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Is the location of cord entanglement associated with antepartum death in monoamniotic twins?

2009; Wiley; Volume: 33; Issue: 2 Linguagem: Inglês

10.1002/uog.6290

1469-0705

Birgit Arabin, Karien E. A. Hack,

Pregnancy and preeclampsia studies

Ultrasound in Obstetrics & GynecologyVolume 33, Issue 2 p. 246-247 Letter to the EditorFree Access Is the location of cord entanglement associated with antepartum death in monoamniotic twins? B. Arabin, Corresponding Author B. Arabin clara-angela@wxs.nl Department of Perinatology, Isala Clinics, Zwolle, The Netherlands and Clara Angela Foundation, Center of Research and Development, Witten, GermanyDepartment of Perinatology, Isala Clinics, Zwolle, The Netherlands and Clara Angela Foundation, Center of Research and Development, Witten, GermanySearch for more papers by this authorK. Hack, K. Hack Department of Perinatology, Isala Clinics, Zwolle, The Netherlands and Clara Angela Foundation, Center of Research and Development, Witten, GermanySearch for more papers by this author B. Arabin, Corresponding Author B. Arabin clara-angela@wxs.nl Department of Perinatology, Isala Clinics, Zwolle, The Netherlands and Clara Angela Foundation, Center of Research and Development, Witten, GermanyDepartment of Perinatology, Isala Clinics, Zwolle, The Netherlands and Clara Angela Foundation, Center of Research and Development, Witten, GermanySearch for more papers by this authorK. Hack, K. Hack Department of Perinatology, Isala Clinics, Zwolle, The Netherlands and Clara Angela Foundation, Center of Research and Development, Witten, GermanySearch for more papers by this author First published: 27 January 2009 https://doi.org/10.1002/uog.6290Citations: 7AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat In monochorionic monoamniotic twin pregnancies two fetuses develop within the same amniotic sac as a result of the splitting of a single blastocyst after the ectodermal plate and amniogenic-committed cells have emerged from the inner cell mass. The first review to emphasize the high mortality (40–70%) and the low prevalence (2–5% of all monochorionic twin pregnancies) of monoamniotic twin pregnancies appeared in 19351. In a more recent review article it was shown that out of 20 intrauterine deaths in monoamniotic twin pregnancies, 13 (65%) were explained by cord entanglement and cord accidents2. Color flow mapping combined with Doppler velocimetry and more recently three-dimensional ultrasonography, even in the first trimester, have revolutionized the prenatal diagnosis of cord entanglement3-5 and have confirmed previous suggestions that the proximity of cord insertions at the chorionic plate does not seem to predict whether or not cords become entangled6. In 1999 we published a series of three cases with monoamniotic placentation and early diagnosis of cord entanglement in this journal, in which we differentiated between cord entanglement close to the umbilical insertions interposed between the ventral surface of the two fetuses and entanglement close to the chorionic plate3. Meanwhile, we have collected and documented 18 monoamniotic twin pregnancies in which the diagnosis and location of cord entanglement were recorded in the first trimester. We retrospectively analyzed the rate of prenatal, perinatal and neonatal death related to the location of cord entanglement (Table 1). Within this group, three pairs were characterized by entanglement close to the umbilical insertions with the twins positioned opposite each other. Two of these pregnancies resulted in antepartum death of both twins before viability at 16 and 22 weeks' gestation. In one case antepartum death of only one twin was diagnosed at 22 weeks. The mother was admitted and anemia of the co-twin was excluded by serial Doppler measurements of the peak velocity in the middle cerebral artery. At 32 weeks a Cesarean section was performed. The co-twin developed uneventfully. Among the remaining 15 monoamniotic twin pregnancies in which cord entanglement had been visualized close to the chorionic plate in the first trimester, no antenatal deaths occurred. Two twins of one pair died owing to preterm delivery at 23 weeks, one twin died 8 days postpartum owing to prematurity and one twin died 12 days postpartum because of an intra-abdominal tumor (infantile myofibromatosis). Both corresponding co-twins developed uneventfully (Table 1). Table 1. Prenatal, perinatal and neonatal mortality of 36 monoamniotic twins with early cord entanglement either close to the umbilical insertion (n = 6) or close to the placenta (n = 30) Study group Prenatal deaths Perinatal deaths Neonatal deaths Total deaths Umbilical entanglement (n = 6) 5/6 0 0 5/6 Placental entanglement (n = 30) 0/30 2/30** From one pair of twins—premature birth at 23 weeks. 2/30†† From two pairs of twins; one fetal tumor and one premature birth at 26 weeks. In each case the other twin survived. 4/30 Total (n = 36) 5/36 2/36 2/36 9/36 Data are presented as n. * From one pair of twins—premature birth at 23 weeks. † From two pairs of twins; one fetal tumor and one premature birth at 26 weeks. In each case the other twin survived. Most authors agree that intensified fetal surveillance with fetal heart rate monitoring, Doppler ultrasound and even hospitalization when viability is reached can lead to improved outcome2, 7, 8. Early gradual strangulation of the umbilical cords might thus be detected by intense surveillance, and immediate delivery might prevent perinatal complications. Our preliminary data suggest that there might be an association between antepartum death and the location of cord entanglement. If this observation is repeated in larger cohorts, then it may have an impact on informed consent, intensity of surveillance and timing of delivery of monoamniotic twins. References References 1Quingley J. Monoamniotic twin pregnancy. Am J Obstet Gynecol 1935; 29: 354– 362. Google Scholar 2Allen VM, Windrim R, Barrett J, Ohlsson A. Management of monoamniotic twin pregnancies: a case series and systematic review of the literature. BJOG 2001; 108: 931– 936. CrossrefCASPubMedWeb of Science®Google Scholar 3Arabin B, Laurini RN, van Eyck J. Early prenatal diagnosis of cord entanglement in monoamniotic multiple pregnancies. Ultrasound Obstet Gynecol 1999; 13: 181– 186. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 4Overton TG, Denbow ML, Duncan KR, Fisk NM. First-trimester cord entanglement in monoamniotic twins. Ultrasound Obstet Gynecol 1999; 13: 140– 142. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 5Sebire NJ, Souka A, Skentou H, Geerts L, Nicolaides KH. First trimester diagnosis of monoamniotic twin pregnancies. Ultrasound Obstet Gynecol 2000; 16: 223– 225. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 6Benirschke K, Kaufmann P. Pathology of the Human Placenta ( 2nd edn). Springer: New York, Heidelberg, Berlin, 1990. CrossrefGoogle Scholar 7Rodis JF, McIlveen PF, Egan JF, Borgida AF, Turner GW, Campbell WA. Monoamniotic twins: improved perinatal survival with accurate prenatal diagnosis and antenatal fetal surveillance. Am J Obstet Gynecol 1997; 177: 1046– 1049. CrossrefCASPubMedWeb of Science®Google Scholar 8 Heyborne KD, Porreco RP, Garite TJ, Phair K, Abril D. Improved perinatal survival of monoamniotic twins with intensive inpatient monitoring. Am J Obstet Gynecol 2005; 192: 96– 101. CrossrefPubMedWeb of Science®Google Scholar B. Arabin*, K. Hack*, * Department of Perinatology, Isala Clinics, Zwolle, The Netherlands and Clara Angela Foundation, Center of Research and Development, Witten, Germany Citing Literature Volume33, Issue2February 2009Pages 246-247 ReferencesRelatedInformation