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Khalil A, Prasad S, Woolfall K, Mitchell TK, Kirkham JJ, Yaghi O, Ricketts T, Attilakos G, Bailie C, Cornforth C, Denbow M, Hardman L, Harrold J, Parasuraman R, Leven S, Marsden J, Mendoza J, Mousa T, Nanda S, Thilaganathan B, Turner M, Watson M, Wilding K, Popa M, Alfirevic Z, Anumba D, Ashcroft RE, Baschet A, da Silva Costa F, Deprest J, Fenwick N, Haak MC, Healey A, Hecher K, Impey L, Jackson RJ, Johnstone ED, Lewi L, Lopriore E, Papageorghiou AT, Pasupathy D, Sandall J, Sharp A, Thangaratinam S, Vollmer B, Yinon Y. FERN: is it possible to conduct a randomised controlled trial of intervention or expectant management for early-onset selective fetal growth restriction in monochorionic twin pregnancy - protocol for a prospective multicentre mixed-methods feasibility study. BMJ Open 2024; 14:e080021. [PMID: 39153765 PMCID: PMC11331819 DOI: 10.1136/bmjopen-2023-080021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 05/30/2024] [Indexed: 08/19/2024] Open
Abstract
INTRODUCTION Selective fetal growth restriction (sFGR) in monochorionic twin pregnancy, defined as an estimated fetal weight (EFW) of one twin <10th centile and EFW discordance ≥25%, is associated with stillbirth and neurodisability for both twins. The condition poses unique management difficulties: on the one hand, continuation of the pregnancy carries a risk of death of the smaller twin, with a high risk of co-twin demise (40%) or co-twin neurological sequelae (30%). On the other, early delivery to prevent the death of the smaller twin may expose the larger twin to prematurity, with the associated risks of long-term physical, emotional and financial costs from neurodisability, such as cerebral palsy.When there is severe and early sFGR, before viability, delivery is not an option. In this scenario, there are currently three main management options: (1) expectant management, (2) selective termination of the smaller twin and (3) placental laser photocoagulation of interconnecting vessels. These management options have never been investigated in a randomised controlled trial (RCT). The best management option is unknown, and there are many challenges for a potential RCT. These include the rarity of the condition resulting in a small number of eligible pregnancies, uncertainty about whether pregnant women will agree to participate in such a trial and whether they will agree to be randomised to expectant management or active fetal intervention, and the challenges of robust and long-term outcome measures. Therefore, the main objective of the FERN study is to assess the feasibility of conducting an RCT of active intervention vs expectant management in monochorionic twin pregnancies with early-onset (prior to 24 weeks) sFGR. METHODS AND ANALYSIS The FERN study is a prospective mixed-methods feasibility study. The primary objective is to recommend whether an RCT of intervention vs expectant management of sFGR in monochorionic twin pregnancy is feasible by exploring women's preference, clinician's preference, current practice and equipoise and numbers of cases. To achieve this, we propose three distinct work packages (WPs). WP1: A Prospective UK Multicentre Study, WP2A: a Qualitative Study Exploring Parents' and Clinicians' Views and WP3: a Consensus Development to Determine Feasibility of a Trial. Eligible pregnancies will be recruited to WP1 and WP2, which will run concurrently. The results of these two WPs will be used in WP3 to develop consensus on a future definitive study. The duration of the study will be 53 months, composed of 10 months of setup, 39 months of recruitment, 42 months of data collection, and 5 months of data analysis, report writing and recommendations. The pragmatic sample size for WP1 is 100 monochorionic twin pregnancies with sFGR. For WP2, interviews will be conducted until data saturation and sample variance are achieved, that is, when no new major themes are being discovered. Based on previous similar pilot studies, this is anticipated to be approximately 15-25 interviews in both the parent and clinician groups. Engagement of at least 50 UK clinicians is planned for WP3. ETHICS AND DISSEMINATION This study has received ethical approval from the Health Research Authority (HRA) South West-Cornwall and Plymouth Ethics Committee (REC reference 20/SW/0156, IRAS ID 286337). All participating sites will undergo site-specific approvals for assessment of capacity and capability by the HRA. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. The results from the FERN project will be used to inform future studies. TRIAL REGISTRATION NUMBER This study is included in the ISRCTN Registry (ISRCTN16879394) and the NIHR Central Portfolio Management System (CPMS), CRN: Reproductive Health and Childbirth Specialty (UKCRN reference 47201).
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Affiliation(s)
- Asma Khalil
- Fetal Medicine Unit, St George's University Hospital, London, UK
- Fetal Medicine Unit, Liverpool Women’s Hospital, University of Liverpool, Liverpool, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Smriti Prasad
- Fetal Medicine Unit, St George's University Hospital, London, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Tracy Karen Mitchell
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Jamie J Kirkham
- Centre for Biostatistics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Odai Yaghi
- Fetal Medicine Unit, St George's University Hospital, London, UK
| | - Tracey Ricketts
- Department of Women’s and Children’s Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | - George Attilakos
- Women's Health Division, University College London Hospitals NHS Foundation Trust, Institute for Women's Health, University College London, London, UK
| | | | - Christine Cornforth
- Department of Women’s and Children’s Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | - Mark Denbow
- Fetal Medicine Unit, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Jane Harrold
- Department of Women’s and Children’s Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | - Rajeswari Parasuraman
- Wessex Fetal Maternal Medicine unit, University Southampton NHS Foundation Trust, Princess Anne Hospital, Southampton, UK
| | | | | | | | | | | | | | - Mark Turner
- Department of Women’s and Children’s Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | | | - Karen Wilding
- Clinical Directorate, Faulty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Mariana Popa
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Zarko Alfirevic
- Department of Women’s and Children’s Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | - Dilly Anumba
- Academic Unit of Reproductive and Developmental Medicine, Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | | | - Ahmet Baschet
- Johns Hopkins Center for Fetal Therapy Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Fabrício da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Jan Deprest
- Fetal Medicine Unit, Dept. Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Dept of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | | | - Monique C Haak
- Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Netherlands
| | - Andy Healey
- King's Health Economics, Health Service, and Population Research Department, King's College London, London, UK
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lawrence Impey
- Department of Fetal Medicine, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard J Jackson
- Department of Statistics, Liverpool Clinical Trials Unit, University of Liverpool, Liverpool, UK
| | - Edward D Johnstone
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester, UK
| | - Liesbeth Lewi
- Fetal Medicine Unit, Dept. Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Dept of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Enrico Lopriore
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Aris T Papageorghiou
- Fetal Medicine Unit, St George's University Hospital, London, UK
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, UK
| | - Dharmintra Pasupathy
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jane Sandall
- Division of Women's Health, Women's Health Academic Centre, King's College, London, St. Thomas' Hospital, London, UK
| | - Andrew Sharp
- Department of Women’s and Children’s Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women’s Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - Brigitte Vollmer
- Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan 52621, Israel
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Xia S, Ye Y, Liu J, Qiu H, Lin M, He Z, Huang L, Wang M, Luo Y. The Role of MALAT1 in Regulating the Proangiogenic Functions, Invasion, and Migration of Trophoblasts in Selective Fetal Growth Restriction. Biomolecules 2024; 14:988. [PMID: 39199376 PMCID: PMC11352967 DOI: 10.3390/biom14080988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 08/01/2024] [Accepted: 08/09/2024] [Indexed: 09/01/2024] Open
Abstract
Epigenetic regulation is an important entry point to study the pathogenesis of selective fetal growth restriction (sFGR), and an understanding of the role of long noncoding RNAs (lncRNAs) in sFGR is lacking. Our study aimed to investigate the potential role of a lncRNA, metastasis-associated lung adenocarcinoma transcript 1 (MALAT1), in sFGR using molecular biology experiments and gain- or loss-of-function assays. We found that the levels of MALAT1, ERRγ, and HSD17B1 were downregulated and that of miR-424 was upregulated in the placental shares of the smaller twins. Moreover, angiogenesis was impaired in the placental share of the smaller fetus and MALAT1 could regulate the paracrine effects of trophoblasts on endothelium angiogenesis and proliferation by regulating miR-424. In trophoblasts, MALAT1 could competitively bind to miR-424 to regulate the expression of ERRγ and HSD17B1, thus regulating trophoblast invasion and migration. MALAT1 overexpression could decrease apoptosis and promote proliferation, alleviating cell damage induced by hypoxia. Taken together, the downregulation of MALAT1 can reduce the expression of ERRγ and HSD17B1 by competitively binding to miR-424, impairing the proangiogenic effect of trophoblasts, trophoblast invasion and migration, and the ability of trophoblasts to compensate for hypoxia, which may be involved in the pathogenesis of sFGR through various aspects.
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Affiliation(s)
- Shuting Xia
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China; (S.X.); (Y.Y.); (J.L.); (H.Q.); (M.L.); (Z.H.); (L.H.); (M.W.)
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou 510080, China
| | - Yingnan Ye
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China; (S.X.); (Y.Y.); (J.L.); (H.Q.); (M.L.); (Z.H.); (L.H.); (M.W.)
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou 510080, China
| | - Jialiu Liu
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China; (S.X.); (Y.Y.); (J.L.); (H.Q.); (M.L.); (Z.H.); (L.H.); (M.W.)
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou 510080, China
| | - Hanfei Qiu
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China; (S.X.); (Y.Y.); (J.L.); (H.Q.); (M.L.); (Z.H.); (L.H.); (M.W.)
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou 510080, China
| | - Minhuan Lin
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China; (S.X.); (Y.Y.); (J.L.); (H.Q.); (M.L.); (Z.H.); (L.H.); (M.W.)
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou 510080, China
| | - Zhiming He
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China; (S.X.); (Y.Y.); (J.L.); (H.Q.); (M.L.); (Z.H.); (L.H.); (M.W.)
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou 510080, China
| | - Linhuan Huang
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China; (S.X.); (Y.Y.); (J.L.); (H.Q.); (M.L.); (Z.H.); (L.H.); (M.W.)
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou 510080, China
| | - Malie Wang
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China; (S.X.); (Y.Y.); (J.L.); (H.Q.); (M.L.); (Z.H.); (L.H.); (M.W.)
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou 510080, China
| | - Yanmin Luo
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China; (S.X.); (Y.Y.); (J.L.); (H.Q.); (M.L.); (Z.H.); (L.H.); (M.W.)
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou 510080, China
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Mitchell TK, Popa M, Ashcroft RE, Prasad S, Sharp A, Carnforth C, Turner M, Khalil A, Fenwick N, Leven S, Woolfall K. Balancing key stakeholder priorities and ethical principles to design a trial comparing intervention or expectant management for early-onset selective fetal growth restriction in monochorionic twin pregnancy: FERN qualitative study. BMJ Open 2024; 14:e080488. [PMID: 39122401 PMCID: PMC11331883 DOI: 10.1136/bmjopen-2023-080488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 07/16/2024] [Indexed: 08/12/2024] Open
Abstract
OBJECTIVES As part of the FERN feasibility study, this qualitative research aimed to explore parents' and clinicians' views on the acceptability, feasibility and design of a randomised controlled trial (RCT) of active intervention versus expectant management in monochorionic (MC) diamniotic twin pregnancies with early-onset (prior to 24 weeks) selective fetal growth restriction (sFGR). Interventions could include laser treatment or selective termination which could lead to the death or serious disability of one or both twins. DESIGN Qualitative semi-structured interviews with parents and clinicians. Data were analysed using reflexive thematic analysis and considered against the Principles of Biomedical Ethics. PARTICIPANTS AND SETTING We interviewed 19 UK parents experiencing (six mothers, two partners) or had recently experienced (eight mothers, three partners) early-onset sFGR in MC twin pregnancy and 14 specialist clinicians from the UK and Europe. RESULTS Participants viewed the proposed RCT as 'ethically murky' because they believed that the management of sFGR in MC twin pregnancy should be individualised according to the type and severity of sFGR. Clinicians prioritised the gestational age, size, decrease in growth velocity, access to the placental vessels and acceptability of intervention for parents. Discussions and decision-making about selective termination appeared to cause long-term harm (maleficence). The most important outcome for parents and clinicians was 'live birth'. For clinicians, this was the live birth of at least one twin. For parents, this meant the live birth of both twins, even if this meant that their babies had neurodevelopmental impairment or disabilities. CONCLUSIONS All three pregnancy management approaches for sFGR in MC twin pregnancy carry risks and benefits, and the ultimate goal for parents is to receive individualised care to achieve the best possible outcome for both twins. An RCT was not acceptable to parents or clinicians or seen as ethically appropriate. Alternative study designs should be considered to answer this important research question.
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Affiliation(s)
| | - Mariana Popa
- Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | | | - Smriti Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Andrew Sharp
- Department of Women’s and Children’s Health, University of Liverpool, Liverpool, UK
| | - Christine Carnforth
- Clinical Directorate Professional Services, University of Liverpool, Liverpool, UK
| | - Mark Turner
- Department of Women’s and Children’s Health, University of Liverpool, Liverpool, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Natasha Fenwick
- Research and Resources Officer, Twins Trust, London, Hampshire, UK
| | | | - The FERN study team
- Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
- School of Law, City University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Department of Women’s and Children’s Health, University of Liverpool, Liverpool, UK
- Clinical Directorate Professional Services, University of Liverpool, Liverpool, UK
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Research and Resources Officer, Twins Trust, London, Hampshire, UK
- Twins Trust, Woking, Surrey, UK
| | - Kerry Woolfall
- Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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Prasad S, Khalil A, Kirkham JJ, Sharp A, Woolfall K, Mitchell TK, Yaghi O, Ricketts T, Popa M, Alfirevic Z, Anumba D, Ashcroft R, Attilakos G, Bailie C, Baschat AA, Cornforth C, Costa FDS, Denbow M, Deprest J, Fenwick N, Haak MC, Hardman L, Harrold J, Healey A, Hecher K, Parasuraman R, Impey L, Jackson R, Johnstone E, Leven S, Lewi L, Lopriore E, Oconnor I, Harding D, Marsden J, Mendoza J, Mousa T, Nanda S, Papageorghiou AT, Pasupathy D, Sandall J, Thangaratinam S, Thilaganathan B, Turner M, Vollmer B, Watson M, Wilding K, Yinon Y. Diagnosis and management of selective fetal growth restriction in monochorionic twin pregnancies: A cross-sectional international survey. BJOG 2024. [PMID: 38956742 DOI: 10.1111/1471-0528.17891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/25/2024] [Accepted: 06/02/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVE To identify current practices in the management of selective fetal growth restriction (sFGR) in monochorionic diamniotic (MCDA) twin pregnancies. DESIGN Cross-sectional survey. SETTING International. POPULATION Clinicians involved in the management of MCDA twin pregnancies with sFGR. METHODS A structured, self-administered survey. MAIN OUTCOME MEASURES Clinical practices and attitudes to diagnostic criteria and management strategies. RESULTS Overall, 62.8% (113/180) of clinicians completed the survey; of which, 66.4% (75/113) of the respondents reported that they would use an estimated fetal weight (EFW) of <10th centile for the smaller twin and an inter-twin EFW discordance of >25% for the diagnosis of sFGR. For early-onset type I sFGR, 79.8% (75/94) of respondents expressed that expectant management would be their routine practice. On the other hand, for early-onset type II and type III sFGR, 19.3% (17/88) and 35.7% (30/84) of respondents would manage these pregnancies expectantly, whereas 71.6% (63/88) and 57.1% (48/84) would refer these pregnancies to a fetal intervention centre or would offer fetal intervention for type II and type III cases, respectively. Moreover, 39.0% (16/41) of the respondents would consider fetoscopic laser surgery (FLS) for early-onset type I sFGR, whereas 41.5% (17/41) would offer either FLS or selective feticide, and 12.2% (5/41) would exclusively offer selective feticide. For early-onset type II and type III sFGR cases, 25.9% (21/81) and 31.4% (22/70) would exclusively offer FLS, respectively, whereas 33.3% (27/81) and 32.9% (23/70) would exclusively offer selective feticide. CONCLUSIONS There is significant variation in clinician practices and attitudes towards the management of early-onset sFGR in MCDA twin pregnancies, especially for type II and type III cases, highlighting the need for high-level evidence to guide management.
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Affiliation(s)
- Smriti Prasad
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
| | - Jamie J Kirkham
- Centre for Biostatistics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Andrew Sharp
- Department of Women's and Children's Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Tracy Karen Mitchell
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Odai Yaghi
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Tracey Ricketts
- Department of Women's and Children's Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | - Mariana Popa
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Zarko Alfirevic
- Department of Women's and Children's Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | - Dilly Anumba
- Academic Unit of Reproductive and Developmental Medicine, Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | | | - George Attilakos
- Women's Health Division, University College London Hospitals NHS Foundation Trust, London, UK
- Institute for Women's Health, University College London, London, UK
| | - Carolyn Bailie
- Fetal Medicine Unit, Royal Jubilee Maternity Hospital, Belfast, UK
| | - Ahmet A Baschat
- Department of Gynecology & Obstetrics, Johns Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine Cornforth
- Department of Women's and Children's Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | - Fabricio Da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Mark Denbow
- Fetal Medicine Unit, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Jan Deprest
- Fetal Medicine Unit, Department Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | | | - Monique C Haak
- Fetal Medicine Unit, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jane Harrold
- Department of Women's and Children's Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | - Andy Healey
- King's Health Economics, Health Service and Population Research Department, King's College London, London, UK
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rajeswari Parasuraman
- Wessex Fetal Maternal Medicine Unit, University Southampton NHS Foundation Trust, Princess Anne Hospital, Southampton, UK
| | - Lawrence Impey
- Department of Fetal Medicine, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Jackson
- Department of Statistics, Liverpool Clinical Trials Unit, University of Liverpool, Liverpool, UK
| | - Edward Johnstone
- Division of Developmental Biology and Medicine, Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester, UK
| | | | - Liesbeth Lewi
- Fetal Medicine Unit, Department Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Enrico Lopriore
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Isabella Oconnor
- PPIE, FERN project, Harris Wellbeing of Women Research Centre, University of Liverpool, UK
| | - Danielle Harding
- PPIE, FERN project, Harris Wellbeing of Women Research Centre, University of Liverpool, UK
| | - Joel Marsden
- PPIE, FERN project, Harris Wellbeing of Women Research Centre, University of Liverpool, UK
| | - Jessica Mendoza
- PPIE, FERN project, Harris Wellbeing of Women Research Centre, University of Liverpool, UK
| | - Tommy Mousa
- Maternal and Fetal Medicine Unit, University of Leicester, Leicester, UK
| | - Surabhi Nanda
- Fetal Medicine Unit, Guy's and St Thomas's Hospital, Evelina London Children's Hospital, King's College London, London, UK
| | - Aris T Papageorghiou
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Dharmintra Pasupathy
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jane Sandall
- Division of Women's Health, King's College London, Women's Health Academic Centre, King's Health Partners, London, UK
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Baskaran Thilaganathan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mark Turner
- Department of Women's and Children's Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK
| | - Brigitte Vollmer
- Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton Children's Hospital, Southampton, UK
| | - Michelle Watson
- PPIE, FERN project, Harris Wellbeing of Women Research Centre, University of Liverpool, UK
| | - Karen Wilding
- Clinical Directorate, Faulty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Yoav Yinon
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel
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Yamamoto R, Ozawa K, Wada S, Sago H, Nagasaki S, Takano M, Nakata M, Nozaki M, Ishii K. Infant outcome at 3 years of age of monochorionic twins with Type-II or -III selective fetal growth restriction and isolated oligohydramnios that underwent fetoscopic laser photocoagulation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:758-763. [PMID: 38031151 DOI: 10.1002/uog.27551] [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: 07/18/2023] [Revised: 10/17/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE To examine infant outcomes at 3 years of age in monochorionic twin pregnancies with Type-II or -III selective fetal growth restriction (sFGR) and isolated oligohydramnios who underwent fetoscopic laser photocoagulation (FLP). METHODS This multicenter prospective cohort study included monochorionic diamniotic twins that underwent FLP for sFGR between 16 and 25 weeks' gestation. The indication for performing FLP was Type-II or -III sFGR with oligohydramnios of the growth-restricted (FGR) twin in which the maximum vertical pocket of amniotic fluid was ≤ 2 cm. This was done in the absence of a typical diagnosis of twin-twin transfusion syndrome. The primary outcome was intact survival rate of both infants at the corrected gestational age of 40 weeks and at 3 years of age. Intact survival at the corrected age of 40 weeks was defined as survival without Grade-III or -IV intraventricular hemorrhage or cystic periventricular leukomalacia. Intact survival at 3 years of age was defined as survival without neurodevelopmental morbidity, which included cerebral palsy, neurodevelopmental impairment with a total developmental quotient of < 70, bilateral deafness or bilateral blindness. RESULTS Among 45 patients with sFGR, 30 (66.7%) were classified as having Type-II and 15 (33.3%) as Type-III sFGR. The prevalence of intact survival at the corrected age of 40 weeks was 51.1% (n = 23) in FGR twins and 95.5% (n = 42) in larger twins. The prevalence of intact survival at 3 years of age was 46.7% (n = 21) in FGR twins and 86.4% (n = 38) in larger twins. There was one case of miscarriage. Among the 24 FGR twins who were not classified as having intact survival at 3 years of age, 22 (91.7%) cases suffered fetal or infant demise (other than miscarriage), and there was one case of neurodevelopmental impairment. All larger twins who were not diagnosed with intact survival at 3 years of age (n = 6 (13.6%)) had neurological morbidity. CONCLUSIONS FGR twins and their larger cotwins, when subjected to FLP owing to sFGR coupled with umbilical artery Doppler abnormalities and isolated oligohydramnios, exhibit low rates of neurological morbidity and low mortality, respectively. Therefore, FLP for Type-II or -III sFGR with oligohydramnios may be a feasible management option and one that is preferable to expectant management. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - K Ozawa
- National Center for Child Health and Development, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Tokyo, Japan
| | - S Wada
- National Center for Child Health and Development, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Tokyo, Japan
| | - H Sago
- National Center for Child Health and Development, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Tokyo, Japan
| | - S Nagasaki
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - M Takano
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - M Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - M Nozaki
- Department of Neonatology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - K Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
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D'Antonio F, Khalil A. Reply. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:708. [PMID: 38695212 DOI: 10.1002/uog.27656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/01/2024] [Indexed: 06/22/2024]
Affiliation(s)
- F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - 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
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
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Qiu T, Guo Y, Cheng W, Chen Y, Shen H, Xu L. Outcome of monochorionic diamniotic twin pregnancy with selective intrauterine growth restriction, a single center study in China. Clin Imaging 2024; 106:110032. [PMID: 38042047 DOI: 10.1016/j.clinimag.2023.110032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 11/12/2023] [Accepted: 11/19/2023] [Indexed: 12/04/2023]
Abstract
INTRODUCTION This retrospective study aimed to evaluate clinical outcomes of monochorionic diamniotic (MCDA) twins with selective intrauterine growth restriction (sIUGR). MATERIALS AND METHODS MCDA twins, either sIUGR and non-sIUGR, underwent expectant management from 2016 to 2019 in our hospital were included. sIUGR fetuses were classified into three types according to umbilical artery Doppler assessment. Non-sIUGR were considered as the control group. Outcomes were pregnancy outcomes and maternal complications. RESULTS Forty-three sIUGR (type I: 23; type II: 14, and type III: 6) and 282 non-sIUGR fetuses were included. The sIUGR group had a significantly earlier birth, lower birth weight of the twins, larger inter-twin weight difference, lower Apgar score of the twins, and higher intrauterine fetal death (IUFD) than the non-sIUGR group (all p < 0.001). The same trend was found in the sIUGR type II group compared to type I and III groups. A significantly lower gestational diabetes rate (p = 0.01) and placenta weight (p < 0.001), and higher proportions of abnormal placental umbilical cord insertion (p < 0.001), and ultrasound Doppler monitoring indicators (p = 0.006) were found in the sIUGR group than the non-sIUGR group. CONCLUSIONS The MCDA twins with sIUGR showed poorer outcomes than the non-sIUGR group. Doppler interrogation was a useful clinical marker for fetal outcome.
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Affiliation(s)
- Tian Qiu
- Department of Obstetrics and Gynecology, The Sixth People's Hospital of Shanghai Affiliated to Shanghai Jiao Tong University, 600 Yishan Road, Shanghai 200233, China
| | - Yuna Guo
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital Affiliated to Shanghai Jiao Tong University, 910 Hengshan Road, Shanghai 200030, China
| | - Weiwei Cheng
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital Affiliated to Shanghai Jiao Tong University, 910 Hengshan Road, Shanghai 200030, China
| | - Yan Chen
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital Affiliated to Shanghai Jiao Tong University, 910 Hengshan Road, Shanghai 200030, China
| | - Hong Shen
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital Affiliated to Shanghai Jiao Tong University, 910 Hengshan Road, Shanghai 200030, China
| | - Liang Xu
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital Affiliated to Shanghai Jiao Tong University, 910 Hengshan Road, Shanghai 200030, China.
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D'antonio F, Prasad S, Masciullo L, Eltaweel N, Khalil A. Selective fetal growth restriction in dichorionic diamniotic twin pregnancy: systematic review and meta-analysis of pregnancy and perinatal outcomes. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:164-172. [PMID: 37519089 DOI: 10.1002/uog.26302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/27/2023] [Accepted: 06/05/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE Most of the published literature on selective fetal growth restriction (sFGR) has focused on monochorionic twin pregnancies. The aim of this systematic review was to report on the outcome of dichorionic diamniotic (DCDA) twin pregnancies complicated by sFGR. METHODS MEDLINE, EMBASE and The Cochrane Library databases were searched. The inclusion criteria were DCDA twin pregnancies complicated by sFGR. The outcomes explored were intrauterine death (IUD), neonatal death and perinatal death (PND), survival of at least one and both twins, preterm birth (PTB) (either spontaneous or iatrogenic) prior to 37, 34, 32 and 28 weeks' gestation, pre-eclampsia (PE) or gestational hypertension, neurological, respiratory and infectious morbidity, Apgar score < 7 at 5 min, necrotizing enterocolitis, retinopathy of prematurity and admission to the neonatal intensive care unit (NICU). A composite outcome of neonatal morbidity, defined as the occurrence of respiratory, neurological or infectious morbidity, was also evaluated. Random-effects meta-analysis was used to analyze the data, and results are reported as pooled proportion or odds ratio (OR) with 95% CI. RESULTS Thirteen studies reporting on 1339 pregnancies with sFGR and 6316 pregnancies without sFGR were included. IUD occurred in 2.6% (95% CI, 1.1-4.7%) of fetuses from DCDA pregnancies with sFGR and 0.6% (95% CI, 0.3-9.7%) of those from DCDA pregnancies without sFGR, while the respective values for PND were 5.2% (95% CI, 3.5-7.3%) and 1.7% (95% CI, 0.1-5.7%). Spontaneous or iatrogenic PTB before 37 weeks complicated 84.1% (95% CI, 55.6-99.2%) of pregnancies with sFGR and 69.1% (95% CI, 45.4-88.4%) of those without sFGR. The respective values for PTB before 34, 32 and 28 weeks were 18.4% (95% CI, 4.4-38.9%), 13.0% (95% CI, 9.5-17.1%) and 1.5% (95% CI, 0.6-2.3%) in pregnancies with sFGR and 10.2% (95% CI, 3.1-20.7%), 7.8% (95% CI, 6.8-9.0%) and 1.8% (95% CI, 1.3-2.4%) in those without sFGR. PE or gestational hypertension complicated 19.9% (95% CI, 12.4-28.6%) of pregnancies with sFGR and 12.8% (95% CI, 10.4-15.4%) of those without sFGR. Composite morbidity occurred in 28.2% (95% CI, 7.8-55.1%) of fetuses from pregnancies with sFGR and 13.9% (95% CI, 6.5-23.5%) of those from pregnancies without sFGR. When stratified according to the sFGR status within a twin pair, composite morbidity occurred in 39.0% (95% CI, 11.1-71.5%) of growth-restricted fetuses and 29.9% (95% CI, 3.5-65.0%) of appropriately grown fetuses (OR, 1.9 (95% CI, 1.7-3.1)), while the respective values for PND were 3.0% (95% CI, 1.8-4.5%) and 1.6% (95% CI, 0.9-2.6%) (OR, 2.1 (95% CI, 1.0-4.1)). On risk analysis, DCDA pregnancies complicated by sFGR had a significantly higher risk of IUD (OR, 5.2 (95% CI, 3.2-8.6)) and composite morbidity or admission to the NICU (OR, 3.2 (95% CI, 1.9-5.6)) compared to those without sFGR, while there was no difference in the risk of PTB before 34 weeks (P = 0.220) or PE/gestational hypertension (P = 0.210). CONCLUSIONS DCDA twin pregnancies complicated by sFGR are at high risk of perinatal morbidity and mortality. The findings of this systematic review are relevant for counseling and management of complicated DCDA twin pregnancies, in which twin-specific, rather than singleton, outcome data should be used. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F D'antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - S Prasad
- 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
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London, UK
| | - L Masciullo
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London, UK
| | - N Eltaweel
- Division of Biomedical Science, Warwick Medical School, University of Warwick, University Hospital of Coventry and Warwickshire, Coventry, 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
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
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Paiva TM, Santana EF, Casati MF, Araujo Júnior E. Neurological morbidity in monochorionic twins with selective fetal growth restriction. Minerva Obstet Gynecol 2023; 75:565-572. [PMID: 35758094 DOI: 10.23736/s2724-606x.22.05068-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The increased risks of various obstetric, maternal and fetal comorbidities of monochorionic twin pregnancies are widely known. However, despite its high prevalence and significance, the assessment of neurological morbidity as more commonly in selective fetal growth restriction (sFGR) is concerned with more health care. This literature review aims to provide more information about such an assessment. To this end, retrospective cases of sFGR were studied in monochorionic twins, already diagnosed, classified and who had the recommended management, published between 2001 and 2018 in 17 scientific articles. In the assessment of fetal mortality, the highest risk of death of the restricted fetus was found in type 3 of sFGR, while type 2 sFGR was responsible for the highest death rates of both fetuses and also the lowest mean gestational age at delivery, 30.9 weeks. Regarding neurological morbidity, however, studies have shown a higher risk of brain damage in the habitually growing twin compared to the restricted one in the case of sFGR. This may be due to prematurity or intermittent diastolic flow on Doppler in type 2 and 3 of sFGR, however, statements about its pathophysiology still lack further studies.
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Affiliation(s)
| | - Eduardo F Santana
- Albert Einstein Medical School, São Paulo, Brazil
- Unit of Fetal Medicine, Albert Einstein Hospital, São Paulo, Brazil
| | - Murilo F Casati
- Department of Obstetrics and Gynecology, ABC Medical School (FMABC), Santo André, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil -
- Municipal University of São Caetano do Sul (USCS), Bela Vista Campus, São Paulo, Brazil
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10
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Shanahan MA, Bebbington MW. Monochorionic Twins: TTTS, TAPS, and Selective Fetal Growth Restriction. Clin Obstet Gynecol 2023; 66:825-840. [PMID: 37910135 DOI: 10.1097/grf.0000000000000821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
With an increasing incidence of twin gestations, understanding the inherent risks associated with these pregnancies is essential in modern obstetrics. The unique differences in placentation in monochorionic twins leads to unique complications, including twin-to-twin transfusion syndrome, the twin anemia-polycythemia sequence, and selective fetal growth restriction. Not only does the understanding of the monochorionic placenta lead to an understanding of the pathophysiology of the complications of monochorionic twins, but it also has led to the development of highly effective directed fetal therapy via fetoscopic laser coagulation used in twin-to-twin transfusion syndrome.
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Affiliation(s)
- Matthew A Shanahan
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston
| | - Michael W Bebbington
- Department of Women's Health, Comprehensive Fetal Care Center, University of Texas at Austin, Dell Medical School, Austin, Texas
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Lin Z, Wang X, Li L, Yuan P, Zhao Y, Wei Y. A study on the correlation of placental anastomosis and superficial vascular branches of selective fetal growth restriction in monochorionic diamniotic twins. BMC Pregnancy Childbirth 2023; 23:827. [PMID: 38037010 PMCID: PMC10691090 DOI: 10.1186/s12884-023-06157-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 11/24/2023] [Indexed: 12/02/2023] Open
Abstract
INTRODUCTION The main purpose of the present study was to investigate the correlation between placental anastomosis and superficial vascular branches in selective fetal growth restriction (sFGR) in monochorionic diamniotic twins. MATERIALS AND METHODS This was a retrospective analysis of the pregnancy data and placental perfusion of 395 patients with monochorionic diamniotic (MCDA) twin pregnancies delivered at our hospital from April 2013 to April 2020. We divided the patients into two groups and compared the number of placental superficial vascular branches in sFGR twins and normal MCDA twins. The correlation between the placental anastomosis and the number of superficial vascular branches in sFGR and normal MCDA twins was also investigated. RESULTS The number of umbilical arterial branches and umbilical venous branches was less than larger twins in sFGR, larger twins in normal MCDA and smaller twins in normal MCDA. (11.83 [4-44], 21.82 [7-50], 19.72 [3-38], 14.85 [0-31], p < 0.001, 6.08 [1-18], 9.60 [3-22], 9.96 [2-22], 8.38 [1-20], p < 0.00) For smaller twins in the sFGR group, the number of umbilical venous branches was positively associated with AA anastomosis overall diameter, AV anastomosis overall diameter and all anastomosis overall diameter. (r = 0.194, 0.182 and 0.211, p < 0.05) CONCLUSIONS: The risk of sFGR may arise when the placenta from MCDA twins shows a poor branching condition of placental superficial vessels. For the smaller twin of sFGR, regular ultrasound examination of the number of the umbilical venous branches may help to predict artery-to-artery (AA) overall diameter, artery-to-vein (AV) overall diameter and all anastomosis overall diameter.
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Affiliation(s)
- Zhiman Lin
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing, 100191, China
| | - Xueju Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing, 100191, China.
| | - Luyao Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing, 100191, China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing, 100191, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing, 100191, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing, 100191, China
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12
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Huang N, Chen W, Jiang H, Yang J, Zhang Y, Shi H, Wang Y, Yuan P, Qiao J, Wei Y, Zhao Y. Metabolic dynamics and prediction of sFGR and adverse fetal outcomes: a prospective longitudinal cohort study. BMC Med 2023; 21:455. [PMID: 37996847 PMCID: PMC10666385 DOI: 10.1186/s12916-023-03134-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Selective fetal growth restriction (sFGR) is an extreme complication that significantly increases the risk of perinatal mortality and long-term adverse neurological outcomes in offspring, affecting approximately 15% of monochorionic diamniotic (MCDA) twin pregnancies. The lack of longitudinal cohort studies hinders the early prediction and intervention of sFGR. METHODS We constructed a prospective longitudinal cohort study of sFGR, and quantified 25 key metabolites in 337 samples from maternal plasma in the first, second, and third trimester and from cord plasma. In particular, our study examined fetal growth and brain injury data from ultrasonography and used the Ages and Stages Questionnaire-third edition subscale (ASQ-3) to evaluate the long-term neurocognitive behavioral development of infants aged 2-3 years. Furthermore, we correlated metabolite levels with ultrasound data, including physical development and brain injury indicators, and ASQ-3 data using Spearman's-based correlation tests. In addition, special combinations of differential metabolites were used to construct predictive models for the occurrence of sFGR and fetal brain injury. RESULTS Our findings revealed various dynamic patterns for these metabolites during pregnancy and a maximum of differential metabolites between sFGR and MCDA in the second trimester (n = 8). The combination of L-phenylalanine, L-leucine, and L-isoleucine in the second trimester, which were closely related to fetal growth indicators, was highly predictive of sFGR occurrence (area under the curve [AUC]: 0.878). The combination of L-serine, L-histidine, and L-arginine in the first trimester and creatinine in the second trimester was correlated with long-term neurocognitive behavioral development and showed the capacity to identify fetal brain injury with high accuracy (AUC: 0.94). CONCLUSIONS The performance of maternal plasma metabolites from the first and second trimester is superior to those from the third trimester and cord plasma in discerning sFGR and fetal brain injury. These metabolites may serve as useful biomarkers for early prediction and promising targets for early intervention in clinical settings.
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Affiliation(s)
- Nana Huang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Wei Chen
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China
| | - Hai Jiang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Jing Yang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Youzhen Zhang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Huifeng Shi
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Ying Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Jie Qiao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China.
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, China.
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China.
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, China.
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China.
- State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China.
- Beijing Advanced Innovation Center for Genomics, Beijing, China.
- Peking-Tsinghua Center for Life Sciences, Peking University, Beijing, China.
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China.
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, China.
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China.
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing, 100191, China.
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, China.
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China.
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Zhang Y, Du S, Hu T, Xu S, Lu H, Xu C, Li J, Zhu X. Establishment of a model for predicting preterm birth based on the machine learning algorithm. BMC Pregnancy Childbirth 2023; 23:779. [PMID: 37950186 PMCID: PMC10636958 DOI: 10.1186/s12884-023-06058-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 10/09/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The purpose of this study was to construct a preterm birth prediction model based on electronic health records and to provide a reference for preterm birth prediction in the future. METHODS This was a cross-sectional design. The risk factors for the outcomes of preterm birth were assessed by multifactor logistic regression analysis. In this study, a logical regression model, decision tree, Naive Bayes, support vector machine, and AdaBoost are used to construct the prediction model. Accuracy, recall, precision, F1 value, and receiver operating characteristic curve, were used to evaluate the prediction performance of the model, and the clinical application of the model was verified. RESULTS A total of 5411 participants were included and were used for model construction. AdaBoost model has the best prediction ability among the five models. The accuracy of the model for the prediction of "non-preterm birth" was the highest, reaching 100%, and that of "preterm birth" was 72.73%. CONCLUSIONS By constructing a preterm birth prediction model based on electronic health records, we believe that machine algorithms have great potential for preterm birth identification. However, more relevant studies are needed before its application in the clinic.
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Affiliation(s)
- Yao Zhang
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Sisi Du
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Tingting Hu
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China
- People's Hospital of Deyang City, Deyang, Sichuan, China
| | - Shichao Xu
- The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Hongmei Lu
- The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Chunyan Xu
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China
- Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang, China
| | - Jufang Li
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China.
- Wenzhou Manna Medical Technology Ltd, Wenzhou, Zhejiang, China.
| | - Xiaoling Zhu
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China.
- Wenzhou Manna Medical Technology Ltd, Wenzhou, Zhejiang, China.
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Mustafa HJ, Javinani A, Heydari MH, Saldaña AV, Rohita DK, Khalil A. Selective intrauterine growth restriction without concomitant twin-to-twin transfusion syndrome, natural history, and risk factors for fetal death: A systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101105. [PMID: 37527736 DOI: 10.1016/j.ajogmf.2023.101105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 06/19/2023] [Accepted: 07/14/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE This study aimed to evaluate the natural history of selective intrauterine growth restriction in monochorionic twin pregnancies based on the Gratacós classification, including progression of, improvement in, or stability of umbilical artery Dopplers and progression to twin-to-twin transfusion syndrome or twin anemia polycythemia syndrome. We also aimed to investigate risk factors for smaller twin demise. DATA SOURCES A systematic search was performed to identify relevant studies published in English up to June 2022 using the databases PubMed, Scopus, and Web of Science STUDY ELIGIBILITY: We used retrospective and prospective studies published in English that reported on selective intrauterine growth restriction without concomitant twin-to-twin transfusion syndrome. STUDY APPRAISAL AND SYNTHESIS METHODS Articles that investigated selective intrauterine growth restriction progression and outcomes by umbilical artery Doppler end-diastolic flow (Gratacós classification) were included. Type I included selective intrauterine growth restriction cases with positive end-diastolic flow, type II included those cases with persistently absent end-diastolic flow, and type III included cases with intermittent absent or reversed end-diastolic flow. Pregnancies in which a diagnosis of twin-to-twin transfusion syndrome or twin anemia polycythemia sequence was made before the diagnosis of selective intrauterine growth restriction were not included in the analysis. A random effects model was used to pool the odds ratios and the corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value. RESULTS A total of 17 studies encompassing 2748 monochorionic pregnancies complicated by selective intrauterine growth restriction were included in the analysis. The incidence of stable, deteriorating, or improving umbilical artery Dopplers in type I cases was 68% (95% confidence interval, 26-89), 23% (95% confidence interval, 7-40), and 9% (95% confidence interval, 0.0-100), respectively. In type II cases, the incidence was 40% (95% confidence interval, 18-81), 50% (95% confidence interval, 23-82), and 10% (95% confidence interval, 4-37), respectively, and in type III cases, the incidence was 55% (95% confidence interval, 2-99), 23% (95% confidence interval, 9-43), and 22% (95% confidence interval, 6-54), respectively. The risk for progression to twin-to-twin transfusion syndrome was comparable between type I (7%) and type III (9%) cases and occurred in 4% (95% confidence interval, 0-67) of type II cases with no significant subgroup differences. Progression to twin anemia polycythemia syndrome was highest in type I cases (12%) and comparable between type II (2%) and III (1%) cases with no significant subgroup differences. Risk factors for smaller twin demise were earlier gestational age at diagnosis (mean difference, -2.69 weeks; 95% confidence interval, -4.94 to -0.45; I2, 45%), larger intertwin weight discordance (mean difference, 34%; 95% confidence interval, 1.35-5.38; I2, 28%), deterioration of umbilical artery Dopplers for each of type II and III cases (odds ratio, 3.05; 95% confidence interval, 1.36-6.84; I2, 24%; and odds ratio, 4.5; 95% confidence interval, 2.31-8.77; I2, 0.0%, respectively), and absent or reversed ductus venosus a-wave for each of type II and III cases (odds ratio, 3.35; 95% confidence interval, 2.28-4.93; I2, 0.0%; and odds ratio, 2.36; 95% confidence interval, 1.08-5.13; I2, 0.0%, respectively). Progression to twin-to-twin transfusion syndrome was not significantly associated with smaller twin demise for each of type II and III selective intrauterine growth restriction cases. CONCLUSION These findings improve our understanding of the natural history of the types of selective intrauterine growth restriction and of the predictors of smaller twin demise in type II and III selective intrauterine growth restriction cases. The current data provide vital counseling points and support the need for modifications of the current selective intrauterine growth restriction classification system to include the variations in umbilical artery and ductus venosus Dopplers to better identify a cohort that might benefit from fetal intervention for which future multicenter prospective randomized trials are needed.
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Affiliation(s)
- Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN (Dr Mustafa); Fetal Center, Riley Children's Health and Indiana University Health, Indianapolis, IN (Dr Mustafa).
| | - Ali Javinani
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr Javinani)
| | - Mohammad-Hossein Heydari
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran (Dr Heydari)
| | - Alexander Vásquez Saldaña
- Escuela de Medicina Humana de la Facultad de Ciencias, National University of Santa, Perú (Dr Saldaña)
| | - Dipesh K Rohita
- Koirala Institute of Health Sciences, Dharan, Nepal (Dr Rohita)
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom (Dr Khalil); Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom (Dr Khalil)
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D'Antonio F, Marinceu D, Prasad S, Eltaweel N, Khalil A. Outcome following laser surgery of twin-twin transfusion syndrome complicated by selective fetal growth restriction: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:320-327. [PMID: 37204823 DOI: 10.1002/uog.26252] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE The published literature reports mostly on the outcome of twin pregnancies complicated by twin-twin transfusion syndrome (TTTS) without considering whether the pregnancy is also complicated by another pathology, such as selective fetal growth restriction (sFGR). The aim of this systematic review was to report on the outcome of monochorionic diamniotic (MCDA) twin pregnancies undergoing laser surgery for TTTS that were complicated by sFGR and those not complicated by sFGR. METHODS MEDLINE, EMBASE and Cochrane databases were searched. The inclusion criteria were studies reporting on MCDA twin pregnancies with TTTS undergoing laser therapy that were complicated by sFGR and those not complicated by sFGR. The primary outcome was the overall fetal loss following laser surgery, defined as miscarriage and intrauterine death. The secondary outcomes included fetal loss within 24 h after laser surgery, survival at birth, preterm birth (PTB) prior to 32 weeks of gestation, PTB prior to 28 weeks, composite neonatal morbidity, neurological and respiratory morbidity, and survival free from neurological impairment. All outcomes were explored in the overall population of twin pregnancies complicated by sFGR vs those not complicated by sFGR in the setting of TTTS and in the donor and recipient twins separately. Random-effects meta-analysis was used to combine data and the results are reported as pooled odds ratios (OR) with 95% CI. RESULTS Five studies (1710 MCDA twin pregnancies) were included in the qualitative synthesis and four in the meta-analysis. The overall risk of fetal loss after laser surgery was significantly higher in MCDA twin pregnancies with TTTS complicated by sFGR (20.90% vs 14.42%), with a pooled OR of 1.6 (95% CI, 1.3-1.9) (P < 0.001). The risk of fetal loss was significantly higher in MCDA twin pregnancies with TTTS and sFGR for the donor but not for the recipient twin. The rate of live twins was 79.1% (95% CI, 72.6-84.9%) in TTTS pregnancies with sFGR and 85.6% (95% CI, 81.0-89.6%) in those without sFGR (pooled OR, 0.6 (95% CI, 0.5-0.8)) (P < 0.001). There was no significant difference in the risk of PTB prior to 32 weeks of gestation (P = 0.308) or prior to 28 weeks (P = 0.310). Assessment of short- and long-term morbidity was affected by the small number of cases. There was no significant difference in the risk of composite (P = 0.506) or respiratory (P = 0.531) morbidity between twins complicated by TTTS with vs those without sFGR, while the risk of neurological morbidity was significantly higher in those with TTTS and sFGR (pooled OR, 1.8 (95% CI, 1.1-2.9)) (P = 0.034). The risk of neurological morbidity was significantly higher for the donor twin (pooled OR, 2.4 (95% CI, 1.1-5.2)) (P = 0.029) but not for the recipient twin (P = 0.361). Survival free from neurological impairment was observed in 70.8% (95% CI, 45.0-91.0%) of twin pregnancies with TTTS complicated by sFGR and in 75.8% (95% CI, 51.9-93.3%) of those not complicated by sFGR, with no difference between the two groups. CONCLUSIONS sFGR in MCDA pregnancies with TTTS represents an additional risk factor for fetal loss following laser surgery. The findings of this meta-analysis may be useful for individualized risk assessment of twin pregnancy complicated by TTTS and tailored counseling of the parents prior to laser surgery. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - D Marinceu
- Department of Obstetrics and Gynecology, The York Hospital, York, UK
| | - S Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - N Eltaweel
- Division of Biomedical Science, Warwick Medical School, University of Warwick, University Hospital Coventry and Warwickshire, Coventry, 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
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
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D’Antonio F, Eltaweel N, Prasad S, Flacco ME, Manzoli L, Khalil A. Cervical cerclage for prevention of preterm birth and adverse perinatal outcome in twin pregnancies with short cervical length or cervical dilatation: A systematic review and meta-analysis. PLoS Med 2023; 20:e1004266. [PMID: 37535682 PMCID: PMC10456178 DOI: 10.1371/journal.pmed.1004266] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 08/25/2023] [Accepted: 06/23/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND The optimal approach to prevent preterm birth (PTB) in twins has not been fully established yet. Recent evidence suggests that placement of cervical cerclage in twin pregnancies with short cervical length at ultrasound or cervical dilatation at physical examination might be associated with a reduced risk of PTB. However, such evidence is based mainly on small studies thus questioning the robustness of these findings. The aim of this systematic review was to determine the role of cervical cerclage in preventing PTB and adverse maternal or perinatal outcomes in twin pregnancies. METHODS AND FINDINGS Key databases searched and date of last search: MEDLINE, Embase, and CINAHL were searched electronically on 20 April 2023. Eligibility criteria: Inclusion criteria were observational studies assessing the risk of PTB among twin pregnancies undergoing cerclage versus no cerclage and randomized trials in which twin pregnancies were allocated to cerclage for the prevention of PTB or to a control group (e.g., placebo or treatment as usual). The primary outcome was PTB <34 weeks of gestation. The secondary outcomes were PTB <37, 32, 28, 24 weeks of gestation, gestational age at birth, the interval between diagnosis and birth, preterm prelabor rupture of the membranes (pPROM), chorioamnionitis, perinatal loss, and perinatal morbidity. Subgroup analyses according to the indication for cerclage (short cervical length or cervical dilatation) were also performed. Risk of bias assessment: The risk of bias of the included randomized controlled trials (RCTs) was assessed using the Revised Cochrane risk-of-bias tool for randomized trials, while that of the observational studies using the Newcastle-Ottawa scale (NOS). Statistical analysis: Summary risk ratios (RRs) of the likelihood of detecting each categorical outcome in exposed versus unexposed women, and (b) summary mean differences (MDs) between exposed and unexposed women (for each continuous outcome), with their 95% confidence intervals (CIs) were computed using head-to-head meta-analyses. Synthesis of the results: Eighteen studies (1,465 twin pregnancies) were included. Placement of cervical cerclage in women with a twin pregnancy with a short cervix at ultrasound or cervical dilatation at physical examination was associated with a reduced risk of PTB <34 weeks of gestation (RR: 0.73, 95% CI [0.59, 0.91], p = 0.005 corresponding to a 16% difference in the absolute risk, AR), <32 (RR: 0.69, 95% CI [0.57, 0.84], p < 0.001; AR: 16.92%), <28 (RR: 0.54, 95% [CI 0.43, 0.67], 0.001; AR: 18.29%), and <24 (RR: 0.48, 95% CI [0.23, 0.97], p = 0.04; AR: 15.57%) weeks of gestation and a prolonged gestational age at birth (MD: 2.32 weeks, 95% [CI 0.99, 3.66], p < 0.001). Cerclage in twin pregnancy with short cervical length or cervical dilatation was also associated with a reduced risk of perinatal loss (RR: 0.38, 95% CI [0.25, 0.60], p < 0.001; AR: 19.62%) and composite adverse outcome (RR: 0.69, 95% CI [0.53, 0.90], p = 0.007; AR: 11.75%). Cervical cerclage was associated with a reduced risk of PTB <34 weeks both in women with cervical length <15 mm (RR: 0.74, 95% CI [0.58, 0.95], p = 0.02; AR: 29.17%) and in those with cervical dilatation (RR: 0.68, 95% CI [0.57, 0.80], p < 0.001; AR: 35.02%). The association between cerclage and prevention of PTB and adverse perinatal outcomes was exclusively due to the inclusion of observational studies. The quality of retrieved evidence at GRADE assessment was low. CONCLUSIONS Emergency cerclage for cervical dilation or short cervical length <15 mm may be potentially associated with a reduction in PTB and improved perinatal outcomes. However, these findings are mainly based upon observational studies and require confirmation in large and adequately powered RCTs.
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Affiliation(s)
- Francesco D’Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Nashwa Eltaweel
- Division of Biomedical Science, Warwick Medical School University of Warwick, University Hospital of Coventry and Warwickshire, Coventry, United Kingdom
| | - Smriti Prasad
- Fetal Medicine Unit, St George’s Hospital, London, United Kingdom
| | - Maria Elena Flacco
- Department of Environmental and Preventive Sciences, University of Ferrara, Ferrara, Italy
| | - Lamberto Manzoli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Asma Khalil
- Fetal Medicine Unit, St George’s Hospital, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George’s University of London, London, United Kingdom
- Twins Trust Centre for Research and Clinical Excellence, St George’s Hospital, London, United Kingdom
- Fetal Medicine Unit, Liverpool Women’s Hospital, University of Liverpool, Liverpool, United Kingdom
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Kozinszky Z, Surányi A. The High-Risk Profile of Selective Growth Restriction in Monochorionic Twin Pregnancies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040648. [PMID: 37109605 PMCID: PMC10141888 DOI: 10.3390/medicina59040648] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/13/2023] [Indexed: 04/29/2023]
Abstract
The present review aims to provide a critical appraisal of the sonographic diagnosis and follow-up and to evaluate the optimal clinical management of monochorionic twin pregnancies where one of the twins is complicated by selective fetal growth restriction (sFGR). The classification is based on the umbilical artery (UA) diastolic flow reflecting the outcome. If the sFGR twin has positive diastolic flow (Type I) then the prognosis is good, and it does not require close surveillance. Biweekly or weekly sonographic and Doppler surveillance and fetal monitoring are recommended strategies to detect unpredictable complications in type II and type III forms, which are defined by persistently absent/reverse end-diastolic flow (AREDF) or cyclically intermittent absent/reverse end-diastolic flow (iAREDF) in the umbilical waveforms, respectively. The latest forms are associated with an increased risk of unexpected fetal demise of the smaller twin and 10-20% risk of neurological injury in the larger twin in addition to the overall risk of prematurity. The clinical course can be affected by elective fetal therapy ('dichorinization' of the placenta with laser or selective fetal reduction) or elective delivery in the presence of severe fetal deterioration. The prediction of the clinical outcome in complicated cases of type II and III sFGR cases remains elusive. Novel routines in fetal and placental scans in order to predict neurological impairments and unexpected fetal death to optimize the delivery time-point are needed.
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Affiliation(s)
- Zoltan Kozinszky
- Department of Obstetrics and Gynaecology, Danderyds Hospital, 182 88 Stockholm, Sweden
| | - Andrea Surányi
- Department of Obstetrics and Gynaecology, Albert Szent-Györgyi Medical School, University of Szeged, 6725 Szeged, Hungary
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Chen L, Zhou W, Zhang Y, Zhao W, Wen H. Natural evolution and risk factors for adverse outcome in selective intrauterine growth restriction under expectant management: A retrospective observational study. Int J Gynaecol Obstet 2023. [PMID: 36651697 DOI: 10.1002/ijgo.14679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/06/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the natural evolution of and risk factors for the adverse outcome of monochorionic twins with selective intrauterine growth restriction (sIUGR) under expectant management. METHODS Retrospective study conducted in a single tertiary referral center. The clinical characteristics and neonatal outcomes of 153 patients with sIUGR under expectant management were evaluated, and the risk factors leading to adverse outcomes were explored. RESULTS Fifty-one patients (33.3%) showed a changed pattern in umbilical artery Doppler at the last examination, occurring in all types of sIUGR. Compared with type Ia, the gestational age of diagnosis was earlier, the estimated fetal body weight difference at diagnosis was greater, and the rate of severe neonatal complications in both fetuses was significantly higher in type Ib (P < 0.05). Univariate and multivariate logistic regression analyses showed that type II (odds ratio [OR] 5.41, 95% confidence interval [CI] 2.34-12.51; P < 0.001) and type III (OR 9.11, 95% CI 3.02-27.50; P < 0.001) were associated with adverse perinatal outcomes in sIUGR. CONCLUSION Type II and III sIUGR are independent risk factors predicting adverse outcomes of sIUGR. Different types of sIUGR could convert to each other. The outcome of type Ib is poorer than that of type Ia.
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Affiliation(s)
- Lu Chen
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Weixiao Zhou
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Yanhua Zhang
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Wei Zhao
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Hong Wen
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
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Does Fetal Growth Adequacy Affect the Nutritional Composition of Mothers' Milk?: A Historical Cohort Study. Am J Perinatol 2023; 40:163-171. [PMID: 33878767 DOI: 10.1055/s-0041-1727278] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The study aimed to assess the association between intrauterine growth of preterm infants and energy and macronutrient contents in their mothers' milk. STUDY DESIGN A historical cohort of mothers of preterm infants was assessed according to offspring's intrauterine growth. Fetal growth restriction (FGR) was defined as small-for-gestational age or appropriate for gestational age with fetal growth deceleration. During the first 4 weeks after delivery, the composition of daily pool samples of mothers' milk was measured by using a mid-infrared human milk analyzer. Explanatory models for milk energy, true protein, total carbohydrate, and fat contents were obtained by generalized additive mixed effects regression models. RESULTS In total, 127 milk samples were analyzed from 73 mothers who delivered 92 neonates. Energy content was significantly higher in mothers with chronic hypertension (average: +6.28 kcal/dL; 95% confidence interval [CI]: 0.54-12.01; p = 0.034) and for extremely preterm compared with very preterm infants (average: +5.95 kcal/dL; 95% CI: 2.16-9.73; p = 0.003), and weakly associated with single pregnancies (average: +3.38 kcal/dL; 95% CI: 0.07-6.83; p = 0.057). True protein content was significantly higher in mothers with chronic hypertension (average: +0.91 g/dL; 95% CI: 0.63-1.19; p < 0.001) and with hypertension induced by pregnancy (average: +0.25 g/dL, 95% CI: 0.07-0.44; p = 0.007), and for extremely preterm compared with very and moderate preterm infants (average: +0.19; 95% CI: 0.01-0.38; p = 0.043 and +0.28 g/dL; 95% CI: 0.05-0.51; p = 0.017, respectively). Fat content was weakly and negatively associated with FGR, both in SGA infants and AGA infants with fetal growth deceleration (average: -0.44 g/dL; 95% CI: -0.92 to -0.05; p = 0.079 and average: -0.36 g/dL; 95% CI: -0.74 to -0.02; p = 0.066, respectively). CONCLUSION Energy and macronutrient contents in mothers' milk of preterm infants was significantly and positively associated with the degree of prematurity and hypertension. The hypothesis that the composition of milk is associated with FGR was not demonstrated. KEY POINTS · Energy and protein are higher for more immature infants.. · Energy and/or protein is higher in hypertension.. · Fat may be lower for infants with intrauterine growth restriction..
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D'Antonio F, Herrera M, Oronzii L, Khalil A. Solomon technique vs selective fetoscopic laser photocoagulation for twin-twin transfusion syndrome: systematic review and meta-analysis of maternal and perinatal outcomes. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:731-738. [PMID: 36240516 DOI: 10.1002/uog.26095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To ascertain maternal and perinatal outcomes of monochorionic twin pregnancies complicated by twin-twin transfusion syndrome (TTTS) treated with the Solomon technique compared with selective fetoscopic laser photocoagulation (SFLP) of placental anastomoses. METHODS MEDLINE, EMBASE and The Cochrane Library were searched to identify relevant studies. The outcomes observed were perinatal loss and survival, preterm prelabor rupture of membranes (PPROM), preterm birth (PTB), gestational age (GA) at delivery, interval between laser treatment and delivery, maternal bleeding, septostomy or chorioamniotic separation, placental abruption, twin anemia-polycythemia sequence (TAPS), recurrence of TTTS, neonatal morbidity and neurological morbidity. Random-effects head-to-head meta-analyses were used to analyze the data. Pooled odds ratios (OR) and mean differences (MD) and their 95% CIs were calculated. RESULTS Nine studies were included in the systematic review. There was generally no difference in the main maternal and pregnancy characteristics between pregnancies treated using the Solomon technique and those treated using SFLP of placental anastomoses. The risks of fetal loss (pooled OR, 0.69 (95% CI, 0.50-0.95); P = 0.023), neonatal death (pooled OR, 0.37 (95% CI, 0.16-0.84); P = 0.018) and perinatal loss (pooled OR, 0.56 (95% CI, 0.38-0.83); P = 0.004) were significantly lower in pregnancies treated using the Solomon technique than in those treated with SFLP. Likewise, pregnancies treated using the Solomon technique had a significantly higher chance of survival of at least one twin (pooled OR, 2.31 (95% CI, 1.03-5.19); P = 0.004) and double survival (pooled OR, 2.18 (95% CI, 1.29-3.70); P = 0.001). There was no difference in the risk of PPROM (P = 0.603), PPROM within 10 days from laser surgery (P = 0.982), PTB (P = 0.207), maternal bleeding (P = 0.219), septostomy or chorioamniotic separation (P = 0.224) or chorioamnionitis (P = 0.135) between the two groups, while the risk of placental abruption was higher in pregnancies treated using the Solomon technique (pooled OR, 2.90 (95% CI, 1.55-5.44); P = 0.001). In the Solomon technique group, pregnancies delivered at a significantly earlier GA than did those treated with SFLP (pooled MD, -0.625 weeks (95% CI, -0.90 to -0.35 weeks); P < 0.001), while there was no difference in the interval between laser treatment and delivery (P = 0.589). The rate of recurrence of TTTS was significantly lower in pregnancies undergoing the Solomon technique (pooled OR, 0.43 (95% CI, 0.22-0.81); P < 0.001), while there was no difference in the risk of TAPS between the two groups (P = 0.792). Finally, there was no difference in the overall risk of neonatal morbidity (P = 0.382) or neurological morbidity (P = 0.247) between the two groups. CONCLUSIONS Monochorionic twin pregnancies complicated by TTTS undergoing laser treatment using the Solomon technique had a significantly higher survival rate and lower recurrence rate of TTTS but were associated with an increased risk of placental abruption and earlier GA at delivery compared to those treated with SFLP. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - M Herrera
- Maternal Fetal Medicine Department, Colsanitas Clinic, Colombian University Clinic - Pediatric Clinic, Bogota, Colombia
- Maternal Fetal Medicine Foundation, Fetal Health Foundation, Bogota, Colombia
| | - L Oronzii
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - 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
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
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Cali G, Labate F, Cucinella G, Fabio M, Buca D, Di Girolamo R, Khalil A, D'Antonio F. Placenta accreta spectrum disorders in twin pregnancies as an under reported clinical entity: a case series and systematic review. J Matern Fetal Neonatal Med 2022; 35:8848-8851. [PMID: 35282751 DOI: 10.1080/14767058.2021.2005568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/06/2021] [Accepted: 11/09/2021] [Indexed: 10/18/2022]
Abstract
Recent reports suggested a potential association between twin pregnancy and the occurrence of placenta accreta spectrum (PAS) disorders. Despite this, scarce data on PAS disorders in twins has been reported in the published literature. We present a series of twelve twin pregnancies complicated by PAS from two large institutions over 5 years. A systematic review of the literature was also conducted in order to find studies reporting on the risk factors, prenatal diagnosis using ultrasound and clinical outcomes of PAS in twin pregnancies.
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Affiliation(s)
- Giuseppe Cali
- Department of Obstetrics and Gynecology, Ospedali Riuniti, Palermo, Italy
| | - Francesco Labate
- Department of Obstetrics and Gynecology, Ospedali Riuniti, Palermo, Italy
| | - Gaspare Cucinella
- Department of Obstetrics and Gynecology, Ospedali Riuniti, Palermo, Italy
| | - Manuela Fabio
- Department of Obstetrics and Gynecology, Ospedali Riuniti, Palermo, Italy
| | - Danilo Buca
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Raffaella Di Girolamo
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Asma Khalil
- Fetal Medicine Unit, Saint George's University of London, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
- The Twins Trust Centre for Research and Clinical Excellence, Saint George's Hospital, London, United Kingdom
| | - Francesco D'Antonio
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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22
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Selective Fetal Growth Restriction in Monochorionic Diamniotic Twins: Diagnosis and Management. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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23
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D'Antonio F, Khalil A. Screening and diagnosis of chromosomal abnormalities in twin pregnancy. Best Pract Res Clin Obstet Gynaecol 2022; 84:229-239. [DOI: 10.1016/j.bpobgyn.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/02/2022] [Indexed: 11/16/2022]
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24
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Long-term effects of selective fetal growth restriction (LEMON): a cohort study of neurodevelopmental outcome in growth discordant identical twins in the Netherlands. THE LANCET CHILD & ADOLESCENT HEALTH 2022; 6:624-632. [DOI: 10.1016/s2352-4642(22)00159-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/17/2022] [Accepted: 05/17/2022] [Indexed: 12/30/2022]
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25
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Discordance in twins: association versus prediction. Best Pract Res Clin Obstet Gynaecol 2022; 84:33-42. [DOI: 10.1016/j.bpobgyn.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/14/2022] [Indexed: 11/16/2022]
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26
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Emrani SE, Groene SG, Verweij EJ, Slaghekke F, Khalil A, Klink JMMV, Tiblad E, Lewi L, Lopriore E. Gestational Age at Birth and outcome in Monochorionic Twins with Different Types of Selective Fetal Growth Restriction: A Systematic Literature Review. Prenat Diagn 2022; 42:1094-1110. [PMID: 35808908 PMCID: PMC9543733 DOI: 10.1002/pd.6206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/15/2022] [Accepted: 07/03/2022] [Indexed: 11/09/2022]
Abstract
This systematic review aims to assess the gestational age at birth and perinatal outcome (intrauterine demise (IUD), neonatal mortality and severe cerebral injury) in monochorionic (MC) twins with selective fetal growth restriction (sFGR), according to Gratacós classification based on umbilical artery Doppler flow patterns in the smaller twin. Seventeen articles were included. Gestational age at birth varied from 33.0-36.0 weeks in type I, 27.6-32.4 weeks in type II, and 28.3-33.8 weeks in type III. IUD rate differed from 0-4% in type I to 0-40% in type II and 0-23% in type III. Neonatal mortality rate was between 0-10% in type I, 0-38% in type II, and 0-17% in type III. Cerebral injury was present in 0-2% of type I, 2-30% of type II and 0-33% of type III cases. The timing of delivery in sFGR varied substantially among studies, particularly in type II and III. The quality of evidence was moderate due to heterogenous study populations with varying definitions of sFGR and perinatal outcome parameters, as well as a lack of consensus on the use of the Gratacós classification, leading to substantial incomparability. Our review identifies the urgent need for uniform antenatal diagnostic criteria and definitions of outcome parameters. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Salma El Emrani
- Neonatology, Willem-Alexander Children's Hospital, Dept. of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie G Groene
- Neonatology, Willem-Alexander Children's Hospital, Dept. of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Joanne Verweij
- Fetal Medicine, Dept. of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Fetal Medicine, Dept. of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Asma Khalil
- Fetal Medicine Unit, Dept. of Obstetrics, St George's Hospital, University of London, London, UK, Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of, UK; and Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, London, UK
| | - Jeanine M M van Klink
- Neonatology, Willem-Alexander Children's Hospital, Dept. of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Eleonor Tiblad
- Center for Fetal Medicine, Pregnancy Care and Delivery, Women´s Health, Karolinska University Hospital, and Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Liesbeth Lewi
- Fetal Medicine, Dept. of Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Enrico Lopriore
- Neonatology, Willem-Alexander Children's Hospital, Dept. of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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27
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Chmait SR, Monson MA, Korst LM, Llanes A, Chon AH. Selective Fetal Growth Restriction Type III: Application of a Recent Expert Consensus Definition. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1657-1666. [PMID: 34668582 DOI: 10.1002/jum.15847] [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: 04/29/2021] [Revised: 08/31/2021] [Accepted: 09/11/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Per a recent expert definition, diagnosis of selective fetal growth restriction (sFGR) in monochorionic diamniotic twins is based on an estimated fetal weight (EFW) <3% as sole criterion and/or combinations of 4 contributory criteria (1 twin EFW <10%; 1 twin abdominal circumference <10%; EFW discordance ≥25%; and smaller twin umbilical artery [UA] pulsatility index >95th percentile). We assessed these criteria in sFGR Type III (intermittent absent or reversed end-diastolic flow of the UA [iAREDF]) patients to test whether meeting the more stringent parameters of the consensus definition had worse outcomes, that is, progression to sFGR Type II (persistent AREDF) or twin-twin transfusion syndrome; or secondarily, decreased dual survivorship. METHODS This was a retrospective study of referred sFGR Type III patients (2006-2017). Patients were retrospectively categorized using consensus criteria for 2 comparisons: 1) EFW <3% versus remaining cohort; 2) EFW <3% or met all 4 contributory criteria versus remaining cohort. RESULTS Forty-eight patients were studied. Comparison 1: EFW <3% patients (58.3%) were not more likely to demonstrate disease progression (46.4% versus 65.0%, P = .2489) or worse dual survivorship (78.6% versus 85.0%, P = .7161). Comparison 2: EFW <3% or met all 4 contributory criteria (75.0%) patients were not more likely than the others to demonstrate progression (44.4% versus 83.3%, P = .0235) or worse dual survivorship (80.6% versus 83.3%, P = 1.0000). CONCLUSIONS In a referred cohort of sFGR Type III patients, there was no evidence that meeting more stringent parameters of the consensus definition was associated with disease progression or dual survivorship.
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Affiliation(s)
- Sami R Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Martha A Monson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lisa M Korst
- Childbirth Research Associates, North Hollywood, CA, USA
| | - Arlyn Llanes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andrew H Chon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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28
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Van Mieghem T, Lewi L, Slaghekke F, Lopriore E, Yinon Y, Raio L, Baud D, Dekoninck P, Melamed N, Huszti E, Sun L, Shinar S. Prediction of fetal death in monochorionic twin pregnancies complicated by Type-III selective fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:756-762. [PMID: 35258125 DOI: 10.1002/uog.24896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/02/2022] [Accepted: 02/15/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Monochorionic diamniotic twin pregnancies complicated by Type-III selective fetal growth restriction (sFGR) are at high risk of fetal death. The aim of this study was to identify predictors of fetal death in these pregnancies. METHODS This was an international multicenter retrospective cohort study. Type-III sFGR was defined as fetal estimated fetal weight (EFW) of one twin below the 10th percentile and intertwin EFW discordance of ≥ 25% in combination with intermittent absent or reversed end-diastolic flow in the umbilical artery of the smaller fetus. Predictors of fetal death were recorded longitudinally throughout gestation and assessed in univariable and multivariable logistic regression models. The classification and regression trees (CART) method was used to construct a prediction model of fetal death using significant predictors derived from the univariable analysis. RESULTS A total of 308 twin pregnancies (616 fetuses) were included in the analysis. In 273 (88.6%) pregnancies, both twins were liveborn, whereas 35 pregnancies had single (n = 19 (6.2%)) or double (n = 16 (5.2%)) fetal death. On univariable analysis, earlier gestational age at diagnosis of Type-III sFGR, oligohydramnios in the smaller twin and deterioration in umbilical artery Doppler flow were associated with an increased risk of fetal death, as was larger fetal EFW discordance, particularly between 24 and 32 weeks' gestation. None of the parameters identified on univariable analysis maintained statistical significance on multivariable analysis. The CART model allowed us to identify three risk groups: a low-risk group (6.8% risk of fetal death), in which umbilical artery Doppler did not deteriorate; an intermediate-risk group (16.3% risk of fetal death), in which umbilical artery Doppler deteriorated but the diagnosis of sFGR was made at or after 16 + 5 weeks' gestation; and a high-risk group (58.3% risk of fetal death), in which umbilical artery Doppler deteriorated and gestational age at diagnosis was < 16 + 5 weeks' gestation. CONCLUSIONS Type-III sFGR is associated with a high risk of fetal death. A prediction algorithm can help to identify the highest-risk group, which is characterized by Doppler deterioration and early referral. Further studies should investigate the potential benefit of fetal surveillance and intervention in this cohort. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T Van Mieghem
- Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F Slaghekke
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Y Yinon
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - L Raio
- Department of Obstetrics and Gynecology, Inselspital, University of Bern, Bern, Switzerland
| | - D Baud
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - P Dekoninck
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - N Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - E Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - L Sun
- Fetal Medicine Unit & Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - S Shinar
- Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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29
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Prediction of Fetal Growth Restriction for Fetal Umbilical Arterial/Venous Blood Flow Index Evaluated by Ultrasonic Doppler under Intelligent Algorithm. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:7451185. [PMID: 35633923 PMCID: PMC9135523 DOI: 10.1155/2022/7451185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/17/2022] [Accepted: 04/23/2022] [Indexed: 11/20/2022]
Abstract
The empirical wavelet transform (EWT) algorithm was applied in ultrasound to explore the predictive value for fetal growth restriction (FGR) in fetal arteriovenous indexes. 142 pregnant women who received prenatal ultrasonic examination and delivered were selected. They were classified into control group and FGR group. There were 102 patients with normal pregnancy in the control group, and 40 patients with delayed fetal growth in the FGR group. The extended triple collocation (ETC) algorithm was employed to divide the Fourier spectrum of signals adaptively, and the constructed small filter banks were classified into corresponding intervals. The instantaneous frequency was analyzed, and the arterial blood flow indexes of the two groups were compared. The results showed that the time-frequency analysis method under EWT had lower normalization error and higher accuracy. The inner diameter and cross-sectional area of FGR were remarkably smaller than those of the control group, and the differences were statistically significant (P < 0.05). There were no significant differences in mean blood flow and mean blood velocity between the control group and FGR group (P > 0.05). The arterial blood flow parameters of the systolic flow velocity (VS) and the diastolic flow velocity (VD) in the FGR group were notably lower than those in the control group, and the differences were significant (P < 0.05). In conclusion, the frequency principal component extracted by EWT algorithm was less disturbed by noise, which could accurately and effectively evaluate fetal arteriovenous blood flow indexes and predict FGR.
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30
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Mercier J, Gremillet L, Netter A, Chau C, Gire C, Tosello B. Neonatal and Long-Term Prognosis of Monochorionic Diamniotic Pregnancies Complicated by Selective Growth Restriction. CHILDREN 2022; 9:children9050708. [PMID: 35626885 PMCID: PMC9139785 DOI: 10.3390/children9050708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/25/2022] [Accepted: 05/10/2022] [Indexed: 11/16/2022]
Abstract
Background: There are few data concerning the neonatal and long-term prognosis of monochorionic biamniotic twin pregnancies (MCBA) complicated by selective intrauterine growth restriction (sIUGR). The aim of the study is to assess the neurological outcomes at two years of age of these newborns and compares these outcomes to those of newborns resulting from intrauterine growth restriction (IUGR) pregnancies. Methods: The study focuses on a cross-sectional prospective cohort of patients treated between 2012 and 2019 in Marseille, France. The primary endpoint is the overall score of the Ages and Stages questionnaires (ASQ) at two years, which assesses the global neurodevelopment. The secondary endpoint is the assessment of neonatal morbi-mortality for both groups (composite endpoint). Results: In total, 251 patients were included in the analysis: 67 in the sIUGR group and 184 in the IUGR group. There was no statistically significant difference in the overall ASQ score at two years but there was the finest motor skills impairment in the IUGR group. The areas most often impaired were communication and fine motor skills. There were no significant differences between the neonatal morbi-mortality of the two groups (adjusted OR = 0.95, p = 0.9). Conclusions: Newborns from MCBA pregnancies with sIUGR appear to have similar overall neurological development to IUGR. Notably, IUGR seems to have the most moderate neurobehavioral disorder (fine motor) as a consequence of impaired antenatal brain development due to placenta insufficiency leading to chronic hypoxia.
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Affiliation(s)
- Jessica Mercier
- Department of Neonatal Medicine, North Hospital, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France; (J.M.); (C.G.)
| | - Letizia Gremillet
- Department of Gynecology and Obstetrics, North Hospital, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France; (L.G.); (A.N.); (C.C.)
| | - Antoine Netter
- Department of Gynecology and Obstetrics, North Hospital, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France; (L.G.); (A.N.); (C.C.)
- CNRS, IRD, IMBE, Aix Marseille Université, 13003 Marseille, France
| | - Cécile Chau
- Department of Gynecology and Obstetrics, North Hospital, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France; (L.G.); (A.N.); (C.C.)
| | - Catherine Gire
- Department of Neonatal Medicine, North Hospital, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France; (J.M.); (C.G.)
- CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille Université, 13005 Marseille, France
| | - Barthélémy Tosello
- Department of Neonatal Medicine, North Hospital, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France; (J.M.); (C.G.)
- CNRS, EFS, ADES, Aix Marseille Univ, 13915 Marseille, France
- Correspondence: ; Tel.: +33-(0)4-9196-4822
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31
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Neonatal management and outcome in complicated monochorionic twins: What have we learned in the past decade and what should you know? Best Pract Res Clin Obstet Gynaecol 2022; 84:218-228. [PMID: 35513960 DOI: 10.1016/j.bpobgyn.2022.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 11/20/2022]
Abstract
Monochorionic (MC) twin pregnancies are at increased risk of neonatal morbidity and mortality due to the shared placenta with vascular connections that can give rise to various complications, including twin-twin transfusion syndrome, twin anemia polycythemia sequence (TAPS), selective fetal growth restriction, and other hematological imbalances at birth. Each complication presents its own challenges and considerations in the neonatal period. Measurement of hemoglobin levels and reticulocyte count is required to establish a correct diagnosis. Placenta dye injection is needed to properly distinguish between the various conditions. Risk factors for adverse outcome in MC twins include prematurity, severe cerebral injury, and the type of MC pregnancy complication. We, therefore, recommend cerebral ultrasound examinations in all complicated MC twins at birth to rule out a severe brain injury. Lastly, we strongly encourage screening for hearing loss using automated auditory brainstem response in all spontaneous TAPS donors to prevent permanent speech development delay.
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Buca D, Di Mascio D, Khalil A, Acharya G, Van Mieghem T, Hack K, Murata M, Anselem O, D'Amico A, Muzii L, Liberati M, Nappi L, D'Antonio F. Neonatal Morbidity of Monoamniotic Twin Pregnancies: A Systematic Review and Meta-analysis. Am J Perinatol 2022; 39:243-251. [PMID: 32722824 DOI: 10.1055/s-0040-1714420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study was aimed to report the incidence of neonatal morbidity in monochorionic monoamniotic (MCMA) twin pregnancies according to gestational age at birth and type of management adopted (inpatient or outpatient). STUDY DESIGN Medline and Embase databases were searched. Inclusion criteria were nonanomalous MCMA twins. The primary outcome was a composite score of neonatal morbidity, defined as the occurrence of at least one of the following outcomes: respiratory morbidity, overall neurological morbidity, severe neurological morbidity, and infectious morbidity, necrotizing enterocolitis at different gestational age windows (24-30, 31-32, 33-34, and 35-36 weeks). Secondary outcomes were the individual components of the primary outcome and admission to neonatal intensive care unit (NICU). Subanalysis according to the type of surveillance strategy (inpatient compared with outpatient) was also performed. Random effect meta-analyses were used to analyze the data. RESULTS A total of 14 studies including 685 MCMA twin pregnancies without fetal anomalies were included. At 24 to 30, 31 to 32, 33 to 34, and 35 to 36 weeks of gestation, the rate of composite morbidity was 75.4, 65.5, 37.6, and 18.5%, respectively, the rate of respiratory morbidity was 74.2, 59.1, 35.5, and 12.2%, respectively, while overall neurological morbidity occurred in 15.3, 10.2, 4.3, and 0% of the cases, respectively. Infectious morbidity complicated 13, 4.2, 3.1, and 0% of newborns while 92.1, 81.6, 58.7, and 0% of cases required admission to NICU. Morbidity in pregnancies delivered between 35 and 36 weeks of gestation was affected by the very small sample size of cases included. When comparing the occurrence of overall morbidity according to the type of management (inpatient or outpatient), there was no difference between the two surveillance strategies (p = 0.114). CONCLUSION MCMA pregnancies are at high risk of composite neonatal morbidity, mainly respiratory morbidity that gradually decreases with increasing gestational age at delivery with a significant reduction for pregnancies delivered between 33 and 34 weeks. We found no difference in the occurrence of neonatal morbidity between pregnancies managed as inpatient or outpatient. KEY POINTS · MCMA pregnancies are at high risk of composite neonatal morbidity, mainly respiratory morbidity.. · Neonatal morbidity gradually decreases with increasing GA at delivery, mostly between 33 and 34 weeks.. · There is no difference in the occurrence of neonatal morbidity between in- or outpatient management..
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Affiliation(s)
- Danilo Buca
- Department of Obstetrics and Gynecology, Centre for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Daniele Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Asma Khalil
- Fetal Medicine Unit, Saint George's Hospital, London, United Kingdom.,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St. George's University of London, London, United Kingdom
| | - Ganesh Acharya
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.,Women's Health and Perinatology Research Group, UiT-The Arctic University of Norway and University Hospital of North Norway, Tromsø, Norway
| | - Tim Van Mieghem
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Karien Hack
- Department of Obstetrics and Gynecology, Gelre Hospitals Apeldoorn, The Netherlands
| | - Masaharu Murata
- Center for Maternal, Fetal and Neonatal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Olivia Anselem
- Maternité Port-Royal, Groupe Hospitalier Cochin-Broca-Hôtel-Dieu, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Alice D'Amico
- Department of Obstetrics and Gynecology, Centre for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco Liberati
- Department of Obstetrics and Gynecology, Centre for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Luigi Nappi
- Department of Obstetrics and Gynecology, Fetal Medicine and Cardiology Unit, University of Foggia, Foggia, Italy
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, Fetal Medicine and Cardiology Unit, University of Foggia, Foggia, Italy
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33
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Wang Y, Shi H, Wang X, Yuan P, Wei Y, Zhao Y. Early- and late-onset selective fetal growth restriction in monochorionic twin pregnancy with expectant management. J Gynecol Obstet Hum Reprod 2022; 51:102314. [PMID: 35042000 DOI: 10.1016/j.jogoh.2022.102314] [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: 09/15/2021] [Revised: 01/07/2022] [Accepted: 01/14/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to identify selective fetal growth restriction (sFGR) in monochorionic twin (MCT) pregnancy with expectant management. METHODS We retrospectively analyzed cases of sFGR between January 2015 and December 2019 in Peking University Third Hospital. We included sFGR according to the International Society of Ultrasound in Obstetrics and Gynecology diagnostic criteria. We excluded those cases where a significant fetal structural abnormality, twin reversed arterial perfusion (TRAP), genetic syndrome or aneuploidy; cases terminated for maternal complications or for personal reasons; pregnancies that had a fetal intervention, such as fetoscopic laser photocoagulation (FLP) for vascular anastomoses, fetal reduction by radiofrequency ablation (RFA) and microwave ablation (MVA). We didn't excluded those cases that had amnioreduction therapy. According to the gestational age at onset (before 24 weeks or after), data were analyzed to identify the risk factors associated with fetal prognostic outcomes. Primary outcomes included survival of at least one twin and both twins. Secondary outcomes included gestational age of delivery, live birth weight, Apgar <7 in 5 min, admission to the neonatal unit and neonatal death. Kruskal-Wallis rank tests were used to compare non-normally distributed data, whereas categorical data were matched using Fisher's exact test or χ2 tests. ANOVA was used to compare normally distributed data, followed by a post-hoc Bonferroni analysis. Multivariate binary logistic regression was used to identify the factors connected with intrauterine death. RESULTS There were 119 pregnancies that qualified for investigation, 75 (63.0%) were categorized as early-onset sFGR and 44 (37.0%) as late-onset sFGR. The rate of survival of at least one twin (82.7% vs. 95.5%), survival of both twins (73.3% vs. 88.6%) were all reduced in the early-onset sFGR group, compared to the late-onset sFGR group. Babies born alive of fetal growth restriction (FGR) and appropriate growth for gestational age (AGA) fetuses showed similar results in the two groups regarding birth weight, 5-min Apgar score <7, neonatal death, and 28-day survival rate. A multivariable model was used to predict the intrauterine death of at least one twin. The odds ratio were significantly higher for superimposed twin-twin transfusion syndrome (TTTS) (OR 17.915, 95%CI 3.699∼86.756) and Types Ⅱ/Ⅲ sFGR (OR 4.619, 95%CI 1.074∼19.869). CONCLUSIONS In MCT pregnancies, early-onset sFGR had a poorer survival of at least one or both twins, but there was no statistical difference in the prognosis after live birth, neither for FGR babies nor those of AGA. Superimposed TTTS and Types Ⅱ/Ⅲ sFGR had a worse perinatal outcome. This information could be provided to the parents during prenatal counselling.
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Affiliation(s)
- Ying Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Huifeng Shi
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xueju Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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Gremillet L, Netter A, Tosello B, D'Ercole C, Bretelle F, Chau C. Selective intrauterine growth restriction of monochorionic diamniotic twin pregnancies: What is the neonatal prognosis? J Gynecol Obstet Hum Reprod 2021; 51:102304. [PMID: 34974148 DOI: 10.1016/j.jogoh.2021.102304] [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: 07/29/2021] [Revised: 12/12/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study compares the neonatal morbidity and mortality of the smallest twins of monochorionic diamniotic (MCDA) pregnancies complicated with selective intrauterine growth restriction (sIUGR) with newborns from singleton pregnancies with intrauterine growth restriction (IUGR). METHODS We conducted a retrospective cohort study of patients managed at the prenatal diagnosis center in a single tertiary care hospital between 2012 and 2019. MCDA twin pregnancies complicated with sIUGR (sIUGR group) were compared with singleton pregnancies with IUGR (IUGR group). The primary outcome was the comparison in neonatal morbidity and mortality between the two groups. RESULTS The analysis included 251 patients: 67 in the sIUGR group and 184 in the IUGR group. The two groups were comparable in gestational age and birth weight (p > 0.05). Multivariate analysis controlling for factors that may influence neonatal status showed no significant difference between the two groups in any of the neonatal morbidity criteria or the composite morbidity-mortality endpoint (adjusted OR = 0.946 [95% CI = 0.317-2.827]; p = 0.921). CONCLUSION Despite supposedly different pathophysiological mechanisms, neonates from MCDA pregnancies complicated with sIUGR and those from singleton pregnancies with IUGR appear to have identical neonatal morbidity and mortality .
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Affiliation(s)
- Letizia Gremillet
- Department of Gynecology and Obstetrics, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Antoine Netter
- Department of Gynecology and Obstetrics, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France; Aix Marseille Univ, Avignon University, CNRS, IRD, IMBE, Marseille, France.
| | - Barthélemy Tosello
- Department of Neonatal Medicine, North Hospital, Assistance Publique-Hôpitaux de Marseille, Marseille, France; CNRS, EFS, ADES, Aix-Marseille Univ, Marseille, France
| | - Claude D'Ercole
- Department of Gynecology and Obstetrics, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France; EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
| | - Florence Bretelle
- Department of Gynecology and Obstetrics, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France; Research Unit on Tropical and Emerging Infectious Diseases, UM63, CNRS 7278, IRD 198, INSERM 1095, Marseille, France
| | - Cécile Chau
- Department of Gynecology and Obstetrics, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France
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Reference values for fetal Doppler-based cardiocirculatory indices in monochorionic-diamniotic twin pregnancy. BMC Pregnancy Childbirth 2021; 21:797. [PMID: 34847869 PMCID: PMC8630902 DOI: 10.1186/s12884-021-04255-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/08/2021] [Indexed: 12/05/2022] Open
Abstract
Background Placental anastomoses in monochorionic diamniotic (MCDA) twin pregnancy have a major impact on fetal circulation. This study was designed to define reference ranges of cardiac and vascular Doppler indices in MCDA twin pregnancies. Methods This cross-sectional study included 442 uncomplicated MCDA twin fetuses undergoing Doppler ultrasonography at 18–35 weeks of gestation. Left and right myocardial performance index (LV-MPI, RV-MPI), E/A ratio of atrioventricular valves, pulsatility indices of umbilical artery, middle cerebral artery (MCA), and ductus venosus (DV), cerebroplacental ratio, peak systolic velocity of MCA, S/a ratio of DV, and early diastolic filling time of ductus venosus (DV-E) were evaluated under standardized settings. The equation models between Doppler indices and gestational age (GA) were fitted. After adjustment for GA, the correlations between MPI and fetal heart rate (FHR), and between MPI and DV indices were analyzed. Results Estimated centiles of Doppler indices were derived as a function of GA, being distinct in values from those of singletons. There was no correlation between GA-adjusted MPI and FHR. DV-E was inversely related to LV-MPI. Conclusions MCDA twins showed significant changes in some Doppler indices throughout gestation with quantitative differences from singletons, emphasizing the importance of MC twin-specific reference values for clinical application. Further adjustment of MPI for FHR was unnecessary. DV-E is a vascular index indirectly representing fetal diastolic function. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04255-w.
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Wang Y, Zhang A, Stock T, Lopriore E, Oepkes D, Wang Q. The accuracy of prenatal diagnosis of selective fetal growth restriction with second trimester Doppler ultrasound in monochorionic diamniotic twin pregnancies. PLoS One 2021; 16:e0255897. [PMID: 34370786 PMCID: PMC8351928 DOI: 10.1371/journal.pone.0255897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 07/26/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Selective fetal restriction growth (sFGR) is one of the common diseases of monochorionic diamniotic (MCDA) twin pregnancies, resulting in many adverse outcomes. At present, second trimester ultrasonography is widely used in the prenatal diagnosis of sFGR, but the diagnostic effectiveness is still uncertain. The aim of this study is to assess the diagnostic accuracy of second trimester Doppler ultrasound measurements for sFGR. METHODS A retrospective study included 280 pregnant women (118 with and 162 without sFGR) with MCDA pregnancies was conducted in the fetal medicine center from Leiden University Medical Center from January 2008 to December 2013. The women participating had already undergone an ultrasound examination in the second trimester. The postnatal criteria of sFGR was a single birth weight (BW) < 3 rd percentile in a twin, or birth weight discordance (BWD)≥25% between two twins, while the BW of the smaller twin < 10th percentile. Early prenatal diagnosis of sFGR was defined as a single EFW < 3 rd percentile in a twin, or at least 2 of the following 4 parameters must be met (fetal weight of one fetus < 10th percentile, AC of one fetus <10th percentile, EFW discordance≥25%, UA pulsatility index (PI) of the smaller fetus > 95th percentile). According to the diagnosis of sFGR after birth, we evaluate diagnostic effectiveness of Doppler ultrasound in the second trimester for sFGR. RESULTS Of these 280 participants, the mean age was 32.06 ± 4.76 years. About 43.9% of pregnant women were primiparas. The ability of second trimester Doppler ultrasound to accurately diagnosed sFGR is 75.4%, missed diagnosis rate and the misdiagnosis rate were 24.6% and 10.5% respectively. The ROC curve indicated that the combination of AC discordance, EFW discordance, and small fetal UA blood flow was the best diagnostic indicator of sFGR in MCDA pregnancy with the AUC was 0.882 (95%CI, 0.839-0.926). CONCLUSIONS Second trimester Doppler and ultrasound measurements is an effective method for early prenatal diagnosis of sFGR. The combined indicator of AC discordance, EFW discordance, and the small fetal UA blood flow reaches highest diagnostic value.
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Affiliation(s)
- Yao Wang
- Public Health School, Medical College of Qingdao University, Qingdao, China
| | - Ai Zhang
- Qingdao Women and Children’s Hospital, Qingdao University, Qingdao, China
| | - Tineck Stock
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Qiuzhen Wang
- Public Health School, Medical College of Qingdao University, Qingdao, China
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Filipecka-Tyczka D, Jakiel G, Kajdy A, Rabijewski M. Is growth restriction in twin pregnancies a double challenge? - A narrative review. JOURNAL OF MOTHER AND CHILD 2021; 24:24-30. [PMID: 34233387 PMCID: PMC8330357 DOI: 10.34763/jmotherandchild.20202404.d-20-00016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Foetal growth restriction (FGR) complicates about 25-47% of twin pregnancies. One or both foetuses can be restricted. Pregnancies with discordant growth of foetuses are associated with a sevenfold increased risk of neonatal morbidity. MATERIALS AND METHODS This is a narrative or traditional literature review. A literature search was performed to present a comprehensive, critical and objective analysis of the current knowledge on growth restriction in twin pregnancies. RESULTS The definitions of FGR in twin pregnancies and selective FGR (sFGR) differ between international societies. In 2019, the Delphi procedure aimed to unify the definitions of sFGR in twin pregnancies. Several growth charts for twins have been published. However, most societies recommend singleton growth charts as better in detecting hypoxic complications of FGR in twin pregnancies. Discordant growth in twins results from placental insufficiency, congenital anomalies, chromosomal aberrations and TORCH infections. CONCLUSIONS Definitions and management of sFGR depend on chorionicity. The management aims to protect the properly growing foetus from ischemic complications or in utero death. In most cases, expectant management, strict surveillance and preterm labour are the methods of choice. Due to the co-existence of properly growing and small foetuses in one uterus, determining the appropriate time for delivery is challenging. In the case of preterm labour, even late preterm, antenatal corticosteroid therapy (ACT) in FGR twin pregnancies is beneficial because it decreases neonatal morbidity.
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Affiliation(s)
| | - Grzegorz Jakiel
- Centre of Postgraduate Medical Education, 1st Obstetrics and Gynecology Clinic, Warsaw, Poland
| | - Anna Kajdy
- Department of Reproductive Health, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Michał Rabijewski
- Department of Reproductive Health, Centre of Postgraduate Medical Education, Warsaw, Poland
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Wang X, Li L, Yuan P, Zhao Y, Wei Y. Placental characteristics in different types of selective fetal growth restriction in monochorionic diamniotic twins. Acta Obstet Gynecol Scand 2021; 100:1688-1693. [PMID: 34075586 DOI: 10.1111/aogs.14204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/10/2021] [Accepted: 05/27/2021] [Indexed: 01/15/2023]
Abstract
INTRODUCTION This study aimed to explore the differences in placental characteristics among three types of selective fetal growth restriction (sFGR) in monochorionic diamniotic twin pregnancies. MATERIAL AND METHODS A total of 123 placentas with sFGR between April 2013 and October 2019 were retrospectively analyzed after dye injection. Placental characteristics were compared among the three types. RESULTS The gestational age at diagnosis and delivery was less in sFGR II and III than in sFGR I (22.9 [21.7-33.6], 23.3 [20.0-26.1] and 25.7 [19.0-35.0] weeks, p < 0.001; 32.3 [31.6-35.1], 34.1 [29.9-34.7] and 35.5 [34.0-37.0] weeks, p < 0.001). The birthweight discordance ratio was less in sFGR I than in sFGR II (0.28 [0.14-0.43] and 0.30 [0.23-0.37], p < 0.001). The prevalence of a thick artery-artery anastomosis was higher in sFGR III than in sFGR I or II (81.8%, 44.9% and 48.6%, p = 0.010). The placental territory discordance ratio was higher in sFGR II and III than in sFGR I (0.60 [0.17-0.88], 0.60 [0.01-0.80] and 0.50 [0.01-0.71], p = 0.001). CONCLUSIONS Compared with sFGR I, the earlier onset time of sFGR II and III might be due to their higher placental territory discordance. The prevalence of thick artery-artery anastomoses was expected to be higher in sFGR III than in sFGR I or II.
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Affiliation(s)
- Xueju Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Luyao Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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Ochsenbein-Kölble N. Twin pregnancies. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:246-269. [PMID: 33622004 DOI: 10.1055/a-1344-4812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Twin pregnancies, resulting in 2-3 % of all deliveries, are high risk pregnancies which need specialized care. A correct dating of pregnancy and the assessment of the chorionicity/amnionicity in the first trimester (< = 13 + 6 gestational weeks, GW) is essential for further monitoring. During first trimester risk stratification of monochorionic pregnancies includes evaluation of discordance of crown-rump-lengths, nuchal translucencies and amniotic fluid. At 16 GW sonographic risk evaluation of monochorionic twins involves differences in amniotic fluid and abdominal circumferences and detection of a velamentous cord insertion. A screening for fetal malformations with cervical length measurement as screening for preterm birth (cut-off < 25 mm) should be offered all twin pregnancies around 20 GW. In uncomplicated dichorionic pregnancies US examination should be performed every 4 weeks onwards to check fetal growth and amniotic fluid. An intertwin weight discordance > 20 % identifies pregnancies at increased risk of adverse outcome. Monochorionic pregnancies should be followed at least every two weeks for screening of twin-twin transfusion syndrome (TTTS), twin-anemia-polycythemia-sequence (TAPS) and selective fetal growth retardation (sFGR) with a start at 16 GW. The type 1-3 classification of sFGR in monochorionic twins depends on the pattern of end-diastolic velocity at the umbilical artery Doppler. The diagnosis of TTTS requires the presence of an oligyohydramnios (deepest vertical pocket (DVP) < 2 cm) in the donor twin and a polyhydramnios (DVP > 8 cm) in the recipient twin. However, the diagnosis of TAPS is based on the finding of discordant MCA Doppler values with a delta-MCA PV > 0.5 MoM.
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Affiliation(s)
- Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zürich and University of Zurich, Zurich, Switzerland
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Oronzii L, D'Antonio F, Tinari S, D'Amico A, DI Sebastiano F, DI Mascio D, Liberati M, Buca D. Induction of labor in late FGR. Minerva Obstet Gynecol 2021; 73:490-493. [PMID: 33949825 DOI: 10.23736/s2724-606x.21.04820-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Late-onset FGR is a peculiar condition characterized by the inability for the fetus to reach its growth potential diagnosed from 32 weeks of gestation. Placental insufficiency is among the leading causes of late FGR and is commonly due to a primary maternal cardiovascular non-adaptation potentially leading to fetal decompensation during labor especially once exposed to uterine hyperstimulation. Abnormalities that usually characterize late FGR include reduced fetal growth, decreased Amniotic Fluid Index, and loss of fetal heart rate variability at CTG. Fetal hemodynamics study by Doppler ultrasound significantly improved management of pregnancies affected by fetal growth restriction. A major issue when dealing with pregnancies complicated by late FGR is how to induce these women. Induction of labor (IOL) can be essentially accomplished by pharmacological and non-pharmacological agents. Recent studies suggested that the pregnancies complicated by late FGR should undergo a tailored approach for IOL in view of the higher risk of fetal decompensation following uterine hyperstimulation. The present review aims to provide an up to date on the different types of IOL which can guide clinical management.
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Affiliation(s)
- Ludovica Oronzii
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Francesco D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Sara Tinari
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Alice D'Amico
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Francesca DI Sebastiano
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Daniele DI Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University, Rome, Italy
| | - Marco Liberati
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Danilo Buca
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy -
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Batsry L, Matatyahu N, Avnet H, Weisz B, Lipitz S, Mazaki-Tovi S, Yinon Y. Perinatal outcome of monochorionic diamniotic twin pregnancy complicated by selective intrauterine growth restriction according to umbilical artery Doppler flow pattern: single-center study using strict fetal surveillance protocol. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:748-755. [PMID: 32573847 DOI: 10.1002/uog.22128] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/05/2020] [Accepted: 06/15/2020] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To determine the perinatal outcome of monochorionic diamniotic (MCDA) twin pregnancies complicated by selective intrauterine growth restriction (sIUGR), which were classified according to the umbilical artery (UA) Doppler flow pattern of the IUGR twin. METHODS This was a retrospective cohort study of all MCDA twin pregnancies diagnosed with sIUGR and managed at a single tertiary referral center between 2012 and 2018. Cases were classified according to the UA Doppler flow pattern of the IUGR twin as Type I (positive end-diastolic flow), Type II (persistently absent/reversed end-diastolic flow) or Type III (intermittently absent/reversed end-diastolic flow). Patients with Type-II or -III sIUGR were hospitalized at 26-28 weeks of gestation for increased fetal surveillance. Perinatal and immediate and long-term neurodevelopmental outcomes were stratified according to the UA Doppler flow pattern at the final examination. Intact survival rate was defined as the number of infants surviving without neurological impairment, divided by the total number of fetuses. Composite adverse outcome, defined as any mortality, presence of severe brain lesions on postnatal transcranial ultrasound or severe neurological morbidity, was also assessed. RESULTS Of 88 MCDA twin pregnancies with sIUGR included in the study, 28 underwent selective termination by cord occlusion using radiofrequency ablation, resulting in a perinatal survival rate of 89.3% and a median gestational age (GA) at delivery of 33.8 (interquartile range (IQR), 28.8-38.2) weeks for the large cotwin. Expectant management was employed in 60 cases. In 26 (43.3%) cases in the expectant-management group, the classification according to the UA Doppler flow pattern changed during gestation, resulting in 26 (43.3%) cases of Type-I, 22 (36.7%) cases of Type-II and 12 (20.0%) cases of Type-III sIUGR at the final examination. The perinatal survival rate of both twins with sIUGR Types I, II and III at the final examination was 100%, 81.8% and 75.0%, respectively (P = 0.04). Two cases of double fetal death and one case of single fetal death occurred 1-4 weeks after the Doppler pattern had changed from Type I or Type II to Type III. The median GA at delivery was 34.8 (IQR, 33.1-35.7) weeks in Type I, 30.3 (IQR, 28.6-32.1) weeks in Type II and 32.0 (IQR, 31.3-32.6) weeks in Type III (P < 0.01). The total intact survival rate was 100% for Type I, 77.3% for Type II and 75.0% for Type III (P < 0.001). Multivariate analysis demonstrated that early GA at diagnosis (odds ratio (OR), 0.83 (95% CI, 0.69-0.99); P = 0.04) and the presence of Type II or III vs Type I at the last examination (OR, 13.16 (95% CI, 1.53-113.32); P = 0.02) were associated with preterm birth < 32 weeks' gestation. Early GA at diagnosis was also associated with the composite adverse outcome (OR, 0.60 (95% CI, 0.36-0.99); P = 0.04). CONCLUSIONS The classification system of MCDA pregnancy complicated by sIUGR, according to the UA Doppler flow pattern of the IUGR twin at final examination, is associated with perinatal outcome. Importantly, the UA Doppler flow pattern can change during gestation, which has an impact on the risk of fetal death. Nevertheless, under strict fetal surveillance, the perinatal outcome of these pregnancies is favorable. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L Batsry
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - N Matatyahu
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Avnet
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - B Weisz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Lipitz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Mazaki-Tovi
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Yinon
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Nakanishi K, Muto H, Yamamoto R, Kawaguchi H, Hayashi S, Ishii K. Prevalence of umbilical artery Doppler waveform abnormality during the early second trimester and the subsequent variation of waveforms in monochorionic diamniotic twin pregnancies: A prospective cohort study. J Obstet Gynaecol Res 2021; 47:2338-2346. [PMID: 33899318 DOI: 10.1111/jog.14799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/25/2021] [Accepted: 04/02/2021] [Indexed: 11/29/2022]
Abstract
AIM To investigate the prevalence of qualitative abnormal umbilical artery Doppler waveforms (Abnormal UA) during the early second trimester and the subsequent variation of waveforms in monochorionic diamniotic (MCDA) twin pregnancies. METHODS This prospective cohort study included 153 MCDA twin pregnancies. Pulsed Doppler examinations for UA were performed at four points, including the free-loop (FL) and near the placental cord insertion site (CI) of each UA, between 16 and 17 weeks' gestation. Cases were classified into positive diastolic waveforms (Type I), persistent Abnormal UA (Type II), and intermittent Abnormal UA (Type III). When the diastolic velocity in UA Doppler was positive twice after different sequential recordings, the cases were determined to have achieved normalization. Follow-up Doppler examinations of the UA were performed at 24, 28, and 32 weeks' gestation. RESULTS Of all 153 cases, 38 (25%; 19 Type II and 19 Type III cases) showed Abnormal UA at the first examination. Abnormal UA was detectable at FL in all selective intrauterine growth restriction (sIUGR) cases, whereas it was noted only at CI site in some non-sIUGR cases. Abnormal UA normalized in 12 (63%) Type II and 15 (79%) Type III cases. CONCLUSIONS A quarter of MCDA twin pregnancies in the early second trimester demonstrated Abnormal UA. In MCDA twins with Abnormal UA between 16 and 17 weeks' gestation, it is preferable to follow them up to consider the possibility of normalization of Abnormal UA as well as features of UA waveforms specific to FL and CI.
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Affiliation(s)
- Kentaro Nakanishi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Haruka Muto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Haruna Kawaguchi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Shusaku Hayashi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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Perinatal Outcome of Selective Intrauterine Growth Restriction in Monochorionic Twins: Evaluation of a Retrospective Cohort in a Developing Country. Twin Res Hum Genet 2021; 24:37-41. [PMID: 33745489 DOI: 10.1017/thg.2021.7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Selective intrauterine growth restriction (sIUGR) in monochorionic twin pregnancies is associated with greater morbidity and mortality for both fetuses when compared to singleton and dichorionic pregnancies. This retrospective cohort study aimed to assess the perinatal outcomes of monochorionic twin pregnancies affected by this disorder and conducted expectantly, by analyzing the results according to the end-diastolic flow in the umbilical artery Doppler of the smaller twin (type I: persistently forward/type II: persistently absent or reversed/type III: intermittently absent or reversed). Seventy-five monochorionic diamniotic twin pregnancies with sIUGR were included in this study. sIUGR was defined by estimated fetal weight below the 3rd centile for gestational age, or below the 10th centile, when associated with at least one of the following three criteria: abdominal circumference below the 10th percentile, umbilical artery pulsatility index of the smaller twin above the 95th percentile, or estimated fetal weight discordance of 25% or more. Perinatal outcomes were analyzed from the prenatal period to hospital discharge and included perinatal death, neurological injury, retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), and sepsis. The mortality rate was 1.33% in this cohort. The overall morbidity rate was lower in type I twin pregnancies. In conclusion, this study shows that sIUGR type I has lower morbidity than types II and III in expectant management.
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Wang X, Li L, Yuan P, Zhao Y, Wei Y. Pregnancy outcomes and placental characteristics of selective intrauterine growth restriction with or without twin anemia polythemia sequence. Placenta 2020; 104:89-93. [PMID: 33296736 DOI: 10.1016/j.placenta.2020.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION To investigate differences in the pregnancy outcomes and placental characteristics of selective intrauterine growth restriction (sIUGR) with or without twin anemia polythemia sequence (TAPS). METHODS sIUGR patients were assigned into two groups based on the occurrence of TAPS. The pregnancy outcomes and placental characteristics were compared. A diameter of ≥2 mm was defined as thick anastomosis. RESULTS The prevalence of artery-to-artery (AA) (45.5% vs 88.6%, P = 0.002) and thick AA (0% vs 53.5%) in TAPS group were lower than non-TAPS group. The overall diameter of AA (0.5 (0.4-1.3) vs 2.5 (0.3-7.1) mm, P = 0.001) in TAPS group was smaller than non-TAPS group. The prevalence of thick artery-to-vein (AV) (0% vs 36.0%) in TAPS group was lower than non-TAPS group. Also, the overall diameter of AV (0.9 (0.6-2.1) vs 4.8 (0.3-17.8) mm, P < 0.001) in TAPS group was smaller than non-TAPS group. The total quantity (2 (1-6) vs 6 (1-16), P = 0.001), and the overall diameter of anastomoses (1.1 (0.6-4.7) vs 7.5 (0.5-22.4) mm, P < 0.001) were smaller in TAPS group than non-TAPS group. The placental territory discordance ratio of TAPS group was smaller than non-TAPS group (0.39 (0.13-0.56) vs 0.56 (0.01-0.88), P = 0.008). The umbilical cord insertion distance ratio in TAPS group was higher than non-TAPS group (0.81 ± 0.12 vs 0.57 ± 0.20, P < 0.001). DISCUSSION The placental anastomoses of sIUGR with TAPS were small. sIUGR with TAPS had smaller differences in placental share and larger distances between umbilical cord insertions.
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Affiliation(s)
- Xueju Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing, 100191, China.
| | - Luyao Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing, 100191, China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing, 100191, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing, 100191, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 Hua Yuan North Road, Hai Dian District, Beijing, 100191, China
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Di Mascio D, Khalil A, D'Amico A, Buca D, Benedetti Panici P, Flacco ME, Manzoli L, Liberati M, Nappi L, Berghella V, D'Antonio F. Outcome of twin-twin transfusion syndrome according to Quintero stage of disease: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:811-820. [PMID: 32330342 DOI: 10.1002/uog.22054] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/29/2020] [Accepted: 04/12/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To report the outcome of pregnancies complicated by twin-twin transfusion syndrome (TTTS) according to Quintero stage. METHODS MEDLINE, EMBASE and CINAHL databases were searched for studies reporting the outcome of pregnancies complicated by TTTS stratified according to Quintero stage (I-V). The primary outcome was fetal survival rate according to Quintero stage. Secondary outcomes were gestational age at birth, preterm birth (PTB) before 34, 32 and 28 weeks' gestation and neonatal morbidity. Outcomes are reported according to the different management options (expectant management, laser therapy or amnioreduction) for pregnancies with Stage-I TTTS. Only cases treated with laser therapy were considered for those with Stages-II-IV TTTS and only cases managed expectantly were considered for those with Stage-V TTTS. Random-effects head-to-head meta-analysis was used to analyze the extracted data. RESULTS Twenty-six studies (2699 twin pregnancies) were included. Overall, 610 (22.6%) pregnancies were diagnosed with Quintero stage-I TTTS, 692 (25.6%) were Stage II, 1146 (42.5%) were Stage III, 247 (9.2%) were Stage IV and four (0.1%) were Stage V. Survival of at least one twin occurred in 86.9% (95% CI, 84.0-89.7%) (456/552) of pregnancies with Stage-I, in 85% (95% CI, 79.1-90.1%) (514/590) of those with Stage-II, in 81.5% (95% CI, 76.6-86.0%) (875/1040) of those with Stage-III, in 82.8% (95% CI, 73.6-90.4%) (172/205) of those with Stage-IV and in 54.6% (95% CI, 24.8-82.6%) (5/9) of those with Stage-V TTTS. The rate of a pregnancy with no survivor was 11.8% (95% CI, 8.4-15.8%) (69/564) in those with Stage-I, 15.0% (95% CI, 9.9-20.9%) (76/590) in those with Stage-II, 18.6% (95% CI, 14.2-23.4%) (165/1040) in those with Stage-III, 17.2% (95% CI, 9.6-26.4%) (33/205) in those with Stage-IV and in 45.4% (95% CI, 17.4-75.2%) (4/9) in those with Stage-V TTTS. Gestational age at birth was similar in pregnancies with Stages-I-III TTTS, and gradually decreased in those with Stages-IV and -V TTTS. Overall, the incidence of PTB and neonatal morbidity increased as the severity of TTTS increased, but data on these two outcomes were limited by the small sample size of the included studies. When stratifying the analysis of pregnancies with Stage-I TTTS according to the type of intervention, the rate of fetal survival of at least one twin was 84.9% (95% CI, 70.4-95.1%) (94/112) in cases managed expectantly, 86.7% (95% CI, 82.6-90.4%) (249/285) in those undergoing laser therapy and 92.2% (95% CI, 84.2-97.6%) (56/60) in those after amnioreduction, while the rate of double survival was 67.9% (95% CI, 57.0-77.9%) (73/108), 69.7% (95% CI, 61.6-77.1%) (203/285) and 80.8% (95% CI, 62.0-94.2%) (49/60), respectively. CONCLUSIONS Overall survival in monochorionic diamniotic pregnancies affected by TTTS is higher for earlier Quintero stages (I and II), but fetal survival rates are moderately high even in those with Stage-III or -IV TTTS when treated with laser therapy. Gestational age at birth was similar in pregnancies with Stages-I-III TTTS, and gradually decreased in those with Stages-IV and -V TTTS treated with laser and expectant management, respectively. In pregnancies affected by Stage-I TTTS, amnioreduction was associated with slightly higher survival compared with laser therapy and expectant management, although these findings may be confirmed only by future head-to-head randomized trials. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - 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
| | - A D'Amico
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - D Buca
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - P Benedetti Panici
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - M E Flacco
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - L Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - M Liberati
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - L Nappi
- Fetal Medicine and Cardiology Unit, Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - V Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - F D'Antonio
- Fetal Medicine and Cardiology Unit, Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Shanahan MA, Bebbington MW. Placental Anatomy and Function in Twin Gestations. Obstet Gynecol Clin North Am 2020; 47:99-116. [PMID: 32008674 DOI: 10.1016/j.ogc.2019.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
With an increasing incidence of twin gestations, understanding the inherent risks associated with these pregnancies is essential in modern obstetrics. The unique differences in placentation in twins contribute to the increased risks. Monochorionic twins are susceptible to complications because of their unique placental architecture, including twin-to-twin transfusion syndrome, the twin anemia-polycythemia sequence, selective intrauterine growth restriction, and the twin reversed arterial perfusion sequence. Knowing the clinical correlations of placental anatomy in these gestations helps perinatal pathologists perform a more informed placental evaluation, allowing for better care for the mother and her children.
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Affiliation(s)
- Matthew A Shanahan
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, Mailstop 8064-37-1005, St. Louis, MO 63110, USA
| | - Michael W Bebbington
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, Mailstop 8064-37-1005, St. Louis, MO 63110, USA.
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Kalafat E, Abiola A, Thilaganathan B, Bhide A, Khalil A. The Association Between Hypertension in Pregnancy and Preterm Birth with Fetal Growth Restriction in Singleton and Twin Pregnancy: Use of Twin Versus Singleton Charts. J Clin Med 2020; 9:jcm9082518. [PMID: 32764227 PMCID: PMC7464003 DOI: 10.3390/jcm9082518] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/27/2020] [Accepted: 07/31/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To compare the rates of fetal growth restriction (FGR) in singleton and twin pregnancies using singleton and twin-specific birthweight standards. METHODS The study included liveborn twin and singleton pregnancies between January 2000 and January 2019. Hypertensive disorders of pregnancy (HDP) included gestational hypertension and pre-eclampsia. The study outcomes were FGR or small-for-gestational-age (SGA) at birth as assessed using singleton and twin reference charts. RESULTS The analysis included 1473 twin and 62,432 singleton pregnancies. In singleton pregnancies the risk of PTB <34 weeks without HDP (OR 2.82, p < 0.001), delivery ≥34 weeks with HDP (OR 2.38, p < 0.001), and PTB <34 weeks with HDP (OR 13.65, p < 0.001) were significantly higher in the pregnancies complicated by FGR compared to those without. When selective fetal growth restriction (sFGR) was assessed using the singleton standard, the risk of PTB <34 weeks without HDP (OR 1.03, p = 0.872), delivery ≥34 weeks with HDP (OR 1.36, p = 0.160) were similar in the pregnancies complicated by sFGR compared to those without, while the risk of PTB <34 weeks with HDP (OR 2.41, p = 0.025) was significantly higher in the pregnancies complicated by sFGR compared to those without. When sFGR was assessed using the twin-specific chart, the risk of PTB <34 weeks without HDP (OR 3.55, p < 0.001), delivery ≥34 weeks with HDP (OR 3.17, p = 0.004), and PTB <34 weeks with HDP (OR 5.69, p < 0.001) were significantly higher in the pregnancies complicated by sFGR compared to those without. The stronger and more consistent association persisted in the subgroup analyses according to chorionicity. The strength of association in dichorionic twin pregnancies resembles that of the singletons more closely and consistently when the FGR was diagnosed using the twin-specific charts. CONCLUSION FGR in twin pregnancies has a stronger and more consistent association with HDP and PTB when using twin-specific rather than singleton charts. This study provides further evidence supporting the use of twin-specific charts when assessing fetal growth in twin pregnancies.
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Affiliation(s)
- Erkan Kalafat
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, Cranmer Terrace, London SW17 0RE, UK; (E.K.); (A.A.); (B.T.); (A.B.)
- Department of Statistics, Faculty of Arts and Science, Middle East Technical University, 06800 Ankara, Turkey
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ankara University, 06230 Ankara, Turkey
| | - Aisha Abiola
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, Cranmer Terrace, London SW17 0RE, UK; (E.K.); (A.A.); (B.T.); (A.B.)
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, Cranmer Terrace, London SW17 0RE, UK; (E.K.); (A.A.); (B.T.); (A.B.)
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George′s University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Amar Bhide
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, Cranmer Terrace, London SW17 0RE, UK; (E.K.); (A.A.); (B.T.); (A.B.)
| | - Asma Khalil
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, Cranmer Terrace, London SW17 0RE, UK; (E.K.); (A.A.); (B.T.); (A.B.)
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George′s University of London, Cranmer Terrace, London SW17 0RE, UK
- Twins Trust Centre for Research and Clinical excellence, St George’s Hospital, Blackshaw road, Tooting, London SW17 0QT, UK
- Correspondence: ; Tel.: +44-20-3299-8256
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48
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Badr DA, Carlin A, Kang X, Cos Sanchez T, Olivier C, Jani JC, Bevilacqua E. Evaluation of the new expert consensus-based definition of selective fetal growth restriction in monochorionic pregnancies. J Matern Fetal Neonatal Med 2020; 35:2338-2344. [PMID: 32627604 DOI: 10.1080/14767058.2020.1786053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: To compare the outcomes of a cohort of monochorionic pregnancies with selective fetal growth restriction (sFGR) diagnosed according to the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) definition published in 2015 with a cohort considered as sFGR according to new expert consensus-based diagnostic parameters published in 2019.Methods: This was a retrospective study, conducted between January 1st 2010 and July 30th 2019. We reviewed the medical records of all the monochorionic pregnancies followed in our center including perinatal outcomes. Pregnancies complicated by fetal anomalies, infection, twin-twin transfusion syndrome, twin anaemia-polycythemia sequence and twin reversed arterial perfusion sequence were excluded. Patients were grouped according to the 2015 ISUOG definition into: normal (Group 1), sFGR (Group 2), and monochorionic pregnancies with abnormal growth that did not fulfill the full criteria for sFGR (Group 3). After the initial classifications were made, an additional group, was created, including all pregnancies reclassified as sFGR according to the 2019 expert consensus parameters (Group 4).Results: During the study period, 291 monochorionic pregnancies were followed in our center, 132 of whom were eligible for inclusion in the final analysis. The prevalence of sFGR increased from 17.4% to 26.5% after applying the expert consensus-based parameters to the study population. Compared to group 1, group 2 had higher rates of emergency cesarean, neonatal intensive care admissions, invasive and noninvasive ventilation, surfactant use, metabolic disorders and lower gestational ages at birth. In contrast, the neonatal outcomes of Groups 1 and 4 were not significantly different.Conclusion: When the 2019 consensus-based diagnostic parameters for sFGR were applied to our study population, the number of sFGR cases increased by over 50%, without any improvements in perinatal outcomes. Larger prospective studies are needed to examine the potential clinical implications of these new parameters for sFGR in monochorionic pregnancies.
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Affiliation(s)
- Dominique A Badr
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew Carlin
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Xin Kang
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Teresa Cos Sanchez
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Camille Olivier
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Elisa Bevilacqua
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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Colmant C, Lapillonne A, Stirnemann J, Belaroussi I, Leroy-Terquem E, Kermovant-Duchemin E, Bussieres L, Ville Y. Impact of different prenatal management strategies in short- and long-term outcomes in monochorionic twin pregnancies with selective intrauterine growth restriction and abnormal flow velocity waveforms in the umbilical artery Doppler: a retrospective observational study of 108 cases. BJOG 2020; 128:401-409. [PMID: 32416618 DOI: 10.1111/1471-0528.16318] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To review perinatal and neurodevelopmental outcome (NDO) following selective fetoscopic laser coagulation (SFLC), cord coagulation (CC) or expectant management of monochorionic diamniotic twin pregnancies complicated with selective intrauterine growth restriction (sIUGR) and absent or reverse end-diastolic flow (AREDF) in the umbilical arteries (UA). DESIGN AND SETTING Single-centre retrospective observational study. POPULATION 108 cases of sIUGR diagnosed before 26+6 weeks' gestation with AREDF in the UA. METHODS Survival rate and potential risk factors were analysed. NDO was assessed using parental questionnaires. MAIN OUTCOMES MEASURES Survival, gestational age at delivery and NDO. RESULTS SFLC, CC and EM were performed in 13, 50 and 45 cases, respectively, with an overall survival of 23.1, 40 and 77.8% and intrauterine demise of the co-twin of 30.8, 10 and 6.7% respectively. Intrauterine demise of the sIUGR twin occurred in 76.9 and 17.8% following SFLC and EM, respectively. The discordance in EFW at diagnosis was higher and absent/negative a-wave in the ductus venosus (DV) was more prevalent in the surgical groups. NDO in survivors at follow up was abnormal in 0 and 18% in the smaller twin following SFLC and EM, respectively, and in 25, 24 and 21% in the larger twin following SFLC, CC and EM, respectively. CONCLUSION SFLC yielded a poor result. EM seems a valid option when EFW discordance is <30% and a-wave in DV is positive. Otherwise, CC should be considered to protect the AGA co-twin. The long-term outcome of both small and large twins seems unaffected by the choice in primary prenatal management strategy. TWEETABLE ABSTRACT In type II sIUGR in MC twins, long-term neurodevelopment is normal in over 80% of the survivors.
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Affiliation(s)
- C Colmant
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - A Lapillonne
- EA7328 and PACT, Université Paris Descartes, Paris, France.,Neonatology and Intensive Care Unit, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - J Stirnemann
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,EA7328 and PACT, Université Paris Descartes, Paris, France
| | - I Belaroussi
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | | | - E Kermovant-Duchemin
- EA7328 and PACT, Université Paris Descartes, Paris, France.,Neonatology and Intensive Care Unit, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - L Bussieres
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,EA7328 and PACT, Université Paris Descartes, Paris, France
| | - Y Ville
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,EA7328 and PACT, Université Paris Descartes, Paris, France
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50
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Curado J, Sileo F, Bhide A, Thilaganathan B, Khalil A. Early- and late-onset selective fetal growth restriction in monochorionic diamniotic twin pregnancy: natural history and diagnostic criteria. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:661-666. [PMID: 31432560 DOI: 10.1002/uog.20849] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/08/2019] [Accepted: 07/31/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the natural history and outcome of selective fetal growth restriction (sFGR) in monochorionic diamniotic (MCDA) twin pregnancy, according to gestational age at onset and various reported diagnostic criteria, and to quantify the risk of superimposed twin-to-twin transfusion syndrome (TTTS). METHODS This was a cohort study of MCDA twin pregnancies that had their routine antenatal care from the first trimester at St George's Hospital, London, UK. Pregnancies had ultrasound examinations every 2 weeks at 16-24 weeks and then every 2-3 weeks until delivery. The diagnostic criteria for sFGR were estimated fetal weight (EFW) of one twin < 10th centile and intertwin EFW discordance ≥ 25%. We also applied other diagnostic criteria reported in a recent Delphi consensus. Pregnancies in which the diagnosis of TTTS was made before that of sFGR were not included in the analysis. Pregnancies that underwent fetal intervention for sFGR were excluded. The incidence of sFGR was compared between the different diagnostic criteria, overall and according to gestational age at onset. In all subsequent analyses, cases of sFGR included those diagnosed according to any of the criteria. The Gratacós classification of sFGR was applied (Type I, II or III). Pregnancy outcomes included miscarriage, intrauterine death, neonatal death and admission to the neonatal unit. Comparisons between groups were carried out using the Mann-Whitney U-test for continuous variables and the chi-square or Fisher's exact test for categorical variables. RESULTS The analysis included 287 MCDA twin pregnancies. According to the International Society of Ultrasound in Obstetrics and Gynecology diagnostic criteria, the incidence of early (< 24 weeks) sFGR was 4.9%, while that of late sFGR was 3.8%. When applying the various diagnostic criteria, the incidence of early sFGR varied from 1.7% to 9.1% and that of late sFGR varied from 1.1% to 5.9%. In early-onset cases, the incidence of Type I sFGR was 80.8%, that of Type II was 15.4% and that of Type III was 3.8%. The corresponding figures in late-onset cases were 94.4%, 5.6% and 0%. The incidence of superimposed TTTS was 26.9% in cases affected by early-onset sFGR and 5.6% in those affected by late-onset sFGR. The incidence of perinatal death was 8.0% in early-onset sFGR and 5.6% in late-onset sFGR (P = 0.661). Admission to the neonatal unit occurred in 61.0% and 52.9% of cases, respectively (P = 0.484). CONCLUSIONS In MCDA twin pregnancies, early-onset sFGR is slightly more common than is late-onset sFGR, although this difference was not significant, and is associated with worse perinatal outcome. The incidence of Types II and III sFGR is higher in early-onset sFGR. The incidence also varies according to the diagnostic criteria used, which supports the use of standardized international diagnostic criteria. Superimposed TTTS is more common in early- than in late-onset sFGR. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J Curado
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - F Sileo
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - A Bhide
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, 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 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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