Ultrasound in twin pregnancies.

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    Author information: 1 Outremont QC. John's NL. To make recommendations for the best use of ultrasound in twin pregnancies. Optimization of ultrasound dating in twin pregnancies. There were no date restrictions.

    Studies were restricted to those with available English or French abstracts or text. Searches were updated twins a regular basis and ultrasound into the guideline to September Grey unpublished literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

    There are insufficient data to make recommendations on repeat anatomical assessments in twin pregnancies. Therefore, a complete anatomical survey at each scan may not be needed following a complete and normal dating. III 2. There are insufficient data to recommend a routine preterm labour surveillance protocol in terms of frequency, timing, and optimal cervical length thresholds. II-2 3. Singleton growth curves currently provide the best predictors of adverse outcome in twins and may be used for evaluating growth abnormalities.

    Ultrasound 4. II-2 5. Although there is insufficient evidence to ultrasound a specific schedule for ultrasound assessment of twin gestation, most experts recommend twins ultrasound assessment every 2 to 3 weeks, starting at 16 weeks of gestation for monochorionic pregnancies and every 3 to 4 weeks, starting from the dating scan 18 to 22 weeks for dichorionic pregnancies. II-1 6. Dating artery Doppler may be useful in the surveillance of twin gestations when there are complications involving the placental circulation or fetal hemodynamic physiology.

    II-2 7. Although many methods of evaluating the level of amniotic fluid in ultrasound deepest vertical pocket, single pocket, amniotic fluid index have been described, there twins not enough evidence to suggest that one method ultrasound more predictive than the others of adverse pregnancy outcome.

    II-3 8. Referral ultrasound an appropriate high-risk pregnancy centre is indicated when ultrasound unique to twins are suspected on ultrasound. II-2 These complications include: 1. Twin-to-twin transfusion syndrome 2. Ultrasound twins gestation 3. Conjoined twins 4. Twin reversed arterial perfusion sequence 5.

    Single fetal dating in the second or third trimester 6. Growth discordance in monochorionic twins. Recommendations 1. All patients who are suspected to have a twin pregnancy on first trimester physical examination or who are at risk e. II-2A 2. Every attempt should be made to determine and report amnionicity and chorionicity when a twin pregnancy is dating. II-2A 3. Although the accuracy in confirmation of gestational twins at the first and second trimester is comparable, dating should be done with first trimester ultrasound.

    II-2A 4. Beyond the first trimester, it is suggested that a combination of parameters rather than a single parameter should be used to confirm gestational age. II-2C 5. When twin pregnancy is the result of in vitro fertilization, accurate determination of gestational age should be made from the date of embryo transfer.

    II-1A 6. There is insufficient evidence to make a recommendation of which fetus when discordant for size to use to date a twin pregnancy. However, to avoid dating a situation of early intrauterine growth dating in one twin, most experts agree that the clinician may dating dating pregnancy using the larger fetus. III-C 7. In twin pregnancies, aneuploidy screening using nuchal transluscency measurements should be ultrasound. II-2B 8. Detailed ultrasound twins to screen twins fetal anomalies should be offered, preferably between 18 and 22 weeks' gestation, in all twin pregnancies.

    II-2B 9. When ultrasound is used to twins for preterm birth in a twin gestation, endovaginal twins measurement of the cervical length should be performed. II-2A Increased fetal surveillance should be considered when there is either growth restriction diagnosed in one twin or significant growth discordance.

    Umbilical artery Doppler should not be twins offered in uncomplicated twin pregnancies. I-E

    Ultrasound in Twin Pregnancies. No. , June This document reflects emerging clinical and scientific advances on the date issued and is subject to. Dating of the pregnancy (determining gestational age); Determining chorionicity and amnionicity; Twin labeling; Timing, frequency and content. Missed twins at dating scan - How to get a good woman. It is not easy for women to find a good man, and to be honest it is not easy for a man to find a good.

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    A dating rare mechanism can cause the transverse situation: a dizygotic twin pregnancy is been diagnosed as monochorionic because dating the fusion of the trophoblasts. Number of yolk sacs Ultrasound the past few years, ultrasound is an twins regarding the relation between twins number of yolk sacs and amnionicity. sex dating

    As the frequency of dating pregnancies is increasing, every obstetrician has to know that the correct, accurate, and timely determination of gestational age, chorionicity, and amnionicity has significant importance in the management of a multiple pregnancy. Surveillance, complications, outcome, morbidity, and mortality are totally different in a monochorionic and a dichorionic pregnancy. In this chapter, we will present ultrasound sonographic figures that are visualized in the first trimester in a multiple pregnancy and help ulrtasound define the gestational age, chorionicity, and amnionicity.

    We will classify them into two periods: ultrasound early first trimester, including the 10 first weeks of gestation and the late first trimester including the period between the twins and 14th week of gestation. Finally, we will review some interesting, although infrequent, cases from the literature, showing that pitfalls in the determination of both chorionicity and amnionicity exist and highlighting the importance of being aware of their subsistence.

    Multiple Pregnancy - New Challenges. It is a well-established fact that multiple pregnancies occur more commonly nowadays than a few decades ago. The progress of reproductive technologies and in vitro fertilization has played a major role in this increase. As we speak about history, the vast majority ultrasounr multiple pregnancies that occurred in the past were diagnosed during the intrapartum period [ 2 ].

    Today, as the tiwns of ultrasound has become a routine in daily medical practice, multiple pregnancies are diagnosed in the initial ultrasound scan [ 3 ]. Beyond the diagnosis of early multiple pregnancy, ultrasound scan is more than necessary to define chorionicity, amnionicity, and gestational age [ 4 ].

    In this chapter, we will present the ultrasound figures that help us determine gestational age, chorionicity, and amnionicity, focused on the 14 first weeks of gestation in multiple pregnancies. Nonetheless, we will review some cases from the literature that show that situations can be a little more complicated and may lead to a false diagnosis of chorionicity and amnionicity, in order to highlight fwins when we manage multiple pregnancies, we have to be alert about exceptions despite being infrequent [ 5 ].

    A twin pregnancy can be either dizygotic two-third of twin pregnanciesin which two different eggs are fertilized by two different sperms, and in this case, the pregnancy is always dichorionic-diamniotic or monozygotic. A monozygotic pregnancy occurs when an egg is fertilized by one sperm, producing one embryo, which can split any time, more commonly between day 2 and day 13 after fertilization.

    Chorionicity and amnionicity are differentiated by twins timing of embryo splitting. How the chorionicity and amnionicity are differentiated by twins timing of the embryo splitting in monozygotic twins Table is modified from Simpson L, ultrasound 6 ].

    The accurate determination of gestational age is critical for pregnancy management as it shows wherever the measurements of the fetus are in line for the estimate gestational age [ 4 ]. In dating, a correct pregnancy dating is necessary not only ultrasoound the appropriate timing for screening and diagnostic testing but also for optimal scheduling of delivery [ 6 ]. For women with regular cycles, the date of the last menstrual period is used to estimate gestational age, taking into account the biological variability and correct the cycle length.

    For IVF pregnancies, the date of the embryo transfer has been used to define pregnancy dating. The vast majority of authors embraced with multiple pregnancies agree that during the second trimester the evaluation of datjng age is more accurate and it is twins superior to the second trimester [ 4 ].

    Moreover, there is an agreement that the parameters and formulas ultrzsound have been used for dating singleton pregnancies are also accurate for dating multiple pregnancies, since studies in this area include a combination of singleton and multiple pregnancies [ 789 ].

    Modest size discordance is very common in multiple pregnancies [ 4 ]. Some studies suggest that pregnancy dating must be defined by using the mean of the fetuses [ 11 ]. However, more recent studies agreed that if the gestational age is based on the CRL of the larger twin, the possibility of missing a fetus that might develop intrauterine fetal growth restriction IUGR is decreased [ 12 ].

    In the second trimester, a combination of parameters is used to define pregnancy dating such as abdominal circumference, femur length, and biparietal diameter [ 8 ].

    Further discussion about calculating gestational age in second trimester is beyond the scope of this chapter. Early and accurate definition of chorionicity and amnionicity has an undeniably determinant role in the management of multiple pregnancies, since chorionicity plays a key role in the appearance of complications: monochorionic-monoamniotic twins present the highest mortality and morbidity.

    There is no doubt that the continuous surveillance and the timely intervention can optimize the outcome of the pregnancy [ 4 ]. The determination of chorionicity and amnionicity is better to be done in the first trimester [ 4 ].

    At this point, we will classify the determination based on gestational age, separated in two periods: the first before the 10th week of gestation and the second that includes the period from week 10 to dwting Three ultrasound findings can help in the detection of chorionicity: These are 1 the number of observable gestational sacs, 2 the number of amniotic sacs within the chorionic cavity, and 3 the number of yolk sacs [ 4 ].

    The number of the gestational sacs and the number of fetal heartbeats in early multiple pregnancy scan are strongly related with chorionicity: each gestational sac will form a distinct placenta and chorion. Therefore, visualization of a single ultrasound sac with two visible heart beats indicates a monochorionic twin pregnancy, while the presentation of two distinctive gestational sacs implies a dichorionic pregnancy Picture 1 [ 18 ].

    Dichorionic diamniotic pregnancy at 5 weeks of gestation. The two separate gestational sacs with one yolk sac each are visible and a thick septum separates them. Identification of the number of amniotic sacs present in a single gestational sac helps define amnionicity in a monochorionic pregnancy.

    Prior ultrasounc the 10th week of gestation, dating amnions grow outward from the embryonic disk and at that age are not big enough to contact each other and create the intertwin septum [ 4 ]. As a result, separate and distinct amnions indicate a diamniotic twin pregnancy Pictures 2ab and 3ab. The evaluation of the amnion should be done diligently via transvaginal daring since the intertwin membrane is extremely thin and it may be invisible via transabdominal ultrasound.

    Even when the separate amnions cannot be visualized via the transvaginal ultrasound, their absence can be confirmed by demonstrating umbilical cord enlargement by using pulsed wave Doppler and identifying two distinct heart rates [ 3 ]. In addition, the impossible visualization of the intertwin membrane ultrasound be technical: if the membrane xating parallel to the ultrasound beam or because the ultrasound gain is low, the membrane may be hard to evaluate.

    This problem can be solved by changing the angle of insonation and increasing gain facilitates visualization [ 5 ]. Another way to confirm amnionicity, wherever there is any doubt about the presence of the intertwin membrane, is to suggest a small chain of repeat scans [ 4 ].

    The size of the empty sac has been measured. However, is evaluation twins intertwin membrane always that simple? There are two rare yet important situations that dating lead to a false diagnosis of monoamniotic twins. The first case is when the monochorionic-diamniotic twins are ultrasound with twin-to-twin transfusion syndrome TTTS the donor twin has severe oligohydramnios or anhydramnios, and the intertwin membrane collapses resulting in wrapping the donor twin. The collapse of the membrane can be overtaken if we evaluate extremely carefully the wrapping membrane around the limbs of the donor twin.

    Rupture of the membrane may occur spontaneously, but more often is a complication of invasive in utero procedures. Discontinuity of the membrane and cord enlargement can be visualized on the ultrasound scan. Other facts helping in the identification of the membrane rupture are the location of the fetuses in the same side of the warped membrane, the equal quantity of amniotic fluid in both sides of the dividing membrane in a pregnancy, which was complicated with TTTS, and of course a previous diagnosis of a monochorionic-diamniotic twin pregnancy [ 5 ].

    Over the ultrasouhd few years, there is an uncertainty regarding the relation ultrasound the number of yolk sacs and amnionicity. Datiny there are two yolk sacs present in the extraembryonic coelom, the pregnancy will be regarded as diamniotic. However, a single yolk ultrawound cannot set the definitive twisn of a monoamniotic pregnancy. If a single twins sac is detected, a repeat first trimester scan is undertaken, or a refer to a tertiary center with advanced experience in multiple pregnancies dating be helpful [ 34 ].

    As the pregnancy continues, the ultrasound dating that help in the determination of chorionicity and amnionicity are changing: gestational sacs are now fused and the intertwin membrane is formed. As a result, four twinss ultrasound figures set the diagnosis of chorionicity and amnionicity. If a male and a female fetus are identified in the late first or early second trimester, a dichorionic twin pregnancy is the rule.

    However, gender discordance is the biggest pitfall for the diagnosis of chorionicity. Discordant fetal sex phenotype can be present in monochorionic ultrasound, leading to a false diagnosis of dichorionic twins. A false diagnosis of dichorionic twins might be the result of a postzygotic sex chromosome aneuploidy. For instance, there is a 46,XY zygote which splits, but a postzygotic anaphase lag can cause the loss of the Y tiwns in one of the twins.

    If we want to take our example a step forward, postzygotic nondisjunction after the anaphase lag can lead to mosaicism in the monozygotic twins leading to two embryos with a variety of proportion of 45,XO and 46,XY cells.

    Postzygotic anaphase lag causing ultrasound discordance due to loss of Y chromosome in one of the fetuses. A sex discordance in monozygotic twins can also be caused by a trisomic 47,XXY zygote. Beyond sex chromosome abnormalities, sex discordance may be the result of epigenetic single gene defects in only one of the monoygotic twins, effecting testis-determining genes such as SOX9 which inhibits the expression of SRY gene [ 2324 ].

    Nonetheless, sex discordance may be caused by malformed genitalia unrelated to chromosomal or genetic disorders. It is well established that a monochorionic twin pregnancy is complicated dating with selective growth restriction [ 25 ], and ultrasound is a known complication of IUGR [ 26 ultrasound, 27 ]. As hypospadias might lead to female sex phenotype, confusion about chorionicity is expected, as the IUCR male fetus will present with female external genitalia, while the normally developing twin will be present as a normal male fetus.

    Cloacal malformation in one of the female dating karyotype 46,XX leads twins phallus-like structure, causing phenotypically male external genitalia. The outcome is again confusion of chorionicity [ 28 ]. A very rare mechanism can cause the transverse situation: a dizygotic twin pregnancy is been diagnosed as monochorionic because of the fusion of the trophoblasts.

    Two distinct blastocysts produce two distinctive trophoblasts. If these trophoblasts fuse before the implantation, the result is the creation of a placental mass. The fused placenta will form vascular anastomoses, and the twins can exchange blood cells. As a result, blood chimerism of two populations of blood cells will be present in both fetuses [ 29 twins, 30 ].

    This mechanism is present more frequently datingg pregnancies carried out from ART because of the disruption of the zona pellucida and spatial proximity of multiple embryos [ ultradound31 ]. Dizygotic twins forming a monochorionic placenta have significant importance dating these twins are genetically and phenotypically normal and they have to be distinguished from the pathological sex discordance [ 5 ]. It is logical that the visualization of two separate placental masses confirms dichorionicity as a single placenta identifies monochorionicity [ 4 ].

    Careful ultrasound evaluation has to be done in order to define the presence of a single placenta or two placentas in abutment. As the pattern above, monochorionic twins may form a bipartite placenta.

    As a result, two separated placental masses are present twins datinv nearly equal-sized placental lobes, which can be totally separated or connected by chorion laeve. Things can be more complicated when dating placental mass has its own umbilical cord ultrasound. Bipartite placenta can be sating from the dichorionic placental masses by using color Doppler and identifying vascular anastomoses that are present between the two lobes. Thus, this leads to the conclusion that if an ostensibly dichorionic pregnancy is complicated with TTTS, the diagnosis of a monochorionic pregnancy with bipartite placenta has to be considered [ 32333435 ].

    The intertwin membrane of a dichorionic pregnancy comprises three layers of three membranes: datihg, as twins monochorionic pregnancy consists only two layers of amnion.

    Therefore, intertwin membrane in a dichorionic pregnancy is thicker and more echogenic than the intertwin membrane in monochorionic pregnancies. The intertwin membrane has to be carefully detected and if it cannot be visualized, a transvaginal ultrasound scan has to be performed, to set the definitive diagnosis of monoamniotic pregnancy [ 4 ]. When a single placental mass is visualized and chorionicity is identified as monochorionic, evaluation of the intertwin membrane characteristics is the key to determine amnionicity.

    The most significant sonographic figure twins demonstrates monoamniocity is the demonstration of cord enlargement from the placental or umbilical origin and it is identified easier via color Doppler. Other important findings intimating monoamnionicity are the entanglement of limbs or observation of a limb circumscribing the other, the failure datin find the membrane between the two cord insertions in the placenta ultraosund 4 ], and the short intercord distance [ 5 ].

    However, intertwin membrane thickness difference between monochorionic and dichorionic pregnancy decreases during gestation [ 36 ]. In addition, the measurement of the thickness of the membrane is not widely accepted since this parameter can be affected by many factors such as the position and the quality of the probe, and as a result, it has poor reproducibility [ 37 dating. A rare but significant pitfall may lead to a wrong determination of a monochorionic pregnancy as dichorionic is the intrauterine synechiae in twin pregnancy with a fetus with anencephaly.

    Intrauterine synechiae can mimic the thick dichorionic membrane [ 38 ]. Ultrasouns septum is not the intertwin membrane and does not include the layer of chorion between the layers of amnion. It shows a projecting zone of tissue which is as echogenic as the dating it has a triangular shape in twins and it is wider at the chorionic surface of the placenta, extending into, and tapering to a point within, the intertwin membrane [ 3940 ].

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    In fact, twins comprise about 3% of all live births in the United States [1]. scan in 3–4 weeks can be helpful to determine pregnancy dating [10]. Who Gets the Test? Ultrasounds -- or sonograms -- are a common part of prenatal care. If you're having twins, you'll get ultrasounds more often. Missed twins at dating scan - How to get a good woman. It is not easy for women to find a good man, and to be honest it is not easy for a man to find a good.

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