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Hopkins MK, Neumann O, Kuller JA, Dugoff L. First Trimester Ultrasound and Aneuploidy Screening in Twins. Clin Obstet Gynecol 2023; 66:774-780. [PMID: 37438894 DOI: 10.1097/grf.0000000000000797] [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: 07/14/2023]
Abstract
All patients with twin pregnancy should have first trimester ultrasound and be offered screening for chromosomal aneuploidy as well as diagnostic testing. Screening for aneuploidy in twins presents unique challenges compared with singletons. Cell-free DNA screening should be considered first-line; however, this option may not be available or may have limitations in certain clinical scenarios, such as vanishing twins. If cell-free DNA screening is not available, maternal serum marker screening in conjunction with nuchal translucency assessment should be offered. Patients with positive aneuploidy screening tests or fetal structural abnormalities should be offered diagnostic testing.
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Affiliation(s)
- Maeve K Hopkins
- Obstetrics & Gynecology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Olivia Neumann
- Obstetrics & Gynecology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey A Kuller
- Division of Maternal and Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - Lorraine Dugoff
- Divisions of Maternal and Fetal Medicine and Reproductive Genetics, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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2
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Dugoff L, Koelper NC, Chasen ST, Russo ML, Roman AS, Limaye MA, Ranzini AC, Clifford CM, Biggio JR, Subramaniam A, Seasely A, Patil AS, Weed S, Page JM, Nicholas S, Idler J, Rao RR, Crowder A, Shree R, McLennan G, Bromley B. Cell-free DNA screening for trisomy 21 in twin pregnancy: a large multicenter cohort study. Am J Obstet Gynecol 2023; 229:435.e1-435.e7. [PMID: 37030426 DOI: 10.1016/j.ajog.2023.04.002] [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: 12/12/2022] [Revised: 04/03/2023] [Accepted: 04/03/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Analysis of cell-free DNA from maternal blood provides effective screening for trisomy 21 in singleton pregnancies. Data on cell-free DNA screening in twin gestations are promising although limited. In previous twin studies, cell-free DNA screening was primarily performed in the second trimester and many studies did not report chorionicity. OBJECTIVE This study aimed to evaluate the screening performance of cell-free DNA for trisomy 21 in twin pregnancies in a large, diverse cohort. A secondary aim was to evaluate screening performance for trisomy 18 and trisomy 13. STUDY DESIGN This was a retrospective cohort study of twin pregnancies from 17 centers for which cell-free DNA screening was performed from December 2011 to February 2020 by one laboratory using massively parallel sequencing technology. Medical record review was conducted for all newborns and data on the birth outcome, the presence of any congenital abnormalities, phenotypic appearance at birth, and any chromosomal testing that was undertaken in the antenatal or postnatal period were extracted. Cases with a possible fetal chromosomal abnormality with no genetic test results were reviewed by a committee of maternal-fetal medicine geneticists. Cases with a vanishing twin and inadequate follow-up information were excluded. A minimum of 35 confirmed cases of trisomy 21 was required to capture a sensitivity of at least 90% with a prevalence of at least 1.9% with 80% power. Test characteristics were calculated for each outcome. RESULTS A total of 1764 samples were sent for twin cell-free DNA screening. Of those, 78 cases with a vanishing twin and 239 cases with inadequate follow-up were excluded, leaving a total of 1447 cases for inclusion in the analysis. The median maternal age was 35 years and the median gestational age at cell-free DNA testing was 12.3 weeks. In total, 81% of the twins were dichorionic. The median fetal fraction was 12.4%. Trisomy 21 was detected in 41 of 42 pregnancies, yielding a detection rate of 97.6% (95% confidence interval, 83.8-99.7). There was 1 false negative and no false positive cases. Trisomy 21 was detected in 38 out of 39 dichorionic twin pregnancies, yielding a detection rate of 97.4% (95% confidence interval, 82.6-99.7). Trisomy 18 was detected in 10 of the 10 affected pregnancies. There was 1 false positive case. Trisomy 13 was detected in 4 of the 5 cases, yielding a detection rate of 80% (95% confidence interval, 11.1-99.2). There was one false negative and no false positive cases. The nonreportable rate was low at 3.9 %. CONCLUSION Cell-free DNA testing is effective in screening for trisomy 21 in twin gestations from the first trimester of pregnancy. Detection of trisomy 21 was high in dichorionic and monochorionic twins, and the nonreportable result rates were low. This study included high numbers of cases of trisomy 18 and 13 when compared with the current literature. Although screening for these conditions in twins seems to be promising, the numbers were too small to make definitive conclusions regarding the screening efficacy for these conditions. It is possible that cell-free DNA testing performance may differ among laboratories and vary with screening methodologies.
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Affiliation(s)
- Lorraine Dugoff
- Division of Reproductive Genetics, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Nathanael C Koelper
- Department of Obstetrics and Gynecology, Center for Research on Reproduction and Women's Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Stephen T Chasen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NewYork Presbyterian-Weill Cornell Medical Center, New York, NY
| | - Melissa L Russo
- Division of Maternal-Fetal Medicine, Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Meghana A Limaye
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Angela C Ranzini
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The MetroHealth System, Cleveland, OH
| | - Caitlin M Clifford
- Division of Maternal-Fetal Medicine, University of Michigan, Ann Arbor, MI
| | - Joseph R Biggio
- Section of Maternal Fetal Medicine, Women's Service Line, Department of Obstetrics and Gynecology, Ochsner Health, New Orleans, LA
| | - Akila Subramaniam
- Division of Maternal-Fetal Medicine, Center for Women's Reproductive Health, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
| | - Angela Seasely
- Division of Maternal-Fetal Medicine, Center for Women's Reproductive Health, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
| | - Avinash S Patil
- Department of Obstetrics and Gynecology, The University of Arizona College of Medicine-Phoenix, Phoenix, AZ
| | - Samantha Weed
- Franciscan Maternal-Fetal Medicine Associates, Tacoma, WA
| | - Jessica M Page
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Utah Healthcare and Intermountain Healthcare, Salt Lake City, UT
| | - Sara Nicholas
- Axia Women's Health Main Line Perinatal Associates, Wynnewood, PA
| | - Jay Idler
- Allegheny Health Network, Drexel University College of Medicine, Pittsburgh, PA
| | - Rashmi R Rao
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | | | - Raj Shree
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | | | - Bryann Bromley
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
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3
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Buckley L, Hopkins M, Kuller JA, Dugoff L. Prenatal Genetic Screening in Twin Pregnancy. Clin Obstet Gynecol 2023; 66:624-628. [PMID: 37436940 DOI: 10.1097/grf.0000000000000805] [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: 07/14/2023]
Abstract
Twin pregnancy presents unique considerations for aneuploidy screening. Pre-test counseling regarding benefits, alternatives, and options for aneuploidy screening should be provided to all patients carrying twin pregnancy. This article aims to review the options for aneuploidy screening in twin pregnancy including the potential benefits and limitations.
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Affiliation(s)
- Lauren Buckley
- Obstetrics & Gynecology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Maeve Hopkins
- Obstetrics & Gynecology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey A Kuller
- Division of Maternal and Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - Lorraine Dugoff
- Division of Maternal and Fetal Medicine and Reproductive Genetics, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Kantor V, Mo L, DiNonno W, Howard K, Palsuledesai CC, Parmar S, Chithiwala Z, Jelsema R, Xu W, Hedriana HL. Positive predictive value of a single nucleotide polymorphism (SNP)-based NIPT for aneuploidy in twins: Experience from clinical practice. Prenat Diagn 2022; 42:1587-1593. [PMID: 36336878 PMCID: PMC10100335 DOI: 10.1002/pd.6262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/28/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Twins account for approximately 1 in 30 live births in the United States. However, there are limited clinical experience studies published in noninvasive prenatal testing (NIPT) for detecting aneuploidies in twins. This study reports the performance of an SNP-based NIPT in the largest cohort with known outcomes for high-risk aneuploidy results. METHOD This is a retrospective analysis of 18,984 results from commercial single-nucleotide polymorphism (SNP)-based NIPT tests performed in twins between October 2, 2017 and December 31, 2019. Follow-up for all 211 high-risk cases was solicited. RESULTS Follow-up outcomes were obtained in 105 cases. Positive predictive values (PPVs) for high-risk results were 88.7% (63/71, 95% Confidence Interval [CI]: 79.0%-95.0%) for trisomy 21% and 72.7% (8/11, 95% CI: 39.0%-94.0%) for trisomy 18. The results were stratified into monozygotic (MZ) and dizygotic (DZ). The PPVs in MZ were 100% for both trisomy 21 (4/4, 95% CI: 40%-100%) and trisomy 18 (1/1, 95% CI: 2.5%-100%). No trisomy 13 cases were detected in the MZ group. The PPVs in DZ were 88.1% (59/67, 95% CI: 77.8%-94.7%), 70.0% (7/10, 95% CI: 34.8%-93.3%), and 66.7% (2/3, 95% CI: 9.4%-99.2%) for trisomy 21, trisomy 18, and trisomy 13, respectively. CONCLUSION The performance of SNP-based NIPT in this large twin cohort was comparable to previously reported twin NIPT studies. SNP-based NIPT allows for zygosity-based PPV assessment.
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Affiliation(s)
| | - Lihong Mo
- University of California, Davis, California, USA
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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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6
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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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Prevalence of common aneuploidy in twin pregnancies. J Hum Genet 2022; 67:261-265. [PMID: 34974528 PMCID: PMC9035385 DOI: 10.1038/s10038-021-01001-0] [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: 08/07/2021] [Revised: 11/19/2021] [Accepted: 11/26/2021] [Indexed: 11/12/2022]
Abstract
The incidence of chromosomal abnormalities in twin pregnancies is not well-studied. In this retrospective study, we investigated the frequency of chromosomal abnormalities in twin pregnancies and compared the incidence of chromosomal abnormalities in dichorionic diamniotic (DD) and monochorionic diamniotic (MD) twins. We used data from 57 clinical facilities across Japan. Twin pregnancies of more than 12 weeks of gestation managed between January 2016 and December 2018 were included in the study. A total of 2899 and 1908 cases of DD and MD twins, respectively, were reported, and the incidence of chromosomal abnormalities in one or both fetuses was 0.9% (25/2899) and 0.2% (4/1908) in each group (p = 0.004). In this study, the most common chromosomal abnormality was trisomy 21 (51.7% [15/29]), followed by trisomy 18 (13.8% [4/29]) and trisomy 13 (6.9% [2/29]). The incidence of trisomy 21 in MD twins was lower than that in DD twins (0.05% vs. 0.5%, p = 0.007). Trisomy 21 was less common in MD twins, even when compared with the expected incidence in singletons (0.05% vs. 0.3%, RR 0.15 [95% CI 0.04–0.68]). The risk of chromosomal abnormality decreases in twin pregnancies, especially in MD twins.
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8
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Special Considerations Regarding Antenatal Care and Pregnancy Complications in Dichorionic Twin Pregnancies. Am J Obstet Gynecol MFM 2021; 4:100500. [PMID: 34637959 DOI: 10.1016/j.ajogmf.2021.100500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/18/2021] [Accepted: 10/04/2021] [Indexed: 02/07/2023]
Abstract
Twin pregnancies account for about 3.3% of all deliveries in the United States with the majority of them being dichorionic diamniotic (DCDA). Maternal physiological adaption in twin pregnancies is exaggerated and the rate of almost every maternal and fetal complication is higher when compared to singleton pregnancies. Therefore, twin pregnancies necessitate closer antenatal surveillance by care providers who are familiar with the specific challenges unique to these pregnancies, and there is evidence that following women with twins in a specialized twin clinic can result in improved obstetrical outcomes. The importance of the first antenatal visit in twin pregnancies cannot be over emphasized and should preferably take place early in gestation as it is the optimal period to correctly identify the number of fetuses and the type of placentation (chorionicity and amnionicity). This will allow the patients, families, and caregivers to make the appropriate modifications and to tailor an optimal antenatal follow-up plan. This plan should focus on general recommendations such as weight gain and level of activity, education regarding complications specific to twin pregnancies along with the relevant symptoms and indications to seek care, as well as on close maternal and fetal monitoring. In this review, we summarize available evidence and current guidelines regarding antenatal care in DCDA twin pregnancies.
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Hopkins MK, Dugoff L. Screening for aneuploidy in twins. Am J Obstet Gynecol MFM 2021; 4:100499. [PMID: 34634497 DOI: 10.1016/j.ajogmf.2021.100499] [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: 06/01/2021] [Revised: 08/26/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
All pregnant women should be offered screening for aneuploidy. Twin pregnancies present unique challenges in aneuploidy screening. This review describes available aneuploidy screening options and their benefits and limitations in twin pregnancy, along with describing special circumstances, such as vanishing twins and diagnostic testing in twin pregnancy. No method of aneuploidy screening is as accurate in twin pregnancies as singleton pregnancies. Cell-free DNA screening should be considered a first-line approach; however, this option may not be available or may have limitations in certain clinical scenarios, such as vanishing twins. If cell-free DNA screening is not available, nuchal translucency and/or maternal serum marker screening can be offered.
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Affiliation(s)
- Maeve K Hopkins
- Division of Maternal and Fetal Medicine, Ob/Gyn & Women's Health Institute, Cleveland Clinic, Cleveland, OH (Dr Hopkins).
| | - Lorraine Dugoff
- Divisions of Maternal and Fetal Medicine and Reproductive Genetics, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA (Dr Dugoff)
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10
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Ogawa M, Hasuo Y, Taura Y, Tsunematsu R, Shikada S, Matsushita Y, Sato K. Attitude changes toward prenatal testing among women with twin pregnancies after the introduction of noninvasive prenatal testing: A single-center study in Japan. J Obstet Gynaecol Res 2021; 47:3813-3820. [PMID: 34490692 PMCID: PMC9292293 DOI: 10.1111/jog.15010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 07/27/2021] [Accepted: 08/27/2021] [Indexed: 11/27/2022]
Abstract
Aim This study aimed to evaluate changes in prenatal testing among women with twin pregnancies before and after the introduction of noninvasive prenatal testing (NIPT). To date, no consensus on prenatal testing for twin pregnancies has been reached in Japan. Methods Women pregnant with twins who requested prenatal testing at Kyushu Medical Center from 2005 to 2018 were included in this study. Genetic counseling was provided to all participants. Their chosen methods of testing were collected and classified as invasive diagnosis (ID), noninvasive screening (NIS), and no test requested (NR). Parity, chorionicity, and methods of conception were assessed as attributes. The study period was divided into three terms according to testing availability in our center. Results After NIPT was introduced in our center, the use of ID methods decreased and eventually disappeared while NIS came to the forefront. NR was also the preferred choice of women with twin pregnancies before the introduction of NIPT and decreased but did not disappear after introducing NIPT. Women with twin pregnancies who underwent assisted reproduction initially showed hesitation to undergo testing but showed a strong preference for NIS after the introduction of NIPT. Differences in choice according to parity, chorionicity, and methods of conception were found before the introduction of NIPT but disappeared after introducing NIPT. Conclusion Increasing information about NIPT has apparently influenced the attitudes of women with twin pregnancies to prenatal testing in Japan. In particular, those who conceive through assisted reproductive technologies exhibited a strong preference for NIPT.
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Affiliation(s)
- Masanobu Ogawa
- Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Department of Clinical Genetics and Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Yasuyuki Hasuo
- Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Department of Obstetrics and Gynecology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Genetic Counseling Clinic, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yumiko Taura
- Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Department of Obstetrics and Gynecology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Genetic Counseling Clinic, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Ryosuke Tsunematsu
- Department of Gynecology, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Sawako Shikada
- Department of Clinical Genetics and Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Yuki Matsushita
- Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Genetic Counseling Clinic, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Department of Pediatrics, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Kazuo Sato
- Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Department of Pediatrics, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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11
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Yeaton‐Massey A, Sparks TN, Norton ME, Jelliffe‐Pawlowski L, Currier RJ. Twin chorionicity and zygosity both vary with maternal age. Prenat Diagn 2021; 41:1074-1079. [DOI: 10.1002/pd.5997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Amanda Yeaton‐Massey
- Department of Obstetrics, Gynecology & Reproductive Sciences University of California San Francisco California USA
| | - Teresa N. Sparks
- Department of Obstetrics, Gynecology & Reproductive Sciences University of California San Francisco California USA
| | - Mary E. Norton
- Department of Obstetrics, Gynecology & Reproductive Sciences University of California San Francisco California USA
| | - Laura Jelliffe‐Pawlowski
- Preterm Birth Initiative ‐ California University of California San Francisco School of Medicine San Francisco California USA
- Department of Epidemiology and Biostatistics University of California San Francisco School of Medicine San Francisco California USA
| | - Robert J. Currier
- Department of Pediatrics University of California San Francisco School of Medicine San Francisco California USA
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12
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Benn P, Rebarber A. Non-invasive prenatal testing in the management of twin pregnancies. Prenat Diagn 2021; 41:1233-1240. [PMID: 34170028 PMCID: PMC8518532 DOI: 10.1002/pd.5989] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 12/02/2022]
Abstract
Twin pregnancies are common and associated with pregnancy complications and adverse outcomes. Prenatal clinical management is intensive and has been hampered by inferior screening and less acceptable invasive testing. For aneuploidy screening, meta‐analyses show that non‐invasive prenatal testing (NIPT) through analysis of cell‐free DNA (cf‐DNA) is superior to serum and ultrasound‐based tests. The positive predictive value for NIPT is driven strongly by the discriminatory power of the assay and only secondarily by the prior risk. Uncertainties in a priori risks for aneuploidies in twin pregnancies are therefore of lesser importance with NIPT. Additional information on zygosity can be obtained using NIPT. Establishing zygosity can be helpful when chorionicity was not reliably established early in pregnancy or where the there is a concern for one versus two affected fetuses. In dizygotic twin pregnancies, individual fetal fractions can be measured to ensure that both values are satisfactory. Vanishing twins can be identified by NIPT. Although clinical utility of routinely detecting vanishing twins has not yet been demonstrated, there are individual cases where cf‐DNA analysis could be helpful in explaining unusual clinical or laboratory observations. We conclude that cf‐DNA analysis and ultrasound have synergistic roles in the management of multiple gestational pregnancies.
What's already known about this topic?
In singleton pregnancies, non‐invasive prenatal testing (NIPT) for fetal aneuploidy is more effective than conventional serum and ultrasound‐based screening tests. NIPT is more complex in dizygotic twin pregnancies due to the presence of two fetal genotypes. Overall fetal fraction is higher in twin pregnancies but the individual contribution for each fetus is lower.
What does this study add?
A review of cell‐free DNA testing in twin pregnancies. Individual fetal fractions in dizygotic twin pregnancies can be measured. Zygosity can be established using NIPT and this can be particularly useful when there are concerns about chorionicity or determining whether one versus two fetuses are affected. Vanishing twins can be detected through NIPT and this testing could be considered for some apparently singleton pregnancies with complications.
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Affiliation(s)
- Peter Benn
- Department of Genetics and Genome Sciences, UConn Health, Farmington, Connecticut, USA
| | - Andrei Rebarber
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Division of Maternal Fetal Medicine, Englewood Hospital, Englewood, New Jersey, USA
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Cao D, Sun J, Li N, Li Z, Liu W, Chen M. Monozygotic twins discordant for homologous Robertsonian translocation trisomy 21 of 46, XX, + 21, der (21;21) (q10; q10) in a twin-to-twin transfusion syndrome, case report. BMC Pregnancy Childbirth 2021; 21:101. [PMID: 33516175 PMCID: PMC7847594 DOI: 10.1186/s12884-021-03587-x] [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: 11/20/2020] [Accepted: 01/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background Monozygotic twins are nearly identical in genotype and phenotype because monozygotic twins arise from one fertilized oocyte. In all cases of discordant karyotype in monozygotic twins, trisomy 21 accounts for about one in 385,000. Monozygotic twins discordant for Robertsonian translocation trisomy 21 of the der (21;21)(q10;q10), in which the additional chromosome originates from the father is rare. Case presentation A 28-year-old parous woman, G3P1A0, came to our institution for a dating scan at 8 weeks of gestation. The transvaginal ultrasound examination demonstrated a monochorionic diamniotic pregnancy. She and her husband were healthy, with no family history of trisomy 21 or other congenital diseases. The ultrasound examination of nuchal translucency thickness was discordant in twins at 13 weeks (twin A, NT 1.4 mm with CRL being 65 mm; twin B, NT 7.8 mm with CRL being 69 mm). At 17+ 4 weeks, twin A was normal, but ventricular septal defect and the hypoplastic left heart was detected in twin B. The deepest vertical pocket was 18 mm in twin A (oligohydramnios) and 102 mm in Twin B (polyhydramnios). The bladder in twin A was absent. Ultrasound findings indicated TTTS Stage II. Amniocentesis was performed for the two fetuses. The karyotyping results revealed 46, XX in twin A but 46,XX,+ 21,der (21;21)(q10;q10) in twin B. For twin B, the parents opted for selective fetal termination by radiofrequency ablation. The procedure was uneventful. At 40+ 5 weeks, twin A was born with a birth weight of 4120 g by vaginal delivery. Conclusions The early detection of discordant karyotype and twin-to-twin transfusion syndrome is beneficial to the early intervention. In monozygotic twins with a discordant anomaly, the discordant karyotype should be considered. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03587-x.
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Affiliation(s)
- Dingya Cao
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, 510150, China
| | - Jimei Sun
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, 510150, China
| | - Nan Li
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, 510150, China
| | - Zhihua Li
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, 510150, China
| | - Weiqiang Liu
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, 510150, China
| | - Min Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, 510150, China.
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14
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Abstract
Prenatal testing for chromosomal abnormalities is designed to provide an accurate assessment of a patient's risk of carrying a fetus with a chromosomal disorder. A wide variety of prenatal screening and diagnostic tests are available; each offers varying levels of information and performance, and each has relative advantages and limitations. When considering screening test characteristics, no one test is superior in all circumstances, which results in the need for nuanced, patient-centered counseling from the obstetric care professional and complex decision making by the patient. Each patient should be counseled in each pregnancy about options for testing for fetal chromosomal abnormalities. It is important that obstetric care professionals be prepared to discuss not only the risk of fetal chromosomal abnormalities but also the relative benefits and limitations of the available screening and diagnostic tests. Testing for chromosomal abnormalities should be an informed patient choice based on provision of adequate and accurate information, the patient's clinical context, accessible health care resources, values, interests, and goals. All patients should be offered both screening and diagnostic tests, and all patients have the right to accept or decline testing after counseling.The purpose of this Practice Bulletin is to provide current information regarding the available screening test options available for fetal chromosomal abnormalities and to review their benefits, performance characteristics, and limitations. For information regarding prenatal diagnostic testing for genetic disorders, refer to Practice Bulletin No. 162, Prenatal Diagnostic Testing for Genetic Disorders. For additional information regarding counseling about genetic testing and communicating test results, refer to Committee Opinion No. 693, Counseling About Genetic Testing and Communication of Genetic Test Results. For information regarding carrier screening for genetic conditions, refer to Committee Opinion No. 690, Carrier Screening in the Age of Genomic Medicine and Committee Opinion No. 691, Carrier Screening for Genetic Conditions. This Practice Bulletin has been revised to further clarify methods of screening for fetal chromosomal abnormalities, including expanded information regarding the use of cell-free DNA in all patients regardless of maternal age or baseline risk, and to add guidance related to patient counseling.
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15
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Palomaki GE, Chiu RWK, Pertile MD, Sistermans EA, Yaron Y, Vermeesch JR, Vora NL, Best RG, Wilkins-Haug L. International Society for Prenatal Diagnosis Position Statement: cell free (cf)DNA screening for Down syndrome in multiple pregnancies. Prenat Diagn 2020; 41:1222-1232. [PMID: 33016373 DOI: 10.1002/pd.5832] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/27/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Glenn E Palomaki
- Department of Pathology and Laboratory Medicine, Women & Infants Hospital and the Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Rossa W K Chiu
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Mark D Pertile
- Victorian Clinical Genetics Services (VCGS), Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Erik A Sistermans
- Department of Clinical Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yuval Yaron
- Prenatal Genetic Diagnosis Unit, Genetic Institute, Tel Aviv Medical Center, Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | | | - Neeta L Vora
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robert G Best
- University of South Carolina SOM Greenville, Greenville, South Carolina, USA
| | - Louise Wilkins-Haug
- Division of Maternal Fetal Medicine and Reproductive Genetics, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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16
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Cuckle H, Benn P. Review of epidemiological factors (other than maternal age) that determine the prevalence of common autosomal trisomies. Prenat Diagn 2020; 41:536-544. [PMID: 32895968 DOI: 10.1002/pd.5822] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/24/2020] [Accepted: 09/02/2020] [Indexed: 12/22/2022]
Abstract
The birth prevalence of each common autosomal trisomy (21, 18 and 13) increases with advancing maternal age and this is the most important epidemiological risk factor. Prevalence during pregnancy is also dependent on gestational age. Other factors claimed to influence prevalence include paternal age, ethnicity, family history, premature reproductive aging, parity, twinning, smoking, environmental exposures, maternal medical conditions, and predispositions. We review the evidence for these associations since they may provide insights into causal mechanisms. When investigating potential co-factors it is important to adequately allow for maternal age and minimize its confounding contribution. This is well illustrated by reports of an inverse paternal age effect where there is strong correlation between parental ages. Gestational age at diagnosis, availability of prenatal screening, diagnostic testing, and elective termination of affected pregnancies and healthcare disparities also confound the studies on ethnicity, medical conditions, and predispositions or environmental factors. Data from twin zygosity studies demonstrate the importance of differences in fetal viability for affected pregnancies. We conclude that existing epidemiological evidence for most of the co-factors discussed should currently be considered tenuous; history of Down syndrome, albeit biased, may be an exception. The co-factors may yet provide clues to hitherto poorly understood causal pathways.
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Affiliation(s)
- Howard Cuckle
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Peter Benn
- Department of Genetics and Genome Sciences, University of Connecticut Health Center, Farmington, Connecticut, USA
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17
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Hedriana H, Martin K, Saltzman D, Billings P, Demko Z, Benn P. Cell-free DNA fetal fraction in twin gestations in single-nucleotide polymorphism-based noninvasive prenatal screening. Prenat Diagn 2019; 40:179-184. [PMID: 31711265 PMCID: PMC7027570 DOI: 10.1002/pd.5609] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/19/2019] [Accepted: 10/26/2019] [Indexed: 12/14/2022]
Abstract
Objectives The performance of noninvasive prenatal screening (NIPS) for fetal aneuploidy in twin pregnancies is dependent on the amount of placentally derived cell‐free DNA, the “fetal fraction (FF),” present in maternal plasma. We report FF values in monozygotic (MZ) and dizygotic (DZ) pregnancies. Methods We reviewed FF in pregnancies at 10 to 20 completed weeks gestational age based on single‐nucleotide polymorphism (SNP)‐based NIPS where zygosity was routinely established in twin pregnancies. The cohort included 121 446 (96.3%) singleton, 1454 (1.2%) MZ, and 3161 (2.5%) DZ pregnancies. For DZ twins, individual FFs were measured. Results Combined FF for DZ and MZ fetuses were 35% and 26% greater than singletons, respectively. The individual FF contributions from each fetus in DZ twins were, on average, 32% less than singletons. FF in DZ twin pairs were moderately correlated (Pearson correlation coefficient.66). When a threshold of 2.8% FF was applied to define uninterpretable results, 1.7% (2102/121 446) of singletons, 0.8% (11/1454) of MZ pairs, and 5.6% (178/3161) of DZ pairs were uninterpretable. Conclusion For optimal aneuploidy NIPS in twin pregnancies, zygosity should be established and in DZ twins FF for both fetuses should be determined to identify those cases where results can be reliably interpreted. What's already known about this topic?
Adequate cell‐free fetal DNA (fetal fraction [FF]) is essential for noninvasive prenatal screening. FFs in twin pregnancies may be higher or lower than that found in singleton pregnancies.
What does this study add?
In this large series of twin pregnancies, the average total FF was higher than for singletons but the per fetus FF was lower. There can be large differences in the two FFs in dizygotic twin pregnancies. Optimal prenatal aneuploidy screening in twin pregnancies requires information on both zygosity and the individual FFs.
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Affiliation(s)
- Herman Hedriana
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California Davis Health, Sacramento, CA
| | | | | | | | | | - Peter Benn
- Department of Genetics and Genome Sciences, UConn Health, Farmington, CT
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18
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Sperling JD, Zlatnik MG, Norton ME, Currier RJ. Pregnancy loss after amniocentesis in monochorionic and dichorionic twin pregnancies: Results from a large population-based dataset. Prenat Diagn 2019; 39:896-900. [PMID: 31218716 DOI: 10.1002/pd.5502] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/25/2019] [Accepted: 06/08/2019] [Indexed: 01/30/2023]
Affiliation(s)
- Jeffrey D Sperling
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal Fetal Medicine, University of California, San Francisco, CA
| | - Marya G Zlatnik
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal Fetal Medicine, University of California, San Francisco, CA
| | - Mary E Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal Fetal Medicine, University of California, San Francisco, CA
| | - Robert J Currier
- Department of Pediatrics, University of California, San Francisco, CA
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19
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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:jcm8070937. [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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20
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Abstract
In the decades since the introduction of ultrasound into routine obstetric practice, the advantages of ultrasound have moved beyond the simple ability to identify multiple pregnancies antenatally to the possibility of screening them for fetal anomalies, pre-eclampsia, preterm birth, and the complications specific to monochorionic pregnancies. Screening studies have often excluded twins because physiological differences impact on the validity and sensitivity of the screening tests in routine use in singletons, and therefore, the evidence of screening performance in multiple pregnancy lags behind the evidence from singleton pregnancies. In general, most pregnancy complications are more common in twin pregnancy, but screening tests are less accurate or well validated. In this review article we present the current state of the evidence and avenues for future research relating to the use of ultrasound and screening for complications in twin pregnancies, including the monochorionicity-related pathologies, such as twin-twin transfusion syndrome, selective growth restriction, twin anaemia-polycythaemia sequence and twin reversed arterial perfusion sequence.
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Affiliation(s)
| | - Asma Khalil
- Fetal Medicine Unit, St George's University of London, London, UK.
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21
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Bender W, Dugoff L. Screening for Aneuploidy in Multiple Gestations. Obstet Gynecol Clin North Am 2018; 45:41-53. [DOI: 10.1016/j.ogc.2017.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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22
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Situs Inversus Totalis in Twins: A Brief Review and a Life History / Twin Research: Twin Studies of Trisomy 21; Monozygotic Twin Concordance for Bilateral Coronoid Hyperplasia; Prenatal Hormonal Effects in Mixed-Sex Non-Human Primate Litters; Insurance Mandates and Twinning After In Vitro Fertilization / News Reports: First Report of Identical Twin Puppies; Twins Sisters Turn 100; Remembering an Identical Twin Production Designer; New York City Marathon Quadruplets. Twin Res Hum Genet 2017; 20:90-95. [PMID: 28105968 DOI: 10.1017/thg.2016.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The presence of situs inversus totalis (full reversal of internal organs) in twins is briefly reviewed. Information gathered from 35-year-old monozygotic (MZ) female twin pair discordant for this condition is presented. This is followed by summaries of research on the frequency of trisomy 21 (Down syndrome) in twins, the first case of MZ twin concordance for bilateral coronoid hyperplasia, prenatal hormonal effects in mixed-sex non-human primate litters, and links between insurance mandates and twinning following in vitro fertilization. The final section of this article describes twin-related events reported in the news, namely, the first recorded birth of identical twin puppies; the 100th birthday celebration of a pair of fraternal female twins, the passing of an award-winning identical twin production designer, and the first running of the New York City Marathon by a set of quadruplets.
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23
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Twin Studies in Brazil: Projects and Plans / Twin Research: Infant Twins' Viewing of Social Scenes; Religiosity and Substance Abuse; Down Syndrome Among Twins; Twin Case of Chronic Periodontitis / In the News: The Twin 'Property Brothers', Twins With Cerebral Palsy; Twins Affected With the Zika Virus; Twin Writers Derek and Roddy; Twins on Sports Teams; Local Quads. Twin Res Hum Genet 2017; 20:481-488. [PMID: 28975876 DOI: 10.1017/thg.2017.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Twin research in Brazil twin has expanded enormously in recent years, engaging the interests and efforts of many investigators, students and twins. Descriptions and brief summaries of this work and talks given by investigators at local conferences are presented, based on my four-city lecture tour. This is followed by summaries of twin research on infants' viewing of social scenes, religiosity and substance abuse, Down syndrome, and chronic periodontitis. This article concludes with twin-related news and information of general interest, including identical twin property designers, twins with cerebral palsy, twins affected with the Zika virus, a pair of twin writers, twins in sports, and a set of quadruplets from my childhood neighborhood in Riverdale, New York.
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