Advertisement

Monochorionic diamniotic twin pregnancies

  • Liesbeth Lewi
    Correspondence
    Corresponding author: Liesbeth Lewi, MD, PhD.
    Affiliations
    Department of Obstetrics and Gynecology, Universitaire Ziekenhuizen, Leuven, Leuven, Belgium

    Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
    Search for articles by this author
Published:October 10, 2021DOI:https://doi.org/10.1016/j.ajogmf.2021.100501
      About 1 in 5 twin pregnancies are monochorionic diamniotic. In these twins, transfusion imbalances may develop because of the vascular anastomoses that are invariably present. The most severe imbalance is twin-twin transfusion syndrome, which presents as a significant amniotic fluid difference diagnosed on ultrasound scan, usually before 26 weeks. Another transfusion imbalance is twin anemia polycythemia sequence, which is a severe hemoglobin difference occurring mainly after 26 weeks in previously uncomplicated pregnancies. Fetoscopic laser coagulation of the anastomoses addresses the cause of these transfusion imbalances. Beside transfusion imbalances, the monochorionic placenta may be unevenly divided, or one part may be dysfunctional, leading to an intertwin growth difference of more than 20%. Here, laser ablation of the anastomoses will usually not cure the problem, but it aims to protect the appropriately growing twin if the growth-restricted cotwin dies. In monochorionic twins, structural anomalies are twice as common as in singleton pregnancies, probably because of a teratogenic effect of the embryonic splitting or because of transfusion imbalances. In contrast, chromosomal anomalies seem less common, possibly because they more likely result in an early demise. Selective reduction is feasible in monochorionic pregnancies but carries increased risks of loss, miscarriage, and early birth than selective reduction in a dichorionic setting. Finally, if one monochorionic twin dies spontaneously, its cotwin may acutely exsanguinate into the demised cotwin, which may result in the loss of both twins or brain damage in the surviving twin. This update addresses the pathophysiology, diagnosis, and management of these common complications in monochorionic diamniotic twin pregnancies.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology MFM
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Lewi L
        • Jani J
        • Blickstein I
        • et al.
        The outcome of monochorionic diamniotic twin gestations in the era of invasive fetal therapy: a prospective cohort study.
        Am J Obstet Gynecol. 2008; 199 (514.e1–8)
        • Couck I
        • Ponnet S
        • Deprest J
        • Devlieger R
        • De Catte L
        • Lewi L.
        Outcome of monochorionic twin pregnancy with selective fetal growth restriction at 16, 20 or 30 weeks according to new Delphi consensus definition.
        Ultrasound Obstet Gynecol. 2020; 56: 821-830
        • Syngelaki A
        • Hammami A
        • Bower S
        • Zidere V
        • Akolekar R
        • Nicolaides KH.
        Diagnosis of fetal non-chromosomal abnormalities on routine ultrasound examination at 11-13 weeks’ gestation.
        Ultrasound Obstet Gynecol. 2019; 54: 468-476
        • Syngelaki A
        • Cimpoca B
        • Litwinska E
        • Akolekar R
        • Nicolaides KH.
        Diagnosis of fetal defects in twin pregnancies at routine 11-13-week ultrasound examination.
        Ultrasound Obstet Gynecol. 2020; 55: 474-481
        • Boyle B
        • Morris JK
        • McConkey R
        • et al.
        Prevalence and risk of Down syndrome in monozygotic and dizygotic multiple pregnancies in Europe: implications for prenatal screening.
        BJOG. 2014; 121: 809-819
        • Judah H
        • Gil MM
        • Syngelaki A
        • et al.
        Cell-free DNA testing of maternal blood in screening for trisomies in twin pregnancy: updated cohort study at 10-14 weeks and meta-analysis.
        Ultrasound Obstet Gynecol. 2021; 58: 178-189
        • Ortibus E
        • Lopriore E
        • Deprest J
        • et al.
        The pregnancy and long-term neurodevelopmental outcome of monochorionic diamniotic twin gestations: a multicenter prospective cohort study from the first trimester onward.
        Am J Obstet Gynecol. 2009; 200 (494.e1–8)
        • Couck I
        • Ponnet S
        • Thewissen L
        • et al.
        The detection, outcome, and presentation of twin-twin transfusion syndrome in monochorionic diamniotic twin pregnancies followed with a protocol of fortnightly ultrasound examination.
        Fetal Diagn Ther. 2021; 48: 353-360
        • Khalil A
        • Rodgers M
        • Baschat A
        • et al.
        ISUOG Practice Guidelines: role of ultrasound in twin pregnancy.
        Ultrasound Obstet Gynecol. 2016; 47: 247-263
        • Couck I
        • Lewi L.
        The placenta in twin-to-twin transfusion syndrome and twin anemia polycythemia sequence.
        Twin Res Hum Genet. 2016; 19: 184-190
        • Lewi L
        • Cannie M
        • Blickstein I
        • et al.
        Placental sharing, birthweight discordance, and vascular anastomoses in monochorionic diamniotic twin placentas.
        Am J Obstet Gynecol. 2007; 197 (587.e1–8)
        • Couck I
        • Jespers A
        • Deprest J
        • Lewi L.
        The vascular equator in monochorionic twin placentas.
        Placenta. 2020; 99: 193-196
        • Denbow ML
        • Eckersley R
        • Welsh AW
        • et al.
        Ex vivo delineation of placental angioarchitecture with the microbubble contrast agent levovist.
        Am J Obstet Gynecol. 2000; 182: 966-971
        • Zhao DP
        • Cambiaso O
        • Otaño L
        • et al.
        Veno-venous anastomoses in twin-twin transfusion syndrome: a multicenter study.
        Placenta. 2015; 36: 911-914
        • Lopriore E
        • Deprest J
        • Slaghekke F
        • et al.
        Placental characteristics in monochorionic twins with and without twin anemia-polycythemia sequence.
        Obstet Gynecol. 2008; 112: 753-758
        • Mahieu-Caputo D
        • Meulemans A
        • Martinovic J
        • et al.
        Paradoxic activation of the renin-angiotensin system in twin-twin transfusion syndrome: an explanation for cardiovascular disturbances in the recipient.
        Pediatr Res. 2005; 58: 685-688
        • Senat MV
        • Deprest J
        • Boulvain M
        • Paupe A
        • Winer N
        • Ville Y.
        Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome.
        N Engl J Med. 2004; 351: 136-144
        • Khalil A.
        Modified diagnostic criteria for twin-to-twin transfusion syndrome prior to 18 weeks’ gestation: time to change?.
        Ultrasound Obstet Gynecol. 2017; 49: 804-805
        • Dekoninck P
        • Deprest J
        • Lewi P
        • et al.
        Gestational age-specific reference ranges for amniotic fluid assessment in monochorionic diamniotic twin pregnancies.
        Ultrasound Obstet Gynecol. 2013; 41: 649-652
        • Quintero RA
        • Chmait RH.
        The cocoon sign: a potential sonographic pitfall in the diagnosis of twin - twin transfusion syndrome.
        Ultrasound Obstet Gynecol. 2004; 23: 38-41
        • Couck I
        • Mourad Tawfic N
        • Deprest J
        • De Catte L
        • Devlieger R
        • Lewi L
        Does site of cord insertion increase risk of adverse outcome, twin-to-twin transfusion syndrome and discordant growth in monochorionic twin pregnancy?.
        Ultrasound Obstet Gynecol. 2018; 52: 385-389
        • Tollenaar LSA
        • Lopriore E
        • Middeldorp JM
        • et al.
        Prevalence of placental dichotomy, fetal cardiomegaly and starry-sky liver in twin anemia-polycythemia sequence.
        Ultrasound Obstet Gynecol. 2020; 56: 395-399
        • Khalil A
        • Beune I
        • Hecher K
        • et al.
        Consensus definition and essential reporting parameters of selective fetal growth restriction in twin pregnancy: a Delphi procedure.
        Ultrasound Obstet Gynecol. 2019; 53: 47-54
        • Quintero RA
        • Morales WJ
        • Allen MH
        • Bornick PW
        • Johnson PK
        • Kruger M.
        Staging of twin-twin transfusion syndrome.
        J Perinatol. 1999; 19: 550-555
        • Bamberg C
        • Diehl W
        • Diemert A
        • Sehner S
        • Hecher K.
        Differentiation between TTTS Stages I vs II and III vs IV does not affect probability of double survival after laser therapy.
        Ultrasound Obstet Gynecol. 2021; 58: 201-206
        • Khalil A
        • Gordijn S
        • Ganzevoort W
        • et al.
        Consensus diagnostic criteria and monitoring of twin anemia-polycythemia sequence: Delphi procedure.
        Ultrasound Obstet Gynecol. 2020; 56: 388-394
        • Slaghekke F
        • Kist WJ
        • Oepkes D
        • et al.
        Twin anemia-polycythemia sequence: diagnostic criteria, classification, perinatal management and outcome.
        Fetal Diagn Ther. 2010; 27: 181-190
        • Donepudi R
        • Papanna R
        • Snowise S
        • Johnson A
        • Bebbington M
        • Moise Jr., KJ
        Does anemia-polycythemia complicating twin-twin transfusion syndrome affect outcome after fetoscopic laser surgery?.
        Ultrasound Obstet Gynecol. 2016; 47: 340-344
        • Slaghekke F
        • Lopriore E
        • Lewi L
        • et al.
        Fetoscopic laser coagulation of the vascular equator versus selective coagulation for twin-to-twin transfusion syndrome: an open-label randomised controlled trial.
        Lancet. 2014; 383: 2144-2151
        • Tollenaar LSA
        • Lopriore E
        • Faiola S
        • et al.
        Post-laser twin anemia polycythemia sequence: diagnosis, management, and outcome in an international cohort of 164 cases.
        J Clin Med. 2020; 9: 1759
        • Akkermans J
        • Peeters SH
        • Klumper FJ
        • Lopriore E
        • Middeldorp JM
        • Oepkes D.
        Twenty-five years of fetoscopic laser coagulation in twin-twin transfusion syndrome: a systematic review.
        Fetal Diagn Ther. 2015; 38: 241-253
        • Gijtenbeek M
        • Eschbach SJ
        • Middeldorp JM
        • et al.
        The value of echocardiography and Doppler in the prediction of fetal demise after laser coagulation for TTTS: a systematic review and meta-analysis.
        Prenat Diagn. 2019; 39: 838-847
        • Eschbach SJ
        • Boons LS
        • Wolterbeek R
        • et al.
        Prediction of single fetal demise after laser therapy for twin-twin transfusion syndrome.
        Ultrasound Obstet Gynecol. 2016; 47: 356-362
        • Gabby LC
        • Chon AH
        • Korst LM
        • Llanes A
        • Miller DA
        • Chmait RH.
        Survival outcomes by fetal weight discordance after laser surgery for twin-twin transfusion syndrome complicated by donor fetal growth restriction.
        Fetal Diagn Ther. 2020; ([Epub ahead of print])
        • Stirnemann J
        • Slaghekke F
        • Khalek N
        • et al.
        Intrauterine fetoscopic laser surgery versus expectant management in stage 1 twin-to-twin transfusion syndrome: an international randomized trial.
        Am J Obstet Gynecol. 2021; 224 (528.e1–12.)
        • Middeldorp JM
        • Sueters M
        • Lopriore E
        • et al.
        Fetoscopic laser surgery in 100 pregnancies with severe twin-to-twin transfusion syndrome in the Netherlands.
        Fetal Diagn Ther. 2007; 22: 190-194
        • Baud D
        • Windrim R
        • Keunen J
        • et al.
        Fetoscopic laser therapy for twin-twin transfusion syndrome before 17 and after 26 weeks’ gestation.
        Am J Obstet Gynecol. 2013; 208 (197.e1–7)
        • van Klink JM
        • Koopman HM
        • Rijken M
        • Middeldorp JM
        • Oepkes D
        • Lopriore E.
        Long-term neurodevelopmental outcome in survivors of twin-to-twin transfusion syndrome.
        Twin Res Hum Genet. 2016; 19: 255-261
        • Aertsen M
        • Van Tieghem De Ten Berghe C
        • Deneckere S
        • Couck I
        • De Catte L
        • Lewi L.
        The prevalence of brain lesions after in utero surgery for twin-to-twin transfusion syndrome on third-trimester MRI: a retrospective cohort study.
        Eur Radiol. 2021; 31: 4097-4103
        • Stirnemann JJ
        • Quibel T
        • Essaoui M
        • Salomon LJ
        • Bussieres L
        • Ville Y.
        Timing of delivery following selective laser photocoagulation for twin-to-twin transfusion syndrome.
        Am J Obstet Gynecol. 2012; 207 (127.e1–6)
        • Couck I
        • Valenzuela I
        • Russo F
        • Lewi L.
        Spontaneous regression of twin anemia-polycythemia sequence presenting in first trimester.
        Ultrasound Obstet Gynecol. 2020; 55: 839-840
        • Lewi L
        • Gucciardo L
        • Huber A
        • et al.
        Clinical outcome and placental characteristics of monochorionic diamniotic twin pairs with early- and late-onset discordant growth.
        Am J Obstet Gynecol. 2008; 199 (511.e1–7)
        • Tollenaar LSA
        • Slaghekke F
        • Lewi L
        • et al.
        Treatment and outcome of 370 cases with spontaneous or post-laser twin anemia-polycythemia sequence managed in 17 fetal therapy centers.
        Ultrasound Obstet Gynecol. 2020; 56: 378-387
        • Gheysen W
        • Strybol D
        • Moerman P
        • et al.
        Discordance for placental mesenchymal dysplasia in a monochorionic diamniotic twin pregnancy: a case report.
        Clin Case Rep. 2018; 6: 1557-1560
        • Tollenaar LSA
        • Lopriore E
        • Slaghekke F
        • et al.
        High risk of long-term neurodevelopmental impairment in donor twins with spontaneous twin anemia-polycythemia sequence.
        Ultrasound Obstet Gynecol. 2020; 55: 39-46
        • Gratacós E
        • Lewi L
        • Muñoz B
        • et al.
        A classification system for selective intrauterine growth restriction in monochorionic pregnancies according to umbilical artery Doppler flow in the smaller twin.
        Ultrasound Obstet Gynecol. 2007; 30: 28-34
        • Batsry L
        • Matatyahu N
        • Avnet H
        • et al.
        Perinatal outcome of monochorionic diamniotic twin pregnancy complicated by selective intrauterine growth restriction according to umbilical artery Doppler flow pattern: single-center study using strict fetal surveillance protocol.
        Ultrasound Obstet Gynecol. 2021; 57: 748-755
        • Peeva G
        • Bower S
        • Orosz L
        • Chaveeva P
        • Akolekar R
        • Nicolaides KH.
        Endoscopic placental laser coagulation in monochorionic diamniotic twins with Type II selective fetal growth restriction.
        Fetal Diagn Ther. 2015; 38: 86-93
        • Colmant C
        • Lapillonne A
        • Stirnemann J
        • et al.
        Impact of different prenatal management strategies in short- and long-term outcomes in monochorionic twin pregnancies with selective intrauterine growth restriction and abnormal flow velocity waveforms in the umbilical artery Doppler: a retrospective observational study of 108 cases.
        BJOG. 2021; 128: 401-409
        • Parra-Cordero M
        • Bennasar M
        • Martínez JM
        • Eixarch E
        • Torres X
        • Gratacós E.
        Cord occlusion in monochorionic twins with early selective intrauterine growth restriction and abnormal umbilical artery Doppler: a consecutive series of 90 cases.
        Fetal Diagn Ther. 2016; 39: 186-191
        • Lewi L
        • Blickstein I
        • Van Schoubroeck D
        • et al.
        Diagnosis and management of heterokaryotypic monochorionic twins.
        Am J Med Genet A. 2006; 140: 272-275
        • Essaoui M
        • Nizon M
        • Beaujard MP
        • et al.
        Monozygotic twins discordant for 18q21.2qter deletion detected by array CGH in amniotic fluid.
        Eur J Med Genet. 2013; 56: 502-505
        • Machin GA.
        Some causes of genotypic and phenotypic discordance in monozygotic twin pairs.
        Am J Med Genet. 1996; 61: 216-228
        • Souter VL
        • Kapur RP
        • Nyholt DR
        • et al.
        A report of dizygous monochorionic twins.
        N Engl J Med. 2003; 349: 154-158
        • Lewi L
        • Valencia C
        • Gonzalez E
        • Deprest J
        • Nicolaides KH.
        The outcome of twin reversed arterial perfusion sequence diagnosed in the first trimester.
        Am J Obstet Gynecol. 2010; 203 (213.e1–4)
        • van Riel M
        • Brison N
        • Baetens M
        • et al.
        Performance and diagnostic value of genome-wide noninvasive prenatal testing in multiple gestations.
        Obstet Gynecol. 2021; 137: 1102-1108
        • Gaerty K
        • Greer RM
        • Kumar S.
        Systematic review and metaanalysis of perinatal outcomes after radiofrequency ablation and bipolar cord occlusion in monochorionic pregnancies.
        Am J Obstet Gynecol. 2015; 213: 637-643
        • Lewi L
        • Gratacos E
        • Ortibus E
        • et al.
        Pregnancy and infant outcome of 80 consecutive cord coagulations in complicated monochorionic multiple pregnancies.
        Am J Obstet Gynecol. 2006; 194: 782-789
        • Mackie FL
        • Rigby A
        • Morris RK
        • Kilby MD.
        Prognosis of the co-twin following spontaneous single intrauterine fetal death in twin pregnancies: a systematic review and meta-analysis.
        BJOG. 2019; 126: 569-578
        • Senat MV
        • Bernard JP
        • Loizeau S
        • Ville Y.
        Management of single fetal death in twin-to-twin transfusion syndrome: a role for fetal blood sampling.
        Ultrasound Obstet Gynecol. 2002; 20: 360-363
        • Griffiths PD
        • Bradburn M
        • Campbell MJ
        • et al.
        Use of MRI in the diagnosis of fetal brain abnormalities in utero (MERIDIAN): a multicentre, prospective cohort study.
        Lancet. 2017; 389: 538-546