1
|
Hopkins MK, Neumann O, Kuller JA, Dugoff L. First Trimester Ultrasound and Aneuploidy Screening in Twins. Clin Obstet Gynecol 2023; 66:774-780. [PMID: 37438894 DOI: 10.1097/grf.0000000000000797] [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: 07/14/2023]
Abstract
All patients with twin pregnancy should have first trimester ultrasound and be offered screening for chromosomal aneuploidy as well as diagnostic testing. Screening for aneuploidy in twins presents unique challenges compared with singletons. Cell-free DNA screening should be considered first-line; however, this option may not be available or may have limitations in certain clinical scenarios, such as vanishing twins. If cell-free DNA screening is not available, maternal serum marker screening in conjunction with nuchal translucency assessment should be offered. Patients with positive aneuploidy screening tests or fetal structural abnormalities should be offered diagnostic testing.
Collapse
Affiliation(s)
- Maeve K Hopkins
- Obstetrics & Gynecology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Olivia Neumann
- Obstetrics & Gynecology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey A Kuller
- Division of Maternal and Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - Lorraine Dugoff
- Divisions of Maternal and Fetal Medicine and Reproductive Genetics, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
2
|
Hopkins MK, Dugoff L. Screening for aneuploidy in twins. Am J Obstet Gynecol MFM 2021; 4:100499. [PMID: 34634497 DOI: 10.1016/j.ajogmf.2021.100499] [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: 06/01/2021] [Revised: 08/26/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
All pregnant women should be offered screening for aneuploidy. Twin pregnancies present unique challenges in aneuploidy screening. This review describes available aneuploidy screening options and their benefits and limitations in twin pregnancy, along with describing special circumstances, such as vanishing twins and diagnostic testing in twin pregnancy. No method of aneuploidy screening is as accurate in twin pregnancies as singleton pregnancies. Cell-free DNA screening should be considered a first-line approach; however, this option may not be available or may have limitations in certain clinical scenarios, such as vanishing twins. If cell-free DNA screening is not available, nuchal translucency and/or maternal serum marker screening can be offered.
Collapse
Affiliation(s)
- Maeve K Hopkins
- Division of Maternal and Fetal Medicine, Ob/Gyn & Women's Health Institute, Cleveland Clinic, Cleveland, OH (Dr Hopkins).
| | - Lorraine Dugoff
- Divisions of Maternal and Fetal Medicine and Reproductive Genetics, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA (Dr Dugoff)
| |
Collapse
|
3
|
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.
Collapse
Affiliation(s)
- Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zürich and University of Zurich, Zurich, Switzerland
| |
Collapse
|
4
|
Simpson L, Maturen KE, Feldstein VA, Oliver ER, Poder L, Strachowski LM, Sussman BL, Weber TM, Winter T, Zelop CM, Glanc P. ACR Appropriateness Criteria® Nuchal Translucency Evaluation at 11 to 14 Weeks of Gestation. J Am Coll Radiol 2020; 17:S447-S458. [PMID: 33153556 DOI: 10.1016/j.jacr.2020.09.007] [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: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/20/2022]
Abstract
A fetus with an increased nuchal translucency at 11 to 14 weeks gestation is at risk for aneuploidy, genetic syndromes, structural anomalies, and intrauterine fetal demise in both single and twin gestations. In addition to referral to genetics for counseling and consideration of diagnostic genetic testing, a detailed anatomic survey and fetal echocardiogram are indicated in the second trimester to screen for congenital malformations and major heart defects. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Collapse
Affiliation(s)
- Lynn Simpson
- Columbia University, New York, New York; American College of Obstetricians and Gynecologists.
| | | | | | - Edward R Oliver
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Liina Poder
- University of California San Francisco, San Francisco, California
| | | | - Betsy L Sussman
- The University of Vermont Medical Center, Burlington, Vermont
| | | | - Tom Winter
- University of Utah, Salt Lake City, Utah
| | - Carolyn M Zelop
- Valley Hospital, Ridgewood, New Jersey and NYU School of Medicine, New York, New York; American College of Obstetricians and Gynecologists
| | - Phyllis Glanc
- Specialty Chair, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
5
|
Syngelaki A, Cimpoca B, Litwinska E, Akolekar R, Nicolaides KH. Diagnosis of fetal defects in twin pregnancies at routine 11-13-week ultrasound examination. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:474-481. [PMID: 31788879 DOI: 10.1002/uog.21938] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/20/2019] [Accepted: 11/22/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To examine the performance of the routine 11-13-week scan in detecting fetal defects in twin pregnancies and to examine if, in pregnancies with a fetal defect, compared to those with normal fetuses, there is increased incidence of nuchal translucency thickness (NT) ≥ 95th and ≥ 99th percentiles or intertwin discordance in crown-rump length (CRL) ≥ 10% and ≥ 15%. METHODS This was a retrospective analysis of prospectively collected data in twin pregnancies undergoing routine ultrasound examination for fetal anatomy, according to standardized protocols, at 11-13 weeks' gestation between 2002 and 2019. Pregnancies with known chromosomal abnormality were excluded. The final diagnosis of fetal defect was based on the results of postnatal examination in cases of live birth and on the findings of the last ultrasound examination in cases of pregnancy termination, miscarriage or stillbirth. The performance of the 11-13-week scan in the detection of fetal defects was determined. RESULTS The study population of 6366 twin pregnancies with two live fetuses at 11-13 weeks' gestation included 4979 (78.2%) dichorionic (DC) and 1387 (21.8%) monochorionic (MC) twin pregnancies. The main findings were: first, the overall incidence of fetal defects was higher in MC than in DC twins (2.8% vs 1.3%); second, the proportion of defects diagnosed in the first trimester was higher in MC than in DC twins (52.6% vs 27.1%); third, the pattern of defects in relation to detectability at the 11-13-week scan (always detectable, sometimes detectable and never detectable) was similar to that reported previously in singleton pregnancies; fourth, always-detectable defects included acrania, alobar holoprosencephaly, encephalocele, pentalogy of Cantrell, exomphalos, body-stalk anomaly, twin reversed arterial perfusion sequence and conjoined twins; fifth, the incidence of fetal NT ≥ 95th percentile was higher in those with than in those without a defect (16.5% vs 4.5% in DC twins and 19.2% vs 5.9% in MC twins) and this was also true for NT ≥ 99th percentile (8.3% vs 1.0% in DC twins and 15.4% vs 2.0% in MC twins); and sixth, the incidence of CRL discordance ≥ 10% was higher in those with than in those without a defect (20.2% vs 7.9% in DC twins and 33.8% vs 9.3% in MC twins) and this was also true for CRL discordance ≥ 15% (10.1% vs 1.9% in DC twins and 28.2% vs 2.8% in MC twins). CONCLUSIONS First, fetal defects are more common in MC than in DC twin pregnancies. Second, first-trimester detection of fetal defects in DC twin pregnancies is similar to that in singleton pregnancies. Third, first-trimester detectability of defects in MC twins is higher than in DC twins. Fourth, in twin pregnancies with a fetal defect, there is higher intertwin discordance in CRL and incidence of increased NT, but the predictive performance of screening by these markers is poor. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- A Syngelaki
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - B Cimpoca
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - E Litwinska
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - R Akolekar
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
- Institute of Medical Sciences, Canterbury Christ Church University, Chatham, UK
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| |
Collapse
|
6
|
Cimpoca B, Syngelaki A, Litwinska E, Muzaferovic A, Nicolaides KH. Increased nuchal translucency at 11-13 weeks' gestation and outcome in twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:318-325. [PMID: 31773823 DOI: 10.1002/uog.21935] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/15/2019] [Accepted: 11/22/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate the value of increased fetal nuchal translucency thickness (NT) at the 11-13-week scan in the prediction of adverse outcome in dichorionic (DC), monochorionic diamniotic (MCDA) and monochorionic monoamniotic (MCMA) twin pregnancies. METHODS This was a retrospective analysis of prospectively collected data on twin pregnancies undergoing routine ultrasound examination at 11-13 weeks' gestation between 2002 and 2019. In pregnancies with no major defects or chromosomal abnormalities, we examined the value of increased NT ≥ 95th percentile in one or both fetuses in the prediction of, first, miscarriage or death of one or both fetuses at < 20 and < 24 weeks' gestation in DC, MCDA and MCMA twin pregnancies, second, death of one or both fetuses or neonates at ≥ 24 weeks in DC, MCDA and MCMA twin pregnancies, third, development of twin-twin transfusion syndrome (TTTS) or selective fetal growth restriction (sFGR) treated by endoscopic laser surgery at < 20 and ≥ 20 weeks' gestation in MCDA pregnancies, and, fourth, either fetal loss or laser surgery at < 20 weeks' gestation in MCDA pregnancies. RESULTS The study population of 6225 twin pregnancies included 4896 (78.7%) DC, 1274 (20.5%) MCDA and 55 (0.9%) MCMA pregnancies. The incidence of NT ≥ 95th percentile in one or both fetuses in DC twin pregnancies was 8.3%; in MCDA twins the incidence was significantly higher (10.4%; P = 0.016), but in MCMA twins it was not significantly different (9.1%; P = 0.804) from that in DC twins. In DC twin pregnancies, the incidence of high NT was not significantly different between those with two survivors and those with adverse outcome. In MCMA twin pregnancies, the number of cases was too small for meaningful assessment of the relationship between high NT and adverse outcome. In MCDA twin pregnancies with at least one fetal death or need for endoscopic laser surgery at < 20 weeks' gestation, the incidence of NT ≥ 95th percentile was significantly higher than in those with two survivors (23.5% vs 9.8%; P < 0.0001). Kaplan-Meier analysis in MCDA twin pregnancies showed that, in those with NT ≥ 95th percentile, there was significantly lower survival at < 20 weeks' gestation than in those with NT < 95th percentile (P = 0.001); this was not the case for survival at ≥ 20 weeks (P = 0.960). The performance of screening by fetal NT ≥ 95th percentile for prediction of either fetal loss or need for endoscopic laser surgery at < 20 weeks' gestation was poor, with a detection rate of 23.5% at a false-positive rate of 8.9%, and the relative risk, in comparison to fetal NT < 95th percentile, was 2.640 (95% CI, 1.854-3.758; P < 0.0001). In MCDA twin pregnancies, the overall rate of fetal loss or need for laser surgery at < 20 weeks' gestation was 10.7% but, in the subgroups with NT ≥ 95th and NT ≥ 99th percentiles, which constituted 10.4% and 3.3% of the total, the rates increased to 24.1% and 40.5%, respectively. CONCLUSIONS In MCDA twin pregnancies with no major fetal abnormalities, measurement of NT at the 11-13-week scan is a poor screening test for adverse pregnancy outcome. However, the finding in one or both fetuses of NT ≥ 95th percentile, and more so ≥ 99th percentile, is associated with a substantially increased risk of fetal loss or need for endoscopic laser surgery at < 20 weeks' gestation. The extent to which closer monitoring and earlier intervention in the high-risk group can reduce these complications remains to be determined. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- B Cimpoca
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Syngelaki
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - E Litwinska
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Muzaferovic
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| |
Collapse
|
7
|
Glanc P, Nyberg DA, Khati NJ, Deshmukh SP, Dudiak KM, Henrichsen TL, Poder L, Shipp TD, Simpson L, Weber TM, Zelop CM. ACR Appropriateness Criteria ® Multiple Gestations. J Am Coll Radiol 2018; 14:S476-S489. [PMID: 29101986 DOI: 10.1016/j.jacr.2017.08.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/28/2022]
Abstract
Women with twin or higher-order pregnancies will typically have more ultrasound examinations than women with a singleton pregnancy. Most women will have at minimum a first trimester scan, a nuchal translucency evaluation scan, fetal anatomy scan at 18 to 22 weeks, and one or more scans in the third trimester to evaluate growth. Multiple gestations are at higher risk for preterm delivery, congenital anomalies, fetal growth restriction, placenta previa, vasa previa, and velamentous cord insertion. Chorionicity and amnionicity should be determined as early as possible when a twin pregnancy is identified to permit triage of the monochorionic group into a closer surveillance model. Screening for congenital heart disease is warranted in monochorionic twins because they have an increased rate of congenital cardiac anomalies. In addition, monochorionic twins have a higher risk of developing cardiac abnormalities in later gestation related to right ventricular outflow obstruction, in particular the subgroups with twin-twin transfusion syndrome or selective intrauterine growth restriction. Monochorionic twins have unique complications including twin-to-twin transfusion syndrome, twin embolization syndrome, and acardius, or twin-reversed arterial perfusion sequence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Collapse
Affiliation(s)
| | - Phyllis Glanc
- Principal Author and Specialty Chair, Sunnybrook Health Sciences Centre, Bayview Campus, Toronto, Ontario, Canada.
| | - David A Nyberg
- Co-Author, The Old Vicarage, Worcester Park, United Kingdom
| | - Nadia J Khati
- Panel Chair, George Washington University Hospital, Washington, District of Columbia
| | | | | | | | - Liina Poder
- University of California San Francisco, San Francisco, California
| | - Thomas D Shipp
- Brigham & Women's Hospital, Boston, Massachusetts; American College of Obstetrics and Gynecology
| | - Lynn Simpson
- Columbia University Medical Center, New York, New York; American College of Obstetrics and Gynecology
| | | | - Carolyn M Zelop
- Valley Hospital, Ridgewood, New Jersey and NYU School of Medicine, New York, New York; American College of Obstetrics and Gynecology
| |
Collapse
|
8
|
Bender W, Dugoff L. Screening for Aneuploidy in Multiple Gestations. Obstet Gynecol Clin North Am 2018; 45:41-53. [DOI: 10.1016/j.ogc.2017.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
|
9
|
|
10
|
Morin L, Lim K. N° 260-Échographie et grossesse gémellaire. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:e436-e452. [PMID: 28935067 DOI: 10.1016/j.jogc.2017.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
11
|
Audibert F, Gagnon A. No. 262-Prenatal Screening for and Diagnosis of Aneuploidy in Twin Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:e347-e361. [DOI: 10.1016/j.jogc.2017.06.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
12
|
Audibert F, Gagnon A. N o 262-Dépistage et diagnostic prénatals de l’aneuploïdie en ce qui concerne les grossesses gémellaires. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:e329-e346. [DOI: 10.1016/j.jogc.2017.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
13
|
First-trimester Ultrasound and Aneuploidy Screening in Multifetal Pregnancies. Clin Obstet Gynecol 2015; 58:559-73. [PMID: 26133496 DOI: 10.1097/grf.0000000000000129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
First-trimester ultrasound provides valuable information to help optimize the management of multifetal pregnancies. First trimester ultrasound the use of ultrasound and screening for aneuploidy has been well studied in singleton pregnancies. While evidence supporting the use of ultrasound in multiple gestations is well established, aneuploidy screening continues to evolve and its role in the prenatal setting has been less well studied. We review the importance of early first trimester ultrasound in assessing gestational age and chorionicity and early identification of anomalies, and review the various methods and limitations of aneuploidy screening and invasive diagnostic procedures in multiples.
Collapse
|
14
|
Abstract
The purpose of this article was to discuss the process of setting up a nuchal translucency (NT) screening clinic in clinical practice, how to interpret the information in combination with other clinical tests, what to do if abnormal results are obtained, and to illustrate some of the fetal anomalies that are associated with an increased NT. The NT was initially implemented to predict the likelihood of a fetus with Down syndrome. Maternal age can be combined with fetal NT and maternal serum biochemistry (free β-hCG and PAPP-A) at 11 to 14 weeks to identify about 90% of affected fetuses. Setting up a clinic to perform the NT screening requires certified physicians and certified sonographers. Certification can be obtained for both physicians and sonographers through Nuchal Translucency Quality Review and Fetal Medicine Foundation. Cell-free DNA testing is now altering what our patients are choosing to evaluate fetuses at risk for chromosomal anomalies and congenital anomalies. Common pitfalls to performing, interpreting, and conveying results of the NT are illustrated in this article. Nasal bone measurement, fetal anatomy examination and fetal echocardiography are tools that add sensitivity to the detection of chromosomal abnormalities. Examples of fetal anomalies discovered during the NT screening are also illustrated. Screening for obstetric complications is an additional benefit to the NT clinic.
Collapse
|
15
|
Monni G, Iuculano A, Zoppi MA. Screening and Invasive Testing in Twins. J Clin Med 2014; 3:865-82. [PMID: 26237482 PMCID: PMC4449657 DOI: 10.3390/jcm3030865] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/26/2014] [Accepted: 06/27/2014] [Indexed: 11/16/2022] Open
Abstract
Prenatal screening and testing for trisomy 21 in twin pregnancies poses a number of challenges: the exact estimate of the a priori risk of trisomy 21, the choice of prenatal screening test and/or invasive techniques to employ for the diagnosis and the impact of the result on the options of treatment in case of discordant results within a twin pair or among multiples. These different aspects are discussed below while recognizing that many issues remain unresolved.
Collapse
Affiliation(s)
- Giovanni Monni
- Department of Obstetrics and Gynecology, Prenatal and Preimplantation Genetic Diagnosis, Fetal Therapy, Ospedale Microcitemico, via Jenner, 09121 Cagliari, Italy.
| | - Ambra Iuculano
- Department of Obstetrics and Gynecology, Prenatal and Preimplantation Genetic Diagnosis, Fetal Therapy, Ospedale Microcitemico, via Jenner, 09121 Cagliari, Italy.
| | - Maria Angelica Zoppi
- Department of Obstetrics and Gynecology, Prenatal and Preimplantation Genetic Diagnosis, Fetal Therapy, Ospedale Microcitemico, via Jenner, 09121 Cagliari, Italy.
| |
Collapse
|
16
|
Boyle B, Morris JK, McConkey R, Garne E, Loane M, Addor MC, Gatt M, Haeusler M, Latos-Bielenska A, Lelong N, McDonnell R, Mullaney C, O'Mahony M, Dolk H. Prevalence and risk of Down syndrome in monozygotic and dizygotic multiple pregnancies in Europe: implications for prenatal screening. BJOG 2014; 121:809-19; discussion 820. [PMID: 24495335 PMCID: PMC4234000 DOI: 10.1111/1471-0528.12574] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine risk of Down syndrome (DS) in multiple relative to singleton pregnancies, and compare prenatal diagnosis rates and pregnancy outcome. DESIGN Population-based prevalence study based on EUROCAT congenital anomaly registries. SETTING Eight European countries. POPULATION 14.8 million births 1990-2009; 2.89% multiple births. METHODS DS cases included livebirths, fetal deaths from 20 weeks, and terminations of pregnancy for fetal anomaly (TOPFA). Zygosity is inferred from like/unlike sex for birth denominators, and from concordance for DS cases. MAIN OUTCOME MEASURES Relative risk (RR) of DS per fetus/baby from multiple versus singleton pregnancies and per pregnancy in monozygotic/dizygotic versus singleton pregnancies. Proportion of prenatally diagnosed and pregnancy outcome. STATISTICAL ANALYSIS Poisson and logistic regression stratified for maternal age, country and time. RESULTS Overall, the adjusted (adj) RR of DS for fetus/babies from multiple versus singleton pregnancies was 0.58 (95% CI 0.53-0.62), similar for all maternal ages except for mothers over 44, for whom it was considerably lower. In 8.7% of twin pairs affected by DS, both co-twins were diagnosed with the condition. The adjRR of DS for monozygotic versus singleton pregnancies was 0.34 (95% CI 0.25-0.44) and for dizygotic versus singleton pregnancies 1.34 (95% CI 1.23-1.46). DS fetuses from multiple births were less likely to be prenatally diagnosed than singletons (adjOR 0.62 [95% CI 0.50-0.78]) and following diagnosis less likely to be TOPFA (adjOR 0.40 [95% CI 0.27-0.59]). CONCLUSIONS The risk of DS per fetus/baby is lower in multiple than singleton pregnancies. These estimates can be used for genetic counselling and prenatal screening.
Collapse
Affiliation(s)
- B Boyle
- EUROCAT Central Registry, Centre for Maternal Fetal and Infant Research, Institute for Nursing and Health Research, University of Ulster, Newtownabbey, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Optimal antenatal care for twin and triplet pregnancy: The evidence base. Best Pract Res Clin Obstet Gynaecol 2014; 28:305-17. [DOI: 10.1016/j.bpobgyn.2013.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 11/06/2013] [Accepted: 12/10/2013] [Indexed: 11/21/2022]
|
18
|
Gagnon A, Audibert F. Prenatal screening and diagnosis of aneuploidy in multiple pregnancies. Best Pract Res Clin Obstet Gynaecol 2013; 28:285-94. [PMID: 24485166 DOI: 10.1016/j.bpobgyn.2013.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 12/17/2013] [Indexed: 11/29/2022]
Abstract
Prenatal screening for aneuploidy has changed significantly over the last 30 years, from being age-based to maternal serum and ultrasound based techniques. Multiple pregnancies present particular challenges with regards to screening as serum-based screening techniques are influenced by all feti while ultrasound-based techniques can be fetus specific. Tests currently available tend to not perform as well in multiple compared to singleton pregnancies. Considerations must be given to these variations when discussing and performing screening for aneuploidy in this situation. Prenatal invasive diagnosis techniques in multiple pregnancies bring their own challenges from a technical and counselling point of view, in particular with regards to sampling error, mapping and assignment of results and management of abnormal results. This review addresses these particular challenges and provides information to facilitate care.
Collapse
Affiliation(s)
- Alain Gagnon
- University of British Columbia, Vancouver, British Columbia, Canada.
| | | |
Collapse
|
19
|
Flöck A, Reinsberg J, Berg C, Gembruch U, Geipel A. Impact of chorionicity on first-trimester nuchal translucency screening in ART twin pregnancies. Prenat Diagn 2013; 33:722-5. [DOI: 10.1002/pd.4107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 03/04/2013] [Accepted: 03/05/2013] [Indexed: 11/11/2022]
Affiliation(s)
- A. Flöck
- Department of Obstetrics and Prenatal Medicine; University Medical School Bonn; Bonn Germany
| | - J. Reinsberg
- Division of Reproductive Medicine and Gynecologic Endocrinology; University Medical School Bonn; Bonn Germany
| | - C. Berg
- Department of Obstetrics and Prenatal Medicine; University Medical School Bonn; Bonn Germany
- Division of Prenatal Medicine and Gynaecologic Ultrasound; University of Cologne; Cologne Germany
| | - U. Gembruch
- Department of Obstetrics and Prenatal Medicine; University Medical School Bonn; Bonn Germany
| | - A. Geipel
- Department of Obstetrics and Prenatal Medicine; University Medical School Bonn; Bonn Germany
| |
Collapse
|
20
|
Prats P, Rodríguez I, Comas C, Puerto B. Analysis of three different strategies in prenatal screening for Down's syndrome in twin pregnancies. J Matern Fetal Neonatal Med 2013; 26:1404-9. [PMID: 23488563 DOI: 10.3109/14767058.2013.784252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To compare the performance of three different strategies in prenatal screening for Down's syndrome in twins [nuchal translucency, the combined test, the combined test + ductus venosus pulsatility index (DVPI)]. METHODS We included 277 twin pregnancies with two cases of trisomy 21 (both dichorionic). We performed a computer simulation of Down's syndrome NT screening, combined test screening and the combined test with the addition of DVPI screening using the commercialized software SsdwLab6. The strategies were compared using the area under the receiver operating characteristic curve. RESULTS NT screening false-positive rate (FPR) was 10.9% (95% CI: 8.3-13.5). The combined test FPR was 6.2% (95% CI: 4.1-8.2%) and the combined test plus DVPI was 6% (95% CI: 4-8). FPR was higher in advanced maternal age patients. Detection rate was 100% in all cases. The area under the curve was 0.987 (95% CI: 0.972-0.994) in NT screening; 0.987 (95% CI: 0.978-0.997) in the combined test and 0.983 (95% CI: 0.977-0.996) in the combined test + DVPI. CONCLUSIONS Down's syndrome screening is feasible in twins with low FPR. The results of this study are similar to the results achieved in singletons. The combined test appears to be the most effective. The addition of DVIP does not significantly improve the prenatal screening for trisomy 21.
Collapse
Affiliation(s)
- Pilar Prats
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain.
| | | | | | | |
Collapse
|
21
|
Abstract
OBJECTIVE To review the literature with respect to the use of diagnostic ultrasound in the management of twin pregnancies. To make recommendations for the best use of ultrasound in twin pregnancies. OUTCOMES Reduction in perinatal mortality and morbidity and short- and long-term neonatal morbidity in twin pregnancies. Optimization of ultrasound use in twin pregnancies. EVIDENCE Published literature was retrieved through searches of PubMed and the Cochrane Library in 2008 and 2009 using appropriate controlled vocabulary (e.g., twin, ultrasound, cervix, prematurity) and key words (e.g., acardiac, twin, reversed arterial perfusion, twin-to-twin transfusion syndrome, amniotic fluid). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions. Studies were restricted to those with available English or French abstracts or text. Searches were updated on a regular basis and incorporated into the guideline to September 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The evidence collected was reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada, with input from members of the Maternal Fetal Medicine Committee and the Genetics Committee of the SOGC. The recommendations were made according to the guidelines developed by The Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS The benefit expected from this guideline is facilitation and optimization of the use of ultrasound in twin pregnancy. SUMMARY STATEMENTS: 1. There are insufficient data to make recommendations on repeat anatomical assessments in twin pregnancies. Therefore, a complete anatomical survey at each scan may not be needed following a complete and normal assessment. (III) 2. There are insufficient data to recommend a routine preterm labour surveillance protocol in terms of frequency, timing, and optimal cervical length thresholds. (II-2) 3. Singleton growth curves currently provide the best predictors of adverse outcome in twins and may be used for evaluating growth abnormalities. (III) 4. It is suggested that growth discordance be defined using either a difference (20 mm) in absolute measurement in abdominal circumference or a difference of 20% in ultrasound-derived estimated fetal weight. (II-2) 5. Although there is insufficient evidence to recommend a specific schedule for ultrasound assessment of twin gestation, most experts recommend serial ultrasound assessment every 2 to 3 weeks, starting at 16 weeks of gestation for monochorionic pregnancies and every 3 to 4 weeks, starting from the anatomy scan (18 to 22 weeks) for dichorionic pregnancies. (II-1) 6. Umbilical artery Doppler may be useful in the surveillance of twin gestations when there are complications involving the placental circulation or fetal hemodynamic physiology. (II-2) 7. Although many methods of evaluating the level of amniotic fluid in twins (deepest vertical pocket, single pocket, amniotic fluid index) have been described, there is not enough evidence to suggest that one method is more predictive than the others of adverse pregnancy outcome. (II-3) 8. Referral to an appropriate high-risk pregnancy centre is indicated when complications unique to twins are suspected on ultrasound. (II-2) These complications include: 1. Twin-to-twin transfusion syndrome 2. Monoamniotic twins gestation 3. Conjoined twins 4. Twin reversed arterial perfusion sequence 5. Single fetal death in the second or third trimester 6. Growth discordance in monochorionic twins. Recommendations 1. All patients who are suspected to have a twin pregnancy on first trimester physical examination or who are at risk (e.g., pregnancies resulting from assisted reproductive technologies) should have first trimester ultrasound performed. (II-2A) 2. Every attempt should be made to determine and report amnionicity and chorionicity when a twin pregnancy is identified. (II-2A) 3. Although the accuracy in confirmation of gestational age at the first and second trimester is comparable, dating should be done with first trimester ultrasound. (II-2A) 4. Beyond the first trimester, it is suggested that a combination of parameters rather than a single parameter should be used to confirm gestational age. (II-2C) 5. When twin pregnancy is the result of in vitro fertilization, accurate determination of gestational age should be made from the date of embryo transfer. (II-1A) 6. There is insufficient evidence to make a recommendation of which fetus (when discordant for size) to use to date a twin pregnancy. However, to avoid missing a situation of early intrauterine growth restriction in one twin, most experts agree that the clinician may consider dating pregnancy using the larger fetus. (III-C) 7. In twin pregnancies, aneuploidy screening using nuchal transluscency measurements should be offered. (II-2B) 8. Detailed ultrasound examination to screen for fetal anomalies should be offered, preferably between 18 and 22 weeks' gestation, in all twin pregnancies. (II-2B) 9. When ultrasound is used to screen for preterm birth in a twin gestation, endovaginal ultrasound measurement of the cervical length should be performed. (II-2A) 10. Increased fetal surveillance should be considered when there is either growth restriction diagnosed in one twin or significant growth discordance. (II-2A) 11. Umbilical artery Doppler should not be routinely offered in uncomplicated twin pregnancies. (I-E) 12. For defining oligohydramnios and polyhydramnios, the ultrasonographer should use the deepest vertical pocket in either sac: oligohydramnios when < 2 cm and polyhydramnios when > 8 cm. (II-2B).
Collapse
|
22
|
Nakajima Y, Masaoka N. Neonatal periventricular leukomalacia without evidence of twin-to-twin transfusion syndrome following discordance in nuchal translucency: a case report. J Med Ultrason (2001) 2012; 39:181-5. [DOI: 10.1007/s10396-012-0353-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 01/17/2012] [Indexed: 10/28/2022]
|
23
|
Lepage N, Chaudhry A, Konforte D, Shaw J, Veljkovic K, Dennis A, Rashid S, Farrell SA. Standardized Procedural Practices of the Ontario Prenatal Screening Program for aneuploidies and open neural tube defects. Clin Biochem 2012; 45:1152-7. [PMID: 22732525 DOI: 10.1016/j.clinbiochem.2012.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 06/13/2012] [Accepted: 06/14/2012] [Indexed: 01/23/2023]
Abstract
BACKGROUND/OBJECTIVES The Ontario Prenatal Screening Program (OPSP) follows internationally recognized standardized procedures for laboratories and genetics clinics. However, it has been found that some procedures are subject to interpretation, so the current procedures are designed to facilitate a unified approach in the interpretation of literature recommendations. In Ontario, the OPSP offers multiple screening modalities with integrated prenatal screening (including both first and second trimester markers) being the most commonly chosen option. Other screening modalities include first trimester screening, second trimester quad screening, serum integrated screening, and NT-Quad. METHODS The standardization was based on a literature review and on current practices in Ontario. RESULTS/DISCUSSION The main finding of the review was a paucity of published data relating to the procedures and the decision-making processes involved in prenatal screening. The purpose of this publication is to provide the most up-to-date and pertinent information for clinical laboratory professionals involved with prenatal screening for Down syndrome, trisomy 18 and open neural tube defects.
Collapse
Affiliation(s)
- Nathalie Lepage
- Department of Pathology and Laboratory Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Linskens IH, de Mooij YM, Twisk JW, Kist WJ, Oepkes D, van Vugt JM. Discordance in Nuchal Translucency Measurements in Monochorionic Diamniotic Twins as Predictor of Twin-to-Twin Transfusion Syndrome. Twin Res Hum Genet 2012; 12:605-10. [DOI: 10.1375/twin.12.6.605] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractObjective:Discordance in nuchal translucency measurements in monochorionic diamniotic twin pregnancies was assessed as predictor of Twin-to-Twin Transfusion Syndrome.Study Design:A total of 61 monochorionic diamniotic twins were enrolled. Nuchal translucency (NT) and crown-rump-length (CRL) discordance was calculated as the percentage of delta NT and CRL (absolute difference NT/CRL fetus 1 and fetus 2) of the largest measurement, and correlated with subsequent development of Twin-to-Twin Transfusion Syndrome.Results:Twin-to-Twin Transfusion Syndrome developed in 14/61 (23%) of cases. A NT discordance of 20% or more best predicted Twin-to-Twin Transfusion Syndrome development, with a sensitivity of 64% and a specificity of 78%. We found a positive predictive value of 50% and negative predicted value of 86% for Twin-to-Twin Transfusion Syndrome development if NT discordance was 20% or more.Conclusion:NT discordance of more than 20% in monochorionic diamniotic twins is associated with an increased risk for subsequent development of Twin-to-Twin Transfusion Syndrome, and with earlier presentation of symptoms.
Collapse
|
25
|
Are first-trimester screening markers altered in assisted reproductive technologies pregnancies? Curr Opin Obstet Gynecol 2011; 23:183-9. [PMID: 21415744 DOI: 10.1097/gco.0b013e3283455972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review the current literature on first-trimester screening with respect to specific issues for assisted reproductive technologies (ARTs) singleton and twin pregnancies. RECENT FINDINGS A number of different first-trimester sonographic and biochemical markers have been validated in first-trimester screening for trisomy 21. Among sonographic markers, measurement of fetal nuchal translucency is the most investigated and least affected screening method in ART pregnancies, achieving comparable results in singletons and twins compared with spontaneous conceptions. The small deviation of nuchal translucency thickness observed in ART singletons did not influence overall screening performance, including the number of false-positive results. First-trimester maternal serum free β-human chorionic gonadotropin and pregnancy-associated plasma protein-A levels are more obviously altered in assisted conceptions and carry the risk of higher false-positive rates if not adjusted accordingly. The reason behind the alterations is currently not quite explored, but might be attributed to infertility and a higher incidence of placental disorders rather than to the use of ART. In twin pregnancies, chorionicity is an important confounding variable with evident impact on nuchal translucency measurements and maternal biochemistry, but both issues have not been sufficiently investigated in ART twins so far. SUMMARY First-trimester measurement of fetal nuchal translucency in singleton and twin gestations is associated with similar screening results when compared with spontaneous conception. Adjustments for the mode of conception are required if maternal serum biochemistry is included in the screening algorithm. Further studies on assisted conception twins are essential to permit more conclusive results on this issue.
Collapse
|
26
|
Audibert F, Gagnon A, Douglas Wilson R, Audibert F, Blight C, Brock JA, Cartier L, Désilets VA, Gagnon A, Johnson JA, Langlois S, Murphy-Kaulbeck L, Okun N, Pastuck M, Senikas V, Langlois S, Chitayat D, Désilets VA, Geraghty MT, Marcadier J, Nelson TN, Skidmore D, Siu V, Tihy F. Prenatal Screening for and Diagnosis of Aneuploidy in Twin Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2011. [DOI: 10.1016/s1701-2163(16)34963-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
27
|
|
28
|
Affiliation(s)
- Kypros H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital,London, UK and Department of Fetal Medicine, University College Hospital, London, UK.
| |
Collapse
|
29
|
Madsen HN, Ball S, Wright D, Tørring N, Petersen OB, Nicolaides KH, Spencer K. A reassessment of biochemical marker distributions in trisomy 21-affected and unaffected twin pregnancies in the first trimester. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:38-47. [PMID: 20878678 DOI: 10.1002/uog.8845] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To estimate the difference between levels of the two biochemical markers pregnancy-associated plasma protein-A (PAPP-A) and maternal serum free β-human chorionic gonadotropin (free β-hCG) in twin pregnancies relative to singleton pregnancies and establish an improved screening procedure for chromosomal abnormalities such as trisomy 21 in twin pregnancies. METHODS 4843 unaffected and 47 trisomy 21-affected twin pregnancies were included in the study. Chorionicity-specific medians were generated for PAPP-A and free β-hCG from gestational ages 8 to 14 weeks. Multiple of the median values for each of the biochemical markers were calculated. Detection rates and false-positive rates were estimated for screening tests incorporating nuchal translucency and maternal age, with and without biochemistry. RESULTS Medians for the two biochemical markers for monochorionic and dichorionic twins in unaffected pregnancies show a gestational age-specific increase relative to singleton medians. Allowing for gestation and chorionicity, twin pregnancies affected with trisomy 21 had higher levels of free β-hCG and lower levels of PAPP-A. Adding biochemistry into the risk assessment using a fixed risk cut-off of 1 in 100 increased the detection rate for fetal trisomy 21 in dizygotic twin pregnancies from 78 to 90%, and decreased the false-positive rate from 8.0 to 5.9%. CONCLUSION Generation of chorionicity-specific medians for the biochemical markers and their use in risk assessment can improve the performance of first-trimester screening for chromosomal abnormalities in twins to a level comparable with that in singleton pregnancies.
Collapse
Affiliation(s)
- H N Madsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Skejby, Denmark.
| | | | | | | | | | | | | |
Collapse
|
30
|
Tchirikov M. Monochorionic twin pregnancy: screening, pathogenesis of complications and management in the era of microinvasive fetal surgery. J Perinat Med 2010; 38:451-9. [PMID: 20629496 DOI: 10.1515/jpm.2010.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The management of monochorionic (MC) twin pregnancies varies in different medical centers. This paper compares screening methods to predict the complications of the MC twin pregnancy and different treatment methods. METHODS We performed a literature search without language restriction in Cochrane library and PubMed (1970-2009). Case series and cohort screening studies, pathogenesis and management of complications of MC pregnancy were included. RESULTS Elevated risk for intrauterine fetal death (IUFD) and twin-to-twin transfusion syndrome (TTTS) can be detected sonographically. Monitoring of MC pregnancies at increased risk and regular training sessions for the operating team combined with reduced fetoscopic amniotic membrane damage increase fetal survival rate from laser coagulation to nearly 100% for at least one fetus and to 90% for both. CONCLUSION Monitoring of MC pregnancies at increased risk and laser treatment of TTTS in medical centers with sufficient experience might improve neonatal outcome.
Collapse
Affiliation(s)
- Michael Tchirikov
- Department of Obstetrics and Fetal Medicine, Clinic of Obstetrics and Gynecology, University Medical Center of Johannes Gutenberg University Mainz, Mainz, Germany.
| |
Collapse
|
31
|
Cheng PJ, Huang SY, Shaw SW, Hsiao CH, Kao CC, Chueh HY, Hsieh TT. Difference in nuchal translucency between monozygotic and dizygotic spontaneously conceived twins. Prenat Diagn 2010; 30:247-50. [DOI: 10.1002/pd.2450] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
32
|
Abstract
OBJECTIVES To determine the most efficient and tailored screening method for aneuploidies in twins for the French population. MATERIAL AND METHODS Articles were searched using the PubMed and the Cochrane libraries. RESULTS In cases of twin pregnancies, the aneuploidy's risk related to maternal age as well as gestational age must be considered as being the same as in singletons. In bichorionic twins, we have to consider individually the nuchal translucency thickness of each twin. In monochorionic twins, we have to consider a range of risks related to the nuchal translucency measurements of each twins. The additional benefit of maternal serum biochemistry screening in twins is not as established as in singletons. CONCLUSION The most appropriate method of screening for aneuploidies in twin pregnancies is based during the first trimester of pregnancy on the risk related to maternal age combined with those related to the nuchal translucency measurement. In the absence of first-trimester screening, it is possible to offer a screening method based on the second trimester maternal serum biochemistry and/or by a targeted ultrasound.
Collapse
Affiliation(s)
- E Quarello
- Hôpital Saint-Joseph, Pôle Parents-Enfants, Unité d'échographie obstétricale, Service de gynécologie-obstétrique, 26, bd de Louvain, 13285 Marseille cedex 8, France.
| |
Collapse
|
33
|
Zoppi MA. Nuchal translucency screening in monochorionic twin pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:491-493. [PMID: 19852038 DOI: 10.1002/uog.7465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
|
34
|
Sepulveda W, Wong AE, Casasbuenas A. Nuchal translucency and nasal bone in first-trimester ultrasound screening for aneuploidy in multiple pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 33:152-156. [PMID: 18985621 DOI: 10.1002/uog.6222] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To review our experience with first-trimester screening of chromosomal abnormalities in multiple pregnancies using nuchal translucency (NT) thickness measurement and nasal bone assessment. METHODS Cases of multiple pregnancy presenting for first-trimester ultrasound evaluation and with viable fetuses measuring between 45 and 84 mm were recruited for this study. Crown-rump length, NT thickness, the presence or absence of the nasal bone and chorionicity were determined and the information prospectively collected in a dedicated database. RESULTS There were 206 twin pregnancies, eight sets of triplets, and one set of quadruplets, totalling 440 screened fetuses. Information on perinatal outcome was available in all cases. The NT thickness was measured in all cases and was found to be greater than the 95(th) percentile in six (8.6%) of the 70 monochorionic fetuses and in 10 (2.7%) of the 370 dichorionic fetuses (P < 0.05, Fisher's exact test). The nasal bone was successfully assessed in 421 of the 440 (95.7%) fetuses and found to be absent in only four cases, three of which were found to have aneuploidy. Chromosomal abnormalities were diagnosed in six fetuses from one monochorionic and four dichorionic twin pregnancies. Five of the six affected cases were associated with increased NT thickness (sensitivity 83.3%), whereas the nasal bone was absent in only three of the aneuploid fetuses (sensitivity 50%). CONCLUSIONS First-trimester ultrasound screening for chromosomal abnormalities using NT thickness in multiple pregnancies is highly sensitive. However, nasal bone assessment is not only limited in sensitivity but also more challenging in multiple than in singleton pregnancies owing to difficulties in obtaining adequate views of the fetal face.
Collapse
Affiliation(s)
- W Sepulveda
- Fetal Medicine Center, Department of Obstetrics and Gynecology, Clinica Las Condes, Santiago, Chile.
| | | | | |
Collapse
|
35
|
Goncé A, Borrell A, Casals E, Steinvarcel F, Serés A, Cararach V, Gratacós E. Cribado de aneuploidía en gestación gemelar: resultados de la aplicación del test combinado. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s0304-5013(08)73319-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
36
|
Casasbuenas A, Wong AE, Sepulveda W. Nuchal translucency thickness in monochorionic multiple pregnancies: value in predicting pregnancy outcome. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2008; 27:363-369. [PMID: 18314514 DOI: 10.7863/jum.2008.27.3.363] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the value of first-trimester nuchal translucency (NT) thickness in predicting the pregnancy outcome in monochorionic multiple pregnancies. METHODS Thirty monochorionic multiple pregnancies were evaluated for NT thickness at a median gestational age of 12 weeks (range, 11-14 weeks). Information on pregnancy outcome was obtained from all cases. A poor pregnancy outcome was defined as fetal death or miscarriage before 24 weeks, development of twin-twin transfusion syndrome (TTTS), or preterm delivery before 32 weeks. RESULTS The NT thickness was above the 95th percentile for gestational age in at least 1 fetus in 5 (17%) pregnancies, and a poor pregnancy outcome was recorded in 14 (47%) pregnancies. The overall sensitivity was 36% (5/14); specificity, 100% (16/16); positive predictive value, 100% (5/5); and negative predictive value, 64% (16/25). In pregnancies with increased compared with normal NT thickness, no significant correlation was found with the subsequent development of TTTS (1/5 [20%] versus 5/25 [20%]) and miscarriage or fetal death before 24 weeks (1/5 [20%] versus 3/25 [12%]). However, among the 20 pregnancies not complicated by TTTS or loss before 24 weeks, there was a significantly increased rate of delivery before 32 weeks in the former group (3/4 [75%] versus 1/16 [6.3%]; P = .01). CONCLUSIONS In monochorionic multiple pregnancies, an increased NT thickness measurement had a high specificity and positive predictive value for adverse perinatal outcomes. However, the sensitivity and negative predictive value were low, with a normal NT thickness measurement poorly predicting development of complications; therefore, close sonographic follow-up should be carried out in all cases, irrespective of NT thickness.
Collapse
Affiliation(s)
- Alexandra Casasbuenas
- Fetal Medicine Center, Department of Obstetrics and Gynecology, Clinica Las Condes, Santiago, Chile
| | | | | |
Collapse
|
37
|
Spencer K, Kagan KO, Nicolaides KH. Screening for trisomy 21 in twin pregnancies in the first trimester: an update of the impact of chorionicity on maternal serum markers. Prenat Diagn 2008; 28:49-52. [DOI: 10.1002/pd.1923] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
38
|
Quarello E, Ville Y. [Screening for aneuploidies in twins]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2007; 35:1195-1203. [PMID: 18037327 DOI: 10.1016/j.gyobfe.2007.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Accepted: 09/21/2007] [Indexed: 05/25/2023]
Abstract
The incidence of twins has dramatically increased in the last two decades. The theorical risk of aneuploidy is higher than in singletons. Screening for aneuploidies should be offered in all twin pregnancies. This review examines the current methods and evidence regarding screening for fetal aneuploidies in twin pregnancies.
Collapse
Affiliation(s)
- E Quarello
- Service de gynécologie-obstétrique, centre hospitalier intercommunal de Poissy, 10, rue du Champ-Gaillard, 78303 Poissy, France.
| | | |
Collapse
|
39
|
Abstract
First-trimester risk assessment for fetal aneuploidy using nuchal translucency (NT) measurement is rapidly gaining popularity in the United States. In combination with maternal serum markers in the first trimester, the screening performance is exceptionally good, with detection rates of more than 80% at a screen positive rate of 5%. Recently, the method has been validated for screening for Down syndrome and other aneuploidies in multicenter trials in the United States and elsewhere. Compliance with established criteria for measurement of the NT is essential to achieve uniform reliability and high screening test sensitivity. There is an international consensus about the importance of specific training in the NT examination, conformity to standards of NT measurement, and regular audit for quality assurance. In the United States, the Nuchal Translucency Quality Review program has been developed to administer credentialing and quality review for registered practitioners. The Nuchal Translucency Quality Review credentials signify the proficiency of the sonographer or sonologist in NT measurement and participation in a regular quality assurance audit. We encourage accreditation of clinical sites offering first-trimester risk assessment to ensure the highest quality care.
Collapse
Affiliation(s)
- Celeste Sheppard
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, TX, USA.
| | | |
Collapse
|
40
|
Breathnach FM, Malone FD. Screening for aneuploidy in first and second trimesters: is there an optimal paradigm? Curr Opin Obstet Gynecol 2007; 19:176-82. [PMID: 17353686 DOI: 10.1097/gco.0b013e3280895e00] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review serves to explore the recent literature regarding aneuploidy screening in both first and second trimesters. We aim to construct a comparative analysis of a range of proposed strategies for screening for trisomy 21. RECENT FINDINGS First trimester combined screening (sonographic nuchal translucency combined with serum markers pregnancy-associated plasma protein A and the free beta subunit of human chorionic gonadotrophin) has superseded second trimester serum screening (alpha-fetoprotein, total human chorionic gonadotrophin, unconjugated estriol with or without inhibin-A) as a screening paradigm for the detection of trisomy 21. This move is attributed to the recognition of superior detection rates, lower false-positive rates and earlier results associated with the former strategy. Septated cystic hygroma has been recognized as a distinct entity which confers a high risk of aneuploidy and structural malformations. Further advances in screening performance are achievable by combining the results of first and second-trimester screens in a sequential manner, with much interest generated by programs that only include second-trimester testing contingent upon first-trimester results. SUMMARY Screening strategies for aneuploidy continue to evolve, with the most recent evidence favouring a contingent sequential approach.
Collapse
Affiliation(s)
- Fionnuala M Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | | |
Collapse
|
41
|
Walker SP, Meagher S, White SM. Confined blood chimerism in monochorionic dizygous (MCDZ) twins. Prenat Diagn 2007; 27:369-72. [PMID: 17286316 DOI: 10.1002/pd.1670] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To present the risk factors, prenatal and postnatal implications of monochorionic dyzygotic twinning. METHODS We present a case of monochorionic twins diagnosed on first-trimester ultrasound following a 2-embryo transfer in vitro fertilisation pregnancy. Postnatal buccal smears performed as part of a twin research study revealed the twins to be dizygous, and DNA testing on peripheral blood lymphocytes confirmed the presence of blood chimerism. RESULTS Despite the monochorionic placentation, buccal swabs revealed discordant results for all four microsatellite loci tested, consistent with dizygosity. Zygosity testing on peripheral blood lymphocytes revealed that, of the nine DNA microsatellite loci tested, three had all four parental alleles represented. This result was concordant between the twins. The diagnosis of blood chimerism was thus confirmed, presumably due to the inter-twin vascular anastomoses of the monochorionic placenta. CONCLUSION Monochorionic dizygous twinning is rare, but appears to be more common after assisted reproduction. It is presumed that outer cell mass fusion may occur when two embryos are replaced in close proximity. These pregnancies are not only at risk for the usual complications of monochorionicity, but also have the potential to be heterokaryotypic. Postnatally, the twins may have long-term blood chimerism.
Collapse
Affiliation(s)
- Susan P Walker
- Perinatal Medicine, Mercy Hospital for Women, 163 Studley Road, Heidelberg 3084, Australia.
| | | | | |
Collapse
|
42
|
Cheng PJ, Shaw SW, Shih JC, Soong YK. Monozygotic twins discordant for monosomy 21 detected by first-trimester nuchal translucency screening. Obstet Gynecol 2006; 107:538-41. [PMID: 16449179 DOI: 10.1097/00006250-200602001-00041] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chromosomal abnormality in one fetus of a monozygotic twin pregnancy is rare, and discussion of prenatal detection of such a case offers some insight into this clinical problem. CASE A 28-year-old gravida 1 had ultrasound screening at 11 weeks of gestation that revealed a monochorionic, diamniotic twin pregnancy with increased nuchal translucency (7.7 mm) in one fetus. Subsequent evaluation showed one 45,XY,-21 karyotype and one normal male karyotype. The pregnancy was monozygous by DNA analysis. The affected neonate died 5 minutes after delivery of both twins by cesarean. CONCLUSION Monochorionic twins discordant for fetal abnormalities can be evaluated with molecular analysis. Study of such cases may reveal the extent to which an early diagnosis can lead to therapeutic interventions to support survival of the viable twin.
Collapse
Affiliation(s)
- Po-Jen Cheng
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taiwan.
| | | | | | | |
Collapse
|
43
|
Current awareness in prenatal diagnosis. Prenat Diagn 2005. [DOI: 10.1002/pd.1025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
44
|
Abstract
There is extensive evidence that effective screening for major chromosomal abnormalities can be provided in the first trimester of pregnancy. Randomized studies have established that the risk of miscarriage from chorionic villus sampling in the first trimester is the same as for amniocentesis in the second trimester. Prospective studies have demonstrated that screening by a combination of fetal nuchal translucency (NT) and maternal serum free-beta-human chorionic gonadotropin (hCG) and pregnancy-associated plasma protein-A (PAPP-A) can identify 90% of fetuses with trisomy 21 and other major chromosomal abnormalities for a false-positive rate of 5%. This is superior to the 30% detection rate achieved by maternal age and 65% by second-trimester maternal serum biochemistry. A further improvement in the effectiveness of first-trimester screening is likely to be achieved by a risk-orientated two-stage approach. In this, the patients are subdivided into a high-risk group, requiring invasive testing, a low-risk group, which can be reassured that an abnormality is unlikely, and an intermediate-risk group (risk of 1 in 101 to 1 in 1000), in which further assessment is performed by first-trimester ultrasound examination (for presence/absence of the nasal bone or presence/absence of tricuspid regurgitation or normal/abnormal Doppler velocity waveform in the ductus venosus), and chorionic villus sampling is performed if their adjusted risk becomes 1 in 100 or more. As with all aspects of good clinical practice, those performing first-trimester scans should be appropriately trained and their results subjected to external quality assurance. This process was well established by the Fetal Medical Foundation several years ago and is widely accepted internationally.
Collapse
Affiliation(s)
- Kypros H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College, London University, London, UK.
| |
Collapse
|