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a Department
of Obstetrics and Gynaecology, The Royal Women’s Hospital, Parkville, VIC, Australia;
b Pauline
Gandel Imaging Centre, The Royal Women’s Hospital, Parkville, VIC, Australia; c Pregnancy Research Centre,
Department of Maternal Fetal Medicine, The Royal Women’s Hospital, Parkville, VIC, Australia; d The University of
Melbourne, Department of Obstetrics and Gynaecology, The Royal Women’s Hospital, Parkville, VIC, Australia;
e Department of Maternal Fetal Medicine, The Royal Women’s Hospital, Parkville, VIC, Australia
Keywords were included in the analysis. There was one yolk sac identi-
Monoamniotic twins · Yolk sac · Twin pregnancy · Adverse fied in 26 cases (68%) and two yolk sacs in 12 cases (32%).
pregnancy outcome · First trimester ultrasound Two yolk sacs were associated with a higher proportion of
male fetuses (33%, 4 out of 12, vs. 8%, 2 out of 26; p = 0.01).
There were no other significant differences between one
Abstract and two yolk sacs for maternal or neonatal outcomes. Con-
Background: Detection of a single yolk sac on early first tri- clusions: Two yolk sacs are present in up to a third of all
mester ultrasound was previously thought to be a reliable MCMA twin pregnancies, dispelling the original concept
diagnostic feature of monochorionic monoamniotic (MCMA) that a single yolk sac is diagnostic of MCMA pregnancies.
twin pregnancies. Objectives: To determine the frequency Yolk sac number should not be used to determine amnionic-
of two yolk sacs in MCMA twin pregnancies and the associa- ity. The presence of two yolk sacs on first trimester ultra-
tion of yolk sac number with pregnancy outcomes. Meth- sound is associated with an increased rate of male fetuses.
ods: A retrospective cohort analysis of MCMA twins man- The number of yolk sacs has no other significant impact on
aged at a tertiary obstetric centre from January 2003 until perinatal outcomes. © 2019 S. Karger AG, Basel
February 2017. All MCMA twin pregnancies were diagnosed
on tertiary centre ultrasound and, where possible, placental
histopathology postnatally. All MCMA twin pregnancies, in-
cluding conjoined twins, with available first trimester ultra- Introduction
sounds from 5 to 11 weeks’ gestation were included in the
analysis. MCMA pregnancies without available first trimester Monochorionic monoamniotic (MCMA) twins are
ultrasounds and triplet pregnancies which included a MCMA thought to result from separation of a single cell mass at
pair were excluded from the study. Results: Sixty-seven days 8–12 following fertilization and are characterized by
MCMA cases were identified over 14 years. Thirty-eight cases a single chorionic and amniotic sac [1]. These pregnan-
128.252.67.66 - 2/18/2019 10:44:34 AM
E-Mail karger@karger.com
Parkville, VIC 3052 (Australia)
www.karger.com/fdt
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38 MCMA twins
included in
analysis
Table 2. MCMA twin pregnancy outcomes based on yolk sac number in pregnancies resulting in two live births
Table 3. Neonatal outcomes for the 21 MCMA pregnancies resulting in two live births
Values are presented as mean ± SD or n (%). MCMA, monochorionic monoamniotic; SD, standard deviation;
NICU, neonatal intensive care unit. a Based on growth charts by Hadlock et al. [26].
at the parents’ request or miscarried during the first tri- All pregnancies with both fetuses surviving to 17
mester. weeks’ gestation (n = 21) continued to result in two live
There was a higher proportion of pregnancies with fe- births after 28 weeks’ gestation, with a mean gestational
male fetuses (50%, 19 of 38) compared to male fetuses age at birth of 31 weeks’ gestation. All pregnancies were
(16%, 6 of 38) in all pregnancies. There were 13 cases delivered by caesarean section. Fifty-seven percent (12 of
(34%) in which fetal sex could not be determined due to 21) had planned caesarean sections at 32–33 weeks’ gesta-
early gestation at demise. In the two-yolk-sacs group, tion, while 43% (9 of 21) underwent unplanned caesarean
there was a statistically significant higher proportion of sections at 27–32 weeks’ gestation. The indications for the
pregnancies with male fetuses with 4 of 12 (33%) com- 9 unplanned caesarean sections were: abnormal cardioto-
pared to 2 of 26 (8%) in the one-yolk-sac group (p = 0.01). cography (3), preterm labour (2), twin anaemia polycy-
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