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Xia Y, Huang L, Long Z, Chen Y, Gao L, Hua R, Li S, Wang Y. The association of preconceptional folic acid supplementation with gestational age and preterm birth risk in twin pregnancies: a prospective cohort study in China. Eur J Nutr 2024; 63:107-119. [PMID: 37733259 DOI: 10.1007/s00394-023-03223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 07/24/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE This study aims to explore the association of maternal preconceptional folic acid (FA) supplementation with gestational age and preterm birth in twin pregnancies, and whether the association varies by chorionicity or conception mode. METHODS From November 2018 to December 2021, the information of FA supplementation and pregnancy outcomes were collected in twin pregnant women. The linear regression models and the logistic regression were used to test the association of preconceptional FA supplementation with gestational age at delivery and preterm birth and premature rupture of membranes (PROM). RESULTS A total of 416 twin pregnancies were included. Compared with no use in twins, maternal preconceptional FA use was associated with a 0.385-week longer gestational age (95% CI 0.019-0.751) and lower risk of preterm birth < 36 weeks (adjusted OR 0.519; 95% CI 0.301-0.895) and PROM (adjusted OR 0.426; 95% CI 0.215-0.845). The protective effect on preterm birth < 36 weeks and PROM is similar whether taking FA supplements alone or multivitamins. However, the associations varied by chorionicity and conception mode of twins or compliance with supplementation. The positive associations between preconceptional FA use and gestational age only remained significant among twins via assisted reproductive technology or dichorionic diamniotic twins. Significant protective effects on preterm birth < 36 weeks and PROM were only found among women who took FA at least 4 times a week before conception. CONCLUSION Maternal preconceptional FA supplementation was associated with longer gestation duration and lower risk of preterm birth < 36 weeks and PROM in twin pregnancies. To improve the success of their pregnancies, reproductive women should start taking FA supplements well before conception and with good compliance.
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Affiliation(s)
- Yuanqing Xia
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Department, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, 910 Hengshan Road, Xuhui District, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
- Shanghai Municipal Key Clinical Specialty, Shanghai, 200030, China
| | - Lili Huang
- School of Public Health, Shanghai Jiao Tong University, 227 South Chongqing Road, Huangpu District, Shanghai, 200025, China
| | - Zichong Long
- School of Public Health, Shanghai Jiao Tong University, 227 South Chongqing Road, Huangpu District, Shanghai, 200025, China
| | - Yiting Chen
- School of Public Health, Shanghai Jiao Tong University, 227 South Chongqing Road, Huangpu District, Shanghai, 200025, China
| | - Li Gao
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Department, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, 910 Hengshan Road, Xuhui District, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
- Shanghai Municipal Key Clinical Specialty, Shanghai, 200030, China
| | - Renyi Hua
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Department, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, 910 Hengshan Road, Xuhui District, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
- Shanghai Municipal Key Clinical Specialty, Shanghai, 200030, China
| | - Shenghui Li
- School of Public Health, Shanghai Jiao Tong University, 227 South Chongqing Road, Huangpu District, Shanghai, 200025, China.
| | - Yanlin Wang
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Department, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, 910 Hengshan Road, Xuhui District, Shanghai, 200030, China.
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China.
- Shanghai Municipal Key Clinical Specialty, Shanghai, 200030, China.
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Oliver E, Navaratnam K, Gent J, Khalil A, Sharp A. Comparison of International Guidelines on the Management of Twin Pregnancy. Eur J Obstet Gynecol Reprod Biol 2023; 285:97-104. [PMID: 37087836 DOI: 10.1016/j.ejogrb.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/28/2023] [Accepted: 04/04/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVES To review current international clinical guidelines on the antenatal and intrapartum management of twin pregnancies, examining areas of consensus and conflict. METHODS We conducted a database search using Medline, Pubmed, Scopus, Academic Search Complete, CINAHL and ERCI Guidelines website. Guidelines were screened for eligibility using our inclusion and exclusion criteria. Those deemed eligible were quality assessed using the AGREE II tool and relevant data was extracted. RESULTS We identified 21 relevant guidelines from 16 countries including two international society guidelines. There was consensus in determination of chorionicity and amnionicity within the first trimester, fetal anomaly scan between 18 and 22 weeks and the recommended screening for twin-to-twin transfusion syndrome (TTTS). For those that provided intrapartum guidance, there was agreement in recommending caesarean section to deliver monochorionic monoamniotic (MCMA) twins, epidural anaesthesia for intrapartum analgesia and the use of cardiotocography (CTG) for intrapartum fetal monitoring. The main areas of conflict included cervical length screening, frequency of ultrasound surveillance, timing of delivery of dichorionic twin pregnancies and circumstances for recommending vaginal delivery. There was a lack of advice on intrapartum management. CONCLUSIONS This review has highlighted the need for unified international guidance on the management of twin pregnancy. Comparisons of current guidance demonstrates a lack of confidence in the management of labour in twin pregnancies. Further evidence on intrapartum care of twin pregnancies is needed to inform practice guidelines and improve both short and long term maternal and fetal outcomes.
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Kozinszky Z, Surányi A. The High-Risk Profile of Selective Growth Restriction in Monochorionic Twin Pregnancies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040648. [PMID: 37109605 PMCID: PMC10141888 DOI: 10.3390/medicina59040648] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/13/2023] [Indexed: 04/29/2023]
Abstract
The present review aims to provide a critical appraisal of the sonographic diagnosis and follow-up and to evaluate the optimal clinical management of monochorionic twin pregnancies where one of the twins is complicated by selective fetal growth restriction (sFGR). The classification is based on the umbilical artery (UA) diastolic flow reflecting the outcome. If the sFGR twin has positive diastolic flow (Type I) then the prognosis is good, and it does not require close surveillance. Biweekly or weekly sonographic and Doppler surveillance and fetal monitoring are recommended strategies to detect unpredictable complications in type II and type III forms, which are defined by persistently absent/reverse end-diastolic flow (AREDF) or cyclically intermittent absent/reverse end-diastolic flow (iAREDF) in the umbilical waveforms, respectively. The latest forms are associated with an increased risk of unexpected fetal demise of the smaller twin and 10-20% risk of neurological injury in the larger twin in addition to the overall risk of prematurity. The clinical course can be affected by elective fetal therapy ('dichorinization' of the placenta with laser or selective fetal reduction) or elective delivery in the presence of severe fetal deterioration. The prediction of the clinical outcome in complicated cases of type II and III sFGR cases remains elusive. Novel routines in fetal and placental scans in order to predict neurological impairments and unexpected fetal death to optimize the delivery time-point are needed.
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Affiliation(s)
- Zoltan Kozinszky
- Department of Obstetrics and Gynaecology, Danderyds Hospital, 182 88 Stockholm, Sweden
| | - Andrea Surányi
- Department of Obstetrics and Gynaecology, Albert Szent-Györgyi Medical School, University of Szeged, 6725 Szeged, Hungary
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Xodo S, Orsaria M, Londero AP. What is the success rate of trial of labor in monochorionic diamniotic twins? A systematic review and meta-analysis of observational studies. Am J Obstet Gynecol MFM 2023; 5:100767. [PMID: 36220551 DOI: 10.1016/j.ajogmf.2022.100767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This meta-analysis aimed to evaluate the success rate of trial of labor in monochorionic diamniotic pregnancies and the impact of delivery mode on neonatal outcomes. DATA SOURCES Searches were performed in MEDLINE/PubMed, Embase, Scopus, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the International Clinical Trials Registry Platform from the inception of each database until April 2022. STUDY ELIGIBILITY CRITERIA Selection criteria included observational studies analyzing the delivery mode among monochorionic diamniotic gestations. METHODS All analyses were carried out using an intention-to-treat approach, evaluating women according to the delivery mode to which they were assigned in the original studies. RESULTS Seventeen studies met the eligibility criteria and were suitable for qualitative and quantitative analysis. In total, 4116 women were analyzed. This meta-analysis showed that trial of labor in monochorionic diamniotic pregnancies resulted in vaginal delivery of both twins in 75.5% of cases (95% confidence interval, 69.1-80.9). Failure to deliver the second twin vaginally occurred in 3.8% of cases (95% confidence interval, 2.5-5.7). In addition, the neonatal outcomes were comparable among women with monochorionic diamniotic pregnancy undergoing different planned delivery modes. Neonatal death occurred in 3.7 per 1000 cases in the planned cesarean delivery group and in 1.6 per 1000 cases in the planned vaginal delivery group. Perinatal death was observed in 7.5 per 1000 cases in the planned cesarean delivery group and in 5.8 per 1000 cases in the planned vaginal delivery group. Umbilical artery pH <7.00 occurred in 0 per 1000 cases in the planned cesarean delivery and 4.6 per 1000 cases in the planned vaginal delivery group. Neonatal intensive care unit stay of >72 hours had a prevalence of 59.7 per 1000 cases in the planned cesarean delivery and 42.8 per 1000 cases in the planned vaginal delivery group. CONCLUSION This meta-analysis showed that trial of labor in monochorionic diamniotic pregnancies is successful in most cases and relatively safe, considering that neonatal and perinatal mortality and severe morbidity were comparable between the trial of labor and planned cesarean delivery groups. Therefore, the choice of planned delivery mode in twin gestations should not be made a priori.
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Affiliation(s)
- Serena Xodo
- Department of Gynecology and Obstetrics, School of Medicine of Udine, Udine, Italy (Dr Xodo).
| | - Maria Orsaria
- Institute of Pathology, School of Medicine of Udine, Udine, Italy (Dr Orsaria)
| | - Ambrogio P Londero
- Academic Unit of Obstetrics and Gynaecology; Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, Genoa, Italy (Dr Londero)
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Routine Doppler Ultrasound in Twin Pregnancy. Best Pract Res Clin Obstet Gynaecol 2022; 84:43-54. [DOI: 10.1016/j.bpobgyn.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/14/2022] [Indexed: 11/15/2022]
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Hayata E, Nakata M, Morita M. Time trend analysis of perinatal mortality, stillbirth, and early neonatal mortality of multiple pregnancies for each gestational week from the year 2000 to 2019: A population-based study in Japan. PLoS One 2022; 17:e0272075. [PMID: 35877663 PMCID: PMC9312402 DOI: 10.1371/journal.pone.0272075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 07/12/2022] [Indexed: 11/18/2022] Open
Abstract
Multiple pregnancies pose a high risk of morbidity and mortality in both mothers and infants; thus, obtaining reliable information based on a large population is essential to improve management. We used the maternal and child health statistics, which are published annually, from the database of the Ministry of Health, Labor, and Welfare. The data obtained were aggregated in 5-year intervals, and we used them to analyze the proportion of the number of births for each week of pregnancy to the total of each singleton and multiple pregnancy. For perinatal health indicators (perinatal mortality, stillbirth, and neonatal mortality), the obtained data were calculated and plotted on graphs for each week of pregnancy. Moreover, these indicators were calculated by dividing them into first twin and second twin fetuses. Stillbirth weights were aggregated in several groups, and a histogram was displayed. Between 2000 and 2019, there were 21,068,275 live births, 67,666 stillbirths, and 16,443 early neonatal deaths, excluding 7,148 (7,104 singletons, 44 multiple births) cases, in which the exact gestational weeks at birth were unknown. More than 95% of multiple pregnancies were twin births. Perinatal mortality, stillbirth, and early neonatal mortality rates in multiple pregnancies were the lowest at approximately 37 weeks of gestation and lower than those of single pregnancies at approximately 36 weeks of gestation. Perinatal mortality and stillbirth rates were higher during the delivery of the second twins than the first-born twins, but the early neonatal mortality rate remained approximately the same during the delivery of both twins. As the data in the government database are accumulated and published continuously, indicators can be calculated in the future using the method presented in this study. Further, our findings may be useful for policymaking related to managing multiple pregnancies.
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Affiliation(s)
- Eijiro Hayata
- Department of Obstetrics and Gynecology, Toho University School of Medicine, Tokyo, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University School of Medicine, Tokyo, Japan
- * E-mail:
| | - Mineto Morita
- Department of Obstetrics and Gynecology, Toho University School of Medicine, Tokyo, Japan
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Aviram A, Barrett JFR, Melamed N, Mei-Dan E. Mode of delivery in multiple pregnancies. Am J Obstet Gynecol MFM 2021; 4:100470. [PMID: 34454159 DOI: 10.1016/j.ajogmf.2021.100470] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/25/2021] [Accepted: 08/18/2021] [Indexed: 11/25/2022]
Abstract
The mode of delivery in multiple pregnancies has been subject to vigorous debates during the last few decades. Although observational and retrospective data were accumulated, it was not until the publication of the Twin Birth Study that evidence-based recommendations could emerge. However, although some of the most pressing questions were answered by the Twin Birth Study, other questions were left outside the scope of the study. The questions were of great interest and included the following topics: the impact of gestational age, the influence of chorionicity, and the generalizability of the results for women with a previous uterine scar. The current evidence supported a trial of labor in dichorionic-diamniotic or monochorionic-diamniotic twin pregnancies in which the first twin is in cephalic presentation at ≥32 weeks' gestation. Dichorionic-diamniotic, monochorionic-diamniotic, and monochorionic-monoamniotic twins should be delivered at 37 0/7 to 38 0/7, 36 0/7 to 37 0/7, and 32 0/7 to 34 0/7 weeks' gestation, respectively. Breech extraction done by a competent healthcare provider seemed to offer a higher chance of successful vaginal delivery of the second twin than the external cephalic version. The current data did not allow for a clear recommendation regarding the mode of delivery in very preterm birth of low birthweight twins, but most studies did not demonstrate a clear benefit of cesarean delivery vs trial of labor. Furthermore, a trial of labor seemed safe in women with a previous cesarean delivery. Cesarean delivery is likely beneficial for twin pregnancies with the first twin in breech presentation, monochorionic-monoamniotic twins, and higher-order multiple pregnancies. In all multiple pregnancies, delivery should be performed by an experienced practitioner competent in multiple pregnancy deliveries.
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Affiliation(s)
- Amir Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan).
| | - Jon F R Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
| | - Elad Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
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Kehl S, Hösli I, Pecks U, Reif P, Schild RL, Schmidt M, Schmitz D, Schwarz C, Surbek D, Abou-Dakn M. Induction of Labour. Guideline of the DGGG, OEGGG and SGGG (S2k, AWMF Registry No. 015-088, December 2020). Geburtshilfe Frauenheilkd 2021; 81:870-895. [PMID: 34393254 DOI: 10.1055/a-1519-7713] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 01/17/2023] Open
Abstract
Aim The aim of this official guideline published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG) in cooperation with the Austrian Society of Gynaecology and Obstetrics (OEGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG) is to provide a consensus-based overview of the indications, methods and general management of induction of labour by evaluating the relevant literature. Methods This S2k guideline was developed using a structured consensus process which included representative members from various professions; the guideline was commissioned by the guidelines commission of the DGGG, OEGGG and SGGG. Recommendations The guideline provides recommendations on the indications, management, methods, monitoring and special situations occurring in the context of inducing labour.
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Affiliation(s)
- Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Irene Hösli
- Frauenklinik, Universitätsspital Basel, Basel, Switzerland
| | - Ulrich Pecks
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Philipp Reif
- Frauenheilkunde und Geburtshilfe, Universitätsklinikum Graz, Graz, Austria
| | - Ralf L Schild
- Klinik für Geburtshilfe und Perinatalmedizin, Diakovere Krankenhaus gGmbH, Hannover, Germany
| | - Markus Schmidt
- Frauenheilkunde und Geburtshilfe, Sana Kliniken Duisburg, Duisburg, Germany
| | - Dagmar Schmitz
- Institut für Geschichte, Theorie und Ethik der Medizin, Uniklinik RWTH Aachen, Aachen, Germany
| | - Christiane Schwarz
- Fachbereich Hebammenwissenschaft, Institut für Gesundheitswissenschaften, Universität zu Lübeck, Lübeck, Germany
| | - Daniel Surbek
- Frauenklinik, Inselspital, Universitätsspital Bern, Bern, Switzerland
| | - Michael Abou-Dakn
- Klinik für Gynäkologie, St. Joseph Krankenhaus, Berlin Tempelhof, Berlin, Germany
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Yu FNY, Mak ASL, Chan NM, Siu KL, Ma TWL, Leung KY. Prospective risk of stillbirth and neonatal complications for monochorionic diamniotic and dichorionic diamniotic twins after 24 weeks of gestation. J Obstet Gynaecol Res 2021; 47:3127-3135. [PMID: 34137119 DOI: 10.1111/jog.14866] [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: 01/05/2021] [Revised: 05/07/2021] [Accepted: 05/16/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Our study compared the prospective risks of intrauterine fetal death (IUFD), neonatal death (NND), perinatal death (PND), and neonatal morbidities in monochorionic diamniotic (MCDA) and dichorionic diamniotic (DCDA) twin pregnancies. METHODS This retrospective cohort study included twin pregnancies who had antenatal care and delivery in a public hospital from 2011 to 2018. Exclusion criteria included monoamnionicity, one/both twin miscarriage, twin-twin transfusion syndrome, or lethal congenital abnormalities. All twins were managed in multiple pregnancy clinic with standardized protocols. Gestational age-specific IUFD, NND, PND, and neonatal morbidity rates were compared according to chorionicity. RESULTS Three hundred seventy-eight MCDA and 1282 DCDA twins were included. MCDA twins had higher risks of PND (1.9% vs. 0.7% in DCDA twins, p = 0.05), composite neonatal morbidity (p = 0.01), preterm delivery (p < 0.01), and low birth weight (p < 0.01). The prospective risk of IUFD was 0.6% and 0.4% for MCDA and DCDA twins, respectively after 34 weeks' gestation. No NND occurred among deliveries after 30 weeks. The risk of neonatal morbidity of MCDA twins fell from 22.7% at 34 weeks to 2.7% at 37 weeks (p < 0.01). For DCDA twins, the risk of morbidity fell insignificantly from 36 to 38 weeks (4.0% vs. 3.4%, p = 0.60). Logistic regression analysis suggested that the increased risk of perinatal morbidities was related to the higher rate of preterm delivery in MCDA twins rather than chorionicity. CONCLUSION With close fetal monitoring, the risk of late IUFD in twin pregnancies without major complications is low. Perinatal morbidity can be minimized by avoiding late preterm deliveries in twin pregnancies.
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Affiliation(s)
- Florrie Nga Yui Yu
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Annisa Shui Lam Mak
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Ngai Man Chan
- Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Kiu Lok Siu
- Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Teresa Wei Ling Ma
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Kwok Yin Leung
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China.,Gleneagles Hong Kong, Hong kong Special Administrative Region, China
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Management of Twin Pregnancies: A Comparative Review of National and International Guidelines. Obstet Gynecol Surv 2021; 75:419-430. [PMID: 32735684 DOI: 10.1097/ogx.0000000000000803] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Twin pregnancies are associated with a higher risk of perinatal mortality and morbidity compared with singleton and require more intensive prenatal care. Objective The aim of this study was to review and compare the recommendations from published guidelines on twin pregnancies. Evidence Acquisition A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the National Institute for Health and Care Excellence, the Institute of Obstetricians and Gynaecologists of the Royal College of Physicians of Ireland, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, and the American College of Obstetricians and Gynecologists on the management of twin pregnancies was conducted. Results All the guidelines highlight the importance of an accurate assessment of chorionicity, amnionicity, and gestational age in the first trimester. They also recommend the performance of nuchal translucency and a detailed anomaly scan. The ultrasound surveillance protocol is similar in all guidelines, that is, every 2 weeks for monochorionic and every 4 weeks for dichorionic twins. On the other hand, there are differences regarding the timing and mode of delivery, especially in monochorionic diamniotic twins, in the definition and management of fetal growth discordance, the use of cervical length to screen for preterm birth, and the timing of corticosteroids' administration. Conclusions The differences in the reviewed guidelines on the management of twin pregnancies highlight the need for an adoption of an international consensus, in order to improve perinatal outcomes of twin pregnancies.
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De La Calle M, Delgado JL, Verlohren S, Escudero AI, Bartha JL, Campillos JM, Aguarón De La Cruz A, Chantraine F, García Hernández JÁ, Herraiz I, Llurba E, Kurka H, Guo G, Sillman J, Hund M, Perales Marín A. Gestational Age-Specific Reference Ranges for the sFlt-1/PlGF Immunoassay Ratio in Twin Pregnancies. Fetal Diagn Ther 2021; 48:288-296. [PMID: 33784677 DOI: 10.1159/000514378] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 01/09/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Establish reference ranges for the Elecsys® soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) immunoassay ratio in twin pregnancies. METHODS Data analyzed were from 3 prospective studies: Prediction of Short-Term Outcome in Pregnant Women with Suspected Preeclampsia (PE) (PROGNOSIS), Study of Early-onset PE in Spain (STEPS), and a multicenter case-control study. Median, 5th, and 95th percentiles for sFlt-1, PlGF, and the sFlt-1/PlGF ratios were determined for normal twin pregnancies for 7 gestational windows and compared with the previous data for singleton pregnancies. RESULTS The reference range analysis included 269 women with normal twin pregnancies. Before 29 weeks' gestation, median, 5th, and 95th percentiles for sFlt-1/PlGF ratios did not differ between twin and singleton pregnancies. From 29 weeks' gestation to delivery, median, 5th, and 95th percentiles for sFlt-1/PlGF ratios were substantially higher in twin versus singleton pregnancies. sFlt-1 values were higher in women with twin pregnancies across all gestational windows. PlGF values were similar or higher in twin versus singleton pregnancies; PlGF concentrations increased from 10 weeks + 0 days to 28 weeks + 6 days' gestation. CONCLUSIONS Reference ranges for the sFlt-1/PlGF ratio are similar in women with twin and singleton pregnancies until 29 weeks' gestation but appear higher in twin pregnancies thereafter.
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Affiliation(s)
- Maria De La Calle
- Division of Obstetrics and Maternal and Fetal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | - Juan L Delgado
- Department of Gynecology and Obstetrics, Universidad de Murcia and IMIB-Arrixaca, Murcia, Spain
| | - Stefan Verlohren
- Department of Obstetrics, Charité - Universitätsmedizin, Berlin, Germany
| | - Ana Isabel Escudero
- Department of Obstetrics and Gynaecology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Jose L Bartha
- Division of Obstetrics and Maternal and Fetal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | - Jose M Campillos
- Department of Obstetrics, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Angel Aguarón De La Cruz
- Department of Gynecology and Obstetrics, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Frederic Chantraine
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Liège, site CHR de la Citadelle, Liège, Belgium
| | - José Ángel García Hernández
- Department of Obstetrics and Gynecology, Hospital Universitario Materno Infantil de Canarias, Gran Canaria, Spain
| | - Ignacio Herraiz
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit-SAMID, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - Elisa Llurba
- Obstetrics and Gynaecology Department, High Risk Unit & Biomedical Research Institute Sant Pau (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain.,School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Institute of Health Carlos III, Maternal and Child Health and Development Network II (SAMID II) RD12/0026, Madrid, Spain
| | - Hedwig Kurka
- Biostatistics and Data Management CPS, Roche Diagnostics GmbH, Penzberg, Germany
| | - Ge Guo
- Biostatistics and Data Management CPS, Roche Diagnostics Operations, Inc., Indianapolis, Indiana, USA
| | - Johanna Sillman
- Centralised and Point of Care Solutions, Roche Diagnostics International Ltd., Rotkreuz, Switzerland
| | - Martin Hund
- Centralised and Point of Care Solutions, Roche Diagnostics International Ltd., Rotkreuz, Switzerland
| | - Alfredo Perales Marín
- Department of Obstetrics and Gynecology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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12
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Complications of Monochorionic Diamniotic Twins: Stepwise Approach for Early Identification, Differential Diagnosis, and Clinical Management. MATERNAL-FETAL MEDICINE 2020. [DOI: 10.1097/fm9.0000000000000076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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13
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Optimal delivery timing for dizygotic twins - the short- and long-term perspective. J Dev Orig Health Dis 2020; 12:88-93. [PMID: 32127072 DOI: 10.1017/s2040174420000100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Major obstetrics and gynecology societies offer inconsistent recommendation regarding optimal delivery timing in uncomplicated dizygotic twins. We sought to investigate the impact of delivery timing within term gestation, in dizygotic twins, on the short- and long-term offspring morbidity. A prospectively analyzed cohort of dizygotic twin deliveries was conducted. All women delivered at a regional tertiary medical center, at term (≥37 0/7), between the years 1991 and 2014, were included. The primary exposure was delivery at 37 0/7-37 + 6/7 weeks, while delivery at ≥38 0/7 weeks' gestation was considered the reference. Neonatal short- and long-term outcomes according to hospitalizations of offspring up to 18 years of age due to cardiac, respiratory, hematological, neurological, and infectious morbidity were compared. Kaplan-Meier survival curves were used to compare cumulative incidences per each major-system hospitalization. Cox regression models were used to estimate the adjusted hazard ratios, while adjusting for variables with clinical importance. During the study period, 612 dizygotic twin deliveries met the inclusion criteria. Of them, 200 (31.3%) occurred at 37-37 6/7 weeks, and 412 (68.7%) occurred at ≥38 0/7 weeks' gestation. In the long-term analysis, rates of hospitalizations involving several major morbidity categories exhibited comparable rates in both groups. The Cox regression models did not demonstrate an independent association between gestational age within term and later major pediatric morbidity in offspring (total long-term morbidity: adjusted hazard ratio 1.33, 95% confidence interval 0.77-2.29). Dizygotic twin deliveries occurring at different gestational ages within term do not appear to significantly impact on major short- and long-term outcomes.
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14
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Zeltzer J, Shand AW, Kelly P, Hopper JL, Scurrah KJ, Nassar N. Early birth is a key factor in educational disadvantage of twins: A data linkage study. Acta Paediatr 2020; 109:534-540. [PMID: 31402475 DOI: 10.1111/apa.14966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/03/2019] [Accepted: 08/09/2019] [Indexed: 11/26/2022]
Abstract
AIM To assess educational outcomes of twins and quantify the degree this is mediated by gestational age and other perinatal factors. METHODS We conducted a population-based record-linkage cohort study of all live births ≥24 weeks gestation in New South Wales, Australia with a corresponding standardised school test result for grade 3 in 2008-2014. The primary outcome was whether a child met the National Minimum Standard (NMS) cut-off in literacy and numeracy domains. Robust multivariable Poisson models were used to obtain adjusted relative risks (aRRs), and mediation analysis conducted to assess contributing factors on the causal pathway. RESULTS Of 351 791 liveborn infants, 10 365 (2.9%) were twins. After adjusting for maternal covariates and compared with singletons, twins had an increased risk of not meeting the NMS for all five literacy and numeracy domains (aRR 1.27-1.45, P < .001). Gestational age alone mediated up to 73% of aRRs and small for gestational age further attenuated these effects with only minimal risk remaining after adjusting for all mediators (aRR 0.94-1.07). CONCLUSION Almost all of the educational disadvantage experienced by twins, compared with singletons, is attributable to the risk associated with shorter gestational age, and partly by poor foetal growth. These findings support efforts to prolong gestation of twin pregnancies.
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Affiliation(s)
- Justin Zeltzer
- Child Population and Translational Health Research, Children's Hospital at Westmead Clinical School University of Sydney Sydney NSW Australia
| | - Antonia W. Shand
- Child Population and Translational Health Research, Children's Hospital at Westmead Clinical School University of Sydney Sydney NSW Australia
- Maternal Fetal Medicine Department Royal Hospital for Women Randwick NSW Australia
| | - Patrick Kelly
- School of Public Health University of Sydney Sydney NSW Australia
| | - John L. Hopper
- Twins Research Australia, Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health University of Melbourne Melbourne Vic. Australia
| | - Katrina J. Scurrah
- Twins Research Australia, Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health University of Melbourne Melbourne Vic. Australia
| | - Natasha Nassar
- Child Population and Translational Health Research, Children's Hospital at Westmead Clinical School University of Sydney Sydney NSW Australia
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15
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Delivery timing after laser surgery for twin-twin transfusion syndrome. J Perinatol 2020; 40:248-255. [PMID: 31611614 DOI: 10.1038/s41372-019-0532-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/12/2019] [Accepted: 08/19/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare outcomes of twin-twin transfusion syndrome (TTTS) patients who underwent early elective delivery vs. expectant management. STUDY DESIGN Retrospective study of monochorionic diamniotic twins who underwent laser surgery for TTTS and had dual survivors at 32 weeks. Patients who underwent elective delivery between 32 0/7 to 35 6/7 weeks ("early elective group") were compared with all patients who delivered ≥36 0/7 weeks ("expectant management group"). The primary outcome was a composite of fetal and neonatal morbidity. RESULTS The final study population was comprised of 15 early elective and 119 expectant management patients. Those in the early elective group were seven times more likely to experience the primary outcome (OR 7.38 [2.01-27.13], p = 0.0026). CONCLUSION Among patients who underwent laser surgery for TTTS who had dual survivors at 32 weeks, elective delivery prior to 36 weeks did not appear to be protective.
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16
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Rissanen ARS, Jernman RM, Gissler M, Nupponen IK, Nuutila ME. Perinatal outcomes in Finnish twins: a retrospective study. BMC Pregnancy Childbirth 2019; 20:2. [PMID: 31892322 PMCID: PMC6938609 DOI: 10.1186/s12884-019-2670-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/10/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND To establish the changes in perinatal morbidity and mortality in twin pregnancies in Finland, a retrospective register research was conducted. Our extensive data from a 28-year study period provide important information on the outcome of twin pregnancies in Finland that has previously not been reported to this extent. METHODS All 23,498 twin pregnancies with 46,996 children born in Finland during 1987-2014 were included in the study. Data were gathered from the Medical Birth Register and the Hospital Discharge Register (Finnish Institute for Health and Welfare, Finland) regarding perinatal mortality (PNM) and morbidity. For statistical analysis, binomial regression analysis and crosstabs were performed. The results are expressed in means, percentages and ranges with comparison to singletons when appropriate. Odds ratios from binomial regression analysis are reported. A p-value <0.05 was considered statistically significant. RESULTS There were 46,363 liveborn and 633 stillborn twins in Finland during 1987-2014. Perinatal mortality decreased markedly, from 45.1 to 6.5 per 1000 for twin A and from 54.1 to 11.9 per 1000 for twin B during the study period. Yet, the PNM difference between twin A and B remained. Early neonatal mortality did not differ between twins, but has decreased in both. Asphyxia, respiratory distress syndrome, need for antibiotics and Neonatal Intensive Care Unit (NICU) stay were markedly more common in twin B. CONCLUSIONS In Finland, PNM and early neonatal mortality in twins decreased significantly during 1987-2014 and are nowadays very low. However, twin B still faces more complications. The outline provided may be used to further improve the monitoring and thus perinatal outcome of twins, especially twin B.
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Affiliation(s)
- Annu-Riikka Susanna Rissanen
- Department of Obstetrics and Gynecology, University of Helsinki and Welfare District of Päijät-Häme, Keskussairaalankatu 7, 15850, Lahti, Finland.
| | - Riina Maria Jernman
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 2, PL 140, 00029 HUS, Helsinki, Finland
| | - Mika Gissler
- Finnish Institute for Health and Welfare, Mannerheimintie 166, PL 30, 00271, Helsinki, Finland
- Karolinska Institute, Stockholm, Sweden
| | - Irmeli Katriina Nupponen
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, PL 347, 00029 HUS, Helsinki, Finland
| | - Mika Erkki Nuutila
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 2, PL 140, 00029 HUS, Helsinki, Finland
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17
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Affiliation(s)
- Cecilie Halling
- Department of Childrens Health, University of Texas Southwestern, Dallas, Texas, USA.,Department of Paediatrics, Rotunda Hospital, Dublin, Ireland
| | - John David Corcoran
- Department of Paediatrics, Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, Faculty of Medicine and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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18
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Delivery of the second twin: influence of presentation on neonatal outcome, a case controlled study. BMC Pregnancy Childbirth 2018; 18:176. [PMID: 29776396 PMCID: PMC5960113 DOI: 10.1186/s12884-018-1815-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 05/01/2018] [Indexed: 12/15/2022] Open
Abstract
Background Spontaneous vaginal twin delivery after 32nd week of gestation is safe when first twin presenting cephalic. Aim of this study is to identify obstetric factors influencing the condition of second twin and to verify whether non-cephalic presentation and vaginal breech delivery of the second twin is safe. Methods This is a retrospective case controlled cohort study of 717 uncomplicated twin deliveries ≥32 + 0 weeks of gestation from 2005 to 2014 in two tertiary perinatal centers. Obstetric parameters were evaluated in three groups with descriptive, univariate logistic regression analysis for perinatal outcome of second twins. Results The three groups included twins delivered by elective cesarean section ECS (n = 277, 38.6%), by unplanned cesarean section UPC (n = 233, 32.5%) and vaginally (n = 207, 28.9%). Serious adverse fetal outcome is rare and we found no differences between the groups. Second twins after ECS had significant better umbilical artery UA pH (p < 0.001) and better Apgar compared to UPC (p = 0.002). Variables for a fetal population “at risk” for adverse neonatal outcome after vaginal delivery (UA pH < 7.20, Apgar 5´ < 9) were associated with higher gestational age (p = 0.001), longer twin-twin interval (p = 0.05) and vacuum extraction of twin A (p = 0.04). Non-cephalic presentation of second twins was not associated (UA pH < 7.20 OR 1.97, CI 95% 0.93–4.22, p = 0.07, Apgar 5´ < 9 OR 1.63, CI 95% 0.70–3.77, p = 0.25, Transfer to neonatal intermediate care unit p = 0.48). Twenty-one second twins (2,9%) were delivered by cesarean section following vaginal delivery of the first twin. Even though non-cephalic presentation was overrepresented in this subgroup, outcome variables were not significantly different compared to cephalic presentation. Conclusions Even though elective cesarean means reduced stress for second twins this seems not to be clinically relevant. Non-cephalic presentation of the second twin does not significantly influence the perinatal outcome of the second twin but might be a risk factor for vaginal-cesarean birth.
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19
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Yamamoto R, Ishii K, Muto H, Ota S, Kawaguchi H, Hayashi S, Mitsuda N. Incidence of and risk factors for severe maternal complications associated with hypertensive disorders after 36 weeks' gestation in uncomplicated twin pregnancies: A prospective cohort study. J Obstet Gynaecol Res 2018; 44:1221-1227. [PMID: 29673002 DOI: 10.1111/jog.13650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/03/2018] [Indexed: 11/27/2022]
Abstract
AIM To elucidate the incidence of and risk factors for severe hypertensive disorders (HD) and related maternal complications in uncomplicated twin pregnancies that reached 36 weeks' gestation. METHODS We conducted a prospective cohort study of twin pregnancies delivered after 36 weeks' gestation. Cases of twin-twin transfusion syndrome, twin anemia-polycythemia sequence, malformed fetuses, monoamniotic twins, selective reduction, fetal therapy and HD or fetal death before 35 weeks' gestation were excluded. The study's primary outcome was the incidence of severe maternal complications, including severe HD, eclampsia, placental abruption, HELLP (hemolysis, elevated liver enzyme and low platelet) syndrome, pulmonary edema and cerebrovascular disease. Perinatal factors associated with the primary outcome were identified using a multivariate logistic regression model. RESULTS In 330 enrolled women, the number of cases with the primary outcome was 28 (8.5%; 95% confidence interval 5.9-12.0), including 25 cases of severe HD and each one case of placental abruption, HELLP syndrome and eclampsia. The rate of severe maternal complications significantly increased with gestational age, demonstrating 1.2% at 36 weeks, 3.9% at 37 weeks and 6.4% at 38 weeks. Only gestational proteinuria was identified as the independent risk factor for severe maternal complications (adjusted odds ratio 17.1 [95% confidence interval 6.71-45.4]). CONCLUSION Severe maternal HD and related complications increased from late preterm to early term; particularly, patients with gestational proteinuria were at high risk.
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Affiliation(s)
- Ryo Yamamoto
- 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
| | - Shiyo Ota
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Haruna Kawaguchi
- 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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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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Reitter A, Daviss BA, Krimphove MJ, Johnson KC, Schlößer R, Louwen F, Bisits A. Mode of birth in twins: data and reflections. J OBSTET GYNAECOL 2018; 38:502-510. [PMID: 29433366 DOI: 10.1080/01443615.2017.1393402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Our primary objective was to compare neonatal and maternal outcomes in women with twin pregnancies, beyond 32 weeks, having a planned vaginal birth or a planned caesarean section (CS). This was a retrospective cohort study from a single tertiary centre over nine years. 534 sets of twins ≥32 + 0 weeks of gestation were included. 401 sets were planned vaginally and 133 sets were planned by CS. We compared a composite adverse perinatal outcome (perinatal mortality or serious neonatal morbidity; five minute APGAR score ≤4, neurological abnormality and need for intubation) and a composite maternal adverse outcome (major haemorrhage, trauma or infection) between the groups. There were no significant differences. Given the similarity of these results with several other larger studies of twin birth, we sought to look at reasons why there is still a rising rate of CS for twin births. We further make suggestions for keeping this rate to a sensible minimum. Impact statement What is already known on this subject? The largest randomised controlled study comparing planned vaginal birth with planned CSs for lower risk twins between 32 and 39 weeks of gestation, showed no added safety from planned CS. However, in most of the Western countries this conclusion has failed to increase the number of planned vaginal births for lower risk twins. What do the results of this study add? This observational study from a single tertiary centre provides external validation of the twin trial results in a practical day-to-day setting. It also provides insights as to how planned vaginal birth can be developed and maintained, with a key focus on safety and maternal participation in decision making. It does focus on consent and providing accurate data. What are the implications of these findings for clinical practice and/or further research? There are good grounds to encourage vaginal birth for low-risk twin pregnancies. The trend of rising caesarean rates in low-risk twin pregnancies worldwide will erode important skills for the conduct of vaginal births without any clear benefit for mothers or babies. The current situation demands careful thought about implementing innovative training opportunities for younger obstetricians. Finally, we need intelligent responses to many non-evidence-based factors which can drive clinical practice.
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Affiliation(s)
- A Reitter
- a Department of Obstetrics and Gynaecology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - B A Daviss
- b Department of Obstetrics and Gynaecology, Midwifery Division , Montfort Hospital , Ottawa , Canada
| | - M J Krimphove
- a Department of Obstetrics and Gynaecology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - K C Johnson
- c Department of Epidemiology and Community Medicine , University of Ottawa , Ottawa , Canada
| | - R Schlößer
- d Department of Pediatrics, Division Neonatology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - F Louwen
- a Department of Obstetrics and Gynaecology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - A Bisits
- e Department of Obstetrics and Gynecology, Royal Hospital for Women , University of New South Wales , Randwick , Australia
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22
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Kadji C, Bevilacqua E, Hurtado I, Carlin A, Cannie MM, Jani JC. Comparison of conventional 2D ultrasound to magnetic resonance imaging for prenatal estimation of birthweight in twin pregnancy. Am J Obstet Gynecol 2018; 218:128.e1-128.e11. [PMID: 29045850 DOI: 10.1016/j.ajog.2017.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/29/2017] [Accepted: 10/06/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND During prenatal follow-up of twin pregnancies, accurate identification of birthweight and birthweight discordance is important to identify the high-risk group and plan perinatal care. Unfortunately, prenatal evaluation of birthweight discordance by 2-dimensional ultrasound has been far from optimal. OBJECTIVE The objective of the study was to prospectively compare estimates of fetal weight based on 2-dimensional ultrasound (ultrasound-estimated fetal weight) and magnetic resonance imaging (magnetic resonance-estimated fetal weight) with actual birthweight in women carrying twin pregnancies. STUDY DESIGN Written informed consent was obtained for this ethics committee-approved study. Between September 2011 and December 2015 and within 48 hours before delivery, ultrasound-estimated fetal weight and magnetic resonance-estimated fetal weight were conducted in 66 fetuses deriving from twin pregnancies at 34.3-39.0 weeks; gestation. Magnetic resonance-estimated fetal weight derived from manual measurement of fetal body volume. Comparison of magnetic resonance-estimated fetal weight and ultrasound-estimated fetal weight measurements vs birthweight was performed by calculating parameters as described by Bland and Altman. Receiver-operating characteristic curves were constructed for the prediction of small-for-gestational-age neonates using magnetic resonance-estimated fetal weight and ultrasound-estimated fetal weight. For twins 1 and 2 separately, the relative error or percentage error was calculated as follows: (birthweight - ultrasound-estimated fetal weight (or magnetic resonance-estimated fetal weight)/birthweight) × 100 (percentage). Furthermore, ultrasound-estimated fetal weight, magnetic resonance-estimated fetal weight, and birthweight discordance were calculated as 100 × (larger estimated fetal weight-smaller estimated fetal weight)/larger estimated fetal weight. The ultrasound-estimated fetal weight discordance and the birthweight discordance were correlated using linear regression analysis and Pearson's correlation coefficient. The same was done between the magnetic resonance-estimated fetal weight and birthweight discordance. To compare data, the χ2, McNemar test, Student t test, and Wilcoxon signed rank test were used as appropriate. We used the Fisher r-to-z transformation to compare correlation coefficients. RESULTS The bias and the 95% limits of agreement of ultrasound-estimated fetal weight are 2.99 (-19.17% to 25.15%) and magnetic resonance-estimated fetal weight 0.63 (-9.41% to 10.67%). Limits of agreement were better between magnetic resonance-estimated fetal weight and actual birthweight as compared with the ultrasound-estimated fetal weight. Of the 66 newborns, 27 (40.9%) were of weight of the 10th centile or less and 21 (31.8%) of the fifth centile or less. The area under the receiver-operating characteristic curve for prediction of birthweight the 10th centile or less by prenatal ultrasound was 0.895 (P < .001; SE, 0.049), and by magnetic resonance imaging it was 0.946 (P < .001; SE, 0.024). Pairwise comparison of receiver-operating characteristic curves showed a significant difference between the areas under the receiver-operating characteristic curves (difference, 0.087, P = .049; SE, 0.044). The relative error for ultrasound-estimated fetal weight was 6.8% and by magnetic resonance-estimated fetal weight, 3.2% (P < .001). When using ultrasound-estimated fetal weight, 37.9% of fetuses (25 of 66) were estimated outside the range of ±10% of the actual birthweight, whereas this dropped to 6.1% (4 of 66) with magnetic resonance-estimated fetal weight (P < .001). The ultrasound-estimated fetal weight discordance and the birthweight discordance correlated significantly following the linear equation: ultrasound-estimated fetal weight discordance = 0.03 + 0.91 × birthweight (r = 0.75; P < .001); however, the correlation was better with magnetic resonance imaging: magnetic resonance-estimated fetal weight discordance = 0.02 + 0.81 × birthweight (r = 0.87; P < .001). CONCLUSION In twin pregnancies, magnetic resonance-estimated fetal weight performed immediately prior to delivery is more accurate and predicts small-for-gestational-age neonates significantly better than ultrasound-estimated fetal weight. Prediction of birthweight discordance is better with magnetic resonance imaging as compared with ultrasound.
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23
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Bracero LA, Huff C, Blitz MJ, Plata MJ, Seybold DJ, Broce M. Ultrasound and histological measurements of dividing membrane thickness in twin gestations. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:470-475. [PMID: 27790818 DOI: 10.1002/uog.17337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/08/2016] [Accepted: 10/16/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To determine how prenatal ultrasound measurements of dividing membrane thickness correlate with postnatal histological measurements and chorionicity in twin gestations. METHODS This was a prospective, longitudinal cohort study of twin gestations. Dividing membrane thickness was measured by transabdominal ultrasound, with the insonation beam both parallel and perpendicular to the membrane, in the second or third trimester, depending on when care was established. Ultrasound examinations were performed every 4 weeks following initial assessment until delivery. Measurements of membrane thickness from the first ultrasound examination were compared with histological measurements after delivery. RESULTS A total of 45 twin pregnancies (32 dichorionic, 13 monochorionic) were included. Mean gestational age at initial ultrasound examination was 24.1 ± 7.3 weeks. Parallel ultrasound measurements of membrane thickness were 1.6 ± 0.8 mm for monochorionic and 2.5 ± 0.9 mm for dichorionic gestations (P = 0.001). Perpendicular ultrasound measurements were 1.6 ± 0.3 mm for monochorionic and 2.2 ± 0.8 mm for dichorionic gestations (P = 0.009). Inter- and intraobserver reliability of ultrasound measurements were 0.847 and 0.950, respectively. Parallel and perpendicular ultrasound measurements correlated better with each other (R = 0.807, P < 0.001) than with histological measurements of membrane thickness (Rparallel = 0.538, P < 0.001; Rperpendicular = 0.529, P < 0.001). Receiver-operating characteristics curve analyses to predict histological membrane thickness > 50th percentile resulted in an area under the curve (AUC) of 0.828 for parallel (P < 0.001) and 0.874 for perpendicular (P < 0.001) measurements with a cut-off value of 1.9 mm for both approaches. The AUCs for parallel and perpendicular measurements to predict dichorionicity were 0.892 (P < 0.001) and 0.823 (P < 0.001) with cut-off values of 1.9 and 1.8 mm, respectively. CONCLUSION Prenatal ultrasound measurement of twin dividing membrane thickness is positively correlated with postnatal histological measurement. Dichorionicity can be determined by a magnified dividing membrane thickness ≥ 1.9 mm. Measurements with the ultrasound beam parallel to the dividing membrane may be more accurate than perpendicular measurements. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- L A Bracero
- Department of Obstetrics and Gynecology, West Virginia University Charleston Campus, Charleston, WV, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hofstra Northwell School of Medicine, Southside Hospital, Bay Shore, NY, USA
| | - C Huff
- Department of Obstetrics and Gynecology, West Virginia University Charleston Campus, Charleston, WV, USA
| | - M J Blitz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hofstra Northwell School of Medicine, North Shore University Hospital, Manhasset, NY, USA
| | - M J Plata
- Department of Pathology, Charleston Area Medical Center, Charleston, WV, USA
| | - D J Seybold
- Center for Health Services & Outcomes Research, Charleston Area Medical Center, Charleston, WV, USA
| | - M Broce
- Center for Health Services & Outcomes Research, Charleston Area Medical Center, Charleston, WV, USA
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Relevance of routine Doppler sampling at the two umbilical arteries in the follow-up of dichorionic twin pregnancies with intrauterine growth-restricted fetuses. J Gynecol Obstet Hum Reprod 2017; 46:285-289. [DOI: 10.1016/j.jogoh.2016.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 10/07/2016] [Accepted: 10/10/2016] [Indexed: 11/22/2022]
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25
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Simões T, Queirós A, Marujo AT, Valdoleiros S, Silva P, Blickstein I. Prospective risk of intrauterine death of monochorionic twins: update. J Perinat Med 2016; 44:871-874. [PMID: 26630688 DOI: 10.1515/jpm-2015-0319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/26/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To calculate an updated prospective risk of fetal death in monochorionic-biamniotic (MCBA) twins. STUDY DESIGN We evaluated 520 MCBA twin pregnancies that had intensive prenatal surveillance and delivered in a single Portuguese referral center. The prospective risk of fetal death was calculated as the total number of deaths at the beginning of the gestational period divided by the number of continuing pregnancies at or beyond that period. Data were compared to the 2006 previous report. RESULTS Nearly 80% of the neonates weighed <2500 g, including 13.5% who weighed <1500 g. Half were born at <36 weeks, including 13.8% who were born at <32 weeks. The data indicate an increased IUFD rate over time - 16 fetal deaths per pregnancy (3.1%) and 22 IUFDs per fetus (2.1%). The rate of IUFD after 32-33 weeks, however, was halved (1/187 pregnancies and 1/365 fetuses, 0.5 and 0.3%, respectively). CONCLUSION Intensive prenatal surveillance might decrease the unexpected fetal death rates after 33 week's gestation and our data do not support elective preterm birth for uncomplicated MCBA twins.
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Cheong-See F, Schuit E, Arroyo-Manzano D, Khalil A, Barrett J, Joseph KS, Asztalos E, Hack K, Lewi L, Lim A, Liem S, Norman JE, Morrison J, Combs CA, Garite TJ, Maurel K, Serra V, Perales A, Rode L, Worda K, Nassar A, Aboulghar M, Rouse D, Thom E, Breathnach F, Nakayama S, Russo FM, Robinson JN, Dodd JM, Newman RB, Bhattacharya S, Tang S, Mol BWJ, Zamora J, Thilaganathan B, Thangaratinam S. Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis. BMJ 2016; 354:i4353. [PMID: 27599496 PMCID: PMC5013231 DOI: 10.1136/bmj.i4353] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine the risks of stillbirth and neonatal complications by gestational age in uncomplicated monochorionic and dichorionic twin pregnancies. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, and Cochrane databases (until December 2015). REVIEW METHODS Databases were searched without language restrictions for studies of women with uncomplicated twin pregnancies that reported rates of stillbirth and neonatal outcomes at various gestational ages. Pregnancies with unclear chorionicity, monoamnionicity, and twin to twin transfusion syndrome were excluded. Meta-analyses of observational studies and cohorts nested within randomised studies were undertaken. Prospective risk of stillbirth was computed for each study at a given week of gestation and compared with the risk of neonatal death among deliveries in the same week. Gestational age specific differences in risk were estimated for stillbirths and neonatal deaths in monochorionic and dichorionic twin pregnancies after 34 weeks' gestation. RESULTS 32 studies (29 685 dichorionic, 5486 monochorionic pregnancies) were included. In dichorionic twin pregnancies beyond 34 weeks (15 studies, 17 830 pregnancies), the prospective weekly risk of stillbirths from expectant management and the risk of neonatal death from delivery were balanced at 37 weeks' gestation (risk difference 1.2/1000, 95% confidence interval -1.3 to 3.6; I(2)=0%). Delay in delivery by a week (to 38 weeks) led to an additional 8.8 perinatal deaths per 1000 pregnancies (95% confidence interval 3.6 to 14.0/1000; I(2)=0%) compared with the previous week. In monochorionic pregnancies beyond 34 weeks (13 studies, 2149 pregnancies), there was a trend towards an increase in stillbirths compared with neonatal deaths after 36 weeks, with an additional 2.5 per 1000 perinatal deaths, which was not significant (-12.4 to 17.4/1000; I(2)=0%). The rates of neonatal morbidity showed a consistent reduction with increasing gestational age in monochorionic and dichorionic pregnancies, and admission to the neonatal intensive care unit was the commonest neonatal complication. The actual risk of stillbirth near term might be higher than reported estimates because of the policy of planned delivery in twin pregnancies. CONCLUSIONS To minimise perinatal deaths, in uncomplicated dichorionic twin pregnancies delivery should be considered at 37 weeks' gestation; in monochorionic pregnancies delivery should be considered at 36 weeks. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014007538.
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Affiliation(s)
- Fiona Cheong-See
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London E1 2AB, UK
| | - Ewoud Schuit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, Netherlands Stanford Prevention Research Center, Stanford University, Palo Alto, Stanford, CA 94305, USA
| | - David Arroyo-Manzano
- Clinical Biostatistics Unit, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Asma Khalil
- Fetal Medicine Unit, St George's Healthcare NHS Trust, London SW17 0QT, UK
| | - Jon Barrett
- Evaluative Clinical Sciences, Women and Babies Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - K S Joseph
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC V6Z 2K5, Canada
| | - Elizabeth Asztalos
- Department of Newborn and Developmental Paediatrics, Women and Babies Research Program, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Karien Hack
- Department of Gynaecology and Obstetrics, Diakonessenhuis, 3582 KE Utrecht, Netherlands
| | - Liesbeth Lewi
- Department of Obstetrics-Gynaecology, University Hospitals, 3000 Leuven, Belgium Department of Development and Regeneration: Pregnancy, Fetus and Neonate, KU Leuven, Belgium
| | - Arianne Lim
- Department of Obstetrics and Gynaecology, Academic Medical Centre, 1105 AZ Amsterdam, Netherlands
| | - Sophie Liem
- Department of Obstetrics and Gynaecology, Academic Medical Centre, 1105 AZ Amsterdam, Netherlands
| | - Jane E Norman
- University of Edinburgh MRC Centre for Reproductive Health, Queen's Medical Research Institute, Edinburgh EH16 4TY, UK
| | - John Morrison
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
| | - C Andrew Combs
- Obstetrix Collaborative Research Network, Center for Research, Education and Quality, Mednax National Medical Group, FL 33323, USA
| | - Thomas J Garite
- Obstetrix Collaborative Research Network, Center for Research, Education and Quality, Mednax National Medical Group, FL 33323, USA University of California Irvine, Irvine, CA 92697, USA
| | - Kimberly Maurel
- Obstetrix Collaborative Research Network, Center for Research, Education and Quality, Mednax National Medical Group, FL 33323, USA
| | - Vicente Serra
- Maternal-Fetal Medicine Unit, Instituto Valenciano de Infertilidad, University of Valencia, Spain Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Valencia, Jefe Servicio Obstetricia Hospital U P La FE, Torre F, Valencia, Espana
| | - Alfredo Perales
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Valencia, Jefe Servicio Obstetricia Hospital U P La FE, Torre F, Valencia, Espana Department of Obstetrics, University Hospital La Fe, Valencia, 46026 València, Spain
| | - Line Rode
- Centre of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Katharina Worda
- Department of Obstetrics and Gynaecology, Medical University of Vienna, 1090 Wien, Austria
| | - Anwar Nassar
- Department of Obstetrics and Gynaecology, American University of Beirut Medical Centre, Riad El Solh, Beirut 1107 2020, Lebanon
| | - Mona Aboulghar
- The Egyptian IVF Centre, Maadi and Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Oula, Giza, Egypt
| | - Dwight Rouse
- Department of Obstetrics and Gynecology, Women and Infants Hospital, Brown University Women and Infants Hospital, Providence, RI 02905, USA
| | - Elizabeth Thom
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Republic of Ireland
| | - Fionnuala Breathnach
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Republic of Ireland
| | - Soichiro Nakayama
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka 594-1101, Japan
| | - Francesca Maria Russo
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, 20126 Milan, Italy
| | - Julian N Robinson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jodie M Dodd
- Robinson Research Institute, and Discipline of Obstetrics and Gynaecology, University of Adelaide, North Adelaide SA 5006, Australia
| | - Roger B Newman
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC 29403, USA
| | - Sohinee Bhattacharya
- University of Aberdeen, Dugald Baird Centre for Research on Women's Health, Aberdeen Maternity Hospital, Aberdeen AB25 2ZL, UK
| | - Selphee Tang
- Department of Obstetrics and Gynecology, Alberta Health Services, Calgary, AB T2N 2T9, Canada
| | - Ben Willem J Mol
- Australian Research Centre for Health of Women and Babies, Robinson Institute, University of Adelaide, North Adelaide, SA 5006, Australia
| | - Javier Zamora
- Clinical Biostatistics Unit, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | | | - Shakila Thangaratinam
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London E1 2AB, UK
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Abstract
Preterm birth is a major concern in modern obstetrics, and an important source of morbidity and mortality in newborns. Among twin pregnancies, especially, preterm birth is highly prevalent, and it accounts for almost 50% of the complications observed in this obstetrical population. In this article, we review the existing literature regarding the prediction and prevention of preterm birth in both symptomatic and asymptomatic twin pregnancies. In asymptomatic twin pregnancies, the best two predictive tests were cervical length (CL) measurement and cervicovaginal fetal fibronectin (fFN) testing. A single measurement of transvaginal CL at 20-24 weeks of gestation <20 mm or <25 mm is a good predictor of spontaneous preterm birth at <28, <32, and <34 weeks of gestation. A CL beyond 25 mm is associated with a 2% risk for birth before 28 weeks and with a 65% chance for a term pregnancy. Cervicovaginal fFN may be slightly less accurate than CL; however, it has a high negative predictive value in women presenting with threatened preterm labor, as <2% of these women will deliver within one week if the fFN is negative. In symptomatic twin pregnancies, no tests have proven accurate in predicting the risk of preterm birth. For the prevention of preterm birth in asymptomatic twins, regardless of CL, no treatment including bed rest, limitation of home activities, prophylactic tocolysis, progesterone, or cerclage has been shown to reduce the rate of preterm birth. Cervical pessaries might be of interest in cases where there is a short cervix (<25 mm and <38 mm, respectively) but these results need to confirmed in future trials.
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Affiliation(s)
- F Fuchs
- Departement de Gynécologie-Obstétrique, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris (APHP), Le Kremlin Bicêtre, France; INSERM, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, Villejuif, France; Université Paris-Sud, UMRS 1018, Villejuif, France
| | - M-V Senat
- Departement de Gynécologie-Obstétrique, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris (APHP), Le Kremlin Bicêtre, France; INSERM, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, Villejuif, France; Université Paris-Sud, UMRS 1018, Villejuif, France.
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Halling C, Malone FD, Breathnach FM, Stewart MC, McAuliffe FM, Morrison JJ, Dicker P, Manning F, Corcoran JD. Neuro-developmental outcome of a large cohort of growth discordant twins. Eur J Pediatr 2016; 175:381-9. [PMID: 26490567 DOI: 10.1007/s00431-015-2648-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/28/2015] [Accepted: 10/02/2015] [Indexed: 10/22/2022]
Abstract
UNLABELLED Our aims were to study the effect of birthweight growth discordance (≥20%) on neuro-developmental outcome of monochorionic and dichorionic twins and to compare the relative effects of foetal growth discordance and prematurity on cognitive outcome. We performed a cross-sectional multicentre prospective follow-up study from a cohort of 948 twin pregnancies. One hundred nineteen birthweight-discordant twin pairs were examined (24 monochorionic pairs) and were matched for gestational age at delivery with 111 concordant control pairs. Participants were assessed with the Bayley Scales between 24 and 42 months of age. Analysis was by paired t test for intra-twin pair differences and by multiple linear regression. Compared to the larger twin of a discordant pair, the smaller twin performed significantly worse in cognition (mean composite cognitive score difference = -1.7, 95% confidence interval (CI) = 0.3-3.1, p = 0.01) and also in language and motor skills. Prematurity prior to 33 weeks' gestation, however, had a far greater impact on cognitive outcomes (mean cognitive composite score difference = -5.8, 95% CI = 1.2-10.5, p = 0.008). CONCLUSION Birthweight growth discordance of ≥20% confers an independent adverse effect on long-term neuro-development of the smaller twin. However, prior to 33 weeks' gestation, gestational age at birth adversely affects cognitive development to a greater extent than foetal growth discordance.
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Affiliation(s)
- Cecilie Halling
- The Rotunda Hospital, Dublin, Ireland. .,Division of Neonatal-Perinatal Medicine, UT Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | | | | | - Moira C Stewart
- Royal Victoria Maternity Hospital, Belfast, Northern Ireland, UK.
| | - Fionnuala M McAuliffe
- Obstetrics and Gynaecology, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.
| | - John J Morrison
- Obstetrics and Gynecology, National University of Ireland, Galway, Ireland. .,University Hospital Galway, Galway, Ireland.
| | - Patrick Dicker
- Royal College of Surgeons in Ireland, Dublin 2, Ireland.
| | - Fiona Manning
- Royal College of Surgeons in Ireland, Dublin 2, Ireland.
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Dichorionic twin ultrasound surveillance: sonography every 4 weeks significantly underperforms sonography every 2 weeks: results of the Prospective Multicenter ESPRiT Study. Am J Obstet Gynecol 2015; 213:551.e1-5. [PMID: 26259909 DOI: 10.1016/j.ajog.2015.07.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 07/30/2015] [Indexed: 01/27/2023]
Abstract
OBJECTIVE A 2-week ultrasound scanning schedule for monochorionic twins is endorsed widely. There is a lack of robust data to inform a schedule for the surveillance of dichorionic gestations. We aimed to determine how ultrasound scanning that is performed at 2- or 4-week intervals (or every 4 weeks before 32 weeks' gestation and every 2 weeks thereafter) may impact the prenatal detection of fetal growth restriction (FGR) and ultimately influence timing of delivery. STUDY DESIGN In a consecutive cohort of 789 dichorionic twin pregnancies that were recruited prospectively for the multicenter Evaluation of Sonographic Predictors of Restricted Growth in Twins study, ultrasound determination of fetal growth and interrogation of umbilical and middle cerebral artery Doppler scans were performed every 2 weeks from 24 weeks' gestation until delivery. Complete delivery and perinatal outcome data were recorded for all pregnancies. Where delivery was prompted by FGR, abnormal umbilical artery Doppler examination or poor biophysical profile and in the absence of ruptured membranes, onset of labor, preeclampsia, or antepartum hemorrhage, the delivery was considered "ultrasound-indicated." For ultrasound-indicated deliveries, detection probabilities for FGR/abnormal umbilical artery Doppler scans/poor biophysical were determined according to the interval between examinations, by the suppression if alternate examination data. RESULTS Among 789 dichorionic twin pregnancies, 66 pairs (8%) had an "ultrasound indicated" delivery. Detection of FGR was reduced from 88-69%, and detection of abnormal umbilical artery Doppler was reduced from 82-62% when a 4-week ultrasound schedule was simulated. Both of these reductions reached statistical significance. There was a nonsignificant trend toward a reduction in the recording of oligohydramnios with a 4-week interval between examinations. CONCLUSION This study suggests that the ultrasound surveillance program of every 2 weeks that is recommended currently for monochorionic twins should be extended to dichorionic gestations.
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30
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The North American Fetal Therapy Network Consensus Statement: prenatal management of uncomplicated monochorionic gestations. Obstet Gynecol 2015; 125:1236-1243. [PMID: 25932853 DOI: 10.1097/aog.0000000000000723] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Owing to vascular connections within a single placenta, monochorionic gestations present distinctive prenatal management challenges. Complications that can arise as a result of unbalanced hemodynamic exchange (twin-twin transfusion syndrome and twin anemia polycythemia sequence) and unequal placental sharing (selective fetal growth restriction) should be kept in mind while prenatal management is being planned. Because of unique monochorionic angioarchitecture, what happens to one twin can directly affect the other. Death of one twin can result in death or permanent disability of the co-twin. Early detection of these unique disease processes through frequent ultrasonographic surveillance may allow the opportunity for earlier referral, intervention, or both and potentially better outcomes. Therefore, monochorionic gestations should be managed differently than dichorionic gestations or singletons. The purpose of this document is to present in detail methods for monitoring and management of uncomplicated monochorionic gestations and to review the evidence for the roles of these methods for detection of complications in clinical practice. Finally, we present evidence-based and expert opinion-supported recommendations developed by the North American Fetal Therapy Network for the diagnosis, surveillance, and delivery of uncomplicated monochorionic gestations.
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31
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Ribicic R, Kranjcec I, Borosak J, Tumbri J, Mihovilovic Prajz L, Ribicic T. Perinatal outcome of singleton versus twin late preterm infants: do twins mature faster than singletons? J Matern Fetal Neonatal Med 2015; 29:1520-4. [DOI: 10.3109/14767058.2015.1053449] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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32
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Berezowsky A, Mazkereth R, Ashwal E, Mazaki-Tovi S, Schiff E, Weisz B, Lipitz S, Yinon Y. Neonatal outcome of late preterm uncomplicated monochorionic twins: what is the optimal time for delivery? J Matern Fetal Neonatal Med 2015; 29:1252-6. [PMID: 26030679 DOI: 10.3109/14767058.2015.1043262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine the neonatal outcome at late prematurity of uncomplicated monochorionic (MC) twin pregnancies. METHODS A retrospective cohort study of 166 patients with uncomplicated MC diamniotic twins delivered between 34 and 37 weeks of gestation at a single tertiary center. The study population was classified into four groups according to the gestational age at delivery: (1) 34 weeks, (2) 35 weeks, (3) 36 weeks and (4) 37 weeks. Neonatal outcome measures were compared between the groups. RESULTS Neonatal morbidity was significantly higher at 34 weeks of gestation compared to the other three groups including respiratory distress syndrome, oxygen requirement, hypothermia and hyperbilirubinemia. Moreover, the rate of admission to the special care unit and need for phototherapy were significantly higher in newborns born at 36 weeks compared to 37 weeks of gestation (p = 0.02 and 0.03 respectively). Multiple regression analysis revealed that the risk for adverse neonatal outcome was significantly associated with gestational age at delivery. Of note, there were no fetal or neonatal deaths in our cohort. CONCLUSIONS The risk of neonatal morbidity of uncomplicated MC twins delivered at 34-37 weeks of gestation significantly decreases with advanced gestation. Therefore, under close fetal surveillance, uncomplicated MC twin pregnancies should be delivered at 37 weeks of gestation.
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Affiliation(s)
| | - Ram Mazkereth
- b Department of Neonatology , Edmond and Lily Safra Children Hospital, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University , Israel
| | - Eran Ashwal
- a Department of Obstetrics and Gynecology and
| | | | - Eyal Schiff
- a Department of Obstetrics and Gynecology and
| | - Boaz Weisz
- a Department of Obstetrics and Gynecology and
| | | | - Yoav Yinon
- a Department of Obstetrics and Gynecology and
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Page JM, Pilliod RA, Snowden JM, Caughey AB. The risk of stillbirth and infant death by each additional week of expectant management in twin pregnancies. Am J Obstet Gynecol 2015; 212:630.e1-7. [PMID: 25797235 DOI: 10.1016/j.ajog.2015.03.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 02/11/2015] [Accepted: 03/17/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of the study was to compare the fetal/infant mortality risk associated with each additional week of expectant management with the mortality risk of immediate delivery in women with twin gestations. STUDY DESIGN A retrospective cohort study was performed utilizing 2006-2008 National linked birth certificate and death certificate data. The incidence of stillbirth and infant death were determined for each week of pregnancy from 32 0/7 weeks' through 40 6/7 weeks' gestation. Pregnancies complicated by fetal anomalies were excluded. These measures were combined to estimate the theoretic risk of remaining pregnant an additional week by adding the risk of stillbirth during the extra week of pregnancy with the risk of infant death encountered with delivery during the following week. This composite fetal/infant mortality risk was compared with the risk of infant death associated with delivery at the corresponding gestational age. RESULTS The risk of stillbirth increased with increasing gestational age, for example, between 37 and 38 weeks' gestation (12.5 per 10,000 vs 22.5 per 10,000; P<.05). As expected, the risk of infant death following delivery gradually decreased as pregnancies approached term gestation. Week-by-week differences were statistically significant (P<.05) between 32 and 36 weeks with decreasing risk of infant death at advancing gestational ages. The composite risk of stillbirth and infant death associated with an additional week of pregnancy had a significant increase from 37 to 38 weeks' gestation (43.9 per 10,000 vs 59.2 per 10,000; P<.05). At 37 weeks' gestation, the relative risk of mortality was statistically significantly lower with immediate delivery as compared with expectant management (relative risk, 0.87; 95% confidence interval, 0.77-0.99). CONCLUSION Our results suggest that fetal/infant death risk is minimized at 37 weeks' gestation; however, individual maternal and fetal characteristics must also be taken into account when determining the optimal timing of delivery for twin pregnancies.
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Affiliation(s)
- Jessica M Page
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT.
| | - Rachel A Pilliod
- Department of Obstetrics and Gynecology, Brigham and Womens Hospital and Massachusetts General Hospital, Boston, MA
| | - Jonathan M Snowden
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
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Abstract
It is well established that the death of one fetus in a monochorionic twin pregnancy places the surviving twin at significant risk for neuro-developmental delay or death. Although the early 1st trimester "vanishing twin" has not traditionally been considered a major risk, the precise gestational threshold beyond which a surviving twin is at risk remains uncertain. Most experts recommend serial ultrasounds and fetal MRI in the survivor, to look for evidence of ischaemic brain injury. We present a case of early monochorionic twin demise at 14-16 weeks, with evolving ventriculomegaly and ischaemic changes on fetal MRI in the co-twin, leading to termination of pregnancy at 28 weeks.
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Affiliation(s)
- Colin A Walsh
- Department of Fetal MedicineRoyal North Shore HospitalSydneyNew South WalesAustralia; Northern Clinical School University of SydneySydneyNew South WalesAustralia
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Galjaard S, Moerman P, Corveleyn A, Devlieger R, Lewi L. Partial monochorionic and monoamniotic twin pregnancies: a report of two cases. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:722-724. [PMID: 24816904 DOI: 10.1002/uog.13403] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Indexed: 06/03/2023]
Abstract
Monochorionic (MC) twin pregnancies are at increased risk of adverse outcome because of the vascular anastomoses that connect the two fetal circulations. MC monoamniotic (MA) twins are at an even higher risk because of their almost universal cord entanglement and possible compression, which can cause an acute transfusion imbalance between the twins. Chorionicity and amnionicity should be determined during the first-trimester ultrasound examination to identify high-risk MC and MA twin pregnancies for which a fortnightly follow-up may improve outcome. Although this can be achieved readily by assessing and counting the membranes that separate the twins, some pitfalls may occur. We present our observations of two monozygotic twin pairs with an intermediate type of monodichorionic and monodiamniotic twin pregnancy. The first was recognized during the first-trimester scan and the second during the second-trimester scan.
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Affiliation(s)
- S Galjaard
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
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Radzinsky V, Akhmadeev N, Fatkullin I, Fatkullin F. Abdominal delivery in the intact amniotic sac in twin pregnancy. J Matern Fetal Neonatal Med 2014; 28:1939-42. [PMID: 25308206 DOI: 10.3109/14767058.2014.973393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE There has been an increasing trend for Caesarean deliveries in twin pregnancies over the last decades; preferred mode of delivery is still unclear. The article presents the mode of twin delivery within intact amniotic sac. METHODS The intrapartum courses in 70 matched twin pairs extracted by Caesarean section were analysed. Neonates were distributed to two groups - main (delivered "en caul") and control (delivered by conventional Caesarean section) groups, and subdivided according to gestational age at the time of delivery: 28-30 weeks, 31-33 weeks and 34-37 weeks. Neonates delivered first and second were matched by pairs. RESULTS The duration of Caesarean section was higher in the main group (delivered "en caul"). Apgar score at 5-th min depend on the gestational age at birth and was higher in main group. Mechanical ventilation term and length of hospital stay were lower in main group. Postnatal neurological examination showed lower incidence of brain damage in the main group. During the first year of life, neonates extracted within intact amniotic sac showed lower morbidity rate. This was correct also for pairs of neonates matched by delivery order. CONCLUSIONS Presented method improves neonates' Apgar score, reduces the need for resuscitation and influence of intrapartum negative factors. The length of hospital stay and hospitalisation rate for the first year of life were also lower in neonates delivered "en caul", providing an economical benefit.
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Affiliation(s)
- Viktor Radzinsky
- a Department of Medicine , Peoples' Friendship University of Russia , Moscow , Russia and
| | - Nariman Akhmadeev
- b Department of Obstetrics and Gynaecology , Kazan State Medical University , Kazan , Tatarstan , Russia
| | - Ildar Fatkullin
- b Department of Obstetrics and Gynaecology , Kazan State Medical University , Kazan , Tatarstan , Russia
| | - Farid Fatkullin
- b Department of Obstetrics and Gynaecology , Kazan State Medical University , Kazan , Tatarstan , Russia
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Agarwal K. Uncomplicated Monochorionic Twins––Is Elective Preterm Delivery Mandatory? JOURNAL OF FETAL MEDICINE 2014. [DOI: 10.1007/s40556-014-0020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wood S, Tang S, Ross S, Sauve R. Stillbirth in twins, exploring the optimal gestational age for delivery: a retrospective cohort study. BJOG 2014; 121:1284-90; discussion 1291. [DOI: 10.1111/1471-0528.12866] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2014] [Indexed: 11/28/2022]
Affiliation(s)
- S Wood
- Department of Obstetrics & Gynecology and Community Health Sciences; University of Calgary; Calgary AB Canada
| | - S Tang
- Department of Obstetrics & Gynecology and Community Health Sciences; University of Calgary; Calgary AB Canada
| | - S Ross
- Department of Obstetrics & Gynecology and Community Health Sciences; University of Calgary; Calgary AB Canada
| | - R Sauve
- Department of Pediatrics and Community Health Sciences; University of Calgary; Calgary AB Canada
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Barrett JF. Twin delivery: Method, timing and conduct. Best Pract Res Clin Obstet Gynaecol 2014; 28:327-38. [DOI: 10.1016/j.bpobgyn.2013.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 10/29/2013] [Accepted: 12/11/2013] [Indexed: 10/25/2022]
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Makrydimas G, Sotiriadis A. Prediction of preterm birth in twins. Best Pract Res Clin Obstet Gynaecol 2014; 28:265-72. [DOI: 10.1016/j.bpobgyn.2013.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 10/24/2013] [Accepted: 11/28/2013] [Indexed: 10/25/2022]
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Lewi L, Deprest J. Management of twin pregnancies: where do we go from here? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 41:601-604. [PMID: 23712884 DOI: 10.1002/uog.12502] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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O'Connor C, McAuliffe FM, Breathnach FM, Geary M, Daly S, Higgins JR, Dornan J, Morrison JJ, Burke G, Higgins S, Mooney E, Dicker P, Manning F, McParland P, Malone FD. Prediction of outcome in twin pregnancy with first and early second trimester ultrasound. J Matern Fetal Neonatal Med 2013; 26:1030-5. [PMID: 23413819 DOI: 10.3109/14767058.2013.766701] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To establish if first or second trimester biometry is a useful adjunct in the prediction of adverse perinatal outcome in twin pregnancy. METHODS A consecutive cohort of 1028 twin pregnancies was enrolled for the Evaluation of Sonographic Predictors of Restricted growth in Twins (ESPRiT) study, a prospective study conducted at eight academic centers. Outcome data was recorded for 1001 twin pairs that completed the study. Ultrasound biometry was available for 960 pregnancies. Biometric data obtained between 11 and 22 weeks were evaluated as predictors of a composite of adverse perinatal outcome (mortality, hypoxic ischemic encephalopathy, periventricular leukomalacia, necrotizing enterocolitis, respiratory distress, or sepsis), preterm delivery (PTD) and birthweight discordance greater than 18% (18% BW). Outcomes were adjusted for chorionicity and gestational age using Cox Proportional Hazards regression. RESULTS Differences in crown-rump length (CRL) were not predictive of adverse perinatal outcome. Between 14 and 22 weeks, a difference in abdominal circumference (AC) of more than 10% was the most useful predictor of adverse outcome, PTD and 18% or more BW discordance in all twins. Overall the strongest correlation was observed for intertwin differences in biometry between 18 and 22 weeks. CONCLUSION Biometry in the early second trimester can successfully identify twin pregnancies at increased risk. Intertwin AC difference of greater than 10% between 14 and 22 weeks gestation was the best individual predictor of perinatal risk in all twins. Sonographic biometry in the early second trimester should therefore be utilized to establish perinatal risk, thus allowing prenatal care to be improved.
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Affiliation(s)
- Clare O'Connor
- UCD Obstetrics & Gynaecology, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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Lewi L, Deprest J, Hecher K. The vascular anastomoses in monochorionic twin pregnancies and their clinical consequences. Am J Obstet Gynecol 2013; 208:19-30. [PMID: 23103301 DOI: 10.1016/j.ajog.2012.09.025] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/10/2012] [Accepted: 09/21/2012] [Indexed: 11/18/2022]
Abstract
Monochorionic twin pregnancies are at increased risk of adverse outcome because of the vascular anastomoses that connect the 2 fetal circulation systems. The shared circulation is responsible for some unique complications in monochorionic twins, such as the twin-to-twin transfusion syndrome, the twin anemia polycythemia sequence, the twin reversed arterial perfusion sequence, and monoamniotic twinning. Another consequence of the shared circulation is that the well-being of one twin critically depends on that of the other. In this review, we will describe the technique of placental injection. Further, we will discuss the role of the vascular anastomoses in each of the complications described above and provide an update on their management.
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Weisz B, Hogen L, Yinon Y, Mazaki S, Gindes L, Schiff E, Lipitz S. Mode of delivery and neonatal outcome in uncomplicated monochorionic twin pregnancies. J Matern Fetal Neonatal Med 2012; 25:2721-4. [DOI: 10.3109/14767058.2012.712560] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Optimum Timing for Planned Delivery of Uncomplicated Monochorionic and Dichorionic Twin Pregnancies. Obstet Gynecol 2012. [DOI: 10.1097/aog.0b013e3182588baa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Optimum timing for planned delivery of uncomplicated monochorionic and dichorionic twin pregnancies. Obstet Gynecol 2012; 119:1276; author reply 1276. [PMID: 22617607 DOI: 10.1097/aog.0b013e3182588b95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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