Screening, Management and Delivery in Twin Pregnancy

Abstract

The following AWMF guideline (DGGG/AGG & DEGUM responsible) deals with the diagnosis, screening and management of twins as well as the timing and mode of birth.

Twin pregnancies can be classified as dichorionic diamniotic (DC DA), monochorionic diamniotic (MC DA) and monochorionic monoamniotic (MC MA) which are always monochorionic.

Twin pregnancies can be concordant (both twins are affected) or discordant (only one twin is affected) for chromosomal defects, malformations, growth restriction and hemodynamic disorders.

Chorionicity is the prognostically most significant parameter. Monochorial twins have significantly higher risks of intrauterine morbidity and mortality compared to dichorial twins.

In particular, general aspects of twin pregnancies such as dating, determination of chorionicity and amnionicity, the labeling of twin fetuses and the perinatal switch phenomenon are discussed.

Routine monitoring of MC and DC twin pregnancies with ultrasound at 11–13^+ 6 weeks of gestation for chromosomal defects, invasive prenatal diagnosis, first-trimester NT or CRL discrepancies, early diagnosis of fetal anatomical defects, and management of twins with abnormalities, including selective fetocide, is described.

Second trimester screening and management for preterm birth, intrauterine selective growth restriction (sFGR), classification of monochorial twins with sFGR, and management of the surviving twin after the death of the co-twin are described.

Complications exclusively affecting MC twins include Twin to Twin Transfusion Syndrome (TTTS) with the important topics screening, prognosis, complications of laser therapy, timing of delivery, risks for brain abnormalities and delayed neurological development, Twin Anemia-Polycythemia Sequence (TAPS) and Twin Reversed Arterial Perfusion (TRAP) Sequence. This also includes MC MA twins as well as conjoined twins.

Finally, the birth mode and time for DC and MC twin pregnancies are described.

The information is summarized in 62 recommendations for action, 4 tables and 8 illustrations with comprehensive background texts.

The guideline is an international guideline adaptation (ISUOG, NICE) as well as a systematic literature search and is up-to-date.

Key words

twins - monochorionic - dichorionic - monoamniotic - TTTS

^* Constantin von Kaisenberg and Philipp Klaritsch share first authorship.

Publikationsverlauf

Eingereicht: 29. Mai 2020

Angenommen: 09. August 2020

Artikel online veröffentlicht:
05. Oktober 2020

• References

• 1 Khalil A, Rodgers M, Baschat A. et al. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247-263
• 2 NICE. National Institute for Health and Care Excellence Clinical Guideline 129: Multiple Pregnancy – The Management of Twin and Triplet Pregnancies in the Antenatal Period. London: 2011 In, Multiple Pregnancy: The Management of Twin and Triplet Pregnancies in the Antenatal Period
• 3 NICE. National Institute for Health and Care Excellence Guideline 137: Twin and Triplet Pregnancy. London: 2019
• 4 Dias T, Mahsud-Dornan S, Thilaganathan B. et al. First-trimester ultrasound dating of twin pregnancy: are singleton charts reliable?. BJOG 2010; 117: 979-984
• 5 Salomon LJ, Cavicchioni O, Bernard JP. et al. Growth discrepancy in twins in the first trimester of pregnancy. Ultrasound Obstet Gynecol 2005; 26: 512-516
• 6 Maruotti GM, Saccone G, Morlando M. et al. First-trimester ultrasound determination of chorionicity in twin gestations using the lambda sign: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2016; 202: 66-70
• 7 Dias T, Ladd S, Mahsud-Dornan S. et al. Systematic labeling of twin pregnancies on ultrasound. Ultrasound Obstet Gynecol 2011; 38: 130-133
• 8 D'Antonio F, Khalil A, Thilaganathan B. et al. Second-trimester discordance and adverse perinatal outcome in twins: the STORK multiple pregnancy cohort. BJOG 2014; 121: 422-429
• 9 Sueters M, Middeldorp JM, Lopriore E. et al. Timely diagnosis of twin-to-twin transfusion syndrome in monochorionic twin pregnancies by biweekly sonography combined with patient instruction to report onset of symptoms. Ultrasound Obstet Gynecol 2006; 28: 659-664
• 10 de Villiers SF, Slaghekke F, Middeldorp JM. et al. Placental characteristics in monochorionic twins with spontaneous versus post-laser twin anemia-polycythemia sequence. Placenta 2013; 34: 456-459
• 11 Prats P, Rodriguez I, Comas C. et al. Systematic review of screening for trisomy 21 in twin pregnancies in first trimester combining nuchal translucency and biochemical markers: a meta-analysis. Prenat Diagn 2014; 34: 1077-1083
• 12 Kagan KO, Sonek J, Wagner P. et al. Principles of first trimester screening in the age of non-invasive prenatal diagnosis: screening for other major defects and pregnancy complications. Arch Gynecol Obstet 2017; 296: 635-643
• 13 Dagklis T, Plasencia W, Maiz N. et al. Choroid plexus cyst, intracardiac echogenic focus, hyperechogenic bowel and hydronephrosis in screening for trisomy 21 at 11 + 0 to 13 + 6 weeks. Ultrasound Obstet Gynecol 2008; 31: 132-135
• 14 Chaveeva P, Wright A, Syngelaki A. et al. First-trimester screening for trisomies in pregnancies with vanishing twin. Ultrasound Obstet Gynecol 2020; 55: 326-331
• 15 Gil MM, Accurti V, Santacruz B. et al. Analysis of cell-free DNA in maternal blood in screening for aneuploidies: updated meta-analysis. Ultrasound Obstet Gynecol 2017; 50: 302-314
• 16 Salomon LJ, Alfirevic Z, Bilardo CM. et al. ISUOG practice guidelines: performance of first-trimester fetal ultrasound scan. Ultrasound Obstet Gynecol 2013; 41: 102-113
• 17 von Kaisenberg C, Chaoui R, Häusler M. et al. Qualitätsanforderungen an die Ultraschalluntersuchung in der Frühschwangerschaft (DEGUM-Stufe I) zwischen 4+0 und 13+6 Schwangerschaftswochen. Ultraschall in Med 2016; 37: 297-302
• 18 Agarwal K, Alfirevic Z. Pregnancy loss after chorionic villus sampling and genetic amniocentesis in twin pregnancies: a systematic review. Ultrasound Obstet Gynecol 2012; 40: 128-134
• 19 Gallot D, Velemir L, Delabaere A. et al. [Which invasive diagnostic procedure should we use for twin pregnancies: chorionic villous sampling or amniocentesis?]. J Gynecol Obstet Biol Reprod (Paris) 2009; 38: S39-S44
• 20 Hansen M, Kurinczuk JJ, Milne E. et al. Assisted reproductive technology and birth defects: a systematic review and meta-analysis. Hum Reprod Update 2013; 19: 330-353
• 21 Ghi T, Sotiriadis A, Calda P. et al. ISUOG Practice Guidelines: invasive procedures for prenatal diagnosis. Ultrasound Obstet Gynecol 2016; 48: 256-268
• 22 Evans MI, Goldberg JD, Horenstein J. et al. Selective termination for structural, chromosomal, and mendelian anomalies: international experience. Am J Obstet Gynecol 1999; 181: 893-897
• 23 Kagan KO, Gazzoni A, Sepulveda-Gonzalez G. et al. Discordance in nuchal translucency thickness in the prediction of severe twin-to-twin transfusion syndrome. Ultrasound Obstet Gynecol 2007; 29: 527-532
• 24 Mackie FL, Hall MJ, Morris RK. et al. Early prognostic factors of outcomes in monochorionic twin pregnancy: systematic review and meta-analysis. Am J Obstet Gynecol 2018; 219: 436-446
• 25 Merz E, Eichhorn KH, von Kaisenberg C. et al. Aktualisierte Qualitätsanforderungen an die weiterführende differenzierte Ultraschalluntersuchung in der pränatalen Diagnostik (= DEGUM-Stufe II) im Zeitraum von 18 + 0 bis 21 + 6 Schwangerschaftswochen. Ultraschall in Med 2012; 33: 593-596
• 26 Carvalho JS. Gynecology ISoUiOa, Gynecology. et al. ISUOG Practice Guidelines (updated): sonographic screening examination of the fetal heart. Ultrasound Obstet Gynecol 2013; 41: 348-359
• 27 Chaoui R, Heling K, Mielke G. et al. Qualitätsanforderungen der DEGUM zur Durchführung der fetalen Echokardiografie. Ultraschall in Med 2008; 29: 197-200
• 28 Machin G. Non-identical monozygotic twins, intermediate twin types, zygosity testing, and the non-random nature of monozygotic twinning: a review. Am J Med Genet C Semin Med Genet 2009; 151C: 110-127
• 29 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
• 30 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
• 31 Conde-Agudelo A, Romero R, Hassan SS. et al. Transvaginal sonographic cervical length for the prediction of spontaneous preterm birth in twin pregnancies: a systematic review and metaanalysis. Am J Obstet Gynecol 2010; 203: 128e121–112
• 32 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
• 33 Leombroni M, Liberati M, Fanfani F. et al. Diagnostic accuracy of ultrasound in predicting birth-weight discordance in twin pregnancy: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2017; 50: 442-450
• 34 D’Antonio F, Odibo AO, Prefumo F. et al. Weight discordance and perinatal mortality in twin pregnancy: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 52: 11-23
• 35 Sueters M, Oepkes D. Diagnosis of twin-to-twin transfusion syndrome, selective fetal growth restriction, twin anaemia-polycythaemia sequence, and twin reversed arterial perfusion sequence. Best Pract Res Clin Obstet Gynaecol 2014; 28: 215-226
• 36 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: 511e511-e517
• 37 Khalil A, D'Antonio F, Dias T. et al. Ultrasound estimation of birth weight in twin pregnancy: comparison of biometry algorithms in the STORK multiple pregnancy cohort. Ultrasound Obstet Gynecol 2014; 44: 210-220
• 38 Gratacos E, Lewi L, Munoz 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
• 39 Chalouhi GE, Marangoni MA, Quibel T. et al. Active management of selective intrauterine growth restriction with abnormal Doppler in monochorionic diamniotic twin pregnancies diagnosed in the second trimester of pregnancy. Prenat Diagn 2013; 33: 109-115
• 40 Senat MV, Loizeau S, Couderc S. et al. The value of middle cerebral artery peak systolic velocity in the diagnosis of fetal anemia after intrauterine death of one monochorionic twin. Am J Obstet Gynecol 2003; 189: 1320-1324
• 41 Hillman SC, Morris RK, Kilby MD. Co-twin prognosis after single fetal death: a systematic review and meta-analysis. Obstet Gynecol 2011; 118: 928-940
• 42 Ong SS, Zamora J, Khan KS. et al. Prognosis for the co-twin following single-twin death: a systematic review. BJOG 2006; 113: 992-998
• 43 van Klink JM, van Steenis A, Steggerda SJ. et al. Single fetal demise in monochorionic pregnancies: incidence and patterns of cerebral injury. Ultrasound Obstet Gynecol 2015; 45: 294-300
• 44 Quintero RA, Morales WJ, Allen MH. et al. Staging of twin-twin transfusion syndrome. J Perinatol 1999; 19: 550-555
• 45 Roberts D, Neilson JP, Kilby MD. et al. Interventions for the treatment of twin-twin transfusion syndrome. Cochrane Database Syst Rev 2014;
• 46 Senat MV, Deprest J, Boulvain M. et al. Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. N Engl J Med 2004; 351: 136-144
• 47 Diehl W, Diemert A, Grasso D. et al. Fetoscopic laser coagulation in 1020 pregnancies with twin-twin transfusion syndrome demonstrates improvement in double-twin survival rate. Ultrasound Obstet Gynecol 2017; 50: 728-735
• 48 Khalil A, Cooper E, Townsend R. et al. Evolution of Stage 1 Twin-to-Twin Transfusion Syndrome (TTTS): Systematic Review and Meta-Analysis. Twin Res Hum Genet 2016; 19: 207-216
• 49 Hecher K, Gardiner HM, Diemert A. et al. Long-term outcomes for monochorionic twins after laser therapy in twin-to-twin transfusion syndrome. Lancet Child Adolesc Health 2018; 2: 525-535
• 50 Khalil A, Gordijn S, Ganzevoort W. et al. Consensus diagnostic criteria and monitoring of twin anemia polycythemia sequence: a Delphi procedure. Ultrasound Obstet Gynecol 2019;
• 51 Tavares de Sousa M, Fonseca A, Hecher K. Role of fetal intertwin difference in middle cerebral artery peak systolic velocity in predicting neonatal twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol 2019; 53: 794-797
• 52 Slaghekke F, van Klink JM, Koopman HM. et al. Neurodevelopmental outcome in twin anemia-polycythemia sequence after laser surgery for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2014; 44: 316-321
• 53 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
• 54 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
• 55 Lopriore E, Slaghekke F, Oepkes D. et al. Hematological characteristics in neonates with twin anemia-polycythemia sequence (TAPS). Prenat Diagn 2010; 30: 251-255
• 56 Hecher K, Lewi L, Gratacos E. et al. Twin reversed arterial perfusion: fetoscopic laser coagulation of placental anastomoses or the umbilical cord. Ultrasound Obstet Gynecol 2006; 28: 688-691
• 57 Pagani G, D'Antonio F, Khalil A. et al. Intrafetal laser treatment for twin reversed arterial perfusion sequence: cohort study and meta-analysis. Ultrasound Obstet Gynecol 2013; 42: 6-14
• 58 Tavares de Sousa M, Glosemeyer P, Diemert A. et al. First-trimester intervention in twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol 2020; 55: 47-49
• 59 Rossi AC, Prefumo F. Impact of cord entanglement on perinatal outcome of monoamniotic twins: a systematic review of the literature. Ultrasound Obstet Gynecol 2013; 41: 131-135
• 60 Dodd JM, Deussen AR, Grivell RM. et al. Elective birth at 37 weeks’ gestation for women with an uncomplicated twin pregnancy. Cochrane Database Syst Rev 2014;
• 61 Saccone G, Berghella V. Planned delivery at 37 weeks in twins: a systematic review and meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med 2016; 29: 685-689
• 62 Cheong-See F, Schuit E, Arroyo-Manzano D. et al. Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis. BMJ 2016; 354: i4353
• 63 Danon D, Sekar R, Hack KE. et al. Increased stillbirth in uncomplicated monochorionic twin pregnancies: a systematic review and meta-analysis. Obstet Gynecol 2013; 121: 1318-1326
• 64 Page JM, Pilliod RA, Snowden JM. et al. The risk of stillbirth and infant death by each additional week of expectant management in twin pregnancies. Am J Obstet Gynecol 2015; 212: 630e631-637
• 65 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: 166-174
• 66 Van Mieghem T, De Heus R, Lewi L. et al. Prenatal management of monoamniotic twin pregnancies. Obstet Gynecol 2014; 124: 498-506
• 67 Kilby M, Bricker LobotRCoOaG. Management of Monochorionic Twin Pregnancy: Green-top Guideline No. 51. BJOG 2017; 124: e1-e45
• 68 Committee on Practice B-O, Society for Maternal-Fetal M. Practice Bulletin No. 169: Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies. Obstet Gynecol 2016; 128: e131-e146
• 69 RANZCOG, Board, Council. Management of monochorionic twin pregnancy. College Statement 42 2011. https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Management-of-Monochorionic-Twins-(C-Obs-42)-review-July-2017.pdf?ext=.pdf
• 70 Vayssiere C, Benoist G, Blondel B. et al. Twin pregnancies: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2011; 156: 12-17
• 71 Barrett JF, Hannah ME, Hutton EK. et al. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med 2013; 369: 1295-1305
• 72 Hofmeyr GJ, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. Cochrane Database Syst Rev 2015;
• 73 Asztalos EV, Hannah ME, Hutton EK. et al. Twin Birth Study: 2-year neurodevelopmental follow-up of the randomized trial of planned cesarean or planned vaginal delivery for twin pregnancy. Am J Obstet Gynecol 2016; 214: 371e371-371, e319
• 74 Hutton EK, Hannah ME, Ross S. et al. Maternal outcomes at 3 months after planned caesarean section versus planned vaginal birth for twin pregnancies in the Twin Birth Study: a randomised controlled trial. BJOG 2015; 122: 1653-1662
• 75 Schmitz T, Korb D, Battie C. et al. Neonatal morbidity associated with vaginal delivery of noncephalic second twins. Am J Obstet Gynecol 2018; 218: 449e441-449, e413
• 76 Schmitz T, Prunet C, Azria E. et al. Association Between Planned Cesarean Delivery and Neonatal Mortality and Morbidity in Twin Pregnancies. Obstet Gynecol 2017; 129: 986-995
• 77 Goossens S, Ensing S, van der Hoeven M. et al. Comparison of planned caesarean delivery and planned vaginal delivery in women with a twin pregnancy: A nation wide cohort study. Eur J Obstet Gynecol Reprod Biol 2018; 221: 97-104
• 78 Korb D, Deneux-Tharaux C, Seco A. et al. Risk of Severe Acute Maternal Morbidity According to Planned Mode of Delivery in Twin Pregnancies. Obstet Gynecol 2018; 132: 647-655
• 79 Dagenais C, Lewis-Mikhael AM, Grabovac M. et al. What is the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs? A systematic review and meta-analyses. BMC Pregnancy Childbirth 2017; 17: 397
• 80 Sentilhes L, Oppenheimer A, Bouhours AC. et al. Neonatal outcome of very preterm twins: policy of planned vaginal or cesarean delivery. Am J Obstet Gynecol 2015; 213: 73e71-73, e77