Ultrasound Obstet Gynecol 2008; 31: 669675

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.5362

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

E. GRATACOS*,
E. ANTOLIN*, L. LEWI, J. M. MARTINEZ*, E. HERNANDEZ-ANDRADE*,

R. ACOSTA-ROJAS*, G. ENRIQUEZ,
L. CABERO** and J. DEPREST
*Department of MaternalFetal Medicine (ICGON) and Fetal and Perinatal Research Group (IDIBAPS), Hospital Clinic, University of
Barcelona, Center for Biomedical Research on Rare Diseases (CIBER-ER) and Departments of Pediatric Radiology and **Obstetrics,
Vall dHebron University Hospital, Barcelona and Department of Obstetrics and Gynecology, Hospital Gregorio Maranon,
Universidad

Complutense de Madrid, Madrid, Spain and Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Leuven,
Belgium

K E Y W O R D S: fetoscopic placental laser coagulation; intermittent absent or reversed end-diastolic flow; monochorionic twins;
neurological damage; perinatal outcome; selective intrauterine growth restriction

ABSTRACT
Objectives To assess the feasibility and impact on perinatal outcome of fetoscopic laser coagulation of placental anastomoses in monochorionic twins with selective
intrauterine growth restriction (sIUGR) and intermittent
absent or reversed end-diastolic flow (iAREDF) in the
umbilical artery (Type III), in comparison with expectant
management.

associated with death of the cotwin in 50% (3/6) and

0% (0/12) of these cases, respectively (P = 0.02). The
prevalence of periventricular leukomalacia in the larger
fetus was 4/28 (14.3%) in the expectant management
group and 1/17 (5.9%) in the laser group (P = 0.63).
Conclusions Laser coagulation in sIUGR-iAREDF pregnancies is technically difficult and not always feasible.
Placental dichorionization significantly increases the proportion of fetuses with intrauterine death of the growthrestricted twin, but it protects the normal twin from its
cotwins death in the event of demise of the growthrestricted twin. Copyright 2008 ISUOG. Published by
John Wiley & Sons, Ltd.

Methods This is a descriptive study of the outcome of

18 cases of monochorionic twins with Type III sIUGR
treated with laser, and 31 pregnancies managed expectantly over the same period. All newborns underwent
neonatal brain ultrasound scans. Perinatal outcome and
the incidence of neurological damage were compared
between the two groups.

INTRODUCTION

Results Laser coagulation could be performed in only

88.9% (16/18) of cases owing to technical difficulties,
and in 12.5% (2/16) a second procedure was required
to achieve complete coagulation of the large artery-toartery anastomosis. Mean gestational age at delivery was
31.0 (range, 2633) weeks in the expectant management
group and 32.6 (range, 2338) weeks in the laser group
(P = 0.32). Overall perinatal survival was 85.5% (53/62)
and 63.9% (23/36), respectively (P = 0.02). Intrauterine
demise of the smaller twin occurred in 19.4% (6/31)
and 66.7% (12/18), respectively (P = 0.001), and was

Selective intrauterine growth restriction (sIUGR) occurs

in around 1015% of monochorionic (MC) twins1,2 . The
condition is increasingly considered to be an important
complication of MC twins, with potentially significant
risks for both fetuses1 4 . Unequal placental sharing is
the most important factor determining the appearance of
growth discordance5,6 , but the clinical evolution is largely
influenced by the pattern of placental anastomoses6 . Thus,
MC pregnancies with sIUGR may be associated with
remarkable differences in clinical behavior and outcome.
We have recently provided evidence that a classification

Servei de Medicina Maternofetal (ICGON), Hospital Clnic (Seu Maternitat), Sabino de Arana 1, 08028
Correspondence to: Dr E. Gratacos,
Barcelona, Spain (e-mail: egratacos@clinic.ub.es)
Accepted: 21 March 2008

Copyright 2008 ISUOG. Published by John Wiley & Sons, Ltd.

ORIGINAL PAPER

670

using umbilical artery (UA) Doppler findings in the

fetus with IUGR correlates with distinct clinical forms7 .
According to this classification, pregnancies are defined as
Type I (normal UA Doppler findings), Type II (persistent
absent or reversed end-diastolic velocity flow, AREDF) or
Type III (intermittent AREDF, iAREDF).
Intermittent AREDF is a sign defined by the presence of
intermittent, normally cyclical changes in the diastolic
flow component of the UA Doppler image, and it
invariably indicates the presence of large arterioarterial
(AA) anastomoses8 10 . We have previously reported that
these pregnancies are associated with an atypical clinical
evolution7,9 . The smaller twin often fails to develop
the Doppler signs normally accompanying hypoxic
deterioration of severe IUGR fetuses9 . However, it may
present unexpected intrauterine fetal demise (IUFD) in
around 15% of cases. On the other hand, the appropriatefor-gestational age (AGA) twin has a higher risk of
postnatal white matter lesions, even if the smaller twin is
born alive4 . Because the risks for poor perinatal outcome
cannot be monitored on the basis of signs of fetal
deterioration in the growth-restricted twin, management
of these pregnancies represents a challenge.
It is thought that the poor outcome associated with
Type III sIUGR pregnancies is due to a particularly high
risk of acute fetofetal transfusion accidents through the
large AA anastomoses ever present in these cases7 10 .
Theoretically, a placental dichorionization, such as
performed in twintwin transfusion syndrome (TTTS)
using fetoscopic laser coagulation, should completely
prevent the occurrence of these fetofetal transfusion
accidents. However, a fetoscopic procedure itself carries
an increased risk of obstetric complications. In addition,
interruption of the intertwin blood transfer might have
unexpected effects on the fetuses. Laser coagulation of
placental vessels has been proposed previously for sIUGR,
but so far has only been tested in MC-sIUGR Type II
pregnancies11 . It is uncertain whether this therapy would
be of benefit for Type III pregnancies.
During a 3-year period, a small number of patients
with the diagnosis of sIUGR and the presence of iAREDF
have been treated with laser coagulation of the placental
anastomoses at the institutions participating in this study.
The aim of this study was to describe our experience of
the feasibility and perinatal outcome of laser therapy, in
comparison to outcome in a cohort of patients followed
expectantly over a similar period.

Gratacos
et al.
participating institutions (Hospital Clinic and UZ Leuven)
was used as a control group for comparisons. All patients
were followed up and recruited in the context of a large
collaborative study on MC twins (EuroTwin2Twin). The
study protocols were approved by the institutional ethics
committees and written consent was obtained from all
pregnant women. Twenty-two pregnancies included in
this study in the expectant management group have been
reported in a previous descriptive study on the natural
history and classification of sIUGR7 .
Selective IUGR was defined as an estimated fetal
weight in one fetus below the 10th centile, in the
absence of ultrasound signs consistent with the presence
of severe TTTS12 . Type III sIUGR was identified by
the presence of iAREDF, which was defined as the
clear observation of different abnormal diastolic patterns
(A/REDF) alternating with positive diastolic flow in
a short time interval during fetal quiescence and in
the absence of maternal breathing (Figure 1). These
findings were confirmed on several examinations in
all cases. Doppler and ultrasound examinations were
performed using a Siemens Sonoline Antares (Siemens
Medical Systems, Malvern, PA, USA) or a Voluson 730
Expert (GE Healthcare Technologies, Milwaukee, WI,
USA) ultrasound machine with 62-MHz and 74-MHz
curved-array probes.
Fetoscopic placental laser coagulation was performed
following a similar protocol to that described previously,
with some modifications12 . After careful examination
of the position of the fetuses and the placenta, the
fetoscope was inserted into the sac that theoretically
would allow the best approach to the placental vascular
equator. When required, the sac was distended with
an amnioinfusion of warmed Ringer lactate until a
proper view of the placenta was achieved. If required,
an ultrasound-guided amniodrainage was performed in
the contralateral sac using a 20-G needle to move the
intertwin membrane away from the vascular equator and
improve vision. The vascular equator was then explored

METHODS
This descriptive clinical series includes all cases of
sIUGR treated with laser therapy during a 3-year period
(20032006) by two fetal surgery teams at three hospitals.
One group offered laser therapy as one of the management
Barcelona),
options (Hospital Clinic and Vall dHebron,
whereas laser treatment was not offered routinely by the
other group (UZ Leuven) and was considered only at the
parents request. A consecutive sample of cases followed
up during the same period and delivering at two of the

Copyright 2008 ISUOG. Published by John Wiley & Sons, Ltd.

Figure 1 Characteristic intermittent absent or reversed end-diastolic

umbilical artery flow velocity pattern showing cyclically positive,
absent and reversed end-diastolic flow over a short time interval.

Ultrasound Obstet Gynecol 2008; 31: 669675.

Laser in monochorionic twins with sIUGR

systematically and all vessels identified as intertwin
anastomoses were coagulated with a neodymium :
yttriumaluminumgarnet laser (Sharplan, London, UK)
or a diode laser (Ceralas D50, CeramOptec Inc.,
Bonn, Germany; Dornier system, Munich, Germany).
Elective septostomy was contemplated if, in spite of the
above maneuvers, part of the vascular equator crossed
the intertwin membrane and could not be examined
optimally. After the operation had been completed,
Doppler imaging of the UA was performed to confirm
the disappearance of the intermittent flow (Figure 2).
Patients were normally discharged within 2448 h after
the procedure.
Cases in both study groups were followed according
to standard clinical protocols. Fetal well-being was
monitored weekly or at closer intervals if indicated by the
results of the fetal monitoring tests. Doppler examinations
included UA, middle cerebral artery and ductus venosus
(DV), in combination with fetal biophysical profile
and, in pregnancies above 28 weeks, fetal heart rate
trace analysis. Severe fetal deterioration suggesting the

Figure 2 Disappearance of the intermittent absent or reversed

end-diastolic umbilical artery flow velocity pattern in both
umbilical arteries (a and b) of the same fetus as in Figure 1
immediately after laser surgery.

Copyright 2008 ISUOG. Published by John Wiley & Sons, Ltd.

671

need for active management, i.e. cord occlusion or

delivery, was diagnosed by the managing physicians
according to the following criteria: before 28 weeks,
persistently absent or reversed flow in the DV during
atrial contraction; after 28 weeks, pulsatility index (PI) in
the DV persistently > 2 SD and/or persistently abnormal
fetal heart rate traces and/or abnormal biophysical
profile. In the expectant management group, if fetal
deterioration was not apparent, delivery was performed
electively around 32 weeks after maternal administration
of corticosteroid therapy for fetal maturation. IUGR
fetuses with iAREDF normally fail to show hemodynamic
signs of fetal deterioration7 and this arbitrary cut-off was
chosen as a balance between the risks of preterm birth and
the risks of fetal death or neurological morbidity in MC
twins with sIUGR3,4 . The protocol considered the option
of cord occlusion in the event of severe fetal deterioration
before 28 weeks, but no cases met this criterion during
the reported period.
All controls and most cases treated with laser delivered
in one of the institutions participating in the study.
If the delivery was in the referring center, perinatal
outcome was retrieved from the managing physicians.
Perinatal outcome could be recorded in all cases.
All neonates underwent ultrasound brain scans on at
least one, and preferably two, occasions, at or before
the fourth day of postnatal life and at 28 7 days
when required. Significant abnormal findings, including
intraventricular hemorrhage (IVH) and particularly
periventricular leukomalacia (PVL), were recorded. IVH
was classified into four grades: Grade 1, subependymal
hemorrhage or hemorrhage of the germinal matrix;
Grade 2, extension of the subependymal hemorrhage
into the ventricle without ventricular enlargement;
Grade 3, hemorrhage extending into the ventricles
with ventriculomegaly; and Grade 4, extension to
the adjacent brain parenchyma13 . PVL was classified
according to the white matter pattern as follows: transient
periventricular echodensities persisting for 7 days or
longer; periventricular echodensities evolving into small
localized frontoparietal cystic lesions; periventricular
densities evolving into extensive periventricular cystic
lesions; and densities extending into the deep white matter,
evolving into extensive cystic lesions14 . Examination
of the placenta in laser cases with two survivors was
performed for the presence of patent vessels according to
previously described methods of placental injection15 .
Data were stored in a database and analyzed with
the SPSS 13.0 statistical package (Chicago, IL, USA).
Qualitative data were compared by means of Chi-square
test or Fishers exact test as appropriate. Continuous
variables were compared using the MannWhitney Utest. The association between laser therapy and main
outcome measures was adjusted for gestational age, DVPI and estimated fetal weight discordance at diagnosis,
and gestational age at delivery by logistic regression.
Results were analyzed on an intention-to-treat basis.

Ultrasound Obstet Gynecol 2008; 31: 669675.

Gratacos
et al.

672

RESULTS
A total of 49 monochorionic twins with sIUGR Type III
were included in the study. Thirty-one cases were managed
expectantly and 18 underwent selective photocoagulation
of communicating vessels. Laser treatment was performed
at a median gestational age of 22.2 (range, 18.026.4)
weeks. The placenta was completely anterior in six cases,
partially or totally lateral in five and completely posterior
in seven cases. In all but one (94%) of the procedures,
the fetoscope was inserted into the sac of the larger twin.
Amnioinfusion was required in 77.7% (14/18) of cases.
In two (11%) cases, elective septostomy was performed
to achieve full inspection of the vascular equator. The
vascular equator could be fully inspected in all patients,
and the presence of one large AA connection among the
placental anastomoses was confirmed in all cases. The
median operating time was 50 (range, 2075) min. Laser
coagulation was actually performed in 88.9% (16/18) of
cases. In two cases, both at > 25 weeks gestational age,
laser coagulation was considered technically impossible
by the responsible surgeons, owing to a combination of
very large communicating vessels, a very short distance
between the placental cord insertions and an anterior
placenta.
In all 16 cases in which the operation could be
completed, disappearance of iAREDF was observed
immediately by UA Doppler imaging at the end of the
operation. However, reappearance of the intermittent
flow was observed within 48 h in two of these fetuses.
Both patients underwent repeat fetoscopy a few days

later and in both the AA anastomosis was recoagulated

with no further reappearance of the intermittent pattern.
Altogether, in the 16 cases in which placental coagulation
was performed successfully, immediate UA Doppler
imaging in the smaller twin after laser treatment showed
positive diastolic flow in six cases (37.5%), absent enddiastolic flow in seven (43.7%) and reversed end-diastolic
flow in three (18.7%). After laser treatment, all cases
were followed up weekly with fetoplacental Doppler
examination. There were no instances of increased peak
systolic velocity in the middle cerebral artery in any
fetus. Premature rupture of membranes before 32 weeks
gestational age occurred in 11% (2/18) of patients treated
with fetoscopy. No fetal or obstetric complications were
observed in the two cases in which a septostomy was
performed. One patient delivered one liveborn neonate
spontaneously at 31 weeks gestation and the other was
delivered by elective Cesarean section at 32 weeks to
reduce the complications associated with a monoamniotic
pregnancy. The placenta was available for analysis in 4/5
laser cases with two survivors. No patent anastomoses
were found.
Perinatal outcomes in the study groups are shown
in Table 1. No difference in gestational age at delivery
was observed between the two groups. Overall perinatal
survival was significantly higher in the expectant
management than in the laser group, although the rate
of pregnancies with survival of at least one fetus was
similar. The difference in overall survival was mainly
explained by a threefold risk of IUFD of the IUGR twin
in the laser group: 66.7% (12/18) in the overall group but

Table 1 Perinatal outcome according to management strategy

Parameter
Gestational age at diagnosis (weeks)
Gestational age at delivery (weeks)
Estimated fetal weight discordance (%)
Ductus venosus PI at diagnosis
Larger twin
Smaller twin
Birth weight (g)
Larger twin
Smaller twin
Intrauterine fetal death
Overall
Larger twin
Smaller twin
At least one fetus alive
Two fetuses alive
Intraventricular hemorrhage
Overall
Larger twin
Smaller twin
Periventricular leukomalacia
Overall
Larger twin
Smaller twin

Expectant management
(n = 31)
22.0 (16.026.0)
31.0 (26.033.0)
33 (1966)
0.57 (0.390.90)
0.96 (0.481.30)
1500 (9303300)
950 (5702130)

Laser treatment
(n = 18)

Adjusted P*

22.0 (18.025.0)
32.6 (23.038.0)
38 (2545)

0.21
0.32
0.22

0.11
0.26

0.24
0.39

0.66 (0.420.87)
1.04 (0.561.28)
2155 (10003450)
750 (6501330)

9/62 (14.5)
3/31 (9.7)
6/31 (19.4)
28/31 (90.3)
25/31 (80.6)

13/36 (36.1)
1/18 (5.6)
12/18 (66.7)
18/18 (100)
5/18 (27.8)

0.02
0.97
0.001
0.29
< 0.001

0.95
0.01
0.99
0.005

3/53 (5.7)
2/28 (7.1)
1/25 (4)

2/23 (8.7)
0/17 (0)
2/6 (33.3)

0.58
0.51
0.08

0.99
0.11

4/53 (7.5)
4/28 (14.3)
0/25 (0)

2/23 (8.7)
1/17 (5.9)
1/6 (16.7)

0.9
0.63
0.19

0.15
1.0

Results are expressed as median (range) or n (%). *Adjusted for gestational age, interfetal weight discordance and ductus venosus of smaller
twin at diagnosis, and gestational age at delivery. Discordance was calculated as ((larger smaller)/larger) 100. PI, pulsatility index.

Copyright 2008 ISUOG. Published by John Wiley & Sons, Ltd.

Ultrasound Obstet Gynecol 2008; 31: 669675.

Laser in monochorionic twins with sIUGR

75% (12/16) of cases in which laser coagulation could
be performed successfully. IUFD of the smaller twin after
laser treatment occurred within 72 h in three cases, before
the first 2 weeks in three cases and within a 38-week
period in the remaining six cases. IUFD occurred only in
fetuses presenting AREDF in the UA immediately after
laser treatment, and it was predictable by the detection
of critical Doppler signs (reversed diastolic flow in the
UA and reversed atrial flow in the DV) in all cases. On
the contrary, in the six cases of IUFD observed in the
expectant management group, fetal death occurred in
association with a normal DV Doppler pattern within
1 week of fetal death in all IUGR fetuses. Death of the
smaller twin was associated with concomitant death of
the AGA twin in 50% (3/6) of cases in the expectant
group and in 0% (0/12) in the laser group (P = 0.02).
In one case treated with laser therapy, the larger twin
died unexpectedly 5 days after the procedure. There were
no cases with double fetal death in the laser group. No
significant differences were observed in the prevalence of
PVL or IVH in the larger twin between the two groups.

DISCUSSION
Current management options in MC twin pregnancies
with sIUGR include either expectant management with
close surveillance, termination of pregnancy or umbilical
cord occlusion in cases of high risk of in-utero fetal
demise16 . Selective coagulation of the communicating
vessels was first proposed by Quintero et al. as an
alternative approach in order to dichorionize the
placenta and prevent the risks associated with intrauterine
death of one fetus11 . The authors reported the results of
this approach in a preliminary clinical series including
28 sIUGR pregnancies with persistent AREDF in the UA,
defined as Type II according to the classification quoted
above7 . Seventeen pregnancies were managed expectantly
and 11 treated with laser coagulation. The study suggested
a reduction in the risks of concomitant demise of the
larger fetus and neurological damage in newborn babies,
although, as reported by the authors, neurological followup was not systematic9 .
In the present observational study we evaluated the
feasibility and impact of this therapy in pregnancies with
Type III sIUGR, which are associated with considerable
differences in pregnancy course compared with Type
II cases. The data provide evidence that fetoscopic
laser coagulation is feasible in these pregnancies, but
associated with considerably more technical difficulties
than laser treatment for TTTS. The procedure resulted in
a significantly higher risk of IUFD for the smaller fetus,
but a reduction in the risk of concomitant death of the
AGA twin after demise of the IUGR fetus. The sample
size in this study prevented any meaningful comparison
in terms of the prevalence of neurological damage in the
larger fetus. Finally, it must be stressed that this study
was a descriptive series and therefore potentially subject
to selection bias. The results in terms of perinatal outcome

Copyright 2008 ISUOG. Published by John Wiley & Sons, Ltd.

673

should be confirmed in prospective controlled studies or

randomized controlled trials.
Although feasible, laser coagulation in Type III sIUGR
was technically challenging, even for surgeons well trained
in laser coagulation for TTTS, each with over 300
procedures. In TTTS, placental inspection is facilitated
because the intertwin membrane is collapsed against
a considerably flattened chorionic plate due to the
polyhydramnios/oligoanhydramnios sequence. In sIUGR,
normal amniotic fluid levels rendered visualization
difficult and amnioinfusion was commonly required.
Quintero et al. also reported the use of amnioinfusion in
10/11 cases of Type II sIUGR treated by laser11 . In spite
of amnioinfusion, inspection of the vascular equator may
still be impossible if part of the intertwin anastomosis
is located in the other twins sac. Thus, septostomy, a
procedure that is virtually never used in laser treatment for
TTTS, was required in 11% (2/18) of cases. Alternatively,
Quintero et al. reported the use of a second entry in the
sac of the other twin11 , which might avoid the risks of
septostomy. Laser coagulation of placental vessels was
not considered feasible in two cases. This was because of
a combination of two limiting factors: a suboptimal angle
for visualization and coagulation of the vessel owing to
the anterior placental insertion and a large size of the AA
anastomosis, clearly beyond 3 mm in each case. The latter
factor was in turn influenced by a close insertion of the
cords in both cases and a relatively advanced gestational
age. This experience stresses the need for seriously
considering laser coagulation in sIUGR Type III late in
the second trimester, particularly in the presence of an
anterior placenta and/or nearby umbilical cord insertions.
Of more concern was the reappearance of AA flow in two
cases considered to be treated successfully by fetoscopic
inspection and Doppler examination. Although increasing
experience could reduce the failure rate, this might remain
a possible complication in the presence of very large size
AA anastomoses. In summary, laser coagulation in sIUGR
pregnancies presents important differences compared with
the same procedure in TTTS, and these result in longer
and more difficult operations. The presence of large AA
anastomoses in Type III cases may further increase the
technical demands and occasionally render the operation
impossible.
Placental dichorionization clearly had a negative impact
on the survival of the IUGR fetus. Although comparisons
in this study were performed on an intention-to-treat
basis, only 16 cases were actually treated, so the true
rate of IUFD after surgical placental dichorionization was
75% (12/16). The MC placenta strongly interferes in the
natural history of growth restriction, and bidirectional
fetal flow interchange often has a protective effect on
the IUGR fetus, whereby flow from the larger twin
acts as a rescue transfusion for the smaller6,17 . As
a consequence, the degree of fetal weight discrepancy
is normally less than that expected for the magnitude
of discordancy in the placental territories6,7,17 . This
effect is most pronounced in Type III sIUGR, where
the ratio of placental territories of the larger to the

Ultrasound Obstet Gynecol 2008; 31: 669675.

Gratacos
et al.

674

smaller twin may be as high as 1817 . Large AA

anastomoses, as characteristically present in these cases,
may act as functional arteriovenous anastomoses so
that the larger twin perfuses part of the placenta of
the smaller fetus, partially compensating the extreme
placental insufficiency17,18 . Thus, large AA vascular
anastomoses, which are the basis for the high risk of acute
hemodynamic accidents in Type III sIUGR pregnancies,
are also indispensable for the in-utero survival of the
smaller twin in most instances. Finally, one normally
grown twin died unexpectedly after laser therapy. Of
note, this complication was also reported by Quintero
et al. in their clinical series11 . These cases illustrate that
placental dichorionization with laser coagulation might
occasionally have deleterious effects on the normal twin
that should be considered when offering this therapy to
patients.
Unfortunately, this study leaves open the question of
whether dichorionization could reduce the risk of white
matter damage in the normal sized twin, as present in these
pregnancies4 . The sample size prevented any comparison
in this respect. Although the question should be addressed
in a randomized trial, this would possibly be impractical
today considering the rarity of the condition. There is
a need for further clinical series confirming previous
findings and allowing a better understanding of the clinical
evolution and pathophysiology of this condition. Selective
IUGR affects around 10% of MC pregnancies and of
these only a proportion are Type III. With similar rates
of neonatal abnormal brain scans to those reported in
this study (i.e. 515%), such a study would require the
enrolment of in excess of 300 pregnancies. However,
we believe that the hypothesis is plausible and that the
question is relevant. Although the prevalence is relatively
low, a 15% rate of neonatal neurological damage in an
otherwise normal fetus represents a significant risk. Longterm postnatal outcome of these infants could reveal a
higher prevalence of abnormal neurological development,
as suggested by long-term follow-up studies in MC
pregnancies with sIUGR19 .
If our findings are confirmed in future studies,
some women may prefer to maximize their chances
of having one normal infant. Thus, a proportion of
parents might ask for an active therapy, that being laser
dichorionization or even cord occlusion. The latter has
proved to be a relatively safe procedure in MC twin
pregnancies, and it could be a more straightforward
option than laser coagulation for active management
of MC twin pregnancies with sIUGR13 . In the absence
of clear data from randomized trials, information given
to parents and clinical decisions could be substantially
improved by increasing available data by means of
large collaborative observational series, which should
help further to document the natural history of the
different types of sIUGR in MC twin pregnancies
and the outcomes observed with different management
options.

Copyright 2008 ISUOG. Published by John Wiley & Sons, Ltd.

ACKNOWLEDGMENTS
This work was partially supported by grants from the
European Commission (V Framework EuroTwin2Twin
QLG1-CT-2002-01632), the Spanish Fondo de Investigaciones Sanitarias (FIS 02/0738), Thrasher Research
Fund (Salt Lake City, UT, USA), CEREBRA foundation for the brain injured child and Marie Curie
Actions for early stage research training (EST)
(FETAL-MED 019707-2).

REFERENCES
1. Lewi L, Van Schoubroeck D, Gratacos E, Witters I, Timmerman D, Deprest J. Monochorionic diamniotic twins: complications and management options. Curr Opin Obstet Gynecol
2003; 15: 177194.
2. Acosta-Rojas R, Becker J, Munoz-Abellana B, Ruiz C, Carreras E, Gratacos E. Twin chorionicity and the risk of adverse
perinatal outcome. Int J Gynaecol Obstet 2007; 96: 98102.
3. Adegbite AL, Castille S, Ward S, Bajoria R. Prevalence of
cranial scan abnormalities in preterm twins in relation to
chorionicity and discordant birth weight. Eur J Obstet Gynecol
Reprod Biol 2005; 119: 4755.
E, Carreras E, Becker J, Lewi L, Enrquez G, Per4. Gratacos
apoch J, Higueras T, Cabero L, Deprest J. 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: 159163.
5. Fick AL, Feldstein VA, Norton ME, Wassel Fyr C, Caughey AB,
Machin GA. Unequal placental sharing and birth weight
discordance in monochorionic diamniotic twins. Am J Obstet
Gynecol 2006; 195: 178183.
6. Denbow ML, Cox P, Taylor M, Hammal DM, Fisk NM. Placental angioarchitecture in monochorionic twin pregnancies:
relationship to fetal growth, fetofetal transfusion syndrome,
and pregnancy outcome. Am J Obstet Gynecol 2000; 182:
417426.
E, Lewi L, Munoz
M, Acosta-Rojas R, Hernandez7. Gratacos
Andrade E, Martnez JM, Carreras E, Deprest J. 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:
2834.
8. Wee LY, Taylor MJ, Vanderheyden T, Talbert D, Fisk NM.
Transmitted arterio-arterial anastomosis waveforms causing
cyclically intermittent absent/reversed end-diastolic umbilical artery flow in monochorionic twins. Placenta 2003; 24:
772778.
E, Lewi L, Carreras E, Becker J, Higueras T, Deprest J,
9. Gratacos
Cabero L. 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: 456460.
10. Hecher K, Jauniaux E, Campbell S, Deane C, Nicolaides K.
Artery-to-artery anastomosis in monochorionic twins. Am J
Obstet Gynecol 1994; 171: 570572.
11. 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: 689696.
12. Gratacos E, Deprest J. Current experience with fetoscopy and
the Eurofetus registry for fetoscopic procedures. Eur J Obstet
Gynecol Reprod Biol 2000; 92: 151159.
13. Papile LA, Burstein J, Burstein R, Koffler H. Incidence and
evolution of subependymal and intraventricular hemorrhage:
a study of infants with birth weights less than 1500 g. J Pediatr
1978; 92: 529534.

Ultrasound Obstet Gynecol 2008; 31: 669675.

Laser in monochorionic twins with sIUGR

14. De Vries LS, Eken P, Dubowitz LM. The spectrum of leukomalacia using cranial ultrasound. Behav Brain Res 1992; 49: 16.
15. Lewi L, Jani J, Cannie M, Robyr R, Ville Y, Hecher K,
Gratacos E, Vandecruys H, Vandecaveye V, Dymarkowski S,
Deprest J. Intertwin anastomoses in monochorionic placentas
after fetoscopic laser coagulation for twin-to-twin transfusion
syndrome: is there more than meets the eye? Am J Obstet
Gynecol 2006; 194: 790795.
16. Lewi L, Gratacos E, Ortibus E, Van Schoubroeck D, Carreras E, Higueras T, Perapoch J, Deprest J. Pregnancy and
infant outcome of 80 consecutive cord coagulations in complicated monochorionic multiple pregnancies. Am J Obstet

Copyright 2008 ISUOG. Published by John Wiley & Sons, Ltd.

675
Gynecol 2006; 194: 782789.
17. Lewi L, Cannie M, Blickstein I, Jani J, Huber A, Hecher K,
Dymarkowski S, Gratacos E, Lewi P, Deprest J. Placental
sharing, birthweight discordance and vascular anastomoses in
monochorionic diamniotic twin placentas. Am J Obstet Gynecol
2007; 197: 587.e1e8.
18. De Groot R, Van Den Wijngaard JP, Umur A, Beek JF,
Nikkels PG, Van Gemert MJ. Modeling acardiac twin pregnancies. Ann N Y Acad Sci 2007; 1101: 235249.
19. Adegbite AL, Castille S, Ward S, Bajoria R. Neuromorbidity in
preterm twins in relation to chorionicity and discordant birth
weight. Am J Obstet Gynecol 2004; 190: 156163.

Ultrasound Obstet Gynecol 2008; 31: 669675.