Dichorionic Pregnancies Research Articles

Vitamin D Supply of Twins during Fetal Life, Its Relation to Anthropometric Parameters of Newborns and the Analysis of Other Factors Related to Birth Size

Background/Objectives: Vitamin D deficiencies are very common in pregnant women, raising concerns about adverse health outcomes in children. This issue has hardly been studied in multiple pregnancies, the prevalence of which has been steadily increasing. Therefore, our study investigated the relationship between newborns’ anthropometric parameters and the concentration of 25(OH)D in maternal blood of women with twin pregnancies and umbilical cord blood. Methods: The study included 50 women who gave birth after the 36th week of twin gestation. The concentration of 25(OH)D was determined in maternal blood collected during the antenatal period and in the umbilical cord blood of 100 newborns. Anthropometric parameters of the newborns (birth weight, length and head and chest circumference) were obtained from hospital records. Data on nutrition and lifestyle during pregnancy were collected from the patients during an interview conducted by a dietitian. Results: No relationship between maternal and neonatal cord blood vitamin D concentrations and any of the anthropometric parameters of the newborns was found. However, only 6% of the mothers and 13% of the newborns had vitamin D deficiency (≤20 ng/mL). The type of pregnancy and maternal height were the main factors associated with neonatal size. Newborns from dichorionic pregnancies were on average 202 g heavier (p < 0.001) and 1 cm longer (p = 0.006) than newborns from monochorionic pregnancies. Newborns of mothers ≤160 cm in height had on average 206 g lower birth weight (p = 0.006) and were 3.5 cm shorter (p = 0.003) compared to newborns of taller mothers. Conclusions: Therefore, in our study, the neonatal size of twins was not related to the vitamin D status but to other factors such as the type of pregnancy and maternal height.

Twin-to-Twin Transfusion Syndrome in a Dichorionic Diamniotic Pregnancy with Unusual Ultrasound Findings

Abstract Introduction/Objective Twin-to-twin transfusion syndrome (TTTS) is a complication of twin gestations which affects approximately 1-3 per 10,000 births and is most commonly observed in monochorionic diamniotic twins. The authors present a rare case of TTTS occurring in dichorionic diamniotic twins and literature review. Methods/Case Report The patient was initially found to have a twin pregnancy at 12 weeks of gestation with ultrasound findings suggestive of monochorionic diamniotic twins, but subsequent ultrasounds demonstrated a twin- peak sign, indicating a dichorionic diamniotic gestation. Her pregnancy was subsequently complicated by the discovery of TTTS at 26 weeks of gestation leading to her hospitalization for inpatient fetal surveillance and amnioreduction. She was discharged in stable condition. However, despite close follow-up, there was ultimately intrauterine demise of Twin B (donor twin) at 30 weeks and 6 days gestational age. There were no other complications during the course of pregnancy. Examination of the placenta at autopsy was consistent with a dichorionic diamniotic pregnancy with anastomoses within the fused placenta and evidence of prolonged oligohydramnios by presence of amnion nodosum, supporting the clinical and sonographic findings of TTTS. Results (if a Case Study enter NA) NA Conclusion In summary, this is a rare case of TTTS occurring in a dichorionic diamniotic twin gestation with clinical, sonographic, and pathologic findings. Only five cases have been reported thus far in the literature.

Is Feto-Maternal Transfusion after Cesarean Delivery Different in Singleton and Twin Pregnancy?

Background: The aim of the study was to investigate if feto-maternal transfusion was related to the size of the fetal-maternal interface, and, therefore, was larger in twin pregnancy in comparison with singleton pregnancy. Methods: Blood samples from women with singleton (n = 11), and monochorionic (n = 11) and dichorionic (n = 13) twin gestations were tested. Flow cytometry tests with hemoglobin F, glycophorin A, and hemoglobin F and carbonic anhydrase simultaneous staining were used to detect fetal red blood cells and maternal F cells. Results: In all cases, the volume of feto-maternal transfusion was estimated to be low. The highest rate of fetal red blood cells in the maternal circulation was observed in the blood of women with dichorionic twin gestations both before and after delivery. An increase in fetal red blood cells was observed after cesarean section in singletons and twins. The median rate of maternal F cells was 2.23% in singleton, 2.1% in monochorionic and 3.95% in dichorionic pregnancy. Conclusions: Feto-maternal transfusion during pregnancy may be related to the multiplicity and chorionicity of pregnancy.

Trans-abdominal fetal reduction in higher order multiple pregnancies: a pioneer cohort retrospective study in Nepal.

To share the initial experience of trans-abdominal multifetal pregnancy reduction (MFPR) in Nepal. The procedure was performed in 108 patients in a private hospital over a period of 3 years. Under ultrasound guidance, intracardiac injection of 0.2-3.0ml of 15% w/v (2mEq/ml) potassium chloride (KCl) was administered via trans-abdominal route. A total of 108 fetal reduction procedures were carried out at the seventh to fifteenth weeks of gestation, a maximum of 44 (40.7%) of which were done at the ninth to tenth weeks of gestation. A total of 123 fetuses were reduced. Out of total 108 multifetal pregnancies, 96 (88.8%) were due to in-vitro fertilization (IVF). Eighty-five pregnancies (78.7%) underwent reduction from triplet to twin. The second-time reduction was needed in five cases. Two attempts (in the same sitting) were required in three cases. The inadvertent demise of the second fetus was noted in three cases of dichorionic tri-amniotic triplet pregnancy. Ultrasound-guided trans-abdominal fetal reduction performed between the seventh and twelfth weeks of gestation is safe and effective.

Outcome of Twins Discordant for Major Anomalies

Abstract Objectives This article determines the incidence, management, and outcomes of twins discordant for major structural anomalies. Materials and Methods A retrospective observational study was conducted from 2011 to 2021. Pregnant women discordant for major malformations as confirmed postnatally were included in the study. Demographic and clinical details were collected from medical records. Determining the incidence and profile of twins discordant for major structural anomalies and their management and outcomes were considered as primary objectives that were detailed in dichorionic (DC) and monochorionic (MC) twin pregnancies. Results A total of 83 subjects were included, with an incidence of 1.76% in DC pregnancies and 1.4% in MC pregnancies. Major structural anomalies among DC twins were musculoskeletal (26%), followed by circulatory system anomalies (20.2%), while among MC twins, the majority were found to be central nervous system anomalies (35.7%). Gastrointestinal system anomalies were found the least, with 5.8% in DC anomalous twins, and none were observed in MC anomalous twins. Live birth rate among anomalous twins was found to be 79.71 and 64.29%, and in normal cotwins, it was 92.75 and 85.71% in DC and MC twins, respectively. Surviving anomalous twins underwent postnatal surgery or intervention in 25/69 (36.2%) DC twins, out of which 20 infants were alive and healthy. In the MC anomalous twin group, 3/14 (21.42%) underwent surgical correction; all were alive and well. Postnatally, babies were followed up until 2 years of life. The survival rate for anomalous twins was 47.82% in DC and 35.7% in MC twins. Normal cotwins had overall favorable outcomes, with a survival rate of 89.8 and 85.7% in DC and MC twins, respectively. Conclusion In DC twins discordant for major anomalies, expectant management is a safe option.

Clinical significance for assessing adaptive hemostasis changes during multiple pregnancy after in vitro fertilization

Aim: to assess adaptive hemostasis changes in multiple dichorionic pregnancy after in vitro fertilization (IVF). Materials and Methods. A prospective observational randomized controlled trial was conducted by examining 58 and 46 pregnant women with multiple dichorionic diamniotic twins resulting from applying assisted reproductive technologies (ART) and spontaneous delivery (comparison group), respectively. Hemostasis parameters were studied as follows: activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time (TT), fibrinogen, antithrombin, protein C, protein S, functions of protein С (РrоС Global test), D-dimer, platelet aggregation with adenosine-5-diphosphate (ADP), ristocetin, and collagen. Results. A high coagulation potential was revealed, more prominent after using ART (p < 0.05). Fibrinogen level gradually increased while gestation age increased, whereas APTT, PT and TT level decreased. In the group with natural conception, fibrinogen increased by 22 % in the second trimester, reaching 4.5 g/L (95 % CI = 4,2–4,8) and by 6 % in the third trimester, reaching 4.8 g/L (95 % CI = 4,3–5,4), whereas in the IVF group – by 26 %, reaching 5.3 g/L (95 % CI = 4,7–5,6) and by 21 %, reaching (6.5 g/L; 95 % CI = 5,2–6,8) in relevant trimester of pregnancy, respectively. Antithrombin level was lower in IVF patients – 76.8 % (95 % CI = 72.6 – 81.0) in the second trimester, reaching 70.6 % (95 % CI = 64.8–76.4) in the third trimester (p < 0.001). Protein C level did not differ significantly between groups and was low within the reference range. The aggregatogram demonstrated a high platelet hemostatic potential in IVF patients (p < 0.05) as early as in the first trimester: ADP-induced aggregation – 68.3 % (95 % CI = 62.9–73.7), ristocetin-induced aggregation – 53.1 % (95 % = CI 48.7–58.5), collagen-induced aggregation – 58.4 % (95 % CI = 52.1–64.7). In the third trimester, both platelet aggregation and functional activity (ADP-induced aggregation – 64.5 % [95 % CI = 59.3–69.7], ristocetin-induced aggregation – 68.4 % [95 % CI = 63.2–73.6], collagen-induced aggregation – 50.7 % [95 % CI = 44.3–57.1]; p < 0.05) and D-dimer level persistently increased, also more prominently in the IVF group (1.60 ± 0.46 ng/ml; p < 0.05). Conclusion. Gestational adaptation in induced multiple pregnancies is at high risk of breach in compensatory mechanisms and requires monitoring for timely detection of decompensation signs and their correction to prolong pregnancy till optimal delivery time frame.

Rescue cervical cerclage in twin pregnancy with spontaneous cervical dilatation at 8-week gestation

AbstractPremature spontaneous cervical dilatation can happen among pregnant women leading to miscarriage, preterm labor, or premature delivery. We present a case of twin pregnancy with spontaneous cervical dilatation and membranes bulging into the vagina at 8-week gestation. A 34-year-old primigravida presented to our clinic with complaints of cramping pain in the lower abdomen. Her per speculum pelvic examination showed evidence of dilated cervical os and amniotic membranes bulging through the cervix into the vagina. Her sonogram suggested a dichorionic diamniotic pregnancy of 8-week gestation. Her TVS examination revealed that the internal os was dilated. Both fetuses were alive with regular fetal heart rate. Rescue cervical cerclage by modified Shirodkar’s technique was done under general anesthesia. She was administered prophylactic antibiotics and tocolytic. She was closely followed up at regular intervals and observed for signs of chorioamnionitis. She delivered at 35 weeks of gestation with two female children with birth weights 2.3 kg and 2.1 kg, respectively.

Combined hysteroscopic Bigatti shaver (IBS) and resectoscope removal of a heterotopic cesarean scar pregnancy in the first trimester

To report a case of heterotopic cesarean scar pregnancy reduction using a combined hysteroscopic integrated Bigatti shaver (IBS) and resectoscope with the preservation of a normal gestational sac in the uterine cavity under simultaneous transabdominal ultrasound guidance. Video article. University-affiliated hospital. A 30-year-old woman, G5P2A2L2, with two previous cesarean deliveries and a history of fertility problems, was admitted with a heterotopic cesarean scar pregnancy at 7+2 gestational weeks. Ultrasound examination showed a dichorionic diamniotic pregnancy. The first gestational sac (1.7 × 1.7 × 0.6 cm) was located in the previous hysterotomy scars, with a thin layer of myometriummeasuring 0.2 cm in thickness and a rich blood supply. The second chorionic sac (2.8 × 2.4 × 1.8 cm) was observed at the uterine fundus. Normal cardiac activity and yolk sacs were observed in both gestational sacs. The couple strongly desired to preserve the intrauterine pregnancy. After Institutional Review Board approval was obtained, a hysteroscopic IBS combined with a bipolar resectoscope was used to remove the heterotopic cesarean scar pregnancy while preserving the intrauterine gestational sac under simultaneous transabdominal ultrasound guidance. The heterotopic cesarean scar pregnancy was completely resected using hysteroscopy, and the gestational sac in the uterine cavity was successfully preserved. Trophoblastic tissue was confirmed using histopathological examination. The patient had an unremarkable postoperative recovery. Subsequent serial ultrasonography confirmed a single ongoing pregnancy with normal growth parameters and a normal placental site. The inability of an IBS to perform coagulation can be offset by its combination with the bipolar resectoscope. Hysteroscopic IBS combined with resectoscope to remove a heterotopic cesarean scar pregnancy offers a short operation time and minimum blood loss. It could be an optimized approach for the management of heterotopic cesarean scar pregnancy in the first trimester when an intrauterine pregnancy needs to be preserved.

Case Report: Dichorionic twins pregnancy with placenta abruption

Pregnancies involving dichorionic twins have been recognized for their distinct difficulties and complications. The care and outcomes of such pregnancies are further complicated by placental abruption, an uncommon but significant obstetric event. We describe a case of placental abruption in a dichorionic twin pregnancy, including the clinical manifestations, diagnosis, treatment, and prognosis of the mother and fetus. Pregnancies with two separate chorions, or dichorionic pregnancies, are a special type of multiple gestation. Early separation of the placenta from the uterine wall is a potentially fatal event that can have a major influence on the health of both the mother and fetus. It is a key complication of placental abruption. We describe a 32-year-old primigravida who complained of sudden onset abdominal pain and vaginal bleeding at 28 weeks of gestation. She had dichorionic twin pregnancy after 10 weeks of gestation, as determined by ultrasonography. The patient remained stable, and repeated ultrasounds verified that there was no further placental separation. The patient underwent an elective caesarean section at 35 weeks of gestation because of a higher risk of recurrent abruption. Two healthy newborns were delivered, and their weights were consistent with their gestational age.

The association between neonatal birthweight discordance and preeclampsia in twin pregnancy.

To investigate the association between neonatal birthweight (NBW) discordance and preeclampsia (PE) in twin pregnancy. This was a single-center retrospective cohort study. Women with two live births in the First Affiliated Hospital of Sun Yat-sen University from January 2011 to June 2020 were eligible. They were classified into four groups based on the quartiles of NBW discordance in monochorionic (MC) and dichorionic (DC) twin pregnancy. The relationship between NBW discordance and the risk of PE was assessed by logistic regression, subgroup analyses was further analyzed. A total of 1566 women were eligible for the final analysis, there were 445 MC cases and 1121 DC cases. No matter in monochorionic or dichorionic pregnancy, higher NBW discordance quartiles were associated with increased risks of PE. Compared with women in the lowest NBW discordance quartile, women in the highest NBW discordance quartile had approximately 3.6 and 6.0 times risk of PE in monochorionic and dichorionic pregnancy respectively. The association between quartiles of NBW discordance and the risk of PE were higher in dichorionic pregnancy than in monochorionic pregnancy. No matter in MC or DC pregnancy, no significant interaction effects were identified for maternal age, pregnancy body mass index, mode of conception and whether complicated with gestational diabetes mellitus. The increased NBW discordance quartile was related to an increased risk of PE. Assessing estimated fetal weight discordance by using ultrasound in clinical practice to predict PE remained to be further researched.

Second twin outcome at birth: retrospective analysis in a single tertiary centre in Malaysia.

To investigate factors associated with outcome of second twin during labour. The study was a retrospective cohort study in a single tertiary centre in Malaysia from 2014 until 2018 involving all twin pregnancies delivered at or more than 24weeks of gestation. Total of 409 twin pregnancies were included. Dichorionic twin comprises of 54.5 % (n=223) and 45.5 % (n=186) are monochorionic. Women with dichorionic pregnancies are significantly older (p<0.001), have more pre-existing medical disorders (p=0.011) and fetal structural anomalies (p=0.009). Monochorionic pregnancies are significantly more amongst Malay (p=0.01) and conceived spontaneously (p<0.001). There are significantly more fetuses both in cephalic presentation (p=0.026), birthweight discrepancy more than 20 % (p=0.038) and shorter mean inter-twin delivery duration (p=0.048) in monochorionic pregnancies. Second twin delivered with Apgar score <7 is significantly more in dichorionic pregnancies (p=0.006). The second twin is associated with lower birthweight, small for gestational age and arterial cord pH<7.25. Within the group of women who delivered both fetuses vaginally, there was significantly more second twins with intertwin delivery duration less than 30 min who were delivered vaginally without instrumentation (p=0.018). There was significantly more second twin with intertwin delivery duration of 30 min and more with arterial cord pH<7.25 (p=0.045). Those who delivered spontaneously had inter-twin delivery duration within 15-29 min. The outcome of second twin is not influenced by type of twin, gestational age at delivery, inter-twin delivery duration, mode of delivery and presentation at birth. The neonatal outcome for the second twin at birth is not influenced by type of twin, gestational age at delivery, inter-twin delivery duration, mode of delivery and presentation at birth in a cohort managed with non-active management of the second twin in Malaysia.

Pregnancy and obstetric outcomes of dichorionic triamniotic triplet pregnancies with selective foetal reduction after assisted reproductive technology

BackgroundIt is generally beneficial and recommended that dichorionic triamniotic (DCTA) triplet pregnancies be reduced to monochorionic (MC) twin or singleton pregnancies after assisted reproductive technology (ART). However, some infertile couples still have a firm desire to retain twins. For this reason, the best foetal reduction strategies need to be available for infertile couples and clinicians. Given that data on the elective reduction of DCTA triplet pregnancies to twin pregnancies are scarce, we investigated the outcomes of elective reduction of DCTA triplet pregnancies through the retrospective analysis of previous data.MethodPatients with DCTA triplet pregnancies who underwent elective foetal reduction between January 2012 and June 2020 were recruited. A total of 67 eligible patients with DCTA triplet pregnancies were divided into two groups: a DCTA-to-dichorionic diamniotic (DCDA) twin group (n = 38) and a DCTA-to-monochorionic diamniotic (MCDA) twin group (n = 29); the basic clinical data of the two groups were collected for comparison.ResultsCompared with the DCDA-to-MCDA twin group, the DCTA-to-DCDA twin group had lower rates of complete miscarriage (7.89% versus 31.03%, p = 0.014), early complete miscarriage (5.26% versus 24.14%, p = 0.034), late preterm birth (25.71% versus 65.00%, p = 0.009) and very low birth weight (0 versus 11.11%, p = 0.025). In addition, the DCTA-to-DCDA twin group had higher rates of full-term delivery (65.71% versus 25.00%, p = 0.005), survival (92.11% versus 68.97%, p = 0.023), and taking the babies home (92.11% versus 68.97%, p = 0.023) than did the DCTA-to-MCDA twin group. In terms of neonatal outcomes, a significantly greater gestational age (38.06 ± 2.39 versus 36.28 ± 2.30, p = 0.009), average birth weight (3020.77 ± 497.33 versus 2401.39 ± 570.48, p < 0.001), weight of twins (2746.47 ± 339.64 versus 2251.56 ± 391.26, p < 0.001), weight of the larger neonate (2832.94 ± 320.58 versus 2376.25 ± 349.95, p < 0.001) and weight of the smaller neonate (2660.00 ± 345.34 versus 2126.88 ± 400.93, p < 0.001) was observed in the DCTA-to-DCDA twin group compared to the DCTA-to-MCDA twin group.ConclusionThe DCTA-to-DCDA twin group had better pregnancy and neonatal outcomes than the DCTA-to-MCDA twin group. This reduction approach may be beneficial for patients with dichorionic triamniotic triplet pregnancies who have a strong desire to have DCDA twins.

Complete mole coexisting with a normal fetus in a dichorionic diamniotic pregnancy: A case report

Background: Complete hydatidiform mole with a coexisting normal pregnancy is an exceptionally rareoccurrence with a reported incidence of 1 in 22,000-100,000 pregnancies. Management remainscontroversial due to the risk of maternal and fetal complications and limited data on optimalmanagement.Case presentation: A para 1 + 0 presented to the Maternal Fetal Unit at 19 weeks. Ultrasound revealed atwin pregnancy with a single live fetus in one sac and a second sac with multiple cystic lesions and atypical snow-storm appearance consistent with a complete molar pregnancy. The placenta of the molarpregnancy was also low-lying, covering the internal cervical os. She had several episodes of antepartumhemorrhage, which was managed expectantly because she was keen on conception. At 25 weeks, shepresented with copious vaginal bleeding and chills. Speculum examination revealed vesicles withultrasound revealing a single live fetus, but complete molar pregnancy was not observed. Afteradmission, the patient became febrile with tachycardia. Amniocentesis was performed to rule outintraamniotic infection in viable pregnancy. A decision was made to undertake an emergencyhysterotomy because of deteriorating maternal status, placenta previa, and breech presentation.Maternal blood culture was positive for group B Streptococcus, with fetal blood and amniotic fluid culturesbeing sterile. Histopathology of the placenta revealed features consistent with acute chorioamnionitis andperipheral molar pregnancy.Conclusion: This case highlights the difficulty in the management of such cases, as illustrated bymultiple episodes of antepartum hemorrhage and subsequent maternal sepsis. Multidisciplinary care andshared decision making remain integral to management.

The prognostic role of CRL discordance in first trimester ultrasound.

In the first trimester, intertwin crown-rump length (CRL) discordance has emerged as a notable factor linked to adverse perinatal health effects. It is frequently employed as a basis for counseling parents regarding potential adverse pregnancy outcomes. Despite its established association with adverse outcomes, the significance of CRL discordance in substantially predicting pregnancy problems and its efficacy in pregnancy screening remain subjects of ongoing discussion. The aim of this manuscript is to present current knowledge on CRL discordance. PubMed was searched for related articles with terms "Crown-Rump length", "Prenatal Screening", "Twin pregnancy", "Discordance". Twenty-two studies were included in our study with six reporting data on monochorionic and 16 assessing the correlation between CRL discordance and adverse pregnancy outcomes. Fetal loss at the 20th and 24th week of the pregnancy, SGA neonates, pre-term delivery (32 weeks), perinatal death (24 weeks) are all reported adverse outcomes associated with CRL discordance. The reported cut-off for increased risk of adverse perinatal outcomes is a discordance of at least 10% or more. Increased CRL (>10 %) discordance is linked to a higher risk of sFGR in both monochorionic and dichorionic pregnancies, fetal loss, and preterm delivery.

Maternal and fetal outcomes after planned cesarean or vaginal delivery in twin pregnancy: a comparison between 2 third level birth centers

Background Twin pregnancy is associated with higher risks of adverse perinatal outcomes for both the mother and the babies. Among the many challenges in the follow-up of twin pregnancies, the mode of delivery is the last but not the least decision to be made, with the main influencing factors being amnionicity and fetal presentation. The aim of the study was to compare perinatal outcomes in two European centers using different protocols for twin birth in case of non-cephalic second twin; the Italian patients being delivered mainly by cesarean section with those in Belgium being routinely offered the choice of vaginal delivery (VD). Methods This was a dual center international retrospective observational study. The population included 843 women with a twin pregnancy ≥ 32 weeks (dichorionic or monochorionic diamniotic pregnancies) and a known pregnancy outcome. The population was stratified according to chorionicity. Demographic and pregnancy data were reported per pregnancy, whereas neonatal outcomes were reported per fetus. We used multiple logistic regression models to adjust for possible confounding variables and to compute the adjusted odds ratio (adjOR) for each maternal or neonatal outcome. Results The observed rate of cesarean delivery was significantly higher in the Italian cohort: 85% for dichorionic pregnancies and 94.4% for the monochorionic vs 45.2% and 54.4% respectively in the Belgian center (p-value < 0.001). We found that Belgian cohort showed significantly higher rates of NICU admission, respiratory distress at birth and Apgar score of < 7 after 5 min. Despite these differences, the composite severe adverse outcome was similar between the two groups. Conclusion In this study, neither the presentation of the second twin nor the chorionicity affected maternal and severe neonatal outcomes, regardless of the mode of delivery in two tertiary care centers, but VD was associated to a poorer short-term neonatal outcome.

Perinatal Outcome of Twin Pregnancies in Relation to Chorionicity at a Tertiary Care Centre in Central Kerala, India: A Prospective Cohort Study

Introduction: In recent years, there has been a significant increase in the incidence of multiple births due to advanced maternal age at conception and the growing use of infertility treatment. Multiple pregnancies are associated with both maternal and perinatal complications. Maternal complications include anaemia, gestational hypertension, gestational diabetes, preterm labour, operative delivery and postpartum haemorrhage. Preterm birth, growth discordance and complications specific to monochorionic twins predispose these babies to adverse perinatal outcomes. Aim: To assess the perinatal outcomes of twin pregnancies and compare the outcomes of monochorionic and dichorionic pregnancies. Materials and Methods: The present prospective cohort study was conducted in the Department of Obstetrics and Gynaecology, Government Medical College (Tertiary care centre), Thrissur, Kerala, India, from September 2019 to August 2020. All twins who delivered at a gestational age of ≥28 weeks during the study period were recruited, totaling 76 twin pregnancies. A structured proforma was used to collect demographic and clinical details, including mode of conception, chorionicity, maternal complications, intrapartum events and neonatal outcomes. Data were analysed using Epi Info software. Results: The mean maternal age of the study participants was 28.39±6.29 years. The incidence of twin pregnancies delivering at ≥28 weeks at Government Medical College, Thrissur, during the study period was 2.8% (76 twins out of 2709 deliveries). Infertility treatment (ovulation induction alone or Assisted Reproductive Techniques (ART) was associated with dichorionic twinning in 19.7% (15 out of 76 twin pregnancies), with a p-value of 0.008. Maternal complications were similar in both dichorionic and monochorionic twins. Preterm Premature Rupture of Membranes (PPROM) occurred in 23 (28.75%) twin pregnancies, 19 (23.75%) had Gestational Diabetes Mellitus while 13 (16.25%) participants had anaemia. Foetal growth restriction, congenital anomalies, and discordant growth were more prevalent in monochorionic twin pregnancies compared to dichorionic twin pregnancies. Although the proportion of babies requiring Neonatal Intensive Care Unit (NICU) admission was higher in monochorionic twins (64% vs 53.9%), the proportion of neonatal deaths was nearly equal between monochorionic and dichorionic twins (10% vs 9.8%). Conclusion: In the present study, there was no statistical difference in maternal complications between monochorionic and dichorionic twins. However, monochorionic pregnancies had a poorer perinatal outcome compared to dichorionic pregnancies.

The role of estimated fetal weight discordance in dichorionic twin pregnancies.

Evaluation of relative fetal growth in the form of estimated fetal weight discordance (EFWd) is a necessary element of any ultrasound examination in twin pregnancies. It is one of the criteria for the diagnosis of selective fetal growth restriction (sFGR) according to the most established worldwide guidelines. Apart from the effectiveness of this parameter for the diagnosis of sFGR, it may also be used as an independent factor for risk stratification of neonatal and maternal complications. Furthermore, numerous studies have proven the greater prognostic value of EFWd in dichorionic pregnancies, which may result from differences in the pathogenesis of fetal growth abnormalities in mono- and dichorionic pregnancies. Because of the variability of this parameter throughout pregnancy, there is an ongoing discussion regarding replacing or individualizing it with percentile charts. An additional element, complementary to EFWd in assessing the risk of complications in twin pregnancies is the use of this measurement in combination with Doppler assessment, which increases its predictive value. The use of EFWd as one of the factors influencing care and decision-making in dichorionic twin pregnancies seems to be a simple and effective method, however, further research assessing the use and possible applications of this indicator is necessary.

Intertwin nuchal translucency difference predicts the chance of co-twin death after fetal reduction in dichorionic triplet pregnancies: a retrospective analysis study

ObjectivesTo compare the clinical outcomes of different multifetal pregnancy reduction (MFPR) programs in dichorionic (DC) triplets, and explore the association between early ultrasound characteristics and co-twin death after potassium chloride (KCl) injection into one monochorionic (MC) twin.MethodsWe retrospectively reviewed the data of DC triplets who underwent MFPR at our center during 2012–2021. Patients were grouped as follows: intracardiac KCl injection into one MC twin (group A), intracardiac KCl injection into both MC twins simultaneously (group B), and reduction of the singleton fetus (group C) and pregnancy outcomes were compared. Logistic regression was used to determine whether ultrasound measurements at 11–13+6 weeks predicted co-twin death and the receiver operator characteristic (ROC) analysis was conducted to assess the predictive performance.ResultsFinally, we enrolled 184 patients. 153 cases were in group A, and 18, 13 cases were in group B and C respectively. Gestational age at the time of MFPR did not differ among the 3 groups (median: 12^frac67 weeks). The survival rate was 89.6%, 88.9%, and 92.3% in group A, B, and C respectively, which was comparable among groups. Preterm birth was more common in group C (10/12, 83.3%). After KCl injection into one MC twin, co-twin death occurred in 86.3% cases (132/153) within 1 day; however, 3 patients had 2 live births each, with normal postnatal development. Intertwin nuchal translucency (NT) difference/discordance significantly predicted co-twin death within 1 day after MFPR, and the areas under the ROC curve were 0.694 and 0.689, respectively.ConclusionsFor MFPR in DC triplet pregnancies, reduction of the MC twins results in less preterm birth, and women with KCl injection into either one or both MC twins had similar outcomes. Large intertwin NT difference/discordance was associated with co-twin death within 1 day after KCl injection into one of the MC twins.

EXIT-to-airway for obstructing fetal neck masses: a singular methodology for monochorionic and dichorionic twin pregnancies

INTRODUCTION: Fetal airway obstruction in one twin of a diamniotic pregnancy presents unique challenges. Very few cases of Ex-Utero-Intrapartum-Treatment (EXIT) procedures for twin pregnancy have been reported and only in dichorionic pregnancies. We report a singular methodology for EXIT-to-airway procedures in two pregnancies involving monochorionic and dichorionic twins. CASE PRESENTATION: Two cases of EXIT-to-airway in twin pregnancies were performed in 2018-2019 at a regional fetal treatment center. Case 1 involved a giant cervical teratoma in a monochorionic-diamniotic twin pregnancy with preterm labor at 29 weeks. Case 2 involved a dichorionic-diamniotic pregnancy with a large cervical lymphatic malformation with preterm labor at 36 weeks. In each case, the polyhydramnios caused the affected twin’s amniotic sac to be the presenting sac for the surgical approach. Bronchoscopy and successful intubation was completed after 22 and 10 minutes of uteroplacental bypass, respectively. The bystander twins were delivered second without intubation and resuscitated without perinatal distress. CONCLUSION: EXIT-to-airway appears to be a reasonable option for twins including monochorionic pregnancies, via delivery of the affected twin first followed by delivery of the bystander twin. Thoughtful preparation and counseling by an experienced multidisciplinary team permits an EXIT-to-airway approach for twin pregnancies even in an emergent setting.

Associations between velamentous or marginal cord insertion and risk of adverse perinatal outcomes in twin pregnancies: a retrospective cohort study

BackgroundVelamentous cord insertion (VCI) and marginal cord insertion (MCI) are well-known risk factors for adverse perinatal outcomes in singleton pregnancies. However, the potential links between VCI or MCI and perinatal outcomes in twin pregnancies have yet to be systematically evaluated. This study aimed to investigate the relationships between VCI or MCI and perinatal outcomes in twin pregnancies.MethodsThis retrospective single-center cohort study included women with twin pregnancies who gave birth in a tertiary hospital in Southwest, China between January 2017 and December 2022. VCI and MCI were identified by abdominal ultrasound and confirmed after placental delivery. Logistic regression, multinomial logit regression and generalized estimation equation models were used to evaluate the association between VCI or MCI and perinatal outcomes.ResultsA total of 3682 twin pregnancies were included, including 100 (2.7%) pregnancies with VCI and 149 (4.0%) pregnancies with MCI. Compared to pregnancies with normal cord insertion, both monochorionic and dichorionic pregnancies with VCI were associated with an increased risk of preterm delivery 32–34 weeks (aRRR 2.94, 95% CI 1.03–8.39; aRRR 2.55, 95% CI 1.19–5.46, respectively), while pregnancies with MCI were not associated with preterm delivery. VCI was associated with a higher incidence of placental previa (aOR 6.36, 95% CI 1.92–21.04) in monochorionic pregnancies and placental accreta (aOR 1.85, 95% CI 1.06–3.23) in dichorionic pregnancies. MCI was associated with an increased risk of preeclampsia (aOR 3.07, 95% CI 1.49–6.32), intertwin birthweight discordance ≥ 20% (aOR 2.40, 95% CI 1.08–5.60) and selective fetal growth restriction (aOR 2.46, 95% CI 1.08–5.60) in monochorionic pregnancies and small-for-gestational age neonates (aOR 1.97, 95% CI 1.24–3.14) in dichorionic pregnancies.ConclusionsVCI was associated with an increased risk of preterm delivery in twin pregnancies irrespective of chorionicity, whereas MCI was associated with an increased preeclampsia risk, significant intertwin birthweight discordance in monochorionic pregnancies and small-for-gestational age neonates in dichorionic pregnancies.