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Monochorionic Monoamniotic Twins: Neonatal Outcome

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Monochorionic Monoamniotic Twins: Neonatal Outcome Journal of Perinatology (2006) 26, 170–175 r 2006 Nature Publishing Group All rights reserved. 0743-8346/06 $30 www.nature.com/jp ORIGINAL ARTICLE Monochorionic monoamniotic twins: neonatal outcome L Cordero1, A Franco2 and SD Joy2 1Department of Pediatrics and Obstetrics, Division of Neonatal-Perinatal Medicine, College of Medicine and Public Health, The Ohio State University Medical Center, The Ohio State University, Columbus, OH, USA and 2Department of Obstetrics and Gynecology, College of Medicine and Public Health, The Ohio State University, Columbus, OH, USA Introduction Background: Monochorionic monoamniotic twins (MoMo) occur in one Every year 4 million infants are born in the United States and of 10 000 pregnancies. Cord entanglement, malformations, twin-to-twin approximately 130 000 of them are twins.1 The prevalence of twin transfusion syndrome (TTS) and prematurity are responsible for their high deliveries has increased 48% between 1990 and 1998.1 Of great perinatal morbidity and mortality. concern is that although twins represented only 2.5% of the entire Objective: To report our experience with 36 sets of MoMo twins (1990 to group, they accounted for 12.6% of the total perinatal mortality.2 2005) and to provide updated information for counseling. Only one-third of all twins are monozygotic, but 75% of the Methods: Chorionicity was determined by placental examination, monozygotic twins are monochorionic. Among monochorionic gestational age and TTS clinically and by sonography. Intrauterine twins, about 2% are monochorionic monoamniotic (MoMo), 18% growth restriction (IUGR) was diagnosed with a twin-specific nomogram. monochorionic diamniotic (MoDi) with twin-to-twin transfusion syndrome (TTS) and 80% MoDi without TTS.3 Monochorionic Results: Cord entanglement was observed in 15 pregnancies, but only monoamniotic twins have the highest incidence of perinatal losses, one twin with entanglement and a true knot, experienced related congenital malformations, perinatal mortality and perinatal morbidity. Four of 71 live births were IUGR. Malformations were morbidity.3–5 diagnosed prenatally (one hypoplastic left heart and one body stalk) and The purpose of the present investigation is to report the clinical postnatally (one vertebral anomalies-anal atresia-tracheoesophageal outcome of 36 sets of MoMo twins consecutively born in our fistula-renal defect (VATER) and two lung hypoplasias). Twin-to-twin Institution. We also provide practicing neonatologists with updated transfusion syndrome affected three sets of twins. Five twin sets delivered information for counseling parents. before 31, 19 sets at 31 to 32 and 12 sets at 33 to 34 weeks. Six of 71 (8%) twins died (four malformations, one TTS and one 26 weeks premature). Head ultrasounds in 59 of 65 survivors showed two (3%) periventricular Methods leukomalacia, five (9%) Grade I–II intraventricular hemorrhage and 52 (88%) normal. Demographic and clinical data were obtained from medical records of women with MoMo twin pregnancies and their infants born at Conclusions: Monochorionic monoamniotic twins remain a group The Ohio State University Medical Center between 1990 and 2005. at risk for cord entanglement, congenital malformations, TTS and This study was approved by the Institutional Review Board. prematurity. Although their neonatal mortality and morbidity is high, Conjoined twins and gestations other than twins were excluded. outcomes for survival are better than anticipated. Gestational age (GA) was determined by sonography or by Journal of Perinatology (2006) 26, 170–175. doi:10.1038/sj.jp.7211457; examination of the newborn infant. Within each set, twins were published online 9 February 2006 classified according to their birth weight into either large or small Keywords: monochorionic; monoamniotic; twins; perinatal; neonatal; size. Inter-twin growth discordance was calculated as the difference outcome between the birth weight of the large and the small twin expressed as a percentage of the large twin birth weight.6 Twin pregnancies were considered discordant if the inter-pair differences in birth weights were X20%. Correspondence: Dr L Cordero, Department of Pediatrics and Obstetrics, Division of Neonatal- Chorionicity was established by histological examination of the Perinatal Medicine, The Ohio State University Medical Center, The Ohio State University, placenta and zygosity was determined by chorionicity, infant’s N118 Doan Hall, 410 W. 10th Avenue, Columbus, OH 43210-1228, USA. gender and blood group.7 Based on sonographic and pathologic E-mail: [email protected] Received 3 October 2005; revised 8 December 2005; accepted 19 December 2005; published evidence, all monochorionic gestations were classified as MoMo or online 9 February 2006 MoDi. Twin-to-twin transfusion syndrome was diagnosed by the Monochorionic monoamniotic twins L Cordero et al 171 recognition of a single placenta, same gender, twins weight Table 1 Monochorionic monoamniotic pregnancies discordance, intrauterine growth restriction in the small (donor), Pregnant patients no. 36 normal or large size of the recipient, hemodynamic compromise of 8,9 Maternal age (years) 25 (16–34) the recipient and polyhydramnios. Twin-to-twin transfusion Primigravida no. (%) 11 (31) 10 syndrome severity was staged sonographically. Discordant fetal growth no. (%) 4 (11) Acute fetal distress was diagnosed by fetal heart rate Fetal growth restriction no. (%) 4 (11) abnormalities (late decelerations or decreased beat to beat Preeclampsia no. (%) 3 (9) variability) or by decreases in the biophysical profile score.11 Preterm labor no. (%) 19 (53) Chronic fetal distress was defined by growth restriction in Congenital malformations no. (%) 4 (11) combination with abnormal fetal Doppler values, oligohydramnios Twin-to-twin transfusion no. (%) 3 (9) or with both.11 Neonatal depression was considered severe when Acute/chronic fetal distress no. (%) 10 (29) 1- and 5-min Apgar scores were p3. Depending on maternal and Antepartum steroids no. (%) 33 (92) fetal conditions, MoMo pregnancies were monitored as in-patient Umbilical cord entanglement no. (%) 15 (42) Umbilical cord true knot no. (%) 5 (14) or as outpatient. Fetal management goal was to deliver by elective Cesarean delivery no. (%) 34 (94) cesarean at 32 to 34 weeks of gestation. Live births no. (%) 71 (99) Birth weight and GA for each individual twin were plotted on a 30 weeks gestational age at delivery no. (%) 5 (14) 12 p growth nomogram specific for twins. Infants who plotted at the 31–32 weeks gestational age at delivery no. (%) 19 (53) 10th percentile or lower were considered intrauterine growth 33–34 weeks gestational age at delivery no. (%) 12 (33) restricted. Umbilical cord hemoglobin (Hgb) was studied. For the few instances when cord blood was not available, the first arterial or venous Hgb recorded was used. Respiratory distress syndrome was diagnosed using clinical and Antepartum steroids were given to 33 (92%) of the 36 women radiographic parameters. The need for mechanical ventilation and who delivered vaginally (two cases) or by cesarean (34 cases). All for exogenous surfactant was determined by the attending 36 mothers delivered 71 live infants and one stillbirth. Although neonatologist. Severe bronchopulmonary dysplasia was diagnosed this delivery occurred at 32 weeks, an autopsy failed to in infants receiving supplemental oxygen at 36 weeks determine the cause for fetal demise that occurred at postconceptional age. Intraventricular hemorrhages were approximately at 22 weeks. Five (14%) twin sets were delivered documented by head ultrasound and were graded.13 at p30 weeks, 19 (53%) sets at 31 to 32 weeks and 12 (33%) sets at 33 to 34 weeks. Statistical analysis Comparisons between groups and subgroups were made using the Student’s t-test for interval and w2 analysis and Fisher’s exact test Umbilical cord entanglement for categorical data. Values were reported as mean, standard Entanglement was diagnosed at the time of delivery in 15 of the 36 deviation (s.d.), range and median. (42%) pregnancies. In 10 of these cases (67%), entanglement occurred without true knots and none of these twins showed complications attributable to umbilical cord accidents. In the Results remaining five (33%) pregnancies, there were entanglements of the The study population consisted of 36 women with MoMo cord with true knots. Eight twins experienced no complications. In pregnancies and their seventy-one live born infants (Table 1). the remaining case, twin ‘A’, whose true knot was very tight, had None of the pregnancies were conceived with artificial reproductive Apgar scores of 2 and 3, was anemic (10 g/dl cord Hgb), required techniques. Twenty-five (69%) of the mothers were Caucasian and packed red blood cells for treatment of hypotension, but 11 (31%) were African American. The median age was 25 years survived without complications. Twin ‘B’ had Apgar scores 6 (range 16 to 35) and one-third of the mothers were primigravida. and 6, was polycythemic (20 g/Hgb) and had an uncomplicated Twenty-six of the 36 (72%) twin sets were females. hospital course. Antepartum complications noted in 36 pregnancies included Only one of the 30 (3%) infants with entangled cord was discordant fetal growth in four (11%), fetal growth restriction in one considered to be intrauterine growth restricted. or both twins in four (11%), preeclampsia in three (9%), congenital malformations in four (11%) and TTS in three (9%). Two of the three Congenital malformations pregnancies complicated by TTS were
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