Abstract
Objectives
Some monochorionic twin pregnancies need intensive cardiac management even in the
absence of twin-to-twin transfusion syndrome after birth. The purpose of this study
was to investigate risk factors related to persistent hypotension requiring cardiotonic
agent use among monochorionic twin pregnancies without twin-to-twin transfusion syndrome.
Study design
This was a retrospective study of 316 monochorionic twin pregnancies without twin-to-twin
transfusion syndrome (632 babies). All cases were treated in the neonatal intensive
care unit. Hypotension was defined as mean arterial blood pressure below the norm
for gestational age. Decreased left ventricular ejection fraction was defined as a
value <60%. Dopamine, dobutamine and phosphodiesterase III inhibitor were used as
cardiotonic agents for hypotension persisting even after adequate infusion.
Results
Among the 632 cases, 33 (5.2%) needed cardiotonic agents for persistent hypotension.
The frequency of persistent hypotension with decreased left ventricular ejection fraction
was significantly higher among larger twins (4.4%) than among smaller twins (0.6%,
p = 0.0038). In larger twins, multivariate analysis showed that Z-score for cardiothoracic
area ratio (odds ratio, 2.31; p < 0.001), tricuspid regurgitation (odds ratio, 6.34;
p = 0.015) and gestational age at delivery (odds ratio, 0.66; p < 0.001) correlated
with persistent hypotension. In smaller twins, univariate analysis showed gestational
age at delivery, birth weight, Z-score for birth weight and Z-score for cardiothoracic
area ratio of the larger twin were related to persistent hypotension. Concentration
of brain natriuretic peptide in the umbilical vein in larger and smaller twins were
significantly correlated (coefficient of correlation = 0.792, p < 0.001).
Conclusions
In monochorionic twin pregnancies, attention needs to be given to cardiac size along
with amniotic fluid and fetal growth. Both larger and smaller twins carry risks of
persistent hypotension after birth. Close observation is needed, especially in cases
where the larger twin displays cardiomegaly despite absence of twin-to-twin transfusion
syndrome.
Keywords
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References
- Twin chorionicity and the risk of stillbirth.Obstet Gynecol. 2008; 111: 301-308
- Neuromorbidity in preterm twins in relation to chorionicity and discordant birth weight.Am J Obstet Gynecol. 2004; 190: 156-163
- Increased perinatal mortality and morbidity in monochorionic versus dichorionic twin pregnancies: clinical implications of a large Dutch cohort study.BJOG. 2008; 115: 58-67
- Natural history of twin-twin transfusion syndrome.J Reprod Med. 2001; 46: 480-484
- A classification system for selective intrauterine growth restriction in monochorionic pregnancies according to umbilical artery Doppler flow in the smaller twin.Ultrasound Obstet Gynecol. 2007; 30: 28-34
- Perinatal outcome of monochorionic twins with selective intrauterine growth restriction and different types of umbilical artery Doppler under expectant management.Fetal Diagn Ther. 2009; 26: 157-161
- Prevalence and management of late fetal complications following successful selective laser coagulation of chorionic plate anastomoses in twin-to-twin transfusion syndrome.Am J Obstet Gynecol. 2006; 194: 796-803
- Neonatal outcome in preterm monochorionic twins with twin-to-twin transfusion syndrome after intrauterine treatment with amnioreduction or fetoscopic laser surgery: comparison with dichorionic twins.Am J Obstet Gynecol. 2007; 196: e1-7
- Clinical and echographic features of in utero cardiac dysfunction in the recipient twin in twin-twin transfusion syndrome.Br Heart J. 1994; 72: 74-79
- Cardiac dysfunction in twin-twin transfusion syndrome: a prospective, longitudinal study.Obstet Gynecol. 1998; 92: 557-562
- Prenatal cardiovascular manifestations in the twin-to-twin transfusion syndrome recipients and the impact of therapeutic amnioreduction.Am J Obstet Gynecol. 2005; 192: 892-902
- Natriuretic peptides in the pathogenesis of cardiac dysfunction in the recipient fetus of twin-twin transfusion syndrome.Am J Obstet Gynecol. 2002; 186: 121-127
- Cardiac hypertrophy of one fetus and selective growth restriction of the other fetus in a monochorionic twin pregnancy.J Obstet Gynaecol Res. 2010; 36: 401-404
- N-terminal pro-brain natriuretic peptide levels in monochorionic diamniotic twins with selective intrauterine growth restriction.J Perinatol. 2014; 34: 6-10
- Mean arterial blood pressure and neonatal cerebral lesions.Arch Dis Child. 1987; 62: 1068-1069
- Blood pressure and cerebral haemorrhage and ischaemia in very low birthweight infants.Early Hum Dev. 1989; 19: 103-110
- Influence of acidosis, hypoxemia, and hypotension on neurodevelopmental outcome in very low birth weight infants.Pediatrics. 1995; 95: 238-243
- Pathophysiology of the cardiovascular system and neonatal hypotension.Neonatal Netw. 2015; 34: 31-39
- Assessment of the intraobserver variability in the measurement of fetal cardiothoracic ratio using ellipse and diameter methods.Ultrasound Obstet Gynecol. 2006; 28: 53-56
- Sonographische Messungen am fetalen Herzen in der Vierkammerblick-Ebene.Geburtshilfe Frauenheilkd. 1994; 54: 92-97
- Development of audit measures and guidelines for good practice in the management of neonatal respiratory distress syndrome. Report of a Joint Working Group of the British Association of Perinatal Medicine and the Research Unit of the Royal College of Physicians.Arch Dis Child. 1992; 67 (No authors listed): 1221-1227
- Terminology and Diagnostic Criteria Committee of The Japan Society of Ultrasonics in Medicine. Standard measurement of cardiac function indexes.J Med Ultrason. 2006; 33: 123-127
- Staging of twin-twin transfusion syndrome.J Perinatol. 1999; 19: 550-555
- Incidence and characteristics of umbilical artery intermittent absent and/or reversed end-diastolic flow in complicated and uncomplicated monochorionic twin pregnancies.Ultrasound Obstet Gynecol. 2004; 23: 456-460
- Twin anemia-polycythemia sequence: diagnostic criteria, classification, perinatal management and outcome.Fetal Diagn Ther. 2010; 27: 181-190
- Hematological characteristics in neonates with twin anemiapolycythemia sequence (TAPS).Prenat Diagn. 2010; 30: 251-255
- The relationship between amniotic fluid levels of brain-type natriuretic peptide and recipient cardiomyopathy in twin-twin transfusion syndrome.Am J Obstet Gynecol. 2010; 203: e1-7
- Paradoxic activation of the renin-angiotensin system in twin-twin transfusion syndrome: an explanation for cardiovascular disturbances in the recipient.Pediatr Res. 2005; 58: 685-688
Article info
Publication history
Published online: August 23, 2019
Accepted:
August 22,
2019
Received in revised form:
July 29,
2019
Received:
April 5,
2019
Identification
Copyright
© 2019 Published by Elsevier B.V.
