Identify PAIS Risk in Preterm Monochorionic Twins
Executive Brief
- The News: PAIS affects 1 in 18 monochorionic twin pairs.
- Clinical Win: 89% of PAIS cases have pregnancy complications.
- Target Specialty: Neonatologists managing preterm monochorionic twins.
Key Data at a Glance
Condition: Prenatal arterial ischemic stroke (PAIS)
Prevalence: 1 in 18 pairs (1.5%)
Risk Factors: Immature cerebral circulation, unique placental factors
Pregnancy Complications: 89%
Sample Size (N=): 1183 twin pairs
Gestational Age: Less than 35 weeks
Identify PAIS Risk in Preterm Monochorionic Twins
1. In this group of premature monochorionic twins, prenatal arterial ischemic stroke (PAIS) primarily affects the recipient twin and is associated with pregnancy complications.
Evidence Rating Level: 2 (Good)
Prenatal arterial ischemic stroke (PAIS) is a disruption of cerebral blood flow occurring from 20 weeks of gestation until 28 days after birth. PAIS is a leading cause of unilateral cerebral palsy and other neurological issues in children. Much of the previous literature has focused on full-term infants, providing limited evidence on preterm infants. This is especially true for monochorionic twins, who are also at risk due to immature cerebral circulation and unique placental factors. To assess this gap, this retrospective cohort study aimed to determine the timing of PAIS in monochorionic twins and identify risk factors, stroke patterns, and neurodevelopmental outcomes. Participants included 1183 twin pairs born at less than 35 weeks’ gestation, and PAIS was diagnosed in 1 in 18 pairs (1.5%). Pregnancy complications occurred in 89% of cases, with twin-to-twin transfusion syndrome (TTTS) presenting in 13 cases, followed by single fetal demise in 2 cases, and twin anemia polycythemia sequence (TAPS) in 1 case. The timing of strokes was quite similar, with 6 cases occurring antenatal, 7 occurring perinatal, and 5 occurring postnatal. Overall, PAIS occurring in monochorionic twins can occur during the antenatal, perinatal and postnatal period, emphasizing the importance of routine neuroimaging for early detection.
Click to read this study in Stroke
Clinical Perspective — Dr. Pooja Sinha, General Medicine
Workflow: As I manage monochorionic twins, I'm now more likely to order routine neuroimaging, given that PAIS can occur antenatally, perinatally, or postnatally. With 1 in 18 pairs at risk, I'd prioritize this in my daily routine, especially for those with complications like twin-to-twin transfusion syndrome (TTTS). This means I'll be working more closely with radiology to ensure timely scans.
Economics: The article doesn't address cost directly, but I know that routine neuroimaging for high-risk pregnancies like monochorionic twins can be resource-intensive. Given the 89% complication rate in PAIS cases, it's likely that early detection and intervention will be cost-effective in the long run, even if the initial outlay is higher.
Patient Outcomes: I'm concerned about the 1.5% risk of PAIS in monochorionic twins, as it's a leading cause of unilateral cerebral palsy and other neurological issues. With 6 cases occurring antenatally, 7 perinatally, and 5 postnatally, it's clear that early detection is crucial – and routine neuroimaging can help identify at-risk babies, allowing for timely intervention and potentially improving neurodevelopmental outcomes.
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