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Kalafat E, Liu B, Barratt I, Bhate R, Papageorghiou A, Khalil A. Risk factors associated with stillbirth and adverse perinatal outcomes in dichorionic twin pregnancies complicated by selective fetal growth restriction: a cohort study. BJOG 2024; 131:189-198. [PMID: 37308720 DOI: 10.1111/1471-0528.17564] [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: 08/29/2022] [Revised: 03/18/2023] [Accepted: 05/18/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The main aim of this study was to investigate the perinatal outcomes of dichorionic twin pregnancies complicated by selective fetal growth restriction (sFGR). DESIGN Retrospective cohort study. SETTING Tertiary reference centre. POPULATION Dichorionic twin pregnancies complicated by sFGR between 2000 and 2019 in St George's University Hospital. METHODS Regression analyses were performed using generalised linear models and mixed-effects generalised linear models where appropriate to account for pregnancy level dependency in variables. Time to event analyses were performed with mixed-effects Cox regression models. MAIN OUTCOME MEASURES Stillbirth, neonatal death or neonatal unit admission with morbidity in one or both twins. RESULTS A total of 102 (of 2431 dichorionic twin pregnancies) pregnancies complicated by sFGR were included in the study. The Cochrane-Armitage test revealed a significant trend for increased adverse perinatal outcome rates with more severe forms of umbilical artery flow impedance, i.e. reversed, absent, positive with resistant flow and positive flow without resistance. A multivariable model including maternal and conception characteristics had poor predictive accuracy for stillbirth (area under the curve: 0.68, 95% confidence interval [CI] 0.55-0.81) and composite adverse perinatal outcomes (area under the curve: 0.58, 95% CI 0.47-0.70). When umbilical artery Doppler parameters were added to the models, the area under the curve values improved to 0.95 (95% CI 0.89-0.99) and 0.83 (95% CI 0.73-0.92) for stillbirth and composite adverse perinatal outcomes, respectively. CONCLUSION In dichorionic twin pregnancies complicated by sFGR, the umbilical artery Z-scores were associated with both intrauterine death and adverse perinatal outcomes.
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Affiliation(s)
- Erkan Kalafat
- Department of Obstetrics and Gynaecology, School of Medicine, Koc University, Istanbul, Turkey
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey
| | - Becky Liu
- Fetal Medicine Unit, St George's University Hospitals, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals, London, UK
| | - Imogen Barratt
- Fetal Medicine Unit, St George's University Hospitals, London, UK
| | - Rohan Bhate
- Fetal Medicine Unit, St George's University Hospitals, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals, London, UK
| | | | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Kawaguchi H, Kuritani Y, Yamamoto R, Hayashi S, Ishii K. Neonatal respiratory complications in twins at 36-38 weeks of gestation. Pediatr Int 2024; 66:e15767. [PMID: 38924178 DOI: 10.1111/ped.15767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 02/20/2024] [Accepted: 03/12/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Twin pregnancies are associated with a high risk of perinatal mortality and morbidity. Late preterm or early term delivery is frequently performed to avoid unexpected fetal death in uncomplicated twin pregnancies. Nonetheless, delivery before full term is associated with neonatal respiratory complications. This study aimed to evaluate perinatal respiratory complications in twins delivered between 36 and 38 weeks of gestation. METHODS A retrospective cohort study was conducted on twins delivered between 36 and 38 weeks of gestation from January 2008 to June 2020. The primary outcomes were the incidence of composite neonatal respiratory morbidity, which included respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, mechanical ventilation or continuous positive airway pressure according to gestational age at delivery, and chorionicity. The relationship between gestational age at delivery and composite neonatal respiratory morbidity was evaluated using multivariate logistic regression analysis adjusted for potential confounders. RESULTS This study included 1608 twins (614 monochorionic diamniotic twins, 994 dichorionic diamniotic twins). At 36, 37, and 38 weeks of gestation, the frequencies of composite neonatal respiratory morbidity were 19.4%, 10.7%, and 9.2% in dichorionic diamniotic twins and 13.6%, 8.7%, and 9.4% in monochorionic diamniotic twins, respectively. In dichorionic diamniotic twins, the composite neonatal respiratory morbidity rate was higher for twins delivered at 36 weeks of gestation than for those delivered at 37 weeks. No significant differences between monochorionic diamniotic twins were detected. CONCLUSIONS In uncomplicated dichorionic diamniotic twin pregnancies, delivery should be considered after 37 weeks of gestation to reduce neonatal respiratory complications.
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Affiliation(s)
- Haruna Kawaguchi
- Department of Maternal-Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yoshihiro Kuritani
- Department of Obstetrics/Gynecology, Osaka General Medical Center, Osaka, Japan
| | - Ryo Yamamoto
- 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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Prasad S, Khalil A. Twin charts should be the standard reference to assess growth in twin pregnancy. Curr Opin Obstet Gynecol 2023; 35:403-410. [PMID: 37560793 DOI: 10.1097/gco.0000000000000898] [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: 08/11/2023]
Abstract
PURPOSE OF REVIEW Twin pregnancies are characterized by slower growth velocity compared with singletons, especially during the third trimester and, therefore, tend to be smaller than singletons. Growth surveillance is instrumental in the identification of twin pregnancies at risk of adverse outcomes. Whether the phenomenon of slow growth is an adaptive physiological response or represents pathological growth lag, is controversial. In this review, we focus on the evidence related to the types of growth charts employed for twin pregnancies. RECENT FINDINGS Consistent evidence has emerged over the past few years from large independent cohorts in different countries suggesting that twin-specific standards perform better in identifying growth-restricted twin pregnancies at risk of adverse perinatal outcomes, without resulting in an increase in interventions or iatrogenic prematurity. SUMMARY The current evidence supports the use of twin-specific reference charts. Concerted efforts should be made to derive prospective evidence from large multicentre studies on various aspects of the implementation of twin-specific standards.
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Affiliation(s)
- Smriti Prasad
- Fetal Medicine Unit, St George's University Hospital
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London
- Twins and Multiples Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospital
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London
- Twins and Multiples Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
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Assessment of fetal growth in twins: which method to use? Best Pract Res Clin Obstet Gynaecol 2022; 84:104-114. [DOI: 10.1016/j.bpobgyn.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 08/15/2022] [Indexed: 11/21/2022]
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Khalil A, Reed K. Key messages for obstetricians and fetal medicine specialists from the confidential enquiry into stillbirth and neonatal death in twins. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:799-803. [PMID: 33463820 DOI: 10.1002/uog.23594] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- A Khalil
- Twins Trust Centre for Research and Clinical Excellence, 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, St George's University Hospitals NHS Foundation Trust, London, UK
| | - K Reed
- Twins Trust, Aldershot, UK
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Khalil A. The rate of twin birth is declining. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:784-785. [PMID: 33629783 DOI: 10.1002/uog.23620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/08/2021] [Accepted: 02/12/2021] [Indexed: 06/12/2023]
Affiliation(s)
- A Khalil
- Twins Trust Centre for Research and Clinical Excellence, 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, St George's University Hospitals NHS Foundation Trust, London, UK
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Yu FNY, Mak ASL, Chan NM, Siu KL, Ma TWL, Leung KY. Prospective risk of stillbirth and neonatal complications for monochorionic diamniotic and dichorionic diamniotic twins after 24 weeks of gestation. J Obstet Gynaecol Res 2021; 47:3127-3135. [PMID: 34137119 DOI: 10.1111/jog.14866] [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: 01/05/2021] [Revised: 05/07/2021] [Accepted: 05/16/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Our study compared the prospective risks of intrauterine fetal death (IUFD), neonatal death (NND), perinatal death (PND), and neonatal morbidities in monochorionic diamniotic (MCDA) and dichorionic diamniotic (DCDA) twin pregnancies. METHODS This retrospective cohort study included twin pregnancies who had antenatal care and delivery in a public hospital from 2011 to 2018. Exclusion criteria included monoamnionicity, one/both twin miscarriage, twin-twin transfusion syndrome, or lethal congenital abnormalities. All twins were managed in multiple pregnancy clinic with standardized protocols. Gestational age-specific IUFD, NND, PND, and neonatal morbidity rates were compared according to chorionicity. RESULTS Three hundred seventy-eight MCDA and 1282 DCDA twins were included. MCDA twins had higher risks of PND (1.9% vs. 0.7% in DCDA twins, p = 0.05), composite neonatal morbidity (p = 0.01), preterm delivery (p < 0.01), and low birth weight (p < 0.01). The prospective risk of IUFD was 0.6% and 0.4% for MCDA and DCDA twins, respectively after 34 weeks' gestation. No NND occurred among deliveries after 30 weeks. The risk of neonatal morbidity of MCDA twins fell from 22.7% at 34 weeks to 2.7% at 37 weeks (p < 0.01). For DCDA twins, the risk of morbidity fell insignificantly from 36 to 38 weeks (4.0% vs. 3.4%, p = 0.60). Logistic regression analysis suggested that the increased risk of perinatal morbidities was related to the higher rate of preterm delivery in MCDA twins rather than chorionicity. CONCLUSION With close fetal monitoring, the risk of late IUFD in twin pregnancies without major complications is low. Perinatal morbidity can be minimized by avoiding late preterm deliveries in twin pregnancies.
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Affiliation(s)
- Florrie Nga Yui Yu
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Annisa Shui Lam Mak
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Ngai Man Chan
- Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Kiu Lok Siu
- Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Teresa Wei Ling Ma
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Kwok Yin Leung
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China.,Gleneagles Hong Kong, Hong kong Special Administrative Region, China
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Khalil A, Giallongo E, Bhide A, Papageorghiou AT, Thilaganathan B. Reduction in twin stillbirth following implementation of NICE guidance. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:566-571. [PMID: 32304623 DOI: 10.1002/uog.22051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 03/23/2020] [Accepted: 04/06/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE There has been an unprecedented fall in the rate of stillbirth in twin pregnancy in the UK. It is contested whether implementation of the National Institute for Health and Care Excellence (NICE) guidance on the antenatal management of uncomplicated twin pregnancies has contributed to this change. The aim of this study was to investigate whether the implementation of NICE guidance was associated with a reduction in the rate of stillbirth in twin pregnancies delivered in a large UK hospital. METHODS This was a retrospective cohort study including all twin pregnancies delivered at St George's Hospital, London, UK, between 2000 and 2018. Data were analyzed according to two time periods: before implementation of the NICE guidance on twins (before June 2013; pre-NICE) and after its implementation (after June 2013; post-NICE). The exclusion criteria were higher-order multiple gestations, pregnancies of unknown chorionicity, pregnancies complicated by miscarriage, those that underwent termination and those diagnosed with vanishing twin. The main outcome was stillbirth. Other outcomes included neonatal death (NND), admission to the neonatal intensive care unit (NICU) and emergency Cesarean section. We planned a priori a sensitivity analysis according to chorionicity. The chi-square test and Mann-Whitney U-test were used to compare outcomes between the study groups. RESULTS We included in the analysis 1666 twin pregnancies (3332 fetuses), of which 1114 pregnancies (2228 fetuses) were delivered before and 552 pregnancies (1104 fetuses) after June 2013. Of those, 1299 were dichorionic and 354 were monochorionic diamniotic. The incidence of stillbirth was significantly lower in the post-NICE than in the pre-NICE group (3.6 per 1000 births vs 13.5 per 1000 births; P = 0.008). The reduction in stillbirth rate was from 8.5 to 3.6 per 1000 births (P = 0.161) in dichorionic and from 33.6 to 3.8 per 1000 births (P = 0.011) in monochorionic diamniotic twin pregnancies. There was no significant difference in the rates of NND (P = 0.625), NICU admission (P = 0.506) or emergency Cesarean section (P = 0.820) between the two groups. The median gestational age at delivery was significantly lower in the post-NICE than in the pre-NICE group (median 36.3 vs 36.9 weeks; P < 0.001), as a consequence of a significant increase in preterm birth between 34 and 37 weeks' gestation (39.3% vs 27.0%; P = 0.002), but not before 34 weeks (P = 0.473). CONCLUSIONS A significant reduction of > 70% in the stillbirth rate in twin pregnancies was noted after implementation of the NICE guidance. This reduction was statistically significant in monochorionic, but not dichorionic, twin pregnancies. The improvement in twin pregnancy outcome was achieved without a concomitant increase in NND, admission to the NICU or emergency Cesarean section. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- 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 Hospital, London, UK
| | - E Giallongo
- 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
| | - A T Papageorghiou
- 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
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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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Gulati N, Mackie FL, Cox P, Marton T, Heazell A, Morris RK, Kilby MD. Cause of intrauterine and neonatal death in twin pregnancies (CoDiT): development of a novel classification system. BJOG 2020; 127:1507-1515. [PMID: 32359214 DOI: 10.1111/1471-0528.16291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Twin pregnancies have a significantly higher perinatal mortality than singleton pregnancies. Current classification systems for perinatal death lack twin-specific categories, potentially leading to loss of important information regarding cause of death. We introduce and test a classification system designed to assign a cause of death in twin pregnancies (CoDiT). DESIGN Retrospective cross-sectional study. SETTING Tertiary maternity unit in England with a perinatal pathology service. POPULATION Twin pregnancies in the West Midlands affected by fetal or neonatal demise of one or both twins between 1 January 2005 and 31 December 2016 in which postmortem examination was undertaken. METHODS A multidisciplinary panel designed CoDiT by adapting the most appropriate elements of singleton classification systems. The system was tested by assigning cause of death in 265 fetal and neonatal deaths from 144 twin pregnancies. Cause of death was validated by another obstetrician blinded to the original classification. MAIN OUTCOME MEASURES Inter-rater, intra-rater, inter-disciplinary agreement and cause of death. RESULTS Cohen's Kappa demonstrated 'strong' (>0.8) inter-rater, intra-rater and inter-disciplinary agreement (95% CI 0.70-0.91). The commonest cause of death irrespective of chorionicity was the placenta; twin-to-twin transfusion syndrome (TTTS) was the commonest placental cause in monochorionic twins and acute chorioamnionitis in dichorionic twins. CONCLUSIONS This novel classification system records causes of death in twin pregnancies from postmortem reports with high inter-user agreement. We highlight differences in aetiology of death between monochorionic and dichorionic twins. TWEETABLE ABSTRACT New classification system for #twin cause of death 'CoDiT' shows high rater agreement.
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Affiliation(s)
- N Gulati
- Institute of Metabolism & Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK
| | - F L Mackie
- Institute of Metabolism & Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK
| | - P Cox
- Cellular Pathology Department, Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - T Marton
- Cellular Pathology Department, Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Aep Heazell
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, UK.,St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R K Morris
- Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK.,Institute of Applied Health Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - M D Kilby
- Institute of Metabolism & Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK
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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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Kilby MD, Gibson JL, Ville Y. Falling perinatal mortality in twins in the UK: organisational success or chance? BJOG 2018; 126:341-347. [PMID: 30358075 DOI: 10.1111/1471-0528.15517] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2018] [Indexed: 11/28/2022]
Abstract
In June 2018, Mothers and Babies Reducing Risks through Audits and Confidential Enquiries across the UK (MBRRACE-UK) published a Perinatal Surveillance report of an audit between 2013-2016. This noted that the stillbirth rate for twins nearly halved between 2014-2016; whereas the stillbirth rate for singletons remained static. There was a statistically significant reduction in the rate of stillbirth in twins over this period from 11.07 (95% CI, 9.78-12.47) to 6.16 (95% CI, 5.20-7.24) per 1000 total births. This commentary discusses these observations, the effects of twin chorionicity, and the potential obstetric and neonatal interventions, as well as public health improvements, that may have influenced these findings.
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Affiliation(s)
- M D Kilby
- Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - J L Gibson
- Maternal and Fetal Medicine, Ian Donald Fetal Medicine Centre, Queen Elizabeth University Hospital, Glasgow, UK
| | - Y Ville
- Department of Obstetrics and Gynaecology, Paris Descartes University, Paris, France.,Department of Obstetrics and Fetal Medicine, Necker-Enfants-Malades Hospital, Paris, France
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