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

Thalia Mok; Yalda Afshar; Lawrence D. Platt; Rong Guo; Rashmi R. Rao; Ilina D. Pluym; Neil S. Silverman; Christina S. Han

doi:10.1055/s-0041-1732456

American Journal of Perinatology, Table of Contents

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

Authors

Thalia Mok

¹Division 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

¹Division 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

¹Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California

²Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
Rong Guo

³Department of Medicine Statistics Core, David Geffen School of Medicine, Los Angeles, California
Rashmi R. Rao

¹Division 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

¹Division 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

¹Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California

²Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
Christina S. Han

¹Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California

²Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California

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-Δ_PSV-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-Δ_PSV-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-Δ_PSV-MoM and CPR-Δ.

Results A total of 143 MCDA pregnancies met inclusion criteria. There was a significant association between MCA-Δ_PSV-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-Δ_PSV-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-Δ_PSV-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

Full Text

References

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