Prospective risk of intrauterine death of monochorionic twins: update

Simões, Teresinha; Queirós, Alexandra; Marujo, Ana Teresa; Valdoleiros, Sandra; Silva, Patrı́cia; Blickstein, Isaac

doi:10.1515/jpm-2015-0319

Cited by 7 publications

(7 citation statements)

References 17 publications

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“…There is a 5-fold increased risk of stillbirth among twin gestations. MCDA twins have a higher rate of stillbirth than do DCDA twins [108] . Monoamniotic twins have the highest rate of stillbirth, with rates quoted as high as 80%, primarily due to cord accidents due to entanglement in utero.…”

Section: Mortalitymentioning

confidence: 92%

Re-Thinking Elective Single Embryo Transfer: Increased Risk of Monochorionic Twinning - A Systematic Review

Dziadosz

Evans²

2017

Fetal Diagn Ther

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Background/Objectives: Multiple pregnancies have tripled in the United States over the past 3 decades. Attributed to increasing maternal age at delivery but more so assisted reproductive technological advances, an effort has been made to decrease twinning through elective single embryo transfer. We sought to review and evaluate risks of monochorionic twinning as a predictable consequence of increasing utilization of elective single embryo transfer on perinatal outcomes. Primary outcomes included twinning rates, fetal anomalies, growth, preterm birth, and mortality. Secondary outcomes included neurological and pulmonary disability, intrauterine growth restriction, and congenital cardiac anomalies and twin-twin transfusion syndrome. Data sources: PubMed and Embase. Results: A total of 106 studies identified by systematic search met the inclusion criteria. The trend for lower numbers of embryos transferred has inadvertently led to an increase in monochorionic twinning. This is associated with worse outcomes compared to dichorionic twinning and singleton gestations for all outcomes studied. Discussion: Of great concern for monochorionic twins is the risk profile of significant morbidity and mortality. Transfer of 2 embryos should be considered to avoid higher risks inherent to the shared placental phenomena related to monochorionic twins.

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Section: Mortalitymentioning

confidence: 92%

Re-Thinking Elective Single Embryo Transfer: Increased Risk of Monochorionic Twinning - A Systematic Review

Dziadosz

Evans²

2017

Fetal Diagn Ther

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“…One year later, a Portuguese study of 193 monochorionic, diamniotic twin pregnancies found that the prospective risk of fetal death after 32 weeks in women undergoing weekly fetal testing was much lower, at 1.2%. 29 One notable difference exists between these 2 studies. Namely, the first study did not employ weekly fetal testing, as did the second, but rather ultrasound examination every 2 weeks.…”

Section: Delivery Timing Considerations In Uncomplicated Monochorionimentioning

confidence: 99%

Fetal Surveillance and Timing of Delivery for Multiples

Unal¹

2015

Clinical Obstetrics &Amp; Gynecology

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This chapter describes the current evidence and recommendations for surveillance and delivery timing for multifetal gestations. Ultrasound surveillance should include early determination of chorionicity, anatomic survey for all twins with fetal echocardiography for monochorionic twins, and growth assessment every 4 weeks. Monochorionic twins should also undergo ultrasound surveillance for twin-twin transfusion syndrome every 2 weeks starting at 16 weeks. Weekly testing with nonstress tests or biophysical profiles is recommended at 32 weeks for monochorionic, diamniotic twins, and 34 weeks for dichorionic twins. If this surveillance is reassuring, optimal delivery timing is 36 weeks 0 days to 37 weeks 0 days for monochorionic, diamniotic twins, and 37 week 0 days to 38 weeks 0 days for dichorionic twins.

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“…The Lisbon research group repeated their seminal study related to the prospective risk of intrauterine fetal death in MC twins [7]. Despite the publication of several studies on this subject, significant differences exist in recruitment and management of these sets.…”

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confidence: 99%

Multiple gestation: more research challenges to come

Blickstein

2016

Journal of Perinatal Medicine

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Nearly 1500 papers were published in the past 5 years with the subject heading of "twin" or "multiple pregnancies". This figure undoubtedly represents the ever increasing interest in this group of high-risk pregnancies. It is very impossible to encompass the myriad issues that caught the attention of clinicians when dealing with difficult clinical cases related to twins and triplets which prompted research. This issue of the Journal of Perinatal Medicine includes 10 papers on various aspects of multiple pregnancy and birth. Three papers deal with the quarter-century-old issue of discordant birth weight [1]. In the first, Biron-Shental and her colleagues [2] evaluated the possible association between intermediate birth weight discordance (> 20% difference) and infertility treatment. As in all likelihood the two embryos were conceived by the same method of infertility treatment [intracytoplasmic sperm injection (ICSI) vs. in vitro fertilization (IVF), ovulation induction vs. IVF, fresh vs. thawed embryos, etc.], the authors unsurprisingly found similar discordant levels as well as similar outcomes. As the authors did not detail the incidence of nulliparas (but the average parity) one is unable to appreciate the influence of this important confounding variable. The second paper reviews available data on outcomes related to estimated fetal weight (EFW) and crown-rump length (CRL) discordance [3]. Whereas the former was found to be associated with adverse outcomes, the latter was not. The authors also wonder about the best cut-off of EFW difference to describe severe discordance. As EFW is a poor predictor of discordance (because of the ± situation that exists [4,5]), one should aim for a higher value (i.e. 25%-30% difference) to avoid over diagnosis. Moreover, it appears that discordance, per se, is not that important unless the smaller twin is small for gestational age (SGA) or exhibits clear growth restriction on repeated scans [i.e. selective intrauterine growth restriction (IUGR)] [6]. In fact, moderate levels of discordance have been shown to be an adaptive measure to increase gestational age.The authors rightly noted the differences between the mechanism and significance of selective IUGR in monochorionic (MC) and dichorionic (DC) twins.Three papers of this batch discuss various aspects of monochorionicity. The Lisbon research group repeated their seminal study related to the prospective risk of intrauterine fetal death in MC twins [7]. Despite the publication of several studies on this subject, significant differences exist in recruitment and management of these sets. Thus, the paper of Simoes and her colleagues [6] showed that, with doubling of the sample size over time since the last report in 2006, and with implementation of intensive prenatal surveillance, a relatively low unexpected fetal death rate after 33 weeks' gestation could be achieved. These findings evidently do not support elective preterm birth for uncomplicated MC twins proposed by several authorities. At present it appears that close surveil...

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Prospective risk of intrauterine death of monochorionic twins: update

Abstract: Intensive prenatal surveillance might decrease the unexpected fetal death rates after 33 week's gestation and our data do not support elective preterm birth for uncomplicated MCBA twins.

Cited by 7 publications

References 17 publications

Re-Thinking Elective Single Embryo Transfer: Increased Risk of Monochorionic Twinning - A Systematic Review

Re-Thinking Elective Single Embryo Transfer: Increased Risk of Monochorionic Twinning - A Systematic Review

Fetal Surveillance and Timing of Delivery for Multiples

Multiple gestation: more research challenges to come

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