Application of Umbilical Artery Classification in Complicated Monochorionic Twins

Abstract

We report our experience on the application of Gratacos' classification in a cohort of monochorionic pregnancies complicated by selective intra-uterine growth retardation based on the Doppler assessment of the umbilical artery. Materials and methods: A retrospective study was conducted on 52 cases of monochorionic twin pregnancies, in which one twin presented an abdominal circumference at or below the 10th percentile for gestational age. Cases were classified into three types according to the umbilical artery Doppler in the smaller twin. Subsequently, patients were divided into two groups: the selective IntraUterine Growth Retardation group and the Twin-to-Twin Transfusion Syndrome (TTTS) group. Results: Of the total 52 cases, 37 were classified as Type I, 12 as Type II, and 3 as Type III cases. In the total group, progressive fetal deterioration of the smaller fetus requiring active management was observed in 66.7% of Type II and 11.1% of Type I cases (p < .001), and in no Type III case. Unexpected fetal death of the smaller twin was observed more frequently in Type III (two cases, 66.7%) than in Types I and II cases (5% and 33%, respectively). Among the 52 cases, TTTS with oligo-polyhydramnios sequence was diagnosed in 10 cases. The remaining 42 cases were therefore defined as selective intra-uterine growth retardation. In the selective IntraUterine Growth Retardation group, results were similar to those obtained for the whole population. Conclusions: Classification of complicated monochorionic twins based on the umbilical artery Doppler is particularly important for counseling, even when we include TTTS cases, and permits the prediction of clinical evolution and perinatal outcome.

Perinatal outcome of monochorionic twin pregnancy complicated by selective fetal growth restriction according to management: systematic review and meta‐analysis

“…There were eight studies (332 twins) on expectant management in Type‐I sFGR, one study (six fetuses) reporting the outcome of pregnancies complicated by Type‐I sFGR treated with laser therapy of placental anastomoses, and two studies (six twins) reporting the outcome of Type‐I sFGR treated with SR of the smaller twin (Table , Figure a).…”

Variation in outcome reporting across studies evaluating interventions for selective fetal growth restriction

“…MEDLINE, EMBASE, CINAHL, http://clinicaltrials.gov and The Cochrane Library databases were searched electronically using a comprehensive search strategy (Appendix S1). Thirty‐nine studies were included in the analysis, comprising 21 retrospective and 13 prospective cohort studies, three non‐comparative studies, one case–control and one cross‐sectional study (Table ). Fetal, neonatal and perinatal mortality were reported commonly across the included studies.…”

“…Laser EFW of smaller twin < −1.5 SD Pasquini (2015) 27 Retro cohort 42 77 Expectant AC of smaller twin ≤ 10 th centile for gestational age Peeva (2015) 28 Retro cohort 142 NS Laser < 22 weeks: AC < 5 th centile; ≥ 22 weeks: EFW < 5 th centile AND EFW difference ≥ 25% Yinon (2015) 29 Retro cohort 23 Retro cohort 24 NS Cord occlusion EFW < 10 th centile in one twin AND intertwin weight difference > 25% Gao (2012) 35 Case-control 38 NS Expectant Birth weight < 10 th centile AND intertwin EFW discordance > 20% Lanna (2012) 38 Retro cohort 30 28 Cord occlusion Not specified Ishii (2011) 39 Retro cohort 101 152 Expectant EFW < 10 th centile in one twin Weisz (2011) 40 Prosp cohort 37 74 Expectant EFW < 10 th centile in one twin Chang (2010) 42 Prosp cohort 27 54 Expectant EFW < 10 th centile in one twin Smith (2010) 41 Retro cohort Unclear Unclear Expectant Birth-weight discordance > 25% Chang (2009) 44 and perinatal mortality were reported commonly across the included studies. Over half of the included studies reported live birth, intrauterine demise and neonatal mortality, although most did not report mortality by smaller or larger twin status.…”

“…Fetoscopic intervention in sFGR is known to be more technically challenging than in TTTS, principally due to the absence of polyhydramnios, which limits the Hailing (2016) 61 Parra-Cordero (2016) 59 Pasquini (2015) 27 Peeva (2015) 28 Chalouhi (2013) 33 Ishii (2011) 39 Weisz (2011) 40 Chang (2010) 42 Ishii (2009) 45 Chang (2009) 44 Gratacós (2008) 46 Lewi (2008) 47 Lopriore (2008) 49 Lewi (2008) 13 Muñoz-Abellana (2007) 51 Gratacós (2007) 15 Gratacós (2004) 55 Gratacós (2004) 56 Figure 1 Reporting of fetal, neonatal and childhood outcomes in 20 largest studies investigating interventions for selective fetal growth restriction in monochorionic diamniotic twin pregnancy. Only first author of each study is given.…”

Selective intrauterine growth restriction in monochorionic-diamniotic twins: diagnosis and management

“…En el caso del STFF, en el gemelo receptor hay polihidramnios y aumento del tamaño de la vejiga; en caso de RCIUs, el gemelo mayor tendrá́ líquido amniótico y vejiga normal y una discordancia en el peso fetal (Tabla 2). El uso del Doppler de la arteria umbilical, también aporta datos para diferenciar ambas entidades 64 . Sin embargo, se debe considerar la posibilidad que ambas entidades se presenten juntas, estimado en un 40% de las veces 65,66 lo que modifica sustancialmente el propósito de sobrevida de ambos fetos 73 especialmente en el donador.…”