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Objective:To explore the perinatal characteristics and early postnatal circulatory function of the larger fetus in monochorionic diamniotic twin pregnancy complicated with selective intrauterine growth restriction (sIUGR).Methods:From February 2018 to August 2022, a total of 91 larger fetuses of the sIUGR pregnancies who were hospitalized in the neonatal intensive care unit of Peking University Third Hospital were retrospectively included. The perinatal factors, clinical monitoring indicators, and echocardiographic data of the larger twins in pregnancies with three types of sIUGR were compared using one-way analysis of variance and LSD test, Kruskal-Wallis H test, Chi-square test, and Bonferroni correction. Results:The gestational age, birth weight, and placental weight were (30.6±1.5) weeks, (1 503.9±286.4) g, and (548±120) g in the type Ⅱ sIUGR larger twins and were (30.5±2.3) weeks, (1 523.5±424.4) g, and (560±109) g in type Ⅲ, which were all smaller, lower, and lighter than those in the type Ⅰ[(33.0±1.7) weeks, (2 022.1±372.3) g, and (630±131) g, respectively] (LSD test, all P<0.05). Compared with type Ⅰ sIUGR larger twins, type Ⅱ and Ⅲ sIUGR larger twins had longer hospital stay [36.0 d (27.0-43.0 d) and 32.0 d (15.0-47.0 d) vs. 17.0 d (9.5-22.0 d)], higher proportion of preterm births due to fetal distress [63.6% (21/33) and 75.0% (15/20) vs. 31.6% (12/38), χ2=7.30 and 9.93] (Bonferroni correction, all P<0.017); Compared with type Ⅰ sIUGR larger twins, type Ⅱ sIUGR larger twins had higher proportion of postnatal use of vasoactive drugs [45.5% (15/33) vs. 18.4% (7/38), χ2=6.04, P=0.014]. The interventricular septum thickness was larger in the type Ⅲ sIUGR larger twins than those in the type Ⅰ and Ⅱ twins [(4.4±1.4) vs. (3.8±0.9) and (3.3±0.9) mm]; the thickness of left ventricular free wall was the largest in the type Ⅲ larger twins, followed by those in the type Ⅰ and type Ⅱ [(4.6±1.3) vs. (3.1±0.7) vs. (2.7±0.6) mm]; the left ventricular end-diastolic diameter, right ventricular outflow tract diameter, right ventricular anteroposterior diameter, and pulmonary artery diameter in type Ⅰ larger twins were increased comparing with those in type Ⅱ and Ⅲ [left ventricular end-diastolic diameter: (15.0±2.1) vs. (13.4±2.3) and (12.3±3.2) mm; right ventricular outflow tract diameter: (8.7±1.4) vs. (7.3±1.4) and (7.1±0.8) mm; right ventricular anteroposterior diameter: (7.1±1.5) vs. (6.5±0.9) and (6.4±1.0) mm; pulmonary artery diameter: (6.8±1.1) vs. (6.3±0.9) and (6.3±0.8) mm] (LSD test, all P<0.05). Conclusion:The larger fetuses of type Ⅱ and Ⅲ sIUGR pregnancies had smaller gestational age and lighter birth weight who are more prone to have fetal distress, so it is necessary to strengthen dynamic monitoring and circulatory support for such neonates during the perinatal period and early postnatal period. The thickening of the left ventricular wall and interventricular septum in the early postnatal period of type Ⅲ larger fetuses may lead to the decrease of ventricular diastolic function reserve, thereby the evaluation and monitoring of the myocardial diastolic function of these neonates in the early postnatal period are critical.
ABSTRACT
Objective @#To delineate the similarities and differences among general characteristics and maternal⁃fetal outcomes in patients with selective intrauterine growth restriction( sIUGR) in monochorionic and dichorionic twin , and to compare the disparate patient types with dichorionic twin sIUGR , with an intent to furnish vital insights for clinical diagnosis and prognostic assessment. @*Methods @#Clinical data were collected from 89 patients with twin pregnancies diagnosed with sIUGR. Statistical analyses used the t ⁃test , rank⁃sum test , and chi⁃square test.@*Results@#Pregnant women with dichorionic twins often leverage multiple assisted reproductive technologies. The maternal outcome for dichorionic twins were significantly later than that for monochorionic twins. Furthermore , the incidence of gestational diabetes mellitus was higher in dichorionic twins compared to monochorionic twins. In terms of fetal outcomes , the proportion of normal neonates with Apgar scores ≥8 , body mass , and the incidence of type I sIUGR in dichorionic twin pregnancieswere significantly higher than those in monochorionic twin pregnancies. Conversely , occurrences of umbilical cord sail attachment and a smaller placental share were significantly higher in monochorionic twins. In assessing variations in sIUGR typologies among dichorionic twins , one case of intrauterine death was happened in a pregnancy with type Ⅱ/ Ⅲ sIUGR typology , but none in type I. Pregnancies with type I sIUGR typology had a significantly higher proportion of large and small fetuses with Apgar scores ≥8 and better birth quality of smaller fetuses. @*Conclusions @#Compared to monochorionic twin pregnancies , there are superior maternal and fetal prognosis for dichorionic twin pregnancies with sIUGR . Clinical management should , therefore , prioritize greater attention to monochorionic twin pregnancies. In addition , this study discovers more complex outcomes in type Ⅱ/ Ⅲ pregnancies among dichorionic twins , a subject area currently lacking sufficient domestic research , thereby underlining the need for meticulous monitoring and prompt intervention.
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We present four cases of monochorionic twin pregnancies with diagnosis of type III selective intrauterine growth restriction, highlighting the ultrasonographic characteristics (evaluation of the umbilical artery intermittent reverse diastole and the superficial arterio-arterial anastomosis), its evolution during pregnancy and its follow-up during the first month of life.
Se presenta cuatro casos de gestaciones dobles monocoriales afectadas con restricción selectiva de crecimiento de tipo III, con énfasis en las características ecográficas (evaluación de la diástole intermitente reversa de la arteria umbilical y la anastomosis superficial arterio-arterial), evolución durante la gestación y seguimiento hasta el mes de vida.
ABSTRACT
Objective To explore the clinical characteristics of monochorionic or dichorionic twin pregnancy and the high-risk factors for selective intrauterine growth restriction.Methods 460 women with twin pregnancy were divided into a monochorionic group and a dichorion group.The related clinical features were compared between the two groups.Logistic regression was used to analyze the high-risk factors for selective intrauterine growth restriction.Results The maternal age,conception way,and mode of delivery differed significantly between the two groups (P ＜ 0.05).There were significant differences in the rates of selective intrauterine growth restriction and preterm premature rupture of membranes (P ＜ 0.05).The neonatal weight (large or small) and the rate of neonatal transfer differed significantly (P ＜ 0.05).Logistic regression showed that gestational age and birth weight were the risk factors.Conclusions The chorionic nature plays an important role in the process and outcomes of maternal pregnancy.Monochorionic pregnancy is a high risk factor for selective intrauterine growth restriction,meaning the major cause of selective intrauterine growth restriction may originate from the placenta,with should be a placenta-derived disease.
ABSTRACT
La Restricción Selectiva del Crecimiento Intrauterino se produce en 10 a 19% de los gemelos monocoriónicos, y se asocia con un aumento importante de la mortalidad y la morbilidad perinatal. La evolución clínica está dada en gran parte por la presencia de anastomosis vaculares y la distribución placentaria asimétrica. Se propuso una clasificación en tres tipos según el Doppler de la arteria umbilical del gemelo más pequeño, la que sé que se correlaciona con distintos comportamientos clínicos y características de la placenta, lo que ayuda en el asesoramiento y conducta obstétrica. Los del tipo I tienen un pronóstico favorable por el resultado perinatal satisfactorio por lo que se recomienda un seguimiento cercano por ecografía y Doppler. Los de tipo II tienen un mal pronóstico y el tipo III un pronóstico intermedio e impredecible. En estos dos últimos se puede realizar un manejo expectante hasta que se observe deterioro del feto pequeño, considerando la posibilidad de la coagulación con láser o la oclusión del cordón (feticidio selectivo). Ambas conductas aparentemente aumentan las posibilidades de supervivencia del feto de peso normal.
Selective intrauterine growth restriction occurs in 10-19% of monochorionic twins, and is associated with increased mortality important and perinatal morbidity. The clinical course is given largely by the presence of placental vascular anastomosis and asymmetric distribution. It classified into three types according to the proposed Doppler umbilical artery smaller twin, the one that correlates with different clinical behaviors and characteristics of the placenta, which helps in counseling and obstetric conduct. The type I have a favorable prognosis for satisfactory perinatal outcome so closely monitored by ultrasound and Doppler is recommended. The type II has a poor prognosis and type III intermediate and unpredictable prognosis. In these last two you can make an expectant management until deterioration of the small fetus is observed, considering laser coagulation or cord occlusion (selective feticide). Both behaviors appear to increase the chances of survival of the fetus of normal weight.
Subject(s)
Humans , Female , Pregnancy , Fetal Growth Retardation/diagnosis , Fetal Growth Retardation/therapy , Pregnancy, Twin , Arteriovenous Anastomosis , Twins, Monozygotic/classification , Umbilicus/blood supply , Follow-Up Studies , Ultrasonography, Doppler, Pulsed , Fetal Growth Retardation/physiopathologyABSTRACT
La restricción de crecimiento intrauterino selectivo es una complicación de la gestación monocorial poco frecuente, caracterizada por el déficit de crecimiento de uno de los fetos, fenómeno que se explica principalmente por la distribución asimétrica del territorio placentario. La influencia de las anastomosis vasculares determina el tipo de evolución de cada caso. El estudio Doppler de la arteria umbilical del feto con restricción es la mejor maneja de valorar el comportamiento clínico y la posible evolución, con la finalidad de minimizar el riesgo de muerte intraútero y el daño cerebral que podrían sufrir ambos fetos.
Selective intrauterine growth restriction is arare complication of monochorionic gestation characterized by growth deficiency of one fetus, phenomenon due to asymmetric distribution of the placental territory; the influence of the vascular anastomosis determines the type of evolution in each case. Umbilical artery Doppler study ofthe restricted fetus determines the clinical status and possible outcome in order to minimize risk of intrauterine death and brain da mage in both fetuses.
ABSTRACT
Objective To evaluate the fetal cardiovascular function in selective intrauterine growth restriction (sIUGR)in monochorionic diamniotic(MCDA)twins by using 2D and color Doppler ultrasonography. Methods Twenty - four sIUGR pregnancies and 20 normal MCDA twins pregnancies were enrolled at the First Affiliated Hospital of Sun Yat - Sen University from December 2013 to September 2014,and cardiac structure of fetus and Doppler patterns of the umbilical artery(UA),umbilical vein(UV),pulsatility index of ductus venosus(DV - PI),atrioventricular valve, semilunar valve,tricuspid annulus systolic displacement(TAPSE),fractional shortening of left ventricle short axis(FS) and myocardial performance index(Tei index)of both ventricles were assessed. Results Cardiothoracic ratio,heart rate,DV - PI,FS,TAPSE,Tei index of the left ventricle(0. 34 ± 0. 03,0. 34 ± 0. 04),Tei index of the right ventricle (0. 35 ± 0. 03,0. 35 ± 0. 03)were not significantly different compared with those of the normal MCDA twins(all P ﹥0. 05). Cardiothoracic ratio,ventricular wall thickness,isovolumetric relaxation time( IRT),isovolumetric contraction time(ICT),TAPSE and tricuspid regurgitation(TR)in the larger twins of sIUGR were significantly bigger than those in the smaller twins of sIUGR(all P ﹤ 0. 05),Tei index of both ventricles in the larger twin of sIUGR was significantly higher than that in the smaller twins of sIUGR(Tei index of left ventricle:0. 43 ± 0. 06 vs 0. 35 ± 0. 04,Tei index of right ventricle:0. 43 ± 0. 06 vs 0. 34 ± 0. 04,P ﹤ 0. 05),the peak E in early diastolic / the peak A in atrial contraction (E/ A),the percentage of inflow during of cardiac cycle length(inflow/ CCL)in larger twin of sIUGR were significantly lower than those in smaller twin of sIUGR(all P ﹤ 0. 05). Conclusions There was no difference of cardiac function in normal MCDA twins,at the beginning of the diagnosis of sIUGR,cardiac dysfunction were found in larger twin,follow -up examination are helpful to clinical decision.
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PURPOSE: The purpose of this study was to assess the natural history and perinatal outcomes of twin gestations according to chorionicity. METHODS: We retrospectively reviewed the medical records of 99 monochorionic (MC) and 206 dichorionic (DC) twin gestations delivered at Il Sin Christian Hospital in Busan between January 2002 and December 2007. The incidences of twin-to-twin transfusion syndrome (TTS) and selective intrauterine growth restriction (sIUGR), as well as perinatal morbidity and mortality, were evaluated. RESULTS: MC twins had a lower gestational age (35.7 vs. 36.6 weeks, P=0.03) at birth and a higher incidence of intrauterine fetal loss (10% vs. 1.5%, P<0.001) than DC twins. The incidence of intrauterine fetal loss was higher in MC sIUGR than in DC sIUGR (19% vs. 2.5%, P=0.025) twins. The number of admissions to the neonatal intensive care unit (NICU; 31% vs. 16%, P=0.042), and the incidence of periventricular leukomalacia (7% vs. 0%, P=0.031), and respiratory distress syndrome with surfactant treatment (27% vs. 11%, P=0.049) were higher in MC than DC twins. The incidences of sIUGR and TTS were 21 and 9% among the MC twins. The incidences of intrauterine fetal loss were higher in MC twins with TTS [6 of 9 (67%)] or sIUGR [4 of 21 (19%)] than uncomplicated MC twins (P<0.001). The frequency of admission to the NICU (P=0.001), the length of hospital stay (P=0.033), the prevalence of periventricular leukomalacia (P=0.011), and intraventricular hemorrhage (P=0.007) were also higher in MC with TTS or sIUGR than in uncomplicated MC twins. CONCLUSION: The incidence of neonatal complications was higher in MC twins, especially those gestations complicated by TTS or sIUGR.