Obstetrical outcomes after first‐trimester chorionic villus sampling in twin pregnancies: A retrospective case–control study

Objective To estimate the chorionic villus sampling (CVS)‐related risk of fetal loss in twin pregnancy after adjustment for chorionicity, nuchal translucency thickness (NT), intertwin discordance in crown–rump length (CRL), maternal demographic characteristics and serum pregnancy‐associated plasma protein‐A (PAPP‐A) and free β‐human chorionic gonadotropin (β‐hCG). Methods This was a multicenter study from eight fetal medicine units in which the leadership were trained at the Harris Birthright Research Centre for Fetal Medicine in London, UK, and in which the protocols for screening, invasive testing and pregnancy management are similar. Data were obtained prospectively from women with twin pregnancy undergoing routine ultrasound examination at 11–13 weeks' gestation. Multivariable logistic regression analysis with backward stepwise elimination was used to examine whether CVS provided a significant independent contribution to the prediction of risk of fetal loss after adjusting for maternal and pregnancy characteristics, including maternal age, racial origin and weight, method of conception, smoking status, parity, chorionicity, intertwin discordance in CRL, fetal NT ≥ 95th percentile and free β‐hCG and PAPP‐A multiples of the median. Similarly, within the CVS group, multivariable logistic regression analysis was used to investigate the effect of the number of intrauterine needle insertions and size of the needle on the risk of fetal loss. Results The study population of 8581 twin pregnancies undergoing ultrasound examination at 11–13 weeks' gestation included 316 dichorionic and 129 monochorionic twins that had CVS. First, in twin pregnancies undergoing CVS, compared to those not undergoing CVS, there was a 2‐fold increased risk of fetal loss at < 24 weeks' gestation and of loss at any stage in pregnancy. Second, the factors providing a significant independent contribution to the prediction of miscarriage or fetal loss in twin pregnancy were increased maternal weight, black racial origin, monochorionicity, and more so monoamnionicity, large intertwin discordance in CRL and increased fetal NT, and, in the case of fetal loss at any stage, there was also a contribution from assisted conception and low serum PAPP‐A. Third, after adjustment for maternal and pregnancy characteristics, CVS did not provide a significant contribution to the risk of fetal loss. Fourth, in twin pregnancies that had CVS, there was no significant contribution to fetal loss from the number of intrauterine needle insertions or needle size. Conclusion The 2‐fold increased risk of fetal loss following CVS in twin pregnancy can, to a great extent, be explained by maternal and pregnancy characteristics rather than the invasive procedure itself. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Section: Comparison With Other Studiesmentioning

confidence: 82%

Section: Discussionmentioning

confidence: 95%

Section: Introductionmentioning

confidence: 99%

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Fetal loss after chorionic villus sampling in twin pregnancy

Elger

Akolekar

Syngelaki

et al. 2021

“…Four studies 24,28,34,35 (567 pregnancies) reported the overall risk of fetal loss in twin pregnancies undergoing CVS. Head‐to‐head meta‐analyses comparing directly women undergoing and those not undergoing CVS showed no significant difference in overall fetal loss (two studies 24,35 : 3/201 vs 5/218; OR,1.61 ( P = 0.5); RD, 0.003 ( P = 0.8)); all cases of fetal loss occurred before 24 weeks of gestation and analysis of the rate of fetal loss before 24 weeks therefore demonstrated the same results (Table 3).…”

Section: Resultsmentioning

confidence: 99%

“…Table S2 shows the definition of overall fetal loss, the indication for invasive prenatal diagnosis and the exclusion criteria in each of the included studies. These 16 studies 9,10,23–36 included 3419 twin pregnancies undergoing an invasive procedure and 2517 twin pregnancies not undergoing invasive prenatal diagnosis. Twin pregnancies included both DC and MC pregnancies; however, we could not find any study reporting the occurrence of fetal loss exclusively in monoamniotic gestations.…”

Section: Resultsmentioning

confidence: 99%

Risk of fetal loss following amniocentesis or chorionic villus sampling in twin pregnancy: systematic review and meta‐analysis

Mascio

Khalil

Rizzo

et al. 2020

Objective To assess the rate of fetal loss following amniocentesis or chorionic villus sampling (CVS) in twin pregnancy. Methods MEDLINE, EMBASE and Cochrane databases were searched for studies reporting procedure‐related complications following amniocentesis or CVS in twin pregnancy. The primary outcome was the rate of procedure‐related fetal loss. The secondary outcomes were fetal loss occurring before 24 weeks of gestation and fetal loss occurring within 4 weeks after the procedure. Head‐to‐head meta‐analyses were used to compare directly each outcome, between women undergoing amniocentesis and those not undergoing amniocentesis and between women undergoing CVS and those not undergoing CVS, and to compute pooled risk differences (RD) between women exposed and those not exposed to each invasive procedure. Additionally, meta‐analyses of proportions were used to estimate the pooled rates of each of the three outcomes in women undergoing amniocentesis or CVS and in controls. Results Sixteen studies (3419 twin pregnancies undergoing and 2517 not undergoing an invasive procedure) were included. Head‐to‐head meta‐analyses comparing directly twin pregnancies undergoing and those not undergoing amniocentesis showed a higher risk for overall fetal loss in those undergoing amniocentesis (odds ratio (OR), 1.46 (P = 0.04); RD, 0.013 (P = 0.04)), while there was no difference in the risk of either fetal loss before 24 weeks of gestation (OR, 1.59 (P = 0.06); RD, 0.010 (P = 0.11)) or fetal loss within 4 weeks after the procedure (OR, 1.38 (P = 0.3); RD, 0.003 (P = 0.8)). Overall, the pooled rate of fetal loss was 2.4% (95% CI, 1.4–3.6%) in twin pregnancies undergoing amniocentesis compared with 2.4% (95% CI, 0.9–4.6%) in those not undergoing amniocentesis. Head‐to‐head meta‐analyses directly comparing twin pregnancies undergoing and those not undergoing CVS showed no significant difference in either overall fetal loss (OR, 1.61 (P = 0.5); RD, 0.003 (P = 0.8)) or fetal loss before 24 weeks of gestation (OR, 1.61 (P = 0.5); RD, 0.003 (P = 0.8)). Overall, the pooled rate of fetal loss was 2.0% (95% CI, 0.0–6.5%) in twin pregnancies undergoing CVS compared with 1.8% (95% CI, 0.3–4.2%) in those not undergoing CVS. Conclusion The risk of fetal loss following amniocentesis and CVS in twins is lower than reported previously and the rate of fetal loss before 24 weeks of gestation, or within 4 weeks after the procedure, did not differ from the background risk in twin pregnancy not undergoing invasive prenatal testing. These data can guide prenatal counseling for twin pregnancies undergoing invasive procedures. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Risk of fetal loss after chorionic villus sampling in twin pregnancy derived from propensity score matching analysis

Gil

Rodríguez-Fernández

Elger

et al. 2022

Objective To estimate the risk of fetal loss associated with chorionic villus sampling (CVS) in twin pregnancy, using propensity score analysis. Methods This was a multicenter cohort study of women with twin pregnancy undergoing ultrasound examination at 11–13 weeks' gestation, performed in eight fetal medicine units in which the leadership were trained at the Harris Birthright Research Centre for Fetal Medicine in London, UK, and in which the protocols for screening, invasive testing and pregnancy management are similar. The risk of death of at least one fetus was compared between pregnancies that had and those that did not have CVS, after propensity score matching (1:1 ratio). This procedure created two comparable groups by balancing the maternal and pregnancy characteristics that lead to CVS being performed, similar to how randomization operates in a randomized clinical trial. Results The study population of 8581 twin pregnancies included 445 that had CVS. Death of one or two fetuses at any stage during pregnancy occurred in 11.5% (51/445) of pregnancies in the CVS group and in 6.3% (515/8136) in the non‐CVS group (P < 0.001). The propensity score algorithm matched 258 cases that had CVS with 258 non‐CVS cases; there was at least one fetal loss in 29 (11.2%) cases in the CVS group and in 35 (13.6%) cases in the matched non‐CVS group (odds ratio (OR), 0.81; 95% CI, 0.48–1.35; P = 0.415). However, there was a significant interaction between the risk of fetal loss after CVS and the background risk of fetal loss; when the background risk was higher, the risk of fetal loss after CVS decreased (OR, 0.46; 95% CI, 0.23–0.90), while, in pregnancies with a lower background risk of fetal loss, the risk of fetal loss after CVS increased (OR, 2.45; 95% CI, 0.95–7.13). The effects were statistically significantly different (P‐value of the interaction = 0.005). For a pregnancy in which the background risk of fetal loss was about 6% (the same as in our non‐CVS population), there was no change in the risk of fetal loss after CVS, but, when the background risk was more than 6%, the posterior risk was paradoxically reduced, and when the background risk was less than 6%, the posterior risk increased exponentially; for example, if the background risk of fetal loss was 2.0%, the relative risk was 2.8 and the posterior risk was 5.6%. Conclusion In twin pregnancy, after accounting for the risk factors that lead to both CVS and spontaneous fetal loss and confining the analysis to pregnancies at lower prior risk, CVS seems to increase the risk of fetal loss by about 3.5% above the patient's background risk. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.