The February issue of Ultrasound in Obstetrics & Gynecology has a special focus on twin pregnancy, including a series of papers on the management of monoamniotic twin pregnancy, with an accompanying Editorial addressing pitfalls in this area of research. Also included in this issue are studies on two-dimensional ultrasound for postmortem examination, the cost-effectiveness of first-trimester screening and early aspirin initiation for early-onset pre-eclampsia, and the association between pelvic floor muscle trauma and contraction in parous women.
Management of monoamniotic twin pregnancy
While monochorionic monoamniotic (MCMA) twin pregnancies are rare, their complication rate is high, with fetal or neonatal loss rates of up to 20–50%. Despite this, the optimal type of management of MCMA pregnancy has still to be elucidated.
Articles in this issue of the Journal attempt to provide further clarification on how best to manage MCMA twin pregnancy. The MONOMONO study compared perinatal outcomes of inpatient vs outpatient fetal surveillance in uncomplicated MCMA twin pregnancies, finding that inpatient surveillance is associated with similar fetal mortality as outpatient management. Glinianaia et al. estimated the prevalence of MCMA twin pregnancies and described their perinatal outcome and clinical management, finding that twins surviving beyond 24 weeks of gestation had a higher survival rate compared with in previous decades, probably due to early diagnosis, close surveillance and elective birth around 32–34 weeks of gestation.
A Systematic Review by D’Antonio et al. used data from these studies and 23 others to quantify the incidence of perinatal mortality in MCMA twin pregnancy and assess the risk of mortality in those managed as inpatients compared with those managed as outpatients. It was found that there is a high risk of perinatal loss during the third trimester, and that inpatient management seems to be associated with a lower rate of mortality (download the accompanying Journal Club slides).
In an accompanying Editorial, Van Mieghem and Shub argue that the frequency and method of surveillance of MCMA twin pregnancies should be the focus of research, rather than the location of surveillance, calling into question the validity of the conclusions of the MONOMONO study and the Systematic Review by D’Antonio et al.
Other articles in this issue include…
Postmortem examination of human fetuses: comparison of two-dimensional ultrasound with invasive autopsy
Virtual autopsy following fetal death, using techniques such as magnetic resonance imaging, may be a suitable alternative to conventional invasive methods. Ultrasound is a widely available, cheap modality and could potentially be used by fetal medicine specialists as a first-line examination before other techniques are indicated. In this Original Article, Kang et al. assessed the diagnostic accuracy of postmortem two-dimensional ultrasound, finding that, while maceration may lead to failure of postmortem ultrasound examination in some cases, this technique achieves diagnostically acceptable levels of accuracy for fetal brain and abdominal organs, compared with conventional autopsy.
Cost-effectiveness of first-trimester screening with early preventative use of aspirin in women at high risk of early-onset pre-eclampsia
Pre-eclampsia is associated with increased utilization of healthcare resources, placing a large burden on the system. Screening by maternal factors and biomarkers at 11–13 weeks with initiation of aspirin in those identified as high risk is effective at reducing the risk of early-onset pre-eclampsia Ortved et al. evaluated the cost-effectiveness of such a first-trimester screening program, in comparison to current practice in Canada, finding it to have the potential to prevent a significant number of early-onset pre-eclampsia cases with a substantial associated cost saving to the healthcare system in Canada
Association between pelvic floor muscle trauma and contraction in parous women from a general population
The levator ani muscle (LAM) plays an important role in the maintenance of continence and support of the pelvic organs. LAM trauma may be associated with increased risk of pelvic organ prolapse later in life. Nyhus et al. investigated the association between pelvic floor muscle contraction, LAM trauma and POP in parous women. LAM macrotrauma was associated with weaker pelvic floor muscle contraction measured using palpation, perineometry and ultrasound, and women with POP had weaker contraction than did women without POP.
Also out this month is a new Virtual Issue on twin pregnancy, containing a selection of relevant articles from UOG.
Coming up in next month’s issue is a series of papers reporting on the management of prenatally diagnosed spina bifida.