Do Twin-Specific Nomograms Really Make a Difference?
BACKGROUND AND PURPOSE:
Currently, ACOG does not specify growth rates or nomograms for fetal growth assessment in twins
Mendez-Figueroa et al. (Amer J Perinatol, 2017) sought to determine the ability of twin-specific nomograms, compared to singleton nomograms, to detect growth abnormalities in twin pregnancies and whether abnormal growth is associated with adverse outcomes twins
Secondary analysis of Maternal-Fetal Medicine Units (MFMU) twin databases from previous studies
Inclusion criteria included
nonanomalous twins ≥24w0d
Alexander et al. (singleton data)
Ananth et al. (dichorionic twin data)
SGA: birthweight ≤ 10th percentile
AGA: between 11th and 89th percentile
LGA: ≥ 90Th percentile
Composite neonatal morbidity (CNM) included
5-minute Apgar score < 4, respiratory distress syndrome, mechanical ventilation, intraventricular hemorrhage grade III or IV, necrotizing enterocolitis grade 2 or 3, neonatal sepsis, periventricular leukomalacia, confirmed seizure, stillbirth, or neonatal death
Logistic regression models were adjusted for maternal race, body mass index, neonatal sex, study, and twin correlation
Using a singleton nomogram
More twins categorized as SGA (33% vs 4%)
CNM was higher in SGA compared to AGA (adjusted odds ratio [OR] 1.19; 95% CI 1.08–1.32)
Stillbirth rates among was higher in SGA twins compared to AGA (aOR 3.57; 95% CI 2.16–5.90)
Neonatal mortality rates were similar in SGA and AGA
Using a twin-specific nomogram
More twins categorized as LGA (1.9% vs 0.2%)
Higher odds of CNM in SGA compared to AGA (aOR 1.68; 95% CI 1.23–2.29)
Higher odds of stillbirth in SGA compared to AGA (aOR 7.54; 95% CI 4.2–13.6)
Higher odds of neonatal mortality in SGA compared to AGA (aOR 4.59; 95% CI 2.76–7.63)
Singleton nomograms will misclassify twins that are SGA and at risk for adverse outcomes
Unlike singletons, LGA twins did not appear to have an increased risk of adverse outcomes which may due to route of delivery and earlier gestational age at delivery
Use of twin-specific nomograms will decrease pregnancies classified as SGA but increase identification of pregnancies at risk for adverse outcomes
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