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Stellon MA, Joshi DS, Beninati M, Antony KM, Bohrer J, Hinshaw JL, Monroe E, Winchester C, Lobeck I. Management of twin reversed arterial perfusion (TRAP) sequence with microwave ablation: A case report and review of the literature. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024. [PMID: 38940580 DOI: 10.1002/jcu.23754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/29/2024] [Accepted: 06/09/2024] [Indexed: 06/29/2024]
Abstract
Twin reversed arterial perfusion (TRAP) sequence carries a high mortality risk to the "pump twin." Management involves disrupting blood flow to the acardiac mass. In this case, the pregnant patient presented at 20 weeks 6 days with Stage IIb TRAP Sequence and underwent percutaneous ultrasound-guided microwave ablation (MWA) of the acardiac mass at 21 weeks 0 days. The probe traversed the thorax of the acardiac mass and ablated the confluence of the umbilical vessels. A healthy child was delivered at 33 weeks 5 days gestation. This report demonstrates the utility of MWA in TRAP sequence and describes a novel approach.
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Affiliation(s)
- Michael A Stellon
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Devashish S Joshi
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Michael Beninati
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kathleen M Antony
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Justin Bohrer
- Department of Obstetrics and Gynecology, Gunderson Health System, La Crosse, Wisconsin, USA
| | - J Louis Hinshaw
- Department of Interventional Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Eric Monroe
- Department of Interventional Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Casey Winchester
- Center for Perinatal Care, UnityPoint Health Meriter Hospital, Madison, Wisconsin, USA
| | - Inna Lobeck
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Walcutt JE, Kline-Fath BM, Zhang B, Lim FY, Habli MA, Divanovic AA, Nagaraj UD. Fetal magnetic resonance imaging, ultrasound, and echocardiography findings in twin reversed arterial perfusion sequence. Pediatr Radiol 2024; 54:702-714. [PMID: 38488924 DOI: 10.1007/s00247-024-05879-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Twin reversed arterial perfusion (TRAP) sequence is a rare complication of monochorionic multiple gestation pregnancies, in which the pump twin provides hemodynamic support to a nonviable co-twin (acardius). Fetal magnetic resonance imaging (MRI) is used to detect pump twin abnormalities, particularly brain ischemia, prior to fetal intervention to interrupt umbilical blood flow to the acardius. OBJECTIVE To summarize the imaging findings of TRAP sequence pregnancies in a large series. MATERIALS AND METHODS A single-center retrospective review was performed of all TRAP sequence pregnancies referred for fetal MRI (2004-2021). Fetal MRI, ultrasound, and echocardiography data were collected. RESULTS Eighty-eight TRAP sequence pregnancies with MRI were included (mean gestational age, 19.8±2.8 weeks). Demise of the pump twin was noted in two pregnancies at the time of MRI. By MRI, 12% (10/86) of live pump twins had abnormalities, including 3% (3/86) with brain abnormalities and 9% (8/86) with extra-cranial abnormalities. By echocardiography, 7% (6/86) of pump twins had structural cardiac abnormalities. Three acardius morphological subtypes were identified by MRI: acephalus (55%, 48/88), anceps (39%, 34/88), and amorphous (7%, 6/88). The mean ultrasound acardius to pump twin ratio A/P ratio, calculated for each twin pair as the ratio of the acardius trunk (and head, if present) plus limb volume to the pump twin estimated fetal weight) differed among the three acardius subtypes (P=.03). The mean A/P ratio moderately correlated with pump twin cardiothoracic ratio and combined cardiac output (Pearson's r=0.45 and 0.48, respectively, both P<.001). CONCLUSION Fetal MRI of TRAP sequence pregnancies found anomalies in a substantial number of pump twins. The three acardius subtypes differed in A/P ratio, which moderately correlated with the pump twin cardiothoracic ratio and combined cardiac output.
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Affiliation(s)
- Julie E Walcutt
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
- Division of Radiology, Children's Nebraska, 8200 Dodge Street, Omaha, NE, 68114, USA.
- Department of Radiology, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Beth M Kline-Fath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Department of Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mounira A Habli
- Department of Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Obstetrics and Gynecology, TriHealth Good Samaritan Hospital, Cincinnati, OH, USA
| | - Allison A Divanovic
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Usha D Nagaraj
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Nicolì P, Damiani GR, Gaetani M, Dellino M, Vitagliano A, Malvasi A, Cazzato G, Cascardi E, Marzullo A, Alfonso R, Cicinelli E, Vimercati A. "The Strange Case of Dr Pump and Mr Acardiac": The Twin Reversed Arterial Perfusion (TRAP) Sequence in Two Monochorionic Monoamniotic (MCMA) Twin Pregnancies-Diagnosis, Prognosis and Management: Review of Literature. Diagnostics (Basel) 2023; 13:3109. [PMID: 37835852 PMCID: PMC10572342 DOI: 10.3390/diagnostics13193109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
The Twin Reversed Arterial Perfusion (TRAP) Sequence is an extremely rare complication of monochorionic twin pregnancies, with one severely malformed twin (the "acardiac") lacking autonomous placental blood supply and being perfused by the co-twin (the "pump"), through arterio-arterial (and sometimes also veno-venous) vascular anastomoses located on the placental surface. The prognosis is poor: mortality is 100% in the acardiac twin because of its severe malformations and about 50-55% in the pump twin, mainly due to heart failure and prematurity. So, the goal of perinatal management of the TRAP twin pregnancy is to deliver a healthy and near-term pump twin without heart failure or fetal hydrops. Intuitively, the earlier the diagnosis, the better the outcome. Herein, we report two cases of monochorionic monoamniotic (MCMA) twin pregnancies complicated by the TRAP Sequence, which are of interest since the objective of early diagnosis was achieved by means of transvaginal and 3D ultrasound, two techniques which revealed themselves as being useful to this purpose but are underused in the literature. The second aim of this study is to provide an overview of literature data about the diagnosis, prognosis establishment, and management of this rare condition, which are still debated and unclear due to negligible poor-quality evidence.
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Affiliation(s)
- Pierpaolo Nicolì
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Gianluca Raffaello Damiani
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Maria Gaetani
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Miriam Dellino
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Amerigo Vitagliano
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | | | - Gerardo Cazzato
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Eliano Cascardi
- Department of Medical Sciences, University of Turin, 10124 Turin, Italy
- Pathology Unit, FPO-IRCCS Candiolo Cancer Institute, 10060 Candiolo, Italy
| | - Andrea Marzullo
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Raffaello Alfonso
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Ettore Cicinelli
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Antonella Vimercati
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
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Rahimi-Sharbaf F, Shirazi M, Hessami K, Saleh M, Golshahi F, Saeedi S, Shirdel Abdolmaleki A, Mousavi Vahed SH, Nouri B, Sahebdel B. Radiofrequency Ablation and Intrauterine Transfusion in a Delayed Diagnosed Acardiac Twin Pregnancy. Case Rep Obstet Gynecol 2023; 2023:3243820. [PMID: 37680203 PMCID: PMC10482538 DOI: 10.1155/2023/3243820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/21/2022] [Accepted: 07/11/2023] [Indexed: 09/09/2023] Open
Abstract
Twin reversed arterial perfusion (TRAP) sequence or acardiac twin is a rare and severe complication of monochorionic multiple pregnancies. Acardiac twin accounts for 10% of all TRAP sequences, which is the most morphologically developed acardius. We present an undiagnosed TRAP sequence case up to 24 weeks of gestation who underwent successful amnioreduction, radiofrequency ablation (RFA), and intrauterine transfusion (IUT). During follow-up, hydrops of surviving co-twin disappeared, and fetal heart function improved. Finally, a healthy girl weighing 2400 g was born at 36 weeks of gestation. To our knowledge, this is the first reported acardiac twin pregnancy, which requires IUT, in addition to RFA, due to late diagnosis. Therefore, this case report presents successful management options for TRAP sequence cases diagnosed late in pregnancy.
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Affiliation(s)
- Fatemeh Rahimi-Sharbaf
- Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Shirazi
- Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Maasoumeh Saleh
- Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Golshahi
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Saeedi
- Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Behnaz Nouri
- Department of Community Medicine, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Behrokh Sahebdel
- Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Molina-Giraldo S, Torres-Valencia N, Johnson A, Lewi L, Ryan G, Sepúlveda W. The Management of Acardiac Twinning: Twin Reverse Arterial Perfusion Sequence - An International Survey. Fetal Diagn Ther 2023; 50:446-453. [PMID: 37536303 DOI: 10.1159/000531791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/27/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION The optimal approach and therapy method for the acardiac twin with a reverse arterial perfusion sequence has not yet been established. The aim of this study was to determine the clinical practice patterns among international fetal therapy units in their management of these cases. METHODS A survey was sent to fetal centers across the world via email between December 2020 and December 2021. RESULTS Responses were obtained from 77% contacted centers. The most frequent ultrasound variables used in the evaluation of twin reverse arterial perfusion sequence include echocardiographic assessment of the pump twin and umbilical artery Doppler waveforms in the acardiac and pump twins, in 90% and 80% of the centers, respectively. Most centers in Europe and Latin America propose an in utero intervention in all cases. Most centers in Europe and Latin America prefer interstitial laser ablation, whereas radiofrequency ablation (RFA) is preferred in North America. The earliest gestational age for an intervention is on mean 13 weeks in Europe, which is earlier than the other geographic areas (p = 0.001). CONCLUSIONS Most centers agreed that antenatal evaluation should include echocardiography along with the UA Doppler waveform measurements, and the most frequently used interventions were interstitial laser ablation or RFA at a median between 14 and 26 weeks.
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Affiliation(s)
- Saulo Molina-Giraldo
- Section of Fetal Therapy and Fetal Surgery Unit, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology Hospital de San José, Department of Obstetrics and Gynecology Fundación Universitaria de Ciencias de la Salud - FUCS, Bogota, Colombia
- Fetal Therapy and Surgery Network - FetoNetwork, Bogota, Colombia
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics Faculty of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
| | - Natalia Torres-Valencia
- Section of Fetal Therapy and Fetal Surgery Unit, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology Hospital de San José, Department of Obstetrics and Gynecology Fundación Universitaria de Ciencias de la Salud - FUCS, Bogota, Colombia,
- Fetal Therapy and Surgery Network - FetoNetwork, Bogota, Colombia,
| | - Anthony Johnson
- The Fetal Center, Children's Memorial Hospital, University of Texas Health Science Center, Houston, Texas, USA
| | - Liesbeth Lewi
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Universitaire Ziekenhuizen, Leuven, Belgium
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Greg Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Waldo Sepúlveda
- FETALMED-Maternal-Fetal Diagnostic Center, Fetal Imaging Unit, Santiago, Chile
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Lee HS, Abbasi N, Van Mieghem T, Mei-Dan E, Audibert F, Brown R, Coad S, Lewi L, Barrett J, Ryan G. Directive clinique n o 440 : Prise en charge de la grossesse gémellaire monochoriale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:607-628.e8. [PMID: 37541735 DOI: 10.1016/j.jogc.2023.05.019] [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: 08/06/2023]
Abstract
OBJECTIF Cette directive clinique passe en revue les données probantes sur la prise en charge de la grossesse gémellaire monochoriale normale et compliquée. POPULATION CIBLE Les femmes menant une grossesse gémellaire ou multiple de haut rang. BéNéFICES, RISQUES ET COûTS: L'application des recommandations de cette directive devrait améliorer la prise en charge des grossesses gémellaires (ou multiples de haut rang) monochoriales compliquées et non compliquées. Ces recommandations aideront les fournisseurs de soins à surveiller adéquatement les grossesses gémellaires monochoriales ainsi qu'à détecter et prendre en charge rapidement les complications associées de façon optimale afin de réduire les risques de morbidité et mortalité périnatales. Ces recommandations impliquent une surveillance échographique plus fréquente en cas de grossesse monochoriale qu'en cas de grossesse bichoriale. DONNéES PROBANTES: La littérature publiée a été colligée par des recherches dans les bases de données PubMed et Cochrane Library au moyen de termes MeSH pertinents (Twins, Monozygotic; Ultrasonography, Prenatal; Placenta; Fetofetal Transfusion; Fetal Death; Fetal Growth Retardation). Les résultats ont été restreints aux revues systématiques, aux essais cliniques randomisés et aux études observationnelles. Aucune date limite n'a été appliquée, mais les résultats ont été limités aux contenus en anglais ou en français. MéTHODES DE VALIDATION: Les auteurs principaux ont rédigé le contenu et les recommandations et ils se sont entendus sur ces derniers. Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Spécialistes en médecine fœto-maternelle, obstétriciens, radiologues, échographistes, médecins de famille, infirmières, sages-femmes, résidents et autres fournisseurs de soins de santé qui s'occupent de femmes menant une grossesse gémellaire ou multiple de haut rang. RéSUMé POUR TWITTER: Directive canadienne (SOGC) pour le diagnostic, la surveillance échographique et la prise en charge des complications de la grossesse gémellaire monochoriale (p. ex., STT, TAPS, retard de croissance sélectif, cojumeau acardiaque, monoamnionicité et mort d'un jumeau). DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Pathak S, Raj G. Vanishing acardiac twin with TRAP syndrome: A case report. Radiol Case Rep 2023; 18:2735-2737. [PMID: 37304313 PMCID: PMC10250825 DOI: 10.1016/j.radcr.2023.05.025] [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: 02/17/2023] [Revised: 05/04/2023] [Accepted: 05/07/2023] [Indexed: 06/13/2023] Open
Abstract
Acardiac twin is a rare complication of monochorionic twin pregnancy. We present case of a 24 years-old primigravida with monochorionic pregnancy having an amorphous acardiac twin diagnosed during routine first trimester ultrasound scan. She was managed expectantly since there were no signs of hemodynamic compromise in the normal twin with close ultrasound fetal surveillance using gray scale and color Doppler ultrasound. Spontaneous regression of vascularity with reduced size of the acardiac twin was seen subsequently.
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Lee HS, Abbasi N, Van Mieghem T, Mei-Dan E, Audibert F, Brown R, Coad S, Lewi L, Barrett J, Ryan G. Guideline No. 440: Management of Monochorionic Twin Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:587-606.e8. [PMID: 37541734 DOI: 10.1016/j.jogc.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
OBJECTIVE This guideline reviews the evidence-based management of normal and complicated monochorionic twin pregnancies. TARGET POPULATION Women with monochorionic twin or higher order multiple pregnancies. BENEFITS, HARMS, AND COSTS Implementation of these recommendations should improve the management of both complicated and uncomplicated monochorionic (and higher order multiple) twin pregnancies. They will help users monitor monochorionic twin pregnancies appropriately and identify and manage monochorionic twin complications optimally in a timely manner, thereby reducing perinatal morbidity and mortality. These recommendations entail more frequent ultrasound monitoring of monochorionic twins compared to dichorionic twins. EVIDENCE Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate MeSH headings (Twins, Monozygotic; Ultrasonography, Prenatal; Placenta; Fetofetal Transfusion; Fetal Death; Fetal Growth Retardation). Results were restricted to systematic reviews, randomized controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. VALIDATION METHODS The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE Maternal-fetal medicine specialists, obstetricians, radiologists, sonographers, family physicians, nurses, midwives, residents, and other health care providers who care for women with monochorionic twin or higher order multiple pregnancies. TWEETABLE ABSTRACT Canadian (SOGC) guidelines for the diagnosis, ultrasound surveillance and management of monochorionic twin pregnancy complications, including TTTS, TAPS, sFGR (sIUGR), acardiac (TRAP), monoamniotic twins and intrauterine death of one MC twin. SUMMARY STATEMENTS RECOMMENDATIONS.
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Alshanafey S, Al-Nemer M, Tulbah M, Khan RM, Sahan NA, Mugbel MA, Al-Hazzani F, Almutairi G, Kurdi W. Management of twin reversed arterial perfusion sequence: eight cases over 13 years. Ann Saudi Med 2023; 43:199-203. [PMID: 37554025 DOI: 10.5144/0256-4947.2023.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Twin reversed arterial perfusion (TRAP) sequence is a rare condition that affects primarily monozygotic monochorionic twin pregnancies in which a normal twin acts as a pump (donor) for an acardiac recipient (perfuse) twin. OBJECTIVE We report our experience over the last 13 years at a tertiary health care center. DESIGN Descriptive, retrospective case series SETTING: Tertiary health care center PATIENTS AND METHODS: All TRAP cases managed between the years 2009 and 2022 at our Fetal Diagnosis and Therapy Center were included. Data recorded included demographic and clinical information which was used to generate descriptive data. Patients were managed by a multidisciplinary team with variable interventions. MAIN OUTCOME MEASURE Survival of normal twin SAMPLE SIZE: Eight RESULTS: Eight pregnant women with TRAP syndrome were managed at our center during that period. One was monozygotic monochorionic and the others were monochorionic diamniotic. Median maternal age at presentation was 27 years and median gestational age at diagnosis was 23 weeks. All were diagnosed with ultrasound (US) imaging. Three were managed with bipolar ligation of the cord of the acardiac twin under general anesthesia, one US-guided (single port) and 2 fetoscopic (2 ports) with a median operative time of 39 minutes. The last five cases were managed with US-guided radiofrequency ablation (RFA) under local anesthesia, one needed 2 sessions, 1 week apart. The median duration of the RFA procedure was 23 minutes. There were no complications and all had viable normal babies born at a median of 32 weeks of gestation (6 C-section, 2 spontaneous membrane rupture). CONCLUSIONS Acardiac twin cord ligation and RFA are feasible and safe options with excellent outcome for TRAP syndrome. RFA may be preferable owing to its less invasiveness under local anesthesia. LIMITATIONS None, given the rarity of the disease and the study design. CONFLICT OF INTEREST None.
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Affiliation(s)
- Saud Alshanafey
- From the Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Maha Al-Nemer
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Maha Tulbah
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Rubina Ma Khan
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Nada Al Sahan
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Maisoon Al Mugbel
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fahad Al-Hazzani
- From the Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gawaher Almutairi
- From the Department of Fetal Therapy, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Wesam Kurdi
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Application of Color Doppler with 3- and 4-Dimensional Ultrasonography in the Prenatal Evaluation of Fetal Extracardiac and Placental Abnormalities. Healthcare (Basel) 2023; 11:healthcare11040488. [PMID: 36833022 PMCID: PMC9956359 DOI: 10.3390/healthcare11040488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/05/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023] Open
Abstract
Using color Doppler flow imaging or high-definition flow imaging with three-dimensional volume or spatio-temporal image correlation (STIC) in the glass-body mode allows displaying both gray-scale and color information of the heart cycle-related flow events and vessel spatial relationship. Conventionally, STIC in the glass-body mode has been used to examine the fetal heart and assess heart defects. Recently, a novel application of STIC in the visualization of abdominal precordial veins and intraplacental vascularization in singleton pregnancies has been reported. The aim of this present review is to discuss the use of color Doppler with three- and four-dimensional ultrasonography in the evaluation of extracardiac, placental, umbilical cord and twin abnormalities with examples. The glass-body mode is complementary to conventional 2D ultrasonography. Further studies are required to investigate use of the glass-body mode in the assessment of intraplacental vascularization in singleton and twin pregnancies.
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Anh ND, Thu Ha NT, Sim NT, Toan NK, Thuong PTH, Duc NM. Twin reversed arterial perfusion sequence-a rare and dangerous complication form of monochorionic twins: A case report. World J Clin Cases 2022; 10:10214-10219. [PMID: 36246815 PMCID: PMC9561595 DOI: 10.12998/wjcc.v10.i28.10214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/09/2022] [Accepted: 08/23/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Twin reversed arterial perfusion (TRAP) sequence is an extremely rare congenital anomaly in monochorionic (MC) twins. The condition is characterized by a malformed fetus (acardiac twin) without cardiac activities being perfused by a structurally normal one (pump twin) via an artery-to-artery anastomosis in a reverse direction.
CASE SUMMARY We described the first case of TRAP to receive laser surgery in Vietnam. The 26-wk pregnancy was originally misdiagnosed in another hospital as MC twins with single intrauterine fetal death. Following admission to our center, the diagnosis was amended to a 26-wk TRAP sequence stage IIb. The acardiac twin was 7.5 cm at the longest length, the ratio of the weight of the acardiac twin to the weight of the pump twin was more than 90%, the pump twin showed fetal distress with absent diastolic flow in umbilical artery of pump twin, and the peak systolic velocity in the middle cerebral artery = 1.6 MoM. We performed emergency laser photocoagulation of the acardiac twin’s umbilical cord. After surgery, we successfully maintained the pregnancy for 8 wk and ended it electively by cesarean section at 34 wk of gestation due to rupture of membranes.
CONCLUSION TRAP should be appropriately diagnosed and treated early to avoid complications of the pump twin. Fetoscopic laser photocoagulation is a new and effective treatment for this condition.
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Affiliation(s)
- Nguyen Duy Anh
- Fetal Medicine Center, Hanoi Obstetrics and Gynecology Hospital, Hanoi 100000, Vietnam
| | - Nguyen-Thi Thu Ha
- Department of Assisted Reproduction, Hanoi Obstetrics and Gynecology Hospital, Hanoi 100000, Vietnam
| | - Nguyen-Thi Sim
- Fetal Medicine Center, Hanoi Obstetrics and Gynecology Hospital, Hanoi 100000, Vietnam
| | - Nguyen Khac Toan
- Department of Obstetrics and Gynecology, Hanoi University of Medicine and Pharmacy, Hanoi 100000, Vietnam
| | - Phan-Thi Huyen Thuong
- Department of Obstetrics and Gynecology, Hanoi University of Medicine and Pharmacy, Hanoi 100000, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City 700000, Vietnam
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12
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Twin Reversed Arterial Perfusion Sequence: Prenatal Diagnosis and Treatment. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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13
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Dhanju G, Breddam A. Twin reversed arterial perfusion (TRAP) sequence: A case report and a brief literature review. Radiol Case Rep 2022; 17:1682-1691. [PMID: 35342490 PMCID: PMC8942792 DOI: 10.1016/j.radcr.2022.02.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/19/2022] [Indexed: 11/24/2022] Open
Abstract
Twin reversed arterial perfusion (TRAP) sequence is rare in monochorionic twin pregnancies. TRAP sequence is distinct from other multifetal pregnancies in that one of the twins has normal anatomy while the other twin has a varied amount of characteristic abnormal features. In the literature, mortality is reported 100% in the abnormal twin. We report 1 case of TRAP sequence at our institution in which the diagnosis of TRAP sequence was missed in the first trimester at another hospital. The patient, a 33-year-old G1P0A0, did not have any follow-up after her first scan until the routine second-trimester ultrasound at our institution. Both the radiologist and the sonographer did not appreciate the differential diagnosis of TRAP sequence in their clinical decision-making. The TRAP diagnosis was established after the ultrasound performed at the fetal assessment unit in our hospital. Radiofrequency ablation (RFA) procedure was performed to give the normal twin a chance to survive, but unfortunately, the prognosis was poor in this case. We conclude that diagnosing a TRAP sequence is very important early in the pregnancy for a positive outcome in the normal twin. A robust collaboration among radiologists and obstetricians is vital for the best outcome of the normal twin.
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14
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Brock CO, Johnson A. Twin reverse arterial perfusion: Timing of intervention. Best Pract Res Clin Obstet Gynaecol 2022; 84:127-142. [PMID: 35466064 DOI: 10.1016/j.bpobgyn.2022.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/13/2022] [Indexed: 11/24/2022]
Abstract
Twin reverse arterial perfusion (TRAP) sequence is a severe anomaly in monochorionic twins where one twin has profound corporeal underdevelopment and acardia. The normal "pump" co-twin provides blood flow to the acardiac twin through placental anastomoses which may lead to cardiac failure and pump twin demise as well as preterm delivery from severe polyhydramnios. Treatments include radiofrequency ablation, bipolar cord coagulation, and intrafetal laser with each aimed at occluding blood flow to the acardiac twin. However, none of these modalities has proven superior in terms of either pump twin survival or minimization of complications, including preterm premature rupture of membranes, preterm birth, or unexpected co-twin demise. The optimal timing of treatment is also unknown, without clear indications for intervention versus expectant management. Very early treatment of TRAP (i.e., <16 weeks) has been proposed to reduce first-trimester demise; however, this approach remains experimental. Further investigation is required to determine the best treatment and timing of intervention for TRAP.
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Affiliation(s)
- Clifton O Brock
- Department of Obstetrics, Gynecology and Reproductive Services, University of Texas Health Science Center at Houston, United States; The Fetal Center at Children's Memorial Hermann Hospital, United States
| | - Anthony Johnson
- Department of Obstetrics, Gynecology and Reproductive Services, University of Texas Health Science Center at Houston, United States; The Fetal Center at Children's Memorial Hermann Hospital, United States.
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15
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Gemert MJC, Ross MG, Wijngaard JPHM, Nikkels PGJ. Hypothesized pathogenesis of acardius acephalus, acormus, amorphus, anceps, acardiac edema, single umbilical artery, and pump twin risk prediction. Birth Defects Res 2021; 114:149-164. [PMID: 34931489 PMCID: PMC9299632 DOI: 10.1002/bdr2.1976] [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: 10/09/2021] [Accepted: 12/04/2021] [Indexed: 11/16/2022]
Abstract
Background Acardiac twinning complicates monochorionic twin pregnancies in ≈2.6%, in which arterioarterial (AA) and venovenous placental anastomoses cause a reverse circulation between prepump and preacardiac embryos and cessation of cardiac function in the preacardiac. Literature suggested four acardiac body morphologies in which select (groups of) organs fail to develop, deteriorate, or become abnormal: acephalus (≈64%, [almost] no head, part of body, legs), amorphus (≈22%, amorphous tissue lump), anceps (≈10%, cranial bones, well‐developed), and acormus (≈4%, head only). We sought to develop hypotheses that could explain acardiac pathogenesis, its progression, and develop methods for clinical testing. Methods We used qualitatively described pathophysiology during development, including twin‐specific AA and Hyrtl's anastomoses, the short umbilical cord syndrome, high capillary permeability, properties of spontaneous aborted embryos, and Pump/Acardiac umbilical venous diameter (UVD) ratios. Results We propose that each body morphology has a specific pathophysiologic pathway. An acephalus acardius may be larger than an anceps, verifiable from UVD ratio measurements. A single umbilical artery develops when one artery, unconnected to the AA, vanishes due to flow reduction by Hyrtl's anastomotic resistance. Acardiac edema may result from acardiac body hypoxemia combined with physiological high fetal capillary permeability, high interstitial compliance and low albumin synthesis. Morphological changes may occur after acardiac onset. Pump twin risk follows from UVD ratios. Conclusion Our suggested outcomes agree reasonably well with reported onset, incidence, and progression of acardiac morphologies. Guidance for clinical prediction and testing requires ultrasound anatomy/circulation study, from the first trimester onward.
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Affiliation(s)
- Martin J. C. Gemert
- Department of Biomedical Engineering & Physics Amsterdam UMC Amsterdam The Netherlands
| | - Michael G. Ross
- Department of Obstetrics and Gynecology Harbor UCLA Medical Center Torrance California USA
| | - Jeroen P. H. M. Wijngaard
- Department of Clinical Chemistry, Hematology and Immunology Diakonessenhuis Utrecht Zeist Doorn Utrecht The Netherlands
| | - Peter G. J. Nikkels
- Department of Pathology, Wilhelmina Children’s Hospital University Medical Center Utrecht The Netherlands
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16
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Chan KS, Chuang YC, Lin TY, Shaw SW. A Taiwan's experience: A case report and review of literature of successful early intrauterine treatment with radiofrequency ablation in twin reversed arterial perfusion (TRAP) sequence. J Formos Med Assoc 2021; 120:1394-1399. [PMID: 33583701 DOI: 10.1016/j.jfma.2021.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 01/20/2021] [Accepted: 01/24/2021] [Indexed: 11/30/2022] Open
Abstract
Acardiac twin or twin reversed arterial perfusion (TRAP) sequence is a rare medical complication of Monozygotic twins. Taiwanese Obstetricians usually treat TRAP sequence conservatively. Occasionally, repeated amnio-reduction is performed to decompress the polyhydramnios caused by the TRAP sequence, even though there was no correction of the pathophysiologic mechanism. Radiofrequency ablation is a minimally invasive, percutaneous technique that can effectively obliterate blood supply to an acardiac twin to preserve and protect the pump twin. This recent technique has never been used before for the treatment of the TRAP sequence in Taiwan. This article reported the first-hand experience of acardiac twin management with RFA in Taipei Chang Gung Memorial Hospital.
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Affiliation(s)
- Kok-Seong Chan
- Malaysian Ministry of Health, Malaysia; Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Ya-Chun Chuang
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Tzu-Yi Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Steven W Shaw
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Prenatal Cell and Gene Therapy Group, Institute for Women's Health University College London, London, United Kingdom.
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17
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‘TRAP-ped with an Acardius’: Case Series of Twin Reversed Arterial Perfusion (TRAP) Sequence and Review of Literature. JOURNAL OF FETAL MEDICINE 2021. [DOI: 10.1007/s40556-020-00286-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractTwin reversed arterial perfusion (TRAP) sequence is a rare but severe condition that affects monochorionic (MC) multifetal pregnancies. In twin pregnancies, it is characterized by a normally developed twin and another twin with missing heart function (acardiac twin or TRAP twin). A variety of risks and complications may affect the normal twin. Management of such pregnancies can be either expectant or interventional. We report four cases of TRAP sequence treated in our institutions and supply an overview on currently existing literature. This case series demonstrates the heterogeneity in manifestations and clinical course of patients affected by this condition. Furthermore, it includes an acardius amorphous of considerable size delivered at 35.6 weeks of gestation.
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18
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Sharma D, Tsibizova VI. Current perspective and scope of fetal therapy: part 1. J Matern Fetal Neonatal Med 2020; 35:3783-3811. [PMID: 33135508 DOI: 10.1080/14767058.2020.1839880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical Science, Jaipur, India
| | - Valentina I Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, Saint Petersburg, Russia
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19
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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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20
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Vitucci A, Fichera A, Fratelli N, Sartori E, Prefumo F. Twin Reversed Arterial Perfusion Sequence: Current Treatment Options. Int J Womens Health 2020; 12:435-443. [PMID: 32547251 PMCID: PMC7266514 DOI: 10.2147/ijwh.s214254] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Twin reversed arterial perfusion (TRAP) sequence is a specific and severe complication of monochorionic multiple pregnancy, characterized by vascular anastomosis and partial or complete lack of cardiac development in one twin. Despite its rarity, interest in the international literature is rising, and we aimed to review its pathogenesis, prenatal diagnostic features and treatment options. Due to the parasitic hemodynamic dependence of the acardiac twin on the pump twin, the management of these pregnancies aims to maximize the pump twin's chances of survival. If treatment is needed, the best timing of intervention is still debated, although the latest studies encourage intervention in the first trimester of pregnancy. As for the technique of choice to interrupt the vascular supply to the acardiac twin, ultrasound-guided laser coagulation and radiofrequency ablation of the intrafetal vessels are usually the preferred approaches.
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Affiliation(s)
- Annachiara Vitucci
- Division of Obstetrics and Gynecology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Anna Fichera
- Division of Obstetrics and Gynecology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Nicola Fratelli
- Division of Obstetrics and Gynecology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Enrico Sartori
- Division of Obstetrics and Gynecology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Federico Prefumo
- Division of Obstetrics and Gynecology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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21
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Wataganara T, Phithakwatchara N, Pooliam J, Jaingam S, Thongkloung P, Mongkolchat N, Viboonchart S, Nawapun K. Morphology, intrafetal vascular pattern, and umbilical artery Doppler indices of acardiac twins. Prenat Diagn 2020; 40:958-965. [PMID: 32297344 DOI: 10.1002/pd.5710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/10/2020] [Accepted: 04/12/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Twin reversed arterial perfusion (TRAP) sequence consists of acardiac twin (A) paradoxically perfused by pump twin (P) through an umbilical artery (UA). We proposed characterization of acardiac twins with intrafetal vascular pattern (IVP), and assessed its correlation with morphology and UA Doppler indices. METHODS We prospectively evaluated 21 cases of TRAP sequence. Morphology (acardia vs hemicardia) and IVP (simple vs complex) of acardiac twins were characterized with ultrasound and color Doppler. Twins weight ratio (A/P Wt) and UA Doppler indices of acardiac and pump twins including (1) difference of systolic/diastolic ratio (UA ∆S/D), (2) difference of resistance index (UA ∆RI), and (3) ratio of pulsatility index (UA PI A/P) were calculated. RESULTS The median (min, max) gestational age at diagnosis was 18 (11, 27) weeks. Acardia (n = 14) were associated with simple IVP (n = 16) (P < .05). After exclusion of acardia with complex IVP (n = 1), the A/P Wt, UA ∆S/D, UA ∆RI, and UA PI A/P of acardia with simple IVP (n = 13), hemicardia with simple IVP (n = 3), and hemicardia with complex IVP (n = 4) were not significantly different (P > .05). CONCLUSIONS Most of acardiac twins were acardia with simple IVP. Morphology and IVP of acardiac twins were not associated with UA Doppler indices.
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Affiliation(s)
- Tuangsit Wataganara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Nisarat Phithakwatchara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Julaporn Pooliam
- Division of Clinical Epidemiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suparat Jaingam
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Piyatida Thongkloung
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Nadda Mongkolchat
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Sommai Viboonchart
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Katika Nawapun
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
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22
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Seshadri S, Shinde RR, Ram U. Intrafetal laser for midtrimester TRAP sequence-experience from a single center. Prenat Diagn 2020; 40:885-891. [PMID: 32281112 DOI: 10.1002/pd.5707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 12/16/2018] [Accepted: 04/06/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To report our experience and evaluate outcomes in monochorionic pregnancies with Twin Reversed Arterial Perfusion sequence with intrafetal laser therapy. METHODS Retrospective review of records of all pregnancies with TRAP sequence treated by intrafetal laser therapy between 2011 January and 2015 December that were retrieved and analysed. RESULTS Electronic search of the scan database retrieved 57 cases of TRAP sequence during the study period, 7 triplets and 50 monochorionic twins. Intrafetal laser was done in 27 cases, 22 cases of twins and 5 cases of triplets. In the twins group, median gestational age at intervention was 22.5 weeks, the earliest done at 16.3 weeks. The median gestational age at delivery and birth weight was 37 weeks and 2.5 Kgs. The median procedure and delivery interval was 14 weeks. Live birth rate was 17/22 (77%) the pump survival rate was 16/22 (73%). Pregnancies with non-surviving pump were 5 in numbers (5/22). A repeat procedure was warranted in one case. In the triplet group, median gestational age at intervention, delivery and procedure delivery interval was 18, 35 and 17 weeks. CONCLUSION Intrafetal laser is simple, effective and the treatment of choice to interrupt the vascular supply to acardiac twin.
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Affiliation(s)
| | - Roopa R Shinde
- Fetal Medicine Department, Mediscan Systems, Chennai, India
| | - Uma Ram
- Obstetrics and Gynecology, Seethapathy Clinic & Hospital, Chennai, India
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23
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Abstract
The growth of the field of fetal surgery over the last two decades driven by new indications and data from prospective randomized trials supporting prenatal intervention has resulted in techniques protocols and methodologies that have gained confidence by insuring good outcomes. Error traps are methods or techniques that usually work well in most of the cases, but which are apt to fail under certain specific circumstances. The very confidence the surgeon develops in these techniques or methodologies makes them a trap for the unwary surgeon. The purpose of this article is to discuss common error traps in fetal interventions, including ultrasound guided procedures, fetoscopic surgery, open fetal surgery and EXIT procedures. Awareness of these error traps and approaches to avoid them may enhance fetal surgical outcomes and reduce complications rates.
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Affiliation(s)
- Jose L Peiro
- Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, College of Medicine at University of Cincinnati, and the Cincinnati Children's Hospital Medical Center (CCHMC). Cincinnati, OH, USA
| | - Timothy M Crombleholme
- Fetal Care Center Dallas, Division of Pediatric Surgery, Department of Surgery, and the Medical City Children's Hospital, Suite C 742, 7777 Forrest Lane, Dallas, TX 75230, USA.
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24
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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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25
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Zhang ZT, Yang T, Liu CX, Li N. Treatment of twin reversed arterial perfusion sequence with radiofrequency ablation and expectant management: A single center study in China. Eur J Obstet Gynecol Reprod Biol 2018; 225:9-12. [PMID: 29626712 DOI: 10.1016/j.ejogrb.2018.03.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 03/20/2018] [Accepted: 03/23/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the treatment of pregnancies in different stages complicated by TRAP sequence at a single medical center in China. STUDY DESIGN A retrospective study evaluating 25 pregnancies with TRAP sequence was performed at Shengjing Hospital in Shenyang, Liaoning between 2012 and 2016. Patients were diagnosed by ultrasound and categorized into three groups (Ia, IIa and IIb) and were expectantly managed or performed RFA (radiofrequency ablation) according to their stage of TRAP sequence. Perinatal outcomes and survival rates were analyzed. RESULTS There were four cases in stage Ia, 19 cases in stage IIa, and two cases in stage IIb. Cases in stage Ia were expectantly managed. Among cases in stage IIa, we performed RFA (radiofrequency ablation) in 10 cases and expectant management in 6 cases, with the remainder of the patients refusing intrauterine treatment. We applied RFA to treat one case in stage IIb and the other was managed expectantly. For expectant management group and the RFA group, the survival rates were both 64%(7/11). All pump twins in stage Ia survived and the average gestational age at delivery was 37.9 weeks. In stage IIa, the overall survival rate of the pump twin was 70% (7/10) and the average gestational age at delivery was 35.8 weeks in cases treated by RFA. The survival rate was 50% (3/6) and the average gestational age at delivery was 32.8 weeks in expectantly managed cases in stage IIa. No pump twin survived in stage IIa without treatment (3 cases refused any therapy who were excluded) or in stage IIb. CONCLUSION Expectant management is effective for treatment of TRAP sequence in stage Ia. In stage IIa, RFA improves the prognosis of pump twins.
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Affiliation(s)
- Zhi-Tao Zhang
- Department of Gynaecology and Obstetrics, ShengJing Hospital Affiliated to China Medical University, Shen Yang City, Liao Ning Province, China
| | - Tian Yang
- Department of Gynaecology and Obstetrics, ShengJing Hospital Affiliated to China Medical University, Shen Yang City, Liao Ning Province, China
| | - Cai-Xia Liu
- Department of Gynaecology and Obstetrics, ShengJing Hospital Affiliated to China Medical University, Shen Yang City, Liao Ning Province, China.
| | - Na Li
- Department of Gynaecology and Obstetrics, ShengJing Hospital Affiliated to China Medical University, Shen Yang City, Liao Ning Province, China
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26
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Radiofrequency ablation for selective reduction in complex monochorionic multiple pregnancies: A case series. Taiwan J Obstet Gynecol 2017; 56:740-744. [DOI: 10.1016/j.tjog.2017.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 01/26/2023] Open
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27
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Khedr S, Jazaerly T, Kostadinov S. Placental Teratoma, Omphalomesenteric Duct Remnant, or Intestinal Organoid (Enteroid) Differentiation: A Diagnostic Dilemma. J Pediatr Genet 2017; 6:252-257. [PMID: 29142770 PMCID: PMC5683956 DOI: 10.1055/s-0037-1603916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/18/2017] [Indexed: 10/19/2022]
Abstract
We report an unusual case of fully developed fetal intestinal segment(s) within a nodule on the chorionic plate of the placenta of a 27-year-old female patient at 37 weeks gestation with spontaneous vaginal delivery. Gross examination of the placenta revealed a chorionic plate nodule near the insertion of the umbilical cord, which, upon microscopic evaluation, raised the differential diagnostic possibilities of placental teratoma, vitelline/omphalomesenteric duct anomaly, and intestinal organoid differentiation. We discuss the distinguishing features, morphogenesis, and clinical significance of the aforementioned entities and review the pertinent medical literature.
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Affiliation(s)
- Salwa Khedr
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island, United States
| | - Tarek Jazaerly
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School of Brown University, Kent Hospital, Warwick, Rhode Island, United States
| | - Stefan Kostadinov
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island, United States
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Morin L, Lim K. N° 260-Échographie et grossesse gémellaire. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:e436-e452. [PMID: 28935067 DOI: 10.1016/j.jogc.2017.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Dubey S, Verma M, Goel P, Punia R. Twin Reversed Arterial Perfusion: To Treat or Not? J Clin Diagn Res 2017; 11:QD05-QD07. [PMID: 28274006 DOI: 10.7860/jcdr/2017/24400.9140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 11/11/2016] [Indexed: 11/24/2022]
Abstract
Acardiac twinning or Twin Reverse Arterial Perfusion (TRAP)-sequence is a rare complication of monochorionic twin pregnancy. Whether to start elective or therapeutic treatment in TRAP-sequence is still controversial. In the present case, acardiac twin was not diagnosed till her delivery at 39 weeks. A healthy baby weighing 2.45 kg was delivered along with another amorphous mass (acardiac twin) of about 150 g which was attached to the placenta with a short and separate cord. As outcome of normal twin vary according to the growth of acardiac twin, frequent follow-up of the normal twin is required to look for the features of heart failure. Hence, the diagnosis of acardiac twin is essential in early pregnancy.
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Affiliation(s)
- Sunita Dubey
- Assistant Professor, Department of Obstetrics and Gynaecology, Government Medical College and Hospital , Chandigarh, India
| | - Meesha Verma
- Senior Resident, Department of Obstetrics and Gynaecology, Government Medical College and Hospital , Chandigarh, India
| | - Poonam Goel
- Professor, Department of Obstetrics and Gynaecology, Government Medical College and Hospital , Chandigarh, India
| | - Rps Punia
- Professor, Department of Pathology, Government Medical College and Hospital , Chandigarh, India
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Nizyaeva NV, Lyapin VM, Kuznetzova MN, Baranova EE, Trofimov DY, Tumanova UN, Mikhailova AN, Kostyukov KV, Gladkova KA. [Twin reversed arterial perfusion syndrome in the monochorionic diamniotic placenta with the development of an acardiac fetus]. Arkh Patol 2016; 78:33-36. [PMID: 27804944 DOI: 10.17116/patol201678533-36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The article describes an acardiac fetus in a patient with monochorionic diamniotic twin pregnancy with reversed arterial perfusion syndrome at 30 weeks' gestation. It gives postmortem fetal computed tomographic and pathoanatomic data. Microarray of acardiac fetal tissues revealed that there was deletion of chromosome 19 - arr [hg19] 19p13.3q11 (260,911-23,005,001) x1; size, 23 Mbp; the signal level in about 30% of fetal tissue cells containing deletion.
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Affiliation(s)
- N V Nizyaeva
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - V M Lyapin
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - M N Kuznetzova
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - E E Baranova
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - D Yu Trofimov
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - U N Tumanova
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - A N Mikhailova
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - K V Kostyukov
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - K A Gladkova
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
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van Gemert MJ, Ross MG, Nikkels PG, Wijngaard JPVD. Acardiac twin pregnancies part III: Model simulations. ACTA ACUST UNITED AC 2016; 106:1008-1015. [DOI: 10.1002/bdra.23559] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/07/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Martin J.C. van Gemert
- Department of Biomedical Engineering & Physics, Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Michael G. Ross
- Department of Obstetrics and Gynecology; Harbor UCLA Medical Center; Torrance California
| | - Peter G.J. Nikkels
- Department of Pathology, Wilhelmina Children's Hospital; University Medical Center; Utrecht The Netherlands
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Nizyaeva NV, Кostyukov KV, Gladkova KA, Kulikova GV, Shchegolev AI. [Role of twin reversed arterial perfusion syndrome in the development of fetus acardius]. Arkh Patol 2016; 78:54-57. [PMID: 27600783 DOI: 10.17116/patol201678454-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Monochorionic multiple pregnancy has a higher risk for obstetric complications, including those due to the development of twin-to-twin transfusion syndrome and reversed arterial perfusion syndrome (TRAP sequence). The latter occurs in 0.1% of all monochorionic pregnancies. The basis for TRAP sequence is a relationship between arterial and venous anastomoses from the appropriate placental areas, causing a recipient fetus to develop at the expense of a donor fetus. The presence of abnormal anastomoses is considered to be a main cause of acardia. The prognosis for a donor fetus is also unfavorable: the mortality rates in the absence of intrauterine correction are as high as 55%.
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Affiliation(s)
- N V Nizyaeva
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - K V Кostyukov
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - K A Gladkova
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - G V Kulikova
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - A I Shchegolev
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
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Sugibayashi R, Ozawa K, Sumie M, Wada S, Ito Y, Sago H. Forty cases of twin reversed arterial perfusion sequence treated with radio frequency ablation using the multistep coagulation method: a single-center experience. Prenat Diagn 2016; 36:437-43. [PMID: 26934598 DOI: 10.1002/pd.4800] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 02/17/2016] [Accepted: 02/25/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To report the pregnancy outcomes of patients with twin reversed arterial perfusion (TRAP) sequence treated by radiofrequency ablation (RFA). METHODS This was a retrospective study of TRAP sequences treated in a single center between March 2002 and February 2015. Forty patients underwent RFA with expandable tines through a multistep coagulation method between 15 and 26 gestational weeks. The primary outcome was neonatal survival to discharge. RESULTS The overall survival of the pump twin was 85%. The survival rates in monochorionic-monoamniotic (MCMA) pregnancies and monochorionic-diamniotic pregnancies were 66.7% (4/6) and 87.9% (29/33), respectively. One triplet was treated successfully and delivered at 36 weeks of gestation. One of 35 live births (2.9%) had preterm premature rupture of membranes less than 34 weeks, resulting in infant death. In five intrauterine pump twin deaths, two cases were MCMA twins with cord entanglement, and three cases were MCDA twins with acardius anceps. CONCLUSIONS Our study supports the effectiveness of RFA for TRAP sequence after 15 weeks of gestation. The presence of MCMA twins or acardius anceps is associated with a high risk of pump twin death after RFA. © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Rika Sugibayashi
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masahiro Sumie
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Ito
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Khalil A, Rodgers M, Baschat A, Bhide A, Gratacos E, Hecher K, Kilby MD, Lewi L, Nicolaides KH, Oepkes D, Raine-Fenning N, Reed K, Salomon LJ, Sotiriadis A, Thilaganathan B, Ville Y. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:247-63. [PMID: 26577371 DOI: 10.1002/uog.15821] [Citation(s) in RCA: 334] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 05/27/2023]
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - M Rodgers
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Bhide
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - E Gratacos
- Fetal Medicine Units and Departments of Obstetrics, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germaniy
| | - M D Kilby
- Centre for Women’s and Children's Health, University of Birmingham and Fetal Medicine Centre, Birmingham Women’s Foundation Trust, Birmingham, UK
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, UK
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - N Raine-Fenning
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - K Reed
- Twin and Multiple Births Association (TAMBA)
| | - L J Salomon
- Hopital Necker-Enfants Malades, AP-HP, Universit´e Paris Descartes, Paris, France
| | - A Sotiriadis
- Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - B Thilaganathan
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - Y Ville
- Hospital Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
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Ruiz-Cordero R, Birusingh RJ, Pelaez L, Azouz M, Rodriguez MM. Twin Reversed Arterial Perfusion Sequence (TRAPS): An Illustrative Series of 13 Cases. Fetal Pediatr Pathol 2016; 35:63-80. [PMID: 26847661 DOI: 10.3109/15513815.2015.1131785] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Twin reversed-arterial-perfusion sequence (TRAPS) is a rare and severe complication of monochorionic twin pregnancies. It usually occurs in the setting of monochorionic placentation, when the heart of a normal appearing twin serves as the pump for one or more dysmorphic twins whose head, thoracic organs, and upper extremities do not fully develop or do not develop at all and thus lack cardiac activity. Anomalous vascular placental architecture causes a shift in arterial flow towards the acardiac twin(s). The exact physiopathologic mechanisms that lead to this devastating phenomenon are not well known. We reviewed the maternal history and the surgical pathology reports of the fetuses and placentas of 13 different cases of TRAPS that were collected in a 23-year study period at a single institution. Herein we summarize the characteristic findings and illustrate specific mechanical feto-placental circulation issues that appear to be instrumental in the development of TRAPS.
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Affiliation(s)
| | | | - Liset Pelaez
- a Pathology, University of Miami , Miami , Florida , USA
| | - Michel Azouz
- b Radiology, University of Miami , Miami , Florida , USA
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van Gemert MJ, Pistorius LR, Benirschke K, Bonsel GJ, Vandenbussche FP, Paarlberg KM, van den Wijngaard JP, Nikkels PG. Hypothesis acardiac twin pregnancies: Pathophysiology-based hypotheses suggest risk prediction by pump/acardiac umbilical venous diameter ratios. ACTA ACUST UNITED AC 2015; 106:114-21. [DOI: 10.1002/bdra.23467] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Martin J.C. van Gemert
- Department of Biomedical Engineering & Physics; Academic Medical Center; Amsterdam The Netherlands
| | - Lourens R. Pistorius
- Department of Obstetrics and Gynecology; University Medical Center; Utrecht The Netherlands
| | - Kurt Benirschke
- Department of Pathology; University of California at San Diego; San Diego California
| | - Gouke J. Bonsel
- Department of Public Health and Obstetrics and Gynecology; Erasmus Medical Center; Rotterdam The Netherlands
| | | | - K. Marieke Paarlberg
- Department of Obstetrics and Gynecology; Gelre Teaching Hospitals; Apeldoorn The Netherlands
| | | | - Peter G.J. Nikkels
- Department of Pathology, Wilhelmina Children's Hospital; University Medical Center; Utrecht The Netherlands
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Buyukkaya A, Tekbas G, Buyukkaya R. Twin Reversed Arterial Perfusion (TRAP) Sequence; Characteristic Gray-Scale and Doppler Ultrasonography Findings. IRANIAN JOURNAL OF RADIOLOGY 2015; 12:e14979. [PMID: 26557268 PMCID: PMC4632132 DOI: 10.5812/iranjradiol.12(3)2015.14979] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 02/01/2014] [Indexed: 01/03/2023]
Abstract
Twin reversed arterial perfusion (TRAP) sequence is a syndrome with poor prognosis, seen only in monochorionic monozygotic twin pregnancies. The incidence is one in 35.000 births and one in 100 monozygotic twin pregnancies. It is characterized with a recipient fetus exhibiting lethal anomalies including acardia and a pump fetus. Mortality is usually due to heart failure or premature labor caused by polyhydramnios of pump fetus. Herein, we report a case of TRAP sequence that emphasizes the importance of gray-scale and color Doppler imaging in the diagnosis and management of TRAP sequence.
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Affiliation(s)
- Ayla Buyukkaya
- Department of Radiology, Duzce Ataturk Government Hospital, Duzce, Turkey
- Corresponding author: Ayla Buyukkaya, Department of Radiology, Duzce Ataturk Government Hospital, Duzce, Turkey. Tel: +90-3805421390, Fax: +90-3805421387, E-mail:
| | - Guven Tekbas
- Department of Radiology, School of Medicine, Dicle University, Diyarbakır, Turkey
| | - Ramazan Buyukkaya
- Department of Radiology, School of Medicine, Duzce University, Duzce, Turkey
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Pepe F, Teodoro MC, Luca C, Privitera F. Conservative management in a case of uncomplicated trap sequence: a case report and brief literature review. J Prenat Med 2015; 9:29-34. [PMID: 27358695 PMCID: PMC4909109 DOI: 10.11138/jpm/2015.9.3.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION twin reversed arterial perfusion (TRAP) sequence is a rare anomaly that occurs in monochorionic twins with overall mortality rate ranging from 50% to 70% in the normal fetus, above all for congestive cardiac failure. CASE REPORT a 31-year-old Caucasian gravida was referred to our fetomaternal medicine unit in the 25 gestational age. Ultrasound examination revealed a monochorionic, biamniotic twin pregnancy with a donor fetus showing normal morphology and growth corresponding to gestational age. The recipient twin appeared grossly abnormal with no head, upper limbs, heart, or thoracic structures and massive, diffuse, soft tissue edema. Fetal Doppler and fetal echocardiography revealed normal parameters. The patient refused any treatment and was monitored with weekly ultrasonography and Doppler ultrasound examination. She underwent cesarean section due to premature labor/rupture of membranes secondary to a mild polyhydramnios, at 36 weeks gestational age and delivered an apparent normal female live baby weighing 2550 gr, and another female acardius acephalus twin, birth weight 1300 gr. This baby had rudimental edematous lower limbs, pelvic bone, lower sacral vertebrae, and absence of thorax and cephalic structures. CONCLUSION although the literature suggest that early intrafetal laser treatment of TRAP sequence is advantageous, our case shows that pregnancies referred late would still require a tailored approach after a risk-benefit assessment.
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Peyvandi S, Feldstein VA, Hirose S, Rand L, Brook MM, Moon-Grady AJ. Twin-reversed arterial perfusion sequence associated with decreased fetal cerebral vascular impedance. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:447-51. [PMID: 25157457 PMCID: PMC4503362 DOI: 10.1002/uog.14650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 08/10/2014] [Accepted: 08/13/2014] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Twin-reversed arterial perfusion (TRAP) sequence affects 1% of monochorionic twin pregnancies and is caused by abnormal vascular connections between a pump twin and an acardiac mass. The effects of abnormal vascular connections on cerebral vasculature in the pump twin are unknown. We hypothesize that abnormal cerebral vascular impedance, as assessed by the pulsatility index (PI), is present in pump twins and that fetal intervention alters cerebral impedance. METHODS Fetal echocardiograms performed between 2010 and 2013 in pregnancies diagnosed with TRAP (n = 19), recorded at presentation, and uncomplicated monochorionic twin pregnancies (controls, n = 18; 36 fetuses) were analyzed. In all subjects, the middle cerebral artery (MCA)-PI, combined cardiac output (CCO) and cardiothoracic ratio were calculated, and the values for cases and controls were compared. RESULTS The mean gestational age at the time of echocardiography was 20 weeks in both groups. MCA-PI was lower in TRAP cases than in controls (1.55 (95% CI, 1.47-1.64) vs 1.74 (95% CI, 1.65-1.82), respectively; P = 0.004). CCO in TRAP cases was mildly elevated for gestational age (199.7 (95% CI, 138.4-261.1) mL/min) compared with that of controls (131.4 (95% CI, 102.2-160.7) mL/min). In six TRAP cases with a second echocardiogram available, the mean MCA-PI increased after intervention, from 1.5 (95% CI, 1.3-1.7) to 1.8 (95% CI, 1.4-2.2). CONCLUSIONS TRAP pump twins have lower cerebral vascular impedance than do controls, suggestive of a brain-sparing effect. MCA-PI appeared to increase in a small group of pump twins after intervention. These findings suggest a fetal cerebral autoregulatory response to a high cardiac output state that begins to change after fetal intervention. The long-term implications for neurodevelopmental outcome warrant further study.
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Affiliation(s)
- S. Peyvandi
- Division of Cardiology, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
| | - V. A. Feldstein
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA, USA
| | - S. Hirose
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
| | - L. Rand
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA, USA
| | - M. M. Brook
- Division of Cardiology, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
| | - A. J. Moon-Grady
- Division of Cardiology, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
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Sommerfeldt JC, Putnins RE, Fung KFK, Grynspan D, Koujok K. AIRP best cases in radiologic-pathologic correlation: twin reversed arterial perfusion sequence. Radiographics 2014; 34:1385-90. [PMID: 25208286 DOI: 10.1148/rg.345130043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Joseph C Sommerfeldt
- From the Departments of Radiology (J.C.S., R.E.P., K.K.) and Pathology (D.G.), Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON, Canada K1H 8L1; and Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, Ontario, Canada (K.F.K.F.)
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Early pregnancy assessment in multiple pregnancies. Best Pract Res Clin Obstet Gynaecol 2014; 28:201-14. [DOI: 10.1016/j.bpobgyn.2013.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 11/19/2013] [Indexed: 02/04/2023]
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Pagani G, D'Antonio F, Khalil A, Papageorghiou A, Bhide A, Thilaganathan B. Intrafetal laser treatment for twin reversed arterial perfusion sequence: cohort study and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:6-14. [PMID: 23640771 DOI: 10.1002/uog.12495] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 04/14/2013] [Accepted: 04/25/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To ascertain the outcome of twin reversed arterial perfusion (TRAP) sequence cases managed in our unit and to review systematically cases reported in the literature treated with intrafetal laser therapy. METHODS This was a retrospective cohort study of all TRAP sequence cases identified from 2000 to 2012 at our center. Pregnancy management and outcomes were ascertained from maternal and neonatal records. We also performed a meta-analysis of the literature on the use of intrafetal laser therapy for the treatment of TRAP. Adverse pregnancy outcome was defined as a composite of intrauterine death (IUD) and preterm birth before 37 weeks' gestation. RESULTS Twenty-three cases of TRAP were identified during the study period. Six were managed conservatively and 17 were treated with laser therapy. All cases managed conservatively were complicated by IUD at a median gestational age of 14 + 4 (interquartile range (IQR), 12 + 4 to 16 + 5) weeks. Among the treated cases, 14 (82%) delivered a healthy twin at a median gestational age of 37 + 1 (IQR, 34 + 0 to 38 + 3) weeks. Ten studies were reviewed in detail and the data were combined with those from the current study. The overall neonatal survival was 80%. Adverse pregnancy outcome was significantly lower when the treatment was performed before 16 weeks' gestation (19 vs 66%, P = 0.0025). CONCLUSION The study data demonstrate a high risk of spontaneous fetal demise in early pregnancy, lack of accurate prognostic markers and improved pregnancy outcome after laser therapy in cases of TRAP. In these cases we recommend elective treatment with intrafetal laser therapy at between 13 and 16 weeks' gestation.
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Affiliation(s)
- G Pagani
- Fetal Medicine Unit, Division of Developmental Sciences, St George's Hospital Medical School, London, UK
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Weichert A, Kalache K, Hein P, Brauer M, Hinkson L, Henrich W. Radiofrequency ablation as a minimally invasive procedure in the treatment of twin reversed arterial perfusion sequence in twin pregnancy. JOURNAL OF CLINICAL ULTRASOUND : JCU 2013; 41:245-247. [PMID: 22573605 DOI: 10.1002/jcu.21932] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Accepted: 03/19/2012] [Indexed: 05/31/2023]
Abstract
Twin reversed arterial perfusion sequence is a rare anomaly of monochorionic multiple pregnancies affecting 1 of 35,000 pregnancies and 1% of monochorionic twin pregnancies. In this condition the affected twin has lethal malformations including poor or absent heart development and is reversely perfused by a structurally normal co-twin. We report a case of a 21-year-old woman with a monochorionic twin pregnancy affected by twin reversed arterial perfusion sequence. This case highlights the therapeutic options and the management by radiofrequency ablation, which has been shown to be an easy and reliable technique with a high success rate compared with technically demanding fetoscopic procedures.
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Affiliation(s)
- Alexander Weichert
- Department of Obstetrics, Charité Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
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Vila-Vives JM, Hidalgo-Mora JJ, Perales-Puchalt A, Diago V, Plana A, Perales A. Spontaneous arrest of flow in a TRAP sequence. J OBSTET GYNAECOL 2013; 33:313-4. [PMID: 23550871 DOI: 10.3109/01443615.2012.761182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- J M Vila-Vives
- Department of Obstetrics, La Fe University Hospital, Valencia, USA.
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Cabassa P, Fichera A, Prefumo F, Taddei F, Gandolfi S, Maroldi R, Frusca T. The use of radiofrequency in the treatment of twin reversed arterial perfusion sequence: a case series and review of the literature. Eur J Obstet Gynecol Reprod Biol 2013; 166:127-32. [DOI: 10.1016/j.ejogrb.2012.10.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 07/29/2012] [Accepted: 10/05/2012] [Indexed: 10/27/2022]
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Prasad RHS, Prasad TR, Kumar KD. TRAP Sequence - An Interesting Entity in Twins. J Clin Imaging Sci 2012; 2:56. [PMID: 23230538 PMCID: PMC3515936 DOI: 10.4103/2156-7514.100997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 05/05/2012] [Indexed: 01/07/2023] Open
Abstract
Twin reversed arterial perfusion (TRAP) sequence, is a rare malformation occurring in monozygotic multiple gestations. One well-developed normal (pump) twin and the other twin with absent cardiac structure (acardiac), who is hemodynamically dependent on the normal (pump) twin are characteristic of this syndrome. The acardiac twin develops multiple anomalies that make survival difficult. The prognosis of the pump twin is variable with mortality rate ranging from 50% to 70%. Complications that affect the prognosis of the pump twin include complications of congestive cardiac failure due to increased cardiac demand, prematurity secondary to preterm delivery, and polyhydramnios. Because of these complications prompt detection, follow-up, and treatment of this condition is very important. We report two cases of TRAP sequence that emphasizes the importance of gray-scale and color Doppler imaging in diagnosis, detection of poor prognostic features, follow-up, and management of TRAP sequence.
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Affiliation(s)
- R H Srinivas Prasad
- Department of Radio-Diagnosis and Imaging, MVJ Medical, College and Research Hospital, Bangalore, Karnataka, India
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Abstract
OBJECTIVE To review the literature with respect to the use of diagnostic ultrasound in the management of twin pregnancies. To make recommendations for the best use of ultrasound in twin pregnancies. OUTCOMES Reduction in perinatal mortality and morbidity and short- and long-term neonatal morbidity in twin pregnancies. Optimization of ultrasound use in twin pregnancies. EVIDENCE Published literature was retrieved through searches of PubMed and the Cochrane Library in 2008 and 2009 using appropriate controlled vocabulary (e.g., twin, ultrasound, cervix, prematurity) and key words (e.g., acardiac, twin, reversed arterial perfusion, twin-to-twin transfusion syndrome, amniotic fluid). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions. Studies were restricted to those with available English or French abstracts or text. Searches were updated on a regular basis and incorporated into the guideline to September 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The evidence collected was reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada, with input from members of the Maternal Fetal Medicine Committee and the Genetics Committee of the SOGC. The recommendations were made according to the guidelines developed by The Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS The benefit expected from this guideline is facilitation and optimization of the use of ultrasound in twin pregnancy. SUMMARY STATEMENTS: 1. There are insufficient data to make recommendations on repeat anatomical assessments in twin pregnancies. Therefore, a complete anatomical survey at each scan may not be needed following a complete and normal assessment. (III) 2. There are insufficient data to recommend a routine preterm labour surveillance protocol in terms of frequency, timing, and optimal cervical length thresholds. (II-2) 3. Singleton growth curves currently provide the best predictors of adverse outcome in twins and may be used for evaluating growth abnormalities. (III) 4. It is suggested that growth discordance be defined using either a difference (20 mm) in absolute measurement in abdominal circumference or a difference of 20% in ultrasound-derived estimated fetal weight. (II-2) 5. Although there is insufficient evidence to recommend a specific schedule for ultrasound assessment of twin gestation, most experts recommend serial ultrasound assessment every 2 to 3 weeks, starting at 16 weeks of gestation for monochorionic pregnancies and every 3 to 4 weeks, starting from the anatomy scan (18 to 22 weeks) for dichorionic pregnancies. (II-1) 6. Umbilical artery Doppler may be useful in the surveillance of twin gestations when there are complications involving the placental circulation or fetal hemodynamic physiology. (II-2) 7. Although many methods of evaluating the level of amniotic fluid in twins (deepest vertical pocket, single pocket, amniotic fluid index) have been described, there is not enough evidence to suggest that one method is more predictive than the others of adverse pregnancy outcome. (II-3) 8. Referral to an appropriate high-risk pregnancy centre is indicated when complications unique to twins are suspected on ultrasound. (II-2) These complications include: 1. Twin-to-twin transfusion syndrome 2. Monoamniotic twins gestation 3. Conjoined twins 4. Twin reversed arterial perfusion sequence 5. Single fetal death in the second or third trimester 6. Growth discordance in monochorionic twins. Recommendations 1. All patients who are suspected to have a twin pregnancy on first trimester physical examination or who are at risk (e.g., pregnancies resulting from assisted reproductive technologies) should have first trimester ultrasound performed. (II-2A) 2. Every attempt should be made to determine and report amnionicity and chorionicity when a twin pregnancy is identified. (II-2A) 3. Although the accuracy in confirmation of gestational age at the first and second trimester is comparable, dating should be done with first trimester ultrasound. (II-2A) 4. Beyond the first trimester, it is suggested that a combination of parameters rather than a single parameter should be used to confirm gestational age. (II-2C) 5. When twin pregnancy is the result of in vitro fertilization, accurate determination of gestational age should be made from the date of embryo transfer. (II-1A) 6. There is insufficient evidence to make a recommendation of which fetus (when discordant for size) to use to date a twin pregnancy. However, to avoid missing a situation of early intrauterine growth restriction in one twin, most experts agree that the clinician may consider dating pregnancy using the larger fetus. (III-C) 7. In twin pregnancies, aneuploidy screening using nuchal transluscency measurements should be offered. (II-2B) 8. Detailed ultrasound examination to screen for fetal anomalies should be offered, preferably between 18 and 22 weeks' gestation, in all twin pregnancies. (II-2B) 9. When ultrasound is used to screen for preterm birth in a twin gestation, endovaginal ultrasound measurement of the cervical length should be performed. (II-2A) 10. Increased fetal surveillance should be considered when there is either growth restriction diagnosed in one twin or significant growth discordance. (II-2A) 11. Umbilical artery Doppler should not be routinely offered in uncomplicated twin pregnancies. (I-E) 12. For defining oligohydramnios and polyhydramnios, the ultrasonographer should use the deepest vertical pocket in either sac: oligohydramnios when < 2 cm and polyhydramnios when > 8 cm. (II-2B).
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Treatment of twin reversed arterial perfusion sequence with alcohol ablation or bipolar cord coagulation. Int J Gynaecol Obstet 2012; 117:257-9. [DOI: 10.1016/j.ijgo.2011.12.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Revised: 12/22/2011] [Accepted: 02/21/2012] [Indexed: 11/21/2022]
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Lattanzi W, De Vincenzo RP, De Giorgio F, Stigliano E, Capelli A, Arena V. An Acephalus Acardius Amorphous Fetus in a Monochorionic Pregnancy With Sex Discrepancy. Twin Res Hum Genet 2012. [DOI: 10.1375/twin.9.5.697] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractAcephalus acardia is among the most severe malformations described in fetuses, with an incidence of about 1 in 35,000 births and is due to twin-to-twin transfusion syndrome, frequently occurring in monochorionic twin pregnancies. The severity of the syndrome depends upon the type of the anastomoses arising between the vascular networks of the two fetuses, usually configuring the ‘twin reverse arterial perfusion syndrome’. No clear and univocal etiological explanation is known, though few cases with chromosomal abnormalities have been reported so far. In some cases the fusion of two or more separate placentae of dizygotic fetuses occurs, leading to monochorionic twinning. Few cases of acardius amorphous with complete autoptical examination have been described so far. We report a case of acephalus acardius amorphus fetus, showing features of extremely severe sistemic immaturity with very few structured organs. Defined external and autoptic examinations have been performed on the dismorphic twin, along with the histological examination of tissue samples. Kariotype analysis showed sex discrepancy between the twins, as a normal female kariotype had been detected in the acephalus acardius while the living co-twin was a normal healthy male. The analysis of the placenta showed the vascular anomalies leading to the twin-to-twin transfusion syndrome.
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