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Grand Rounds

Do Twin-Specific Nomograms Really Make a Difference?

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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

METHODS:

  • Secondary analysis of Maternal-Fetal Medicine Units (MFMU) twin databases from previous studies
  • Inclusion criteria included
    • nonanomalous twins ≥24w0d
  • Nomograms used
    • 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

RESULTS:

  • 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)

CONCLUSION:

  • 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

Learn More – Primary Sources:

Growth among Twins: Use of Singleton versus Twin- Specific Growth Nomograms

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Related ObG Topics:

Planned C-Section or Vaginal Delivery in Twins?
Preventing Preterm Birth in Twins – What works?
Do Twins or Singletons Have a Higher Rate of Preterm Mortality?

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