Outcome of monochorionic twin pregnancy with selective fetal growth restriction at 16, 20 or 30 weeks according to new Delphi consensus definition

Abstract

Objectives To report the outcome of selective fetal growth restriction (sFGR) diagnosed according to the new Delphi consensus definition, and determine potential predictors of survival, in a cohort of unselected monochorionic diamniotic twin pregnancies. Methods This was a retrospective study of monochorionic diamniotic twin pregnancies followed from the first trimester onward, which were diagnosed with sFGR at 16, 20 or 30 weeks' gestation. sFGR was defined according to the new Delphi consensus criteria as presence of either an estimated fetal weight (EFW) < 3rd centile in one twin or at least two of the following: EFW of one twin < 10th centile, abdominal circumference of one twin < 10th centile, EFW discordance ≥ 25% or umbilical artery pulsatility index of the smaller twin > 95th centile. The primary outcomes were the overall survival rate (up to day 28 after birth) and risk of loss of one or both twins. We further determined possible predictors of survival using uni‐ and multivariate generalized estimated equation modeling. Results We analyzed 675 pregnancies, of which 177 (26%) were diagnosed with sFGR at 16, 20 or 30 weeks. The overall survival rate was 313/354 (88%) with 146/177 (82%) pregnancies resulting in survival of both twins, 21/177 (12%) in survival of one twin and 10/177 (6%) in loss of both twins. Subsequent twin anemia–polycythemia sequence (TAPS) developed in 6/177 (3%) and twin–twin transfusion syndrome (TTTS) in 17/177 (10%) pregnancies. All TAPS fetuses survived. The survival rate in sFGR pregnancies that subsequently developed TTTS was 65% (22/34), compared with 91% (279/308) in those with isolated sFGR (no subsequent TAPS or TTTS) (P < 0.001). The majority of sFGR cases were Type I (110/177 (62%)) and had a survival rate of 96% (212/220), as compared with a survival of 55% (12/22) in those with Type‐II (P < 0.001) and 83% (55/66) in those with Type‐III (P = 0.006) sFGR. The majority of sFGR pregnancies (130/177 (73%)) were first diagnosed at 16 or 20 weeks (early onset), with a survival rate of 85% (221/260), as compared with a survival of 98% (92/94) in sFGR first diagnosed at 30 weeks (late onset) (P = 0.04). A major anomaly in at least one twin was present in 28/177 (16%) sFGR cases. In these pregnancies, survival was 39/56 (70%), compared with 274/298 (92%) in those without an anomaly (P < 0.001). Subsequent development of TTTS (odds ratio (OR), 0.18 (95% CI, 0.06–0.52)), Type‐II sFGR (OR, 0.06 (95% CI, 0.02–0.24)) and Type‐III sFGR (OR, 0.21 (95% CI, 0.07–0.60)) and presence of a major anomaly in at least one twin (OR, 0.12 (95% CI, 0.04–0.34)), but not gestational age at first diagnosis, were independently associated with decreased survival. Conclusions Isolated sFGR is associated with a 90% survival rate in monochorionic diamniotic twin pregnancies. The subsequent development of TTTS, absent or reversed end‐diastolic flow in the umbilical artery of the smaller twin and the presence of a major anomaly adversely affect survival in sFGR. Copyright © 2020 ISUOG. Published by J...

Monochorionic diamniotic twins: What do I tell the prospective parents?

“…Structural anomalies are twice as common in MCDA twins (5%) as in singletons (2.5%), and although they are monozygotic, in 90% only one twin is affected. 25 Several hypotheses exist to explain this increased risk. The splitting itself may be teratogenic.…”

“…The collision of the two circulations in the large and bidirectional artery-to-artery anastomosis causes a cyclical variation in the smaller twin's cord and is most apparent at its placental insertion (Figure 6). 25,38 6.5 | TRAP TRAP is another rare and unique complication. It affects around 2.5% of monochorionic twins or 1 in 15 000 pregnancies.…”

The Association Between Hypertension in Pregnancy and Preterm Birth with Fetal Growth Restriction in Singleton and Twin Pregnancy: Use of Twin Versus Singleton Charts

“…Moreover, we observed that the recently proposed sFGR diagnostic criteria applied to birthweight had a stronger and more consistent relationship with adverse events such as HDP and PTB. Couck et al have studied the utility of the new Delphi consensus criteria for detecting perinatal adverse outcomes at different gestational ages and compared it to estimated fetal weight (EFW) discordance [ 10 ]. They reported similar predictive value but they used an EFW chart derived from a singleton population.…”

“…Twin-specific growth and birthweight charts are available but their use in clinical practice is currently controversial [ 6 , 7 , 8 ]. Most studies use singleton standards for the evaluation of twins [ 9 , 10 ], but the results of these studies may change significantly if twin-specific standards are used [ 11 ]. Moreover, the diagnostic criteria for selective fetal growth restriction (sFGR) do not recommend a specific reference standard to use, despite including weight percentile thresholds as part of the diagnostic criteria [ 12 , 13 ].…”

Critical Coarctation of the Aorta in Selective Fetal Growth Restriction and the Role of Coronary Stent Implantation

“…All our cases affected the smaller twin of a monochorionic pair with sFGR, and none had TTTS. In an un- selected cohort of monochorionic twin pregnancies [19], there were 64 live-born twin pairs with a birth weight of more than 25%. Of these 64, 3 growth-restricted twins were diagnosed with a critical CoA, leading to an estimated incidence of about 5%.…”