Preterm premature rupture of membranes is a collateral effect of improvement in perinatal outcomes following fetoscopic coagulation of chorionic vessels for twin–twin transfusion syndrome: a retrospective observational study of 1092 cases

Objective To evaluate infant survival according to the Doppler pattern of impedance to blood flow in the umbilical arteries (UAs) prior to laser surgery, in pregnancies with twin‐to‐twin transfusion syndrome (TTTS). Methods This was a retrospective study of women with a monochorionic diamniotic twin pregnancy who underwent laser surgery for TTTS between January 2012 and May 2018 at a single institution. Absolute intertwin difference in UA pulsatility index (DUAPI) was measured within 48 h prior to laser surgery. Twins with intermittent or persistent absent/reversed end‐diastolic flow (EDF) in the UA (UA‐EDF) were analyzed separately. Survival of both or at least one infant at birth and at 30 days postpartum was compared between pregnancies with an intertwin DUAPI of ≥ 0.4 and those with an intertwin DUAPI of < 0.4, as well as between fetuses with intermittent and those with persistent absent/reversed UA‐EDF. Parametric and non‐parametric tests were used for analysis. Regression analysis was performed to determine if intertwin DUAPI and intermittent or persistent absent/reversed UA‐EDF were associated independently with infant survival, while controlling for gestational age at delivery, Quintero stage and other important confounding variables. Results Of 231 TTTS pregnancies that underwent laser surgery during the study period, UA Doppler information could be retrieved for 206 and delivery information was available for 184, which comprised the study population. Rates of double‐twin survival at birth were significantly higher in pregnancies with an intertwin DUAPI of < 0.4 than in those with an intertwin DUAPI of ≥ 0.4 (83.9% (78/93) vs 50.0% (12/24); P < 0.001). Double‐infant survival at birth was higher in pregnancies with intermittent compared to those with persistent absent/reversed UA‐EDF (73.0% (27/37) vs 36.7% (11/30); P = 0.003). Regression analysis demonstrated that an intertwin DUAPI of < 0.4 was associated with increased survival of both twins at delivery (P < 0.001) and at 30 days postpartum (P = 0.002), as well as increased survival of at least one twin at delivery (P = 0.009). Similarly, intermittent absent/reversed UA‐EDF was associated with increased survival of both twins at delivery (P = 0.007) and at 30 days after birth (P = 0.015). Conclusions Evaluation of intertwin differences in UA impedance to blood flow as well as identification of intermittent or persistent absent or reversed UA‐EDF prior to laser surgery could help in the prediction of double‐infant survival at birth and to 30 days in twin pregnancies with TTTS. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

“…The survival rates seen in our study (two live births in 69.6% cases and at least one live birth in 88.6%) are comparable with those described in two large cohorts of TTTS cases 17,18 .…”

Section: Discussionsupporting

confidence: 89%

Association between impedance to blood flow in umbilical arteries and infant survival in twin‐to‐twin transfusion syndrome

Espinoza

Belfort

Shamshirsaz

et al. 2020

“…In MCDA twin pregnancies with CRL discordance of ≥ 15%, and possibly those with discordance of ≥ 10%, the parents should be counseled on the increased risk of early fetal loss and development of severe TTTS and/or sFGR requiring endoscopic laser surgery, and a scan should be offered at 14 weeks' gestation, in addition to the recommended one at 16 weeks. In most cases, the scan would be reassuring but, in a high proportion of cases, there could be evidence of severe early TTTS or sFGR; should that be the case, early endoscopic laser surgery could be considered despite the associated increased risk of procedure‐related preterm premature rupture of membranes and miscarriage.…”

Section: Discussionmentioning

confidence: 99%

Intertwin discordance in fetal size at 11–13 weeks' gestation and pregnancy outcome

Litwińska

Syngelaki

Cimpoca-Raptis

et al. 2020

CONTRIBUTIONWhat are the novel findings of this work? In both dichorionic (DC) and monochorionic diamniotic (MCDA) twin pregnancies, increased discordance in fetal crown-rump length (CRL) is associated with an increased risk of fetal death at < 20 and < 24 weeks' gestation, perinatal death at ≥ 24 weeks, preterm birth at < 32 and < 37 weeks, birth of at least one small-for-gestational-age neonate and birth-weight discordance of ≥ 20% and ≥ 25%, but CRL discordance is a poor screening test for adverse pregnancy outcome. However, in DC twins, CRL discordance of ≥ 15% is associated with a high risk of fetal loss at < 20 and < 24 weeks' gestation and, in MCDA twins, CRL discordance of ≥ 10%, and more so discordance of ≥ 15% and ≥ 20%, is associated with a very high risk of fetal loss at < 20 and < 24 weeks. What are the clinical implications of this work?In MCDA and DC twin pregnancies with large CRL discordance, the parents should be counseled on the increased risk of fetal loss and the need for early assessment and possible intervention. ABSTRACT Objective To investigate the value of intertwin discordance in fetal crown-rump length (CRL) at the 11-13-week scan in the prediction of adverse outcome in dichorionic (DC), monochorionic diamniotic (MCDA) and monochorionic monoamniotic (MCMA) twin pregnancies.Methods This was a retrospective analysis of prospectively collected data on twin pregnancies undergoing routine ultrasound examination at 11-13 weeks' gestation between 2002 and 2019. In pregnancies with no major abnormalities, we examined the value of intertwin discordance in fetal CRL in DC, MCDA and MCMA twins in the prediction of fetal loss at < 20 and < 24 weeks' gestation, perinatal death at ≥ 24 weeks, preterm delivery at < 32 and < 37 weeks, birth of at least one small-for-gestational-age (SGA) neonate with birth weight < 5 th percentile and intertwin birth-weight discordance of ≥ 20% and ≥ 25%. ResultsFirst, the study population of 6225 twin pregnancies included 4896 (78.7%) DC, 1274 (20.4%) MCDA and 55 (0.9%) MCMA twin pregnancies. Second, median CRL discordance in DC twin pregnancies (3.2%;interquartile range (IQR), 1.4-5.8%) was lower than in MCDA twins (3.6%; IQR, 1.6-6.2%; P = 0.0008), but was not significantly different from that in MCMA twins (2.9%; IQR, 1.2-5.1%; P = 0.269). Third, compared to CRL discordance in DC twin pregnancies with two non-SGA live births at ≥ 37 weeks' gestation, there was significantly larger CRL discordance in both DC and MCDA twin pregnancies complicated by fetal death at < 20 and < 24 weeks' gestation, perinatal death at ≥ 24 weeks, preterm birth at < 32 and < 37 weeks, birth of at least one SGA neonate and birth-weight discordance ≥ 20% and ≥ 25%, and in MCDA twin pregnancies undergoing endoscopic laser surgery. Fourth, the predictive performance of CRL discordance for each adverse pregnancy outcome was poor, with areas under the receiver-operating-characteristics curves ranging from 0.533 to 0.624. However, in both DC and MCDA twin pregnancies with large CRL discordance,...

“…One implication of our findings is that, in pregnancies with NT ≥ 95 th percentile in one or both fetuses, the parents should be counseled regarding the increased risk of early fetal loss and possible development of TTTS and/or sFGR requiring endoscopic laser surgery and a scan should be offered at 14 weeks' gestation, in addition to the recommended one at 16 weeks. In most cases, the scan would be reassuring but, in a high proportion of cases, there could be evidence of severe early TTTS or sFGR; should that be the case, early endoscopic laser surgery at 14–15 weeks could be considered despite the associated increased risk of procedure‐related preterm prelabor rupture of membranes and miscarriage.…”

Section: Discussionmentioning

confidence: 99%

Increased nuchal translucency at 11–13 weeks' gestation and outcome in twin pregnancy

Cimpoca-Raptis

Syngelaki

Litwińska

et al. 2020

Objective To investigate the value of increased fetal nuchal translucency thickness (NT) at the 11–13‐week scan in the prediction of adverse outcome in dichorionic (DC), monochorionic diamniotic (MCDA) and monochorionic monoamniotic (MCMA) twin pregnancies. Methods This was a retrospective analysis of prospectively collected data on twin pregnancies undergoing routine ultrasound examination at 11–13 weeks' gestation between 2002 and 2019. In pregnancies with no major defects or chromosomal abnormalities, we examined the value of increased NT ≥ 95th percentile in one or both fetuses in the prediction of, first, miscarriage or death of one or both fetuses at < 20 and < 24 weeks' gestation in DC, MCDA and MCMA twin pregnancies, second, death of one or both fetuses or neonates at ≥ 24 weeks in DC, MCDA and MCMA twin pregnancies, third, development of twin–twin transfusion syndrome (TTTS) or selective fetal growth restriction (sFGR) treated by endoscopic laser surgery at < 20 and ≥ 20 weeks' gestation in MCDA pregnancies, and, fourth, either fetal loss or laser surgery at < 20 weeks' gestation in MCDA pregnancies. Results The study population of 6225 twin pregnancies included 4896 (78.7%) DC, 1274 (20.5%) MCDA and 55 (0.9%) MCMA pregnancies. The incidence of NT ≥ 95th percentile in one or both fetuses in DC twin pregnancies was 8.3%; in MCDA twins the incidence was significantly higher (10.4%; P = 0.016), but in MCMA twins it was not significantly different (9.1%; P = 0.804) from that in DC twins. In DC twin pregnancies, the incidence of high NT was not significantly different between those with two survivors and those with adverse outcome. In MCMA twin pregnancies, the number of cases was too small for meaningful assessment of the relationship between high NT and adverse outcome. In MCDA twin pregnancies with at least one fetal death or need for endoscopic laser surgery at < 20 weeks' gestation, the incidence of NT ≥ 95th percentile was significantly higher than in those with two survivors (23.5% vs 9.8%; P < 0.0001). Kaplan–Meier analysis in MCDA twin pregnancies showed that, in those with NT ≥ 95th percentile, there was significantly lower survival at < 20 weeks' gestation than in those with NT < 95th percentile (P = 0.001); this was not the case for survival at ≥ 20 weeks (P = 0.960). The performance of screening by fetal NT ≥ 95th percentile for prediction of either fetal loss or need for endoscopic laser surgery at < 20 weeks' gestation was poor, with a detection rate of 23.5% at a false‐positive rate of 8.9%, and the relative risk, in comparison to fetal NT < 95th percentile, was 2.640 (95% CI, 1.854–3.758; P < 0.0001). In MCDA twin pregnancies, the overall rate of fetal loss or need for laser surgery at < 20 weeks' gestation was 10.7% but, in the subgroups with NT ≥ 95th and NT ≥ 99th percentiles, which constituted 10.4% and 3.3% of the total, the rates increased to 24.1% and 40.5%, respectively. Conclusions In MCDA twin pregnancies with no major fetal abnormalities, measurement of NT at the 11–13‐we...