OC18.06: Management of selective intrauterine growth restriction with abnormal Doppler in monochorionic diamniotic (MCDA) twin pregnancies

Objectives: Review outcome following interventional and expectant management of MCDA twin pregnancies complicated with selective intrauterine growth restriction (sIUGR) and absent or reverse end-diastolic flow (AREDF) in the umbilical arteries. Methods: All cases of sIUGR defined as abdominal circumference (AC) <5th centile and AREDF before 26+6 weeks, between 2011 and 2017. Management options included selective fetoscopic laser coagulation (SFLC) of inter-twin anatomoses, cord coagulation (CC), or expectant management (EM). Discordance in EFW and positive a-wave on the ductus venosus (DV) at diagnosis were considered as potential predictors for perinatal survival. Results: Of 108 cases, 13, 50 and 45 were managed by SFLC, CC and EM. Overall survival was 23%(6/26), 40%(40/100) and 77.8%(70/90) respectively. The discordance in EFW at diagnosis was more marked and negative a-wave in DV was more prevalent in both intervention groups. Intrauterine demise of the co-twin occurred in 30.8%(4/13), 10%(5/50) and 6.7%(3/45) respectively and was associated with demise of the smaller twin following SFLC and EM in 76.9%(10/13) and 17.8%(8/45) respectively. AC < 3 z-scores and absent a-wave in the ductus venosus were predictive of spontaneous demise in the EM group. Mean gestational age at delivery was 30 (29-32), 35 (32-35) and 32 (29-32) weeks following SFLC, CC and EM respectively. Conclusions: SFLC yielded poor results. Expectant management is a valid option as some will improve and allow a favourable neonatal outcome with few spontaneous fetal demise during follow-up. However, in cases with high discordance, AREDF and abnormal DV Doppler, CC should be considered to protect the co-twin.