Birthweight discordance and neonatal morbidity in twin pregnancies: A systematic review and meta‐analysis

Mascio, Daniele Di; Acharya, Ganesh; Khalil, Asma; Odibo, Anthony O.; Prefumo, Federico; Liberati, Marco; Buca, Danilo; Manzoli, Lamberto; Flacco, Maria Elena; Brunelli, Roberto; Panici, Pierluigi Benedetti; D’Antonio, F.

doi:10.1111/aogs.13613

Cited by 39 publications

(38 citation statements)

References 42 publications

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“…The presence of a large birthweight discordance between twins is strongly associated with adverse perinatal outcomes 4 and obstetricians tend to evaluate the degree of inter‐twin growth discordance by size on ultrasound examination in clinical practice. Nevertheless, the predictability of ultrasound examination parameters may be influenced by many factors, particularly the GA, and this should be acknowledged.…”

Section: Discussionmentioning

confidence: 99%

Ultrasound in the prediction of birthweight discordance in dichorionic twins

Lei

Zheng

Papageorghiou

et al. 2021

Acta Obstet Gynecol Scand

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Introduction Large birthweight discrepancy has been identified as a risk factor for perinatal morbidity and mortality in twin pregnancies. However, it remains unclear whether such discordance can be predicted by various biological indices with specific cut‐off values, and how these depend on the gestational age. We aimed to determine the most effective way to predict large birthweight discordance at various gestational ages. Material and methods A retrospective cohort study of dichorionic twins, live‐born between 2008 and 2018, was conducted. Discordances in biparietal diameter, head circumference, humerus and femur length, abdominal circumference, and estimated fetal weight were calculated—([larger twin − smaller twin] / larger twin) × 100%—and compared between those with and without a large birthweight discordance (≥20%). Receiver operating characteristic curves were constructed to analyze the predictive characteristics of each parameter. Results Of 598 dichorionic twin pregnancies included, 83 (13.9%) had a birthweight discordance ≥20%. Group differences in biparietal diameter and head circumference discordance were the earliest to emerge (before 20 weeks of gestation), but became insignificant after 36 weeks, followed by humerus and femur length, estimated fetal weight discordance (after 20 weeks), and abdominal circumference discordance (after 28 weeks). The best predictors (with cut‐off values) were discordance in biparietal diameter ≥7.8% at <20 weeks, head circumference ≥4.5% at 20‐23+6 weeks, humerus length ≥4.5% at 24‐27+6 weeks, and estimated fetal weight discordance (≥11.6% at 28‐31+6 weeks, ≥10.5% at 32‐35+6 weeks, and ≥15.0% ≥36 weeks), with sensitivity and specificity of 52%‐77% and 69%‐82%, respectively. Conclusions Different predictors and cut‐off values may be useful for predicting large inter‐twin birthweight discordance in dichorionic twins at different gestational ages. It is more accurate to use biparietal diameter and head circumference discordance in the early second trimester, humerus length discordance in the late second trimester, and estimated fetal weight discordance in the third trimester.

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Section: Discussionmentioning

confidence: 99%

Ultrasound in the prediction of birthweight discordance in dichorionic twins

Lei

Zheng

Papageorghiou

et al. 2021

Acta Obstet Gynecol Scand

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“…Monochorionic (MC) twin pregnancies are at increased risk of perinatal morbidity and mortality compared with dichorionic (DC) gestations, mostly owing to conditions arising from their placental vascular arrangement, such as twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence and twin reversed arterial perfusion sequence [1][2][3][4][5][6][7][8][9][10][11] .…”

Section: Introductionmentioning

confidence: 99%

Outcome of twin–twin transfusion syndrome according to Quintero stage of disease: systematic review and meta‐analysis

Mascio

Khalil

D’Amico

et al. 2020

Ultrasound in Obstet & Gyne

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Objectives To report the outcome of pregnancies complicated by twin–twin transfusion syndrome (TTTS) according to Quintero stage. Methods MEDLINE, EMBASE and CINAHL databases were searched for studies reporting the outcome of pregnancies complicated by TTTS stratified according to Quintero stage (I–V). The primary outcome was fetal survival rate according to Quintero stage. Secondary outcomes were gestational age at birth, preterm birth (PTB) before 34, 32 and 28 weeks' gestation and neonatal morbidity. Outcomes are reported according to the different management options (expectant management, laser therapy or amnioreduction) for pregnancies with Stage‐I TTTS. Only cases treated with laser therapy were considered for those with Stages‐II–IV TTTS and only cases managed expectantly were considered for those with Stage‐V TTTS. Random‐effects head‐to‐head meta‐analysis was used to analyze the extracted data. Results Twenty‐six studies (2699 twin pregnancies) were included. Overall, 610 (22.6%) pregnancies were diagnosed with Quintero stage‐I TTTS, 692 (25.6%) were Stage II, 1146 (42.5%) were Stage III, 247 (9.2%) were Stage IV and four (0.1%) were Stage V. Survival of at least one twin occurred in 86.9% (95% CI, 84.0–89.7%) (456/552) of pregnancies with Stage‐I, in 85% (95% CI, 79.1–90.1%) (514/590) of those with Stage‐II, in 81.5% (95% CI, 76.6–86.0%) (875/1040) of those with Stage‐III, in 82.8% (95% CI, 73.6–90.4%) (172/205) of those with Stage‐IV and in 54.6% (95% CI, 24.8–82.6%) (5/9) of those with Stage‐V TTTS. The rate of a pregnancy with no survivor was 11.8% (95% CI, 8.4–15.8%) (69/564) in those with Stage‐I, 15.0% (95% CI, 9.9–20.9%) (76/590) in those with Stage‐II, 18.6% (95% CI, 14.2–23.4%) (165/1040) in those with Stage‐III, 17.2% (95% CI, 9.6–26.4%) (33/205) in those with Stage‐IV and in 45.4% (95% CI, 17.4–75.2%) (4/9) in those with Stage‐V TTTS. Gestational age at birth was similar in pregnancies with Stages‐I–III TTTS, and gradually decreased in those with Stages‐IV and ‐V TTTS. Overall, the incidence of PTB and neonatal morbidity increased as the severity of TTTS increased, but data on these two outcomes were limited by the small sample size of the included studies. When stratifying the analysis of pregnancies with Stage‐I TTTS according to the type of intervention, the rate of fetal survival of at least one twin was 84.9% (95% CI, 70.4–95.1%) (94/112) in cases managed expectantly, 86.7% (95% CI, 82.6–90.4%) (249/285) in those undergoing laser therapy and 92.2% (95% CI, 84.2–97.6%) (56/60) in those after amnioreduction, while the rate of double survival was 67.9% (95% CI, 57.0–77.9%) (73/108), 69.7% (95% CI, 61.6–77.1%) (203/285) and 80.8% (95% CI, 62.0–94.2%) (49/60), respectively. Conclusions Overall survival in monochorionic diamniotic pregnancies affected by TTTS is higher for earlier Quintero stages (I and II), but fetal survival rates are moderately high even in those with Stage‐III or ‐IV TTTS when treated with laser therapy. Gestational age at birth was similar in pregnancies with Sta...

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“…The main rationale for using discordant growth in dichorionic twins as a risk factor for adverse perinatal outcomes, that in turn justifies closer antenatal surveillance and iatrogenic preterm delivery, is that it might indicate growth restriction of the smaller twin, with the larger twin serving as a naturally occurring control. However to date, data on the optimal cutoff that should be used to define discordant growth in twins have been conflicting [18] with recommendations currently ranging from 15 to 30% [15][16][17]32]. One potential explanation for this controversy is the fact that many studies failed to account for important confounding factors such as chorionicity, complications related to monochorionic twins such as twin-to-twin transfusion syndrome, structural or genetic anomalies of the smaller twin, and SGA of the smaller twin [9,15,16,18].…”

Section: Interpretation Of the Results In The Context Of Previous Obsmentioning

confidence: 99%

Pathologic Basis for the Definition of Discordant Growth in Dichorionic Twins

et al. 2021

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Objective: The aim of the current study was to identify the optimal cutoff that should define discordance in dichorionic twin gestations through correlation with abnormal placental pathology as a specific measure of fetal growth restriction of the smaller twin. Methods: We performed a retrospective cohort study of all women with dichorionic twin pregnancies who gave birth in a single center between 2002 and 2015. We investigated the association between the level of growth discordance and maternal vascular malperfusion (MVM) pathology in the placenta of the smaller twin, with and without adjustment for whether the smaller twin is small for gestational age (SGA). Results: A total of 1,198 women with dichorionic twin gestation met the study criteria. The rate of MVM pathology in the placenta of the smaller twin increased with the level of discordance and was most obvious for discordance ≥25% (rate of MVM 12.0% compared with 2.8% in cases with discordance <10%, adjusted relative risk [aRR] 3.71, 95% confidence interval [CI] 1.97–6.99). When the analysis was adjusted for SGA of the smaller twin, discordance was independently associated with MVM pathology only when growth discordance was ≥25% (aRR 2.18, 95%-CI 1.01–4.93), while SGA was strongly associated with MVM pathology irrespective of the level of discordance. Conclusion: Our findings suggest that discordant growth in dichorionic twins should raise the concern of fetal growth restriction of the smaller twin, irrespective of whether the smaller twin is SGA, only when the discordance s ≥25%. The association of lower levels of discordance with abnormal placental pathology is mainly driven by the confounding effect of SGA of the smaller twin.

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Birthweight discordance and neonatal morbidity in twin pregnancies: A systematic review and meta‐analysis

Cited by 39 publications

References 42 publications

Ultrasound in the prediction of birthweight discordance in dichorionic twins

Ultrasound in the prediction of birthweight discordance in dichorionic twins

Outcome of twin–twin transfusion syndrome according to Quintero stage of disease: systematic review and meta‐analysis

Pathologic Basis for the Definition of Discordant Growth in Dichorionic Twins

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