How the chorionicity and amnionicity are differentiated by the timing of the embryo splitting in monozygotic twins (Table is modified from Simpson L, 2015 [6]).
\r\n\t
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He successively held the positions of Assistant and Associate Professor in the Department of Agronomy at the Guangxi University, China from 2012 to 2014. He joined the faculty as an Associate Professor in the Department of Agronomy at the HAU in 2015 and was promoted to the position of Professor in 2017. He worked as a visiting fellow at the International Programs-College of Agriculture and Life Sciences, Cornell University, USA in 2017 and 2018. He serves as a committee member of the Crop Cultivation Professional Council of the Crop Science Society of China and a committee member of the Council of the International Forum on Rice Development. He obtained 5 research grants from the National Natural Science Foundation of China and the Ministry of Science and Technology of China. He is a first and/or corresponding author of more than 70 publications in international journals and an editor of 2 books. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"47569",title:"Surgical Treatment of Odontogenic Periapical Lesions",doi:"10.5772/59270",slug:"surgical-treatment-of-odontogenic-periapical-lesions",body:'Periradicular surgical practise is done for the treatment or prevention of periradicular pathologies. Abscess drainage, periapical surgery, corrective surgery, intentional replantation, and root removal are the most commonly performed types of periradicular surgery. Conventional endodontic treatment is generally a successful procedure; however, in 10% to 15% of cases the symptoms can persist or spontaneously recur. Findings such as a draining fistula, pain on mastication, or the incidental noting of a radiolucency increasing in size indicate problems with the initial endodontic procedure. Surgery then becomes a an important part of treatment in such cases. A decision on whether to approach the case surgically or to consider orthograde (through the coronal portion of the tooth) endodontic retreatment is dictated by various clinical and anatomic situations. Apicoectomy, apical surgery, endodontic surgery, root resection, root amputation are the terms which are used for surgery involving the root apex to treat the apical infection. It is the cutting off of the apical portion of the root and curettage of periapical necrotic, granulomatous, inflammatory or cystic lesions. In spite of adequate endodontic treatment, if periapical lesions are not resolved, then apical surgery is taken to consideration.
Apical anomaly of root that blocks appropriate root canal theraphy
Presence of lateral/accessory canal/apical region perforations
Roots with broken instruments/overfillings
Fracture of apical third of the root
Formation of periapical granuloma or odontogenic cyst related with apex
Draining sinus tract/nonresponsive to RCT
Extension of root canal sealant cement/filling beyond the apex
Presence of systemic diseases—leukaemia, uncontrolled diabetes, anaemia, thyrotoxicosis, etc.
Teeth damaged beyond restoration
Teeth with deep periodontal pockets and grade III mobility
Traumatic occlusion
Poor root crown ratio
Acute infection which is nonresponsive to the treatment
Anatomic structures (e.g., adjacent nerves and vessels)
Structures interfere with access and visibility
The basic purpose of periapical surgery can be determined as follows:
Elimination of disease
Prevention of disease
Removal of damaged or redundant tissue
Improvement of function and esthetics.
In order to achieve these goals, following principles have to be estimated:
Preoperatively;
Developing a surgical diagnosis
Intraoperatively;
Aseptic technique
Flap design
Tissue handling
Haemostasis
Dead space management
Decontamination and debridement
Suturing
Post operatively;
Oedema control
İnfection control
Patient’s general health and nutrition
Follow-up.
Surgical access is a compromise between the need for visibility of the surgical site and the potential damage to adjacent structures. A properly designed and carefully reflected flap results in good access and uncomplicated healing. Although several possibilities exist, the three most common incisions are
Submarginal curved (i.e., semilunar) (fig:1)
Submarginal, and full mucoperiosteal (i. e., sulcular) (fig:2)
Submarginal and full mucoperiosteal incision has a three-corner (i.e., triangular, trapezoidal, rectangular).(fig:3)
Semilunar incision
Submarginal incision
Full mucoperiosteal incision
Despite the commonly use of semilunar incision among practitioners, it’s limitations and potential complications should be considered deply before surgery. Semilunar incision
is a slightly curved half-moon horizontal incision in the alveolar mucosa. Although the location allows easy reflection and quick access to the periradicular structures, it limits the clinician in providing full evaluation of the root surface. The incision is based primarily in the unattached or alveolar mucosa, which heal more slowly with a greater chance of dehiscence than a flap based primarily in attached or keratinized tissue. In addition, the flap design carries the flap over the inflamed surgical site, and this inflamed mucosa is at a high risk of breakdown. Other disadvantages to this incision include excessive hemorrhage, delayed healing, and scarring; this design is therefore contraindicated for most endodontic surgery.
The horizontal component of the submarginal incision is in attached gingiva with one or two accompanying vertical incisions. Generally, the incision is scalloped in the horizontal line, with obtuse angles at the corners. The incision is used most successfully in the maxillary anterior region or, occasionally, with maxillary premolars with crowns. Because of the design, prerequisites are at least 4 mm of attached gingiva and good periodontal health. The major advantage is esthetics. Leaving the gingiva intact around the margins of crowns is less likely to result in bone resorption with tissue recession and crown margin exposure. Compared with the semilunar incision, the submarginal provides less risk of incising over a bony defect and provides better access and visibility. Disadvantages include hemorrhage along the cut margins into the surgical site and occasional healing by scarring, compared with the full mucoperiosteal sulcular incision.
The full mucoperiosteal incision is made into the gingival sulcus, extending to the gingival crest. This procedure includes elevation of interdental papilla, free gingival margin, attached gingiva, and alveolar mucosa. One or two vertical relaxing incisions may be used, creating a triangular or rectangular design.
The full mucoperiosteal design is preferred over the other two techniques. The advantages include maximum access and visibility, not incising over the lesion or bony defect, fewer tendencies for hemorrhage, complete visibility of the root, allowance of root planing and bone contouring, and reduced likelihood of healing with scar formation. The disadvantages are that the flap is more difficult to replace and to suture; also, gingival recession can develop if the flap is not reapproximated well, exposing crown margins or cervical root surfaces.
Periapical exposure must be achievedafter full thickness flap elevation by using a sterile round surgical burr. Mostly the cortical bone overlying the apex has been resorbed due to underlying apical pathosis, exposing a soft tissue lesion. If the opening is small, it is enlarged, until approximately half the root and the lesion are visible. With a limited bony opening, radiographs are used in conjunction with root and bone topography to locate the apex. Regardless of the handpiece used, there should be copious irrigation with a syringe or through the handpiece with sterile saline solution. Enough overlying bone should be removed to expose the area around the apex and at least half the length of the root. Good access and visibility are important; the bony window must be adequate. The clinician should not be concerned about the bone removal because once the infection resolves, the bone will reform. The exposure of the root is done before resecting the root to avoid the potential of blending the root in with the bone and losing surgical orientation. This is especially critical in the mandible where the bone is dense. Lower incisor roots are carefully exposed because the proximity with adjacent teeth could lead to treatment of the wrong apex. Fig:4
Periapical exposure
Granulomatous, inflamed tissue around the periradicular area should be removed to gain access and visibility of the apex, to obtain a biopsy for histologic examination (when indicated), and to minimize hemorrhage. If possible, the tissue should be enucleated with a suitably sized sharp curette. Fig:5
Apical third of the root is most likely the most difficult part to obturate properly. Presence of accessory canals increases at the apex as well, which may have not been initially cleaned and debrided, thereby leaving a source of continued infection. In general, approximately 2 to 3 mm of the root is resected more if necessary for apical access or if an instrument is lodged in the apical region; less if too much removal would further compromise stability of an already short root.Fig:5
Root resection
Root preperation for retrograd filling
Suturing after retrograd filling
An angled micro handpiece and micro round bur or ultrasonic tip can be used for retropreparation. The bur or tip is placed at the apical opening of the canal and guided gently deeper into the canal as it cuts. Once the retropreparation is completed the prepared cavity is inspected. The gutta-percha at the base is recondensedwith small 0.5 mm microplugger (Fig:6). After that orot end filling material can be applied. The aim of placing root end filling material is to establish an apical seal that inhibits the leakage of residual irritants from the root canal into the surrounding tissues (Fig:7).
After finishing surgical procedures the flap is returned to its original position and is held with moderate digital pressure and moistened gauze. Primary closure of the elevated flap is gained by basic or interrupted sutures. Absorbable monoflament or sling suture material is commonly used. After suturing, the flap should again be compressed digitally with moistened gauze for several minutes to express more hemorrhage. This limits postoperative swelling and promotes more rapid healing and adequate positioning of the flap.
Oral and written information should be supplied in simple, straightforward language. Patient should be informed about the procedure and what is coming next. A chart like the one below can be prepared and given to patient.
Do not raise the lip to look at the suture.
Place an icepack on the outside of the face 20 min. out of every 1½ hour for the first
day of surgery
Instruct to do salt wateror clorhexidine rinsing 3 times daily preferably after meal.
Do not chew any hard food with the tooth for 1 week.
Do not brush in the area of surgery for 1 week.
Maintain good oral hygiene.
Soft diet is suggested for the first 4 days.
Damage to the anatomic structures, bleeding, splattering of retrograd filling material at the operation site, incomplete root resection and curettage process, inadequate flap closure, healing problems of soft tissue, scar formation are the most common complications that may occur should be considered during and after the surgical procedure.
Healing capacity of involved tissues after periapical surgery is considered as good. Under the conditions that the diagnosis and treatment planning is held carefully and the intraoperative procedures achieved successfully most of the cases reveals long term uneventful follow up.
The patient applied to our our clinic with the complaint of swelling at right maxillar buccal area. Via radiographic and clinical examination, an intrabony lesion was observed between right maxillary lateral and first molar tooth apices about 5x2 cm in size. All teeth related to lesion were devital. An aspiration biopsy performed and characteristic yellowish fluid which has kollesterin crystals in it was gained which lead us to define the lesion as a radicular cyst due to necrose pulp tissues.
Treatment plan was to have endodontic treatment after that to enucleate the cyst totally, achieve apicoectomies to all related teeth apexes and reconstruct the intrabony defect by cancellous-bone grafts and membranes. We receipt postoperative antibiotic theraupy per os (amoxicillin 875 mg+clavulanate 125 mg 2x1) for ten days. Defect area started to filled with healing tissue from the base of the cavity and the complaints of the patient disappeared considerably.
OPTG view before surgery
Incision
Exposure of Cystic Lesion
Elevation of Cyst Epithelium
A 43-year-old female patient referred to our clinic with incidental OPTG examination finding of a homogenous radiolucent, sharply lined lesion located between canine teeth in anterior maxilla. On clinical examination, oral mucosa was intact and there was no evidence of bony expansion on both buccal and palatal sides. Pulp vitality testing was performed for all maxillary anterior teeth, 12 and 22 were found to be non-vital. With an inital diagnosis of inflammatory dentigerous cyst, enucleation of the lesion was planned. Prior to surgery, endodontic treatment of all involved teeth were completed. On surgical exploration, there was no expansed buccal bone was observed. After reaching the cyst capsule and performing resection of the involved roots, two seperate cystic cavities extending palatally behind the roots that have been seperated on the midline with a bony septa were encountered. Lesions were totally enucleated and submitted to histopathological examination. Result of histopathological examination was fibrotic capsule with medium degree of mononuclear cell infiltration, hyperplastic stratified squamous epithelium. In the postoperative period, healing was uneventful.
Cystic cavity
Graft material
Application of collagen membrane
Adaptation of flap
Primary closure of area
OPTG view
CT image
CT image
CT image
Cystic cavity
Histopathologic evaluation
36-year-old female patient admitted to our clinic with complaints of pain.Clinical and radiographic examination revealed a demarcated radiolucent leson at the the apexes of the teeth no:25,26,27. An electrical vitality test examination related to the teeth 24, 25and 27 was performed which found that teeth are non-vital, and these findings suggest that lesion was caused by non vital pulp tissues of related teeth. CT results showed that maxillary sinus bone compact and buccal cortex were perforated elevated and sinus floor was elevated by the lesion. After completion of endodontic treatment of related teeth patient have been operated under intravenous conscious sedation. During the operation, primarily by aspiration of cyst fluid pressure is reduced and the 2,3x2x1 cm sized radicular cyst was enucleated. Apical resections of relevant teeth were performed an operation region was primarily closed by 3.0 silk suture. Enucleated lesionwas sent to histopathologic examination for definitive diagnosis sent for and diagnosis was confirmed as periradicular cyst epithelium.
OPTG view
CT image
CT image
Exposure of lesion area
Aspiration of cystic liquid
Enucleation of cyst epithelium
Cyst epithelium
Cystic cavity
Primary closure of lesion area
Histopathologic evaluation
It is a well-established fact that multiple pregnancies occur more commonly nowadays than a few decades ago. The progress of reproductive technologies and in vitro fertilization has played a major role in this increase. In fact, twins comprise about 3% of all live births in the United States [1]. As we speak about history, the vast majority of multiple pregnancies that occurred in the past were diagnosed during the intrapartum period [2]. Today, as the use of ultrasound has become a routine in daily medical practice, multiple pregnancies are diagnosed in the initial ultrasound scan [3]. Beyond the diagnosis of early multiple pregnancy, ultrasound scan is more than necessary to define chorionicity, amnionicity, and gestational age [4].
In this chapter, we will present the ultrasound figures that help us determine gestational age, chorionicity, and amnionicity, focused on the 14 first weeks of gestation in multiple pregnancies. We will also focalize the discussion on twin pregnancies, as they comprise >98% of multiple pregnancies and the vast majority of studies today include twin pregnancies [4]. Nonetheless, we will review some cases from the literature that show that situations can be a little more complicated and may lead to a false diagnosis of chorionicity and amnionicity, in order to highlight that when we manage multiple pregnancies, we have to be alert about exceptions despite being infrequent [5].
A twin pregnancy can be either dizygotic (two-third of twin pregnancies), in which two different eggs are fertilized by two different sperms, and in this case, the pregnancy is always dichorionic-diamniotic or monozygotic. A monozygotic pregnancy occurs when an egg is fertilized by one sperm, producing one embryo, which can split any time, more commonly between day 2 and day 13 after fertilization. Chorionicity and amnionicity are differentiated by the timing of embryo splitting. Table 1 presents this differentiation and the frequency of each type of a monozygotic pregnancy [3].
Time of embryo splitting (in days) | Chorionicity | Amnionicity | Frequency (%) |
---|---|---|---|
2–3 | Dichorionic | Diamniotic | 30 |
3–8 | Monochorionic | Diamniotic | 70 |
8–13 | Monochorionic | Monoamniotic | <1 |
How the chorionicity and amnionicity are differentiated by the timing of the embryo splitting in monozygotic twins (Table is modified from Simpson L, 2015 [6]).
The accurate determination of gestational age is critical for pregnancy management as it shows wherever the measurements of the fetus are in line for the estimate gestational age [4]. In addition, a correct pregnancy dating is necessary not only for the appropriate timing for screening and diagnostic testing but also for optimal scheduling of delivery [6]. For women with regular cycles, the date of the last menstrual period is used to estimate gestational age, taking into account the biological variability and correct the cycle length. For IVF pregnancies, the date of the embryo transfer has been used to define pregnancy dating. The vast majority of authors embraced with multiple pregnancies agree that during the second trimester the evaluation of gestational age is more accurate and it is statistically superior to the second trimester [4]. Moreover, there is an agreement that the parameters and formulas that have been used for dating singleton pregnancies are also accurate for dating multiple pregnancies, since studies in this area include a combination of singleton and multiple pregnancies [7, 8, 9].
In the first trimester—before the 14th week of gestation—crown-rump length (CRL) is the parameter that is used in order to estimate gestational age with 5–7 days of deviation [7, 8, 9]. If there is a doubt about the reliability of the menstrual cycle or if the woman is administrated late for care, a repeat scan in 3–4 weeks can be helpful to determine pregnancy dating [10].
Modest size discordance is very common in multiple pregnancies [4]. Some studies suggest that pregnancy dating must be defined by using the mean of the fetuses [11]. However, more recent studies agreed that if the gestational age is based on the CRL of the larger twin, the possibility of missing a fetus that might develop intrauterine fetal growth restriction (IUGR) is decreased [12]. Salomon et al. [13] suggested that the CRL of the smallest fetus can estimate more accurately the gestational age, if the intertwin CRL discrepancy is less than the 95th percentile, using charts from studies. An interesting finding is that if the intertwin discordance in CRL is higher than 10%, the possibility of pregnancy loss, aneuploidy, or congenital anomalies is increased [3, 14, 15].
In the second trimester, a combination of parameters is used to define pregnancy dating such as abdominal circumference, femur length, and biparietal diameter [8]. Further discussion about calculating gestational age in second trimester is beyond the scope of this chapter.
Early and accurate definition of chorionicity and amnionicity has an undeniably determinant role in the management of multiple pregnancies, since chorionicity plays a key role in the appearance of complications: monochorionic-monoamniotic twins present the highest mortality and morbidity. There is no doubt that the continuous surveillance and the timely intervention can optimize the outcome of the pregnancy [4].
The determination of chorionicity and amnionicity is better to be done in the first trimester [4]. If chorionicity is defined in the first trimester, accuracy is extremely close to 100% and if the definition is carried out in the second trimester, correct assignment decreases to 90% [16, 17].
At this point, we will classify the determination based on gestational age, separated in two periods: the first before the 10th week of gestation and the second that includes the period from week 10 to week 14.
Three ultrasound findings can help in the detection of chorionicity: These are (1) the number of observable gestational sacs, (2) the number of amniotic sacs within the chorionic cavity, and (3) the number of yolk sacs [4].
The number of the gestational sacs and the number of fetal heartbeats in early multiple pregnancy scan are strongly related with chorionicity: each gestational sac will form a distinct placenta and chorion. Therefore, visualization of a single gestational sac with two visible heart beats indicates a monochorionic twin pregnancy, while the presentation of two distinctive gestational sacs implies a dichorionic pregnancy (Picture 1) [18]. The number of gestational sacs is the parameter with the highest accuracy to define chorionicity which is extremely close to 100% [16].
Dichorionic diamniotic pregnancy at 5 weeks of gestation. The two separate gestational sacs with one yolk sac each are visible and a thick septum separates them.
Identification of the number of amniotic sacs present in a single gestational sac helps define amnionicity in a monochorionic pregnancy. Prior to the 10th week of gestation, the amnions grow outward from the embryonic disk and at that age are not big enough to contact each other and create the intertwin septum [4]. As a result, separate and distinct amnions indicate a diamniotic twin pregnancy (Pictures 2a, b and 3a, b). The evaluation of the amnion should be done diligently via transvaginal ultrasound since the intertwin membrane is extremely thin and it may be invisible via transabdominal ultrasound. Even when the separate amnions cannot be visualized via the transvaginal ultrasound, their absence can be confirmed by demonstrating umbilical cord enlargement by using pulsed wave Doppler and identifying two distinct heart rates [3]. In addition, the impossible visualization of the intertwin membrane may be technical: if the membrane is parallel to the ultrasound beam or because the ultrasound gain is low, the membrane may be hard to evaluate. This problem can be solved by changing the angle of insonation and increasing gain facilitates visualization [5]. Another way to confirm amnionicity, wherever there is any doubt about the presence of the intertwin membrane, is to suggest a small chain of repeat scans [4].
(a) 3D imaging of dichorionic diamniotic pregnancy at 6 weeks of gestation. (b) 3D imaging of dichorionic diamniotic pregnancy at 6 weeks of gestation.
(a) Dichorionic diamniotic pregnancy with one of the pregnancies having miscarried. The size of the empty sac has been measured. (b) 3D imaging of DCDA pregnancy in which one of the sacs appears “empty” due to miscarriage.
However, is evaluation of intertwin membrane always that simple? There are two rare yet important situations that may lead to a false diagnosis of monoamniotic twins. The first case is when the monochorionic-diamniotic twins are complicated with twin-to-twin transfusion syndrome (TTTS) the donor twin has severe oligohydramnios or anhydramnios, and the intertwin membrane collapses resulting in wrapping the donor twin. The collapse of the membrane can be overtaken if we evaluate extremely carefully the wrapping membrane around the limbs of the donor twin. A possible rupture of the intertwine membrane is another case that may lead to “pseudo-MA” twins. Rupture of the membrane may occur spontaneously, but more often is a complication of invasive in utero procedures. Discontinuity of the membrane and cord enlargement can be visualized on the ultrasound scan. Other facts helping in the identification of the membrane rupture are the location of the fetuses in the same side of the warped membrane, the equal quantity of amniotic fluid in both sides of the dividing membrane in a pregnancy, which was complicated with TTTS, and of course a previous diagnosis of a monochorionic-diamniotic twin pregnancy [5].
Over the past few years, there is an uncertainty regarding the relation between the number of yolk sacs and amnionicity. If there are two yolk sacs present in the extraembryonic coelom, the pregnancy will be regarded as diamniotic. However, a single yolk sac cannot set the definitive diagnosis of a monoamniotic pregnancy. This is well-established since it is known that the differentiation of a yolk sac and an amnion occur very close to each other in time, around 6–8 days after fertilization [5]. If a single yolk sac is detected, a repeat first trimester scan is undertaken, or a refer to a tertiary center with advanced experience in multiple pregnancies can be helpful [3, 4].
As the pregnancy continues, the ultrasound signs that help in the determination of chorionicity and amnionicity are changing: gestational sacs are now fused and the intertwin membrane is formed. As a result, four other ultrasound figures set the diagnosis of chorionicity and amnionicity. These are: (1) sex discordance, (2) distinct placentas number, (3) intertwin membrane characteristics and (4) chorionic peak sign—‘λ’ sign.
If a male and a female fetus are identified in the late first or early second trimester, a dichorionic twin pregnancy is the rule. However, gender discordance is the biggest pitfall for the diagnosis of chorionicity. Discordant fetal sex phenotype can be present in monochorionic twins, leading to a false diagnosis of dichorionic twins.
A false diagnosis of dichorionic twins might be the result of a postzygotic sex chromosome aneuploidy. For instance, there is a 46,XY zygote which splits, but a postzygotic anaphase lag can cause the loss of the Y chromosome in one of the twins. The karyotype of one of the fetuses will be 46,XY which corresponds to a normal male fetus, while the other karyotype will be 45,XO which is a female fetus with Turner syndrome (Figure 1). If we want to take our example a step forward, postzygotic nondisjunction after the anaphase lag can lead to mosaicism in the monozygotic twins leading to two embryos with a variety of proportion of 45,XO and 46,XY cells. The phenotype of this individual will correspond to the amount of cells having the abnormal karyotype (Figure 2) [19, 20].
Postzygotic anaphase lag causing sex discordance due to loss of Y chromosome in one of the fetuses.
Postzygotic nondisjunction leading to both fetuses with gonadal mosaicism.
A sex discordance in monozygotic twins can also be caused by a trisomic 47,XXY zygote. A process known as trisomy rescue can lead to either the production of a normal 46,XY male fetus (loss of X chromosome) or a normal 46,XX female fetus (loss of Y chromosome) Hence, this mechanism causes the production of two euploids fetuses from a trisomic zygote (Figure 3) [21]. In addition, confusion might be caused if a 46,XY zygote splits with nondisjunction of the Y chromosome, producing a male fetus with a 47,XYY karyotype and a female fetus with a 45,XO karyotype, Turner syndrome, and female sex phenotype (Figure 4) [22].
Trisomy rescue.
Nondisjunction of chromosome Y.
Beyond sex chromosome abnormalities, sex discordance may be the result of epigenetic single gene defects in only one of the monoygotic twins, effecting testis-determining genes such as SOX9 which inhibits the expression of SRY gene [23, 24].
Nonetheless, sex discordance may be caused by malformed genitalia unrelated to chromosomal or genetic disorders. It is well established that a monochorionic twin pregnancy is complicated frequently with selective growth restriction [25], and hypospadias is a known complication of IUGR [26, 27]. As hypospadias might lead to female sex phenotype, confusion about chorionicity is expected, as the IUCR male fetus will present with female external genitalia, while the normally developing twin will be present as a normal male fetus. Cloacal malformation in one of the female fetuses (karyotype 46,XX) leads to phallus-like structure, causing phenotypically male external genitalia. The outcome is again confusion of chorionicity [28].
A very rare mechanism can cause the transverse situation: a dizygotic twin pregnancy is been diagnosed as monochorionic because of the fusion of the trophoblasts. Two distinct blastocysts produce two distinctive trophoblasts. If these trophoblasts fuse before the implantation, the result is the creation of a placental mass. The fused placenta will form vascular anastomoses, and the twins can exchange blood cells. As a result, blood chimerism of two populations of blood cells will be present in both fetuses [29, 30]. This mechanism is present more frequently in pregnancies carried out from ART because of the disruption of the zona pellucida and spatial proximity of multiple embryos [29, 31]. Dizygotic twins forming a monochorionic placenta have significant importance because these twins are genetically and phenotypically normal and they have to be distinguished from the pathological sex discordance [5].
It is logical that the visualization of two separate placental masses confirms dichorionicity as a single placenta identifies monochorionicity [4]. Careful ultrasound evaluation has to be done in order to define the presence of a single placenta or two placentas in abutment.
As the pattern above, monochorionic twins may form a bipartite placenta. This sonographic finding is visible in 3% of monochorionic twin pregnancies. As a result, two separated placental masses are present with two nearly equal-sized placental lobes, which can be totally separated or connected by chorion laeve. Things can be more complicated when each placental mass has its own umbilical cord connection. Bipartite placenta can be distinguished from the dichorionic placental masses by using color Doppler and identifying vascular anastomoses that are present between the two lobes. Thus, this leads to the conclusion that if an ostensibly dichorionic pregnancy is complicated with TTTS, the diagnosis of a monochorionic pregnancy with bipartite placenta has to be considered [32, 33, 34, 35].
The intertwin membrane of a dichorionic pregnancy comprises three layers of three membranes: amnion-chorion-amnion, as the monochorionic pregnancy consists only two layers of amnion. Therefore, intertwin membrane in a dichorionic pregnancy is thicker and more echogenic than the intertwin membrane in monochorionic pregnancies. Measuring the thickness of the membrane can help us define chorionicity: a membrane thicker than 2 mm indicates dichorionicity (positive predictive value: 95%), and if the membrane is thinner than 2 mm, the possibility of monochorionic pregnancy is about 90% [4].
The intertwin membrane has to be carefully detected and if it cannot be visualized, a transvaginal ultrasound scan has to be performed, to set the definitive diagnosis of monoamniotic pregnancy [4]. When a single placental mass is visualized and chorionicity is identified as monochorionic, evaluation of the intertwin membrane characteristics is the key to determine amnionicity. The most significant sonographic figure that demonstrates monoamniocity is the demonstration of cord enlargement from the placental or umbilical origin and it is identified easier via color Doppler. Other important findings intimating monoamnionicity are the entanglement of limbs or observation of a limb circumscribing the other, the failure to find the membrane between the two cord insertions in the placenta [4], and the short intercord distance [5].
However, intertwin membrane thickness difference between monochorionic and dichorionic pregnancy decreases during gestation [36]. In addition, the measurement of the thickness of the membrane is not widely accepted since this parameter can be affected by many factors such as the position and the quality of the probe, and as a result, it has poor reproducibility [37]. A rare but significant pitfall may lead to a wrong determination of a monochorionic pregnancy as dichorionic is the intrauterine synechiae in twin pregnancy with a fetus with anencephaly. Intrauterine synechiae can mimic the thick dichorionic membrane [38]. This septum is not the intertwin membrane and does not include the layer of chorion between the layers of amnion.
The chorionic peak sign or the “λ” sign supports strongly dichorionicity, with an accuracy of 99% [5]. It shows a projecting zone of tissue which is as echogenic as the placenta; it has a triangular shape in cross-section; and it is wider at the chorionic surface of the placenta, extending into, and tapering to a point within, the intertwin membrane [39, 40]. The absence of the “λ” sign or the presence of “T” sign indicates monochorionicity. The “T” sign represents the two opposing amnions “standing” at the base of the intertwin membrane [10].
The chorionic peak sign is ideally evaluated during the late first trimester or the very early second trimester, as in second trimester, it is more difficult to be visualized and it might be disappeared at 16–20 weeks of gestation, leading to a false negative “λ” sign. As a result, the impossible depiction of the “λ” sign in late second trimester cannot exclude dichorionicity [41, 42]. Nonetheless, a false positive “λ” sign might also exist. This can be due to umbilical cord insertion into the intertwin membrane or because of the visualization of a hematoma presented along the insertion of the membrane. Another interesting reason that may lead to a false positive “λ” sign is the presence of an echogenic retrograded yolk sac of the placental junction of the intertwin membrane in a monochorionic-diamniotic twin gestation. The sonographic finding that succors determinate the true “λ” sign is that the true “λ” has been seen along with the whole insertion area, in contrast to the false “λ” sign, which appears in only a small region of the intertwin membrane [43, 44]. Finally, in very rare instances, the placentation may be both monochorionic and dichorionic, and each chorionicity is presented in different regions of the intertwin membrane. Therefore, the same intertwin membrane has parts with two layers of amnions and parts with three layers: amnion-chorion-amnion [45, 46, 47]. This situation shows the importance of scanning the whole insertion of the intertwin membrane in early ultrasound assessment of multiple pregnancy.
In some cases and despite the best possible ultrasound assessment, chorionicity is impossible to be defined. In these situations, the pregnancy has to be considered as monochorionic. Therefore, surveillance has to be as close as in monochorionic pregnancies [45], and this is discussed below.
Surveillance in multiple pregnancies has a significant importance, as it plays the major role in the detection of complications that are associated with a high-risk pregnancy, and it is well known that multiple pregnancy is a classic example of a high-risk pregnancy. However, the appropriate frequency of the ultrasound assessment in both dichorionic and monochorionic pregnancies, which provides the best balance between cost and effectiveness, is not be established and worldwide accepted [3].
Finberg et al. [46] suggested repeat scans every 4–6 weeks for noncomplicated dichorionic pregnancies. However, in current daily medical routine, surveillance is closer: follow-up ultrasound assessments are performed every 3–4 weeks [4, 47]. But, if a complication is suspected, and more specifically when CRL, estimated fetal weight or amniotic fluid volume are different between the two fetuses, routine scans have to be repeated every 2 weeks, or within a week [48].
It is a well-established fact that surveillance in monochorionic pregnancies has to be closer in relation to a dichorionic pregnancy. Finberg et al. [46] recommended ultrasound monitoring for noncomplicated monochorionic twins every 3–4 weeks. As the pattern mentioned previously, nowadays, routine scans are performed more frequently: they are performed every 2–3 weeks, starting from the gestational age of 16 weeks. Finally, in some cases, surveillance is even closer: a follow-up scan can be repeated every 2 weeks.
The parameters that are necessary to be evaluated in these follow-up scans are estimated fetal weight and fetal biometry, amniotic fluid volume, and Doppler assessment of the umbilical artery [49].
There is no doubt that multiple pregnancies are now more frequent than a few years before, due to the spreading of artificial reproductive technologies. Determination of gestational age, chorionicity, and amnionicity has to be done as soon as possible and ideally in the first trimester of the pregnancy, as the accuracy of the determining sonographic figures is extremely close to 100%, in contrast to the definition in the second trimester whose accuracy is slightly decreased. Last but not least, timely determination of both chorionicity and amnionicity can optimize the outcome of the pregnancy, as the correct and early intervention or a refer to a tertiary center could be really valuable.
We would like to thank Kyriaki Savva, PhD student of Cyprus Institute of Neurology and Genetics, for her comments that greatly improved the manuscript.
IntechOpen implements a robust policy to minimize and deal with instances of fraud or misconduct. As part of our general commitment to transparency and openness, and in order to maintain high scientific standards, we have a well-defined editorial policy regarding Retractions and Corrections.
",metaTitle:"Retraction and Correction Policy",metaDescription:"Retraction and Correction Policy",metaKeywords:null,canonicalURL:"/page/retraction-and-correction-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"IntechOpen’s Retraction and Correction Policy has been developed in accordance with the Committee on Publication Ethics (COPE) publication guidelines relating to scientific misconduct and research ethics:
\\n\\n1. RETRACTIONS
\\n\\nA Retraction of a Chapter will be issued by the Academic Editor, either following an Author’s request to do so or when there is a 3rd party report of scientific misconduct. Upon receipt of a report by a 3rd party, the Academic Editor will investigate any allegations of scientific misconduct, working in cooperation with the Author(s) and their institution(s).
\\n\\nA formal Retraction will be issued when there is clear and conclusive evidence of any of the following:
\\n\\nPublishing of a Retraction Notice will adhere to the following guidelines:
\\n\\n1.2. REMOVALS AND CANCELLATIONS
\\n\\n2. STATEMENTS OF CONCERN
\\n\\nA Statement of Concern detailing alleged misconduct will be issued by the Academic Editor or publisher following a 3rd party report of scientific misconduct when:
\\n\\nIntechOpen believes that the number of occasions on which a Statement of Concern is issued will be very few in number. In all cases when such a decision has been taken by the Academic Editor the decision will be reviewed by another editor to whom the author can make representations.
\\n\\n3. CORRECTIONS
\\n\\nA Correction will be issued by the Academic Editor when:
\\n\\n3.1. ERRATUM
\\n\\nAn Erratum will be issued by the Academic Editor when it is determined that a mistake in a Chapter originates from the production process handled by the publisher.
\\n\\nA published Erratum will adhere to the Retraction Notice publishing guidelines outlined above.
\\n\\n3.2. CORRIGENDUM
\\n\\nA Corrigendum will be issued by the Academic Editor when it is determined that a mistake in a Chapter is a result of an Author’s miscalculation or oversight. A published Corrigendum will adhere to the Retraction Notice publishing guidelines outlined above.
\\n\\n4. FINAL REMARKS
\\n\\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\\n\\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
\\n\\nThe general principles set out above apply to Retractions and Corrections issued in all IntechOpen publications.
\\n\\nAny suggestions or comments on this Policy are welcome and may be sent to permissions@intechopen.com.
\\n\\nPolicy last updated: 2017-09-11
\\n"}]'},components:[{type:"htmlEditorComponent",content:'IntechOpen’s Retraction and Correction Policy has been developed in accordance with the Committee on Publication Ethics (COPE) publication guidelines relating to scientific misconduct and research ethics:
\n\n1. RETRACTIONS
\n\nA Retraction of a Chapter will be issued by the Academic Editor, either following an Author’s request to do so or when there is a 3rd party report of scientific misconduct. Upon receipt of a report by a 3rd party, the Academic Editor will investigate any allegations of scientific misconduct, working in cooperation with the Author(s) and their institution(s).
\n\nA formal Retraction will be issued when there is clear and conclusive evidence of any of the following:
\n\nPublishing of a Retraction Notice will adhere to the following guidelines:
\n\n1.2. REMOVALS AND CANCELLATIONS
\n\n2. STATEMENTS OF CONCERN
\n\nA Statement of Concern detailing alleged misconduct will be issued by the Academic Editor or publisher following a 3rd party report of scientific misconduct when:
\n\nIntechOpen believes that the number of occasions on which a Statement of Concern is issued will be very few in number. In all cases when such a decision has been taken by the Academic Editor the decision will be reviewed by another editor to whom the author can make representations.
\n\n3. CORRECTIONS
\n\nA Correction will be issued by the Academic Editor when:
\n\n3.1. ERRATUM
\n\nAn Erratum will be issued by the Academic Editor when it is determined that a mistake in a Chapter originates from the production process handled by the publisher.
\n\nA published Erratum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n3.2. CORRIGENDUM
\n\nA Corrigendum will be issued by the Academic Editor when it is determined that a mistake in a Chapter is a result of an Author’s miscalculation or oversight. A published Corrigendum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n4. FINAL REMARKS
\n\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\n\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
\n\nThe general principles set out above apply to Retractions and Corrections issued in all IntechOpen publications.
\n\nAny suggestions or comments on this Policy are welcome and may be sent to permissions@intechopen.com.
\n\nPolicy last updated: 2017-09-11
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