PREDICTION OF ADVERSE PREGNANCY OUTCOME IN TWIN PREGNANCIES COMPLICATED BY SELECTIVE INTRAUTERINE GROWTH RESTRICTION Priya Agarwal, Basky Thilaganathan, Amar Bhide, Aris Papageorghiou, Asma Khalil
Table 1 independent predictors of fetal demise 95% CI 0.66- 0.92 1.49- 12.02
P-value 0.003 0.007
0.00
GA UA Doppler
OR 0.79 4.24
0.75
110 (220 fetuses) were included in the analysis. Multivariate logistic regression identified gestational age (GA) at diagnosis (OR 0.79; 95% CI 0.66-0.92; p=0.003) and the umbilical artery (UA) Doppler (OR 4.24; 95% CI 1.49-12.02; p=0.007) as independent predictors of the risk of fetal demise. The area under the curve (AUC) was 0.80 (95% CI 0.70-0.91). GA at diagnosis (OR 0.82; 95% CI 0.71-0.95; p=0.008), the UA Doppler (OR 2.90; 95% CI 1.23-6.82; p=0.015), TTTS (OR 0.14; 95% CI 0.20-0.93; p=0.042) and laser treatment (OR 13.28; 95% CI 1.94-91.03; p=0.008) were significantly associated with the risk of fetal demise of either the smaller or larger twin. The area under the curve was 0.81 (95% CI 0.74-0.88).
0.50
A universal disparity on the definition of selective intrauterine growth restriction (sIUGR) exists. However, NICE guidelines advise the diagnostic criteria as an estimated fetal weight of less than 10% and birthweight discordancy between the twins of at least 25%1. sIUGR is associated with increased mortality and morbidity2. The complications of sIUGR are well established, however, factors contributing towards it are not. The aim of this study is to predict adverse outcome in monochorionic diamniotic (MCDA) twin pregnancies complicated by sIUGR.
0.25
Results
Sensitivity
Background
1.00
St George’s University of London
Figure 1 left to right showing monochorionic diamniotic and dichorionic diamniotic sIUGR pregnancies, respectively
Methods This was a cohort study including 123 pregnancies. The diagnosis of sIUGR was made when the estimated fetal weight (EFW) of one twin was less than 10% centile and the EFW discordance was greater than 25%. Pregnancies complicated by structural abnormality or aneuploidy, or those undergoing termination were excluded. The outcome, fetal demise was ascertained. Regression analysis was used to identify the risk factors and ROC curve analysis was used to assess the predictive accuracy.
Table 2 Risk factors associated with adverse perinatal outcome GA UA Doppler TTTS Laser
OR 0.82 2.90 0.14 13.28
95% CI 0.71- 0.95 1.26- 6.82 0.2- 0.93 (1.94- 91.03)
P-value 0.008 0.015 0.042 0.008
0.00
0.25
0.50
0.75
1.00
1 - Specificity Area under ROC curve = 0.8107
Figure 3 showing area under the curve for adverse outcomes of pregnancies complicated by sIUGR
Conclusion Gestational age at diagnosis, umbilical artery Doppler and laser treatment were the most important determinants of the risk of fetal demise in MCDA twin pregnancies, complicated by sIUGR.
References 1. NICE, National Institute for Health and Care Excellence. Guidance, Fetal Complications. Multiple pregnancy: The management of twin and triplet pregnancies in the antenatal period (2011). Figure 2 showing ultrasound images of pregnancies complicated by sIUGR
Figure 4 from left to right showing ultrasound Doppler scans type 1, type 2 and type 3 sIUGR pregnancies respectively
2. Valsky, DV et al. Selective intrauterine growth restriction in monochorionic twins; pathophysiology, diagnostic approach and management dilemmas. Seminars in fetal and neonatal medicine (2010) 15(6): 342-348.