Expectant management in di-chorionic pregnancies complicated by discordant anomalous twin

Abstract

Fetal malformations are more frequent in twins than in singletons. The aim of our study was to define the influence of a malformed twin on di-chorionic pregnancy outcomes. We performed a retrospective cohort study of di-chorionic pregnancies delivered between 2000 and 2015. Exclusion criteria were: both twins affected by fetal malformations, double intra-uterine fetal death in pregnancies without fetal malformation, selective feticide and therapeutic pregnancy termination. We compared maternal and fetal outcomes of di-chorionic pregnancies not complicated by fetal malformations with pregnancies affected by a single malformed fetus with conservative management. We included 642 di-chorionic pregnancies: 56 (case group, 8.7%) with one twin affected by a malformation (20 minor, 36 major ones), 586 (control group, 91.3%) without fetal malformation. No differences were found on maternal and not malformed co-twin outcomes when compared to pregnancies with no malformation; case vs control group presented similar rates of preeclampsia (8.9% vs. 10.8%, respectively), intrauterine growth restriction (7.1% vs. 9.4%) and composite adverse neonatal outcomes (19.6% vs. 15.1%). No case of fetal death in not malformed co-twin was reported. Expectant management could be a safe option for both mother and co-twin in case of di-chorionic twin pregnancy complicated by only one malformed fetus.

Ultrasound surveillance in twin pregnancy: An update for practitioners

“…Where intrauterine demise of the affected twin is anticipated, expectant management is appropriate in dichorionic pregnancies with a low risk of preterm labour and delivery of the surviving co-twin. 26 In monochorionic pregnancies, demise of one twin is more often followed by neurological injury (24% compared to 2%) or death of the unaffected co-twin (15% compared to 3%) because of the interdependent fetoplacental circulation. 27,28 In this circumstance, selective feticide of the affected twin may be preferable.…”

Outcome of Twins Discordant for Major Anomalies

“…3 When a structural anomaly detected on ultrasound is found to be lethal, requires postnatal surgery, and has an increased risk of functional or neurological impairment, it is considered a major structural anomaly. 4 Major adverse outcomes associated with discordance are preterm birth, fetal growth restriction (FGR) and perinatal loss. [5][6][7] Studies on higher population sizes have also stated that further evaluations are required.…”

Antenatal and prepregnancy care – prevention of perinatal morbidity and mortality

“…This is a bigger dilemma in monochorionic than in dichorionic twins. Reassuring are the data from a retrospective study of dichorionic twins (one with a malformation) by Algeri et al [13] of 642 cases (56 with major/minor -36/20 malformations vs. 586 controls) managed expectantly that showed no difference in outcome. While this is reassuring it would have been useful to investigate the psychological impact of the co-existing malformed fetus on the mother as this is more likely to be a factor considering that often dichorionic twins behave as two separate pregnancies.…”