their care. In this review, we summarise the latest evidence relating to ultrasound surveillance of twin pregnancies including first trimester assessment and screening, growth surveillance and the detection and management of the complications of monochorionic pregnancies including twin-to-twin-transfusion syndrome, selective fetal growth restriction, twin reversed arterial perfusion sequence and conjoined twinning.
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Affiliation(s)
- R Townsend
- Fetal Medicine Unit, St. George's University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, St. George's University of London, London, UK
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Ohuma EO, Njim T, Sharps MC. Current Issues in the Development of Foetal Growth References and Standards. CURR EPIDEMIOL REP 2018; 5:388-398. [PMID: 30596003 PMCID: PMC6290707 DOI: 10.1007/s40471-018-0168-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE OF REVIEW This paper discusses the current issues in the development of foetal charts and is informed by a scoping review of studies constructing charts between 2012 and 2018. RECENT FINDINGS The scoping review of 20 articles revealed that there is still a lack of consensus on how foetal charts should be constructed and whether an international chart that can be applied across populations is feasible. Many of these charts are in clinical use today and directly affect the identification of at risk newborns that require treatment and nutritional strategies. However, there is no agreement on important design features such as inclusion and exclusion criteria; sample size and agreement on definitions such as what constitutes a healthy population of pregnant women that can be used for constructing foetal standards. SUMMARY This paper therefore reiterates some of these current issues and the scoping review showcases the heterogeneity in the studies developing foetal charts between 2012 and 2018. There is no consensus on these pertinent issues and hence if not resolved will lead to continued surge of foetal reference and standard charts which will only exacerbate the current problem of not being able to make direct comparisons of foetal size and growth across populations.
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Affiliation(s)
- Eric O. Ohuma
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine University of Oxford, Old Road Campus, Oxford, OX3 7BN UK
| | - Tsi Njim
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Megan C. Sharps
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9WL UK
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Townsend R, Khalil A. Fetal growth restriction in twins. Best Pract Res Clin Obstet Gynaecol 2018; 49:79-88. [DOI: 10.1016/j.bpobgyn.2018.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 02/15/2018] [Indexed: 12/12/2022]
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Abstract
In the decades since the introduction of ultrasound into routine obstetric practice, the advantages of ultrasound have moved beyond the simple ability to identify multiple pregnancies antenatally to the possibility of screening them for fetal anomalies, pre-eclampsia, preterm birth, and the complications specific to monochorionic pregnancies. Screening studies have often excluded twins because physiological differences impact on the validity and sensitivity of the screening tests in routine use in singletons, and therefore, the evidence of screening performance in multiple pregnancy lags behind the evidence from singleton pregnancies. In general, most pregnancy complications are more common in twin pregnancy, but screening tests are less accurate or well validated. In this review article we present the current state of the evidence and avenues for future research relating to the use of ultrasound and screening for complications in twin pregnancies, including the monochorionicity-related pathologies, such as twin-twin transfusion syndrome, selective growth restriction, twin anaemia-polycythaemia sequence and twin reversed arterial perfusion sequence.
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Affiliation(s)
| | - Asma Khalil
- Fetal Medicine Unit, St George's University of London, London, UK.
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Neves AR, Nunes F, Branco M, Almeida MDC, Santos Silva I. The role of ultrasound in the prediction of birth weight discordance in twin pregnancies: are we there yet? J Perinat Med 2018; 46:163-168. [PMID: 28755531 DOI: 10.1515/jpm-2016-0371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 06/12/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To analyze the accuracy of ultrasound prediction of birth weight discordance (BWD) and the influence of chorionicity and fetal growth restriction (FGR) on ultrasound performance. METHODS Retrospective analysis of 176 twin pregnancies at a Portuguese tertiary center, between 2008 and 2014. Last ultrasound biometry was recorded. Cases with delivery before 24 weeks, fetal malformations, interval between last ultrasound and deliver >3 weeks, twin-to-twin transfusion syndrome and monoamniotic pregnancies were excluded. The accuracy of prediction of BWD was assessed using the area under the receiver-operating characteristics curve (AUC). RESULTS BWD ≥20% was present in 21.6% of twin pregnancies. EBW had the best predictive performance for BWD (AUC 0.838, 95%CI 0.760-0.916), with a negative predictive value of 86.9% and a positive predictive value of 51.3%. Chorionicity did not influence ultrasound performance. None of the biometric variables analyzed was predictive of BWD in pregnancies without FGR. CONCLUSION The accuracy of ultrasound in the prediction of BWD is limited, particularly in pregnancies without fetal growth restriction. Clinical decisions should not rely on BWD alone.
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Affiliation(s)
- Ana Raquel Neves
- Department of Obstetrics B, Centro Hospitalar e Universitário de Coimbra, Rua Augusta, 17, 3000-045, Coimbra, Portugal, Tel.: +351239400400
| | - Filipa Nunes
- Department of Obstetrics B, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Miguel Branco
- Department of Obstetrics B, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Maria do Céu Almeida
- Department of Obstetrics B, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Isabel Santos Silva
- Department of Obstetrics B, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Torres X, Bennasar M, Eixarch E, Rueda C, Goncé A, Muñoz M, Marimón E, Martínez J, Gratacós E, Figueras F. Gender-Specific Antenatal Growth Reference Charts in Monochorionic Twins. Fetal Diagn Ther 2017; 44:202-209. [DOI: 10.1159/000484555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 10/13/2017] [Indexed: 11/19/2022]
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Gardosi J. Toward safe standards for assessment of fetal growth in twin pregnancy. Am J Obstet Gynecol 2017; 216:431-433. [PMID: 28477719 DOI: 10.1016/j.ajog.2017.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 03/20/2017] [Indexed: 11/30/2022]
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Ghi T, Prefumo F, Fichera A, Lanna M, Periti E, Persico N, Viora E, Rizzo G. Development of customized fetal growth charts in twins. Am J Obstet Gynecol 2017; 216:514.e1-514.e17. [PMID: 28065816 DOI: 10.1016/j.ajog.2016.12.176] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/14/2016] [Accepted: 12/29/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Twin gestations are at significantly higher risk of fetal growth restriction in comparison with singletons. Using fetal biometric charts customized for obstetrical and parental characteristics may facilitate an accurate assessment of fetal growth. OBJECTIVE The objective of the study was to construct reference charts for the gestation of fetal biometric parameters stratified by chorionicity and customized for obstetrical and parental characteristics. STUDY DESIGN Fetal biometric measurements obtained from serial ultrasound examinations in uncomplicated twin pregnancies delivering after 36 weeks of gestation were collected by 19 Italian fetal medicine units under the auspices of the Società Italiana di Ecografia Ostetrica e Ginecologica. The measurements acquired in each fetus at each examination included biparietal diameter, head circumference, abdominal circumference, and femur length. Multilevel linear regression models were used to adjust for the serial ultrasonographic measurements obtained and the clustering of each fetus in twin pregnancy. The impact of maternal and paternal characteristics (height, weight, ethnicity), parity, fetal sex, and mode of conception was also considered. Models for each parameter were stratified by fetal chorionicity and compared with our previously constructed growth curves for singletons. RESULTS The data set included 1781 twin pregnancies (dichorionic, n = 1289; monochorionic diamniotic, n = 492) with 8923 ultrasonographic examinations with a median of 5 (range, 2-8) observations per pregnancy in dichorionic and 6 in (range, 2-11) monochorionic pregnancies. Growth curves of twin pregnancies differed from those of singletons, and differences were more marked in monochorionic twins and during the third trimester. A significant influence of parental characteristics was found. CONCLUSION Curves of fetal biometric measurements in twins are influenced by parental characteristics. There is a reduction in the growth rate during the third trimester. The reference limits for gestation constructed in this study may provide a useful tool for a more accurate assessment of fetal growth in twin pregnancies.
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Affiliation(s)
- Tullio Ghi
- Department of Obstetrics and Gynecology, University of Parma, Italy
| | - Federico Prefumo
- Department of Obstetrics and Gynecology, University of Brescia, Italy
| | - Anna Fichera
- Department of Obstetrics and Gynecology, University of Brescia, Italy
| | - Mariano Lanna
- Department of Obstetrics and Gynecology, University of Milan, Buzzi Children's Hospita, Italy
| | - Enrico Periti
- Department of Obstetrics and Gynecology, Presidio Ospedaliero Centro Piero Palagi, Firenze, Italy
| | - Nicola Persico
- Department of Obstetrics and Gynecology, L. Mangiagalli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Elsa Viora
- Department of Obstetrics and Gynecology, Ospedale Sant'Anna, Turin, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, University of Rome Tor Vergata, Rome, Italy.
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Gabbay-Benziv R, Crimmins S, Contag SA. Reference Values for Sonographically Estimated Fetal Weight in Twin Gestations Stratified by Chorionicity: A Single Center Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:793-798. [PMID: 28072479 DOI: 10.7863/ultra.16.02049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 07/13/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To determine reference values for sonography-based estimated fetal weight (EFW) in twin gestations in one single tertiary medical center in the United States. METHODS A retrospective longitudinal analysis of EFW evaluations of fetuses of twin gestations between November 2006 and June 2016. Fetuses with major congenital anomalies or chromosomal abnormalities were excluded. Estimated fetal weight was calculated using the Hadlock 1985 formula. Linear mixed models were used to allow for multiple but inconsistent observations among individuals, and to account for intertwin differences as well as for gender. Reference values were constructed using a best-fit regression model for estimation of mean and standard deviation at each gestational age after normalization of variables. Chorionicity-specific curves were constructed. RESULTS A total of 5515 ultrasound examinations were performed in 2115 twin pregnancies between 24 and 38 weeks of gestation (2.6 ± 4.0 scans/pregnancy). Values corresponding to the 5th, 10th, 50th, 90th, and 95th percentiles for EFW are presented for every gestational age. At 28, 32, and 36 weeks, values were as follows: 855, 1109, and 1363 g; 1351, 1732, and 2294 g; and 1363, 2112, and 2881 g for the 10th, 50th, and 90th percentiles, respectively. Chorionicity-specific curves are presented for comparison with previously published references. CONCLUSIONS Reference values for sonographic-based fetal growth are presented for clinical and research use.
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Affiliation(s)
- Rinat Gabbay-Benziv
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland USA
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
| | - Sarah Crimmins
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland USA
| | - Stephen A Contag
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland USA
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Bricelj K, Blickstein I, Bržan-Šimenc G, Janša V, Lučovnik M, Verdenik I, Trojner-Bregar A, Tul N. Growth curves for twins in Slovenia. J Matern Fetal Neonatal Med 2016; 30:479-481. [PMID: 27053137 DOI: 10.1080/14767058.2016.1175425] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Abnormalities of fetal growth are more common in twins. We introduce the growth curves for monitoring fetal growth in twin pregnancies in Slovenia. Slovenian National Perinatal Information System for the period between 2002 and 2010 was used to calculate birth weight percentiles for all live born twins for each week from 22nd to 40th week. The calculated percentiles of birth weight for all live-born twins in Slovenia served as the basis for drawing 'growth' curves. The calculated growth curves for twins will help accurately diagnose small or large twin fetuses for their gestational age in the native central European population.
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Affiliation(s)
- Katja Bricelj
- a Perinatology Unit, Department of Obstetrics and Gynecology , University Medical Center Ljubljana , Ljubljana , Slovenia , and
| | - Isaac Blickstein
- b Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot , Affiliated with the Hadassah-Hebrew University School of Medicine , Jerusalem , Israel
| | - Gabrijela Bržan-Šimenc
- a Perinatology Unit, Department of Obstetrics and Gynecology , University Medical Center Ljubljana , Ljubljana , Slovenia , and
| | - Vid Janša
- a Perinatology Unit, Department of Obstetrics and Gynecology , University Medical Center Ljubljana , Ljubljana , Slovenia , and
| | - Miha Lučovnik
- a Perinatology Unit, Department of Obstetrics and Gynecology , University Medical Center Ljubljana , Ljubljana , Slovenia , and
| | - Ivan Verdenik
- a Perinatology Unit, Department of Obstetrics and Gynecology , University Medical Center Ljubljana , Ljubljana , Slovenia , and
| | - Andreja Trojner-Bregar
- a Perinatology Unit, Department of Obstetrics and Gynecology , University Medical Center Ljubljana , Ljubljana , Slovenia , and
| | - Nataša Tul
- a Perinatology Unit, Department of Obstetrics and Gynecology , University Medical Center Ljubljana , Ljubljana , Slovenia , and
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Khalil A, Rodgers M, Baschat A, Bhide A, Gratacos E, Hecher K, Kilby MD, Lewi L, Nicolaides KH, Oepkes D, Raine-Fenning N, Reed K, Salomon LJ, Sotiriadis A, Thilaganathan B, Ville Y. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:247-63. [PMID: 26577371 DOI: 10.1002/uog.15821] [Citation(s) in RCA: 334] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 05/27/2023]
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - M Rodgers
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Bhide
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - E Gratacos
- Fetal Medicine Units and Departments of Obstetrics, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germaniy
| | - M D Kilby
- Centre for Women’s and Children's Health, University of Birmingham and Fetal Medicine Centre, Birmingham Women’s Foundation Trust, Birmingham, UK
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, UK
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - N Raine-Fenning
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - K Reed
- Twin and Multiple Births Association (TAMBA)
| | - L J Salomon
- Hopital Necker-Enfants Malades, AP-HP, Universit´e Paris Descartes, Paris, France
| | - A Sotiriadis
- Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - B Thilaganathan
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - Y Ville
- Hospital Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
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Nakano JCN, Liao AW, de Lourdes Brizot M, Miyadahira M, Francisco RPV, Zugaib M. Fetal growth according to different reference ranges in twin pregnancies with placental insufficiency. Clinics (Sao Paulo) 2015; 70:816-9. [PMID: 26735222 PMCID: PMC4676322 DOI: 10.6061/clinics/2015(12)09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 09/14/2015] [Indexed: 11/20/2022] Open
Abstract
The aim of this study was to compare different fetal growth curves in twin pregnancies with severe placental insufficiency. A retrospective cross-sectional analysis of 47 twin pregnancies with absent or reverse end diastolic flow in the umbilical artery of one fetus was performed. Pregnancies with major fetal abnormalities, twin-twin transfusion or three or more fetuses were not included. The estimated fetal weight zeta-scores were calculated for both fetuses (abnormal Doppler and co-twin) according to the following criteria: Hadlock, Liao and Araújo. The abdominal circumference zeta-scores were calculated according to Hadlock, Liao, Araújo, Ong and Stirrup. The mean estimates of the zeta-score values were calculated using generalized estimating equation regression analysis. The mean gestational age at inclusion was 27.4 ± 4.7 weeks. The fetal sex and the interaction Doppler findings × criteria correlated significantly with the zeta-score values (p < 0.001 for both variables). The estimated fetal weight mean zeta-scores (standard error) according to each criteria were as follows: Hadlock - abnormal Doppler: -2.98 (0.18), co-twin: -1.16 (0.15); Liao - abnormal Doppler: -2.89 (0.24), co-twin: -0.58 (0.19); and Araújo - abnormal Doppler: -3.05 (0.29), co-twin: -0.75 (0.18). Values for abdominal circumference were as follows: Hadlock - abnormal Doppler: -3.14 (0.26), co-twin: -1.13 (0.19); Liao - abnormal Doppler: -2.63 (0.27), co-twin: -0.42 (0.19); Araújo - abnormal Doppler: -2.44 (0.22), co-twin: -0.71 (0.14); Ong - abnormal Doppler: -3.36 (0.34), co-twin: -1.48 (0.23); and Stirrup AD -- -2.36 (0.14), co-twin: -1.18 (0.10). Sex- and plurality-specific charts should be used in the evaluation of fetal growth in twin pregnancies with placental insufficiency.
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Affiliation(s)
- Julianny Cavalheiro Nery Nakano
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Obstetrícia e Ginecologia, São Paulo/SP, Brazil
| | - Adolfo Wenjaw Liao
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Obstetrícia e Ginecologia, São Paulo/SP, Brazil
- Corresponding author: E-mail:
| | - Maria de Lourdes Brizot
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Obstetrícia e Ginecologia, São Paulo/SP, Brazil
| | - Mariana Miyadahira
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Obstetrícia e Ginecologia, São Paulo/SP, Brazil
| | - Rossana Pulcineli Vieira Francisco
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Obstetrícia e Ginecologia, São Paulo/SP, Brazil
| | - Marcelo Zugaib
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Obstetrícia e Ginecologia, São Paulo/SP, Brazil
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Discordance in fetal biometry and Doppler are independent predictors of the risk of perinatal loss in twin pregnancies. Am J Obstet Gynecol 2015; 213:222.e1-222.e10. [PMID: 25731693 DOI: 10.1016/j.ajog.2015.02.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/17/2015] [Accepted: 02/19/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Impaired fetal growth might be better evaluated in twin pregnancies by assessing the intertwin discordance rather than the individual fetal size. The aim of this study was to investigate the prediction of perinatal loss in twin pregnancy using discordance in fetal biometry and Doppler. STUDY DESIGN This was a retrospective cohort study in a tertiary referral center. The estimated fetal weight (EFW), umbilical artery (UA) pulsatility index (PI), middle cerebral artery (MCA) PI, cerebroplacental ratio (CPR), and their discordance recorded at the last ultrasound assessment before delivery or demise of one or both fetuses were converted into centiles or multiples of the median (MoM). The discordance was calculated as the larger value-smaller value/larger value. A logistic regression analysis was performed to identify, and adjust for, potential confounders. The predictive accuracy was assessed using receiver-operating characteristic curve analysis. RESULTS The analysis included 620 (464 dichorionic diamniotic and 156 monochorionic diamniotic) twin pregnancies (1240 fetuses). Perinatal loss of one or both fetuses complicated 16 pregnancies (2.6%). The combination of EFW discordance and CPR discordance had the best predictive performance (area under the curve, 0.96; 95% confidence interval, 0.92-1.00) for perinatal mortality. The detection rate, false-positive rate, positive likelihood ratio, and negative likelihood ratio were 87.5%, 6.7%, 13.08, and 0.13, respectively. The EFW centile, EFW below the 10th centile (small for gestational age), UA PI discordance, MCA PI discordance, and MCA PI MoM were significantly associated with the risk of perinatal loss on univariate analysis, but these associations became nonsignificant after adjusting for other confounders (P = .097, P = .090, P = .687, P = .360, and P = .074, respectively). The UA PI MoM, CPR MoM, EFW discordance, and CPR discordance were all independent predictors of the risk of perinatal loss, even after adjusting for potential confounders (P = .022, P = .002, P < .001, and P = .010, respectively). CONCLUSION EFW discordance and CPR discordance are independent predictors of the risk of perinatal loss in twin pregnancies. Their combination could identify the majority of twin pregnancies at risk of perinatal loss. These findings highlight the importance of discordance in Doppler indices of fetal hypoxia, as well as fetal size, in assessing the risk of perinatal mortality.
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An ultrasound-based fetal weight reference for twins. Am J Obstet Gynecol 2015; 213:224.e1-9. [PMID: 25899626 DOI: 10.1016/j.ajog.2015.04.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The objective of the study was to construct an ultrasound-based estimated fetal weight-for-gestational-age reference for twin fetuses, stratified by chorionicity. STUDY DESIGN We performed a retrospective cohort study of live-born nonanomalous twins delivered longer than 34 weeks at the Royal Victoria Hospital (Montreal, Canada). Fetal weight was estimated using ultrasound biometric measurements combined using Hadlock's formula. Multilevel linear regression models were used to adjust for clustering by twin pregnancy and to account for the serial ultrasound measurements taken on each fetus. Based on this model, smoothed estimates of fetal weight were made for the third, 10th, 50th, 90th, and 97th percentiles of the fetal weight distribution. Fetal weight references were stratified by fetal chorionicity. RESULTS A total of 642 twin fetuses with a total of 3078 ultrasound observations were included. Sixteen percent of the cohort was monochorionic. Fetal growth accelerated in the second trimester and continued in a linear pattern in the third trimester until term. As expected, the median weight for monochorionic twins was lighter than the median weight for dichorionic twins throughout pregnancy. CONCLUSION The reference values created in this study address serious methodological limitations of existing reference charts and thus provide an improved tool for assessing fetal growth in twin pregnancies. Importantly, dichorionic twins deviated from singleton reference charts at approximately 32 weeks, whereas monochorionic twins deviated at 28 weeks.
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