Selective Fetal Growth Restriction in Monochorionic Twin Pregnancies

6/20/22, 3:03 AM 120803
Official reprint from UpToDate®
www.uptodate.com
© 2022 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Selective fetal growth restriction in monochorionic twin

pregnancies
Authors: Jena Miller, MD, Mara Rosner, MD, MPH, Ahmet Alexander Baschat, MD
Section Editor: Lynn L Simpson, MD
Deputy Editor: Vanessa A Barss, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2022. | This topic last updated: May 19, 2022.
INTRODUCTION
Selective fetal growth restriction (sFGR) refers to growth restriction of one fetus of a
monochorionic twin pair. It is a common complication of monochorionic twins that results from
discordant placental sharing and is different from the placenta-based growth restriction
resulting from deficient uteroplacental perfusion that occurs in dichorionic twins and singletons
[1]. sFGR is important because it is associated with significant risks for perinatal morbidity and
mortality [2-4].
This topic will discuss the pathophysiology, diagnosis, and management of sFGR. The diagnosis
and management of growth restriction in singletons and in dichorionic twins are reviewed
separately. (See "Identification and diagnosis of fetal growth restriction" and "Fetal growth
restriction: Evaluation and management" and "Twin pregnancy: Management of pregnancy
complications", section on 'Growth restriction and discordance'.)
PATHOPHYSIOLOGY
The "vascular equator" is an imaginary line that can be drawn along the vascular anastomoses
between twins sharing a monochorionic placenta. This line can be used to estimate the
percentage of placental territory belonging to each fetus. In sFGR, the placental territory is
distributed unequally between twins: one twin benefits from having the majority share of the
https://www.uptodate.com/contents/120803/print 1/31
6/20/22, 3:03 AM 120803
placenta while the growth-restricted twin is supported by a smaller portion of the placenta (
figure 1 and picture 1) [5-8].
In addition, when the placental share is significantly different, the number and size of the
vascular anastomoses between the twins are also different [9-12], which affects volume
exchange between twins and transfer of nutrients and oxygen. Increasing discordance in
placental share increases net volume flow between the twins, leading to more interdependent
circulations [10,13-16]. This impacts the natural history of the disease: Clinical deterioration is
often less predictable and slower than would be anticipated in FGR complicating singleton or
dichorionic twin pregnancies [17,18].
Other factors can also contribute to growth restriction. For example, a velamentous placental
cord insertion can further impair the smaller twin's ability to access its placental territory.
Velamentous placental cord insertion is found in up to approximately 30 percent of
monochorionic twins and is strongly associated with both sFGR (odds ratio [OR] 9.24, 95% CI
2.05-58.84) and growth discordance >25 percent (OR 6.81, 95% CI 1.67-34.12) [13,19,20].
INCIDENCE
sFGR affects 10 to 15 percent of monochorionic twin pregnancies [21,22].
PRESENTATION
Ultrasound examinations are routinely performed in multiple gestations. Accurate

determination of chorionicity and gestational age are crucial to appropriately monitor and
manage these pregnancies. (See "Twin pregnancy: Overview", section on 'Assessment of
chorionicity and amnionicity' and "Twin pregnancy: Overview", section on 'Determination of
gestational age'.)
Crown rump length (CRL) discordancy of a monochorionic pregnancy on a first-trimester

ultrasound can be the first sign of developing sFGR [23]. If CRLs are discordant, it is important
to use the CRL of the larger twin for assignment of gestational age in naturally conceived
pregnancies. (See "Diagnosis and outcome of first-trimester growth delay", section on
'Discordant first-trimester fetal size in twin pregnancies'.)
Most sFGR is detected during routine sonographic monitoring of monochorionic pregnancies,

which is initiated in the early second trimester. Our protocol is depicted in the table ( table 1)
and identifies sFGR, twin-twin transfusion syndrome, and twin anemia polycythemia sequence.
6/20/22, 3:03 AM 120803
DIAGNOSIS
Diagnosis of sFGR is typically made in the second trimester based on fetal biometric
measurements, growth discordance, and umbilical artery (UA) Doppler parameters. Third-
trimester diagnosis is less common and associated with more favorable outcomes [24,25].
sFGR is defined by Delphi criteria as [26,27]:
● Estimated fetal weight (EFW) <3rd percentile of one fetus

or
● At least two of the following four criteria:
• EFW <10th percentile for one twin

• Abdominal circumference <10th percentile for one twin
• UA pulsatility index >95th percentile for the smaller twin
• Weight discordance ≥25 percent
Percent weight discordance is calculated using the following equation:
(EFW larger twin weight – EFW smaller twin weight) / (EFW larger twin weight × 100)
Doppler technique — Importantly, interpretation of the UA Doppler is not the same as in

singleton or dichorionic multiple pregnancies since it not only reflects the relative size
differences in placental share but also the magnitude of hemodynamically significant vascular
communications between the twins [28].
Proper acquisition of the UA waveform is required for accurate assessment and interpretation.
● Reproducibility of measurements is greater if the measurement is obtained in a free loop

of the umbilical cord with an insonation angle close to 0 degrees during fetal quiescence.
● Focal zone, gain, and pulse repetition frequency should be adjusted to maximize the
frame rate.
● The sweep speed should initially be set to visualize four to six waveforms and should take
up approximately 75 percent of the Doppler screen [29]. To evaluate variation or
oscillation of end-diastolic velocity in the UA, the sweep speed needs to be slowed to
demonstrate the classic pattern in >6 waveforms ( waveform 1).
6/20/22, 3:03 AM 120803
● Maternal breath holding may be required to exclude interference during measurement of

the waveform [28,30].
● Both UAs should be sampled as the flow pattern may differ. However, interarterial
anastomoses, if present, can equalize blood flow between arteries even though the
placental territories supplied by the umbilical arteries are different [31].
● UA waveforms are best identified close to the placental cord insertion where intertwin
anastomoses on the placenta have the most impact on the umbilical artery Doppler flows,
particularly in the setting of close placental cord insertions. Evaluation for proximate
placental cord insertion (distance between cord insertions below the fifth percentile, or 3.3
to 4.0 cm across gestation) is prudent as intermittent absent or reversed end-diastolic
velocity (as in type 3 sFGR, discussed below) is more common in this setting [32].
CLASSIFICATION
The pattern of the umbilical artery (UA) waveform and end-diastolic velocity of the smaller fetus
are used to classify sFGR into three types ( waveform 2) that are predictive of the anticipated
clinical course and risk profile [33-35]. This is an important designation to make since it is used
to guide counseling and management decisions.
● Type 1 sFGR is characterized by persistently forward UA end-diastolic velocity without

variation in the waveform with normal or elevated resistance. It is associated with the
most stable course and a typically favorable outcome; the mean gestational age at birth
was 35.4 weeks in one large series [33]. In a meta-analysis of observational studies
including 786 monochorionic pregnancies complicated by sFGR, when expectantly
managed, type 1 sFGR was associated with the lowest risk for unanticipated fetal demise,
3.1 percent (95% CI 1.1-5.9), and a high rate of intact survival, 97.9 percent (95% CI 93.6-
99.9) [36].
Late onset sFGR (ie, identified after 26 weeks) is typically type 1. Although these fetuses
usually have a benign course, they are at increased risk for hemoglobin differences at
birth (ie, twin anemia polycythemia sequence), which occurs in up to 38 percent of cases
[6].
● Type 2 sFGR is characterized by fixed absent or fixed reversed UA end-diastolic velocity

without variation of the waveform in the smaller twin. It is associated with midtrimester
deterioration of the growth-restricted fetus; the mean gestational age at birth was 30.7
weeks in the same large series described above [33].
6/20/22, 3:03 AM 120803
Although pregnancies with type 2 sFGR are anticipated to have a predictable pattern of
deterioration and a longer latency period between diagnosis and deterioration than type 3
sFGR, they are considered to have the worst prognosis due to the significant risk of single
fetal demise and preterm birth [36,37].
In the meta-analysis described above, when expectantly managed, fetal demise occurred
in 16.6 percent (95% CI 6.9-29.5) of cases, with neonatal death in an additional 6.4 percent
(95% CI 0.2-28.2) [36]. For survivors, 89.3 percent (95% CI 71.8-97.7 percent) were
neurologically intact.
● Type 3 sFGR is characterized by a pathognomonic UA waveform that has a variable flow

pattern that cycles between forward, absent, and reversed flow over a short interval (
waveform 1), which is termed intermittent absent/reversed end-diastolic flow (iAREDF).
This results from a large artery-to-artery anastomosis (AAA) on the placental surface and
represents the bidirectional volume flow across these vessels. It is more commonly
observed in the UA of the smaller fetus since the interface of the two waveforms is shifted
toward the smaller twin and the AAA has a larger proportionate impact on the fetus with
smaller placental share [12]. An AAA allows perfusion of oxygen and nutrients from the
larger fetus to a portion of the smaller twin's placenta; consequently, type 3 sFGR is
associated with the largest degree of placental territory discordance [9,16,33,38,39].
These cases have the most unpredictable clinical course, and unanticipated fetal demise
can occur in a short interval, even after a reassuring ultrasound assessment. In the meta-
analysis described above, when expectantly managed, fetal demise occurred in 13.2
percent (95% CI 7.2-20.5), with neonatal death in an additional 6.8 percent (95% CI 0.7-
18.6) [36]. In a large multicenter study of 328 pregnancies with type 3 sFGR, single fetal
demise occurred in 5.8 percent and double demise occurred in 4.9 percent of expectantly
managed patients [40]. Normalization of umbilical artery Doppler flow occurred in 13.7
percent of cases and was associated with improved fetal growth of the smaller twin [18].
These pregnancies are also at the highest risk for neurologic morbidity, particularly of the
larger twin. Only 61.9 percent (95% CI 38.4-81.9) have been reported to have intact
survival, most likely attributable to the more unstable hemodynamic environment [30,36].
DIAGNOSTIC EVALUATION
Due to substantial overlap between sFGR, twin-twin transfusion syndrome [TTTS], and twin
anemia polycythemia sequence [TAPS] ( table 2), a systematic approach to evaluation is
6/20/22, 3:03 AM 120803
required to arrive at the correct diagnosis and initiate management planning [41]. All variables
that define these conditions need to be ascertained. The final diagnosis should describe the
entire spectrum of findings.
● Once sFGR or discordant fetal growth is suspected, the first step is a detailed anatomic
survey to assess for structural fetal anomalies that may complicate up to 7 percent of
monochorionic twin pairs and contribute to abnormal growth [42-45]. Among sFGR cases,
a major fetal anomaly in at least one twin (usually the smaller twin) has been noted in 16
percent of cases [46].
Viral infection can affect one or both fetuses and lead to growth restriction, so maternal
history of signs/symptoms or ultrasound markers of viral infection other than isolated FGR
require additional investigation, such as maternal serology for CMV and toxoplasmosis
[47].
Rarely, monochorionic twins have discordant karyotypes. This is most often observed in
the context of discordant fetal anomalies [48,49]. Screening or diagnostic testing for
aneuploidy is recommended in anomalous fetuses when the findings will impact clinical
decision making [50,51]. (See "Prenatal genetic evaluation of the fetus with anomalies or
soft markers".)
● The second step is to evaluate amniotic fluid for oligohydramnios/polyhydramnios

sequence to diagnose or exclude coexistent TTTS [52]. Distinguishing TTTS complicated by
growth restriction of the donor twin from sFGR can be difficult since in both situations the
growth restricted fetus may have oligohydramnios ( table 2). Once fluid criteria for TTTS
are met (defined as maximum vertical pocket <2 cm for the donor and >8 cm for the
recipient), appropriate management for stage-based disease is required, regardless of
coexisting sFGR or twin weight discordance [53]. (See "Twin-twin transfusion syndrome:
Screening, prevalence, pathophysiology, and diagnosis" and "Twin-twin transfusion
syndrome: Management and outcome".)
● The third step is to evaluate middle cerebral artery-peak systolic velocity (MCA-PSV) in both
twins to diagnose or exclude coexistent TAPS. (See "Twin anemia-polycythemia sequence
(TAPS)", section on 'Diagnostic criteria'.)
Fetal anemia in monochorionic twins can also be caused by parvovirus infection,

alloimmunization, hemoglobinopathy (eg, alpha-thalassemia major), or massive
fetomaternal transfusion. (See "Parvovirus B19 infection during pregnancy" and "RhD
alloimmunization in pregnancy: Overview" and "Prenatal screening and testing for
hemoglobinopathy" and "Spontaneous massive fetomaternal hemorrhage".)
6/20/22, 3:03 AM 120803
When TTTS and TAPS were not present at diagnosis of sFGR, TTTS subsequently developed in 10
percent of cases and TAPS subsequently developed in 3 percent of cases in a retrospective
series of 177 sFGR cases [46].
PREGNANCY MANAGEMENT
The goal when managing pregnancies with sFGR is to identify those that can be safely managed
conservatively versus those that might benefit from fetal intervention. The strategy for risk
assessment and management that has evolved is based on gestational age, prognosis,
technical considerations, and patient values and preferences [41].
Classification-based approach — The approach depicted in the algorithms and described

below is based on personal experience, expert opinion, and data from observational studies.
Randomized trials have not been performed.
● sFGR type 1 – Expectant management with weekly ultrasound surveillance (umbilical

artery [UA], middle cerebral artery [MCA]) is the preferred approach for these mild cases
identified in the second trimester, as described in the algorithm ( algorithm 1). Weekly
biophysical profile scoring (BPP) is added at 28 to 32 weeks. If the UA pulsatility index
increases to >95th percentile or the MCA pulsatility index falls below the 5th percentile, we
would increase surveillance to twice weekly and also monitor for abnormalities in the
ductus venosus (DV) waveform. Worsening of the UA Doppler pattern in the growth-
restricted fetus is observed in up to 26 percent of these cases [17]; however, this typically
takes months to develop, and the likelihood for serious fetal deterioration (venous
Doppler abnormalities, a low BPP score, or oligohydramnios [33,54,55]) or demise is low
when the UA flow is consistently forward.
If fetal status remains reassuring, as it usually does, we suggest delivery at 34+0 to 35+6
weeks as pregnancies with sFGR are not "uncomplicated" twins and have a higher rate for
unanticipated demise than uncomplicated monochorionic twins in which delivery may be
delayed until 37+6 weeks [56]. Earlier delivery is indicated if standard maternal or fetal
indications for delivery develop.
The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) suggests

timing delivery in sFGR based on assessment of fetal well-being, interval growth, BPP, DV
waveform, and/or nonstress testing and points out that the risk of fetal demise in these
pregnancies is increased, so delivery might be indicated even before fetal deterioration
becomes evident [26].
6/20/22, 3:03 AM 120803
● sFGR types 2 and 3 – The approach to moderate and severe sFGR is more complicated (
algorithm 2) due to the higher rates of adverse outcomes, particularly fetal demise
[2,42] (see 'Outcome by severity of sFGR' below). Demise of one twin can result in acute
fetal transfusion and volume shifts, which leads to double fetal demise or neurologic
damage in the surviving co-twin in up to 30 percent of cases [14,54,57-60].
Prior to the lower limit of viability, intervention with either selective fetal reduction [61-63]
or fetoscopic laser ablation of intertwin placental vascular anastomoses can be considered
in cases with fetal deterioration (progression from type 2 to type 3 sFGR, venous Doppler
abnormalities [33,54,55], or oligohydramnios in the growth-restricted fetus [57,64]).
Coexisting oligohydramnios has been associated with impending fetal mortality.
Fetoscopic laser ablation is associated with high mortality for the sFGR fetus and does not
guarantee survival for the normally grown fetus, but may protect this fetus from the
consequences of co-twin demise [55,65-72]. Elevated MCA Doppler peak systolic velocity
(PSV) and abnormal venous Dopplers have been suggested as strong predictors of demise
of the growth restricted fetus after laser [73]. The procedure may be more technically
challenging compared with fetoscopic laser ablation for treatment of twin-twin transfusion
syndrome and may not always be possible in cases of pure sFGR [57,67,68]. If laser
ablation is performed, then these pregnancies are managed similarly to dichorionic twins.
In patients who decline these interventions, we perform weekly Doppler surveillance of

UA, MCA, and DV beginning at diagnosis and begin BPPs with each ultrasound assessment
performed at ≥28 weeks. If Doppler findings remain stable and BPPs are reassuring,
weekly outpatient monitoring until delivery is reasonable. If Doppler findings worsen (eg,
deterioration of the UA Doppler pattern, such as progressive reversed end-diastolic
velocity or DV pulsatility index >95th percentile) or if oligohydramnios develops, we would
increase surveillance with Dopplers/BPP to two to three times weekly and consider
hospital admission for daily fetal monitoring with nonstress tests if delivery for fetal
indications would be considered [74].
We deliver these pregnancies by 32+0 for UA reversed end-diastolic flow and by 34+0
weeks for UA absent end-diastolic flow, with earlier delivery for standard obstetric
indications [28,40,75].
Antenatal corticosteroids — Betamethasone or dexamethasone is administered if fetal status

deteriorates or prior to planned preterm delivery (see "Antenatal corticosteroid therapy for
reduction of neonatal respiratory morbidity and mortality from preterm delivery"). UA Doppler
flow may improve transiently after administration of betamethasone [76].
6/20/22, 3:03 AM 120803
OUTCOME
A core outcome set is available for studies investigating management of these pregnancies
[77].
Outcome by severity of sFGR — The risks of fetal demise of one or both fetuses, progression,
preterm birth, and survival are depicted in the table ( table 3). In a review including 177 cases
of sFGR, isolated sFGR (no subsequent twin-twin transfusion syndrome [TTTS] or twin anemia
polycythemia sequence [TAPS]) had a 91 percent survival rate; survival was lower in sFGR
associated with a major anomaly (70 percent survival) or subsequent development of TTTS (65
percent survival) [46]. The majority of cases were type 1 sFGR (110/177) and had a survival rate
of 96 percent, as compared with a survival rate of 55 percent (12/22) in those with type 2 sFGR
and 83 percent (55/66) in those with type 3 sFGR.
Neurodevelopmental outcome — A systematic review on the impact of sFGR or birth weight

discordance on long-term neurodevelopment in monochorionic twins found that survivors of
sFGR are at increased risk for neurodevelopmental impairment, with the smaller twin having
the poorer outcomes, but highlighted the lack of available data [42,78]. For the sFGR fetus, the
analysis reported long-term rates of moderate and severe neurologic morbidity of 3 and 6
percent, respectively; for the larger co-twin, these rates were 1 and 5 percent, respectively.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Fetal growth restriction"
and "Society guideline links: Multiple gestation".)
SUMMARY AND RECOMMENDATIONS
● Incidence – Selective fetal growth restriction (sFGR) refers to growth restriction of one
fetus of a monochorionic twin pair due to discordant placental sharing ( figure 1 and
picture 1). It affects 10 to 15 percent of these pregnancies. (See 'Introduction' above
and 'Pathophysiology' above and 'Incidence' above.)
● Identification of sFGR – Beginning in the early second trimester, monochorionic twin

pregnancies should routinely undergo serial ultrasound examinations to monitor for
development of sFGR as well as twin-twin transfusion syndrome (TTTS) and twin anemia
6/20/22, 3:03 AM 120803
polycythemia sequence (TAPS). An example of a monitoring protocol is depicted in the

table ( table 1). (See 'Presentation' above.)
● Diagnosis – The diagnosis of sFGR is based on the following (see 'Diagnosis' above):
• Estimated fetal weight (EFW) <3rd percentile of one fetus or
• At least two of the four following criteria:
- EFW <10th percentile for one twin

- Abdominal circumference <10th percentile for one twin
- Weight discordance ≥25 percent
- Umbilical artery (UA) pulsatility index >95th percentile for the smaller twin
● Classification – The pattern of the UA waveform and end-diastolic velocity of the smaller
fetus are used to classify affected fetuses into type 1, type 2, or type 3 sFGR (
waveform 2), which predicts the anticipated clinical course ( table 3) and risk profile.
Type 2 sFGR has the worst prognosis due to the high risk of single fetal demise and
preterm birth. Proper Doppler technique is essential to accurately assess the umbilical
artery Doppler pattern. (See 'Classification' above and 'Doppler technique' above.)
● Diagnostic evaluation – In a high proportion of cases, sFGR coexists with TTTS, TAPS, or
discordant fetal anomalies. Due to substantial overlap between these disorders, a
systematic approach to evaluation is required to arrive at the correct diagnosis and initiate
management planning. (See 'Diagnostic evaluation' above.)
● Management – Our approach to managing these pregnancies is depicted in the

algorithms ( algorithm 1 and algorithm 2). (See 'Pregnancy management' above.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Burton GJ, Jauniaux E. Pathophysiology of placental-derived fetal growth restriction. Am J

Obstet Gynecol 2018; 218:S745.
2. Buca D, Pagani G, Rizzo G, et al. Outcome of monochorionic twin pregnancy with selective
intrauterine growth restriction according to umbilical artery Doppler flow pattern of
smaller twin: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2017;
50:559.
6/20/22, 3:03 AM 120803
3. D'Antonio F, Odibo AO, Prefumo F, et al. Weight discordance and perinatal mortality in twin
pregnancy: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 52:11.
4. Weiner E, Barber E, Feldstein O, et al. Placental Histopathology Differences and Neonatal
Outcome in Dichorionic-Diamniotic as Compared to Monochorionic-Diamniotic Twin
Pregnancies. Reprod Sci 2018; 25:1067.
5. Fick AL, Feldstein VA, Norton ME, et al. Unequal placental sharing and birth weight
discordance in monochorionic diamniotic twins. Am J Obstet Gynecol 2006; 195:178.
6. Lewi L, Gucciardo L, Huber A, et al. Clinical outcome and placental characteristics of

monochorionic diamniotic twin pairs with early- and late-onset discordant growth. Am J
Obstet Gynecol 2008; 199:511.e1.
7. De Paepe ME, Shapiro S, Young L, Luks FI. Placental characteristics of selective birth weight
discordance in diamniotic-monochorionic twin gestations. Placenta 2010; 31:380.
8. Zhao D, Lipa M, Wielgos M, et al. Comparison Between Monochorionic and Dichorionic

Placentas With Special Attention to Vascular Anastomoses and Placental Share. Twin Res
Hum Genet 2016; 19:191.
9. Denbow ML, Cox P, Taylor M, et al. Placental angioarchitecture in monochorionic twin

pregnancies: relationship to fetal growth, fetofetal transfusion syndrome, and pregnancy
outcome. Am J Obstet Gynecol 2000; 182:417.
10. Sun LM, Li Y, Zou G, et al. Monochorionic twins with unequal placental sharing: why can the
outcome still be favorable? J Matern Fetal Neonatal Med 2016; 29:1261.
11. Lanna MM, Consonni D, Faiola S, et al. Color-dye injection of monochorionic placentas and
correlation with pregnancy complications. Placenta 2015; 36:1095.
12. Wang X, Li L, Yuan P, et al. Comparison of pregnancy outcomes and placental
characteristics between selective fetal growth restriction with and without thick arterio-
arterial anastomosis in monochorionic diamniotic twins. BMC Pregnancy Childbirth 2022;
22:15.
13. Konno H, Murakoshi T, Yamashita A, Matsushita M. Roles of venovenous anastomosis and
umbilical cord insertion abnormalities in birthweight discordance in monochorionic-
diamniotic twin pregnancies without twin-twin transfusion syndrome. J Obstet Gynaecol
Res 2018; 44:623.
14. Lewi L, Cannie M, Blickstein I, et al. Placental sharing, birthweight discordance, and
vascular anastomoses in monochorionic diamniotic twin placentas. Am J Obstet Gynecol
2007; 197:587.e1.
6/20/22, 3:03 AM 120803
15. Hack KE, Nikkels PG, Koopman-Esseboom C, et al. Placental characteristics of

monochorionic diamniotic twin pregnancies in relation to perinatal outcome. Placenta
2008; 29:976.
16. Wang X, Shi H, Li L, et al. The relationship between placental characteristics and
birthweight discordance in different types of selective intrauterine growth restriction in
monochorionic diamniotic twins: A single-center 7 year cohort study. Prenat Diagn 2021;
41:1518.
17. Rustico MA, Consonni D, Lanna M, et al. Selective intrauterine growth restriction in
monochorionic twins: changing patterns in umbilical artery Doppler flow and outcomes.
Ultrasound Obstet Gynecol 2017; 49:387.
18. Shinar S, Xing W, Lewi L, et al. Growth patterns of monochorionic twin pregnancy
complicated by Type-III selective fetal growth restriction. Ultrasound Obstet Gynecol 2022;
59:371.
19. Lopriore E, Pasman SA, Klumper FJ, et al. Placental characteristics in growth-discordant
monochorionic twins: a matched case-control study. Placenta 2012; 33:171.
20. Kalafat E, Thilaganathan B, Papageorghiou A, et al. Significance of placental cord insertion
site in twin pregnancy. Ultrasound Obstet Gynecol 2018; 52:378.
21. Sebire NJ, Snijders RJ, Hughes K, et al. The hidden mortality of monochorionic twin
pregnancies. Br J Obstet Gynaecol 1997; 104:1203.
22. Lewi L, Jani J, Blickstein I, et al. The outcome of monochorionic diamniotic twin gestations
in the era of invasive fetal therapy: a prospective cohort study. Am J Obstet Gynecol 2008;
199:514.e1.
23. Memmo A, Dias T, Mahsud-Dornan S, et al. Prediction of selective fetal growth restriction
and twin-to-twin transfusion syndrome in monochorionic twins. BJOG 2012; 119:417.
24. Wang Y, Shi H, Wang X, et al. Early- and late-onset selective fetal growth restriction in
monochorionic twin pregnancy with expectant management. J Gynecol Obstet Hum
Reprod 2022; 51:102314.
25. Curado J, Sileo F, Bhide A, et al. Early- and late-onset selective fetal growth restriction in
monochorionic diamniotic twin pregnancy: natural history and diagnostic criteria.
26. Khalil A, Rodgers M, Baschat A, et al. ISUOG Practice Guidelines: role of ultrasound in twin
pregnancy. Ultrasound Obstet Gynecol 2016; 47:247.
27. Khalil A, Beune I, Hecher K, et al. Consensus definition and essential reporting parameters
of selective fetal growth restriction in twin pregnancy: a Delphi procedure. Ultrasound
6/20/22, 3:03 AM 120803
Obstet Gynecol 2019; 53:47.

28. Bennasar M, Eixarch E, Martinez JM, Gratacós E. Selective intrauterine growth restriction in
monochorionic diamniotic twin pregnancies. Semin Fetal Neonatal Med 2017; 22:376.
29. Bhide A, Acharya G, Baschat A, et al. ISUOG Practice Guidelines (updated): use of Doppler
velocimetry in obstetrics. Ultrasound Obstet Gynecol 2021; 58:331.
30. Gratacós E, Lewi L, Carreras E, et al. 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.
31. Raio L, Ghezzi F, di Naro E, et al. In-utero characterization of the blood flow in the Hyrtl
anastomosis. Placenta 2001; 22:597.
32. Eschbach SJ, Tollenaar LSA, Oepkes D, et al. Intermittent absent and reversed umbilical
artery flows in appropriately grown monochorionic diamniotic twins in relation to
proximate cord insertion: A harmful combination? Prenat Diagn 2020; 40:1284.
33. Gratacós E, Lewi L, Muñoz B, et al. 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. Pasquini L, Conticini S, Tomaiuolo T, et al. Application of Umbilical Artery Classification in
Complicated Monochorionic Twins. Twin Res Hum Genet 2015; 18:601.
35. Batsry L, Matatyahu N, Avnet H, et al. Perinatal outcome of monochorionic diamniotic twin
pregnancy complicated by selective intrauterine growth restriction according to umbilical
artery Doppler flow pattern: single-center study using strict fetal surveillance protocol.
36. Townsend R, D'Antonio F, Sileo FG, et al. Perinatal outcome of monochorionic twin
pregnancy complicated by selective fetal growth restriction according to management:
systematic review and meta-analysis. Ultrasound Obstet Gynecol 2019; 53:36.
37. Vanderheyden TM, Fichera A, Pasquini L, et al. Increased latency of absent end-diastolic
flow in the umbilical artery of monochorionic twin fetuses. Ultrasound Obstet Gynecol
2005; 26:44.
38. Wee LY, Taylor MJ, Vanderheyden T, et al. Transmitted arterio-arterial anastomosis
waveforms causing cyclically intermittent absent/reversed end-diastolic umbilical artery
flow in monochorionic twins. Placenta 2003; 24:772.
39. Groene SG, Tollenaar LSA, Slaghekke F, et al. Placental characteristics in monochorionic
twins with selective intrauterine growth restriction in relation to the umbilical artery
Doppler classification. Placenta 2018; 71:1.
6/20/22, 3:03 AM 120803
40. Shinar S, Xing W, Pruthi V, et al. Outcome of monochorionic twin pregnancy complicated by
Type-III selective intrauterine growth restriction. Ultrasound Obstet Gynecol 2021; 57:126.
41. Gratacós E, Ortiz JU, Martinez JM. A systematic approach to the differential diagnosis and
management of the complications of monochorionic twin pregnancies. Fetal Diagn Ther
2012; 32:145.
42. Rustico MA, Lanna M, Faiola S, et al. Major Discordant Structural Anomalies in
Monochorionic Twins: Spectrum and Outcomes. Twin Res Hum Genet 2018; 21:546.
43. Pettit KE, Merchant M, Machin GA, et al. Congenital heart defects in a large, unselected
cohort of monochorionic twins. J Perinatol 2013; 33:457.
44. Glinianaia SV, Rankin J, Wright C. Congenital anomalies in twins: a register-based study.
Hum Reprod 2008; 23:1306.
45. Gul A, Cebeci A, Aslan H, et al. Perinatal outcomes of twin pregnancies discordant for major
fetal anomalies. Fetal Diagn Ther 2005; 20:244.
46. Couck I, Ponnet S, Deprest J, et al. Outcome of monochorionic twin pregnancy with
selective fetal growth restriction at 16, 20 or 30 weeks according to new Delphi consensus
definition. Ultrasound Obstet Gynecol 2020; 56:821.
47. Yinon Y, Yagel S, Tepperberg-Dikawa M, et al. Prenatal diagnosis and outcome of congenital
cytomegalovirus infection in twin pregnancies. BJOG 2006; 113:295.
48. Rock KR, Millard S, Seravalli V, et al. Discordant anomalies and karyotype in a
monochorionic twin pregnancy: a call for comprehensive genetic evaluation. Ultrasound
49. Nieuwint A, Van Zalen-Sprock R, Hummel P, et al. 'Identical' twins with discordant
karyotypes. Prenat Diagn 1999; 19:72.
50. Lewi L, Lewi P, Diemert A, et al. The role of ultrasound examination in the first trimester
and at 16 weeks' gestation to predict fetal complications in monochorionic diamniotic twin
pregnancies. Am J Obstet Gynecol 2008; 199:493.e1.
51. Maiz N, Nicolaides KH. Ductus venosus in the first trimester: contribution to screening of
chromosomal, cardiac defects and monochorionic twin complications. Fetal Diagn Ther
2010; 28:65.
52. Quintero RA, Morales WJ, Allen MH, et al. Staging of twin-twin transfusion syndrome. J
Perinatol 1999; 19:550.
53. Senat MV, Deprest J, Boulvain M, et al. Endoscopic laser surgery versus serial
amnioreduction for severe twin-to-twin transfusion syndrome. N Engl J Med 2004; 351:136.
6/20/22, 3:03 AM 120803
54. Gratacós E, Carreras E, Becker J, et al. Prevalence of neurological damage in monochorionic

twins with selective intrauterine growth restriction and intermittent absent or reversed
end-diastolic umbilical artery flow. Ultrasound Obstet Gynecol 2004; 24:159.
55. Ishii K, Murakoshi T, Takahashi Y, et al. 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.
56. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—
Obstetrics, Society for Maternal-Fetal Medicine. Multifetal Gestations: Twin, Triplet, and
Higher-Order Multifetal Pregnancies: ACOG Practice Bulletin, Number 231. Obstet Gynecol
2021; 137:e145.
57. Ishii K, Murakoshi T, Hayashi S, et al. Ultrasound predictors of mortality in monochorionic

twins with selective intrauterine growth restriction. Ultrasound Obstet Gynecol 2011; 37:22.
58. Hillman SC, Morris RK, Kilby MD. Co-twin prognosis after single fetal death: a systematic
review and meta-analysis. Obstet Gynecol 2011; 118:928.
59. Mackie FL, Rigby A, Morris RK, Kilby MD. Prognosis of the co-twin following spontaneous
single intrauterine fetal death in twin pregnancies: a systematic review and meta-analysis.
BJOG 2019; 126:569.
60. van Klink JM, van Steenis A, Steggerda SJ, et al. Single fetal demise in monochorionic
pregnancies: incidence and patterns of cerebral injury. Ultrasound Obstet Gynecol 2015;
45:294.
61. Lewi L, Gratacos E, Ortibus E, et al. Pregnancy and infant outcome of 80 consecutive cord
coagulations in complicated monochorionic multiple pregnancies. Am J Obstet Gynecol
2006; 194:782.
62. Parra-Cordero M, Bennasar M, Martínez JM, et al. Cord Occlusion in Monochorionic Twins
with Early Selective Intrauterine Growth Restriction and Abnormal Umbilical Artery
Doppler: A Consecutive Series of 90 Cases. Fetal Diagn Ther 2016; 39:186.
63. Bebbington MW, Danzer E, Moldenhauer J, et al. Radiofrequency ablation vs bipolar
umbilical cord coagulation in the management of complicated monochorionic pregnancies.
64. Monaghan C, Kalafat E, Binder J, et al. Prediction of adverse pregnancy outcome in
monochorionic diamniotic twin pregnancy complicated by selective fetal growth restriction.
65. Chalouhi GE, Marangoni MA, Quibel T, et al. Active management of selective intrauterine
growth restriction with abnormal Doppler in monochorionic diamniotic twin pregnancies
6/20/22, 3:03 AM 120803
diagnosed in the second trimester of pregnancy. Prenat Diagn 2013; 33:109.

66. Quintero RA, Bornick PW, Morales WJ, Allen MH. Selective photocoagulation of
communicating vessels in the treatment of monochorionic twins with selective growth
retardation. Am J Obstet Gynecol 2001; 185:689.
67. Gratacós E, Antolin E, Lewi L, et al. Monochorionic twins with selective intrauterine growth
restriction and intermittent absent or reversed end-diastolic flow (Type III): feasibility and
perinatal outcome of fetoscopic placental laser coagulation. Ultrasound Obstet Gynecol
2008; 31:669.
68. Ishii K, Nakata M, Wada S, et al. Feasibility and preliminary outcomes of fetoscopic laser
photocoagulation for monochorionic twin gestation with selective intrauterine growth
restriction accompanied by severe oligohydramnios. J Obstet Gynaecol Res 2015; 41:1732.
69. Peeva G, Bower S, Orosz L, et al. Endoscopic Placental Laser Coagulation in Monochorionic
Diamniotic Twins with Type II Selective Fetal Growth Restriction. Fetal Diagn Ther 2015;
38:86.
70. Ishii K, Wada S, Takano M, et al. Survival Rate without Brain Abnormalities on Postnatal
Ultrasonography among Monochorionic Twins after Fetoscopic Laser Photocoagulation for
Selective Intrauterine Growth Restriction with Concomitant Oligohydramnios. Fetal Diagn
Ther 2019; 45:21.
71. Miyadahira MY, Brizot ML, Carvalho MHB, et al. Type II and III Selective Fetal Growth
Restriction: Perinatal Outcomes of Expectant Management and Laser Ablation of Placental
Vessels. Clinics (Sao Paulo) 2018; 73:e210.
72. Koch A, Favre R, Viville B, et al. Expectant management and laser photocoagulation in
isolated selective intra-uterine growth restriction: A single-center series. J Gynecol Obstet
Hum Reprod 2017; 46:731.
73. Chmait RH, Chon AH, Korst LM, et al. Selective intrauterine growth restriction (SIUGR) type
II: proposed subclassification to guide surgical management. J Matern Fetal Neonatal Med
2022; 35:1184.
74. Weisz B, Hogen L, Yinon Y, et al. Perinatal outcome of monochorionic twins with selective
IUGR compared with uncomplicated monochorionic twins. Twin Res Hum Genet 2011;
14:457.
75. Valsky DV, Eixarch E, Martinez JM, et al. Selective intrauterine growth restriction in
monochorionic twins: pathophysiology, diagnostic approach and management dilemmas.
Semin Fetal Neonatal Med 2010; 15:342.
76. Chang YL, Chang SD, Chao AS, et al. Placenta share discordance and umbilical artery
Doppler change after antenatal betamethasone administration in monochorionic twins
6/20/22, 3:03 AM 120803
with selective intrauterine growth restriction: is there a link? Twin Res Hum Genet 2012;
15:680.
77. Townsend R, Duffy JMN, Sileo F, et al. Core outcome set for studies investigating
management of selective fetal growth restriction in twins. Ultrasound Obstet Gynecol 2020;
55:652.
78. Groene SG, Tollenaar LSA, Oepkes D, et al. The Impact of Selective Fetal Growth Restriction
or Birth Weight Discordance on Long-Term Neurodevelopment in Monochorionic Twins: A
Systematic Literature Review. J Clin Med 2019; 8.
Topic 120803 Version 14.0
6/20/22, 3:03 AM 120803
GRAPHICS
Unequal placental sharing resulting in sFGR
In sFGR, the placental territory is distributed unequally between twins: one twin benefits from
having the majority of the placental share while the growth-restricted twin is starved because of
access to only a small portion of the placenta.
sFGR: selective fetal growth restriction.
Graphic 122606 Version 2.0
6/20/22, 3:03 AM 120803
sFGR placenta after dye injection
Arteries are yellow and veins are purple. The sFGR twin has a smaller placental share and marginal
placental cord insertion (clamped cord at 11 o'clock position). Several artery-to-vein anastomoses and one
large artery-to-artery anastomosis are present.
6/20/22, 3:03 AM 120803
Ultrasound screening protocol for monitoring monochorionic multifetal

pregnancies
Gestational Purpose of ultrasound examination and frequency

age
11 to 14 weeks One examination for:

Assessment of gestational age and estimated date of delivery
Assessment of chorioamnionicity
Measurement of nuchal translucency*
16 AND 18 weeks Fetal size

Early fetal anatomic survey, including presence and size of fetal bladders
MVP of amniotic fluid
Doppler measurement of MCA-PSV
Doppler measurement of end-diastolic velocity in the UA
Assessment for PDE
20 weeks Fetal size

Detailed fetal anatomic survey, including presence and size of fetal bladders
MVP
Doppler measurement of UA end-diastolic flow velocity
PDE
Evaluate placental cord insertion sites (proximate cord insertion is defined
by a distance between cord insertions below the fifth percentile for
gestational age or by 3.3 to 4.0 cm at any gestational age)
20 to 22 weeks Transvaginal ultrasound measurement of cervical length

Fetal echocardiogram
22 to 32 weeks Serial examinations of fetal growth every 4 weeks

Serial examinations of the following every 2 weeks:
MVP
Presence and size of fetal bladders
PDE
32 to 36 weeks Continue serial examinations of fetal growth every 4 weeks

Weekly examinations:
Biophysical profile score
6/20/22, 3:03 AM 120803

PDE
MVP: maximum vertical pocket; MCA: middle cerebral artery; PSV: peak systolic velocity; UA:
umbilical artery; PDE: placental discordance echogenicity.
* Increased nuchal translucency has been associated with trisomy 21, a variety of congenital
anomalies, developmental and genetic syndromes, and twin-twin transfusion syndrome. Refer to
UpToDate content on cystic hygroma and increased nuchal translucency.
Modified from:
1. Khalil A, Rodgers M, Baschat A, et al. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. Ultrasound
2. Society for Maternal-Fetal Medicine, Simpson LL. Twin-twin transfusion syndrome. Am J Obstet Gynecol 2013; 208:3.
3. Sueters M, Middeldorp JM, Lopriore E, et al. Timely diagnosis of twin-to-twin transfusion syndrome in monochorionic
twin pregnancies by biweekly sonography combined with patient instruction to report onset of symptoms. Ultrasound
6/20/22, 3:03 AM 120803
Variation in the umbilical artery waveform in type 3 sFGR
Type 3 sFGR is characterized by a pathognomonic umbilical artery waveform that has a variable flow pattern
cycles between forward, absent, and reversed flow over a short interval, which is termed intermittent
absent/reversed end-diastolic flow.
6/20/22, 3:03 AM 120803
Doppler waveforms in types 1, 2, and 3 sFGR
(A) Type 1 sFGR. Persistently forward umbilical artery end-diastolic flow without variation in the
waveform and normal or elevated resistance.
(B) Type 2 sFGR. Fixed absent or fixed reversed umbilical artery end-diastolic flow without variation of the
waveform in the smaller twin.
(C) Type 3 sFGR. Variable umbilical artery flow pattern that cycles between forward, absent, and reversed flo
over a short interval.
6/20/22, 3:03 AM 120803
Courtesy of Jena Miller, MD.
6/20/22, 3:03 AM 120803
Similarities and differences among TTTS, TAPS, and sFGR on ultrasound

examination of both twins
Ultrasound finding TTTS TAPS sFGR
Fluid discordance +++++ – ++
Oligohydramnios in Oligohydramnios in
one sac and the sac of
polyhydramnios in the the intrauterine
other sac growth restricted twin,
normal amniotic fluid
volume in the AGA
twin
Growth discordance
++ + +++++
(>25% difference
50% will have 100% will have
between twins)
estimated fetal weight estimated fetal weight
<10th percentile <10th percentile
MCA Doppler ++ +++++ +

discordance
(>1.5 MoM in
donor/anemic and
<0.8 MoM in
recipient/plethoric)
Fetal bladder Small donor bladder – –

discordance and/or enlarged
recipient bladder
Ductus venosus +++++ ++ ++

abnormalities
Fetal hydrops +++++ + –
Placental ++ +++++ –

appearance: Donor
side hyperechoic and
thickened, recipient
side normal
"+" signifies the prominence of the ultrasound finding. "–" signifies that the ultrasound finding is not
associated with the diagnosis.
TTTS: twin-twin transfusion syndrome; TAPS: twin anemia polycythemia sequence; sFGR: selective
fetal growth restriction; AGA: appropriate for gestational age; MCA: middle cerebral artery; MoM:
multiples of the median.
6/20/22, 3:03 AM 120803
6/20/22, 3:03 AM 120803
Pregnancy management after diagnosis of type 1

sFGR
Type 1 sFGR is defined by persistently forward flow on UA Doppler.

Fetuses with nonreassuring BPPs are generally delivered.
sFGR: selective fetal growth restriction; UA: umbilical artery; MCA:

middle cerebral artery; BPP: biophysical profile (including nonstress
test); DV: ductus venosus; PI: pulsatility index.
* Doppler results indicating worsening disease warranting more

frequent fetal surveillance include UA PI >95th percentile, MCA PI
<5th percentile, or progression to type 2 or 3 sFGR.
6/20/22, 3:03 AM 120803
Pregnancy management after diagnosis of type 2

and type 3 sFGR
Type 2 sFGR is characterized by fixed absent or fixed reversed UA

end-diastolic velocity without variation of the waveform in the
smaller twin; type 3 sFGR is characterized by variable flow pattern
that cycles between forward, absent, and reversed flow over a short
interval (ie, intermittent absent/reversed end-diastolic flow).
sFGR: selective fetal growth restriction; UV: umbilical vein; DV:

ductus venosus; MCA: middle cerebral artery; BPP: biophysical
profile; UA: umbilical artery; PI: pulsatility index; NST: nonstress test.
* Signs of worsening disease include progression from type 2 to

type 3 sFGR, DV PI >95th percentile, development of absent or
reversed a-wave in the DV waveform, and oligohydramnios in the
sac of the smaller twin.
6/20/22, 3:03 AM 120803
¶ Consider admission for daily NSTs if delivery for fetal indications

would be considered.
6/20/22, 3:03 AM 120803
Rates of adverse outcomes in sFGR by type
IUFD Average Neonatal death

Double
sFGR Fetal gestational
fetal
type FGR Larger deterioration age at FGR Larger
OR loss O
fetus fetus delivery fetus fetus
1 4.3
4.1
1.4
1.9
16
33.7
3.3
2.8
2.
(2.0- (1.2- (0.4- (0.5-4.3) (4-36) (33.0-34.3) (0.9- (1.0- (0.
7.5) 8.7) 5.0) 7.0) 5.5) 7.5
2 14.4
9.2
1.8
7.0
59
30.9
12.1
4.9
2.
(5.9- (3.8- (0.9- (3.1- (34-82) (30.0-31.8) (4.6- (2.3- (1.
25.9) 16.6) 3.7) 12.5) 22.4) 8.4) 5.9
3 15.6
4.9
3.4
4.9
10
32.0
3.9
4.4
1.
(9.8- (1.8- (1.3- (1.8-9.4) (5-17) (31.3-32.8) (0.7- (1.0- (0.
22.6) 9.4) 8.8) 9.6) 10.2) 4.5
All values displayed as percentages (95% CI).
sFGR: selective fetal growth restriction;

IUFD: intrauterine fetal demise;
FGR: fetal growth
restriction;
OR: odds ratio.
Data from: Buca D, Pagani G, Rizzo G, et al. Outcome of monochorionic twin pregnancy with selective intrauterine growth
restriction according to umbilical artery Doppler flow pattern of smaller twin: systematic review and meta-analysis.
6/20/22, 3:03 AM 120803
Contributor Disclosures
Jena Miller, MD No relevant financial relationship(s) with ineligible companies to disclose. Mara Rosner,
MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Ahmet Alexander
Baschat, MD No relevant financial relationship(s) with ineligible companies to disclose. Lynn L Simpson,
MD No relevant financial relationship(s) with ineligible companies to disclose. Vanessa A Barss, MD,
FACOG No relevant financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

Selective Fetal Growth Restriction in Monochorionic Twin Pregnancies

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Selective Fetal Growth Restriction in Monochorionic Twin Pregnancies

Uploaded by

Copyright:

Available Formats

6/20/22, 3:03 AM 120803

Official reprint from UpToDate®

Selective fetal growth restriction in monochorionic twin

sFGR affects 10 to 15 percent of monochorionic twin pregnancies [21,22].

Ultrasound examinations are routinely performed in multiple gestations. Accurate

Crown rump length (CRL) discordancy of a monochorionic pregnancy on a first-trimester

Most sFGR is detected during routine sonographic monitoring of monochorionic pregnancies,

sFGR is defined by Delphi criteria as [26,27]:

● Estimated fetal weight (EFW) <3rd percentile of one fetus

● At least two of the following four criteria:

• EFW <10th percentile for one twin

Percent weight discordance is calculated using the following equation:

Doppler technique — Importantly, interpretation of the UA Doppler is not the same as in

● Reproducibility of measurements is greater if the measurement is obtained in a free loop

● Maternal breath holding may be required to exclude interference during measurement of

● Type 1 sFGR is characterized by persistently forward UA end-diastolic velocity without

● Type 2 sFGR is characterized by fixed absent or fixed reversed UA end-diastolic velocity

● Type 3 sFGR is characterized by a pathognomonic UA waveform that has a variable flow

● The second step is to evaluate amniotic fluid for oligohydramnios/polyhydramnios

Fetal anemia in monochorionic twins can also be caused by parvovirus infection,

Classification-based approach — The approach depicted in the algorithms and described

● sFGR type 1 – Expectant management with weekly ultrasound surveillance (umbilical

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) suggests

In patients who decline these interventions, we perform weekly Doppler surveillance of

Antenatal corticosteroids — Betamethasone or dexamethasone is administered if fetal status

Neurodevelopmental outcome — A systematic review on the impact of sFGR or birth weight

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Identification of sFGR – Beginning in the early second trimester, monochorionic twin

polycythemia sequence (TAPS). An example of a monitoring protocol is depicted in the

• Estimated fetal weight (EFW) <3rd percentile of one fetus or

• At least two of the four following criteria:

- EFW <10th percentile for one twin

● Management – Our approach to managing these pregnancies is depicted in the

Use of UpToDate is subject to the Terms of Use.

1. Burton GJ, Jauniaux E. Pathophysiology of placental-derived fetal growth restriction. Am J

6. Lewi L, Gucciardo L, Huber A, et al. Clinical outcome and placental characteristics of

8. Zhao D, Lipa M, Wielgos M, et al. Comparison Between Monochorionic and Dichorionic

9. Denbow ML, Cox P, Taylor M, et al. Placental angioarchitecture in monochorionic twin

15. Hack KE, Nikkels PG, Koopman-Esseboom C, et al. Placental characteristics of

Obstet Gynecol 2019; 53:47.

54. Gratacós E, Carreras E, Becker J, et al. Prevalence of neurological damage in monochorionic

57. Ishii K, Murakoshi T, Hayashi S, et al. Ultrasound predictors of mortality in monochorionic

diagnosed in the second trimester of pregnancy. Prenat Diagn 2013; 33:109.

Unequal placental sharing resulting in sFGR

sFGR: selective fetal growth restriction.

Graphic 122606 Version 2.0

sFGR placenta after dye injection

sFGR: selective fetal growth restriction.

Graphic 122607 Version 3.0

Ultrasound screening protocol for monitoring monochorionic multifetal

Gestational Purpose of ultrasound examination and frequency

11 to 14 weeks One examination for:

16 AND 18 weeks Fetal size

20 weeks Fetal size

20 to 22 weeks Transvaginal ultrasound measurement of cervical length

22 to 32 weeks Serial examinations of fetal growth every 4 weeks

32 to 36 weeks Continue serial examinations of fetal growth every 4 weeks

Doppler measurement of UA end-diastolic flow velocity

Graphic 118804 Version 5.0

Variation in the umbilical artery waveform in type 3 sFGR

sFGR: selective fetal growth restriction.

Graphic 122627 Version 2.0