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Chu TY, Chen CP, Chen PC, Chien YC, Yu HT, Lo LM, Hsieh TT, Shaw SW. A novel technique with cool-tip radiofrequency ablation for selective fetal reduction in complicated monochorionic twin. Taiwan J Obstet Gynecol 2025; 64:298-302. [PMID: 40049815 DOI: 10.1016/j.tjog.2024.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2024] [Indexed: 05/13/2025] Open
Abstract
OBJECTIVE To invent a novel method for selective fetal reduction in monochorionic (MC) twin using cool-tip radiofrequency ablation (RFA) and analysis the perinatal outcome. MATERIAL AND METHODS Complicated MC twins including twin-to twin transfusion syndrome (TTTS), selective fetal growth restriction (sFGR) and twin reverse arterial perfusion sequence (TRAP) were enrolled from 2020 to 2024. All cases were indicated for selective fetal reduction due to expected poor outcome. Equilateral triangle method using single puncture 4 times ablation with 17G cool-tip RFA to cord insertion site, umbilical vein and two umbilical arteries for complete stopping the blood flow. The power was starting from 60 W, 80 W, 80 W and 100 W 1 min each site. Outcome were analyzed. RESULTS A total of 51 cases were collected and treated in a single medical center. We divided first 20 cases as tradition group using single point ablation and novel 4-point ablation group after 21st cases. The overall co-twin survival rate after RFA procedure was 88 % (45 out of 51) in whole series. However, the co-twin survival rate in the novel 4-point group was better than single point group (93.5 % vs 80 %) with statistically significance. The maternal age, procedure at gestational age, procedure time and preterm birth rate did not show statistically difference between two groups. CONCLUSIONS This novel equilateral triangle method to stop all the umbilical blood flow achieved the high successful rate without maternal complication. The 17 g cool-tip RFA worked at low temperature to avoid thermal damage. This might be the new choice of RFA in monochorionic pregnancies.
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Affiliation(s)
- Ting Yi Chu
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Chih-Ping Chen
- Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Pei-Chen Chen
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and Tzu Chi University, Hualien, Taiwan; Institute of Pharmacology and Toxicology, College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Chen Chien
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsing-Tse Yu
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Liang-Ming Lo
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - T'sang-T'ang Hsieh
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Steven W Shaw
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Zhang HP, Bao L, Wu JJ, Zhou YQ. Independent risk factors for twin pregnancy adverse fetal outcomes before 28 gestational week by first trimester ultrasound screening. World J Radiol 2025; 17:103111. [PMID: 39876883 PMCID: PMC11755904 DOI: 10.4329/wjr.v17.i1.103111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2024] [Revised: 12/24/2024] [Accepted: 01/17/2025] [Indexed: 01/21/2025] Open
Abstract
BACKGROUND The incidence of multiple pregnancies has increased worldwide recently and women with a twin pregnancy are at higher risk of adverse outcomes compared with women with a singleton pregnancy. It is important to understand the risk factors for adverse fetal outcomes in twin pregnancy in order to guide clinical management. AIM To identify the independent risk factors, including maternal personal and family medical histories and first trimester ultrasound screening findings, for adverse fetal outcomes of twin pregnancy before 28 weeks of gestation. METHODS The data of 126 twin pregnancies in our hospital, including pregnancy outcomes, first trimester ultrasound screening findings and maternal medical history, were retrospectively collected. Twenty-nine women with adverse outcomes were included in the abnormal group and the remaining 97 women were included in the control group. RESULTS Patients in the abnormal group were more likely to be monochorionic diamniotic (13/29 vs 20/97, P= 0.009), with a higher mean pulsatility index (PI, 1.57 ± 0.55 vs 1.28 ± 0.42, P = 0.003; cutoff value: 1.393) or a higher mean resistance index (0.71 ± 0.11 vs 0.65 ± 0.11, P = 0.008; cutoff value: 0.683) or early diastolic notch of bilateral uterine arteries (UtAs, 10/29 vs 15/97, P = 0.024) or with abnormal ultrasound findings (13/29 vs 2/97, P < 0.001), compared with the control group. Monochorionic diamnioticity, higher mean PI of bilateral UtAs and abnormal ultrasound findings during first trimester screening were independent risk factors for adverse fetal outcomes (P < 0.05). CONCLUSION First trimester ultrasound screening for twin pregnancy identifies independent risk factors and is useful for the prediction of fetal outcomes.
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Affiliation(s)
- Hui-Ping Zhang
- Department of Ultrasound, Shanghai Changning Maternity and Infant Health Hospital, East China Normal University, Shanghai 200050, China
| | - Li Bao
- Department of Ultrasound, Shanghai Changning Maternity and Infant Health Hospital, East China Normal University, Shanghai 200050, China
| | - Jing-Jing Wu
- Department of Ultrasound, Shanghai Changning Maternity and Infant Health Hospital, East China Normal University, Shanghai 200050, China
| | - Yu-Qing Zhou
- Department of Ultrasound, Shanghai Changning Maternity and Infant Health Hospital, East China Normal University, Shanghai 200050, China
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Liberty G, Reyzer SM, Shenhav S, Anteby EY, Cohen SM, Yagel S. Ultrasound diagnosis of first trimester umbilical cord entanglement in monochorionic monoamniotic twins - case report and review of the literature. BMC Pregnancy Childbirth 2024; 24:801. [PMID: 39604909 PMCID: PMC11603871 DOI: 10.1186/s12884-024-06962-6] [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: 10/29/2023] [Accepted: 11/07/2024] [Indexed: 11/29/2024] Open
Abstract
BACKGROUND Diagnosis of umbilical cord entanglement (UCE) by ultrasound (US) in monochorionic monoamniotic (MCMA) twins in the second and third trimesters is common. However, only a few cases have been reported on the diagnosis of UCE as early as the first trimester. Herein, we report a case of the earliest-ever sonographic diagnosis of UCE and demonstrate the feasibility of its diagnosis by US. CASE PRESENTATION A 32-year-old gravida 2 para 1 woman conceived after assisted reproductive technology (ART) treatment. In transvaginal US examination at 8.5 gestational weeks, two embryos with regular heartbeats in the same amniotic sac and with only one yolk sac were demonstrated. The fetal crown-rump lengths were 20 and 21 mm, appropriate for 8.4 and 8.5 gestational weeks, respectively. HD-flow power Doppler 2D and 3D US demonstrated two tightly entangled umbilical cords of the two fetuses. Spectral Doppler US showed two different heart rates (162 and 167 beats per minute) and blood flow in opposite directions from the point of entanglement of the two umbilical cords. This was consistent with a diagnosis of a first-trimester MCMA pregnancy with UCE. Missed abortion of the two embryos was diagnosed by US examination at 10.5 weeks, and the pregnancy was terminated by dilatation and curettage without further complications. CONCLUSIONS UCE in the first trimester may occur as early as eight gestational weeks, and its diagnosis by ultrasound is feasible. UCE diagnosed in the first trimester may be a poor prognostic factor.
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Affiliation(s)
- Gad Liberty
- Barzilai Medical Centre Ashkelon, Obstetrics and Gynecology, Negev Faculty of Health Sciences, Ben-Gurion University, Hahistadrut Street 2, Ashkelon, 7827801, Israel.
| | - Sarit Mash Reyzer
- Barzilai Medical Centre Ashkelon, Obstetrics and Gynecology, Negev Faculty of Health Sciences, Ben-Gurion University, Hahistadrut Street 2, Ashkelon, 7827801, Israel
| | - Simon Shenhav
- Barzilai Medical Centre Ashkelon, Obstetrics and Gynecology, Negev Faculty of Health Sciences, Ben-Gurion University, Hahistadrut Street 2, Ashkelon, 7827801, Israel
| | - Eyal Y Anteby
- Barzilai Medical Centre Ashkelon, Obstetrics and Gynecology, Negev Faculty of Health Sciences, Ben-Gurion University, Hahistadrut Street 2, Ashkelon, 7827801, Israel
| | - Sarah M Cohen
- Hadassah University Hospital, Mt Scopus, Obstetrics and Gynecology, Jerusalem, Israel
| | - Simcha Yagel
- Hadassah University Hospital, Mt Scopus, Obstetrics and Gynecology, Jerusalem, Israel
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Wang Y, Tian Y, Luo J. The "Hand as Foot" teaching method in twin pregnancy. Asian J Surg 2024; 47:3970-3971. [PMID: 38724361 DOI: 10.1016/j.asjsur.2024.04.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/25/2024] [Indexed: 09/05/2024] Open
Affiliation(s)
- Yuhan Wang
- Hangzhou TCM Hospital of Zhejiang Chinese Medical University (Hangzhou Hospital of Traditional Chinese Medicine), Hangzhou, China
| | - Yishu Tian
- Center for Reproductive Medicine, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
| | - Jiamin Luo
- Center for Reproductive Medicine, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China.
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Gebb JS, Khalek N, Whitehead MT, Oliver ER. Monochorionic Twin Complications and Fetoscopic Interventions. Magn Reson Imaging Clin N Am 2024; 32:513-528. [PMID: 38944438 DOI: 10.1016/j.mric.2024.02.010] [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] [Indexed: 07/01/2024]
Abstract
Monochorionic twins are at risk for complications due to the presence of placental vascular anastomoses, including twin-twin transfusion syndrome, twin anemia-polycythemia sequence, selective fetal growth restriction, and twin reversed arterial perfusion sequence. While ultrasound is the primary modality to screen for the development of these complications, MRI plays an important role in assessing monochorionic twin pregnancies for the development of other complications, such as neurologic injury. In this article, the authors review the ultrasound imaging findings associated with monochorionic twin complications, management options, and the role for MRI in these pregnancies.
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Affiliation(s)
- Juliana S Gebb
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 7th Floor, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Department of Surgery, Children's Hospital of Philadelphia, 3500 Civic Center Boulevard, 2nd Floor, Philadelphia, PA 19104, USA; General, Thoracic and Fetal Surgery, The Hub for Clinical Collaboration@CHOP, 3500 Civic Center Boulevard, 2nd Floor, Philadelphia, PA 19104, USA
| | - Nahla Khalek
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 7th Floor, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Department of Surgery, Children's Hospital of Philadelphia, 3500 Civic Center Boulevard, 2nd Floor, Philadelphia, PA 19104, USA; General, Thoracic and Fetal Surgery, The Hub for Clinical Collaboration@CHOP, 3500 Civic Center Boulevard, 2nd Floor, Philadelphia, PA 19104, USA
| | - Matthew T Whitehead
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 7th Floor, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 3rd Floor, Philadelphia, PA 19104, USA; Neuroradiology, The Hub for Clinical Collaboration@CHOP, 3500 Civic Center Boulevard, 2nd Floor, Philadelphia, PA 19104, USA
| | - Edward R Oliver
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 7th Floor, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 3rd Floor, Philadelphia, PA 19104, USA.
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Maltez BS, Tarsa M, Leibel SL. Umbilical Cord Abnormality in a Monochorionic-Monoamniotic Twin Pregnancy. Neoreviews 2024; 25:e66-e69. [PMID: 38161185 DOI: 10.1542/neo.25-1-e66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Byron S Maltez
- School of Medicine, University of California, San Diego, San Diego, CA
| | - Maryam Tarsa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, San Diego, CA
| | - Sandra L Leibel
- Department of Pediatrics, University of California, San Diego, San Diego, CA
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Kozinszky Z, Surányi A. The High-Risk Profile of Selective Growth Restriction in Monochorionic Twin Pregnancies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040648. [PMID: 37109605 PMCID: PMC10141888 DOI: 10.3390/medicina59040648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/13/2023] [Indexed: 04/29/2023]
Abstract
The present review aims to provide a critical appraisal of the sonographic diagnosis and follow-up and to evaluate the optimal clinical management of monochorionic twin pregnancies where one of the twins is complicated by selective fetal growth restriction (sFGR). The classification is based on the umbilical artery (UA) diastolic flow reflecting the outcome. If the sFGR twin has positive diastolic flow (Type I) then the prognosis is good, and it does not require close surveillance. Biweekly or weekly sonographic and Doppler surveillance and fetal monitoring are recommended strategies to detect unpredictable complications in type II and type III forms, which are defined by persistently absent/reverse end-diastolic flow (AREDF) or cyclically intermittent absent/reverse end-diastolic flow (iAREDF) in the umbilical waveforms, respectively. The latest forms are associated with an increased risk of unexpected fetal demise of the smaller twin and 10-20% risk of neurological injury in the larger twin in addition to the overall risk of prematurity. The clinical course can be affected by elective fetal therapy ('dichorinization' of the placenta with laser or selective fetal reduction) or elective delivery in the presence of severe fetal deterioration. The prediction of the clinical outcome in complicated cases of type II and III sFGR cases remains elusive. Novel routines in fetal and placental scans in order to predict neurological impairments and unexpected fetal death to optimize the delivery time-point are needed.
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Affiliation(s)
- Zoltan Kozinszky
- Department of Obstetrics and Gynaecology, Danderyds Hospital, 182 88 Stockholm, Sweden
| | - Andrea Surányi
- Department of Obstetrics and Gynaecology, Albert Szent-Györgyi Medical School, University of Szeged, 6725 Szeged, Hungary
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Perinatal outcome in monoamniotic twin pregnancies during a 10-year period: a single center, descriptive study. Arch Gynecol Obstet 2023; 307:233-239. [PMID: 35347381 PMCID: PMC9836963 DOI: 10.1007/s00404-022-06506-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 03/04/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To retrospectively investigate perinatal outcome of monoamniotic twin pregnancies in a tertiary center during a 10 year period. METHODS A retrospective analysis of all monoamniotic pregnancies managed at Karolinska University Hospital, Stockholm, Sweden 2010-2019 was performed. The primary outcomes were live birth rate, neonatal death and perinatal survival. The secondary outcomes were late miscarriage, gestational age at delivery and frequency of fetal complications. RESULTS Twenty-two monoamniotic pregnancies, with 44 fetuses, were identified. Thirty-five of 44 fetuses (80%) were liveborn. Of 36 fetuses reaching 24 weeks gestation, 35 (97%) were liveborn. There were no neonatal deaths, thus the perinatal survival was 97%. The mean gestational age at birth was 32.5 weeks (SD ± 1.5). CONCLUSIONS The live birth rate and perinatal survival of monoamniotic pregnancies managed at Karolinska University Hospital was high and comparable to previously published data.
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Single Intrauterine Death in Twin Pregnancy: Evidenced-based Counselling and Management. Best Pract Res Clin Obstet Gynaecol 2022; 84:205-217. [DOI: 10.1016/j.bpobgyn.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022]
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Wojas A, Martin KA, Koyen Malashevich A, Hashimoto K, Parmar S, White R, Demko Z, Billings P, Jelsema R, Rebarber A. Clinician-reported Chorionicity and Zygosity Assignment using single-nucleotide polymorphism-based cell-free DNA Lessons learned from 55,344 Twin Pregnancies. Prenat Diagn 2022; 42:1235-1241. [PMID: 35997139 PMCID: PMC9541063 DOI: 10.1002/pd.6218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/06/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022]
Abstract
Objective Prenatal chorionicity assessment relies on ultrasound, which can be confounded by many factors. Noninvasive assessment of zygosity is possible using single nucleotide polymorphism (SNP)‐based cell‐free DNA testing. Our objective was to determine the relationship between provider‐reported chorionicity and SNP‐cfDNA assignment of twin zygosity. Methods All twin pregnancy blood samples received by a reference laboratory between September 27, 2017 and September 8, 2021 were included. Chorionicity assignment was requested on the requisition, recorded as; monochorionic (MC), dichorionic, or “don't know”. SNP‐cfDNA zygosity results, monozygotic (MZ) or dizygotic (DZ), were correlated with chorionicity assignment. Results 59,471 twin samples (median gestational age = 12.0 weeks at draw) were received and analyzed; 55,344 (93.1%) received zygosity assignment. SNP‐cfDNA reported 16,673 (30.1%) MZ and 38,671 (69.9%) as DZ. Provider‐reported chorionicity was compared to the zygosity assignment for each case. Of 6283 provider‐reported MC twins, 318 (5.1%) were reported as DZ using SNP‐cfDNA. Conclusion(s) One in 20 suspected MC twin pregnancies were reported as DZ using SNP‐cfDNA. Approximately 30% of 55,344 twin pregnancies were found to be MZ, including cases where chorionicity was unknown. SNP‐cfDNA zygosity assessment is a useful adjunct assessment for twin pregnancies, particularly those reported as MC or without determined chorionicity. What's already known about the topic?
The assignment of chorionicity early in pregnancy can improve perinatal outcomes of twin pregnancies. Prenatal assessment of chorionicity relies on ultrasound (US), and the accuracy of US can be confounded by many factors, including gestational age (GA) and operator experience. Noninvasive assessment of zygosity is now possible using single nucleotide polymorphism (SNP)‐based cell‐free DNA (cfDNA). What does this study add?
This is the first population‐based study describing the correlation between cfDNA assessment of zygosity and chorionicity. In 55,344 twin pregnancies, approximately 30% were found to be monozygotic (MZ), including cases where chorionicity was unknown. We found that one in 20 suspected monochorionic (MC) twin pregnancies were reported as dizygotic (DZ) twins (DZ) by SNP‐cfDNA testing. SNP‐cfDNA zygosity assessment is a useful adjunct assessment for twin pregnancies, particularly those reported as MC or without determined chorionicity.
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Affiliation(s)
- Anna Wojas
- Department of Obstetrics, Gynecology, and Reproductive Science, Mt. Sinai, New York, NY, USA
| | | | | | | | | | | | | | | | | | - Andrei Rebarber
- Department of Obstetrics, Gynecology, and Reproductive Science, Mt. Sinai, New York, NY, USA
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Delima.khairudin, Khalil A. MONOCHORIONIC monoamniotic twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2022; 84:96-103. [DOI: 10.1016/j.bpobgyn.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 11/25/2022]
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Stefanovic V, Nupponen I, Jernman RM. Excellent perinatal outcome of monoamniotic twin pregnancy with timely diagnosis and optimal management - a retrospective cohort study. J Perinat Med 2022; 50:533-538. [PMID: 35377568 DOI: 10.1515/jpm-2021-0612] [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: 11/16/2021] [Accepted: 03/04/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Monoamniotic twins represent a high-risk pregnancy requiring intense follow-up, elective birth and careful consideration of the mode and timing of delivery. We conducted this study to evaluate the perinatal and neonatal outcomes of monoamniotic twin pregnancies in the largest tertiary hospital in Finland. METHODS This was a retrospective cohort study including all monoamniotic twin pregnancies during a 17-year period (2002-2018) managed in Helsinki University Hospital. Data on mothers and children were collected from patient files. Chorionicity and amnionicity were defined in first-trimester ultrasound screening. RESULTS There were altogether 31 monoamniotic twin pregnancies during the study period, including four cases of conjoined twins which all underwent termination of pregnancy, and three miscarriages. In the remaining 24 pregnancies that continued past 24 weeks of gestation there was 97.9% survival (one intrauterine death). Three pregnancies were complicated with twin-to-twin transfusion syndrome. All children were delivered by cesarean section with a mean gestational age of 32 + 5 weeks (27 + 1-34 + 2 weeks). Respiratory distress syndrome (RDS) was observed in 57% (27/47) of neonates and grade I-II intraventricular haemorrhage (IVH) in 6.3% (3/47) of neonates. There were no neonatal deaths and no maternal complications. CONCLUSIONS Monoamniotic twinning is a rare form of pregnancy and carries risks for perinatal and neonatal complications. With timely diagnosis, close monitoring in specialized feto-maternal unit and elective delivery at 32-34 weeks the outcome is usually excellent.
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Affiliation(s)
- Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Mecical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Irmeli Nupponen
- Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Riina Maria Jernman
- Department of Obstetrics and Gynecology, Fetomaternal Mecical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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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: 1.3] [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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Buca D, Di Mascio D, Khalil A, Acharya G, Van Mieghem T, Hack K, Murata M, Anselem O, D'Amico A, Muzii L, Liberati M, Nappi L, D'Antonio F. Neonatal Morbidity of Monoamniotic Twin Pregnancies: A Systematic Review and Meta-analysis. Am J Perinatol 2022; 39:243-251. [PMID: 32722824 DOI: 10.1055/s-0040-1714420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study was aimed to report the incidence of neonatal morbidity in monochorionic monoamniotic (MCMA) twin pregnancies according to gestational age at birth and type of management adopted (inpatient or outpatient). STUDY DESIGN Medline and Embase databases were searched. Inclusion criteria were nonanomalous MCMA twins. The primary outcome was a composite score of neonatal morbidity, defined as the occurrence of at least one of the following outcomes: respiratory morbidity, overall neurological morbidity, severe neurological morbidity, and infectious morbidity, necrotizing enterocolitis at different gestational age windows (24-30, 31-32, 33-34, and 35-36 weeks). Secondary outcomes were the individual components of the primary outcome and admission to neonatal intensive care unit (NICU). Subanalysis according to the type of surveillance strategy (inpatient compared with outpatient) was also performed. Random effect meta-analyses were used to analyze the data. RESULTS A total of 14 studies including 685 MCMA twin pregnancies without fetal anomalies were included. At 24 to 30, 31 to 32, 33 to 34, and 35 to 36 weeks of gestation, the rate of composite morbidity was 75.4, 65.5, 37.6, and 18.5%, respectively, the rate of respiratory morbidity was 74.2, 59.1, 35.5, and 12.2%, respectively, while overall neurological morbidity occurred in 15.3, 10.2, 4.3, and 0% of the cases, respectively. Infectious morbidity complicated 13, 4.2, 3.1, and 0% of newborns while 92.1, 81.6, 58.7, and 0% of cases required admission to NICU. Morbidity in pregnancies delivered between 35 and 36 weeks of gestation was affected by the very small sample size of cases included. When comparing the occurrence of overall morbidity according to the type of management (inpatient or outpatient), there was no difference between the two surveillance strategies (p = 0.114). CONCLUSION MCMA pregnancies are at high risk of composite neonatal morbidity, mainly respiratory morbidity that gradually decreases with increasing gestational age at delivery with a significant reduction for pregnancies delivered between 33 and 34 weeks. We found no difference in the occurrence of neonatal morbidity between pregnancies managed as inpatient or outpatient. KEY POINTS · MCMA pregnancies are at high risk of composite neonatal morbidity, mainly respiratory morbidity.. · Neonatal morbidity gradually decreases with increasing GA at delivery, mostly between 33 and 34 weeks.. · There is no difference in the occurrence of neonatal morbidity between in- or outpatient management..
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Affiliation(s)
- Danilo Buca
- Department of Obstetrics and Gynecology, Centre for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Daniele Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Asma Khalil
- Fetal Medicine Unit, Saint George's Hospital, London, United Kingdom.,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St. George's University of London, London, United Kingdom
| | - Ganesh Acharya
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.,Women's Health and Perinatology Research Group, UiT-The Arctic University of Norway and University Hospital of North Norway, Tromsø, Norway
| | - Tim Van Mieghem
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Karien Hack
- Department of Obstetrics and Gynecology, Gelre Hospitals Apeldoorn, The Netherlands
| | - Masaharu Murata
- Center for Maternal, Fetal and Neonatal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Olivia Anselem
- Maternité Port-Royal, Groupe Hospitalier Cochin-Broca-Hôtel-Dieu, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Alice D'Amico
- Department of Obstetrics and Gynecology, Centre for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco Liberati
- Department of Obstetrics and Gynecology, Centre for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Luigi Nappi
- Department of Obstetrics and Gynecology, Fetal Medicine and Cardiology Unit, University of Foggia, Foggia, Italy
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, Fetal Medicine and Cardiology Unit, University of Foggia, Foggia, Italy
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16
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Van Mieghem T, Abbasi N, Shinar S, Keunen J, Seaward G, Windrim R, Ryan G. Monochorionic monoamniotic twin pregnancies. Am J Obstet Gynecol MFM 2021; 4:100520. [PMID: 34728404 DOI: 10.1016/j.ajogmf.2021.100520] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/06/2021] [Accepted: 10/19/2021] [Indexed: 12/21/2022]
Abstract
Monoamniotic twin pregnancies are rare, but early diagnosis of such pregnancies is critical, as the incidence of complications in these pregnancies is much higher than in diamniotic or dichorionic twin pregnancies. Overall, only 70% of all monoamniotic twins will survive. Furthermore, approximately half of fetal deaths in these pregnancies are because of the high incidence of fetal anomalies (15%-25%), such as twin reversed arterial perfusion sequence and conjoined twinning. Therefore, early anatomy screening in the first trimester of pregnancy is recommended. Other causes of fetal death in these pregnancies include twin-twin transfusion syndrome, tight cord entanglement, or acute hemodynamic imbalances through the large placental vascular anastomoses. After viability, fetal surveillance can be intensified, as this decreases the risk of in utero death. Both inpatient and outpatient surveillance are reasonable. If otherwise uncomplicated, monoamniotic twins should be delivered at 33 to 34 weeks' gestation. Most centers will deliver by cesarean delivery, but some continue to advocate for vaginal delivery. Lastly, neonatal morbidity is high in monoamniotic twin pregnancies and is mainly related to prematurity.
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Affiliation(s)
- Tim Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Ontario Fetal Centre, Toronto, Ontario, Canada.
| | - Nimrah Abbasi
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Shiri Shinar
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Johannes Keunen
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Gareth Seaward
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Rory Windrim
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Ontario Fetal Centre, Toronto, Ontario, Canada
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17
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Management of monoamniotic twin pregnancies: Where, when, how? J Gynecol Obstet Hum Reprod 2021; 51:102232. [PMID: 34563720 DOI: 10.1016/j.jogoh.2021.102232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/26/2021] [Accepted: 09/20/2021] [Indexed: 12/19/2022]
Abstract
Management difficulties for monochorionic monoamniotic (MCMA) twin pregnancy reflect the absence of high-quality research into optimal types of monitoring, essential as MCMA twins have a high risk of intrauterine and neonatal death with perinatal mortality. D'Antonio et al's meta-analysis and the MonoMono study published in 2019, investigated the impact of monitoring location, out- or in-patient, of MCMA pregnancies and concluded that no specific management location is associated with improvement in prognosis. To evaluate the optimal timing for delivery of MCMA pregnancies, Van Mieghem and Chitrit carried out retrospective studies comparing gestational age of intrauterine death and risk of neonatal complication. The crossover point between the propective risk of intrauterine fetal death and neonatal complication was found at 32,33 weeks of gestation (WG), in accordance with American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynaecologists recommendations but inclusion of complicated pregnancies and analysis of fetuses individually may be regarded as a bias. The majority of studies of MCMA pregnancies focused on elective scheduled cesareans, with only rare retrospective studies reporting on vaginal delivery. Of these, two recent studies carried out by French teams suggest that vaginal deliveries may be as safe as cesarean births for MCMA twin pregnancies when specific criteria are met. In summary, concerning MCMA pregnancies, prognosis is not found to improve with inpatient management, optimal timing for delivery is at approximately 33 GW and vaginal delivery should not be excluded.
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18
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Glinianaia SV, Rankin J, Khalil A, Binder J, Waring G, Curado J, Pateisky P, Thilaganathan B, Sturgiss SN, Hannon T. Effect of monochorionicity on perinatal outcome and growth discordance in triplet pregnancy: collaborative multicenter study in England, 2000-2013. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:440-448. [PMID: 31997424 DOI: 10.1002/uog.21987] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/17/2020] [Accepted: 01/20/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To compare perinatal outcome and growth discordance between trichorionic triamniotic (TCTA) and dichorionic triamniotic (DCTA) or monochorionic triamniotic (MCTA) triplet pregnancies. METHODS This was a multicenter cohort study using population-based data on triplet pregnancies from 11 Northern Survey of Twin and Multiple Pregnancy (NorSTAMP) maternity units and the Southwest Thames Region of London Obstetric Research Collaborative (STORK) multiple pregnancy cohort, for 2000-2013. Perinatal outcomes (from ≥ 24 weeks' gestation to 28 days of age), intertriplet fetal growth and birth-weight (BW) discordance and neonatal morbidity were analyzed in TCTA compared with DCTA/MCTA pregnancies. RESULTS Monochorionic placentation of a pair or trio in triplet pregnancy (n = 72) was associated with a significantly increased risk of perinatal mortality (risk ratio, 2.7 (95% CI, 1.3-5.5)) compared with that in TCTA pregnancies (n = 68), due mainly to a much higher risk of stillbirth (risk ratio, 5.4 (95% CI, 1.6-18.2)), with 57% of all stillbirth cases resulting from fetofetal transfusion syndrome, while there was no significant difference in neonatal mortality (P = 0.60). The associations with perinatal mortality and stillbirth persisted when considering only pregnancies not affected by a major congenital anomaly. DCTA/MCTA triplets had lower BW and demonstrated greater BW discordance than did TCTA triplets (P = 0.049). Severe BW discordance of > 35% was 2.5-fold higher in DCTA/MCTA compared with TCTA pregnancies (26.1% vs 10.4%), but this difference did not reach statistical significance (P = 0.06), presumably due to low numbers. Triplets in both groups were delivered by Cesarean section in over 95% of cases, at a similar gestational age (median, 33 weeks' gestation). The rate of respiratory (P = 0.28) or infectious (P = 0.08) neonatal morbidity was similar between the groups. CONCLUSIONS Despite close antenatal surveillance, monochorionic placentation of a pair or trio in triamniotic triplet pregnancy was associated with a significantly increased stillbirth risk, mainly due to fetofetal transfusion syndrome, and with greater size discordance. In liveborn triplets, there was no adverse effect of monochorionicity on neonatal outcome. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S V Glinianaia
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - J Rankin
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - J Binder
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - G Waring
- Department of Fetal Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - J Curado
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - P Pateisky
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - S N Sturgiss
- Department of Fetal Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - T Hannon
- Department of Fetal Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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19
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Pasieczna M, Kuran-Ohde J, Kajdy A, Filipecka-Tyczka D, Świątek N, Szymkiewicz-Dangel J. Monoamniotic twins pregnancy complicated by a fetal congenital heart defect – a challenge for perinatal decisions. CASE REPORTS IN PERINATAL MEDICINE 2020. [DOI: 10.1515/crpm-2020-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
To analyze pregnancy management and postnatal follow-up in monochorionic monoamniotic (MCMA) pregnancies complicated by a congenital heart defect (CHD) in one twin and to compare the results with current recommendations concerning time and mode of delivery in MCMA pregnancies.
Cases presentation
Perinatal medical records of five pairs of monoamniotic twins referred to Fetal Cardiology Department were analyzed. 5 out of 23 MCMA pregnancies (21.7%) were complicated by CHD in one fetus. Cesarean section (CS) was performed between 32 and 35 weeks of gestation (WoG). 9 out of 10 neonates had respiratory failure, including all patients with CHD. Twins without congenital abnormalities spent median 21 days (range 10–40 days) in neonatal units. Patients with CHD were transferred to cardiology departments on average 6th day of life. All were operated on later than term-born neonates, 4 out of 5 required stage surgery and their median stay in the hospital was 75 days (range 48–106 days).
Conclusions
According to current recommendations, delivery in MCMA pregnancies should be scheduled at 32–34 weeks. In cases complicated by CHD in one twin, such early delivery complicates surgical treatment and may affect the final outcome. Low body weight and respiratory disorders increase the risk of complications in the perioperative period and prolong hospitalization.
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Affiliation(s)
- Monika Pasieczna
- 2nd Department of Obstetrics and Gynecology , Medical University of Warsaw , Warsaw , Poland
| | - Joanna Kuran-Ohde
- 2nd Department of Obstetrics and Gynecology , Medical University of Warsaw , Warsaw , Poland
- Department of Perinatal Cardiology and Congenital Anomalies , Centre of Postgraduate Medical Education , Warsaw , Poland
| | - Anna Kajdy
- Department of Reproductive Health , Centre of Postgraduate Medical Education , Warsaw , Poland
| | | | - Natalia Świątek
- Scientific Students’ Club of Fetal Cardiology, Medical University of Warsaw , Warsaw , Poland
| | - Joanna Szymkiewicz-Dangel
- Department of Perinatal Cardiology and Congenital Anomalies , Centre of Postgraduate Medical Education , Warsaw , Poland
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20
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Chitrit Y, Korb D, Morin C, Schmitz T, Oury JF, Sibony O. Perinatal mortality and morbidity, timing and route of delivery in monoamniotic twin pregnancies: a retrospective cohort study. Arch Gynecol Obstet 2020; 303:685-693. [PMID: 32902675 DOI: 10.1007/s00404-020-05782-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 08/31/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Monoamniotic twin pregnancies are at high risk of perinatal complications and fetal loss. The objective of this study is to describe the management and outcomes of monoamniotic twin pregnancies in a French university obstetrics department. METHODS Retrospective review of all consecutive monoamniotic twin pregnancies managed between 1992 and 2018 in a level-3 university hospital maternity unit. Antenatal variables, gestational age and other neonatal characteristics at delivery, mode of delivery, and its reason were recorded, together with outcomes, including a composite adverse neonatal outcome. RESULTS Overall, 46 monoamniotic twin pregnancies (92 fetuses) were identified during the study period. Among them, 27 fetal losses and 2 early neonatal deaths were reported. Congenital abnormalities accounted for 33.3% of the 27 fetal losses, and unexpected fetal deaths for 29.6%. Among the 37 women who gave birth to 65 live infants at 23 or more weeks of gestation, 17 had cesarean and 19 vaginal deliveries. Overall and composite adverse neonatal outcomes did not differ significantly for the 33 children born vaginally and the 31 by cesarean deliveries. The prospective risk of intrauterine death in all 92 fetuses reached its nadir of 1.8% at 336/7 weeks. CONCLUSION This series confirms the still high risk of fetal and neonatal death of these twins and shows that congenital abnormalities but also unexpected fetal deaths account for the majority of pre- and postnatal mortality. Our data suggest that vaginal delivery of monoamniotic twins is safe and that delivery for uncomplicated monoamniotic twins should be considered around 33 weeks of gestation, but not later than 35 weeks.
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Affiliation(s)
- Yvon Chitrit
- Department of Gynecology-Obstetrics, Assistance Publique-Hôpitaux de Paris, Robert Debré Hospital, 48, Bd Sérurier, 75935, Paris Cedex 19, France.
| | - Diane Korb
- Department of Gynecology-Obstetrics, Assistance Publique-Hôpitaux de Paris, Robert Debré Hospital, 48, Bd Sérurier, 75935, Paris Cedex 19, France.,Epidemiology and Statistics Research Center/CRESS, University of Paris, INSERM, INRA, 75004, Paris, France
| | - Cecile Morin
- Department of Gynecology-Obstetrics, Assistance Publique-Hôpitaux de Paris, Robert Debré Hospital, 48, Bd Sérurier, 75935, Paris Cedex 19, France.,Université de Paris, INSERM U1141, 75019, Paris, France
| | - Thomas Schmitz
- Department of Gynecology-Obstetrics, Assistance Publique-Hôpitaux de Paris, Robert Debré Hospital, 48, Bd Sérurier, 75935, Paris Cedex 19, France.,Epidemiology and Statistics Research Center/CRESS, University of Paris, INSERM, INRA, 75004, Paris, France
| | - Jean-François Oury
- Department of Gynecology-Obstetrics, Assistance Publique-Hôpitaux de Paris, Robert Debré Hospital, 48, Bd Sérurier, 75935, Paris Cedex 19, France.,University of Paris, Paris, France
| | - Olivier Sibony
- Department of Gynecology-Obstetrics, Assistance Publique-Hôpitaux de Paris, Robert Debré Hospital, 48, Bd Sérurier, 75935, Paris Cedex 19, France.,University of Paris, Paris, France
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21
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Jha P, Morgan TA, Kennedy A. US Evaluation of Twin Pregnancies: Importance of Chorionicity and Amnionicity. Radiographics 2020; 39:2146-2166. [PMID: 31697621 DOI: 10.1148/rg.2019190042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The twin birth rate is increasing in the United States. Twin pregnancies can be dichorionic or monochorionic (MC). MC twins account for 20% of twin pregnancies but 30% of all-cause pregnancy-related complications. This article describes the imaging findings that establish chorionicity and amnionicity. Ideally, these are established in the first trimester when accuracy is high, but they can also be determined later in pregnancy. Complications unique to MC twin pregnancy include twin-twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion sequence, and selective fetal growth restriction. The US features, staging systems, and management of these complications are reviewed, and the consequences of MC twin demise are illustrated. Ongoing surveillance for these conditions starts at 16 weeks gestation. Monoamniotic (MA) twins are a small subset of MC twins. In addition to all of the MC complications, specific MA complications include cord entanglement and conjoined twinning. Radiologists must be able to determine chorionicity and amnionicity and should be aware of potential complications so that patients may be referred to appropriate regional specialized centers. A proposed algorithm for referral to specialized fetal treatment centers is outlined. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Tara A Morgan
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Anne Kennedy
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
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22
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Saccone G, Khalil A, Thilaganathan B, Glinianaia SV, Berghella V, D'Antonio F. Weight discordance and perinatal mortality in monoamniotic twin pregnancy: analysis of MONOMONO, NorSTAMP and STORK multiple-pregnancy cohorts. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:332-338. [PMID: 31132179 DOI: 10.1002/uog.20357] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The primary objective was to quantify the risk of perinatal mortality in non-anomalous monochorionic monoamniotic (MCMA) twin pregnancies complicated by birth-weight (BW) discordance. The secondary objectives were to investigate the effect of inpatient vs outpatient fetal monitoring on the risk of mortality in weight-discordant MCMA twin pregnancies, and to explore the predictive accuracy of BW discordance for perinatal mortality. METHODS This analysis included data on 242 MCMA twin pregnancies (484 fetuses) from three major research collaboratives on twin pregnancy (MONOMONO, STORK and NorSTAMP). The primary outcomes were the risks of intrauterine (IUD), neonatal (NND) and perinatal (PND) death, according to weight discordance at birth from ≥ 10% to ≥ 30%. The secondary outcomes were the association of inpatient vs outpatient fetal monitoring with the risk of mortality in weight-discordant pregnancies, and the accuracy of BW discordance in predicting mortality. Logistic regression and receiver-operating-characteristics-curve analyses were used to analyze the data. RESULTS The risk of IUD was significantly increased in MCMA twin pregnancies with BW discordance ≥ 10% (odds ratio (OR), 2.2; 95% CI, 1.1-4.4; P = 0.022) and increased up to an OR of 4.4 (95% CI, 1.3-14.4; P = 0.001) in those with BW discordance ≥ 30%. This association remained significant on multivariate logistic regression analysis for BW-discordance cut-offs ≥ 20%. However, weight discordance had low predictive accuracy for mortality, with areas under the receiver-operating-characteristics curve of 0.60 (95% CI, 0.46-0.73), 0.52 (95% CI, 0.33-0.72) and 0.57 (95% CI, 0.45-0.68) for IUD, NND and PND, respectively. There was no difference in the risk of overall IUD, single IUD, double IUD, NND or PND between pregnancies managed as an inpatient compared with those managed as an outpatient, for any BW-discordance cut-off. CONCLUSIONS MCMA twin pregnancies with BW discordance are at increased risk of fetal death, signaling a need for increased levels of monitoring. Despite this, the predictive accuracy for mortality is low; thus, detection of BW discordance alone should not trigger intervention, such as iatrogenic delivery. The current data do not demonstrate an advantage of inpatient over outpatient management in these cases. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - S V Glinianaia
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - V Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - F D'Antonio
- Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
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23
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Murgano D, Khalil A, Prefumo F, Mieghem TV, Rizzo G, Heyborne KD, Melchiorre K, Peeters S, Lewi L, Familiari A, Lopriore E, Oepkes D, Murata M, Anselem O, Buca D, Liberati M, Hack K, Nappi L, Baxi LV, Scambia G, Acharya G, D'antonio F. Outcome of twin-to-twin transfusion syndrome in monochorionic monoamniotic twin pregnancy: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:310-317. [PMID: 31595578 DOI: 10.1002/uog.21889] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/15/2019] [Accepted: 09/18/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To explore the outcome of monochorionic monoamniotic (MCMA) twin pregnancies affected by twin-to-twin transfusion syndrome (TTTS). METHODS MEDLINE and EMBASE databases were searched for studies reporting the outcome of MCMA twin pregnancies complicated by TTTS. The primary outcome was intrauterine death (IUD); secondary outcomes were miscarriage, single IUD, double IUD, neonatal death (NND), perinatal death (PND), survival of at least one twin, survival of both twins and preterm birth (PTB) before 32 weeks' gestation. Outcomes were assessed in MCMA twins affected by TTTS not undergoing intervention and in those treated with amniodrainage, laser therapy or cord occlusion. Subgroup analysis was performed including cases diagnosed before 24 weeks. Random-effects meta-analysis of proportions was used to analyze the data. RESULTS Fifteen cohort studies, including 888 MCMA twin pregnancies, of which 44 were affected by TTTS, were included in the review. There was no randomized trial comparing the different management options in MCMA twin pregnancies complicated by TTTS. In cases not undergoing intervention, miscarriage occurred in 11.0% of fetuses, while the incidence of IUD, NND and PND was 25.2%, 12.2% and 31.2%, respectively. PTB complicated 50.5% of these pregnancies. In cases treated by laser surgery, the incidence of miscarriage, IUD, NND and PND was 19.6%, 27.4%, 7.4% and 35.9%, respectively, and the incidence of PTB before 32 weeks' gestation was 64.9%. In cases treated with amniodrainage, the incidence of IUD, NND and PND was 31.3%, 13.5% and 45.7% respectively, and PTB complicated 76.2% of these pregnancies. Analysis of cases undergoing cord occlusion was affected by the very small number of included cases. Miscarriage occurred in 19.2%, while there was no case of IUD or NND of the surviving twin. PTB before 32 weeks occurred in 50.0% of these cases. CONCLUSIONS MCMA twin pregnancies complicated by TTTS are at high risk of perinatal mortality and PTB. Further studies are needed in order to elucidate the optimal type of prenatal treatment in these pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Murgano
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK; and Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - F Prefumo
- Department of Obstetrics and Gynecology, Spedali Riunit, Brescia, Italy
| | - T Van Mieghem
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - G Rizzo
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
| | - K D Heyborne
- Department of Obstetrics and Gynecology, Denver Health and Hospital Authority, Denver, CO, USA; Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO, USA
| | - K Melchiorre
- Department of Obstetrics and Gynecology, 'Spirito Santo' Hospital, Pescara, Italy
| | - S Peeters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Leuven, Belgium
| | - A Familiari
- Department of Obstetrics and Gynecology, Fondazione IRCCS, Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M Murata
- Center for Maternal, Fetal and Neonatal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - O Anselem
- Maternité Port-Royal, Groupe Hospitalier Cochin-Broca-Hôtel-Dieu, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - D Buca
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - M Liberati
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - K Hack
- Department of Obstetrics and Gynecology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - L Nappi
- Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - L V Baxi
- School of Medicine, Columbia University, New York, USA
| | - G Scambia
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - G Acharya
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - F D'antonio
- Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Litwinska E, Syngelaki A, Cimpoca B, Frei L, Nicolaides KH. Outcome of twin pregnancy with two live fetuses at 11-13 weeks' gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:32-38. [PMID: 31613412 DOI: 10.1002/uog.21892] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 09/27/2019] [Accepted: 09/30/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To report and compare pregnancy outcome in dichorionic (DC), monochorionic diamniotic (MCDA) and monochorionic monoamniotic (MCMA) twin pregnancies with two live fetuses at 11-13 weeks' gestation and to examine the impact of endoscopic laser surgery for severe twin-twin transfusion syndrome (TTTS) and/or selective fetal growth restriction (sFGR) on the outcome of MCDA twins. METHODS This was a retrospective analysis of prospectively collected data on twin pregnancies undergoing routine ultrasound examination at 11-13 weeks' gestation between 2002 and 2019. In pregnancies with no major abnormalities, we compared overall survival, fetal loss at < 24 weeks' gestation, perinatal death at ≥ 24 weeks, delivery at < 37 and < 32 weeks, and birth weight < 5th percentile between DC, MCDA and MCMA twins. RESULTS The study population of 6225 twin pregnancies with two live fetuses at 11-13 weeks' gestation with no major abnormalities included 4896 (78.7%) DC, 1274 (20.5%) MCDA and 55 (0.9%) MCMA twins. In DC twins, the rate of loss at < 24 weeks' gestation in all fetuses was 2.3%; this rate was higher in MCDA twins (7.7%; relative risk (RR), 3.258; 95% CI, 2.706-3.923) and more so in MCMA twins (21.8%; RR, 9.289; 95% CI, 6.377-13.530). In DC twins, the rate of perinatal death at ≥ 24 weeks in all twins that were alive at 24 weeks was 1.0%; this rate was higher in MCDA twins (2.5%; RR, 2.456; 95% CI, 1.779-3.389) and more so in MCMA twins (9.3%; RR, 9.130; 95% CI, 4.584-18.184). In DC twins, the rate of preterm birth at < 37 weeks' gestation in pregnancies with at least one liveborn twin was 48.6%; this rate was higher in MCDA twins (88.5%; RR, 1.824; 95% CI, 1.760-1.890) and more so in MCMA twins (100%; RR, 2.060; 95% CI, 2.000-2.121). In DC twins, the rate of preterm birth at < 32 weeks was 7.4%; this rate was higher in MCDA twins (14.2%; RR, 1.920; 95% CI, 1.616-2.281) and more so in MCMA twins (26.8%; RR, 3.637; 95% CI, 2.172-6.089). In DC twin pregnancies with at least one liveborn twin, the rate of a small-for-gestational-age neonate among all liveborn twins was 31.2% and in MCDA twins this rate was higher (37.8%; RR, 1.209; 95% CI, 1.138-1.284); in MCMA twins, the rate was not significantly different (33.3%; RR, 1.067; 95% CI, 0.783-1.455). Kaplan-Meier analysis showed a significant difference in survival in MCDA and MCMA twins, compared to DC twins, for both the interval of 12 to < 24 weeks' gestation (log-rank test, P < 0.0001 for both) and that of ≥ 24 to 38 weeks (log-rank test, P < 0.0001 for both). Endoscopic laser ablation of intertwin communicating placental vessels was carried out in 127 (10.0%) MCDA twin pregnancies for TTTS and/or sFGR and, in 111 of these, surgery was performed at < 24 weeks; both fetuses survived in 62 (55.9%) cases, one fetus survived in 25 (22.5%) cases and there were no survivors in 24 (21.6%) cases. On the extreme assumption that, had laser surgery not been carried out in these cases, all fetuses would have died, the total fetal loss rate at < 24 weeks' gestation in MCDA twins would have been 13.5%. CONCLUSIONS The rates of fetal loss at < 24 weeks' gestation, perinatal death at ≥ 24 weeks and preterm birth are higher in MCDA and more so in MCMA twins than in DC twins. In MCDA twins, the rate of fetal loss may have been reduced by endoscopic laser surgery in those that developed early TTTS and/or sFGR. These data would be useful in counseling parents as to the likely outcome of their pregnancy and in defining strategies for surveillance and interventions in the management of the different types of twin pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Litwinska
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Syngelaki
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - B Cimpoca
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - L Frei
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Mieghem TV, Shub A. Management of monoamniotic twins: the question is not 'where?', but 'how?'. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:151-152. [PMID: 30741449 DOI: 10.1002/uog.20203] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- T Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, 700 University Avenue, Rm 3-912, M5G 1Z5, Toronto, Ontario, Canada
| | - A Shub
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women and University of Melbourne, Melbourne, Victoria, Australia
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D'Antonio F, Odibo A, Berghella V, Khalil A, Hack K, Saccone G, Prefumo F, Buca D, Liberati M, Pagani G, Acharya G. Perinatal mortality, timing of delivery and prenatal management of monoamniotic twin pregnancy: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:166-174. [PMID: 30125418 DOI: 10.1002/uog.20100] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 07/21/2018] [Accepted: 07/27/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To quantify the rate of perinatal mortality in monochorionic monoamniotic (MCMA) twin pregnancies, according to gestational age, and to ascertain the incidence of mortality in pregnancies managed as inpatients compared with those managed as outpatients. METHODS MEDLINE, EMBASE and CINAHL databases were searched for studies on monoamniotic twin pregnancy. The primary outcomes explored were the incidence of intrauterine death (IUD), neonatal death (NND) and perinatal death (PND) in MCMA twins at different gestational-age windows (24-30, 31-32, 33-34, 35-36 and ≥ 37 weeks of gestation). The secondary outcomes were the incidence of IUD, NND and PND in MCMA twins according to the type of fetal monitoring (inpatient vs outpatient), and the incidence of delivery ahead of schedule. Random-effects model meta-analyses were used to analyze the data. RESULTS Twenty-five studies (1628 non-anomalous twins reaching 24 weeks of gestation) were included. Single and double intrauterine deaths occurred in 2.5% (95% CI, 1.8-3.3%) and 3.8% (95% CI, 2.5-5.3%) of cases, respectively. IUD occurred in 4.3% (95% CI, 2.8-6.2%) of twins at 24-30 weeks, in 1.0% (95% CI, 0.6-1.7%) at 31-32 weeks and in 2.2% (95% CI, 0.9-3.9%) at 33-34 weeks of gestation, while there was no case of IUD, either single or double, from 35 weeks of gestation. In MCMA twin pregnancies managed mainly as inpatients, the incidence of IUD was 3.0% (95% CI, 1.4-5.2%), while the corresponding figure for those managed mainly as outpatients was 7.4% (95% CI, 4.4-11.1%). Finally, 37.8% (95% CI, 28.0-48.2%) of MCMA pregnancies were delivered before the scheduled time, due mainly to spontaneous preterm labor or abnormal cardiotocographic findings. CONCLUSIONS MCMA twins are at high risk of perinatal loss during the third trimester of pregnancy, with the large majority of such losses occurring as apparently unexpected events. Inpatient management seems to be associated with a lower rate of mortality, although further studies are needed in order to establish the appropriate type and timing of prenatal assessment in these pregnancies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F D'Antonio
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
| | - A Odibo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - V Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - K Hack
- Department of Obstetrics and Gynecology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - G Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - F Prefumo
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - D Buca
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - M Liberati
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - G Pagani
- Department of Obstetrics and Gynecology, Fondazione Poliambulanza, Brescia, Italy
| | - G Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
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Kirkham FJ, Zafeiriou D, Howe D, Czarpran P, Harris A, Gunny R, Vollmer B. Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins. Eur J Paediatr Neurol 2018; 22:989-1005. [PMID: 30467085 DOI: 10.1016/j.ejpn.2018.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022]
Abstract
Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.
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Affiliation(s)
- Fenella J Kirkham
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom.
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, "Hippokratio' General Hospital, Aristotle University, Thessaloniki, Greece
| | - David Howe
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
| | - Philippa Czarpran
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Ashley Harris
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Roxanna Gunny
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Radiology, St George's hospital, London, United Kingdom
| | - Brigitte Vollmer
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
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