Patterns of discordant growth and adverse neonatal outcomes in twins

Hiersch, Liran; Barrett, Jon; Aviram, Amir; Mei‐Dan, Elad; Yoon, Eugene W.; Zaltz, Arthur; Kingdom, John; Melamed, Nir

doi:10.1016/j.ajog.2021.01.018

Cited by 25 publications

(24 citation statements)

References 46 publications

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“…In our cohort of pregnancies with Type‐III sFGR, growth velocity of the larger twin deviated from singleton growth earlier in gestation, at approximately 23 weeks. This discordance pattern has been shown previously to be associated with high risk of adverse perinatal outcome 17 . Although twin‐specific growth curves may have been beneficial 18 , we compared twin growth to singleton growth curves instead, as these represent optimal fetal growth.…”

Section: Discussionmentioning

confidence: 95%

Growth patterns of monochorionic twin pregnancy complicated by Type‐III selective fetal growth restriction

Shinar

Xing

Lewi

et al. 2022

Ultrasound in Obstet & Gyne

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What are the novel findings of this work?In monochorionic twin pregnancy with Type-III selective fetal growth restriction (sFGR), abnormal fetal growth of the smaller twin is evident from very early in gestation, while estimated fetal weight of the larger twin remains normal throughout pregnancy. Intertwin growth discordance remains stable across gestation. Normalization of umbilical artery Doppler is associated with improved growth of the smaller but not the larger twin. What are the clinical implications of this work?Type-III sFGR is a diagnosis that can be made early in the second trimester, as the growth-restricted twin is already abnormally small at 16 weeks of gestation. Because the dynamic flow pattern in the umbilical artery in these pregnancies has a direct impact on fetal growth, longitudinal umbilical artery Doppler monitoring is essential for risk stratification.

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Section: Discussionmentioning

confidence: 95%

Growth patterns of monochorionic twin pregnancy complicated by Type‐III selective fetal growth restriction

Shinar

Xing

Lewi

et al. 2022

Ultrasound in Obstet & Gyne

View full text Add to dashboard Cite

show abstract

“…In addition, given that twin fetuses are screened with serial ultrasound growth scans, [53][54][55][56][57] it is likely that twin fetuses that are truly growth restricted will be detected by serial ultrasound exams irrespective of which chart is used. Finally, measures such as umbilical and fetal Doppler and intertwin size discordance 53,55,[58][59][60] are likely to further contribute to the detection of growth restricted twin fetuses irrespective of which chart is being used. 61 Still, it should be kept in mind that most of the available data described above are observational in nature, and are further limited by the fact that twin fetuses are usually being followed more closely than singletons and are delivered by 37-38 weeks of gestation.…”

Section: Discussionmentioning

confidence: 99%

Fetal Growth in Twin Pregnancies and the Choice of Growth Chart

Melamed

Hiersch

2022

Maternal Fetal Med

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BackgroundTwin gestations are associated with an increased risk of pregnancy complications such as preterm birth, hypertensive disorders of pregnancy (HDP), and fetal growth restriction (FGR). [1][2][3][4][5] Twin pregnancies are characterized by a slower fetal growth compared to singletons during the third trimester. The mechanisms underlying this phenomenon and whether it represents a pathological FGR or a harmless physiologic adaptation are currently unclear. 6 One important implication of these questions relates to the growth charts that should be used by care providers to monitor growth of twins. If the slower growth represents a pathology, then singleton growth charts should be used to identify the small twin fetus which may be at an increased risk of mortality and morbidity. If, however, the slower growth of twins reflects a benign adaptation, then twin-based charts may be preferable to avoid overdiagnosis of FGR in twin gestations. 7,8 Differences in fetal growth between twin and singleton fetuses A large number of studies have compared the growth of twin fetuses with that of singletons. 9-31 The 50 th centile curves of some of these charts are compared in Figure 1 along with a representative singleton chart as a reference. Twin fetuses demonstrate reduced growth rate starting at approximately 26-28 weeks based on either birthweight-based on ultrasound-based charts (Fig. 1). Because of these differences, the use of singleton charts in twin pregnancies may result in a relatively large proportion of twin fetuses suspected to be growth restricted due to either 'falling off the curve' or being small for gestational age (SGA, defined as weight <10 th centile for gestational age). 7,12,17,31 The slower growth of twin fetuses -pathology or physiology?The most intuitive explanation for the slower growth of twins is the failure of the uteroplacental unit to meet the nutritional demands of two fetuses. [32][33][34][35] However, some have argued against this explanation based on the observation that twins experience slower growth already early in the third trimester, at a time where nutrient supply by the placenta is unlikely to be a limiting factor. 30,36,37 In addition, placentas of SGA twins are less likely to demonstrate histopathological evidence of placental insufficiency compared with SGA singletons. [38][39][40] Others suggested that the slower growth of twins is the result of the physical constraint imposed by the uterine size, 32,33 or due to placental crowding. 33 However, more recent evidence suggests that the slower growth of twins is a physiologic phenomenon that is the result of fetal programming early in pregnancy 41,42 through hormonal 43,44 and epigenetic mechanisms. [45][46][47] This hypothesis is supported by evidence that twins may downregulate their growth rate early in gestation, 36,48 as well as by studies on fetal reduction. 34,49

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“…22,125 However, it should be emphasized that the pattern of growth discordance, which includes the timing of onset and the rate of progression of discordance, is of prognostic significance and is predictive of adverse outcomes, even when the discordance is of a small magnitude (>10%). 126 In a recent study, we identified several distinct discordance growth patterns among twins that demonstrate a doseresponse relationship with adverse outcomes and are more informative than a single measurement of size discordance. 126 We found that early-onset (<24 weeks) progressive discordance had the strongest association with adverse pregnancy outcomes including PTB, preeclampsia, birthweight discordance, and birthweight <10th centile.…”

Section: Screening and Diagnosis Of Fetal Growth Abnormalitiesmentioning

confidence: 99%

“…126 In a recent study, we identified several distinct discordance growth patterns among twins that demonstrate a doseresponse relationship with adverse outcomes and are more informative than a single measurement of size discordance. 126 We found that early-onset (<24 weeks) progressive discordance had the strongest association with adverse pregnancy outcomes including PTB, preeclampsia, birthweight discordance, and birthweight <10th centile.…”

Section: Screening and Diagnosis Of Fetal Growth Abnormalitiesmentioning

confidence: 99%