Value of cerebroplacental ratio in predicting adverse perinatal outcome in uncomplicated twin pregnancies: a retrospective study

Abstract

Purpose

To evaluate the performance of the cerebroplacental ratio (CPR) in predicting operative delivery for intrapartum fetal compromise (OD for IFC) and adverse perinatal outcomes in uncomplicated twin pregnancies with attempted vaginal delivery.

Materials and Methods

This was a retrospective cohort study of 72 twin pregnancies in a single tertiary referral center between January 2018 and August 2024. All MCDA and DCDA twin pregnancies with an attempted vaginal delivery after 34+0 weeks were screened for eligibility and those without further risk factors were included in the study. Outcome parameters were OD for IFC and a composite of adverse perinatal outcomes (CAPO) including OD for IFC, 5-minute Apgar score <7, umbilical artery pH <7.10, or admission to the neonatal intensive care unit (NICU). The predictive performance of CPR was evaluated using ROC analyses and multivariable logistic regression.

Results

16 MCDA and 56 DCDA pregnancies met the inclusion criteria. CAPO of at least one of the twins occurred in 27 (37.5%) of the cases. ROC analyses showed that low CPR MoM of neither the presenting twin nor the second twin predicted CAPO. Similarly, the prediction of the need for OD for IFC of twin 2 was not possible using low CPR MoM as the predicting variable. However, logistic regression analyses showed that nulliparity and twin-to-twin delivery time interval were independently associated with CAPO.

Conclusion

Low CPR MoM was not predictive for CAPO or OD for IFC in uncomplicated twin pregnancies after 34 weeks of gestation. However, nulliparity and twin-to-twin delivery time interval were independently associated with CAPO.

Zusammenfassung

Ziel

Untersuchung der Assoziation zwischen der zerebroplazentaren Ratio (CPR) und der Notwendigkeit einer operativen Entbindung aufgrund eines intrapartalen fetalen Distress (OE wegen IFD) sowie schlechtem perinatalen Outcome in unkomplizierten Zwillingsschwangerschaften mit vaginalem Entbindungsversuch.

Material und Methode

Retrospektive Kohortenstudie von 72 Zwillingsschwangerschaften in einem Zentrum der Maximalversorgung zwischen Januar 2018 und August 2024. Es wurden MCDA- und DCDA-Schwangerschaften mit vaginalem Entbindungsversuch nach 34+0 SSW ohne weitere Risikofaktoren eingeschlossen. Outcome-Parameter waren OE wegen IFD oder das Vorliegen mindestens eines der folgenden Parameter (CAPO): OE wegen IFD, 5-Minuten-Apgar <7, Nabelarterien-pH <7,10 oder Aufnahme auf die Neugeborenen-Intensivstation. Die Vorhersagekraft der CPR wurde mittels ROC-Analyse bzw. multivariabler logistischer Regression untersucht.

Ergebnisse

16 MCDA- und 56 DCDA-Schwangerschaften wurden eingeschlossen. CAPO bei mindestens einem der Zwillinge trat in 27 Fällen (37,5%) auf. ROC-Analysen ergaben, dass weder ein niedrige CPR-MoM des führenden noch des zweiten Zwillings für CAPO prädiktiv war. Es zeigte sich ebenfalls keine Assoziation zwischen dem CPR-MoM mit der Notwendigkeit einer OE wegen IFD des zweiten Zwillings. In der logistischen Regression waren Nulliparität und das „Twin-to-twin Delivery Interval unabhängig mit dem Auftreten von CAPO assoziiert.

Schlussfolgerungen

Ein niedriges CPR-MoM war weder für CAPO noch für die Notwendigkeit einer OE wegen IFD prädiktiv. Jedoch waren Nulliparität und ein verlängertes „Twin-to-twin Delivery Interval“ mit dem Auftreten von CAPO assoziiert.

Keywords

Obstetrics - Cerebroplacental Ratio - Twin pregnancy - Adverse outcome - Operative delivery

• References

• 1 DeVore GR. The importance of the cerebroplacental ratio in the evaluation of fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol 2015; 213: 5-15
• 2 Akolekar R, Ciobanu A, Zingler E. et al. Routine assessment of cerebroplacental ratio at 35–37 weeks’ gestation in the prediction of adverse perinatal outcome. Am J Obstet Gynecol 2019; 221: 65 e61-65 e18
• 3 Conde-Agudelo A, Villar J, Kennedy SH. et al. Predictive accuracy of cerebroplacental ratio for adverse perinatal and neurodevelopmental outcomes in suspected fetal growth restriction: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 52: 430-441
• 4 Novillo-Del Álamo B, Martínez-Varea A, Satorres-Pérez E. et al. Cerebroplacental Ratio as a Predictive Factor of Emergency Cesarean Sections for Intrapartum Fetal Compromise: A Systematic Review. Journal of Clinical Medicine 2024; 13
• 5 Dall’Asta A, Ghi T, Rizzo G. et al. Cerebroplacental ratio assessment in early labor in uncomplicated term pregnancy and prediction of adverse perinatal outcome: prospective multicenter study. Ultrasound Obstet Gynecol 2019; 53: 481-487
• 6 Vollgraff Heidweiller-Schreurs CA, van Osch IR, Heymans MW. et al. Cerebroplacental ratio in predicting adverse perinatal outcome: a meta-analysis of individual participant data. BJOG 2021; 128: 226-235
• 7 Rial-Crestelo M, Lubusky M, Parra-Cordero M. et al. Term planned delivery based on fetal growth assessment with or without the cerebroplacental ratio in low-risk pregnancies (RATIO37): an international, multicentre, open-label, randomised controlled trial. Lancet 2024; 403: 545-553
• 8 Townsend R, Khalil A. Fetal growth restriction in twins. Best Pract Res Clin Obstet Gynaecol 2018; 49: 79-88
• 9 Chauhan SP, Scardo JA, Hayes E. et al. Twins: prevalence, problems, and preterm births. Am J Obstet Gynecol 2010; 203: 305-315
• 10 Cheong-See F, Schuit E, Arroyo-Manzano D. et al. Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis. BMJ 2016; 354: i4353
• 11 von Kaisenberg C, Klaritsch P, Ochsenbein-Kolble N. et al. Screening, Management and Delivery in Twin Pregnancy. Ultraschall in Med 2021; 42: 367-378
• 12 Weitzner O, Barrett J, Murphy KE. et al. National and international guidelines on the management of twin pregnancies: a comparative review. Am J Obstet Gynecol 2023; 229: 577-598
• 13 von Kaisenberg C, Klaritsch P, Ochsenbein-Kölble N. et al. AWMF LL 015–087 S24 Überwachung und Betreuung von Zwillingsschwangerschaften. 2019
• 14 Khalil A, Rodgers M, Baschat A. et al. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247-263
• 15 Bhide A, Acharya G, Baschat A. et al. ISUOG Practice Guidelines (updated): use of Doppler velocimetry in obstetrics. Ultrasound Obstet Gynecol 2021; 58: 331-339
• 16 Faber R, Heling KS, Steiner H. et al. Doppler ultrasound in pregnancy – quality requirements of DEGUM and clinical application (part 2). Ultraschall in Med 2021; 42: 541-550
• 17 Ayres-de-Campos D, Spong CY, Chandraharan E. et al. FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography. Int J Gynaecol Obstet 2015; 131: 13-24
• 18 Hadlock FP, Harrist RB, Carpenter RJ. et al. Sonographic estimation of fetal weight. The value of femur length in addition to head and abdomen measurements. Radiology 1984; 150: 535-540
• 19 Baschat AA, Gembruch U. The cerebroplacental Doppler ratio revisited. Ultrasound Obstet Gynecol 2003; 21: 124-127
• 20 Ciobanu A, Wright A, Syngelaki A. et al. Fetal Medicine Foundation reference ranges for umbilical artery and middle cerebral artery pulsatility index and cerebroplacental ratio. Ultrasound Obstet Gynecol 2019; 53: 465-472
• 21 Turner JM, Mitchell MD, Kumar SS. The physiology of intrapartum fetal compromise at term. Am J Obstet Gynecol 2020; 222: 17-26
• 22 Schiermeier S, von Kaisenberg CS, Kehl S. et al. Fetal Assessment in Pregnancy (Indication and Methodology for Fetal Monitoring in a Low-risk Population). Guideline of the DGGG, DEGUM, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/089, February 2023). Geburtshilfe Frauenheilkd 2023; 83: 996-1016
• 23 Mulcahy C, McAuliffe FM, Breathnach F. et al. Umbilical and fetal middle cerebral artery Doppler reference ranges in a twin population followed longitudinally from 24 to 38 weeks' gestation. Ultrasound Obstet Gynecol 2014; 44: 461-467
• 24 Gaziano EP, Gaziano C, Terrell CA. et al. The cerebroplacental Doppler ratio and neonatal outcome in diamnionic monochorionic and dichorionic twins. J Matern Fetal Med 2001; 10: 371-375
• 25 Mok T, Afshar Y, Platt LD. et al. Predicting Adverse Outcomes in Monochorionic-Diamniotic Twins: The Role of Intertwin Discrepancy in Middle Cerebral Artery Doppler Measurements and the Cerebroplacental Ratio. Am J Perinatol 2021; 38: 1348-1357
• 26 Di Mascio D, Khalil A, D’Amico A. et al. Outcome of twin-twin transfusion syndrome according to Quintero stage of disease: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2020; 56: 811-820
• 27 Rossi AC, Mullin PM, Chmait RH. Neonatal outcomes of twins according to birth order, presentation and mode of delivery: a systematic review and meta-analysis. BJOG 2011; 118: 523-532
• 28 Cukierman R, Heland S, Palmer K. et al. Inter-twin delivery interval, short-term perinatal outcomes and risk of caesarean for the second twin. Aust N Z J Obstet Gynaecol 2019; 59: 375-379
• 29 Stein W, Misselwitz B, Schmidt S. Twin-to-twin delivery time interval: influencing factors and effect on short-term outcome of the second twin. Acta Obstet Gynecol Scand 2008; 87: 346-353
• 30 Lindroos L, Elfvin A, Ladfors L. et al. The effect of twin-to-twin delivery time intervals on neonatal outcome for second twins. BMC Pregnancy Childbirth 2018; 18: 36
• 31 Barrett JF, Hannah ME, Hutton EK. et al. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med 2013; 369: 1295-1305