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JOURNAL ARTICLE

Outcome of twin pregnancies with two live fetuses at 11-13 weeks' gestation

Ewelina Litwinska, Argyro Syngelaki, Brindusa Cimpoca, Laurence Frei, Kypros H Nicolaides
Ultrasound in Obstetrics & Gynecology 2019 October 15
31613412

OBJECTIVES: To report and compare pregnancy outcome in dichorionic (DC), monochorionic-diamniotic (MCDA) and monochorionic-monoamniotic (MCMA) twins with two live fetuses at 11-13 weeks' gestation and examine the impact of endoscopic laser surgery for severe twin-to-twin transfusion syndrome (TTTS) and selective fetal growth restriction (sFGR) on the outcome of MCDA twins.

METHODS: This was a retrospective analysis of prospectively collected data on twin pregnancies undergoing routine ultrasound examination at 11-13 weeks' gestation between 2002 and 2019. In pregnancies with no major abnormalities we compared overall survival, fetal loss at <24 weeks' gestation, perinatal death at ≥24 weeks, delivery at <37 and <32 weeks, and birth weight <5th percentile between DC, MCDA and MCMA twins.

RESULTS: The study population of 6,225 twin pregnancies with two live fetuses at 11-13 weeks' gestation with no major abnormalities, included 4,896 (78.7%) DC, 1,274 (20.4%) MCDA and 55 (0.9%) MCMA twins. In DC twins, the rate of loss of all fetuses at <24 weeks' gestation was 2.3%; this rate was higher in MCDA twins (7.7%, RR 3.258, 95% CI 2.706-3.923) and more so in MCMA twins (21.8%, RR 9.289, 95% CI 6.377-13.530). In DC twins, the rate of perinatal death at ≥24 weeks of all babies that were alive at 24 weeks was 1.0%; this rate was higher in MCDA twins (2.5%, RR 2.456, 95% CI 1.779 - 3.389) and more so in MCMA twins (9.3%, RR 9.130, 95% CI 4.584-18.184). In DC twins, the rate of preterm birth at <37 weeks' gestation in pregnancies with at least one livebirth was 48.6%; this rate was higher in MCDA twins (88.5%, RR 1.824, 95% CI 1.760-1.890) and more so in MCMA twins (100%, RR 2.060, 95% CI 2.000-2.121). In DC twins, the rate of preterm birth at <32 weeks was 7.4%; this rate was higher in MCDA twins (14.2%, RR 1.920, 95% CI 1.616-2.281) and more so in MCMA twins (26.8%, RR 3.637, 95% CI 2.172-6.089). In DC twin pregnancies with at least one livebirth, the rate of small for gestational age neonates among all livebirths was 31.2% and in MCDA twins this rate was higher (37.8%, RR 1.209, 95% CI 1.138-1.284); in MCMA twins the rate was not significantly different (33.3%, RR 1.067, 95% CI 0.783 to 1.455). Kaplan-Meier analysis showed a significant difference in survival between MCDA and MCMA twins, compared to DC twins, for both the interval of 12 to <24 weeks' gestation (log-rank test, P<0.0001 for both) and that of ≥24 to 38 weeks (log-rank test, P<0.0001 for both). Endoscopic laser ablation of inter-twin communicating placental vessels was carried out in 127 (10.0%) MCDA twin pregnancies for TTTS and / or sFGR and in 111 of these surgery was at <24 weeks; both babies survived in 62 (55.9%) cases, one baby survived in 25 (22.5%) cases and there were no survivors in 24 (21.6%) cases. In the extreme assumption that had laser surgery not been carried out in these cases all babies would have died, the total fetal loss rate at <24 weeks' gestation in MCDA twins would have been 13.5%.

CONCLUSIONS: The rates of fetal loss <24 weeks' gestation, perinatal death at ≥24 weeks and preterm birth are higher in MCDA and more so in MCMA twins than in DC twins. In MCDA twins the rate of fetal loss may have been reduced by endoscopic laser surgery in those that developed early TTTS and / or sFGR. These data would be useful in counselling parents as to the likely outcome of their pregnancy and in defining strategies for surveillance and interventions in the management of the different types of twin pregnancies. This article is protected by copyright. All rights reserved.

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