Dichorionic Diamniotic Pregnancy Research Articles

949 EXIT-to-airways for fetal neck mass: extending the procedure to diamniotic-monochorionic twin gestation

Fetal airway obstruction in one twin of a diamniotic pregnancy presents unique challenges especially when a single placenta is shared between the fetuses. Very few cases of Ex-Utero-Intrapartum-Treatment (EXIT) in twin pregnancies have been reported, and only in dichorionic pregnancies. We report a single methodology for EXIT-to-airway procedures in monochorionic and dichorionic twins. We review two EXIT-to-airway in twin pregnancies with a giant cervical mass in one fetus. Two cases of EXIT-to-airway in twin pregnancies were performed in 2018-2019 at a regional fetal treatment center. A multi-disciplinary evaluation was completed, and treatment options developed to accommodate parental goals balancing the risks for both fetuses. Case 1 involved a dichorionic-diamniotic pregnancy with a large cervical lymphatic malformation with labor at 36 weeks. Case 2 involved a giant cervical teratoma in a monochorionic-diamniotic twin pregnancy with preterm labor at 29 weeks. In each case, the polyhydramnios caused the affected twin’s amniotic sac to be the presenting sac for the surgical approach. Continuous monitoring of both fetuses was obtained via pulse-oximetry and intermittent transthoracic echocardiography and continuous transuterine echocardiography. Bronchoscopy and intubation were completed after 10 and 22 minutes of uteroplacental bypass respectively. In each case, the affected fetus was transferred to adjacent operating room for complete mass resection. The unaffected twins were delivered as second without intubation and resuscitated without any perinatal distress. Twins and mothers recovered without complications. EXIT-to-airway appears to be a reasonable option for the safe transition of complicated twins even in the setting of significant prematurity in a monochorionic pregnancy. Continuous monitoring permits safe algorithm-based airway management of the affected twin first and subsequent delivery of the unaffected twin. Thoughtful preparation by an experienced multidisciplinary team permits an EXIT-to-airway approach for twin pregnancies in an emergency setting.

The relationship between fetal thymus volume and preterm birth in dichorionic diamniotic pregnancies

Background: The aim of this study was to compare fetal thymus volume in women who delivered at <36 weeks of pregnancy versus those who did not. Methods: A total of 32 dichorionic-diamniotic twin pregnant women were included in the prospective cohort study. The fetal thymus volumes were measured in the second trimester for each fetus using the VOCAL ultrasonography program. The data of women who experienced preterm labor (delivered at <36 weeks of pregnancy) and the control group (delivered at ≥36 weeks of pregnancy) were compared. Results: The mean thymus volume of each fetus was statistically significantly lower in preterm delivery cases than in the control group. Mean fetal thymus volume could be used as a marker for predicting preterm birth in the study group. The parameter of fetal thymus volume measured in twins at 18–24 weeks can be used as a predictive factor (P < 0.001). When the fetal thymus volume, measured 3-dimensionally by ultrasonography in conjunction with the VOCAL program, was used as a marker for predicting preterm delivery, the cut-off value was found to be 0.5245 cm3, with 83.3% sensitivity and 85.8% specificity (AUC 0.905, P < 0.001, 95% CI, 0.798–0.930). Conclusion: By predicting preterm delivery via measuring the fetal thymus volume in twins, physicians can suggest strategies to prevent preterm delivery at 18–24 weeks of pregnancy. In this way, fetal mortality/morbidity related to preterm delivery may be prevented.

Monozygotic dichorionic-diamniotic pregnancies following single frozen-thawed blastocyst transfer: a retrospective case series

BackgroundThe primary aim of the study is to report cases of monozygotic dichorionic-diamniotic (DC-DA) pregnancies after single frozen-thawed blastocyst transfer.MethodsThis is a retrospective case series. All single frozen-thawed blastocyst transfer cycles performed between June 2013 and December 2018 at the Shanghai Ji Ai Genetics and IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China, were reviewed retrospectively. We included frozen embryo transfer (FET) cycles which clinical pregnancy was confirmed with multiple gestational sacs showed on ultrasonography at around 6 to 7 weeks of gestation. We then conducted an in-depth analysis to further exclude cases which contained newborns of different genders or natural FET cycles.ResultsFive thousand four hundred fifteen frozen-thawed single blastocyst transfer cycles were preformed between June 2013 and December 2018 at the Shanghai Ji Ai Genetics and IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China. Of these, fourteen women underwent a single blastocyst transfer and then achieved clinical pregnancy with an ultrasound diagnosis of multi-chorionic pregnancy. With one natural cycle FET excluded, we finally included thirteen single blastocyst transfer cycles performed in down-regulated controlled FET or hormone replacement FET, in which the possibility of concurrently spontaneous pregnancy was extremely small. These included 13 cases reveal the phenomenon of monozygotic DC-DA twinning after single blastocyst transfer, which challenges the classical theory that only monochorionic pregnancy could happen after 3 days of fertilization.ConclusionThis case series suggest that single blastocyst transfer could result DC-DA pregnancies during IVF treatment.

“Near miss” maternal morbidity following repeat rescue cerclage for twin pregnancy

Objective Repeat cervical cerclage is one of the treatment options described in the literature for when the primary cerclage suture fails. However, infectious complications of cerclage placement may be encountered which are more obvious for the newborn. In our presented case, severe acute maternal morbidity was encountered for the sake of prolonging pregnancy. Case(s) Twenty-seven year old nullipar patient at 23+5 gestational weeks with dichorionic diamniotic pregnancy was admitted to our emergency clinic with complaints of “pain” and “vaginal bleeding”. At 18 weeks of pregnancy she had a Shirodkar cerclage procedure indicated by a short cervical length (14 mm) at our hospital. She presented with “bulging of membranes” to a different institution and underwent a repeat cerclage at 23+3 weeks. Chorioamnionitis was suspected and the patient was counselled for a pregnancy termination. After termination of pregnancy, “cardiac arrest” developed. After 2 minutes of resuscitation sinus rythm was obtained. The patient was admitted to the ICU. Conclusion The role of repeat cerclage is controversial. Efforts should be maximized to rule out underlying intrauterine infection prior to placement of a cerclage suture for there to be a therapeutic benefit of prolonging the pregnancy.

Intraventricular Hemorrhage in a Single Fetus of Dichorionic-Diamniotic Gestation: A Case Report and Review of Literature

AbstractIntraventricular hemorrhage (IVH) is a serious complication of prematurity and is of high concern due to the risk of brain injury and in severe cases, death. We report the first case of IVH in a fetus of dichorionic-diamniotic pregnancy that worsened postnatally. Antenatally, magnetic resonance imaging confirmed a large IVH after ventricular abnormalities were detected by prenatal ultrasound (US). At birth, a grade IV IVH diagnosis was made and progressive ventricle dilatation was noted on weekly US. A ventriculoperitoneal shunt was placed and ventricle dilatation was slightly reduced, however, the IVH was essentially unchanged. The infant was discharged in stable condition at 12-weeks-old and chronic neurological dysfunction is expected. IVH is seen in complicated births of prematurity and antenatal US can inform an examiner if fetal IVH is present. It is important to identify IVH and provide immediate intervention to prevent disease worsening during the antenatal and postnatal period.

Maternal ABVD chemotherapy for Hodgkin lymphoma in a dichorionic diamniotic pregnancy: a case report

BackgroundHodgkin lymphoma (HL) is the most common hematological malignancy during pregnancy. The first-line treatment for HL in pregnancy is the standard ABVD regimen without any drug and/or dose adjustment. However, data on chemotherapy during twin pregnancies are sparse, and a better understanding of the mechanisms involved in exposure to and the toxic effects of anticancer drugs in the fetuses is needed.Case presentationA 41-year-old dichorionic diamniotic pregnant patient was given ABVD treatment for HL at a gestational age of 28 weeks and 3 days. The patient received 2 cycles of chemotherapy with a 15-day therapeutic window including an actual 25 mg/m2 dose of doxorubicin per cycle. Unlike the female twin, the male twin presented four days after birth a left cardiac dysfunction. Doxorubicin cardiotoxicity in the male newborn was also supported by high blood levels of troponin. At one month of age, echocardiography findings were normal. We investigated literature data on physiological aspects of pregnancy that may influence doxorubicin pharmacokinetics, and pharmacodynamic and pharmacokinetic data on the use of doxorubicin in pregnancy. We detailed the role of the transporters in doxorubicin placenta distribution, and tried to understand why only one fetus was affected.ConclusionsFetal safety depends at least on maternal doxorubicin pharmacokinetics.Because of drug interactions (i.e. drug metabolism and drug transport), care should always be taken to avoid maternal pharmacokinetic variability. The toxic effects were discrepant between the dizygotic twins, suggesting additional fetus-specific pharmacokinetic/pharmacodynamic factors in doxorubicin toxicity.

The impact of chorionicity and the type of twin growth on the early neonatal outcome in twin pregnancies – 20 years of experience from one tertiary perinatal center

ObjectiveTwin pregnancies are associated with higher neonatal mortality and morbidity. Growth discordance and monochorionicity are among the factors that worsen the course of pregnancy. The study aimed to assess neonatal conditions and mortality in relation to growth type and chorionicity. Materials and methodsData from 820 pregnant women with twin pregnancies and their 1640 newborns were analyzed. The Apgar score and umbilical artery blood pH, as well as the rate of complications, were compared between dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twins with symmetric and discordant growth. The Student's t-test and the Pearson chi-square test were used for comparisons. ResultsThere were 576 (70.2%) DCDA pregnancies, including 421 (73.1%) with symmetric growth and 155 (26.9%) with discordant growth, and 244 (29.8%) MCDA pregnancies, including 110 (45.1%) with symmetric growth and 134 (54.9%) with discordant growth. A significantly greater percentage of twins with discordant growth occurred in women older than 34 years than in those that were younger. An Apgar score of ≤7 was significantly more common among MCDA discordant twins, while an arterial umbilical blood pH of <7.2 was more common among MCDA twins with symmetric growth. Early neonatal deaths (n = 29; 1.8%), respiratory disorders, and a birth weight of <1500 g were significantly more common in MCDA twins than in DCDA twins. ConclusionMCDA twins with growth discordance are burdened with a higher risk of neonatal morbidity and mortality than symmetric DCDA twins. Chorionicity and growth discordancy are important determinants of the outcome of twin pregnancy.

Challenge in the Management of Twin Pregnancy with Anencephaly of One Fetus in a Low- Income Country: A Case Presentation

Anencephaly of one twin is a frequent congenital abnormality in a twin pregnancy and it’s associated with a poor prognosis of this pregnancy. In developed countries, the goal standard management calls for an interventional fetal medicine either by injection of a cardiotoxic or by intervention on the umbilical cord. Another option is an expectative management with strict follow-up of pregnant women and delivery organized in a level 3 maternity. There is still a challenge in the management of such high risk pregnancy in low income countries. A 37 years-old female, G3P2002, referred from a clinic for the better management of a 28 weeks and 4 days twin pregnancy in labor. Obstetrical ultrasonography realized in the second trimester revealed dichorionic-diamniotic pregnancy and the presence of anencephaly with hydramnios of one twin. The expectative approach was adopted for the management of this high risk pregnancy, unfortunately the death of the fetus occurred despite all the care provided. This case brings to lamp light the difficulties encountered in providing standard obstetrical care for high risk pregnancies in resource limited settings.

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To compare the mean transvaginal ultrasound (TVU) cervical length (CL) at midtrimester screening for spontaneous preterm birth in asymptomatic monochorionic diamniotic versus dichorionic diamniotic twin pregnanciesThis was a multicenter retrospective cohort study. Study subjects were identified at the time of a routine second trimester fetal ultrasound exam at 18 0/7–23 6/7 weeks gestation. We excluded women that received progesterone, pessary, or cerclage. Distribution of CL was determined and normality was examined. Mean of TVU CL were compared between monochorionic diamniotic and dichorionic diamniotic pregnancies. The relationship of TVU CL with gestational age (GA) at delivery and incidence of spontaneous preterm birth (SPTB) at different TVU CL cut offs were assessed. Incidence of short TVU CL, defined as TVU CL ≤30 mm, was also calculated in the two groups.580 women with diamniotic twin pregnancies underwent TVU CL screening between 18 0/6 and 23 6/7 weeks. 175 (30.2%) were monochorionic diamniotic pregnancies, and 405 (69.8%) were dichorionic pregnancies. The demographic characteristics were similar on both groups. The mean GA at TVU CL was about 20 week in both groups. The mean TVU CL was significantly lower in the monochorionic diamniotic (32.8 ± 10.1) compared to the dichorionic (34.9 ± 8.6) group (MD −2.10 mm, 95% CI −3.91 to −0.29). TVU CL ≤30 mm was 16.6% (29/175) in the monochorionic group, and 11.9% (48/405) in the dichorionic group (aOR 1.48, 95% CI 1.03–2.43). Twins with a monochorionic diamniotic pregnancy had a significantly higher incidence of SPTB (53.1% vs 44.9%; aOR 1.22, 95% CI 1.22–1.79). For any given CL measured between 18 0–7 and 23 6/7 weeks, gestational age at delivery for monochorionic diamniotic pregnancies was about 2 weeks earlier compared to dichorionic pregnancies (MD -2.1 weeks; ANCOVA P < 0.001).Monochorionic diamniotic twin pregnancies had a higher rate of spontaneous preterm birth than dichorionic diamniotic pregnancies. The higher rate of spontaneous preterm delivery in monochorionic pregnancies is associated with lower midtrimester TVU CL when compared to dichorionic pregnancies.

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To compare the mean transvaginal ultrasound (TVU) cervical length (CL) at midtrimester screening for spontaneous preterm birth in asymptomatic monochorionic diamniotic versus dichorionic diamniotic twin pregnanciesThis was a multicenter retrospective cohort study. Study subjects were identified at the time of a routine second trimester fetal ultrasound exam at 18 0/7–23 6/7 weeks gestation. We excluded women that received progesterone, pessary, or cerclage. Distribution of CL was determined and normality was examined. Mean of TVU CL were compared between monochorionic diamniotic and dichorionic diamniotic pregnancies. The relationship of TVU CL with gestational age (GA) at delivery and incidence of spontaneous preterm birth (SPTB) at different TVU CL cut offs were assessed. Incidence of short TVU CL, defined as TVU CL ≤30 mm, was also calculated in the two groups.580 women with diamniotic twin pregnancies underwent TVU CL screening between 18 0/6 and 23 6/7 weeks. 175 (30.2%) were monochorionic diamniotic pregnancies, and 405 (69.8%) were dichorionic pregnancies. The demographic characteristics were similar on both groups. The mean GA at TVU CL was about 20 week in both groups. The mean TVU CL was significantly lower in the monochorionic diamniotic (32.8 ± 10.1) compared to the dichorionic (34.9 ± 8.6) group (MD −2.10 mm, 95% CI −3.91 to −0.29). TVU CL ≤30 mm was 16.6% (29/175) in the monochorionic group, and 11.9% (48/405) in the dichorionic group (aOR 1.48, 95% CI 1.03–2.43). Twins with a monochorionic diamniotic pregnancy had a significantly higher incidence of SPTB (53.1% vs 44.9%; aOR 1.22, 95% CI 1.22–1.79). For any given CL measured between 18 0–7 and 23 6/7 weeks, gestational age at delivery for monochorionic diamniotic pregnancies was about 2 weeks earlier compared to dichorionic pregnancies (MD -2.1 weeks; ANCOVA P < 0.001).Monochorionic diamniotic twin pregnancies had a higher rate of spontaneous preterm birth than dichorionic diamniotic pregnancies. The higher rate of spontaneous preterm delivery in monochorionic pregnancies is associated with lower midtrimester TVU CL when compared to dichorionic pregnancies.

Intrauterine Single Fetal Demise in Twin Pregnancy

Intrauterine demise of one of the twin fetuses during second or third trimester of pregnancy is an uncommon complication. Fetal death of a twin during the first trimester is not an uncommon event and does not appear to impair the development of the second twin. However, fetal death during second or third trimester may increase the risk of IUGR, microcephaly, cerebral encephalomalacia, pre eclampsia, preterm labour, perinatal mortality. We present two cases with single fetal demise. Death of one of the two fetuses occurred at 23 weeks of gestation in the first case and at 33 weeks in the second case. Both patients were managed conservatively with close fetal monitoring and serial assessment of mother’s clotting profile. Cesarean section was done especially due to patients’ interest at 34 weeks and 35 weeks respectively. A fetus papyraceous was found in the first case. Both the cases were dichorionic diamniotic pregnancies with no maternal and fetal complications during pregnancy or the post partum period.Delta Med Col J. Jan 2018 6(1): 53-57

428: Midtrimester transvaginal ultrasound cervical length in diamniotic twin pregnancies according to chorionicity

To compare the mean transvaginal ultrasound (TVU) cervical length (CL) at midtrimester screening for spontaneous preterm birth in asymptomatic monochorionic diamniotic versus dichorionic diamniotic twin pregnancies This was a multicenter retrospective cohort study of a prospectively collected database. Study subjects were identified at the time of a routine second trimester fetal ultrasound exam at 18 0/7 - 23 6/7 weeks gestation. Distribution of CL was determined and normality was examined. Mean of TVUCL were compared between monochorionic diamniotic and dichorionic diamniotic pregnancies. The relationship of TVUCL with gestational age (GA) at delivery and incidence of spontaneous preterm birth (SPTB) at different TVUCL cut offs were assessed. Incidence of short TVUCL, defined as TVUCL ≤30mm, was also calculated in the two groups. We excluded women that received progesterone, pessary, or cerclage. 580 women with diamniotic twin pregnancies underwent TVUCL screening between 18 0/6 and 23 6/7 weeks. 175 (30.2%) were monochorionic diamniotic pregnancies, and 405 (69.8%) were dichorionic pregnancies. The demographic characteristics were similar on both groups. The mean GA at TVUCL was about 20 week in both groups. The mean TVUCL was significantly lower in the monochorionic diamniotic (32.8±10.1) compared to the dichorionic (34.9±8.6) group (MD -2.10 mm, 95% CI -3.91 to -0.29). TVUCL ≤30mm was 16.6% (29/175) in the monochorionic group, and 11.9% (48/405) in the dichorionic group (aOR 1.48, 95% CI 1.03 to 2.43). Twins with a monochorionic diamniotic pregnancy had a significantly higher incidence of SPTB <34 weeks (29.7% vs 20.0%; aOR 1.69, 95% CI 1.13 to 2.54). For any given CL measured between 18 0-7 and 23 6/7 weeks, gestational age at delivery for monochorionic diamniotic pregnancies was about 2 weeks earlier compared to dichorionic pregnancies (MD -2.1 weeks; ANCOVA P<0.001). Monochorionic diamniotic twin pregnancies had a higher rate of spontaneous preterm birth than dichorionic diamniotic pregnancies. The higher rate of spontaneous preterm delivery in monochorionic pregnancies is associated with lower midtrimester TVUCL, as well as by the lower gestational age at birth per any given CL in monochorionic diamniotic compared to dichorionic pregnancies.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

PP-26 Neocord: mrna expression of cytochromes and transporters involved in drug metabolism at birth, using human umbilical cord blood

Background Growth, maturation and physiological modifications are mainly responsible for the difference in pharmacokinetics and pharmacodynamics of drugs ob-served between adults and children, especially neonates. Ontogeny of drug metabolising enzymes and transport-ers play an important role in drugs inter-individual phar-macokinetic variability in this population. Data on neona-tal developmental pharmacology remain very limited. Neocord aims to characterise mRNA expression of the main cytochromes and transporters involved in the phar-macokinetics and pharmacodynamics of drugs in twin newborns, using umbilical cord blood, according to iden-tified covariates such as genetic background, pregnancy environment, gestational age, sex, maternal pathologies and treatments, etc. A population of twins will allow a precise comparison of individuals with different or identi-cal genetic background. Methods Umbilical cord blood samples (2.5 ml) were col-lected from women pregnant with twins, both dizygotic and monozygotic, in the maternity ward of Robert-Debre Hospital using PaxGene Blood RNA tubes. Isolation and purification of total RNA from the blood samples was performed using the PAXgene Blood RNA kit with sub-sequent RNA reverse transcription (RT-PCR). Amplification of DNA and gene expression profiling was performed by real-time polymerase chain reaction (qPCR) using Ap-plied Biosystems TaqMan gene expression assay tech-nology. Expression of the 18S ribosomal reference gene was used as internal control for normalisation of expres-sion profiles. A large panel of drug metabolising enzymes and transporters genes was quantified: cytochrome P450 system (n=12), UGT family (n=6), transporters (n=3) and TPMT. Relative gene expression levels between the differ-ent samples were calculated using the ΔΔCt method. Results Fifty umbilical cord blood samples (32 males and 18 females) from 25 women pregnant with twins, deliv-ering between April 2015 and March 2017, were collect-ed. Median age of the women was 33.2 years (23.2–49.5) and median gestational age at delivery was 37.3 weeks of amenorrhea (34.4–39.6). Nineteen women delivered at term and 6 delivered before 37 weeks. Five women had a monochorionic diamniotic pregnancy and 20 women had a dichorionic diamniotic pregnancy. Monochorionic twins were assumed to be monozygotic (n=10) and dif-ferent-sex twins as dizygotic (n=20). Zygosity of the 20 same-sex dichorionic twins could not be assessed. Preliminary results were obtained after analysis of 30 cord blood samples. Females (n=12) and males (n=18) showed no differences of weight or gestational age at birth. From these 15 twins pairs: UGT1A6 and UGT2B7 expressions were not found in umbilical cord blood samples while others were expressed at different levels. Gene expression was different between newborn genders (p Conclusion Identification of differences in protein ex-pression profiles will allow a better understanding of the pharmacokinetics and pharmacodynamics variability of drugs in the newborn. Such factors will help improving neonatal care and define appropriate dose regimens in the neonatal population.

P 16 Cross sectional study of placental growth factor in multiple pregnancy

Introduction Pre-eclampsia is a complex complication of pregnancy which may result in serious morbidity to both mother and baby. Women with a multiple pregnancy have a 2-3-fold increased risk of developing pre-eclampsia. Placental growth factor (PlGF) is an angiogenic biomarker for pre-eclampsia. The integration of its use into routine care in assessment of women presenting with suspected pre term pre-eclampsia is currently the subject of a number of international randomised controlled trials. Currently no reference range exists for PlGF specific to multiple pregnancy. Objectives To develop a multiple pregnancy specific reference range for PlGF using an enzyme-linked immunosorbent assay (ELISA). Methods Prospective cross sectional study of multiple pregnancies attending a tertiary maternity hospital from July 2015–March 2017. PIGF levels were measured in maternal plasma samples by Quantikine® ELISA. Results 200 samples were analysed, 160/200 from Dichorionic Diamniotic (DCDA) twin pregnancies and 32/200 from Monochorionic Diamniotic (MCDA) twin pregnancies. Gestational age ranged from 12–36 + 6 weeks” and PlGF ranged from 15 to 4720 pg/ml. The mean gestational PlGF tracks development of the placenta with a peak at 24–27 + 6 weeks” gestation and a reduction thereafter. See Table. Conclusion There does not appear to be a difference in mean gestational PlGF between DCDA and MCDA pregnancies to date however sample numbers are small. This twin specific reference range for PlGF may be used in assessment of a pregnant patient presenting with suspected preterm pre-eclampsia.

Patterns of Second- and Third-Trimester Growth and Discordance in Twin Pregnancy: Analysis of the Southwest Thames Obstetric Research Collaborative (STORK) Multiple Pregnancy Cohort

Introduction: This study investigates patterns of intertwin size discordance in dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twin pregnancies. Material and Methods: Ultrasound measurements of twin pregnancies, from 14 weeks to term, were collected by 9 hospitals over a 10-year period. This analysis considers the modelled and observed levels of discordance in abdominal circumference (AC) and estimated fetal weight (EFW) in relation to gestational age. Fitted models were analysed to produce charts displaying the expected range of intertwin discordance in AC and EFW at any given examination. Results: The dataset for analysis included a total of 9,866 ultrasound examinations in 1,802 DCDA and 323 MCDA twin pregnancies. The 95th percentile of intertwin discordance in EFW increased from 18.3% (95% CI, 17.8-18.7%) at 20 weeks to 21.9% (95% CI, 21.3-22.4%) at 30 weeks for DCDA pregnancies. The 95th percentile for intertwin discordance in AC was stable at 10-11% for this period. Slightly higher levels of discordance were observed for MCDA than for DCDA pregnancies. Discussion: The expected range of intertwin discordance in EFW and AC shows differences with gestational age and between DCDA and MCDA pregnancies.

Clinical outcomes after assisted reproductive technology in twin pregnancies: chorionicity-based comparison

The chorionicity–based evaluation of the perinatal risk in twin pregnancies after assisted reproductive technology (ART) is lacking. A retrospective review was performed of all twin pregnancies monitored prenatally and delivered at our hospital between 2010 and 2014. Chorionicity was diagnosed by ultrasound examination at first trimester and confirmed by postnatal pathology. Pregnancy and perinatal outcomes were prospectively recorded. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated in a logistic regression model. A total of 1153 twin pregnancies were analyzed. The occurrence of preterm premature rupture of membranes (PPROM) was 3 times as frequent in monochorionic diamniotic (MCDA) twin pregnancies after ART as in those spontaneous counterparts (aOR 3.0; 95%CI 1.1–3.2). The prevalence of intrahepatic cholestasis of pregnancies (ICP) was significantly higher in dichorionic diamniotic (DCDA) twin pregnancies following ART compared to spontaneous DCDA pregnancies (aOR 3.3; 95%CI 1.3–5.6). Perinatal outcomes did not differ between two conception methods, either in MCDA or DCDA twin pregnancies. Based on differentiation of chorionicity, ART is associated with the increased risk of PPROM in MCDA twin pregnancies and with a higher rate of ICP in DCDA twin gestations. ART does not increase adversity of perinatal outcomes in twin pregnancies.

Prenatal diagnosis of gastric and small bowel atresia: a case series and review of the literature

Objective: To describe seven cases of gastrointestinal tract (GIT) obstructions and to report a skewed review of the literature. Methods: We performed a search of our permanent perinatal database about cases with prenatal ultrasound and MRI diagnosis of gastrointestinal tract obstructions between 2006 and 2013. All cases were followed until hospital discharge and pre-natal diagnosis were confirmed by fetal MRI, postnatal imaging and/or intra-operative findings. Maternal age, parity, gestational age at diagnosis, ultrasound findings, gestational age at delivery, Apgar scores at 1 and 5 min and postnatal outcome have been recorded. Results: We identified seven cases of gastric and small bowel atresia. Karyotype was normal in six cases and abnormal in one co-twin [46,XY dup (20) (qq13.1q13.3)dn] of a dichorionic-diamniotic pregnancy. The mean ± SD for maternal age, gestational age at diagnosis, gestational at delivery, birth weight and Apgar scores at 1 and 5 min were 30.8 ± 4.8 years, 29.8 ± 3.7 weeks, 2507.5 ± 727.5 g and 5.6 ± 2.1, 7.6 ± 1.6, respectively. All fetuses’ undergone surgical procedures in the postnatal period and all of them were discharged live from the hospital. Conclusion: Prompted antenatal detection of gastrointestinal tract obstruction using ultrasound proved to be diagnostic in all cases. Fetal MRI aid was a useful complementary diagnostic investigation. Correct pre-natal diagnosis allows adequate counseling, delivery planning and management care by a multidisciplinary team.

Umbilical and fetal middle cerebral artery Doppler reference ranges in a twin population followed longitudinally from 24 to 38 weeks' gestation

To construct monochorionic diamniotic (MCDA) and dichorionic diamniotic (DCDA) twin reference ranges for umbilical artery (UA) pulsatility index (PI), UA resistance index (RI), fetal middle cerebral artery (MCA) PI and peak systolic velocity (PSV) and cerebroplacental ratio (CPR) from 24 weeks' to 38 weeks' gestation and compare these with published normal values for singleton pregnancies. This prospective multicenter cohort study included 1028 unselected twin pairs recruited over a 2-year period. Participants with dichorionic twins underwent fortnightly ultrasound surveillance from 24 weeks' gestation, with monochorionic twins being followed every 2 weeks from 16 weeks until delivery. A total of 7536 fetal Doppler examinations in 618 twin pregnancies were included in the analysis, with reference ranges for MCDA and DCDA pregnancies constructed for each of the Doppler indices using multilevel modeling. UA-PI and UA-RI appear to be higher in twins than in singletons, and MCA-PI and MCA-PSV appear to be lower. The CPR also appears to be lower in twins than in singletons. Similar MCA indices were observed in MCDA and DCDA twins. We have established longitudinal reference ranges for UA-PI and UA-RI, MCA-PI and MCA-PSV and CPR in twin pregnancies, which appear to differ from those in singleton pregnancies. The derived twin-specific reference ranges may be more appropriate in the surveillance of these high-risk pregnancies. Applying the singleton CPR cut-off of ≤ 1.0 may lead to a large number of false-positive diagnoses of cerebral redistribution in twin fetuses.

First-trimester fetal growth discordance and development of preeclampsia in dichorionic twin pregnancies

To investigate the relation between first-trimester fetal growth discrepancy, as assessed by crown-rump length (CRL) at 11+0 to 13+6 weeks of gestation, and subsequent development of preeclampsia (PE) in dichorionic diamniotic (DCDA) twin pregnancies. The association between inter-twin CRL and birth weight (BW) discrepancy was also investigated. This was a retrospective, case-control study of DCDA twin pregnancies. Inter-twin CRL discrepancy was calculated as 100×(larger CRL-smaller CRL)/larger CRL. BW discordance was calculated as 100×(larger BW-smaller BW)/larger BW. The study included 299 DCDA pregnancies that remained normotensive and 35 that subsequently developed PE. There was no significant difference in the inter-twin CRL discrepancy between pregnancies complicated by PE and those that were not [3.2%, interquartile range (IQR): 0.5-4.5% vs. 3.3%, IQR: 1.4-5.5%; P=0.17]. There was a positive correlation between inter-twin CRL and BW discrepancy but only in pregnancies that remained normotensive (P<0.001). In women that subsequently developed PE, there was no association between inter-twin CRL and BW discordance (P=0.54). In unselected DCDA twins, first-trimester CRL discrepancy is not different between pregnancies that subsequently develop PE and those that remain normotensive. Furthermore, in pregnancies that are complicated by PE, the association between inter-twin CRL and BW discrepancy appears to be lost.

Ultrasound management and clinical outcome of twin pregnancies

The rate of multiple pregnancies is showing a significant increase in Western countries. Twin gestations should be considered a high-risk condition because they are responsible for a disproportionate amount of overall perinatal morbidity and mortality. We used a specialised ultrasound protocol based on chorionicity to monitor 44 twin pregnancies (61% dichorionic diamniotic (DD) and 39% monochorionic diamniotic (MD)). Adverse pregnancy outcomes and pre-term deliveries were more common in MD pregnancies than in DD pregnancies; the rate of extreme pre-term delivery (< 32 weeks) was almost three-times higher in MD than in DD pregnancies (41% vs 15%) and perinatal complications were more frequent in MD than in DD pregnancies (59% vs 22%), but fetal anomalies were more frequent in DD than in MD pregnancies (30% vs 24%). Periodic ultrasound follow-up would predict the pregnancies that are at greater risk for fetal and neonatal complications and these should be monitored more closely.