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Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies: ACOG Practice Bulletin, Number 231. Obstet Gynecol 2021; 137:e145-e162. [PMID: 34011891 DOI: 10.1097/aog.0000000000004397] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The incidence of multifetal gestations in the United States has increased dramatically over the past several decades. For example, the rate of twin births increased 76% between 1980 and 2009, from 18.9 to 33.3 per 1,000 births (1). However, after more than three decades of increases, the twin birth rate declined 4% during 2014-2018 to 32.6 twins per 1,000 total births in 2018 (2). The rate of triplet and higher-order multifetal gestations increased more than 400% during the 1980s and 1990s, peaking at 193.5 per 100,000 births in 1998, followed by a modest decrease to 153.4 per 100,000 births by 2009 (3). The triplet and higher-order multiple birth rate was 93.0 per 100,000 births for 2018, an 8% decline from 2017 (101.6) and a 52% decline from the 1998 peak (193.5) (4). The long-term changes in the incidence of multifetal gestations has been attributed to two main factors: 1) a shift toward an older maternal age at conception, when multifetal gestations are more likely to occur naturally, and 2) an increased use of assisted reproductive technology (ART), which is more likely to result in a multifetal gestation (5). A number of perinatal complications are increased with multiple gestations, including fetal anomalies, preeclampsia, and gestational diabetes. One of the most consequential complications encountered with multifetal gestations is preterm birth and the resultant infant morbidity and mortality. Although multiple interventions have been evaluated in the hope of prolonging these gestations and improving outcomes, none has had a substantial effect. The purpose of this document is to review the issues and complications associated with twin, triplet, and higher-order multifetal gestations and present an evidence-based approach to management.
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Zeng X, Li X, Qin L, Huang W, Jin S, Yu H. Isolated absence of nasal bone in 1 fetus in a dizygotic pregnancy after in vitro fertilization: A case report. Medicine (Baltimore) 2020; 99:e22558. [PMID: 33019467 PMCID: PMC7535647 DOI: 10.1097/md.0000000000022558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE During ultrasound prenatal screening, absence of the fetal nasal bone is used as a marker for common aneuploidies in singleton pregnancies. However, its application in multiple pregnancies is less sensitive and more challenging owing to difficulties in obtaining adequate views of the fetal face. PATIENT CONCERNS A 38-year-old woman with dichorionic-diamniotic (DCDA) pregnancy and a history of in vitro fertilization and embryo transfer was referred to our hospital with the absence of the nasal bone noted on ultrasound images obtained during the second trimester in 1 fetus. DIAGNOSIS Prenatal sonographic examination revealed the absence of the nasal bone in 1 fetus in the DCDA gestation. Amniocentesis performed on the dual amniotic sacs revealed normal karyotypes for each twin. The absence of the nasal bone was confirmed on a radiograph obtained postnatally in 1 infant. INTERVENTIONS The mother underwent routine outpatient care according to the gestational age and successfully delivered following lower-segment cesarean section. OUTCOMES Two live infants were uneventfully delivered. Radiography confirmed the absence of the nasal bone in 1 of the newborns on postnatal day 3. The infants were followed up until 2 years and 9 months of age, which revealed normal appearance and eating and breathing functions. LESSONS Prenatal diagnosis of the absence of nasal bone in 1 fetus of DCDA pregnancy has rarely been reported. Although a fetus with the absence of the nasal bone in DCDA gestation poses a significant risk of aneuploidy, it is acceptable when the defect is an isolated anomaly after ruling out genetic abnormalities. Appropriate consultation should be provided for these patients.
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Affiliation(s)
- Xun Zeng
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Xiaohong Li
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Lang Qin
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Wei Huang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Song Jin
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Haiyan Yu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
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Adra A, Khalife D, Usta IM, Hobeika E, Mirza F, Ghulmiyyah L, Nassar AH. Practice patterns of obstetric care in twin gestations: the value of MFM consultation. J Matern Fetal Neonatal Med 2020; 35:3453-3459. [PMID: 32954875 DOI: 10.1080/14767058.2020.1821640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the practice patterns among Lebanese obstetricians regarding obstetric care of twins and to compare selected practice patterns between general obstetricians and maternal fetal medicine physicians. METHODS Questionnaires distributed during the annual meeting of the Lebanese Society of Obstetrics and Gynecology. RESULTS Questionnaires were returned by 69.2% of the 296 physicians approached. Ten percent had fellowship training in Maternal Fetal Medicine (MFM). Thirty-nine percent perform cervical length measurement at 20-24 weeks of gestation and 34% recommend vaginal progesterone in case of a short cervix. When comparing selected practice patterns between MFM & general obstetricians, MFM specialists were less likely to perform cervical cerclage in the first trimester (5.9% versus 49%, p = .001), more likely to offer prenatal screening for aneuploidy (66.6% vs 46.4%, p = .03), less likely to use vaginal progesterone in the second trimester in the case of a short cervix (42.1% vs 61.8%, p = .04), less likely to perform serial ultrasound exam in the third trimester to assess fetal growth (50% vs 78%, p = .005) and more likely to deliver monoamniotic twins at 32-34 weeks of gestation (55% vs 37%, p = .05). CONCLUSION Because of the different background of the Lebanese physicians, MFM specialists are more likely to follow obstetric care guidelines in twin gestation.
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Affiliation(s)
- Abdallah Adra
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Dalia Khalife
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ihab M Usta
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Elie Hobeika
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Mirza
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Labib Ghulmiyyah
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Sensitivity of Nasal Bone as Aneuploidy Marker—First Trimester versus Second Trimester Assessment. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0128-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Practice Bulletin No. 169: Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies. Obstet Gynecol 2016; 128:e131-46. [DOI: 10.1097/aog.0000000000001709] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Quarello E, Jacquemard F, Ville Y. [Screening of aneuploidies in twin pregnancies in 2016: We may miss the boat if we fail to take action]. ACTA ACUST UNITED AC 2016; 44:457-60. [PMID: 27363614 DOI: 10.1016/j.gyobfe.2016.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Indexed: 10/21/2022]
Affiliation(s)
- E Quarello
- Unité d'échographie et de diagnostic prénatal, hôpital Saint-Joseph, 26, boulevard de Louvain, 13285 Marseille cedex 08, France; Institut de médecine de la reproduction, 6, rue Rocca, 13008 Marseille, France.
| | - F Jacquemard
- Centre de diagnostic prénatal, hôpital américain de Paris, 63, boulevard Victor-Hugo, 92200 Neuilly-sur-Seine, France
| | - Y Ville
- Service d'obstétrique et de médecine fœtale, université Paris Descartes, hôpital Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France
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Gustavo Rencoret P. Embarazo gemelar. REVISTA MÉDICA CLÍNICA LAS CONDES 2014. [DOI: 10.1016/s0716-8640(14)70645-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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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.
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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.
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Down syndrome screening in assisted conception twins: an iatrogenic medical challenge. Obstet Gynecol Surv 2014; 68:825-34. [PMID: 24193195 DOI: 10.1097/ogx.0000000000000001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to provide a critical analysis of the impact of assisted conception on prenatal screening for Down syndrome (DS) in twin pregnancies and the value of various screening modalities for early detection of anomalies. METHODS The literature was searched using PubMed and the Cochrane Library focusing on prenatal screening and antenatal care of assisted-conception twin pregnancies. RESULTS Serum screening alone is of limited value in detecting aneuploid twins, because the unaffected cotwin can "mask" the abnormal serum results of an affected one. In addition, this test can designate the pregnancy as at high risk but not identify the affected fetus. Nuchal translucency (NT) screening is the best available modality and a highly effective screening method for twin pregnancies. Among twins, NT alone has a 69% DS detection rate, first-trimester combined NT and serum biochemistry has a 72% DS detection rate, and an integrated screen will have an 80% DS detection rate at a 5% FPR. The data in the literature concerning the effect of assisted conception on maternal serum screening markers in twin pregnancies are scarce. CONCLUSIONS Down syndrome screening in assisted-conception twins presents clinical and technical challenges. Therefore, assisted-conception twins need close monitoring from conception to delivery, by a practitioner familiar with the available screening modalities and their relative accuracy.
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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]
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Petousis S, Margioula-Siarkou C, Kalogiannidis I, Prapas N. Twin Pregnancy and Antenatal Examination: An Overview. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2013. [DOI: 10.1007/s13669-013-0057-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Peuhkurinen S, Laitinen P, Honkasalo T, Ryynanen M, Marttala J. Comparison of combined, biochemical and nuchal translucency screening for Down syndrome in first trimester in Northern Finland. Acta Obstet Gynecol Scand 2013; 92:769-74. [DOI: 10.1111/aogs.12095] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 01/10/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Sini Peuhkurinen
- Department of Obstetrics and Gynecology; Oulu University Hospital; Oulu; Finland
| | - Paivi Laitinen
- Clinical Chemistry and Hematology; Helsinki University Hospital; Helsinki; Finland
| | - Timppa Honkasalo
- Department of Obstetrics and Gynecology; Oulu University Hospital; Oulu; Finland
| | - Markku Ryynanen
- Department of Obstetrics and Gynecology; Oulu University Hospital; Oulu; Finland
| | - Jaana Marttala
- Department of Obstetrics and Gynecology; Oulu University Hospital; Oulu; Finland
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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.
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Affiliation(s)
- Pilar Prats
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain.
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Cuckle H, Moskovitch M, Vaknin Z, Levental S, Rosen H, Maymon R. Nuchal translucency screening in triplets: Down syndrome risk calculation taking account of between-fetus correlations. Prenat Diagn 2012; 32:214-9. [DOI: 10.1002/pd.2929] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Howard Cuckle
- Department of Obstetrics and Gynecology; Columbia University Medical Center; New York NY USA
| | - Miki Moskovitch
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Israel
| | - Zvi Vaknin
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Israel
| | - Sharon Levental
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Israel
| | - Hadar Rosen
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Israel
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Sepulveda W, Wong AE, Dezerega V. First-trimester sonographic findings in trisomy 18: a review of 53 cases. Prenat Diagn 2010; 30:256-9. [PMID: 20112232 DOI: 10.1002/pd.2462] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To report our experience with first-trimester sonographic findings in pregnancies complicated by trisomy 18. METHODS Proven cases of trisomy 18 undergoing sonographic examination between 11 + 0 and 13 + 6 weeks of gestation were retrospectively identified. Information on maternal demographics, prenatal sonographic findings, and chromosomal analysis results was obtained by reviewing the ultrasound reports and medical records. RESULTS During the 12-year period from July 1997 to June 2009, 53 cases of full trisomy 18 had first-trimester sonographic examination performed at our institution. All but one fetus displayed one or more abnormal sonographic finding, most commonly increased nuchal translucency thickness (n = 48, 91%). Absent or hypoplastic nasal bone was documented in 53% of the fetuses in which this marker was specifically looked for. Structural anomalies included omphalocele in 11 (21%), abnormal posturing of the hands in three (6%), megacystis in two (4%), and abnormal four-chamber view of the heart in two (4%). Early-onset fetal growth restriction and bradycardia were documented in 14 (26%) and 4 (8%) of the cases, respectively. CONCLUSIONS Our study demonstrates that a large number of fetuses with trisomy 18 have abnormal sonographic findings in the first trimester. However, the sonographic features usually found in the second-trimester are difficult to detect at an early gestational age. The recognition of the specific first-trimester sonographic pattern of trisomy 18 may allow improved detection of this serious condition in early pregnancy.
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Affiliation(s)
- Waldo Sepulveda
- Fetal Medicine Center, Department of Obstetrics and Gynecology, Clinica Las Condes, Santiago, Chile.
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