Intermittent absent and reversed umbilical artery flows in appropriately grown monochorionic diamniotic twins in relation to proximate cord insertion: A harmful combination?

Objective

To compare the prevalence of intermittent absent or reversed end-diastolic flow (iAREDF) in the umbilical artery in appropriately grown monochorionic diamniotic (MCDA) pregnancies with and without proximate cord insertion (PCI), and to evaluate pregnancy outcome.

Methods

The prevalence of iAREDF in MCDA pregnancies with PCI (n = 11) was compared with a control group without PCI (n = 33). PCI was defined as a distance between the cord insertions below the fifth percentile. Placental sharing, number, and diameter of anastomoses were assessed by placental examination. Pregnancy outcome was evaluated.

Results

iAREDF was present in 7/11 PCI pregnancies, compared with 0/33 in the control group (P ≤ .01). All PCI pregnancies and 94% of controls had arterioarterial (AA)-anastomoses (P = .56), the diameter was larger in the PCI group, respectively 3.3 vs 2.1 mm (P = .03). Three cases with iAREDF had adverse outcome, two resulted in fetal death of which one with brain damage in the co-twin, another underwent early premature emergency section for fetal distress.

Conclusion

iAREDF occurs in a large proportion of MCDA pregnancies with PCI and is related to the diameter of the AA anastomosis. We hypothesize that iAREDF in appropriately grown MCDA twin pregnancies reflects an unstable hemodynamic balance with an increased risk for fetal deterioration. Whether outcome in these pregnancies can be improved by altered management requires further investigation.

     

Antenatal corticosteroids and outcomes in gastroschisis: A multicenter retrospective cohort study

Objective

In gastroschisis, there is evidence to suggest that gut dysfunction develops secondary to bowel inflammation; we aimed to evaluate the effect of maternal antenatal corticosteroids administered for obstetric reasons on time to full enteral feeds in a multicenter cohort study of gastroschisis infants.

Methods

A three center, retrospective cohort study (1992-2013) with linked fetal/neonatal gastroschisis data was conducted. The primary outcome measure was time to full enteral feeds (a surrogate measure for bowel function) and secondary outcome measure was length of hospital stay. Analysis included Mann-Whitney and Cox regression.

Results

Of 500 patients included in the study, 69 (GA at birth 34 [25-38] weeks) received antenatal corticosteroids and 431 (GA at birth 37 [31-41] weeks) did not. Antenatal corticosteroids had no effect on the rate of reaching full feeds (Hazard ratio HR 1.0 [95% CI: 0.8-1.4]). However, complex gastroschisis (HR 0.3 [95% CI: 0.2-0.4]) was associated with an increased time to reach full feeds and later GA at birth (HR 1.1 per week increase in GA [95% CI: 1.1-1.2]) was associated with a decreased time to reach full feeds.

Conclusion

Maternal antenatal corticosteroids use, under current antenatal steroid protocols, in gastroschisis is not associated with an improvement in neonatal outcomes such as time to full enteral feeds or length of hospital stay.     

Antepartum rupture of the intertwin-dividing membrane in monochorionic diamniotic twins: a case report and review of the literature

We report a case of monochorionic diamniotic twin gestation confirmed by ultrasound visualization of the thin intertwin-dividing membrane at 32 weeks' gestation. Ultrasound at 36 weeks failed to demonstrate the thin dividing membrane. The pregnancy ended a few days later with spontaneous vaginal delivery of the first twin. The second twin was in transverse lie with no membranes that could be felt around. Severe fetal heart rate deceleration developed, prompting delivery by emergency caesarean section. Cord entanglement was noted at the time of delivery, which resulted in severe perinatal morbidity of the second twin. The antepartum rupture of the dividing membrane must have happened some time between 32 and 36 weeks. The etiology for this intrauterine disruption is unknown. A review of the literature about the antepartum rupture of the intertwin-dividing membrane is described, along with its possible causes and complications. In addition, we discuss possible causes of incorrect amnionicity determination, and thus how to minimize these pitfalls. We conclude that antepartum disruption of the intertwin-dividing membrane is more common than previously thought. Moreover, prenatal ultrasonographic visualization of a dividing membrane in a diamniotic twin pregnancy does not rule out future change in this environment to a monoamniotic one, with all its perinatal morbidity and mortality complications, which result mainly from cord entanglement. This suggests a modification in the method and frequency of the prenatal fetal well-being follow-up, as well as the time and mode of delivery. Copyright © 2005 John Wiley & Sons, Ltd.