Cell-mediated and humoral immune responses to human cytomegalovirus in pregnant women with vertically transmitted infection following primary infection: A case report.

Human cytomegalovirus (HCMV) is the major cause of neurological sequelae in infants. Immune control of primary HCMV infection appears to depend on the interaction between humoral and cell-mediated immune responses. We report the case of an HCMV-transmitter mother observed with dissociation between humoral and cell-mediated immune responses. The patient had immunoglobulin (Ig) G and M positivity at 11 weeks of gestation and showed fetal hyperechoic bowel and minimal ascites at 21 weeks of gestation. At 25 weeks of gestation, the polymerase chain reaction result for HCMV using amniotic fluid was positive. The numbers of spots in the enzyme-linked immunosorbent spot (ELISPOT) assay at 25, 36, and 39 weeks of gestation were three, five, and six spots/2 × 105 peripheral blood mononuclear cells, respectively. Furthermore, IgG avidity indexes (AIs) at 21, 25, 36, and 39 weeks of gestation were 37.6, 49.7, 72.5, and 74.3, respectively. At 40+1 weeks of gestation, the patient delivered a symptomatic infected newborn with a weight of 2,384 g (-2.6 SD) and a head circumference of 30 cm (-2.6 SD). The neonate had a petechial rash and bilateral hearing loss although did not show liver dysfunction or thrombocytopenia. Cranial magnetic resonance imaging revealed mild ventriculomegaly, left lateral/parietal polymicrogyria, and a punctate white matter lesion. This case showed that IgG AI increased with increasing gestational age, whereas the numbers of spots in the ELISPOT assay had no change. The dissociation between humoral and cell-mediated immune responses may be characteristic of the immune response of a transmitter mother.

Fetal heart rate patterns complicated by chorioamnionitis and subsequent cerebral palsy in Japan.

AIM: This retrospective study was performed to investigate whether certain fetal heart rate patterns were associated with subsequent cerebral palsy (CP) in infants with chorioamnionitis at or near term. METHODS: We used cases registered by the Japan Obstetric Compensation System for CP, which is a nationwide population-based database. Among them, 133 infants with chorioamnionitis who were born at ≥34 weeks of gestation were enrolled. All infants underwent magnetic resonance imaging (MRI), and all fetal heart rate charts had been interpreted according to the National Institute of Child Health and Human Development criteria, focusing on antepartum and immediately before delivery. RESULTS: The incidence of CP after chorioamnionitis at ≥34 weeks of gestation was 0.3 per 10 000 in Japan. Between the clinical (24%) and subclinical groups (76%), the incidence of abnormal fetal heart rate patterns did not differ. According to the MRI classification, 88% of the infants with CP showed hypoxic-ischemic encephalopathy. Half of the infants with CP experienced terminal bradycardia, leading to severe acidosis and exclusively to hypoxic-ischemic encephalopathy. In another half, who did not experience bradycardia, 80% had moderate acidosis (pH 7.00-7.20) resulting in hypoxic-ischemic encephalopathy, and the remaining 20% showed non-acidosis resulting in brain damage other than hypoxic-ischemic encephalopathy. The fetal heart rate patterns before the terminal bradycardia showed that the incidence rates of late deceleration or decreased variability were high (>60%). CONCLUSION: Fifty percent of pregnant women with chorioamnionitis-related CP had terminal bradycardia that exclusively resulted in hypoxic-ischemic encephalopathy.

[Evaluation of the Japanese version of HLS-Q12 in older adults].

Objectives　The purpose of this study was to evaluate the internal consistency and factorial validity of the Japanese version of HLS-Q12 health literacy rating scale when used with older adults.Methods　A questionnaire-based mail survey was conducted among older adults living in a community. The data collection period was from January to February 2022. The Japanese version of HLS-Q12 was used to obtain data on health literacy of older adults, and the internal consistency and factorial validity of the scale were evaluated using Cronbach's alpha coefficient and confirmatory factor analysis, respectively. In addition, a Rasch model was used to conduct a detailed analysis on each questionnaire item.Results　Questionnaires were distributed among 3,572 people, out of which, 1,082 responses were received from older adults (over 65 years of age). Cronbach's alpha coefficient was 0.8 or higher, indicating no internal consistency issues. According to the confirmatory factor analysis, CFI was equal to 0.933, AGFI, 0.876, and RMSEA, 0.092; thus, all indicators met certain evaluation levels. However, deviation from one of the multiple fit criteria was confirmed for the value of RMSEA, indicating that the error between the estimated value calculated by the scale and the true value was relatively large. Analysis of each question item using the Rasch model showed that all the questions met the criteria of Infit MSQ and were suitable in their question structure.Conclusion　Following the evaluation of the HLS-Q12 scale in older adults, the scale was found to be reliable and valid at a certain level. However, the value of RMSEA indicated that it was relatively large in terms of the error between the estimated value calculated by the scale and the true value.

Synthesis and Structural Characterization of ß-Turn Mimics Containing (Z)-Chloroalkene Dipeptide Isosteres.

Described here is the synthetic, spectroscopic, crystallographic, and computational analysis of a series of peptidomimetics containing l-Xaa-d-Yaa-type (Z)-chloroalkene dipeptide isosteres (CADIs) that were measured in an investigation of the ß-turn mimicry of this peptide bond surrogate. We found that the 1,3-allylic strain across the chloroalkene moiety engenders the hyperconjugative interactions between the chloroalkene moiety and the C-H bonding or antibonding orbitals of the C-H bonds in allylic positions. These effects contribute significantly to the stabilization of ß-turn structures.

Association between fetal vascular malperfusion and gestational diabetes.

AIM: Diabetes mellitus (DM) is a major complication in pregnancy. Placental lesions with DM remain unclear and controversial. Recently, the terms of placental pathological findings, such as maternal and fetal vascular malperfusions (MVM and FVM, respectively) were introduced by the Amsterdam Placental Workshop Group Consensus Statement (APWGCS). FVM cases were classified as the partial obstruction type (global FVM) and the complete obstruction type (segmental FVM). The aim of this study was to clarify the pathological characteristics of the placenta with pregestational DM/gestational DM; GDM according to APWGCS. METHODS: We studied the placentas of 182 DM women (27 pregestational DM and 155 GDM) and control placentas of 460 women without DM during 2011-2018. We excluded cases of intrauterine fetal death or multiple pregnancies. We reviewed microscopical findings including, MVM, FVM, chorioamnionitis with the slides according to the APWGCS. RESULTS: Microscopically, the incidence of FVM was significantly higher in GDM patients than control (17% vs. 10%, p = 0.0138), but not significant in pregestational DM (11%, p = 0.7410). Segmental FVM (complete obstruction) was significantly more observed in GDM than control group (5% vs. 0.4%, p = 0.0013). Segmental FVM in GDM showed high incidence of light-for-dates infant (three of seven cases, 43%, p = 0.0288). In addition, several segmental FVM findings (villous stromal-vascular karyorrhexis and stem vessel occlusion) were frequently noted in 2 or 3 points positive of 75 g oral glucose tolerance test than 1 point positive GDM. CONCLUSION: Our placental findings suggest disorder of carbohydrate metabolism might affect the fetal vascular damage, especially complete fetal vascular obstruction.

Near-infrared photoimmunotherapy (NIR-PIT) on cholangiocarcinoma using a novel catheter device with light emitting diodes.

Near-infrared photoimmunotherapy (NIR-PIT) is a novel therapy for cancers that uses NIR light and antibody-photosensitizer (IR700) conjugates. However, it is difficult to deliver NIR light into the bile duct for cholangiocarcinoma (CCA) from the conventional extracorporeal apparatus. Thus, in this study, we developed a dedicated catheter with light emitting diodes (LEDs) that supersedes conventional external irradiation devices; we investigated the therapeutic effect of NIR-PIT for CCA using the novel catheter. The new catheter was designed to be placed in the bile duct and a temperature sensor was attached to the tip of the catheter to avoid thermal burn. An anti-epidermal growth factor receptor (EGFR) antibody, Panitumumab-IR700 conjugate or anti-human epidermal growth factor receptor type 2 (HER2) antibody, Trastuzumab-IR700 conjugate, was used with EGFR- or HER2-expressing cell lines, respectively. The in vitro efficacy of NIR-PIT was confirmed in cultured cells; the capability of the new catheter for NIR-PIT was then tested in a mouse tumor model. NIR-PIT via the developed catheter treated CCA xenografts in mice. NIR-PIT had an effect in Panitumumab-IR700 conjugate- and Trastuzumab-IR700 conjugate-treated CCA cells that depended on the receptor expression level. Tumor growth was significantly suppressed in mice treated with NIR-PIT using the novel catheter compared with controls (P < .01). NIR-PIT was an effective treatment for EGFR- and HER2-expressing CCA cells, and the novel catheter with mounted LEDs was useful for NIR-PIT of CCA.

A case of facial cellulitis caused by group B streptococcus in an extremely low birthweight infant.

Group B streptococcus (GBS) is an important pathogen that causes neonatal sepsis and meningitis, which have high mortality and morbidity. Cellulitis is a rare presentation of late-onset neonatal GBS infection. We report the case of an extremely low birthweight infant with facial cellulitis caused by late-onset GBS infection. A 590-g male neonate was delivered by Cesarean section at 23 gestational weeks due to intrauterine GBS infection. Although he was effectively treated with 2 weeks of antimicrobial therapy for early-onset GBS sepsis, he subsequently developed facial and submandibular cellulitis caused by GBS at 44 days of age. He was treated with debridement and antibiotic therapy, and after 2 months his facial involvement had improved, but cosmetic issues remained. Neonatal GBS infection requires a prompt sepsis workup followed by the initiation of empiric antibiotic therapy. Additionally, lifesaving surgical debridement is sometimes necessary for cellulitis, even in premature infants.

Intrapartum fetal heart rate patterns and perinatal outcome in chorioamnionitis at or beyond 34 weeks of gestation.

AIM: To investigate intrapartum fetal heart rate (FHR) patterns in women with chorioamnionitis at or beyond 34 weeks of gestation in relation to neonatal outcome and to compare clinical and subclinical chorioamnionitis. METHODS: A retrospective questionnaire survey on deliveries during 2015 was conducted by the Perinatology Committee of the Japan Society of Obstetrics and Gynecology from 2016 to 2018. A total of 498 singleton births complicated by chorioamnionitis delivered at ≥34 weeks of gestation without major congenital malformations were included. The subjects were divided into clinical and subclinical chorioamnionitis groups based on Lencki's criteria. Poor perinatal outcome was defined as death or brain damage. We analyzed clinical features, FHR patterns in the last 2 h before delivery, gestational age, birthweight, Apgar score, umbilical arterial blood gas analysis, and infant's outcome. RESULTS: Incidence of chorioamnionitis at ≥34 weeks of gestation was 0.59% (522/87827). Clinical and subclinical chorioamnionitis comprised 240 and 258 cases, respectively. Abnormal FHR patterns (late deceleration or decreased baseline variability) were significantly associated with poor perinatal outcome. Combined late deceleration and decreased variability showed low positive predictive value (12.8%) and high negative predictive value (99.5%), and was significantly associated with long-term poor outcome in clinical chorioamnionitis only (odds ratio: 29.4, p < 0.01). Poor perinatal outcome showed no significant difference between the clinical and subclinical chorioamnionitis groups. CONCLUSIONS: Combined late deceleration and decreased variability could predict poor perinatal outcome in clinical chorioamnionitis. Poor perinatal outcome occurred in infants born to mothers with clinical and subclinical chorioamnionitis.

Domain structures of mucosa-associated lymphoid tissue lymphoma translocation 1 protein for nuclear localization in oral carcinoma cells and the proliferation inhibition.

Mucosa-associated lymphoid tissue lymphoma translocation 1 protein (MALT1) consisting of death domain, Ig-like domains and caspase-like domain is expressed in nucleus of oral carcinoma cells, and loss of the expression closely associates with disease progression and stimulates proliferation of the cells. However, nothing is known about the molecular backgrounds. In this study, eight constructs with different domain constitution of human MALT1 and six constructs were transiently and stably transfected into oral carcinoma cell lines, respectively. The immunoblot analysis showed that constructs containing caspase-like domain was expressed in nucleus and the domain-deleted constructs in cytoplasm. Immunocytochemistry of stably transfected HSC2 oral carcinoma cells confirmed the caspase-like domain-dependent nuclear localization. Involvement of domains in proliferation of stably transfected HSC2 cells was quantified by the real-time and conventional colorimetric assays. In contrast to suppression of the proliferation by full-length wild-type MALT1, any domain-deleted constructs enhanced the proliferation. Death domain construct without caspase-like domain suppressed the proliferation when it was localized in nucleus by ligating with the nuclear localization signal. These results demonstrate that nuclear localization of MALT1 in oral carcinoma cells depends on the presence of caspase-like domain and that death domain nuclear entity is responsible for MALT1 inhibition of oral carcinoma cell proliferation. Nuclear localization of death domain led by caspase-like domain may suppress oral carcinoma progression.

Characteristics and influence of Mycoplasma/Ureaplasma cultures in amniotic fluid on perinatal outcomes.

AIM: To investigate the effects of Mycoplasma/Ureaplasma cultured in amniotic fluid on perinatal characteristics in preterm delivery between 22 and 33 weeks of gestation. METHODS: The study was conducted in a tertiary perinatal center and involved 38 pregnant women who had undergone amniocentesis to evaluate intrauterine infection due to preterm labor or premature rupture of membranes. The subjects were divided into three groups based on the culture results: negative (Negative Group, n = 24), positive for Mycoplasma/Ureaplasma (M/U Group, n = 6), and positive for other pathogens (Other Pathogens Group, n = 8). One-way analysis of variance was used to compare the three groups. RESULTS: The incidence of histological chorioamnionitis and neonatal sepsis was significantly different among the three groups (the Negative Group and the Other Pathogens Group, P < 0.01; the M/U Group and the Other Pathogens Group, P = 0.03). In the M/U Group, no infants had sepsis, severe intraventricular hemorrhage, cystic periventricular leukomalacia, or poor neurological outcomes, but one infant developed bronchopulmonary dysplasia and needed home oxygen treatment. Although one died of gastrorrhexis, the remaining five patients had normal brain magnetic resonance imaging findings and developed normally. CONCLUSION: The presence of Mycoplasma/Ureaplasma isolated from amniotic fluid did not cause neonatal sepsis or poor prognosis. In some infants, there was no histological chorioamnionitis in the placenta. These pathogens thus seem to be less invasive than any other microbes with respect to perinatal outcomes.

Hmga2 regulation of tooth formation and association with Sox2 and Nanog expression.

Tooth formation is accomplished under strict genetic programs. Although patients with chromosome 12q14 aberration shows tooth phenotype including the size and eruption timing with bone growth anomaly, its etiology is uncertain. Here, we examined expression of Hmga2, which is encoded at chromosome 12q14, in mouse tooth germs and analyzed the involvement in lower first molar (M1) and mandibular bone development. Hmga2 expression was immunohistochemically detected at enamel organ and the surrounding mesenchyme of the M1 germs. The expression was dynamically changed with gestation and rapidly decreased in postnatal mice. In Hmga2-/- mice, the M1 germs and crowns were diminished in size, and formation and eruption of molars were delayed with mandibular bone growth retardation. Hmga2 cDNA or siRNA transfection showed that Hmga2 transcriptionally up-regulates expression of stem cell factors, Sox2 and Nanog. They were co-localized with Hmga2 in the germs, but differentially distributed at enamel organ and mesenchyme in Hmga2-/- mice. These results demonstrate that Hmga2 expressed in tooth germs regulates the growth, sizing and eruption and stem cell factor expression in different compartment of the germ and associates with mandibular bone growth. Although future studies are needed, the present study demonstrates HMGA2 regulation of tooth genesis with skeletal development.

Oral diatrizoate acid for meconium-related ileus in extremely preterm infants.

BACKGROUND: Intestinal disorders are common in very low-birthweight infants. The purpose of this study was to evaluate the impact of prophylactic oral Gastrografin® (diatrizoate acid) on meconium-related ileus (MRI) in extremely preterm infants. METHODS: This was a retrospective case-control study of infants born extremely preterm at <28 weeks of gestation and treated with diatrizoate acid (prophylactic group) or not (control group) in the periods 2007-2014 and 2000-2009, respectively. In the 2007-2014 period, 120 infants received prophylactic diatrizoate acid solution. From the 165 infants in the control group, we selected 120 infants matched for gestational age. Cases of death before 72 h of life or congenital abnormalities were excluded. Intestinal disorders, time until full enteral feeding, duration of hospital stay, mortality rate, and neurodevelopmental outcome were compared. RESULTS: MRI occurred in six infants in the control group and in none of the infants in the prophylactic group (P = 0.039). Median time until full enteral feeding was 25 versus 22 days (P < 0.01), hospital stay was 142 versus 126 days (P < 0.01), and mortality rate for infants aged 24-27 weeks was 8.2% versus 0% (P = 0.021), respectively. CONCLUSIONS: Prophylactic oral diatrizoate acid reduced MRI in extremely preterm infants without side-effects and decreased the mortality rate of infants born at 24-27 weeks, and is thus beneficial in extremely preterm infants.

Antithrombin improves the maternal and neonatal outcomes but not the angiogenic factors in extremely growth-restricted fetuses at <28 weeks of gestation.

AIMS: Severe preterm fetal growth restriction (FGR) remote from term is problematic. We aimed to investigate the effect of maternally-administered antithrombin on maternal and neonatal outcomes. A prospective, one-arm, pilot study was performed in 14 women with severe FGR (≤5th centile) at <28 weeks of gestation, without hypertensive disorders. Maternal plasma concentrations of soluble Feline McDonough Sarcoma (FMS)-like trypsin kinase-1 (sFlt-1) and placental growth factor (PlGF) were measured and categorized into three groups: group 1; low sFlt-1 and high PlGF, group 2; moderate sFlt-1 and low PlGF, and group 3; high sFlt-1 and low PlGF. Antithrombin was administered for 3 days. The incidence of perinatal mortality, infant morbidity, and the period of pregnancy prolongation were compared. RESULTS: In group 1 (n=4), their pregnancies were extended for longer periods and the maternal and infant outcomes were good. The prolongation periods were shorter in groups 2 (n=3) and 3 (n=7), which resulted in poor maternal [severe preeclampsia or hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome] and infant outcomes. CONCLUSIONS: The evaluation of the maternal sFlt-1 and PlGF at 21-27 weeks of gestation is useful in the managements of severe FGR. Antithrombin treatment could prolong the pregnancies with low sFlt-1 and high PlGF without negatively affecting maternal or fetal health.

Fetal left ventricular non-compaction cardiomyopathy with ascites: A case report.

Here we report a case of fetal left ventricular non-compaction cardiomyopathy with ascites and cardiac dysfunction at a gestational age of 34+5  weeks. Laboratory tests did not reveal any sign of viral infection in utero. A female neonate weighing 2436 g was delivered by emergency cesarean section due to non-reassuring fetal status. Postnatal echocardiography confirmed left ventricular non-compaction cardiomyopathy with severe cardiac failure. Although she was treated effectively during the acute period by continuous flow peritoneal dialysis, surgical ligation of a patent ductus arteriosus, and inhaled nitric oxide, she died on day 41 of life. Symptoms of severe cardiac dysfunction appeared antenatally in this patient and the outcome was poor.

Preterm labor and neonatal sepsis caused by intrauterine Helicobacter cinaedi infection.

Helicobacter cinaedi is a rare pathogen but known to cause bacteremia, cellulitis and enterocolitis. Recently, cases of involving various organs are increasingly reported such as endocarditis, meningitis, and kidney cyst infection. We report a case of intrauterine H. cinaedi infection leading preterm birth and neonatal sepsis. A 29-year-old pregnant women who was no underlying disease hospitalized due to threatened preterm labor at 22 weeks of gestation. Clinical findings showed uterine tenderness, fever, leukocytosis and elevated C-reactive protein. H. cinaedi was isolated from amniotic fluid obtained by transabdominal amniocentesis. We diagnosed as intrauterine H. cinaedi infection and administered intravenous ampicillin followed by oxytocin to terminate pregnancy. A live 446 g male infant was delivered. The patient was no signs of infection throughout postpartum course and discharged on post-delivery day 5. The neonate was admitted in neonatal intensive care unit and administered ampicillin and amikacin. H. cinaedi was isolated from umbilical cord blood culture. He has no signs of infection on day 5 but died from uncontrollable hyperglycemia and ketoacidosis on 15 days of age. H. cinaedi can cause intrauterine infection during pregnancy and lead preterm labor and neonatal sepsis.

Intrapartum fetal heart rate patterns preceding terminal bradycardia in infants (>34 weeks) with poor neurological outcome: A regional population-based study in Japan.

AIM: Intrapartum fetal bradycardia necessitates immediate operative delivery. Our aim was to investigate the hypothesis that some non-reassuring fetal heart rate (FHR) patterns were present before the onset of terminal bradycardia in infants who developed subsequent brain damage. MATERIAL AND METHODS: From a population-based study of 65,197 deliveries, 190 stillbirths, 115 neonatal deaths, and 136 neurologically high-risk infants were registered by the Miyazaki Perinatal Conference. There were 15 cases of neurologically high-risk infants born at >34 weeks of gestation exhibiting intrapartum terminal bradycardia. Focusing on the brain-damaged infants, we retrospectively analyzed FHR patterns for at least 1 h prior to the bradycardia. RESULTS: Brain damage (cerebral palsy [n = 11] and mental retardation [n = 2]) was diagnosed at 2 years old in 13 out of 15 neurologically high-risk infants. Two infants had bradycardia on admission. In the remaining 11 infants, FHR patterns were reassuring in six (55%) and non-reassuring in five (45%), including late decelerations (n = 4) and variable decelerations (n = 2). Clinically relevant factors in the non-reassuring group included intrauterine infection (n = 3), malpresentation with umbilical cord coiling (n = 1), and unknown causes (n = 1). Clinically relevant features in the reassuring group included cord prolapse (n = 1), vaginal breech delivery (n = 1), shoulder dystocia (n = 1), rupture of membranes (n = 1), and unknown causes (n = 2). CONCLUSION: More than half of the brain-damaged infants born at >34 weeks of gestation who exhibited intrapartum terminal bradycardia had unremarkable FHR patterns before abrupt-onset bradycardia. For those with non-reassuring patterns preceding bradycardia, intrauterine infection was the major sentinel event.

Did antepartum hypoxic insult caused by fetal vessel thrombosis influence the procalcitonin level in umbilical blood? A case report.

We report a case of marked elevation of the procalcitonin level in umbilical blood and neonatal blood at birth. The mother did not perceive fetal motion. Antepartum fetal heart rate monitoring showed a loss of variability and absence of acceleration. No fetal breathing movement, fetal movement, or fetal tone were observed by ultrasonography. The female neonate was delivered by cesarean section at 25 weeks of gestation, with birthweight 774 g. The umbilical arterial pH value at birth was 7.29. Mild elevation in interleukin-6 and tumor necrosis factor-α in umbilical blood were observed. Cytochrome c showed a high level in umbilical and neonatal blood at birth. Placental histopathology revealed multiple fetal vessel thrombosis in the large stem villi and chorionic vessels. The neonate showed no infectious signs throughout the neonatal period. Computed tomography at 3 months of age revealed atrophy in the cerebrum and cerebellum. At 1 year after birth, the infant showed spastic quadriplegia. In this case, antepartum asphyxia due to fetal vessel thrombosis may have influenced the elevation of procalcitonin level in umbilical blood and neonatal blood at birth.

Prospective study of the MD-twin score for antepartum evaluation of monochorionic diamniotic twins and its correlation with perinatal outcomes.

AIM: To assess the outcome of monochorionic diamniotic (MD) twins with the aid of the MD-twin score. METHODS: We enrolled 112 MD-twin women in a tertiary perinatal center from 1997 to 2009. The MD-twin score was prospectively applied once per week to women who did not have twin-to-twin transfusion syndrome (TTTS) after 26 weeks of gestation. The MD-twin score consists of five variables: (i) fetal weight discordance; (ii) amniotic fluid discordance; (iii) hydrops fetalis; (iv) umbilical cord insertion; and (v) fetal heart rate monitoring. Normal was assigned a value of 0, abnormal was assigned 1, and total score was used for evaluation. Women with scores of 2 at 26 weeks gestation were managed expectantly until the score reached 3. Outcome measures were fetal death, neonatal death and neurological sequelae. The incidence of poor outcome according to score was investigated. The characteristics of MD twins with poor outcome were investigated. RESULTS: MD-twin scores were applied to 90 women. Among them, 79 had scores of 2 or less and all had good outcomes. There were 11 women with a score of 3, four of whom had adverse outcome for at least one twin. Neonates born to women with scores of 0-2 had good outcomes without respect to birthweight percentile, while neonates with scores of 3 had poor outcomes when their birthweight percentile was less than the third percentile. CONCLUSION: The MD-twin score is applicable to 90% of MD twins without TTTS. An MD-twin score of 2 is reassuring, while a score of 3 indicates increased risks for adverse outcome.