Diagnosis and management of selective fetal growth restriction in monochorionic twin pregnancies: A cross-sectional international survey

Smriti Prasad¹, Asma Khalil^{1

2

3}, Jamie J Kirkham⁴, Andrew Sharp⁵, Kerry Woolfall⁶, Tracy Karen Mitchell⁶, Odai Yaghi¹, Tracey Ricketts⁵, Mariana Popa⁶, Zarko Alfirevic⁵, Dilly Anumba⁷, Richard Ashcroft⁸, George Attilakos^{9

10}, Carolyn Bailie¹¹, Ahmet A Baschat¹², Christine Cornforth⁵, Fabricio Da Silva Costa¹³, Mark Denbow¹⁴, Jan Deprest^{15

16}, Natasha Fenwick¹⁷, Monique C Haak¹⁸, Louise Hardman¹⁹, Jane Harrold⁵, Andy Healey²⁰, Kurt Hecher²¹, Rajeswari Parasuraman²², Lawrence Impey²³, Richard Jackson²⁴, Edward Johnstone²⁵, Shauna Leven¹⁷, Liesbeth Lewi^{15

16}, Enrico Lopriore²⁶, Isabella Oconnor²⁷, Danielle Harding²⁷, Joel Marsden²⁷, Jessica Mendoza²⁷, Tommy Mousa²⁸, Surabhi Nanda²⁹, Aris T Papageorghiou^{1

30}, Dharmintra Pasupathy³¹, Jane Sandall³², Shakila Thangaratinam^{33

34

35}, Baskaran Thilaganathan¹, Mark Turner⁵, Brigitte Vollmer³⁶, Michelle Watson²⁷, Karen Wilding³⁷, Yoav Yinon³⁸; FERN Study Team

Affiliations

¹ Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK.
² Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.
³ Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK.
⁴ Centre for Biostatistics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
⁵ Department of Women's and Children's Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK.
⁶ Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK.
⁷ Academic Unit of Reproductive and Developmental Medicine, Department of Human Metabolism, University of Sheffield, Sheffield, UK.
⁸ City Law School, University of London, London, UK.
⁹ Women's Health Division, University College London Hospitals NHS Foundation Trust, London, UK.
¹⁰ Institute for Women's Health, University College London, London, UK.
¹¹ Fetal Medicine Unit, Royal Jubilee Maternity Hospital, Belfast, UK.
¹² Department of Gynecology & Obstetrics, Johns Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, Maryland, USA.
¹³ Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia.
¹⁴ Fetal Medicine Unit, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
¹⁵ Fetal Medicine Unit, Department Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.
¹⁶ Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.
¹⁷ Twins Trust, Woking, UK.
¹⁸ Fetal Medicine Unit, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
¹⁹ Liverpool Women's NHS Foundation Trust, Liverpool, UK.
²⁰ King's Health Economics, Health Service and Population Research Department, King's College London, London, UK.
²¹ Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²² Wessex Fetal Maternal Medicine Unit, University Southampton NHS Foundation Trust, Princess Anne Hospital, Southampton, UK.
²³ Department of Fetal Medicine, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
²⁴ Department of Statistics, Liverpool Clinical Trials Unit, University of Liverpool, Liverpool, UK.
²⁵ Division of Developmental Biology and Medicine, Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester, UK.
²⁶ Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands.
²⁷ PPIE, FERN project, Harris Wellbeing of Women Research Centre, University of Liverpool, UK.
²⁸ Maternal and Fetal Medicine Unit, University of Leicester, Leicester, UK.
²⁹ Fetal Medicine Unit, Guy's and St Thomas's Hospital, Evelina London Children's Hospital, King's College London, London, UK.
³⁰ Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK.
³¹ Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
³² Division of Women's Health, King's College London, Women's Health Academic Centre, King's Health Partners, London, UK.
³³ WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
³⁴ National Institute for Health and Care Research (NIHR) Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK.
³⁵ Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
³⁶ Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton Children's Hospital, Southampton, UK.
³⁷ Clinical Directorate, Faulty of Health and Life Sciences, University of Liverpool, Liverpool, UK.
³⁸ Fetal Medicine Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel.

PMID: 38956742
DOI: 10.1111/1471-0528.17891

Diagnosis and management of selective fetal growth restriction in monochorionic twin pregnancies: A cross-sectional international survey

Smriti Prasad et al. BJOG. 2024 Nov.

. 2024 Nov;131(12):1684-1693.

doi: 10.1111/1471-0528.17891. Epub 2024 Jul 2.

Authors

Affiliations

¹ Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK.
² Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.
³ Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK.
⁴ Centre for Biostatistics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
⁵ Department of Women's and Children's Health, Faculty of Health & Life Sciences, Harris Wellbeing of Women Research Centre, University of Liverpool, Liverpool, UK.
⁶ Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK.
⁷ Academic Unit of Reproductive and Developmental Medicine, Department of Human Metabolism, University of Sheffield, Sheffield, UK.
⁸ City Law School, University of London, London, UK.
⁹ Women's Health Division, University College London Hospitals NHS Foundation Trust, London, UK.
¹⁰ Institute for Women's Health, University College London, London, UK.
¹¹ Fetal Medicine Unit, Royal Jubilee Maternity Hospital, Belfast, UK.
¹² Department of Gynecology & Obstetrics, Johns Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, Maryland, USA.
¹³ Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia.
¹⁴ Fetal Medicine Unit, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
¹⁵ Fetal Medicine Unit, Department Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.
¹⁶ Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.
¹⁷ Twins Trust, Woking, UK.
¹⁸ Fetal Medicine Unit, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
¹⁹ Liverpool Women's NHS Foundation Trust, Liverpool, UK.
²⁰ King's Health Economics, Health Service and Population Research Department, King's College London, London, UK.
²¹ Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²² Wessex Fetal Maternal Medicine Unit, University Southampton NHS Foundation Trust, Princess Anne Hospital, Southampton, UK.
²³ Department of Fetal Medicine, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
²⁴ Department of Statistics, Liverpool Clinical Trials Unit, University of Liverpool, Liverpool, UK.
²⁵ Division of Developmental Biology and Medicine, Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester, UK.
²⁶ Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands.
²⁷ PPIE, FERN project, Harris Wellbeing of Women Research Centre, University of Liverpool, UK.
²⁸ Maternal and Fetal Medicine Unit, University of Leicester, Leicester, UK.
²⁹ Fetal Medicine Unit, Guy's and St Thomas's Hospital, Evelina London Children's Hospital, King's College London, London, UK.
³⁰ Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK.
³¹ Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
³² Division of Women's Health, King's College London, Women's Health Academic Centre, King's Health Partners, London, UK.
³³ WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
³⁴ National Institute for Health and Care Research (NIHR) Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK.
³⁵ Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
³⁶ Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton Children's Hospital, Southampton, UK.
³⁷ Clinical Directorate, Faulty of Health and Life Sciences, University of Liverpool, Liverpool, UK.
³⁸ Fetal Medicine Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel.

PMID: 38956742
DOI: 10.1111/1471-0528.17891

Abstract

Objective: To identify current practices in the management of selective fetal growth restriction (sFGR) in monochorionic diamniotic (MCDA) twin pregnancies.

Design: Cross-sectional survey.

Setting: International.

Population: Clinicians involved in the management of MCDA twin pregnancies with sFGR.

Methods: A structured, self-administered survey.

Main outcome measures: Clinical practices and attitudes to diagnostic criteria and management strategies.

Results: Overall, 62.8% (113/180) of clinicians completed the survey; of which, 66.4% (75/113) of the respondents reported that they would use an estimated fetal weight (EFW) of <10th centile for the smaller twin and an inter-twin EFW discordance of >25% for the diagnosis of sFGR. For early-onset type I sFGR, 79.8% (75/94) of respondents expressed that expectant management would be their routine practice. On the other hand, for early-onset type II and type III sFGR, 19.3% (17/88) and 35.7% (30/84) of respondents would manage these pregnancies expectantly, whereas 71.6% (63/88) and 57.1% (48/84) would refer these pregnancies to a fetal intervention centre or would offer fetal intervention for type II and type III cases, respectively. Moreover, 39.0% (16/41) of the respondents would consider fetoscopic laser surgery (FLS) for early-onset type I sFGR, whereas 41.5% (17/41) would offer either FLS or selective feticide, and 12.2% (5/41) would exclusively offer selective feticide. For early-onset type II and type III sFGR cases, 25.9% (21/81) and 31.4% (22/70) would exclusively offer FLS, respectively, whereas 33.3% (27/81) and 32.9% (23/70) would exclusively offer selective feticide.

Conclusions: There is significant variation in clinician practices and attitudes towards the management of early-onset sFGR in MCDA twin pregnancies, especially for type II and type III cases, highlighting the need for high-level evidence to guide management.

Keywords: clinical trial; cord occlusion; definition; diagnosis; fetal growth restriction; feticide; fetoscopic laser surgery; intervention; intrauterine demise; morbidity; mortality; multiple; neonatal; pregnancy; prognosis; small for gestational age; stillbirth; surgery; survey.

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References

REFERENCES

1. Management of monochorionic twin pregnancy. BJOG. 2017;124:e1–e45. https://doi.org/10.1111/1471‐0528.14188
1. ISUOG. Role of ultrasound in twin pregnancy [Internet] [cited 2023 Apr 22]. Available from: https://www.isuog.org/resource/role‐of‐ultrasound‐in‐twin‐pregnancy‐pdf....
1. Khalil A, Beune I, Hecher K, Wynia K, Ganzevoort W, Reed K, et al. Consensus definition and essential reporting parameters of selective fetal growth restriction in twin pregnancy: a Delphi procedure. Ultrasound Obstet Gynecol. 2019;53(1):47–54.
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Diagnosis and management of selective fetal growth restriction in monochorionic twin pregnancies: A cross-sectional international survey

Affiliations

Diagnosis and management of selective fetal growth restriction in monochorionic twin pregnancies: A cross-sectional international survey

Authors

Affiliations

Abstract

References

REFERENCES

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical