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OBSTETRICS
Discordant twins: diagnosis, evaluation and management

Jena Miller, MD; Suneet P. Chauhan, MD; Alfred Z. Abuhamad, MD
Approximately 16% of twin gestations have discordance of at least 20%. We identified 14

risk factors for divergent growth that can be categorized as maternal, fetal, or placental.
Determination of chorionicity and serial ultrasound evaluation with a high index of suspicion for divergent growth is required for the diagnosis and stratification of risk. The highest
reported likelihood ratio for detection of discordance was 5.9 during the first trimester
examination and 6.0 for the second trimester. Although our ability to identify discordant
twins is limited, once suspected and at viable gestational age, these pregnancies should
have antepartum testing. Discordant growth alone is not an indication for preterm birth.
Although there are multiple publications on the increased morbidity and mortality rates
with discordant growth, there is a paucity of reports on how to manage them optimally and
deliver them in a timely manner.
Key words: chorionicity, discordance, discordant twins
nique to multiple gestations, discordance is the difference in the

weights of the fetuses. According to the
American College of Obstetricians and
Gynecologists (ACOG) practice bulletin on multiple gestation, discordant
growth is associated with increased
likelihood of anomalies, intrauterine
growth restriction (IUGR), preterm
birth, infection of 1 fetus, stillbirth,
umbilical arterial pH 7.10, admission to neonatal intensive care unit, respiratory distress, and death within 1
week of birth.1 Despite the known association with a multitude of adverse
outcomes, what is debated about discordant twins are the following factors
that decrease or predispose to discordant growth: the ability to identify abnormal growth, the threshold of discordance that significantly increases
the perinatal complication rate, the comorbidities that alter the likelihood of
From the Department of Obstetrics and
Gynecology, Eastern Virginia Medical School,
Norfolk, VA.
Received April 22, 2011; revised June 15,
2011; accepted June 21, 2011.
The authors report no conflict of interest.
Reprints not available from the authors.
0002-9378/$36.00
2012 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2011.06.075
10
poor outcome, and how to manage divergent growth.

The purpose of this review article
was to summarize the literature on discordant growth among nonanomalous
twins. We will discuss the various definitions, risk factors, and evaluation
and management strategies. Because of
the breadth of the subject matter,
we will not focus on monoamniotic
twins, twin-twin transfusion syndrome, anomalous fetuses, death of a
twin, or suboptimal growth among
twins.
Definition
Discordance is defined with the larger
twin as the standard of growth and is calculated by the following equation:
(larger estimated or actual weight
smaller estimated or actual weight)/
larger estimate or actual weight). While
acknowledging the lack of consensus on
the precise threshold of discordance that
is linked with complications, ACOG
considers a 15-25% difference in actual
weight among twins to be discordant.1
The consensus statement by the Society
of Obstetricians Gynecologists of Canada specifies that discordance is a difference of abdominal circumference (AC)
of 20 mm or estimated fetal weight
(EFW) difference of 20%. the Society of
Obstetricians Gynecologists of Canada
American Journal of Obstetrics & Gynecology JANUARY 2012
recommends that the EFW be derived

from biparietal diameter with AC or a
combination of AC and femur length.2
Prevalence and detection

of discordant growth
A summary of 31 publications with
1.1 million twins indicates that the
likelihood of discordance of 20% is
16% (180,302/1,130,505 twin pregnancies; range, 14 41%; Table 1).3-33 Eight
publications provided evidence of discordance of at least 30%; discordance
has occurred in 5% of twins (42,373/
854,331 twin pregnancies; range, 3
10%.9,11,12,15,21,22,34,35 The rate of discordance, however, varied among publications with 1000 vs 1000-9999 vs
10,000 cohorts (Figure 1; P .0001
for both comparisons). Discordance of
at least 20% was significantly higher in 15
publications from foreign countries
(17%; 11,369/65,997 twin pregnancies5-7,16,19, 22-26, 29-31,33,35) than in 16 reports from the United Sates (16%;
168,933/1,064,790 twin pregnancies; odds
ratio [OR], 1.10; 95% confidence interval
[CI], 1.08 1.123,4,9-15,17,18,20,21,27,28,32).
Even among publications with 1000
cohorts, discordance of 20% occurred
significantly more commonly in other
countries (19%; 520/2,712 twin pregnancies5,7,16,19,25,26,29,31,33,35) than in the
United States (16%; 225/1,445 twin
pregnancies; OR, 1.28; 95% CI, 1.08
1.523,4,10,11,18,27,28). In 2006, there were
137,085 twin pairs born in the United
States; if 16% were discordant, we estimate that there are approximately
22,000 discordant twin pairs born per
year.
Table 2 shows predictive accuracies of
8 publications that gauged the reliability
of the detection of 20% discordance7,13,18,27,31,36-38 and 6 reports about
the identification of discordance of at
least 25%.7,24,39-42 The sensitivity of the
detection of difference in weights of
20% ranged from 3193%; for 25%
difference, the range was 23-61%. More
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Expert Reviews
TABLE 1
Likelihood of twin discordant growth

Twins, n
Discordance
>20%, n
Discordance
>20%, %
Study
Year
Country
Study period
Watson et al3
1991
USA
No mention
94
21
22
Eberle et al
1993
USA
1986-1992
147
36
24
Jensen and Jenssen
1995
Norway
1990-1993
73
14
19
Cheung et al
1995
Canada
1989-1992
122
28
23
Blickstein et al
1996
Israel
No mention
90
20
22
Yalin et al
1998
Turkey
1994-1995
357
115
32
Hollier et al
1999
USA
1988-1996
1370
194
14
Grobman and Parilla
1999
USA
1992-1988
44
18
41
Foley et al
2000
USA
No mention
500
62
12
Demissie et al
2002
USA
1995-1997
148,577
24,190
16
Kalish et al
2003
USA
2000-2002
130
16
12
Branum and Schoendorf
2003
USA
1995-1997
128,163
19,253
15
Sannoh et al
2003
USA
1995-1997
294,568
47,796
16
Smiljan Severinski et al
2004
Croatia
1993-2001
351
53
15
Amaru et al
2004
USA
1992-2001
1318
208
16
Chauhan et al
2004
USA
No mention
126
24
19
Usta et al
2005
Lebanon
1984-2000
679
81
12
Tan et al
2005
USA
1995-1997
147,262
23,071
16
Kontopoulos et al
2005
USA
1995-1998
340,446
53,584
16
Wen et al
2005
Canada
1986-1997
59,034
10,092
17
Armson et al
2006
Canada
1988-2002
1542
211
14
Chang et al
2006
Taiwan
1991-2002
1257
195
16
Canpolat et al
2006
Turkey
2000-2004
266
54
20
Pongpanich and
Borriboonhirunsarn26
2006
Thailand
2003-2004
150
35
23
Tai and Grobman
2007
USA
2000-2006
169
24
14
Belogolovkin et al
2007
USA
2000-2005
279
42
15
Appleton et al
2007
Portugal
1989-2002
230
54
23
Hack et al
2008
Netherlands
1995-2004
1305
351
27
Banks et al
2008
United Kingdom
2002-2004
108
26
24
Nawab et al
2008
USA
2001-2004
1597
394
25
Alam Machado Rde et al
2009
Brazil
1998-2004
151
40
26
1,130,505
180,302
16
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4
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12
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14
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24
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25
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27
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28
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29
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30
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32
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33
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TOTAL
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Miller. Discordant twins. Am J Obstet Gynecol 2012.
importantly, only 36% of these reports

(5/14) provided likelihood ratios, which
ranged from 1.3 6.0. It should be noted
that according to the Society of Obstetricians Gynecologists of Canada,2 the sensitivity of the detection of discordant
growth with AC alone is 80% and with

EFW is 25-55%.
We should not assume that it is feasible to identify the divergent growth. The
reasons for our inabilities to identify discordant growth are the potential for pub-
lication bias, most reports are from tertiary

centers and not community hospitals, the
vagaries of sonographic EFW,43 the
known inabilities to identify abnormal
fetal growth with singleton fetuses,44 and
most reports do not provide the likeli-
JANUARY 2012 American Journal of Obstetrics & Gynecology
11
Expert Reviews
Obstetrics
FIGURE 1
Likelihood of discordance
and sample size
Sample size of published reports and the likelihood of twin discordance are given.
hood ratios. The highest likelihood ratio

was 6 (Table 3); according to the guidelines promulgated by the EvidenceBased Medicine Working Group,45 a diagnostic test is definitively useful if the
likelihood ratio is 10 or 0.1.
Thus, in summary, discordance of at
least 20% occurs in approximately 16% of
twin pairs, and discordance of 30% occurs in 5% of twin pairs. Although sonographic examination is not the ideal diagnostic test to detect discordance, it is
possible to identify it in the first trimester
with measurements of crown-rump length
(CRL) and in the second and third trimesters with a comparison of AC or EFW.
Risk factors
There are several known factors that influence the likelihood of twins being discordant, and they can be categorized as
maternal, fetal, or placental (Table
3).15,20,24,28,40,46-60 Some reports contradict each other. For example, there is a
disagreement on whether maternal age,
parity, use of an assisted reproductive
technique, and type of twin gestation are
risk factors for discordant growth. Possible explanations for the contradictory
findings are the different populations
that are being studied, small sample size,
environmental and genetic cofactors
that predispose fetuses to either insufficient or accelerated growth.61,62 These
patterns may not affect each fetus
equally, which leads to separate growth
trajectories for each twin.
Fetal risk factors for divergent growth
include having monochorionic (rather
12
than dichorionic) twins, opposite sex of

fetuses, and, infrequently, transplacental
viral infection such as cytomegalovirus
of only 1 fetus of a twin pair.53 Clinicians
should consider infection of a single twin
if sonographic examination is notable
for growth restriction with abnormal intracranial or intraabdominal calcifications or effusions. An unusual combination of findings in a monochorionic twin
pregnancy (such as discordant sex, fetal
size, or cystic hygroma in a single twin)
may represent discordant phenotypic
mosaicism; amniocentesis of both twins
should be considered for diagnosis.56,63
Among singleton fetuses, placenta
previa is considered a risk factor for
growth restriction. For twins, however,
we were unable to find publications that
correlated previa with discordance. Similarly, placental abruption increases the
likelihood of suboptimal growth in singletons, but there is a paucity of reports
for twins. Velamentous cord insertion is
associated with impaired fetal growth
in singleton fetuses54 and discordant
growth in twins, although its effect with
multiple gestations is variable. In twin
gestations, the effect of velamentous
cord insertion is dependent on chorionicity. Hanley et al55 noted a high incidence of velamentous cord insertion in
twins (13-21%) and reported that it is
significantly more common in monochorionic, than dichorionic, twin pairs
(18% vs 6%; P .001). Additionally, its
impact on birthweight discordance is
13.5 times greater for monochorionic diamniotic twin gestations than for dichorionic diamniotic twins.55 Two other
publications also evaluated the effect of
abnormal placental cord insertion on
birthweight discordance and showed
similar results.56,57
Some placental factors that are linked
with discordance (such as placental
weight and placental sharing) can be investigated only postnatally. Placental
weight in severely discordant twins is
lower for the smaller twin in dichorionic
pregnancies, and total placental weight is
decreased for monochorionic discordant twins.58 Another entity specific to
monochorionic twin pairs that is associated with birthweight discordance is the
concept of placental sharing, which is de-
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fined as the percentage of the total placental mass that is allocated to each twin
and is determined on the basis of the distribution of chorionic vessels with the
use of dye injection on placental specimens. Uneven placental sharing of
25% was significantly different among
discordant vs nondiscordant twins (56%
vs 19%, respectively; P .0001).57 As
placental share diverges, discordance increases up to 4 times.57,59,60
The pattern and size of vascular anastomoses that are present in monochorionic placentas is also associated with
growth discordance that manifests either
early or late in gestation. In a study of 178
twin pairs, placentas with growth discordance at 20 weeks gestation had more
unequally shared vessels and had an increased number of arterioarterial anastomoses with larger diameters compared
with those with late-onset discordant
growth. Clinically, these pregnancies experienced higher rates of Doppler abnormalities, mostly intermittent absent end
diastolic blood flow in the umbilical artery, fetal death, and earlier gestational age
at delivery for fetal indications (33 2
weeks gestation), compared with those
pregnancies with late-onset growth discordance or concordant growth (35 2
weeks; P .001).60
First trimester
Early ultrasound evaluation to establish
chorionicity is essential for the management of a twin pregnancy because it establishes the timeline for subsequent screening intervals and narrows the differential
diagnosis for the underlying cause of diverging fetal growth. Chorionicity can be
determined in 99% of pregnancies in the
first trimester by the presence of a singular
placental mass with a thin intervening
membrane and absence of the lambda
sign.64,65 In general, exclusion of monochorionicity removes the contribution of
disproportionate placental sharing and
vascular anastomoses as an underlying
cause of discordant growth.
Discrepant fetal size is identified in the
first trimester by the difference in CRL
between twin pairs divided by the CRL of
the larger twin. It does not vary based on
chorionicity66,67 or fetal sex.68 Differ-
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Expert Reviews
TABLE 2
Detection of discordant twins
Variable
Pub
in
Incidencea
Diagnostic test
Sensitivity,
%b
Specificity,
%b
Positive
predictive
value, %b
Negative
predictive
value, %b
Likelihood
ratio
Discordance 20%c
.......................................................................................................................................................................................................................................................................................................................................................................
36
Storlazzi et al
1987
23 (10/43)
EFW 20
80
93
80
93
AC 20 mm
80
85
62
83
...........................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
37
Rodis et al
1990
48 (14/29)
EFW 20
86
80
80
86
Hill et al
1994
37 (18/49)
EFW 20
93
86
72
97
AC 20 mm
83
90
83
90
EFW 20
50
93
67
87
AC 18 mm
65
64
34
86
31
95
45
91
.......................................................................................................................................................................................................................................................................................................................................................................
38
...........................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
7
Blickstein et al
1996
22 (20/90)
...........................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
13
Kalish et al
2003
12 (16/130)
CRL 3 days
Chauhan et al
2004
19 (24/126)
EFW 20
Tai and Grobman
2007
13 (24/78)
CRL 11
54
90
46
92
Banks et al
2008
24 (26/108)
CRL difference
59 (3679)
60 (4872)
5.9
.......................................................................................................................................................................................................................................................................................................................................................................
18
d
.......................................................................................................................................................................................................................................................................................................................................................................
27
.......................................................................................................................................................................................................................................................................................................................................................................
31
1.5
................................................................................................................................................................................................................................................................................................................................................................................
c
Discordance 25%
.......................................................................................................................................................................................................................................................................................................................................................................
39
Chamberlain et al
1991
9 (8/85)
EFW 25
37
98
75
93
AC 20 mm
43
91
53
77
EFW 25
23
96
50
88
AC 18 mm
61
61
21
90
EFW 25
33
94
33
94
5.3
1.3
...........................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
7
Blickstein et al
1996
14 (13/90)
...........................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
40
Caravello et al
1997
9 (21/242)
...........................................................................................................................................................................................................................................................................................................
AC 20 mm
43
68
11
93
Gernt et al
2001
17 (33/192)
EFW 25
55 (3672)
97 (9399)
82 (5994)
91 (8594)
Klam et al
2005
13 (64/503)
EFW 25
37
96
59
90
AC ratio 0.93
61
84
40
93
EFW 25
60 (5070)
98
75
95
.......................................................................................................................................................................................................................................................................................................................................................................
41
.......................................................................................................................................................................................................................................................................................................................................................................
42
...........................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
24
Chang et al
2006
10 (60/575)
................................................................................................................................................................................................................................................................................................................................................................................
AC, abdominal circumference; CI, confidence interval; CRL, crown-rump length; EFW, estimated fetal weight.
a
Data are presented as percentage (n/N); b Data are presented as percentage (95% CI); c (Larger estimated or actual weight smaller estimated or actual weight)/larger estimate or actual weight;
6.1 (95% CI, 2.515.1) for dichorionic twins and 6.0 (95% CI, 1.8 20.0) for monochorionic twins.
ences in CRL may represent the separate

genetic potential of each fetus in dizygotic
pregnancies and unequal early division of
the cell mass in monozygotic pregnancies.66 In a study of 159 dichorionic twin
pregnancies, if the CRL difference was
10%, the risk of fetal structural and chromosomal anomalies was significantly
higher (22% vs 3%; P .01).68 Other investigators have identified additional complications that the discrepant CRL measurement may predict (Table 4). The green
guideline, by the Royal College of Obstetricians and Gynecologists (RCOG), on the
management of monochorionic twin
pregnancy affirms that discordance of CRL

of 10% is a risk factor for perinatal
death.69
As alluded to earlier, a difference in
CRL is not a reliable predictor for birthweight discordance (Table 2). Bhide et
al67 found a correlation between CRL
discrepancy and birthweight discordance in dichorionic twins, but not
monochorionic twins. The authors speculated that the absence of a relationship
in monochorionic twins was due to a
smaller sample size and reduced power
because only 25% of the study population
(n 125) were monochorionic pregnan-
cies. These findings suggest that growth

potential is not determined completely in
the first trimester and that the identification of intertwin CRL discordance cannot
substitute for serial assessment of growth
parameters and anatomy.
In summary, first-trimester ultrasound examination of twins is exceptionally reliable to determine chorionicity. Although CRL discordance has
been used as screening tests to predict
second- and third-trimester complications, there is disagreement among
publications, because of referral bias;
most studies have been performed by
13
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TABLE 3
Factors that influence discordant growth of twins

Variable
Increase
Decrease
Maternal
Maternal age of 30 years
Nulliparity
Maternal age26
Assisted reproduction vs spontaneous

twins40,46
Constant maternal weight gain

throughout gestation50
Pregnancy with assisted reproduction
20
No Influence
28
.......................................................................................................................................................................................................................................................................................................................................
26
.......................................................................................................................................................................................................................................................................................................................................
15,47
26
Nulliparity
Parity
.......................................................................................................................................................................................................................................................................................................................................
48
Tobacco use
.......................................................................................................................................................................................................................................................................................................................................
49
No prenatal care
.......................................................................................................................................................................................................................................................................................................................................
50
Fluctuating change in body mass index
................................................................................................................................................................................................................................................................................................................................................................................
51
51
26
Fetal
Monochorionic
Dichorionic
Chorionicity
.......................................................................................................................................................................................................................................................................................................................................
28,52
24
Sex-discordant twins
Reduced and nonreduced twins
.......................................................................................................................................................................................................................................................................................................................................
28
Small for gestational age in either fetus
.......................................................................................................................................................................................................................................................................................................................................
53
Viral infection
................................................................................................................................................................................................................................................................................................................................................................................
54-57
Placenta
Velamentous cord insertion
.......................................................................................................................................................................................................................................................................................................................................
57-59
Placental sharing
.......................................................................................................................................................................................................................................................................................................................................
51
Placental weight
.......................................................................................................................................................................................................................................................................................................................................
60
Pattern and size of vascular anastomoses
................................................................................................................................................................................................................................................................................................................................................................................
experienced centers and have a small

sample size. According to Sebire et
al,66 5000 first-trimester twin sonographic examinations are necessary to
confirm that CRL discordance is associated with adverse outcomes.
Second trimester
Although the ACOG does not provide
recommendations on the frequency of
sonographic examinations for twins, the
RCOG advocates ultrasound evaluation
for monochorionic twins every 2-3

weeks from 16 weeks gestation onwards.69 They recommend specific documentation of AC, amniotic fluid maximal and vertical pocket and the
identification of the dividing membrane
TABLE 4
First-trimester prediction for twin complications and adverse outcome
Author
Sebire et al66
549 MC/DC
Chorionicity Abnormal
CRL percentage
difference
Intrauterine
Twin-twin
growth
transfusion Adverse pregnancy
Discordance restriction Anomaly syndrome outcome
No
No
DC-aneuploidy; spontaneous
abortion; IUFD
................................................................................................................................................................................................................................................................................................................................................................................
13
Kalish et al
130 DC
CRL discrepancy Yes

3 d
Yes
CRL discordance Yes

10%
CRL discordance Yes

11%
Yes
Yes
IUFD
................................................................................................................................................................................................................................................................................................................................................................................
68
Kalish et al
159 DC
Yes
IUFD
................................................................................................................................................................................................................................................................................................................................................................................
27
Tai and Grobman
178 MC/DC
Yes
Composite-neonatal intensive
care unit admission;
respiratory distress
syndrome; intraventricular
hemorrhage grade 3-4;
necrotizing enterocolitis;
sepsis; perinatal death
................................................................................................................................................................................................................................................................................................................................................................................
31
Banks et al
135 DC
CRL % difference No
Bhide et al
507 MC/DC
CRL discrepancy MC-no;

95%
DC-yes
MC-IUFD
................................................................................................................................................................................................................................................................................................................................................................................
67
................................................................................................................................................................................................................................................................................................................................................................................
CRL, crown-rump length; DC, dichorionic; IUFD, intrauterine fetal death; MC, monochorionic.
14
Obstetrics
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and umbilical artery Doppler studies after 24 weeks gestation (Figure 2). Increased monitoring frequency of monochorionic twins is necessary because these twin
pairs are at substantially higher risk of the development of the complications of growth
restriction, fetal death, preterm delivery, and
perinatal death than their dichorionic
counterparts.70
Sonographic examination in the first
and second trimester can identify monochorionic twins who are at increased risk
of morbidity and death. Lewi et al60 in
2008 evaluated a 2-step screening strategy
that combined information from the firsttrimester nuchal translucency ultrasound
examination and an ultrasound examination at 16 weeks gestation to establish the
risk for monochorionic twin pregnancies
to experience twin-twin transfusion syndrome, discordance of at least 25%, or intrauterine fetal death (Figure 3). Although
this schema needs verification, it may be
helpful for the establishment of monitoring intervals or counseling for these
patients.
In summary, the second trimester allows
classification of monochorionic twins,
classification into high- and low-risk pregnancies, and the identification of those
who are likely to experience discordance.
Third trimester
After 24 weeks gestation, the aim of ultrasound surveillance is to identify discordant or insufficient fetal growth. Despite the limitations for the detection of
growth discordance (Table 2), when it
is suspected, subsequent monitoring
should be based on the identification and
prevention of morbidity of the smaller
twin. Continuation of the pregnancy for
discordant twins is more important if 1
of the twin pairs is small for gestational
age rather than both being appropriate
for gestational age. There is a higher rate
of admission to the neonatal intensive
care unit for discordant twins, compared
with concordant twin pairs (OR, 5.69;
95% CI, 3.24 10.00), and of higher neonatal morbidity (OR, 3.13; 95% CI,
1.39 7.01) and death (OR, 2.97; 95% CI,
1.30 5.70) when 1 twin is small for gestational age.11,29
No clear evidence exists on the monitoring frequency that optimizes out-
Expert Reviews
FIGURE 2
Ultrasound surveillance of twin pregnancies
The degree sign indicates that the data may be limited to specialized centers for specific indications;
the asterisk indicates bladder filling, amniotic fluid assessment, Doppler finding (umbilical artery,
ductus venosus, umbilical venous).
AF, amniotic fluid; CRL, crown-rump length; DV, ductus venosus; ECHO, echocardiogram; NT, nuchal translucency; T/V US CL, transvaginal ultrasound cervical length; TTTS, twin-twin transfusion syndrome; UA, umbilical artery.
come or is cost-effective. Reported management guidelines are based on local

practice, which is often at referral centers
that care for complicated twin pregnancies.71-73 For example, monochorionic
twins typically are monitored with biweekly ultrasound evaluation of growth,
amniotic fluid, and, in some cases, umbilical artery Doppler scans until delivery.71,73 Monochorionic twins should be
monitored more frequently than dichorionic twins because (1) the risk of in
utero death is higher (3.6% for monochorionic vs 1.1% for dichorionic in a
series of 1000 consecutive twin pairs in
seemingly uncomplicated pregnancies,72
despite normal monitoring71,74) and (2)
the substantial risk of death or neurologic damage in the surviving cotwin in
the event of fetal death, which increases
to 20% with advancing gestation.75,76
Currently, there are no guidelines on
how often ultrasound surveillance
should be performed with dichorionic
twins, although it can be less frequent

than with monochorionic twins.1,69
Nonetheless, subtle ultrasound findings
with dichorionic twins may allude to underlying abnormalities in fetoplacental
perfusion that lead to growth discordance.77 For instance, changes in amniotic fluid and a difference in the systolic/
diastolic ratio of the umbilical artery
between twins of 15% may precede
sonographic detection of abnormal fetal
growth.78,79 Therefore, a high index of
suspicion for growth abnormalities must
be maintained for all twins throughout
gestation.
Nonstress testing,80,81 biophysical
profile score,82 and umbilical artery
Doppler assessment83 have all been
shown to be useful in twin pregnancies
but have not been evaluated in prospective studies and sample sizes of these
studies that have ranged from 3-94
women. The timing for the initiation of
antenatal surveillance has not been de-
15
Expert Reviews
Obstetrics
FIGURE 3
Two-step screening strategy for complicated

outcomea in monochorionic twins
16W, 16 weeks; AC, abdominal circumference; AFV, amniotic fluid volume; CI, cord insertion; CRL, crown rump length; NT, nuchal
translucency; T1, first trimester.
Twin-twin transfusion syndrome, severe discordant growth (25% birthweight difference if live born; 20% ultrasound estimated fetal
weight if intrauterine fetal death), or intrauterine fetal death. Survival-number of infants alive at 28 days of life divided by fetuses in the first
trimester.
Monitoring monochorionic twins adapted, with permission from Lewi et al.60

lineated clearly and is variable (Table 5).

ACOG recommends that antepartum
testing in multiple gestations be performed in circumstances in which it is
indicated in singleton fetuses, such as fetal growth restriction or maternal dis-
ease. Once viability is reached and discordant growth is identified, antenatal

testing should be started.
To summarize, in the third trimester
when discordant growth is identified,
antepartum surveillance should be
www.AJOG.org
started. Because of a paucity of publications on antenatal testing for twins, the
management is akin to singleton fetuses
who undergo surveillance.
Delivery timing
There are limited data to establish the
optimal timing of delivery for twin pregnancies. ACOG does not provide clear
recommendations on this topic, but the
RCOG advocates for delivery by 37
weeks gestation for monochorionic and
38 weeks gestation for dichorionic twins
in the absence of complications.69 Four
studies have proposed delivery recommendations for monochorionic twins
based on observed rates of fetal death in
the third trimester (Table 5). Although
the protocols and the rate of stillbirth
varies, in the most recent publication
with 309 monochorionic twin pairs,
there were no fetal deaths after 34 weeks
gestation in any pregnancies that were either uncomplicated (76%) or with twintwin transfusion syndrome (12%) or
growth discordance (12%).73 For twins
with significant growth discordance
(25% difference), gestational age at delivery was significantly earlier than those
without complications (33 vs 35 weeks;
P .0001); no fetal deaths were seen
24 weeks gestation in this subgroup.
The authors suggest that after 34 weeks
gestation without a clinical indication
for delivery, pregnancy should be continued until 36-37 weeks gestation to
TABLE 5
Uncomplicated monochorionic pregnancies, fetal death, and delivery recommendations
Mode of evaluation
24
28
32
34
Recommended
delivery time,
wk
Barigye et al71
151
20
Ultrasound scan every 2 wka
4.6
4.7
4.3
3.3
32
Simes et al
193
24
Ultrasound scan every 2 wk at 30 wk, every

wk at 30 wk, nonstress test/biophysical
profileb
2.6
2.1
1.2
0.7
36
Study
Started
evaluative, wk
Week, %
................................................................................................................................................................................................................................................................................................................................................................................
84
................................................................................................................................................................................................................................................................................................................................................................................
72
Lee et al
1000
NA
Not available
2.3
1.6
1.7
34-35
309
24
Ultrasound scan every 2 wk;

nonstress test or biophysical profilec
1.3
0.9
0.5
36-37
................................................................................................................................................................................................................................................................................................................................................................................
73
Smith et al
................................................................................................................................................................................................................................................................................................................................................................................
a
Growth, amniotic fluid assessment, and Doppler findings (umbilical artery, umbilical vein, ductus venosus after 1999, chorionic plate for arterioarterial anastomoses after 1995); b At 30 weeks
gestation, Doppler scan (umbilical artery and middle cerebral artery, if abnormal growth), nonstress test/biophysical profile daily to twice weekly, depending on clinical condition; c Growth, amniotic
fluid assessment and umbilical artery Doppler scan, if growth or amniotic fluid volume discordance is noted in ongoing pregnancies at 24 weeks gestation; nonstress test or biophysical profile
at least weekly at 32 weeks gestation.
16
www.AJOG.org
avoid the consequences of iatrogenic late
preterm birth.73
For dichorionic twins, optimal delivery timing for those with growth discordance is unreported. Although the consequences of a single death do not
directly impact the surviving cotwin, the
psychologic effects for the parents
should not be underestimated. When
delivery is indicated based on results of
antenatal testing for 1 twin, counseling
for iatrogenic prematurity in the healthy
cotwin is necessary and should be done
by the neonatologist. Alternatively, in
the setting of reassuring fetal testing,
there is a paucity of data that advocates
elective preterm delivery for growth discordance in dichorionic twins.
Intrapartum management
The 3 clinically relevant combinations of
fetal presentations for twin gestations in
labor are (1) vertex-vertex, (2) vertexnonvertex, and (3) both nonvertex. Recommendations regarding mode of delivery for twin gestations are based on the
presentation of twin A and on the absolute and weight difference in relation to
the presenting twin.1,85 When the presenting twin is vertex, the possible route
of deliveries are vaginal, planned cesarean section delivery, or combined (vaginal and cesarean delivery) if complications, such as cord prolapse, placental
abruption, fetal distress, or malpresentation of the second twin occur. Combined
delivery occurs in approximately 4%,
and discordance of 25% is not a risk
factor for it.86
When the second twin is nonvertex,
controversy exists over the optimal route
of delivery. Five studies compared
breech extraction to external cephalic
version for delivery of 342 second
twins.87-91 The combined data indicate
that cesarean delivery is significantly
more frequent when external cephalic
version is attempted instead of breech
extraction (42% vs 2%; OR, 28.5; 95%
CI, 1173.7). Both fetal distress (18% vs
5%; OR, 36.9; 95% CI, 4.9 278.3) and
complications (15% vs 2%; OR, 7.24;
95% CI, 2.66 19.72) were significantly
more common with external cephalic
version than breech extraction.92 ACOG
and RCOG support breech extraction
Obstetrics
for the delivery of a nonvertex second
twin.1,69 When the presenting twin is
nonvertex, ACOG recommends cesarean delivery because of the risk of fetal
entanglement and potential death.1,85
For discordant twins, 3 studies of 6008
total pregnancies have implicated discordance as a factor for adverse perinatal
outcome.23,93,94 In a study of 1542 twin
pairs after vaginal delivery of the first
twin, second twins had the highest composite adverse perinatal outcome (perinatal death, birth asphyxia, respiratory
distress syndrome, neonatal infection,
and birth trauma) when birthweight of
the second twin was 20% larger than
the presenting twin (relative risk, 3.75;
95% CI, 1.62 8.68). Both Armson et al23
and Stein et al94 observed that increased
delivery interval also contributed to adverse outcome. A delivery interval of
15 minutes carried a 1.3 times higher
risk of composite adverse outcome (95%
CI, 1.02177; P .03), but when the delivery interval increased to 15-30 minutes, the risk was 2.3 times higher (95%
CI, 1.433.67; P .001).23
Active management of the second
stage and proper patient selection for
vaginal delivery may decrease the complication rates.95-97 Leung et al95 showed
that delivery interval was correlated inversely with deterioration in umbilical
arterial pH, increased pCO2, and base excess. More importantly, neonatal acidosis (arterial pH 7.00) was absent when
the second twin delivered within 15 minutes; however, when the delivery interval
was 30 minutes, the risk of acidosis was
27%.95 Two studies investigated active
management of the second stage and its
effect on immediate neonatal outcome
in a total of 1045 twins.96,97 Active management involves maternal pushing, amniotomy, and oxytocin administration
in an engaged vertex second twin vs immediate breech extraction or internal
podalic version in an unengaged vertex
second twin. With active management of
758 twins, Schmitz et al96 accomplished a
mean delivery interval of 4.9 3.2 minutes, with no differences in neonatal
morbidity.
When vaginal delivery is planned,
standard protocols should be considered
that include established intravenous
Expert Reviews
access, continuous fetal monitoring

throughout labor, availability of sufficient nursing, anesthesiology and pediatric support, blood product use of an
ultrasound machine, and the ability to
perform a cesarean delivery rapidly if
indicated.97-99 In a population-based
study, the neonatal mortality rate was increased for vaginal, compared with cesarean, delivery when birthweight discordance was 40%,100 but this should
not preclude vaginal delivery in appropriately selected and counseled patients.
Morbidity and mortality
Establishing a link between twin discordance and peripartum complications is
imperative because it influences management, potentially improves outcomes, and may influence study design.
The difficulties in the correlation of discordance with morbidity and death are
(1) the small sample size of most studies,
(2) almost all reports have linked actual
weights, which are unavailable until after
delivery, with complications rather than
sonographic estimate of weight, which is
available antenatally, (3) sex, (4) presentation, (5) gestational age, (6) medicalobstetric complications, (7) antenatal
surveillance, (8) the use of corticosteroids, (9) suboptimal growth, (10)
anomalies, (11) route of delivery and
(12) the availability of neonatal intensive
care unit, all of which influence outcome, regardless of discordancy.
Acknowledging the lack of consensus
on the precise threshold of discordance
that is associated with complications,
ACOG provides a range. When the difference among the twins birthweight is
15-25%, there is an increased risk of
morbidity and death.1 For twins of the
same sex and even without abruption,
discordance of 15% is associated with
delivery at 32 weeks gestation, stillbirth, and perinatal death. With abruption, for example, neonatal death is increased when discordance is 5%.
Alternatively, if there is no abruption
and the sexers are different, an increased
number of deaths occur with discordance of 30%.101 With discordance of
at least 20%, there is an increased risk of
cesarean delivery for nonreassuring fetal
heart rate tracing, neonatal acidosis, ad-
17
Expert Reviews
Obstetrics
mission to neonatal intensive care unit,

and respiratory distress syndrome.102,103
It should be acknowledged that some
studies have noted either that there is no
morbidity with discordance or that complications occur only if there is a concomitant condition.19,25,33 Alam et al,33
for example, reported that adverse outcomes with a discordance of 20% is associated with abnormal growth; if the
difference is at least 25%, then morbidity
is associated with the route of delivery or
a congenital anomaly. One potential explanation for the contradictory findings
is the small sample size of most studies.
Amaru et al,17 for example, noted that,
even with 1300 twins in the study, it was
underpowered to detect a difference in
poor outcomes. Other explanations for
conflicting conclusions are the comorbidities, the use of data from birth certificates rather than detailed review of the
chart, and not taking the antepartum or
intrapartum management into account.
Comment
This review on discordancy permits us to
gauge its rate (Table 1; Figure 1) and
identify the risk factors. Considering the
vagaries of estimating fetal weight with
singleton fetuses,43 our inability to identify discordance with measurements of
biometric parameters is expected. Establishing chorionicity in the first trimester
is imperative because it permits early
identification and treatment of certain
complications. Although there are limited data on the false-negative rate for
twins who undergo antenatal tests,103
discordant growth after fetal viability is
an indication for surveillance. Preterm
delivery for discordance alone should
not be undertaken.
We do acknowledge that one of the
weaknesses of this review is that many of
the research articles do not differentiate
between monochorionic and dichorionic twins, except when they show the
difference in outcomes between same sex
and different sex fetuses. Ideally, the discussion of dichorionic and monochorionic twins should be separate because
discordant growth in the latter type is almost always the result of twin-twin
transfusion syndrome or selective intrauterine growth restriction from unequal
18
sharing of the placenta. Both complications require more rigorous evaluation

and have different staging criteria; management techniques are still evolving.
Although we have identified the risk
factors, the possibility of decreasing the
likelihood should be investigated. Improvement in the detection of discordance with measurements of soft tissues
(such as cheek-to-cheek, upper arm, or
thigh) is a possibility,104,105 as is the use
of a neural network106 or 3-dimensional
ultrasound imaging.107,108 A multicenter
study could address the optimum surveillance schedule and timing of delivery
for twin pregnancies that have suspected
f
discordance.
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Expert Reviews

Discordant twins: diagnosis, evaluation and management

Approximately 16% of twin gestations have discordance of at least 20%. We identified 14

nique to multiple gestations, discordance is the difference in the

poor outcome, and how to manage divergent growth.

American Journal of Obstetrics & Gynecology JANUARY 2012

recommends that the EFW be derived

Prevalence and detection

Likelihood of twin discordant growth

Jensen and Jenssen

Grobman and Parilla

Branum and Schoendorf

Tai and Grobman

Alam Machado Rde et al

Miller. Discordant twins. Am J Obstet Gynecol 2012.

importantly, only 36% of these reports

growth with AC alone is 80% and with

lication bias, most reports are from tertiary

JANUARY 2012 American Journal of Obstetrics & Gynecology

hood ratios. The highest likelihood ratio

than dichorionic) twins, opposite sex of

American Journal of Obstetrics & Gynecology JANUARY 2012

Detection of discordant twins

Tai and Grobman

Miller. Discordant twins. Am J Obstet Gynecol 2012.

ences in CRL may represent the separate

pregnancy affirms that discordance of CRL

cies. These findings suggest that growth

JANUARY 2012 American Journal of Obstetrics & Gynecology

Factors that influence discordant growth of twins

Maternal age of 30 years

Assisted reproduction vs spontaneous

Constant maternal weight gain

Pregnancy with assisted reproduction

Fluctuating change in body mass index

Reduced and nonreduced twins

Small for gestational age in either fetus

Velamentous cord insertion

Pattern and size of vascular anastomoses

Miller. Discordant twins. Am J Obstet Gynecol 2012.

experienced centers and have a small

for monochorionic twins every 2-3

First-trimester prediction for twin complications and adverse outcome

CRL discrepancy Yes

CRL discordance Yes

CRL discordance Yes

Tai and Grobman

CRL discrepancy MC-no;

American Journal of Obstetrics & Gynecology JANUARY 2012

Ultrasound surveillance of twin pregnancies

come or is cost-effective. Reported management guidelines are based on local

twins, although it can be less frequent

JANUARY 2012 American Journal of Obstetrics & Gynecology

Two-step screening strategy for complicated

Monitoring monochorionic twins adapted, with permission from Lewi et al.60

lineated clearly and is variable (Table 5).

ease. Once viability is reached and discordant growth is identified, antenatal

Uncomplicated monochorionic pregnancies, fetal death, and delivery recommendations

Ultrasound scan every 2 wka

Ultrasound scan every 2 wk at 30 wk, every

Ultrasound scan every 2 wk;

Miller. Discordant twins. Am J Obstet Gynecol 2012.

American Journal of Obstetrics & Gynecology JANUARY 2012

access, continuous fetal monitoring