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Am J Perinatol 2021; 38(13): 1348-1357
DOI: 10.1055/s-0041-1732456
SMFM Fellowship Series Article

Predicting Adverse Outcomes in Monochorionic-Diamniotic Twins: The Role of Intertwin Discrepancy in Middle Cerebral Artery Doppler Measurements and the Cerebroplacental Ratio

Thalia Mok 
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
,
Yalda Afshar
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
,
Lawrence D. Platt
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
2   Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
,
Rong Guo
3   Department of Medicine Statistics Core, David Geffen School of Medicine, Los Angeles, California
,
Rashmi R. Rao
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
,
Ilina D. Pluym
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
,
Neil S. Silverman
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
2   Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
,
Christina S. Han
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
2   Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
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Abstract

Objective This study was aimed to evaluate the role of intertwin discrepancy in middle cerebral artery peak systolic velocity (MCA-PSV) and cerebroplacental ratio (CPR) for the prediction of adverse outcomes in monochorionic-diamniotic (MCDA) twin pregnancies.

Study Design A retrospective cohort study of MCDA pregnancies that underwent ultrasound surveillance at a perinatal referral center from 2007 to 2017. Intertwin MCA-PSV discrepancy (MCA-ΔPSV-MoM) was defined as the absolute difference of MCA-PSV multiple of the median (MoM) for gestational age between twins. Intertwin CPR discrepancy (CPR-Δ) was defined as the absolute difference of CPR between twins. The maximum MCA-ΔPSV-MoM and CPR-Δ before and after 26 weeks of gestation were assessed as predictors of pregnancy and neonatal outcomes through simple logistic regression models and Pearson's correlation coefficients. Receiver operating characteristic (ROC) curves were generated to determine the predictive value of maximum MCA-ΔPSV-MoM and CPR-Δ.

Results A total of 143 MCDA pregnancies met inclusion criteria. There was a significant association between MCA-ΔPSV-MoM at <26 weeks and the development of twin anemia-polycythemia sequence (TAPS; p = 0.007), intrauterine fetal demise (IUFD; p = 0.009), and neonatal intensive care unit (NICU) admission (p < 0.05). MCA-ΔPSV-MoM at ≥26 weeks was associated with the development of TAPS (p < 0.001). CPR-Δ at <26 weeks was associated with the development of twin-twin transfusion syndrome (TTTS; p = 0.03) and NICU admission (p = 0.02). MCA-ΔPSV-MoM at ≥26 weeks was highly predictive of TAPS (area under curve [AUC] = 0.92). A cut-off of 0.44 would identify TAPS with 100% sensitivity and 73% specificity.

Conclusion In MCDA pregnancies, intertwin MCA and CPR discrepancies are associated with adverse pregnancy and neonatal outcomes, including TAPS, TTTS, IUFD, and NICU admission. Evaluation of intertwin MCA and CPR differences demonstrated the potential for clinical predictive utility in the surveillance of MCDA twin pregnancies.

Key Points

  • Intertwin discrepancy of MCA-PSV and CPR is associated with adverse pregnancy outcomes.

  • Intertwin differences in Doppler ultrasound may occur prior to meeting diagnostic criteria for TTTS or TAPS.

  • There is potential clinical predictive utility in MCA and CPR surveillance of MCDA twin pregnancies.

Keywords

intertwin discrepancy - monochorionic-diamniotic twins - middle cerebral artery - cerebroplacental ratio - Doppler

Note

This work was previously presented as a poster presentation at the 28th World Congress on Ultrasound in Obstetrics and Gynecology, October 20–24, 2018, Singapore.




Publication History

Received: 16 November 2020

Accepted: 17 June 2021

Article published online:
19 July 2021

© 2021. Thieme. All rights reserved.

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