MONOCORIAL
MONOCHORIAL TWIN PREGNANCY
Dr. Emerson Murúa talks about monochorionic twins. Multiple pregnancies have increased significantly in recent years, along with maternal and fetal complications, with chorionicity being the main prognostic factor for pregnancy.
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Twin pregnancies are classified according to their zygosity (which determines the risk of genetic diseases) and chorionicity, which is actually the most relevant factor regarding perinatal outcomes. Approximately two-thirds are dizygotic (dicorious-diamniotic or BCBA), and between 25-30% are monozygotic. Of the monozygotic twins, 20% are BCBA; 75% are MCBA, 2% are MCMA, and 1% are conjoined twins.
FETAL COMPLICATIONS
• Prematurity
• Twin-to-twin transfusion syndrome (TTTS)
• IUGRs (selective IUGR)
• Twin death
• TAPS sequence
• TRAP sequence
• Discordant fetal structural abnormalities
• Chromosomal abnormality: their risk is similar
• Fetal/perinatal death: the risk increases 5-6 times in monochorionic pregnancies.
MATERNAL COMPLICATIONS
The most common are: Hyperemesis gravidarum (x2-4), edema, hypertension during pregnancy (x3-4), anemia, intrahepatic cholestasis (x2), thromboembolic disease (x3), fatty liver or obstetric hemorrhage (x2-4) due to placenta previa, abruption, or postpartum hemorrhage, which can be expected more frequently.
MONOCHORIAL PREGNANCY DATING
The CRL should be between 45 and 84 mm. The one with the highest CRL is chosen.
ANEUPLOID SCREENING
The risk of aneuploidy is the same for both fetuses, so we only calculate one for the 3 classic chromosomal abnormalities using the average of the 2 nuchal translucency (NT). The detection rate for T21 is similar to that for singleton pregnancies (90%), with a slightly higher FP rate (5%).
PREVENTION OF PREECLAMPSIA (PE)
Current PE screening for singleton pregnancies is not applicable to twins. According to the US Task Force, multiple pregnancies in themselves constitute a major risk factor for PE. Therefore, aspirin (ASA) 150 mg every 24 hours should be administered starting before week 16 as a preventive measure.
GENERAL RECOMMENDATIONS FOR TWIN PREGNANCIES
• Total weight gain of 16-20 kg.
• Increase intake of fruits, oily fish (omega-3 fatty acids reduce proinflammatory factors and the risk of prematurity), and vegetables.
• Iron therapy and folic acid and calcium supplementation.
• Adjust physical activity (rest does not reduce the risk of prematurity, but increases the risk of thromboembolic disease, osteoporosis, and decreases muscle mass).
VISIT FREQUENCY
If there are no complications, every 15 days after the first-trimester ultrasound until week 34. Thereafter, weekly visits.
COMPLETION
GMCBA: Preferably between 36-37 weeks.
GMCMA: Preferably between 32-32+6 weeks, after fetal lung maturation and neuroprophylaxis, given its monochorionic component. CESAREAN SECTION
FETAL GROWTH DEFECTS
Growth is considered discordant when the estimated weight difference is 20-25%. A greater discordance is an independent factor for a poor prognosis.
CIR: As in singleton pregnancies, it is defined when the FEP of one of the fetuses is in a percentile lower than 3 with no signs of FFT. In monochorionic pregnancies, it is related to the proportion of placenta available to each fetus. The risks include fetal death for the GI fetus and neurological sequelae in a fetus of adequate weight.
ACTION IN THE EVENT OF THE DEATH OF ONE OF THE TWINS
Vascular communications are responsible for the fact that, when one twin dies, the surviving twin suffers an acute transfusion/exsanguination into the co-twin's circulation, leading to severe hypotension and hypoperfusion, with a high risk of neurological injury in 30% of cases. This occurs within the first 2 hours of death, as the circulation of the affected fetus subsequently collapses.
DELAYED DELIVERY OF A TWIN
Delayed delivery of the second twin is justified when the delivery of the first twin occurs in times of extreme prematurity, which increases the survival of the second fetus. Complications include maternal morbidity, local infection or endometritis, sepsis, chorioamnionitis, postpartum hemorrhage, NIPPD, and hysterectomy, but not maternal death.
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