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Jaingam S, Phithakwatchara N, Nawapun K, Viboonchart S, Watananirun K, Wataganara T. A conditional standard for the customized fetal growth trajectory in twin pregnancy. Am J Obstet Gynecol MFM 2024; 6:101223. [PMID: 37951579 DOI: 10.1016/j.ajogmf.2023.101223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/20/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND The difference in the birth weights between twins and singletons grows with advancing gestation. Although many fetal weight standards based on ultrasonographic measurements have been created for tracking fetal growth in twin pregnancies, their applicability to other groups is limited by the fact that they are population specific. OBJECTIVE This study aimed to generate conditional centiles for growth assessment of twin fetuses and to compare them with other population-based growth standards for singleton and twin fetuses. STUDY DESIGN This was a retrospective, longitudinal study of ultrasound-based estimated fetal weight data of normal twin fetuses delivered after 34 weeks of gestation. Linear mixed effects models that adjusted for maternal characteristics, fetal gender, and chorionicity were used to evaluate the relationship between estimated fetal weight and gestational age. The estimated fetal weight reference values were calculated using conditional centile based on the estimated fetal weight at an earlier gestational age. To compare our results with previous studies, fetal growth curves were generated using a formula we created that included maternal characteristics and the estimated fetal weight at 24 weeks of gestation in these studies. In a subgroup analysis of our low-risk twin babies born at full term, we calculated the number of fetuses who were reclassified as being in the bottom 10th percentile using each of the previous population-based standard. RESULTS A total of 2644 ultrasounds with a median of 4 scans per fetus from 572 twin pregnancies were included in this analysis. In the cohort, 36% of the fetuses were monochorionic. Maternal age, body mass index, and the interaction between fetal gender and chorionicity were significantly associated with estimated fetal weight. The predicted growth curves matched the growth standard for twins. In our low-risk group, when the singleton standard was used, the incidence of estimated fetal weight <10th percentile was above 20% from gestational week 24 to 38, and this incidence varied when reclassified using other population-based twin standards. CONCLUSION This conditional growth chart was specifically designed to assess fetal growth in twin pregnancies, but it is generalizable to other populations.
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Affiliation(s)
- Suparat Jaingam
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nisarat Phithakwatchara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Katika Nawapun
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sommai Viboonchart
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanokwaroon Watananirun
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tuangsit Wataganara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Zheng W, Zhang KX, Yuan XX, Luo JY, Wang J, Song W, Liang SN, Wang XX, Guo CM, Li GH. Maternal weight, blood lipids, and the offspring weight trajectories during infancy and early childhood in twin pregnancies. World J Pediatr 2023; 19:961-971. [PMID: 36877432 DOI: 10.1007/s12519-023-00703-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 02/07/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND The intrauterine environment has a profound and long-lasting influence on the health of the offspring. However, its impact on the postnatal catch-up growth of twin children remains unclarified. Therefore, this study aimed to explore the maternal factors in pregnancy associated with twin offspring growth. METHODS This study included 3142 live twin children born to 1571 mothers from the Beijing Birth Cohort Study conducted from 2016 to 2021 in Beijing, China. Original and corrected weight-for-age standard deviation scores of the twin offspring from birth to 36 months of age were calculated according to the World Health Organization Child Growth Standards. The corresponding weight trajectories were identified by the latent trajectory model. Maternal factors in pregnancy associated with the weight trajectories of the twin offspring were examined after adjustment for potential confounders. RESULTS Five weight trajectories of the twin children were identified, with 4.9% (154/3142) exhibiting insufficient catch-up growth, 30.6% (961/3142), and 46.8% (1469/3142) showing adequate catch-up growth from different birth weights, and 15.0% (472/3142) and 2.7% (86/3142) showing various degrees of excessive catch-up growth. Maternal short stature [adjusted odds ratio (OR) = 0.691, 95% confidence interval (CI) = 0.563-0.848, P = 0.0004] and lower total gestational weight gain (GWG) (adjusted OR = 0.774, 95% CI = 0.616-0.972, P = 0.03) were associated with insufficient catch-up growth of the offspring. Maternal stature (adjusted OR = 1.331, 95% CI = 1.168-1.518, P < 0.001), higher pre-pregnancy body mass index (BMI) (adjusted OR = 1.230, 95% CI = 1.090-1.387, P < 0.001), total GWG (adjusted OR = 1.207, 95% CI = 1.068-1.364, P = 0.002), GWG rate (adjusted OR = 1.165, 95% CI = 1.027-1.321, P = 0.02), total cholesterol (TC) (adjusted OR = 1.150, 95% CI = 1.018-1.300, P = 0.03) and low-density lipoprotein-cholesterol (LDL-C) (adjusted OR = 1.177, 95% CI = 1.041-1.330) in early pregnancy were associated with excessive growth of the offspring. The pattern of weight trajectories was similar between monochorionic and dichorionic twins. Maternal height, pre-pregnancy BMI, GWG, TC and LDL-C in early pregnancy were positively associated with excess growth in dichorionic twins, yet a similar association was observed only between maternal height and postnatal growth in monochorionic twins. CONCLUSION This study identified the effect of maternal stature, weight status, and blood lipid profiles during pregnancy on postnatal weight trajectories of the twin offspring, thereby providing a basis for twin pregnancy management to improve the long-term health of the offspring.
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Affiliation(s)
- Wei Zheng
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing, 100026, China
| | - Ke-Xin Zhang
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing, 100026, China
| | - Xian-Xian Yuan
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing, 100026, China
| | - Jin-Ying Luo
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing, 100026, China
- Obstetrics and Gynecology Department, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, China
| | - Jia Wang
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing, 100026, China
| | - Wei Song
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing, 100026, China
| | - Sheng-Nan Liang
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing, 100026, China
| | - Xiao-Xin Wang
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing, 100026, China
| | - Cui-Mei Guo
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing, 100026, China
| | - Guang-Hui Li
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China.
- Beijing Maternal and Child Health Care Hospital, Beijing, 100026, China.
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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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Dall'Asta A, Rizzo G, Ghi T. Clinical implementation of twin-specific growth charts: still more work to do. Am J Obstet Gynecol 2023; 228:253-254. [PMID: 36244409 DOI: 10.1016/j.ajog.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/07/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Andrea Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Fondazione Policlinico di Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Via Gramsci 14, 43126 Parma, Italy.
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Casati D, Zavatta A, Cortinovis I, Spada E, Faiola S, Laoreti A, Cetin I, Lanna M. Cerebro-placental and umbilico-cerebral ratios in uncomplicated monochorionic twins: Longitudinal references and comparison with singletons. Prenat Diagn 2022; 42:1111-1119. [PMID: 35801284 DOI: 10.1002/pd.6210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/24/2022] [Accepted: 07/03/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Monochorionic twins (MC) are at high risk of adverse outcomes and Doppler investigation of umbilical and cerebral flows is mandatory for their surveillance. The cerebro-placental (CPR) and umbilico-cerebral (UCR) ratios are considered non-invasive measures of fetal adaptation to hypoxemia. We aimed to provide longitudinal references for CPR and UCR from 16 to 37 weeks of gestation that are specific for MC twins, and compare these with singleton charts. METHODS Longitudinal study of a cohort of consecutive uncomplicated MC twin pregnancies monitored at our unit from 2010 to 2018. The estimated centile curves were obtained estimating the median with fractional polynomials by a multilevel model and the external centiles through the residuals. The comparison with singletons references was made through graphic evaluation. RESULTS One-hundred-fifty-two MC pregnancies were included with a median of 10 longitudinal ultrasounds each. References for CPR and UCR in function of gestational age are presented. Compared to singletons, MC twins showed an earlier and greater circulatory redistribution with lower CPR and higher UCR median values. CONCLUSIONS MC twin-specific references for CPR and UCR suitable for serial monitoring are presented. The comparison with singleton references demonstrates substantial differences in the hemodynamic balance that must be considered when interpreting findings in MC twins. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Daniela Casati
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Alice Zavatta
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Ivan Cortinovis
- Laboratory G.A. Maccacaro, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Elena Spada
- Laboratorio della Conoscenza - Carlo Corchia A.P.S, Florence, Italy
| | - Stefano Faiola
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Arianna Laoreti
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Irene Cetin
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Mariano Lanna
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
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Rizzini N, Fratelli N, Negri B, Odicino FE, Sartori E, Risso FM, Prefumo F, Fichera A. Chorionicity, birth weight discordance and neonatal morbidity in uncomplicated twin pregnancies delivered from 36 weeks. Eur J Obstet Gynecol Reprod Biol 2022; 271:214-218. [PMID: 35228093 DOI: 10.1016/j.ejogrb.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/14/2022] [Accepted: 02/19/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate the association between chorionicity, birth weight discordance and neonatal morbidity in uncomplicated twin pregnancies progressing to at least 36 weeks of gestation. STUDY DESIGN This was a retrospective single centre cohort study of all twin pregnancies referred to our twin clinic between 2011 and 2018. Outcome details were obtained from the computerized maternity and neonatal records. The primary outcome was incidence of composite neonatal morbidity according to chorionicity. We also determined the incidence of composite neonatal morbidity in pregnancies with birth weight discordance. Logistic regression was used to identify and adjust for potential confounders. RESULTS Three hundred and eighty-five twin pregnancies (286 dichorionic, 99 monochorionic) were included. Gestational age at birth was significantly lower in pregnancies complicated by neonatal morbidity (p = 0.013) compared with those which were not. On multivariable logistic regression analysis, gestational age at birth (p = 0.031) and birth weight discordance (p = 0.004), but not chorionicity (p = 0.626) were independently associated with neonatal morbidity. CONCLUSION(S) In uncomplicated twin pregnancies chorionicity is not associated with neonatal morbidity. Gestational age at birth is the major determinant of neonatal outcome while the clinical impact of weight discordance seems marginally significant.
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Affiliation(s)
- Nicoletta Rizzini
- Division of Obstetrics and Gynecology, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Nicola Fratelli
- Division of Obstetrics and Gynecology, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Beatrice Negri
- Division of Obstetrics and Gynecology, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Franco E Odicino
- Division of Obstetrics and Gynecology, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Enrico Sartori
- Division of Obstetrics and Gynecology, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesco M Risso
- Neonatalogy and Neonatal Intensive Care Unit, ASST Spedali Civili, Brescia, Italy
| | - Federico Prefumo
- Division of Obstetrics and Gynecology, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
| | - Anna Fichera
- Division of Obstetrics and Gynecology, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Segev M, Djurabayev B, Hadi E, Yinon Y, Rabinowicz S, Hoffmann C, Shrot S. Third Trimester Structural and Diffusion Brain Imaging after Single Intrauterine Fetal Death in Monochorionic Twins: MRI-Based Cohort Study. AJNR Am J Neuroradiol 2022; 43:620-626. [PMID: 35332016 PMCID: PMC8993195 DOI: 10.3174/ajnr.a7475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Single intrauterine fetal death increases the risk of antenatal brain lesions in the surviving twin. We evaluated the prevalence of structural brain lesions, biometry, and diffusivity on routine third trimester MR imaging performed following single intrauterine fetal death. MATERIALS AND METHODS In a retrospective MR imaging-based cohort study, we compared 29 monochorionic twins complicated with single intrauterine fetal death (14 following laser ablation treatment for twin-to-twin transfusion syndrome, 8 following selective fetal reduction, and 7 spontaneous) with 2 control cohorts (49 singleton fetuses and 28 uncomplicated twin fetuses). All fetuses in the single intrauterine fetal death group underwent fetal brain MR imaging as a routine third trimester evaluation. Structural brain lesions were analyzed. Cerebral biometry and diffusivity were measured and compared. RESULTS Brain lesions consistent with the evolution of prior ischemic injury were found in 1 of 29 fetuses, not detected by ultrasound. No acute brain infarction, hemorrhage, or cortical abnormalities were found. Supratentorial biometric measurements in the single intrauterine fetal death group were significantly smaller than those in the singleton group, but not significantly different from those in the uncomplicated twin group. There were no significant differences in ADC values of the cerebral hemispheres, basal ganglia, and pons between the single intrauterine fetal death group and either control group. CONCLUSIONS Although smaller brain biometry was found, normal diffusivity in surviving twins suggests normal parenchymal microstructure. The rate of cerebral structural injury was relatively low in our cohort, arguing against the routine use of fetal brain MR imaging in twin pregnancies complicated with single intrauterine fetal death. Larger prospective studies are necessary to guide appropriate surveillance protocol and parental counseling in twin pregnancies complicated by single intrauterine fetal death.
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Affiliation(s)
- M Segev
- From the Section of Neuroradiology (M.S., B.D., C.H., S.S.)
| | - B Djurabayev
- From the Section of Neuroradiology (M.S., B.D., C.H., S.S.)
| | - E Hadi
- Division of Diagnostic Imaging, Diagnostic Ultrasound Unit of the Institute of Obstetrical and Gynecological Imaging (E.H.)
| | - Y Yinon
- Department of Obstetrics and Gynecology, and Fetal Medicine Unit (Y.Y.), Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat-Gan, Israel.,Sackler School of Medicine (Y.Y., C.H., S.S.), Tel Aviv University, Tel-Aviv, Israel
| | - S Rabinowicz
- Pediatric Neurology Unit (S.R.), The Edmond and Lilly Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - C Hoffmann
- From the Section of Neuroradiology (M.S., B.D., C.H., S.S.).,Sackler School of Medicine (Y.Y., C.H., S.S.), Tel Aviv University, Tel-Aviv, Israel
| | - S Shrot
- From the Section of Neuroradiology (M.S., B.D., C.H., S.S.) .,Sackler School of Medicine (Y.Y., C.H., S.S.), Tel Aviv University, Tel-Aviv, Israel
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Hiersch L, Barrett J, Fox NS, Rebarber A, Kingdom J, Melamed N. Should twin-specific growth charts be used to assess fetal growth in twin pregnancies? Am J Obstet Gynecol 2022; 227:10-28. [PMID: 35114185 DOI: 10.1016/j.ajog.2022.01.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/24/2022] [Accepted: 01/24/2022] [Indexed: 11/17/2022]
Abstract
One of the hallmarks of twin pregnancies is the slower rate of fetal growth when compared with singleton pregnancies during the third trimester. The mechanisms underlying this phenomenon and whether it represents pathology or benign physiological adaptation are currently unclear. One important implication of these questions relates to the type growth charts that should be used by care providers to monitor growth of twin fetuses. If the slower growth represents pathology (ie, intrauterine growth restriction caused uteroplacental insufficiency), it would be preferable to use a singleton growth chart to identify a small twin fetus that is at risk for perinatal mortality and morbidity. If, however, the relative smallness of twins is the result of benign adaptive mechanisms, it is likely preferable to use a twin-based charts to avoid overdiagnosis of intrauterine growth restriction in twin pregnancies. In the current review, we addressed this question by describing the differences in fetal growth between twin and singleton pregnancies, reviewing the current knowledge regarding the mechanisms responsible for slower fetal growth in twins, summarizing available empirical evidence on the diagnostic accuracy of the 2 types of charts for intrauterine growth restriction in twin pregnancies, and addressing the question of whether uncomplicated dichorionic twins are at an increased risk for fetal death when compared with singleton fetuses. We identified a growing body of evidence that shows that the use of twin charts can reduce the proportion of twin fetuses identified with suspected intrauterine growth restriction by up to 8-fold and can lead to a diagnosis of intrauterine growth restriction that is more strongly associated with adverse perinatal outcomes and hypertensive disorders than a diagnosis of intrauterine growth restriction based on a singleton-based chart without compromising the detection of twin fetuses at risk for adverse outcomes caused by uteroplacental insufficiency. We further found that small for gestational age twins are less likely to experience adverse perinatal outcomes or to have evidence of uteroplacental insufficiency than small for gestational age singletons and that recent data question the longstanding view that uncomplicated dichorionic twins are at an increased risk for fetal death caused by placental insufficiency. Overall, it seems that, based on existing evidence, the of use twin charts is reasonable and may be preferred over the use of singleton charts when monitoring the growth of twin fetuses. Still, it is important to note that the available data have considerable limitations and are primarily derived from observational studies. Therefore, adequately-powered trials are likely needed to confirm the benefit of twin charts before their use is adopted by professional societies.
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Affiliation(s)
- Liran Hiersch
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lis Maternity Hospital, Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jon Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nathan S Fox
- Icahn School of Medicine at Mount Sinai, New York, NY; Maternal Fetal Medicine Associates, PLLC, New York, NY
| | - Andrei Rebarber
- Icahn School of Medicine at Mount Sinai, New York, NY; Maternal Fetal Medicine Associates, PLLC, New York, NY
| | - John Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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9
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Ortiz JU, Torres X, Bennasar M, Eixarch E, Gómez O, Crovetto F, Lobmaier SM, Martinez JM, Gratacós E, Crispi F. Left myocardial performance index in monochorionic diamniotic twin pairs complicated by selective fetal growth restriction with abnormal umbilical artery Doppler. Prenat Diagn 2021; 41:1504-1509. [PMID: 34437722 DOI: 10.1002/pd.6037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/07/2021] [Accepted: 08/24/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate left myocardial performance index (MPI) and its time intervals in monochorionic diamniotic (MCDA) twin pairs complicated by selective fetal growth restriction (sFGR) with abnormal (persistent -type II- or intermittent -type III- absent or reversed end-diastolic flow) umbilical artery Doppler. METHODS Retrospective study including 16 MCDA twin pairs with sFGR type II, 26 MCDA twin pairs with sFGR type III and 42 gestational age-matched uncomplicated MCDA twin pairs in a single tertiary center. Left isovolumetric contraction time (ICT), ejection time (ET), and isovolumetric relaxation time (IRT) were measured and MPI calculated by conventional Doppler at diagnosis of sFGR. RESULTS In sFGR type II, the smaller twin had shorter ET and prolonged IRT and MPI, while the larger twin showed prolonged ICT and MPI as compared to uncomplicated MCDA twins. In sFGR type III, the smaller twin had shorter ICT and ET, while the larger twin showed prolonged ICT, IRT, and MPI in comparison to controls. CONCLUSION A differential pattern of MPI time intervals could be observed in MCDA twins with sFGR type II and III. All twins had echocardiographic signs of pressure/volume overload, except the smaller twin type III with shorter systolic times probably reflecting reduced volume load.
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Affiliation(s)
- Javier U Ortiz
- Division of Obstetrics and Perinatal Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ximena Torres
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Mar Bennasar
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Elisenda Eixarch
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Olga Gómez
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Francesca Crovetto
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Silvia M Lobmaier
- Division of Obstetrics and Perinatal Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Josep M Martinez
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Eduard Gratacós
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Fatima Crispi
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Gleason JL, Yeung E, Sundaram R, Mendola P, Bell EM, Vafai Y, Robinson SL, Putnick DL, Grantz KL. Developmental outcomes in small-for-gestational age twins using a singleton vs twin birthweight reference in Upstate KIDS. Am J Obstet Gynecol MFM 2021; 3:100465. [PMID: 34416423 DOI: 10.1016/j.ajogmf.2021.100465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Limited data exist about the potential developmental delays in appropriately grown twins; furthermore, twins may be at higher risk of developmental delay than singletons. Small-for-gestational age is a risk factor for developmental delay and is based on singleton birthweight references, which may misclassify small-for-gestational age in a subset of appropriately grown twins. OBJECTIVE This study aimed to evaluate the risk of developmental delay in twins classified as small-for-gestational age according to the twin and singleton birthweight references (<10th percentile). STUDY DESIGN In a birth cohort (2008-2010) of twins (n=1790) and singletons (n=3829) where parents completed Ages & Stages Questionnaires for child development between 4 and 36 months, we used a US population-based birthweight reference to categorize singletons and twins as small-for-gestational age. Uncertain small-for-gestational age twins were defined as small-for-gestational age by a singleton reference (<10th percentile) and not by a twin reference, and twin-reference small-for-gestational age twins were defined as small-for-gestational age by a twin reference. Adjusted generalized linear mixed-effects models were used to estimate the odds of failure on any Ages & Stages Questionnaires domain and on each of the 5 domains (fine motor, gross motor, communication, personal-social, and problem-solving domains); random intercepts accounted for repeated measures and twin clustering. RESULTS Compared with non-small-for-gestational age twins (>10th percentile), uncertain small-for-gestational age twins did not have higher odds of Ages & Stages Questionnaires failure (adjusted odds ratio, 1.28; 95% confidence interval, 0.91-1.80). Compared with non-small-for-gestational age singletons, both twin-reference and uncertain small-for-gestational age twins had higher odds of Ages & Stages Questionnaires failure, with the highest risk conferred to twin-reference small-for-gestational age twins (twin-reference adjusted odds ratio, 3.14 [95% confidence interval, 1.94-5.10]; uncertain adjusted odds ratio, 2.35 [95% confidence interval, 1.69-3.26]; P<.01 for trend). Results remained consistent when limiting analyses to term births (≥37 weeks' gestation). CONCLUSION Although a singleton reference may overestimate small-for-gestational age in twins, the findings indicated that a singleton birthweight reference may be appropriate for twins because it identifies more twins at risk of developmental delay than a twin reference.
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Affiliation(s)
- Jessica L Gleason
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (Drs Gleason, Yeung, Mendola, Vafai, Robinson, Putnick, and Grantz)
| | - Edwina Yeung
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (Drs Gleason, Yeung, Mendola, Vafai, Robinson, Putnick, and Grantz)
| | - Rajeshwari Sundaram
- Biostatistics Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (Dr Sundaram)
| | - Pauline Mendola
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (Drs Gleason, Yeung, Mendola, Vafai, Robinson, Putnick, and Grantz)
| | - Erin M Bell
- Departments of Environmental Health Sciences and Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, NY (Dr Bell)
| | - Yassaman Vafai
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (Drs Gleason, Yeung, Mendola, Vafai, Robinson, Putnick, and Grantz)
| | - Sonia L Robinson
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (Drs Gleason, Yeung, Mendola, Vafai, Robinson, Putnick, and Grantz)
| | - Diane L Putnick
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (Drs Gleason, Yeung, Mendola, Vafai, Robinson, Putnick, and Grantz)
| | - Katherine L Grantz
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (Drs Gleason, Yeung, Mendola, Vafai, Robinson, Putnick, and Grantz).
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11
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Hiersch L, Barrett J, Aviram A, Mei-Dan E, Yoon EW, Zaltz A, Kingdom J, Melamed N. Patterns of discordant growth and adverse neonatal outcomes in twins. Am J Obstet Gynecol 2021; 225:187.e1-187.e14. [PMID: 33508311 DOI: 10.1016/j.ajog.2021.01.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Intertwin size discordance is an independent risk factor for adverse neonatal outcomes in twin pregnancies. However, size discordance at a given point in gestation fails to take into consideration information, such as the timing of onset and the rate of progression of discordance, that may be of prognostic value. OBJECTIVE In this study, we aimed to identify distinct patterns of discordant fetal growth in twin pregnancies and to determine whether these patterns are predictive of adverse pregnancy outcomes. STUDY DESIGN This was a retrospective cohort study of women with twin pregnancies in a single tertiary referral center between January 2011 and April 2020, who had at least 3 ultrasound examinations during pregnancy that included assessment of fetal biometry. Size discordance was calculated at each ultrasound examination, and pregnancies were classified into 1 of 4 predetermined patterns based on the timing of onset and the progression of discordance: pattern 1, no significant discordance group (referent); pattern 2, early (<24 weeks' gestation) progressive discordance group; pattern 3, early discordance with plateau group; or pattern 4, late (≥24 weeks' gestation) discordance group. The associations of discordance pattern (using pattern 1 as referent) with preterm birth, preeclampsia, size discordance at birth, and birthweight<10th percentile were expressed as adjusted relative risk with 95% confidence intervals and were compared with those observed for a single measurement of size discordance at 32 weeks' gestation. RESULTS Of 2075 women with a twin gestation who were identified during the study period, 1059 met the study criteria. Of the 1059 women, 599 (57%) were classified as no significant discordance (pattern 1), 23 (2%) as early progressive discordance (pattern 2), 160 (15%) as early discordance with plateau (pattern 3), and 277 (26%) as late discordance (pattern 4). The associations of discordance pattern with preterm birth at <34 weeks' gestation and preeclampsia were strongest for pattern 2 (rates of 43% [adjusted relative risk, 3.43; 95% confidence interval, 2.10-5.62] and 17% [adjusted relative risk, 5.81; 95% confidence interval, 2.31-14.60], respectively), intermediate for pattern 3 (rates of 23% [adjusted relative risk, 1.82; 95% confidence interval, 1.28-2.59] and 6% [adjusted relative risk, 2.08; 95% confidence interval, 1.01-4.43], respectively), and weakest for pattern 4 (rates of 12% [adjusted relative risk, 0.96; 95% confidence interval, 0.65-1.42] and 4% [adjusted relative risk, 1.41; 0.68-2.92], respectively). In contrast, a single measurement of size discordance at 32 weeks' gestation showed no association with preeclampsia and only a weak association with preterm birth at <34 weeks' gestation. CONCLUSION We identified 4 distinct discordance growth patterns among twins that demonstrated a dose-response relationship with adverse outcomes and seemed to be more informative than a single measurement of size discordance.
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Lyu S, Gao L, Sun J, Zhao X, Wu Y, Hua R, Wang Y. The association between maternal complications and small for gestational age in twin pregnancies using singleton and twin birth weight references. J Matern Fetal Neonatal Med 2021; 35:7459-7465. [PMID: 34311666 DOI: 10.1080/14767058.2021.1949703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In singleton pregnancies, maternal complications, such as preeclampsia and thyroid dysfunction are associated with small for gestational age (SGA). However, data on the association between SGA and maternal complications in twin pregnancies are limited and conflicting. Small sample size and the application of singleton birth weight reference (SBWR) to define SGA in twins may be reasons for the inconsistent conclusions. Purpose of this study was to define SGA in dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twin pregnancies using both SBWR and twin birth weight reference (TBWR) and to determine whether certain maternal complications are associated with SGA in twin pregnancies. MATERIALS AND METHODS This retrospective cohort study included all twins delivered in a single tertiary center between 2013 and 2018. SGA was defined as a twin with birth weight <10th centile for gestational age using either SBWR or TBWR. The association between SGA and maternal complications was analyzed separately for DCDA and MCDA twin pregnancies, expressed as odds ratio (OR) and adjusted odds ratio (aOR) with 95% confidence interval (95%-CI). RESULTS A total of 2005 DCDA and 467 MCDA twin pregnancies were enrolled. In DCDA pregnancies, SGA was significantly associated with PE according to TBWR (22.73 vs. 14.56%, aOR 1.823, 95%-CI 1.137-2.922). This association was even more pronounced between SGA and severe PE (9.09 vs. 4.54%, aOR 2.234, 95%-CI 1.115-4.479). In turn, PE was associated with higher risk of SGA defined according to TBWR (8.31 vs. 4.99%, aOR 1.825, 95%-CI 1.139-2.925). No association was detected between SGA and other maternal complications. Using SBWR, no association was found between preeclampsia and SGA. In MCDA pregnancies, according to TBWR, SGA was associated only with severe PE (12.5 vs. 4.06%, aOR 3.470, 95%-CI 1.256-9.587) and lower risk of PROM (aOR 0.067, 95%-CI 0.014-0.322). CONCLUSION PE was associated with SGA in DCDA pregnancies only when TBWR was used, suggesting that DCDA pregnancies complicated with PE should be closely monitored for signs of SGA and vice versa. In MCDA pregnancies, SGA defined according to TBWR was associated with only severe PE (but not with all PE) and lower risk of PROM. More basic experiments are needed to investigate the mechanisms underlying PE and SGA in DCDA and MCDA twin pregnancies respectively.
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Affiliation(s)
- Shuping Lyu
- Prenatal Diagnosis Department, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Li Gao
- Prenatal Diagnosis Department, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Jinling Sun
- Prenatal Diagnosis Department, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Xinrong Zhao
- Prenatal Diagnosis Department, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Yi Wu
- Prenatal Diagnosis Department, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Renyi Hua
- Prenatal Diagnosis Department, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Yanlin Wang
- Prenatal Diagnosis Department, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
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13
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Physical Activity Patterns of Women with a Twin Pregnancy-A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18157724. [PMID: 34360017 PMCID: PMC8345556 DOI: 10.3390/ijerph18157724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 11/16/2022]
Abstract
Background: No specific physical activity guidelines are available for women in multiple pregnancy. Aim of the study was to assess the knowledge and experience of women regarding physical activity during their latest twin pregnancy. Methods: A cross-sectional study including women after a twin delivery was conducted in Poland. A questionnaire was distributed in 2018 via web pages and Facebook groups designed for pregnant women. Results: 652 women filled out the questionnaire completely. Only 25% of women performed any physical exercises during twin gestation. The frequency of preterm delivery was similar in physically active and non-active participants. 35% of the respondents claimed to have gained information on proper activity from obstetricians during antenatal counselling while 11% claimed to be unable to identify the reliable sources of information. 7% of women admitted to feel discriminated by social opinion on exercising during a twin pregnancy. Conclusions: The population of women with a twin gestation is not sufficiently physically active and is often discouraged from performing exercises during gestation. Therefore, it is crucial to inform obstetricians to recommend active lifestyle during a twin gestation and to provide reliable information on physical activity to pregnant women. Further research on this topic is necessary in order for obstetric providers to counsel women on appropriate exercise with a twin pregnancy.
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Development of fetal growth charts in twins stratified by chorionicity and mode of conception: a retrospective cohort study in China. Chin Med J (Engl) 2021; 134:1819-1827. [PMID: 34238852 PMCID: PMC8367024 DOI: 10.1097/cm9.0000000000001616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Twin pregnancies continue to increase worldwide; however, the current clinical prenatal evaluation for the intrauterine growth of twins still relies on the growth standards of singletons. We attempted to establish a set of fetal biometric references for Chinese twin pregnancies, stratified by chorionicity and conception mode as spontaneously conceived monochorionic diamniotic (SC-MCDA), spontaneously conceived dichorionic diamniotic (SC-DCDA), and assisted reproductive technology dichorionic diamniotic (ART-DCDA) twins. METHODS From 2016 to 2019, the ultrasonographic fetal biometric measurements were longitudinally collected in pregnant women, including fetal weight, biparietal diameter, head circumference, abdominal circumference, femur length, and humerus length. The linear mixed models were used to test the difference of growth patterns between groups, and the growth curve of each biometric parameter was modeled by a generalized additive model for location scale and shape. RESULTS A total of 929 twin pregnant women and 2019 singleton pregnant women, met the inclusion criteria. Among twin pregnancies, 148 were SC-MCDA, 215 were SC-DCDA, and 566 were ART-DCDA twins. Overall, SC-DCDA twins grew faster than SC-MCDA twins, while slower than ART-DCDA twins (all P < 0.05), and all of the three groups showed significant differences comparing with singletons, especially during the third trimester. Hence, the customized fetal growth charts of each fetal biometric parameter were, respectively, constructed for SC-MCDA, SC-DCDA, and ART-DCDA twins. CONCLUSIONS The fetal biometric trajectories demonstrated characteristic patterns according to chorionicity and conception mode. To fill the gap, we modeled fetal biometric parameters for Chinese SC-MCDA, SC-DCDA, and ART-DCDA twin pregnancies, hoping to provide a reference for the further establishment of fetal growth reference values for Chinese twin fetuses.
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15
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Chen J, Zhang J, Liu Y, Wei X, Yang Y, Zou G, Zhang Y, Duan T, Sun L. Fetal growth standards for Chinese twin pregnancies. BMC Pregnancy Childbirth 2021; 21:436. [PMID: 34158005 PMCID: PMC8220745 DOI: 10.1186/s12884-021-03926-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/01/2021] [Indexed: 11/15/2022] Open
Abstract
Background The common use of singleton fetal growth standard to access twin growth might lead to over-monitoring and treatment. We aimed to develop fetal growth standards for Chinese twins based on ultrasound measurements, and compare it with Zhang’s and other twin fetal growth charts. Methods A cohort of uncomplicated twin pregnancies were prospectively followed in 2014–2017. Smoothed estimates of fetal growth percentiles for both monochorionic (MC) and dichorionic (DC) twins were obtained using a linear mixed model. We also created growth charts for twins using a model-based approach proposed by Zhang et al. Our twin standards were compared with Hadlock’s (singleton) in predicting adverse perinatal outcomes. Results A total of 398 twin pregnancies were included, with 214 MC and 582 DC live-born twins. The MC twins were slightly lighter than the DC twins, with small differences throughout the gestation. Our ultrasound-based fetal weight standards were comparable to that using Zhang’s method. Compared with previous references/standards from the US, Brazil, Italy and UK, our twins had very similar 50th percentiles, but narrower ranges between the 5th and 95th or 10th and 90th percentiles. Compared with the Hadlock’s standard, the risks of neonatal death and adverse perinatal outcomes for small for gestational age (SGA) versus non-SGA were substantially elevated using our standards. Conclusions A normal fetal growth standard for Chinese twins was created. The differences between MC and DC twins were clinically insignificant. The 50th weight percentiles of the Chinese twins were identical to those in other races/ethnicities but the ranges were markedly narrower. Our standard performed much better than the Hadlock’s in predicting low birth weight infants associated with adverse perinatal outcomes in twin pregnancies. The present study also indicated that Zhang’s method is applicable to Chinese twins, and other areas may use Zhang’s method to generate their own curves for twins if deemed necessary. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03926-y.
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Affiliation(s)
- Jianping Chen
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 2699 West Gaoke Rd, Shanghai, 201204, China
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Liu
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 2699 West Gaoke Rd, Shanghai, 201204, China
| | - Xing Wei
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 2699 West Gaoke Rd, Shanghai, 201204, China
| | - Yingjun Yang
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 2699 West Gaoke Rd, Shanghai, 201204, China
| | - Gang Zou
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 2699 West Gaoke Rd, Shanghai, 201204, China
| | - Yun Zhang
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 2699 West Gaoke Rd, Shanghai, 201204, China
| | - Tao Duan
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 2699 West Gaoke Rd, Shanghai, 201204, China
| | - Luming Sun
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 2699 West Gaoke Rd, Shanghai, 201204, China.
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Predictive Accuracy of Singleton Versus Customized Twin Growth Chart for Adverse Perinatal Outcome: A Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18042016. [PMID: 33669723 PMCID: PMC7921915 DOI: 10.3390/ijerph18042016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/06/2021] [Accepted: 02/16/2021] [Indexed: 11/17/2022]
Abstract
Background: Fetal growth of twins differs from singletons. The objective was to assess the fetal growth in twin gestations in relation to singleton charts and customized twin charts, respectively, followed by a comparison of the frequency of neonatal complications in small-for-gestational-age (SGA) twins. Methods: We performed an analysis of twin pregnancies with established chorionicity with particular emphasis on postnatal adverse outcomes in newborns classified as SGA. Neonatal birth weight was comparatively assessed using both singleton and twin growth charts with following percentile estimation. Using a statistical model, we established the prediction strength of neonatal complications in SGA twins for both methods. Results: The dataset included 322 twin pairs (247 cases of dichorionic and 75 cases of monochorionic diamniotic gestations). Utilization of twin-specific normograms was less likely to label twins as SGA—nevertheless, this diagnosis strongly correlated with risk of observing adverse outcomes. Using a chart dedicated for twin pregnancies predicted newborn complications in the SGA group with higher sensitivity and had better positive predictive value regarding postnatal morbidity. Conclusions: Estimating twin growth with customized charts provides better prognosis of undesirable neonatal events in the SGA group comparing to singleton nomograms and consequently might determine neonatal intensive care prenatal approach.
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17
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Perinatal Outcomes of Small for Gestational Age in Twin Pregnancies: Twin vs. Singleton Charts. J Clin Med 2021; 10:jcm10040643. [PMID: 33567545 PMCID: PMC7916041 DOI: 10.3390/jcm10040643] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 01/31/2021] [Accepted: 02/05/2021] [Indexed: 02/07/2023] Open
Abstract
Twin pregnancies are commonly assessed using singleton growth and birth weight reference charts. This practice has led to a significant number of twins labelled as small for gestational age (SGA), causing unnecessary interventions and increased risk of iatrogenic preterm birth. However, the use of twin-specific charts remains controversial. This study aims to assess whether twin-specific estimated fetal weight (EFW) and birth weight (BW) charts are more predictive of adverse outcomes compared to singleton charts. Centiles of EFW and BW were calculated using previously published singleton and twin charts. Categorical data were compared using Chi-square or McNemar tests. The study included 1740 twin pregnancies, with the following perinatal adverse outcomes recorded: perinatal death, preterm birth <34 weeks, hypertensive disorders of pregnancy (HDP) and admissions to the neonatal unit (NNU). Twin-specific charts identified prenatally and postnatally a smaller proportion of infants as SGA compared to singleton charts. However, twin charts showed a higher percentage of adverse neonatal outcomes in SGA infants than singleton charts. For example, perinatal death (SGA 7.2% vs. appropriate for gestational age (AGA) 2%, p < 0.0001), preterm birth <34 weeks (SGA 42.1% vs. AGA 16.4%, p < 0.0001), HDP (SGA 21.2% vs. AGA 13.5%, p = 0.015) and NNU admissions (SGA 69% vs. AGA 24%, p < 0.0001), when compared to singleton charts (perinatal death: SGA 2% vs. AGA 1%, p = 0.029), preterm birth <34 weeks: (SGA 20.6% vs. AGA 17.4%, p = 0.020), NNU admission: (SGA 34.5% vs. AGA 23.9%, p < 0.000). There was no significant association between HDP and SGA using the singleton charts (p = 0.696). In SGA infants, according to the twin charts, the incidence of abnormal umbilical artery Doppler was significantly more common than in SGA using the singleton chart (27.0% vs. 8.1%, p < 0.001). In conclusion, singleton charts misclassify a large number of twins as at risk of fetal growth restriction. The evidence suggests that the following twin-specific charts could reduce unnecessary medical interventions prenatally and postnatally.
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Mei Y, Yu J, Wen L, Fan X, Zhao Y, Li J, Qiao J, Fu H, Leong P, Saffery R, Tong Q, Kilby MD, Qi H, Tong C, Baker PN. Perinatal outcomes and offspring growth profiles in twin pregnancies complicated by gestational diabetes mellitus: A longitudinal cohort study. Diabetes Res Clin Pract 2021; 171:108623. [PMID: 33316314 DOI: 10.1016/j.diabres.2020.108623] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/16/2020] [Accepted: 12/08/2020] [Indexed: 11/23/2022]
Abstract
AIMS To evaluate the influence of gestational diabetes mellitus (GDM) on the perinatal outcomes of twin pregnancies and its impact on fetal growth profiles of twin offspring from 6 weeks to 12 months of corrected age. METHODS A longitudinal cohort study was conducted among pregnant women with twins and their twin offspring. All information on perinatal outcomes and child growth trajectories from 6 weeks to 12 months of corrected age were obtained and analyzed using a general linear model and logistic regression models. RESULTS GDM was not correlated with adverse perinatal outcomes of twin pregnancies; however, in monochorionic diamniotic (MCDA), but not dichorionic diamniotic (DCDA) twin pregnancies, GDM was correlated with gestational hypertension disorder and a fetus being small for gestational age (OR, 2.68; 95% CI 1.16-6.04 and OR, 0.35; 95% CI 0.16-0.76, respectively). In both MCDA and DCDA groups, GDM was positively associated with a higher risk of childhood overweight at 6 months of corrected age (2.32 [1.05, 5.09] and 2.00 [1.13, 3.53]). CONCLUSIONS GDM had a greater impact on MCDA twin pregnancies in terms of maternal gestational hypertension disease and small for gestational age of newborns. Additionally, twin offspring exposed to GDM had a higher risk of being overweight at 6 months of corrected age irrespective of chorionicity. CLINICAL TRIAL REGISTRATION ChiCTR-OOC-16008203.
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Affiliation(s)
- Youwen Mei
- Department of Obstetrics, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; International Collaborative Jointed Laboratory of Maternal and Fetal Medicine, Ministry of Education, Chongqing Medical University, Chongqing 400016, China; State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing 400016, China
| | - Jiaxiao Yu
- Department of Obstetrics, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; International Collaborative Jointed Laboratory of Maternal and Fetal Medicine, Ministry of Education, Chongqing Medical University, Chongqing 400016, China; State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing 400016, China
| | - Li Wen
- Department of Obstetrics, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; International Collaborative Jointed Laboratory of Maternal and Fetal Medicine, Ministry of Education, Chongqing Medical University, Chongqing 400016, China; State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing 400016, China
| | - Xin Fan
- Department of Child Healthcare, Chongqing Health Center for Women and Children, Chongqing, China
| | - Yan Zhao
- Department of Child Healthcare, Chongqing Health Center for Women and Children, Chongqing, China
| | - Jie Li
- Department of Obstetrics, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Juan Qiao
- Department of Obstetrics, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; International Collaborative Jointed Laboratory of Maternal and Fetal Medicine, Ministry of Education, Chongqing Medical University, Chongqing 400016, China; State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing 400016, China
| | - Huijia Fu
- Department of Obstetrics, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; International Collaborative Jointed Laboratory of Maternal and Fetal Medicine, Ministry of Education, Chongqing Medical University, Chongqing 400016, China; State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing 400016, China
| | - Pamela Leong
- Cancer, Disease and Developmental Epigenetics, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Pediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Richard Saffery
- Cancer, Disease and Developmental Epigenetics, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Pediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Qi Tong
- Chongqing Population and Family Planning Science and Technology Research Institute, Chongqing 400020, China; NHC Key Laboratory of Birth Defects and Reproductive Health, Chongqing 400020, China
| | - Mark D Kilby
- Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, B15 2TG, UK; Institute of Metabolism & Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Hongbo Qi
- Department of Obstetrics, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; International Collaborative Jointed Laboratory of Maternal and Fetal Medicine, Ministry of Education, Chongqing Medical University, Chongqing 400016, China; State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing 400016, China.
| | - Chao Tong
- Department of Obstetrics, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; International Collaborative Jointed Laboratory of Maternal and Fetal Medicine, Ministry of Education, Chongqing Medical University, Chongqing 400016, China; State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing 400016, China.
| | - Philip N Baker
- College of Life Sciences, University of Leicester, Leicester LE1 7RH, UK
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19
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Li W, Chung CYL, Wang CC, Chan TF, Leung MBW, Chan OK, Wu L, Appiah K, Chaemsaithong P, Cheng YKY, Poon LCY, Leung TY. Monochorionic twins with selective fetal growth restriction: insight from placental whole-transcriptome analysis. Am J Obstet Gynecol 2020; 223:749.e1-749.e16. [PMID: 32437666 DOI: 10.1016/j.ajog.2020.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/24/2020] [Accepted: 05/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The underlying pathomechanism in placenta-related selective fetal growth restriction in monochorionic diamniotic twin pregnancy is not known. OBJECTIVE This study aimed to investigate any differences in placental transcriptomic profile between the selectively growth-restricted twins and the normally grown cotwins in monochorionic diamniotic twin pregnancies. STUDY DESIGN This was a prospective study of monochorionic diamniotic twin pregnancies complicated by selective fetal growth restriction. Placental biopsy specimens were obtained from the subjects in the delivery suite. The placental transcriptome of the selectively growth-restricted twin was compared with that of the normally grown cotwin. This study was divided into 2 stages: (1) gene discovery phase in which placental tissues from 5 monochorionic diamniotic twin pregnancies complicated by selective fetal growth restriction plus 2 control twin pregnancies underwent transcriptome profiling, and transcriptome profiling was carried out using whole-genome RNA sequencing; and (2) validation phase in which placental tissues from 13 monochorionic diamniotic twin pregnancies with selective fetal growth restriction underwent RNA and protein validation. RNA and protein expression levels of candidate genes were determined using quantitative real-time polymerase chain reaction and immunohistochemistry staining. RESULTS A total of 1429 transcripts were differentially expressed in the placentae of selectively growth-restricted twin pairs, where 610 were up-regulated and 819 were down-regulated. Endoplasmic reticulum lectin and mannose 6-phosphate receptor were consistently differentially up-regulated in all placentae of selectively growth-restricted twins. Quantitative real-time polymerase chain reaction and immunohistochemistry staining were used to validate the results (P<.05). CONCLUSION The expression of endoplasmic reticulum lectin and mannose 6-phosphate receptor, which are important for angiogenesis and fetal growth, was significantly increased in the placentae of selectively growth-restricted twin of a monochorionic twin pair.
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Affiliation(s)
- Wei Li
- Department of Obstetrics and Gynaecology, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Claire Yik Lok Chung
- School of Life Sciences, the Chinese University of Hong Kong, Shatin, Hong Kong; Hong Kong Bioinformatics Centre, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Chi Chiu Wang
- Department of Obstetrics and Gynaecology, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong; Department of Reproduction and Development, Li Ka Shing Institute of Health Sciences, the Chinese University of Hong Kong, Shatin, Hong Kong; School of Biomedical Sciences, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ting Fung Chan
- School of Life Sciences, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Maran Bo Wah Leung
- Department of Obstetrics and Gynaecology, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Oi Ka Chan
- Department of Obstetrics and Gynaecology, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong; Hong Kong Bioinformatics Centre, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ling Wu
- Department of Obstetrics and Gynaecology, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kubi Appiah
- Department of Obstetrics and Gynaecology, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Piya Chaemsaithong
- Department of Obstetrics and Gynaecology, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yvonne Kwun Yue Cheng
- Department of Obstetrics and Gynaecology, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Liona Chiu Yee Poon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tak Yeung Leung
- Department of Obstetrics and Gynaecology, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong.
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20
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Savirón-Cornudella R, Esteban LM, Aznar-Gimeno R, Pérez-López FR, Ezquerro MC, Pérez PD, Maza JMC, Sanz G, Larraz BC, Tajada-Duaso M. A cohort study of fetal growth in twin pregnancies by chorionicity: comparison with European and American standards. Eur J Obstet Gynecol Reprod Biol 2020; 253:238-248. [PMID: 32898769 DOI: 10.1016/j.ejogrb.2020.08.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/03/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To develop fetal growth standards for twin gestations by placental chorionicity in a Spanish population and compare them with European and American standards to estimate the suitability of their use in clinical practice. STUDY DESIGN This was a retrospective cohort study of 518 twin pregnancies, 435 dichorionic-diamniotic and 83 monochorionic-diamniotic, performed between January 2012 and December 2017. A total of 4,783 and 1,455 estimated fetal weights were considered from the 17th to the 37th week of gestation, using multilevel models, to build dichorionic-diamniotic and monochorionic-diamniotic standards, respectively. The percentages of small and large for gestational age were calculated as a model adjustment measure and adjustment to the studied data and the values provided by our model were compared against those of six European and American twin standards and three singleton standards. Correlation analyses between percentile predictions were performed using Cohen kappa coefficient. The predictive ability to detect small for gestational age was also provided by the sensitivity and positive predictive value. RESULTS We found slight differences between standards by chorionicity, being dichorionic-diamniotic percentiles slightly higher than monochorionic-diamniotic ones from the 17th to 37th weeks' gestation. For dichorionic-diamniotic cases, both our standard (9.8-8.2) and that of Grantz (8.2-10.5) showed good adjustments for the 10th and 90th percentiles while the other compared standards underestimated or overestimated them. For monochorionic-diamniotic cases, both our standard (10.2-8.5) and that of Shivkumar (11.4-6.8) had the most suitable adjustment. The correlation analysis between small and large for gestational age cases provided by standards, showed clear differences among them. Kappa's coefficient showed a substantial agreement between both Ananth (0.7) and Stirrup (0.69) dichorionic-diamniotic cases and our standard. There was also a substantial agreement between the Shivkumar (0.77) standard and our results for monochorionic-diamniotic cases. The correlation was moderate for all other comparisons. CONCLUSIONS Our model showed a good adjustment to the studied population. There are clear differences among small and large for gestational age cases provided by twin standards in our studied population. The twin growth standards depend on the population characteristics and model structure. We found the use of singleton standards for twin pregnancies inadequate.
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Affiliation(s)
- Ricardo Savirón-Cornudella
- Department of Obstetrics and Gynecology, Villalba General Hospital, Camino de Moralzarzal M-608 Km, Calle Alpedrete 41, 28400 Collado Villalba, Madrid, Spain.
| | - Luis M Esteban
- Department of Applied mathematics, Escuela Universitaria Politécnica de La Almunia, Universidad de Zaragoza, Calle Mayor 5, 50100, La Almunia de Doña Godina, Zaragoza, Spain.
| | - Rocío Aznar-Gimeno
- Deparment of BigData and Cognitive systems. Instituto Tecnológico de Aragon, ITAINNOVA, María de Luna 7-8, 50018, Zaragoza, Spain.
| | - Faustino R Pérez-López
- Department of Obstetrics and Gynecology, University of Zaragoza, Faculty of Medicine and Instituto de Investigación Sanitaria Aragón, Domingo Miral s/n, 50009, Zaragoza, Spain.
| | - Marta Chóliz Ezquerro
- Department of Obstetrics and Gynecology, Miguel Servet University Hospital, Isabel La Católica 3, 50009, Zaragoza, Spain.
| | - Peña Dieste Pérez
- Department of Obstetrics and Gynecology, Miguel Servet University Hospital, Isabel La Católica 3, 50009, Zaragoza, Spain.
| | - José M Campillos Maza
- Department of Obstetrics and Gynecology, Miguel Servet University Hospital, Isabel La Católica 3, 50009, Zaragoza, Spain.
| | - Gerardo Sanz
- Department of Statistical Methods and Institute for Biocomputation and Physics of Complex Systems-BIFI, University of Zaragoza, Calle Pedro Cerbuna 12, 50009, Zaragoza, Spain.
| | - Berta Castán Larraz
- Department of Obstetrics and Gynecology, San Pedro Hospital, Calle Piqueras 98, 26006, Logroño, La Rioja, Spain.
| | - Mauricio Tajada-Duaso
- Department of Obstetrics and Gynecology, Miguel Servet University Hospital, Isabel La Católica 3, 50009, Zaragoza, Spain.
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21
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Saletra-Bielińska A, Kosińska-Kaczyńska K, Szymusik I, Kaczyński B, Brawura-Biskupski-Samaha R, Kozłowski S, Jarmużek P, Walasik I, Wielgoś M. Both Low and High PAPP-A Concentrations in the First Trimester of Pregnancy Are Associated with Increased Risk of Delivery before 32 Weeks in Twin Gestation. J Clin Med 2020; 9:jcm9072099. [PMID: 32635314 PMCID: PMC7408854 DOI: 10.3390/jcm9072099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/21/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022] Open
Abstract
In twin gestation, the relationship between pregnancy associated plasma protein (PAPP-A) and perinatal outcome is unclear. The aim of the study was to determine if low and high concentrations of PAPP-A in the first trimester are related to perinatal outcome in twins. A retrospective study was conducted. Medical data of women in twin pregnancies who delivered between 2013 and 2018 were analyzed. PAPP-A concentrations were measured between 10 + 0 and 13 + 6 weeks. The associations between low (<10th percentile) and high (>90th percentile) values of PAPP-A and pregnancy complications were analyzed. A total of 304 patients were included. PAPP-A <10th percentile was associated with a high risk of preterm delivery (OR 6.14; 95% CI 2.1-18), delivery <34 weeks (OR 2.39; 95% CI 1.1-5.1) or <32 weeks (OR3.06; 95% CI 1.4-6.8). Significant relations between PAPP-A >90th percentile and delivery <34 weeks (OR4.09; 95% CI 1.8-9.1) or <32 weeks (OR 2.83; 95% CI 1.2-6.6) were found. PAPP-A >90th percentile was related to high risk of intrauterine fetal demise (OR 10; 95% CI 2.4-42.5). Both low and high PAPP-A concentrations seem to be related to pregnancy outcome. Further research is needed to investigate evaluation of risk of pregnancy complications according to PAPP-A concentrations as a continuous variable.
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Affiliation(s)
- Aleksandra Saletra-Bielińska
- Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.S.-B.); (I.S.); (R.B.-B.-S.); (P.J.); (M.W.)
| | - Katarzyna Kosińska-Kaczyńska
- Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.S.-B.); (I.S.); (R.B.-B.-S.); (P.J.); (M.W.)
- Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, 01-809 Warsaw, Poland
- Correspondence:
| | - Iwona Szymusik
- Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.S.-B.); (I.S.); (R.B.-B.-S.); (P.J.); (M.W.)
| | - Bartosz Kaczyński
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Robert Brawura-Biskupski-Samaha
- Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.S.-B.); (I.S.); (R.B.-B.-S.); (P.J.); (M.W.)
| | - Szymon Kozłowski
- University Center for Woman and Newborn Health of the Medical University of Warsaw, 02-015 Warsaw, Poland;
| | - Patrycja Jarmużek
- Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.S.-B.); (I.S.); (R.B.-B.-S.); (P.J.); (M.W.)
| | - Izabela Walasik
- Students Scientific Association at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-015 Warsaw, Poland;
| | - Mirosław Wielgoś
- Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.S.-B.); (I.S.); (R.B.-B.-S.); (P.J.); (M.W.)
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22
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Dall'Asta A, Rizzo G, Kiener A, Volpe N, Di Pasquo E, Roletti E, Mappa I, Makatsariya A, Maruotti GM, Saccone G, Sarno L, Papaccio M, Fichera A, Prefumo F, Ottaviani C, Stampalija T, Frusca T, Ghi T. Identification of large-for-gestational age fetuses using antenatal customized fetal growth charts: Can we improve the prediction of abnormal labor course? Eur J Obstet Gynecol Reprod Biol 2020; 248:81-88. [PMID: 32199297 DOI: 10.1016/j.ejogrb.2020.03.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/05/2020] [Accepted: 03/09/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Fetal overgrowth is an acknowledged risk factor for abnormal labor course and maternal and perinatal complications. The objective of this study was to evaluate whether the use of antenatal ultrasound-based customized fetal growth charts in fetuses at risk for large-for-gestational age (LGA) allows a better identification of cases undergoing caesarean section due to intrapartum dystocia. MATERIAL AND METHODS An observational study involving four Italian tertiary centers was carried out. Women referred to a dedicated antenatal clinic between 35 and 38 weeks due to an increased risk of having an LGA fetus at birth were prospectively selected for the study purpose. The fetal measurements obtained and used for the estimation of the fetal size were biparietal diameter, head circumference, abdominal circumference and femur length, were prospectively collected. LGA fetuses were defined by estimated fetal weight (EFW) >95th centile either using the standard charts implemented by the World Health Organization (WHO) or the customized fetal growth charts previously published by our group. Patients scheduled for elective caesarean section (CS) or for elective induction for suspected fetal macrosomia or submitted to CS or vacuum extraction (VE) purely due to suspected intrapartum distress were excluded. The incidence of CS due to labor dystocia was compared between fetuses with EFW >95th centile according WHO or customized antenatal growth charts. RESULTS Overall, 814 women were eligible, however 562 were considered for the data analysis following the evaluation of the exclusion criteria. Vaginal delivery occurred in 466 (82.9 %) women (435 (77.4 %) spontaneous vaginal delivery and 31 (5.5 %) VE) while 96 had CS. The EFW was >95th centile in 194 (34.5 %) fetuses according to WHO growth charts and in 190 (33.8 %) by customized growth charts, respectively. CS due to dystocia occurred in 43 (22.2 %) women with LGA fetuses defined by WHO curves and in 39 (20.5 %) women with LGA defined by customized growth charts (p 0.70). WHO curves showed 57 % sensitivity, 72 % specificity, 24 % PPV and 91 % NPV, while customized curves showed 52 % sensitivity, 73 % specificity, 23 % PPV and 91 % NPV for CS due to labor dystocia. CONCLUSIONS The use of antenatal ultrasound-based customized growth charts does not allow a better identification of fetuses at risk of CS due to intrapartum dystocia.
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Affiliation(s)
- Andrea Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy; Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, United Kingdom
| | - Giuseppe Rizzo
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy; Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Ariane Kiener
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - Nicola Volpe
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - Elvira Di Pasquo
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - Enrica Roletti
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - Ilenia Mappa
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
| | - Alexander Makatsariya
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy; Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Giuseppe Maria Maruotti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Laura Sarno
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Marta Papaccio
- Department of Obstetrics and Gynaecology, University of Brescia, Spedali Civili Di Brescia, Brescia, Italy
| | - Anna Fichera
- Department of Obstetrics and Gynaecology, University of Brescia, Spedali Civili Di Brescia, Brescia, Italy
| | - Federico Prefumo
- Department of Obstetrics and Gynaecology, University of Brescia, Spedali Civili Di Brescia, Brescia, Italy
| | - Chiara Ottaviani
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy; Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy; Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Tiziana Frusca
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy.
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23
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Liotto N, Roggero P, Giuliani F, Morniroli D, Giannì ML, Bracco B, Menis C, Orsi A, Piemontese P, Amato O, Mosca F. How does gestational age affect growth and body composition of preterm twins? Pediatr Res 2020; 87:57-61. [PMID: 31401647 DOI: 10.1038/s41390-019-0530-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 06/03/2019] [Accepted: 07/25/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Twins experience altered growth compared to singletons. The primary aim of this study was to compare growth and body composition (BC) of twin and singleton preterm infants from birth to 3 months according to gestational age (GA). Secondary aims were to evaluate the effect of chorionicity and mode of feeding on twins' BC. METHODS Anthropometric measurements and BC were performed at term and 3 months in preterm infants (GA < 37 weeks). Infants were categorized as: extremely, very, moderate and late preterm infants. Chorionicity was assigned as monochorionic, dichorionic or multichorionic. Mode of feeding was recorded as any human milk feeding vs formula feeding. RESULTS Five hundred and seventy-six preterm infants were included (223 twins). Late-preterm twins were lighter and shorter at each study point; fat-free mass (FFM) was lower in these infants at each study point, compared to singletons. No differences were found between twins and singleton on the other category. Multichorionic infants had an FFM deficit compared to monochorionic and dichorionic at term, whereas no differences were found at 3 months. FFM at term was negatively associated with being twin and formula-fed. CONCLUSIONS Twins and singletons born before 34 weeks' GA showed similar anthropometry and BC. Conversely, twin late-preterm infants showed different growth and BC compared to singletons.
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Affiliation(s)
- Nadia Liotto
- NICU Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Paola Roggero
- NICU Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Francesca Giuliani
- Department of Pediatrics, Ospedale Infantile Regina Margherita, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Daniela Morniroli
- NICU Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Maria L Giannì
- NICU Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Beatrice Bracco
- NICU Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Camilla Menis
- NICU Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Anna Orsi
- NICU Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pasqua Piemontese
- NICU Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Orsola Amato
- NICU Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- NICU Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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24
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Casati D, Pellegrino M, Cortinovis I, Spada E, Lanna M, Faiola S, Cetin I, Rustico MA. Longitudinal Doppler references for monochorionic twins and comparison with singletons. PLoS One 2019; 14:e0226090. [PMID: 31809530 PMCID: PMC6897428 DOI: 10.1371/journal.pone.0226090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/19/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To construct monochorionic (MC) twin-specific longitudinal Doppler references for umbilical artery pulsatility index (UA-PI), middle cerebral artery (MCA) PI and peak systolic velocity (PSV) and ductus venosus (DV) PI derived from a strictly selected cohort of uncomplicated MC twins. The secondary aim of the study was to compare our findings with singleton reference charts. METHODS A retrospective evaluation was made of all consecutive uncomplicated MC twin pregnancies referred to our Unit from 2010 to 2018. Fortnightly serial examinations were performed of UA-PI, MCA-PI, MCA-PSV and DV-PI, according with the clinical protocol, from 20 to 37 weeks of gestation. We included cases with at least four ultrasound examinations, delivery at our hospital and complete neonatal follow up. A two-step method was used to trace the estimated centile curves: estimation of the median was performed with appropriate fractional polynomials by a multilevel model and estimation of the external centiles through the residuals (quantile regression). The comparison with singletons was made by plotting the references derived from the present study on the referred charts commonly used for singletons. RESULTS The study group comprised 150 uncomplicated MC twin pairs. Estimated centiles (3rd, 5th, 10th, 50th, 90th, 95th, 97th) of UA-PI, MCA-PI, MCA-PSV and DV-PI in function of the gestational age are presented. The comparison with singletons showed substantial differences, with higher UA-PI and lower MCA-PI and PSV median values in MC twins. Median DV PI values were similar to the values for singletons, while the upper centiles were higher in MC twins. CONCLUSIONS This study sets out MC twin-specific longitudinal references for UA-PI, MCA-PI, MCA-PSV and DV-PI derived from the largest series of uncomplicated MC twin pregnancies presently available. The comparison with singleton reference values underscores the deviation from physiology that is intrinsic to these unique pregnancies and supports the need for MC twin-specific charts.
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Affiliation(s)
- Daniela Casati
- Fetal Therapy Unit 'Umberto Nicolini', Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
- * E-mail:
| | - Marcella Pellegrino
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Ivan Cortinovis
- Laboratory G.A. Maccacaro, Department of Clinical Sciences and Community Health, University of Milan Milan, Italy
| | - Elena Spada
- Neonatal Unit, University of Turin, City of Health and Science of Turin, Turin, Italy
| | - Mariano Lanna
- Fetal Therapy Unit 'Umberto Nicolini', Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Stefano Faiola
- Fetal Therapy Unit 'Umberto Nicolini', Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Irene Cetin
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Maria Angela Rustico
- Fetal Therapy Unit 'Umberto Nicolini', Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
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Wilkof Segev R, Gelman M, Maor-Sagie E, Shrim A, Hallak M, Gabbay-Benziv R. New reference values for biometrical measurements and sonographic estimated fetal weight in twin gestations and comparison to previous normograms. J Perinat Med 2019; 47:757-764. [PMID: 31373899 DOI: 10.1515/jpm-2019-0207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 07/15/2019] [Indexed: 11/15/2022]
Abstract
Objective To construct new reference values for biometrical measurements and sonographic estimated fetal weight (sEFW) in twin gestations and compare them to previously published normograms. Methods A retrospective analysis of sEFW evaluations of twin gestations was performed between 2011 and 2016 in a single university-affiliated medical center. sEFW was calculated using the Hadlock 1985 formula. To avoid selection bias, one evaluation per pregnancy was randomly selected. Following mathematical transformation to obtain normality of values, normograms were constructed using a best-fit regression model for estimation of mean and standard deviation at each gestational age (GA). Normograms were validated by applying all observations to ensure equal distribution at parallel percentiles. Our normograms were then compared to previously published sEFW normograms for twin gestations. Results A total of 864 sEFW evaluations were performed on 195 twin pregnancies at 22-39 gestational weeks. Of them, 390 entered the primary analysis. The rest were left for validation. Seventy percent of the cohort were dichorionic-diamniotic twins (136/195), 16% (32/195) were monochorionic-diamniotic twins and three (1.5%) were monochorionic-monoamniotic twins. Twenty-four fetuses lacked data on chorionicity. The rest were monochorionic twins or were of unknown chorionicity. Values corresponding to the 2.5th, 10th, 50th, 90th and 97.5th percentiles for sEFW are presented for every GA. Validation by applying all 864 evaluations on constructed normograms was achieved. Comparison to previously published twins' sEFW normograms demonstrated wide variation between curves. Conclusion New reference values for biometrical measurements and sEFW in twin gestations are presented for clinical and research use. Comparison to other curves demonstrates the wide variability and need for further investigation on twin's normal growth.
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Affiliation(s)
- Renana Wilkof Segev
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera 38100, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Milana Gelman
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera 38100, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Esther Maor-Sagie
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera 38100, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Alon Shrim
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera 38100, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Mordechai Hallak
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera 38100, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Rinat Gabbay-Benziv
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera 38100, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
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Amyx MM, Albert PS, Bever AM, Hinkle SN, Owen J, Grobman WA, Newman RB, Chien EK, Gore-Langton RE, Buck Louis GM, Grantz KL. Associations between estimated foetal weight discordance and clinical characteristics within dichorionic twins: The NICHD Fetal Growth Studies. Paediatr Perinat Epidemiol 2019; 33:332-342. [PMID: 31478227 PMCID: PMC7593826 DOI: 10.1111/ppe.12570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/07/2019] [Accepted: 06/23/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Birthweight discordance is well studied, with less known about longitudinal inter-twin differences in foetal growth. OBJECTIVE To examine inter-twin per cent differences in EFW (EFW% ), head (HC% ) and abdominal circumference (AC% ), and femur length (FL% ) across gestation in dichorionic twin gestations and explore associated characteristics. METHODS Foetal biometrics were assessed by ultrasound and EFW calculated at ≤6 study visits among women with dichorionic twin pregnancies enrolled in the NICHD Fetal Growth Studies cohort (US, 2012-2013). Inter-twin per cent difference was defined: ([Sizelarger twin - Sizesmaller twin ]/Sizelarger twin × 100). Linear mixed models evaluated per cent differences in foetal biometrics at 15 weeks and their change per week overall and by maternal/neonatal characteristics in unadjusted and adjusted models. RESULTS In 140 pregnancies, inter-twin per cent differences increased across gestation for EFW (0.18%/week, 95% confidence interval [CI] 0.10, 0.27), HC (0.03%/week, 95% CI 0.00, 0.06), and AC (0.03%/week, 95%CI -0.01, 0.08) but decreased for FL (-0.03%/week, 95% CI -0.09, 0.02). After adjustment, change in EFW% difference across gestation differed by pre-pregnancy body mass index (BMI [kg/m2 ]; underweight [<18.5]; normal weight [18.5-24.9]; overweight [25.0-29.9]; obese [≥30.0]; Pinteraction = .022); and conception method (in vitro fertilisation [IVF], intrauterine insemination, ovulation induction medication, donor egg/embryo, none; Pinteraction = .060). While EFW% difference increased with normal pre-pregnancy BMI (0.24%/week, 95% CI 0.12, 0.37), little change was noted with pre-pregnancy obesity (0.01%/week, 95% CI -0.15, 0.17). EFW% difference increased in conceptions without fertility treatments (0.23%/week, 95% CI 0.11, 0.34) but not IVF conceptions (-0.00%/week, 95% CI -0.16, 0.16). Similar patterns of differences across gestation were noted for HC% by conception method (Pinteraction = .026) and AC% by pre-pregnancy BMI (Pinteraction = .071); changes in HC% differed by parity (nulliparous, multiparous; Pinteraction = .004). CONCLUSIONS EFW% difference increased across gestation in dichorionic twins, but remained stable with pre-pregnancy obesity or IVF conception, patterns mirrored for HC and AC. Research is needed to understand pathologic versus physiologic differential twin growth trajectories.
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Affiliation(s)
- Melissa M. Amyx
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Paul S. Albert
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Alaina M. Bever
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Stefanie N. Hinkle
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - John Owen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama, Birmingham, School of Medicine, Birmingham, Alabama
| | | | - Roger B. Newman
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina
| | - Edward K. Chien
- Women and Infants Hospital of Rhode Island, Providence, Rhode Island
| | | | - Germaine M. Buck Louis
- Dean’s Office, College of Health and Human Services, George Mason University, Fairfax, Virginia
| | - Katherine L. Grantz
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Akkuş T, Erdoğan G. Ultrasonographic evaluation of feto-placental tissues at different intrauterine locations in rabbit. Theriogenology 2019; 138:16-23. [PMID: 31280181 DOI: 10.1016/j.theriogenology.2019.06.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/25/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
The main purpose of examining multiparous species with real-time ultrasonography is to determine the gestational age and make various fetal measurements for early diagnosis of growth anomalies and sibling mismatches. This study investigated changes in fetometric measurements, obstetric Doppler indices and placental image analysis results based on gestational age and fetal location in fetuses located cranially and caudally between 16 and 24 days gestation in 22 healthy pregnant New Zealand rabbits. The first study group consisted of fetuses positioned at the cranial end (n = 22) while the second group consisted of fetuses positioned at the caudal end (n = 22) in each pregnancy. Fetal biparietal head diameter (BPD) and trunk diameter (TD) were measured, and mean grayness values (MGV) were determined from placental image analysis of each fetus. Using Doppler USG, the pulsatile (PI) and resistance (RI) indices of the uterine artery (UtA) and umbilical artery (UmA) were recorded. By the end of the study, BPD and TD values for cranial and caudal fetuses had significantly increased with gestational age (P < 0.001). The MGV values of caudal fetuses were significantly higher (except for the 16th day) (P < 0.05). The UtA PI value of the caudal fetuses was significantly higher (except for the 18th day) (P < 0.01). The UtA RI values of caudal fetuses were significantly higher than cranial ones on the 16 and 24th days (P < 0.05). The PI of the UmA increased until the 20th day before decreasing significantly in both study groups (P < 0.001). The UmA RI value decreased according to the gestational age in both groups (P < 0.001). It was significantly higher in the caudal fetuses on the 20th day (P < 0.05). The somatic rate of all fetuses peaked at the end of the second trimester, although caudal fetuses had higher fetometric values, and this location difference also affected placental echotexture. In both vessels of caudal fetuses, pulsatility and resistance values were higher. The 20th day of pregnancy was a threshold for the Doppler exam results. In conclusion, growth and metabolic status of fetuses located in different uterine locations in healthy pregnant New Zealand rabbits vary. Based on the these growth curves and hemodynamic data, more comprehensive studies of intrauterine life may be possible.
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Affiliation(s)
- Tuğra Akkuş
- Harran University, Faculty of Veterinary Medicine, Department of Obstetrics and Gynecology, Sanliurfa, Turkey.
| | - Güneş Erdoğan
- Aydin Adnan Menderes University, Faculty of Veterinary Medicine, Department of Obstetrics and Gynecology, Aydin, Turkey
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Hiersch L, Okby R, Freeman H, Rosen H, Nevo O, Barrett J, Melamed N. Differences in fetal growth patterns between twins and singletons. J Matern Fetal Neonatal Med 2019; 33:2546-2555. [PMID: 30501543 DOI: 10.1080/14767058.2018.1555705] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objective: Twin fetus growth is delayed during the third trimester compared to singletons. Whether this phenomenon should be considered a normal physiologic characteristic of twins or a pathologic process inherent to twin pregnancies is currently unclear. Information on the growth rate of the individual fetal biometric indices may provide more insight into the mechanisms underlying these differences between twins and singletons. Our aim was to compare fetal growth pattern between twin and singleton fetuses.Methods: This was a retrospective study of women with an uncomplicated twin pregnancy who underwent sonographic fetal weight estimation between 16 and 38 weeks' gestation in a single referral center. Twins-specific regression models were generated for biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL) and fetal weight as a function of gestational age and were compared to published singletons-based curves.Results: Overall 543 women were eligible for the study and underwent a total of 3401 sonographic weight estimations. Estimated weight of twin fetus emerged as lower than that of singletons starting at 26 weeks of gestation, and these differences increased with gestational age, reaching a mean difference of 300-350 g or of ∼10% at term. The growth of all four biometric indices was slower in twins compared to singletons, but the differences were most pronounced for AC which had the largest relative contribution to the lower fetal weight in twins (51.7 ± 7.3%), while the relative contribution of FL, HC, and BPD was smaller (26.4 ± 10.7, 15.5 ± 3.0, and 6.4%±5.7%, respectively). This was also reflected by a higher HC/AC ratio in twins compared with singletons starting at 22 weeks of gestation. The likelihood of a twin fetus being diagnosed as small for gestational age (fetal weight <10th percentile) was significantly lower when the newly developed twins-based curves (rather than singletons-based curves) were used (OR: 0.39, 95%-CI: 0.34-0.44).Conclusion: Twin fetus experience slowing of growth beginning at ∼26 weeks of gestation and a greater degree of asymmetric growth pattern compared with singletons. These findings suggest that the slower growth of twins may reflect a state of "relative growth restriction" compared with singleton gestations.
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Affiliation(s)
- Liran Hiersch
- Sackler Faculty of Medicine, Lis Maternity Hospital affiliated to Tel Aviv University, Tel Aviv, Israel
| | - Rania Okby
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Howie Freeman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Hadar Rosen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Ori Nevo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Canada
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Kalafat E, Sebghati M, Thilaganathan B, Khalil A. Predictive accuracy of Southwest Thames Obstetric Research Collaborative (STORK) chorionicity-specific twin growth charts for stillbirth: a validation study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:193-199. [PMID: 29660172 DOI: 10.1002/uog.19069] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 04/05/2018] [Accepted: 04/06/2018] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Twin pregnancy is associated with a 2-3-fold increased risk of stillbirth compared with singleton pregnancy. Despite the fact that the growth pattern in twins has been shown to be different from that in singletons, it is controversial whether twin-specific growth charts should be used routinely. A major goal of prenatal ultrasound is to identify fetuses with growth restriction at risk of stillbirth. The main aim of this study was to compare the performance of chorionicity-specific twin charts with singleton charts, both customized and non-customized, in the antenatal prediction of small-for-gestational-age (SGA) stillborn and liveborn fetuses. METHODS This was a multicenter cohort study analyzing data from the Southwest Thames Obstetric Research Collaborative (STORK) multiple pregnancy cohort (2000-2009) and a second cohort of twin pregnancies at St George's University Hospital (SGH) (2011-2016). The STORK cohort was used to compare the performance of the twin charts and non-customized singleton charts of Poon et al. and the SGH cohort was used to validate the twin-specific charts and compare their performance against customized (Gestation Related Optimal Weight (GROW)) and non-customized (Poon) singleton charts. The primary outcome was the prediction of SGA cases that were stillborn and those that were liveborn in twin pregnancies. Estimated fetal weight (EFW) available from the last examination (24 weeks' gestation and onwards) before delivery or demise was used to classify the fetuses as SGA (EFW < 10th centile or < 3rd centile) or appropriate for gestational age. The proportions of predicted SGA stillbirths and SGA live births were calculated using the three different charts. RESULTS The STORK cohort consisted of 1850 dichorionic (DC) and 300 monochorionic (MC) twin pregnancies. The SGH cohort consisted of 579 DC and 180 MC twin pregnancies. The stillbirth rates in the STORK and SGH cohorts were 1.1% and 1.3%, respectively. In those liveborn in the STORK cohort, using a 10th -centile cut-off to define SGA, the non-customized singleton chart classified a significantly greater proportion as SGA than did the twin chart, regardless of chorionicity (P < 0.001). However, there was no significant difference between the twin and the non-customized singleton charts with regard to the proportion of stillbirth cases that were classified as SGA (P = 0.479). In the SGH cohort, the non-customized singleton chart classified 8.5% of all liveborn fetuses as SGA (EFW < 10th centile) compared with 12.8% using the customized singleton chart and 7.1% using the twin chart (P < 0.001 and P = 0.005, respectively). However, there was no significant difference among the three charts in the proportion of stillbirths classified as SGA, regardless of chorionicity (P = 0.999). Similar results were obtained when the third centile cut-off was used to define SGA. CONCLUSIONS Compared with the STORK chorionicity-specific twin charts, the customized and non-customized singleton charts classified prenatally as SGA more liveborn fetuses. However, the three charts classified as SGA a similar proportion of stillborn cases. Our preliminary results suggest that these twin charts could safely reduce unnecessary medical intervention in twin pregnancies. Further research on the topic is needed before clinical recommendations can be made. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Kalafat
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
- Middle East Technical University, Department of Statistics, Ankara, Turkey
| | - M Sebghati
- 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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Walker AR, Waites BT, Caughey AB. Twins versus singleton pregnancies: outcomes in small for gestational age late preterm deliveries. J Matern Fetal Neonatal Med 2018; 33:895-900. [PMID: 30078342 DOI: 10.1080/14767058.2018.1508438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Compared to singleton pregnancies, small for gestational age (SGA) and twin gestations experience adverse maternal and neonatal outcomes. Specific data regarding outcomes in late preterm SGA twin gestations are lacking.Objective: This study sought to compare pregnancy outcomes of late preterm (≥34 and <37 weeks) SGA twins versus singletons. In addition, we sought to stratify the comparisons by <10 and <5 percentile categories.Study design: In this retrospective cohort of 1.85 million pregnancies, we identified 10,646 nonanomalous, SGA, late preterm singleton and twin pregnancies. Births at gestational ages <34 and ≥37 weeks were excluded. Multivariate regression analyses and Chi-squared test were used for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance.Results: After controlling for race, education, parity, prenatal care, diabetes, and hypertensive disease, twin pregnancies were less likely to experience neonatal death (aOR 0.14; 95% CI 0.03-0.63; p = .01) and intrauterine fetal demise (IUFD) (aOR 0.16; 95% CI 0.08-0.31; p < .001) compared to SGA <10 percentile singletons. Cesarean rates were higher in SGA <10 [percentile twin pregnancies (aOR 3.40; 95% CI 3.01-3.90; p < .001) as were postpartum hemorrhage (aOR 2.01; 95% CI 1.52-2.67; p < .001) and transfusion (aOR 1.54; 95% CI 1.52-2.67; p = .024).Conclusion: Late preterm SGA twin pregnancies were more like to be complicated by cesarean delivery, postpartum hemorrhage, and maternal transfusion compared to singleton pregnancies. However, neonatal death and IUFD were less common in SGA twin gestations.
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Affiliation(s)
- Allison R Walker
- Department of Obstetrics and Gynecology, Oregon Health & Sciences University, Portland, OR, USA
| | - Bethany T Waites
- Department of Obstetrics and Gynecology, Oregon Health & Sciences University, Portland, OR, USA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Sciences University, Portland, OR, USA
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Deter RL, Lee W, Yeo L, Erez O, Ramamurthy U, Naik M, Romero R. Individualized growth assessment: conceptual framework and practical implementation for the evaluation of fetal growth and neonatal growth outcome. Am J Obstet Gynecol 2018; 218:S656-S678. [PMID: 29422206 DOI: 10.1016/j.ajog.2017.12.210] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 12/16/2017] [Accepted: 12/18/2017] [Indexed: 01/23/2023]
Abstract
Fetal growth abnormalities can pose significant consequences on perinatal morbidity and mortality of nonanomalous fetuses. The most widely accepted definition of fetal growth restriction is an estimated fetal weight less than the 10th percentile for gestational age according to population-based criteria. However, these criteria do not account for the growth potential of an individual fetus, nor do they effectively separate constitutionally small fetuses from ones that are malnourished. Furthermore, conventional approaches typically evaluate estimated fetal weight at a single time point, rather than using serial scans, to evaluate growth. This article provides a conceptual framework for the individualized growth assessment of a fetus/neonate based on measuring second-trimester growth velocity of fetal size parameters to estimate growth potential. These estimates specify size models that generate individualized third-trimester size trajectories and predict birth characteristics. Comparisons of measured and predicted values are used to separate normally growing fetuses from those with growth abnormalities. This can be accomplished with individual anatomical parameters or sets of parameters. A practical and freely available software (Individualized Growth Assessment Program) has been developed to allow implementation of this approach for clinical and research purposes.
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Affiliation(s)
- Russell L Deter
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX; Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI
| | - Lami Yeo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Detroit Medical Center, Hutzel Women's Hospital, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Offer Erez
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer sheva, Israel
| | - Uma Ramamurthy
- Office of Research Informational Technology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Medha Naik
- Office of Research Informational Technology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI
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Torres X, Bennasar M, Eixarch E, Rueda C, Goncé A, Muñoz M, Marimón E, Martínez J, Gratacós E, Figueras F. Gender-Specific Antenatal Growth Reference Charts in Monochorionic Twins. Fetal Diagn Ther 2017; 44:202-209. [DOI: 10.1159/000484555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 10/13/2017] [Indexed: 11/19/2022]
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Gardosi J. Toward safe standards for assessment of fetal growth in twin pregnancy. Am J Obstet Gynecol 2017; 216:431-433. [PMID: 28477719 DOI: 10.1016/j.ajog.2017.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 03/20/2017] [Indexed: 11/30/2022]
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