R E V I E W

A R T I C L E

Monochorionic Twin with Selective

Intrauterine Growth Restriction
Yao-Lung Chang*

A monochorionic twin pregnancy with selective intrauterine growth restriction (IUGR) of

one twin is defined as one twin with an estimated fetal weight below the 10th percentile
for gestational age. Selective IUGR occurs in about 12% of twin pregnancies. The incidence
of IUGR is similar in dichorionic and monochorionic twin pregnancies, but the risk of neuro-
logic damage to the fetus is greater in monochorionic twin pregnancy. Monochorionic
twins have the highest risk of complications, because the well-being of one fetus crucially
depends on that of the other because of vascular anastomoses in the common placenta.
The spontaneous demise of the twin with selective IUGR may result in the concomitant
demise of the twin who is appropriate for gestational age (AGA) in up to 40% of cases or
in neurologic damage of the AGA twin in up to 30% of cases. However, even in the
absence of single intrauterine fetal death, the risk of neurologic damage is still increased
in monochorionic as compared with dichorionic twin pregnancies. Because monochori-
onic twins with selective IUGR lack a definite treatment process as in twin-twin transfu-
sion syndrome, this article reviews the ultrasound diagnosis, etiologies, Doppler findings,
classification, and the management of such high risk pregnancies.

KEY WORDS intrauterine growth restriction, monochorionic twin, umbilical

artery Doppler, placental share

J Med Ultrasound 2008;16(3):194201

Introduction known and unique complications, including twin-

Twin gestation is more complex and has increased
perinatal morbidity and mortality rates compared
with singleton pregnancies [1]. Poor perinatal out-
come is not only the result of prematurity, fetal
growth restriction, and structural and chromosomal
anomalies. Monochorionic twins (MC) have well
twin transfusion syndrome (TTTS) and twin reversed
arterial perfusion (TRAP) sequence [2]. However,
MC with selective intrauterine growth restriction
(IUGR), which is also a unique complication in MC,
is less discussed. MC have the highest risk of com-
plications and the well-being of one fetus crucially
depends on that of the other because of vascular

Received: April 7, 2008 Accepted: July 15, 2008

Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University
College of Medicine, Tao-Yuan, Taiwan.
*Address correspondence to: Dr. Yao-Lung Chang, Department of Obstetrics and Gynecology, Chang Gung
Memorial Hospital, Linkou Medical Center, 5, Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan.
E-mail: j12054@cgmh.org.tw

194 J Med Ultrasound 2008 Vol 16 No 3 Elsevier & CTSUM. All rights reserved.

anastomoses in the common placenta. Even exclud-
ing these unique complications, the prognosis of
MC is still poorer than that of dichorionic twins [3].
Twin pregnancy with selective IUGR occurs in
about 12% of twin pregnancies [46], and the inci-
dence of IUGR is similar in both dichorionic and
monochorionic twin pregnancies. Unequal placental
sharing has been found to be the primary contrib-
utor to birth weight discordance in MC [5]. MC with
selective IUGR usually presents with significant dis-
cordance in fetal size and, on first impression, can
be assumed to be TTTS. These cases vary from sim-
ple amniotic fluid volume discordance to isolated
polyhydramnios and isolated oligohydramnios.
The main pathophysiologic basis for MC with
selective IUGR is the placental territory factor, which
arises from unequal sharing of the placenta in MC,
and is different from the vascular communicating
factor in TTTS. Since September 2005, there have
been approximately 20 cases of MC with selective
IUGR transferred to Chang Gung Memorial Hospital,
Linko Medical Center, and half of these cases were
initially diagnosed as TTTS at other hospitals. Three
of the cases eventually met the criteria for TTTS
after a few weeks of follow-up. Thus, there is the
possibility that MC with an unequal placental share
and an eventual superimposed vascular factor will
be diagnosed with TTTS. After years of testing, the
treatment of TTTS has become more definite [7].
However, the optimal management of MC with
selective IUGR is still lacking [8]. In this article, we
will discuss the unique high-risk MC pregnancy.
Definition and Diagnosis of MC with
Selective IUGR
Before the diagnosis of MC with selective IUGR is
made, it is necessary to know how to diagnosis MC
using ultrasound. Among the criteria used to predict
MC using ultrasound, the most reliable indicator
for dichorionicity (to exclude the diagnosis of MC)
is the presence of two separate placentas which
have a sensitivity and a specificity of 97.4% and
100%, respectively. The most useful test to predict
Monochorionic Twin with Selective IUGR
monochorionicity is the T sign which has a sensitivity
of 100% and a specificity of 98.2% [9]. The accuracy
is increased when ultrasound is performed before
14 weeks gestation [10]. Every twin pregnancy has
to be tested for chorionicity in the first trimester.
If two separate sacs are seen in the first trimester,
then a dichorionic pregnancy is diagnosed.
MC with selective IUGR is defined as a MC preg-
nancy with a small fetus, and the estimated fetal
weight determined by sonography is usually below
the 10th percentile [11]. To define IUGR in a twin
pregnancy is somewhat different from a singleton
pregnancy [12]. However, using the definition of
IUGR in a singleton pregnancy to predict IUGR in a
twin pregnancy is acceptable [8] because IUGR is a
poor prognostic indicator for the fetus, and using
a looser definition to predict IUGR in a twin preg-
nancy in order to obtain closer fetal monitoring may
be acceptable. Some authors have suggested that
intertwine weight discordance should be considered
in the definition of MC with selective IUGR. How-
ever, IUGR could increase perinatal complications,
so we did not use intertwine weight discordance in
the diagnostic criteria in this article.
Differential Diagnosis of MC with
Selective IUGR and TTTS
The etiology of TTTS appears to result from a net
unbalanced blood flow between two monochori-
onic fetuses through placental vascular communica-
tions, which results in a donor twin and a recipient
twin. Actual documentation of this unbalanced
blood flow remains elusive [13]. The most unique
feature of MC with selective IUGR is the lack of the
polyhydramnios/oligohydramnios sequel. Generally,
the etiology of TTTS is a vascular factor and that of
MC with selective IUGR is a placental territory factor.
However, a previous study has shown that when the
vascular factor in the etiology of TTTS is removed,
an unequal placental share would also be found
[14]. In MC with selective IUGR, an unbalanced
vascular communication would exist, but the vas-
cular factor would not be severe enough to cause
J Med Ultrasound 2008 Vol 16 No 3 195
 Y.L. Chang
marked amniotic fluid discordance as in TTTS. We
have had experience of cases initially diagnosed as
MC with selective IUGR even without discordant
amniotic fluid (AF), which progressed to TTTS
weeks later.
Etiologies of MC with Selective IUGR
Placental factors
The placenta has a striking functional reserve capac-
ity, which has been shown in studies where fetal
oxygen consumption has been artificially increased
[15,16]. It was thus concluded that the placenta is
usually small because the infant is small, but its small
size does not act as a contributory factor to fetal
growth restriction [15]. Quintero et al found that
the individual placental mass could be determined
in MC [17], so we also used the same concept to
estimate the placental share in MC with selective
IUGR. In our previous publication [18], the placental
share was severely unequal in MC with selective
IUGR (Fig. 1). The discordance in estimated fetal
weight detected by ultrasound before birth was
less than the degree of discordance in unequal pla-
cental share in such cases. We confirmed that the
placental territory factor plays a major role in MC
with selective IUGR.
Territory of AGA twin Territory of IUGR twin
Fig. 1. Unequal placental sharing in the monochorionic twin
with selective intrauterine growth restriction (IUGR). The
IUGR twin had a much smaller-than-normal placental share
for appropriate-for-gestational age twin.
196 J Med Ultrasound 2008 Vol 16 No 3
Vascular factors
In our series of MC with selective IUGR [18], all
the AGA twins had the largest placental share.
However, in MC without IUGR, there was one case
where the smaller twin had the larger placental
share. It has been hypothesized that in such cases
(larger twin with the smaller placental share),
there may be net arteriovenous anastomosis from
the larger twin to the smaller twin [19,20]. There-
fore, we cannot rule out the possibility that there
is net flow from the twin with a larger placental
territory to perfuse the twin with a smaller placen-
tal mass. However, the incidence of the small twin
having a larger placental share in MC has been
reported to be only 1.37% (7/509) and the type of
vascular anastomosis has been proven not to be
significantly associated with the birth weight dis-
cordance in MC [19]. So, the communicating vas-
cular factor possibly plays a role in the etiology of
IUGR in MC, but the role is less important than the
placental share factor.
Genetic factors
As the twins are identical, genetic factors would
not be involved in MC.
Doppler Findings in MC with
Selective IUGR
Umbilical artery (UA) Doppler
MC with selective IUGR has been classified into
three types using UA Doppler of the IUGR twin [21].
These three types of MC with selective IUGR are
based on UA Doppler findings: (1) normal, defined
as positive diastolic velocity; (2) persistent, absent
or reversed end-diastolic velocity (AREDV); and (3)
intermittent AREDV. Doppler assessment of the UA
is an established test of fetal well-being in high-risk
pregnancies. In singleton pregnancies, AREDV has
been attributed to increased downstream placen-
tal resistance because of a reduction in the number
of small muscular arteries [22,23]. AREDV in TTTS
has also been associated with poor perinatal out-
come [24,25]. The etiology of AREDV in the donor

twin has also been studied in cases receiving laser
therapy; small placental territory and intertwined
artery to artery anastomoses have been recognized
as the cause [14]. However, there have been very
few cases of MC with selective IUGR which have
been treated with laser therapy, so other than the
small placental territory, the type of intertwined
anastomoses has been suspected but has not been
proven as the cause of AREDV in the IUGR twin.
Interestingly, intermittent AREDV in TTTS was not
recognized as an abnormal Doppler finding in the
Quintero staging system [26]. However, in MC with
selective IUGR, intermittent UA AREDV has been
recognized as a subgroup with an elevated risk of
intrauterine demise in the smaller twin and neuro-
logic damage in the larger twin. This latter finding
is not restricted to this condition but has also been
found in cases of intrauterine fetal death of the
cotwin [27]. Therefore, UA Doppler of the IUGR
twin has the strongest prognostic role in MC with
selective IUGR.
Umbilical venous (UV) Doppler
UV blood flow reflects the placental circuit of fetal
circulation and is crucial for intrauterine develop-
ment [28]. Placental blood flow, which represents
approximately 30% of the biventricular fetal car-
diac output [29], is reported to be reduced in IUGR
[3032]. Although the significant fetal weight dis-
cordance can be estimated in twin pregnancy
before birth [33], the degree of unequal placental
share cannot be predicted before delivery. In a
previous study of TTTS, the donor twin had a sig-
nificantly smaller UV flow before laser therapy
[34,35]. In our experience, the UV flow was also
decreased in the IUGR twin compared with the AGA
counterpart in MC with selective IUGR. This decrease
in UV flow has been detected as early as 16 weeks
gestation.
Middle cerebral artery (MCA) Doppler
MCA peak systolic velocity (PSV) in singleton preg-
nancies has been widely used in the detection of
fetal anemia and has also proved useful in TTTS
following laser therapy [36]. Currently, MCA PSV
Monochorionic Twin with Selective IUGR
has no obvious role in MC with IUGR if there is no
twin intrauterine demise. In MC, the MCA PSV has
been reported to be unstable because of the vas-
cular anastomoses [37]. The role of MCA PSV may
be related to the detection of the severity of ago-
nal transfusion in IUGR twin intrauterine fetal death.
If MCA PSV is significantly elevated after one twin
intrauterine fetal death, the possibility of severe
anemia in the surviving twin is high.
Amniotic fluid (AF) level
MC with selective IUGR could present with discor-
dance in AF level between the twins but is not nec-
essary for the diagnosis. AF is produced by fetal
urine after 20 weeks of gestation. In the case of MC
with extreme AF discordance, this condition was
categorized as TTTS. Usually the IUGR twin would
have a lower level of AF than the AGA counterpart
in MC with selective IUGR. Currently, there are no
studies comparing the outcomes of MC with selec-
tive IUGR with or without AF discordance. However,
in MC with selective IUGR, those with discordance
in AF level and UA AREDV would have an adverse
perinatal outcome compared with those with nor-
mal IUGR twin UA Doppler [38]. Therefore, UA
Doppler findings may be a stronger prognostic
marker than AF level.
Classification
The classification of MC with IUGR mainly depends
on the pattern of UA Doppler in the IUGR twin
[21,39]. The reason for the classification of MC with
IUGR is that the spontaneous demise of the twin
with selective IUGR may result in the concomitant
demise of the twin who is AGA in up to 40% of
cases or in neurologic damage in the AGA twin in
up to 30% of cases [39]. AREDV of the UA in the
IUGR twin also poses an increased risk of fetal [21]
and neonatal death [18]. The MC with selective
IUGR were subsequently classified into one of three
types according to the characteristics of UA Doppler
flow as evaluated on the first examination: type I
(positive end-diastolic flow in the UA), type II
J Med Ultrasound 2008 Vol 16 No 3 197
 Y.L. Chang
(AREDV constantly observed during the examination)
or type III which was defined as the clear observation
of AREDV alternating with a short period of positive
diastolic flow, in the absence of fetal and maternal
breathing. This classification may be of help in clin-
ical decision making and when comparing clinical
studies [21]. However, in our experience, only AREDV
in the IUGR twin has prognostic value [18].
Individual Fetal/Placental Ratio in
MC with Selective IUGR
The placenta, as the maternalfetal interface, is
responsible for the exchange of oxygen and all
nutrients between the mother and the fetus, and is,
thereby, a principal determining factor in fetal birth
weight. Because placental weight and birth weight
are available on patient records, these parameters
are accessible. In general, placental size and fetal
size are directly related and experimental reduction
of placental size by uterine carunclectomy prior to
pregnancy has been shown to result in smaller
fetuses in sheep [40]. In MC, the placental share
plays a role in the ratio of intertwine birth weight;
the exact placental share between the two fetuses
can only be detected after delivery by placenta ex-
amination. Therefore, prenatal diagnosis of unequal
placental sharing is not possible, but the signifi-
cant intertwined birth weight discordance can be
predicted by sonographic examination [33]. The
weight of placentas from small-for-gestational age
infants has been reported to be reduced when
compared with those of AGA infants. However,
changes in the fetal/placental (F/P) ratio in single-
tons depends on gestational age at delivery, and
even at the same gestational age, the ratio varies
quite widely [15,41]. We have found that the indi-
vidual F/P ratios between the twin fetuses in MC
with selective IUGR were significantly different [18].
The F/P ratio in the IUGR twin was significantly
larger than that in the AGA twin. The fetal weights
were not proportional to the placental mass in the
twins; the degree of birth weight discordance has
to be smaller than that of the discordance in the
198 J Med Ultrasound 2008 Vol 16 No 3
placental share in order for the F/P ratio to reach
statistical significance. In these IUGR twins, their
birth weights are low, but their placental weights
are even lower. The discordance in estimated fetal
weight by ultrasound detected before birth did not
reflect the degree of discordance in placental shar-
ing in such cases. So, by studying the F/P ratio in
MC with selective IUGR, we have found that the
etiology of IUGR in one twin can mainly be attri-
buted to the small placental factor. However, a
smaller placenta territory does not necessarily make
the twin smaller. If the placental territory is small
enough, then the affected twin would have IUGR.
In MC with selective IUGR, the F/P ratio of the
IUGR twin is significantly higher than that of the
AGA counterpart, so the fetal weights are not pro-
portional to the placental masses of the twins. The
discordance in estimated fetal weight by ultrasound
detected before birth does not reflect the degree
of discordance in placental share.
Management of MC with Selective IUGR
Current management of MC with selective IUGR
involves expectant management and early delivery
(if warranted), termination of pregnancy, selective
laser photocoagulation of communicating vessels
or umbilical cord occlusion [39]. Most cases of MC
with selective IUGR are managed by expectant
management. The key steps are close monitoring
and prompt delivery. There have been reports that
the use of daily biophysical profiles to monitor such
cases can prolong pregnancy with an acceptable
perinatal outcome [42]. In our hospital, MC with
selective IUGR are managed conservatively; for those
MC with selective IUGR and normal IUGR twin UA
Doppler, follow-up visits in the clinic at 2-week
intervals and patient education to self-monitor
fetal movement and check daily body weight are
encouraged. If fetal movement decreases or the
UA Doppler shows abnormal results, then hospital
admission is required. In cases with abnormal IUGR
twin UA Doppler, these cases are admitted to hospi-
tal after 2426 weeks of gestation. After admission,

Repeat deceleration of the fetal
heart rate of the IUGR twin
Fig. 2. The fetal heart beat monitor in the monochorionic twin
with selective intrauterine growth restriction (IUGR). The fetal
heart beat of the IUGR twin showed repeat variable deceleration.
patients are monitored by continuous fetal moni-
toring, if repeated fetal heart beat deceleration is
detected (Fig. 2) (usually detected in the IUGR
twin), then corticosteroids are given to improve
fetal lung maturity followed by prompt delivery. In
our preliminary report [18], MC with selective IUGR
with normal IUGR twin UA Doppler had a 100%
survival rate and had a perinatal death rate of 20%
when the UA Doppler of the IUGR twin was abnor-
mal. The perinatal deaths in these cases of abnormal
IUGR twin UA Doppler were not confined to the
IUGR twin. Some of the MC with selective IUGR
would progress to TTTS after only weeks of follow-
up. These fetuses usually had abnormal IUGR twin
UA Doppler. If these cases met the criteria for TTTS,
they were usually at least stage III TTTS. In addi-
tion, because they were highly suspected of hav-
ing small placental territory in the donor (previous
IUGR) twin, the prognosis was usually poor even
after laser therapy [14].
Quintero et al conducted a pioneering study
using laser therapy to convert the monochorionic
placenta to a functioning dichorionic placenta. It
was claimed that the neurologic deficit in the IUGR
twin would decrease; however, the mortality rate
in the small twin was the same [39]. Laser therapy
of the communicating vessels in MC with selective
IUGR is more difficult than in TTTS, because MC
with IUGR usually lack polyhydramnios. Thus, to
insert a fetoscope and to carry out laser therapy on
the communicating vessels would be more difficult
Monochorionic Twin with Selective IUGR
than in TTTS, owing to a lack of adequate operat-
ing field. In unfamiliar hands, this could make the
condition worse.
If the diagnosis of MC with selective IUGR is
detected relatively early in the gestational period,
and the IUGR twin faced impending death, then
selective feticide of the IUGR twin can be per-
formed. This would reduce the risk of exsanguina-
tion in the AGA twin and could be performed by
bipolar cord coagulation, ligation of the cord or
laser photocoagulation. Laser photocoagulation to
occlude the cord can usually only be performed at
a relatively early gestational age because of the
cord size. At a later gestational age, cord occlusion
by bipolar coagulation or ligation under fetoscopic
guidance can be performed.
The management of MC with selective IUGR is
currently still a dilemma; however, close monitor-
ing and prompt delivery are the key steps in man-
agement. The differential diagnosis between MC
with selective IUGR and TTTS is important, because
TTTS has more agreeable management methods
[7]. Laser therapy of the communicating vessels
between the two fetuses in MC with selective IUGR
is more difficult than in TTTS, and can only be
performed by experienced personnel.
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