Perinatal Outcome of Monochorionic Twins with Selective Intrauterine Growth Restriction and Different Types of Umbilical Artery Doppler under Expectant Management

Abstract

Objectives: To evaluate the prognosis of monochorionic twins with selective intrauterine growth restriction (sIUGR), classified according to the type of umbilical artery Doppler, under expectant management. Methods: The outcome of 81 cases with isolated sIUGR was evaluated according to a classification based on umbilical artery (UA) Doppler diastolic flow in the IUGR twin (I: present, II: constantly absent/reverse, III: intermittently absent/reverse). Selective feticide was not considered due to legal constraints. Perinatal outcomes included perinatal death and neurological outcome at 6 months of age. Results: From 81 cases with the diagnosis of sIUGR, twin-twin transfusion was diagnosed in 18 cases. This left 63 cases, of which 23 were classified as type I (36.5%), 27 as type II (42.9%) and 13 as type III (20.6%). Intrauterine death occurred in 4.3% (1), 29.6% (8) and 15.4% (2) among IUGR twins, and 4.3% (1), 22.2% (6) and 0.0% (0) among larger twins. Neonatal death occurred in 0.0% (0), 18.5% (5) and 0.0% (0) among IUGR twins, and 0.0% (0), 11.1% (3) and 23.0% (3) among larger twins. Neurological abnormalities at 6 months were found in 4.3% (1), 14.8% (4) and 23.1% (3) in smaller twins and 0.0% (0), 11.1% (3) and 38.5% (5) in larger twins, respectively. Intact survival at 6 months was recorded in 91% (21), 37% (10) and 61% (8) in smaller twins and 95% (22), 55% (15) and 38% (5) in larger twins, respectively. Conclusion: The outcome in monochorionic twins with sIUGR and abnormal umbilical artery Doppler is poor under expectant management. Normal Doppler seems to be associated with a good prognosis.

Application of Umbilical Artery Classification in Complicated Monochorionic Twins

“…These results are similar to those of Ishii et al (2009), who reported 29.6% IUD of smaller twin and 22.2% IUD of larger twin. This group had a high rate of deterioration (total group 67%; sIUGR group 50%), but differently from group III, this could be predicted by Doppler, allowing prenatal treatment or delivery.…”

Selective intrauterine growth restriction in monochorionic-diamniotic twins: diagnosis and management

“…Los patrones de anastomosis placentarias son similares a los MC no complicados. Si bien tienen territorios placentarios con distribución desigual, en el 70% de las gestaciones del tipo I se describe la presencia de una gran anastomosis arterio-arterial (> 2 mm) que juntamente con el alto número de anastomosis generan un buen intercambio bidireccional de flujo entre los fetos, lo que atenúa los efectos de la insuficiencia placentaria en el feto más pequeño, además del trabajo compensatorio que realiza el feto de tamaño normal permitiendo una transfusión de rescate inter-gemelar 13,45,39 Por tal motivo, tienen buen pronóstico casi similar a los MC no complicados y muy bajo riesgo de muerte fetal intrauterina del fetopequeño (2 -4%) 45,40 . En una cohorte de 39 pares de gemelos de tipo I, no reportaron daño cerebral en los gemelos sobrevivientes 45 .…”

Perinatal Mortality in Multiple Pregnancy

“…First, since these pregnancies must by definition be delivered before the death of the IUGR fetus, the normal twin is exposed to severe prematurity with its known consequences in terms of neurodevelopmental sequelae. Second, even if prematurity is avoided, there may be an increased prevalence of neurological complications in the normally grown twin due to a high risk of acute feto-fetal transfusion accidents in utero (Ishii et al, 2009). The specific risks for these two complications may vary in different types of sIUGR, as discussed later.…”