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Bevilacqua E, Torcia E, Meli F, Josse J, Bonanni G, Olivier C, Romanzi F, Carlin A, Familiari A, Jani JC, Lanzone A, Badr DA. Maternal and fetal outcomes after planned cesarean or vaginal delivery in twin pregnancy: a comparison between 2 third level birth centers. J Matern Fetal Neonatal Med 2024; 37:2350676. [PMID: 38724257 DOI: 10.1080/14767058.2024.2350676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/28/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Twin pregnancy is associated with higher risks of adverse perinatal outcomes for both the mother and the babies. Among the many challenges in the follow-up of twin pregnancies, the mode of delivery is the last but not the least decision to be made, with the main influencing factors being amnionicity and fetal presentation. The aim of the study was to compare perinatal outcomes in two European centers using different protocols for twin birth in case of non-cephalic second twin; the Italian patients being delivered mainly by cesarean section with those in Belgium being routinely offered the choice of vaginal delivery (VD). METHODS This was a dual center international retrospective observational study. The population included 843 women with a twin pregnancy ≥ 32 weeks (dichorionic or monochorionic diamniotic pregnancies) and a known pregnancy outcome. The population was stratified according to chorionicity. Demographic and pregnancy data were reported per pregnancy, whereas neonatal outcomes were reported per fetus. We used multiple logistic regression models to adjust for possible confounding variables and to compute the adjusted odds ratio (adjOR) for each maternal or neonatal outcome. RESULTS The observed rate of cesarean delivery was significantly higher in the Italian cohort: 85% for dichorionic pregnancies and 94.4% for the monochorionic vs 45.2% and 54.4% respectively in the Belgian center (p-value < 0.001). We found that Belgian cohort showed significantly higher rates of NICU admission, respiratory distress at birth and Apgar score of < 7 after 5 min. Despite these differences, the composite severe adverse outcome was similar between the two groups. CONCLUSION In this study, neither the presentation of the second twin nor the chorionicity affected maternal and severe neonatal outcomes, regardless of the mode of delivery in two tertiary care centers, but VD was associated to a poorer short-term neonatal outcome.
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Affiliation(s)
- Elisa Bevilacqua
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Eleonora Torcia
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Unit of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Federica Meli
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Unit of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Juliette Josse
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Giulia Bonanni
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Camille Olivier
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Federica Romanzi
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrew Carlin
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Alessandra Familiari
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Jacques C Jani
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Antonio Lanzone
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Unit of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Dominique A Badr
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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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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Tollenaar LSA, Slaghekke F, Middeldorp JM, Lopriore E. Fetal anemia in monochorionic twins: a review on diagnosis, management, and outcome. Expert Rev Hematol 2023; 16:9-16. [PMID: 36609186 DOI: 10.1080/17474086.2023.2166921] [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: 01/09/2023]
Abstract
INTRODUCTION Monochorionic twins may develop fetal anemia when blood is unequally distributed via the placental vascular anastomoses. This review focuses on the causes of fetal anemia in complicated monochorionic twins and highlights the differences in management and outcome. AREAS COVERED Fetal anemia can occur in the context of twin anemia polycythemia sequence (TAPS), chronic twin-twin transfusion syndrome (TTTS) and acute peripartum TTTS, and in cotwins after single fetal demise. Diagnosis of fetal anemia is based on abnormal Doppler ultrasound measurements. Management options include fetoscopic laser surgery, intrauterine blood transfusion, or expectant management, depending on the type of complication and the severity of the disease. In all complications, fetal anemia may lead to perinatal mortality, neonatal morbidity, severe cerebral injury, and long-term neurodevelopmental impairment. In TAPS specifically, anemic donors may also show bilateral deafness. EXPERT OPINION Knowledge on the diagnosis and optimal treatment in TTTS is nowadays widespread, but caregivers often fail to distinguish TAPS from acute peripartum TTTS at birth. A full blood count including reticulocyte count is required, and placental dye injection is extremely helpful to reach the correct diagnosis and establish the optimal management.
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Affiliation(s)
- L S A Tollenaar
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - F Slaghekke
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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da Silva Rocha J, Guedes-Martins L, Cunha A. Twin Anemia-Polycythemia Sequence (TAPS): From Basic Research to Clinical Practice. Curr Vasc Pharmacol 2023; 21:91-105. [PMID: 36718965 DOI: 10.2174/1570161121666230131112930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/30/2022] [Accepted: 12/30/2022] [Indexed: 02/01/2023]
Abstract
Twin pregnancy is associated with an increased risk of perinatal and maternal complications, and early establishment of the chorionicity type defines this risk. In monochorionic (MC) pregnancies, the fetuses share the same placental mass and exhibit vascular anastomoses crossing the intertwin membrane, and the combination and pattern of anastomoses determine the primary clinical picture and occurrence of future complications. Twin Anemia-Polycythemia Sequence (TAPS) was first described in 2006 after fetoscopic laser surgery in twin-to-twin transfusion syndrome (TTTS) twins, and in 2007, the first spontaneous cases were reported, recognizing TAPS as an individualized vascular identity in fetofetal transfusion syndromes. There are two types of TAPS: spontaneous (3-5%) and iatrogenic or postlaser (2-16%). TAPS consists of small diameter arteriovenous anastomoses (<1 mm) and low-rate, small-caliber AA anastomoses in the absence of amniotic fluid discordances. There are certain antenatal and postnatal diagnostic criteria, which have progressively evolved over time. New, additional secondary markers have been proposed, and their reliability is being studied. The best screening protocol for TAPS in MC twins is still a matter of debate. This review provides a survey of the relevant literature on the epidemiology, vascular pathophysiology, underlying hemodynamic factors that regulate mismatched vascular connections, and diagnostic criteria of this condition. The aim is to increase awareness and knowledge about this recently identified and frequently unrecognized and misdiagnosed pathology.
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Affiliation(s)
- Joana da Silva Rocha
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
| | - Luís Guedes-Martins
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
- Centro Hospitalar Universitário do Porto EPE, Centro Materno Infantil do Norte, Centro de Medicina Fetal, Serviço de Obstetrícia, Departamento da Mulher e da Medicina Reprodutiva, Largo Prof. Abel Salazar, Porto 4099-001, Portugal
- Unidade de Investigação e Formação - Centro Materno Infantil do Norte, Porto 4099-001, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-319 Portugal
| | - Ana Cunha
- Centro Hospitalar Universitário do Porto EPE, Centro Materno Infantil do Norte, Centro de Medicina Fetal, Serviço de Obstetrícia, Departamento da Mulher e da Medicina Reprodutiva, Largo Prof. Abel Salazar, Porto 4099-001, Portugal
- Unidade de Investigação e Formação - Centro Materno Infantil do Norte, Porto 4099-001, Portugal
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Kim MJ, Kim HM, Cha HH, Kim H, Kim HS, Seong WJ. Acute Twin-to-Twin Transfusion Syndrome Resulting in Fetal Bradycardia and Neonatal Death: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121813. [PMID: 36557014 PMCID: PMC9783626 DOI: 10.3390/medicina58121813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/23/2022] [Accepted: 12/08/2022] [Indexed: 12/13/2022]
Abstract
In monochorionic twins with no evidence of chronic twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence, a sudden onset of fetal transfusion syndrome after the second trimester of pregnancy is defined as acute twin-to-twin transfusion syndrome. Labor pain, change in the fetal position, and birth order are known risk factors for this condition, and the hemoglobin level of the donor twin is usually reported to be <12 g/dL. We report a recent case of acute twin-to-twin transfusion syndrome without effective labor pain causing cervical changes, resulting in fetal bradycardia and neonatal death after birth; however, the anemia of the donor twin was not as severe as has been reported previously in twin-to-twin transfusion syndrome cases.
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Affiliation(s)
- Mi Ju Kim
- Department of Obstetrics and Gynecology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
- Department of Obstetrics and Gynecology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Republic of Korea
| | - Hyun Mi Kim
- Department of Obstetrics and Gynecology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
- Department of Obstetrics and Gynecology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Republic of Korea
| | - Hyun-Hwa Cha
- Department of Obstetrics and Gynecology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
- Department of Obstetrics and Gynecology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Republic of Korea
| | - Haemin Kim
- Department of Obstetrics and Gynecology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Republic of Korea
| | - Hyo-Shin Kim
- Department of Obstetrics and Gynecology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Republic of Korea
| | - Won Joon Seong
- Department of Obstetrics and Gynecology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
- Department of Obstetrics and Gynecology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Republic of Korea
- Correspondence:
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Kosińska-Kaczyńska K, Witwicki J, Saletra-Bielińska A, Krajewski P, Krysiak A, Brawura-Biskupski-Samaha R, Walasik I, Zgliczyńska M, Malicka E, Szymusik I. Hemoglobin differences in twins are related to the time of cord clamping, not intertwin transfusion - a prospective cohort study. BMC Pregnancy Childbirth 2022; 22:619. [PMID: 35931974 PMCID: PMC9354348 DOI: 10.1186/s12884-022-04942-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Delayed cord clamping increases placental transfusion. In vaginal deliveries higher hemoglobin concentrations are found in the second-born twin. We hypothesized it is unrelated to intertwin transfusion but to the time of cord clamping. Methods: It was a prospective cohort study of 202 women delivering twins > 32 weeks of gestation. Monoamniotic pregnancy, antenatal intertwin transfusions, fetal demise or major abnormalities were excluded from the study. The time of cord clamping depended on the obstetrician’s decision. Hemoglobin, hematocrit, and reticulocyte count were measured at birth and during the second day of life. Results At birth, hemoglobin and hematocrit levels were significantly higher in the first-born twins delivered with delayed than with early cord clamping. Higher hemoglobin and hematocrit levels were observed during the second day of life in all twins delivered with delayed cord clamping. The lowest levels were observed in twins delivered with early cord clamping. Infants delivered with delayed cord clamping were at a lower risk of respiratory disorders and NICU hospitalization. Conclusion The observed differences in Hgb concentrations between the infants in a twin pregnancy are related to cord clamping time.
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Affiliation(s)
- Katarzyna Kosińska-Kaczyńska
- Department of Obstetrics, Perinatology and Neonatology, the Center of Postgraduate Medical Education, Ul. Cegłowska 80, 01-809, Warsaw, Poland. .,2Nd Department of Obstetrics and Gynecology of, the Center of Postgraduate Medical Education, ul. Cegłowska 80, 01-809, Warsaw, Poland.
| | - Jacek Witwicki
- Department of Neonatology of the Center, Postgraduate Medical Education, Ul. Cegłowska 80, 01-809, Warsaw, Poland
| | - Aleksandra Saletra-Bielińska
- 1St Department of Obstetrics and Gynecology, Medical University of Warsaw, pl. Starynkiewicza 1/3, 02-015, Warsaw, Poland
| | - Paweł Krajewski
- 1St Department of Obstetrics and Gynecology, Medical University of Warsaw, pl. Starynkiewicza 1/3, 02-015, Warsaw, Poland
| | - Adam Krysiak
- Department of Neonatology of the Center, Postgraduate Medical Education, Ul. Cegłowska 80, 01-809, Warsaw, Poland
| | - Robert Brawura-Biskupski-Samaha
- 2Nd Department of Obstetrics and Gynecology of, the Center of Postgraduate Medical Education, ul. Cegłowska 80, 01-809, Warsaw, Poland
| | - Izabela Walasik
- Students' Scientific Association at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, pl. Starynkiewicza 1/3, 02-015, Warsaw, Poland
| | - Magdalena Zgliczyńska
- 2Nd Department of Obstetrics and Gynecology of, the Center of Postgraduate Medical Education, ul. Cegłowska 80, 01-809, Warsaw, Poland
| | - Ewa Malicka
- 2Nd Department of Obstetrics and Gynecology of, the Center of Postgraduate Medical Education, ul. Cegłowska 80, 01-809, Warsaw, Poland
| | - Iwona Szymusik
- 1St Department of Obstetrics and Gynecology, Medical University of Warsaw, pl. Starynkiewicza 1/3, 02-015, Warsaw, Poland
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Wang X, Li L, Yuan P, Zhao Y, Wei Y. Placental characteristics of selective intrauterine growth restriction with changing patterns in umbilical artery Doppler flow in monochorionic diamniotic twins. J Perinat Med 2022; 50:433-437. [PMID: 35038812 DOI: 10.1515/jpm-2021-0523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/14/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To compare the placental features between selective intrauterine growth restriction (sIUGR) patients, with dynamic classification (DC) and stable classifications (SC). METHODS A cohort study was conducted from 1st April 2013 to 1st April 2020, we recruited sIUGR patients who had delivered at our center and examined placental characteristics with dye injection. The primary outcome was placental characteristics. RESULTS The prevalence of large artery-artery anastomosis (AAA) was significantly higher in sIUGR with DC than sIUGR with SC (88.2 vs. 46.6%, p=0.001). The total diameter of AAA was significantly larger in sIUGR with DC than sIUGR with SC [2.9 (1.4, 7.0) vs. 2.4 (0.3, 7.1) mm, p=0.032]. The total number of artery-vein anastomosis was significantly smaller in sIUGR with DC than sIUGR with SC [3 (1, 12) vs. 5 (1, 15), p=0.023]. The incidence of neonatal asphyxias of growth-restricted fetuses were higher in sIUGR with DC than sIUGR with SC (23.5 vs. 5.9%, p=0.033). CONCLUSIONS Large AAA is probably associated to sIUGR with dynamic classification.
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Affiliation(s)
- Xueju Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, P.R. China
| | - Luyao Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, P.R. China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, P.R. China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, P.R. China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, P.R. China
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Neonatal management and outcome in complicated monochorionic twins: What have we learned in the past decade and what should you know? Best Pract Res Clin Obstet Gynaecol 2022; 84:218-228. [PMID: 35513960 DOI: 10.1016/j.bpobgyn.2022.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 11/20/2022]
Abstract
Monochorionic (MC) twin pregnancies are at increased risk of neonatal morbidity and mortality due to the shared placenta with vascular connections that can give rise to various complications, including twin-twin transfusion syndrome, twin anemia polycythemia sequence (TAPS), selective fetal growth restriction, and other hematological imbalances at birth. Each complication presents its own challenges and considerations in the neonatal period. Measurement of hemoglobin levels and reticulocyte count is required to establish a correct diagnosis. Placenta dye injection is needed to properly distinguish between the various conditions. Risk factors for adverse outcome in MC twins include prematurity, severe cerebral injury, and the type of MC pregnancy complication. We, therefore, recommend cerebral ultrasound examinations in all complicated MC twins at birth to rule out a severe brain injury. Lastly, we strongly encourage screening for hearing loss using automated auditory brainstem response in all spontaneous TAPS donors to prevent permanent speech development delay.
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Long-term follow-up of complicated monochorionic twin pregnancies: Focus on neurodevelopment. Best Pract Res Clin Obstet Gynaecol 2022; 84:166-178. [PMID: 35491308 DOI: 10.1016/j.bpobgyn.2022.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/13/2022] [Indexed: 11/23/2022]
Abstract
Monochorionic twin pregnancies have an increased risk of morbidity and mortality. Due to the advancements in screening and treatment strategies, mortality rates have decreased. Improving survival rates demands a shift in scope toward long-term outcomes. In this review, we focus on neurodevelopmental outcome in survivors from complicated monochorionic twin pregnancies, including twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence (TAPS), acute peripartum TTTS, acute perimortem TTTS, selective fetal growth restriction (sFGR) and monoamnionicity. Our aim is to provide an overview of the current knowledge on the long-term outcome in survivors, including psychomotor development and quality of life, and provide recommendations for future research and follow-up programs.
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Large Hemoglobin Differences at Birth in Monochorionic Twins with a Placental Chorangioma and Delayed Cord Clamping. Twin Res Hum Genet 2021; 24:281-284. [PMID: 34879894 DOI: 10.1017/thg.2021.46] [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] [Indexed: 11/06/2022]
Abstract
We report a case of a monochorionic diamniotic twin with an uncomplicated pregnancy, but with an unexpected large intertwin hemoglobin (Hb) difference at birth. Twin 1 was delivered vaginally and had an uneventful neonatal course. The umbilical cord of Twin 1 was clamped approximately 5 min after birth. After the birth of Twin 1, Twin 2 developed severe bradycardia and showed limited cardiac output on ultrasound, for which an emergency cesarean section was performed. A full blood count revealed an Hb of 20.1 g/dL for Twin 1 and 10.2 g/dL for Twin 2 (intertwin difference 9.9 g/dL). Reticulocyte counts were similar, 40‰ and 38‰, respectively. Placental examination revealed 10 vascular anastomoses, including one arterio-arterial anastomosis with a diameter of 1.4 mm. Additionally, a large chorangioma was present on the placental surface of Twin 2. There was no color difference on the maternal side of the placenta. Based on the reticulocyte count ratio and the placental characteristics, twin anemia polycythemia sequence was ruled out as the cause of the large intertwin Hb difference. In this report, we discuss the various potential causes that could explain the large intertwin Hb difference including the role of delayed cord clamping in Twin 1, and the role of a large chorangioma, which may have attracted blood from the fetal circulation of Twin 2.
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Schmitz T, Korb D, Azria E, Garabédian C, Rozenberg P, Sénat MV, Sentilhes L, Vayssière C, Winer N, Goffinet F. Perinatal outcome after planned vaginal delivery in monochorionic compared with dichorionic twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:592-599. [PMID: 33078466 DOI: 10.1002/uog.23518] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/19/2020] [Accepted: 10/05/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To assess, according to chorionicity, the perinatal outcome of twin pregnancy in which vaginal delivery is planned. METHODS JUMODA (JUmeaux MODe d'Accouchement) was a national prospective population-based cohort study of twin pregnancies, delivered in 176 maternity units in France, from February 2014 to March 2015. In this planned secondary analysis, we assessed, according to chorionicity, the perinatal outcome of twin pregnancies, in which vaginal delivery was planned, that delivered at or after 32 weeks of gestation with the first twin in cephalic presentation. In order to select a population with well-recognized indications for planned vaginal delivery, we applied the same exclusion criteria as those in the Twin Birth Study, an international randomized trial. Monochorionic twin pregnancies with twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence were defined as complicated and were excluded. The primary outcome was a composite of intrapartum mortality and neonatal morbidity and mortality. Multivariable logistic regression models were used to control for potential confounders. Subgroup analyses were conducted according to birth order (first or second twin) and gestational age at delivery (< 37 or ≥ 37 weeks of gestation). RESULTS Among 3873 twin pregnancies, in which vaginal delivery was planned, that delivered at ≥ 32 weeks' gestation with the first twin in cephalic presentation, meeting the inclusion criteria of the Twin Birth Study, 729 (18.8%) were uncomplicated monochorionic twin pregnancies and 3144 (81.2%) were dichorionic twin pregnancies. The rate of composite intrapartum mortality and neonatal morbidity and mortality did not differ between uncomplicated monochorionic (27/1458 (1.9%)) and dichorionic (107/6288 (1.7%)) twin pregnancies when adjusting for conception by assisted reproductive technologies (adjusted relative risk, 1.07 (95% CI, 0.66-1.75)). No significant difference in the primary outcome was found between the groups on subgroup analyses according to birth order and gestational age at delivery. CONCLUSION When vaginal delivery is planned, and delivery occurs at ≥ 32 weeks of gestation with the first twin in cephalic presentation, uncomplicated monochorionic twin pregnancy is not associated with a higher rate of composite intrapartum mortality and neonatal morbidity and mortality compared with dichorionic twin pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T Schmitz
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Service de Gynécologie Obstétrique, Paris, France
- Université de Paris, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - D Korb
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Service de Gynécologie Obstétrique, Paris, France
- Université de Paris, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - E Azria
- Université de Paris, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
- Maternité Notre Dame de Bon Secours, Groupe Hospitalier Saint-Joseph, Paris, France
| | - C Garabédian
- CHRU de Lille, Maternité Jeanne de Flandre, Lille, France
- Université de Lille 2, Lille, France
| | - P Rozenberg
- Centre Hospitalier Intercommunal de Poissy, Service de Gynécologie Obstétrique, Poissy, France
- Université de Versailles Saint-Quentin-en-Yvelines, Versailles, France
| | - M V Sénat
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Gynécologie Obstétrique, Le Kremlin-Bicêtre, Paris, France
- Université Paris Sud, Le Kremlin-Bicêtre, Paris, France
| | - L Sentilhes
- CHU de Bordeaux, Service de Gynécologie Obstétrique, Bordeaux, France
- Université de Bordeaux, Bordeaux, France
| | - C Vayssière
- CHU de Toulouse, Service de Gynécologie Obstétrique, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| | - N Winer
- CHU de Nantes, Service de Gynécologie Obstétrique, Nantes, France
- Université de Nantes, Nantes, France
| | - F Goffinet
- Université de Paris, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
- Assistance Publique-Hôpitaux de Paris, Maternité Port-Royal, Paris, France
- DHU Risques et Grossesse, Paris, France
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12
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Tollenaar LSA, Prins SA, Beuger S, Slaghekke F, Oepkes D, Lopriore E. Twin Anemia Polycythemia Sequence in a Dichorionic Twin Pregnancy Leading to Severe Cerebral Injury in the Recipient. Fetal Diagn Ther 2021; 48:321-326. [PMID: 33774643 DOI: 10.1159/000514408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 11/23/2020] [Indexed: 11/19/2022]
Abstract
Twin anemia polycythemia sequence (TAPS) is a form of chronic imbalanced feto-fetal transfusion through minuscule placental anastomoses leading to anemia in the TAPS donor and polycythemia in the TAPS recipient and has been reported only in monochorionic twins. We report a very unusual case of TAPS which developed in a dichorionic twin pair, born at a gestational age of 33+2. Twin 1 (recipient) was polycythemic and had a hemoglobin value of 22.4 g/dL, whereas twin 2 (donor) was anemic with a hemoglobin value of 9.8 g/dL and an increased reticulocyte count (72‰). Color dye injection of the placenta revealed the presence of a deep-hidden small veno-venous anastomosis. Dichorionicity was confirmed on histologic examination. Aside from respiratory distress syndrome, the donor twin had an uncomplicated neonatal course. The recipient twin developed a post-hemorrhagic ventricular dilatation requiring treatment with a ventriculoperitoneal shunt and Rickham reservoir. This report shows that in dichorionic twins, placental anastomoses can be present, which can lead to the development of TAPS with severe consequences. Therefore, when a pale and plethoric dichorionic twin pair is born, a complete diagnostic work-up is required, including a full blood count with reticulocytes and placental injection, to investigate the presence and nature of potential underlying feto-fetal transfusion. Once the diagnosis of TAPS has been established, cerebral ultrasound, hearing screening, and long-term follow-up are strongly recommended as these twins have increased risk for severe cerebral injury, hearing loss, and long-term neurodevelopmental impairment.
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Affiliation(s)
| | - Sandra A Prins
- Department of Pediatrics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Sabine Beuger
- Department of Pediatrics, Noordwest Ziekenhuisgroep Den Helder, Den Helder, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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13
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Twin Anemia Polycythemia Sequence: Knowledge and Insights After 15 Years of Research. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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14
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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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15
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Affiliation(s)
- Shunji Suzuki
- a Department of Obstetrics and Gynecology , Japanese Red Cross Katsushika Maternity Hospital , Tokyo , Japan
| | - Yumene Kubota
- a Department of Obstetrics and Gynecology , Japanese Red Cross Katsushika Maternity Hospital , Tokyo , Japan
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16
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Tollenaar LSA, Zhao DP, Middeldorp JM, Oepkes D, Slaghekke F, Lopriore E. Can color difference on the maternal side of the placenta distinguish between acute peripartum twin-twin transfusion syndrome and twin anemia-polycythemia sequence? Placenta 2017; 57:189-193. [PMID: 28864011 DOI: 10.1016/j.placenta.2017.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 06/17/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate the color difference between two placental shares in monochorionic placentas with acute peripartum twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia sequence (TAPS). METHODS We evaluated all digital pictures of TAPS, acute peripartum TTTS and a control group of uncomplicated monochorionic placentas examined at our center. We determined the color intensity of the individual placental share on the maternal side of each monochorionic placenta using an image-processing program and calculated the color difference ratio (CDR). RESULTS Digital pictures of 5 acute peripartum TTTS, 25 TAPS and 54 control group placentas were included in this study. The median CDR in acute peripartum TTTS was significantly lower compared to TAPS placentas, 1.20 (inter-quartile range (IQR) 1.05-1.20) and 2.50 (IQR 1.85-3.34), respectively (p < 0.01), and was comparable to the control group (CDR 1.11, IQR 1.05-1.22). CONCLUSION TAPS placentas have a higher CDR compared to acute peripartum TTTS placentas. Examining color difference on the maternal side of the placenta might help distinguish between acute peripartum TTTS and TAPS.
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Affiliation(s)
- Lisanne S A Tollenaar
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, The Netherlands.
| | - Danny P Zhao
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, The Netherlands
| | - Johanna M Middeldorp
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, The Netherlands
| | - Dick Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, The Netherlands
| | - Femke Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, The Netherlands
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17
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Verbeek L, Slaghekke F, Sueters M, Middeldorp JM, Klumper FJ, Haak MC, Oepkes D, Lopriore E. Hematological disorders at birth in complicated monochorionic twins. Expert Rev Hematol 2017; 10:525-532. [PMID: 28460542 DOI: 10.1080/17474086.2017.1324290] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Monochorionic twins are at risk of severe complications including twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence (TAPS) and acute peripartum TTTS. The pathophysiology is based on inter-twin blood transfusion through placental vascular anastomoses. Areas covered: This review focuses on the incidence, management and outcome of neonatal hematological complications at birth in TTTS, TAPS and acute peripartum TTTS. Expert commentary: Hematological disorders are often present at birth in monochorionic twins and include acute or chronic anemia, polycythemia and thrombocytopenia. Routine measurement of complete blood counts in all complicated monochorionic twins is strongly recommended. Increased awareness on these disorders and correct diagnostic tests will lead to prompt and adequate management at birth.
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Affiliation(s)
- Lianne Verbeek
- a Division of Neonatology, Department of Pediatrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Femke Slaghekke
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Marieke Sueters
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Johanna M Middeldorp
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Frans J Klumper
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Monique C Haak
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Dick Oepkes
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Enrico Lopriore
- a Division of Neonatology, Department of Pediatrics , Leiden University Medical Center , Leiden , The Netherlands
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18
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Hemoglobin Differences in Uncomplicated Monochorionic Twins in Relation to Birth Order and Mode of Delivery. Twin Res Hum Genet 2016; 19:241-5. [DOI: 10.1017/thg.2016.23] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Aim: To determine the differences in hemoglobin (Hb) levels in the first 2 days after birth in uncomplicated monochorionic twins in relation to birth order and mode of delivery. Methods: All consecutive uncomplicated monochorionic pregnancies with two live-born twins delivered at our center were included in this retrospective study. We recorded Hb levels at birth and on day 2, and analyzed Hb levels in association with birth order, mode of delivery, and time interval between delivery of twin 1 and 2. Results: A total of 290 monochorionic twin pairs were analyzed, including 171 (59%) twins delivered vaginally and 119 (41%) twins born by cesarean section (CS). In twins delivered vaginally, mean Hb levels at birth and on day 2 were significantly higher in second-born twins compared to first-born twins: 17.8 versus 16.1 g/dL and 18.0 versus 14.8 g/dL, respectively (p < .01). Polycythemia was detected more often in second-born twins (12%, 20/166) compared to first-born twins (1%, 2/166; p < .01). Hb differences within twin pairs delivered by CS were not statistically or clinically significant. We found no association between inter-twin delivery time intervals and Hb differences. Conclusions: Second-born twins after vaginal delivery have higher Hb levels and more often polycythemia than their co-twin, but not when born by CS.
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19
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Tollenaar LS, Zhao DP, Middeldorp JM, Slaghekke F, Oepkes D, Lopriore E. Color Difference in Placentas with Twin Anemia-Polycythemia Sequence: An Additional Diagnostic Criterion? Fetal Diagn Ther 2016; 40:123-7. [DOI: 10.1159/000442154] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/30/2015] [Indexed: 11/19/2022]
Abstract
Objective: To determine the color intensity difference between the 2 placental shares in monochorionic placentas with twin anemia-polycythemia sequence (TAPS). Methods: We evaluated all digital pictures of TAPS placentas examined at our center and compared them to a control group of uncomplicated monochorionic placentas. We determined the color intensity of individual placental share on the maternal side of each monochorionic placenta using an image processing program and calculated the color difference ratio (CDR). Results: Digital pictures of 19 TAPS and 19 uncomplicated monochorionic placentas were included in this study. The TAPS group consisted of 12 spontaneous TAPS placentas (63%) and 7 post-laser TAPS placentas (37%). The median CDR in the group with TAPS was significantly higher than in the control group, 2.73 (range 1.73-6.36) versus 1.09 (range 1.00-1.35), respectively (p < 0.01). We found a positive correlation between CDR and inter-twin hemoglobin (Hb) difference in the TAPS group (R = 0.66, p < 0.01) but not in the control group (R = 0.04, p = 0.87). Conclusion: TAPS placentas have a significantly higher CDR compared to uncomplicated monochorionic twin placentas. Large inter-twin Hb differences in TAPS are associated with higher CDR.
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20
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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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21
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Sananès N, Veujoz M, Severac F, Barthoulot M, Meyer N, Weingertner AS, Kohler M, Guerra F, Gaudineau A, Nisand I, Favre R. Evaluation of the Utility of in utero Treatment of Twin Anemia-Polycythemia Sequence. Fetal Diagn Ther 2015; 38:170-8. [PMID: 25790745 DOI: 10.1159/000380822] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/09/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the interest in the in utero treatment of twin anemia-polycythemia sequence (TAPS). METHODS The obstetrical and neonatal data on all cases of TAPS followed up in our institution between 2006 and 2013 were reviewed. Statistical analyses were conducted using Bayesian methods. RESULTS Twenty cases of TAPS were included. Laser therapy or intrauterine transfusion (IUT) was performed on the donor twin in 9 cases. Eleven cases were included in the 'nontreated' group (managed expectantly or diagnosed at birth). The gestational age at diagnosis was lower in the group with treated TAPS [difference (diff) = -22.20 days (-57.13, 14.28), probability (Pr) (diff >0) = 10.6%]. The rate of preterm premature rupture of membranes was higher in the group with treated TAPS [diff = 22.5% (-14, 57), Pr (diff >0) = 89%], but overall mortality was similar. The interval between diagnosis and delivery was longer [diff = 44.37 days (9.41, 77.90), Pr (diff >0) = 99.2%], the TAPS resolution rate was higher [diff = 49.9% (12, 81), Pr (diff >0) = 99.4%], and the neonatal transfusion rate was lower [diff = -30.5% (-60, 0), Pr (diff >0) = 2.6%] in the treated group. CONCLUSION In utero treatment for TAPS is associated with a higher resolution rate of TAPS and a longer time between diagnosis and birth, but overall mortality is the same as with expectant management.
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Affiliation(s)
- Nicolas Sananès
- Department of Obstetrics and Gynecology, Strasbourg University Teaching Hospitals, Strasbourg, France
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22
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Garabedian C, Poulain C, Duhamel A, Subtil D, Houfflin-Debarge V, Deruelle P. Intrapartum management of twin pregnancies: are uncomplicated monochorionic pregnancies more at risk of complications than dichorionic pregnancies? Acta Obstet Gynecol Scand 2015; 94:301-7. [PMID: 25494703 DOI: 10.1111/aogs.12558] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 12/03/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To analyze mode of delivery and neonatal morbidity according to chorionicity in a hospital birth center with a policy of vaginal delivery for twins. STUDY DESIGN Retrospective analysis over a 13-year period. SETTING Department of Obstetrics, University Hospital, Lille, France. POPULATION In all, 1009 twin pregnancies were included, divided into 171 uncomplicated monochorionic pregnancies (17%) and 838 dichorionic pregnancies (83%). METHODS We compared the monochorionic and the dichorionic populations. MAIN OUTCOME MEASURES Rate of cesarean section and neonatal outcome (umbilical artery pH, Apgar score and neonatal complications). RESULTS The rate of cesarean sections was 45.7% with no difference found based on chorionicity. The reasons for elective cesarean section were mainly noncephalic presentation, which was more frequent in dichorionic than in monochorionic (48.8% vs. 37.2%, p = 0.025) pregnancies. Birthweight was lower in monochorionic twins (2249 ± 469 g vs. 2329 ± 478 g, p = 0.045). The rate of umbilical artery cord blood values with a pH < 7.10 was similar in monochorionic and dichorionic pregnancies. There was no difference in neonatal complications between the two groups. CONCLUSION Monochorionic and dichorionic twin pregnancies had similar delivery outcomes. The neonatal outcome for twin 2 was not different between monochorionic and dichorionic pregnancies. Vaginal birth could be offered to women with twin pregnancies regardless of chorionicity.
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Affiliation(s)
- Charles Garabedian
- Department of Obstetrics, Jeanne de Flandre Hospital, Lille, France; Unit EA 4489 Perinatal Environment and Growth, Faculty of Medicine, Henri-Warembourg, University of Lille, Lille, France
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23
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Veujoz M, Sananès N, Severac F, Meyer N, Weingertner AS, Kohler M, Guerra F, Gaudineau A, Nisand I, Favre R. Evaluation of prenatal and postnatal diagnostic criteria for twin anemia-polycythemia sequence. Prenat Diagn 2015; 35:281-8. [DOI: 10.1002/pd.4545] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 10/30/2014] [Accepted: 12/01/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Marine Veujoz
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Nicolas Sananès
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
- INSERM, UMR-S 1121, ‘Biomatériaux et Bioingénierie’; Strasbourg France
| | - François Severac
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
- Department of Public Health; Strasbourg University Teaching Hospital; Strasbourg France
| | - Nicolas Meyer
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
- Department of Public Health; Strasbourg University Teaching Hospital; Strasbourg France
| | - Anne-Sophie Weingertner
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Monique Kohler
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Fernando Guerra
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Adrien Gaudineau
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Israël Nisand
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Romain Favre
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
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24
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Yokouchi T, Murakoshi T, Mishima T, Yano H, Ohashi M, Suzuki T, Shinno T, Matsushita M, Nakayama S, Torii Y. Incidence of spontaneous twin anemia-polycythemia sequence in monochorionic-diamniotic twin pregnancies: Single-center prospective study. J Obstet Gynaecol Res 2014; 41:857-60. [DOI: 10.1111/jog.12641] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 10/15/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Tae Yokouchi
- Division of Obstetrics and Perinatology; Maternal and Perinatal Care Center; Seirei Hamamatsu General Hospital; Shizuoka Japan
| | - Takeshi Murakoshi
- Division of Obstetrics and Perinatology; Maternal and Perinatal Care Center; Seirei Hamamatsu General Hospital; Shizuoka Japan
| | - Takashi Mishima
- Division of Obstetrics and Perinatology; Maternal and Perinatal Care Center; Seirei Hamamatsu General Hospital; Shizuoka Japan
| | - Hiroko Yano
- Division of Obstetrics and Perinatology; Maternal and Perinatal Care Center; Seirei Hamamatsu General Hospital; Shizuoka Japan
| | - Madoka Ohashi
- Division of Obstetrics and Perinatology; Maternal and Perinatal Care Center; Seirei Hamamatsu General Hospital; Shizuoka Japan
| | - Takashi Suzuki
- Division of Obstetrics and Perinatology; Maternal and Perinatal Care Center; Seirei Hamamatsu General Hospital; Shizuoka Japan
| | - Takashi Shinno
- Division of Obstetrics and Perinatology; Maternal and Perinatal Care Center; Seirei Hamamatsu General Hospital; Shizuoka Japan
| | - Mitsuru Matsushita
- Division of Obstetrics and Perinatology; Maternal and Perinatal Care Center; Seirei Hamamatsu General Hospital; Shizuoka Japan
| | - Satoru Nakayama
- Division of Obstetrics and Perinatology; Maternal and Perinatal Care Center; Seirei Hamamatsu General Hospital; Shizuoka Japan
| | - Yuichi Torii
- Division of Obstetrics and Perinatology; Maternal and Perinatal Care Center; Seirei Hamamatsu General Hospital; Shizuoka Japan
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25
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Yamashita A, Ishii K, Taguchi T, Mabuchi A, Ota S, Sasahara J, Hayashi S, Mitsuda N. Adverse perinatal outcomes related to the delivery mode in women with monochorionic diamniotic twin pregnancies. J Perinat Med 2014; 42:769-75. [PMID: 24728848 DOI: 10.1515/jpm-2014-0072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 03/24/2014] [Indexed: 11/15/2022]
Abstract
AIMS The association between the planned delivery mode and adverse perinatal outcomes of monochorionic diamniotic (MCDA) twin pregnancies at ≥36 weeks' gestation was evaluated. METHODS This retrospective cohort study included uncomplicated MCDA twin pregnancies delivered after 36 weeks' gestation during a 10-year period. Cases were classified into the trial of labor (TOL) or cesarean section (CS) group according to the planned delivery mode. The primary outcome was a composite of adverse outcomes for at least one twin, including intrauterine fetal death (IUFD) after 36 weeks, neonatal death, umbilical artery pH<7.1, 5-min Apgar scores<7, hypoxic ischemic encephalopathy (HIE), meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), or acute feto-fetal hemorrhage (AFFH). The relationship between outcomes and the planned delivery mode was evaluated using a multiple logistic regression analysis. RESULTS We included the 310 pregnancies delivered after 36 weeks' gestation. After excluding 15 patients, the final analysis included 295 MCDA pregnancies: 63% had delivered through TOL and 37% through CS. The incidences of composite adverse outcomes in the TOL and CS groups were 4.3% and 1.9%, respectively. No IUFD, neonatal death, MAS, RDS, or AFFH was observed; two infants in each group developed HIE. Adverse outcomes were not significantly associated with any risk factor, including delivery through TOL. CONCLUSION TOL may not influence the perinatal outcomes of MCDA twin pregnancies delivered at ≥36 weeks' gestation.
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MESH Headings
- Adolescent
- Adult
- Cesarean Section/adverse effects
- Cohort Studies
- Female
- Fetal Death/etiology
- Humans
- Incidence
- Infant, Newborn
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/mortality
- Logistic Models
- Male
- Outcome Assessment, Health Care
- Pregnancy
- Pregnancy, Twin
- Retrospective Studies
- Risk Factors
- Trial of Labor
- Twins, Monozygotic
- Young Adult
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26
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Gapp-Born E, Sananes N, Weingertner AS, Guerra F, Kohler M, Fritz G, Viville B, Gaudineau A, Langer B, Sauleau E, Nisand I, Favre R. Predictive value of cardiovascular parameters in twin-to-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:427-433. [PMID: 24585420 DOI: 10.1002/uog.13351] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 02/01/2014] [Accepted: 02/18/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate the prognostic value of the Children's Hospital Of Philadelphia (CHOP) cardiovascular score and the modified myocardial performance index (MPI), in determining the risk of recipient fetal loss in twin-to-twin transfusion syndrome (TTTS). METHODS This cohort study was based on data collected prospectively from 105 pregnancies complicated by TTTS (Quintero stages I-IV) and treated with laser photocoagulation between May 2008 and February 2013. Fetuses underwent detailed anatomical and Doppler ultrasonography with cardiac assessment as part of routine care. CHOP score and right MPI were calculated and cut-offs selected using receiver-operating characteristics curve analysis. These were compared according to loss of recipient fetus, using univariate and multivariate logistic regression. The correlation between CHOP score, MPI and Quintero stage was determined and we investigated differences in MPI before and after laser coagulation in a cohort of 90 recipient fetuses. RESULTS Rates of recipient fetal loss were significantly higher when the CHOP score was ≥ 3 (39.5% vs 12.9%, P = 0.002) and when MPI z-score was > 1.645 (34.5% vs 10.6%, P = 0.004). After adjustment for Quintero stage, the risk of recipient fetal loss remained significantly higher when the CHOP score was ≥ 3 (odds ratio, 3.09; 95% CI, 1.035-9.21). There was a positive correlation between CHOP score, MPI and Quintero stage. MPI was significantly lower after compared with before laser coagulation. CONCLUSION CHOP score and MPI are predictors of recipient fetal loss in TTTS and may be used to supplement Quintero's classification.
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Affiliation(s)
- E Gapp-Born
- Department of Obstetrics and Gynaecology, Strasbourg University Teaching Hospital, Strasbourg, France
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Mabuchi A, Ishii K, Yamamoto R, Taguchi T, Murata M, Hayashi S, Mitsuda N. Clinical characteristics of monochorionic twins with large hemoglobin level discordance at birth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:311-315. [PMID: 24585685 DOI: 10.1002/uog.13343] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 02/02/2014] [Accepted: 02/14/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To evaluate neonatal outcomes and clinical characteristics of monochorionic diamniotic (MCDA) twins with a large intertwin hemoglobin (Hb) difference at birth. METHODS This was a retrospective cohort study of MCDA twin gestations delivered at Osaka Medical Center and Research Institute for Maternal and Child Health between 2003 and 2012. Cases of pregnancy termination, acardiac twins or intrauterine death were excluded. A large intertwin Hb difference at birth was defined as > 8.0 g/dL according to the postnatal criteria for twin anemia-polycythemia sequence (TAPS). The intertwin reticulocyte count ratio (RCR) was calculated by dividing the reticulocyte count of the anemic twin by that of the polycythemic twin. Cases with Hb differences were divided into two groups according to the RCR, TAPS when the RCR was > 1.7 and acute fetofetal hemorrhage (AFFH) when the RCR was ≤ 1.7. Neonatal outcomes were compared between the TAPS and AFFH groups. RESULTS During the study period, 432 MCDA twin pregnancies of a total of 532 born at our hospital were analyzed. There were 12 (2.8%) cases of a large intertwin Hb difference. The median gestational age at birth of these cases was 34 (range, 23-38) weeks, and all were delivered by Cesarean section. There were seven (1.6%) cases of TAPS and five (1.2%) of AFFH. The neonatal survival rate was 91.7%; in one pair of twins with TAPS neonatal death occurred. All (100%) cases with TAPS and two (40%) with AFFH required blood transfusion or partial-exchange transfusion for at least one infant. CONCLUSIONS Although the incidence of TAPS and AFFH may be low in MCDA twins, many affected neonates required treatment for hematological abnormalities. Delivery of MCDA twins via Cesarean section does not appear to prevent AFFH, despite the absence of labor.
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Affiliation(s)
- A Mabuchi
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
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Seelbach-Goebel B. Twin Birth Considering the Current Results of the "Twin Birth Study". Geburtshilfe Frauenheilkd 2014; 74:838-844. [PMID: 25278625 PMCID: PMC4175125 DOI: 10.1055/s-0034-1383064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 08/20/2014] [Accepted: 08/20/2014] [Indexed: 01/26/2023] Open
Abstract
The rate of caesarean sections in multiple births has grown sharply worldwide. The reason for this may be the results of large retrospective cohort studies from the 1990s, which displayed an increased risk of mortality and morbidity, especially for the second twin, in the case of vaginal births. Multiple monocentric analyses have not been able to confirm this. As a prospective, multi-centre randomised study, the Twin Birth Study published in 2013, in which 105 clinics in 25 countries took part, showed that, under optimum conditions, there was no difference in neonatal and maternal mortality and morbidity if the birth was planned to be vaginal or via caesarean. Detailed analyses, which would be helpful in choosing the type of birth method and obstetric management in the event of vaginal birth, have not previously been published. Retrospective studies must be referred to for this.
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Affiliation(s)
- B. Seelbach-Goebel
- Hospital of the Merciful Brothers – St. Hedwig Clinic, Department of Obstetrics and Gynaecology of the University , of Regensburg, Regensburg
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