Diamniotic Twin Research Articles

A Prospective Study on Perinatal Outcomes of In Vitro Fertilization-conceived Dichorionic Diamniotic Twins with Crown–Rump Length Discordancy

A Prospective Study on Perinatal Outcomes of In Vitro Fertilization-conceived Dichorionic Diamniotic Twins with Crown–Rump Length Discordancy

Preterm Prelabour Rupture of Membranes before Viability in Twin Pregnancies: What Can We Expect?

Preterm prelabour rupture of membranes (PPROMs) before viability carries significant perinatal mortality and morbidity. Clinical management and prenatal counselling are a challenge, especially in twin pregnancies, due to scarce evidence on how previable PPROM affects this population. The aim of this study was to describe pregnancy outcomes of twin pregnancies complicated with previable PPROM and evaluate potential prognostic factors that may predict perinatal mortality. A retrospective cohort including dichorionic and monochorionic diamniotic twin pregnancies complicated with PPROM before 24 + 0 weeks of pregnancy was evaluated. Perinatal outcomes of pregnancies managed expectantly were described. Factors predicting perinatal mortality or reaching periviability (defined from 23 + 0 weeks onwards) were evaluated. Of the 45 patients included, 7 (15.6%) spontaneously delivered within the first 24 h after diagnosis. Two patients (5.3%) requested selective termination of the affected twin. In the 36 ongoing pregnancies that opted for expectant management, the overall survival rate was 35/72 (48.6%). There were 25/36 (69.4%) patients who delivered after 23 + 0 weeks of pregnancy. When periviability was achieved, neonatal survival increased up to 35/44 (79.5%). Gestational age at delivery was the only independent risk factor of perinatal mortality. The overall survival rate of twin pregnancies complicated with previable PPROM is poor but similar to singletons. No prognostic factors, apart from achieving periviability, were identified as individual predictors of perinatal mortality.

Can maternal serum midkine level predict chorionicity in twin pregnancies?

Sometimes it can be difficult to chorionicity determination in twin pregnancies. This study aimed to compare maternal serum midkine levels between twin and singleton pregnancies. We also evaluated the relationship between chorionicity and maternal serum midkine level in twin pregnancies. The present prospective cohort study included 16 patients with monochorionic diamniotic twin pregnancies, 38 with dichorionic diamniotic twin pregnancies, and 66 healthy singleton pregnancies admitted to Ankara City Hospital Perinatology Clinic between June 2021 and June 2022. Demographic features, clinical characteristics, and serum midkine levels were compared between the groups. Additionally, a receiver operator characteristics (ROC) analysis was performed to assess the performance of midkine for detecting chorionicity. The median maternal serum midkine level was found to be 0.64 ng/ml in twin pregnancies and 0.26 ng/ml in singleton pregnancies (p < 0.001). When twin pregnancies were compared in terms of chorionicity, serum midkine level was determined as 1.20 ng/ml in the monochorionic diamniotic group and 0.50 ng/ml in the dichorionic diamniotic group (p = 0.034). An optimal cut-off value of 1.03 ng/ml was found for the determination of chorionicity (AUC: 0.68, p = 0.03, 95% CI: 0.53–0.83, %56.3 sensitivity, 76.3% specificity). In advanced weeks of pregnancy, biomarkers can be used as helpful parameters for ultrasonography in the diagnosis of twin pregnancies. Maternal serum midkine levels might be used to determine chorionicity in equivocal cases.

The use of a modified rescue cervical cerclage in a diamniotic dichorionic twin pregnancy that had cervical dilatation

AbstractObjectiveWe describe the successful utilization of a modified rescue cerclage in a 32‐year‐old G4 P1213 woman of Afro‐Caribbean descent with a Diamniotic Dichorionic twin gestation who presented at 20 weeks and 2 days for a routine anomaly scan and was found to have a dilated (1.7 cm) and short (0.49 cm) cervix.DesignA standard prophylactic cervical cerclage was done at 12 weeks' gestation using Mersilene™ tape. For the rescue cerclage, the client was placed in a steep Trendelenburg position, with back filling of the bladder. The cervix was grasped with ring forceps, and an inflated foley balloon catheter was introduced into the cervical opening to aid in reduction of membranes. In addition to the initial cerclage, two 1‐ Prolene™ sutures were inserted distally to the tape and a second Mersilene™ tape was inserted proximally at the vesicocervical junction (reinforcement cerclages). The first Prolene™ was to provide additional structural support to prevent prolapse of the membrane. The second Prolene™ was used to close the external cervical or to minimize the risk of an ascending infection. The procedure was uneventful and postoperatively she was treated with antibiotics, vaginal micronized progesterone and venous thromboembolism prophylaxis. The membranes remained intact.ResultThe twins were successfully delivered by a scheduled repeat caesarean section at 36 weeks with Twin 1 Apgar scores of 9 and 9 at 1 and 5 min, respectively, and Twin 2 Apgar scores of 8 and 10, respectively.ConclusionIn the context of a challenging obstetric history as in this case, a more aggressive approach inclusive of reinforcement cerclage may be considered. The successful outcomes in this case further reiterates the need for larger clinical trials with pregnant individuals with larger cervical dilations at entry.

Reconsidering the effectiveness of low-dose aspirin in prevention of pre-eclampsia among otherwise low risk twin gestations: A historical cohort study.

To investigate the effectiveness of low-dose aspirin (LDA) in the prevention of pre-eclampsia (PE) among otherwise low-risk twin gestations. A historical cohort study consisting of all pregnant individuals with dichorionic diamniotic (DCDA) twin pregnancy who delivered between 2014 and 2020. Patients treated with LDA were matched by a 1:4 ratio to individuals who were not treated with LDA by age, body mass index and parity. During the study period, 2271 individuals carrying DCDA pregnancies delivered at our center. Of these, 404 were excluded for one or more additional major risk factors. The remaining cohort consisted of 1867 individuals of whom 142 (7.6%) were treated with LDA and were compared with a 1:4 matched group of 568 individuals who were not treated. The rate of preterm PE did not differ significantly between the two groups (18 [12.7%] in the LDA group vs. 55 [9.7%] in the no-LDA group; P= 0.294, adjusted odds ratio 1.36, 95% confidence interval 0.77-2.40). There were no other significant between-group differences. Low-dose aspirin treatment in pregnant individuals with DCDA twin gestations without additional major risk factors was not associated with a reduction in the rate of preterm PE.

Comparative Study of Perinatal Outcome in Uncomplicated Monochorionic Diamniotic versus Dichorionic Diamniotic Twins at a Specialized Twin Clinic—A Prospective Study

Abstract Background Monochorionic twins have higher perinatal morbidity and mortality than dichorionic twins. However, there is conflicting data on outcomes of uncomplicated monochorionic twins. Purpose of the Study The aim of this study is to compare the outcomes of apparently uncomplicated monochorionic twins to dichorionic twins. Methods This is a prospective study conducted from August 2019 to December 2020 at a specialized twin clinic. All twins, whose chorionicity was determined before 14 weeks with two live fetuses at 24 weeks, were recruited. Complicated monochorionic diamniotic (MCDA) twins with twin-to-twin transfusion syndrome, twin anemia polycythemia syndrome, selective fetal growth restriction before 24 weeks and single or double fetal demise before 24 weeks were excluded. Other exclusion criteria were major congenital and chromosomal abnormalities, higher order multiples, monoamniotic twins, and twins with undetermined chorionicity antenatally. Both the groups were followed till delivery and neonates followed till 28 days. Maternal and neonatal outcomes were studied and compared. Results One-hundred forty-eight mothers with dichorionic diamniotic (DCDA) and 74 with uncomplicated MCDA were studied. Mean gestational age at delivery was 35 weeks in both the groups. Maternal, fetal, and neonatal morbidities were similar in both, except early onset preeclampsia that was higher in the DCDA group. Prospective risk of stillbirth for DCDA and MCDA after 24 weeks was 1.35 and 4.05%, respectively. Prospective risk of stillbirth for DCDA and MCDA after 30 weeks was 1.49 and 0%, respectively. Conclusion The maternal and perinatal outcomes in uncomplicated MCDA twins are similar to DCDA twins. Prospective risk of stillbirth after 30 weeks is extremely low. Hence, uncomplicated MCDA twins should not be delivered electively before 36 weeks.

Prediction of dual survival following fetoscopic laser photocoagulation for twin-twin transfusion syndrome.

To develop a model based on factors available at the time of diagnosis of twin-twin transfusion syndrome (TTTS) for predicting the probability of dual twin survival following fetoscopic laser photocoagulation (FLP) using a machine-learning algorithm. This was a retrospective study of data collected at two university-affiliated tertiary fetal centers between 2012 and 2021. The cohort included monochorionic diamniotic twin pregnancies complicated by TTTS that underwent FLP. Data were stratified based on survival 30 days after delivery, and cases with dual survival were compared to those without dual survival. A random forest machine-learning algorithm was used to construct a prediction model, and the relative importance value was calculated for each parameter that presented a statistically significant difference between the two study groups and was included in the model. The holdout method was applied to check overfitting of the random forest algorithm. A prediction model for dual twin survival 30 days after delivery was presented based on the test set. The study included 537 women with monochorionic diamniotic twin pregnancy, of whom 346 (64.4%) had dual twin survival at 30 days after delivery and were compared with 191 (35.6%) cases that had one or no survivors. Univariate analysis demonstrated no differences in demographic parameters between the groups. At the time of diagnosis, the dual-survival group had lower rates of estimated fetal weight (EFW) < 10th centile for gestational age in the donor twin (56.4% vs 69.4%; P = 0.004), intertwin EFW discordance > 25% (40.8% vs 56.5%; P = 0.001) and anterior placenta (40.5% vs 50.0%; P = 0.034). Comparison of Doppler findings between the two groups demonstrated significant differences in the donor twin, with a lower rate of pulsatility index (PI) > 95th centile in the umbilical artery and ductus venosus and a lower rate of PI < 5th centile in the fetal middle cerebral artery in the dual-survival group. Relative importance values for each of these six parameters were calculated, allowing the construction of a prediction model with an area under the receiver-operating-characteristics curve of 0.916 (95% CI, 0.887-0.946). We developed a predictive model for dual survival in monochorionic twin pregnancies following FLP for TTTS, which incorporates six variables obtained at the time of diagnosis of TTTS, including donor EFW < 10th centile, intertwin EFW discordance > 25%, anterior placenta and abnormal PI in the umbilical artery, ductus venosus and middle cerebral artery of the donor twin. This clinically applicable tool may improve treatment planning and patient counseling. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Premature monochorionic monoamniotic twins have lower lung compliance at birth than matched dichorionic diamniotic twins.

Premature infants are born with immature lungs that demonstrate abnormal pulmonary function with differences in passive respiratory system compliance and resistance, and functional residual capacity. To our knowledge, no studies have evaluated differences in neonatal pulmonary function based on the type of twin gestation, or chorionicity. Given the effect of chorionicity on outcomes, we aimed to study the effect of twin type, monochorionic monoamniotic (MCMA) vs dichorionic diamniotic (DCDA), on neonatal early pulmonary function tests. In this prospective cohort study, 5 sets of DCDA twins were matched to 5 sets of MCMA twins on gestational age at delivery, latency from antenatal corticosteroid exposure, birthweight, race and gender. Mean values were compared for passive respiratory system compliance and resistance, functional residual capacity, and tidal volume. MCMA infants had a significantly lower compliance (0.64 vs 1.25 mL/cm H2O /kg; p = 0.0001) and significantly higher resistance (0.130 vs 0.087 cm H2O /mL/sec; p = 0.0003) than DCDA infants. Functional residual capacity was lower for MCMA than DCDA infants (17.5 vs 23.4 mL/kg; p = 0.17). Further, 80% of MCMA infants required intubation for surfactant administration compared to 20% of DCDA infants, indicating the clinical significance of these objective measures. Due to the matched case-control design, causality cannot be established. However, we speculate that these differences in lung function may derive from differential exposure to preterm labor and endogenous maternal corticosteroid exposure. Further study is necessary to establish the true causal relationship.

A case report of an atypical haemolytic uremic syndrome in pregnancy: something wicked this way comes

BackgroundAtypical Haemolytic Uremic Syndrome is an acute life-threatening condition, characterized by the clinical triad of microangiopathic hemolytic anaemia, thrombocytopenia, kidney injury. Management of pregnants affected by Atypical Haemolytic Uremic Syndrome can be a serious concern for obstetric anesthesiologist in the delivery room and in the intensive care unit.Case presentationA 35-year-old primigravida with a monochorionic diamniotic twin pregnancy, presented with an acute haemorrhage due to retained placenta after elective caesarean section and underwent surgical exploration. In the postoperative period, the patient progressively developed hypoxemic respiratory failure and, later on, anaemia, severe thrombocytopenia, and acute kidney injury. A timely diagnosis of Atypical Haemolytic Uremic Syndrome was made. Non-invasive ventilation and high-flow nasal cannula oxygen therapy sessions were initially required. Hypertensive crisis and fluid overload were aggressively treated with a combination of beta and alpha adrenergic blockers (labetalol 0,3 mg/kg/h by continuous intravenous infusion for the first 24 hours, bisoprolol 2,5 mg twice daily for the first 48 hours, doxazosin 2 mg twice daily), central sympatholytics (methyldopa 250 mg twice daily for the first 72 hours, transdermal clonidine 5 mg by the third day), diuretics (furosemide 20 mg three times daily), calcium antagonists (amlodipine 5 mg twice daily).Eculizumab 900 mg was administered via intravenous infusion once per week, attaining hematological and renal remissions. The patient also received several blood transfusion units and anti- meningococcal B, anti-pneumococcal, anti-haemophilus influenzae type B vaccination.Her clinical condition progressively improved, and she was finally discharged from intensive care unit 5 days after admission.ConclusionsThe clinical course of this report underlines how crucial it is for the obstetric anaesthesiologist to promptly identify Atypical Haemolytic Uremic Syndrome, since early initiation of eculizumab, together with supportive therapy, has a direct effect on patient outcome.

Does Progesterone Prevent Preterm Labor in Complicated Monochorionic Twin Pregnancies after Radiofrequency Ablation of One Fetus?

Background: Twin pregnancies have a higher risk of preterm labor than singletons. Otherwise, progesterone using to reduce the risk of preterm labor in twin pregnancies remains controversial. Therefore, this study evaluated the effect of intramuscular progesterone to prevent preterm labor in complicated monochorionic diamniotic twin pregnancies after Radiofrequency Ablation (RFA) of one fetus.&#x0D; Methods: Pregnant women with monochorionic diamniotic twin pregnancies of 16 to 26 weeks of gestational age in an academic center were randomly assigned to receive intramuscular 17-hydroxy progesterone caproate weekly until 36 weeks of gestational age after RFA of one fetus and a control group who did not receive intervention after RFA. Demographic and obstetrical characteristics, as well as maternal, fetal and neonatal outcomes were compared between groups.&#x0D; Results: In total, 79 participants were recruited in the study. The mean±SD of gestational age at delivery in case and control groups were 34.6±3.8 and 34.6±5.1 with no significant difference (p=0.967). Neonatal outcomes including birth weight (p=0.870), intensive care unit admission (p=0.415), premature preterm rupture of membrane (p=0.115) and pregnancy outcome (live birth, fetal demise or neonatal death) (p=0.524) were not different either. Indeed, gestational age at delivery was inversely related to cervical length at the time of procedure and maternal body mass index, but these differences were not statistically significant. Also, there was no significant difference in terms of gestational diabetes, which was a worrying complication of 17-hydroxy progesterone caproate.&#x0D; Conclusion: Although 17-hydroxy progesterone caproate seems to be safe with no apparent maternal and neonatal side effects, it does not prolong pregnancy after RFA. Further studies with longer follow up and larger sample size are suggested.

Prediction of Monochorionic Diamniotic Twin Pregnancy Outcomes Based on Early Second Trimester Ultrasound

Background: Association between second trimester ultrasound findings and twin pregnancy outcome is still unclear. Study aimed to evaluate the performance of second trimester ultrasound scan in the prediction of monochorionic diamniotic twin pregnancies outcomes. Methods: Prospective-cohort study of all consecutive healthy women with monochorionic twin pregnancies followed-up and delivered in five years was undertaken. During second trimester screening (16–18 weeks) fetal biometry was measured (biparietal diameter–BPD, abdominal circumference–AC, femur length–FL, estimated fetal weight–EFW) and inter-twin discordance noted. Amniotic fluid amount was determined. Pregnancy outcomes were having live-born twins, Apgar sores and birth-weights, pregnancy complications and gestational week of delivery. Results: Receiver operating characteristics (ROC) analysis showed that BPD (p = 0.018), AC (p = 0.019) and FL (p = 0.015) were good predictors of having live-born twins. Regression analysis showed that the most important factors influencing twins’ survival to term were inter-twin AC, BPD and FL differences. Fetal discordance in BPD, AC and FL explained correctly 76.3%, 76.5% and 58% of pregnancy outcomes. If second trimester inter-twin BPD difference was &lt;2.5 mm, AC difference was &lt;17 mm and FL difference was &lt;1.5 mm survival of twins was better, complications were less frequent, delivery mostly occurred closer to term, twins had higher birth-weights and better Apgar scores. Second trimester EFW of twin and its difference as well as the amniotic fluid amount were not associated with examined pregnancy outcomes. Conclusions: Discordant twins’ growth in the second trimester registered by ultrasound reliably implies on adverse monochorionic diamniotic twin pregnancy outcome.

Granulocyte colony-stimulating factor in assisted reproductive technology treatment does not increase the risk of adverse perinatal outcomes in twin pregnancies

The aim of the study is to compare the perinatal outcomes of twin pregnancies resulting from assisted reproductive technology (ART) treatment in which granulocyte colony-stimulating factor (G-CSF) was used with those in which it was not. In this retrospective study, the clinical data of 122 dichorionic diamniotic twin pregnancies were reviewed. Pregnancies were divided into two groups, G-CSF-treated and non-G-CSF treated. Maternal age, gestational week at birth, oligohydramnios, gestational hypertension, pre-eclampsia, preterm birth, first-trimester bleeding, gestational diabetes, rupture of membrane, foetal congenital anomalies, admission to the neonatal intensive care unit, birth weight (BW), small for gestational age, BW discordance, Apgar score and placental weight were compared between the groups. IMPACT STATEMENT What is already known on this subject? Granulocyte colony-stimulating factor (G-CSF) administrations increase pregnancy outcomes and do not have a negative effect on perinatal outcomes in singleton pregnancies. What the results of this study add? This study showed that the perinatal outcome of dichorionic diamniotic twin pregnancies conceived after assisted reproductive technology (ART) treatment was similar in the GSF administrated and non-GSF administrated groups. What the implications are of these findings for clinical practice and/or further research? Using G-CSF to increase the success of ART does not seem to have an adverse outcome in the dichorionic diamniotic twin pregnancies.

First-trimester biomarkers and ultrasound biometries in relation to growth discordance in monochorionic diamniotic twins

Objective The aim of this study was to investigate the association and predictive value between intertwin discordance in first trimester biometries crown-rump length (CRL) and nuchal translucency (NT), and the first trimester biochemical markers PAPP-A and free β-hCG in relation to birth weight discordance (BWD) ≥25% in monochorionic diamniotic (MCDA) twin pregnancies. Methods First trimester screening information and pregnancy outcome data on MCDA twin pregnancies with delivery from July 2008 to July 2017 were retrieved from the Danish Fetal Medicine Database. CRL discordance was divided into: <10% (reference group) and ≥10%. NT discordance was divided into: <20% (reference group) and ≥20%. The twin pregnancies were classified according to BWD into the following groups: <10% (reference group), 10–24.9%, and ≥25% including cases undergoing umbilical cord occlusion due to selective fetal growth restriction (sFGR). The twin pregnancies with the most severe BWD (BWD ≥25%) were subdivided into three groups including cases with only one growth-restricted (<10th centile) infant defined as sFGR, and cases where both twins were <10th centile. Median multiples of the median (MoM) values of PAPP-A and free ß-hCG were compared with the group with BWD <10% using the Wilcoxon two-sample test. The ability of CRL discordance and NT discordance to predict BWD ≥25% was examined by the area under the receiver operator characteristic (ROC) curve. Results A total of 762 MCDA pregnancies were included. The proportion of pregnancies with CRL discordance ≥10% and NT discordance ≥20% was significantly higher in the group with severe BWD discordance (27.0% vs. 4.7% (p < 0.001) and 40.9% vs. 23.9% (p = 0.001), respectively). When examining the three subgroups of severe BWD, we found a significantly higher percentage of pregnancies with CRL discordance ≥10% in the group where umbilical cord occlusion was performed (52.6% vs. 4.7% in the group with BWD <10% (p < 0.001)) and in the group of BWD ≥25% with sFGR (21.7% vs. 4.7% (p < 0.001)). Additionally, a significantly higher percentage of pregnancies with NT discordance ≥20% was found in the group where umbilical cord occlusion was performed (52.6% vs. 23.9% (p = 0.005)) and in the group with both twins <10th centile (66.7% vs. 23.9% (p = 0.003)). No statistically significant differences were found when comparing levels of PAPP-A and free β-hCG MoMs with the group with BWD <10%. In ROC curves, CRL discordance yielded an AUC for prediction of BWD ≥25% of 0.70 (95% CI 0.63–0.76), and for NT discordance AUC was 0.59 (95% CI 0.52–0.66)). OR for any BWD ≥ 25% was 6.7 (95% CI 3.8–12.0) for pregnancies with a CRL discordance ≥10% compared to pregnancies with a CRL discordance <10%. Conclusions This study shows that a discordance in CRL and NT in MCDA twins are both significantly associated with development of BWD. The most important predictor remains CRL discordance ≥10%, thereby suggesting the unequal growth pattern in many cases with BWD is evident already in the first trimester of the pregnancy. No association was found between first trimester biochemical markers and severe BWD.

Perinatal Outcomes and Neurodevelopment 1 Year after Birth in Discordant Twins According to Chorionicity.

Background and Objectives: This study aimed to compare maternal complications, perinatal outcomes, and neurodevelopment 1 year after the birth between concordant and discordant twins in monochorionic and dichorionic twins. Materials and Methods: This retrospective study included twin pregnancies delivered between 24 + 1 and 38 + 2 weeks of gestation between January 2011 and September 2019. Chorionicity was confirmed by ultrasonography and was categorized into monochorionic and dichorionic. Each was then divided into two groups (concordant and discordant) according to birth weight discordancy. Maternal complications and neonatal outcomes, including neurodevelopmental delays, were compared between the two groups. Results: A total of 298 pairs of twin pregnancies were enrolled, of which 58 (19.26%) women were pregnant with monochorionic diamniotic twins and 240 (80.54%) with dichorionic diamniotic twins. In both monochorionic and dichorionic twins, the discordant twins had a greater incidence of emergency deliveries because of iatrogenic causes than the concordant twins. Among dichorionic twins, discordant twins had lower birth weight rates and higher hospitalization rates and morbidities than concordant twins. Among monochorionic twins, discordant twins had a lower birth weight and higher neonatal mortality than concordant twins. The neonatal size was not a predictor of neurodevelopment in this group. Based on the logistic regression analysis, male sex, respiratory distress syndrome, and bronchopulmonary dysplasia were risk factors for the neurodevelopmental delay; birth weight discordancy was significant only in dichorionic twins. Conclusions: Perinatal outcomes in discordant twins may be poor, and neurodevelopment 1 year after birth was worse in discordant twins than in concordant twins. Discordancy in twins can be a risk factor for neurodevelopmental delay.

Spontaneous dichorionic diamniotic twin pregnancy following a leuprolide acetate trigger and freeze all cycle for OHSS risk: A case report

Introduction: Gonadotropin-releasing hormone (GnRH) agonist triggers are increasingly used in antagonist in vitro fertilization (IVF) cycles to prevent ovarian hyperstimulation syndrome (OHSS) following a robust ovarian response. The luteolytic effects of GnRH agonists inhibit implantation or spontaneous pregnancy, warranting freezing available blastocysts for future transfer after the risk of OHSS subsides. Case Report: A 33-year-old G1P1 with secondary infertility due to polycystic ovarian syndrome underwent IVF with a GnRH antagonist cycle. A leuprolide acetate trigger for final oocyte maturation was prescribed given her risk of OHSS. A spontaneous dichorionic/diamniotic twin pregnancy ensued. Conclusion: This case reinforces the importance of advising abstinence during the stimulation phase of an IVF cycle and that, although rare, the endometrium may allow for spontaneous conception following a leuprolide acetate trigger, which may further potentiate the risk of late OHSS.

Dilemmas of modern neonatology: care of extremely preterm infants.

At 21 + 5 weeks’ gestation with a dichorionic diamniotic twin pregnancy, Shakina and Kevin presented at a community hospital with Shakina in threatened preterm labour. She was transferred to Mount Sinai Hospital, Toronto, for further evaluation and management of the pregnancy. One hour after

Physical development of preterm monochorionic diamniotic twins at birth: retrospective cohort study

Background. Much controversy surrounds the estimation of anthropometric parameters in multiple newborns. In newborn monochorionic diamniotic twins, these parameters can be affected by specific antenatal complications.Objectives. To estimate the physical development parameters of preterm monochorionic diamniotic twins according to standards proposed within the INTERGROWTH-21st project, taking specific intrauterine complications into account.Methods. The anthropometric data were analyzed in 148 pairs of newborn monochorionic diamniotic twins, who were divided into three groups according to the presence of specific intrauterine complications: Group I (n = 56 pairs) — twin-to-twin transfusion syndrome (TTTS); Group II (n = 38 pairs) — selective intrauterine growth restriction (sIUGR); Group III (n = 58 pairs) — absence of the above-mentioned specific complications. The obtained data were statistically processed on a personal computer via variation statistics methods using Microsoft Excel spreadsheets (Microsoft, USA) and an online service available at https://medstatistic.ru.Results. Newborns with sIUGR (37–100.0%) and 26 (49.1%) donors fell into the category of newborns light for gestational age. Disharmonious (3–10th percentile) and markedly disharmonious (below the 3rd percentile) physical development at birth was most commonly observed in newborns with sIUGR and, to a lesser extent, in donors (OR — 9.2; 95% CI — 3.2–24.3; p &lt; 0.05), which was noted only occasionally in monochorionic twins from other groups. A combined decrease in the values of birth centiles for head circumference, body weight, and body length was found in 13 (35.1%) newborns with sIUGR and in 12 (22.6%) donors, which may mark the severity of antenatal complications and the development of neurological deficit.Conclusion. Monochorionic diamniotic twins include newborns having greater and lower body weights. In the newborn having a lower birth weight, specific complications associated with monochorionic multiple pregnancy result in body weight and length deficit, disharmonious development due to the lack of nourishment (22.6% in the TTTS group and 73.0% in the sIUGR group), as well as delayed head circumference growth in 56.8% of newborns with sIUGR.

Fetal Growth Restriction and Long-Term Cardiovascular Morbidity of Offspring in Dichorionic-Diamniotic Twin Pregnancies.

Objective: We opted to investigate whether fetal growth restriction (FGR) in dichorionic-diamniotic twins is a risk factor for long-term cardiovascular morbidity in offspring. Study design: A population-based retrospective cohort study, comparing long-term cardiovascular morbidity among FGR and non-FGR twins, born between the years 1991 and 2021 in a tertiary medical center. Study groups were followed until 18 years of age (6570 days) for cardiovascular-related morbidity. A Kaplan-Meier survival curve compared the cumulative cardiovascular morbidity. A Cox proportional hazard model assisted with adjusting for confounders. Results: In this study, 4222 dichorionic-diamniotic twins were included; 116 were complicated with FGR and demonstrated a significantly higher rate of long-term cardiovascular morbidity (4.4% vs. 1.3%, OR = 3.4, 95% CI 1.35-8.78, p = 0.006). The cumulative incidence of long-term cardiovascular morbidity was significantly higher among FGR twins (Kaplan-Meier Log rank test p = 0.007). A Cox proportional-hazard model found an independent association between FGR and long-term cardiovascular morbidity, when adjusted for both birth order and gender (adjusted HR 3.3, 95% CI 1.31-8.19, p = 0.011). Conclusions: FGR in dichorionic-diamniotic twins is independently associated with an increased risk for long-term cardiovascular morbidity in offspring. Therefore, increased surveillance may be beneficial.

A Case of Sex Discordant Dichorionic Diamniotic Twins after Single Embryo Transfer and the Importance of Zygosity Testing

Single embryo transfer (SET) is a technique used in assisted reproductive treatment (ART) that is used to promote singleton pregnancies. To date, there are five reported cases of dizygotic twin pregnancies with mothers who underwent SET. Here, we present a sixth case of a dichorionic, diamniotic twin pregnancy with sex discordance. The patient is a 34-year-old woman with unexplained secondary infertility who underwent in vitro fertilization (IVF) and frozen-thawed embryo transfer from a SET. The ultrasonographic images from the first and second trimester scans identified dichorionic, diamniotic twin gestations. The delivery was full term and postnatal genetic testing confirmed 46, XX, and 46, XY offspring. Pathology reports of the placental and membrane findings reported diamniotic, dichorionic twins. There was no zygosity testing conducted, thus it is unknown if the twins are monozygotic or dizygotic. Two possible etiologies for sex-discordant twins, in this case, are concurrent natural conception via breakthrough ovulation at the time of SET, or discordant postzygotic nondisjunction of a single embryo. Multiple gestations may still occur in the setting of SET and zygosity testing in these instances would better elucidate our understanding of this occurrence. Moreover, improved data on the zygosity of multiple gestations following SET may enhance patient counseling.

Suspected twin anemia polycythemia sequence in a dichorionic, diamniotic twin pregnancy: a case report

BackgroundTwin anemia polycythemia sequence is a rare complication in monochorionic twin pregnancy.Case presentationWe describe a case of dichorionic twin pregnancy presenting with suspected twin anemia polycythemia sequence. A 31-year-old White female, on her third pregnancy, had a routine ultrasound scan at 12 weeks gestation, which demonstrated a dichorionic twin pregnancy with one placenta located in the anterior wall and the other in the posterior wall of the uterus. At 21 weeks, a scan demonstrated a 24% growth discordance between the two fetuses with normal Doppler studies and amniotic fluid. At 27 weeks, one twin showed signs of anemia and the other polycythemia; the fetal middle cerebral artery peak systolic velocity was high in the anemic fetus and low in the polycythemic twin (1.8 and 0.5 multiples of the median). An intrauterine blood transfusion was carried out and this increased the fetal hemoglobin concentration in the anemic twin from 3.5 to 12.5 g/dL. At 29 weeks, delivery by cesarean section was carried out because of evidence from middle cerebral artery peak systolic velocity of recurrence of anemia in one twin and worsening polycythemia in the co-twin; at birth the hemoglobin concentrations were 5.6 and 24.9 g/dL, respectively. Histopathological examination confirmed dichorionicity with no communicating vessels between the two placentas.ConclusionsThis is the first case of twin anemia polycythemia sequence in a dichorionic, diamniotic twin pregnancy where intrauterine blood transfusion was used to prolong the pregnancy by almost 2 weeks in a “twin anemia polycythemia sequence-like” setting.