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Mok T, Afshar Y, Platt LD, Guo R, Rao RR, Pluym ID, Silverman NS, Han CS. Predicting Adverse Outcomes in Monochorionic-Diamniotic Twins: The Role of Intertwin Discrepancy in Middle Cerebral Artery Doppler Measurements and the Cerebroplacental Ratio. Am J Perinatol 2021; 38:1348-1357. [PMID: 34282577 DOI: 10.1055/s-0041-1732456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study was aimed to evaluate the role of intertwin discrepancy in middle cerebral artery peak systolic velocity (MCA-PSV) and cerebroplacental ratio (CPR) for the prediction of adverse outcomes in monochorionic-diamniotic (MCDA) twin pregnancies. STUDY DESIGN A retrospective cohort study of MCDA pregnancies that underwent ultrasound surveillance at a perinatal referral center from 2007 to 2017. Intertwin MCA-PSV discrepancy (MCA-ΔPSV-MoM) was defined as the absolute difference of MCA-PSV multiple of the median (MoM) for gestational age between twins. Intertwin CPR discrepancy (CPR-Δ) was defined as the absolute difference of CPR between twins. The maximum MCA-ΔPSV-MoM and CPR-Δ before and after 26 weeks of gestation were assessed as predictors of pregnancy and neonatal outcomes through simple logistic regression models and Pearson's correlation coefficients. Receiver operating characteristic (ROC) curves were generated to determine the predictive value of maximum MCA-ΔPSV-MoM and CPR-Δ. RESULTS A total of 143 MCDA pregnancies met inclusion criteria. There was a significant association between MCA-ΔPSV-MoM at <26 weeks and the development of twin anemia-polycythemia sequence (TAPS; p = 0.007), intrauterine fetal demise (IUFD; p = 0.009), and neonatal intensive care unit (NICU) admission (p < 0.05). MCA-ΔPSV-MoM at ≥26 weeks was associated with the development of TAPS (p < 0.001). CPR-Δ at <26 weeks was associated with the development of twin-twin transfusion syndrome (TTTS; p = 0.03) and NICU admission (p = 0.02). MCA-ΔPSV-MoM at ≥26 weeks was highly predictive of TAPS (area under curve [AUC] = 0.92). A cut-off of 0.44 would identify TAPS with 100% sensitivity and 73% specificity. CONCLUSION In MCDA pregnancies, intertwin MCA and CPR discrepancies are associated with adverse pregnancy and neonatal outcomes, including TAPS, TTTS, IUFD, and NICU admission. Evaluation of intertwin MCA and CPR differences demonstrated the potential for clinical predictive utility in the surveillance of MCDA twin pregnancies. KEY POINTS · Intertwin discrepancy of MCA-PSV and CPR is associated with adverse pregnancy outcomes.. · Intertwin differences in Doppler ultrasound may occur prior to meeting diagnostic criteria for TTTS or TAPS.. · There is potential clinical predictive utility in MCA and CPR surveillance of MCDA twin pregnancies..
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Affiliation(s)
- Thalia Mok
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Lawrence D Platt
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.,Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
| | - Rong Guo
- Department of Medicine Statistics Core, David Geffen School of Medicine, Los Angeles, California
| | - Rashmi R Rao
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Ilina D Pluym
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Neil S Silverman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.,Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
| | - Christina S Han
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.,Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
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Pessel C, Merriam A, Vani K, Brubaker SG, Zork N, Zhang Y, Simpson LL, Gyamfi-Bannerman C, Miller R. Do Doppler studies enhance surveillance of uncomplicated monochorionic diamniotic twins? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:569-575. [PMID: 25792571 DOI: 10.7863/ultra.34.4.569] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To determine whether isolated abnormal Doppler indices before 28 weeks predict adverse pregnancy outcomes in uncomplicated monochorionic diamniotic (MCDA) twins. METHODS A retrospective cohort study of MCDA twin pregnancies receiving antenatal testing at a single center between 2007 and 2013 was conducted. Sonographic surveillance, including Doppler velocimetric studies of the umbilical artery, ductus venosus, and middle cerebral artery of each twin, was initiated by 28 weeks and repeated at least every 2 weeks. All pregnancies were deemed "uncomplicated" at initial sonography, without evidence of polyhydramnios, oligohydramnios, intrauterine growth restriction, twin growth discordance of at least 20%, structural or chromosomal anomalies, or unclear chorionicity. Pregnancies were divided into 2 groups: those with isolated Doppler abnormalities before 28 weeks and those with normal Doppler indices. The primary outcome was a composite including twin-twin transfusion syndrome, intrauterine growth restriction of more than 1 twin, growth discordance of at least 20%, preterm delivery before 34 weeks for fetal indications, or demise of more than 1 fetus. RESULTS Ninety-six patients were included, with 22 (22.9%) having isolated Doppler abnormalities before 28 weeks. The incidence of the primary outcome did not differ between groups (36.4% versus 28.4%; P = .47). The abnormal Doppler group underwent a greater number of sonographic examinations (15 versus 10; P= .001) and more antenatal admissions for fetal concerns (50.0% versus 12.2%; P < .001). CONCLUSIONS Isolated Doppler abnormalities are commonly encountered in uncomplicated MCDA pregnancies before 28 weeks yet are not clearly predictive of twin-specific complications. Doppler abnormalities were associated with increased sonographic surveillance and antenatal hospitalizations, suggesting an influence on physician practice patterns. Data may not support Doppler studies before 28 weeks for routine MCDA twin monitoring.
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Affiliation(s)
- Cara Pessel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA (C.P., S.G.B., N.Z., L.L.S., C.G.-B., R.M.); Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, Delaware USA (A.M.); Columbia University College of Physicians and Surgeons, New York, New York USA (K.V.); and Department of Biostatistics, Joseph L. Mailman School of Public Health, Columbia University, New York, New York USA (Y.Z.)
| | - Audrey Merriam
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA (C.P., S.G.B., N.Z., L.L.S., C.G.-B., R.M.); Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, Delaware USA (A.M.); Columbia University College of Physicians and Surgeons, New York, New York USA (K.V.); and Department of Biostatistics, Joseph L. Mailman School of Public Health, Columbia University, New York, New York USA (Y.Z.)
| | - Kavita Vani
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA (C.P., S.G.B., N.Z., L.L.S., C.G.-B., R.M.); Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, Delaware USA (A.M.); Columbia University College of Physicians and Surgeons, New York, New York USA (K.V.); and Department of Biostatistics, Joseph L. Mailman School of Public Health, Columbia University, New York, New York USA (Y.Z.)
| | - Sara G Brubaker
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA (C.P., S.G.B., N.Z., L.L.S., C.G.-B., R.M.); Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, Delaware USA (A.M.); Columbia University College of Physicians and Surgeons, New York, New York USA (K.V.); and Department of Biostatistics, Joseph L. Mailman School of Public Health, Columbia University, New York, New York USA (Y.Z.)
| | - Noelia Zork
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA (C.P., S.G.B., N.Z., L.L.S., C.G.-B., R.M.); Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, Delaware USA (A.M.); Columbia University College of Physicians and Surgeons, New York, New York USA (K.V.); and Department of Biostatistics, Joseph L. Mailman School of Public Health, Columbia University, New York, New York USA (Y.Z.)
| | - Yuan Zhang
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA (C.P., S.G.B., N.Z., L.L.S., C.G.-B., R.M.); Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, Delaware USA (A.M.); Columbia University College of Physicians and Surgeons, New York, New York USA (K.V.); and Department of Biostatistics, Joseph L. Mailman School of Public Health, Columbia University, New York, New York USA (Y.Z.)
| | - Lynn L Simpson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA (C.P., S.G.B., N.Z., L.L.S., C.G.-B., R.M.); Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, Delaware USA (A.M.); Columbia University College of Physicians and Surgeons, New York, New York USA (K.V.); and Department of Biostatistics, Joseph L. Mailman School of Public Health, Columbia University, New York, New York USA (Y.Z.)
| | - Cynthia Gyamfi-Bannerman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA (C.P., S.G.B., N.Z., L.L.S., C.G.-B., R.M.); Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, Delaware USA (A.M.); Columbia University College of Physicians and Surgeons, New York, New York USA (K.V.); and Department of Biostatistics, Joseph L. Mailman School of Public Health, Columbia University, New York, New York USA (Y.Z.)
| | - Russell Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York USA (C.P., S.G.B., N.Z., L.L.S., C.G.-B., R.M.); Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, Delaware USA (A.M.); Columbia University College of Physicians and Surgeons, New York, New York USA (K.V.); and Department of Biostatistics, Joseph L. Mailman School of Public Health, Columbia University, New York, New York USA (Y.Z.)
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Hack KEA, Derks JB, Elias SG, van Mameren FA, Koopman-Esseboom C, Mol BWJ, Lopriore E, Schaap AHP, Arabin B, Duvekot JJ, Go ATJI, Wieselmann E, Eggink AJ, Willekes C, Vandenbussche FPHA, Visser GHA. Perinatal mortality and mode of delivery in monochorionic diamniotic twin pregnancies ≥ 32 weeks of gestation: a multicentre retrospective cohort study. BJOG 2011; 118:1090-7. [PMID: 21585638 DOI: 10.1111/j.1471-0528.2011.02955.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study perinatal mortality rates in a cohort of 465 monochorionic (MC) twins without twin-twin transfusion syndrome (TTS) born at 32 weeks of gestation or later since reported interauterine fetal death (IUFD) rates >32 weeks of gestations in the literature vary, leading to varying recommendations on the optimal timing of delivery, and to investigate the relation between perinatal mortality and mode of delivery. DESIGN Multicentre retrospective cohort study. SETTING Ten perinatal referral centres in the Netherlands. POPULATION All MC twin pregnancies without TTTS delivered at ≥ 32 weeks of gestation between January 2000 and December 2005. METHODS The medical records of all MC twin pregnancies without TTTS delivered at the ten perinatal referral centres in the Netherlands between January 2000 and December 2005 were reviewed. MAIN OUTCOME MEASURES Perinatal mortality in relation to gestational age and mode of delivery at ≥ 32 weeks of gestation. RESULTS After 32 weeks of gestation, five out of 930 fetuses died in utero and there were six neonatal deaths (6 per 1000 infants). In women who delivered ≥ 37 weeks, perinatal mortality was 7 per 1000 infants. Trial of labour was attempted in 376 women and was successful in 77%. There were three deaths in deliveries with a trial of labour (8 per 1000 deliveries), of which two were related to mode of delivery. Infants born by caesarean section without labour had an increased risk of neonatal morbidity and respiratory distress syndrome. CONCLUSIONS In MC twin pregnancies the incidence of intrauterine fetal death is low ≥ 32 weeks of gestation. Therefore, planned preterm delivery before 36 weeks does not seem to be justified. The risk of intrapartum death is also low, at least in tertiary centres.
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Affiliation(s)
- K E A Hack
- Department of Obstetrics, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, the Netherlands.
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