1
|
Yamamoto R, Ozawa K, Wada S, Sago H, Nagasaki S, Takano M, Nakata M, Nozaki M, Ishii K. Infant outcome at 3 years of age of monochorionic twins with Type-II or -III selective fetal growth restriction and isolated oligohydramnios that underwent fetoscopic laser photocoagulation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:758-763. [PMID: 38031151 DOI: 10.1002/uog.27551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/17/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE To examine infant outcomes at 3 years of age in monochorionic twin pregnancies with Type-II or -III selective fetal growth restriction (sFGR) and isolated oligohydramnios who underwent fetoscopic laser photocoagulation (FLP). METHODS This multicenter prospective cohort study included monochorionic diamniotic twins that underwent FLP for sFGR between 16 and 25 weeks' gestation. The indication for performing FLP was Type-II or -III sFGR with oligohydramnios of the growth-restricted (FGR) twin in which the maximum vertical pocket of amniotic fluid was ≤ 2 cm. This was done in the absence of a typical diagnosis of twin-twin transfusion syndrome. The primary outcome was intact survival rate of both infants at the corrected gestational age of 40 weeks and at 3 years of age. Intact survival at the corrected age of 40 weeks was defined as survival without Grade-III or -IV intraventricular hemorrhage or cystic periventricular leukomalacia. Intact survival at 3 years of age was defined as survival without neurodevelopmental morbidity, which included cerebral palsy, neurodevelopmental impairment with a total developmental quotient of < 70, bilateral deafness or bilateral blindness. RESULTS Among 45 patients with sFGR, 30 (66.7%) were classified as having Type-II and 15 (33.3%) as Type-III sFGR. The prevalence of intact survival at the corrected age of 40 weeks was 51.1% (n = 23) in FGR twins and 95.5% (n = 42) in larger twins. The prevalence of intact survival at 3 years of age was 46.7% (n = 21) in FGR twins and 86.4% (n = 38) in larger twins. There was one case of miscarriage. Among the 24 FGR twins who were not classified as having intact survival at 3 years of age, 22 (91.7%) cases suffered fetal or infant demise (other than miscarriage), and there was one case of neurodevelopmental impairment. All larger twins who were not diagnosed with intact survival at 3 years of age (n = 6 (13.6%)) had neurological morbidity. CONCLUSIONS FGR twins and their larger cotwins, when subjected to FLP owing to sFGR coupled with umbilical artery Doppler abnormalities and isolated oligohydramnios, exhibit low rates of neurological morbidity and low mortality, respectively. Therefore, FLP for Type-II or -III sFGR with oligohydramnios may be a feasible management option and one that is preferable to expectant management. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- R Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - K Ozawa
- National Center for Child Health and Development, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Tokyo, Japan
| | - S Wada
- National Center for Child Health and Development, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Tokyo, Japan
| | - H Sago
- National Center for Child Health and Development, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Tokyo, Japan
| | - S Nagasaki
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - M Takano
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - M Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - M Nozaki
- Department of Neonatology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - K Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| |
Collapse
|
2
|
Nassr AA, Hessami K, Corroenne R, Sanz Cortes M, Donepudi R, Espinoza J, Yamamoto R, Stirnemann J, Ishii K, Belfort MA, Chmait RH, Shamshirsaz AA. Outcome of laser photocoagulation in monochorionic diamniotic twin pregnancy complicated by Type-II selective fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:369-373. [PMID: 36704956 DOI: 10.1002/uog.26165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/05/2022] [Accepted: 01/09/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES To evaluate the outcome of monochorionic diamniotic (MCDA) twins complicated by Type-II selective fetal growth restriction (sFGR) who underwent fetoscopic laser photocoagulation and to validate a previously proposed subclassification system for Type-II sFGR in a large multicenter cohort. METHODS This retrospective multicenter cohort study included all MCDA twins complicated by Type-II sFGR who underwent laser photocoagulation of placental anastomoses at four large tertiary fetal-care centers between 2006 and 2020. Cases were subclassified according to a recently proposed system based on Doppler evaluation of the ductus venosus (DV) and middle cerebral artery (MCA) into Type-IIA (normal DV flow and MCA peak systolic velocity (PSV) of the growth-restricted fetus) or Type-IIB (absent or reversed flow in the DV during atrial contraction and/or MCA-PSV ≥ 1.5 multiples of the median of the growth-restricted fetus). Demographic characteristics and pregnancy outcomes were compared between the groups. Data are presented as mean ± SD or n (%) as appropriate. P-values < 0.05 were considered statistically significant. RESULTS A total of 98 patients with MCDA twins met our inclusion criteria, with 56 subclassified as Type IIA and 42 as Type IIB. Demographic characteristics were similar between the groups; however, Type-IIB cases had a significantly earlier gestational age at diagnosis and at laser surgery, as well as larger intertwin estimated fetal weight discordance, which may be a reflection of disease severity. Postnatal survival of the growth-restricted fetus to 30 days of age was significantly lower in Type-IIB compared to Type-IIA cases (23.8% vs 46.4%; P = 0.034). CONCLUSIONS In MCDA twins complicated by Type-II sFGR and treated with laser photocoagulation of placental anastomoses, preoperative Doppler assessment of the DV and MCA helped identify a subset of patients at increased risk of demise of the growth-restricted fetus following intervention. This study provides valuable information for guiding surgical management and patient counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - K Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R Corroenne
- Department of Obstetrics and Gynecology, University Paris Descartes, Hopital Necker-Enfants Malades, Paris, France
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R Yamamoto
- Department of Maternal-Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
| | - J Stirnemann
- Department of Obstetrics and Gynecology, University Paris Descartes, Hopital Necker-Enfants Malades, Paris, France
| | - K Ishii
- Department of Maternal-Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R H Chmait
- Department of Obstetrics and Gynecology, Los Angeles Fetal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| |
Collapse
|
3
|
Kim SH, Jung YM, Park CW, Park JS, Jun JK, Park MH, Hwang HS, Lee SM. Management of the smaller twin with impending compromise in twin pregnancies complicated by selective fetal growth restriction: a questionnaire-based study of clinical practice patterns. BMC Pregnancy Childbirth 2023; 23:344. [PMID: 37173629 PMCID: PMC10176903 DOI: 10.1186/s12884-023-05616-3] [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: 08/11/2022] [Accepted: 04/15/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND In twin pregnancies complicated by selective fetal growth restriction (sFGR), if the smaller twin is in the state of impending intra-uterine death (IUD), immediate delivery will reduce the risk of IUD of the smaller twin while exposing the larger twin to iatrogenic preterm birth (PTB). Therefore, the management options would either be to maintain pregnancy for the maturation of the larger twin despite the risk of IUD of the smaller twin or immediate delivery to prevent IUD of the smaller twin. However, the optimal gestational age of management transition from maintaining pregnancy to immediate delivery has not been established. The objective of this study was to evaluate the physician's perspective on the optimal timing of immediate delivery in twin pregnancies complicated by sFGR. METHODS An online cross-sectional survey was performed with obstetricians and gynecologists (OBGYN) in South Korea. The questionnaire asked the following: (1) whether participants would maintain or immediately deliver a twin pregnancy complicated by sFGR with signs of impending IUD of the smaller twin; (2) the optimal gestational age of management transition from maintaining pregnancy to immediate delivery in a twin pregnancy with impending IUD of the smaller twin; and (3) the limit of viability and intact survival in general preterm neonates. RESULTS A total of 156 OBGYN answered the questionnaires. In a clinical scenario of dichorionic (DC) twin pregnancy complicated by sFGR with signs of impending IUD of the smaller twin, 57.1% of the participants answered that they would immediately deliver the twin pregnancy. However, 90.4% answered that they would immediately deliver the pregnancy in the same scenario for monochorionic (MC) twin pregnancy. The participants designated 30 weeks for DC twin and 28 weeks for MC twin pregnancies as the optimal gestational age of management transition from maintaining pregnancy to immediate delivery. The participants regarded 24 weeks as the limit of viability and 30 weeks as the limit of intact survival in general preterm neonates. The optimal gestational age of management transition for DC twin pregnancy was correlated with the limit of intact survival in general preterm neonates (p < 0.001), but not with the limit of viability. However, the optimal gestational age of management transition for MC twin pregnancy was associated with both the limit of intact survival (p = 0.012) and viability with marginal significance (p = 0.062). CONCLUSIONS Participants preferred to immediately deliver twin pregnancies complicated by sFGR with impending IUD of the smaller twin at the limit of intact survival (30 weeks) for DC twin pregnancies and at the midway between the limit of intact survival and viability (28 weeks) for MC twin pregnancies. More research is needed to establish guidelines regarding the optimal delivery timing for twin pregnancies complicated by sFGR.
Collapse
Affiliation(s)
- So-Hee Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Department of Obstetrics and Gynecology, Cheju Halla General Hospital, Jeju, Korea
| | - Young Mi Jung
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Department of Obstetrics and Gynecology, Guro Hospital, College of Medicine, Korea University, Seoul, South Korea
| | - Chan-Wook Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Joong Shin Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Jong Kwan Jun
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Mi Hye Park
- Department of Obstetrics and Gynecology, Ewha Womans University, Seoul, Korea
| | - Han Sung Hwang
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea.
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120-1 Neungdong-Ro (Hwayang dong), Gwangjin-Gu, Seoul, 05030, Korea.
| | - Seung Mi Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
- Innovative Medical Technology Research Institute, Seoul National University Hospital, Seoul, South Korea.
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, South Korea.
| |
Collapse
|
4
|
Buskmiller C, Munoz JL, Cortes MS, Donepudi RV, Belfort MA, Nassr AA. Laser therapy versus expectant management for selective fetal growth restriction in monochorionic twins: A systematic review. Prenat Diagn 2023; 43:687-698. [PMID: 36991554 DOI: 10.1002/pd.6348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/01/2023] [Accepted: 03/17/2023] [Indexed: 03/31/2023]
Abstract
Selective fetal growth restriction (sFGR) complicates 10%-26% of monochorionic twins. Treatment options include cord coagulation, expectant management, and fetoscopic laser photocoagulation. This review compared laser to expectant management for situations when cord coagulation is not an option. The MEDLINE, EMBASE, and Cochrane databases were queried for studies that compared laser to expectant management for sFGR. GRADE was used to assess quality prior to meta-analysis. A random-effects model was used to generate relative risks. Six studies were included, encompassing 299 pregnancies. One study was randomized and the remainder were retrospective cohorts. Laser is associated with more fetal deaths of the FGR twin compared to expectant management (risk ratio [RR] 2.5, 95% confidence interval [CI] 1.43-4.37, p = 0.001, I2 = 48%). Neonatal deaths and gestational age at delivery did not differ. Laser was associated with decreased abnormal neuroimaging in the AGA twin (RR 0.25, 95% CI 0.07-0.97, p = 0.05). Neurodevelopmental outcomes did not differ, although these data are limited. Laser causes more fetal deaths of the FGR twin without altering gestational age at delivery or rates of neonatal death. The literature is heterogeneous and the level of bias is high. Randomized trials that address laser for type II sFGR are needed and should include long-term neurological outcomes.
Collapse
|
5
|
Selective Fetal Growth Restriction in Monochorionic Diamniotic Twins: Diagnosis and Management. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
|
6
|
von Kaisenberg C, Klaritsch P, Ochsenbein-Kölble N, Hodel ME, Nothacker M, Hecher K. Screening, Management and Delivery in Twin Pregnancy. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:367-378. [PMID: 33017845 DOI: 10.1055/a-1248-8896] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The following AWMF guideline (DGGG/AGG & DEGUM responsible) deals with the diagnosis, screening and management of twins as well as the timing and mode of birth.Twin pregnancies can be classified as dichorionic diamniotic (DC DA), monochorionic diamniotic (MC DA) and monochorionic monoamniotic (MC MA) which are always monochorionic.Twin pregnancies can be concordant (both twins are affected) or discordant (only one twin is affected) for chromosomal defects, malformations, growth restriction and hemodynamic disorders.Chorionicity is the prognostically most significant parameter. Monochorial twins have significantly higher risks of intrauterine morbidity and mortality compared to dichorial twins.In particular, general aspects of twin pregnancies such as dating, determination of chorionicity and amnionicity, the labeling of twin fetuses and the perinatal switch phenomenon are discussed.Routine monitoring of MC and DC twin pregnancies with ultrasound at 11-13+ 6 weeks of gestation for chromosomal defects, invasive prenatal diagnosis, first-trimester NT or CRL discrepancies, early diagnosis of fetal anatomical defects, and management of twins with abnormalities, including selective fetocide, is described.Second trimester screening and management for preterm birth, intrauterine selective growth restriction (sFGR), classification of monochorial twins with sFGR, and management of the surviving twin after the death of the co-twin are described.Complications exclusively affecting MC twins include Twin to Twin Transfusion Syndrome (TTTS) with the important topics screening, prognosis, complications of laser therapy, timing of delivery, risks for brain abnormalities and delayed neurological development, Twin Anemia-Polycythemia Sequence (TAPS) and Twin Reversed Arterial Perfusion (TRAP) Sequence. This also includes MC MA twins as well as conjoined twins.Finally, the birth mode and time for DC and MC twin pregnancies are described.The information is summarized in 62 recommendations for action, 4 tables and 8 illustrations with comprehensive background texts.The guideline is an international guideline adaptation (ISUOG, NICE) as well as a systematic literature search and is up-to-date.
Collapse
Affiliation(s)
| | - Philipp Klaritsch
- Department of Obstetrics and Gynecology, Medical University Graz, Austria
| | | | | | - Monika Nothacker
- AWMF-Institut für Medizinisches Wissensmanagement (AWMF-IMWi), University of Marburg, Germany
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
7
|
Couck I, Ponnet S, Deprest J, Devlieger R, De Catte L, Lewi L. Outcome of monochorionic twin pregnancy with selective fetal growth restriction at 16, 20 or 30 weeks according to new Delphi consensus definition. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:821-830. [PMID: 31945801 DOI: 10.1002/uog.21975] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/24/2019] [Accepted: 12/31/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To report the outcome of selective fetal growth restriction (sFGR) diagnosed according to the new Delphi consensus definition, and determine potential predictors of survival, in a cohort of unselected monochorionic diamniotic twin pregnancies. METHODS This was a retrospective study of monochorionic diamniotic twin pregnancies followed from the first trimester onward, which were diagnosed with sFGR at 16, 20 or 30 weeks' gestation. sFGR was defined according to the new Delphi consensus criteria as presence of either an estimated fetal weight (EFW) < 3rd centile in one twin or at least two of the following: EFW of one twin < 10th centile, abdominal circumference of one twin < 10th centile, EFW discordance ≥ 25% or umbilical artery pulsatility index of the smaller twin > 95th centile. The primary outcomes were the overall survival rate (up to day 28 after birth) and risk of loss of one or both twins. We further determined possible predictors of survival using uni- and multivariate generalized estimated equation modeling. RESULTS We analyzed 675 pregnancies, of which 177 (26%) were diagnosed with sFGR at 16, 20 or 30 weeks. The overall survival rate was 313/354 (88%) with 146/177 (82%) pregnancies resulting in survival of both twins, 21/177 (12%) in survival of one twin and 10/177 (6%) in loss of both twins. Subsequent twin anemia-polycythemia sequence (TAPS) developed in 6/177 (3%) and twin-twin transfusion syndrome (TTTS) in 17/177 (10%) pregnancies. All TAPS fetuses survived. The survival rate in sFGR pregnancies that subsequently developed TTTS was 65% (22/34), compared with 91% (279/308) in those with isolated sFGR (no subsequent TAPS or TTTS) (P < 0.001). The majority of sFGR cases were Type I (110/177 (62%)) and had a survival rate of 96% (212/220), as compared with a survival of 55% (12/22) in those with Type-II (P < 0.001) and 83% (55/66) in those with Type-III (P = 0.006) sFGR. The majority of sFGR pregnancies (130/177 (73%)) were first diagnosed at 16 or 20 weeks (early onset), with a survival rate of 85% (221/260), as compared with a survival of 98% (92/94) in sFGR first diagnosed at 30 weeks (late onset) (P = 0.04). A major anomaly in at least one twin was present in 28/177 (16%) sFGR cases. In these pregnancies, survival was 39/56 (70%), compared with 274/298 (92%) in those without an anomaly (P < 0.001). Subsequent development of TTTS (odds ratio (OR), 0.18 (95% CI, 0.06-0.52)), Type-II sFGR (OR, 0.06 (95% CI, 0.02-0.24)) and Type-III sFGR (OR, 0.21 (95% CI, 0.07-0.60)) and presence of a major anomaly in at least one twin (OR, 0.12 (95% CI, 0.04-0.34)), but not gestational age at first diagnosis, were independently associated with decreased survival. CONCLUSIONS Isolated sFGR is associated with a 90% survival rate in monochorionic diamniotic twin pregnancies. The subsequent development of TTTS, absent or reversed end-diastolic flow in the umbilical artery of the smaller twin and the presence of a major anomaly adversely affect survival in sFGR. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- I Couck
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - S Ponnet
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London Hospital, London, UK
| | - R Devlieger
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L De Catte
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L Lewi
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| |
Collapse
|
8
|
Shiro M, Yamamoto R, Ichikawa C, Nakanishi K, Kawaguchi H, Hayashi S, Takeuchi M, Ishii K. Placental histopathological features of fetoscopic laser photocoagulation for monoaminotic diamniotic twin pregnancies. Placenta 2020; 100:159-163. [PMID: 32980047 DOI: 10.1016/j.placenta.2020.07.002] [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: 03/16/2020] [Revised: 06/08/2020] [Accepted: 07/06/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION This study aimed to compare the histopathological placental features of monochorionic diamniotic (MCDA) twins who did and did not undergo fetoscopic laser photocoagulation (FLP). METHODS This was a retrospective single-institution cohort study on MCDA twins who underwent FLP between October 2010 and December 2018. The control group included MCDA twins who did not undergo FLP and were delivered during the same period in the institute. The incidence of chorioamnionitis (CAM), funisitis, and other pathological findings was compared between the FLP and control groups after matching by gestational age at delivery. RESULTS In total, 292 MCDA pregnant women who underwent FLP and 356 controls gave birth during the study period. After matching the two groups in the ratio 1:1 by gestational age at delivery, each group comprised 194 subjects. The incidence of histological CAM with Blanc association (stage I, 6.2% vs. 3.1%, crude odds ratio (cOR) = 3.1, P = 0.052; stage II, 7.2% vs. 5.7%, cOR = 1.6, P = 0.30; stage III, 2.1% vs. 2.6%, cOR = 0.66, P = 0.52) and funisitis (artery, 5.2% vs. 3.6%, cOR = 1.3, P = 0.63; vein 7.2% vs. 4.1%, cOR = 1.6, P = 0.29) was not statistically significant difference between the FLP and control groups. The FLP group demonstrated a higher incidence of partial placental infarction than the control group (10.3% vs. 3.1%, cOR = 4.3, P = 0.004, adjusted OR = 2.8, P = 0.031). DISCUSSION FLP did not appear to increase the incidence of histological CAM or funisitis in subjects matched by gestational age at delivery. The FLP group demonstrated a higher incidence of partial placental infarction than the control group.
Collapse
Affiliation(s)
- Michihisa Shiro
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Chihiro Ichikawa
- Department of Pathology, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Kentaro Nakanishi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Haruna Kawaguchi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Shusaku Hayashi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Makoto Takeuchi
- Department of Pathology, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan.
| |
Collapse
|
9
|
Colmant C, Lapillonne A, Stirnemann J, Belaroussi I, Leroy-Terquem E, Kermovant-Duchemin E, Bussieres L, Ville Y. Impact of different prenatal management strategies in short- and long-term outcomes in monochorionic twin pregnancies with selective intrauterine growth restriction and abnormal flow velocity waveforms in the umbilical artery Doppler: a retrospective observational study of 108 cases. BJOG 2020; 128:401-409. [PMID: 32416618 DOI: 10.1111/1471-0528.16318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To review perinatal and neurodevelopmental outcome (NDO) following selective fetoscopic laser coagulation (SFLC), cord coagulation (CC) or expectant management of monochorionic diamniotic twin pregnancies complicated with selective intrauterine growth restriction (sIUGR) and absent or reverse end-diastolic flow (AREDF) in the umbilical arteries (UA). DESIGN AND SETTING Single-centre retrospective observational study. POPULATION 108 cases of sIUGR diagnosed before 26+6 weeks' gestation with AREDF in the UA. METHODS Survival rate and potential risk factors were analysed. NDO was assessed using parental questionnaires. MAIN OUTCOMES MEASURES Survival, gestational age at delivery and NDO. RESULTS SFLC, CC and EM were performed in 13, 50 and 45 cases, respectively, with an overall survival of 23.1, 40 and 77.8% and intrauterine demise of the co-twin of 30.8, 10 and 6.7% respectively. Intrauterine demise of the sIUGR twin occurred in 76.9 and 17.8% following SFLC and EM, respectively. The discordance in EFW at diagnosis was higher and absent/negative a-wave in the ductus venosus (DV) was more prevalent in the surgical groups. NDO in survivors at follow up was abnormal in 0 and 18% in the smaller twin following SFLC and EM, respectively, and in 25, 24 and 21% in the larger twin following SFLC, CC and EM, respectively. CONCLUSION SFLC yielded a poor result. EM seems a valid option when EFW discordance is <30% and a-wave in DV is positive. Otherwise, CC should be considered to protect the AGA co-twin. The long-term outcome of both small and large twins seems unaffected by the choice in primary prenatal management strategy. TWEETABLE ABSTRACT In type II sIUGR in MC twins, long-term neurodevelopment is normal in over 80% of the survivors.
Collapse
Affiliation(s)
- C Colmant
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - A Lapillonne
- EA7328 and PACT, Université Paris Descartes, Paris, France.,Neonatology and Intensive Care Unit, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - J Stirnemann
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,EA7328 and PACT, Université Paris Descartes, Paris, France
| | - I Belaroussi
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | | | - E Kermovant-Duchemin
- EA7328 and PACT, Université Paris Descartes, Paris, France.,Neonatology and Intensive Care Unit, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - L Bussieres
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,EA7328 and PACT, Université Paris Descartes, Paris, France
| | - Y Ville
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,EA7328 and PACT, Université Paris Descartes, Paris, France
| |
Collapse
|
10
|
Chmait RH, Chon AH, Korst LM, Stephen Y, Llanes A, Ouzounian JG. Selective intrauterine growth restriction (SIUGR) type II: proposed subclassification to guide surgical management. J Matern Fetal Neonatal Med 2020; 35:1184-1191. [PMID: 32233709 DOI: 10.1080/14767058.2020.1745177] [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: 10/24/2022]
Abstract
Background: Optimal surgical management of monochorionic diamniotic twins complicated by selective intrauterine growth restriction (SIUGR) type II is unknown. Surgical management may involve selective laser photocoagulation of communicating vessels (SLPCV), which offers the possibility of dual twin survivors versus umbilical cord occlusion (UCO) of the SIUGR twin.Objective: To identify patient characteristics associated with SIUGR twin survival for those undergoing SLPCV.Study design: All patients studied were those who underwent fetal treatment for SIUGR type II at our center from 2006-2018. SIUGR type II was defined as an estimated fetal weight <10th percentile with persistent absent and/or reversed end diastolic flow in the umbilical artery of the SIUGR twin, in the absence of twin-twin transfusion syndrome. Patients were offered SLPCV versus UCO, and those undergoing SLPCV, patient characteristics associated with 30-day survival of the SIUGR twin were examined using bivariate analysis and multiple logistic regression models.Results: Fifty-four consecutive SIUGR type II patients were treated, 45 via SLPCV and nine via UCO. Of the 45 SLPCV cases, there were 16 (35.6%) with SIUGR twin (and dual) survival. SIUGR twin survival appeared associated with middle cerebral artery (MCA) peak systolic velocity (psv) <1.5 multiples of the median, and forward atrial systolic flow in the ductus venosus (DV). In a post hoc analysis, we subsequently categorized patients as: SIUGR type IIa (N = 32 (71.1%)): normal MCA psv, and normal DV waveform, versus SIUGR type IIb (N = 13 (28.9%)): MCA psv ≥1.5 multiples of the median, and/or DV with absent or reversed atrial systolic flow. Thirty-day survival of the SIUGR twin was 50% for type IIa and 0% for type IIb.Conclusion: Over one-third of SIUGR type II patients experienced dual survival after treatment with laser surgery. Normal MCA psv and normal DV waveforms were associated with SIUGR type II survival of the SIUGR twin. Post hoc exploration and subclassification of SIUGR type II patients by preoperative Doppler indices created two groups, one (type IIa) with 50% survival and one (type IIb) with 0% survival of the SIUGR twin after laser surgery. Upon further confirmation, these findings may provide guidance for counseling patients and conducting fetal therapy.
Collapse
Affiliation(s)
- Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, CA, USA
| | - Andrew H Chon
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, CA, USA
| | - Lisa M Korst
- Childbirth Research Associates, North Hollywood, CA, USA
| | - Y Stephen
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, CA, USA
| | - Arlyn Llanes
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, CA, USA
| | - Joseph G Ouzounian
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, CA, USA
| |
Collapse
|
11
|
Fetal therapies as standard prenatal care in Japan. Obstet Gynecol Sci 2020; 63:108-116. [PMID: 32206649 PMCID: PMC7073354 DOI: 10.5468/ogs.2020.63.2.108] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/25/2019] [Accepted: 09/09/2019] [Indexed: 11/09/2022] Open
Abstract
With recent advances in fetal medicine, various attempts have been made to save fetuses facing perinatal death or devastating consequences despite optimal management after birth. The concept of the fetus as a patient has been established through the application of in utero treatments. This paper reviews fetal therapies in order to highlight the role of perinatal medicine as standard prenatal care. Fetal therapies consist of medical therapy, percutaneous ultrasound-guided surgery, fetoscopic surgery, and open fetal surgery. In the 1980s, with advances in ultrasound imaging, percutaneous ultrasound-guided surgeries such as vesicoamniotic shunting for lower urinary tract obstruction and thoracoamniotic shunting (TAS) for fetal hydrothorax (FHT) were started. In the 1990s, fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) was introduced, and later, a fetoscopic approach for congenital diaphragmatic hernia was also established. The revival of open fetal surgery, introduced in the 1980s by pediatric surgeons, began in the 2010s after a successful clinical study for myelomeningocele. Although many fetal therapies are still considered experimental, some have proven effective, such as FLS for TTTS, TAS for primary FHT, and radiofrequency ablation (RFA) for twin reversed arterial perfusion (TRAP) sequence. These three fetal therapies have been approved for coverage by Japan National Health Insurance as a result of clinical studies performed in Japan. FLS for TTTS, TAS for primary FHT, and RFA for TRAP sequence have become standard prenatal care approaches in Japan. These three minimally invasive fetal therapies will help improve the perinatal outcomes of fetuses with these disorders.
Collapse
|
12
|
Sileo FG, Duffy JMN, Townsend R, Khalil A. Variation in outcome reporting across studies evaluating interventions for selective fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:10-15. [PMID: 30084183 DOI: 10.1002/uog.19192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/19/2018] [Accepted: 07/23/2018] [Indexed: 06/08/2023]
Affiliation(s)
- F G Sileo
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Prenatal Medicine Unit, Obstetrics and Gynaecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - J M N Duffy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Balliol College, University of Oxford, Oxford, UK
| | - R Townsend
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| |
Collapse
|
13
|
Good clinical practice advice: Role of ultrasound in the management of twin pregnancy. Int J Gynaecol Obstet 2019; 144:338-339. [PMID: 30710366 DOI: 10.1002/ijgo.12743] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
14
|
|
15
|
Khalil A, Duffy JMN, Perry H, Ganzevoort W, Reed K, Baschat AA, Deprest J, Gratacos E, Hecher K, Lewi L, Lopriore E, Oepkes D, Papageorghiou A, Gordijn SJ. Study protocol: developing, disseminating, and implementing a core outcome set for selective fetal growth restriction in monochorionic twin pregnancies. Trials 2019; 20:35. [PMID: 30626413 PMCID: PMC6327411 DOI: 10.1186/s13063-018-3153-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 12/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Selective fetal growth restriction in monochorionic twin pregnancies is associated with an increased risk of perinatal mortality and morbidity and represents a clinical dilemma. Interventions include expectant management with early preterm delivery if there are signs of fetal compromise, selective termination of the compromised twin, fetoscopic laser coagulation of the communicating placental vessels or termination of the whole pregnancy. Previous studies evaluating interventions have reported many different outcomes and outcome measures. Such variation makes comparing, contrasting, and combining results challenging, limiting ongoing research on this uncommon condition to inform clinical practice. We aim to produce, disseminate, and implement a core outcome set for selective fetal growth restriction research in monochorionic twin pregnancies. METHODS An international steering group, including professionals, researchers, and lay experts, has been established to oversee the development of this core outcome set. The methods have been guided by the Core Outcome Measures in Effectiveness Trials Initiative Handbook. Potential core outcomes will be developed by undertaking a systematic review of studies evaluating interventions for selective fetal growth restriction in monochorionic twin pregnancies. Potential core outcomes will be entered into a three-round Delphi survey and key stakeholders including clinical professionals, researchers, and lay experts will be invited to participate. Repeated reflection and rescoring of individual outcomes should encourage group and individual stakeholder convergence towards consensus outcomes which will be entered into a modified Nominal Group Technique to finalize the core outcome set. Once core outcomes have been agreed, we will establish standardized definitions and recommend high-quality measurement instruments for each outcome. DISCUSSION The development, dissemination, and implementation of a core outcome set for selective fetal growth restriction should ensure that future research protocols select, collect, and report outcomes and outcome measures in a standardized manner. Data synthesis will be possible on a broad level and rigorous implementation should advance the quality of research studies and their effective use in order to guide clinical practice, improve patient care, maternal, short-term perinatal outcomes, and long-term neurodevelopmental outcomes. TRIAL REGISTRATION Core Outcome Measures in Effectiveness Trials (COMET) registration number: 998. International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42018092697 . 18th April 2018.
Collapse
Affiliation(s)
- Asma Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK. .,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
| | - James M N Duffy
- Balliol College, University of Oxford, Broad Street, Oxford, OX1 3BJ, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Helen Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK.,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Keith Reed
- Twin and Multiple Births Association (TAMBA), The Manor House Manor Park, Church Hill, Aldershot, GU12 4JU, UK
| | - Ahmet A Baschat
- The Johns Hopkins Center for Fetal Therapy, 600 North Wolfe, Nelson 228, Baltimore, MD, 21287, USA
| | - Jan Deprest
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Herestraat, 49 3000, Leuven, Belgium
| | - Eduardo Gratacos
- Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Deu, Universitat de Barcelona; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Neues Klinikum, Gebäude O10 Martinistr. 52, 20246, Hamburg, Germany
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Herestraat, 49 3000, Leuven, Belgium
| | - Enrico Lopriore
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, K-06-35, P.O. Box 9600, 2300RC, Leiden, The Netherlands
| | - Dick Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, K-06-35, P.O. Box 9600, 2300RC, Leiden, The Netherlands
| | - Aris Papageorghiou
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Sanne J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | |
Collapse
|
16
|
Townsend R, D'Antonio F, Sileo FG, Kumbay H, Thilaganathan B, Khalil A. Perinatal outcome of monochorionic twin pregnancy complicated by selective fetal growth restriction according to management: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:36-46. [PMID: 30207011 DOI: 10.1002/uog.20114] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/26/2018] [Accepted: 09/03/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To explore the impact of severity and management (expectant, laser treatment or selective reduction) on perinatal outcome of monochorionic twin pregnancies complicated by selective fetal growth restriction (sFGR). METHODS MEDLINE, EMBASE, CINAHL, ClinicalTrials.gov and The Cochrane Library databases were searched for studies on outcome following expectant management, laser treatment or selective reduction in monochorionic twin pregnancies complicated by sFGR. Only pregnancies affected by sFGR and categorized according to the Gratacós classification (Type I, II or III) were included. The primary outcome was mortality, including single and double intrauterine (IUD), neonatal (NND) and perinatal deaths. Secondary outcomes were neonatal morbidity, abnormal postnatal brain imaging, intraventricular hemorrhage, periventricular leukomalacia, respiratory distress syndrome, admission to neonatal intensive care unit and survival free from neurological complications (intact survival). Meta-analyses of proportions were used to analyze the extracted data according to management, severity of sFGR and fetal size (smaller vs larger twin). RESULTS Sixteen observational studies (786 monochorionic twin pregnancies) were included. In pregnancies complicated by Type-I sFGR managed expectantly, IUD occurred in 3.1% (95% CI, 1.1-5.9%) of fetuses and 97.9% (95% CI, 93.6-99.9%) of twins had intact survival. In pregnancies complicated by Type-I sFGR treated using laser therapy, IUD occurred in 16.7% (95% CI, 0.4-64.1%) of fetuses and, in those treated using selective reduction, IUD occurred in 0% (95% CI, 0-34.9%) of cotwins, with no evidence of neurological complications in the survivors. In pregnancies complicated by Type-II sFGR managed expectantly, IUD occurred in 16.6% (95% CI, 6.9-29.5%) and NND in 6.4% (95% CI, 0.2-28.2%) of fetuses, and 89.3% (95% CI, 71.8-97.7%) of twins survived without neurological compromise. In Type-II sFGR pregnancies treated using laser therapy, IUD occurred in 44.3% (95% CI, 22.2-67.7%) of fetuses, while none of the affected cases experienced morbidity and survivors were free of neurological complications. Of pregnancies undergoing selective reduction, IUD of the cotwin occurred in 5.0% (95% CI, 0.03-20.5%) and NND in 3.7% (95% CI, 0.2-11.1%), and 90.6% (95% CI, 42.3-94.3%) of surviving cotwins were free from neurological complications. In pregnancies complicated by Type-III sFGR managed expectantly, IUD occurred in 13.2% (95% CI, 7.2-20.5%) and NND in 6.8% (95% CI, 0.7-18.6%) of fetuses, and 61.9% (95% CI, 38.4-81.9%) of twins had intact survival. In pregnancies complicated by Type-III sFGR treated with laser therapy, IUD occurred in 32.9% (95% CI, 20.9-46.2%) of fetuses and all surviving twins were without neurological complications. Finally, in pregnancies with Type-III sFGR treated with selective reduction, NND occurred in 5.2% (95% CI, 0.8-12.8%) of cotwins and 98.8% (95% CI, 93.9-99.9%) had intact survival. CONCLUSION Type-I sFGR is characterized by good perinatal outcome when managed expectantly, which represents the most reasonable management strategy for the large majority of affected cases. Pregnancies complicated by Type-II or -III sFGR treated with fetoscopic laser ablation have a higher rate of mortality but lower rate of morbidity compared with those managed expectantly, supporting the use of fetal therapy at gestations remote from neonatal viability. Data on outcome following selective reduction are scarce. In view of the lack of evidence from randomized controlled trials, prenatal management of sFGR should be individualized according to gestational age at diagnosis, severity of growth discordance and magnitude of Doppler anomalies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- R Townsend
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - F D'Antonio
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, Tromsø, Norway
| | - F G Sileo
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - H Kumbay
- GKT School of Medicine, King's College, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| |
Collapse
|
17
|
Khalil A, Beune I, Hecher K, Wynia K, Ganzevoort W, Reed K, Lewi L, Oepkes D, Gratacos E, Thilaganathan B, Gordijn SJ. Consensus definition and essential reporting parameters of selective fetal growth restriction in twin pregnancy: a Delphi procedure. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:47-54. [PMID: 29363848 DOI: 10.1002/uog.19013] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 01/01/2018] [Accepted: 01/08/2018] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Twin pregnancy complicated by selective fetal growth restriction (sFGR) is associated with increased perinatal mortality and morbidity. Inconsistencies in the diagnostic criteria for sFGR employed in existing studies hinder the ability to compare or combine their findings. It is therefore challenging to establish robust evidence-based management or monitoring pathways for these pregnancies. The main aim of this study was to determine, by expert consensus using a Delphi procedure, the key diagnostic features of and the essential reporting parameters in sFGR. METHODS A Delphi process was conducted among an international panel of experts in sFGR in twin pregnancy. Panel members were provided with a list of literature-based parameters for diagnosing sFGR and were asked to rate their importance on a five-point Likert scale. Parameters were described as solitary (sufficient to diagnose sFGR, even if all other parameters are normal) or contributory (those that require other abnormal parameter(s) to be present for the diagnosis of sFGR). Consensus was sought to determine the cut-off values for accepted parameters, as well as parameters used in the monitoring, management and assessment of outcome of twin pregnancy complicated by sFGR. The questions were presented in two separate categories according to chorionicity. RESULTS A total of 72 experts were approached, of whom 60 agreed to participate and entered the first round; 48 (80%) completed all four rounds. For the definition of sFGR irrespective of chorionicity, one solitary parameter (estimated fetal weight (EFW) of one twin < 3rd centile) was agreed. For monochorionic twin pregnancy, at least two out of four contributory parameters (EFW of one twin < 10th centile, abdominal circumference of one twin < 10th centile, EFW discordance of ≥ 25%, and umbilical artery pulsatility index of the smaller twin > 95th centile) were agreed. For sFGR in dichorionic twin pregnancy, at least two out of three contributory parameters (EFW of one twin < 10th centile, EFW discordance of ≥ 25%, and umbilical artery pulsatility index of the smaller twin > 95th centile) were agreed. CONCLUSIONS Consensus-based diagnostic features of sFGR in both monochorionic and dichorionic twin pregnancies, as well as cut-off values for the parameters involved, were agreed upon by a panel of experts. Future studies are needed to validate these diagnostic features before they can be used in clinical trials of interventions. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - I Beune
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - K Wynia
- Department of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - K Reed
- Twin and Multiple Births Association (TAMBA), UK
| | - L Lewi
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, KU, Leuven, Belgium
- Department of Development and Regeneration, KU, Leuven, Belgium
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Gratacos
- Fetal Medicine Unit and Department of Obstetrics, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - S J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
18
|
Perry H, Duffy JMN, Umadia O, Khalil A. Outcome reporting across randomized trials and observational studies evaluating treatments for twin-twin transfusion syndrome: systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:577-585. [PMID: 29607558 DOI: 10.1002/uog.19068] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 03/19/2018] [Accepted: 03/27/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Twin-twin transfusion syndrome (TTTS) is associated with significant mortality and morbidity. Potential treatments for the condition require robust evaluation. The aim of this study was to evaluate outcome reporting across observational studies and randomized controlled trials assessing treatments for TTTS. METHODS Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE were searched from inception to August 2016. Observational studies and randomized controlled trials reporting outcome following treatment for TTTS in monochorionic-diamniotic twin pregnancy and monochorionic-triamniotic or dichorionic-triamniotic triplet pregnancy were included. Outcome reporting was systematically extracted and categorized. RESULTS Six randomized trials and 94 observational studies were included, reporting data from 20 071 maternal participants and 3199 children. Six different treatments were evaluated. Included studies reported 62 different outcomes, including six fetal, seven offspring mortality, 25 neonatal, six early childhood and 18 maternal/operative outcomes. Outcomes were reported inconsistently across trials. For example, when considering offspring mortality, 31 (31%) studies reported live birth, 31 (31%) reported intrauterine death, 49 (49%) reported neonatal mortality and 17 (17%) reported perinatal mortality. Four (4%) studies reported respiratory distress syndrome. Only 19 (19%) studies were designed for long-term follow-up and 11 (11%) of these reported cerebral palsy. CONCLUSIONS Studies evaluating treatments for TTTS have often neglected to report clinically important outcomes, especially neonatal morbidity outcomes, and most are not designed for long-term follow-up. The development of a core outcome set could help standardize outcome collection and reporting in TTTS studies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J M N Duffy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
- Balliol College, University of Oxford, Oxford, UK
| | - O Umadia
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| |
Collapse
|
19
|
Kawaguchi H, Ishii K, Muto H, Yamamoto R, Hayashi S, Mitsuda N. The incidence of unexpected critical complications in monochorionic diamniotic twin pregnancies according to the interval period between ultrasonographic evaluations. J Obstet Gynaecol Res 2018; 45:318-324. [PMID: 30306664 DOI: 10.1111/jog.13827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/03/2018] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to evaluate the incidence of unexpected critical complications (UCC) in monochorionic diamniotic (MCDA) twin pregnancies according to ultrasonographic scan interval. METHODS This retrospective single-center cohort study, conducted between January 2005 and April 2015, investigated the incidence of UCC in patients with MCDA twin pregnancies undergoing weekly ultrasound (Group A) and those undergoing biweekly ultrasound (Group B). We also examined the incidence of predictable critical complications according to ultrasound interval. RESULTS Of all 385 cases, the total incidence of UCC was 20 (5.2%), including 14 cases of twin-twin transfusion syndrome and 6 cases of intrauterine fetal death. The incidence of UCC was 3.9% in Group A and 9.0% in Group B (P = 0.046). In contrast, the incidence of predictable critical complications was 6.7% in Group A and 9.0% in Group B (P = 0.440). CONCLUSION The incidence of UCC in patients with MCDA twin pregnancies was significantly lower in patients undergoing weekly ultrasound. Our results suggest that weekly ultrasound evaluation for patients with MCDA pregnancy is more effective for early detection of UCC such as intrauterine fetal death and twin-twin transfusion syndrome ; however, further investigations are needed to determine whether weekly ultrasound evaluation can improve clinical outcomes.
Collapse
Affiliation(s)
- Haruna Kawaguchi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Haruka Muto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Shusaku Hayashi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Nobuaki Mitsuda
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| |
Collapse
|
20
|
Townsend R, Khalil A. Fetal growth restriction in twins. Best Pract Res Clin Obstet Gynaecol 2018; 49:79-88. [DOI: 10.1016/j.bpobgyn.2018.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 02/15/2018] [Indexed: 12/12/2022]
|
21
|
Ishii K, Wada S, Takano M, Nakata M, Murakoshi T, Sago H. Survival Rate without Brain Abnormalities on Postnatal Ultrasonography among Monochorionic Twins after Fetoscopic Laser Photocoagulation for Selective Intrauterine Growth Restriction with Concomitant Oligohydramnios. Fetal Diagn Ther 2018; 45:21-27. [DOI: 10.1159/000486130] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 12/05/2017] [Indexed: 11/19/2022]
|
22
|
Sago H, Ishii K, Sugibayashi R, Ozawa K, Sumie M, Wada S. Fetoscopic laser photocoagulation for twin-twin transfusion syndrome. J Obstet Gynaecol Res 2018; 44:831-839. [PMID: 29436080 PMCID: PMC5969296 DOI: 10.1111/jog.13600] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/31/2017] [Indexed: 12/27/2022]
Abstract
The aim of this study was to review fetoscopic laser photocoagulation (FLP), which ablates placental vascular anastomoses to treat twin–twin transfusion syndrome (TTTS). A review of studies reporting on the procedures, outcomes, complications and nonconventional applications of FLP for TTTS was conducted. FLP has been established as the primary treatment for monochorionic twin pregnancy associated with TTTS at 16–26 weeks. FLP is the only therapy that directly addresses the underlying pathophysiology. The recent technique modification of FLP, referred to as the ‘Solomon technique’, induces selective coagulation to connect the anastomoses ablation sites and has been introduced to reduce residual anastomoses. The perinatal survival following FLP improved significantly with advances in the technique after its introduction. The recent survival rates of both twins and at least one twin are 70% and more than 90%, respectively. However, there is still an 11–14% risk of long‐term neurodevelopment impairment. The premature rupture of membranes that leads to preterm labor is a common complication after FLP. FLP is a valuable treatment option for feto‐fetal transfusion syndrome in triplets and for TTTS after 26 weeks. FLP for selective intrauterine growth restriction may be potentially beneficial when accompanied by abnormal Doppler findings and oligohydramnios. FLP is the optimal treatment option for TTTS at 16–26 weeks of gestation. FLP appears to be applicable in triplets, TTTS after 26 weeks and cases of selective intrauterine growth restriction with abnormal Doppler findings and oligohydramnios. FLP is the most common and successful fetal intervention. Improvement in the neurodevelopmental outcomes after FLP is a future focus.
Collapse
Affiliation(s)
- Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Rika Sugibayashi
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masahiro Sumie
- Department of Obstetrics, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Seiji Wada
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
23
|
Djaafri F, Stirnemann J, Mediouni I, Colmant C, Ville Y. Twin-twin transfusion syndrome - What we have learned from clinical trials. Semin Fetal Neonatal Med 2017; 22:367-375. [PMID: 29122542 DOI: 10.1016/j.siny.2017.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Monochorionic twin pregnancies are at increased risk for adverse outcome compared to dichorionic twin pregnancies and singletons. Monochorionic-specific complications include twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence, single intrauterine fetal demise and its consequences on the co-twin, and selective intrauterine growth restriction. Whereas the natural history of monochorionic-specific complications carries a high risk of fetal death or severe neurologic disability, a framework now exists, based on well-designed clinical trials, for optimal treatment of these entities. Fetoscopic selective laser coagulation of anastomotic vessels on the chorionic plate has been clearly demonstrated to improve survival and neurologic outcomes for Quintero stage ≥2 TTTS. However, many challenges remain unsolved, the most important of which is preterm premature rupture of membranes. Further improvement in the outcomes of monochorionic pregnancies will require improvements in the rate of premature delivery, and improved diagnosis and treatment strategies for early and late onset TTTS.
Collapse
Affiliation(s)
- Fatiha Djaafri
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Julien Stirnemann
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France
| | - Imen Mediouni
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Claire Colmant
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Yves Ville
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France.
| |
Collapse
|
24
|
Koch A, Favre R, Viville B, Fritz G, Kohler M, Guerra F, Lecointre L, Gaudineau A, Langer B, Weingertner AS, Sananès N. Expectant management and laser photocoagulation in isolated selective intra-uterine growth restriction: A single-center series. J Gynecol Obstet Hum Reprod 2017; 46:731-736. [DOI: 10.1016/j.jogoh.2017.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/07/2017] [Accepted: 09/19/2017] [Indexed: 11/15/2022]
|
25
|
Ozawa K, Sugibayashi R, Wada S, Sumie M, Ishii K, Nakata M, Murakoshi T, Ito Y, Sago H. Fetoscopic laser photocoagulation for amniotic fluid discordance bordering on twin-twin transfusion syndrome: Feasibility, perinatal and long-term outcomes. J Obstet Gynaecol Res 2017; 43:1256-1262. [PMID: 28544517 DOI: 10.1111/jog.13349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/16/2017] [Accepted: 03/12/2017] [Indexed: 11/30/2022]
Abstract
AIM This study investigated the feasibility and safety of fetoscopic laser photocoagulation (FLP) for amniotic fluid discordance (AFD) bordering on twin-twin transfusion syndrome (TTTS) with an absent or reverse end-diastolic velocity (AREDV) in the umbilical artery (UA), and evaluated the perinatal and long-term outcomes. METHODS A prospective intervention study was performed between 20 + 0 and 25 + 6 weeks of gestation (UMIN000004165). AFD bordering on TTTS was defined as maximum vertical pocket (MVP) of amniotic fluid in one twin's sac ≤3 cm and amniotic fluid MVP in the other twin's sac ≥7 cm excluding TTTS. Neurodevelopmental outcome was evaluated at 6 months and at 3 years of age. RESULTS Eleven women were treated without complications between September 2010 and July 2011. In all cases amnioinfusion was required, with a median surgical time of 70 min. There were nine cases of selective intrauterine growth restriction in which the growth discordant rate was >25%. The survival rates of the donor and recipient twins were 27.3% (3/11) and 100% (11/11), respectively. None of the surviving donor twins and two of the 11 recipient twins had hemiplegia at 6 months of age. One additional recipient twin had developmental delay at 3 years of age. CONCLUSIONS Fetoscopic laser photocoagulation for AFD bordering on TTTS with AREDV in the UA was feasible without complications but frequently resulted in donor twin death and a high survival rate of the recipient twin, albeit with neurodevelopmental abnormalities in some cases. FLP does not seem to be a promising treatment option for AFD bordering on TTTS.
Collapse
Affiliation(s)
- Katsusuke Ozawa
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rika Sugibayashi
- 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
| | - Masahiro Sumie
- Department of Obstetrics, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Takeshi Murakoshi
- Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, 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
| |
Collapse
|
26
|
Tangi A, Negri B, Fichera A, Fratelli N, Prefumo F. Late appearance of umbilical artery end-diastolic flow in selective intrauterine growth restriction complicating monochorionic diamniotic twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:546-547. [PMID: 27804170 DOI: 10.1002/uog.17344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 06/06/2023]
Affiliation(s)
- A Tangi
- Department of Obstetrics and Gynaecology, University of Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - B Negri
- Department of Obstetrics and Gynaecology, University of Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - A Fichera
- Department of Obstetrics and Gynaecology, University of Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - N Fratelli
- Department of Obstetrics and Gynaecology, University of Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - F Prefumo
- Department of Obstetrics and Gynaecology, University of Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| |
Collapse
|
27
|
Doel T, Shakir DI, Pratt R, Aertsen M, Moggridge J, Bellon E, David AL, Deprest J, Vercauteren T, Ourselin S. GIFT-Cloud: A data sharing and collaboration platform for medical imaging research. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2017; 139:181-190. [PMID: 28187889 PMCID: PMC5312116 DOI: 10.1016/j.cmpb.2016.11.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/03/2016] [Accepted: 11/03/2016] [Indexed: 05/06/2023]
Abstract
OBJECTIVES Clinical imaging data are essential for developing research software for computer-aided diagnosis, treatment planning and image-guided surgery, yet existing systems are poorly suited for data sharing between healthcare and academia: research systems rarely provide an integrated approach for data exchange with clinicians; hospital systems are focused towards clinical patient care with limited access for external researchers; and safe haven environments are not well suited to algorithm development. We have established GIFT-Cloud, a data and medical image sharing platform, to meet the needs of GIFT-Surg, an international research collaboration that is developing novel imaging methods for fetal surgery. GIFT-Cloud also has general applicability to other areas of imaging research. METHODS GIFT-Cloud builds upon well-established cross-platform technologies. The Server provides secure anonymised data storage, direct web-based data access and a REST API for integrating external software. The Uploader provides automated on-site anonymisation, encryption and data upload. Gateways provide a seamless process for uploading medical data from clinical systems to the research server. RESULTS GIFT-Cloud has been implemented in a multi-centre study for fetal medicine research. We present a case study of placental segmentation for pre-operative surgical planning, showing how GIFT-Cloud underpins the research and integrates with the clinical workflow. CONCLUSIONS GIFT-Cloud simplifies the transfer of imaging data from clinical to research institutions, facilitating the development and validation of medical research software and the sharing of results back to the clinical partners. GIFT-Cloud supports collaboration between multiple healthcare and research institutions while satisfying the demands of patient confidentiality, data security and data ownership.
Collapse
Affiliation(s)
- Tom Doel
- Translational Imaging Group, Centre for Medical Imaging Computing, University College London, London, UK.
| | - Dzhoshkun I Shakir
- Translational Imaging Group, Centre for Medical Imaging Computing, University College London, London, UK
| | - Rosalind Pratt
- Translational Imaging Group, Centre for Medical Imaging Computing, University College London, London, UK; Institute for Women's Health, University College London, London, UK
| | - Michael Aertsen
- Department of Imaging & Pathology, UZ Leuven, Leuven, Belgium
| | | | - Erwin Bellon
- Department of Imaging & Pathology, UZ Leuven, Leuven, Belgium; Department of Information Technology, UZ Leuven, Leuven, Belgium
| | - Anna L David
- Institute for Women's Health, University College London, London, UK
| | - Jan Deprest
- Institute for Women's Health, University College London, London, UK; Department of Obstetrics, UZ Leuven, Leuven, Belgium
| | - Tom Vercauteren
- Translational Imaging Group, Centre for Medical Imaging Computing, University College London, London, UK
| | - Sébastien Ourselin
- Translational Imaging Group, Centre for Medical Imaging Computing, University College London, London, UK
| |
Collapse
|
28
|
Oepkes D, Sueters M. Antenatal fetal surveillance in multiple pregnancies. Best Pract Res Clin Obstet Gynaecol 2017; 38:59-70. [DOI: 10.1016/j.bpobgyn.2016.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022]
|
29
|
|
30
|
Wang G, Zuluaga MA, Pratt R, Aertsen M, Doel T, Klusmann M, David AL, Deprest J, Vercauteren T, Ourselin S. Slic-Seg: A minimally interactive segmentation of the placenta from sparse and motion-corrupted fetal MRI in multiple views. Med Image Anal 2016; 34:137-147. [PMID: 27179367 PMCID: PMC5052128 DOI: 10.1016/j.media.2016.04.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 04/06/2016] [Accepted: 04/23/2016] [Indexed: 11/30/2022]
Abstract
Segmentation of the placenta from fetal MRI is challenging due to sparse acquisition, inter-slice motion, and the widely varying position and shape of the placenta between pregnant women. We propose a minimally interactive framework that combines multiple volumes acquired in different views to obtain accurate segmentation of the placenta. In the first phase, a minimally interactive slice-by-slice propagation method called Slic-Seg is used to obtain an initial segmentation from a single motion-corrupted sparse volume image. It combines high-level features, online Random Forests and Conditional Random Fields, and only needs user interactions in a single slice. In the second phase, to take advantage of the complementary resolution in multiple volumes acquired in different views, we further propose a probability-based 4D Graph Cuts method to refine the initial segmentations using inter-slice and inter-image consistency. We used our minimally interactive framework to examine the placentas of 16 mid-gestation patients from MRI acquired in axial and sagittal views respectively. The results show the proposed method has 1) a good performance even in cases where sparse scribbles provided by the user lead to poor results with the competitive propagation approaches; 2) a good interactivity with low intra- and inter-operator variability; 3) higher accuracy than state-of-the-art interactive segmentation methods; and 4) an improved accuracy due to the co-segmentation based refinement, which outperforms single volume or intensity-based Graph Cuts.
Collapse
Affiliation(s)
- Guotai Wang
- Translational Imaging Group, CMIC, University College London, London, UK.
| | - Maria A Zuluaga
- Translational Imaging Group, CMIC, University College London, London, UK
| | - Rosalind Pratt
- Translational Imaging Group, CMIC, University College London, London, UK; Institute for Women's Health, University College London, London, UK
| | - Michael Aertsen
- Department of Radiology, University Hospitals KU Leuven, Leuven, Belgium
| | - Tom Doel
- Translational Imaging Group, CMIC, University College London, London, UK
| | - Maria Klusmann
- Department of Radiology, University College London Hospital, London, UK
| | - Anna L David
- Institute for Women's Health, University College London, London, UK
| | - Jan Deprest
- Department of Obstetrics, University Hospitals KU Leuven, Leuven, Belgium
| | - Tom Vercauteren
- Translational Imaging Group, CMIC, University College London, London, UK
| | - Sébastien Ourselin
- Translational Imaging Group, CMIC, University College London, London, UK
| |
Collapse
|
31
|
Peeva G, Chaveeva P, Gil Guevara E, Akolekar R, Nicolaides KH. Endoscopic Placental Laser Coagulation in Dichorionic and Monochorionic Triplet Pregnancies. Fetal Diagn Ther 2016; 40:174-180. [PMID: 26910557 DOI: 10.1159/000443792] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 12/28/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report the outcome of monochorionic (MC) and dichorionic (DC) triamniotic (TA) triplet pregnancies treated with endoscopic laser coagulation of the communicating placental vessels for severe feto-fetal transfusion syndrome (FFTS) and selective fetal growth restriction (sFGR). METHODS Laser surgery was performed at 18 (15-24) weeks' gestation in 11 MCTA and 33 DCTA pregnancies complicated by FFTS and 14 DCTA pregnancies complicated by sFGR. Data from our study and previous reports were pooled using meta-analytic techniques. RESULTS Survival of at least one baby and survival among all fetuses was 97.0 and 72.7% in DCTA pregnancies with FFTS, 78.6 and 52.4% in DCTA pregnancies with sFGR and 81.8 and 39.4% in MCTA pregnancies with FFTS. In the combined data from our study and previous reports, the pooled survival rates in 132 DCTA pregnancies with FFTS were 94.4 and 76.1%, and in 29 MCTA pregnancies with FFTS, they were 80.6 and 57.5%. CONCLUSIONS Survival after laser surgery is higher in DC triplets with FFTS than in those with sFGR and in DC than in MC triplets with FFTS.
Collapse
Affiliation(s)
- Gergana Peeva
- Harris Birthright Research Centre of Fetal Medicine, King's College Hospital, London, UK
| | | | | | | | | |
Collapse
|
32
|
Kermorvant-Duchemin E, Ville Y. Prenatal diagnosis of congenital malformations for the better and for the worse. J Matern Fetal Neonatal Med 2016; 30:1402-1406. [DOI: 10.1080/14767058.2016.1214707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
33
|
Stagnati V, Pagani G, Fichera A, Prefumo F. Intertwin discrepancy in middle cerebral artery peak systolic velocity and third-trimester fetal growth restriction in monochorionic-diamniotic twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:66-71. [PMID: 26173065 DOI: 10.1002/uog.14944] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/30/2015] [Accepted: 07/02/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To assess the role of intertwin discrepancy in middle cerebral artery peak systolic velocity (MCA-PSV) for the prediction of late selective intrauterine growth restriction (sIUGR) at birth and birth weight discrepancy of > 25% (BW-25) in otherwise uncomplicated monochorionic-diamniotic (MCDA) twin pregnancies. METHODS This was a cohort study including all MCDA pregnancies followed in a tertiary fetal medicine unit between 2008 and 2013. Exclusion criteria were referral after first trimester, abnormal karyotype, structural anomalies, twin-to-twin transfusion syndrome, twin anemia-polycythemia sequence and sIUGR detected before 28 weeks. MCA-PSV values of both twins measured in the second trimester (18-24 weeks) and early third trimester (26-32 weeks) were converted in multiples of the median (MoM). sIUGR was defined as birth weight < 5(th) centile. The relationship between MCA-PSV discrepancy, sIUGR and BW-25 was assessed by logistic regression analysis. Receiver-operating characteristics (ROC) curves were used to ascertain the predictive value of MCA-PSV discrepancy for such complications. RESULTS In total, 136 MCDA twin pregnancies were included in the analysis. Thirty (22.1%) were complicated with sIUGR at birth and 12 (8.8%) were complicated with BW-25. Logistic regression analysis identified MCA-PSV discrepancy as an independent predictor for sIUGR. ROC curves identified third-trimester MCA-PSV discrepancy as the best predictor for both sIUGR (area under ROC curve (AUC), 0.73 (95% CI, 0.62-0.85)) and BW-25 (AUC, 0.79 (95% CI, 0.65-0.93)). The optimal cut-off point for MCA-PSV discrepancy was 0.30 MoM (sensitivity, 70% and specificity, 69% for sIUGR; sensitivity, 83% and specificity, 72% for BW-25). CONCLUSION In MCDA twin pregnancies, MCA-PSV discrepancy is associated with both sIUGR at birth and BW discordance. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- V Stagnati
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - G Pagani
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - A Fichera
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - F Prefumo
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| |
Collapse
|
34
|
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
| |
Collapse
|
35
|
Hayashi S, Anami A, Ishii K, Oba MS, Takahashi Y, Nakata M, Murotsuki J, Murakoshi T, Sago H. Outcome of monochorionic twin pregnancies with moderate amniotic fluid discordance adjoining twin-twin transfusion syndrome. Prenat Diagn 2016; 36:170-6. [DOI: 10.1002/pd.4765] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 12/09/2015] [Accepted: 12/20/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Satoshi Hayashi
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine; National Center for Child Health and Development; Tokyo Japan
| | - Ai Anami
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine; National Center for Child Health and Development; Tokyo Japan
- Department of Obstetrics and Gynecology; National Hospital Organization Beppu Medical Center; Beppu Japan
| | - Keisuke Ishii
- Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Izumi Japan
| | - Mari S. Oba
- Department of Biostatistics, Graduate school of Medicine; Yokohama City University; Yokohama Japan
| | - Yuichiro Takahashi
- Department of Fetal-Maternal Medicine; Nagara Medical Center; Gifu Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology; Toho University Omori Medical Center; Tokyo Japan
| | - Jun Murotsuki
- Department of Obstetrics; Miyagi Children's Hospital; Sendai Japan
| | - Takeshi Murakoshi
- Division of Perinatology, Maternal and Perinatal Care Center; Seirei Hamamatsu General Hospital; Hamamatsu Japan
| | - Haruhiko Sago
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine; National Center for Child Health and Development; Tokyo Japan
| |
Collapse
|
36
|
Beauquier-Maccotta B, Chalouhi GE, Picquet AL, Carrier A, Bussières L, Golse B, Ville Y. Impact of Monochorionicity and Twin to Twin Transfusion Syndrome on Prenatal Attachment, Post Traumatic Stress Disorder, Anxiety and Depressive Symptoms. PLoS One 2016; 11:e0145649. [PMID: 26751570 PMCID: PMC4709103 DOI: 10.1371/journal.pone.0145649] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 12/07/2015] [Indexed: 11/19/2022] Open
Abstract
Monochronioric (MC) twin pregnancies are considered as high-risk pregnancies with potential complications requiring in-utero interventions. We aimed to assess prenatal attachment, anxiety, post-traumatic stress disorder (PTSD) and depressive symptoms in MC pregnancies complicated with Twin-To-Twin-transfusion syndrome (TTTS) in comparison to uncomplicated monochorionic (UMC) and dichorionic pregnancies (DC). Auto-questionnaires were filled out at diagnosis of TTTS and at successive milestones. Prenatal attachment, PTSD, anxiety and perinatal depression were evaluated respectively by the Prenatal Attachment Inventory (PAI) completed for each twin, the Post-traumatic Checklist Scale (PCLS), the State-Trait Anxiety Inventory (STAI) and the Edinburgh Perinatal Depression Scale (EPDS). There was no significant difference in the PAI scores between the two twins. In the DC and UMC groups, PAI scores increased throughout pregnancy, whilst it didn't for TTTS group. TTTS and DC had a similar prenatal attachment while MC mothers expressed a significantly higher attachment to their fetuses and expressed it earlier. At the announcement of TTTS, 72% of the patients present a score over the threshold at the EPDS Scale, with a higher score for TTTS than for DC (p = 0.005), and UMC (p = 0.007) at the same GA. 30% of mothers in TTTS group have PTSD during pregnancy. 50% of TTTS- patients present an anxiety score over the threshold (STAI-Scale), with a score significantly higher in TTTS than in UMC (p<0.001) or DC (p<0.001). The proportion of subject with a STAI-State over the threshold is also significantly higher in TTTS than in DC at 20 GW (p = 0.01) and at 26 GW (p<0.05). The STAI-state scores in UMC and DC increase progressively during pregnancy while they decrease significantly in TTTS. TTTS announcement constitutes a traumatic event during a pregnancy with an important risk of PTSD, high level of anxiety and an alteration of the prenatal attachment. These results should guide the psychological support provided to these patients.
Collapse
Affiliation(s)
- Berengere Beauquier-Maccotta
- Department of Child and Adolescent Psychiatry, Necker-Enfants-Malades Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Gihad E. Chalouhi
- Obstetrics and Fetal Medicine Department, Necker-Enfants-Malades Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Rare Disease Center- TTTS, Necker-Enfants-Malades Hospital, APHP, Paris, France
| | - Anne-Laure Picquet
- Rare Disease Center- TTTS, Necker-Enfants-Malades Hospital, APHP, Paris, France
| | - Aude Carrier
- Obstetrics and Fetal Medicine Department, Necker-Enfants-Malades Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Rare Disease Center- TTTS, Necker-Enfants-Malades Hospital, APHP, Paris, France
| | - Laurence Bussières
- Rare Disease Center- TTTS, Necker-Enfants-Malades Hospital, APHP, Paris, France
| | - Bernard Golse
- Department of Child and Adolescent Psychiatry, Necker-Enfants-Malades Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Yves Ville
- Obstetrics and Fetal Medicine Department, Necker-Enfants-Malades Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Rare Disease Center- TTTS, Necker-Enfants-Malades Hospital, APHP, Paris, France
| |
Collapse
|
37
|
Ishii K, Nakata M, Wada S, Murakoshi T, Sago H. Feasibility and preliminary outcomes of fetoscopic laser photocoagulation for monochorionic twin gestation with selective intrauterine growth restriction accompanied by severe oligohydramnios. J Obstet Gynaecol Res 2015; 41:1732-7. [PMID: 26369752 DOI: 10.1111/jog.12827] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/02/2015] [Accepted: 07/05/2015] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to clarify the feasibility and perinatal outcomes of fetoscopic laser photocoagulation (FLP) for monochorionic twin gestation with selective intrauterine growth restriction (sIUGR) accompanied by both abnormal umbilical artery Doppler waveforms and isolated severe oligohydramnios of the sIUGR twin. METHODS In this prospective clinical trial, which included 10 cases with absent or reversed end-diastolic flow in the umbilical artery and severe oligohydramnios of the sIUGR twin, the main outcomes investigated were the feasibility of FLP and the rate of severe FLP-related maternal complications. The survival rate and incidence of neurological abnormalities of the twins at 28 days of age were also evaluated. RESULTS FLP was completed for all cases without major intraoperative maternal complications, although one case experienced threatened preterm labor requiring intensive treatment after the procedure. Three sIUGR and 10 larger twins were alive without neurological abnormalities at 28 days of age, while intrauterine fetal death occurred in the remaining seven sIUGR twins. CONCLUSION FLP for monochorionic twins with sIUGR, especially when accompanied by abnormal Doppler and severe oligohydramnios of the sIUGR twin, appears to be feasible and potentially beneficial for the larger twin, as well as for some sIUGR twins.
Collapse
Affiliation(s)
- Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Tokuyama Central Hospital, Shunan, Japan
| | - Seiji Wada
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Takeshi Murakoshi
- Department of Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Haruhiko Sago
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
38
|
Parra-Cordero M, Bennasar M, Martínez JM, Eixarch E, Torres X, Gratacós E. Cord Occlusion in Monochorionic Twins with Early Selective Intrauterine Growth Restriction and Abnormal Umbilical Artery Doppler: A Consecutive Series of 90 Cases. Fetal Diagn Ther 2015; 39:186-91. [DOI: 10.1159/000439023] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 06/10/2015] [Indexed: 11/19/2022]
Abstract
Objective: To describe perinatal outcomes achieved with cord occlusion (CO) in monochorionic twins with severe selective intrauterine growth restriction (sIUGR) and abnormal umbilical artery Doppler in the IUGR twin (types II and III). Methods: We studied a consecutive series of 90 cases of sIUGR with abnormal Doppler treated with CO of the IUGR fetus. Abnormal Doppler was defined as continuous (type II, n = 41) or intermittent (type III, n = 49) absent/reversed end-diastolic flow. All cases presented at least one of the following severity criteria: gestational age (GA) <22 weeks, inter-twin estimated weight discordance >35%, reversed end-diastolic umbilical artery flow or ductus venosus pulsatility index >95th centile. We prospectively recorded pregnancy course and perinatal outcome. Results: Median GA at surgery was 20.6 weeks and mean duration 22.4 min. Miscarriage (<24 weeks) occurred in 3.3% (3/90) and preterm delivery <32 weeks in 7.1% (6/84) of continuing pregnancies. GA at delivery was 36.4 weeks and neonatal survival of the larger twin was achieved in 93.3%. Conclusion: In a consecutive series studied by an experienced team, CO in monochorionic twins with severe sIUGR type II or III was associated with delivery >32 weeks in 92.9% and neonatal survival of the normal twin in 93.3% of pregnancies.
Collapse
|
39
|
|
40
|
Stagnati V, Chalouhi GE, Essaoui M, Giuseppi A, Stirnemann JJ, Le Bidois J, Ville Y. Pulmonary stenosis in complicated monochorionic twin pregnancies: prevalence, management and outcome. Prenat Diagn 2015; 35:1085-92. [DOI: 10.1002/pd.4650] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 06/06/2015] [Accepted: 07/06/2015] [Indexed: 11/06/2022]
Affiliation(s)
- V. Stagnati
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
- Maternal Fetal Medicine Unit; University of Brescia, Spedali Civili di Brescia; Brescia Italy
| | - G. E. Chalouhi
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - M. Essaoui
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - A. Giuseppi
- Neonatology Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - J. J. Stirnemann
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - J. Le Bidois
- Pediatric Cardiology Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - Y. Ville
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| |
Collapse
|
41
|
Peeva G, Bower S, Orosz L, Chaveeva P, Akolekar R, Nicolaides KH. Endoscopic Placental Laser Coagulation in Monochorionic Diamniotic Twins with Type II Selective Fetal Growth Restriction. Fetal Diagn Ther 2015; 38:86-93. [DOI: 10.1159/000374109] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 12/29/2014] [Indexed: 11/19/2022]
Abstract
Objective: To determine predictors of survival in monochorionic diamniotic twins with selective fetal growth restriction type II (sFGR-II), with or without twin-to-twin transfusion syndrome (TTTS), treated by endoscopic placental laser coagulation. Methods: Laser surgery was performed at 20 (15-27) weeks' gestation in 405 cases of sFGR-II with and 142 without coexisting TTTS. Multivariable logistic regression analysis was performed to determine significant predictors of survival to discharge from hospital. Results: There was survival of the small twin in 216 (39.5%) and of the large twin in 379 (69.3%) cases. Significant predictors of survival of both the small and larger twin were ductus venosus Doppler findings in the small twin, gestational age at laser and cervical length, but not the presence of TTTS or Doppler findings in the large twin. Conclusions: In sFGR-II, survival after laser surgery is primarily dependent on the condition of the small twin.
Collapse
|
42
|
Mathis J, Raio L, Baud D. Fetal laser therapy: applications in the management of fetal pathologies. Prenat Diagn 2015; 35:623-36. [DOI: 10.1002/pd.4587] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 02/21/2015] [Accepted: 02/26/2015] [Indexed: 12/23/2022]
Affiliation(s)
- Jérôme Mathis
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
| | - Luigi Raio
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
| | - David Baud
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
| |
Collapse
|
43
|
Gustavo Rencoret P. Embarazo gemelar. REVISTA MÉDICA CLÍNICA LAS CONDES 2014. [DOI: 10.1016/s0716-8640(14)70645-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
44
|
Lewi L, Devlieger R, De Catte L, Deprest J. Growth discordance. Best Pract Res Clin Obstet Gynaecol 2013; 28:295-303. [PMID: 24361179 DOI: 10.1016/j.bpobgyn.2013.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/25/2013] [Accepted: 12/04/2013] [Indexed: 10/25/2022]
Abstract
Poor growth is a common problem in twin pregnancies, and management poses some unique challenges as the wellbeing of both twins have to be taken into account at all times. The decision to deliver the twins to prevent an intrauterine demise of the growth-restricted twin will, therefore, depends on the chances of intact postnatal survival of both twins. In monochorionic twins, management is complicated further by the fact that the wellbeing of one twin critically depends on that of the other twin because of the shared circulation. In the event of demise of the growth-restricted twin, the larger twin may also die or sustain brain damage because of an acute exsanguination into the feto-placental unit of its demised co-twin. In the pre-viable period, invasive fetal therapy may, therefore, be indicated to protect the appropriately growing twin.
Collapse
Affiliation(s)
- Liesbeth Lewi
- Fetal Medicine Unit, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Roland Devlieger
- Fetal Medicine Unit, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Luc De Catte
- Fetal Medicine Unit, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Jan Deprest
- Fetal Medicine Unit, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| |
Collapse
|