Perinatal Outcomes of Monochorionic Twin Pregnancies with Selective Fetal Growth Restriction According to Umbilical Artery Dopplers and Fetal intervention: a Systematic Review and Meta-analysis

Abstract

Abstract Objective To investigate perinatal outcomes of monochorionic twins complicated by selective fetal growth restriction (sFGR) classified according to umbilical artery (UA) Doppler and type of management including expectant management, fetoscopic laser therapy, and selective reduction of the smaller twin. Methods A systematic search was performed in 3 databases until June 2022. The primary outcome was mortality including intrauterine fetal demise (IUFD), neonatal death (NND), and perinatal death (PND), and secondary outcomes were gestational age at birth, birthweight, and neonatal outcomes including survival free from neurological complications (intact survival). Meta-analyses of proportions were used to analyze the extracted data. Results 27 studies encompassing 354 monochorionic twin pregnancies with type I sFGR, 421 type II sFGR, and 475 type III sFGR were included. In pregnancies with type I sFGR managed expectantly, the smaller twin IUFD occurred in 2% (95% CI 1–6), NND in 2% (95% CI 0–50), while 96% (95% CI 88–99) survived without neurological compromise. In pregnancies with type I sFGR managed with laser, smaller twin IUFD occurred in 12% (95% CI 4–25). In type II sFGR managed expectantly, smaller twin IUFD occurred in 18% (95% CI 1–30), NND in 17% (95% CI 1–26), and 38% (95% CI 22–56) survived without neurological compromise. In pregnancies with type II sFGR managed with laser, smaller twin IUFD occurred in 55% (95% CI 48–63), and 42% (95% CI 3–54) survived without neurological compromise. In type III sFGR managed expectantly, smaller twin IUFD occurred in 16% (95% CI 11–23), NND in 5% (95% CI 3–8), and 62% (95% CI 32–86) survived without neurological compromise. With laser, the smaller twin IUFD occurred in 16% (95% CI 11–23), PND in 63% (95% CI 37–84), and 80% (95% CI 44–97) survived without neurological compromise. Conclusion Type I sFGR has low risk of IUFD with expectant management. Type III sFGR had higher morbidity and mortality with laser therapy compared to expectant management. Type II sFGR treated with laser therapy had higher mortality but somehow lower morbidity compared to those managed expectantly, with scarce outcomes data following selective reduction.