Neurodevelopmental outcome in twin anemia-polycythemia sequence after laser surgery for twin-twin transfusion syndrome

OBJECTIVE

To evaluate the long-term neurodevelopmental outcome in children who developed twin anemia-polycythemia sequence (TAPS) after fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS).

METHODS

Neurological, motor and cognitive development was assessed in a consecutive cohort of TTTS survivors treated with laser surgery between 2004 and 2011 and complicated by post-laser TAPS. Primary outcome was neurodevelopmental impairment, a composite outcome including any of the following: cerebral palsy, bilateral deafness, blindness, severe motor and/or cognitive developmental delay (>2 SD below the mean). A risk analysis on cognitive outcome was performed.

RESULTS

During the study period, 33/306 (11%) monochorionic twin pairs developed TAPS after laser surgery for TTTS. Survival was 53/66 (80%). Long-term outcome was assessed in 47/53 (89%) children. The incidence of neurodevelopmental impairment was 4/47 (9%), occurring in one donor (1/20; 5%) and three recipients (3/27; 11%) (P=0.63). Mild-to-moderate cognitive delay, i.e. scores below 85, was detected in 8/47 (17%) children. Risk factors for low cognitive scores were low gestational age at birth (P=0.02) and low birth weight (P<0.01). The lowest cognitive scores were detected in the subgroup of TAPS survivors treated with intrauterine transfusion (median score, 82.5).

CONCLUSIONS

Neurodevelopmental impairment and cognitive delay were found in almost one in five children surviving post-laser TAPS. Better treatment and, ideally, prevention of this complication after laser treatment for TTTS is urgently needed.

Laser surgery as a management option for twin anemia-polycythemia sequence

OBJECTIVE

To evaluate the effectiveness of laser treatment for antenatally detected twin anemia-polycythemia sequence (TAPS) compared with intrauterine transfusion or expectant management.

METHODS

All monochorionic twin pregnancies with TAPS managed between 2005 and 2013 in two European fetal therapy centers were evaluated. The outcomes of TAPS cases treated primarily with laser surgery were compared with the outcomes of cases managed expectantly or treated with intrauterine transfusion.

RESULTS

In this retrospective study 52 cases of TAPS were detected antenatally and were managed with either laser surgery (n=8; 15%) or intrauterine blood transfusion (n=17; 33%) or expectantly (n=27; 52%). Perinatal survival in the laser group was 94% (15/16) vs 85% (29/34) in the intrauterine-transfusion group and 83% (45/54) in the expectant-management group (P=0.30). The rates of severe neonatal morbidity in liveborn neonates in the laser, intrauterine-transfusion and expectant-management groups were 7% (1/15), 38% (12/32) and 24% (12/50), respectively (P=0.17). There was a significant reduction in respiratory distress syndrome in cases treated by laser. No severe postnatal hematological complications were detected in the laser group compared with 72% (23/32) in the intrauterine-transfusion group and 52% (26/50) in the expectant-management group (P<0.01). Median time between diagnosis and birth was 11 weeks in the laser group compared to 5 weeks after intrauterine transfusion and 8 weeks after expectant management (P<0.01). After injection of colored dye no residual anastomoses were found in the laser group.

CONCLUSIONS

Laser surgery for TAPS appears to improve perinatal outcome by prolonging pregnancy and reducing respiratory distress syndrome. Larger, adequately controlled studies are needed to reach firm conclusions on the optimal management of TAPS.

The risk for hyperoxaemia after apnoea, bradycardia and hypoxaemia in preterm infants

OBJECTIVE

To investigate the occurrence and duration of oxygen saturation (SpO₂) ≥95%, after extra oxygen for apnoea, bradycardia, cyanosis (ABC), and the relation with the duration of bradycardia and/or SpO₂ ≤80%.

METHODS

All preterm infants <32 weeks' gestation supported with nasal continuous positive airway pressure (nCPAP) admitted to our centre were eligible for the study. We retrospectively identified all episodes of ABCs. In ABCs where oxygen supply was increased, duration and severity of bradycardia (<80 bpm), SpO₂ ≤80%, SpO₂ ≥95% and their correlation were investigated.

RESULTS

In 56 infants, 257 ABCs occurred where oxygen supply was increased. SpO₂ ≥95% occurred after 79% (202/257) of the ABCs, duration of extra oxygen supply was longer in ABCs with SpO₂ ≥95% than without SpO₂ ≥95% (median (IQR) 20 (8-80) vs 2 (2-3) min; p<0.001)). The duration of SpO₂ ≥95% was longer than bradycardia and SpO₂ ≤80% (median (IQR) 13 (4-30) vs 1 (1-1) vs 2 (1-2) min; p<0.001). SpO₂ ≥95% lasted longer when infants were in ambient air than when oxygen was given before the ABC occurred (median (IQR)15 (5-38) min vs 6 (3-24) min; p<0.01).

CONCLUSIONS

In preterm infants supported with nCPAP in the neonatal intensive care unit (NICU), SpO₂ ≥95% frequently occurred when oxygen was increased for ABCs and lasted longer than the bradycardia and SpO₂ ≤80%.

Early-onset thrombocytopenia in near-term and term infants with perinatal asphyxia

BACKGROUND

Neonates after perinatal asphyxia are at increased risk of thrombocytopenia. The correlation between perinatal asphyxia and the risk and severity of early-onset thrombocytopenia is not well known.

OBJECTIVE

To estimate the incidence, severity and risk factors for early-onset thrombocytopenia in neonates after perinatal asphyxia.

METHODS

We included all newborns (gestational age ≥ 36 weeks) admitted to our neonatal nursery due to perinatal asphyxia in this retrospective study. We collected platelet counts that were obtained within the first 48 h of life to estimate the incidence and severity of early-onset thrombocytopenia.

RESULTS

A total number of 171 neonates with perinatal asphyxia were included in the study. The incidence of early-onset thrombocytopenia (platelet count < 150 × 109/l) was 51% (87/171). Several factors were associated with increased risk of early-onset thrombocytopenia, including prolonged prothrombin time (PT) [odds ratio (OR) 1·18, 95% confidence interval (CI) 1·08–1·30, P < 0·01], prolonged activated partial thromboplastin time (APTT) (OR 1·07, 95% CI 1·03–1·11, P < 0·01), low Apgar score at 10 min (OR 1·25, 95% CI 1·08–1·45, P < 0·01) and high serum lactate (OR 1·12, 95% CI 1·06–1·19, P < 0·01). After multiple logistic regression analysis, we found an independent association between early-onset thrombocytopenia and prolonged PT (OR 1·15, 95% CI 1·00–1·33, P = 0·045) and higher lactate level (OR 1·15, 95% CI 1·03–1·28, P = 0·01).

CONCLUSIONS

Early-onset thrombocytopenia occurs frequently in neonates after perinatal asphyxia and is independently associated with PT and lactate level.

Perinatal asphyxia in monochorionic versus dichorionic twins: incidence, risk factors and outcome

OBJECTIVE

To estimate the incidence, risk factors, severity and outcome after perinatal asphyxia in monochorionic (MC) versus dichorionic (DC) twins.

METHODS

We included all consecutive near-term MC and DC twins with perinatal asphyxia admitted to our neonatal ward between 2004 and 2013 and compared the perinatal characteristics and neonatal outcome between both groups.

RESULTS

The incidence of perinatal asphyxia in MC and DC twin infants was 4.0 (11/272) and 4.0% (8/200; p = 1.00). In contrast to DC twins, asphyxia in MC twins was strongly associated with acute exsanguination and anemia at birth; 64% (7/11) in MC twins and 0% (0/8) in DC twins (p < 0.01). Median hemoglobin level at birth in the MC and DC groups was 11.5 and 18.6 g/dl, respectively (p < 0.01).

CONCLUSIONS

Perinatal asphyxia in MC twins is often associated with severe anemia at birth due to acute hemorrhage through the placental vascular anastomoses.

Perinatal outcome after selective feticide in monochorionic twin pregnancies

OBJECTIVE

To evaluate the incidence and risk factors of adverse perinatal outcome in complicated monochorionic twin pregnancies treated with selective feticide.

METHODS

This was a retrospective analysis of prospectively collected data from a consecutive, national cohort. All monochorionic twin pregnancies treated with selective feticide at Leiden University Medical Center between June 2000 and November 2011 were included. Obstetric and neonatal data were recorded. The primary outcome measure was adverse perinatal outcome, including fetal or neonatal demise or severe neonatal morbidity.

RESULTS

Data on perinatal outcome were obtained in all cases (n = 131). Overall perinatal survival rate was 67.2% (88/131). Median gestational age at delivery was 34 (interquartile range, 23-38) weeks. Neonatal mortality and morbidity rate in liveborn children was 4.3% (4/92) and 12.0 % (11/92), respectively. Severe cerebral injury was detected in three children. The overall incidence of adverse perinatal outcome was 41.2% (54/131). Median gestational age at occurrence of preterm prelabor rupture of membranes (PPROM) was 19.0 weeks and 32.0 weeks in cases with and without adverse perinatal outcome, respectively (P = 0.017). Liveborn children with adverse perinatal outcome were born at a lower median gestational age (29.0 weeks) than were children without adverse perinatal outcome (38.0 weeks) (P < 0.001).

CONCLUSIONS

The risk of adverse perinatal outcome after selective feticide is high and associated with low gestational age at occurrence of PPROM and low gestational age at delivery. Long-term follow-up to assess neurodevelopmental outcome in survivors is required.

Severe cerebral injury in a recipient with twin anemia-polycythemia sequence

Twin anemia-polycythemia sequence (TAPS) results from slow intertwin blood transfusion through minuscule placental vascular anastomoses and is characterized by large intertwin hemoglobin differences in the absence of amniotic fluid discordance. The optimal management of TAPS is not clear. We report a case of TAPS detected antenatally by Doppler ultrasound examination at 15 + 6 weeks' gestation. After counseling, the parents opted for expectant management. Regular Doppler measurements were performed and these remained fairly stable. An emergency Cesarean section was performed at 34 + 5 weeks following signs of fetal distress. The donor twin was severely anemic while the recipient twin had severe polycythemia-hyperviscosity syndrome. On day 1, the recipient developed respiratory insufficiency and subclinical status epilepticus. Magnetic resonance imaging showed a total loss of gray-white matter differentiation as a sign of severe diffuse cerebral ischemia and bilateral intra- and extra-axial hemorrhages. There was almost complete lack of arterial and venous cerebral blood flow. On day 3 intensive care treatment was withdrawn in view of the severity of the brain injury. This case report demonstrates that TAPS may lead to severe cerebral injury and fatal outcome in the recipient twin, and highlights the importance of antenatal Doppler ultrasound monitoring and choice of management.

Changes in respiratory support of preterm infants in the last decade: are we improving?

BACKGROUND

Ventilator-induced lung injury has been recognized as a major contributing factor for bronchopulmonary dysplasia (BPD) in preterm infants. In the last decade, focus has shifted towards a more gentle respiratory approach.

AIM

To evaluate whether guideline changes in respiratory management in the delivery room and the unit improved the incidence of BPD in very preterm infants.

METHODS

Three cohorts of infants <30 weeks of gestation, born at the Leiden University Medical Center in the Netherlands in 1996-1997 (cohort '96), 2003-2004 (cohort '03) and 2008-2009 (cohort '08), were compared retrospectively. The major change was increasing use of continuous positive airway pressure in time, and monitoring the tidal volume during mechanical ventilation in cohort '08. The primary outcome was BPD at 36 weeks.

RESULTS

The incidence of BPD did not change from 47% in cohort '96 to 55% in cohort '03 (n.s.), but decreased significantly to 37% in cohort '08 (cohort '96 vs. '08 and cohort '03 vs. '08: p < 0.01). We observed the same effect when only moderate and severe BPD were counted with 27% in cohort '96, 31% in cohort '03 and 14% in '08 (cohort '96 vs. '03: p = n.s., cohort '96 vs. '08: p < 0.01, cohort '03 vs. '08: p < 0.05). The mortality rate was not significantly different between the three cohorts.

CONCLUSION

The incidence of BPD in our cohort of preterm infants has decreased during the last decade and could be due to the changes in respiratory management.

Perinatal mortality and mode of delivery in monochorionic diamniotic twin pregnancies ≥ 32 weeks of gestation: a multicentre retrospective cohort study

OBJECTIVE

To study perinatal mortality rates in a cohort of 465 monochorionic (MC) twins without twin-twin transfusion syndrome (TTS) born at 32 weeks of gestation or later since reported interauterine fetal death (IUFD) rates >32 weeks of gestations in the literature vary, leading to varying recommendations on the optimal timing of delivery, and to investigate the relation between perinatal mortality and mode of delivery.

DESIGN

Multicentre retrospective cohort study.

SETTING

Ten perinatal referral centres in the Netherlands.

POPULATION

All MC twin pregnancies without TTTS delivered at ≥ 32 weeks of gestation between January 2000 and December 2005.

METHODS

The medical records of all MC twin pregnancies without TTTS delivered at the ten perinatal referral centres in the Netherlands between January 2000 and December 2005 were reviewed.

MAIN OUTCOME MEASURES

Perinatal mortality in relation to gestational age and mode of delivery at ≥ 32 weeks of gestation.

RESULTS

After 32 weeks of gestation, five out of 930 fetuses died in utero and there were six neonatal deaths (6 per 1000 infants). In women who delivered ≥ 37 weeks, perinatal mortality was 7 per 1000 infants. Trial of labour was attempted in 376 women and was successful in 77%. There were three deaths in deliveries with a trial of labour (8 per 1000 deliveries), of which two were related to mode of delivery. Infants born by caesarean section without labour had an increased risk of neonatal morbidity and respiratory distress syndrome.

CONCLUSIONS

In MC twin pregnancies the incidence of intrauterine fetal death is low ≥ 32 weeks of gestation. Therefore, planned preterm delivery before 36 weeks does not seem to be justified. The risk of intrapartum death is also low, at least in tertiary centres.