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Litwinska E, Litwinska M, Czuba B, Gach A, Kwiatkowski S, Kosinski P, Kaczmarek P, Wielgos M. Amniocentesis in Twin Pregnancies: Risk Factors of Fetal Loss. J Clin Med 2022; 11:jcm11071937. [PMID: 35407545 PMCID: PMC9000006 DOI: 10.3390/jcm11071937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/11/2022] [Accepted: 03/28/2022] [Indexed: 12/10/2022] Open
Abstract
This study aims to determine if second trimester amniocentesis in twin pregnancies provides a significant independent contribution in the prediction of miscarriage or fetal loss at any stage of pregnancy. This was a retrospective cohort study of women with twin gestations booked for routine prenatal care in four fetal medicine units in Poland in the years 2010-2020. The study population included: (1) twin pregnancies that underwent amniocentesis at 16-20 weeks' gestation; (2) twin pregnancies that did not require any further testing and were followed-up routinely. Univariable and multivariable regression analysis was used to define which maternal and pregnancy characteristics provided a significant independent contribution in the prediction of miscarriage and fetal loss at any stage of pregnancy. In the study period, 2645 twin pregnancies were eligible for analysis. There were 144 cases of miscarriage defined as fetal loss of one or both twins before 24 weeks and 40 cases of intrauterine death of one or both twins after 24 weeks. A total number of 162 twin pregnancies underwent amniocentesis at 16-20 weeks' gestation. The rate of miscarriage before 24 weeks and the rate of fetal loss at any stage of pregnancy in the group that underwent amniocentesis was 10.49% and 13.58%, respectively, compared to 5.11% and 6.52% that did not undergo amniocentesis. Multivariable regression analysis showed that factors providing a significant independent contribution in the prediction of miscarriage and fetal loss at any stage of pregnancy were monochorionicity (MC), large intertwin discordance in crown-rump length (CRL), low Pregnancy Related Plasma Protein (PAPP-A) MoM and nuchal translucency (NT) above 95th centile. Amniocentesis in twin pregnancies does not provide a significant contribution in the prediction of miscarriage or fetal loss at any stage of pregnancy.
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Affiliation(s)
- Ewelina Litwinska
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, 03-242 Warsaw, Poland; (M.L.); (M.W.)
- Correspondence: ; Tel.: +48-601-636-778
| | - Magdalena Litwinska
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, 03-242 Warsaw, Poland; (M.L.); (M.W.)
| | - Bartosz Czuba
- Women’s Health, Faculty of Health Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Agnieszka Gach
- Department of Genetics, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland;
| | - Sebastian Kwiatkowski
- Clinical Department of Obstetrics and Gynecology, Pomeranian Medical University, 71-455 Szczecin, Poland;
| | - Przemyslaw Kosinski
- Department of Obstetrics, Perinatology and Gynecology, Medical University of Warsaw, 03-242 Warsaw, Poland;
| | - Piotr Kaczmarek
- Department of Gynecology, Fertility and Fetal Therapy, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland;
| | - Miroslaw Wielgos
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, 03-242 Warsaw, Poland; (M.L.); (M.W.)
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Navaratnam K, Alfirevic Z. Amniocentesis and chorionic villus sampling: Green-top Guideline No. 8. BJOG 2021; 129:e1-e15. [PMID: 34693616 DOI: 10.1111/1471-0528.16821] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Wertheimer A, Decter D, Borovich A, Trigerman S, Bardin R, Hadar E, Krispin E. Amniocentesis in twin gestation: the association between gestational age at procedure and complications. Arch Gynecol Obstet 2021; 305:1169-1175. [DOI: 10.1007/s00404-021-06242-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/07/2021] [Indexed: 11/29/2022]
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Ogawa M, Hasuo Y, Taura Y, Tsunematsu R, Shikada S, Matsushita Y, Sato K. Attitude changes toward prenatal testing among women with twin pregnancies after the introduction of noninvasive prenatal testing: A single-center study in Japan. J Obstet Gynaecol Res 2021; 47:3813-3820. [PMID: 34490692 PMCID: PMC9292293 DOI: 10.1111/jog.15010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 07/27/2021] [Accepted: 08/27/2021] [Indexed: 11/27/2022]
Abstract
Aim This study aimed to evaluate changes in prenatal testing among women with twin pregnancies before and after the introduction of noninvasive prenatal testing (NIPT). To date, no consensus on prenatal testing for twin pregnancies has been reached in Japan. Methods Women pregnant with twins who requested prenatal testing at Kyushu Medical Center from 2005 to 2018 were included in this study. Genetic counseling was provided to all participants. Their chosen methods of testing were collected and classified as invasive diagnosis (ID), noninvasive screening (NIS), and no test requested (NR). Parity, chorionicity, and methods of conception were assessed as attributes. The study period was divided into three terms according to testing availability in our center. Results After NIPT was introduced in our center, the use of ID methods decreased and eventually disappeared while NIS came to the forefront. NR was also the preferred choice of women with twin pregnancies before the introduction of NIPT and decreased but did not disappear after introducing NIPT. Women with twin pregnancies who underwent assisted reproduction initially showed hesitation to undergo testing but showed a strong preference for NIS after the introduction of NIPT. Differences in choice according to parity, chorionicity, and methods of conception were found before the introduction of NIPT but disappeared after introducing NIPT. Conclusion Increasing information about NIPT has apparently influenced the attitudes of women with twin pregnancies to prenatal testing in Japan. In particular, those who conceive through assisted reproductive technologies exhibited a strong preference for NIPT.
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Affiliation(s)
- Masanobu Ogawa
- Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Department of Clinical Genetics and Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Yasuyuki Hasuo
- Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Department of Obstetrics and Gynecology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Genetic Counseling Clinic, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yumiko Taura
- Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Department of Obstetrics and Gynecology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Genetic Counseling Clinic, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Ryosuke Tsunematsu
- Department of Gynecology, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Sawako Shikada
- Department of Clinical Genetics and Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Yuki Matsushita
- Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Genetic Counseling Clinic, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Department of Pediatrics, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Kazuo Sato
- Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Department of Pediatrics, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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Di Mascio D, Khalil A, Rizzo G, Buca D, Liberati M, Martellucci CA, Flacco ME, Manzoli L, D'Antonio F. Risk of fetal loss following amniocentesis or chorionic villus sampling in twin pregnancy: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:647-655. [PMID: 32632979 DOI: 10.1002/uog.22143] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the rate of fetal loss following amniocentesis or chorionic villus sampling (CVS) in twin pregnancy. METHODS MEDLINE, EMBASE and Cochrane databases were searched for studies reporting procedure-related complications following amniocentesis or CVS in twin pregnancy. The primary outcome was the rate of procedure-related fetal loss. The secondary outcomes were fetal loss occurring before 24 weeks of gestation and fetal loss occurring within 4 weeks after the procedure. Head-to-head meta-analyses were used to compare directly each outcome, between women undergoing amniocentesis and those not undergoing amniocentesis and between women undergoing CVS and those not undergoing CVS, and to compute pooled risk differences (RD) between women exposed and those not exposed to each invasive procedure. Additionally, meta-analyses of proportions were used to estimate the pooled rates of each of the three outcomes in women undergoing amniocentesis or CVS and in controls. RESULTS Sixteen studies (3419 twin pregnancies undergoing and 2517 not undergoing an invasive procedure) were included. Head-to-head meta-analyses comparing directly twin pregnancies undergoing and those not undergoing amniocentesis showed a higher risk for overall fetal loss in those undergoing amniocentesis (odds ratio (OR), 1.46 (P = 0.04); RD, 0.013 (P = 0.04)), while there was no difference in the risk of either fetal loss before 24 weeks of gestation (OR, 1.59 (P = 0.06); RD, 0.010 (P = 0.11)) or fetal loss within 4 weeks after the procedure (OR, 1.38 (P = 0.3); RD, 0.003 (P = 0.8)). Overall, the pooled rate of fetal loss was 2.4% (95% CI, 1.4-3.6%) in twin pregnancies undergoing amniocentesis compared with 2.4% (95% CI, 0.9-4.6%) in those not undergoing amniocentesis. Head-to-head meta-analyses directly comparing twin pregnancies undergoing and those not undergoing CVS showed no significant difference in either overall fetal loss (OR, 1.61 (P = 0.5); RD, 0.003 (P = 0.8)) or fetal loss before 24 weeks of gestation (OR, 1.61 (P = 0.5); RD, 0.003 (P = 0.8)). Overall, the pooled rate of fetal loss was 2.0% (95% CI, 0.0-6.5%) in twin pregnancies undergoing CVS compared with 1.8% (95% CI, 0.3-4.2%) in those not undergoing CVS. CONCLUSION The risk of fetal loss following amniocentesis and CVS in twins is lower than reported previously and the rate of fetal loss before 24 weeks of gestation, or within 4 weeks after the procedure, did not differ from the background risk in twin pregnancy not undergoing invasive prenatal testing. These data can guide prenatal counseling for twin pregnancies undergoing invasive procedures. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - G Rizzo
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - D Buca
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - M Liberati
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - C A Martellucci
- Department of Biomedical Sciences and Public Health, University of the Marche Region, Ancona, Italy
| | - M E Flacco
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - L Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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Kim MS, Ahn E, Lee SB, Moon MJ, Kang S. Obstetrical outcomes after first-trimester chorionic villus sampling in twin pregnancies: A retrospective case-control study. J Obstet Gynaecol Res 2019; 45:1466-1471. [PMID: 31099123 DOI: 10.1111/jog.13993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 04/14/2019] [Indexed: 01/18/2023]
Abstract
AIM Prenatal diagnostic testing by chorionic villus sampling (CVS) is sometimes recommended for women with twin pregnancies. However, few studies have compared the outcomes between twins with CVS and control twins without intervention. This study aimed to compare the obstetrical outcomes of CVS in twin pregnancies and those in non-intervention twin pregnancies. METHODS First-trimester transabdominal CVS was performed on dichorionic-diamniotic twins (n = 54; Group 1) between December 2006 and January 2017 at the Department of Obstetrics and Gynecology at our hospital, and the data were retrospectively analyzed. CVS risks were evaluated by comparing obstetrical outcomes with those of a control population of 155 dichorionic-diamniotic twins without intervention (Group 2). RESULTS The difference in the overall fetal loss rate (Group 1, 7.4% vs Group 2, 3.9%; P = 0.287) between the two groups was not statistically significant. The miscarriage rate, defined as delivery at <24 gestational weeks, and early preterm delivery, defined as delivery at <34 gestational weeks, were not significant between the groups (miscarriage: Group 1, 5.6% vs Group 2, 3.2%; P = 0.428; early preterm delivery: Group 1, 11.1% vs Group 2, 9.0%; P = 0.788). The mean gestational age at delivery, birth weights and neonatal intensive care unit admission rate were not statistically significant between the groups. Thus, the overall fetal loss rate and obstetrical outcomes of Group 1 were comparable with those of Group 2. CONCLUSION In conclusion, the overall obstetrical outcomes were not significantly different between twins with CVS and control twins with the advantage of enabling early decision-making about selective feticide in twins with CVS.
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Affiliation(s)
- Mi S Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
| | - Eunhee Ahn
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
| | - Soo B Lee
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
| | - Myoung J Moon
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
| | - Sukho Kang
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
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Kim MS, Moon MJ, Kang S, Jung SH, Chang SW, Ki HJ, Kim B, Ahn E. Obstetrical Outcomes of Amniocentesis or Chorionic Villus Sampling in Dichorionic Twin Pregnancies. J Korean Med Sci 2019; 34:e142. [PMID: 31074255 PMCID: PMC6509361 DOI: 10.3346/jkms.2019.34.e142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/24/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Under certain situations, women with twin pregnancies may be counseled to undergo invasive prenatal diagnostic testing. Chorionic villus sampling and amniocentesis are the two generally performed invasive prenatal diagnostic tests. Studies comparing procedure-related fetal loss between first-trimester chorionic villus sampling and second-trimester amniocentesis in twin pregnancies are limited. This study aimed to evaluate the procedure-related fetal loss and the obstetrical outcomes of these two procedures, chorionic villus sampling and amniocentesis in twin pregnancies. METHODS The data from dichorionic-diamniotic twin pregnancies on which first-trimester chorionic villus sampling (n = 54) or second-trimester amniocentesis (n = 170) was performed between December 2006 and January 2017 in a single center were retrospectively analyzed. The procedure-related fetal loss was classified as loss of one or all fetuses within 4 weeks of procedure, and overall fetal loss was classified as loss of one or all fetuses during the gestation. The groups were compared with respect to the procedure-related and obstetrical outcomes. RESULTS The difference in proportion of procedure-related fetal loss rate (1.9% for chorionic villus sampling vs. 1.8% for amniocentesis; P = 1.000) and the overall fetal loss rate (7.4% for chorionic villus sampling vs. 4.7% for amniocentesis; P = 0.489) between the two groups was not significant. The mean gestational ages at delivery were not statistically significant. CONCLUSION Both the overall fetal loss rate and the procedure-related fetal loss rate of chorionic villus sampling and amniocentesis in dichorionic twin pregnancies had no statistical significance. Both procedures can be safely used individually.
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Affiliation(s)
- Mi Sun Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam, Korea
| | - Myoung Jin Moon
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam, Korea
| | - Sukho Kang
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam, Korea
| | - Sang Hee Jung
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam, Korea
| | - Sung Woon Chang
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam, Korea
| | - Hyo Jin Ki
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam, Korea
| | - Bohye Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam, Korea
| | - Eunhee Ahn
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam, Korea.
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Connolly KA, Eddleman KA. Amniocentesis: A contemporary review. World J Obstet Gynecol 2016; 5:58-65. [DOI: 10.5317/wjog.v5.i1.58] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 10/27/2015] [Accepted: 12/15/2015] [Indexed: 02/05/2023] Open
Abstract
Amniocentesis is an essential tool in obstetrics. Invasive testing remains the only modality for diagnostic genetic testing and the only way to provide comprehensive testing for chromosomal abnormalities. Despite increasing use of cell free fetal deoxyribonucleic acid (DNA) testing, amniocentesis should still be offered to all women who desire more complete and accurate genetic testing. Counseling patients on the limitations of screening tests is of the upmost importance and amniocentesis should continue to be recommended to confirm positive results from cell free fetal DNA testing or in the case of failed cell free fetal DNA test. As cell free fetal DNA screening has not adequately been studied in multiple gestations, its use is not recommended in this population and invasive testing should be offered. Amniocentesis is also very useful in providing additional information in settings other than genetic testing the second and third trimester. If intraamniotic infection is suspected, but the clinical findings are not enough to guide management, amniocentesis can provide testing that can both immediately clarify the picture (interleukin-6, gram stain, glucose levels) and finally confirm the presence of infection (culture). It can also be used to detect the presence of intrauterine viral infections. Additionally, amniocentesis may be used to test for markers of fetal lung maturity. The American Congress of Obstetricians and Gynecologists recommends that amniocentesis for this indication not be used in cases where late preterm delivery is indicated. It may be useful in guiding decision-making, however, when late preterm delivery is indicated, but when exact timing is unclear. Regardless of the indication, amniocentesis appears to be a relatively low risk procedure with minimal risk to the patient. Additional randomized controlled trials are not likely, as they are not feasible to due extremely high number of participants that would be needed to detect a difference in loss rates. Based on current literature, however, the risk of pregnancy loss from second trimester amniocentesis is low in both singleton and twin gestations. We counsel patients that technique has changed since the original studies in the 1970s and feel comfortable quoting a loss rate of 1/500-1/1000 based on contemporary data.
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Current principles and practice of ethics and law in perinatal medicine. CURRENT HEALTH SCIENCES JOURNAL 2014; 40:162-9. [PMID: 25729600 PMCID: PMC4340435 DOI: 10.12865/chsj.40.03.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 06/10/2014] [Indexed: 12/03/2022]
Abstract
One of the most controversial discussion topics in modern bioethics, science or philosophy is represented by the beginning of the individual human life. It is ethically, medically and scientifically correct that the human conception product to be born, so to gain personality and individuality, to be treated as a patient since the intrauterine life. Intrauterine foetal interventions, performed in various therapeutic purposes are still in the experimental stage even in centres with rich experience in perinatal medicine. Progresses truly outstanding are present especially in the prenatal diagnostic methods. Non invasive prenatal testing represents without a doubt a great progress in prenatal diagnosis, but from this point of view, the role of practitioners in the field of perinatal medicine, on counselling and addressing the indication of this test becomes essential. Beyond cultural, national, social or related differences, in perinatal medicine practice is particularly important to respect and permanently reassess the ethical codes. Our paper is targeting to spotlight the essential principles and practice of ethics and law in perinatal medicine nowadays on one hand, and to bring an update review on a controversial topic on the other hand.
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Maymon R, Cuckle H, Svirsky R, Sheena L, Melcer Y, Rozen H, Ben-Ami I. Nuchal translucency in twins according to mode of assisted conception and chorionicity. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:38-43. [PMID: 24339187 DOI: 10.1002/uog.13278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 11/04/2013] [Accepted: 11/29/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The impact of nuchal translucency (NT) screening in twins conceived after use of assisted reproduction technology (ART) has not been addressed properly in the literature. The aim of the current study was to assess, in a large cohort from a single center, NT in twins following various modes of ART as compared with NT in spontaneously-conceived twins and to differentiate results with regard to chorionicity. METHODS Retrospective data from 825 twin pregnancies were available for this study. All pregnant women underwent NT screening and chorionicity determination between 11 + 0 and 13 + 6 weeks' gestation in our center. Information about mode of conception and pregnancy outcome was obtained from hospital records and by telephone interviews. Twins were classified as having been conceived after in-vitro fertilization (IVF) with the woman's own or a donated embryo, after non-IVF ART or spontaneously. NT distribution in subgroups of fetuses was compared on the basis of the multiple of the normal median (MoM), SD of log10 MoM estimated by the 90(th) -10(th) centile range divided by 2.563 and the proportion of NT values exceeding the normal 95(th) centile which was 1.641 MoM in the singletons. RESULTS NT values were statistically significantly higher in ART pregnancies as compared with spontaneously-conceived pregnancies (Wilcoxon rank-sum test, P < 0.05) with medians of 1.073 and 1.038 MoM, respectively, but the proportion with values above the normal 95(th) percentile did not differ (chi-square test, P = 0.89). Among the ART twins, NT values were significantly higher for those conceived using IVF methods (P < 0.005), with a median of 1.082 MoM, compared with a median of 1.022 MoM using other methods. However, although a greater proportion exceeded the 95(th) centile (7.3% compared with 4.8%) this difference did not reach statistical significance (P = 0.17). There were no differences in NT values according to chorionicity (Wilcoxon rank-sum test, P = 0.75). The standard deviation of log10 NT was similar for all subgroups of twins. The correlation coefficient between fetuses in ART pregnancies was statistically significantly lower than that in spontaneously-conceived pregnancies (P < 0.05) but no significant differences were found between types of ART or according to chorionicity. CONCLUSIONS There was a small but significant increase in NT levels among ART pregnancies, which appeared to be confined to those conceived using IVF, and a small reduction in the correlation between fetuses. These effects probably have little impact on the estimated risk based on algorithms in use today.
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Affiliation(s)
- R Maymon
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Gagnon A, Audibert F. Prenatal screening and diagnosis of aneuploidy in multiple pregnancies. Best Pract Res Clin Obstet Gynaecol 2013; 28:285-94. [PMID: 24485166 DOI: 10.1016/j.bpobgyn.2013.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 12/17/2013] [Indexed: 11/29/2022]
Abstract
Prenatal screening for aneuploidy has changed significantly over the last 30 years, from being age-based to maternal serum and ultrasound based techniques. Multiple pregnancies present particular challenges with regards to screening as serum-based screening techniques are influenced by all feti while ultrasound-based techniques can be fetus specific. Tests currently available tend to not perform as well in multiple compared to singleton pregnancies. Considerations must be given to these variations when discussing and performing screening for aneuploidy in this situation. Prenatal invasive diagnosis techniques in multiple pregnancies bring their own challenges from a technical and counselling point of view, in particular with regards to sampling error, mapping and assignment of results and management of abnormal results. This review addresses these particular challenges and provides information to facilitate care.
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Affiliation(s)
- Alain Gagnon
- University of British Columbia, Vancouver, British Columbia, Canada.
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Lenis-Cordoba N, Sánchez MÁ, Bello-Muñoz JC, Sagalá-Martinez J, Campos N, Carreras-Moratonas E, Cabero-Roura L. Amniocentesis and the risk of second trimester fetal loss in twin pregnancies: results from a prospective observational study. J Matern Fetal Neonatal Med 2013; 26:1537-41. [PMID: 23544929 DOI: 10.3109/14767058.2013.791271] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIM To compare the rate of pregnancy loss between twin pregnancies undergoing a genetic amniocentesis (AC) and a control group with similar characteristics. METHODS Prospective observational study on a population of twin pregnancies referred to our prenatal diagnosis unit for screening from 1990 to 2010. Those women referred for an AC were compared with those without indication for the procedure. Primary outcomes were pregnancy loss within the 4 weeks after procedure and pregnancy loss before 24 weeks. Secondary outcome included neonatal morbidity, gestational age at delivery and birth weight. results: Maternal characteristics were similar for both groups, except for maternal age. There was neither difference in the pregnancy loss rate within 4 weeks (2.7 versus 2.6%) nor in the loss rate before 24 weeks of gestation (1.2 versus 1.1%). Gestational age at birth was 36 weeks for both groups. Chorionicity and gestational age at procedure played no role in modifying the risk. CONCLUSION Based on our results, there is no difference in the pregnancy loss rate in twin gestations, regardless of chorionicity or gestational age at procedure, either within 4 weeks after the procedure or before 24 weeks, in patients who undergo AC when compared with patients who do not.
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Agarwal K, Alfirevic Z. Pregnancy loss after chorionic villus sampling and genetic amniocentesis in twin pregnancies: a systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:128-134. [PMID: 22125091 DOI: 10.1002/uog.10152] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/10/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To review the available evidence regarding pregnancy loss following first-trimester chorionic villus sampling (CVS) and mid-trimester genetic amniocentesis in twins. METHODS We searched the MEDLINE database from January 1990 to May 2011 for randomized and cohort studies reporting on the risk of pregnancy loss after first-trimester CVS performed between 9 and 14 weeks and after genetic amniocentesis performed between 14 and 22 weeks. Where appropriate, we calculated pooled proportions and relative risks with 95% CI. RESULTS No randomized studies were found. For CVS, nine studies fulfilled the inclusion criteria. The overall pregnancy-loss rate was 3.84% (95% CI, 2.48-5.47; n = 4). The rate of pregnancy loss before 20 weeks was 2.75% (95% CI, 1.28-4.75; n = 3) and before 28 weeks was 3.44% (95% CI, 1.67-5.81; n = 3). For amniocentesis, the overall pregnancy-loss rate was 3.07% (95% CI, 1.83-4.61; n = 4). The rate of pregnancy loss before 20 weeks was 2.25% (95% CI, 1.23-3.57; n = 2), before 24 weeks was 2.54% (95% CI, 1.43-3.96; n = 9) and before 28 weeks was 1.70% (95% CI, 0.37-3.97; n = 5). Pooled data from four case-control studies showed a higher risk (2.59% vs. 1.53%) of pregnancy loss before 24 weeks following amniocentesis (relative risk = 1.81; 95% CI, 1.02-3.19). There were no statistically significant differences in reported pregnancy loss between transabdominal and transcervical approaches, use of a single-needle system vs. a double-needle system and single uterine entry vs. double uterine entry in the CVS group. Similarly, in the amniocentesis group, there was no statistically significant difference in fetal loss between the single uterine entry vs. the double uterine entry. CONCLUSION In the absence of randomized studies, it is not possible to estimate accurately the excess risk following invasive procedures in twins. Currently available data show similar overall pregnancy-loss rates for both amniocentesis and CVS with the excess risk of around 1% above the background risk.
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Affiliation(s)
- K Agarwal
- Department of Obstetrics & Gynecology, Maulana Azad Medical College, New Delhi, India
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Vink J, Fuchs K, D'Alton ME. Amniocentesis in twin pregnancies: a systematic review of the literature. Prenat Diagn 2012; 32:409-16. [PMID: 22028248 PMCID: PMC3330135 DOI: 10.1002/pd.2897] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Using published data, we sought to determine the amniocentesis-related loss rate in twin gestations. METHODS We searched the PUBMED database using keywords "amniocentesis", "twin" and "twins" to identify articles evaluating genetic amniocentesis in twin gestations published from January 1970 to December 2010. Random effects models were used to pool procedure-related loss rates from included studies. RESULTS The definition of "loss" varied across the 17 studies identified (Table 1). The pooled procedure-related loss rate at < 24 weeks was 3.5% (95% confidence interval [CI] 2.6-4.7) (Figure 2). Pooled loss rates at < 28 weeks (Figure 4) and to term (Figure 5) could not be calculated due to unacceptable heterogeneity of available data. Seven studies included a control (no amniocentesis) group and reported a pooled odds ratio for total pregnancy loss among cases of 1.8 (95% CI 1.2-2.7) (Figure 3). Only 1 study reported procedure-related loss rates by chorionicity (7.7% among monochorionics vs 1.4% among controls; p 0.02). CONCLUSION Analysis of published data demonstrated a pooled amniocentesis-related loss rate of 3.5% in twin gestations < 24 weeks. Pooled loss rates within other post-amniocentesis intervals or other gestational age windows and the impact of chorionicity on procedure-related loss rates cannot be determined from published data.
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Affiliation(s)
- Joy Vink
- Department of OB/GYN, Division of Maternal Fetal Medicine, Columbia University Medical Center, New York, NY 347-880-2492 USA.
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Kan ASY, Lee CP, Leung KY, Chan BCP, Tang MHY, Chan VHY. Outcome of twin pregnancies after amniocentesis. J Obstet Gynaecol Res 2012; 38:376-82. [DOI: 10.1111/j.1447-0756.2011.01721.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kalogiannidis I, Petousis S, Prapa S, Dagklis T, Karkanaki A, Prapas Y, Prapas N. Amniocentesis-related adverse outcomes in diamniotic twins: is there a difference compared to singleton pregnancies? Eur J Obstet Gynecol Reprod Biol 2011; 155:23-6. [DOI: 10.1016/j.ejogrb.2010.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Revised: 09/16/2010] [Accepted: 11/07/2010] [Indexed: 11/16/2022]
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Twins: prevalence, problems, and preterm births. Am J Obstet Gynecol 2010; 203:305-15. [PMID: 20728073 DOI: 10.1016/j.ajog.2010.04.031] [Citation(s) in RCA: 249] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 04/12/2010] [Accepted: 04/19/2010] [Indexed: 11/21/2022]
Abstract
The rate of twin pregnancies in the United States has stabilized at 32 per 1000 births in 2006. Aside from determining chorionicity, first-trimester screening and second-trimester ultrasound scanning should ascertain whether there are structural or chromosomal abnormalities. Compared with singleton births, genetic amniocentesis-related loss at <24 weeks of gestation for twin births is higher (0.9% vs 2.9%, respectively). Selective termination for an anomalous fetus is an option, although the pregnancy loss rate is 7% at experienced centers. For singleton and twin births for African American and white women, approximately 50% of preterm births are indicated; approximately one-third of these births are spontaneous, and 10% of the births occur after preterm premature rupture of membranes. From 1989-2000, the rate of preterm twin births increased, for African American and white women alike, although the perinatal mortality rate has actually decreased. As with singleton births, tocolytics should be used judiciously and only for a limited time (<48 hours) in twin births. Administration of antenatal corticosteroids is an evidence-based recommendation.
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Simonazzi G, Curti A, Farina A, Pilu G, Bovicelli L, Rizzo N. Amniocentesis and chorionic villus sampling in twin gestations: which is the best sampling technique? Am J Obstet Gynecol 2010; 202:365.e1-5. [PMID: 20060095 DOI: 10.1016/j.ajog.2009.11.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 08/27/2009] [Accepted: 11/10/2009] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare the fetal loss rate <24 weeks and the preterm premature rupture of the membranes <34 weeks' gestation according to type of invasive procedure and to sampling techniques in twins. STUDY DESIGN Retrospective cohort study of 204 twin pregnancies, who underwent amniocentesis (100) or chorionic villus sampling (104). RESULTS Fetal loss rate <4 weeks was 3.85% in chorionic villus sampling group and 4.00% in amniocentesis group (P value not significant). According to sampling technique, fetal loss rate was 4.17% (chorionic villus sampling 1 puncture), 2.70% (amniocentesis 1 puncture), 3.75% (chorionic villus sampling 2 punctures), and 4.76% (amniocentesis 2 punctures), (P values not significant). Preterm premature rupture of the membranes rate <34 weeks was 8.2% chorionic villus sampling group and 10% in amniocentesis group (P value not significant). According to sampling technique, preterm premature rupture of the membranes rate was 12.5% (chorionic villus sampling 1 puncture), 8.1% (amniocentesis 1 puncture), 6.9% (chorionic villus sampling 2 punctures), and 11.1 % (amniocentesis 2 punctures), (P values not significant). CONCLUSION Double entry technique does not affect significantly the outcomes evaluated, in both amniocentesis and chorionic villus sampling.
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Affiliation(s)
- Giuliana Simonazzi
- Department of Obstetrics and Gynecology, St. Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
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Quel prélèvement choisir pour les grossesses gémellaires : choriocentèse ou amniocentèse ? ACTA ACUST UNITED AC 2009; 38:S39-44. [DOI: 10.1016/s0368-2315(09)73558-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Zhong XY, Holzgreve W. MALDI-TOF MS in Prenatal Genomics. ACTA ACUST UNITED AC 2009; 36:263-272. [PMID: 21049077 DOI: 10.1159/000223098] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Accepted: 05/14/2009] [Indexed: 12/23/2022]
Abstract
Prenatal diagnosis aims either to provide the reassurance to the couples at risk of having an affected child by timely appropriate therapy or to give the parents a chance to decide the fate of the unborn babies with health problems. Invasive prenatal diagnosis (IPD) is accurate, however, carrying a risk of miscarriage. Non-invasive prenatal diagnosis (NIPD) has been developed based on the existing of fetal genetic materials in maternal circulation; however, a minority fetal DNA in majority maternal background DNA hinders the detections of fetal traits. Different protocols and assays, such as homogenous MassEXTEND (hME), single allele base extension reaction (SABER), precise measuring copy number variation of each allele, and quantitative methylation and expression analysis using the high-throughput sensitive matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS), allow NIPD for single gene disorders, fetal blood group genotyping and fetal aneuploidies as well as the development of fetal gender-independent biomarkers in maternal circulation for management of pathological pregnancies. In this review, we summarise the use of MALDI-TOF MS in prenatal genomics.
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Affiliation(s)
- Xiao Yan Zhong
- Laboratory for Prenatal Medicine and Gynaecological Oncology, University Women's Hospital /Department Research, University of Basel, Switzerland
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Pregnancy loss rate after mid-trimester amniocentesis in twin pregnancies. Am J Obstet Gynecol 2009; 200:257.e1-6. [PMID: 19136086 DOI: 10.1016/j.ajog.2008.09.872] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 07/18/2008] [Accepted: 09/26/2008] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this study was to estimate the attributable pregnancy loss rate of mid-trimester amniocentesis in twin pregnancies. STUDY DESIGN A 16-year retrospective cohort of all twin pregnancies that underwent ultrasound evaluation at a large tertiary care medical center was followed for pregnancy outcomes. Women who underwent amniocentesis were compared with those who did not. Fetal loss was defined as loss before 24 weeks' gestation. Univariable, stratified, multivariable, and time-to-event analyses were performed. RESULTS Of 1934 twin pregnancies, 311 women elected amniocentesis. Women who elected amniocentesis were more likely to experience a pregnancy loss than those who did not (3.2% vs 1.4%; risk difference, 1.80%; 95% CI, -0.24 to 3.84%), which was significant after adjustment for advanced maternal age, chorionicity, sonographic findings, alcohol exposure, and race (adjusted odds ratio, 2.9; 95% CI, 1.2-6.9). CONCLUSION The attributable risk of pregnancy loss before 24 weeks' gestation after mid-trimester amniocentesis in twin pregnancies is 1 in 56 (1.8%). This information will be useful in counseling patients with twin pregnancies who are considering amniocentesis.
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Abstract
The incidence of twins, triplets, and high-order multiples has increased dramatically in the last two decades secondary to greater reliance on fertility treatments and to delayed childbearing. Offspring of a multiple gestation are at increased risk for both chromosomal and structural abnormalities. Prenatal diagnosis in these patients is challenging. Options for screening tests are limited. Invasive diagnostic procedures are complex. Likewise, physicians and patients may be faced with the dilemma of deciding how to manage discordant results. The following paper will review the unique concerns associated with prenatal diagnosis in a multiple pregnancy and the current methods of prenatal screening in these patients. Invasive prenatal diagnosis will also be explored.
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Abstract
This review discusses the various invasive techniques currently performed in multiple pregnancies.
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Affiliation(s)
- Meredith Rochon
- Division of Maternal-Fetal Medicine, Mount Sinai Medical Center, 5 East 98th Street, Box 1171, New York, NY 10029, USA.
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Abstract
Chromosomal anomalies and mendelian diseases are more frequent in multiple gestations than in singletons. Prenatal diagnosis is recommended in multiple pregnancies whenever indicated. Invasive testing using amniocentesis or chorionic villus sampling can be performed safely. Chorionic villus sampling has a significant advantage over amniocentesis because it offers rapid karyotyping and biochemical and DNA studies at an early stage of pregnancy. Only experienced centers should perform these procedures because of the technical aspects and the expertise needed in handling discordant results.
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Affiliation(s)
- Zvi Appelman
- Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot 76100, Israel.
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Bhide A, Thilaganathan B. What prenatal diagnosis should be offered in multiple pregnancy? Best Pract Res Clin Obstet Gynaecol 2004; 18:531-42. [PMID: 15279815 DOI: 10.1016/j.bpobgyn.2004.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The issues surrounding prenatal diagnosis in multiple pregnancy are complex. Accurate determination of chorionicity is vital and an inability to determine this should trigger consideration for referral to a specialist. The choice of screening method for detection of chromosomal abnormality is limited, and existing data demonstrates the advantages of nuchal translucency screening. The possibility of obtaining discordant results and options for management should be discussed in advance. Invasive tests are technically more difficult and associated with a higher risk of procedure-related pregnancy loss than less invasive methods. Repeat invasive testing is required more often in multiple pregnancies than in singleton pregnancies. Selective termination is technically feasible in both mono- and dichorionic pregnancies, although the risks are higher with the former. It is likely to be more acceptable than high-order multifetal reduction performed in the absence of fetal abnormality.
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Affiliation(s)
- Amaranth Bhide
- Fetal Medicine Unit, Academic Department of Obstetrics and Gynaecology, St George's Hospital Medical School, London SW17 0QT, UK.
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Nicolaides KH. Nuchal translucency and other first-trimester sonographic markers of chromosomal abnormalities. Am J Obstet Gynecol 2004; 191:45-67. [PMID: 15295343 DOI: 10.1016/j.ajog.2004.03.090] [Citation(s) in RCA: 345] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is extensive evidence that effective screening for major chromosomal abnormalities can be provided in the first trimester of pregnancy. Prospective studies in a total of 200,868 pregnancies, including 871 fetuses with trisomy 21, have demonstrated that increased nuchal translucency can identify 76.8% of fetuses with trisomy 21, which represents a false-positive rate of 4.2%. When fetal nuchal translucency was combined with maternal serum free-beta-human chorionic gonadotropin and pregnancy-associated plasma protein-A in prospective studies in a total of 44,613 pregnancies, including 215 fetuses with trisomy 21, the detection rate was 87.0% for a false-positive rate of 5.0%. Studies from specialist centers with 15,822 pregnancies, which included 397 fetuses with trisomy 21, have demonstrated that the absence of the nasal bone can identify 69.0% of trisomy 21 fetuses, which represents a false-positive rate of 1.4%. It has been estimated that first-trimester screening by a combination of sonography and maternal serum testing can identify 97% of trisomy 21 fetuses, which represents a false-positive rate of 5%, or that the detection rate can be 91%, which represents a false-positive rate of 0.5%. In addition to increased nuchal translucency, important sonographic markers for chromosomal abnormalities, include fetal growth restriction, tachycardia, abnormal flow in the ductus venosus, megacystis, exomphalos and single umbilical artery. Most pregnant women prefer screening in the first, rather than in the second, trimester. As with all aspects of good clinical practice, those care givers who perform first-trimester screening should be trained appropriately, and their results should be subjected to external quality assurance.
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Affiliation(s)
- Kypros H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College, London University, Denmark Hill, London SE5 8RX.
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Ralston SJ, Craigo SD. Ultrasound-guided procedures for prenatal diagnosis and therapy. Obstet Gynecol Clin North Am 2004; 31:101-23. [PMID: 15062449 DOI: 10.1016/s0889-8545(03)00124-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Ultrasonography has expanded the capabilities of perinatologists to examine,test, and treat the fetus. Amniocentesis and CVS are safe and widely available procedures, which can be used to diagnose a multitude of abnormalities through karyotype analysis and molecular studies. CVS allows earlier diagnosis, but both procedures can provide highly accurate results in the first half of pregnancy. Cordocentesis has fewer indications, but allows direct laboratory testing of fetal blood. Fetocentesis and fetal biopsy are reserved for limited indications, but can play a crucial role in the diagnosis of some conditions, which cannot be assessed less invasively. Fetal transfusion is an important tool in the treatment of isoimmunization, some other forms of fetal anemia, and alloimmune thrombocytopenia. Amnioreduction is a commonly used procedure for the treatment of polyhydramnios and TTTS. Multifetal reduction and selective termination offer previously unavailable options to patients carrying multiple gestations. Fetal shunts can reduce perinatal morbidity and mortality in cases of bladder outlet obstruction and hydrothorax. The limited experience with cord ligation procedures and balloon valvuloplasty suggests these relatively new procedures may serve a greater role in the future as techniques are improved. By providing guidance for all of these procedures, real-time ultrasonography has revolutionized prenatal diagnosis and therapy; it will continue to be a crucial component in evaluating and treating complicated pregnancies.
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Affiliation(s)
- Steven J Ralston
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tufts University School of Medicine, Tufts-New England Medical Center, 750 Washington Street, Box 360, Boston, MA 02111, USA
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Graham G, Simpson LL. Diagnosis and Management of Obstetrical Complications Unique to Multiple Gestations. Clin Obstet Gynecol 2004; 47:163-80. [PMID: 15024283 DOI: 10.1097/00003081-200403000-00019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- George Graham
- New York Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
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Picone O, Dommergues M. Stratégies de diagnostic prénatal et prise en charge des pathologies liées aux grossesses multiples. ACTA ACUST UNITED AC 2004; 32:153-9. [PMID: 15123140 DOI: 10.1016/j.gyobfe.2003.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2003] [Accepted: 07/31/2003] [Indexed: 10/26/2022]
Abstract
In the first trimester, ultrasound is crucial to screen for aneuploidies based on nuchal translucency, to diagnose major birth defects, and to establish chorionicity. Indeed prenatal diagnosis strategies as well as obstetrical management options are largely based on placental type. In the second trimester, maternal serum screening is not as effective, and ultrasound screening is more difficult in twins than in singletons. When a severe abnormality in found in one twin, selective termination of pregnancy may be considered. This technique is safe in dichorionic twins, but hazardous in monochorionic pregnancies. Selective termination in dichorionic twins is safer in the first trimester, underscoring the need for early prenatal diagnosis in twins. Monochorionic twin pregnancies carry specific risks, such as the twin-to-twin transfusion syndrome, which can be treated by endoscopic photo-coagulation of intertwin anastomoses in the severe early onset cases, or by amnioreduction in milder cases.
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Affiliation(s)
- O Picone
- Maternité, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France.
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Abstract
PURPOSE OF REVIEW The incidence of multiple gestations has increased significantly with advances in assisted reproductive techniques resulting in a concomitant increase in invasive procedures in these pregnancies. Commonly performed invasive procedures include amniocentesis, chorionic villus sampling, multifetal pregnancy reduction, and selective termination. Amniocentesis and chorionic villus sampling are also performed in singleton pregnancies, while multifetal pregnancy reduction and selective termination are procedures that are unique to multiple gestations. RECENT FINDINGS With increased operator experience, pregnancy loss rates after chorionic villus sampling, multifetal pregnancy reduction, and selective termination have decreased to acceptably low levels. Amniocentesis and chorionic villus sampling continue to have similar loss rates in experienced hands. A recent study suggests that amniocentesis in twins may have a higher post-procedural loss rate than in singletons; this may be due to the higher background loss rate of twins. There has been a recent increase in multifetal pregnancy reduction to a singleton with a trend towards improved outcomes over reduction to twins; future studies should focus on whether this confers a definitive advantage. Newer data suggests that selective termination after 20 weeks gestation in experienced hands does not increase loss rates over those procedures performed before 20 weeks. Newer techniques, such as cord coagulation, continue to be developed for selective termination in monochorionic pregnancies, though still with considerable morbidity and mortality. SUMMARY In summary, invasive procedures in multiple gestations are now commonly performed with. It is our hope that primary prevention of high order multiple pregnancies by optimization of assisted reproductive techniques will decrease the need for these procedures.
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Affiliation(s)
- Meredith Rochon
- Department of Obstetrics, Gynecology, and Reproductive Science, Division of Maternal-Fetal Medicine, Mount Sinai Medical Center, New York, New York 10029, USA.
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Papp C, Papp Z. Chorionic villus sampling and amniocentesis: what are the risks in current practice? Curr Opin Obstet Gynecol 2003; 15:159-65. [PMID: 12634608 DOI: 10.1097/00001703-200304000-00011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Public demand for genetic counselling and prenatal diagnosis has increased during the past decade. As invasive diagnostic methods, such as chorionic villus sampling and amniocentesis, still have an important role to play in evaluating the fetus, one of the most important questions to address during genetic counselling is the procedure-related risk of these techniques. RECENT FINDINGS The possible factors modifying the specific risk of the actual fetus are discussed, together with factors that have an impact on procedure-related fetal loss and other complications. Risk factors regarding twin pregnancies, first and second-trimester chorionic villus sampling, early and mid-trimester amniocentesis are discussed separately. New developments have recently occurred in the laboratory techniques used in prenatal diagnosis. Their impact on genetic counselling and the employment of invasive techniques are also addressed. SUMMARY During genetic counselling, an individually tailored risk assessment needs to be established before any invasive procedure. This should take into account all the factors modifying the specific risk for aneuploidy or other disorders of the fetus, as well as the actual procedure-related risks.
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Affiliation(s)
- Csaba Papp
- 1st Department of Obstetrics and Gynecology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
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Affiliation(s)
- Lorraine Dugoff
- Department of Obtetrics and Gynecology, University of Colorado Health Sciences Center, Denver, Colorado 80262, USA.
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Antsaklis A, Souka AP, Daskalakis G, Kavalakis Y, Michalas S. Second-trimester amniocentesis vs. chorionic villus sampling for prenatal diagnosis in multiple gestations. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2002; 20:476-481. [PMID: 12423485 DOI: 10.1046/j.1469-0705.2002.00826.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To study the impact of invasive procedures for prenatal diagnosis on multiple pregnancies and compare first-trimester chorionic villus sampling with second-trimester amniocentesis. DESIGN Retrospective study of 347 second-trimester amniocenteses and 69 chorionic villus sampling procedures. RESULTS Miscarriage occurred in 4.18% of women after amniocentesis and 4.54% of women after chorionic villus sampling. In the amniocentesis group the risk of miscarriage was higher in the cases with transplacental entry (4.54%) than in those with transamniotic entry (2.08%). The rates of preterm delivery < or = 32 weeks and preterm delivery < or = 35 weeks in the amniocentesis group were 11.8% and 32.4% and in the chorionic villus sampling group 16.66% and 23.8%, respectively. Total fetal loss rate was similar in the amniocentesis group (8.8%) and the chorionic villus sampling group (10.22%). In the 21 cases where selective feticide was carried out the total fetal loss rate was lower in the chorionic villus sampling group (8.3%) than in the amniocentesis group (11.1%), although the difference did not reach statistical significance. CONCLUSION Chorionic villus sampling appears to be a safe alternative to amniocentesis and should be considered as the method of choice particularly when there is a high risk of an affected fetus necessitating selective feticide.
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Affiliation(s)
- A Antsaklis
- First Department of Obstetrics and Gynecology, Alexandra Maternity Hospital, University of Athens, Athens, Greece
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Abstract
In multiple pregnancies, first trimester ultrasound is crucial to diagnose chorionicity, to detect major structural defects, and to screen for chromosomal abnormalities based on nuchal translucency measurement. The efficacy of nuchal translucency measurement screening in twins might be improved when combined with first trimester maternal serum screening. In twins as in singletons, the risk of fetal loss attendant to chorionic villi sampling and to amniocentesis are similar. When an invasive procedure is indicated in twins, chorionic villi sampling has, over amniocentesis, the advantage of allowing selective termination to be performed in the first trimester, when the procedure related risk of miscarriage is minimal. It has the disadvantage of leading to ambiguous results in up to 2% of cases. While chorionic villi sampling is the choice technique in pregnancies at very high risk, amniocentesis is still indicated in cases at more moderate risk. In monochorionic pregnancies, selective termination can now be performed using a variety of techniques including bipolar or monopolar cord coagulation, and, in acardiac twins, alcohol ablation. However, selective termination remains more hazardous in monochorionic than in dichorionic pregnancies. The outcome of the twin-to-twin transfusion syndrome has been substantially improved by laser photocoagulation of placental shunts and by amniodrainage, but randomized trials are needed to establish the optimal therapeutic strategy, and further pathophysiologic research might result in new treatments.
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Affiliation(s)
- Marc Dommergues
- Marternity, Necker Hospital for Sick Children, Paris, France.
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