Presence of an Umbilical Artery Notch in Monochorionic/Monoamniotic Twins

Abstract

Objective: To examine the association between an umbilical artery notch and fetal deterioration in monochorionic/monoamniotic (MC/MA) twins. Methods: Six MC/MA twin pregnancies were admitted at 24-28 weeks of gestation for close fetal surveillance until elective delivery at 32 weeks or earlier in the presence of signs of fetal deterioration. Ultrasound (US) examinations were performed twice weekly. The presence of cord entanglement, umbilical artery notch, abnormal Doppler parameters, a non-reassuring fetal heart rate pattern, or an abnormal fetal biophysical profile were evaluated. Results: Umbilical cord entanglement was observed on US in all pregnancies. The presence of an umbilical artery notch was noted in four out of six pregnancies and in two of them an umbilical artery notch was seen in both twins. The umbilical artery pulsatility index was normal in all fetuses. Doppler parameters of the middle cerebral artery and ductus venosus, fetal biophysical profile and fetal heart rate monitoring remained normal until delivery in all pregnancies. All neonates experienced morbidity related to prematurity; however, all were discharged home in good condition. Conclusion: The presence of an umbilical artery notch and cord entanglement, without other signs of fetal deterioration, are not indicative of an adverse perinatal outcome.

Anomalies of the placenta and umbilical cord in twin gestations

“…59 A small cases series has also shown that the presence of a notch in umbilical artery waveform is not associated with an adverse perinatal outcome. 61 Furthermore, even in cases complicated with severe TTTS requiring laser surgery, survival rate remains at 75%, 62 confirming a better perinatal outcome for MCMA pregnancies than previously reported.…”

ISUOG Practice Guidelines: role of ultrasound in twin pregnancy

“…A systematic review including a total of 114 monoamniotic twin sets (228 fetuses) with cord entanglement concluded that cord entanglement does not contribute to prenatal morbidity and mortality in monoamniotic twin pregnancy. Moreover, the presence of an umbilical artery notch, without other signs of fetal deterioration, is not indicative of an adverse perinatal outcome ( EVIDENCE LEVEL: 2– ).…”

Perinatal mortality, timing of delivery and prenatal management of monoamniotic twin pregnancy: systematic review and meta‐analysis

“…The incidence of mortality varied according to gestational-age window. IUD occurred in 4.3% (95% Kristiansen (2015) 18 Prefumo (2015) 19 Anselem (2015) 20 Van Mieghem (2014) 21 Murata (2013) 23 Suzuki (2013) 24 Aurioles-Garibay (2014) 22 Dias (2011) 25 Quinn (2011) 26 Assuncao (2010) 27 Baxi (2010) 28 Hack (2009) 29 Arabin (2009) 30 Heflin (2008) 31 Cordero (2006) CI, 2.8-6.2%) of cases at 24-30 weeks, 1.0% (95% CI, 0.6-1.7%) at 31-32 weeks and in 2.2% (95% CI, 0.9-3.9%) at 33-34 weeks of gestation, while there was no IUD, either single or double, from 35 weeks of gestation, although the sample size was small (Table 3, Figure 3). sIUD and dIUD occurred, respectively, in 2.0% (95% CI, 1.4-2.7%) and 2.9% (95% CI, 1.8-4.2%) of twins at 24-30 weeks, 0.6% (95% CI, 0.2-1.1%) and 0.7% (95% CI, 0.3-1.2%) at 31-32 weeks, and 1.0% (95% CI, 0.4-1.9%) and 1.6% (95% CI, 0.6-3.0%) of cases at 33-34 weeks of gestation.…”

“…When analyzing those studies reporting the etiology of IUD, 29.5% (95% CI, 13.5-48.8%; I 2 = 55.2%) of the overall losses were due to TTTS or growth restriction, while 54.0% (95% CI, 37.1-71.3%; I 2 = 42.8%) were unexpected IUD. Furthermore, from 31 weeks of (a) (b) Saccone (2019) 16 Prefumo (2015) 19 Van Mieghem (2014) 21 Murata (2013) 23 Aurioles-Garibay (2014) 22 Quinn (2011) 26 Baxi (2010) 28 Hack (2009) 29 DeFalco (2006) 34 Heyborne (2005) 35 Ezra (2005) 36 Allen (2001) 39 Combined Saccone (2019) 16 Kristiansen (2015) 18 Anselem (2015) 20 Van Mieghem (2014) 21 Dias (2011) 25 Hack (2009) 29 Heflin (2008) 31 Pasquini (2006) 33 DeFalco (2006) 34 Heyborne (2005) 35 Ezra (2005) 36 Demaria (2004) 37 Sau (2003) 38 Allen (2001) gestation, all IUDs included in the present systematic review were reported to be unexpected and not the consequence of a chronic condition that can be potentially identified in utero. Twenty studies reported the incidence of mortality in pregnancies managed mainly as inpatients and/or those followed up as outpatients.…”

“…The 25 studies included 1068 MCMA pregnancies (2136 twins); information on perinatal mortality according to the gestational age at loss was provided for 814 non-anomalous twin pairs (1628 twins) reaching 24 weeks of gestation, which represent the population analyzed in this systematic review. 16 Glinianaia (2019) 17 Kristiansen (2015) 18 Prefumo (2015) 19 Anselem (2015) 20 Van Mieghem (2014) 21 Aurioles-Garibay (2014) 22 Murata (2013) 23 Suzuki (2013) 24 Dias (2011) 25 Quinn (2011) 26 Assuncao (2010) 27 Baxi (2010) 28 Hack (2009) 29 Arabin (2009) 30 Heflin (2008) 31 Cordero (2006) 32 Pasquini (2006) 33 DeFalco (2006) 34 Heyborne (2005) 35 Ezra (2005) 36 Demaria (2004) 37 Sau (2003) 38 Allen (2001) 39 Sebire (2000) 40 Only first author is given for each study. Study can be awarded maximum of one star for each numbered item within selection and outcome categories.…”