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Pinho BB, Neves M, Pasion R, Matias A. Velamentous cord insertion in monochorionic twin pregnancies: a step forward in screening for twin to twin transfusion syndrome and birthweight discordance? J Perinat Med 2023; 51:1147-1153. [PMID: 37323000 DOI: 10.1515/jpm-2023-0161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/11/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Two major complications of monochorionic diamniotic (MCDA) twin pregnancies are twin to twin transfusion syndrome (TTTS) and birthweight discordance. The current screening ultrasound test for these pathologies combines the detection of nuchal translucency discrepancy and abnormal ductus venosus in at least one twin, in the first trimester. We aim to determine whether combining the presence of velamentous cord insertion in at least one twin increases screening efficiency. METHODS This was a retrospective cohort with a sample of 136 MCDA twin pregnancies followed at Centro Hospitalar Universitário São João, during a 16-year period. RESULTS The combination of abnormal ductus venosus in at least one twin and nuchal translucency discrepancy is associated with the development of TTTS with an OR of 10.455, but not with birthweight discordance. The combination of these first trimester markers with velamentous cord insertion is not associated with the development of either outcome. CONCLUSIONS The presence of velamentous cord insertion in MCDA pregnancies is not associated to TTTS development. Therefore, the addition of this marker to the first trimester screening would not effectively predict the development of birthweight discordance or TTTS. However, a positive currently used screening test increases the risk of developing TTTS by about ten times.
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Affiliation(s)
- Beatriz B Pinho
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mafalda Neves
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Rita Pasion
- HEI-LAB, Lusófona University, Porto, Portugal
| | - Alexandra Matias
- Department of Obstetrics and Gynecology, University Hospital of S. João, Faculty of Medicine, i3S, Porto, Portugal
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Chhikara U, Anand K, Sharma A, Prasad S, Kaul A. Performance of Ductus Venosus Doppler (at 11-13 + 6 Weeks) in Predicting Adverse Fetal Outcomes in Indian Population: Going Beyond Aneuploidies: Going Beyond Aneuploidies. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2877-2883. [PMID: 35274332 DOI: 10.1002/jum.15976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/13/2022] [Accepted: 02/25/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The objective of this study is to examine the performance of Ductus venosus (DV) Doppler done at the routine first trimester screening (11-13 + 6 weeks) in predicting the adverse fetal outcomes in Indian population. METHODS This observational study was conducted between 2013 and 2019, on 4340 singleton pregnancies. Ductus Doppler were considered abnormal if DV pulsatility index values were >95th centile for that gestation or with a reversed "a" wave. Anatomical survey was done to rule out other abnormalities. Women were followed up till delivery and outcomes were divided into 4 groups: 1) aneuploidies; 2) cardiac defects; 3) non-cardiac structural abnormalities; and 4) miscarriages before 24 weeks or fetal deaths after 24 weeks. RESULTS Prevalence of abnormal DV Doppler is 5.12% (205/4004). There were significantly higher number of fetal losses (4.4 versus 0.3%), aneuploidies (10.2 versus 1.7%), fetal cardiac defects (5.9 versus 1.4%), and non-cardiac structural defects (5.4 versus 1.4%) among the pregnancies with abnormal DV Doppler in comparison to those with normal flow (P < .001). Logistic regression analysis has shown that significant contribution to fetal chromosomal abnormalities and cardiac defects was associated with abnormal DV. Other factors which were found to have a significant association with adverse fetal outcome were increased nuchal translucency and increased body mass index (BMI). CONCLUSION DV Doppler in first trimester can be used as a screening tool for cardiac defects and fetal deaths. Women with abnormal DV Dopplers should be offered fetal echocardiography at 18-22 weeks and third trimester growth scans with Dopplers.
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Affiliation(s)
- Urvashi Chhikara
- Apollo Centre for Fetal Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | - Keerthana Anand
- Apollo Centre for Fetal Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | - Akshatha Sharma
- Apollo Centre for Fetal Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | - Smriti Prasad
- Apollo Centre for Fetal Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | - Anita Kaul
- Apollo Centre for Fetal Medicine, Indraprastha Apollo Hospital, New Delhi, India
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3
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Uncomplicated Monochorionic Twins: Two Normal Hearts Sharing One Placenta. J Clin Med 2020; 9:jcm9113602. [PMID: 33182282 PMCID: PMC7695261 DOI: 10.3390/jcm9113602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/24/2020] [Accepted: 11/02/2020] [Indexed: 12/27/2022] Open
Abstract
Cardiovascular dysfunction has been reported in complicated monochorionic diamniotic (MCDA) pregnancies; however, little is known whether hemodynamic changes occur in uncomplicated MCDA twins. A prospective observational study was conducted including 100 uncomplicated MCDA twins matched by gestational age to 200 low-risk singletons. Echocardiography was performed at 26-30 weeks gestation and cord blood B-type natriuretic peptide (BNP) was measured at delivery. In both groups, z-scores for echocardiographic parameters were within normal ranges; however the monochorionic group had larger atrial areas (mean (standard deviation) right atria-to-heart ratio: 17.0 (2) vs. 15.9 (1); p = 0.018; left atria-to-heart ratio: 17.0 (3) vs. 15.8 (2); p < 0.001) and signs of concentric hypertrophy (right relative wall thickness: 0.66 (0.12) vs. 0.56 (0.11); p < 0.001; left relative wall thickness: 0.69 (0.14) vs. 0.58 (0.12); p < 0.001). Longitudinal function was increased in twins, leading to higher tricuspid annular plane systolic excursion (6.9 mm (0.9) vs. 5.9 mm (0.7); p < 0.001) and mitral annular plane systolic excursion (4.9 mm (0.8) vs. 4.4 mm (1.1); p < 0.001. BNP levels at birth were also higher in MCDA twins (median [interquartile range]: 20.81 pg/mL [16.69-34.01] vs. 13.14 pg/mL [9.17-19.84]; p < 0.001). Thus, uncomplicated MCDA fetuses have normal cardiac shape and function, but signs of cardiac adaptation were identified by echocardiographic and biochemical parameters, when compared with singletons.
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Simpson L, Maturen KE, Feldstein VA, Oliver ER, Poder L, Strachowski LM, Sussman BL, Weber TM, Winter T, Zelop CM, Glanc P. ACR Appropriateness Criteria® Nuchal Translucency Evaluation at 11 to 14 Weeks of Gestation. J Am Coll Radiol 2020; 17:S447-S458. [PMID: 33153556 DOI: 10.1016/j.jacr.2020.09.007] [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: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/20/2022]
Abstract
A fetus with an increased nuchal translucency at 11 to 14 weeks gestation is at risk for aneuploidy, genetic syndromes, structural anomalies, and intrauterine fetal demise in both single and twin gestations. In addition to referral to genetics for counseling and consideration of diagnostic genetic testing, a detailed anatomic survey and fetal echocardiogram are indicated in the second trimester to screen for congenital malformations and major heart defects. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Lynn Simpson
- Columbia University, New York, New York; American College of Obstetricians and Gynecologists.
| | | | | | - Edward R Oliver
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Liina Poder
- University of California San Francisco, San Francisco, California
| | | | - Betsy L Sussman
- The University of Vermont Medical Center, Burlington, Vermont
| | | | - Tom Winter
- University of Utah, Salt Lake City, Utah
| | - Carolyn M Zelop
- Valley Hospital, Ridgewood, New Jersey and NYU School of Medicine, New York, New York; American College of Obstetricians and Gynecologists
| | - Phyllis Glanc
- Specialty Chair, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Ge Y, Xia L, Wu Y, Cao H. Employ ductus venous blood flow in the early detection of trisomy 21, trisomy 18, and trisomy 13: A meta-analysis. Medicine (Baltimore) 2019; 98:e14773. [PMID: 30896619 PMCID: PMC6708835 DOI: 10.1097/md.0000000000014773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Ductus venosus (DV) Doppler has been suggested as a biomarker for the early screening of trisomy diseases. However, results from different studies have been largely inconsistent. This study aimed to investigate the relationship between DV and top 3 fetal aneuploidies by a systematical meta-analysis: trisomy 21 (T21), trisomy 18 (T18), and trisomy 13 (T13). METHODS We performed a literature search covering articles from Medline, PubMed, RePORTER, and Elsevier publications. DV-T21/T18/T13 relation data were extracted from 9, 7, and 6 previous studies, respectively, including 31,053, 28,092 and 26,721 pregnant women worldwide. Both random-effects and fixed-effect model were used to study the log odds ratio (LOR) of T21, T18, and T13 in case of DV. Four potential influential factors were studied using a multiple linear regression (MLR) model, including maternal age, data age, sample size, and population region. RESULTS DV was significantly related to T21, T18, and T13 (LOR = 3.44, 3.89 and 3.46; P value <2.1E-13). Significant between-study variance was observed for T21 (P value <1.71E-14), but not for T18 (P value >.05) and T13 (P value >.87). MLR results suggested that significant influential factors could include population region (P value <.0021), but not sample size, data age, and maternal age (P value >.078). CONCLUSIONS Integrating DV could help in the detection of trisomy. However, accuracy and validity may vary depending on the population regions, which need further study.
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Affiliation(s)
- Yibing Ge
- Special Inspection Section of Anhui Military Hospital of Armed Police Force, Hefei
| | - Lili Xia
- Department of Ultrasound, Tongling People's Hospital, Tongling, Anhui Province
| | - Yun Wu
- Department of Ultrasonography, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, Jiangsu Province
| | - Hongbao Cao
- Department of Psychiatry, First Hospital/First Clinical Medical College of Shanxi Medical University, Taiyuan, China
- Department of Genomics Research, R&D Solutions, Elsevier Inc., Rockville, MD
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Townsend R, Khalil A. Ultrasound surveillance in twin pregnancy: An update for practitioners. ULTRASOUND (LEEDS, ENGLAND) 2018; 26:193-205. [PMID: 30479634 PMCID: PMC6243450 DOI: 10.1177/1742271x18794013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 06/28/2018] [Indexed: 01/31/2023]
Abstract
Ultrasound has revolutionised the management of multiple pregnancies and their complications. Increasing frequency of twin pregnancies mandates familiarity of all clinicians with the relevant pathologies and evidence-based surveillance and management protocols for their care. In this review, we summarise the latest evidence relating to ultrasound surveillance of twin pregnancies including first trimester assessment and screening, growth surveillance and the detection and management of the complications of monochorionic pregnancies including twin-to-twin-transfusion syndrome, selective fetal growth restriction, twin reversed arterial perfusion sequence and conjoined twinning.
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Affiliation(s)
- R Townsend
- Fetal Medicine Unit, St. George's University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, St. George's University of London, London, UK
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Mackie FL, Hall MJ, Morris RK, Kilby MD. Early prognostic factors of outcomes in monochorionic twin pregnancy: systematic review and meta-analysis. Am J Obstet Gynecol 2018; 219:436-446. [PMID: 29763608 DOI: 10.1016/j.ajog.2018.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/11/2018] [Accepted: 05/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Monochorionic twin pregnancies are high-risk, however at present, no screening test is available to predict which monochorionic twin pregnancy will develop complications. OBJECTIVE We sought to assess ability of first-trimester pregnancy-related factors (ultrasound measurements, maternal characteristics, biomarkers) to predict complications in monochorionic twin pregnancies. DATA SOURCES Data sources were MEDLINE, Embase, ISI Web of Science, CINAHL, the Cochrane Central Registration of Controlled Trials and Research Registers, and Google Scholar, from inception to May 12, 2017. Gray literature and bibliographies of articles were checked. STUDY ELIGIBILITY CRITERIA Studies that reported ultrasound measurements, maternal characteristics, or potential biomarkers, measured in the first trimester in monochorionic-diamniotic twin pregnancies, where the potential prognostic ability between the variable and twin-twin transfusion syndrome, growth restriction, or intrauterine fetal death could be assessed, were included. STUDY APPRAISAL AND SYNTHESIS METHODS Quality assessment was evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology checklist by 2 reviewers independently. For meta-analysis, odds ratios using a random effects model, or standardized mean difference were calculated. If a moderate association was found, the prognostic ability was evaluated by calculating the sensitivity and specificity. Risk of heterogeneity was reported as I2 and publication bias was visually assessed by funnel plots and quantitatively by Egger test. RESULTS In all, 48 studies were eligible for inclusion. Twenty meta-analyses could be performed. A moderate association was demonstrated in 3 meta-analyses, between: nuchal translucency >95th centile in one/both fetuses and twin-twin transfusion syndrome (odds ratio, 2.29 [95% confidence interval, 1.05-4.96], I2 = 6.6%, 4 studies, 615 pregnancies); crown-rump length discordance ≥10% and twin-twin transfusion syndrome (odds ratio, 2.43 [95% confidence interval, 1.13-5.21], I2 = 14.1%, 3 studies, 708 pregnancies); and maternal ethnicity and twin-twin transfusion syndrome (odds ratio, 2.12 [95% confidence interval, 1.17-3.83], I2 = 0.0%, 5 studies, 467 pregnancies), but none demonstrated a prognostic ability for any outcome under investigation. CONCLUSION It is not currently possible to predict adverse outcomes in monochorionic twin pregnancies. We have revealed a lack of research investigating first-trimester biomarkers in monochorionic twin pregnancies. Different assessment methods and definitions of each variable and outcome were an issue and this highlights the need for a large cohort study to evaluate these factors.
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Affiliation(s)
- Fiona L Mackie
- Center for Women's and Children Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.
| | - Matthew J Hall
- Medical School, University of Birmingham, Birmingham, United Kingdom
| | - R Katie Morris
- Center for Women's and Children Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom; West Midlands Fetal Medicine Centre, Birmingham Women's and Children's National Health Service Foundation Trust, Edgbaston, United Kingdom
| | - Mark D Kilby
- Center for Women's and Children Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom; West Midlands Fetal Medicine Centre, Birmingham Women's and Children's National Health Service Foundation Trust, Edgbaston, United Kingdom
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Kawaguchi H, Ishii K, Muto H, Yamamoto R, Hayashi S, Mitsuda N. The incidence of unexpected critical complications in monochorionic diamniotic twin pregnancies according to the interval period between ultrasonographic evaluations. J Obstet Gynaecol Res 2018; 45:318-324. [PMID: 30306664 DOI: 10.1111/jog.13827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/03/2018] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to evaluate the incidence of unexpected critical complications (UCC) in monochorionic diamniotic (MCDA) twin pregnancies according to ultrasonographic scan interval. METHODS This retrospective single-center cohort study, conducted between January 2005 and April 2015, investigated the incidence of UCC in patients with MCDA twin pregnancies undergoing weekly ultrasound (Group A) and those undergoing biweekly ultrasound (Group B). We also examined the incidence of predictable critical complications according to ultrasound interval. RESULTS Of all 385 cases, the total incidence of UCC was 20 (5.2%), including 14 cases of twin-twin transfusion syndrome and 6 cases of intrauterine fetal death. The incidence of UCC was 3.9% in Group A and 9.0% in Group B (P = 0.046). In contrast, the incidence of predictable critical complications was 6.7% in Group A and 9.0% in Group B (P = 0.440). CONCLUSION The incidence of UCC in patients with MCDA twin pregnancies was significantly lower in patients undergoing weekly ultrasound. Our results suggest that weekly ultrasound evaluation for patients with MCDA pregnancy is more effective for early detection of UCC such as intrauterine fetal death and twin-twin transfusion syndrome ; however, further investigations are needed to determine whether weekly ultrasound evaluation can improve clinical outcomes.
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Affiliation(s)
- Haruna Kawaguchi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Haruka Muto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Shusaku Hayashi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Nobuaki Mitsuda
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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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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10
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Current Strategy of Fetal Therapy II: Invasive Fetal Interventions. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0132-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Wagner P, Sonek J, Klein J, Hoopmann M, Abele H, Kagan KO. First-trimester ultrasound screening for trisomy 21 based on maternal age, fetal nuchal translucency, and different methods of ductus venosus assessment. Prenat Diagn 2017; 37:680-685. [DOI: 10.1002/pd.5065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/30/2017] [Accepted: 05/07/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Philipp Wagner
- Department of Obstetrics and Gynaecology; University of Tuebingen; Tuebingen Germany
| | - Jiri Sonek
- Fetal Medicine Foundation USA; Dayton OH USA
- Division of Maternal Fetal Medicine; Wright State University; Dayton OH USA
| | - Jessika Klein
- Department of Obstetrics and Gynaecology; University of Tuebingen; Tuebingen Germany
| | - Markus Hoopmann
- Department of Obstetrics and Gynaecology; University of Tuebingen; Tuebingen Germany
| | - Harald Abele
- Department of Obstetrics and Gynaecology; University of Tuebingen; Tuebingen Germany
| | - Karl Oliver Kagan
- Department of Obstetrics and Gynaecology; University of Tuebingen; Tuebingen Germany
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Stagnati V, Zanardini C, Fichera A, Pagani G, Quintero RA, Bellocco R, Prefumo F. Early prediction of twin-to-twin transfusion syndrome: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:573-582. [PMID: 27270878 DOI: 10.1002/uog.15989] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 05/08/2016] [Accepted: 05/17/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To assess the role of first- and early second-trimester markers in the prediction of twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies. METHODS Electronic databases MEDLINE, EMBASE and ClinicalTrials.gov were searched from inception to April 2014, using the MeSH term 'fetofetal transfusion' in combination with phrases 'predictive value', 'sensitivity', 'specificity', 'false positive', 'false negative', 'screening', 'accuracy' and 'ROC'. Study quality was assessed using the PRISMA guidelines and QUADAS-2 tool. A meta-analysis was planned for the following predictive factors: intertwin nuchal translucency (NT) discrepancy; NT > 95th percentile in at least one twin; intertwin crown-rump length (CRL) discrepancy as a percentage of the larger CRL; abnormal ductus venosus (DV) flow in at least one twin. The outcome assessed was TTTS, defined according to the presence of a twin oligohydramnios-polyhydramnios sequence. The diagnostic performance of the predictive factors was evaluated for each included study. RESULTS The electronic search identified 152 records, of which 23 were assessed in full for eligibility. We identified 13 eligible studies that reported the predictive accuracy of ultrasound parameters, measured before 16 weeks, for the development of TTTS, including a total of 1991 pregnancies, of which 323 developed TTTS. An increased risk of TTTS was associated with: intertwin NT discrepancy (positive likelihood ratio (LR+), 1.92 (95% CI, 1.25-2.96); negative likelihood ratio (LR-), 0.65 (95% CI, 0.50-0.84)); NT > 95th percentile (LR+, 2.63 (95% CI, 1.51-4.58); LR-, 0.85 (95% CI, 0.75-0.96)); CRL discrepancy > 10% (LR+, 1.80 (95% CI, 1.05-3.07); LR-, 0.92 (95% CI, 0.81-1.05)); abnormal DV flow (LR+, 4.77 (95% CI, 1.33-17.04; LR-, 0.49 (95% CI, 0.17-1.41)). The highest sensitivities were observed for intertwin NT discrepancy (52.8% (95% CI, 43.8-61.7%)) and abnormal DV flow (50.0% (95% CI, 33.4-66.6%)). CONCLUSION Monochorionic twin pregnancies with intertwin NT discrepancy, NT > 95th percentile, intertwin CRL discrepancy > 10% or abnormal DV flow on first-trimester ultrasound examination are at significantly increased risk of developing TTTS. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- V Stagnati
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - C Zanardini
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - A Fichera
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - G Pagani
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - R A Quintero
- Jackson Fetal Therapy Institute, Jackson Memorial Hospital, Miami, FL, USA
| | - R Bellocco
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - F Prefumo
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
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Matias A, Montenegro N. Ductus venosus in twins: science matters. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:787. [PMID: 27256659 DOI: 10.1002/uog.15927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- A Matias
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Hospital of S. João, 4200 Porto Hospital of S. João, Porto, Portugal
| | - N Montenegro
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Hospital of S. João, 4200 Porto Hospital of S. João, Porto, Portugal
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Khalil A. Reply. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:787-788. [PMID: 27256658 DOI: 10.1002/uog.15928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK.
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Abstract
Twin-to-twin transfusion syndrome (TTTS) is the major complication of monochorionic (MC) pregnancy. The outcomes of this condition have been significantly improved after the introduction and widespread uptake of fetoscopic laser ablation over the last decade. However, there is still a significant fetal loss rate and morbidity associated with this condition. Improvements in the management of TTTS will require improvements in many areas. They are likely to involve refinements in the prediction of the disease and clarification of the optimum frequency of surveillance and monitoring. Improvements in training for fetoscopic surgery as well as in the technique of fetoscopic laser ablation may lead to better outcomes. New technologies as well as a better understanding of the pathophysiology of TTTS may lead to adjuvant medical therapies that may also improve short- and long-term results.
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16
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Wohlmuth C, Gardiner HM, Diehl W, Hecher K. Fetal cardiovascular hemodynamics in twin-twin transfusion syndrome. Acta Obstet Gynecol Scand 2016; 95:664-71. [PMID: 26872246 DOI: 10.1111/aogs.12871] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 01/08/2016] [Indexed: 01/31/2023]
Abstract
Twin-twin transfusion syndrome (TTTS) complicates 10-15% of monochorionic-diamniotic (MCDA) pregnancies. It originates from unbalanced transfer of fluid and vasoactive mediators from one twin to its co-twin via placental anastomoses. This results in hypovolemia in the donor and hypervolemia and vasoconstriction in the recipient twin. Consequently, the recipient demonstrates cardiovascular alterations including atrioventricular valve regurgitation, diastolic dysfunction, and pulmonary stenosis/atresia that do not necessarily correlate with Quintero-stages. Selective fetoscopic laser photocoagulation of placental vascular anastomoses disrupts the underlying pathophysiology and usually improves cardiovascular function in the recipient with normalization of systolic and diastolic function within weeks after treatment. Postnatal studies have demonstrated early decreased arterial distensibility in ex-donor twins, but 10-year follow up is encouraging with survivors showing normal cardiovascular function after TTTS. However, prediction and appropriate early management of TTTS remain poor. Assessment of the cardiovascular system provides additional insight into the pathophysiology and severity of TTTS and may permit more targeted early surveillance of MCDA pregnancies in future. It should form an integral part of the diagnostic algorithm.
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Affiliation(s)
- Christoph Wohlmuth
- The Fetal Center, UT Health School of Medicine, Houston, TX, USA.,Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria
| | | | - Werner Diehl
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
First-trimester pregnancy evaluation using fetal and maternal parameters not only allows for diagnoses to be made early in gestation but can also assess the risk of complications that become clinically evident later in pregnancy. This evaluation makes it possible for pregnancy care to be individualized. In select cases, treatment that reduces the risk of complications can be started early in pregnancy. Even though cell free DNA is a significant advance in diagnosing fetal aneuploidy, the combination of first-trimester ultrasound and maternal serum biochemistries casts a much wider diagnostic net; therefore, the 2 technologies are best used in combination.
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Affiliation(s)
- Jiri D Sonek
- Center for Maternal-Fetal Medicine, Ultrasound, and Genetics, Fetal Medicine Foundation of USA, Wright State University, Berry Pavilion, 1 Wyoming Street, Dayton, OH 45409, USA.
| | - Karl Oliver Kagan
- Department of Gynecology and Obstetrics, Universitäts-Frauenklinik, Calwerstrasse, Tübingen 772076, Germany
| | - Kypros H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, 16-20 Windsor Walk, London SE5 8BB, UK
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Khalil A, Rodgers M, Baschat A, Bhide A, Gratacos E, Hecher K, Kilby MD, Lewi L, Nicolaides KH, Oepkes D, Raine-Fenning N, Reed K, Salomon LJ, Sotiriadis A, Thilaganathan B, Ville Y. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:247-63. [PMID: 26577371 DOI: 10.1002/uog.15821] [Citation(s) in RCA: 334] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 05/27/2023]
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - M Rodgers
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Bhide
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - E Gratacos
- Fetal Medicine Units and Departments of Obstetrics, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germaniy
| | - M D Kilby
- Centre for Women’s and Children's Health, University of Birmingham and Fetal Medicine Centre, Birmingham Women’s Foundation Trust, Birmingham, UK
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, UK
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - N Raine-Fenning
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - K Reed
- Twin and Multiple Births Association (TAMBA)
| | - L J Salomon
- Hopital Necker-Enfants Malades, AP-HP, Universit´e Paris Descartes, Paris, France
| | - A Sotiriadis
- Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - B Thilaganathan
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - Y Ville
- Hospital Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
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Zanardini C, Prefumo F, Fichera A, Botteri E, Frusca T. Fetal cardiac parameters for prediction of twin-to-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:434-440. [PMID: 24919586 DOI: 10.1002/uog.13442] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 05/29/2014] [Accepted: 06/05/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To assess myocardial performance index measured by conventional Doppler (MPI) and by tissue Doppler imaging (MPI') at 18 weeks' gestation in monochorionic diamniotic twins for the prediction of twin-to-twin transfusion syndrome (TTTS). METHODS This was a single-center observational study of 100 uncomplicated monochorionic diamniotic twin pregnancies attending the twin pregnancy clinic at the University Hospital Spedali Civili of Brescia from 2009 to 2012. MPI and MPI' were obtained from the left (LV) and right (RV) ventricles of each twin at around 18 weeks of gestation (range, 17 + 1 to 19 + 4 weeks) and fortnightly thereafter. Cases which later developed TTTS formed the study group, and the remaining controls were subdivided into those continuing as uncomplicated pregnancies and those which later developed selective intrauterine growth restriction (sIUGR). Data were analyzed by receiver-operating characteristics curve analysis and univariate and multivariable logistic regression. RESULTS Of the 100 pregnancies, 88 were controls (84 uncomplicated and four developed sIUGR) and 12 developed TTTS. RV-MPI and LV-MPI, and LV-MPI' were significantly higher in future TTTS recipients than in controls, while RV-MPI' was significantly lower in donors. RV-MPI and LV-MPI and LV-MPI' were found to be predictive indicators in pregnancies that had not yet developed TTTS. Their negative predictive values were > 90%, and their specificities > 80%. The best performing index was LV-MPI', with a sensitivity of 91.7% and specificity of 88.6%. CONCLUSIONS Before diagnosis of TTTS, the cardiac function (as assessed by MPI and MPI') of the future donor twin is not grossly abnormal, but that of the recipient is abnormal. We identified cardiac indices predictive of the subsequent development of TTTS, and suggest a possible role of these indices in planning the follow-up of monochorionic diamniotic twin pregnancies.
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Affiliation(s)
- C Zanardini
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy; PhD Programme in Reproduction and Development, University of Trieste, Trieste, Italy
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Current principles and practice of ethics and law in perinatal medicine. CURRENT HEALTH SCIENCES JOURNAL 2014; 40:162-9. [PMID: 25729600 PMCID: PMC4340435 DOI: 10.12865/chsj.40.03.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 06/10/2014] [Indexed: 12/03/2022]
Abstract
One of the most controversial discussion topics in modern bioethics, science or philosophy is represented by the beginning of the individual human life. It is ethically, medically and scientifically correct that the human conception product to be born, so to gain personality and individuality, to be treated as a patient since the intrauterine life. Intrauterine foetal interventions, performed in various therapeutic purposes are still in the experimental stage even in centres with rich experience in perinatal medicine. Progresses truly outstanding are present especially in the prenatal diagnostic methods. Non invasive prenatal testing represents without a doubt a great progress in prenatal diagnosis, but from this point of view, the role of practitioners in the field of perinatal medicine, on counselling and addressing the indication of this test becomes essential. Beyond cultural, national, social or related differences, in perinatal medicine practice is particularly important to respect and permanently reassess the ethical codes. Our paper is targeting to spotlight the essential principles and practice of ethics and law in perinatal medicine nowadays on one hand, and to bring an update review on a controversial topic on the other hand.
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Monni G, Iuculano A, Zoppi MA. Screening and Invasive Testing in Twins. J Clin Med 2014; 3:865-82. [PMID: 26237482 PMCID: PMC4449657 DOI: 10.3390/jcm3030865] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/26/2014] [Accepted: 06/27/2014] [Indexed: 11/16/2022] Open
Abstract
Prenatal screening and testing for trisomy 21 in twin pregnancies poses a number of challenges: the exact estimate of the a priori risk of trisomy 21, the choice of prenatal screening test and/or invasive techniques to employ for the diagnosis and the impact of the result on the options of treatment in case of discordant results within a twin pair or among multiples. These different aspects are discussed below while recognizing that many issues remain unresolved.
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Affiliation(s)
- Giovanni Monni
- Department of Obstetrics and Gynecology, Prenatal and Preimplantation Genetic Diagnosis, Fetal Therapy, Ospedale Microcitemico, via Jenner, 09121 Cagliari, Italy.
| | - Ambra Iuculano
- Department of Obstetrics and Gynecology, Prenatal and Preimplantation Genetic Diagnosis, Fetal Therapy, Ospedale Microcitemico, via Jenner, 09121 Cagliari, Italy.
| | - Maria Angelica Zoppi
- Department of Obstetrics and Gynecology, Prenatal and Preimplantation Genetic Diagnosis, Fetal Therapy, Ospedale Microcitemico, via Jenner, 09121 Cagliari, Italy.
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Down syndrome screening in assisted conception twins: an iatrogenic medical challenge. Obstet Gynecol Surv 2014; 68:825-34. [PMID: 24193195 DOI: 10.1097/ogx.0000000000000001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to provide a critical analysis of the impact of assisted conception on prenatal screening for Down syndrome (DS) in twin pregnancies and the value of various screening modalities for early detection of anomalies. METHODS The literature was searched using PubMed and the Cochrane Library focusing on prenatal screening and antenatal care of assisted-conception twin pregnancies. RESULTS Serum screening alone is of limited value in detecting aneuploid twins, because the unaffected cotwin can "mask" the abnormal serum results of an affected one. In addition, this test can designate the pregnancy as at high risk but not identify the affected fetus. Nuchal translucency (NT) screening is the best available modality and a highly effective screening method for twin pregnancies. Among twins, NT alone has a 69% DS detection rate, first-trimester combined NT and serum biochemistry has a 72% DS detection rate, and an integrated screen will have an 80% DS detection rate at a 5% FPR. The data in the literature concerning the effect of assisted conception on maternal serum screening markers in twin pregnancies are scarce. CONCLUSIONS Down syndrome screening in assisted-conception twins presents clinical and technical challenges. Therefore, assisted-conception twins need close monitoring from conception to delivery, by a practitioner familiar with the available screening modalities and their relative accuracy.
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Prenatal Screening Using Maternal Markers. J Clin Med 2014; 3:504-20. [PMID: 26237388 PMCID: PMC4449694 DOI: 10.3390/jcm3020504] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 03/28/2014] [Accepted: 03/28/2014] [Indexed: 11/17/2022] Open
Abstract
Maternal markers are widely used to screen for fetal neural tube defects (NTDs), chromosomal abnormalities and cardiac defects. Some are beginning to broaden prenatal screening to include pregnancy complications such as pre-eclampsia. The methods initially developed for NTDs using a single marker have since been built upon to develop high performance multi-maker tests for chromosomal abnormalities. Although cell-free DNA testing is still too expensive to be considered for routine application in public health settings, it can be cost-effective when used in combination with existing multi-maker marker tests. The established screening methods can be readily applied in the first trimester to identify pregnancies at high risk of pre-eclampsia and offer prevention though aspirin treatment. Prenatal screening for fragile X syndrome might be adopted more widely if the test was to be framed as a form of maternal marker screening.
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Optimal antenatal care for twin and triplet pregnancy: The evidence base. Best Pract Res Clin Obstet Gynaecol 2014; 28:305-17. [DOI: 10.1016/j.bpobgyn.2013.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 11/06/2013] [Accepted: 12/10/2013] [Indexed: 11/21/2022]
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Early pregnancy assessment in multiple pregnancies. Best Pract Res Clin Obstet Gynaecol 2014; 28:201-14. [DOI: 10.1016/j.bpobgyn.2013.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 11/19/2013] [Indexed: 02/04/2023]
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Prats P, Rodríguez I, Comas C, Puerto B. Analysis of three different strategies in prenatal screening for Down's syndrome in twin pregnancies. J Matern Fetal Neonatal Med 2013; 26:1404-9. [PMID: 23488563 DOI: 10.3109/14767058.2013.784252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To compare the performance of three different strategies in prenatal screening for Down's syndrome in twins [nuchal translucency, the combined test, the combined test + ductus venosus pulsatility index (DVPI)]. METHODS We included 277 twin pregnancies with two cases of trisomy 21 (both dichorionic). We performed a computer simulation of Down's syndrome NT screening, combined test screening and the combined test with the addition of DVPI screening using the commercialized software SsdwLab6. The strategies were compared using the area under the receiver operating characteristic curve. RESULTS NT screening false-positive rate (FPR) was 10.9% (95% CI: 8.3-13.5). The combined test FPR was 6.2% (95% CI: 4.1-8.2%) and the combined test plus DVPI was 6% (95% CI: 4-8). FPR was higher in advanced maternal age patients. Detection rate was 100% in all cases. The area under the curve was 0.987 (95% CI: 0.972-0.994) in NT screening; 0.987 (95% CI: 0.978-0.997) in the combined test and 0.983 (95% CI: 0.977-0.996) in the combined test + DVPI. CONCLUSIONS Down's syndrome screening is feasible in twins with low FPR. The results of this study are similar to the results achieved in singletons. The combined test appears to be the most effective. The addition of DVIP does not significantly improve the prenatal screening for trisomy 21.
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Affiliation(s)
- Pilar Prats
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain.
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Cuckle H, Maymon R. Role of second-trimester ultrasound in screening for Down syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 41:241-244. [PMID: 23460191 DOI: 10.1002/uog.12397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- H Cuckle
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA.
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Abstract
OBJECTIVE We sought to review the natural history, pathophysiology, diagnosis, and treatment options for twin-twin transfusion syndrome (TTTS). METHODS A systematic review was performed using MEDLINE database, PubMed, EMBASE, and Cochrane Library. The search was restricted to English-language articles published from 1966 through July 2012. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Evidence reports and guidelines published by organizations or institutions such as the National Institutes of Health, Agency for Health Research and Quality, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence, and recommendations were graded accordingly. RESULTS AND RECOMMENDATIONS TTTS is a serious condition that can complicate 8-10% of twin pregnancies with monochorionic diamniotic (MCDA) placentation. The diagnosis of TTTS requires 2 criteria: (1) the presence of a MCDA pregnancy; and (2) the presence of oligohydramnios (defined as a maximal vertical pocket of <2 cm) in one sac, and of polyhydramnios (a maximal vertical pocket of >8 cm) in the other sac. The Quintero staging system appears to be a useful tool for describing the severity of TTTS in a standardized fashion. Serial sonographic evaluation should be considered for all twins with MCDA placentation, usually beginning at around 16 weeks and continuing about every 2 weeks until delivery. Screening for congenital heart disease is warranted in all monochorionic twins, in particular those complicated by TTTS. Extensive counseling should be provided to patients with pregnancies complicated by TTTS including natural history of the disease, as well as management options and their risks and benefits. The natural history of stage I TTTS is that more than three-fourths of cases remain stable or regress without invasive intervention, with perinatal survival of about 86%. Therefore, many patients with stage I TTTS may often be managed expectantly. The natural history of advanced (eg, stage ≥III) TTTS is bleak, with a reported perinatal loss rate of 70-100%, particularly when it presents <26 weeks. Fetoscopic laser photocoagulation of placental anastomoses is considered by most experts to be the best available approach for stages II, III, and IV TTTS in continuing pregnancies at <26 weeks, but the metaanalysis data show no significant survival benefit, and the long-term neurologic outcomes in the Eurofetus trial were not different than in nonlaser-treated controls. Even laser-treated TTTS is associated with a perinatal mortality rate of 30-50%, and a 5-20% chance of long-term neurologic handicap. Steroids for fetal maturation should be considered at 24 0/7 to 33 6/7 weeks, particularly in pregnancies complicated by stage ≥III TTTS, and those undergoing invasive interventions.
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Abstract
Twin-twin transfusion syndrome (TTTS) is a serious condition that affects 10% to 15% of twin pregnancies with monochorionic diamniotic placentation. The pathophysiology of TTTS is not completely understood; however, the presence of unbalanced placental vascular communications within a shared circulation has been implicated in its development. The presentation of TTTS is highly variable, and it does not always progress in a predictable manner. Monochorionic twin gestations should, therefore, be monitored for signs of TTTS with serial sonograms starting in the second trimester. Early TTTS can be managed conservatively. However, without intervention, early-onset advanced TTTS is associated with a high perinatal loss rate and risk of severe neurologic impairment among survivors. Limited studies suggest that fetoscopic laser photocoagulation is the best available treatment for advanced TTTS diagnosed in the second trimester. Even with laser therapy, there remains a significant risk of twin demise and neurologic handicap in survivors.
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Affiliation(s)
- Claudia Mosquera
- Carmen and John Thain Center for Prenatal Pediatrics, Columbia University Medical Center, New York, NY 10032, USA.
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Demirturk F, Caliskan AC, Aytan H, Sahin S. A preliminary retrospective study about the relationship between ductus venosus Doppler indices, nuchal translucency (NT) and biochemical markers in the first and second trimester screening tests. Gynecol Endocrinol 2012; 28:378-81. [PMID: 22364171 DOI: 10.3109/09513590.2011.631633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In our study, we tried to assess the relation between ductus venosus Doppler indices [pulsatility index (PI), resistance index (RI) and S/D] and first-trimester screening markers (MoM of serum pregnancy-associated plasma protein A, pappalysin 1 (PAPP-A), MoM of serum free β-human chorionic gonadotrophin (β-hCG), and nuchal translucency (NT) and second trimester screening markers (MoM of serum α-fetoprotein, MoM of serum total β-hCG and MoM of serum estriol). We analyzed the data of 121 singleton pregnancies. Roche cobas e 601ECLIA (electrochemiluminescence immunoassay) was used to measure MoM of serum PAPP-A and Roche cobas e 602 ECLIA (electrochemiluminescence immunoassay) was used to measure MoM of serum free β-hCG in the first trimester. Beckman Coulter Access 2 Immunoassay was used to measure MoM of serum α-fetoprotein, MoM of serum total β-hCG and MoM of serum estriol in the second trimester. The first author performed all ultrasound screenings and ductus venosus Doppler studies. What we found new in our study is presented as following; MoM of serum α-fetoprotein had a negative correlation with RI of ductus venosus Doppler, MoM of serum estriol had a negative correlation with RI of ductus venosus Doppler and MoM of serum estriol had a negative correlation with S/D of ductus venosus doppler. The results of our study suggest that ductus venosus Doppler can be used to increase the effectiveness of the second trimester screening test.
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Affiliation(s)
- Fazli Demirturk
- Department of Obstetrics and Gynecology, Gaziosmanpasa University, Tokat, Turkey.
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Cuckle H, Moskovitch M, Vaknin Z, Levental S, Rosen H, Maymon R. Nuchal translucency screening in triplets: Down syndrome risk calculation taking account of between-fetus correlations. Prenat Diagn 2012; 32:214-9. [DOI: 10.1002/pd.2929] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Howard Cuckle
- Department of Obstetrics and Gynecology; Columbia University Medical Center; New York NY USA
| | - Miki Moskovitch
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Israel
| | - Zvi Vaknin
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Israel
| | - Sharon Levental
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Israel
| | - Hadar Rosen
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Israel
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Gratacós E, Ortiz J, Martinez J. A Systematic Approach to the Differential Diagnosis and Management of the Complications of Monochorionic Twin Pregnancies. Fetal Diagn Ther 2012; 32:145-55. [DOI: 10.1159/000342751] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 08/04/2012] [Indexed: 11/19/2022]
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Matias A, Maiz N, Montenegro N, Nicolaides K. Ductus venosus flow at 11-13 weeks in the prediction of birth weight discordance in monochorionic twins. J Perinat Med 2011; 39:467-70. [PMID: 21663458 DOI: 10.1515/jpm.2011.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine if assessment of ductus venosus (DV) flow, crown-rump length (CRL) and nuchal translucency (NT) thickness can predict the discordance in birth weight in monochorionic (MC) twin pregnancies resulting in two live births. METHODS In this prospective study, we assessed CRL, NT and DV flow at 11(+0)-13(+6) weeks' gestation in 326 MC twin pregnancies. The study population included 237 pregnancies without major abnormalities or prenatal interventions resulting in two live births. We examined the value of DV flow and discordance in NT and CRL in the prediction of discordance in birth weight. RESULTS In the 237 MC twin pregnancies the median discordance in birth weight was 8.0% (range 0-42.2%). There was no significant association between discordance in either CRL or NT and discordance in birth weight (P=0.116 and P=0.332). In pregnancies with abnormal DV flow in at least one of the fetuses the median discordance in birth weight was higher than in those with normal DV flow in both twins (13.2% vs. 7.8%, P=0.006). CONCLUSIONS In uncomplicated MC twin pregnancies, abnormal DV flow in at least one of the fetuses is associated with a higher discordance in birth weight than in those with normal flow in both fetuses.
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Affiliation(s)
- Alexandra Matias
- Department of Obstetrics and Gynecology, Faculty of Medicine, Hospital of S. João, Porto, Portugal.
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Abstract
ABSTRACT
Ductus venosus is a tiny vessel with a central role in fetal circulation. Combining B-mode with color and pulsed Doppler is feasible to identify this vessel and evaluate the blood flow waveform at 11 to 13 weeks. The higher prevalence of abnormal A-wave in fetuses with abnormal karyotype and/or cardiac defects turned DV evaluation into a useful marker for chromosomal abnormalities and cardiopathies. Even when combined with nuchal translucency (NT) or biochemical markers, DV blood flow evaluation contributes to an increase in sensitivity and reduces false-positive rate. Abnormal ductal flow is also related to a worse fetal and perinatal outcome. In monochorionic twin pregnancies, in addition to NT measurement at 11 to 14 weeks, the Doppler assessment of DV blood flow increases relevantly the performance of screening for those at higher risk of developing twin-to-twin transfusion syndrome. This story of 14 years surely contributed to change the way first trimester screening is being implemented.
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Abstract
The first trimester (11-13 +6 weeks) ultrasound examination is useful for several reasons: determination of an accurate date of confinement, diagnostic purposes, and screening for fetal defects. Nuchal translucency measurement combined with maternal serum markers (free b-human chorionic gonadotropin and pregnancy-associated plasma protein A) is the mainstay of first-trimester screening for chromosomal defects. However, over the past decade additional ultrasound markers have been developed that improve the performance of this type of screening. The novel markers include evaluation of the nasal bone, fronto-maxillary angle measurement, and Doppler evaluations of the blood flow across the tricuspid valve and in the ductus venosus.
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Affiliation(s)
- J Sonek
- Wright State University, Dayton, OH, USA.
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Tchirikov M. Monochorionic twin pregnancy: screening, pathogenesis of complications and management in the era of microinvasive fetal surgery. J Perinat Med 2010; 38:451-9. [PMID: 20629496 DOI: 10.1515/jpm.2010.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The management of monochorionic (MC) twin pregnancies varies in different medical centers. This paper compares screening methods to predict the complications of the MC twin pregnancy and different treatment methods. METHODS We performed a literature search without language restriction in Cochrane library and PubMed (1970-2009). Case series and cohort screening studies, pathogenesis and management of complications of MC pregnancy were included. RESULTS Elevated risk for intrauterine fetal death (IUFD) and twin-to-twin transfusion syndrome (TTTS) can be detected sonographically. Monitoring of MC pregnancies at increased risk and regular training sessions for the operating team combined with reduced fetoscopic amniotic membrane damage increase fetal survival rate from laser coagulation to nearly 100% for at least one fetus and to 90% for both. CONCLUSION Monitoring of MC pregnancies at increased risk and laser treatment of TTTS in medical centers with sufficient experience might improve neonatal outcome.
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Affiliation(s)
- Michael Tchirikov
- Department of Obstetrics and Fetal Medicine, Clinic of Obstetrics and Gynecology, University Medical Center of Johannes Gutenberg University Mainz, Mainz, Germany.
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Abstract
Twin-to-twin transfusion syndrome is a severe complication occurring in 10% of monochorionic twin pregnancies. The disease is usually explained as due to an intrauterine imbalance in intertwin blood exchange, which leads to a volume depleted-donor twin and an overfilled recipient twin. The recipient has signs of cardiac dysfunction, which can be measured using echocardiography or blood and amniotic fluid derived biomarkers. Whereas cardiac dysfunction typically progresses in pregnancies treated with amniodrainage, it usually disappears within a few weeks after fetoscopic laser coagulation of the connecting intertwin anastomoses. Nevertheless, recipients remain at a increased risk of pulmonary stenosis. In this paper, we summarize the cardiac alterations in twin-to-twin transfusion syndrome, describe the changes seen after fetal therapy, list the newly proposed staging systems based on fetal cardiac function, and make recommendations about the use of fetal echocardiography in the evaluation and followup of pregnancies complicated by twin-to-twin transfusion syndrome.
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Abstract
Abstract
For many years, the main use of ultrasound in the first trimester of pregnancy was to confirm viability and to establish gestational age. Indeed, the crown-rump length measurement in the first trimester remains the most accurate method to estimate the gestational age even today. However, improvements in ultrasound equipment and improvement in our understanding of normal and abnormal fetal development allows us now to perform a much more complete first trimester fetal evaluation. This pertains not only to the diagnosis of fetal anomalies but also to screening for fetal defects. The combination of the nuchal translucency measurement and maternal serum biochemistries (free β-hCG and PAPP-A) has been shown to be an extremely efficient way to screen for fetal aneuploidy. The addition of other first trimester markers such as the nasal bone evaluation, frontomaxillary facial angle measurement, and Doppler evaluation of blood flow across the tricuspid valve and through the ductus venosus improves the screening performance even further by increasing the detection rates and decreasing the false positive rates. Several of the first trimester markers also are useful in screening for cardiac defects. Furthermore, significant nuchal translucency thickening has been associated with a variety of genetic and nongenetic syndromes. A recently described first trimester marker called the intracerebral translucency appears to hold great promise in screening for open spine defects. Finally, it appears that a first trimester evaluation (uterine artery Doppler and the measurement of certain biochemical markers in the maternal serum) significantly improves the assessment of the risk of preeclampsia.
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Zoppi MA. Nuchal translucency screening in monochorionic twin pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:491-493. [PMID: 19852038 DOI: 10.1002/uog.7465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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