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Jha P, Morgan TA, Kennedy A. US Evaluation of Twin Pregnancies: Importance of Chorionicity and Amnionicity. Radiographics 2020; 39:2146-2166. [PMID: 31697621 DOI: 10.1148/rg.2019190042] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The twin birth rate is increasing in the United States. Twin pregnancies can be dichorionic or monochorionic (MC). MC twins account for 20% of twin pregnancies but 30% of all-cause pregnancy-related complications. This article describes the imaging findings that establish chorionicity and amnionicity. Ideally, these are established in the first trimester when accuracy is high, but they can also be determined later in pregnancy. Complications unique to MC twin pregnancy include twin-twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion sequence, and selective fetal growth restriction. The US features, staging systems, and management of these complications are reviewed, and the consequences of MC twin demise are illustrated. Ongoing surveillance for these conditions starts at 16 weeks gestation. Monoamniotic (MA) twins are a small subset of MC twins. In addition to all of the MC complications, specific MA complications include cord entanglement and conjoined twinning. Radiologists must be able to determine chorionicity and amnionicity and should be aware of potential complications so that patients may be referred to appropriate regional specialized centers. A proposed algorithm for referral to specialized fetal treatment centers is outlined. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Tara A Morgan
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Anne Kennedy
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
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Yang J, Wei Y, Qi H, Yin N, Yang Y, Li Z, Xu L, Wang X, Yuan P, Li L, Han TL, Zhao Y. Neonatal hair profiling reveals a metabolic phenotype of monochorionic twins with selective intrauterine growth restriction and abnormal umbilical artery flow. Mol Med 2020; 26:37. [PMID: 32357834 PMCID: PMC7193362 DOI: 10.1186/s10020-020-00160-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/20/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Selective intrauterine fetal growth restriction (sIUGR) in monochorionic diamniotic twins, especially types 2&3 with abnormal umbilical artery Doppler, results in increased risk of fetal/perinatal mortality and postnatal disability. We investigate whether the hair metabolome profiles of neonates were associated with the pathophysiological differences across the different clinical forms of sIUGR in twins. METHODS Hair samples were collected at delivery from 10 pairs of type 1 sIUGR twins, 8 pairs of types 2&3 sIUGR twins, and 11 pairs of twins without sIUGR. The hair metabolome was characterized using gas chromatography-mass spectrometry. RESULTS Our results demonstrated that the hair metabolite profiles of the different sIUGR subclinical forms were associated with the averaged fetal growth rate after 28 weeks of gestation but not with birthweight. The hair profiles were capable of discriminating type2&3 sIUGR twins from twins without sIUGR. In particular, the metabolites 2-aminobutyric acid, cysteine, alanine, and tyrosine all displayed areas under the receiver operating characteristic curve were above 0.9. The metabolic pathway analysis highlighted the associations of sIUGR twins with abnormal umbilical artery flow with increased metabolites from a nutrient depletion pathway, glutathione metabolism, and nerve development. CONCLUSION This study offers novel insight into the severity of intrauterine ischemia and hypoxia for T2&3 sIUGR twins, through evaluation of the neonatal hair metabolome.
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Affiliation(s)
- Jing Yang
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China
| | - Yuan Wei
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China
| | - Hongbo Qi
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China.,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China
| | - Nanlin Yin
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China
| | - Yang Yang
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China.,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China
| | - Zailing Li
- Department of Pediatrics, Peking University Third Hospital, Beijing, 100191, China
| | - Lili Xu
- Department of Pediatrics, Peking University Third Hospital, Beijing, 100191, China
| | - Xueju Wang
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China
| | - Pengbo Yuan
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China
| | - Luyao Li
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China
| | - Ting-Li Han
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China. .,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400716, China. .,Liggins Institute, University of Auckland, Auckland, 1142, New Zealand.
| | - Yangyu Zhao
- Department of Obstetrics & Gynecology, Peking University Third Hospital, No.49 North HuaYuan Road, HaiDian District, Beijing, 100191, China.
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Li M, Wang C, Yang Y, Mao L, Chen J, He S, Gou C, Zhang X. Characteristics of vascular anastomoses in monochorionic twin 587 placentas with selective intrauterine growth restriction via 89 three-dimensional computed tomography angiography. Prenat Diagn 2020; 40:715-723. [PMID: 32092161 DOI: 10.1002/pd.5672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 11/22/2019] [Accepted: 02/11/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the characteristics of the choriovascular anatomy, especially the potential role of arteriovenous perfusion imbalance in the pathogenesis of selective intrauterine growth restriction (sIUGR) using three-dimensional computed tomography angiography (3D-CTA). METHOD Computed tomography angiography of the placental choriovascular tree from 15 twins with sIUGR and 15 twins without sIUGR were analyzed, and inter-twin vascular anastomoses were compared between the placentas from these two groups. The parameters evaluated were the presence and measures of artery-to-artery anastomoses (AAA), vein-to-vein anastomoses (VVA) or artery-to-vein anastomoses (AVA). RESULTS The frequency of AAA, VVA, and AVA did not differ significantly between sIUGR and without sIUGR-pairs. The area of the vein draining to the AVA in the larger twin's placenta was significantly greater in sIUGR compared to when no sIUGR was present. Based on the net cross-sectional area difference we speculate that in sIUGR there is net flow from the smaller to the larger twin. CONCLUSION We used 3D-CTA to display the vascular anastomoses in sIUGR twin pairs, demonstrating a difference in cross-sectional diameter of the vein draining to the AVA.
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Affiliation(s)
- Meizhi Li
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Chaoyang Wang
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Yanhong Yang
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Lijuan Mao
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Jiawen Chen
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Shaofu He
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Chenyu Gou
- Department of Obstetrics, Sixth Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
| | - Xiaoling Zhang
- Department of Radiology, First Affiliated Hospital of Sun-yat Sen University, Guangzhou, People's Republic of China
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Purnell ME, Chon AH, Korst LM, Llanes A, Grubbs BH, Chmait RH. Percent Absent End-Diastolic Velocity in the Umbilical Artery and Donor Twin Demise after Laser Surgery for Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2020; 47:572-579. [PMID: 32023611 DOI: 10.1159/000505780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 01/07/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION To examine the association of preoperative absent end-diastolic velocity (AEDV) and percent AEDV (%AEDV) in the umbilical artery (UA) with donor twin intrauterine fetal demise (IUFD) after laser surgery for twin-twin transfusion syndrome (TTTS). METHODS We performed a retrospective study of stage III/IV TTTS patients who underwent laser surgery from 2006 to 2016. Donors were classified as having preoperative persistent AEDV (yes/no). %AEDV was calculated for those with AEDV as 100× the proportion of the total cardiac cycle in AEDV. Using multiple logistic regression, we tested for an association between the outcome donor IUFD and AEDV risk factors (part 1) and %AEDV (part 2). We stratified these analyses by estimated fetal weight (EFW) discordance ≥20 versus <20%. RESULTS Of 344 cases, 153 (44.5%) donors had AEDV. Part 1 did not confirm an independent association between AEDV and donor IUFD. In the part 2 analysis of the 153 patients with AEDV, %AEDV was a positive risk factor for donor IUFD only in those with discordance (n = 129) (OR 1.04, 95% CI 1.01-1.08, p = 0.0278) when adjusting for %EFW discordance, presence of arterioarterial anastomoses, and multiparity. DISCUSSION Among stage III/IV TTTS patients with AEDV, %AEDV was a risk factor for donor IUFD only in the presence of EFW discordance.
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Affiliation(s)
- Margaret E Purnell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Andrew H Chon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, LLC, Los Angeles, California, USA
| | - Arlyn Llanes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Brendan H Grubbs
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,
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Rotar IC, Zaharie G, Staicu A, Preda A, Mureşan D. Fetal cardiovascular alterations in twin-to-twin transfusion syndrome. Med Pharm Rep 2020; 93:5-11. [PMID: 32133441 PMCID: PMC7051825 DOI: 10.15386/mpr-1481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/15/2019] [Accepted: 12/30/2019] [Indexed: 11/23/2022] Open
Abstract
Twin-to-twin transfusion syndrome (TTTS) is the consequence of vascular anastomoses of the shared placenta of monochorionic twin pregnancies. Both circulating inter-twin blood flow and vasoactive mediators imbalance cause hypovolemia in the donor and hypervolemia in the recipient fetus. If left untreated, TTTS has a high perinatal mortality rate and adverse long-term outcomes mainly cardiovascular and neurological. The recipient has cardiovascular changes including atrioventricular valve regurgitation, diastolic dysfunction and pulmonary stenosis/atresia. The maladaptive response to vascular changes determines a constant decreased blood flow in the donor that permanently modifies the arterial structure leading to postnatal alterations in the vascular system. Fetoscopic LASER surgery of placental vascular anastomoses may disrupt the underlying pathophysiology and improves cardiovascular function with normalization of systolic and diastolic function within weeks after treatment. The impact of cardiovascular changes is relevant for the safety of the management of a TTTS case. The improvement of the perinatal survival after intrauterine surgery leads to viable infants with the longer-term sequelae. Therefore accurate quantification of cardiovascular involvement is essential for clinicians for pregnancy management but also for patient counseling about the potential treatment options the outcome.
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Affiliation(s)
- Ioana Cristina Rotar
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,1 Clinic of Obstetrics and Gynecology, Emergency County Hospital, Cluj-Napoca, Romania
| | - Gabriela Zaharie
- Neonatal Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Neonatal Department, Emergency County Hospital, Cluj-Napoca, Romania
| | - Adelina Staicu
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andreia Preda
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Daniel Mureşan
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,1 Clinic of Obstetrics and Gynecology, Emergency County Hospital, Cluj-Napoca, Romania
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Spruijt MS, Lopriore E, J Steggerda S, Slaghekke F, Van Klink JMM. Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond. Expert Rev Hematol 2020; 13:259-267. [PMID: 31971028 DOI: 10.1080/17474086.2020.1720643] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Twin-twin transfusion syndrome (TTTS) is a devastating complication of monochorionic twin pregnancy and remains a major challenge for worldwide fetal medicine specialists. In TTTS, intertwin transfusion through vascular anastomoses in the shared placenta leads to severe hemodynamic imbalance. This review summarizes the current knowledge of TTTS.Areas covered: The most recent insights concerning the management of TTTS, as well as fetal and neonatal complications are described. Relevant articles were selected based on a Pubmed search using the keywords below. Understanding of the underlying pathophysiology has improved greatly as a result of placental injection studies. Advancements in antenatal management have led to increased perinatal survival and a decreased incidence of neonatal complications, including brain injury and neurodevelopmental impairment.Expert opinion: Further opportunities for improvement comprise technological innovations in laser procedures and the prevention of preterm rupture of membranes with subsequent prematurity. A noninvasive treatment such as high-intensity focused ultrasound (HIFU) seems to hold promise for the future treatment of TTTS. Fetal MRI studies are important to improve our understanding of fetal brain injury and should relate their findings to long-term neurodevelopment. International collaboration and centralization of care are of paramount importance to ensure the best care for our patients.
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Affiliation(s)
- Marjolijn S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylke J Steggerda
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M M Van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Aughwane R, Ingram E, Johnstone ED, Salomon LJ, David AL, Melbourne A. Placental MRI and its application to fetal intervention. Prenat Diagn 2020; 40:38-48. [PMID: 31306507 PMCID: PMC7027916 DOI: 10.1002/pd.5526] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/18/2019] [Accepted: 07/08/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Magnetic resonance imaging (MRI) of placental invasion has been part of clinical practice for many years. The possibility of being better able to assess placental vascularization and function using MRI has multiple potential applications. This review summarises up-to-date research on placental function using different MRI modalities. METHOD We discuss how combinations of these MRI techniques have much to contribute to fetal conditions amenable for therapy such as singletons at high risk for fetal growth restriction (FGR) and monochorionic twin pregnancies for planning surgery and counselling for selective growth restriction and transfusion conditions. RESULTS The whole placenta can easily be visualized on MRI, with a clear boundary against the amniotic fluid, and a less clear placental-uterine boundary. Contrasts such as diffusion weighted imaging, relaxometry, blood oxygenation level dependent MRI and flow and metabolite measurement by dynamic contrast enhanced MRI, arterial spin labeling, or spectroscopic techniques are contributing to our wider understanding of placental function. CONCLUSION The future of placental MRI is exciting, with the increasing availability of multiple contrasts and new models that will boost the capability of MRI to measure oxygen saturation and placental exchange, enabling examination of placental function in complicated pregnancies.
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Affiliation(s)
| | - Emma Ingram
- Division of Developmental Biology & MedicineUniversity of ManchesterManchesterUK
| | - Edward D. Johnstone
- Division of Developmental Biology & MedicineUniversity of ManchesterManchesterUK
| | - Laurent J. Salomon
- Hôpital Necker‐Enfants Malades, AP‐HP, EHU PACT and LUMIERE PlatformUniversité Paris DescartesParisFrance
| | - Anna L. David
- Institute for Women's HealthUniversity College LondonLondonUK
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Andrew Melbourne
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Medical Physics and Biomedical EngineeringUniversity College LondonLondonUK
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Early postnatal cardiac manifestations are associated with perinatal brain injury in preterm infants with twin to twin transfusion syndrome. Sci Rep 2019; 9:18505. [PMID: 31811241 PMCID: PMC6898644 DOI: 10.1038/s41598-019-54951-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 11/12/2019] [Indexed: 11/09/2022] Open
Abstract
Altered hemodynamics associated with twin to twin transfusion syndrome (TTTS) can be manifested in the fetal and neonatal heart. This study evaluated the association between cardiac manifestations immediately after birth and brain injury in preterm infants with TTTS. Medical records of preterm infants who were born at <35 weeks of gestation with TTTS and admitted to the neonatal intensive care unit at Seoul National University Children's Hospital between January 2011 and January 2018 were reviewed. TTTS was prenatally diagnosed and staged according to the Quintero criteria. Echocardiographic findings, brain ultrasound and MRI imaging findings were analyzed. Fifty-three infants were enrolled in this study. Thirty-two infants (60.3%) were treated by fetoscopic laser coagulation. Brain injury developed in 15 infants (28.3%). Hypotension within the first week and immediate postnatal cardiac manifestations were more prevalent in the brain injury group. In the multivariate analysis, acute kidney injury and cardiac manifestations, such as ventricular dysfunction and tricuspid regurgitation, were statistically associated with brain injury in the study population. Immediate postnatal cardiac manifestations, such as ventricular dysfunction and tricuspid regurgitation, can serve as surrogate markers for perinatal hemodynamic disturbance, which are associated with early neonatal brain injury in preterm infants with TTTS.
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Walter A, Strizek B, Berg C, Geipel A, Gembruch U, Engels AC. Outcome of monochorionic twins with prenatally diagnosed bipartite placenta. Arch Gynecol Obstet 2019; 302:1549-1552. [PMID: 31768742 DOI: 10.1007/s00404-019-05364-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/25/2019] [Indexed: 12/01/2022]
Abstract
PURPOSE The objective of this study was to identify possible implications and risk factors in monochorionic (MC) twin pregnancies having a bipartite placenta. MATERIALS Between 2014 and 2019 data on such pregnancies was prospectively collected and retrospectively analyzed. Monochorionicity was confirmed either by the presence of a T-sign, one chorion and two separate amnion cavities, or by histological examination postnatally. Bipartite placenta was diagnosed when two placenta lobes were identified with no placental connection between them. Risks of bipartite placenta in MCDA twins were evaluated by background data, prenatal and postnatal outcome. RESULTS Five twin pregnancies were included in the study. 60 % (n = 3) were complicated by twin-twin-transfusion syndrome (TTTS), 20 % by selective intrauterine growth restriction (sIUGR) (n = 1) and 20 % (n = 1) by severe fetal malformations. In every case an intervention was indicated, but in only 60% (n = 3) possible, due to poor surgical conditions. Overall fetal survival rate at birth was 90 %. Neonatal survival rate was 66.63%. CONCLUSION Bipartite placenta is a very rare phenomenon in MCDA twin pregnancies. It seems to be associated with a higher rate of complications, such as TTTS and sIUGR and might induce surgical difficulties in prenatal interventions.
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Affiliation(s)
- Adeline Walter
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.,Department of Obstetrics and Prenatal Medicine, University Hospital Cologne, Kerpener Straße 34, 50931, Cologne, Germany
| | - Annegret Geipel
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Alexander C Engels
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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A Cohort Analysis of Patients with Stage I Twin-to-Twin Transfusion Syndrome from a Major Referral Hospital in Northern China. MATERNAL-FETAL MEDICINE 2019. [DOI: 10.1097/fm9.0000000000000021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Loh M, Bhatia A, Tan KL, Thia E, Yeo GSH. Outcomes following selective fetoscopic laser ablation for twin-to-twin transfusion syndrome: a single-centre experience. Singapore Med J 2019; 61:523-531. [PMID: 31489429 DOI: 10.11622/smedj.2019107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Fetoscopic laser photocoagulation (FLP), a treatment option for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies, is currently the treatment of choice at our centre. We previously reported on our experience of FLP from June 2011 to March 2014. This paper audits our fetal surgery performance since then. METHODS 15 consecutive patients who underwent FLP for Stage II-III TTTS before 26 weeks of gestation from June 2011 to January 2017 were retrospectively reviewed, consisting of five cases from our initial experience and ten subsequent cases. Perioperative, perinatal and neonatal outcomes were analysed. RESULTS Of 15 pregnancies, 10 (66.7%) and 5 (33.3%) were for Stage II and III TTTS respectively, with FLP performed at an earlier Quintero stage in the later cohort. Overall mean gestational ages at presentation, laser and delivery were comparable between the cohorts at 19.7 (15.4-24.3) weeks, 20.3 (16.3-25.0) weeks and 31.2 (27.6-37.0) weeks, respectively. 2 (13.3%) cases had intra-amniotic bleeding and 1 (6.7%) had iatrogenic septostomy. 1 (6.7%) case had persistent TTTS requiring repeat FLP, and another (6.7%) had preterm premature rupture of membranes at seven weeks post procedure. The overall perinatal survival rate was 21 (75.0%) out of 28 infants. One mother underwent termination of pregnancy for social reasons at 1.4 weeks post procedure. Double survival occurred in 8 (57.1%) out of 14 pregnancies, while 13 (92.9%) had at least one survivor. CONCLUSION FLP requires a highly specialised team and tertiary neonatal facility. Continual training improves maternal and perinatal outcomes, ensuring comparable standards with international centres.
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Affiliation(s)
- Michelle Loh
- Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
| | - Anju Bhatia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Kai Lit Tan
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Edwin Thia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - George Seow Heong Yeo
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
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The assessment of placental sharing using X-ray angiogram versus digital photograph: A prospective study. Placenta 2019; 83:1-4. [PMID: 31477201 DOI: 10.1016/j.placenta.2019.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION We aim to compare two different methods for the assessment of placental sharing in monochorionic diamniotic twins: X-ray-angiogram and digital photograph of the placenta. METHOD We included the placentas of a prospective series of twins that were followed from the first trimester onward and resulted in a double live birth or double stillbirth between April 2016 and February 2019. Injection was performed after delivery and an X-ray angiogram was made, as well as a digital photograph. On both of these, the territory of each twin was measured two investigators (IC and LL). Placental sharing discordance was determined using the following formula: (larger territory - smaller territory)/larger territory. We calculated the intra-class correlation coefficients for intra-observer and inter-observer reliability and used Bland-Altman analysis to compare both methods. RESULTS 77 placentas were included in the analysis. For both methods, there was an excellent intra- and inter-observer reliability. The mean difference in sharing (bias) on the X-ray and digital photograph using Bland-Altman analysis was 3,7% (95% CI 1,1% - 6,3%), where the digital photograph tends to overestimate the discordance. Limits of agreement were between -19% and 26%. CONCLUSION Delineation of the placental sharing on a digital photograph slightly overestimates the discordance. Since the venous territory on X-ray angiogram physically determines where each twin gets its oxygenated blood, X-ray angiogram may be a better method to determine placental sharing, although the digital photograph constitutes a valid alternative.
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The roles of superficial anastomoses in twin-twin transfusion syndrome. Placenta 2019; 82:5-9. [PMID: 31174627 DOI: 10.1016/j.placenta.2019.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/08/2019] [Accepted: 05/08/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE We aimed to evaluate whether types of vascular anastomoses affect fetal demise (FD) in twin-twin transfusion syndrome (TTTS) after fetoscopic laser photocoagulation (FLP). METHODS All TTTS patients who underwent FLP in our institution from 2005 to 2017 were included. We described vascular anastomoses during FLP as either arterio-arterial (AA), veno-venous (VV), or arterial-venous (AV), and abnormal fetal Doppler waveforms before FLP. We also analyzed risk factors for FD following FLP. RESULTS In total, 184 TTTS placentas following FLP were analyzed (36 cases of donor-only FD, 12 cases of recipient-only FD, 3 cases of double FD, and 133 cases of both alive). AA anastomoses prevalence, absent or reverse end-diastolic velocity of umbilical artery (UAAREDV) of donor before FLP, gestational age at the time of FLP and operation time of FLP were independent risk factors for donor FD. VV anastomoses prevalence and UAAREDV of recipient before FLP were independent risk factors for recipient FD. VV anastomoses prevalence was higher in double FD cases than in FD of one twin or both alive (p = 0.002). AV anastomoses number and number of cases with more AV anastomoses from donor to recipient were not significantly different between FD and non-FD cases. DISCUSSION AA anastomoses are associated FD of the donor following FLP and may protect the donor from hypovolemia before FLP. VV anastomoses are detected more frequently in FD of the recipient and double FD placentas following FLP and may rescue hypervolemia of the recipient or circulations of both fetuses before FLP.
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Liu Y, Shen Y, Zhang H, Tang Y, Lu G, Lin G, Gong F. Clinical outcomes of multifetal pregnancy reduction in trichorionic and dichorionic triplet pregnancies: A retrospective observational study. Taiwan J Obstet Gynecol 2019; 58:133-138. [PMID: 30638467 DOI: 10.1016/j.tjog.2018.11.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2018] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To observe the pregnancy and perinatal outcomes of trichorionic triplet (TCT) and dichorionic triplet (DCT) pregnancies with or without multifetal pregnancy reduction (MFPR). MATERIALS AND METHODS This was a retrospective study of 732 TCT and 118 DCT pregnancies after IVF/ICSI cycles between October 1999 and May 2014 at the Reproductive & Genetic Hospital of CITIC-Xiangya. The TCT and DCT groups were subdivided into three subgroups: MFPR to single fetus group, MFPR to twins group and expectant group. Pregnancy and perinatal outcomes were compared between different subgroups. RESULTS The resulting subgroups were TCT-Expectant (n = 40), TCT to twin (n = 610), TCT to single (n = 22), DCT-Expectant (n = 17), DCT to twin (n = 50), and DCT to single (n = 22). The groups with MFPR had the better pregnancy and perinatal outcomes. Meanwhile, the significantly higher abortion rates but lower live birth and take home baby rates were found in TCT-Expectant group and DCT-Expectant group (all P < 0.05). Besides, the abortion rate of DCT-Expectant group was much higher than TCT-Expectant group (41% verse 15%, P = 0.032). As for the perinatal outcomes, retaining single fetus group showed the advantage of higher birth weight, and elder gestational age in both DCT and TCT pregnancies (all P < 0.05). CONCLUSION For DCT and TCT pregnancies, MFPR application could reduce the miscarriage rate, while improving live birth and take home baby rates compared to the expectant groups. Especially, when reduced to a single fetus, MFPR could provide the better perinatal outcomes.
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Affiliation(s)
- Yaqiong Liu
- Institute of Reproductive and Stem Cell Engineering, School of Basic Medicine, Central South University, China; Key Laboratory of Reproductive and Stem Cell Engineering, Ministry of Health, China
| | - Yan Shen
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
| | - Hong Zhang
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
| | - Yi Tang
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
| | - Guangxiu Lu
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China; Key Laboratory of Reproductive and Stem Cell Engineering, Ministry of Health, China
| | - Ge Lin
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China; Institute of Reproductive and Stem Cell Engineering, School of Basic Medicine, Central South University, China; Key Laboratory of Reproductive and Stem Cell Engineering, Ministry of Health, China
| | - Fei Gong
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China; Institute of Reproductive and Stem Cell Engineering, School of Basic Medicine, Central South University, China; Key Laboratory of Reproductive and Stem Cell Engineering, Ministry of Health, China.
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The association between inter-twin birth weight discordance and hepatitis C: The United States 2011-2015 twin birth registration data. PLoS One 2019; 14:e0211683. [PMID: 30699205 PMCID: PMC6353199 DOI: 10.1371/journal.pone.0211683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 01/20/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Twins with discordant growth have increased risks of perinatal mortality and morbidity. Previous studies have identified a number of risk factors for inter-twin birth weight discordance, yet no study has examined the effect of maternal hepatitis C infection. METHODS We used the twin birth records extracted from the 2011 to 2015 United States birth records created by the Centers for Disease Control and Prevention. The outcome variable of this study was inter-twin birth weight discordance, defined as [(birth weight of larger twin-birth weight of smaller twin) / birth weight of larger twin]. The independent association of hepatitis C infection with birth weight discordance was examined using the gamma regression or log binomial regression, adjusted by potential confounders. RESULTS Of the 270,256 twin pairs included in the final analysis, 850 (0.31%) had positive hepatitis C. Compared to mothers without hepatitis C, mothers with hepatitis C positive tended to have higher risk of birth weight discordance, but with no statistical significance. After adjustment for potential confounding factors, hepatitis C positive became a significant risk factor for birth weight discordance >25% (relative risk 1.14, 95% confidence interval 1.02-1.29). Sensitivity analyses (by treating birth weight discordance as a continuous outcome or dichotomizing into by different cutoffs) yielded similar results, with relative risks ranging from 1.07 to 1.12 (all P<0.05). CONCLUSION Maternal hepatitis C positive is associated with inter-twin birth weight discordance, an important adverse infant outcome in twin pregnancies, although the effect size is small.
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Katsura D, Takahashi Y, Iwagaki S, Chiaki R, Asai K, Matsui M, Nagai R, Yasumi S, Furuhashi M, Murakami T. Comparison of bilateral and unilateral umbilical artery diastolic blood flow abnormalities in monochorionic diamniotic twin pregnancies. J Matern Fetal Neonatal Med 2019; 33:2933-2940. [PMID: 30585101 DOI: 10.1080/14767058.2018.1564031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Aim: Our study aimed to clarify the prognosis of bilateral and unilateral umbilical artery end-diastolic blood flow abnormalities (BFAs) in monochorionic diamniotic twin pregnancies.Methods: Monochorionic diamniotic twin pregnancies were classified into bilateral (group 1), unilateral (group 2), and no (group 3) umbilical artery end-diastolic BFAs. After the usual obstetric management, short- and long-term prognoses were analyzed.Results: A total of 171 monochorionic diamniotic twins were analyzed and classified into group 1 (13 twins, 7.6%), 2 (12 twins, 7.0%), and 3 (146 twins, 85.4%). Gestational age at delivery was significantly lower in group 1 than in groups 2 and 3 (median, 29.3, 35.6, and 35.6 weeks, respectively; p < .01 and p < .001). The survival rate of fetuses with BFAs was significantly lower in group 1 than in group 2 (23.0% [3/13] versus 100% [12/12]; p < .001). However, the survival rate of the co-twin was not significantly different between groups 1 and 2 (84.6% [11/13] versus 100% [12/12]; p = .48). The survival rate of both fetuses was significantly lower in group 1 than in groups 2 and 3 (53.8% [14/26], 100% [24/24], and 98.6% [288/292], respectively; both p < .001). In cases with fetal therapy, the survival rate of both fetuses tended to be lower in group 1 than in group 2 (44.4% [8/18] versus 83.3% [10/12]; p = .05). In cases without fetal therapy, the gestational age at delivery tended to lower in group 1 than in group 2 and was significantly lower than in group 3 (median, 29.1, 35.6, 35.6 weeks, respectively; p = .05 and p < .05). The survival rate of fetuses with BFA tended to be lower in group 1 than in group 2 (50.0% [2/4] versus 100% [12/12]; p = .05). The survival rate of the co-twin was not significantly different between groups 1 and 2 (100% [4/4] versus 100% [12/12]; p = 1). The survival rate of both fetuses tended to be lower in group 1 than in group 2 and was significantly lower than in group 3 (75% [6/8], 100% [24/24], and 99.2% [278/280], respectively; p = .05 and p < .01).Conclusions: In monochorionic diamniotic twin pregnancies, bilateral umbilical artery end-diastolic BFAs demonstrated a poor prognosis. However, unilateral abnormalities exhibited a good prognosis similar to that in twins with normal umbilical artery blood flow. If such abnormalities are detected during a routine checkup, the umbilical artery pulse wave on the other side should be examined.
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Affiliation(s)
- Daisuke Katsura
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Nagara, Japan
| | - Yuichiro Takahashi
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Nagara, Japan
| | - Shigenori Iwagaki
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Nagara, Japan
| | - Rika Chiaki
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Nagara, Japan
| | - Kazuhiko Asai
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Nagara, Japan
| | - Masako Matsui
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Nagara, Japan
| | - Ryuhei Nagai
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Nagara, Japan
| | - Shunsuke Yasumi
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Nagara, Japan
| | - Madoka Furuhashi
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Nagara, Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu, Japan
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Washburn EE, Sparks TN, Gosnell KA, Rand L, Gonzalez JM, Feldstein VA. Stage I Twin-Twin Transfusion Syndrome: Outcomes of Expectant Management and Prognostic Features. Am J Perinatol 2018; 35. [PMID: 29528469 PMCID: PMC6082735 DOI: 10.1055/s-0038-1627095] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This article describes the natural history of stage I twin-twin transfusion syndrome (TTTS) including risk of progression to higher stage TTTS and pregnancy outcomes, and to identify risk factors for progression. STUDY DESIGN Retrospective cohort study of monochorionic diamniotic (MCDA) twin pregnancies from 2006 to 2016 with expectantly managed Quintero stage I TTTS. RESULTS A total of 30 MCDA twin pregnancies with expectantly managed stage I TTTS were identified. Of these, eight (26.7%) progressed to higher stage TTTS. Median gestational age (GA) at diagnosis for those that progressed was 18.9 ± 2.9 weeks versus 21.4 ± 3.4 weeks in those that remained stable (p = 0.06). Presence of an arterioarterial (A-A) anastomosis was assessed for 20/30 patients, and eight A-A were identified. Of those, 7/8 (87.5%) remained stable. In the complete cohort, a tiny or transiently visible bladder was noted in seven donor twins. Of these, 4/7 (57.1%) progressed. Excluding one termination, 47/58 (81.0%) fetuses survived. CONCLUSION With expectant management of stage I TTTS, nearly three-fourths of pregnancies remain stable and most have survival of ≥ 1 twin. A-A anastomoses were not associated with progression to higher stage TTTS, whereas earlier GA at diagnosis or a small or intermittently visible donor bladder may herald greater risk of progression.
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Affiliation(s)
- Erin E. Washburn
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - Teresa N. Sparks
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - Kristen A. Gosnell
- Fetal Treatment Center, University of California San Francisco, San Francisco, California
| | - Larry Rand
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California,Fetal Treatment Center, University of California San Francisco, San Francisco, California
| | - Juan M. Gonzalez
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California,Fetal Treatment Center, University of California San Francisco, San Francisco, California
| | - Vickie A. Feldstein
- Fetal Treatment Center, University of California San Francisco, San Francisco, California,Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
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Couck I, Mourad Tawfic N, Deprest J, De Catte L, Devlieger R, Lewi L. Does site of cord insertion increase risk of adverse outcome, twin-to-twin transfusion syndrome and discordant growth in monochorionic twin pregnancy? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:385-389. [PMID: 29024208 DOI: 10.1002/uog.18926] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/15/2017] [Accepted: 09/29/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES It is not currently well known to what extent the sites of cord insertion influence the risk of complicated outcome in monochorionic twin pregnancy. The objectives of this study were to examine whether the sites of cord insertion, as determined on prenatal ultrasound examination, affect the risks of adverse outcome, twin-to-twin transfusion syndrome (TTTS) and discordant growth, and whether discordance in insertion sites or velamentous insertion in one or both twins best predicts risk. METHODS This was a retrospective cohort study of monochorionic diamniotic twin pregnancies followed from the first trimester. The cohort was divided into three groups of increasing discordance in cord insertion sites: concordant (normal-normal; marginal-marginal; velamentous-velamentous), intermediate (normal-marginal; marginal-velamentous) and discordant (normal-velamentous). Adverse outcome was defined as fetal or neonatal loss or birth prior to 32 weeks. The associations of adverse outcome, TTTS and discordant growth were assessed using logistic regression analysis with the following predictors: the three groups of insertion sites and velamentous insertion in one or both twins. RESULTS Included in the analysis were 518 pregnancies. On univariate analysis, both discordant and velamentous insertions in one twin increased the risk of adverse outcome, TTTS and discordant growth. Intermediate insertion only increased the risk of discordant growth. Velamentous insertion in both twins increased the risk of adverse outcome and TTTS, but not of discordant growth. Multivariate logistic regression analysis showed velamentous insertion in one or both twins to independently predict adverse outcome and TTTS. For discordant growth, both intermediate/discordant and velamentous cord insertion in one twin were independent predictors. CONCLUSIONS Velamentous cord insertion in one or both twins increases the risk of adverse outcome and TTTS, irrespective of discordance in the insertion sites, whereas the risk of discordant growth is determined by both discordance in insertion sites and velamentous cord insertion in one twin. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I Couck
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - N Mourad Tawfic
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London Hospital, London, UK
| | - L De Catte
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - R Devlieger
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - L Lewi
- Department of Obstetrics and Gynaecology, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Fitzgerald B. Histopathological examination of the placenta in twin pregnancies. APMIS 2018; 126:626-637. [DOI: 10.1111/apm.12829] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/30/2018] [Indexed: 11/26/2022]
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Washburn EE, Sparks TN, Gosnell KA, Rand L, Gonzalez JM, Feldstein VA. Polyhydramnios Affecting a Recipient-like Twin: Risk of Progression to Twin-Twin Transfusion Syndrome and Outcomes. Am J Perinatol 2018; 35:317-323. [PMID: 29287298 PMCID: PMC5842126 DOI: 10.1055/s-0037-1615795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The significance of polyhydramnios of one twin in the absence of oligohydramnios of the cotwin in monochorionic diamniotic (MCDA) twin pregnancies (polyhydramnios affecting a recipient-like twin [PART]) is unknown. Our aim is to assess the risk of progression to twin-twin transfusion syndrome (TTTS) with PART, progression to ≥ stage II TTTS, and neonatal survival. STUDY DESIGN This study was a retrospective cohort study of MCDA twin pregnancies with PART evaluated at a referral center from 2008 to 2015. RESULTS Sixty-four MCDA twin pregnancies with PART were identified. Fifteen (23.4%) progressed to TTTS, including 10 (15.6%) who progressed to ≥ stage II TTTS. Three pregnancies were terminated and one underwent selective reduction by radiofrequency ablation. Overall survival was 113 out of 128 (88.3%). Of those who remained stable, 91.8% (N = 45) had survival of both neonates. In multivariate analysis, the presence of arterioarterial (A-A) anastomosis by in utero Doppler ultrasound was associated with decreased risk of progression to TTTS (odds ratio: 0.12, p = 0.03, 95% confidence interval: 0.02-0.78). CONCLUSION Most MCDA twin pregnancies with PART do not progress to TTTS and have a favorable prognosis. Progression rates are higher than observed in uncomplicated MCDA twins; however, so close surveillance is warranted. The presence of an A-A anastomosis appears to confer decreased risk of progression to TTTS.
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Affiliation(s)
- Erin E. Washburn
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California
| | - Teresa N. Sparks
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California
| | - Kristen A. Gosnell
- Fetal Treatment Center, University of California, San Francisco, California
| | - Larry Rand
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California,Fetal Treatment Center, University of California, San Francisco, California
| | - Juan M. Gonzalez
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California,Fetal Treatment Center, University of California, San Francisco, California
| | - Vickie A. Feldstein
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California,Fetal Treatment Center, University of California, San Francisco, California,Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
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Wohlmuth C, Boudreaux D, Moise KJ, Johnson A, Papanna R, Bebbington M, Gardiner HM. Cardiac pathophysiology in twin-twin transfusion syndrome: new insights into its evolution. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:341-348. [PMID: 28370497 DOI: 10.1002/uog.17480] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 02/15/2017] [Accepted: 03/22/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES In twin-twin transfusion syndrome (TTTS), unbalanced transfer of vasoactive mediators and fluid from the donor to the recipient cotwin alters their cardiovascular function. The aims of this study were to describe the impact of TTTS on fetal cardiac function in a large cohort of monochorionic-diamniotic (MCDA) pregnancies, and determine the early hemodynamic response to selective fetoscopic laser photocoagulation (SFLP). METHODS Echocardiography was performed in 145 MCDA pregnancies, including 26 uncomplicated MCDA, 61 TTTS Stages I+II and 58 TTTS Stages III+IV pregnancies, prior to SFLP for TTTS. Echocardiographic data after SFLP were available in a subset of 41/119 (34%) TTTS cases at a mean of 1.7 ± 1.9 days. Mitral (MAPSE) and tricuspid (TAPSE) annular systolic excursion, myocardial performance index (MPI), tissue Doppler velocities (E', A', S') and filling pressures (E/E') were measured and transformed into Z-scores. Ventricular pressure was estimated from peak atrioventricular regurgitation velocity. RESULTS Left ventricular hemodynamics of the recipient twin were affected in early TTTS. In all stages of TTTS, left MPI and E/E' of the recipient twin were elevated in comparison to those of the donor (all P < 0.05), with reduced recipient left S' in TTTS Stages III+IV (P < 0.001). Ventricular pressure was elevated for gestational age (median, 42 mmHg (range, 20-65 mmHg)) in 11 of 14 recipients in which this parameter was measured. Between-group difference in right ventricular E/E' was significant only in TTTS Stages III+IV recipients compared with TTTS Stages I+II (P = 0.007) and uncomplicated MCDA (P = 0.041). Recipient left and right MPI decreased while S', MAPSE and TAPSE increased after SFLP; in donors, left E/E' and cardiac output increased. CONCLUSIONS Cardiac function of the recipient twin in TTTS is abnormal, even in the early stages of the disease. Left ventricular filling pressures are elevated and systolic function is decreased before abnormalities in the right heart become apparent. SFLP produces rapid hemodynamic improvement. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Wohlmuth
- The Fetal Center, Children's Memorial Hermann Hospital and the Department of Obstetrics, Gynecology and Reproductive Science, UTHealth McGovern Medical School, Houston, TX, USA
- Department of Obstetrics and Gynecology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - D Boudreaux
- The Fetal Center, Children's Memorial Hermann Hospital and the Department of Obstetrics, Gynecology and Reproductive Science, UTHealth McGovern Medical School, Houston, TX, USA
| | - K J Moise
- The Fetal Center, Children's Memorial Hermann Hospital and the Department of Obstetrics, Gynecology and Reproductive Science, UTHealth McGovern Medical School, Houston, TX, USA
| | - A Johnson
- The Fetal Center, Children's Memorial Hermann Hospital and the Department of Obstetrics, Gynecology and Reproductive Science, UTHealth McGovern Medical School, Houston, TX, USA
| | - R Papanna
- The Fetal Center, Children's Memorial Hermann Hospital and the Department of Obstetrics, Gynecology and Reproductive Science, UTHealth McGovern Medical School, Houston, TX, USA
| | - M Bebbington
- The Fetal Center, Children's Memorial Hermann Hospital and the Department of Obstetrics, Gynecology and Reproductive Science, UTHealth McGovern Medical School, Houston, TX, USA
| | - H M Gardiner
- The Fetal Center, Children's Memorial Hermann Hospital and the Department of Obstetrics, Gynecology and Reproductive Science, UTHealth McGovern Medical School, Houston, TX, USA
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Xiao Y, Shen M, Ma S, Tao X, Wen SW, Tan H. The association between weight gain during pregnancy and intertwin delivery weight discordance using 2011-2015 birth registration data from the USA. Int J Gynaecol Obstet 2018; 141:371-377. [DOI: 10.1002/ijgo.12451] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 11/26/2017] [Accepted: 01/23/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Yanni Xiao
- Department of Epidemiology and Health Statistics; Xiangya School of Public Health; Central South University; Changsha China
- Hunan University of Medicine; Huaihua China
| | - Minxue Shen
- Department of Epidemiology and Health Statistics; Xiangya School of Public Health; Central South University; Changsha China
- Department of Dermatology; Xiangya Hospital; Central South University; Changsha China
| | - Shujuan Ma
- Department of Epidemiology and Health Statistics; Xiangya School of Public Health; Central South University; Changsha China
| | - Xuan Tao
- Ningxiang General Hospital; Ningxiang China
| | - Shi Wu Wen
- Department of Epidemiology and Health Statistics; Xiangya School of Public Health; Central South University; Changsha China
- OMNI Research Group; Department of Obstetrics and Gynecology; Faculty of Medicine; University of Ottawa; Ottawa ON Canada
- Ottawa Hospital Research Institute; Clinical Epidemiology Program; University of Ottawa; Ottawa ON Canada
- School of Epidemiology and Public Health; Faculty of Medicine; University of Ottawa; Ottawa ON Canada
| | - Hongzhuan Tan
- Department of Epidemiology and Health Statistics; Xiangya School of Public Health; Central South University; Changsha China
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Konno H, Murakoshi T, Yamashita A, Matsushita M. Roles of venovenous anastomosis and umbilical cord insertion abnormalities in birthweight discordance in monochorionic-diamniotic twin pregnancies without twin-twin transfusion syndrome. J Obstet Gynaecol Res 2018; 44:623-629. [PMID: 29316011 DOI: 10.1111/jog.13567] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 11/08/2017] [Indexed: 12/12/2022]
Abstract
AIM We evaluated risk factors for birthweight discordance in monochorionic diamniotic (MCDA) twin pregnancies without twin-twin transfusion syndrome (TTTS). METHODS We investigated all MCDA twin placentas injected with colored dye at our institution between 2007 and 2015. We excluded pairs of twins with TTTS, fetal demise, or severe fetal malformation. All pairs of twins were assigned to the discordant group (birthweight discordance ≥ 25%) or the concordant group (birthweight discordance < 25%). In each pair of twins, we described vascular anastomoses as either arterioarterial, venovenous (VV), or arterial-venous, and abnormal umbilical cord insertion as either marginal or velamentous. We also recorded placental sharing discordance. RESULTS A total of 150 placentas were analyzed. The incidence of VV anastomosis in the discordant group (40%) was significantly higher than that in the concordant group (12%, P = 0.005). Unilateral abnormal umbilical cord insertion was significantly more common in the discordant group (85%) than in the concordant group (38%, P < 0.001). Placental sharing discordance was seen more frequently in the discordant group than in the concordant group. Multiple logistic analysis revealed that VV anastomosis (odds ratio: 4.7; 95% confidence interval: 1.2-18.6, P < 0.01) and unilateral abnormal umbilical cord insertion of the smaller twin (odds ratio: 5.7; 95% confidence interval: 1.4-22.9, P < 0.01) were independent risk factors for birthweight discordance. CONCLUSION VV anastomoses and unilateral abnormal umbilical cord insertion of the smaller twin are independent risk factors for birthweight discordance in MCDA twin pregnancies without TTTS.
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Affiliation(s)
- Hiroko Konno
- Division of Obstetrics and Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Takeshi Murakoshi
- Division of Obstetrics and Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Akiko Yamashita
- Division of Obstetrics and Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Mitsuru Matsushita
- Division of Obstetrics and Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
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Ascherl R, Sorge I, Thome U, Hirsch FW, Bläser A, Kiess W, Merkenschlager A. Severe gyration and migration disorder in fetofetal transfusion syndrome: two case reports and a review of the literature on the neurological outcome of children with lesions on neuroimaging. Childs Nerv Syst 2018; 34:155-163. [PMID: 28971247 DOI: 10.1007/s00381-017-3595-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 09/03/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Fetofetal transfusion syndrome is a dreaded cause of morbidity and mortality in monochorionic pregnancies. CASE REPORTS We present two pairs of twins one of which we have followed for more than 6 years. The donors suffer from cerebral palsy, orofacial, and motor problems, and both are significantly smaller than their recipient twins. Interestingly, cranial MRI revealed medial frontal lobe polymicrogyria, ventriculomegaly, and decreased thickness in both parietal lobes in both donors. We suggest this as a possible feature of fetofetal transfusion syndrome. REVIEW A minireview of the literature on neuroimaging and neurodevelopmental outcome in fetofetal transfusion syndrome is presented. CONCLUSION While the close resemblance of the imaging features of both cases is likely incidental further study of a connection between migration and gyration disorders and fetofetal transfusion syndrome is warranted.
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Affiliation(s)
- Rudolf Ascherl
- Hospital for Children and Adolescents, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany.
| | - Ina Sorge
- Department of Imaging and Radiotherapy, Section Pediatric Radiology, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany
| | - Ulrich Thome
- Division of Neonatology, Hospital for Children and Adolescents, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany
| | - Franz Wolfgang Hirsch
- Department of Imaging and Radiotherapy, Section Pediatric Radiology, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany
| | - Annett Bläser
- Division of Neonatology, Hospital for Children and Adolescents, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany
| | - Wieland Kiess
- Hospital for Children and Adolescents, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany
| | - Andreas Merkenschlager
- Division of Neuropediatrics, Hospital for Children and Adolescents, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany
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Kadji C, Bevilacqua E, Hurtado I, Carlin A, Cannie MM, Jani JC. Comparison of conventional 2D ultrasound to magnetic resonance imaging for prenatal estimation of birthweight in twin pregnancy. Am J Obstet Gynecol 2018; 218:128.e1-128.e11. [PMID: 29045850 DOI: 10.1016/j.ajog.2017.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/29/2017] [Accepted: 10/06/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND During prenatal follow-up of twin pregnancies, accurate identification of birthweight and birthweight discordance is important to identify the high-risk group and plan perinatal care. Unfortunately, prenatal evaluation of birthweight discordance by 2-dimensional ultrasound has been far from optimal. OBJECTIVE The objective of the study was to prospectively compare estimates of fetal weight based on 2-dimensional ultrasound (ultrasound-estimated fetal weight) and magnetic resonance imaging (magnetic resonance-estimated fetal weight) with actual birthweight in women carrying twin pregnancies. STUDY DESIGN Written informed consent was obtained for this ethics committee-approved study. Between September 2011 and December 2015 and within 48 hours before delivery, ultrasound-estimated fetal weight and magnetic resonance-estimated fetal weight were conducted in 66 fetuses deriving from twin pregnancies at 34.3-39.0 weeks; gestation. Magnetic resonance-estimated fetal weight derived from manual measurement of fetal body volume. Comparison of magnetic resonance-estimated fetal weight and ultrasound-estimated fetal weight measurements vs birthweight was performed by calculating parameters as described by Bland and Altman. Receiver-operating characteristic curves were constructed for the prediction of small-for-gestational-age neonates using magnetic resonance-estimated fetal weight and ultrasound-estimated fetal weight. For twins 1 and 2 separately, the relative error or percentage error was calculated as follows: (birthweight - ultrasound-estimated fetal weight (or magnetic resonance-estimated fetal weight)/birthweight) × 100 (percentage). Furthermore, ultrasound-estimated fetal weight, magnetic resonance-estimated fetal weight, and birthweight discordance were calculated as 100 × (larger estimated fetal weight-smaller estimated fetal weight)/larger estimated fetal weight. The ultrasound-estimated fetal weight discordance and the birthweight discordance were correlated using linear regression analysis and Pearson's correlation coefficient. The same was done between the magnetic resonance-estimated fetal weight and birthweight discordance. To compare data, the χ2, McNemar test, Student t test, and Wilcoxon signed rank test were used as appropriate. We used the Fisher r-to-z transformation to compare correlation coefficients. RESULTS The bias and the 95% limits of agreement of ultrasound-estimated fetal weight are 2.99 (-19.17% to 25.15%) and magnetic resonance-estimated fetal weight 0.63 (-9.41% to 10.67%). Limits of agreement were better between magnetic resonance-estimated fetal weight and actual birthweight as compared with the ultrasound-estimated fetal weight. Of the 66 newborns, 27 (40.9%) were of weight of the 10th centile or less and 21 (31.8%) of the fifth centile or less. The area under the receiver-operating characteristic curve for prediction of birthweight the 10th centile or less by prenatal ultrasound was 0.895 (P < .001; SE, 0.049), and by magnetic resonance imaging it was 0.946 (P < .001; SE, 0.024). Pairwise comparison of receiver-operating characteristic curves showed a significant difference between the areas under the receiver-operating characteristic curves (difference, 0.087, P = .049; SE, 0.044). The relative error for ultrasound-estimated fetal weight was 6.8% and by magnetic resonance-estimated fetal weight, 3.2% (P < .001). When using ultrasound-estimated fetal weight, 37.9% of fetuses (25 of 66) were estimated outside the range of ±10% of the actual birthweight, whereas this dropped to 6.1% (4 of 66) with magnetic resonance-estimated fetal weight (P < .001). The ultrasound-estimated fetal weight discordance and the birthweight discordance correlated significantly following the linear equation: ultrasound-estimated fetal weight discordance = 0.03 + 0.91 × birthweight (r = 0.75; P < .001); however, the correlation was better with magnetic resonance imaging: magnetic resonance-estimated fetal weight discordance = 0.02 + 0.81 × birthweight (r = 0.87; P < .001). CONCLUSION In twin pregnancies, magnetic resonance-estimated fetal weight performed immediately prior to delivery is more accurate and predicts small-for-gestational-age neonates significantly better than ultrasound-estimated fetal weight. Prediction of birthweight discordance is better with magnetic resonance imaging as compared with ultrasound.
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Djaafri F, Stirnemann J, Mediouni I, Colmant C, Ville Y. Twin-twin transfusion syndrome - What we have learned from clinical trials. Semin Fetal Neonatal Med 2017; 22:367-375. [PMID: 29122542 DOI: 10.1016/j.siny.2017.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Monochorionic twin pregnancies are at increased risk for adverse outcome compared to dichorionic twin pregnancies and singletons. Monochorionic-specific complications include twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence, single intrauterine fetal demise and its consequences on the co-twin, and selective intrauterine growth restriction. Whereas the natural history of monochorionic-specific complications carries a high risk of fetal death or severe neurologic disability, a framework now exists, based on well-designed clinical trials, for optimal treatment of these entities. Fetoscopic selective laser coagulation of anastomotic vessels on the chorionic plate has been clearly demonstrated to improve survival and neurologic outcomes for Quintero stage ≥2 TTTS. However, many challenges remain unsolved, the most important of which is preterm premature rupture of membranes. Further improvement in the outcomes of monochorionic pregnancies will require improvements in the rate of premature delivery, and improved diagnosis and treatment strategies for early and late onset TTTS.
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Affiliation(s)
- Fatiha Djaafri
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Julien Stirnemann
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France
| | - Imen Mediouni
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Claire Colmant
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Yves Ville
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France.
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Bennasar M, Eixarch E, Martinez JM, Gratacós E. Selective intrauterine growth restriction in monochorionic diamniotic twin pregnancies. Semin Fetal Neonatal Med 2017; 22:376-382. [PMID: 28532678 DOI: 10.1016/j.siny.2017.05.001] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Selective intrauterine growth restriction (sIUGR) affects 10-15% of all monochorionic pregnancies. Early severe forms are associated with intrauterine demise or neurological adverse outcome for both twins. The characteristics of umbilical artery (UA) Doppler in the IUGR fetus determine three clinical types: (I) normal UA Doppler and associated with good prognosis; (II) persistently absent/reverse UA end-diastolic flow and associated with early deterioration of the IUGR twin and very preterm delivery; (III) intermittently absent/reverse end-diastolic flow in the UA, and associated with unexpected fetal demise or neurological injury in one or both twins. Types II and III pose important challenges for management. Placental laser or cord occlusions do not seem to increase survival, but they might improve the outcomes of the larger twin. The use of an algorithm with severity criteria may help in counseling and planning management.
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Affiliation(s)
- Mar Bennasar
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Elisenda Eixarch
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Josep Maria Martinez
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Eduard Gratacós
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain.
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Buca D, Pagani G, Rizzo G, Familiari A, Flacco ME, Manzoli L, Liberati M, Fanfani F, Scambia G, D'Antonio F. Outcome of monochorionic twin pregnancy with selective intrauterine growth restriction according to umbilical artery Doppler flow pattern of smaller twin: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:559-568. [PMID: 27859836 DOI: 10.1002/uog.17362] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/08/2016] [Accepted: 11/11/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To explore the outcome of monochorionic twin pregnancies affected by selective intrauterine growth restriction (sIUGR) according to the umbilical artery Doppler pattern of the smaller twin. METHODS An electronic search of MEDLINE, EMBASE, CINAHL and ClinicalTrials.gov databases (2000-2016) was performed. sIUGR was defined as the presence of one twin with an estimated fetal weight and/or abdominal circumference < 10th or < 5th percentile and classified according to the umbilical artery Doppler flow pattern of the smaller twin (Type I: persistently positive; Type II: persistently absent/reversed; Type III: intermittently absent/reversed). Primary outcomes were perinatal mortality, intrauterine death, neonatal death and double fetal loss. Secondary outcomes were neonatal morbidity, including abnormal postnatal brain imaging, intraventricular hemorrhage, periventricular leukomalacia, admission to neonatal intensive care unit and respiratory distress syndrome, deterioration of fetal status, gestational age at delivery and degree of birth-weight discordance. A composite adverse outcome, defined as the presence of any mortality or abnormal brain findings, was also assessed. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale. A random-effects meta-analysis was used to compute the summary odds ratios (ORs), mean differences (MD) and proportions for the different outcomes. RESULTS Thirteen studies (610 pregnancies) were included. The risk of perinatal mortality was higher in twins affected by Type II compared with Type I sIUGR (OR, 4.1 (95% CI, 1.6-10.3)), whereas there was no difference among the other variants of growth restriction. Risk of abnormal postnatal brain imaging was significantly higher in twins affected by either Type II (OR, 4.9 (95% CI, 1.9-12.9)) or Type III (OR, 8.2 (95% CI, 2.0-33.1)) sIUGR compared with Type I sIUGR. The risk for neonatal intensive care unit admission was higher in Type II compared with Type I sIUGR (OR, 18.3 (95% CI, 1.0-339.7)). Twin pregnancies affected by Type I sIUGR were delivered at a significantly later gestational age compared with Type II (MD, 2.8 (95% CI, 1.83-3.86) weeks) and Type III (MD, 2.1 (95% CI, 0.97-3.19) weeks). The degree of birth-weight discordance was higher in Type II compared with Type I (MD, 21.6% (95% CI, 9.9-33.2%)) and Type III (MD, 9.3% (95% CI, 3.8-14.9%)) sIUGR. CONCLUSION Monochorionic twin pregnancies affected by Type II sIUGR are at a higher risk of perinatal mortality and morbidity compared with Type I. The likelihood of an abnormal outcome is usually not significantly different between sIUGR Types II and III, although the latter has an unpredictable clinical course. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Buca
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - G Pagani
- Department of Obstetrics and Gynecology, Fondazione Poliambulanza, Brescia, Italy
| | - G Rizzo
- Department of Obstetrics and Gynaecology, University of Rome Tor Vergata, Rome, Italy
| | - A Familiari
- Department of Maternal-Fetal Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - M E Flacco
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
| | - L Manzoli
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
| | - M Liberati
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - F Fanfani
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - G Scambia
- Department of Maternal-Fetal Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - F D'Antonio
- Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, Tromsø, Norway
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Caloone J, Huissoud C, Kocot A, Vincenot J, Dehay C, Giroud P, Misery P, Allias F, Rudigoz RC, Melodelima D. Non-invasive high-intensity focused ultrasound treatment of the placenta: a preliminary in-vivo study using a simian model. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:635-641. [PMID: 27804180 DOI: 10.1002/uog.17350] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To demonstrate the feasibility and efficacy of high-intensity focused ultrasound (HIFU) for the non-invasive creation of placental lesions in a simian model. METHODS Eight pregnant monkeys were exposed to HIFU treatment after anesthesia, using a toroidal HIFU 2.5-MHz transducer with an integrated ultrasound imaging probe. Lesions on the placental tissue were created non-invasively by placing the HIFU probe on the skin surface. Fetal and maternal parameters, such as maternal heart rate, fetal heart rate and subcutaneous and intra-amniotic fluid temperature, were recorded during HIFU exposure. Cesarean section was performed immediately after the procedure to extract the placenta and examine the fetus and the maternal abdominal cavity. Placental HIFU lesions were assessed by ultrasound, gross pathology and histology. RESULTS The mean gestational age of the monkeys was 72 ± 4 days. In total, 13 HIFU procedures were performed. The acoustic power and exposure time were increased progressively. This gradual increase in total energy delivered was used to determine a set of parameters to create reproducible lesions in the placenta without complications. Five placental lesions were observed with average diameters of 6.4 ± 0.5 mm and 7.8 ± 0.7 mm and an average depth of 3.8 ± 1.5 mm. Ultrasound examination of the placentae revealed hyperechoic regions that correlated well with macroscopic analysis of the HIFU lesions. Necrosis of placental tissue exposed to HIFU was confirmed with macroscopic and microscopic analysis. There was no significant variation in maternal and fetal parameters during HIFU exposure. CONCLUSIONS This study demonstrates the feasibility of HIFU applied non-invasively to the placental unit in an in-vivo pregnant monkey model. The technique is safe in the immediate short term and is potentially translatable to human pregnancy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J Caloone
- Inserm, U1032, Laboratory of Therapeutic Applications of Ultrasound, Lyon, France
- Université de Lyon, Lyon, France
- Department of Obstetrics and Gynecology, Croix Rousse University Hospital, Lyon, France
| | - C Huissoud
- Department of Obstetrics and Gynecology, Croix Rousse University Hospital, Lyon, France
- Stem Cell and Brain Research Institute, Institut National de la Sante et de la Recherche Médicale U846, Bron, France
| | - A Kocot
- Inserm, U1032, Laboratory of Therapeutic Applications of Ultrasound, Lyon, France
- Université de Lyon, Lyon, France
| | - J Vincenot
- Inserm, U1032, Laboratory of Therapeutic Applications of Ultrasound, Lyon, France
- Université de Lyon, Lyon, France
| | - C Dehay
- Stem Cell and Brain Research Institute, Institut National de la Sante et de la Recherche Médicale U846, Bron, France
| | - P Giroud
- Stem Cell and Brain Research Institute, Institut National de la Sante et de la Recherche Médicale U846, Bron, France
| | - P Misery
- Stem Cell and Brain Research Institute, Institut National de la Sante et de la Recherche Médicale U846, Bron, France
| | - F Allias
- Université de Lyon, Lyon, France
- Department of Pathology, Croix Rousse University Hospital, Lyon, France
| | - R C Rudigoz
- Department of Obstetrics and Gynecology, Croix Rousse University Hospital, Lyon, France
| | - D Melodelima
- Inserm, U1032, Laboratory of Therapeutic Applications of Ultrasound, Lyon, France
- Université de Lyon, Lyon, France
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81
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De Paepe ME, Gündoğan F, Mao Q, Chu S, Shapiro S. Redness discordance in monochorionic twin placentas: Correlation with clinical and placental findings. Placenta 2017; 60:54-60. [PMID: 29208240 DOI: 10.1016/j.placenta.2017.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/18/2017] [Accepted: 10/21/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION/OBJECTIVES Recent studies suggest redness (color) discordance of the placental basal plate may be a marker for twin anemia-polycythemia sequence (TAPS), a recently described complication of diamniotic-monochorionic twinning characterized by marked intertwin hemoglobin (Hb) discordance in the absence of oligohydramnios-polyhydramnios. In this study, we determined the clinicoplacental and choriovascular correlates of basal plate color discordance in monochorionic twin placentas, and assessed its value as postnatal indicator of TAPS. METHODS We performed a clinicoplacental analysis of 100 consecutive non-TTTS diamniotic-monochorionic twin placentas with available photographic documentation of the basal plate. Basal plate redness was quantified by computer-assisted analysis of digital images and expressed as intertwin color difference ratio (CDR). RESULTS The CDR ranged between 1.00 and 3.58 (median CDR: 1.14; 90th %ile: 1.98). Compared to twins with low CDR (N = 90), twins with high CDR (≥2.0; N = 10) had significantly higher hemoglobin difference (11.25 g/dL versus 2.55 g/dL) and significantly fewer and smaller artery-to-artery (AA) and artery-to-vein (AV) anastomoses. Apgar scores and birth weights were equivalent in both groups. Among the 10 twin sets with high CDR, six (60%) qualified as TAPS, as defined by intertwin Hb difference >8 g/dL and absent or very small AA and AV anastomoses. Conversely, 6 of 8 (75%) twin sets with TAPS had a CDR ≥ 2.0. CONCLUSION Intertwin CDR correlates with intertwin hemoglobin difference and chorionic angioarchitecture. A CDR value ≥ 2.0 (the 90%ile value for CDR derived from the present cohort) has high specificity (96%), but relatively low positive predictive value (60%) as indicator of TAPS, as currently defined.
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Affiliation(s)
- Monique E De Paepe
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States; Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, Providence, RI, 02905, United States.
| | - Füsun Gündoğan
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States; Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, Providence, RI, 02905, United States
| | - Quanfu Mao
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
| | - Sharon Chu
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
| | - Svetlana Shapiro
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
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Tan KH. Progress in obstetrics and gynaecology - evidence-based practices and practice-based evidence reviews. Singapore Med J 2017. [PMID: 28642959 DOI: 10.11622/smedj.2017047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kok Hian Tan
- Division of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
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83
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Thia E, Thain S, Yeo GSH. Fetoscopic laser photocoagulation in twin-to-twin transfusion syndrome: experience from a single institution. Singapore Med J 2017; 58:321-326. [PMID: 27056209 PMCID: PMC5474527 DOI: 10.11622/smedj.2016067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Twin-to-twin transfusion syndrome (TTTS) is the most common serious complication of monochorionic (MC) twin pregnancies, with perinatal mortality rates of up to 90% if untreated. This study aimed to review the perinatal and perioperative outcomes of MC twin pregnancies treated for TTTS by fetoscopic laser photocoagulation (FLP) since its introduction at KK Women's and Children's Hospital (KKH), Singapore, in 2011. METHODS This was a retrospective review of five consecutive patients who underwent FLP of placental anastomoses for TTTS at KKH from June 2011 to March 2014. FLP was offered to patients who were diagnosed with TTTS of at least Quintero Stage II before 26 weeks of gestation. The main outcome measures were perioperative complications and perinatal survival rates. RESULTS Five sets of MC twin pregnancies underwent FLP during the study period - three pregnancies were diagnosed with Stage III TTTS and two pregnancies with Stage II TTTS. Median gestational ages at initial presentation, laser photocoagulation and delivery were 19 (range 17-20) weeks, 20 (range 19-23) weeks and 29 (range 28-34) weeks, respectively. One patient had bleeding into the amniotic cavity intraprocedurally. Overall, the perinatal survival rate, double-infant survival rate and survival rate for at least one twin were 60% (6/10 fetuses), 40% (2/5 twins) and 80% (4/5 twins), respectively. CONCLUSION FLP is a feasible treatment for TTTS, with minimal maternal complications. Perinatal survival rates of this patient group that was managed at our centre were comparable to those of international centres.
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Affiliation(s)
- Edwin Thia
- Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Serene Thain
- Department of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, Singapore
| | - George SH Yeo
- Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore
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Gosavi A, Vijayakumar PD, Ng BSW, Loh MH, Tan LG, Johana N, Tan YW, Sandikin D, Su LL, Wataganara T, Biswas A, Choolani MA, Mattar CNZ. Rapid initiation of fetal therapy services with a system of learner-centred training under proctorship: the National University Hospital (Singapore) experience. Singapore Med J 2017; 58:311-320. [PMID: 27439783 PMCID: PMC5474526 DOI: 10.11622/smedj.2016127] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Management of complicated monochorionic twins and certain intrauterine structural anomalies is a pressing challenge in communities that still lack advanced fetal therapy. We describe our efforts to rapidly initiate selective feticide using radiofrequency ablation (RFA) and selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS), and present the latter as a potential model for aspiring fetal therapy units. METHODS Five pregnancies with fetal complications were identified for RFA. Three pregnancies with Stage II TTTS were selected for SFLP. While RFA techniques utilising ultrasonography skills were quickly mastered, SFLP required stepwise technical learning with an overseas-based proctor, who provided real-time hands-off supervision. RESULTS All co-twins were live-born following selective feticide; one singleton pregnancy was lost. Fetoscopy techniques were learned in a stepwise manner and procedures were performed by a novice team of surgeons under proctorship. Dichorionisation was completed in only one patient. Five of six twins were live-born near term. One pregnancy developed twin anaemia-polycythaemia sequence, while another was complicated by co-twin demise. DISCUSSION Proctor-supervised directed learning facilitated the rapid provision of basic fetal therapy services by our unit. While traditional apprenticeship is important for building individual expertise, this system is complementary and may benefit other small units committed to providing these services.
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Affiliation(s)
- Arundhati Gosavi
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Pradip D Vijayakumar
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Bryan SW Ng
- Department of Anaesthesia, National University Health System, Singapore
| | - May-Han Loh
- Department of Anaesthesia, National University Health System, Singapore
| | - Lay Geok Tan
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nuryanti Johana
- Department of Reproductive Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Yi Wan Tan
- Department of Reproductive Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Dedy Sandikin
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lin Lin Su
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tuangsit Wataganara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Arijit Biswas
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mahesh A Choolani
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Citra NZ Mattar
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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85
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Verbeek L, Slaghekke F, Sueters M, Middeldorp JM, Klumper FJ, Haak MC, Oepkes D, Lopriore E. Hematological disorders at birth in complicated monochorionic twins. Expert Rev Hematol 2017; 10:525-532. [PMID: 28460542 DOI: 10.1080/17474086.2017.1324290] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Monochorionic twins are at risk of severe complications including twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence (TAPS) and acute peripartum TTTS. The pathophysiology is based on inter-twin blood transfusion through placental vascular anastomoses. Areas covered: This review focuses on the incidence, management and outcome of neonatal hematological complications at birth in TTTS, TAPS and acute peripartum TTTS. Expert commentary: Hematological disorders are often present at birth in monochorionic twins and include acute or chronic anemia, polycythemia and thrombocytopenia. Routine measurement of complete blood counts in all complicated monochorionic twins is strongly recommended. Increased awareness on these disorders and correct diagnostic tests will lead to prompt and adequate management at birth.
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Affiliation(s)
- Lianne Verbeek
- a Division of Neonatology, Department of Pediatrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Femke Slaghekke
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Marieke Sueters
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Johanna M Middeldorp
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Frans J Klumper
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Monique C Haak
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Dick Oepkes
- b Department of Obstetrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Enrico Lopriore
- a Division of Neonatology, Department of Pediatrics , Leiden University Medical Center , Leiden , The Netherlands
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86
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Atallah A, Bolze PA, Buenerd A, Marino S, Massardier J, Gaucherand P, Massoud M. Injection des anastomoses vasculaires pour la compréhension des complications propres aux grossesses monochoriales. ACTA ACUST UNITED AC 2017; 45:269-275. [DOI: 10.1016/j.gofs.2017.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/13/2017] [Indexed: 11/16/2022]
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Ylilehto E, Palomäki O, Huhtala H, Uotila J. Term twin birth - impact of mode of delivery on outcome. Acta Obstet Gynecol Scand 2017; 96:589-596. [PMID: 28240343 DOI: 10.1111/aogs.13122] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 02/16/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The main aims of this study were to compare maternal and neonatal outcomes in term twin birth according to the planned mode of delivery and to study the effects of chorionicity and inter-twin delivery time on neonatal outcome. MATERIAL AND METHODS A single-center cohort study of 495 women with twin deliveries at ≥37+0 weeks of gestation. Term twin deliveries were divided into a trial of labor group (TOL, 69.3%) and a planned cesarean section (CS) group (30.7%). The primary outcomes were maternal and neonatal morbidity. RESULTS 80.8% of women attempting TOL achieved vaginal birth. In the TOL group, mothers had less bleeding [median 500 mL (range 150-2700 mL) vs. 950 mL (range 150-3500 mL), p < 0.001) and fewer surgical complications (3.2% vs. 8.6%, p = 0.011), whereas second twins more often had five-minute Apgar scores of <7 (5.0% vs. 0%, p = 0.002) or umbilical artery pH < 7.05 (5.7% vs. 0%, p = 0.003), compared with the planned CS group. There was a slight, non-significant tendency for more NICU admissions in the TOL group, yet the need for NICU treatment was infrequent in the whole study material. Outcomes among dichorionic (DC) second twins were similar to those in the whole material, but among monochorionic (MC) second twins there were no differences between the TOL and planned CS groups. In secondary analysis, a five-minute Apgar score <7 occurred significantly more often in the DC group among second twins if the inter-twin delivery time exceeded 30 min. CONCLUSIONS TOL is a good option for women with twin pregnancy at term, regardless of chorionicity. Active management of labor for the second twin is important, also in DC births. Maternal outcomes were more favorable with TOL and although low Apgar scores and low umbilical blood pH may be more frequent after TOL - especially with the second twin - serious neonatal morbidity is rare and does not differ from that after planned CS.
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Affiliation(s)
- Elina Ylilehto
- School of Medicine, University of Tampere, Tampere, Finland.,Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Outi Palomäki
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Jukka Uotila
- School of Medicine, University of Tampere, Tampere, Finland.,Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
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88
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Rustico MA, Consonni D, Lanna M, Faiola S, Schena V, Scelsa B, Introvini P, Righini A, Parazzini C, Lista G, Barretta F, Ferrazzi E. Selective intrauterine growth restriction in monochorionic twins: changing patterns in umbilical artery Doppler flow and outcomes. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:387-393. [PMID: 27062653 DOI: 10.1002/uog.15933] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 02/14/2016] [Accepted: 03/30/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To describe changes in umbilical artery (UA) Doppler flow in monochorionic diamniotic (MCDA) twins affected by selective intrauterine growth restriction (sIUGR), to correlate Doppler findings with pregnancy course and perinatal outcome, and to report postnatal follow-up. METHODS This was a retrospective study of 140 MCDA twins with sIUGR. UA end-diastolic flow, defined as Doppler waveform pattern Type I (persistently positive), Type II (persistently absent or persistently reversed) or Type III (intermittently absent or intermittently reversed), was recorded at first examination and monitored weekly until double or single intrauterine fetal death (IUFD), bipolar cord coagulation or delivery. All neonates had an early neonatal brain scan, magnetic resonance imaging, when indicated, and neurological assessment during infancy. Rates (per 100 person-weeks) and hazard ratios (HR) of IUFD in the IUGR twin in each pregnancy were calculated considering UA Doppler pattern as a time-dependent variable. RESULTS At first examination, there were 65 cases with UA Doppler waveform pattern Type I, 62 with Type II and 13 with Type III. Of the 65 Type-I cases, 48 (74%) remained stable, while 17 (26%) changed to either Type II absent (14%), Type II reversed (9%) or Type III (3%). Of 62 Type-II cases (47 with absent and 15 with reversed flow), 33 (53%) remained stable (18 with absent and all 15 with reversed flow). The 29 Type-II absent cases which changed became Type II reversed (24/47, 51%) or Type III (5/47, 11%). All 13 Type-III cases remained stable. Compared with Type I, the risk of IUFD (adjusted for estimated fetal weight discordance and amniotic fluid deepest vertical pocket) was highest when the pregnancy was or became Type II reversed (HR, 9.5; 95% CI, 2.7-32.7) or Type II absent (HR, 4.3; 95% CI, 1.3-14.3). Mild neurological impairment was more prevalent in the IUGR twin than in the large cotwin (7% vs 1%, P = 0.02). CONCLUSIONS Risk stratification based on UA Doppler is useful for planning ultrasound surveillance. However, patterns can change over time, with important consequences for management and outcome. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M A Rustico
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Vittore Buzzi Children's Hospital, Università degli Studi di Milano, Milan, Italy
| | - D Consonni
- Department of Preventive Medicine, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - M Lanna
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Vittore Buzzi Children's Hospital, Università degli Studi di Milano, Milan, Italy
| | - S Faiola
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Vittore Buzzi Children's Hospital, Università degli Studi di Milano, Milan, Italy
| | - V Schena
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Vittore Buzzi Children's Hospital, Università degli Studi di Milano, Milan, Italy
| | - B Scelsa
- Unit of Pediatric Neurology, Vittore Buzzi Children's Hospital, Università degli Studi di Milano, Milan, Italy
| | - P Introvini
- Neonatal Intensive Care Unit, Vittore Buzzi Children's Hospital, Università degli Studi di Milano, Milan, Italy
| | - A Righini
- Department of Radiology and Neuroradiology, Vittore Buzzi Children's Hospital, Università degli Studi di Milano, Milan, Italy
| | - C Parazzini
- Department of Radiology and Neuroradiology, Vittore Buzzi Children's Hospital, Università degli Studi di Milano, Milan, Italy
| | - G Lista
- Neonatal Intensive Care Unit, Vittore Buzzi Children's Hospital, Università degli Studi di Milano, Milan, Italy
| | - F Barretta
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - E Ferrazzi
- Department of Gynecology, Obstetrics and Neonatology, Vittore Buzzi Children's Hospital, Università degli Studi di Milano, Milan, Italy
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Long L, Yan J, Li Q, Zhou Z, Deng H, Wang C, Zou Y, Cai J. Intrauterine fetal death in triplet gestation caused by feto-fetal transfusion syndrome - a case report. Forensic Sci Res 2016; 2:213-217. [PMID: 30483645 PMCID: PMC6197143 DOI: 10.1080/20961790.2016.1264915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 11/21/2016] [Indexed: 10/24/2022] Open
Abstract
Feto-fetal transfusion syndrome (FFTS) severely affects monochorionic (MC) multiple pregnancies and affects 1 in 1600 pregnancies overall. The number of increasing disputed obstetrics cases in China is related to unavailability of prompt diagnosis of FFTS. We present here a woman with a MC triplet pregnancy with intrauterine fetal death at 33 weeks of gestation due to FFTS. Subsequent pathological anatomy showed that the MC placenta contained vascular anastomoses, including arterio-arterial anastomosis and arterio-venous anastomosis. These anastomoses led to unidirectional blood flow with the absence of adequate compensatory counter-transfusion and bi-directional flow. When encountering such challenging conditions, medical practitioners should discreetly compare the fetuses' characteristics with features of placental blood vessels and consult morphological and pathological findings. Furthermore, they should perform ultrasound examinations, particularly focussing on fetal size differences and the maximum vertical pocket in the diagnosis of FFTS, especially in MC multiple pregnancies with abdominal symptoms.
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Affiliation(s)
- Lingling Long
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Jie Yan
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China.,Department of Forensic Pathology, Hunan Xiangya Judicial Identification Center, Changsha, China
| | - Qiyan Li
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Ziqi Zhou
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Haixiao Deng
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Chudong Wang
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Ying Zou
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China.,Department of Forensic Pathology, Hunan Xiangya Judicial Identification Center, Changsha, China
| | - Jifeng Cai
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China.,Department of Forensic Pathology, Hunan Xiangya Judicial Identification Center, Changsha, China
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90
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Wohlmuth C, Osei FA, Moise KJ, Wieser I, Johnson A, Papanna R, Bebbington M, Gardiner HM. Changes in ductus venosus flow profile in twin-twin transfusion syndrome: role in risk stratification. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:744-751. [PMID: 26989864 DOI: 10.1002/uog.15916] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/27/2016] [Accepted: 03/07/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To evaluate changes in ductus venosus (DV) waveforms and the timing of these changes in twin-twin transfusion syndrome (TTTS), to relate these to disease severity and to assess the clinical applicability of the suggested measurements in the prediction of TTTS. METHODS DV time intervals and velocity-time integrals (VTI) normalized to cardiac cycle and total VTI, respectively, as well as velocity ratios were analyzed in 149 monochorionic diamniotic (MCDA) twin pairs. Pregnancies were assigned to the following groups: uncomplicated MCDA (n = 29); TTTS Stages I+II (n = 50); TTTS Stages III+IV (n = 49); and pre-TTTS (n = 21), of which 14 remained stable and seven progressed to TTTS. Intertwin differences were calculated as larger/recipient minus smaller/donor and related to disease severity. Receiver-operating characteristics curve analysis was used to distinguish TTTS vs uncomplicated MCDA and pre-TTTS progressing to TTTS vs non-progressing pre-TTTS. Intra- and interobserver reliability of measurement of DV parameters were evaluated using intraclass correlation coefficients (ICCs). RESULTS No intertwin differences in DV parameters were found in uncomplicated MCDA pregnancies. Diastolic VTIs and filling times were significantly shorter in recipient twins in TTTS cases and in larger pre-TTTS twins in comparison with their cotwins. Time intervals, VTIs and velocity ratios correlated significantly with Quintero stages. An intertwin difference in early filling time (eT) normalized to cardiac cycle, eT (%) ≤ -3.6%, could differentiate TTTS from uncomplicated MCDA pregnancies (82.8% sensitivity; 79.8% specificity) and eT (%) ≤ -2.8% predicted progression to TTTS (73.1% sensitivity; 67.4% specificity). CONCLUSIONS DV flow profiles and timing of waveform events are already altered in pre-TTTS and early-stage disease, reflecting abnormal ventricular filling and circulatory imbalance. Intertwin comparison of filling times and VTI may allow prediction of evolving TTTS in MCDA pregnancies. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Wohlmuth
- The Fetal Center at Children's Memorial Hermann Hospital, UTHealth McGovern Medical School, Houston, TX, USA
- Department of Obstetrics and Gynecology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - F A Osei
- The Fetal Center at Children's Memorial Hermann Hospital, UTHealth McGovern Medical School, Houston, TX, USA
| | - K J Moise
- The Fetal Center at Children's Memorial Hermann Hospital, UTHealth McGovern Medical School, Houston, TX, USA
| | - I Wieser
- Department of Obstetrics and Gynecology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - A Johnson
- The Fetal Center at Children's Memorial Hermann Hospital, UTHealth McGovern Medical School, Houston, TX, USA
| | - R Papanna
- The Fetal Center at Children's Memorial Hermann Hospital, UTHealth McGovern Medical School, Houston, TX, USA
| | - M Bebbington
- The Fetal Center at Children's Memorial Hermann Hospital, UTHealth McGovern Medical School, Houston, TX, USA
| | - H M Gardiner
- The Fetal Center at Children's Memorial Hermann Hospital, UTHealth McGovern Medical School, Houston, TX, USA
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92
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Hiersch L, Eitan M, Ashwal E, Weisz B, Chayen B, Lipitz S, Yinon Y. Amniotic fluid discordance in monochorionic diamniotic twin pregnancies is associated with increased risk for twin anemia-polycythemia sequence. Prenat Diagn 2016; 36:1099-1103. [DOI: 10.1002/pd.4939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 09/05/2016] [Accepted: 09/29/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Liran Hiersch
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Mayan Eitan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Eran Ashwal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Boaz Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Benny Chayen
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Shlomo Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
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93
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Fishel-Bartal M, Weisz B, Mazaki-Tovi S, Ashwal E, Chayen B, Lipitz S, Yinon Y. Can middle cerebral artery peak systolic velocity predict polycythemia in monochorionic-diamniotic twins? Evidence from a prospective cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:470-475. [PMID: 26663574 DOI: 10.1002/uog.15838] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 11/10/2015] [Accepted: 11/20/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE The antenatal diagnosis of twin anemia-polycythemia sequence (TAPS) in monochorionic-diamniotic (MCDA) twin pregnancies is based on elevated peak systolic velocity in the middle cerebral artery (MCA-PSV) in the donor twin and decreased MCA-PSV in the recipient twin. However, the association between these parameters and polycythemia has not yet been established. The aim of this study was to determine whether MCA-PSV can predict polycythemia in MCDA pregnancies. METHODS This was a prospective cohort study of MCDA pregnancies recruited at 14-18 weeks' gestation from a single tertiary care center between January 2011 and June 2014. Fetal MCA Doppler waveforms were recorded every 2 weeks from 18 weeks' gestation until delivery. Only those with an MCA-PSV measurement within 1 week of delivery were included in the analysis. Neonatal hematocrit level was determined in all twins from venous blood obtained within 4 h of delivery. Polycythemia was defined as a hematocrit of > 65%, and anemia as a hematocrit of < 45%. TAPS was diagnosed when an intertwin hemoglobin difference of > 8 g/dL and reticulocyte count ratio of > 1.7 were observed. RESULTS Of 162 MCDA pregnancies followed during the study period, 69 had an MCA-PSV measurement within 1 week of delivery and were included in the study. Twenty-five neonates were diagnosed with polycythemia and nine twin pairs met the criteria for TAPS. In a pooled analysis, MCA-PSV was negatively correlated with neonatal hematocrit (P = 0.017, r = -0.215) and was significantly higher in anemic fetuses than in normal controls (1.15 multiples of the median (MoM) vs 1.02 MoM, respectively; P = 0.001). However, MCA-PSV was similar among polycythemic and normal fetuses (0.95 MoM vs 1.02 MoM, respectively; P = 0.47). Intertwin difference in MCA-PSV (delta MCA-PSV) was positively correlated with intertwin hematocrit difference (P = 0.002, r = 0.394). Moreover, twin pregnancies with an intertwin hematocrit difference of > 24% had a significantly greater delta MCA-PSV than did those with an intertwin hematocrit difference of ≤ 24% (delta MCA-PSV, 19 vs 5 cm/s; P < 0.001). CONCLUSIONS MCA-PSV is not significantly decreased in polycythemic MCDA twins. However, delta MCA-PSV is associated with a large intertwin difference in hematocrit, and its use may be better than conventional methods for the risk assessment of TAPS. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Fishel-Bartal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - B Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Mazaki-Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Ashwal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - B Chayen
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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94
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Wohlmuth C, Osei FA, Moise KJ, Johnson A, Papanna R, Bebbington M, Gardiner HM. Aortic distensibility as a surrogate for intertwin pulse pressure differences in monochorionic pregnancies with and without twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:193-199. [PMID: 26663469 DOI: 10.1002/uog.15836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/21/2015] [Accepted: 12/04/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Twin-twin transfusion syndrome (TTTS) complicates 10-15% of monochorionic diamniotic (MCDA) twin pregnancies. The donor response to hypovolemia allows the transfer of vasoactive mediators to the recipient, causing increased recipient afterload and hypertension. Our objective was to apply a novel speckle-tracking technique to measure the aortic fractional area change (AFAC) during the cardiac cycle in MCDA twins with and without TTTS, and identify intertwin differences in AFAC and parameters of cardiac function. METHODS High-frame rate four-chamber views of the fetal heart, including the mid-thoracic aorta, were collected prospectively in MCDA twin pairs referred to our center between June 2014 and April 2015. Using speckle-tracking software, the endovascular border of the aorta was traced manually during systole, with guidance on cardiac cycle timing by anatomical M-mode. AFAC, defined as the difference between maximum and minimum area divided by minimum area, expressed as a percentage, was calculated offline and averaged over three cardiac cycles. Tissue Doppler and displacement were used to measure long-axis cardiac function. Intra- and interclass correlation coefficients were used to test observer variability. RESULTS Fifty-one MCDA twin pregnancies were included, comprising uncomplicated MCDA (n = 14), TTTS Stages 1/2 (n = 21) and TTTS Stages 3/4 (n = 16). Median gestational age was 20.4 (range, 16.2-27.5) weeks. Mean ± SD heart rate was 142.6 ± 7.2 bpm with no significant intertwin pair differences. AFAC was significantly higher in recipients than in donors of TTTS pairs (Stages 1/2: 72.3 ± 29.9% vs 43.7 ± 19.3%, P < 0.001; Stages 3/4: 75.2 ± 29.2% vs 42.5 ± 18.4%, P = 0.002), consistent with higher recipient pulse pressure. No intertwin differences in AFAC were seen in uncomplicated MCDA pairs. Inter- and intraclass correlation coefficients for AFAC were 0.894 and 0.888. AFAC correlated significantly with combined cardiac output (r = 0.252, P = 0.011) and left and right E/E' ratio (left: r = 0.302, P = 0.004; right: r = 0.247, P = 0.030). CONCLUSION AFAC is a quantifiable and reproducible method to assess aortic distensibility and is a promising tool to monitor the response to prelaser therapeutic interventions in pregnancies with TTTS. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Wohlmuth
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
- Department of Obstetrics and Gynecology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - F A Osei
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
| | - K J Moise
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
| | - A Johnson
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
| | - R Papanna
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
| | - M Bebbington
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
| | - H M Gardiner
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
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95
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Shaw CJ, Civale J, Botting KJ, Niu Y, Ter Haar G, Rivens I, Giussani DA, Lees CC. Noninvasive high-intensity focused ultrasound treatment of twin-twin transfusion syndrome: A preliminary in vivo study. Sci Transl Med 2016; 8:347ra95. [PMID: 27412787 DOI: 10.1126/scitranslmed.aaf2135] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/13/2016] [Indexed: 02/11/2024]
Abstract
We investigated the efficacy, maternofetal responses, and safety of using high-intensity focused ultrasound (HIFU) for noninvasive occlusion of placental vasculature compared to sham treatment in anesthetized pregnant sheep. This technique for noninvasive occlusion of placental vasculature may be translatable to the treatment of conditions arising from abnormal placental vasculature, such as twin-twin transfusion syndrome (TTTS). Eleven pregnant sheep were instrumented with maternal and fetal arterial catheters and time-transit flow probes to monitor cardiovascular, acid-base, and metabolic status, and then exposed to HIFU (n = 5) or sham (n = 6) ablation of placental vasculature through the exposed uterine surface. Placental vascular flow was occluded in 28 of 30 targets, and histological examination confirmed occlusion in 24 of 30 targets. In both HIFU and sham exposures, uterine contact reduced maternal uterine artery flow, but delivery of oxygen and glucose to the fetal brain remained normal. HIFU can consistently occlude in vivo placental vessels and ablate blood flow in a pregnant sheep model. Cardiovascular and metabolic fetal responses suggest that the technique is safe in the short term and potentially translatable to human pregnancy.
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Affiliation(s)
- Caroline J Shaw
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK. Institute of Reproductive and Developmental Biology, Imperial College London, London W12 0HS, UK
| | - John Civale
- Joint Department of Physics, Institute of Cancer Research, Sutton, London SM2 5NG, UK
| | - Kimberley J Botting
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - Youguo Niu
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - Gail Ter Haar
- Joint Department of Physics, Institute of Cancer Research, Sutton, London SM2 5NG, UK
| | - Ian Rivens
- Joint Department of Physics, Institute of Cancer Research, Sutton, London SM2 5NG, UK
| | - Dino A Giussani
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - Christoph C Lees
- Institute of Reproductive and Developmental Biology, Imperial College London, London W12 0HS, UK. Department of Obstetrics and Gynaecology, University Hospitals Leuven, 3000 Leuven, Belgium.
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96
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Comparison Between Monochorionic and Dichorionic Placentas With Special Attention to Vascular Anastomoses and Placental Share. Twin Res Hum Genet 2016; 19:191-6. [DOI: 10.1017/thg.2016.19] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Placental vascular anastomoses in twins lead to a shared circulation and may subsequently enable the development of severe complications such as twin–twin transfusion syndrome (TTTS) and twin anemia–polycythemia sequence (TAPS). The presence of vascular anastomoses has frequently and systematically been studied in monochorionic (MC) placentas, but only rarely in dichorionic (DC) placentas. The aim of this study was to compare the prevalence of vascular anastomoses and evaluate the sharing discordance in MC and DC placentas. All consecutive placentas of MC and DC twins delivered at the Leiden University Medical Center (the Netherlands) and Medical University of Warsaw (Poland) from 2012 to 2015 were routinely injected with colored dye and included in the study. We excluded twin pregnancies treated with fetoscopic laser surgery. A total of 258 placentas were analyzed in this study, including 134 MC placentas and 124 DC placentas. Vascular anastomoses were present in 99% (133/134) of MC placentas and 0% of DC placentas (p < .01). Placental share discordance between MC twins was significantly larger compared to DC twins, 19.8 (interquartile range [IQR] 8.1–33.3) and 10.8 (IQR 6.2–19.0), respectively (p < .01). Vascular anastomoses associated complications occurred in 16% (22/134) MC twins. Our findings show that vascular anastomoses are almost ubiquitous in MC placentas, but non-existent in DC placentas. In addition, unequal placental sharing appears to be more common in MC than in DC placentas.
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97
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Wilson I, Henry A, Hinch E, Meriki N, Challis D, Smoleniec J, Welsh AW. Audit of immediate outcomes for MCDA twins following laser therapy for twin-twin transfusion syndrome at the NSW Fetal Therapy Centre. Aust N Z J Obstet Gynaecol 2016; 56:289-94. [PMID: 27029675 DOI: 10.1111/ajo.12464] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 03/03/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To audit immediate pregnancy and neonatal outcomes of selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS) at the New South Wales Fetal Therapy Centre. METHODS Retrospective cohort study of 151 TTTS cases undergoing SLPCV between July 2003 and May 2013, evaluating procedural details, delivery and perinatal outcomes. RESULTS The majority of cases were Stage III at SLPCV (56.9%), although proportion of Stage II SLPCV increased over time (P = 0.03). Survival to hospital discharge of at least one baby was 85.6% and dual survival was 52.5%. Median gestational age at delivery was 32.6 weeks (IQR 29.0-35.0 weeks) with a median of 11.4 weeks (IQR 8.3-14.7) from laser to delivery. Median birthweight was 1792 g (IQR 1288-2233 g), with 75% of babies admitted to the nursery, predominantly secondary to prematurity. Immediate SLPCV complications were in utero fetal demise <1 week postprocedure in 27 fetuses (19.6%) and/or ruptured membranes <1 week postprocedure in 9 fetuses (6.6%). CONCLUSIONS This Australian series shows that local outcomes after SLPCV for stages II-IV TTTS remain equal to the international published literature and have remained stable after an initial learning curve. Women were more likely to be Stage II rather than III in the more recent years. However, this does not appear to be attributable to altered referral patterns.
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Affiliation(s)
- Isabella Wilson
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Amanda Henry
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Maternal Fetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia.,Women's and Children's Health, St George Hospital, Sydney, New South Wales, Australia
| | - Ellen Hinch
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Neama Meriki
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Obstetrics & Gynaecology, King Saud Hospital, Riyadh, Saudi Arabia
| | - Daniel Challis
- Department of Maternal Fetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - John Smoleniec
- Department of Maternal-Fetal Medicine, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Alec William Welsh
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Maternal Fetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
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98
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Wohlmuth C, Gardiner HM, Diehl W, Hecher K. Fetal cardiovascular hemodynamics in twin-twin transfusion syndrome. Acta Obstet Gynecol Scand 2016; 95:664-71. [PMID: 26872246 DOI: 10.1111/aogs.12871] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 01/08/2016] [Indexed: 01/31/2023]
Abstract
Twin-twin transfusion syndrome (TTTS) complicates 10-15% of monochorionic-diamniotic (MCDA) pregnancies. It originates from unbalanced transfer of fluid and vasoactive mediators from one twin to its co-twin via placental anastomoses. This results in hypovolemia in the donor and hypervolemia and vasoconstriction in the recipient twin. Consequently, the recipient demonstrates cardiovascular alterations including atrioventricular valve regurgitation, diastolic dysfunction, and pulmonary stenosis/atresia that do not necessarily correlate with Quintero-stages. Selective fetoscopic laser photocoagulation of placental vascular anastomoses disrupts the underlying pathophysiology and usually improves cardiovascular function in the recipient with normalization of systolic and diastolic function within weeks after treatment. Postnatal studies have demonstrated early decreased arterial distensibility in ex-donor twins, but 10-year follow up is encouraging with survivors showing normal cardiovascular function after TTTS. However, prediction and appropriate early management of TTTS remain poor. Assessment of the cardiovascular system provides additional insight into the pathophysiology and severity of TTTS and may permit more targeted early surveillance of MCDA pregnancies in future. It should form an integral part of the diagnostic algorithm.
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Affiliation(s)
- Christoph Wohlmuth
- The Fetal Center, UT Health School of Medicine, Houston, TX, USA.,Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria
| | | | - Werner Diehl
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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99
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Hamou B, Wainstock T, Mastrolia SA, Beer-Weisel R, Staretz-Chacham O, Dukler D, Rafaeli-Yehudai T, Mazor M, Erez O. Induction of labor in twin gestation: lessons from a population based study. J Matern Fetal Neonatal Med 2016; 29:3999-4007. [PMID: 26864351 DOI: 10.3109/14767058.2016.1152252] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The route of delivery and the role of induction of labor in twin gestations are controversial. The aim of this study was to determine the efficacy of induction of labor in twin gestations. METHODS This retrospective population based cohort study included 4605 twin gestations divided into following groups: 1) spontaneous parturition (n = 2937, 63.78%); 2) induction of labor (n = 653, 14.2%) and 3) elective cesarean delivery (n = 1015, 22.04%). RESULTS The rate of vaginal delivery in the labor induction group was 81% (529/653). In comparison to the other study groups, induction of labor in twins was independently associated with a 77% reduction in the risk of cesarean delivery (OR 0.23; 95% CI 0.18-0.31) and a 78% reduction in the risk of postpartum death for the second twin (OR 0.22; 95% CI 0.05-0.94). The rate of nulliparity, term delivery and labor dystocia was higher in the induction of labor group (p < 0.001 in all comparisons). CONCLUSIONS Our results suggest that induction of labor in twin gestation is successful and is independently associated with substantial reduction in the risk of cesarean delivery and postpartum death of the second twin.
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Affiliation(s)
- Batel Hamou
- a Department of Obstetrics and Gynecology , Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Tamar Wainstock
- b Department of Epidemiology , Faculty of Health Sciences, Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Salvatore Andrea Mastrolia
- a Department of Obstetrics and Gynecology , Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev , Beer Sheva , Israel .,c Department of Obstetrics and Gynecology , Azienda Ospedaliera Universitaria Policlinico Di Bari, School of Medicine, University of Bari "Aldo Moro" , Bari , Italy
| | - Ruthy Beer-Weisel
- a Department of Obstetrics and Gynecology , Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Orna Staretz-Chacham
- d Department of Neonatology , Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev , Beer Sheva , Israel , and
| | - Doron Dukler
- a Department of Obstetrics and Gynecology , Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Tal Rafaeli-Yehudai
- a Department of Obstetrics and Gynecology , Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Moshe Mazor
- a Department of Obstetrics and Gynecology , Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Offer Erez
- e Maternity Department D, Obstetrical Day Care Unit, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev , Beer Sheva , Israel
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100
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Van Winden KR, Quintero RA, Kontopoulos EV, Korst LM, Llanes A, Chmait RH. Decreased Total Placental Mass Found in Twin-Twin Transfusion Syndrome Gestations with Selective Growth Restriction. Fetal Diagn Ther 2016; 40:116-22. [DOI: 10.1159/000442153] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/30/2015] [Indexed: 11/19/2022]
Abstract
Introduction: We examined placental weight characteristics associated with donor selective intrauterine growth restriction (SIUGR) among patients with twin-twin transfusion syndrome (TTTS) who underwent laser surgery. Materials and Methods: Fresh placental specimens were studied. Pregnancies with higher-order multiples, fetal demise, or disrupted or nonsubmitted placental specimens were excluded. Placental characteristics prospectively collected included total placental weight, individual placental weight, and placental share. Data were compared between pregnancies with SIUGR (TTTS + SIUGR group) and those without SIUGR (TTTS-only group). Results: Of 369 consecutive patients who underwent laser surgery for TTTS, 155 (42%) met inclusion criteria: 91 with TTTS + SIUGR and 64 with TTTS-only. Compared to the TTTS-only group, patients in the TTTS + SIUGR group had a lower total placental weight (608 ± 163 vs. 687 ± 224 g, p = 0.012), with a lower donor individual placental weight (237 ± 91 vs. 291 ± 124 g, p = 0.002), but no apparent difference in the individual placental weight of recipient twins (371 ± 109 vs. 396 ± 133 g, p = 0.211). Donor placental share was smaller in those pregnancies affected by SIUGR (38.7 ± 9.6 vs. 42.3 ± 9.8%, p = 0.029). Discussion: TTTS patients with SIUGR had a lower total placental weight and a lower donor individual placental weight compared to those without SIUGR. These findings suggest that differences in donor individual placental weights for SIUGR gestations may not solely be related to differences in placental share.
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