Placental sharing, birthweight discordance and vascular anastomoses in monochorionic diamniotic twin placentas

Lewi, Liesbeth; Cannie, Mieke; Jani, Jacques; Hecher, Kurt; Huber, Agnes; Gratacós, Eduard; Lewi, Paul; Deprest, Jan

doi:10.1016/j.ajog.2006.10.195

Cited by 84 publications

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“…often seen in nsIUGR twins than in sIUGR twins. Our findings led us to question whether sIUGR and nsIUGR arise from different mechanisms regarding placental angio-structure, the former being related to vascular communication, as described in previous studies, 3,5,14,15 and the latter to placental insufficiency. Also, we wondered if the older maternal age in the nsIUGR-related cases is a predictor of placental insufficiency.…”

Section: Discussionmentioning

confidence: 93%

Intrauterine growth restriction in monochorionic-diamniotic twins

Machado

Brizot

Miyadahira

et al. 2014

Rev. Assoc. Med. Bras.

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IntrauterIne growth restrIctIon In monochorIonIc-dIamnIotIc twIns rev assoc med Bras 2014; 60(6):585-590 585Original articleIntrauterine growth restriction in monochorionic-diamniotic twins Conflict of interest: noneObjective: to evaluate neonatal morbidity and mortality in monochorionic--diamniotic (MCDA) twin pregnancies complicated by selective intrauterine growth restriction (sIUGR) and non-selective intrauterine growth resctriction (nsIUGR). Methods: neonatal morbidity parameters and mortality were analyzed in 34 twins with IUGR (< 10 th percentile on twins' growth charts): 18 with sIUGR and 16 with nsIUGR. The sIUGR group was made up of 18 pregnancies in which growth was restricted in only one fetus (n = 18). The nsIUGR group was composed of 8 pregnancies in which both fetuses presented restricted growth (n = 16).Cases of twin-to-twin transfusion syndrome and fetal malformation were not included in the study. Results: the MCDA twin pregnancies with sIUGR had a higher rate of orotracheal intubation (p = 0.001) and mechanical ventilation (p = 0.0006), as well as longer than average fasting time (p = 0.014) compared to those in which the fetuses had nsIUGR. A higher incidence was also observed of types II and III umbilical artery Doppler velocimetry patterns in the sIUGR cases (p = 0.002). There was no significant difference between the two groups as to mortality during pregnancy and the neonatal period (p = 0.09). Conclusion: in MCDA twin pregnancies, sIUGR presents more severe umbilical artery Doppler velocimetry abnormalities and worse morbidity than nsIUGR.

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Section: Discussionmentioning

confidence: 93%

Intrauterine growth restriction in monochorionic-diamniotic twins

Machado

Brizot

Miyadahira

et al. 2014

Rev. Assoc. Med. Bras.

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“…MC twins are considered to be at increased risk of adverse outcome compared to DC twins because of vascular anastomoses on the placenta [4][5][6] . Also, in MC pairs, ultrasound examination allows identification of the rare MA twins who are at an even higher risk because of cord entanglement 7 .…”

Section: Discussionmentioning

confidence: 99%

Partial monochorionic and monoamniotic twin pregnancies: a report of two cases

Galjaard

Moerman²,

Corveleyn

et al. 2014

Ultrasound Obstet Gynecol

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Monochorionic (MC) twin pregnancies are at increased CASE REPORTSThe first case was a spontaneous twin pregnancy of a 25-year-old woman, gravida 2 para 1, referred at 12 weeks' gestation for chorionicity determination. Ultrasound showed only two thin separating amniotic membranes at the lower part of the intertwin septum and one thick chorionic membrane in conjunction with two thin amniotic membranes at the upper part (Figure 1), resulting in the diagnosis of a partial monochorionic (MC) twin pregnancy. The pregnancy was followed up as an MC twin pregnancy with fortnightly ultrasound examinations. The pregnancy was uneventful and the patient delivered two healthy girls of 2535g and 2595g at 36 weeks' gestation. Postnatal macroscopic evaluation of the intertwin membrane confirmed our diagnosis, showing both an opaque and a translucent part of the septum (Figure 2). Placental injection documented the presence of vascular anastomoses across the MC part of the septum. Pathological examination of the intertwin septum confirmed both the amnion-amnion and amnion-chorion-amnion attachment, indicating a partial MC and dichorionic (DC) septum (Figure 3), as was diagnosed at the first-trimester scan. DNA fingerprinting using fibroblasts cultured from the umbilical cords confirmed monozygosity.The second case was a twin pregnancy conceived by intracytoplasmatic sperm injection in a 26-year-old woman, gravida 3 para 1. The first-trimester scan showed two thin amniotic membranes (Figure 4, inset), typical in an MC diamniotic (DA) twin pregnancy, and a fortnightly follow-up scan was recommended. Re-evaluation at 20 weeks' gestation showed that the intertwin septum no longer separated the two twins, but that both were on the same side of the septum and their cords were entangled. The initial diagnosis of a diamniotic pregnancy was therefore changed to a partial monoamniotic (MA) pregnancy. From 28 weeks onwards, the woman was managed as an inpatient to provide fetal surveillance and treatment for fetal lung maturation, as is usual for MA pairs1 . An emergency Cesarean section was performed at 31 weeks' gestation because of preterm prelabor rupture of membranes and the clinical suspicion of placental abruption. Two healthy boys of 1630g and 1440g were delivered. Postpartum macroscopic evaluation confirmed the presence of cord entanglement and revealed a partial DA intertwin septum between the cord insertions (Figure 4). Examination of the injected placenta documented the presence of vascular anastomoses, as typically seen in MC placentas.

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“…Como analizaremos más adelante una de las principales causas es la mala distribución del territorio placentario, pero lamentablemente la ecografía prenatal no puede estimarla. Sin embargo, el sitio de inserción del cordón se puede determinar de forma confiable 9 , y la combinación de una inserción del cordón velamentosa y la otra inserción central puede servir como un marcador de intercambio placentario desigual, y por lo tanto identificar un grupo de gemelos monocoriónicos de alto riesgo para crecimiento discordante 17 .…”

Section: Definicion Y Diagnosticounclassified

“…La asimetría placentaria es a menudo asociada a la inserción del cordón muy excéntrica o velamentosa 16 , aunque no está claro si la inserción velamentosa es una mera consecuencia del desplazamiento asimétrico del ecuador vascular o si tiene alguna implicancia en la fisiopatología. Además de la discordancia del territorio placentario, un segundo factor que influye en gran medida la discordancia de peso fetal y la historia natural de RCIUs en gemelos MC, es la presencia de anastomosis vasculares en el placenta 17,18 , las cuales tienen una fuerte injerencia en la evolución. La cantidad y el tipo de flujo interfetal cambia en función del número y tipo de anastomosis, lo cual determinará una amplia variación en el comportamiento clínico.…”

Section: Etiopatogeniaunclassified

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

Cosp

2016

Rev. Nac. (Itauguá)

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RESUMENLa Restricción Selectiva del Crecimiento Intrauterino se produce en 10 a 19% de los gemelos monocoriónicos y se asocia con un aumento importante de la mortalidad y la morbilidad perinatal. La evolución clínica está dada en gran parte por la presencia de anastomosis vaculares y la distribución placentaria asimétrica. Se propuso una clasificación en tres tipos según el Doppler de la arteria umbilical del gemelo más pequeño, la que sé que se correlaciona con distintos comportamientos clínicos y características de la placenta, lo que ayuda en el asesoramiento y conducta obstétrica. Los del tipo I tienen un pronóstico favorable por el resultado perinatal satisfactorio por lo que se recomienda un seguimiento cercano por ecografía y Doppler. Los de tipo II tienen un mal pronóstico y el tipo III un pronóstico intermedio e impredecible. En estos dos últimos se puede realizar un manejo expectante hasta que se observe deterioro del feto pequeño, considerando la posibilidad de la coagulación con láser o la oclusión del cordón (feticidio selectivo). Ambas conductas aparentemente aumentan las posibilidades de supervivencia del feto de peso normal.Palabras claves: restricción selectiva del crecimiento intrauterino, diagnóstico, manejo, gemelos monocoriales, doppler, terapia fetal ABSTRACT Selective intrauterine growth restriction occurs in 10-19% of monochorionic twins and is associated with increased mortality important and perinatal morbidity. The clinical course is given largely by the presence of placental vascular anastomosis and asymmetric distribution. It classified into three types according to the proposed Doppler umbilical artery smaller twin, the one that correlates with different clinical behaviors and characteristics of the placenta, which helps in counseling and obstetric conduct. The type I have a favorable prognosis for satisfactory perinatal outcome so closely monitored by ultrasound and Doppler is recommended. The type II has a poor prognosis and type III intermediate and unpredictable prognosis. In these last two you can make an expectant management until deterioration of the small fetus is observed, considering laser coagulation or cord occlusion(selective feticide). Both behaviors appear to increase the chances of survival of the fetus of normal weight.

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Placental sharing, birthweight discordance and vascular anastomoses in monochorionic diamniotic twin placentas

Cited by 84 publications

References 0 publications

Intrauterine growth restriction in monochorionic-diamniotic twins

Intrauterine growth restriction in monochorionic-diamniotic twins

Partial monochorionic and monoamniotic twin pregnancies: a report of two cases

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

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