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In vitro simulation of acute feto-fetal transfusion in case of single intrauterine fetal death in monochorionic twins. Placenta 2021; 111:26-32. [PMID: 34146967 DOI: 10.1016/j.placenta.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/04/2021] [Accepted: 05/25/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Thanks to shared circulation in monochorionic twins, single intrauterine fetal death (IUD) may lead to acute feto-fetal transfusion (aFFTR). The objective of the study was to describe our model of aFFTR simulation after IUD in monochorionic (MC) twins. METHODS Prospective study analyzed 99 fresh MC placentas with the physiological course. A specially designed protocol was used for the preparation and analysis of the placentas. A pair of infusion sets fixed together using a mechanical mercury sphygmomanometer cuff was connected to the cannulated umbilical arteries. The tonometer was pressurized up to 30 and 40 mmHg. A positive finding of aFFTR was determined as the amount exceeding 1 ml of dye flowed out of the umbilical cord simulating a dead fetus. The number and types of anastomoses, types, and distances between cords insertions, and the size of the placental areas for each fetus were also statistically analyzed. The placental angioarchitecture with and without proven aFFTR was statistically compared, odds ratio (OR) and multivariable logistic analysis were performed. RESULTS A total of 49/99 (49.5%) cases of aFFTR was proven, and the average transfusion time of 1 ml was 30 s (19-46 s). aFFTR was present in 49/78 (62.8%) of placentas with arterio-arterial (AA) anastomosis. The median diameter of AA anastomoses with the present, and absent aFFTRF was 2.0 mm and 1.0 mm, respectively. The proven interfetal transfusion was 8%, 31%, and 61% in AA anastomoses with a diameter below 0,5 mm, 0,5-1,5 mm, and above 1,5 mm, respectively (p < 0,001). AA anastomoses diameter >1.5 mm had OR of 44.2 (95% CI 5.54-352.39). In the case of coexistence of AA anastomosis and umbilical cord distance ≤5th percentile, the aFFTRF occurred in 90.9%. DISCUSSION The potential risk of aFFTR in monochorionic twins is mainly due to the presence and nature of AA anastomoses. The diameter and length of the vessels play a crucial role, which is clinically related to the distance of the umbilical cords insertions.
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van Gemert MJC, Ross MG, van den Wijngaard JPHM, Nikkels PGJ. Acardiac twin pregnancies part VI: Why does acardiac twinning occur only in the first trimester? Birth Defects Res 2021; 113:687-695. [PMID: 33580607 PMCID: PMC8247889 DOI: 10.1002/bdr2.1882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/20/2020] [Accepted: 01/30/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Clinical observation suggests that acardiac twinning occurs only in the first trimester. In part, this contradicts our previous analysis (part IV) of Benirschke's concept that unequal embryonic splitting causes unequal embryo/fetal blood volumes and pressures. Our aim is to explain why acardiac onset is restricted to the first trimester. METHODS We applied the vascular resistance scheme of two fetuses connected by arterio-arterial (AA) and veno-venous (VV) anastomoses, the small VV resistance approximated as zero. The smaller twin has volume fraction α < 1 of the assumed normal larger twin, and has only access to fraction X < 1 of its placenta; the larger twin's larger mean arterial pressure accesses the remaining fraction. Before 13 weeks, embryos have a much smaller vascular resistance than placentas. After 13 weeks, when maternal blood provides oxygen, smaller twins can increase their vascular volume by hypoxemia-mediated neovascularization. Estimated AA radii at 40 weeks, rAA (40), are 0.5-1.3 mm. RESULTS Embryos with α < 0.33 unlikely survive 13 weeks and acardiac twinning occurs under appropriate conditions (AA-VV, small placenta). Acardiac body perfusion occurs because of a much smaller vascular resistance than the placenta. When α > 0.33 and rAA (40)=1.3 mm, modeled survival is >32 weeks. CONCLUSION Before 13 weeks, embryos with α < 0.33 cannot survive and may result in the onset of acardia. Beyond 13 weeks, fetuses with α ≥ 0.33 survive because rAA (40) is too small for acardiac onset. Following fetal demise, exsanguination from the live twin increases its blood volume and, we assumed also, its vascular resistance. Perfusion then occurs through the lower resistance placenta.
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Affiliation(s)
- Martin J C van Gemert
- Department of Biomedical Engineering & Physics, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Michael G Ross
- Department of Obstetrics and Gynecology, Harbor UCLA Medical Center, Torrance, California, USA
| | | | - Peter G J Nikkels
- Department of Pathology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
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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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Wohlmuth C, Osei FA, Moise KJ, Johnson A, Papanna R, Bebbington M, Gardiner HM. Aortic distensibility as a surrogate for intertwin pulse pressure differences in monochorionic pregnancies with and without twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:193-199. [PMID: 26663469 DOI: 10.1002/uog.15836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/21/2015] [Accepted: 12/04/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Twin-twin transfusion syndrome (TTTS) complicates 10-15% of monochorionic diamniotic (MCDA) twin pregnancies. The donor response to hypovolemia allows the transfer of vasoactive mediators to the recipient, causing increased recipient afterload and hypertension. Our objective was to apply a novel speckle-tracking technique to measure the aortic fractional area change (AFAC) during the cardiac cycle in MCDA twins with and without TTTS, and identify intertwin differences in AFAC and parameters of cardiac function. METHODS High-frame rate four-chamber views of the fetal heart, including the mid-thoracic aorta, were collected prospectively in MCDA twin pairs referred to our center between June 2014 and April 2015. Using speckle-tracking software, the endovascular border of the aorta was traced manually during systole, with guidance on cardiac cycle timing by anatomical M-mode. AFAC, defined as the difference between maximum and minimum area divided by minimum area, expressed as a percentage, was calculated offline and averaged over three cardiac cycles. Tissue Doppler and displacement were used to measure long-axis cardiac function. Intra- and interclass correlation coefficients were used to test observer variability. RESULTS Fifty-one MCDA twin pregnancies were included, comprising uncomplicated MCDA (n = 14), TTTS Stages 1/2 (n = 21) and TTTS Stages 3/4 (n = 16). Median gestational age was 20.4 (range, 16.2-27.5) weeks. Mean ± SD heart rate was 142.6 ± 7.2 bpm with no significant intertwin pair differences. AFAC was significantly higher in recipients than in donors of TTTS pairs (Stages 1/2: 72.3 ± 29.9% vs 43.7 ± 19.3%, P < 0.001; Stages 3/4: 75.2 ± 29.2% vs 42.5 ± 18.4%, P = 0.002), consistent with higher recipient pulse pressure. No intertwin differences in AFAC were seen in uncomplicated MCDA pairs. Inter- and intraclass correlation coefficients for AFAC were 0.894 and 0.888. AFAC correlated significantly with combined cardiac output (r = 0.252, P = 0.011) and left and right E/E' ratio (left: r = 0.302, P = 0.004; right: r = 0.247, P = 0.030). CONCLUSION AFAC is a quantifiable and reproducible method to assess aortic distensibility and is a promising tool to monitor the response to prelaser therapeutic interventions in pregnancies with TTTS. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Wohlmuth
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
- Department of Obstetrics and Gynecology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - F A Osei
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
| | - K J Moise
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
| | - A Johnson
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
| | - R Papanna
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
| | - M Bebbington
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
| | - H M Gardiner
- The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA
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van Lier MG, Lopriore E, Vandenbussche FP, Streekstra GJ, Siebes M, Nikkels PG, Oepkes D, van Gemert MJ, van den Wijngaard JP. Acardiac twinning: High resolution three-dimensional reconstruction of a low resistance case. ACTA ACUST UNITED AC 2015; 106:213-7. [DOI: 10.1002/bdra.23477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Revised: 11/14/2015] [Accepted: 11/23/2015] [Indexed: 11/12/2022]
Affiliation(s)
- Monique G.J.T.B. van Lier
- Department of Biomedical Engineering and Physics; Academic Medical Center-University of Amsterdam; Amsterdam The Netherlands
| | - Enrico Lopriore
- Division of Neonatology; Department of Pediatrics; Leiden University Medical Center; Leiden
| | | | - Geert J. Streekstra
- Department of Biomedical Engineering and Physics; Academic Medical Center-University of Amsterdam; Amsterdam The Netherlands
| | - Maria Siebes
- Department of Biomedical Engineering and Physics; Academic Medical Center-University of Amsterdam; Amsterdam The Netherlands
| | - Peter G.J. Nikkels
- Department of Pathology; University Medical Center and Wilhelmina Children's Hospital; Utrecht The Netherlands
| | - Dick Oepkes
- Department of Obstetrics; Leiden University Medical Center; Leiden
| | - Martin J.C. van Gemert
- Department of Biomedical Engineering and Physics; Academic Medical Center-University of Amsterdam; Amsterdam The Netherlands
| | - Jeroen P.H.M. van den Wijngaard
- Department of Biomedical Engineering and Physics; Academic Medical Center-University of Amsterdam; Amsterdam The Netherlands
- Department of Clinical Chemistry and Laboratory Medicine; Leiden University Medical Center; Leiden The Netherlands
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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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Intrauterine transfusion combined with partial exchange transfusion for twin anemia polycythemia sequence: Modeling a novel technique. Placenta 2015; 36:599-602. [DOI: 10.1016/j.placenta.2015.01.194] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 01/23/2015] [Accepted: 01/26/2015] [Indexed: 11/17/2022]
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Jones K, Tierney K, Grubbs BH, Pruetz JD, Detterich J, Chmait RH. Fetoscopic Laser Photocoagulation of Feeding Vessels to a Large Placental Chorioangioma following Fetal Deterioration after Amnioreduction. Fetal Diagn Ther 2012; 31:191-5. [DOI: 10.1159/000331944] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/16/2011] [Indexed: 11/19/2022]
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Baschat A, Chmait RH, Deprest J, Gratacós E, Hecher K, Kontopoulos E, Quintero R, Skupski DW, Valsky DV, Ville Y. Twin-to-twin transfusion syndrome (TTTS). J Perinat Med 2011; 39:107-12. [PMID: 21142846 DOI: 10.1515/jpm.2010.147] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Twin-to-twin transfusion syndrome (TTTS) is a severe complication of monochorionic (MC) twin pregnancies, characterized by the development of unbalanced chronic blood transfer from one twin, defined as donor twin, to the other, defined as recipient, through placental anastomoses. If left untreated, TTTS is associated with very high perinatal mortality and morbidity rates, due to a combination of fetal and/or obstetric complications. The reported prevalence is 10-15% of all MC twins, or about 1 in 2000 pregnancies. This consensus document reviews available evidence and offers practical guidance to clinicians by providing recommendations on various aspects concerning diagnosis and management of TTTS.
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Affiliation(s)
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- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, School of Medicine, Baltimore, MD, USA
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Papanna R, Mann LK, Molina S, Johnson A, Moise KJ. Changes in the recipient fetal Tei index in the peri-operative period after laser photocoagulation of placental anastomoses for twin-twin transfusion syndrome. Prenat Diagn 2011; 31:176-80. [DOI: 10.1002/pd.2673] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2010] [Revised: 09/19/2010] [Accepted: 10/24/2010] [Indexed: 11/09/2022]
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van Gemert M, van den Wijngaard J, Lopriore E, Lewi L, Deprest J, Vandenbussche F. Simulated Sequential Laser Therapy of Twin–Twin Transfusion Syndrome. Placenta 2008; 29:609-13. [DOI: 10.1016/j.placenta.2008.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 03/27/2008] [Accepted: 04/08/2008] [Indexed: 11/26/2022]
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