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Mei-Dan E, Jain V, Melamed N, Lim KI, Aviram A, Ryan G, Barrett J. Directive clinique no 428 : Prise en charge de la grossesse gémellaire bichoriale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:835-851.e1. [DOI: 10.1016/j.jogc.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Mei-Dan E, Jain V, Melamed N, Lim KI, Aviram A, Ryan G, Barrett J. Guideline No. 428: Management of Dichorionic Twin Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:819-834.e1. [PMID: 35798461 DOI: 10.1016/j.jogc.2022.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To review evidence-based recommendations for the management of dichorionic twin pregnancies. TARGET POPULATION Pregnant women with a dichorionic twin pregnancy. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in this guideline may improve the management of twin pregnancies and reduce neonatal and maternal morbidity and mortality. EVIDENCE Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (e.g., twin, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date limits, but results were limited to English- or French-language materials. VALIDATION METHODS The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE Obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, radiologists, and other health care providers who care for women with twin pregnancies. SUMMARY STATEMENTS RECOMMENDATIONS.
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Tang M, Tian X, Luo J, Zhang X, Ran S, Xiong J, Chen Y, Chen G. Twin-Twin Transfusion Syndrome After Radiofrequency Ablation in Dizygotic Monochorionic Triamniotic Triplet Pregnancy With Sex Discordance: A Case Report. Front Med (Lausanne) 2022; 9:924356. [PMID: 35847790 PMCID: PMC9280862 DOI: 10.3389/fmed.2022.924356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background We report a case of dizygotic monochorionic triamniotic triplet pregnancy. Twin-twin transfusion syndrome was subsequently diagnosed combined with sex discordance in the two surviving fetuses after one fetus was reduced, which is extremely rare and has not been previously reported. Case Presentation After reducing one fetus by radiofrequency ablation of a monochorionic triamniotic triplet pregnancy, twin-twin transfusion syndrome was subsequently diagnosed combined with sex discordance in the two surviving fetuses. Amniotic fluid for chromosome analysis showed normal karyotype 46, XY/46, XX of the donor and recipient fetus, and short tandem repeat (STR) analysis revealed dizygotic twins. Conclusions Through this is an unusual case, we aim to emphasize the importance of accurate diagnosis of chorionicity and zygosity in sex discordant triplet pregnancy, which is the key to appropriate clinical management.
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Affiliation(s)
- Mingming Tang
- Department of Perinatal Surgery, Chongqing Health Center for Women and Children, Chongqing, China
| | - Xingbo Tian
- Department of Perinatal Surgery, Chongqing Health Center for Women and Children, Chongqing, China
| | - Jianglai Luo
- Department of Perinatal Surgery, Chongqing Health Center for Women and Children, Chongqing, China
| | - Xiaohang Zhang
- Department of Ultrasound, Chongqing Health Center for Women and Children, Chongqing, China
| | - Suzhen Ran
- Department of Ultrasound, Chongqing Health Center for Women and Children, Chongqing, China
| | - Jiaojiao Xiong
- Department of Prenatal Diagnosis, Chongqing Health Center for Women and Children, Chongqing, China
| | - Yanlin Chen
- Department of Pathology, Chongqing Health Center for Women and Children, Chongqing, China
| | - Gongli Chen
- Department of Perinatal Surgery, Chongqing Health Center for Women and Children, Chongqing, China
- *Correspondence: Gongli Chen
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Giorgione V, Melchiorre K, O'Driscoll J, Khalil A, Sharma R, Thilaganathan B. Maternal echocardiographic changes in twin pregnancies with and without pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:619-626. [PMID: 35000243 DOI: 10.1002/uog.24852] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/23/2021] [Accepted: 12/22/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Twin pregnancies are at increased risk of developing hypertensive disorders of pregnancy (HDP) compared with singleton pregnancies, resulting in a substantially higher rate of maternal and perinatal complications. The strain caused by twin pregnancy on the maternal cardiovascular system has not been studied extensively. The objective of this study was to evaluate the changes in maternal cardiac morphology and diastolic function in a cohort of women with normotensive and those with hypertensive twin pregnancies. METHODS This was a cross-sectional study conducted at a tertiary referral university center. Women with singleton or twin pregnancy were enrolled prospectively to undergo maternal transthoracic echocardiography throughout pregnancy. Multiples of the median (MoM) were calculated for each index using a reference group of uncomplicated singleton pregnancies (n = 411) in order to adjust for changes associated with gestational age. Cardiac findings were indexed for body surface area and compared among normotensive twin pregnancies, singleton pregnancies complicated by HDP and twin pregnancies complicated by HDP. RESULTS The total cohort included 119 HDP singleton pregnancies, 52 normotensive twin pregnancies and 24 HDP twin pregnancies. Left ventricular mass index (LVMi) MoM (median (interquartile range)) did not differ between singleton pregnancies complicated by HDP and normotensive twin pregnancies, but was significantly higher in HDP twin compared with HDP singleton pregnancies (1.31 (1.08-1.53) vs 1.17 (0.98-1.35), P = 0.032). Two diastolic indices, left atrial volume index MoM (1.12 (0.66-1.38) vs 0.65 (0.55-0.84), P = 0.003) and E/e' MoM (1.29 (1.09-1.54) vs 0.99 (0.99-1.02), P = 0.036), were significantly higher in HDP twin compared with normotensive twin pregnancies. In normotensive twin compared with HDP singleton pregnancies, stroke volume index (SVi) MoM was higher (1.20 (1.03-1.36) vs 1.00 (0.81-1.15), P = 0.004) and total vascular resistance index (TVRi) was lower (0.73 (0.70-0.86) vs 1.29 (1.04-1.56), P < 0.0001). In contrast, SVi MoM was lower (1.10 (1.02-1.35) vs 1.20 (1.03-1.36), P = 0.018) and TVRi was higher (1.00 (0.88-1.31) vs 0.73 (0.70-0.86), P = 0.029) in HDP twin compared with normotensive twin pregnancies. CONCLUSION The maternal cardiovascular system is altered severely in twin pregnancy with or without HDP. Despite the low total vascular resistance, cardiac changes in normotensive twin pregnancies are comparable to those seen in singleton pregnancies complicated by HDP, reflecting the high cardiovascular demand imposed by twin pregnancy. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Giorgione
- 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
| | - K Melchiorre
- Department of Obstetrics and Gynaecology, Spirito Santo Tertiary Level Hospital of Pescara, Pescara, Italy
| | - J O'Driscoll
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
- School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, 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
| | - R Sharma
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Lu J, Ting YH, Leung TY. Determining chorionicity and amnionicity in twin pregnancies: Pitfalls. Best Pract Res Clin Obstet Gynaecol 2022; 84:2-16. [PMID: 35490102 DOI: 10.1016/j.bpobgyn.2022.03.005] [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: 02/09/2022] [Accepted: 03/14/2022] [Indexed: 11/02/2022]
Abstract
Although the accuracy of chorioamnionicity determination in multiple pregnancy is nearly 100%, some pitfalls do exist. These pitfalls may arise from some confusing sonographic appearance or because of certain rare variations of twinning going against the general principles. Pitfalls in chorionicity determination include (1) the disappearance of the twin peak sign with the regression of chorion frondosum and thinning of the intertwin membrane with advancing gestation; (2) fake twin peak sign because of other structures creeping into the intertwin membrane-placental junction; (3) intrauterine septum or synechia being mistaken as a thick intertwin membrane; (4) bipartite placenta in monochorionic twin being misinterpreted as two separate placentas of dichorionic twin; (5) erroneous fetal sex determination in sex chromosome mosaicism, monogenic disorders, and malformed genitalia in one fetus; and (6) rare twinning types such as dizygotic monochorionic twin and sesquizygotic twin. Pitfalls in amnionicity determination are (1) the lack of correlation between the number of yolk sacs and amnionicity and (2) failure to visualize the intertwin membrane because of technical issues.
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Affiliation(s)
- Jing Lu
- Laboratory of Research and Diagnosis of Gynecological Diseases of Xiamen City, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Yuen Ha Ting
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong
| | - Tak Yeung Leung
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong.
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Ting YH, Poon LCY, Tse WT, Chung MY, Wah YM, Hui ASY, Law KM, Chaemsaithong P, Leung TY. Outcome of radiofrequency ablation for selective fetal reduction before vs at or after 16 gestational weeks in complicated monochorionic pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:214-220. [PMID: 32730679 DOI: 10.1002/uog.22160] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/03/2020] [Accepted: 07/20/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To investigate whether gestational age at intervention (< or ≥ 16 weeks) and other factors affect the risk of loss of the cotwin after selective fetal reduction using radiofrequency ablation (RFA) in monochorionic (MC) pregnancy. METHODS This was a single-center retrospective analysis of 63 consecutive RFA procedures performed at our institution from January 2011 to October 2019 for selective fetal reduction in complicated MC pregnancies. Indications for RFA were twin reversed arterial perfusion sequence (13 cases), twin-to-twin transfusion syndrome (12 cases), twin anemia-polycythemia sequence (two cases), selective fetal growth restriction (10 cases), discordant anomalies (17 cases) and multifetal pregnancy reduction in triplets or quadruplets with a MC pair (nine cases). Twenty-six (41.3%) of these procedures were performed before and 37 (58.7%) after 16 weeks. Potential factors that could affect the risk of loss of the cotwin, including gestational age at RFA, order of multiple pregnancy, amnionicity, indication for RFA and number of ablation cycles, were assessed first by univariate analysis and then by multivariate analysis. RESULTS There were 17 (27.0%) cotwin losses. Ablation cycles numbering four or more was the only factor among those investigated to be associated with loss of the cotwin after RFA (P = 0.035; odds ratio, 5.21), while the indication for RFA, order of multiple pregnancy, amnionicity and gestational age at RFA had no effect. Comparing RFA performed at < 16 vs ≥ 16 weeks, there was no difference in the rate of cotwin loss (23.1% vs 29.7%; P = 0.558) or preterm prelabor rupture of the membranes before 34 weeks (7.7% vs 5.4%; P = 0.853), or in the median gestational age at delivery (36.2 vs 37.3 weeks; P = 0.706). CONCLUSIONS RFA is a promising tool for early selective fetal reduction in MC pregnancy before 16 weeks. Four or more ablation cycles is a major risk factor for cotwin loss. Careful assessment pre- and post-RFA, together with proficient operative skills to minimize the number of ablation cycles, are the mainstay to ensure that this procedure is effective and safe. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Y H Ting
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - L C Y Poon
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - W T Tse
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - M Y Chung
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Y M Wah
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - A S Y Hui
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - K M Law
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - P Chaemsaithong
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - T Y Leung
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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Ochsenbein-Kölble N. Twin pregnancies. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:246-269. [PMID: 33622004 DOI: 10.1055/a-1344-4812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Twin pregnancies, resulting in 2-3 % of all deliveries, are high risk pregnancies which need specialized care. A correct dating of pregnancy and the assessment of the chorionicity/amnionicity in the first trimester (< = 13 + 6 gestational weeks, GW) is essential for further monitoring. During first trimester risk stratification of monochorionic pregnancies includes evaluation of discordance of crown-rump-lengths, nuchal translucencies and amniotic fluid. At 16 GW sonographic risk evaluation of monochorionic twins involves differences in amniotic fluid and abdominal circumferences and detection of a velamentous cord insertion. A screening for fetal malformations with cervical length measurement as screening for preterm birth (cut-off < 25 mm) should be offered all twin pregnancies around 20 GW. In uncomplicated dichorionic pregnancies US examination should be performed every 4 weeks onwards to check fetal growth and amniotic fluid. An intertwin weight discordance > 20 % identifies pregnancies at increased risk of adverse outcome. Monochorionic pregnancies should be followed at least every two weeks for screening of twin-twin transfusion syndrome (TTTS), twin-anemia-polycythemia-sequence (TAPS) and selective fetal growth retardation (sFGR) with a start at 16 GW. The type 1-3 classification of sFGR in monochorionic twins depends on the pattern of end-diastolic velocity at the umbilical artery Doppler. The diagnosis of TTTS requires the presence of an oligyohydramnios (deepest vertical pocket (DVP) < 2 cm) in the donor twin and a polyhydramnios (DVP > 8 cm) in the recipient twin. However, the diagnosis of TAPS is based on the finding of discordant MCA Doppler values with a delta-MCA PV > 0.5 MoM.
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Affiliation(s)
- Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zürich and University of Zurich, Zurich, Switzerland
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AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12 Weeks 0 Days and 13 Weeks 6 Days. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:E1-E16. [PMID: 32852128 DOI: 10.1002/jum.15477] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 06/11/2023]
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Changes in the Ultrasonographical Appearance of Intertwin-Dividing Membrane of Monochorionic Diamniotic Twin Pregnancy. Twin Res Hum Genet 2021; 24:130-132. [PMID: 33853703 DOI: 10.1017/thg.2021.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ultrasound determination of chorionicity in the first trimester has a high accuracy, but it is associated with some pitfalls. This report presents changes in ultrasound findings during a monochorionic pregnancy with chorionic membrane folding (CMF). The patient was a 32-year-old woman, gravida 2 para 0. Her transvaginal ultrasonography identified two gestational sacs (GSs) and two embryos at 7 weeks of gestation. At 9 weeks' gestation, an ultrasound image showed a lambda sign at both sides and the interruption of chorionic membranes, resulting in the diagnosis of a monochorionic diamniotic (MCDA) twin pregnancy with CMF. At 11 weeks' gestation, an ultrasound image showed a lambda sign at one portion of the septum and a T sign at another portion. This change suggested that the folded chorionic membrane had partially flattened. At 35 weeks' gestation, an emergency cesarean section was performed. Two healthy male neonates were delivered. Histological placental examination confirmed that the intertwin membrane was composed of two amniotic membranes without a folded chorionic membrane, confirming the diagnosis of a MCDA twin pregnancy. This case presents two important ultrasound chorionicity findings: a monochorionic pregnancy with CMF can show two GSs and a lambda sign and the CMF can flatten or change during the pregnancy.
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Jha P, Morgan TA, Kennedy A. US Evaluation of Twin Pregnancies: Importance of Chorionicity and Amnionicity. Radiographics 2020; 39:2146-2166. [PMID: 31697621 DOI: 10.1148/rg.2019190042] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The twin birth rate is increasing in the United States. Twin pregnancies can be dichorionic or monochorionic (MC). MC twins account for 20% of twin pregnancies but 30% of all-cause pregnancy-related complications. This article describes the imaging findings that establish chorionicity and amnionicity. Ideally, these are established in the first trimester when accuracy is high, but they can also be determined later in pregnancy. Complications unique to MC twin pregnancy include twin-twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion sequence, and selective fetal growth restriction. The US features, staging systems, and management of these complications are reviewed, and the consequences of MC twin demise are illustrated. Ongoing surveillance for these conditions starts at 16 weeks gestation. Monoamniotic (MA) twins are a small subset of MC twins. In addition to all of the MC complications, specific MA complications include cord entanglement and conjoined twinning. Radiologists must be able to determine chorionicity and amnionicity and should be aware of potential complications so that patients may be referred to appropriate regional specialized centers. A proposed algorithm for referral to specialized fetal treatment centers is outlined. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Tara A Morgan
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Anne Kennedy
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
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Lewi L. Monochorionic diamniotic twins: What do I tell the prospective parents? Prenat Diagn 2020; 40:766-775. [PMID: 32279339 DOI: 10.1002/pd.5705] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 12/31/2022]
Abstract
Monochorionic diamniotic twins occur in about 1 in 300 pregnancies. Compared with dichorionic twins, they face increased risks because of the shared circulation. In about 15%, an imbalance in blood exchange occurs, such as twin-twin transfusion syndrome and twin anemia polycythemia sequence. In this review, we summarize the latest evidence on the management of monochorionic diamniotic twin pregnancies and their specific complications, with a focus on information that is relevant for prospective parents.
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Affiliation(s)
- Liesbeth Lewi
- Department of Development and Regeneration, KULeuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
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Wataganara T, Yapan P, Moungmaithong S, Sompagdee N, Phithakwatchara N, Limsiri P, Nawapun K, Rekhawasin T, Talungchit P. Additional benefits of three-dimensional ultrasound for prenatal assessment of twins. J Perinat Med 2020; 48:102-114. [PMID: 31961794 DOI: 10.1515/jpm-2019-0409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/05/2019] [Indexed: 12/18/2022]
Abstract
Three-dimensional ultrasound (3DUS) may provide additional information for prenatal assessment of twins. It may improve the diagnostic confidence of dating, nuchal translucency (NT) and chorionicity assignment in twin pregnancies. The "virtual 3DUS placentoscopy" can guide selective fetoscopic laser photocoagulation (SFLP) to treat twin-twin transfusion syndrome (TTTS). Volumetric assessment of the dysmorphic acardiac twin with the Virtual Organ Computer-aided Analysis (VOCAL) software is more accurate than the conventional ultrasound measurement. Twin anemia polycythemia (TAP) sequence and selective intrauterine growth restriction (sIUGR) may be clinically monitored with 3DUS placental volume (PV) and power Doppler vascular indices. Congenital anomalies are more common in twins. Evaluation of fetal anomalies with 3DUS could assist perinatal management. The 3DUS power Doppler can provide a better understanding of true and false umbilical cord knots, which are commonly found in monoamniotic (MA) twins. Single demise in monochorionic (MC) twin pregnancies can cause severe neurologic morbidity in the surviving co-twin. Prenatal prediction of brain injury in the surviving co-twin with unremarkable neurosonographic examination is difficult. The 3DUS power Doppler may aid in prenatal detection of subtle abnormal cerebral perfusion. Prenatal assessment of conjoined twins with 3DUS is important if emergency postnatal surgical separation is anticipated. There is no significant additional advantage in using real-time 3DUS to guide prenatal interventions. Assessment of the cervix and pelvic floor during twin pregnancies is enhanced with 3DUS. Due to lack of high-quality studies, routine prenatal 3DUS in twin pregnancies needs to be balanced with risks of excessive ultrasound exposure.
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Affiliation(s)
- Tuangsit Wataganara
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Piengbulan Yapan
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Sakita Moungmaithong
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Nalat Sompagdee
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Nisarat Phithakwatchara
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Pattarawan Limsiri
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Katika Nawapun
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Thanapa Rekhawasin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Pattarawalai Talungchit
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Walter A, Strizek B, Berg C, Geipel A, Gembruch U, Engels AC. Outcome of monochorionic twins with prenatally diagnosed bipartite placenta. Arch Gynecol Obstet 2019; 302:1549-1552. [PMID: 31768742 DOI: 10.1007/s00404-019-05364-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/25/2019] [Indexed: 12/01/2022]
Abstract
PURPOSE The objective of this study was to identify possible implications and risk factors in monochorionic (MC) twin pregnancies having a bipartite placenta. MATERIALS Between 2014 and 2019 data on such pregnancies was prospectively collected and retrospectively analyzed. Monochorionicity was confirmed either by the presence of a T-sign, one chorion and two separate amnion cavities, or by histological examination postnatally. Bipartite placenta was diagnosed when two placenta lobes were identified with no placental connection between them. Risks of bipartite placenta in MCDA twins were evaluated by background data, prenatal and postnatal outcome. RESULTS Five twin pregnancies were included in the study. 60 % (n = 3) were complicated by twin-twin-transfusion syndrome (TTTS), 20 % by selective intrauterine growth restriction (sIUGR) (n = 1) and 20 % (n = 1) by severe fetal malformations. In every case an intervention was indicated, but in only 60% (n = 3) possible, due to poor surgical conditions. Overall fetal survival rate at birth was 90 %. Neonatal survival rate was 66.63%. CONCLUSION Bipartite placenta is a very rare phenomenon in MCDA twin pregnancies. It seems to be associated with a higher rate of complications, such as TTTS and sIUGR and might induce surgical difficulties in prenatal interventions.
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Affiliation(s)
- Adeline Walter
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.,Department of Obstetrics and Prenatal Medicine, University Hospital Cologne, Kerpener Straße 34, 50931, Cologne, Germany
| | - Annegret Geipel
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Alexander C Engels
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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14
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Norwitz ER, McNeill G, Kalyan A, Rivers E, Ahmed E, Meng L, Vu P, Egbert M, Shapira M, Kobara K, Parmar S, Goel S, Prins SA, Aruh I, Persico N, Robins JC, Kirshon B, Demko ZP, Ryan A, Billings PR, Rabinowitz M, Benn P, Martin KA, Hedriana HL. Validation of a Single-Nucleotide Polymorphism-Based Non-Invasive Prenatal Test in Twin Gestations: Determination of Zygosity, Individual Fetal Sex, and Fetal Aneuploidy. J Clin Med 2019; 8:E937. [PMID: 31261782 PMCID: PMC6679081 DOI: 10.3390/jcm8070937] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/20/2019] [Accepted: 06/26/2019] [Indexed: 12/19/2022] Open
Abstract
We analyzed maternal plasma cell-free DNA samples from twin pregnancies in a prospective blinded study to validate a single-nucleotide polymorphism (SNP)-based non-invasive prenatal test (NIPT) for zygosity, fetal sex, and aneuploidy. Zygosity was evaluated by looking for either one or two fetal genome complements, fetal sex was evaluated by evaluating Y-chromosome loci, and aneuploidy was assessed through SNP ratios. Zygosity was correctly predicted in 100% of cases (93/93; 95% confidence interval (CI) 96.1%-100%). Individual fetal sex for both twins was also called with 100% accuracy (102/102; 95% weighted CI 95.2%-100%). All cases with copy number truth were also correctly identified. The dizygotic aneuploidy sensitivity was 100% (10/10; 95% CI 69.2%-100%), and overall specificity was 100% (96/96; 95% weighted CI, 94.8%-100%). The mean fetal fraction (FF) of monozygotic twins (n = 43) was 13.0% (standard deviation (SD), 4.5%); for dizygotic twins (n = 79), the mean lower FF was 6.5% (SD, 3.1%) and the mean higher FF was 8.1% (SD, 3.5%). We conclude SNP-based NIPT for zygosity is of value when chorionicity is uncertain or anomalies are identified. Zygosity, fetal sex, and aneuploidy are complementary evaluations that can be carried out on the same specimen as early as 9 weeks' gestation.
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Affiliation(s)
- Errol R Norwitz
- Tufts Medical Center and Tufts University School of Medicine, Boston, MA 02111, USA
| | | | | | | | | | - Ling Meng
- Natera, Inc., San Carlos, CA 94070, USA
| | | | | | | | | | | | | | | | - Israel Aruh
- Dr. Israel Aruh's IVF and Infertility Clinic, 35220 Izmir, Turkey
| | | | - Jared C Robins
- Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Brian Kirshon
- Houston Perinatal Associates, Houston, TX 77054, USA
| | | | | | | | | | | | | | - Herman L Hedriana
- Natera, Inc., San Carlos, CA 94070, USA.
- University of California Davis Health, Sacramento, CA 95819, USA.
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15
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Fenton C, Reidy K, Demyanenko M, Palma-Dias R, Cole S, Umstad MP. The Significance of Yolk Sac Number in Monoamniotic Twins. Fetal Diagn Ther 2019; 46:193-199. [PMID: 30763938 DOI: 10.1159/000496204] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 12/13/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Detection of a single yolk sac on early first trimester ultrasound was previously thought to be a reliable diagnostic feature of monochorionic monoamniotic (MCMA) twin pregnancies. OBJECTIVES To determine the frequency of two yolk sacs in MCMA twin pregnancies and the association of yolk sac number with pregnancy outcomes. METHODS A retrospective cohort analysis of MCMA twins managed at a tertiary obstetric centre from January 2003 until February 2017. All MCMA twin pregnancies were diagnosed on tertiary centre ultrasound and, where possible, placental histopathology postnatally. All MCMA twin pregnancies, including conjoined twins, with available first trimester ultrasounds from 5 to 11 weeks' gestation were included in the analysis. MCMA pregnancies without available first trimester ultrasounds and triplet pregnancies which included a MCMA pair were excluded from the study. RESULTS Sixty-seven MCMA cases were identified over 14 years. Thirty-eight cases were included in the analysis. There was one yolk sac identified in 26 cases (68%) and two yolk sacs in 12 cases (32%). Two yolk sacs were associated with a higher proportion of male fetuses (33%, 4 out of 12, vs. 8%, 2 out of 26; p = 0.01). There were no other significant differences between one and two yolk sacs for maternal or neonatal outcomes. CONCLUSIONS Two yolk sacs are present in up to a third of all MCMA twin pregnancies, dispelling the original concept that a single yolk sac is diagnostic of MCMA pregnancies. Yolk sac number should not be used to determine amnionicity. The presence of two yolk sacs on first trimester ultrasound is associated with an increased rate of male fetuses. The number of yolk sacs has no other significant impact on perinatal outcomes.
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Affiliation(s)
- Christine Fenton
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia,
| | - Karen Reidy
- Pauline Gandel Imaging Centre, The Royal Women's Hospital, Parkville, Victoria, Australia.,Pregnancy Research Centre, Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Marina Demyanenko
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Ricardo Palma-Dias
- Pauline Gandel Imaging Centre, The Royal Women's Hospital, Parkville, Victoria, Australia.,Pregnancy Research Centre, Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia.,The University of Melbourne, Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Stephen Cole
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Mark P Umstad
- The University of Melbourne, Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia
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