TITLE:
Necrotizing Enterocolitis in Multi Fetal Pregnancies: Can We Find a Key in Placental Abnormalities? A Retrospective Data Analysis
AUTHORS:
Rosan R. Aapkes, Karien E. A. Hack, Corine Koopman-Esseboom, Peter G. J. Nikkels, Jan B. Derks, Hens A. A. Brouwers
KEYWORDS:
NEC, Placenta, Multi Fetal Pregnancy, Twin Pregnancy
JOURNAL NAME:
Open Journal of Obstetrics and Gynecology,
Vol.9 No.12,
December
31,
2019
ABSTRACT: Objective: We aimed to evaluate the relationship between chorionicity, placental
abnormalities and necrotizing enterocolitis in multiple pregnancies. We
hypothesized that unbalanced interfetal transfusion through vascular
anastomoses in monochorionic placentation causes hypoperfusion of the
intestinal mucosa, increasing the risk of developing necrotizing enterocolitis. Material and methods: All women with multiple pregnancies who delivered at the University
Medical Center Utrecht between January 1995 and December 2015 were
retrospectively selected. We compared baseline characteristics and neonatal and
maternal outcomes. Secondly, we analyzed ultrasound and placental pathology
findings of monochorionic multiples with and without necrotizing enterocolitis.
Finally, we compared illness characteristics of necrotizing enterocolitis in
monochorionic multiples with necrotizing enterocolitis in dichorionic
multiples. Results: We
included 2859 dichorionic and 817 monochorionic neonates. Necrotizing
enterocolitis occurred significantly more often in monochorionic as compared to
dichorionic neonates (3.3% and 1.6% respectively), also after correction for
birthweight, gestational age and nulliparity (OR 1.7, 95% CI 1.0 - 2.8).
Ultrasound abnormalities were not associated with necrotizing enterocolitis.
Histopathology showed that necrotizing enterocolitis was significantly
associated with the presence of unbalanced interfetal transfusion (76.9% of
monochorionic with necrotizing enterocolitis versus 31.4% of cases without
necrotizing enterocolitis, P = 0.001). Conclusion: Necrotizing enterocolitis
is more common in monochorionic multiples as compared to dichorionic multiples,
at least in part due to the presence of and related to the presence of
unbalanced interfetal transfusion through arterial-venous anastomoses in the
placenta. Possibly, subtle ischemic damage caused by intra-uterine fetal
hypotension or anemia plays a key role in the development of necrotizing
enterocolitis in monochorionic twins.