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Am J Perinatol
DOI: 10.1055/a-2600-0585
Original Article

Monitoring Methods for Monoamniotic Twin Pregnancies: Multicenter Retrospective Study of 149 Cases

Norbert Winer 
1   Department of Gynecology and Obstetrics, University Hospital, Nantes, France
2   Nantes Université, CHU Nantes, INRAE, UMR 1280, PhAN, Nantes, France
,
Louise Cariou De Vergie
1   Department of Gynecology and Obstetrics, University Hospital, Nantes, France
,
Laure Maillet Dumas
1   Department of Gynecology and Obstetrics, University Hospital, Nantes, France
,
Thibault Thubert
1   Department of Gynecology and Obstetrics, University Hospital, Nantes, France
2   Nantes Université, CHU Nantes, INRAE, UMR 1280, PhAN, Nantes, France
3   Department of Neonatology, Nantes University Hospital, Nantes, France
4   Laboratoire Motricité, Interactions, Performances (MIP), UR 4334, UFR STAPS, Nantes Université, Nantes, France
,
Emilie Misbert
1   Department of Gynecology and Obstetrics, University Hospital, Nantes, France
,
Cyril Flamant
3   Department of Neonatology, Nantes University Hospital, Nantes, France
,
Vincent Dochez
1   Department of Gynecology and Obstetrics, University Hospital, Nantes, France
2   Nantes Université, CHU Nantes, INRAE, UMR 1280, PhAN, Nantes, France
3   Department of Neonatology, Nantes University Hospital, Nantes, France
4   Laboratoire Motricité, Interactions, Performances (MIP), UR 4334, UFR STAPS, Nantes Université, Nantes, France
,
Bernard Branger
1   Department of Gynecology and Obstetrics, University Hospital, Nantes, France
,
the French Monoamniotic Group› Author Affiliations
Funding None.
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Abstract

Objective

Monoamniotic twins is rare and associated with a high rate of perinatal morbidity and mortality. In addition to the common risks, more specific complications, cord entanglement in particular, worsen their prognosis. The literature about the optimal gestational age for birth and mode of delivery is still conflicting. To evaluate strategy used in France for the prenatal and intrapartum management monoamniotic twin pregnancies in France.

Study Design

This retrospective multicenter study retrieved the strategies and outcomes for 149 monoamniotic twin pregnancies from 10 university hospitals in France over an 18-year period. Two methods of managing the follow-up methods of these pregnancies with a propensity score were distinguished: follow-up in a participating maternity unit as an inpatient or outpatient. Two populations were analyzed: inpatients and outpatients were compared among all pregnancies and fetuses from 260/7 to 346/7 weeks of gestation (n = 92). All pregnancies and fetuses not born after 350/7 weeks of gestation (n = 57) were analyzed separately. The primary endpoints were intrauterine and perinatal mortality rates.

Results

Perinatal mortality didn't differ between the 38 inpatient and 54 outpatient pregnancies (15.8 vs. 14.8%). The same was true for all fetuses and newborns with 7 deaths out of 76 (9.2% for inpatients) and 10 deaths out of 108 (9.2% for outpatients, p = 0.99). Finally, 57 pregnancies (33%) continued past 35 weeks. One death in utero was observed at 20 weeks and only one other at 35 weeks (1.5%).

Conclusion

This study shows no differences between inpatient and outpatient management and suggests that some perinatal centers envision continuing these pregnancies past 35 weeks. Vaginal delivery is not strictly contraindicated, although cesarean delivery is safe and most often recommended.

Key Points

  • Monoamniotic twin pregnancies are rare with an elevated risk of fetal and neonatal mortality.

  • To monitor the risk factors closely, they can be managed either as inpatients or outpatients.

  • Delivery, most often by cesarean, around 32 to 34 weeks, is recommended because of the rare but avoidable and thus especially distressing in utero deaths.

  • Controversy persists, nonetheless, about management (inpatient or outpatient), optimal gestation age for delivery, and mode of delivery

Keywords

monoamniotic twin pregnancies - monochorionic monoamniotic - inpatients - outpatients - cord entanglement

Authors' Contributions

L.C.V., L.M.D., B.B., and N.W. performed the literature search, conceived the study, participated in the project design, obtained the funding, drafted the manuscript, edited, and approved the final manuscript. V.D., T.T., E.M., and C.F. approved the study, participated in the project design, read, revised, and approved the final manuscript. B.B. performed the statistical analyses and revised and approved the final manuscript. N.W. reports that he is a consultant for Roche Diagnostic France.


* French Monoamniotic Group:


• Prof. O. Sibony and Prof. Thomas Schmitz, Robert Debré Hospital Maternity Ward, Paris, France.


• Prof. V. Houfflin-Debarge and Dr. P. Vaast, Lille University Hospital Center Maternity Ward.


• Prof. Y. Ville, Prof. L Salomon, Dr. G. Chalouhi, and Dr. C. Vellupilai, Necker Hospital Maternity Ward, Paris, France.


• Prof. P. Rozenberg, Poissy-Saint Germain en Laye Intercommunal Hospital Maternity Ward.


• Prof. Goffinet and Dr. O. Anselem, Port-Royal Maternity Hospital, Paris, France.


• Prof. Riethmuller, Besançon Regional University Hospital Center Maternity Ward.


• Prof. A. Benachi, Antoine Béclère Hospital Maternity Ward, Clamart, France.


• Dr. F. Biquard, Dr. P. Gillard, and Pr. Descamps, Angers University Hospital Center Maternity Ward.


• Prof. F. Pierre and Dr. M. Dugué-Marechaud, Poitiers University Hospital Center Maternity Ward.




Publication History

Received: 26 May 2024

Accepted: 05 May 2025

Article published online:
28 May 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Benirschke K, Kim CK. Multiple pregnancy. 1. N Engl J Med 1973; 288 (24) 1276-1284
    PubMedSearch in Google Scholar
  • 2 Tessen JA, Zlatnik FJ. Monoamniotic twins: a retrospective controlled study. Obstet Gynecol 1991; 77 (06) 832-834
    PubMedSearch in Google Scholar
  • 3 Shub A, Walker SP. Planned early delivery versus expectant management for monoamniotic twins. Cochrane Database Syst Rev 2015; 2015 (04) CD008820
    PubMedSearch in Google Scholar
  • 4 Hoskins IA, Combs CA. Patient Safety and Quality Committee, Society for Maternal-Fetal Medicine. Electronic address: smfm@smfm.org. Society for Maternal-Fetal Medicine special statement: updated checklists for management of monochorionic twin pregnancy. Am J Obstet Gynecol 2020; 223 (05) B16-B20
    CrossrefPubMedSearch in Google Scholar
  • 5 ACOG Practice Bulletin No. ACOG practice bulletin no. 144: multifetal gestations: twin, triplet, and higher-order multifetal pregnancies. Obstet Gynecol 2014; 123 (05) 1118-1132
    CrossrefPubMedSearch in Google Scholar
  • 6 Winer N, Caroit Y, Le Vaillant C, Philippe HJ. [Monoamniotic twins: diagnosis and management]. J Gynecol Obstet Biol Reprod (Paris) 2009; 38 (8, suppl): S85-S89
    PubMedSearch in Google Scholar
  • 7 Vayssière C, Benoist G, Blondel B. et al; French College of Gynaecologists and Obstetricians. Twin pregnancies: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2011; 156 (01) 12-17
    CrossrefPubMedSearch in Google Scholar
  • 8 Ho DE, Imai K, King G. et al. MatchIt: nonparametric preprocessing for parametric causal inference. J Stat Softw 2011; 42 (08) 1-28
    PubMedSearch in Google Scholar
  • 9 Anselem O, Mephon A, Le Ray C, Marcellin L, Cabrol D, Goffinet F. Continued pregnancy and vaginal delivery after 32 weeks of gestation for monoamniotic twins. Eur J Obstet Gynecol Reprod Biol 2015; 194: 194-198
    PubMedSearch in Google Scholar
  • 10 Van Mieghem T, Lewi L, Slaghekke F. et al; Collaborators. Prediction of fetal death in monochorionic twin pregnancies complicated by Type-III selective fetal growth restriction. Ultrasound Obstet Gynecol 2022; 59 (06) 756-762
    PubMedSearch in Google Scholar
  • 11 Mieghem TV, Shub A. Management of monoamniotic twins: the question is not 'where?', but 'how?'. Ultrasound Obstet Gynecol 2019; 53 (02) 151-152
    PubMedSearch in Google Scholar
  • 12 Chitrit Y, Korb D, Morin C, Schmitz T, Oury JF, Sibony O. Perinatal mortality and morbidity, timing and route of delivery in monoamniotic twin pregnancies: a retrospective cohort study. Arch Gynecol Obstet 2021; 303 (03) 685-693
    PubMedSearch in Google Scholar
  • 13 Allen VM, Windrim R, Barrett J, Ohlsson A. Management of monoamniotic twin pregnancies: a case series and systematic review of the literature. BJOG 2001; 108 (09) 931-936
    PubMedSearch in Google Scholar
  • 14 Hack KE, Derks JB, Schaap AH. et al. Perinatal outcome of monoamniotic twin pregnancies. Obstet Gynecol 2009; 113 (2 Pt 1): 353-360
    PubMedSearch in Google Scholar
  • 15 Heyborne KD, Porreco RP, Garite TJ, Phair K, Abril D. Obstetrix/Pediatrix Research Study Group. Improved perinatal survival of monoamniotic twins with intensive inpatient monitoring. Am J Obstet Gynecol 2005; 192 (01) 96-101
    PubMedSearch in Google Scholar
  • 16 Roqué H, Gillen-Goldstein J, Funai E, Young BK, Lockwood CJ. Perinatal outcomes in monoamniotic gestations. J Matern Fetal Neonatal Med 2003; 13 (06) 414-421
    PubMedSearch in Google Scholar
  • 17 Deutsch AB, Miller E, Spellacy WN, Mabry R. Ultrasound to identify cord knotting in monoamniotic monochorionic twins. Twin Res Hum Genet 2007; 10 (01) 216-218
    PubMedSearch in Google Scholar
  • 18 Dias T, Mahsud-Dornan S, Bhide A, Papageorghiou AT, Thilaganathan B. Cord entanglement and perinatal outcome in monoamniotic twin pregnancies. Ultrasound Obstet Gynecol 2010; 35 (02) 201-204
    PubMedSearch in Google Scholar
  • 19 Kuwata T, Matsubara S, Suzuki M. 3D color Doppler of monoamniotic twin cord entanglement. Arch Gynecol Obstet 2010; 281 (05) 973-974
    PubMedSearch in Google Scholar
  • 20 Rodis JF, Vintzileos AM, Campbell WA, Deaton JL, Fumia F, Nochimson DJ. Antenatal diagnosis and management of monoamniotic twins. Am J Obstet Gynecol 1987; 157 (05) 1255-1257
    PubMedSearch in Google Scholar
  • 21 Chauhan SP, Scardo JA, Hayes E, Abuhamad AZ, Berghella V. Twins: prevalence, problems, and preterm births. Am J Obstet Gynecol 2010; 203 (04) 305-315
    CrossrefPubMedSearch in Google Scholar
  • 22 Fox NS, Rebarber A, Klauser CK, Roman AS, Saltzman DH. Intrauterine growth restriction in twin pregnancies: incidence and associated risk factors. Am J Perinatol 2011; 28 (04) 267-272
    PubMedSearch in Google Scholar
  • 23 Beasley E, Megerian G, Gerson A, Roberts NS. Monoamniotic twins: case series and proposal for antenatal management. Obstet Gynecol 1999; 93 (01) 130-134
    PubMedSearch in Google Scholar
  • 24 DeFalco LM, Sciscione AC, Megerian G. et al. Inpatient versus outpatient management of monoamniotic twins and outcomes. Am J Perinatol 2006; 23 (04) 205-211
    PubMedSearch in Google Scholar
  • 25 Ezra Y, Shveiky D, Ophir E. et al. Intensive management and early delivery reduce antenatal mortality in monoamniotic twin pregnancies. Acta Obstet Gynecol Scand 2005; 84 (05) 432-435
    PubMedSearch in Google Scholar
  • 26 Pasquini L, Wimalasundera RC, Fichera A, Barigye O, Chappell L, Fisk NM. High perinatal survival in monoamniotic twins managed by prophylactic sulindac, intensive ultrasound surveillance, and cesarean delivery at 32 weeks' gestation. Ultrasound Obstet Gynecol 2006; 28 (05) 681-687
    PubMedSearch in Google Scholar
  • 27 Van Mieghem T, De Heus R, Lewi L. et al. Prenatal management of monoamniotic twin pregnancies. Obstet Gynecol 2014; 124 (03) 498-506
    CrossrefPubMedSearch in Google Scholar
  • 28 D'Antonio F, Odibo A, Berghella V. et al. Perinatal mortality, timing of delivery and prenatal management of monoamniotic twin pregnancy: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2019; 53 (02) 166-174
    PubMedSearch in Google Scholar
  • 29 Ancel PY, Goffinet F, Kuhn P. et al; EPIPAGE-2 Writing Group. Survival and morbidity of preterm children born at 22 through 34 weeks' gestation in France in 2011: results of the EPIPAGE-2 cohort study. JAMA Pediatr 2015; 169 (03) 230-238
    CrossrefPubMedSearch in Google Scholar
  • 30 Baxi LV, Walsh CA. Monoamniotic twins in contemporary practice: a single-center study of perinatal outcomes. J Matern Fetal Neonatal Med 2010; 23 (06) 506-510
    PubMedSearch in Google Scholar
  • 31 Delabaere A, Bouchet P, Sendy F, Petillon F, Gallot D. Management of monoamniotic twin pregnancies: where, when, how?. J Gynecol Obstet Hum Reprod 2022; 51 (01) 102232
    CrossrefPubMedSearch in Google Scholar
  • 32 Riethmuller D, Lantheaume S, Teffaud O, Menget A, Maillet R, Schaal JP. [Obstetrical and neonatal prognosis of monoamniotic twin gestations]. J Gynecol Obstet Biol Reprod (Paris) 2004; 33 (07) 632-636
    PubMedSearch in Google Scholar
  • 33 Haukoos JSLR, Lewis RJ. The propensity score. JAMA 2015; 314 (15) 1637-1638
    PubMedSearch in Google Scholar
  • 34 Van Mieghem T, Abbasi N, Shinar S. et al. Monochorionic monoamniotic twin pregnancies. Am J Obstet Gynecol MFM 2022; 4 (2S): 100520
    PubMedSearch in Google Scholar
  • 35 Khairudin D, Khalil A. Monochorionic monoamniotic twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2022; 84: 96-103
    PubMedSearch in Google Scholar