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Gijtenbeek M, Haak MC, Huberts TJP, Middeldorp JM, Klumper FJCM, Slaghekke F, Lopriore E, Oepkes D, van Klink JMM. Perioperative fetal hemodynamic changes in twin-twin transfusion syndrome and neurodevelopmental outcome at two years of age. Prenat Diagn 2020; 40:825-830. [PMID: 32266998 PMCID: PMC7383478 DOI: 10.1002/pd.5690] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 11/21/2022]
Abstract
Objective To investigate whether perioperative fetal hemodynamic changes in twin‐to‐twin transfusion syndrome (TTTS) are associated with neurodevelopmental impairment (NDI) at two years. Methods Doppler parameters of three sonograms (day before, first day after and 1 week after laser surgery for TTTS) were assessed for correlation with neurodevelopmental outcome at two years (2008‐2016). NDI was defined as: cerebral palsy, deafness, blindness, and/or a Bayley‐III cognitive/motor developmental test‐score > 2SD below the mean. Results Long‐term outcome was assessed in 492 TTTS survivors. NDI was present in 5% (24/492). After adjustment for severe cerebral injury (present in 4%), associated with NDI were: middle cerebral artery peak systolic velocity (MCA‐PSV) >1.5 multiples of the median (MoM) 1 day after surgery (odds ratio [OR] 4.96; 95% confidence interval [CI]: 1.17‐21.05, P = .03), a change from normal umbilical artery pulsatility index (UA‐PI) presurgery to UA‐PI >p95 postsurgery (OR 4.19; 95% CI: 1.04‐16.87, P = .04), a change from normal to MCA‐PSV >1.5MoM (OR 4.75; 95% CI: 1.43‐15.77, P = .01). Conclusion Perioperative fetal hemodynamic changes in TTTS pregnancies treated with laser are associated with poor neurodevelopmental outcome. Prospective research on the cerebrovascular response to altered hemodynamic conditions is necessary to further understand the cerebral autoregulatory capacity of the fetus in relation to neurodevelopmental outcome.
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Affiliation(s)
- Manon Gijtenbeek
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique C Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom J P Huberts
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M M van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Li M, Wang C, Yang Y, Mao L, Chen J, He S, Gou C, Zhang X. Characteristics of vascular anastomoses in monochorionic twin 587 placentas with selective intrauterine growth restriction via 89 three-dimensional computed tomography angiography. Prenat Diagn 2020; 40:715-723. [PMID: 32092161 DOI: 10.1002/pd.5672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 11/22/2019] [Accepted: 02/11/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the characteristics of the choriovascular anatomy, especially the potential role of arteriovenous perfusion imbalance in the pathogenesis of selective intrauterine growth restriction (sIUGR) using three-dimensional computed tomography angiography (3D-CTA). METHOD Computed tomography angiography of the placental choriovascular tree from 15 twins with sIUGR and 15 twins without sIUGR were analyzed, and inter-twin vascular anastomoses were compared between the placentas from these two groups. The parameters evaluated were the presence and measures of artery-to-artery anastomoses (AAA), vein-to-vein anastomoses (VVA) or artery-to-vein anastomoses (AVA). RESULTS The frequency of AAA, VVA, and AVA did not differ significantly between sIUGR and without sIUGR-pairs. The area of the vein draining to the AVA in the larger twin's placenta was significantly greater in sIUGR compared to when no sIUGR was present. Based on the net cross-sectional area difference we speculate that in sIUGR there is net flow from the smaller to the larger twin. CONCLUSION We used 3D-CTA to display the vascular anastomoses in sIUGR twin pairs, demonstrating a difference in cross-sectional diameter of the vein draining to the AVA.
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Affiliation(s)
- Meizhi Li
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Chaoyang Wang
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Yanhong Yang
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Lijuan Mao
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Jiawen Chen
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Shaofu He
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Chenyu Gou
- Department of Obstetrics, Sixth Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Xiaoling Zhang
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
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The Influence of Chorion Type on Health Measures at Birth and Dental Development in Australian and Dutch Twins: A Comparative Study. Twin Res Hum Genet 2015; 18:368-74. [DOI: 10.1017/thg.2015.43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Chorion type may significantly influence the prenatal environment of twins. This study explored the associations between chorion type and gestational age, birth weight, birth length, and the timing of emergence of the first primary tooth in two populations of twins, Australian and Dutch. Additionally, we investigated the relationship between chorion type and birth weight discordance (BWD) in order to determine whether a significant relationship existed between discordance in birth weight and discordance in the timing of emergence of the first primary tooth. The two study samples consisted of 409 Australian twin pairs and 301 Dutch twin pairs, all of European ancestry. Data were collected through a combination of questionnaires and recording charts administered to the parents and through linkage with biological databases. In the Australian sample, monozygotic monochorionic (MZMC) twins experienced the shortest mean gestation time (35 weeks), the lowest mean birth length (46 cm) and the lowest mean birth weight (2.3 kg) compared with other twin groups. For the same variables in the Dutch sample, these trends with MZMC twinning were not observed. Chorion type did not significantly affect the mean timing of emergence of the first primary tooth in either sample. Monochorionicity was found to be significantly associated with BWD in both samples, but there was a significant association between BWD in MZMC twin pairs and timing of emergence of the first primary tooth only in the Australian sample. Results from this study support previous findings that the timing of emergence of the first primary tooth is influenced strongly by genetic factors and is well protected from environmental disturbances.
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Singh A, Singh A, Surapaneni T, Nirmalan PK. Pre-eclampsia (PE) and Chorionicity in Women with Twin Gestations. J Clin Diagn Res 2014; 8:100-2. [PMID: 24596736 DOI: 10.7860/jcdr/2014/7806.3902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 10/14/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pre-Eclampsia (PE) affects 6-31% of pregnant women with multiple gestations. There are conflicting reports on the association of PE with Chorionicity and zygosity; however, there is a lack of information on this potential association in a population of pregnant Asian Indian women. AIM To determine as to whether chorionicity and zygosity were associated with PE in a population of Asian Indian women with twin gestations. SETTINGS AND DESIGN A retrospective observational study was done at a single tertiary care centre in Southern India. MATERIAL AND METHODS The study included pregnant women with twin gestations, who was delivered at the study institute in 2012. Hypertension in pregnancy was categorized, based on the criteria of the International Society for the Study of Hypertension in Pregnancy. Chorionicity was determined by using ultrasonography and zygosity was determined, based on clinical criteria. Point estimates and the 95% Confidence Intervals (CI) around point estimates of PE and associations of chorionicity and zygosity with PE were determined by using bivariate analysis, logistic regression models and area under Receiver Operator Characteristic (ROC) curves. RESULTS This study included 208 women with twin gestations. The incidence of PE in dichorionic twin gestations was 13.17% (n=22, 95% CI: 8.66, 18.96), it was 4.87% (n=2, 95% CI: 0.83, 15.19) in monochorionic twin gestations, it was 16.36% (n=9, 95% CI: 8.29, 27.91) in dizygous twin gestations and it was 4.88% (n=2, 95% CI: 0.83, 15.19) in monozygous twin gestations. Neither chorionicity (adjusted OR: 2.59, 95% CI: 0.55, 12.19) nor zygosity (adjusted OR 2.72, 95% CI: 0.49, 15.13) were associated with PE In a multivariate logistic regression model. CONCLUSION Although it was not statistically significant, the clinical incidence of PE was higher in dichorionic and dizygous twin gestations.
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Affiliation(s)
- Anupama Singh
- Consultant, Department of Obstetric Medicine, Multiple Pregnancy Unit, Fernandez Hospital Pvt Ltd , Hyderabad, India
| | - Arati Singh
- Fellow, Department of Obstetric Medicine, High Risk Pregnancy, Fernandez Hospital Pvt Ltd , Hyderabad, India
| | | | - Praveen Kumar Nirmalan
- Head, Department of Obstetric Medicine, Woman and Child Health Research Unit, Fernandez Hospital Pvt Ltd , Hyderabad, India
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Petousis S, Margioula-Siarkou C, Kalogiannidis I, Prapas N. Twin Pregnancy and Antenatal Examination: An Overview. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2013. [DOI: 10.1007/s13669-013-0057-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Placental endoglin levels in diamniotic-monochorionic twin gestations: correlation with clinical and placental characteristics. Placenta 2013; 34:261-8. [PMID: 23306069 DOI: 10.1016/j.placenta.2012.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 11/10/2012] [Accepted: 12/18/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE While endoglin has been implicated in the pathogenesis of various complications in singleton pregnancies, its potential contribution to complications of monochorionic twinning remains largely undetermined. The aim of this study was to determine the correlation between relevant clinical and pathological variables and placental endoglin levels in diamniotic-monochorionic twin pregnancies. METHODS Endoglin expression was studied by immunohistochemistry and Western blot in a prospective cohort of 68 non-TTTS and 7 TTTS monochorionic twin placentas. Placental endoglin levels were correlated with clinical and placental characteristics associated with twin-to-twin transfusion syndrome (TTTS) and selective growth restriction, including birth weight discordance, uneven placental sharing, peripheral cord insertion and choriovascular anatomy. RESULTS In non-TTTS gestations discordant for these criteria, placental endoglin levels were significantly higher for the twin with smaller birth weight, intrauterine growth restriction, and/or abnormal ultrasound Doppler studies than for the more normal co-twin. Similarly, placental endoglin levels were significantly higher in the placental territory with smaller share and/or peripheral cord insertion in cases discordant for these placental characteristics. In TTTS gestations, placental endoglin levels tended to be higher for donor twins than for recipients. There was no correlation between endoglin levels and superficial choriovascular anastomoses. CONCLUSIONS While the exact functional implications remain to be determined, our findings suggest a strong correlation between unbalanced placental endoglin levels and intertwin growth discordance in monochorionic twins.
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Sullivan AE, Hopkins PN, Weng HY, Henry E, Lo JOT, Varner MW, Esplin MS. Delivery of monochorionic twins in the absence of complications: analysis of neonatal outcomes and costs. Am J Obstet Gynecol 2012; 206:257.e1-7. [PMID: 22284957 DOI: 10.1016/j.ajog.2011.12.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 12/05/2011] [Accepted: 12/19/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We sought to estimate the optimal time to deliver uncomplicated monochorionic-diamnionic (MCDA) twins. STUDY DESIGN Data were retrospectively obtained from twin pregnancies from 2000 through 2009. The gestational week-specific prospective perinatal mortality risk was calculated. A cohort of MCDA twins with nonindicated deliveries was analyzed separately. Neonatal outcomes and costs were compared between MCDA twins with nonindicated deliveries born at specific weeks of gestation, and those born the subsequent week. RESULTS There were 5894 dichorionic-diamnionic twins and 1704 MCDA twins. After 28 weeks, the gestational week-specific prospective risk of perinatal mortality did not differ between groups. There were 948 MCDA twins with nonindicated deliveries. Until 37 weeks, the risk of severe neonatal morbidity, perinatal mortality, and hospital costs were greater for fetuses delivered compared to fetuses born in a subsequent week. CONCLUSION To optimize neonatal outcome and decrease hospital costs, MCDA twins should not be delivered <37 weeks unless medically indicated.
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Affiliation(s)
- Amy Elizabeth Sullivan
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
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Asztalos EV, Barrett JFR, Lacy M, Luther M. Evaluating 2 Year Outcome in Twins ≤ 30 Weeks Gestation at Birth: A Regional Perinatal Unit's Experience. ACTA ACUST UNITED AC 2012. [DOI: 10.1375/twin.4.6.431] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractWith improved technology in assisted reproductive medicine, there has been an absolute increase in the numbers of twin pregnancies with an associated increase in perinatal mortality and morbidity. This increase in perinatal mortality and morbidity is largely due to a higher incidence of delivering preterm as compared to singletons. Twin pregnancies have their unique complications that include abnormal placental communication and discordant growth which are associated with perinatal mortality and morbidity. The objectives of this study were two-fold: i) to determine if the morbidity/mortality outcome at 18–24 months corrected age seen in a cohort of twins born between 24–30 weeks gestation was significantly different as compared to singleton preterm infants of the same gestation; and ii) to determine and evaluate any differences between monochorionic (MC) and dichorionic (DC) twins. Twins 24–30 weeks gestation at birth born between 01/01/97–30/06/99 were identified and prospectively followed to 18–24 months corrected age (c.a.). They were matched with a singleton infant of the same gender and within 1 week of the same gestation. Obstetrical, neonatal and neurodevelopmental data were gathered and analyzed. The primary outcome was death or the presence of a severe neurodevelopmental deficit at 18–24 months corrected age. Of the 56 sets of twins identified, 52 sets were followed prospectively with 101 infants available for matching. In this cohort, twin pregnancies had a lower incidence of pregnancy-induced hypertension and premature rupture of membranes than singletons (p < 0.05). The two groups were comparable in neonatal characteristics. The incidence of death or severe disability was 29.7% in twins vs. 22.8% in singletons (p = 0.337, Fisher's exact test). The major area of deficit was in the cognitive category for both groups, 9.9% vs. 7.9% respectively. MC twins made up 35.6%; DC twins 64.4%. Twin to twin transfusion syndrome (TTTS) occurred in 6.9%. Discordant growth occurred more frequently in MC pregnancies (p = 0.016). MC twins tended to be more premature, lower in birth weight, and experience neonatal morbidity in the form of patent ductus arteriosus and sepsis (p < 0.05) as compared to DC twins. However, the primary outcome of death or severe neurodevelopmental deficit at 18–24 months c.a. was not significantly different between the two groups, 38.9% (MC) vs. 24.6% (DC), (p = 0.173, Fisher's exact test). Neurodevelopmental morbidity or mortality in twins with TTTS was 42%. Mortality and severe neurodevelopmental morbidity were not significantly higher in twins as compared to singletons in this cohort. However, the trend is slightly higher in twins, which may have clinical significance. Though not statistically significant, the incidence of 38.9% in adverse outcome with MC twins may be clinically significant. With the number of twins steadily increasing, further monitoring is required to determine future directions in intervention and research. Early recognition of monochorionicity remains essential to optimize care and neurodevelopment for these infants.
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Chang YL, Chang SD, Chao AS, Hsieh PCC, Wang CN, Wang TH. Fetal hemodynamic changes following maternal betamethasone administration in monochorionic twin pregnancies featuring one twin with selective growth restriction and abnormal umbilical artery Doppler. J Obstet Gynaecol Res 2011; 37:1671-6. [DOI: 10.1111/j.1447-0756.2011.01602.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pan M, Chen M, Leung TY, Sahota DS, Ting YH, Lau TK. Outcome of monochorionic twin pregnancies with abnormal umbilical artery Doppler between 16 and 20 weeks of gestation. J Matern Fetal Neonatal Med 2011; 25:277-80. [DOI: 10.3109/14767058.2011.573830] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Burton A, Ananth CV. Contributions of ischaemic placental disease to preterm birth in twin gestations. J Matern Fetal Neonatal Med 2011; 23:1183-6. [PMID: 20121387 DOI: 10.3109/14767050903580375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the extent to which ischaemic placental disease (IPD)--defined as women or newborns diagnosed with pre-eclampsia, small for gestational age (SGA), or abruption, is associated with preterm birth in twin gestations. METHODS A population-based study of women who delivered twin live births and stillbirths at 20-44 weeks gestation from 1995-2004 in the US was performed (n=1,105,666). We compared the frequency of IPD in term and preterm (<37 weeks) twin births. SGA was defined as twins with birthweight<10th percentile for gestational age, and corrected for infant sex. The association between IPD and preterm birth was expressed as hazard ratio, derived from Cox proportional hazard regression models after adjusting for potential confounders. RESULTS The overall rate of twin preterm birth was 57%. IPD was present in 20% of twin preterm births in comparison to a rate of 16% at term. Both pre-eclampsia and abruption, but not SGA, were associated with increased preterm birth rates. Women with two or more of the IPD conditions were more likely to deliver at preterm than at term gestations. CONCLUSION In comparison to twin births delivered at term, IPD is more common in preterm births. Efforts to understand the role of IPD in twin gestations based on preterm birth subtypes may reveal important insights.
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Affiliation(s)
- Aiyanna Burton
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, UMDNJ-Robert Johnson Medical School, New Brunswick, NJ 08901-1977, USA
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De Paepe M, Shapiro S, Young L, Luks F. Placental characteristics of selective birth weight discordance in diamniotic-monochorionic twin gestations. Placenta 2010; 31:380-6. [DOI: 10.1016/j.placenta.2010.02.018] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 02/23/2010] [Accepted: 02/24/2010] [Indexed: 11/24/2022]
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Placental markers of twin-to-twin transfusion syndrome in diamniotic–monochorionic twins: A morphometric analysis of deep artery-to-vein anastomoses. Placenta 2010; 31:269-76. [DOI: 10.1016/j.placenta.2009.12.024] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 11/05/2009] [Accepted: 12/22/2009] [Indexed: 11/20/2022]
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Ding DC, Hsu S, Chu TW, Lai HC, Chen WH. Utility of Doppler velocimetry in correlating with outcomes in severe discordant twins. J OBSTET GYNAECOL 2009; 26:198-9. [PMID: 16698623 DOI: 10.1080/01443610500508253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Twin birth weight discordance is associated with poor perinatal outcome. Three cases of severe discordant twins were serially assessed by ultrasound biometry and the Doppler ultrasonography of both the middle cerebral artery (MCA) and umbilical artery (UA) to measure pulsatility index (PI), resistance index (RI), and the systolic and diastolic ratio (S/D ratio). The birth weight discrepancies in three cases are 38%, 69% and 68%, respectively. Doppler velocimetry revealed a discrepancy in the S/D ratio of MCA and UA more than 15%. Absent end-diastolic flow, or the brain sparing effect, was noted in three small twins. Cerebral-umbilical S/D ratio (CUR) (MCA/UA) of the twins was above 1 in large ones and below 1 in small ones. The small twin in case 3 expired after delivery. In conclusion, if the CUR of the S/D ratio of the fetus is below 1, the prognosis might be poor and fetal weight discordancy might be progressively larger.
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Affiliation(s)
- Dah-Ching Ding
- Graduate Institute of Medical Science, School of Medicine, Tzu Chi University, Taiwan, R.O.C.
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Habli M, Livingston J, Harmon J, Lim FY, Plozin W, Crombleholme T. The outcome of twin-twin transfusion syndrome complicated with placental insufficiency. Am J Obstet Gynecol 2008; 199:424.e1-6. [PMID: 18928994 DOI: 10.1016/j.ajog.2008.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Revised: 05/05/2008] [Accepted: 07/07/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim was to evaluate the incidence and perinatal outcomes of TTTS complicated with placental insufficiency (PI/TTTS). STUDY DESIGN This was a retrospective study of all TTTS with PI. PI is defined as estimated fetal weight < 10% with elevated head circumference/abdominal circumference ratio and weight discordance > 20%. RESULTS Fifty-two out of 270 (19%) pregnancies met criteria. Forty-nine (94.2%) donor twins were diagnosed with PI/TTTS. Fifteen were treated with amnioreduction, 26 with selective fetoscopic laser photocoagulation, 4 with donor intrafetal radiofrequency ablation (RFA), and 7 had expectant management. There was a high incidence of abnormal Dopplers and abnormal placental cord insertion in the donor twin (58% marginal, 35% membranous) with a mean estimated fetoscopic donor placental share of 26.1 +/- 14.3%. There was a significant decrease in the overall donor survival rate of 61% (4 RFA selected donors were excluded) as compared to overall recipient survival rate of 85%, respectively (P = .009). There was no significant difference in donor or recipient survival rate among the treatment groups (P = .058). CONCLUSION Placental insufficiency impacts the survival of the affected twins in the setting of TTTS. Studies are needed for appropriate treatment in TTTS with placental insufficiency.
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Reolon R, Rotta N, Agranonik M, Silva AMD, Goldani M. Influence of intrauterine and extrauterine growth on neurodevelopmental outcome of monozygotic twins. Braz J Med Biol Res 2008; 41:694-9. [DOI: 10.1590/s0100-879x2008005000032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Accepted: 06/09/2008] [Indexed: 11/22/2022] Open
Affiliation(s)
- R.K. Reolon
- Universidade Federal do Rio Grande do Sul, Brasil
| | - N.T. Rotta
- Universidade Federal do Rio Grande do Sul, Brasil
| | - M. Agranonik
- Universidade Federal do Rio Grande do Sul, Brasil
| | | | - M.Z. Goldani
- Universidade Federal do Rio Grande do Sul, Brasil
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Chang YL, Chang SD, Chao AS, Hsieh PCC, Wang CN, Tseng LH. The individual fetal weight/estimated placental weight ratios in monochorionic twins with selective intrauterine growth restriction. Prenat Diagn 2008; 28:217-21. [PMID: 18264953 DOI: 10.1002/pd.1918] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To evaluate the individual fetal weight/estimated placental weight ratios (F/P ratio) of the two fetuses in monochorionic (MC) twins with selective intrauterine growth restriction (IUGR). MATERIAL AND METHODS MC twin with selective IUGR was defined as an estimated fetal weight below the 10th percentile in one twin of MC pregnancy. The estimated individual placental weight was obtained by cutting the placenta along the vascular equator into two territories. A total of 15 MC twins with selective IUGR and 18 MC twins without selective IUGR were included in this study. RESULTS The individual F/P ratio in the IUGR twin is significantly higher than that in the appropriate for gestational age (AGA) one in MC twin with selective IUGR (6.4 vs 4.0 respectively, p < 0.001). In MC twin without IUGR, the F/P ratios are not significantly different between the two fetuses (5.4 vs 5.1, respectively). CONCLUSION The high F/P ratio in the IUGR twin in MC with selective IUGR may be due to the placental reserve phenomenon, so that a smaller placental territory may suffice to perfuse the IUGR twin. In other words, in MC twin gestations with an IUGR twin, the fetal weights are not proportional to the placental masses.
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Affiliation(s)
- Yao-Lung Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 5, Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan, ROC.
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Hack KEA, Kaandorp JJ, Derks JB, Elias SG, Pistorius L, Visser GHA. The value of umbilical artery Doppler velocimetry in the antenatal surveillance of uncomplicated monochorionic twin pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 31:662-668. [PMID: 18504772 DOI: 10.1002/uog.5363] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To investigate the predictive value of abnormal umbilical artery Doppler findings on outcome in uncomplicated monochorionic (MC) twin pregnancies. METHODS Sixty-seven MC twin pregnancies, with antenatal care and delivery at the University Medical Center, Utrecht, The Netherlands, between 1999 and 2004, were studied. Pregnancies with antenatal signs of twin-to-twin transfusion syndrome were excluded. We analyzed the data according to both the last Doppler measurement of the umbilical artery before delivery and the presence of any abnormal Doppler measurement during the course of pregnancy. Risks of mortality and total neonatal morbidity were stratified according to the Doppler findings in one or both fetuses at the time of each standard ultrasound assessment in order to estimate the risk associated with an abnormal Doppler finding at or before that specific gestational age. RESULTS Mortality rates were similar in the normal and abnormal Doppler groups. Using both group definitions, total neonatal morbidity was higher in the abnormal Doppler group; this was significant at > 32 weeks' gestation, and was due to lower birth weight and earlier gestational age at delivery. There was no mortality at > or = 36 weeks in the abnormal Doppler group, but there were four perinatal deaths in the normal Doppler group. Gestational age at delivery was significantly lower when one or more abnormal Doppler findings had been present (median, 34 + 1 weeks vs. 36 + 3 weeks) and infants with abnormal Doppler findings weighed on average 261 g (95% CI, 21-502 g) less than those with normal findings. CONCLUSIONS In MC twins, abnormal Doppler flow of the umbilical artery identifies a subgroup at risk for preterm delivery, low birth weight and neonatal morbidity, but with a similar mortality risk to those with normal Doppler flow. At term, mortality occurred only in the group with normal Doppler findings, suggesting that fetal surveillance is insufficient in uncomplicated term MC twin pregnancies.
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Affiliation(s)
- K E A Hack
- Department of Obstetrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.
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Russell Z, Quintero RA, Kontopoulos EV. Intrauterine growth restriction in monochorionic twins. Semin Fetal Neonatal Med 2007; 12:439-49. [PMID: 17761462 DOI: 10.1016/j.siny.2007.06.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Intrauterine growth restriction (IUGR) occurs in approximately 3-10% of singleton pregnancies, in 9.1% of all twins, and in 9.9% of monochorionic twins. Spontaneous demise of the IUGR twin may occur and may result in concomitant demise or severe neurological handicap of the other twin. Currently, monochorionic twins with selective IUGR (SIUGR) are managed expectantly. Alternatively, all adverse consequences resulting from the potential demise of the SIUGR twin could be averted by unlinking the circulations between the two fetuses. The latter can be achieved by laser photocoagulation of communicating vessels or by umbilical-cord occlusion. The purpose of this chapter is to review this important entity in obstetrics.
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Affiliation(s)
- Zoi Russell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, 4 Columbia Drive, Suite 529, Tampa, FL 33606, USA
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Abstract
Any discussion of multiple pregnancy figures prominently in the consideration of the medicolegal aspects of placental pathology. Multiple gestations are common and becoming more so with assisted reproductive techniques, and multiples are associated with a disproportionate share of complications that may result in disputes over quality of care. Higher rates of intrauterine growth retardation, prematurity, stillbirth, morbidity, mortality, cerebral palsy, anomalous development, and malformation as compared with singletons are well documented in multiple pregnancy and should be anticipated. Monochorionic placentation and complications of vascular anastomosis are important factors contributing to poor outcome. Other factors, although occurring in all gestations, are relevant because they are more common in multiple gestations.
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Affiliation(s)
- Deborah J Gersell
- Department of Pathology, St. John's Mercy Medical Center, 615 S. New Ballas Road, St. Louis, MO 63141, USA
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Abstract
Twin-twin transfusion syndrome (TTTS) complicates approximately 1 in 5 of all monochorionic, diamniotic twin pregnancies. If of early onset and untreated, severe TTTS is associated with a dismal prognosis, with perinatal mortality rates exceeding 90%. The most controversial issue regarding the optimal treatment of TTTS has centered on the use of amniocentesis or laser until the first and only randomized trial on interventions for TTTS was published a couple of years ago, comparing laser to amnioreduction. That report confirmed that the laser group had a higher likelihood of the survival of at least one twin to 28 days of age and to 6 months of age. Infants in the laser group also had a lower incidence of cystic periventricular leukomalacia and were more likely to be free of neurologic complications at 6 months of age (52% vs. 31%, p = 0.003). Although not every case of TTTS is an eligible candidate for fetoscopic-guided laser therapy, it is recommended that obstetricians who have the chance to manage TTTS in their daily practice be familiar with the rationale behind this laser treatment for TTTS.
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Affiliation(s)
- Yao-Lung Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Tao-Yuan, Taiwan.
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Twin chorionicity and the risk of adverse perinatal outcome. Int J Gynaecol Obstet 2007; 96:98-102. [DOI: 10.1016/j.ijgo.2006.11.002] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2006] [Revised: 10/29/2006] [Accepted: 11/01/2006] [Indexed: 11/21/2022]
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Cordero L, Franco A, Joy SD, O'shaughnessy RW. Monochorionic diamniotic infants without twin-to-twin transfusion syndrome. J Perinatol 2005; 25:753-8. [PMID: 16281049 DOI: 10.1038/sj.jp.7211405] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Monochorionic-diamniotic twins (MoDi) occur in 0.3% of all pregnancies. Twin-to-twin transfusion syndrome (TTS) that occurs in 20% of MoDi pregnancies is associated with high perinatal morbidity and mortality. MoDi twins without TTS are more frequent (80%) but have been scarcely reported. OBJECTIVE To study perinatal morbidity and mortality of 74 MoDi twin sets without TTS and to compare it to that of 38 sets of MoDi twins with TTS. METHODS Chorionicity was determined by gender and placental examination. Gestational age (GA) was set by sonography and pediatric examination. TTS was diagnosed clinically and by sonography, discordance was defined by twins birth weight difference > or =20%, and fetal growth restriction was determined by using a twin-specific nomogram. RESULTS MoDi twin pregnancies without and with TTS were similar in demographics, live births, history of preeclampsia, fetal distress and cesarean delivery. They were different (p<0.01) in discordant pregnancies (36 and 79%), GA at delivery (32 and 29 weeks) intrauterine growth restriction (39 and 89%) and neonatal mortality (12 and 36%). Concordant (47 sets) and discordant (27 sets) MoDi twins without TTS were clinically similar. CONCLUSIONS MoDi twins without TTS have high rates of birth weight discordance, fetal growth restriction, fetal distress, prematurity and cesarean delivery. Although their perinatal mortality is low, the reported occurrence and the short- and long-term impacts of fetal and neonatal morbidities warrants attention.
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MESH Headings
- Amnion/diagnostic imaging
- Amnion/pathology
- Cause of Death
- Chorion/diagnostic imaging
- Chorion/pathology
- Diseases in Twins/diagnostic imaging
- Diseases in Twins/mortality
- Diseases in Twins/pathology
- Female
- Fetal Distress/diagnostic imaging
- Fetal Distress/mortality
- Fetal Distress/pathology
- Fetal Growth Retardation/diagnostic imaging
- Fetal Growth Retardation/mortality
- Fetal Growth Retardation/pathology
- Fetofetal Transfusion/diagnostic imaging
- Fetofetal Transfusion/mortality
- Fetofetal Transfusion/pathology
- Gestational Age
- Humans
- Infant, Low Birth Weight
- Infant, Newborn
- Infant, Premature, Diseases/diagnostic imaging
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/pathology
- Male
- Placenta/diagnostic imaging
- Placenta/pathology
- Pregnancy
- Risk
- Survival Analysis
- Twins, Dizygotic
- Twins, Monozygotic
- Ultrasonography, Prenatal
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Affiliation(s)
- Leandro Cordero
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics and Obstetrics, College of Medicine and Public Health, The Ohio State University, Columbus, OH 43210-1228, USA
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Abstract
Infertility treatments have produced an increase in multiple gestations with twins accounting for 3.3% of births in the United States in 2002. Over that same time period, premature deliveries increased from 10.7% in 1992 to 12.1% in 2002. High-order multiple gestations have also increased, and virtually all of those deliver prematurely. Clinicians are facing the challenge of managing these complicated pregnancies. Neonatal outcome will primarily depend on the gestational age at delivery and the birth weight of the babies. Care is directed at aggressively and proactively preventing preterm delivery. Ultrasound assessments are made frequently to assess fetal anatomical abnormalities, nuchal translucency, fetal growth, cervical length, amniotic fluid, and biophysical profile. Stress reduction and activity reduction will decrease uterine activity, and tocolytic drugs are employed to decrease background contractions to reduce preterm labor (PTL). Fetal fibronectin testing helps predict risk of PTL, and magnesium sulfate tocolysis is used in aggressive dosing to arrest PTL if it occurs. Outcomes are presented and discussed. Successful outcomes are not only possible, but probable.
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Affiliation(s)
- John P Elliott
- Department of Obstetrics and Gynecology, Banner Good Samaritan Medical Center, Phoenix, AZ 85006, USA.
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Mahieu-Caputo D, Meulemans A, Martinovic J, Gubler MC, Delezoide AL, Muller F, Madelenat P, Fisk NM, Dommergues M. Paradoxic activation of the renin-angiotensin system in twin-twin transfusion syndrome: an explanation for cardiovascular disturbances in the recipient. Pediatr Res 2005; 58:685-8. [PMID: 16189193 DOI: 10.1203/01.pdr.0000180558.03164.e8] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Despite advances in treatment, twin-to-twin transfusion syndrome (TTTS) still carries a high risk for perinatal mortality and morbidity. Simple blood transfer from the donor to the recipient twin cannot explain all of the features of this disease, in particular the recipient's hypertensive cardiomyopathy. We report a case in which TTTS resulted in preterm delivery with early neonatal death of both twins, allowing assessment of the renin angiotensin system (RAS) status of each fetus, both by cord blood renin and aldosterone assay and by renal immunohistochemistry. The donor had severe oliguria/oligohydramnios, whereas the recipient, in addition to severe polyuria/polyhydramnios, had cardiomyopathy, atrioventricular regurgitation, and ascites. Although immunohistochemistry demonstrated that renal secretion of renin was up-regulated in the donor and down-regulated in the recipient, cord blood levels of renin and aldosterone were similar, with high renin levels in both twins. This observation supports the hypothesis that despite renal RAS down-regulation, the recipient is exposed to RAS effectors elaborated in the donor and transferred via placental shunts. This may contribute to cardiomyopathy and hypertension in the recipient, which cannot be accounted for by hypervolemia alone. We thus hypothesized that in TTTS, the recipient's hypertensive cardiomyopathy could be due to a mechanism similar to the classical model of hypertension referred to as "2 kidneys-1 clip." Thus the hypovolemic donor twin, comparable to the clipped kidney, produces vasoactive hormones that compromise the recipient, comparable to the normal kidney, causing hypertension and cardiomyopathy.
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De Paepe ME, DeKoninck P, Friedman RM. Vascular Distribution Patterns in Monochorionic Twin Placentas. Placenta 2005; 26:471-5. [PMID: 15950060 DOI: 10.1016/j.placenta.2004.06.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2004] [Revised: 03/18/2004] [Accepted: 06/29/2004] [Indexed: 10/25/2022]
Abstract
Several recent publications have focused on the association between the occurrence of twin-to-twin transfusion syndrome (TTTS) in diamniotic-monochorionic twins and the presence of a number of selected anatomic placental characteristics (distribution of vascular territory, cord insertion, type and number of inter-twin anastomoses). In contrast, the potential importance of the vascular distribution patterns of the individual twins remains to be elucidated. Based on its gross architectural distribution pattern, chorionic vasculature is traditionally described as disperse, magistral or mixed. The aim of this study was (1) to determine the relative prevalence of these vascular distribution patterns in monochorionic twin placentas, and (2) to correlate these patterns with the presence of TTTS and known anatomic placental features linked to TTTS. The placentas of 89 consecutive diamniotic-monochorionic twins (15 with TTTS, 74 without TTTS), examined at Women and Infants Hospital, were studied. Disperse vascular patterns were seen in 53% of twins, and magistral or mixed patterns in 47%. The prevalence of magistral/mixed vascular patterns was significantly higher in TTTS gestations than in non-TTTS gestations (60% versus 44%, P<0.05) and, in TTTS gestations, much higher in donor twins than in recipient twins (87% versus 33%, P<0.005). A strong association was found between the presence of magistral/mixed patterns and marginal/velamentous cord insertion, low number of inter-twin anastomoses, and uneven distribution of the vascular territories. These findings suggest that the magistral/mixed vascular distribution pattern may represent an important placental architectural feature contributing to the complex pathophysiology of TTTS.
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Affiliation(s)
- M E De Paepe
- Department of Pathology, Women and Infants Hospital and Brown Medical School, 101 Dudley Street, Providence, RI 02905, United States.
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Karageyim Karsidag AY, Kars B, Dansuk R, Api O, Unal O, Turan MC, Goynumer G. Brain Damage to the Survivor within 30 min of Co-Twin Demise in Monochorionic Twins. Fetal Diagn Ther 2005; 20:91-5. [PMID: 15692200 DOI: 10.1159/000082429] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2003] [Accepted: 01/07/2004] [Indexed: 11/19/2022]
Abstract
Single fetal death in a twin pregnancy in the late second or early third trimester is associated with significant morbidity and mortality rate in the surviving co-twin, especially in monochorionic twin pregnancies. The common causes are twin-to-twin transfusion syndrome, chromosomal abnormalities, and congenital anomalies of the fetus or anomalies of the umbilical cord-placenta. Here we report a case of monochorionic twin pregnancy in which one fetus had a single umbilical artery (SUA) while the co-twin had two umbilical arteries. The twin with SUA died in utero at the 30th week of gestation and the other fetus was delivered by cesarean section immediately due to fetal distress diagnosed by cardiotocography. Disseminated intravascular coagulation and multicystic encephalomalacia have been observed in the surviving neonate. This case and review of the literature suggest that neurologic complication rates are also increased in monochorionic twin pregnancies with single fetal demise despite the immediate delivery as in our case.
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Eckert MA, Leonard CM, Molloy EA, Blumenthal J, Zijdenbos A, Giedd JN. The epigenesis of planum temporale asymmetry in twins. Cereb Cortex 2002; 12:749-55. [PMID: 12050086 PMCID: PMC2739006 DOI: 10.1093/cercor/12.7.749] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Variation in hemispheric asymmetry of the planum temporale (PT) has been related to verbal ability. The degree to which genetic and environmental factors mediate PT asymmetry is not known. This study examined the heritability for planar asymmetry in 12 dizygotic (DZ) and 27 monozygotic (MZ) male twin pairs who were between 6 and 16 years of age. There was weak but positive evidence for heritability of planar asymmetry. Co-twin similarity for planar asymmetry and Sylvian fissure morphology increased when excluding twins discordant for writing hand and when excluding twins exhibiting birth weight differences >20% from the analyses. Birth weight differences were also related to twin differences in total cerebral volume, but not central sulcus asymmetry. These results suggest that exogenous perinatal factors affect the epigenesis of planar asymmetry development.
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Affiliation(s)
- Mark A Eckert
- Department of Neuroscience, McKnight Brain Institute of the University of Florida, Gainesville, FL 32610, USA.
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