Impact of placental sharing and large bidirectional anastomoses on birthweight discordance in monochorionic twins: a retrospective cohort study in 449 cases

Groene, Sophie G.; OPENSHAW, Kristine M.; JANSÉN-STORBACKA, Laura R.; Slaghekke, Femke; Haak, Monique; Heijmans, Bastiaan T.; Klink, Jeanine M.M. van; Roest, Arno A.W.; Meeren, Lotte E. van der; Lopriore, Enrico

doi:10.1016/j.ajog.2022.05.059

Cited by 11 publications

(4 citation statements)

References 32 publications

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“…Unequal division of the inner cell mass, as suggested by Benirschke, potentially precedes this discrepancy, resulting in a reduced number of precursor cells in the smaller twin, further influencing growth and organogenesis 21,91 . Bidirectional anastomoses play a crucial role in preventing transfusion imbalances and a large, shared circulation, supports the growth of the smaller twin 92–94 …”

Section: Discussionmentioning

confidence: 99%

“…21,91 Bidirectional anastomoses play a crucial role in preventing transfusion imbalances and a large, shared circulation, supports the growth of the smaller twin. [92][93][94] The renin-angiotensin system activation might also occur in sFGR, independent of the presence of TTTS. Elevated renin levels have been found in both the larger and smaller twins, especially in cases of high birthweight discordance.…”

Section: Cardiac Adaptation Sfgrmentioning

confidence: 99%

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Cardiac adaptation and malformation in twin–twin transfusion syndrome and selective fetal growth restriction: A systematic review

Noll,

Gijtenbeek,

Verweij

et al. 2024

Prenatal Diagnosis

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ObjectivesThis systematic review explores cardiac adaptation in monochorionic (MC) twins with twin–twin transfusion syndrome (TTTS) or selective fetal growth restriction (sFGR) and assesses the risk of congenital heart defects (CHDs).MethodsAdhering to PRISMA guidelines, 63 studies were reviewed (49 on cardiac adaptation, 13 on CHD, one on both). A narrative synthesis of cardiac adaptation patterns was performed. Additionally, a meta‐analysis compared the livebirth prevalence of CHD in TTTS and sFGR against uncomplicated MC twins.ResultsIn TTTS recipients, cardiac function may be impaired for diastolic, systolic, as well as global functions, while in donors, cardiac function is generally preserved. In sFGR, large twins may show hypertrophic cardiomyopathy, and small twins may show impaired systolic function. Co‐occurrence of TTTS and sFGR magnifies cardiac impact but is often underreported. Meta‐analysis for CHD prevalence revealed a relative risk ratio of 3.5 (95% CI: 2.5–4.9) for TTTS and 2.2 (95%CI: 1.3–3.5) for sFGR compared with uncomplicated MC twins.ConclusionsThis study highlights the well‐documented cardiac adaptation in TTTS, contrasting with limited understanding in sFGR. Elevated CHD risks were observed in both conditions. Enhanced cardiovascular surveillance is warranted in complicated MC twin pregnancies. Future research should explore cardiac adaptation in sFGR and its long‐term consequences.

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Section: Discussionmentioning

confidence: 99%

Section: Cardiac Adaptation Sfgrmentioning

confidence: 99%

Cardiac adaptation and malformation in twin–twin transfusion syndrome and selective fetal growth restriction: A systematic review

Noll,

Gijtenbeek,

Verweij

et al. 2024

Prenatal Diagnosis

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“…Unequal placental share with one twin having the majority of the share is considered the primary pathology behind sFGR [18]. Due to a smaller placental share, circulation of the growth-restricted fetus is often dependent on the appropriately grown fetus through placental anastomoses [19,20].…”

Section: Discussionmentioning

confidence: 99%

Predictors of Poor Outcomes in Monochorionic Diamniotic Twin Pregnancies Complicated by Selective Fetal Growth Restriction

Soni,

Gebb,

Miller

et al. 2024

Fetal Diagn Ther

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Introduction: The aim of the study was to identify predictors of poor outcomes in monochorionic diamniotic twin (MCDA) pregnancies with selective fetal growth restriction (sFGR), irrespective of the umbilical artery (UA) Doppler abnormalities. Methods: Single-center retrospective analysis of MCDA twins diagnosed with sFGR that opted for expectant management between 2010 and 2021. The presence of any of the following variables in the growth-restricted fetus: low amniotic fluid volume (DVP ≤2 cm), lack of a cycling bladder, absent or reversed flow in the ductus venosus (DV) with atrial contraction, and elevated middle cerebral artery peak systolic velocity (MCA-PSV) defined as ≥1.50 multiples of the median was categorized as complicated. sFGR cases were classified as simple in the absence of the above-mentioned variables. Results: Overall, 63.3% of cases qualified as simple, and 36.7% were complicated. Intertwin EFW discordance was higher in the complicated category (26 vs. 33%, p = 0.0002). The median gestational age at delivery was earlier (33 weeks vs. 30.5 weeks, p = 0.002), and the likelihood of survival was lower in the complicated category (p < 0.0001). The likelihood of two survivors to discharge was lower in type I complicated cases (70% in complicated type I vs. 97.1% in simple type I, p = 0.0003). On logistic regression analysis, an increase in the “complicated” score negatively correlated with two survivors to discharge (p < 0.0001). An ROC curve was created, and the AUC was 0.79. Increasing intertwin EFW discordance also decreased the probability of two survivors to discharge. Conclusion: The presence of oligohydramnios, lack of a cycling bladder, abnormal DV Doppler, and elevated MCA-PSV in the growth restricted fetus is associated with poor perinatal outcomes and a lower likelihood of having two survivors to discharge. The addition of intertwin EFW discordance to these variables helped improve the survival predictability.

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“…Furthermore, we did not observe any Type-III sFGR pregnancies in which only the smaller twin was affected by CHD. In these pregnancies, the larger diameter of AAA has been shown to mitigate the effect of unequal placental sharing on birth-weight discordance between twins 26 , resulting in better oxygenation of the small twin compared with other Gratac ós types.…”

Section: Discussionmentioning

confidence: 99%

Congenital heart defects in monochorionic twin pregnancy complicated by selective fetal growth restriction

Faiola

Casati

Stellio

et al. 2023

Ultrasound in Obstet & Gyne

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What are the novel findings of this work? Monochorionic diamniotic (MCDA) twin pregnancies complicated by selective fetal growth restriction (sFGR) showed a higher rate of congenital heart defects (CHD) compared with uncomplicated MCDA pregnancies. Larger and smaller twins showed a similar prevalence of CHD, but considerably different subtypes of cardiac abnormality. What are the clinical implications of this work?Women with MCDA pregnancies complicated by sFGR should be referred to a tertiary care hospital in which routine pre-and postnatal cardiac evaluation, treatment and long-term follow-up are available.

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Impact of placental sharing and large bidirectional anastomoses on birthweight discordance in monochorionic twins: a retrospective cohort study in 449 cases

Cited by 11 publications

References 32 publications

Cardiac adaptation and malformation in twin–twin transfusion syndrome and selective fetal growth restriction: A systematic review

Cardiac adaptation and malformation in twin–twin transfusion syndrome and selective fetal growth restriction: A systematic review

Predictors of Poor Outcomes in Monochorionic Diamniotic Twin Pregnancies Complicated by Selective Fetal Growth Restriction

Congenital heart defects in monochorionic twin pregnancy complicated by selective fetal growth restriction

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