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

Townsend, Rosemary; D’Antonio, F.; Sileo, Filomena Giulia; Kumbay, H.; Thilaganathan, B.; Khalil, Asma

doi:10.1002/uog.20114

Cited by 72 publications

(85 citation statements)

References 34 publications

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“…According to a recent systematic review, expectant management is appropriate in most cases of Type I sFGR. For Types II and III sFGR diagnosed before 24 weeks, fetal therapy may contribute to higher mortality with lower morbidity of the surviving twin. Although perinatal mortality in multiple pregnancy seems to be decreasing, the rate of stillbirth is still much higher compared with that in singletons.…”

Section: Discussionmentioning

confidence: 99%

Early‐ and late‐onset selective fetal growth restriction in monochorionic diamniotic twin pregnancy: natural history and diagnostic criteria

Curado

Sileo

Bhide

et al. 2020

Ultrasound in Obstet & Gyne

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CONTRIBUTIONWhat are the novel findings of this work? Using a well-characterized unselected population of monochorionic diamniotic (MCDA) pregnancies, we have provided insight into the natural history of selective fetal growth restriction (sFGR), according to gestational age at onset, as well as the risk of superimposed twin-to-twin transfusion syndrome. Different diagnostic criteria of sFGR were applied and compared in this population. What are the clinical implications of this work?This study describes the outcome of a population of MCDA twin pregnancies managed expectantly. The findings provide valuable information for better and more accurate counseling of parents. ABSTRACTObjectives To evaluate the natural history and outcome of selective fetal growth restriction (sFGR) in monochorionic diamniotic (MCDA) twin pregnancy, according to gestational age at onset and various reported diagnostic criteria, and to quantify the risk of superimposed twin-to-twin transfusion syndrome (TTTS).Methods This was a cohort study of MCDA twin pregnancies that had their routine antenatal care from the first trimester at St George's Hospital, London, UK. Pregnancies had ultrasound examinations every 2 weeks at 16-24 weeks and then every 2-3 weeks until delivery. The diagnostic criteria for sFGR were estimated fetal weight (EFW) of one twin < 10 th centile and intertwin EFW discordance ≥ 25%. We also applied other diagnostic criteria reported in a recent Delphi consensus. Pregnancies in which the diagnosis of TTTS was made before that of sFGR were not included in the Correspondence to: analysis. Pregnancies that underwent fetal intervention for sFGR were excluded. The incidence of sFGR was compared between the different diagnostic criteria, overall and according to gestational age at onset. In all subsequent analyses, cases of sFGR included those diagnosed according to any of the criteria. The Gratacós classification of sFGR was applied (Type I, II or III). Pregnancy outcomes included miscarriage, intrauterine death, neonatal death and admission to the neonatal unit. Comparisons between groups were carried out using the Mann-Whitney U-test for continuous variables and the chi-square or Fisher's exact test for categorical variables. ResultsThe analysis included 287 MCDA twin pregnancies. According to the International Society of Ultrasound in Obstetrics and Gynecology diagnostic criteria, the incidence of early (< 24 weeks) sFGR was 4.9%, while that of late sFGR was 3.8%. When applying the various diagnostic criteria, the incidence of early sFGR varied from 1.7% to 9.1% and that of late sFGR varied from 1.1% to 5.9%. In early-onset cases, the incidence of Type I sFGR was 80.8%, that of Type II was 15.4% and that of Type III was 3.8%. The corresponding figures in late-onset cases were 94.4%, 5.6% and 0%. The incidence of superimposed TTTS was 26.9% in cases affected by early-onset sFGR and 5.6% in those affected by late-onset sFGR. The incidence of perinatal death was 8.0% in early-onset sFGR and 5.6% in late-onset sFGR (P = 0.661)...

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Section: Discussionmentioning

confidence: 99%

Early‐ and late‐onset selective fetal growth restriction in monochorionic diamniotic twin pregnancy: natural history and diagnostic criteria

Curado

Sileo

Bhide

et al. 2020

Ultrasound in Obstet & Gyne

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“…The management of SIUGR remains controversial [30]. Our original pilot study showed that laser ablation of the placental vascular anastomoses in SIUGR patients was possible [1].…”

Section: Discussionmentioning

confidence: 99%

Neurodevelopmental outcome of monochorionic twins with selective intrauterine growth restriction (SIUGR) type II: laser versus expectant management

Quintero

Kontopoulos

Williams

et al. 2019

The Journal of Maternal-Fetal & Neonatal Medicine

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Objective: To compare the neurodevelopmental outcome of monochorionic-diamniotic twins (MCDA) with type II selective intrauterine growth restriction (SIUGR-II) managed in utero either expectantly or with laser. Materials and methods: Postnatal neurodevelopmental assessment was conducted on the children of patients that had been antenatally diagnosed with SIUGR-II between 16 and 26 weeks gestational age (GA) and that had been randomly assigned to expectant management (EM) versus laser therapy (LT). The assessment was conducted by trained specialists using the Battelle Developmental Inventory (BDI-2). BDI-2 total and domain (adaptive, personal-social, communication, motor, and cognitive) composite scores for the appropriately grown (AGA) and growthrestricted (IUGR) twins were compared by treatment arm. Results: Twenty patients diagnosed with SIUGR had undergone block randomization between two centers to either expectant management (EM) (6) or laser therapy (LT) (14). The mean (SD) GA at diagnosis was no different between the EM and LT groups [21.5 (2.0) versus 21.1 (2.8) weeks, p ¼ .7414, respectively]. However, GA at delivery was significantly lower in the EM versus LT groups [28.3 (1.8) versus 33.4 (3.8) weeks, p ¼ .0039]. At 6 months, all 20 AGA babies were alive, whereas only 3/6 (50%) of the IUGR babies in the EM group and 4/14 (29%) in the LT group were alive (p ¼ .6126). One family in the EM group and two families in the LT group declined BDI-2 assessment. The mean (SD) age at BDI-2 assessment was no different between the EM and LT groups [75.6 (14.4) versus 70.7 (18.2) months, p ¼ .5618, respectively]. For the AGA children, there were no significant differences in total BDI-2 scores for the EM versus LT [97.4 (10.4) versus 98.0 (19.6), p ¼ .8741], nor in any of the domain composite scores. For the IUGR children, no statistically significant differences were detected in total BDI-2 scores between the EM and LT [72.0 (31.1) versus 92.8 (22.1), p ¼ .643], nor in any of the domain composite scores. The comparison of standardized scores between the AGA and IUGR pairs was significantly different, but within the normal range. Conclusions: Neurodevelopmental outcomes for SIUGR-II MCDA twins were similarly favorable, whether managed expectantly or with laser treated. However, the significantly different GA at delivery (28.3 versus 33.4 weeks, p ¼ .0039, expectant versus laser, respectively) may suggest improved outcomes in laser-treated patients in a larger cohort.

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“…MC pregnancies can be complicated by selective fetal growth restriction (sFGR) due to unequal placental share, twin-twin transfusion syndrome (TTTS), and twin Gabby/Chon/Korst/Llanes/Chmait Fetal Diagn Ther 2020;47:817-823 818 DOI: 10.1159/000509401 anemia polycythemia sequence due to unequal sharing of blood through placental vascular communications, and potentially lethal discordant anomalies [1][2][3]. These complications increase the risk of perinatal morbidity and mortality [4][5][6][7][8][9][10]. In the event of fetal demise of one twin, the co-twin has an increased risk of neurological morbidity and death [11][12][13].…”

Section: Introductionmentioning

confidence: 99%

Risk Factors for Co-Twin Fetal Demise following Radiofrequency Ablation in Multifetal Monochorionic Gestations

et al. 2020

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Background: Umbilical cord occlusion via radiofrequency ablation (RFA) is utilized to maximize outcomes of the cotwin in complicated multifetal monochorionic (MC) gestations. However, post-procedure co-twin fetal demise is of concern. Objective: The aim of this study was to determine risk factors for co-twin fetal demise following RFA. Methods: This is a retrospective study of MC multiples that underwent RFA. Indications for RFA included twin reversed arterial perfusion (TRAP) sequence, selective fetal growth restriction (sFGR) type II, discordant lethal anomalies, and twin-twin transfusion syndrome (TTTS) with proximate placental cord insertion sites. The primary outcome was co-twin fetal demise. Bivariate analyses and multiple logistic regression modeling of identified risk factors were conducted. Results: Of 36 patients studied, surgical indications were: TRAP (n = 15, 41.7%), sFGR (n = 10, 27.8%), discordant anomalies (n = 9, 25.0%), and TTTS (n = 2, 5.6%). Nine patients (25.0%) experienced a co-twin fetal demise. In multiple logistic regression analysis, fetal growth restriction (FGR) of one co-twin was associated with increased risk of co-twin fetal demise (OR = 10.85, 95% CI 1.03-114.48, p = 0.0474) and a preoperative diagnosis of TRAP was protective against fetal demise (OR = 0.06, 95% CI 0.00-0.84, p = 0.0368). Conclusion: Co-twin FGR was associated with an increased risk of post-RFA demise. When compared to other indications, patients with TRAP sequence were less likely to have a co-twin demise.

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

Cited by 72 publications

References 34 publications

Early‐ and late‐onset selective fetal growth restriction in monochorionic diamniotic twin pregnancy: natural history and diagnostic criteria

Early‐ and late‐onset selective fetal growth restriction in monochorionic diamniotic twin pregnancy: natural history and diagnostic criteria

Neurodevelopmental outcome of monochorionic twins with selective intrauterine growth restriction (SIUGR) type II: laser versus expectant management

Risk Factors for Co-Twin Fetal Demise following Radiofrequency Ablation in Multifetal Monochorionic Gestations

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