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Berger DS, Lee YM. Timing of Delivery for Twins. Clin Obstet Gynecol 2023; 66:884-890. [PMID: 37910137 DOI: 10.1097/grf.0000000000000813] [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: 11/03/2023]
Abstract
The optimal gestational age for delivery of twin gestations balances the risk to the mother with the risks to the fetus and newborn. Primary considerations should include chorionicity and the presence or absence of other obstetrical complications such as fetal growth restriction or hypertensive disorders of pregnancy. More than half of twin gestations will deliver preterm, and a significant portion will be due to spontaneous labor or medical indications, such that the timing of delivery for twins is typically less determined by the provider discretion. Future studies are needed to assist in clarifying the optimal timing for delivery of twin pregnancies.
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Affiliation(s)
- Dana Senderoff Berger
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, NYU Grossman School of Medicine
| | - Young Mi Lee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, Maternal Fetal Care Center, New York, New York
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2
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Xia S, You K, Lin M, Huang L, He Z, Huang X, Luo Y. Intertwin nuchal translucency difference predicts the chance of co-twin death after fetal reduction in dichorionic triplet pregnancies: a retrospective analysis study. BMC Pregnancy Childbirth 2023; 23:747. [PMID: 37872490 PMCID: PMC10594729 DOI: 10.1186/s12884-023-06064-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/12/2023] [Indexed: 10/25/2023] Open
Abstract
OBJECTIVES To compare the clinical outcomes of different multifetal pregnancy reduction (MFPR) programs in dichorionic (DC) triplets, and explore the association between early ultrasound characteristics and co-twin death after potassium chloride (KCl) injection into one monochorionic (MC) twin. METHODS We retrospectively reviewed the data of DC triplets who underwent MFPR at our center during 2012-2021. Patients were grouped as follows: intracardiac KCl injection into one MC twin (group A), intracardiac KCl injection into both MC twins simultaneously (group B), and reduction of the singleton fetus (group C) and pregnancy outcomes were compared. Logistic regression was used to determine whether ultrasound measurements at 11-13+6 weeks predicted co-twin death and the receiver operator characteristic (ROC) analysis was conducted to assess the predictive performance. RESULTS Finally, we enrolled 184 patients. 153 cases were in group A, and 18, 13 cases were in group B and C respectively. Gestational age at the time of MFPR did not differ among the 3 groups (median: [Formula: see text] weeks). The survival rate was 89.6%, 88.9%, and 92.3% in group A, B, and C respectively, which was comparable among groups. Preterm birth was more common in group C (10/12, 83.3%). After KCl injection into one MC twin, co-twin death occurred in 86.3% cases (132/153) within 1 day; however, 3 patients had 2 live births each, with normal postnatal development. Intertwin nuchal translucency (NT) difference/discordance significantly predicted co-twin death within 1 day after MFPR, and the areas under the ROC curve were 0.694 and 0.689, respectively. CONCLUSIONS For MFPR in DC triplet pregnancies, reduction of the MC twins results in less preterm birth, and women with KCl injection into either one or both MC twins had similar outcomes. Large intertwin NT difference/discordance was associated with co-twin death within 1 day after KCl injection into one of the MC twins.
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Affiliation(s)
- Shuting Xia
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Kaniok You
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Minhuan Lin
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Linhuan Huang
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Zhiming He
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Xuan Huang
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China
| | - Yanmin Luo
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China.
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, People's Republic of China.
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Single Intrauterine Death in Twin Pregnancy: Evidenced-based Counselling and Management. Best Pract Res Clin Obstet Gynaecol 2022; 84:205-217. [DOI: 10.1016/j.bpobgyn.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022]
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So PL, Li KW, Yeung TW, Sin WK. Multicystic encephalomalacia and gastrointestinal injury following single fetal death in first trimester and subsequent fetofetal transfusion syndrome in a monochorionic triplet pregnancy: a case report. BMC Pregnancy Childbirth 2019; 19:311. [PMID: 31455300 PMCID: PMC6712839 DOI: 10.1186/s12884-019-2459-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 08/14/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Monochorionic multifetal pregnancies are at increased risk of adverse perinatal outcome because of placental vascular anastomoses. We present a case of multicystic encephalomalacia and gastrointestinal injury in two surviving fetuses following single fetal death in first trimester and subsequent fetofetal transfusion syndrome in a monochorionic triplet pregnancy. CASE PRESENTATION A 31-year-old nulliparous woman had a spontaneous monochorionic triamniotic triplet pregnancy. Three live fetuses with single placenta were seen at 8-week ultrasound scan. One fetus demised at 11 weeks and 3 days of gestation. Dilated echogenic bowel and ascites were found in one surviving fetus at 23 weeks of gestation. At 28 weeks of gestation, the pregnancy was complicated by fetofetal transfusion syndrome in which discordant amniotic fluid volumes were found. Two days later, emergency Caesarean section was performed because of worsening of fetal Doppler and biophysical profile. One baby was found to have jejunal atresia requiring surgery at 4 days old. He had periventricular leukomalacia and intracranial haemorrhage, but subsequent normal neurological development. Another baby had gastric perforation requiring surgery at 2 days old. He was confirmed to have multicystic encephalomalacia by cranial ultrasound and magnetic resonance imaging. He suffered from developmental delay, epilepsy and cerebral palsy. CONCLUSION This case alerts the obstetricians the possible hypoxic-ischemic injury to the survivors of monochorionic triplet pregnancy after the co-triplet death in the first trimester and fetofetal transfusion syndrome. Antenatal assessment and postnatal follow-up are important for these high-risk multiple pregnancies.
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Affiliation(s)
- Po Lam So
- Department of Obstetrics and Gynecology, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, Hong Kong, Special Administrative Region of China
| | - Ka Wah Li
- Department of Paediatrics and Adolescent Medicine, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, Hong Kong, Special Administrative Region of China
| | - Tsz Wai Yeung
- Department of Radiology, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, Hong Kong, Special Administrative Region of China
| | - Wai Kuen Sin
- Department of Obstetrics and Gynecology, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, Hong Kong, Special Administrative Region of China
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Kirkham FJ, Zafeiriou D, Howe D, Czarpran P, Harris A, Gunny R, Vollmer B. Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins. Eur J Paediatr Neurol 2018; 22:989-1005. [PMID: 30467085 DOI: 10.1016/j.ejpn.2018.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022]
Abstract
Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.
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Affiliation(s)
- Fenella J Kirkham
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom.
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, "Hippokratio' General Hospital, Aristotle University, Thessaloniki, Greece
| | - David Howe
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
| | - Philippa Czarpran
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Ashley Harris
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Roxanna Gunny
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Radiology, St George's hospital, London, United Kingdom
| | - Brigitte Vollmer
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
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Arınkan SA, Arısoy R, Api M. Assesment of pregnancy outcomes among twin pregnancies with single fetal demise regarding chorionicity and fetal death time. J Turk Ger Gynecol Assoc 2018; 20:147-153. [PMID: 30063212 PMCID: PMC6751832 DOI: 10.4274/jtgga.galenos.2018.2018.0053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective The objective of this study was to assess maternal and perinatal outcomes of twin pregnancies with single fetal demise in terms of chorionicity and fetal death time. Material and Methods All deliveries between January 2008 and July 2015 were reviewed retrospectively and 85 twin pregnancies with single fetal demise were included. These cases were grouped according to chorionicity and fetal death time. Results The incidence of single fetal demise was 4.7%. The mean delivery week was later in the dichorionic group (34.16±4.65) than in the monochorionic group (31.1±3.83). The ratios of deliveries before the 34th gestational week were 71.4% in monochorionics and 35% in dichorionics. Monochorionics had a 13 times greater risk for having delivery before the 37th gestational week and a 4 times greater risk for having delivery before the 34th gestational week compared with dichorionics. Furthermore, monochorionics had a 7 times greater risk for having abruptio placenta compared with dichorionics. The newborn intensive care unit admission ratios were 61.3% in dichorionics and 85.7% in monochorionics. Also, monochorionics had a 3.7 times greater risk for admission to newborn intensive care unit compared with dichorionics. Conclusion We recommend follow-up of twin pregnancies with single fetal demise in terms of premature birth, regardless of chorionicity. Also, close monitoring is recommended for monochorionic twin pregnancies with single fetal demise in terms of premature birth before 34 weeks of gestation, abruptio placenta, the need for neonatal intensive care, and respiratory distress syndrome.
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Affiliation(s)
- Sevcan Arzu Arınkan
- Department of Obstetrics and Gynecology, İstanbul Zeynep Kamil Maternity and Pediatric Training and Research Hospital, İstanbul, Turkey
| | - Resul Arısoy
- Department of Obstetrics and Gynecology, İstanbul Zeynep Kamil Maternity and Pediatric Training and Research Hospital, İstanbul, Turkey
| | - Murat Api
- Department of Obstetrics and Gynecology, İstanbul Zeynep Kamil Maternity and Pediatric Training and Research Hospital, İstanbul, Turkey
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Suzuki S. Single Fetal Demise at 10 - 14 Weeks of Monochorionic and Dichorionic Twin Pregnancy. J Clin Med Res 2016; 8:331-3. [PMID: 26985254 PMCID: PMC4780497 DOI: 10.14740/jocmr2479w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2016] [Indexed: 11/23/2022] Open
Abstract
Background We examined the perinatal outcomes in cases of at least one fetal demise in monochorionic and diamniotic twin pregnancies. Methods We reviewed the obstetric records of all Japanese twin pregnancies managed beyond 9 weeks’ gestation at Japanese Red Cross Katsushika Maternity Hospital between 2008 and 2014. Results The incidence in the monochorionic twin pregnancies was significantly higher than that in the dichorionic twin pregnancies (8.3% vs. 2.6%, odds ratio: 3.40, 95% confidence interval: 1.5 - 7.6, P < 0.01). Of these, 60.0% were diagnosed as fetal demise of both fetuses at the same time (vs. dichorionic twin pregnancy: odds ratio: 12.0, 95% confidence interval: 1.3 - 120, P = 0.04). The rate of “vanishing twin” in cases of at least one fetal demise at 10 - 14 weeks’ gestation in the monochorionic twin pregnancies was significantly lower than that in the diamniotic twin pregnancies (30.0% vs. 88.9%, odds ratio: 0.05, 95% confidence interval: 0.01 - 0.53, P = 0.01). Conclusion The incidence of fetal demise and the influence on the co-twin in monochorionic twin pregnancy is greater than those in dichorionic twin pregnancy.
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Affiliation(s)
- Shunji Suzuki
- Department of Obstetrics and Gynecology, Japanese Red Cross Katsushika Maternity Hospital, 5-11-12 Tateishi, Katsushika-ku, Tokyo 124-0012, Japan.
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8
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9
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Abstract
It is well established that the death of one fetus in a monochorionic twin pregnancy places the surviving twin at significant risk for neuro-developmental delay or death. Although the early 1st trimester "vanishing twin" has not traditionally been considered a major risk, the precise gestational threshold beyond which a surviving twin is at risk remains uncertain. Most experts recommend serial ultrasounds and fetal MRI in the survivor, to look for evidence of ischaemic brain injury. We present a case of early monochorionic twin demise at 14-16 weeks, with evolving ventriculomegaly and ischaemic changes on fetal MRI in the co-twin, leading to termination of pregnancy at 28 weeks.
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Affiliation(s)
- Colin A Walsh
- Department of Fetal MedicineRoyal North Shore HospitalSydneyNew South WalesAustralia; Northern Clinical School University of SydneySydneyNew South WalesAustralia
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10
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Abstract
The objective of this review is to assess the evidence that supports the use of ultrasound in twin pregnancies. Although many of the indications for obstetric ultrasound are the same in both singleton and multiple gestations, there are special considerations as well as unique conditions in twins that require additional imaging studies. The reasons for ultrasound in twins include pregnancy dating, determination of chorionicity, nuchal translucency assessment, anatomical survey, placental evaluation, cervical length assessment, routine fetal growth, and serial surveillance of pregnancies complicated by anomalies, cervical shortening, fetal growth disturbances, and amniotic fluid abnormalities. Twins with monochorionic placentation require heightened scrutiny for monoamnionicity, conjoined twins, twin reversed arterial perfusion (TRAP) syndrome, twin-twin transfusion syndrome, unequal placental sharing with discordant twin growth or selective intrauterine fetal growth restriction (IUGR), twin anemia-polycythemia sequence (TAPS), and single fetal demise. Ultrasound is essential for the detection and management of conditions that can complicate dichorionic and monochorionic twin pregnancies.
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Affiliation(s)
- Lynn L Simpson
- Department of Obstetrics and Gynecology, Columbia University Medical Center, 622 W 168th St, PH-16, NY 10032.
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Sato H, Murata H, Sato K, Kawaharamura K, Hamanishi S, Hirose M. Encephalomalacia in surviving twin after single fetal death diagnosed at 18 weeks of gestation in monochorionic twin pregnancy. AMERICAN JOURNAL OF CASE REPORTS 2013; 14:341-4. [PMID: 24009813 PMCID: PMC3762521 DOI: 10.12659/ajcr.889478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 07/10/2013] [Indexed: 11/22/2022]
Abstract
Patient: Female, 28 Final Diagnosis: Single intrauterine fetal death Symptoms: — Medication: — Clinical Procedure: — Specialty: Obstetrics and Gynecology
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Affiliation(s)
- Hiroshi Sato
- Department of Obstetrics and Gynecology, Hyogo Prefectural Tsukaguchi Hospital, Hyogo, Japan
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12
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Abstract
AbstractFetal death in a twin conception during second and third trimester is associated with increased risk of cerebral injury in the surviving twin. The aim of this study is to test the hypothesis that even early fetal losses as a ‘vanishing’ twin may be associated with an increased risk of cerebral impairment in the surviving twin. The study population comprised 362 pregnant women attending Liverpool Women's Hospital recruited between 1999 and 2001. Women were classified according to the first ultrasound scan into 3 groups: vanishing twin, twin and singleton. The vanishing twin group was further subdivided into ‘definite’ and ‘probable’. Children from these pregnancies were assessed at 1 year of age for their development and neurological function using the Griffiths Mental and Developmental Scales and Optimality score. Children from 229 pregnancies (63.2%) attended the assessment. Information on children from a further 21 (5.8%) pregnancies was obtained through a review of hospital records. Cerebral impairment was found in 2 children from the vanishing twin group, 2 from the twin group and none from the singleton group. When cases with definite vanishing twin are considered there is a significant difference between the vanishing twin and singleton group (relative risk 6.1; 95% confidence interval 1.5–8.3; p = .03). An additional study with an increased sample size would enable a more robust conclusion.
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Affiliation(s)
- Dhullipala Anand
- School of Reproductive and Developmental Medicine, University of Liverpool, Liverpool Women's Foundation NHS Trust, Liverpool, United Kingdom.
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Nakamura K, Kato M, Sasaki A, Kanai M, Hayasaka K. Congenital dysplastic microcephaly and hypoplasia of the brainstem and cerebellum with diffuse intracranial calcification. J Child Neurol 2012; 27:218-21. [PMID: 21940696 DOI: 10.1177/0883073811416239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Congenital microcephaly with intracranial calcification is a rare condition presented in heterogeneous diseases. Here, we report the case of a 1-year-old boy with severe congenital microcephaly and diffuse calcification. Neuroimaging studies showed a diffuse simplified gyral pattern; a very thin cortex; ventricular dilatation; very small basal ganglia, thalamus, and brainstem; and cerebellar hypoplasia with diffuse calcification. Clinical features of intrauterine infections, such as neonatal jaundice, hepatomegaly, and thrombocytopenia, were not found. Serological tests, cultures, and polymerase chain reaction analysis were negative for viral infections. The etiology of pseudo-toxoplasmosis, rubella, cytomegalovirus, and herpes simplex syndrome is still unknown. This study describes the most severe form of pseudo-toxoplasmosis, rubella, cytomegalovirus, and herpes simplex syndrome reported to date, with the patient showing microcephaly and calcification or band-like intracranial calcification with simplified gyration and polymirogyria.
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Affiliation(s)
- Kazuyuki Nakamura
- Department of Pediatrics, Yamagata University Faculty of Medicine, Yamagata, Japan.
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Discordant twins: diagnosis, evaluation and management. Am J Obstet Gynecol 2012; 206:10-20. [PMID: 21864822 DOI: 10.1016/j.ajog.2011.06.075] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Revised: 06/15/2011] [Accepted: 06/21/2011] [Indexed: 11/21/2022]
Abstract
Approximately 16% of twin gestations have discordance of at least 20%. We identified 14 risk factors for divergent growth that can be categorized as maternal, fetal, or placental. Determination of chorionicity and serial ultrasound evaluation with a high index of suspicion for divergent growth is required for the diagnosis and stratification of risk. The highest reported likelihood ratio for detection of discordance was 5.9 during the first trimester examination and 6.0 for the second trimester. Although our ability to identify discordant twins is limited, once suspected and at viable gestational age, these pregnancies should have antepartum testing. Discordant growth alone is not an indication for preterm birth. Although there are multiple publications on the increased morbidity and mortality rates with discordant growth, there is a paucity of reports on how to manage them optimally and deliver them in a timely manner.
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15
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Newman RB, Unal ER. Multiple gestations: timing of indicated late preterm and early-term births in uncomplicated dichorionic, monochorionic, and monoamniotic twins. Semin Perinatol 2011; 35:277-85. [PMID: 21962627 DOI: 10.1053/j.semperi.2011.05.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In this work we review the indications for late preterm and early-term birth in uncomplicated dichorionic, monochorionic, and monoamniotic twin gestations. Uncomplicated dichorionic twins have optimal outcomes when delivered at 38 weeks' gestation. Monochorionic twins, however, are at greater risk for unexpected stillbirth, and a management plan of late preterm delivery (34-37 weeks) after informed consent is reasonable. Monoamniotic twins are at even greater risk for sudden intrauterine fetal demise, and it is recommended that these expectant mothers be managed by inpatient hospitalization with fetal testing 1-3 times per day and delivery between 32 and 34 weeks' gestation. Recommendations are also provided for the circumstance of single intrauterine fetal demise in a twin gestation.
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Affiliation(s)
- Roger B Newman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical University of South Carolina, Charleston, SC 29425, USA.
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Abstract
Abstract
Improvements in ultrasound technology, including transvaginal sonography and higher frequency probes, have led to a better understanding of early pregnancy development. These advances and the increasing availability of ultrasound allow women to have an earlier and more accurate assessment of their pregnancy. First trimester sonographic signs have been identified that can be used to reassure women that their pregnancy is progressing normally or counsel them that their pregnancy will fail. In addition, first trimester ultrasound can accurately predict the type of twinning in multiple gestations, allowing for appropriate counseling and management.
Objectives
Know the first trimester ultrasound findings of a normal intrauterine pregnancy
Understand the ultrasound findings that diagnose an early pregnancy failure
Know the ultrasound criteria used to diagnose a multifetal gestation
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Malhotra A, Menahem S, Shekleton P, Gillam L. Medical and ethical considerations in twin pregnancies discordant for serious cardiac disease. J Perinatol 2009; 29:662-7. [PMID: 19626028 DOI: 10.1038/jp.2009.88] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Prenatal ultrasound has led to the early diagnosis of major anomalies. However, the ready availability of this technology has led to increasing challenges for physicians counseling affected parents, which is all the more difficult in a twin pregnancy with only one affected fetus. This paper reviews the medical and ethical considerations in twin pregnancies discordant for a serious cardiac condition. STUDY DESIGN Six recent twin pregnancies discordant for a serious cardiac condition and their outcomes are presented. Options considered in the management of the pregnancy were to continue or terminate the pregnancy, selectively terminate the affected twin or to decide whether to treat the affected twin once delivered. An approach to decision making in such situations has been formulated after critical analysis of the factors involved. RESULTS Four of the six pregnancies were monochorionic twins. Two sets of parents decided to terminate the pregnancy. In the four that continued, two opted for the affected twin to be appropriately managed once delivered. A further two considered selective termination but opted to continue the pregnancy because of the risk of premature labor and/or cerebral hypoxia following such intervention. They sought a commitment, however, that they be given the option whether to treat the affected twin following delivery. Eventually both elected to have their babies treated, one of whom died in the postoperative period. DISCUSSION Medical considerations included the risks of continuation of the pregnancy for the mother and her twins, the safety of termination (total or selective), and the risks to the unaffected fetus. Ethical issues revolved around concepts of autonomy, beneficence and justice from the standpoint of the family and the twins. The gestation and the viability of the twins played an important role in decision making and approaches, taking into account the local legal and other considerations. CONCLUSION Attention is drawn to the complexities of the issues involved in twin pregnancies complicated by a serious cardiac condition in one of the twins. Optimal counseling requires sound clinical knowledge about the medical risks to the mother and her twins, and a clear understanding of the key ethical considerations. Such an approach will assist parents in their very difficult decision making.
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Affiliation(s)
- A Malhotra
- Department of Neonatalogy, Monash Medical Centre, Melbourne, Australia
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18
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Pharoah P, Dundar Y. Monozygotic twinning, cerebral palsy and congenital anomalies. Hum Reprod Update 2009; 15:639-48. [DOI: 10.1093/humupd/dmp019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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O'Brien BM. MFM/geneticist view on prenatal management of twins. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2009; 151C:155-61. [PMID: 19378337 DOI: 10.1002/ajmg.c.30210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Twin pregnancies are associated with an increase in both fetal and maternal morbidity and mortality. Health care supervision is complex, increasingly requiring care from maternal-fetal medicine specialists. This review discusses optimal twin prenatal management, which includes recognizing increased twin pregnancy risks specific to twin-types; counseling families regarding fetal complications, ranging from prematurity to cerebral palsy; screening for aneuploidy and open neural tube defects; specific twin guidelines for diagnostic testing, including chorionic villus sampling and amniocentesis; and monitoring for maternal complications.
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Affiliation(s)
- Barbara M O'Brien
- Division of Maternal Fetal Medicine, Brown University, Providence, RI 02905, USA.
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O’Donoghue K, Rutherford MA, Engineer N, Wimalasundera RC, Cowan FM, Fisk NM. Transfusional fetal complications after single intrauterine death in monochorionic multiple pregnancy are reduced but not prevented by vascular occlusion. BJOG 2009; 116:804-12. [DOI: 10.1111/j.1471-0528.2009.02128.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pharoah POD, Glinianaia SV, Rankin J. Congenital anomalies in multiple births after early loss of a conceptus. Hum Reprod 2008; 24:726-31. [PMID: 19059945 PMCID: PMC2646789 DOI: 10.1093/humrep/den436] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Congenital anomalies are more common in twins than singletons but in the majority, aetiology is not known. Our aim was to test the hypothesis that survivors of an early loss in a multiple conception, compared with all singletons, are at increased risk of congenital anomaly. METHODS Data were abstracted from the UK population-based Northern Multiple Pregnancy Register and Northern Congenital Abnormality Survey, 1998-2004. RESULTS Among 3311 twin conceptions, both conceptuses were lost at <16 weeks gestation in 67, and one conceptus in 142 conceptions. Of the 142 singleton survivors, two died in infancy, two were terminated for a congenital anomaly and 11 of 138 had a congenital anomaly (prevalence 915.5 per 10,000 births). There were 197 congenital anomalies among 5948 registered twin births (331.2 per 10,000). The relative risk (RR) of congenital anomalies in a singleton with early loss of a conceptus and twins was 2.40 [95% confidence interval (CI): 1.34-4.29]. There were 4265 infants with a congenital anomaly among the 206 914 singletons [206.1 per 10,000 births: RR twin:singleton 1.61 (95% CI 1.40-1.89)]. CONCLUSIONS A highly significant increase in the risk of congenital anomaly in survivors from a multiple conception following early loss of a conceptus supports the hypothesis that many congenital anomalies are associated with monozygotic multiple conceptions.
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Affiliation(s)
- P O D Pharoah
- Department of Public Health, University of Liverpool, Liverpool L69 3GB, UK.
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23
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Morokuma S, Tsukimori K, Anami A, Fukushima K, Morioka T, Wake N. Brain injury of the survivor diagnosed at 18 weeks of gestation after intrauterine demise of the co-twin: a case report. Fetal Diagn Ther 2007; 23:146-8. [PMID: 18046074 DOI: 10.1159/000111596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2006] [Accepted: 11/16/2006] [Indexed: 11/19/2022]
Abstract
Brain injury in a surviving fetus following the demise of a monochorionic co-twin has only rarely been reported in the first trimester or early second trimester; most documented cases were beyond 20 weeks of gestation.
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Affiliation(s)
- Seiichi Morokuma
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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25
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Lee YM, Simpson LL. Major fetal structural malformations: the role of new imaging modalities. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2007; 145C:33-44. [PMID: 17290442 DOI: 10.1002/ajmg.c.30117] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prenatal diagnosis has embraced a recent wave of innovative imaging modalities including three-dimensional (3D) ultrasound and fetal magnetic resonance imaging (MRI). Traditional two-dimensional (2D) ultrasonography remains the standard method by which major structural abnormalities are diagnosed antenatally, but advances in technology are opening new doors. Growth in our knowledge about fetal development, improved patient counseling, and more favorable perinatal outcomes are all potential benefits of incorporating new imaging modalities into clinical practice.
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Affiliation(s)
- Young Mi Lee
- Columbia University Medical Center, Department of Obstetrics and Gynecology, New York, NY 10032, USA.
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26
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Lee YM, Cleary-Goldman J, D'Alton ME. The impact of multiple gestations on late preterm (near-term) births. Clin Perinatol 2006; 33:777-92; abstract viii. [PMID: 17148004 DOI: 10.1016/j.clp.2006.09.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multiple pregnancies currently account for 3% of all births in the United States but are disproportionately responsible for larger rates of prematurity and significant neonatal morbidity. The mean birth age for most multi-fetal pregnancies occurs during the late preterm period when both spontaneous preterm labor and iatrogenic premature birth because of obstetrical or maternal complications are common. Multiples pose numerous unique challenges, emphasizing the significant impact of plurality on late preterm births.
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Affiliation(s)
- Young Mi Lee
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Columbia University Medical Center, New York, NY 10032, USA.
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27
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Abstract
Multiple gestations present unique challenges to the modern obstetrician. Many twin and high-order multiple pregnancies are delivered between 34 and 37 weeks' gestation either secondary to preterm labor or obstetrical complications necessitating intervention. Recognizing the increasing prevalence of multiple gestations and the impact of late preterm deliveries in modern practice, this review analyzes the impact of multiple pregnancies on perinatal outcomes, reviews the strategies to prevent preterm labor, and summarizes potential indications for late preterm delivery. In this paper, "late preterm" has been used instead of "near-term," as the former was considered more appropriate to reflect this subgroup of preterm infants in a workshop on this topic held in July 2005, organized by the National Institute of Child Health and Human Development.
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Affiliation(s)
- Young Mi Lee
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Columbia University Medical Center, New York, NY 10032, USA.
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28
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Hu LS, Caire J, Twickler DM. MR findings of complicated multifetal gestations. Pediatr Radiol 2006; 36:76-81. [PMID: 16284762 DOI: 10.1007/s00247-005-0021-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2005] [Revised: 08/05/2005] [Accepted: 08/22/2005] [Indexed: 10/25/2022]
Abstract
This paper presents a review of various complications of multifetal gestations identified on MR imaging and highlights findings of those complications unique to monochorionic twinning. The goal is to illustrate the potential of MR as a useful application in these clinical circumstances. A total of 32 women with multifetal gestations and suspected complication detected initially by US underwent T2-weighted MR imaging. Additional T1-weighted images were obtained when intracranial hemorrhage was suspected. MR and US findings were compared in all cases. Of 32 cases, six demonstrated fetal complications specific to monochorionic twinning; the findings consisted of conjoined twins (n=2), twin-twin transfusion syndrome (n=1), co-twin demise with embolic disease (n=2), and twin-reversed arterial perfusion. (TRAP) syndrome (n=1). MR imaging confirmed US findings in all cases and was particularly helpful in delineating the extent of intracranial complications of monochorionic twins. The technique also showed improved anatomical detail in cases of conjoined twins. MR imaging provided additional information in cases of complicated monochorionic twinning, making it a useful complementary technique when combined with initial sonographic assessment.
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Affiliation(s)
- Leland S Hu
- Department of Radiology, Southwestern Medical Center, University of Texas, 5323 Harry Hines Blvd., Dallas, 75390, USA
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Sueters M, Middeldorp JM, Oepkes D, Lopriore E, Vandenbussche FPHA. Twin-to-twin transfusion syndrome at 11 weeks of gestation. Am J Obstet Gynecol 2005; 193:887-8. [PMID: 16150297 DOI: 10.1016/j.ajog.2005.02.095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Revised: 01/06/2005] [Accepted: 02/14/2005] [Indexed: 10/25/2022]
Abstract
Second-trimester twin-to-twin transfusion is well known, but first-trimester cases rarely have been described. We present the case of a monochorionic twin at 11+0 weeks of gestation with single increased nuchal translucency and normal karyotypes. At 12+5 weeks of gestation, double intrauterine death was diagnosed, followed by delivery of a strikingly red and white fetus.
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Affiliation(s)
- Marieke Sueters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Monteagudo A, Roman AS. Ultrasound in multiple gestations: twins and other multifetal pregnancies. Clin Perinatol 2005; 32:329-54, vi. [PMID: 15922786 DOI: 10.1016/j.clp.2005.02.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Ultrasound has an important role not only in assessing amnionicity and chorionicity but also in diagnosing abnormalities and providing fetal surveillance throughout the duration of gestation.
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Affiliation(s)
- Ana Monteagudo
- Department of Obstetrics and Gynecology, NYU School of Medicine, 530 First Avenue, NB9N26-B, New York, NY 10016, USA.
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Abstract
Cleary-Goldman and d'Alton discuss the implications of a new study in PLoS Medicine examining the risk of fetal death in uncomplicated monochorionic diamnotic twin pregnancies.
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Affiliation(s)
- Jane Cleary-Goldman
- Division of Maternal Fetal Medicine, Columbia University Medical Center, New York, New York, USA.
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