Birth weight discordance and adverse perinatal outcomes

Association between first-trimester uterine artery Doppler and crown-rump length with growth discordance: does it make a difference

OBJECTIVES

The purpose of this study was to investigate the association between first-trimester uterine artery pulsatility index (UtA-PI) and crown-rump length discordance (CRLD) with growth discordance (GD) in twins and analyze the influence of chorionicity in these parameters.

METHODS

This retrospective analysis integrated data from the twin pregnancy database of Centro Hospitalar São João (2019-2023), including 184 fetuses, with 19 monochorionic and 73 dichorionic gestations. To determine the association between UtA-PI and CRLD with GD, correlation analyses were computed and linear regression models were carried out. Separate analyses were conducted for each type of placentation. Logistic regression analysis was carried out to determine the association of mean UtA-PI and CRLD with severe GD, defined as discordance ≥25 %.

RESULTS

GD≥25 % was detected in 9.80 % of pregnancies. A statistically significant difference between monochorionic and dichorionic gestations was found in crown-rump length (p=0.009), CRLD (p<0.001) and birth weight (p=0.025), but not in mean UtA-PI (p=0.853) or GD (p=0.556). Mean UtA-PI was significantly higher in discordant than in concordant pairs (p<0.001), but that association was not seen in CRLD (p=0.931). Mean UtA-PI and GD were correlated by the regression line "GD=3.844 × UtA-PI + 6.638", with R2 0.027. CRLD and GD were correlated by the regression line "GD=0.280 × CRLD + 10.79", with R2 0.010. Mean UtA-PI, but not CRLD, was significantly associated with severe GD (odds ratio, 22.753; p=0.002).

CONCLUSIONS

Mean UtA-PI, but not CRLD, is associated with GD. The prevalence of severe GD increases significantly with increasing mean UtA-PI.

Perinatal outcomes and growth discordance of triplet pregnancies based on chorionicity: a retrospective cohort study

BACKGROUND

The worldwide occurrence of triplet pregnancy is estimated to be 0.093%, with a natural incidence of approximately 1 in 8000. This study aims to analyze the neonatal health status and birth weight discordance (BWD) of triplets based on chorionicity from birth until discharge.

METHODS

This was a retrospective study. We reviewed a total of 136 triplet pregnancies at our tertiary hospital between January 1, 2001, and December 31, 2021. Maternal and neonatal outcomes, inter-triplet BWD, neonatal morbidity, and mortality were analyzed.

RESULTS

Among all cases, the rates of intrauterine death, neonatal death, and perinatal death were 10.29, 13.07, and 24.26%, respectively. Thirty-seven of the cases resulted in fetal loss, including 13 with fetal anomalies. The maternal complications and neonatal outcomes of the 99 triplet pregnancies without fetal loss were compared across different chorionicities, including a dichorionic (DC) group (41 cases), trichorionic (TC) group (37 cases), and monochorionic (MC) group (21 cases). Neonatal hypoproteinemia (P < 0.001), hyperbilirubinemia (P < 0.019), and anemia (P < 0.003) exhibited significant differences according to chorionicity, as did the distribution of BWD (P < 0.001). More than half of the cases in the DC and TC groups had a BWD < 15%, while those in the MC group had a BWD < 50% (47.6%). TC pregnancy decreased the risk of neonatal anemia (adjusted odds ratio [AOR] = 0.084) and need for blood transfusion therapy after birth (AOR = 0.119). In contrast, a BWD > 25% increased the risk of neonatal anemia (AOR = 10.135) and need for blood transfusion after birth (AOR = 7.127). TC pregnancy, MCDA or MCTA, and BWD > 25% increased neonatal hypoproteinemia, with AORs of 4.629, 5.123, and 5.343, respectively.

CONCLUSIONS

The BWD differed significantly according to chorionicity. Additionally, TC pregnancies reduced the risk of neonatal anemia and need for blood transfusion, but increased the risk of neonatal hypoproteinemia. In contrast, the BWD between the largest and smallest triplets increased the risk of neonatal anemia and the need for blood transfusion. TC pregnancy, MCDA or MCTA, and BWD > 25% increased the risks of neonatal hypoproteinemia. However, due to the limited number of triplet pregnancies, further exploration of the underlying mechanism is warranted.

Long-term adverse neurodevelopmental outcomes of discordant twins delivered at term: A nationwide population-based study

OBJECTIVE

To evaluate long-term adverse neurodevelopmental outcomes of discordant twins delivered at term.

DESIGN

Retrospective cohort study.

SETTING

Nationwide (Republic of Korea).

POPULATION

All twin children delivered at term between 2007 and 2010.

METHODS

The study population was divided into two groups according to inter-twin birthweight discordancy: the 'concordant twin group', twin pairs with inter-twin birthweight discordancy less than 20%; and the 'discordant twin group', twin pairs with inter-twin birthweight discordancy of 20% or more. The risk of long-term adverse neurodevelopmental outcomes was compared between the concordant twin group and the discordant twin group. Long-term adverse neurodevelopmental outcomes between smaller and larger twin children within twin pairs were further analysed. The composite adverse neurodevelopmental outcome was defined as the presence of at least one of the following: motor developmental delay, cognitive developmental delay, autism spectrum disorders/attention deficit hyperactivity disorders, tics/stereotypical behaviour or epileptic/febrile seizure.

MAIN OUTCOME MEASURES

Long-term adverse neurodevelopmental outcome.

RESULTS

Of 22 468 twin children (11 234 pairs) included, 3412 (15.19%) twin children were discordant. The risk of composite adverse neurodevelopmental outcome was higher in the discordant twin group than in the concordant twin group (adjusted hazard ratio [HR] 1.13, 95% CI 1.03-1.24). The long-term adverse neurodevelopmental outcomes were not significantly different between smaller and larger twin children in discordant twin pairs (adjusted HR 1.01, 95% CI 0.81-1.28).

CONCLUSION

In twin pairs delivered at term, an inter-twin birthweight discordancy of 20% or greater was associated with long-term adverse neurodevelopmental outcomes; and long-term adverse neurodevelopmental outcomes were not significantly different in smaller or larger twin children in discordant twin pairs.

Fetal growth restriction, neonatal morbidity and placental pathology in dichorionic twins-a comparison of twin-specific versus singleton growth charts‏‏

INTRODUCTION

Fetal growth restriction (FGR) in dichorionic diamniotic (DCDA) twin gestations is a known complication associated with adverse neonatal outcomes. The international guidelines have no consensus on whether to use singleton or twin-specific growth charts. Thus, we aimed to compare growth charts in correlation with pregnancy outcomes and placental histopathology.

METHODS

The medical files of all DCDA twin deliveries between 2010 and 2020 were reviewed. Birthweight percentile for gestational age (GA) for each individual neonate was assigned using the updated local singleton and twin-specific growth chart. We then divided the study population into two groups, neonates that were FGR based on the local singleton charts (FGR-singleton group) versus FGR on both twin-specific and singleton charts (FGR-twin group). Placental lesions were classified as lesions related to maternal or fetal malperfusion lesions (MVM, FVM), vascular and villous changes, and inflammatory lesions.

RESULTS

Overall, 185 neonates met the inclusion criteria. The FGR-twin group (59/185) had a higher rate of PE, lower GA at delivery, lower birthweight, and a higher rate of neonatal composite adverse outcomes compared to the FGR-singleton group. Moreover, placental pathology of the FGR-twin group demonstrated a higher rate of MVM lesions (p = 0.035).

DISCUSSION

In our cohort, neonates considered FGR based on twin-specific charts had worse neonatal outcomes with underlying placental insufficiency demonstrated by a higher rate of placental malperfusion vascular lesions. Our findings support using a twin-specific chart to diagnose FGR that is more clinically relevant.

Role of birthweight discordance in preterm twins' outcomes in the Korean neonatal network

BACKGROUND

Twin pregnancies can be complicated by birthweight (BW) discordance. We analyzed the impact of BW discordance on clinical outcomes of very-low-birthweight (VLBW) twins.

METHODS

The study population was preterm infants in the Korean Neonatal Network registry. Multivariate logistic regression analyses were used to determine the contribution of BW discordance on respiratory morbidities and mortality of VLBW infants. Also, we assessed the effect of small for gestational age (SGA) on morbidity and mortality in discordant twins (DTs) and compared separately the clinical outcomes of smaller and larger DTs with different singletons matched for perinatal factors including BW percentile.

RESULTS

A total of 935 twin pairs [1548 concordant twins (CTs) and 322 DTs] were included. BW discordance was associated with increased odds of moderate bronchopulmonary dysplasia, mortality, and composite outcomes. Compared with the CTs, the smaller, but not larger, DTs had greater odds of morbidities and mortality. DTs had higher odds of adverse neonatal outcome when combined with SGA. Meanwhile, DTs had morbidities and mortality similar to singletons matched for BW percentile.

CONCLUSION

BW discordance in VLBW twins adversely affects neonatal mortality or respiratory morbidity which is predominant in smaller DTs. The impact of BW discordance could be increased through SGA.

Prevalence and Factors Associated With Intertwin Birth Weight Discordance Among Same-Sex Twins in Lombardy, Northern Italy

This population-based cohort study investigated the prevalence, potential risk factors, and consequences of birth weight discordance (BWD) among same-sex twins. We retrieved data from the automated system of healthcare utilization databases of Lombardy Region, Northern Italy (2007-2021). BWD was defined as 30% or more disparity in birth weights between the larger and the smaller twin. Multivariate logistic regression was used to analyze the risk factors of BWD in deliveries with same-sex twins. In addition, the distribution of several neonatal outcomes was assessed overall and according to BWD level (i.e., ≤20%, 21-29, and ≥30%). Finally, a stratified analysis by BWD was performed to assess the relationship between assisted reproductive technologies (ART) and neonatal outcomes. We identified 11,096 same-sex twin deliveries; 556 (5.0%) pairs of twins were affected by BWD. Multivariate logistic regression analysis showed that maternal age ≥35 years (OR 1.26, 95% CI [1.05,5.51]), low level of education (OR 1.34, 95% CI [1.05, 1.70]), and ART (OR 1.16, 95% CI [0.94, 1.44], almost significant due to the low power) were independent risk factors for BWD in same-sex twins. Conversely, parity (OR 0.73, 95% CI [0.60, 0.89]) was inversely related. All the adverse outcomes observed were more common among BWD pairs than non-BWD ones. Instead, a protective effect of ART was observed for most neonatal outcomes considered among BWD twins. Our results suggest that conception after ART increases the risk of developing a high disparity between the weights of the two twins. However, the presence of BWD may complicate twin pregnancies, compromising neonatal outcomes, regardless of the modality of conception.

Is there an impact of fetal sex in dichorionic discordant twins on placental histopathological abnormalities?

INTRODUCTION

Growth discordancy in dichorionic diamniotic (DCDA) twin gestations is a known complication associated with adverse neonatal outcomes. We aimed to study the differences in placental pathology, in relation to fetal sex, in DCDA twin gestations complicated with growth discordancy.

METHODS

The medical files of all DCDA twin deliveries complicated by growth discordancy between 2010 and 2020 were reviewed. Growth discordance was defined as a gap between twin birthweights > 20%. A comparison was made between female vs. male growth discordant twins. Placental lesions were classified as lesions related to maternal or fetal malperfusion lesions (MVM, FVM), vascular and villous changes, and inflammatory lesions.

RESULTS

Included 174 DCDA twins. Eighty-eight were in the discordant female group and eighty-six in the discordant male group. The groups did not differ in maternal demographics, pregnancy characteristics, and neonatal outcome. The discordant male group had a higher rate of placental MVM lesions as compared to the discordant female group (p = 0.003). The increased rate of placental MVM lesions in the discordant male group compared to the discordant female group did not change whether its co-twin was of similar or opposite sex.

DISCUSSION

Higher rate of MVM lesions characterizes growth discordant male neonates in DCDA twin gestations. This finding could represent a different adaptation of male fetuses to a hostile intrauterine environment.

Assessment of different thresholds of birthweight discordance for early neonatal outcomes: retrospective analysis of 2348 twin pregnancies

Background

The optimal threshold of birthweight discordance (BWD) remains controversial. This study aimed to evaluate the associations between BWD at different thresholds and early neonatal outcomes and to assess their predictive accuracy.

Methods

This was a retrospective cohort study using a birthweight data with the chorionicity information of 2348 liveborn twin pairs at a gestational age of ≥26 weeks, from 2012 to 2018. The percentage of BWD was calculated by dividing the actual birthweight difference by the weight of the larger twin and multiplying by 100. Outcomes of interest included neonatal intensive care unit (NICU) admission, neonatal respiratory distress syndrome (NRDS), ventilator support and a composite outcome combining major morbidities and neonatal death. Logistic regression models were performed to estimate the association between neonatal outcomes and BWD with different thresholds (≥15.0%, ≥20.0%, ≥25% and ≥ 30%). Generalized estimated equation (GEE) models were used to address intertwin correlation. Restrictive cubic spline (RCS) models were established to draw the dose-response relationship between BWD and the odds ratios of outcomes. Clustered receiver operating characteristic (ROC) curve analyses were performed to assess the predictive accuracy.

Results

Of 2348 twin pairs, including 1946 dichorionic twin pairs and 402 monochorionic twin pairs, BWD was significantly associated with NICU admission, regardless of the thresholds used. The incidence of NRDS, ventilator support and the composite outcome were significantly higher when a threshold of ≥20% or greater was chosen. The dose-response relationship showed nonlinear growth in the risk of adverse neonatal outcomes with increasing BWD. ROC analyses showed a low significant AUROC of 0.569 (95% CI: 0.526–0.612) for predicting NICU admission but no significant AUROCs for predicting other outcomes. A BWD of ≥30% provided a moderate increase in the likelihood of NICU admission [positive likelihood ratio (LR⁺) = 5.77].

Conclusion

Although BWD is independently associated with adverse neonatal outcomes, it is not a single predictor for neonatal outcomes given the weak discriminative ability to predict neonatal outcomes. A cutoff of 30% is more practical for risk stratification among twin gestations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04417-4.

Gestational hypertensive disease and birthweight discordance in twin pregnancies: a systematic review and meta-analysis

INTRODUCTION

The objective of this systematic review was to explore the association between gestational hypertensive disease (GHD) and birthweight discordance in twin pregnancies.

METHODS

PubMed, Embase, Web of Science and Cochrane Library were systematically searched for studies reporting the risk of birthweight discordance in twin pregnancies complicated compared with those not complicated by GHD from establishment until July 2021. Risk of bias was assessed with the Newcastle-Ottawa Scale. According to the classification of GHD, sub-group analyses reporting cases with gestational hypertension (GH), chronic hypertension (CH) and preeclampsia (PE) were performed separately. Stratification by twin chorionicity (dichorionic (DC) and monochorionic (MC)) was also conducted. When there was substantial heterogeneity (I² ≥ 50%), the random effect mode was used to estimate the pooled risk ratio, otherwise the fixed effect model was used.

RESULTS

Nine studies (303,204 twin pregnancies) were included. GHD (OR 1.45, 95% CI 1.41-1.49) was a risk factor for intertwin birthweight discordance [PE (OR 1.69, 95% CI 1.33-2.16); CH (OR 1.59, 95% CI 1.46-1.73); GH (OR1.45, 95%Cl 1.10-1.92]. After stratification, birthweight discordance was related to GHD (OR 2.51, 95% CI 2.01-3.14), GH (OR 2.08, 95% CI 1.33-3.25) and PE (OR 2.74, 95% CI 2.09-3.61) in DC pregnancies, but no longer associated with GHD and PE in MC group.

CONCLUSIONS

Twin gestations complicated with GHD, especially in DC pregnancies, were at significantly higher risk of birthweight discordance.

Low birth weight as a predictor of adverse health outcomes during adulthood in twins: a systematic review and meta-analysis

BACKGROUND

Low birth weight might affect adverse health outcomes during a lifetime. Our study analyzes the association between low birth weight and negative health outcomes during adulthood in twin populations.

METHODS

Searches were conducted using databases inclusive of MEDLINE, CINAHL, Web of Science, and EBSCO. Observational studies on twins with low birth weight and adverse health outcomes during adulthood were included. Two reviewers independently screened the papers, and a third reviewer resolved the conflicts between the two reviewers. Following abstract and title screening, full-texts were screened to obtain eligibility. Eligible full-text articles were then assessed for quality using a modified Downs and Black checklist. Studies with a score within one standard deviation of the mean were included in the analysis. A fixed-effect model was used for analysis.

RESULTS

3987 studies were screened describing low birth weight as a risk factor for adverse health outcomes during adulthood for all twelve-body systems (circulatory, digestive, endocrine, lymphatic, muscular, nervous, reproductive, respiratory, skeletal, urinary, and integumentary systems). One hundred fourteen articles made it through full-text screening, and 14 of those articles were assessed for quality. Five papers were selected to perform two meta-analyses for two outcomes: asthma and cerebral palsy. For asthma, the meta-analyses of three studies suggested a higher odds of low birth weight twins developing asthma (OR 1.33, 95% CI 1.24-1.44, I2 = 77%). Meta-analysis for cerebral palsy included two studies and suggested a 4.88 times higher odds of low birth weight twins developing cerebral palsy compared to normal birth weight twins (OR 4.88, 95% CI 2.34-10.19, I2 = 79%). We could not find enough studies for other adverse health outcomes to pool data for a Forest plot.

CONCLUSIONS

The odds of low birth weight were found to be high in both asthma and cerebral palsy. There are not enough studies of similar nature (study types, similar body systems) to ensure a meaningful meta-analysis. We recommend that future research considers following up on twins to obtain data about adverse health outcomes during their adult lives.

Ultrasound for diagnosis of birth weight discordance in twin pregnancies

BACKGROUND

There is a need to standardize monitoring in obstetric research of twin pregnancies. Identification of birth weight discordance (BWD), defined as a difference in the birth weights of twins, is a well-documented phenomenon in twin pregnancies. Ultrasound for the diagnosis of BWD informs complex decision making including whether to intervene medically (via laser photo coagulation) or deliver the twins to avoid fetal morbidities or even death. The question is, how accurate is this measurement?

OBJECTIVES

To determine the diagnostic accuracy (sensitivity and specificity) of ultrasound estimated fetal weight discordance (EFWD) of 20% and 25% using different estimated biometric ultrasound measurements compared with the actual BWD as the reference standard in twin pregnancies.

SEARCH METHODS

The search for this review was performed on 15 March 2019. We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), seven other databases, conference proceedings, reference lists and contacted experts. There were no language or date restrictions applied to the electronic searches, and no methodological filters to maximize sensitivity.

SELECTION CRITERIA

We selected cohort-type studies with delayed verification that evaluated the accuracy of biometric measurements at ultrasound scanning of twin pregnancies that had been proposed for the diagnosis of estimated BWD, compared to BWD measurements after birth as a reference standard. In addition, we only selected studies that considered twin pregnancies and applied a reference standard for EFWD for the target condition of BWD.

DATA COLLECTION AND ANALYSIS

We screened all titles generated by electronic database searches. Two review authors independently assessed the abstracts of all potentially relevant studies. We assessed the identified full papers for eligibility, and extracted data to create 2 × 2 tables. Two review authors independently performed quality assessment using the QUADAS-2 tool. We excluded studies that did not report data in sufficient detail to construct 2 × 2 tables, and where this information was not available from the primary investigators. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 39 eligible studies with a median study sample size of 140. In terms of risk of bias, there were many unclear statements regarding patient selection, index test and use of proper reference standard. Twenty-one studies (53%) were of methodological concern due to flow and timing. In terms of applicability, most studies were of low concern. Ultrasound for diagnosis of BWD in twin pregnancies at 20% cut-off Twenty-two studies provided data for a BWD of 20% and the summary estimate of sensitivity was 0.51 (95% CI 0.42 to 0.60), and the summary estimate of specificity was 0.91 (95% CI 0.89 to 0.93) (8005 twin pregnancies; very low-certainty evidence). Ultrasound for diagnosis of BWD in twin pregnancies at 25% cut-off Eighteen studies provided data using a BWD discordance of 25%. The summary estimate of sensitivity was 0.46 (95% CI 0.26 to 0.66), and the summary estimate of specificity was 0.93 (95% CI 0.89 to 0.96) (6471 twin pregnancies; very low-certainty evidence). Subgroup analyses were possible for both BWD of 20% and 25%. The diagnostic accuracy did not differ substantially between estimation by abdominal circumference and femur length but femur length had a trend towards higher sensitivity and specificity. Subgroup analyses were not possible by sex of twins, chorionicity or gestational age due to insufficient data.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that EFWD identified by ultrasound has low sensitivity but good specificity in detecting BWD in twin pregnancies. There is uncertain diagnostic value of EFWD; this review suggests there is insufficient evidence to support this index as the sole measure for clinical decision making to evaluate the prognosis of twins with growth discordance. The diagnostic accuracy of other measures including amniotic fluid index and umbilical artery Doppler resistive indices in combination with ultrasound for clinical intervention requires evaluation. Future well-designed studies could also evaluate the impact of chorionicity, sex and gestational age in the diagnostic accuracy of ultrasound for EFWD.

Predictive value of prenatal ultrasound parameters for dichorionic growth discordant twins

BACKGROUND

Twin growth discordance was demonstrated to be a risk factor for adverse perinatal outcomes, and prenatal ultrasonographic methods were utilized to predict twin growth discordance to improve outcomes. The results currently reported are not consistent due to the poor unified parameters and gestational durations.

METHODS

A total of 71 dichorionic twins with growth discordance and 346 dichorionic twins with normal growth were respectively included in the retrospective cohort study. The weight discordance of more than 25% was defined as a "growth discordant twin". The clinical baseline information, maternal outcomes, twin birth weights and fetal growth parameters (which were measured by ultrasound) were compared between the two groups from early gestation to late gestation. Multiple logistic regression and receiver operating characteristic curves were adopted to evaluate the predictive value of the growth parameters.

RESULTS

Compared with normal dichorionic twins, the clinical baseline conditions were similar in the twins those finally developed growth discordance. The fetal growth parameters and the deepest volume pocket of amniotic fluid in early and mid-pregnancy showed no obvious predictive values. The fetal growth parameters in late pregnancy showed predictive values, especially the discordance of estimated fetal weight (EFW) in the early third-trimester (P < 0.001, area under the curve, 0.822; the cut-off value, 20%; sensitivity, 66.67%; specificity, 91.30%; positive predictive value, 88.46%).

CONCLUSION

Two assessment approaches were suggested and adopted to predict twin growth discordance in the current study. Twin growth should be assessed longitudinally and dynamically. Normal twins may show growth imbalance in the early stage. The discordance of EFW in late pregnancy may be a useful indicator for a growth discordance of more than 25%, which is required further confirmation.

Growth patterns and associated risk factors of congenital malformations in twins

BACKGROUND

The rate of twinning continues to increase due to the combined effect of a rise in parental age and increased use of assisted reproductive technology. The risk of congenital anomalies in twins is higher than in singletons, but it is less well reported in relation to growth patterns. We focused to the auxological outcome of twin pregnancies when one or both of twins are affected by one or more malformations.

METHODS

We conducted a retrospective observational study reviewing the clinical charts of twins admitted in the period between January 2003 and December 2018 at the University Hospital of Palermo. The associations between malformations and anthropometric variables at birth were analyzed by comparison within each twin pair and regarding each variable as ordered difference between the two twins.

RESULTS

We studied data of 488 neonates (52% females) from 244 pregnancies. The rate of major congenital anomalies was 11%, affecting significantly the smaller twin (p = .00018; Odds ratio 3.21; 95% CI 1.65 6.59). Malformation class distribution was as following: genitourinary (24%), gastrointestinal (20%), cardiovascular (18.5%), musculoskeletal (11%), central nervous system (9%), syndromic (9%), ocular (5.5%) and diaphragmatic hernia (2%). The most predictive value, the Birthweight (BW) difference mean ratio in malformed versus not malformed neonates (- 0.31 vs 0.02; p = .0016) was distributed equally lower than zero in all malformed twins, except for those with congenital heart defects (p = .0000083). Microcephaly (head circumference < 2 standard deviation, SD) was present in 3% of symmetrically smaller twin, and severe microcephaly (< 3 SD) was present in 0.6%. We found that an intertwin BW discordance of 18% or greater identified 50% of neonates with microcephaly, but only 11% of malformed twins.

CONCLUSIONS

In case of one twin with a BW < 10th centile, a concomitant intertwin BW discordance ≥18% could reveal an increased risk for microcephaly but not for malformation. Lower values of BW, Ponderal index, Body mass index but above all negative value of BW difference mean ratio are associated with malformations in twin pairs.

The Relationship between Birth Weight Discordance and Adverse Infant Mortality among Monozygotic and Dizygotic Twins in Japan, 1995-2008

Using vital statistics in Japan (1995-2008), 154,578 live-born twin pairs (128,236 monozygotic [MZ] and 180,920 dizygotic [DZ]) were identified. The proportion of severe discordance among live-born twin births was twice as high in Japanese than Caucasian infants. There were 1858 MZ and 1620 DZ infant deaths. Computation of the relationship between infant mortality rate and birth weight discordance among the twins was performed. Discordance levels were classified into seven groups: <5%, five groups from 5-9% to 25-29%, and ≥30%.The mortality rate was significantly higher in MZ than DZ twins for discordances except at 5-9% and 10-14%. The lowest rate for MZ twins was at 5-9% (7.5 per 1000 live twins) and significantly increased from 10-14% (9.4) to ≥30% (83.4), while the lowest rate for DZ twins was at <5% (6.7), which significantly increased at 10-14% (8.0) and from 25-29% (12.1) to ≥30% (35.5). The relationship was also computed in two gestational age groups (<28 and ≥28 weeks). For births at <28 weeks, three discordances (after 20-24%) in MZ twins were associated with adverse mortality rate. For births at ≥28 weeks, the same relationship was obtained after 10-14% in MZ and after 20-24% in DZ twins. The relationship from 2002 to 2008 showed that the mortality rates significantly increased after 10-14% for both types of twins. In conclusion, five discordance levels in MZ and three levels in DZ twins were associated with adverse mortality rates.

Intrauterine growth discordance across gestation and birthweight discordance in dichorionic twins

BACKGROUND

Although intertwin size difference is an important measure of fetal growth, the appropriate cut point to define discordance is unclear. Few studies have assessed intertwin differences in estimated fetal weight longitudinally or in relation to size differences at birth.

OBJECTIVES

The objectives of the study were to estimate the magnitude of percentage differences in estimated fetal weight across gestation in dichorionic twins in relation to a fixed discordance cut point and compare classification of aberrant fetal growth by different measures (estimated fetal weight differences, birthweight discordance, small for gestational age).

STUDY DESIGN

Women aged 18-45 years from 8 US centers with dichorionic twin pregnancies at 8 weeks 0 days to 13 weeks 6 days gestation planning to deliver in participating hospitals were recruited into the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies-Dichorionic Twins study and followed through delivery (n = 140; 2012-2013). Ultrasounds were conducted at 6 targeted study visits to obtain fetal biometrics and calculate estimated fetal weight. Percent estimated fetal weight and birthweight differences were calculated: ([weight_larger - weight_smaller]/weight_larger)*100; discordance was defined as ≥18% for illustration. Birth sizes for gestational age (both, 1, or neither small for gestational age) were determined; twins were categorized into combined birthweight plus small for gestational age groups: birthweight discordance ≥18% (yes, no) with both, 1, or neither small for gestational age. Linear mixed-models estimated percentiles of estimated fetal weight percent differences across gestation and compared estimated fetal weight differences between combined birthweight discordance and small for gestational age groups. A Fisher exact test compared birthweight discordance and small for gestational age classifications.

RESULTS

Median estimated fetal weight percentage difference increased across gestation (5.9% at 15.0, 8.4% at 38.0 weeks), with greater disparities at higher percentiles (eg, 90th percentile: 15.6% at 15.0, 26.3% at 38.0 weeks). As gestation advanced, an increasing percentage of pregnancies were classified as discordant using a fixed cut point: 10% at 27.0, 15% at 34.0, and 20% at 38.0 weeks. Birthweight discordance and small for gestational age classifications differed (P = .002); for birthweight discordance ≥18% vs <18%: 44% vs 71% had neither small for gestational age; 56% vs 18% had 1 small for gestational age; no cases (0%) vs 11% had both small for gestational age, respectively. Estimated fetal weight percent difference varied across gestation by birthweight discordance plus small for gestational age classification (P = .040). Estimated fetal weight percentage difference increased with birthweight discordance ≥18% (neither small for gestational age: 0.46%/week [95% confidence interval, 0.08-0.84]; 1 small for gestational age: 0.57%/week [95% confidence interval, 0.25-0.90]) but less so without birthweight discordance (neither small for gestational age: 0.17%/week [95% confidence interval, 0.06-0.28]; 1 small for gestational age: 0.03%/week [95% confidence interval, -0.17 to 0.24]); both small for gestational age: 0.10%/week [95% confidence interval, -0.15 to 0.36]).

CONCLUSION

The percentage of dichorionic pregnancies exceeding a fixed discordance cut point increased over gestation. A fixed cut point for defining twin discordance would identify an increasing percentage of twins as discordant as gestation advances. Small for gestational age and percentage weight differences assess distinct aspects of dichorionic twin growth. A percentile cut point may be more clinically useful for defining discordance, although further study is required to assess whether any specific percentile cut point correlates to adverse outcomes.

Associations between estimated foetal weight discordance and clinical characteristics within dichorionic twins: The NICHD Fetal Growth Studies

BACKGROUND

Birthweight discordance is well studied, with less known about longitudinal inter-twin differences in foetal growth.

OBJECTIVE

To examine inter-twin per cent differences in EFW (EFW_% ), head (HC_% ) and abdominal circumference (AC_% ), and femur length (FL_% ) across gestation in dichorionic twin gestations and explore associated characteristics.

METHODS

Foetal biometrics were assessed by ultrasound and EFW calculated at ≤6 study visits among women with dichorionic twin pregnancies enrolled in the NICHD Fetal Growth Studies cohort (US, 2012-2013). Inter-twin per cent difference was defined: ([Size_{larger twin}  - Size_{smaller twin} ]/Size_{larger twin}  × 100). Linear mixed models evaluated per cent differences in foetal biometrics at 15 weeks and their change per week overall and by maternal/neonatal characteristics in unadjusted and adjusted models.

RESULTS

In 140 pregnancies, inter-twin per cent differences increased across gestation for EFW (0.18%/week, 95% confidence interval [CI] 0.10, 0.27), HC (0.03%/week, 95% CI 0.00, 0.06), and AC (0.03%/week, 95%CI -0.01, 0.08) but decreased for FL (-0.03%/week, 95% CI -0.09, 0.02). After adjustment, change in EFW_% difference across gestation differed by pre-pregnancy body mass index (BMI [kg/m² ]; underweight [<18.5]; normal weight [18.5-24.9]; overweight [25.0-29.9]; obese [≥30.0]; P_interaction  = .022); and conception method (in vitro fertilisation [IVF], intrauterine insemination, ovulation induction medication, donor egg/embryo, none; P_interaction  = .060). While EFW_% difference increased with normal pre-pregnancy BMI (0.24%/week, 95% CI 0.12, 0.37), little change was noted with pre-pregnancy obesity (0.01%/week, 95% CI -0.15, 0.17). EFW_% difference increased in conceptions without fertility treatments (0.23%/week, 95% CI 0.11, 0.34) but not IVF conceptions (-0.00%/week, 95% CI -0.16, 0.16). Similar patterns of differences across gestation were noted for HC_% by conception method (P_interaction  = .026) and AC_% by pre-pregnancy BMI (P_interaction  = .071); changes in HC_% differed by parity (nulliparous, multiparous; P_interaction  = .004).

CONCLUSIONS

EFW_% difference increased across gestation in dichorionic twins, but remained stable with pre-pregnancy obesity or IVF conception, patterns mirrored for HC and AC. Research is needed to understand pathologic versus physiologic differential twin growth trajectories.

Magnetic resonance imaging for prenatal estimation of birthweight in pregnancy: review of available data, techniques, and future perspectives

Fetuses at the extremes of growth abnormalities carry a risk of perinatal morbidity and death. Their identification traditionally is done by 2-dimensional ultrasound imaging, the performance of which is not always optimal. Magnetic resonance imaging superbly depicts fetal anatomy and anomalies and has contributed largely to the evaluation of high-risk pregnancies. In 1994, magnetic resonance imaging was introduced for the estimation of fetal weight, which is done by measuring the fetal body volume and converting it through a formula to fetal weight. Approximately 10 studies have shown that magnetic resonance imaging is more accurate than 2-dimensional ultrasound imaging in the estimation of fetal weight. Yet, despite its promise, the magnetic resonance imaging technique currently is not implemented clinically. Over the last 5 years, this technique has evolved quite rapidly. Here, we review the literature data, provide details of the various measurement techniques and formulas, consider the application of the magnetic resonance imaging technique in specific populations such as patients with diabetes mellitus and twin pregnancies, and conclude with what we believe could be the future perspectives and clinical application of this challenging technique. The estimation of fetal weight by ultrasound imaging is based mainly on an algorithm that takes into account the measurement of biparietal diameter, head circumference, abdominal circumference, and femur length. The estimation of fetal weight by magnetic resonance imaging is based on one of the 2 formulas: (1) magnetic resonance imaging-the estimation of fetal weight (in kilograms)=1.031×fetal body volume (in liters)+0.12 or (2) magnetic resonance imaging-the estimation of fetal weight (in grams)=1.2083×fetal body volume (in milliliters)ˆ0.9815. Comparison of these 2 formulas for the detection of large-for-gestational age neonates showed similar performance for preterm (P=.479) and for term fetuses (P=1.000). Literature data show that the estimation of fetal weight with magnetic resonance imaging carries a mean or median relative error of 2.6 up to 3.7% when measurements were performed at <1 week from delivery; whereas for the same fetuses, the relative error at 2-dimensional ultrasound imaging varied between 6.3% and 11.4%. Further, in a series of 270 fetuses who were evaluated within 48 hours from birth and for a fixed false-positive rate of 10%, magnetic resonance imaging detected 98% of large-for-gestational age neonates (≥95th percentile for gestation) compared with 67% with ultrasound imaging estimates. For the same series, magnetic resonance imaging applied to the detection of small-for-gestational age neonates ≤10th percentile for gestation, for a fixed 10% false-positive rate, reached a detection rate of 100%, compared with only 78% for ultrasound imaging. Planimetric measurement has been 1 of the main limitations of magnetic resonance imaging for the estimation of fetal weight. Software programs that allow semiautomatic segmentation of the fetus are available from imaging manufacturers or are self-developed. We have shown that all of them perform equally well for the prediction of large-for-gestational age neonates, with the advantage of the semiautomatic methods being less time-consuming. Although many challenges remain for this technique to be generalized, a 2-step strategy after the selection of a group who are at high risk of the extremes of growth abnormalities is the most likely scenario. Results of ongoing studies are awaited (ClinicalTrials.gov Identifier # NCT02713568).

Pregnancy and perinatal outcomes of first-trimester crown-rump length discordant IVF dichorionic twin pregnancies - a retrospective cohort study

RESEARCH QUESTION

This study aimed to evaluate the association between discordance in crown-rump length (CRL) and adverse pregnancy and perinatal outcomes in dichorionic twin pregnancies.

DESIGN

This was a retrospective cohort study of dichorionic twin pregnancies after IVF that showed two live fetuses at the first ultrasound scan between 6 ⁺⁵ and 8 weeks gestational age from 1 January 2015 to 31 December 2016. Study groups were defined by the presence or absence of 20% or more discordance in CRL. The primary outcomes were early fetal loss of one or both fetuses before 12 weeks and birthweight discordance. Secondary outcomes included fetal anomalies, fetal loss between 12 and 28 weeks, stillbirth, small for gestational age (SGA) at birth, low birthweight (LBW), very low birthweight (VLBW), admission to the neonatal intensive care unit (NICU) and preterm delivery (PTD).

RESULTS

CRL-discordant twin pregnancies were more likely to end in the loss of one fetus before 12 weeks' gestation (odds ratio [OR] 15.877, 95% confidence interval [CI] 10.495-24.019). Discordant twin pregnancies with twin deliveries had a significantly higher risk of birthweight discordance (OR 1.943, 95% CI 1.032-3.989). There was no significant difference in perinatal outcomes including fetal anomalies, PTD, LBW, VLBW, SGA, neonatal death and admission to NICU between singleton or twin deliveries.

CONCLUSIONS

Discordant twin pregnancies were at increased risk of one fetal loss prior to 12 weeks' gestation. Except for birthweight discordance, there was no significant difference between CRL discordance and other adverse perinatal outcomes.

The differences in placental pathology and neonatal outcome in singleton vs. twin gestation complicated by small for gestational age

OBJECTIVE

We aimed to compare placental histopathology and neonatal outcome between dichorionic diamniotic (DCDA) twins and singleton pregnancies complicated by small for gestational age (SGA).

METHODS

Medical files and placental pathology reports from all deliveries between 2008 and 2017 of SGA neonates, (birthweight < 10th percentile), were reviewed. Comparison was made between singleton pregnancies complicated with SGA (singletons SGA group) and DCDA twin pregnancies (Twins SGA group), in which only one of the neonates was SGA. Placental diameters were compared between the groups. Placental lesions were classified into maternal and fetal vascular malperfusion lesions (MVM and FVM), maternal (MIR) and fetal (FIR) inflammatory responses, and chronic villitis. Neonatal outcome parameters included composite of early neonatal complications.

RESULTS

The twins SGA group (n = 66) was characterized by a higher maternal age (p = 0.011), lower gestational age at delivery (34.9 ± 3.1 vs. 37.7 ± 2.6 weeks, p < 0.001), and a higher rate of preeclampsia (p = 0.010), compared to the singletons SGA group (n = 500). Adverse composite neonatal outcome was more common in the twins SGA group (p < 0.001). Placental villous lesions related to MVM (p < 0.001) and composite MVM lesions (p = 0.04) were more common in the singletons SGA group. On multivariate logistic regression analysis, the singletons SGA group was independently associated with placental villous lesions (aOR 3.6, 95% CI 1.9-7.0, p < 0.001) and placental MVM lesions (aOR 2.44, 95% CI 1.29-4.61, p = 0.006).

CONCLUSION

Placentas from SGA singleton pregnancies have more MVM lesions as compared to placentas from SGA twin pregnancies, suggesting different mechanisms involved in abnormal fetal growth in singleton and twin gestations.

Comparison of conventional 2D ultrasound to magnetic resonance imaging for prenatal estimation of birthweight in twin pregnancy

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.