ISUOG Practice Guidelines: role of ultrasound in twin pregnancy

Khalil, Asma; Rodgers, M. T.; Baschat, Ahmet; Bhide, A.; Gratacós, Eduard; Hecher, Kurt; Kilby, Mark D.; Lewi, Liesbeth; Nicolaides, Kypros H.; Oepkes, Dick; Raine‐Fenning, Nick; Reed, Keith; Salomon, Laurent; Sotiriadis, Alexandros; Thilaganathan, B.; Ville, Y.

doi:10.1002/uog.15821

Cited by 525 publications

(672 citation statements)

References 140 publications

(187 reference statements)

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“…Exaggerated mortality but also morbidity have been observed in monochorionic twins following sIUD, the most severe being brain injuries in approximately 1 out of 4 cases [17][18][19][20]. Brain damage in the surviving twin can occur as early as 30 min post mortem of the co-twin and has been reported to be present in postnatal cranial imaging in approximately 34% of monochorionic single survivors [21,22]. We want to stress the importance of brain imaging 4-6 weeks after the death of the co-twin to screen for evidence of cerebral morbidity [21].…”

Section: Discussionmentioning

confidence: 99%

“…Brain damage in the surviving twin can occur as early as 30 min post mortem of the co-twin and has been reported to be present in postnatal cranial imaging in approximately 34% of monochorionic single survivors [21,22]. We want to stress the importance of brain imaging 4-6 weeks after the death of the co-twin to screen for evidence of cerebral morbidity [21]. In cases with evidence for serious neurological harm, late termination of pregnancy may be considered.…”

Section: Discussionmentioning

confidence: 99%

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A Modified Technique for Cord Transection in Monochorionic Monoamniotic Twin Pregnancies

Greimel¹,

Csapó²,

Haeusler³

et al. 2018

Fetal Diagn Ther

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Monochorionic monoamniotic (MA) twins are at increased risk for intrauterine demise (IUD) and discordant anomalies. Selective feticide by cord occlusion may be an option in case of unfavorable discordant problems. In MA pregnancies, however, the surviving co-twin still remains at serious risk for IUD due to progressive cord entanglement. Cord transection has therefore been recommended to protect the survivor. This procedure may turn out to be difficult. We herein describe a modified fetoscopic technique for laser transection using a grasping forceps. We present technical details and clinical outcome in 2 cases of cord transection: one following cord occlusion and the other following spontaneous IUD. Cord transection was performed at 19 and 26 weeks gestation, respectively. A 3 Fr grasping forceps with a working length of 35 cm was used for controlled manipulation of the umbilical cord during transection. There were no procedure-related complications and both surviving co-twins had favorable neonatal outcome. Cord transection using a grasping forceps facilitates easy and precise fetoscopic release of the umbilical cord. To the best of our knowledge, this is the first report on post mortem cord transection after spontaneous single IUD with favorable outcome for the survivor.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

A Modified Technique for Cord Transection in Monochorionic Monoamniotic Twin Pregnancies

Greimel¹,

Csapó²,

Haeusler³

et al. 2018

Fetal Diagn Ther

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“…This fact may imply a bias in their population recruitment by selecting a higher baseline risk subgroup which might have needed a closer ultrasound follow-up, such as MC twins with weight discordance between both fetuses up to almost 25% or amniotic fluid discordance without being classified as TTTS. Also, we excluded all prenatally diagnosed sIUGR fetuses, according to EFW centile in multiple pregnancies and intertwin discordance, as stated in recent guidelines [19]. However, as the aim of our study was to construct prenatal charts, we have not excluded cases with birthweight outcomes under the 10th percentile of born neonates.…”

Section: Discussionmentioning

confidence: 99%

“…Fetal weight was estimated through Hadlock’s formulae [18]. Patients who subsequently developed TTTS [3] (defined as the presence of oligohydramnios [defined as a maximal vertical pocket of ≤2 cm] in one sac and polyhydramnios [a maximal vertical pocket of ≥8 cm] in the other sac), sIUGR [19] (defined as an intertwin fetal discordance ≥25% and EFW <10th centile according to multiple gender charts), and discordant malformation were excluded for the analysis. We also excluded fetuses with a postnatal diagnosis of malformations, patients with preterm delivery <35 weeks, and patients who suffered maternal diseases that could affect fetal growth such as preeclampsia and gestational diabetes.…”

Section: Methodsmentioning

confidence: 99%

Gender-Specific Antenatal Growth Reference Charts in Monochorionic Twins

et al. 2017

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Objective: To create antenatal gender-specific reference growth charts in uncomplicated monochorionic diamniotic twins. Materials and Methods: This is a prospective longitudinal study in which uncomplicated monochorionic (MC) twin pregnancies were included from 23 + 4 weeks of gestation onwards. Estimated fetal weight (EFW) and biometric parameters (biparietal diameter, head circumference, abdominal circumference, and femur length) were evaluated in both fetuses every 2 weeks using standardized methodology. Maternal and fetal complications were excluded. Charts were fitted for each biometric parameter and EFW in relation to gestational age and fetal gender using multilevel mixed models. Results: The final analysis included a total of 456 ultrasound examinations in 62 MC twins, with a mean of 7 scans per pregnancy (range 5–8). The mean as well as 5th and 95th percentiles of each biometric parameter and EFW were adjusted in relation to gender and gestational age between 24 and 37 weeks of gestation. Male fetuses have higher reference values than females, and the disparity is larger in the upper centiles of the distribution. Discussion: We provide gender-specific reference growth charts for MC twins. We suggest that these charts will improve prenatal MC twin assessment and surveillance, with a more accurate classification of normal or growth-restricted fetuses adjusted per sex.

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“…It was with great interest that we read the recently published guidelines on the role of ultrasound in twin pregnancy 1 . Although the content is in many ways commendable, the disregard of previous pivotal publications relating to the topic is disappointing.…”

mentioning

confidence: 99%

Ductus venosus in twins: science matters

Matias

Montenegro

2016

Ultrasound in Obstet & Gyne

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It was with great interest that we read the recently published guidelines on the role of ultrasound in twin pregnancy 1 . Although the content is in many ways commendable, the disregard of previous pivotal publications relating to the topic is disappointing. On Page 251, when the authors discuss the implications of discordance in nuchal translucency thickness (NT) and crown-rump length (CRL), they ignore the clinically relevant contribution of abnormal flow in the ductus venosus (DV) in screening for twin-to-twin transfusion syndrome (TTTS).We know from the papers of Sebire et al. 2,3 that a higher prevalence of increased NT was noted among monochorionic (MC) twins along with a four-fold increase in the risk of developing TTTS in this subgroup. An intertwin difference in NT of more than 20% was a stronger marker for TTTS, but its sensitivity was unsatisfactory (around 50%) 4 .From our published peer-reviewed work, we could clearly demonstrate that abnormal DV blood flow in at least one fetus, used as the only marker, was associated with a relative risk for developing TTTS of 11.86, with a sensitivity of 75.0% and a specificity of 92.0% 5 .If we further consider the combination of NT and DV blood flow in twin pregnancies with non-discrepant NT but abnormal DV blood flow in at least one of the fetuses, the risk of developing TTTS was found to be increased by a factor of 10, and for those presenting with discrepant NT ≥ 0.6 mm along with abnormal DV blood flow, the risk of developing TTTS was 21 times higher 5 . These conclusions were based on evaluation of 99 MC twin pairs (a not inconsiderable number), in good agreement with the results of Maiz et al. 6 from 179 MC pairs. We believe that the role of the DV in screening for TTTS in MC twin pregnancy cannot be overlooked, since it is clinically relevant and may contribute to the improvement of obstetric management.The emphasis given in the published guidelines 1 to discrepant CRL in screening for TTTS seems exaggerated. Discrepancy in CRL between twins was only indicative of a high risk of developing TTTS in those with a difference ≥ 10 mm 7 . However, CRL discrepancies of this magnitude are rarely found in clinical practice, leading to a low sensitivity (8.3%) when applied to our study population.Furthermore, we have shown that, in twin pregnancies with abnormal DV flow in at least one fetus, the median discordance in birth weight was greater than it was in those with normal DV flow in both twins (13.2% vs 7.8%, P = 0.006) 8 .We fully support that evidence-based guidelines should be produced by experts. However, we cannot peacefully accept that peer-reviewed, clinically relevant work that is easily accessible should be overlooked. It is unfortunate that politics is frequently a trigger for publication, but we believe that science still matters and should prevail.

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ISUOG Practice Guidelines: role of ultrasound in twin pregnancy

Cited by 525 publications

References 140 publications

A Modified Technique for Cord Transection in Monochorionic Monoamniotic Twin Pregnancies

A Modified Technique for Cord Transection in Monochorionic Monoamniotic Twin Pregnancies

Gender-Specific Antenatal Growth Reference Charts in Monochorionic Twins

Ductus venosus in twins: science matters

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