Velamentous cord insertion in monochorionic twin pregnancies: a step forward in screening for twin to twin transfusion syndrome and birthweight discordance?

Beatriz B. Pinho; Mafalda Neves; Rita Pasion; Alexandra Matias

doi:10.1515/jpm-2023-0161

Article

Velamentous cord insertion in monochorionic twin pregnancies: a step forward in screening for twin to twin transfusion syndrome and birthweight discordance?

Beatriz B. Pinho , Mafalda Neves , Rita Pasion and Alexandra Matias

Published/Copyright: June 19, 2023

Published by

Become an author with De Gruyter Brill

Submit Manuscript Author Information Explore this Subject

From the journal Journal of Perinatal Medicine Volume 51 Issue 9

Abstract

Objectives

Two major complications of monochorionic diamniotic (MCDA) twin pregnancies are twin to twin transfusion syndrome (TTTS) and birthweight discordance. The current screening ultrasound test for these pathologies combines the detection of nuchal translucency discrepancy and abnormal ductus venosus in at least one twin, in the first trimester. We aim to determine whether combining the presence of velamentous cord insertion in at least one twin increases screening efficiency.

Methods

This was a retrospective cohort with a sample of 136 MCDA twin pregnancies followed at Centro Hospitalar Universitário São João, during a 16-year period.

Results

The combination of abnormal ductus venosus in at least one twin and nuchal translucency discrepancy is associated with the development of TTTS with an OR of 10.455, but not with birthweight discordance. The combination of these first trimester markers with velamentous cord insertion is not associated with the development of either outcome.

Conclusions

The presence of velamentous cord insertion in MCDA pregnancies is not associated to TTTS development. Therefore, the addition of this marker to the first trimester screening would not effectively predict the development of birthweight discordance or TTTS. However, a positive currently used screening test increases the risk of developing TTTS by about ten times.

Keywords: birthweight discordance; ductus venosus; monochorionic diamniotic twin pregnancies; nuchal translucency; twin to twin transfusion syndrome; velamentous cord insertion

Corresponding author: Beatriz B. Pinho, Faculty of Medicine of the University of Porto, Al. Prof. Hernâni Monteiro, 4200 – 319 Porto, Portugal, E-mail: beatrizbrancopinho@gmail.com

Acknowledgments

The authors would like to thank Cláudia Camila Dias, PhD for her contribution on data analysis and Neil Murray for the English language review of the text.

Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Informed consent was obtained from all individuals included in this study.
Ethical approval: This study was approved by the Ethical Committee of Centro Hospitalar Universitário de São João.

References

1. Pandya, VM, Colmant, C, Stirnemann, J, Salomon, LJ, Ville, Y. Comparison of crown-rump length discordance and abnormal cord insertions as first-trimester predictors of poor outcome in monochorionic diamniotic twin pregnancies. J Matern Fetal Neonatal Med 2022;35:3254–8. https://doi.org/10.1080/14767058.2020.1818199.Search in Google Scholar PubMed

2. Couck, I, Mourad Tawfic, N, Deprest, J, De Catte, L, Devlieger, R, Lewi, L. Does site of cord insertion increase risk of adverse outcome, twin-to-twin transfusion syndrome and discordant growth in monochorionic twin pregnancy? Ultrasound Obstet Gynecol 2018;52:385–9. https://doi.org/10.1002/uog.18926.Search in Google Scholar PubMed

3. Kent, EM, Breathnach, FM, Gillan, JE, McAuliffe, FM, Geary, MP, Daly, S, et al.. Placental cord insertion and birthweight discordance in twin pregnancies: results of the national prospective ESPRiT Study. Am J Obstet Gynecol 2011;205:376.e1–7. https://doi.org/10.1016/j.ajog.2011.06.077.Search in Google Scholar PubMed

4. Hack, KE, Nikkels, PG, Koopman-Esseboom, C, Derks, JB, Elias, SG, van Gemert, MJ, et al.. Placental characteristics of monochorionic diamniotic twin pregnancies in relation to perinatal outcome. Placenta 2008;29:976–81. https://doi.org/10.1016/j.placenta.2008.08.019.Search in Google Scholar PubMed

5. Costa-Castro, T, Zhao, DP, Lipa, M, Haak, MC, Oepkes, D, Severo, M, et al.. Velamentous cord insertion in dichorionic and monochorionic twin pregnancies – does it make a difference? Placenta 2016;42:87–92. https://doi.org/10.1016/j.placenta.2016.04.007.Search in Google Scholar PubMed

6. Johnson, A Diagnosis and management of twin-twin transfusion syndrome. Clin Obstet Gynecol 2015;58:611–31. https://doi.org/10.1097/grf.0000000000000128.Search in Google Scholar

7. Stagnati, V, Zanardini, C, Fichera, A, Pagani, G, Quintero, RA, Bellocco, R, et al.. Early prediction of twin-to-twin transfusion syndrome: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2017;49:573–82. https://doi.org/10.1002/uog.15989.Search in Google Scholar PubMed

8. Matias, A, Montenegro, N, Areias, JC. Anticipating twin-twin transfusion syndrome in monochorionic twin pregnancy. Is there a role for nuchal translucency and ductus venosus blood flow evaluation at 11–14 weeks? Twin Res 2000;3:65–70. https://doi.org/10.1375/136905200320565490.Search in Google Scholar PubMed

9. Matias, A, Ramalho, C, Montenegro, N. Search for hemodynamic compromise at 11–14 weeks in monochorionic twin pregnancy: is abnormal flow in the ductus venosus predictive of twin-twin transfusion syndrome? J Matern Fetal Neonatal Med 2005;18:79–86. https://doi.org/10.1080/14767050500232565.Search in Google Scholar PubMed

10. Benoit, RM, Baschat, AA. Twin-to-twin transfusion syndrome: prenatal diagnosis and treatment. Am J Perinatol 2014;31:583–94. https://doi.org/10.1055/s-0034-1372428.Search in Google Scholar PubMed

11. Wang, X, Shi, H, Li, L, Yuan, P, Zhao, Y, Wei, Y. Study of the placental characteristics and time of onset of twin-to-twin transfusion syndrome. Placenta 2021;103:10–5. https://doi.org/10.1016/j.placenta.2020.10.012.Search in Google Scholar PubMed

12. Bamberg, C, Hecher, K. Update on twin-to-twin transfusion syndrome. Best Pract Res Clin Obstet Gynaecol 2019;58:55–65. https://doi.org/10.1016/j.bpobgyn.2018.12.011.Search in Google Scholar PubMed

13. Van Mieghem, T, Deprest, J, Klaritsch, P, Gucciardo, L, Done’, E, Verhaeghe, J, et al.. Ultrasound prediction of intertwin birth weight discordance in monochorionic diamniotic twin pregnancies. Prenat Diagn 2009;29:240–4. https://doi.org/10.1002/pd.2212.Search in Google Scholar PubMed

14. D’Antonio, F, Odibo, AO, Prefumo, F, Khalil, A, Buca, D, Flacco, ME, et al.. Weight discordance and perinatal mortality in twin pregnancy: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018;52:11–23. https://doi.org/10.1002/uog.18966.Search in Google Scholar PubMed

15. De Paepe, ME, Shapiro, S, Young, L, Luks, FI. Placental characteristics of selective birth weight discordance in diamniotic-monochorionic twin gestations. Placenta 2010;31:380–6. https://doi.org/10.1016/j.placenta.2010.02.018.Search in Google Scholar PubMed

16. Fratelli, N, Prefumo, F, Fichera, A, Valcamonico, A, Marella, D, Frusca, T. Nuchal translucency thickness and crown rump length discordance for the prediction of outcome in monochorionic diamniotic pregnancies. Early Hum Dev 2011;87:27–30. https://doi.org/10.1016/j.earlhumdev.2010.09.375.Search in Google Scholar PubMed

17. Matias, A, Maiz, N, Montenegro, N, Nicolaides, K. Ductus venosus flow at 11–13 weeks in the prediction of birth weight discordance in monochorionic twins. J Perinat Med 2011;39:467–70. https://doi.org/10.1515/jpm.2011.047.Search in Google Scholar PubMed

18. Matias, A, Montenegro, N, Loureiro, T, Cunha, M, Duarte, S, Freitas, D, et al.. Screening for twin-twin transfusion syndrome at 11–14 weeks of pregnancy: the key role of ductus venosus blood flow assessment. Ultrasound Obstet Gynecol 2010;35:142–8. https://doi.org/10.1002/uog.7533.Search in Google Scholar PubMed

19. Ferraro, ZM, Zhang, T, Moretti, F, Fung-Kee-Fung, K. The association between intertwin difference in first trimester crown-rump length, nuchal translucency, and birth weight discordance in twin pregnancies: a retrospective cohort study. J Pregnancy 2022;2022:6539038. https://doi.org/10.1155/2022/6539038.Search in Google Scholar PubMed PubMed Central

20. Matias, A, Blickstein, I, editors. Developmental and fetal origins of differences in monozygotic twins: from genetics to environmental factors. Cambridge, Massachusetts, US: Academic Press; 2020.Search in Google Scholar

21. Maiz, N, Staboulidou, I, Leal, AM, Minekawa, R, Nicolaides, KH. Ductus venosus Doppler at 11 to 13 weeks of gestation in the prediction of outcome in twin pregnancies. Obstet Gynecol 2009;113:860–5. https://doi.org/10.1097/aog.0b013e31819c9f66.Search in Google Scholar PubMed

22. Lin, D, Fan, D, Wu, S, Rao, J, Zhang, H, Chen, T, et al.. Role of velamentous cord insertion in monochorionic twin pregnancies: a PRISMA-compliant systematic review and meta-analysis of observational studies. J Matern Fetal Neonatal Med 2020;33:2377–86. https://doi.org/10.1080/14767058.2018.1551350.Search in Google Scholar PubMed

23. Sobhani, NC, Sparks, TN, Gosnell, KA, Rand, L, Gonzalez, JM, Feldstein, VA. Outcomes of monochorionic, diamniotic twin pregnancies with prenatally diagnosed intertwin weight discordance. Am J Perinatol 2021;38:649–56. https://doi.org/10.1055/s-0040-1721697.Search in Google Scholar PubMed PubMed Central

24. Lopriore, E, Sueters, M, Middeldorp, JM, Oepkes, D, Walther, FJ, Vandenbussche, FP. Velamentous cord insertion and unequal placental territories in monochorionic twins with and without twin-to-twin-transfusion syndrome. Am J Obstet Gynecol 2007;196:159.e1–5. https://doi.org/10.1016/j.ajog.2006.10.865.Search in Google Scholar PubMed

25. Costa-Castro, T, De Villiers, S, Montenegro, N, Severo, M, Oepkes, D, Matias, A, et al.. Velamentous cord insertion in monochorionic twins with or without twin-twin transfusion syndrome: does it matter? Placenta 2013;34:1053–8. https://doi.org/10.1016/j.placenta.2013.08.009.Search in Google Scholar PubMed

26. Couck, I, Mourad Tawfic, N, Deprest, J, De Catte, L, Devlieger, R, Lewi, L. Does site of cord insertion increase risk of adverse outcome, twin-to-twin transfusion syndrome and discordant growth in monochorionic twin pregnancy? Ultrasound Obstet Gynecol 2018;52:385–9. https://doi.org/10.1002/uog.18926.Search in Google Scholar PubMed

27. Hanley, ML, Ananth, CV, Shen-Schwarz, S, Smulian, JC, Lai, YL, Vintzileos, AM. Placental cord insertion and birth weight discordancy in twin gestations. Obstet Gynecol 2002;99:477–82. https://doi.org/10.1097/00006250-200203000-00018.Search in Google Scholar

28. Montenegro, N, Matias, A, Areias, JC, Barros, H. Ductus venosus revisited: a Doppler blood flow evaluation in the first trimester of pregnancy. Ultrasound Med Biol 1997;23:171–6. https://doi.org/10.1016/s0301-5629(96)00202-5.Search in Google Scholar PubMed

29. Quintero, RA. Twin-twin transfusion syndrome. Clin Perinatol 2003;30:591–600. https://doi.org/10.1016/s0095-5108(03)00051-4.Search in Google Scholar PubMed

30. Fries, MH, Goldstein, RB, Kilpatrick, SJ, Golbus, MS, Callen, PW, Filly, RA. The role of velamentous cord insertion in the etiology of twin-twin transfusion syndrome. Obstet Gynecol 1993;81:569–74.Search in Google Scholar

31. Yonetani, N, Ishii, K, Kawamura, H, Mabuchi, A, Hayashi, S, Mitsuda, N. Significance of velamentous cord insertion for twin-twin transfusion syndrome. Fetal Diagn Ther 2015;38:276–81. https://doi.org/10.1159/000381639.Search in Google Scholar PubMed

32. Maiz, N, Valencia, C, Emmanuel, EE, Staboulidou, I, Nicolaides, KH. Screening for adverse pregnancy outcome by ductus venosus Doppler at 11–13 + 6 weeks of gestation. Obstet Gynecol 2008;112:598–605. https://doi.org/10.1097/aog.0b013e3181834608.Search in Google Scholar PubMed

33. D’Antonio, F, Khalil, A, Pagani, G, Papageorghiou, AT, Bhide, A, Thilaganathan, B. Crown-rump length discordance and adverse perinatal outcome in twin pregnancies: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2014;44:138–46. https://doi.org/10.1002/uog.13335.Search in Google Scholar PubMed

34. Bhide, A, Sankaran, S, Sairam, S, Papageorghiou, AT, Thilaganathan, B. Relationship of intertwin crown-rump length discrepancy to chorionicity, fetal demise and birth-weight discordance. Ultrasound Obstet Gynecol 2009;34:131–5. https://doi.org/10.1002/uog.6396.Search in Google Scholar PubMed

35. Nunes, JS, Sousa, M, Montenegro, N, Matias, A. Twin pregnancies, crown-rump length and birthweight discordancy: the influence of chorionicity. Rev Bras Ginecol Obstet 2020;42:529–34. https://doi.org/10.1055/s-0040-1712128.Search in Google Scholar PubMed PubMed Central

Received: 2023-04-25

Accepted: 2023-05-11

Published Online: 2023-06-19

Published in Print: 2023-11-27

You are currently not able to access this content.

Articles in the same Issue

https://doi.org/10.1515/jpm-2023-0161

Keywords for this article

birthweight discordance; ductus venosus; monochorionic diamniotic twin pregnancies; nuchal translucency; twin to twin transfusion syndrome; velamentous cord insertion