Advertisement

Is bigger better? A comparison of growth restriction rates using the crown-rump length derived due date from the smaller versus larger twin

Published:January 18, 2023DOI:https://doi.org/10.1016/j.ajogmf.2023.100869

      BACKGROUND

      Although the smaller twin's crown-rump length is most accurate in establishing the estimated due date in dichorionic gestations, societal guidelines favor the use of the larger twin measurements based on concern for missing a diagnosis of fetal growth restriction.

      OBJECTIVE

      This study aimed to compare the accuracy of the diagnosis of early- and late-onset fetal growth restriction in dichorionic twin gestations conceived by assisted reproductive technology using the estimated due date as established by the crown-rump length of the smaller vs larger twin.

      STUDY DESIGN

      This was a 10-year retrospective cohort study of nonanomalous, dichorionic gestations conceived with assisted reproductive technology at 2 institutions. The incidence of early-onset (<32 weeks of gestation) and late-onset (≥32 weeks of gestation) growth restriction derived from the Hadlock formula using the smaller and larger crown-rump length estimated due date was compared with the true estimated due date by assisted reproductive technology. Statistical significance was determined using the Fisher exact test. The incidence of missed fetal growth restriction cases, false-positive rate, and error were calculated along with the relative risk for a missed diagnosis using the smaller crown-rump length.

      RESULTS

      A total of 176 subjects were screened: 81 had a fetal growth ultrasound at 24 to <32 weeks of gestation, and 58 had a fetal growth ultrasound at ≥32 weeks of gestation. There was a significant difference in the incidence of fetal growth restriction using the 3 dating strategies in both gestational age ranges (P<.001) with the smaller crown-rump length estimated due date more closely approximating the true rate. Before 32 weeks of gestation, the smaller crown-rump length estimated due date missed 2.5% of fetal growth restriction cases, whereas the larger crown-rump length estimated due date missed 0.6% of fetal growth restriction cases, with false-positive and error rates of 1.2% and 3.7% and 5.5% and 6.2%, respectively. After 32 weeks of gestation, the smaller crown-rump length estimated due date missed 1.8% of cases, whereas the larger crown-rump length estimated due date missed 0% of cases, with false-positive and error rates of 2.6% and 4.4% and 5.3% and 5.3%, respectively. The relative risk for a missed diagnosis of fetal growth restriction using the smaller crown-rump length estimated due date was 1.77 for early-onset growth restriction and 1.22 for late-onset growth restriction.

      CONCLUSION

      Using the estimated due date derived from the smaller twin led to a more accurate detection of fetal growth restriction at a cost of a higher missed diagnosis rate.

      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

        • Salomon LJ
        • Cavicchioni O
        • Bernard JP
        • Duyme M
        • Ville Y.
        Growth discrepancy in twins in the first trimester of pregnancy.
        Ultrasound Obstet Gynecol. 2005; 26: 512-516
        • Chaudhuri K
        • Su LL
        • Wong PC
        • et al.
        Determination of gestational age in twin pregnancy: which fetal crown-rump length should be used?.
        J Obstet Gynaecol Res. 2013; 39: 761-765
        • DeYoung TH
        • Stortz SK
        • Riffenburgh RH
        • et al.
        Establishing the most accurate due date in dichorionic twin gestations by first and second trimester ultrasound.
        J Ultrasound Med. 2021; 40: 2319-2327
        • Pettker CM
        • Goldberg JD
        • El-Sayed YY.
        Methods for estimating the due date. Committee Opinion No. 700.
        Obstet Gynecol. 2017; 129: e150-e154
      1. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics, Society for Maternal-Fetal Medicine. Multifetal gestations: twin, triplet, and higher-order multifetal pregnancies: ACOG Practice Bulletin, Number 231.
        Obstet Gynecol. 2021; 137: e145-e162
        • Khalil A
        • Rodgers M
        • Baschat A
        • et al.
        ISUOG Practice Guidelines: role of ultrasound in twin pregnancy.
        Ultrasound Obstet Gynecol. 2016; 47: 247-263
        • National Collaborating Centre for Women's and Children's Health (UK)
        Multiple pregnancy: the management of twin and triplet pregnancies in the antenatal period.
        RCOG Press, London, United Kingdom2011
        • Martins JG
        • Biggio JR
        • Abuhamad A
        • Society for Maternal-Fetal Medicine (SMFM)
        Society for Maternal-Fetal Medicine Consult Series #52: diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012).
        Am J Obstet Gynecol. 2020; 223: B2-17
        • Madden JV
        • Flatley CJ
        • Kumar S.
        Term small-for-gestational-age infants from low-risk women are at significantly greater risk of adverse neonatal outcomes.
        Am J Obstet Gynecol. 2018; 218 (525.e1–9)
        • Hadlock FP
        • Shah YP
        • Kanon DJ
        • Lindsey JV.
        Fetal crown-rump length: reevaluation of relation to menstrual age (5-18 weeks) with high-resolution real-time US.
        Radiology. 1992; 182: 501-505
        • Gjerris AC
        • Loft A
        • Pinborg A
        • Tabor A
        • Christiansen M.
        First-trimester screening in pregnancies conceived by assisted reproductive technology: significance of gestational dating by oocyte retrieval or sonographic measurement of crown-rump length.
        Ultrasound Obstet Gynecol. 2008; 32: 612-617
        • Tunón K
        • Eik-Nes SH
        • Grøttum P
        • Von Düring V
        • Kahn JA.
        Gestational age in pregnancies conceived after in vitro fertilization: a comparison between age assessed from oocyte retrieval, crown-rump length and biparietal diameter.
        Ultrasound Obstet Gynecol. 2000; 15: 41-46
        • Seravalli V
        • Maoloni L
        • Pasquini L
        • et al.
        The impact of assisted reproductive technology on prenatally diagnosed fetal growth restriction in dichorionic twin pregnancies.
        PLoS One. 2020; 15e0231028
        • McDonald SD
        • Han Z
        • Mulla S
        • et al.
        Preterm birth and low birth weight among in vitro fertilization singletons: a systematic review and meta-analyses.
        Eur J Obstet Gynecol Reprod Biol. 2009; 146: 138-148
        • Wennerholm UB
        • Bergh C
        • Hagberg H
        • Sultan B
        • Wennergren M.
        Gestational age in pregnancies after in vitro fertilization: comparison between ultrasound measurement and actual age.
        Ultrasound Obstet Gynecol. 1998; 12: 170-174
        • Sun H
        • Gong TT
        • Jiang YT
        • Zhang S
        • Zhao YH
        • Wu QJ.
        Global, regional, and national prevalence and disability-adjusted life-years for infertility in 195 countries and territories, 1990-2017: results from a global burden of disease study, 2017.
        Aging (Albany NY). 2019; 11: 10952-10991
        • Galic I
        • Negris O
        • Warren C
        • Brown D
        • Bozen A
        • Jain T.
        Disparities in access to fertility care: who's in and who's out.
        F S Rep. 2021; 2: 109-117