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Mustafa HJ, Javinani A, Krispin E, Tadbiri H, Espinoza J, Shamshirsaz AA, Nassr AA, Donepudi R, Belfort MA, Cortes MS, Harman C, Turan OM. Fetoscopic laser surgery for twin-to-twin transfusion syndrome in DCTA triplets compared to MCDA twins: collaborative study and literature review. J Matern Fetal Neonatal Med 2022; 35:10348-10354. [PMID: 36529927 DOI: 10.1080/14767058.2022.2128649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To compare the outcomes of dichorionic triamniotic (DCTA) triplets with that of monochorionic diamniotic (MCDA) twin gestations undergoing fetoscopic laser surgery (FLS) for treatment of twin-to-twin transfusion syndrome (TTTS). METHODS Retrospective cohort study of prospectively collected data of consecutive DCTA triplet and MCDA twin pregnancies with TTTS that underwent FLS at two fetal treatment centers between 2012 and 2020. Preoperative, operative and, postoperative variables were collected. Perinatal outcomes were investigated. Primary outcome was survival to birth and to neonatal period. Secondary outcomes were gestational age (GA) at birth and procedure-to-delivery interval. Literature review was conducted in which PubMed, Web of Science, and Scopus were searched from inception to September, 2020. RESULTS Twenty four sets of DCTA triplets were compared to MCDA twins during the study period. There were no significant differences in survival (no survivor, single, or double survivors) to birth and to the neonatal period of the MC twin pairs of the DCTA triplets vs MCDA twins. Median GA at delivery was approximately three weeks earlier in DCTA triplets compared to MCDA twins (28.4 weeks vs 31.4 weeks, p = .035, respectively). Rates of preterm birth (PTB) less than 32 and less than 28 weeks were significantly higher in DCTA triplets compared to twins (<32 weeks: 70.8% vs 51.1%, p = .037, respectively, and <28 weeks: 37.5% vs 20.8%, p = .033, respectively). CONCLUSION Perinatal survival including fetal and neonatal are comparable between DCTA triplets and MCDA twins. However, this might have resulted from the small sample size of the DCTA triplets. GA at delivery is earlier in triplets, which could be due to the nature of triplet gestation rather than to the laser procedure itself.
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Affiliation(s)
- Hiba J Mustafa
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ali Javinani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Eyal Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Hooman Tadbiri
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Christopher Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Mustafa HJ, Javinani A, Krispin E, Tadbiri H, Shamshirsaz AA, Espinoza J, Nassr AA, Donepudi R, Belfort MA, Sanz Cortes M, Harman C, Turan OM. Perinatal outcomes of fetoscopic laser surgery for twin-twin transfusion syndrome in triplet pregnancy: cohort study, systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:42-51. [PMID: 35229918 DOI: 10.1002/uog.24887] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The aims of this study were to investigate the perinatal outcome of dichorionic triamniotic (DCTA) and monochorionic triamniotic (MCTA) triplet pregnancies complicated by twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser photocoagulation (FLP) in two academic fetal centers, and to conduct a systematic review of previously published data to investigate perinatal survival in this targeted population. METHODS The first part of the study was a retrospective cohort study of prospectively collected data of consecutive triplet pregnancies with TTTS that underwent FLP at two fetal treatment centers between 2012 and 2020. Demographic, preoperative and operative variables and postoperative outcome were collected. Perinatal outcomes were investigated. The second part of the study was a systematic review and meta-analysis of studies evaluating the outcome of DCTA and/or MCTA triplet pregnancies, including our cohort study. PubMed, Web of Science and Scopus were searched from inception to September 2020. Primary outcomes were fetal survival (survival to birth), neonatal survival (survival to 28 days of age) and gestational age (GA) at birth. RESULTS A total of 31 sets of triplets with TTTS managed with FLP were included in the cohort study. Of these, 24 were DCTA and seven were MCTA. There were no significant differences in preoperative and operative variables between the two groups. There were also no significant differences between groups in GA at delivery or perinatal survival rate, including fetal and neonatal survival of at least one triplet, at least two triplets and all three triplets. Nine studies, including our cohort study, were included in the systematic review (156 DCTA and 37 MCTA triplet pregnancies treated with FLP). The overall fetal and neonatal survival was 79% (95% CI, 75-83%) and 75% (95% CI, 71-79%), respectively, in DCTA cases and 74% (95% CI, 52-92%) and 71% (95% CI, 49-89%), respectively, in MCTA cases. The rate of preterm birth before 28 weeks and before 32 weeks' gestation was 14% (95% CI, 4-29%) and 61% (95% CI, 50-72%), respectively, in DCTA triplets and 21% (95% CI, 3-45%) and 82% (95% CI, 62-96%), respectively, in MCTA triplets. CONCLUSIONS Triplet pregnancies with TTTS are at high risk of adverse perinatal outcome and preterm birth, regardless of chorionicity. The rate of survival after FLP in MCTA triplets was higher in our study than that reported in previous studies and is currently comparable with survival in DCTA triplets, which could be due to improved surgical skills. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- H J Mustafa
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - A Javinani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - E Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - H Tadbiri
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - C Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - O M Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Wada S, Ozawa K, Sago H. New challenges of fetal therapy in Japan. J Obstet Gynaecol Res 2022; 48:2100-2111. [PMID: 35676616 PMCID: PMC9544758 DOI: 10.1111/jog.15320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/20/2022] [Indexed: 12/01/2022]
Abstract
Aim To review new challenges of fetal therapy in Japan after the establishment of four existing fetal therapies as standard prenatal care with National Health Insurance coverage over the past 20 years. Methods Reported studies and our current research activities related to four fetal therapies newly performed in Japan were reviewed. Results Fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia (CDH) aims to occlude the trachea using a detachable balloon to promote lung growth. Following the recent successful completion of an international randomized controlled trial for CDH, in which we participated, FETO is offered for severe left CDH to perform balloon insertion at 27–29 weeks and removal at 34 weeks of gestation. Fetal cystoscopy (FC) for low urinary tract obstruction was introduced to overcome the demerits of vesicoamniotic shunting. FC may provide a proper diagnosis by visual observation of the urethra and physiological treatment of the posterior urethral valve. The effectiveness of open fetal surgery for myelomeningocele (MMC), direct surgery with laparotomy and hysterotomy, for ameliorating hindbrain herniation and the motor function was demonstrated, but it was also associated with substantial maternal and fetal risks. Fetal aortic valvuloplasty (FAV), ultrasound‐guided fetal aortic balloon dilation for critical aortic stenosis with evolving hypoplastic left heart syndrome may improve left heart development and maintain biventricular circulation. Feasibility and safety studies for FC, MMC open fetal surgery, and FAV are currently ongoing. Conclusions Clinical research on FETO, FC, MMC open fetal surgery, and FAV has proceeded with careful preparations in Japan.
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Affiliation(s)
- Seiji Wada
- 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
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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4
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Takano M, Nakata M, Ishii K, Wada S, Sumie M, Yamamoto R, Ozawa K, Sakuma J, Nagasaki S, Sago H. Outcomes of fetoscopic laser surgery for twin-to-twin transfusion syndrome between 26 and 27 weeks of gestation in Japan. J Obstet Gynaecol Res 2021; 47:3821-3827. [PMID: 34227180 DOI: 10.1111/jog.14922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/09/2021] [Accepted: 06/26/2021] [Indexed: 12/31/2022]
Abstract
AIM The purpose of this study was to investigate the outcomes of fetoscopic laser photocoagulation (FLP) for twin-to-twin transfusion syndrome (TTTS) in Japan. METHODS The retrospective cohort study (2012-2018) was conducted in monochorionic twin pregnancies that underwent FLP for TTTS between 26 and 27 weeks from 2012 to 2018. The perioperative data, maternal complications, gestational age (GA) at delivery, neonatal complications, and survival of infants at 28 days of age were analyzed. At term-equivalent age, severe neurological complications were identified by imaging study. RESULTS Of 644 patients, 28 (4.3%) underwent FLP between 26 and 27 weeks, and 26 were analyzed. FLP procedures were technically successful in all cases. There were no cases of major maternal complications after surgery. Preterm rupture of membranes occurred in 34.6% of cases, and the mean GA at delivery was 33.2 ± 3.1 weeks. The survival of both twins was found in 23 (88.4%) cases, and the perinatal survival rate of at least one twin at 28 days of age was 100%. Severe neurological complications were found in six (12.2%) cases out of 49. CONCLUSIONS FLP for TTTS between 26 and 27 weeks provided a good prognosis and caused no major maternal complications. However, severe neurological findings were found in 12% of infants.
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Affiliation(s)
- Mayumi Takano
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Seiji Wada
- Division of Fetal Medicine, 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
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Katsusuke Ozawa
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Junya Sakuma
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Sumito Nagasaki
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Haruhiko Sago
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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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.
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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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.
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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
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8
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Nakata M, Ishii K, Sumie M, Takano M, Hirata H, Murata S, Takahashi Y, Murakoshi T, Sago H. A prospective pilot study of fetoscopic laser surgery for twin-to-twin transfusion syndrome between 26 and 27 weeks of gestation. Taiwan J Obstet Gynecol 2017; 55:512-4. [PMID: 27590373 DOI: 10.1016/j.tjog.2016.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The aim of this study is to clarify the feasibility and efficacy of fetoscopic laser photocoagulation of placental vascular communicating vessels (FLP) on twin-twin transfusion syndrome (TTTS) after 26 weeks of gestation. MATERIALS AND METHODS This is a prospective pilot study investigating all cases of TTTS between 26 weeks and 27 weeks during 2012 and 2013 in Japan. The primary endpoints in this study were the feasibility of FLP and rate of harmful complications for the mother's health. Also, perinatal prognosis was investigated. RESULTS Six cases were enrolled and underwent FLP. Two of the six cases were classified preoperatively as Quintero Stage II and four cases were Stage III. FLP was completely achieved in all six cases. No severe maternal complications were noted during and immediately after the surgery. All but one case continued the pregnancies > 14 days after FLP. The median gestational age at delivery was 33.4 weeks (28.0-36.6 weeks). All 12 fetuses survived at the 28(th) day in the neonatal period. No case was diagnosed with cerebral lesion at the neonatal period. CONCLUSION This prospective pilot study shows that FLP could be a therapeutic option for TTTS between 26 weeks and 27 weeks of gestation.
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Affiliation(s)
- Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan; Perinatal Care Center, Tokuyama Central Hospital, Shunan, Japan.
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Masahiro Sumie
- Fetal Medicine, National Center of Child Health and Development, Tokyo, Japan
| | - Mayumi Takano
- Perinatal Care Center, Tokuyama Central Hospital, Shunan, Japan
| | - Hiroko Hirata
- Perinatal Care Center, Tokuyama Central Hospital, Shunan, Japan
| | - Susumu Murata
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama, Japan
| | | | - Takeshi Murakoshi
- Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Haruhiko Sago
- Fetal Medicine, National Center of Child Health and Development, Tokyo, Japan
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9
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Long L, Yan J, Li Q, Zhou Z, Deng H, Wang C, Zou Y, Cai J. Intrauterine fetal death in triplet gestation caused by feto-fetal transfusion syndrome - a case report. Forensic Sci Res 2016; 2:213-217. [PMID: 30483645 PMCID: PMC6197143 DOI: 10.1080/20961790.2016.1264915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 11/21/2016] [Indexed: 10/24/2022] Open
Abstract
Feto-fetal transfusion syndrome (FFTS) severely affects monochorionic (MC) multiple pregnancies and affects 1 in 1600 pregnancies overall. The number of increasing disputed obstetrics cases in China is related to unavailability of prompt diagnosis of FFTS. We present here a woman with a MC triplet pregnancy with intrauterine fetal death at 33 weeks of gestation due to FFTS. Subsequent pathological anatomy showed that the MC placenta contained vascular anastomoses, including arterio-arterial anastomosis and arterio-venous anastomosis. These anastomoses led to unidirectional blood flow with the absence of adequate compensatory counter-transfusion and bi-directional flow. When encountering such challenging conditions, medical practitioners should discreetly compare the fetuses' characteristics with features of placental blood vessels and consult morphological and pathological findings. Furthermore, they should perform ultrasound examinations, particularly focussing on fetal size differences and the maximum vertical pocket in the diagnosis of FFTS, especially in MC multiple pregnancies with abdominal symptoms.
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Affiliation(s)
- Lingling Long
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Jie Yan
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China.,Department of Forensic Pathology, Hunan Xiangya Judicial Identification Center, Changsha, China
| | - Qiyan Li
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Ziqi Zhou
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Haixiao Deng
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Chudong Wang
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China
| | - Ying Zou
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China.,Department of Forensic Pathology, Hunan Xiangya Judicial Identification Center, Changsha, China
| | - Jifeng Cai
- Department of Forensic Science, School of Basic Medical Science, Central South University, Changsha, China.,Department of Forensic Pathology, Hunan Xiangya Judicial Identification Center, Changsha, China
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10
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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.
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Affiliation(s)
- Gergana Peeva
- Harris Birthright Research Centre of Fetal Medicine, King's College Hospital, London, UK
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11
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Simões T, Queiros A, Gonçalves MR, Periquito I, Silva P, Blickstein I. Perinatal outcome of dichorionic-triamniotic as compared to trichorionic triplets. J Perinat Med 2016; 44:875-879. [PMID: 26501156 DOI: 10.1515/jpm-2015-0230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 09/15/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate if the perinatal outcomes of dichorionic-triamniotic (DC) triplets are significantly different than that of trichorionic (TC) triplets. STUDY DESIGN Comparison of maternal and neonatal data of 44 DC to 46 TC triplets, using univariate analysis. RESULTS DC triplets were significantly more common after spontaneous conception but all other maternal characteristics as well complications and cesarean section rates were similar. Both groups had similar incidence of birth at <32 and <28 weeks as well as similar incidence of very low and extremely low birth weight. There was similar incidence of neonatal morbidity except for twin-twin transfusion syndrome (13.6%) in the DC group. The stillbirth rate was 45/1000 and 29/1000, the early neonatal mortality rates were 63/1000 and 45/1000, and the perinatal mortality rate was 106/1000 and 72/1000 for DC and TC triplets, respectively (all not significantly different). CONCLUSIONS Our data indicate that DC twins are not significantly disadvantaged compared to TC triplets and the similar outcomes might be reassuring for those who consider continuing their DC triplet pregnancy.
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12
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Yamamoto R, Ishii K, Mabuchi A, Oota S, Haino K, Hayashi S, Kanagawa T, Mitsusda N. Prior uterine bleeding is associated with low visibility due to discolored amniotic fluid on fetoscopic laser photocoagulation. J Obstet Gynaecol Res 2016; 42:1652-1656. [PMID: 27647818 DOI: 10.1111/jog.13133] [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: 04/29/2016] [Revised: 07/08/2016] [Accepted: 07/18/2016] [Indexed: 11/30/2022]
Abstract
AIM To investigate the association between uterine bleeding preceding fetoscopic laser photocoagulation (FLP) and the presence of discolored amniotic fluid that impedes FLP. METHODS A retrospective review of all multiple gestations requiring FLP at the present institution was conducted. The rate of low visibility because of discolored amniotic fluid at the beginning of FLP was compared between patients with and without a history of uterine bleeding, defined as either genital bleeding or ultrasonographically detected subchorionic hematoma. RESULTS The prevalence of low visibility because of discolored amniotic fluid was 4.5% (seven in 156 patients). Two of the seven cases of low visibility resulted in double fetal death. The incidence of low visibility was significantly higher in the group with uterine bleeding before surgery compared with that without bleeding (28.6% vs 0.74%, P < 0.001). CONCLUSIONS Patients with a history of uterine bleeding prior to FLP may encounter more technical difficulties owing to discolored amniotic fluid during FLP.
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Affiliation(s)
- Ryo Yamamoto
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Keisuke Ishii
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Aki Mabuchi
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Shiyo Oota
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Kazufumi Haino
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Shusaku Hayashi
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Takeshi Kanagawa
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Nobuaki Mitsusda
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
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13
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Chalouhi GE, Quibel T, Benzina N, Bernard JP, Essaoui M, Ville Y. [Outcome of triplet pregnancies managed for twin-to-twin transfusion syndrome: A single center experience]. ACTA ACUST UNITED AC 2016; 45:929-935. [PMID: 26995685 DOI: 10.1016/j.jgyn.2015.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/28/2015] [Accepted: 08/25/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Study the outcomes of triplet pregnancies (GGG) complicated with twin-to-twin transfusion syndrome (TTTS) treated with laser fetoscopy. METHODS Retrospective study of interventions, outcomes and perinatal follow-up of GGG treated for TTS. RESULTS Between 2002 and 2013, 25 GGG complicated by TTTS were seen in our center, 20 dichorionic and 5 monochorionic. The mean gestational age (GA) at diagnosis of TTTS was 19.7 GW (±2.4) with 2, 4, 16 and 1 pregnancies at Quintero's stage I, II, III and V, respectively. They had a fetoscopy at an average GA of 19 GW and 6 days. There were 3 (13.0%) late miscarriages. The average GA at delivery was of 29.6 GW overall (26.3 GW and 31.1 GW in monochorionic and dichorionic pregnancies respectively). The overall fetal survival rate was 57.97% (40% and 66.7% in the group of monochorionic dichorionic pregnancies, respectively). However, neonatal mortality (<28 days) is 17.5%. CONCLUSION GGG operated by fetoscopy for TTTS have a survival rate of three, at least 2 and at least 1 fetus of 21.7%, 69.6% and 82.6% respectively. The overall fetal survival rate is 59.97%. There is a tendency for better survival rates in dichorionic GGG compared to monochorionic GGG (P=0.079).
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Affiliation(s)
- G E Chalouhi
- Centre maladies rares, syndrome transfuseur-transfusé, hôpital Necker-Enfants-Malades, AP-HP, 75015 Paris, France; Maternité et service de médecine fœtale, hôpital Necker-Enfants-Malades, université Paris Descartes, Sorbonne Paris Cité, AP-HP, 149, rue de Sèvres, Paris, France
| | - T Quibel
- Service de gynécologie obstétrique, centre hospitalier intercommunal Poissy-Saint-Germain-en-Laye, 78300 Poissy, France
| | - N Benzina
- Centre maladies rares, syndrome transfuseur-transfusé, hôpital Necker-Enfants-Malades, AP-HP, 75015 Paris, France; Maternité et service de médecine fœtale, hôpital Necker-Enfants-Malades, université Paris Descartes, Sorbonne Paris Cité, AP-HP, 149, rue de Sèvres, Paris, France
| | - J-P Bernard
- Centre maladies rares, syndrome transfuseur-transfusé, hôpital Necker-Enfants-Malades, AP-HP, 75015 Paris, France; Maternité et service de médecine fœtale, hôpital Necker-Enfants-Malades, université Paris Descartes, Sorbonne Paris Cité, AP-HP, 149, rue de Sèvres, Paris, France
| | - M Essaoui
- Centre maladies rares, syndrome transfuseur-transfusé, hôpital Necker-Enfants-Malades, AP-HP, 75015 Paris, France; Maternité et service de médecine fœtale, hôpital Necker-Enfants-Malades, université Paris Descartes, Sorbonne Paris Cité, AP-HP, 149, rue de Sèvres, Paris, France
| | - Y Ville
- Centre maladies rares, syndrome transfuseur-transfusé, hôpital Necker-Enfants-Malades, AP-HP, 75015 Paris, France; Maternité et service de médecine fœtale, hôpital Necker-Enfants-Malades, université Paris Descartes, Sorbonne Paris Cité, AP-HP, 149, rue de Sèvres, Paris, France.
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Sato Y, Ishii K, Yokouchi T, Murakoshi T, Kiyoshi K, Nakayama S, Yonetani N, Mitsuda N. Incidences of Feto-Fetal Transfusion Syndrome and Perinatal Outcomes in Triplet Gestations with Monochorionic Placentation. Fetal Diagn Ther 2016; 40:181-186. [PMID: 26760043 DOI: 10.1159/000443610] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 12/21/2015] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This study aimed to determine the incidences of feto-fetal transfusion syndrome (FFTS) and perinatal outcomes in triplet gestations with monochorionic placentation. MATERIALS AND METHODS In this retrospective cohort study, we evaluated the incidences of FFTS and perinatal outcomes at 28 days of age in cases of triplet gestations with monochorionic placentation who visited our centers before 16 weeks of gestation and delivered over a period of 11 years. RESULTS In 41 triplet gestations (17 monochorionic triamniotic, 22 dichorionic triamniotic, 1 dichorionic diamniotic, and 1 monochorionic monoamniotic), the incidence of FFTS was 17.1%, and the median gestational age at FFTS diagnosis was 19 weeks. In 123 triplets, the incidences of fetal death and neonatal death at 28 days of age were 8.1 and 0.9%, respectively. None of the surviving infants had grade 3 or 4 intraventricular hemorrhage, while cystic periventricular leukomalacia occurred in 6 of 113 infants (5.3%). The incidence of poor outcomes (death or any major neurological complication at 28 days of age) was 13.8%. DISCUSSION Seventeen percent of triplet pregnancies with monochorionic placentation developed FFTS, and 14% had a poor outcome. Therefore, triplet gestations with monochorionic placentation should be followed carefully.
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Affiliation(s)
- Yuka Sato
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
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15
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Blumenfeld YJ, Shamshirsaz AA, Belfort MA, Hintz SR, Moaddab A, Ness A, Chueh J, El-Sayed YY, Ruano R. Fetofetal Transfusion Syndrome in Monochorionic-Triamniotic Triplets Treated with Fetoscopic Laser Ablation: Report of Two Cases and A Systematic Review. AJP Rep 2015; 5:e153-60. [PMID: 26495175 PMCID: PMC4603872 DOI: 10.1055/s-0035-1552931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/28/2015] [Indexed: 12/03/2022] Open
Abstract
Objective This study aims to determine the clinical outcomes of monochorionic-triamniotic (MT) pregnancies complicated by severe fetofetal transfusion undergoing laser photocoagulation. Study Design We report two cases of MT triplets complicated by fetofetal transfusion syndrome (FFTS) and a systematic review classifying cases into different subtypes: MT with two donors and one recipient, MT with one donor and two recipients, MT with one donor, one recipient, and one unaffected triplet. The number of neonatal survivors was analyzed based on this classification as well as Quintero staging. Results A total of 26 cases of MT triples complicated by FFTS were analyzed. In 56% of the cases, the FFTS involved all three triplets, 50% of whom had an additional donor and 50% an additional recipient. Among the 24 cases that survived beyond 1 week after the procedure, the average gestational age of delivery was 29.6 weeks, and the average interval from procedure to delivery was 10.1 weeks. The overall neonatal survival rate was 71.7%, with demises occurring equally between donor and recipient triplets. Overall neonatal survival including survival of at least two fetuses occurred with equal frequency between the different groups. Conclusion Significant neonatal survival can be achieved in most cases of MT triplets with FFTS.
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Affiliation(s)
- Yair J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Texas Children's Hospital Pavilion for Women, Houston, Texas
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Texas Children's Hospital Pavilion for Women, Houston, Texas
| | - Susan R Hintz
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Amirhossein Moaddab
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Texas Children's Hospital Pavilion for Women, Houston, Texas
| | - Amen Ness
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Jane Chueh
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Yasser Y El-Sayed
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Texas Children's Hospital Pavilion for Women, Houston, Texas
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16
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D'Antonio F, Thilaganathan B, Toms J, Manzoli L, Bhide A, Papageorghiou A, Khalil A. Perinatal outcome after fetoscopic laser surgery for twin-to-twin transfusion syndrome in triplet pregnancies. BJOG 2015; 123:328-36. [DOI: 10.1111/1471-0528.13553] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2015] [Indexed: 12/30/2022]
Affiliation(s)
- F D'Antonio
- Fetal Medicine Unit; Division of Developmental Sciences; St George's University of London; London UK
| | - B Thilaganathan
- Fetal Medicine Unit; Division of Developmental Sciences; St George's University of London; London UK
| | - J Toms
- Fetal Medicine Unit; Division of Developmental Sciences; St George's University of London; London UK
| | - L Manzoli
- Department of Medicine and Aging Sciences; University of Chieti; Chieti Italy
- CeSI Biotech; Chieti Italy
| | - A Bhide
- Fetal Medicine Unit; Division of Developmental Sciences; St George's University of London; London UK
| | - A Papageorghiou
- Fetal Medicine Unit; Division of Developmental Sciences; St George's University of London; London UK
| | - A Khalil
- Fetal Medicine Unit; Division of Developmental Sciences; St George's University of London; London UK
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Faas BH, Ghidini A, Van Mieghem T, Chitty LS, Deprest J, Bianchi DW. In case you missed it: thePrenatal Diagnosiseditors bring you the most significant advances of 2014. Prenat Diagn 2015; 35:29-34. [DOI: 10.1002/pd.4551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Brigitte H. Faas
- Department of Human Genetics; Radboud University Medical Centre; Nijmegen The Netherlands
| | - Alessandro Ghidini
- Obstetrics and Gynecology; Georgetown University Hospital; Washington DC USA
| | - Tim Van Mieghem
- Obstetrics and Gynaecology; University Hospitals Leuven; Leuven Belgium
- Academic Department Development and Regeneration; Biomedical Sciences; KU Leuven Leuven Belgium
| | - Lyn S. Chitty
- UCL Institute of Child Health; Great Ormond Street Hospital for Children and UCLH NHS Foundation Trusts; London England UK
| | - Jan Deprest
- Obstetrics and Gynaecology; University Hospitals Leuven; Leuven Belgium
- Academic Department Development and Regeneration; Biomedical Sciences; KU Leuven Leuven Belgium
| | - Diana W. Bianchi
- Mother Infant Research Institute; Tufts Medical Center; Boston MA USA
- Floating Hospital for Children; Boston MA USA
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